Differences in outcomes by race/ethnicity after thoracic surgery in a large integrated health system

Background

Disparities exist throughout surgery. We aimed to assess for racial/ethnic disparities among outcomes in a large thoracic surgery patient population.

Methods

We reviewed all thoracic surgery patients treated at our integrated health system from January 1, 2016-December 31, 2020. Post-operative outcomes including length of stay (LOS), 30-day return to the emergency department (30d-ED), 30-day readmission, 30- and 90-day outpatient appointments, and 30- and 90-day mortality were compared by race/ethnicity. Bivariate analyses and multivariable logistic regression were performed. Our multivariable models adjusted for age, sex, body mass index, Charlson Comorbidity Index, surgery type, neighborhood deprivation index, insurance, and home region.

Results

Of 2730 included patients, 59.4 % were non-Hispanic White, 15.0 % were Asian, 11.9 % were Hispanic, 9.6 % were Black, and 4.1 % were Other. Median (Q1-Q3) LOS (in hours) was shortest among non-Hispanic White (37.3 (29.2-76.1)) and Other (36.5 (29.3-75.4)) patients followed by Hispanic (46.8 (29.9-78.1)) patients with Asian (51.3 (30.7-81.9)) and Black (53.7 (30.6-101.6)) patients experiencing the longest LOS (p < 0.01). 30d-ED rates were highest among Hispanic patients (21.3 %), followed by Black (19.2 %), non-Hispanic White (18.1 %), Asian (13.4 %), and Other (8.0 %) patients (p < 0.01). On multivariable analysis, Hispanic ethnicity (Odds Ratio (OR) 1.43 (95 % CI 1.03-1.97)) and Medicaid insurance (OR 2.37 (95 % CI 1.48-3.81)) were associated with higher 30d-ED rates. No racial/ethnic disparities were found among other outcomes.

Conclusions

Despite parity across multiple surgical outcomes, disparities remain related to patient encounters within our system. Health systems must track such disparities in addition to standard clinical outcomes.

Key message

While our large integrated health system has been able to demonstrate parity across many major surgical outcomes among our thoracic surgery patients, race/ethnicity disparities persist including in the number of post-operative return trips to the emergency department. Tracking outcome disparities to a granular level such as return visits to the emergency department and number of follow up appointments is critical as health systems strive to achieve equitable care.

Disease characteristics, effectiveness, and safety of vestronidase alfa for the treatment of patients with mucopolysaccharidosis VII in a novel, longitudinal, multicenter disease monitoring program

BACKGROUND

Mucopolysaccharidosis VII (MPS VII) is an ultra-rare, autosomal recessive, debilitating, progressive lysosomal storage disease caused by reduced activity of β-glucuronidase (GUS) enzyme. Vestronidase alfa (recombinant human GUS) intravenous enzyme replacement therapy is an approved treatment for patients with MPS VII.

METHODS

This disease monitoring program (DMP) is an ongoing, multicenter observational study collecting standardized real-world data from patients with MPS VII (N ≈ 50 planned) treated with vestronidase alfa or any other management approach. Data are monitored and recorded in compliance with Good Clinical Practice guidelines and planned interim analyses of captured data are performed annually. Here we summarize the safety and efficacy outcomes as of 17 November 2022.

RESULTS

As of the data cutoff date, 35 patients were enrolled: 28 in the Treated Group and seven in the Untreated Group. Mean (SD) age at MPS VII diagnosis was 4.5 (4.0) years (range, 0.0 to 12.4 years), and mean (SD) age at DMP enrollment was 13.9 (11.1) years (range, 1.5 to 50.2 years). Ten patients (29%) had a history of nonimmune hydrops fetalis. In the 23 patients who initiated treatment prior to DMP enrollment, substantial changes in mean excretion from initial baseline to DMP enrollment were observed for the three urinary glycosaminoglycans (uGAGs): dermatan sulfate (DS), -84%; chondroitin sulfate (CS), -55%; heparan sulfate (HS), -42%. Also in this group, mean reduction from initial baseline to months 6, 12, and 24 were maintained for uGAG DS (-84%, -87%, -89%, respectively), CS (-70%, -71%, -76%, respectively), and HS (+ 3%, -32%, and - 41%, respectively). All adverse events (AEs) were consistent with the known vestronidase alfa safety profile. No patients discontinued vestronidase alfa. One patient died.

CONCLUSIONS

To date, the DMP has collected invaluable MPS VII disease characteristic data. The benefit-risk profile of vestronidase alfa remains unchanged and favorable for its use in the treatment of pediatric and adult patients with MPS VII. Reductions in DS and CS uGAG demonstrate effectiveness of vestronidase alfa to Month 24. Enrollment is ongoing.

An Ontario Health (Cancer Care Ontario) Clinical Practice Guideline: Surveillance Strategies in Patients with Stage I, II, III or Resectable IV Melanoma Who Were Treated with Curative Intent

AIMS

To make recommendations on managing the surveillance of patients with stage I, II, III or resectable IV melanoma who are clinically free of disease following treatment with curative intent.

MATERIALS AND METHODS

This guideline was developed by Ontario Health's (Cancer Care Ontario's) Program in Evidence-Based Care and the Melanoma Disease Site Group (including seven medical oncologists, four surgical oncologists, three dermatologists, one radiation oncologist and one patient representative). The MEDLINE, EMBASE, Cochrane Library, PROSPERO databases and the main relevant guideline websites were searched. Internal and external reviews were conducted, with final approval by the Program in Evidence-Based Care and the Melanoma Disease Site Group. The Grading of Recommendations, Assessment, Development and Evaluation approach was followed, and the Modified Delphi method was used.

RESULTS

Based on the current evidence (eight eligible original study papers and four relevant guidelines) and the clinical opinions of the authors of this guideline, the initial recommendations were made. To reach 75% agreement for each recommendation, the Melanoma Disease Site Group (16 members) voted twice and one recommendation was voted on three times. After a comprehensive internal and external review process (including national and international reviewers), 12 recommendations, three weak recommendations and six qualified statements were ultimately made.

CONCLUSIONS

After a systematic review, a comprehensive internal and external review process and a consensus process, the current guideline has been created. The guideline authors believe that this guideline will help clinicians, patients and policymakers make well-informed healthcare decisions that will guide them in clinical melanoma surveillance and ultimately assist in improving patient outcomes.

Severe CNS involvement in a subset of long-term treated children with infantile-onset Pompe disease

INTRODUCTION

The standard of care for patients with infantile-onset Pompe disease (IOPD) is enzyme replacement therapy (ERT), which does not cross the blood brain barrier. While neuromuscular manifestations of IOPD are well-described, central nervous system (CNS) manifestations of this disorder are far less characterized. Here we describe severe CNS-related neurological manifestations including seizures and encephalopathy in six individuals with IOPD.

METHOD

We identified six children with IOPD who developed CNS manifestations such as seizures and/or encephalopathy. We studied their brain magnetic resonance imaging scans (MRIs) and graded the severity of white matter hyperintensities (WMHI) using the Fazekas scale scoring system as previously published. Longitudinal cognitive measures were available from 4/6 children.

RESULTS

All six IOPD patients (4 males/2 females) had been treated with ERT for 12-15 years. Seizures and/or encephalopathy were noted at a median age at onset of 11.9 years (range 9-15 years). All were noted to have extensive WMHI in the brain MRIs and very high Fazekas scores which preceded the onset of neurological symptoms. Longitudinal IQ scores from four of these children suggested developmental plateauing.

DISCUSSION

Among a subset of IOPD patients on long-term ERT, CNS manifestations including hyperreflexia, encephalopathy and seizures may become prominent, and there is likely an association between these symptoms and significant WMHI on MRI. Further study is needed to identify risk factors for CNS deterioration among children with IOPD and develop interventions to prevent neurological decline.

Association of Risk Factors and Comorbidities With Chronic Pain in the Elderly Population

INTRODUCTION/OBJECTIVE

Chronic pain disorders affect about 20% of adults in the United States, and it disproportionately affects individuals living in the neighborhoods of extreme socioeconomic disadvantage. In many instances, chronic pain has been noted to arise from an aggregation of multiple risk factors and events. Therefore, it is of importance to recognize the modifiable risk factors. The aim of this study was to investigate the comorbid medical conditions and risk factors associated with chronic pain disorders in patients aged 65 years and older.

METHODS

Our team retrospectively reviewed medical records of elderly patients (65 years and older) who were evaluated in our outpatient medicine office between July 1, 2020 and June 30, 2021 for acute problems, management of chronic medical problems, or well visits. We divided our patients into a group who suffered from chronic pain disorder, and another group who did not have chronic pain disorder. The association of variables were compared between those groups.

RESULTS

Of the 2431 patients, 493 (20.3%) had a chronic pain disorder. A higher frequency of females in the group with chronic pain disorder was found compared to the group without a chronic pain disorder (60.6% vs 55.2%; P = .033). The mean ages between the two groups were similar in the group with a chronic pain disorder compared to the group without (76.35 ± 7.5 year vs 76.81 ± 7.59 year; P = .228). There were significant associations of certain comorbidities in the group with a chronic pain disorder compared to the group without a chronic pain disorder, such as depression (21.9% vs 15.2%; P < .001), anxiety (27.0% vs 17.1%; P < .001), chronic obstructive pulmonary disease (8.7% vs 6.1%; P = .036), obstructive sleep apnea (16.8% vs 11.6%; P = .002), gastroesophageal reflux disease (40.8% vs 29.0%; P < .001), osteoarthritis (49.3% vs 26.1%; P < .001), other rheumatologic diseases (24.9% vs 19.4%; P = .006), and peripheral neuropathy (14.4% vs 5.3%; P < .001).

CONCLUSION

Female sex, depression, anxiety, chronic obstructive pulmonary disease, obstructive sleep apnea, gastroesophageal reflux disease, osteoarthritis, other rheumatologic diseases, and peripheral neuropathy were significantly associated with chronic pain disorder in elderly patients, while BMI was not associated with chronic pain disorder.

Survival Outcomes of Extensive Stage Small Cell Lung Cancer Patients Treated with Consolidative Thoracic Radiotherapy at a Tertiary Cancer Center

PURPOSE/OBJECTIVE(S)

Most small cell lung cancer cases present as Stage IV (M1) or extensive stage (ES-SCLC), which are defined as tumor extending outside the hemithorax without a tolerable radiation portal. The CREST trial demonstrated improved local control with a modest overall survival (OS) benefit at the 2-year secondary endpoint of 14% survival with consolidative thoracic radiotherapy (CTRT) compared to 3% without CTRT. Low toxicity rates were also observed. This study reports our institutional ES-SCLC experience for patients treated with CTRT.

MATERIALS/METHODS

A retrospective review was conducted on ES-SCLC patients treated with CTRT at our institution between 2014 and 2019. CTRT was defined as ≥30 Gy of thoracic radiotherapy. OS and tolerability of treatment were assessed in this population. Chemotherapy details were also captured. OS rate was determined using the Kaplan-Meier method and the time from start of CTRT to last date of follow-up or death. CTRT tolerability was determined using incidence and grade of esophagitis and radiation pneumonitis as per CTCAE v5.

RESULTS

We identified 100 ES-SCLC patients treated with any thoracic RT at our institute, of which 45 received thoracic RT for palliative intent or with <30 Gy. The remaining 55 patients received ≥30 Gy CTRT and were included for analysis. The median age was 65.1 years (range 46.6-86.9) and 36 (65%) were male. The median follow-up for this sample was 0.8 (range 0.03-4.2) years. Median chemotherapy cycles were 6 (range 1-6), most receiving ≥4 cycles (87%) and completing chemotherapy prior to CTRT initiation (91%) with a minority concurrently receiving chemotherapy and CTRT (9%). Platinum chemotherapy was the most common (96%) with 2 patients receiving etoposide alone (4%). The most common CTRT regimens were 30 Gy in 10 fractions (80%) followed by 40 Gy in 15 fractions (9%) and 45 Gy in 30 twice-daily fractions (7%). Most patients (67%) were treated with IMRT/VMAT technique, while the remaining (33%) patients were treated with 3DCRT. The median survival time was 1.3 years with 1- and 2-year OS of 57.2% (CI 44.0 - 74.3%) and 26.1% (CI 12.9 - 52.7%), respectively. CTRT was well tolerated with no grade 4+ toxicities. The most common toxicity was esophagitis with 21 patients (39%), of which 15 were G1 (28%) and 6 were G2 (11%). Radiation pneumonitis was present in 5 patients (9.2%) with 1 G1 (2%), 3 G2 (6%), and 1 G3 (2%) cases.

CONCLUSION

Consolidative TRT for ES-SCLC in this institutional series was at least as good as the reported CREST outcome with modest acute toxicities in this cohort. Disease burden at diagnosis, chemotherapy response, patterns of failure, and subsequent therapies will be further investigated.

Clinical Acceptability of Artificial Intelligence-Screened Interstitial Lung Disease (AI-ILD) in Lung Cancer Patients Treated with Radiotherapy

PURPOSE/OBJECTIVE(S)

Patients with interstitial lung disease (ILD) treated with thoracic radiotherapy (RT) are at greater risk of pulmonary toxicity. Automatic universal screening for ILD allows radiation oncologists (ROs) to risk stratify patients and implement necessary modifications to their respiratory monitoring or treatment. Automatic screening however may affect RO workload and so it is imperative to assess the clinical acceptability of this tool.

MATERIALS/METHODS

We have developed a machine learning algorithm to identify patients who are at high risk of having ILD based on RT planning computed tomography (CT) images. A quality improvement (QI) project was initiated to test feasibility and acceptability of the machine learning algorithm. If positive, the results of the machine learning algorithm were made available to ROs via structured electronic reporting. ROs were prompted to review the patient and consider expert radiologist consultation if thought appropriate. All electronic surveys and qualitative comments were summarized to describe clinical acceptability. Expert radiologist established gold standard ILD status of all patients on the study. A formal review of RO feedback was collected for all screen-positive, true-positive cases.

RESULTS

Two hundred forty cases were screened of which 45 were flagged as AI-ILD positive and the responsible RO notified. Of these 45 screen-positive cases, all continued on to RT except for 3 patients with tumor progression. From these 45, 24 surveys were completed, 21 had no prior suspicion of ILD. There were 7 true-positives, of which 1 had a survey response. Based on the survey responses, 88% of cases underwent review by the responsible RO. In 16 cases this automatic notification prompted case consultation with an expert radiologist. Expert review was performed from 10 minutes up to 53 hours after the email prompt to the radiologist, with median response time of 1.5 hours. In the 7 screen-positive, true-positive cases, only 2 were not previously known to the responsible RO. In the two cases where true-positive ILD status was previously unknown, one was a mild case of ILD and the other had previously received thoracic RT at this institution without ILD being identified, in both cases the ROs were grateful that this diagnosis was identified prior to treatment. RO confidence in the machine learning prediction was moderate due to the high proportion of false positives.

CONCLUSION

Based on available survey results, more than 75% of the screen-positive cases were reviewed by the responsible RO and two-thirds of these involved expert radiology input. RO feedback was generally positive and this tool was rated as a net benefit despite the high rate of false-positives and the need for clarification.

Association of Artificial Intelligence-Screened Interstitial Lung Disease with Radiation Pneumonitis and Mortality in Locally Advanced Non-Small Cell Lung Cancer

PURPOSE/OBJECTIVE(S)

Radiation pneumonitis (RP) is a common and dose-limiting toxicity following radiotherapy for non-small cell lung cancer (NSCLC). Patients with interstitial lung disease (ILD) are believed to be at increased risk of developing complications including RP, ILD progression, or death. An automated method to identify patients prior to radiotherapy at high risk of developing toxicities or death may allow clinicians to mitigate risk through informed treatment planning and careful patient monitoring.

MATERIALS/METHODS

All locally advanced NSCLC patients treated with definitive radiation from 2006-2021 with a minimum 1 year of follow-up were assessed. RP and mortality data were prospectively collected and retrospectively reviewed. A convolutional neural network (CNN) was previously developed and validated to identify patients with radiographic ILD using planning computed tomography (CT) images, with an accuracy of 0.82. Planning CT scans for the retrospective cohort were used as input to the CNN, with artificial intelligence-screened ILD (AI-ILD) score as an output. AI-ILD scores above our established threshold were labeled as AI-ILD+. The association between AI-ILD score, AI-ILD+/-, mean lung dose (MLD), and the primary outcome of grade ≥2 (G2+) RP or mortality, as well as the secondary outcomes of G2+ RP and mortality were assessed using Wilcoxon rank sum test, univariate and multivariable logistic regression, and Kaplan-Meier survival analysis.

RESULTS

Of 799 patients reviewed, 745 eligible patients were included in the analysis; grade 0-5 RP was reported in 51.3%, 27.1%, 16.9%, 4.0%, 0.1%, and 0.5% of patients respectively. Overall, 22.9% of patients were AI-ILD+, and therefore at high risk (>20% chance) of having true ILD. On UVA, AI-ILD score, AI-ILD+ and MLD were significantly associated with the primary outcome of G2+ RP or mortality, as well as the secondary outcome of mortality. However, only MLD was significantly associated with the secondary outcome of G2+ RP. On MVA, both AI-ILD+ (OR 1.42, 95% CI 1.02-1.97, p = 0.04) and MLD (OR 1.13, 95% 1.05-1.21, p = 0.008) were significantly associated with G2+ RP or mortality. On Kaplan-Meier analysis, the median toxicity-free survival (TFS) time for AI-ILD+ and AI-ILD- patients were 1.7 and 3.4 years respectively, with a 2-year TFS of 48.3% vs. 59.3% (log-rank test: p = 0.02). There was no significant difference in rates of G2+ RP.

CONCLUSION

The AI-ILD algorithm can detect high risk patients with significantly decreased TFS following definitive treatment for NSCLC. AI-ILD classification was not associated with a significant difference in rates of RP when accounting for MLD. Future work will focus on improving the classification algorithm, expert radiologist validation of this dataset, and exploring reasons for the mortality difference in AI-ILD+ patients.

Adapted method for rapid detection and quantification of pathogen Campylobacter jejuni from environmental water samples

Building on a previously developed workflow for rapid and sensitive pathogen detection by qPCR, this work has established a sample treatment strategy that produces consistent quantification efficiencies (QEs) for Campylobacter jejuni against a complex and highly variable sample matrix from a suburban river. The individual treatments most effective at minimizing the inhibitory effects of the sample matrix were pH buffering with HEPES (50 mM, pH 5.7) and addition of the surfactant Tween 20 (2% v/v). Unexpectedly, sample acidification (pH 4-5) resulting from the use of aged Tween 20 that had undergone partial hydrolysis, appeared to play a key role in enhancing QE. This effect could be replicated by direct pH adjustment with dilute hydrochloric acid and may be linked to the solubilization and removal of inhibitory particles at an acidic pH. While the effectiveness of each individual treatment method varied, a combined treatment of either HEPES buffer + Tween 20, or direct pH adjustment + Tween 20, consistently produced QEs of 60%-70% and up to 100%, respectively, over a sampling period of one year. The consistency and scalability of this workflow make it a suitable alternative to culture-based ISO methods for detecting Campylobacter spp.

SPTSSA variants alter sphingolipid synthesis and cause a complex hereditary spastic paraplegia

Sphingolipids are a diverse family of lipids with critical structural and signalling functions in the mammalian nervous system, where they are abundant in myelin membranes. Serine palmitoyltransferase, the enzyme that catalyses the rate-limiting reaction of sphingolipid synthesis, is composed of multiple subunits including an activating subunit, SPTSSA. Sphingolipids are both essential and cytotoxic and their synthesis must therefore be tightly regulated. Key to the homeostatic regulation are the ORMDL proteins that are bound to serine palmitoyltransferase and mediate feedback inhibition of enzymatic activity when sphingolipid levels become excessive. Exome sequencing identified potential disease-causing variants in SPTSSA in three children presenting with a complex form of hereditary spastic paraplegia. The effect of these variants on the catalytic activity and homeostatic regulation of serine palmitoyltransferase was investigated in human embryonic kidney cells, patient fibroblasts and Drosophila. Our results showed that two different pathogenic variants in SPTSSA caused a hereditary spastic paraplegia resulting in progressive motor disturbance with variable sensorineural hearing loss and language/cognitive dysfunction in three individuals. The variants in SPTSSA impaired the negative regulation of serine palmitoyltransferase by ORMDLs leading to excessive sphingolipid synthesis based on biochemical studies and in vivo studies in Drosophila. These findings support the pathogenicity of the SPTSSA variants and point to excessive sphingolipid synthesis due to impaired homeostatic regulation of serine palmitoyltransferase as responsible for defects in early brain development and function.

Case report on the role of aggressive palliative surgery in lung NUT carcinoma after induction chemoimmunotherapy

INTRODUCTION AND IMPORTANCE

NUT (nuclear protein in testis) carcinoma of the lung is an aggressive, poorly differentiated squamous cell carcinoma that has a poor prognosis. Currently, there are no recommended guidelines with limited literature regarding the management of primary NUT carcinoma of the lung.

CASE PRESENTATION

A 28-year-old male presented with 2 weeks of intractable chest pain and shortness of breath and was found to have Stage IV pleural NUT carcinoma. After 2 cycles of chemoimmunotherapy, the patient's symptoms persisted with worsening functional status. Palliative surgery was performed via an extrapleural pneumonectomy with significant improvement in symptoms and activities of daily living.

CLINICAL DISCUSSION

With no current treatment guidelines, we demonstrate the benefit of surgical resection of advanced pleural NUT carcinoma to improve quality of life. Prognosis is poor with a median survival around 7 months and 3 months with an associated mass. The patient presented pre-operatively with intractable pleuritic chest pain and shortness of breath, limiting activities of daily living that persisted despite chemoimmunotherapy. Our surgical goal was to improve the patient's respiratory status and mitigate pain symptoms via extensive surgical debulking. The patient was able to achieve a higher quality of life and survived longer than the median average, passing away 1 year after diagnosis.

CONCLUSION

The management of NUT carcinoma of the lung remains challenging. The role of surgical resection for palliation in advanced tumors has not been previously described and may provide improved quality of life in carefully selected patients.

Utilization and Outcomes of Observation for Spontaneous Pneumothorax at an Integrated Health System

INTRODUCTION

Though limited, recent evidence supports observation rather than intervention for spontaneous pneumothorax management. We sought to compare the utilization and outcomes between observation and intervention for patients with primary and secondary spontaneous pneumothoraces.

METHODS

A retrospective cohort study of all adults presenting to Kaiser Permanente Northern California emergency rooms with spontaneous pneumothorax from 2016 to 2020 was performed. Those with prior pneumothoraces, tension physiology, bilateral pneumothoraces, effusions, and prior thoracic procedures or surgery on the affected side were excluded. Groups included observation versus intervention. Baseline clinicodemographic variables and outcomes were compared. Treatment was considered successful if further interventions were not required for pneumothorax resolution. Wilcoxon rank-sum tests, chi-square tests, Fischer exact tests, and multivariable logistic regression models were performed.

RESULTS

Of the 386 patients with primary spontaneous pneumothorax, age, race/ethnicity, body mass index, smoking status, and the Charlson comorbidity index were not different between treatment groups. Of 86 patients with secondary spontaneous pneumothorax, age, gender, and smoking status were not different between treatment groups. Among patients with primary pneumothoraces, 83 underwent observation while 303 underwent intervention. The success rate was 92.8% for observation and 60.4% for intervention (P < 0.0001). Among patients with secondary pneumothoraces, 15 underwent observation while 71 underwent intervention, with a successful rate of 73.3% for observation and 32.4% for intervention (P = 0.003).

CONCLUSIONS

Given the high success rates for observation of both small and moderate primary and secondary pneumothoraces, observation should be considered for clinically stable patients. Observation may be the superior choice for decreasing morbidity and healthcare costs.

Using memes to promote student engagement and classroom community during remote learning

As colleges moved to online teaching during the COVID-19 pandemic, many instructors found it difficult to maintain student engagement and classroom community in the virtual environment. We developed a semester-long activity for a molecular biology research methodology course where students created, and shared original memes related to course content with peers through group chat. Surveys and semi-structured interviews revealed that the exercise was effective in promoting student engagement, a sense of community, and relieving stress.

Bi-allelic ATG4D variants are associated with a neurodevelopmental disorder characterized by speech and motor impairment

Autophagy regulates the degradation of damaged organelles and protein aggregates, and is critical for neuronal development, homeostasis, and maintenance, yet few neurodevelopmental disorders have been associated with pathogenic variants in genes encoding autophagy-related proteins. We report three individuals from two unrelated families with a neurodevelopmental disorder characterized by speech and motor impairment, and similar facial characteristics. Rare, conserved, bi-allelic variants were identified in ATG4D, encoding one of four ATG4 cysteine proteases important for autophagosome biogenesis, a hallmark of autophagy. Autophagosome biogenesis and induction of autophagy were intact in cells from affected individuals. However, studies evaluating the predominant substrate of ATG4D, GABARAPL1, demonstrated that three of the four ATG4D patient variants functionally impair ATG4D activity. GABARAPL1 is cleaved or "primed" by ATG4D and an in vitro GABARAPL1 priming assay revealed decreased priming activity for three of the four ATG4D variants. Furthermore, a rescue experiment performed in an ATG4 tetra knockout cell line, in which all four ATG4 isoforms were knocked out by gene editing, showed decreased GABARAPL1 priming activity for the two ATG4D missense variants located in the cysteine protease domain required for priming, suggesting that these variants impair the function of ATG4D. The clinical, bioinformatic, and functional data suggest that bi-allelic loss-of-function variants in ATG4D contribute to the pathogenesis of this syndromic neurodevelopmental disorder.

Continuing a search for a diagnosis: the impact of adolescence and family dynamics

The "diagnostic odyssey" describes the process those with undiagnosed conditions undergo to identify a diagnosis. Throughout this process, families of children with undiagnosed conditions have multiple opportunities to decide whether to continue or stop their search for a diagnosis and accept the lack of a diagnostic label. Previous studies identified factors motivating a family to begin searching, but there is limited information about the decision-making process in a prolonged search and how the affected child impacts a family's decision. This study aimed to understand how families of children with undiagnosed diseases decide whether to continue to pursue a diagnosis after standard clinical testing has failed. Parents who applied to the Undiagnosed Disease Network (UDN) at the National Institutes of Health (NIH) were recruited to participate in semi-structured interviews. The 2015 Supportive Care Needs model by Pelenstov, which defines critical needs in families with rare/undiagnosed diseases, provided a framework for interview guide development and transcript analysis (Pelentsov et al in Disabil Health J 8(4):475-491, 2015. https://doi.org/10.1016/J.DHJO.2015.03.009 ). A deductive, iterative coding approach was used to identify common unifying themes. Fourteen parents from 13 families were interviewed. The average child's age was 11 years (range 3-18) and an average 63% of their life had been spent searching for a diagnosis. Our analysis found that alignment or misalignment of parent and child needs impact the trajectory of the diagnostic search. When needs and desires align, reevaluation of a decision to pursue a diagnosis is limited. However, when there is conflict between parent and child desires, there is reevaluation, and often a pause, in the search. This tension is exacerbated when children are adolescents and attempting to balance their dependence on parents for medical care with a natural desire for independence. Our results provide novel insights into the roles of adolescents in the diagnostic odyssey. The tension between desired and realistic developmental outcomes for parents and adolescents impacts if, and how, the search for a diagnosis progresses.

Institutionalizing Community-engaged Translational Science in an Academic Institution: A Community Stakeholder-Driven Process

BACKGROUND

Although studies have described the power imbalance in academic-community partnerships, little has been published describing how community-based participatory research-informed practitioners can change academic institutions to promote more effective community-engaged research.

OBJECTIVES

This paper describes a university-funded community-based participatory project in which academic researchers and their community partners worked together to articulate, develop and advocate for institutionalizing best practices for equitable partnerships throughout the university.

METHODS

Findings derive from a collaborative ethnographic process evaluation.

RESULTS

The study describes the integral steps proposed to promote equitable community-university research collaboration, the process by which these principles and best practice recommendations were developed, and the institutional change outcomes of this process.

CONCLUSIONS

When universities make even small investments toward promoting and nurturing community-engaged research, the quality of the science can be enhanced to advance health equity and community-university relationships can improve, particularly if based on trust, mutual respect, and openness to accomplish a shared vision.

Comorbidities and Risk Factors Associated With Insomnia in the Elderly Population

INTRODUCTION/OBJECTIVES

Sleep disorders affect around 50 to 70 million Americans, with chronic insomnia being the most common, especially in the elderly population. With an 11-fold increase in the US office visits due to insomnia, from 0.8 to 9.4 million, between 1993 and 2015, it is imperative to identify the modifiable risk factors. The aim of our study was to examine the association of risk factors and comorbid medical conditions with insomnia in patients 65 years, and older.

METHODS

We performed a retrospective electronic medical record review of the patients aged 65 years and older, who visited our suburban internal medicine office between July 1, 2020 and June 30, 2021. Patients were divided into insomnia group, and the group without insomnia. The associated variables were compared.

RESULTS

Among 2431 patients, 247 patients (10.2%) had insomnia. Mean ages of the patients in the insomnia group and the group without insomnia were comparable (77 ± 8.1 year vs 76 ± 7.5 year; P = .211). There was a significantly greater frequency of women in the insomnia group compared to the group without insomnia (63.2% vs 55.5%; P = .022). In the insomnia group, there were significantly higher frequencies of association of certain comorbidities compared to the group without insomnia, such as dementia (6.5% vs 3.4%; P = .015), depression (30.8% vs 14.9%; P < 0.001), anxiety disorder (34.4% vs 17.4%; P < .001), atrial fibrillation (19.4% vs 13.4%; P = .01), and chronic pain disorders (32.8% vs 18.9%; P < .001). Logistic regression analysis showed significantly greater odds of insomnia in patients who had depression (OR = 1.860, 95% CI 1.342-2.576; P < .001), anxiety (OR = 1.845, 95% CI 1.342-2.537; P < .001), and chronic pain disorders (OR = 1.901, 95% CI 1.417-2.549; P < .001).

CONCLUSIONS

Female sex, dementia, depression, anxiety, chronic pain disorders, and atrial fibrillation are associated with insomnia in the elderly patients. Presence of depression, anxiety, and chronic pain disorders are associated with greater odds of having insomnia in the elderly patients.

A rapid and non-invasive proteomic analysis using DBS and buccal swab for multiplexed second-tier screening of Pompe disease and Mucopolysaccharidosis type I

PURPOSE

Current newborn screening programs for Pompe disease (PD) and mucopolysaccharidosis type I (MPS I) suffer from a high false positive rate and long turnaround time for clinical follow up. This study aimed to develop a novel proteomics-based assay for rapid and accurate second-tier screening of PD and MPS I. A fast turnaround assay would enable the identification of severe cases who need immediate clinical follow up and treatment.

METHODS

We developed an immunocapture coupled with mass spectrometry-based proteomics (Immuno-SRM) assay to quantify GAA and IDUA proteins in dried blood spots (DBS) and buccal swabs. Sensitivity, linearity, reproducibility, and protein concentration range in healthy control samples were determined. Clinical performance was evaluated in known PD and MPS I patients as well as pseudodeficiency and carrier cases.

RESULTS

Using three 3.2 mm punches (~13.1 μL of blood) of DBS, the assay showed reproducible and sensitive quantification of GAA and IDUA. Both proteins can also be quantified in buccal swabs with high reproducibility and sensitivity. Infantile onset Pompe disease (IOPD) and severe MPS I cases are readily identifiable due to the absence of GAA and IDUA, respectively. In addition, late onset Pompe disease (LOPD) and attenuated MPS I patients showed much reduced levels of the target protein. By contrast, pseudodeficiency and carrier cases exhibited significant higher target protein levels compared to true patients.

CONCLUSION

Direct quantification of endogenous GAA and IDUA peptides in DBS by Immuno-SRM can be used for second-tier screening to rapidly identify severe PD and MPS I patients with a turnaround time of <1 week. Such patients could benefit from immediate clinical follow up and possibly earlier treatment.

Deeply Virtual Compton Scattering Cross Section at High Bjorken x_{B}

We report high-precision measurements of the deeply virtual Compton scattering (DVCS) cross section at high values of the Bjorken variable x_{B}. DVCS is sensitive to the generalized parton distributions of the nucleon, which provide a three-dimensional description of its internal constituents. Using the exact analytic expression of the DVCS cross section for all possible polarization states of the initial and final electron and nucleon, and final state photon, we present the first experimental extraction of all four helicity-conserving Compton form factors (CFFs) of the nucleon as a function of x_{B}, while systematically including helicity flip amplitudes. In particular, the high accuracy of the present data demonstrates sensitivity to some very poorly known CFFs.

Menopausal hormone therapy: what are the problems in the perception of Chinese physicians?

OBJECTIVE

This study aimed to investigate Chinese physicians' perception and attitudes toward menopausal hormone therapy (MHT).

METHODS

This nationwide online survey was conducted in China. Physicians registered in the WeChat groups of the Gynecological Endocrinology Committee of China's Maternal and Child Health Care Association received a message invitation to complete this anonymous online survey from April 2020 to July 2020. Physicians' knowledge of and attitudes toward MHT were surveyed.

RESULTS

In total, 4672 questionnaires were submitted; only completed questionnaires could be submitted. The message was sent to 6021 doctors, so the response rate was 77.6%. Overall, 77.9-92.9% of physicians knew the common indications and contraindications to MHT. Additionally, 90.6%, 85.4%, 80.7% and 37.5% of physicians thought that MHT would increase the risk of venous thrombosis, breast cancer, endometrial cancer and weight gain, respectively. In total, 58.1% of the physicians mistakenly believed that a sex hormone test was one of the necessary examinations to reassess MHT prescription during follow-up visits. We found that 68.5% of physicians would consider using MHT themselves or recommend MHT to their partners in the future, and 11.4% were currently using MHT.

CONCLUSIONS

Most Chinese physicians have basic knowledge of MHT. Their misunderstandings about MHT mainly centered on the risks of endometrial cancer, weight gain and the necessary examinations during follow-up visits. These misunderstandings need to be clarified in future professional training programs.

Form Factors and Two-Photon Exchange in High-Energy Elastic Electron-Proton Scattering

We present new precision measurements of the elastic electron-proton scattering cross section for momentum transfer (Q^{2}) up to 15.75  (GeV/c)^{2}. Combined with existing data, these provide an improved extraction of the proton magnetic form factor at high Q^{2} and double the range over which a longitudinal or transverse separation of the cross section can be performed. The difference between our results and polarization data agrees with that observed at lower Q^{2} and attributed to hard two-photon exchange (TPE) effects, extending to 8  (GeV/c)^{2} the range of Q^{2} for which a discrepancy is established at >95% confidence. We use the discrepancy to quantify the size of TPE contributions needed to explain the cross section at high Q^{2}.

Universal Enzyme-Based Field Workflow for Rapid and Sensitive Quantification of Water Pathogens

A universal filtration and enzyme-based workflow has been established to allow for the rapid and sensitive quantification of leading pathogens Cryptosporidium parvum, Giardia gamblia, Campylobacter jejuni, and Escherichia coli from tap water samples with volumes up to 100 mL, and the potential to scale up to larger volumes. qPCR limits of quantification as low as four oocysts for Cryptosporidium, twelve cysts for Giardia, two cells for C. jejuni, and nineteen cells for E. coli per reaction were achieved. A polycarbonate filter-based sampling method coupled with the prepGEM enzyme-based DNA extraction system created a single-step transfer workflow that required as little as 20 min of incubation time and a 100 µL reaction mix. The quantification via qPCR was performed directly on the prepGEM extract, bypassing time-consuming, labour-intensive conventional culture-based methods. The tap water samples were shown to contain insoluble particles that inhibited detection by reducing the quantification efficiency of a representative pathogen (C. jejuni) to 30-60%. This sample inhibition was effectively removed by an on-filter treatment of 20% (v/v) phosphoric acid wash. Overall, the established workflow was able to achieve quantification efficiencies of 92% and higher for all four leading water pathogens, forming the basis of a rapid, portable, and low-cost solution to water monitoring.

APEX-mediated Proximity Labeling of Proteins in Cells Targeted by Extracellular Vesicles

Extracellular vesicles (EVs) are thought to mediate intercellular communication through the delivery of cargo proteins and RNA to target cells. The uptake of EVs is often followed visually using lipophilic-dyes or fluorescently-tagged proteins to label membrane constituents that are then internalized into recipient cells ( Christianson et al., 2013 ; De Jong et al., 2019 ). However, these methods do not probe the exposure of EV cargo to intracellular compartments, such as the cytoplasm and nucleus, where protein or RNA molecules could elicit functional changes in recipient cells. In this protocol, we employ an EV cargo protein-APEX fusion to detect proximity interactions with recipient cell cytoplasmic/nuclear targets. This approach results in the biotinylation of proteins in close contact with the reporter fusion and thus permits profiling of biotinylated proteins affinity purified on immobilized streptavidin beads. Graphic abstract: Schematic showing three steps of APEX-mediated proximity labeling of proteins in cells targeted by EVs.

Dapagliflozin decreases atherosclerotic plaque instability via regulating macrophage pyroptosis

Background

Vulnerable plaques are characterized by infiltration of inflammatory cells, playing a key role in the progression of acute coronary events. It's important to clarify the inflammatory mechanism of unstable plaque formation. Several clinical trials have demonstrated that dapagliflozin could reduce major adverse cardiac events in whether diabetic or non-diabetic patients. However, the underlying cardioprotective mechanism of dapagliflozin remains unclear. This study was aimed to investigate the role of dapagliflozin in regulating macrophage pyroptosis and vulnerable plaque formation.

Methods

20 ApoE−/− mice (control) were fed with high fat diet while another 20 ApoE−/− mice were challenged with high fat diet plus dapagliflozin for 12 weeks. The extent and instability of atherosclerotic plaque was determined by oil-red staining, HE staining, immunofluorescence staining and electron microscopy. Changes in subsets of immune cells were evaluated by flow cytometry. Plasma cytokines were assessed by ELISA. Microarray analysis was applied to detect gene expressions while Western blot and real-time PCR was used to assess gene expression levels.

Results

Morphology studies revealed that dapagliflozin could inhibit plaque formation and reduce instability in ApoE−/− mice. FACS data showed that dapagliflozin could decrease CD11b+Ly6Chigh M1 macrophages differentiation and inhibit foam cells formation in ApoE−/− mice. Microarray analysis and in vitro studies exhibited that dapagliflozin could induce the down regulation of NLRP3, caspase-1, IL-1β, IL-18 and MMP-7/10/12/14 to retard macrophage pyroptosis and foam cell formation.

Conclusions

We have characterized a novel role for dapagliflozin in modulating atherosclerotic lesion development and progression. We envision that this study may provide several potential therapeutic targets for treatment of acute coronary syndromes.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Shanghai Sailing Program

Deep Exclusive Electroproduction of π^{0} at High Q^{2} in the Quark Valence Regime

We report measurements of the exclusive neutral pion electroproduction cross section off protons at large values of x_{B} (0.36, 0.48, and 0.60) and Q^{2} (3.1 to 8.4  GeV^{2}) obtained from Jefferson Lab Hall A experiment E12-06-014. The corresponding structure functions dσ_{T}/dt+εdσ_{L}/dt, dσ_{TT}/dt, dσ_{LT}/dt, and dσ_{LT^{'}}/dt are extracted as a function of the proton momentum transfer t-t_{min}. The results suggest the amplitude for transversely polarized virtual photons continues to dominate the cross section throughout this kinematic range. The data are well described by calculations based on transversity generalized parton distributions coupled to a helicity flip distribution amplitude of the pion, thus providing a unique way to probe the structure of the nucleon.

Biomonitoring of volatile organic compounds (VOCs) among hairdressers in salons primarily serving women of color: A pilot study

Hairdressers are exposed to volatile organic compounds (VOCs), many of which have been linked to acute and chronic health effects. Those hairdressers serving an ethnic clientele may potentially experience disproportionate exposures from frequent use of products containing VOCs or different VOC concentrations contained in products which are marketed to the specific needs of their clientele. However, no biomonitoring studies have investigated occupational exposures in this population. In the present pilot study, we sought to characterize concentrations and exposure determinants for 28 VOC biomarkers in post-shift urine samples among 23 hairdressers primarily serving an ethnic clientele. VOC biomarker concentrations among hairdressers of color were compared to concentrations among a comparison group of 17 office workers and a representative sample of women participating in the U.S. National Health and Nutrition Examination Survey. VOC biomarkers were detected in all hairdressers with higher concentrations observed among hairdressers serving a predominantly Black versus Latino clientele, and among hairdressers overall versus office workers and women in the U.S. general population. Median biomarker concentrations for acrolein,1,3-butadiene, and xylene in hairdressers were more than twice as high as those observed among office workers. Median concentrations for 1-bromopropane, acrolein and 1,3-butadiene were more than four times higher among all hairdressers compared to those reported among women in the U.S. general population. Select salon services (e.g., sister locs, flat ironing, permanent hair coloring, permanent waves or texturizing, Brazilian blowout or keratin treatment, etc.) were also associated with higher VOC biomarker concentrations among hairdressers. This pilot study represents the first biomonitoring analysis to characterize VOC exposures among women hairdressers of color and to provide evidence that this occupational population may experience elevated VOC exposures compared to women in the U.S. general population. Results from our study represent an important first step in elucidating occupational VOC exposures in this understudied occupational group. Larger studies among a racially and ethnically diverse cohort of hairdressers are warranted to confirm our findings and inform future exposure interventions in this understudied occupational population.

Targeted long-read sequencing identifies missing disease-causing variation

Despite widespread clinical genetic testing, many individuals with suspected genetic conditions lack a precise diagnosis, limiting their opportunity to take advantage of state-of-the-art treatments. In some cases, testing reveals difficult-to-evaluate structural differences, candidate variants that do not fully explain the phenotype, single pathogenic variants in recessive disorders, or no variants in genes of interest. Thus, there is a need for better tools to identify a precise genetic diagnosis in individuals when conventional testing approaches have been exhausted. We performed targeted long-read sequencing (T-LRS) using adaptive sampling on the Oxford Nanopore platform on 40 individuals, 10 of whom lacked a complete molecular diagnosis. We computationally targeted up to 151 Mbp of sequence per individual and searched for pathogenic substitutions, structural variants, and methylation differences using a single data source. We detected all genomic aberrations-including single-nucleotide variants, copy number changes, repeat expansions, and methylation differences-identified by prior clinical testing. In 8/8 individuals with complex structural rearrangements, T-LRS enabled more precise resolution of the mutation, leading to changes in clinical management in one case. In ten individuals with suspected Mendelian conditions lacking a precise genetic diagnosis, T-LRS identified pathogenic or likely pathogenic variants in six and variants of uncertain significance in two others. T-LRS accurately identifies pathogenic structural variants, resolves complex rearrangements, and identifies Mendelian variants not detected by other technologies. T-LRS represents an efficient and cost-effective strategy to evaluate high-priority genes and regions or complex clinical testing results.

13C Metabolic Flux Analysis Indicates Endothelial Cells Attenuate Metabolic Perturbations by Modulating TCA Activity

Disrupted endothelial metabolism is linked to endothelial dysfunction and cardiovascular disease. Targeted metabolic inhibitors are potential therapeutics; however, their systemic impact on endothelial metabolism remains unknown. In this study, we combined stable isotope labeling with ¹³C metabolic flux analysis (¹³C MFA) to determine how targeted inhibition of the polyol (fidarestat), pentose phosphate (DHEA), and hexosamine biosynthetic (azaserine) pathways alters endothelial metabolism. Glucose, glutamine, and a four-carbon input to the malate shuttle were important carbon sources in the baseline human umbilical vein endothelial cell (HUVEC) ¹³C MFA model. We observed two to three times higher glutamine uptake in fidarestat and azaserine-treated cells. Fidarestat and DHEA-treated HUVEC showed decreased ¹³C enrichment of glycolytic and TCA metabolites and amino acids. Azaserine-treated HUVEC primarily showed ¹³C enrichment differences in UDP-GlcNAc. ¹³C MFA estimated decreased pentose phosphate pathway flux and increased TCA activity with reversed malate shuttle direction in fidarestat and DHEA-treated HUVEC. In contrast, ¹³C MFA estimated increases in both pentose phosphate pathway and TCA activity in azaserine-treated cells. These data show the potential importance of endothelial malate shuttle activity and suggest that inhibiting glycolytic side branch pathways can change the metabolic network, highlighting the need to study systemic metabolic therapeutic effects.

Ruling out Color Transparency in Quasielastic ^{12}C(e,e^{'}p) up to Q^{2} of 14.2 (GeV/c)^{2}

Quasielastic ^{12}C(e,e^{'}p) scattering was measured at spacelike 4-momentum transfer squared Q^{2}=8, 9.4, 11.4, and 14.2  (GeV/c)^{2}, the highest ever achieved to date. Nuclear transparency for this reaction was extracted by comparing the measured yield to that expected from a plane-wave impulse approximation calculation without any final state interactions. The measured transparency was consistent with no Q^{2} dependence, up to proton momenta of 8.5  GeV/c, ruling out the quantum chromodynamics effect of color transparency at the measured Q^{2} scales in exclusive (e,e^{'}p) reactions. These results impose strict constraints on models of color transparency for protons.

Co-occurrence of Metachromatic Leukodystrophy in Phelan-McDermid Syndrome

Phelan-McDermid syndrome or 22q13.3 deletion syndrome is a rare neurodevelopmental disorder characterized by neonatal hypotonia, severe speech delay, moderate to profound intellectual disability, and minor dysmorphic features. Regression of developmental milestones is often recognized as characteristic of this syndrome. We report a 6-year-old patient with Phelan-McDermid syndrome who presented with rapid neurologic deterioration secondary to metachromatic leukodystrophy due to a mutation of the arylsulfatase A gene (ARSA) on the other allele of 22q13.3. Metachromatic leukodystrophy was diagnosed later after clinical deterioration. Currently, there are no guidelines for screening Phelan-McDermid syndrome patients for metachromatic leukodystrophy. We propose screening for urine sulfatides at the time of Phelan-McDermid syndrome diagnosis to identify patients with pre-symptomatic or early symptomatic metachromatic leukodystrophy as it is important to facilitate discussion of treatment options and prognosis and provide medical surveillance for associated complications.

Probing the Deuteron at Very Large Internal Momenta

We measure ^{2}H(e,e^{'}p)n cross sections at 4-momentum transfers of Q^{2}=4.5±0.5  (GeV/c)^{2} over a range of neutron recoil momenta p_{r}, reaching up to ∼1.0  GeV/c. We obtain data at fixed neutron recoil angles θ_{nq}=35°, 45°, and 75° with respect to the 3-momentum transfer q[over →]. The new data agree well with previous data, which reached p_{r}∼500  MeV/c. At θ_{nq}=35° and 45°, final state interactions, meson exchange currents, and isobar currents are suppressed and the plane wave impulse approximation provides the dominant cross section contribution. We compare the new data to recent theoretical calculations, where we observe a significant discrepancy for recoil momenta p_{r}>700  MeV/c.

Tutorial: Triheptanoin and Nutrition Management for Treatment of Long-Chain Fatty Acid Oxidation Disorders

BACKGROUND

Patients with severe long-chain fatty acid oxidation disorders (LC-FAODs) experience serious morbidity and mortality despite traditional dietary management including medium-chain triglyceride (MCT)-supplemented, low-fat diets. Triheptanoin is a triglyceride oil that is broken down to acetyl-coenzyme A (CoA) and propionyl-CoA, which replenishes deficient tricarboxylic acid cycle intermediates. We report the complex medical and nutrition management of triheptanoin therapy initiated emergently for 3 patients with LC-FAOD.

METHODS

Triheptanoin (Ultragenyx Pharmaceutical, Inc, Novato, CA, USA) was administered to 3 patients with LC-FAOD on a compassionate-use basis. Triheptanoin was mixed with non-MCT-containing low-fat formula. Patients were closely followed with regular cardiac and laboratory monitoring.

RESULTS

Cardiac ejection fraction normalized after triheptanoin initiation. Patients experienced fewer hospitalizations related to metabolic crises while on triheptanoin. Patient 1 has tolerated oral administration without difficulty since birth. Patients 2 and 3 experienced increased diarrhea. Recurrent breakdown of the silicone gastrostomy tube occurred in patient 3, whereas the polyurethane nasogastric tube for patient 2 remained intact. Patient 3 experiences recurrent episodes of elevated creatine kinase levels and muscle weakness associated with illness. Patient 3 had chronically elevated C10-acylcarnitines while on MCT supplementation, which normalized after initiation of triheptanoin and discontinuation of MCT oil.

CONCLUSIONS

Triheptanoin can ameliorate acute cardiomyopathy and increase survival in patients with severe LC-FAOD. Substituting triheptanoin for traditional MCT-based treatment improves clinical outcomes. MCT oil might be less effective in carnitine-acylcarnitine translocase deficiency patients compared with other FAODs and needs further investigation.

SIRT5 deficiency enhances the proliferative and therapeutic capacities of adipose-derived mesenchymal stem cell via metabolic switching

Background

Mesenchymal stem/stromal cells (MSCs) render potential therapies for multiple ischemic diseases. However, in vitro expansion of MSCs before application leads to a metabolic switch from glycolysis to oxidative phosphorylation, drastically impairing their proliferative and therapeutic capacities.

Purpose

Here we aim to identify the role of SIRT5, a master metabolic regulator, in culture expansion of adipose-derived MSCs (ADMSCs).

Methods

SIRT5 deficiencyADMSCs was obtained from Sirt5−/− mice and their metabolic pattern and proliferation capacity were tested during in vitro expansion. Hind limb ischemic model was established to evaluated the therapeutic function of Sirt5−/−ADMSCs.

Results

SIRT5 protein level was upregulated in ADMCSs undergoing culture expansion. Sirt5−/−ADMSCs during in vitro expansion exhibited higher proliferation rate, delayed senescence and enhanced antioxidant capacity. SIRT5 deficiency induced hypersuccinylation of metabolic-related proteins, leading to attenuated mitochondrial respiration with elevated glycolysis and pentose phosphate pathway. Furthermore, lowering succinylation level by glycine treatment reversed the altered metabolism and enhanced proliferation of Sirt5−/−ADMSCs. In mice hind limb ischemic model, SIRT5−/−ADMSCs treatment achieved better blood flow recovery and angiogenesis compared to WT ADMSCs treatment.

Conclusion

We reveal that SIRT5 is a key regulator of ADMSCs undergoing in vitro culture. Ablation of SIRT5 leads to reversed metabolic pattern, enhanced proliferative capacity and improved therapeutic outcomes. Our data provide a potential target for enhancing MSC functional properties during bio-manufacturing in future MSC therapy. Such work may not only benefit MSC cell therapy, but could extent to a wide variety of other stem cells that share similar metabolic pattern.

Graphic Abstract

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Major Research Plan of the National Natural Science Foundation of China. National Science Fund for Distinguished Young Scholars.

The Impact of Rapid Exome Sequencing on Medical Management of Critically Ill Children

OBJECTIVES

To evaluate the clinical usefulness of rapid exome sequencing (rES) in critically ill children with likely genetic disease using a standardized process at a single institution. To provide evidence that rES with should become standard of care for this patient population.

STUDY DESIGN

We implemented a process to provide clinical-grade rES to eligible children at a single institution. Eligibility included (a) recommendation of rES by a consulting geneticist, (b) monogenic disorder suspected, (c) rapid diagnosis predicted to affect inpatient management, (d) pretest counseling provided by an appropriate provider, and (e) unanimous approval by a committee of 4 geneticists. Trio exome sequencing was sent to a reference laboratory that provided verbal report within 7-10 days. Clinical outcomes related to rES were prospectively collected. Input from geneticists, genetic counselors, pathologists, neonatologists, and critical care pediatricians was collected to identify changes in management related to rES.

RESULTS

There were 54 patients who were eligible for rES over a 34-month study period. Of these patients, 46 underwent rES, 24 of whom (52%) had at least 1 change in management related to rES. In 20 patients (43%), a molecular diagnosis was achieved, demonstrating that nondiagnostic exomes could change medical management in some cases. Overall, 84% of patients were under 1 month old at rES request and the mean turnaround time was 9 days.

CONCLUSIONS

rES testing has a significant impact on the management of critically ill children with suspected monogenic disease and should be considered standard of care for tertiary institutions who can provide coordinated genetics expertise.

Phosphatidylinositol 4-kinase IIIβ mediates contraction-induced GLUT4 translocation and shows its anti-diabetic action in cardiomyocytes

In the diabetic heart, long-chain fatty acid (LCFA) uptake is increased at the expense of glucose uptake. This metabolic shift ultimately leads to insulin resistance and a reduced cardiac function. Therefore, signaling kinases that mediate glucose uptake without simultaneously stimulating LCFA uptake could be considered attractive anti-diabetic targets. Phosphatidylinositol-4-kinase-IIIβ (PI4KIIIβ) is a lipid kinase downstream of protein kinase D1 (PKD1) that mediates Golgi-to-plasma membrane vesicular trafficking in HeLa-cells. In this study, we evaluated whether PI4KIIIβ is involved in myocellular GLUT4 translocation induced by contraction or oligomycin (an F₁F₀-ATP synthase inhibitor that activates contraction-like signaling). Pharmacological targeting, with compound MI14, or genetic silencing of PI4KIIIβ inhibited contraction/oligomycin-stimulated GLUT4 translocation and glucose uptake in cardiomyocytes but did not affect CD36 translocation nor LCFA uptake. Addition of the PI4KIIIβ enzymatic reaction product phosphatidylinositol-4-phosphate restored oligomycin-stimulated glucose uptake in the presence of MI14. PI4KIIIβ activation by PKD1 involves Ser294 phosphorylation and altered its localization with unchanged enzymatic activity. Adenoviral PI4KIIIβ overexpression stimulated glucose uptake, but did not activate hypertrophic signaling, indicating that unlike PKD1, PI4KIIIβ is selectively involved in GLUT4 translocation. Finally, PI4KIIIβ overexpression prevented insulin resistance and contractile dysfunction in lipid-overexposed cardiomyocytes. Together, our studies identify PI4KIIIβ as positive and selective regulator of GLUT4 translocation in response to contraction-like signaling, suggesting PI4KIIIβ as a promising target to rescue defective glucose uptake in diabetics.

Activating variants in PDGFRB result in a spectrum of disorders responsive to imatinib monotherapy

More than 50 individuals with activating variants in the receptor tyrosine kinase PDGFRB have been reported, separated based on clinical features into solitary myofibromas, infantile myofibromatosis, Penttinen syndrome with premature aging and osteopenia, Kosaki overgrowth syndrome, and fusiform aneurysms. Despite their descriptions as distinct clinical entities, review of previous reports demonstrates substantial phenotypic overlap. We present a case series of 12 patients with activating variants in PDGFRB and review of the literature. We describe five patients with PDGFRB activating variants whose clinical features overlap multiple diagnostic entities. Seven additional patients from a large family had variable expressivity and late-onset disease, including adult onset features and two individuals with sudden death. Three patients were treated with imatinib and had robust and rapid response, including the first two reported infants with multicentric myofibromas treated with imatinib monotherapy and one with a recurrent p.Val665Ala (Penttinen) variant. Along with previously reported individuals, our cohort suggests infants and young children had few abnormal features, while older individuals had multiple additional features, several of which appeared to worsen with advancing age. Our analysis supports a diagnostic entity of a spectrum disorders due to activating variants in PDGFRB. Differences in reported phenotypes can be dramatic and correlate with advancing age, genotype, and to mosaicism in some individuals.

Abstract C122: Efficacy of in-language mailers on receipt of colorectal cancer screening among Chinese Americans: A randomized controlled trial

Background: Colorectal cancer (CRC) is the second most common cancer among Chinese Americans, the largest group of Asian Americans. Asian Americans and Chinese Americans are less likely than non-Hispanic whites to be screened for CRC. There are few randomized controlled trials (RCT) of interventions to increase CRC screening among Chinese Americans. Methods: A community-academic research team consisting of academic researchers and community organization leaders collaborated with 3 health care systems to develop an intervention called Small Media Interventions for Limited English Speakers (SMILES) project. The SMILES intervention consisted of a mailed letter and brochure about CRC screening in English and Chinese sent twice over the course of 1 month. The mailer also included a link to a website which provided additional in-language written and video information about CRC screening. Chinese American patients aged 50 to 75 who were due for CRC screening in 3 healthcare systems (an academic medical center, a community hospital network, and a federally-qualified health center) in San Francisco were eligible for the RCT. Eligible patients were randomized to the intervention arm versus a usual care comparison arm. Intervention participants were also given the opportunity to return a postcard indicating that they had read the mailer. CRC screening status were assessed using electronic health record 9 months after the first mailing. Results: There were 1,707 enrolled patients with 929 in the intervention arm and 778 in the comparison arm. The average age was 59.6 years (SD 6.0), with 45.6% female, 12.4% English speakers, 63.2% Cantonese speakers, and 10.8% Mandarin speakers. At 9-month post-intervention initiation, the CRC screening rate was 51.9% in the intervention group and 49.5% in the comparison group (p=0.331). For the age group 50 to 60, the screening rate was 47.4% vs. 42.2% (p&lt;0.0001). Multivariable analyses showed that the adjusted odds ratio for the intervention was 1.10 (95% CI: 1.001, 1.21). Other significant factors associated with CRC screening at post-intervention were female sex (OR: 1.37, 95% CI: 1.10, 1.71), age 61-75 (OR: 1.64, 95% CI: 1.57, 1.71, ref. age 50-60), and speaking a Chinese language (OR: 2.42, 95% CI: 1.22, 4.76). In multivariable analyses of the intervention group only, those who had documented engagement with the intervention (returning a postcard or going to the website) had an OR of 2.96 (95% CI: 2.08, 4.21) for CRC screening receipt compared to those who did not. Conclusions: A linguistically appropriate intervention to promote CRC screening among Chinese Americans using a mailed reminder, brochure, and access to a website led to a modest but significant increase in CRC screening compared to usual care among overdue patients in 3 healthcare systems. Mailed in-language materials should be considered as a low-resource intervention to increase CRC screening among Chinese Americans.

Citation Format: Tung T Nguyen, Janice Tsoh, Angela Sun, Kent Woo, Joyce Cheng, Ching Wong, Jian Zhang, Janet Bernet, Stella Pan, Ginny Gildengorin. Efficacy of in-language mailers on receipt of colorectal cancer screening among Chinese Americans: A randomized controlled trial [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C122.

Abstract C017: The Patient COUNTS Study: Patient Cancer OUtreach, Navigation, Technology, and Support

Background: While cancer is the most common cause of death for Asian Americans, many Asian American cancer patients do not receive appropriate treatment nor supportive care. The Patient COUNTS project aims to provide these patients and their caregivers with accessible, culturally-relevant, and linguistically-appropriate navigation resources that utilize technology to reduce disparities and improve quality of life. Methods: With feedback from a Patient Advisory Council and focus groups with cancer patients and caregivers, we developed a patient navigation program for Asian Americans that is currently being pilot tested with patients in Northern California. We are also developing an online patient portal that will enable newly diagnosed colorectal, liver, and lung cancer patients to access appropriate resources and virtual navigation. The portal and navigation will be available in English, Chinese (Cantonese/Mandarin), and Vietnamese, with ability to collect patient-generated health data (e.g., quality of life) and provide tailored resources and navigation. Results: We conducted 4 focus groups and 3 individual interviews with 17 participants in 4 languages (English, Mandarin, Cantonese, or Vietnamese). Key emerging themes include: 1) information unawareness or overload; 2) emotional support; 3) navigation needs; and 4) resource access. Participants with limited English proficiency often did not know to ask or what to ask for regarding their diagnosis or treatment. Some, however, were confused and overwhelmed by the amount of information from many sources. Receiving encouragement to fight cancer was described as crucial in their cancer care; family, friends, doctors, nurses or hospital staff were the primary sources of such emotional support. Although most participants were unfamiliar with navigation, they thought it was very desirable once an explanation was provided. Participants wanted information on symptoms and side effects management. They recommended providing information on sensitive topics (e.g., stigma, dying) only when asked by the patient. Access to information in both their native language and English are important for their comprehensive and communication with others. For participants with end-stage disease, information on palliative care and clinical trials should be provided. These findings guided the development of our patient navigation program to provide information on cancer, treatment, living with cancer, emotional well-being, resources (access to health care, financial, transportation, housing, food and nutrition, child/adult care). Conclusions: Our formative research found significant needs among Asian American cancer patients and suggestions for how to address those needs. Implementing the in-person pilot and online portal will enable us to identify key elements of an effective, sustainable, and disseminable navigation program for Asian American cancer patients and their caregivers.

Citation Format: Salma Shariff-Marco, Debora Oh, Janice Tsoh, Ching Wong, Laura Allen, Janet Chu, Hoan Bui, Corina Liew, Angela Sun, Joyce Cheng, Lei Chun Fung, Scarlett Lin Gomez, Tung Nguyen. The Patient COUNTS Study: Patient Cancer OUtreach, Navigation, Technology, and Support [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C017.