Citations

ABSTRACT Understanding clinical trajectories of sepsis patients is crucial for prognostication, resource planning, and to inform digital twin models of critical illness. This study aims to identify common clinical trajectories based on dynamic assessment of cardiorespiratory support using a validated electronic health record data that covers retrospective cohort of 19,177 patients with sepsis admitted to intensive care units (ICUs) of Mayo Clinic Hospitals over 8-year period. Patient trajectories were modeled from ICU admission up to 14 days using an unsupervised machine learning two-stage clustering method based on cardiorespiratory support in ICU and hospital discharge status. Of 19,177 patients, 42% were female with a median age of 65 (interquartile range [IQR], 55–76) years, The Acute Physiology, Age, and Chronic Health Evaluation III score of 70 (IQR, 56–87), hospital length of stay (LOS) of 7 (IQR, 4–12) days, and ICU LOS of 2 (IQR, 1–4) days. Four distinct trajectories were identified: fast recovery (27% with a mortality rate of 3.5% and median hospital LOS of 3 (IQR, 2–15) days), slow recovery (62% with a mortality rate of 3.6% and hospital LOS of 8 (IQR, 6–13) days), fast decline (4% with a mortality rate of 99.7% and hospital LOS of 1 (IQR, 0–1) day), and delayed decline (7% with a mortality rate of 97.9% and hospital LOS of 5 (IQR, 3–8) days). Distinct trajectories remained robust and were distinguished by Charlson Comorbidity Index, The Acute Physiology, Age, and Chronic Health Evaluation III scores, as well as day 1 and day 3 SOFA ( P < 0.001 ANOVA). These findings provide a foundation for developing prediction models and digital twin decision support tools, improving both shared decision making and resource planning.

ABSTRACTBackground/AimEosinophilic granulomatosis with polyangiitis (EGPA) is a multisystemic disease associated with nasal polyposis. Multiple biologics are used for managing EGPA, including some approved for nasal polyps (NP). This study investigated real‐world biologic prescription patterns for EGPA and their impact on NP and endoscopic sinus surgery (ESS) use.MethodsEGPA patients with NP treated with a biologic at any Mayo Clinic site (January 2010 to January 2024) were identified by querying the unified electronic medical record. Patterns of biologic therapy, clinical course, impact on NP, and performance of ESS were studied.ResultsEighty patients were identified. Overall, 71 of 80 (88.75%) patients underwent ESS, with 62 of 80 (77.5%) undergoing 131 ESS procedures prior to biologic therapy. ESS for recalcitrant NP (47 episodes) was performed on 38 of 80 (47.5%) patients on biologics. Biologic monotherapy was used in 90% (72) of patients; mepolizumab (81.9%) was the most common, followed by rituximab (23.6%), benralizumab (18.1%), and dupilumab (12.5%). Switching of biologics was observed in 28 of 80 patients. Concurrent dual‐biologic therapy was used in eight (10%) patients. For patients on single‐agent biologic therapy, ESS was performed on 52.5% of patients on mepolizumab, 23.5% on rituximab, 42.8% on benralizumab, and 22.2% on dupilumab.ConclusionsMultidisciplinary multi‐modality treatment with biologics and ESS appeared to be the mainstay of controlling NP in EGPA. Mepolizumab was the most frequently used biologic. Dual biologic therapy was necessary in 10% of patients. Overall, 71 of 80 (88.75%) patients had ESS, with almost half the study population (47.5%) undergoing ESS after initiating biologic treatment.

Background and Objectives: Ventilator-associated pneumonia (VAP) poses a significant threat to the clinical outcomes and hospital stays of mechanically ventilated patients, particularly those recovering from cardiac arrest. Given the already elevated mortality rates in cardiac arrest cases, the addition of VAP further diminishes the chances of survival. Consequently, a paramount focus on VAP prevention becomes imperative. This review endeavors to comprehensively delve into the nuances of VAP, specifically in patients requiring mechanical ventilation in post-cardiac arrest care. The overarching objectives encompass (I) exploring the etiology, risk factors, and pathophysiology of VAP, (II) delving into available diagnostic modalities, and (III) providing insights into the management options and recent treatment guidelines. Methods: A literature search was conducted using PubMed, MEDLINE, and Google Scholar databases for articles about VAP and Cardiac arrest. We used the MeSH terms “VAP”, “Cardiac arrest”, “postcardiac arrest syndrome”, and “postcardiac arrest syndrome”. The clinical presentation, diagnostic, and management strategies of VAP were summarized, and all authors reviewed the selection and decided which studies to include. Key Content and Findings: The incidence and mortality rates of VAP exhibit significant variability, yet a recurring pattern emerges, marked by prolonged hospitalization and exacerbated clinical outcomes. This pattern is attributed to the elevated incidence of drug-resistant infections and the delayed initiation of antimicrobial treatment. This review focuses on VAP, aiming to offer valuable insights into the efficient identification and management of this fatal complication in post-cardiac arrest patients. Conclusion: The prognosis for survival after cardiac arrest is already challenging, and the outlook becomes even more daunting when complicated by VAP. The timely diagnosis of VAP and initiation of antibiotics pose considerable challenges, primarily due to the invasive nature of obtaining high-quality samples and the time required for speciation and identification of antimicrobial sensitivity. The controversy surrounding prophylactic antibiotics persists, but promising new strategies have been proposed; however, they are still awaiting well-designed clinical trials.

Purpose: This study evaluated the predictive value of SCAI shock staging for mortality in patients with sepsis and septic shock admitted to the medical ICU. Materials and Methods: This is a single-center historical cohort study. We analyzed data for adults (≥ 18-year-old) admitted to the medical ICU at Mayo Clinic St. Mary’s campus with sepsis between June 1, 2018, and December 31, 2021. Sepsis was identified using the Sepsis-III criteria. Patients were stratified based on SCAI shock staging. Our primary outcome was all-cause 30-day mortality. Results: We identified 3,079 eligible adult patients with sepsis or septic shock. The distribution of SCAI shock stages A through E was 9%, 12%, 25%, 49%, and 5%, respectively. The overall 30-day mortality was 24%. There was progression in all outcomes including ICU, hospital and 30-day mortality across SCAI shock stages. However, only SCAI shock stages D and E, had statistically significant adjusted HRs of 1.6 and 3, respectively. When compared to SOFA score, SCAI shock staging performed similarly in predicting ICU mortality with no statistically significant difference in AUCs, p-value of 0.07. Conclusions: Our results support the use of SCAI shock staging in critically ill medical patients with sepsis and septic shock for risk stratification. We propose that the SCAI shock staging may be used as a universal system for grading the severity of shock in critically ill patients regardless of etiology.

Background/Objectives: CSCs are critical drivers of the tumor and stem cell phenotypes of glioblastoma (GBM) cells. Chromatin modifications play a fundamental role in driving a GBM CSC phenotype. The goal of this study is to further our understanding of how stem cell-driving events control changes in chromatin architecture that contribute to the tumor-propagating phenotype of GBM. Methods: We utilized computational analyses to identify a subset of clinically relevant genes that were predicted to be repressed in a Polycomb repressive complex 2 (PRC2)-dependent manner in GBM upon induction of stem cell-driving events. These associations were validated in patient-derived GBM neurosphere models using state-of-the-art molecular techniques to express, silence, and measure microRNA (miRNA) and gene expression changes. Advanced Poly(β-amino ester) nanoparticle formulations (PBAEs) were used to deliver miRNAs in vivo to orthotopic human GBM tumor models. Results: We show that glioma stem cell (GSC) formation and tumor propagation involve the crosstalk between multiple epigenetic mechanisms, resulting in the repression of the miRNAs that regulate PRC2 function and histone H3 lysine 27 tri-methylation (H3K27me3). We also identified miR-217-5p as an EZH2 regulator repressed in GSCs and showed that miR-217-5p reconstitution using advanced nanoparticle formulations re-activates the PRC2-repressed genes, inhibits GSC formation, impairs tumor growth, and enhances the effects of ionizing radiation in an orthotopic model of GBM. Conclusions: These findings suggest that inhibiting PRC2 function by targeting EZH2 with miR-217-5p advanced nanoparticle formulations could have a therapeutic benefit in GBM.

Abstract Background The majority of missense variants in clinical genetic tests are classified as variants of uncertain significance. Prior research has shown that the deleterious effects and the subsequent molecular consequence of variants are often conserved among paralogous protein sequences within a gene family. Here, we systematically quantified on an exome-wide scale if the existence of pathogenic variants in paralogous genes at a conserved position could serve as evidence for the pathogenicity of a new variant. For the gene family of voltage-gated sodium channels where variants and expert-curated clinical phenotypes were available, we also assessed whether phenotype patterns of multiple disorders for each gene were also conserved across variant positions within the gene family. Methods We developed a framework that assesses the presence of pathogenic missense variants located in conserved residues across paralogous genes. We systematically mapped 2.5 million pathogenic and general population variants from the ClinVar, HGMD, and gnomAD databases onto a total of 9,990 genes and aligned them by gene families. We evaluated the quantity of classifiable amino acids by utilizing pathogenic variants identified in databases alone and then compared this assessment to the inclusion of paralogous pathogenic variants. We validated and quantified the evidence of conserved pathogenic paralogous variants in variant pathogenicity classification. Results Considering conserved pathogenic variants in paralogous genes, increased the number of classifiable variants 2.8-fold across the exome, compared to pathogenic variants in the gene of interest alone. The presence of a pathogenic variant in a paralogous gene is associated with a positive likelihood ratio of 8.32 for variant pathogenicity. The likelihood ratio was gene family-specific. Across ten genes encoding voltage-gated sodium channels and 22 expert-curated disorders, we identified cross-paralog correlated phenotypes based on 3D structure spatial position. For example, the established loss-of-function disorders SCN1A-associated Dravet syndrome, SCN2A-associated autism, SCN5A-associated Brugarda Syndrome, and SCN8A-associated neurodevelopmental disorder without seizures were correlated in their spatial variant position on structure. Finally, we show that phenotype integration in paralog variant selection improves variant classification. Conclusion Our results show that paralogous variants, in particular with phenotype information can enhance our understanding of variant effects.

Abstract Despite aggressive therapy consisting of surgery followed by radio/chemotherapy Glioblastoma (GBM) recurs in almost all patients and, currently, there are no proven therapies to treat recurrent GBM (rGBM). Recent developments in nanomedicine provide new and promising opportunities to develop new targeted therapeutics to treat brain tumors. In this study we combine bioinformatics, forward-thinking understanding of miRNA biology and cutting-edge nucleic acid delivery vehicles to advance targeted therapeutics for rGBM. Bioinformatic analysis of RNA sequencing from GSCs and clinical rGBM specimens identified TGF-beta receptor II (TGFBR2) signaling as a targetable pathway in rGBM. Mechanistically, we show that alterations in chromatin state driven by stem-cell driving events are conducive to a therapy-resistant state induced by TGFBR2. We show that blocking TGFBR2 via molecular and pharmacological approaches decreases the stem cell capacity, cell viability and re-sensitizes clinical rGBM isolates to temozolomide (TMZ) in vitro. Network analysis of SMAD2/3 targets enriched in rGBM predicted a subset of miRNAs that can target multiple genes within this set. Notably, miR-590-3p was predicted to inhibit 37 SMAD 2/3 gene targets that are also enriched in rGBMs. Bioinformatics analysis also showed that expression of 24 of those 37 miR-590-3p targets are positively correlated with TGFBR2 expression in rGBM clinical specimens. Consistent with these predictions, miR-590-3p inhibited expression of 25 of the 37 targets across 3 distinct therapy-resistant GSC isolates. To translate these in vitro finding, we developed novel bioreducible Lipophilic poly(β-amino ester) nanoparticles (LiPBAEs) for in vivo miRNA delivery. Following direct intratumoral infusion, these nanomiRs efficiently distribute through the tumors and spatial transcriptomic analysis (STA) found a decrease in 34 out of the 37 miR- 590-3p targets in animals that received the active nanomiR compared to control miRNA. Furthermore, STA identified 3 cell populations with distinct transcriptomic profiles reflecting a gradient pharmacodynamic response within tumors that received miR-590-3p nanomiRs with decreasing target expression towards the core of the tumor closest to catheter tip placement. To test the effect of 590-3p nanomiR therapy on survival, animals bearing pre-established intracranial rGBM xenografts received three infusions of either control or miR-590-3p nanomiRs every other day beginning on post-implantation day 7. All 10 animals treated with control nanomiRs were either dead or premorbid requiring euthanasia by post-implantation day 23. In contrast, 3 of 10 animals treated with miR-590-3p nanomiRs remained alive and healthy by post-implantation day 45, at which time the experiment was terminated. These results show that miRNA-based targeted therapeutics provide new opportunities to treat rGBM and bypass the resistance that is developed to standard of care. Citation Format: Hernando Lopez-Bertoni, Jack Korleski, Sophie Sall, Kathryn Luly, Maya K Johnson, Amanda L Johnson, Harmon Khela, Bachchu Lal, TC Taylor, Jean Micheal Ashby, Hector Alonso, Alice Li, Stephany Tzeng, John Laterra, Jordan J Green. Multipronged SMAD Pathway Targeting by LiPBAE miR-590-3p NanomiRs Inhibits Recurrent Glioblastoma Growth and Prolongs Survival [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: RNAs as Drivers, Targets, and Therapeutics in Cancer; 2024 Nov 14-17; Bellevue, Washington. Philadelphia (PA): AACR; Mol Cancer Ther 2024;23(11_Suppl):Abstract nr PR011.

Abstract This study reports the first pig-to-human lung xenotransplantation using a six gene-edited pig lung. A left lung from a gene-edited Chinese Bama Xiang pig was transplanted into a 39-year-old brain-dead human recipient. The xenograft maintained viability and functionality for 216 hours without signs of hyperacute rejection. Postoperatively, severe edema resembling primary graft dysfunction (PGD) was observed, potentially due to ischemia-reperfusion injury. Antibody-mediated rejection appeared to contribute to xenograft damage on postoperative days 3 and 6, with partial recovery by day 9 under the current immunosuppressive regimen. This pioneering study suggests that genetically modified pig lungs could potentially be used for future clinical applications in xenotransplantation.