Citations

ABSTRACT Suicidality contributes substantially to global morbidity and mortality, yet despite its heritability, its biological etiology remains largely elusive. We conducted multi-ancestry genome-wide association study meta-analyses of suicidal ideation (259,747 cases), suicide attempt (64,993 cases), suicide death (9,197 cases), and suicidal behavior (suicide attempt/ death, 75,300 cases), across 54 cohorts (e.g., the Psychiatric Genomics Consortium, Million Veteran Program, UK Biobank). We identified 77 significant loci across meta-analyses, including 59 previously unreported for suicidality. SNP-based heritability ranged from 2.0-6.7% and there were strong, yet incomplete, genetic correlations between suicidality phenotypes (0.70-0.88). Fine-mapping prioritized putative causal SNPs and 20 credible genes. Enrichment analyses implicated synaptic pathways and neuronal populations predominantly in subcortical brain regions (e.g., amygdala excitatory, medium spiny, hippocampal CA1-3). Together, these findings establish suicidality as a polygenic set of traits with both shared and distinct genetic influences, providing a foundation for future studies of suicide biology and etiology.

Abstract Disclosure: A. Zhang: None. J. Kapoor: None. C. Deveney: None. A.G. Cope: None. M.M. Walther-Antonio: None. N. Chia: None. C.W. Pattanayak: None. M.J. Tetel: None. The vaginal microbiome (VM) consists of the microorganisms and their metabolites residing in the vaginal tract and is critical for maintaining female reproductive health. The Lactobacillus species predominate most VMs and produce lactic acid, which has been cited as a key protector of vaginal health. Alterations in the finely balanced vaginal microbiome can cause infections, such as bacterial vaginosis, and may contribute to the development of endometrial and ovarian cancer. While it is well-established that stress and the gut microbiome impact each other via the gut-brain axis, the influence of stress, hormones, and lifestyle factors on the VM composition remains poorly understood. We investigated the relationship between stress, hormones (menstruation, hormonal contraception), lifestyle factors (diet, exercise, sleep), and the VM composition. In this 10-week study, healthy, young female volunteers (n=62) provided daily vaginal and fecal swabs, weekly stress ratings, daily data on sleep and activity (via FitBit) and diet information. High-throughput 16S rRNA sequencing was used to identify the vaginal microbial composition of each sample. Types of hormonal birth control were none (n=30), local progestin (n=9), systemic progestin-only (n=7), or systemic estrogens and progestin combined (n=16). Consistent with our previous study, vaginal microbial diversity, as measured by the Shannon index, varied by type of hormonal birth control, with participants not on hormonal birth control having the highest average diversity. There was a positive relationship between average stress and vaginal microbial diversity, with preliminary results suggesting that this relationship depends on hormonal birth control status. Participants who menstruated during the 10-week study had a higher vaginal microbial diversity than those who did not. We are currently analyzing which microbes contribute to these differences in vaginal microbial diversity. Microbiota and fungal data from the daily vaginal and fecal swab samples will be analyzed to determine how stress, hormones and/or lifestyle factors relate to crosstalk between the vaginal and gut microbiomes. These findings may provide long-term, time-longitudinal insights into how these two important microbiomes are involved in important aspects of women’s health. Presentation: Sunday, July 13, 2025

Abstract Disclosure: S. Thota-Kammili: None. J.A. McNeil: None. S.J. Peres: None. M.A. Edgar: None. J.P. Reynolds: None. J. Eleazer: None. A.Y. Chang: None. Introduction: 45,X/46,X,psrY mosaicism has been reported in the context of prenatal diagnosis with few reports on the developmental phenotype through adulthood. The 45,X/46,XY karyotype is well-studied and linked to ambiguous genitalia, dysgenetic gonads, and increased gonadal tumor risk. Less is known about 45,X/46,X,psrY mosaicism, characterized by partial Y chromosome retention. Phenotypic variability with a broad spectrum of phenotypes including Turner syndrome features, delayed puberty, hypogonadism and infertility depends on the extent and functionality of preserved Y chromosome material. We present a case of 45,X/46,X,idic(Y)(q11.21) mosaicism in an individual assigned male at birth, with a nonbinary intersex gender identity who received gender affirming feminizing hormone therapy (GAHT) before orchiectomy. Clinical Case: This is a case of a 36 y.o. patient who was found to have 45,X/46,X +mar chromosomal abnormality prenatally and initially diagnosed with Turner’s syndrome. At birth, patient had male genitalia, descended testes, and only slight hypospadias. Subsequent Y-DNA studies determined the unknown marker to be the sex determining region of the Y chromosome. Early evaluations showed appropriate responses to LHRH and ACTH, and developmental milestones were met without major health or behavioral concerns aside from a delay in puberty. The patient experienced early gender incongruence and faced questioning for gender expression. Delayed puberty led to testosterone therapy, worsening distress. Parents did not share the medical history with the patient until adulthood, when they notified them about the potential for infertility. During infertility evaluation, semen analysis revealed azoospermia. Testosterone therapy was re-attempted for hypogonadism but resulted in increased distress and patient began GAHT. Patient sought a second opinion on previous diagnosis of differences of sexual development (DSD). Chromosomal analysis revealed the 45,X/46,X,idic(Y)(q11.21) mosaicism, with duplication of Yp and deletion of the Yq. Pt was referred to urology for bilateral orchiectomy to reduce gonadal tumor risk and gender dysphoria. Pathology revealed atrophic seminiferous tubules with complete absence of spermatogenesis which were populated by Sertoli cells only and surrounded by thickened basal lamina. Leydig cells were markedly depleted. These changes are seen in transgender patients treated with estrogen prior to orchiectomy. Conclusion: Our case expands the phenotypic characterization of 45,X/46,X,idic(Y)(q11.21) mosaicism by detailing clinical features and previously unreported testicular pathology. This patient had minimal developmental concerns, and testicular pathology reflected changes associated with GAHT, highlighting the variability in phenotypic expression of 45,X/45,X,psrY mosaicism. Presentation: Sunday, July 13, 2025

Abstract Disclosure: A.M. Gonzalez Gil: None. E.F. Elli: None. R.J. Singh: None. S. Peres: None. A.Y. Chang: None. Background: Treatment of hypercortisolism in primary bilateral macronodular adrenal hyperplasia (PBMAH) with mild autonomous cortisol secretion (MACS) can be challenging. Medical treatment is useful for therapeutic purposes and as a bridge for adrenalectomy. We present the case of a patient who benefited from mifepristone but developed hyperestrogenism. Clinical Case: A 64-year-old man with prediabetes, hypertension, and cardiovascular disease had incidentally discovered bilateral nodular adrenal enlargement on CT scan following coronary artery bypass surgery. A few months later, he reported increasing fatigue, brain fog, weight gain, and worsening blood pressure. Physical exam showed no features of hypercortisolism. Work-up revealed baseline AM cortisol 17.3 mcg/dL [reference range (RR) 4.8-20], ACTH 10 pg/mL (RR 7.2-63) and DHEA-S 55 mcg/dL (RR 12-227); two abnormal AM cortisols after 1 mg overnight dexamethasone (5.4 and 6.9 mcg/dL; cut-off <1.8), and a normal 24-hour urine free cortisol (23 mcg/24h, RR 3.5-45). 24-hour urine metanephrines and aldosterone/renin ratio were normal. A 2-hour 75 g oral glucose tolerance test was diagnostic for type 2 diabetes mellitus (2-hour glucose 214 mg/dL). Baseline total testosterone (TT) was 366 ng/dL (RR 264-916) with normal follicle stimulating hormone (FSH) and luteinizing hormone (LH)concentrations. After a diagnosis of MACS, adrenal vein sampling showed bilateral excess cortisol secretion (lateralization ratio 1.09). Medical management versus right adrenalectomy based on nodule burden were offered, and he started mifepristone. With initial symptom improvement, his dose was increased from 300 mg to 300 mg alternating with 600 mg daily. When he developed increased blood pressure and hypokalemia, eplerenone was added. After 6 months of mifepristone and 5 months eplerenone 50 mg daily, he developed tender gynecomastia with elevated estradiol (106 pg/mL, RR ≤39), low TT (112 ng/dL) and undetectable FSH and LH. As expected with mifepristone, 17-hydroxyprogesterone was high (933 ng/dL, RR 51-190), but androstenedione and DHEA-S were normal. Reduction in mifepristone and eplerenone decreased estradiol levels (56 pg/mL) but gonadotrophins remained undetectable and TT decreased to 72 ng/dL. Despite discontinuation of eplerenone for 1 month, estradiol again increased (91 pg/mL), TT remained low (77 ng/dL), and mastalgia persisted. A decision to stop mifepristone and proceed with right adrenalectomy was made. Conclusion: This is a previously unreported incident of symptomatic estradiol-induced secondary hypogonadism on mifepristone therapy. Hyperestrogenism with gynecomastia and secondary hypogonadism with mifepristone suggests that some individuals may convert cortisol precursors to estradiol. Presentation: Saturday, July 12, 2025

Abstract Central nervous system (CNS) tumors often harbor alterations in genes regulating key cellular pathways, including fibroblast growth factor receptor (FGFR) genes. Here, we report the efficacy and safety of treatment with pemigatinib, an oral, potent, selective FGFR1-3 inhibitor, in patients with advanced FGFR-altered CNS tumors. FIGHT-207 was a single-arm, open-label, phase 2 study of pemigatinib in patients with advanced solid tumors harboring FGFR fusions/rearrangements or other mutations. Patients received pemigatinib 13.5 mg once daily until disease progression or unacceptable toxicity. Endpoints included tumor response and safety. Of the 13 patients with CNS tumors in FIGHT-207, 10 had glioblastoma. Fibroblast growth factor receptor alterations were FGFR3-TACC3 fusions (n = 9), FGFR1 K656E mutations (n = 2), FGFR1 N546K mutation (n = 1), and FGFR1-MITF fusion (n = 1). Three patients (23%) displayed objective responses (1 complete, 2 partial). Safety was consistent with the overall FIGHT-207 population. Pemigatinib had antitumor activity and a manageable safety profile in patients with CNS tumors.

Abstract Background Monoclonal antibody therapies (t-mabs) are known to interfere in serum immunofixation, as they show up as a discrete band. Until recently, most of the t-mabs were IgG kappa monoclonal immunoglobulins, and laboratories were familiar with the clue of a cathodal migrating IgG kappa in a patient sample, suggesting this could be daratumumab or another t-mab in the report. However, with the advent of novel antibody-based medications, identification via traditional laboratory methods has grown more complex. Teclistamab-cqyv is an IgG4 lambda T-cell engager bispecific antibody targeting B-cell maturation antigen (BCMA) and CD3 on T cells, used in relapsed and refractory multiple myeloma. The goal of this study was to determine if teclistamab could be detected on serum immunofixation and mass-fix. Methods Residual waste serum samples with no monoclonal protein via mass-fix (a MALDI-TOF based assay used in place of serum immunofixation) and variable polyclonal background were used to spike teclistamab (n=3). Briefly, one sample had total IgG < 500 mg/dL measured by nephelometry on a Siemens BNII (431 mg/dL, hypo gamma), a second sample had IgG within reference intervals (779 mg/dL, normal gamma) and the third sample had IgG > 1600 mg/dL (1950 mg/dL, polyclonal hypergamma). Each sample was divided into 3 aliquots and spiked with teclistamab (Tecvayli, Johnson &Johnson) obtained from the pharmacy, at final concentrations of 10, 20, and 40 mg/dL in the serum samples. The nine artificial samples were subjected to immunofixation electrophoresis (Sebia) and a new monoclonal protein study using mass-fix, a laboratory developed test. Results In the serum immunofixation experiments, a single discrete IgG lambda band was visible in the hypogamma and normal gamma samples (Table 1) when teclistamab was present at 20 mg/dL or 40 mg/dL. No bands were observed for the 10 mg/dL spike in hypos or normals. No teclistamab was detected at any concentration in the hypergamma sample. When mass-fix was performed, monoclonal protein spikes consistent with the expected mass of the two unique lambda light chains associated with teclistamab (22624Da and 22636Da) were identified in the hypo and normal gamma samples at the 3 concentrations tested: 10, 20, and 40 mg/dL. No mass-fix spikes were seen above the polyclonal spectra in the hypergamma samples. Conclusion The polyclonal background of immunoglobulins in a serum specimen plays a significant role in the identification of any monoclonal protein. Teclistamab is a new IgG lambda t-mab with potential to show up as an interference in both immunofixation and mass-fix, depending on the amount of polyclonal IgG present. Without positive identification, teclistamab presence could complicate interpretation of a patient’s response to treatment. This proof-of-concept study shows that mass-fix can detect smaller concentrations of teclistamab than immunofixation, therefore would be more prone to identifying this t-mab than labs employing the gel-based immunofixation method.

Abstract Background The diagnosis of monoclonal gammopathies relies on the detection of monoclonal immunoglobulins (M-proteins) in serum or urine. Mass-Fix utilizes matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) mass spectrometry (MS) to detect and quantify M-proteins. This method employs immunoaffinity enrichment using antibodies against heavy chains (HC) and light chains (LC), followed by MS analysis to determine M-protein isotypes. Mass-Fix has also revealed novel M-protein characteristics, including LC glycosylation and fragmentation, facilitated by measuring the mass of LC. LC glycosylation is as an independent risk factor for disease progression of monoclonal gammopathy of undetermined significance (MGUS), while light chain fragments have been postulated as the origin of amyloid light chain (AL) plaques. Since Mass-Fix enriches intact immunoglobulins before dissociating LCs, it potentially enhances fragment detection. However, the precise nature and clinical significance of these fragments remain to be fully elucidated. Methods Mass-Fix serum results from Mayo Clinic patients tested from September 10, 2018, to October 1, 2024, were reviewed for the presence of M-protein and LC fragments. The frequency and the isotype of fragment LC fragments was determined in the M-protein positive cohort (n=15410). Patients diagnosed with either MGUS (n=6996), AL amyloidosis (n=315), or both (n=32) who had positive M-protein results on Mass-Fix, either prior to or within one month after the diagnosis, were included for a retrospective clinical association study of LC fragments and disease. To validate that these fragments were not artifacts of MS analysis, PAGE gel analysis and Western blots were performed using clinical residual serum from 9 patients: 2 IgG/kappa and 3 IgG/lambda patients with detectable LC fragments and 2 IgG/kappa and 2 IgG/lambda patients without fragments. Samples were purified using antibodies against gamma heavy chains and reduced with TCEP prior to gel electrophoresis and Western blot. Results Of the 15410 patients with monoclonal proteins detected by Mass-Fix, 2896 (18.7%) had detectable LC fragments; kappa fragments in 1533 and lambda fragments in 1363. Most often, the fragments were observed in pairs, with combined molecular weight typically equaled that of the full-length monoclonal LC present in the same sample. LC fragments were observed more frequently among patients diagnosed with AL amyloidosis (118/347=34%) compared to those without the diagnosis (685/6996=10%), with an odds ratio of 4.75 (95% CI, 3.75-6.01). PAGE with Coomassie blue staining revealed bands with sizes representing LC fragments in the five M-protein samples with detectable LC fragments on Mass-Fix, while no such bands observed in those without LC fragments. Western blot using anti-kappa or anti-lambda antibodies confirmed the identity of the bands with higher molecular weight as a fragment of LC in each of the IgG/kappa and IgG/lambda samples. Conclusion Mass-Fix is able to discriminate LC fragments from intact LC based on their sizes. The detection of LC fragments with Western blot without ionization suggests a biological origin rather than analytical artifacts from MS. The clinical association study suggests that LC fragments may have utility in increasing the suspicion of AL amyloidosis in M-protein positive patients with LC fragments, potentially facilitating earlier intervention and improving patient outcomes.

Abstract Background The Freelite serum free light chain (FLC) assay has been widely used for detecting and monitoring monoclonal gammopathies. Reference intervals (RIs) established by Katzmann et al. in 2002 have served as the standard values for interpreting kappa/lambda FLC ratios. However, multiple reports suggested an assay drift and clinical laboratories started to move towards locally established RIs given the challenge in verifying original RIs. The assay drift over time increased kappa concentration measurements and was attributed to an interaction between the kappa FLC calibrator and serum proteins, including alpha-1-antitrypsin. A stabilized calibrator was developed to improve consistency of results with original RI. The objective of this study was to assess whether the new updated kappa calibrator would warrant a RI update. Methods Healthy adult donors’ serum samples were selected from the institution quality unit. Exclusion criteria included autoimmune diseases, cancers and renal disease. FLC measurements were obtained on the Optilite by turbidimetry using routine reagents for kappa (old lot); the new lot of reformulated kappa calibrator, and a single measurement for lambda FLC. FLC ratios were calculated with the old lot and new lot. All samples were tested by MASS-FIX to confirm absence of a monoclonal protein. Bootstrap resampling (10,000 replicates) estimated standard errors, with statistical significance defined as p < 0.05. Clinical significance was assessed per CLSI EP28-A3 guidelines. A RI was considered for partitioning by sex if the mean difference between males and females exceeded 25% of the RI width or if >4% of either sex had values beyond RI limits. Similar tests were applied to age groups (<60 and =60 years). Results 465 donors (48.2% male, 51.8% female) aged 30-89 years were used. Sixteen donors with incidental monoclonal proteins identified by MASS-FIX were excluded, for a final n=449. No clinically significant relationships of results were found with sex or age. The updated kappa calibrator resulted in a measurable shift down in FLC values with the new lot of reagents. The kappa FLC concentration and corresponding FLC ratio decreased by a median -12.1%, see table 1 for absolute values When reviewing Optilite results of the new lot, 98/449 samples were outside the kappa concentration original RI (21%). Lambda concentration RI was shifted up on Optilite when compared to original RI but passes verification (1.6% of samples, acceptance criteria < or =10%). 19 samples (4.2%) were outside the original RI for the FLC ratio of 0.26 to 1.65 (all >1.65), which was originally established as a 100% diagnostic range. The calibrator reformulation, while decreasing test results by >10%, was not sufficient to verify the original RI for kappa and still left a few cases outside the original diagnostic range for the FLC ratio. Conclusion This study assessed the impact of the stabilized calibrator on RIs for the Optilite Freelite assay. These findings suggest revisiting existing RIs to ensure continued accuracy in clinical interpretation and should be further evaluated with additional lots of reagents for robustness.