Citations

Abstract Background Cardiac valve tissue obtained during the surgical management of infective endocarditis (IE) and sent for culture may influence postoperative antibiotic therapy. We sought to identify clinical and microbiologic risk factors associated with positive valve cultures (PVC) and IE relapses in a cohort of patients undergoing surgical management. Methods This is a retrospective, multi-center study of patients with surgical management during the acute (<42 days) course of IE-directed antibiotic therapy. The rate of PVC, IE relapse, and mortality were collected. Univariate and multivariable logistic regressions were performed to identify risk factors associated with PVC. Results Of 113 patients included, 36 (31.9%) had PVC. Univariate and multivariable analyses showed preoperative antibiotic duration and pathogens were associated with PVC. Median (IQR) days of preoperative antibiotics were 6.5 (4.0-11.0) for patients with PVC compared to 13.0 (8.0-21.0) for those with negative valve cultures (NVC). In a multivariable model, preoperative antibiotic administration decreased the risk of PVC (OR 0.85 per day, CI 0.77-0.91). Enterococcal IE increased the risk of PVC compared to streptococcal IE (OR 4.16, CI 1.07-17.48). Of note, 33 (63.2%) patients with NVC received a median (IQR) of 8 (5, 18.5) days of intravenous antibiotics per patient. Only one IE relapse was identified and occurred in a patient with NVC. Conclusions Both preoperative antibiotic duration and causative pathogen were associated with PVC. IE relapses were rare and unrelated to PVC. There may be an opportunity to shorten postoperative antibiotic durations following surgical management in patients with IE.

Abstract Posaconazole delayed-release (DR) tablets are labelled as ‘do not crush’ medications. Despite this designation, emerging research demonstrates successful attainment of therapeutic serum concentrations, suggesting that they may be pharmacokinetically superior to the immediate-release (IR) suspension when given via enteric feeding tube (EFT). While crushed posaconazole DR tablets may be better suited than the IR suspension to attain therapeutic serum concentrations, several practical factors must be considered, including lack of dose equivalency between crushed DR tablets for EFT administration and DR tablets swallowed whole and the risk of EFT occlusion. This article summarizes the current evidence on posaconazole serum concentrations with crushed DR tablets administered via EFT, explores risks of this practice and provides mitigation strategies for application in the clinical setting, including proposed dosing and administration practices.

Abstract EZHIP (EZH inhibitory protein) is a cancer-testis antigen (CTA) typically restricted to germline cells, where it inhibits Polycomb repressive complex 2 (PRC2)-mediated deposition of the repressive histone mark H3K27me3. Its aberrant expression in H3K27M mutation-negative diffuse midline gliomas (DMGs) and ependymomas leads to PRC2 inhibition and widespread epigenomic dysregulation. H3K27M-mutant gliomas are similarly characterized by global loss of H3K27me3 due to inhibition of PRC2 by the oncohistone H3K27M, positioning EZHIP as a functional epigenetic mimetic of this mutation.To explore its role in tumorigenesis, we overexpressed EZHIP in the H3K27 wild-type DMG cell lines that lack H3K27M mutations. EZHIP overexpression resulted in a significant reduction in H3K27me3 levels, indicating PRC2 inhibition. In a Nestin-TVA mouse model of DMG, the introduction of EZHIP into neural stem cells via the RCAS-EZHIP-P2A-PDGFβ vector led to the development of aggressive, high-grade diffuse gliomas. The tumorigenic potential of EZHIP was further supported by Western blot analysis of EZHIP-expressing neural stem cells, which revealed increased expression of stem cell markers, including Nanog, GFAP, and Nestin, consistent with a stem-like transcriptional state. RNA and ATAC sequencing of EZHIP-overexpressing DMG cell lines, compared to their isogenic wild-type counterparts, revealed a substantial increase in the number of upregulated genes typically repressed by PRC2, indicating widespread transcriptional activation associated with PRC2 inhibition. Comparative transcriptional analysis further showed that EZHIP-induced gene expression changes more closely resembled those in PRC2 knockout cells rather than in cells harboring the H3K27M mutation. Together, these findings highlight the complex role of EZHIP in disrupting PRC2-mediated gene silencing, promoting gliomagenesis, and altering the epigenomic landscape. While EZHIP and H3K27M mutations share some mechanistic similarities in inhibiting PRC2, key differences in their downstream effects suggest distinct contributions to tumor development. These findings advance our understanding of EZHIP-driven gliomas and reveal potential therapeutic vulnerabilities that could inform future treatments.

ABSTRACT Introduction Extracorporeal membrane oxygenation (ECMO) is a life‐saving intervention for refractory cardiopulmonary failure. Despite advancements reducing complications, ECMO remains associated with acute kidney injury (AKI), often requiring kidney replacement therapy (KRT). Studies report up to 45% of ECMO patients needing KRT, significantly increasing mortality. A prior meta‐analysis suggested a declining mortality trend in recent years. Methodology Following PRISMA guidelines, PubMed, MEDLINE, EMBASE, and Cochrane Library were searched (2000–2024) for randomized and observational studies on adult ECMO patients requiring KRT. Data extraction covered study characteristics, patient demographics, ECMO type, KRT timing, and clinical outcomes. Quality was assessed using the Newcastle–Ottawa Scale. Statistical analyses were performed using RevMan 5.4.1 under a random‐effects model, with mortality as the primary outcome. Result A total of 24 studies (6347 patients) met the inclusion criteria, including 23 observational studies and one RCT. The mean age of ECMO + KRT patients was 51 years in observational studies and 61.2 years in the RCT, with cardiogenic shock as the most common ECMO indication. Meta‐analysis showed a significantly higher mortality in ECMO + KRT patients (RR: 1.86, 95% CI: 1.63–2.12, p < 0.001), with infections and bleeding as key contributors. Subgroup analysis revealed no significant survival difference based on KRT timing, while Veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) was associated with worse outcomes than Veno‐venous extracorporeal membrane oxygenation (VV‐ECMO). The RCT reported 61.9% mortality at 30 days in ECMO + KRT patients. Conclusion KRT during ECMO is associated with increased mortality, likely due to the severity of illness and complications like infections and bleeding. The optimal timing of KRT initiation remains unclear, and no significant survival benefit was found for early KRT. Further large‐scale RCTs are needed to optimize management strategies.

Abstract Aims Coronary angiography might contain clinically relevant information, beyond its traditional role in delineating coronary artery disease. We sought to explore the role of deep learning (DL) in detecting right ventricular dysfunction from routinely acquired cine images during coronary angiography. Methods and results 3D-convolutional neural networks (CNN) were trained to identify right ventricle (RV) dysfunction from diagnostic angiography of the right coronary artery (RCA). The model’s input was two cine angiograms from LAO and RAO projections. The model’s output was normal vs. abnormal RV function. Ground truth on RV function was obtained from the nearest transthoracic echocardiogram to the coronary angiogram. Two analyses were performed to identify (i) any RV dysfunction (≥mild) and (ii) significant RV dysfunction (≥mild–moderate). A total of 10 336 coronary angiograms from 9849 patients (mean age 66, 36% women) were included. The cohort was split into training (70%), validation (15%), and testing (15%) sets. In the testing sets, the models attained an area under the ROC curve (AUC), sensitivity, and specificity of 0.82 (95% CI: 0.80–0.84), 0.75, and 0.74, for detecting any RV dysfunction, and 0.83 (95% CI: 0.80–0.86), 0.82, and 0.70 for detecting significant (≥mild–moderate) RV dysfunction. Combining an ECG-driven AI model with the angio-driven model improved the AUC values to 0.83 and 0.87 for detecting any or advanced RV dysfunction, respectively. Conclusion A novel deep learning algorithm yielded acceptable classification accuracy in detecting RV dysfunction from routine cine angiography of the RCA. The model’s performance improved further by adding ECG to its inputs.

Abstract Background Posaconazole immediate release (IR) suspension is the standard product for enteral feeding tube (EFT) administration but has erratic pharmacokinetic behavior and results in sub satisfactory concentrations. Limited evidence suggests that the posaconazole oral delayed-release (DR) tablets may be crushed. Methods This was a retrospective cohort study of hospitalized adults who received EFT administration of posaconazole IR suspension or crushed DR tablets between 2018 and 2024. Patients were eligible if they had at least one serum concentration drawn ≥5 days after posaconazole initiation. The primary outcome was the attainment of therapeutic (≥700ng/mL for prophylaxis, ≥1,000ng/mL for treatment) serum concentration within 30 days. Secondary outcomes included time to therapeutic serum concentration, adverse drug effects, and frequency of clogged EFT. Multivariable cox proportional hazards regression was used to assess the relationship between posaconazole formulation and attainment of therapeutic concentrations while adjusting for confounding variables. Results Of the included patients, 100 received DR tablets and 48 received IR suspension. There were no significant differences in baseline characteristics or severity of illness. Among DR tablet and IR suspension recipients, 59% and 23% achieved therapeutic concentrations, respectively (p &lt; 0.001). After adjusting for age, sex, BMI, drug interactions, posaconazole indication, malabsorptive gastrointestinal conditions, IR suspension was significantly less likely than crushed DR tablets to achieve therapeutic posaconazole concentrations within 30-days (HR 0.37, 95% CI 0.20-0.71; p &lt; 0.003). The crushed DR tablet group required less total daily posaconazole to achieve therapeutic concentrations (400 vs 600 mg/day, p = 0.003). Clogged EFTs were more frequent in the crushed DR tablet group (27% vs 10%, p = 0.022), while no differences were observed in the occurrence of hepatotoxicity or hypokalemia. Conclusion Administration of crushed posaconazole DR tablets via EFT is more likely to attain therapeutic concentrations compared to IR suspension. The optimal technique for administering crushed DR tablets to prevent EFT complications warrants investigation. Disclosures Patrick M. Wieruszewski, PharmD, FCCM, Wolters Kluwer/UpToDate: Advisor/Consultant

Abstract BACKGROUND Diffuse midline gliomas (DMGs) and posterior fossa group A (PFA) ependymomas are aggressive pediatric brain tumors. Most DMGs harbor histone H3.3K27M or G34R mutations, or exhibit EZHIP overexpression. With a median survival of just 9–15 months, DMGs are among the most lethal human cancers. PFAs, nearly universally overexpress EZHIP and have a 5-year survival rate of ~50%. Unlike K27M or EZHIP-overexpressing DMGs, G34R-mutant tumors retain H3K27me3. METHODS Using the RCAS/Nestin-TVA system, we introduced H3.3 K27M–, G34R–, or S31A–P2A–PDGFβ or H3.3WT–P2A–PDGFβ into neonatal mice. Controls included, histone mutants EZHIP alone and ΔEZHIP (PRC2-binding-deficient). Tumor bearing mice were assessed for incidence, grade, survival, and H3K27me3 and H3.3S31P status. RESULTS H3.3K27M, G34R, and S31A–P2A–PDGFβ induced high-grade gliomas with significantly reduced survival (p &lt; 0.001). Mechanistically, G34R—like K27M—reduced mitotic Ser31 phosphorylation (S31P), causing chromosomal instability and impaired p53 checkpoint function. S31A directly modeled loss of S31P and similarly drove high-grade tumor formation. H3.3WT–P2A–PDGFβ induced only low-grade lesions. EZHIP–P2A–PDGFβ enhanced tumor grade but not survival; only EZHIP fully abolished H3K27me3. ΔEZHIP and all unlinked constructs were non-tumorigenic. CONCLUSION These models establish a robust platform to dissect glioma drivers and chromatin vulnerabilities. We previously showed that H3.3K27M reduces S31P, promoting chromosomal instability and impaired p53 function. We now demonstrate that H3.3G34R also reduces S31P and drives tumor formation in vivo. Direct loss of S31P via H3.3S31A is likewise sufficient for gliomagenesis. Although EZHIP does not alter S31P, it promotes genome instability through distinct mechanisms—disrupting PALB2–BRCA2-mediated DNA repair and mislocalizing TopoIIα, a process dependent on H3K27me3. H3.3K27M, G34R, and EZHIP thus converge on genome instability through distinct pathways. This platform supports mechanistic and therapeutic studies and is now being expanded using tetracycline-regulated expression to investigate tumor maintenance.

Abstract BACKGROUND Posterior fossa group A ependymomas (PFAs) and diffuse midline gliomas (DMGs) are lethal pediatric brain tumors characterized by global loss of H3K27me3. This epigenetic disruption is caused by either EZHIP overexpression or H3.1/H3.3K27M mutations, which are mutually exclusive. EZHIP is aberrantly expressed in nearly all PFAs and approximately 10% of DMGs, while K27M mutations are found in ~80% of DMGs. In normal development, EZHIP expression is restricted to primordial germ cells during meiosis. We used human neural stem cells (NSCs), which give rise to ependymal and oligodendrocyte precursor lineages, to model EZHIP’s developmental effects. These cell types reflect the likely cells of origin for PFAs and DMGs, making them a biologically relevant platform to interrogate early tumorigenic mechanisms. METHODS AND RESULTS EZHIP was expressed in NSCs, astrocytes, and DMG lines. In NSCs, EZHIP induced strong repression of genome stability and mitotic fidelity genes, confirmed by gene set enrichment analysis (NES –2.91, p = 1e–10), and activated stem-like developmental programs. This repression was not observed in differentiated cells or tumor lines, indicating an NSC-specific vulnerability. The repressed targets were highly enriched for E2F-regulated genes (NES –3.61, p = 1e–10). EZHIP-expressing NSCs showed reduced DNA repair capacity, mitotic abnormalities, and continued proliferation. EZHIP is known to impair double-strand break repair by binding PALB2 and blocking BRCA2 recruitment, and to disrupt TopoIIα localization via H3K27me3 depletion, compounding mitotic stress in NSCs. CONCLUSIONS EZHIP disrupts genome maintenance and promotes transformation selectively in neural progenitors during a defined developmental window. Published data show that H3.3K27M induces profound transcriptional reprogramming in week 13 human NSCs, but these effects are diminished or absent by week 19, suggesting a shared, time-limited window of epigenetic vulnerability in both H3K27M- and EZHIP-driven tumors. Understanding this context-dependent repression has important implications for identifying stage-specific therapeutic vulnerabilities in pediatric gliomas.

Abstract Background Posaconazole immediate release (IR) suspension is the standard product for enteral feeding tube (EFT) administration but has erratic pharmacokinetic behaviour, often resulting in subtherapeutic concentrations. Limited evidence suggests that posaconazole oral delayed-release (DR) tablets may be crushed. Methods This was a retrospective cohort study of hospitalized adults who received EFT administration of posaconazole IR suspension or crushed DR tablets between 2018 and 2024. Patients were eligible if they had at least one serum drug concentration drawn ≥5 days after posaconazole initiation. The primary outcome was attainment of therapeutic drug concentrations. Secondary outcomes included time to therapeutic serum concentration, adverse drug events, and frequency of occluded EFT. Results Of the included patients, 48 received IR suspension and 100 received DR tablets. Baseline characteristics and severity of illnesses were well balanced. Among IR suspension and crushed DR tablet recipients, 39% and 80% achieved therapeutic concentrations, respectively (P = 0.002). After adjusting for age, sex, BMI, drug interactions, posaconazole indication and malabsorptive conditions, crushed DR tablets were significantly more likely than IR suspension to achieve therapeutic posaconazole concentrations within 30 days (HR 5.22, 95% CI 2.35–11.61). Occluded EFTs were more frequent among crushed DR tablet recipients (27% versus 10%, P = 0.022), while no differences were observed in the occurrence of hepatotoxicity or hypokalaemia. Conclusions With EFT administration, crushed posaconazole DR tablets were associated with a greater likelihood of achieving therapeutic concentrations compared with IR suspension. The optimal technique for administering crushed DR tablets to prevent EFT complications warrants investigation.

AbstractINTRODUCTIONTransgenic mice overexpressing familial Alzheimer's disease (AD) mutations (FAD) show non‐physiological traits, and their immunocompetent backgrounds limit their use in AD immunotherapy research. Preclinical models that reflect human immune responses in AD are needed.METHODSUsing CRISPR‐Cas9, we developed single (NA) and double (NAPS) knock‐in (KI) amyloid precursor protein (APP)KM670,671NL (Swedish) and presenilin 1 (PS 1)M146VFAD mutations on an immunodeficient NOG (NOD.Cg‐PrkdcscidIl2rgtm1Sug/JicTac) background. The models were confirmed by Sanger sequencing and evaluated for AD‐like pathology.RESULTSBoth NA and NAPS mice developed pathology without overexpression artifacts. Mutation‐induced upregulation of APP‐CTF‐β led to intraneuronal human amyloid beta (Aβ) (6E10) deposits and amyloid‐associated microgliosis as early as 3 months, which increased with age. The addition of the PS 1M146V mutation doubled the amyloid load. The models displayed broad neuronal loss, resulting in brain atrophy in older mice.DISCUSSIONThese models replicate intraneuronal amyloid pathology and, with human immune reconstitution potential, enable novel studies of human immune responses in AD.Highlights A novel Alzheimer's disease (AD) knock‐in (KI) mouse was developed and characterized on an immunodeficient NOG background. The model provides a platform for human immune studies and the evaluation of immunotherapies for AD. The KI mice demonstrate intraneuronal Aβ deposits and amyloid‐associated microglial reactions. KI mice demonstrate extensive neuronal loss. Human immune reconstitution enables studies of infectious AD co‐morbidities, such as the human immunodeficiency and herpes simplex viruses.