This is a keyword searchable list of recent abstracts and project descriptions provided by faculty, residents, and fellows, or autogenerated from recent published abstracts. For questions or to add/edit/remove a project, email dlamming@medicine.wisc.edu
Research Projects
| Project ID | Faculty Name | Dept/Division | Faculty Email | Project Title | Abstract |
|---|---|---|---|---|---|
| 1 | Maxfield Flynn | ENDO | mflynn@medicine.wisc.edu | Improving Awareness on Daily Calcium Requirements and How to Meet Them Using Calcium-Rich Foods in Postmenopausal Patients with Osteoporosis in the Outpatient Setting | |
| 2 | Jennifer Weiss | GI | jmw@medicine.wisc.edu | Peutz-Jeghers Syndrome and lung cancer risk: Does the risk meet the threshold for lung cancer screening? | Systematic review of published literature on risk of lung cancer in Peutz-Jeghers Syndrome. Lung cancer risks will be compared to the 5-year, 10-year- and lifetime risks for lung cancer in the general population based on pack-years of smoking and age to determine if new recommendations for lung cancer screening can be made for individuals with PJS. |
| 3 | Jennifer Weiss | GI | jmw@medicine.wisc.edu | Comparing the life experience of patients with the most common hereditary colon cancer syndromes: Lynch syndrome versus Hereditary Polyposis Syndromes | Comparison of transcripts from interviews of individuals living with Lynch syndrome and Hereditary Polyposis Syndromes for themes that are common across or different between the syndromes to help inform interventions to improve care delivery. The data was collected as part of a larger project through the Health Experiences Research Network (https://www.healthexperiencesusa.org/) module on "Cancer Risk That Runs in Families" |
| 4 | Sara McCoy | RHEUM | ssmccoy@medicine.wisc.edu | Qualitative Review on the Burden of Sjogren's | Sjogren's disease is a systemic autoimmune disease characterized by hallmark severe dryness, pain and fatigue. We are working as part of a group called OMERACT (Outcomes in Rheumatology) to develop new clinical trial endpoints. As part of this, we first need to describe the lived patient experience. To do this, we are perfoming a qualitative review of the literature. This is an international effort involving at least three continents. We have already developed a search strategy and pulled the requisite titles. we now neeed to review titles and abstract themes. this will result in a collabotrative publication. |
| 5 | Amali Samarasinghe | APCC-AA | amali.samarasinghe@wisc.edu | Impact of Respiratory Infections in Fungal Allergic Asthma | Using laboratory models of respiratory diseases, we have identified novel functions of eosinophils as modulators of host defense in the lungs. Various ongoing projects are available to determine mechanisms by which eosinophils, 1) are activated by respiratory infectious agents and how they respond to these stimuli directly; 2) crosstalk with other leukocytes in the lungs to activate host defenses during viral and bacterial infections. |
| 6 | Monica Liu | APCC-Pulm | mliu@medicine.wisc.edu | Modeling lung disease using patient-derived organoids | Our overarching goal is to uncover and manipulate mechanisms of inflammatory and fibrosing lung disease using patients' own cells. Current projects include generating lung organoids from patients' bronchoalveolar lavage fluid to study acute lung transplant rejection, or validating and further developing our in vitro models. We have the ability to collect specimens from any pulmonary procedure, so motivated trainees are also welcome to propose a basic or translational research project using these resources. |
| 7 | Nathan Sandbo | APCC-Pulm | nsandbo@medicine.wisc.edu | Elucidating the mechanisms by which enzymes of the Hexosamine Biosynthetic Pathway play a role in the development of Pulmonary Fibrosis | Pulmonary Fibrosis is a disease of excessive lung scarring caused by aberrant extracellular matrix (ECM) assembly by lung fibroblasts. ECM is a complex system of macromolecules, produced and modulated by a myriad of enzymes within the fibroblasts. Fibroblasts, when differentiated into myofibroblasts, have a robust profibrotic phenotype. The Hexosamine Biosynthetic Pathway (HBP) is a nutrient sensing, glucose repurposing, pathway made up of enzymes involved in the differentiation of myofibroblasts, as well as the regulation and production of ECM macromolecules. The HBP is essential for the production of uridine diphosphate N-acetylglucosamine (UDP-GlcNAc), a vital component of N- linked and O-linked glycosylation, which are posttranslational modifications of proteins, many that are known to play a role in the regulation of ECM. We have found that there is elevated expression of key enzymes of the HBP (such as glutamine fructose-6-phosphate transaminase 2 (GFPT2)) in human lung fibrosis (Idiopathic pulmonary fibrosis) and mouse models of lung fibrosis. Additionally, we have found that modulating the enzyme glutamine fructose-6-phosphate transaminase 2 (GFPT2) impacts the expression of fibronectin, a prominent marker of lung fibrosis. GFPT2 is a rate limiting enzyme of the HBP and differences in expression directly impact the function of the HBP. Thus, we hypothesize that the HBP is essential for the development of lung fibrosis. For this project, the student would study GFPT2 and other prospective enzymes in the HBP in cell culture and ex vivo tissue models of lung fibrosis and assist with investigations using the in vivo models of lung fibrosis. By way of short hairpin RNA (shRNA) lentivirus, GFPT2 can be attenuated in both human lung fibroblast cell culture (in vitro) and human precision cut lung slices (PCLS – ex vivo). In addition, we have in hand a GFPT2 global and conditional knockout mouse, for investigating the role of GFPT2 in the bleomycin-induced mouse model of fibrosis (in vivo). The impact that reduction of GFPT2 will have on both the fibroblast to myofibroblast differentiation as well as the ECM architecture will be measured. In the process of performing this work, the student will generate data leading to an abstract and poster for presentation at the DOM Research Day as well as presenting their data at the annual American Thoracic Society Conference. This research will allow the student to learn important basic science technical, data analysis, and scientific presentation skills including but not limited to: hypothesis generation/testing, tissue culture procedures, human and mouse tissue handling and processing, RNA and protein isolation, quantitative real-time PCR, SDS Page/western blotting, immunocytochemistry, data analysis, data presentation, and scientific communication/writing. The student will be supported by full-time research staff/faculty and pursue this project in a team-science environment. |
| 8 | Nathan Sandbo | APCC-Pulm | nsandbo@medicine.wisc.edu | Determining the mechanisms by which coculturing human macrophages with established human lung fibroblasts acts to polarize macrophages towards a profibrotic phenotype to better understand the development of pulmonary fibrosis. | Pulmonary Fibrosis is a disease of excessive lung scarring caused by aberrant extracellular matrix (ECM) assembly by lung fibroblasts. Lung fibroblasts can be differentiated towards a more ECM producing fibroblast, termed myofibroblasts, in many known and yet unknown ways. There is proven cross talk between lung macrophages and lung fibroblasts that can exacerbate the differentiation towards the profibrotic myofibroblast, yet the mechanisms remain elusive, and it is not clear if fibroblast phenotype can influence macrophage polarization. We have discovered that when macrophages are cocultured on established human lung fibroblasts, macrophages become polarized to a profibrotic phenotype that is found in human lung fibrosis. We hypothesize that these interactions can create a circular feedback loop between macrophages and fibroblasts during lung fibrosis. For this project, the student would utilize our existing and well established coculture model system with the human macrophage cell line THP-1 cells and primary human lung fibroblasts. The interested student would investigate whether this interaction depends on a soluble factor from the macrophages to the fibroblasts and/or whether this interaction was dependent on cell-cell contact between the macrophages and the fibroblasts. To determine whether a soluble factor is involved, the macrophages and fibroblasts would be cocultured in a Transwell system where the cell media is shared but macrophage and fibroblast cell contact is prevented. In addition, fibroblasts would be incubated with conditioned media from macrophages to determine if a factor from macrophages is sufficient to promote a fibrotic phenotype in the fibroblasts (and the reverse: conditioned media from fibroblasts exposed to macrophages). Alternatively, to determine if the cell-cell interaction is necessary, the macrophages will be cocultured with fibroblasts with molecular tools (antibody blocking and siRNA) to modulate this cell-cell interaction to determine whether this interaction is necessary or sufficient to polarize macrophages towards a profibrotic phenotype. In the process of performing this work, the student will generate data leading to an abstract and poster for presentation at the DOM Research Day as well as presenting their data at the annual American Thoracic Society Conference. This research will allow the student to learn important basic science technical, data analysis, and scientific presentation skills including but not limited to: hypothesis generation/testing, tissue culture procedures, RNA and protein isolation, quantitative real-time PCR, SDS Page/western blotting, immunocytochemistry, data analysis, data presentation, and scientific communication/writing. The student will be supported by full-time research staff/faculty and pursue this project in a team-science environment. |
| 9 | Loren Denlinger | APCC-Pulm | lcd@medicine.wisc.edu | Acute Biomarkers of Sustained Loss of Lung Function After Recovery from Asthma Exacerbations | Rationale: Among patients with severe asthma, those with baseline elevations in both sputum eosinophils and neutrophils have the greatest risk of longitudinal loss of lung function. Several eicosanoid mediators have both bronchoconstrictive and chemotactic properties. We hypothesized that during asthma exacerbations, individuals with acutely high sputum eosinophils and neutrophils would have the largest decline in lung function at recovery, and that measurements of acute levels of eicosanoids might serve as a noninvasive biomarker of this risk. Methods: This was a secondary analysis of an IRB-approved study that has been previously described. 21 participants at the University of Wisconsin had complete data for nasal lavage, sputum, and lung function measurements at baseline, acute, and recovery visits surrounding exacerbations. Samples with negative viral testing at the time of acute visit were excluded. Changes in lung function were compared to the baseline visit after bronchodilator response. Sputum samples were processed by the Severe Asthma Research Program protocol, with percentages counted from review of 300 cells after staining. Nasal lavage samples were analyzed for eicosanoid levels including thromboxane B2 (TXB2) and prostaglandin E2 (PGE2) via ELISA and EIA protocols per the manufacturer. Participants were stratified by asthma severity defined according to ATS/ERS guidelines. Multivariate modeling was performed using a stepwise approach and significance established at p<0.05. Results: Increased sputum eosinophils at the time of exacerbation were significantly correlated with reduced post-bronchodilator FEV1 (p=0.05) and FVC (p<0.05) at the recovery visit, when controlled for baseline spirometry. There was no observed relationship between recovery lung function and sputum neutrophils at the acute visit. Increased TXB2 from nasal lavage at the acute visit was correlated with reduced FEV1/FVC (p<0.01), and increased PGE2 was correlated with a near significant reduction in FEV1/FVC (p=0.07) at the acute visit. Conclusions: Among a cohort of patients with severe asthma, higher acute sputum eosinophil count was correlated with reduced lung function at the recovery visit, however, sputum neutrophils did not significantly impact lung function at the acute or recovery visit. Additionally, higher nasal oxylipin TXB2 and PGE2 levels were associated with reduced lung function at the acute visit only. This suggests that characterization of exacerbation sputum and nasal fluid, easily accessible at the time of an acute visit, may aid in identifying patients at risk for progressive lung function decline. Further investigation of other exacerbation covariates via multivariate modeling may further define at-risk individuals. |
| 10 | Loren Denlinger | APCC-Pulm | lcd@medicine.wisc.edu | Serum cAMP levels are increased in patients with asthma. | |
| 11 | Loren Denlinger | APCC-Pulm | lcd@medicine.wisc.edu | Development of an asthma health-care burden score as a measure of severity and predictor of remission in SARP III and U-BIOPRED: results from two major longitudinal asthma cohorts. | Current asthma guidelines, including those of the European Respiratory Society (ERS) and American Thoracic Society (ATS), suboptimally predict asthma remission, disease severity, and health-care utilisation. We aimed to establish a novel approach to assess asthma severity based on asthma health-care burden data. We analysed prospectively collected data from the Severe Asthma Research Program III (SARP III; USA) and the European Unbiased Biomarkers for the Prediction of Respiratory Disease Outcomes (U-BIOPRED; 11 European countries) to calculate a composite burden score based on asthma exacerbations and health-care utilisation, which was modified to include the use of short-acting beta agonists (SABAs) to reflect asthma symptom burden. In SARP III, 528 adult participants with asthma were followed up for a mean of 4·4 (SD 1·6) years, and 312 (59%) had severe asthma according to the ERS-ATS definition. Among the 205 participants with asthma who used rescue SABAs daily, 90 used these two or more times a day. In U-BIOPRED, 509 adult participants with asthma were followed up for 1 year, and 421 (83%) had severe asthma. The burden score was less than 1·29 per patient-year in 106 (34%) of 312 SARP III participants and in 80 (19%) of 421 U-BIOPRED participants with severe asthma. By contrast, the burden score was above the median value in 58 (28%) SARP III and 24 (27%) U-BIOPRED participants with non-severe asthma. In both cohorts, the burden score negatively correlated with lung function, asthma control, and quality of life. A burden score of 0·15 or lower predicted asthma remission with a sensitivity greater than 91% and a specificity of 99%. Our findings highlight considerable discrepancies between the current definition of asthma severity and our burden score. Although the definition of severe asthma proposed by the ERS-ATS and the and Global Initiative for Asthma (GINA) is based on prescribed asthma medications, our personalised health-care burden score includes patient-centred data that reflect disease severity and accurately predicts asthma remission. Subject to prospective validation, the burden score could help to optimise the management of high-risk individuals with asthma. SARP III: US National Heart, Lung, and Blood Institute; AstraZeneca; Boehringer Ingelheim; Genentech; GlaxoSmithKline; Sanofi Genzyme/Regeneron; and Teva Pharmaceuticals. Innovative Medicines Initiative Joint Undertaking (EU's Seventh Framework Programme and European Federation of Pharmaceutical Industries and Associations) and eTRIKS project. |
| 12 | Loren Denlinger | APCC-Pulm | lcd@medicine.wisc.edu | Type 1 Immune Responses Related to Viral Infection Influence Corticosteroid Response in Asthma. | Corticosteroid-responsive type 2 (T2) inflammation underlies the T2-high asthma endotype. However, we hypothesized that type 1 (T1) inflammation, possibly related to viral infection, may also influence corticosteroid response. To determine the frequency and within-patient variability of T1-high, T2-high, and T1/T2-high asthma endotypes and whether virally influenced T1-high disease influences corticosteroid response in asthma. Patients in the Severe Asthma Research Program (SARP)-3 had sputum collected at baseline, after intramuscular (triamcinolone acetonide) corticosteroid treatment, and at 1 and 3-year follow-ups. Sputum cell RNA was used for whole transcriptome gene network and viral metagenomic analyses. We then profiled patients as highly expressing T1 and/or T2 gene networks and established the influence of these endotypes on corticosteroid responsiveness and likelihood of viral transcript detection in the airways. We found that 22% and 35% of asthma patients highly expressed T1 and T2 network genes, respectively, and that 8.5% highly expressed both networks. Asthma severity outcomes were worse in T2-high compared to T1-high asthma and most severe in the T1-high/T2-high subgroup. Corticosteroid treatment strongly suppressed T2 but poorly suppressed T1 gene expression, and corticosteroid-associated improvements in FEV1 occurred only in patients with T1-low/T2-high disease and not in T1-high/T2-high patients. Viral metagenomic analyses uncovered that 24% of asthma sputum samples tested positive for a respiratory virus and high viral carriage was associated with 14-fold increased risk of T1-high disease. Airway type 1 immune responses are relatively common in asthma, are largely corticosteroid-resistant, and are associated with sub-clinical viral infection. |
| 13 | Loren Denlinger | APCC-Pulm | lcd@medicine.wisc.edu | Proteomic Analysis of Asthma Airway Inflammation Post-Allergen Challenge: A Heterogeneous Response. | |
| 14 | Loren Denlinger | APCC-Pulm | lcd@medicine.wisc.edu | Mitochondrial DNA copy number variation in asthma risk, severity, and exacerbations. | Asthma pathophysiology is associated with mitochondrial dysfunction. Mitochondrial DNA copy number (mtDNA-CN) has been used as a proxy of mitochondrial function, with lower levels indicating mitochondrial dysfunction in population studies of cardiovascular diseases and cancers. We investigated whether lower levels of mtDNA-CN are associated with asthma diagnosis, severity, and exacerbations. mtDNA-CN is evaluated in blood from 2 cohorts: UK Biobank (UKB) (asthma, n = 39,147; no asthma, n = 302,302) and Severe Asthma Research Program (SARP) (asthma, n = 1283; nonsevere asthma, n = 703). Individuals with asthma have lower mtDNA-CN compared to individuals without asthma in UKB (beta, -0.006 [95% confidence interval, -0.008 to -0.003], P = 6.23 × 10-6). Lower mtDNA-CN is associated with asthma prevalence, but not severity in UKB or SARP. mtDNA-CN declines with age but is lower in individuals with asthma than in individuals without asthma at all ages. In a 1-year longitudinal study in SARP, mtDNA-CN was associated with risk of exacerbation; those with highest mtDNA-CN had the lowest risk of exacerbation (odds ratio 0.333 [95% confidence interval, 0.173 to 0.542], P = .001). Biomarkers of inflammation and oxidative stress are higher in individuals with asthma than without asthma, but the lower mtDNA-CN in asthma is independent of general inflammation or oxidative stress. Mendelian randomization studies suggest a potential causal relationship between asthma-associated genetic variants and mtDNA-CN. mtDNA-CN is lower in asthma than in no asthma and is associated with exacerbations. Low mtDNA-CN in asthma is not mediated through inflammation but is associated with a genetic predisposition to asthma. |
| 15 | Loren Denlinger | APCC-Pulm | lcd@medicine.wisc.edu | Utility of eosinophil peroxidase as a biomarker of eosinophilic inflammation in asthma. | The relative utility of eosinophil peroxidase (EPX) and blood and sputum eosinophil counts as disease biomarkers in asthma is uncertain. We sought to determine the utility of EPX as a biomarker of systemic and airway eosinophilic inflammation in asthma. EPX protein was measured by immunoassay in serum and sputum in 110 healthy controls to establish a normal reference range and in repeated samples of serum and sputum collected during 3 years of observation in 480 participants in the Severe Asthma Research Program 3. Over 3 years, EPX levels in patients with asthma were higher than normal in 27% to 31% of serum samples and 36% to 53% of sputum samples. Eosinophils and EPX correlated better in blood than in sputum (rs values of 0.74 and 0.43, respectively), and high sputum EPX levels occurred in 27% of participants with blood eosinophil counts less than 150 cells/μL and 42% of participants with blood eosinophil counts between 150 and 299 cells/μL. Patients with persistently high sputum EPX values for 3 years were characterized by severe airflow obstruction, frequent exacerbations, and high mucus plug scores. In 59 patients with asthma who started mepolizumab during observation, serum EPX levels normalized in 96% but sputum EPX normalized in only 49%. Lung function remained abnormal even when sputum EPX normalized. Serum EPX is a valid protein biomarker of systemic eosinophilic inflammation in asthma, and sputum EPX levels are a more sensitive biomarker of airway eosinophilic inflammation than sputum eosinophil counts. Eosinophil measures in blood frequently miss airway eosinophilic inflammation, and mepolizumab frequently fails to normalize airway eosinophilic inflammation even though it invariably normalizes systemic eosinophilic inflammation. |
| 16 | Loren Denlinger | APCC-Pulm | lcd@medicine.wisc.edu | Comparison of Asthma Phenotypes in Severe Asthma Cohorts (SARP, U-BIOPRED, ProAR and COREA) From 4 Continents. | Asthma is a clinical syndrome with various underlying pathomechanisms and clinical phenotypes. Genetic, ethnic, and geographic factors may influence the differences in clinical presentation, severity, and prognosis. We compared the characteristics of asthma based on the geographical background by analyzing representative cohorts from the United States, Europe, South America, and Asia using the Severe Asthma Research Program (SARP), Unbiased Biomarkers for the Prediction of Respiratory Disease Outcomes (U-BIOPRED), Program for Control of Asthma in Bahia (ProAR), and Cohort for Reality and Evolution of Adult Asthma in Korea (COREA), respectively. The clinical characteristics and medications for the SARP (n = 669), U-BIOPRED (n = 509), ProAR (n = 996), and COREA (n = 3,748) were analyzed. Subgroup analysis was performed for severe asthma. The mean age was highest and lowest in the COREA and SARP, respectively. The asthma onset age was lowest in the ProAR. The mean body mass index was highest and lowest in the SARP and COREA, respectively. Baseline pulmonary function was lowest and highest in the U-BIOPRED and COREA, respectively. The number of patients with acute exacerbation in the previous year was highest in U-BIOPRED. The mean blood eosinophil count was highest in COREA. The total immunoglobulin E was highest in the ProAR. The frequency of atopy was highest in the SARP. The principal component analysis plot revealed differences among all cohorts. The cohorts from 4 different continents exhibited different clinical and physiological characteristics, probably resulting from the interplay between genetic susceptibility and geographical factors. |
| 17 | Loren Denlinger | APCC-Pulm | lcd@medicine.wisc.edu | A Novel Air Trapping Segment Score Identifies Opposing Effects of Obesity and Eosinophilia on Air Trapping in Asthma. | Rationale: Density thresholds in computed tomography (CT) lung scans quantify air trapping (AT) at the whole-lung level but are not informative for AT in specific bronchopulmonary segments. Objectives: To apply a segment-based measure of AT in asthma to investigate the clinical determinants of AT in asthma. Methods: In each of 19 bronchopulmonary segments in CT lung scans from 199 patients with asthma, AT was categorized as present if lung attenuation was less than -856 Hounsfield units at expiration in ⩾15% of the lung area. The resulting AT segment score (0-19) was related to patient outcomes. Measurements and Main Results: AT varied at the lung segment level and tended to persist at the patient and lung segment levels over 3 years. Patients with widespread AT (⩾10 segments) had more severe asthma (P < 0.05). The mean (±SD) AT segment score in patients with a body mass index ⩾30 kg/m2 was lower than in patients with a body mass index <30 kg/m2 (3.5 ± 4.6 vs. 5.5 ± 6.3; P = 0.008), and the frequency of AT in lower lobe segments in obese patients was less than in upper and middle lobe segments (35% vs. 46%; P = 0.001). The AT segment score in patients with sputum eosinophils ⩾2% was higher than in patients without sputum eosinophilia (7.0 ± 6.1 vs. 3.3 ± 4.9; P < 0.0001). Lung segments with AT more frequently had airway mucus plugging than lung segments without AT (48% vs. 18%; P ⩽ 0.0001). Conclusions: In patients with asthma, air trapping is more severe in those with airway eosinophilia and mucus plugging, whereas those who are obese have less severe trapping because their lower lobe segments are spared. |
| 18 | Loren Denlinger | APCC-Pulm | lcd@medicine.wisc.edu | A common polymorphism in the Intelectin-1 gene influences mucus plugging in severe asthma. | By incompletely understood mechanisms, type 2 (T2) inflammation present in the airways of severe asthmatics drives the formation of pathologic mucus which leads to airway mucus plugging. Here we investigate the molecular role and clinical significance of intelectin-1 (ITLN-1) in the development of pathologic airway mucus in asthma. Through analyses of human airway epithelial cells we find that ITLN1 gene expression is highly induced by interleukin-13 (IL-13) in a subset of metaplastic MUC5AC+ mucus secretory cells, and that ITLN-1 protein is a secreted component of IL-13-induced mucus. Additionally, we find ITLN-1 protein binds the C-terminus of the MUC5AC mucin and that its deletion in airway epithelial cells partially reverses IL-13-induced mucostasis. Through analysis of nasal airway epithelial brushings, we find that ITLN1 is highly expressed in T2-high asthmatics, when compared to T2-low children. Furthermore, we demonstrate that both ITLN-1 gene expression and protein levels are significantly reduced by a common genetic variant that is associated with protection from the formation of mucus plugs in T2-high asthma. This work identifies an important biomarker and targetable pathways for the treatment of mucus obstruction in asthma. |
| 19 | Loren Denlinger | APCC-Pulm | lcd@medicine.wisc.edu | Protein-Protein interactive networks identified in bronchoalveolar lavage of severe compared to nonsevere asthma. | Previous bronchoalveolar lavage fluid (BALF) proteomic analysis has evaluated limited numbers of subjects for only a few proteins of interest, which may differ between asthma and normal controls. Our objective was to examine a more comprehensive inflammatory biomarker panel in quantitative proteomic analysis for a large asthma cohort to identify molecular phenotypes distinguishing severe from nonsevere asthma. Bronchoalveolar lavage fluid from 48 severe and 77 nonsevere adult asthma subjects were assessed for 75 inflammatory proteins, normalized to BALF total protein concentration. Validation of BALF differences was sought through equivalent protein analysis of autologous sputum. Subjects' data, stratified by asthma severity, were analysed by standard statistical tests, principal component analysis and 5 machine learning algorithms. The severe group had lower lung function and greater health care utilization. Significantly increased BALF proteins for severe asthma compared to nonsevere asthma were fibroblast growth factor 2 (FGF2), TGFα, IL1Ra, IL2, IL4, CCL8, CCL13 and CXCL7 and significantly decreased were platelet-derived growth factor a-a dimer (PDGFaa), vascular endothelial growth factor (VEGF), interleukin 5 (IL5), CCL17, CCL22, CXCL9 and CXCL10. Four protein differences were replicated in sputum. FGF2, PDGFaa and CXCL7 were independently identified by 5 machine learning algorithms as the most important variables for discriminating severe and nonsevere asthma. Increased and decreased proteins identified for the severe cluster showed significant protein-protein interactions for chemokine and cytokine signalling, growth factor activity, and eosinophil and neutrophil chemotaxis differing between subjects with severe and nonsevere asthma. These inflammatory protein results confirm altered airway remodelling and cytokine/chemokine activity recruiting leukocytes into the airways of severe compared to nonsevere asthma as important processes even in stable status. |
| 20 | Nizar Jarjour | APCC-Pulm | nnj@medicine.wisc.edu | Identification of Bronchial Epithelial Genes Associated with Type-2 Eosinophilic Inflammation in Asthma. | Airway inflammation has a critical role in asthma pathogenesis and pathophysiology. Yet, the molecular pathways contributing to airway inflammation are not fully known, particularly Type-2 (T2) inflammation characterized by both eosinophilia and higher FeNO levels. To identify genes whose level of expression in epithelial brushing samples were associated with both bronchoalveolar lavage (BAL) eosinophilia and generation of FeNO. We performed segmental allergen bronchoprovocation (SBP-Ag) in participants with asthma, and RNA-sequencing (RNA-seq) analyses of BAL cells and brushing samples before and 48 h after SBP-Ag to identify regulation of eosinophil recruitment and FeNO changes. Allergen bronchoprovocation increased FeNO levels, which correlated with eosinophilia. Thirteen genes were identified in brushing samples, whose expression changed in response to SBP-Ag and correlated with both airway eosinophilia and FeNO levels after SBP-Ag. Among these 13 genes, the epithelial cell product, CDH26/cadherin-26 contributed to the amplification of T2 inflammation, as reflected by eosinophilia and FeNO, and causal mediation analyses with pro-T2 and pro-eosinophilic cytokine mediators in BAL fluids. Among the genes associated with reduced eosinophilia and FeNO, HEY2 is known to enhance cell proliferation, migration, invasion, and epithelial-to-mesenchymal transition (EMT), as well as to reduce apoptosis. This unbiased RNA-seq analysis in participants with allergic asthma revealed several epithelial cell genes, particularly CDH26, that may be critical for the development or augmentation of T2 inflammation in asthma. |
| 21 | Nizar Jarjour | APCC-Pulm | nnj@medicine.wisc.edu | Development of an asthma health-care burden score as a measure of severity and predictor of remission in SARP III and U-BIOPRED: results from two major longitudinal asthma cohorts. | Current asthma guidelines, including those of the European Respiratory Society (ERS) and American Thoracic Society (ATS), suboptimally predict asthma remission, disease severity, and health-care utilisation. We aimed to establish a novel approach to assess asthma severity based on asthma health-care burden data. We analysed prospectively collected data from the Severe Asthma Research Program III (SARP III; USA) and the European Unbiased Biomarkers for the Prediction of Respiratory Disease Outcomes (U-BIOPRED; 11 European countries) to calculate a composite burden score based on asthma exacerbations and health-care utilisation, which was modified to include the use of short-acting beta agonists (SABAs) to reflect asthma symptom burden. In SARP III, 528 adult participants with asthma were followed up for a mean of 4·4 (SD 1·6) years, and 312 (59%) had severe asthma according to the ERS-ATS definition. Among the 205 participants with asthma who used rescue SABAs daily, 90 used these two or more times a day. In U-BIOPRED, 509 adult participants with asthma were followed up for 1 year, and 421 (83%) had severe asthma. The burden score was less than 1·29 per patient-year in 106 (34%) of 312 SARP III participants and in 80 (19%) of 421 U-BIOPRED participants with severe asthma. By contrast, the burden score was above the median value in 58 (28%) SARP III and 24 (27%) U-BIOPRED participants with non-severe asthma. In both cohorts, the burden score negatively correlated with lung function, asthma control, and quality of life. A burden score of 0·15 or lower predicted asthma remission with a sensitivity greater than 91% and a specificity of 99%. Our findings highlight considerable discrepancies between the current definition of asthma severity and our burden score. Although the definition of severe asthma proposed by the ERS-ATS and the and Global Initiative for Asthma (GINA) is based on prescribed asthma medications, our personalised health-care burden score includes patient-centred data that reflect disease severity and accurately predicts asthma remission. Subject to prospective validation, the burden score could help to optimise the management of high-risk individuals with asthma. SARP III: US National Heart, Lung, and Blood Institute; AstraZeneca; Boehringer Ingelheim; Genentech; GlaxoSmithKline; Sanofi Genzyme/Regeneron; and Teva Pharmaceuticals. Innovative Medicines Initiative Joint Undertaking (EU's Seventh Framework Programme and European Federation of Pharmaceutical Industries and Associations) and eTRIKS project. |
| 22 | Nizar Jarjour | APCC-Pulm | nnj@medicine.wisc.edu | Oncostatin-M Is Produced by Human Eosinophils and Expression Is Increased in Uncontrolled Severe Asthma. | |
| 23 | Nizar Jarjour | APCC-Pulm | nnj@medicine.wisc.edu | Multicohort Analysis of Bronchial Epithelial Cell Expression in Healthy Subjects and Patients with Asthma Reveals Four Clinically Distinct Clusters. | Asthma is a heterogeneous disease with variable presentation and characteristics. There is a critical need to identify underlying molecular endotypes of asthma. We performed the largest transcriptomic analysis of 808 bronchial epithelial cell (BEC) samples across 11 independent cohorts, including 3 cohorts from the Severe Asthma Research Program (SARP). Using 7 datasets (218 asthma patients, 148 healthy controls) as discovery cohorts, we identified 505 differentially expressed genes (DEGs), which we validated in the remaining four datasets. Unsupervised clustering using the 505 DEGs identified four reproducible clusters of patients with asthma across all datasets corresponding to healthy controls, mild/moderate asthma, and severe asthma with significant differences in several clinical markers of severity, including pulmonary function, T2 inflammation, FeNO, and max bronchodilator reversibility. Importantly, we found the same clusters in pediatric patients using nasal lavage fluid cells, demonstrating the gene signature and clusters are not confounded by age and conserved in both lower and upper airways. The four asthma clusters may represent a unifying framework for understanding the molecular heterogeneity of asthma. Further study could potentially enable a precision medicine approach of matching therapies with asthma patients most likely to benefit. |
| 24 | Nizar Jarjour | APCC-Pulm | nnj@medicine.wisc.edu | Breaking up Mucus Plugs in Asthma. | |
| 25 | Nizar Jarjour | APCC-Pulm | nnj@medicine.wisc.edu | Type 1 Immune Responses Related to Viral Infection Influence Corticosteroid Response in Asthma. | Corticosteroid-responsive type 2 (T2) inflammation underlies the T2-high asthma endotype. However, we hypothesized that type 1 (T1) inflammation, possibly related to viral infection, may also influence corticosteroid response. To determine the frequency and within-patient variability of T1-high, T2-high, and T1/T2-high asthma endotypes and whether virally influenced T1-high disease influences corticosteroid response in asthma. Patients in the Severe Asthma Research Program (SARP)-3 had sputum collected at baseline, after intramuscular (triamcinolone acetonide) corticosteroid treatment, and at 1 and 3-year follow-ups. Sputum cell RNA was used for whole transcriptome gene network and viral metagenomic analyses. We then profiled patients as highly expressing T1 and/or T2 gene networks and established the influence of these endotypes on corticosteroid responsiveness and likelihood of viral transcript detection in the airways. We found that 22% and 35% of asthma patients highly expressed T1 and T2 network genes, respectively, and that 8.5% highly expressed both networks. Asthma severity outcomes were worse in T2-high compared to T1-high asthma and most severe in the T1-high/T2-high subgroup. Corticosteroid treatment strongly suppressed T2 but poorly suppressed T1 gene expression, and corticosteroid-associated improvements in FEV1 occurred only in patients with T1-low/T2-high disease and not in T1-high/T2-high patients. Viral metagenomic analyses uncovered that 24% of asthma sputum samples tested positive for a respiratory virus and high viral carriage was associated with 14-fold increased risk of T1-high disease. Airway type 1 immune responses are relatively common in asthma, are largely corticosteroid-resistant, and are associated with sub-clinical viral infection. |
| 26 | Nizar Jarjour | APCC-Pulm | nnj@medicine.wisc.edu | Proteomic Analysis of Asthma Airway Inflammation Post-Allergen Challenge: A Heterogeneous Response. | |
| 27 | Nizar Jarjour | APCC-Pulm | nnj@medicine.wisc.edu | Asthma innovations from the second International Collaborative Asthma Network (ICAN) forum. | Asthma continues to cause morbidity and mortality despite advances in treatment that include biologics targeting Type 2 inflammation. The International Collaborative Asthma Network (ICAN) forum was developed with the primary goal of promoting innovative, collaborative research that focuses on mechanisms and treatment for asthma that does not respond or that responds poorly to currently available treatments. The mission of ICAN is innovation, collaboration, translation, and increasing high quality research. At the second ICAN meeting, presenters covered a broad scope and depth of asthma-related topics in the categories of complex data, novel therapeutics and diagnostics, breath analysis and microbiome, disease mechanisms, systemic effects, and circadian rhythm. Key actionable needs and research topics were identified during the group discussions. The presentations and discussions that occurred at the second ICAN had an immediate impact on asthma research in the form of new collaborations and implementation of new research ideas and techniques. The forum also served to connect early-stage investigators with investigators who are well established, thereby fostering innovation, translation, and collaboration well into the future. A third ICAN meeting is planned for 2025 to further the innovations and collaborations that will translate into novel therapies and diagnostics to improve the lives of patients with asthma. |
| 28 | Nizar Jarjour | APCC-Pulm | nnj@medicine.wisc.edu | Mitochondrial DNA copy number variation in asthma risk, severity, and exacerbations. | Asthma pathophysiology is associated with mitochondrial dysfunction. Mitochondrial DNA copy number (mtDNA-CN) has been used as a proxy of mitochondrial function, with lower levels indicating mitochondrial dysfunction in population studies of cardiovascular diseases and cancers. We investigated whether lower levels of mtDNA-CN are associated with asthma diagnosis, severity, and exacerbations. mtDNA-CN is evaluated in blood from 2 cohorts: UK Biobank (UKB) (asthma, n = 39,147; no asthma, n = 302,302) and Severe Asthma Research Program (SARP) (asthma, n = 1283; nonsevere asthma, n = 703). Individuals with asthma have lower mtDNA-CN compared to individuals without asthma in UKB (beta, -0.006 [95% confidence interval, -0.008 to -0.003], P = 6.23 × 10-6). Lower mtDNA-CN is associated with asthma prevalence, but not severity in UKB or SARP. mtDNA-CN declines with age but is lower in individuals with asthma than in individuals without asthma at all ages. In a 1-year longitudinal study in SARP, mtDNA-CN was associated with risk of exacerbation; those with highest mtDNA-CN had the lowest risk of exacerbation (odds ratio 0.333 [95% confidence interval, 0.173 to 0.542], P = .001). Biomarkers of inflammation and oxidative stress are higher in individuals with asthma than without asthma, but the lower mtDNA-CN in asthma is independent of general inflammation or oxidative stress. Mendelian randomization studies suggest a potential causal relationship between asthma-associated genetic variants and mtDNA-CN. mtDNA-CN is lower in asthma than in no asthma and is associated with exacerbations. Low mtDNA-CN in asthma is not mediated through inflammation but is associated with a genetic predisposition to asthma. |
| 29 | Nizar Jarjour | APCC-Pulm | nnj@medicine.wisc.edu | Utility of eosinophil peroxidase as a biomarker of eosinophilic inflammation in asthma. | The relative utility of eosinophil peroxidase (EPX) and blood and sputum eosinophil counts as disease biomarkers in asthma is uncertain. We sought to determine the utility of EPX as a biomarker of systemic and airway eosinophilic inflammation in asthma. EPX protein was measured by immunoassay in serum and sputum in 110 healthy controls to establish a normal reference range and in repeated samples of serum and sputum collected during 3 years of observation in 480 participants in the Severe Asthma Research Program 3. Over 3 years, EPX levels in patients with asthma were higher than normal in 27% to 31% of serum samples and 36% to 53% of sputum samples. Eosinophils and EPX correlated better in blood than in sputum (rs values of 0.74 and 0.43, respectively), and high sputum EPX levels occurred in 27% of participants with blood eosinophil counts less than 150 cells/μL and 42% of participants with blood eosinophil counts between 150 and 299 cells/μL. Patients with persistently high sputum EPX values for 3 years were characterized by severe airflow obstruction, frequent exacerbations, and high mucus plug scores. In 59 patients with asthma who started mepolizumab during observation, serum EPX levels normalized in 96% but sputum EPX normalized in only 49%. Lung function remained abnormal even when sputum EPX normalized. Serum EPX is a valid protein biomarker of systemic eosinophilic inflammation in asthma, and sputum EPX levels are a more sensitive biomarker of airway eosinophilic inflammation than sputum eosinophil counts. Eosinophil measures in blood frequently miss airway eosinophilic inflammation, and mepolizumab frequently fails to normalize airway eosinophilic inflammation even though it invariably normalizes systemic eosinophilic inflammation. |
| 30 | Sameer Mathur | APCC-AA | skmathur@wisc.edu | Real-world mepolizumab treatment in eosinophilic granulomatosis with polyangiitis reduces disease burden in the United States. | Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare, chronic inflammatory disease characterized by asthma and small/medium vessel vasculitis. Mepolizumab is approved for use in EGPA disease management alongside oral corticosteroids (OCS), but evidence of its real-world impact is limited. To compare real-world treatment patterns and health outcomes, particularly OCS use, EGPA-related hospitalizations/relapses, and asthma exacerbations pre- and post-mepolizumab initiation in US patients with EGPA. Patients with EGPA receiving more than or equal to 2 mepolizumab doses were identified using administrative claims data from Komodo Health's Comprehensive Dataset (between December 2016-March 2020). Outcomes assessed pre- and post-mepolizumab initiation included corticosteroid/other medication use, EGPA-related hospitalizations/relapses, and asthma exacerbations. Overall, 114 patients were identified; of these, 60 (53%) received mepolizumab 300 mg at index. Average daily OCS dose per dispensing was significantly lower post- vs pre-mepolizumab initiation (21.2 vs 26.8 mg/d, 21% relative reduction, P < .001); mean number of OCS bursts also decreased (0.9 vs 1.8, 50% relative reduction, P < .001). Patients experienced significantly lower rates of EGPA-related hospitalization (0.86 vs 1.55 per-person year [PPY], 49% relative reduction, P = .004) and EGPA relapse (3.18 vs 3.94 PPY, 19% relative reduction, P = .004) post- vs pre-initiation. Most patients (91%) had an asthma diagnosis at baseline; among these patients, asthma exacerbation rates were significantly lower post- vs pre-initiation (1.05 vs 1.84 PPY, 42% relative reduction, P = .004). Mepolizumab was associated with significant steroid-sparing benefits and significantly reduced rates of EGPA-related hospitalizations, EGPA relapses, and asthma exacerbations in this real-world study of US patients with EGPA, confirming the benefits of mepolizumab treatment seen in clinical trials. |
| 31 | Sameer Mathur | APCC-AA | skmathur@wisc.edu | Eosinophil count testing in patients with asthma varies by healthcare provider type in the US: a retrospective study. | Patients with asthma with an eosinophilic phenotype may be eligible for additional treatment options to improve disease control; however, the prevalence and frequency of eosinophil testing is unknown. This study assessed blood eosinophil count testing prevalence in patients with asthma by exacerbation frequency and healthcare provider (HCP) type. This was a retrospective, longitudinal, real-world study (GSK ID: 214470) utilizing the Merative Explorys® Universe electronic health records database. Eligible patients had ≥ 2 asthma diagnostic codes (January 2016-December 2018) (Index date: first asthma diagnosis). Outcomes included patient demographics and clinical characteristics (12 months pre-index [baseline]), and prevalence of blood eosinophil count testing, stratified by exacerbation frequency (infrequent exacerbations [< 2]) or frequent exacerbations [≥ 2] or primary HCP (Allergist/Pulmonologist, a primary care physician [PCP] or other HCP) during the 12 months post-index (follow-up). Of 400,254 patients included (mean age: 51.2 years; 70.8% female), the most common provider type at baseline was a PCP (76.8%). A higher proportion of patients with frequent exacerbations had blood eosinophil count tests at baseline (55.4-69.5%) and follow-up (67.9-75.1%), compared with patients with infrequent exacerbations (55.5-63.7%, 62.4-67.3%). Significantly more patients in the Allergist/Pulmonologist subgroup had ≥ 1 blood eosinophil count test result compared with patients in the PCP subgroup at both baseline (59.9% vs. 50.7%; p < 0.001) and follow-up (59.0% vs. 56.2%; p < 0.001). In the total population, the mean (SD) number of tests ordered was 3.4 (5.3) and 4.1 (6.4) during the baseline and follow-up periods, respectively. A greater mean number of tests were ordered for patients with frequent exacerbations, most apparently in the Allergist/Pulmonologist subgroup during baseline and follow-up (7.4 vs. 4.9). For patients with frequent exacerbations and blood eosinophil count test results, the mean (SD) number of tests ranged from 3.1 (4.6) to 5.8 (8.3) at baseline and 5.1 (8.5) to 7.4 (10.6) during follow-up. The prevalence of blood eosinophil count testing in patients with asthma remains suboptimal. Routine blood eosinophil count testing should be considered by HCPs for patients with asthma to increase identification of the eosinophilic asthma phenotype, which may inform the decision to advance to targeted biologic therapy. |
| 32 | Sameer Mathur | APCC-AA | skmathur@wisc.edu | Topical corticosteroids for hives and itch (urticaria): Systematic review and Bayesian meta-analysis of randomized trials. | Topical corticosteroids are widely used as a treatment for itch and wheals (urticaria), but their benefits and harms are unclear. To systematically synthesize the benefits and harms of topical corticosteroids for the treatment of urticaria. We searched MEDLINE, EMBASE, and CENTRAL from database inception to March 23, 2024, for randomized trials comparing topical corticosteroids with placebo for patients with urticaria (either chronic spontaneous or inducible urticaria or acute urticaria elicited from skin/intradermal allergy testing). Paired reviewers independently screened records, extracted data, and assessed risk of bias. Random-effects meta-analyses addressed urticaria severity, itch severity (numeric rating scale; range 0-10; higher is worse), and adverse events. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach informed certainty of evidence ratings. PROSPERO registration: CRD42023455182. A total of 19 randomized controlled trials enrolled 379 participants with a median of mean age of 30.1 (range 21.1-44.0) years. Compared with placebo, topical corticosteroids may reduce wheal size (ratio of means 0.47, 95% CI 0.38-0.59; low certainty) and itch severity (mean difference -1.30, 95% CI -5.07 to 2.46; very low certainty). Topical corticosteroids result in little to no difference in overall adverse events (94 fewer patients per 1000, 95% credible intervals 172 fewer to 12 more; high certainty). Compared with placebo, topical corticosteroids may result in a reduction of wheal size and little to no difference in overall adverse events. Topical corticosteroids may reduce itch severity, but the evidence is very uncertain. Future large, randomized trials addressing the use of topical corticosteroids would further support optimal urticaria management. |
| 33 | Sameer Mathur | APCC-AA | skmathur@wisc.edu | Leukotriene receptor antagonists as add-on therapy to antihistamines for urticaria: Systematic review and meta-analysis of randomized clinical trials. | The benefits and harms of adding antileukotrienes to H1 antihistamines (AHs) for the management of urticaria (hives, itch, and/or angioedema) remain unclear. We sought to systematically synthesize the treatment outcomes of antileukotrienes in combination with AHs versus AHs alone for acute and chronic urticaria. As part of updating American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters urticaria guidelines, we searched Medline, Embase, Central, LILACS, WPRIM, IBECS, ICTRP, CBM, CNKI, VIP, Wanfang, US Food and Drug Administration, and European Medicines Agency databases from inception to December 18, 2023, for randomized controlled trials (RCTs) evaluating antileukotrienes and AHs versus AHs alone in patients with urticaria. Paired reviewers independently screened citations, extracted data, and assessed risk of bias. Random effects models pooled effect estimates for urticaria activity, itch, wheal, sleep, quality of life, and harms. The GRADE approach informed certainty of evidence ratings. The study was registered at the Open Science Framework (osf.io/h2bfx/). Thirty-four RCTs enrolled 3324 children and adults. Compared to AHs alone, the combination of a leukotriene receptor antagonist with AHs probably modestly reduces urticaria activity (mean difference, -5.04; 95% confidence interval, -6.36 to -3.71; 7-day urticaria activity score) with moderate certainty. We made similar findings for itch and wheal severity as well as quality of life. Adverse events were probably not different between groups (moderate certainty); however, no RCT reported on neuropsychiatric adverse events. Among patients with urticaria, adding leukotriene receptor antagonists to AHs probably modestly improves urticaria activity with little to no increase in overall adverse events. The added risk of neuropsychiatric adverse events in this population with leukotriene receptor antagonists is small and uncertain. |
| 34 | Sameer Mathur | APCC-AA | skmathur@wisc.edu | Biologic therapy in rare eosinophil-associated disorders: remaining questions and translational research opportunities. | Rare eosinophil-associated disorders (EADs), including hypereosinophilic syndrome, eosinophilic granulomatosis with polyangiitis, and eosinophilic gastrointestinal disorders, are a heterogeneous group of conditions characterized by blood and/or tissue hypereosinophilia and eosinophil-related clinical manifestations. Although the recent availability of biologic therapies that directly and indirectly target eosinophils has the potential to dramatically improve treatment options for all EADs, clinical trials addressing their safety and efficacy in rare EADs have been relatively few. Consequently, patient access to therapy is limited for many biologics, and the establishment of evidence-based treatment guidelines has been extremely difficult. In this regard, multicenter retrospective collaborative studies focusing on disease manifestations and treatment responses in rare EADs have provided invaluable data for physicians managing patients with these conditions and helped identify important questions for future translational research. During the Clinical Pre-Meeting Workshop held in association with the July 2023 biennial meeting of the International Eosinophil Society in Hamilton, Ontario, Canada, the successes and limitations of pivotal multicenter retrospective studies in EADs were summarized and unmet needs regarding the establishment of guidelines for use of biologics in rare EADs were discussed. Key topics of interest included (1) clinical outcome measures, (2) minimally invasive biomarkers of disease activity, (3) predictors of response to biologic agents, and (4) long-term safety of eosinophil depletion. Herein, we report a summary of these discussions, presenting a state-of-the-art overview of data currently available for each of these topics, the limitations of the data, and avenues for future data generation through implementation of multidisciplinary and multicenter studies. |
| 35 | Sameer Mathur | APCC-AA | skmathur@wisc.edu | Dupilumab for chronic spontaneous urticaria-marvelous or meek? | |
| 36 | Sameer Mathur | APCC-AA | skmathur@wisc.edu | Efficacy and Safety of Systemic Corticosteroids for Urticaria: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. | Short courses of adjunctive systemic corticosteroids are commonly used to treat acute urticaria and chronic urticaria flares (both with and without mast cell-mediated angioedema), but their benefits and harms are unclear. To evaluate the efficacy and safety of treating acute urticaria or chronic urticaria flares with versus without systemic corticosteroids. We searched the MEDLINE, EMBASE, CENTRAL, CNKI, VIP, Wanfang, and CBM databases from inception to July 8, 2023, for randomized controlled trials of treating urticaria with versus without systemic corticosteroids. Paired reviewers independently screened records, extracted data, and appraised risk of bias with the Cochrane 2.0 tool. We performed random-effects meta-analyses of urticaria activity, itch severity, and adverse events. We assessed certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluations (GRADE) approach. We identified 12 randomized trials enrolling 944 patients. For patients with low or moderate probability (17.5%-64%) to improve with antihistamines alone, add-on systemic corticosteroids likely improve urticaria activity by a 14% to 15% absolute difference (odds ratio [OR], 2.17, 95% confidence interval [CI]: 1.43-3.31; number needed to treat [NNT], 7; moderate certainty). Among patients with a high chance (95.8%) for urticaria to improve with antihistamines alone, add-on systemic corticosteroids likely improved urticaria activity by a 2.2% absolute difference (NNT, 45; moderate certainty). Corticosteroids may improve itch severity (OR, 2.44; 95% CI: 0.87-6.83; risk difference, 9%; NNT, 11; low certainty). Systemic corticosteroids also likely increase adverse events (OR, 2.76; 95% CI: 1.00-7.62; risk difference, 15%; number needed to harm, 9; moderate certainty). Systemic corticosteroids for acute urticaria or chronic urticaria exacerbations likely improve urticaria, depending on antihistamine responsiveness, but also likely increase adverse effects in approximately 15% more. |
| 37 | Sameer Mathur | APCC-AA | skmathur@wisc.edu | Food allergy symptoms in adults and children using the Food Allergy Research & Education Patient Registry. | |
| 38 | Sameer Mathur | APCC-AA | skmathur@wisc.edu | Plain Language Summary of principles for improving the care of people with eosinophil-associated diseases. | Eosinophil-associated diseases (EADs) are a group of conditions in which eosinophils (a type of white blood cell) are thought to play a key role in the disease and how it develops. Some EADs are common, such as atopic dermatitis (also called eczema) and a subtype of asthma called eosinophilic asthma, while others are rare, such as hypereosinophilic syndrome (a condition in which a person has a very high number of eosinophils in both the blood and one or more organs). People with EADs face many problems related to their conditions. Symptoms such as severe abdominal pain, itch, or shortness of breath impact both the patient as well as their friends and family. Patients with EADs also experience delays to diagnosis and treatment as well as financial barriers. Healthcare professionals sometimes fail to recognize the complex set of symptoms that characterize an EAD, and this may cause delays in reaching a correct diagnosis. As a result, it may take longer for a patient to get the best care and the most effective treatments, which may contribute to poor health. The goal of this charter is to describe the key elements of good quality care, which all people with EADs deserve, as well as to present an action plan to improve health and overall well-being for people with EADs. Proposed use of this patient charter: The principles described in this charter (a written guide to achieve an outcome) show the core elements of quality care that people with EADs must receive. They also describe clear steps to reduce the burden on patients and their caregivers and to improve patient health outcomes. We urge healthcare professionals, hospitals, and policymakers around the world to adopt these principles quickly. By doing this, people with EADs will be more likely to receive an accurate and timely diagnosis and have access to quality care and treatment in the right setting. |
| 39 | Sameer Mathur | APCC-AA | skmathur@wisc.edu | Omalizumab for treatment of idiopathic angioedema. | Omalizumab has been found to improve outcomes in patients with chronic spontaneous urticaria (CSU). Idiopathic angioedema (IAE) is increasingly being recognized as a condition with similar underlying mechanisms as CSU and a form of CSU. We hypothesized that add-on therapy with omalizumab would benefit patients with uncontrolled IAE. To study the safety and efficacy of omalizumab for the treatment of IAE in adults. We conducted a randomized, placebo-controlled trial to study the efficacy of omalizumab in adults with 2 or more episodes of angioedema (AE) in the past 6 months for which no clinical or laboratory cause of AE could be found. A total of 10 patients were randomized on a 1:1 basis to receive omalizumab 300 mg subcutaneously or placebo every 4 weeks for 24 weeks with a 12-week follow-up period. The primary endpoint was the change in the Angioedema Activity Score. Secondary endpoints included the Angioedema Quality of Life Questionnaire, the Visual Analogue Scale, and the number of angioedema episodes per month. We observed improvement in the Angioedema Activity Score (-2.93 ln odds; 95% confidence interval [CI], -4.84 to -1.02; P = .003), Visual Analogue Scale (-3.49 ln odds; 95% CI, -6.58 to -0.40; P = .03), Angioedema Quality of Life Questionnaire (-9.43 score; 95% CI, -17.63 to -1.24; P = .03), and number of angioedema episodes per month (-1.93 ln count; 95% CI, -3.23 to -0.63; P = .005) in patients who received omalizumab vs placebo. This study provides preliminary prospective evidence that omalizumab improves outcomes in patients with IAE. ClinicalTrials.gov Identifier: NCT02966314. gov URL:https://clinicaltrials.gov/ct2/show/NCT02966314?term=omalizumab&cond=Angioedema&draw=2&rank=1. |
| 40 | Lixin Rui | HEM/ONC | lrui@medicine.wisc.edu | Combination fedratinib and venetoclax has activity against human B-ALL with high FLT3 expression. | Treatment of relapsed/refractory B cell acute lymphoblastic leukemia (B-ALL) remains a challenge, particularly in patients who do not respond to traditional chemotherapy or immunotherapy. The objective of this study was to assess the efficacy of fedratinib, a semi selective JAK2 inhibitor and venetoclax, a selective BCL-2 inhibitor, on human B-ALL using both single-agent and combinatorial treatments. The combination treatment of fedratinib and venetoclax improved killing of the human B-ALL cell lines RS4;11 and SUPB-15 in vitro over single-agent treatments. This combinatorial effect was not detected in the human B-ALL cell line NALM-6, which was less responsive to fedratinib due to the absence of Flt3 expression. The combination treatment induces a unique gene expression profile relative to single-agent treatment and with an enrichment in apoptotic pathways. Finally, the combination treatment was superior to single agent treatment in an in vivo xenograft model of human B-ALL, with a two-week treatment regimen significantly improving overall survival while inducing CD19 expression. Overall, our data demonstrates the efficacy of a combinatorial treatment strategy of fedratinib and venetoclax against human B-ALL expressing high levels of Flt3. |
| 41 | Lixin Rui | HEM/ONC | lrui@medicine.wisc.edu | Targeting DNMT3A-mediated oxidative phosphorylation to overcome ibrutinib resistance in mantle cell lymphoma. | The use of Bruton tyrosine kinase (BTK) inhibitors such as ibrutinib achieves a remarkable clinical response in mantle cell lymphoma (MCL). Acquired drug resistance, however, is significant and affects long-term survival of MCL patients. Here, we demonstrate that DNA methyltransferase 3A (DNMT3A) is involved in ibrutinib resistance. We find that DNMT3A expression is upregulated upon ibrutinib treatment in ibrutinib-resistant MCL cells. Genetic and pharmacological analyses reveal that DNMT3A mediates ibrutinib resistance independent of its DNA-methylation function. Mechanistically, DNMT3A induces the expression of MYC target genes through interaction with the transcription factors MEF2B and MYC, thus mediating metabolic reprogramming to oxidative phosphorylation (OXPHOS). Targeting DNMT3A with low-dose decitabine inhibits the growth of ibrutinib-resistant lymphoma cells both in vitro and in a patient-derived xenograft mouse model. These findings suggest that targeting DNMT3A-mediated metabolic reprogramming to OXPHOS with decitabine provides a potential therapeutic strategy to overcome ibrutinib resistance in relapsed/refractory MCL. |
| 42 | Lixin Rui | HEM/ONC | lrui@medicine.wisc.edu | Hypomethylating agent decitabine sensitizes diffuse large B-cell lymphoma to venetoclax. | Despite recent advances in the therapy of diffuse large B-cell lymphoma (DLBCL), many patients are still not cured. Therefore, new therapeutic strategies are needed. The anti-apoptotic B-cell lymphoma 2 (BCL2) gene is commonly dysregulated in DLBCL due to various mechanisms such as chromosomal translocation t(14;18)(q32;q21) and copy number alterations; however, targeting BCL-2 with the selective inhibitor, venetoclax, led to response in only a minority of patients. Thus, we sought to identify a rational combination partner of venetoclax to improve its activity against DLBCL cells. Utilizing a functional assay, dynamic BH3 profiling, we found that the DNA hypomethylating agent decitabine increased mitochondrial apoptotic priming and BCL-2 dependence in DLBCL cells. RNA-sequencing analysis revealed that decitabine suppressed the pro-survival PI3K-AKT pathway and altered the mitochondria membrane composition in DLBCL cell lines. Additionally, it induced a DNA damage response and increased BAX and BAK activities. The combination of decitabine and venetoclax synergistically suppressed proliferation of DLBCL cells both in vitro and in vivo in a DLBCL cell line-derived xenograft mouse model. Our study suggests that decitabine plus venetoclax is a promising combination to explore clinically in DLBCL. |
| 43 | Lixin Rui | HEM/ONC | lrui@medicine.wisc.edu | EGR1-mediated metabolic reprogramming to oxidative phosphorylation contributes to ibrutinib resistance in B-cell lymphoma. | The use of Bruton tyrosine kinase inhibitors, such as ibrutinib, to block B-cell receptor signaling has achieved a remarkable clinical response in several B-cell malignancies, including mantle cell lymphoma (MCL) and diffuse large B-cell lymphoma (DLBCL). Acquired drug resistance, however, is significant and affects the long-term survival of these patients. Here, we demonstrate that the transcription factor early growth response gene 1 (EGR1) is involved in ibrutinib resistance. We found that EGR1 expression is elevated in ibrutinib-resistant activated B-cell-like subtype DLBCL and MCL cells and can be further upregulated upon ibrutinib treatment. Genetic and pharmacological analyses revealed that overexpressed EGR1 mediates ibrutinib resistance. Mechanistically, TCF4 and EGR1 self-regulation induce EGR1 overexpression that mediates metabolic reprogramming to oxidative phosphorylation (OXPHOS) through the transcriptional activation of PDP1, a phosphatase that dephosphorylates and activates the E1 component of the large pyruvate dehydrogenase complex. Therefore, EGR1-mediated PDP1 activation increases intracellular adenosine triphosphate production, leading to sufficient energy to enhance the proliferation and survival of ibrutinib-resistant lymphoma cells. Finally, we demonstrate that targeting OXPHOS with metformin or IM156, a newly developed OXPHOS inhibitor, inhibits the growth of ibrutinib-resistant lymphoma cells both in vitro and in a patient-derived xenograft mouse model. These findings suggest that targeting EGR1-mediated metabolic reprogramming to OXPHOS with metformin or IM156 provides a potential therapeutic strategy to overcome ibrutinib resistance in relapsed/refractory DLBCL or MCL. |
| 44 | Lixin Rui | HEM/ONC | lrui@medicine.wisc.edu | Exploiting PRMT5 as a target for combination therapy in mantle cell lymphoma characterized by frequent ATM and TP53 mutations. | Constant challenges for the treatment of mantle cell lymphoma (MCL) remain to be recurrent relapses and therapy resistance, especially in patients harboring somatic mutations in the tumor suppressors ATM and TP53, which are accumulated as therapy resistance emerges and the disease progresses, consistent with our OncoPrint results that ATM and TP53 alterations were most frequent in relapsed/refractory (R/R) MCL. We demonstrated that protein arginine methyltransferase-5 (PRMT5) was upregulated in R/R MCL, which predicted a poor prognosis. PRMT5 inhibitors displayed profound antitumor effects in the mouse models of MCL with mutated ATM and/or TP53, or refractory to CD19-targeted CAR T-cell therapy. Genetic knockout of PRMT5 robustly inhibited tumor growth in vivo. Co-targeting PRMT5, and ATR or CDK4 by using their inhibitors showed synergistic antitumor effects both in vitro and in vivo. Our results have provided a rational combination therapeutic strategy targeting multiple PRMT5-coordinated tumor-promoting processes for the treatment of R/R MCL with high mutation burdens. |
| 45 | Lixin Rui | HEM/ONC | lrui@medicine.wisc.edu | BAF155 methylation drives metastasis by hijacking super-enhancers and subverting anti-tumor immunity. | Subunits of the chromatin remodeler SWI/SNF are the most frequently disrupted genes in cancer. However, how post-translational modifications (PTM) of SWI/SNF subunits elicit epigenetic dysfunction remains unknown. Arginine-methylation of BAF155 by coactivator-associated arginine methyltransferase 1 (CARM1) promotes triple-negative breast cancer (TNBC) metastasis. Herein, we discovered the dual roles of methylated-BAF155 (me-BAF155) in promoting tumor metastasis: activation of super-enhancer-addicted oncogenes by recruiting BRD4, and repression of interferon α/γ pathway genes to suppress host immune response. Pharmacological inhibition of CARM1 and BAF155 methylation not only abrogated the expression of an array of oncogenes, but also boosted host immune responses by enhancing the activity and tumor infiltration of cytotoxic T cells. Moreover, strong me-BAF155 staining was detected in circulating tumor cells from metastatic cancer patients. Despite low cytotoxicity, CARM1 inhibitors strongly inhibited TNBC cell migration in vitro, and growth and metastasis in vivo. These findings illustrate a unique mechanism of arginine methylation of a SWI/SNF subunit that drives epigenetic dysregulation, and establishes me-BAF155 as a therapeutic target to enhance immunotherapy efficacy. |
| 46 | Lixin Rui | HEM/ONC | lrui@medicine.wisc.edu | EGR1 Addiction in Diffuse Large B-cell Lymphoma. | Early growth response gene (EGR1) is a transcription factor known to be a downstream effector of B-cell receptor signaling and Janus kinase 1 (JAK1) signaling in diffuse large B-cell lymphoma (DLBCL). While EGR1 is characterized as a tumor suppressor in leukemia and multiple myeloma, the role of EGR1 in lymphoma is unknown. Here we demonstrate that EGR1 is a potential oncogene that promotes cell proliferation in DLBCL. IHC analysis revealed that EGR1 expression is elevated in DLBCL compared with normal lymphoid tissues and the level of EGR1 expression is higher in activated B cell-like subtype (ABC) than germinal center B cell-like subtype (GCB). EGR1 expression is required for the survival and proliferation of DLBCL cells. Genomic analyses demonstrated that EGR1 upregulates expression of MYC and E2F pathway genes through the CBP/p300/H3K27ac/BRD4 axis while repressing expression of the type I IFN pathway genes by interaction with the corepressor NAB2. Genetic and pharmacologic inhibition of EGR1 synergizes with the BRD4 inhibitor JQ1 or the type I IFN inducer lenalidomide in growth inhibition of ABC DLBCL both in cell cultures and xenograft mouse models. Therefore, targeting oncogenic EGR1 signaling represents a potential new targeted therapeutic strategy in DLBCL, especially for the more aggressive ABC DLBCL. IMPLICATIONS: The study characterizes EGR1 as a potential oncogene that promotes cell proliferation and defines EGR1 as a new molecular target in DLBCL, the most common non-Hodgkin lymphoma. |
| 47 | Lixin Rui | HEM/ONC | lrui@medicine.wisc.edu | CXCR4 allows T cell acute lymphoblastic leukemia to escape from JAK1/2 and BCL2 inhibition through CNS infiltration. | Targeting the JAK/STAT and BCL2 pathways in patients with relapsed/refractory T cell acute lymphoblastic leukemia (T-ALL) may provide an alternative approach to achieve clinical remissions. Ruxolitinib and venetoclax show a dose-dependent effect on T-ALL individually, but combination treatment reduces survival and proliferation of T-ALL in vitro. Using a xenograft model, the combination treatment fails to improve survival, with death from hind limb paralysis. Despite on-target inhibition by the drugs, histopathology demonstrates increased leukemic infiltration into the central nervous system (CNS) as compared to liver or bone marrow. Liquid chromatography-tandem mass spectroscopy shows that ruxolitinib and venetoclax insufficiently cross into the CNS. The addition of the CXCR4 inhibitor plerixafor with ruxolitinib and venetoclax reduces clinical scores and enhances survival. While combination therapy with ruxolitinib and venetoclax shows promise for treating T-ALL, additional inhibition of the CXCR4-CXCL12 axis may be needed to maximize the possibility of complete remission. |
| 48 | Lixin Rui | HEM/ONC | lrui@medicine.wisc.edu | Loss-of-function of Fbxo10, encoding a post-translational regulator of BCL2 in lymphomas, has no discernible effect on BCL2 or B lymphocyte accumulation in mice. | Regulation of the anti-apoptotic BCL2 protein determines cell survival and is frequently abnormal in B cell lymphomas. An evolutionarily conserved post-translational mechanism for over-expression of BCL2 in human B cell lymphomas and the BCL2 paralogue CED-9 in Caenorhabditis elegans results from loss-of-function mutations in human FBXO10 and its C.elegans paralogue DRE-1, a BCL2/CED-9-binding subunit of the SKP-CULLIN-FBOX (SCF) ubiquitin ligase. Here, we tested the role of FBXO10 in BCL2 regulation by producing mice with two different CRISPR/Cas9-engineered Fbxo10 mutations: an Asp54Lys (E54K) missense mutation in the FBOX domain and a Cys55SerfsTer55 frameshift (fs) truncating mutation. Mice homozygous for either mutant allele were born at the expected Mendelian frequency and appeared normal in body weight and appearance as adults. Spleen B cells from homozygous mutant mice did not have increased BCL2 protein, nor were the numbers of mature B cells or germinal centre B cells increased as would be expected if BCL2 was increased. Other lymphocyte subsets that are also regulated by BCL2 levels also displayed no difference in frequency in homozygous Fbxo10 mutant mice. These results support one of two conclusions: either FBXO10 does not regulate BCL2 in mice, or it does so redundantly with other ubiquitin ligase complexes. Possible candidates for the latter include FBXO11 or ARTS-XIAP. The difference between the role of FBXO10 in regulating BCL2 protein levels in C. elegans and in human DLBCL, relative to single-gene deficient mouse leukocytes, should be further investigated. |
| 49 | Lixin Rui | HEM/ONC | lrui@medicine.wisc.edu | DNA methyltransferases in hematological malignancies. | DNA methyltransferases (DNMTs) are an evolutionarily conserved family of DNA methylases, transferring a methyl group onto the fifth carbon of a cytosine residue. The mammalian DNMT family includes three major members that have functional methylation activities, termed DNMT1, DNMT3A, and DNMT3B. DNMT3A and DNMT3B are responsible for methylation establishment, whereas DNMT1 maintains methylation during DNA replication. Accumulating evidence demonstrates that regulation of DNA methylation by DNMTs is critical for normal hematopoiesis. Aberrant DNA methylation due to DNMT dysregulation and mutations is known as an important molecular event of hematological malignancies, such as DNMT3A mutations in acute myeloid leukemia. In this review, we first describe the basic methylation mechanisms of DNMTs and their functions in lymphocyte maturation and differentiation. We then discuss the current understanding of DNA methylation heterogeneity in leukemia and lymphoma to highlight the importance of studying DNA methylation targets. We also discuss DNMT mutations and pathogenic roles in human leukemia and lymphoma. We summarize the recent understanding of how DNMTs interact with transcription factors or cofactors to repress the expression of tumor suppressor genes. Finally, we highlight current clinical studies using DNMT inhibitors for the treatment of these hematological malignancies. |
| 50 | Noelle LoConte | HEM/ONC | ns3@medicine.wisc.edu | Phase I/II Trial of Perioperative Avelumab in Combination With Chemoradiation in the Treatment of Stage II/III Resectable Esophageal and Gastroesophageal Junction Cancer. | Standard treatment of patients with stage II/III esophageal or gastroesophageal junction (E/GEJ) cancer involves neoadjuvant chemoradiation (nCRT), resection, and immunotherapy. Our trial evaluated the addition of perioperative avelumab to standard treatments. Patients with resectable E/GEJ cancers received avelumab with nCRT and adjuvant avelumab after resection. Primary endpoints for phase I and II portions were safety and pathologic complete response (pCR) rate, respectively. Secondary endpoints included recurrence-free survival (RFS), surgical complication prevalence, and R0 resection rate. Twenty-two patients enrolled in the study. Median follow-up during data cutoff was 23.9 months. There were no dose-limiting toxicities during the run-in phase. Nineteen patients (86.4%) underwent resection with R0 resection rate of 78.9% and with pCR rate of 26%. Most common treatment-related adverse events (TRAE) were cytopenias from chemoradiation. Aside from one grade ≥ 3 avelumab-related hypersensitivity, no grade ≥ 3 avelumab TRAEs were seen. Median RFS was not reached, and 1-year RFS and overall survival were 71% and 81%, respectively. The study was terminated before full planned accrual due to standard practice change based on the CheckMate 577 trial. The addition of perioperative avelumab to nCRT was tolerable and demonstrated promising outcomes. |
| 51 | Noelle LoConte | HEM/ONC | ns3@medicine.wisc.edu | Carboplatin and Paclitaxel Chemoradiation for Localized Anal Cancer in Patients Not Eligible for Mitomycin and 5-Fluorouracil. | Although squamous cell carcinoma of the anus (SCCA) is a relatively uncommon malignancy in the United States, it continues to increase in incidence. Treatment for locoregional disease includes mitomycin and 5-fluorouracil with radiation. This combination is associated with significant toxicity, limiting its use in patients who are older or have certain comorbidities. Carboplatin and paclitaxel (C/P) is an accepted treatment regimen for metastatic SCCA. We aim to evaluate the efficacy and toxicity of weekly C/P given with radiation for patients unable to receive standard chemoradiation for SCCA. From our cancer registry, adult patients who received weekly intravenous C/P concurrent with standard-dose radiation for localized SCCA were included in this study. Clinical response was determined based on the evidence of disease on imaging and/or anoscopy. Toxicities were graded according to the CTCAE v5. Ten patients were included; eight were female, and the median age was 75.5 years (54-87). Six had T2 disease, and four had T3 tumors. Four had node-positive disease. The majority (70%) of patients were dosed at standard C (AUC 2) and P (50 mg/m2), with a limited subset requiring dose reduction for baseline performance status. Patients completed a mean of 78.3% (40-100%) of the intended treatments. A total of 89% of the patients achieved a complete clinical response. With a median follow-up of 25.8 months (3.4-50.4 months), 67% of the patients are alive and without recurrence. Two patients have had local recurrence, and one patient had metastatic progression. The most common toxicities of any grade included leukopenia (100%), anemia (100%), radiation dermatitis (100%), diarrhea (100%), and fatigue (100%). Grade 3 or higher toxicities included neutropenic fever (20%), neutropenia (30%), and anemia (30%). This study demonstrates promising tolerability and efficacy for weekly C/P chemoradiation for patients with anal cancer unable to receive mitomycin and 5-fluorouracil. This regimen merits further investigation in prospective clinical trials. |
| 52 | Noelle LoConte | HEM/ONC | ns3@medicine.wisc.edu | Understanding futility in pancreaticoduodenectomy: Insights from a national cohort. | Pancreaticoduodenectomy (PD), the only surgical option for right-sided pancreatic ductal adenocarcinoma (PDAC), carries significant morbidity. Not all patients may be deriving a survival benefit from this operation. We sought to identify the rate of futile PD and its associated factors in a large national cohort. We performed a retrospective analysis using the National Cancer Database (2004-2020), including all patients who underwent PD for non-metastatic PDAC. The primary outcome was operative futility, which was defined as death within 12 months of diagnosis despite PD. Multivariable regression was used to identify factors associated with futility. We performed a subgroup analysis on patients who received neoadjuvant systemic therapy. Data from 66 326 patients were analyzed, and 16 772 (25.3%) underwent PD that met criteria for futility. Macroscopically positive margins (odds ratio [OR]: 2.87; 95% confidence interval [CI]: 2.36-3.48), poor tumor differentiation (OR: 2.44; 95% CI: 2.25-2.65), and N2 nodal stage (OR: 2.09; 95% CI: 1.98-2.20) were associated with the greatest odds of futility. Meanwhile, receipt of any systemic therapy (OR: 0.33; 95% CI: 0.31-0.34), receipt of any radiation (OR: 0.60; 95% CI: 0.57-0.63), and receipt of neoadjuvant systemic therapy (OR: 0.62; 95% CI: 0.57-0.66) were associated with the lowest odds of futility. In the neoadjuvant subgroup, a longer diagnosis-to-surgery interval was associated with lower odds of futility. PD was futile in about one quarter of patients. Futility was associated with higher age and worse tumor biology. Receipt of neoadjuvant therapy resulted in fewer futile operations. |
| 53 | Noelle LoConte | HEM/ONC | ns3@medicine.wisc.edu | Patient resourcefulness and caregiver burden are interlinked with quality of life. | |
| 54 | Noelle LoConte | HEM/ONC | ns3@medicine.wisc.edu | Change in Trust in US Government Health Agencies for Cancer Information in the COVID-19 Era. | This cross-sectional study assesses changes in levels of public trust in US government health agencies providing cancer information. |
| 55 | Noelle LoConte | HEM/ONC | ns3@medicine.wisc.edu | Colon Cancer Survival Among South Asian Americans: A Cross-Sectional Analysis of a National Dataset. | Colon cancer (CC) is one of the most common cancers among South Asian Americans (SAAs). The objective of this study was to measure differences in risk-adjusted survival among SAAs with CC compared to non-Hispanic Whites (NHWs) using a representative national dataset from the United States. A retrospective analysis of patients with CC in the National Cancer Database (2004-2020) was performed. Differences in presentation, management, median overall survival (OS), three-year survival, and five-year survival between SAAs and NHWs were compared. Kaplan-Meier analysis and multivariable Cox regression were used to assess differences in survival outcomes, adjusting for demographics, presentation, and treatments received. Data from 2873 SAA and 639,488 NHW patients with CC were analyzed. SAAs were younger at diagnosis (62.2 versus 69.5 y, P < 0.001), higher stage (stage III [29.0% versus 26.2%, P = 0.001] or Stage IV [21.4% versus 20.0%, P = 0.001]), and experienced delays to first treatment (SAA 5.9% versus 4.9%, P = 0.003). SAAs with CC had higher OS (median not achieved versus 68.1 mo for NHWs), three-year survival (76.3% versus 63.4%), and five-year survival (69.1% versus 52.9%). On multivariable Cox regression, SAAs with CC had a lower risk of death across all stages (hazard ratio: 0.64, P < 0.001). In this national study, SAA patients with CC presented earlier in life with more advanced disease, and a higher proportion experienced treatment delay compared to NHW patients. Despite these differences, SAAs had better adjusted OS than NHW, warranting further exploration of tumor biology and socioeconomic determinants of cancer outcomes in SAAs. |
| 56 | Noelle LoConte | HEM/ONC | ns3@medicine.wisc.edu | Same People, Different Results: Categorizing Cancer Registry Cases Across the Rural-Urban Continuum. | Many rural-urban indexes are utilized in cancer research. This variation introduces inconsistencies between studies. Recommendations on index use have prioritized geographical unit over feasibility of inclusion in analysis. We evaluated rural-urban indexes and recommend one for use to increase comparability across studies. We assessed 9 US rural-urban indexes regarding their respective rural and urban code ranges; geographical unit, land area, and population distributions; percent agreement; suitability for analysis; and integration feasibility for national, state, and local cancer research. We referenced 1569 Wisconsin Pancreatic Cancer Registry patients to demonstrate how index choice affects patient categorization. Six indexes categorized rural and urban areas. Indexes agreed on binary rural-urban designation for 88.8% of the US population. As ternary variables, they agreed for 83.4%. For cancer registry patients, this decreased to 73.4% and 60.4% agreement, respectively. Rural-Urban Continuum Codes (RUCC) performed the best in differentiating metropolitan, micropolitan, and rural counties; availability for retrospective and prospective studies; and continuous coding for analysis. Urban/rural patient categorization changed with index selection. We conclude that RUCC is an appropriate and feasible rural-urban index to include in cancer research, as it is standardly available in national cancer registries, can be matched to patient's county of residence for local research, and it had the least amount of fluctuation of the indices analyzed. Utilizing RUCC as a continuous variable across studies with a rural-urban component will increase reproducibility and comparability of results and eliminate rural-urban index choice as a potential source of discrepancy between studies. |
| 57 | Noelle LoConte | HEM/ONC | ns3@medicine.wisc.edu | Cervical Cancer and a History of Incarceration: Examining a Social Determinant of Health. | Females who are incarcerated are disproportionately burdened by cancer, particularly cervical cancer. We measured the odds of cervical cancer compared with nonscreenable cancers for females who were incarcerated before diagnosis. By comparing a cancer for which screening and vaccination are available with cancers for which neither are available, we aimed to assess the relationship of incarceration with diseases for which preventive care mitigates risk. We created a novel data set combining cancer data from a large cancer center with incarceration data from the state department of corrections. We then estimated the odds of cervical cancer relative to nonscreenable cancers for those with and without a history of incarceration. Females with a history of incarceration had greater odds of being diagnosed with cervical cancer compared with nonscreenable cancers (odds ratio = 7.04; 95% confidence interval [CI]: 4.4-11.0) relative to those who had not been incarcerated. Adjusting for race and age, the odds of cervical cancer remained significantly greater for those with a history of incarceration (adjusted odds ratio = 3.86; 95% CI: 2.3-6.3). Our findings support the need for expanded cervical cancer screening and vaccination opportunities for incarcerated females and increased access to preventive health care after release. |
| 58 | Noelle LoConte | HEM/ONC | ns3@medicine.wisc.edu | Correction to: The current status of survivorship care provision at the state level: a Wisconsin-based assessment. | |
| 59 | Noelle LoConte | HEM/ONC | ns3@medicine.wisc.edu | Engaging Communities in Cancer Prevention and Control Activity Prioritization through a Statewide Needs Assessment: A Case Study from Nebraska. | Community outreach and engagement (COE) activities are important in identifying catchment area needs, communicating these needs, and facilitating activities relevant to the population. The National Cancer Institute-designated cancer centers are required to conduct catchment-wide cancer needs assessments as part of their COE activities. The University of Nebraska Medical Center Buffett Cancer Center undertook a three-year-long process to conduct a needs assessment, identify priorities, and develop workgroups to implement cancer prevention and control activities. Activities were conducted through collaborations with internal and external partners. The needs assessment focused on prevention, early detection, and treatment of cancer and involved secondary data analysis and focus groups with identified underrepresented priority populations (rural, African American, Hispanic, Native American, and LGBTQ+ populations). Results were tailored and disseminated to specific audiences via internal and external reports, infographics, and presentations. Several workgroups were developed through meetings with the internal and external partners to address identified priorities. COE-specific initiatives and metrics have been incorporated into University of Nebraska Medical Center and Buffett Cancer Center strategic plans. True community engagement takes a focused effort and significant resources. A systemic and long-term approach is needed to develop trusted relationships between the COE team and its local communities. |
| 60 | Mark Albertini | HEM/ONC | mra@medicine.wisc.edu | Administration of intratumoral GD2-directed interleukin-2 immunocytokine and local radiation therapy to activate immune rejection of spontaneous canine melanoma. | Canine malignant melanoma provides a clinically relevant, large animal parallel patient population to study the GD2-reactive hu14.18-IL-2 immunocytokine as it is similar to human melanoma and expresses GD2. The objectives of this study were to evaluate safety, radiation fractionation, and identify informative biomarkers of an in-situ tumor vaccine involving local radiation therapy plus intratumoral-immunocytokine in melanoma tumor-bearing dogs. Twelve dogs (six dogs/arm) with locally advanced or metastatic melanoma were randomized to receive a single 8 Gy fraction (arm A) or three 8 Gy fractions over 1 week (arm B) to the primary site and regional lymph nodes (when clinically involved) with the single or last fraction 5 days before intratumoral-immunocytokine at 12 mg/m 2 on 3 consecutive days. Serial tumor biopsies were obtained. All 12 dogs completed protocol treatment, and none experienced significant or unexpected adverse events. Evidence of antitumor activity includes one dog with a complete response at day 60, one dog with a partial response at day 60, and four dogs with mixed responses. Histology of serial biopsies shows a variably timed increase in intratumoral lymphocytic inflammation in some dogs. Canine NanoString analyses of serial biopsies identified changes in gene signatures of innate and adaptive cell types versus baseline. There were no significant differences in NanoString results between arm A and arm B. We conclude that intratumoral-immunocytokine in combination with local radiation therapy in canine melanoma is well tolerated and has antitumor activity with the potential to inform clinical development in melanoma patients. |
| 61 | Mark Albertini | HEM/ONC | mra@medicine.wisc.edu | Development of a next-generation sequencing protocol for the canine T cell receptor beta chain repertoire. | Profiling the T cell receptor (TCR) repertoire using next-generation sequencing has become common in both human and translational research. Companion dogs with spontaneous tumors, including canine melanoma, share several features, e.g., natural occurrence, shared environmental exposures, natural outbred population, and immunocompetence. T cells play an important role in the adaptive immune system by recognizing specific antigens via a surface TCR. As such, understanding the canine T cell response to vaccines, cancer, immunotherapies, and infectious diseases is critically important for both dog and human health. Off-the-shelf commercial reagents, kits and services are readily available for human, non-human primate, and mouse in this context. However, these resources are limited for the canine. In this study, we present a cost-effective protocol for analysis of canine TCR beta chain genes. Workflow can be accomplished in 1-2 days starting with total RNA and resulting in libraries ready for sequencing on Illumina platforms. |
| 62 | Mark Albertini | HEM/ONC | mra@medicine.wisc.edu | NK cells propagate T cell immunity following in situ tumor vaccination. | We report an in situ vaccination, adaptable to nearly any type of cancer, that combines radiotherapy targeting one tumor and intratumoral injection of this site with tumor-specific antibody and interleukin-2 (IL-2; 3xTx). In a phase I clinical trial, administration of 3xTx (with an immunocytokine fusion of tumor-specific antibody and IL-2, hu14.18-IL2) to subjects with metastatic melanoma increases peripheral CD8+ T cell effector polyfunctionality. This suggests the potential for 3xTx to promote antitumor immunity against metastatic tumors. In poorly immunogenic syngeneic murine melanoma or head and neck carcinoma models, 3xTx stimulates CD8+ T cell-mediated antitumor responses at targeted and non-targeted tumors. During 3xTx treatment, natural killer (NK) cells promote CTLA4+ regulatory T cell (Treg) apoptosis in non-targeted tumors. This is dependent on NK cell expression of CD86, which is upregulated downstream of KLRK1. NK cell depletion increases Treg infiltration, diminishing CD8+ T cell-dependent antitumor response. These findings demonstrate that NK cells sustain and propagate CD8+ T cell immunity following 3xTx. |
| 63 | Mark Albertini | HEM/ONC | mra@medicine.wisc.edu | Neutrophil-to-eosinophil ratio as a biomarker for clinical outcomes in advanced stage melanoma patients treated with anti-PD-1 therapy. | Neutrophil-to-lymphocyte ratios (NLR) and eosinophil counts are associated with improved survival in melanoma patients treated with immune checkpoint inhibitors, but no study has investigated neutrophil-to-eosinophil ratios (NER) as a predictive indicator in this population. In this retrospective study evaluating anti-PD-1 treated patients with advanced melanoma, progression-free survival (PFS), overall survival (OS), objective response rates (ORR), and risk of high-grade (grade ≥3) immune-related adverse events (irAEs) were compared between groups defined by median pretreatment NLR and NER as well as median NLR and NER at 1-month post-treatment. Lower baseline NLR and NER were associated with improved OS [HR: 0.504, 95% CI: 0.328-0.773, p = .002 and HR: 0.442, 95% CI: 0.288-0.681, p < .001, respectively] on univariate testing. After accounting for multiple covariates, our multivariate analysis found that lower pretreatment NER was associated with better ORR (by irRECIST) (OR: 2.199, 95% CI: 1.071-4.582, p = .033) and improved OS (HR: 0.480, 95% CI: 0.296-0.777, p = .003). Baseline NLR, 1-month NLR, and 1-month NER were not associated with ORR, PFS, or OS outcomes; but 1-month NER correlated with lower risk of grade ≥3 irAEs (OR: 0.392, 95% CI: 0.165-0.895, p = .029). Our findings suggest baseline NER merits additional investigation as a novel prognostic marker for advanced melanoma patients receiving anti-PD-1-based regimens. |
| 64 | Mark Albertini | HEM/ONC | mra@medicine.wisc.edu | SURROGATE SELECTION OVERSAMPLES EXPANDED T CELL CLONOTYPES. | Inference from immunological data on cells in the adaptive immune system may benefit from modeling specifications that describe variation in the sizes of various clonal sub-populations. We develop one such specification in order to quantify the effects of surrogate selection assays, which we confirm may lead to an enrichment for amplified, potentially disease-relevant T cell clones. Our specification couples within-clonotype birth-death processes with an exchangeable model across clonotypes. Beyond enrichment questions about the surrogate selection design, our framework enables a study of sampling properties of elementary sample diversity statistics; it also points to new statistics that may usefully measure the burden of somatic genomic alterations associated with clonal expansion. We examine statistical properties of immunological samples governed by the coupled model specification, and we illustrate calculations in surrogate selection studies of melanoma and in single-cell genomic studies of T cell repertoires. |
| 65 | Mark Albertini | HEM/ONC | mra@medicine.wisc.edu | Molecular characterization of hypoxanthine guanine phosphoribosyltransferase mutant T cells in human blood: The concept of surrogate selection for immunologically relevant cells. | Somatic cell gene mutations arise in vivo due to replication errors during DNA synthesis occurring spontaneously during normal DNA synthesis or as a result of replication on a DNA template damaged by endogenous or exogenous mutagens. In principle, changes in the frequencies of mutant cells in vivo in humans reflect changes in exposures to exogenous or endogenous DNA damaging insults, other factors being equal. It is becoming increasingly evident however, that somatic mutations in humans have a far greater range of interpretations. For example, mutations in lymphocytes provide invaluable probes for in vivo cellular and molecular processes, providing identification of clonal amplifications of these cells in autoimmune and infectious diseases, transplantation recipients, paroxysmal nocturnal hemoglobinuria (PNH), and cancer. The assay for mutations of the X-chromosomal hypoxanthine guanine phosphoribosyltransferase (HPRT) gene has gained popular acceptance for this purpose since viable mutant cells can be recovered for molecular and other analyses. Although the major application of the HPRT T cell assay remains human population monitoring, the enrichment of activated T cells in the mutant fraction in individuals with ongoing immunological processes has demonstrated the utility of surrogate selection, a method that uses somatic mutation as a surrogate marker for the in vivo T cell proliferation that underlies immunological processes to investigate clinical disorders with immunological features. Studies encompassing a wide range of clinical conditions are reviewed. Despite the historical importance of the HPRT mutation system in validating surrogate selection, there are now additional mutational and other methods for identifying immunologically active T cells. These methods are reviewed and provide insights for strategies to extend surrogate selection in future studies. |
| 66 | Mark Albertini | HEM/ONC | mra@medicine.wisc.edu | Safety and feasibility of an in situ vaccination and immunomodulatory targeted radionuclide combination immuno-radiotherapy approach in a comparative (companion dog) setting. | Murine syngeneic tumor models have revealed efficacious systemic antitumor responses following primary tumor in situ vaccination combined with targeted radionuclide therapy to secondary or metastatic tumors. Here we present studies on the safety and feasibility of this approach in a relevant translational companion dog model (n = 17 dogs) with advanced cancer. The three component of the combination immuno-radiotherapy approach were employed either separately or in combination in companion dogs with advanced stage cancer. In situ vaccination was achieved through the administration of hypofractionated external beam radiotherapy and intratumoral hu14.18-IL2 fusion immunocytokine injections to the index tumor. In situ vaccination was subsequently combined with targeted radionuclide therapy using a theranostic pairing of IV 86Y-NM600 (for PET imaging and subject-specific dosimetry) and IV 90Y-NM600 (therapeutic radionuclide) prescribed to deliver an immunomodulatory 2 Gy dose to all metastatic sites in companion dogs with metastatic melanoma or osteosarcoma. In a subset of dogs, immunologic parameters preliminarily assessed. The components of the immuno-radiotherapy combination were well tolerated either alone or in combination, resulting in only transient low grade (1 or 2) adverse events with no dose-limiting events observed. In subject-specific dosimetry analyses, we observed 86Y-NM600 tumor:bone marrow absorbed-dose differential uptakes ≥2 in 4 of 5 dogs receiving the combination, which allowed subsequent safe delivery of at least 2 Gy 90Y-NM600 TRT to tumors. NanoString gene expression profiling and immunohistochemistry from pre- and post-treatment biopsy specimens provide evidence of tumor microenvironment immunomodulation by 90Y-NM600 TRT. The combination of external beam radiotherapy, intratumoral immunocytokine, and targeted radionuclide immuno-radiotherapy known to have activity against syngeneic melanoma in murine models is feasible and well tolerated in companion dogs with advanced stage, spontaneously arising melanoma or osteosarcoma and has immunomodulatory potential. Further studies evaluating the dose-dependent immunomodulatory effects of this immuno-radiotherapy combination are currently ongoing. |
| 67 | Mark Albertini | HEM/ONC | mra@medicine.wisc.edu | Development and validation of a longitudinal soft-tissue metastatic lesion matching algorithm. | Metastatic cancer presents with many, sometimes hundreds of metastatic lesions through the body, which often respond heterogeneously to treatment. Therefore, lesion-level assessment is necessary for a complete understanding of disease response. Lesion-level assessment typically requires manual matching of corresponding lesions, which is a tedious, subjective, and error-prone task. This study introduces a fully automated algorithm for matching of metastatic lesions in longitudinal medical images. The algorithm entails four steps: (1) image registration, (2) lesion dilation, (3) lesion clustering, and (4) linear assignment. In step (1), 3D deformable registration is used to register the scans. In step (2), lesion contours are conformally dilated. In step (3), lesion clustering is evaluated based on local metrics. In step (4), matching is assigned based on non-greedy cost minimization. The algorithm was optimized (e.g. choice of deformable registration algorithm, dilatation size) and validated on 140 scan-pairs of 32 metastatic cancer patients from two independent clinical trials, who received longitudinal PET/CT scans as part of their treatment response assessment. Registration error was evaluated using landmark distance. A sensitivity study was performed to evaluate the optimal lesion dilation magnitude. Lesion matching performance accuracy was evaluated for all patients and for a subset with high disease burden. Two investigated deformable registration approaches (whole body deformable and articulated deformable registrations) led to similar performance with the overall registration accuracy between 2.3 and 2.6 mm. The optimal dilation magnitude of 25 mm yielded almost a perfect matching accuracy of 0.98. No significant matching accuracy decrease was observed in the subset of patients with high lesion disease burden. In summary, lesion matching using our new algorithm was highly accurate and a significant improvement, when compared to previously established methods. The proposed method enables accurate automated metastatic lesion matching in whole-body longitudinal scans. |
| 68 | Mark Albertini | HEM/ONC | mra@medicine.wisc.edu | Retrograde Balloon-Assisted Deep Enteroscopy in the Diagnosis of Metastatic Melanoma. | A 74-year-old male with a history of metastatic melanoma presents with persistently abnormal small bowel findings on PET-CT scan. The patient had persistent FDG uptake near the ileocolic junction on imaging, concerning for metastatic melanoma. Capsule endoscopy demonstrated ulcerated mucosa in the distal ileum. This area was biopsied and tattooed via retrograde double-balloon enteroscopy to confirm the diagnosis of metastatic melanoma and facilitate subsequent small bowel resection. The case illustrates a unique case of metastatic melanoma to the small bowel and the utility of capsule endoscopy and balloon-assisted enteroscopy to assist in diagnosis and management of metastatic disease. |
| 69 | Mark Albertini | HEM/ONC | mra@medicine.wisc.edu | Immune adverse events (irAEs) with adjuvant ipilimumab in melanoma, use of immunosuppressants and association with outcome: ECOG-ACRIN E1609 study analysis. | The impact of immune-related adverse events (irAEs) occurring from adjuvant use of immunotherapy and of their management on relapse-free survival (RFS) and overall survival (OS) outcomes is currently not well understood. E1609 enrolled 1673 patients with resected high-risk melanoma and evaluated adjuvant ipilimumab 3 mg/kg (ipi3) and 10 mg/kg (ipi10) versus interferon-α. We investigated the association of irAEs and of use of immunosuppressants with RFS and OS for patients treated with ipilimumab (n=1034). Occurrence of grades 1-2 irAEs was associated with RFS (5 years: 52% (95% CI 47% to 56%) vs 41% (95% CI 31% to 50%) with no AE; p=0.006) and a trend toward improved OS (5 years: 75% (95% CI 71% to 79%) compared with 67% (95% CI 56% to 75%) with no AE; p=0.064). Among specific irAEs, grades 1-2 rash was most significantly associated with RFS (p=0.002) and OS (p=0.003). In multivariate models adjusting for prognostic factors, the most significant associations were seen for grades 1-2 rash with RFS (p<0.001, HR=0.70) and OS (p=0.01, HR=0.71) and for grades 1-2 endocrine+rash with RFS (p<0.001, HR=0.66) and OS (p=0.008, HR=0.7). Overall, grades 1-2 irAEs had the best prognosis in terms of RFS and OS and those with grades 3-4 had less RFS benefits and no OS advantage over no irAE. Patients experiencing grades 3-4 irAE had significantly higher exposure to corticosteroids and immunosuppressants than those with grades 1-2 (92% vs 60%; p<0.001), but no significant associations were found between corticosteroid and immunosuppressant use and RFS or OS. In investigating the impact of non-corticosteroid immunosuppressants, although there were trends toward better RFS and OS favoring cases who were not exposed, no significant associations were found. Rash and endocrine irAEs were independent prognostic factors of RFS and OS in patients treated with adjuvant ipilimumab. Patients experiencing lower grade irAEs derived the most benefit, but we found no significant evidence supporting a negative impact of high dose corticosteroids and immunosuppressants more commonly used to manage grades 3-4 irAEs. |
| 70 | David Kosoff | HEM/ONC | dkosoff1@medicine.wisc.edu | Dynamic reciprocal interactions between activated T cells and tumor associated macrophages drive macrophage reprogramming and proinflammatory T cell migration within prostate tumor models. | Tumor-associated macrophages (TAMs) have been implicated as a tumor microenvironment (TME) cell population, which may be playing a vital role in the inhibition of effective T cell responses in the prostate TME. In this manuscript, we leverage a novel microscale cell culture platform, known as Stacks, to investigate mono-, co-, and tri-culture TME models comprised of prostate tumor cell lines, primary macrophages, and autologous T cells from patients with prostate cancer. Through multiplexed analysis of these multi-cellular prostate tumor models, we capture a dynamic interaction between primary TAMs and activated T cells that resulted in reciprocal proinflammatory activation of both cell populations upon interaction. These findings suggest that activated T cells are capable of reprogramming immunosuppressive TAMs in the context of prostate tumor models and that TAM reprogramming may play a key supportive role in restoring proinflammatory T cell tumor responses in the prostate TME. |
| 71 | David Kosoff | HEM/ONC | dkosoff1@medicine.wisc.edu | Clinical cell-surface targets in metastatic and primary solid cancers. | Therapies against cell-surface targets (CSTs) represent an emerging treatment class in solid malignancies. However, high-throughput investigations of CST expression across cancer types have been reliant on data sets of mostly primary tumors, despite therapeutic use most commonly in metastatic disease. We identified a total of 818 clinical trials of CST therapies with 78 CSTs. We assembled a data set spanning RNA-seq and microarrays in 7,927 benign samples, 16,866 primary tumor samples, and 6,124 metastatic tumor samples. We also utilized single-cell RNA-seq data from 36 benign tissues and 558 primary and metastatic tumor samples, and matched RNA versus protein expression in 29 benign tissue samples, 1,075 tumor samples, and 942 cell lines. High RNA expression accurately predicted high protein expression across CST therapies in benign tissues, tumor samples, and cell lines. We compared metastatic versus primary tumor expression, identified potential opportunities for repositioning, and matched cell lines to tumor types based on CST and global RNA expression. We evaluated single-cell heterogeneity across tumors, and identified rare normal cell subpopulations that may contribute to toxicity. Finally, we identified combinations of CST therapies for which bispecific approaches could improve tumor specificity. This study helps better define the landscape of CST expression in metastatic and primary cancers. |
| 72 | David Kosoff | HEM/ONC | dkosoff1@medicine.wisc.edu | Mechanistic Characterization of Cancer-associated Fibroblast Depletion via an Antibody-Drug Conjugate Targeting Fibroblast Activation Protein. | Cancer-associated fibroblasts (CAF) are a prominent cell type within the tumor microenvironment (TME) where they are known to promote cancer cell growth and survival, angiogenesis, drug resistance, and immunosuppression. The transmembrane prolyl protease fibroblast activation protein (FAP) is expressed on the surface of highly protumorigenic CAFs found in the stroma of nearly every cancer of epithelial origin. The widespread expression of FAP has made it an attractive therapeutic target based on the underlying hypothesis that eliminating protumorigenic CAFs will disrupt the cross-talk between components of TME resulting in cancer cell death and immune infiltration. This hypothesis, however, has never been directly proven. To eliminate FAP-expressing CAFs, we developed an antibody-drug conjugate using our anti-FAP antibody, huB12, coupled to a monomethyl auristatin E (huB12-MMAE) payload. After determining that huB12 was an effective targeting vector, we found that huB12-MMAE potently eliminated FAP-expressing cells as monocultures in vitro and significantly prolonged survival in vivo using a xenograft engineered to overexpress FAP. We investigated the effects of selectively eliminating CAFs using a layered, open microfluidic cell coculture platform, known as the Stacks. Analysis of mRNA and protein expression found that treatment with huB12-MMAE resulted in the increased secretion of the proinflammatory cytokines IL6 and IL8 by CAFs and an associated increase in expression of proinflammatory genes in cancer cells. We also detected increased secretion of CSF1, a cytokine involved in myeloid recruitment and differentiation. Our findings suggest that the mechanism of FAP-targeted therapies is through effects on the immune microenvironment and antitumor immune response. The direct elimination of FAP-expressing CAFs disrupts the cross-talk with cancer cells leading to a proinflammatory response and alterations in the immune microenvironment and antitumor immune response. |
| 73 | David Kosoff | HEM/ONC | dkosoff1@medicine.wisc.edu | A platform-independent AI tumor lineage and site (ATLAS) classifier. | Histopathologic diagnosis and classification of cancer plays a critical role in guiding treatment. Advances in next-generation sequencing have ushered in new complementary molecular frameworks. However, existing approaches do not independently assess both site-of-origin (e.g. prostate) and lineage (e.g. adenocarcinoma) and have minimal validation in metastatic disease, where classification is more difficult. Utilizing gradient-boosted machine learning, we developed ATLAS, a pair of separate AI Tumor Lineage and Site-of-origin models from RNA expression data on 8249 tumor samples. We assessed performance independently in 10,376 total tumor samples, including 1490 metastatic samples, achieving an accuracy of 91.4% for cancer site-of-origin and 97.1% for cancer lineage. High confidence predictions (encompassing the majority of cases) were accurate 98-99% of the time in both localized and remarkably even in metastatic samples. We also identified emergent properties of our lineage scores for tumor types on which the model was never trained (zero-shot learning). Adenocarcinoma/sarcoma lineage scores differentiated epithelioid from biphasic/sarcomatoid mesothelioma. Also, predicted lineage de-differentiation identified neuroendocrine/small cell tumors and was associated with poor outcomes across tumor types. Our platform-independent single-sample approach can be easily translated to existing RNA-seq platforms. ATLAS can complement and guide traditional histopathologic assessment in challenging situations and tumors of unknown primary. |
| 74 | David Kosoff | HEM/ONC | dkosoff1@medicine.wisc.edu | PARP inhibitors in metastatic prostate cancer. | Poly-ADP ribose polymerase inhibitors (PARPi) are an emerging therapeutic option for the treatment of prostate cancer. Their primary mechanism of action is via induction of synthetic lethality in cells with underlying deficiencies in homologous recombination repair (HRR). In men with metastatic castrate-resistant prostate cancer (mCRPC) and select HRR pathway alterations, PARPi treatment has been shown to induce objective tumor responses as well as improve progression free and overall survival. Presently, there are two PARPi, olaparib and rucaparib, that are FDA approved in the treatment of mCRPC. Ongoing research is focused on identifying which HRR alterations are best suited to predict response to PARPi so that these therapies can be most effectively utilized in the clinic. While resistance to PARPi remains a concern, combination therapies may represent a mechanism to overcome or delay resistance. |
| 75 | David Kosoff | HEM/ONC | dkosoff1@medicine.wisc.edu | A clinical-grade liquid biomarker detects neuroendocrine differentiation in prostate cancer. | BackgroundNeuroendocrine prostate cancer (NEPC) is an aggressive subtype, the presence of which changes the prognosis and management of metastatic prostate cancer.MethodsWe performed analytical validation of a Circulating Tumor Cell (CTC) multiplex RNA qPCR assay to identify the limit of quantification (LOQ) in cell lines, synthetic cDNA, and patient samples. We next profiled 116 longitudinal samples from a prospectively collected institutional cohort of 17 patients with metastatic prostate cancer (7 NEPC, 10 adenocarcinoma) as well as 265 samples from 139 patients enrolled in 3 adenocarcinoma phase II trials of androgen receptor signaling inhibitors (ARSIs). We assessed a NEPC liquid biomarker via the presence of neuroendocrine markers and the absence of androgen receptor (AR) target genes.ResultsUsing the analytical validation LOQ, liquid biomarker NEPC detection in the longitudinal cohort had a per-sample sensitivity of 51.35% and a specificity of 91.14%. However, when we incorporated the serial information from multiple liquid biopsies per patient, a unique aspect of this study, the per-patient predictions were 100% accurate, with a receiver-operating-curve (ROC) AUC of 1. In the adenocarcinoma ARSI trials, the presence of neuroendocrine markers, even while AR target gene expression was retained, was a strong negative prognostic factor.ConclusionOur analytically validated CTC biomarker can detect NEPC with high diagnostic accuracy when leveraging serial samples that are only feasible using liquid biopsies. Patients with expression of NE genes while retaining AR-target gene expression may indicate the transition to neuroendocrine differentiation, with clinical characteristics consistent with this phenotype.FundingNIH (DP2 OD030734, 1UH2CA260389, R01CA247479, and P30 CA014520), Department of Defense (PC190039 and PC200334), and Prostate Cancer Foundation (Movember Foundation - PCF Challenge Award). |
| 76 | David Kosoff | HEM/ONC | dkosoff1@medicine.wisc.edu | Longitudinal Molecular Profiling of Circulating Tumor Cells in Metastatic Renal Cell Carcinoma. | Liquid biopsies in metastatic renal cell carcinoma (mRCC) provide a unique approach to understand the molecular basis of treatment response and resistance. This is particularly important in the context of immunotherapies, which target key immune-tumor interactions. Unlike metastatic tissue biopsies, serial real-time profiling of mRCC is feasible with our noninvasive circulating tumor cell (CTC) approach. We collected 457 longitudinal liquid biopsies from 104 patients with mRCC enrolled in one of two studies, either a prospective cohort or a phase II multicenter adaptive immunotherapy trial. Using a novel CTC capture and automated microscopy platform, we profiled CTC enumeration and expression of HLA I and programmed cell death-ligand 1 (PD-L1). Given their diametric immunological roles, we focused on the HLA I to PD-L1 ratio (HP ratio). Patients with radiographic responses showed significantly lower CTC abundances throughout treatment. Furthermore, patients whose CTC enumeration trajectory was in the highest quartile (> 0.12 CTCs/mL annually) had shorter overall survival (median 17.0 months v 21.1 months, P < .001). Throughout treatment, the HP ratio decreased in patients receiving immunotherapy but not in patients receiving tyrosine kinase inhibitors. Patients with an HP ratio trajectory in the highest quartile (≥ 0.0012 annually) displayed significantly shorter overall survival (median 18.4 months v 21.2 months, P = .003). In the first large longitudinal CTC study in mRCC to date to our knowledge, we identified the prognostic importance of CTC enumeration and the change over time of both CTC enumeration and the HP ratio. These insights into changes in both tumor burden and the molecular profile of tumor cells in response to different treatments provide potential biomarkers to predict and monitor response to immunotherapy in mRCC. |
| 77 | David Kosoff | HEM/ONC | dkosoff1@medicine.wisc.edu | Integrated analysis of the tumor microenvironment using a reconfigurable microfluidic cell culture platform. | The tumor microenvironment (TME) is a complex network of non-malignant cells and stroma that perform a wide array of vital roles in tumor growth, immune evasion, metastasis, and therapeutic resistance. These highly diverse roles have been shown to be critically important to the progression of cancers and have already shown potential as therapeutic targets. Therefore, there has been a tremendous push to elucidate the pathways that underlie these roles and to develop new TME-directed therapies for cancer treatment. Unfortunately, TME-focused research has been limited by a lack of translational in vitro culture platforms that can model this highly complex niche and can support the integrated analysis of cell biology and function. In the current study, we investigate whether an independently developed reconfigurable microfluidic platform, known as Stacks, can address the critical need for translational multi-cellular tumor models and integrated analytics in TME research. We present data on multi-cellular culture of primary human cells in Stacks as well as the orthogonal analysis of cellular polarization, differentiation, migration, and cytotoxicity in this reconfigurable system. These expanded capabilities of Stacks are highly relevant to the cancer research community with the potential to enhance clinical translation of pre-clinical TME studies and to yield novel biological insight into TME crosstalk, metastasis, and responses to novel drug combinations or immune therapies. |
| 78 | David Kosoff | HEM/ONC | dkosoff1@medicine.wisc.edu | Microfluidics in vascular biology research: a critical review for engineers, biologists, and clinicians. | Neovascularization, the formation of new blood vessels, has received much research attention due to its implications for physiological processes and diseases. Most studies using traditional in vitro and in vivo platforms find challenges in recapitulating key cellular and mechanical cues of the neovascularization processes. Microfluidic in vitro models have been presented as an alternative to these limitations due to their capacity to leverage microscale physics to control cell organization and integrate biochemical and mechanical cues, such as shear stress, cell-cell interactions, or nutrient gradients, making them an ideal option for recapitulating organ physiology. Much has been written about the use of microfluidics in vascular biology models from an engineering perspective. However, a review introducing the different models, components and progress for new potential adopters of these technologies was absent in the literature. Therefore, this paper aims to approach the use of microfluidic technologies in vascular biology from a perspective of biological hallmarks to be studied and written for a wide audience ranging from clinicians to engineers. Here we review applications of microfluidics in vascular biology research, starting with design considerations and fabrication techniques. After that, we review the state of the art in recapitulating angiogenesis and vasculogenesis, according to the hallmarks recapitulated and complexity of the models. Finally, we discuss emerging research areas in neovascularization, such as drug discovery, and potential future directions. |
| 79 | David Kosoff | HEM/ONC | dkosoff1@medicine.wisc.edu | Advancing Treatment of Bone Metastases through Novel Translational Approaches Targeting the Bone Microenvironment. | Bone metastases represent a lethal condition that frequently occurs in solid tumors such as prostate, breast, lung, and renal cell carcinomas, and increase the risk of skeletal-related events (SREs) including pain, pathologic fractures, and spinal cord compression. This unique metastatic niche consists of a multicellular complex that cancer cells co-opt to engender bone remodeling, immune suppression, and stromal-mediated therapeutic resistance. This review comprehensively discusses clinical challenges of bone metastases, novel preclinical models of the bone and bone marrow microenviroment, and crucial signaling pathways active in bone homeostasis and metastatic niche. These studies establish the context to summarize the current state of investigational agents targeting BM, and approaches to improve BM-targeting therapies. Finally, we discuss opportunities to advance research in bone and bone marrow microenvironments by increasing complexity of humanized preclinical models and fostering interdisciplinary collaborations to translational research in this challenging metastatic niche. |
| 80 | Joshua Lang | HEM/ONC | jmlang@medicine.wisc.edu | Clinical Implementation of Minimal Residual Disease Testing in Genitourinary Cancers: Bridging Promise and Practice. | |
| 81 | Joshua Lang | HEM/ONC | jmlang@medicine.wisc.edu | Germline and somatic testing for homologous repair deficiency in patients with prostate cancer (part 1 of 2). | Unfortunately, not all metastatic castration resistant prostate cancer (mCRPC) patients receive available life-prolonging systemic therapies, emphasizing the need to optimize mCRPC treatment selections. Better guidelines are necessary to determine genetic testing in prostate cancer. In this two-part expert opinion-based guide, we provide an expert consensus opinion on the utilization of germline and somatic testing to detect HRR alterations in patients with mCRPC. This guide was developed by a multidisciplinary expert panel that convened in 2023-2024, including representatives from medical oncology, urology, radiation oncology, pathology, medical genomics, and basic science. We argue for the widespread adoption of germline testing in all patients with prostate cancer and for somatic mutations testing in patients at the time of recurrent/metastatic disease. In this first part, we review how genomic testing is performed. We also review how to overcome certain barriers to integrate genetic and biomarker testing into clinical practice. |
| 82 | Joshua Lang | HEM/ONC | jmlang@medicine.wisc.edu | Therapeutic implications of homologous repair deficiency testing in patients with prostate cancer (Part 2 of 2). | Unfortunately, not all metastatic castration-resistant prostate cancer (mCRPC) patients receive available life-prolonging systemic therapies, emphasizing the need to optimize mCRPC treatment selections. Better guidelines are necessary to determine genetic testing for prostate cancer. In this two-part expert opinion-based guide, we provide an expert consensus opinion on the utilization of germline and somatic testing to detect HRR alterations in patients with mCRPC. This guide was developed by a multidisciplinary expert panel that convened in 2023-2024, including representatives from medical oncology, urology, radiation oncology, pathology, medical genomics, and basic science. In this second part, we highlight how genetic testing can lead to improved, life-prolonging mCRPC therapeutic strategies based on a review of the recent phase III trials and subsequent regulatory approvals for PARP inhibitors in mCRPC. |
| 83 | Joshua Lang | HEM/ONC | jmlang@medicine.wisc.edu | Clinical cell-surface targets in metastatic and primary solid cancers. | Therapies against cell-surface targets (CSTs) represent an emerging treatment class in solid malignancies. However, high-throughput investigations of CST expression across cancer types have been reliant on data sets of mostly primary tumors, despite therapeutic use most commonly in metastatic disease. We identified a total of 818 clinical trials of CST therapies with 78 CSTs. We assembled a data set spanning RNA-seq and microarrays in 7,927 benign samples, 16,866 primary tumor samples, and 6,124 metastatic tumor samples. We also utilized single-cell RNA-seq data from 36 benign tissues and 558 primary and metastatic tumor samples, and matched RNA versus protein expression in 29 benign tissue samples, 1,075 tumor samples, and 942 cell lines. High RNA expression accurately predicted high protein expression across CST therapies in benign tissues, tumor samples, and cell lines. We compared metastatic versus primary tumor expression, identified potential opportunities for repositioning, and matched cell lines to tumor types based on CST and global RNA expression. We evaluated single-cell heterogeneity across tumors, and identified rare normal cell subpopulations that may contribute to toxicity. Finally, we identified combinations of CST therapies for which bispecific approaches could improve tumor specificity. This study helps better define the landscape of CST expression in metastatic and primary cancers. |
| 84 | Joshua Lang | HEM/ONC | jmlang@medicine.wisc.edu | Integrated analyses highlight interactions between the three-dimensional genome and DNA, RNA and epigenomic alterations in metastatic prostate cancer. | The impact of variations in the three-dimensional structure of the genome has been recognized, but solid cancer tissue studies are limited. Here, we performed integrated deep Hi-C sequencing with matched whole-genome sequencing, whole-genome bisulfite sequencing, 5-hydroxymethylcytosine (5hmC) sequencing and RNA sequencing across a cohort of 80 biopsy samples from patients with metastatic castration-resistant prostate cancer. Dramatic differences were present in gene expression, 5-methylcytosine/5hmC methylation and in structural variation versus mutation rate between A and B (open and closed) chromatin compartments. A subset of tumors exhibited depleted regional chromatin contacts at the AR locus, linked to extrachromosomal circular DNA (ecDNA) and worse response to AR signaling inhibitors. We also identified topological subtypes associated with stark differences in methylation structure, gene expression and prognosis. Our data suggested that DNA interactions may predispose to structural variant formation, exemplified by the recurrent TMPRSS2-ERG fusion. This comprehensive integrated sequencing effort represents a unique clinical tumor resource. |
| 85 | Joshua Lang | HEM/ONC | jmlang@medicine.wisc.edu | Mechanistic Characterization of Cancer-associated Fibroblast Depletion via an Antibody-Drug Conjugate Targeting Fibroblast Activation Protein. | Cancer-associated fibroblasts (CAF) are a prominent cell type within the tumor microenvironment (TME) where they are known to promote cancer cell growth and survival, angiogenesis, drug resistance, and immunosuppression. The transmembrane prolyl protease fibroblast activation protein (FAP) is expressed on the surface of highly protumorigenic CAFs found in the stroma of nearly every cancer of epithelial origin. The widespread expression of FAP has made it an attractive therapeutic target based on the underlying hypothesis that eliminating protumorigenic CAFs will disrupt the cross-talk between components of TME resulting in cancer cell death and immune infiltration. This hypothesis, however, has never been directly proven. To eliminate FAP-expressing CAFs, we developed an antibody-drug conjugate using our anti-FAP antibody, huB12, coupled to a monomethyl auristatin E (huB12-MMAE) payload. After determining that huB12 was an effective targeting vector, we found that huB12-MMAE potently eliminated FAP-expressing cells as monocultures in vitro and significantly prolonged survival in vivo using a xenograft engineered to overexpress FAP. We investigated the effects of selectively eliminating CAFs using a layered, open microfluidic cell coculture platform, known as the Stacks. Analysis of mRNA and protein expression found that treatment with huB12-MMAE resulted in the increased secretion of the proinflammatory cytokines IL6 and IL8 by CAFs and an associated increase in expression of proinflammatory genes in cancer cells. We also detected increased secretion of CSF1, a cytokine involved in myeloid recruitment and differentiation. Our findings suggest that the mechanism of FAP-targeted therapies is through effects on the immune microenvironment and antitumor immune response. The direct elimination of FAP-expressing CAFs disrupts the cross-talk with cancer cells leading to a proinflammatory response and alterations in the immune microenvironment and antitumor immune response. |
| 86 | Joshua Lang | HEM/ONC | jmlang@medicine.wisc.edu | Assessment of TROP2, CEACAM5 and DLL3 in metastatic prostate cancer: Expression landscape and molecular correlates. | Therapeutic approaches targeting proteins on the surface of cancer cells have emerged as an important strategy for precision oncology. To capitalize on the potential impact of drugs targeting surface proteins, detailed knowledge about the expression patterns of the target proteins in tumor tissues is required. In castration-resistant prostate cancer (CRPC), agents targeting prostate-specific membrane antigen (PSMA) have demonstrated clinical activity. However, PSMA expression is lost in a significant number of CRPC tumors. The identification of additional cell surface targets is necessary to develop new therapeutic approaches. Here, we performed a comprehensive analysis of the expression heterogeneity and co-expression patterns of trophoblast cell-surface antigen 2 (TROP2), delta-like ligand 3 (DLL3), and carcinoembryonic antigen-related cell adhesion molecule 5 (CEACAM5) in CRPC samples from a rapid autopsy cohort. We show that DLL3 and CEACAM5 exhibit the highest expression in neuroendocrine prostate cancer (NEPC), while TROP2 is expressed across different CRPC molecular subtypes, except for NEPC. We further demonstrated that AR alterations were associated with higher expression of PSMA and TROP2. Conversely, PSMA and TROP2 expression was lower in RB1-altered tumors. In addition to genomic alterations, we show a tight correlation between epigenetic states, particularly histone H3 lysine 27 methylation (H3K27me3) at the transcriptional start site and gene body of TACSTD2 (encoding TROP2), DLL3, and CEACAM5, and their respective protein expression in CRPC patient-derived xenografts. Collectively, these findings provide insights into patterns and determinants of expression of TROP2, DLL3, and CEACAM5 with implications for the clinical development of cell surface targeting agents in CRPC. |
| 87 | Joshua Lang | HEM/ONC | jmlang@medicine.wisc.edu | Combining Dual Checkpoint Immunotherapy with Ablative Radiation to All Sites of Oligometastatic Non-Small Cell Lung Cancer: Toxicity and Efficacy Results of a Phase 1b Trial. | Ablative local treatment of all radiographically detected metastatic sites in patients with oligometastatic non-small cell lung cancer (NSCLC) increases progression-free survival (PFS) and overall survival (OS). Prior studies demonstrated the safety of combining stereotactic body radiation therapy (SBRT) with single-agent immunotherapy. We investigated the safety of combining SBRT to all metastatic tumor sites with dual checkpoint, anticytotoxic T-lymphocyte-associated protein 4 (anti-CTLA-4), and anti-programmed cell death ligand 1 (anti-PD-L1) immunotherapy for patients with oligometastatic NSCLC. We conducted a phase 1b clinical trial in patients with oligometastatic NSCLC with up to 6 sites of extracranial metastatic disease. All sites of disease were treated with SBRT to a dose of 30 to 50 Gy in 5 fractions. Dual checkpoint immunotherapy was started 7 days after completion of radiation using anti-CTLA-4 (tremelimumab) and anti-PD-L1 (durvalumab) immunotherapy for a total of 4 cycles followed by durvalumab alone until progression or toxicity. Of the 17 patients enrolled in this study, 15 patients received at least 1 dose of combination immunotherapy per protocol. The study was closed early (17 of planned 21 patients) due to slow accrual during the COVID-19 pandemic. Grade 3+ treatment-related adverse events were observed in 6 patients (40%), of which only one was possibly related to the addition of SBRT to immunotherapy. Median PFS was 42 months and median OS has not yet been reached. Delivering ablative SBRT to all sites of metastatic disease in combination with dual checkpoint immunotherapy did not result in excessive rates of toxicity compared with historical studies of dual checkpoint immunotherapy alone. Although the study was not powered for treatment efficacy results, durable PFS and OS results suggest potential therapeutic benefit compared with immunotherapy or radiation alone in this patient population. |
| 88 | Joshua Lang | HEM/ONC | jmlang@medicine.wisc.edu | A platform-independent AI tumor lineage and site (ATLAS) classifier. | Histopathologic diagnosis and classification of cancer plays a critical role in guiding treatment. Advances in next-generation sequencing have ushered in new complementary molecular frameworks. However, existing approaches do not independently assess both site-of-origin (e.g. prostate) and lineage (e.g. adenocarcinoma) and have minimal validation in metastatic disease, where classification is more difficult. Utilizing gradient-boosted machine learning, we developed ATLAS, a pair of separate AI Tumor Lineage and Site-of-origin models from RNA expression data on 8249 tumor samples. We assessed performance independently in 10,376 total tumor samples, including 1490 metastatic samples, achieving an accuracy of 91.4% for cancer site-of-origin and 97.1% for cancer lineage. High confidence predictions (encompassing the majority of cases) were accurate 98-99% of the time in both localized and remarkably even in metastatic samples. We also identified emergent properties of our lineage scores for tumor types on which the model was never trained (zero-shot learning). Adenocarcinoma/sarcoma lineage scores differentiated epithelioid from biphasic/sarcomatoid mesothelioma. Also, predicted lineage de-differentiation identified neuroendocrine/small cell tumors and was associated with poor outcomes across tumor types. Our platform-independent single-sample approach can be easily translated to existing RNA-seq platforms. ATLAS can complement and guide traditional histopathologic assessment in challenging situations and tumors of unknown primary. |
| 89 | Joshua Lang | HEM/ONC | jmlang@medicine.wisc.edu | ASSESSMENT OF CELL SURFACE TARGETS IN METASTATIC PROSTATE CANCER: EXPRESSION LANDSCAPE AND MOLECULAR CORRELATES. | Therapeutic approaches targeting proteins on the surface of cancer cells have emerged as an important strategy for precision oncology. To fully capitalize on the potential impact of drugs targeting surface proteins, detailed knowledge about the expression patterns of the target proteins in tumor tissues is required. In castration-resistant prostate cancer (CRPC), agents targeting prostate-specific membrane antigen (PSMA) have demonstrated clinical activity. However, PSMA expression is lost in a significant number of CRPC tumors, and the identification of additional cell surface targets is necessary in order to develop new therapeutic approaches. Here, we performed a comprehensive analysis of the expression and co-expression patterns of trophoblast cell-surface antigen 2 (TROP2), delta-like ligand 3 (DLL3), and carcinoembryonic antigen-related cell adhesion molecule 5 (CEACAM5) in CRPC samples from a rapid autopsy cohort. We show that DLL3 and CEACAM5 exhibit the highest expression in neuroendocrine prostate cancer (NEPC), while TROP2 is expressed across different CRPC molecular subtypes, except for NEPC. We observed variable intra-tumoral and inter-tumoral heterogeneity and no dominant metastatic site predilections for TROP2, DLL3, and CEACAM5. We further show that AR amplifications were associated with higher expression of PSMA and TROP2 but lower DLL3 and CEACAM5 levels. Conversely, PSMA and TROP2 expression was lower in RB1-altered tumors. In addition to genomic alterations, we demonstrate a tight correlation between epigenetic states, particularly histone H3 lysine 27 methylation (H3K27me3) at the transcriptional start site and gene body of TACSTD2 (encoding TROP2), DLL3, and CEACAM5, and their respective protein expression in CRPC patient-derived xenografts. Collectively, these findings provide novel insights into the patterns and determinants of expression of TROP2, DLL3, and CEACAM5 with important implications for the clinical development of cell surface targeting agents in CRPC. |
| 90 | Douglas McNeel | HEM/ONC | dm3@medicine.wisc.edu | Long-term follow up of patients treated with a DNA vaccine (pTVG-hp) for PSA-recurrent prostate cancer. | We have previously reported two single-agent phase I trials, evaluating the dose or schedule, of a DNA vaccine (pTVG-HP) encoding prostatic acid phosphatase (PAP) administered with GM-CSF as the adjuvant. These were in patients with PSA-recurrent, radiographically non-metastatic, prostate cancer (PCa). We report here the long-term safety and overall survival of these patients. Specifically, 22 patients with non-metastatic, castration-sensitive PCa (nmCSPC) were treated with pTVG-HP, 100-1500 µg, administered over 12 weeks and followed for 15 y. 17 patients with non-metastatic castration-resistant PCa (nmCRPC) were treated with 100 µg pTVG-HP with different schedules of administration over 1 y and followed for 5 y. No adverse events were detected in long-term follow-up from either trial that were deemed possibly related to vaccination. Patients with nmCSPC had a median overall survival of 12.3 y, with 5/22 (23%) alive at 15 y. 8/22 (36%) died due to prostate cancer with a median survival of 11.0 y, and 9/22 (41%) died of other causes. Patients with nmCRPC had a median overall survival of 4.5 y, with 8/17 (47%) alive at 5 y. The presence of T-cells specific for the PAP target antigen was detectable in 6/10 (60%) individuals with nmCSPC, and 3/5 (60%) individuals with nmCRPC, many years after immunization. The detection of immune responses to the vaccine target years after immunization suggests durable immunity can be elicited in patients using a DNA vaccine encoding a tumor-associated antigen.Trial Registration: NCT00582140 and NCT00849121. |
| 91 | Douglas McNeel | HEM/ONC | dm3@medicine.wisc.edu | Toll-like receptor agonists as cancer vaccine adjuvants. | Cancer immunotherapy has emerged as a promising strategy to treat cancer patients. Among the wide range of immunological approaches, cancer vaccines have been investigated to activate and expand tumor-reactive T cells. However, most cancer vaccines have not shown significant clinical benefit as monotherapies. This is likely due to the antigen targets of vaccines, "self" proteins to which there is tolerance, as well as to the immunosuppressive tumor microenvironment. To help circumvent immune tolerance and generate effective immune responses, adjuvants for cancer vaccines are necessary. One representative adjuvant family is Toll-Like receptor (TLR) agonists, synthetic molecules that stimulate TLRs. TLRs are the largest family of pattern recognition receptors (PRRs) that serve as the sensors of pathogens or cellular damage. They recognize conserved foreign molecules from pathogens or internal molecules from cellular damage and propel innate immune responses. When used with vaccines, activation of TLRs signals an innate damage response that can facilitate the development of a strong adaptive immune response against the target antigen. The ability of TLR agonists to modulate innate immune responses has positioned them to serve as adjuvants for vaccines targeting infectious diseases and cancers. This review provides a summary of various TLRs, including their expression patterns, their functions in the immune system, as well as their ligands and synthetic molecules developed as TLR agonists. In addition, it presents a comprehensive overview of recent strategies employing different TLR agonists as adjuvants in cancer vaccine development, both in pre-clinical models and ongoing clinical trials. |
| 92 | Douglas McNeel | HEM/ONC | dm3@medicine.wisc.edu | Sequence of androgen receptor-targeted vaccination with androgen deprivation therapy affects anti-prostate tumor efficacy. | Androgen deprivation therapy (ADT) is the primary treatment for recurrent and metastatic prostate cancer. In addition to direct antitumor effects, ADT has immunomodulatory effects such as promoting T-cell infiltration and enhancing antigen processing/presentation. Previous studies in our laboratory have demonstrated that ADT also leads to increased expression of the androgen receptor (AR) and increased recognition of prostate tumor cells by AR-specific CD8+T cells. We have also demonstrated that ADT combined with a DNA vaccine encoding the AR significantly slowed tumor growth and improved the survival of prostate tumor-bearing mice. The current study aimed to investigate the impact of the timing and sequencing of ADT with vaccination on the tumor immune microenvironment in murine prostate cancer models to further increase the antitumor efficacy of vaccines. Male FVB mice implanted with Myc-CaP tumor cells, or male C57BL/6 mice implanted with TRAMP-C1 prostate tumor cells, were treated with a DNA vaccine encoding AR (pTVG-AR) and ADT. The sequence of administration was evaluated for its effect on tumor growth, and tumor-infiltrating immune populations were characterized. Vaccination prior to ADT (pTVG-AR → ADT) significantly enhanced antitumor responses and survival. This was associated with increased tumor infiltration by CD4+ and CD8+ T cells, including AR-specific CD8+T cells. Depletion of CD8+T cells prior to ADT significantly worsened overall survival. Following ADT treatment, however, Gr1+ myeloid-derived suppressor cells (MDSCs) increased, and this was associated with fewer infiltrating T cells and reduced tumor growth. Inhibiting Gr1+MDSCs recruitment, either by using a CXCR2 antagonist or by cycling androgen deprivation with testosterone replacement, improved antitumor responses and overall survival. Vaccination prior to ADT significantly improved antitumor responses, mediated in part by increased infiltration of CD8+T cells following ADT. Targeting MDSC recruitment following ADT further enhanced antitumor responses. These findings suggest logical directions for future clinical trials to improve the efficacy of prostate cancer vaccines. |
| 93 | Douglas McNeel | HEM/ONC | dm3@medicine.wisc.edu | Combining toll-like receptor agonists with immune checkpoint blockade affects antitumor vaccine efficacy. | T cell checkpoint receptors are expressed when T cells are activated, and modulation of the expression or signaling of these receptors can alter the function of T cells and their antitumor efficacy. We previously found that T cells activated with cognate antigen had increases in the expression of PD-1, and this was attenuated in the presence of multiple toll-like receptor (TLR) agonists, notably TLR3 plus TLR9. In the current report, we sought to investigate whether combining TLR agonists with immune checkpoint blockade can further augment vaccine-mediated T cell antitumor immunity in murine tumor models. TLR agonists (TLR3 plus TLR9) and immune checkpoint inhibitors (antibodies targeting PD-1, CTLA-4, LAG-3, TIM-3 or VISTA) were combined and delivered with vaccines or vaccine-activated CD8+T cells to E.G7-OVA or MyC-CaP tumor-bearing mice. Tumors were assessed for growth and then collected and analyzed by flow cytometry. Immunization of E.G7-OVA tumor-bearing mice with SIINFEKL peptide vaccine, coadministered with TLR agonists and αCTLA-4, demonstrated greater antitumor efficacy than immunization with TLR agonists or αCTLA-4 alone. Conversely, the antitumor efficacy was abrogated when vaccine and TLR agonists were combined with αPD-1. TLR agonists suppressed PD-1 expression on regulatory T cells (Tregs) and activated this population. Depletion of Tregs in tumor-bearing mice led to greater antitumor efficacy of this combination therapy, even in the presence of αPD-1. Combining vaccination with TLR agonists and αCTLA-4 or αLAG-3 showed greater antitumor than with combinations with αTIM-3 or αVISTA. The combination of TLR agonists and αCTLA-4 or αLAG-3 can further improve the efficacy of a cancer vaccine, an effect not observed using αPD-1 due to activation of Tregs when αPD-1 was combined with TLR3 and TLR9 agonists. These data suggest that optimal combinations of TLR agonists and immune checkpoint blockade may improve the efficacy of human anticancer vaccines. |
| 94 | Douglas McNeel | HEM/ONC | dm3@medicine.wisc.edu | Myeloid-derived suppressor cells attenuate the antitumor efficacy of radiopharmaceutical therapy using (90)Y-NM600 in combination with androgen deprivation therapy in murine prostate tumors. | Androgen deprivation therapy (ADT) is pivotal in treating recurrent prostate cancer and is often combined with external beam radiation therapy (EBRT) for localized disease. However, for metastatic castration-resistant prostate cancer, EBRT is typically only used in the palliative setting, because of the inability to radiate all sites of disease. Systemic radiation treatments that preferentially irradiate cancer cells, known as radiopharmaceutical therapy or targeted radionuclide therapy (TRT), have demonstrable benefits for treating metastatic prostate cancer. Here, we explored the use of a novel TRT, 90Y-NM600, specifically in combination with ADT, in murine prostate tumor models. 6-week-old male FVB mice were implanted subcutaneously with Myc-CaP tumor cells and given a single intravenous injection of 90Y-NM600, in combination with ADT (degarelix). The combination and sequence of administration were evaluated for effect on tumor growth and infiltrating immune populations were analyzed by flow cytometry. Sera were assessed to determine treatment effects on cytokine profiles. ADT delivered prior to TRT (ADT→TRT) resulted in significantly greater antitumor response and overall survival than if delivered after TRT (TRT→ADT). Studies conducted in immunodeficient NRG mice failed to show a difference in treatment sequence, suggesting an immunological mechanism. Myeloid-derived suppressor cells (MDSCs) significantly accumulated in tumors following TRT→ADT treatment and retained immune suppressive function. However, CD4+ and CD8+ T cells with an activated and memory phenotype were more prevalent in the ADT→TRT group. Depletion of Gr1+MDSCs led to greater antitumor response following either treatment sequence. Chemotaxis assays suggested that tumor cells secreted chemokines that recruited MDSCs, notably CXCL1 and CXCL2. The use of a selective CXCR2 antagonist, reparixin, further improved antitumor responses and overall survival when used in tumor-bearing mice treated with TRT→ADT. The combination of ADT and TRT improved antitumor responses in murine models of prostate cancer, however, this was dependent on the order of administration. This was found to be associated with one treatment sequence leading to an increase in infiltrating MDSCs. Combining treatment with a CXCR2 antagonist improved the antitumor effect of this combination, suggesting a possible approach for treating advanced human prostate cancer. |
| 95 | Douglas McNeel | HEM/ONC | dm3@medicine.wisc.edu | Phase 2 trial of a DNA vaccine (pTVG-HP) and nivolumab in patients with castration-sensitive non-metastatic (M0) prostate cancer. | We have previously reported that a plasmid DNA vaccine encoding prostatic acid phosphatase (pTVG-HP) had greater clinical activity when given in combination with pembrolizumab to patients with metastatic, castration-resistant prostate cancer. The current trial was conducted to evaluate vaccination with PD-1 blockade, using nivolumab, in patients with early, recurrent (M0) prostate cancer. Patients with M0 prostate cancer were treated with pTVG-HP (100 µg administered intradermally) and nivolumab (240 mg intravenous infusion) every 2 weeks for 3 months, and then every 4 weeks for 1 year of total treatment. Patients were then followed for an additional year off treatment. The primary objectives were safety and complete prostate-specific antigen (PSA) response (PSA50%. Median PSA doubling times were 5.9 months pretreatment, 25.6 months on-treatment (p=0.001), and 9.0 months in the subsequent year off-treatment. The overall median radiographic progression-free survival was not reached. Grade 3 or 4 events included adrenal insufficiency, fatigue, lymphopenia, and increased amylase/lipase. 9/19 (47%) patients developed immune-related adverse effects (irAE). The development of irAE and increased CXCL9 were associated with increased PSA doubling time. Quantitative NaF PET/CT imaging showed the resolution of subclinical lesions along with the development of new lesions at each time point. In this population, combining nivolumab with pTVG-HP vaccination was safe, and immunologically active, prolonged the time to disease progression, but did not eradicate disease. Quantitative imaging suggested that additional treatments targeting mechanisms of resistance may be required to eliminate tumors. NCT03600350. |
| 96 | Douglas McNeel | HEM/ONC | dm3@medicine.wisc.edu | First-in-human phase I/Ib study of NIZ985, a recombinant heterodimer of IL-15 and IL-15Rα, as a single agent and in combination with spartalizumab in patients with advanced and metastatic solid tumors. | Preclinically, interleukin-15 (IL-15) monotherapy promotes antitumor immune responses, which are enhanced when IL-15 is used in combination with immune checkpoint inhibitors (ICIs). This first-in-human study investigated NIZ985, a recombinant heterodimer comprising physiologically active IL-15 and IL-15 receptor α, as monotherapy and in combination with spartalizumab, an anti-programmed cell death protein-1 (anti-PD-1) monoclonal antibody, in patients with advanced solid tumors. This phase I/Ib study had two dose-escalation arms: single-agent NIZ985 administered subcutaneously thrice weekly (TIW, 2 weeks on/2 weeks off) or once weekly (QW, 3 weeks on/1 week off), and NIZ985 TIW or QW administered subcutaneously plus spartalizumab (400 mg intravenously every 4 weeks (Q4W)). The dose-expansion phase investigated NIZ985 1 µg/kg TIW/spartalizumab 400 mg Q4W in patients with anti-PD-1-sensitive or anti-PD-1-resistant tumor types stratified according to approved indications. The primary objectives were the safety, tolerability, and the maximum tolerated doses (MTDs) and/or recommended dose for expansion (RDE) of NIZ985 for the dose-expansion phase. As of February 17, 2020, 83 patients (median age: 63 years; range: 28-85) were treated in dose escalation (N=47; single-agent NIZ985: n=27; NIZ985/spartalizumab n=20) and dose expansion (N=36). No dose-limiting toxicities occurred nor was the MTD identified. The most common treatment-related adverse event (TRAE) was injection site reaction (primarily grades 1-2; single-agent NIZ985: 85% (23/27)); NIZ985/spartalizumab: 89% [50/56]). The most common grade 3-4 TRAE was decreased lymphocyte count (single-agent NIZ985: 7% [2/27]; NIZ985/spartalizumab: 5% [3/56]). The best overall response was stable disease in the single-agent arm (30% (8/27)) and partial response in the NIZ985/spartalizumab arm (5% [3/56]; melanoma, pancreatic cancer, gastric cancer). In dose expansion, the disease control rate was 45% (5/11) in the anti-PD-1-sensitive and 20% (5/25) in the anti-PD-1-resistant tumor type cohorts. Pharmacokinetic parameters were similar across arms. The transient increase in CD8+ T cell and natural killer cell proliferation and induction of several cytokines occurred in response to the single-agent and combination treatments. NIZ985 was well tolerated in the single-agent and NIZ985/spartalizumab regimens. The RDE was established at 1 µg/kg TIW. Antitumor activity of the combination was observed against tumor types known to have a poor response to ICIs. NCT02452268. |
| 97 | Douglas McNeel | HEM/ONC | dm3@medicine.wisc.edu | Vaccines as treatments for prostate cancer. | Prostate cancer is a leading cause of death in men worldwide. For over 30 years, growing interest has focused on the development of vaccines as treatments for prostate cancer, with the goal of using vaccines to activate immune cells capable of targeting prostate cancer to either eradicate recurrent disease or at least delay disease progression. This interest has been prompted by the prevalence and long natural history of the disease and by the fact that the prostate is an expendable organ. Thus, an immune response elicited by vaccination might not need to target the tumour uniquely but could theoretically target any prostate tissue. To date, different vaccine approaches and targets for prostate cancer have been evaluated in clinical trials. Overall, five approaches have been assessed in randomized phase III trials and sipuleucel-T was approved as a treatment for metastatic castration-resistant prostate cancer, being the only vaccine approved to date by the FDA as a treatment for cancer. Most vaccine approaches showed safety and some evidence of immunological activity but had poor clinical activity when used as monotherapies. However, increased activity has been observed when these vaccines were used in combination with other immune-modulating therapies. This evidence suggests that, in the future, prostate cancer vaccines might be used to activate and expand tumour-specific T cells as part of combination approaches with agents that target tumour-associated immune mechanisms of resistance. |
| 98 | Douglas McNeel | HEM/ONC | dm3@medicine.wisc.edu | B cells require licensing by dendritic cells to serve as primary antigen-presenting cells for plasmid DNA. | DNA vaccines have been an attractive approach for treating cancer patients, however have demonstrated modest immunogenicity in human clinical trials. Dendritic cells (DCs) are known to cross-present DNA-encoded antigens expressed in bystander cells. However, we have previously reported that B cells, and not DCs, serve as primary antigen-presenting cells (APCs) following passive uptake of plasmid DNA. Here we sought to understand the requirements for B cells to present DNA-encoded antigens, to ultimately increase the immunogenicity of plasmid DNA vaccines. Using ovalbumin-specific OT-1 CD8+ T cells and isolated APC populations, we demonstrated that following passive uptake of plasmid DNA, B cells but not DC, can translate the encoded antigen. However, CD8 T cells were only activated by B cells when they were co-cultured with DCs. We found that a cell-cell contact is required between B cells and DCs. Using MHCI KO and re-purification studies, we demonstrated that B cells were the primary APCs and DCs serve to license this function. We further identified that the gene expression profiles of B cells that have been licensed by DCs, compared to the B cells that have not, are vastly different and have signatures similar to B cells activated with a TLR7/8 agonist. Our data demonstrate that B cells transcribe and translate antigens encoded by plasmid DNA following passive uptake, however require licensing by live DC to present antigen to CD8 T cells. Further study of the role of B cells as APCs will be important to improve the immunological efficacy of DNA vaccines. |
| 99 | Douglas McNeel | HEM/ONC | dm3@medicine.wisc.edu | Niraparib with Abiraterone Acetate and Prednisone for Metastatic Castration-Resistant Prostate Cancer: Phase II QUEST Study Results. | Niraparib (NIRA) is a highly selective inhibitor of poly (adenosine diphosphate-ribose) polymerase, PARP1 and PARP2, which play a role in DNA repair. The phase II QUEST study evaluated NIRA combinations in patients with metastatic castration-resistant prostate cancer who were positive for homologous recombination repair gene alterations and had progressed on 1 prior line of novel androgen receptor-targeted therapy. Results from the combination of NIRA with abiraterone acetate plus prednisone, which disrupts androgen axis signaling through inhibition of CYP17, showed promising efficacy and a manageable safety profile in this patient population. |
| 100 | Francisco Alvarado | CVM | falvarad@medicine.wisc.edu | Early pathological mechanisms in a mouse model of heart failure with preserved ejection fraction. | Heart failure with preserved ejection fraction (HFpEF) constitutes more than half of all HF cases, yet evidence-based therapies remain lacking due to limited understanding of its underlying pathological mechanisms. Our study aimed to uncover early pathological mechanisms in HFpEF by exposing mice to dietary conditions resembling a Western diet-rich in fats, salt, and low in fiber-alongside excess mineralocorticoids to replicate significant aspects of human HFpEF. Echocardiography was performed at both 3-wk and 6-wk intervals postchallenge, revealing cardiac alterations as early as 3 wk. While ejection fraction remained preserved, mice exhibited signs of diastolic dysfunction, reduced stroke volume, and left atrial enlargement. In addition, changes in pulmonary flow velocities were noted by the 3-wk mark, suggesting elevated pulmonary pressure. Extracardiac comorbidities included organ congestion, increased adiposity, impaired glucose tolerance, and hypercholesterolemia. Molecular analyses unveiled evidence of low-grade inflammation, oxidative stress, and impaired NO-cGMP-PKG signaling, contributing to the observed decrease in titin phosphorylation, thereby impacting myocardial stiffness. In addition, impaired nitric oxide (NO) signaling might have influenced the alterations observed in coronary flow reserve. Moreover, dysregulation of calcium signaling in cardiomyocytes and reduced sarcoplasmic reticulum (SR) load were observed. Interestingly, elevated phosphorylation of cMyBP-C was linked to preserved ejection fraction despite reduced SR load. We also observed intestinal atrophy, possibly due to a high-fat diet, low dietary fiber intake, and diminished gut perfusion, potentially contributing to systemic low-grade inflammation. These findings reveal how excess mineralocorticoid salt-induced hypertension and dietary factors, like high-fat and low-fiber intake, contribute to cardiac dysfunction and metabolic disturbances, offering insights into early HFpEF pathology in this model.NEW & NOTEWORTHY Our study demonstrates that feeding mice a Western diet rich in fat and salt and low in fiber alongside excess mineralocorticoids replicates aspects of human HFpEF. Cardiac alterations including diastolic dysfunction and decreased stroke volume with preserved ejection fraction were observed. Extracardiac effects included organ congestion, adiposity, glucose intolerance, and intestinal atrophy. Molecular analysis revealed inflammation, oxidative stress, impaired NO-cGMP-PKG signaling pathways, and altered calcium signaling in cardiomyocytes, shedding light on early pathological changes in HFpEF. |
| 101 | Francisco Alvarado | CVM | falvarad@medicine.wisc.edu | Dual ablation of the RyR2-Ser2808 and RyR2-Ser2814 sites increases propensity for pro-arrhythmic spontaneous Ca(2+) releases. | During exercise or stress, the sympathetic system stimulates cardiac contractility via β-adrenergic receptor (β-AR) activation, resulting in phosphorylation of the cardiac ryanodine receptor (RyR2). Three RyR2 phosphorylation sites have taken prominence in excitation-contraction coupling: S2808 and S2030 are described as protein kinase A specific and S2814 as a Ca2+/calmodulin kinase type-2-specific site. To examine the contribution of these phosphosites to Ca2+ signalling, we generated double knock-in (DKI) mice in which Ser2808 and Ser2814 phosphorylation sites have both been replaced by alanine (RyR2-S2808A/S2814A). These mice did not exhibit an overt phenotype. Heart morphology and haemodynamic parameters were not altered. However, they had a higher susceptibility to arrhythmias. We performed confocal Ca2+ imaging and electrophysiology experiments. Isoprenaline was used to stimulate β-ARs. Measurements of Ca2+ waves and latencies in myocytes revealed an increased propensity for spontaneous Ca2+ releases in DKI myocytes, both in control conditions and during β-AR stimulation. In DKI cells, waves were initiated from a lower threshold concentration of Ca2+ inside the sarcoplasmic reticulum, suggesting higher Ca2+ sensitivity of the RyRs. The refractoriness of Ca2+ spark triggering depends on the Ca2+ sensitivity of the RyR2. We found that RyR2-S2808A/S2814A channels were more Ca2+ sensitive in control conditions. Isoprenaline further shortened RyR refractoriness in DKI cardiomyocytes. Together, our results suggest that ablation of both the RyR2-Ser2808 and RyR2-S2814 sites increases the propensity for pro-arrhythmic spontaneous Ca2+ releases, as previously suggested for hyperphosphorylated RyRs. Given that the DKI cells present a full response to isoprenaline, the data suggest that phosphorylation of Ser2030 might be sufficient for β-AR-mediated sensitization of RyRs. KEY POINTS: Phosphorylation of cardiac sarcoplasmic reticulum Ca2+-release channels (ryanodine receptors, RyRs) is involved in the regulation of cardiac function. Ablation of both the RyR2-Ser2808 and RyR2-Ser2814 sites increases the propensity for pro-arrhythmic spontaneous Ca2+ releases, as previously suggested for hyperphosphorylated RyRs. The intra-sarcoplasmic reticulum Ca2+ threshold for spontaneous Ca2+ wave generation is lower in RyR2-double-knock-in cells. The RyR2 from double-knock-in cells exhibits increased Ca2+ sensitivity. Phosphorylation of Ser2808 and Ser2814 might be important for basal activity of the channel. Phosphorylation of Ser2030 might be sufficient for a β-adrenergic response. |
| 102 | Francisco Alvarado | CVM | falvarad@medicine.wisc.edu | Cardiac overexpression of a mitochondrial SUR2A splice variant impairs cardiac function and worsens myocardial ischemia reperfusion injury in female mice. | The small splice variant of the sulfonylurea receptor protein isoform 2 A (SUR2A-55) targets mitochondria and enhances mitoKATP activity. In male mice the overexpression of this protein promotes cardioprotection, reducing myocardial injury after an ischemic insult. However, it is unclear what impact SUR2A-55 overexpression has on the female myocardium. To investigate the impact of SU2R2A-55 on the female heart, mice with cardiac specific transgenic overexpression of SUR2A-55 (TGSUR2A-55) were examined by resting echocardiography and histopathology. In addition, hearts were subjected to ischemia reperfusion (IR) injury. Female TGSUR2A-55 mice had resting LV dysfunction and worse hemodynamic recovery with increased infarct size after IR injury. RNA-seq analysis found 227 differential expressed genes between WT and TGSUR2A-55 female mouse hearts that were enriched in pathways of cellular metabolism. This was in direct contrast to male mice that had only four differentially expressed genes. Female TGSUR2A-55 mice compared to female WT mice had reduced cardiomyocyte mitochondrial membrane potential without a change in electron transport chain protein expression. In addition, isolated mitochondria from female TGSUR2A-55 hearts displayed reduced sensitivity to ATP and diazoxide suggestive of increased mitoKATP activity. In conclusion, our data suggests that female TGSUR2A-55 mice are unable to tolerate a more active mitoKATP channel leading to LV dysfunction and worse response to IR injury. This is in direct contrast to our prior report showing cardioprotection in male mice overexpressing SUR2A-55 in heart. Future research directed at examining the expression and activity of mitoKATP subunits according to sex may elucidate different treatments for male and female patients. |
| 103 | Francisco Alvarado | CVM | falvarad@medicine.wisc.edu | Calpain inhibition takes center stage against atrial fibrillation in the diabetic heart. | |
| 104 | Francisco Alvarado | CVM | falvarad@medicine.wisc.edu | Clustering properties of the cardiac ryanodine receptor in health and heart failure. | The cardiac ryanodine receptor (RyR2) is an intracellular Ca2+ release channel vital for the function of the heart. Physiologically, RyR2 is triggered to release Ca2+ from the sarcoplasmic reticulum (SR) which enables cardiac contraction; however, spontaneous Ca2+ leak from RyR2 has been implicated in the pathophysiology of heart failure (HF). RyR2 channels have been well documented to assemble into clusters within the SR membrane, with the organisation of RyR2 clusters recently gaining interest as a mechanism by which the occurrence of pathological Ca2+ leak is regulated, including in HF. In this review, we explain the terminology relating to key nanoscale RyR2 clustering properties as both single clusters and functionally grouped Ca2+ release units, with a focus on the advancements in super-resolution imaging approaches which have enabled the detailed study of cluster organisation. Further, we discuss proposed mechanisms for modulating RyR2 channel organisation and the debate regarding the potential impact of cluster organisation on Ca2+ leak activity. Finally, recent experimental evidence investigating the nanoscale remodelling and functional alterations of RyR2 clusters in HF is discussed with consideration of the clinical implications. |
| 105 | Francisco Alvarado | CVM | falvarad@medicine.wisc.edu | Caveolae-associated cAMP/Ca(2+)-mediated mechano-chemical signal transduction in mouse atrial myocytes. | Caveolae are tiny invaginations in the sarcolemma that buffer extra membrane and contribute to mechanical regulation of cellular function. While the role of caveolae in membrane mechanosensation has been studied predominantly in non-cardiomyocyte cells, caveolae contribution to cardiac mechanotransduction remains elusive. Here, we studied the role of caveolae in the regulation of Ca2+ signaling in atrial cardiomyocytes. In Langendorff-perfused mouse hearts, atrial pressure/volume overload stretched atrial myocytes and decreased caveolae density. In isolated cells, caveolae were disrupted through hypotonic challenge that induced a temporal (<10 min) augmentation of Ca2+ transients and caused a rise in Ca2+ spark activity. Similar changes in Ca2+ signaling were observed after chemical (methyl-β-cyclodextrin) and genetic ablation of caveolae in cardiac-specific conditional caveolin-3 knock-out mice. Acute disruption of caveolae, both mechanical and chemical, led to the elevation of cAMP level in the cell interior, and cAMP-mediated augmentation of protein kinase A (PKA)-phosphorylated ryanodine receptors (at Ser2030 and Ser2808). Caveolae-mediated stimulatory effects on Ca2+ signaling were abolished via inhibition of cAMP production by adenyl cyclase antagonists MDL12330 and SQ22536, or reduction of PKA activity by H-89. A compartmentalized mathematical model of mouse atrial myocytes linked the observed changes to a microdomain-specific decrease in phosphodiesterase activity, which disrupted cAMP signaling and augmented PKA activity. Our findings add a new dimension to cardiac mechanobiology and highlight caveolae-associated cAMP/PKA-mediated phosphorylation of Ca2+ handling proteins as a novel component of mechano-chemical feedback in atrial myocytes. |
| 106 | Francisco Alvarado | CVM | falvarad@medicine.wisc.edu | Allosteric modulation of ryanodine receptor RyR1 by nucleotide derivatives. | The coordinated release of Ca2+ from the sarcoplasmic reticulum (SR) is critical for excitation-contraction coupling. This release is facilitated by ryanodine receptors (RyRs) that are embedded in the SR membrane. In skeletal muscle, activity of RyR1 is regulated by metabolites such as ATP, which upon binding increase channel open probability (Po). To obtain structural insights into the mechanism of RyR1 priming by ATP, we determined several cryo-EM structures of RyR1 bound individually to ATP-γ-S, ADP, AMP, adenosine, adenine, and cAMP. We demonstrate that adenine and adenosine bind RyR1, but AMP is the smallest ATP derivative capable of inducing long-range (>170 Å) structural rearrangements associated with channel activation, establishing a structural basis for key binding site interactions that are the threshold for triggering quaternary structural changes. Our finding that cAMP also induces these structural changes and results in increased channel opening suggests its potential role as an endogenous modulator of RyR1 conductance. |
| 107 | Francisco Alvarado | CVM | falvarad@medicine.wisc.edu | Overexpression of a Short Sulfonylurea Splice Variant Increases Cardiac Glucose Uptake and Uncouples Mitochondria by Regulating ROMK Activity. | The mitochondrial splice variant of the sulfonylurea receptor (SUR2A-55) is associated with protection from myocardial ischemia-reperfusion (IR) injury, increased mitochondrial ATP sensitive K+ channel activity (mitoKATP) and altered glucose metabolism. While mitoKATP channels composed of CCDC51 and ABCB8 exist, the mitochondrial K+ pore regulated by SUR2A-55 is unknown. We explored whether SUR2A-55 regulates ROMK to form an alternate mitoKATP. We assessed glucose uptake in mice overexpressing SUR2A-55 (TGSUR2A-55) compared with WT mice during IR injury. We then examined the expression level of ROMK and the effect of ROMK modulation on mitochondrial membrane potential (Δψm) in WT and TGSUR2A-55 mice. TGSUR2A-55 had increased glucose uptake compared to WT mice during IR injury. The expression of ROMK was similar in WT compared to TGSUR2A-55 mice. ROMK inhibition hyperpolarized resting cardiomyocyte Δψm from TGSUR2A-55 mice but not from WT mice. In addition, TGSUR2A-55 and ROMK inhibitor treated WT isolated cardiomyocytes had enhanced mitochondrial uncoupling. ROMK inhibition blocked diazoxide induced Δψm depolarization and prevented preservation of Δψm from FCCP perfusion in WT and to a lesser degree TGSUR2A-55 mice. In conclusion, cardio-protection from SUR2A-55 is associated with ROMK regulation, enhanced mitochondrial uncoupling and increased glucose uptake. |
| 108 | Francisco Alvarado | CVM | falvarad@medicine.wisc.edu | Preserved cardiac performance and adrenergic response in a rabbit model with decreased ryanodine receptor 2 expression. | Ryanodine receptor 2 (RyR2) is an ion channel in the heart responsible for releasing into the cytosol most of the Ca2+ required for contraction. Proper regulation of RyR2 is critical, as highlighted by the association between channel dysfunction and cardiac arrhythmia. Lower RyR2 expression is also observed in some forms of heart disease; however, there is limited information on the impact of this change on excitation-contraction (e-c) coupling, Ca2+-dependent arrhythmias, and cardiac performance. We used a constitutive knock-out of RyR2 in rabbits (RyR2-KO) to assess the extent to which a stable decrease in RyR2 expression modulates Ca2+ handling in the heart. We found that homozygous knock-out of RyR2 in rabbits is embryonic lethal. Remarkably, heterozygotes (KO+/-) show ~50% loss of RyR2 protein without developing an overt phenotype at the intact animal and whole heart levels. Instead, we found that KO+/- myocytes show (1) remodeling of RyR2 clusters, favoring smaller groups in which channels are more densely arranged; (2) lower Ca2+ spark frequency and amplitude; (3) slower rate of Ca2+ release and mild but significant desynchronization of the Ca2+ transient; and (4) a significant decrease in the basal phosphorylation of S2031, likely due to increased association between RyR2 and PP2A. Our data show that RyR2 deficiency, although remarkable at the molecular and subcellular level, has only a modest impact on global Ca2+ release and is fully compensated at the whole-heart level. This highlights the redundancy of RyR2 protein expression and the plasticity of the e-c coupling apparatus. |
| 109 | Francisco Alvarado | CVM | falvarad@medicine.wisc.edu | Mechanisms of ryanodine receptor 2 dysfunction in heart failure. | |
| 110 | Lee Eckhardt | CVM | lle@medicine.wisc.edu | A PAS-targeting hERG1 activator reduces arrhythmic events in Jervell and Lange-Nielsen syndrome patient-derived hiPSC-CMs. | The hERG1 potassium channel conducts the cardiac repolarizing current, IKr. hERG1 has emerged as a therapeutic target for cardiac diseases marked by prolonged actional potential duration (APD). Unfortunately, many hERG1 activators display off-target and proarrhythmic effects that limit their therapeutic potential. A Per-Arnt-Sim (PAS) domain in the hERG1 N-terminus reduces IKr by slowing channel activation and promoting inactivation. Disrupting PAS activity increases IKr and shortens APD in human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs). We thus hypothesized that the hERG1 PAS domain could represent a therapeutic target to reduce arrhythmogenic potential in a long QT syndrome (LQTS) background. To test this, we measured the antiarrhythmic capacity of a PAS-disabling single-chain variable fragment antibody, scFv2.10, in a hiPSC-CM line derived from a Jervell and Lange Nielsen syndrome (JLN) patient. JLN is a severe form of LQTS caused by autosomal recessive mutations in KCNQ1. The patient in this study carried compound heterozygous mutations in KCNQ1. Corresponding JLN hiPSC-CMs displayed prolonged APD and early after depolarizations (EADs). Disrupting PAS with scFv2.10 increased IKr, shortened APD, and reduced the incidence of EADs. These data demonstrate that the hERG1 PAS domain could serve as a therapeutic target to treat disorders of cardiac electrical dysfunction. |
| 111 | Lee Eckhardt | CVM | lle@medicine.wisc.edu | The impact of common and rare genetic variants on bradyarrhythmia development. | To broaden our understanding of bradyarrhythmias and conduction disease, we performed common variant genome-wide association analyses in up to 1.3 million individuals and rare variant burden testing in 460,000 individuals for sinus node dysfunction (SND), distal conduction disease (DCD) and pacemaker (PM) implantation. We identified 13, 31 and 21 common variant loci for SND, DCD and PM, respectively. Four well-known loci (SCN5A/SCN10A, CCDC141, TBX20 and CAMK2D) were shared for SND and DCD, while others were more specific for SND or DCD. SND and DCD showed a moderate genetic correlation (rg = 0.63). Cardiomyocyte-expressed genes were enriched for contributions to DCD heritability. Rare-variant analyses implicated LMNA for all bradyarrhythmia phenotypes, SMAD6 and SCN5A for DCD and TTN, MYBPC3 and SCN5A for PM. These results show that variation in multiple genetic pathways (for example, ion channel function, cardiac developmental programs, sarcomeric structure and cellular homeostasis) appear critical to the development of bradyarrhythmias. |
| 112 | Lee Eckhardt | CVM | lle@medicine.wisc.edu | Modeling Idiopathic Ventricular Fibrillation Using iPSC Cardiomyocytes and Computational Approaches: A Proof-of-Concept Study. | Idiopathic ventricular fibrillation (IVF) is an unrefined diagnosis representing a heterogeneous patient group without a structural or genetic definition. IVF treatment is not mechanistic-based due to the lack of experimental patient-models. We sought to create a methodology to assess cellular arrhythmia mechanisms for IVF as a proof-of-concept study. Using IVF patient-specific induced pluripotent stem cell-derived cardiomyocytes, we integrate electrophysiological optical mapping with computational modeling to characterize the cellular phenotype. This approach flips the traditional paradigm using a biophysically detailed computational model to solve the problem inversely. Insight into the cellular mechanisms of this patient's IVF phenotype could also serve as a therapeutic testbed. |
| 113 | Lee Eckhardt | CVM | lle@medicine.wisc.edu | Dynamic role of hormones on Brugada syndrome phenotype. | |
| 114 | Lee Eckhardt | CVM | lle@medicine.wisc.edu | Arrhythmia Research at a Tipping Point: The Need for Disruptive Science and Technology. | |
| 115 | Lee Eckhardt | CVM | lle@medicine.wisc.edu | Global Proteomic Analysis Reveals Alterations in Differentially Expressed Proteins between Cardiopathic Lamin A/C Mutations. | Lamin A/C (LMNA) is an important component of nuclear lamina. Mutations cause arrhythmia, heart failure, and sudden cardiac death. While LMNA-associated cardiomyopathy typically has an aggressive course that responds poorly to conventional heart failure therapies, there is variability in severity and age of penetrance between and even within specific mutations, which is poorly understood at the cellular level. Further, this heterogeneity has not previously been captured to mimic the heterozygous state, nor have the hundreds of clinical LMNA mutations been represented. Herein, we have overexpressed cardiopathic LMNA variants in HEK cells and utilized state-of-the-art quantitative proteomics to compare the global proteomic profiles of (1) aggregating Q353 K alone, (2) Q353 K coexpressed with WT, (3) aggregating N195 K coexpressed with WT, and (4) nonaggregating E317 K coexpressed with WT to help capture some of the heterogeneity between mutations. We analyzed each data set to obtain the differentially expressed proteins (DEPs) and applied gene ontology (GO) and KEGG pathway analyses. We found a range of 162 to 324 DEPs from over 6000 total protein IDs with differences in GO terms, KEGG pathways, and DEPs important in cardiac function, further highlighting the complexity of cardiac laminopathies. Pathways disrupted by LMNA mutations were validated with redox, autophagy, and apoptosis functional assays in both HEK 293 cells and in induced pluripotent stem cell derived cardiomyocytes (iPSC-CMs) for LMNA N195 K. These proteomic profiles expand our repertoire for mutation-specific downstream cellular effects that may become useful as druggable targets for personalized medicine approach for cardiac laminopathies. |
| 116 | Lee Eckhardt | CVM | lle@medicine.wisc.edu | Top stories on the study of inherited arrhythmias using iPSCs. | |
| 117 | Lee Eckhardt | CVM | lle@medicine.wisc.edu | Meta-Analysis of Genome-Wide Association Studies Reveals Genetic Mechanisms of Supraventricular Arrhythmias. | Substantial data support a heritable basis for supraventricular tachycardias, but the genetic determinants and molecular mechanisms of these arrhythmias are poorly understood. We sought to identify genetic loci associated with atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular accessory pathways or atrioventricular reciprocating tachycardia (AVAPs/AVRT). We performed multiancestry meta-analyses of genome-wide association studies to identify genetic loci for AVNRT (4 studies) and AVAP/AVRT (7 studies). We assessed evidence supporting the potential causal effects of candidate genes by analyzing relations between associated variants and cardiac gene expression, performing transcriptome-wide analyses, and examining prior genome-wide association studies. Analyses comprised 2384 AVNRT cases and 106 489 referents, and 2811 AVAP/AVRT cases and 1,483 093 referents. We identified 2 significant loci for AVNRT, which implicate NKX2-5 and TTN as disease susceptibility genes. A transcriptome-wide association analysis supported an association between reduced predicted cardiac expression of NKX2-5 and AVNRT. We identified 3 significant loci for AVAP/AVRT, which implicate SCN5A, SCN10A, and TTN/CCDC141. Variant associations at several loci have been previously reported for cardiac phenotypes, including atrial fibrillation, stroke, Brugada syndrome, and electrocardiographic intervals. Our findings highlight gene regions associated with ion channel function (AVAP/AVRT), as well as cardiac development and the sarcomere (AVAP/AVRT and AVNRT) as important potential effectors of supraventricular tachycardia susceptibility. |
| 118 | Lee Eckhardt | CVM | lle@medicine.wisc.edu | Clinical Management of Brugada Syndrome: Commentary From the Experts. | Although there is consensus on the management of patients with Brugada Syndrome with high risk for sudden cardiac arrest, asymptomatic or intermediate-risk patients present clinical management challenges. This document explores the management opinions of experts throughout the world for patients with Brugada Syndrome who do not fit guideline recommendations. Four real-world clinical scenarios were presented with commentary from small expert groups for each case. All authors voted on case-specific questions to evaluate the level of consensus among the entire group in nuanced diagnostic and management decisions relevant to each case. Points of agreement, points of controversy, and gaps in knowledge are highlighted. |
| 119 | Lee Eckhardt | CVM | lle@medicine.wisc.edu | The Changing Complexities of Opioid-Related Sudden Death. | |
| 120 | Alexey Glukhov | CVM | aglukhov@medicine.wisc.edu | Modeling Idiopathic Ventricular Fibrillation Using iPSC Cardiomyocytes and Computational Approaches: A Proof-of-Concept Study. | Idiopathic ventricular fibrillation (IVF) is an unrefined diagnosis representing a heterogeneous patient group without a structural or genetic definition. IVF treatment is not mechanistic-based due to the lack of experimental patient-models. We sought to create a methodology to assess cellular arrhythmia mechanisms for IVF as a proof-of-concept study. Using IVF patient-specific induced pluripotent stem cell-derived cardiomyocytes, we integrate electrophysiological optical mapping with computational modeling to characterize the cellular phenotype. This approach flips the traditional paradigm using a biophysically detailed computational model to solve the problem inversely. Insight into the cellular mechanisms of this patient's IVF phenotype could also serve as a therapeutic testbed. |
| 121 | Alexey Glukhov | CVM | aglukhov@medicine.wisc.edu | Neutral sphingomyelinase regulates mechanotransduction in human engineered cardiac tissues and mouse hearts. | Cardiovascular disease is the leading cause of death in the USA and is known to be exacerbated by elevated mechanical stress from hypertension. Caveolae are plasma membrane structures that buffer mechanical stress but have been found to be reduced in pathological conditions associated with chronically stretched myocardium. To explore the physiological implications of the loss of caveolae, we used human engineered cardiac tissue (ECT) constructs, composed of human induced pluripotent stem cell (hiPSC)-derived cardiomyocytes and hiPSC-derived cardiac fibroblasts, to develop a long-term cyclic stretch protocol that recapitulates the effects of hypertension on caveolae expression, membrane tension, and the β-adrenergic response. Leveraging this new stretch protocol, we identified neutral sphingomyelinases (nSMase) as mechanoregulated mediators of caveolae loss, ceramide production and the blunted β-adrenergic response in this human cardiac model. Specifically, in our ECT model, nSMase inhibition via GW4869 prevented stretch-induced loss of caveolae-like structures, mitigated nSMase-dependent ceramide production, and maintained the ECT contractile kinetic response to isoprenaline. These findings are correlated with a blood lipidomic analysis in middle-aged and older adults, which revealed an increase of the circulating levels of ceramides in adults with hypertension. Furthermore, we found that conduction slowing from increased pressure loading in mouse left ventricle was abolished in the context of nSMase inhibition. Collectively, these findings identify nSMase as a potent drug target for mitigating stretch-induced effects on cardiac function. KEY POINTS: We have developed a new stretch protocol for human engineered cardiac tissue that recapitulates changes in plasma membrane morphology observed in animal models of pressure/volume overload. Stretch of engineered cardiac tissue induces activation of neutral sphingomyelinase (nSMase), generation of ceramide, and disassembly of caveolae. Activation of nSMase blunts cardiac β-adrenergic contractile kinetics and mediates stretch-induced slowing of conduction and upstroke velocity. Circulating ceramides are increased in adults with hypertension, highlighting the clinical relevance of stretch-induced nSMase activity. |
| 122 | Alexey Glukhov | CVM | aglukhov@medicine.wisc.edu | Caveolar Compartmentalization of Pacemaker Signaling is Required for Stable Rhythmicity of Sinus Nodal Cells and is Disrupted in Heart Failure. | Heart rhythm relies on complex interactions between electrogenic membrane proteins and intracellular Ca2+ signaling in sinoatrial node (SAN) myocytes; however, mechanisms underlying the functional organization of proteins involved in SAN pacemaking and its structural foundation remain elusive. Caveolae are nanoscale, plasma membrane pits that compartmentalize various ion channels and transporters, including those involved in SAN pacemaking, via binding with the caveolin-3 scaffolding protein, but the precise role of caveolae in cardiac pacemaker function is unknown. Our objective was to determine the role of caveolae in SAN pacemaking and dysfunction (SND). Biochemical co-purification, in vivo electrocardiogram monitoring, ex vivo optical mapping, in vitro confocal Ca2+ imaging, and immunofluorescent and electron microscopy analyses were performed in wild type, cardiac-specific caveolin-3 knockout, and 8-weeks post-myocardial infarction heart failure (HF) mice. SAN tissue samples from donor human hearts were used for biochemical studies. We utilized a novel 3-dimensional single SAN cell mathematical model to determine the functional outcomes of protein nanodomain-specific localization and redistribution in SAN pacemaking. In both mouse and human SANs, caveolae compartmentalized HCN4, Cav1.2, Cav1.3, Cav3.1 and NCX1 proteins within discrete pacemaker signalosomes via direct association with caveolin-3. This compartmentalization positioned electrogenic sarcolemmal proteins near the subsarcolemmal sarcoplasmic reticulum (SR) membrane and ensured fast and robust activation of NCX1 by subsarcolemmal local SR Ca2+ release events (LCRs), which diffuse across ~15-nm subsarcolemmal cleft. Disruption of caveolae led to the development of SND via suppression of pacemaker automaticity through a 50% decrease of the L-type Ca2+ current, a negative shift of the HCN current (I f) activation curve, and a 40% reduction of Na+/Ca2+-exchanger function, along with ~2.3-times widening of the sarcolemma-SR distance. These changes significantly decreased the SAN depolarizing force, both during diastolic depolarization and upstroke phase, leading to bradycardia, sinus pauses, recurrent development of SAN quiescence, and significant increase in heart rate lability. Computational modeling, supported by biochemical studies, identified NCX1 redistribution to extra-caveolar membrane as the primary mechanism of SAN pauses and quiescence due to the impaired ability of NCX1 to be effectively activated by LCRs and trigger action potentials. HF remodeling mirrored caveolae disruption leading to NCX1-LCR uncoupling and SND. SAN pacemaking is driven by complex protein interactions within a nanoscale caveolar pacemaker signalosome. Disruption of caveolae leads to SND, potentially demonstrating a new dimension of SAN remodeling and providing a newly recognized target for therapy. |
| 123 | Alexey Glukhov | CVM | aglukhov@medicine.wisc.edu | Mechanisms of stretch-induced electro-anatomical remodeling and atrial arrhythmogenesis. | Atrial fibrillation (AF) is the most common cardiac rhythm disorder, often occurring in the setting of atrial distension and elevated myocardialstretch. While various mechano-electrochemical signal transduction pathways have been linked to AF development and progression, the underlying molecular mechanisms remain poorly understood, hampering AF therapies. In this review, we describe different aspects of stretch-induced electro-anatomical remodeling as seen in animal models and in patients with AF. Specifically, we focus on cellular and molecular mechanisms that are responsible for mechano-electrochemical signal transduction and the development of ectopic beats triggering AF from pulmonary veins, the most common source of paroxysmal AF. Furthermore, we describe structural changes caused by stretch occurring before and shortly after the onset of AF as well as during AF progression, contributing to longstanding forms of AF. We also propose mechanical stretch as a new dimension to the concept "AF begets AF", in addition to underlying diseases. Finally, we discuss the mechanisms of these electro-anatomical alterations in a search for potential therapeutic strategies and the development of novel antiarrhythmic drugs targeted at the components of mechano-electrochemical signal transduction not only in cardiac myocytes, but also in cardiac non-myocyte cells. |
| 124 | Alexey Glukhov | CVM | aglukhov@medicine.wisc.edu | Mind the Gap: Does Junctophilin 2 Gear the Coupled-Clock System in Pacemaker Cardiomyocytes? | [Figure: see text] |
| 125 | Alexey Glukhov | CVM | aglukhov@medicine.wisc.edu | Caveolae-associated cAMP/Ca(2+)-mediated mechano-chemical signal transduction in mouse atrial myocytes. | Caveolae are tiny invaginations in the sarcolemma that buffer extra membrane and contribute to mechanical regulation of cellular function. While the role of caveolae in membrane mechanosensation has been studied predominantly in non-cardiomyocyte cells, caveolae contribution to cardiac mechanotransduction remains elusive. Here, we studied the role of caveolae in the regulation of Ca2+ signaling in atrial cardiomyocytes. In Langendorff-perfused mouse hearts, atrial pressure/volume overload stretched atrial myocytes and decreased caveolae density. In isolated cells, caveolae were disrupted through hypotonic challenge that induced a temporal (<10 min) augmentation of Ca2+ transients and caused a rise in Ca2+ spark activity. Similar changes in Ca2+ signaling were observed after chemical (methyl-β-cyclodextrin) and genetic ablation of caveolae in cardiac-specific conditional caveolin-3 knock-out mice. Acute disruption of caveolae, both mechanical and chemical, led to the elevation of cAMP level in the cell interior, and cAMP-mediated augmentation of protein kinase A (PKA)-phosphorylated ryanodine receptors (at Ser2030 and Ser2808). Caveolae-mediated stimulatory effects on Ca2+ signaling were abolished via inhibition of cAMP production by adenyl cyclase antagonists MDL12330 and SQ22536, or reduction of PKA activity by H-89. A compartmentalized mathematical model of mouse atrial myocytes linked the observed changes to a microdomain-specific decrease in phosphodiesterase activity, which disrupted cAMP signaling and augmented PKA activity. Our findings add a new dimension to cardiac mechanobiology and highlight caveolae-associated cAMP/PKA-mediated phosphorylation of Ca2+ handling proteins as a novel component of mechano-chemical feedback in atrial myocytes. |
| 126 | Alexey Glukhov | CVM | aglukhov@medicine.wisc.edu | Guidelines for assessment of cardiac electrophysiology and arrhythmias in small animals. | Cardiac arrhythmias are a major cause of morbidity and mortality worldwide. Although recent advances in cell-based models, including human-induced pluripotent stem cell-derived cardiomyocytes (iPSC-CM), are contributing to our understanding of electrophysiology and arrhythmia mechanisms, preclinical animal studies of cardiovascular disease remain a mainstay. Over the past several decades, animal models of cardiovascular disease have advanced our understanding of pathological remodeling, arrhythmia mechanisms, and drug effects and have led to major improvements in pacing and defibrillation therapies. There exist a variety of methodological approaches for the assessment of cardiac electrophysiology and a plethora of parameters may be assessed with each approach. This guidelines article will provide an overview of the strengths and limitations of several common techniques used to assess electrophysiology and arrhythmia mechanisms at the whole animal, whole heart, and tissue level with a focus on small animal models. We also define key electrophysiological parameters that should be assessed, along with their physiological underpinnings, and the best methods with which to assess these parameters. |
| 127 | Alexey Glukhov | CVM | aglukhov@medicine.wisc.edu | A phenotype-based forward genetic screen identifies Dnajb6 as a sick sinus syndrome gene. | Previously we showed the generation of a protein trap library made with the gene-break transposon (GBT) in zebrafish (Danio rerio) that could be used to facilitate novel functional genome annotation towards understanding molecular underpinnings of human diseases (Ichino et al, 2020). Here, we report a significant application of this library for discovering essential genes for heart rhythm disorders such as sick sinus syndrome (SSS). SSS is a group of heart rhythm disorders caused by malfunction of the sinus node, the heart's primary pacemaker. Partially owing to its aging-associated phenotypic manifestation and low expressivity, molecular mechanisms of SSS remain difficult to decipher. From 609 GBT lines screened, we generated a collection of 35 zebrafish insertional cardiac (ZIC) mutants in which each mutant traps a gene with cardiac expression. We further employed electrocardiographic measurements to screen these 35 ZIC lines and identified three GBT mutants with SSS-like phenotypes. More detailed functional studies on one of the arrhythmogenic mutants, GBT411, in both zebrafish and mouse models unveiled Dnajb6 as a novel SSS causative gene with a unique expression pattern within the subpopulation of sinus node pacemaker cells that partially overlaps with the expression of hyperpolarization activated cyclic nucleotide gated channel 4 (HCN4), supporting heterogeneity of the cardiac pacemaker cells. |
| 128 | Alexey Glukhov | CVM | aglukhov@medicine.wisc.edu | Caveolin-3 prevents swelling-induced membrane damage via regulation of I(Cl,swell) activity. | Caveola membrane structures harbor mechanosensitive chloride channels (MCCs; including chloride channel 2, chloride channel 3, and SWELL1, also known as LRRC8A) that form a swelling-activated chloride current (ICl,swell) and play an important role in cell volume regulation and mechanoelectrical signal transduction. However, the role of the muscle-specific caveolar scaffolding protein caveolin-3 (Cav3) in regulation of MCC expression, activity, and contribution to membrane integrity in response to mechanical stress remains unclear. Here we showed that Cav3-transfected (Cav3-positive) HEK293 cells were significantly resistant to extreme (<20 milliosmole) hypotonic swelling compared with native (Cav3-negative) HEK293 cells; the percentage of cells with membrane damage decreased from 45% in Cav3-negative cells to 17% in Cav3-positive cells (p < 0.05). This mechanoprotection was significantly reduced (p < 0.05) when cells were exposed to the ICl,swell-selective inhibitor 4-[(2-butyl-6,7-dichloro-2-cyclopentyl-2,3-dihydro-1-oxo-1H-inden-5-yl)oxy]butanoic acid (10 μM). These results were recapitulated in isolated mouse ventricular myocytes, where the percentage of cardiomyocytes with membrane damage increased from 47% in control cells to 78% in 4-[(2-butyl-6,7-dichloro-2-cyclopentyl-2,3-dihydro-1-oxo-1H-inden-5-yl)oxy]butanoic acid-treated cells (p < 0.05). A higher resistance to hypotonic swelling in Cav3-positive HEK293 cells was accompanied by a significant twofold increase of ICl,swell current density and SWELL1 protein expression, whereas ClC-2/3 protein levels remained unchanged. Förster resonance energy transfer analysis showed a less than 10-nm membrane and intracellular association between Cav3 and SWELL1. Cav3/SWELL1 membrane Förster resonance energy transfer efficiency was halved in mild (220 milliosmole) hypotonic solution as well as after disruption of caveola structures via cholesterol depletion by 1-h treatment with 10 mM methyl-β-cyclodextrin. A close association between Cav3 and SWELL1 was confirmed by co-immunoprecipitation analysis. Our findings indicate that, in the MCCs tested, SWELL1 abundance and activity are regulated by Cav3 and that their association relies on membrane tension and caveola integrity. This study highlights the mechanoprotective role of Cav3, which is facilitated by complimentary SWELL1 expression and activity. |
| 129 | Alexey Glukhov | CVM | aglukhov@medicine.wisc.edu | Region-specific distribution of transversal-axial tubule system organization underlies heterogeneity of calcium dynamics in the right atrium. | The atrial myocardium demonstrates the highly heterogeneous organization of the transversal-axial tubule system (TATS), although its anatomical distribution and region-specific impact on Ca2+ dynamics remain unknown. Here, we developed a novel method for high-resolution confocal imaging of TATS in intact live mouse atrial myocardium and applied a custom-developed MATLAB-based computational algorithm for the automated analysis of TATS integrity. We observed a twofold higher (P < 0.01) TATS density in the right atrial appendage (RAA) than in the intercaval regions (ICR, the anatomical region between the superior vena cava and atrioventricular junction and between the crista terminalis and interatrial septum). Whereas RAA predominantly consisted of well-tubulated myocytes, ICR showed partially tubulated/untubulated cells. Similar TATS distribution was also observed in healthy human atrial myocardium sections. In both mouse atrial preparations and isolated mouse atrial myocytes, we observed a strong anatomical correlation between TATS distribution and Ca2+ transient synchronization and rise-up time. This region-specific difference in Ca2+ transient morphology disappeared after formamide-induced detubulation. ICR myocytes showed a prolonged action potential duration at 80% of repolarization as well as a significantly lower expression of RyR2 and Cav1.2 proteins but similar levels of NCX1 and Cav1.3 compared with RAA tissue. Our findings provide a detailed characterization of the region-specific distribution of TATS in mouse and human atrial myocardium, highlighting the structural foundation for anatomical heterogeneity of Ca2+ dynamics and contractility in the atria. These results could indicate different roles of TATS in Ca2+ signaling at distinct anatomical regions of the atria and provide mechanistic insight into pathological atrial remodeling.NEW & NOTEWORTHY Mouse and human atrial myocardium demonstrate high variability in the organization of the transversal-axial tubule system (TATS), with more organized TATS expressed in the right atrial appendage. TATS distribution governs anatomical heterogeneity of Ca2+ dynamics and thus could contribute to integral atrial contractility, mechanics, and arrhythmogenicity. |
| 130 | Timothy Kamp | CVM | tjk@medicine.wisc.edu | A PAS-targeting hERG1 activator reduces arrhythmic events in Jervell and Lange-Nielsen syndrome patient-derived hiPSC-CMs. | The hERG1 potassium channel conducts the cardiac repolarizing current, IKr. hERG1 has emerged as a therapeutic target for cardiac diseases marked by prolonged actional potential duration (APD). Unfortunately, many hERG1 activators display off-target and proarrhythmic effects that limit their therapeutic potential. A Per-Arnt-Sim (PAS) domain in the hERG1 N-terminus reduces IKr by slowing channel activation and promoting inactivation. Disrupting PAS activity increases IKr and shortens APD in human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs). We thus hypothesized that the hERG1 PAS domain could represent a therapeutic target to reduce arrhythmogenic potential in a long QT syndrome (LQTS) background. To test this, we measured the antiarrhythmic capacity of a PAS-disabling single-chain variable fragment antibody, scFv2.10, in a hiPSC-CM line derived from a Jervell and Lange Nielsen syndrome (JLN) patient. JLN is a severe form of LQTS caused by autosomal recessive mutations in KCNQ1. The patient in this study carried compound heterozygous mutations in KCNQ1. Corresponding JLN hiPSC-CMs displayed prolonged APD and early after depolarizations (EADs). Disrupting PAS with scFv2.10 increased IKr, shortened APD, and reduced the incidence of EADs. These data demonstrate that the hERG1 PAS domain could serve as a therapeutic target to treat disorders of cardiac electrical dysfunction. |
| 131 | Timothy Kamp | CVM | tjk@medicine.wisc.edu | Cardiac L-type calcium channel regulation by Leucine-Rich Repeat-Containing Protein 10. | L-type calcium channels (LTCCs), the major portal for Ca2+ entry into cardiomyocytes, are essential for excitation-contraction coupling and thus play a central role in regulating overall cardiac function. LTCC function is finely tuned by multiple signaling pathways and accessory proteins. Leucine-rich repeat-containing protein 10 (LRRC10) is a little studied cardiomyocyte-specific protein recently identified as a modulator of LTCCs. LRRC10 exerts a remarkable effect on LTCC function, more than doubling L-type Ca2+ current (ICa,L) amplitude in a heterologous expression system by altering the gating of the channels without changing their surface membrane expression. Genetic ablation of LRRC10 expression in mouse and zebrafish hearts leads to a significant reduction in ICa,L density and a slowly progressive dilated cardiomyopathy in mice. Rare sequence variants of LRRC10 have been identified in dilated cardiomyopathy and sudden unexplained nocturnal cardiac death syndrome, but these variants have not been clearly linked to disease. Nevertheless, the DCM-associated variant, I195T, converted LRRC10 from a ICa,L potentiator to a ICa,L suppressor, thus illustrating the wide dynamic range of LRRC10-mediated ICa,L regulation. This review focuses on the contemporary knowledge of LTCC modulation by LRRC10 and discusses potential directions for future investigations. |
| 132 | Timothy Kamp | CVM | tjk@medicine.wisc.edu | Integrated multi-omics analysis identifies features that predict human pluripotent stem cell-derived progenitor differentiation to cardiomyocytes. | Human pluripotent stem cell-derived cardiomyocytes (hPSC-CMs) are advancing cardiovascular development and disease modeling, drug testing, and regenerative therapies. However, hPSC-CM production is hindered by significant variability in the differentiation process. Establishment of early quality markers to monitor lineage progression and predict terminal differentiation outcomes would address this robustness and reproducibility roadblock in hPSC-CM production. An integrated transcriptomic and epigenomic analysis assesses how attributes of the cardiac progenitor cell (CPC) affect CM differentiation outcome. Resulting analysis identifies predictive markers of CPCs that give rise to high purity CM batches, including TTN, TRIM55, DGKI, MEF2C, MAB21L2, MYL7, LDB3, SLC7A11, and CALD1. Predictive models developed from these genes provide high accuracy in determining terminal CM purities at the CPC stage. Further, insights into mechanisms of batch failure and dominant non-CM cell types generated in failed batches are elucidated. Namely EMT, MAPK, and WNT signaling emerge as significant drivers of batch divergence, giving rise to off-target populations of fibroblasts/mural cells, skeletal myocytes, epicardial cells, and a non-CPC SLC7A11+ subpopulation. This study demonstrates how integrated multi-omic analysis of progenitor cells can identify quality attributes of that progenitor and predict differentiation outcomes, thereby improving differentiation protocols and increasing process robustness. |
| 133 | Timothy Kamp | CVM | tjk@medicine.wisc.edu | Neutral sphingomyelinase regulates mechanotransduction in human engineered cardiac tissues and mouse hearts. | Cardiovascular disease is the leading cause of death in the USA and is known to be exacerbated by elevated mechanical stress from hypertension. Caveolae are plasma membrane structures that buffer mechanical stress but have been found to be reduced in pathological conditions associated with chronically stretched myocardium. To explore the physiological implications of the loss of caveolae, we used human engineered cardiac tissue (ECT) constructs, composed of human induced pluripotent stem cell (hiPSC)-derived cardiomyocytes and hiPSC-derived cardiac fibroblasts, to develop a long-term cyclic stretch protocol that recapitulates the effects of hypertension on caveolae expression, membrane tension, and the β-adrenergic response. Leveraging this new stretch protocol, we identified neutral sphingomyelinases (nSMase) as mechanoregulated mediators of caveolae loss, ceramide production and the blunted β-adrenergic response in this human cardiac model. Specifically, in our ECT model, nSMase inhibition via GW4869 prevented stretch-induced loss of caveolae-like structures, mitigated nSMase-dependent ceramide production, and maintained the ECT contractile kinetic response to isoprenaline. These findings are correlated with a blood lipidomic analysis in middle-aged and older adults, which revealed an increase of the circulating levels of ceramides in adults with hypertension. Furthermore, we found that conduction slowing from increased pressure loading in mouse left ventricle was abolished in the context of nSMase inhibition. Collectively, these findings identify nSMase as a potent drug target for mitigating stretch-induced effects on cardiac function. KEY POINTS: We have developed a new stretch protocol for human engineered cardiac tissue that recapitulates changes in plasma membrane morphology observed in animal models of pressure/volume overload. Stretch of engineered cardiac tissue induces activation of neutral sphingomyelinase (nSMase), generation of ceramide, and disassembly of caveolae. Activation of nSMase blunts cardiac β-adrenergic contractile kinetics and mediates stretch-induced slowing of conduction and upstroke velocity. Circulating ceramides are increased in adults with hypertension, highlighting the clinical relevance of stretch-induced nSMase activity. |
| 134 | Timothy Kamp | CVM | tjk@medicine.wisc.edu | Caveolar Compartmentalization of Pacemaker Signaling is Required for Stable Rhythmicity of Sinus Nodal Cells and is Disrupted in Heart Failure. | Heart rhythm relies on complex interactions between electrogenic membrane proteins and intracellular Ca2+ signaling in sinoatrial node (SAN) myocytes; however, mechanisms underlying the functional organization of proteins involved in SAN pacemaking and its structural foundation remain elusive. Caveolae are nanoscale, plasma membrane pits that compartmentalize various ion channels and transporters, including those involved in SAN pacemaking, via binding with the caveolin-3 scaffolding protein, but the precise role of caveolae in cardiac pacemaker function is unknown. Our objective was to determine the role of caveolae in SAN pacemaking and dysfunction (SND). Biochemical co-purification, in vivo electrocardiogram monitoring, ex vivo optical mapping, in vitro confocal Ca2+ imaging, and immunofluorescent and electron microscopy analyses were performed in wild type, cardiac-specific caveolin-3 knockout, and 8-weeks post-myocardial infarction heart failure (HF) mice. SAN tissue samples from donor human hearts were used for biochemical studies. We utilized a novel 3-dimensional single SAN cell mathematical model to determine the functional outcomes of protein nanodomain-specific localization and redistribution in SAN pacemaking. In both mouse and human SANs, caveolae compartmentalized HCN4, Cav1.2, Cav1.3, Cav3.1 and NCX1 proteins within discrete pacemaker signalosomes via direct association with caveolin-3. This compartmentalization positioned electrogenic sarcolemmal proteins near the subsarcolemmal sarcoplasmic reticulum (SR) membrane and ensured fast and robust activation of NCX1 by subsarcolemmal local SR Ca2+ release events (LCRs), which diffuse across ~15-nm subsarcolemmal cleft. Disruption of caveolae led to the development of SND via suppression of pacemaker automaticity through a 50% decrease of the L-type Ca2+ current, a negative shift of the HCN current (I f) activation curve, and a 40% reduction of Na+/Ca2+-exchanger function, along with ~2.3-times widening of the sarcolemma-SR distance. These changes significantly decreased the SAN depolarizing force, both during diastolic depolarization and upstroke phase, leading to bradycardia, sinus pauses, recurrent development of SAN quiescence, and significant increase in heart rate lability. Computational modeling, supported by biochemical studies, identified NCX1 redistribution to extra-caveolar membrane as the primary mechanism of SAN pauses and quiescence due to the impaired ability of NCX1 to be effectively activated by LCRs and trigger action potentials. HF remodeling mirrored caveolae disruption leading to NCX1-LCR uncoupling and SND. SAN pacemaking is driven by complex protein interactions within a nanoscale caveolar pacemaker signalosome. Disruption of caveolae leads to SND, potentially demonstrating a new dimension of SAN remodeling and providing a newly recognized target for therapy. |
| 135 | Timothy Kamp | CVM | tjk@medicine.wisc.edu | Engineering a robust and anisotropic cardiac-specific extracellular matrix scaffold for cardiac patch tissue engineering. | Extracellular matrix (ECM) fabricated using human induced pluripotent stem cells (hiPSCs)-derived cardiac fibroblasts (hiPSC-CFs) could serve as a completely biological scaffold for an engineered cardiac patch, leveraging the unlimited source and outstanding reproducibility of hiPSC-CFs. Additionally, hiPSC-CF-derived ECM (hiPSC-CF-ECM) holds the potential to enhance maturation of exogenous cardiomyocytes, such as hiPSC-derived cardiomyocytes (hiPSC-CMs), by providing a microenvironment rich in cardiac-specific biochemical and signaling cues. However, achieving sufficient robustness of hiPSC-CF-ECM is challenging. This study aims to achieve appropriate ECM deposition, scaffold thickness, and mechanical strength of an aligned hiPSC-CF-ECM by optimizing the culture period, ranging from 2 to 10 weeks, of hiPSC-CFs grown on micro-grated substrates, which can direct the alignment of both hiPSC-CFs and their secreted ECM. The hiPSC-CFs demonstrated a production rate of 13.5 µg ECM per day per 20,000 cells seeded. An anisotropic nanofibrous hiPSC-CF-ECM scaffold with a thickness of 20.0 ± 2.1 µm was achieved after 6 weeks of culture, followed by decellularization. Compositional analysis through liquid chromatography-mass spectrometry (LC-MS) revealed the presence of cardiac-specific fibrillar collagens, non-fibrillar collagens, and matricellular proteins. Uniaxial tensile stretching of the hiPSC-CF-ECM scaffold indicated robust tensile resilience. Finally, hiPSCs-CMs cultured on the hiPSC-CF-ECM exhibited alignment following the guidance of ECM nanofibers and demonstrated mature organization of key structural proteins. The culture duration of the anisotropic hiPSC-CF-ECM was successfully refined to achieve a robust scaffold containing structural proteins that resembles cardiac microenvironment. This completely biological, anisotropic, and cardiac-specific ECM holds great potential for cardiac patch engineering. |
| 136 | Timothy Kamp | CVM | tjk@medicine.wisc.edu | Diminished Immune Cell Adhesion in Hypoimmune ICAM-1 Knockout Pluripotent Stem Cells. | Hypoimmune gene edited human pluripotent stem cells (hPSCs) are a promising platform for developing reparative cellular therapies that evade immune rejection. Existing first-generation hypoimmune strategies have used CRISPR/Cas9 editing to modulate genes associated with adaptive (e.g., T cell) immune responses, but have largely not addressed the innate immune cells (e.g., monocytes, neutrophils) that mediate inflammation and rejection processes occurring early after graft transplantation. We identified the adhesion molecule ICAM-1 as a novel hypoimmune target that plays multiple critical roles in both adaptive and innate immune responses post-transplantation. In a series of studies, we found that ICAM-1 blocking or knock-out (KO) in hPSC-derived cardiovascular therapies imparted significantly diminished binding of multiple immune cell types. ICAM-1 KO resulted in diminished T cell proliferation responses in vitro and in longer in vivo retention/protection of KO grafts following immune cell encounter in NeoThy humanized mice. The ICAM-1 KO edit was also introduced into existing first-generation hypoimmune hPSCs and prevented immune cell binding, thereby enhancing the overall hypoimmune capacity of the cells. This novel hypoimmune editing strategy has the potential to improve the long-term efficacy and safety profiles of regenerative therapies for cardiovascular pathologies and a number of other diseases. |
| 137 | Timothy Kamp | CVM | tjk@medicine.wisc.edu | Global Proteomic Analysis Reveals Alterations in Differentially Expressed Proteins between Cardiopathic Lamin A/C Mutations. | Lamin A/C (LMNA) is an important component of nuclear lamina. Mutations cause arrhythmia, heart failure, and sudden cardiac death. While LMNA-associated cardiomyopathy typically has an aggressive course that responds poorly to conventional heart failure therapies, there is variability in severity and age of penetrance between and even within specific mutations, which is poorly understood at the cellular level. Further, this heterogeneity has not previously been captured to mimic the heterozygous state, nor have the hundreds of clinical LMNA mutations been represented. Herein, we have overexpressed cardiopathic LMNA variants in HEK cells and utilized state-of-the-art quantitative proteomics to compare the global proteomic profiles of (1) aggregating Q353 K alone, (2) Q353 K coexpressed with WT, (3) aggregating N195 K coexpressed with WT, and (4) nonaggregating E317 K coexpressed with WT to help capture some of the heterogeneity between mutations. We analyzed each data set to obtain the differentially expressed proteins (DEPs) and applied gene ontology (GO) and KEGG pathway analyses. We found a range of 162 to 324 DEPs from over 6000 total protein IDs with differences in GO terms, KEGG pathways, and DEPs important in cardiac function, further highlighting the complexity of cardiac laminopathies. Pathways disrupted by LMNA mutations were validated with redox, autophagy, and apoptosis functional assays in both HEK 293 cells and in induced pluripotent stem cell derived cardiomyocytes (iPSC-CMs) for LMNA N195 K. These proteomic profiles expand our repertoire for mutation-specific downstream cellular effects that may become useful as druggable targets for personalized medicine approach for cardiac laminopathies. |
| 138 | Timothy Kamp | CVM | tjk@medicine.wisc.edu | More Bang for the Buck: Using miRNA-Treated Human iPSC-Derived Cardiomyocytes for Cardiac Repair. | [Figure: see text] |
| 139 | Timothy Kamp | CVM | tjk@medicine.wisc.edu | Mechanisms of RBM20 Cardiomyopathy: Insights From Model Systems. | RBM20 (RNA-binding motif protein 20) is a vertebrate- and muscle-specific RNA-binding protein that belongs to the serine-arginine-rich family of splicing factors. The RBM20 gene was first identified as a dilated cardiomyopathy-linked gene over a decade ago. Early studies in Rbm20 knockout rodents implicated disrupted splicing of RBM20 target genes as a causative mechanism. Clinical studies show that pathogenic variants in RBM20 are linked to aggressive dilated cardiomyopathy with early onset heart failure and high mortality. Subsequent studies employing pathogenic variant knock-in animal models revealed that variants in a specific portion of the arginine-serine-rich domain in RBM20 not only disrupt splicing but also hinder nucleocytoplasmic transport and lead to the formation of RBM20 biomolecular condensates in the sarcoplasm. Conversely, mice harboring a disease-associated variant in the RRM (RNA recognition motif) do not show evidence of adverse remodeling or exhibit sudden death despite disrupted splicing of RBM20 target genes. Thus, whether disrupted splicing, biomolecular condensates, or both contribute to dilated cardiomyopathy is under debate. Beyond this, additional questions remain, such as whether there is sexual dimorphism in the presentation of RBM20 cardiomyopathy. What are the clinical features of RBM20 cardiomyopathy and why do some individuals develop more severe disease than others? In this review, we summarize the reported observations and discuss potential mechanisms of RBM20 cardiomyopathy derived from studies employing in vivo animal models and in vitro human-induced pluripotent stem cell-derived cardiomyocytes. Potential therapeutic strategies to treat RBM20 cardiomyopathy are also discussed. |
| 140 | Hector Valdivia | CVM | hvaldivia@wisc.edu | Dual ablation of the RyR2-Ser2808 and RyR2-Ser2814 sites increases propensity for pro-arrhythmic spontaneous Ca(2+) releases. | During exercise or stress, the sympathetic system stimulates cardiac contractility via β-adrenergic receptor (β-AR) activation, resulting in phosphorylation of the cardiac ryanodine receptor (RyR2). Three RyR2 phosphorylation sites have taken prominence in excitation-contraction coupling: S2808 and S2030 are described as protein kinase A specific and S2814 as a Ca2+/calmodulin kinase type-2-specific site. To examine the contribution of these phosphosites to Ca2+ signalling, we generated double knock-in (DKI) mice in which Ser2808 and Ser2814 phosphorylation sites have both been replaced by alanine (RyR2-S2808A/S2814A). These mice did not exhibit an overt phenotype. Heart morphology and haemodynamic parameters were not altered. However, they had a higher susceptibility to arrhythmias. We performed confocal Ca2+ imaging and electrophysiology experiments. Isoprenaline was used to stimulate β-ARs. Measurements of Ca2+ waves and latencies in myocytes revealed an increased propensity for spontaneous Ca2+ releases in DKI myocytes, both in control conditions and during β-AR stimulation. In DKI cells, waves were initiated from a lower threshold concentration of Ca2+ inside the sarcoplasmic reticulum, suggesting higher Ca2+ sensitivity of the RyRs. The refractoriness of Ca2+ spark triggering depends on the Ca2+ sensitivity of the RyR2. We found that RyR2-S2808A/S2814A channels were more Ca2+ sensitive in control conditions. Isoprenaline further shortened RyR refractoriness in DKI cardiomyocytes. Together, our results suggest that ablation of both the RyR2-Ser2808 and RyR2-S2814 sites increases the propensity for pro-arrhythmic spontaneous Ca2+ releases, as previously suggested for hyperphosphorylated RyRs. Given that the DKI cells present a full response to isoprenaline, the data suggest that phosphorylation of Ser2030 might be sufficient for β-AR-mediated sensitization of RyRs. KEY POINTS: Phosphorylation of cardiac sarcoplasmic reticulum Ca2+-release channels (ryanodine receptors, RyRs) is involved in the regulation of cardiac function. Ablation of both the RyR2-Ser2808 and RyR2-Ser2814 sites increases the propensity for pro-arrhythmic spontaneous Ca2+ releases, as previously suggested for hyperphosphorylated RyRs. The intra-sarcoplasmic reticulum Ca2+ threshold for spontaneous Ca2+ wave generation is lower in RyR2-double-knock-in cells. The RyR2 from double-knock-in cells exhibits increased Ca2+ sensitivity. Phosphorylation of Ser2808 and Ser2814 might be important for basal activity of the channel. Phosphorylation of Ser2030 might be sufficient for a β-adrenergic response. |
| 141 | Hector Valdivia | CVM | hvaldivia@wisc.edu | The Impact of Extracellular Histones and Absence of Toll-like Receptors on Cardiac Functional and Electrical Disturbances in Mouse Hearts. | In polymicrobial sepsis, the extracellular histones, mainly released from activated neutrophils, significantly contribute to cardiac dysfunction (septic cardiomyopathy), as demonstrated in our previous studies using Echo-Doppler measurements. This study aims to elucidate the roles of extracellular histones and their interactions with Toll-like receptors (TLRs) in cardiac dysfunction. Through ex vivo assessments of ECG, left ventricle (LV) function parameters, and in vivo Echo-Doppler studies in mice perfused with extracellular histones, we aim to provide comprehensive insights into the mechanisms underlying sepsis-induced cardiac dysfunction. Langendorff-perfused hearts from both wild-type and TLR2, TLR3, or TLR4 knockout (KO) mice were examined. Paced mouse hearts were perfused with histones to assess contractility and relaxation. Echo-Doppler studies evaluated cardiac dysfunction after intravenous histone injection. Histone perfusion caused defects in contractility and relaxation, with TLR2 and TLR3 KO mice being partially protected. Specifically, TLR2 KO mice exhibited the greatest reduction in Echo-Doppler abnormalities, while TLR4 KO exacerbated cardiac dysfunction. Among individual histones, H1 induced the most pronounced abnormalities in cardiac function, apoptosis of cardiomyocytes, and LDH release. Our data highlight significant interactions between histones and TLRs, providing insights into histones especially H1 as potential therapeutic targets for septic cardiomyopathy. Further studies are needed to explore specific histone-TLR interactions and their mechanisms. |
| 142 | Hector Valdivia | CVM | hvaldivia@wisc.edu | Phosphorylation of RyR2 simultaneously expands the dyad and rearranges the tetramers. | We have previously demonstrated that type II ryanodine receptors (RyR2) tetramers can be rapidly rearranged in response to a phosphorylation cocktail. The cocktail modified downstream targets indiscriminately, making it impossible to determine whether phosphorylation of RyR2 was an essential element of the response. Here, we used the β-agonist isoproterenol and mice homozygous for one of the following clinically relevant mutations: S2030A, S2808A, S2814A, or S2814D. We measured the length of the dyad using transmission electron microscopy (TEM) and directly visualized RyR2 distribution using dual-tilt electron tomography. We found that the S2814D mutation, by itself, significantly expanded the dyad and reorganized the tetramers, suggesting a direct link between the phosphorylation state of the tetramer and its microarchitecture. S2808A and S2814A mutant mice, as well as wild types, had significant expansions of their dyads in response to isoproterenol, while S2030A mutants did not. In agreement with functional data from these mutants, S2030 and S2808 were necessary for a complete β-adrenergic response, unlike S2814 mutants. Additionally, all mutants had unique effects on the organization of their tetramer arrays. Lastly, the correlation of structural with functional changes suggests that tetramer-tetramer contacts play an important functional role. We thus conclude that both the size of the dyad and the arrangement of the tetramers are linked to the state of the channel tetramer and can be dynamically altered by a β-adrenergic receptor agonist. |
| 143 | Hector Valdivia | CVM | hvaldivia@wisc.edu | Comparison of the structure-function of five newly members of the calcin family. | Calcins are a group of scorpion toxin peptides specifically binding to ryanodine receptors (RyRs) with high affinity, and have the ability to activate and stabilize RyR in a long-lasting subconductance state. Five newly calcins synthesized compounds exhibit typical structural characteristics of a specific family through chemical synthesis and virtual analysis. As the calcins from the same species, Petersiicalcin1 and Petersiicalcin2, Jendekicalcin2 and Jendekicalcin3, have only one residue difference. Both Petersiicalcin1 and Petersiicalcin2 exhibited different affinities in stimulating [3H]ryanodine binding, but the residue mutation resulted in a 2.7 folds difference. Other calcins also exhibited a stimulatory effect on [3H]ryanodine binding to RyR1, however, their affinities were significantly lower than that of Petersiiicalcin1 and Petersiiicalcin2. The channel domain of RyR1 was found to be capable of binding with the basic residues of these calcins, which also exhibited interactions with the S6 helices on RyR1. Dynamic simulations were conducted for Petersiicalcin1 and Petersiicalcin2, which demonstrated their ability to form a highly stable conformation and resulting in an asymmetric tetramer structure of RyR1. The discovery of five newly calcins further enriches the diversity of the natural calcin family, which provides more native peptides for the structure-function analysis between calcin and RyRs. |
| 144 | Hector Valdivia | CVM | hvaldivia@wisc.edu | The Effect of Acidic Residues on the Binding between Opicalcin1 and Ryanodine Receptor from the Structure-Functional Analysis. | Calcin is a group ligand with high affinity and specificity for the ryanodine receptors (RyRs). Little is known about the effect of its acidic residues on the spacial structure as well as the interaction with RyRs. We screened the opicalcin1 acidic mutants and investigated the effect of mutation on activity. The results indicated that all acidic mutants maintained the structural features, but their surface charge distribution underwent significant changes. Molecular docking and dynamics simulations were used to analyze the interaction between opicalcin1 mutants and RyRs, which demonstrated that all opicalcin1 mutants effectively bound to the channel domain of RyR1. This stable binding induced a pronounced asymmetry in the structure of the RyR tetramer, exhibiting a high degree of structural dissimilarity. [3H]Ryanodine binding to RyR1 was enhanced in D2A and D15A, which was similar to opicalcin1, but that effect was suppressed in E12A and E29A and reversed for the DE-4A, thereby inhibiting ryanodine binding. Opicalcin1 and DE-4A also exhibited the ability to form stable docking structures with RyR2. Acidic residues play a crucial role in the structure of calcin and its functional interaction with RyRs that is beneficial for the calcin optimization to develop more active peptide lead compounds for RyR-related diseases. |
| 145 | Hector Valdivia | CVM | hvaldivia@wisc.edu | OpiCa1-PEG-PLGA nanomicelles antagonize acute heart failure induced by the cocktail of epinephrine and caffeine. | Reducing Ca2+ content in the sarcoplasmic reticulum (SR) through ryanodine receptors (RyRs) by calcin is a potential intervention strategy for the SR Ca2+ overload triggered by β-adrenergic stress in acute heart diseases. OpiCal-PEG-PLGA nanomicelles were prepared by thin film dispersion, of which the antagonistic effects were observed using an acute heart failure model induced by epinephrine and caffeine in mice. In addition, cardiac targeting, self-stability as well as biotoxicity were determined. The synthesized OpiCa1-PEG-PLGA nanomicelles were elliptical with a particle size of 72.26 nm, a PDI value of 0.3, and a molecular weight of 10.39 kDa. The nanomicelles showed a significant antagonistic effect with 100 % survival rate to the death induced by epinephrine and caffeine, which was supported by echocardiography with significantly recovered heart rate, ejection fraction and left ventricular fractional shortening rate. The FITC labeled nanomicelles had a strong membrance penetrating capacity within 2 h and cardiac targeting within 12 h that was further confirmed by immunohistochemistry with a self-prepared OpiCa1 polyclonal antibody. Meanwhile, the nanomicelles can keep better stability and dispersibility in vitro at 4 °C rather than 20 °C or 37 °C, while maintain a low but stable plasma OpiCa1 concentration in vivo within 72 h. Finally, no obvious biotoxicities were observed by CCK-8, flow cytometry, H&E staining and blood biochemical examinations. Our study also provide a novel nanodelivery pathway for targeting RyRs and antagonizing the SR Ca2+ disordered heart diseases by actively releasing SR Ca2+ through RyRs with calcin. |
| 146 | Hector Valdivia | CVM | hvaldivia@wisc.edu | Sorcin promotes migration in cancer and regulates the EGF-dependent EGFR signaling pathways. | The epidermal growth factor receptor (EGFR) is one of the main tumor drivers and is an important therapeutic target for many cancers. Calcium is important in EGFR signaling pathways. Sorcin is one of the most important calcium sensor proteins, overexpressed in many tumors, that promotes cell proliferation, migration, invasion, epithelial-to-mesenchymal transition, malignant progression and resistance to chemotherapeutic drugs. The present work elucidates a functional mechanism that links calcium homeostasis to EGFR signaling in cancer. Sorcin and EGFR expression are significantly correlated and associated with reduced overall survival in cancer patients. Mechanistically, Sorcin directly binds EGFR protein in a calcium-dependent fashion and regulates calcium (dys)homeostasis linked to EGF-dependent EGFR signaling. Moreover, Sorcin controls EGFR proteostasis and signaling and increases its phosphorylation, leading to increased EGF-dependent migration and invasion. Of note, silencing of Sorcin cooperates with EGFR inhibitors in the regulation of migration, highlighting calcium signaling pathway as an exploitable target to enhance the effectiveness of EGFR-targeting therapies. |
| 147 | Hector Valdivia | CVM | hvaldivia@wisc.edu | Cryo-EM analysis of scorpion toxin binding to Ryanodine Receptors reveals subconductance that is abolished by PKA phosphorylation. | Calcins are peptides from scorpion venom with the unique ability to cross cell membranes, gaining access to intracellular targets. Ryanodine Receptors (RyR) are intracellular ion channels that control release of Ca2+ from the endoplasmic and sarcoplasmic reticulum. Calcins target RyRs and induce long-lived subconductance states, whereby single-channel currents are decreased. We used cryo-electron microscopy to reveal the binding and structural effects of imperacalcin, showing that it opens the channel pore and causes large asymmetry throughout the cytosolic assembly of the tetrameric RyR. This also creates multiple extended ion conduction pathways beyond the transmembrane region, resulting in subconductance. Phosphorylation of imperacalcin by protein kinase A prevents its binding to RyR through direct steric hindrance, showing how posttranslational modifications made by the host organism can determine the fate of a natural toxin. The structure provides a direct template for developing calcin analogs that result in full channel block, with potential to treat RyR-related disorders. |
| 148 | Hector Valdivia | CVM | hvaldivia@wisc.edu | Preserved cardiac performance and adrenergic response in a rabbit model with decreased ryanodine receptor 2 expression. | Ryanodine receptor 2 (RyR2) is an ion channel in the heart responsible for releasing into the cytosol most of the Ca2+ required for contraction. Proper regulation of RyR2 is critical, as highlighted by the association between channel dysfunction and cardiac arrhythmia. Lower RyR2 expression is also observed in some forms of heart disease; however, there is limited information on the impact of this change on excitation-contraction (e-c) coupling, Ca2+-dependent arrhythmias, and cardiac performance. We used a constitutive knock-out of RyR2 in rabbits (RyR2-KO) to assess the extent to which a stable decrease in RyR2 expression modulates Ca2+ handling in the heart. We found that homozygous knock-out of RyR2 in rabbits is embryonic lethal. Remarkably, heterozygotes (KO+/-) show ~50% loss of RyR2 protein without developing an overt phenotype at the intact animal and whole heart levels. Instead, we found that KO+/- myocytes show (1) remodeling of RyR2 clusters, favoring smaller groups in which channels are more densely arranged; (2) lower Ca2+ spark frequency and amplitude; (3) slower rate of Ca2+ release and mild but significant desynchronization of the Ca2+ transient; and (4) a significant decrease in the basal phosphorylation of S2031, likely due to increased association between RyR2 and PP2A. Our data show that RyR2 deficiency, although remarkable at the molecular and subcellular level, has only a modest impact on global Ca2+ release and is fully compensated at the whole-heart level. This highlights the redundancy of RyR2 protein expression and the plasticity of the e-c coupling apparatus. |
| 149 | Hector Valdivia | CVM | hvaldivia@wisc.edu | Region-specific distribution of transversal-axial tubule system organization underlies heterogeneity of calcium dynamics in the right atrium. | The atrial myocardium demonstrates the highly heterogeneous organization of the transversal-axial tubule system (TATS), although its anatomical distribution and region-specific impact on Ca2+ dynamics remain unknown. Here, we developed a novel method for high-resolution confocal imaging of TATS in intact live mouse atrial myocardium and applied a custom-developed MATLAB-based computational algorithm for the automated analysis of TATS integrity. We observed a twofold higher (P < 0.01) TATS density in the right atrial appendage (RAA) than in the intercaval regions (ICR, the anatomical region between the superior vena cava and atrioventricular junction and between the crista terminalis and interatrial septum). Whereas RAA predominantly consisted of well-tubulated myocytes, ICR showed partially tubulated/untubulated cells. Similar TATS distribution was also observed in healthy human atrial myocardium sections. In both mouse atrial preparations and isolated mouse atrial myocytes, we observed a strong anatomical correlation between TATS distribution and Ca2+ transient synchronization and rise-up time. This region-specific difference in Ca2+ transient morphology disappeared after formamide-induced detubulation. ICR myocytes showed a prolonged action potential duration at 80% of repolarization as well as a significantly lower expression of RyR2 and Cav1.2 proteins but similar levels of NCX1 and Cav1.3 compared with RAA tissue. Our findings provide a detailed characterization of the region-specific distribution of TATS in mouse and human atrial myocardium, highlighting the structural foundation for anatomical heterogeneity of Ca2+ dynamics and contractility in the atria. These results could indicate different roles of TATS in Ca2+ signaling at distinct anatomical regions of the atria and provide mechanistic insight into pathological atrial remodeling.NEW & NOTEWORTHY Mouse and human atrial myocardium demonstrate high variability in the organization of the transversal-axial tubule system (TATS), with more organized TATS expressed in the right atrial appendage. TATS distribution governs anatomical heterogeneity of Ca2+ dynamics and thus could contribute to integral atrial contractility, mechanics, and arrhythmogenicity. |
| 150 | Adam Gepner | CVM | agepner@medicine.wisc.edu | Associations of circulating T-cell subsets with carotid artery stiffness: the multiethnic study of atherosclerosis. | Arterial stiffness measured by total pulse wave velocity (T-PWV) is associated with an increased risk of multiple age-related diseases. T-PWV can be described by structural (S-PWV) and load-dependent (LD-PWV) arterial stiffening. T-cells have been implicated in arterial remodeling, arterial stiffness, and hypertension in humans and animals; however, it is unknown whether T-cells are risk factors for T-PWV or its components. Therefore, we evaluated the cross-sectional associations of peripheral T-cell subpopulations with T-PWV, S-PWV, and LD-PWV. Peripheral blood T-cells were characterized using flow cytometry, and carotid artery stiffness was measured using B-mode ultrasound to calculate T-PWV at the baseline examination in a participant subset of the Multi-Ethnic Study of Atherosclerosis (MESA, n = 1,984). A participant-specific exponential model was used to calculate S-PWV and LD-PWV based on elastic modulus and blood pressure gradients. The associations between five primary (P-significance < 0.01) and 25 exploratory (P-significance < 0.05) immune cell subpopulations, per 1-SD increment, and arterial stiffness measures were assessed using adjusted linear regression models. For the primary analysis, higher CD4+CD28-CD57+, but not CD8+CD28-CD57+, T-cells were associated with higher LD-PWV (β = 0.04 m/s, P < 0.01) after adjusting for covariates. None of the remaining T-cell subpopulations in the primary analysis were associated with T-PWV or S-PWV. For the exploratory analysis, several memory and differentiated/senescence-associated CD4+ and CD8+ T-cell subpopulations were associated with greater T-PWV, S-PWV, and LD-PWV after adjusting for covariates. In conclusion, we highlight novel associations in humans between CD4+ and CD8+ memory and differentiated/senescence-associated T-cell subpopulations and measures of arterial stiffness in MESA. These results warrant longitudinal, prospective studies that examine changes in T-cell subpopulations and arterial stiffness in humans.NEW & NOTEWORTHY We investigated associations between T-cells and novel measures of structural and load-dependent arterial stiffness in a large multiethnic cohort. The primary analysis revealed that pro-inflammatory, senescence-associated CD4+CD28-CD57+ T-cells were associated with higher load-dependent arterial stiffness. An exploratory analysis revealed that multiple pro-inflammatory CD4+ and CD8+ T-cell subpopulations were associated with both higher structural and load-dependent arterial stiffness. These results suggest that pro-inflammatory T-cells may contribute to arterial stiffness through both arterial remodeling and elevated blood pressure. |
| 151 | Adam Gepner | CVM | agepner@medicine.wisc.edu | Using an in-office passive leg raise to identify older adults with suboptimal blood pressure control. | Passive leg raise (PLR) is a simple, dynamic maneuver that has been used to increase preload to the heart. We hypothesize that PLR may offer a new and efficient office-based tool for assessing blood pressure (BP) control in older adults. One hundred and three veterans (≥60 years old) without known cardiovascular disease and varying degrees of blood pressure control were included in this cross-sectional cohort study. Twenty-four hour ambulatory BP monitoring identified Veterans with optimal and suboptimal BP control (≥125/75 mmHg). Bioimpedance electrodes (Baxter Medical, Deerfield, Illinois, USA) and brachial BP were used to calculate hemodynamic parameter changes across PLR states [pre-PLR, active PLR (3 min), and post-PLR]. Multiple linear regression was used to assess associations between BP control status with changes in hemodynamic parameters between PLR states. The 24-h ambulatory BP monitoring identified 43 (42%) older Veterans with optimal BP control (mean age of 70.5 ± 7.0 years) and 55 (54%) with suboptimal BP (mean age of 71.3 ± 8.7 years). Veterans with suboptimal BP control had significantly reduced change in total peripheral resistance (ΔTPR) (7.0 ± 156.0 vs. 127.3 ± 145.6 dynes s/cm 5 ; P = 0.002) following PLR compared with Veterans with optimal BP control. Suboptimal BP control ( β = -0.35, P = 0.004) had a significant association with reduced ΔTPR, even after adjusting for demographic variables. Measuring PLR-induced hemodynamic changes in the office setting may represent an alternative way to identify older adults with suboptimal BP control when 24-h ambulatory BP monitoring is not available. |
| 152 | Adam Gepner | CVM | agepner@medicine.wisc.edu | Associations of circulating T-cell subsets in carotid artery stiffness: the Multi-Ethnic Study of Atherosclerosis. | Arterial stiffness measured by total pulse wave velocity (T-PWV) is associated with increased risk of multiple age-related diseases. T-PWV can be described by structural (S-PWV) and load-dependent (LD-PWV) arterial stiffening. T-cells have been associated with arterial remodeling, blood pressure, and arterial stiffness in humans and animals; however, it is unknown whether T-cells are related to S-PWV or LD-PWV. Therefore, we evaluated the cross-sectional associations of peripheral T-cell subpopulations with T-PWV, S-PWV, and LD-PWV stiffness. Peripheral blood T-cells were characterized using flow cytometry and the carotid artery was measured using B-mode ultrasound to calculate T-PWV at the baseline examination in a subset of the Multi-Ethnic Study of Atherosclerosis (MESA, n=1,984). A participant-specific exponential model was used to calculate S-PWV and LD-PWV based on elastic modulus and blood pressure gradients. The associations between five primary (p-significance<0.01) and twenty-five exploratory (p-significance<0.05) immune cell subpopulations, per 1-SD increment, and arterial stiffness measures were assessed using adjusted, linear regressions. For the primary analysis, higher CD4+CD28-CD57+ T-cells were associated with higher LD-PWV (β=0.04 m/s, p<0.01) after adjusting for co-variates. For the exploratory analysis, T-cell subpopulations that commonly shift with aging towards memory and differentiated/immunosenescent phenotypes were associated with greater T-PWV, S-PWV, and LD-PWV after adjusting for co-variates. In this cross-sectional study, several T-cell subpopulations commonly associated with aging were related with measures of arterial stiffness. Longitudinal studies that examine changes in T-cell subpopulations and measures of arterial stiffness are warranted. |
| 153 | Adam Gepner | CVM | agepner@medicine.wisc.edu | Carotid Artery Stiffness Mechanisms Are Associated With End Organ Damage and All-Cause Mortality: MESA (Multi-Ethnic Study of Atherosclerosis). | Background Arterial stiffness can be separated into 2 main mechanisms: (1) load-dependent stiffening from higher blood pressure and (2) structural stiffening due to remodeling of the vessel wall. The relationship between stiffness mechanisms and end organ damage is unknown. Methods and Results MESA (Multi-Ethnic Study of Atherosclerosis) participants with carotid ultrasound were included in this study (n=6147). Carotid pulse wave velocity (cPWV) was calculated to represent total stiffness. Structural stiffness was calculated by adjusting cPWV to a 120/80 mm Hg blood pressure with participant-specific models. Load-dependent stiffness was the difference of total and structural stiffness. Associations with incident chronic kidney disease (CKD), dementia, and mortality were assessed with adjusted Cox models. During 14.3±4.8 years of follow-up, 773 CKD events, 535 dementia events, and 1529 deaths occurred. Total cPWV was associated with mortality (hazard ratio [HR], per 1 m/s, 1.04 [95% CI, 1.01-1.08], P=0.02) and dementia (HR, 1.06 [95% CI, 1.01-1.12], P=0.03) but not CKD (HR, 1.03 [95% CI, 0.98-1.08], P=0.33). Structural cPWV was significantly associated with mortality (HR, 1.04 [95% CI, 1.00-1.08], P=0.04) but not CKD (HR, 1.00 [95% CI, 0.94-1.05], P=0.86) or dementia (HR, 1.06 [95% CI, 0.99-1.13], P=0.06). Load-dependent cPWV was significantly associated with CKD (HR, 1.38 [95% CI, 1.17-1.63], P<0.001) but not mortality (HR, 1.11 [95% CI, 0.99-1.25], P=0.07) or dementia (HR, 1.14 [95% CI, 0.94-1.38], P=0.19). Conclusions The mechanisms of arterial stiffness were associated with all-cause mortality and CKD. Structural stiffness was associated with all-cause mortality, and load-dependent stiffness was associated with CKD. Total stiffness was associated with dementia but load-dependent and structural stiffness were not. |
| 154 | Adam Gepner | CVM | agepner@medicine.wisc.edu | Biomechanics models predict increasing smooth muscle tone as a novel therapeutic target for central arterial dysfunction in hypertension. | Vasodilation can paradoxically increase arterial stiffness in older, hypertensive adults. This study modeled increasing smooth muscle tone as a therapeutic strategy to improve central arterial dysfunction in hypertension using participant-specific simulations. Participant-specific models of the carotid artery were parameterized from vascular ultrasound measures of nitroglycerin-induced vasodilation in 18 hypertensive veterans. The acute changes in carotid artery mechanics were simulated for changes of ±2, ±4, and ±6% in smooth muscle tone and ±5, ±10, and ±15 mmHg in mean arterial pressure (MAP). The chronic carotid artery adaptations were simulated based on the hypothesis that the carotid artery will remodel wall-cross sectional area to maintain mechanical homeostasis. A 6% increase in smooth muscle tone acutely decreased carotid pulse wave velocity from 6.89 ± 1.24 m/s to 5.83 ± 1.73 m/s, and a 15 mmHg decrease in MAP decreased carotid pulse wave velocity to 6.17 ± 1.23 m/s. A 6% increase in smooth muscle tone acutely decreased wall stress from 76.2 ± 12.3 to 64.2 ± 10.4 kPa, and a 15 mmHg decrease in MAP decreased wall stress to 60.6 ± 10.7 kPa. A 6% increase in smooth muscle tone chronically decreased wall cross-sectional area from 18.3 ± 5.4 to 15.2 ± 4.9 mm 2, and a 15 mmHg decrease in MAP decreased wall cross-sectional area to 14.3 ± 4.6 mm 2 . In participant-specific simulation, increasing smooth muscle tone can have a stronger or equivalent effect on carotid artery mechanics compared with decreasing blood pressure. Increasing central arterial smooth muscle tone may be a novel therapeutic target to improve central arterial dysfunction in older, hypertensive adults and should be a focus of future research. |
| 155 | Adam Gepner | CVM | agepner@medicine.wisc.edu | Methods of arterial stiffness calculation and cardiovascular disease events: the multiethnic study of atherosclerosis. | A wide variety of different formulae have been used to calculate local arterial stiffness with little external validation in relationship to cardiovascular events. We compared the associations of several arterial stiffness calculations in a large, multiethnic cohort. The multi-ethnic study of atherosclerosis (MESA) is a longitudinal study of 6814 adults without clinical cardiovascular disease (CVD) at enrollment. MESA participants with CVD surveillance through year 2018 and carotid ultrasound ( n = 5873) or aorta MRI ( n = 3175) at the baseline exam (2000-2002) were included. We analyzed 21 different calculations of local arterial stiffness. Cross-sectional and longitudinal statistical analyses were performed in addition to Cox hazard modeling for associations with CVD events (myocardial infarction, resuscitated cardiac arrest, stroke, adjudicated angina, and cardiovascular death). Carotid artery stiffness calculations had variable correlations with each other ( r = 0.56-0.99); aortic stiffness measures were similar ( r = 0.66-0.99). Nevertheless, for CVD events, the hazard ratio (HR) per standard deviation change were similar for all carotid stiffness calculations with HRs in the range of 1.00-1.10 (equivalence P < 0.001). For the aorta, aortic distensibility coefficient had a stronger association with CVD events (HR 1.18 [1.02-1.37]) compared to aorta Peterson's elastic modulus (HR 0.98 [0.89-1.07]) and aorta pulse wave velocity (HR 1.00 [0.90-1.11]). HRs between all other aortic stiffness calculations were equivalent ( P < 0.01). Different methods of calculating local arterial stiffness largely gave equivalent results, indicating that the variety of different arterial stiffness calculations in use do not cause inconsistent findings. |
| 156 | Adam Gepner | CVM | agepner@medicine.wisc.edu | Association of statin therapy with progression of carotid arterial stiffness: the Multi-Ethnic Study of Atherosclerosis (MESA). | Arterial stiffness progresses with age and is a predictor of adverse cardiovascular disease events. Studies examining associations of statin therapy with arterial stiffness have yielded mixed results. Associations between the duration and intensity of statin therapy and arterial stiffness have not been studied in a prospective multiethnic cohort. MESA participants (n = 1242) with statin medication use data at each exam (1-5) and who had undergone B-mode carotid ultrasound at baseline and at Exam 5 after (mean ± [SD]) 9.4 ± 0.5 years were analyzed. Carotid arterial stiffness was measured using the distensibility coefficient (DC) and Young's elastic modulus (YEM). Linear regression models were used to evaluate associations between DC and YEM and statin treatment duration and intensity. At baseline, participants were 66.5 ± 8.1 years old, 41% female, 36% White, 30% African American, 14% Chinese American, and 20% Hispanic. The mean baseline low-density lipoprotein cholesterol (LDL-C) was 149.5 ± 14.5 mg/dL. After adjusting for age, sex, race/ethnicity, and CVD risk factors, the percent changes in DC and YEM were found to not be significantly different in individuals on statin therapy at any combination of visits (1-4) compared to participants never on statin therapy (all p > 0.32). There were also no differences in the percent change in DC and YEM based on statin therapy intensity by quartile (all p > 0.14) over the 10-year follow-up period. Based on the aforementioned results, statin therapy was not associated with changes in carotid artery stiffness over nearly a decade of follow-up regardless of therapy duration or intensity. |
| 157 | Adam Gepner | CVM | agepner@medicine.wisc.edu | Exercise increases arterial stiffness independent of blood pressure in older Veterans. | Exercise-induced changes in arterial function could contribute to a hypertensive response to exercise (HRE) in older individuals. We performed the present analysis to define the acute arterial stiffness response to exercise in ambulatory older adults. Thirty-nine Veterans (>60 years old), without known cardiovascular disease, participated in this study, including 19 Veterans who were hypertensive (70.8 ± 6.8 years, 53% women) and 20 Veterans who were normotensive (72.0 ± 9.3 years, 40% women). Arterial stiffness parameters were measured locally with carotid artery ultrasound and regionally with carotid-femoral pulse wave velocity (cfPWV) before and during the 10 min after participants performed a Balke maximal exercise treadmill stress test. The arterial stiffness response to exercise was similar for control and hypertensive participants. At 6 min postexercise, cfPWV was significantly increased (Δ1.5 ± 1.9 m/s, P = 0.004) despite mean blood pressure (BP) having returned to its baseline value (Δ1 ± 8 mmHg, P = 0.79). Arterial mechanics modeling also showed BP-independent increases in arterial stiffness with exercise ( P < 0.05). Postexercise cfPWV was correlated with postexercise SBP ( r = 0.50, P = 0.004) while baseline cfPWV ( r = 0.13, P = 1.00), and postexercise total peripheral resistance ( r = -0.18, P = 1.00) were not. In older Veterans, exercise increases arterial stiffness independently of BP and the arterial stiffness increase with exercise is associated with increased postexercise SBP. BP-independent increases in arterial stiffness with exercise could contribute to a HRE in older adults. |
| 158 | Adam Gepner | CVM | agepner@medicine.wisc.edu | Effects of nitroglycerin-induced vasodilation on elastic and muscular artery stiffness in older Veterans. | Vascular smooth muscle tone may play an important role in the physiology of increased arterial stiffness that occurs with aging. This study evaluated the impact of smooth muscle tone on arterial stiffness in older individuals following nitroglycerin-induced vasodilation in elastic and muscular arteries. Forty older Veterans (≥60 years old) without known cardiovascular disease were included in this study. Twenty Veterans were included as hypertensive participants (70.8 ± 6.6 years, 10 females), and 20 were included as normotensive controls (72.0 ± 9.3 years, 8 females). Nitroglycerin (NTG)-induced changes in arterial stiffness were measured locally with vascular ultrasound in the carotid and brachial arteries and regionally by carotid-femoral pulse wave velocity (cfPWV) with tonometry. With NTG treatment, both hypertensive participants and normotensive controls Veterans showed increased carotid PWV (6.4 ± 1.3 m/s to 7.2 ± 1.4 m/s, Δ 0.8 ± 1.1 m/s, p = 0.007) and cfPWV (8.6 ± 1.9 m/s to 9.5 ± 2.4 m/s, Δ 0.9 ± 2.3 m/s, p = 0.020) but did not show changes in brachial PWV (11.2 ± 2.4 m/s to 11.1 ± 2.2 m/s, Δ -0.2 ± 2.5 m/s, p = 0.72). The carotid artery was dilated more in control participants than hypertensive Veterans (Δ 0.54 ± 0.19 mm vs. 0.42 ± 0.12 mm, p = 0.022). Brachial artery dilation was similar between the two groups (Δ 0.55 ± 0.26 mm vs. 0.51 ± 0.20 mm, p = 0.46). In older Veterans without known cardiovascular disease, NTG-induced vasodilation increased elastic artery stiffness but did not change muscular artery stiffness. Increased central arterial stiffness and a decrease in the arterial stiffness gradient could offset some of the benefits of lowering blood pressure in older patients who are prescribed vasodilators as an antihypertensive therapy. Elastic artery stiffening with vasodilation warrants further investigation, as it may be important for antihypertensive medication selection and influence CVD development. |
| 159 | Adam Gepner | CVM | agepner@medicine.wisc.edu | Carotid Artery Stiffness Mechanisms in Hypertension and Their Association with Echolucency and Texture Features: The Multi-ethnic Study of Atherosclerosis (MESA). | Arterial stiffness, echolucency and texture features are altered with hypertension and associated with increased cardiovascular disease risk. The relationship between these markers and structural and load-dependent artery wall changes in hypertension are poorly understood. The Multi-ethnic Study of Atherosclerosis (MESA) is a longitudinal study of 6814 adults from six communities across the United States designed to study subclinical cardiovascular disease. From B-mode imaging of the right common carotid artery at the baseline MESA examination, we calculated carotid artery Young's elastic modulus (YEM, n = 5894) and carotid artery gray-scale texture features (n = 1403). The standard YEM calculation represented total arterial stiffness. Structural stiffness was calculated by adjusting YEM to a standard blood pressure of 120/80 mm Hg with participant-specific models. Load-dependent stiffness was the difference between total and structural stiffness. We found that load-dependent YEM was elevated in hypertensive individuals compared with normotensive individuals (35.7 ± 105.5 vs. -62.0 ± 112.4 kPa, p < 0.001) but that structural YEM was similar (425.3 ± 274.8 vs. 428.4 ± 293.0 kPa, p = 0.60). Gray-scale measures of heterogeneity in carotid artery wall texture (gray-level difference statistic contrast) had small but statistically signification correlations with carotid artery stiffness mechanisms. This association was positive for structural YEM (0.107, p < 0.001), while for load-dependent YEM, the association was negative (-0.064, p = 0.02). In conclusion, increased arterial stiffness in hypertension was owing solely to the non-linear mechanics of having higher blood pressure, not structural changes in the artery wall, and high load-dependent stiffness was associated with a more homogenous carotid artery wall texture. This is potentially related to arterial remodeling associated with subclinical atherosclerosis and future cardiovascular disease development. These results also indicate that gray-scale texture features from ultrasound imaging had a small but statistically significant association with load-dependent arterial stiffness and that gray-scale texture features may be partially load dependent. |
| 160 | James Stein | CVM | jhs@medicine.wisc.edu | Validity of the E-Cigarette Wisconsin Inventory of Smoking Dependence Motives (e-WISDM) in Exclusive E-Cigarette Users: Evidence from a Laboratory Self-Administration Study. | Prior research suggests that the e-Cigarette Wisconsin Inventory of Smoking Dependence Motives (e-WISDM) distinguishes primary (e-PDM) and secondary dependence (e-SDM), however, there is little research on these e-WISDM dimensions and prior research comprised dual users (using cigarettes and e-cigarettes) and those using older generations of e-cigarettes. Those exclusively using contemporary e-cigarettes (N = 164) completed the e-WISDM and a laboratory self-administration session and rated pre-use expectancies and post-use experiences. Only a 1-factor model limited to the primary scales (Automaticity, Tolerance, Craving, Loss of Control) achieved good model fit. The e-PDM was correlated with the Penn State Electronic Cigarette Dependence Index (PS-ECDI), r = .79, p < .001. The e-PDM and PS-ECDI were similarly correlated with use topography and self-reported measures. Analyses of motive profiles identified Taste, Tolerance, and Automaticity as the most strongly endorsed motives in the full sample. Subgroup analyses indicated primary motives were more elevated in in daily vs. non-daily e-cigarette users and participants with vs. without a history of smoking cigarettes. Taste motives were stronger in users of 3rd vs. 4th generation e-cigarettes. These findings suggest that the four e-PDM subscales are a concise, reliable, and valid measure of core e-cigarette dependence motives that are related to meaningful dependence attributes. Electronic cigarettes (e-cigarettes) are dependence-producing. Instruments that measure e-cigarette dependence are necessary to identify users who may have difficulty quitting e-cigarettes and who are at risk for use-related harms. The four subscales of the e-WISDM PDM index self-reported heavy e-cigarette use, craving, automatic or mindless use, and perceived loss of control over use. The current research supports the validity of the e-WISDM PDM as a measure of core e-cigarette dependence in users of today's e-cigarette devices. |
| 161 | James Stein | CVM | jhs@medicine.wisc.edu | GLS2 links glutamine metabolism and atherosclerosis by remodeling artery walls. | Metabolic dysregulation, including perturbed glutamine-glutamate homeostasis, is common among patients with cardiovascular diseases, but the underlying mechanisms remain largely unknown. Using the human MESA cohort, here we show that plasma glutamine-glutamate ratio is an independent risk factor for carotid plaque progression. Mice deficient in glutaminase-2 (Gls2), the enzyme that mediates hepatic glutaminolysis, developed accelerated atherosclerosis and susceptibility to catastrophic cardiac events, while Gls2 overexpression partially protected from disease progression. High-throughput transcriptional profiling and high-resolution structural biology imaging of aortas showed that Gls2 deficiency perturbed extracellular matrix composition and increased vessel stiffness. This results from an imbalance of glutamine- and glutamate-dependent cross-linked proteins within atherosclerotic lesions and cellular remodeling of plaques. Thus, hepatic glutaminolysis functions as a potent regulator of glutamine homeostasis, which affects the aortic wall structure during atherosclerotic plaque progression. |
| 162 | James Stein | CVM | jhs@medicine.wisc.edu | E-Cigarette Use in Adults. | This JAMA Insights explores the adverse effects and health outcomes of e-cigarettes vs combusted cigarettes and the effectiveness of using e-cigarettes as a smoking cessation aid among US adults. |
| 163 | James Stein | CVM | jhs@medicine.wisc.edu | Brief Report: Low-Dose Methotrexate Does Not Affect Measures of HIV-1 Persistence in Individuals With Chronically Treated HIV-1 Infection. | People with HIV-1 often have chronic inflammation leading to severe non-AIDS morbidity and mortality. The AIDS Clinical Trials Group Study A5314 sought to lower inflammation with low-dose methotrexate (LDMTX). The primary study outcomes were reported previously but here we present the impact of LDMTX on multiple measures of HIV-1 persistence. A5314 was a phase 2 randomized, double-blind, multicenter trial in 176 adult people with HIV-1 on virally suppressive antiretroviral therapy. LDMTX (5-15 mg/wk) was administered for 24 weeks with an additional 12 weeks of participant follow-up. The current analyses of HIV-1 persistence were restricted to 60 participants (30 LDMTX and 30 placebo) randomly selected from the total population. Plasma HIV-1 RNA, total HIV-1 DNA, and cell-associated HIV-1 RNA (CA HIV-1 RNA) were measured by sensitive quantitative PCR assays. LDMTX treatment had no significant effect on sensitive measures of plasma HIV-1 RNA, HIV-1 DNA, CA HIV-1 RNA, or CA HIV-1 RNA/DNA ratio at any time point or from baseline to week 24. As observed in the main study, absolute peripheral CD4+ and CD8+ T-cell numbers decreased from baseline to week 24 among the 30 participants receiving LDMTX compared with placebo (median decrease of -31.5 CD4+ T cells/µL, -83.5 CD8+ T cells/µL). LDMTX had no significant effect on any measure of HIV-1 persistence in plasma or peripheral blood mononuclear cells. Further studies are needed to determine whether other immunosuppressive and/or immunoreductive interventions are safe and capable of affecting HIV-1 persistence. |
| 164 | James Stein | CVM | jhs@medicine.wisc.edu | LXR signaling pathways link cholesterol metabolism with risk for prediabetes and diabetes. | BACKGROUNDPreclinical studies suggest that cholesterol accumulation leads to insulin resistance. We previously reported that alterations in a monocyte cholesterol metabolism transcriptional network (CMTN) - suggestive of cellular cholesterol accumulation - were cross-sectionally associated with obesity and type 2 diabetes (T2D). Here, we sought to determine whether the CMTN alterations independently predict incident prediabetes/T2D risk, and correlate with cellular cholesterol accumulation.METHODSMonocyte mRNA expression of 11 CMTN genes was quantified among 934 Multi-Ethnic Study of Atherosclerosis (MESA) participants free of prediabetes/T2D; cellular cholesterol was measured in a subset of 24 monocyte samples.RESULTSDuring a median 6-year follow-up, lower expression of 3 highly correlated LXR target genes - ABCG1 and ABCA1 (cholesterol efflux) and MYLIP (cholesterol uptake suppression) - and not other CMTN genes, was significantly associated with higher risk of incident prediabetes/T2D. Lower expression of the LXR target genes correlated with higher cellular cholesterol levels (e.g., 47% of variance in cellular total cholesterol explained by ABCG1 expression). Further, adding the LXR target genes to overweight/obesity and other known predictors significantly improved prediction of incident prediabetes/T2D.CONCLUSIONThese data suggest that the aberrant LXR/ABCG1-ABCA1-MYLIP pathway (LAAMP) is a major T2D risk factor and support a potential role for aberrant LAAMP and cellular cholesterol accumulation in diabetogenesis.FUNDINGThe MESA Epigenomics and Transcriptomics Studies were funded by NIH grants 1R01HL101250, 1RF1AG054474, R01HL126477, R01DK101921, and R01HL135009. This work was supported by funding from NIDDK R01DK103531 and NHLBI R01HL119962. |
| 165 | James Stein | CVM | jhs@medicine.wisc.edu | Economic Evaluation of Enhanced vs Standard Varenicline Treatment for Tobacco Cessation. | Smoking is the leading preventable cause of death and illness in the US. Identifying cost-effective smoking cessation treatment may increase the likelihood that health systems deliver such treatment to their patients who smoke. To evaluate the cost-effectiveness of standard vs enhanced varenicline use (extended varenicline treatment or varenicline in combination with nicotine replacement therapy) among individuals trying to quit smoking. This economic evaluation assesses the Quitting Using Intensive Treatments Study (QUITS), which randomized 1251 study participants who smoked into 4 conditions: (1) 12-week varenicline monotherapy (n = 315); (2) 24-week varenicline monotherapy (n = 311); (3) 12-week varenicline combination treatment with nicotine replacement therapy patch (n = 314); or (4) 24-week varenicline combination treatment with nicotine replacement therapy patch (n = 311). Study enrollment occurred in Madison and Milwaukee, Wisconsin, between November 11, 2017, and July 2, 2020. Statistical analysis took place from May to October 2023. The primary outcome was 7-day point prevalence abstinence (biochemically confirmed with exhaled carbon monoxide level ≤5 ppm) at 52 weeks. The incremental cost-effectiveness ratio (ICER), or cost per additional person who quit smoking, was calculated using decision tree analysis based on abstinence and cost for each arm of the trial. Of the 1251 participants, mean (SD) age was 49.1 (11.9) years, 675 (54.0%) were women, and 881 (70.4%) completed the 52-week follow-up. Tobacco cessation at 52 weeks was 25.1% (79 of 315) for 12-week monotherapy, 24.4% (76 of 311) for 24-week monotherapy, 23.6% (74 of 314) for 12-week combination therapy, and 25.1% (78 of 311) for 24-week combination therapy, respectively. The total mean (SD) cost was $1175 ($365) for 12-week monotherapy, $1374 ($412) for 12-week combination therapy, $2022 ($813) for 24-week monotherapy, and $2118 ($1058) for 24-week combination therapy. The ICER for 12-week varenicline monotherapy was $4681 per individual who quit smoking and $4579 per quality-adjusted life-year (QALY) added. The ICER for 24-week varenicline combination therapy relative to 12-week monotherapy was $92 000 000 per additional individual who quit smoking and $90 000 000 (95% CI, $15 703 to dominated or more costly and less efficacious) per additional QALY. This economic evaluation of standard vs enhanced varenicline treatment for smoking cessation suggests that 12-week varenicline monotherapy was the most cost-effective treatment option at the commonly cited threshold of $100 000/QALY. This study provides patients, health care professionals, and other stakeholders with increased understanding of the health and economic impact of more intensive varenicline treatment options. |
| 166 | James Stein | CVM | jhs@medicine.wisc.edu | Discrimination, Smoking, and Cardiovascular Disease Risk: A Moderated Mediation Analysis With MESA. | Carotid intima-media thickness (cIMT) and carotid plaque are reliable indicators of cardiovascular disease risk, and research highlights that racial and ethnic minority individuals generally exhibit higher cIMT and carotid plaque than White individuals. At present, the mechanisms driving these disparities among different racial and ethnic and biological sex groups are poorly understood. Data came from the baseline examination of MESA (Multi-Ethnic Study of Atherosclerosis). A total of 6814 participants aged 45 to 84 years free of clinical cardiovascular disease completed assessments on health behavior and perceived discrimination. Four sex-stratified moderated mediation models examined associations between discrimination, cigarette smoking, and mean cIMT and plaque. We hypothesized that cigarette use would mediate the association between discrimination and carotid artery disease features, and that these would differ by race and ethnicity. Indirect effects of discrimination on plaque were observed among Hispanic women such that discrimination was associated with cigarette use and, in turn, higher plaque (β=0.04 [95% CI, 0.01-0.08]). Indirect effects of discrimination on mean cIMT were found among Hispanic (β=0.003 [95% CI, 0.0001-0.007]) and White men (β=0.04 [95% CI, 0.01-0.08]) such that discrimination was associated with cigarette use and, in turn, higher cIMT. Finally, a positive indirect effect of discrimination on plaque was observed among Hispanic men (β=0.03 [95% CI, 0.004-0.07]). No other racial and ethnic differences were observed. To understand and address social determinants of cardiovascular disease, researchers must incorporate an intersectional framework that will allow us to understand the complex nature of discrimination and cardiovascular disease risk for individuals of varying intersecting identities and social positions. |
| 167 | James Stein | CVM | jhs@medicine.wisc.edu | Incidental Coronary Artery Calcium on Chest CT in Persons Without Known Atherosclerotic Cardiovascular Disease. | This cross-sectional study examines the expected prevalence of coronary artery calcium (CAC) on chest computed tomography (CT) in people without clinical atherosclerotic cardiovascular disease (ASCVD) by age, sex, and race and ethnicity. |
| 168 | James Stein | CVM | jhs@medicine.wisc.edu | In Vivo Adaptive Bayesian Regularized Lagrangian Carotid Strain Imaging for Murine Carotid Arteries and Its Associations With Histological Findings. | Non-invasive methods for monitoring arterial health and identifying early injury to optimize treatment for patients are desirable. The objective of this study was to demonstrate the use of an adaptive Bayesian regularized Lagrangian carotid strain imaging (ABR-LCSI) algorithm for monitoring of atherogenesis in a murine model and examine associations between the ultrasound strain measures and histology. Ultrasound radiofrequency (RF) data were acquired from both the right and left common carotid artery (CCA) of 10 (5 male and 5 female) ApoE tm1Unc/J mice at 6, 16 and 24 wk. Lagrangian accumulated axial, lateral and shear strain images and three strain indices-maximum accumulated strain index (MASI), peak mean strain of full region of interest (ROI) index (PMSRI) and strain at peak axial displacement index (SPADI)-were estimated using the ABR-LCSI algorithm. Mice were euthanized (n = 2 at 6 and 16 wk, n = 6 at 24 wk) for histology examination. Sex-specific differences in strain indices of mice at 6, 16 and 24 wk were observed. For male mice, axial PMSRI and SPADI changed significantly from 6 to 24 wk (mean axial PMSRI at 6 wk = 14.10 ± 5.33% and that at 24 wk = -3.03 ± 5.61%, p < 0.001). For female mice, lateral MASI increased significantly from 6 to 24 wk (mean lateral MASI at 6 wk = 10.26 ± 3.13% and that at 24 wk = 16.42 ± 7.15%, p = 0.048). Both cohorts exhibited strong associations with ex vivo histological findings (male mice: correlation between number of elastin fibers and axial PMSRI: rs = 0.83, p = 0.01; female mice: correlation between shear MASI and plaque score: rs = 0.77, p = 0.009). The results indicate that ABR-LCSI can be used to measure arterial wall strain in a murine model and that changes in strain are associated with changes in arterial wall structure and plaque formation. |
| 169 | James Stein | CVM | jhs@medicine.wisc.edu | Cardiovascular and Pulmonary Responses to Acute Use of Electronic Nicotine Delivery Systems and Combustible Cigarettes in Long-Term Users. | The acute cardiovascular and pulmonary effects of contemporary electronic nicotine delivery systems (ENDS) in long-term users are not known. What are the cardiovascular and pulmonary responses to an acute 15-min product use challenge with ENDS and combustible cigarettes in regular nicotine-containing product users compared with control participants who do not use tobacco or vape? Observational challenge study before and after nicotine-containing product use of 395 individuals who used ENDS exclusively (n = 164; exhaled carbon monoxide level, 5 ppm; positive urine NicCheck I results), and control participants (n = 114; carbon monoxide level, < 5 ppm; negative urine NicCheck I results). During the 15-min product challenge, cigarette users took a median of 14.0 puffs (interquartile range [IQR], 9.3 puffs); ENDS users took 9.0 puffs (IQR, 7.5 puffs; P < .001). After product challenge, compared with control participants, ENDS users showed greater increases in adjusted mean differences in systolic BP (5.6 mm Hg [95% CI, 4.4-6.8 mm Hg] vs 2.3 mm Hg [95% CI, 0.8-3.8 mm Hg]; P = .001), diastolic BP (4.2 mm Hg [95% CI, 3.3-5.0 mm Hg] vs 2.0 mm Hg [95% CI, 1.1-3.0 mm Hg; P = .003), and heart rate (4.8 beats/min [95% CI, 4.0-5.6 beats/min] vs -1.3 beats/min [95% CI, -2.2 to -0.3 beats/min]; P < .001) and greater reductions in brachial artery diameter (-0.011 cm [95% CI, -0.013 to 0.009 cm] vs -0.006 cm [95% CI, -0.004 to -0.009 cm]; P = .003), time-domain heart rate variability (-7.2 ms [95% CI, -10.5 to -3.7 ms] vs 3.6 ms [95% CI, 1.6-9.3 ms]; P = .001), and FEV1 (ENDS: -4.1 [95% CI, -5.4 to -2.8] vs control participants: -1.1 [95% CI, -2.7 to 0.6]; P = .005) with values similar to those of cigarette users. ENDS users performed worse than control participants on all exercise parameters, notably metabolic equivalents (METs; adjusted mean difference, 1.28 METs [95% CI, 0.73-1.83 METs]; P < .001) and 60-s heart rate recovery (adjusted mean difference, 2.9 beats/min [95% CI, 0.7-5.0 beats/min]; P = .008). ENDS users had acute worsening of blood pressure, heart rate, and heart rate variability, as well as vasoconstriction, impaired exercise tolerance, and increased airflow obstruction after vaping, compared to control participants. ClinicalTrials.gov; No.: NCT03863509; URL: www. gov. |
| 170 | Amish Raval | CVM | anr@medicine.wisc.edu | Renal Arteriosclerosis in kidney biopsies associated with higher 10-year atherosclerotic cardiovascular disease in lupus nephritis. | Patients with lupus nephritis (LN), including those below age 50, face significantly higher risk of atherosclerotic cardiovascular disease (ASCVD) vs. peers. This highlights the need for identifying specific ASCVD risk factors in LN. Renal arteriosclerosis in kidney biopsies (subclinical arteriosclerosis) may be able to predict future clinical ASCVD events. However, renal arteriosclerosis is under-reported in LN biopsies and is not taken into consideration when ASCVD risk is calculated. Therefore, we aimed to systematically grade renal arteriosclerosis in kidney biopsies at LN diagnosis and examined associations with 10- & 20-year ASCVD occurrence. Adults with biopsy proven LN were included. Clinical ASCVD, including fatal & non-fatal events, were adjudicated. Utilizing standard Banff grading criteria, all biopsies at LN diagnosis were re-read to grade renal arteriosclerosis. Covariables (e.g., socio-demographics, comorbidities, med exposure) were abstracted. Using Cox models, factors (including renal arteriosclerosis) associated with 10- & 20-year clinical ASCVD were examined. Among 209 patients, 36 & 49 clinical ASCVD occurred within 10 & 20 years. Renal arteriosclerosis (>25%) was associated with 3x higher 10-year ASCVD. High area deprivation index (>80) & longer angiotensin converting enzyme inhibitor (ACEi) exposure were associated with 4x higher & 0.65x lower ASCVD occurrence. Adding renal arteriosclerosis >25% improved model performance for 10-year ASCVD risk estimation from 65% to 80%. Similar associations were seen with 20-year ASCVD. Renal arteriosclerosis >25%, area deprivation, ACEi exposure could inform ASCVD risk stratification in LN. Prospective studies should validate findings and inform clinical use. |
| 171 | Amish Raval | CVM | anr@medicine.wisc.edu | Topology observing 3D device reconstruction from continuous-sweep limited angle fluoroscopy. | Minimally invasive procedures usually require navigating a microcatheter and guidewire through endoluminal structures such as blood vessels and airways to sites of the disease. For numerous clinical applications, two-dimensional (2D) fluoroscopy is the primary modality used for real-time image guidance during navigation. However, 2D imaging can pose challenges for navigation in complex structures. Real-time 3D visualization of devices within the anatomic context could provide considerable benefits for these procedures. Continuous-sweep limited angle (CLA) fluoroscopy has recently been proposed to provide a compromise between conventional rotational 3D acquisitions and real-time fluoroscopy. The purpose of this work was to develop and evaluate a noniterative 3D device reconstruction approach for CLA fluoroscopy acquisitions, which takes into account endoluminal topology to avoid impossible paths between disconnected branches. The algorithm relies on a static 3D roadmap (RM) of vessels or airways, which may be generated from conventional cone beam CT (CBCT) acquisitions prior to navigation. The RM is converted to a graph representation describing its topology. During catheter navigation, the device is segmented from the live 2D projection images using a deep learning approach from which the centerlines are extracted. Rays from the focal spot to detector pixels representing 2D device points are identified and intersections with the RM are computed. Based on the RM graph, a subset of line segments is selected as candidates to exclude device paths through disconnected branches of the RM. Depth localization for each point along the device is then performed by finding the point closest to the previous 3D reconstruction along the candidate segments. This process is repeated as the projection angle changes for each CLA image frame. The approach was evaluated in a phantom study in which a catheter and guidewire were navigated along five pathways within a complex vessel phantom. The result was compared to static cCBCT acquisitions of the device in the final position. The average root mean squared 3D distance between CLA reconstruction and reference centerline was 1.87±0.30$1.87 \pm 0.30$ mm. The Euclidean distance at the device tip was 2.92±2.35$2.92 \pm 2.35$ mm. The correct pathway was identified during reconstruction in 100%$100\%$ of frames ( n=1475$n=1475$ ). The percentage of 3D device points reconstructed inside the 3D roadmap was 91.83±2.52%$91.83 \pm 2.52\%$ with an average distance of 0.62±0.30$0.62 \pm 0.30$ mm between the device points outside the roadmap and the nearest point within the roadmap. This study demonstrates the feasibility of reconstructing curvilinear devices such as catheters and guidewires during endoluminal procedures including intravascular and transbronchial interventions using a noniterative reconstruction approach for CLA fluoroscopy. This approach could improve device navigation in cases where the structure of vessels or airways is complex and includes overlapping branches. |
| 172 | Amish Raval | CVM | anr@medicine.wisc.edu | Human left ventricular cardiac fibroblasts undergo a dynamic shift in secretome and gene expression toward a cardiac myofibroblast phenotype during early passage in typical culture expansion conditions. | Cardiac fibroblasts (CFs) are critical components of the cardiac niche and primarily responsible for assembly and maintenance of the cardiac extracellular matrix (ECM). CFs are increasingly of interest for tissue engineering and drug development applications, as they provide synergistic support to cardiomyocytes through direct cell-to-cell signaling and cell-to-ECM interactions via soluble factors, including cytokines, growth factors and extracellular vesicles. CFs can be activated to a cardiac myofibroblast (CMF) phenotype upon injury or stimulation with transforming growth factor beta 1. Once activated, CMFs assemble collagen-rich ECM, which is vitally important to stabilize scar formation following myocardial infarction, for example. Although there is greater experience with culture expansion of CFs among non-human strains, very little is known about human CF-to-CMF transitions and expression patterns during culture expansion. In this study, we evaluated for shifts in inflammatory and angiogenic expression profiles of human CFs in typical culture expansion conditions. Understanding shifts in cellular expression patterns during CF culture expansion is critically important to establish quality benchmarks and optimize large-scale manufacturing for future clinical applications. |
| 173 | Amish Raval | CVM | anr@medicine.wisc.edu | The CardiAMP Cell Therapy for Heart Failure trial. | |
| 174 | Amish Raval | CVM | anr@medicine.wisc.edu | Identifying molecular and functional similarities and differences between human primary cardiac valve interstitial cells and ventricular fibroblasts. | Introduction: Fibroblasts are mesenchymal cells that predominantly produce and maintain the extracellular matrix (ECM) and are critical mediators of injury response. In the heart, valve interstitial cells (VICs) are a population of fibroblasts responsible for maintaining the structure and function of heart valves. These cells are regionally distinct from myocardial fibroblasts, including left ventricular cardiac fibroblasts (LVCFBs), which are located in the myocardium in close vicinity to cardiomyocytes. Here, we hypothesize these subpopulations of fibroblasts are transcriptionally and functionally distinct. Methods: To compare these fibroblast subtypes, we collected patient-matched samples of human primary VICs and LVCFBs and performed bulk RNA sequencing, extracellular matrix profiling, and functional contraction and calcification assays. Results: Here, we identified combined expression of SUSD2 on a protein-level, and MEOX2, EBF2 and RHOU at a transcript-level to be differentially expressed in VICs compared to LVCFBs and demonstrated that expression of these genes can be used to distinguish between the two subpopulations. We found both VICs and LVCFBs expressed similar activation and contraction potential in vitro, but VICs showed an increase in ALP activity when activated and higher expression in matricellular proteins, including cartilage oligomeric protein and alpha 2-Heremans-Schmid glycoprotein, both of which are reported to be linked to calcification, compared to LVCFBs. Conclusion: These comparative transcriptomic, proteomic, and functional studies shed novel insight into the similarities and differences between valve interstitial cells and left ventricular cardiac fibroblasts and will aid in understanding region-specific cardiac pathologies, distinguishing between primary subpopulations of fibroblasts, and generating region-specific stem-cell derived cardiac fibroblasts. |
| 175 | Amish Raval | CVM | anr@medicine.wisc.edu | Direct innominate artery access for transcatheter aortic valve replacement. | Hostile vascular disease can pose a challenge for transcatheter aortic valve replacement, for which the preferred access is via a common femoral artery. However, extensive peripheral arterial disease may also preclude traditional points of alternative access in some patients. Herein, we describe two patients in whom successful transcatheter aortic valve replacement was performed via direct innominate artery access. |
| 176 | Amish Raval | CVM | anr@medicine.wisc.edu | Association of Renal Arteriosclerosis With Atherosclerotic Cardiovascular Disease Risk in Lupus Nephritis. | Lupus nephritis (LN) predicts a 9-fold higher atherosclerosis cardiovascular disease (ASCVD) risk, highlighting the urgent need to target ASCVD prevention. Studies in IgA nephropathy reported that severe renal arteriosclerosis (r-ASCL) in diagnostic biopsies strongly predicted ASCVD risk. We recently found that 50% of LN pathology reports overlooked r-ASCL reporting, which could explain prior negative LN ASCVD risk studies. The present study was undertaken to examine associations between a composite of reported and overread r-ASCL and ASCVD events in LN. Data were abstracted from all LN patients who underwent diagnostic biopsy between 1994 and 2017, including demographic information, ASCVD risk factors, and pathology reports at the time of LN diagnosis. We manually validated all incident ASCVD events. We overread 25% of the biopsies to grade r-ASCL using the Banff criteria. We supplemented the overread r-ASCL grade, when available, to determine the composite of reported and overread r-ASCL grade. Among 189 incident LN patients, 78% were female, 73% White, and the median age was 25 years. Overall, 31% had any reported r-ASCL, and 7% had moderate-to-severe r-ASCL. After incorporating systematically re-examined r-ASCL grade, the prevalence of any and moderate-to-severe r-ASCL increased to 39% and 12%, respectively. We found 22 incident ASCVD events over 11 years of follow-up. Using a composite of reported and overread r-ASCL grade, we found that severe r-ASCL in diagnostic LN biopsies was associated with 9-fold higher odds of ASCVD. Severe r-ASCL can predict ASCVD in LN; therefore, larger studies are required to systematically report r-ASCL and examine ASCVD associations. |
| 177 | Amish Raval | CVM | anr@medicine.wisc.edu | Dare to dream? Cell-based therapies for heart failure after DREAM-HF: Review and roadmap for future clinical study. | Clinical trials of cell-based therapies for heart failure have resulted in significant strides forward in our understanding of the potential the failing heart has for regeneration and repair. Yet, two decades on, the need for novel cell-based therapies for heart failure has never been greater. The DREAM-HF trial, which was presented as a late-breaking trial at the American Heart Association Scientific Sessions 2021 did not meet the primary heart failure outcome, but did show a large, clinically significant reduction in major adverse cardiovascular events (MACE) in patients receiving cells, an effect that was most pronounced in patients with evidence of maladaptive inflammation. These results represent an important step forward in our understanding of how cell-based therapies can exert beneficial effects in patients with heart failure and should serve as a guide for future clinical efforts. In light of the results of DREAM-HF, this review serves to provide an understanding of the current state of cell-based therapies for heart failure, as well as to highlight major knowledge gaps and suggest guiding principles for clinical trials of cell therapy going forward. Using the knowledge gained from DREAM-HF along with the trials that preceded it, the potential for breakthrough cell-based therapies for heart failure in the coming decade is immense. |
| 178 | Amish Raval | CVM | anr@medicine.wisc.edu | Prognosis of paradoxical low-flow low-gradient aortic stenosis after transcatheter aortic valve replacement. | In paradoxical low-flow low-gradient severe aortic stenosis (PLFLG AS) patients, stroke volume index (SVI) is reduced despite preserved left ventricular ejection fraction (LVEF). Although reduced SVI is already known as a poor prognostic predictor, the outcomes of PLFLG AS patients after transcatheter aortic valve replacement (TAVR) have not been clearly defined. We retrospectively investigated the post-TAVR outcomes of PLFLG AS patients in comparison with normal-flow high-gradient aortic stenosis (NFHG AS) patients. The current observational study included 245 patients with NFHG AS (mean transaortic pressure gradient ≥40 mmHg and LVEF ≥ 50%) and 48 patients with PLFLG AS (mean transaortic pressure gradient <40 mmHg, LVEF ≥ 50% and SVI < 35 ml/m2). The endpoints were all-cause mortality, hospitalization for valve-related symptoms or worsening congestive heart failure and New York Heart Association functional class III or IV. PLFLG AS patients had a significantly higher proportion with a history of atrial fibrillation/flutter as compared with NFHG AS patients. All-cause mortality of PLFLG AS patients was worse than that of NFHG AS patients (P = 0.047). Hospitalization for valve-related symptoms or worsening congestive heart failure was more frequent in PLFLG AS patients than in NFHG AS patients (P = 0.041). New York Heart Association functional class III-IV after TAVR was more frequently observed in PLFLG AS patients (P = 0.019). The outcomes of PLFLG AS patients were worse than those of NFHG AS patients in this study. Preexisting atrial fibrillation/flutter was frequent in PLFLG AS patients, and may affect their post-TAVR outcomes. Therefore, closer post-TAVR follow-up should be considered for these patients. |
| 179 | Amish Raval | CVM | anr@medicine.wisc.edu | Technical and clinical study of x-ray-based surface echo probe tracking using an attached fiducial apparatus. | Several types of structural heart intervention (SHI) use information from multiple imaging modalities to complete an interventional task. For example, in transcatheter aortic valve replacement (TAVR), placement and deployment of a bioprosthetic aortic valve in the aorta is primarily guided by x-ray fluoroscopy (XRF), and echocardiography provides visualization of cardiac anatomy and blood flow. However, simultaneous interpretation of independent x-ray and echo displays remains a challenge for the interventionalist. The purpose of this work was to develop a novel echo/x-ray co-registration solution in which volumetric transthoracic echo (TTE) is transformed to the x-ray coordinate system by tracking the three-dimensional (3D) pose of a probe fiducial attachment from its appearance in two-dimensional (2D) x-ray images. A fiducial attachment for a commercial TTE probe consisting of rings of high-contrast ball bearings was designed and fabricated. The 3D pose (position and orientation) of the fiducial attachment is estimated from a 2D x-ray image using an algorithm in which a virtual point cloud model of the attachment is iteratively rotated, translated, and forward-projected onto the image until the average sum-of-squares of grayscale values at the projected points is minimized. Fiducial registration error (FRE) and target registration error (TRE) of this approach were evaluated in phantom studies using TAVR-relevant gantry orientations and four standard acoustic windows for the TTE probe. A patient study was conducted to assess the clinical suitability of the fiducial attachment prototype during TTE imaging of patients undergoing SHI. TTE image quality for the task of guiding a transcatheter procedure was evaluated in a reviewer study. The 3D FRE ranged from 0.32 ± 0.03 mm (mean ± SD) to 1.31 ± 0.05 mm, depending on C-arm orientation and probe acoustic window. The 3D TRE ranged from 1.06 ± 0.03 mm to 2.42 ± 0.06 mm. Fiducial pose estimation was stable when >75% of the fiducial markers were visible in the x-ray image. A panel of reviewers graded the presentation of heart valves in TTE images from 48 SHI patients. While valve presentation did not differ significantly between acoustic windows (P > 0.05), the mitral valve did achieve a significantly higher image quality compared to the aortic and tricuspid valves (P < 0.001). Overall, reviewers perceived sufficient image quality in 76.5% of images of the mitral valve, 54.9% of images of the aortic valve, and 48.6% of images of the tricuspid valve. Fiducial-based tracking of a commercial TTE probe is compatible with clinical SHI workflows and yields 3D target registration error of less than 2.5 mm for a variety of x-ray gantry geometries and echo probe acoustic windows. Although TTE image quality with respect to target valve anatomy was sufficient for the majority of cases examined, prescreening of patients for sufficient TTE quality would be helpful. |
| 180 | Farhan Raza | CVM | fraza@medicine.wisc.edu | Cardiopulmonary Exercise Testing, Rehabilitation, and Exercise Training in Postpulmonary Embolism. | Long-term exercise intolerance and functional limitations are common after an episode of acute pulmonary embolism (PE), despite 3 to 6 months of anticoagulation. These persistent symptoms are reported in more than half of the patients with acute PE and are referred as "post-PE syndrome." Although these functional limitations can occur from persistent pulmonary vascular occlusion or pulmonary vascular remodeling, significant deconditioning can be a major contributing factor. Herein, the authors review the role of exercise testing to elucidate the mechanisms of exercise limitations to guide next steps in management and exercise training for musculoskeletal deconditioning. |
| 181 | Farhan Raza | CVM | fraza@medicine.wisc.edu | Using an in-office passive leg raise to identify older adults with suboptimal blood pressure control. | Passive leg raise (PLR) is a simple, dynamic maneuver that has been used to increase preload to the heart. We hypothesize that PLR may offer a new and efficient office-based tool for assessing blood pressure (BP) control in older adults. One hundred and three veterans (≥60 years old) without known cardiovascular disease and varying degrees of blood pressure control were included in this cross-sectional cohort study. Twenty-four hour ambulatory BP monitoring identified Veterans with optimal and suboptimal BP control (≥125/75 mmHg). Bioimpedance electrodes (Baxter Medical, Deerfield, Illinois, USA) and brachial BP were used to calculate hemodynamic parameter changes across PLR states [pre-PLR, active PLR (3 min), and post-PLR]. Multiple linear regression was used to assess associations between BP control status with changes in hemodynamic parameters between PLR states. The 24-h ambulatory BP monitoring identified 43 (42%) older Veterans with optimal BP control (mean age of 70.5 ± 7.0 years) and 55 (54%) with suboptimal BP (mean age of 71.3 ± 8.7 years). Veterans with suboptimal BP control had significantly reduced change in total peripheral resistance (ΔTPR) (7.0 ± 156.0 vs. 127.3 ± 145.6 dynes s/cm 5 ; P = 0.002) following PLR compared with Veterans with optimal BP control. Suboptimal BP control ( β = -0.35, P = 0.004) had a significant association with reduced ΔTPR, even after adjusting for demographic variables. Measuring PLR-induced hemodynamic changes in the office setting may represent an alternative way to identify older adults with suboptimal BP control when 24-h ambulatory BP monitoring is not available. |
| 182 | Farhan Raza | CVM | fraza@medicine.wisc.edu | Cardiopulmonary exercise testing in pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. | Cardiopulmonary exercise testing allows for a comprehensive assessment of the mechanism of exercise limitation in pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. Competitive pathophysiologic mechanisms may affect the clinical interpretation of cardiopulmonary disease as they relate to dyspnea, leg fatigue, and exercise intolerance. |
| 183 | Farhan Raza | CVM | fraza@medicine.wisc.edu | Volume calibration with cardiac MRI versus hypertonic saline for right ventricular pressure-volume loops with exercise: Impact on ventricular function and ventricular-vascular coupling. | Right ventricular (RV) pressure-volume (PV) loops require postacquisition volume calibration by cardiac MRI (CMR) or hypertonic saline (HS). We defined the impact of these 2 volume calibration methods on rest-to-exercise ventricular contractility (end-systolic elastance: Ees), arterial afterload (Ea), and coupling (Ees/Ea). In a prospective study, 82 RV PV-loop datapoints (rest, exercise stages every 25 W, and recovery) and CMR were acquired in 19 participants. In comparison to CMR, HS-based calibration overestimated RV end-systolic volume at rest, mean (SD) by +38 ml (48) and end-diastolic volume by +46 ml (68), resulting in underestimated right ventricular ejection fraction (RVEF) by -8%. However, Ees and Ea were similar at rest (r2 = 0.76 and 0.71, respectively, p < 0.001 for both), and Ees:Ea was identical (r2 = 1.00, p < 0.001). Exercise metrics also remained similar: RV reserve (ΔEes) and change in coupling (ΔEes/Ea). In comparison to CMR (gold-standard), HS-based calibration underestimates RVEF at rest; however, it is a robust approach for measuring coupling and RV reserve. |
| 184 | Farhan Raza | CVM | fraza@medicine.wisc.edu | Ventricular interdependent phenotype of mixed Cpc-pulmonary hypertension and HFpEF with normal left atrium: Impact on CPET metrics and clinical outcomes. | Among 45 CpcPH/heart failure with preserved ejection fraction participants, 11 with normal left atrium (compared to 34 with abnormal left atrium, p < 0.05 for all) had low left ventricle (LV) transmural pressure (2.9 ± 2.4 vs. 6.2 ± 2.9 mmHg), and increased right ventricle (RV):LV ratio (2.41 ± 1.09 vs. 1.46 ± 0.66) and interventricular septal angle (149 ± 8 vs. 136 ± 10), indicating exaggerated ventricular interdependence from a dilated RV. |
| 185 | Farhan Raza | CVM | fraza@medicine.wisc.edu | Right ventricular outflow tract diameter change with exercise: a prospective exercise echocardiography and invasive CPET study. | While cardiac output reserve with exercise predicts outcomes in cardiac and pulmonary vascular disease, precise quantification of exercise cardiac output requires invasive cardiopulmonary testing (iCPET). To improve the accuracy of cardiac output reserve estimation with transthoracic echocardiography (TTE), this prospective study aims to define changes in right ventricular outflow tract diameter (RVOTd) with exercise and its relationship with invasively measured haemodynamics. Twenty subjects underwent simultaneous TTE and iCPET, with data collected at rest, leg-raise, 25 W, 50 W (n = 16), 75 W (n = 14), and 100 W (n = 6). This was followed by a second exercise study with real-time RV pressure-volume loops at similar stages (except leg-raise). The overall cohort included heart failure with preserved ejection fraction (n = 12), pulmonary arterial hypertension (n = 5), and non-cardiac dyspnoea (n = 3). RVOTd was reverse engineered from the TTE-derived RVOT velocity time integral (VTI) and iCPET-derived stroke volume, using the formula: Fick stroke volume = RVOT VTI × RVOT area (wherein RVOT area = π × [RVOTd/2]2). RVOTd increased by nearly 3-4% at every 25 W increment. Using linear regression models, where each subject is treated as a categorical variable and adjusting for subject intercept, RVOTd was correlated with haemodynamic variables (cardiac output, heart rate, pulmonary artery and RV pressures). Of all the predictor haemodynamic variables, cardiac output had the highest r2 model fit (adjusted r2 = 0.68), with a unit increase in cardiac output associated with a 0.0678 increase in RVOTd (P < 0.001). Our findings indicate that RVOTd increases by 3-4% with every 25 W increment, predominantly correlated with cardiac output augmentation. These results can improve the accuracy of cardiac output reserve estimation by adjusting for RVOTd with graded exercise during non-invasive CPET and echocardiogram. However, future studies are needed to define these relationships for left ventricular outflow tract diameter. |
| 186 | Farhan Raza | CVM | fraza@medicine.wisc.edu | Relationship of TAPSE Normalized by Right Ventricular Area With Pulmonary Compliance, Exercise Capacity, and Clinical Outcomes. | While tricuspid annular plane systolic excursion (TAPSE) captures the predominant longitudinal motion of the right ventricle (RV), it does not account for ventricular morphology and radial motion changes in various forms of pulmonary hypertension. This study aims to account for both longitudinal and radial motions by dividing TAPSE by RV area and to assess its clinical significance. We performed a retrospective analysis of 71 subjects with New York Heart Association class II to III dyspnea who underwent echocardiogram and invasive cardiopulmonary exercise testing (which defined 4 hemodynamic groups: control, isolated postcapillary pulmonary hypertension, combined postcapillary pulmonary hypertension, and pulmonary arterial hypertension). On the echocardiogram, TAPSE was divided by RV area in diastole (TAPSE/RVA-D) and systole (TAPSE/RVA-S). Analyses included correlations (Pearson and linear regression), receiver operating characteristic, and survival curves. On linear regression analysis, TAPSE/RVA metrics (versus TAPSE) had a stronger correlation with pulmonary artery compliance (r=0.48-0.54 versus 0.38) and peak VO2 percentage predicted (0.23-0.30 versus 0.18). Based on the receiver operating characteristic analysis, pulmonary artery compliance ≥3 mL/mm Hg was identified by TAPSE/RVA-D with an under the curve (AUC) of 0.79 (optimal cutoff ≥1.1) and by TAPSE/RVA-S with an AUC of 0.83 (optimal cutoff ≥1.5), but by TAPSE with only an AUC of 0.67. Similarly, to identify peak VO2 <50% predicted, AUC of 0.66 for TAPSE/RVA-D and AUC of 0.65 for TAPSE/RVA-S. Death or cardiovascular hospitalization at 12 months was associated with TAPSE/RVA-D ≥1.1 (HR, 0.38 [95% CI, 0.11-0.56]) and TAPSE/RVA-S ≥1.5 (HR, 0.44 [95% CI, 0.16-0.78]), while TAPSE was not associated with adverse outcomes (HR, 0.99 [95% CI, 0.53-1.94]). Among 31 subjects with available cardiac magnetic resonance imaging, RV ejection fraction was better correlated with novel metrics (TAPSE/RVA-D r=0.378 and TAPSE/RVA-S r=0.328) than TAPSE (r=0.082). In a broad cohort with suspected pulmonary hypertension, TAPSE divided by RV area was superior to TAPSE alone in correlations with pulmonary compliance and exercise capacity. As a prognostic marker of right heart function, TAPSE/RVA-D <1.1 and TAPSE/RVA-S <1.5 predicted adverse cardiovascular outcomes. |
| 187 | Farhan Raza | CVM | fraza@medicine.wisc.edu | Titin: roles in cardiac function and diseases. | The giant protein titin is an essential component of muscle sarcomeres. A single titin molecule spans half a sarcomere and mediates diverse functions along its length by virtue of its unique domains. The A-band of titin functions as a molecular blueprint that defines the length of the thick filaments, the I-band constitutes a molecular spring that determines cell-based passive stiffness, and various domains, including the Z-disk, I-band, and M-line, serve as scaffolds for stretch-sensing signaling pathways that mediate mechanotransduction. This review aims to discuss recent insights into titin's functional roles and their relationship to cardiac function. The role of titin in heart diseases, such as dilated cardiomyopathy and heart failure with preserved ejection fraction, as well as its potential as a therapeutic target, is also discussed. |
| 188 | Farhan Raza | CVM | fraza@medicine.wisc.edu | Distensibility, an Early Disease Marker of Pulmonary Vascular Health: Ready for Clinical Application. | |
| 189 | Farhan Raza | CVM | fraza@medicine.wisc.edu | Cardiopulmonary Exercise Testing, Rehabilitation, and Exercise Training in Postpulmonary Embolism. | Long-term exercise intolerance and functional limitations are common after an episode of acute pulmonary embolism (PE), despite 3 to 6 months of anticoagulation. These persistent symptoms are reported in more than half of the patients with acute PE and are referred as "post-PE syndrome." Although these functional limitations can occur from persistent pulmonary vascular occlusion or pulmonary vascular remodeling, significant deconditioning can be a major contributing factor. Herein, the authors review the role of exercise testing to elucidate the mechanisms of exercise limitations to guide next steps in management and exercise training for musculoskeletal deconditioning. |
| 190 | Mohun Ramratnam | CVM | mramrat@medicine.wisc.edu | Cardiac overexpression of a mitochondrial SUR2A splice variant impairs cardiac function and worsens myocardial ischemia reperfusion injury in female mice. | The small splice variant of the sulfonylurea receptor protein isoform 2 A (SUR2A-55) targets mitochondria and enhances mitoKATP activity. In male mice the overexpression of this protein promotes cardioprotection, reducing myocardial injury after an ischemic insult. However, it is unclear what impact SUR2A-55 overexpression has on the female myocardium. To investigate the impact of SU2R2A-55 on the female heart, mice with cardiac specific transgenic overexpression of SUR2A-55 (TGSUR2A-55) were examined by resting echocardiography and histopathology. In addition, hearts were subjected to ischemia reperfusion (IR) injury. Female TGSUR2A-55 mice had resting LV dysfunction and worse hemodynamic recovery with increased infarct size after IR injury. RNA-seq analysis found 227 differential expressed genes between WT and TGSUR2A-55 female mouse hearts that were enriched in pathways of cellular metabolism. This was in direct contrast to male mice that had only four differentially expressed genes. Female TGSUR2A-55 mice compared to female WT mice had reduced cardiomyocyte mitochondrial membrane potential without a change in electron transport chain protein expression. In addition, isolated mitochondria from female TGSUR2A-55 hearts displayed reduced sensitivity to ATP and diazoxide suggestive of increased mitoKATP activity. In conclusion, our data suggests that female TGSUR2A-55 mice are unable to tolerate a more active mitoKATP channel leading to LV dysfunction and worse response to IR injury. This is in direct contrast to our prior report showing cardioprotection in male mice overexpressing SUR2A-55 in heart. Future research directed at examining the expression and activity of mitoKATP subunits according to sex may elucidate different treatments for male and female patients. |
| 191 | Mohun Ramratnam | CVM | mramrat@medicine.wisc.edu | Overexpression of a Short Sulfonylurea Splice Variant Increases Cardiac Glucose Uptake and Uncouples Mitochondria by Regulating ROMK Activity. | The mitochondrial splice variant of the sulfonylurea receptor (SUR2A-55) is associated with protection from myocardial ischemia-reperfusion (IR) injury, increased mitochondrial ATP sensitive K+ channel activity (mitoKATP) and altered glucose metabolism. While mitoKATP channels composed of CCDC51 and ABCB8 exist, the mitochondrial K+ pore regulated by SUR2A-55 is unknown. We explored whether SUR2A-55 regulates ROMK to form an alternate mitoKATP. We assessed glucose uptake in mice overexpressing SUR2A-55 (TGSUR2A-55) compared with WT mice during IR injury. We then examined the expression level of ROMK and the effect of ROMK modulation on mitochondrial membrane potential (Δψm) in WT and TGSUR2A-55 mice. TGSUR2A-55 had increased glucose uptake compared to WT mice during IR injury. The expression of ROMK was similar in WT compared to TGSUR2A-55 mice. ROMK inhibition hyperpolarized resting cardiomyocyte Δψm from TGSUR2A-55 mice but not from WT mice. In addition, TGSUR2A-55 and ROMK inhibitor treated WT isolated cardiomyocytes had enhanced mitochondrial uncoupling. ROMK inhibition blocked diazoxide induced Δψm depolarization and prevented preservation of Δψm from FCCP perfusion in WT and to a lesser degree TGSUR2A-55 mice. In conclusion, cardio-protection from SUR2A-55 is associated with ROMK regulation, enhanced mitochondrial uncoupling and increased glucose uptake. |
| 192 | Mohun Ramratnam | CVM | mramrat@medicine.wisc.edu | Cardiac sodium-dependent glucose cotransporter 1 is a novel mediator of ischaemia/reperfusion injury. | We previously reported that sodium-dependent glucose cotransporter 1 (SGLT1) is highly expressed in cardiomyocytes and is further up-regulated in ischaemia. This study aimed to determine the mechanisms by which SGLT1 contributes to ischaemia/reperfusion (I/R) injury. Mice with cardiomyocyte-specific knockdown of SGLT1 (TGSGLT1-DOWN) and wild-type controls were studied. In vivo, the left anterior descending coronary artery was ligated for 30 min and reperfused for 48 h. Ex vivo, isolated perfused hearts were exposed to 20 min no-flow and up to 2 h reperfusion. In vitro, HL-1 cells and isolated adult murine ventricular cardiomyocytes were exposed to 1 h hypoxia and 24 h reoxygenation (H/R). We found that TGSGLT1-DOWN hearts were protected from I/R injury in vivo and ex vivo, with decreased infarct size, necrosis, dysfunction, and oxidative stress. 5'-AMP-activated protein kinase (AMPK) activation increased SGLT1 expression, which was abolished by extracellular signal-related kinase (ERK) inhibition. Co-immunoprecipitation studies showed that ERK, but not AMPK, interacts directly with SGLT1. AMPK activation increased binding of the hepatocyte nuclear factor 1 and specificity protein 1 transcription factors to the SGLT1 gene, and HuR to SGLT1 mRNA. In cells, up-regulation of SGLT1 during H/R was abrogated by AMPK inhibition. Co-immunoprecipitation studies showed that SGLT1 interacts with epidermal growth factor receptor (EGFR), and EGFR interacts with protein kinase C (PKC). SGLT1 overexpression activated PKC and NADPH oxidase 2 (Nox2), which was attenuated by PKC inhibition, EGFR inhibition, and/or disruption of the interaction between EGFR and SGLT1. During ischaemia, AMPK up-regulates SGLT1 through ERK, and SGLT1 interacts with EGFR, which in turn increases PKC and Nox2 activity and oxidative stress. SGLT1 may represent a novel therapeutic target for mitigating I/R injury. |
| 193 | Mohun Ramratnam | CVM | mramrat@medicine.wisc.edu | Deletion of Sulfonylurea Receptor 2 in the Adult Myocardium Enhances Cardiac Glucose Uptake and Is Cardioprotective. | The adult myocardium relies on oxidative metabolism. In ischemic myocardium, such as the embryonic heart, glycolysis contributes more prominently as a fuel source. The sulfonylurea receptor 2 (SUR2) was previously implicated in the normal myocardial transition from glycolytic to oxidative metabolism that occurs during adaptation to postnatal life. This receptor was now selectively deleted in adult mouse myocardium resulting in protection from ischemia reperfusion injury. SUR2-deleted cardiomyocytes had enhanced glucose uptake, and SUR2 forms a complex with the major glucose transporter. These data identify the SUR2 receptor as a target to shift cardiac metabolism to protect against myocardial injury. |
| 194 | Mohun Ramratnam | CVM | mramrat@medicine.wisc.edu | Transgenic overexpression of the SUR2A-55 splice variant in mouse heart reduces infract size and promotes protective mitochondrial function. | ATP-sensitive potassium channels found in both the sarcolemma (sarcKATP) and mitochondria (mitoKATP) of cardiomyocytes are important mediators of cardioprotection during ischemic heart disease. Sulfonylurea receptor isoforms (SUR2), encoded by Abcc9, an ATP-binding cassette family member, form regulatory subunits of the sarcKATP channel and are also thought to regulate mitoKATP channel activity. A short-form splice variant of SUR2 (SUR2A-55) was previously shown to target mitochondria and display diaxoxide and ATP insensitive KATP activity when co-expressed with the inward rectifier channels Kir6.2 and Kir6.1. We hypothesized that mice with cardiac specific overexpression of SUR2A-55 would mediate cardioprotection from ischemia by altering mitoKATP properties. Mice overexpressing SUR2A-55 (TGSUR2A-55) in cardiomyocytes were generated and showed no significant difference in echocardiographic measured chamber dimension, percent fractional shortening, heart to body weight ratio, or gross histologic features compared to normal mice at 11-14 weeks of age. TGSUR2A-55 had improved hemodynamic functional recovery and smaller infarct size after ischemia reperfusion injury compared to WT mice in an isolated hanging heart model. The mitochondrial membrane potential of TGSUR2A-55 mice was less sensitive to ATP, diazoxide, and Ca2+ loading. These data suggest that the SUR2A-55 splice variant favorably affects mitochondrial function leading to cardioprotection. These data support a role for the regulation of mitoKATP activity by SUR2A-55. |
| 195 | Mohun Ramratnam | CVM | mramrat@medicine.wisc.edu | Gene-Targeted Mice with the Human Troponin T R141W Mutation Develop Dilated Cardiomyopathy with Calcium Desensitization. | Most studies of the mechanisms leading to hereditary dilated cardiomyopathy (DCM) have been performed in reconstituted in vitro systems. Genetically engineered murine models offer the opportunity to dissect these mechanisms in vivo. We generated a gene-targeted knock-in murine model of the autosomal dominant Arg141Trp (R141W) mutation in Tnnt2, which was first described in a human family with DCM. Mice heterozygous for the mutation (Tnnt2R141W/+) recapitulated the human phenotype, developing left ventricular dilation and reduced contractility. There was a gene dosage effect, so that the phenotype in Tnnt2R141W/+mice was attenuated by transgenic overexpression of wildtype Tnnt2 mRNA transcript. Male mice exhibited poorer survival than females. Biomechanical studies on skinned fibers from Tnnt2R141W/+ hearts showed a significant decrease in pCa50 (-log[Ca2+] required for generation of 50% of maximal force) relative to wildtype hearts, indicating Ca2+ desensitization. Optical mapping studies of Langendorff-perfused Tnnt2R141W/+ hearts showed marked increases in diastolic and peak systolic intracellular Ca2+ ([Ca2+]i), and prolonged systolic rise and diastolic fall of [Ca2+]i. Perfused Tnnt2R141W/+ hearts had slower intrinsic rates in sinus rhythm and reduced peak heart rates in response to isoproterenol. Tnnt2R141W/+ hearts exhibited a reduction in phosphorylated phospholamban relative to wildtype mice. However, crossing Tnnt2R141W/+ mice with phospholamban knockout (Pln-/-) mice, which exhibit increased Ca2+ transients and contractility, had no effect on the DCM phenotype. We conclude that the Tnnt2 R141W mutation causes a Ca2+ desensitization and mice adapt by increasing Ca2+-transient amplitudes, which impairs Ca2+ handling dynamics, metabolism and responses to β-adrenergic activation. |
| 196 | Mohun Ramratnam | CVM | mramrat@medicine.wisc.edu | Transgenic knockdown of cardiac sodium/glucose cotransporter 1 (SGLT1) attenuates PRKAG2 cardiomyopathy, whereas transgenic overexpression of cardiac SGLT1 causes pathologic hypertrophy and dysfunction in mice. | The expression of a novel cardiac glucose transporter, SGLT1, is increased in glycogen storage cardiomyopathy secondary to mutations in PRKAG2. We sought to determine the role of SGLT1 in the pathogenesis of PRKAG2 cardiomyopathy and its role in cardiac structure and function. Transgenic mice with cardiomyocyte-specific overexpression of human T400N mutant PRKAG2 cDNA (TG(T400N)) and transgenic mice with cardiomyocyte-specific RNA interference knockdown of SGLT1 (TG(SGLT1-DOWN)) were crossed to produce double-transgenic mice (TG(T400N)/TG(SGLT1-DOWN)). Tet-off transgenic mice conditionally overexpressing cardiac SGLT1 in the absence of doxycycline were also constructed (TG(SGLT-ON)). Relative to TG(T400N) mice, TG(T400N)/TG(SGLT1-DOWN) mice exhibited decreases in cardiac SGLT1 expression (63% decrease, P<0.05), heart/body weight ratio, markers of cardiac hypertrophy, and cardiac glycogen content. TG(T400N)/TG(SGLT1-DOWN) mice had less left ventricular dilation at age 12 weeks compared to TG(T400N) mice. Relative to wildtype (WT) mice, TG(SGLT1-ON) mice exhibited increases in heart/body weight ratio, glycogen content, and markers of cardiac hypertrophy at ages 10 and 20 weeks. TG(SGLT1-ON) mice had increased myocyte size and interstitial fibrosis, and progressive left ventricular dysfunction. When SGLT1 was suppressed after 10 weeks of overexpression (TG(SGLT1-ON/OFF)), there was a reduction in cardiac hypertrophy and improvement in left ventricular failure. Cardiac knockdown of SGLT1 in a murine model of PRKAG2 cardiomyopathy attenuates the disease phenotype, implicating SGLT1 in the pathogenesis. Overexpression of SGLT1 causes pathologic cardiac hypertrophy and left ventricular failure that is reversible. This is the first report of cardiomyocyte-specific transgenic knockdown of a target gene. |
| 197 | Hilary Faust | APCC-Pulm | hfaust@medicine.wisc.edu | Modeling lung endothelial dysfunction in sepsis-associated ARDS using a microphysiological system. | Endothelial dysfunction is a critical feature of acute respiratory distress syndrome (ARDS) associated with higher disease severity and worse outcomes. Preclinical in vivo models of sepsis and ARDS have failed to yield useful therapies in humans, perhaps due to interspecies differences in inflammatory responses and heterogeneity of human host responses. Use of microphysiological systems (MPS) to investigate lung endothelial function may shed light on underlying mechanisms and targeted treatments for ARDS. We assessed the response to plasma from critically ill sepsis patients in our lung endothelial MPS through measurement of endothelial permeability, expression of adhesion molecules, and inflammatory cytokine secretion. Sepsis plasma induced areas of endothelial cell (EC) contraction, loss of cellular coverage, and luminal defects. EC barrier function was significantly worse following incubation with sepsis plasma compared to healthy plasma. EC ICAM-1 expression, IL-6 and soluble ICAM-1 secretion increased significantly more after incubation with sepsis plasma compared with healthy plasma. Plasma from sepsis patients who developed ARDS further increased IL-6 and sICAM-1 compared to plasma from sepsis patients without ARDS and healthy plasma. Our results demonstrate the proof of concept that lung endothelial MPS can enable interrogation of specific mechanisms of endothelial dysfunction that promote ARDS in sepsis patients. |
| 198 | Hilary Faust | APCC-Pulm | hfaust@medicine.wisc.edu | Regional citrate and systemic heparin are adequate to maintain filter half-life for COVID-19 patients on continuous renal replacement therapy. | The aim of our study is to compare clotting of CRRT filters in patients with COVID-19-associated AKI versus septic shock-associated AKI. Retrospective study of adult ICU patients with COVID-19 compared to those with septic shock admitted to a tertiary hospital April-October 2020. Independent t test and chi-square test used to determine statistical significance of CRRT filter clotting between the two groups. Time-to-event data analyzed with Kaplan-Meier curves. Analyses performed on Microsoft Excel and MedCalc. Twenty-seven ICU patients with AKI requiring CRRT were included, 13 with COVID-19 and 14 non-COVID-19 patients with septic shock. The mean half-life of CRRT hemofilter was similar in COVID-19 patients compared to non-COVID-19 patients (27.4 vs. 27.5 h, p = 0.79). The number of CRRT hemofilter changes per day was similar in both groups (0.6 filter changes per day, p = 0.84). However, significantly more patients with COVID-19 were on systemic heparin (69% vs. 13%, p = 0.02). We found that COVID-19 patients with AKI requiring CRRT had similar CRRT hemofilter half-life compared with sepsis-associated AKI patients with use of regional citrate and systemic heparin. Further studies are needed to find which methods of anticoagulation are optimal in patients with COVID-19 infection with AKI requiring CRRT. |
| 199 | Hilary Faust | APCC-Pulm | hfaust@medicine.wisc.edu | Early Plasma Nuclear DNA, Mitochondrial DNA, and Nucleosome Concentrations Are Associated With Acute Kidney Injury in Critically Ill Trauma Patients. | Circulating nucleic acids, alone and in complex with histones as nucleosomes, have been proposed to link systemic inflammation and coagulation after trauma to acute kidney injury (AKI). We sought to determine the association of circulating nucleic acids measured at multiple time points after trauma with AKI risk. We conducted a prospective cohort study of trauma patients, collecting plasma on presentation and at 6, 12, 24, and 48 hours, defining AKI over the first 6 days by Kidney Disease Improving Global Outcomes serum creatinine and dialysis criteria. We determined kinetics of plasma mitochondrial DNA (mtDNA), nuclear DNA (nDNA), and nucleosome levels across time points and associations with AKI using multivariable linear mixed-effects models, adjusted for injury characteristics and blood transfusions. We evaluated the association of presentation nucleic acid damage-associated molecular patterns (DAMP) concentrations with subsequent AKI, adjusting for injury severity using multivariable logistic regression. Academic level I trauma center. Trauma patients (n = 55) requiring intensive care for greater than or equal to 24 hours after presentation. None. AKI developed in 17 patients (31%), a median of 12.0 hours (interquartile range, 6.2-24.1 hr) after presentation. mtDNA demonstrated a time-varying association with AKI (p = 0.022, interaction with time point), with differences by AKI status not emerging until 24 hours (β = 0.97 [95% CI, 0.03-1.90] log copies/uL; p = 0.043). Patients who developed AKI had higher nDNA across all time points (overall β = 1.41 log copies/uL [0.86-1.95 log copies/uL]; p < 0.001), and presentation levels were significantly associated with subsequent AKI (odds ratio [OR], 2.55 [1.36-4.78] per log copy/uL; p = 0.003). Patients with AKI had higher nucleosome levels at presentation (β = 0.32 [0.00-0.63] arbitrary unit; p = 0.048), a difference that was more pronounced at 24 hours (β = 0.41 [0.06-0.76]; p = 0.021) and 48 hours (β = 0.71 [0.35-1.08]; p < 0.001) (p = 0.075, interaction with time point). Plasma nucleic acid DAMPs have distinct kinetics and associations with AKI in critically ill trauma patients. nDNA at presentation predicts subsequent AKI and may be amenable to targeted therapies in this population. |
| 200 | Hilary Faust | APCC-Pulm | hfaust@medicine.wisc.edu | RAGE interacts with the necroptotic protein RIPK3 and mediates transfusion-induced danger signal release. | RBC transfusion is associated with increased morbidity and mortality in critically ill patients. Endothelial cell necroptosis and subsequent damage-associated molecular pattern (DAMP) release has been identified as a mechanism of injury following RBC transfusion. Mounting evidence implicates the pro-inflammatory pattern recognition receptor, Receptor for Advanced Glycation End Products (RAGE), in initiating cell death programmes such as necroptosis. Here, we demonstrate the role of RAGE in endothelial necroptosis, as deletion of RAGE attenuates necroptotic cell death in response to TNFα, LPS or CpG-DNA. We show direct interaction of RAGE with the critical mediator of necroptosis, Receptor Interacting Protein Kinase 3 (RIPK3), during necroptosis. Furthermore, we observe decreased plasma High Mobility Group Box 1 (HMGB1) and RIPK3 levels in RAGE deficient mice compared to WT mice post-transfusion, substantiating the role for RAGE in transfusion-induced DAMP release in vivo. Collectively, these findings underscore RAGE as an essential mediator of regulated necrosis and post-transfusion DAMP release. Further studies to understand the role of RAGE and the necroptotic pathway in transfusion-induced organ injury may offer key targets to mitigate transfusion-related risks, including the risk of ARDS, in susceptible hosts. |
| 201 | Hilary Faust | APCC-Pulm | hfaust@medicine.wisc.edu | Thromboelastography to Detect Hypercoagulability and Reduced Fibrinolysis in Coronavirus Disease 2019 Acute Respiratory Distress Syndrome Patients. | Microvascular thrombosis contributes to acute respiratory distress syndrome pathophysiology and has been demonstrated in coronavirus disease 2019-associated acute respiratory distress syndrome. Clinical laboratory measurements of coagulation and disseminated intravascular coagulation, such as coagulation factor function, platelet count, and fibrinogen, may not fully reflect the extent of microvascular thrombosis present in these patients. We investigated thromboelastography in patients with coronavirus disease 2019-associated acute respiratory distress syndrome with the objective of characterizing suspected coagulopathy and impaired fibrinolysis. Retrospective observational cohort study. Single-center academic medical center. Ten patients with polymerase chain reaction-confirmed coronavirus disease 2019 disease complicated by acute respiratory distress syndrome. Measurement of thromboelastography (n = 10) and thrombolysis with alteplase (n = 4). Hypercoagulability and decreased or absent fibrinolysis were demonstrated by thromboelastography. Thrombocytopenia and hypofibrinogenemia were not observed, while seven of 10 patients had elevated d-dimer values. For patients who received thrombolytic therapy, repeat thromboelastography demonstrated improvements in coagulation index and lysis at 30 minutes reflecting reduced hypercoagulability and increased fibrinolysis. One major bleeding complication was detected following thrombolysis. Eight of 10 patients survived and were successfully extubated, and six of 10 have since been discharged. In coronavirus disease 2019 patients with acute respiratory distress syndrome in whom thromboelastography was performed, hypercoagulability and impaired fibrinolysis were observed. In the context of autopsy studies demonstrating pulmonary microvascular thromboses in coronavirus disease 2019 patients, noninvasive detection of hypercoagulability and deficient fibrinolysis in coronavirus disease 2019 acute respiratory distress syndrome using thromboelastography could improve understanding and management of coronavirus disease 2019. |
| 202 | Hilary Faust | APCC-Pulm | hfaust@medicine.wisc.edu | Collateral damage: necroptosis in the development of lung injury. | Cell death is increasingly recognized as a driving factor in the development of acute lung injury. Necroptosis, an immunogenic regulated cell death program important in innate immunity, has been implicated in the development of lung injury in a diverse range of conditions. Characterized by lytic cell death and consequent extracellular release of endogenous inflammatory mediators, necroptosis can be both beneficial and deleterious to the host, depending on the context. Here, we review recent investigations linking necroptosis and the development of experimental lung injury. We assess the consequences of necroptosis during bacterial pneumonia, viral infection, sepsis, and sterile injury, highlighting increasing evidence from in vitro studies, animal models, and clinical studies that implicates necroptosis in the pathogenesis of ARDS. Lastly, we highlight current challenges in translating laboratory findings to the bedside. |
| 203 | Hilary Faust | APCC-Pulm | hfaust@medicine.wisc.edu | Plasma Mitochondrial DNA Levels Are Associated With ARDS in Trauma and Sepsis Patients. | Critically ill patients who develop ARDS have substantial associated morbidity and mortality. Circulating mitochondrial DNA (mtDNA) released during critical illness causes endothelial dysfunction and lung injury in experimental models. This study hypothesized that elevated plasma mtDNA is associated with ARDS in critically ill patients with trauma and sepsis. Plasma mtDNA concentrations were measured at ED presentation and approximately 48 h later in separate prospective cohorts of critically ill patients with trauma and sepsis. ARDS was classified according to the Berlin definition. The association of mtDNA with ARDS was tested by using multivariable logistic regression, adjusted for covariates previously shown to contribute to ARDS risk in each population. ARDS developed in 41 of 224 (18%) trauma patients and in 45 of 120 (38%) patients with sepsis. Forty-eight-hour mtDNA levels were significantly associated with ARDS (trauma: OR, 1.58/log copies/μL; 95% CI, 1.14-2.19 [P = .006]; sepsis: OR, 1.52/log copies/μL; 95% CI, 1.12-2.06 [P = .007]). Plasma mtDNA on presentation was not significantly associated with ARDS in either cohort. In patients with sepsis, 48-h mtDNA was more strongly associated with ARDS among those with a nonpulmonary infectious source (OR, 2.20/log copies/μL; 95% CI, 1.36-3.55 [P = .001], n = 69) than those with a pulmonary source (OR, 1.04/log copies/μL; 95% CI, 0.68-1.59 [P = .84], n = 51; P = .014 for interaction). Plasma mtDNA levels were associated with incident ARDS in two critical illness populations. Given supportive preclinical data, our findings suggest a potential link between circulating mtDNA and lung injury and merit further investigation as a potentially targetable mediator of ARDS. |
| 204 | Jacqueline Kruser | APCC-Pulm | jkruser@wisc.edu | Study protocol for a randomized controlled trial: Integrating the 'Time-limited Trial' in the emergency department. | Time-limited trial (TLT) is a structured approach between clinicians and seriously ill patients or their surrogates to discuss patients' values and preferences, prognosis, and shared decision-making to use specific therapies for a prespecified period of time in the face of prognostic uncertainty. Some evidence exists that this approach may lead to more patient-centered care in the intensive care unit; however, it has never been evaluated in the emergency department (ED). The study protocol aims to assess the feasibility and acceptability of TLTs initiated in the ED. We will conduct a parallel group, clinician-level, pilot randomized clinical trial among 40 ED clinicians. We will measure feasibility (e.g., the time it takes to conduct the TLTs by ED clinicians) and clinician and patient-reported acceptability of the TLT, and also track patients' clinical outcomes via medical record review. This study protocol will investigate the potential of TLT initiated in the ED to lead to patient-centered intensive care utilization. By doing so, the study intends to improve palliative care integration for seriously ill older adults in the ED and intensive care unit. ClinicalTrials.gov ID: NCT06378151 https://clinicaltrials.gov/study/NCT06378151; Pre-results; a randomized controlled trial: Time-limited Trials in the Emergency Department. |
| 205 | Jacqueline Kruser | APCC-Pulm | jkruser@wisc.edu | The Equipoise Ruler: A National Survey on Surgeon Judgment About the Value of Surgery. | To understand professional norms regarding the value of surgery. Agreed-upon professional norms may improve surgical decision-making by contextualizing the nature of surgical treatment for patients. However, the extent to which these norms exist among surgeons practicing in the United States is not known. We administered a survey with 30 exemplar cases asking surgeons to use their best judgment to place each case on a scale ranging from "definitely would do this surgery" to "definitely would not do this surgery." We then asked surgeons to repeat their assessments after providing responses from the first survey. We interviewed respondents to characterize their rationale. We received 580 responses, a response rate of 28.5%. For 19 of 30 cases, there was consensus (≥60% agreement) about the value of surgery (range: 63% to 99%). There was little within-case variation when the mode was for surgery and more variation when the mode was against surgery or equipoise. Exposure to peer response increased the number of cases with consensus. Women were more likely to endorse a nonoperative approach when treatment had high mortality. Specialists were less likely to operate for salvage procedures. Surgeons noted their clinical practice was to withhold judgment and let patients decide despite their assessment. Professional judgment about the value of surgery exists along a continuum. While there is less variation in judgment for cases that are highly beneficial, consensus can be improved by exposure to the assessments of peers. |
| 206 | Jacqueline Kruser | APCC-Pulm | jkruser@wisc.edu | Characterizing the Use of Time-Limited Trials in Patients With Acute Respiratory Failure: A Prospective, Single-Center Observational Study. | A time-limited trial (TLT) is a collaborative plan among clinicians, patients, and families to use life-sustaining therapy for a defined duration, after which the patient's response informs whether to continue care directed toward recovery or shift the focus toward comfort. TLTs are a promising approach to help navigate uncertainty in critical illness, yet little is known about their current use. To characterize TLT use in patients with acute respiratory failure (ARF). Prospective 12-month observational cohort study at an U.S. academic medical center of adult ICU patients with ARF receiving invasive mechanical ventilation for greater than or equal to 48 hours. Primary exposure was TLT participation, identified by patients' ICU physician. Patient characteristics, care delivery elements, and hospital outcomes were extracted from the electronic medical record. Among 176 eligible patients, 36 (20.5%) participated in a TLT. Among 18 ICU attending physicians, nine (50%) participated in greater than or equal to 1 TLT (frequency 0-39% of patients cared for). Median TLT duration was 3.0 days (interquartile range [IQR], 3.0-4.5 d). TLT patients had a higher mean age (67.4 yr [sd, 12.0 yr] vs. 60.0 yr [sd, 16.0 yr]; p < 0.01), higher Charlson Comorbidity Index (5.1 [sd, 2.2] vs. 3.8 [sd, 2.6]; p < 0.01), and similar Sequential Organ Failure Assessment score (9.6 [sd, 3.3] vs. 9.5 [sd, 3.7]; p = 0.93), compared with non-TLT patients. TLT patients were more likely to die or be discharged to hospice (80.6% vs. 42.1%; p < 0.05) and had shorter ICU length of stay (median, 5.7 d [IQR, 4.0-9.0 d] vs. 10.3 d [IQR, 5.5-14.5 d]; p < 0.01). In this study, approximately one in five patients with ARF participated in a TLT. Our findings suggest TLTs are used primarily in patients near end of life but with substantial physician variation, highlighting a need for evidence to guide optimal use. |
| 207 | Jacqueline Kruser | APCC-Pulm | jkruser@wisc.edu | Interhospital Transfer of Patients With Acute Respiratory Failure in the United States: A Scoping Review. | Interhospital transfer of patients with acute respiratory failure (ARF) is relevant in the current landscape of critical care delivery. However, current transfer practices for patients with ARF are highly variable, poorly formalized, and lack evidence. We aim to synthesize the existing evidence, identify knowledge gaps, and highlight persisting questions related to interhospital transfer of patients with ARF. Ovid Medline, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Embase, CINAHL Plus, and American Psychological Association. We included studies that evaluated or described hospital transfers of adult (age > 18) patients with ARF between January 2020 and 2024 conducted in the United States. Using predetermined search terms and strategies, a total of 3369 articles were found across all databases. After deduplication, 1748 abstracts were screened by authors with 45 articles that advanced to full-text review. This yielded 16 studies that fit our inclusion criteria. The studies were reviewed in accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews by three authors. Included studies were mostly retrospective analyses of heterogeneous patients with various etiologies and severity of ARF. Overall, transferred patients were younger, had high severity of illness, and were more likely to have commercial insurance compared with nontransferred cohorts. There is a paucity of data examining why patients get transferred. Studies that retrospectively evaluated outcomes between transferred and nontransferred cohorts found no differences in mortality, although transferred patients have a longer length of stay. There is limited evidence to suggest that patients transferred early in their course have improved outcomes. Our scoping review highlights the sparse evidence and the urgent need for further research into understanding the complexity behind ARF transfers. Future studies should focus on defining best practices to inform clinical decision-making and improve downstream outcomes. |
| 208 | Jacqueline Kruser | APCC-Pulm | jkruser@wisc.edu | Optimal management of radiation pneumonitis: Findings of an international Delphi consensus study. | Radiation pneumonitis (RP) is a dose-limiting toxicity for patients undergoing radiotherapy (RT) for lung cancer, however, the optimal practice for diagnosis, management, and follow-up for RP remains unclear. We thus sought to establish expert consensus recommendations through a Delphi Consensus study. In Round 1, open questions were distributed to 31 expert clinicians treating thoracic malignancies. In Round 2, participants rated agreement/disagreement with statements derived from Round 1 answers using a 5-point Likert scale. Consensus was defined as ≥ 75 % agreement. Statements that did not achieve consensus were modified and re-tested in Round 3. Response rate was 74 % in Round 1 (n = 23/31; 17 oncologists, 6 pulmonologists); 82 % in Round 2 (n = 19/23; 15 oncologists, 4 pulmonologists); and 100 % in Round 3 (n = 19/19). Thirty-nine of 65 Round 2 statements achieved consensus; a further 10 of 26 statements achieved consensus in Round 3. In Round 2, there was agreement that risk stratification/mitigation includes patient factors; optimal treatment planning; the basis for diagnosis of RP; and that oncologists and pulmonologists should be involved in treatment. For uncomplicated radiation pneumonitis, an equivalent to 60 mg oral prednisone per day, with consideration of gastroprotection, is a typical initial regimen. However, in this study, no consensus was achieved for dosing recommendation. Initial steroid dose should be administered for a duration of 2 weeks, followed by a gradual, weekly taper (equivalent to 10 mg prednisone decrease per week). For severe pneumonitis, IV methylprednisolone is recommended for 3 days prior to initiating oral corticosteroids. Final consensus statements included that the treatment of RP should be multidisciplinary, the uncertainty of whether pneumonitis is drug versus radiation-induced, and the importance risk stratification, especially in the scenario of interstitial lung disease. This Delphi study achieved consensus recommendations and provides practical guidance on diagnosis and management of RP. |
| 209 | Jacqueline Kruser | APCC-Pulm | jkruser@wisc.edu | Barriers and Facilitators to End-of-Life Care Delivery in ICUs: A Qualitative Study. | To understand frontline ICU clinician's perceptions of end-of-life care delivery in the ICU. Qualitative observational cross-sectional study. Seven ICUs across three hospitals in an integrated academic health system. ICU clinicians (physicians [critical care, palliative care], advanced practice providers, nurses, social workers, chaplains). None. In total, 27 semi-structured interviews were conducted, recorded, and transcribed. The research team reviewed all transcripts inductively to develop a codebook. Thematic analysis was conducted through coding, category formulation, and sorting for data reduction to identify central themes. Deductive reasoning facilitated data category formulation and thematic structuring anchored on the Systems Engineering Initiative for Patient Safety model identified that work systems (people, environment, tools, tasks) lead to processes and outcomes. Four themes were barriers or facilitators to end-of-life care. First, work system barriers delayed end-of-life care communication among clinicians as well as between clinicians and families. For example, over-reliance on palliative care people in handling end-of-life discussions prevented timely end-of-life care discussions with families. Second, clinician-level variability existed in end-of-life communication tasks. For example, end-of-life care discussions varied greatly in process and outcomes depending on the clinician leading the conversation. Third, clinician-family-patient priorities or treatment goals were misaligned. Conversely, regular discussion and joint decisions facilitated higher familial confidence in end-of-life care delivery process. These detailed discussions between care teams aligned priorities and led to fewer situations where patients/families received conflicting information. Fourth, clinician moral distress occurred from providing nonbeneficial care. Interviewees reported standardized end-of-life care discussion process incorporated by the people in the work system including patient, family, and clinicians were foundational to delivering end-of-life care that reduced both patient and family suffering, as well as clinician moral distress. Standardized work system communication tasks may improve end-of life discussion processes between clinicians and families. |
| 210 | Jacqueline Kruser | APCC-Pulm | jkruser@wisc.edu | Time-Limited Trials for Patients With Critical Illness: A Review of the Literature. | Since the 1990s, time-limited trials have been described as an approach to navigate uncertain benefits and limits of life-sustaining therapies in patients with critical illness. In this review, we aim to synthesize the evidence on time-limited trials in critical care, establish what is known, and highlight important knowledge gaps. We identified 18 empirical studies and 15 ethical analyses about time-limited trials in patients with critical illness. Observational studies suggest time-limited trials are part of current practice in ICUs in the United States, but their use varies according to unit and physician factors. Some ICU physicians are familiar with, endorse, and have participated in time-limited trials, and some older adults appear to favor time-limited trial strategies over indefinite life-sustaining therapy or care immediately focused on comfort. When time-limited trials are used, they are often implemented incompletely and challenged by systematic barriers (eg, continually rotating ICU staff). Predictive modeling studies support prevailing clinical wisdom that prognostic uncertainty decreases over time in the ICU for some patients. One study prospectively comparing usual ICU care with an intervention designed to support time-limited trials yielded promising preliminary results. Ethical analyses describe time-limited trials as a pragmatic approach within the longstanding discussion about withholding and withdrawing life-sustaining therapies. Time-limited trials are endorsed by physicians, align with the priorities of some older adults, and are part of current practice. Substantial efforts are needed to test their impact on patient-centered outcomes, improve their implementation, and maximize their potential benefit. |
| 211 | Jacqueline Kruser | APCC-Pulm | jkruser@wisc.edu | Urea cycle disorders in critically Ill adults. | Urea cycle disorders (UCDs) cause elevations in ammonia which, when severe, cause irreversible neurologic injury. Most patients with UCDs are diagnosed as neonates, though mild UCDs can present later - even into adulthood - during windows of high physiologic stress, like critical illness. It is crucial for clinicians to understand when to screen for UCDs and appreciate how to manage these disorders in order to prevent devastating neurologic injury or death. Hyperammonemia, particularly if severe, causes time- and concentration-dependent neurologic injury. Mild UCDs presenting in adulthood are increasingly recognized, so broader screening in adults is recommended. For patients with UCDs, a comprehensive, multitiered approach to management is needed to prevent progression and irreversible injury. Earlier exogenous clearance is increasingly recognized as an important complement to other therapies. UCDs alter the core pathway for ammonia metabolism. Screening for mild UCDs in adults with unexplained neurologic symptoms can direct care and prevent deterioration. Management of UCDs emphasizes decreasing ongoing ammonia production, avoiding catabolism, and supporting endogenous and exogenous ammonia clearance. Core neuroprotective and supportive critical care supplements this focused therapy. |
| 212 | Jacqueline Kruser | APCC-Pulm | jkruser@wisc.edu | Mapping the process of ICU care delivery to improve treatment decisions in acute respiratory failure. | Evidence suggests system-level norms and care processes influence individual patients' medical decisions, including end-of-life decisions for patients with critical illnesses like acute respiratory failure. Yet, little is known about how these processes unfold over the course of a patient's critical illness in the intensive care unit (ICU). Our objective was to map current-state ICU care delivery processes for patients with acute respiratory failure and to identify opportunities to improve the process. We conducted a process mapping study at two academic medical centers, using focus groups and semi-structured interviews. The 70 participants represented 17 distinct roles in ICU care, including interprofessional medical ICU and palliative care clinicians, surrogate decision makers, and patient survivors. Participants refined and endorsed a process map of current-state care delivery for all patients admitted to the ICU with acute respiratory failure requiring mechanical ventilation. The process contains four critical periods for active deliberation about the use of life-sustaining treatments. However, active deliberation steps are inconsistently performed and frequently disrupted, leading to prolongation of life-sustaining treatment by default, without consideration of patients' individual goals and priorities. Interventions to standardize active deliberation in the ICU may improve treatment decisions for ICU patients with acute respiratory failure. |
| 213 | Jacqueline Kruser | APCC-Pulm | jkruser@wisc.edu | The Duality of "Goals of Care" Language: A Qualitative Focus Group Study With Frontline Clinicians. | The phrase "goals of care" (GOC) is common in serious illness care, yet it lacks clarity and consistency. Understanding how GOC is used across healthcare contexts is an opportunity to identify and mitigate root causes of serious illness miscommunication. We sought to characterize frontline palliative and critical care clinicians' understanding and use of the phrase GOC in clinical practice. We conducted a secondary qualitative thematic analysis of focus group transcripts (n = 10), gathered as part of a parent study of care delivery for patients with respiratory failure. Participants (n = 59) were members of the palliative and critical care interprofessional teams at two academic medical centers. Clinicians primarily use GOC as a shorthand signal among team members to indicate a patient is nearing the end of life. This signal can also indicate conflict with patients and families when clinicians' expectations-typically an expected "transition" toward a different type of care-are not met. Clinicians distinguish their clinical use of GOC from an "ideal" meaning of the phrase, which is broader than end of life and focused on patients' values. Palliative care specialists encourage other clinicians to shift toward the "ideal" GOC concept in clinical practice. Frontline palliative and critical care clinicians understand a duality in GOC, as an idealized concept and as an expeditious signal for clinical care. Our findings suggest ambiguous phrases like GOC persist because of unmet needs for better ways to discuss and address diverse and complex priorities for patients with serious illness. |
| 214 | Majid Afshar | APCC-Pulm | mafshar@medicine.wisc.edu | Uncertainty estimation in diagnosis generation from large language models: next-word probability is not pre-test probability. | To evaluate large language models (LLMs) for pre-test diagnostic probability estimation and compare their uncertainty estimation performance with a traditional machine learning classifier. We assessed 2 instruction-tuned LLMs, Mistral-7B-Instruct and Llama3-70B-chat-hf, on predicting binary outcomes for Sepsis, Arrhythmia, and Congestive Heart Failure (CHF) using electronic health record (EHR) data from 660 patients. Three uncertainty estimation methods-Verbalized Confidence, Token Logits, and LLM Embedding+XGB-were compared against an eXtreme Gradient Boosting (XGB) classifier trained on raw EHR data. Performance metrics included AUROC and Pearson correlation between predicted probabilities. The XGB classifier outperformed the LLM-based methods across all tasks. LLM Embedding+XGB showed the closest performance to the XGB baseline, while Verbalized Confidence and Token Logits underperformed. These findings, consistent across multiple models and demographic groups, highlight the limitations of current LLMs in providing reliable pre-test probability estimations and underscore the need for improved calibration and bias mitigation strategies. Future work should explore hybrid approaches that integrate LLMs with numerical reasoning modules and calibrated embeddings to enhance diagnostic accuracy and ensure fairer predictions across diverse populations. LLMs demonstrate potential but currently fall short in estimating diagnostic probabilities compared to traditional machine learning classifiers trained on structured EHR data. Further improvements are needed for reliable clinical use. |
| 215 | Majid Afshar | APCC-Pulm | mafshar@medicine.wisc.edu | The TRIPOD-LLM reporting guideline for studies using large language models. | Large language models (LLMs) are rapidly being adopted in healthcare, necessitating standardized reporting guidelines. We present transparent reporting of a multivariable model for individual prognosis or diagnosis (TRIPOD)-LLM, an extension of the TRIPOD + artificial intelligence statement, addressing the unique challenges of LLMs in biomedical applications. TRIPOD-LLM provides a comprehensive checklist of 19 main items and 50 subitems, covering key aspects from title to discussion. The guidelines introduce a modular format accommodating various LLM research designs and tasks, with 14 main items and 32 subitems applicable across all categories. Developed through an expedited Delphi process and expert consensus, TRIPOD-LLM emphasizes transparency, human oversight and task-specific performance reporting. We also introduce an interactive website ( https://tripod-llm.vercel.app/ ) facilitating easy guideline completion and PDF generation for submission. As a living document, TRIPOD-LLM will evolve with the field, aiming to enhance the quality, reproducibility and clinical applicability of LLM research in healthcare through comprehensive reporting. |
| 216 | Majid Afshar | APCC-Pulm | mafshar@medicine.wisc.edu | Lessons learned on information retrieval in electronic health records: a comparison of embedding models and pooling strategies. | Applying large language models (LLMs) to the clinical domain is challenging due to the context-heavy nature of processing medical records. Retrieval-augmented generation (RAG) offers a solution by facilitating reasoning over large text sources. However, there are many parameters to optimize in just the retrieval system alone. This paper presents an ablation study exploring how different embedding models and pooling methods affect information retrieval for the clinical domain. Evaluating on 3 retrieval tasks on 2 electronic health record (EHR) data sources, we compared 7 models, including medical- and general-domain models, specialized encoder embedding models, and off-the-shelf decoder LLMs. We also examine the choice of embedding pooling strategy for each model, independently on the query and the text to retrieve. We found that the choice of embedding model significantly impacts retrieval performance, with BGE, a comparatively small general-domain model, consistently outperforming all others, including medical-specific models. However, our findings also revealed substantial variability across datasets and query text phrasings. We also determined the best pooling methods for each of these models to guide future design of retrieval systems. The choice of embedding model, pooling strategy, and query formulation can significantly impact retrieval performance and the performance of these models on other public benchmarks does not necessarily transfer to new domains. The high variability in performance across different query phrasings suggests that the choice of query may need to be tuned and validated for each task, or even for each institution's EHR. This study provides empirical evidence to guide the selection of models and pooling strategies for RAG frameworks in healthcare applications. Further studies such as this one are vital for guiding empirically-grounded development of retrieval frameworks, such as in the context of RAG, for the clinical domain. |
| 217 | Majid Afshar | APCC-Pulm | mafshar@medicine.wisc.edu | Development and Evaluation of Machine Learning Models for the Detection of Emergency Department Patients with Opioid Misuse from Clinical Notes. | The accurate identification of Emergency Department (ED) encounters involving opioid misuse is critical for health services, research, and surveillance. We sought to develop natural language processing (NLP)-based models for the detection of ED encounters involving opioid misuse. A sample of ED encounters enriched for opioid misuse was manually annotated and clinical notes extracted. We evaluated classic machine learning (ML) methods, fine-tuning of publicly available pretrained language models, and a previously developed convolutional neural network opioid classifier for use on hospitalized patients (SMART-AI). Performance was compared to ICD-10-CM codes. Both raw text and text transformed to the United Medical Language System were evaluated. Face validity was evaluated by term feature importance. There were 1123 encounters used for training, validation, and testing. Of the classic ML methods, XGBoost had the highest AU_PRC (0.936), accuracy (0.887), and F1 score (0.863) which outperformed ICD-10-CM codes [accuracy 0.870; F1 0.830]. Logistic regression, support vector machine, and XGBoost models had higher AU_PRC using transformed text, while decision trees performed better using raw text. Excluding XGBoost, fine-tuned pre-trained language models outperformed classic ML methods. The best performing model was the fine-tuned SMART-AI based model with domain adaptation [AU_PRC 0.948; accuracy 0.882; F1 0.851]. Explainability analyses showed the most predictive terms were 'heroin', 'opioids', 'alcoholic intoxication, chronic', 'cocaine', 'opiates', and 'suboxone'. NLP-based models outperform entry of ICD-10-CM diagnosis codes for the detection of ED encounters with opioid misuse. Fine tuning with domain adaptation for pre-trained language models resulted in improved performance. |
| 218 | Majid Afshar | APCC-Pulm | mafshar@medicine.wisc.edu | LCD benchmark: long clinical document benchmark on mortality prediction for language models. | The application of natural language processing (NLP) in the clinical domain is important due to the rich unstructured information in clinical documents, which often remains inaccessible in structured data. When applying NLP methods to a certain domain, the role of benchmark datasets is crucial as benchmark datasets not only guide the selection of best-performing models but also enable the assessment of the reliability of the generated outputs. Despite the recent availability of language models capable of longer context, benchmark datasets targeting long clinical document classification tasks are absent. To address this issue, we propose Long Clinical Document (LCD) benchmark, a benchmark for the task of predicting 30-day out-of-hospital mortality using discharge notes of Medical Information Mart for Intensive Care IV and statewide death data. We evaluated this benchmark dataset using baseline models, from bag-of-words and convolutional neural network to instruction-tuned large language models. Additionally, we provide a comprehensive analysis of the model outputs, including manual review and visualization of model weights, to offer insights into their predictive capabilities and limitations. Baseline models showed 28.9% for best-performing supervised models and 32.2% for GPT-4 in F1 metrics. Notes in our dataset have a median word count of 1687. Our analysis of the model outputs showed that our dataset is challenging for both models and human experts, but the models can find meaningful signals from the text. We expect our LCD benchmark to be a resource for the development of advanced supervised models, or prompting methods, tailored for clinical text. |
| 219 | Majid Afshar | APCC-Pulm | mafshar@medicine.wisc.edu | Using Phosphatidylethanol as an Adjunct to Self-Reported Alcohol Use Improves Identification of Liver Fibrosis Risk. | Accurate assessment of alcohol use informs prevention and management of liver disease. We examined whether phosphatidylethanol (PEth, an alcohol metabolite) blood concentrations are associated with liver fibrosis risk independently of self-reported alcohol use, among persons with and without HIV. We pooled individual-level data from 12 studies from the United States, Russia, Uganda, and South Africa with PEth, Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), and fibrosis-4 (FIB-4) measurements. We conducted mixed-effects logistic regression of the relationship between PEth and AUDIT-C as continuous variables (after checking linearity), with high FIB-4 (≥2.67). We divided PEth (range 0-1,000) by 83.3 to put it on the same scale as AUDIT-C (0-12) to directly compare odds ratios. Adjusted models included sex, race/ethnicity, age, body mass index, HIV, and virologic suppression status. Among 4,644 adults, the median age was 49 years (interquartile range [IQR]: 40-55), 998 (21%) were female, and 3,520 (76%) were living with HIV, among whom 2,386 (68%) were virologically suppressed. Median PEth was 13 ng/mL (IQR: <8-132.0) and median AUDIT-C was 3 (IQR: 1-6); 554 (12%) had high FIB-4. The adjusted odds ratios per 83.3 ng/mL difference in PEth and one-unit difference in AUDIT-C with high FIB-4 were 1.15 (95%CI: 1.08-1.22) and 1.03 (95%CI: 1.00-1.07), respectively. Findings were similar when PEth and AUDIT-C were treated as categorical variables. PEth was independently associated with high FIB-4, with a larger odds ratio than that of the association of AUDIT-C. The use of PEth may improve identification of alcohol use and liver fibrosis prevention and management. |
| 220 | Majid Afshar | APCC-Pulm | mafshar@medicine.wisc.edu | Outcomes and Cost-Effectiveness of an EHR-Embedded AI Screener for Identifying Hospitalized Adults at Risk for Opioid Use Disorder. | Hospitalized adults with opioid use disorder (OUD) are at high risk for adverse events and rehospitalizations. This pre-post quasi-experimental study evaluated whether an AI-driven OUD screener embedded in the electronic health record (EHR) was non-inferior to usual care in identifying patients for Addiction Medicine consults, aiming to provide a similarly effective but more scalable alternative to human-led ad hoc consultations. The AI screener analyzed EHR notes in real-time with a convolutional neural network to identify patients at risk and recommend consultation. The primary outcome was the proportion of patients receiving consults, comparing a 16-month pre-intervention period to an 8-month post-intervention period with the AI screener. Consults did not change between periods (1.35% vs 1.51%, p < 0.001 for non-inferiority). The AI screener was associated with a reduction in 30-day readmissions (OR: 0.53, 95% CI: 0.30-0.91, p = 0.02) with an incremental cost of $6,801 per readmission avoided, demonstrating its potential as a scalable, cost-effective solution for OUD care. NCT05745480. |
| 221 | Majid Afshar | APCC-Pulm | mafshar@medicine.wisc.edu | Correction: Prior emergency medical services utilization is a risk factor for in-hospital death among patients with substance misuse: a retrospective cohort study. | |
| 222 | Majid Afshar | APCC-Pulm | mafshar@medicine.wisc.edu | Development and Validation of a Machine Learning Model for Early Detection of Untreated Infection. | Early diagnostic uncertainty for infection causes delays in antibiotic administration in infected patients and unnecessary antibiotic administration in noninfected patients. To develop a machine learning model for the early detection of untreated infection (eDENTIFI), with the presence of infection determined by clinician chart review. Three thousand three hundred fifty-seven adult patients hospitalized between 2006 and 2018 at two health systems in Illinois, United States. We validated in 1632 patients in a third Illinois health system using area under the receiver operating characteristic curve (AUC). Using a longitudinal discrete-time format, we trained a gradient boosted machine model to predict untreated infection in the next 6 hours using routinely available patient demographics, vital signs, and laboratory results. eDENTIFI had an AUC of 0.80 (95% CI, 0.79-0.81) in the validation cohort and outperformed the systemic inflammatory response syndrome criteria with an AUC of 0.64 (95% CI, 0.64-0.65; p < 0.001). The most important features were body mass index, age, temperature, and heart rate. Using a threshold with a 47.6% sensitivity, eDENTIFI detected infection a median 2.0 hours (interquartile range, 0.9-5.2 hr) before antimicrobial administration, with a negative predictive value of 93.6%. Antibiotic administration guided by eDENTIFI could have decreased unnecessary IV antibiotic administration in noninfected patients by 10.8% absolute or 46.4% relative percentage points compared with clinicians. eDENTIFI could both decrease the time to antimicrobial administration in infected patients and unnecessary antibiotic administration in noninfected patients. Further prospective validation is needed. |
| 223 | Majid Afshar | APCC-Pulm | mafshar@medicine.wisc.edu | Rapid and Robust Identification of Sepsis Using SeptiCyte RAPID in a Heterogeneous Patient Population. | Background/Objective: SeptiCyte RAPID is a transcriptional host response assay that discriminates between sepsis and non-infectious systemic inflammation (SIRS) with a one-hour turnaround time. The overall performance of this test in a cohort of 419 patients has recently been described [Balk et al., J Clin Med 2024, 13, 1194]. In this study, we present the results from a detailed stratification analysis in which SeptiCyte RAPID performance was evaluated in the same cohort across patient groups and subgroups encompassing different demographics, comorbidities and disease, sources and types of pathogens, interventional treatments, and clinically defined phenotypes. The aims were to identify variables that might affect the ability of SeptiCyte RAPID to discriminate between sepsis and SIRS and to determine if any patient subgroups appeared to present a diagnostic challenge for the test. Methods: (1) Subgroup analysis, with subgroups defined by individual demographic or clinical variables, using conventional statistical comparison tests. (2) Principal component analysis and k-means clustering analysis to investigate phenotypic subgroups defined by unique combinations of demographic and clinical variables. Results: No significant differences in SeptiCyte RAPID performance were observed between most groups and subgroups. One notable exception involved an enhanced SeptiCyte RAPID performance for a phenotypic subgroup defined by a combination of clinical variables suggesting a septic shock response. Conclusions: We conclude that for this patient cohort, SeptiCyte RAPID performance was largely unaffected by key variables associated with heterogeneity in patients suspected of sepsis. |
| 224 | Matthew Churpek | APCC-Pulm | mchurpek@medicine.wisc.edu | Uncertainty estimation in diagnosis generation from large language models: next-word probability is not pre-test probability. | To evaluate large language models (LLMs) for pre-test diagnostic probability estimation and compare their uncertainty estimation performance with a traditional machine learning classifier. We assessed 2 instruction-tuned LLMs, Mistral-7B-Instruct and Llama3-70B-chat-hf, on predicting binary outcomes for Sepsis, Arrhythmia, and Congestive Heart Failure (CHF) using electronic health record (EHR) data from 660 patients. Three uncertainty estimation methods-Verbalized Confidence, Token Logits, and LLM Embedding+XGB-were compared against an eXtreme Gradient Boosting (XGB) classifier trained on raw EHR data. Performance metrics included AUROC and Pearson correlation between predicted probabilities. The XGB classifier outperformed the LLM-based methods across all tasks. LLM Embedding+XGB showed the closest performance to the XGB baseline, while Verbalized Confidence and Token Logits underperformed. These findings, consistent across multiple models and demographic groups, highlight the limitations of current LLMs in providing reliable pre-test probability estimations and underscore the need for improved calibration and bias mitigation strategies. Future work should explore hybrid approaches that integrate LLMs with numerical reasoning modules and calibrated embeddings to enhance diagnostic accuracy and ensure fairer predictions across diverse populations. LLMs demonstrate potential but currently fall short in estimating diagnostic probabilities compared to traditional machine learning classifiers trained on structured EHR data. Further improvements are needed for reliable clinical use. |
| 225 | Matthew Churpek | APCC-Pulm | mchurpek@medicine.wisc.edu | Can Machine Learning Raise Early Goal-Directed Therapy From the Grave? | |
| 226 | Matthew Churpek | APCC-Pulm | mchurpek@medicine.wisc.edu | Using Machine Learning to Predict Weight Gain in Adults: an Observational Analysis From the All of Us Research Program. | Obesity, defined as a body mass index ≥30 kg/m2, is a major public health concern in the United States. Preventative approaches are essential, but they are limited by an inability to accurately predict individuals at highest risk of weight gain. Our objective was to develop accurate weight gain prediction models using the National Institutes of Health All of Us dataset. We hypothesized that machine learning models using both electronic health record and behavioral survey data would outperform models using electronic health record data alone. The All of Us dataset was used to identify adults between 18 and 70 ys old with weight measurements 2 y apart between 2008 and 2022. Patients with a history of cancer, bariatric surgery, or pregnancy were excluded. Demographics, vital signs, laboratory results, comorbidities, and survey data (Alcohol Use Disorder Identification Test, Patient-Reported Outcomes Measurement Information System physical and mental health scores) were included as model parameters. Elastic net and XGBoost machine learning models were developed with and without survey data to predict ≥10% total body weight gain within 2 y. The data were split into a training sample (60%) and a testing sample (40%), and parameters were tuned using 10-fold cross-validation. Performance was compared using area under the receiver operating characteristic curves (AUCs). Our cohort consisted of 34,715 patients (mean [SD] age 50.9 [13.4] y; 45.7% White; 55.3% female). Over a 2-y span, 10.4% of the cohort gained ≥10% total body weight. AUCs were 0.677 [95% DeLong confidence interval 0.665-0.688] for elastic net and 0.706 [0.695-0.717] for XGBoost. Incorporation of survey data did not improve predictability, with AUCs of 0.681 [0.669-0.692] and 0.705 [0.694-0.716], respectively. Our machine learning weight gain prediction models had modest performance that was not improved by survey data. The addition of other All of Us variables, including genomic data, may be informative in future studies. |
| 227 | Matthew Churpek | APCC-Pulm | mchurpek@medicine.wisc.edu | Lessons learned on information retrieval in electronic health records: a comparison of embedding models and pooling strategies. | Applying large language models (LLMs) to the clinical domain is challenging due to the context-heavy nature of processing medical records. Retrieval-augmented generation (RAG) offers a solution by facilitating reasoning over large text sources. However, there are many parameters to optimize in just the retrieval system alone. This paper presents an ablation study exploring how different embedding models and pooling methods affect information retrieval for the clinical domain. Evaluating on 3 retrieval tasks on 2 electronic health record (EHR) data sources, we compared 7 models, including medical- and general-domain models, specialized encoder embedding models, and off-the-shelf decoder LLMs. We also examine the choice of embedding pooling strategy for each model, independently on the query and the text to retrieve. We found that the choice of embedding model significantly impacts retrieval performance, with BGE, a comparatively small general-domain model, consistently outperforming all others, including medical-specific models. However, our findings also revealed substantial variability across datasets and query text phrasings. We also determined the best pooling methods for each of these models to guide future design of retrieval systems. The choice of embedding model, pooling strategy, and query formulation can significantly impact retrieval performance and the performance of these models on other public benchmarks does not necessarily transfer to new domains. The high variability in performance across different query phrasings suggests that the choice of query may need to be tuned and validated for each task, or even for each institution's EHR. This study provides empirical evidence to guide the selection of models and pooling strategies for RAG frameworks in healthcare applications. Further studies such as this one are vital for guiding empirically-grounded development of retrieval frameworks, such as in the context of RAG, for the clinical domain. |
| 228 | Matthew Churpek | APCC-Pulm | mchurpek@medicine.wisc.edu | Distinct immune profiles and clinical outcomes in sepsis subphenotypes based on temperature trajectories. | Sepsis is a heterogeneous syndrome. Identification of sepsis subphenotypes with distinct immune profiles could lead to targeted therapies. This study investigates the immune profiles of patients with sepsis following distinct body temperature patterns (i.e., temperature trajectory subphenotypes). Hospitalized patients from four hospitals between 2018 and 2022 with suspicion of infection were included. A previously validated temperature trajectory algorithm was used to classify study patients into temperature trajectory subphenotypes. Microbiological profiles, clinical outcomes, and levels of 31 biomarkers were compared between these subphenotypes. The 3576 study patients were classified into four temperature trajectory subphenotypes: hyperthermic slow resolvers (N = 563, 16%), hyperthermic fast resolvers (N = 805, 23%), normothermic (N = 1693, 47%), hypothermic (N = 515, 14%). The mortality rate was significantly different between subphenotypes, with the highest rate in hypothermics (14.2%), followed by hyperthermic slow resolvers 6%, normothermic 5.5%, and lowest in hyperthermic fast resolvers 3.6% (p < 0.001). After multiple testing correction for the 31 biomarkers tested, 20 biomarkers remained significantly different between temperature trajectories: angiopoietin-1 (Ang-1), C-reactive protein (CRP), feline McDonough sarcoma-like tyrosine kinase 3 ligand (Flt-3l), granulocyte colony stimulating factor (G-CSF), granulocyte-macrophage colony stimulating factor (GM-CSF), interleukin (IL)-15, IL-1 receptor antagonist (RA), IL-2, IL-6, IL-7, interferon gamma-induced protein 10 (IP-10), monocyte chemoattractant protein-1 (MCP-1), human macrophage inflammatory protein 3 alpha (MIP-3a), neutrophil gelatinase-associated lipocalin (NGAL), pentraxin-3, thrombomodulin, tissue factor, soluble triggering receptor expressed on myeloid cells-1 (sTREM-1), and vascular cellular adhesion molecule-1 (vCAM-1).The hyperthermic fast and slow resolvers had the highest levels of most pro- and anti-inflammatory cytokines. Hypothermics had suppressed levels of most cytokines but the highest levels of several coagulation markers (Ang-1, thrombomodulin, tissue factor). Sepsis subphenotypes identified using the universally available measurement of body temperature had distinct immune profiles. Hypothermic patients, who had the highest mortality rate, also had the lowest levels of most pro- and anti-inflammatory cytokines. |
| 229 | Matthew Churpek | APCC-Pulm | mchurpek@medicine.wisc.edu | Outcomes and Cost-Effectiveness of an EHR-Embedded AI Screener for Identifying Hospitalized Adults at Risk for Opioid Use Disorder. | Hospitalized adults with opioid use disorder (OUD) are at high risk for adverse events and rehospitalizations. This pre-post quasi-experimental study evaluated whether an AI-driven OUD screener embedded in the electronic health record (EHR) was non-inferior to usual care in identifying patients for Addiction Medicine consults, aiming to provide a similarly effective but more scalable alternative to human-led ad hoc consultations. The AI screener analyzed EHR notes in real-time with a convolutional neural network to identify patients at risk and recommend consultation. The primary outcome was the proportion of patients receiving consults, comparing a 16-month pre-intervention period to an 8-month post-intervention period with the AI screener. Consults did not change between periods (1.35% vs 1.51%, p < 0.001 for non-inferiority). The AI screener was associated with a reduction in 30-day readmissions (OR: 0.53, 95% CI: 0.30-0.91, p = 0.02) with an incremental cost of $6,801 per readmission avoided, demonstrating its potential as a scalable, cost-effective solution for OUD care. NCT05745480. |
| 230 | Matthew Churpek | APCC-Pulm | mchurpek@medicine.wisc.edu | Correction: Prior emergency medical services utilization is a risk factor for in-hospital death among patients with substance misuse: a retrospective cohort study. | |
| 231 | Matthew Churpek | APCC-Pulm | mchurpek@medicine.wisc.edu | Development and Validation of a Machine Learning Model for Early Detection of Untreated Infection. | Early diagnostic uncertainty for infection causes delays in antibiotic administration in infected patients and unnecessary antibiotic administration in noninfected patients. To develop a machine learning model for the early detection of untreated infection (eDENTIFI), with the presence of infection determined by clinician chart review. Three thousand three hundred fifty-seven adult patients hospitalized between 2006 and 2018 at two health systems in Illinois, United States. We validated in 1632 patients in a third Illinois health system using area under the receiver operating characteristic curve (AUC). Using a longitudinal discrete-time format, we trained a gradient boosted machine model to predict untreated infection in the next 6 hours using routinely available patient demographics, vital signs, and laboratory results. eDENTIFI had an AUC of 0.80 (95% CI, 0.79-0.81) in the validation cohort and outperformed the systemic inflammatory response syndrome criteria with an AUC of 0.64 (95% CI, 0.64-0.65; p < 0.001). The most important features were body mass index, age, temperature, and heart rate. Using a threshold with a 47.6% sensitivity, eDENTIFI detected infection a median 2.0 hours (interquartile range, 0.9-5.2 hr) before antimicrobial administration, with a negative predictive value of 93.6%. Antibiotic administration guided by eDENTIFI could have decreased unnecessary IV antibiotic administration in noninfected patients by 10.8% absolute or 46.4% relative percentage points compared with clinicians. eDENTIFI could both decrease the time to antimicrobial administration in infected patients and unnecessary antibiotic administration in noninfected patients. Further prospective validation is needed. |
| 232 | Matthew Churpek | APCC-Pulm | mchurpek@medicine.wisc.edu | Early Warning Scores With and Without Artificial Intelligence. | Early warning decision support tools to identify clinical deterioration in the hospital are widely used, but there is little information on their comparative performance. To compare 3 proprietary artificial intelligence (AI) early warning scores and 3 publicly available simple aggregated weighted scores. This retrospective cohort study was performed at 7 hospitals in the Yale New Haven Health System. All consecutive adult medical-surgical ward hospital encounters between March 9, 2019, and November 9, 2023, were included. Simultaneous Epic Deterioration Index (EDI), Rothman Index (RI), eCARTv5 (eCART), Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), and NEWS2 scores. Clinical deterioration, defined as a transfer from ward to intensive care unit or death within 24 hours of an observation. Of the 362 926 patient encounters (median patient age, 64 [IQR, 47-77] years; 200 642 [55.3%] female), 16 693 (4.6%) experienced a clinical deterioration event. eCART had the highest area under the receiver operating characteristic curve at 0.895 (95% CI, 0.891-0.900), followed by NEWS2 at 0.831 (95% CI, 0.826-0.836), NEWS at 0.829 (95% CI, 0.824-0.835), RI at 0.828 (95% CI, 0.823-0.834), EDI at 0.808 (95% CI, 0.802-0.812), and MEWS at 0.757 (95% CI, 0.750-0.764). After matching scores at the moderate-risk sensitivity level for a NEWS score of 5, overall positive predictive values (PPVs) ranged from a low of 6.3% (95% CI, 6.1%-6.4%) for an EDI score of 41 to a high of 17.3% (95% CI, 16.9%-17.8%) for an eCART score of 94. Matching scores at the high-risk specificity of a NEWS score of 7 yielded overall PPVs ranging from a low of 14.5% (95% CI, 14.0%-15.2%) for an EDI score of 54 to a high of 23.3% (95% CI, 22.7%-24.2%) for an eCART score of 97. The moderate-risk thresholds provided a median of at least 20 hours of lead time for all the scores. Median lead time at the high-risk threshold was 11 (IQR, 0-69) hours for eCART, 8 (IQR, 0-63) hours for NEWS, 6 (IQR, 0-62) hours for NEWS2, 5 (IQR, 0-56) hours for MEWS, 1 (IQR, 0-39) hour for EDI, and 0 (IQR, 0-42) hours for RI. In this cohort study of inpatient encounters, eCART outperformed the other AI and non-AI scores, identifying more deteriorating patients with fewer false alarms and sufficient time to intervene. NEWS, a non-AI, publicly available early warning score, significantly outperformed EDI. Given the wide variation in accuracy, additional transparency and oversight of early warning tools may be warranted. |
| 233 | Matthew Churpek | APCC-Pulm | mchurpek@medicine.wisc.edu | Causes, Diagnostic Testing, and Treatments Related to Clinical Deterioration Events Among High-Risk Ward Patients. | Timely intervention for clinically deteriorating ward patients requires that care teams accurately diagnose and treat their underlying medical conditions. However, the most common diagnoses leading to deterioration and the relevant therapies provided are poorly characterized. We aimed to determine the diagnoses responsible for clinical deterioration, the relevant diagnostic tests ordered, and the treatments administered among high-risk ward patients using manual chart review. This was a multicenter retrospective observational study in inpatient medical-surgical wards at four health systems from 2006 to 2020. Randomly selected patients (1000 from each health system) with clinical deterioration, defined by reaching the 95th percentile of a validated early warning score, electronic Cardiac Arrest Risk Triage, were included. Clinical deterioration was confirmed by a trained reviewer or marked as a false alarm if no deterioration occurred for each patient. For true deterioration events, the condition causing deterioration, relevant diagnostic tests ordered, and treatments provided were collected. Of the 4000 included patients, 2484 (62%) had clinical deterioration confirmed by chart review. Sepsis was the most common cause of deterioration (41%; n = 1021), followed by arrhythmia (19%; n = 473), while liver failure had the highest in-hospital mortality (41%). The most common diagnostic tests ordered were complete blood counts (47% of events), followed by chest radiographs (42%) and cultures (40%), while the most common medication orders were antimicrobials (46%), followed by fluid boluses (34%) and antiarrhythmics (19%). We found that sepsis was the most common cause of deterioration, while liver failure had the highest mortality. Complete blood counts and chest radiographs were the most common diagnostic tests ordered, and antimicrobials and fluid boluses were the most common medication interventions. These results provide important insights for clinical decision-making at the bedside, training of rapid response teams, and the development of institutional treatment pathways for clinical deterioration. |
| 234 | Anoop Mayampurath | BMI | mayampurath@wisc.edu | Uncertainty estimation in diagnosis generation from large language models: next-word probability is not pre-test probability. | To evaluate large language models (LLMs) for pre-test diagnostic probability estimation and compare their uncertainty estimation performance with a traditional machine learning classifier. We assessed 2 instruction-tuned LLMs, Mistral-7B-Instruct and Llama3-70B-chat-hf, on predicting binary outcomes for Sepsis, Arrhythmia, and Congestive Heart Failure (CHF) using electronic health record (EHR) data from 660 patients. Three uncertainty estimation methods-Verbalized Confidence, Token Logits, and LLM Embedding+XGB-were compared against an eXtreme Gradient Boosting (XGB) classifier trained on raw EHR data. Performance metrics included AUROC and Pearson correlation between predicted probabilities. The XGB classifier outperformed the LLM-based methods across all tasks. LLM Embedding+XGB showed the closest performance to the XGB baseline, while Verbalized Confidence and Token Logits underperformed. These findings, consistent across multiple models and demographic groups, highlight the limitations of current LLMs in providing reliable pre-test probability estimations and underscore the need for improved calibration and bias mitigation strategies. Future work should explore hybrid approaches that integrate LLMs with numerical reasoning modules and calibrated embeddings to enhance diagnostic accuracy and ensure fairer predictions across diverse populations. LLMs demonstrate potential but currently fall short in estimating diagnostic probabilities compared to traditional machine learning classifiers trained on structured EHR data. Further improvements are needed for reliable clinical use. |
| 235 | Anoop Mayampurath | BMI | mayampurath@wisc.edu | Lessons learned on information retrieval in electronic health records: a comparison of embedding models and pooling strategies. | Applying large language models (LLMs) to the clinical domain is challenging due to the context-heavy nature of processing medical records. Retrieval-augmented generation (RAG) offers a solution by facilitating reasoning over large text sources. However, there are many parameters to optimize in just the retrieval system alone. This paper presents an ablation study exploring how different embedding models and pooling methods affect information retrieval for the clinical domain. Evaluating on 3 retrieval tasks on 2 electronic health record (EHR) data sources, we compared 7 models, including medical- and general-domain models, specialized encoder embedding models, and off-the-shelf decoder LLMs. We also examine the choice of embedding pooling strategy for each model, independently on the query and the text to retrieve. We found that the choice of embedding model significantly impacts retrieval performance, with BGE, a comparatively small general-domain model, consistently outperforming all others, including medical-specific models. However, our findings also revealed substantial variability across datasets and query text phrasings. We also determined the best pooling methods for each of these models to guide future design of retrieval systems. The choice of embedding model, pooling strategy, and query formulation can significantly impact retrieval performance and the performance of these models on other public benchmarks does not necessarily transfer to new domains. The high variability in performance across different query phrasings suggests that the choice of query may need to be tuned and validated for each task, or even for each institution's EHR. This study provides empirical evidence to guide the selection of models and pooling strategies for RAG frameworks in healthcare applications. Further studies such as this one are vital for guiding empirically-grounded development of retrieval frameworks, such as in the context of RAG, for the clinical domain. |
| 236 | Anoop Mayampurath | BMI | mayampurath@wisc.edu | Correction: Prior emergency medical services utilization is a risk factor for in-hospital death among patients with substance misuse: a retrospective cohort study. | |
| 237 | Anoop Mayampurath | BMI | mayampurath@wisc.edu | MRI and Clinical Variables for Prediction of Outcomes After Pediatric Severe Traumatic Brain Injury. | Traumatic brain injury (TBI) is a leading cause of death and disability in children, and predicting functional outcome after TBI is challenging. Magnetic resonance imaging (MRI) is frequently conducted after severe TBI; however, the predictive value of MRI remains uncertain. To identify early MRI measures that predict long-term outcome after severe TBI in children and to assess the added predictive value of MRI measures over well-validated clinical predictors. This preplanned prognostic study used data from the Approaches and Decisions in Acute Pediatric TBI (ADAPT) prospective observational comparative effectiveness study. The ADAPT study enrolled 1000 consecutive children (aged 3 at 6 months after injury). In this prognostic study of children with severe TBI, the addition of MRI measures significantly improved outcome prediction over well-established and validated clinical predictors. Magnetic resonance imaging should be considered in children with severe TBI to inform prognosis and may also promote stratification of patients in future clinical trials. |
| 238 | Anoop Mayampurath | BMI | mayampurath@wisc.edu | Prior emergency medical services utilization is a risk factor for in-hospital death among patients with substance misuse: a retrospective cohort study. | Substance misuse poses a significant public health challenge, characterized by premature morbidity and mortality, and heightened healthcare utilization. While studies have demonstrated that previous hospitalizations and emergency department visits are associated with increased mortality in patients with substance misuse, it is unknown whether prior utilization of emergency medical service (EMS) is similarly associated with poor outcomes among this population. The objective of this study is to determine the association between EMS utilization in the 30 days before a hospitalization or emergency department visit and in-hospital outcomes among patients with substance misuse. We conducted a retrospective analysis of adult emergency department visits and hospitalizations (referred to as a hospital encounter) between 2017 and 2021 within the Substance Misuse Data Commons, which maintains electronic health records from substance misuse patients seen at two University of Wisconsin hospitals, linked with state agency, claims, and socioeconomic datasets. Using regression models, we examined the association between EMS use and the outcomes of in-hospital death, hospital length of stay, intensive care unit (ICU) admission, and critical illness events, defined by invasive mechanical ventilation or vasoactive drug administration. Models were adjusted for age, comorbidities, initial severity of illness, substance misuse type, and socioeconomic status. Among 19,402 encounters, individuals with substance misuse who had at least one EMS incident within 30 days of a hospital encounter experienced a higher likelihood of in-hospital mortality (OR 1.52, 95% CI [1.05 - 2.14]) compared to those without prior EMS use, after adjusting for confounders. Using EMS in the 30 days prior to an encounter was associated with a small increase in hospital length of stay but was not associated with ICU admission or critical illness events. Individuals with substance misuse who have used EMS in the month preceding a hospital encounter are at an increased risk of in-hospital mortality. Enhanced monitoring of EMS users in this population could improve overall patient outcomes. |
| 239 | Anoop Mayampurath | BMI | mayampurath@wisc.edu | Development and external validation of deep learning clinical prediction models using variable-length time series data. | To compare and externally validate popular deep learning model architectures and data transformation methods for variable-length time series data in 3 clinical tasks (clinical deterioration, severe acute kidney injury [AKI], and suspected infection). This multicenter retrospective study included admissions at 2 medical centers that spanned 2007-2022. Distinct datasets were created for each clinical task, with 1 site used for training and the other for testing. Three feature engineering methods (normalization, standardization, and piece-wise linear encoding with decision trees [PLE-DTs]) and 3 architectures (long short-term memory/gated recurrent unit [LSTM/GRU], temporal convolutional network, and time-distributed wrapper with convolutional neural network [TDW-CNN]) were compared in each clinical task. Model discrimination was evaluated using the area under the precision-recall curve (AUPRC) and the area under the receiver operating characteristic curve (AUROC). The study comprised 373 825 admissions for training and 256 128 admissions for testing. LSTM/GRU models tied with TDW-CNN models with both obtaining the highest mean AUPRC in 2 tasks, and LSTM/GRU had the highest mean AUROC across all tasks (deterioration: 0.81, AKI: 0.92, infection: 0.87). PLE-DT with LSTM/GRU achieved the highest AUPRC in all tasks. When externally validated in 3 clinical tasks, the LSTM/GRU model architecture with PLE-DT transformed data demonstrated the highest AUPRC in all tasks. Multiple models achieved similar performance when evaluated using AUROC. The LSTM architecture performs as well or better than some newer architectures, and PLE-DT may enhance the AUPRC in variable-length time series data for predicting clinical outcomes during external validation. |
| 240 | Anoop Mayampurath | BMI | mayampurath@wisc.edu | Automated stratification of trauma injury severity across multiple body regions using multi-modal, multi-class machine learning models. | The timely stratification of trauma injury severity can enhance the quality of trauma care but it requires intense manual annotation from certified trauma coders. The objective of this study is to develop machine learning models for the stratification of trauma injury severity across various body regions using clinical text and structured electronic health records (EHRs) data. Our study utilized clinical documents and structured EHR variables linked with the trauma registry data to create 2 machine learning models with different approaches to representing text. The first one fuses concept unique identifiers (CUIs) extracted from free text with structured EHR variables, while the second one integrates free text with structured EHR variables. Temporal validation was undertaken to ensure the models' temporal generalizability. Additionally, analyses to assess the variable importance were conducted. Both models demonstrated impressive performance in categorizing leg injuries, achieving high accuracy with macro-F1 scores of over 0.8. Additionally, they showed considerable accuracy, with macro-F1 scores exceeding or near 0.7, in assessing injuries in the areas of the chest and head. We showed in our variable importance analysis that the most important features in the model have strong face validity in determining clinically relevant trauma injuries. The CUI-based model achieves comparable performance, if not higher, compared to the free-text-based model, with reduced complexity. Furthermore, integrating structured EHR data improves performance, particularly when the text modalities are insufficiently indicative. Our multi-modal, multiclass models can provide accurate stratification of trauma injury severity and clinically relevant interpretations. |
| 241 | Anoop Mayampurath | BMI | mayampurath@wisc.edu | Development of a Human Evaluation Framework and Correlation with Automated Metrics for Natural Language Generation of Medical Diagnoses. | In the evolving landscape of clinical Natural Language Generation (NLG), assessing abstractive text quality remains challenging, as existing methods often overlook generative task complexities. This work aimed to examine the current state of automated evaluation metrics in NLG in healthcare. To have a robust and well-validated baseline with which to examine the alignment of these metrics, we created a comprehensive human evaluation framework. Employing ChatGPT-3.5-turbo generative output, we correlated human judgments with each metric. None of the metrics demonstrated high alignment; however, the SapBERT score-a Unified Medical Language System (UMLS)- showed the best results. This underscores the importance of incorporating domain-specific knowledge into evaluation efforts. Our work reveals the deficiency in quality evaluations for generated text and introduces our comprehensive human evaluation framework as a baseline. Future efforts should prioritize integrating medical knowledge databases to enhance the alignment of automated metrics, particularly focusing on refining the SapBERT score for improved assessments. |
| 242 | Anoop Mayampurath | BMI | mayampurath@wisc.edu | The Pediatric Data Science and Analytics Subgroup of the Pediatric Acute Lung Injury and Sepsis Investigators Network: Use of Supervised Machine Learning Applications in Pediatric Critical Care Medicine Research. | Perform a scoping review of supervised machine learning in pediatric critical care to identify published applications, methodologies, and implementation frequency to inform best practices for the development, validation, and reporting of predictive models in pediatric critical care. Scoping review and expert opinion. We queried CINAHL Plus with Full Text (EBSCO), Cochrane Library (Wiley), Embase (Elsevier), Ovid Medline, and PubMed for articles published between 2000 and 2022 related to machine learning concepts and pediatric critical illness. Articles were excluded if the majority of patients were adults or neonates, if unsupervised machine learning was the primary methodology, or if information related to the development, validation, and/or implementation of the model was not reported. Article selection and data extraction were performed using dual review in the Covidence tool, with discrepancies resolved by consensus. Articles reporting on the development, validation, or implementation of supervised machine learning models in the field of pediatric critical care medicine. None. Of 5075 identified studies, 141 articles were included. Studies were primarily (57%) performed at a single site. The majority took place in the United States (70%). Most were retrospective observational cohort studies. More than three-quarters of the articles were published between 2018 and 2022. The most common algorithms included logistic regression and random forest. Predicted events were most commonly death, transfer to ICU, and sepsis. Only 14% of articles reported external validation, and only a single model was implemented at publication. Reporting of validation methods, performance assessments, and implementation varied widely. Follow-up with authors suggests that implementation remains uncommon after model publication. Publication of supervised machine learning models to address clinical challenges in pediatric critical care medicine has increased dramatically in the last 5 years. While these approaches have the potential to benefit children with critical illness, the literature demonstrates incomplete reporting, absence of external validation, and infrequent clinical implementation. |
| 243 | Anoop Mayampurath | BMI | mayampurath@wisc.edu | Alcohol Withdrawal Severity Measures for Identifying Patients Requiring High-Intensity Care. | Alcohol withdrawal syndrome (AWS) may progress to require high-intensity care. Approaches to identify hospitalized patients with AWS who received higher level of care have not been previously examined. This study aimed to examine the utility of Clinical Institute Withdrawal Assessment Alcohol Revised (CIWA-Ar) for alcohol scale scores and medication doses for alcohol withdrawal management in identifying patients who received high-intensity care. A multicenter observational cohort study of hospitalized adults with alcohol withdrawal. University of Chicago Medical Center and University of Wisconsin Hospital. Inpatient encounters between November 2008 and February 2022 with a CIWA-Ar score greater than 0 and benzodiazepine or barbiturate administered within the first 24 hours. The primary composite outcome was patients who progressed to high-intensity care (intermediate care or ICU). None. Among the 8742 patients included in the study, 37.5% (n = 3280) progressed to high-intensity care. The odds ratio for the composite outcome increased above 1.0 when the CIWA-Ar score was 24. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) at this threshold were 0.12 (95% CI, 0.11-0.13), 0.95 (95% CI, 0.94-0.95), 0.58 (95% CI, 0.54-0.61), and 0.64 (95% CI, 0.63-0.65), respectively. The OR increased above 1.0 at a 24-hour lorazepam milligram equivalent dose cutoff of 15 mg. The sensitivity, specificity, PPV, and NPV at this threshold were 0.16 (95% CI, 0.14-0.17), 0.96 (95% CI, 0.95-0.96), 0.68 (95% CI, 0.65-0.72), and 0.65 (95% CI, 0.64-0.66), respectively. Neither CIWA-Ar scores nor medication dose cutoff points were effective measures for identifying patients with alcohol withdrawal who received high-intensity care. Research studies for examining outcomes in patients who deteriorate with AWS will require better methods for cohort identification. |
| 244 | Peter Kleinschmidt | GIM | pkleinschmidt@uwhealth.org | CancelRx case study: implications for clinic and community pharmacy work systems. | Medication prescribing and discontinuation processes are complex and involve the patient, numerous health care professionals, organizations, health information technology (IT). CancelRx is a health IT that automatically communicates medication discontinuations from the clinic electronic health record to the community pharmacy dispensing platform, theoretically improving communication. CancelRx was implemented across a Midwest academic health system in October 2017. The health system also operates 15 outpatient community pharmacies. The goal of this qualitative study was to describe how both the clinic and community pharmacy work systems change and interact over time regarding medication discontinuations, before and after CancelRx implantation. Medical Assistants (n = 9), Community Pharmacists (n = 12), and Pharmacy Administrators (n = 3), employed by the health system were interviewed across 3-time periods between 2017 and 2018- 3-months prior to CancelRx implementation, 3-months after CancelRx implementation, and 9-months after CancelRx implementation. Interviews were audio recorded, transcribed, and conducted a hybrid analysis with deductive content analysis following the Systems Engineering Initiative for Patient Safety (SEIPS) framework and inductive analysis to capture additional codes and themes. CancelRx changed the medication discontinuation process at both clinics and community pharmacies. In the clinics, the workflows and medication discontinuation tasks changed over time while MA roles and clinic staff communication practices remained variable. In the pharmacy, CancelRx automated and streamlined how medication discontinuation messages were received and processed, but also increased workload for the pharmacists and introduced new errors. This study utilizes a systems approach to assess disparate systems within a patient network. Future studies may consider health IT implications for systems that are not in the same health system as well as assessing the role of implementation decisions on health IT use and dissemination. |
| 245 | Peter Kleinschmidt | GIM | pkleinschmidt@uwhealth.org | CancelRx Case Study: Implications for Clinic and Community Pharmacy Work Systems. | The medication prescribing, and de-prescribing process is complex with numerous actors, organizations, and health information technology (IT). CancelRx is a health IT that automatically communicates medication discontinuations from the clinic electronic health record to the community pharmacy's dispensing platform, theoretically improving communication. CancelRx was implemented across a Midwest academic health system in October 2017. The goal of this study was to describe how both the clinic and community pharmacy work systems change and interact over time regarding medication discontinuations. Medical Assistants (n = 9), Community Pharmacists (n = 12), and Pharmacy Administrators (n =3), employed by the health system were interviewed across 3-time periods- 3-months prior to CancelRx implementation, 3-months after CancelRx implementation, and 9-months after CancelRx implementation. Interviews were audio recorded, transcribed, and analyzed via deductive content analysis. CancelRx changed the medication discontinuation process at both clinics and community pharmacies. In the clinics, the workflows and medication discontinuation tasks changed over time while MA roles and clinic staff communication practices remained variable. In the pharmacy, CancelRx automated and streamlined how medication discontinuation messages were received and processed, but also increased workload for the pharmacists and introduced new errors. This study utilizes a systems approach to assess disparate systems within a patient network. Future studies may consider health IT implications for systems that are not in the same health system as well as assessing the role of implementation decisions on health IT use and dissemination. |
| 246 | Peter Kleinschmidt | GIM | pkleinschmidt@uwhealth.org | Impact of CancelRx on discontinuation of controlled substance prescriptions: an interrupted time series analysis. | Prescription opioid misuse is a serious national crisis; in 2018 the top drugs involved in prescription overdose deaths included pain medications (opioids), benzodiazepines, and stimulants. Health information technology (health IT) provides a means to address this crisis through technologies that streamline the prescribing and discontinuation process. CancelRx is a health IT function that communicates when medications, such as controlled substances, are discontinued at the clinic and therefore should not be filled at the pharmacy. Prior to CancelRx, the communication of discontinued medications was a manual process, requiring the patient or a clinic staff member to personally contact the pharmacy to inform them of the change. The objective of this study was to assess how controlled substance medication discontinuations were communicated over time, before and after the implementation of CancelRx. Secondary data from a midwestern academic health system electronic health record and pharmacy platform were collected 12-months prior to CancelRx implementation and for 12-months post implementation. The study utilized an interrupted time series analysis (ITSA) to capture the percentage of controlled substance medications that were discontinued in the clinic's electronic health record and discontinued in the pharmacy's dispensing software. The ITSA plotted the percentage of successful discontinuation messages over time, particularly after the health system's implementation of CancelRx, a novel technology. After CancelRx implementation there was an immediate (change = 77.7 percentage point) and significant (p < 0.001) increase in the number of controlled substance medications that were successfully discontinued at the pharmacy after being discontinued in the clinic. This change was sustained in the year following CancelRx (slope = 0.03 pp, 95% CI - 0.050 to 0.110) and did not revert to pre-CancelRx levels. The health IT functionality was able to effectively complete discontinuation tasks and potentially reduce workload for clinic staff. Overall, this study demonstrates the role that technology can play in promoting communication between clinics and pharmacies, especially when medications such as controlled substances are discontinued. |
| 247 | Peter Kleinschmidt | GIM | pkleinschmidt@uwhealth.org | CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting. | Medication list discrepancies between outpatient clinics and pharmacies can lead to medication errors. Within the last decade, a new health information technology (IT), CancelRx, emerged to send a medication cancellation message from the clinic's electronic health record (EHR) to the outpatient pharmacy's software. The objective of this study was to measure the impact of CancelRx on reducing medication discrepancies between the EHR and pharmacy dispensing software. CancelRx was implemented in October 2017 at an academic health system. For 12 months prior, and 12 months after CancelRx implementation, data were collected on discontinued medications in the health system's EHR and whether those prescriptions were successfully discontinued in the pharmacy's dispensing software. An interrupted time series analysis was conducted to model the occurrence of prescriptions successfully discontinued over time. There was an immediate (lag = 0), significant (P < 0.001), and sustained (post-implementation slope 0.02) increase in the proportion of successful medication discontinuations after CancelRx implementation (from 34% to 93%). CancelRx had variable impact based on whether the clinic was primary care (71.4% change prepost) or specialty care (53.9% change prepost). CancelRx reduced the time between when a medication was discontinued in the clinic EHR and pharmacy dispensing software. CancelRx automated a manual process and illustrated the role for health IT in communicating medication discontinuations between clinics and pharmacies. Overall, CancelRx had a marked benefit on medication list discrepancies and illustrated how health IT can be used across different settings to improve patient care. |
| 248 | Peter Kleinschmidt | GIM | pkleinschmidt@uwhealth.org | Impact of a problem-oriented view on clinical data retrieval. | The electronic health record (EHR) data deluge makes data retrieval more difficult, escalating cognitive load and exacerbating clinician burnout. New auto-summarization techniques are needed. The study goal was to determine if problem-oriented view (POV) auto-summaries improve data retrieval workflows. We hypothesized that POV users would perform tasks faster, make fewer errors, be more satisfied with EHR use, and experience less cognitive load as compared with users of the standard view (SV). Simple data retrieval tasks were performed in an EHR simulation environment. A randomized block design was used. In the control group (SV), subjects retrieved lab results and medications by navigating to corresponding sections of the electronic record. In the intervention group (POV), subjects clicked on the name of the problem and immediately saw lab results and medications relevant to that problem. With POV, mean completion time was faster (173 seconds for POV vs 205 seconds for SV; P < .0001), the error rate was lower (3.4% for POV vs 7.7% for SV; P = .0010), user satisfaction was greater (System Usability Scale score 58.5 for POV vs 41.3 for SV; P < .0001), and cognitive task load was less (NASA Task Load Index score 0.72 for POV vs 0.99 for SV; P < .0001). The study demonstrates that using a problem-based auto-summary has a positive impact on 4 aspects of EHR data retrieval, including cognitive load. EHRs have brought on a data deluge, with increased cognitive load and physician burnout. To mitigate these increases, further development and implementation of auto-summarization functionality and the requisite knowledge base are needed. |
| 249 | Peter Kleinschmidt | GIM | pkleinschmidt@uwhealth.org | Human Factors and Ergonomics in Health Care and Patient Safety from the Perspective of Medical Residents. | It is critical to understand, analyze and improve the work system of medical residents in order to support the care processes in which they are involved, as well as their educational processes. The discipline of human factors (or ergonomics) (HFE) provides systems concepts and methods to improve the multi-faceted work system of medical residents and, therefore, care processes and educational processes, and outcomes for both patients and residents. In this chapter, we apply the SEIPS (Systems Engineering Initiative for Patient Safety) model to the work system of residents, and use it to explain how the outcomes of patient safety and medical resident well-being are related. Various challenges need to be addressed in order to improve residents’ work system. In particular, it is critical to adopt a systems approach that can optimize multiple outcomes for a range of stakeholders. In line with the participatory ergonomics approach, we contend that residents have a critical role to play in improving their work system; we describe various ways that this can be accomplished. |
| 250 | Peter Kleinschmidt | GIM | pkleinschmidt@uwhealth.org | Application of human factors to improve usability of clinical decision support for diagnostic decision-making: a scenario-based simulation study. | In this study, we used human factors (HF) methods and principles to design a clinical decision support (CDS) that provides cognitive support to the pulmonary embolism (PE) diagnostic decision-making process in the emergency department. We hypothesised that the application of HF methods and principles will produce a more usable CDS that improves PE diagnostic decision-making, in particular decision about appropriate clinical pathway. We conducted a scenario-based simulation study to compare a HF-based CDS (the so-called CDS for PE diagnosis (PE-Dx CDS)) with a web-based CDS (MDCalc); 32 emergency physicians performed various tasks using both CDS. PE-Dx integrated HF design principles such as automating information acquisition and analysis, and minimising workload. We assessed all three dimensions of usability using both objective and subjective measures: effectiveness (eg, appropriate decision regarding the PE diagnostic pathway), efficiency (eg, time spent, perceived workload) and satisfaction (perceived usability of CDS). Emergency physicians made more appropriate diagnostic decisions (94% with PE-Dx; 84% with web-based CDS; p<0.01) and performed experimental tasks faster with the PE-Dx CDS (on average 96 s per scenario with PE-Dx; 117 s with web-based CDS; p<0.001). They also reported lower workload (p<0.001) and higher satisfaction (p<0.001) with PE-Dx. This simulation study shows that HF methods and principles can improve usability of CDS and diagnostic decision-making. Aspects of the HF-based CDS that provided cognitive support to emergency physicians and improved diagnostic performance included automation of information acquisition (eg, auto-populating risk scoring algorithms), minimisation of workload and support of decision selection (eg, recommending a clinical pathway). These HF design principles can be applied to the design of other CDS technologies to improve diagnostic safety. |
| 251 | Peter Kleinschmidt | GIM | pkleinschmidt@uwhealth.org | MRSA Septicemia With Septic Arthritis and Prostatic, Intraretinal, Periapical, and Lung Abscesses. | Methicillin-resistant staphylococcus aureus (MRSA) bacteremia is a life-threatening illness and a major global health care problem. It can cause metastatic and complicated infections. A 58-year-old man with uncontrolled type 2 diabetes mellitus presented with altered mental status after a fall. He was found to have a hip fracture, diabetic ketoacidosis, and MRSA bacteremia. This was complicated by septic knee arthritis, prostatic abscess, intraretinal abscess, periapical abscesses, and pulmonary abscesses. He was treated with intravenous vancomycin and oral linezolid and eventually recovered. Severe metastatic MRSA infection was likely due, in part, to the patient's uncontrolled diabetes, as he has no underlying immunodeficiency and was HIV negative. Prostatic abscesses are a relatively rare occurrence that typically develop in immunocompromised patients. This case is an interesting confluence of sequelae of MRSA bacteremia and reinforces the necessity for clinicians to be diligent when evaluating a patient with a suspected prostatic abscess. |
| 252 | Peter Kleinschmidt | GIM | pkleinschmidt@uwhealth.org | The Design of PE Dx, a CDS to Support Pulmonary Embolism Diagnosis in the ED. | Designing and implementing clinical decision support (CDS) in health care has been challenging. Attempts have been made to design and implement CDS to support clinical procedures, but many of these CDSs have met user resistance. One possible explanation for the lack of acceptability can be the poor design of the CDS. In this study, we describe the design of PE Dx, a CDS built to support the diagnosis of pulmonary embolism (PE) in the emergency department (ED) using human factors methods. |
| 253 | Peter Kleinschmidt | GIM | pkleinschmidt@uwhealth.org | Role network measures to assess healthcare team adaptation to complex situations: the case of venous thromboembolism prophylaxis. | Hospitals are complex environments that rely on clinicians working together to provide appropriate care to patients. These clinical teams adapt their interactions to meet changing situational needs. Venous thromboembolism (VTE) prophylaxis is a complex process that occurs throughout a patient's hospitalisation, presenting five stages with different levels of complexity: admission, interruption, re-initiation, initiation, and transfer. The objective of our study is to understand how the VTE prophylaxis team adapts as the complexity in the process changes; we do this by using social network analysis (SNA) measures. We interviewed 45 clinicians representing 9 different cases, creating 43 role networks. The role networks were analysed using SNA measures to understand team changes between low and high complexity stages. When comparing low and high complexity stages, we found two team adaptation mechanisms: (1) relative increase in the number of people, team activities, and interactions within the team, or (2) relative increase in discussion among the team, reflected by an increase in reciprocity. Practitioner Summary: The reason for this study was to quantify team adaptation to complexity in a process using social network analysis (SNA). The VTE prophylaxis team adapted to complexity by two different mechanisms, by increasing the roles, activities, and interactions among the team or by increasing the two-way communication and discussion throughout the team. We demonstrated the ability for SNA to identify adaptation within a team. |
| 254 | Dudley Lamming | ENDO | dlamming@medicine.wisc.edu | Late-life protein or isoleucine restriction impacts physiological and molecular signatures of aging. | Restricting the intake of protein or the branched-chain amino acid isoleucine promotes healthspan and extends lifespan in young or adult mice. However, their effects when initiated in aged animals are unknown. Here we investigate the consequences of consuming a diet with 67% reduction of all amino acids (low AA) or of isoleucine alone (low Ile), in male and female C57BL/6J.Nia mice starting at 20 months of age. Both dietary regimens effectively promote overall metabolic health without reducing calorie intake. Both low AA and low Ile diets improve aspects of frailty and slow multiple molecular indicators of aging rate; however, the low Ile diet reduces grip strength in both sexes and has mixed, sexually dimorphic effects on the heart. These results demonstrate that low AA and low Ile diets can promote aspects of healthy aging in aged mice and suggest that similar interventions might promote healthy aging in older adults. |
| 255 | Dudley Lamming | ENDO | dlamming@medicine.wisc.edu | Dietary lipid is largely deposited in skin and rapidly affects insulating properties. | Skin has been shown to be a regulatory hub for energy expenditure and metabolism: mutations of skin lipid metabolism enzymes can change the rate of thermogenesis and susceptibility to diet-induced obesity. However, little is known about the physiological basis for this function. Here we show that the thermal properties of skin are highly reactive to diet: within three days, a high fat diet reduces heat transfer through skin. In contrast, a dietary manipulation that prevents obesity accelerates energy loss through skins. We found that skin was the largest target in a mouse body for dietary fat delivery, and that dietary triglyceride was assimilated both by epidermis and by dermal white adipose tissue. Skin from mice calorie-restricted for 3 weeks did not take up circulating lipids and showed a highly depleted stratum corneum. Dietary triglyceride acyl groups persist in skin for weeks after feeding. Using multi-modal lipid profiling, we have implicated both keratinocytes and sebocytes in the altered lipids which correlate with thermal function. In response to high fat feeding, wax diesters and ceramides accumulate, and triglycerides become more saturated. In contrast, in response to the dramatic loss of adipose tissue that accompanies restriction of the branched chain amino acid isoleucine, skin becomes more heat-permeable, resisting changes induced by Western diet feeding, with a signature of depleted signaling lipids. We propose that skin should be routinely included in physiological studies of lipid metabolism, given the size of the skin lipid reservoir and its adaptable functionality. |
| 256 | Dudley Lamming | ENDO | dlamming@medicine.wisc.edu | Quantification of healthspan in aging mice: introducing FAMY and GRAIL. | The population around the world is graying, and as many of these individuals will spend years suffering from the burdens of age associated diseases, understanding how to increase healthspan, defined as the period of life free from disease and disability, is an urgent priority of geroscience research. The lack of agreed-upon quantitative metrics for measuring healthspan in aging mice has slowed progress in identifying interventions that do not simply increase lifespan, but also healthspan. Here, we define FAMY (Frailty-Adjusted Mouse Years) and GRAIL (Gauging Robust Aging when Increasing Lifespan) as new summary statistics for quantifying healthspan in mice. FAMY integrates lifespan data with longitudinal measurements of a widely utilized clinical frailty index, while GRAIL incorporates these measures and also adds information from widely utilized healthspan assays and the hallmarks of aging. Both metrics are conceptually similar to quality-adjusted life years (QALY), a widely utilized measure of disease burden in humans, and can be readily calculated from data acquired during longitudinal and cross-sectional studies of mouse aging. We find that interventions generally thought to promote health, including calorie restriction, robustly improve healthspan as measured by FAMY and GRAIL. Finally, we show that the use of GRAIL provides new insights, and identify dietary restriction of protein or isoleucine as interventions that robustly promote healthspan but not longevity in female HET3 mice. We suggest that the routine integration of these measures into studies of aging in mice will allow the identification and development of interventions that promote healthy aging even in the absence of increased lifespan. |
| 257 | Dudley Lamming | ENDO | dlamming@medicine.wisc.edu | Fasting is required for many of the benefits of calorie restriction in the 3xTg mouse model of Alzheimer's disease. | Caloric restriction (CR) is a widely recognized geroprotective intervention that slows or prevents Alzheimer's disease (AD) in animal models. CR is typically implemented via feeding mice a single meal per day; as CR mice rapidly consume their food, they are subject to a prolonged fast between meals. While CR has been shown to improve metabolic and cognitive functions and suppress pathological markers in AD mouse models, the specific contributions of fasting versus calorie reduction remains unclear. Here, we investigated the contribution of fasting and energy restriction to the beneficial effects of CR on AD progression. To test this, we placed 6-month-old 3xTg mice on one of several diet regimens, allowing us to dissect the effects of calories and fasting on metabolism, AD pathology, and cognition. We find that energy restriction alone, without fasting, was sufficient to improve glucose tolerance and reduce adiposity in both sexes, and to reduce Aβ plaques and improve aspects of cognitive performance in females. However, we find that a prolonged fast between meals is necessary for many of the benefits of CR, including improved insulin sensitivity, reduced phosphorylation of tau, decreased neuroinflammation, inhibition of mTORC1 signaling, and activation of autophagy, as well as for the full cognitive benefits of CR. Finally, we find that fasting is essential for the benefits of CR on survival in male 3xTg mice. Overall, our results demonstrate that fasting is required for the full benefits of a CR diet on the development and progression of AD in 3xTg mice, and suggest that both when and how much we eat influences the development and progress of AD. |
| 258 | Dudley Lamming | ENDO | dlamming@medicine.wisc.edu | Non-canonical metabolic and molecular effects of calorie restriction are revealed by varying temporal conditions. | Calorie restriction (CR) extends lifespan and healthspan in diverse species. Comparing ad libitum- and CR-fed mice is challenging due to their significantly different feeding patterns, with CR-fed mice consuming their daily meal in 2 h and then subjecting themselves to a prolonged daily fast. Here, we examine how ad libitum- and CR-fed mice respond to tests performed at various times and fasting durations and find that the effects of CR-insulin sensitivity, circulating metabolite levels, and mechanistic target of rapamycin 1 (mTORC1) activity-result from the specific temporal conditions chosen, with CR-induced improvements in insulin sensitivity observed only after a prolonged fast, and the observed differences in mTORC1 activity between ad libitum- and CR-fed mice dependent upon both fasting duration and the specific tissue examined. Our results demonstrate that much of our understanding of the effects of CR are related to when, relative to feeding, we choose to examine the mice. |
| 259 | Dudley Lamming | ENDO | dlamming@medicine.wisc.edu | Acarbose ameliorates Western diet-induced metabolic and cognitive impairments in the 3xTg mouse model of Alzheimer's disease. | Age is the greatest risk factor for Alzheimer's disease (AD) as well as for other disorders that increase the risk of AD such as diabetes and obesity. There is growing interest in determining if interventions that promote metabolic health can prevent or delay AD. Acarbose is an anti-diabetic drug that not only improves glucose homeostasis, but also extends the lifespan of wild-type mice. Here, we test the hypothesis that acarbose will not only preserve metabolic health, but also slow or prevent AD pathology and cognitive deficits in 3xTg mice, a model of AD, fed either a Control diet or a high-fat, high-sucrose Western diet (WD). We find that acarbose decreases the body weight and adiposity of WD-fed 3xTg mice, increasing energy expenditure while also stimulating food consumption, and improves glycemic control. Both male and female WD-fed 3xTg mice have worsened cognitive deficits than Control-fed mice, and these deficits are ameliorated by acarbose treatment. Molecular and histological analysis of tau and amyloid pathology identified sex-specific effects of acarbose which are uncoupled from the dramatic improvements in cognition in females, suggesting that the benefits of acarbose on AD may be largely driven by improved metabolic health. In conclusion, our results suggest that acarbose may be a promising intervention to prevent, delay, or even treat AD, especially in individuals consuming a WD. |
| 260 | Dudley Lamming | ENDO | dlamming@medicine.wisc.edu | A nutrigeroscience approach: Dietary macronutrients and cellular senescence. | Cellular senescence, a process in which a cell exits the cell cycle in response to stressors, is one of the hallmarks of aging. Senescence and the senescence-associated secretory phenotype (SASP)-a heterogeneous set of secreted factors that disrupt tissue homeostasis and promote the accumulation of senescent cells-reprogram metabolism and can lead to metabolic dysfunction. Dietary interventions have long been studied as methods to combat age-associated metabolic dysfunction, promote health, and increase lifespan. A growing body of literature suggests that senescence is responsive to diet, both to calories and specific dietary macronutrients, and that the metabolic benefits of dietary interventions may arise in part through reducing senescence. Here, we review what is currently known about dietary macronutrients' effect on senescence and the SASP, the nutrient-responsive molecular mechanisms that may mediate these effects, and the potential for these findings to inform the development of a nutrigeroscience approach to healthy aging. |
| 261 | Dawn Davis | ENDO | dbd@medicine.wisc.edu | The prostaglandin E(2) EP3 receptor has disparate effects on islet insulin secretion and content in β-cells in a high-fat diet-induced mouse model of obesity. | Signaling through prostaglandin E2 EP3 receptor (EP3) actively contributes to the β-cell dysfunction of type 2 diabetes (T2D). In T2D models, full-body EP3 knockout mice have a significantly worse metabolic phenotype than wild-type controls due to hyperphagia and severe insulin resistance resulting from loss of EP3 in extra-pancreatic tissues, masking any potential beneficial effects of EP3 loss in the β cell. We hypothesized β-cell-specific EP3 knockout (EP3 βKO) mice would be protected from high-fat diet (HFD)-induced glucose intolerance, phenocopying mice lacking the EP3 effector, Gαz, which is much more limited in its tissue distribution. When fed a HFD for 16 wk, though, EP3 βKO mice were partially, but not fully, protected from glucose intolerance. In addition, exendin-4, an analog of the incretin hormone, glucagon-like peptide 1, more strongly potentiated glucose-stimulated insulin secretion in islets from both control diet- and HFD-fed EP3 βKO mice as compared with wild-type controls, with no effect of β-cell-specific EP3 loss on islet insulin content or markers of replication and survival. However, after 26 wk of diet feeding, islets from both control diet- and HFD-fed EP3 βKO mice secreted significantly less insulin as a percent of content in response to stimulatory glucose, with or without exendin-4, with elevated total insulin content unrelated to markers of β-cell replication and survival, revealing severe β-cell dysfunction. Our results suggest that EP3 serves a critical role in temporally regulating β-cell function along the progression to T2D and that there exist Gαz-independent mechanisms behind its effects.NEW & NOTEWORTHY The EP3 receptor is a strong inhibitor of β-cell function and replication, suggesting it as a potential therapeutic target for the disease. Yet, EP3 has protective roles in extrapancreatic tissues. To address this, we designed β-cell-specific EP3 knockout mice and subjected them to high-fat diet feeding to induce glucose intolerance. The negative metabolic phenotype of full-body knockout mice was ablated, and EP3 loss improved glucose tolerance, with converse effects on islet insulin secretion and content. |
| 262 | Dawn Davis | ENDO | dbd@medicine.wisc.edu | Diazobutanone-assisted isobaric labelling of phospholipids and sulfated glycolipids enables multiplexed quantitative lipidomics using tandem mass spectrometry. | Mass spectrometry-based quantitative lipidomics is an emerging field aiming to uncover the intricate relationships between lipidomes and disease development. However, quantifying lipidomes comprehensively in a high-throughput manner remains challenging owing to the diverse lipid structures. Here we propose a diazobutanone-assisted isobaric labelling strategy as a rapid and robust platform for multiplexed quantitative lipidomics across a broad range of lipid classes, including various phospholipids and glycolipids. The diazobutanone reagent is designed to conjugate with phosphodiester or sulfate groups, while accommodating various functional groups on different lipid classes, enabling subsequent isobaric labelling for high-throughput multiplexed quantitation. Our method demonstrates excellent performance in terms of labelling efficiency, detection sensitivity, quantitative accuracy and broad applicability to various biological samples. Finally, we performed a six-plex quantification analysis of lipid extracts from lean and obese mouse livers. In total, we identified and quantified 246 phospholipids in a high-throughput manner, revealing lipidomic changes that may be associated with obesity in mice. |
| 265 | Dawn Davis | ENDO | dbd@medicine.wisc.edu | Metformin Monotherapy Alters the Human Plasma Lipidome Independent of Clinical Markers of Glycemic Control and Cardiovascular Disease Risk in a Type 2 Diabetes Clinical Cohort. | Type 2 diabetes (T2D) is a rising pandemic worldwide. Diet and lifestyle changes are typically the first intervention for T2D. When this intervention fails, the biguanide metformin is the most common pharmaceutical therapy. Yet its full mechanisms of action remain unknown. In this work, we applied an ultrahigh resolution, mass spectrometry-based platform for untargeted plasma metabolomics to human plasma samples from a case-control observational study of nondiabetic and well-controlled T2D subjects, the latter treated conservatively with metformin or diet and lifestyle changes only. No statistically significant differences existed in baseline demographic parameters, glucose control, or clinical markers of cardiovascular disease risk between the two T2D groups, which we hypothesized would allow the identification of circulating metabolites independently associated with treatment modality. Over 3000 blank-reduced metabolic features were detected, with the majority of annotated features being lipids or lipid-like molecules. Altered abundance of multiple fatty acids and phospholipids were found in T2D subjects treated with diet and lifestyle changes as compared with nondiabetic subjects, changes that were often reversed by metformin. Our findings provide direct evidence that metformin monotherapy alters the human plasma lipidome independent of T2D disease control and support a potential cardioprotective effect of metformin worthy of future study. SIGNIFICANCE STATEMENT: This work provides important new information on the systemic effects of metformin in type 2 diabetic subjects. We observed significant changes in the plasma lipidome with metformin therapy, with metabolite classes previously associated with cardiovascular disease risk significantly reduced as compared to diet and lifestyle changes. While cardiovascular disease risk was not a primary outcome of our study, our results provide a jumping-off point for future work into the cardioprotective effects of metformin, even in well-controlled type 2 diabetes. |
| 266 | Dawn Davis | ENDO | dbd@medicine.wisc.edu | What the BTBR/J mouse has taught us about diabetes and diabetic complications. | Human and mouse genetics have delivered numerous diabetogenic loci, but it is mainly through the use of animal models that the pathophysiological basis for their contribution to diabetes has been investigated. More than 20 years ago, we serendipidously identified a mouse strain that could serve as a model of obesity-prone type 2 diabetes, the BTBR (Black and Tan Brachyury) mouse (BTBR T+ Itpr3tf/J, 2018) carrying the Lepob mutation. We went on to discover that the BTBR-Lepob mouse is an excellent model of diabetic nephropathy and is now widely used by nephrologists in academia and the pharmaceutical industry. In this review, we describe the motivation for developing this animal model, the many genes identified and the insights about diabetes and diabetes complications derived from >100 studies conducted in this remarkable animal model. |
| 269 | Dawn Davis | ENDO | dbd@medicine.wisc.edu | Corrigendum to "Islet allografts expressing a PD-L1 and IDO fusion protein evade immune rejection and reverse preexisting diabetes in immunocompetent mice without systemic immunosuppression" [American Journal of Transplantation (2022) 2571-2585]. | |
| 270 | Dawn Davis | ENDO | dbd@medicine.wisc.edu | A plasma membrane-associated glycolytic metabolon is functionally coupled to K(ATP) channels in pancreatic α and β cells from humans and mice. | The ATP-sensitive K+ (KATP) channel is a key regulator of hormone secretion from pancreatic islet endocrine cells. Using direct measurements of KATP channel activity in pancreatic β cells and the lesser-studied α cells, from both humans and mice, we provide evidence that a glycolytic metabolon locally controls KATP channels on the plasma membrane. The two ATP-consuming enzymes of upper glycolysis, glucokinase and phosphofructokinase, generate ADP that activates KATP. Substrate channeling of fructose 1,6-bisphosphate through the enzymes of lower glycolysis fuels pyruvate kinase, which directly consumes the ADP made by phosphofructokinase to raise ATP/ADP and close the channel. We further show the presence of a plasma membrane-associated NAD+/NADH cycle whereby lactate dehydrogenase is functionally coupled to glyceraldehyde-3-phosphate dehydrogenase. These studies provide direct electrophysiological evidence of a KATP-controlling glycolytic signaling complex and demonstrate its relevance to islet glucose sensing and excitability. |
| 271 | Andrea Galmozzi | ENDO | agalmozzi@medicine.wisc.edu | Fast and deep phosphoproteome analysis with the Orbitrap Astral mass spectrometer. | Owing to its roles in cellular signal transduction, protein phosphorylation plays critical roles in myriad cell processes. That said, detecting and quantifying protein phosphorylation has remained a challenge. We describe the use of a novel mass spectrometer (Orbitrap Astral) coupled with data-independent acquisition (DIA) to achieve rapid and deep analysis of human and mouse phosphoproteomes. With this method, we map approximately 30,000 unique human phosphorylation sites within a half-hour of data collection. The technology is benchmarked to other state-of-the-art MS platforms using both synthetic peptide standards and with EGF-stimulated HeLa cells. We apply this approach to generate a phosphoproteome multi-tissue atlas of the mouse. Altogether, we detect 81,120 unique phosphorylation sites within 12 hours of measurement. With this unique dataset, we examine the sequence, structural, and kinase specificity context of protein phosphorylation. Finally, we highlight the discovery potential of this resource with multiple examples of phosphorylation events relevant to mitochondrial and brain biology. |
| 272 | Andrea Galmozzi | ENDO | agalmozzi@medicine.wisc.edu | Deconstructing Adipose Tissue Heterogeneity One Cell at a Time. | As a central coordinator of physiologic metabolism, adipose tissue has long been appreciated as a highly plastic organ that dynamically responds to environmental cues. Once thought of as a homogenous storage depot, recent advances have enabled deep characterizations of the underlying structure and composition of adipose tissue depots. As the obesity and metabolic disease epidemics continue to accelerate due to modern lifestyles and an aging population, elucidation of the underlying mechanisms that control adipose and systemic homeostasis are of critical importance. Within the past decade, the emergence of deep cell profiling at tissue- and, recently, single-cell level has furthered our understanding of the complex dynamics that contribute to tissue function and their implications in disease development. Although many paradigm-shifting findings may lie ahead, profound advances have been made to forward our understanding of the adipose tissue niche in both health and disease. Now widely accepted as a highly heterogenous organ with major roles in metabolic homeostasis, endocrine signaling, and immune function, the study of adipose tissue dynamics has reached a new frontier. In this review, we will provide a synthesis of the latest advances in adipose tissue biology made possible by the use of single-cell technologies, the impact of epigenetic mechanisms on adipose function, and suggest what next steps will further our understanding of the role that adipose tissue plays in systemic physiology. |
| 273 | Andrea Galmozzi | ENDO | agalmozzi@medicine.wisc.edu | Heme biosynthesis regulates BCAA catabolism and thermogenesis in brown adipose tissue | The distinctive color of brown adipose tissue (BAT) is attributed to its high content of heme-rich mitochondria. Despite this, the mechanisms by which BAT regulates intracellular heme levels remain largely unexplored. Here, we demonstrate that heme biosynthesis is the primary source of heme in brown adipocytes. Inhibiting heme biosynthesis results in an accumulation of the branched-chain amino acids (BCAAs) valine and isoleucine, due to a heme-associated metabolon that channels BCAA-derived carbons into heme biosynthesis. Heme synthesis-deficient brown adipocytes display reduced mitochondrial respiration and lower UCP1 levels compared to wild-type cells. While exogenous heme supplementation can restore intracellular heme levels and mitochondrial function, UCP1 downregulation persists. This sustained UCP1 suppression is linked to epigenetic regulation induced by the accumulation of propionyl-CoA, a byproduct of disrupted heme synthesis. Finally, disruption of heme biosynthesis in BAT impairs thermogenic response and, in female, but not male, mice, hinders the cold-induced clearance of circulating BCAAs in a sex-hormone-dependent manner. These findings establish adipose heme biosynthesis as a key regulator of thermogenesis and sex-dependent BCAA homeostasis. |
| 274 | Andrea Galmozzi | ENDO | agalmozzi@medicine.wisc.edu | Isolation and Differentiation of Primary White and Brown Preadipocytes from Newborn Mice. | The understanding of the mechanisms underlying adipocyte differentiation and function has greatly benefited from the use of immortalized white preadipocyte cell lines. These cultured cell lines, however, have limitations. They do not fully capture the diverse functional spectrum of the heterogenous adipocyte populations that are now known to exist within white adipose depots. To provide a more physiologically relevant model to study the complexity of white adipose tissue, a protocol has been developed and optimized to enable simultaneous isolation of primary white and brown adipocyte progenitors from newborn mice, their rapid expansion in culture, and their differentiation in vitro into mature, fully functional adipocytes. The primary advantage of isolating primary cells from newborn, rather than adult mice, is that the adipose depots are actively developing and are, therefore, a rich source of proliferating preadipocytes. Primary preadipocytes isolated using this protocol differentiate rapidly upon reaching confluence and become fully mature in 4-5 days, a temporal window that accurately reflects the appearance of developed fat pads in newborn mice. Primary cultures prepared using this strategy can be expanded and studied with high reproducibility, making them suitable for genetic and phenotypic screens and enabling the study of the cell-autonomous adipocyte phenotypes of genetic mouse models. This protocol offers a simple, rapid, and inexpensive approach to study the complexity of adipose tissue in vitro. |
| 275 | Michelle Kimple | ENDO | mkimple@medicine.wisc.edu | Gα(z)-independent and -dependent Improvements With EPA Supplementation on the Early Type 1 Diabetes Phenotype of NOD Mice. | Prostaglandin E2 (PGE2) is a key mediator of inflammation and is derived from the omega-6 polyunsaturated fatty acid, arachidonic acid (AA). In the β-cell, the PGE2 receptor, Prostaglandin EP3 receptor (EP3), is coupled to the unique heterotrimeric G protein alpha subunit, Gɑz to reduce the production of cyclic adenosine monophosphate (cAMP), a key signaling molecule that activates β-cell function, proliferation, and survival pathways. Nonobese diabetic (NOD) mice are a strong model of type 1 diabetes (T1D), and NOD mice lacking Gɑz are protected from hyperglycemia. Therefore, limiting systemic PGE2 production could potentially improve both the inflammatory and β-cell dysfunction phenotype of T1D. Here, we sought to evaluate the effect of eicosapentaenoic acid (EPA) feeding, which limits PGE2 production, on the early T1D phenotype of NOD mice in the presence and absence of Gαz. Wild-type and Gαz knockout NOD mice were fed a control or EPA-enriched diet for 12 weeks, beginning at age 4 to 5 weeks. Oral glucose tolerance, splenic T-cell populations, islet cytokine/chemokine gene expression, islet insulitis, measurements of β-cell mass, and measurements of β-cell function were quantified. EPA diet feeding and Gɑz loss independently improved different aspects of the early NOD T1D phenotype and coordinated to alter the expression of certain cytokine/chemokine genes and enhance incretin-potentiated insulin secretion. Our results shed critical light on the Gαz-dependent and -independent effects of dietary EPA enrichment and provide a rationale for future research into novel pharmacological and dietary adjuvant therapies for T1D. |
| 276 | Michelle Kimple | ENDO | mkimple@medicine.wisc.edu | The prostaglandin E(2) EP3 receptor has disparate effects on islet insulin secretion and content in β-cells in a high-fat diet-induced mouse model of obesity. | Signaling through prostaglandin E2 EP3 receptor (EP3) actively contributes to the β-cell dysfunction of type 2 diabetes (T2D). In T2D models, full-body EP3 knockout mice have a significantly worse metabolic phenotype than wild-type controls due to hyperphagia and severe insulin resistance resulting from loss of EP3 in extra-pancreatic tissues, masking any potential beneficial effects of EP3 loss in the β cell. We hypothesized β-cell-specific EP3 knockout (EP3 βKO) mice would be protected from high-fat diet (HFD)-induced glucose intolerance, phenocopying mice lacking the EP3 effector, Gαz, which is much more limited in its tissue distribution. When fed a HFD for 16 wk, though, EP3 βKO mice were partially, but not fully, protected from glucose intolerance. In addition, exendin-4, an analog of the incretin hormone, glucagon-like peptide 1, more strongly potentiated glucose-stimulated insulin secretion in islets from both control diet- and HFD-fed EP3 βKO mice as compared with wild-type controls, with no effect of β-cell-specific EP3 loss on islet insulin content or markers of replication and survival. However, after 26 wk of diet feeding, islets from both control diet- and HFD-fed EP3 βKO mice secreted significantly less insulin as a percent of content in response to stimulatory glucose, with or without exendin-4, with elevated total insulin content unrelated to markers of β-cell replication and survival, revealing severe β-cell dysfunction. Our results suggest that EP3 serves a critical role in temporally regulating β-cell function along the progression to T2D and that there exist Gαz-independent mechanisms behind its effects.NEW & NOTEWORTHY The EP3 receptor is a strong inhibitor of β-cell function and replication, suggesting it as a potential therapeutic target for the disease. Yet, EP3 has protective roles in extrapancreatic tissues. To address this, we designed β-cell-specific EP3 knockout mice and subjected them to high-fat diet feeding to induce glucose intolerance. The negative metabolic phenotype of full-body knockout mice was ablated, and EP3 loss improved glucose tolerance, with converse effects on islet insulin secretion and content. |
| 277 | Michelle Kimple | ENDO | mkimple@medicine.wisc.edu | EP3 signaling is decoupled from the regulation of glucose-stimulated insulin secretion in β-cells compensating for obesity and insulin resistance. | Of the β-cell signaling pathways altered by obesity and insulin resistance, some are adaptive while others contribute to β-cell failure. Two critical second messengers are Ca2+ and cAMP, which control the timing and amplitude of insulin secretion. Previous work has shown the importance of the cAMP-inhibitory Prostaglandin EP3 receptor (EP3) in mediating the β-cell dysfunction of type 2 diabetes (T2D). Here, we used three groups of C57BL/6J mice as a model of the progression from metabolic health to T2D: wildtype, normoglycemic LeptinOb (NGOB), and hyperglycemic LeptinOb (HGOB). Robust increases in β-cell cAMP and insulin secretion were observed in NGOB islets as compared to wildtype controls; an effect lost in HGOB islets, which exhibited reduced β-cell cAMP and insulin secretion despite increased glucose-dependent Ca2+ influx. An EP3 antagonist had no effect on β-cell cAMP or Ca2+ oscillations, demonstrating agonist-independent EP3 signaling. Finally, using sulprostone to hyperactivate EP3 signaling, we found EP3-dependent suppression of β-cell cAMP and Ca2+ duty cycle effectively reduces insulin secretion in HGOB islets, while having no impact insulin secretion on NGOB islets, despite similar and robust effects on cAMP levels and Ca2+ duty cycle. Finally, increased cAMP levels in NGOB islets are consistent with increased recruitment of the small G protein, Rap1GAP, to the plasma membrane, sequestering the EP3 effector, Gɑz, from inhibition of adenylyl cyclase. Taken together, these results suggest that rewiring of EP3 receptor-dependent cAMP signaling contributes to the progressive changes in β cell function observed in the LeptinOb model of diabetes. |
| 278 | Michelle Kimple | ENDO | mkimple@medicine.wisc.edu | Metformin Monotherapy Alters the Human Plasma Lipidome Independent of Clinical Markers of Glycemic Control and Cardiovascular Disease Risk in a Type 2 Diabetes Clinical Cohort. | Type 2 diabetes (T2D) is a rising pandemic worldwide. Diet and lifestyle changes are typically the first intervention for T2D. When this intervention fails, the biguanide metformin is the most common pharmaceutical therapy. Yet its full mechanisms of action remain unknown. In this work, we applied an ultrahigh resolution, mass spectrometry-based platform for untargeted plasma metabolomics to human plasma samples from a case-control observational study of nondiabetic and well-controlled T2D subjects, the latter treated conservatively with metformin or diet and lifestyle changes only. No statistically significant differences existed in baseline demographic parameters, glucose control, or clinical markers of cardiovascular disease risk between the two T2D groups, which we hypothesized would allow the identification of circulating metabolites independently associated with treatment modality. Over 3000 blank-reduced metabolic features were detected, with the majority of annotated features being lipids or lipid-like molecules. Altered abundance of multiple fatty acids and phospholipids were found in T2D subjects treated with diet and lifestyle changes as compared with nondiabetic subjects, changes that were often reversed by metformin. Our findings provide direct evidence that metformin monotherapy alters the human plasma lipidome independent of T2D disease control and support a potential cardioprotective effect of metformin worthy of future study. SIGNIFICANCE STATEMENT: This work provides important new information on the systemic effects of metformin in type 2 diabetic subjects. We observed significant changes in the plasma lipidome with metformin therapy, with metabolite classes previously associated with cardiovascular disease risk significantly reduced as compared to diet and lifestyle changes. While cardiovascular disease risk was not a primary outcome of our study, our results provide a jumping-off point for future work into the cardioprotective effects of metformin, even in well-controlled type 2 diabetes. |
| 279 | Michelle Kimple | ENDO | mkimple@medicine.wisc.edu | What the BTBR/J mouse has taught us about diabetes and diabetic complications. | Human and mouse genetics have delivered numerous diabetogenic loci, but it is mainly through the use of animal models that the pathophysiological basis for their contribution to diabetes has been investigated. More than 20 years ago, we serendipidously identified a mouse strain that could serve as a model of obesity-prone type 2 diabetes, the BTBR (Black and Tan Brachyury) mouse (BTBR T+ Itpr3tf/J, 2018) carrying the Lepob mutation. We went on to discover that the BTBR-Lepob mouse is an excellent model of diabetic nephropathy and is now widely used by nephrologists in academia and the pharmaceutical industry. In this review, we describe the motivation for developing this animal model, the many genes identified and the insights about diabetes and diabetes complications derived from >100 studies conducted in this remarkable animal model. |
| 280 | Michelle Kimple | ENDO | mkimple@medicine.wisc.edu | Plasma Prostaglandin E(2) Metabolite Levels Predict Type 2 Diabetes Status and One-Year Therapeutic Response Independent of Clinical Markers of Inflammation. | Over half of patients with type 2 diabetes (T2D) are unable to achieve blood glucose targets despite therapeutic compliance, significantly increasing their risk of long-term complications. Discovering ways to identify and properly treat these individuals is a critical problem in the field. The arachidonic acid metabolite, prostaglandin E2 (PGE2), has shown great promise as a biomarker of β-cell dysfunction in T2D. PGE2 synthesis, secretion, and downstream signaling are all upregulated in pancreatic islets isolated from T2D mice and human organ donors. In these islets, preventing β-cell PGE2 signaling via a prostaglandin EP3 receptor antagonist significantly improves their glucose-stimulated and hormone-potentiated insulin secretion response. In this clinical cohort study, 167 participants, 35 non-diabetic, and 132 with T2D, were recruited from the University of Wisconsin Hospital and Clinics. At enrollment, a standard set of demographic, biometric, and clinical measurements were performed to quantify obesity status and glucose control. C reactive protein was measured to exclude acute inflammation/illness, and white cell count (WBC), erythrocyte sedimentation rate (ESR), and fasting triglycerides were used as markers of systemic inflammation. Finally, a plasma sample for research was used to determine circulating PGE2 metabolite (PGEM) levels. At baseline, PGEM levels were not correlated with WBC and triglycerides, only weakly correlated with ESR, and were the strongest predictor of T2D disease status. One year after enrollment, blood glucose management was assessed by chart review, with a clinically-relevant change in hemoglobin A1c (HbA1c) defined as ≥0.5%. PGEM levels were strongly predictive of therapeutic response, independent of age, obesity, glucose control, and systemic inflammation at enrollment. Our results provide strong support for future research in this area. |
| 281 | Michelle Kimple | ENDO | mkimple@medicine.wisc.edu | A human pancreatic ECM hydrogel optimized for 3-D modeling of the islet microenvironment. | Extracellular matrix (ECM) plays a multitude of roles, including supporting cells through structural and biochemical interactions. ECM is damaged in the process of isolating human islets for clinical transplantation and basic research. A platform in which islets can be cultured in contact with natural pancreatic ECM is desirable to better understand and support islet health, and to recapitulate the native islet environment. Our study demonstrates the derivation of a practical and durable hydrogel from decellularized human pancreas that supports human islet survival and function. Islets embedded in this hydrogel show increased glucose- and KCl-stimulated insulin secretion, and improved mitochondrial function compared to islets cultured without pancreatic matrix. In extended culture, hydrogel co-culture significantly reduced levels of apoptosis compared to suspension culture and preserved controlled glucose-responsive function. Isolated islets displayed altered endocrine and non-endocrine cell arrangement compared to in situ islets; hydrogel preserved an islet architecture more similar to that observed in situ. RNA sequencing confirmed that gene expression differences between islets cultured in suspension and hydrogel largely fell within gene ontology terms related to extracellular signaling and adhesion. Natural pancreatic ECM improves the survival and physiology of isolated human islets. |
| 282 | Michelle Kimple | ENDO | mkimple@medicine.wisc.edu | Effects of Arachidonic Acid and Its Metabolites on Functional Beta-Cell Mass. | Arachidonic acid (AA) is a polyunsaturated 20-carbon fatty acid present in phospholipids in the plasma membrane. The three primary pathways by which AA is metabolized are mediated by cyclooxygenase (COX) enzymes, lipoxygenase (LOX) enzymes, and cytochrome P450 (CYP) enzymes. These three pathways produce eicosanoids, lipid signaling molecules that play roles in biological processes such as inflammation, pain, and immune function. Eicosanoids have been demonstrated to play a role in inflammatory, renal, and cardiovascular diseases as well type 1 and type 2 diabetes. Alterations in AA release or AA concentrations have been shown to affect insulin secretion from the pancreatic beta cell, leading to interest in the role of AA and its metabolites in the regulation of beta-cell function and maintenance of beta-cell mass. In this review, we discuss the metabolism of AA by COX, LOX, and CYP, the roles of these enzymes and their metabolites in beta-cell mass and function, and the possibility of targeting these pathways as novel therapies for treating diabetes. |
| 283 | Michelle Kimple | ENDO | mkimple@medicine.wisc.edu | Pharmacological blockade of the EP3 prostaglandin E(2) receptor in the setting of type 2 diabetes enhances β-cell proliferation and identity and relieves oxidative damage. | Type 2 diabetes is characterized by hyperglycemia and inflammation. Prostaglandin E2, which signals through four G protein-coupled receptors (EP1-4), is a mediator of inflammation and is upregulated in diabetes. We have shown previously that EP3 receptor blockade promotes β-cell proliferation and survival in isolated mouse and human islets ex vivo. Here, we analyzed whether systemic EP3 blockade could enhance β-cell mass and identity in the setting of type 2 diabetes using mice with a spontaneous mutation in the leptin receptor (Leprdb). Four- or six-week-old, db/+, and db/db male mice were treated with an EP3 antagonist daily for two weeks. Pancreata were analyzed for α-cell and β-cell proliferation and β-cell mass. Islets were isolated for transcriptomic analysis. Selected gene expression changes were validated by immunolabeling of the pancreatic tissue sections. EP3 blockade increased β-cell mass in db/db mice through enhanced β-cell proliferation. Importantly, there were no effects on α-cell proliferation. EP3 blockade reversed the changes in islet gene expression associated with the db/db phenotype and restored the islet architecture. Expression of the GLP-1 receptor was slightly increased by EP3 antagonist treatment in db/db mice. In addition, the transcription factor nuclear factor E2-related factor 2 (Nrf2) and downstream targets were increased in islets from db/db mice in response to treatment with an EP3 antagonist. The markers of oxidative stress were decreased. The current study suggests that EP3 blockade promotes β-cell mass expansion in db/db mice. The beneficial effects of EP3 blockade may be mediated through Nrf2, which has recently emerged as a key mediator in the protection against cellular oxidative damage. |
| 284 | Michelle Kimple | ENDO | mkimple@medicine.wisc.edu | Prostaglandin EP3 receptor signaling is required to prevent insulin hypersecretion and metabolic dysfunction in a non-obese mouse model of insulin resistance. | When homozygous for the LeptinOb mutation (Ob), Black-and-Tan Brachyury (BTBR) mice become morbidly obese and severely insulin resistant, and by 10 wk of age, frankly diabetic. Previous work has shown prostaglandin EP3 receptor (EP3) expression and activity is upregulated in islets from BTBR-Ob mice as compared with lean controls, actively contributing to their β-cell dysfunction. In this work, we aimed to test the impact of β-cell-specific EP3 loss on the BTBR-Ob phenotype by crossing Ptger3 floxed mice with the rat insulin promoter (RIP)-CreHerr driver strain. Instead, germline recombination of the floxed allele in the founder mouse-an event whose prevalence we identified as directly associated with underlying insulin resistance of the background strain-generated a full-body knockout. Full-body EP3 loss provided no diabetes protection to BTBR-Ob mice but, unexpectedly, significantly worsened BTBR-lean insulin resistance and glucose tolerance. This in vivo phenotype was not associated with changes in β-cell fractional area or markers of β-cell replication ex vivo. Instead, EP3-null BTBR-lean islets had essentially uncontrolled insulin hypersecretion. The selective upregulation of constitutively active EP3 splice variants in islets from young, lean BTBR mice as compared with C57BL/6J, where no phenotype of EP3 loss has been observed, provides a potential explanation for the hypersecretion phenotype. In support of this, high islet EP3 expression in Balb/c females versus Balb/c males was fully consistent with their sexually dimorphic metabolic phenotype after loss of EP3-coupled Gαz protein. Taken together, our findings provide a new dimension to the understanding of EP3 as a critical brake on insulin secretion.NEW & NOTEWORTHY Islet prostaglandin EP3 receptor (EP3) signaling is well known as upregulated in the pathophysiological conditions of type 2 diabetes, contributing to β-cell dysfunction. Unexpected findings in mouse models of non-obese insulin sensitivity and resistance provide a new dimension to our understanding of EP3 as a key modulator of insulin secretion. A previously unknown relationship between mouse insulin resistance and the penetrance of rat insulin promoter-driven germline floxed allele recombination is critical to consider when creating β-cell-specific knockouts. |
| 295 | Vincent Cryns | ENDO | vlcryns@medicine.wisc.edu | A p85 isoform switch enhances PI3K activation on endosomes by a MAP4- and PI3P-dependent mechanism. | Phosphatidylinositol 3-kinase α (PI3Kα) is a heterodimer of p110α catalytic and p85 adaptor subunits that is activated by agonist-stimulated receptor tyrosine kinases. Although p85α recruits p110α to activated receptors on membranes, p85α loss, which occurs commonly in cancer, paradoxically promotes agonist-stimulated PI3K/Akt signaling. p110α localizes to microtubules via microtubule-associated protein 4 (MAP4), facilitating its interaction with activated receptor kinases on endosomes to initiate PI3K/Akt signaling. Here, we demonstrate that in response to agonist stimulation and p85α knockdown, the residual p110α, coupled predominantly to p85β, exhibits enhanced recruitment with receptor tyrosine kinases to endosomes. Moreover, the p110α C2 domain binds PI3-phosphate, and this interaction is also required to recruit p110α to endosomes and for PI3K/Akt signaling. Stable knockdown of p85α, which mimics the reduced p85α levels observed in cancer, enhances cell growth and tumorsphere formation, and these effects are abrogated by MAP4 or p85β knockdown, underscoring their role in the tumor-promoting activity of p85α loss. |
| 296 | Vincent Cryns | ENDO | vlcryns@medicine.wisc.edu | Nuclear phosphoinositide signaling promotes YAP/TAZ-TEAD transcriptional activity in breast cancer. | The Hippo pathway effectors Yes-associated protein 1 (YAP) and its homolog TAZ are transcriptional coactivators that control gene expression by binding to TEA domain (TEAD) family transcription factors. The YAP/TAZ-TEAD complex is a key regulator of cancer-specific transcriptional programs, which promote tumor progression in diverse types of cancer, including breast cancer. Despite intensive efforts, the YAP/TAZ-TEAD complex in cancer has remained largely undruggable due to an incomplete mechanistic understanding. Here, we report that nuclear phosphoinositides function as cofactors that mediate the binding of YAP/TAZ to TEADs. The enzymatic products of phosphoinositide kinases PIPKIα and IPMK, including phosphatidylinositol 4,5-bisphosphate (PI(4,5)P2) and phosphatidylinositol 3,4,5-trisphosphate (P(I3,4,5)P3), bridge the binding of YAP/TAZ to TEAD. Inhibiting these kinases or the association of YAP/TAZ with PI(4,5)P2 and PI(3,4,5)P3 attenuates YAP/TAZ interaction with the TEADs, the expression of YAP/TAZ target genes, and breast cancer cell motility. Although we could not conclusively exclude the possibility that other enzymatic products of IPMK such as inositol phosphates play a role in the mechanism, our results point to a previously unrecognized role of nuclear phosphoinositide signaling in control of YAP/TAZ activity and implicate this pathway as a potential therapeutic target in YAP/TAZ-driven breast cancer. |
| 297 | Vincent Cryns | ENDO | vlcryns@medicine.wisc.edu | Environmental pollutants and phosphoinositide signaling in autoimmunity. | Environmental pollution stands as one of the most critical challenges affecting human health, with an estimated mortality rate linked to pollution-induced non-communicable diseases projected to range from 20% to 25%. These pollutants not only disrupt immune responses but can also trigger immunotoxicity. Phosphoinositide signaling, a pivotal regulator of immune responses, plays a central role in the development of autoimmune diseases and exhibits high sensitivity to environmental stressors. Among these stressors, environmental pollutants have become increasingly prevalent in our society, contributing to the initiation and exacerbation of autoimmune conditions. In this review, we summarize the intricate interplay between phosphoinositide signaling and autoimmune diseases within the context of environmental pollutants and contaminants. We provide an up-to-date overview of stress-induced phosphoinositide signaling, discuss 14 selected examples categorized into three groups of environmental pollutants and their connections to immune diseases, and shed light on the associated phosphoinositide signaling pathways. Through these discussions, this review advances our understanding of how phosphoinositide signaling influences the coordinated immune response to environmental stressors at a biological level. Furthermore, it offers valuable insights into potential research directions and therapeutic targets aimed at mitigating the impact of environmental pollutants on the pathogenesis of autoimmune diseases. SYNOPSIS: Phosphoinositide signaling at the intersection of environmental pollutants and autoimmunity provides novel insights for managing autoimmune diseases aggravated by pollutants. |
| 298 | Vincent Cryns | ENDO | vlcryns@medicine.wisc.edu | Linking Phosphoinositides to Proteins: A Novel Signaling PIPeline. | Phosphoinositide (PIPn) signaling plays pivotal roles in myriad biological processes and is altered in many diseases including cancer. Canonical PIPn signaling involves membrane-associated PIPn lipid second messengers that modulate protein recruitment and activity at membrane focal points. In the nucleus, PIPn signaling operates separately from membranous compartments defining the paradigm of non-canonical PIPn signaling. However, the mechanisms by which this non-membranous nuclear PIPn pool is established and mediates stress signaling is poorly understood. The recent discovery of a p53-signalosome by Chen et al. (Nature Cell Biology 2022) represents a new PIPn signaling axis that operates independently from membrane structures where PIPns are dynamically linked to nuclear p53 and modified by PIPn kinases and phosphatases, allowing the activation of a nuclear PI 3-kinase/Akt pathway that is entirely distinct from the canonical membrane-localized pathway. Here, we will discuss emerging insights about the non-canonical PIPn pathway, which links PIPns to a growing number of cellular targets and highlight the similarities/differences with its canonical counterpart. We will also discuss potential therapeutic targets in this non-canonical PIPn pathway, which is likely to be deregulated in many diseases. |
| 299 | Vincent Cryns | ENDO | vlcryns@medicine.wisc.edu | Regulation of Cell Adhesion and Migration via Microtubule Cytoskeleton Organization, Cell Polarity, and Phosphoinositide Signaling. | The capacity for cancer cells to metastasize to distant organs depends on their ability to execute the carefully choreographed processes of cell adhesion and migration. As most human cancers are of epithelial origin (carcinoma), the transcriptional downregulation of adherent/tight junction proteins (e.g., E-cadherin, Claudin and Occludin) with the concomitant gain of adhesive and migratory phenotypes has been extensively studied. Most research and reviews on cell adhesion and migration focus on the actin cytoskeleton and its reorganization. However, metastasizing cancer cells undergo the extensive reorganization of their cytoskeletal system, specifically in originating/nucleation sites of microtubules and their orientation (e.g., from non-centrosomal to centrosomal microtubule organizing centers). The precise mechanisms by which the spatial and temporal reorganization of microtubules are linked functionally with the acquisition of an adhesive and migratory phenotype as epithelial cells reversibly transition into mesenchymal cells during metastasis remains poorly understood. In this Special Issue of "Molecular Mechanisms Underlying Cell Adhesion and Migration", we highlight cell adhesion and migration from the perspectives of microtubule cytoskeletal reorganization, cell polarity and phosphoinositide signaling. |
| 300 | Vincent Cryns | ENDO | vlcryns@medicine.wisc.edu | Regulation of Phosphoinositide Signaling by Scaffolds at Cytoplasmic Membranes. | Cytoplasmic phosphoinositides (PI) are critical regulators of the membrane-cytosol interface that control a myriad of cellular functions despite their low abundance among phospholipids. The metabolic cycle that generates different PI species is crucial to their regulatory role, controlling membrane dynamics, vesicular trafficking, signal transduction, and other key cellular events. The synthesis of phosphatidylinositol (3,4,5)-triphosphate (PI3,4,5P3) in the cytoplamic PI3K/Akt pathway is central to the life and death of a cell. This review will focus on the emerging evidence that scaffold proteins regulate the PI3K/Akt pathway in distinct membrane structures in response to diverse stimuli, challenging the belief that the plasma membrane is the predominant site for PI3k/Akt signaling. In addition, we will discuss how PIs regulate the recruitment of specific scaffolding complexes to membrane structures to coordinate vesicle formation, fusion, and reformation during autophagy as well as a novel lysosome repair pathway. |
| 301 | Vincent Cryns | ENDO | vlcryns@medicine.wisc.edu | Breast cancer risk for women with diabetes and the impact of metformin: A meta-analysis. | Diabetes mellitus has been associated with increased breast cancer (BC) risk; however, the magnitude of this effect is uncertain. This study focused on BC risk for women with type 2 diabetes mellitus (T2DM). Two separate meta-analyses were conducted (1) to estimate the relative risk (RR) of BC for women with T2DM and (2) to evaluate the risk of BC for women with T2DM associated with the use of metformin, a common diabetes treatment. In addition, subgroup analyses adjusting for obesity as measured by body mass index (BMI) and menopausal status were also performed. Studies were identified via PubMed/Scopus database and manual search through April 2021. A total of 30 and 15 studies were included in the first and second meta-analyses, respectively. The summary RR of BC for women with T2DM was 1.15 (95% confidence interval [CI], 1.09-1.21). The subgroup analyses adjusting BMI and adjusting BMI and menopause resulted in a summary RR of 1.22 (95% CI, 1.15-1.30) and 1.20 (95% CI, 1.05-1.36), respectively. For women with T2DM, the summary RR of BC was 0.82 (95% CI, 0.60-1.12) for metformin users compared with nonmetformin users. Women with T2DM were more likely to be diagnosed with BC and this association was strengthened by adjusting for BMI and menopausal status. No statistically significant reduction of BC risk was observed among metformin users. These two meta-analyses can inform decision-making for women with type 2 diabetes regarding their use of metformin and the use of screening mammography for early detection of breast cancer. |
| 302 | Vincent Cryns | ENDO | vlcryns@medicine.wisc.edu | A p53-phosphoinositide signalosome regulates nuclear AKT activation. | The tumour suppressor p53 and PI3K-AKT pathways have fundamental roles in the regulation of cell growth and apoptosis, and are frequently mutated in cancer. Here, we show that genotoxic stress induces nuclear AKT activation through a p53-dependent mechanism that is distinct from the canonical membrane-localized PI3K-AKT pathway. Following genotoxic stress, a nuclear PI3K binds p53 in the non-membranous nucleoplasm to generate a complex of p53 and phosphatidylinositol 3,4,5-trisphosphate (PtdIns(3,4,5)P3), which recruits AKT, PDK1 and mTORC2 to activate AKT and phosphorylate FOXO proteins, thereby inhibiting DNA damage-induced apoptosis. Wild-type p53 activates nuclear AKT in an on/off fashion following stress, whereas mutant p53 dose-dependently stimulates high basal AKT activity. The p53-PtdIns(3,4,5)P3 complex is dephosphorylated to p53-phosphatidylinositol 4,5-bisphosphate by PTEN to inhibit AKT activation. The nuclear p53-phosphoinositide signalosome is distinct from the canonical membrane-localized pathway and insensitive to PI3K inhibitors currently in the clinic, which underscores its therapeutic relevance. |
| 303 | Vincent Cryns | ENDO | vlcryns@medicine.wisc.edu | Targeting the methionine addiction of cancer. | Methionine is the initiator amino acid for protein synthesis, the methyl source for most nucleotide, chromatin, and protein methylation, and the carbon backbone for various aspects of the cellular antioxidant response and nucleotide biosynthesis. Methionine is provided in the diet and serum methionine levels fluctuate based on dietary methionine content. Within the cell, methionine is recycled from homocysteine via the methionine cycle, which is linked to nutrient status via one-carbon metabolism. Unlike normal cells, many cancer cells, both in vitro and in vivo, show high methionine cycle activity and are dependent on exogenous methionine for continued growth. However, the molecular mechanisms underlying the methionine dependence of diverse malignancies are poorly understood. Methionine deprivation initiates widespread metabolic alterations in cancer cells that enable them to survive despite limited methionine availability, and these adaptive alterations can be specifically targeted to enhance the activity of methionine deprivation, a strategy we have termed "metabolic priming". Chemotherapy-resistant cell populations such as cancer stem cells, which drive treatment-resistance, are also sensitive to methionine deprivation, suggesting dietary methionine restriction may inhibit metastasis and recurrence. Several clinical trials in cancer are investigating methionine restriction in combination with other agents. This review will explore new insights into the mechanisms of methionine dependence in cancer and therapeutic efforts to translate these insights into enhanced clinical activity of methionine restriction in cancer. |
| 304 | Vincent Cryns | ENDO | vlcryns@medicine.wisc.edu | Methionine restriction exposes a targetable redox vulnerability of triple-negative breast cancer cells by inducing thioredoxin reductase. | Tumor cells are dependent on the glutathione and thioredoxin antioxidant pathways to survive oxidative stress. Since the essential amino acid methionine is converted to glutathione, we hypothesized that methionine restriction (MR) would deplete glutathione and render tumors dependent on the thioredoxin pathway and its rate-limiting enzyme thioredoxin reductase (TXNRD). Triple (ER/PR/HER2)-negative breast cancer (TNBC) cells were treated with control or MR media and the effects on reactive oxygen species (ROS) and antioxidant signaling were examined. To determine the role of TXNRD in MR-induced cell death, TXNRD1 was inhibited by RNAi or the pan-TXNRD inhibitor auranofin, an antirheumatic agent. Metastatic and PDX TNBC mouse models were utilized to evaluate in vivo antitumor activity. MR rapidly and transiently increased ROS, depleted glutathione, and decreased the ratio of reduced glutathione/oxidized glutathione in TNBC cells. TXNRD1 mRNA and protein levels were induced by MR via a ROS-dependent mechanism mediated by the transcriptional regulators NRF2 and ATF4. MR dramatically sensitized TNBC cells to TXNRD1 silencing and the TXNRD inhibitor auranofin, as determined by crystal violet staining and caspase activity; these effects were suppressed by the antioxidant N-acetylcysteine. H-Ras-transformed MCF-10A cells, but not untransformed MCF-10A cells, were highly sensitive to the combination of auranofin and MR. Furthermore, dietary MR induced TXNRD1 expression in mammary tumors and enhanced the antitumor effects of auranofin in metastatic and PDX TNBC murine models. MR exposes a vulnerability of TNBC cells to the TXNRD inhibitor auranofin by increasing expression of its molecular target and creating a dependency on the thioredoxin pathway. |
| 305 | Allan Brasier | ENDO | abrasier@wisc.edu | Interactions between epithelial mesenchymal plasticity, barrier dysfunction and innate immune pathways shape the genesis of allergic airway disease. | In genetically predisposed individuals, exposure to aeroallergens and infections from RNA viruses shape epithelial barrier function, leading to Allergic Asthma (AA). Here, activated pattern recognition receptors (PRRs) in lower airway sentinel cells signal epithelial injury-repair pathways leading to cell-state changes [epithelial mesenchymal plasticity (EMP)], barrier disruption and sensitization. 1. Characteristics of sentinel epithelial cells of the bronchoalveolar junction, 2. The effect of aeroallergens on epithelial PRRs, 3. Role of tight junctions (TJs) in barrier function and how aeroallergens disrupt their function, 4. Induction of mucosal TGF autocrine loops activating type-2 innate lymphoid cells (ICL2s) leading to Th2 polarization, 5. How respiratory syncytial virus (RSV) directs goblet cell hyperplasia, and 6. Coupling of endoplasmic reticulum (ER) stress to metabolic adaptations and effects on basal lamina remodeling. When aeroallergens or viral infections activate innate immunity in sentinel cells of the bronchoalveolar junction, normal barrier function is disrupted, promoting chronic inflammation and Th2 responses. An improved mechanistic understanding of how activated PRRs induce EMP couples with TJ disruption, metabolic reprogramming and ECM deposition provides new biologically validated targets to restore barrier function, reduce sensitization, and remodeling in AA. |
| 306 | Allan Brasier | ENDO | abrasier@wisc.edu | Optimizing external advisory committee meetings of Clinical and Translational Science Awards through focused pre-review. | External advisory committees (EACs) are critical peer-review meetings that drive improvement at Clinical and Translational Science Award Program Hubs. Despite their ubiquity, evaluations of EAC optimization and effective implementation remain scarce. We present a two-tiered approach to optimizing EAC meetings through (1) in-depth, topically focused "pre-review" meetings comprised of external topic experts and at least one standing "full-board" EAC member, followed by (2) a traditional "full-board" EAC meeting. This approach allowed pre-review discussion of program-focused topics and specific recommendations, later delivered to the full-board for review and direction. To evaluate this approach, we interviewed 18 people who planned, administered, or attended pre-review and/or full-board meetings, including internal Hub staff, external topic experts, and standing EAC members. Thematic analysis was used to explore planning, implementation, and value of our two-tiered approach versus the traditional single full-board approach. Interviewees preferred the two-tiered approach, noting benefits including additional time to reflect, shared identification of strengths and challenges, and discussion of solutions to share later with the full-board. Those who attended pre-review meetings described building "transformational," rather than "transactional," relationships with invitees through more discussion and inter-hub sharing. That increased sharing invited more exploration, discussion, and planning of next steps toward innovation. |
| 307 | Allan Brasier | ENDO | abrasier@wisc.edu | Editorial: Mucosal adaptations to chronic airway injury: mechanisms and interrelationships of epithelial plasticity on innate immunity and airway remodeling. | |
| 308 | Allan Brasier | ENDO | abrasier@wisc.edu | NF-κB/RelA signaling in secretoglobin progenitors mediates plasticity and MMP-induced barrier disruption in house dust mite-induced allergic asthma. | The mechanisms how aeroallergens induce sensitization are incompletely understood. The house dust mite (HDM) Dermatophagoides pteronyssius (Der p) is a ubiquitous aeroallergen that represents a major cause of allergic rhinitis and asthma. Herein, we tested whether HDM-induced aeroallergen exposure sensitivity is caused by the innate-immune response in small airway epithelial cells. HDM exposure is a rapid activator of NF-κB/RelA in the Secretoglobin (Scgb1a1+) lineage associated with upregulation of NF-κB/RelA-dependent markers of epithelial plasticity. To determine the effect of epithelial NF-κB signaling, NF-κB was depleted in a tamoxifen (TMX)-inducible Scgb1a1-CreERTM mouse within a CL57B/L6 background. Corn oil or TMX-treated/RelA-depleted [RelA knockdown (KD)] mice were repetitively exposed to airway HDM challenges to induce airway hyperresponsiveness (AHR). Strikingly, we observed that HDM induces hallmarks of epithelial plasticity through upregulation of the mesenchymal core factors SNAI1 and ZEB1 and production of metalloproteinase (MMP)9 that are RelA-dependent. Downstream, HDM-induced mucous metaplasia, Th2 polarization, allergen sensitivity, and airway hyperreactivity were all reduced in the RelA-depleted mice. Mechanistically, HDM-induced functional and structural barrier disruption was dependent on RelA signaling and associated with active MMP secretion into the bronchoalveolar lavage fluid. To establish the role of MMP2/9 in barrier disruption, we observe that a small-molecule MMP inhibitor (SB-3CT) blocked HDM-induced barrier disruption and activation of plasticity in naïve wild-type (WT) mice. Loss of functional barrier was associated with MMP disruption of zona occludens (ZO)-1 containing adherens junctions. Overall, this data indicates that host innate signaling in the Scgb1a1+ progenitors is directly linked to epithelial plasticity, MMP9 secretion, and enhanced barrier permeability that allows allergen penetration, sensitization producing allergic asthma (AA) in vivo. We propose that maintenance of epithelial integrity may reduce allergic sensitization and AA.NEW & NOTEWORTHY Allergic asthma from house dust mite (HDM) allergy causes substantial morbidity. This study examines the dynamic changes in small airway epithelial cells in a mouse model of HDM exposure. Our findings indicate that NF-κB/RelA signaling mediates matrix metalloproteinase production, disrupting the epithelial barrier resulting in allergic sensitization. Our findings bring new insight into mechanisms for epithelial cell-state change in the allergen response, creating a potential therapeutic pathway for maintaining barrier function in asthma. |
| 309 | Allan Brasier | ENDO | abrasier@wisc.edu | Cooperative interaction of interferon regulatory factor -1 and bromodomain-containing protein 4 on RNA polymerase activation for intrinsic innate immunity. | The human orthopneumovirus, Respiratory Syncytial Virus (RSV), is the causative agent of severe lower respiratory tract infections (LRTI) and exacerbations of chronic lung diseases. In immune competent hosts, RSV productively infects highly differentiated epithelial cells, where it elicits robust anti-viral, cytokine and remodeling programs. By contrast, basal cells are relatively resistant to RSV infection, in part, because of constitutive expression of an intrinsic innate immune response (IIR) consisting of a subgroup of interferon (IFN) responsive genes. The mechanisms controlling the intrinsic IIR are not known. Here, we use human small airway epithelial cell hSAECs as a multipotent airway stem cell model to examine regulatory control of an intrinsic IIR pathway. We find hSAECs express patterns of intrinsic IIRs, highly conserved with pluri- and multi-potent stem cells. We demonstrate a core intrinsic IIR network consisting of Bone Marrow Stromal Cell Antigen 2 (Bst2), Interferon Induced Transmembrane Protein 1 (IFITM1) and Toll-like receptor (TLR3) expression are directly under IRF1 control. Moreover, expression of this intrinsic core is rate-limited by ambient IRF1• phospho-Ser 2 CTD RNA Polymerase II (pSer2 Pol II) complexes binding to their proximal promoters. In response to RSV infection, the abundance of IRF1 and pSer2 Pol II binding is dramatically increased, with IRF1 complexing to the BRD4 chromatin remodeling complex (CRC). Using chromatin immunoprecipitation in IRF1 KD cells, we find that the binding of BRD4 is IRF1 independent. Using a small molecule inhibitor of the BRD4 acetyl lysine binding bromodomain (BRD4i), we further find that BRD4 bromodomain interactions are required for stable BRD4 promoter binding to the intrinsic IIR core promoters, as well as for RSV-inducible pSer2 Pol II recruitment. Surprisingly, BRD4i does not disrupt IRF1-BRD4 interactions, but disrupts both RSV-induced BRD4 and IRF1 interactions with pSer2 Pol II. We conclude that the IRF1 functions in two modes- in absence of infection, ambient IRF1 mediates constitutive expression of the intrinsic IIR, whereas in response to RSV infection, the BRD4 CRC independently activates pSer2 Pol II to mediates robust expression of the intrinsic IIR. These data provide insight into molecular control of anti-viral defenses of airway basal cells. |
| 310 | Allan Brasier | ENDO | abrasier@wisc.edu | Developing a Translational Team Training Program using the Wisconsin Interventions in Team Science Framework. | The Clinical and Translational Science Awards (CTSA) Program supports a national network of medical research institutions working to improve the translational process. High-performing translational teams (TTs) are critical for advancing evidence-based approaches that improve human health. When focused on content-appropriate knowledge, skills, and attitudes, targeted training results in the substantial internalization of training content, producing new skills that can be applied to improve team outputs, outcomes, and benefits. More rigorous approaches to develop, test, and evaluate interventions are needed, and we used the Wisconsin Interventions in Team Science framework as a model to systematize our efforts. We designed, built, and tested a five-session TT Training Program for translational researchers. The 90-minute sessions were pilot-tested with 47 postdoctoral fellows and evaluated through a structured evaluation plan. Ninety-five percent of post-session survey respondents indicated that the content and skills provided would make them more effective collaborators, and one hundred percent would recommend the sessions to colleagues. Respondents' scores increased from pretest to posttest for most learning outcomes. Refinements from participant feedback are described. This work provides a foundation for the continued evolution of evidence-based training programs in the CTSA environment. |
| 311 | Allan Brasier | ENDO | abrasier@wisc.edu | Substrate-specific binding of 8-oxoguanine DNA glycosylase 1 (OGG1) reprograms mucosal adaptations to chronic airway injury. | Recent advances have uncovered the non-random distribution of 7, 8-dihydro-8-oxoguanine (8-oxoGua) induced by reactive oxygen species, which is believed to have epigenetic effects. Its cognate repair protein, 8-oxoguanine DNA glycosylase 1 (OGG1), reads oxidative substrates and participates in transcriptional initiation. When redox signaling is activated in small airway epithelial cells, the DNA repair function of OGG1 is repurposed to transmit acute inflammatory signals accompanied by cell state transitions and modification of the extracellular matrix. Epithelial-mesenchymal and epithelial-immune interactions act cooperatively to establish a local niche that instructs the mucosal immune landscape. If the transitional cell state governed by OGG1 remains responsive to inflammatory mediators instead of differentiation, the collateral damage provides positive feedback to inflammation, ascribing inflammatory remodeling to one of the drivers in chronic pathologies. In this review, we discuss the substrate-specific read through OGG1 has evolved in regulating the innate immune response, controlling adaptations of the airway to environmental and inflammatory injury, with a focus on the reader function of OGG1 in initiation and progression of epithelial to mesenchymal transitions in chronic pulmonary disease. |
| 312 | Allan Brasier | ENDO | abrasier@wisc.edu | Epigenetic control of type III interferon expression by 8-oxoguanine and its reader 8-oxoguanine DNA glycosylase1. | Interferons (IFNs) are secreted cytokines with the ability to activate expression of IFN stimulated genes that increase resistance of cells to virus infections. Activated transcription factors in conjunction with chromatin remodelers induce epigenetic changes that reprogram IFN responses. Unexpectedly, 8-oxoguanine DNA glycosylase1 (Ogg1) knockout mice show enhanced stimuli-driven IFN expression that confers increased resistance to viral and bacterial infections and allergen challenges. Here, we tested the hypothesis that the DNA repair protein OGG1 recognizes 8-oxoguanine (8-oxoGua) in promoters modulating IFN expression. We found that functional inhibition, genetic ablation, and inactivation by post-translational modification of OGG1 significantly augment IFN-λ expression in epithelial cells infected by human respiratory syncytial virus (RSV). Mechanistically, OGG1 bound to 8-oxoGua in proximity to interferon response elements, which inhibits the IRF3/IRF7 and NF-κB/RelA DNA occupancy, while promoting the suppressor NF-κB1/p50-p50 homodimer binding to the IFN-λ2/3 promoter. In a mouse model of bronchiolitis induced by RSV infection, functional ablation of OGG1 by a small molecule inhibitor (TH5487) enhances IFN-λ production, decreases immunopathology, neutrophilia, and confers antiviral protection. These findings suggest that the ROS-generated epigenetic mark 8-oxoGua via its reader OGG1 serves as a homeostatic thresholding factor in IFN-λ expression. Pharmaceutical targeting of OGG1 activity may have clinical utility in modulating antiviral response. |
| 313 | Allan Brasier | ENDO | abrasier@wisc.edu | Metformin Monotherapy Alters the Human Plasma Lipidome Independent of Clinical Markers of Glycemic Control and Cardiovascular Disease Risk in a Type 2 Diabetes Clinical Cohort. | Type 2 diabetes (T2D) is a rising pandemic worldwide. Diet and lifestyle changes are typically the first intervention for T2D. When this intervention fails, the biguanide metformin is the most common pharmaceutical therapy. Yet its full mechanisms of action remain unknown. In this work, we applied an ultrahigh resolution, mass spectrometry-based platform for untargeted plasma metabolomics to human plasma samples from a case-control observational study of nondiabetic and well-controlled T2D subjects, the latter treated conservatively with metformin or diet and lifestyle changes only. No statistically significant differences existed in baseline demographic parameters, glucose control, or clinical markers of cardiovascular disease risk between the two T2D groups, which we hypothesized would allow the identification of circulating metabolites independently associated with treatment modality. Over 3000 blank-reduced metabolic features were detected, with the majority of annotated features being lipids or lipid-like molecules. Altered abundance of multiple fatty acids and phospholipids were found in T2D subjects treated with diet and lifestyle changes as compared with nondiabetic subjects, changes that were often reversed by metformin. Our findings provide direct evidence that metformin monotherapy alters the human plasma lipidome independent of T2D disease control and support a potential cardioprotective effect of metformin worthy of future study. SIGNIFICANCE STATEMENT: This work provides important new information on the systemic effects of metformin in type 2 diabetic subjects. We observed significant changes in the plasma lipidome with metformin therapy, with metabolite classes previously associated with cardiovascular disease risk significantly reduced as compared to diet and lifestyle changes. While cardiovascular disease risk was not a primary outcome of our study, our results provide a jumping-off point for future work into the cardioprotective effects of metformin, even in well-controlled type 2 diabetes. |
| 314 | Allan Brasier | ENDO | abrasier@wisc.edu | RSV replication modifies the XBP1s binding complex on the IRF1 upstream enhancer to potentiate the mucosal anti-viral response. | The unfolded protein response (UPR) has emerged as an important signaling pathway mediating anti-viral defenses to Respiratory Syncytial Virus (RSV) infection. Earlier we found that RSV replication predominantly activates the evolutionarily conserved Inositol Requiring Enzyme 1α (IRE1α)-X-Box Binding Protein 1 spliced (XBP1s) arm of the Unfolded Protein Response (UPR) producing inflammation, metabolic adaptation and cellular plasticity, yet the mechanisms how the UPR potentiates inflammation are not well understood. To understand this process better, we examined the genomic response integrating RNA-seq and Cleavage Under Targets and Release Using Nuclease (CUT&RUN) analyses. These data were integrated with an RNA-seq analysis conducted on RSV-infected small airway cells ± an IRE1α RNAse inhibitor. We identified RSV induced expression changes in ~3.2K genes; of these, 279 required IRE1α and were enriched in IL-10/cytokine signaling pathways. From this data set, we identify those genes directly under XBP1s control by CUT&RUN. Although XBP1s binds to ~4.2 K high-confidence genomic binding sites, surprisingly only a small subset of IL10/cytokine signaling genes are directly bound. We further apply CUT&RUN to find that RSV infection enhances XBP1s loading on 786 genomic sites enriched in AP1/Fra-1, RELA and SP1 binding sites. These control a subset of cytokine regulatory factor genes including IFN response factor 1 (IRF1), CSF2, NFKB1A and DUSP10. Focusing on the downstream role of IRF1, selective knockdown (KD) and overexpression experiments demonstrate IRF1 induction controls type I and -III interferon (IFN) and IFN-stimulated gene (ISG) expression, demonstrating that ISG are indirectly regulated by XBP1 through IRF1 transactivation. Examining the mechanism of IRF1 activation, we observe that XBP1s directly binds a 5' enhancer sequence whose XBP1s loading is increased by RSV. The functional requirement for the enhancer is demonstrated by targeting a dCas9-KRAB silencer, reducing IRF1 activation. Chromatin immunoprecipitation shows that XBP1 is required, but not sufficient, for RSV-induced recruitment of activated phospho-Ser2 Pol II to the enhancer. We conclude that XBP1s is a direct activator of a core subset of IFN and cytokine regulatory genes in response to RSV. Of these IRF1 is upstream of the type III IFN and ISG response. We find that RSV modulates the XBP1s binding complex on the IRF1 5' enhancer whose activation is required for IRF1 expression. These findings provide novel insight into how the IRE1α-XBP1s pathway potentiates airway mucosal anti-viral responses. |
| 315 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Non-colorectal Cancer Screening and Vaccinations in Patients with Inflammatory Bowel Disease: Expert Review. | The aim of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) is to provide best practice advice (BPA) statements for gastroenterologists and other health care providers who provide care to patients with inflammatory bowel disease (IBD). The focus is on IBD-specific screenings (excluding colorectal cancer screening, which is discussed separately) and vaccinations. We provide guidance to ensure that patients are up to date with the disease-specific cancer screenings, vaccinations, as well as advice for mental health and general wellbeing. This expert review was commissioned and approved by the AGA CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. The BPA statements were drawn from reviewing existing literature combined with expert opinion to provide practical advice on the screening for non-colorectal cancers and vaccinations in patients with IBD. Because this was not a systematic review, formal rating of the quality of evidence or strength of the presented considerations was not performed. BPA 1. All adult patients with IBD should receive age-appropriate cancer screening. BPA 2. Adult women with IBD should follow age-appropriate screening for cervical dysplasia. Data are insufficient to determine whether patients receiving combined immunosuppression or thiopurines require more frequent screening. Shared decision making and individual risk stratification are encouraged. BPA 3. All adult patients with IBD should follow skin cancer primary prevention practices by avoiding excessive exposure to the sun's ultraviolet radiation. Patients on immunomodulators, anti-tumor necrosis factor (anti-TNF) biologic agents, or small molecules should undergo yearly total body skin exam (TBSE). Patients with any history of thiopurine use should continue with yearly TBSE even after thiopurine cessation. BPA 4. At every colonoscopy, a thorough perianal and anal examination should be performed. Special attention should be made to inspection of the anal canal of patients with perianal Crohn's disease, anal stricture, human papilloma virus (HPV), human immunodeficiency virus (HIV), and those who engage in anoreceptive intercourse. BPA 5. Gastroenterology clinicians should discuss age-appropriate vaccines with adult patients who have IBD and share responsibility with primary care providers for administering these vaccines. Patients with IBD should follow the adult immunization schedule recommended by the Centers for Disease Control and Prevention (CDC) for all vaccines with the exception of live vaccines; Patients receiving immune modifying agents should be counseled against receiving live vaccines. Immunization history to the two live pediatric vaccines, varicella and measles, mumps, and rubella (MMR) vaccine series is presumptive evidence of immunity; All adults 18-26 years should receive HPV vaccine series and those between 27-45 years should be vaccinated if they are likely to have a new sexual partner. BPA 6. Inactivated vaccines are safe in patients with IBD and their administration are not associated with exacerbation of IBD activity. We suggest patients receive vaccines at the earliest opportunity and preferably off corticosteroids or at the lowest tolerable corticosteroid dose. BPA 7. All adult patients with IBD should be evaluated for latent hepatitis B infection. Patients who have previously completed a full hepatitis B vaccine series but are not seroprotected (anti-HBs < 10 mIU/mL) should receive a single challenge dose of hepatitis B vaccine; Four to eight weeks after this challenge dose, their hepatitis B surface antibody (anti-HBs) levels should be measured to evaluate for an amnestic response; An amnestic response, indicated by an anti-HBs level ≥ 10 mIU/mL (seroprotection), suggests immunologic memory and no further doses are needed; If no amnestic response is observed, the patient should complete a second full two or three dose series of hepatitis B vaccination. BPA 8. All adult patients with IBD should receive an annual inactivated influenza vaccine; Patients receiving anti-TNF monotherapy or who have undergone a solid organ transplant can benefit from a high dose influenza vaccine; Older adults 65 years of age and older should receive a high dose, recombinant, or adjuvanted influenza vaccine. Live attenuated intranasal vaccines should be avoided. BPA 9. All adult patients with IBD aged 19-64 years should receive an initial pneumococcal vaccine, with an subsequent second pneumococcal vaccine administered at 65 years of age and older. BPA 10. All adult patients with IBD who are 60 years of age and older should receive a respiratory syncytial virus (RSV) vaccine. There is no preference for any of the available RSV vaccines. BPA 11. All adult patients 19 years of age and older receiving immune-modifying therapies, or with plans to initiate immune-modifying therapies, should receive a recombinant herpes zoster (RZV) vaccine series, regardless of their prior varicella vaccination status. BPA 12. Bone densitometry should be considered in patients with IBD, regardless of age, when risk factors for osteopenia and osteoporosis are present. These risk factors include low body mass index (BMI; <20), greater than 3 months of cumulative corticosteroid exposure, current smoking, post-menopausal status, or hypogonadism. In the absence of other factors, bone densitometry should be considered for post-menopausal women and men 65 years or older. BPA 13. All adult patients with IBD should be screened for depression and anxiety annually. Patients who screen positive for depression or anxiety should be referred to the appropriate specialist, be it their primary care physician or a mental health specialist. |
| 316 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Editorial: Updated COVID-19 Boosters-Tailoring Protection for Patients With IBD. | |
| 317 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Widening access to recombinant zoster vaccination in IBD. | |
| 318 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Letter: Enhancing the Rigor of Research on Herpes Zoster Risk in IBD Patients Post-SARS-CoV2: Recommendations for Global and Detailed Analyses-Authors' Reply. | |
| 319 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Inadvertent live vaccine administration in adult patients with inflammatory bowel disease on immunosuppressive therapy. | Live vaccines are contraindicated in patients on immunosuppressive therapy. We conducted a retrospective study evaluating the administration of a live vaccine in patients with IBD on immunosuppressive therapy. The primary outcome was to determine clinical or disseminated disease episodes within three months of vaccine administration in patients who inadvertently received a live vaccine. Thirty-five patients met the inclusion criteria. Twenty-two received the measles, mumps, and varicella (MMR) vaccine, nine received the live zoster vaccine, and one received the varicella vaccine (VAR). Three patients received both the MMR and VAR. The majority of our cohort (20, 57 %) were on anti-tumor necrosis factor, followed by azathioprine (12, 34 %) and vedolizumab (3, 9 %). Although live vaccines are contraindicated in patients on immunosuppressive therapy, none of the patients in this study reported any infections after inadvertent immunization. Further studies are required to address the safety and effectiveness of live vaccine administration in this population. |
| 320 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Patients with Inflammatory Bowel Disease are at Increased Risk for Complications of Herpes Zoster. | Patients with inflammatory bowel disease (IBD) are at an increased risk for vaccine-preventable diseases, such as herpes zoster (HZ). The aim of this study was to determine whether complications of HZ are more frequent in patients with IBD than in non-IBD controls. This was a retrospective, cohort study using the Optum Research Database. Patients with IBD were matched 1:1 to non-IBD controls based on age, sex, and index year, which was defined as the diagnosis of HZ. We then identified the complications of HZ that occurred up to 90 days after the index date. We compared patients with IBD with non-IBD controls and evaluated the 90-day risk of HZ complications. We used a composite primary outcome for any HZ complication. Secondary outcomes were risk factors for complications. A total of 4756 patients with IBD met the inclusion criteria and were matched to the controls. Patients with IBD were more likely to have complications of HZ than controls (738 [15.52%] vs 595 [12.51%]; P < .0001). Patients with IBD with higher comorbidity scores were more likely to develop complications (1.86 vs 1.18; P < .0001). In the logistic regression analysis of patients with IBD having a higher comorbidity score, above 50 years of age, on anti-tumor necrosis factor (TNF) or corticosteroids were all at increased risk of a complication of HZ. Patients with IBD are more likely to have complications of HZ than controls. Efforts are needed to increase HZ vaccine uptake to reduce the morbidity of HZ. |
| 321 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Utility of a Third Heplisav-B Dose in Patients With Inflammatory Bowel Disease Without Immunity After 2-Dose Heplisav-B Vaccination. | Hepatitis B virus (HBV) vaccination is recommended in patients with inflammatory bowel disease (IBD). Although the 2-dose Heplisav-B vaccine has proven effective, more than 20% of patients with IBD do not seroconvert. We prospectively evaluated the effectiveness of a third Heplisav-B dose in patients with IBD lacking HBV immunity despite 2-dose vaccination. Adults with IBD who had received 2-dose Heplisav-B vaccination between 2018 and 2023 were identified. Seroconversion was defined as hepatitis B surface antibody (HBsAb) ≥ 10 IU/L measured at ≥4 weeks after vaccination. Patients who did not seroconvert were prospectively offered a third Heplisav-B dose, followed by repeat HBsAb measurement. Demographic, clinical, medication, and vaccination data were compared between those who did and did not seroconvert. Of 192 patients identified, 71.9% (138/192) seroconverted after 2-dose Heplisav-B vaccination. The 54 patients (28.1%) who did not seroconvert were more likely to be male, have diabetes, chronic kidney disease, or elevated Charlson Comorbidity Index. Of the 54 patients, 30 (55.6%) elected to receive a third Heplisav-B dose, with 56.7% (17/30) achieving seroconversion (median HBsAb titer 376 IU/L, IQR 47-1,000 IU/L) despite a median intervaccination time of 416 days (IQR 90.8-667.8). No differences were noted between patients who did vs did not seroconvert after third-dose vaccination. In patients with IBD lacking HBV immunity despite 2-dose Heplisav-B vaccination, administration of a third dose resulted in a 56.7% seroconversion rate. Our results suggest that administration of an additional Heplisav-B dose may be an effective strategy in patients lacking immunity despite primary 2-dose vaccination. |
| 322 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Safety of Rotavirus Vaccination in Infants That Were Exposed to Biologics In Utero: A Systematic Review. | In infants that were exposed to biologics in utero, gastroenterology societal guidelines have either recommended against administration of the live rotavirus vaccine until 6-12 months of age or until serum biologic levels are undetectable. We performed a systematic review to evaluate the safety of rotavirus vaccination in biologic-exposed infants. EMBASE, PubMed, Scopus, and Cochrane databases were searched from 2006 to 2024 for original data reporting on the safety of rotavirus vaccination in infants that were exposed to anti-tumor necrosis factors (TNFs) (ie, infliximab, adalimumab, golimumab, certolizumab) and non-TNF biologics (ie, vedolizumab, ustekinumab, rizankizumab, mirikizumab) in utero. A database search yielded 7185 screening results of which 10 studies met inclusion criteria. There were over 300 instances of rotavirus vaccination in biologic-exposed infants (n = 162 exposed to anti-TNFs, n = 142 exposed to non-TNF biologics). Biologic-exposed infants were not at an increased risk of severe adverse events or adverse events of any severity related to rotavirus vaccination. Administration of the live rotavirus vaccine appears to be safe in biologic-exposed infants. As such, with careful examination of the risks and benefits, there may be a role for rotavirus vaccination in this population. We performed a systematic review evaluating the safety of rotavirus vaccination in infants that were exposed to anti-TNFs and non-TNF biologics in utero. There was no increased risk of adverse events associated with rotavirus vaccination in this population. |
| 323 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Hepatitis B-CpG Vaccine Series for Healthcare Workers Who Are Hepatitis B Vaccine Nonresponders. | This prospective study enrolled healthcare workers (HCWs) who were nonresponders following at least 5 doses of aluminum-adjuvanted hepatitis B vaccine who received the 2-dose Heplisav-B (HepB-CpG) (Dynavax Technologies Corporation, Emeryville, CA) series. After 2 doses of HepB-CpG, 43/47 (91%) participants, and with 1 dose, 41/49 (84%) responded. HepB-CpG could be the preferred vaccine in HCW nonresponders. Clinical Trials Registration. Clinicaltrials.gov NCT04456504. |
| 324 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | High Rates of Seroprotection to Hepatitis B After a Hepatitis B Challenge Dose in Previously Vaccinated Patients with Inflammatory Bowel Disease on Immunosuppressive Therapy. | Healthy populations have high rates of sustained vaccine-induced seroprotection to hepatitis B virus, but previous studies in immunosuppressed patients with inflammatory bowel disease (IBD) have shown suboptimal seroprotection rates. A challenge dose of hepatitis B vaccine (HepB) is recommended in previously vaccinated individuals who are seronegative to elicit an anamnestic response and determine if they are seroprotected. The aim of our study was to determine sustained seroprotection rates to hepatitis B vaccine (HepB) in patients with IBD. This was a single-center prospective study of patients with IBD previously vaccinated with a three dose HepB series. Patients had a hepatitis B surface antibody (anti-HBs) drawn; if it was below 10 mIU/mL, they received a challenge dose of the HepB vaccine to assess for anamnestic response and sustained seroprotection. The primary outcome was to determine the rate of sustained seroprotection (anti-HBs ≥ 10). A total of 168 patients met inclusion criteria, mean age 35.7 years ± 13.6 standard deviation (SD). Initially 120 (71.4%) had anti-HBs ≥ 10 mIU/mL, with median anti-HBs of 37 mIU/mL (interquartile range 0-234); 48 (28.6%) needed a challenge dose, of which 34 responded with anti-HBs ≥ 10 mIU/mL. In total, 154 (91.7%) demonstrated sustained seroprotection to HepB. Those not seroprotected were more likely to have been vaccinated on immunosuppressive therapy or after their diagnosis of IBD. Most vaccinated patients with IBD maintain sustained seroprotection to HepB despite prolonged exposure to immunosuppression. This contradicts prior studies and shows that immunosuppression does not lead to loss of seroprotection. |
| 325 | Richard Halberg | GI | rbhalberg@medicine.wisc.edu | Colorectal cancer-associated bacteria are broadly distributed in global microbiomes and drivers of precancerous change. | The gut microbiome is implicated in the pathogenesis of colorectal cancer (CRC), but the full scope of this dialogue is unknown. Here we aimed to define the scale and membership of the body of CRC- and health-associated gut bacteria in global populations. We performed a microbiome-CRC correlation analysis of published ultra-deep shotgun metagenomic sequencing data from global microbiome surveys, utilizing a de novo (reference-agnostic) gene-level clustering approach to identify protein-coding co-abundant gene (CAGs) clusters. We link an unprecedented ~ 23-40% of gut bacteria to CRC or health, split nearly evenly as CRC- or health-associated. These microbes encode 2319 CAGs encompassing 427,261 bacterial genes significantly enriched or depleted in CRC. We identified many microbes that had not previously been linked to CRC, thus expanding the scope of "known unknowns" of CRC-associated microbes. We performed an agnostic CAG-based screen of bacterial isolates and validated predicted effects of previously unimplicated bacteria in preclinical models, in which we observed differential induction of precancerous adenomas and field effects. Single-cell RNA sequencing disclosed microbiome-induced senescence-associated gene expression signatures in discrete colonic populations including fibroblasts. In organoid co-cultures, primary colon fibroblasts from mice with microbiomes promoted significantly greater growth than fibroblasts from microbiome-depleted mice. These results offer proof-of-principle for gene-level metagenomic analysis enabling discovery of microbiome links to health and demonstrate that the microbiome can drive precancer states, thereby potentially revealing novel cancer prevention opportunities. |
| 326 | Richard Halberg | GI | rbhalberg@medicine.wisc.edu | MAD1 upregulation sensitizes to inflammation-mediated tumor formation. | Mitotic Arrest Deficient 1 (gene name MAD1L1), an essential component of the mitotic spindle assembly checkpoint, is frequently overexpressed in colon cancer, which correlates with poor disease-free survival. MAD1 upregulation induces two phenotypes associated with tumor promotion in tissue culture cells-low rates of chromosomal instability (CIN) and destabilization of the tumor suppressor p53. Using CRISPR/Cas9 gene editing, we generated a novel mouse model by inserting a doxycycline (dox)-inducible promoter and HA tag into the endogenous mouse Mad1l1 gene, enabling inducible expression of HA-MAD1 following exposure to dox in the presence of the reverse tet transactivator (rtTA). A modest 2-fold overexpression of MAD1 in murine colon resulted in decreased p53 expression and increased mitotic defects consistent with CIN. After exposure to the colon-specific inflammatory agent dextran sulfate sodium (DSS), 31% of mice developed colon lesions, including a mucinous adenocarcinoma, while none formed in control animals. Lesion incidence was particularly high in male mice, 57% of which developed at least one hyperplastic polyp, adenoma or adenocarcinoma in the colon. Notably, mice expressing HA-MAD1 also developed lesions in tissues in which DSS is not expected to induce inflammation. These findings demonstrate that MAD1 upregulation is sufficient to promote colon tumorigenesis in the context of inflammation in immune-competent mice. |
| 327 | Richard Halberg | GI | rbhalberg@medicine.wisc.edu | The Hallmarks of Precancer. | Research on precancers, as defined as at-risk tissues and early lesions, is of high significance given the effectiveness of early intervention. We discuss the need for risk stratification to prevent overtreatment, an emphasis on the role of genetic and epigenetic aging when considering risk, and the importance of integrating macroenvironmental risk factors with molecules and cells in lesions and at-risk normal tissues for developing effective intervention and health policy strategies. |
| 328 | Richard Halberg | GI | rbhalberg@medicine.wisc.edu | Farnesoid X receptor mediates macrophage-intrinsic responses to suppress colitis-induced colon cancer progression. | Bile acids (BAs) affect the intestinal environment by ensuring barrier integrity, maintaining microbiota balance, regulating epithelium turnover, and modulating the immune system. As a master regulator of BA homeostasis, farnesoid X receptor (FXR) is severely compromised in patients with inflammatory bowel disease (IBD) and colitis-associated colorectal cancer (CAC). At the front line, gut macrophages react to the microbiota and metabolites that breach the epithelium. We aim to study the role of the BA/FXR axis in macrophages. This study demonstrates that inflammation-induced epithelial abnormalities compromised FXR signaling and altered BAs' profile in a mouse CAC model. Further, gut macrophage-intrinsic FXR sensed aberrant BAs, leading to pro-inflammatory cytokines' secretion, which promoted intestinal stem cell proliferation. Mechanistically, activation of FXR ameliorated intestinal inflammation and inhibited colitis-associated tumor growth, by regulating gut macrophages' recruitment, polarization, and crosstalk with Th17 cells. However, deletion of FXR in bone marrow or gut macrophages escalated the intestinal inflammation. In summary, our study reveals a distinctive regulatory role of FXR in gut macrophages, suggesting its potential as a therapeutic target for addressing IBD and CAC. |
| 329 | Richard Halberg | GI | rbhalberg@medicine.wisc.edu | Natural History of Colorectal Polyps Undergoing Longitudinal in Vivo CT Colonography Surveillance. | Background The natural history of colorectal polyps is not well characterized due to clinical standards of care and other practical constraints limiting in vivo longitudinal surveillance. Established CT colonography (CTC) clinical screening protocols allow surveillance of small (6-9 mm) polyps. Purpose To assess the natural history of colorectal polyps followed with CTC in a clinical screening program, with histopathologic correlation for resected polyps. Materials and Methods In this retrospective study, CTC was used to longitudinally monitor small colorectal polyps in asymptomatic adult patients from April 1, 2004, to August 31, 2020. All patients underwent at least two CTC examinations. Polyp growth patterns across multiple time points were analyzed, with histopathologic context for resected polyps. Regression analysis was performed to evaluate predictors of advanced histopathology. Results In this study of 475 asymptomatic adult patients (mean age, 56.9 years ± 6.7 [SD]; 263 men), 639 unique polyps (mean initial diameter, 6.3 mm; volume, 50.2 mm3) were followed for a mean of 5.1 years ± 2.9. Of these 639 polyps, 398 (62.3%) underwent resection and histopathologic evaluation, and 41 (6.4%) proved to be histopathologically advanced (adenocarcinoma, high-grade dysplasia, or villous content), including two cancers and 38 tubulovillous adenomas. Advanced polyps showed mean volume growth of +178% per year (752% per year for adenocarcinomas) compared with +33% per year for nonadvanced polyps and -3% per year for unresected, unretrieved, or resolved polyps (P < .001). In addition, 90% of histologically advanced polyps achieved a volume of 100 mm3 and/or volume growth rate of 100% per year, compared with 29% of nonadvanced and 16% of unresected or resolved polyps (P < .001). Polyp volume-to-diameter ratio was also significantly greater for advanced polyps. For polyps observed at three or more time points, most advanced polyps demonstrated an initial slower growth interval, followed by a period of more rapid growth. Conclusion Small colorectal polyps ultimately proving to be histopathologically advanced neoplasms demonstrated substantially faster growth and attained greater overall size compared with nonadvanced polyps. Clinical trial registration no. NCT00204867 © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Dachman in this issue. |
| 330 | Richard Halberg | GI | rbhalberg@medicine.wisc.edu | Potential roles of FGF5 as a candidate therapeutic target in prostate cancer. | Fibroblast growth factor (FGF) is a secreted ligand that is widely expressed in embryonic tissues but its expression decreases with age. In the developing prostate, FGF5 has been proposed to interact with the Hedgehog (Hh) signaling pathway to guide mitogenic processes. In the adult prostate, the FGF/FGFR signaling axis has been implicated in prostate carcinogenesis, but focused studies on FGF5 functions in the prostate are limited. Functional studies completed in other cancer models point towards FGF5 overexpression as an oncogenic driver associated with stemness, metastatic potential, proliferative capacity, and increased tumor grade. In this review, we explore the significance of FGF5 as a therapeutic target in prostate cancer (PCa) and other malignancies; and we introduce a potential route of investigation to link FGF5 to benign prostatic hyperplasia (BPH). PCa and BPH are two primary contributors to the disease burden of the aging male population and have severe implications on quality of life, psychological wellbeing, and survival. The development of new FGF5 inhibitors could potentially alleviate the health burden of PCa and BPH in the aging male population. |
| 331 | Richard Halberg | GI | rbhalberg@medicine.wisc.edu | Growth rates and histopathological outcomes of small (6-9 mm) colorectal polyps based on CT colonography surveillance and endoscopic removal. | The natural history of small polyps is not well established and rests on limited evidence from barium enema studies decades ago. Patients with one or two small polyps (6-9 mm) at screening CT colonography (CTC) are offered CTC surveillance at 3 years but may elect immediate colonoscopy. This practice allows direct observation of the growth of subcentimetre polyps, with histopathological correlation in patients undergoing subsequent polypectomy. Of 11 165 asymptomatic patients screened by CTC over a period of 16.4 years, 1067 had one or two 6-9 mm polyps detected (with no polyps ≥10 mm). Of these, 314 (mean age, 57.4 years; M:F, 141:173; 375 total polyps) elected immediate colonoscopic polypectomy, and 382 (mean age 57.0 years; M:F, 217:165; 481 total polyps) elected CTC surveillance over a mean of 4.7 years. Volumetric polyp growth was analysed, with histopathological correlation for resected polyps. Polyp growth and regression were defined as volume change of ±20% per year, with rapid growth defined as +100% per year (annual volume doubling). Regression analysis was performed to evaluate predictors of advanced histology, defined as the presence of cancer, high-grade dysplasia (HGD) or villous components. Of the 314 patients who underwent immediate polypectomy, 67.8% (213/314) harboured adenomas, 2.2% (7/314) with advanced histology; no polyps contained cancer or HGD. Of 382 patients who underwent CTC surveillance, 24.9% (95/382) had polyps that grew, while 62.0% (237/382) remained stable and 13.1% (50/382) regressed in size. Of the 58.6% (224/382) CTC surveillance patients who ultimately underwent colonoscopic resection, 87.1% (195/224) harboured adenomas, 12.9% (29/224) with advanced histology. Of CTC surveillance patients with growing polyps who underwent resection, 23.2% (19/82) harboured advanced histology vs 7.0% (10/142) with stable or regressing polyps (OR: 4.0; p<0.001), with even greater risk of advanced histology in those with rapid growth (63.6%, 14/22, OR: 25.4; p<0.001). Polyp growth, but not patient age/sex or polyp morphology/location were significant predictors of advanced histology. Small 6-9 mm polyps present overall low risk to patients, with polyp growth strongly associated with higher risk lesions. Most patients (75%) with small 6-9 mm polyps will see polyp stability or regression, with advanced histology seen in only 7%. The minority of patients (25%) with small polyps that do grow have a 3-fold increased risk of advanced histology. |
| 332 | Richard Halberg | GI | rbhalberg@medicine.wisc.edu | A Highly Sensitive Pan-Cancer Test for Microsatellite Instability. | Microsatellite instability (MSI) is an evolving biomarker for cancer detection and treatment. MSI was first used to identify patients with Lynch syndrome, a hereditary form of colorectal cancer (CRC), but has recently become indispensable in predicting patient response to immunotherapy. To address the need for pan-cancer MSI detection, a new multiplex assay was developed that uses novel long mononucleotide repeat (LMR) markers to improve sensitivity. A total of 469 tumor samples from 20 different cancer types, including 319 from patients with Lynch syndrome, were tested for MSI using the new LMR MSI Analysis System. Results were validated by using deficient mismatch repair (dMMR) status according to immunohistochemistry as the reference standard and compared versus the Promega pentaplex MSI panel. The sensitivity of the LMR panel for detection of dMMR status by immunohistochemistry was 99% for CRC and 96% for non-CRC. The overall percent agreement between the LMR and Promega pentaplex panels was 99% for CRC and 89% for non-CRC tumors. An increased number of unstable markers and the larger size shifts observed in dMMR tumors using the LMR panel increased confidence in MSI determinations. The LMR MSI Analysis System expands the spectrum of cancer types in which MSI can be accurately detected. |
| 333 | Richard Halberg | GI | rbhalberg@medicine.wisc.edu | SpotClean adjusts for spot swapping in spatial transcriptomics data. | Spatial transcriptomics is a powerful and widely used approach for profiling the gene expression landscape across a tissue with emerging applications in molecular medicine and tumor diagnostics. Recent spatial transcriptomics experiments utilize slides containing thousands of spots with spot-specific barcodes that bind RNA. Ideally, unique molecular identifiers (UMIs) at a spot measure spot-specific expression, but this is often not the case in practice due to bleed from nearby spots, an artifact we refer to as spot swapping. To improve the power and precision of downstream analyses in spatial transcriptomics experiments, we propose SpotClean, a probabilistic model that adjusts for spot swapping to provide more accurate estimates of gene-specific UMI counts. SpotClean provides substantial improvements in marker gene analyses and in clustering, especially when tissue regions are not easily separated. As demonstrated in multiple studies of cancer, SpotClean improves tumor versus normal tissue delineation and improves tumor burden estimation thus increasing the potential for clinical and diagnostic applications of spatial transcriptomics technologies. |
| 334 | Richard Halberg | GI | rbhalberg@medicine.wisc.edu | Multi-ancestral origin of intestinal tumors: Impact on growth, progression, and drug efficacy. | Data are steadily accruing that demonstrate that intestinal tumors are frequently derived from multiple founding cells, resulting in tumors comprised of distinct ancestral clones that might cooperate or alternatively compete, thereby potentially impacting different phases of the disease process. We sought to determine whether tumors with a multi-ancestral architecture involving at least two distinct clones show increased tumor number, growth, progression, or resistance to drug intervention. Mice carrying the Min allele of Apc were generated that were mosaic with only a subset of cells in the intestinal epithelium expressing an activated form of PI3K, a key regulatory kinase affecting several important cellular processes. These cells were identifiable as they fluoresced green, whereas all other cells fluoresced red. Cell lineage tracing revealed that many intestinal tumors from our mouse model were derived from at least two founding cells, those expressing the activated PI3K (green) and those which did not (red). Heterotypic tumors with a multi-ancestral architecture as evidenced by a mixture of green and red cells exhibited increased tumor growth and invasiveness. Clonal architecture also had an impact on tumor response to low-dose aspirin. Aspirin treatment resulted in a greater reduction of heterotypic tumors derived from multiple founding cells as compared to tumors derived from a single founding cell. These data indicate that genetically distinct tumor-founding cells can contribute to early intratumoral heterogeneity. The coevolution of the founding cells and their progeny enhances colon tumor progression and impacts the response to aspirin. These findings are important to a more complete understanding of tumorigenesis with consequences for several distinct models of tumor evolution. They also have practical implications to the clinic. Mouse models with heterogenous tumors are likely better for predicting drug efficacy as compared to models in which the tumors are highly homogeneous. Moreover, understanding how interactions among different populations in a single heterotypic tumor with a multi-ancestral architecture impact response to a single agent and combination therapies are necessary to fully develop personalized medicine. |
| 336 | Andrew Hryckowian | GI | hryckowian@medicine.wisc.edu | Re-framing the importance of Group B Streptococcus as a gut-resident pathobiont. | Streptococcus agalactiae (Group B Streptococcus, GBS) is a Gram-positive bacterial species that causes disease in humans across the lifespan. While antibiotics are used to mitigate GBS infections, it is evident that antibiotics disrupt human microbiomes (which can predispose people to other diseases later in life), and antibiotic resistance in GBS is on the rise. Taken together, these unintended negative impacts of antibiotics highlight the need for precision approaches for minimizing GBS disease. One possible approach involves selectively depleting GBS in its commensal niches before it can cause disease at other body sites or be transmitted to at-risk individuals. One understudied commensal niche of GBS is the adult gastrointestinal (GI) tract, which may predispose colonization at other body sites in individuals at risk for GBS disease. However, a better understanding of the host-, microbiome-, and GBS-determined variables that dictate GBS GI carriage is needed before precise GI decolonization approaches can be developed. In this review, we synthesize current knowledge of the diverse body sites occupied by GBS as a pathogen and as a commensal. We summarize key molecular factors GBS utilizes to colonize different host-associated niches to inform future efforts to study GBS in the GI tract. We also discuss other GI commensals that are pathogenic in other body sites to emphasize the broader utility of precise de-colonization approaches for mitigating infections by GBS and other bacterial pathogens. Finally, we highlight how GBS treatments could be improved with a more holistic understanding of GBS enabled by continued GI-focused study. |
| 338 | Andrew Hryckowian | GI | hryckowian@medicine.wisc.edu | Exogenous butyrate inhibits butyrogenic metabolism and alters virulence phenotypes in Clostridioides difficile. | The gut microbiome engenders colonization resistance against the diarrheal pathogen Clostridioides difficile, but the molecular basis of this colonization resistance is incompletely understood. A prominent class of gut microbiome-produced metabolites important for colonization resistance against C. difficile is short-chain fatty acids (SCFAs). In particular, one SCFA (butyrate) decreases the fitness of C. difficile in vitro and is correlated with C. difficile-inhospitable gut environments, both in mice and in humans. Here, we demonstrate that butyrate-dependent growth inhibition in C. difficile occurs under conditions where C. difficile also produces butyrate as a metabolic end product. Furthermore, we show that exogenous butyrate is internalized into C. difficile cells and is incorporated into intracellular CoA pools where it is metabolized in a reverse (energetically unfavorable) direction to crotonyl-CoA and (S)-3-hydroxybutyryl-CoA and/or 4-hydroxybutyryl-CoA. This internalization of butyrate and reverse metabolic flow of a butyrogenic pathway(s) in C. difficile coincides with alterations in toxin release and sporulation. Together, this work highlights butyrate as a marker of a C. difficile-inhospitable environment to which C. difficile responds by releasing its diarrheagenic toxins and producing environmentally resistant spores necessary for transmission between hosts. These findings provide foundational data for understanding the molecular and genetic basis of how C. difficile growth is inhibited by butyrate and how butyrate alters C. difficile virulence in the face of a highly competitive and dynamic gut environment.IMPORTANCEThe gut microbiome engenders colonization resistance against the diarrheal pathogen Clostridioides difficile, but the molecular basis of this colonization resistance is incompletely understood, which hinders the development of novel therapeutic interventions for C. difficile infection (CDI). We investigated how C. difficile responds to butyrate, an end-product of gut microbiome community metabolism which inhibits C. difficile growth. We show that exogenously produced butyrate is internalized into C. difficile, which inhibits C. difficile growth by interfering with its own butyrate production. This growth inhibition coincides with increased toxin release from C. difficile cells and the production of environmentally resistant spores necessary for transmission between hosts. Future work to disentangle the molecular mechanisms underlying these growth and virulence phenotypes will likely lead to new strategies to restrict C. difficile growth in the gut and minimize its pathogenesis during CDI. |
| 340 | Andrew Hryckowian | GI | hryckowian@medicine.wisc.edu | Determinants of Gastrointestinal Group B Streptococcus Carriage in Adults. | Streptococcus agalactiae (Group B Streptococcus, GBS) is a commensal Gram-positive bacterium found in the human gastrointestinal and urogenital tracts. Much of what is known about GBS relates to the diseases it causes in pregnant people and neonates. However, GBS is a common cause of disease in the general population with 90% of GBS mortality occurring in non-pregnant people. There are limited data about the predisposing factors for GBS and the reservoirs in the body. To gain an understanding of the determinants of gastrointestinal GBS carriage, we used stool samples and associated metadata to determine the prevalence and abundance of GBS in the gut microbiome of adults and find risk factors for GBS status. We used 754 stool samples collected from adults in Wisconsin from 2016-2017 to test for the prevalence and abundance of GBS using a Taqman probe-based qPCR assay targeting two GBS-specific genes: cfp and sip. We compared the microbiome compositions of the stool samples by GBS status using 16S rRNA analysis. We compared associations with GBS status and 557 survey variables collected during sample acquisition (demographics, diet, overall health, and reproductive health) using univariate and multivariate analyses. We found 137/754 (18%) of participants had detectable GBS in their stool samples with a median abundance of 104 copies per nanogram of starting DNA. There was no difference in GBS status or abundance based on gender. Beta-diversity, Bray-Curtis and Unweighted UniFrac, was significantly different based on carrier status of the participant. Prior to p-value correction, 59/557 (10.6%) survey variables were significantly associated with GBS carrier status and 11/547 (2.0%) variables were significantly associated with abundance (p-value<0.05). After p-value correction, 2/547 (0.4%) variables were associated with GBS abundance: an increased abundance of GBS was associated with a decreased frequency since last dental checkup (p<0.001) and last dental cleaning (p<0.001). Increased GBS abundance was significantly associated with increased frequency of iron consumption (p=0.007) after p-value correction in multivariate models. GBS is found in stool samples from adults in Wisconsin at similar frequencies as pregnant individuals screened with rectovaginal swabs. We did not find associations between risk factors historically associated with GBS in pregnant people, suggesting that risk factors for GBS carriage in pregnancy may differ from those in the general population. We found that frequency of iron consumption and dental hygiene are risk factors for GBS carriage in Wisconsin adults. Given that these variables were not assayed in previous GBS surveys, it is possible they also influence carriage in pregnant people. Taken together, this work serves as a foundation for future work in developing approaches to decrease GBS abundance in carriers. |
| 342 | Andrew Hryckowian | GI | hryckowian@medicine.wisc.edu | Butyrate Differentiates Permissiveness to Clostridioides difficile Infection and Influences Growth of Diverse C. difficile Isolates. | A disrupted "dysbiotic" gut microbiome engenders susceptibility to the diarrheal pathogen Clostridioides difficile by impacting the metabolic milieu of the gut. Diet, in particular the microbiota-accessible carbohydrates (MACs) found in dietary fiber, is one of the most powerful ways to affect the composition and metabolic output of the gut microbiome. As such, diet is a powerful tool for understanding the biology of C. difficile and for developing alternative approaches for coping with this pathogen. One prominent class of metabolites produced by the gut microbiome is short-chain fatty acids (SCFAs), the major metabolic end products of MAC metabolism. SCFAs are known to decrease the fitness of C. difficile in vitro, and high intestinal SCFA concentrations are associated with reduced fitness of C. difficile in animal models of C. difficile infection (CDI). Here, we use controlled dietary conditions (8 diets that differ only by MAC composition) to show that C. difficile fitness is most consistently impacted by butyrate, rather than the other two prominent SCFAs (acetate and propionate), during murine model CDI. We similarly show that butyrate concentrations are lower in fecal samples from humans with CDI than in those from healthy controls. Finally, we demonstrate that butyrate impacts growth in diverse C. difficile isolates. These findings provide a foundation for future work which will dissect how butyrate directly impacts C. difficile fitness and will lead to the development of diverse approaches distinct from antibiotics or fecal transplant, such as dietary interventions, for mitigating CDI in at-risk human populations. IMPORTANCE Clostridioides difficile is a leading cause of infectious diarrhea in humans, and it imposes a tremendous burden on the health care system. Current treatments for C. difficile infection (CDI) include antibiotics and fecal microbiota transplant, which contribute to recurrent CDIs and face major regulatory hurdles, respectively. Therefore, there is an ongoing need to develop new ways to cope with CDI. Notably, a disrupted "dysbiotic" gut microbiota is the primary risk factor for CDI, but we incompletely understand how a healthy microbiota resists CDI. Here, we show that a specific molecule produced by the gut microbiota, butyrate, is negatively associated with C. difficile burdens in humans and in a mouse model of CDI and that butyrate impedes the growth of diverse C. difficile strains in pure culture. These findings help to build a foundation for designing alternative, possibly diet-based, strategies for mitigating CDI in humans. |
| 345 | Jennifer Weiss | GI | jmw@medicine.wisc.edu | Editorial: Disparities in early onset colorectal cancer. | |
| 346 | Jennifer Weiss | GI | jmw@medicine.wisc.edu | Barriers to Colonoscopy Quality Measurement in Rural Wisconsin. | Patients in rural areas have reduced colonoscopy access, which is critical for colorectal cancer prevention. General surgeons perform most colonoscopies in rural areas. The Surgical Collaborative of Wisconsin's Rural Task Force identified colonoscopy as a high priority initiative due to high volume and lack of quality measure access, both necessary for assessing and improving performance. Assess the capacity for colonoscopy quality measurement and improvement in rural Wisconsin hospitals. In October 2019-January 2020, the Surgical Collaborative of Wisconsin, Rural Wisconsin Health Cooperative, and Wisconsin Collaborative for Healthcare Quality collaborated to design/distribute a survey to 44 Rural Wisconsin Health Cooperative hospitals (n = 25 completed, response rate 57%). Descriptive statistics summarized survey items. Surgeons in each of six rural hospitals participated in stakeholder interviews. Rural Wisconsin Health Cooperative hospitals. Colonoscopy providers, procedure volume/capacity, informatics and quality measurement infrastructure, barriers to quality measurement and improvement. Most colonoscopy providers in rural hospitals were surgeons (66.3%) followed by family/internal medicine (20.0%) and gastroenterologists (13.8%). Average hospital volume/week was 19.9 colonoscopies (SD = 13.4). Hospitals reported operating at ~75% capacity. Withdrawal time was the most tracked measure (44.0%), followed by adenoma detection (36.0%), and cecal intubation (28.0%) rates. Approximately one-third of hospitals (36.0%) utilized procedure reporting software. Most hospitals (80.0%) did not have access to onsite pathology. Surgeons reported barriers to quality measurement/improvement, including insufficient resources for electronic medical record-based reporting and the need for targeted educational opportunities that do not require travel. Single state; may not represent experience of all rural hospitals. The lack of access to colonoscopy quality measures suggests the opportunity to develop a flexible approach that considers reporting software availability and electronic medical record differences. Improving access to measures and education/training opportunities may improve availability of high-quality colonoscopy for patients in rural Wisconsin. See Video Abstract. |
| 347 | Jennifer Weiss | GI | jmw@medicine.wisc.edu | Genetic Testing Utilization: Discrepancies Between Somatic and Germline Results in Patients With Cancer Reviewed at the UW Health Precision Medicine Molecular Tumor Board. | Somatic and germline testing are increasingly used to estimate risks for patients with cancer. Although both germline testing and somatic testing can identify genetic variants that could change a patient's care and eligible treatments, the aims of these tests and their technologies are fundamentally different and cannot be used interchangeably. This study examines the timing and results of somatic and germline genetic testing for patients with cancer at UW Health. Eight hundred and seventy-seven participants underwent somatic genetic testing, which was reviewed by the Precision Medicine Molecular Tumor Board (PMMTB). Patients were diagnosed with cancers, including breast, colorectal, endometrial, pancreatic, or ovarian cancer, and met National Comprehensive Cancer Network criteria for germline genetic testing. Germline testing details were collected by medical record review. The results of this study found that only 310 patients (35%) had germline evaluation before PMMTB review. The percent of germline pathogenic/likely pathogenic variants identified in actionable genes was 28%. Most germline variants were identified in the BRCA1 (26%) and BRCA2 (28%) genes. In total, 65% (54/83) of germline variants were detected with both germline testing and somatic testing; however, 35% (29/83) of germline variants were not identified on somatic results. These results demonstrate the importance of combination germline and somatic testing. This study highlights the differences in genetic testing types and demonstrates that conducting germline testing at earlier stages of diagnoses is necessary to identify potentially actionable and treatment-specific variants in patients with cancer. |
| 348 | Jennifer Weiss | GI | jmw@medicine.wisc.edu | Racial, Ethnic, and Geographic Disparities in Immunization Rates Among Patients With Inflammatory Bowel Disease. | Racial and ethnic disparities exist in the treatment of IBD. These disparities exist in adult vaccine uptake among the general population and may extend to patients with IBD. The primary aim of this study was to determine whether racial, ethnic, or geographic disparities existed in influenza vaccine uptake among patients with IBD. We performed a multicenter, retrospective cohort study evaluating adult vaccine uptake among patients with IBD seen at two tertiary referral centers between September 2019 and February 2020. The primary outcome was to determine if racial/ethnic and geographic disparities existed in influenza vaccine uptake for the two prior seasons. Our secondary outcomes were to determine if disparities existed for pneumococcal, zoster, or hepatitis B vaccines. Among the 2453 patients who met the inclusion criteria, most identified as non-Hispanic White (89.9%), were on immunosuppressive therapy (74.5%), and received the influenza vaccine in both seasons (56.0%). Older age (prevalence ratio (PR) 0.98; 95% confidence interval (95%CI) 0.98-0.99; P < .001) and non-Hispanic White patients (PR 0.76, 95%CI 0.59-0.98, P < 0.03) were significantly more likely to be immunized. Black patients (PR 1.37; 95%CI 1.18-1.59; P < .001) and those living in underserved geographic areas (PR 1.35; 95%CI 1.17-1.56; P < 0.001) were less likely to be immunized. Racial/ethnic and geographic disparities were identified for pneumococcal, zoster, and hepatitis B vaccine uptake. Racial and ethnic vaccination uptake disparities exist among patients with IBD; patients from medically underserved areas are also vulnerable to these disparities Studies identifying patient, provider, and system-level opportunities to address these disparities are needed. |
| 349 | Jennifer Weiss | GI | jmw@medicine.wisc.edu | Uptake Rates of Three COVID-19 Vaccine Doses and Risk Factors for Incomplete Vaccination Among Patients With Inflammatory Bowel Disease Residing in Wisconsin: A Single-Center Cohort. | Patients with inflammatory bowel disease on systemic corticosteroids may be at higher risk of adverse outcomes of COVID-19 infection, and vaccination is an essential preventive measure. Uptake of the original 2-dose COVID-19 messenger RNA (mRNA) primary vaccine series was previously high among patients with inflammatory bowel disease, while uptake of subsequent doses based on interval recommendations made by the Advisory Committee on Immunization Practice remains unknown. Herein, we evaluated uptake of 3 COVID-19 mRNA vaccine doses among patients with inflammatory bowel disease. A total of 1012 patients were identified; 728 (71.9%) patients received 3 COVID-19 vaccine doses. Multivariable logistic regression revealed that younger age (odds ratio [OR] 1.02; 95% CI, 1.01 - 1.03; P = 0.001), rural status (OR 3.44; 95% CI, 2.17 - 5.56; P < 0.001), underrepresented minority status (OR 3.85; 95% CI, 1.89 - 7.69; P < 0.001), and absence of influenza vaccination (OR 8.17; 95% CI, 5.41 - 12.33; P < 0.001) were significantly associated with incomplete COVID-19 vaccination. Of 1362 patients, 83.3% completed a COVID-19 vaccination series. Younger patients had increased odds of not completing a COVID-19 vaccination series (mean [SD] 46.7 [14.7] vs 54.3 [15.8]; OR 1.03; 95% CI, 1.02-1.04; P < 0.001). Those who identified as non-White (1.88; 95% CI, 1.16-3.04; P = 0.010) or current smoker (1.85, 95% CI, 1.85-2.79; P = 0.004) had increased odds of not completing a COVID-19 vaccination series. Those who resided in rural ZIP codes (1.81; 95% CI, 1.35-2.43; P < 0.001), had not received a 2019-2020 influenza vaccine (5.13; 95% CI, 3.79-6.96; P < 0.001), or had lower comorbidity scores (2.95; 95% CI, 1.98-4.41; P < 0.001) had higher odds of not completing a COVID-19 vaccination series. Receipt of 3 COVID-19 mRNA vaccine doses is high overall among patients with inflammatory bowel disease. Younger age, underrepresented race/ethnicity, rural status, and lack of influenza vaccination are associated with incomplete COVID-19 vaccination. |
| 350 | Jennifer Weiss | GI | jmw@medicine.wisc.edu | High but Inequitable COVID-19 Vaccine Uptake Among Rehabilitation Patients. | There is a paucity of studies evaluating vaccine uptake in adults with neurological and musculoskeletal medical conditions. We sought to evaluate the rates of COVID-19 vaccine uptake in patients seen in an outpatient rehabilitation clinic. We conducted a retrospective, single center study of adults seen at an outpatient rehabilitation clinic from December 1, 2020, through June 30, 2021, with an active Wisconsin Immunization Registry record. The primary outcome was completion of a COVID-19 primary vaccine series. Of 1362 patients, 83.3% completed a COVID-19 vaccination series. Younger patients had increased odds of not completing a COVID-19 vaccination series (mean [SD] 46.7 [14.7] vs 54.3 [15.8]; OR 1.03; 95% CI, 1.02-1.04; P < 0.001). Those who identified as non-White (1.88; 95% CI, 1.16-3.04; P = 0.010) or current smoker (1.85, 95% CI, 1.85-2.79; P = 0.004) had increased odds of not completing a COVID-19 vaccination series. Those who resided in rural ZIP codes (1.81; 95% CI, 1.35-2.43; P < 0.001), had not received a 2019-2020 influenza vaccine (5.13; 95% CI, 3.79-6.96; P < 0.001), or had lower comorbidity scores (2.95; 95% CI, 1.98-4.41; P < 0.001) had higher odds of not completing a COVID-19 vaccination series. There was a high rate of COVID-19 vaccine uptake among patients seen in a rehabilitation clinic, though racial, ethnic, and geographic differences did exist. Further studies are needed to determine why these disparities exist and investigate interventions to increase vaccine uptake in these populations. |
| 351 | Jennifer Weiss | GI | jmw@medicine.wisc.edu | AGA Clinical Practice Guideline on the Role of Biomarkers for the Management of Crohn's Disease. | Biomarkers are used frequently for evaluation and monitoring of patients with Crohn's disease (CD). This American Gastroenterological Association (AGA) guideline is intended to support practitioners in decisions about the use of biomarkers for the management of CD. A multidisciplinary panel of content experts and guideline methodologists used the Grading of Recommendations Assessment, Development and Evaluation framework to formulate patient-centered clinical questions and review evidence on the performance of fecal calprotectin, serum C-reactive protein (CRP), and Endoscopic Healing Index in patients with established CD who were asymptomatic, had symptoms of varying severity, or were in surgically induced remission. Biomarker performance was assessed against the gold standard of endoscopic activity, defined as a Simple Endoscopic Score for Crohn's Disease ≥3. The panel used the Grading of Recommendations Assessment, Development and Evaluation Evidence-to-Decision framework to develop recommendations for use of biomarkers in various settings. Implementation considerations were formulated for each recommendation to inform clinical practice. The guideline panel made 11 conditional recommendations. In patients with CD in symptomatic remission, the panel suggests use of a biomarker- and symptom-based monitoring strategy over symptoms alone. In patients in symptomatic remission, a fecal calprotectin <150 μg/g and normal CRP rules out active inflammation, avoiding endoscopic evaluation for assessment of disease activity. However, elevated biomarkers in this setting merit confirmation with endoscopy before treatment adjustment. In patients with CD with mild symptoms, neither normal nor elevated biomarkers alone are sufficiently accurate to determine endoscopic activity. In patients with CD with moderate to severe symptoms, elevated fecal calprotectin or serum CRP suggests endoscopic activity, precluding routine endoscopic assessment for disease activity. In patients with CD in surgically induced remission in low-risk patients on pharmacologic prophylaxis, a normal fecal calprotectin reliably rules out endoscopic recurrence. In other postoperative settings, the panel suggests endoscopic assessment for establishing postoperative recurrence. In patients with CD, fecal calprotectin and serum CRP can inform disease management in both asymptomatic and symptomatic disease. Discordance between symptom assessment and biomarker value may merit endoscopic evaluation for confirmation of status of disease activity. |
| 352 | Jennifer Weiss | GI | jmw@medicine.wisc.edu | High Uptake of Three COVID-19 Vaccine Doses Among Liver Transplant Recipients. | |
| 353 | Jennifer Weiss | GI | jmw@medicine.wisc.edu | AGA Clinical Practice Guideline on the Role of Biomarkers for the Management of Ulcerative Colitis. | Biomarkers are used frequently for noninvasive monitoring and treatment decision making in the management of patients with ulcerative colitis (UC). This American Gastroenterological Association (AGA) guideline is intended to support practitioners in decisions about the use of biomarkers for the management of UC. A multidisciplinary panel of content experts and guideline methodologists used the Grading of Recommendations Assessment, Development and Evaluation framework to prioritize clinical questions, identify patient-centered outcomes, and conduct an evidence synthesis on the clinical performance of serum C-reactive protein (CRP), fecal calprotectin, and fecal lactoferrin as biomarkers of disease activity in patients with established UC in symptomatic remission or with active symptoms. The guideline panel used the Evidence-to-Decision framework to develop recommendations for the use of biomarkers for monitoring and management of UC and provided implementation considerations for clinical practice. The guideline panel made 7 conditional recommendations. In patients with UC in symptomatic remission, the panel suggests the use of a biomarker- and symptom-based monitoring strategy over a symptom-based monitoring strategy. For patients in symptomatic remission, the panel suggests using fecal calprotectin 150 μg/g, elevated fecal lactoferrin, or elevated CRP to inform treatment decisions and avoid routine endoscopic assessment of disease. However, in patients in symptomatic remission but elevated biomarkers, and in patients with moderate to severe symptoms with normal biomarkers, the panel suggests endoscopic assessment of disease to inform treatment decisions. In patients with UC with mild symptoms, the panel suggests endoscopic assessment of disease activity to inform treatment decisions. The panel identified the use of a biomarker-based monitoring strategy over an endoscopy-based monitoring strategy as a knowledge gap. The panel also proposed key implementation considerations for optimal use of biomarkers, and identified areas for future research. In patients with UC, noninvasive biomarkers, including fecal calprotectin, fecal lactoferrin, and serum CRP can inform disease monitoring and management. |
| 354 | Jennifer Weiss | GI | jmw@medicine.wisc.edu | Yield of upper gastrointestinal screening in colonic adenomatous polyposis of unknown etiology: a multicenter study. | Background and study aims The majority of patients with 10 or more cumulative colorectal adenomas have uninformative genetic testing and meet criteria for colonic adenomatous polyposis of unknown etiology (CPUE). The yield of upper gastrointestinal screening in patients with CPUE after multi-gene panel testing is unknown and our objective was to characterize this. Patient and methods A multicenter, retrospective analysis of screening upper endoscopies in adults with CPUE after multi-gene panel testing was performed. Those with a history of gastroduodenal neoplasia prior to CPUE diagnosis were excluded. Demographic and clinical variables were collected and compared. Results One hundred and twenty-eight patients with CPUE were included from five participating centers. Nine (7.0 %) had gastroduodenal neoplasia on initial screening upper endoscopy. Those with over 100 colorectal adenomas had a significantly higher rate of gastroduodenal neoplasia than those with 20-99 or 10-19 colorectal adenomas (44.4 % vs 4.1 % vs 4.4 %, P = 0.002). Similar results were seen when the analysis was restricted to only duodenal or ampullary adenomas. The only malignancy was a gastric cancer in a patient with 20 to 99 colorectal adenomas. When comparing patients with gastroduodenal neoplasia to those without, the only significantly different characteristic was the cumulative number of colorectal adenomas. Conclusions We found a 7 % rate of gastroduodenal neoplasia in patients with CPUE after multi-gene panel testing. Although patients with ≥ 100 colorectal adenomas had a significantly higher risk, over 4 % of patients with 10 to 99 colorectal adenomas had gastroduodenal neoplasia. Given this, we recommend a screening upper endoscopy at the time of a colonoscopy after CPUE diagnosis. |
| 355 | Ozioma Okonkwo | GERI | ozioma@medicine.wisc.edu | Menopausal hormone therapy is associated with worse levels of Alzheimer's disease biomarkers in APOE ε4-carrying women: An observational study. | Menopausal hormone therapy (MHT), along with the apolipoprotein E (APOE) ε4 allele, has been suggested as a possible risk factor for Alzheimer's disease (AD). However, the relationship between MHT and cerebrospinal fluid (CSF) biomarkers is unknown: we investigated this association, and whether APOE ε4 carrier status moderates it. In an observational study of 136 cognitively unimpaired female participants (Mage = 66.0; standard deviation = 6.3), we examined whether MHT use alone or in interaction with APOE ε4 carrier status was associated with CSF levels of phosphorylated tau (p-tau), amyloid beta (Aβ)40, Aβ42, p-tau/Aβ42, and Aβ42/40 ratios. Significant interactions were found between APOE ε4 and MHT use for CSF biomarkers. APOE ε4 carriers who were MHT users showed worse levels of CSF p-tau/Aβ42 and Aβ42/40 ratios than all other users and non-users. The presence of both APOE ε4 and MHT may be associated with elevated amyloid deposition and AD pathology in this sample of participants who demonstrated high familial AD risk. Significant interactions were found between apolipoprotein E (APOE) ε4 and menopausal hormone therapy (MHT) use for cerebrospinal fluid (CSF) phosphorylated tau (p-tau)/amyloid beta (Aβ)42 and Aβ42/40 ratios. APOE ε4 carriers who were MHT users showed worse levels of CSF biomarkers than non-users and non-carriers, both users and non-users. Younger age at MHT initiation was associated with worse levels of the p-tau/Aβ42 and Aβ42/40 ratios in carriers only. The presence of both APOE ε4 carriage and MHT use may be associated with elevated amyloid deposition and AD pathology. Further studies with larger sample sizes are necessary to confirm the differences observed in the current study. |
| 356 | Ozioma Okonkwo | GERI | ozioma@medicine.wisc.edu | Alzheimer's Disease Neuroimaging Initiative: Two decades of pioneering Alzheimer's disease research and future directions. | |
| 357 | Ozioma Okonkwo | GERI | ozioma@medicine.wisc.edu | Delayed primacy recall in AVLT is associated with medial temporal tau PET burden in cognitively unimpaired adults. | Alzheimer's disease (AD) can be diagnosed by in vivo abnormalities of amyloid-β plaques (A) and tau accumulation (T) biomarkers. Previous studies have shown that analyses of serial position performance in episodic memory tests, and especially, delayed primacy, are associated with AD pathology even in individuals who are cognitively unimpaired. The earliest signs of cortical tau pathology are observed in medial temporal lobe (MTL) regions, yet it is unknown if serial position markers are also associated with early tau load in these regions. This study of cognitively unimpaired older individuals examined whether serial position scores in word-list recall cross-sectionally predicted tau PET load in the MTL, and were able to discriminate between biomarker profiles, based on AT classification. Data from 490 participants (mean age = 68.8 ± 7.2) were extracted from two cohorts, which were merged into one sample. Linear regression analyses were carried out with regional volume-controlled tau (18F-MK-6240) PET SUVR of the entorhinal cortex (EC), parahippocampal cortex (PHC) and hippocampus (H) as outcomes, cross-sectional memory scores from the Rey Auditory Verbal Learning Test as predictors (total and delayed recall, along with serial position scores) and control variables, in separate analyses for each outcome and predictor. The sample was then stratified by biomarker profile and ANCOVAs were conducted with the strongest scores from the regression analyses, AT groups as fixed factor and the covariates. Higher delayed primacy significantly predicted lower tau PET in EC, PHC, and H, cross-sectionally. Higher total recall scores predicted lower EC tau, but delayed primacy showed the best model fit, as indicated by AICs. ANCOVAs showed that AVLT metrics did not significantly discriminate between A-T- and A+T+, after correcting for multiple comparisons. Serial position analysis of word-list recall, particularly delayed primacy, may be a valuable tool for identifying in vivo tau pathology in cognitively unimpaired individuals. |
| 358 | Ozioma Okonkwo | GERI | ozioma@medicine.wisc.edu | Overview of Alzheimer's Disease Neuroimaging Initiative and future clinical trials. | The overall goal of the Alzheimer's Disease Neuroimaging Initiative (ADNI) is to optimize and validate biomarkers for clinical trials while sharing all data and biofluid samples with the global scientific community. ADNI has been instrumental in standardizing and validating amyloid beta (Aβ) and tau positron emission tomography (PET) imaging. ADNI data were used for the US Food and Drug Administration (FDA) approval of the Fujirebio and Roche Elecsys cerebrospinal fluid diagnostic tests. Additionally, ADNI provided data for the trials of the FDA-approved treatments aducanumab, lecanemab, and donanemab. More than 6000 scientific papers have been published using ADNI data, reflecting ADNI's promotion of open science and data sharing. Despite its enormous success, ADNI has some limitations, particularly in generalizing its data and findings to the entire US/Canadian population. This introduction provides a historical overview of ADNI and highlights its significant accomplishments and future vision to pioneer "the clinical trial of the future" focusing on demographic inclusivity. HIGHLIGHTS: The Alzheimer's Disease Neuroimaging Initiative (ADNI) introduced a novel model for public-private partnerships and data sharing. It successfully validated amyloid and Tau PET imaging, as well as CSF and plasma biomarkers, for diagnosing Alzheimer's disease. ADNI generated and disseminated vital data for designing AD clinical trials. |
| 359 | Ozioma Okonkwo | GERI | ozioma@medicine.wisc.edu | Dementia risk reduction in the African context: Multi-national implementation of multimodal strategies to promote healthy brain aging in Africa (the Africa-FINGERS project). | Dementia prevention in Africa is critically underexplored, despite the continent's high prevalence of modifiable risk factors. With a predominantly young and middle-aged population, Africa presents a prime opportunity to implement evidence-based strategies that could significantly reduce future dementia cases and mitigate its economic impact. The multinational Africa-FINGERS program offers an innovative solution, pioneering culturally sensitive, multidomain interventions tailored to the unique challenges of the region. Leveraging insights from landmark global studies such as Worldwide-FINGERS and Alzheimer's Disease Neuroimaging Initiative, the program employs a multideterminant precision prevention framework, grounded in community based systems dynamics. Africa-FINGERS further integrates cutting-edge state-of-the-art multimodal biomarker evaluations tailored to regional contexts, with the goal of advancing brain health and establishing a global standard for dementia prevention. This groundbreaking initiative highlights the potential for scalableand sustainable interventions, thus is poised to transform dementia risk reduction efforts across the continent. HIGHLIGHTS: Dementia rates are escalating in Africa, largely due to longer life spans and increased prevalence of modifiable risk factors. Yet, few regional interventions have directly targeted lifestyle factors to reduce dementia risk. The multinational Africa-FINGERS study will address this gap by adapting the successful FINGERS lifestyle intervention to African populations. Africa-FINGERS will pioneer a culturally informed, multidomain dementia risk reduction intervention in the African region through feasibility dementia prevention trials in rural and urban sites across Kenya and Nigeria in the first instance, enrolling 600 at-risk adults (≥ 50 years). The program adopts participatory research methods to develop culturally appropriate interventions and build infrastructure to evaluate dementia biomarkers from ante and post mortem samples. A cost-effectiveness analysis will be conducted to guide the strategic implementation of Africa-FINGERS into regional health systems. The Africa-FINGERS strategy aligns with the Worldwide-FINGERS framework and integrates the global Alzheimer's Disease Neuroimaging Initiative approach, emphasizing multimodal analysis. |
| 360 | Ozioma Okonkwo | GERI | ozioma@medicine.wisc.edu | The Health Equity Scholars Program: Fostering Culturally Competent and Successful Independent Investigators in Alzheimer's Disease and Related Dementia Research. | The Health Equity Scholars Program (HESP) addresses the critical need for a diverse, culturally competent workforce to study and treat older adults from underrepresented populations (URPs) with Alzheimer's disease and related dementias (AD/ADRD). The HESP offers tailored mentored training in AD/ADRD research concepts, aiming to develop successful independent researchers. It recruits Scholars from underrepresented backgrounds as well as those passionate about AD/ADRD health equity research. We (1) describe the fundamental elements of the HESP, and (2) present preliminary data from the HESP program evaluation results performed by an outside agency, pre-post participation surveys, and Scholar accomplishments. The HESP Scholars reported high rates of proficiency, satisfaction, and competency in nearly all evaluated areas, and have been successful in obtaining grants, promotions, and publications. These initial outcomes data suggest that the HESP is meeting its objective of diversifying the workforce in the field of AD/ADRD research and care. The Health Equity Scholars Program aims to cultivate a diverse and culturally competent workforce, who are well-prepared to study and treat underrepresented older adults with Alzheimer's disease and related dementias (AD/ADRD). The program provides tailored mentored training in AD/ADRD research concepts, with the goal of nurturing successful independent researchers. Rigorous evaluation processes for applications ensure the selection of highly qualified Scholars. The program includes tailored training activities such as seminars and grant writing workshops, and tracks Scholar achievements while undergoing annual external evaluation to enhance its training program iteratively. |
| 361 | Ozioma Okonkwo | GERI | ozioma@medicine.wisc.edu | The Alzheimer's Disease Neuroimaging Initiative-4 (ADNI-4) Engagement Core: A culturally informed, community-engaged research (CI-CER) model to advance brain health equity. | The Alzheimer's Disease Neuroimaging Initiative-4 (ADNI-4) Engagement Core was launched to advance Alzheimer's disease (AD) and AD-related dementia (ADRD) health equity research in underrepresented populations (URPs). We describe our evidence-based, scalable culturally informed, community-engaged research (CI-CER) model and demonstrate its preliminary success in increasing URP enrollment. URPs include ethnoculturally minoritized, lower education (≤ 12 years), and rural populations. The CI-CER model includes: (1) culturally informed methodology (e.g., less restrictive inclusion/exclusion criteria, sociocultural measures, financial compensation, results disclosure, Spanish Language Capacity Workgroup) and (2) inclusive engagement methods (e.g., the Engagement Core team; Hub Sites; Community-Science Partnership Board). As of April 2024, 60% of ADNI-4 new in-clinic enrollees were from ethnoculturally or educationally URPs. This exceeds ADNI-4's ≥ 50% URP representation goal for new enrollees but may not represent final enrollment. Findings show a CI-CER model increases URP enrollment in AD/ADRD clinical research and has important implications for clinical trials to advance health equity. The Alzheimer's Disease Neuroimaging Initiative-4 (ADNI-4) uses a culturally informed, community-engaged research (CI-CER) approach. The CI-CER approach is scalable and sustainable for broad, multisite implementation. ADNI-4 is currently exceeding its inclusion goals for underrepresented populations. |
| 362 | Ozioma Okonkwo | GERI | ozioma@medicine.wisc.edu | The Consortium for Clarity in ADRD Research Through Imaging (CLARiTI). | The presence of multiple pathologies is the largest predictor of dementia. A major gap in the field is the in vivo detection of mixed pathologies and their antecedents. The Alzheimer's Disease Research Centers (ADRCs) are uniquely positioned to address this gap. The ADRCs longitudinally follow ≈ 17,000 participants, ranging from cognitively unimpaired to dementia, arising from Alzheimer's disease (AD) and related dementias (ADRD; e.g., AD, Lewy body disorders, vascular). Motivated by the Alzheimer's Disease Neuroimaging Initiative's (ADNI) impact, the ADRC Consortium for Clarity in ADRD Research Through Imaging (CLARiTI) was formed. Leveraging existing ADRC infrastructure, CLARiTI will integrate standardized imaging and plasma collection to characterize mixed pathologies and use community-engaged research methods to ensure that ≥ 25% of the sample is from underrepresented populations (e.g., ethnoculturally minoritized, low education). The resulting ADRD profiles, within a more diverse sample, will provide key resources for ADRCs and an unprecedented, more generalizable publicly available imaging-plasma dataset. HIGHLIGHTS: In vivo detection of mixed pathologies is critical for Alzheimer's disease and related dementias research. The Alzheimer's Disease Research Centers (ADRCs) are uniquely positioned to address gaps related to mixed pathologies. The ADRC Consortium for Clarity in ADRD Research Through Imaging (CLARiTI) will enhance this national program by adding standardized imaging and plasma collection to existing ADRC infrastructure. This effort will provide key resources for ADRCs and an unprecedented publicly available imaging-plasma-neuropath dataset. |
| 363 | Ozioma Okonkwo | GERI | ozioma@medicine.wisc.edu | Visual read of [F-18]florquinitau PET that includes and extends beyond the mesial temporal lobe is associated with increased plasma pTau217 and cognitive decline in a cohort that is enriched with risk for Alzheimer's disease. | Patterns of signal from tau positron emission tomography (tau-PET) confined to the medial temporal lobe (MTL) or extended into the neocortex may be relevant for Alzheimer's disease (AD) research if they are linked to differential biomarker levels and cognitive decline. Visual assessment of Tau-PET [F-18]florquinitau (FQT) exams from 728 initially non-demented older adults yielded four uptake groups: tau-negative (T-), MTL-only (T+MTL), neocortex-only (T+Neo), or both (T+MTL&Neo). Mixed effects models assessed group differences in retrospective cognitive and plasma pTau217 trajectories. T+MTL&Neo was the most common T+ group (n = 97; 93% A+) and exhibited the sharpest worsening in cognitive and pTau217 trajectories before tau PET. The T+MTL&Neo category represents an intermediate to advanced stage of AD preceded by rising ptau217 and progressive cognitive decline. The pTau217 finding suggests that A+, T+ in MTL or neocortex could represent early AD stages, with a higher likelihood of progressing to more advanced stages. Visual assessments of Tau-PET FQT revealed four distinct uptake groups: tau-negative (T-), MTL-only (T+MTL), neocortex-only (T+Neo), or both (T+MTL&Neo). Amyloid positive participants in the T+MTL and T+MTL&Neo categories showed a retrospectively faster decline in their cognitive trajectories, and a sharper increase in pTau217 levels in plasma, compared to T-. The T+MTL&Neo group displayed sharper trajectories compared with the other Tau positive groups in both their cognitive scores and pTau217 plasma levels. Our results suggest that participants with Tau present in both MTL and neocortex represent an intermediate to advanced stage of AD, whereas participants with signals confined to either MTL or neocortex could represent earlier AD stages. |
| 364 | Ozioma Okonkwo | GERI | ozioma@medicine.wisc.edu | Amyloid-β positivity is less prevalent in cognitively unimpaired KLOTHO KL-VS heterozygotes. | Klotho, encoded by the KLOTHO gene, is an anti-aging and neuroprotective protein. KLOTHO KL-VS heterozygosity (KL-VSHET) is hypothesized to be protective against the accumulation of Alzheimer's disease (AD) neuropathological hallmarks (amyloid-β (Aβ) and tau). We examine whether being positive for Aβ (A+) or tau (T+), or A/T joint status [positive for Aβ (A + T-), tau (A-T+), both (A + T+) or neither (A-T-)] vary by KL-VS and whether serum klotho protein levels vary based on A+, T+, or A/T status in a cohort enriched for AD risk. The sample consisted of 704 cognitively unimpaired, late middle-aged, and older adults; MeanAge(SD) = 64.9(8.3). Serum klotho was available for a sub-sample of 396 participants; MeanAge(SD) = 66.8(7.4). Covariate-adjusted logistic regression examined whether A + or T+, and multinomial regression examined whether A/T status, vary by KL-VS genotype. Covariate-adjusted linear regression examined whether serum klotho levels differ based on A+, T+, or A/T status. A+ prevalence was lower in KL-VSHET (p = 0.05), with no differences in T + prevalence (p = 0.52). KL-VSHET also had marginally lower odds of being A + T- (p = 0.07). Serum klotho levels did not differ based on A+, T+, or A/T status (all ps ≥ 0.40). KL-VSHET is associated with lower odds of being positive for Aβ, regardless of whether one is also positive for tau. Conversely, the likelihood of being tau positive did not differ based on KL-VS genotype. Our findings add to the growing KLOTHO literature and suggests the need for further research focused on understanding the mechanisms underlying KL-VS-related putative resilience to AD. |
| 365 | Sterling Johnson | GERI | scj@medicine.wisc.edu | Menopausal hormone therapy is associated with worse levels of Alzheimer's disease biomarkers in APOE ε4-carrying women: An observational study. | Menopausal hormone therapy (MHT), along with the apolipoprotein E (APOE) ε4 allele, has been suggested as a possible risk factor for Alzheimer's disease (AD). However, the relationship between MHT and cerebrospinal fluid (CSF) biomarkers is unknown: we investigated this association, and whether APOE ε4 carrier status moderates it. In an observational study of 136 cognitively unimpaired female participants (Mage = 66.0; standard deviation = 6.3), we examined whether MHT use alone or in interaction with APOE ε4 carrier status was associated with CSF levels of phosphorylated tau (p-tau), amyloid beta (Aβ)40, Aβ42, p-tau/Aβ42, and Aβ42/40 ratios. Significant interactions were found between APOE ε4 and MHT use for CSF biomarkers. APOE ε4 carriers who were MHT users showed worse levels of CSF p-tau/Aβ42 and Aβ42/40 ratios than all other users and non-users. The presence of both APOE ε4 and MHT may be associated with elevated amyloid deposition and AD pathology in this sample of participants who demonstrated high familial AD risk. Significant interactions were found between apolipoprotein E (APOE) ε4 and menopausal hormone therapy (MHT) use for cerebrospinal fluid (CSF) phosphorylated tau (p-tau)/amyloid beta (Aβ)42 and Aβ42/40 ratios. APOE ε4 carriers who were MHT users showed worse levels of CSF biomarkers than non-users and non-carriers, both users and non-users. Younger age at MHT initiation was associated with worse levels of the p-tau/Aβ42 and Aβ42/40 ratios in carriers only. The presence of both APOE ε4 carriage and MHT use may be associated with elevated amyloid deposition and AD pathology. Further studies with larger sample sizes are necessary to confirm the differences observed in the current study. |
| 366 | Sterling Johnson | GERI | scj@medicine.wisc.edu | Delayed primacy recall in AVLT is associated with medial temporal tau PET burden in cognitively unimpaired adults. | Alzheimer's disease (AD) can be diagnosed by in vivo abnormalities of amyloid-β plaques (A) and tau accumulation (T) biomarkers. Previous studies have shown that analyses of serial position performance in episodic memory tests, and especially, delayed primacy, are associated with AD pathology even in individuals who are cognitively unimpaired. The earliest signs of cortical tau pathology are observed in medial temporal lobe (MTL) regions, yet it is unknown if serial position markers are also associated with early tau load in these regions. This study of cognitively unimpaired older individuals examined whether serial position scores in word-list recall cross-sectionally predicted tau PET load in the MTL, and were able to discriminate between biomarker profiles, based on AT classification. Data from 490 participants (mean age = 68.8 ± 7.2) were extracted from two cohorts, which were merged into one sample. Linear regression analyses were carried out with regional volume-controlled tau (18F-MK-6240) PET SUVR of the entorhinal cortex (EC), parahippocampal cortex (PHC) and hippocampus (H) as outcomes, cross-sectional memory scores from the Rey Auditory Verbal Learning Test as predictors (total and delayed recall, along with serial position scores) and control variables, in separate analyses for each outcome and predictor. The sample was then stratified by biomarker profile and ANCOVAs were conducted with the strongest scores from the regression analyses, AT groups as fixed factor and the covariates. Higher delayed primacy significantly predicted lower tau PET in EC, PHC, and H, cross-sectionally. Higher total recall scores predicted lower EC tau, but delayed primacy showed the best model fit, as indicated by AICs. ANCOVAs showed that AVLT metrics did not significantly discriminate between A-T- and A+T+, after correcting for multiple comparisons. Serial position analysis of word-list recall, particularly delayed primacy, may be a valuable tool for identifying in vivo tau pathology in cognitively unimpaired individuals. |
| 367 | Sterling Johnson | GERI | scj@medicine.wisc.edu | Whole genome methylation sequencing in blood from persons with mild cognitive impairment and dementia due to Alzheimer's disease identifies cognitive status. | Whole genome methylation sequencing (WGMS) in blood identifies differential DNA methylation in persons with late-onset dementia due to Alzheimer's disease (AD) but has not been tested in persons with mild cognitive impairment (MCI). We used WGMS to compare DNA methylation levels at 25,244,219 CpG loci in 382 blood samples from 99 persons with MCI, 109 with AD, and 174 who are cognitively unimpaired (CU). WGMS identified 9756 differentially methylated positions (DMPs) in persons with MCI, including 1743 differentially methylated genes encoding proteins in biological pathways related to synapse organization, dendrite development, and ion transport. A total of 447 DMPs exhibit progressively increasing or decreasing DNA methylation levels among CU, MCI, and AD that correspond to cognitive status. WGMS identifies DMPs in known and newly detected genes in blood from persons with MCI and AD that support blood DNA methylation levels can distinguish cognitive status. Whole genome methylation levels in blood from 99 persons with mild cognitive impairment (MCI), 109 with Alzheimer's disease, and 174 who are cognitively unimpaired were analyzed. Nine thousand seven hundred fifty-six differentially methylated positions (DMPs) were identified in MCI. One thousand seven hundred forty-three genes comprise one or more DMPs in persons with MCI. Fifty-eight DMPs and 392 differentially methylated genes are shared among the three pairwise comparisons. Four hundred forty-seven DMPs exhibit progressive changes that correspond to cognitive status. |
| 368 | Sterling Johnson | GERI | scj@medicine.wisc.edu | Performance of study partner reports in a non-demented at-risk sample. | The Clinical Dementia Rating (CDR) Scale is a gold standard for staging impairment in Alzheimer's disease and other dementias (ADRD). The Quick Dementia Rating System (QDRS) offers similar results in 3 to 5 minutes without a trained clinician. This study aimed to (1) investigate concordance between comparably derived QDRS and CDR global scores, (2) examine item-level QDRS/CDR agreement, and (3) compare sample characteristics and cognitive performance across QDRS/CDR global concordant/discordant groups. The study included 351 QDRS/CDR pairs from 297 participants in the Wisconsin Registry for Alzheimer's Prevention (WRAP). Analyses included descriptive indices of QDRS/CDR agreement, lasso logistic regression, tetrachoric correlations, and linear mixed models. The QDRS global/CDR global concordance rate is 70.66%. Memory item discrepancies were primarily responsible for QDRS/CDR global rating discordance. Average cognitive scores were highest in concordant-normal QDRS/CDR and lowest in concordant-abnormal QDRS/CDR. The QDRS effectively screened for impairment in this sample. Future analyses will investigate QDRS relations to ADRD biomarkers. The Quick Dementia Rating System (QDRS) effectively screened for impairment in Alzheimer's disease and other dementias (ADRD) in a non-demented sample. Concordance rate between QDRSCDR global and Clinical Dementia Rating (CDR) Scale global scores is 70.66%. Memory item discrepancies primarily cause QDRS/CDR global score discordance. Cognitive scores are associated with QDRS/CDR concordances/discordances. Future analyses will explore QDRS relations to ADRD biomarkers. |
| 369 | Sterling Johnson | GERI | scj@medicine.wisc.edu | Sex and APOE ε4 allele differences in longitudinal white matter microstructure in multiple cohorts of aging and Alzheimer's disease. | The effects of sex and apolipoprotein E (APOE)-Alzheimer's disease (AD) risk factors-on white matter microstructure are not well characterized. Diffusion magnetic resonance imaging data from nine well-established longitudinal cohorts of aging were free water (FW)-corrected and harmonized. This dataset included 4741 participants (age = 73.06 ± 9.75) with 9671 imaging sessions over time. FW and FW-corrected fractional anisotropy (FAFWcorr) were used to assess differences in white matter microstructure by sex and APOE ε4 carrier status. Sex differences in FAFWcorr in projection tracts and APOE ε4 differences in FW limbic and occipital transcallosal tracts were most pronounced. There are prominent differences in white matter microstructure by sex and APOE ε4 carrier status. This work adds to our understanding of disparities in AD. Additional work to understand the etiology of these differences is warranted. Sex and apolipoprotein E (APOE) ε4 carrier status relate to white matter microstructural integrity. Females generally have lower free water-corrected fractional anisotropy compared to males. APOE ε4 carriers tended to have higher free water than non-carriers. |
| 370 | Sterling Johnson | GERI | scj@medicine.wisc.edu | The striatum is an early, accurate indicator of amyloid burden using [(11)C]PiB in Down syndrome: comparison of two radiotracers. | Adults with Down syndrome demonstrate striatum-first amyloid accumulation with [11C]PiB PET imaging, which has not been replicated with [18F]florbetapir (FBP). Early striatal accumulation has not been temporally quantified with respect to global cortical measures. Longitudinal PiB (n=175 participants) and FBP (n=92 participants) data from the Alzheimer Biomarkers Consortium-Down Syndrome were used to measure cortical and striatal binding. Generalized temporal models for cortical and striatal amyloid accumulation were created using the sampled iterative local approximation (SILA) method. PiB demonstrated greater striatal-to-cortical ratios than FBP. SILA analysis revealed striatal amyloid burden occurs 3.40 (2.39) years earlier than the cortex in PiB. There was no difference between the cortex and striatum in FBP. Among adults with Down syndrome, the striatum consistently accumulates amyloid earlier than the cortex when measured with PiB. This suggests the striatum is more sensitive to the onset of PiB PET-detectable amyloid in Down syndrome. |
| 371 | Sterling Johnson | GERI | scj@medicine.wisc.edu | Lower neurovascular coupling response despite higher cerebral blood flow at rest in apolipoprotein ɛ4 positive adults. | Cerebral blood flow at rest declines with age. However, age-related changes in functional measures of cerebrovascular health including cerebrovascular reactivity and neurovascular coupling are not well understood. Additionally, the effect of apolipoprotein E (APOE) ε4, a strong genetic risk factor for Alzheimer's disease, on cerebral blood flow and cerebrovascular function remains unclear. APOEε4 positive (APOEε4+; n = 37, age = 63±4y) and APOEε4 negative (APOEε4-; n = 50, age = 63±4y) cognitively unimpaired adults participated in this study. Macrovascular cerebral blood flow and microvascular cerebral perfusion were measured using 4D flow MRI and pseudo-continuous arterial spin labeling MRI, respectively. Cerebrovascular reactivity and neurovascular coupling were assessed by measuring middle cerebral artery blood velocity in response to hypercapnia and the n-back test, respectively. Neurovascular coupling was lower in APOEε4+ compared with APOEε4- adults (P<0.05), despite higher cerebral blood flow and cerebrovascular reactivity to hypercapnia. Alterations in neurovascular coupling may occur early, prior to changes in cognition, in aging APOEε4 carriers. |
| 372 | Sterling Johnson | GERI | scj@medicine.wisc.edu | Targeted Proteomic Biomarker Profiling Using NULISA in a cohort enriched with risk for Alzheimer's Disease and Related Dementias. | Targeted proteomic assays may be useful for diagnosing and staging Alzheimer's disease and related dementias (ADRD). We evaluated the performance of a 120-marker central nervous system (CNS) NUcleic acid-Linked Immuno-Sandwich Assay (NULISA) panel in samples spanning the AD spectrum. Cross-sectional plasma samples (n=252) were analyzed using Alamar's NULISAseq CNS panel. ROC analyses demonstrated NULISAseq-pTau217 accuracy in detecting amyloid (A) and tau (T) PET positivity. Differentially expressed proteins were identified using volcano plots. NULISAseq-pTau217 accurately classified A/T PET status with ROC AUCs of 0.92/0.86. pTau217 was upregulated in A+, T+, and impaired groups with log2-fold changes of 1.21, 0.57 and 4.63, respectively, compared to A-. Interestingly, pTDP43-409 was also upregulated in the impaired group and correlated with declining hippocampal volume and cognitive trajectories. This study shows the potential of a targeted proteomics panel for characterizing brain changes pertinent to ADRD. The promising pTDP43-409 findings require further replication. |
| 373 | Sterling Johnson | GERI | scj@medicine.wisc.edu | The Consortium for Clarity in ADRD Research Through Imaging (CLARiTI). | The presence of multiple pathologies is the largest predictor of dementia. A major gap in the field is the in vivo detection of mixed pathologies and their antecedents. The Alzheimer's Disease Research Centers (ADRCs) are uniquely positioned to address this gap. The ADRCs longitudinally follow ≈ 17,000 participants, ranging from cognitively unimpaired to dementia, arising from Alzheimer's disease (AD) and related dementias (ADRD; e.g., AD, Lewy body disorders, vascular). Motivated by the Alzheimer's Disease Neuroimaging Initiative's (ADNI) impact, the ADRC Consortium for Clarity in ADRD Research Through Imaging (CLARiTI) was formed. Leveraging existing ADRC infrastructure, CLARiTI will integrate standardized imaging and plasma collection to characterize mixed pathologies and use community-engaged research methods to ensure that ≥ 25% of the sample is from underrepresented populations (e.g., ethnoculturally minoritized, low education). The resulting ADRD profiles, within a more diverse sample, will provide key resources for ADRCs and an unprecedented, more generalizable publicly available imaging-plasma dataset. HIGHLIGHTS: In vivo detection of mixed pathologies is critical for Alzheimer's disease and related dementias research. The Alzheimer's Disease Research Centers (ADRCs) are uniquely positioned to address gaps related to mixed pathologies. The ADRC Consortium for Clarity in ADRD Research Through Imaging (CLARiTI) will enhance this national program by adding standardized imaging and plasma collection to existing ADRC infrastructure. This effort will provide key resources for ADRCs and an unprecedented publicly available imaging-plasma-neuropath dataset. |
| 374 | Sterling Johnson | GERI | scj@medicine.wisc.edu | Visual read of [F-18]florquinitau PET that includes and extends beyond the mesial temporal lobe is associated with increased plasma pTau217 and cognitive decline in a cohort that is enriched with risk for Alzheimer's disease. | Patterns of signal from tau positron emission tomography (tau-PET) confined to the medial temporal lobe (MTL) or extended into the neocortex may be relevant for Alzheimer's disease (AD) research if they are linked to differential biomarker levels and cognitive decline. Visual assessment of Tau-PET [F-18]florquinitau (FQT) exams from 728 initially non-demented older adults yielded four uptake groups: tau-negative (T-), MTL-only (T+MTL), neocortex-only (T+Neo), or both (T+MTL&Neo). Mixed effects models assessed group differences in retrospective cognitive and plasma pTau217 trajectories. T+MTL&Neo was the most common T+ group (n = 97; 93% A+) and exhibited the sharpest worsening in cognitive and pTau217 trajectories before tau PET. The T+MTL&Neo category represents an intermediate to advanced stage of AD preceded by rising ptau217 and progressive cognitive decline. The pTau217 finding suggests that A+, T+ in MTL or neocortex could represent early AD stages, with a higher likelihood of progressing to more advanced stages. Visual assessments of Tau-PET FQT revealed four distinct uptake groups: tau-negative (T-), MTL-only (T+MTL), neocortex-only (T+Neo), or both (T+MTL&Neo). Amyloid positive participants in the T+MTL and T+MTL&Neo categories showed a retrospectively faster decline in their cognitive trajectories, and a sharper increase in pTau217 levels in plasma, compared to T-. The T+MTL&Neo group displayed sharper trajectories compared with the other Tau positive groups in both their cognitive scores and pTau217 plasma levels. Our results suggest that participants with Tau present in both MTL and neocortex represent an intermediate to advanced stage of AD, whereas participants with signals confined to either MTL or neocortex could represent earlier AD stages. |
| 375 | Rozalyn Anderson | GERI | rozalyn.anderson@wisc.edu | Reversal of neuronal tau pathology via adiponectin receptor activation. | Changes in brain mitochondrial metabolism are coincident with functional decline; however, direct links between the two have not been established. Here, we show that mitochondrial targeting via the adiponectin receptor activator AdipoRon (AR) clears neurofibrillary tangles (NFTs) and rescues neuronal tauopathy-associated defects. AR reduced levels of phospho-tau and lowered NFT burden by a mechanism involving the energy-sensing kinase AMPK and the growth-sensing kinase GSK3b. The transcriptional response to AR included broad metabolic and functional pathways. Induction of lysosomal pathways involved activation of LC3 and p62, and restoration of neuronal outgrowth required the stress-responsive kinase JNK. Negative consequences of NFTs on mitochondrial activity, ATP production, and lipid stores were corrected. Defects in electrophysiological measures (e.g., resting potential, resistance, spiking profiles) were also corrected. These findings reveal a network linking mitochondrial function, cellular maintenance processes, and electrical aspects of neuronal function that can be targeted via adiponectin receptor activation. |
| 376 | Rozalyn Anderson | GERI | rozalyn.anderson@wisc.edu | Depth-Dependent Contributions of Various Vascular Zones to Cerebral Autoregulation and Functional Hyperemia: An In-Silico Analysis. | Autoregulation and neurogliavascular coupling are key mechanisms that modulate myogenic tone (MT) in vessels to regulate cerebral blood flow (CBF) during resting state and periods of increased neural activity, respectively. To determine relative contributions of distinct vascular zones across different cortical depths in CBF regulation, we developed a simplified yet detailed and computationally efficient model of the mouse cerebrovasculature. The model integrates multiple simplifications and generalizations regarding vascular morphology, the hierarchical organization of mural cells, and potentiation/inhibition of MT in vessels. Our analysis showed that autoregulation is the result of the synergy between these factors, but achieving an optimal balance across all cortical depths and throughout the autoregulation range is a complex task. This complexity explains the non-uniformity observed experimentally in capillary blood flow at different cortical depths. In silico simulations of cerebral autoregulation support the idea that the cerebral vasculature does not maintain a plateau of blood flow throughout the autoregulatory range and consists of both flat and sloped phases. We learned that small-diameter vessels with large contractility, such as penetrating arterioles and precapillary arterioles, have major control over intravascular pressure at the entry points of capillaries and play a significant role in CBF regulation. However, temporal alterations in capillary diameter contribute moderately to cerebral autoregulation and minimally to functional hyperemia. In addition, hemodynamic analysis shows that while hemodynamics within capillaries remain relatively stable across all cortical depths throughout the entire autoregulation range, significant variability in hemodynamics can be observed within the first few branch orders of precapillary arterioles or transitional zone vessels. The computationally efficient cerebrovasculature model, proposed in this study, provides a novel framework for analyzing dynamics of the CBF regulation where hemodynamic and vasodynamic interactions are the foundation on which more sophisticated models can be developed. |
| 377 | Rozalyn Anderson | GERI | rozalyn.anderson@wisc.edu | ImAge quantitates aging and rejuvenation. | For efficient, cost-effective and personalized healthcare, biomarkers that capture aspects of functional, biological aging, thus predicting disease risk and lifespan more accurately and reliably than chronological age, are essential. We developed an imaging-based chromatin and epigenetic age (ImAge) that captures intrinsic age-related trajectories of the spatial organization of chromatin and epigenetic marks in single nuclei, in mice. We show that such trajectories readily emerge as principal changes in each individual dataset without regression on chronological age, and that ImAge can be computed using several epigenetic marks and DNA labeling. We find that interventions known to affect biological aging induce corresponding effects on ImAge, including increased ImAge upon chemotherapy treatment and decreased ImAge upon caloric restriction and partial reprogramming by transient OSKM expression in liver and skeletal muscle. Further, ImAge readouts from chronologically identical mice inversely correlated with their locomotor activity, suggesting that ImAge may capture elements of biological and functional age. In sum, we developed ImAge, an imaging-based biomarker of aging with single-cell resolution rooted in the analysis of spatial organization of epigenetic marks. |
| 378 | Rozalyn Anderson | GERI | rozalyn.anderson@wisc.edu | Mass Spectrometry-Based Multiomics Identifies Metabolic Signatures of Sarcopenia in Rhesus Monkey Skeletal Muscle. | Sarcopenia is a progressive disorder characterized by age-related loss of skeletal muscle mass and function. Although significant progress has been made over the years to identify the molecular determinants of sarcopenia, the precise mechanisms underlying the age-related loss of contractile function remains unclear. Advances in "omics" technologies, including mass spectrometry-based proteomic and metabolomic analyses, offer great opportunities to better understand sarcopenia. Herein, we performed mass spectrometry-based analyses of the vastus lateralis from young, middle-aged, and older rhesus monkeys to identify molecular signatures of sarcopenia. In our proteomic analysis, we identified proteins that change with age, including those involved in adenosine triphosphate and adenosine monophosphate metabolism as well as fatty acid beta oxidation. In our untargeted metabolomic analysis, we identified metabolites that changed with age largely related to energy metabolism including fatty acid beta oxidation. Pathway analysis of age-responsive proteins and metabolites revealed changes in muscle structure and contraction as well as lipid, carbohydrate, and purine metabolism. Together, this study discovers new metabolic signatures and offers new insights into the molecular mechanisms underlying sarcopenia for the evaluation and monitoring of a therapeutic treatment of sarcopenia. |
| 379 | Rozalyn Anderson | GERI | rozalyn.anderson@wisc.edu | Reversal of neuronal tau pathology, metabolic dysfunction, and electrophysiological defects via adiponectin pathway-dependent AMPK activation. | Changes in brain mitochondrial metabolism are coincident with functional decline; however, direct links between the two have not been established. Here, we show that mitochondrial targeting via the adiponectin receptor activator AdipoRon (AR) clears neurofibrillary tangles (NFTs) and rescues neuronal tauopathy-associated defects. AR reduced levels of phospho-tau and lowered NFT burden by a mechanism involving the energy-sensing kinase AMPK and the growth-sensing kinase GSK3b. The transcriptional response to AR included broad metabolic and functional pathways. Induction of lysosomal pathways involved activation of LC3 and p62, and restoration of neuronal outgrowth required the stress-responsive kinase JNK. Negative consequences of NFTs on mitochondrial activity, ATP production, and lipid stores were corrected. Defects in electrophysiological measures (e.g., resting potential, resistance, spiking profiles) were also corrected. These findings reveal a network linking mitochondrial function, cellular maintenance processes, and electrical aspects of neuronal function that can be targeted via adiponectin receptor activation. |
| 380 | Rozalyn Anderson | GERI | rozalyn.anderson@wisc.edu | Geroprotector drugs and exercise: friends or foes on healthy longevity? | Physical activity and several pharmacological approaches individually combat age-associated conditions and extend healthy longevity in model systems. It is tantalizing to extrapolate that combining geroprotector drugs with exercise could extend healthy longevity beyond any individual treatment. However, the current dogma suggests that taking leading geroprotector drugs on the same day as exercise may limit several health benefits. Here, we review leading candidate geroprotector drugs and their interactions with exercise and highlight salient gaps in knowledge that need to be addressed to identify if geroprotector drugs can have a harmonious relationship with exercise. |
| 381 | Rozalyn Anderson | GERI | rozalyn.anderson@wisc.edu | Imaging-based chromatin and epigenetic age, ImAge, quantitates aging and rejuvenation. | Biomarkers of biological age that predict the risk of disease and expected lifespan better than chronological age are key to efficient and cost-effective healthcare1-3. To advance a personalized approach to healthcare, such biomarkers must reliably and accurately capture individual biology, predict biological age, and provide scalable and cost-effective measurements. We developed a novel approach - image-based chromatin and epigenetic age (ImAge) that captures intrinsic progressions of biological age, which readily emerge as principal changes in the spatial organization of chromatin and epigenetic marks in single nuclei without regression on chronological age. ImAge captured the expected acceleration or deceleration of biological age in mice treated with chemotherapy or following a caloric restriction regimen, respectively. ImAge from chronologically identical mice inversely correlated with their locomotor activity (greater activity for younger ImAge), consistent with the widely accepted role of locomotion as an aging biomarker across species. Finally, we demonstrated that ImAge is reduced following transient expression of OSKM cassette in the liver and skeletal muscles and reveals heterogeneity of in vivo reprogramming. We propose that ImAge represents the first-in-class imaging-based biomarker of aging with single-cell resolution. |
| 382 | Rozalyn Anderson | GERI | rozalyn.anderson@wisc.edu | Mitochondrial regulator PGC-1a in neuronal metabolism and brain aging. | The brain is a high energy tissue, and the cell types of which it is comprised are distinct in function and in metabolic requirements. The transcriptional co-activator PGC-1a is a master regulator of mitochondrial function and is highly expressed in the brain; however, its cell-type specific role in regulating metabolism has not been well established. Here, we show that PGC-1a is responsive to aging and that expression of the neuron specific PGC-1a isoform allows for specialization in metabolic adaptation. Transcriptional profiles of the cortex from male mice show an impact of age on immune, inflammatory, and neuronal functional pathways and a highly integrated metabolic response that is associated with decreased expression of PGC-1a. Proteomic analysis confirms age-related changes in metabolism and further shows changes in ribosomal and RNA splicing pathways. We show that neurons express a specialized PGC-1a isoform that becomes active during differentiation from stem cells and is further induced during the maturation of isolated neurons. Neuronal but not astrocyte PGC-1a responds robustly to inhibition of the growth sensitive kinase GSK3b, where the brain specific promoter driven dominant isoform is repressed. The GSK3b inhibitor lithium broadly reprograms metabolism and growth signaling, including significantly lower expression of mitochondrial and ribosomal pathway genes and suppression of growth signaling, which are linked to changes in mitochondrial function and neuronal outgrowth. In vivo, lithium treatment significantly changes the expression of genes involved in cortical growth, endocrine, and circadian pathways. These data place the GSK3b/PGC-1a axis centrally in a growth and metabolism network that is directly relevant to brain aging. |
| 383 | Craig Atwood | GERI | csa@medicine.wisc.edu | Endocrine Dyscrasia in the Etiology and Therapy of Alzheimer's Disease. | The increase in the incidence of dementia over the last century correlates strongly with the increases in post-reproductive lifespan during this time. As post-reproductive lifespan continues to increase it is likely that the incidence of dementia will also increase unless therapies are developed to prevent, slow or cure dementia. A growing body of evidence implicates age-related endocrine dyscrasia and the length of time that the brain is subjected to this endocrine dyscrasia, as a key causal event leading to the cognitive decline associated with aging and Alzheimer's disease (AD), the major form of dementia in our society. In particular, the elevations in circulating gonadotropins, resulting from the loss of gonadal sex hormone production with menopause and andropause, appear central to the development of AD neuropathology and cognitive decline. This is supported by numerous cell biology, preclinical animal, and epidemiological studies, as well as human clinical studies where suppression of circulating luteinizing hormone and/or follicle-stimulating hormone with either gonadotropin-releasing hormone analogues, or via physiological hormone replacement therapy, has been demonstrated to halt or significantly slow cognitive decline in those with AD. This review provides an overview of past and present studies demonstrating the importance of hypothalamic-pituitary-gonadal hormone balance for normal cognitive functioning, and how targeting age-related endocrine dyscrasia with hormone rebalancing strategies provides an alternative treatment route for those with AD. |
| 384 | Craig Atwood | GERI | csa@medicine.wisc.edu | Playing Russian Roulette with Alzheimer's Disease Patients: Do the Cognitive Benefits of Lecanemab Outweigh the Risk of Edema, Stroke and Encephalitis? | The questionable approval of aducanumab and the recent approval of lecanemab (Leqembi; Eisai and Biogen) by the FDA has raised the issue of safety (stroke, meningitis, and encephalitis) over efficacy (slowing of cognitive decline). This communication recounts the important physiological functions of amyloid-β as a barrier protein with unique sealant and anti-pathogenic activities important for maintaining vascular integrity coupled with innate immune functions that prevent encephalitis and meningitis. The approval of a drug that obviates both of these purposive functions increases the risk of hemorrhage, edema and downstream pathogenic outcomes and should be clearly outlined to patients. |
| 385 | Craig Atwood | GERI | csa@medicine.wisc.edu | The roles of GnRH in the human central nervous system. | It is widely known that GnRH plays a role in facilitating reproductive function via the HPG axis, and this was once believed to be its only function. However, over the last several decades important neuromodulatory roles of GnRH in multiple brain functions have been elucidated. Multiple GnRH isoforms and receptors have been detected outside the HPG-axis across different species. In this review, we focus on the human CNS where GnRH I and II isoforms and a functional GnRH I receptor have been isolated. We first describe the traditional understanding of GnRH within the hypothalamus and the pituitary and current clinical use of GnRH analogues. We then review the location and function of GnRH-producing neurons and receptors located outside the HPG axis. We next review the GnRH I and II neuron location and quantity and GnRH I receptor gene expression throughout the human brain, using the Allen Brain Map Atlas. This analysis demonstrates a wide expression of GnRH throughout the brain, including prominent expression in the basal forebrain and cerebellum. Lastly, we examine the potential role of GnRH in aging and inflammation and its therapeutic potential for neurodegenerative disease and spinal cord lesions. |
| 386 | Craig Atwood | GERI | csa@medicine.wisc.edu | Positron Emission Tomography reveals age-associated hypothalamic microglial activation in women. | In rodents, hypothalamic inflammation plays a critical role in aging and age-related diseases. Hypothalamic inflammation has not previously been assessed in vivo in humans. We used Positron Emission Tomography (PET) with a radiotracer sensitive to the translocator protein (TSPO) expressed by activated microglia, to assess correlations between age and regional brain TSPO in a group of healthy subjects (n = 43, 19 female, aged 23-78), focusing on hypothalamus. We found robust age-correlated TSPO expression in thalamus but not hypothalamus in the combined group of women and men. This pattern differs from what has been described in rodents. Prominent age-correlated TSPO expression in thalamus in humans, but in hypothalamus in rodents, could reflect evolutionary changes in size and function of thalamus versus hypothalamus, and may be relevant to the appropriateness of using rodents to model human aging. When examining TSPO PET results in women and men separately, we found that only women showed age-correlated hypothalamic TSPO expression. We suggest this novel result is relevant to understanding a stark sex difference in human aging: that only women undergo loss of fertility-menopause-at mid-life. Our finding of age-correlated hypothalamic inflammation in women could have implications for understanding and perhaps altering reproductive aging in women. |
| 387 | Craig Atwood | GERI | csa@medicine.wisc.edu | Estropause, Sex Hormones and Metal Homeostasis in the Mouse Brain. | Alterations in brain metal ion homeostasis have been reported with aging and are implicated in the pathogenesis of neurodegenerative diseases. To assess whether age-related changes in hypothalamic-pituitary-gonadal (HPG) hormones might be involved in modulating brain metal ion homeostasis, we treated 7.5-month intact, sham-ovariecomized and ovariectomized C57B6SJL mice with vehicle or leuprolide acetate (for 9-months) to differentiate between whether sex steroids or gonadotropins might modulate brain metal ion concentrations. Unlike other aging mammals, there was no increase in plasma luteinizing hormone (LH) and follicle-stimulating hormone (FSH) concentrations following estropause in mice, suggesting there was sufficient residual production by the follicle depleted ovary, of sex steroids like estrogens and protein hormones like the inhibins, in order to suppress pituitary LH/FSH production. Castration on the other hand induced significant increases in circulating LH and FSH. Modulation of plasma sex steroid and gonadotropin levels did not significantly alter the concentrations of brain metals tested (Fe, Zn, Cu, Mn, Co, Ni, Al, Li), although there was a tendency for a decrease in all brain metals following ovariectomy (low estrogens and progesterone, high gonadotropins), a response that was reversed with leuprolide acetate treatment (low sex steroids, low gonadotropins). Brain Cu concentration was the only metal correlated with plasma LH (-0.37, n = 30, p < 0.05) and FSH (-0.42, n = 29, p < 0.01). This study demonstrates that sex hormones do not markedly alter brain metal ion homeostasis, unlike previously reported studies of circulating metal ion homeostasis. The role of gonadotropins in regulating metal ion homeostasis does however warrant further study. |
| 388 | Craig Atwood | GERI | csa@medicine.wisc.edu | Rationale, study design and implementation of the LUCINDA Trial: Leuprolide plus Cholinesterase Inhibition to reduce Neurologic Decline in Alzheimer's. | The LUCINDA Trial (Leuprolide plus Cholinesterase Inhibition to reduce Neurologic Decline in Alzheimer's) is a 52 week, randomized, placebo-controlled trial of leuprolide acetate (Eligard) in women with Alzheimer's disease (AD). Leuprolide acetate is a gonadotropin analogue commonly used for hormone-sensitive conditions such as prostate cancer and endometriosis. This repurposed drug demonstrated efficacy in a previous Phase II clinical trial in those women with AD who also received a stable dose of the acetylcholinesterase inhibitor donepezil (Bowen et al., 2015). Basic biological, epidemiological and clinical trial data suggest leuprolide acetate mediates improvement and stabilization of neuropathology and cognitive performance via the modulation of gonadotropin and/or gonadotropin-releasing hormone signaling. LUCINDA will enroll 150 women with mild-moderate AD who are receiving a stable dose of donepezil from three study sites in the United States. Cognition and function are the primary outcome measures as assessed by the Alzheimer's Disease Assessment Scale-Cognitive Subscale. Blood and MRI biomarkers are also measured to assess hormonal, inflammatory and AD biomarker changes. We present the protocol for LUCINDA and discuss trial innovations and challenges including changes necessitated by the covid-19 pandemic and study drug procurement issues. |
| 389 | Craig Atwood | GERI | csa@medicine.wisc.edu | Hypogonadism induced by surgical stress and brain trauma is reversed by human chorionic gonadotropin in male rats: A potential therapy for surgical and TBI-induced hypogonadism? | Hypogonadotropic hypogonadism (HH) is an almost universal, yet underappreciated, endocrinological complication of traumatic brain injury (TBI). The goal of this study was to determine whether the developmental hormone human chorionic gonadotropin (hCG) treatment could reverse HH induced by a TBI. Plasma samples were collected at post-surgery/post-injury (PSD/PID) days -10, 1, 11, 19 and 29 from male Sprague-Dawley rats (5- to 6-month-old) that had undergone a Sham surgery (craniectomy alone) or CCI injury (craniectomy + bilateral moderate-to-severe CCI injury) and treatment with saline or hCG (400 IU/kg; i.m.) every other day. Both Sham and CCI injury significantly decreased circulating testosterone (T), 11-deoxycorticosterone (11-DOC) and corticosterone concentrations to a similar extent (79.1% vs. 80.0%; 46.6% vs. 48.4%; 56.2% vs. 32.5%; respectively) by PSD/PID 1. hCG treatment returned circulating T to baseline concentrations by PSD/PID 1 (8.9 ± 1.5 ng/ml and 8.3 ± 1.9 ng/ml; respectively) and was maintained through PSD/PID 29. hCG treatment significantly, but transiently, increased circulating progesterone (P4) ~3-fold (30.2 ± 10.5 ng/ml and 24.2 ± 5.8 ng/ml) above that of baseline concentrations on PSD 1 and PID 1, respectively. hCG treatment did not reverse hypoadrenalism following either procedure. Together, these data indicate that (1) craniectomy is sufficient to induce persistent hypogonadism and hypoadrenalism, (2) hCG can reverse hypogonadism induced by a craniectomy or craniectomy +CCI injury, suggesting that (3) craniectomy and CCI injury induce a persistent hypogonadism by decreasing hypothalamic and/or pituitary function rather than testicular function in male rats. The potential role of hCG as a cheap, safe and readily available treatment for reversing surgery or TBI-induced hypogonadism is discussed. |
| 390 | Craig Atwood | GERI | csa@medicine.wisc.edu | Development of Classification Models for the Prediction of Alzheimer's Disease Utilizing Circulating Sex Hormone Ratios. | While sex hormones are essential for normal cognitive health, those individuals with greater endocrine dyscrasia around menopause and with andropause are more likely to develop cognitive loss and Alzheimer's disease (AD). To assess whether circulating sex hormones may provide an etiologically significant, surrogate biomarker, for cognitive decline. Plasma (n = 152) and serum (n = 107) samples from age- and gender-matched AD and control subjects from the Wisconsin Alzheimer's Disease Research Center (ADRC) were analyzed for 11 steroids and follicle-stimulating hormone. Logistic regression (LR), correlation analyses, and recursive partitioning (RP) were used to examine the interactions of hormones and hormone ratios and their association with AD. Models generated were then tested on an additional 43 ADRC samples. The wide variation and substantial overlap in the concentrations of all circulating sex steroids across control and AD groups precluded their use for predicting AD. Classification tree analyses (RP) revealed interactions among single hormones and hormone ratios that associated with AD status, the most predictive including only the hormone ratios identified by LR. The strongest associations were observed between cortisol, cortisone, and androstenedione with AD, with contributions from progesterone and 17β-estradiol. Utilizing this model, we correctly predicted 81% of AD test cases and 64% of control test cases. We have developed a diagnostic model for AD, the Wisconsin Hormone Algorithm Test for Cognition (WHAT-Cog), that utilizes classification tree analyses of hormone ratios. Further refinement of this technology could provide a quick and cheap diagnostic method for screening those with AD. |
| 391 | Craig Atwood | GERI | csa@medicine.wisc.edu | Author Correction: Genetic meta-analysis of diagnosed Alzheimer's disease identifies new risk loci and implicates Aβ, tau, immunity and lipid processing. | An amendment to this paper has been published and can be accessed via a link at the top of the paper. |
| 392 | Craig Atwood | GERI | csa@medicine.wisc.edu | Genetic meta-analysis of diagnosed Alzheimer's disease identifies new risk loci and implicates Aβ, tau, immunity and lipid processing. | Risk for late-onset Alzheimer's disease (LOAD), the most prevalent dementia, is partially driven by genetics. To identify LOAD risk loci, we performed a large genome-wide association meta-analysis of clinically diagnosed LOAD (94,437 individuals). We confirm 20 previous LOAD risk loci and identify five new genome-wide loci (IQCK, ACE, ADAM10, ADAMTS1, and WWOX), two of which (ADAM10, ACE) were identified in a recent genome-wide association (GWAS)-by-familial-proxy of Alzheimer's or dementia. Fine-mapping of the human leukocyte antigen (HLA) region confirms the neurological and immune-mediated disease haplotype HLA-DR15 as a risk factor for LOAD. Pathway analysis implicates immunity, lipid metabolism, tau binding proteins, and amyloid precursor protein (APP) metabolism, showing that genetic variants affecting APP and Aβ processing are associated not only with early-onset autosomal dominant Alzheimer's disease but also with LOAD. Analyses of risk genes and pathways show enrichment for rare variants (P = 1.32 × 10-7), indicating that additional rare variants remain to be identified. We also identify important genetic correlations between LOAD and traits such as family history of dementia and education. |
| 394 | Adam Konopka | GERI | akonopka@medicine.wisc.edu | The common marmoset as a translational model of age-related osteoarthritis. | Age-related osteoarthritis (OA) is a degenerative joint disease characterized by pathological changes in nearly every intra- and peri-articular tissue that contributes to disability in older adults. Studying the etiology of age-related OA in humans is difficult due to an unpredictable onset and insidious nature. A barrier in developing OA modifying therapies is the lack of translational models that replicate human joint anatomy and age-related OA progression. The purpose of this study was to determine whether the common marmoset is a faithful model of human age-related knee OA. Semi-quantitative microCT scoring revealed greater radiographic OA in geriatric versus adult marmosets, and the age-related increase in OA prevalence was similar between marmosets and humans. Quantitative assessments indicate greater medial tibial cortical and trabecular bone thickness and heterogeneity in geriatric versus adult marmosets which is consistent with an age-related increase in focal subchondral bone sclerosis. Additionally, marmosets displayed an age-associated increase in synovitis and calcification of the meniscus and patella. Histological OA pathology in the medial tibial plateau was greater in geriatric versus adult marmosets driven by articular cartilage damage, proteoglycan loss, and altered chondrocyte cellularity. The age-associated increase in medial tibial cartilage OA pathology and meniscal calcification was greater in female versus male geriatric marmosets. Overall, marmosets largely replicate human OA as evident by similar 1) cartilage and skeletal morphology, 2) age-related progression in OA pathology, and 3) sex differences in OA pathology with increasing age. Collectively, these data suggest that the common marmoset is a highly translatable model of the naturally occurring, age-related OA seen in humans. |
| 395 | Adam Konopka | GERI | akonopka@medicine.wisc.edu | Impact of long-term rapamycin treatment on age-related osteoarthritis in common marmoset. | Pharmacologic inhibition of the mechanistic target of rapamycin (mTOR) can attenuate experimental osteoarthritis (OA) in young, male preclinical models. However, the potential of mTOR inhibition as a therapeutic mechanism for OA remains unknown. The goal of this study was to determine if mTOR-inhibition by oral rapamycin can modify OA pathology in the common marmoset, a translational model of age-associated OA. microCT and histopathologic assessments of the knee were performed on formalin-fixed hindlimbs obtained from common marmosets treated with oral rapamycin (n=24; 1mg/kg/day) or parallel control group (n=41). Rapamycin started at 9.2±3.0 years old and lasted until death (2.1±1.5 years). In a subset of marmosets, contralateral hind limbs were collected to determine mTOR signaling in several joint tissues. Rapamycin decreased P-RPS6Ser235/36 and increased P-Akt2Ser473 in cartilage, meniscus, and infrapatellar fat pad, suggesting inhibition of mTORC1 but not mTORC2 signaling. Rapamycin-treated marmosets had lower lateral synovium score versus control but there was no difference in the age-related increase in microCT or cartilage OA scores. Subchondral bone thickness and thickness variability were not different with age but were lower in rapamycin-treated geriatric marmosets, which was largely driven by females. Rapamycin also tended to worsen age-related meniscus calcification in female marmosets. Oral rapamycin attenuated mTORC1 signaling and may have caused feedback activation of mTORC2 signaling in joint tissues. Despite modifying site-specific aspects of synovitis, rapamycin did not modify the age-associated increase in OA in geriatric marmosets. Conversely, rapamycin may have had deleterious effects on meniscus calcification and lateral tibia subchondral bone, primarily in geriatric female marmosets. |
| 397 | Adam Konopka | GERI | akonopka@medicine.wisc.edu | Geroprotector drugs and exercise: friends or foes on healthy longevity? | Physical activity and several pharmacological approaches individually combat age-associated conditions and extend healthy longevity in model systems. It is tantalizing to extrapolate that combining geroprotector drugs with exercise could extend healthy longevity beyond any individual treatment. However, the current dogma suggests that taking leading geroprotector drugs on the same day as exercise may limit several health benefits. Here, we review leading candidate geroprotector drugs and their interactions with exercise and highlight salient gaps in knowledge that need to be addressed to identify if geroprotector drugs can have a harmonious relationship with exercise. |
| 398 | Adam Konopka | GERI | akonopka@medicine.wisc.edu | Resistance exercise protects mice from protein-induced fat accretion. | Low-protein (LP) diets extend the lifespan of diverse species and are associated with improved metabolic health in both rodents and humans. Paradoxically, many athletes and bodybuilders consume high-protein (HP) diets and protein supplements, yet are both fit and metabolically healthy. Here, we examine this paradox using weight pulling, a validated progressive resistance exercise training regimen, in mice fed either an LP diet or an isocaloric HP diet. We find that despite having lower food consumption than the LP group, HP-fed mice gain significantly more fat mass than LP-fed mice when not exercising, while weight pulling protected HP-fed mice from this excess fat accretion. The HP diet augmented exercise-induced hypertrophy of the forearm flexor complex, and weight pulling ability increased more rapidly in the exercised HP-fed mice. Surprisingly, exercise did not protect from HP-induced changes in glycemic control. Our results confirm that HP diets can augment muscle hypertrophy and accelerate strength gain induced by resistance exercise without negative effects on fat mass, and also demonstrate that LP diets may be advantageous in the sedentary. Our results highlight the need to consider both dietary composition and activity, not simply calories, when taking a precision nutrition approach to health. |
| 399 | Adam Konopka | GERI | akonopka@medicine.wisc.edu | Blazing a trail for the clinical use of rapamycin as a geroprotecTOR. | Treatment with rapamycin, an inhibitor of the mechanistic Target Of Rapamycin Complex One (mTORC1) protein kinase, has been repeatedly demonstrated to extend lifespan and prevent or delay age-related diseases in diverse model systems. Concerns over the risk of potentially serious side effects in humans, including immunosuppression and metabolic disruptions, have cautiously limited the translation of rapamycin and its analogs as a treatment for aging associated conditions. During the last decade, we and others have developed a working model that suggests that while inhibition of mTORC1 promotes healthy aging, many of the negative side effects of rapamycin are associated with "off-target" inhibition of a second mTOR complex, mTORC2. Differences in the kinetics and molecular mechanisms by which rapamycin inhibits mTORC1 and mTORC2 suggest that a therapeutic window for rapamycin could be exploited using intermittent dosing schedules or alternative rapalogs that may enable more selective inhibition of mTORC1. However, the optimal dosing schedules and the long-term efficacy of such interventions in humans are unknown. Here, we highlight ongoing or upcoming clinical trials that will address outstanding questions regarding the safety, pharmacokinetics, pharmacodynamics, and efficacy of rapamycin and rapalogs on several clinically oriented outcomes. Results from these early phase studies will help guide the design of phase 3 clinical trials to determine whether rapamycin can be used safely to inhibit mTORC1 for the treatment and prevention of age-related diseases in humans. |
| 400 | Adam Konopka | GERI | akonopka@medicine.wisc.edu | Antecedent Metabolic Health and Metformin (ANTHEM) Aging Study: Rationale and Study Design for a Randomized Controlled Trial. | The antidiabetic medication metformin has been proposed to be the first drug tested to target aging and extend healthspan in humans. While there is extensive epidemiological support for the health benefits of metformin in patient populations, it is not clear if these protective effects apply to those free of age-related disease. Our previous data in older adults without diabetes suggest a dichotomous change in insulin sensitivity and skeletal muscle mitochondrial adaptations after metformin treatment when co-prescribed with exercise. Those who entered the study as insulin-sensitive had no change to detrimental effects while those who were insulin-resistant had positive changes. The objective of this clinical trial is to determine if (a) antecedent metabolic health and (b) skeletal muscle mitochondrial remodeling and function mediate the positive or detrimental effects of metformin monotherapy, independent of exercise, on the metabolism and biology of aging. In a randomized, double-blind clinical trial, adults free of chronic disease (n = 148, 40-75 years old) are stratified as either insulin-sensitive or resistant based on homeostatic model assessment of insulin resistance (≤2.2 or ≥2.5) and take 1 500 mg/day of metformin or placebo for 12 weeks. Hyperinsulinemic-euglycemic clamps and skeletal muscle biopsies are performed before and after 12 weeks to assess primary outcomes of peripheral insulin sensitivity and mitochondrial remodeling and function. Findings from this trial will identify clinical characteristics and cellular mechanisms involved in modulating the effectiveness of metformin treatment to target aging that could inform larger Phase 3 clinical trials aimed at testing aging as a treatment indication for metformin. Clinical Trials Registration Number: NCT04264897. |
| 401 | Adam Konopka | GERI | akonopka@medicine.wisc.edu | Small-Scale Randomized Controlled Trial to Explore the Impact of β-Hydroxy-β-Methylbutyrate Plus Vitamin D(3) on Skeletal Muscle Health in Middle Aged Women. | β-Hydroxy-β-methylbutyrate (HMB), a leucine metabolite, can increase skeletal muscle size and function. However, HMB may be less effective at improving muscle function in people with insufficient Vitamin D3 (25-OH-D < 30 ng/mL) which is common in middle-aged and older adults. Therefore, we tested the hypothesis that combining HMB plus Vitamin D3 (HMB + D) supplementation would improve skeletal muscle size, composition, and function in middle-aged women. In a double-blinded fashion, women (53 ± 1 yrs, 26 ± 1 kg/m2, n = 43) were randomized to take placebo or HMB + D (3 g Calcium HMB + 2000 IU D per day) during 12 weeks of sedentary behavior (SED) or resistance exercise training (RET). On average, participants entered the study Vitamin D3 insufficient while HMB + D increased 25-OH-D to sufficient levels after 8 and 12 weeks. In SED, HMB + D prevented the loss of arm lean mass observed with placebo. HMB + D increased muscle volume and decreased intermuscular adipose tissue (IMAT) volume in the thigh compared to placebo but did not change muscle function. In RET, 12-weeks of HMB + D decreased IMAT compared to placebo but did not influence the increase in skeletal muscle volume or function. In summary, HMB + D decreased IMAT independent of exercise status and may prevent the loss or increase muscle size in a small cohort of sedentary middle-aged women. These results lend support to conduct a longer duration study with greater sample size to determine the validity of the observed positive effects of HMB + D on IMAT and skeletal muscle in a small cohort of middle-aged women. |
| 402 | Adam Konopka | GERI | akonopka@medicine.wisc.edu | Correction to: Rapamycin-induced hyperglycemia is associated with exacerbated age-related osteoarthritis. | |
| 404 | Mariana Pehar | GERI | mapehar@medicine.wisc.edu | Nicotinamide Adenine Dinucleotide Precursor Supplementation Modulates Neurite Complexity and Survival in Motor Neurons from Amyotrophic Lateral Sclerosis Models. | Aims: Increasing nicotinamide adenine dinucleotide (NAD+) availability has been proposed as a therapeutic approach to prevent neurodegeneration in amyotrophic lateral sclerosis (ALS). Accordingly, NAD+ precursor supplementation appears to exert neuroprotective effects in ALS patients and mouse models. The mechanisms mediating neuroprotection remain uncertain but could involve changes in multiple cell types. We investigated a potential direct effect of the NAD+ precursor nicotinamide mononucleotide (NMN) on the health of cultured induced pluripotent stem cell (iPSC)-derived human motor neurons and in motor neurons isolated from two ALS mouse models, that is, mice overexpressing wild-type transactive response DNA binding protein-43 (TDP-43) or the ALS-linked human superoxide dismutase 1 with the G93A mutation (hSOD1G93A). Results: NMN treatment increased the complexity of neuronal processes in motor neurons isolated from both mouse models and in iPSC-derived human motor neurons. In addition, NMN prevented neuronal death induced by trophic factor deprivation. In mouse and human motor neurons expressing ALS-linked mutant superoxide dismutase 1, NMN induced an increase in glutathione levels, but this effect was not observed in nontransgenic or TDP-43 overexpressing motor neurons. In contrast, NMN treatment normalized the TDP-43 cytoplasmic mislocalization induced by its overexpression. Innovation: NMN can directly act on motor neurons to increase the growth and complexity of neuronal processes and prevent the death induced by trophic factor deprivation. Conclusion: Our results support a direct beneficial effect of NAD+ precursor supplementation on the maintenance of the neuritic arbor in motor neurons. Importantly, this was observed in motor neurons isolated from two different ALS models, with and without involvement of TDP-43 pathology, supporting its therapeutic potential in sporadic and familial ALS. Antioxid. Redox Signal. 41, 573-589. |
| 405 | Mariana Pehar | GERI | mapehar@medicine.wisc.edu | FABP7 drives an inflammatory response in human astrocytes and is upregulated in Alzheimer's disease. | Alzheimer's disease (AD), the most common cause of dementia in the elderly, is characterized by the accumulation of intracellular neurofibrillary tangles, extracellular amyloid plaques, and neuroinflammation. In partnership with microglial cells, astrocytes are key players in the regulation of neuroinflammation. Fatty acid binding protein 7 (FABP7) belongs to a family of conserved proteins that regulate lipid metabolism, energy homeostasis, and inflammation. FABP7 expression is largely restricted to astrocytes and radial glia-like cells in the adult central nervous system. We observed that treatment of primary hippocampal astrocyte cultures with amyloid β fragment 25-35 (Aβ25-35) induces FABP7 upregulation. In addition, FABP7 expression is upregulated in the brain of APP/PS1 mice, a widely used AD mouse model. Co-immunostaining with specific astrocyte markers revealed increased FABP7 expression in astrocytes. Moreover, astrocytes surrounding amyloid plaques displayed increased FABP7 staining when compared to non-plaque-associated astrocytes. A similar result was obtained in the brain of AD patients. Whole transcriptome RNA sequencing analysis of human astrocytes differentiated from induced pluripotent stem cells (i-astrocytes) overexpressing FABP7 identified 500 transcripts with at least a 2-fold change in expression. Gene Ontology enrichment analysis identified (i) positive regulation of cytokine production and (ii) inflammatory response as the top two statistically significant overrepresented biological processes. We confirmed that wild-type FABP7 overexpression induces an NF-κB-driven inflammatory response in human i-astrocytes. On the other hand, the expression of a ligand-binding impaired mutant FABP7 did not induce NF-κB activation. Together, our results suggest that the upregulation of FABP7 in astrocytes could contribute to the neuroinflammation observed in AD. |
| 406 | Mariana Pehar | GERI | mapehar@medicine.wisc.edu | Nicotinamide Adenine Dinucleotide (NAD(+))-Dependent Signaling in Neurological Disorders. | Significance: Nicotinamide adenine dinucleotide (NAD+) participates in redox reactions and NAD+-dependent signaling processes, which couples the enzymatic degradation of NAD+ to posttranslational modifications of proteins or the production of second messengers. Cellular NAD+ levels are dynamically controlled by synthesis and degradation, and dysregulation of this balance has been associated with acute and chronic neuronal dysfunction. Recent Advances: A decline in NAD+ has been observed during normal aging and since aging is the primary risk factor for many neurological disorders, NAD+ metabolism has become a promising therapeutic target and prolific research field in recent years. Critical Issues: In many neurological disorders, either as a primary feature or as consequence of the pathological process, neuronal damage is accompanied by dysregulated mitochondrial homeostasis, oxidative stress, or metabolic reprogramming. Modulating NAD+ availability appears to have a protective effect against such changes observed in acute neuronal damage and age-related neurological disorders. Such beneficial effects could be, at least in part, due to the activation of NAD+-dependent signaling processes. Future Directions: While in many instances the protective effect has been ascribed to the activation of sirtuins, approaches that directly test the role of sirtuins or that target the NAD+ pool in a cell-type-specific manner may be able to provide further mechanistic insight. Likewise, these approaches may afford greater efficacy to strategies aimed at harnessing the therapeutic potential of NAD+-dependent signaling in neurological disorders. Antioxid. Redox Signal. 39, 1150-1166. |
| 407 | Mariana Pehar | GERI | mapehar@medicine.wisc.edu | NR1D1 downregulation in astrocytes induces a phenotype that is detrimental to cocultured motor neurons. | Nuclear receptor subfamily 1 group D member 1 (NR1D1, also known as Rev-erbα) is a nuclear transcription factor that is part of the molecular clock encoding circadian rhythms and may link daily rhythms with metabolism and inflammation. NR1D1, unlike most nuclear receptors, lacks a ligand-dependent activation function domain 2 and is a constitutive transcriptional repressor. Amyotrophic lateral sclerosis (ALS) is the most common adult-onset motor neuron disease, caused by the progressive degeneration of motor neurons in the spinal cord, brain stem, and motor cortex. Approximately 10%-20% of familial ALS is caused by a toxic gain-of-function induced by mutations of the Cu/Zn superoxide dismutase (SOD1). Dysregulated clock and clock-controlled gene expression occur in multiple tissues from mutant hSOD1-linked ALS mouse models. Here we explore NR1D1 dysregulation in the spinal cord of ALS mouse models and its consequences on astrocyte-motor neuron interaction. NR1D1 protein and mRNA expression are significantly downregulated in the spinal cord of symptomatic mice expressing mutant hSOD1, while no changes were observed in age-matched animals overexpressing wild-type hSOD1. In addition, NR1D1 downregulation in primary astrocyte cultures induces a pro-inflammatory phenotype and decreases the survival of cocultured motor neurons. NR1D1 orchestrates the cross talk between physiological pathways identified to be disrupted in ALS (e.g., metabolism, inflammation, redox homeostasis, and circadian rhythms) and we observed that downregulation of NR1D1 alters astrocyte-motor neuron interaction. Our results suggest that NR1D1 could be a potential therapeutic target to prevent astrocyte-mediated motor neuron toxicity in ALS. |
| 408 | Mariana Pehar | GERI | mapehar@medicine.wisc.edu | Role and Therapeutic Potential of RAGE Signaling in Neurodegeneration. | Activation of the receptor for advanced glycation end products (RAGE) has been shown to play an active role in the development of multiple neurodegenerative diseases, including Alzheimer's disease, Parkinson's disease, and Amyotrophic Lateral Sclerosis. Although originally identified as a receptor for advanced glycation end products, RAGE is a pattern recognition receptor able to bind multiple ligands. The final outcome of RAGE signaling is defined in a context and cell type specific manner and can exert both neurotoxic and neuroprotective functions. Contributing to the complexity of the RAGE signaling network, different RAGE isoforms with distinctive signaling capabilities have been described. Moreover, multiple RAGE ligands bind other receptors and RAGE antagonism can significantly affect their signaling. Here, we discuss the outcome of celltype specific RAGE signaling in neurodegenerative pathologies. In addition, we will review the different approaches that have been developed to target RAGE signaling and their therapeutic potential. A clear understanding of the outcome of RAGE signaling in a cell type- and disease-specific manner would contribute to advancing the development of new therapies targeting RAGE. The ability to counteract RAGE neurotoxic signaling while preserving its neuroprotective effects would be critical for the success of novel therapies targeting RAGE signaling. |
| 409 | Mariana Pehar | GERI | mapehar@medicine.wisc.edu | Altered expression of clock and clock-controlled genes in a hSOD1-linked amyotrophic lateral sclerosis mouse model. | Most physiological processes in mammals are subjected to daily oscillations that are governed by a circadian system. The circadian rhythm orchestrates metabolic pathways in a time-dependent manner and loss of circadian timekeeping has been associated with cellular and system-wide alterations in metabolism, redox homeostasis, and inflammation. Here, we investigated the expression of clock and clock-controlled genes in multiple tissues (suprachiasmatic nucleus, spinal cord, gastrocnemius muscle, and liver) from mutant hSOD1-linked amyotrophic lateral sclerosis (ALS) mouse models. We identified tissue-specific changes in the relative expression, as well as altered daily expression patterns, of clock genes, sirtuins (Sirt1, Sirt3, and Sirt6), metabolic enzymes (Pfkfb3, Cpt1, and Nampt), and redox regulators (Nrf2, G6pd, and Pgd). In addition, astrocytes transdifferentiated from induced pluripotent stem cells from SOD1-linked and FUS RNA binding protein-linked ALS patients also displayed altered expression of clock genes. Overall, our results raise the possibility of disrupted cross-talk between the suprachiasmatic nucleus and peripheral tissues in hSOD1G93A mice, preventing proper peripheral clock regulation and synchronization. Since these changes were observed in symptomatic mice, it remains unclear whether this dysregulation directly drives or it is a consequence of the degenerative process. However, because metabolism and redox homeostasis are intimately entangled with circadian rhythms, our data suggest that altered expression of clock genes may contribute to metabolic and redox impairment in ALS. Since circadian dyssynchrony can be rescued, these results provide the groundwork for potential disease-modifying interventions. |
| 410 | Mariana Pehar | GERI | mapehar@medicine.wisc.edu | FABP7 upregulation induces a neurotoxic phenotype in astrocytes. | Fatty acid binding proteins (FABPs) are key regulators of lipid metabolism, energy homeostasis, and inflammation. They participate in fatty acid metabolism by regulating their uptake, transport, and availability of ligands to nuclear receptors. In the adult brain, FABP7 is especially abundant in astrocytes that are rich in cytoplasmic granules originated from damaged mitochondria. Mitochondrial dysfunction and oxidative stress have been implicated in the neurodegenerative process observed in amyotrophic lateral sclerosis (ALS), either as a primary cause or as a secondary component of the pathogenic process. Here we investigated the expression of FABP7 in animal models of human superoxide dismutase 1 (hSOD1)-linked ALS. In the spinal cord of symptomatic mutant hSOD1-expressing mice, FABP7 is upregulated in gray matter astrocytes. Using a coculture model, we examined the effect of increased FABP7 expression in astrocyte-motor neuron interaction. Our data show that FABP7 overexpression directly promotes an NF-κB-driven pro-inflammatory response in nontransgenic astrocytes that ultimately is detrimental for motor neuron survival. Addition of trophic factors, capable of supporting motor neuron survival in pure cultures, did not prevent motor neuron loss in cocultures with FABP7 overexpressing astrocytes. In addition, astrocyte cultures obtained from symptomatic hSOD1-expressing mice display upregulated FABP7 expression. Silencing endogenous FABP7 in these cultures decreases the expression of inflammatory markers and their toxicity toward cocultured motor neurons. Our results identify a key role of FABP7 in the regulation of the inflammatory response in astrocytes and identify FABP7 as a potential therapeutic target to prevent astrocyte-mediated motor neuron toxicity in ALS. |
| 411 | Mariana Pehar | GERI | mapehar@medicine.wisc.edu | Effects of RAGE inhibition on the progression of the disease in hSOD1(G93A) ALS mice. | Astrocytes play a key role in the progression of amyotrophic lateral sclerosis (ALS) by actively inducing the degeneration of motor neurons. Motor neurons isolated from receptor for advanced glycation end products (RAGE)-knockout mice are resistant to the neurotoxic signal derived from ALS-astrocytes. Here, we confirmed that in a co-culture model, the neuronal death induced by astrocytes over-expressing the ALS-linked mutant hSOD1G93A is prevented by the addition of the RAGE inhibitors FPS-ZM1 or RAP. These inhibitors also prevented the motor neuron death induced by spinal cord extracts from symptomatic hSOD1G93A mice. To evaluate the relevance of this neurotoxic mechanism in ALS pathology, we assessed the therapeutic potential of FPS-ZM1 in hSOD1G93A mice. FPS-ZM1 treatment significantly improved hind-limb grip strength in hSOD1G93A mice during the progression of the disease, reduced the expression of atrophy markers in the gastrocnemius muscle, improved the survival of large motor neurons, and reduced gliosis in the ventral horn of the spinal cord. However, we did not observe a statistically significant effect of the drug in symptoms onset nor in the survival of hSOD1G93A mice. Maintenance of hind-limb grip strength was also observed in hSOD1G93A mice with RAGE haploinsufficiency [hSOD1G93A ;RAGE(+/-)], further supporting the beneficial effect of RAGE inhibition on muscle function. However, no benefits were observed after complete RAGE ablation. Moreover, genetic RAGE ablation significantly shortened the median survival of hSOD1G93A mice. These results indicate that the advance of new therapies targeting RAGE in ALS demands a better understanding of its physiological role in a cell type/tissue-specific context. |
| 412 | Mariana Pehar | GERI | mapehar@medicine.wisc.edu | Decreased glutathione levels cause overt motor neuron degeneration in hSOD1(WT) over-expressing mice. | Mutations in Cu/Zn-superoxide dismutase (SOD1) cause familial forms of amyotrophic lateral sclerosis (ALS), a fatal disorder characterized by the progressive loss of motor neurons. Several lines of evidence have shown that SOD1 mutations cause ALS through a gain of a toxic function that remains to be fully characterized. A significant share of our understanding of the mechanisms underlying the neurodegenerative process in ALS comes from the study of rodents over-expressing ALS-linked mutant hSOD1. These mutant hSOD1 models develop an ALS-like phenotype. On the other hand, hemizygous mice over-expressing wild-type hSOD1 at moderate levels (hSOD1WT, originally described as line N1029) do not develop paralysis or shortened life-span. To investigate if a decrease in antioxidant defenses could lead to the development of an ALS-like phenotype in hSOD1WT mice, we used knockout mice for the glutamate-cysteine ligase modifier subunit [GCLM(-/-)]. GCLM(-/-) mice are viable and fertile but display a 70-80% reduction in total glutathione levels. GCLM(-/-)/hSOD1WT mice developed overt motor symptoms (e.g. tremor, loss of extension reflex in hind-limbs, decreased grip strength and paralysis) characteristic of mice models over-expressing ALS-linked mutant hSOD1. In addition, GCLM(-/-)/hSOD1WT animals displayed shortened life span. An accelerated decrease in the number of large neurons in the ventral horn of the spinal cord and degeneration of spinal root axons was observed in symptomatic GCLM(-/-)/hSOD1WT mice when compared to age-matched GCLM(+/+)/hSOD1WT mice. Our results show that under conditions of chronic decrease in glutathione, moderate over-expression of wild-type SOD1 leads to overt motor neuron degeneration, which is similar to that induced by ALS-linked mutant hSOD1 over-expression. |
| 413 | Luigi Puglielli | GERI | lp1@medicine.wisc.edu | sn-Position-Resolved Quantification of Aminophospholipids by Isotopic N,N-Dimethyl Leucine Labeling and High-Resolution Ion Mobility Mass Spectrometry. | Aminophospholipids (APLs), composed of phosphatidylethanolamines (PEs) and phosphatidylserines (PSs), are vital components of mammalian cell membranes and lipoproteins, participating in both homeostasis and cellular signaling. Their structural changes, including the permutation of fatty acid connectivity (sn-positions), due to dysfunctional metabolic processes have been linked to many diseases. However, the accurate quantification of APLs with unambiguous fatty acyl assignment through routine label-free LC-MS/MS lipidomic analysis remains a major challenge. In this study, we explore the functionalization of the free primary amine groups of APLs using amine-reactive isotopic N,N-dimethyl leucine (iDiLeu) and employ high-resolution ion mobility MS (IM-MS) to develop a novel method for sensitive discernment and accurate quantification of APL sn-isomers. With high-resolution demultiplexing (HRdm) providing IM resolving power >200, labeled sn-isomeric pairs of APLs (ΔCCS ≈ 1%) demonstrate excellent, near baseline separation. In addition to greatly enhanced sensitivity, 5-plex iDiLeu labeling enables the construction of an internal 4-point calibration curve and therefore absolute quantification of APL sn-isomers in a single run. This strategy enabled precise annotation and quantification of 239 APLs including 60 pairs of sn-isomers in the mouse cortex. Additionally, we were able to find ratio changes in multiple APL sn-isomer pairs between wild type and APP/PS1 Alzheimer's disease (AD) model mice at different ages, indicating their strong correlation to AD progression. This strategy could provide universal utility in unraveling the alteration of APL sn-isomers, which have long been considered as the "dark matter" of traditional lipidomic analyses, leading to more precise elucidation of molecular mechanisms of various diseases. |
| 414 | Luigi Puglielli | GERI | lp1@medicine.wisc.edu | Ca(+2) and Nε-lysine acetylation regulate the CALR-ATG9A interaction in the lumen of the endoplasmic reticulum. | The acetylation of autophagy protein 9 A (ATG9A) in the lumen of the endoplasmic reticulum (ER) by ATase1 and ATase2 regulates the induction of reticulophagy. Analysis of the ER-specific ATG9A interactome identified calreticulin (CALR), an ER luminal Ca+2-binding chaperone, as key for ATG9A activity. Specifically, if acetylated, ATG9A is sequestered by CALR and prevented from engaging FAM134B and SEC62. Under this condition, ATG9A is unable to activate the autophagy core machinery. In contrast, when non-acetylated, ATG9A is released by CALR and able to engage FAM134B and SEC62. In this study, we report that Ca+2 dynamics across the ER membrane regulate the ATG9A-CALR interaction as well as the ability of ATG9A to trigger reticulophagy. We show that the Ca+2-binding sites situated on the C-domain of CALR are essential for the ATG9A-CALR interaction. Finally, we show that K359 and K363 on ATG9A can influence the ATG9A-CALR interaction. Collectively, our results disclose a previously unidentified aspect of the complex mechanisms that regulate ATG9A activity. They also offer a possible area of intersection between Ca+2 metabolism, acetyl-CoA metabolism, and ER proteostasis. |
| 415 | Luigi Puglielli | GERI | lp1@medicine.wisc.edu | Fasting is required for many of the benefits of calorie restriction in the 3xTg mouse model of Alzheimer's disease. | Caloric restriction (CR) is a widely recognized geroprotective intervention that slows or prevents Alzheimer's disease (AD) in animal models. CR is typically implemented via feeding mice a single meal per day; as CR mice rapidly consume their food, they are subject to a prolonged fast between meals. While CR has been shown to improve metabolic and cognitive functions and suppress pathological markers in AD mouse models, the specific contributions of fasting versus calorie reduction remains unclear. Here, we investigated the contribution of fasting and energy restriction to the beneficial effects of CR on AD progression. To test this, we placed 6-month-old 3xTg mice on one of several diet regimens, allowing us to dissect the effects of calories and fasting on metabolism, AD pathology, and cognition. We find that energy restriction alone, without fasting, was sufficient to improve glucose tolerance and reduce adiposity in both sexes, and to reduce Aβ plaques and improve aspects of cognitive performance in females. However, we find that a prolonged fast between meals is necessary for many of the benefits of CR, including improved insulin sensitivity, reduced phosphorylation of tau, decreased neuroinflammation, inhibition of mTORC1 signaling, and activation of autophagy, as well as for the full cognitive benefits of CR. Finally, we find that fasting is essential for the benefits of CR on survival in male 3xTg mice. Overall, our results demonstrate that fasting is required for the full benefits of a CR diet on the development and progression of AD in 3xTg mice, and suggest that both when and how much we eat influences the development and progress of AD. |
| 416 | Luigi Puglielli | GERI | lp1@medicine.wisc.edu | Acarbose ameliorates Western diet-induced metabolic and cognitive impairments in the 3xTg mouse model of Alzheimer's disease. | Age is the greatest risk factor for Alzheimer's disease (AD) as well as for other disorders that increase the risk of AD such as diabetes and obesity. There is growing interest in determining if interventions that promote metabolic health can prevent or delay AD. Acarbose is an anti-diabetic drug that not only improves glucose homeostasis, but also extends the lifespan of wild-type mice. Here, we test the hypothesis that acarbose will not only preserve metabolic health, but also slow or prevent AD pathology and cognitive deficits in 3xTg mice, a model of AD, fed either a Control diet or a high-fat, high-sucrose Western diet (WD). We find that acarbose decreases the body weight and adiposity of WD-fed 3xTg mice, increasing energy expenditure while also stimulating food consumption, and improves glycemic control. Both male and female WD-fed 3xTg mice have worsened cognitive deficits than Control-fed mice, and these deficits are ameliorated by acarbose treatment. Molecular and histological analysis of tau and amyloid pathology identified sex-specific effects of acarbose which are uncoupled from the dramatic improvements in cognition in females, suggesting that the benefits of acarbose on AD may be largely driven by improved metabolic health. In conclusion, our results suggest that acarbose may be a promising intervention to prevent, delay, or even treat AD, especially in individuals consuming a WD. |
| 417 | Luigi Puglielli | GERI | lp1@medicine.wisc.edu | miR-92a-3p and miR-320a are Upregulated in Plasma Neuron-Derived Extracellular Vesicles of Patients with Frontotemporal Dementia. | Despite the efforts to identify fluid biomarkers to improve diagnosis of Frontotemporal dementia (FTD), only a few candidates have been described in recent years. In a previous study, we identified three circulating miRNAs (miR-92a-3p, miR-320a and miR-320b) differentially expressed in FTD patients with respect to healthy controls and/or Alzheimer's disease (AD) patients. Now, we investigated whether those changes could be due to miRNAs contained in neuron-derived extracellular vesicles (NDEVs). We also evaluated miRNAs content in total plasma EVs and in CSF samples. The analysis of plasma NDEVs carried out on 40 subjects including controls (n = 13), FTD (n = 13) and AD (n = 14) patients, showed that both miR-92a-3p and miR-320a levels were triplicated in the FTD group if compared with CT and AD patients. Increased levels of the same miRNAs were found also in CSF derived from FTD group compared to CTs. No differences were observed in expression levels of miR-320b among the three groups. Worthy of note, all miRNAs analysed were increased in an FTD cell model, MAPT IVS10 + 16 neurons. Our results suggest that miR-92a and miR-320a in NDEVs could be proposed as FTD biomarkers. |
| 418 | Luigi Puglielli | GERI | lp1@medicine.wisc.edu | Spatially and temporally probing distinctive glycerophospholipid alterations in Alzheimer's disease mouse brain via high-resolution ion mobility-enabled sn-position resolved lipidomics. | Dysregulated glycerophospholipid (GP) metabolism in the brain is associated with the progression of neurodegenerative diseases including Alzheimer's disease (AD). Routine liquid chromatography-mass spectrometry (LC-MS)-based large-scale lipidomic methods often fail to elucidate subtle yet important structural features such as sn-position, hindering the precise interrogation of GP molecules. Leveraging high-resolution demultiplexing (HRdm) ion mobility spectrometry (IMS), we develop a four-dimensional (4D) lipidomic strategy to resolve GP sn-position isomers. We further construct a comprehensive experimental 4D GP database of 498 GPs identified from the mouse brain and an in-depth extended 4D library of 2500 GPs predicted by machine learning, enabling automated profiling of GPs with detailed acyl chain sn-position assignment. Analyzing three mouse brain regions (hippocampus, cerebellum, and cortex), we successfully identify a total of 592 GPs including 130 pairs of sn-position isomers. Further temporal GPs analysis in the three functional brain regions illustrates their metabolic alterations in AD progression. |
| 419 | Luigi Puglielli | GERI | lp1@medicine.wisc.edu | Spatial selectivity of ATase inhibition in mouse models of Charcot-Marie-Tooth disease. | The endoplasmic reticulum acetylation machinery has emerged as a new branch of the larger endoplasmic reticulum quality control system. It regulates the selection of correctly folded polypeptides as well as reticulophagy-mediated removal of toxic protein aggregates with the former being a particularly important aspect of the proteostatic functions of endoplasmic reticulum acetylation. Essential to this function is the Nε-lysine acetyltransferase activity of acetyltransferase 1 and acetyltransferase 2, which regulates the induction of endoplasmic reticulum-specific autophagy through the acetylation of the autophagy-related protein 9A. Here, we used three mouse models of Charcot-Marie-Tooth disease, peripheral myelin protein 22/Tr-J, C3-peripheral myelin protein 22 and myelin protein zero/ttrr, to study spatial and translational selectivity of endoplasmic reticulum acetyltransferase inhibitors. The results show that inhibition of the endoplasmic reticulum acetyltransferases selectively targets misfolding/pro-aggregating events occurring in the lumen of the organelle. Therefore, they establish acetyltransferase 1 and acetyltransferase 2 as the first proven targets for disease-causing proteotoxic states that initiate within the lumen of the endoplasmic reticulum/secretory pathway. |
| 420 | Luigi Puglielli | GERI | lp1@medicine.wisc.edu | Protein restriction slows the development and progression of pathology in a mouse model of Alzheimer's disease. | Dietary protein is a critical regulator of metabolic health and aging. Low protein diets are associated with healthy aging in humans, and dietary protein restriction extends the lifespan and healthspan of mice. In this study, we examined the effect of protein restriction (PR) on metabolic health and the development and progression of Alzheimer's disease (AD) in the 3xTg mouse model of AD. Here, we show that PR promotes leanness and glycemic control in 3xTg mice, specifically rescuing the glucose intolerance of 3xTg females. PR induces sex-specific alterations in circulating and brain metabolites, downregulating sphingolipid subclasses in 3xTg females. PR also reduces AD pathology and mTORC1 activity, increases autophagy, and improves the cognition of 3xTg mice. Finally, PR improves the survival of 3xTg mice. Our results suggest that PR or pharmaceutical interventions that mimic the effects of this diet may hold promise as a treatment for AD. |
| 421 | Luigi Puglielli | GERI | lp1@medicine.wisc.edu | Protein restriction slows the development and progression of Alzheimer's disease in mice. | Dietary protein is a critical regulator of metabolic health and aging. Low protein diets are associated with healthy aging in humans, and many independent groups of researchers have shown that dietary protein restriction (PR) extends the lifespan and healthspan of mice. Here, we examined the effect of PR on metabolic health and the development and progression of Alzheimer's disease (AD) in the 3xTg mouse model of AD. We found that PR has metabolic benefits for 3xTg mice and non-transgenic controls of both sexes, promoting leanness and glycemic control in 3xTg mice and rescuing the glucose intolerance of 3xTg females. We found that PR induces sex-specific alterations in circulating metabolites and in the brain metabolome and lipidome, downregulating sphingolipid subclasses including ceramides, glucosylceramides, and sphingomyelins in 3xTg females. Consumption of a PR diet starting at 6 months of age reduced AD pathology in conjunction with reduced mTORC1 activity, increased autophagy, and had cognitive benefits for 3xTg mice. Finally, PR improved the survival of 3xTg mice. Our results demonstrate that PR slows the progression of AD at molecular and pathological levels, preserves cognition in this mouse model of AD, and suggests that PR or pharmaceutical interventions that mimic the effects of this diet may hold promise as a treatment for AD. |
| 422 | Luigi Puglielli | GERI | lp1@medicine.wisc.edu | CHRISTMAS: Chiral Pair Isobaric Labeling Strategy for Multiplexed Absolute Quantitation of Enantiomeric Amino Acids. | Amino acids (AAs) in the d-form are involved in multiple pivotal neurological processes, although their l-enantiomers are most commonly found. Mass spectrometry-based analysis of low-abundance d-AAs has been hindered by challenging enantiomeric separation from l-AAs, low sensitivity for detection, and lack of suitable internal standards for accurate quantification. To address these critical gaps, N,N-dimethyl-l-leucine (l-DiLeu) tags are first validated as novel chiral derivatization reagents for chromatographic separation of 20 pairs of d/l-AAs, allowing the construction of a 4-plex isobaric labeling strategy for enantiomer-resolved quantification through single step tagging. Additionally, the creative design of N,N-dimethyl-d-leucine (d-DiLeu) reagents offers an alternative approach to generate analytically equivalent internal references of d-AAs using d-DiLeu-labeled l-AAs. By labeling cost-effective l-AA standards using paired d- and l-DiLeu, this approach not only enables absolute quantitation of both d-AAs and l-AAs from complex biological matrices with enhanced precision but also significantly boosts the combined signal intensities from all isobaric channels, greatly improving the detection and quantitation of low-abundance AAs, particularly d-AAs. We term this quantitative strategy CHRISTMAS, which stands for chiral pair isobaric labeling strategy for multiplexed absolute quantitation. Leveraging the ion mobility collision cross section (CCS) alignment, interferences from coeluting isomers/isobars are effectively filtered out to provide improved quantitative accuracy. From wild-type and Alzheimer's disease (AD) mouse brains, we successfully quantified 20 l-AAs and 5 d-AAs. The significant presence and differential trends of certain d-AAs compared to those of their l-counterparts provide valuable insights into the involvement of d-AAs in aging, AD progression, and neurodegeneration. |
| 423 | Jane Mahoney | GERI | jm2@medicine.wisc.edu | Examination of a hope- and fear-based message targeting older adults who smoke: A randomized trial. | Older adults who smoke are half as likely to make a quit attempt, but more likely to maintain abstinence using evidence-based treatments. Awareness of the increased risk of dementia among people who currently smoke may motivate cessation in this population, but messages have not been tested. 820 adults who smoke, ages 50-80, with no history of dementia completed an online survey examining one of three randomly assigned messages (Control N = 266, Fear N = 274, Hope N = 280) on motivation and intentions to quit. Fear and Hope messages were based on the link between smoking and dementia. Fear increased motivation to quit [t(813) = 2.818, p = 0.005] more than Control. Hope did not differ from Control [t(813) = 1.908, p = 0.057] or Fear [t(813) = 0.937, p = 0.349] in change in motivation to quit. There were no differences between messages in change in intention to quit, F(2, 817) = 0.825, p = 0.439. Future work should examine feasibility and acceptability of fear-based motivational messages on quitting success. |
| 424 | Jane Mahoney | GERI | jm2@medicine.wisc.edu | Call the experts: identifying stakeholders in the long-term care of youth with hypospadias. | Long-term follow-up for individuals with hypospadias remains a critical area of need, yet evidence-based guidelines for such follow-up are lacking, and the role of involvement of relevant experts is not yet established. Using our hypospadias-specific health-related quality of life conceptual framework and a subsequent qualitative study of prepubertal males and parents of males with hypospadias, we identified potential priorities for long-term follow-up of youth with hypospadias. Using thematic codes from our patient and parent interviews, we searched PubMed for relevant articles and identified the specialties represented by all the authors of these articles. Our search strategy revealed consistent expertise across HRQOL themes and subthemes, including pediatric and adult urology, health psychology, psychiatry, endocrinology, genetics, and social work. Communication experts, as well as patients and families, were also represented in our literature search. Using these findings, we compiled a comprehensive list of potential stakeholders to inform the development of holistic care guidelines for individuals with hypospadias. By engaging these stakeholders, we aim to develop consensus-based, long-term follow-up guidelines and tools to address the evolving physical and psychosocial needs of people with hypospadias over a lifetime. The use of qualitatively derived thematic codes to search for relevant literature is an accessible approach to identifying relevant stakeholders. These findings underscore the importance of involving diverse, multidisciplinary expertise to ensure comprehensive, patient-centered care in complex genitourinary conditions. |
| 425 | Jane Mahoney | GERI | jm2@medicine.wisc.edu | Using Systems Engineering and Implementation Science to Design an Implementation Package for Preoperative Comprehensive Geriatric Assessment Among Older Adults Having Major Abdominal Surgery: Protocol for a 3-Phase Study. | Older Americans, a growing segment of the population, have an increasing need for surgical services, and they experience a disproportionate burden of postoperative complications compared to their younger counterparts. A preoperative comprehensive geriatric assessment (pCGA) is recommended to reduce risk and improve surgical care delivery for this population, which has been identified as vulnerable. The pCGA optimizes multiple chronic conditions and factors commonly overlooked in routine preoperative planning, including physical function, polypharmacy, nutrition, cognition, mental health, and social and environmental support. The pCGA has been shown to decrease postoperative morbidity, mortality, and length of stay in a variety of surgical specialties. Although national guidelines recommend the use of the pCGA, a paucity of strategic guidance for implementation limits its uptake to a few academic medical centers. By applying implementation science and human factors engineering methods, this study will provide the necessary evidence to optimize the implementation of the pCGA in a variety of health care settings. The purpose of this paper is to describe the study protocol to design an adaptable, user-centered pCGA implementation package for use among older adults before major abdominal surgery. This protocol uses systems engineering methods to develop, tailor, and pilot-test a user-centered pCGA implementation package, which can be adapted to community-based hospitals in preparation for a multisite implementation trial. The protocol is based upon the National Institutes of Health Stage Model for Behavioral Intervention Development and aligns with the goal to develop behavioral interventions with an eye to real-world implementation. In phase 1, we will use observation and interviews to map the pCGA process and identify system-based barriers and facilitators to its use among older adults undergoing major abdominal surgery. In phase 2, we will apply user-centered design methods, engaging health care providers, patients, and caregivers to co-design a pCGA implementation package. This package will be applicable to a diverse population of older patients undergoing major abdominal surgery at a large academic hospital and an affiliate community site. In phase 3, we will pilot-test and refine the pCGA implementation package in preparation for a future randomized controlled implementation-effectiveness trial. We anticipate that this study will take approximately 60 months (April 2023-March 2028). This study protocol will generate (1) a detailed process map of the pCGA; (2) an adaptable, user-centered pCGA implementation package ready for feasibility testing in a pilot trial; and (3) preliminary pilot data on the implementation and effectiveness of the package. We anticipate that these data will serve as the basis for future multisite hybrid implementation-effectiveness clinical trials of the pCGA in older adults undergoing major abdominal surgery. The expected results of this study will contribute to improving perioperative care processes for older adults before major abdominal surgery. DERR1-10.2196/59428. |
| 426 | Jane Mahoney | GERI | jm2@medicine.wisc.edu | Qualitative Message Development to Motivate Quitting Smoking in Older Adults: Dementia May Motivate Quitting. | Compared to younger adults, older adults who smoke cigarettes are half as likely to make a quit attempt, but more likely to maintain abstinence using evidence-based smoking treatments (EBSTs), illustrating the need for motivational messages to promote cessation through EBSTs. It is unclear whether messaging regarding the association between smoking and dementia might motivate older adults to quit. We conducted 90-min semi-structured qualitative interviews and surveys via telephone with 24 U.S. older adults who smoke (ages 50-75) with no cognitive impairment history. Rapid content analysis revealed the most reported health-related concern of aging was dementia/cognitive loss/loss of functioning. However, most participants were unaware of the association between cognitive decline and smoking. Participants had seen previous smoking cessation advertisements, but most did not feel motivated to quit by them. The majority found a message about smoking raising dementia risk and quitting decreasing that risk to be motivational for cessation. Exact message content preference varied, but 2 broad categories arose: hope- and fear-based messages. Most participants stated willingness to use some cessation pharmacotherapy and half were willing to use cessation counseling. Participants preferred messages to come from older adults who were successful quitters. To our knowledge, this was the first study to explore potential motivational messages targeting older adult smokers, including the potential acceptability of a dementia-related message in this context. This work supports patient desire for targeted motivational messages for older adult smokers. Messages highlighting the link between smoking and dementia are perceived to be motivational for this group; future work should compare a hope- to fear-based messages. |
| 427 | Jane Mahoney | GERI | jm2@medicine.wisc.edu | Outcomes Associated With Translating Evidence-Based Research Into Practice: The Physical Activity for Lifelong Success Program. | Few programs assess for outcomes once translated into practice. The Physical Activity for Lifelong Success program was developed as a center-based public health intervention and shown to improve walking speed and distance among older adults with type 2 diabetes. We adapted the program for community-based delivery by lay leaders to physically inactive older adults. We followed the Replicating Effective Programs framework to identify community stakeholders, adapt, implement, and evaluate fidelity of delivery in community settings, and plan for maintenance and evolution. Sixteen community sites enrolled 184 adults (mean age 73.5 y, 85% female, 93% White) in 21 workshops. Baseline and postworkshop measures assessed participants' health-related quality of life, physical function, and physical fitness. Data were analyzed using Fisher exact tests, Student t test, and paired linear regression with fixed effects. Fidelity testing indicated leader training was sufficient to maintain key elements with delivery. Data from 122 participants showed improvements in chair stands (P < .001), arm curls (P < .001), 2-minute step test (P < .001), sit-and-reach (P = .001), 8-foot up-and-go (P < .001), and 10-m walk (P < .001). Adaptation of Physical Activity for Lifelong Success for implementation by community organizations for physically inactive older adults demonstrates that fidelity and effectiveness can be maintained after program translation. |
| 428 | Jane Mahoney | GERI | jm2@medicine.wisc.edu | Deployment of Real-time Natural Language Processing and Deep Learning Clinical Decision Support in the Electronic Health Record: Pipeline Implementation for an Opioid Misuse Screener in Hospitalized Adults. | The clinical narrative in electronic health records (EHRs) carries valuable information for predictive analytics; however, its free-text form is difficult to mine and analyze for clinical decision support (CDS). Large-scale clinical natural language processing (NLP) pipelines have focused on data warehouse applications for retrospective research efforts. There remains a paucity of evidence for implementing NLP pipelines at the bedside for health care delivery. We aimed to detail a hospital-wide, operational pipeline to implement a real-time NLP-driven CDS tool and describe a protocol for an implementation framework with a user-centered design of the CDS tool. The pipeline integrated a previously trained open-source convolutional neural network model for screening opioid misuse that leveraged EHR notes mapped to standardized medical vocabularies in the Unified Medical Language System. A sample of 100 adult encounters were reviewed by a physician informaticist for silent testing of the deep learning algorithm before deployment. An end user interview survey was developed to examine the user acceptability of a best practice alert (BPA) to provide the screening results with recommendations. The planned implementation also included a human-centered design with user feedback on the BPA, an implementation framework with cost-effectiveness, and a noninferiority patient outcome analysis plan. The pipeline was a reproducible workflow with a shared pseudocode for a cloud service to ingest, process, and store clinical notes as Health Level 7 messages from a major EHR vendor in an elastic cloud computing environment. Feature engineering of the notes used an open-source NLP engine, and the features were fed into the deep learning algorithm, with the results returned as a BPA in the EHR. On-site silent testing of the deep learning algorithm demonstrated a sensitivity of 93% (95% CI 66%-99%) and specificity of 92% (95% CI 84%-96%), similar to published validation studies. Before deployment, approvals were received across hospital committees for inpatient operations. Five interviews were conducted; they informed the development of an educational flyer and further modified the BPA to exclude certain patients and allow the refusal of recommendations. The longest delay in pipeline development was because of cybersecurity approvals, especially because of the exchange of protected health information between the Microsoft (Microsoft Corp) and Epic (Epic Systems Corp) cloud vendors. In silent testing, the resultant pipeline provided a BPA to the bedside within minutes of a provider entering a note in the EHR. The components of the real-time NLP pipeline were detailed with open-source tools and pseudocode for other health systems to benchmark. The deployment of medical artificial intelligence systems in routine clinical care presents an important yet unfulfilled opportunity, and our protocol aimed to close the gap in the implementation of artificial intelligence-driven CDS. ClinicalTrials.gov NCT05745480; https://www.clinicaltrials.gov/ct2/show/NCT05745480. |
| 429 | Jane Mahoney | GERI | jm2@medicine.wisc.edu | Training dementia care professionals to help caregivers improve the management of behavioral and psychological symptoms of dementia using the DICE Approach: A pilot study. | Most persons living with dementia (PLWD) exhibit behavioral or psychological symptoms of dementia (BPSD) over the course of the illness. The DICE Approach (DICE) is a framework that enables caregivers to identify, evaluate, and manage BPSD. This pilot pre-post test study examined the effects of DICE training on dementia care professionals' self-efficacy, knowledge, and attitudes regarding care of patients with BPSD. Participants underwent either in-person DICE training or, during the pandemic, online training. Case consultations were offered as additional learning opportunities in challenging situations. Of 134 participants in the trainings, 122 (91.0%) provided survey data for one or more instruments before and after training. Participants experienced significant improvement in knowledge and attitudes with respect to BPSD and improvement in self-efficacy with respect to helping caregivers respond to BPSD. Training dementia care professionals in DICE can improve their capacity to support caregivers in the management of BPSD. |
| 430 | Jane Mahoney | GERI | jm2@medicine.wisc.edu | Training professional caregivers to screen for report of cognitive changes in persons with intellectual disability. | By age 60, 60% of adults with Down syndrome (DS) have dementia. Detecting dementia in persons with intellectual disability (ID) can be challenging because their underlying cognitive impairment can confound presentation of dementia symptoms and because adults with ID may have difficulty reporting symptoms. The National Task Group Early Detection Screen for Dementia (NTG-EDSD) was developed to aid detection of report of cognitive impairment in adults with ID. We implemented an educational curriculum using the NTG-EDSD and evaluated the impact of the intervention on professional caregivers' self-assessed capacity to identify persons with ID and dementia. We held five in-person training sessions for professional caregivers of persons with ID, partnering with various managed care organizations and social services agencies. We assessed knowledge and attitudes at baseline; immediately after training; and 1 week, 1 month, and 6 months after training. A total of 154 direct care workers, case managers, health-care providers, and other social services staff attended the trainings. Satisfaction with the NTG-EDSD training was high; 94% of attendees agreed or strongly agreed that they could use the NTG-EDSD with their clients. After training, attendees reported a marked increase in confidence in their ability to track various health circumstances and detect functional decline in their clients, although some gains were not sustained over time. As a result of the training, one managed care organization made the NTG-EDSD a standard part of its assessment of adults with DS starting at age 40. Social services and health-care professionals can learn to document signs of cognitive decline in adults with ID using the NTG-EDSD. Attendees were highly satisfied with the training, experienced an increase in confidence in their care of persons with ID, and found the NTG- EDSD feasible to use. Because not all gains were sustained over time, booster trainings may be necessary. |
| 431 | Jane Mahoney | GERI | jm2@medicine.wisc.edu | Using Smart Displays to Implement an eHealth System for Older Adults With Multiple Chronic Conditions: Protocol for a Randomized Controlled Trial. | Voice-controlled smart speakers and displays have a unique but unproven potential for delivering eHealth interventions. Many laptop- and smartphone-based interventions have been shown to improve multiple outcomes, but voice-controlled platforms have not been tested in large-scale rigorous trials. Older adults with multiple chronic health conditions, who need tools to help with their daily management, may be especially good candidates for interventions on voice-controlled devices because these patients often have physical limitations, such as tremors or vision problems, that make the use of laptops and smartphones challenging. The aim of this study is to assess whether participants using an evidence-based intervention (ElderTree) on a smart display will experience decreased pain interference and improved quality of life and related measures in comparison with participants using ElderTree on a laptop and control participants who are given no device or access to ElderTree. A total of 291 adults aged ≥60 years with chronic pain and ≥3 additional chronic conditions will be recruited from primary care clinics and community organizations and randomized 1:1:1 to ElderTree access on a smart display along with their usual care, ElderTree access on a touch screen laptop along with usual care, or usual care alone. All patients will be followed for 8 months. The primary outcomes are differences between groups in measures of pain interference and psychosocial quality of life. The secondary outcomes are between-group differences in system use at 8 months, physical quality of life, pain intensity, hospital readmissions, communication with medical providers, health distress, well-being, loneliness, and irritability. We will also examine mediators and moderators of the effects of ElderTree on both platforms. At baseline, 4 months, and 8 months, patients will complete written surveys comprising validated scales selected for good psychometric properties with similar populations. ElderTree use data will be collected continuously in system logs. We will use linear mixed-effects models to evaluate outcomes over time, with treatment condition and time acting as between-participant factors. Separate analyses will be conducted for each outcome. Recruitment began in August 2021 and will run through April 2023. The intervention period will end in December 2023. The findings will be disseminated via peer-reviewed publications. To our knowledge, this is the first study with a large sample and long time frame to examine whether a voice-controlled smart device can perform as well as or better than a laptop in implementing a health intervention for older patients with multiple chronic health conditions. As patients with multiple conditions are such a large cohort, the implications for cost as well as patient well-being are significant. Making the best use of current and developing technologies is a critical part of this effort. ClinicalTrials.gov NCT04798196; https://clinicaltrials.gov/ct2/show/NCT04798196. PRR1-10.2196/37522. |
| 432 | Jane Mahoney | GERI | jm2@medicine.wisc.edu | Effect of an eHealth intervention on older adults' quality of life and health-related outcomes: a randomized clinical trial. | By 2030, the number of US adults age ≥65 will exceed 70 million. Their quality of life has been declared a national priority by the US government. Assess effects of an eHealth intervention for older adults on quality of life, independence, and related outcomes. Multi-site, 2-arm (1:1), non-blinded randomized clinical trial. Recruitment November 2013 to May 2015; data collection through November 2016. Three Wisconsin communities (urban, suburban, and rural). Purposive community-based sample, 390 adults age ≥65 with health challenges. long-term care, inability to get out of bed/chair unassisted. Access (vs. no access) to interactive website (ElderTree) designed to improve quality of life, social connection, and independence. Primary outcome: quality of life (PROMIS Global Health). Secondary: independence (Instrumental Activities of Daily Living); social support (MOS Social Support); depression (Patient Health Questionnaire-8); falls prevention (Falls Behavioral Scale). Moderation: healthcare use (Medical Services Utilization). Both groups completed all measures at baseline, 6, and 12 months. Three hundred ten participants (79%) completed the 12-month survey. There were no main effects of ElderTree over time. Moderation analyses indicated that among participants with high primary care use, ElderTree (vs. control) led to better trajectories for mental quality of life (OR=0.32, 95% CI 0.10-0.54, P=0.005), social support received (OR=0.17, 95% CI 0.05-0.29, P=0.007), social support provided (OR=0.29, 95% CI 0.13-0.45, P<0.001), and depression (OR= -0.20, 95% CI -0.39 to -0.01, P=0.034). Supplemental analyses suggested ElderTree may be more effective among people with multiple (vs. 0 or 1) chronic conditions. Once randomized, participants were not blind to the condition; self-reports may be subject to memory bias. Interventions like ET may help improve quality of life and socio-emotional outcomes among older adults with more illness burden. Our next study focuses on this population. ClinicalTrials.gov ; registration ID number: NCT02128789. |
| 437 | Carey Gleason | GERI | ceg@medicine.wisc.edu | Menopausal hormone therapy is associated with worse levels of Alzheimer's disease biomarkers in APOE ε4-carrying women: An observational study. | Menopausal hormone therapy (MHT), along with the apolipoprotein E (APOE) ε4 allele, has been suggested as a possible risk factor for Alzheimer's disease (AD). However, the relationship between MHT and cerebrospinal fluid (CSF) biomarkers is unknown: we investigated this association, and whether APOE ε4 carrier status moderates it. In an observational study of 136 cognitively unimpaired female participants (Mage = 66.0; standard deviation = 6.3), we examined whether MHT use alone or in interaction with APOE ε4 carrier status was associated with CSF levels of phosphorylated tau (p-tau), amyloid beta (Aβ)40, Aβ42, p-tau/Aβ42, and Aβ42/40 ratios. Significant interactions were found between APOE ε4 and MHT use for CSF biomarkers. APOE ε4 carriers who were MHT users showed worse levels of CSF p-tau/Aβ42 and Aβ42/40 ratios than all other users and non-users. The presence of both APOE ε4 and MHT may be associated with elevated amyloid deposition and AD pathology in this sample of participants who demonstrated high familial AD risk. Significant interactions were found between apolipoprotein E (APOE) ε4 and menopausal hormone therapy (MHT) use for cerebrospinal fluid (CSF) phosphorylated tau (p-tau)/amyloid beta (Aβ)42 and Aβ42/40 ratios. APOE ε4 carriers who were MHT users showed worse levels of CSF biomarkers than non-users and non-carriers, both users and non-users. Younger age at MHT initiation was associated with worse levels of the p-tau/Aβ42 and Aβ42/40 ratios in carriers only. The presence of both APOE ε4 carriage and MHT use may be associated with elevated amyloid deposition and AD pathology. Further studies with larger sample sizes are necessary to confirm the differences observed in the current study. |
| 438 | Carey Gleason | GERI | ceg@medicine.wisc.edu | Perceptions about preclinical Alzheimer's disease biomarker collection procedure influences willingness to participate: Findings from an ethnoracially diverse study. | Past research suggests that ethnoracialized groups differ in their willingness to engage in preclinical Alzheimer's disease (AD) research overall. Studies indicated that participation willingness was affected by attitudes toward research and perceived invasiveness of biomarker collection techniques. However, comparative quantitative studies are few, and minoritized groups are under-included. In a cross-sectional online survey, we sought to explore community-based adults' willingness to engage in preclinical AD biomarker testing, comparing their attitudes about research and different types of biomarker procedures. We conducted an online survey with a diverse group of participants. African American (AA), American Indian/Alaska Native (AI/AN), Latinx (LTX), and Non-Hispanic White (NHW) adults aged 26-90 were asked about their research attitudes, biomarkers, and willingness to participate in specific biomarker test procedures (i.e., brain imaging via PET scanning, blood draws, and cerebrospinal fluid collection by lumbar puncture). We also assessed participants' perceived safety, burden, and distress for each of the three biomarker collection methods. To understand the association between research willingness and ethnoracial identity, we ran linear regression models for each procedure, adjusting for age, gender, educational attainment, and attitudes toward research. The AA group expressed greater willingness to engage in biomarker testing involving blood draws than the NHW group. The AI/AN group was significantly less willing to undergo lumbar puncture than the NHW group; this difference remained after adjusting for various sociodemographic factors and research attitudes. Respondents' willingness to engage in preclinical AD biomarker research was affected by their perceptions about the testing collection procedure. |
| 439 | Carey Gleason | GERI | ceg@medicine.wisc.edu | Associations of blood pressure with white matter hyperintensities later in life; influence of short-term menopausal hormone therapy. | To assess the association of systolic and diastolic blood pressure (SBP and DBP) in recently menopausal women with white matter hyperintensity (WMH) volume later in life and determine whether short-term menopausal hormone therapy (mHT) modifies these associations. Kronos Early Estrogen Prevention Study (KEEPS) was a multicenter, randomized, double-blinded, placebo-controlled 4-year mHT trial (oral conjugated equine estrogens or transdermal 17β-estradiol). KEEPS continuation was an observational follow-up of the participants 10 years after the end of mHT. The associations between KEEPS baseline blood pressure (BP) with KEEPS continuation WMH volume were examined adjusting for covariates in model 1 (age, total intracranial volume, study site, mHT type) and model 2 (additionally conventional CVD risk factors). Interaction terms (BP × mHT type) were added into the linear regression models. The mean ± SD ages of participants were 53 (±2) years at KEEPS baseline and 67 (±2) years at KEEPS continuation. Elevated BP at KEEPS baseline was associated with greater WMH volume measured 14 years later (model 1: SBP: β = 0.01 [95% CI, 0.001-0.01] and DBP: β = 0.01 [95% CI, 0.003-0.03]) and after additionally adjusting for CVD risk factors (model 2). We did not find any evidence that mHT versus placebo modified these associations. Topographically, higher BP was associated with greater periventricular WMH in the frontal and parietal lobes. Our findings suggest the importance of maintaining normal BP in recently postmenopausal women with low CVD risk, irrespective of short-term mHT usage, to potentially reduce the risk of WMH later in life. |
| 440 | Carey Gleason | GERI | ceg@medicine.wisc.edu | Implementation of a Social Media Strategy for Public Health Promotion in Black, American Indian or Alaska Native, and Hispanic or Latino Communities During the COVID-19 Pandemic: Cross-Sectional Study. | Individuals identifying as Black, American Indian or Alaska Native, or Hispanic or Latino lack access to culturally appropriate accurate information and are the target of disinformation campaigns, which create doubt in science and health care providers and might play a role in sustaining health disparities related to the COVID-19 pandemic. This study aims to create and disseminate culturally and medically appropriate social media messages for Black, Latino, and American Indian or Alaska Native communities in Wisconsin and evaluate their reach and effectiveness in addressing the information needs of these communities. Our team identified relevant COVID-19 topics based on feedback from their respective community, developed lay format materials, and translated materials into culturally appropriate social media messages that community advocates delivered across their respective communities. Social media metrics (reach, engagement, and impressions) were collected using Sprout Social and Facebook Analytics. We hosted 9 focus groups with community members to learn about their social media use. These data were analyzed using an inductive approach, using NVivo software (release 1.7) to code content. Between August 2021 and January 2023, we created 980 unique social media posts that reached 88,790 individuals and gathered >6700 engagements. Average reach per post was similar across the 3 communities, despite differences in the number of posts and followers on each page: 119.46 (Latino individuals), 111.74 (Black individuals), and 113.11 (Oneida Nation members). The type of posts that had higher engagement rate per reached person (ERR) varied across communities and platforms, with the highest being live videos for the Latino community on Facebook (ERR 9.4%), videos for the Black community on Facebook (ERR 19.53%), and social media messages for the Oneida Nation community (ERR 59.01%). Our project presents a unique and effective model for health messages and highlights the need for tailoring social media messages and approaches for minoritized audiences (eg, age, gender, race, and ethnicity). Further research studies are needed to explore how specific types of information affect the dissemination of information and the implications for health communications. |
| 441 | Carey Gleason | GERI | ceg@medicine.wisc.edu | Association of Caregiving Receipt With Mental Health Utilization in a National Cohort of Older Adults. | There exist significant age disparities in mental health (MH) utilization, such that older adults, including older veterans, are much less likely to use MH services. In-home caregivers represent a novel, yet understudied, pathway to increase appropriate utilization. We sought to examine the association between receiving caregiving assistance and MH utilization and test moderation effects of cognitive status and depression severity in a sample of older veterans. Cross-sectional, mixed effects logistic regression with moderation analyses was used with a unique data resource combining survey data from the 2000-2012 U.S. Health and Retirement Study with Veterans Affairs (VA) healthcare administrative records. The analytic sample included N=1,957 Community-dwelling veterans (mean age 68.2 [9.7]), primarily male (96.5%) and non-Hispanic white (77.0%). Measures included MH utilization extracted from VA records or self-report; CESD-8 for depressive symptoms; and the Langa-Weir cognitive status classification using the modified TICS. After accounting for demographics, spousal caregiver availability, health factors, and socioeconomic status, caregiving receipt was associated with two-fold odds of MH utilization, compared to receiving no assistance (8,839 person-year observations; OR = 2.02; 95% CI 1.54-2.65) and remained similar following VA policy changes to enhance MH access. Exploratory analyses revealed that categories of cognition and depressive symptoms may moderate the association. Receipt of any in-home caregiving is associated with increased likelihood of MH use by older adults. Caregivers may represent an underutilized resource to reduce age-related mental health access disparities. |
| 442 | Carey Gleason | GERI | ceg@medicine.wisc.edu | Long-term cognitive effects of menopausal hormone therapy: Findings from the KEEPS Continuation Study. | Findings from Kronos Early Estrogen Prevention Study (KEEPS)-Cog trial suggested no cognitive benefit or harm after 48 months of menopausal hormone therapy (mHT) initiated within 3 years of final menstrual period. To clarify the long-term effects of mHT initiated in early postmenopause, the observational KEEPS Continuation Study reevaluated cognition, mood, and neuroimaging effects in participants enrolled in the KEEPS-Cog and its parent study the KEEPS approximately 10 years after trial completion. We hypothesized that women randomized to transdermal estradiol (tE2) during early postmenopause would show cognitive benefits, while oral conjugated equine estrogens (oCEE) would show no effect, compared to placebo over the 10 years following randomization in the KEEPS trial. The KEEPS-Cog (2005-2008) was an ancillary study to the KEEPS (NCT00154180), in which participants were randomized into 3 groups: oCEE (Premarin, 0.45 mg/d), tE2 (Climara, 50 μg/d) both with micronized progesterone (Prometrium, 200 mg/d for 12 d/mo) or placebo pills and patch for 48 months. KEEPS Continuation (2017-2022), an observational, longitudinal cohort study of KEEPS clinical trial, involved recontacting KEEPS participants approximately 10 years after the completion of the 4-year clinical trial to attend in-person research visits. Seven of the original 9 sites participated in the KEEPS Continuation, resulting in 622 women of original 727 being invited to return for a visit, with 299 enrolling across the 7 sites. KEEPS Continuation participants repeated the original KEEPS-Cog test battery which was analyzed using 4 cognitive factor scores and a global cognitive score. Cognitive data from both KEEPS and KEEPS Continuation were available for 275 participants. Latent growth models (LGMs) assessed whether baseline cognition and cognitive changes during KEEPS predicted cognitive performance at follow-up, and whether mHT randomization modified these relationships, adjusting for covariates. Similar health characteristics were observed at KEEPS randomization for KEEPS Continuation participants and nonparticipants (i.e., women not returning for the KEEPS Continuation). The LGM revealed significant associations between intercepts and slopes for cognitive performance across almost all domains, indicating that cognitive factor scores changed over time. Tests assessing the effects of mHT allocation on cognitive slopes during the KEEPS and across all years of follow-up including the KEEPS Continuation visit were all statistically nonsignificant. The KEEPS Continuation study found no long-term cognitive effects of mHT, with baseline cognition and changes during KEEPS being the strongest predictors of later performance. Cross-sectional comparisons confirmed that participants assigned to mHT in KEEPS (oCEE and tE2 groups) performed similarly on cognitive measures to those randomized to placebo, approximately 10 years after completion of the randomized treatments. These findings suggest that mHT poses no long-term cognitive harm; conversely, it provides no cognitive benefit or protective effects against cognitive decline. In these KEEPS Continuation analyses, there were no long-term cognitive effects of short-term exposure to mHT started in early menopause versus placebo. These data provide reassurance about the long-term neurocognitive safety of mHT for symptom management in healthy, recently postmenopausal women, while also suggesting that mHT does not improve or preserve cognitive function in this population. |
| 443 | Carey Gleason | GERI | ceg@medicine.wisc.edu | Ethno-racial differences in depressive symptom endorsement: Evaluation of brief forms of the Geriatric Depression Scale in older adults. | Depression among older adults is a pressing public health concern, necessitating accurate assessment tools. The Geriatric Depression Scale (GDS) offers a brief and efficient means of screening depressive symptoms, yet its performance across ethno-racial groups remains understudied. This study aimed to compare the ability of various brief forms of the GDS to detect depressive symptoms and to assess potential ethno-racial differences in symptom endorsement among White, Black/African-American, and American Indian/Alaska Native older adults. Data were obtained from the Wisconsin Alzheimer's Disease Research Center (ADRC) clinical cohort, comprising 555 cognitively healthy individuals at risk for dementia. We used participants' baseline data for this cross-sectional analysis. Depressive symptoms were assessed using multiple brief forms of the GDS, derived from a systematic review and meta-analysis. We examined internal consistency and correlations with global Clinical Dementia Rating (CDR) scores. We conducted Kruskal-Wallis tests and post hoc pairwise comparisons to assess ethno-racial group differences in symptom endorsement. Descriptive statistics revealed a predominance of female and White participants, with notable representation from Black and American Indian/Alaska Native groups. All GDS versions demonstrated moderate to high internal consistency. Significant positive correlations were observed between GDS scores and global CDR scores. Ethno-racial group differences in depressive symptom endorsement were evident, with Black participants consistently reporting higher levels of symptoms across most GDS versions. However, American Indian/Alaska Native participants endorsed significantly fewer symptoms than Black participants in one GDS version. The study highlights the importance of considering ethno-racial differences in depressive symptomatology when assessing older adults. While the GDS demonstrates overall reliability, variations in symptom endorsement across different ethno-racial groups underscore the need for culturally sensitive assessment tools and interventions. Future research should further explore these group differences and develop tailored approaches to depression screening and treatment in diverse older adult populations. |
| 444 | Carey Gleason | GERI | ceg@medicine.wisc.edu | Longitudinal normative standards for cognitive tests and composites using harmonized data from two Wisconsin AD-risk-enriched cohorts. | Published norms are typically cross-sectional and often are not sensitive to preclinical cognitive changes due to dementia. We developed and validated demographically adjusted cross-sectional and longitudinal normative standards using harmonized outcomes from two Alzheimer's disease (AD) risk-enriched cohorts. Data from the Wisconsin Registry for Alzheimer's Prevention and the Wisconsin Alzheimer's Disease Research Center were combined. Quantile regression was used to develop unconditional (cross-sectional) and conditional (longitudinal) normative standards for 18 outcomes using data from cognitively unimpaired participants (N = 1390; mean follow-up = 9.25 years). Validity analyses (N = 2456) examined relationships between percentile scores (centiles), consensus-based cognitive statuses, and AD biomarker levels. Unconditional and conditional centiles were lower in those with consensus-based impairment or biomarker positivity. Similarly, quantitative biomarker levels were higher in those whose centiles suggested decline. This study presents normative standards for cognitive measures sensitive to pre-clinical changes. Future directions will investigate potential clinical applications of longitudinal normative standards. Quantile regression was used to construct longitudinal norms for cognitive tests. Poorer percentile scores were related to concurrent diagnosis and Alzheimer's disease biomarkers. A ShinyApp was built to display test scores and norms and flag low performance. |
| 445 | Carey Gleason | GERI | ceg@medicine.wisc.edu | Ethnoracialized group differences in attitudes and knowledge about schizophrenia and willingness to engage in biomarker research: The UBIGR Study. | Although there is renewed optimism in biomarker research in schizophrenia, there is also need for greater inclusion of historically underrepresented groups in the research. In the present study, we surveyed 599 African American, 352 American Indian/Alaska Native, and 725 NonHispanic White participants about their attitudes toward research, knowledge and attitudes about schizophrenia, and willingness to engage in biomarker testing. Attitudes toward research were examined using the standardized 7-item Research Attitudes Questionnaire (RAQ) measure. Using structural equation modeling (SEM), we tested our predictive model of the likelihood of willingness to engage in biomarker testing for schizophrenia risk. Members of historically underrepresented groups were less willing to engage in biomarker testing. Overall, attitudes toward research, particularly trust, influenced biomarker testing willingness. These findings suggest that factors influencing willingness to engage in schizophrenia biomarker testing may be modifiable by outreach engagement and education. |
| 446 | Carey Gleason | GERI | ceg@medicine.wisc.edu | Relationships of Cognitive Measures with Cerebrospinal Fluid but Not Imaging Biomarkers of Alzheimer Disease Vary between Black and White Individuals. | Biomarkers of Alzheimer disease vary between groups of self-identified Black and White individuals in some studies. This study examined whether the relationships between biomarkers or between biomarkers and cognitive measures varied by racialized groups. Cerebrospinal fluid (CSF), amyloid positron emission tomography (PET), and magnetic resonance imaging measures were harmonized across four studies of memory and aging. Spearman correlations between biomarkers and between biomarkers and cognitive measures were calculated within each racialized group, then compared between groups by standard normal tests after Fisher's Z-transformations. The harmonized dataset included at least one biomarker measurement from 495 Black and 2,600 White participants. The mean age was similar between racialized groups. However, Black participants were less likely to have cognitive impairment (28% vs 36%) and had less abnormality of some CSF biomarkers including CSF Aβ42/40, total tau, p-tau181, and neurofilament light. CSF Aβ42/40 was negatively correlated with total tau and p-tau181 in both groups, but at a smaller magnitude in Black individuals. CSF Aβ42/40, total tau, and p-tau181 had weaker correlations with cognitive measures, especially episodic memory, in Black than White participants. Correlations of amyloid measures between CSF (Aβ42/40, Aβ42) and PET imaging were also weaker in Black than White participants. Importantly, no differences based on race were found in correlations between different imaging biomarkers, or in correlations between imaging biomarkers and cognitive measures. Relationships between CSF biomarkers but not imaging biomarkers varied by racialized groups. Imaging biomarkers performed more consistently across racialized groups in associations with cognitive measures. ANN NEUROL 2024;95:495-506. |
| 447 | Sanjay Asthana | GERI | sa@medicine.wisc.edu | Delayed primacy recall in AVLT is associated with medial temporal tau PET burden in cognitively unimpaired adults. | Alzheimer's disease (AD) can be diagnosed by in vivo abnormalities of amyloid-β plaques (A) and tau accumulation (T) biomarkers. Previous studies have shown that analyses of serial position performance in episodic memory tests, and especially, delayed primacy, are associated with AD pathology even in individuals who are cognitively unimpaired. The earliest signs of cortical tau pathology are observed in medial temporal lobe (MTL) regions, yet it is unknown if serial position markers are also associated with early tau load in these regions. This study of cognitively unimpaired older individuals examined whether serial position scores in word-list recall cross-sectionally predicted tau PET load in the MTL, and were able to discriminate between biomarker profiles, based on AT classification. Data from 490 participants (mean age = 68.8 ± 7.2) were extracted from two cohorts, which were merged into one sample. Linear regression analyses were carried out with regional volume-controlled tau (18F-MK-6240) PET SUVR of the entorhinal cortex (EC), parahippocampal cortex (PHC) and hippocampus (H) as outcomes, cross-sectional memory scores from the Rey Auditory Verbal Learning Test as predictors (total and delayed recall, along with serial position scores) and control variables, in separate analyses for each outcome and predictor. The sample was then stratified by biomarker profile and ANCOVAs were conducted with the strongest scores from the regression analyses, AT groups as fixed factor and the covariates. Higher delayed primacy significantly predicted lower tau PET in EC, PHC, and H, cross-sectionally. Higher total recall scores predicted lower EC tau, but delayed primacy showed the best model fit, as indicated by AICs. ANCOVAs showed that AVLT metrics did not significantly discriminate between A-T- and A+T+, after correcting for multiple comparisons. Serial position analysis of word-list recall, particularly delayed primacy, may be a valuable tool for identifying in vivo tau pathology in cognitively unimpaired individuals. |
| 448 | Sanjay Asthana | GERI | sa@medicine.wisc.edu | Whole genome methylation sequencing in blood from persons with mild cognitive impairment and dementia due to Alzheimer's disease identifies cognitive status. | Whole genome methylation sequencing (WGMS) in blood identifies differential DNA methylation in persons with late-onset dementia due to Alzheimer's disease (AD) but has not been tested in persons with mild cognitive impairment (MCI). We used WGMS to compare DNA methylation levels at 25,244,219 CpG loci in 382 blood samples from 99 persons with MCI, 109 with AD, and 174 who are cognitively unimpaired (CU). WGMS identified 9756 differentially methylated positions (DMPs) in persons with MCI, including 1743 differentially methylated genes encoding proteins in biological pathways related to synapse organization, dendrite development, and ion transport. A total of 447 DMPs exhibit progressively increasing or decreasing DNA methylation levels among CU, MCI, and AD that correspond to cognitive status. WGMS identifies DMPs in known and newly detected genes in blood from persons with MCI and AD that support blood DNA methylation levels can distinguish cognitive status. Whole genome methylation levels in blood from 99 persons with mild cognitive impairment (MCI), 109 with Alzheimer's disease, and 174 who are cognitively unimpaired were analyzed. Nine thousand seven hundred fifty-six differentially methylated positions (DMPs) were identified in MCI. One thousand seven hundred forty-three genes comprise one or more DMPs in persons with MCI. Fifty-eight DMPs and 392 differentially methylated genes are shared among the three pairwise comparisons. Four hundred forty-seven DMPs exhibit progressive changes that correspond to cognitive status. |
| 449 | Sanjay Asthana | GERI | sa@medicine.wisc.edu | X-chromosome-wide association study for Alzheimer's disease. | Due to methodological reasons, the X-chromosome has not been featured in the major genome-wide association studies on Alzheimer's Disease (AD). To address this and better characterize the genetic landscape of AD, we performed an in-depth X-Chromosome-Wide Association Study (XWAS) in 115,841 AD cases or AD proxy cases, including 52,214 clinically-diagnosed AD cases, and 613,671 controls. We considered three approaches to account for the different X-chromosome inactivation (XCI) states in females, i.e. random XCI, skewed XCI, and escape XCI. We did not detect any genome-wide significant signals (P ≤ 5 × 10-8) but identified seven X-chromosome-wide significant loci (P ≤ 1.6 × 10-6). The index variants were common for the Xp22.32, FRMPD4, DMD and Xq25 loci, and rare for the WNK3, PJA1, and DACH2 loci. Overall, this well-powered XWAS found no genetic risk factors for AD on the non-pseudoautosomal region of the X-chromosome, but it identified suggestive signals warranting further investigations. |
| 450 | Sanjay Asthana | GERI | sa@medicine.wisc.edu | Midlife and late-life environmental exposures on dementia risk in the Wisconsin Longitudinal Study: The modifying effects of ApoE. | Late-life air pollution exposure is associated with an increased risk for dementia, with this effect exacerbated among apolipoprotein E-4 (ApoE-4) carriers. However, whether midlife occupational exposures likewise influence dementia outcomes, and varies as a function of ApoE-4 status is unknown. Using data from 3814 participants in the Wisconsin Longitudinal Study (WLS), we employed weighted logistic regression to evaluate associations between midlife occupational respiratory exposures and late-life air pollution on all-cause dementia risk, stratified by ApoE-4 status. Midlife occupational exposure was associated with increased odds of all-cause dementia preferentially among ApoE-4 noncarriers (odds ratio [OR] = 1.59, p = 0.01), whereas higher late-life urban air pollution exposure was associated with increased dementia risk among ApoE-4 carriers (OR = 1.258, p = 0.029). Associations between environmental exposures and dementia risk vary based on the timing of exposure and ApoE-4 status. While late-life environmental exposures are associated with dementia among ApoE-4 carriers, for noncarriers midlife environmental exposure confers the greatest risk. The effect of adult environmental respiratory exposures on subsequent dementia risk varies as a function of both ApoE-4 carrier status and exposure timing. Midlife occupational exposure to respiratory hazards is preferentially associated with increased dementia odds among ApoE-4 noncarriers. Late-life exposure to ambient air pollution is associated with dementia risk, but only among ApoE-4 carriers. While higher exposure to PM2.5 increases the risk for dementia, higher exposure to ozone was associated with reduced risk for dementia among ApoE-4 carriers. |
| 451 | Sanjay Asthana | GERI | sa@medicine.wisc.edu | Targeted Proteomic Biomarker Profiling Using NULISA in a cohort enriched with risk for Alzheimer's Disease and Related Dementias. | Targeted proteomic assays may be useful for diagnosing and staging Alzheimer's disease and related dementias (ADRD). We evaluated the performance of a 120-marker central nervous system (CNS) NUcleic acid-Linked Immuno-Sandwich Assay (NULISA) panel in samples spanning the AD spectrum. Cross-sectional plasma samples (n=252) were analyzed using Alamar's NULISAseq CNS panel. ROC analyses demonstrated NULISAseq-pTau217 accuracy in detecting amyloid (A) and tau (T) PET positivity. Differentially expressed proteins were identified using volcano plots. NULISAseq-pTau217 accurately classified A/T PET status with ROC AUCs of 0.92/0.86. pTau217 was upregulated in A+, T+, and impaired groups with log2-fold changes of 1.21, 0.57 and 4.63, respectively, compared to A-. Interestingly, pTDP43-409 was also upregulated in the impaired group and correlated with declining hippocampal volume and cognitive trajectories. This study shows the potential of a targeted proteomics panel for characterizing brain changes pertinent to ADRD. The promising pTDP43-409 findings require further replication. |
| 452 | Sanjay Asthana | GERI | sa@medicine.wisc.edu | Visual read of [F-18]florquinitau PET that includes and extends beyond the mesial temporal lobe is associated with increased plasma pTau217 and cognitive decline in a cohort that is enriched with risk for Alzheimer's disease. | Patterns of signal from tau positron emission tomography (tau-PET) confined to the medial temporal lobe (MTL) or extended into the neocortex may be relevant for Alzheimer's disease (AD) research if they are linked to differential biomarker levels and cognitive decline. Visual assessment of Tau-PET [F-18]florquinitau (FQT) exams from 728 initially non-demented older adults yielded four uptake groups: tau-negative (T-), MTL-only (T+MTL), neocortex-only (T+Neo), or both (T+MTL&Neo). Mixed effects models assessed group differences in retrospective cognitive and plasma pTau217 trajectories. T+MTL&Neo was the most common T+ group (n = 97; 93% A+) and exhibited the sharpest worsening in cognitive and pTau217 trajectories before tau PET. The T+MTL&Neo category represents an intermediate to advanced stage of AD preceded by rising ptau217 and progressive cognitive decline. The pTau217 finding suggests that A+, T+ in MTL or neocortex could represent early AD stages, with a higher likelihood of progressing to more advanced stages. Visual assessments of Tau-PET FQT revealed four distinct uptake groups: tau-negative (T-), MTL-only (T+MTL), neocortex-only (T+Neo), or both (T+MTL&Neo). Amyloid positive participants in the T+MTL and T+MTL&Neo categories showed a retrospectively faster decline in their cognitive trajectories, and a sharper increase in pTau217 levels in plasma, compared to T-. The T+MTL&Neo group displayed sharper trajectories compared with the other Tau positive groups in both their cognitive scores and pTau217 plasma levels. Our results suggest that participants with Tau present in both MTL and neocortex represent an intermediate to advanced stage of AD, whereas participants with signals confined to either MTL or neocortex could represent earlier AD stages. |
| 453 | Sanjay Asthana | GERI | sa@medicine.wisc.edu | Author Correction: Whole-body metabolic modelling reveals microbiome and genomic interactions on reduced urine formate levels in Alzheimer's disease. | |
| 454 | Sanjay Asthana | GERI | sa@medicine.wisc.edu | Amyloid-β positivity is less prevalent in cognitively unimpaired KLOTHO KL-VS heterozygotes. | Klotho, encoded by the KLOTHO gene, is an anti-aging and neuroprotective protein. KLOTHO KL-VS heterozygosity (KL-VSHET) is hypothesized to be protective against the accumulation of Alzheimer's disease (AD) neuropathological hallmarks (amyloid-β (Aβ) and tau). We examine whether being positive for Aβ (A+) or tau (T+), or A/T joint status [positive for Aβ (A + T-), tau (A-T+), both (A + T+) or neither (A-T-)] vary by KL-VS and whether serum klotho protein levels vary based on A+, T+, or A/T status in a cohort enriched for AD risk. The sample consisted of 704 cognitively unimpaired, late middle-aged, and older adults; MeanAge(SD) = 64.9(8.3). Serum klotho was available for a sub-sample of 396 participants; MeanAge(SD) = 66.8(7.4). Covariate-adjusted logistic regression examined whether A + or T+, and multinomial regression examined whether A/T status, vary by KL-VS genotype. Covariate-adjusted linear regression examined whether serum klotho levels differ based on A+, T+, or A/T status. A+ prevalence was lower in KL-VSHET (p = 0.05), with no differences in T + prevalence (p = 0.52). KL-VSHET also had marginally lower odds of being A + T- (p = 0.07). Serum klotho levels did not differ based on A+, T+, or A/T status (all ps ≥ 0.40). KL-VSHET is associated with lower odds of being positive for Aβ, regardless of whether one is also positive for tau. Conversely, the likelihood of being tau positive did not differ based on KL-VS genotype. Our findings add to the growing KLOTHO literature and suggests the need for further research focused on understanding the mechanisms underlying KL-VS-related putative resilience to AD. |
| 455 | Sanjay Asthana | GERI | sa@medicine.wisc.edu | Whole genome methylation sequencing in blood from persons with mild cognitive impairment and dementia due to Alzheimer's disease identifies cognitive status. | Whole genome methylation sequencing (WGMS) in blood identifies differential DNA methylation in persons with late-onset dementia due to Alzheimer's disease (AD) but has not been tested in persons with mild cognitive impairment (MCI). We used WGMS to compare DNA methylation levels at 25,244,219 CpG loci in 382 blood samples from 99 persons with MCI, 109 with AD, and 174 who are cognitively unimpaired (CU). WGMS identified 9,756 differentially methylated positions (DMPs) in persons with MCI, including 1,743 differentially methylated genes encoding proteins in biological pathways related to synapse organization, dendrite development, and ion transport. 447 DMPs exhibit progressively increasing or decreasing DNA methylation levels between CU, MCI, and AD that correspond to cognitive status. WGMS identifies DMPs in known and newly detected genes in blood from persons with MCI and AD that support blood DNA methylation levels as candidate biomarkers of cognitive status. |
| 456 | Sanjay Asthana | GERI | sa@medicine.wisc.edu | Story recall performance and AT classification via positron emission tomography: A comparison of logical memory and Craft Story 21. | Early detection of Alzheimer's disease (AD) is one of the critical components of the global response to the growing dementia crisis. Analysis of serial position performance in story recall tests has yielded sensitive metrics for the prediction of AD at low cost. In this study, we examined whether serial position markers in two story recall tests (the logical memory test, LMT, and the Craft Story 21 test, CST) were sensitive to cross-sectional biomarker-based assessment of in vivo neuropathology. Participants were selected from the Wisconsin Registry of Alzheimer's Prevention (n = 288; WRAP) and the Alzheimer's Disease Research Center (n = 156; ADRC), both from the University of Wisconsin-Madison. Average age at PET was 68.9 (6.7) and 67.0 (8.0), respectively. Data included tau and PiB PET, and LMT for WRAP participants and CST for ADRC participants. Two sets of Bayesian analyses (logistic regressions and ANCOVAs) were conducted within each cohort, separately. Results indicated that the A+T+ classification was best predicted, cross-sectionally, by the recency ratio (Rr), indexing how much of the end of the story was forgotten between initial learning and delayed assessment. Rr outperformed traditional scores and discriminated between A+T+ and A+T-/A-T-, in both cohorts. Overall, this study confirms that serial position analysis of LMT and CST data, and particularly Rr as an index of recency loss, is a valuable tool for the identification of in vivo tau pathology in individuals free of dementia. Diagnostic considerations are discussed. |
| 457 | Barbara Bendlin | GERI | bbb@medicine.wisc.edu | Menopausal hormone therapy is associated with worse levels of Alzheimer's disease biomarkers in APOE ε4-carrying women: An observational study. | Menopausal hormone therapy (MHT), along with the apolipoprotein E (APOE) ε4 allele, has been suggested as a possible risk factor for Alzheimer's disease (AD). However, the relationship between MHT and cerebrospinal fluid (CSF) biomarkers is unknown: we investigated this association, and whether APOE ε4 carrier status moderates it. In an observational study of 136 cognitively unimpaired female participants (Mage = 66.0; standard deviation = 6.3), we examined whether MHT use alone or in interaction with APOE ε4 carrier status was associated with CSF levels of phosphorylated tau (p-tau), amyloid beta (Aβ)40, Aβ42, p-tau/Aβ42, and Aβ42/40 ratios. Significant interactions were found between APOE ε4 and MHT use for CSF biomarkers. APOE ε4 carriers who were MHT users showed worse levels of CSF p-tau/Aβ42 and Aβ42/40 ratios than all other users and non-users. The presence of both APOE ε4 and MHT may be associated with elevated amyloid deposition and AD pathology in this sample of participants who demonstrated high familial AD risk. Significant interactions were found between apolipoprotein E (APOE) ε4 and menopausal hormone therapy (MHT) use for cerebrospinal fluid (CSF) phosphorylated tau (p-tau)/amyloid beta (Aβ)42 and Aβ42/40 ratios. APOE ε4 carriers who were MHT users showed worse levels of CSF biomarkers than non-users and non-carriers, both users and non-users. Younger age at MHT initiation was associated with worse levels of the p-tau/Aβ42 and Aβ42/40 ratios in carriers only. The presence of both APOE ε4 carriage and MHT use may be associated with elevated amyloid deposition and AD pathology. Further studies with larger sample sizes are necessary to confirm the differences observed in the current study. |
| 458 | Barbara Bendlin | GERI | bbb@medicine.wisc.edu | Delayed primacy recall in AVLT is associated with medial temporal tau PET burden in cognitively unimpaired adults. | Alzheimer's disease (AD) can be diagnosed by in vivo abnormalities of amyloid-β plaques (A) and tau accumulation (T) biomarkers. Previous studies have shown that analyses of serial position performance in episodic memory tests, and especially, delayed primacy, are associated with AD pathology even in individuals who are cognitively unimpaired. The earliest signs of cortical tau pathology are observed in medial temporal lobe (MTL) regions, yet it is unknown if serial position markers are also associated with early tau load in these regions. This study of cognitively unimpaired older individuals examined whether serial position scores in word-list recall cross-sectionally predicted tau PET load in the MTL, and were able to discriminate between biomarker profiles, based on AT classification. Data from 490 participants (mean age = 68.8 ± 7.2) were extracted from two cohorts, which were merged into one sample. Linear regression analyses were carried out with regional volume-controlled tau (18F-MK-6240) PET SUVR of the entorhinal cortex (EC), parahippocampal cortex (PHC) and hippocampus (H) as outcomes, cross-sectional memory scores from the Rey Auditory Verbal Learning Test as predictors (total and delayed recall, along with serial position scores) and control variables, in separate analyses for each outcome and predictor. The sample was then stratified by biomarker profile and ANCOVAs were conducted with the strongest scores from the regression analyses, AT groups as fixed factor and the covariates. Higher delayed primacy significantly predicted lower tau PET in EC, PHC, and H, cross-sectionally. Higher total recall scores predicted lower EC tau, but delayed primacy showed the best model fit, as indicated by AICs. ANCOVAs showed that AVLT metrics did not significantly discriminate between A-T- and A+T+, after correcting for multiple comparisons. Serial position analysis of word-list recall, particularly delayed primacy, may be a valuable tool for identifying in vivo tau pathology in cognitively unimpaired individuals. |
| 459 | Barbara Bendlin | GERI | bbb@medicine.wisc.edu | Melatonin: A potential nighttime guardian against Alzheimer's. | In the context of the escalating global health challenge posed by Alzheimer's disease (AD), this comprehensive review considers the potential of melatonin in both preventive and therapeutic capacities. As a naturally occurring hormone and robust antioxidant, accumulating evidence suggests melatonin is a compelling candidate to consider in the context of AD-related pathologies. The review considers several mechanisms, including potential effects on amyloid-beta and pathologic tau burden, antioxidant defense, immune modulation, and regulation of circadian rhythms. Despite its promise, several gaps need to be addressed prior to clinical translation. These include conducting additional randomized clinical trials in patients with or at risk for AD dementia, determining optimal dosage and timing, and further determining potential side effects, particularly of long-term use. This review consolidates existing knowledge, identifies gaps, and suggests directions for future research to better understand the potential of melatonin for neuroprotection and disease mitigation within the landscape of AD. |
| 460 | Barbara Bendlin | GERI | bbb@medicine.wisc.edu | Targeted Proteomic Biomarker Profiling Using NULISA in a cohort enriched with risk for Alzheimer's Disease and Related Dementias. | Targeted proteomic assays may be useful for diagnosing and staging Alzheimer's disease and related dementias (ADRD). We evaluated the performance of a 120-marker central nervous system (CNS) NUcleic acid-Linked Immuno-Sandwich Assay (NULISA) panel in samples spanning the AD spectrum. Cross-sectional plasma samples (n=252) were analyzed using Alamar's NULISAseq CNS panel. ROC analyses demonstrated NULISAseq-pTau217 accuracy in detecting amyloid (A) and tau (T) PET positivity. Differentially expressed proteins were identified using volcano plots. NULISAseq-pTau217 accurately classified A/T PET status with ROC AUCs of 0.92/0.86. pTau217 was upregulated in A+, T+, and impaired groups with log2-fold changes of 1.21, 0.57 and 4.63, respectively, compared to A-. Interestingly, pTDP43-409 was also upregulated in the impaired group and correlated with declining hippocampal volume and cognitive trajectories. This study shows the potential of a targeted proteomics panel for characterizing brain changes pertinent to ADRD. The promising pTDP43-409 findings require further replication. |
| 461 | Barbara Bendlin | GERI | bbb@medicine.wisc.edu | Visual read of [F-18]florquinitau PET that includes and extends beyond the mesial temporal lobe is associated with increased plasma pTau217 and cognitive decline in a cohort that is enriched with risk for Alzheimer's disease. | Patterns of signal from tau positron emission tomography (tau-PET) confined to the medial temporal lobe (MTL) or extended into the neocortex may be relevant for Alzheimer's disease (AD) research if they are linked to differential biomarker levels and cognitive decline. Visual assessment of Tau-PET [F-18]florquinitau (FQT) exams from 728 initially non-demented older adults yielded four uptake groups: tau-negative (T-), MTL-only (T+MTL), neocortex-only (T+Neo), or both (T+MTL&Neo). Mixed effects models assessed group differences in retrospective cognitive and plasma pTau217 trajectories. T+MTL&Neo was the most common T+ group (n = 97; 93% A+) and exhibited the sharpest worsening in cognitive and pTau217 trajectories before tau PET. The T+MTL&Neo category represents an intermediate to advanced stage of AD preceded by rising ptau217 and progressive cognitive decline. The pTau217 finding suggests that A+, T+ in MTL or neocortex could represent early AD stages, with a higher likelihood of progressing to more advanced stages. Visual assessments of Tau-PET FQT revealed four distinct uptake groups: tau-negative (T-), MTL-only (T+MTL), neocortex-only (T+Neo), or both (T+MTL&Neo). Amyloid positive participants in the T+MTL and T+MTL&Neo categories showed a retrospectively faster decline in their cognitive trajectories, and a sharper increase in pTau217 levels in plasma, compared to T-. The T+MTL&Neo group displayed sharper trajectories compared with the other Tau positive groups in both their cognitive scores and pTau217 plasma levels. Our results suggest that participants with Tau present in both MTL and neocortex represent an intermediate to advanced stage of AD, whereas participants with signals confined to either MTL or neocortex could represent earlier AD stages. |
| 462 | Barbara Bendlin | GERI | bbb@medicine.wisc.edu | Author Correction: Whole-body metabolic modelling reveals microbiome and genomic interactions on reduced urine formate levels in Alzheimer's disease. | |
| 463 | Barbara Bendlin | GERI | bbb@medicine.wisc.edu | Gut microbial metabolism in Alzheimer's disease and related dementias. | Multiple studies over the last decade have established that Alzheimer's disease and related dementias (ADRD) are associated with changes in the gut microbiome. These alterations in organismal composition result in changes in the abundances of functions encoded by the microbial community, including metabolic capabilities, which likely impact host disease mechanisms. Gut microbes access dietary components and other molecules made by the host and produce metabolites that can enter circulation and cross the blood-brain barrier (BBB). In recent years, several microbial metabolites have been associated with or have been shown to influence host pathways relevant to ADRD pathology. These include short chain fatty acids, secondary bile acids, tryptophan derivatives (such as kynurenine, serotonin, tryptamine, and indoles), and trimethylamine/trimethylamine N-oxide. Notably, some of these metabolites cross the BBB and can have various effects on the brain, including modulating the release of neurotransmitters and neuronal function, inducing oxidative stress and inflammation, and impacting synaptic function. Microbial metabolites can also impact the central nervous system through immune, enteroendocrine, and enteric nervous system pathways, these perturbations in turn impact the gut barrier function and peripheral immune responses, as well as the BBB integrity, neuronal homeostasis and neurogenesis, and glial cell maturation and activation. This review examines the evidence supporting the notion that ADRD is influenced by gut microbiota and its metabolites. The potential therapeutic advantages of microbial metabolites for preventing and treating ADRD are also discussed, highlighting their potential role in developing new treatments. |
| 464 | Barbara Bendlin | GERI | bbb@medicine.wisc.edu | Story recall performance and AT classification via positron emission tomography: A comparison of logical memory and Craft Story 21. | Early detection of Alzheimer's disease (AD) is one of the critical components of the global response to the growing dementia crisis. Analysis of serial position performance in story recall tests has yielded sensitive metrics for the prediction of AD at low cost. In this study, we examined whether serial position markers in two story recall tests (the logical memory test, LMT, and the Craft Story 21 test, CST) were sensitive to cross-sectional biomarker-based assessment of in vivo neuropathology. Participants were selected from the Wisconsin Registry of Alzheimer's Prevention (n = 288; WRAP) and the Alzheimer's Disease Research Center (n = 156; ADRC), both from the University of Wisconsin-Madison. Average age at PET was 68.9 (6.7) and 67.0 (8.0), respectively. Data included tau and PiB PET, and LMT for WRAP participants and CST for ADRC participants. Two sets of Bayesian analyses (logistic regressions and ANCOVAs) were conducted within each cohort, separately. Results indicated that the A+T+ classification was best predicted, cross-sectionally, by the recency ratio (Rr), indexing how much of the end of the story was forgotten between initial learning and delayed assessment. Rr outperformed traditional scores and discriminated between A+T+ and A+T-/A-T-, in both cohorts. Overall, this study confirms that serial position analysis of LMT and CST data, and particularly Rr as an index of recency loss, is a valuable tool for the identification of in vivo tau pathology in individuals free of dementia. Diagnostic considerations are discussed. |
| 465 | Barbara Bendlin | GERI | bbb@medicine.wisc.edu | Gut Microbiome Compositional and Functional Features Associate with Alzheimer's Disease Pathology. | The gut microbiome is a potentially modifiable factor in Alzheimer's disease (AD); however, understanding of its composition and function regarding AD pathology is limited. Shallow-shotgun metagenomic data was used to analyze fecal microbiome from participants enrolled in the Wisconsin Microbiome in Alzheimer's Risk Study, leveraging clinical data and cerebrospinal fluid (CSF) biomarkers. Differential abundance and ordinary least squares regression analyses were performed to find differentially abundant gut microbiome features and their associations with CSF biomarkers of AD and related pathologies. Gut microbiome composition and function differed between people with AD and cognitively unimpaired individuals. The compositional difference was replicated in an independent cohort. Differentially abundant gut microbiome features were associated with CSF biomarkers of AD and related pathologies. These findings enhance our understanding of alterations in gut microbial composition and function in AD, and suggest that gut microbes and their pathways are linked to AD pathology. |
| 466 | Barbara Bendlin | GERI | bbb@medicine.wisc.edu | KLOTHO KL-VS heterozygosity is associated with diminished age-related neuroinflammation, neurodegeneration, and synaptic dysfunction in older cognitively unimpaired adults. | We examined whether the aging suppressor KLOTHO gene's functionally advantageous KL-VS variant (KL-VS heterozygosity [KL-VSHET]) confers resilience against deleterious effects of aging indexed by cerebrospinal fluid (CSF) biomarkers of neuroinflammation (interleukin-6 [IL-6], S100 calcium-binding protein B [S100B], triggering receptor expressed on myeloid cells [sTREM2], chitinase-3-like protein 1 [YKL-40], glial fibrillary acidic protein [GFAP]), neurodegeneration (total α-synuclein [α-Syn], neurofilament light chain protein), and synaptic dysfunction (neurogranin [Ng]). This Alzheimer disease risk-enriched cohort consisted of 454 cognitively unimpaired adults (Mage = 61.5 ± 7.75). Covariate-adjusted multivariate regression examined relationships between age (mean-split[age ≥ 62]) and CSF biomarkers (Roche/NeuroToolKit), and whether they differed between KL-VSHET (N = 122) and non-carriers (KL-VSNC; N = 332). Older age was associated with a poorer biomarker profile across all analytes (Ps ≤ 0.03). In age-stratified analyses, KL-VSNC exhibited this same pattern (Ps ≤ 0.05) which was not significant for IL-6, S100B, Ng, and α-Syn (Ps ≥ 0.13) in KL-VSHET. Although age-related differences in GFAP, sTREM2, and YKL-40 were evident for both groups (Ps ≤ 0.01), the effect magnitude was markedly stronger for KL-VSNC. Higher levels of neuroinflammation, neurodegeneration, and synaptic dysfunction in older adults were attenuated in KL-VSHET. Older age was associated with poorer profiles across all cerebrospinal fluid biomarkers of neuroinflammation, neurodegeneration, and synaptic dysfunction. KLOTHO KL-VS non-carriers exhibit this same pattern, which is does not significantly differ between younger and older KL-VS heterozygotes for interleukin-6, S100 calcium-binding protein B, neurogranin, and total α-synuclein. Although age-related differences in glial fibrillary acidic protein, triggering receptor expressed on myeloid cells, and chitinase-3-like protein 1 are evident for both KL-VS groups, the magnitude of the effect is markedly stronger for KL-VS non-carriers. Higher levels of neuroinflammation, neurodegeneration, and synaptic dysfunction in older adults are attenuated in KL-VS heterozygotes. |
| 467 | Tobey Betthauser | GERI | tjbetthauser@medicine.wisc.edu | Delayed primacy recall in AVLT is associated with medial temporal tau PET burden in cognitively unimpaired adults. | Alzheimer's disease (AD) can be diagnosed by in vivo abnormalities of amyloid-β plaques (A) and tau accumulation (T) biomarkers. Previous studies have shown that analyses of serial position performance in episodic memory tests, and especially, delayed primacy, are associated with AD pathology even in individuals who are cognitively unimpaired. The earliest signs of cortical tau pathology are observed in medial temporal lobe (MTL) regions, yet it is unknown if serial position markers are also associated with early tau load in these regions. This study of cognitively unimpaired older individuals examined whether serial position scores in word-list recall cross-sectionally predicted tau PET load in the MTL, and were able to discriminate between biomarker profiles, based on AT classification. Data from 490 participants (mean age = 68.8 ± 7.2) were extracted from two cohorts, which were merged into one sample. Linear regression analyses were carried out with regional volume-controlled tau (18F-MK-6240) PET SUVR of the entorhinal cortex (EC), parahippocampal cortex (PHC) and hippocampus (H) as outcomes, cross-sectional memory scores from the Rey Auditory Verbal Learning Test as predictors (total and delayed recall, along with serial position scores) and control variables, in separate analyses for each outcome and predictor. The sample was then stratified by biomarker profile and ANCOVAs were conducted with the strongest scores from the regression analyses, AT groups as fixed factor and the covariates. Higher delayed primacy significantly predicted lower tau PET in EC, PHC, and H, cross-sectionally. Higher total recall scores predicted lower EC tau, but delayed primacy showed the best model fit, as indicated by AICs. ANCOVAs showed that AVLT metrics did not significantly discriminate between A-T- and A+T+, after correcting for multiple comparisons. Serial position analysis of word-list recall, particularly delayed primacy, may be a valuable tool for identifying in vivo tau pathology in cognitively unimpaired individuals. |
| 468 | Tobey Betthauser | GERI | tjbetthauser@medicine.wisc.edu | The striatum is an early, accurate indicator of amyloid burden using [(11)C]PiB in Down syndrome: comparison of two radiotracers. | Adults with Down syndrome demonstrate striatum-first amyloid accumulation with [11C]PiB PET imaging, which has not been replicated with [18F]florbetapir (FBP). Early striatal accumulation has not been temporally quantified with respect to global cortical measures. Longitudinal PiB (n=175 participants) and FBP (n=92 participants) data from the Alzheimer Biomarkers Consortium-Down Syndrome were used to measure cortical and striatal binding. Generalized temporal models for cortical and striatal amyloid accumulation were created using the sampled iterative local approximation (SILA) method. PiB demonstrated greater striatal-to-cortical ratios than FBP. SILA analysis revealed striatal amyloid burden occurs 3.40 (2.39) years earlier than the cortex in PiB. There was no difference between the cortex and striatum in FBP. Among adults with Down syndrome, the striatum consistently accumulates amyloid earlier than the cortex when measured with PiB. This suggests the striatum is more sensitive to the onset of PiB PET-detectable amyloid in Down syndrome. |
| 469 | Tobey Betthauser | GERI | tjbetthauser@medicine.wisc.edu | Timeline to symptomatic Alzheimer's disease in people with Down syndrome as assessed by amyloid-PET and tau-PET: a longitudinal cohort study. | Adults with Down syndrome are at risk for Alzheimer's disease. Natural history cohort studies have characterised the progression of Alzheimer's disease biomarkers in people with Down syndrome, with a focus on amyloid β-PET and tau-PET. In this study, we aimed to leverage these well characterised imaging biomarkers in a large cohort of individuals with Down syndrome, to examine the timeline to symptomatic Alzheimer's disease based on estimated years since the detection on PET of amyloid β-positivity, referred to here as amyloid age, and in relation to tau burden as assessed by PET. In this prospective, longitudinal, observational cohort study, data were collected at four university research sites in the UK and USA as part of the Alzheimer's Biomarker Consortium-Down Syndrome (ABC-DS) study. Eligible participants were aged 25 years or older with Down syndrome, had a mental age of at least 3 years (based on a standardised intelligence quotient test), and had trisomy 21 (full, mosaic, or translocation) confirmed through karyotyping. Participants were assessed twice between 2017 and 2022, with approximately 32 months between visits. Participants had amyloid-PET and tau-PET scans, and underwent cognitive assessment with the modified Cued Recall Test (mCRT) and the Down Syndrome Mental Status Examination (DSMSE) to assess cognitive functioning. Study partners completed the National Task Group-Early Detection Screen for Dementia (NTG-EDSD). Generalised linear models were used to assess the association between amyloid age (whereby 0 years equated to 18 centiloids) and mCRT, DSMSE, NTG-EDSD, and tau PET at baseline and the 32-month follow-up. Broken stick regression was used to identify the amyloid age that corresponded to decreases in cognitive performance and increases in tau PET after the onset of amyloid β positivity. 167 adults with Down syndrome, of whom 92 had longitudinal data, were included in our analyses. Generalised linear regressions showed significant quadratic associations between amyloid age and cognitive performance and cubic associations between amyloid age and tau, both at baseline and at the 32-month follow-up. Using broken stick regression models, differences in mCRT total scores were detected beginning 2·7 years (95% credible interval [CrI] 0·2 to 5·4; equating to 29·8 centiloids) after the onset of amyloid β positivity in cross-sectional models. Based on cross-sectional data, increases in tau deposition started a mean of 2·7-6·1 years (equating to 29·8-47·9 centiloids) after the onset of amyloid β positivity. Mild cognitive impairment was observed at a mean amyloid age of 7·4 years (SD 6·6; equating to 56·8 centiloids) and dementia was observed at a mean amyloid age of 12·7 years (5·6; equating to 97·4 centiloids). There is a short timeline to initial cognitive decline and dementia from onset of amyloid β positivity and tau deposition in people with Down syndrome. This newly established timeline based on amyloid age (or equivalent centiloid values) is important for clinical practice and informing the design of Alzheimer's disease clinical trials, and it avoids the limitations of timelines based on chronological age. National Institute on Aging and the National Institute for Child Health and Human Development. |
| 470 | Tobey Betthauser | GERI | tjbetthauser@medicine.wisc.edu | Visual read of [F-18]florquinitau PET that includes and extends beyond the mesial temporal lobe is associated with increased plasma pTau217 and cognitive decline in a cohort that is enriched with risk for Alzheimer's disease. | Patterns of signal from tau positron emission tomography (tau-PET) confined to the medial temporal lobe (MTL) or extended into the neocortex may be relevant for Alzheimer's disease (AD) research if they are linked to differential biomarker levels and cognitive decline. Visual assessment of Tau-PET [F-18]florquinitau (FQT) exams from 728 initially non-demented older adults yielded four uptake groups: tau-negative (T-), MTL-only (T+MTL), neocortex-only (T+Neo), or both (T+MTL&Neo). Mixed effects models assessed group differences in retrospective cognitive and plasma pTau217 trajectories. T+MTL&Neo was the most common T+ group (n = 97; 93% A+) and exhibited the sharpest worsening in cognitive and pTau217 trajectories before tau PET. The T+MTL&Neo category represents an intermediate to advanced stage of AD preceded by rising ptau217 and progressive cognitive decline. The pTau217 finding suggests that A+, T+ in MTL or neocortex could represent early AD stages, with a higher likelihood of progressing to more advanced stages. Visual assessments of Tau-PET FQT revealed four distinct uptake groups: tau-negative (T-), MTL-only (T+MTL), neocortex-only (T+Neo), or both (T+MTL&Neo). Amyloid positive participants in the T+MTL and T+MTL&Neo categories showed a retrospectively faster decline in their cognitive trajectories, and a sharper increase in pTau217 levels in plasma, compared to T-. The T+MTL&Neo group displayed sharper trajectories compared with the other Tau positive groups in both their cognitive scores and pTau217 plasma levels. Our results suggest that participants with Tau present in both MTL and neocortex represent an intermediate to advanced stage of AD, whereas participants with signals confined to either MTL or neocortex could represent earlier AD stages. |
| 471 | Tobey Betthauser | GERI | tjbetthauser@medicine.wisc.edu | Amyloid-β positivity is less prevalent in cognitively unimpaired KLOTHO KL-VS heterozygotes. | Klotho, encoded by the KLOTHO gene, is an anti-aging and neuroprotective protein. KLOTHO KL-VS heterozygosity (KL-VSHET) is hypothesized to be protective against the accumulation of Alzheimer's disease (AD) neuropathological hallmarks (amyloid-β (Aβ) and tau). We examine whether being positive for Aβ (A+) or tau (T+), or A/T joint status [positive for Aβ (A + T-), tau (A-T+), both (A + T+) or neither (A-T-)] vary by KL-VS and whether serum klotho protein levels vary based on A+, T+, or A/T status in a cohort enriched for AD risk. The sample consisted of 704 cognitively unimpaired, late middle-aged, and older adults; MeanAge(SD) = 64.9(8.3). Serum klotho was available for a sub-sample of 396 participants; MeanAge(SD) = 66.8(7.4). Covariate-adjusted logistic regression examined whether A + or T+, and multinomial regression examined whether A/T status, vary by KL-VS genotype. Covariate-adjusted linear regression examined whether serum klotho levels differ based on A+, T+, or A/T status. A+ prevalence was lower in KL-VSHET (p = 0.05), with no differences in T + prevalence (p = 0.52). KL-VSHET also had marginally lower odds of being A + T- (p = 0.07). Serum klotho levels did not differ based on A+, T+, or A/T status (all ps ≥ 0.40). KL-VSHET is associated with lower odds of being positive for Aβ, regardless of whether one is also positive for tau. Conversely, the likelihood of being tau positive did not differ based on KL-VS genotype. Our findings add to the growing KLOTHO literature and suggests the need for further research focused on understanding the mechanisms underlying KL-VS-related putative resilience to AD. |
| 472 | Tobey Betthauser | GERI | tjbetthauser@medicine.wisc.edu | Identification of late-stage tau accumulation using plasma phospho-tau217. | Blood-based disease staging across the Alzheimer's disease (AD) continuum holds the promise to identify individuals that profit from disease-modifying therapies. We set out to identify Braak V+ (Braak V and/or VI) tau PET-positive individuals within amyloid-β (Aβ)-positive individuals using plasma biomarkers. In this cross-sectional study, we assessed 289 individuals from the TRIAD cohort and 306 individuals from the WRAP study across the AD continuum. The participants were evaluated by amyloid-PET with [18F]AZD4694 or [11C]PiB and tau-PET with [18F]MK6240 and measured plasma levels included total tau, phospho-tau isoforms (pTau) pTau-181, pTau-217, pTau-231, and N-terminal tau (NTA-tau). We evaluated the performances of plasma biomarkers using different analytic platforms to predict Braak V+ positivity in Aβ+ individuals. Highest associations with Braak V+ tau positivity in Aβ+ individuals were found for plasma pTau-217+Janssen (AUC [CI95%] = 0.97 [0.94, 1.0]) and ALZpath pTau-217 (AUC [CI95%] = 0.93 [0.86, 1.0]) in TRIAD. Plasma ALZpath pTau-217 separated Braak V+ tau PET-positive individuals in the WRAP longitudinal study (AUC [CI95%] = 0.97 [0.94, 1.0]). Thus, we demonstrate that using adjusted cut-offs, plasma pTau-217 identifies individuals with later Braak stage tau accumulation which will be helpful to stratify patients for treatments and clinical studies. This research is supported by the Weston Brain Institute, Canadian Institutes of Health Research (CIHR) [MOP-11-51-31; RFN 152985, 159815, 162303], Canadian Consortium of Neurodegeneration and Aging (CCNA; MOP-11-51-31 -team 1), the Alzheimer's Association [NIRG-12-92090, NIRP-12-259245], Brain Canada Foundation (CFI Project 34874; 33397), the Fonds de Recherche du Québec-Santé (FRQS; Chercheur Boursier, 2020-VICO-279314). P.R-N and SG are members of the CIHR-CCNA Canadian Consortium of Neurodegeneration in Aging. Colin J. Adair Charitable Foundation. |
| 473 | Tobey Betthauser | GERI | tjbetthauser@medicine.wisc.edu | Rethinking the residual approach: Leveraging machine learning to operationalize cognitive resilience in Alzheimer's disease. | Cognitive resilience describes the phenomenon of individuals evading cognitive decline despite prominent Alzheimer's disease neuropathology. Operationalization and measurement of this latent construct is non-trivial as it cannot be directly observed. The residual approach has been widely applied to estimate CR, where the degree of resilience is estimated through a linear model's residuals. We demonstrate that this approach makes specific, uncontrollable assumptions and likely leads to biased and erroneous resilience estimates. We propose an alternative strategy which overcomes the standard approach's limitations using machine learning principles. Our proposed approach makes fewer assumptions about the data and construct to be measured and achieves better estimation accuracy on simulated ground-truth data. |
| 474 | Tobey Betthauser | GERI | tjbetthauser@medicine.wisc.edu | Story recall performance and AT classification via positron emission tomography: A comparison of logical memory and Craft Story 21. | Early detection of Alzheimer's disease (AD) is one of the critical components of the global response to the growing dementia crisis. Analysis of serial position performance in story recall tests has yielded sensitive metrics for the prediction of AD at low cost. In this study, we examined whether serial position markers in two story recall tests (the logical memory test, LMT, and the Craft Story 21 test, CST) were sensitive to cross-sectional biomarker-based assessment of in vivo neuropathology. Participants were selected from the Wisconsin Registry of Alzheimer's Prevention (n = 288; WRAP) and the Alzheimer's Disease Research Center (n = 156; ADRC), both from the University of Wisconsin-Madison. Average age at PET was 68.9 (6.7) and 67.0 (8.0), respectively. Data included tau and PiB PET, and LMT for WRAP participants and CST for ADRC participants. Two sets of Bayesian analyses (logistic regressions and ANCOVAs) were conducted within each cohort, separately. Results indicated that the A+T+ classification was best predicted, cross-sectionally, by the recency ratio (Rr), indexing how much of the end of the story was forgotten between initial learning and delayed assessment. Rr outperformed traditional scores and discriminated between A+T+ and A+T-/A-T-, in both cohorts. Overall, this study confirms that serial position analysis of LMT and CST data, and particularly Rr as an index of recency loss, is a valuable tool for the identification of in vivo tau pathology in individuals free of dementia. Diagnostic considerations are discussed. |
| 475 | Tobey Betthauser | GERI | tjbetthauser@medicine.wisc.edu | Harmonizing tau positron emission tomography in Alzheimer's disease: The CenTauR scale and the joint propagation model. | Tau-positron emission tomography (PET) outcome data of patients with Alzheimer's disease (AD) cannot currently be meaningfully compared or combined when different tracers are used due to differences in tracer properties, instrumentation, and methods of analysis. Using head-to-head data from five cohorts with tau PET radiotracers designed to target tau deposition in AD, we tested a joint propagation model (JPM) to harmonize quantification (units termed "CenTauR" [CTR]). JPM is a statistical model that simultaneously models the relationships between head-to-head and anchor point data. JPM was compared to a linear regression approach analogous to the one used in the amyloid PET Centiloid scale. A strong linear relationship was observed between CTR values across brain regions. Using the JPM approach, CTR estimates were similar to, but more accurate than, those derived using the linear regression approach. Preliminary findings using the JPM support the development and adoption of a universal scale for tau-PET quantification. Tested a novel joint propagation model (JPM) to harmonize quantification of tau PET. Units of common scale are termed "CenTauRs". Tested a Centiloid-like linear regression approach. Using five cohorts with head-to-head tau PET, JPM outperformed linearregressionbased approach. Strong linear relationship was observed between CenTauRs values across brain regions. |
| 476 | Tobey Betthauser | GERI | tjbetthauser@medicine.wisc.edu | Longitudinal plasma phosphorylated-tau217 and other related biomarkers in a non-demented Alzheimer's risk-enhanced sample. | Understanding longitudinal change in key plasma biomarkers will aid in detecting presymptomatic Alzheimer's disease (AD). Serial plasma samples from 424 Wisconsin Registry for Alzheimer's Prevention participants were analyzed for phosphorylated-tau217 (p-tau217; ALZpath) and other AD biomarkers, to study longitudinal trajectories in relation to disease, health factors, and cognitive decline. Of the participants, 18.6% with known amyloid status were amyloid positive (A+); 97.2% were cognitively unimpaired (CU). In the CU, amyloid-negative (A-) subset, plasma p-tau217 levels increased modestly with age but were unaffected by body mass index and kidney function. In the whole sample, average p-tau217 change rates were higher in those who were A+ (e.g., simple slopes(se) for A+ and A- at age 60 were 0.232(0.028) and 0.038(0.013))). High baseline p-tau217 levels predicted faster preclinical cognitive decline. p-tau217 stands out among markers for its strong association with disease and cognitive decline, indicating its potential for early AD detection and monitoring progression. Phosphorylated-tau217 (p-tau217) trajectories were significantly different in people who were known to be amyloid positive. Subtle age-related trajectories were seen for all the plasma markers in amyloid-negative cognitively unimpaired. Kidney function and body mass index were not associated with plasma p-tau217 trajectories. Higher plasma p-tau217 was associated with faster preclinical cognitive decline. |
| 477 | Laura Eisenmenger | Radiology | leisenmenger@uwhealth.org | Incorporating Radiologist Knowledge Into MRI Quality Metrics for Machine Learning Using Rank-Based Ratings. | Deep learning (DL) often requires an image quality metric; however, widely used metrics are not designed for medical images. To develop an image quality metric that is specific to MRI using radiologists image rankings and DL models. Retrospective. A total of 19,344 rankings on 2916 unique image pairs from the NYU fastMRI Initiative neuro database was used for the neural network-based image quality metrics training with an 80%/20% training/validation split and fivefold cross-validation. 1.5 T and 3 T T1, T1 postcontrast, T2, and FLuid Attenuated Inversion Recovery (FLAIR). Synthetically corrupted image pairs were ranked by radiologists (N = 7), with a subset also scoring images using a Likert scale (N = 2). DL models were trained to match rankings using two architectures (EfficientNet and IQ-Net) with and without reference image subtraction and compared to ranking based on mean squared error (MSE) and structural similarity (SSIM). Image quality assessing DL models were evaluated as alternatives to MSE and SSIM as optimization targets for DL denoising and reconstruction. Radiologists' agreement was assessed by a percentage metric and quadratic weighted Cohen's kappa. Ranking accuracies were compared using repeated measurements analysis of variance. Reconstruction models trained with IQ-Net score, MSE and SSIM were compared by paired t test. P < 0.05 was considered significant. Compared to direct Likert scoring, ranking produced a higher level of agreement between radiologists (70.4% vs. 25%). Image ranking was subjective with a high level of intraobserver agreement ( 94.9%±2.4%$$ 94.9\%\pm 2.4\% $$ ) and lower interobserver agreement ( 61.47%±5.51%$$ 61.47\%\pm 5.51\% $$ ). IQ-Net and EfficientNet accurately predicted rankings with a reference image ( 75.2%±1.3%$$ 75.2\%\pm 1.3\% $$ and 79.2%±1.7%$$ 79.2\%\pm 1.7\% $$ ). However, EfficientNet resulted in images with artifacts and high MSE when used in denoising tasks while IQ-Net optimized networks performed well for both denoising and reconstruction tasks. Image quality networks can be trained from image ranking and used to optimize DL tasks. 3 TECHNICAL EFFICACY: Stage 1. |
| 478 | Laura Eisenmenger | Radiology | leisenmenger@uwhealth.org | Visual read of [F-18]florquinitau PET that includes and extends beyond the mesial temporal lobe is associated with increased plasma pTau217 and cognitive decline in a cohort that is enriched with risk for Alzheimer's disease. | Patterns of signal from tau positron emission tomography (tau-PET) confined to the medial temporal lobe (MTL) or extended into the neocortex may be relevant for Alzheimer's disease (AD) research if they are linked to differential biomarker levels and cognitive decline. Visual assessment of Tau-PET [F-18]florquinitau (FQT) exams from 728 initially non-demented older adults yielded four uptake groups: tau-negative (T-), MTL-only (T+MTL), neocortex-only (T+Neo), or both (T+MTL&Neo). Mixed effects models assessed group differences in retrospective cognitive and plasma pTau217 trajectories. T+MTL&Neo was the most common T+ group (n = 97; 93% A+) and exhibited the sharpest worsening in cognitive and pTau217 trajectories before tau PET. The T+MTL&Neo category represents an intermediate to advanced stage of AD preceded by rising ptau217 and progressive cognitive decline. The pTau217 finding suggests that A+, T+ in MTL or neocortex could represent early AD stages, with a higher likelihood of progressing to more advanced stages. Visual assessments of Tau-PET FQT revealed four distinct uptake groups: tau-negative (T-), MTL-only (T+MTL), neocortex-only (T+Neo), or both (T+MTL&Neo). Amyloid positive participants in the T+MTL and T+MTL&Neo categories showed a retrospectively faster decline in their cognitive trajectories, and a sharper increase in pTau217 levels in plasma, compared to T-. The T+MTL&Neo group displayed sharper trajectories compared with the other Tau positive groups in both their cognitive scores and pTau217 plasma levels. Our results suggest that participants with Tau present in both MTL and neocortex represent an intermediate to advanced stage of AD, whereas participants with signals confined to either MTL or neocortex could represent earlier AD stages. |
| 479 | Laura Eisenmenger | Radiology | leisenmenger@uwhealth.org | Comparison of sequential multi-detector CT and cone-beam CT perfusion maps in 39 subjects with anterior circulation acute ischemic stroke due to a large vessel occlusion. | The critical time between stroke onset and treatment was targeted for reduction by integrating physiological imaging into the angiography suite, potentially improving clinical outcomes. The evaluation was conducted to compare C-Arm cone beam CT perfusion (CBCTP) with multi-detector CT perfusion (MDCTP) in patients with acute ischemic stroke (AIS). Thirty-nine patients with anterior circulation AIS underwent both MDCTP and CBCTP. Imaging results were compared using an in-house algorithm for CBCTP map generation and RAPID for post-processing. Blinded neuroradiologists assessed images for quality, diagnostic utility, and treatment decision support, with non-inferiority analysis (two one-sided tests for equivalence) and inter-reviewer consistency (Cohen's kappa). The mean time from MDCTP to angiography suite arrival was 50±34 min , and that from arrival to the first CBCTP image was 21±8 min . Stroke diagnosis accuracies were 96% [93%, 97%] with MDCTP and 91% [90%, 93%] with CBCTP. Cohen's kappa between observers was 0.86 for MDCTP and 0.90 for CBCTP, showing excellent inter-reader consistency. CBCTP's scores for diagnostic utility, mismatch pattern detection, and treatment decisions were noninferior to MDCTP scores (alpha = 0.05) within 20% of the range. MDCTP was slightly superior for image quality and artifact score (1.8 versus 2.3, p<0.01 ). In this small paper, CBCTP was noninferior to MDCTP, potentially saving nearly an hour per patient if they went directly to the angiography suite upon hospital arrival. |
| 480 | Laura Eisenmenger | Radiology | leisenmenger@uwhealth.org | CSF dynamics throughout the ventricular system using 4D flow MRI: associations to arterial pulsatility, ventricular volumes, and age. | Cerebrospinal fluid (CSF) dynamics are increasingly studied in aging and neurological disorders. Models of CSF-mediated waste clearance suggest that altered CSF dynamics could play a role in the accumulation of toxic waste in the CNS, with implications for Alzheimer's disease and other proteinopathies. Therefore, approaches that enable quantitative and volumetric assessment of CSF flow velocities could be of value. In this study we demonstrate the feasibility of 4D flow MRI for simultaneous assessment of CSF dynamics throughout the ventricular system, and evaluate associations to arterial pulsatility, ventricular volumes, and age. In a cognitively unimpaired cohort (N = 43; age 41-83 years), cardiac-resolved 4D flow MRI CSF velocities were obtained in the lateral ventricles (LV), foramens of Monro, third and fourth ventricles (V3 and V4), the cerebral aqueduct (CA) and the spinal canal (SC), using a velocity encoding (venc) of 5 cm/s. Cerebral blood flow pulsatility was also assessed with 4D flow (venc = 80 cm/s), and CSF volumes were obtained from T1- and T2-weighted MRI. Multiple linear regression was used to assess effects of age, ventricular volumes, and arterial pulsatility on CSF velocities. Cardiac-driven CSF dynamics were observed in all CSF spaces, with region-averaged velocity range and root-mean-square (RMS) velocity encompassing from very low in the LVs (RMS 0.25 ± 0.08; range 0.85 ± 0.28 mm/s) to relatively high in the CA (RMS 6.29 ± 2.87; range 18.6 ± 15.2 mm/s). In the regression models, CSF velocity was significantly related to age in 5/6 regions, to CSF space volume in 2/3 regions, and to arterial pulsatility in 3/6 regions. Group-averaged waveforms indicated distinct CSF flow propagation delays throughout CSF spaces, particularly between the SC and LVs. Our findings show that 4D flow MRI enables assessment of CSF dynamics throughout the ventricular system, and captures independent effects of age, CSF space morphology, and arterial pulsatility on CSF motion. |
| 481 | Laura Eisenmenger | Radiology | leisenmenger@uwhealth.org | Unraveling diurnal and technical variability in cerebral hemodynamics from neurovascular 4D-Flow MRI. | Neurovascular 4D-Flow MRI enables non-invasive evaluation of cerebral hemodynamics including measures of cerebral blood flow (CBF), vessel pulsatility index (PI), and cerebral pulse wave velocity (PWV). 4D-Flow measures have been linked to various neurovascular disorders including small vessel disease and Alzheimer's disease; however, physiological and technical sources of variability are not well established. Here, we characterized sources of diurnal physiological and technical variability in cerebral hemodynamics using 4D-Flow in a retrospective study of cognitively unimpaired older adults (N = 750) and a prospective study of younger adults (N = 10). Younger participants underwent repeated MRI sessions at 7am, 4 pm, and 10 pm. In the older cohort, having an MRI earlier on the day was significantly associated with higher CBF and lower PI. In prospective experiments, time of day significantly explained variability in CBF and PI; however, not in PWV. Test-retest experiments showed high CBF intra-session repeatability (repeatability coefficient (RPC) =7.2%), compared to lower diurnal repeatability (RPC = 40%). PI and PWV displayed similar intra-session and diurnal variability (PI intra-session RPC = 22%, RPC = 24% 7am vs 4 pm; PWV intra-session RPC = 17%, RPC = 21% 7am vs 4 pm). Overall, CBF measures showed low technical variability, supporting diurnal variability is from physiology. PI and PWV showed higher technical variability but less diurnal variability. |
| 482 | Laura Eisenmenger | Radiology | leisenmenger@uwhealth.org | Report from the society of magnetic resonance angiography: clinical applications of 7T neurovascular MR in the assessment of intracranial vascular disease. | In recent years, ultra-high-field magnetic resonance imaging (MRI) applications have been rapidly increasing in both clinical research and practice. Indeed, 7-Tesla (7T) MRI allows improved depiction of smaller structures with high signal-to-noise ratio, and, therefore, may improve lesion visualization, diagnostic capabilities, and thus potentially affect treatment decision-making. Incremental evidence emerging from research over the past two decades has provided a promising prospect of 7T magnetic resonance angiography (MRA) in the evaluation of intracranial vasculature. The ultra-high resolution and excellent image quality of 7T MRA allow us to explore detailed morphological and hemodynamic information, detect subtle pathological changes in early stages, and provide new insights allowing for deeper understanding of pathological mechanisms of various cerebrovascular diseases. However, along with the benefits of ultra-high field strength, some challenges and concerns exist. Despite these, ongoing technical developments and clinical oriented research will facilitate the widespread clinical application of 7T MRA in the near future. In this review article, we summarize technical aspects, clinical applications, and recent advances of 7T MRA in the evaluation of intracranial vascular disease. The aim of this review is to provide a clinical perspective for the potential application of 7T MRA for the assessment of intracranial vascular disease, and to explore possible future research directions implementing this technique. |
| 483 | Laura Eisenmenger | Radiology | leisenmenger@uwhealth.org | Four-dimensional flow MRI for quantitative assessment of cerebrospinal fluid dynamics: Status and opportunities. | Neurological disorders can manifest with altered neurofluid dynamics in different compartments of the central nervous system. These include alterations in cerebral blood flow, cerebrospinal fluid (CSF) flow, and tissue biomechanics. Noninvasive quantitative assessment of neurofluid flow and tissue motion is feasible with phase contrast magnetic resonance imaging (PC MRI). While two-dimensional (2D) PC MRI is routinely utilized in research and clinical settings to assess flow dynamics through a single imaging slice, comprehensive neurofluid dynamic assessment can be limited or impractical. Recently, four-dimensional (4D) flow MRI (or time-resolved three-dimensional PC with three-directional velocity encoding) has emerged as a powerful extension of 2D PC, allowing for large volumetric coverage of fluid velocities at high spatiotemporal resolution within clinically reasonable scan times. Yet, most 4D flow studies have focused on blood flow imaging. Characterizing CSF flow dynamics with 4D flow (i.e., 4D CSF flow) is of high interest to understand normal brain and spine physiology, but also to study neurological disorders such as dysfunctional brain metabolite waste clearance, where CSF dynamics appear to play an important role. However, 4D CSF flow imaging is challenged by the long T1 time of CSF and slower velocities compared with blood flow, which can result in longer scan times from low flip angles and extended motion-sensitive gradients, hindering clinical adoption. In this work, we review the state of 4D CSF flow MRI including challenges, novel solutions from current research and ongoing needs, examples of clinical and research applications, and discuss an outlook on the future of 4D CSF flow. |
| 484 | Laura Eisenmenger | Radiology | leisenmenger@uwhealth.org | Harnessing cognitive trajectory clusterings to examine subclinical decline risk factors. | Cognitive decline in Alzheimer's disease and other dementias typically begins long before clinical impairment. Identifying people experiencing subclinical decline may facilitate earlier intervention. This study developed cognitive trajectory clusters using longitudinally based random slope and change point parameter estimates from a Preclinical Alzheimer's disease Cognitive Composite and examined how baseline and most recently available clinical/health-related characteristics, cognitive statuses and biomarkers for Alzheimer's disease and vascular disease varied across these cognitive clusters. Data were drawn from the Wisconsin Registry for Alzheimer's Prevention, a longitudinal cohort study of adults from late midlife, enriched for a parental history of Alzheimer's disease and without dementia at baseline. Participants who were cognitively unimpaired at the baseline visit with ≥3 cognitive visits were included in trajectory modelling (n = 1068). The following biomarker data were available for subsets: positron emission tomography amyloid (amyloid: n = 367; [11C]Pittsburgh compound B (PiB): global PiB distribution volume ratio); positron emission tomography tau (tau: n = 321; [18F]MK-6240: primary regions of interest meta-temporal composite); MRI neurodegeneration (neurodegeneration: n = 581; hippocampal volume and global brain atrophy); T2 fluid-attenuated inversion recovery MRI white matter ischaemic lesion volumes (vascular: white matter hyperintensities; n = 419); and plasma pTau217 (n = 165). Posterior median estimate person-level change points, slopes' pre- and post-change point and estimated outcome (intercepts) at change point for cognitive composite were extracted from Bayesian Bent-Line Regression modelling and used to characterize cognitive trajectory groups (K-means clustering). A common method was used to identify amyloid/tau/neurodegeneration/vascular biomarker thresholds. We compared demographics, last visit cognitive status, health-related factors and amyloid/tau/neurodegeneration/vascular biomarkers across the cognitive groups using ANOVA, Kruskal-Wallis, χ2, and Fisher's exact tests. Mean (standard deviation) baseline and last cognitive assessment ages were 58.4 (6.4) and 66.6 (6.6) years, respectively. Cluster analysis identified three cognitive trajectory groups representing steep, n = 77 (7.2%); intermediate, n = 446 (41.8%); and minimal, n = 545 (51.0%) cognitive decline. The steep decline group was older, had more females, APOE e4 carriers and mild cognitive impairment/dementia at last visit; it also showed worse self-reported general health-related and vascular risk factors and higher amyloid, tau, neurodegeneration and white matter hyperintensity positive proportions at last visit. Subtle cognitive decline was consistently evident in the steep decline group and was associated with generally worse health. In addition, cognitive trajectory groups differed on aetiology-informative biomarkers and risk factors, suggesting an intimate link between preclinical cognitive patterns and amyloid/tau/neurodegeneration/vascular biomarker differences in late middle-aged adults. The result explains some of the heterogeneity in cognitive performance within cognitively unimpaired late middle-aged adults. |
| 485 | Laura Eisenmenger | Radiology | leisenmenger@uwhealth.org | MR Imaging for Intracranial Vessel Wall Imaging: Pearls and Pitfalls. | Conventional vascular imaging methods have primarily focused on evaluating the vascular lumen. However, these techniques are not intended to evaluate vessel wall abnormalities where many cerebrovascular pathologies reside. With increased interest for the visualization and study of the vessel wall, high-resolution vessel wall imaging (VWI) has gained traction.Over the past two decades, there has been a rapid increase in number of VWI publications with improvements in imaging techniques and expansion on clinical applications. With increasing utility and interest in VWI, application of proper protocols and understanding imaging characteristics of vasculopathies are important for the interpreting radiologists to understand. |
| 486 | Laura Eisenmenger | Radiology | leisenmenger@uwhealth.org | MR Angiography of Extracranial Carotid Disease. | Magnetic resonance angiography sequences, such as time-of-flight and contrast-enhanced angiography, provide clear depiction of vessel lumen, traditionally used to evaluate carotid pathologic conditions such as stenosis, dissection, and occlusion; however, atherosclerotic plaques with a similar degree of stenosis may vary tremendously from a histopathological standpoint. MR vessel wall imaging is a promising noninvasive method to evaluate the content of the vessel wall at high spatial resolution. This is particularly interesting in the case of atherosclerosis as vessel wall imaging can identify higher risk, vulnerable plaques as well as has potential applications in the evaluation of other carotid pathologic conditions. |
| 487 | Victoria Williams | GERI | vwilliams@medicine.wisc.edu | Midlife and late-life environmental exposures on dementia risk in the Wisconsin Longitudinal Study: The modifying effects of ApoE. | Late-life air pollution exposure is associated with an increased risk for dementia, with this effect exacerbated among apolipoprotein E-4 (ApoE-4) carriers. However, whether midlife occupational exposures likewise influence dementia outcomes, and varies as a function of ApoE-4 status is unknown. Using data from 3814 participants in the Wisconsin Longitudinal Study (WLS), we employed weighted logistic regression to evaluate associations between midlife occupational respiratory exposures and late-life air pollution on all-cause dementia risk, stratified by ApoE-4 status. Midlife occupational exposure was associated with increased odds of all-cause dementia preferentially among ApoE-4 noncarriers (odds ratio [OR] = 1.59, p = 0.01), whereas higher late-life urban air pollution exposure was associated with increased dementia risk among ApoE-4 carriers (OR = 1.258, p = 0.029). Associations between environmental exposures and dementia risk vary based on the timing of exposure and ApoE-4 status. While late-life environmental exposures are associated with dementia among ApoE-4 carriers, for noncarriers midlife environmental exposure confers the greatest risk. The effect of adult environmental respiratory exposures on subsequent dementia risk varies as a function of both ApoE-4 carrier status and exposure timing. Midlife occupational exposure to respiratory hazards is preferentially associated with increased dementia odds among ApoE-4 noncarriers. Late-life exposure to ambient air pollution is associated with dementia risk, but only among ApoE-4 carriers. While higher exposure to PM2.5 increases the risk for dementia, higher exposure to ozone was associated with reduced risk for dementia among ApoE-4 carriers. |
| 488 | Victoria Williams | GERI | vwilliams@medicine.wisc.edu | Biological effects of sodium phenylbutyrate and taurursodiol in Alzheimer's disease. | Sodium phenylbutyrate and taurursodiol (PB and TURSO) is hypothesized to mitigate endoplasmic reticulum stress and mitochondrial dysfunction, two of many mechanisms implicated in Alzheimer's disease (AD) pathophysiology. The first-in-indication phase 2a PEGASUS trial was designed to gain insight into PB and TURSO effects on mechanistic targets of engagement and disease biology in AD. The primary clinical efficacy outcome was a global statistical test combining three endpoints relevant to disease trajectory (cognition [Mild/Moderate Alzheimer's Disease Composite Score], function [Functional Activities Questionnaire], and total hippocampal volume on magnetic resonance imaging). Secondary clinical outcomes included various cognitive, functional, and neuropsychiatric assessments. Cerebrospinal fluid (CSF) biomarkers spanning multiple pathophysiological pathways in AD were evaluated in participants with both baseline and Week 24 samples (exploratory outcome). PEGASUS enrolled 95 participants (intent-to-treat [ITT] cohort); cognitive assessments indicated significantly greater baseline cognitive impairment in the PB and TURSO (n = 51) versus placebo (n = 44) group. Clinical efficacy outcomes did not significantly differ between treatment groups in the ITT cohort. CSF interleukin-15 increased from baseline to Week 24 within the placebo group (n = 34). In the PB and TURSO group (n = 33), reductions were observed in core AD biomarkers phosphorylated tau-181 (p-tau181) and total tau; synaptic and neuronal degeneration biomarkers neurogranin and fatty acid binding protein-3 (FABP3); and gliosis biomarker chitinase 3-like protein 1 (YKL-40), while the oxidative stress marker 8-hydroxy-2-deoxyguanosine (8-OHdG) increased. Between-group differences were observed for the Aβ42/40 ratio, p-tau181, total tau, neurogranin, FABP3, YKL-40, interleukin-15, and 8-OHdG. Additional neurodegeneration, inflammation, and metabolic biomarkers showed no differences between groups. While between-group differences in clinical outcomes were not observed, most likely due to the small sample size and relatively short treatment duration, exploratory biomarker analyses suggested that PB and TURSO engages multiple pathophysiologic pathways in AD. Proteostasis and mitochondrial stress play key roles in Alzheimer's disease (AD).Sodium phenylbutyrate and taurursodiol (PB and TURSO) targets these mechanisms.The PEGASUS trial was designed to assess PB and TURSO effects on biologic AD targets.PB and TURSO reduced exploratory biomarkers of AD and neurodegeneration.Supports further clinical development of PB and TURSO in neurodegenerative diseases. |
| 489 | Victoria Williams | GERI | vwilliams@medicine.wisc.edu | Associations Between Midlife Menopausal Hormone Therapy Use, Incident Diabetes, and Late Life Memory in the Wisconsin Longitudinal Study. | Prior research suggests a link between menopausal hormone therapy (MHT) use, memory function, and diabetes risk. The menopausal transition is a modifiable period to enhance long-term health and cognitive outcomes, although studies have been limited by short follow-up periods precluding a solid understanding of the lasting effects of MHT use on cognition. We examined the effects of midlife MHT use on subsequent diabetes incidence and late life memory performance in a large, same-aged, population-based cohort. We hypothesized that the beneficial effects of MHT use on late life cognition would be partially mediated by reduced diabetes risk. 1,792 women from the Wisconsin Longitudinal Study (WLS) were included in analysis. We employed hierarchical linear regression, Cox regression, and causal mediation models to test the associations between MHT history, diabetes incidence, and late life cognitive performance. 1,088/1,792 women (60.7%) reported a history of midlife MHT use and 220/1,792 (12.3%) reported a history of diabetes. MHT use history was associated with better late life immediate recall (but not delayed recall), as well as a reduced risk of diabetes with protracted time to onset. Causal mediation models suggest that the beneficial effect of midlife MHT use on late life immediate recall were at least partially mediated by diabetes risk. Our data support a beneficial effect of MHT use on late life immediate recall (learning) that was partially mediated by protection against diabetes risk, supporting MHT use in midlife as protective against late life cognitive decline and adverse health outcomes. |
| 490 | Victoria Williams | GERI | vwilliams@medicine.wisc.edu | Associations of the Lifestyle for Brain Health index with longitudinal cognition and brain amyloid beta in clinically unimpaired older adults: Findings from the Wisconsin Registry for Alzheimer's Prevention. | Modifiable health and lifestyle factors increase risk of dementia, but whether modifiable factors, when measured in late-midlife, impact the emergence or progression of Alzheimer's disease (AD) pathophysiologic or cognitive changes remains unresolved. In initially cognitively unimpaired, late middle-aged participants (N = 1215; baseline age, M [standard deviation] = 59.3 [6.7] years) from the Wisconsin Registry for Alzheimer's Prevention (WRAP), we investigated the influence of the Lifestyle for Brain Health (LIBRA) index, a lifestyle-based dementia risk score, on AD-related cognitive trajectories and amyloid beta (Aβ) plaque accumulation. Overall, lower baseline LIBRA, denoting healthier lifestyle and lower dementia risk, was related to better overall cognitive performance, but did not moderate apolipoprotein E ε4 or Aβ-related longitudinal cognitive trajectories. LIBRA was not significantly associated with Aβ accumulation or estimated age of Aβ onset. In WRAP, late-midlife LIBRA scores were related to overall cognitive performance, but not AD-related cognitive decline or Aβ accumulation in the preclinical timeframe. The Lifestyle for Brain Health (LIBRA) index was associated with cognitive performance in late-midlife.LIBRA did not moderate apolipoprotein E ε4 or amyloid-related cognitive decline.LIBRA was not associated with the onset or accumulation of amyloid plaques. |
| 491 | Victoria Williams | GERI | vwilliams@medicine.wisc.edu | MarkVCID cerebral small vessel consortium: I. Enrollment, clinical, fluid protocols. | The concept of vascular contributions to cognitive impairment and dementia (VCID) derives from more than two decades of research indicating that (1) most older individuals with cognitive impairment have post mortem evidence of multiple contributing pathologies and (2) along with the preeminent role of Alzheimer's disease (AD) pathology, cerebrovascular disease accounts for a substantial proportion of this contribution. Contributing cerebrovascular processes include both overt strokes caused by etiologies such as large vessel occlusion, cardioembolism, and embolic infarcts of unknown source, and frequently asymptomatic brain injuries caused by diseases of the small cerebral vessels. Cerebral small vessel diseases such as arteriolosclerosis and cerebral amyloid angiopathy, when present at moderate or greater pathologic severity, are independently associated with worse cognitive performance and greater likelihood of dementia, particularly in combination with AD and other neurodegenerative pathologies. Based on this evidence, the US National Alzheimer's Project Act explicitly authorized accelerated research in vascular and mixed dementia along with frontotemporal and Lewy body dementia and AD itself. Biomarker development has been consistently identified as a key step toward translating scientific advances in VCID into effective prevention and treatment strategies. Validated biomarkers can serve a range of purposes in trials of candidate interventions, including (1) identifying individuals at increased VCID risk, (2) diagnosing the presence of cerebral small vessel disease or specific small vessel pathologies, (3) stratifying study participants according to their prognosis for VCID progression or treatment response, (4) demonstrating an intervention's target engagement or pharmacodynamic mechanism of action, and (5) monitoring disease progression during treatment. Effective biomarkers allow academic and industry investigators to advance promising interventions at early stages of development and discard interventions with low success likelihood. The MarkVCID consortium was formed in 2016 with the goal of developing and validating fluid- and imaging-based biomarkers for the cerebral small vessel diseases associated with VCID. MarkVCID consists of seven project sites and a central coordinating center, working with the National Institute of Neurologic Diseases and Stroke and National Institute on Aging under cooperative agreements. Through an internal selection process, MarkVCID has identified a panel of 11 candidate biomarker "kits" (consisting of the biomarker measure and the clinical and cognitive data used to validate it) and established a range of harmonized procedures and protocols for participant enrollment, clinical and cognitive evaluation, collection and handling of fluid samples, acquisition of neuroimaging studies, and biomarker validation. The overarching goal of these protocols is to generate rigorous validating data that could be used by investigators throughout the research community in selecting and applying biomarkers to multi-site VCID trials. Key features of MarkVCID participant enrollment, clinical/cognitive testing, and fluid biomarker procedures are summarized here, with full details in the following text, tables, and supplemental material, and a description of the MarkVCID imaging biomarker procedures in a companion paper, "MarkVCID Cerebral small vessel consortium: II. Neuroimaging protocols." The procedures described here address a range of challenges in MarkVCID's design, notably: (1) acquiring all data under informed consent and enrollment procedures that allow unlimited sharing and open-ended analyses without compromising participant privacy rights; (2) acquiring the data in a sufficiently wide range of study participants to allow assessment of candidate biomarkers across the various patient groups who might ultimately be targeted in VCID clinical trials; (3) defining a common dataset of clinical and cognitive elements that contains all the key outcome markers and covariates for VCID studies and is realistically obtainable during a practical study visit; (4) instituting best fluid-handling practices for minimizing avoidable sources of variability; and (5) establishing rigorous procedures for testing the reliability of candidate fluid-based biomarkers across replicates, assay runs, sites, and time intervals (collectively defined as the biomarker's instrumental validity). Participant Enrollment Project sites enroll diverse study cohorts using site-specific inclusion and exclusion criteria so as to provide generalizable validation data across a range of cognitive statuses, risk factor profiles, small vessel disease severities, and racial/ethnic characteristics representative of the diverse patient groups that might be enrolled in a future VCID trial. MarkVCID project sites include both prospectively enrolling centers and centers providing extant data and samples from preexisting community- and population-based studies. With approval of local institutional review boards, all sites incorporate MarkVCID consensus language into their study documents and informed consent agreements. The consensus language asks prospectively enrolled participants to consent to unrestricted access to their data and samples for research analysis within and outside MarkVCID. The data are transferred and stored as a de-identified dataset as defined by the Health Insurance Portability and Accountability Act Privacy Rule. Similar human subject protection and informed consent language serve as the basis for MarkVCID Research Agreements that act as contracts and data/biospecimen sharing agreements across the consortium. Clinical and Cognitive Data Clinical and cognitive data are collected across prospectively enrolling project sites using common MarkVCID instruments. The clinical data elements are modified from study protocols already in use such as the Alzheimer's Disease Center program Uniform Data Set Version 3 (UDS3), with additional focus on VCID-related items such as prior stroke and cardiovascular disease, vascular risk factors, focal neurologic findings, and blood testing for vascular risk markers and kidney function including hemoglobin A1c, cholesterol subtypes, triglycerides, and creatinine. Cognitive assessments and rating instruments include the Clinical Dementia Rating Scale, Geriatric Depression Scale, and most of the UDS3 neuropsychological battery. The cognitive testing requires ≈60 to 90 minutes. Study staff at the prospectively recruiting sites undergo formalized training in all measures and review of their first three UDS3 administrations by the coordinating center. Collection and Handling of Fluid Samples Fluid sample types collected for MarkVCID biomarker kits are serum, ethylenediaminetetraacetic acid-plasma, platelet-poor plasma, and cerebrospinal fluid (CSF) with additional collection of packed cells to allow future DNA extraction and analyses. MarkVCID fluid guidelines to minimize variability include fasting morning fluid collections, rapid processing, standardized handling and storage, and avoidance of CSF contact with polystyrene. Instrumental Validation for Fluid-Based Biomarkers Instrumental validation of MarkVCID fluid-based biomarkers is operationally defined as determination of intra-plate and inter-plate repeatability, inter-site reproducibility, and test-retest repeatability. MarkVCID study participants both with and without advanced small vessel disease are selected for these determinations to assess instrumental validity across the full biomarker assay range. Intra- and inter-plate repeatability is determined by repeat assays of single split fluid samples performed at individual sites. Inter-site reproducibility is determined by assays of split samples distributed to multiple sites. Test-retest repeatability is determined by assay of three samples acquired from the same individual, collected at least 5 days apart over a 30-day period and assayed on a single plate. The MarkVCID protocols are designed to allow direct translation of the biomarker validation results to multicenter trials. They also provide a template for outside groups to perform analyses using identical methods and therefore allow direct comparison of results across studies and centers. All MarkVCID protocols are available to the biomedical community and intended to be shared. In addition to the instrumental validation procedures described here, each of the MarkVCID kits will undergo biological validation to determine whether the candidate biomarker measures important aspects of VCID such as cognitive function. Analytic methods and results of these validation studies for the 11 MarkVCID biomarker kits will be published separately. The results of this rigorous validation process will ultimately determine each kit's potential usefulness for multicenter interventional trials aimed at preventing or treating small vessel disease related VCID. |
| 492 | Victoria Williams | GERI | vwilliams@medicine.wisc.edu | Assessing Dementia Prevalence in the Wisconsin Longitudinal Study: Cohort Profile, Protocol, and Preliminary Findings. | There is growing consensus that non-genetic determinants of dementia can be linked to various risk- and resiliency-enhancing factors accumulating throughout the lifespan, including socioeconomic conditions, early life experiences, educational attainment, lifestyle behaviors, and physical/mental health. Yet, the causal impact of these diverse factors on dementia risk remain poorly understood due to few longitudinal studies prospectively characterizing these influences across the lifespan. The Initial Lifespan's Impact on Alzheimer's Disease and Related Dementia (ILIAD) study aims to characterize dementia prevalence in the Wisconsin Longitudinal Study (WLS), a 60-year longitudinal study documenting life course trajectories of educational, family, occupational, psychological, cognitive, and health measures. Participants are surveyed using the modified Telephone Interview for Cognitive Status (TICS-m) to identify dementia risk. Those scoring below cutoff undergo home-based neuropsychological, physical/neurological, and functional assessments. Dementia diagnosis is determined by consensus panel and merged with existing WLS data for combined analysis. Preliminary findings demonstrate the initial success of the ILIAD protocol in detecting dementia prevalence in the WLS. Increasing age, hearing issues, lower IQ, male sex, APOE4 positivity, and a steeper annualized rate of memory decline assessed in the prior two study waves, all increased likelihood of falling below the TICS-m cutoff for dementia risk. TICS-m scores significantly correlated with standard neuropsychological performance and functional outcomes. We provide an overview of the WLS study, describe existing key lifespan variables relevant to studies of dementia and cognitive aging, detail the current WLS-ILIAD study protocol, and provide a first glimpse of preliminary study findings. |
| 493 | Ryan Westergaard | ID | rwestergaard@wisc.edu | Medicaid Policy and Hepatitis C Treatment Among Rural People Who Use Drugs. | Restrictive Medicaid policies regarding hepatitis C virus (HCV) treatment may exacerbate rural health care disparities for people who use drugs (PWUD). We assessed associations between Medicaid restrictions and HCV treatment among rural PWUD. We compiled state-specific Medicaid treatment policies across 8 US rural sites in 10 states and merged these with participant survey data. We hypothesized that local restrictions regarding prescriber type, sobriety, and fibrosis estimates were associated with HCV treatment outcomes. We conducted a cross-sectional, ecological analysis of treatment restrictions and HCV treatment outcomes using bivariate analyses to characterize differences between PWUD who initiated HCV treatment and unadjusted logistic regressions to assess associations between restrictions and treatment. Among 944 participants, 111 (12%) reported receiving HCV treatment. Participants receiving treatment were older [median age (interquartile range): 42 (34-53) vs. 35 (29-42), P<0.001], more likely to receive disability support (32% vs. 20%, P=0.002), and less likely to be Medicaid-insured (57% vs. 71%, P < 0.001). More PWUD in states without any restrictions reported receiving treatment (17% vs. 11%, P=0.08) and achieving HCV cure/clearance (42% vs. 30%, P=0.01) than in states with restrictions. Restrictions were associated with lower odds of receiving HCV treatment (odds ratio=0.61, 95% CI: 0.35-1.06, P=0.08). Sensitivity analyses showed a similar association with HCV cure/clearance (odds ratio=0.60, 95% CI: 0.40-0.91, P=0.02). We identified significant unadjusted associations between Medicaid restrictions and receipt of HCV treatment and cure, which has substantial implications for health outcomes among rural PWUD. Lifting remaining Medicaid restrictions will be critical to achieving HCV elimination. |
| 494 | Ryan Westergaard | GERI | rwestergaard@wisc.edu | Rural houselessness among people who use drugs in the United States: Results from the National Rural Opioid Initiative. | Over the last two decades, houselessness and drug-related epidemics both have expanded from urban to rural regions across the United States (US). However, our understanding of the relationship between rural houselessness, drug use, and drug-related harms has not kept pace. The current study addresses this gap by describing houselessness among a large cohort of people who use drugs (PWUD) from rural communities across 10 states. PWUD were recruited using modified chain-referral sampling for a cross-sectional survey capturing houselessness in the prior six months, drug use, drug-related harms, stigma, health service access, and sociodemographic characteristics. Using bivariate logistic regressions, we assessed associations between houselessness and participant characteristics. We also compare site-specific houselessness prevalence to Housing and Urban Development Point-in-Time (PIT) estimates, which are based on counts of sheltered and unsheltered people experiencing houselessness on a single night. Among 3000 PWUD, 53.7 % reported experiencing houselessness. Houselessness was associated with multiple drug-related behaviors that increase the risk of overdose and acquisition of bloodborne infections. Houselessness prevalence was comparable and exceeded PIT estimates for several sites, even though study participants constituted <1 % of each site's adult population and were restricted to PWUD. Our findings highlight that houselessness - historically considered an urban issue - is a significant public health concern for PWUD in rural areas. This demonstrates that addressing drug-related HIV, hepatitis C, and overdose epidemics, among others, in the rural US will require the provision of stable housing and harm reduction services as a pathway to treatment and recovery. |
| 495 | Ryan Westergaard | GERI | rwestergaard@wisc.edu | mHealth Engagement for Antiretroviral Medication Adherence Among People With HIV and Substance Use Disorders: Observational Study. | Despite the increasing popularity of mobile health (mHealth) technologies, little is known about which types of mHealth system engagement might affect the maintenance of antiretroviral therapy among people with HIV and substance use disorders. This study aimed to use longitudinal and detailed system logs and weekly survey data to test a mediation model, where mHealth engagement indicators were treated as predictors, substance use and confidence in HIV management were treated as joint mediators, and antiretroviral therapy adherence was treated as the outcome. We further distinguished the initiation and intensity of system engagement by mode (expression vs reception) and by communication levels (intraindividual vs dyadic vs network). Tailored for people with HIV living with substance use disorders, the mHealth app was distributed among 208 participants aged >18 years from 2 US health clinics. Supervised by medical professionals, participants received weekly surveys through the app to report their health status and medication adherence data. System use was passively collected through the app, operationalized as transformed click-level data, aggregated weekly, and connected to survey responses with a 7-day lagged window. Using the weekly check-in record provided by participants as the unit of analysis (N=681), linear regression and structure equation models with cluster-robust SEs were used for analyses, controlling within-person autocorrelation and group-level error correlations. Racial groups were examined as moderators in the structure equation models. We found that (1) intensity, not initiation, of system use; (2) dyadic message expression and reception; and (3) network expression positively predicted medication adherence through joint mediators (substance use and confidence in HIV management). However, intraindividual reception (ie, rereading saved entries for personal motivation) negatively predicts medication adherence through joint mediators. We also found Black participants have distinct usage patterns, suggesting the need to tailor mHealth interventions for this subgroup. These findings highlight the importance of considering the intensity of system engagement, rather than initiation alone, when designing mHealth interventions for people with HIV and tailoring these systems to Black communities. |
| 496 | Ryan Westergaard | GERI | rwestergaard@wisc.edu | Buprenorphine Injection Among Rural Persons Who Inject Drugs. | This cross-sectional study investigates buprenorphine injection, including factors associated with this use, among rural individuals who inject drugs. |
| 497 | Ryan Westergaard | GERI | rwestergaard@wisc.edu | Barriers to Healthcare and Social Service Utilization Among Rural Older Adults Who Use Drugs. | The objective of this study was to understand barriers to healthcare and social service utilization among older adults residing in rural areas who use drugs. A cross-sectional survey of persons who use opioids or inject drugs in rural counties with high overdose rates across ten states was conducted. For this analysis, participants were restricted to only the 375 individuals aged 50 and older. They were asked about barriers to utilizing healthcare and social services. Multivariate analyses were conducted. The most common barriers were a lack of transportation and a fear of stigma. The average number of barriers was 2.53. Those who were either uninsured or homeless endorsed 37% more barriers. For every five-year increase in age, the number of barriers reduced by 15%. Efforts to reduce these barriers may include expanding eligibility for transportation and housing services and leveraging trusted community members to broker linkages to providers to overcome stigma. |
| 498 | Ryan Westergaard | GERI | rwestergaard@wisc.edu | Differences in hepatitis C virus (HCV) testing and treatment by opioid, stimulant, and polysubstance use among people who use drugs in rural U.S. communities. | People who use drugs (PWUD) in rural communities increasingly use stimulants, such as methamphetamine and cocaine, with opioids. We examined differences in hepatitis C virus (HCV) testing and treatment history among rural PWUD with opioids, stimulants, and other substance use combinations. PWUD were enrolled from ten rural U.S. communities from 2018 to 2020. Participants self-reporting a positive HCV result were asked about their HCV treatment history and drug use history. Drug use was categorized as opioids alone, stimulants alone, both, or other drug(s) within the past 30 days. Prevalence ratios (PR) were yielded using adjusted multivariable log-binomial regression with generalized linear mixed models. Of the 2,705 PWUD, most reported both opioid and stimulant use (74%); while stimulant-only (12%), opioid-only (11%), and other drug use (2%) were less common. Most (76%) reported receiving HCV testing. Compared to other drug use, those who reported opioid use alone had a lower prevalence of HCV testing (aPR = 0.80; 95% CI: 0.63, 1.02). Among participants (n = 944) who self-reported an HCV diagnosis in their lifetime, 111 (12%) ever took anti-HCV medication; those who used both opioids and stimulants were less likely to have taken anti-HCV medication compared with other drug(s) (aPR = 0.41; 95% CI: 0.19, 0.91). In this pre-COVID study of U.S. rural PWUD, those who reported opioid use alone had a lower prevalence of reported HCV testing. Those diagnosed with HCV and reported both opioid and stimulant use were less likely to report ever taking anti-HCV medication. |
| 499 | Ryan Westergaard | GERI | rwestergaard@wisc.edu | Assessing COVID-19 pandemic impacts on the health of PWID using a novel data sharing model. | Using an innovative data sharing model, we assessed the impacts of the COVID-19 pandemic on the health of people who inject drugs (PWID). The PWID Data Collaborative was established in 2021 to promote data sharing across PWID studies in North America. Contributing studies submitted aggregate data on 23 standardized indicators during four time periods: pre-pandemic (Mar 2019 - Feb 2020), early-pandemic (Mar 2020 - Feb 2021), mid-pandemic (Mar 2021 - Feb 2022), and late pandemic (Mar 2022 - Feb 2023). We present study-specific and meta-analyzed estimates for the percentage of PWID who took medications for opioid use disorder, received substance use treatment, shared syringes or injection equipment, had a mental health condition, had been incarcerated, or had experienced houselessness. To examine change over time across indicators, we fit a random effects meta-regression model to prevalence estimates using time as a moderator. Thirteen studies contributed estimates to the Data Collaborative on these indicators, representing 6,213 PWID interviews. We observed minimal change across prevalence of the six indicators between the pre-pandemic (March 2019 - February 2020) and three subsequent time periods, overall or within individual studies. Considerable heterogeneity was observed across study- and time-specific estimates. Limited pandemic-related change observed in indicators of PWID health is likely a result of policy and supportive service-related changes and may also reflect resilience among service providers and PWID themselves. The Data Collaborative is an unprecedented data sharing model with potential to greatly improve the quality and timeliness of data on the health of PWID. |
| 500 | Ryan Westergaard | GERI | rwestergaard@wisc.edu | Associations of stigma, loneliness, and treatment self-regulation with HIV medication adherence among individuals with substance use disorder using a mobile health application. | Medication adherence contributes to poor HIV outcomes, especially among people with HIV and Substance use disorder (SUD). Mobile health applications have been leveraged to improve behavioral health outcomes among this population. Our cross-sectional study examined the relationship between medication adherence with factors such as treatment self-regulation, isolation, and internalized stigma, among people with HIV and SUD using the Addiction Comprehensive Health Enhancement Support System (A-CHESS) mobile app. A sample of 208 participants using A-CHESS to improve treatment adherence completed a survey. Adherence was measured using the Four-item Morisky Medication Adherence Scale and dichotomized (maximum score of 20 points considered as adherent). Positive and negative affect was measured separately using Positive Affect Negative Affect Schedule and loneliness was measured using UCLA three-item Loneliness Scale. Internalized stigma was measured using Internalized AIDS-Related Stigma Scale. Competence/Treatment self-regulation was measured using Treatment Self-regulation Questionnaire. Multivariable logistic regression was used to assess the associations of affect, treatment self-regulation, isolation, and internalized stigma, with adherence to antiretroviral therapy adjusting for age, education, and gender. Among 208 participants in this study, most were Black (n = 137; 66%), male (n = 156; 75%) and had a mean age of 46 (standard deviation = 11.3). The most reported substances associated with missing HIV medication were alcohol (27%) and cocaine/crack (20%). Logistic regression analysis revealed that internalized stigma was significantly associated with HIV medication adherence (OR = 0.82; 95% CI: 0.70-0.99; p = 0.034). Internalized stigma was significantly associated with HIV medication adherence. Further research is needed to better understand this relationship and develop interventions addressing stigma in people with HIV and SUD. |
| 501 | Ryan Westergaard | GERI | rwestergaard@wisc.edu | Behavioral and Health Outcome Differences by Heroin or Methamphetamine Preference Among People in Rural US Communities Who Use Both Substances. | The United States' (US) opioid overdose epidemic has evolved into a combined stimulant/opioid epidemic, a pattern driven in part by mitigating opioid overdose risk, variable substance availability, and personal preferences. This study aimed to investigate the association between self-reported substance preference (heroin or methamphetamine) and behavioral/health outcomes among individuals who used both heroin and methamphetamine in the rural US. The Rural Opioid Initiative is a consortium of 8 research cohorts from 10 states and 65 rural counties that recruited individuals reporting past 30-day injection of any substance or opioid substance use by any route from 1/2018 to 3/2020. Analyses were restricted to participants ⩾18 years, who self-reported either heroin or methamphetamine as their preferred substance and past 30-day use of both heroin and methamphetamine. We examined cross-sectional associations between preferred substance (heroin versus methamphetamine) and behavioral and health outcomes using random effects meta-analysis with adjusted regression models. Among 1239 participants, 61% (n = 752) reported heroin as their preferred substance. Adjusting for age, sex, and race/ethnicity, methamphetamine preference was associated with lower prevalence ratios for current naloxone possession (adjusted prevalence ratio [aPR] = 0.68; 95% Confidence Interval [95% CI] = 0.59-0.78; P-value ⩽ .001), of ever being told they had the hepatitis C virus (HCV; aPR = 0.72; 95% CI: 0.61-0.85; P-value ⩽ .001) and a personal history of overdose (aPR = 0.81; 95% CI = 0.73-0.90; P-value ⩽ .001). In our study analyzing associations between preferred substance and various behavioral and health outcomes amongst people who use both heroin and methamphetamine, a majority of participants preferred heroin. Methamphetamine preference was associated with lower prevalence of naloxone possession, ever being told they had HCV, and prior history of an overdose. This study underscores the need for targeted harm reduction services for people who prefer methamphetamine in rural areas. |
| 502 | Ryan Westergaard | GERI | rwestergaard@wisc.edu | Behaviors and attitudes of college students during an academic semester at two Wisconsin universities during the COVID-19 pandemic. | Characterize college student COVID-19 behaviors and attitudes during the early pandemic. Participants: Students on two university campuses in Wisconsin. Surveys administered in September and November 2020. Few students (3-19%) participated in most in-person activities during the semester, with eating at restaurants as the exception (72-80%) and attending work (35%) and parties (33%) also reported more frequently. The majority wore masks in public (94-99%), but comparatively fewer (42%) did so at parties. Mask-wearing at parties decreased from September to November (p < 0.05). Students attending parties, or consuming more alcohol, were less concerned and more likely to take COVID-19-associated risks. Students were motivated to adhere to COVID-19 prevention measures but gathered socially. Though there was frequent public masking, mask-wearing at parties declined in November and may represent pandemic fatigue. High-yield strategies for decreasing viral spread may include changing masking social norms and engaging with students about creative risk-reduction strategies. |
| 503 | Steven Barczi | GERI | srbarczi@wisc.edu | Impact of Veterans Affairs Geriatric Research, Education, and Clinical Centers: Incubators of innovation in geriatrics. | Since their inception in 1975, the Department of Veterans Affairs Geriatric Research, Education, and Clinical Centers (GRECCs) have served as incubators of innovation in geriatrics. Their contributions to the VA mission were last reviewed in 2012. Herein, we describe the continuing impact of GRECCs in research, clinical, and educational areas, focusing on the period between 2018 and 2022. GRECC research spans the continuum from bench to bedside, with a growing research portfolio notable for highly influential publications. GRECC education connects healthcare professions trainees and practicing clinicians, as well as Veterans and their caregivers, to engaging learning experiences. Clinical advancements, including age-friendly care, span the continuum of care and leverage technology to link disparate geographical sites. GRECCs are uniquely positioned to serve older adults given their alignment with the largest integrated health system in the United States and their integration with academic health centers. As such, the GRECCs honor Veterans as they age by building VA capacity to care for the increasing number of aging Veterans seeking care from VA. GRECC advancements also benefit non-VA healthcare systems, their academic affiliates, and non-Veteran older adults. GRECCs make invaluable contributions to advancing geriatric and gerontological science, training healthcare professionals, and developing innovative models of geriatric care. |
| 504 | Steven Barczi | GERI | srbarczi@wisc.edu | Salary Equity Among Subspecialty Fellows: A Call to Action. | |
| 505 | Steven Barczi | GERI | srbarczi@wisc.edu | Fellowship-trained physicians who let their geriatric medicine certification lapse: A national survey. | Only 62.6% of fellowship-trained and American Board of Internal Medicine (ABIM)-certified geriatricians maintain their specialty certification in geriatric medicine, the lowest rate among all internal medicine subspecialties and the only subspecialty in which physicians maintain their internal medicine certification at higher rates than their specialty certification. This study aims to better understand underlying issues related to the low rate of maintaining geriatric medicine certification in order to inform geriatric workforce development strategies. Eighteen-item online survey of internists who completed a geriatric medicine fellowship, earned initial ABIM certification in geriatric medicine between 1999 and 2009, and maintained certification in internal medicine (and/or another specialty but not geriatric medicine). Survey domains: demographics, issues related to maintaining geriatric medicine certification, professional identity, and current professional duties. 153/723 eligible completed surveys (21.5% response). Top reasons for not maintaining geriatric medicine certification were time (56%), cost of maintenance of certification (MOC) (45%), low Medicare reimbursement for geriatricians' work (32%), and no employer requirement to maintain geriatric medicine certification (31%). Though not maintaining geriatric medicine certification, 68% reported engaging in professional activities related to geriatric medicine. Reflecting on career decisions, 56% would again complete geriatric medicine fellowship, 21% would not, and 23% were unsure. 54% considered recertifying in geriatric medicine. 49% reported flexible MOC assessment options would increase likelihood of maintaining certification. The value proposition of geriatric medicine certification needs strengthening. Geriatric medicine leaders must develop strategies and tactics to reduce attrition of geriatricians by enhancing the value of geriatric medicine expertise to key stakeholders. |
| 506 | Steven Barczi | GERI | srbarczi@wisc.edu | Bridging the Gap in Competency Assessment During Transition from Undergraduate Medical Education to Graduate Medical Education: A Perspective Piece. | |
| 507 | Steven Barczi | GERI | srbarczi@wisc.edu | Looking back, moving forward: A practical guide to implementing the updated ACGME geriatric medicine Milestones 2.0. | The Accreditation Council for Graduate Medical Education (ACGME) developed the Milestones as a tool to aid trainee assessment based on the framework of the six core competencies of practice. Variability in the interpretation and application of the original Milestones prompted the ACGME to convene work groups within the different specialties and subspecialties to update the Milestones. The Geriatric Medicine work group was convened in 2019 with the goal of clarifying and simplifying the language of the Milestones, revising content to be specific to geriatrics, and developing supplemental resources to aid in implementation and use. We suggest using a practical, four-step process to implement the updated Milestones, called the Milestones 2.0, in fellowship programs by: (1) training faculty in the use of the Milestones 2.0, including an overview of the background and updates, (2) mapping the Milestones 2.0 to existing assessments, (3) educating fellows about the Milestones 2.0 and (4) presenting and discussing the Milestones 2.0 at Clinical Competency Committee meetings. This systematic approach promotes the development of a shared mental model for trainee assessments. |
| 508 | Steven Barczi | GERI | srbarczi@wisc.edu | Emerging from the Pandemic: AAIM Recommendations for Internal Medicine Residency and Fellowship Interview Standards. | |
| 509 | Steven Barczi | GERI | srbarczi@wisc.edu | GRECC Connect: Geriatrics Telehealth to Empower Health Care Providers and Improve Management of Older Veterans in Rural Communities. | A telehealth program supports meaningful partnerships between urban geriatric specialists and rural health care providers to facilitate increased access to specialty care. |
| 510 | Steven Barczi | GERI | srbarczi@wisc.edu | Veterans Affairs Geriatric Scholars Program: Enhancing Existing Primary Care Clinician Skills in Caring for Older Veterans. | The Veterans Affairs Geriatric Scholars Program (GSP) is a continuing professional development program to integrate geriatrics into the clinical practices of primary care providers and select associated health professions that support primary care teams. GSP uses a blended program educational format, and the minimal requirements are to attend an intensive course in geriatrics, participate in an interactive workshop on quality improvement (QI), and initiate a local QI project to demonstrate application of new knowledge to benefit older veterans. Using a retrospective post/pre survey design, the effect of GSP on clinical practices and behaviors and variation of that effect on clinicians working in rural and nonrural settings were evaluated. Significant improvement was found in the frequency of using evidence-based brief standardized assessments, clinical decision-making, and standards of care. Significant subgroup differences were observed in peer-to-peer information sharing between rural and nonrural clinicians. Overall, 77% of the sample reported greater job satisfaction after participating in GSP. The program is a successful model for advancing postgraduate education in geriatrics and a model that might be replicated to increase access to quality health care, particularly in rural areas. |
| 511 | Steven Barczi | GERI | srbarczi@wisc.edu | Effects of sleep-disordered breathing on cerebrovascular regulation: A population-based study. | Cerebrovascular regulation is impaired in patients with moderate to severe obstructive sleep apnea; however, it is unknown whether this impairment exists in individuals with less severe sleep-disordered breathing. To test the hypothesis that cerebrovascular responses to hypercapnia are attenuated in a nonclinical population-based cohort. A rebreathing test that raised end-tidal CO₂ tension by 10 mm Hg was performed during wakefulness in 373 participants of the Wisconsin Sleep Cohort. We measured cerebral flow velocity (transcranial Doppler ultrasound); heart rate (electrocardiogram); blood pressure (photoplethysmograph); ventilation (pneumotachograph); and end-tidal CO₂ (expired gas analysis). Cerebrovascular CO₂ responsiveness was quantified as the slope of the linear relationship between flow velocity and end-tidal CO₂ during rebreathing. Linear regression analysis was performed using cerebrovascular CO₂ responsiveness as the outcome variable. Main independent variables were the apnea-hypopnea index and the mean level of arterial oxygen saturation during sleep. We observed a positive correlation between cerebrovascular CO₂ responsiveness and the mean level of oxygen saturation during sleep that was statistically significant in unadjusted analysis and after adjustment for known confounders and the increase in arterial pressure during rebreathing. Each 5% decrease in Sa(O₂) during sleep predicted a decrease in cerebrovascular reactivity of 0.4 ± 0.2 cm/second/mm Hg P(ET)CO₂. In contrast, the negative correlation between cerebrovascular CO₂ responsiveness and apnea-hypopnea index was statistically significant only in the unadjusted analysis. Hypercapnic vasodilation in the cerebral circulation is blunted in individuals with sleep-disordered breathing. This impairment is correlated with hypoxemia during sleep. |
| 512 | Steven Barczi | GERI | srbarczi@wisc.edu | Impaired vascular regulation in patients with obstructive sleep apnea: effects of continuous positive airway pressure treatment. | Impaired endothelium-dependent vasodilation has been documented in patients with sleep apnea. This impairment may result in blood flow dysregulation during apnea-induced fluctuations in arterial blood gases. To test the hypothesis that hypoxic and hypercapnic vasodilation in the forearm and cerebral circulation are impaired in patients with sleep apnea. We exposed 20 patients with moderate to severe sleep apnea and 20 control subjects, to isocapnic hypoxia and hyperoxic hypercapnia. A subset of 14 patients was restudied after treatment with continuous positive airway pressure. Cerebral flow velocity (transcranial Doppler), forearm blood flow (venous occlusion plethysmography), arterial pressure (automated sphygmomanometry), oxygen saturation (pulse oximetry), ventilation (pneumotachograph), and end-tidal oxygen and carbon dioxide tensions (expired gas analysis) were measured during three levels of hypoxia and two levels of hypercapnia. Cerebral vasodilator responses to hypoxia (-0.65 +/- 0.44 vs. -1.02 +/- 0.72 [mean +/- SD] units/% saturation; P = 0.03) and hypercapnia (2.01 +/- 0.88 vs. 2.57 +/- 0.89 units/mm Hg; P = 0.03) were smaller in patients versus control subjects. Hypoxic vasodilation in the forearm was also attenuated (-0.05 +/- 0.09 vs. -0.10 +/- 0.09 unit/% saturation; P = 0.04). Hypercapnia did not elicit forearm vasodilation in either group. Twelve weeks of continuous positive airway pressure treatment enhanced hypoxic vasodilation in the cerebral circulation (-0.83 +/- 0.32 vs. -0.46 +/- 0.29 units/% saturation; P = 0.01) and forearm (-0.19 +/- 0.15 vs. -0.02 +/- 0.08 units/% saturation; P = 0.003), and hypercapnic vasodilation in the brain showed a trend toward improvement (2.24 +/- 0.78 vs. 1.76 +/- 0.64 units/mm Hg; P = 0.06). Vasodilator responses to chemical stimuli in the cerebral circulation and the forearm are impaired in many patients with obstructive sleep apnea. Some of these impairments can be improved with continuous positive airway pressure. |
| 513 | Neil Binkley | GERI | nbinkley@wisc.edu | Bone Turnover Markers Predict Changes in Bone Mineral Density in Men Treated with Abaloparatide: Results from ATOM. | Early increases in bone turnover markers (BTMs) in response to anabolic therapy correlate with 18-month bone mineral density (BMD) increases in postmenopausal women with osteoporosis; however, this relationship has not been assessed in men. In this analysis, the correlation between changes from baseline in fasting intact serum procollagen type I N propeptide (PINP) and serum carboxy-terminal cross-linking telopeptide of type I collagen (CTX) at 1, 3, 6, and 12 months and percent increase from baseline in BMD at 12 months in men from the randomized phase 3 ATOM study (NCT03512262) were evaluated using Pearson's correlation coefficients. The uncoupling index (UI), a measure of the balance between markers of bone formation (PINP) and bone resorption (CTX), with positive UI favoring bone formation, was calculated. Results in men were compared to 12-month results for women from the ACTIVE study using the z score test after Fisher's Z transformation. In abaloparatide-treated men, PINP increases at 1 month (r = 0.485), 3 months (r = 0.614), 6 months (r = 0.632), and 12 months (r = 0.521) were highly correlated (P<.0001) with 12-month lumbar spine BMD increases. The mean UI for abaloparatide-treated men was greater than placebo as early as 1 month (2.26 versus -0.25). At month 3, the mean UI for men was greater (1.32) than for women (0.88) (P<.001). There was a significant correlation between 3-month UI and lumbar spine BMD at 12 months in both men (r = 0.453; P<.001) and women (r = 0.252; P<.01); UI at months 6 and 12 were also significantly correlated with 12-month lumbar spine BMD in men and women, but the correlation was stronger in men than women. These data support that early changes in BTMs in men treated with abaloparatide are associated with subsequent changes in BMD similar to what has been reported in women. Trial registration: clinicaltrials.gov Identifier NCT03512262. Bone turnover markers are proteins measured in the blood to evaluate bone formation (PINP) and resorption (CTX). Early change in the balance between these proteins, called the uncoupling index, are related to subsequent changes in bone mineral density (BMD). This study in men treated with abaloparatide showed that increased bone turnover markers and uncoupling index at 1, 3, 6, and 12 months were associated with subsequent changes in BMD. These findings are similar to results in women treated with abaloparatide, supporting that early changes in bone turnover markers can indicate that BMD will increase in response to abaloparatide. |
| 514 | Neil Binkley | GERI | nbinkley@wisc.edu | Association of trabecular bone score corrected for tissue thickness with glucose metabolism in acromegaly. | Acromegaly is associated with increased vertebral fracture (VF) risk regardless of bone mineral density (BMD). However, the vertebral trabecular compartment is still low; a possible contributor to this may be impaired glucose metabolism (GM) which frequently complicates acromegaly. Additionally, soft tissue thickness may confound bone imaging in acromegaly patients. This study aims to assess the association of GM with BMD, trabecular bone score adjusted for BMI (TBSBMI), and trabecular bone score adjusted for tissue thickness (TBSTT) among acromegaly subjects. A cross-sectional study was performed among 70 consecutive acromegaly patients (24 male/46 female, aged 55.1 years) divided in two subgroups: abnormal GM (n = 35) and normal GM (n = 35). Using DXA, BMD, TBSBMI, TBSTT, and VF screening were performed. In all subjects, TBSTT was higher (mean 9.5%) than TBSBMI. Abnormal GM subjects had lower TBSBMI (1.166 ± 0.15) than normal GM subjects (1.232 ± 0.12; p < 0.05). No between-group difference in TBSTT or BMD was observed. In a multiple regression model, the best predictor of TBSTT was HbA1c (p = 0.002). None of the DXA measures or GM parameters was a significant predictor of VF (n = 7). The abnormal GM acromegaly subjects had lower TBSBMI than those with normal GM. TBSTT was higher than TBSBMI, and no between-group difference based on GM status was observed. TBSTT was significantly associated with GM parameters, notably HbA1c. The relationship of TBSTT with GM parameters may imply an effect of GM on trabecular bone microstructure in patients with acromegaly; a further study is indicated. |
| 515 | Neil Binkley | GERI | nbinkley@wisc.edu | Intraoperative physician assessment during total hip arthroplasty correlates with DXA parameters. | Orthopedic surgeons can assess bone status intraoperatively and recommend skeletal health evaluation for patients with poor bone quality. Intraoperative physician assessment (IPA) at the time of total knee arthroplasty correlates with preoperative DXA-measured bone mineral density (BMD). This study evaluated IPA during total hip arthroplasty (THA) as a quantitative measure of bone status based on tactile assessment. This retrospective analysis identified 60 patients (64 hips) undergoing primary THA who had IPA recorded in the operative report and a DXA within 2 years before surgery. Intraoperatively, two surgeons assessed bone quality on a 5-point scale (1 = excellent; 5 = poor). IPA score was compared to DXA BMD and T-score, 3D Shaper measurements, WHO classification, FRAX scores, radiographic Dorr classification, and cortical index. There was a strong correlation between the IPA score and lowest T-score, WHO classification, and FRAX major and hip fracture scores (r = ± 0.485-0.622, all p < 0.001). There was a moderate correlation between IPA score and total hip BMD and 3D Shaper measurements, including trabecular volumetric BMD, cortical surface BMD, and cortical thickness (r = ± 0.326-0.386, all p < 0.01). All patients with below-average IPA scores had osteopenia or osteoporosis by DXA. IPA during THA is a simple, valuable tool for quantifying bone status based on tactile feedback. This information can be used to identify patients with poor bone quality that may benefit from skeletal status evaluation and treatment and provide intraoperative guidance for implant selection. Orthopedic surgeons can assess bone health at the time of surgery. Intraoperative physician assessment (IPA) is a bone quality score based on surgeons' tactile assessment that correlates strongly with the lowest T-score, WHO classification, and FRAX fracture risk. IPA can guide surgical decision-making and future bone health treatment. |
| 516 | Neil Binkley | GERI | nbinkley@wisc.edu | Association of standardized serum 25-hydroxyvitamin D with falls in post-menopausal women. | Vitamin D status has long been related to falls risk. In this planned secondary analysis of a vitamin supplementation trial in postmenopausal women, standardized 25-hydroxyvitamin D concentration up to 60 ng/mL was not associated with increased falls. Women with 25(OH)D ≥ 60 ng/mL had higher odds of ≥ 2 falls. Falls are common and cause fractures. High circulating 25(OH)D may increase falls risk; thus, recent guidance recommends 25(OH)D not exceed 50 ng/mL. Prior falls studies have not reported standardized 25(OH)D (s25D) data. The purpose of this planned secondary analysis of a 4-year calcium/vitamin D supplementation trial was to evaluate the association of s25D with falls. This study recruited 2,303 postmenopausal women. The analytic dataset consisted of pooled concatenated data from years 2-4 (NTotal = 5,732). Serum 25(OH)D was measured annually and subsequently retrospectively standardized using Vitamin D Standardization Program methods. Falls were recorded by diary. Incidence for ≥ 1 fall and ≥ 2 falls was assessed by s25D group (≤ 20, 20- < 30, 30- < 40, 40- < 50, 50- < 60 and ≥ 60 ng/mL) using multivariable logistic regression. Mean (SD) baseline s25D was 32.6 ng/mL (8.3) with no difference between supplement and placebo groups. s25D increased to 41.3 ng/mL at year 2 in the supplement group then remained stable. By s25D group, incidence for ≥ 1 fall varied from 22-32% (p = 0.19). For ≥ 2 falls incidence varied (p = 0.03) from 6% (< 20 ng/mL) to 17% (≥ 60 ng/mL.) There was no significant association between s25D and ≥ 1 fall. Those with s25D ≥ 60 ng/mL had a higher adjusted odds of ≥ 2 falls (OR = 1.99 ± 1.2-3.3) compared to women with s25D of 30- < 40 ng/mL. s25D up to 60 ng/mL was not associated with greater risk for ≥ 1 or ≥ 2 falls. Women with a s25D ≥ 60 ng/mL were at higher odds for ≥ 2 falls, however this group included only ~ 2% of study observations; therefore, confirmation in other cohorts is necessary. |
| 517 | Neil Binkley | GERI | nbinkley@wisc.edu | Effects of Lumbar Spine Vertebral Fractures on Trabecular Bone Score (TBS): The Manitoba BMD Registry. | Trabecular bone score (TBS) is a BMD-independent risk factor for fracture. During BMD reporting, it is standard practice to exclude lumbar vertebral levels affected by structural artifact. It is uncertain whether TBS is affected by lumbar spine fractures. The current study examined the effect of lumbar spine compression fractures on TBS measurements. We identified 656 individuals with vertebral fractures (mean age 75.8 ± 7.9 years, 90.9% female) who had lumbar spine DXA, TBS measurements from L1-L4 and vertebral fracture assessment (VFA) for identifying vertebral fractures. There were 272 cases with lumbar spine fractures and 384 controls with only thoracic spine fractures. L1 TBS and BMD were significantly greater in those with than without lumbar fractures (p< 0.001) but did not significantly differ for other vertebral levels or for L1-L4 combined. TBS and BMD measurements were then renormalized to remove level-specific differences (denoted rTBS and rBMD). The mean difference (all fractured minus all non-fractured vertebrae) was +0.040 (+3.3%) for rTBS and +0.088 g/cm2 (+9.5%) for rBMD (both p <0.001). The largest effect was for L1 with mean difference +0.058 (+4.9%) for rTBS and +0.098 g/cm2 (+10.6%) for rBMD (both p <0.001). The mean difference between fractured and non-fractured levels for rTBS was +0.028 (+2.4%) for grade 1, +0.036 (+3.0%) for grade 2 and +0.059 (+5.0%) for grade 3 fractures; for rBMD +0.051 (+5.5%), +0.076 (+8.2%) and +0.151 (+16.4%) g/cm2, respectively. The impact of excluding lumbar vertebral levels with fracture from the L1-L4 TBS measurement overall was small (-0.011 [-1.0%]; p<0.001) and was also small for grade 3 fractures (-0.020 [-1.7%]; p<0.001). In summary, TBS is mildly increased by VFA-confirmed lumbar vertebral fractures, but the percentage effect is much smaller (less than half) than seen for BMD and minimally affects TBS measured from L1-L4. This would support the use of L1-L4 without exclusions in individuals with lumbar vertebral fractures. |
| 518 | Neil Binkley | GERI | nbinkley@wisc.edu | Skeletal fluorosis: an uncommon cause, yet a rescue treatment? | Skeletal fluorosis (SF) results from chronic exposure to fluoride (F-) causing excessive aberrantly mineralized brittle bone tissue, fractures, and exostoses. There is no established treatment other than avoiding the source of F-. Still, excess F- can persist in bone for decades after exposure ceases. A 50-year-old woman presented with multiple, recurrent, low AQ2 trauma fractures yet high radiologic bone mineral density. Serum F- was elevated, and osteomalacia was documented by non-decalcified transiliac biopsy. She reported intermittently "huffing" a keyboard cleaner containing F- (difluoroethane) for years. Following cessation of her F- exposure, we evaluated the administration of the parathyroid hormone analog, abaloparatide, hoping to increase bone remodeling and diminish her skeletal F- burden. Due to the prolonged half-life of F- in bone, SF can cause fracturing long after F- exposure stops. Anabolic therapy approved for osteoporosis, such as abaloparatide, may induce mineralized bone turnover to replace the poorly mineralized osteomalacic bone characteristic of SF and thereby diminish fracture risk. Following abaloparatide treatment for our patient, there was a decrease in bone density as well as a reduction in F- levels. |
| 519 | Neil Binkley | GERI | nbinkley@wisc.edu | Consensus Statement on Vitamin D Status Assessment and Supplementation: Whys, Whens, and Hows. | The 6th International Conference, "Controversies in Vitamin D," was convened to discuss controversial topics, such as vitamin D metabolism, assessment, actions, and supplementation. Novel insights into vitamin D mechanisms of action suggest links with conditions that do not depend only on reduced solar exposure or diet intake and that can be detected with distinctive noncanonical vitamin D metabolites. Optimal 25-hydroxyvitamin D (25(OH)D) levels remain debated. Varying recommendations from different societies arise from evaluating different clinical or public health approaches. The lack of assay standardization also poses challenges in interpreting data from available studies, hindering rational data pooling and meta-analyses. Beyond the well-known skeletal features, interest in vitamin D's extraskeletal effects has led to clinical trials on cancer, cardiovascular risk, respiratory effects, autoimmune diseases, diabetes, and mortality. The initial negative results are likely due to enrollment of vitamin D-replete individuals. Subsequent post hoc analyses have suggested, nevertheless, potential benefits in reducing cancer incidence, autoimmune diseases, cardiovascular events, and diabetes. Oral administration of vitamin D is the preferred route. Parenteral administration is reserved for specific clinical situations. Cholecalciferol is favored due to safety and minimal monitoring requirements. Calcifediol may be used in certain conditions, while calcitriol should be limited to specific disorders in which the active metabolite is not readily produced in vivo. Further studies are needed to investigate vitamin D effects in relation to the different recommended 25(OH)D levels and the efficacy of the different supplementary formulations in achieving biochemical and clinical outcomes within the multifaced skeletal and extraskeletal potential effects of vitamin D. |
| 520 | Neil Binkley | GERI | nbinkley@wisc.edu | Treatment reclassification in Canada from the Osteoporosis Canada 2023 clinical practice guidelines: the Manitoba BMD Registry. | Osteoporosis Canada 2023 clinical practice guidelines increase the number of individuals recommended or suggested for anti-osteoporosis pharmacotherapy by refining treatment guidance for those who fell within the 2010 guidelines' moderate-risk category. In 2023, Osteoporosis Canada updated its 2010 clinical practice guidelines based upon consideration of fracture history, 10-year major osteoporotic fracture (MOF) risk, and BMD T-score in conjunction with age. The 2023 guidelines eliminated risk categories, including the moderate-risk group that did not provide clear treatment guidance. The current study was performed to appreciate the implications of the shift from 2010 risk categories to 2023 treatment guidance. The study population consisted of 79,654 individuals age ≥ 50 years undergoing baseline DXA testing from January 1996 to March 2018. Each individual was assigned to mutually exclusive categories based on 2010 and 2023 guideline recommendations. Treatment qualification, 10-year predicted and 10-year observed MOF risk were compared. Treatment reclassification under the 2023 guidelines only affected 33.8% of individuals in the 2010 moderate-risk group, with 13.0% assigned to no treatment, 14.4% to suggest treatment, and 6.4% to recommend treatment. During the mean follow-up of 7.2 years, 6364 (8.0%) individuals experienced one or more incidents of MOF. The observed 10-year cumulative incidence of MOF in the study population was 10.5% versus the predicted 10.7% (observed to predicted mean calibration ratio 0.98, 95% CI 0.96-1.00). Individuals reclassified from 2010 moderate risk to 2023 recommend treatment were at greater MOF risk than those in the 2010 moderate-risk group assigned to 2023 suggest treatment or no treatment, but at lower risk than those in the 2010 high-risk group. Osteoporosis Canada 2023 clinical practice guidelines affect individuals within the 2010 moderate-risk category, increasing the number for whom anti-osteoporosis pharmacotherapy is recommended or suggested. Increased treatment could reduce the population burden of osteoporotic fractures, though moderate-risk individuals now qualifying for treatment have a lower predicted and observed fracture risk than high-risk individuals recommended for treatment under the 2010 guidelines. |
| 521 | Neil Binkley | GERI | nbinkley@wisc.edu | Effect of abdominal tissue thickness on trabecular bone score and fracture risk in adults with diabetes: the Manitoba BMD registry. | Individuals with type 2 diabetes have lower trabecular bone score (TBS) and increased fracture risk despite higher bone mineral density. However, measures of trabecular microarchitecture from high-resolution peripheral computed tomography are not lower in type 2 diabetes. We hypothesized that confounding effects of abdominal tissue thickness may explain this discrepancy, since central obesity is a risk factor for diabetes and also artifactually lowers TBS. This hypothesis was tested in individuals aged 40 years and older from a large DXA registry, stratified by sex and diabetes status. When DXA-measured abdominal tissue thickness was not included as a covariate, men without diabetes had lower TBS than women without diabetes (mean difference -0.074, P < .001). TBS was lower in women with versus without diabetes (mean difference -0.037, P < .001), and men with versus without diabetes (mean difference -0.007, P = .042). When adjusted for tissue thickness these findings reversed, TBS became greater in men versus women without diabetes (mean difference +0.053, P < .001), in women with versus without diabetes (mean difference +0.008, P < .001), and in men with versus without diabetes (mean difference +0.014, P < .001). During mean 8.7 years observation, incident major osteoporotic fractures were seen in 7048 (9.6%). Adjusted for multiple covariates except tissue thickness, TBS predicted fracture in all subgroups with no significant diabetes interaction. When further adjusted for tissue thickness, HR per SD lower TBS remained significant and even increased slightly. In conclusion, TBS predicts fractures independent of other clinical risk factors in both women and men, with and without diabetes. Excess abdominal tissue thickness in men and individuals with type 2 diabetes may artifactually lower TBS using the current algorithm, which reverses after accounting for tissue thickness. This supports ongoing efforts to update the TBS algorithm to directly account for the effects of abdominal tissue thickness for improved fracture risk prediction. Individuals with type 2 diabetes are at increased fracture risk despite having higher bone mineral density (BMD). Previous studies suggest that trabecular bone score (TBS), a measure of bone derived from spine DXA images that can be used to assess fracture risk in addition to BMD, may be lower in individuals with type 2 diabetes. However, TBS is artificially lowered by greater abdominal obesity. We showed that abdominal obesity explained the lower TBS measurements that were seen in individuals with type 2 diabetes. However, even when we considered the effect of abdominal obesity, TBS was still able to predict major fractures in both women and men, with and without diabetes. |
| 522 | Neil Binkley | GERI | nbinkley@wisc.edu | Periprosthetic fractures are osteoporotic fractures: missed opportunities for osteoporosis diagnosis. | Joint replacement surgery is common in older adults, leading to increasing periprosthetic fracture (PPFx) occurrence. We reviewed all PPFx seen over a 4-year period at an academic hospital. Clinical osteoporosis could be diagnosed based on existing data in 104 (67%) at the time of PPFx. Periprosthetic fractures are generally osteoporosis-related. Periprosthetic fractures (PPFx) cause morbidity, mortality, and cost. This study's purpose was to describe osteoporosis-related data available at the time of PPFx. The electronic medical record (EMR) of PPFx patients seen over 4 years in a university orthopedic practice were reviewed. Demographic data and osteoporosis relevant parameters were collected. Prior DXA studies were reviewed, and L1 Hounsfield unit (HU) measurements were performed on CT scans obtained within 2 years before PPFx. Clinical osteoporosis was defined as prior diagnosis, prescribed osteoporosis treatment, T-score ≤ - 2.5, HU ≤ 100, or prior fracture. Records of 156 PPFx patients (115 F/41 M), mean (SD) age 75.4 (11.9), were reviewed. Almost all 153/156 (98%) of these fractures were femoral. Falls caused 139 (89%); 12 (8%) were spontaneous. Mean time post-arthroplasty was 7.9 (6.3) years. Prior fragility fracture(s) occurred in 72 (46%); 14 were PPFx. Osteoporosis was previously diagnosed in 45 (29%) and medications prescribed in 41 (26%). Prior to PPFx, DXA data were available in 62, mean (SD) lowest T-score was - 1.9 (0.9) and was ≤ - 2.5 in 19. CT data were available in 46; mean (SD) L1 HU was 79.0 (29.4) and was ≤ 100 in 35. Based on existing data, clinical osteoporosis could have been diagnosed in 104 (67%) at the time of PPFx. Periprosthetic fractures are osteoporosis-related. They occur in older adults, often female, and result from falls; BMD, when assessed, is low. Data available at the time of PPFx often allows osteoporosis diagnosis; this should prompt evaluation and pharmacologic treatment consideration. |
| 523 | Meghan Brennan | ID | mbbrennan@medicine.wisc.edu | Identifying and supporting vaccine champions in pediatric primary care: a qualitative interview study. | Implementation science research identifies clinical champions as instrumental in aligning healthcare professionals' (HCPs) behavior with practice guidelines for delivering health services, including vaccinations. However, we know relatively little about identifying or supporting champions. To characterize who vaccine champions are, what they do, and how to support their work in pediatric primary care. In 2022, we interviewed a purposive sample of peer-nominated or self-identified vaccine champions (n=20) and HCPs who worked with vaccine champions (n=4). We thematically analyzed qualitative data. Vaccine champions' defining characteristics were firsthand primary care experience, whether as providers or nursing staff, and a strong belief in vaccinations as uniquely effective tools for primary prevention. Participants noted these beliefs were "part of the DNA" of specialties like pediatrics and infectious disease, where they perceived champions as especially common. Being "insatiable in their quest for knowledge," champions primarily conceptualized their role as understanding and sharing complex information and performance metric data related to vaccine administration. Champions' role in leading other implementation strategies, such as communication training, was more peripheral. Champions reported that dedicated time and staff support helped them "go above and beyond" to improve vaccination rates. Our findings suggest that vaccine champions can be found among providers and nursing staff with deep clinical experience and commitment to primary prevention through vaccination, including through providing vaccine education to colleagues. Healthcare systems can allocate resources to support champions as educators, while exploring opportunities to extend their role in other implementation strategies to improve vaccination rates. Clinical champions are healthcare professionals who seek to help their colleagues improve the quality of health services, including vaccinations. However, efforts to engage clinical champions are challenged by our limited understanding of these individuals. Thus, we interviewed 24 healthcare professionals from 8 healthcare systems in Wisconsin to explore who vaccine champions are, how they promote vaccination, and how healthcare systems can support them. Our interviewees described vaccine champions as healthcare professionals with direct patient care experience, whether as physicians or nurses, who demonstrated a strong dedication to vaccine promotion primarily through learning and sharing complex vaccine information and data. Having dedicated time was an important support for champions in their efforts to promote vaccination, with champions relying on their colleagues to participate in or assist with those efforts. Interviewees recommended identifying champions through nominations from their colleagues, rather than relying on vaccination rates alone. Healthcare systems may need to provide additional time and staff support to meaningfully engage champions and expand their involvement in other vaccine promotion strategies. |
| 524 | Meghan Brennan | ID | mbbrennan@medicine.wisc.edu | Associations between specialty care and improved outcomes among patients with diabetic foot ulcers. | Specialty care may improve diabetic foot ulcer outcomes. Medically underserved populations receive less specialty care. We aimed to determine the association between specialty care and ulcer progression, major amputation, or death. If a beneficial association is found, increasing access to specialty care might help advance health equity. We retrospectively analyzed a cohort of Wisconsin and Illinois Medicare patients with diabetic foot ulcers (n = 55,409), stratified by ulcer severity (i.e., early stage, osteomyelitis, or gangrene). Within each stratum, we constructed Kaplan-Meier curves for event-free survival, defining events as: ulcer progression, major amputation, or death. Patients were grouped based on whether they received specialty care from at least one of six disciplines: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, and vascular surgery. Multivariate Cox proportional hazard models estimated the association between specialty care and event-free survival, adjusting for sociodemographic factors and comorbidities, and stratifying on ulcer severity. Patients who received specialty care had longer event-free survival compared to those who did not (log-rank p<0.001 for all ulcer severity strata). After adjusting, receipt of specialty care, compared to never, remained associated with improved outcomes for all ulcer severities (early stage adjusted hazard ratio 0.34, 95% CI 0.33-0.35, p<0.001; osteomyelitis aHR 0.22, 95% CI 0.20-0.23, p<0.001; gangrene aHR 0.22, 95% CI 0.20-0.24, p<0.001). Specialty care was associated with longer event-free survivals for patients with diabetic foot ulcers. Increased, equitable access to specialty care might improve diabetic foot ulcer outcomes and disparities. |
| 525 | Meghan Brennan | ID | mbbrennan@medicine.wisc.edu | Next Steps: Studying Diabetic Foot Infections with Next-Generation Molecular Assays. | In 2019, the International Working Group on the Diabetic Foot voiced six concerns regarding the use of molecular microbiology techniques for routine diagnosis of infection complicating diabetic foot ulcers. The purpose of this review is to evaluate contemporary evidence addressing each of these concerns and describe promising avenues for continued development of molecular microbiology assays. Since 2019, the feasibility of conducting metagenomic and metatranscriptomic studies on diabetic foot ulcer samples has been shown. However, these preliminary studies used small samples with concerns for selection bias. We await larger-scale, longitudinal studies, potentially using the recently formed Diabetic Foot Consortium, to identify microbiome profiles associated with infection and patient outcomes. How these results would translate into a clinical diagnostic requires further clarification. High-throughput molecular microbiology techniques are not yet ready for clinical adoption as first-line diagnostics. However, moving from amplicon sequencing to metagenomic and metatranscriptomic studies has the potential to significantly accelerate development of assays that might meaningfully impact patient care. |
| 526 | Meghan Brennan | ID | mbbrennan@medicine.wisc.edu | Executive Summary: Evaluation and Management of Diabetes-related Foot Infections. | |
| 527 | Meghan Brennan | ID | mbbrennan@medicine.wisc.edu | Evaluation and Management of Diabetes-related Foot Infections. | |
| 528 | Meghan Brennan | ID | mbbrennan@medicine.wisc.edu | Association of rurality and identifying as black with receipt of specialty care among patients hospitalized with a diabetic foot ulcer: a Medicare cohort study. | Rural patients with diabetic foot ulcers, especially those identifying as black, face increased risk of major amputation. Specialty care can reduce this risk. However, care disparities might beget outcome disparities. We aimed to determine whether a smaller proportion of rural patients, particularly those identifying as black, receive specialty care compared with the national proportion. This 100% national retrospective cohort examined Medicare beneficiaries hospitalized with diabetic foot ulcers (2013-2014). We report observed differences in specialty care, including: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, or vascular surgery. We used logistic regression to examine possible intersectionality between rurality and race, controlling for sociodemographics, comorbidities, and ulcer severity and including an interaction term between rurality and identifying as black. Overall, 32.15% (n=124 487) of patients hospitalized with a diabetic foot ulcer received specialty care. Among rural patients (n=13 100), the proportion decreased to 29.57%. For patients identifying as black (n=21 649), the proportion was 33.08%. Among rural patients identifying as black (n=1239), 26.23% received specialty care. This was >5 absolute percentage points less than the overall cohort. The adjusted OR for receiving specialty care among rural versus urban patients identifying as black was 0.61 (95% CI 0.53 to 0.71), which was lower than that for rural versus urban patients identifying as white (aOR 0.85, 95% CI 0.80 to 0.89). This metric supported a role for intersectionality between rurality and identifying as black. A smaller proportion of rural patients, particularly those identifying as black, received specialty care when hospitalized with a diabetic foot ulcer compared with the overall cohort. This might contribute to known disparities in major amputations. Future studies are needed to determine causality. |
| 529 | Meghan Brennan | ID | mbbrennan@medicine.wisc.edu | Using the National Institute on Minority Health and Health Disparities framework to better understand disparities in major amputations. | Recently, the United States experienced its first resurgence of major amputations in more than 20 years. Compounding this rise is a longstanding history of disparities. Patients identifying as non-Hispanic Black are twice as likely to lose a limb as those identifying as non-Hispanic White. Those identifying as Latino face a 30% increase. Rural patients are also more likely to undergo major amputations, and the rural-urban disparity is widening. We used the National Institute on Minority Health and Health Disparities framework to better understand these disparities and identify common factors contributing to them. Common factors were abundant and included increased prevalence of diabetes, possible lower rates of foot self-care, transportation barriers to medical appointments, living in disadvantaged neighborhoods, and lack of insurance. Solutions within and outside the health care realm are needed. Health care-specific interventions that embed preventative and ambulatory care services within communities may be particularly high yield. |
| 530 | Meghan Brennan | ID | mbbrennan@medicine.wisc.edu | Regional and racial disparities in major amputation rates among medicare beneficiaries with diabetes: a retrospective study in the southeastern USA. | While rates for non-traumatic lower extremity amputations (LEA) have been declining, concerns exist over disparities. Our objectives are to track major LEA (MLEA) rates over time among Medicare beneficiaries residing in a high diabetes prevalence region in the southeastern USA (the diabetes belt) and surrounding areas. We used Medicare claims files for ~900 000 fee-for-service beneficiaries aged ≥65 years in 2006-2015 to track MLEA rates per 1000 patients with diabetes. We additionally conducted a cross-sectional analysis of data for 2015 to compare regional and racial disparities in major amputation risks after adjusting for demographic, socioeconomic, access-to-care and foot complications and other health factors. The Centers for Disease Control and Prevention defined the diabetes belt as 644 counties across Appalachian and southeastern US counties with high prevalence. MLEA rates were 3.9 per 1000 in the Belt compared with 2.8 in the surrounding counties in 2006 and decreased to 2.3 and 1.6 in 2015. Non-Hispanic black patients had 8.5 and 6.9 MLEAs per 1000 in 2006 and 4.8 and 3.5 in 2015 in the Belt and surrounding counties, respectively, while the rates were similar for non-Hispanic white patients in the two areas. Although amputation rates declined rapidly in both areas, non-Hispanic black patients in the Belt consistently had >3 times higher rates than non-Hispanic whites in the Belt. After adjusting for patient demographics, foot complications and healthcare access, non-Hispanic blacks in the Belt had about twice higher odds of MLEAs compared with non-Hispanic whites in the surrounding areas. Our data show persistent disparities in major amputation rates between the diabetes belt and surrounding counties. Racial disparities were much larger in the Belt. Targeted policies to prevent MLEAs among non-Hispanic black patients are needed to reduce persistent disparities in the Belt. |
| 531 | Meghan Brennan | ID | mbbrennan@medicine.wisc.edu | Effect of health system on the association of rurality and level of disadvantage with receipt of diabetic eye screening. | Rural versus urban disparities have been observed in diabetic eye screening, but whether the level of disadvantage in rural versus urban areas is related to these disparities is unclear. Our goal was to determine the role of level of disadvantage in explaining the effect of health systems on rural and urban disparities in diabetic eye screening. This is a retrospective cohort study using an all-payer, state-wide claims database covering over 75% of Wisconsin residents. We included adults with diabetes (18-75 years old) who had claims billed throughout the baseline (2012-2013) and measurement (2013-2014) years. We performed multivariable regressions to assess factors associated with receipt of diabetic eye screening. The primary exposure was the primary care clinic's combined level of rurality and disadvantage. We adjusted for the health system as well as patient-level variables related to demographics and comorbidities. Health system was defined as an associated group of physicians and/or clinics. A total of 118 707 adults with diabetes from 698 primary care clinics in 143 health systems met the inclusion criteria. Patients from urban underserved clinics were less likely to receive screening than those from rural underserved clinics before adjusting for health system in the model. After adjusting for health system fixed effects, however, the directionality of the relationship between clinic rurality and screening reversed: patients from urban underserved clinics were more likely to receive screening than those from rural underserved clinics. Similar findings were observed for both Medicare and non-Medicare subgroups. The effect of health system on receipt of diabetic eye screening in rural versus urban areas is most pronounced in underserved areas. Health systems, particularly those providing care to urban underserved populations, have an opportunity to increase screening rates by leveraging health system-level interventions to support patients in overcoming barriers from social determinants of health. |
| 532 | Meghan Brennan | ID | mbbrennan@medicine.wisc.edu | Ankle brachial indices and anaerobes: is peripheral arterial disease associated with anaerobic bacteria in diabetic foot ulcers? | Lower extremity amputations from diabetic foot ulcers (DFUs) are rebounding, and new biomarkers that predict wound healing are urgently needed. Anaerobic bacteria have been associated with persistent ulcers and may be a promising biomarker beyond currently recommended vascular assessments. It is unknown whether anaerobic markers are simply a downstream outcome of peripheral arterial disease (PAD) and ischemia, however. Here, we evaluate associations between two measures of anaerobic bacteria-abundance and metabolic activity-and PAD. We built a prospective cohort of 37 patients with baseline ankle brachial index (ABI) results. Anaerobic bacteria were measured in two ways: DNA-based total anaerobic abundance using 16S rRNA gene amplicon sequencing and resulting summed relative abundance, and RNA-based metabolic activity based on bacterial read annotation of metatranscriptomic sequencing. PAD was defined three ways: PAD diagnosis, ABI results, and a dichotomous definition of mild ischemia (versus normal) based on ABI values. Statistical associations between anaerobes and PAD were evaluated using univariate odds ratios (ORs) or Spearman's correlations. Total anaerobe abundance was not significantly associated with PAD diagnosis, ABI results, or mild ischemia (ORPAD = 0.47, 95% CI = 0.023-7.23, p = 0.60; Spearman's correlation coefficientABI = 0.24, p = 0.17; ORmild ischemia = 0.25, 95% CI = 0.005-5.86, p = 0.42). Anaerobic metabolic activity was not significantly associated with PAD diagnosis, ABI results, or mild ischemia (ORPAD = 1.99, 95% CI = 0.17-21.44, p = 0.57; Spearman's correlation coefficientABI = 0.12, p = 0.52; ORmild ischemia = 0.90, 95% CI = 0.03-15.16, p = 0.94). Neither anaerobic abundance nor metabolic activity was strongly associated with our three definitions of PAD. Therefore, anaerobic bacteria may offer additional prognostic value when assessing wound healing potential and should be investigated as potential molecular biomarkers for DFU outcomes. |
| 533 | Blair Golden | HOSP | bpgolden@medicine.wisc.edu | Optimizing better health and care for older adults and their family caregivers: A review of geriatric approaches. | |
| 534 | Blair Golden | HOSP | bpgolden@medicine.wisc.edu | A retrospective cohort study of hospital discharge instructions following delirium episodes. | |
| 535 | Blair Golden | HOSP | bpgolden@medicine.wisc.edu | Partnering is Paramount: Engaging Care Partners to Improve Delirium Identification. | |
| 536 | Blair Golden | HOSP | bpgolden@medicine.wisc.edu | Family Involvement in the Care of Hospitalized Older Adults: Protocol for a Qualitative Evidence Synthesis. | Older adults are frequently hospitalized. Family involvement during these hospitalizations is incompletely characterized in the literature. This study aimed to better understand how families are involved in the care of hospitalized older adults and develop a conceptual model describing the phenomenon of family involvement in the care of hospitalized older adults. We describe the protocol of a qualitative evidence synthesis (QES), a systematic review of qualitative studies. We chose to focus on qualitative studies given the complexity and multifaceted nature of family involvement in care, a type of topic best understood through qualitative inquiry. The protocol describes our process of developing a research question and eligibility criteria for inclusion in our QES based on the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, and Research type) tool. It describes the development of our search strategy, which was used to search MEDLINE (via Ovid), Embase (via Elsevier), PsycINFO (via Ovid), and CINAHL Complete (via EBSCO). Title and abstract screening and full-text screening will occur sequentially. Purposive sampling may be used depending on the volume of studies identified as eligible for inclusion during our screening process. Descriptive data regarding included individual studies will be extracted and summarized in tables. The results from included studies will be synthesized using qualitative methods and used to develop a conceptual model. The conceptual model will be presented to community members via engagement panels for further refinement. As of September 2023, we have assembled a multidisciplinary team including physicians, nurses, health services researchers, a librarian, a social worker, and a health economist. We have finalized our search strategy and executed the search, yielding 8862 total citations. We are currently screening titles and abstracts and anticipate that full-text screening, data extraction, quality appraisal, and synthesis will be completed by summer of 2024. Conceptual model development will then take place with community engagement panels. We anticipate submitting our manuscript for publication in the fall of 2024. This paper describes the protocol for a QES of family involvement in the care of hospitalized older adults. We will use identified themes to create a conceptual model to inform further intervention development and policy change. PROSPERO 465617; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023465617. PRR1-10.2196/53255. |
| 537 | Blair Golden | HOSP | bpgolden@medicine.wisc.edu | Wall-mounted folding chairs to promote resident physician sitting at the hospital bedside. | Sitting at the bedside may improve patient-clinician communication; however, many clinicians do not regularly sit during inpatient encounters. To determine the impact of adding wall-mounted folding chairs inside patient rooms, beyond any impact from a resident education campaign, on the patient-reported frequency of sitting at the bedside by internal medicine resident physicians. Prospective, controlled pre-post trial between 2019 and 2022 (data collection paused 2020-2021 due to COVID-19) at an academic hospital in Baltimore, Maryland. Folding chairs were installed in two of four internal medicine units and educational activities were delivered equally across all units. Patient-reported frequency of sitting at bedside, assessed as means on Likert-type items with 1 being "never" and 5 being "every single time." We also examined the frequency of other patient-reported communication behaviors. Two hundred fifty six and 206 patients enrolled in the pre and post-intervention periods, respectively. The mean frequency of patient-reported sitting by resident physicians increased from 1.8 (SD 1.2) to 2.3 (1.2) on education-only units (absolute difference 0.48 [95% CI: 0.21-0.75]) and from 2.0 (1.3) to 3.2 (1.4) on units receiving chairs (1.16, [0.87-1.45]). Comparing differences between groups using ordered logistic regression adjusting for clustering within residents, units with added chairs had greater increases in sitting (odds ratio 2.05 [1.10-3.82]), spending enough time at the bedside (2.43 [1.32-4.49]), and checking for understanding (3.04 [1.44-6.39]). Improvements in sitting and other behaviors were sustained on both types of units. Adding wall-mounted folding chairs may help promote effective patient-clinician communication. |
| 538 | Blair Golden | HOSP | bpgolden@medicine.wisc.edu | "Nudging" clinicians to communicate more effectively with patients in hospital. | |
| 539 | Blair Golden | HOSP | bpgolden@medicine.wisc.edu | Experiences of in-hospital care among dementia caregivers in the context of high neighborhood-level disadvantage. | Persons living with dementia (PLWD) experience high rates of hospitalization and rehospitalization, exposing them to added risk for adverse outcomes including delirium, hastened cognitive decline, and death. Hospitalizations can also increase family caregiver strain. Despite disparities in care quality surrounding hospitalizations for PLWD, and evidence suggesting that exposure to neighborhood-level disadvantage increases these inequities, experiences with hospitalization among PLWD and family caregivers exposed to greater levels of neighborhood disadvantage are poorly understood. This study examined family caregiver perspectives and experiences of hospitalizations among PLWD in the context of high neighborhood-level disadvantage. We analyzed data from the Stakeholders Understanding of Prevention Protection and Opportunities to Reduce HospiTalizations (SUPPORT) study, an in-depth, multisite qualitative study examining hospitalization and rehospitalization of PLWD in the context of high neighborhood disadvantage, to identify caregiver perspectives and experiences of in-hospital care. Data were analyzed using rapid identification of themes; duplicate transcript review was used to enhance rigor. Data from N = 54 individuals (47 individual interviews, 2 focus groups with 7 individuals) were analyzed. Sixty-three percent of participants identified as Black/African American, 35% as non-Hispanic White, and 2% declined to report. Caregivers' experiences were largely characterized by PLWD receiving suboptimal care that caregivers viewed as influenced by system pressures and inadequate workforce competencies, leading to communication breakdowns and strain. Caregivers described poor collaboration between clinicians and caregivers with regard to in-hospital care delivery, including transitional care. Caregivers also highlighted the lack of person-focused care and the exclusion of the PLWD from care. Caregiver perspectives highlight opportunities for improving hospital care for PLWD in the context of neighborhood disadvantage and recognition of broader issues in care structure that limit their capacity to be actively involved in care. Further work should examine and develop strategies to improve caregiver integration during hospitalizations across diverse contexts. |
| 540 | Blair Golden | HOSP | bpgolden@medicine.wisc.edu | Disparities in 30-day readmission rates among Medicare enrollees with dementia. | Readmissions contribute to excessive care costs and burden for people living with dementia. Assessments of racial disparities in readmissions among dementia populations are lacking, and the role of social and geographic risk factors such as individual-level exposure to greater neighborhood disadvantage is poorly understood. We examined the association between race and 30-day readmissions in a nationally representative sample of Black and non-Hispanic White individuals with dementia diagnoses. This retrospective cohort study used 100% Medicare fee-for-service claims from all 2014 hospitalizations nationwide among Medicare enrollees with dementia diagnosis linked to patient, stay, and hospital factors. The sample consisted of 1,523,142 hospital stays among 945,481 beneficiaries. The relationship between all cause 30-day readmissions and the explanatory variable of self-reported race (Black, non-Hispanic White) was examined via generalized estimating equations approach adjusting for patient, stay, and hospital-level characteristics to model 30-day readmission odds. Black Medicare beneficiaries had 37% higher readmission odds compared to White beneficiaries (unadjusted OR 1.37, CI 1.35-1.39). This heightened readmission risk persisted after adjusting for geographic factors (OR 1.33, CI 1.31-1.34), social factors (OR 1.25, CI 1.23-1.27), hospital characteristics (OR 1.24, CI 1.23-1.26), stay-level factors (OR 1.22, CI 1.21-1.24), demographics (OR 1.21, CI 1.19-1.23), and comorbidities (OR 1.16, CI 1.14-1.17), suggesting racially-patterned disparities in care account for a portion of observed differences. Associations varied by individual-level exposure to neighborhood disadvantage such that the protective effect of living in a less disadvantaged neighborhood was associated with reduced readmissions for White but not Black beneficiaries. Conversely, among White beneficiaries, exposure to the most disadvantaged neighborhoods associated with greater readmission rates compared to White beneficiaries residing in less disadvantaged contexts. There are significant racial and geographic disparities in 30-day readmission rates among Medicare beneficiaries with dementia diagnoses. Findings suggest distinct mechanisms underlying observed disparities differentially influence various subpopulations. |
| 541 | Blair Golden | HOSP | bpgolden@medicine.wisc.edu | Adapting and Testing the Care Partner Hospital Assessment Tool for Use in Dementia Care: Protocol for a 2 Sequential Phase Study. | Research and policy demonstrate the value of and need for systematically identifying and preparing care partners for their caregiving responsibilities while their family member or friend living with dementia is hospitalized. The Care Partner Hospital Assessment Tool (CHAT) has undergone content and face validation and has been endorsed as appropriate by clinicians to facilitate the timely identification and preparation of care partners of older adult patients during their hospitalization. However, the CHAT has not yet been adapted or prospectively evaluated for use with care partners of hospitalized people living with dementia. Adapting and testing the CHAT via a pilot study will provide the necessary evidence to optimize feasibility and enable future efficacy trials. The purpose of this paper is to describe the study protocol for the adaptation and testing of the CHAT for use among care partners of hospitalized people living with dementia to better prepare them for their caregiving responsibilities after hospital discharge. Our protocol is based on the National Institutes of Health Stage Model and consists of 2 sequential phases, including formative research and the main trial. In phase 1, we will use a participatory human-centered design process that incorporates people living with dementia and their care partners, health care administrators, and clinicians to adapt the CHAT for dementia care (ie, the Dementia CHAT [D-CHAT]; stage IA). In phase 2, we will partner with a large academic medical system to complete a pilot randomized controlled trial to examine the feasibility and estimate the size of the effect of the D-CHAT on care partners' preparedness for caregiving (stage IB). We anticipate this study to take approximately 60 months to complete, from study start-up procedures to dissemination. The 2 phases will take place between December 1, 2022, and November 30, 2027. The study protocol will yield (1) a converged-upon, ready-for-feasibility testing D-CHAT; (2) descriptive and feasibility characteristics of delivering the D-CHAT; and (3) effect size estimates of the D-CHAT on care partner preparedness. We anticipate that the resultant D-CHAT will provide clinicians with guidance on how to identify and better prepare care partners for hospitalized people living with dementia. In turn, care partners will feel equipped to fulfill caregiving roles for their family members or friends living with dementia. The expected results of this study are to favorably impact hospital-based care processes and outcomes for people living with dementia and their care partners and to elucidate the essential caregiving role that so many care partners of people living with dementia assume. ClinicalTrials.gov NCT05592366; https://clinicaltrials.gov/ct2/show/NCT05592366. PRR1-10.2196/46808. |
| 542 | Blair Golden | HOSP | bpgolden@medicine.wisc.edu | A survey study of delirium attitudes and knowledge among hospital medicine clinicians. | |
| 543 | Farah Kaiksow | HOSP | fkaiksow@medicine.wisc.edu | Measuring the association between diagnostic errors and neighborhood disadvantage. | Patients who reside in areas of high neighborhood disadvantage have poorer health outcomes; the mechanisms for this disparity are complex. We sought to determine if there was an association between neighborhood disadvantage and diagnostic error among a cohort of adult inpatients who experienced either an ICU transfer or in-hospital death. Using a sample of 527 patients from seven geographically diverse academic medical systems, we compared diagnostic error rates to patients' neighborhood disadvantage levels as measured by the Area Deprivation Index, a validated composite measure of socioeconomic status. In contrast to previous studies that found differences in hospital care based on socioeconomic status, we found no difference in diagnostic error rate between patients based on neighborhood disadvantage. Once a patient reaches the hospital, their risk of diagnostic error is not related to the neighborhood in which they live. |
| 544 | Farah Kaiksow | HOSP | fkaiksow@medicine.wisc.edu | Diagnostic delay: lessons learnt from marginalised voices. | |
| 545 | Farah Kaiksow | HOSP | fkaiksow@medicine.wisc.edu | A beginner's guide to manuscript publication: Getting your paper across the finish line. | |
| 546 | Farah Kaiksow | HOSP | fkaiksow@medicine.wisc.edu | A retrospective cohort study of hospital discharge instructions following delirium episodes. | |
| 547 | Farah Kaiksow | HOSP | fkaiksow@medicine.wisc.edu | Partnering is Paramount: Engaging Care Partners to Improve Delirium Identification. | |
| 548 | Farah Kaiksow | HOSP | fkaiksow@medicine.wisc.edu | Continuity for medical students in the hospital setting: A work in progress. | |
| 549 | Farah Kaiksow | HOSP | fkaiksow@medicine.wisc.edu | Cervical Cancer and a History of Incarceration: Examining a Social Determinant of Health. | Females who are incarcerated are disproportionately burdened by cancer, particularly cervical cancer. We measured the odds of cervical cancer compared with nonscreenable cancers for females who were incarcerated before diagnosis. By comparing a cancer for which screening and vaccination are available with cancers for which neither are available, we aimed to assess the relationship of incarceration with diseases for which preventive care mitigates risk. We created a novel data set combining cancer data from a large cancer center with incarceration data from the state department of corrections. We then estimated the odds of cervical cancer relative to nonscreenable cancers for those with and without a history of incarceration. Females with a history of incarceration had greater odds of being diagnosed with cervical cancer compared with nonscreenable cancers (odds ratio = 7.04; 95% confidence interval [CI]: 4.4-11.0) relative to those who had not been incarcerated. Adjusting for race and age, the odds of cervical cancer remained significantly greater for those with a history of incarceration (adjusted odds ratio = 3.86; 95% CI: 2.3-6.3). Our findings support the need for expanded cervical cancer screening and vaccination opportunities for incarcerated females and increased access to preventive health care after release. |
| 550 | Farah Kaiksow | HOSP | fkaiksow@medicine.wisc.edu | Hospital care while incarcerated: A tale of two policies. | |
| 551 | Farah Kaiksow | HOSP | fkaiksow@medicine.wisc.edu | Hospitalized While Incarcerated: Incarceration-Specific Care Practices. | |
| 552 | Farah Kaiksow | HOSP | fkaiksow@medicine.wisc.edu | Experiences of in-hospital care among dementia caregivers in the context of high neighborhood-level disadvantage. | Persons living with dementia (PLWD) experience high rates of hospitalization and rehospitalization, exposing them to added risk for adverse outcomes including delirium, hastened cognitive decline, and death. Hospitalizations can also increase family caregiver strain. Despite disparities in care quality surrounding hospitalizations for PLWD, and evidence suggesting that exposure to neighborhood-level disadvantage increases these inequities, experiences with hospitalization among PLWD and family caregivers exposed to greater levels of neighborhood disadvantage are poorly understood. This study examined family caregiver perspectives and experiences of hospitalizations among PLWD in the context of high neighborhood-level disadvantage. We analyzed data from the Stakeholders Understanding of Prevention Protection and Opportunities to Reduce HospiTalizations (SUPPORT) study, an in-depth, multisite qualitative study examining hospitalization and rehospitalization of PLWD in the context of high neighborhood disadvantage, to identify caregiver perspectives and experiences of in-hospital care. Data were analyzed using rapid identification of themes; duplicate transcript review was used to enhance rigor. Data from N = 54 individuals (47 individual interviews, 2 focus groups with 7 individuals) were analyzed. Sixty-three percent of participants identified as Black/African American, 35% as non-Hispanic White, and 2% declined to report. Caregivers' experiences were largely characterized by PLWD receiving suboptimal care that caregivers viewed as influenced by system pressures and inadequate workforce competencies, leading to communication breakdowns and strain. Caregivers described poor collaboration between clinicians and caregivers with regard to in-hospital care delivery, including transitional care. Caregivers also highlighted the lack of person-focused care and the exclusion of the PLWD from care. Caregiver perspectives highlight opportunities for improving hospital care for PLWD in the context of neighborhood disadvantage and recognition of broader issues in care structure that limit their capacity to be actively involved in care. Further work should examine and develop strategies to improve caregiver integration during hospitalizations across diverse contexts. |
| 553 | Mark Micek | GIM | mamicek@medicine.wisc.edu | More Tethered to the EHR: EHR Workload Trends Among Academic Primary Care Physicians, 2019-2023. | The purpose of this study is to evaluate recent trends in primary care physician (PCP) electronic health record (EHR) workload. This longitudinal study observed the EHR use of 141 academic PCPs over 4 years (May 2019 to March 2023). Ambulatory full-time equivalency (aFTE), visit volume, and panel size were evaluated. Electronic health record time and inbox message volume were measured per 8 hours of scheduled clinic appointments. From the pre-COVID-19 pandemic year (May 2019 to February 2020) to the most recent study year (April 2022 to March 2023), the average time PCPs spent in the EHR per 8 hours of scheduled clinic appointments increased (+28.4 minutes, 7.8%), as did time in orders (+23.1 minutes, 58.9%), inbox (+14.0 minutes, 24.4%), chart review (+7.2 minutes, 13.0%), notes (+2.9 minutes, 2.3%), outside scheduled hours on days with scheduled appointments (+6.4 minutes, 8.2%), and on unscheduled days (+13.6 minutes, 19.9%). Primary care physicians received more patient medical advice requests (+5.4 messages, 55.5%) and prescription messages (+2.3, 19.5%) per 8 hours of scheduled clinic appointments, but fewer patient calls (-2.8, -10.5%) and results messages (-0.3, -2.7%). While total time in the EHR continued to increase in the final study year (+7.7 minutes, 2.0%), inbox time decreased slightly from the year prior (-2.2 minutes, -3.0%). Primary care physicians' average aFTE decreased 5.2% from 0.66 to 0.63 over 4 years. Primary care physicians' time in the EHR continues to grow. While PCPs' inbox time may be stabilizing, it is still substantially higher than pre-pandemic levels. It is imperative health systems develop strategies to change the EHR workload trajectory to minimize PCPs' occupational stress and mitigate unnecessary reductions in effective physician workforce resulting from the increased EHR burden. |
| 554 | Mark Micek | GIM | mamicek@medicine.wisc.edu | Association of Primary Care Physicians' Ambulatory Full-time Equivalencies With Time in the Electronic Health Record. | This cross-sectional study examines whether primary care physicians (PCPs) in the clinic part-time have reduced electronic health record (EHR) time commensurate with their clinical hours. |
| 555 | Mark Micek | GIM | mamicek@medicine.wisc.edu | Refining Vendor-Defined Measures to Accurately Quantify EHR Workload Outside Time Scheduled With Patients. | Accurately quantifying clinician time spent on electronic health record (EHR) activities outside the time scheduled with patients is critical for understanding occupational stress associated with ambulatory clinic environments. We make 3 recommendations regarding EHR workload measures that are intended to capture time working in the EHR outside time scheduled with patients, formally defined as work outside of work (WOW): (1) separate all time working in the EHR outside of time scheduled with patients from time working in the EHR during time scheduled with patients, (2) do not exclude any time before or after scheduled time with patients, and (3) encourage the EHR vendor and research communities to develop and standardize validated, vendor-agnostic methods for measuring active EHR use. Attributing all EHR work outside time scheduled with patients to WOW, regardless of when it occurs, will produce an objective and standardized measure better suited for use in efforts to reduce burnout, set policy, and facilitate research. |
| 556 | Mark Micek | GIM | mamicek@medicine.wisc.edu | Gender Differences in Primary Care Physicians' Electronic Health Record Use over Time: an Observational Study. | |
| 557 | Mark Micek | GIM | mamicek@medicine.wisc.edu | Primary Care Patients' and Staff's Perceptions of Self-Rooming as Alternative to Waiting Rooms. | Most patients are escorted to exam rooms (escorted rooming) although patients directing themselves to their exam room (self-rooming) saves patient and staff time while increasing patient satisfaction. This study assesses patient and staff perceptions after pragmatic implementation of self-rooming. In October-December 2020, we surveyed patients and staff in 25 primary care clinics after our institution expanded self-rooming from 4 specially built clinics during the COVID-19 pandemic. Semi-structured surveys asked about rooming process used, rooming process preferred, and perceptions of self-rooming compared with escorted rooming. Most patients (n = 1,561) preferred self-rooming (86%), especially among patients aged <65 years and in family medicine clinics. Few patients felt less welcomed (10.6%), less cared about (6.8%), more isolated (15.6%), more lost/confused (7.6%), or more frustrated (3.2%) with self-rooming compared with escorted rooming. Early-adopter clinics that implemented self-rooming ≤2016 had even lower rates of patients feeling more isolated, lost/confused, or frustrated with self-rooming compared with escorted rooming.Over one-half of staff (n = 241; 180 clinical, 61 nonclinical) preferred self-rooming (59%) and thought most patients liked self-rooming (65.8%), especially among clinical staff and in early adopter clinics (≤2016). Few staff reported worse waiting times for patients (12.4%), medical assistants (MAs) (15.9%), and clinicians (16.4%) or worse crowding in waiting areas (1.7%) and hallways (10.1%). Unlike patient-reported confusion (7.6%), most staff thought self-rooming led to more patient confusion (63.8%), except in early-adopter clinics (44.4%). Self-rooming is a patient-centered innovation that is also acceptable to staff. We demonstrated that pragmatic implementation is feasible across primary care without expensive technology or specially designed buildings. |
| 558 | Mark Micek | GIM | mamicek@medicine.wisc.edu | Does a Change in Physician Compensation Lead to Changes in Care Delivery in Family Medicine Clinics? | Many highly capitated systems still pay physicians based on relative value units (RVU), which may lead to excessive office visits. We reviewed electronic health records from the family medicine clinic panel members of 97 physicians and 42 residents to determine if a change from RVUs to panel-based compensation influenced care delivery as defined by the number of office visits and telephone contacts per panel member per month. A retrospective analysis of the electronic health records of patients seen in 4 residency training clinics, 10 community clinics, and 4 regional clinics was conducted. We assessed face-to-face care delivery and telephone call volume for the clinics individually and for the clinics pooled by clinic type from 1 year before to at least 1 year after the change. Change in physician compensation was not found to have an effect on office visits or telephone calls per panel member per month when pooled by clinic categories. Some significant effects were seen in individual clinics without any clear patterns by clinic size or type. Change in physician compensation was not a key driver of care delivery in family medicine clinics. Understanding changes in care delivery may require looking at a broad array of system, physician, and patient factors. |
| 559 | Mark Micek | GIM | mamicek@medicine.wisc.edu | The effect of remote scribes on primary care physicians' wellness, EHR satisfaction, and EHR use. | Physician burnout is a major problem in the United States. Small studies suggest scribes can improve clinician satisfaction, but scribe programs have not been evaluated using separate control groups or structured measures of electronic health record (EHR) use. We conducted a pre-post, non-randomized controlled evaluation of a remote scribe pilot program introduced in September 2019 in an academic primary care practice. Scribes were paired with physicians via an audio-only cellphone connection to hear and document in real-time. Physician wellness was measured with the 10-item Mini-Z and 16-item Professional Fulfillment Index. EHR use was measured using vendor-derived platforms that provide routine EHR-related data. 37 of 38 scribe users (97.4%) and 68 of 160 potential control physicians (42.5%) completed both pre and post intervention questionnaires. Compared with controls, scribe users had improvements in Mini-Z wellness metrics including Joyful Workplace (mean improvement 2.83, 95%CI 0.60, 5.06) and a single-item dichotomized burnout measure (OR 0.15, 95%CI 0.03, 0.71). There were significant reductions among scribe users compared to controls in total EHR time per 8 scheduled hours (-1.14 h, 95%CI -1.55, -0.72), and an increase in the percentage of orders with team contribution (10.4%, 95%CI 5.2, 15.6). These findings remained significant in adjusted analyses. A remote scribe program was associated with improvements in physician wellness and reduced EHR use. Healthcare organizations can consider scribe programs to help improve wellness among their physician workforce. |
| 560 | Mark Micek | GIM | mamicek@medicine.wisc.edu | Patients' View of Their Primary Care Telemedicine During the COVID-19 Pandemic and Implications for Future Integration: A Multimethod Study. | Telemedicine has become an integral part of primary care since the COVID-19 pandemic. This paper reports patients' assessments of their early telemedicine visits. Adult primary care patients who had a telemedicine visit were identified from electronic medical records of a large Midwestern health system and randomly invited to participate in semistructured interviews. Participants compared telemedicine visits (audio and video) to face-to-face visits on measures of satisfaction and answered open-ended questions about the technology, primary care relationships, and ongoing use of telemedicine. Interviews were recorded and responses transcribed for qualitative analysis. The quantitative results revealed participants valued convenience and judged telemedicine visits "about the same" as office visits on satisfaction measures. Participants were largely willing to have another telemedicine visit but were concerned with the technological challenges and lack of physical examination. The qualitative analysis found most participants reported that telemedicine care was best with a known clinician. Further, they judged telemedicine to be best for follow-ups and simple or single problems and believed it should be balanced with face-to-face visits. Participants expect telemedicine will continue and have clearly articulated their telemedicine preferences. These preferences include telemedicine with a known clinician, the visits that they judged most appropriate for telemedicine, the need to balance telemedicine with face-to-face visits, and assured technologic access. The need for quality measures beyond patient satisfaction and the role of team-based telemedicine care emerged as areas for further research. |
| 561 | Mark Micek | GIM | mamicek@medicine.wisc.edu | Organizational strategies to reduce physician burnout and improve professional fulfillment. | Burnout is highly prevalent among physicians and has been associated with negative outcomes for physicians, patients, staff, and health-care organizations. Reducing physician burnout and increasing physician well-being is a priority. Systematic reviews suggest that organization-based interventions are more effective in reducing physician burnout than interventions targeted at individual physicians. This consensus review by leaders in the field across multiple institutions presents emerging trends and exemplary evidence-based strategies to improve professional fulfillment and reduce physician burnout using Stanford's tripartite model of physician professional fulfillment as an organizing framework: practice efficiency, culture, and personal resilience to support physician well-being. These strategies include leadership traits, latitude of control and autonomy, collegiality, diversity, teamwork, top-of-license workflows, electronic health record (EHR) usability, peer support, confidential mental health services, work-life integration and reducing barriers to practicing a healthy lifestyle. The review concludes with evidence-based recommendations on establishing an effective physician wellness program. |
| 562 | Mark Micek | GIM | mamicek@medicine.wisc.edu | Cancer Survivorship Care Plan Utilization and Impact on Clinical Decision-Making at Point-of-Care Visits with Primary Care: Results from an Engineering, Primary Care, and Oncology Collaborative for Survivorship Health. | Every cancer survivor and his/her primary care provider should receive an individualized survivorship care plan (SCP) following curative treatment. Little is known regarding point-of-care utilization at primary care visits. We assessed SCP utilization in the clinical context of primary care visits. Primary care physicians and advanced practice providers (APPs) who had seen survivors following provision of an SCP were identified. Eligible primary care physicians and APPs were sent an online survey, evaluating SCP utilization and influence on decision-making at the point-of-care, accompanied by copies of the survivor's SCP and the clinic note. Eighty-eight primary care physicians and APPs were surveyed November 2016, with 40 (45%) responding. Most respondents (60%) reported discussing cancer or related issues during the visit. Information needed included treatment (66%) and follow-up visits, and the cancer team was responsible for (58%) vs primary care (58%). Respondents acquired this information by asking the patient (79%), checking oncology notes (75%), the SCP (17%), or online resources (8%). Barriers to SCP use included being unaware of the SCP (73%), difficulty locating it (30%), and finding needed information faster via another mechanism (15%). Despite largely not using the SCP for the visit (90%), most respondents (61%) believed one would be quite or very helpful for future visits. Most primary care visits included discussion of cancer or cancer-related issues. SCPs may provide the information necessary to deliver optimal survivor care but efforts are needed to reduce barriers and design SCPs for primary care use. |
| 563 | Nicole Rogus-Pulia | GERI | npulia@wisc.edu | Safety and toxicity of Iopofosine I 131 (CLR 131) with external beam radiation therapy in recurrent or metastatic head and neck cancer: results of a phase 1 single-centre, open-label, single-arm, dose escalation and dose expansion study. | Re-irradiation of recurrent head and neck cancer (HNC) is often limited by tumour adherence to critical structures and/or radiation tolerance of critical normal tissues. Iopofosine I 131 (CLR 131) is a targeted small molecular phospholipid ether (PLE) drug conjugate that delivers iodine-131 selectively to tumour cells. We conducted a phase 1, single-centre, open-label study to determine whether CLR 131 given with reduced dose of external beam radiation therapy (EBRT) would be tolerable and feasible. All participants received previous curative intent treatment with radiotherapy as primary or adjuvant treatment. Eligible participants demonstrated uptake of CLR 131 as indicated via single photon emission CT/CT (SPECT/CT) imaging following CLR 131 test dose. Participants received two therapeutic doses of CLR 131 (days 1 and 8) with SPECT/CT imaging performed to quantitate the biodistribution of CLR 131. Participants subsequently received EBRT to achieve the designated radiation dose (60-70 Gy). The primary endpoint was safety. This trial was registered with ClinicalTrials.gov, NCT04105543, and enrolment and follow-up are complete. Twelve participants completed treatment with CLR 131 and EBRT. Eight participants experienced grade 4 non-DLT haematologic toxicities (2 anaemia, 8 leukopenia, 5 thrombocytopenia) at least probably attributed to CLR 131, consistent with the expected toxicity profile. Haematologic toxicities occurred during weeks 6-8 from the first dose of CLR 131 and resolved within three weeks without sequelae. There were no treatment-related grade 3-4 non-haematologic toxicities. CLR 131 in combination with EBRT did not confer any safety concerns, and was tolerable in participants with recurrent/metastatic HNC. Myelosuppression was consistent with the known toxicity profile of CLR 131. National Institutes of HealthP50 DE026787, National Cancer InstituteP30 CA014520, National Institutes of Health1UL1TR002373, Cellectar, NCT04105543. |
| 564 | Nicole Rogus-Pulia | GERI | npulia@wisc.edu | Dysphagia Is an Underrecognized Risk Factor for Viral Pneumonia Severity. | The aim of this study was to examine the role of pre-existing dysphagia as a risk factor for COVID-19 severity among adults ≥50 years of age presenting to the emergency department (ED). This was a retrospective cohort study that used electronic health record data from two Midwestern EDs in the same health care system. The sample included patients ≥50 years of age who tested positive for SARS-COV-2 during an ED visit between March 15, 2020 and November 19, 2020. Patients were dichotomized based on documented history of dysphagia. The primary outcome was the highest World Health Organization COVID-19 clinical severity score within 30-days of ED arrival. Patients with a score of <4 were classified as non-severe whereas a score ≥4 was considered severe. Chi-square tests were used to assess differences in clinical severity scores between patients with and without dysphagia. A logistic regression model was created to estimate the odds of a severe COVID-19 clinical score. The sample included 126 patients without dysphagia and 40 patients with dysphagia. Patients with a history of dysphagia were more likely to develop severe COVID-19 disease compared to patients without (65.0% vs. 41.3%, p = 0.015). In multivariable analysis, patients with preexisting dysphagia (OR 2.38, 95% CI: 1.05-5.42; p = 0.038) and diabetes (OR 2.42 95% CI: 1.15-5.30; p = 0.021) had significantly increased odds of developing severe COVID-19. This study showed that a pre-existing diagnosis of dysphagia was independently associated with COVID-19 severity in adults ≥50 years of age. |
| 565 | Nicole Rogus-Pulia | GERI | npulia@wisc.edu | Oropharyngeal Dysphagia in Hospitalized Older Adults with Dementia: A Prospective Cohort Study. | Oropharyngeal dysphagia (dysphagia) is highly prevalent (up to 86%) in hospitalized patients with Alzheimer disease and related dementias (ADRD). This study aims to describe the management and clinical course of dysphagia in hospitalized patients with ADRD. Prospective observational cohort study. The study was conducted across 10 hospitals within a large health system in New York. Participants were older adults with ADRD admitted to the medicine service and diagnosed with dysphagia to liquids on speech-language pathologist (SLP) assessment and were recruited between January and June 2023. Baseline characteristics [eg, dementia Functional Assessment Staging Tool (FAST)], dysphagia management (eg, prescribed diet), and clinical course (eg, dysphagia improvement, respiratory complications) were collected. Of patients with ADRD and dysphagia (n = 62), the average age was 86.5 and 66.1% were FAST Stage 7. On admission, 48.4% had pneumonia, 79.0% had delirium, and 69.4% were made nil per os (NPO) for aspiration risk. Of those who received SLP reassessment after diet initiation (n = 25), 76% demonstrated dysphagia improvement; 75% of patients with FAST stage 7 demonstrated improvement. Respiratory complications occurred in 21.0% of patients on the following diets: NPO, nasogastric tube feeding, dysphagia diets, and comfort feeds. In univariate analyses, hospital-acquired dehydration, no dysphagia improvement, and delirium were associated with respiratory complications. The potential for dysphagia improvement in hospitalized patients with ADRD (even those with advanced dementia) highlights the critical need for standardizing reassessment. Further studies are needed to evaluate factors associated with respiratory complications in this population. |
| 566 | Nicole Rogus-Pulia | GERI | npulia@wisc.edu | A Proposed Framework for Rigor and Transparency in Dysphagia Research: Prologue. | Scientific transparency and rigor are essential for the successful translation of knowledge in clinical research. However, the field of oropharyngeal dysphagia research lacks guidelines for methodological design and reporting, hindering accurate interpretation and replication. This article introduces the Framework for RigOr aNd Transparency In REseaRch on Swallowing (FRONTIERS), a new critical appraisal tool intended to support optimal study design and results reporting. The purpose of introducing FRONTIERS at this early phase is to invite pilot use of the tool and open commentary. FRONTIERS was developed by collaborating researchers and trainees from six international dysphagia research labs. Eight domains were identified, related to study design, swallowing assessment methods, and oropharyngeal dysphagia intervention reporting. Small groups generated questions capturing rigor and transparency for each domain, based on examples from the literature. An iterative consensus process informed the refinement and organization of primary and subquestions, culminating in the current initial version of FRONTIERS. FRONTIERS is a novel tool, intended for use by oropharyngeal dysphagia researchers and research consumers across disciplines. A web application enables provisional use of the tool, and an accompanying survey solicits feedback regarding the framework. FRONTIERS seeks to foster rigor and transparency in the design and reporting of oropharyngeal dysphagia research. We encourage provisional use and invite user feedback. A future expert consensus review is planned to incorporate feedback. By promoting scientific rigor and transparency, we hope that FRONTIERS will support evidence-based practice and contribute to improved health outcomes for individuals with oropharyngeal dysphagia. |
| 567 | Nicole Rogus-Pulia | GERI | npulia@wisc.edu | Exercise-Based Dysphagia Treatment: A Proposed Checklist. | Oropharyngeal swallowing exercise-based interventions are frequently utilized to target physiologic mechanisms with the goal of improving swallowing function. However, study replicability and evidence synthesis regarding effects of interventions are limited due to inconsistent reporting on factors known to influence treatment delivery. In order to promote consistency of reporting factors associated with replicability, the authors constructed a set of preferred parameters focused on dysphagia as part of the initial version of the larger tool (Framework for RigOr aNd Transparency In REseaRch on Swallowing or FRONTIERS). Thirty-eight initial questions were assembled by the authors as part of the treatment subsection. Questions were then reviewed by individuals in the FRONTIERS collaborative who have expertise in research, clinical practice, or both. Twenty-four questions were removed following review, reducing the final set of treatment-focused questions to 14 questions. The revised set of questions provides users of the exercise-based treatment section of the FRONTIERS checklist with an initial checklist to promote transparency and rigor to improve study replicability and evidence synthesis. We intend for this treatment section of FRONTIERS to undergo further refinement following commentary and feedback. |
| 568 | Nicole Rogus-Pulia | GERI | npulia@wisc.edu | Criterion (Concurrent) Validity and Clinical Utility of the Tongueometer Device. | Tongue manometry (i.e., tongue pressure measurement) is a commonly used assessment for patients with suspected oral-motor involvement in swallowing disorders. Availability of lingual manometry has changed in recent years, with the introduction of the Tongueometer device being a more affordable tongue manometry system. The purpose of this study was to test concurrent (criterion) validity of the Tongueometer compared to the current standard reference device, the Iowa Oral Performance Instrument (IOPI). Adults without dysphagia were recruited for participation in this study. Standard lingual measurements (swallowing-related pressures, maximum isometric pressure [MIP], and maximum isometric endurance) were recorded, with the bulb anteriorly placed, with both devices, in a randomized order. The Bland-Altman method was used to determine concurrent (criterion) validity of these measurements compared to the clinical standard IOPI device. A recently available suggested corrective value by Curtis et al. (2023) was also applied, with comparisons made between devices both with and without the Curtis correction. The final sample included 70 adult participants aged 20-89 years (Mage = 52.3 years). Measures with the Tongueometer device were significantly lower when compared with the same measures taken using the IOPI (p < .01) for all measures including MIP, endurance, and swallow pressures. The correction suggested by Curtis and colleagues did not ameliorate these differences. The Tongueometer lingual measurements were consistently lower compared to the IOPI. Clinical use of values taken with the Tongueometer device should be compared to normative data published for each specific device. Available features of each device (e.g., display, bulb texture, technology/application) should be considered when selecting which device to use with an individual patient. |
| 569 | Nicole Rogus-Pulia | GERI | npulia@wisc.edu | Thick Liquids and Clinical Outcomes in Hospitalized Patients With Alzheimer Disease and Related Dementias and Dysphagia. | Oropharyngeal dysphagia is common in hospitalized patients with Alzheimer disease and related dementias (ADRD). Although the use of thick liquids in patients with dysphagia has been shown to reduce aspiration on direct visualization, there is no clear evidence that this practice translates into improved clinical outcomes. To determine whether a diet of thick liquids compared with thin liquids is associated with improved outcomes in hospitalized patients with ADRD and dysphagia. This cohort study included adults aged 65 years and older with ADRD who were admitted to the medicine service across 11 diverse hospitals in New York between January 1, 2017, and September 20, 2022, with clinical suspicion of dysphagia during hospitalization and survival for at least 24 hours after hospital arrival. Patients were grouped according to whether at least 75% of their hospital diet consisted of a thick liquid diet or a thin liquid diet. Propensity score matching was used to balance covariates across the 2 groups for the following covariates: demographics (eg, age, sex), baseline clinical characteristics (eg, Charlson Comorbidity Index), and acute presentation (eg, respiratory diagnosis, illness severity, delirium). Hospital outcomes included mortality (primary outcome), respiratory complications (eg, pneumonia), intubation, and hospital length of stay (LOS). Of 8916 patients with ADRD and dysphagia included in the propensity score matched analysis, the mean (SD) age was 85.7 (8.0) years and 4829 were female (54.2%). A total of 4458 patients receiving a thick liquid diet were matched with 4458 patients receiving a thin liquid diet. There was no significant difference in hospital mortality between the thick liquids and thin liquids groups (hazard ratio, 0.92; 95% CI, 0.75-1.14]; P = .46). Compared with patients receiving thin liquids, patients receiving thick liquids were less likely to be intubated (odds ratio [OR], 0.66; 95% CI, 0.54-0.80), but they were more likely to have respiratory complications (OR, 1.73; 95% CI, 1.56-1.91). This cohort study emphasizes the need for prospective studies that evaluate whether thick liquids are associated with improved clinical outcomes in hospitalized patients with ADRD and dysphagia. |
| 570 | Nicole Rogus-Pulia | GERI | npulia@wisc.edu | Deglutologist Practices and Perceptions of the Penetration-Aspiration Scale: A Survey Study. | Successful dysphagia management requires accurate, succinct diagnosis and characterization of swallowing safety impairments. However, the Penetration-Aspiration Scale (PAS) remains the only available tool developed exclusively for assessment of airway protection. To best support efforts to advance the field's understanding of swallowing safety, it is crucial to understand current clinician practice patterns, perceptions, and accuracy regarding the PAS. A 46-item survey was developed and distributed to deglutologists internationally examining: (1) Demographics; (2) Scale Practices; (3) Swallowing Safety Priorities; (4) Scale Perceptions; and (5) Accuracy. The first four sections consisted of questionnaires. In the optional fifth section, respondents were asked to score five videos of swallows collected via videofluoroscopy and previously PAS-scored by two trained raters. In total, 335 responses were analyzed. The majority of respondents self-reported PAS training (84%); 90% of untrained respondents were receptive to training. Respondents reported using the PAS "always" (40%) or "frequently" (29%), and that the PAS carries "a great deal of" weight in assessment (40%). Reported application of the PAS was heterogeneous, with the most common approach being "single worst score per unique presentation" (45%). Most respondents (64%) prioritized a parameter not captured by the PAS. Untrained respondents were significantly more confident with PAS ratings than trained respondents (X2 = 7.47; p = 0.006). Of 1460 PAS ratings provided, 364 of them were accurate (25%) when compared to ratings by trained lab members. Results of this survey reflect ubiquitous use of the PAS, unmet needs for assessment of swallowing safety, low accuracy despite generally high confidence, and heterogenous training that does not correspond to confidence. This emphasizes the need for additional training in clinical application of the PAS as well as development of novel metrics to optimize assessments of swallowing safety. |
| 571 | Nicole Rogus-Pulia | GERI | npulia@wisc.edu | Accuracy of Dysphagia Screening by Non-clinical Research Staff in the Emergency Department. | Although the emergency department (ED) is the initial care setting for the majority of older adults requiring hospital admission, there is a paucity of ED-based dysphagia research in this at-risk population. This is driven by barriers to dysphagia evaluation in this complex care environment. Therefore, we assessed the reliability of trained, non-clinical ED research staff in administering dysphagia screening tools compared to trained speech pathologists (SLPs). We also aimed to determine perceptual screening discrepancies (e.g. voice change) between clinical and non-clinical staff. Forty-two older adults with suspected pneumonia were recruited during an ED visit and underwent dysphagia (Toronto Bedside Swallow Screening Tool; TOR-BSST©) and aspiration (3-oz water swallow test; 3-oz WST) screening by trained non-clinical research staff. Audio-recordings of screenings were re-rated post-hoc by trained, blinded SLPs with discrepancies resolved via consensus. Cohen's kappa (unweighted) revealed moderate agreement in pass/fail ratings between clinical and non-clinical staff for both the TOR-BSST© (k = 0.75) and the 3 oz WST (k = 0.66) corresponding to excellent sensitivity and good specificity for both the TOR-BSST (SN = 94%, SP = 85%) and the 3 oz WST (SN = 90%, SP = 81%). Further analysis of TOR-BSST perceptual parameters revealed that most discrepancies between clinicians and non-clinicians resulted from over-diagnosis of change in vocal quality (53%). These results support the feasibility of non-clinical research staff administering screening tools for dysphagia and aspiration in the ED. Dysphagia screening may not necessitate clinical staff involvement, which may improve feasibility of large-scale ED research. Future training of research staff should focus on perceptual assessment of vocal quality. |
| 572 | Nicole Rogus-Pulia | GERI | npulia@wisc.edu | Ready for Discharge, but Are They Ready to Go Home? Examining Neighborhood-Level Disadvantage as a Marker of the Social Exposome and the Swallowing Care Process in a Retrospective Cohort of Inpatients With Dementia. | Socioeconomically disadvantaged areas are more resource poor, impacting adherence to swallowing care recommendations. Neighborhood-level disadvantage metrics, such as the Area Deprivation Index (ADI), allow for examination of social determinants of health (SDOH) in a precise region. We examined ADI in a cohort of persons living with dementia (PLWD) to determine representation of those residing in areas of socioeconomic disadvantage (high ADI), distribution of swallowing care provided, and frequency of SDOH-related counseling or resource linking prior to discharge. A retrospective chart abstraction was performed for all inpatients with a diagnosis of dementia (N = 204) seen by the Swallow Service at a large academic hospital in 2014. State ADI Deciles 1 (least) to 10 (most socioeconomic disadvantage) and decile groups (1-3, 4-7, and 8-10) were compared with the surrounding county. Frequency of videofluoroscopic swallowing evaluations (VFSEs) based on ADI deciles was recorded. To determine whether SDOH-related counseling or resource linking occurred for those in high ADI (8-10) neighborhoods, speech-language pathology notes, and discharge summaries were reviewed. Descriptive statistics, independent samples t tests, and one-way analysis of variance were calculated. ADI was significantly higher in this cohort (M = 3.84, SD = 2.58) than in the surrounding county (M = 2.79, SD = 1.88, p = .000). There was no significant difference in utilization of swallowing services across decile groups (p = .88). Although the majority (85%) in high ADI areas was recommended diet modifications or alternative nutrition likely requiring extra resources, there was no documentation indicating that additional SDOH resource linking or counseling was provided. These findings raise important questions about the role and responsibility of speech-language pathologists in tailoring swallowing services to challenges posed by the lived environment, particularly in socioeconomically disadvantaged areas. This underscores the need for further research to understand and address gaps in postdischarge support for PLWD in high-ADI regions and advocate for more equitable provision of swallowing care. |
| 573 | Eduard Vasilevskis | HOSP | vasilevski@medicine.wisc.edu | Selective serotonin/serotonin-norepinephrine reuptake inhibitor serum concentrations' association with delirium duration. | |
| 574 | Eduard Vasilevskis | HOSP | vasilevski@medicine.wisc.edu | Days Not at Home: Association of Vulnerability with Healthcare Utilization After Hospitalization for Heart Failure. | Heart failure (HF) hospitalizations are characterized by vulnerability in functioning and frequent post-discharge healthcare utilization in both acute and post-acute settings. To determine, in patients hospitalized for decompensated HF, the association of vulnerability with (1) detailed forms of post-discharge healthcare utilization, and (2) days spent away from home after initial hospital discharge. Secondary analysis of a prospective longitudinal cohort study from a single-center academic institution in the USA. Adults admitted with acute decompensated HF who were discharged alive. The Vulnerable Elders Survey 13 (VES-13) measured functional vulnerability at baseline. The primary outcome was the Highest Healthcare Utilization (HHU) 90 days post-discharge, from the following ordered categories: at home, emergency room visit, skilled nursing facility stay, hospital readmission, or death. The secondary outcome was the proportion of days not at home (DNAH) within the first 90 days. Analyses were performed using a partial proportional odds model with adjustment for demographics and health characteristics. A total of 806 patients were included with median age 65, interquartile range [IQR] 55-73 years. Fewer than half (N = 345 [43%]) of patients remained alive and at home during 90-day follow-up. There were 286 [35%] hospital readmissions and 70 [8.7%] participants died. The median DNAH was 3 [IQR 0-16]. Increased vulnerability was associated with (1) HHU, (2) higher odds of utilizing healthcare or dying versus being at home alive 90 days post-discharge (OR 1.81 [95% CI, 1.35, 2.42]), and (3) higher odds of DNAH in the first 90 days (OR 1.55 [95% CI, 1.27, 1.89]). In this cohort of patients hospitalized for decompensated HF, vulnerability predicted higher levels of healthcare utilization, as well as total days not at home in the 90 days following hospitalization. Vulnerability may have clinical applications to identify patients at greatest need for comprehensive, patient-centered discharge planning. |
| 575 | Eduard Vasilevskis | HOSP | vasilevski@medicine.wisc.edu | Patient, Practice, and Organizational Factors Associated With Early Mobility Performance in Critically Ill Adults. | Adoption of early mobility interventions into intensive care unit (ICU) practice has been slow and varied. To examine factors associated with early mobility performance in critically ill adults and evaluate factors' effects on predicting next-day early mobility performance. A secondary analysis of 66 ICUs' data from patients admitted for at least 24 hours. Mixed-effects logistic regression modeling was done, with area under the receiver operating characteristic curve (AUC) calculated. In 12 489 patients, factors independently associated with higher odds of next-day mobility included significant pain (adjusted odds ratio [AOR], 1.16; 95% CI, 1.09-1.23), documented sedation target (AOR, 1.09; 95% CI, 1.01-1.18), performance of spontaneous awakening trials (AOR, 1.77; 95% CI, 1.59-1.96), spontaneous breathing trials (AOR, 2.35; 95% CI, 2.14-2.58), mobility safety screening (AOR, 2.26; 95% CI, 2.04-2.49), and prior-day physical/occupational therapy (AOR, 1.44; 95% CI, 1.30-1.59). Factors independently associated with lower odds of next-day mobility included deep sedation (AOR, 0.44; 95% CI, 0.39-0.49), delirium (AOR, 0.63; 95% CI, 0.59-0.69), benzodiazepine administration (AOR, 0.85; 95% CI, 0.79-0.92), physical restraints (AOR, 0.74; 95% CI, 0.68-0.80), and mechanical ventilation (AOR, 0.73; 95% CI, 0.68-0.78). Black and Hispanic patients had lower odds of next-day mobility than other patients. Models incorporating patient, practice, and between-unit variations displayed high discriminant accuracy (AUC, 0.853) in predicting next-day early mobility performance. Collectively, several modifiable and nonmodifiable factors provide excellent prediction of next-day early mobility performance. |
| 576 | Eduard Vasilevskis | HOSP | vasilevski@medicine.wisc.edu | A retrospective cohort study of hospital discharge instructions following delirium episodes. | |
| 577 | Eduard Vasilevskis | HOSP | vasilevski@medicine.wisc.edu | Medication Discrepancies among Older Hospitalized Adults Discharged from Post-Acute Care Facilities to Home. | The epidemiology of medication discrepancies during transitions from post-acute care (PAC) to home is poorly described. We sought to describe the frequency and types of medication discrepancies among hospitalized older adults transitioning from PAC to home. A nested cohort analysis. Included participants enrolled in a patient-centered deprescribing trial, for patients (aged ≥50 years and taking at least 5 medications) transitioning from one of 22 PACs to home. We assessed demographic and medication measures at the initial hospitalization. The primary outcome measure was medication discrepancies, with the PAC discharge list serving as reference for comparison to the participant's self-reported medication list at 7 days following PAC discharge. Discrepancies were categorized as additions, omissions, and dose discrepancies and were organized by common medication classes and risk of harm (eg, 2015 Beers Criteria). Ordinal logistic regression assessed for patient risk factors for PAC discharge discrepancy count. A total of 184 participants had 7-day PAC discharge medication data. Participants were predominately female (67%) and Caucasian (83%) with a median of 16 prehospital medications [interquartile range (IQR) 11, 20]. At the 7-day follow-up, 98% of participants had at least 1 medication discrepancy, with a median number of 7 medication discrepancies (IQR 4, 10) per person, 4 (IQR 2, 6) of which were potentially inappropriate medications as defined by the Beers Criteria. Higher medication discrepancies at index hospital admission and receipt of caregiver assistance with medications were 2 key predictors of medication discrepancies in the week after PAC discharge to home. Older patients transitioning home from a PAC facility are at high risk for medication discrepancies. This study underscores the need for interventions targeted at this overlooked transition period, especially as patients resume responsibility for managing their own medications after both a hospital and PAC stay. |
| 578 | Eduard Vasilevskis | HOSP | vasilevski@medicine.wisc.edu | Emergency department visits and hospital readmissions after a deprescribing intervention among hospitalized older adults. | Deprescribing is the planned/supervised method of dose reduction or cessation of medications that might be harmful, or no longer be beneficial. Though benefits of deprescribing are debatable in improving clinical outcomes, it has been associated with decreased number of potentially inappropriate medications, which may potentially reduce the risk of adverse events among hospitalized older adults. With unclear evidence for deprescribing in this population, this study aimed to examine time-to-first unplanned healthcare utilization, which included 90-day emergency department (ED) visits or hospital readmission and associated predictors, during a deprescribing intervention. A secondary data analysis of a clinical trial (Shed-MEDS NCT02979353) was performed. Cox regression was used to compare the time-to-first 90-day ED visit/readmission/death from hospital discharge for the intervention and control groups. Additionally, we performed exploratory analysis of predictors (comorbidities, functional health status, drug burden index (DBI), hospital length of stay, health literacy, food insecurity, and financial burden) associated with the time-to-first 90-day ED visit/readmission/death. The hazard of first 90-day ED visits/readmissions/death was 15% lower in the intervention versus the control group (95% CI: 0.61-1.19, p = 0.352, respectively); however, this difference was not statistically significant. For every additional number of comorbidities (Hazard ratio (HR): 1.12, 95% CI: 1.04-1.21) and each additional day of hospital length of stay (HR: 1.04, 95% CI: 1.01-1.07) were significantly associated with a higher hazard of 90-day ED visit/readmission/death in the intervention group; whereas for each unit of increase in pre-hospital DBI score (HR: 1.08 and HR 1.16, respectively) was significantly associated with a higher hazard of 90-day ED visit/readmission/death in the control group. The intervention and control groups had comparable time-to-first 90-day ED visit/readmission/death during a deprescribing intervention. This finding suggests that deprescribing did not result in a higher risk of ED visit/readmission/death during the 90-day period following hospital discharge. |
| 579 | Eduard Vasilevskis | HOSP | vasilevski@medicine.wisc.edu | Patient-reported predictors of postdischarge mortality after cardiac hospitalization. | Adults hospitalized for cardiovascular events are at high risk for postdischarge mortality. Screening of psychosocial risk is prioritized by the Joint Commission. We tested whether key patient-reported psychosocial and behavioral measures could predict posthospitalization mortality in a cohort of adults hospitalized for a cardiovascular event. We conducted a prospective cohort study to test the prognostic utility of validated patient-reported measures, including health literacy, social support, health behaviors and disease management, and socioeconomic status. Cox survival analyses of mortality were conducted over a median of 3.5 years. Among 2977 adults hospitalized for either acute coronary syndrome or acute decompensated heart failure, the mean age was 53 years, and 60% were male. After adjusting for demographic, clinical, and other psychosocial factors, mortality risk was greatest among patients who reported being unemployed (hazard ratio [HR]: 1.99, 95% confidence interval [CI]): 1.30-3.06), retired (HR: 2.14, 95% CI: 1.60-2.87), or unable to work due to disability (HR: 2.36, 95% CI: 1.73-3.21), as compared to those who were employed. Patient-reported perceived health competence (PHCS-2) and exercise frequency were also associated with mortality risk after adjusting for all other variables (HR: 0.86, 95% CI: 0.73-1.00 per four-point increase in PHCS-2; HR: 0.86, 95% CI: 0.77-0.96 per 3-day increase in exercise frequency, respectively). Patient-reported measures of employment status, perceived health competence, and exercise frequency independently predict mortality after a cardiac hospitalization. Incorporating these brief, valid measures into hospital-based screening may help with prognostication and targeting patients for resources during post-discharge transitions of care. |
| 580 | Eduard Vasilevskis | HOSP | vasilevski@medicine.wisc.edu | Characterizing hospitalization trajectories in the high-need, high-cost population using electronic health record data. | High utilization by a minority of patients accounts for a large share of health care costs, but the dynamics of this utilization remain poorly understood. We sought to characterize longitudinal trajectories of hospitalization among adult patients at an academic medical center from 2017 to 2023. Among 3404 patients meeting eligibility criteria, following an initial "rising-risk" period of 3 hospitalizations in 6 months, growth mixture modeling discerned 4 clusters of subsequent hospitalization trajectories: no further utilization, low chronic utilization, persistently high utilization with a slow rate of increase, and persistently high utilization with a fast rate of increase. Baseline factors associated with higher-order hospitalization trajectories included admission to a nonsurgical service, full code status, intensive care unit-level care, opioid administration, discharge home, and comorbid cardiovascular disease, end-stage kidney or liver disease, or cancer. Characterizing hospitalization trajectories and their correlates in this manner lays groundwork for early identification of those most likely to become high-need, high-cost patients. |
| 581 | David Andes | ID | dra@medicine.wisc.edu | The distinctive pharmacokinetic profile of rezafungin, a long-acting echinocandin developed in the era of modern pharmacometrics. | Echinocandin drugs are the current first-line therapy for fungal infections caused by Candida spp. Most patients require once-daily intravenous (IV) administration in a hospital or outpatient setting for treatment, which may negatively impact their quality of life and stress healthcare resources. Similar to other echinocandins, the novel FDA-, EMA-, and Medical and Healthcare Products Regulatory Agency-approved echinocandin, rezafungin (CD101), exhibited strong antifungal activity against several fungal pathogens and a low drug-drug interaction liability, which are important for medically complex patients. A pharmacometric-based approach has been adopted throughout the development of rezafungin, which contrasts with older echinocandins where dosing regimens were largely derived empirically, and only recently based on pharmacometric guidance. This state-of-the-art approach used model-based simulations incorporating pre-clinical and clinical data as it became available to optimize the dosing regimen for rezafungin. The enhanced stability of the molecular structure and the safety profile of rezafungin allow for the administration of once-weekly IV doses, compared to the daily dosing requirement for other echinocandin drugs, with this distinctive pharmacokinetic profile of rezafungin resulting in a front-loaded dosing regimen with high exposures early in therapy for enhanced fungal killing. The long shelf-life of rezafungin makes this echinocandin more flexible in terms of storage and manufacturing. Demonstrated across clinical development, rezafungin may provide patients with next-generation first-line antifungal treatment for the treatment of candidaemia and invasive candidiasis. |
| 582 | David Andes | ID | dra@medicine.wisc.edu | Dereplication of Natural Product Antifungals via Liquid Chromatography-Tandem Mass Spectrometry and Chemical Genomics. | Recently expanded reports of multidrug-resistant fungal infections underscore the need to develop new and more efficient methods for antifungal drug discovery. A ubiquitous problem in natural product drug discovery campaigns is the rediscovery of known compounds or their relatives; accordingly, we have integrated Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS) for structural dereplication and Yeast Chemical Genomics for bioprocess evaluation into a screening platform to identify such compounds early in the screening process. We identified 450 fractions inhibiting Candida albicans and the resistant strains of C. auris and C. glabrata among more than 40,000 natural product fractions. LC-MS/MS and chemical genomics were then used to identify those with known chemistry and mechanisms of action. The parallel deployment of these orthogonal methods improved the detection of unwanted compound classes over the methods applied individually. |
| 583 | David Andes | ID | dra@medicine.wisc.edu | Genetic interaction analysis of Candida glabrata transcription factors CST6 and UPC2A in the regulation of respiration and fluconazole susceptibility. | Candida glabrata is the second most common cause of invasive candidiasis and is widely known to have reduced susceptibility to fluconazole relative to many other Candida spp. Upc2A is a transcription factor that regulates ergosterol biosynthesis gene expression under conditions of sterol stress such as azole drug treatment or hypoxia. Through an in vitro microevolution experiment, we found that loss-of-function mutants of the ATF/CREB transcription factor CST6 suppresses the fluconazole hyper-susceptibility of the upc2A∆ mutant. Here, we confirm that the cst6∆ upc2A∆ mutants are resistant to fluconazole but not to hypoxia relative to the upc2A∆ mutant. Sterol analysis of these mutants indicates that this suppression phenotype is not due to restoration of ergosterol levels in the cst6∆ upc2A∆ mutant. Furthermore, increased expression of CDR1, the efflux pump implicated in the vast majority of azole-resistant C. glabrata strains, does not account for the suppression phenotype. Instead, our data suggest that this effect is due in part to increased expression of the adhesin EPA3, which has been shown by others to reduce fluconazole susceptibility in C. glabrata. In addition, we find that loss of both UPC2A and CST6 reduces the expression of mitochondrial and respiratory genes and that this also contributes to the suppression phenotype as well as to the resistance of cst6∆ to fluconazole. These latter data further emphasize the connection between mitochondrial function and azole susceptibility. |
| 584 | David Andes | ID | dra@medicine.wisc.edu | Piperacillin/Tazobactam Susceptibility Test Interpretive Criteria for Enterobacterales: Recommendations From the United States Committee on Antimicrobial Susceptibility Testing. | The in vitro susceptibility testing interpretive criteria (STIC) for piperacillin/tazobactam (TZP) against Enterobacterales were recently updated by the US Food and Drug Administration, Clinical and Laboratory Standards Institute, and European Committee on Antimicrobial Susceptibility Testing. The United States Committee on Antimicrobial Susceptibility Testing (USCAST) also recently reviewed TZP STIC for Enterobacterales and arrived at different STIC for Enterobacterales. Here, we explain our recommendations and rationale behind them. Based on our review of the available data, USCAST does not recommend TZP STIC for certain Enterobacterales species that have a moderate to high likelihood of clinically significant AmpC production (Enterobacter cloacae, Citrobacter freundii, and Klebsiella aerogenes only) or for third-generation cephalosporin-nonsusceptible Enterobacterales. USCAST recommends a TZP susceptibility breakpoint of ≤ 16/4 mg/L for third-generation cephalosporin-susceptible Enterobacterales and only endorses the use of extended infusion TZP regimens for patients with infections due to these pathogens. |
| 585 | David Andes | ID | dra@medicine.wisc.edu | In vivo pharmacodynamic evaluation of the novel nystatin derivative BSG005 in the invasive candidiasis and invasive pulmonary aspergillosis mouse models. | Nystatin, a polyene, is one of the oldest antifungal drugs with wide in vitro potency. BSG005 is a novel, chemically modified, nystatin-like molecule in development for systemic therapy. We evaluated the pharmacokinetic/pharmacodynamic (PK/PD) relationships and target exposures using in vivo invasive pulmonary aspergillosis (IPA) and invasive candidiasis (IC) infection models for BSG005 against common fungal pathogens including Aspergillus fumigatus, Candida albicans, Candida auris, and Candida glabrata. For each species group, three to four strains were selected. Minimum inhibitory concentration (MIC) testing was done by Clinical Laboratory Standards Institute (CLSI) methods. Single-dose kinetics for BSG005 were performed at four dose levels. The immunosuppressed mouse IPA model was used for A. fumigatus studies. For all Candida studies, we utilized the neutropenic disseminated candidiasis model. We used quantitative PCR to enumerate Aspergillus in the lung and colony forming units (CFU) counts for Candida in the kidney. Treatment results were evaluated based on both area under the concentration-time curve (AUC)/MIC and maximum plasma concentration (Cmax)/MIC exposures. The BSG005 MIC was 1 mg/L against all strains. Escalating doses of BSG005 resulted in increased effect and, in general, the dose-response curves within each species were concordant. The median 96-h AUC/MIC associated with net stasis was lowest at 6.08 for C. glabrata. Increasing exposures were needed for same outcome for C. auris at 18.7, C. albicans at 29.3, and A. fumigatus at 102.4. Cmax/MIC targets for the four groups were 0.22, 0.48, 0.60, and 1.41. BSG005 demonstrated potent activity against a variety of fungal pathogens in the neutropenic mouse models. Cmax/MIC PK/PD targets were numerically lower than other polyene studies using the same infection models. |
| 586 | David Andes | ID | dra@medicine.wisc.edu | Analogs of the anti-malaria drug mefloquine have broad-spectrum antifungal activity and are efficacious in a model of disseminated Candida auris infection. | Only three classes of antifungal drugs are currently in clinical use. Here, we report that derivatives of the malarial drug mefloquine have broad-spectrum antifungal activity including difficult-to-treat molds and endemic fungi. Pharmacokinetic and efficacy studies of NSC-4377 indicate that it penetrates the central nervous system and is active against Candida auris in vivo. These data strongly support the further development of mefloquine analogs as a potentially new class of antifungal molecules. |
| 587 | David Andes | ID | dra@medicine.wisc.edu | Large-scale investigation for antimicrobial activity reveals novel defensive species across the healthy skin microbiome. | The human skin microbiome constitutes a dynamic barrier that can impede pathogen invasion by producing antimicrobial natural products. Gene clusters encoding for production of secondary metabolites, biosynthetic gene clusters (BGCs), that are enriched in the human skin microbiome relative to other ecological settings, position this niche as a promising source for new natural product mining. Here, we introduce a new human microbiome isolate collection, the EPithelial Isolate Collection (EPIC). It includes a large phylogenetically diverse set of human skin-derived bacterial strains from eight body sites. This skin collection, consisting of 980 strains is larger and more diverse than existing resources, includes hundreds of rare and low-abundance strains, and hundreds of unique BGCs. Using a large-scale co-culture screen to assess 8,756 pairwise interactions between skin-associated bacteria and potential pathogens, we reveal broad antifungal activity by skin microbiome members. Integrating 287 whole isolate genomes and 268 metagenomes from sampling sites demonstrates that while the distribution of BGC types is stable across body sites, specific gene cluster families (GCFs), each predicted to encode for a distinct secondary metabolite, can substantially vary. Sites that are dry or rarely moist harbor the greatest potential for discovery of novel bioactive metabolites. Among our discoveries are four novel bacterial species, three of which exert significant and broad-spectrum antifungal activity. This comprehensive isolate collection advances our understanding of the skin microbiomes biosynthetic capabilities and pathogen-fighting mechanisms, opening new avenues towards antimicrobial drug discovery and microbiome engineering. |
| 588 | David Andes | ID | dra@medicine.wisc.edu | Analogues of the anti-malaria drug mefloquine have broad spectrum antifungal activity and are efficacious in a model of disseminated Candida auris infection. | Only three classes of antifungal drugs are currently in clinical use. Here, we report that derivatives of the malarial drug mefloquine have broad spectrum antifungal activity including difficult to treat molds and endemic fungi. Pharmacokinetic and efficacy studies of NSC-4377 indicate it penetrates the central nervous system and is active against Candida auris in vivo. These data strongly support the further development of mefloquine analogs as a potentially new class of antifungal molecules. |
| 589 | David Andes | ID | dra@medicine.wisc.edu | Systematic analysis of the Candida albicans kinome reveals environmentally contingent protein kinase-mediated regulation of filamentation and biofilm formation in vitro and in vivo. | Protein kinases are critical regulatory proteins in both prokaryotes and eukaryotes. Accordingly, protein kinases represent a common drug target for a wide range of human diseases. Therefore, understanding protein kinase function in human pathogens such as the fungus Candida albicans is likely to extend our knowledge of its pathobiology and identify new potential therapies. To facilitate the study of C. albicans protein kinases, we constructed a library of 99 non-essential protein kinase homozygous deletion mutants marked with barcodes in the widely used SN genetic background. Here, we describe the construction of this library and the characterization of the competitive fitness of the protein kinase mutants under 11 different growth and stress conditions. We also screened the library for protein kinase mutants with altered filamentation and biofilm formation, two critical virulence traits of C. albicans. An extensive network of protein kinases governs these virulence traits in a manner highly dependent on the specific environmental conditions. Studies on specific protein kinases revealed that (i) the cell wall integrity MAPK pathway plays a condition-dependent role in filament initiation and elongation; (ii) the hyper-osmolar glycerol MAPK pathway is required for both filamentation and biofilm formation, particularly in the setting of in vivo catheter infection; and (iii) Sok1 is dispensable for filamentation in hypoxic environments at the basal level of a biofilm but is required for filamentation in normoxia. In addition to providing a new genetic resource for the community, these observations emphasize the environmentally contingent function of C. albicans protein kinases.IMPORTANCECandida albicans is one of the most common causes of fungal disease in humans for which new therapies are needed. Protein kinases are key regulatory proteins and are increasingly targeted by drugs for the treatment of a wide range of diseases. Understanding protein kinase function in C. albicans pathogenesis may facilitate the development of new antifungal drugs. Here, we describe a new library of 99 protein kinase deletion mutants to facilitate the study of protein kinases. Furthermore, we show that the function of protein kinases in two virulence-related processes, filamentation and biofilm formation, is dependent on the specific environmental conditions. |
| 590 | David Andes | ID | dra@medicine.wisc.edu | Case Commentary: Extending our therapeutic range against multidrug-resistant Candida. | Deep-seated Candida spp. infections may necessitate extended durations of antifungal therapy. Increasing resistance to first-line antifungals threatens the most common options for long-term treatment. In this issue, Ponta et al. (Antimicrob Agents Chemother 68:e00750-24, 2024, https://doi.org/10.1128/aac.00750-24) present cases in which they used rezafungin, a novel long-acting echinocandin antifungal, for extended durations. While excellent clinical evidence supports the short-term safety of rezafungin, these cases demonstrate that rezafungin may additionally have a role in long-term suppressive therapy for antifungal-resistant Candida spp. infections. |
| 591 | Jeniel Nett | ID | jenett@medicine.wisc.edu | Candida auris: Epidemiology and Antifungal Strategy. | Candida auris is a recently emerged fungal pathogen that causes severe infections in healthcare settings around the globe. A feature that distinguishes C. auris from other fungal pathogens is its high capacity to colonize skin, leading to widespread outbreaks in healthcare facilities via patient-to-patient transmission. C. auris can persist on skin or in the surrounding environment for extended periods of time, and it exhibits greater antifungal resistance than other Candida species. These factors pose major obstacles for the prevention and treatment of C. auris infection. Recent reports have identified frequently colonized skin sites, risk factors for developing invasive infection, and patterns of antifungal resistance among C. auris strains, all of which help guide therapeutic options. In this review, we highlight key studies of C. auris epidemiology and antifungal resistance, discussing how these factors influence healthcare-associated transmission and treatment outcomes. |
| 592 | Jeniel Nett | ID | jenett@medicine.wisc.edu | Impact of Micafungin on Candida auris β-glucan Masking and Neutrophil Interactions. | Invasive fungal pathogen Candida auris has become a public health threat causing outbreaks of high mortality infections. Drug resistance often limits treatment options. For Candida albicans, subinhibitory concentrations of echinocandins unmask immunostimulatory β-glucan, augmenting immunity. Here we analyze the impact of echinocandin treatment of C. auris on β-glucan exposure and human neutrophil interactions. We show subinhibitory concentrations lead to minimal glucan unmasking and only subtle influences on neutrophil functions for the isolates belonging to circulating clades. The data suggest that echinocandin treatment will not largely alter phagocytic responses. Glucan masking pathways appear to differ between C. auris and C. albicans. |
| 593 | Jeniel Nett | ID | jenett@medicine.wisc.edu | Innate immune response to Candida auris. | Candida auris, a newly emergent fungal species, has been spreading in health care systems and causing life-threatening infections. Intact innate immunity is essential for protection against many invasive fungal infections, including candidiasis. Here, we highlight recent studies exploring immune interactions with C. auris, including investigations using animal models and ex vivo immune cells. We summarize innate immune studies comparing C. auris and the common fungal pathogen Candida albicans. We also discuss how structures of the C. auris cell wall influence immune recognition, the role of soluble host factors in immune recognition, and areas of future study. |
| 594 | Jeniel Nett | ID | jenett@medicine.wisc.edu | Liposomal formulation of a new antifungal hybrid compound provides protection against Candida auris in the ex vivo skin colonization model. | The newly emerged pathogen, Candida auris, presents a serious threat to public health worldwide. This multidrug-resistant yeast often colonizes and persists on the skin of patients, can easily spread from person to person, and can cause life-threatening systemic infections. New antifungal therapies are therefore urgently needed to limit and control both superficial and systemic C. auris infections. In this study, we designed a novel antifungal agent, PQA-Az-13, that contains a combination of indazole, pyrrolidine, and arylpiperazine scaffolds substituted with a trifluoromethyl moiety. PQA-Az-13 demonstrated antifungal activity against biofilms of a set of 10 different C. auris clinical isolates, representing all four geographical clades distinguished within this species. This compound showed strong activity, with MIC values between 0.67 and 1.25 µg/mL. Cellular proteomics indicated that PQA-Az-13 partially or completely inhibited numerous enzymatic proteins in C. auris biofilms, particularly those involved in both amino acid biosynthesis and metabolism processes, as well as in general energy-producing processes. Due to its hydrophobic nature and limited aqueous solubility, PQA-Az-13 was encapsulated in cationic liposomes composed of soybean phosphatidylcholine (SPC), 1,2-dioleoyloxy-3-trimethylammonium-propane chloride (DOTAP), and N-(carbonyl-methoxypolyethylene glycol-2000)-1,2-distearoyl-sn-glycero-3-phosphoethanolamine, sodium salt (DSPE-PEG 2000), and characterized by biophysical and spectral techniques. These PQA-Az-13-loaded liposomes displayed a mean size of 76.4 nm, a positive charge of +45.0 mV, a high encapsulation efficiency of 97.2%, excellent stability, and no toxicity to normal human dermal fibroblasts. PQA-Az-13 liposomes demonstrated enhanced antifungal activity levels against both C. auris in in vitro biofilms and ex vivo skin colonization models. These initial results suggest that molecules like PQA-Az-13 warrant further study and development. |
| 595 | Jeniel Nett | ID | jenett@medicine.wisc.edu | Candida albicans extracellular vesicles trigger type I IFN signalling via cGAS and STING. | The host type I interferon (IFN) pathway is a major signature of inflammation induced by the human fungal pathogen, Candida albicans. However, the molecular mechanism for activating this pathway in the host defence against C. albicans remains unknown. Here we reveal that mice lacking cyclic GMP-AMP synthase (cGAS)-stimulator of IFN genes (STING) pathway components had improved survival following an intravenous challenge by C. albicans. Biofilm-associated C. albicans DNA packaged in extracellular vesicles triggers the cGAS-STING pathway as determined by induction of interferon-stimulated genes, IFNβ production, and phosphorylation of IFN regulatory factor 3 and TANK-binding kinase 1. Extracellular vesicle-induced activation of type I IFNs was independent of the Dectin-1/Card9 pathway and did not require toll-like receptor 9. Single nucleotide polymorphisms in cGAS and STING potently altered inflammatory cytokine production in human monocytes challenged by C. albicans. These studies provide insights into the early innate immune response induced by a clinically significant fungal pathogen. |
| 596 | Jeniel Nett | ID | jenett@medicine.wisc.edu | Mechanisms of pathogenicity for the emerging fungus Candida auris. | Candida auris recently emerged as an urgent public health threat, causing outbreaks of invasive infections in healthcare settings throughout the world. This fungal pathogen persists on the skin of patients and on abiotic surfaces despite antiseptic and decolonization attempts. The heightened capacity for skin colonization and environmental persistence promotes rapid nosocomial spread. Following skin colonization, C. auris can gain entrance to the bloodstream and deeper tissues, often through a wound or an inserted medical device, such as a catheter. C. auris possesses a variety of virulence traits, including the capacity for biofilm formation, production of adhesins and proteases, and evasion of innate immune responses. In this review, we highlight the interactions of C. auris with the host, emphasizing the intersection of laboratory studies and clinical observations. |
| 597 | Jeniel Nett | ID | jenett@medicine.wisc.edu | The Candida albicans ζ-crystallin homolog Zta1 promotes resistance to oxidative stress. | Candida albicans is an important human pathogen that can cause lethal systemic infections. The ability of C. albicans to colonize and establish infections is closely tied to its highly adaptable nature and capacity to resist various types of stress, including oxidative stress. Previous studies showed that four C. albicans proteins belonging to the flavodoxin-like protein family of quinone reductases are needed for resistance to quinones and virulence. Therefore, in this study, we examined the role of a distinct type of quinone reductase, Zta1, and found that it acts in conjunction with the flavodoxin-like proteins to protect against oxidative stress. |
| 598 | Jeniel Nett | ID | jenett@medicine.wisc.edu | Differential skin immune responses in mice intradermally infected with Candida auris and Candida albicans. | Candida auris is a globally emerging fungal pathogen that transmits among individuals in hospitals and nursing home residents. Unlike other Candida species, C. auris predominantly colonizes and persists in skin tissue, resulting in outbreaks of nosocomial infections. Understanding the factors that regulate C. auris skin colonization is critical to develop novel preventive and therapeutic approaches against this emerging pathogen. We established a model of intradermal C. auris inoculation in mice and found that mice infected with C. auris elicit less potent innate and adaptive immune responses in the infected skin compared to C. albicans. These findings help explain the clinical observation of persistent C. auris colonization in skin tissue. |
| 599 | Jeniel Nett | ID | jenett@medicine.wisc.edu | A Candida auris-specific adhesin, Scf1, governs surface association, colonization, and virulence. | Candida auris is an emerging fungal pathogen responsible for health care-associated outbreaks that arise from persistent surface and skin colonization. We characterized the arsenal of adhesins used by C. auris and discovered an uncharacterized adhesin, Surface Colonization Factor (Scf1), and a conserved adhesin, Iff4109, that are essential for the colonization of inert surfaces and mammalian hosts. SCF1 is apparently specific to C. auris, and its expression mediates adhesion to inert and biological surfaces across isolates from all five clades. Unlike canonical fungal adhesins, which function through hydrophobic interactions, Scf1 relies on exposed cationic residues for surface association. SCF1 is required for C. auris biofilm formation, skin colonization, virulence in systemic infection, and colonization of inserted medical devices. |
| 600 | Jeniel Nett | ID | jenett@medicine.wisc.edu | The Candida albicans ζ-crystallin homolog Zta1 promotes resistance to oxidative stress. | The fungal pathogen Candida albicans is capable of causing lethal infections in humans. Its pathogenic potential is due in part to the ability to resist various stress conditions in the host, including oxidative stress. Recent studies showed that a family of four flavodoxin-like proteins (Pst1, Pst2, Pst3, Ycp4) that function as quinone reductases promotes resistance to oxidation and is needed for virulence. Therefore, in this study Zta1 was examined because it belongs to a structurally distinct family of quinone reductases that are highly conserved in eukaryotes and have been called the ζ-crystallins. The levels of Zta1 in C. albicans rapidly increased after exposure to oxidants, consistent with a role in resisting oxidative stress. Accumulation of reactive oxygen species was significantly higher in cells lacking ZTA1 upon exposure to quinones and other oxidants. Furthermore, deletion of ZTA1 in a mutant lacking the four flavodoxin-like proteins, resulted in further increased susceptibility to quinones, indicating that these distinct quinone reductases work in combination. These results demonstrate that Zta1 contributes to C. albicans survival after exposure to oxidative conditions, which increases the understanding of how C. albicans resists stressful conditions in the host. |
| 601 | Christopher Crnich | ID | cjc@medicine.wisc.edu | Is the BLADDER score the "boost" we need? | |
| 602 | Christopher Crnich | ID | cjc@medicine.wisc.edu | Telemedicine for Prescribing Nirmatrelvir/Ritonavir: Safety, Logistics, and Challenges. | Nirmatrelvir/ritonavir can be a useful COVID-19 treatment but is challenging to prescribe safely because of drug-drug interactions. This study describes our experience prescribing nirmatrelvir/ritonavir within a small interdisciplinary team with a specific focus on management of drug-drug interactions. Ascertaining and communicating modifications of concomitant medications is a key safety element. |
| 603 | Christopher Crnich | ID | cjc@medicine.wisc.edu | Controlling Multidrug-Resistant Organisms Across Patient-Sharing Networks. | |
| 604 | Christopher Crnich | ID | cjc@medicine.wisc.edu | Moving behavioral interventions in nursing homes from planning to action: a work system evaluation of a urinary tract infection toolkit implementation. | Implementation evaluations based on a hybrid deductive-inductive approach provide a detailed understanding of organizational choices to introduce and implement complex interventions and may help explain implementation success or failure. However, such evaluations may not be feasible due to resource constraints. Qualitative analyses of artifacts collected for other purposes during implementation may represent a cost-effective method to understand program implementation when robust evaluations are not feasible. This study used a work systems evaluation of how nursing homes (NHs) implemented a urinary tract infection (UTI) recognition and management improvement toolkit. Thirty NHs participated in a randomized control trial in which intervention NHs (n = 12) were assigned a clinical coach who employed a standard template to structure coach calls with the NH champion. A hybrid inductive-deductive approach, using the Systems Engineering Initiative for Patient Safety (SEIPS) model, characterized three action domains related to (1) engagement of staff and providers, (2) distribution of toolkit elements, and (3) toolkit use. A total of 369 coded segments from 148 coach notes generated by three coaches working with 18 NH champions were examined. Planned changes (n = 203) were more frequent compared to actual changes (n = 169). While most NHs quickly engaged staff and providers, which leadership appeared to support, engagement actions were hindered in some NHs due to champion instability or extended champion or medical director absences. Dissemination of materials to family and providers and distribution of tools to staff occurred quickly in 75% of NHs, although delays were encountered in some NHs, usually because of champion instability. Implementing NH practice change is challenging, and studies examining actions to support planned versus actual change in this setting are limited. The application of the SEIPS model to coach notes collected during the implementation of a structured behavioral intervention to improve the recognition and management of UTI in NHs generated unique insights into the work system and how staff attempted to implement changes. This study identified several factors that interfered with progression from planning to actual change. Future studies are needed to better understand how to best support change interventions in NHs. ClinicalTrials.gov, NCT03520010 , Registered May 9, 2018. |
| 605 | Christopher Crnich | ID | cjc@medicine.wisc.edu | Syndromic Antibiograms and Nursing Home Clinicians' Antibiotic Choices for Urinary Tract Infections. | Empirical antibiotic prescribing in nursing homes (NHs) is often suboptimal. The potential for antibiograms to improve empirical antibiotic decision-making in NHs remains poorly understood. To determine whether providing NH clinicians with a urinary antibiogram improves empirical antibiotic treatment of urinary tract infections (UTIs). This was a survey study using clinical vignettes. Participants were recruited via convenience sampling of professional organization listservs of NH clinicians practicing in the US from December 2021 through April 2022. Data were analyzed from July 2022 to June 2023. Respondents were randomized to complete vignettes using a traditional antibiogram (TA), a weighted-incidence syndromic combination antibiogram (WISCA), or no tool. Participants randomized to antibiogram groups were asked to use the antibiogram to empirically prescribe an antibiotic. Participants randomized to the no tool group functioned as controls. Empirical antibiotic selections were characterized as microbiologically (1) active and (2) optimal according to route of administration and spectrum of activity. Of 317 responses, 298 (95%) were included in the analysis. Duplicate responses (15 participants), location outside the US (2 participants), and uninterpretable responses (2 participants) were excluded. Most respondents were physicians (217 respondents [73%]) and had over 10 years of NH practice experience (155 respondents [52%]). A mixed-effects logistic model found that use of the TA (odds ratio [OR], 1.41; 95% CI, 1.19-1.68; P < .001) and WISCA (OR, 1.54; 95% CI, 1.30-1.84; P < .001) were statistically superior to no tool when choosing an active empirical antibiotic. A similarly constructed model found that use of the TA (OR, 1.94; 95% CI, 1.42-2.66; P < .001) and WISCA (OR, 1.7; 95% CI, 1.24-2.33; P = .003) were statistically superior to no tool when selecting an optimal empirical antibiotic. Although there were differences between tools within specific vignettes, when compared across all vignettes, the TA and WISCA performed similarly for active (OR, 1.09; 95% CI, 0.92-1.30; P = .59) and optimal (OR, 0.87; 95% CI, 0.64-1.20; P = .69) antibiotics. Providing NH clinicians with a urinary antibiogram was associated with selection of active and optimal antibiotics when empirically treating UTIs under simulated conditions. Although the antibiogram format was not associated with decision-making in aggregate, context-specific effects may have been present, supporting further study of syndromic antibiograms in clinical practice. |
| 606 | Christopher Crnich | ID | cjc@medicine.wisc.edu | Implementing and validating a home-infusion central-line-associated bloodstream infection surveillance definition. | Central-line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy is necessary to track efforts to reduce infections, but a standardized, validated, and feasible definition is lacking. We tested the validity of a home-infusion CLABSI surveillance definition and the feasibility and acceptability of its implementation. Mixed-methods study including validation of CLABSI cases and semistructured interviews with staff applying these approaches. This study was conducted in 5 large home-infusion agencies in a CLABSI prevention collaborative across 14 states and the District of Columbia. Staff performing home-infusion CLABSI surveillance. From May 2021 to May 2022, agencies implemented a home-infusion CLABSI surveillance definition, using 3 approaches to secondary bloodstream infections (BSIs): National Healthcare Safety Program (NHSN) criteria, modified NHSN criteria (only applying the 4 most common NHSN-defined secondary BSIs), and all home-infusion-onset bacteremia (HiOB). Data on all positive blood cultures were sent to an infection preventionist for validation. Surveillance staff underwent semistructured interviews focused on their perceptions of the definition 1 and 3-4 months after implementation. Interrater reliability scores overall ranged from κ = 0.65 for the modified NHSN criteria to κ = 0.68 for the NHSN criteria to κ = 0.72 for the HiOB criteria. For the NHSN criteria, the agency-determined rate was 0.21 per 1,000 central-line (CL) days, and the validator-determined rate was 0.20 per 1,000 CL days. Overall, implementing a standardized definition was thought to be a positive change that would be generalizable and feasible though time-consuming and labor intensive. The home-infusion CLABSI surveillance definition was valid and feasible to implement. |
| 607 | Christopher Crnich | ID | cjc@medicine.wisc.edu | Implementation of a Prevention Bundle to Decrease Rates of Staphylococcus aureus Surgical Site Infection at 11 Veterans Affairs Hospitals. | While current evidence has demonstrated a surgical site infection (SSI) prevention bundle consisting of preoperative Staphylococcus aureus screening, nasal and skin decolonization, and use of appropriate perioperative antibiotic based on screening results can decrease rates of SSI caused by S aureus, it is well known that interventions may need to be modified to address facility-level factors. To assess the association between implementation of an SSI prevention bundle allowing for facility discretion regarding specific component interventions and S aureus deep incisional or organ space SSI rates. This quality improvement study was conducted among all patients who underwent coronary artery bypass grafting, cardiac valve replacement, or total joint arthroplasty (TJA) at 11 Veterans Administration hospitals. Implementation of the bundle was on a rolling basis with the earliest implementation occurring in April 2012 and the latest implementation occurring in July 2017. Data were collected from January 2007 to March 2018 and analyzed from October 2020 to June 2023. Nasal screening for S aureus; nasal decolonization of S aureus carriers; chlorhexidine bathing; and appropriate perioperative antibiotic prophylaxis according to S aureus carrier status. Facility discretion regarding how to implement the bundle components was allowed. The primary outcome was deep incisional or organ space SSI caused by S aureus. Multivariable logistic regression with generalized estimating equation (GEE) and interrupted time-series (ITS) models were used to compare SSI rates between preintervention and postintervention periods. Among 6696 cardiac surgical procedures and 16 309 TJAs, 95 S aureus deep incisional or organ space SSIs were detected (25 after cardiac operations and 70 after TJAs). While the GEE model suggested a significant association between the intervention and decreased SSI rates after TJAs (adjusted odds ratio, 0.55; 95% CI, 0.31-0.98), there was not a significant association when an ITS model was used (adjusted incidence rate ratio, 0.88; 95% CI, 0.32-2.39). No significant associations after cardiac operations were found. Although this quality improvement study suggests an association between implementation of an SSI prevention bundle and decreased S aureus deep incisional or organ space SSI rates after TJAs, it was underpowered to see a significant difference when accounting for changes over time. |
| 608 | Christopher Crnich | ID | cjc@medicine.wisc.edu | Antibiotic postprescribing modification opportunities among nursing home residents treated for urinary tract infection. | To characterize opportunities to postprescriptively modify antibiotic prescriptions initiated for treatment of suspected urinary tract infection (UTI) in nursing homes. Cross-sectional cohort study. Data from the health records of residents treated for UTI between 2013 and 2014 in 5 Wisconsin nursing homes were abstracted using a structured approach. Explicit definitions were used to identify whether the prescribed antibiotic could have been stopped, shortened, or changed to a nonfluoroquinolone alternative. Antibiotic treatments appropriately modified by study nursing home providers in real time were not considered modifiable. Identification of >1 potential modification opportunity (eg, stop and shorten) per antibiotic treatment event was permitted. In total, 356 eligible antibiotic treatment courses among 249 unique residents were identified. Only 59 antibiotic courses prescribed for treatment of suspected UTI (16.6%) were not amenable to any modification. Discontinuation of treatment due to lack of signs or symptoms of infection was the most frequently identified potential modification opportunity (66.2%). Although less common, substantial numbers of antibiotic treatment courses were potentially amenable to shortening (34%) or agent change (19%) modifications. If applied in concert at 72 hours after antibiotic initiation, stop and shorten modifications could eradicate up to 1,326 avoidable antibiotic days, and change modifications could remove a 32 remaining avoidable fluoroquinolone days. Substantial opportunity exists to enhance the quality of antibiotic prescribing for treatment of suspected UTI in nursing homes through postprescriptive review interventions. Additional studies examining how to best design and implement postprescriptive review interventions in nursing homes are needed. |
| 609 | Christopher Crnich | ID | cjc@medicine.wisc.edu | Characteristics of telemedicine workflows in nursing homes during the COVID-19 pandemic. | The use of telemedicine increased dramatically in nursing homes (NHs) during the COVID-19 pandemic. However, little is known about the actual process of conducting a telemedicine encounter in NHs. The objective of this study was to identify and document the work processes associated with different types of telemedicine encounters conducted in NHs during the COVID-19 pandemic. A mixed methods convergent study was utilized. The study was conducted in a convenience sample of two NHs that had newly adopted telemedicine during the COVID-19 pandemic. Participants included NH staff and providers involved in telemedicine encounters conducted in the study NHs. The study involved semi-structured interviews and direct observation of telemedicine encounters and post-encounter interviews with staff and providers involved in telemedicine encounters observed by research staff. The semi-structured interviews were structured using the Systems Engineering Initiative for Patient Safety (SEIPS) model to collect information about telemedicine workflows. A structured checklist was utilized to document steps performed during direct observations of telemedicine encounters. Information from interviews and observations informed the creation of a process map of the NH telemedicine encounter. A total of 17 individuals participated in semi-structured interviews. Fifteen unique telemedicine encounters were observed. A total of 18 post-encounter interviews with 7 unique providers (15 interviews in total) and three NH staff were performed. A 9-step process map of the telemedicine encounter, along with two microprocess maps related to encounter preparation and activities within the telemedicine encounter, were created. Six main processes were identified: encounter planning, family or healthcare authority notification, pre-encounter preparation, pre-encounter huddle, conducting the encounter, and post-encounter follow-up. The COVID-19 pandemic changed the delivery of care in NHs and increased reliance on telemedicine services in these facilities. Workflow mapping using the SEIPS model revealed that the NH telemedicine encounter is a complex multi-step process and identified weaknesses related to scheduling, electronic health record interoperability, pre-encounter planning, and post-encounter information exchange, which represent opportunities to improve and enhance the telemedicine encounter process in NHs. Given public acceptance of telemedicine as a care delivery model, expanding the use of telemedicine beyond the COVID-19 pandemic, especially for certain NH telemedicine encounters, could improve quality of care. |
| 610 | Christopher Crnich | ID | cjc@medicine.wisc.edu | An Implementation Roadmap for Establishing Remote Infectious Disease Specialist Support for Consultation and Antibiotic Stewardship in Resource-Limited Settings. | Infectious Disease (ID)-trained specialists, defined as ID pharmacists and ID physicians, improve hospital care by providing consultations to patients with complicated infections and by leading programs that monitor and improve antibiotic prescribing. However, many hospitals and nursing homes lack access to ID specialists. Telehealth is an effective tool to deliver ID specialist expertise to resource-limited settings. Telehealth services are most useful when they are adapted to meet the needs and resources of the local setting. In this step-by-step guide, we describe how a tailored telehealth program can be implemented to provide remote ID specialist support for direct patient consultation and to support local antibiotic stewardship activities. We outline 3 major phases of putting a telehealth program into effect: pre-implementation, implementation, and sustainment. To increase the likelihood of success, we recommend actively involving local leadership and other stakeholders in all aspects of developing, implementing, measuring, and refining programmatic activities. |
| 611 | Nasia Safdar | ID | ns2@medicine.wisc.edu | Examining the implementation of a multi-site evidence-based intervention to reduce fluoroquinolone usage: A qualitative content analysis of staff interviews to identify facilitators and barriers. | Clostridioides difficile infection is the most common healthcare-associated infection, causing almost half a million infections in the United States annually. Inappropriate antibiotic usage is a known risk factor. Antibiotic stewardship efforts aim to optimize prescribing. Evidence supports pre-prescription authorization as a highly effective intervention. A pre-prescription intervention for fluoroquinolone antibiotics via a computerized clinical decision support tool called a "best practice alert" (BPA) embedded in the patient's electronic health records has high potential for improving antibiotic stewardship. However, information is scant about the factors that might impact the uptake and effectiveness of this BPA and other similar evidence-based interventions when spread and adopted across multiple independent sites. Therefore, we utilized the Consolidated Framework for Implementation Research (CFIR) to understand the facilitators and barriers to the implementation process that influence clinical and implementation outcomes. In doing so, we conducted semi-structured interviews with 18 healthcare professionals across four hospitals. Our research team performed a qualitative analysis to understand the contextual factors influencing the implementation outcomes, such as acceptability and sustainability. The following themes highlight the factors affecting the implementation of this healthcare innovation. Designing interventions that are customizable and low maintenance. Maturity level of the Antibiotic Stewardship Program. Implementer's experience/attitudes in implementing healthcare innovations. The ability to prioritize initiatives as the organization responds to unintended circumstances (e.g., COVID). Adapting implementation approaches and strategies as technology spreads. |
| 612 | Nasia Safdar | ID | ns2@medicine.wisc.edu | Veteran patient perceptions of a universal gloving intervention for health care-associated infection prevention: A qualitative study. | Universal gloving by health care workers (HCW) for all patient care activities (beyond isolation and standard precautions) has been proposed to reduce health care-associated infection transmission, but patient perceptions of this approach are unclear. We interviewed patients who experienced a universal gloving intervention by HCW within Veterans Affairs inpatient acute care units to understand their perceptions of universal gloving. We conducted interviews with 15 patients across 5 Veterans Affairs hospitals. We used a rapid qualitative inquiry approach to analyze interview transcripts and identified patient perceptions of universal gloving regarding patient knowledge, patient experience, and HCW practice. Patients were highly supportive of HCW use of universal gloving, noting potential benefits for infection prevention, patient and HCW safety, and patient feelings of well-being and care. Patients also communicated support of universal gloving in the context of the COVID-19 pandemic. Universal gloving by HCW may support patients' feelings of safe and positive health care delivery. Patients' positive perception of gloving may facilitate universal gloving as an infection prevention and control strategy. |
| 613 | Nasia Safdar | ID | ns2@medicine.wisc.edu | Early-life upper airway microbiota are associated with decreased lower respiratory tract infections. | Microbial interactions mediating colonization resistance play key roles within the human microbiome, shaping susceptibility to infection from birth. The role of the nasal and oral microbiome in the context of early life respiratory infections and subsequent allergic disease risk remains understudied. Our aim was to gain insight into microbiome-mediated defenses and respiratory pathogen colonization dynamics within the upper respiratory tract during infancy. We performed shotgun metagenomic sequencing of nasal (n = 229) and oral (n = 210) microbiomes from our Wisconsin Infant Study Cohort at age 24 months and examined the influence of participant demographics and exposure history on microbiome composition. Detection of viral and bacterial respiratory pathogens by RT-PCR and culture-based studies with antibiotic susceptibility testing, respectively, to assess pathogen carriage was performed. Functional bioassays were used to evaluate pathogen inhibition by respiratory tract commensals. Participants with early-life lower respiratory tract infection were more likely to be formula fed, attend day care, and experience wheezing. Composition of the nasal, but not oral, microbiome associated with prior lower respiratory tract infection, namely lower alpha diversity, depletion of Prevotella, and enrichment of Moraxella catarrhalis including drug-resistant strains. Prevotella originating from healthy microbiomes had higher biosynthetic gene cluster abundance and exhibited contact-independent inhibition of M catarrhalis. These results suggest interbacterial competition affects nasal pathogen colonization. This work advances understanding of protective host-microbe interactions occurring in airway microbiomes that alter infection susceptibility in early life. |
| 614 | Nasia Safdar | ID | ns2@medicine.wisc.edu | Mixed-Methods Analysis of Provider-Documented and Patient-Reported Urinary Tract Infection Symptoms Among Veterans With Neurogenic Bladder. | Inappropriate urinary tract infection diagnosis in patients with neurogenic bladder may result from ambiguous symptoms experienced by these patients and contributes to antibiotic overuse. Characterization of patient-reported signs and symptoms may help providers more appropriately diagnose urinary tract infections. A previous study collected signs and symptoms recorded in electronic medical records of patients with neurogenic bladder due to spinal cord injury/disorder, multiple sclerosis, and Parkinson's disease with at least one urinary tract infection diagnosis between 2017-2018 at four medical centers. In this study, 23 veterans from this cohort with urinary tract infection diagnoses in the previous year participated in focus groups conducted May 2021-May 2022. Transcripts were coded using mixed deductive and inductive coding. Qualitative data were compared to electronic medical records data to give a comprehensive picture of signs and symptoms. Both providers and patients attributed nonspecific symptoms like urine changes to urinary tract infection, but there was discordance between patients and providers in the identification of other signs and symptoms. Several patients described providers disregarding symptoms other than fever or chills. Optimizing urinary tract infection care for patients with neurogenic bladder could involve improving patient-provider communication about urinary tract infection signs and symptoms and emphasizing thorough elicitation and evaluation of all signs and symptoms. |
| 615 | Nasia Safdar | ID | ns2@medicine.wisc.edu | Antiviral potential of spirulina in individuals with human immunodeficiency virus or Hepatis C virus infections: A systematic review and meta-analysis. | Spirulina, a cyanobacterium or blue-green algae that contains phycocyanin, nutritional supplementation has been evaluated in patients living with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) due to its antiviral properties. This supplementation may be beneficial in low resource settings when awaiting antiretroviral therapy (ART) for HIV. This review aimed to evaluate the effectiveness of Spirulina supplement in antiviral-naïve HIV- and HCV-infected patients by assessing its immunological effect (Cluster of Differentiation 4 or CD-4 T-cell count) and disease progression (viral load). We searched PubMed, Cochrane Library, Scopus, and Web of Science from inception through January 23, 2024. Two authors independently performed the study selection, data extraction, and risk of bias assessment. We pooled data by using a random-effects model and evaluated publication bias by a funnel plot. We identified 5552 articles, 5509 excluded at the title and abstract stage with 44 studies making it to the full text review. Of these 6 studies met the eligibility for inclusion in the final analysis as follows: 4 randomized controlled trials (RCTs) and 2 non-RCTs. The pooled results of the Spirulina intervention found significant improvements in biomarkers of clinical outcomes, viral load (VL) and CD4 T-cell (CD4) counts, in participants of the treatment group compared to controls; the VL had an overall Cohen's d effect size decrease of -2.49 (-4.80, -0.18) and CD4 had an overall effect size increase of 4.09 (0.75, 7.43). [Cohen's d benchmark: 0.2 = small effect; 0.5 = medium effect; 0.8 = large effect]. Findings from this systematic review showed a potential beneficial effect of Spirulina supplementation in HIV- and HCV-infected patients by increasing CD4 counts and decreasing viral load. However, further research in larger controlled clinical trials is needed to fully investigate the effect of this nutritional supplement on clinically relevant outcomes, opportunities for intervention, optimal dose, and cost-benefit of Spirulina supplementation. |
| 616 | Nasia Safdar | ID | ns2@medicine.wisc.edu | Use of human-centric and participatory design for modifying a daily environmental cleaning checklist: a quality improvement study. | A major tenet of healthcare environmental cleaning focuses on high-touch surfaces (HTSs). HTSs have high rates of contamination, yet cleaning compliance remains low, particularly in patient-occupied rooms. This quality improvement study aimed to use human-centric and participatory design to modify an HTS cleaning checklist and conduct initial trial and evaluation. |
| 617 | Nasia Safdar | ID | ns2@medicine.wisc.edu | Gut microbiota patterns associated with duration of diarrhea in children under five years of age in Ethiopia. | Diarrhea claims >500,000 lives annually among children under five years of age in low- and middle-income countries. Mortality due to acute diarrhea (<7 days' duration) is decreasing, but prolonged (7-13 days) and persistent (≥14 days of duration) diarrhea remains a massive challenge. Here, we use a case-control study to decipher if fecal gut microbiota compositional differences between Ethiopian children with acute (n=554) or prolonged/persistent (n=95) diarrhea and frequency-matched non-diarrheal controls (n=663) are linked to diarrheal etiology. We show that diarrhea cases are associated with lower bacterial diversity and enriched in Escherichia spp., Campylobacter spp., and Streptococcus spp. Further, diarrhea cases are depleted in gut commensals such as Prevotella copri, Faecalibacterium prausnitzii, and Dialister succinatiphilus, with depletion being most pronounced in prolonged/persistent cases, suggesting that prolonged duration of diarrhea is accompanied by depletion of gut commensals and that re-establishing these via e.g., microbiota-directed food supplements offer a potential treatment strategy. |
| 618 | Nasia Safdar | ID | ns2@medicine.wisc.edu | Diverse Sources and Latent Reservoirs of Community-Associated Clostridioides difficile Infection. | Clostridioides difficile (C. difficile) is a spore-forming, toxin-producing, anaerobic bacterium infecting the human gastrointestinal tract, causing diarrhea and life-threatening colitis. C. difficile epidemiology continues to evolve, and it is recognized as a major community-associated pathogen in addition to its established role in causing healthcare-associated infection. While current surveillance and prevention measures mainly focus on healthcare-associated C. difficile infections, much less is known about the factors driving community-associated C. difficile infections. This review highlights the potential contribution of reservoirs, including asymptomatic carriers, to community-associated C. difficile transmission. The reservoirs discussed in this review provide potential avenues for research to better understand and reduce community-associated transmission of C. difficile. |
| 619 | Nasia Safdar | ID | ns2@medicine.wisc.edu | Elucidating human gut microbiota interactions that robustly inhibit diverse Clostridioides difficile strains across different nutrient landscapes. | The human gut pathogen Clostridioides difficile displays substantial inter-strain genetic variability and confronts a changeable nutrient landscape in the gut. We examined how human gut microbiota inter-species interactions influence the growth and toxin production of various C. difficile strains across different nutrient environments. Negative interactions influencing C. difficile growth are prevalent in an environment containing a single highly accessible resource and sparse in an environment containing C. difficile-preferred carbohydrates. C. difficile toxin production displays significant community-context dependent variation and does not trend with growth-mediated inter-species interactions. C. difficile strains exhibit differences in interactions with Clostridium scindens and the ability to compete for proline. Further, C. difficile shows substantial differences in transcriptional profiles in co-culture with C. scindens or Clostridium hiranonis. C. difficile exhibits massive alterations in metabolism and other cellular processes in co-culture with C. hiranonis, reflecting their similar metabolic niches. C. hiranonis uniquely inhibits the growth and toxin production of diverse C. difficile strains across different nutrient environments and robustly ameliorates disease severity in mice. In sum, understanding the impact of C. difficile strain variability and nutrient environments on inter-species interactions could help improve the effectiveness of anti-C. difficile strategies. |
| 620 | Nasia Safdar | ID | ns2@medicine.wisc.edu | Knowledge, perceptions, and beliefs about urinary tract infections in persons with neurogenic bladder and impacts on interventions to promote person-centered care. | Qualitative study. To explore how knowledge, perceptions, and beliefs about urinary tract infections (UTIs) among persons with neurogenic bladder (NB) may impact health behaviors and provider management and enhance person-centeredness of interventions to improve UTI management. Three Veterans Affairs (VA) medical centers. Adults with NB due to spinal cord injury/disorder (SCI/D) or multiple sclerosis (MS) with UTI diagnoses in the prior year participated in focus groups. Transcripts were coded using deductive codes linked to the Health Belief Model and inductive codes informed by grounded theory. Twenty-three Veterans (SCI/D, 78%; MS: 18.5%) participated in discussions. Three themes emerged: (1) UTI knowledge; (2) factors affecting the intervention environment; and (3) factors affecting modes of delivery. Knowledge gaps included UTI prevention, specific symptoms most indicative of UTI, and antibiotic side effects. Poor perceptions of providers lacking knowledge about NB and ineffective patient-provider communication were common in the Emergency Department and non-VA facilities, whereas participants had positive perceptions of home-based care. Participants perceived lower severity and frequency of antibiotic risks compared to UTI risks. Participant preferences for education included caregiver involvement, verbal and written materials, and diverse settings like peer groups. Identifying patient perspectives enhances person-centeredness and allows for novel interventions improving patient knowledge and behaviors about UTIs. Partnering with trusted providers and home-based caregivers and improving NB knowledge and communication in certain care settings were important. Patient education should address mental risk representations and incorporate preferences for content delivery to optimize self-efficacy and strengthen cues to action. |
| 621 | Dawd Siraj | ID | dssiraj@medicine.wisc.edu | Gut microbiota patterns associated with duration of diarrhea in children under five years of age in Ethiopia. | Diarrhea claims >500,000 lives annually among children under five years of age in low- and middle-income countries. Mortality due to acute diarrhea (<7 days' duration) is decreasing, but prolonged (7-13 days) and persistent (≥14 days of duration) diarrhea remains a massive challenge. Here, we use a case-control study to decipher if fecal gut microbiota compositional differences between Ethiopian children with acute (n=554) or prolonged/persistent (n=95) diarrhea and frequency-matched non-diarrheal controls (n=663) are linked to diarrheal etiology. We show that diarrhea cases are associated with lower bacterial diversity and enriched in Escherichia spp., Campylobacter spp., and Streptococcus spp. Further, diarrhea cases are depleted in gut commensals such as Prevotella copri, Faecalibacterium prausnitzii, and Dialister succinatiphilus, with depletion being most pronounced in prolonged/persistent cases, suggesting that prolonged duration of diarrhea is accompanied by depletion of gut commensals and that re-establishing these via e.g., microbiota-directed food supplements offer a potential treatment strategy. |
| 622 | Dawd Siraj | ID | dssiraj@medicine.wisc.edu | Emphasis of Diversity, Equity, and Inclusion on US Adult Infectious Disease Fellowship Program Websites in the Era of Virtual Recruitment. | Women and underrepresented-in-medicine applicants value a climate for diversity when selecting graduate medical education training programs. Climate may not be accurately represented during virtual recruitment. Optimizing program websites may help overcome this barrier. We reviewed websites for adult infectious disease fellowships that participated in the 2022 National Resident Matching Program for emphasis on diversity, equity, and inclusion (DEI). Fewer than half expressed DEI language in their mission statement or had a dedicated DEI statement or webpage. Programs should consider emphasizing their commitment to DEI prominently on their websites, which may help recruit candidates from diverse backgrounds. |
| 623 | Dawd Siraj | ID | dssiraj@medicine.wisc.edu | Idiopathic CD4 Lymphocytopenia at 30 Years. | |
| 624 | Dawd Siraj | ID | dssiraj@medicine.wisc.edu | Risk factors for mortality among hospitalized COVID-19 patients in Northern Ethiopia: A retrospective analysis. | COVID-19 is a deadly pandemic caused by an RNA virus that belongs to the family of CORONA virus. To counter the COVID-19 pandemic in resource limited settings, it is essential to identify the risk factors of COVID-19 mortality. This study was conducted to identify the social and clinical determinants of mortality in COVID-19 patients hospitalized in four treatment centers of Tigray, Northern Ethiopia. We reviewed data from 6,637 COVID-19 positive cases that were reported from May 7, 2020 to October 28, 2020. Among these, 925 were admitted to the treatment centers because of their severity and retrospectively analyzed. The data were entered into STATA 16 version for analysis. The descriptive analysis such as median, interquartile range, frequency distribution and percentage were used. Binary logistic regression model was fitted to identify the potential risk factors of mortality of COVID-19 patients. The adjusted odds ratio (AOR) with 95% confidence interval was used to determine the magnitude of the association between the outcome and predictor variables. The median age of the patients was 30 years (IQR, 25-44) and about 70% were male patients. The patients in the non-survivor group were much older than those in the survivor group (median 57.5 years versus 30 years, p-value < 0.001). The overall case fatality rate was 6.1% (95% CI: 4.5% - 7.6%) and was increased to 40.3% (95% CI: 32.2% - 48.4%) among patients with critical and severe illness. The proportions of severe and critical illness in the non-survivor group were significantly higher than those in the survivor group (19.6% versus 5.1% for severe illness and 80.4% versus 4.5% for critical illness, all p-value < 0.001). One or more pre-existing comorbidities were present in 12.5% of the patients: cardiovascular diseases (42.2%), diabetes mellitus (25.0%) and respiratory diseases (16.4%) being the most common comorbidities. The comorbidity rate in the non-survivor group (44.6%) was higher than in the survivor group (10.5%). The results from the multivariable binary regression showed that the odds of mortality was higher for patients who had cardiovascular diseases (AOR = 2.49, 95% CI: 1.03-6.03), shortness of breath (AOR = 9.71, 95% CI: 4.73-19.93) and body weakness (AOR = 3.04, 95% CI: 1.50-6.18). Moreover, the estimated odds of mortality significantly increased with patient's age. Age, cardiovascular diseases, shortness of breath and body weakness were the predictors for mortality of COVID-19 patients. Knowledge of these could lead to better identification of high risk COVID-19 patients and thus allow prioritization to prevent mortality. |
| 625 | Dawd Siraj | ID | dssiraj@medicine.wisc.edu | The impact of war on the health system of the Tigray region in Ethiopia: a response to complaints. | |
| 626 | Dawd Siraj | ID | dssiraj@medicine.wisc.edu | Botulism outbreak in a rural Ethiopia: a case series. | Foodborne botulism, a toxin-mediated illness caused by Clostridium botulinum, is a public health emergency. Types A, B, and E C. botulinum toxins commonly cause human disease. Outbreaks are often associated with homemade and fermented foods. Botulism is rarely reported in Africa and has never been reported in Ethiopia. In March 2015, a cluster of family members from the Wollega, Oromia region, western Ethiopia presented with a symptom constellation suggestive of probable botulism. Clinical examination, epidemiologic investigation, and subsequent laboratory work identified the cause of the outbreak to be accidental ingestion of botulinum toxin in a traditional chili condiment called "Kochi-kocha," cheese, and clarified butter. Ten out of the fourteen family members who consumed the contaminated products had botulism (attack rate 71.4%) and five died (case fatality rate of 50%). Three of the patients were hospitalized, they presented with altered mental status (n = 2), profound neck and truncal weakness (n = 3), and intact extremity strength despite hyporeflexia (n = 3). The remnant food sample showed botulinum toxin type A with mouse bioassay and C. botulinum type A with culture. Blood drawn on day three of illness from 2/3 (66%) cases was positive for botulinum toxin type-A. Additionally, one of these two cases also had C. botulinum type A cultured from a stool specimen. Two of the cases received Botulism antitoxin (BAT). These are the first confirmed cases of botulism in Ethiopia. The disease occurred due to the consumption of commonly consumed homemade foods. Definite diagnoses of botulism cases are challenging, and detailed epidemiologic and laboratory investigations were critical to the identification of this case series. Improved awareness of botulism risk and improved food preparation and storage may prevent future illnesses. The mortality rate of botulism in resource-limited settings remains high. Countries should make a concerted effort to stockpile antitoxin as that is the easiest and quickest intervention after outbreak detection. |
| 627 | Dawd Siraj | ID | dssiraj@medicine.wisc.edu | Prevalence of antimicrobial resistance and its clinical implications in Ethiopia: a systematic review. | Antimicrobial resistance is one of the major public health challenges in Ethiopia. However, there is no comprehensive summary of existing AMR data in the country. To determine the prevalence of antimicrobial resistance and its clinical implications in Ethiopia. A systematic literature search was performed on the PubMed/Medline database. Original studies on antimicrobial resistance conducted in Ethiopia between 1st January 2009 and 31st July 2019 were included. The outcome measure was the number of isolates resistant to antimicrobial agents in terms of specific pathogens, and disease condition. Data was calculated as total number of resistant isolates relative to the total number of isolates per specific pathogen and medication. A total of 48,021 study participants enrolled from 131 original studies were included resulting in 15,845 isolates tested for antimicrobial resistance. The most common clinical sample sources were urine (28%), ear, nose, and throat discharge collectively (27%), and blood (21%). All the studies were cross-sectional and 83% were conducted in hospital settings. Among Gram-positive bacteria, the reported level of resistance to vancomycin ranged from 8% (Enterococcus species) to 20% (S. aureus). E. coli, K. pneumoniae and P. aeruginosa were the most common Gram-negative pathogens resistant to key antimicrobial agents described in the national standard treatment guideline and were associated with diverse clinical conditions: urinary tract infections, diarrhea, surgical site infections, pneumonia, ocular infections, and middle ear infections. Overall, there is a high prevalence of antimicrobial resistance in Ethiopia. Empirical treatment of bacterial infections needs to be guided by up-to-date national guidelines considering local antimicrobial susceptibility patterns. Equipping diagnostic laboratories with culture and drug susceptibility testing facilities, and establishing a strong antimicrobial stewardship program should be high priorities. |
| 628 | Dawd Siraj | ID | dssiraj@medicine.wisc.edu | Current practices and evaluation of barriers and facilitators to surgical site infection prevention measures in Jimma, Ethiopia. | Surgical site infections (SSIs) greatly burden healthcare systems around the world, particularly in low- and middle-income countries. We sought to employ the Systems Engineering Initiative for Patient Safety (SEIPS) model to better characterize SSI prevention practices and factors affecting adherence to prevention guidelines at Jimma University Medical Center (JUMC). Our cross-sectional study consisted of semistructured interviews designed to elicit perceptions of and barriers and facilitators to SSI prevention among surgical staff and observations of current preoperative, perioperative, and postoperative SSI prevention practices in surgical cases. Interviews were recorded, manually transcribed, and thematically coded within the SEIPS framework. Trained observers recorded compliance with the World Health Organization's SSI prevention recommendations. A tertiary-care hospital in Jimma, Ethiopia. Surgical nurses, surgeons, and anesthetists at JUMC. Within 16 individual and group interviews, participants cited multiple barriers to SSI prevention including shortages of water and antiseptic materials, lack of clear SSI guidelines and training, minimal Infection Prevention Control (IPC) interaction with surgical staff, and poor SSI tracking. Observations from nineteen surgical cases revealed high compliance with antibiotic prophylaxis (94.7%), hand scrubbing (100%), sterile gloves and instrument use (100%), incision site sterilization (100%), and use of surgical safety checklist (94.7%) but lower compliance with preoperative bathing (26.3%), MRSA screening (0%), and pre- and postoperative glucose (0%, 10.5%) and temperature (57.9%, 47.3%) monitoring. Utilizing the SEIPS model helped identify institution-specific barriers and facilitators that can inform targeted interventions to increase compliance with currently underperformed SSI prevention practices at JUMC. |
| 629 | Dawd Siraj | ID | dssiraj@medicine.wisc.edu | The impact of war on the health system of the Tigray region in Ethiopia: an assessment. | The war in Tigray region of Ethiopia that started in November 2020 and is still ongoing has brought enormous damage to the health system. This analysis provides an assessment of the health system before and during the war. Evidence of damage was compiled from November 2020 to June 2021 from various reports by the interim government of Tigray, and also by international non-governmental organisations. Comparison was made with data from the prewar calendar year. Six months into the war, only 30% of hospitals, 17% of health centres, 11.5% of ambulances and none of the 712 health posts were functional. As of June 2021, the population in need of emergency food assistance in Tigray increased from less than one million to over 5.2 million. While the prewar performance of antenatal care, supervised delivery, postnatal care and children vaccination was 64%, 73%, 63% and 73%, respectively, but none of the services were likely to be delivered in the first 90 days of the war. A conservative estimate places the number of girls and women raped in the first 5 months of the war to be 10 000. These data indicate a widespread destruction of livelihoods and a collapse of the healthcare system. The use of hunger and rape as a weapon of war and the targeting of healthcare facilities are key components of the war. To avert worsening conditions, an immediate intervention is needed to deliver food and supplies and rehabilitate the healthcare delivery system and infrastructure. |
| 630 | Dawd Siraj | ID | dssiraj@medicine.wisc.edu | Utilizing the SEIPS model to guide hand hygiene interventions at a tertiary hospital in Ethiopia. | We aimed to apply the Systems Engineering Initiative for Patient Safety (SEIPS) model to increase effectiveness and sustainability of the World Health Organization's (WHOs) hand hygiene (HH) guidelines within healthcare systems. Our cross-sectional, mixed-methods study took place at Jimma University Medical Center (JUMC), a tertiary care hospital in Jimma, Ethiopia, between November 2018 and August 2020 and consisted of three phases: baseline assessment, intervention, and follow-up assessment. We conducted questionnaires addressing HH knowledge and attitudes, interviews to identify HH barriers and facilitators within the SEIPS framework, and observations at the WHO's 5 moments of HH amongst healthcare workers (HCWs) at JUMC. We then implemented HH interventions based on WHO guidelines and results from our baseline assessment. Follow-up HH observations were conducted months later during the Covid-19 pandemic. 250 HCWs completed questionnaires with an average knowledge score of 61.4% and attitude scores indicating agreement that HH promotes patient safety. Interview participants cited multiple barriers to HH including shortages and location of HH materials, inadequate training, minimal Infection Prevention Control team presence, and high workload. We found an overall baseline HH compliance rate of 9.4% and a follow-up compliance rate of 72.1%. Drastically higher follow-up compared to baseline compliance rates were likely impacted by our HH interventions and Covid-19. HCWs showed motivation for patient safety despite low HH knowledge. Utilizing the SEIPS model helped identify institution-specific barriers that informed targeted interventions beyond WHO guidelines aimed at increasing effectiveness and sustainability of HH efforts. |
| 631 | Eric Johannsen | ejohannsen@medicine.wisc.edu | Epstein-Barr virus induces host shutoff extensively via BGLF5-independent mechanisms. | Epstein-Barr virus (EBV) is a ubiquitous oncogenic virus associated with multiple cancers and autoimmune diseases. Unlike most herpesviruses, EBV reactivation from latency occurs asymptomatically, allowing it to spread efficiently to other hosts. However, available models are limited by the inefficient and asynchronous reactivation from latency into lytic replication. To address this problem, we develop a dual-fluorescent lytic reporter (DFLR) EBV that specifically labels cells in the early and late stages of replication. Using lymphoblastoid cell lines transformed by DFLR EBV as a model for EBV reactivation in B cells, we observe extensive reprogramming of the host cell transcriptome during lytic cycle progression. This includes widespread shutoff of host gene expression and disruption of mRNA processing. Unexpectedly, host shutoff remains extensive even in cells infected with DFLR EBV deleted for the BGLF5 nuclease. These findings implicate BGLF5-independent mechanisms as the primary drivers of host transcriptome remodeling during EBV lytic replication. | |
| 632 | Eric Johannsen | ejohannsen@medicine.wisc.edu | Human CD4(+) iNKT cell adoptive immunotherapy induces anti-tumour responses against CD1d-negative EBV-driven B lymphoma. | Invariant natural killer T (iNKT) cells are a conserved population of innate T lymphocytes that are uniquely suitable as off-the-shelf cellular immunotherapies due to their lack of alloreactivity. Two major subpopulations of human iNKT cells have been delineated, a CD4- subset that has a TH1/cytolytic profile, and a CD4+ subset that appears polyfunctional and can produce both regulatory and immunostimulatory cytokines. Whether these two subsets differ in anti-tumour effects is not known. Using live cell imaging, we found that CD4- iNKT cells limited growth of CD1d+ Epstein-Barr virus (EBV)-infected B-lymphoblastoid spheroids in vitro, whereas CD4+ iNKT cells showed little or no direct anti-tumour activity. However, the effects of the two subsets were reversed when we tested them as adoptive immunotherapies in vivo using a xenograft model of EBV-driven human B cell lymphoma. We found that EBV-infected B cells down-regulated CD1d in vivo, and administering CD4- iNKT cells had no discernable impact on tumour mass. In contrast, xenotransplanted mice bearing lymphomas showed rapid reduction in tumour mass after administering CD4+ iNKT cells. Immunotherapeutic CD4+ iNKT cells trafficked to both spleen and tumour and were associated with subsequently enhanced responses of xenotransplanted human T cells against EBV. CD4+ iNKT cells also had adjuvant-like effects on monocyte-derived DCs and promoted antigen-dependent responses of human T cells in vitro. These results show that allogeneic CD4+ iNKT cellular immunotherapy leads to marked anti-tumour activity through indirect pathways that do not require tumour cell CD1d expression and that are associated with enhanced activity of antigen-specific T cells. | |
| 633 | Eric Johannsen | ejohannsen@medicine.wisc.edu | Latent Epstein-Barr virus infection collaborates with Myc over-expression in normal human B cells to induce Burkitt-like Lymphomas in mice. | Epstein-Barr virus (EBV) is an important cause of human lymphomas, including Burkitt lymphoma (BL). EBV+ BLs are driven by Myc translocation and have stringent forms of viral latency that do not express either of the two major EBV oncoproteins, EBNA2 (which mimics Notch signaling) and LMP1 (which activates NF-κB signaling). Suppression of Myc-induced apoptosis, often through mutation of the TP53 (p53) gene or inhibition of pro-apoptotic BCL2L11 (BIM) gene expression, is required for development of Myc-driven BLs. EBV+ BLs contain fewer cellular mutations in apoptotic pathways compared to EBV-negative BLs, suggesting that latent EBV infection inhibits Myc-induced apoptosis. Here we use an EBNA2-deleted EBV virus (ΔEBNA2 EBV) to create the first in vivo model for EBV+ BL-like lymphomas derived from primary human B cells. We show that cord blood B cells infected with both ΔEBNA2 EBV and a Myc-expressing vector proliferate indefinitely on a CD40L/IL21 expressing feeder layer in vitro and cause rapid onset EBV+ BL-like tumors in NSG mice. These LMP1/EBNA2-negative Myc-driven lymphomas have wild type p53 and very low BIM, and express numerous germinal center B cell proteins (including TCF3, BACH2, Myb, CD10, CCDN3, and GCSAM) in the absence of BCL6 expression. Myc-induced activation of Myb mediates expression of many of these BL-associated proteins. We demonstrate that Myc blocks LMP1 expression both by inhibiting expression of cellular factors (STAT3 and Src) that activate LMP1 transcription and by increasing expression of proteins (DNMT3B and UHRF1) known to enhance DNA methylation of the LMP1 promoters in human BLs. These results show that latent EBV infection collaborates with Myc over-expression to induce BL-like human B-cell lymphomas in mice. As NF-κB signaling retards the growth of EBV-negative BLs, Myc-mediated repression of LMP1 may be essential for latent EBV infection and Myc translocation to collaboratively induce human BLs. | |
| 634 | Eric Johannsen | ejohannsen@medicine.wisc.edu | Epstein-Barr virus LMP1 protein promotes proliferation and inhibits differentiation of epithelial cells via activation of YAP and TAZ. | Latent Epstein-Barr virus (EBV) infection promotes undifferentiated nasopharyngeal carcinomas (NPCs) in humans, but the mechanism(s) for this effect has been difficult to study because EBV cannot transform normal epithelial cells in vitro and the EBV genome is often lost when NPC cells are grown in culture. Here we show that the latent EBV protein, LMP1 (Latent membrane protein 1), induces cellular proliferation and inhibits spontaneous differentiation of telomerase-immortalized normal oral keratinocytes (NOKs) in growth factor-deficient conditions by increasing the activity of the Hippo pathway effectors, YAP (Yes-associated protein) and TAZ (Transcriptional coactivator with PDZ-binding motif). We demonstrate that LMP1 enhances YAP and TAZ activity in NOKs both by decreasing Hippo pathway-mediated serine phosphorylation of YAP and TAZ and increasing Src kinase-mediated Y357 phosphorylation of YAP. Furthermore, knockdown of YAP and TAZ is sufficient to reduce proliferation and promote differentiation in EBV-infected NOKs. We find that YAP and TAZ are also required for LMP1-induced epithelial-to-mesenchymal transition. Importantly, we demonstrate that ibrutinib (an FDA-approved BTK inhibitor that blocks YAP and TAZ activity through an off-target effect) restores spontaneous differentiation and inhibits proliferation of EBV-infected NOKs at clinically relevant doses. These results suggest that LMP1-induced YAP and TAZ activity contributes to the development of NPC. | |
| 635 | Eric Johannsen | ejohannsen@medicine.wisc.edu | EBV Reactivation from Latency Is a Degrading Experience for the Host. | During reactivation from latency, gammaherpesviruses radically restructure their host cell to produce virion particles. To achieve this and thwart cellular defenses, they induce rapid degradation of cytoplasmic mRNAs, suppressing host gene expression. In this article, we review mechanisms of shutoff by Epstein-Barr virus (EBV) and other gammaherpesviruses. In EBV, canonical host shutoff is accomplished through the action of the versatile BGLF5 nuclease expressed during lytic reactivation. We explore how BGLF5 induces mRNA degradation, the mechanisms by which specificity is achieved, and the consequences for host gene expression. We also consider non-canonical mechanisms of EBV-induced host shutoff. Finally, we summarize the limitations and barriers to accurate measurements of the EBV host shutoff phenomenon. | |
| 636 | Eric Johannsen | ejohannsen@medicine.wisc.edu | Type 1 and Type 2 Epstein-Barr viruses induce proliferation, and inhibit differentiation, in infected telomerase-immortalized normal oral keratinocytes. | Differentiated epithelial cells are an important source of infectious EBV virions in human saliva, and latent Epstein-Barr virus (EBV) infection is strongly associated with the epithelial cell tumor, nasopharyngeal carcinoma (NPC). However, it has been difficult to model how EBV contributes to NPC, since EBV has not been shown to enhance proliferation of epithelial cells in monolayer culture in vitro and is not stably maintained in epithelial cells without antibiotic selection. In addition, although there are two major types of EBV (type 1 (T1) and type 2 (T2)), it is currently unknown whether T1 and T2 EBV behave differently in epithelial cells. Here we inserted a G418 resistance gene into the T2 EBV strain, AG876, allowing us to compare the phenotypes of T1 Akata virus versus T2 AG876 virus in a telomerase-immortalized normal oral keratinocyte cell line (NOKs) using a variety of different methods, including RNA-seq analysis, proliferation assays, immunoblot analyses, and air-liquid interface culture. We show that both T1 Akata virus infection and T2 AG876 virus infection of NOKs induce cellular proliferation, and inhibit spontaneous differentiation, in comparison to the uninfected cells when cells are grown without supplemental growth factors in monolayer culture. T1 EBV and T2 EBV also have a similar ability to induce epithelial-to-mesenchymal (EMT) transition and activate canonical and non-canonical NF-κB signaling in infected NOKs. In contrast to our recent results in EBV-infected lymphoblastoid cells (in which T2 EBV infection is much more lytic than T1 EBV infection), we find that NOKs infected with T1 and T2 EBV respond similarly to lytic inducing agents such as TPA treatment or differentiation. These results suggest that T1 and T2 EBV have similar phenotypes in infected epithelial cells, with both EBV types enhancing cellular proliferation and inhibiting differentiation when growth factors are limiting. | |
| 637 | Eric Johannsen | ejohannsen@medicine.wisc.edu | Rta is the principal activator of Epstein-Barr virus epithelial lytic transcription. | The transition from latent Epstein-Barr virus (EBV) infection to lytic viral replication is mediated by the viral transcription factors Rta and Zta. Although both are required for virion production, dissecting the specific roles played by Rta and Zta is challenging because they induce each other's expression. To circumvent this, we constructed an EBV mutant deleted for the genes encoding Rta and Zta (BRLF1 and BZLF1, respectively) in the Akata strain BACmid. This mutant, termed EBVΔRZ, was used to infect several epithelial cell lines, including telomerase-immortalized normal oral keratinocytes, a highly physiologic model of EBV epithelial cell infection. Using RNA-seq, we determined the gene expression induced by each viral transactivator. Surprisingly, Zta alone only induced expression of the lytic origin transcripts BHLF1 and LF3. In contrast, Rta activated the majority of EBV early gene transcripts. As expected, Zta and Rta were both required for expression of late gene transcripts. Zta also cooperated with Rta to enhance a subset of early gene transcripts (Rtasynergy transcripts) that Zta was unable to activate when expressed alone. Interestingly, Rta and Zta each cooperatively enhanced the other's binding to EBV early gene promoters, but this effect was not restricted to promoters where synergy was observed. We demonstrate that Zta did not affect Rtasynergy transcript stability, but increased Rtasynergy gene transcription despite having no effect on their transcription when expressed alone. Our results suggest that, at least in epithelial cells, Rta is the dominant transactivator and that Zta functions primarily to support DNA replication and co-activate a subset of early promoters with Rta. This closely parallels the arrangement in KSHV where ORF50 (Rta homolog) is the principal activator of lytic transcription and K8 (Zta homolog) is required for DNA replication at oriLyt. | |
| 638 | Eric Johannsen | ejohannsen@medicine.wisc.edu | Reduced IRF4 expression promotes lytic phenotype in Type 2 EBV-infected B cells. | Humans are infected with two types of EBV (Type 1 (T1) and Type 2 (T2)) that differ substantially in their EBNA2 and EBNA 3A/B/C latency proteins and have different phenotypes in B cells. T1 EBV transforms B cells more efficiently than T2 EBV in vitro, and T2 EBV-infected B cells are more lytic. We previously showed that both increased NFATc1/c2 activity, and an NFAT-binding motif within the BZLF1 immediate-early promoter variant (Zp-V3) contained in all T2 strains, contribute to lytic infection in T2 EBV-infected B cells. Here we compare cellular and viral gene expression in early-passage lymphoblastoid cell lines (LCLs) infected with either T1 or T2 EBV strains. Using bulk RNA-seq, we show that T2 LCLs are readily distinguishable from T1 LCLs, with approximately 600 differentially expressed cellular genes. Gene Set Enrichment Analysis (GSEA) suggests that T2 LCLs have increased B-cell receptor (BCR) signaling, NFAT activation, and enhanced expression of epithelial-mesenchymal-transition-associated genes. T2 LCLs also have decreased RNA and protein expression of a cellular gene required for survival of T1 LCLs, IRF4. In addition to its essential role in plasma cell differentiation, IRF4 decreases BCR signaling. Knock-down of IRF4 in a T1 LCL (infected with the Zp-V3-containing Akata strain) induced lytic reactivation whereas over-expression of IRF4 in Burkitt lymphoma cells inhibited both NFATc1 and NFATc2 expression and lytic EBV reactivation. Single-cell RNA-seq confirmed that T2 LCLs have many more lytic cells compared to T1 LCLs and showed that lytically infected cells have both increased NFATc1, and decreased IRF4, compared to latently infected cells. These studies reveal numerous differences in cellular gene expression in B cells infected with T1 versus T2 EBV and suggest that decreased IRF4 contributes to both the latent and lytic phenotypes in cells with T2 EBV. | |
| 639 | Eric Johannsen | ejohannsen@medicine.wisc.edu | Accurate Quantification of Overlapping Herpesvirus Transcripts from RNA Sequencing Data. | Herpesviruses employ extensive bidirectional transcription of overlapping genes to overcome length constraints on their gene product repertoire. As a consequence, many lytic transcripts cannot be measured individually by reverse transcription-quantitative PCR (RT-qPCR) or conventional RNA sequencing (RNA-seq) analysis. A. G. Bruce, S. Barcy, T. DiMaio, E. Gan, et al. (Pathogens 6:11, 2017, https://doi.org/10.3390/pathogens6010011) have proposed an approximation method using unique coding sequences (UCDS) to estimate lytic gene abundance from Kaposi's sarcoma-associated herpesvirus (KSHV) RNA-seq data. Although UCDS has been widely employed, its accuracy, to our knowledge, has never been rigorously validated for any herpesvirus. In this study, we use cap analysis of gene expression sequencing (CAGE-seq) as a gold-standard to determine the accuracy of UCDS for estimating Epstein-Barr virus (EBV) lytic gene expression levels from RNA-seq data. We also introduce the Unique TranScript (UTS) method, which, like UCDS, estimates transcript abundance from changes in mean RNA-seq read depth. UTS is distinguished by its use of empirically determined 5' and 3' transcript ends rather than coding sequence annotations. Compared to conventional read assignment, both UCDS and UTS improved the accuracy of quantitation of overlapping genes, with UTS giving the most-accurate results. The UTS method discards fewer reads and may be advantageous for experiments with less sequencing depth. UTS is compatible with any aligner and, unlike isoform-aware alignment methods, can be implemented on a laptop computer. Our findings demonstrate that the accuracy achieved by complex and expensive techniques such as CAGE-seq can be approximated using conventional short-read RNA-seq data when read assignment methods address transcript overlap. Although our study focuses on EBV transcription, the UTS method should be applicable across all herpesviruses as well as to other genomes with extensively overlapping transcriptomes. IMPORTANCE Many viruses employ extensively overlapping transcript structures. This complexity makes it difficult to quantify gene expression by using conventional methods, including RNA-seq. Although high-throughput techniques that overcome these limitations exist, they are complex, expensive, and scarce in the herpesvirus literature relative to short-read RNA-seq. Here, using Epstein-Barr virus (EBV) as a model, we demonstrate that conventional RNA-seq analysis methods fail to accurately quantify the abundances of many overlapping transcripts. We further show that the previously described Unique CoDing Sequence (UCDS) method and our Unique TranScript (UTS) method greatly improve the accuracy of EBV lytic gene measurements obtained from RNA-seq data. The UTS method has the advantages of discarding fewer reads and being implementable on a laptop computer. Although this study focuses on EBV, the UCDS and UTS methods should be applicable across herpesviruses and for other viruses that make extensive use of overlapping transcription. | |
| 640 | Eric Johannsen | ejohannsen@medicine.wisc.edu | ΔNp63α promotes Epstein-Barr virus latency in undifferentiated epithelial cells. | Epstein-Barr virus (EBV) is a human herpesvirus that causes infectious mononucleosis and contributes to both B-cell and epithelial-cell malignancies. EBV-infected epithelial cell tumors, including nasopharyngeal carcinoma (NPC), are largely composed of latently infected cells, but the mechanism(s) maintaining viral latency are poorly understood. Expression of the EBV BZLF1 (Z) and BRLF1 (R) encoded immediate-early (IE) proteins induces lytic infection, and these IE proteins activate each other's promoters. ΔNp63α (a p53 family member) is required for proliferation and survival of basal epithelial cells and is over-expressed in NPC tumors. Here we show that ΔNp63α promotes EBV latency by inhibiting activation of the BZLF1 IE promoter (Zp). Furthermore, we find that another p63 gene splice variant, TAp63α, which is expressed in some Burkitt and diffuse large B cell lymphomas, also represses EBV lytic reactivation. We demonstrate that ΔNp63α inhibits the Z promoter indirectly by preventing the ability of other transcription factors, including the viral IE R protein and the cellular KLF4 protein, to activate Zp. Mechanistically, we show that ΔNp63α promotes viral latency in undifferentiated epithelial cells both by enhancing expression of a known Zp repressor protein, c-myc, and by decreasing cellular p38 kinase activity. Furthermore, we find that the ability of cis-platinum chemotherapy to degrade ΔNp63α contributes to the lytic-inducing effect of this agent in EBV-infected epithelial cells. Together these findings demonstrate that the loss of ΔNp63α expression, in conjunction with enhanced expression of differentiation-dependent transcription factors such as BLIMP1 and KLF4, induces lytic EBV reactivation during normal epithelial cell differentiation. Conversely, expression of ΔNp63α in undifferentiated nasopharyngeal carcinoma cells and TAp63α in Burkitt lymphoma promotes EBV latency in these malignancies. | |
| 641 | Shannon Kenney | skenney@wisc.edu | Human CD4(+) iNKT cell adoptive immunotherapy induces anti-tumour responses against CD1d-negative EBV-driven B lymphoma. | Invariant natural killer T (iNKT) cells are a conserved population of innate T lymphocytes that are uniquely suitable as off-the-shelf cellular immunotherapies due to their lack of alloreactivity. Two major subpopulations of human iNKT cells have been delineated, a CD4- subset that has a TH1/cytolytic profile, and a CD4+ subset that appears polyfunctional and can produce both regulatory and immunostimulatory cytokines. Whether these two subsets differ in anti-tumour effects is not known. Using live cell imaging, we found that CD4- iNKT cells limited growth of CD1d+ Epstein-Barr virus (EBV)-infected B-lymphoblastoid spheroids in vitro, whereas CD4+ iNKT cells showed little or no direct anti-tumour activity. However, the effects of the two subsets were reversed when we tested them as adoptive immunotherapies in vivo using a xenograft model of EBV-driven human B cell lymphoma. We found that EBV-infected B cells down-regulated CD1d in vivo, and administering CD4- iNKT cells had no discernable impact on tumour mass. In contrast, xenotransplanted mice bearing lymphomas showed rapid reduction in tumour mass after administering CD4+ iNKT cells. Immunotherapeutic CD4+ iNKT cells trafficked to both spleen and tumour and were associated with subsequently enhanced responses of xenotransplanted human T cells against EBV. CD4+ iNKT cells also had adjuvant-like effects on monocyte-derived DCs and promoted antigen-dependent responses of human T cells in vitro. These results show that allogeneic CD4+ iNKT cellular immunotherapy leads to marked anti-tumour activity through indirect pathways that do not require tumour cell CD1d expression and that are associated with enhanced activity of antigen-specific T cells. | |
| 642 | Shannon Kenney | skenney@wisc.edu | Latent Epstein-Barr virus infection collaborates with Myc over-expression in normal human B cells to induce Burkitt-like Lymphomas in mice. | Epstein-Barr virus (EBV) is an important cause of human lymphomas, including Burkitt lymphoma (BL). EBV+ BLs are driven by Myc translocation and have stringent forms of viral latency that do not express either of the two major EBV oncoproteins, EBNA2 (which mimics Notch signaling) and LMP1 (which activates NF-κB signaling). Suppression of Myc-induced apoptosis, often through mutation of the TP53 (p53) gene or inhibition of pro-apoptotic BCL2L11 (BIM) gene expression, is required for development of Myc-driven BLs. EBV+ BLs contain fewer cellular mutations in apoptotic pathways compared to EBV-negative BLs, suggesting that latent EBV infection inhibits Myc-induced apoptosis. Here we use an EBNA2-deleted EBV virus (ΔEBNA2 EBV) to create the first in vivo model for EBV+ BL-like lymphomas derived from primary human B cells. We show that cord blood B cells infected with both ΔEBNA2 EBV and a Myc-expressing vector proliferate indefinitely on a CD40L/IL21 expressing feeder layer in vitro and cause rapid onset EBV+ BL-like tumors in NSG mice. These LMP1/EBNA2-negative Myc-driven lymphomas have wild type p53 and very low BIM, and express numerous germinal center B cell proteins (including TCF3, BACH2, Myb, CD10, CCDN3, and GCSAM) in the absence of BCL6 expression. Myc-induced activation of Myb mediates expression of many of these BL-associated proteins. We demonstrate that Myc blocks LMP1 expression both by inhibiting expression of cellular factors (STAT3 and Src) that activate LMP1 transcription and by increasing expression of proteins (DNMT3B and UHRF1) known to enhance DNA methylation of the LMP1 promoters in human BLs. These results show that latent EBV infection collaborates with Myc over-expression to induce BL-like human B-cell lymphomas in mice. As NF-κB signaling retards the growth of EBV-negative BLs, Myc-mediated repression of LMP1 may be essential for latent EBV infection and Myc translocation to collaboratively induce human BLs. | |
| 643 | Shannon Kenney | skenney@wisc.edu | Effect of Malaria Infection on Epstein-Barr Virus Persistence in Kenyan Children. | The 2 cofactors in the etiology of Burkitt lymphoma (BL) are Epstein-Barr virus (EBV) and repeated Plasmodium falciparum malaria infections. This study evaluated EBV loads in mucosal and systemic compartments of children with malaria and controls. Age was analyzed as a covariate because immunity to malaria in endemic regions is age dependent. Children (2-10 years) with clinical malaria from Western Kenya and community controls without malaria were enrolled. Saliva and blood samples were collected, EBV viral load was assessed by quantitative polymerase chain reaction, and EpiTYPER MassARRAY was used to assess methylation of 3 different EBV genes. Regardless of the compartment, we detected EBV more frequently in malaria cases compared to controls, although the difference was not significant. When EBV was detected, there were no differences in viral load between cases and controls. However, EBV methylation was significantly lower in the malaria group compared to controls in both plasma and saliva (P < .05), indicating increased EBV lytic replication. In younger children before development of immunity to malaria, there was a significant effect of malaria on EBV load in peripheral blood mononuclear cells (P = .04). These data suggest that malaria can directly modulate EBV persistence in children, increasing their risk for BL. | |
| 644 | Shannon Kenney | skenney@wisc.edu | Epstein-Barr virus LMP1 protein promotes proliferation and inhibits differentiation of epithelial cells via activation of YAP and TAZ. | Latent Epstein-Barr virus (EBV) infection promotes undifferentiated nasopharyngeal carcinomas (NPCs) in humans, but the mechanism(s) for this effect has been difficult to study because EBV cannot transform normal epithelial cells in vitro and the EBV genome is often lost when NPC cells are grown in culture. Here we show that the latent EBV protein, LMP1 (Latent membrane protein 1), induces cellular proliferation and inhibits spontaneous differentiation of telomerase-immortalized normal oral keratinocytes (NOKs) in growth factor-deficient conditions by increasing the activity of the Hippo pathway effectors, YAP (Yes-associated protein) and TAZ (Transcriptional coactivator with PDZ-binding motif). We demonstrate that LMP1 enhances YAP and TAZ activity in NOKs both by decreasing Hippo pathway-mediated serine phosphorylation of YAP and TAZ and increasing Src kinase-mediated Y357 phosphorylation of YAP. Furthermore, knockdown of YAP and TAZ is sufficient to reduce proliferation and promote differentiation in EBV-infected NOKs. We find that YAP and TAZ are also required for LMP1-induced epithelial-to-mesenchymal transition. Importantly, we demonstrate that ibrutinib (an FDA-approved BTK inhibitor that blocks YAP and TAZ activity through an off-target effect) restores spontaneous differentiation and inhibits proliferation of EBV-infected NOKs at clinically relevant doses. These results suggest that LMP1-induced YAP and TAZ activity contributes to the development of NPC. | |
| 645 | Shannon Kenney | skenney@wisc.edu | Type 1 and Type 2 Epstein-Barr viruses induce proliferation, and inhibit differentiation, in infected telomerase-immortalized normal oral keratinocytes. | Differentiated epithelial cells are an important source of infectious EBV virions in human saliva, and latent Epstein-Barr virus (EBV) infection is strongly associated with the epithelial cell tumor, nasopharyngeal carcinoma (NPC). However, it has been difficult to model how EBV contributes to NPC, since EBV has not been shown to enhance proliferation of epithelial cells in monolayer culture in vitro and is not stably maintained in epithelial cells without antibiotic selection. In addition, although there are two major types of EBV (type 1 (T1) and type 2 (T2)), it is currently unknown whether T1 and T2 EBV behave differently in epithelial cells. Here we inserted a G418 resistance gene into the T2 EBV strain, AG876, allowing us to compare the phenotypes of T1 Akata virus versus T2 AG876 virus in a telomerase-immortalized normal oral keratinocyte cell line (NOKs) using a variety of different methods, including RNA-seq analysis, proliferation assays, immunoblot analyses, and air-liquid interface culture. We show that both T1 Akata virus infection and T2 AG876 virus infection of NOKs induce cellular proliferation, and inhibit spontaneous differentiation, in comparison to the uninfected cells when cells are grown without supplemental growth factors in monolayer culture. T1 EBV and T2 EBV also have a similar ability to induce epithelial-to-mesenchymal (EMT) transition and activate canonical and non-canonical NF-κB signaling in infected NOKs. In contrast to our recent results in EBV-infected lymphoblastoid cells (in which T2 EBV infection is much more lytic than T1 EBV infection), we find that NOKs infected with T1 and T2 EBV respond similarly to lytic inducing agents such as TPA treatment or differentiation. These results suggest that T1 and T2 EBV have similar phenotypes in infected epithelial cells, with both EBV types enhancing cellular proliferation and inhibiting differentiation when growth factors are limiting. | |
| 646 | Shannon Kenney | skenney@wisc.edu | Rta is the principal activator of Epstein-Barr virus epithelial lytic transcription. | The transition from latent Epstein-Barr virus (EBV) infection to lytic viral replication is mediated by the viral transcription factors Rta and Zta. Although both are required for virion production, dissecting the specific roles played by Rta and Zta is challenging because they induce each other's expression. To circumvent this, we constructed an EBV mutant deleted for the genes encoding Rta and Zta (BRLF1 and BZLF1, respectively) in the Akata strain BACmid. This mutant, termed EBVΔRZ, was used to infect several epithelial cell lines, including telomerase-immortalized normal oral keratinocytes, a highly physiologic model of EBV epithelial cell infection. Using RNA-seq, we determined the gene expression induced by each viral transactivator. Surprisingly, Zta alone only induced expression of the lytic origin transcripts BHLF1 and LF3. In contrast, Rta activated the majority of EBV early gene transcripts. As expected, Zta and Rta were both required for expression of late gene transcripts. Zta also cooperated with Rta to enhance a subset of early gene transcripts (Rtasynergy transcripts) that Zta was unable to activate when expressed alone. Interestingly, Rta and Zta each cooperatively enhanced the other's binding to EBV early gene promoters, but this effect was not restricted to promoters where synergy was observed. We demonstrate that Zta did not affect Rtasynergy transcript stability, but increased Rtasynergy gene transcription despite having no effect on their transcription when expressed alone. Our results suggest that, at least in epithelial cells, Rta is the dominant transactivator and that Zta functions primarily to support DNA replication and co-activate a subset of early promoters with Rta. This closely parallels the arrangement in KSHV where ORF50 (Rta homolog) is the principal activator of lytic transcription and K8 (Zta homolog) is required for DNA replication at oriLyt. | |
| 647 | Shannon Kenney | skenney@wisc.edu | Epstein-Barr virus: Biology and clinical disease. | Epstein-Barr virus (EBV) is a ubiquitous, oncogenic virus that is associated with a number of different human malignancies as well as autoimmune disorders. The expression of EBV viral proteins and non-coding RNAs contribute to EBV-mediated disease pathologies. The virus establishes life-long latency in the human host and is adept at evading host innate and adaptive immune responses. In this review, we discuss the life cycle of EBV, the various functions of EBV-encoded proteins and RNAs, the ability of the virus to activate and evade immune responses, as well as the neoplastic and autoimmune diseases that are associated with EBV infection in the human population. | |
| 648 | Shannon Kenney | skenney@wisc.edu | Reduced IRF4 expression promotes lytic phenotype in Type 2 EBV-infected B cells. | Humans are infected with two types of EBV (Type 1 (T1) and Type 2 (T2)) that differ substantially in their EBNA2 and EBNA 3A/B/C latency proteins and have different phenotypes in B cells. T1 EBV transforms B cells more efficiently than T2 EBV in vitro, and T2 EBV-infected B cells are more lytic. We previously showed that both increased NFATc1/c2 activity, and an NFAT-binding motif within the BZLF1 immediate-early promoter variant (Zp-V3) contained in all T2 strains, contribute to lytic infection in T2 EBV-infected B cells. Here we compare cellular and viral gene expression in early-passage lymphoblastoid cell lines (LCLs) infected with either T1 or T2 EBV strains. Using bulk RNA-seq, we show that T2 LCLs are readily distinguishable from T1 LCLs, with approximately 600 differentially expressed cellular genes. Gene Set Enrichment Analysis (GSEA) suggests that T2 LCLs have increased B-cell receptor (BCR) signaling, NFAT activation, and enhanced expression of epithelial-mesenchymal-transition-associated genes. T2 LCLs also have decreased RNA and protein expression of a cellular gene required for survival of T1 LCLs, IRF4. In addition to its essential role in plasma cell differentiation, IRF4 decreases BCR signaling. Knock-down of IRF4 in a T1 LCL (infected with the Zp-V3-containing Akata strain) induced lytic reactivation whereas over-expression of IRF4 in Burkitt lymphoma cells inhibited both NFATc1 and NFATc2 expression and lytic EBV reactivation. Single-cell RNA-seq confirmed that T2 LCLs have many more lytic cells compared to T1 LCLs and showed that lytically infected cells have both increased NFATc1, and decreased IRF4, compared to latently infected cells. These studies reveal numerous differences in cellular gene expression in B cells infected with T1 versus T2 EBV and suggest that decreased IRF4 contributes to both the latent and lytic phenotypes in cells with T2 EBV. | |
| 649 | Shannon Kenney | skenney@wisc.edu | ΔNp63α promotes Epstein-Barr virus latency in undifferentiated epithelial cells. | Epstein-Barr virus (EBV) is a human herpesvirus that causes infectious mononucleosis and contributes to both B-cell and epithelial-cell malignancies. EBV-infected epithelial cell tumors, including nasopharyngeal carcinoma (NPC), are largely composed of latently infected cells, but the mechanism(s) maintaining viral latency are poorly understood. Expression of the EBV BZLF1 (Z) and BRLF1 (R) encoded immediate-early (IE) proteins induces lytic infection, and these IE proteins activate each other's promoters. ΔNp63α (a p53 family member) is required for proliferation and survival of basal epithelial cells and is over-expressed in NPC tumors. Here we show that ΔNp63α promotes EBV latency by inhibiting activation of the BZLF1 IE promoter (Zp). Furthermore, we find that another p63 gene splice variant, TAp63α, which is expressed in some Burkitt and diffuse large B cell lymphomas, also represses EBV lytic reactivation. We demonstrate that ΔNp63α inhibits the Z promoter indirectly by preventing the ability of other transcription factors, including the viral IE R protein and the cellular KLF4 protein, to activate Zp. Mechanistically, we show that ΔNp63α promotes viral latency in undifferentiated epithelial cells both by enhancing expression of a known Zp repressor protein, c-myc, and by decreasing cellular p38 kinase activity. Furthermore, we find that the ability of cis-platinum chemotherapy to degrade ΔNp63α contributes to the lytic-inducing effect of this agent in EBV-infected epithelial cells. Together these findings demonstrate that the loss of ΔNp63α expression, in conjunction with enhanced expression of differentiation-dependent transcription factors such as BLIMP1 and KLF4, induces lytic EBV reactivation during normal epithelial cell differentiation. Conversely, expression of ΔNp63α in undifferentiated nasopharyngeal carcinoma cells and TAp63α in Burkitt lymphoma promotes EBV latency in these malignancies. | |
| 650 | Shannon Kenney | skenney@wisc.edu | Hippo signaling effectors YAP and TAZ induce Epstein-Barr Virus (EBV) lytic reactivation through TEADs in epithelial cells. | The Epstein-Barr virus (EBV) human herpesvirus is associated with B-cell and epithelial-cell malignancies, and both the latent and lytic forms of viral infection contribute to the development of EBV-associated tumors. Here we show that the Hippo signaling effectors, YAP and TAZ, promote lytic EBV reactivation in epithelial cells. The transcriptional co-activators YAP/TAZ (which are inhibited by Hippo signaling) interact with DNA-binding proteins, particularly TEADs, to induce transcription. We demonstrate that depletion of either YAP or TAZ inhibits the ability of phorbol ester (TPA) treatment, cellular differentiation or the EBV BRLF1 immediate-early (IE) protein to induce lytic EBV reactivation in oral keratinocytes, and show that over-expression of constitutively active forms of YAP and TAZ reactivate lytic EBV infection in conjunction with TEAD family members. Mechanistically, we find that YAP and TAZ interact with, and activate, the EBV BZLF1 immediate-early promoter. Furthermore, we demonstrate that YAP, TAZ, and TEAD family members are expressed at much higher levels in epithelial cell lines in comparison to B-cell lines, and find that EBV infection of oral keratinocytes increases the level of activated (dephosphorylated) YAP and TAZ. Finally, we have discovered that lysophosphatidic acid (LPA), a known YAP/TAZ activator that plays an important role in inflammation, induces EBV lytic reactivation in epithelial cells through a YAP/TAZ dependent mechanism. Together these results establish that YAP/TAZ are powerful inducers of the lytic form of EBV infection and suggest that the ability of EBV to enter latency in B cells at least partially reflects the extremely low levels of YAP/TAZ and TEADs in this cell type. | |
| 651 | Caitlin Pepperell | ID | cspepper@medicine.wisc.edu | Phase variable colony variants are conserved across Gardnerella spp. and exhibit different virulence-associated phenotypes. | The Gardnerella genus, comprising at least 13 species, is associated with the polymicrobial disorder bacterial vaginosis (BV). However, the details of BV pathogenesis are poorly defined, and the contributions made by individual species, including Gardnerella spp., are largely unknown. We report here that colony phenotypes characterized by size (large and small) and opacity (opaque and translucent) are phase variable and are conserved among all tested Gardnerella strains, representing at least 10 different species. With the hypothesis that these different variants could be an important missing piece to the enigma of how BV develops in vivo, we characterized their phenotypic, proteomic, and genomic differences. Beyond increased colony size, large colony variants showed reduced vaginolysin secretion and faster growth rate relative to small colony variants. The ability to inhibit the growth of Neisseria gonorrhoeae and commensal Lactobacillus species varied by strain and, in some instances, differed between variants. Proteomics analyses indicated that 127-173 proteins were differentially expressed between variants. Proteins with increased expression in large variants of both strains were associated with amino acid and protein synthesis and protein folding, whereas those increased in small variants were related to nucleotide synthesis, phosphate transport, ABC transport, and glycogen breakdown. Furthermore, whole genome sequencing analyses revealed an abundance of genes associated with variable homopolymer tracts, implicating slipped strand mispairing in Gardnerella phase variation and illuminating the potential for previously unrecognized heterogeneity within clonal populations. Collectively, these results suggest that phase variants may be primed to serve different roles in BV pathogenesis.IMPORTANCEBacterial vaginosis is the most common gynecological disorder in women of childbearing age. Gardnerella species are crucial to the development of this dysbiosis, but the mechanisms involved in the infection are not understood. We discovered that Gardnerella species vary between two different forms, reflected in bacterial colony size. A slow-growing form makes large amounts of the toxin vaginolysin and is better able to survive in human cervix tissue. A fast-growing form is likely the one that proliferates to high numbers just prior to symptom onset and forms the biofilm that serves as a scaffold for multiple BV-associated anaerobic bacteria. Identification of the proteins that vary between different forms of the bacteria as well as those that vary randomly provides insight into the factors important for Gardnerella infection and immune avoidance. |
| 652 | Caitlin Pepperell | ID | cspepper@medicine.wisc.edu | Adaptation of the Mycobacterium tuberculosis transcriptome to biofilm growth. | Mycobacterium tuberculosis (M. tb), the causative agent of tuberculosis (TB), is a leading global cause of death from infectious disease. Biofilms are increasingly recognized as a relevant growth form during M. tb infection and may impede treatment by enabling bacterial drug and immune tolerance. M. tb has a complicated regulatory network that has been well-characterized for many relevant disease states, including dormancy and hypoxia. However, despite its importance, our knowledge of the genes and pathways involved in biofilm formation is limited. Here we characterize the biofilm transcriptomes of fully virulent clinical isolates and find that the regulatory systems underlying biofilm growth vary widely between strains and are also distinct from regulatory programs associated with other environmental cues. We used experimental evolution to investigate changes to the transcriptome during adaptation to biofilm growth and found that the application of a uniform selection pressure resulted in loss of strain-to-strain variation in gene expression, resulting in a more uniform biofilm transcriptome. The adaptive trajectories of transcriptomes were shaped by the genetic background of the M. tb population leading to convergence on a sub-lineage specific transcriptome. We identified widespread upregulation of non-coding RNA (ncRNA) as a common feature of the biofilm transcriptome and hypothesize that ncRNA function in genome-wide modulation of gene expression, thereby facilitating rapid regulatory responses to new environments. These results reveal a new facet of the M. tb regulatory system and provide valuable insight into how M. tb adapts to new environments. |
| 653 | Caitlin Pepperell | ID | cspepper@medicine.wisc.edu | Making Sense of the Past: Columbus and the European Syphilis Epidemic. | |
| 654 | Caitlin Pepperell | ID | cspepper@medicine.wisc.edu | Decoding a cryptic mechanism of metronidazole resistance among globally disseminated fluoroquinolone-resistant Clostridioides difficile. | Severe outbreaks and deaths have been linked to the emergence and global spread of fluoroquinolone-resistant Clostridioides difficile over the past two decades. At the same time, metronidazole, a nitro-containing antibiotic, has shown decreasing clinical efficacy in treating C. difficile infection (CDI). Most metronidazole-resistant C. difficile exhibit an unusual resistance phenotype that can only be detected in susceptibility tests using molecularly intact heme. Here, we describe the mechanism underlying this trait. We find that most metronidazole-resistant C. difficile strains carry a T-to-G mutation (which we term PnimBG) in the promoter of gene nimB, resulting in constitutive transcription. Silencing or deleting nimB eliminates metronidazole resistance. NimB is related to Nim proteins that are known to confer resistance to nitroimidazoles. We show that NimB is a heme-dependent flavin enzyme that degrades nitroimidazoles to amines lacking antimicrobial activity. Furthermore, occurrence of the PnimBG mutation is associated with a Thr82Ile substitution in DNA gyrase that confers fluoroquinolone resistance in epidemic strains. Our findings suggest that the pandemic of fluoroquinolone-resistant C. difficile occurring over the past few decades has also been characterized by widespread resistance to metronidazole. |
| 655 | Caitlin Pepperell | ID | cspepper@medicine.wisc.edu | The Gonococcal Genetic Island defines distinct sub-populations of Neisseria gonorrhoeae. | The incidence of gonorrhoea is increasing at an alarming pace, and therapeutic options continue to narrow as a result of worsening drug resistance. Neisseria gonorrhoeae is naturally competent, allowing the organism to adapt rapidly to selection pressures including antibiotics. A sub-population of N. gonorrhoeae carries the Gonococcal Genetic Island (GGI), which encodes a type IV secretion system (T4SS) that secretes chromosomal DNA. Previous research has shown that the GGI increases transformation efficiency in vitro, but the extent to which it contributes to horizontal gene transfer (HGT) during infection is unknown. Here we analysed genomic data from clinical isolates of N. gonorrhoeae to better characterize GGI+ and GGI- sub-populations and to delineate patterns of variation at the locus itself. We found the element segregating at an intermediate frequency (61%), and it appears to act as a mobile genetic element with examples of gain, loss, exchange and intra-locus recombination within our sample. We further found evidence suggesting that GGI+ and GGI- sub-populations preferentially inhabit distinct niches with different opportunities for HGT. Previously, GGI+ isolates were reported to be associated with more severe clinical infections, and our results suggest this could be related to metal-ion trafficking and biofilm formation. The co-segregation of GGI+ and GGI- isolates despite mobility of the element suggests that both niches inhabited by N. gonorrhoeae remain important to its overall persistence as has been demonstrated previously for cervical- and urethral-adapted sub-populations. These data emphasize the complex population structure of N. gonorrhoeae and its capacity to adapt to diverse niches. |
| 656 | Caitlin Pepperell | ID | cspepper@medicine.wisc.edu | Comparative Genomics of Streptococcus oralis Identifies Large Scale Homologous Recombination and a Genetic Variant Associated with Infection. | The viridans group streptococci (VGS) are a large consortium of commensal streptococci that colonize the human body. Many species within this group are opportunistic pathogens causing bacteremia and infective endocarditis (IE), yet little is known about why some strains cause invasive disease. Identification of virulence determinants is complicated by the difficulty of distinguishing between the closely related species of this group. Here, we analyzed genomic data from VGS that were isolated from blood cultures in patients with invasive infections and oral swabs of healthy volunteers and then determined the best-performing methods for species identification. Using whole-genome sequence data, we characterized the population structure of a diverse sample of Streptococcus oralis isolates and found evidence of frequent recombination. We used multiple genome-wide association study tools to identify candidate determinants of invasiveness. These tools gave consistent results, leading to the discovery of a single synonymous single nucleotide polymorphism (SNP) that was significantly associated with invasiveness. This SNP was within a previously undescribed gene that was conserved across the majority of VGS species. Using the growth in the presence of human serum and a simulated infective endocarditis vegetation model, we were unable to identify a phenotype for the enriched allele in laboratory assays, suggesting a phenotype may be specific to natural infection. These data highlighted the power of analyzing natural populations for gaining insight into pathogenicity, particularly for organisms with complex population structures like the VGS. IMPORTANCE The viridians group streptococci (VGS) are a large collection of closely related commensal streptococci, with many being opportunistic pathogens causing invasive diseases, such as bacteremia and infective endocarditis. Little is known about virulence determinants in these species, and there is a distinct lack of genomic information available for the VGS. In this study, we collected VGS isolates from invasive infections and healthy volunteers and performed whole-genome sequencing for a suite of downstream analyses. We focused on a diverse sample of Streptococcus oralis genomes and identified high rates of recombination in the population as well as a single genome variant highly enriched in invasive isolates. The variant lies within a previously uncharacterized gene, nrdM, which shared homology with the anaerobic ribonucleoside triphosphate reductase, nrdD, and was highly conserved among VGS. This work increased our knowledge of VGS genomics and indicated that differences in virulence potential among S. oralis isolates were, at least in part, genetically determined. |
| 657 | Caitlin Pepperell | ID | cspepper@medicine.wisc.edu | Need for speed: Key driver of host cell migration varies among mycobacteria. | In this issue of Cell, Saelens et al. describe a new function for mycobacterial Type VII secretion systems: manipulation of host cell migration. They find that a substantial proportion of global TB cases arise from bacteria lacking this function, raising questions about its role in pathoadaptation of Mycobacterium tuberculosis. |
| 658 | Caitlin Pepperell | ID | cspepper@medicine.wisc.edu | Evolution of Tuberculosis Pathogenesis. | Mycobacterium tuberculosis is a globally distributed, lethal pathogen of humans. The virulence armamentarium of M. tuberculosis appears to have been developed on a scaffold of antiphagocytic defenses found among diverse, mostly free-living species of Mycobacterium. Pathoadaptation was further aided by the modularity, flexibility, and interactivity characterizing mycobacterial effectors and their regulators. During emergence of M. tuberculosis, novel genetic material was acquired, created, and integrated with existing tools. The major mutational mechanisms underlying these adaptations are discussed in this review, with examples. During its evolution, M. tuberculosis lost the ability and/or opportunity to engage in lateral gene transfer, but despite this it has retained the adaptability that characterizes mycobacteria. M. tuberculosis exemplifies the evolutionary genomic mechanisms underlying adoption of the pathogenic niche, and studies of its evolution have uncovered a rich array of discoveries about how new pathogens are made. |
| 659 | Caitlin Pepperell | ID | cspepper@medicine.wisc.edu | Rapid adaptation of a complex trait during experimental evolution of Mycobacterium tuberculosis. | Tuberculosis (TB), caused by Mycobacterium tuberculosis (M. tb), is a leading cause of death due to infectious disease. TB is not traditionally associated with biofilms, but M. tb biofilms are linked with drug and immune tolerance and there is increasing recognition of their contribution to the recalcitrance of TB infections. Here, we used M. tb experimental evolution to investigate this complex phenotype and identify candidate loci controlling biofilm formation. We identified novel candidate loci, adding to our understanding of the genetic architecture underlying M. tb biofilm development. Under selective pressure to grow as a biofilm, regulatory mutations rapidly swept to fixation and were associated with changes in multiple traits, including extracellular matrix production, cell size, and growth rate. Genetic and phenotypic paths to enhanced biofilm growth varied according to the genetic background of the parent strain, suggesting that epistatic interactions are important in M. tb adaptation to changing environments. In many environments, bacteria live together in structures called biofilms. Cells in biofilms coordinate with each other to protect the group and allow it to survive difficult conditions. Mycobacterium tuberculosis, the bacterium that causes tuberculosis, forms biofilms when it infects the human body. Biofilms make the infection a lot more difficult to treat, which may be one of the reasons why tuberculosis is the deadliest bacterial infection in the world. Bacteria evolve rapidly over the course of a single infection, but bacteria forming biofilms evolve differently to bacteria living alone. This evolution happens through mutations to the bacterial DNA, which can be small (a single base in a DNA sequence changes to a different base) or larger changes (such as the deletion or insertion of several bases). Smith, Youngblom et al. studied the evolution of tuberculosis growing in biofilms in the lab. As the bacteria evolved, they tended to form thicker biofilms, an effect linked to 14 mutations involving single base DNA changes and four larger ones. Most of the changes were in regulatory regions of DNA, which control whether genes are ‘read’ by cells to produce proteins. These regions often change more though evolution than regions coding for proteins, because they have a coordinated effect on a group of related genes rather than randomly altering individual genes. Smith, Youngblom et al. also showed that biofilms made from different strains of tuberculosis evolved in different ways. Smith Youngblom et al.’s findings provide more information regarding how bacteria adapt to living in biofilms, which may reveal new ways to control them. This could have applications in water treatment, food production and healthcare. Learning how to treat bacteria growing in biofilms could also improve the outcomes for patients infected with tuberculosis. |
| 660 | Caitlin Pepperell | ID | cspepper@medicine.wisc.edu | Genome reorganization during emergence of host-associated Mycobacterium abscessus. | Mycobacterium abscessus is a rapid growing, free-living species of bacterium that also causes lung infections in humans. Human infections are usually acquired from the environment; however, dominant circulating clones (DCCs) have emerged recently in both M. abscessus subsp. massiliense and subsp. abscessus that appear to be transmitted among humans and are now globally distributed. These recently emerged clones are potentially informative about the ecological and evolutionary mechanisms of pathogen emergence and host adaptation. The geographical distribution of DCCs has been reported, but the genomic processes underlying their transition from environmental bacterium to human pathogen are not well characterized. To address this knowledge gap, we delineated the structure of M. abscessus subspecies abscessus and massiliense using genomic data from 200 clinical isolates of M. abscessus from seven geographical regions. We identified differences in overall patterns of lateral gene transfer (LGT) and barriers to LGT between subspecies and between environmental and host-adapted bacteria. We further characterized genome reorganization that accompanied bacterial host adaptation, inferring selection pressures acting at both genic and intergenic loci. We found that both subspecies encode an expansive pangenome with many genes at rare frequencies. Recombination appears more frequent in M. abscessus subsp. massiliense than in subsp. abscessus, consistent with prior reports. We found evidence suggesting that phage are exchanged between subspecies, despite genetic barriers evident elsewhere throughout the genome. Patterns of LGT differed according to niche, with less LGT observed among host-adapted DCCs versus environmental bacteria. We also found evidence suggesting that DCCs are under distinct selection pressures at both genic and intergenic sites. Our results indicate that host adaptation of M. abscessus was accompanied by major changes in genome evolution, including shifts in the apparent frequency of LGT and impacts of selection. Differences were evident among the DCCs as well, which varied in the degree of gene content remodelling, suggesting they were placed differently along the evolutionary trajectory toward host adaptation. These results provide insight into the evolutionary forces that reshape bacterial genomes as they emerge into the pathogenic niche. |
| 661 | Robert Striker | ID | rtstriker@wisc.edu | Risk of developing high-grade squamous intraepithelial lesions or anal cancer after anal condylomata treatment in people living with HIV. | To assess the risk and natural history of developing advanced anal disease after diagnosis of anal condyloma in people living with HIV (PLWH). This was a single-centre retrospective cohort study of PLWH and anal condyloma from 2001 to 2021. Patients who developed advanced anal disease (AAD; anal high-grade squamous intraepithelial lesions and/or anal cancer) were compared to those who did not progress (non-AAD). We assessed the potential association between AAD and condyloma location, recurrence, and treatment modality. AAD-free survival was calculated utilizing Kaplan-Meier methods. A total of 118 PLWH and anal condyloma were included. Mean overall follow-up time was 9.3 years. A total of 31% of patients developed AAD (n = 37). Average time to AAD from condyloma diagnosis was 5.6 years. On multivariate analysis, risk for AAD development was associated with perianal location of condyloma (OR 4.39, p = 0.038) and increased time from initial condyloma diagnosis (OR 1.12, p = 0.008). Higher CD4/CD8 ratios were associated with lower risk of AAD (OR 0.15, p = 0.029). Condyloma recurrence and treatment type were not associated with development of AAD. AAD-free survival was longer in those with intra-anal only condyloma versus those with either perianal disease alone or combined intra-anal/perianal disease (mean survival times: 22.8 vs. 8.7 vs. 10.7 years, p = 0.017). Our study demonstrates the need for careful, long-term follow-up of PLWH and condyloma, particularly in the setting of perianal disease and low CD4/CD8 ratio. Risk of anal disease progression is present even in the setting of condyloma regression following treatment. |
| 668 | Robert Striker | ID | rtstriker@wisc.edu | Immune recovery in HIV-1 infected patients with sustained viral suppression under long-term antiretroviral therapy in Ethiopia. | There is very little data on long-term immune recovery responses in patients on suppressive antiretroviral therapy (ART) in the setting of sub-Saharan Africa (SSA). Thus, we sought to determine CD4+ T-cell, CD8+ T-cell and CD4/CD8 ratio responses in a cohort of HIV infected individuals on sustained suppressive ART followed up for more than a decade. The cohort comprised adult patients who started ART between 2001 and 2007 and followed for up to 14 years. Trends in median CD4+ T-cells, CD8+ T-cells and CD4/CD8 ratio were reviewed retrospectively. Poisson regression models were used to identify factors associated with achieving normalized T-cell biomarkers. Kaplan-Meier curves were used to estimate the probability of attaining normalized counts while on suppressive ART. A total of 227 patients with a median duration of follow-up on ART of 12 (IQR: 10.5-13.0) years were included. CD4 cell count increased from baseline median of 138 cells (IQR: 70-202) to 555 cells (IQR: 417-830). CD4 cell increased continuously up until 5 years, after which it plateaued up until 14 years of follow up. Only 69.6% normalized their CD4 cell count within a median of 6.5 (IQR: 3.0-10.5) years. In addition, only 15.9% of the cohort were able to achieve the median reference CD4+ T-cell threshold count in Ethiopians (≈760 cells/μL). CD8+ T-cell counts increased initially until year 1, after which continuous decrease was ascertained. CD4/CD8 ratio trend revealed continuous increase throughout the course of ART, and increased from a median baseline of 0.14 (IQR: 0.09-0.22) to a median of 0.70 (IQR: 0.42-0.95). However, only 12.3% normalized their ratio (≥ 1.0) after a median of 11.5 years. In addition, only 8.8% of the cohort were able to achieve the median reference ratio of healthy Ethiopians. Determination of both CD4+ and CD8+ T-cells, along with CD4/CD8 ratio is highly relevant in long-term follow-up of patients to assess immune recovery. Monitoring ratio levels may serve as a better biomarker risk for disease progression among patients on long-term ART. In addition, the findings emphasize the relevance of initiation of ART at the early stage of HIV-1 infection. |
| 669 | Robert Striker | ID | rtstriker@wisc.edu | Role of CD4/CD8 ratio on the incidence of tuberculosis in HIV-infected patients on antiretroviral therapy followed up for more than a decade. | The role of CD4/CD8 ratio on the incidence of tuberculosis (TB) in patients on antiretroviral therapy (ART) is unknown. Thus, we sought to determine whether the CD4/CD8 ratio was associated with development of TB in a cohort of HIV infected individuals on ART followed up for more than a decade in the setting of sub-Saharan Africa (SSA). The cohort comprised adult patients who started ART between 2001 and 2007 and followed for up to 15 years. Clinical data were collected in retrospective manner. Patients with an AIDS defining illness or a CD4 count <200 cell/μL were started with a combination of ART. The participants have clinic visits every 6 months and/or as needed. Poisson regression models were used to identify factors associated with development of incident TB. Kaplan-Meier curves were used to estimate the probability of incident TB while on ART. A total of 347 patients with a median duration of follow-up on ART of 11.5 (IQR: 10.0-12.5) years were included. Incident TB developed in 47 patients during the 3259 person-years of follow-up, the majority (76.6%) occurred within five year of ART initiation. On univariate analysis, poor ART adherence (RR:2.57, 95% CI: 1.28-5.17), time-updated CD4 cell count of lower than 200 (RR: 4.86, 95%CI 2.33-10.15), or CD4 cell count between 200 and 500 (RR: 4.68, 95% CI: 2.17-10.09), time-updated CD8 cell count lower than 500 (RR: 2.83 95% CI 1.31-6.10), or CD8 cell count over 1000 (RR: 2.23, 95% CI: 1.12-4.45), time-updated CD4/CD8 ratio of less than 0.30 (RR: 6.00, 95% CI: 2.96-12.14), lack of normalization of CD4 T-cell count (RR: 6.13, 95% CI: 2.20-17.07), and virological failure (RR: 2.35 (95% CI: 1.17-4.71) were all associated with increased risk of incident TB. In multivariate analysis, however, time-updated CD4/CD8 ratio of less than 0.30 (adjusted RR: 4.08, 95% CI: 1.31-12.68) was the only factor associated with increased risk of developing incident TB (p = 0.015). Similar results were obtained in a sensitivity analysis by including only those virally suppressed patients (n = 233, 69% of all patients). In this group, CD4/CD8 ratio of less than 0.30 was associated with development of incident TB (adjusted RR: 4.02, 95% CI: 1.14-14.19, p = 0.031). Overall, the incidence rate of TB in patients with an updated CD4/CD8 ratio of less than 0.30 was more than 5-fold higher when compared with those with a ratio more than 0.45. Low CD4/CD8 ratio is independently associated with an increased risk of incident TB despite viral suppression. CD4/CD8 ratio may serve as a biomarker for identifying patients at risk of TB in patients on ART in the setting of SSA. |
| 670 | Robert Striker | ID | rtstriker@wisc.edu | New 2025 Toxoplasma Project | Approximately 30% of the world has been exposed to the parasite toxoplasma and some fraction of those have viable theoretically asymptomatic cysts in their brain. Correlative data suggests those individuals have subtle cognitive defects, slightly smaller brains, and even an increased risk of epilepsy and schizophrenia, which is consistent with animal studies. We are developing spinal fluid biomarkers of actual cyst burden so those individuals can be diagnosed and potentially treated. |
| 671 | Angela Byars-Winston | GIM | ambyars@wisc.edu | Utilizing mentorship education to promote a culturally responsive research training environment in the biomedical sciences. | There is an urgent and compelling need for systemic change to achieve diversity and inclusion goals in the biomedical sciences. Because faculty hold great influence in shaping research training environments, faculty development is a key aspect in building institutional capacity to create climates in which persons excluded because of their ethnicity or race (PEERs) can succeed. We present a mixed methods case study of one institution's efforts to improve mentorship of PEER doctoral students through mentorship education workshops for faculty. These workshops were one strategy among others intended to improve graduate trainees' experiences, and positively affect institutional climate with respect to racial and ethnic diversity. Surveys of 108 faculty mentors revealed that about 80% overall agreed or strongly agreed with the value of culturally responsive mentoring behaviors but about 63% overall agreed or strongly agreed that they were confident in their ability to enact those behaviors. Through a series of three focus groups, PEER doctoral students reported that they noticed mentors' efforts to address cultural diversity matters and identified some guidance for how to approach such topics. We discuss future directions and implications for using mentorship education to activate systemic change toward inclusive research training environments and promoting the value of mentorship within institutions. |
| 672 | Angela Byars-Winston | GIM | ambyars@wisc.edu | Evaluation of a Virtual Culturally Aware Mentoring Workshop for Biomedical Faculty. | The Culturally Aware Mentoring (CAM) workshop was developed to help biomedical faculty gain awareness and skills to work more effectively with racially and ethnically minoritized mentees. The purpose of this paper is to present evaluation findings from a national cluster randomized comparative study in which CAM was delivered in an online format. We evaluated data from the primary arm of this study, which included 231 biomedical faculty from 12 universities. Overall, participants evaluated both the presentation and content of the online interactive intervention favorably, reporting it helped them become a more culturally aware mentor. They further suggested how the workshop may be improved. We discuss implications for mentorship practitioners and future research directions. |
| 673 | Angela Byars-Winston | GIM | ambyars@wisc.edu | Juneteenth in STEMM and the barriers to equitable science. | We are 52 Black scientists. Here, we establish the context of Juneteenth in STEMM and discuss the barriers Black scientists face, the struggles they endure, and the lack of recognition they receive. We review racism's history in science and provide institutional-level solutions to reduce the burdens on Black scientists. |
| 674 | Angela Byars-Winston | GIM | ambyars@wisc.edu | A randomized controlled trial of an intervention to increase cultural diversity awareness of research mentors of undergraduate students. | Cultural diversity variables like race and/or ethnicity influence research mentoring relationships, but mentors may not know how to address such variables with their mentees. Using a randomized controlled trial design, we tested a mentor training intervention to increase mentors' awareness and skill in addressing cultural diversity in research mentoring relationships, documenting its impact on mentors and their undergraduate mentees' ratings of mentor effectiveness. Participants were a national sample of 216 mentors and 117 mentees from 32 undergraduate research training programs in the United States. Mentors in the experimental condition reported greater gains than those in the comparison condition regarding the relevance of their racial/ethnic identity to mentoring and their confidence to mentor students across diverse cultural identities. Paired mentees of mentors in the experimental group rated their mentors higher at respectfully broaching and creating opportunities to address race/ethnicity matters than those with mentors in the comparison group. Our results support the efficacy of culturally focused mentorship education. |
| 675 | Angela Byars-Winston | GIM | ambyars@wisc.edu | Comparing the Outcomes of Face-to-Face and Synchronous Online Research Mentor Training Using Propensity Score Matching. | In this study, propensity score matching (PSM) was conducted to examine differences in the effectiveness of research mentor training (RMT) implemented using two modes-face-to-face or synchronous online training. This study investigated each training mode and assessed participants' perceived gains in mentoring skills, ability to meet mentees' expectations, and overall quality of mentoring, as well as intention to make changes to their mentoring practices. Additional factors that may contribute to participant outcomes were also examined. In total, 152 mentors trained using a synchronous online platform and 655 mentors trained in in-person workshops were analyzed using the PSM method. Mentors were matched based on similar characteristics, including mentee's career stage, mentor's title, mentor's prior mentoring experience, mentor's race/ethnicity and sex, and mentor's years of experience; results show that both face-to-face and synchronous online modes of RMT are effective. Findings indicated that the training mode did not significantly impact the mentors' perceived training outcomes. Factors associated with the reported training outcomes included dosage (hours of training), facilitator effectiveness, race/ethnicity, and previous mentoring experience. The results of this study demonstrate that mentors' perceived training outcomes are comparable regardless of the training modality used-online versus face-to-face. |
| 676 | Angela Byars-Winston | GIM | ambyars@wisc.edu | Evaluation of a Culturally Responsive Mentorship Education Program for the Advisers of Howard Hughes Medical Institute Gilliam Program Graduate Students. | Effective mentorship is critical to the success of trainees in research career pathways, significantly impacting their research productivity, academic and research self-efficacy, and career satisfaction. Research faculty may be unaware of or unprepared to address mentor-mentee dynamics in mentoring relationships, especially those that go beyond traditional scientific skill development. Addressing mentorship dynamics can be even more challenging for mentors from well-represented backgrounds working with mentees from historically excluded racial/ethnic groups. The Howard Hughes Medical Institute supports programmatic interventions, like the Mentorship Skills Development (MSD) course, an innovative program that aims to advance the mentorship competencies and cultural diversity awareness of mentors. Between 2015 and 2020, more than 200 faculty mentors participated in the MSD. Quantitative and qualitative data reveal significant gains in mentorship skills and cultural awareness, with mentors reporting increases in their confidence to have conversations around race and culture with their mentees. More than 85% reported actual or intended changes to their cultural responsiveness or mentorship behaviors. Importantly, behavioral changes were also observed by their mentees. These data indicate that culturally responsive mentorship education can increase knowledge and efficacy in effective mentorship practices and improve mentorship experiences of both mentors and mentees. |
| 677 | Angela Byars-Winston | GIM | ambyars@wisc.edu | Enhancing Research Mentors' Cultural Awareness in STEM: A Mentor Training Intervention. | Research mentoring relationships are critical to mentees' persistence in STEM careers. Cultural identity variables (gender, race, ethnicity) influence how mentees experience mentoring relationships, including their developmental needs and expectations of mentors. Research shows that mentees from underrepresented groups in STEM often want to discuss topics related to race and ethnicity and how these factors impact their careers. However, many research mentors are uncertain of their ability to broach cultural diversity issues in mentorship, or in strategies to engage in culturally aware mentoring practices. To address this need, we developed an evidence-based mentor training intervention for Enhanced Cultural Awareness (ECA) in mentorship. We implemented this 2hr module online with research mentors (N=62) largely from well-represented racial/ethnic groups in STEM who were mentoring undergraduate researchers from underrepresented racial/ethnic groups. Mentors reported significant gains in skills, attitudes and behaviors related to cultural awareness in mentoring. The majority of mentors found the training valuable, and 97% of mentors reported intending to make changes in mentoring practices post intervention. Our results indicate that the ECA module is an effective tool to increase mentors' capacity to enact culturally aware mentoring practices. Implications for continued research and mentorship education to enhance mentors' cultural awareness are also discussed. |
| 678 | Angela Byars-Winston | GIM | ambyars@wisc.edu | A system-wide health sciences faculty mentor training program is associated with improved effective mentoring and institutional climate. | Mentorship is critical for faculty success, satisfaction, and engagement. However, many faculty, particularly underrepresented racial/ethnic (UR) faculty, lack access to high-quality mentoring. In an effort to improve mentoring for all faculty, we developed and implemented a formally structured faculty mentor training program (FMTP) across UC San Diego Health Sciences, which included institutional support, mentorship training, and department/division mentorship programs. FMTP impact was evaluated using three primary outcome variables: mentoring quality, mentoring behaviors, and institutional climate. Participants' self-assessed mentoring competencies were measured using validated instruments. A total of 391 (23%) of Health Sciences faculty participated in FMTP. Participation rate was higher for women than men (30% versus 17%) and highest for UR faculty (39%). FMTP was implemented in 16 of 19 departments. Self-reported mentoring improved for FMTP participants with mentoring quality (p = 0.009) and meeting mentees' expectations (p = 0.01) continuing to improve for up to 2 years after training. However, participants were unsure if they were meeting UR mentees' expectations. FMTP participants were significantly more satisfied with mentoring quality (p < 0.001) compared to non-participants, with the greatest increase in satisfaction reported by UR faculty (38-61%). UR faculty reported improved overall morale (51-61%) and a perception that the environment was supportive for UR faculty (48-70%). The implementation of a system-wide formal structured FMTP was associated with improved faculty satisfaction, quality of mentoring, and institutional climate, especially for UR faculty. |
| 679 | Angela Byars-Winston | GIM | ambyars@wisc.edu | Value, Support, and Advancement: An Organization's Role in Faculty Career Intentions in Academic Medicine. | Faculty engagement in academic medical centers is essential to advancing efficient healthcare delivery, research productivity, and organizational quality. The authors used turnover theory to empirically examine factors that influence faculty engagement, including both aspirational and attrition-related career intentions. Using a convergent, mixed methods design, the authors surveyed 284 faculty at a large Midwestern public university's school of medicine in Fall 2015, Fall 2016, and Spring 2017. The study's questionnaire included a series of scales which informed three outcome variables (promotion aspirations, leadership aspirations, and intent to leave the organization) and four groups (role strain, work-family conflict, organizational commitment and support, and departmental commitment and support) of predictor variables, all of which have been previously validated with medical faculty populations. The scales were followed by open-ended questions which allowed respondents to further elaborate on their experiences in their organization related to each outcome variable. The authors used a hierarchical multiple regression model to assess the effect of each of the four groups of predictor variables on the outcome variables and then employed an iterative thematic analysis of open-ended responses to further elucidate faculty's reported experiences. Organizational commitment and support were significantly associated with faculty's promotion aspirations, leadership aspirations, and intentions to leave the organization. Thematic analysis of participant responses to open-ended questions further revealed the specific career development support faculty desired, mainly, streamlined and transparent promotion and leadership processes; clear guidance to maneuver these processes; holistic professional development opportunities; feeling valued; and supports for clinical and administrative tasks. Advancing organizational policy that supports infrastructure for evidence-based interventions and programming for the intentional career development of faculty is an important aspect of a proactive talent development and retention model in academic medical centers. |
| 680 | Angela Byars-Winston | GIM | ambyars@wisc.edu | Measuring Research Mentors' Cultural Diversity Awareness for Race/Ethnicity in STEM: Validity Evidence for a New Scale. | Research mentors are reticent to address, and sometimes unaware of how, racial or ethnic differences may influence their mentees' research experiences. Increasing research mentors' cultural diversity awareness (CDA) is one step toward improving mentoring effectiveness, particularly with mentees from underrepresented racial/ethnic groups in science, technology, engineering, and mathematics fields. The indicators of CDA for research mentors are not yet known. Thus, we developed a scale to assess CDA related to race/ethnicity (CDA-R/E) in research mentoring relationships informed by multicultural counseling theory and social cognitive theory. The validation process was guided by classical test theory and item response theory and involved qualitative data, cognitive interviews, and an iterative series of item testing with national samples of mentors and mentees. Confirmatory factor analysis evidenced validity for a three-factor mentor scale assessing attitudes, behavior, and confidence, and a two-factor mentee scale assessing attitudes and behavior. The mentee version captures mentees' perception of the relevance of culturally aware mentoring ("Attitudes") and their perception of the frequency of mentor's culturally aware mentoring behaviors ("Behaviors"). Implications for use of the CDA-R/E scale in practice, such as assessing alignment between mentor and mentee CDA scores, and use in future studies are discussed. |
| 681 | Amy Zelenski | GIM | zelenski@medicine.wisc.edu | Right-sizing interprofessional team training for serious-illness communication: A strength-based approach. | Palliative care communication skills help tailor care to patients' goals. With a palliative care physician shortage, non-physicians must gain these serious illness communication skills. Historically, trainings have targeted physician-only groups; our goal was to train interprofessional teams. Workshops were conducted to teach palliative care communication skills and interprofessional communication. Participants completed surveys which included questions from the Interpersonal Reactivity Index, the Ekman Faces tool, the Consultation and Relational Empathy measure, open-ended questions about empathy, and measures of effective interprofessional practice. Participants felt the workshop improved their ability to listen (p < 0.001), understand patients' concerns (p < 0.001), and show compassion (p = 0.008). It increased the perceived value of peer observation (p < 0.001) and ability to reflect (p = 0.02) during complex conversations. Different types of professionals adopted different communication goals, though all affirmed the importance of active listening. Participants felt they improved their ability to work within an interprofessional team. The course effectively trained 71 clinicians, the majority non-physicians, in serious illness communication and interprofessional team communication skills, and could be reproduced in similar settings. We adapted an approach common to physician-only trainings to diverse interprofessional groups, added a team-based component using Applied Improvisation, and demonstrated its effectiveness. |
| 682 | Amy Zelenski | GIM | zelenski@medicine.wisc.edu | Embedding an Education Intervention about Shared Decision Making into an RCT: Ensuring competency and fidelity. | To describe the outcomes of training nephrology clinicians and clinical research participants, to use the Best Case/Worst Case Communication intervention, for discussions about dialysis initiation for patients with life-limiting illness, during a randomized clinical trial to ensure competency, fidelity to the intervention, and adherence to study protocols and the intervention throughout the trial. We enrolled 68 nephrologists at ten study sites and randomized them to receive training or wait-list control. We collected copies of completed graphic aids (component of the intervention), used with study-enrolled patients, to measure fidelity and adherence. We trained 34 of 36 nephrologists to competence and 27 completed the entire program. We received 60 graphic aids for study-enrolled patients for a 73% return rate in the intervention arm. The intervention fidelity score for the graphic aid reflected completion of all elements throughout the study. We successfully taught the Best Case/Worst Case Communication intervention to clinicians as research participants within a randomized clinical trial. Decisions about dialysis are an opportunity to discuss prognosis and uncertainty in relation to consideration of prolonged life supporting therapy. Our study reveals a strategy to evaluate adherence to a communication intervention in real time during a clinical study. |
| 683 | Amy Zelenski | GIM | zelenski@medicine.wisc.edu | "So, what are you saying?": A qualitative study of surgeon-patient communication in the rectal cancer consultations. | Patients with rectal cancer face a potentially life-limiting disease with multi-modal treatment options conferring substantial symptom burdens. Treatment decisions frequently require trade-offs and input from a multidisciplinary team: ideal cases for shared decision-making. Using qualitative analysis, we characterized the content of communication between surgeons and patients who have rectal cancer. We performed secondary analysis of audio-recorded clinic visits of patients with rectal cancer (n = 18) with colorectal surgeons (n = 8) at 5 academic centers. Four coders used inductive content analysis with an analytical emphasis on communication about decision-making. Surgeons focused on communicating technical details of potential treatment pathways. Patients sought information around prognosis, functional changes, long-term recovery, and next steps. Surgeons laid groundwork for shared decision-making; patient goals were not routinely clarified. Decisions were typically deferred due to uncertainty and missing information needed to determine appropriate treatment options. Our findings suggest avenues for surgeons to enhance communication around rectal cancer decision-making: acknowledging uncertainty and providing concrete information when able, focusing on topics such as prognosis, tradeoffs, and long-term recovery, and clarifying patient preferences. |
| 684 | Amy Zelenski | GIM | zelenski@medicine.wisc.edu | Clinician-Educator Tracks in Internal Medicine: A National Survey. | |
| 685 | Amy Zelenski | GIM | zelenski@medicine.wisc.edu | Zoom Improv is accessible and enhances medical student empathy. | Empathy declines during medical training, despite its importance. In this randomized controlled trial, we assessed the impact of Zoom improv on medical student empathy using a concurrent mixed-methods approach. Quantitative assessment with three survey tools and qualitative assessment by content analysis of Zoom session field notes were conducted. Zoom improv participants had higher empathy scores in perspective-taking and fantasy and lower scores in personal distress compared with the control group. Medical students who participated in Zoom improv exercised emotional expression, active listening, and giving "gifts," which apply to healthcare settings in which affirming team members with empathic concern can advance communication, patient rapport, and teamwork. This pilot study highlights promising findings for the incorporation of Zoom improv in medical education, including enhanced empathy, self-reflection, and understanding how these skills impact work in healthcare. Future studies may expand on the optimal timing to teach improv. Future studies conducted on virtual platforms may also further investigate our finding that the fantasy domain of empathy increases after Zoom improv sessions, whereas this increase in fantasy was absent from previous in-person studies. Given the increase in telehealth and virtual medical visits, exercising empathy skills through a screen during training may be an important addition to medical curricula. |
| 686 | Amy Zelenski | GIM | zelenski@medicine.wisc.edu | Best Case/Worst Case-ICU: protocol for a multisite, stepped-wedge, randomised clinical trial of scenario planning to improve communication in the ICU in US trauma centres for older adults with serious injury. | Poor communication about serious injury in older adults can lead to treatment that is inconsistent with patient preferences, create conflict and strain healthcare resources. We developed a communication intervention called Best Case/Worst Case-intensive care unit (ICU) that uses daily scenario planning, that is, a narrative description of plausible futures, to support prognostication and facilitate dialogue among patients, their families and the trauma ICU team. This article describes a protocol for a multisite, randomised, stepped-wedge study to test the effectiveness of the intervention on the quality of communication (QOC) in the ICU. We will follow all patients aged 50 and older admitted to the trauma ICU for 3 or more days after a serious injury at eight high-volume level 1 trauma centres. We aim to survey one family or 'like family' member per eligible patient 5-7 days following their loved ones' admission and clinicians providing care in the trauma ICU. Using a stepped-wedge design, we will use permuted block randomisation to assign the timing for each site to begin implementation of the intervention and routine use of the Best Case/Worst Case-ICU tool. We will use a linear mixed-effects model to test the effect of the tool on family-reported QOC (using the QOC scale) as compared with usual care. Secondary outcomes include the effect of the tool on reducing clinician moral distress (using the Measure of Moral Distress for Healthcare Professionals scale) and patients' length of stay in the ICU. Institutional review board (IRB) approval was granted at the University of Wisconsin, and all study sites ceded review to the primary IRB. We plan to report results in peer-reviewed publications and national meetings. NCT05780918. |
| 687 | Amy Zelenski | GIM | zelenski@medicine.wisc.edu | Emphasis of Diversity, Equity, and Inclusion on US Adult Infectious Disease Fellowship Program Websites in the Era of Virtual Recruitment. | Women and underrepresented-in-medicine applicants value a climate for diversity when selecting graduate medical education training programs. Climate may not be accurately represented during virtual recruitment. Optimizing program websites may help overcome this barrier. We reviewed websites for adult infectious disease fellowships that participated in the 2022 National Resident Matching Program for emphasis on diversity, equity, and inclusion (DEI). Fewer than half expressed DEI language in their mission statement or had a dedicated DEI statement or webpage. Programs should consider emphasizing their commitment to DEI prominently on their websites, which may help recruit candidates from diverse backgrounds. |
| 688 | Amy Zelenski | GIM | zelenski@medicine.wisc.edu | Gender influences resident physicians' perception of an employee-to-employee recognition program: a mixed methods study. | Burnout is prevalent in medical training. While some institutions have implemented employee-to-employee recognition programs to promote wellness, it is not known how such programs are perceived by resident physicians, or if the experience differs among residents of different genders. We used convergent mixed methods to characterize how residents in internal medicine (IM), pediatrics, and general surgery programs experience our employee-to-employee recognition ("Hi-5″) program. We collected Hi-5s received by residents in these programs from January 1, 2021-December 31, 2021 and coded them for recipient discipline, sex, and PGY level and sender discipline and professional role. We conducted virtual focus groups with residents in each training program. We compared Hi-5 receipt between male and female residents; overall and from individual professions. We submitted focus group transcripts to content analysis with codes generated iteratively and emergent themes identified through consensus coding. Over a 12-month period, residents received 382 Hi-5s. There was no significant difference in receipt of Hi-5s by male and female residents. Five IM, 3 surgery, and 12 pediatric residents participated in focus groups. Residents felt Hi-5s were useful for interprofessional feedback and to mitigate burnout. Residents who identified as women shared concerns about differing expectations of professional behavior and communication based on gender, a fear of backlash when behavior does not align with gender stereotypes, and professional misidentification. The "Hi-5" program is valuable for interprofessional feedback and promotion of well-being but is experienced differently by men and women residents. This limitation of employee-to-employee recognition should be considered when designing equitable programming to promote well-being and recognition. |
| 689 | Amy Zelenski | GIM | zelenski@medicine.wisc.edu | Using nominal group technique to determine skills that applied improvisation can teach health profession education learners. | Applied improvisation (AI) is an approach used in health professions (HP) education to teach skills essential for clinical practice such as communication, teamwork, and empathy. Little is known about which skills can be developed using AI, or those which an AI should prioritize. Our research aims to identify skills essential to include in an AI curriculum for HP learners. A modified nominal group technique (NGT) was conducted to identify and prioritize specific skills which can be taught using AI. This involved silent generation of ideas, round robin, discussions, 2-rounds of preliminary voting, and a final ranking survey to determine a prioritized list of skills to include in an AI curriculum for HP learners. Six content experts participated in the NGT meeting. Initially, 83 skills were identified, and through NGT, a final list of 11 skills essential to an AI curriculum were determined including: adaptability, affirmation of others, acceptance, active listening, being present, cooperation, collaboration with other, advancement, compassionate communication, sharpened non-verbal communication, resilience. Essential skills for an AI curriculum relate to adaptability, attunement, collaboration, affirmation, and advancement. This study is a novel application of NGT as a strategy to organize an approach to curriculum innovations. |
| 690 | Amy Zelenski | GIM | zelenski@medicine.wisc.edu | Discussion-based interprofessional education: A positive step toward promoting shared understanding between surgical residents and nurses. | Interprofessional education during medical training may improve communication by promoting collaboration and the development of shared mental models between professions. We implemented a novel discussion-based intervention for surgical residents and nurses to promote mutual understanding of workflows and communication practices. General surgery residents and inpatient nurses from our institution were recruited to participate. Surveys and paging data were collected prior to and following the intervention. Surveys contained original questions and validated subscales. Interventions involved facilitated discussions about workflows, perceptions of urgency, and technology preferences. Discussions were recorded and transcribed for qualitative content analysis. Pre and post-intervention survey responses were compared with descriptive sample statistics. Group characteristics were compared using Fisher's exact tests. Eleven intervention groups were conducted (2-6 participants per group) (n = 38). Discussions achieved three aims: Information-Sharing (learning about each other's workflows and preferences), 2) Interpersonal Relationship-Building (establishing rapport and fostering empathy) and 3) Interventional Brainstorming (discussing strategies to mitigate communication challenges). Post-intervention surveys revealed improved nurse-reported grasp of resident schedules and tailoring of communication methods based on workflow understanding; however, communication best practices remain limited by organizational and technological constraints. Systems-level changes must be prioritized to allow intentions toward collegial communication to thrive. |
| 691 | Didier Mandelbrot | NEPH | damandel@medicine.wisc.edu | Oxalate nephropathy after kidney transplantation: A common cause of graft dysfunction, but uncommon cause of ureter stricture. | |
| 692 | Didier Mandelbrot | NEPH | damandel@medicine.wisc.edu | Low 25-Hydroxyvitamin D Post-Kidney Transplant Is Associated with Increased Risk of BK Polyomavirus-Associated Nephropathy. | BK viremia (BKPyV-DNAemia) and nephropathy (BKPyVAN) are significant causes of morbidity and mortality in kidney transplant recipients (KTRs). Vitamin D supports immune function, yet low 25-hydroxyvitamin D [25(OH)D] is common among KTRs. The association between serum 25(OH)D, measured 61 days to 2 years post-transplant, and subsequent incident BKPyV-DNAemia and BKPyVAN was examined in KTRs without previous BKPyV-DNAemia or BKPyVAN, respectively. Out of 3308 KTRs, 399 (12%) were vitamin D deficient [25(OH)D ≤ 20 ng/mL], and 916 (27.7%) were insufficient [25(OH)D 21-29 ng/mL]. A total of 184 KTRs developed BKPyV-DNAemia and 44 developed BKPyVAN. The incidence rate (/100 person-years) for BKPyV-DNAemia was 2.88 in the 25(OH)D sufficient group, 2.22 in the insufficient group, and 2.37 in the deficient group. The incidence rate (/100 person-years) for BKPyVAN was 0.30 in the 25(OH)D sufficient group, 0.75 in the insufficient group, and 1.28 in the deficient group. Vitamin D deficiency (adjusted hazard ratio [aHR] compared to 25(OH)D sufficiency: 3.92; 95% CI: 1.66-9.23) and insufficiency (aHR: 2.22; 95% CI: 1.11-4.45) remained significantly associated with the incidence of BKPyVAN after adjustment for baseline characteristics. Low serum 25(OH)D was associated with an increased risk of BKPyVAN but not BKPyV-DNAemia. |
| 693 | Didier Mandelbrot | NEPH | damandel@medicine.wisc.edu | Early clearance of BK polyomavirus-DNAemia among kidney transplant recipients may lead to better graft survival. | BK polyomavirus (BKPyV)-DNAemia is a common complication in kidney transplant recipients (KTRs). The significance of achieving viral clearance at different time intervals is not well understood. All adult KTRs transplanted between January 1, 2015 and December 31, 2017 who developed BKPyV-DNAemia were included. Outcomes were analyzed based on persistent clearance of BKPyV-DNAemia at 3-month intervals up to 2 years after initial detection, and for recipients with persistent BKPyV-DNAemia at last follow-up. Uncensored graft failure, death-censored graft failure (DCGF), and a composite outcome of DCGF or fall in estimated glomerular filtration rate (eGFR) by ≥50% from the time of initial BKPyV-DNAemia were outcomes of interest. Of 224 KTRs with BKPyV-DNAemia, 58 recipients (26%) achieved viral clearance by 3 months after initial detection, 105 (47%) by 6 months, 120 (54%) by 9 months, 141 (63%) by 12 months, 155 (69%) by 15 months, 167 (75%) by 18 months, 180 (80%) by 21 months, and 193 (86%) by 24 months. Nine recipients (4%) had persistent BKPyV-DNAemia at last follow-up. Compared to recipients who achieved viral clearance by 3 months, those who achieved clearance by 6 months (adjusted odds ratio [aOR]: 3.15; 95% confidence interval [CI]: 1.22-8.12; p = .02) and 9 months (aOR: 3.69; 95% CI: 1.02-13.43; p = .04) had significantly increased risk for uncensored graft failure. There was no significant association between time to viral clearance and DCGF or composite outcomes. We found a trend of increased risk for uncensored graft failure among those who cleared BKPyV-DNAemia more slowly. Aiming to clear viremia early, without risking rejection, may be beneficial for allograft function and patient morbidity and mortality. |
| 694 | Didier Mandelbrot | NEPH | damandel@medicine.wisc.edu | Changes in Donor-Derived Cell-Free DNA Before and After Rejection and De Novo DSA Detection in Primary and Repeat Kidney Transplant Recipients. | Serial monitoring of dd-cfDNA and change from baseline can provide meaningful information beyond absolute thresholds. We describe dd-cfDNA trajectories from the baseline before and after acute rejection (AR) and de novo donor-specific antibodies (dnDSA) detection in kidney transplant recipients (KTRs). We included KTR from 02/2019 to 03/2022 with serial dd-cfDNA. The primary analysis compared the time-varying change in dd-cfDNA from baseline in KTR first AR on biopsy [AR] to patients with no-AR on biopsy [no-AR]. 151 KTR were analyzed (AR = 56 KTR, no-AR = 95 KTRs). In the AR group, dd-cfDNA rose ahead of diagnosis: median rise from baseline was 75% at -3 months, 32% at -2 months, and 325% at -1 month before biopsy. At the time of biopsy, the median rise in dd-cfDNA from baseline was 291% (IQR [interquartile range] 88%-1081%) in AR and 17% (IQR 0%- 194%) in no-AR (p < 0.0001). Following treatment, dd-cfDNA values fell in the AR group with a median change from baseline of 94.7% at +1 month, 10.5% at +2 months, and 0% at +3 months. These trajectories were not observed in the no-AR group. Similarly, there were no significant differences in eGFR (estimated glomerular filtration rate) trajectories between the two groups. The median change from baseline to dnDSA detection was 141% (IQR 112%-574%). In KTRs with persistent rejection, median dd-cfDNA was 0.95% (IQR 0.44-1.8) compared to 0.19% (IQR 0.12-0.31) in subjects with no rejection on follow-up (p < 0.001). The significant changes from baseline observed before and after AR show how serial monitoring enhances dd-cfDNA utility and allows for earlier identification of evolving injury and monitoring treatment response. |
| 695 | Didier Mandelbrot | NEPH | damandel@medicine.wisc.edu | Risk Factors for Early Post-transplant Weight Changes Among Simultaneous Pancreas-kidney Recipients and Impact on Outcomes. | There are limited data about the risk factors for weight changes and the association of significant weight changes with graft and metabolic outcomes after simultaneous pancreas and kidney (SPK) transplantation. We included all SPK recipients with both allografts functioning for at least 6 mo post-transplant and categorized them based on the weight changes from baseline to 6 mo post-transplant. We analyzed risk factors for significant weight gain (SWG) and significant weight loss (SWL) over 6 mo post-transplant, as well as outcomes including pancreas uncensored graft failure, pancreas death-censored graft failure (DCGF), composite pancreas graft outcomes of DCGF, use of an antidiabetic agent, or hemoglobin A1C >6.5%, and kidney DCGF. Of 280 SPK recipients, 153 (55%) experienced no significant weight change, 57 (20%) SWG, and 70 (25%) SWL. At 6 mo post-transplant, mean weight changes were 1.2% gain in the no significant weight change group, 13.4% gain in SWG, and 9.6% loss in the SWL groups. In multivariate analysis, the only factor associated with decreased risk for weight gain was older recipient age (aOR, 0.97; 95% confidence intervals, 0.95-0.99). Importantly, SWG or SWL were not associated with pancreas graft failure, P-DCGF, or K-DCGF. Interestingly in the adjusted model, SWG at 6 mo was associated with a lower risk for composite outcomes (HR, 0.35; 95% confidence intervals, 0.14-0.85). Forty-five percent of SPK recipients had significant weight changes by 6 mo post-transplant, but only 20% exhibited SWG. Likely because of proper management, weight changes were not associated with poor outcomes post-SPK transplant. |
| 696 | Didier Mandelbrot | NEPH | damandel@medicine.wisc.edu | Simultaneous Pancreas-Kidney Transplant Outcomes Stratified by Autoantibodies Status and Pretransplant Fasting C-peptide. | Pancreatic beta cell function and islet autoantibodies classically distinguish types of diabetes (type 1 diabetes mellitus [DM] or type 2 DM). Here, we sought to evaluate simultaneous pancreas-kidney (SPK) transplant outcomes stratified by the presence or absence of beta cell function and autoantibodies. SPK recipients were eligible if pretransplant autoantibodies were measured against insulin, islet cell, or glutamic acid decarboxylase 65-kD isoform. Recipients were categorized as A+ or A- based on the detection of ≥1 autoantibodies. Recipients were similarly categorized on the basis of detectable pretransplant fasting C-peptide of ≥2 ng/mL (β+) or 6.5. One hundred eighty-three SPK recipients were included: A+β- (n = 72), A-β- (n = 42), A-β+ (n = 49), and A+β+ (n = 20). We did not detect a statistical difference in non-death-censored pancreas graft failure for A+β- recipients compared with other groups: A-β- (adjusted hazard ratio [aHR]: 0.44; 95% confidence interval [CI], 0.14-1.42), A-β+ (aHR: 1.02; 95% CI, 0.37-2.85), and A+β+ (aHR: 0.67; 95% CI, 0.13-3.33) in adjusted analyses. Similar outcomes were observed for other outcomes. In SPK recipients, outcomes were similar among recipients with classic features of type 1 DM and various other types of DM. |
| 697 | Didier Mandelbrot | NEPH | damandel@medicine.wisc.edu | Navigating challenges in recipient selection for end-chain kidneys. | As a result of the increasing number of transplants being facilitated by kidney paired donation and newer initiatives such as voucher donation, end-chain (EC) kidneys now constitute a considerable proportion of kidney paired donation transplants in the United States. Data on EC kidneys are limited. They may be lower in quality compared with non-EC living donor kidneys. However, they can provide unique opportunities for recipient candidates without living donors. There are no data or algorithms available to guide recipient selection for EC kidneys accepted by a transplant center. Considering the ethical principles of utility, justice, and respect for persons that underlie organ allocation, we discuss 3 potential approaches for recipient selection: (1) adherence to the kidney allocation system, (2) utility maximization; and (3) priority to high-risk candidates, along with examples from our own center's experience. Similar considerations are also relevant to selection of recipients for nondirected donor organs and to out-of-sequence allocation for deceased organ donors. Because EC kidneys represent an increasing proportion of kidney paired donation-facilitated living kidney donor transplantation in the United States and will likely get more medically and surgically complex over time, ongoing research on their utilization and outcomes is needed. |
| 698 | Didier Mandelbrot | NEPH | damandel@medicine.wisc.edu | High Post-Kidney Transplant Serum Uric Acid Levels Are Associated with Detrimental Outcomes. | The potential effects of post-transplant serum uric acid (SUA) levels and outcomes pose a variety of risks among kidney transplant (KTR) recipients. The association between post-transplant SUA and major detrimental outcomes among KTRs remains uncertain. We evaluated all adult kidney transplant recipients (KTRs) transplanted between 1/1/2000 and 12/31/2019. Recipients were included if they had a functioning allograft without any cardiovascular events (CVE) before their earliest SUA measurement within 5-13 months post-transplant.Survival analyses were performed regarding CVEs, CVE-related mortality, death-censored graft failure (DCGF), and uncensored graft failure, within 10 years after transplantation. A total of 3808 eligible KTRs were followed for a median of 7.5 years after transplantation. Recipients with post-transplant SUA > 6.8 mg/dl had significantly higher risk of congestive heart failure (CHF) than those with SUA <6 mg/dl (adjusted hazard ratio [aHR] = 1.55, 95% CI: 1.10-2.19; p = 0.01); uncensored graft failure (aHR = 1.18, 95% CI: 1.02-1.36; p = 0.03), and DCGF (aHR = 1.28, 95% CI: 1.01-1.61; p = 0.04), after adjustment for multiple variables, including kidney graft function. No statistically significant association was found between SUA levels and other CVEs. There was no statistically significant risk for other outcomes of interest when comparing SUA < 6 mg/dl versus 6-6.8 mg/dl. Elevated early post-transplant SUA levels were associated with detrimental post-transplant outcomes, leading to increased morbidity and mortality through CHF, graft failure, and overall death. |
| 699 | Didier Mandelbrot | NEPH | damandel@medicine.wisc.edu | Delayed graft function has comparable associations with early outcomes in primary and repeat transplant among deceased-donor kidney transplant recipients. | Delayed graft function (DGF) is a common complication and is associated with worse outcomes among kidney transplant recipients (KTRs). There are various risk factors for DGF including previous transplant. We hypothesized that DGF among KTRs undergoing repeat transplant has a greater impact on outcomes compared to primary KTRs. All deceased-donor KTRs between 01/2000 and 12/2020 at our center were included. Recipients were categorized as primary KTR or repeat KTR (any number of previous kidney transplants). Outcomes of interest included acute rejection, death-censored graft failure, and patient mortality within 12 months post-transplant. A total of 3137 deceased-donor KTRs were included; 2498(80%) were primary KTRs and 639(20%) were repeat KTRs. The rates of DGF were similar between the groups at 29% and 28%, respectively. Compared to KTRs without DGF, DGF was associated with a greater incidence of death and graft failure in both primary and repeat transplants; however, the risk of rejection was not significantly higher in repeat KTRs (p = 0.72). Comparing primary and repeat KTRs, there were no significant differences in either acute rejection (p-interaction = 0.11), death-censored graft failure (p-interaction = 0.38), or death (p-interaction = 0.37). In subgroup analysis among repeat KTRs with DGF, a repeat transplant with no prior DGF was associated with increased risk for death-censored graft failure and death but not for acute rejection. DGF in the prior transplant was protective against death-censored graft failure (HR: 0.07, 95% CI 0.005-0.98, p = 0.05) (p-interaction = 0.04), but this was not significantly associated with acute rejection or death. DGF is associated with similar detrimental outcomes among primary and repeat KTRs. |
| 700 | Didier Mandelbrot | NEPH | damandel@medicine.wisc.edu | Analysis of Rejection, Infection and Surgical Outcomes in Type I Versus Type II Diabetic Recipients After Simultaneous Pancreas-Kidney Transplantation. | Given the increasing frequency of simultaneous pancreas-kidney transplants performed in recipients with Type II diabetes and CKD, we sought to evaluate possible differences in the rates of allograft rejection, infection, and surgical complications in 298 Type I (T1D) versus 47 Type II (T2D) diabetic recipients of simultaneous pancreas-kidney transplants between 2006-2017. There were no significant differences in patient or graft survival. The risk of biopsy-proven rejection of both grafts was not significantly different between T2D and T1D recipients (HRpancreas = 1.04, p = 0.93; HRkidney = 0.96; p = 0.93). Rejection-free survival in both grafts were also not different between the two diabetes types (ppancreas = 0.57; pkidney = 0.41). T2D had a significantly lower incidence of de novo DSA at 1 year (21% vs. 39%, p = 0.02). There was no difference in T2D vs. T1D recipients regarding readmissions (HR = 0.77, p = 0.25), infections (HR = 0.77, p = 0.18), major surgical complications (HR = 0.89, p = 0.79) and thrombosis (HR = 0.92, p = 0.90). In conclusion, rejection, infections, and surgical complications after simultaneous pancreas-kidney transplant are not statistically significantly different in T2D compared to T1D recipients. |
| 701 | Andrew Braun | APCC-Pulm | atbraun@medicine.wisc.edu | Vanzacaftor-tezacaftor-deutivacaftor versus elexacaftor-tezacaftor-ivacaftor in individuals with cystic fibrosis aged 12 years and older (SKYLINE Trials VX20-121-102 and VX20-121-103): results from two randomised, active-controlled, phase 3 trials. | The goal of cystic fibrosis transmembrane conductance regulator (CFTR) modulators is to reach normal CFTR function in people with cystic fibrosis. Vanzacaftor-tezacaftor-deutivacaftor restored CFTR function in vitro and in phase 2 trials in participants aged 18 years and older resulting in improvements in CFTR function, as measured by sweat chloride concentrations and lung function as measured by spirometry. We aimed to evaluate the efficacy and safety of vanzacaftor-tezacaftor-deutivacaftor compared with standard of care elexacaftor-tezacaftor-ivacaftor in individuals with cystic fibrosis aged 12 years and older. In two randomised, active-controlled, double-blind, phase 3 trials, individuals aged 12 years and older with stable cystic fibrosis with F508del-minimal function (SKYLINE Trial VX20-121-102) or with F508del-F508del, F508del-residual function, F508del-gating, or elexacaftor-tezacaftor-ivacaftor-responsive-non-F508del genotypes (SKYLINE Trial VX20-121-103) were enrolled at 126 and 159 international sites, respectively. Eligible individuals were entered into a 4-week run-in period, during which they received elexacaftor (200 mg once daily), tezacaftor (100 mg once daily), and ivacaftor (150 mg once every 12 h) as two fixed-dose combination tablets in the morning and one ivacaftor tablet in the evening. They were then randomly assigned (1:1) to either elexacaftor (200 mg once daily), tezacaftor (100 mg once daily), and ivacaftor (150 mg once every 12 h) as two fixed-dose combination tablets in the morning and one ivacaftor tablet in the evening, or vanzacaftor (20 mg once daily), tezacaftor (100 mg once daily), and deutivacaftor (250 mg once daily) as two fixed-dose combination tablets in the morning, for the 52-week treatment period. All participants received matching placebo tablets to maintain the treatment blinding. Randomisation was done using an interactive web-response system and stratified by age, FEV1 % predicted, sweat chloride concentration, and previous CFTR modulator use, and also by genotype for Trial VX20-121-103. The primary endpoint for both trials was absolute change in FEV1 % predicted from baseline (most recent value before treatment on day 1) through week 24 (with non-inferiority of vanzacaftor-tezacaftor-deutivacaftor shown if the lower bound of the 95% CI for the primary endpoint was -3·0 or higher). Efficacy was assessed in all participants with the intended CFTR genotype who were randomly assigned to treatment and received at least one dose of study treatment during the treatment period. Safety was assessed in all participants who received at least one dose of study drug during the treatment period. These trials are registered with ClinicalTrials.gov, NCT05033080 (Trial VX20-121-102) and NCT05076149 (Trial VX20-121-103), and are now complete. In Trial VX20-121-102 between Sept 14, 2021, and Oct 18, 2022, 488 individuals were screened, of whom 435 entered the 4-week run-in period, and subsequently 398 were randomly assigned and received at least one dose of elexacaftor-tezacaftor-ivacaftor (n=202) or vanzacaftor-tezacaftor-deutivacaftor (n=196). Median age was 31·0 years (IQR 22·6-38·5), 163 (41%) of 398 participants were female, 235 (59%) were male, and 388 (97%) were White. In Trial VX20-121-103, between Oct 27, 2021, and Oct 26, 2022, 699 individuals were screened, of whom 597 entered the 4-week run-in period, and subsequently 573 participants were randomly assigned and received at least one dose of elexacaftor-tezacaftor-ivacaftor (n=289) or vanzacaftor-tezacaftor-deutivacaftor (n=284). Median age was 33·1 years (IQR 24·5-42·2), 280 (49%) of 573 participants were female, 293 (51%) were male, and 532 (93%) were White. The absolute change in least squares mean FEV1 % predicted from baseline through week 24 for Trial VX20-121-102 was 0·5 (SE 0·3) percentage points in the vanzacaftor-tezacaftor-deutivacaftor group versus 0·3 (0·3) percentage points in the elexacaftor-tezacaftor-ivacaftor group (least squares mean treatment difference of 0·2 percentage points [95% CI -0·7 to 1·1]; p<0·0001), and for Trial VX20-121-103, was 0·2 (SE 0·3) percentage points in the vanzacaftor-tezacaftor-deutivacaftor group versus 0·0 (0·2) percentage points in the elexacaftor-tezacaftor-ivacaftor group (least squares mean treatment difference 0·2 percentage points [95% CI -0·5 to 0·9]; p<0·0001). Most adverse events were mild or moderate, with the most common being infective pulmonary exacerbation (133 [28%] of 480 participants in the pooled vanzacaftor-tezacaftor-deutivacaftor group vs 158 [32%] of 491 in the pooled elexacaftor-tezacaftor-ivacaftor group), cough (108 [23%] vs 101 [21%]), COVID-19 (107 [22%] vs 127 [26%]), and nasopharyngitis (102 [21%] vs 95 [19%]). Vanzacaftor-tezacaftor-deutivacaftor is non-inferior to elexacaftor-tezacaftor-ivacaftor in terms of FEV1 % predicted, and is safe and well tolerated. Once daily dosing with vanzacaftor-tezacaftor-deutivacaftor reduces treatment burden, potentially improving adherence, compared with the twice daily regimen of the current standard of care. The restoration of CFTR function and the potential variants treated are also considerations that should be compared with currently available CFTR modulators. Vertex Pharmaceuticals. |
| 702 | Andrew Braun | APCC-Pulm | atbraun@medicine.wisc.edu | Impact of Discontinuing Both Hypertonic Saline and Dornase Alfa after Elexacaftor-Tezacaftor-Ivacaftor in Cystic Fibrosis. | Rationale: Evaluating approaches to reduce treatment burden is a research priority among people with cystic fibrosis on highly effective modulators, including elexacaftor-tezacaftor-ivacaftor (ETI). Objectives: We sought to evaluate the impact of discontinuing both hypertonic saline (HS) and dornase alfa (DA) versus continuing both therapies among a subgroup of participants in the SIMPLIFY study who sequentially participated in trials evaluating the independent clinical effects of discontinuing HS and DA. Methods: SIMPLIFY participants ≥12 years old on ETI and constituting a subgroup using both HS and DA at study entry were randomized to the HS or DA trial and then randomized 1:1 to continue or discontinue the applicable therapy for 6 weeks. After completion of the first trial, eligible participants could enroll in the second trial beginning with a 2-week run-in. Study outcomes were compared across the duration of SIMPLIFY participation between a cohort remaining on both therapies during SIMPLIFY and a cohort that sequentially discontinued both as a result of trial randomizations. Multivariable regression models were used to estimate treatment differences, adjusted for time between trials, trial order, baseline age, sex at birth, and percent predicted forced expiratory volume in 1 second (ppFEV1) at study entry. Results: Forty-three participants discontinued both therapies by the end of SIMPLIFY, and 63 remained on both, with overall average ppFEV1 of 96.7% at study entry and 3.9 months as the average duration of follow-up from beginning of the first trial to completion of the second trial, including time between trials. No clinically meaningful difference in the change in ppFEV1 from baseline to completion of the second trial was observed between those who discontinued and those who remained on both therapies (difference: 0.22% off-on; 95% confidence interval = -1.60, 2.03). Changes in lung clearance index at 2.5% starting concentration, patient-reported outcomes, and safety outcomes were also comparable. Patient-reported treatment burden, as measured by a Cystic Fibrosis Questionnaire-Revised subscale, significantly decreased in those who discontinued both therapies. Conclusions: SIMPLIFY participants who sequentially discontinued both HS and DA experienced no meaningful changes in clinical outcomes and reported decreased treatment burden as compared with those who remained on both therapies. These data continue to inform a new era of postmodulator care of people with cystic fibrosis. |
| 703 | Andrew Braun | APCC-Pulm | atbraun@medicine.wisc.edu | Vitamin D status and variable responses to supplements depend in part on genetic factors in adults with cystic fibrosis. | Vitamin D sufficiency has been difficult to achieve consistently in patients with cystic fibrosis (CF), even with robust oral supplements. To assess vitamin D status and resistance to supplementation, we studied 80 adults using 25-hydroxyvitamin D (25OHD) determinations and whole genome sequencing to construct polygenic risk scores (PRS) that aggregate variants associated with vitamin D status. The results revealed that 30 % of patients were below the threshold of 30 ng/mL and thus should be regarded as insufficient despite normal vitamin E status, a reflection of adherence to fat soluble vitamin supplementation. The PRS values were significantly correlated with 25OHD concentrations, confirming our results in children with CF, and indicating that genetic factors play a role and have implications for therapy. |
| 704 | Andrew Braun | APCC-Pulm | atbraun@medicine.wisc.edu | Using A Work System Framework to Investigate Pharmacists' Roles in Cystic Fibrosis Management. | Cystic fibrosis (CF) is a genetic disease that requires complex, lifelong treatment regimens to maintain health and reduce disease progression. The aims of this study were 1) to gain the perspectives of multiple health professions to understand medication and well-being challenges of people living with CF; and 2) to apply the Systems Engineering Initiative for Patient Safety (SEIPS) model to further identify opportunities for pharmacists to support people with CF. Health care professionals were recruited from a Cystic Fibrosis Center in the Midwest, to participate in audio-recorded semistructured interviews. Topics examined during the interviews included medication education for patients as well as experiences with outpatient, specialty, and community pharmacists. The themes assessed during the pharmacist interviews included support for people living with CF, preferences in conducting medication education, and pharmacist-specific counseling. Interview transcripts were thematically analyzed into categories to determine major themes. Prevalent codes were categorized into 5 major themes guided by the SEIPS model. Interrater reliability was strong (kappa = 0.94). Five major themes were identified: 1) patient tasks; 2) external environment; 3) organizational conditions; 4) patient medication education; and 5) pharmacists' roles and tasks. Professionals identified the importance of the pharmacist on the multidisciplinary CF care team to enhance patient-centered care for people living with CF. This study highlights health care professionals' views on the unique skillset that pharmacists add to the care team, including a reduction in medication errors, improved adherence, and overall enhanced patient care. |
| 705 | Andrew Braun | APCC-Pulm | atbraun@medicine.wisc.edu | Effects of nasal high flow on nocturnal hypercapnia, sleep, and sympathovagal balance in patients with neuromuscular disorders. | In neuromuscular disorders (NMD), inspiratory muscle weakness may cause sleep-related hypoventilation requiring non-invasive ventilation (NIV). Alternatively, nasal high flow therapy (NHF) may ameliorate mild nocturnal hypercapnia (NH) through washout of anatomical dead space and generation of positive airway pressure. Ventilatory support by NIV or NHF might have favourable short-term effects on sympathovagal balance (SVB). This study comparatively investigated the effects of NHF and NIV on sleep-related breathing and SVB in NMD patients with evolving NH. Transcutaneous CO2 (ptcCO2), peripheral oxygen saturation (SpO2), sleep outcomes and SVB (spectral analysis of heart rate, diastolic blood pressure variability) along with haemodynamic measures (cardiac index, total peripheral resistance index) were evaluated overnight in 17 patients. Polysomnographies (PSG) were randomly split into equal parts with no treatment, NIV and NHF at different flow rates (20 l/min vs. 50 l/min). In-depth analysis of SVB and haemodynamics was performed on 10-min segments of stable N2 sleep taken from each intervention. Compared with no treatment, NHF20 and NHF50 did not significantly change ptcCO2, SpO2 or the apnea hypopnea index (AHI). NHF50 was poorly tolerated. In contrast, NIV significantly improved both gas exchange and AHI without adversely affecting sleep. During daytime, NHF20 and NHF50 had neutral effects on ventilation and oxygenation whereas NIV improved ptcCO2 and SpO2. Effects of NIV and NHF on SVB and haemodynamics were neutral during both night and daytime. NHF does not correct sleep-disordered breathing in NMD patients with NH. Both NHF and NIV exert no immediate effects on SVB. |
| 706 | Andrew Braun | APCC-Pulm | atbraun@medicine.wisc.edu | Effects of nasal high flow on sympathovagal balance, sleep, and sleep-related breathing in patients with precapillary pulmonary hypertension. | In precapillary pulmonary hypertension (PH), nasal high flow therapy (NHF) may favorably alter sympathovagal balance (SVB) and sleep-related breathing through washout of anatomical dead space and alleviation of obstructive sleep apnea (OSA) due to generation of positive airway pressure. To investigate the effects of NHF on SVB, sleep, and OSA in patients with PH, and compare them with those of positive airway pressure therapy (PAP). Twelve patients with PH (Nice class I or IV) and confirmed OSA underwent full polysomnography, and noninvasive monitoring of SVB parameters (spectral analysis of heart rate, diastolic blood pressure variability). Study nights were randomly split into four 2-h segments with no treatment, PAP, NHF 20 L/min, or NHF 50 L/min. In-depth SVB analysis was conducted on 10-min epochs during daytime and stable N2 sleep at nighttime. At daytime and compared with no treatment, NHF20 and NHF50 were associated with a flow-dependent increase in peripheral oxygen saturation but a shift in SVB towards increased sympathetic drive. At nighttime, NHF20 was associated with increased parasympathetic drive and improvements in sleep efficiency, but did not alter OSA severity. NHF50 was poorly tolerated. PAP therapy improved OSA but had heterogenous effects on SVB and neutral effects on sleep outcomes. Hemodynamic effects were neutral for all interventions. In sleeping PH patients with OSA NHF20 but not NHF50 leads to decreased sympathetic drive likely due to washout of anatomical dead space. NHF was not effective in lowering the apnea-hypopnoea index and NHF50 was poorly tolerated. |
| 707 | Andrew Braun | APCC-Pulm | atbraun@medicine.wisc.edu | Newborn screening alone insufficient to improve pulmonary outcomes for cystic fibrosis. | The Wisconsin Cystic Fibrosis Neonatal Screening Project was a randomized clinical trial (RCT) revealing that children receiving an early diagnosis of CF via newborn screening (NBS) had improved nutritional outcomes but similar lung disease severity compared to those who presented clinically. Because the evaluations of these subjects by protocol ended in 2012, our objective was to assess long-term pulmonary and mortality outcomes. Retrospective analysis of the RCT cohort utilized longitudinal outcome measures obtained from the Cystic Fibrosis Foundation Patient Registry (CFFPR). Data included screening assignment, clinical characteristics, percent predicted forced expiratory volume in 1 s (ppFEV1) and mortality. A random intercept model was used to compare the ppFEV1 decline of subjects between the two groups up to age 26 years. Mortality was analyzed using the Kaplan-Meier method. Of the 145 subjects who consented to the original study, 104 subjects met inclusion criteria and had adequate data in the CFFPR. Of 57 subjects in the screened group and 47 in the control group, the rates of ppFEV1 decline were 1.76%/year (95% CI 1.62 to 1.91%) and 1.43%/year (95% CI 1.26 to 1.60%), respectively (p<0.0002). Pseudomonas aeruginosa acquired before 2 years was partially responsible. There was no difference in mortality between the two groups. NBS alone does not improve pulmonary outcomes in CF, particularly when other risk factors supervene. In an era prior to strict infection control and current therapies, NBS for CF may be associated with worse pulmonary outcomes. |
| 708 | Andrew Braun | APCC-Pulm | atbraun@medicine.wisc.edu | Applying whole-genome sequencing in relation to phenotype and outcomes in siblings with cystic fibrosis. | Variations in disease onset and/or severity have often been observed in siblings with cystic fibrosis (CF), despite the same CFTR genotype and environment. We postulated that genomic variation (modifier and/or pharmacogenomic variants) might explain these clinical discordances. From a cohort of patients included in the Wisconsin randomized clinical trial (RCT) of newborn screening (NBS) for CF, we identified two brothers who showed discordant lung disease courses as children, with one milder and the other more severe than average, and a third, eldest brother, who also has severe lung disease. Leukocytes were harvested as the source of DNA, and whole-genome sequencing (WGS) was performed. Variants were identified and analyzed using in-house-developed informatics tools. Lung disease onset and severity were quantitatively different between brothers during childhood. The youngest, less severely affected brother is homozygous for HFE p.H63D. He also has a very rare PLG p.D238N variant that may influence host-pathogen interaction during chronic lung infection. Other variants of interest were found differentially between the siblings. Pharmacogenomics findings were consistent with the middle, most severely affected brother having poor outcomes to common CF treatments. We conclude that genomic variation between siblings with CF is expected. Variable lung disease severity may be associated with differences acting as genetic modifiers and/or pharmacogenomic factors, but large cohort studies are needed to assess this hypothesis. |
| 709 | Andrew Braun | APCC-Pulm | atbraun@medicine.wisc.edu | Amyotrophic Lateral Sclerosis and the Respiratory System. | Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder that always affects the respiratory muscles. It is characterized by degeneration of motor neurons in the brain and spinal cord. Respiratory complications are the most common causes of death in ALS and typically occur within 3 to 5 years of diagnosis. Because ALS affects both upper and lower motor neurons, it causes hyperreflexia, spasticity, muscle fasciculations, muscle atrophy, and weakness. It ultimately progresses to functional quadriplegia. ALS most commonly begins in the limbs, but in about one-third of cases it begins in the bulbar muscles responsible for speech and swallowing. |
| 710 | Andrew Braun | APCC-Pulm | atbraun@medicine.wisc.edu | Cystic fibrosis mutations and genotype-pulmonary phenotype analysis. | Although there are more than 1000 mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, most of them are uncommon and only limited information exists regarding genotype-pulmonary phenotype relationships. We determined and classified the CFTR mutations using denaturing high-performance liquid chromatography and developed new, quantitative methods to categorize pulmonary phenotypes. Two novel alleles were discovered, namely G1047R and 1525-2A-->G, which were accompanied by F508del and G551D mutations, respectively. Assessment of numerous options revealed that CF pulmonary phenotype categorization in children cannot be accomplished with clinical or pulmonary function data but is facilitated by longitudinal quantitative chest radiology. It was most useful to categorize pulmonary disease status by evaluating the typical pattern of abnormalities in patients homozygous for the F508del mutation, and then compare patients with minor mutations to this typical CF pulmonary phenotype. By this method, both patients with novel mutations have pulmonary phenotypes typical of F508del homozygotes. However, patients with class IV mutations (e.g., R347P) or with pancreatic sufficiency showed serial chest radiographs that were atypically mild. Longitudinal quantitative chest radiography provides a new strategy for CF pulmonary phenotype categorization that should be useful for genotype-phenotype delineation in individual patients and in both epidemiologic studies and clinical trials involving groups of children with CF. |
| 711 | Nathan Sandbo | APCC-Pulm | nsandbo@medicine.wisc.edu | Oncostatin-M Is Produced by Human Eosinophils and Expression Is Increased in Uncontrolled Severe Asthma. | |
| 712 | Nathan Sandbo | APCC-Pulm | nsandbo@medicine.wisc.edu | Altered control of breathing in a rat model of allergic lower airway inflammation. | Obstructive sleep apnea (OSA) is highly prevalent in patients with asthma. Asthma, dose-dependently to its duration, promotes incident OSA, suggesting that asthma plays a role in OSA pathogenesis. We hypothesized that asthma-related inflammation alters breathing control mechanisms, specifically the carotid chemoreflex. Accordingly, we measured hypoxic ventilatory responses (HVR) in awake, unrestrained, ovalbumin (OVA)-sensitized Brown Norway rats and compared them with responses in sham-sensitized (SALINE) controls. To differentiate the role of allergic inflammation from bronchoconstriction, we repeated hypoxic ventilatory response (HVR) after administration of formoterol, a long-acting bronchodilator. Blood and bronchoalveolar lavage (BAL) fluid were collected for quantification of inflammatory cytokines. The rise in ventilatory equivalent for O2 evoked by acute exposure to hypoxia was augmented following sensitization by OVA, whereas it remained stable after SALINE. This augmentation was driven by increased breathing frequency with no change in tidal volume. Tachypneic hyperventilation in normoxia was also observed with OVA. Neither the increased HVR nor excessive normoxic ventilation was affected by formoterol, suggesting that they were not secondary to lung mechanical constraints. Higher levels of inflammatory cytokines were observed in BAL fluid and serum of OVA versus SALINE. In OVA, serum interleukin-5 levels significantly correlated with change from baseline in ventilatory responses to severe hypoxia ([Formula: see text], 0.09). These observations are consistent with inflammation-induced enhancement of carotid chemoreflex function, i.e., increased controller gain, and they suggest a possible role for asthma-related allergic inflammation in the ventilatory instability known to promote upper airway collapse and sleep apnea in humans.NEW & NOTEWORTHY Asthma is a risk factor for obstructive sleep apnea (OSA); however, the mechanisms are incompletely understood. In a rat model of allergic inflammation associated with asthma, we found that ventilation in normoxia and ventilatory responses to hypoxia were markedly enhanced and related with systemic inflammation. These alterations indicating carotid chemoreflex sensitization, known to promote ventilatory instability during sleep in humans, may contribute to the increased OSA risk in asthma. |
| 713 | Nathan Sandbo | APCC-Pulm | nsandbo@medicine.wisc.edu | [(64)Cu]Cu-PEG-FUD peptide for noninvasive and sensitive detection of murine pulmonary fibrosis. | Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease resulting in irreversible scarring within the lungs. However, the lack of biomarkers that enable real-time assessment of disease activity remains a challenge in providing efficient clinical decision-making and optimal patient care in IPF. Fibronectin (FN) is highly expressed in fibroblastic foci of the IPF lung where active extracellular matrix (ECM) deposition occurs. Functional upstream domain (FUD) tightly binds the N-terminal 70-kilodalton domain of FN that is crucial for FN assembly. In this study, we first demonstrate the capacity of PEGylated FUD (PEG-FUD) to target FN deposition in human IPF tissue ex vivo. We subsequently radiolabeled PEG-FUD with 64Cu and monitored its spatiotemporal biodistribution via μPET/CT imaging in mice using the bleomycin-induced model of pulmonary injury and fibrosis. We demonstrated [64Cu]Cu-PEG-FUD uptake 3 and 11 days following bleomycin treatment, suggesting that radiolabeled PEG-FUD holds promise as an imaging probe in aiding the assessment of fibrotic lung disease activity. |
| 714 | Nathan Sandbo | APCC-Pulm | nsandbo@medicine.wisc.edu | Implementation of a prospective screening strategy to identify adults with a telomere biology disorder among those undergoing lung transplant evaluation for interstitial lung disease. | Patients with interstitial lung disease (ILD) secondary to telomere biology disorders (TBD) experience increased morbidity after lung transplantation. Identifying patients with TBD may allow for personalized management to facilitate better outcomes. However, establishing a TBD diagnosis in adults is challenging. A TBD screening questionnaire was introduced prospectively into the lung transplant evaluation. Patients with ILD screening positive were referred for comprehensive TBD phenotyping and concurrent telomere length measurement and germline genetic testing. Of 98 patients, 32 (33%) screened positive. Eight patients (8% of total; 25% of patients with a positive screen) met strict TBD diagnostic criteria, requiring either critically short lymphocyte telomeres (<1st percentile) (n = 4), a pathogenic variant in a TBD-associated gene (n = 1), or both (n = 3) along with a TBD clinical phenotype. Additional patients not meeting strict diagnostic criteria had histories consistent with TBD along with telomere lengths <10th percentile and/or rare variants in TBD-associated genes, highlighting a critical need to refine TBD diagnostic criteria for this patient population. A TBD phenotype screening questionnaire in patients with ILD undergoing lung transplant evaluation has a diagnostic yield of 25%. Additional gene discovery, rare variant functional testing, and refined TBD diagnostic criteria are needed to realize the maximum benefit of testing for TBD in patients undergoing lung transplantation. |
| 715 | Nathan Sandbo | APCC-Pulm | nsandbo@medicine.wisc.edu | Cardiovascular and Pulmonary Responses to Acute Use of Electronic Nicotine Delivery Systems and Combustible Cigarettes in Long-Term Users. | The acute cardiovascular and pulmonary effects of contemporary electronic nicotine delivery systems (ENDS) in long-term users are not known. What are the cardiovascular and pulmonary responses to an acute 15-min product use challenge with ENDS and combustible cigarettes in regular nicotine-containing product users compared with control participants who do not use tobacco or vape? Observational challenge study before and after nicotine-containing product use of 395 individuals who used ENDS exclusively (n = 164; exhaled carbon monoxide level, 5 ppm; positive urine NicCheck I results), and control participants (n = 114; carbon monoxide level, < 5 ppm; negative urine NicCheck I results). During the 15-min product challenge, cigarette users took a median of 14.0 puffs (interquartile range [IQR], 9.3 puffs); ENDS users took 9.0 puffs (IQR, 7.5 puffs; P < .001). After product challenge, compared with control participants, ENDS users showed greater increases in adjusted mean differences in systolic BP (5.6 mm Hg [95% CI, 4.4-6.8 mm Hg] vs 2.3 mm Hg [95% CI, 0.8-3.8 mm Hg]; P = .001), diastolic BP (4.2 mm Hg [95% CI, 3.3-5.0 mm Hg] vs 2.0 mm Hg [95% CI, 1.1-3.0 mm Hg; P = .003), and heart rate (4.8 beats/min [95% CI, 4.0-5.6 beats/min] vs -1.3 beats/min [95% CI, -2.2 to -0.3 beats/min]; P < .001) and greater reductions in brachial artery diameter (-0.011 cm [95% CI, -0.013 to 0.009 cm] vs -0.006 cm [95% CI, -0.004 to -0.009 cm]; P = .003), time-domain heart rate variability (-7.2 ms [95% CI, -10.5 to -3.7 ms] vs 3.6 ms [95% CI, 1.6-9.3 ms]; P = .001), and FEV1 (ENDS: -4.1 [95% CI, -5.4 to -2.8] vs control participants: -1.1 [95% CI, -2.7 to 0.6]; P = .005) with values similar to those of cigarette users. ENDS users performed worse than control participants on all exercise parameters, notably metabolic equivalents (METs; adjusted mean difference, 1.28 METs [95% CI, 0.73-1.83 METs]; P < .001) and 60-s heart rate recovery (adjusted mean difference, 2.9 beats/min [95% CI, 0.7-5.0 beats/min]; P = .008). ENDS users had acute worsening of blood pressure, heart rate, and heart rate variability, as well as vasoconstriction, impaired exercise tolerance, and increased airflow obstruction after vaping, compared to control participants. ClinicalTrials.gov; No.: NCT03863509; URL: www. gov. |
| 716 | Nathan Sandbo | APCC-Pulm | nsandbo@medicine.wisc.edu | Functional xenon-129 magnetic resonance imaging response to antifibrotic treatment in idiopathic pulmonary fibrosis. | A measure of regional gas exchange on HP 129Xe MRI was able to detect apparent improvements in IPF patients treated with antifibrotic medication after 1 year, while no such improvements were found in patients treated with conventional therapies https://bit.ly/3ZXipzD. |
| 717 | Nathan Sandbo | APCC-Pulm | nsandbo@medicine.wisc.edu | Hyperpolarized (129)Xe MR Spectroscopy in the Lung Shows 1-year Reduced Function in Idiopathic Pulmonary Fibrosis. | Background Idiopathic pulmonary fibrosis (IPF) is a temporally and spatially heterogeneous lung disease. Identifying whether IPF in a patient is progressive or stable is crucial for treatment regimens. Purpose To assess the role of hyperpolarized (HP) xenon 129 (129Xe) MRI measures of ventilation and gas transfer in IPF generally and as an early signature of future IPF progression. Materials and Methods In a prospective study, healthy volunteers and participants with IPF were consecutively recruited between December 2015 and August 2019 and underwent baseline HP 129Xe MRI and chest CT. Participants with IPF were followed up with forced vital capacity percent predicted (FVC%p), diffusing capacity of the lungs for carbon monoxide percent predicted (DLco%p), and clinical outcome at 1 year. IPF progression was defined as reduction in FVC%p by at least 10%, reduction in DLco%p by at least 15%, or admission to hospice care. CT and MRI were spatially coregistered and a measure of pulmonary gas transfer (red blood cell [RBC]-to-barrier ratio) and high-ventilation percentage of lung volume were compared across groups and across fibrotic versus normal-appearing regions at CT by using Wilcoxon signed rank tests. Results Sixteen healthy volunteers (mean age, 57 years ± 14 [SD]; 10 women) and 22 participants with IPF (mean age, 71 years ± 9; 15 men) were evaluated, as follows: nine IPF progressors (mean age, 72 years ± 7; five women) and 13 nonprogressors (mean age, 70 years ± 10; 11 men). Reduction of high-ventilation percent (13% ± 6.1 vs 8.2% ± 5.9; P = .03) and RBC-to-barrier ratio (0.26 ± 0.06 vs 0.20 ± 0.06; P = .03) at baseline were associated with progression of IPF. Participants with progressive disease had reduced RBC-to-barrier ratio in structurally normal-appearing lung at CT (0.21 ± 0.07 vs 0.28 ± 0.05; P = .01) but not in fibrotic regions of the lung (0.15 ± 0.09 vs 0.14 ± 0.04; P = .62) relative to the nonprogressive group. Conclusion In this preliminary study, functional measures of gas transfer and ventilation measured with xenon 129 MRI and the extent of fibrotic structure at CT were associated with idiopathic pulmonary fibrosis disease progression. Differences in gas transfer were found in regions of nonfibrotic lung. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Gleeson and Fraser in this issue. |
| 718 | Nathan Sandbo | APCC-Pulm | nsandbo@medicine.wisc.edu | Dynamic contrast enhanced MRI for the evaluation of lung perfusion in idiopathic pulmonary fibrosis. | The objective of this work was to apply quantitative and semiquantitative dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) methods to evaluate lung perfusion in idiopathic pulmonary fibrosis (IPF). In this prospective trial 41 subjects, including healthy control and IPF subjects, were studied using DCE-MRI at baseline. IPF subjects were then followed for 1 year; progressive IPF (IPFprog) subjects were distinguished from stable IPF (IPFstable) subjects based on a decline in percent predicted forced vital capacity (FVC % pred) or diffusing capacity of the lung for carbon monoxide (D LCO % pred) measured during follow-up visits. 35 out of 41 subjects were retained for final baseline analysis (control: n=15; IPFstable: n=14; IPFprog: n=6). Seven measures and their coefficients of variation (CV) were derived using temporally resolved DCE-MRI. Two sets of global and regional comparisons were made: control versus IPF groups and control versus IPFstable versus IPFprog groups, using linear regression analysis. Each measure was compared with FVC % pred, D LCO % pred and the lung clearance index (LCI % pred) using a Spearman rank correlation. DCE-MRI identified regional perfusion differences between control and IPF subjects using first moment transit time (FMTT), contrast uptake slope and pulmonary blood flow (PBF) (p≤0.05), while global averages did not. FMTT was shorter for IPFprog compared with both IPFstable (p=0.004) and control groups (p=0.023). Correlations were observed between PBF CV and D LCO % pred (rs= -0.48, p=0.022) and LCI % pred (rs= +0.47, p=0.015). Significant group differences were detected in age (p<0.001), D LCO % pred (p<0.001), FVC % pred (p=0.001) and LCI % pred (p=0.007). Global analysis obscures regional changes in pulmonary haemodynamics in IPF using DCE-MRI in IPF. Decreased FMTT may be a candidate marker for IPF progression. |
| 719 | Nathan Sandbo | APCC-Pulm | nsandbo@medicine.wisc.edu | An open microfluidic coculture model of fibroblasts and eosinophils to investigate mechanisms of airway inflammation. | Interactions between fibroblasts and immune cells play an important role in tissue inflammation. Previous studies have found that eosinophils activated with interleukin-3 (IL-3) degranulate on aggregated immunoglobulin G (IgG) and release mediators that activate fibroblasts in the lung. However, these studies were done with eosinophil-conditioned media that have the capacity to investigate only one-way signaling from eosinophils to fibroblasts. Here, we demonstrate a coculture model of primary normal human lung fibroblasts (HLFs) and human blood eosinophils from patients with allergy and asthma using an open microfluidic coculture device. In our device, the two types of cells can communicate via two-way soluble factor signaling in the shared media while being physically separated by a half wall. Initially, we assessed the level of eosinophil degranulation by their release of eosinophil-derived neurotoxin (EDN). Next, we analyzed the inflammation-associated genes and soluble factors using reverse transcription quantitative polymerase chain reaction (RT-qPCR) and multiplex immunoassays, respectively. Our results suggest an induction of a proinflammatory fibroblast phenotype of HLFs following the coculture with degranulating eosinophils, validating our previous findings. Additionally, we present a new result that indicate potential impacts of activated HLFs back on eosinophils. This open microfluidic coculture platform provides unique opportunities to investigate the intercellular signaling between the two cell types and their roles in airway inflammation and remodeling. |
| 720 | Nathan Sandbo | APCC-Pulm | nsandbo@medicine.wisc.edu | [(68) Ga]Ga-FAPI-46 PET for non-invasive detection of pulmonary fibrosis disease activity. | The lack of effective molecular biomarkers to monitor idiopathic pulmonary fibrosis (IPF) activity or treatment response remains an unmet clinical need. Herein, we determined the utility of fibroblast activation protein inhibitor for positron emission tomography (FAPI PET) imaging in a mouse model of pulmonary fibrosis. Pulmonary fibrosis was induced by intratracheal administration of bleomycin (1 U/kg) while intratracheal saline was administered to control mice. Subgroups from each cohort (n = 3-5) underwent dynamic 1 h PET/CT after intravenously injecting FAPI-46 radiolabeled with gallium-68 ([68 Ga]Ga-FAPI-46) at 7 days and 14 days following disease induction. Animals were sacrificed following imaging for ex vivo gamma counting and histologic correlation. [68 Ga]Ga-FAPI-46 uptake was quantified and reported as percent injected activity per cc (%IA/cc) or percent injected activity (%IA). Lung CT density in Hounsfield units (HU) was also correlated with histologic examinations of lung fibrosis. CT only detected differences in the fibrotic response at 14 days post-bleomycin administration. [68 Ga]Ga-FAPI-46 lung uptake was significantly higher in the bleomycin group than in control subjects at 7 days and 14 days. Significantly (P = 0.0012) increased [68 Ga]Ga-FAPI-46 lung uptake in the bleomycin groups at 14 days (1.01 ± 0.12%IA/cc) vs. 7 days (0.33 ± 0.09%IA/cc) at 60 min post-injection of the tracer was observed. These findings were consistent with an increase in both fibrinogenesis and FAP expression as seen in histology. CT was unable to assess disease activity in a murine model of IPF. Conversely, FAPI PET detected both the presence and activity of lung fibrogenesis, making it a promising tool for assessing early disease activity and evaluating the efficacy of therapeutic interventions in lung fibrosis patients. |
| 721 | Lynn Schnapp | APCC-Pulm | lschnapp@medicine.wisc.edu | Modeling lung endothelial dysfunction in sepsis-associated ARDS using a microphysiological system. | Endothelial dysfunction is a critical feature of acute respiratory distress syndrome (ARDS) associated with higher disease severity and worse outcomes. Preclinical in vivo models of sepsis and ARDS have failed to yield useful therapies in humans, perhaps due to interspecies differences in inflammatory responses and heterogeneity of human host responses. Use of microphysiological systems (MPS) to investigate lung endothelial function may shed light on underlying mechanisms and targeted treatments for ARDS. We assessed the response to plasma from critically ill sepsis patients in our lung endothelial MPS through measurement of endothelial permeability, expression of adhesion molecules, and inflammatory cytokine secretion. Sepsis plasma induced areas of endothelial cell (EC) contraction, loss of cellular coverage, and luminal defects. EC barrier function was significantly worse following incubation with sepsis plasma compared to healthy plasma. EC ICAM-1 expression, IL-6 and soluble ICAM-1 secretion increased significantly more after incubation with sepsis plasma compared with healthy plasma. Plasma from sepsis patients who developed ARDS further increased IL-6 and sICAM-1 compared to plasma from sepsis patients without ARDS and healthy plasma. Our results demonstrate the proof of concept that lung endothelial MPS can enable interrogation of specific mechanisms of endothelial dysfunction that promote ARDS in sepsis patients. |
| 722 | Lynn Schnapp | APCC-Pulm | lschnapp@medicine.wisc.edu | Transcriptomic characterization of lung pericytes in systemic sclerosis-associated pulmonary fibrosis. | Systemic sclerosis (SSc) is a chronic disease characterized by fibrosis and vascular abnormalities in the skin and internal organs, including the lung. SSc-associated pulmonary fibrosis (SSc-PF) is the leading cause of death in SSc patients. Pericytes are key regulators of vascular integrity and endothelial function. The role that pericytes play in SSc-PF remains unclear. We compared the transcriptome of pericytes from SSc-PF lungs (SScL) to pericytes from normal lungs (NORML). We identified 1,179 differentially expressed genes in SScL pericytes. Pathways enriched in SScL pericytes included prostaglandin, PI3K-AKT, calcium, and vascular remodeling signaling. Decreased cyclic AMP production and altered phosphorylation of AKT in response to prostaglandin E2 in SScL pericytes demonstrate the functional consequence of changes in the prostaglandin pathway that may contribute to fibrosis. The transcriptomic signature of SSc lung pericytes suggests that they promote vascular dysfunction and contribute to the loss of protection against lung inflammation and fibrosis. |
| 723 | Lynn Schnapp | APCC-Pulm | lschnapp@medicine.wisc.edu | Human Airway and Alveolar Organoids from BAL Fluid. | |
| 724 | Lynn Schnapp | APCC-Pulm | lschnapp@medicine.wisc.edu | Circulating biomarker analyses in a longitudinal cohort of patients with IPF. | Idiopathic pulmonary fibrosis (IPF) is an incurable interstitial lung disease characterized by fibrosis. Two FDA-approved drugs, pirfenidone and nintedanib, only modestly prolong survival. In this study, we asked whether levels of select circulating biomarkers in patients with IPF demonstrated changes in response to treatment over time and whether treatment with pirfenidone and nintedanib led to differential biomarker expression. Serial plasma samples from 48 patients with IPF on usual treatment and six healthy volunteers were analyzed to identify differentially expressed blood protein. Hypothesis-driven potential biomarker selection was based on recent literature, internal preclinical data, and the PROLIFIC Consortium (Schafer P. 6th Annual IPF Summit. Boston, MA, 2022) proposed biomarkers of pulmonary fibrosis. We compared our findings to public databases to provide insights into relevant signaling pathways in IPF. Of the 26 proteins measured, we found that 11 (SP-D, TIMP1, MMP7, CYFRA21-1, YKL40, CA125, sICAM, IP-10, MDC, CXCL13) were significantly elevated in patients with IPF compared with healthy volunteers but their levels did not significantly change over time. In the IPF samples, seven proteins were elevated in the treatment group compared with the no-treatment group. However, protein profiles were not distinguishable between patients on pirfenidone versus nintedanib. We demonstrated that most proteins differentially detected in our samples were predicted to be secreted from the lung epithelial or interstitial compartments. However, a significant minority of the proteins are not known to be transcriptionally expressed by lung cells, suggesting an ongoing systemic response. Understanding the contributions of the systemic response in IPF may be important as new therapeutics are developed.NEW & NOTEWORTHY In this study, we confirmed protein expression differences in only a subset of predicted biomarkers from IPF and control subjects. Most differentially expressed proteins were predicted to be secreted from lung cells. However, a significant minority of the proteins are not known to be transcriptionally expressed by lung cells, suggesting an ongoing systemic response. The contributions of the systemic response in IPF may be important as new therapeutics are developed. |
| 725 | Lynn Schnapp | APCC-Pulm | lschnapp@medicine.wisc.edu | Accelerating Action: Roadmap for the American Thoracic Society to Address Oppression and Health Inequity in Pulmonary and Critical Care Medicine. | |
| 726 | Lynn Schnapp | APCC-Pulm | lschnapp@medicine.wisc.edu | Historical Reflection as the American Thoracic Society Moves to Combat Racism in Pulmonary and Critical Care Medicine. | |
| 727 | Lynn Schnapp | APCC-Pulm | lschnapp@medicine.wisc.edu | Considerations in Selecting Venues for the American Thoracic Society International Conference: Balancing Competing Priorities of the Society's Diverse Membership. | |
| 728 | Lynn Schnapp | APCC-Pulm | lschnapp@medicine.wisc.edu | Nephronectin is required to maintain right lung lobar separation during embryonic development. | Nephronectin (NPNT) is a basement membrane (BM) protein and high-affinity ligand of integrin α8β1 that is required for kidney morphogenesis in mice. In the lung, NPNT also localizes to BMs, but its potential role in pulmonary development has not been investigated. Mice with a floxed Npnt allele were used to generate global knockouts (KOs). Staged embryos were obtained by timed matings of heterozygotes and lungs were isolated for analysis. Although primary and secondary lung bud formation was normal in KO embryos, fusion of right lung lobes, primarily the medial and caudal, was first detected at E13.5 and persisted into adulthood. The lung parenchyma of KO mice was indistinguishable from wild-type (WT) and lobe fusion did not alter respiratory mechanics in adult KO mice. Interrogation of an existing single-cell RNA-seq atlas of embryonic and adult mouse lungs identified Npnt transcripts in mesothelial cells at E12.5 and into the early postnatal period, but not in adult lungs. KO embryonic lungs exhibited increased expression of laminin α5 and deposition of collagen IV in the mesothelial BM, accompanied by abnormalities in collagen fibrils in the adjacent stroma. Cranial and accessory lobes extracted from KO embryonic lungs fused ex vivo when cultured in juxtaposition, with the area of fusion showing loss of the mesothelial marker Wilms tumor 1. Because a similar pattern of lobe fusion was previously observed in integrin α8 KO embryos, our results suggest that NPNT signaling through integrin α8, likely in the visceral pleura, maintains right lung lobe separation during embryogenesis. |
| 729 | Lynn Schnapp | APCC-Pulm | lschnapp@medicine.wisc.edu | Wellness and Coping of Physicians Who Worked in ICUs During the Pandemic: A Multicenter Cross-Sectional North American Survey. | Few surveys have focused on physician moral distress, burnout, and professional fulfilment. We assessed physician wellness and coping during the COVID-19 pandemic. Cross-sectional survey using four validated instruments. Sixty-two sites in Canada and the United States. Attending physicians (adult, pediatric; intensivist, nonintensivist) who worked in North American ICUs. None. We analysed 431 questionnaires (43.3% response rate) from 25 states and eight provinces. Respondents were predominantly male (229 [55.6%]) and in practice for 11.8 ± 9.8 years. Compared with prepandemic, respondents reported significant intrapandemic increases in days worked/mo, ICU bed occupancy, and self-reported moral distress (240 [56.9%]) and burnout (259 [63.8%]). Of the 10 top-ranked items that incited moral distress, most pertained to regulatory/organizational ( n = 6) or local/institutional ( n = 2) issues or both ( n = 2). Average moral distress (95.6 ± 66.9), professional fulfilment (6.5 ± 2.1), and burnout scores (3.6 ± 2.0) were moderate with 227 physicians (54.6%) meeting burnout criteria. A significant dose-response existed between COVID-19 patient volume and moral distress scores. Physicians who worked more days/mo and more scheduled in-house nightshifts, especially combined with more unscheduled in-house nightshifts, experienced significantly more moral distress. One in five physicians used at least one maladaptive coping strategy. We identified four coping profiles (active/social, avoidant, mixed/ambivalent, infrequent) that were associated with significant differences across all wellness measures. Despite moderate intrapandemic moral distress and burnout, physicians experienced moderate professional fulfilment. However, one in five physicians used at least one maladaptive coping strategy. We highlight potentially modifiable factors at individual, institutional, and regulatory levels to enhance physician wellness. |
| 730 | Lynn Schnapp | APCC-Pulm | lschnapp@medicine.wisc.edu | Be the Change: Advancing Lung Health and Closing the Global Healthcare Gap. | |
| 731 | Mihaela Teodorescu | APCC-Pulm | mt3@medicine.wisc.edu | Altered control of breathing in a rat model of allergic lower airway inflammation. | Obstructive sleep apnea (OSA) is highly prevalent in patients with asthma. Asthma, dose-dependently to its duration, promotes incident OSA, suggesting that asthma plays a role in OSA pathogenesis. We hypothesized that asthma-related inflammation alters breathing control mechanisms, specifically the carotid chemoreflex. Accordingly, we measured hypoxic ventilatory responses (HVR) in awake, unrestrained, ovalbumin (OVA)-sensitized Brown Norway rats and compared them with responses in sham-sensitized (SALINE) controls. To differentiate the role of allergic inflammation from bronchoconstriction, we repeated hypoxic ventilatory response (HVR) after administration of formoterol, a long-acting bronchodilator. Blood and bronchoalveolar lavage (BAL) fluid were collected for quantification of inflammatory cytokines. The rise in ventilatory equivalent for O2 evoked by acute exposure to hypoxia was augmented following sensitization by OVA, whereas it remained stable after SALINE. This augmentation was driven by increased breathing frequency with no change in tidal volume. Tachypneic hyperventilation in normoxia was also observed with OVA. Neither the increased HVR nor excessive normoxic ventilation was affected by formoterol, suggesting that they were not secondary to lung mechanical constraints. Higher levels of inflammatory cytokines were observed in BAL fluid and serum of OVA versus SALINE. In OVA, serum interleukin-5 levels significantly correlated with change from baseline in ventilatory responses to severe hypoxia ([Formula: see text], 0.09). These observations are consistent with inflammation-induced enhancement of carotid chemoreflex function, i.e., increased controller gain, and they suggest a possible role for asthma-related allergic inflammation in the ventilatory instability known to promote upper airway collapse and sleep apnea in humans.NEW & NOTEWORTHY Asthma is a risk factor for obstructive sleep apnea (OSA); however, the mechanisms are incompletely understood. In a rat model of allergic inflammation associated with asthma, we found that ventilation in normoxia and ventilatory responses to hypoxia were markedly enhanced and related with systemic inflammation. These alterations indicating carotid chemoreflex sensitization, known to promote ventilatory instability during sleep in humans, may contribute to the increased OSA risk in asthma. |
| 732 | Mihaela Teodorescu | APCC-Pulm | mt3@medicine.wisc.edu | Chronic intermittent hypoxia increases airway hyperresponsiveness during house dust mites exposures in rats. | Accumulating clinical evidence links Obstructive Sleep Apnea (OSA) with worse outcomes of asthma, but impact on airway function remains sparsely studied. We tested effects of Chronic Intermittent Hypoxia (CIH) - a hallmark of OSA - on airway hyperresponsiveness (AHR), in a rat model of chronic allergen-induced inflammation. Brown Norway rats were exposed to six weeks of CIH or normoxia (NORM) concurrent with weekly house dust mites (HDM) or saline (SAL) challenges. At endpoint, we assessed responses to seven Methacholine (Mch) doses (0, 4, 8, 16, 32, 64, 128 mg/mL) on a FlexiVent system (Scireq). Maximal (or plateau) responses (reactivity) for total respiratory system Resistance (Rrs) and Elastance (Ers), Newtonian airway resistance (RN, a measure of central airways function) and tissue damping (G, a measure of distal airways function) were plotted. HDM/CIH-treated animals demonstrated the highest reactivity to Mch in Rrs and Ers compared to all other groups (HDM/NORM, SAL/CIH and SAL/NORM p < 0.05 for all comparisons, for doses 5-7 for Rrs, and for doses 4-7 for Ers). The enhanced Rrs response was due to an increase in G (doses 4-7, p < 0.05 for comparisons to all other groups), whereas RN was not affected by CIH. In rats chronically challenged with HDM, concurrent CIH exposure induces AHR primarily in the distal airways, which affects the respiratory system frequency-dependent elastic properties. |
| 733 | Mihaela Teodorescu | APCC-Pulm | mt3@medicine.wisc.edu | Four weeks of repetitive acute hypoxic preconditioning did not alleviate allergen-induced airway dysfunction in rats. | Clinical case series suggest beneficial effects of low-dose intermittent hypoxia in asthma. We tested cardiopulmonary effects of repetitive acute hypoxic preconditioning (RAHP) during allergic inflammation. Brown Norway rats were sensitized to house dust mites (HDM) and exposed to 4-week RAHP or normoxia (SHAM), concurrent with weekly HDM or saline (SAL) challenges. We assessed methacholine responses and lung HIF-1α expression at endpoint, and weekly blood pressure (BP). RAHP relative to SHAM: 1) in HDM-challenged rats, showed no protection against HDM-induced airway dysfunction and did not significantly impact BP (week 4 mean BP difference = 10.51 mmHg, p = 0.09) or HIF-1α expression; 2) in SAL-challenged rats, attenuated airway responses to methacholine, reduced BP (week 4 mean BP average difference = -8.72 mmHg, p = 0.04) and amplified HIF-1α expression (p = 0.0086). Four weeks of RAHP did not mitigate the allergen-induced lower airway dysfunction and may detrimentally affect BP. However, it elicited beneficial cardiopulmonary responses in SAL-challenged rats, concurrent with increased HIF-1α expression. |
| 734 | Mihaela Teodorescu | APCC-Pulm | mt3@medicine.wisc.edu | Effects of allergic airway inflammation and chronic intermittent hypoxia on systemic blood pressure. | Asthma and obstructive sleep apnea (OSA) are highly prevalent chronic conditions, and both are associated with systemic hypertension. Additionally, asthma and OSA reciprocally interact, mutually exacerbating each other. In this study, we tested the effect of allergen-induced lower airway inflammation and concurrent chronic intermittent hypoxia (CIH) on systemic blood pressure (BP), pulmonary function, and proinflammatory cytokines, in a rat model. Brown Norway rats were exposed to 43 days of normoxia (NORM) or CIH, concurrent with weekly house dust mite (HDM) challenges. BP was measured 1 day after the last HDM challenge. On day 44, pulmonary function was tested, and blood for Th-2 and Th-1 cytokine levels was collected. HDM significantly increased mean (P = 0.002), systolic (P = 0.003), and diastolic (P = 0.004) BP compared with saline-challenged controls. Higher mean BP significantly correlated to increased total respiratory system resistance (R2 = 0.266, P = 0.002), driven by an association with parenchymal tissue dampening (R2 = 0.166, P = 0.016). HDM relative to saline-challenged controls increased the expression of serum IL-6 (P = 0.008), but no relationships of systemic BP with IL-6 or any other cytokines were found. CIH did not alter the allergen-induced responses on BP, although it tended to increase the expression of serum IL-6 (P = 0.06) and monocyte chemoattractant protein-1 (MCP-1, P = 0.09), regardless of HDM challenge. Chronic allergen-induced airway inflammation results in systemic hypertension that is correlated to the degree of distal airway obstruction induced by the allergen. These effects do not appear to be explained by the associated systemic inflammation. |
| 735 | Mihaela Teodorescu | APCC-Pulm | mt3@medicine.wisc.edu | The need for specificity in quantifying neurocirculatory vs. respiratory effects of eucapnic hypoxia and transient hyperoxia. | The carotid chemoreceptor mediates the ventilatory and muscle sympathetic nerve activity (MSNA) responses to hypoxia and contributes to tonic sympathetic and respiratory drives. It is often presumed that both excitatory and inhibitory tests of chemoreflex function show congruence in the end-organ responses. Ventilatory and neurocirculatory (MSNA, blood pressure and heart rate) responses to chemoreflex inhibition elicited by transient hyperoxia and to chemoreflex excitation produced by steady-state eucapnic hypoxia were measured in a cohort of 82 middle-aged individuals. Ventilatory and MSNA responsiveness to hyperoxia and hypoxia were not significantly correlated within individuals. It was concluded that ventilatory responses to hypoxia and hyperoxia do not predict MSNA responses and it is recommended that tests using the specific outcome of interest, i.e. MSNA or ventilation, are required. Transient hyperoxia is recommended as a sensitive and reliable means of quantifying tonic chemoreceptor-driven levels of sympathetic nervous system activity and respiratory drive. Hypersensitivity of the carotid chemoreceptor leading to sympathetic nervous system activation and ventilatory instability has been implicated in the pathogenesis and consequences of several common clinical conditions. A variety of treatment approaches aimed at lessening chemoreceptor-driven sympathetic overactivity are now under investigation; thus, the ability to quantify this outcome variable with specificity and precision is crucial. Accordingly, we measured ventilatory and neurocirculatory responses to chemoreflex inhibition elicited by transient hyperoxia and chemoreflex excitation produced by exposure to graded, steady-state eucapnic hypoxia in middle-aged men and women (n = 82) with continuous positive airway pressure-treated obstructive sleep apnoea. Progressive, eucapnic hypoxia produced robust and highly variable increases in ventilation (+83 ± 59%) and muscle sympathetic nerve activity (MSNA) burst frequency (+55 ± 31%), whereas transient hyperoxia caused marked reductions in these variables (-35 ± 14% and -42 ± 16%, respectively). Coefficients of variation for ventilatory and MSNA burst frequency responses, indicating test-retest reproducibility, were respectively 9% and 24% for hyperoxia and 35% and 28% for hypoxia. Based on statistical measures of rank correlation or even comparisons across quartiles of corresponding ventilatory and MSNA responses, we found that the magnitudes of ventilatory inhibition with hyperoxia or excitation with eucapnic hypoxia were not correlated with corresponding MSNA responses within individuals. We conclude that, in conscious, behaving humans, ventilatory sensitivities to progressive, steady-state, eucapnic hypoxia and transient hyperoxia do not predict MSNA responsiveness. Our findings also support the use of transient hyperoxia as a reliable, sensitive, measure of the carotid chemoreceptor contribution to tonic sympathetic nervous system activity and respiratory drive. |
| 736 | Mihaela Teodorescu | APCC-Pulm | mt3@medicine.wisc.edu | Restoring Pulmonary and Sleep Services as the COVID-19 Pandemic Lessens. From an Association of Pulmonary, Critical Care, and Sleep Division Directors and American Thoracic Society-coordinated Task Force. | Background: In March 2020, many elective medical services were canceled in response to the coronavirus disease 2019 (COVID-19) pandemic. The daily case rate is now declining in many states and there is a need for guidance about the resumption of elective clinical services for patients with lung disease or sleep conditions.Methods: Volunteers were solicited from the Association of Pulmonary, Critical Care, and Sleep Division Directors and American Thoracic Society. Working groups developed plans by discussion and consensus for resuming elective services in pulmonary and sleep-medicine clinics, pulmonary function testing laboratories, bronchoscopy and procedure suites, polysomnography laboratories, and pulmonary rehabilitation facilities.Results: The community new case rate should be consistently low or have a downward trajectory for at least 14 days before resuming elective clinical services. In addition, institutions should have an operational strategy that consists of patient prioritization, screening, diagnostic testing, physical distancing, infection control, and follow-up surveillance. The goals are to protect patients and staff from exposure to the virus, account for limitations in staff, equipment, and space that are essential for the care of patients with COVID-19, and provide access to care for patients with acute and chronic conditions.Conclusions: Transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a dynamic process and, therefore, it is likely that the prevalence of COVID-19 in the community will wax and wane. This will impact an institution's mitigation needs. Operating procedures should be frequently reassessed and modified as needed. The suggestions provided are those of the authors and do not represent official positions of the Association of Pulmonary, Critical Care, and Sleep Division Directors or the American Thoracic Society. |
| 737 | Mihaela Teodorescu | APCC-Pulm | mt3@medicine.wisc.edu | Asthma and Obstructive Sleep Apnea Overlap: What Has the Evidence Taught Us? | Obstructive sleep apnea (OSA) and asthma are highly prevalent chronic respiratory disorders. Beyond their frequent coexistence arising from their high prevalence and shared risk factors, these disorders feature a reciprocal interaction whereby each disease impacts the severity of the other. Emerging evidence implicates airway and systemic inflammation, neuroimmune interactions, and effects of asthma-controlling medications (corticosteroids) as factors that predispose patients with asthma to OSA. Conversely, undiagnosed or inadequately treated OSA adversely affects asthma control, partly via effects of intermittent hypoxia on airway inflammation and tissue remodeling. In this article, we review multiple lines of recently published evidence supporting this interaction. We provide a set of recommendations for clinicians involved in the care of adults with asthma, and identify critical gaps in our knowledge about this overlap. |
| 738 | Mihaela Teodorescu | APCC-Pulm | mt3@medicine.wisc.edu | Effects of inhaled fluticasone propionate on extrinsic tongue muscles in rats. | Obstructive sleep apnea (OSA) is more common in patients with asthma, and inhaled corticosteroids may contribute to OSA pathogenesis in these patients. This study tested the effects of orally inhaled fluticasone propionate (FP) on extrinsic tongue muscles. Unanesthetized rats were treated with FP or placebo for 28 days. On day 29, tongue retrusive and protrusive functions were tested via hypoglossal nerve stimulation under a state of anesthesia, followed by genioglossus (GG), styloglossus (SG) and hyoglossus (HG) muscle extraction, after euthanasia, for histology [myosin heavy chain (MHC) fibers and laminin content reflecting extracellular matrix (ECM)]. On protrusive testing, FP increased percent maximum tetanic force at 40 Hz (P = 0.03 vs. placebo) and endurance index (P = 0.029 vs. placebo). On retrusive testing, FP increased maximum twitch (P = 0.026 vs. placebo) and tetanic forces (P = 0.02 vs. placebo) with no effect on endurance index. On histology, FP increased GG cross-sectional area of MHC type IIa (P = 0.036 vs. placebo) and tended to increase type IIb (P = 0.057 vs. placebo) fibers and HG MHC IIx fibers (P = 0.065). The FP group had significantly increased laminin-stained areas, of greatest magnitude in the HG muscle. FP affects tongue protrusive and retrusive functions differently, concurrent with a shift in MHC fibers and increased ECM accumulation. These differential alterations may destabilize the tongue's "muscle hydrostat" during sleep and promote collapse.NEW & NOTEWORTHY The effects of inhaled corticosteroid on upper airway may contribute to OSA pathogenesis in asthma. In this study, we tested the effects of orally inhaled fluticasone propionate on tongue protrusive and retrusive functions and on tongue extrinsic muscle fiber composition and molecular properties. We found that fluticasone treatment: 1) increased protrusive endurance and retrusive maximum twitch and tetanic force; and 2) on histology, increased cross-sectional area of myosin heavy chain (MHC) type IIa fibers and tended to increase cross-sectional area of MHC type IIb fibers in the protrusive muscle and of MHC IIx fibers in the retrusors. It also increased laminin-stained areas, across extrinsic tongue muscles, of greatest magnitude in the retrusors; and 3) reduced protein degradation and activated pathways associated with increased protein synthesis in the protrusor. These differential effects on the protrusors and retrusors may destabilize the tongue's "muscle hydrostat" properties during sleep and promote collapse. |
| 739 | Mihaela Teodorescu | APCC-Pulm | mt3@medicine.wisc.edu | Apnea causes microvascular perfusion maldistribution in isolated rat lungs. | Obstructive sleep apnea is associated with significant cardiovascular disease, yet little is known about the effects of OSA on pulmonary microvascular perfusion. In a recent report, we showed that pulmonary microvascular perfusion was significantly mal-distributed in anesthetized, spontaneously breathing rats exposed to five episodes of obstructive apnea. We quantified microvascular perfusion by analyzing trapping patterns of 4 μm diameter fluorescent latex particles infused into the pulmonary circulation after the last episode. We could not determine if the perfusion maldistribution was due to the effects of large subatmospheric intrapleural pressures during apnea, or to precapillary OSA hypoxic vasoconstriction. To address this, we repeated these studies using isolated, buffer-perfused rat lungs (Ppulm art , 10 cm H2 O) ventilated in a chamber (-5 to -15 cm H2 O, 25 breaths/min; Ptrachea = 0). We simulated apnea by clamping the trachea and cycling the chamber pressures between -25 and -35 cm H2 O for five breaths. After five apnea episodes, we infused 4 μm diam. fluorescent latex particles into the pulmonary artery. The number of particles recovered from the venous effluent was 74% greater in nonapneic isolated lungs compared to apneic lungs (P ≤ 0.05). Apneic lungs also had perfusion maldistributions that were 73% greater than those without apnea (P ≤ 0.05). We conclude that simulated apnea in isolated, perfused rat lungs produces significantly greater particle trapping and microvascular perfusion maldistribution than in nonapneic isolated lungs. We believe these effects are due to the large, negative intrapleural pressures produced during apnea, and are not due to hypoxia. |
| 740 | Mihaela Teodorescu | APCC-Pulm | mt3@medicine.wisc.edu | Obstructive apnea causes microvascular perfusion maldistribution in the lungs of rats. | Obstructive sleep apnea (OSA) is associated with significant cardiovascular consequences, including pulmonary hypertension, yet little is known about its effects on pulmonary microvascular perfusion. To investigate effects of OSA on pulmonary microvascular perfusion, we clamped the tracheal cannulas of anesthetized, spontaneously breathing rats to simulate obstructive apnea. The clamp remained in place for 10 breaths before it was released to allow the animals to again breathe spontaneously. We repeated this protocol every 20 s until the rat experienced a total of five apneic episodes of 10 breaths each. We then infused into a femoral vein 108 fluorescent latex particles (4 µm diameter), which became trapped within the pulmonary microcirculation. We removed the lungs, allowed them to air-dry, and quantified the particle distributions in sections of the lungs using dispersion index (DI) analysis, a method we developed previously. The log of the DI (logDI) is a measure of perfusion maldistribution. Greater log(DI) values correspond to greater maldistribution. Apneic lungs had average logDI values of 1.28 (SD 0.24). Rats not subjected to apnea had average logDI values of 0.85 (SD 0.08) ( P ≤ 0.05). Rats that received latex particles 10 min or 24 h after apnea had average logDI values of 0.97 (SD 0.31) and 0.84 (SD 0.38), respectively (not significant). Our results demonstrate, for the first time, that a few apneic events produced significant, but temporary, perfusion maldistribution within the pulmonary microcirculation. Repeated nightly episodes of apnea over months and years may explain why human patients with OSA suffer from significantly greater cardiovascular disease than those without OSA. |
| 741 | Christie Bartels | RHEUM | cb4@medicine.wisc.edu | Geographic Socioeconomic Influences on Disease Activity in Rheumatoid Arthritis in an Academic and Safety Net Hospital System. | The objective of this study was to analyze the impact of the Area Deprivation Index (ADI) on disease activity and cardiovascular comorbidity in rheumatoid arthritis (RA). A retrospective analysis of adult patients with RA was conducted to highlight differences in academic and safety net hospital clinics. Demographics, RA medication history, patient portal engagement, primary care presence, emergency or inpatient visits, RA disease activity and functional scores, Charlson Comorbidity Index (CCI), and cardiovascular disease (CVD) presence were captured. The ADI rank was assigned using nine-digit zip codes. Patients were stratified by the upper versus lower ADI decile group and matched by age, sex, race, ethnicity, insurance, and CCI using propensity score analysis. Patients with RA from the academic practice (n = 542) and the safety net hospital (n = 496) were assessed. In the academic cohort, those with high ADI scores (>8, more deprivation) had higher RA disease activity scores (Routine Assessment of Patient Index Data 3 mean ± SD: high 13.83 ± 6.94 vs low 11.17 ± 7.37, P < 0.0001; Clinical Disease Activity Index mean ± SD: high 11.97 ± 11.74 vs low 9.40 ± 7.97, P < 0.05), more functional impairment (Multidimensional Health Assessment Questionnaire mean ± SD: high 2.99 ± 2.29 vs low 2.34 ± 2.23, P < 0.01), lower MyChart use (P < 0.001), and different smoking history (P < 0.01) compared to those with low ADI scores (<3, less deprivation). In the safety net cohort, there was a statistically significant difference only in smoking status (P < 0.05). CVD was not significantly different in either cohort. The absence of differences in RA disease activity and functional impairment in patients suggests that the ADI may not be as effective at predicting RA disease activity specifically in a safety net health care context. Identifying the discrepancies between the two systems may elucidate areas of improvement for patient care. |
| 742 | Christie Bartels | RHEUM | cb4@medicine.wisc.edu | Renal Arteriosclerosis in kidney biopsies associated with higher 10-year atherosclerotic cardiovascular disease in lupus nephritis. | Patients with lupus nephritis (LN), including those below age 50, face significantly higher risk of atherosclerotic cardiovascular disease (ASCVD) vs. peers. This highlights the need for identifying specific ASCVD risk factors in LN. Renal arteriosclerosis in kidney biopsies (subclinical arteriosclerosis) may be able to predict future clinical ASCVD events. However, renal arteriosclerosis is under-reported in LN biopsies and is not taken into consideration when ASCVD risk is calculated. Therefore, we aimed to systematically grade renal arteriosclerosis in kidney biopsies at LN diagnosis and examined associations with 10- & 20-year ASCVD occurrence. Adults with biopsy proven LN were included. Clinical ASCVD, including fatal & non-fatal events, were adjudicated. Utilizing standard Banff grading criteria, all biopsies at LN diagnosis were re-read to grade renal arteriosclerosis. Covariables (e.g., socio-demographics, comorbidities, med exposure) were abstracted. Using Cox models, factors (including renal arteriosclerosis) associated with 10- & 20-year clinical ASCVD were examined. Among 209 patients, 36 & 49 clinical ASCVD occurred within 10 & 20 years. Renal arteriosclerosis (>25%) was associated with 3x higher 10-year ASCVD. High area deprivation index (>80) & longer angiotensin converting enzyme inhibitor (ACEi) exposure were associated with 4x higher & 0.65x lower ASCVD occurrence. Adding renal arteriosclerosis >25% improved model performance for 10-year ASCVD risk estimation from 65% to 80%. Similar associations were seen with 20-year ASCVD. Renal arteriosclerosis >25%, area deprivation, ACEi exposure could inform ASCVD risk stratification in LN. Prospective studies should validate findings and inform clinical use. |
| 743 | Christie Bartels | RHEUM | cb4@medicine.wisc.edu | Therapeutic Hydroxychloroquine Blood Levels Are Associated With Fewer Hospitalizations and Possible Reduction of Health Disparities in Lupus. | Nonadherence to receiving hydroxychloroquine (HCQ) is associated with a three-fold higher risk of lupus-related hospitalization. Monitoring HCQ blood levels could improve adherence to receiving HCQ and efficacy. Yet, HCQ level monitoring is not routinely done partially due to cost and coverage concerns. To establish HCQ level monitoring cost-effectiveness, we reported the following: (1) risk of acute care by HCQ blood levels, and (2) cost of HCQ monitoring versus acute care visits. HCQ blood levels were measured during routine lupus visits. HCQ levels were categorized as follows: (1) subtherapeutic (1,200 ng/mL). All lupus-related acute care visits (emergency room visits/hospitalizations) after the index clinic visit until next follow-up were abstracted. In our primary analysis, we examined associations between HCQ levels and time to first acute care visit in all patients and subgroups with higher rates of acute care. A total of 39 lupus-related acute care visits were observed in 181 patients. Therapeutic HCQ blood levels were associated with 66% lower rates of acute care. In our cohort, two groups, Black or Hispanic patients and those with public insurance, faced three to four times higher rates of acute care. Levels within 750 to 1,200 ng/mL were associated with 95% lower rates of acute care use in subgroups with higher acute care use. HCQ blood levels within 750 to 1,200 ng/mL are associated with lower rates of acute care in all patients with lupus, including groups with higher rates of acute care. Future clinical trials should establish the causal association between HCQ level monitoring and acute care in patients with lupus. |
| 744 | Christie Bartels | RHEUM | cb4@medicine.wisc.edu | Leveraging the Consolidated Framework for Implementation Research to Develop the American College of Rheumatology's Toolkit for Implementation of Rheumatoid Arthritis Outcome Measures in Clinical Practice: A Qualitative Study. | Despite the recognized benefits of collecting rheumatoid arthritis (RA) outcomes measures, their use in routine care is inconsistent. Using the Consolidated Framework for Implementation Research (CFIR), we conducted semistructured interviews with US rheumatologists and practice personnel to assess workflows, opportunities, and challenges in collecting RA outcome measures. Using insights from interviews, we developed the RA Measures Toolkit to enhance their use in clinical practice. We invited 138 Rheumatology Informatics System for Effectiveness (RISE) registry practices and 5 academic medical centers with ≥30 patients eligible for RA outcome measures to participate in the study. Practices were classified based on their performance in quality payment programs. Recorded interviews were transcribed verbatim and analyzed thematically using deductive and inductive techniques. The findings were used to create the RA Measures Toolkit. We conducted 20 interviews with 38 participants across 20 practices. Key themes within the CFIR domains highlighted the challenges and best practices in RA outcome measure collection and included (1) process: the variability in practices' use of RA outcome measures and the importance of streamlined workflows; (2) intervention: challenges of integrating patient-reported outcomes into electronic health records; and (3) individual characteristics: importance of clinic culture around quality improvement. Using these data, we developed the RA Measures Toolkit, a multimedia online resource, featuring guidelines, best practices, and educational resources to improve the efficiency of current workflows and to enhance patient care. This study identifies critical gaps in the collection of RA outcome measures in US rheumatology practices and provides actionable recommendations and resources to address challenges via the RA Measures Toolkit. |
| 745 | Christie Bartels | RHEUM | cb4@medicine.wisc.edu | Multiplicative Impact of Adverse Social Determinants of Health on Outcomes in Lupus Nephritis: A Meta-analysis and Systematic Review. | Social determinants of health (SDoH) likely contribute to outcome disparities in lupus nephritis (LN). Understanding the overall burden and contribution of each domain could guide future health equity-focused interventions to improve outcomes and reduce disparities in LN. Objectives of this meta-analysis were to 1) determine the association of overall SDoH and specific SDoH domains on LN outcomes and 2) develop a framework for the multidimensional impact of SDoH on LN outcomes. We performed a comprehensive search of studies measuring associations between SDoH and LN outcomes. We examined pooled odds of poor LN outcomes including death, end-stage kidney disease, or cardiovascular disease in patients with and without adverse SDoH. Additionally, we calculated the pooled odds ratios of outcomes by four SDoH domains: individual (eg, insurance), health care (eg, fragmented care), community (eg, neighborhood socioeconomic status), and health behaviors (eg, smoking). Among 531 screened studies, 31 meeting inclusion criteria and 13 with raw data were included in meta-analysis. Pooled odds of poor outcomes were 1.47-fold higher in patients with any adverse SDoH. Patients with adverse SDoH in individual and health care domains had 1.64-fold and 1.77-fold higher odds of poor outcomes. We found a multiplicative impact of having two or more adverse SDoH on LN outcomes. Black patients with public insurance and fragmented care had 12-fold higher odds of poor LN outcomes. Adverse SDoH is associated with poor LN outcomes. Having two or more adverse SDoH, specifically in different SDoH domains, had a multiplicative impact leading to worse LN outcomes, widening disparities. |
| 746 | Christie Bartels | RHEUM | cb4@medicine.wisc.edu | Implementing a Staff-Led Smoking Cessation Intervention in a Diverse Safety-Net Rheumatology Clinic: A Pre-Post Scalability Study in a Low-Resource Setting. | Quit Connect (QC), our specialty clinic smoking cessation intervention, supports clinic staff to check, advise, and connect willing patients to a state quit line or class. QC improved tobacco screening and quit line referrals 26-fold in a predominantly White academic health care system population. Implementing QC includes education, electronic health record (EHR) reminders, and periodic audit feedback. This study tested QC's feasibility and impact in a safety-net rheumatology clinic with a predominantly Black population. In this pre-post study, adult rheumatology visits were analyzed 12 months before through 18 months after QC intervention (November 2019 through November 2021, omitting COVID-19 peak April through November 2020). EHR data compared process and clinical outcomes, including offers, referrals to resources, completed referrals, and documented cessation. Clinic staff engaged in pre-post focus groups and questionnaires regarding intervention feasibility and acceptability. Cost-effectiveness was also assessed. Visit-level patients who smoked were 89.8% Black and 69.5% women (n = 550). Before intervention, clinic staff rarely asked patients about readiness to cut back smoking (<10% assessment). After QC intervention, staff assessed quit readiness in 31.8% of visits with patients who smoked (vs 8.1% before); 58.9% of these patients endorsed readiness to cut back or quit. Of 102 accepting cessation services, 37% (n = 17) of those reached set a quit date. Staff found the intervention feasible and acceptable. Each quit attempt cost approximately $4 to $10. In a safety-net rheumatology clinic with a predominantly Black population, QC improved tobacco screening, readiness-to-quit assessment, and referrals and was also feasible and cost-effective. |
| 747 | Christie Bartels | RHEUM | cb4@medicine.wisc.edu | Alzheimer incidence and prevalence with and without asthma: A Medicare cohort study. | International data suggest that asthma, like other inflammatory diseases, might increase Alzheimer disease (AD) risk. We sought to explore risk pathways and future mitigation strategies by comparing diagnostic claims-based AD incidence and prevalence among US patients with asthma with those without asthma. This cohort study included a national Medicare 20% random sample (2013-2015). Adult patients with asthma with more than 12 months continuous Medicare were compared with subjects without asthma overall and as matched. Asthma was defined by 1 inpatient or 2 outpatient codes for asthma. The main outcomes were 2-year incident or prevalent AD defined by International Classification of Diseases, Ninth Revision code 331.0 or Tenth Revision code G30.0, G30.1, G30.8, or G30.9. Among 5,460,732 total beneficiaries, 678,730 patients were identified with baseline asthma and more often identified as Black or Hispanic, were Medicaid eligible, or resided in a highly disadvantaged neighborhood than those without asthma. Two-year incidence of AD was 1.4% with asthma versus 1.1% without asthma; prevalence was 7.8% versus 5.4% (both P ≤ .001). Per 100,000 patients over 2 years, 303 more incident AD diagnoses occurred in those with asthma, with 2,425 more prevalent cases (P < .001). Multivariable models showed that asthma had greater odds of 2-year AD incidence (adjusted odds ratio, 1.33 [95% CI, 1.29-1.36]; matched 1.2 [95% CI, 1.17-1.24]) and prevalence (adjusted odds ratio, 1.48 [95% CI, 1.47-1.50]; matched 1.25 [95% CI, 1.22-1.27]). Asthma was associated with 20% to 33% increased 2-year incidence and 25% to 48% increased prevalence of claims-based AD in this nationally representative US sample. Future research should investigate risk pathways of underlying comorbidities and social determinants as well as whether there are potential asthma treatments that may preserve brain health. |
| 748 | Christie Bartels | RHEUM | cb4@medicine.wisc.edu | Receipt of rheumatology care and lupus-specific labs among young adults with systemic lupus erythematosus: A US Medicare retention in care cohort study. | In systemic lupus erythematosus, poor disease outcomes occur in young adults, patients identifying as Black or Hispanic, and socioeconomically disadvantaged patients. These identities and social factors differentially shape care access and quality that contribute to lupus health disparities in the US. Thus, our objective was to measure markers of care access and quality, including rheumatology visits (longitudinal care retention) and lupus-specific serology testing, by race and ethnicity, neighborhood disadvantage, and geographic context. This cohort study used a geo-linked 20% national sample of young adult Medicare beneficiaries (ages 18-35) with lupus-coded encounters and a 1-year assessment period. Retention in lupus care required a rheumatology visit in each 6-month period, and serology testing required ≥1 complement or dsDNA antibody test within the year. Multivariable logistic regression models were fit for visit-based retention and serology testing to determine associations with race and ethnicity, neighborhood disadvantage, and geography. Among 1,036 young adults with lupus, 39% saw a rheumatologist every 6 months and 28% had serology testing. White beneficiaries from the least disadvantaged quintile of neighborhoods had higher visit-based retention than other beneficiaries (64% vs 30%-60%). Serology testing decreased with increasing neighborhood disadvantage quintile (aOR 0.80; 95% CI 0.71, 0.90) and in the Midwest (aOR 0.46; 0.30, 0.71). Disparities in care, measured by rheumatology visits and serology testing, exist by neighborhood disadvantage, race and ethnicity, and region among young adults with lupus, despite uniform Medicare coverage. Findings support evaluating lupus care quality measures and their impact on US lupus outcomes. |
| 749 | Christie Bartels | RHEUM | cb4@medicine.wisc.edu | Walk With Ease made easier: A community feasibility pilot study of implementing an arthritis activity intervention. | |
| 750 | Christie Bartels | RHEUM | cb4@medicine.wisc.edu | Trends in avascular necrosis and related arthroplasties in hospitalized patients with systemic lupus erythematosus and rheumatoid arthritis. | Avascular necrosis (AVN) is a devastating complication often necessitating arthroplasty, particularly common in systemic lupus erythematosus (SLE). Limited research exists on arthroplasty trends since new steroid-sparing agents. We analyzed trends and characteristics associated with AVN and AVN-related arthroplasties among SLE and RA hospitalizations using two decades of data from the U.S. National Inpatient Sample (NIS). This cross-sectional study used NIS (2000-2019) to identify hospitalized adults with SLE and RA, with or without AVN, using ICD codes. AVN was further grouped by arthroplasty status. Primary outcomes were AVN and AVN-related arthroplasty rates and time trends in SLE and RA. Baseline sociodemographics and comorbidities were compared. Analyses used STATA and Joinpoint regression to calculate annual percent change (APC). Overall, 42,728 (1.3 %) SLE and 43,600 (0.5 %) RA hospitalizations had concomitant AVN (SLE-AVN and RA-AVN). Of these, 16,724 (39 %) and 25,210 (58 %) underwent arthroplasties, respectively. RA-AVN increased (APC: 0.98*), with a decrease in arthroplasties (APC: -0.82*). In contrast, SLE-AVN initially increased with a breakpoint in 2011 (APC 2000-2011: 1.94* APC 2011-2019 -2.03), with declining arthroplasties (APC -2.03*). AVN hospitalizations consisted of individuals who were younger and of Black race; while arthroplasties were less likely in individuals of Black race or Medicaid coverage. We report a breakpoint in rising SLE-AVN after 2011, which may relate to newer steroid-sparing therapies (i.e., belimumab). AVN-associated arthroplasties decreased in SLE and RA. Fewer AVN-associated arthroplasties were noted for Black patients and those with Medicaid, indicating potential disparities. Further research should examine treatment differences impacting AVN and arthroplasty rates. |
| 751 | Shivani Garg | RHEUM | sgarg@medicine.wisc.edu | Renal Arteriosclerosis in kidney biopsies associated with higher 10-year atherosclerotic cardiovascular disease in lupus nephritis. | Patients with lupus nephritis (LN), including those below age 50, face significantly higher risk of atherosclerotic cardiovascular disease (ASCVD) vs. peers. This highlights the need for identifying specific ASCVD risk factors in LN. Renal arteriosclerosis in kidney biopsies (subclinical arteriosclerosis) may be able to predict future clinical ASCVD events. However, renal arteriosclerosis is under-reported in LN biopsies and is not taken into consideration when ASCVD risk is calculated. Therefore, we aimed to systematically grade renal arteriosclerosis in kidney biopsies at LN diagnosis and examined associations with 10- & 20-year ASCVD occurrence. Adults with biopsy proven LN were included. Clinical ASCVD, including fatal & non-fatal events, were adjudicated. Utilizing standard Banff grading criteria, all biopsies at LN diagnosis were re-read to grade renal arteriosclerosis. Covariables (e.g., socio-demographics, comorbidities, med exposure) were abstracted. Using Cox models, factors (including renal arteriosclerosis) associated with 10- & 20-year clinical ASCVD were examined. Among 209 patients, 36 & 49 clinical ASCVD occurred within 10 & 20 years. Renal arteriosclerosis (>25%) was associated with 3x higher 10-year ASCVD. High area deprivation index (>80) & longer angiotensin converting enzyme inhibitor (ACEi) exposure were associated with 4x higher & 0.65x lower ASCVD occurrence. Adding renal arteriosclerosis >25% improved model performance for 10-year ASCVD risk estimation from 65% to 80%. Similar associations were seen with 20-year ASCVD. Renal arteriosclerosis >25%, area deprivation, ACEi exposure could inform ASCVD risk stratification in LN. Prospective studies should validate findings and inform clinical use. |
| 752 | Shivani Garg | RHEUM | sgarg@medicine.wisc.edu | Therapeutic Hydroxychloroquine Blood Levels Are Associated With Fewer Hospitalizations and Possible Reduction of Health Disparities in Lupus. | Nonadherence to receiving hydroxychloroquine (HCQ) is associated with a three-fold higher risk of lupus-related hospitalization. Monitoring HCQ blood levels could improve adherence to receiving HCQ and efficacy. Yet, HCQ level monitoring is not routinely done partially due to cost and coverage concerns. To establish HCQ level monitoring cost-effectiveness, we reported the following: (1) risk of acute care by HCQ blood levels, and (2) cost of HCQ monitoring versus acute care visits. HCQ blood levels were measured during routine lupus visits. HCQ levels were categorized as follows: (1) subtherapeutic (1,200 ng/mL). All lupus-related acute care visits (emergency room visits/hospitalizations) after the index clinic visit until next follow-up were abstracted. In our primary analysis, we examined associations between HCQ levels and time to first acute care visit in all patients and subgroups with higher rates of acute care. A total of 39 lupus-related acute care visits were observed in 181 patients. Therapeutic HCQ blood levels were associated with 66% lower rates of acute care. In our cohort, two groups, Black or Hispanic patients and those with public insurance, faced three to four times higher rates of acute care. Levels within 750 to 1,200 ng/mL were associated with 95% lower rates of acute care use in subgroups with higher acute care use. HCQ blood levels within 750 to 1,200 ng/mL are associated with lower rates of acute care in all patients with lupus, including groups with higher rates of acute care. Future clinical trials should establish the causal association between HCQ level monitoring and acute care in patients with lupus. |
| 753 | Shivani Garg | RHEUM | sgarg@medicine.wisc.edu | A Bitter Pill to Swallow: The Challenge of Medication Nonadherence in Systemic Lupus Erythematosus. | |
| 754 | Shivani Garg | RHEUM | sgarg@medicine.wisc.edu | Multiplicative Impact of Adverse Social Determinants of Health on Outcomes in Lupus Nephritis: A Meta-analysis and Systematic Review. | Social determinants of health (SDoH) likely contribute to outcome disparities in lupus nephritis (LN). Understanding the overall burden and contribution of each domain could guide future health equity-focused interventions to improve outcomes and reduce disparities in LN. Objectives of this meta-analysis were to 1) determine the association of overall SDoH and specific SDoH domains on LN outcomes and 2) develop a framework for the multidimensional impact of SDoH on LN outcomes. We performed a comprehensive search of studies measuring associations between SDoH and LN outcomes. We examined pooled odds of poor LN outcomes including death, end-stage kidney disease, or cardiovascular disease in patients with and without adverse SDoH. Additionally, we calculated the pooled odds ratios of outcomes by four SDoH domains: individual (eg, insurance), health care (eg, fragmented care), community (eg, neighborhood socioeconomic status), and health behaviors (eg, smoking). Among 531 screened studies, 31 meeting inclusion criteria and 13 with raw data were included in meta-analysis. Pooled odds of poor outcomes were 1.47-fold higher in patients with any adverse SDoH. Patients with adverse SDoH in individual and health care domains had 1.64-fold and 1.77-fold higher odds of poor outcomes. We found a multiplicative impact of having two or more adverse SDoH on LN outcomes. Black patients with public insurance and fragmented care had 12-fold higher odds of poor LN outcomes. Adverse SDoH is associated with poor LN outcomes. Having two or more adverse SDoH, specifically in different SDoH domains, had a multiplicative impact leading to worse LN outcomes, widening disparities. |
| 755 | Shivani Garg | RHEUM | sgarg@medicine.wisc.edu | Receipt of rheumatology care and lupus-specific labs among young adults with systemic lupus erythematosus: A US Medicare retention in care cohort study. | In systemic lupus erythematosus, poor disease outcomes occur in young adults, patients identifying as Black or Hispanic, and socioeconomically disadvantaged patients. These identities and social factors differentially shape care access and quality that contribute to lupus health disparities in the US. Thus, our objective was to measure markers of care access and quality, including rheumatology visits (longitudinal care retention) and lupus-specific serology testing, by race and ethnicity, neighborhood disadvantage, and geographic context. This cohort study used a geo-linked 20% national sample of young adult Medicare beneficiaries (ages 18-35) with lupus-coded encounters and a 1-year assessment period. Retention in lupus care required a rheumatology visit in each 6-month period, and serology testing required ≥1 complement or dsDNA antibody test within the year. Multivariable logistic regression models were fit for visit-based retention and serology testing to determine associations with race and ethnicity, neighborhood disadvantage, and geography. Among 1,036 young adults with lupus, 39% saw a rheumatologist every 6 months and 28% had serology testing. White beneficiaries from the least disadvantaged quintile of neighborhoods had higher visit-based retention than other beneficiaries (64% vs 30%-60%). Serology testing decreased with increasing neighborhood disadvantage quintile (aOR 0.80; 95% CI 0.71, 0.90) and in the Midwest (aOR 0.46; 0.30, 0.71). Disparities in care, measured by rheumatology visits and serology testing, exist by neighborhood disadvantage, race and ethnicity, and region among young adults with lupus, despite uniform Medicare coverage. Findings support evaluating lupus care quality measures and their impact on US lupus outcomes. |
| 756 | Shivani Garg | RHEUM | sgarg@medicine.wisc.edu | Development of the American College of Rheumatology Patient-Reported Outcome Quality Measures for Systemic Lupus Erythematosus. | As part of a Centers for Disease Control and Prevention-funded American College of Rheumatology (ACR) initiative, we sought to develop quality measures related to Patient Reported Outcome Measure (PROM) use for systemic lupus erythematosus (SLE) clinical care. An expert workgroup composed of physician, patient, and researcher representatives convened to identify patient-reported outcome (PRO) domains of greatest importance to people with SLE. A patient advisory panel separately ranked domains. PROMs assessing priority domains were identified through structured literature review, and detailed psychometric reviews were conducted for each PROM. In a Delphi process, the expert workgroup rated PROMs on content validity, psychometric quality, feasibility of implementation, and importance for guiding patient self-management. The patient advisory panel reviewed PROMs in parallel and contributed to the final recommendations. Among relevant PRO domains, the workgroup and patient partners ranked depression, physical function, pain, cognition, and fatigue as high-priority domains. The workgroup recommended at least once yearly measurement for (1) assessment of depression using the Patient Health Questionnaire or Patient Reported Outcomes Measurement Information System (PROMIS) depression scales; (2) assessment of physical function using PROMIS physical function scales or the Multi-Dimensional Health Assessment Questionnaire; and (3) optional assessments of fatigue and cognition. Pain scales evaluated were not found to be sufficiently superior to what is already assessed in most SLE clinic visits. Expert workgroup members and patient partners recommend that clinicians assess depression and physical function at least once yearly in all people with SLE. Additional PROMs addressing cognition and fatigue can also be assessed. Next steps are to incorporate PROM-based quality measures into the ACR The Rheumatology Informatics System for Effectiveness registry. |
| 757 | Shivani Garg | RHEUM | sgarg@medicine.wisc.edu | Reference Range of Hydroxychloroquine Blood Levels That Can Reduce Odds of Active Lupus and Prevent Flares. | Recent data show that lower hydroxychloroquine (HCQ) doses are associated with a two- to six-fold higher risk of lupus flares. Thus, establishing an effective reference range of HCQ blood levels with upper and lower bounds for efficacy may support individualizing HCQ dosing to prevent flares. HCQ levels in whole blood and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) were measured during the baseline visit and again during a standard of care routine follow-up visit. Active cross-sectional lupus at baseline was defined as SLEDAI ≥6; a within subject flare was defined as a subsequent three-point increase in SLEDAI with clinical symptoms requiring therapy change. We examined associations between active lupus and HCQ blood levels at baseline and flares and HCQ levels during 6 to 12-month routine lupus follow-up visits using mixed regression analysis. Among 158 baseline patient visits, 19% had active lupus. Odds of active lupus were 71% lower in patients with levels within a 750 to 1,200 ng/mL range (adjusted odds ratio 0.29, 95% confidence interval 0.08-0.96). Using convenience sampling strategy during a pandemic, we longitudinally followed 42 patients. Among those patients, 17% flared during their follow-up visit. Maintaining HCQ levels within 750 to 1,200 ng/mL reduced the odds of a flare by 26% over a nine-month median follow-up. An effective reference range of HCQ blood levels, 750 to 1,200 ng/mL, was associated with 71% lower odds of active lupus, and maintaining levels within this range reduced odds of flares by 26%. These findings could guide clinicians to individualize HCQ doses to maintain HCQ levels within this range to maximize efficacy. |
| 758 | Shivani Garg | RHEUM | sgarg@medicine.wisc.edu | Development of American College of Rheumatology Quality Measures for Systemic Lupus Erythematosus: A Modified Delphi Process With Rheumatology Informatics System for Effectiveness (RISE) Registry Data Review. | We aimed to develop readily measurable digital quality measure statements for clinical care in systemic lupus erythematosus (SLE) using a multistep process guided by consensus methods. Using a modified Delphi process, an American College of Rheumatology (ACR) workgroup of SLE experts reviewed all North American and European guidelines from 2000 to 2020 on treatment, monitoring, and phenotyping of patients with lupus. Workgroup members extracted quality constructs from guidelines, rated these by importance and feasibility, and generated evidence-based quality measure statements. The ACR Rheumatology Informatics System for Effectiveness (RISE) Registry was queried for measurement data availability. In 3 consecutive Delphi sessions, a multidisciplinary Delphi panel voted on the importance and feasibility of each statement. Proposed measures with consensus on feasibility and importance were ranked to identify the top 3 measures. Review of guidelines and distillation of 57 quality constructs resulted in 15 quality measure statements. Among these, 5 met high consensus for importance and feasibility, including 2 on treatment and 3 on laboratory monitoring measures. The 3 highest-ranked statements were recommended for further measure specification as SLE digital quality measures: 1) hydroxychloroquine use, 2) limiting glucocorticoid use >7.5 mg/day to <6 months, and 3) end-organ monitoring of kidney function and urine protein excretion at least every 6 months. The Delphi process selected 3 quality measures for SLE care on hydroxychloroquine, glucocorticoid reduction, and kidney monitoring. Next, measures will undergo specification and validity testing in RISE and US rheumatology practices as the foundation for national implementation and use in quality improvement programs. |
| 759 | Shivani Garg | RHEUM | sgarg@medicine.wisc.edu | Triphasic: Preeclampsia, Systemic Lupus Erythematosus, and Severe Neutropenia With Use of Granulocyte Colony Stimulating Factor in the Partum and Postpartum Period. | |
| 760 | Shivani Garg | RHEUM | sgarg@medicine.wisc.edu | Improvement in Cutaneous Lupus Erythematosus After Twenty Weeks of Belimumab Use: A Systematic Review and Meta-Analysis. | Cutaneous lupus erythematosus (CLE), with or without systemic lupus erythematosus (SLE), can be debilitating and cause psychological distress. Belimumab, a monoclonal antibody that inhibits B cell activation, is a Federal Drug Administration-approved SLE medication, but less is known on its use in CLE. Moreover, the time to response after starting belimumab in CLE is unknown, which may lead to premature discontinuation in the absence of early perceivable benefits. Thus, the objectives of this meta-analysis were to examine the efficacy of belimumab, as well as the time to response after starting belimumab in patients with CLE with or without SLE. A comprehensive literature search was performed to include studies that examined clinical response in patients with CLE with or without SLE receiving belimumab. A clinical response at 52 weeks in belimumab users versus nonusers was summarized in a random-effects model. Additionally, we calculated the pooled odds ratio (OR) for each consecutive 4-week observation interval to identify time to a clinical response in CLE with or without SLE after starting belimumab. Among 747 screened studies, 14 were included. The pooled odds of clinical response at 52 weeks in belimumab users were 44% higher compared to nonusers (OR 1.44 [95% confidence interval (95% CI) 1.20-1.74], I2 = 0%). A clinical response was first noted after 20 weeks of starting belimumab (OR 1.35 [95% CI 1.01-1.81], I2 = 0%), with a sustained clinical response through 1 year. The findings support belimumab as an effective therapy for CLE with SLE. Likewise, the findings inform patient counseling regarding estimates of 20 weeks to achieve a response. |
| 761 | Sara McCoy | RHEUM | ssmccoy@medicine.wisc.edu | Limited Biomarker Potential for IgG Autoantibodies Reactive to Linear Epitopes in Systemic Lupus Erythematosus or Spondyloarthropathy. | Autoantibodies are commonly used as biomarkers in autoimmune diseases, but there are limitations. For example, autoantibody biomarkers have poor sensitivity or specificity in systemic lupus erythematosus and do not exist in the spondyloarthropathies, impairing diagnosis and treatment. While autoantibodies suitable for strong biomarkers may not exist in these conditions, another possibility is that technology has limited their discovery. The purpose of this study was to use a novel high-density peptide array that enables the evaluation of IgG binding to every possible linear antigen in the entire human peptidome, as well as a novel machine learning approach that incorporates ELISA validation predictability in order to discover autoantibodies that could be developed into sensitive and specific markers of lupus or spondyloarthropathy. We used a peptide array containing the human peptidome, several viral peptidomes, and key post-translational modifications (6 million peptides) to quantify IgG binding in lupus, spondyloarthropathy, rheumatoid arthritis, Sjögren's disease, and control sera. Using ELISA data for 70 peptides, we performed a random forest analysis that evaluated multiple array features to predict which peptides might be good biomarkers, as confirmed by ELISA. We validated the peptide prediction methodology in rheumatoid arthritis and COVID-19, conditions for which the antibody repertoire is well-understood, and then evaluated IgG binding by ELISA to peptides that we predicted would be highly bound specifically in lupus or spondyloarthropathy. Our methodology performed well in validation studies, but peptides predicted to be highly and specifically bound in lupus or spondyloarthropathy could not be confirmed by ELISA. In a comprehensive evaluation of the entire human peptidome, highly sensitive and specific IgG autoantibodies were not identified in lupus or spondyloarthropathy. Thus, the pathogenesis of lupus and spondyloarthropathy may not depend upon unique autoantigens, and other types of molecules should be sought as optimal biomarkers in these conditions. |
| 762 | Sara McCoy | RHEUM | ssmccoy@medicine.wisc.edu | 0JAK Inhibitor Withdrawal Causes a Transient Proinflammatory Cascade: A Potential Mechanism for Major Adverse Cardiac Events. | Our objective was to define the effect of JAK1/2 inhibitor (JAKinib) withdrawal on JAK/STAT biochemical response in the context of systemic rheumatic diseases. We tested Type I (bind kinase active conformation) and Type II (bind kinase inactive conformation) JAKinibs in vitro using mesenchymal stromal cells and endothelial cells. We translated our findings in vivo studying NK cells from rheumatoid arthritis (RA) patients treated with Type I JAKinibs or methotrexate. Type I JAKinibs (ruxolitinib and baricitinib) increased phosphoJAK1 (pJAK1) and pJAK2 of IFNγ-stimulated MSCs and HUVECs in a time- and dose- dependent manner, with effect peaking after 24 hours. As expected, pSTAT1 was completely suppressed by JAKinibs. We found a marked and rapid increase of pSTATs upon discontinuation of Type I JAKinibs, that occurred to a lesser extent after Type II JAKinib withdrawal. Type I JAKinib withdrawal increased interferon and urokinase expression when compared to Type II JAKinib withdrawal. We found NK cells from RA patients taking Type I JAKinibs had a pro-inflammatory profile after JAKinib withdrawal compared to patients on methotrexate. Type I JAKinibs paradoxically accumulate functionally defective pJAK. Upon withdrawal, the primed pJAKs are de-repressed and initiate a pSTAT signaling cascade, resulting in high interferon and urokinase. Type II JAKinibs do not cause pJAK accumulation, pSTAT cascade, and subsequent pro-inflammatory transcripts. The resultant cytokines and proteins produced from this cascade might be associated with adverse cardiac outcomes. Thus, JAKinib withdrawal is a possible mechanism contributing to the major adverse cardiac events described with JAKinib therapy. |
| 763 | Sara McCoy | RHEUM | ssmccoy@medicine.wisc.edu | Novel autoantibodies help diagnose anti-SSA antibody negative Sjögren disease and predict abnormal labial salivary gland pathology. | Sjögren disease (SjD) diagnosis often requires either positive anti-SSA antibodies or a labial salivary gland biopsy with a positive focus score (FS). One-third of patients with SjD lack anti-SSA antibodies (SSA-), requiring a positive FS for diagnosis. Our objective was to identify novel autoantibodies to diagnose 'seronegative' SjD. IgG binding to a high-density whole human peptidome array was quantified using sera from SSA- SjD cases and matched non-autoimmune controls. We identified the highest bound peptides using empirical Bayesian statistical filters, which we confirmed in an independent cohort comprising SSA- SjD (n=76), sicca-controls without autoimmunity (n=75) and autoimmune-feature controls (SjD features but not meeting SjD criteria; n=41). In this external validation, we used non-parametric methods for binding abundance and controlled false discovery rate in group comparisons. For predictive modelling, we used logistic regression, model selection methods and cross-validation to identify clinical and peptide variables that predict SSA- SjD and FS positivity. IgG against a peptide from D-aminoacyl-tRNA deacylase (DTD2) bound more in SSA- SjD than sicca-controls (p=0.004) and combined controls (sicca-controls and autoimmune-feature controls combined; p=0.003). IgG against peptides from retroelement silencing factor-1 and DTD2 were bound more in FS-positive than FS-negative participants (p=0.010; p=0.012). A predictive model incorporating clinical variables showed good discrimination between SjD versus control (area under the curve (AUC) 74%) and between FS-positive versus FS-negative (AUC 72%). We present novel autoantibodies in SSA- SjD that have good predictive value for SSA- SjD and FS positivity. |
| 764 | Sara McCoy | RHEUM | ssmccoy@medicine.wisc.edu | Safety and efficacy of subcutaneous iscalimab (CFZ533) in two distinct populations of patients with Sjögren's disease (TWINSS): week 24 results of a randomised, double-blind, placebo-controlled, phase 2b dose-ranging study. | Sjögren's disease is a chronic autoimmune disease with an unmet need for targeted therapies. The aim of the TWINSS study is to evaluate the safety and efficacy of iscalimab, a monoclonal antibody against CD40, in patients with active Sjögren's disease. This randomised, double-blind, placebo-controlled, phase 2b study, conducted at 71 sites in 23 countries, enrolled patients aged 18 years or older fulfilling the American College of Rheumatology/European Alliance of Associations for Rheumatology (EULAR) 2016 criteria. In the dose-ranging cohort 1, patients with a EULAR Sjögren's Syndrome Disease Activity Index (ESSDAI) score of 5 or higher and a EULAR Sjögren's Syndrome Patient Reported Index (ESSPRI) score of 5 or higher were randomly assigned (1:1:1:1) to subcutaneous iscalimab 150 mg, 300 mg, 600 mg, or placebo. In the proof-of-concept cohort 2, patients with an ESSDAI score of less than 5, ESSPRI (dryness or fatigue) score of 5 or higher, and Impact of Dry Eye on Everyday Life score of 30 or higher were randomly assigned (1:1) to iscalimab 600 mg or placebo. The sponsor, investigator, site personnel, and patients were masked to the treatment assignment. The primary objectives were to demonstrate a dose-response relationship of iscalimab based on the change in ESSDAI from baseline to week 24 in cohort 1 by Multiple Comparison Procedure-Modelling (MCP-Mod), and to assess the effect of iscalimab 600 mg on ESSPRI at week 24 in cohort 2. All the efficacy analyses included all patients who were randomly assigned, and safety analysis included all patients who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov (NCT03905525), and is complete. Between Oct 1, 2019, and Feb 28, 2022, 460 patients were screened; 173 patients were assigned to cohort 1 (44 to iscalimab 150 mg, 43 to 300 mg, 43 to 600 mg, and 43 to placebo) and 100 to cohort 2 (50 to each group). In cohort 1, the MCP step showed a significant dose-response relationship for placebo-adjusted ESSDAI change from baseline in one of four models (Linlog model, one-sided p=0·0041). ESSDAI decreased from baseline to week 24 with all three doses of iscalimab; 150 mg and 600 mg doses showed statistically significant improvement (placebo-adjusted least squares [LS] mean difference -3·0 [95% CI -4·9 to -1·1]; p=0·0025 for 150 mg and -2·9 [-4·9 to -1·0]; p=0·0037 for 600 mg). In cohort 2, ESSPRI showed a trend towards improvement with iscalimab 600 mg (placebo-adjusted LS mean change from baseline -0·57 points [95% CI -1·30 to 0·15]; p=0·12). Serious adverse events were reported in nine patients in cohort 1 (one [2%] of 43 in the placebo group, one [2%] of 44 in the iscalimab 150 mg group, three [7%] of 42 in the 300 mg group, four [9%] of 44 in the 600 mg group) and four patients in cohort 2 (two [4%] of 50 in each group). No deaths occurred over the 24-week period. The study met the primary objective of demonstrating a significant dose-response relationship with iscalimab in terms of disease activity at week 24. Iscalimab was well tolerated and showed initial clinical benefit over placebo in two distinct populations of patients with Sjögren's disease, to be confirmed in larger trials. Novartis Pharma. |
| 765 | Sara McCoy | RHEUM | ssmccoy@medicine.wisc.edu | Identification of outcome domains in primary Sjögren's disease: A scoping review by the OMERACT Sjögren disease working group. | Sjögren's disease (SjD) is a heterogenous disease with a wide range of manifestations, ranging from symptoms of dryness, fatigue, and pain, to systemic involvement. Considerable advances have been made to evaluate systemic activity or patient-reported outcomes, but most of the instruments were not able to assess all domains of this multifaceted disease. The aim of this scoping review was to generate domains that have been assessed in randomized controlled trials, as the first phase of the Outcome Measures in Rheumatology (OMERACT) process of core domain set development. We systematically searched Medline (Pubmed) and EMBASE between 2002 and March 2023 to identify all randomized controlled trials assessing relevant domains, using both a manual approach and an artificial intelligence software (BIBOT) that applies natural language processing to automatically identify relevant abstracts. Domains were mapped to core areas, as suggested by the OMERACT 2.1 Filter. Among the 5,420 references, we included 60 randomized controlled trials, focusing either on overall disease manifestations (53%) or on a single organ/symptom: dry eyes (17%), xerostomia (15%), fatigue (12%), or pulmonary function (3%). The most frequently assessed domains were perceived dryness (52% for overall dryness), fatigue (57%), pain (52%), systemic disease activity (45%), lacrimal gland function (47%) and salivary function (55%), B-cell activation (60%), and health-related quality of life (40%). Our scoping review highlighted the heterogeneity of SjD, in the study designs and domains. This will inform the OMERACT SjD working group to select the most appropriate core domains to be used in SjD clinical trials and to guide the future agenda for outcome measure research in SjD. |
| 766 | Sara McCoy | RHEUM | ssmccoy@medicine.wisc.edu | The Sjögren's Working Group: The 2023 OMERACT meeting and provisional domain generation. | Sjögren's disease (SjD) is a systemic autoimmune exocrinopathy with key features of dryness, pain, and fatigue. SjD can affect any organ system with a variety of presentations across individuals. This heterogeneity is one of the major barriers for developing effective disease modifying treatments. Defining core disease domains comprising both specific clinical features and incorporating the patient experience is a critical first step to define this complex disease. The OMERACT SjD Working Group held its first international collaborative hybrid meeting in 2023, applying the OMERACT 2.2 filter toward identification of core domains. We accomplished our first goal, a scoping literature review that was presented at the Special Interest Group held in May 2023. Building on the domains identified in the scoping review, we uniquely deployed multidisciplinary experts as part of our collaborative team to generate a provisional domain list that captures SjD heterogeneity. |
| 767 | Sara McCoy | RHEUM | ssmccoy@medicine.wisc.edu | Sjögren's disease activity associates with cardiovascular disease and monoclonal gammopathy: a university cohort study of disease activity and comorbidities. | We used the University of Wisconsin cohort to determine the extent to which the EULAR Sjögren's syndrome disease activity index (ESSDAI) was associated with comorbidities that contribute to mortality. Our University of Wisconsin, Madison cohort had 111 patients with Sjögren's Disease (SjD) by 2016 ACR/EULAR criteria and 194 control patients with sicca. Our study was performed from March 1st, 2020 through April 1st, 2023. We collected data using a standardized collection tool, including components of the Charlson Comorbidity Index (CCI). Stratifying our SjD patients by ESSDAI < 5 and ESSDAI ≥ 5, we assessed differences in comorbidities associated with mortality. At time of SjD diagnosis, the ESSDAI ≥ 5 group had increased odds of peripheral vascular disease compared to controls (OR 10.17; 95% CI 1.18-87.87). Patients with a current ESSDAI ≥ 5 were more likely to have a myocardial infarction compared to controls (OR 9.87; 95% CI 1.17-83.49). SjD patients had increased prevalence of monoclonal gammopathy compared to controls (9.3% vs 0.5%, p < 0.001). SjD patients with high ESSDAI at diagnosis had greater prevalence of monoclonal gammopathy compared to the SjD patients with a low ESSDAI (16% vs 5%, p = .04). As reported elsewhere, the ESSDAI ≥ 5 group had increased odds of chronic pulmonary disease (OR 4.37; 95% CI 1.59-11.97). We found high ESSDAI scores were associated with worse cardiovascular outcomes, specifically peripheral vascular disease and myocardial infarction. Furthermore, monoclonal gammopathy was more frequent in SjD patients compared to sicca controls, supporting screening for monoclonal gammopathy in the appropriate clinical scenario. Key Points • High ESSDAI scores are associated with worse cardiovascular outcomes, specifically peripheral vascular disease and myocardial infarction. • Monoclonal gammopathy is more frequent in SjD patients than sicca controls, supporting screening for monoclonal gammopathy in the appropriate clinical scenario. |
| 768 | Sara McCoy | RHEUM | ssmccoy@medicine.wisc.edu | Epidemiology of Sjögren syndrome. | Sjögren syndrome is a phenotypically varied autoimmune disorder that can occur alone in primary Sjögren syndrome or in association with other connective tissue diseases (CTDs), including rheumatoid arthritis, systemic lupus erythematosus (SLE) and systemic sclerosis (SSc). The estimation of the prevalence and incidence of Sjögren syndrome varies depending on diagnostic criteria and study design, making it difficult to estimate geographical and temporal trends. Nonetheless, disease phenotype is influenced by geographical origin, which is a risk factor for systemic activity. Whether mortality in primary Sjögren syndrome is increased compared with that of the general population is not yet known, but extra-glandular manifestations, in particular lymphomas, are clear risk factors for mortality. In CTDs associated with Sjögren syndrome, lymphoma risk seems higher than that of patients with CTD alone, and there is potentially lower disease activity in SLE with Sjögren syndrome and in SSc with Sjögren syndrome than in SLE or SSc alone. |
| 769 | Sara McCoy | RHEUM | ssmccoy@medicine.wisc.edu | Novel and unique rheumatoid factors cross-react with viral epitopes in COVID-19. | Rheumatoid factors (RFs), polyreactive antibodies canonically known to bind two conformational epitopes of IgG Fc, are a hallmark of rheumatoid arthritis but also can arise in other inflammatory conditions and infections. Also, infections may contribute to the development of rheumatoid arthritis and other autoimmune diseases. Recently, RFs only in rheumatoid arthritis were found to bind novel linear IgG epitopes as well as thousands of other rheumatoid arthritis autoantigens. Specific epitopes recognized by infection-induced polyreactive RFs remain undefined but could provide insights into loss of immune tolerance. Here, we identified novel linear IgG epitopes bound by RFs in COVID-19 but not rheumatoid arthritis or other conditions. The main COVID-19 RF was polyreactive, binding two IgG and multiple viral peptides with a tripeptide motif, as well as IgG Fc and SARS-CoV-2 spike proteins. In contrast, a rheumatoid arthritis-specific RF recognized IgG Fc, but not tripeptide motif-containing peptides or spike. Thus, RFs have disease-specific IgG reactivity and distinct polyreactivities that reflect the broader immune response. Moreover, the polyreactivity of a virus-induced RF appears to be attributable to a very short peptide motif. These findings refine our understanding of RFs and provide new insights into how viral infections may contribute to autoimmunity. |
| 770 | Sara McCoy | RHEUM | ssmccoy@medicine.wisc.edu | Emerging treatment for Sjögren's disease: a review of recent phase II and III trials. | Sjögren's Disease, SjD, is a systemic autoimmune disorder characterized by reduced function of the salivary and lacrimal glands. Patients suffer from dryness, fatigue, and pain and may present with or without extra-glandular organ involvement. Symptoms limit SjD patients' quality of life and are the most difficult to improve with therapy. SjD patients are heterogeneous and clustering them into biologically similar subgroups might improve the efficacy of therapies. The need for therapies that address both the symptoms and extra glandular organ involvement of SjD presents an unmet opportunity that has recently attracted a growing interest in the pharmaceutical industry. The goal of this report is to review recent phase II/III studies in SjD. To accomplish our goal, we performed a literature search for phase II/III studies and abstracts recently presented at conferences. This review allows updates the reader on the multitude of recent phase II/III clinical trials. We speculate on how subtypes of SjD will drive future therapeutic targeting and inform pathogenesis. |
| 771 | Miriam Shelef | RHEUM | mshelef@medicine.wisc.edu | Limited Biomarker Potential for IgG Autoantibodies Reactive to Linear Epitopes in Systemic Lupus Erythematosus or Spondyloarthropathy. | Autoantibodies are commonly used as biomarkers in autoimmune diseases, but there are limitations. For example, autoantibody biomarkers have poor sensitivity or specificity in systemic lupus erythematosus and do not exist in the spondyloarthropathies, impairing diagnosis and treatment. While autoantibodies suitable for strong biomarkers may not exist in these conditions, another possibility is that technology has limited their discovery. The purpose of this study was to use a novel high-density peptide array that enables the evaluation of IgG binding to every possible linear antigen in the entire human peptidome, as well as a novel machine learning approach that incorporates ELISA validation predictability in order to discover autoantibodies that could be developed into sensitive and specific markers of lupus or spondyloarthropathy. We used a peptide array containing the human peptidome, several viral peptidomes, and key post-translational modifications (6 million peptides) to quantify IgG binding in lupus, spondyloarthropathy, rheumatoid arthritis, Sjögren's disease, and control sera. Using ELISA data for 70 peptides, we performed a random forest analysis that evaluated multiple array features to predict which peptides might be good biomarkers, as confirmed by ELISA. We validated the peptide prediction methodology in rheumatoid arthritis and COVID-19, conditions for which the antibody repertoire is well-understood, and then evaluated IgG binding by ELISA to peptides that we predicted would be highly bound specifically in lupus or spondyloarthropathy. Our methodology performed well in validation studies, but peptides predicted to be highly and specifically bound in lupus or spondyloarthropathy could not be confirmed by ELISA. In a comprehensive evaluation of the entire human peptidome, highly sensitive and specific IgG autoantibodies were not identified in lupus or spondyloarthropathy. Thus, the pathogenesis of lupus and spondyloarthropathy may not depend upon unique autoantigens, and other types of molecules should be sought as optimal biomarkers in these conditions. |
| 772 | Miriam Shelef | RHEUM | mshelef@medicine.wisc.edu | Novel autoantibodies help diagnose anti-SSA antibody negative Sjögren disease and predict abnormal labial salivary gland pathology. | Sjögren disease (SjD) diagnosis often requires either positive anti-SSA antibodies or a labial salivary gland biopsy with a positive focus score (FS). One-third of patients with SjD lack anti-SSA antibodies (SSA-), requiring a positive FS for diagnosis. Our objective was to identify novel autoantibodies to diagnose 'seronegative' SjD. IgG binding to a high-density whole human peptidome array was quantified using sera from SSA- SjD cases and matched non-autoimmune controls. We identified the highest bound peptides using empirical Bayesian statistical filters, which we confirmed in an independent cohort comprising SSA- SjD (n=76), sicca-controls without autoimmunity (n=75) and autoimmune-feature controls (SjD features but not meeting SjD criteria; n=41). In this external validation, we used non-parametric methods for binding abundance and controlled false discovery rate in group comparisons. For predictive modelling, we used logistic regression, model selection methods and cross-validation to identify clinical and peptide variables that predict SSA- SjD and FS positivity. IgG against a peptide from D-aminoacyl-tRNA deacylase (DTD2) bound more in SSA- SjD than sicca-controls (p=0.004) and combined controls (sicca-controls and autoimmune-feature controls combined; p=0.003). IgG against peptides from retroelement silencing factor-1 and DTD2 were bound more in FS-positive than FS-negative participants (p=0.010; p=0.012). A predictive model incorporating clinical variables showed good discrimination between SjD versus control (area under the curve (AUC) 74%) and between FS-positive versus FS-negative (AUC 72%). We present novel autoantibodies in SSA- SjD that have good predictive value for SSA- SjD and FS positivity. |
| 773 | Miriam Shelef | RHEUM | mshelef@medicine.wisc.edu | Macrophage extracellular traps require peptidylarginine deiminase 2 and 4 and are a source of citrullinated antigens bound by rheumatoid arthritis autoantibodies. | Anti-citrullinated protein antibodies (ACPAs) are a hallmark of rheumatoid arthritis, but the sources of citrullinated antigens as well as which peptidylarginine deiminases (PADs) are required for their production remain incompletely defined. Here, we investigated if macrophage extracellular traps (METs) could be a source of citrullinated proteins bound by APCAs, and if their formation requires PAD2 or PAD4. Thioglycolate-induced peritoneal macrophages from wild-type, PAD2-/-, and PAD4-/- mice or human peripheral blood-derived M1 macrophages were activated with a variety of stimulants, then fixed and stained with DAPI and either anti-citrullinated histone H4 (citH4) antibody or sera from ACPA+ or ACPA- rheumatoid arthritis subjects. METs were visualized by immunofluorescence, confirmed to be extracellular using DNase, and quantified. We found that ionomycin and monosodium urate crystals reliably induced murine citH4+ METs, which were reduced in the absence of PAD2 and lost in the absence of PAD4. Also, IgG from ACPA+, but not ACPA-, rheumatoid arthritis sera bound to murine METs, and in the absence of PAD2 or PAD4, ACPA-bound METs were lost. Finally, ionomycin induced human METs that are citH4+ and ACPA-bound. Thus, METs may contribute to the pool of citrullinated antigens bound by ACPAs in a PAD2- and PAD4-dependent manner, providing new insights into the targets of immune tolerance loss in rheumatoid arthritis. |
| 774 | Miriam Shelef | RHEUM | mshelef@medicine.wisc.edu | Mass Spectrometry-Based Precise Identification of Citrullinated Histones via Limited Digestion and Biotin Derivative Tag Enrichment. | Histone citrullination is an essential epigenetic post-translational modification (PTM) that affects many important physiological and pathological processes, but effective tools to study histone citrullination are greatly limited due to several challenges, including the small mass shift caused by this PTM and its low abundance in biological systems. Although previous studies have reported frequent occurrences of histone citrullination, these methods failed to provide a high-throughput and site-specific strategy to detect histone citrullination. Recently, we developed a biotin thiol tag that enabled precise identification of protein citrullination coupled with mass spectrometry. However, very few histone citrullination sites were identified, likely due to the highly basic nature of these proteins. In this study, we develop a novel method utilizing limited digestion and biotin derivative tag enrichment to facilitate direct in vivo identification of citrullination sites on histones. We achieve improved coverage of histone identification via partial enzymatic digestion and lysine block by dimethylation. With biotin tag-assisted chemical derivatization and enrichment, we also achieve precise annotation of histone citrullination sites with high confidence. We further compare different fragmentation methods and find that the electron-transfer-dissociation-based approach enables the most in-depth analysis and characterization. In total, we unambiguously identify 18 unique citrullination sites on histones in human astrocytoma U87 cells, including 15 citrullinated sites being detected for the first time. Some of these citrullination sites are observed to exhibit noticeable alterations in response to DNA damage, which demonstrates the superiority of our strategy in understanding the roles of histone citrullination in critical biological processes. |
| 775 | Miriam Shelef | RHEUM | mshelef@medicine.wisc.edu | Novel and unique rheumatoid factors cross-react with viral epitopes in COVID-19. | Rheumatoid factors (RFs), polyreactive antibodies canonically known to bind two conformational epitopes of IgG Fc, are a hallmark of rheumatoid arthritis but also can arise in other inflammatory conditions and infections. Also, infections may contribute to the development of rheumatoid arthritis and other autoimmune diseases. Recently, RFs only in rheumatoid arthritis were found to bind novel linear IgG epitopes as well as thousands of other rheumatoid arthritis autoantigens. Specific epitopes recognized by infection-induced polyreactive RFs remain undefined but could provide insights into loss of immune tolerance. Here, we identified novel linear IgG epitopes bound by RFs in COVID-19 but not rheumatoid arthritis or other conditions. The main COVID-19 RF was polyreactive, binding two IgG and multiple viral peptides with a tripeptide motif, as well as IgG Fc and SARS-CoV-2 spike proteins. In contrast, a rheumatoid arthritis-specific RF recognized IgG Fc, but not tripeptide motif-containing peptides or spike. Thus, RFs have disease-specific IgG reactivity and distinct polyreactivities that reflect the broader immune response. Moreover, the polyreactivity of a virus-induced RF appears to be attributable to a very short peptide motif. These findings refine our understanding of RFs and provide new insights into how viral infections may contribute to autoimmunity. |
| 776 | Miriam Shelef | RHEUM | mshelef@medicine.wisc.edu | Inhibition of neutrophil extracellular trap formation alleviates vascular dysfunction in type 1 diabetic mice. | While neutrophil extracellular traps (NETs) have previously been linked to some diabetes-associated complications, such as dysfunctional wound healing, their potential role in diabetic vascular dysfunction has not been studied. Diabetic Akita mice were crossed with either Elane-/- or Pad4-/- mice to generate NET-deficient diabetic mice. By 24 weeks of age, Akita aortae showed markedly impaired relaxation in response to acetylcholine, indicative of vascular dysfunction. Both Akita-Elane-/- mice and Akita-Pad4-/- mice had reduced levels of circulating NETs and improved acetylcholine-mediated aortic relaxation. Compared with wild-type aortae, the thromboxane metabolite TXB2 was roughly 10-fold higher in both intact and endothelium-denuded aortae of Akita mice. In contrast, Akita-Elane-/- and Akita-Pad4-/- aortae had TXB2 levels similar to wild type. In summary, inhibition of NETosis by two independent strategies prevented the development of vascular dysfunction in diabetic Akita mice. Thromboxane was up-regulated in the vessel walls of NETosis-competent diabetic mice, suggesting a role for neutrophils in driving the production of this vasoconstrictive and atherogenic prostanoid. |
| 777 | Miriam Shelef | RHEUM | mshelef@medicine.wisc.edu | Anti-Citrullinated Protein Antibody Reactivity towards Neutrophil-Derived Antigens: Clonal Diversity and Inter-Individual Variation. | Why the adaptive immune system turns against citrullinated antigens in rheumatoid arthritis (RA) and whether anti-citrullinated protein antibodies (ACPAs) contribute to pathogenesis are questions that have triggered intense research, but still are not fully answered. Neutrophils may be crucial in this context, both as sources of citrullinated antigens and also as targets of ACPAs. To better understand how ACPAs and neutrophils contribute to RA, we studied the reactivity of a broad spectrum of RA patient-derived ACPA clones to activated or resting neutrophils, and we also compared neutrophil binding using polyclonal ACPAs from different patients. Neutrophils were activated by Ca2+ ionophore, PMA, nigericin, zymosan or IL-8, and ACPA binding was studied using flow cytometry and confocal microscopy. The roles of PAD2 and PAD4 were studied using PAD-deficient mice or the PAD4 inhibitor BMS-P5. ACPAs broadly targeted NET-like structures, but did not bind to intact cells or influence NETosis. We observed high clonal diversity in ACPA binding to neutrophil-derived antigens. PAD2 was dispensable, but most ACPA clones required PAD4 for neutrophil binding. Using ACPA preparations from different patients, we observed high patient-to-patient variability in targeting neutrophil-derived antigens and similarly in another cellular effect of ACPAs, the stimulation of osteoclast differentiation. Neutrophils can be important sources of citrullinated antigens under conditions that lead to PAD4 activation, NETosis and the extrusion of intracellular material. A substantial clonal diversity in targeting neutrophils and a high variability among individuals in neutrophil binding and osteoclast stimulation suggest that ACPAs may influence RA-related symptoms with high patient-to-patient variability. |
| 778 | Miriam Shelef | RHEUM | mshelef@medicine.wisc.edu | Anti-membrane Antibodies Persist at Least One Year and Discriminate Between Past Coronavirus Disease 2019 Infection and Vaccination. | The consequences of past coronavirus disease 2019 (COVID-19) infection for personal and population health are emerging, but accurately identifying distant infection is a challenge. Anti-spike antibodies rise after both vaccination and infection and anti-nucleocapsid antibodies rapidly decline. We evaluated anti-membrane antibodies in COVID-19 naive, vaccinated, and convalescent subjects to determine if they persist and accurately detect distant infection. We found that anti-membrane antibodies persist for at least 1 year and are a sensitive and specific marker of past COVID-19 infection. Thus, anti-membrane and anti-spike antibodies together can differentiate between COVID-19 convalescent, vaccinated, and naive states to advance public health and research. |
| 779 | Miriam Shelef | RHEUM | mshelef@medicine.wisc.edu | A Novel Selective Inhibitor JBI-589 Targets PAD4-Mediated Neutrophil Migration to Suppress Tumor Progression. | Neutrophils are closely involved in the regulation of tumor progression and formation of premetastatic niches. However, the mechanisms of their involvement and therapeutic regulation of these processes remain elusive. Here, we report a critical role of neutrophil peptidylarginine deiminase 4 (PAD4) in neutrophil migration in cancer. In several transplantable and genetically engineered mouse models, tumor growth was accompanied by significantly elevated enzymatic activity of neutrophil PAD4. Targeted deletion of PAD4 in neutrophils markedly decreased the intratumoral abundance of neutrophils and led to delayed growth of primary tumors and dramatically reduced lung metastases. PAD4-mediated neutrophil accumulation by regulating the expression of the major chemokine receptor CXCR2. PAD4 expression and activity as well as CXCR2 expression were significantly upregulated in neutrophils from patients with lung and colon cancers compared with healthy donors, and PAD4 and CXCR2 expression were positively correlated in neutrophils from patients with cancer. In tumor-bearing mice, pharmacologic inhibition of PAD4 with the novel PAD4 isoform-selective small molecule inhibitor JBI-589 resulted in reduced CXCR2 expression and blocked neutrophil chemotaxis. In mouse tumor models, targeted deletion of PAD4 in neutrophils or pharmacologic inhibition of PAD4 with JBI-589 reduced both primary tumor growth and lung metastases and substantially enhanced the effect of immune checkpoint inhibitors. Taken together, these results suggest a therapeutic potential of targeting PAD4 in cancer. PAD4 regulates tumor progression by promoting neutrophil migration and can be targeted with a small molecule inhibitor to suppress tumor growth and metastasis and increase efficacy of immune checkpoint blockade therapy. |
| 780 | Miriam Shelef | RHEUM | mshelef@medicine.wisc.edu | Rheumatoid Factor and Anti-Modified Protein Antibody Reactivities Converge on IgG Epitopes. | Rheumatoid arthritis (RA) patients often develop rheumatoid factors (RFs), antibodies that bind IgG Fc, and anti-modified protein antibodies (AMPAs), multireactive autoantibodies that commonly bind citrullinated, homocitrullinated, and acetylated antigens. Recently, antibodies that bind citrulline-containing IgG epitopes were discovered in RA, suggesting that additional undiscovered IgG epitopes could exist and that IgG could be a shared antigen for RFs and AMPAs. This study was undertaken to reveal new IgG epitopes in rheumatic disease and to determine if multireactive AMPAs bind IgG. Using sera from patients with RA, systemic lupus erythematosus, Sjögren's disease (SjD), or spondyloarthropathy, IgG binding to native, citrulline-containing, and homocitrulline-containing linear epitopes of the IgG constant region was evaluated by peptide array, with highly bound epitopes further evaluated by enzyme-linked immunosorbent assay (ELISA). Binding of monoclonal AMPAs to IgG-derived peptides and IgG Fc was also evaluated by ELISA. Seropositive RA sera showed high IgG binding to multiple citrulline- and homocitrulline-containing IgG-derived peptides, whereas anti-SSA+ sera from SjD patients showed consistent binding to a single linear native epitope of IgG in the hinge region. Monoclonal AMPAs bound citrulline- and homocitrulline-containing IgG peptides and modified IgG Fc. The repertoire of epitopes bound by AMPAs includes modified IgG epitopes, positioning IgG as a common antigen that connects the otherwise divergent reactivities of RFs and AMPAs. |
| 781 | Amy Kind | GERI | amy.kind@wisc.edu | Differential associations of neighborhood disadvantage, race/ethnicity, and cognitive status with experiences of psychosocial distress in the HABS-HD cohort. | Understanding how contextual socioeconomic factors are associated with psychosocial distress among different ethnoracial groups is important for addressing health disparities in individuals at risk for Alzheimer's disease. Using Health and Aging Brain Study-Health Disparities (HABS-HD) data collected between 2017 and 2023, we examined the association of neighborhood disadvantage with psychosocial distress using demographically adjusted linear regression models, stratified by ethnoracial group and cognitive status. We included 630 non-Hispanic Black, 1109 Hispanic, and 1068 non-Hispanic White older adults deemed cognitively normal (CN) or diagnosed with mild cognitive impairment (MCI). Residing in areas of greater neighborhood disadvantage was associated with increased chronic stress (CS) among CN White participants, but this relationship was attenuated among White participants with MCI. Regardless of cognitive status, severe levels of disadvantage were associated with increased CS and depression among Black participants. Aging in more disadvantaged neighborhoods was associated with greater CS and depression for Black and White participants. Greater neighborhood disadvantage was associated with increased depression and chronic stress for White and Black individuals. Individuals with mild cognitive impairment reported greater levels of psychosocial distress. These findings are relevant for addressing mental health inequity in aging populations. |
| 782 | Amy Kind | GERI | amy.kind@wisc.edu | Childhood Community Disadvantage and MRI-Derived Structural Brain Integrity After Age 65 Years. | Prior studies associate late-life community disadvantage with worse brain health. It is relatively unknown if childhood community disadvantage associates with late-life brain health. To test associations between childhood residence in an economically disadvantaged community, individual income and education, and late-life cortical brain volumes and white matter integrity. This cohort study was conducted in the ongoing harmonized cohorts KHANDLE (Kaiser Healthy Aging and Diverse Life Experiences Study; initiated 2017) and STAR (Study of Healthy Aging in African Americans; initiated 2018) using all available data collected out of a regional integrated health care delivery network in California between cohort initiation and analysis initiation in June 2023. Eligible participants were Kaiser Permanente Northern California member ages 65 years or older. Data were analyzed between June and November 2023. Residence at birth was geocoded and linked to historical Area Deprivation Indices (ADI). ADI is a nationally ranked percentile; community disadvantage was defined as ADI of 80 or higher. Regional brain volumes and white matter integrity measures were derived from a random subset of participants who underwent 3T magnetic resonance imaging. Models adjusted for race and ethnicity, sex, and parental education. Of a total 2161 individuals in the combined cohort, 443 individuals were eligible for imaging (mean [SD] age, 76.3 [6.5] years; 253 female [57.1%]; 56 Asian [12.6%], 212 Black [47.9%], 67 Latino [15.1%], 109 White [24.6%]). Imaging participants had a mean (SD) 15.0 (2.5) years of education, and 183 (41.3%) earned $55 000 to $99 999 annually. Fifty-four participants (12.2%) resided in a disadvantaged childhood community. Childhood community disadvantage was associated with smaller gray matter volumes overall (-0.39 cm3; 95% CI, -0.65 to -0.10 cm3) and in the cerebellum (-0.39 cm3; 95% CI, -0.66 to -0.09 cm3), hippocampus (-0.37 cm3; 95% CI, -0.68 to -0.04 cm3), and parietal cortex (-0.25 cm3; 95% CI, -0.46 to -0.04 cm3) and larger mean lateral ventricle (0.44 cm3; 95% CI, 0.12 to 0.74 cm3), third ventricle (0.28 cm3; 95% CI, 0.03 to 0.55 cm3), and white matter hyperintensity volume (0.31 cm3; 95% CI, 0.06 to 0.56 cm3). Educational attainment and late-life income did not mediate these associations. In this cohort study of racially and ethnically diverse health plan members, childhood community disadvantage was associated with worse late-life brain health independent of individual socioeconomic status. Future work should explore alternative pathways (eg, cardiovascular health) that may explain observed associations. |
| 783 | Amy Kind | GERI | amy.kind@wisc.edu | Honoring the 20th Anniversary of Blue Cross and Blue Shield United's Gift to Improve Health in Wisconsin. | |
| 784 | Amy Kind | GERI | amy.kind@wisc.edu | Patient Neighborhood Adversity Associated With Access Not Wait Time to Parathyroidectomy. | Delays to treatment of primary hyperparathyroidism (PHPT) escalates patient morbidity, which particularly affects individuals from under-resourced areas already facing health disparities. We hypothesized that PHPT patients from socially and economically deprived areas encounter longer waits to surgery. Utilizing a prospectively maintained database, we identified PHPT patients aged ≥18 undergoing initial parathyroidectomy between 2013 and 2022 at an academic, tertiary care center. Patient's social and economic advantage levels were classified into deciles using the Area Deprivation Index (ADI), which accounts for 17 social determinants of health. The time from first hypercalcemic value to surgery was compared across ADI groups via linear regression, controlling for pertinent care process factors. Among 1132 patients, 68.9% were from low, 19.1% from medium, and 12.0% from high-disadvantage areas, diverging from the hospital's catchment population (55.2%, 26.6%, and 18.1%, respectively, P < 0.01). Patients from high-disadvantage areas exhibited higher comorbidity rates (55.2% versus 38.2%, P < 0.01) and were predominantly rural residents (66.2% vs. 5.8%, P < 0.01) compared to low-disadvantage areas. Similar biochemical and clinical features were shown across ADI groups. The median time from abnormal calcium to surgery was 648 d (IQR 543-753), with high-disadvantage patients experiencing a median treatment delay of 527 d, compared to 657 and 633 d for medium and low-disadvantage patients, respectively (P = 0.38). Linear regression analysis showed no association between ADI and treatment delay. The high-disadvantage group underwent parathyroidectomy at lower rates than expected, but there were no significant delays in surgery among disadvantaged patients who were ultimately treated. This suggests that while social determinants may correlate to care access, they do not necessarily prolong treatment for those with established care. |
| 785 | Amy Kind | GERI | amy.kind@wisc.edu | Provision of Home & Community Based Services to Veterans by Race, Rurality, and Neighborhood Deprivation Index. | Home and community-based services (HCBS) enable frail patients to remain at home. We examined whether there were neighborhood-deprivation, racial, or rural disparities in HCBS utilization provided to Veterans by the Department of Veterans Affairs (VA) or Medicare by comparing the adjusted utilization rate of a historically disadvantaged group with the predicted utilization rate had it been treated as the historically dominant group. Among the 2.7 million VA patients over 66 years old in 2019, 11.0% were Black, 39.2% lived in rural settings, 15.3%/29.2%/30.9%/24.7% lived in least/mild/moderate/most-deprived neighborhoods. On average, 11.2% received VA or Medicare HCBS. Veterans residing in more deprived neighborhoods had 0.11-0.95% higher adjusted probability of receiving HCBS than expected had they resided in the least deprived neighborhoods. Veterans residing in rural areas had 0-0.7% lower HCBS rates than expected had they been treated like urban Veterans. Black Veterans were 0.8-1.2% more likely to receive HCBS than expected had they been treated like White Veterans. Findings indicate that VA resources were equitably employed, aligning with probable HCBS needs, suggesting that VA's substantial and long-standing investment in HCBS for care of frail Veterans could serve as a model for other payers and providers in the U.S. |
| 786 | Amy Kind | GERI | amy.kind@wisc.edu | Evaluating Policy Changes for Adjusting Payment to Address Health Disparities. | This study analyzes area-level Health Equity Benchmark Adjustment formula changes to demonstrate how policy choices result in resource reallocation. |
| 787 | Amy Kind | GERI | amy.kind@wisc.edu | Area Deprivation and Disease Severity in Adult Patients With Discoid Lupus Erythematosus. | The association of area deprivation with outcomes in discoid lupus erythematosus (DLE) remains poorly understood. To determine the association between US Census block measures of deprivation and disease severity in adult patients with DLE. This cross-sectional study included 154 patients with DLE seen between January 1, 2007, and January 1, 2024, at a single-center referral-based specialty rheumatologic-dermatology clinic in Philadelphia, Pennsylvania. Patients were aged 18 to 73 years and were enrolled in the University of Pennsylvania's Cutaneous Lupus Erythematosus Database study. Data were analyzed between January 1, 2024, and May 8, 2024. Residence in a highly disadvantaged area as geocoded by a state area deprivation index (ADI). The main outcome was DLE disease severity as codified by the validated Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) damage and activity scores. A total of 154 adult patients with DLE (128 women [83%] and 26 men [17%]; mean [SD] age, 43 [13] years; 6 [4%] Asian individuals, 98 [64%] Black individuals, 2 [1%] Hispanic individuals, 46 [30%] White individuals, and 2 individuals [1%] with other race or ethnicity; 78 [51%] with an ADI >5; 43 who currently smoked [28%];and 56 [36%] with concurrent systemic lupus erythematosus) were included in the analysis. By multivariable logistic regression, residence within communities with an ADI greater than 5 was associated with nearly 4-fold greater odds of moderate to severe damage (odds ratio [OR], 3.90; 95% CI, 1.27-12.69] and activity (OR, 3.31; 95% CI, 1.27-9.44). Concurrent cigarette smoking was similarly associated with greater odds of moderate to severe damage (OR, 3.15; 95% CI, 1.09-10.29). After controlling for ADI and other confounders, race was not significantly associated with DLE disease severity. The results of this cross-sectional study suggest that geospatial disadvantage is associated with DLE disease severity independent of race. This invites a paradigm shift that considers the social context within which racial disparities are observed, highlighting the potential for geographically targeted interventions and policy changes to improve patient outcomes in DLE. |
| 788 | Amy Kind | GERI | amy.kind@wisc.edu | Multi-level social determinants of health, inflammation, and postoperative delirium in older adults. | |
| 789 | Amy Kind | GERI | amy.kind@wisc.edu | Alzheimer incidence and prevalence with and without asthma: A Medicare cohort study. | International data suggest that asthma, like other inflammatory diseases, might increase Alzheimer disease (AD) risk. We sought to explore risk pathways and future mitigation strategies by comparing diagnostic claims-based AD incidence and prevalence among US patients with asthma with those without asthma. This cohort study included a national Medicare 20% random sample (2013-2015). Adult patients with asthma with more than 12 months continuous Medicare were compared with subjects without asthma overall and as matched. Asthma was defined by 1 inpatient or 2 outpatient codes for asthma. The main outcomes were 2-year incident or prevalent AD defined by International Classification of Diseases, Ninth Revision code 331.0 or Tenth Revision code G30.0, G30.1, G30.8, or G30.9. Among 5,460,732 total beneficiaries, 678,730 patients were identified with baseline asthma and more often identified as Black or Hispanic, were Medicaid eligible, or resided in a highly disadvantaged neighborhood than those without asthma. Two-year incidence of AD was 1.4% with asthma versus 1.1% without asthma; prevalence was 7.8% versus 5.4% (both P ≤ .001). Per 100,000 patients over 2 years, 303 more incident AD diagnoses occurred in those with asthma, with 2,425 more prevalent cases (P < .001). Multivariable models showed that asthma had greater odds of 2-year AD incidence (adjusted odds ratio, 1.33 [95% CI, 1.29-1.36]; matched 1.2 [95% CI, 1.17-1.24]) and prevalence (adjusted odds ratio, 1.48 [95% CI, 1.47-1.50]; matched 1.25 [95% CI, 1.22-1.27]). Asthma was associated with 20% to 33% increased 2-year incidence and 25% to 48% increased prevalence of claims-based AD in this nationally representative US sample. Future research should investigate risk pathways of underlying comorbidities and social determinants as well as whether there are potential asthma treatments that may preserve brain health. |
| 790 | Amy Kind | GERI | amy.kind@wisc.edu | Disparities in the treatment of primary hyperparathyroidism: A scoping review and conceptual model. | Primary hyperparathyroidism is underdiagnosed and surgical treatment is underutilized and inequitably distributed. We present a review of the current literature on disparities in the treatment of hyperparathyroidism, with a focus on gaps in knowledge and paths forward. We searched PubMed and Scopus for abstracts related to disparities in hyperparathyroidism. 16 articles (of 1541) met inclusion criteria. The most commonly examined disparity was race. Notably, Black, Hispanic, and Asian patients were less likely to undergo surgery after diagnosis, face delays in obtaining treatment, and less likely to see a high-volume surgeon. Similar disparities in care were noted among those without insurance, older patients, and patients with limited English proficiency. There are clear inequities in the treatment of hyperparathyroidism. Current research is in an early "identification" phase of disparities research; a new conceptual model based on established socioecological frameworks is provided to help move the field forward to "understanding" and "intervening" in surgical disparities. |
| 791 | Andrea Gilmore Bykovskyi | EM | algilmore@wisc.edu | Moving beyond tokenism: Sustaining engagement of persons living with dementia in identifying emergency research priorities. | The Geriatric Emergency Care Applied Research Network 2.0-Advancing Dementia Care (GEAR 2.0-ADC) aims to advance research efforts to improve the emergency care of persons living with dementia (PLWDs). To support this objective, GEAR 2.0-ADC convened a virtual consensus conference to prioritize emergency care research opportunities for PLWDs inclusive of perspectives of PLWDs to ensure identification of research gaps in response to their experiences and priorities. Inclusion of PLWDs as research partners is increasingly recognized as a best practice, however, approaches to facilitating consensus participation are lacking. Best practices for supporting the engagement of PLWDs in a consensus conference, applied across its three phases (pre-conference, during the conference, and post-conference), include: establishing a learning environment focused on research priorities before the event, presenting information in ways that align with participants' learning preferences while accommodating cognitive impairments, and providing multiple opportunities and methods for gathering post-conference feedback from PLWDs. These strategies were identified by PLWDs and care partners (CPs) through semi-structured interviews, who were involved in the convening process, aimed at exploring ways to enhance facilitation techniques for participants. Additionally, these summarized insights aim to encourage the use of community-engaged approaches in discussions and consensus-building around research priorities in emergency care, particularly for PLWDs and their CPs. |
| 792 | Andrea Gilmore Bykovskyi | EM | algilmore@wisc.edu | Emergency Department Visits Among Patients With Dementia Before and After Diagnosis. | This cohort study assesses changes in emergency department (ED) use among Medicare beneficiaries aged 65 years and older before and after receiving a diagnosis of dementia. |
| 793 | Andrea Gilmore Bykovskyi | EM | algilmore@wisc.edu | A retrospective cohort study of hospital discharge instructions following delirium episodes. | |
| 794 | Andrea Gilmore Bykovskyi | EM | algilmore@wisc.edu | Receipt of rheumatology care and lupus-specific labs among young adults with systemic lupus erythematosus: A US Medicare retention in care cohort study. | In systemic lupus erythematosus, poor disease outcomes occur in young adults, patients identifying as Black or Hispanic, and socioeconomically disadvantaged patients. These identities and social factors differentially shape care access and quality that contribute to lupus health disparities in the US. Thus, our objective was to measure markers of care access and quality, including rheumatology visits (longitudinal care retention) and lupus-specific serology testing, by race and ethnicity, neighborhood disadvantage, and geographic context. This cohort study used a geo-linked 20% national sample of young adult Medicare beneficiaries (ages 18-35) with lupus-coded encounters and a 1-year assessment period. Retention in lupus care required a rheumatology visit in each 6-month period, and serology testing required ≥1 complement or dsDNA antibody test within the year. Multivariable logistic regression models were fit for visit-based retention and serology testing to determine associations with race and ethnicity, neighborhood disadvantage, and geography. Among 1,036 young adults with lupus, 39% saw a rheumatologist every 6 months and 28% had serology testing. White beneficiaries from the least disadvantaged quintile of neighborhoods had higher visit-based retention than other beneficiaries (64% vs 30%-60%). Serology testing decreased with increasing neighborhood disadvantage quintile (aOR 0.80; 95% CI 0.71, 0.90) and in the Midwest (aOR 0.46; 0.30, 0.71). Disparities in care, measured by rheumatology visits and serology testing, exist by neighborhood disadvantage, race and ethnicity, and region among young adults with lupus, despite uniform Medicare coverage. Findings support evaluating lupus care quality measures and their impact on US lupus outcomes. |
| 795 | Andrea Gilmore Bykovskyi | EM | algilmore@wisc.edu | Using concept mapping to identify recruitment and engagement strategies for inclusion of LGBTQIA+ populations in Alzheimer's disease and related dementia research. | Past Alzheimer's disease and related dementias (ADRD) research has not considered ways to ensure the representation of diverse sexual and gender minorities. This study used concept mapping (CM) to identify strategies for engaging and recruiting LGBTQIA+ older adults living with memory loss and their caregivers into ADRD research. CM, involving brainstorming, thematic analysis, and rating of strategies, was conducted with 46 members from one national and three local community advisory boards. Data was analyzed using The Concept Systems Global MAX™ web platform. One hundred twenty-two solutions were identified from June through December 2022, and represented five key themes: aging focused, LGBTQIA+ specific, memory loss and caregiving support focused, physical advertisements, and other media. Promising strategies included partnering with LGBTQIA+ health centers, attending social groups for older adults, and increasing community representation in marketing. Tailored strategies, building trust, and community involvement are essential for engaging LGBTQIA+ individuals living with memory loss or ADRD and their caregivers in ADRD-focused research. Innovative ways to ensure the inclusion of LGBTQIA+ older adults in Alzheimer's disease and related dementias (ADRD) research can be bolstered through collaboration with key community stakeholders.Promising strategies for recruitment and engagement include partnering with LGBTQIA+ centers, attending social groups for older adults, and ensuring diverse representation in marketing.Tailored recruitment and engagement strategies are crucial for building trust with LGBTQIA+ populations to increase participation in ADRD research. |
| 796 | Andrea Gilmore Bykovskyi | EM | algilmore@wisc.edu | Nurses' perceptions of the design, implementation, and adoption of machine learning clinical decision support: A descriptive qualitative study. | The purpose of this study was to explore nurses' perspectives on Machine Learning Clinical Decision Support (ML CDS) design, development, implementation, and adoption. Qualitative descriptive study. Nurses (n = 17) participated in semi-structured interviews. Data were transcribed, coded, and analyzed using Thematic analysis methods as described by Braun and Clarke. Four major themes and 14 sub-themes highlight nurses' perspectives on autonomy in decision-making, the influence of prior experience in shaping their preferences for use of novel CDS tools, the need for clarity in why ML CDS is useful in improving practice/outcomes, and their desire to have nursing integrated in design and implementation of these tools. This study provided insights into nurse perceptions regarding the utility and usability of ML CDS as well as the influence of previous experiences with technology and CDS, change management strategies needed at the time of implementation of ML CDS, the importance of nurse-perceived engagement in the development process, nurse information needs at the time of ML CDS deployment, and the perceived impact of ML CDS on nurse decision making autonomy. This study contributes to the body of knowledge about the use of AI and machine learning (ML) in nursing practice. Through generation of insights drawn from nurses' perspectives, these findings can inform successful design and adoption of ML Clinical Decision Support. |
| 797 | Andrea Gilmore Bykovskyi | EM | algilmore@wisc.edu | An observational study protocol to capture, validate and characterise lucid episodes in people living with advanced dementia receiving hospice care. | Lucid episodes (LEs) in advanced neurodegenerative disease, characterised by a transient recovery of abilities, have been reported across neurological conditions, including Alzheimer's disease and related dementias. Evidence on LEs in dementia is extremely limited and draws predominantly from retrospective case reports. Lucidity in dementia has received growing attention given the clinical, caregiving and potential epidemiological implications of even a temporary return of abilities in advanced disease. Following a funding initiative by the National Institute on Aging, several new investigations are focused on establishing foundational evidence on lucidity in dementia. The objectives of this study are to capture, characterise and validate potential LEs via audiovisual observation, computational linguistic and timed-event coding of audiovisual data, and informant case review for face validation of LEs. This prospective multifaceted observational study will investigate LEs in advanced dementia through longitudinal audiovisual observation within an inpatient hospice unit. Audiovisual data will be coded to generate variables of participant verbal output, verbal expressions, non-verbal communicative actions and functional behaviours to enable measurement of features that can be used to characterise LEs. Multiple methods will be used to identify potential LEs including field interviews with caregivers/clinicians who witness significant events during data collection, reports from research staff who witness significant events during data collection and detection by researchers during video data processing procedures. Potential LEs will undergo a structured case review with informants familiar with the participant to facilitate validation and enable triangulation across measures generated through coding. This study will be conducted in accordance with all Federal Policies for the Protection of Human Subjects and the protocol (ID 2021-1243) has been approved by the University of Wisconsin-Madison Institutional Review Board. Findings will be disseminated via scientific conferences, journal publications and newsletters shared with participants and through dementia-focused and caregiver-focused networks. |
| 798 | Andrea Gilmore Bykovskyi | EM | algilmore@wisc.edu | Feasibility and Acceptability of a Multifaceted Observational Protocol to Investigate Lucidity in Advanced Dementia. | Episodes of lucidity (ELs), characterized by spontaneous, transient recovery of abilities, are reported across neurological conditions, including advanced dementia. Despite the significance of these events, existing research is limited to retrospective reports. Approaches to prospectively capturing and characterizing ELs in dementia are lacking. This pilot study determined the feasibility and acceptability of a multifaceted observational protocol to capture, characterize, and validate ELs in individuals with advanced dementia in hospice. Feasibility was measured through enrollment/retention rates, workload/usability assessment of video observation, and data processing procedures to facilitate the measurement of verbal and nonverbal features for EL characterization. The acceptability of observation and informant validation procedures was qualitatively examined with clinician and family caregiver participants. Study procedures were endorsed as highly acceptable among clinician (N = 49) and caregiver (N = 16) participants, demonstrating higher than anticipated thresholds for observation duration. Enrollment and retention rates for patient participants (N = 6) were 100% and 84%, respectively. Workload and usability measures demonstrated low disruptiveness and high ease of use after training. Longitudinal video observation among individuals with advanced dementia in hospice care for the detection of lucidity was feasible and highly acceptable. Multidimensional, temporal coding of features of ELs is feasible but time-intensive. |
| 799 | Andrea Gilmore Bykovskyi | EM | algilmore@wisc.edu | Promoting diverse perspectives: Addressing health disparities related to Alzheimer's and all dementias. | Dementia research lacks appropriate representation of diverse groups who often face substantial adversity and greater risk of dementia. Current research participants are primarily well-resourced, non-Hispanic White, cisgender adults who live close to academic medical centers where much of the research is based. Consequently, the field faces a knowledge gap about Alzheimer's-related risk factors in those other groups. The Alzheimer's Association hosted a virtual conference on June 14-16, 2021, supported in part by the National Institute on Aging (R13 AG072859-01), focused on health disparities. The conference was held entirely online and consisted of 2 days of core programming and a day of focused meetings centered on American Indian and Alaska Natives and on LGBTQIA+ populations. Over 1300 registrants attended discussions focused on the structural and systemic inequities experienced across diverse groups, as well as ways to investigate and address these inequities. |
| 800 | Andrea Gilmore Bykovskyi | EM | algilmore@wisc.edu | "Nudging" clinicians to communicate more effectively with patients in hospital. | |
| 801 | Maxfield Flynn | ENDO | mflynn@medicine.wisc.edu | Integrating planetary health education into tertiary curricula: a practical toolbox for implementation. | To present a series of case studies from our respective countries and disciplines on approaches to implementing the Planetary Health Education Framework in university health professional education programs, and to propose a curriculum implementation and evaluation toolbox for educators to facilitate the adoption of similar initiatives in their programs. We emphasize the importance of applying an Indigenous lens to curriculum needs assessment, development, implementation, and evaluation. Case studies from Australia and United States were collated using a six-stage design-based educational research framework (Focus, Formulation, Contextualization, Definition, Implementation, Evaluation) for teaching planetary health and methods of curriculum evaluation. These components were then mapped to derive the curriculum implementation toolbox reflecting the six-stage design-based educational research framework. The case studies demonstrated different approaches to successful integration of the Planetary Health Education Framework in medicine, nursing, public health, and allied health disciplines. This integration often involved Indigenous perspectives on environmental stewardship, holistic health, and community well-being into the curriculum. The case studies also highlighted the importance of community engagement, cultural competency, and interdisciplinary collaboration in curriculum development. Findings from case studies were used to propose a curriculum implementation toolbox to assist educators in adapting and integrating planetary health education into their own programs. While valuable frameworks for teaching planetary health in health science programs exist, challenges remain in implementing these frameworks in real-world educational environments. The proposed curriculum implementation toolbox offers practical strategies and resources for educators to incorporate these principles into their teaching. Additionally, the case studies reported here contribute to the growing body of literature on planetary health education pertinent to addressing the triple planetary crisis. |
| 802 | Maxfield Flynn | ENDO | mflynn@medicine.wisc.edu | Daily Sodium Monitoring and Fluid Intake Protocol: Preventing Recurrent Hospitalization in Adipsic Diabetes Insipidus. | Management of diabetes insipidus (DI) is usually facilitated by an intact thirst mechanism prompting water ingestion in times of rising osmolality. Maintenance of eunatremia can be quite difficult in patients with DI and adipsia because of the absence of this homeostatic mechanism. Few published protocols for management of these complex cases exist. We report a case of a 16-year-old girl who had a diagnosis of craniopharyngioma with preoperative hypopituitarism and central DI. She underwent transsphenoidal resection in 2013 and additionally developed postoperative cognitive impairment and hypothalamic dysfunction, including adipsia. She subsequently experienced widely dysregulated sodium levels, necessitating inpatient care ∼30% of days in 2014 and 2015. We created a protocol for this patient that uses a fixed daily dose of subcutaneous DDAVP combined with daily modulation of fluid intake based on daily serum sodium measurement. The protocol provides guidance for the day's fluid intake based on both the current sodium result and the rate of change from the previous day. Since the adoption of the protocol in June 2016, the patient has had a dramatic reduction in hospitalizations. Use of a protocol for providing recommendations for fluid intake based on the sodium level and rate of change may help to maintain normal sodium levels in such patients, decreasing hospitalization and improving quality of life. |
| 803 | Megan Piper | GIM | mep@ctri.wisc.edu | Optimizing diabetes management interventions for Black and Hispanic adults using the multiphase optimization strategy: Protocol for a randomized mixed methods factorial trial. | Black and Hispanic adults with diabetes are more likely to experience diabetes complications and die from diabetes compared to non-Hispanic whites. This disparity may be due to medication adherence being negatively affected by social determinants of health (SDOH) and negative beliefs about diabetes and diabetes medicines. Pharmacist delivered medication therapy management (MTM) improves clinical outcomes. However, pharmacists have limited capacity and expertise to address SDOH barriers and health misperceptions. Supplementing MTM with Community Health Workers (CHWs) to address these factors may be more effective with potential for implementation. To investigate what combination of two possible components, pharmacist delivered MTM and CHWs addressing SDOH barriers and health misperceptions, represents the optimized intervention for Black and Hispanic adults with uncontrolled diabetes. We will use a 2 × 2 factorial design (MTM, CHW: ON vs. OFF) where participants will be randomized to one of four treatment conditions in a 6-month intervention delivered mostly by phone. We will recruit 376 Black or Hispanic adults with type 2 diabetes and hemoglobin A1C of ≥8 %, a clinical indicator of uncontrolled type 2 diabetes. The primary outcome is A1C measured at 6 months, and at 12 months for sustained change. The secondary outcome is medication adherence. Several psychosocial factors will be examined as potential mediators. An embedded experimental mixed methods approach will be used to obtain participant perspectives through qualitative interviews and integrated to assess intervention acceptability. Our findings will identify the optimized intervention, e.g., comprising MTM or CHW or both intervention components, that effectively and efficiently improves diabetes outcomes among Black and Hispanic adults with uncontrolled diabetes, informing dissemination. |
| 804 | Megan Piper | GIM | mep@ctri.wisc.edu | Understanding the motivational mechanisms for smoking and vaping among dual users and exclusive smokers. | Understanding the motivational processes that influence e-cigarette use in a laboratory setting may help elucidate mechanisms that support long-term ecigarette use, which could have significant clinical and public health consequences. Secondary analyses were conducted on data from exclusive smokers (N=47) and dual users (N=88) who underwent a laboratory ad lib use session. Participants were given 10minutes to smoke (exclusive smokers) or vape (dual users) as much as they wanted. Withdrawal was assessed pre- and post-use. Smoking and vaping behavior was coded from session videos. Person-level predictors included cigarette/ecigarette craving-relief expectancies, demographics, and cigarette/e-cigarette use and dependence. Smoking and vaping status was assessed at Year 1 using self-reported 30-day point prevalence. Data were analyzed using general linear models and logistic regressions. Both groups reported reductions in withdrawal after product use, including cigarette craving. Baseline e-cigarette craving-relief expectancies, pre-session ecigarette craving, heaviness of e-cigarette use, and relative e-cigarette dependence were significant univariate predictors of continued vaping in dual users at Year 1 (ORs>1.04, ps.16). E-cigarette use alleviated withdrawal, including cigarette and e-cigarette craving, in dual users. Laboratory use behavior did not differ between dual users using e-cigarettes and exclusive smokers using cigarettes. Greater e-cigarette craving-relief expectancies, e-cigarette craving, heaviness of e-cigarette use, and morning product use pattern ('relative dependence') may reflect mechanisms that sustain e-cigarette use. |
| 805 | Megan Piper | GIM | mep@ctri.wisc.edu | Health Risks Associated with Adopting New-Generation Disposable Products Among Young Adults Who Use E-Cigarettes. | New-generation disposable e-cigarettes have become increasingly popular among young adults in the USA since the FDA's partial flavor ban. This study aims to examine longitudinal changes in health risks among young adults who adopted these novel products, as well as the health effects of device types beyond the effects of other important e-cigarette characteristics. This study recruited e-cigarette users via voluntary response sampling from three college campuses in the USA to respond to four-wave online surveys conducted in four consecutive semesters. Among the participants who adopted disposables during the study, their health risks (dependence symptoms, respiratory symptoms, combustible tobacco use) and e-cigarette consumption characteristics (use frequency, nicotine concentration and flavors) before and after the adoption were compared using paired-sample t- or McNemar's tests. Generalized linear mixed models with a random intercept were conducted on data from the entire sample to investigate the effects of device type (tank, cartridge/pod, disposable) on health risks, controlling for other e-cigarette consumption characteristics. The study sample of 650 e-cigarette users were, on average, 20 years old, with 49% being male, 70% being White, and 13% being Hispanic. Adopting disposables may increase secondary dependence motives (t = 2.42, p < 0.05) and the use of higher levels of nicotine concentration (t = 2.09, p < 0.05) and sweet flavors (x2 = 22.53, p < 0.05) but decrease the number of times of vaping per day (t = -2.18, p < 0.05) and the use of menthol flavors (x2 = 4.57, p < 0.05). Tank use is associated with a higher level of primary dependence motives (b = 0.1998, p < 0.05) and a greater odds of using combustible tobacco (b = 0.4772, p < 0.05). Although disposable use is not associated with the likelihood of using combustible tobacco, it is associated with higher levels of both primary (b = 0.2158, p < 0.05) and secondary (b = 0.2533, p < 0.05) dependence motives. It is not the device type, but rather the frequency of vaping, that affects respiratory symptoms (b = 0.0602, p < 0.05). The findings indicate that when young adults switch to disposables, their e-cigarette dependence and use of sweet-flavored e-liquids increase. Even after controlling for use frequency, nicotine concentration and flavors, using disposables is related to not only instrumental motives that are influenced by psychological and environmental contexts but also heavy, automatic use that can operate without environmental cues. Given the health risks associated with disposable e-cigarettes, more comprehensive tobacco product regulations that consider the impact of device types may be needed. |
| 806 | Megan Piper | GIM | mep@ctri.wisc.edu | E-Cigarette Use in Adults. | This JAMA Insights explores the adverse effects and health outcomes of e-cigarettes vs combusted cigarettes and the effectiveness of using e-cigarettes as a smoking cessation aid among US adults. |
| 807 | Megan Piper | GIM | mep@ctri.wisc.edu | Helping Black Patients in Wisconsin Quit Smoking: A Call for Clinical Action. | |
| 808 | Megan Piper | GIM | mep@ctri.wisc.edu | Implementing a Staff-Led Smoking Cessation Intervention in a Diverse Safety-Net Rheumatology Clinic: A Pre-Post Scalability Study in a Low-Resource Setting. | Quit Connect (QC), our specialty clinic smoking cessation intervention, supports clinic staff to check, advise, and connect willing patients to a state quit line or class. QC improved tobacco screening and quit line referrals 26-fold in a predominantly White academic health care system population. Implementing QC includes education, electronic health record (EHR) reminders, and periodic audit feedback. This study tested QC's feasibility and impact in a safety-net rheumatology clinic with a predominantly Black population. In this pre-post study, adult rheumatology visits were analyzed 12 months before through 18 months after QC intervention (November 2019 through November 2021, omitting COVID-19 peak April through November 2020). EHR data compared process and clinical outcomes, including offers, referrals to resources, completed referrals, and documented cessation. Clinic staff engaged in pre-post focus groups and questionnaires regarding intervention feasibility and acceptability. Cost-effectiveness was also assessed. Visit-level patients who smoked were 89.8% Black and 69.5% women (n = 550). Before intervention, clinic staff rarely asked patients about readiness to cut back smoking (<10% assessment). After QC intervention, staff assessed quit readiness in 31.8% of visits with patients who smoked (vs 8.1% before); 58.9% of these patients endorsed readiness to cut back or quit. Of 102 accepting cessation services, 37% (n = 17) of those reached set a quit date. Staff found the intervention feasible and acceptable. Each quit attempt cost approximately $4 to $10. In a safety-net rheumatology clinic with a predominantly Black population, QC improved tobacco screening, readiness-to-quit assessment, and referrals and was also feasible and cost-effective. |
| 809 | Megan Piper | GIM | mep@ctri.wisc.edu | Comparison of Indicators of Dependence for Vaping and Smoking: Trends Between 2017 and 2022 Among Youth in Canada, England, and the United States. | The current study sought to examine trends in indicators of dependence for youth vaping and smoking during a period of rapid evolution in the e-cigarette market. Data are from repeat cross-sectional online surveys conducted between 2017 and 2022 among youth aged 16-19 in Canada, England, and the United States (US). Participants were 23 145 respondents who vaped and/or smoked in the past 30 days. Four dependence indicators were assessed for smoking and vaping (perceived addiction, frequent strong urges, time to first use after waking, days used in past month) and two for vaping only (use events per day, e-cigarette dependence scale). Regression models examined differences by survey wave and country, adjusting for sex, age, race, and exclusive/dual use. All six indicators of dependence increased between 2017 and 2022 among youth who vaped in the past 30 days (p < .001 for all). For example, more youth reported strong urges to vape at least most days in 2022 than in 2017 (Canada: 26.5% to 53.4%; England: 25.5% to 45.4%; US: 31.6% to 50.3%). In 2017, indicators of vaping dependence were substantially lower than for smoking; however, by 2022, youth vaping was associated with a greater number of days used in the past month (Canada, US), shorter time to first use (all countries), and a higher likelihood of frequent strong urges (Canada, US) compared to youth smoking. From 2017 to 2022, indicators of vaping dependence increased substantially. By 2022, vaping dependence indices were comparable to those of smoking. Indicators of vaping dependence among youth have increased substantially since 2017 to levels that are comparable to cigarette dependence among youth who smoke. Future research should examine factors underlying the increase in dependence among youth who vape, including changes to the nicotine profile and design of e-cigarette products. |
| 810 | Megan Piper | GIM | mep@ctri.wisc.edu | Investigating Best Practices for Ecological Momentary Assessment: Nationwide Factorial Experiment. | Ecological momentary assessment (EMA) is a measurement methodology that involves the repeated collection of real-time data on participants' behavior and experience in their natural environment. While EMA allows researchers to gain valuable insights into dynamic behavioral processes, the need for frequent self-reporting can be burdensome and disruptive. Compliance with EMA protocols is important for accurate, unbiased sampling; yet, there is no "gold standard" for EMA study design to promote compliance. The purpose of this study was to use a factorial design to identify optimal study design factors, or combinations of factors, for achieving the highest completion rates for smartphone-based EMAs. Participants recruited from across the United States were randomized to 1 of 2 levels on each of 5 design factors in a 2×2×2×2×2 design (32 conditions): factor 1-number of questions per EMA survey (15 vs 25); factor 2-number of EMAs per day (2 vs 4); factor 3-EMA prompting schedule (random vs fixed times); factor 4-payment type (US $1 paid per EMA vs payment based on the percentage of EMAs completed); and factor 5-EMA response scale type (ie, slider-type response scale vs Likert-type response scale; this is the only within-person factor; each participant was randomized to complete slider- or Likert-type questions for the first 14 days or second 14 days of the study period). All participants were asked to complete prompted EMAs for 28 days. The effect of each factor on EMA completion was examined, as well as the effects of factor interactions on EMA completion. Finally, relations between demographic and socioenvironmental factors and EMA completion were examined. Participants (N=411) were aged 48.4 (SD 12.1) years; 75.7% (311/411) were female, 72.5% (298/411) were White, 18.0% (74/411) were Black or African American, 2.7% (11/411) were Asian, 1.5% (6/411) were American Indian or Alaska Native, 5.4% (22/411) belonged to more than one race, and 9.6% (38/396) were Hispanic/Latino. On average, participants completed 83.8% (28,948/34,552) of scheduled EMAs, and 96.6% (397/411) of participants completed the follow-up survey. Results indicated that there were no significant main effects of the design factors on compliance and no significant interactions. Analyses also indicated that older adults, those without a history of substance use problems, and those without current depression tended to complete more EMAs than their counterparts. No other demographic or socioenvironmental factors were related to EMA completion rates. Finally, the app was well liked (ie, system usability scale score=82.7), and there was a statistically significant positive association between liking the app and EMA compliance. Study results have broad implications for developing best practices guidelines for future studies that use EMA methodologies. ClinicalTrials.gov number NCT05194228; https://clinicaltrials.gov/study/NCT05194228. |
| 811 | Megan Piper | GIM | mep@ctri.wisc.edu | Statistical methods for predicting e-cigarette use events based on beat-to-beat interval (BBI) data collected from wearable devices. | The prevalence of e-cigarette use among young adults in the USA is high (14%). Although the majority of users plan to quit vaping, the motivation to make a quit attempt is low and available support during a quit attempt is limited. Using wearable sensors to collect physiological data (eg, heart rate) holds promise for capturing the right timing to deliver intervention messages. This study aims to fill the current knowledge gap by proposing statistical methods to (1) de-noise beat-to-beat interval (BBI) data from smartwatches worn by 12 young adult regular e-cigarette users for 7 days; and (2) summarize the de-noised data by event and control segments. We also conducted a comprehensive review of conventional methods for summarizing heart rate variability (HRV) and compared their performance with the proposed method. The results show that the proposed singular spectrum analysis (SSA) can effectively de-noise the highly variable BBI data, as well as quantify the proportion of total variation extracted. Compared to existing HRV methods, the proposed second order polynomial model yields the highest area under the curve (AUC) value of 0.76 and offers better interpretability. The findings also indicate that the average heart rate before vaping is higher and there is an increasing trend in the heart rate before the vaping event. Importantly, the development of increasing heart rate observed in this study implies that there may be time to intervene as this physiological signal emerges. This finding, if replicated in a larger scale study, may inform optimal timings for delivering messages in future intervention. |
| 812 | Megan Piper | GIM | mep@ctri.wisc.edu | Psychometric Properties of the FTCD and Brief WISDM: Support for Validity in a Legal-System-Involved Sample. | The Fagerström test for cigarette dependence (FTCD) and Brief Wisconsin index of smoking dependence motives (WISDM) are widely used measures of smoking dependence. The FTCD was previously found to have 1-factor and 2-factor structures and Brief WISDM has been found to have an 11-factor and 11-factor hierarchical structure. As such, the current study sought to further investigate the psychometric properties of the FTCD and Brief WISDM with a novel criminal-legal system-involved sample using both a factor-analytic and an item response theory (IRT) approach. Data from 517 criminal-legal system-involved adults (ie, 18 years of age or older) who smoke from Alabama, USA were analyzed. Confirmatory factor analyses (CFA) were conducted on 1-factor and 2-factor structures of the FTCD and 1-factor, 11-factor, and 11-factor hierarchical structures of the Brief WISDM. IRT analyses investigating item discrimination and threshold parameters were also conducted on the brief WISDM. The CFA showed poor fit for a single-factor structure and mixed results for two 2-factor results for the FTCD. CFA also showed poor fit for a single-factor and mixed results for the 11-factor model. Initial IRT investigations using the 11-factor model showed strong item discrimination, but non-ordered threshold parameters. Two-factor structures for the FTCD and the 11-factor model for the Brief WISDM were partially supported in a criminal-legal population, suggesting continued support for the multidimensional structure of the measures. Additionally, exploratory IRT analyses suggested good discrimination across the use spectrum for the Brief WISDM. The Fagerström Test of Cigarette Dependence (FTCD) and Brief Wisconsin index of smoking dependence motives (WISDM) are two widely used measures of nicotine dependence, though previous research has shown mixed results for their internal consistency and factor structure. The current study used a unique sample of criminal-legal-involved participants who generally have moderate to high levels of nicotine dependence. The current study found that the FTCD displayed poor internal consistency, a poor fit for a single-factor model, but mixed support for two two-factor models. The Brief-WISDM was found to have strong internal consistency, a poor fit for a single-factor model, but mixed fit for an 11-factor model and good item discrimination. |
| 813 | William Busse | APCC-AA | wwb@medicine.wisc.edu | Identification of Bronchial Epithelial Genes Associated with Type-2 Eosinophilic Inflammation in Asthma. | Airway inflammation has a critical role in asthma pathogenesis and pathophysiology. Yet, the molecular pathways contributing to airway inflammation are not fully known, particularly Type-2 (T2) inflammation characterized by both eosinophilia and higher FeNO levels. To identify genes whose level of expression in epithelial brushing samples were associated with both bronchoalveolar lavage (BAL) eosinophilia and generation of FeNO. We performed segmental allergen bronchoprovocation (SBP-Ag) in participants with asthma, and RNA-sequencing (RNA-seq) analyses of BAL cells and brushing samples before and 48 h after SBP-Ag to identify regulation of eosinophil recruitment and FeNO changes. Allergen bronchoprovocation increased FeNO levels, which correlated with eosinophilia. Thirteen genes were identified in brushing samples, whose expression changed in response to SBP-Ag and correlated with both airway eosinophilia and FeNO levels after SBP-Ag. Among these 13 genes, the epithelial cell product, CDH26/cadherin-26 contributed to the amplification of T2 inflammation, as reflected by eosinophilia and FeNO, and causal mediation analyses with pro-T2 and pro-eosinophilic cytokine mediators in BAL fluids. Among the genes associated with reduced eosinophilia and FeNO, HEY2 is known to enhance cell proliferation, migration, invasion, and epithelial-to-mesenchymal transition (EMT), as well as to reduce apoptosis. This unbiased RNA-seq analysis in participants with allergic asthma revealed several epithelial cell genes, particularly CDH26, that may be critical for the development or augmentation of T2 inflammation in asthma. |
| 814 | William Busse | APCC-AA | wwb@medicine.wisc.edu | Dysregulation of Airway and Systemic Interferon Responses Promote Asthma Exacerbations in Urban Children. | Determining why some upper respiratory illnesses provoke asthma exacerbations remains an unmet need. To identify transcriptome-wide gene expression changes associated with colds that progress to exacerbation. 208 urban children (6-17 years) with exacerbation-prone asthma were prospectively monitored for up to two cold illnesses. Exacerbation illnesses (Ex+), defined as colds leading to asthma exacerbations requiring systemic corticosteroids within 10 days, were compared to colds that resolved without exacerbation (Ex-). Peripheral blood and nasal lavage samples were collected at baseline and during colds for RNA sequencing. Interferon gene expression was compared between Ex+ and Ex- illnesses. Generalized additive modeling revealed interferon response kinetics. Multiple linear regression models compared interferon expression to clinical variables. 106 participants were evaluated during 154 colds. There was greater up-regulation of differentially expressed interferon genes during Ex+ illnesses compared to Ex-. Ex+ illnesses had greater average and steeper rise in interferon expression. Within three days of illness, interferon expression was positively associated with nasal rhinovirus quantity (nasal:adjustedR2=0.48, p=0.015; blood:adjustedR2=0.22, p=0.013) and interferon expression was negatively associated with FEV1 percent predicted (nasal:β=-0.010, p=0.048; blood:β=-0.008, p=0.023). Participants with lower baseline interferon expression had shorter time to exacerbation, higher risk for exacerbation with viral illnesses and greater increase in interferon expression during viral colds (nasal:β=-0.80, p<0.0001; blood:β=-0.75, p<0.0001). Dysregulated interferon responses are important contributors to asthma exacerbation risk in children. Low baseline interferon expression followed by greater up-regulation of interferon pathways in airway and blood during respiratory illnesses increased exacerbation risk. Targeting this pathway in at-risk individuals holds promise for the personalized prevention of asthma exacerbations. |
| 815 | William Busse | APCC-AA | wwb@medicine.wisc.edu | Rhinoconjunctivitis Symptoms in Children and Adolescents with Asthma: A Longitudinal Clustering Analysis. | Rhinoconjunctivitis phenotypes are conventionally described based on symptom severity, duration and seasonality and aeroallergen sensitization. It is not known whether these phenotypes fully reflect the patterns of symptoms seen at a population level. To identify phenotypes of rhinoconjunctivitis based on symptom intensity and seasonality using an unbiased approach and to compare their characteristics. A cohort of children with asthma in low-income urban environments was prospectively followed with a rhinoconjunctivitis activity questionnaire and their upper and lower airway disease was managed for 12 months with every 2-month visits based on standardized algorithms. We identified individual rhinoconjunctivitis symptom trajectories and clusters of those trajectories and compared the clusters focusing on atopic characteristics. Data obtained from 619 children yielded 5 symptom clusters: two had high symptoms (22.5%) but differed in seasonal pattern, one had medium symptoms (13.6%), one had medium nasal congestion only (20.4%) and one had low symptoms (43.6%). The latter was further split into two subgroups if nasal corticosteroids were frequently prescribed (23.6%) or not (20.0%). Seasonal variation was absent in the low symptom clusters. The number of allergic sensitizations and family history of allergic airway disease were higher in the high symptom clusters, but allergic sensitization did not explain differences in seasonality. This study identified rhinoconjunctivitis phenotypes that have not been previously reported and were not differentiated by demographics, or measures of atopy and type 2 inflammation. Factors beyond allergy need to be investigated to better understand the pathobiology of rhinoconjunctivitis. |
| 816 | William Busse | APCC-AA | wwb@medicine.wisc.edu | Dupilumab Induces Long-Term On-Treatment Clinical Remission in Patients With Type 2 Asthma. | Remission is proposed as a multicomponent outcome for patients with severe asthma. This post hoc analysis of QUEST (NCT02414854) and TRAVERSE (NCT02134028) evaluated whether dupilumab treatment leads to clinical asthma remission (≥12 months with no severe exacerbations, zero oral corticosteroid use, stabilized or improved lung function, patient-reported asthma control <1.5) and assessed its durability in patients with uncontrolled, moderate to severe type 2 asthma (blood eosinophils ≥150 cells/μL or fractional exhaled nitric oxide ≥20 ppb at parent-study baseline) who are not receiving maintenance oral corticosteroids. In QUEST, patients (aged ≥12 years) were randomized to dupilumab 200/300 mg or placebo every 2 weeks for 52 weeks. In TRAVERSE, all patients received dupilumab 300 mg every 2 weeks for up to 96 weeks. We assessed the proportion of patients meeting criteria for on-treatment clinical remission up to 48 weeks of TRAVERSE. At QUEST baseline, 1,040 patients receiving dupilumab and 544 taking placebo had type 2 asthma; of those, 842 (dupilumab/dupilumab) and 437 (placebo/dupilumab) enrolled in TRAVERSE. At QUEST week 52 (year 1), 37.2% of patients receiving dupilumab met clinical remission criteria, compared with 22.2% taking placebo (all P < .001). At week 48 of TRAVERSE (year 2 overall), 42.8% (dupilumab/dupilumab) and 33.4% (placebo/dupilumab) of patients met clinical remission criteria. Overall, 29.5% of patients in the dupilumab/dupilumab group met the criteria at both years 1 and 2. Dupilumab treatment enabled approximately one third of patients with type 2 asthma to meet the multicomponent end point for on-treatment clinical asthma remission for up to 2 years. |
| 817 | William Busse | APCC-AA | wwb@medicine.wisc.edu | The role of biologics in inducing remission in asthma. | Asthma remissions have been identified as a new treatment outcome and as based on experience with biologics. Remissions are defined as no symptoms, no exacerbations, no use of systemic corticosteroids, and stabilization (optimization) of lung functions; all these criteria need to be sustained for at least 1 year. This study discussed the evolution of remissions, the evolving criteria, and experiences in achieving remission after treatment with biologics. In severe, uncontrolled asthma, treatment with biologics has led to remissions in 20% to 35% of the subjects treated. It is proposed that remissions will become a new and important treatment outcome for asthma. |
| 818 | William Busse | APCC-AA | wwb@medicine.wisc.edu | Oncostatin-M Is Produced by Human Eosinophils and Expression Is Increased in Uncontrolled Severe Asthma. | |
| 819 | William Busse | APCC-AA | wwb@medicine.wisc.edu | Breaking up Mucus Plugs in Asthma. | |
| 820 | William Busse | APCC-AA | wwb@medicine.wisc.edu | Stability of Fractional Exhaled Nitric Oxide and its Relationship with Exacerbation in Patients Aged 6 Years or Older with Uncontrolled, Moderate-to-Severe Asthma. | |
| 821 | William Busse | APCC-AA | wwb@medicine.wisc.edu | Salience network resting state functional connectivity during airway inflammation in asthma: A feature of mental health resilience? | Inflammation is an established contributor to the pathophysiology of depression and the prevalence of depression in those with chronic inflammatory disease is two- to four-fold higher than the general population. Yet little is known about the neurobiological changes that confer depression or resilience to depression, that occur when episodes of heightened inflammation are frequent or span many years. We used an innovative combination of longitudinal resting state functional magnetic resonance imaging coupled to segmental bronchial provocation with allergen (SBP-Ag) to assess changes in resting state functional connectivity (rsFC) of the salience network (SN) caused by an acute inflammatory exacerbation in twenty-six adults (15 female) with asthma and varying levels of depressive symptoms. Eosinophils measured in bronchoalveolar lavage fluid and blood provided an index of allergic inflammation and the Beck Depression Inventory provided an index of depressive symptoms. We found that in those with the highest symptoms of depression at baseline, SN rsFC declined most from pre- to post-SBP-Ag in the context of a robust eosinophilic response to challenge, but in those with low depressive symptoms SN rsFC was maintained or increased, even in those with the most pronounced SBP-Ag response. Thus, the maintenance of SN rsFC during inflammation may be a biomarker of resilience to depression, perhaps via more effective orchestration of large-scale brain network dynamics by the SN. These findings advance our understanding of the functional role of the SN during inflammation and inform treatment recommendations for those with comorbid inflammatory disease and depression. |
| 822 | William Busse | APCC-AA | wwb@medicine.wisc.edu | Home and school pollutant exposure, respiratory outcomes, and influence of historical redlining. | The discriminatory and racist policy of historical redlining in the United States during the 1930s played a role in perpetuating contemporary environmental health disparities. Our objectives were to determine associations between home and school pollutant exposure (fine particulate matter [PM2.5], NO2) and respiratory outcomes (Composite Asthma Severity Index, lung function) among school-aged children with asthma and examine whether associations differed between children who resided and/or attended school in historically redlined compared to non-redlined neighborhoods. Children ages 6 to 17 with moderate-to-severe asthma (N = 240) from 9 US cities were included. Combined home and school exposure to PM2.5 and NO2 was calculated based on geospatially assessed monthly averaged outdoor pollutant concentrations. Repeated measures of Composite Asthma Severity Index and lung function were collected. Overall, 37.5% of children resided and/or attended schools in historically redlined neighborhoods. Children in historically redlined neighborhoods had greater exposure to NO2 (median: 15.4 vs 12.1 parts per billion) and closer distance to a highway (median: 0.86 vs 1.23 km), compared to those in non-redlined neighborhoods (P < .01). Overall, PM2.5 was not associated with asthma severity or lung function. However, among children in redlined neighborhoods, higher PM2.5 was associated with worse asthma severity (P .005). Our findings highlight the significance of historical redlining and current environmental health disparities among school-aged children with asthma, specifically, the environmental injustice of PM2.5 exposure and its associations with respiratory health. |
| 823 | Kimberly Mueller | GERI | kdmueller@wisc.edu | Menopausal hormone therapy is associated with worse levels of Alzheimer's disease biomarkers in APOE ε4-carrying women: An observational study. | Menopausal hormone therapy (MHT), along with the apolipoprotein E (APOE) ε4 allele, has been suggested as a possible risk factor for Alzheimer's disease (AD). However, the relationship between MHT and cerebrospinal fluid (CSF) biomarkers is unknown: we investigated this association, and whether APOE ε4 carrier status moderates it. In an observational study of 136 cognitively unimpaired female participants (Mage = 66.0; standard deviation = 6.3), we examined whether MHT use alone or in interaction with APOE ε4 carrier status was associated with CSF levels of phosphorylated tau (p-tau), amyloid beta (Aβ)40, Aβ42, p-tau/Aβ42, and Aβ42/40 ratios. Significant interactions were found between APOE ε4 and MHT use for CSF biomarkers. APOE ε4 carriers who were MHT users showed worse levels of CSF p-tau/Aβ42 and Aβ42/40 ratios than all other users and non-users. The presence of both APOE ε4 and MHT may be associated with elevated amyloid deposition and AD pathology in this sample of participants who demonstrated high familial AD risk. Significant interactions were found between apolipoprotein E (APOE) ε4 and menopausal hormone therapy (MHT) use for cerebrospinal fluid (CSF) phosphorylated tau (p-tau)/amyloid beta (Aβ)42 and Aβ42/40 ratios. APOE ε4 carriers who were MHT users showed worse levels of CSF biomarkers than non-users and non-carriers, both users and non-users. Younger age at MHT initiation was associated with worse levels of the p-tau/Aβ42 and Aβ42/40 ratios in carriers only. The presence of both APOE ε4 carriage and MHT use may be associated with elevated amyloid deposition and AD pathology. Further studies with larger sample sizes are necessary to confirm the differences observed in the current study. |
| 824 | Kimberly Mueller | GERI | kdmueller@wisc.edu | Delayed primacy recall in AVLT is associated with medial temporal tau PET burden in cognitively unimpaired adults. | Alzheimer's disease (AD) can be diagnosed by in vivo abnormalities of amyloid-β plaques (A) and tau accumulation (T) biomarkers. Previous studies have shown that analyses of serial position performance in episodic memory tests, and especially, delayed primacy, are associated with AD pathology even in individuals who are cognitively unimpaired. The earliest signs of cortical tau pathology are observed in medial temporal lobe (MTL) regions, yet it is unknown if serial position markers are also associated with early tau load in these regions. This study of cognitively unimpaired older individuals examined whether serial position scores in word-list recall cross-sectionally predicted tau PET load in the MTL, and were able to discriminate between biomarker profiles, based on AT classification. Data from 490 participants (mean age = 68.8 ± 7.2) were extracted from two cohorts, which were merged into one sample. Linear regression analyses were carried out with regional volume-controlled tau (18F-MK-6240) PET SUVR of the entorhinal cortex (EC), parahippocampal cortex (PHC) and hippocampus (H) as outcomes, cross-sectional memory scores from the Rey Auditory Verbal Learning Test as predictors (total and delayed recall, along with serial position scores) and control variables, in separate analyses for each outcome and predictor. The sample was then stratified by biomarker profile and ANCOVAs were conducted with the strongest scores from the regression analyses, AT groups as fixed factor and the covariates. Higher delayed primacy significantly predicted lower tau PET in EC, PHC, and H, cross-sectionally. Higher total recall scores predicted lower EC tau, but delayed primacy showed the best model fit, as indicated by AICs. ANCOVAs showed that AVLT metrics did not significantly discriminate between A-T- and A+T+, after correcting for multiple comparisons. Serial position analysis of word-list recall, particularly delayed primacy, may be a valuable tool for identifying in vivo tau pathology in cognitively unimpaired individuals. |
| 825 | Kimberly Mueller | GERI | kdmueller@wisc.edu | Articulatory precision from connected speech as a marker of cognitive decline in Alzheimer's disease risk-enriched cohorts. | Mild cognitive impairment (MCI) has been recognized as a possible precursor to Alzheimer's disease (AD). Recent research focusing on connected speech has uncovered various features strongly correlated with MCI due to AD and related dementias. Despite these advancements, the impact of early cognitive decline on articulatory precision has not been thoroughly investigated. This study introduced the phoneme log-likelihood ratio (PLLR) to assess the articulatory precision of speakers across different cognitive status levels and compared its effectiveness to existing well-studied acoustic features. The study utilized speech recordings from a picture description task, which included data from 324 cognitively unimpaired participants with low amyloid-β burden (CU, Aβ(-)), 47 cognitively unimpaired participants with high amyloid-β burden (CU, Aβ(+)), 69 participants with MCI, and 20 participants with dementia. Nine acoustic features were extracted from the speech recordings, covering three categories: speech fluency, speech pace, and articulatory precision. Welch's t-test and Hedge's g were adopted to assess their discriminative ability. A reduction in speech fluency and pace was observed among participants in the MCI and dementia groups. The PLLR shows large effect sizes in distinguishing between cognitively unimpaired participants with low Aβ burden and those diagnosed with MCI or dementia. Additionally, the test-retest reliability experiment indicated moderate repeatability of the features under study. The study reveals PLLR as a sensitive indicator capable of detecting subtle articulatory variations across groups, while also providing further support for the association between reduced articulatory precision and early cognitive decline. |
| 826 | Kimberly Mueller | GERI | kdmueller@wisc.edu | Story recall performance and AT classification via positron emission tomography: A comparison of logical memory and Craft Story 21. | Early detection of Alzheimer's disease (AD) is one of the critical components of the global response to the growing dementia crisis. Analysis of serial position performance in story recall tests has yielded sensitive metrics for the prediction of AD at low cost. In this study, we examined whether serial position markers in two story recall tests (the logical memory test, LMT, and the Craft Story 21 test, CST) were sensitive to cross-sectional biomarker-based assessment of in vivo neuropathology. Participants were selected from the Wisconsin Registry of Alzheimer's Prevention (n = 288; WRAP) and the Alzheimer's Disease Research Center (n = 156; ADRC), both from the University of Wisconsin-Madison. Average age at PET was 68.9 (6.7) and 67.0 (8.0), respectively. Data included tau and PiB PET, and LMT for WRAP participants and CST for ADRC participants. Two sets of Bayesian analyses (logistic regressions and ANCOVAs) were conducted within each cohort, separately. Results indicated that the A+T+ classification was best predicted, cross-sectionally, by the recency ratio (Rr), indexing how much of the end of the story was forgotten between initial learning and delayed assessment. Rr outperformed traditional scores and discriminated between A+T+ and A+T-/A-T-, in both cohorts. Overall, this study confirms that serial position analysis of LMT and CST data, and particularly Rr as an index of recency loss, is a valuable tool for the identification of in vivo tau pathology in individuals free of dementia. Diagnostic considerations are discussed. |
| 827 | Kimberly Mueller | GERI | kdmueller@wisc.edu | An observational study protocol to capture, validate and characterise lucid episodes in people living with advanced dementia receiving hospice care. | Lucid episodes (LEs) in advanced neurodegenerative disease, characterised by a transient recovery of abilities, have been reported across neurological conditions, including Alzheimer's disease and related dementias. Evidence on LEs in dementia is extremely limited and draws predominantly from retrospective case reports. Lucidity in dementia has received growing attention given the clinical, caregiving and potential epidemiological implications of even a temporary return of abilities in advanced disease. Following a funding initiative by the National Institute on Aging, several new investigations are focused on establishing foundational evidence on lucidity in dementia. The objectives of this study are to capture, characterise and validate potential LEs via audiovisual observation, computational linguistic and timed-event coding of audiovisual data, and informant case review for face validation of LEs. This prospective multifaceted observational study will investigate LEs in advanced dementia through longitudinal audiovisual observation within an inpatient hospice unit. Audiovisual data will be coded to generate variables of participant verbal output, verbal expressions, non-verbal communicative actions and functional behaviours to enable measurement of features that can be used to characterise LEs. Multiple methods will be used to identify potential LEs including field interviews with caregivers/clinicians who witness significant events during data collection, reports from research staff who witness significant events during data collection and detection by researchers during video data processing procedures. Potential LEs will undergo a structured case review with informants familiar with the participant to facilitate validation and enable triangulation across measures generated through coding. This study will be conducted in accordance with all Federal Policies for the Protection of Human Subjects and the protocol (ID 2021-1243) has been approved by the University of Wisconsin-Madison Institutional Review Board. Findings will be disseminated via scientific conferences, journal publications and newsletters shared with participants and through dementia-focused and caregiver-focused networks. |
| 828 | Kimberly Mueller | GERI | kdmueller@wisc.edu | Longitudinal normative standards for cognitive tests and composites using harmonized data from two Wisconsin AD-risk-enriched cohorts. | Published norms are typically cross-sectional and often are not sensitive to preclinical cognitive changes due to dementia. We developed and validated demographically adjusted cross-sectional and longitudinal normative standards using harmonized outcomes from two Alzheimer's disease (AD) risk-enriched cohorts. Data from the Wisconsin Registry for Alzheimer's Prevention and the Wisconsin Alzheimer's Disease Research Center were combined. Quantile regression was used to develop unconditional (cross-sectional) and conditional (longitudinal) normative standards for 18 outcomes using data from cognitively unimpaired participants (N = 1390; mean follow-up = 9.25 years). Validity analyses (N = 2456) examined relationships between percentile scores (centiles), consensus-based cognitive statuses, and AD biomarker levels. Unconditional and conditional centiles were lower in those with consensus-based impairment or biomarker positivity. Similarly, quantitative biomarker levels were higher in those whose centiles suggested decline. This study presents normative standards for cognitive measures sensitive to pre-clinical changes. Future directions will investigate potential clinical applications of longitudinal normative standards. Quantile regression was used to construct longitudinal norms for cognitive tests. Poorer percentile scores were related to concurrent diagnosis and Alzheimer's disease biomarkers. A ShinyApp was built to display test scores and norms and flag low performance. |
| 829 | Kimberly Mueller | GERI | kdmueller@wisc.edu | Feasibility and Acceptability of a Multifaceted Observational Protocol to Investigate Lucidity in Advanced Dementia. | Episodes of lucidity (ELs), characterized by spontaneous, transient recovery of abilities, are reported across neurological conditions, including advanced dementia. Despite the significance of these events, existing research is limited to retrospective reports. Approaches to prospectively capturing and characterizing ELs in dementia are lacking. This pilot study determined the feasibility and acceptability of a multifaceted observational protocol to capture, characterize, and validate ELs in individuals with advanced dementia in hospice. Feasibility was measured through enrollment/retention rates, workload/usability assessment of video observation, and data processing procedures to facilitate the measurement of verbal and nonverbal features for EL characterization. The acceptability of observation and informant validation procedures was qualitatively examined with clinician and family caregiver participants. Study procedures were endorsed as highly acceptable among clinician (N = 49) and caregiver (N = 16) participants, demonstrating higher than anticipated thresholds for observation duration. Enrollment and retention rates for patient participants (N = 6) were 100% and 84%, respectively. Workload and usability measures demonstrated low disruptiveness and high ease of use after training. Longitudinal video observation among individuals with advanced dementia in hospice care for the detection of lucidity was feasible and highly acceptable. Multidimensional, temporal coding of features of ELs is feasible but time-intensive. |
| 830 | Kimberly Mueller | GERI | kdmueller@wisc.edu | A comparison of story-recall metrics to predict hippocampal volume in older adults with and without cognitive impairment. | Objective: Process-based scores of episodic memory tests, such as the recency ratio (Rr), have been found to compare favourably to, or to be better than, most conventional or "traditional" scores employed to estimate memory ability in older individuals (Bock et al., 2021; Bruno et al., 2019). We explored the relationship between process-based scores and hippocampal volume in older adults, while comparing process-based to traditional story recall-derived scores, to examine potential differences in their predictive abilities. Methods: We analysed data from 355 participants extracted from the WRAP and WADRC databases, who were classified as cognitively unimpaired, or exhibited mild cognitive impairment (MCI) or dementia. Story Recall was measured with the Logical Memory Test (LMT) from the Weschler Memory Scale Revised, collected within twelve months of the magnetic resonance imaging scan. Linear regression analyses were conducted with left or right hippocampal volume (HV) as outcomes separately, and with Rr, Total ratio, Immediate LMT, or Delayed LMT scores as predictors, along with covariates. Results: Higher Rr and Tr scores significantly predicted lower left and right HV, while Tr showed the best model fit of all, as indicated by AIC. Traditional scores, Immediate LMT and Delayed LMT, were significantly associated with left and right HV, but were outperformed by both process-based scores for left HV, and by Tr for right HV. Conclusions: Current findings show the direct relationship between hippocampal volume and all the LMT scores examined here, and that process-based scores outperform traditional scores as markers of hippocampal volume. |
| 831 | Kimberly Mueller | GERI | kdmueller@wisc.edu | Early ultrasonic vocalization deficits and related thyroarytenoid muscle pathology in the transgenic TgF344-AD rat model of Alzheimer's disease. | Alzheimer's disease (AD) is a progressive neurologic disease and the most common cause of dementia. Classic pathology in AD is characterized by inflammation, abnormal presence of tau protein, and aggregation of β-amyloid that disrupt normal neuronal function and lead to cell death. Deficits in communication also occur during disease progression and significantly reduce health, well-being, and quality of life. Because clinical diagnosis occurs in the mid-stage of the disease, characterizing the prodrome and early stages in humans is currently challenging. To overcome these challenges, we use the validated TgF344-AD (F344-Tg(Prp-APP, Prp-PS1)19/Rrrc) transgenic rat model that manifests cognitive, behavioral, and neuropathological dysfunction akin to AD in humans. The overarching goal of our work is to test the central hypothesis that pathology and related behavioral deficits such as communication dysfunction in part manifest in the peripheral nervous system and corresponding target tissues already in the early stages. The primary aims of this study are to test the hypotheses that: (1) changes in ultrasonic vocalizations (USV) occur in the prodromal stage at 6 months of age and worsen at 9 months of age, (2) inflammation as well as AD-related pathology can be found in the thyroarytenoid muscle (TA) at 12 months of age (experimental endpoint tissue harvest), and to (3) demonstrate that the TgF344-AD rat model is an appropriate model for preclinical investigations of early AD-related vocal deficits. USVs were collected from male TgF344-AD (N = 19) and wildtype (WT) Fischer-344 rats (N = 19) at 6 months (N = 38; WT: n = 19; TgF344-AD: n = 19) and 9 months of age (N = 18; WT: n = 10; TgF344-AD: n = 8) and acoustically analyzed for duration, mean power, principal frequency, low frequency, high frequency, peak frequency, and call type. RT-qPCR was used to assay peripheral inflammation and AD-related pathology via gene expressions in the TA muscle of male TgF344-AD rats (n = 6) and WT rats (n = 6) at 12 months of age. This study revealed a significant reduction in mean power of ultrasonic calls from 6 to 9 months of age and increased peak frequency levels over time in TgF344-AD rats compared to WT controls. Additionally, significant downregulation of AD-related genes Uqcrc2, Bace2, Serpina3n, and Igf2, as well as downregulation of pro-inflammatory gene Myd88 was found in the TA muscle of TgF344-AD rats at 12 months of age. Our findings demonstrate early and progressive vocal deficits in the TgF344-AD rat model. We further provide evidence of dysregulation of AD-pathology-related genes as well as inflammatory genes in the TA muscles of TgF344-AD rats in the early stage of the disease, confirming this rat model for early-stage investigations of voice deficits and related pathology. |
| 832 | Kimberly Mueller | GERI | kdmueller@wisc.edu | Delayed primacy recall performance predicts post mortem Alzheimer's disease pathology from unimpaired ante mortem cognitive baseline. | We propose a novel method to assess delayed primacy in the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) memory test. We then examine whether this measure predicts post mortem Alzheimer's disease (AD) neuropathology in individuals who were clinically unimpaired at baseline. A total of 1096 individuals were selected from the Rush Alzheimer's Disease Center database registry. All participants were clinically unimpaired at baseline, and had subsequently undergone brain autopsy. Average age at baseline was 78.8 (6.92). A Bayesian regression analysis was carried out with global pathology as an outcome; demographic, clinical, and apolipoprotein E (APOE) data as covariates; and cognitive predictors, including delayed primacy. Global AD pathology was best predicted by delayed primacy. Secondary analyses showed that delayed primacy was mostly associated with neuritic plaques, whereas total delayed recall was associated with neurofibrillary tangles. Sex differential associations were observed. We conclude that CERAD-derived delayed primacy is a useful metric for early detection and diagnosis of AD in unimpaired individuals. We propose a novel method to analyse serial position in the CERAD memory test.We analyse data from 1096 individuals who were cognitively unimpaired at baseline.Delayed primacy predicts post mortem pathology better than traditional metrics. |
| 833 | Cynthia Carlsson | GERI | cmc@medicine.wisc.edu | Comparison of sample characteristics of Wisconsin Alzheimer's Disease Research Center participants with the Wisconsin state population-An evaluation of the recruitment effort. | Understanding how a research sample compares to the population from which it is drawn can help inform future recruitment planning. We compared the Wisconsin Alzheimer's Disease Research Center (WADRC) participant sample to the Wisconsin state population (WI-pop) on key demographic, social exposome, and vascular risk measures. The WADRC sample included 930 participants. Population statistics were estimated using several national and state data sources. We compared WADRC to WI-pop for two age groups, 45-64 years and ≥65 years, separately. Compared to WI-pop, WADRC participants were older and included more women, more Black and American Indian individuals, and fewer Hispanic and Asian individuals. WADRC participants had higher levels of educational attainment, consisted of smaller proportions living in rural areas and disadvantaged neighborhoods, and showed lower vascular risks. Greater differences between WADRC and WI-pop were found for most metrics in the ≥65 group compared to the 45-64 group. The findings revealed opportunities to increase enrollment from the Hispanic/Latino and Asian American populations, to include participants from a broader range of educational backgrounds, and to enroll more residents from rural areas and disadvantaged neighborhoods, which may lead to a broader distribution of cardiovascular risk factors. Expanding sociodemographic and health profiles represented in the participant candidate pool for study selection and including those who are underrepresented in research may potentially reduce selection bias but not eliminate it. Statistical approaches can be applied to address bias and generalize findings from a study sample to its target population by adjusting for their differences in the joint distribution of covariates. Although research centers have different regional populations and specific recruitment focuses for scientific reasons, evaluating their participant characteristics may help plan engagement efforts to improve the inclusion of underrepresented groups and collaboratively support generalizable research nationwide. We compared the characteristics of Wisconsin Alzheimer's Disease Research Center (WADRC) participants with the Wisconsin population.Metrics of comparison included demographics, social exposomes, and vascular risks.WADRC participants are different from the Wisconsin population.We explored the implications and causes of the differences.We discussed strategies for engaging and recruiting underrepresented groups. |
| 834 | Cynthia Carlsson | GERI | cmc@medicine.wisc.edu | Computerized cognitive testing to capture cognitive decline in Alzheimer's disease: Longitudinal findings from the ARMADA study. | Timely detection and tracking of Alzheimer's disease (AD) -related cognitive decline has become a public health priority. We investigated whether the NIH Toolbox for Assessment of Neurological and Behavioral Function-Cognition Battery (NIHTB-CB) detects AD-related cognitive decline. N = 171 participants (age 76.5 ± 8; 53% female, 34% Aβ-positive) from the ARMADA study completed the NIHTB-CB at baseline, 12 months, and 24 months. Linear mixed-effect models correcting for demographics were used to examine cross-sectional and longitudinal NIHTB-CB scores in individuals across the clinical AD spectrum. Compared to Aβ-negative healthy controls, Aβ-positive individuals with amnestic MCI or mild AD performed worse on all NIHTB-CB measures and showed an accelerated decline in processing speed, working memory, and auditory word comprehension tests. These findings support the use of the NIHTB-CB in early AD, but also imply that the optimal NIHTB-CB composite score to detect change over time may differ across clinical stages of AD. Future directions include replication of these findings in larger and more demographically diverse samples. We examined NIH Toolbox-Cognition Battery scores across the clinical AD spectrum.All NIH Toolbox tests detected cross-sectional cognitive impairment in MCI-to-mild AD.Three NIH Toolbox tests captured further decline over time in MCI-to-mild AD.The NIH Toolbox can facilitate timely detection of AD-related cognitive decline. |
| 835 | Cynthia Carlsson | GERI | cmc@medicine.wisc.edu | Clinical criteria for limbic-predominant age-related TDP-43 encephalopathy. | Limbic predominant age-related TDP-43 encephalopathy neuropathologic change (LATE-NC) is highly prevalent in late life and a common co-pathology with Alzheimer's disease neuropathologic change (ADNC). LATE-NC is a slowly progressive, amnestic clinical syndrome. Alternatively, when present with ADNC, LATE-NC is associated with a more rapid course. With the emergence of anti-amyloid therapeutics, discrimination of LATE-NC from ADNC is critical and will lead to greater clinical recognition of amnestic patients without ADNC. Furthermore, co-pathology with LATE-NC may influence outcomes of these therapeutics. Thus there is a need to identify patients during life with likely LATE-NC. We propose criteria for clinical diagnosis of LATE as an initial framework for further validation. In the context of progressive memory loss and substantial hippocampal atrophy, criteria are laid out for probable (amyloid negative) or possible LATE (amyloid biomarkers are unavailable or when amyloid is present, but hippocampal neurodegeneration is out of proportion to expected pure ADNC). HIGHLIGHTS: Limbic-predominant age-related TDP-43 encephalopathy (LATE) is a highly prevalent driver of memory loss in late life. LATE neuropathic change (LATE-NC) is a common co-pathology with Alzheimer's disease neuropathic change (ADNC) and may influence outcomes with emerging disease-modifying medicines. We provide initial clinical criteria for diagnosing LATE during life either when LATE-NC is the likely primary driver of symptoms or when observed in conjunction with AD. Definitions of possible and probable LATE are provided. |
| 836 | Cynthia Carlsson | GERI | cmc@medicine.wisc.edu | Delayed primacy recall in AVLT is associated with medial temporal tau PET burden in cognitively unimpaired adults. | Alzheimer's disease (AD) can be diagnosed by in vivo abnormalities of amyloid-β plaques (A) and tau accumulation (T) biomarkers. Previous studies have shown that analyses of serial position performance in episodic memory tests, and especially, delayed primacy, are associated with AD pathology even in individuals who are cognitively unimpaired. The earliest signs of cortical tau pathology are observed in medial temporal lobe (MTL) regions, yet it is unknown if serial position markers are also associated with early tau load in these regions. This study of cognitively unimpaired older individuals examined whether serial position scores in word-list recall cross-sectionally predicted tau PET load in the MTL, and were able to discriminate between biomarker profiles, based on AT classification. Data from 490 participants (mean age = 68.8 ± 7.2) were extracted from two cohorts, which were merged into one sample. Linear regression analyses were carried out with regional volume-controlled tau (18F-MK-6240) PET SUVR of the entorhinal cortex (EC), parahippocampal cortex (PHC) and hippocampus (H) as outcomes, cross-sectional memory scores from the Rey Auditory Verbal Learning Test as predictors (total and delayed recall, along with serial position scores) and control variables, in separate analyses for each outcome and predictor. The sample was then stratified by biomarker profile and ANCOVAs were conducted with the strongest scores from the regression analyses, AT groups as fixed factor and the covariates. Higher delayed primacy significantly predicted lower tau PET in EC, PHC, and H, cross-sectionally. Higher total recall scores predicted lower EC tau, but delayed primacy showed the best model fit, as indicated by AICs. ANCOVAs showed that AVLT metrics did not significantly discriminate between A-T- and A+T+, after correcting for multiple comparisons. Serial position analysis of word-list recall, particularly delayed primacy, may be a valuable tool for identifying in vivo tau pathology in cognitively unimpaired individuals. |
| 837 | Cynthia Carlsson | GERI | cmc@medicine.wisc.edu | Memory screening in the community: Facilitating earlier dementia diagnosis and care-Preliminary data. | This program evaluation was conducted to assess the effectiveness of a community memory screening initiative across 25 Aging and Disability Resource Centers, spanning 39 counties and 5 tribal communities in the state of Wisconsin. We evaluated the screened individuals' characteristics and reasons for screening, the screen results and topics addressed during screening, the rate of sending positive screens to primary care providers, and the incidence of subsequent dementia diagnosis as well as health behavior changes. Program evaluation results showed 791 completed surveys from individuals, indicating the program's accessibility and potential to reach populations in both urban and rural counties across Wisconsin. Evaluation results also showed that brain health was the most frequently discussed topic during memory screens (discussed during 689 screens, 87.1%), along with other topics such as potential causes of dementia symptoms (670 screens, 84.5%), dementia warning signs (656, 83%), the importance of early detection (605 screens, 76.5%), and caregiver support (106 screens, 13.4%). Of all 791, a total of 273 (34.5%) individuals had screen results sent to a primary care provider. Follow-up surveys completed with a subset of individuals (n = 49) who had their results sent to a primary care provider indicated that 10 (20%) received a diagnosis of dementia and over half made a health behavior change to improve brain health. The evaluation results presented herein highlight the program's success in addressing the critical need for accessible dementia-related services. Overall, our evaluation results underscore the importance of community-based initiatives in promoting early dementia detection and intervention, which are crucial for disease management. |
| 838 | Cynthia Carlsson | GERI | cmc@medicine.wisc.edu | Amyloid-β positivity is less prevalent in cognitively unimpaired KLOTHO KL-VS heterozygotes. | Klotho, encoded by the KLOTHO gene, is an anti-aging and neuroprotective protein. KLOTHO KL-VS heterozygosity (KL-VSHET) is hypothesized to be protective against the accumulation of Alzheimer's disease (AD) neuropathological hallmarks (amyloid-β (Aβ) and tau). We examine whether being positive for Aβ (A+) or tau (T+), or A/T joint status [positive for Aβ (A + T-), tau (A-T+), both (A + T+) or neither (A-T-)] vary by KL-VS and whether serum klotho protein levels vary based on A+, T+, or A/T status in a cohort enriched for AD risk. The sample consisted of 704 cognitively unimpaired, late middle-aged, and older adults; MeanAge(SD) = 64.9(8.3). Serum klotho was available for a sub-sample of 396 participants; MeanAge(SD) = 66.8(7.4). Covariate-adjusted logistic regression examined whether A + or T+, and multinomial regression examined whether A/T status, vary by KL-VS genotype. Covariate-adjusted linear regression examined whether serum klotho levels differ based on A+, T+, or A/T status. A+ prevalence was lower in KL-VSHET (p = 0.05), with no differences in T + prevalence (p = 0.52). KL-VSHET also had marginally lower odds of being A + T- (p = 0.07). Serum klotho levels did not differ based on A+, T+, or A/T status (all ps ≥ 0.40). KL-VSHET is associated with lower odds of being positive for Aβ, regardless of whether one is also positive for tau. Conversely, the likelihood of being tau positive did not differ based on KL-VS genotype. Our findings add to the growing KLOTHO literature and suggests the need for further research focused on understanding the mechanisms underlying KL-VS-related putative resilience to AD. |
| 839 | Cynthia Carlsson | GERI | cmc@medicine.wisc.edu | Story recall performance and AT classification via positron emission tomography: A comparison of logical memory and Craft Story 21. | Early detection of Alzheimer's disease (AD) is one of the critical components of the global response to the growing dementia crisis. Analysis of serial position performance in story recall tests has yielded sensitive metrics for the prediction of AD at low cost. In this study, we examined whether serial position markers in two story recall tests (the logical memory test, LMT, and the Craft Story 21 test, CST) were sensitive to cross-sectional biomarker-based assessment of in vivo neuropathology. Participants were selected from the Wisconsin Registry of Alzheimer's Prevention (n = 288; WRAP) and the Alzheimer's Disease Research Center (n = 156; ADRC), both from the University of Wisconsin-Madison. Average age at PET was 68.9 (6.7) and 67.0 (8.0), respectively. Data included tau and PiB PET, and LMT for WRAP participants and CST for ADRC participants. Two sets of Bayesian analyses (logistic regressions and ANCOVAs) were conducted within each cohort, separately. Results indicated that the A+T+ classification was best predicted, cross-sectionally, by the recency ratio (Rr), indexing how much of the end of the story was forgotten between initial learning and delayed assessment. Rr outperformed traditional scores and discriminated between A+T+ and A+T-/A-T-, in both cohorts. Overall, this study confirms that serial position analysis of LMT and CST data, and particularly Rr as an index of recency loss, is a valuable tool for the identification of in vivo tau pathology in individuals free of dementia. Diagnostic considerations are discussed. |
| 840 | Cynthia Carlsson | GERI | cmc@medicine.wisc.edu | Gut Microbiome Compositional and Functional Features Associate with Alzheimer's Disease Pathology. | The gut microbiome is a potentially modifiable factor in Alzheimer's disease (AD); however, understanding of its composition and function regarding AD pathology is limited. Shallow-shotgun metagenomic data was used to analyze fecal microbiome from participants enrolled in the Wisconsin Microbiome in Alzheimer's Risk Study, leveraging clinical data and cerebrospinal fluid (CSF) biomarkers. Differential abundance and ordinary least squares regression analyses were performed to find differentially abundant gut microbiome features and their associations with CSF biomarkers of AD and related pathologies. Gut microbiome composition and function differed between people with AD and cognitively unimpaired individuals. The compositional difference was replicated in an independent cohort. Differentially abundant gut microbiome features were associated with CSF biomarkers of AD and related pathologies. These findings enhance our understanding of alterations in gut microbial composition and function in AD, and suggest that gut microbes and their pathways are linked to AD pathology. |
| 841 | Cynthia Carlsson | GERI | cmc@medicine.wisc.edu | KLOTHO KL-VS heterozygosity is associated with diminished age-related neuroinflammation, neurodegeneration, and synaptic dysfunction in older cognitively unimpaired adults. | We examined whether the aging suppressor KLOTHO gene's functionally advantageous KL-VS variant (KL-VS heterozygosity [KL-VSHET]) confers resilience against deleterious effects of aging indexed by cerebrospinal fluid (CSF) biomarkers of neuroinflammation (interleukin-6 [IL-6], S100 calcium-binding protein B [S100B], triggering receptor expressed on myeloid cells [sTREM2], chitinase-3-like protein 1 [YKL-40], glial fibrillary acidic protein [GFAP]), neurodegeneration (total α-synuclein [α-Syn], neurofilament light chain protein), and synaptic dysfunction (neurogranin [Ng]). This Alzheimer disease risk-enriched cohort consisted of 454 cognitively unimpaired adults (Mage = 61.5 ± 7.75). Covariate-adjusted multivariate regression examined relationships between age (mean-split[age ≥ 62]) and CSF biomarkers (Roche/NeuroToolKit), and whether they differed between KL-VSHET (N = 122) and non-carriers (KL-VSNC; N = 332). Older age was associated with a poorer biomarker profile across all analytes (Ps ≤ 0.03). In age-stratified analyses, KL-VSNC exhibited this same pattern (Ps ≤ 0.05) which was not significant for IL-6, S100B, Ng, and α-Syn (Ps ≥ 0.13) in KL-VSHET. Although age-related differences in GFAP, sTREM2, and YKL-40 were evident for both groups (Ps ≤ 0.01), the effect magnitude was markedly stronger for KL-VSNC. Higher levels of neuroinflammation, neurodegeneration, and synaptic dysfunction in older adults were attenuated in KL-VSHET. Older age was associated with poorer profiles across all cerebrospinal fluid biomarkers of neuroinflammation, neurodegeneration, and synaptic dysfunction. KLOTHO KL-VS non-carriers exhibit this same pattern, which is does not significantly differ between younger and older KL-VS heterozygotes for interleukin-6, S100 calcium-binding protein B, neurogranin, and total α-synuclein. Although age-related differences in glial fibrillary acidic protein, triggering receptor expressed on myeloid cells, and chitinase-3-like protein 1 are evident for both KL-VS groups, the magnitude of the effect is markedly stronger for KL-VS non-carriers. Higher levels of neuroinflammation, neurodegeneration, and synaptic dysfunction in older adults are attenuated in KL-VS heterozygotes. |
| 842 | Cynthia Carlsson | GERI | cmc@medicine.wisc.edu | Post-GWAS multiomic functional investigation of the TNIP1 locus in Alzheimer's disease highlights a potential role for GPX3. | Recent genome-wide association studies (GWAS) have reported a genetic association with Alzheimer's disease (AD) at the TNIP1/GPX3 locus, but the mechanism is unclear. We used cerebrospinal fluid (CSF) proteomics data to test (n = 137) and replicate (n = 446) the association of glutathione peroxidase 3 (GPX3) with CSF biomarkers (including amyloid and tau) and the GWAS-implicated variants (rs34294852 and rs871269). CSF GPX3 levels decreased with amyloid and tau positivity (analysis of variance P = 1.5 × 10-5) and higher CSF phosphorylated tau (p-tau) levels (P = 9.28 × 10-7). The rs34294852 minor allele was associated with decreased GPX3 (P = 0.041). The replication cohort found associations of GPX3 with amyloid and tau positivity (P = 2.56 × 10-6) and CSF p-tau levels (P = 4.38 × 10-9). These results suggest variants in the TNIP1 locus may affect the oxidative stress response in AD via altered GPX3 levels. Cerebrospinal fluid (CSF) glutathione peroxidase 3 (GPX3) levels decreased with amyloid and tau positivity and higher CSF phosphorylated tau. The minor allele of rs34294852 was associated with lower CSF GPX3. levels when also controlling for amyloid and tau category. GPX3 transcript levels in the prefrontal cortex were lower in Alzheimer's disease than controls. rs34294852 is an expression quantitative trait locus for GPX3 in blood, neutrophils, and microglia. |
| 843 | Rebecca Langhough | WAI | langhough@wisc.edu | Menopausal hormone therapy is associated with worse levels of Alzheimer's disease biomarkers in APOE ε4-carrying women: An observational study. | Menopausal hormone therapy (MHT), along with the apolipoprotein E (APOE) ε4 allele, has been suggested as a possible risk factor for Alzheimer's disease (AD). However, the relationship between MHT and cerebrospinal fluid (CSF) biomarkers is unknown: we investigated this association, and whether APOE ε4 carrier status moderates it. In an observational study of 136 cognitively unimpaired female participants (Mage = 66.0; standard deviation = 6.3), we examined whether MHT use alone or in interaction with APOE ε4 carrier status was associated with CSF levels of phosphorylated tau (p-tau), amyloid beta (Aβ)40, Aβ42, p-tau/Aβ42, and Aβ42/40 ratios. Significant interactions were found between APOE ε4 and MHT use for CSF biomarkers. APOE ε4 carriers who were MHT users showed worse levels of CSF p-tau/Aβ42 and Aβ42/40 ratios than all other users and non-users. The presence of both APOE ε4 and MHT may be associated with elevated amyloid deposition and AD pathology in this sample of participants who demonstrated high familial AD risk. Significant interactions were found between apolipoprotein E (APOE) ε4 and menopausal hormone therapy (MHT) use for cerebrospinal fluid (CSF) phosphorylated tau (p-tau)/amyloid beta (Aβ)42 and Aβ42/40 ratios. APOE ε4 carriers who were MHT users showed worse levels of CSF biomarkers than non-users and non-carriers, both users and non-users. Younger age at MHT initiation was associated with worse levels of the p-tau/Aβ42 and Aβ42/40 ratios in carriers only. The presence of both APOE ε4 carriage and MHT use may be associated with elevated amyloid deposition and AD pathology. Further studies with larger sample sizes are necessary to confirm the differences observed in the current study. |
| 844 | Rebecca Langhough | WAI | langhough@wisc.edu | Delayed primacy recall in AVLT is associated with medial temporal tau PET burden in cognitively unimpaired adults. | Alzheimer's disease (AD) can be diagnosed by in vivo abnormalities of amyloid-β plaques (A) and tau accumulation (T) biomarkers. Previous studies have shown that analyses of serial position performance in episodic memory tests, and especially, delayed primacy, are associated with AD pathology even in individuals who are cognitively unimpaired. The earliest signs of cortical tau pathology are observed in medial temporal lobe (MTL) regions, yet it is unknown if serial position markers are also associated with early tau load in these regions. This study of cognitively unimpaired older individuals examined whether serial position scores in word-list recall cross-sectionally predicted tau PET load in the MTL, and were able to discriminate between biomarker profiles, based on AT classification. Data from 490 participants (mean age = 68.8 ± 7.2) were extracted from two cohorts, which were merged into one sample. Linear regression analyses were carried out with regional volume-controlled tau (18F-MK-6240) PET SUVR of the entorhinal cortex (EC), parahippocampal cortex (PHC) and hippocampus (H) as outcomes, cross-sectional memory scores from the Rey Auditory Verbal Learning Test as predictors (total and delayed recall, along with serial position scores) and control variables, in separate analyses for each outcome and predictor. The sample was then stratified by biomarker profile and ANCOVAs were conducted with the strongest scores from the regression analyses, AT groups as fixed factor and the covariates. Higher delayed primacy significantly predicted lower tau PET in EC, PHC, and H, cross-sectionally. Higher total recall scores predicted lower EC tau, but delayed primacy showed the best model fit, as indicated by AICs. ANCOVAs showed that AVLT metrics did not significantly discriminate between A-T- and A+T+, after correcting for multiple comparisons. Serial position analysis of word-list recall, particularly delayed primacy, may be a valuable tool for identifying in vivo tau pathology in cognitively unimpaired individuals. |
| 845 | Rebecca Langhough | WAI | langhough@wisc.edu | Performance of study partner reports in a non-demented at-risk sample. | The Clinical Dementia Rating (CDR) Scale is a gold standard for staging impairment in Alzheimer's disease and other dementias (ADRD). The Quick Dementia Rating System (QDRS) offers similar results in 3 to 5 minutes without a trained clinician. This study aimed to (1) investigate concordance between comparably derived QDRS and CDR global scores, (2) examine item-level QDRS/CDR agreement, and (3) compare sample characteristics and cognitive performance across QDRS/CDR global concordant/discordant groups. The study included 351 QDRS/CDR pairs from 297 participants in the Wisconsin Registry for Alzheimer's Prevention (WRAP). Analyses included descriptive indices of QDRS/CDR agreement, lasso logistic regression, tetrachoric correlations, and linear mixed models. The QDRS global/CDR global concordance rate is 70.66%. Memory item discrepancies were primarily responsible for QDRS/CDR global rating discordance. Average cognitive scores were highest in concordant-normal QDRS/CDR and lowest in concordant-abnormal QDRS/CDR. The QDRS effectively screened for impairment in this sample. Future analyses will investigate QDRS relations to ADRD biomarkers. The Quick Dementia Rating System (QDRS) effectively screened for impairment in Alzheimer's disease and other dementias (ADRD) in a non-demented sample. Concordance rate between QDRSCDR global and Clinical Dementia Rating (CDR) Scale global scores is 70.66%. Memory item discrepancies primarily cause QDRS/CDR global score discordance. Cognitive scores are associated with QDRS/CDR concordances/discordances. Future analyses will explore QDRS relations to ADRD biomarkers. |
| 846 | Rebecca Langhough | WAI | langhough@wisc.edu | Targeted Proteomic Biomarker Profiling Using NULISA in a cohort enriched with risk for Alzheimer's Disease and Related Dementias. | Targeted proteomic assays may be useful for diagnosing and staging Alzheimer's disease and related dementias (ADRD). We evaluated the performance of a 120-marker central nervous system (CNS) NUcleic acid-Linked Immuno-Sandwich Assay (NULISA) panel in samples spanning the AD spectrum. Cross-sectional plasma samples (n=252) were analyzed using Alamar's NULISAseq CNS panel. ROC analyses demonstrated NULISAseq-pTau217 accuracy in detecting amyloid (A) and tau (T) PET positivity. Differentially expressed proteins were identified using volcano plots. NULISAseq-pTau217 accurately classified A/T PET status with ROC AUCs of 0.92/0.86. pTau217 was upregulated in A+, T+, and impaired groups with log2-fold changes of 1.21, 0.57 and 4.63, respectively, compared to A-. Interestingly, pTDP43-409 was also upregulated in the impaired group and correlated with declining hippocampal volume and cognitive trajectories. This study shows the potential of a targeted proteomics panel for characterizing brain changes pertinent to ADRD. The promising pTDP43-409 findings require further replication. |
| 847 | Rebecca Langhough | WAI | langhough@wisc.edu | Visual read of [F-18]florquinitau PET that includes and extends beyond the mesial temporal lobe is associated with increased plasma pTau217 and cognitive decline in a cohort that is enriched with risk for Alzheimer's disease. | Patterns of signal from tau positron emission tomography (tau-PET) confined to the medial temporal lobe (MTL) or extended into the neocortex may be relevant for Alzheimer's disease (AD) research if they are linked to differential biomarker levels and cognitive decline. Visual assessment of Tau-PET [F-18]florquinitau (FQT) exams from 728 initially non-demented older adults yielded four uptake groups: tau-negative (T-), MTL-only (T+MTL), neocortex-only (T+Neo), or both (T+MTL&Neo). Mixed effects models assessed group differences in retrospective cognitive and plasma pTau217 trajectories. T+MTL&Neo was the most common T+ group (n = 97; 93% A+) and exhibited the sharpest worsening in cognitive and pTau217 trajectories before tau PET. The T+MTL&Neo category represents an intermediate to advanced stage of AD preceded by rising ptau217 and progressive cognitive decline. The pTau217 finding suggests that A+, T+ in MTL or neocortex could represent early AD stages, with a higher likelihood of progressing to more advanced stages. Visual assessments of Tau-PET FQT revealed four distinct uptake groups: tau-negative (T-), MTL-only (T+MTL), neocortex-only (T+Neo), or both (T+MTL&Neo). Amyloid positive participants in the T+MTL and T+MTL&Neo categories showed a retrospectively faster decline in their cognitive trajectories, and a sharper increase in pTau217 levels in plasma, compared to T-. The T+MTL&Neo group displayed sharper trajectories compared with the other Tau positive groups in both their cognitive scores and pTau217 plasma levels. Our results suggest that participants with Tau present in both MTL and neocortex represent an intermediate to advanced stage of AD, whereas participants with signals confined to either MTL or neocortex could represent earlier AD stages. |
| 848 | Rebecca Langhough | WAI | langhough@wisc.edu | Identification of late-stage tau accumulation using plasma phospho-tau217. | Blood-based disease staging across the Alzheimer's disease (AD) continuum holds the promise to identify individuals that profit from disease-modifying therapies. We set out to identify Braak V+ (Braak V and/or VI) tau PET-positive individuals within amyloid-β (Aβ)-positive individuals using plasma biomarkers. In this cross-sectional study, we assessed 289 individuals from the TRIAD cohort and 306 individuals from the WRAP study across the AD continuum. The participants were evaluated by amyloid-PET with [18F]AZD4694 or [11C]PiB and tau-PET with [18F]MK6240 and measured plasma levels included total tau, phospho-tau isoforms (pTau) pTau-181, pTau-217, pTau-231, and N-terminal tau (NTA-tau). We evaluated the performances of plasma biomarkers using different analytic platforms to predict Braak V+ positivity in Aβ+ individuals. Highest associations with Braak V+ tau positivity in Aβ+ individuals were found for plasma pTau-217+Janssen (AUC [CI95%] = 0.97 [0.94, 1.0]) and ALZpath pTau-217 (AUC [CI95%] = 0.93 [0.86, 1.0]) in TRIAD. Plasma ALZpath pTau-217 separated Braak V+ tau PET-positive individuals in the WRAP longitudinal study (AUC [CI95%] = 0.97 [0.94, 1.0]). Thus, we demonstrate that using adjusted cut-offs, plasma pTau-217 identifies individuals with later Braak stage tau accumulation which will be helpful to stratify patients for treatments and clinical studies. This research is supported by the Weston Brain Institute, Canadian Institutes of Health Research (CIHR) [MOP-11-51-31; RFN 152985, 159815, 162303], Canadian Consortium of Neurodegeneration and Aging (CCNA; MOP-11-51-31 -team 1), the Alzheimer's Association [NIRG-12-92090, NIRP-12-259245], Brain Canada Foundation (CFI Project 34874; 33397), the Fonds de Recherche du Québec-Santé (FRQS; Chercheur Boursier, 2020-VICO-279314). P.R-N and SG are members of the CIHR-CCNA Canadian Consortium of Neurodegeneration in Aging. Colin J. Adair Charitable Foundation. |
| 849 | Rebecca Langhough | WAI | langhough@wisc.edu | Story recall performance and AT classification via positron emission tomography: A comparison of logical memory and Craft Story 21. | Early detection of Alzheimer's disease (AD) is one of the critical components of the global response to the growing dementia crisis. Analysis of serial position performance in story recall tests has yielded sensitive metrics for the prediction of AD at low cost. In this study, we examined whether serial position markers in two story recall tests (the logical memory test, LMT, and the Craft Story 21 test, CST) were sensitive to cross-sectional biomarker-based assessment of in vivo neuropathology. Participants were selected from the Wisconsin Registry of Alzheimer's Prevention (n = 288; WRAP) and the Alzheimer's Disease Research Center (n = 156; ADRC), both from the University of Wisconsin-Madison. Average age at PET was 68.9 (6.7) and 67.0 (8.0), respectively. Data included tau and PiB PET, and LMT for WRAP participants and CST for ADRC participants. Two sets of Bayesian analyses (logistic regressions and ANCOVAs) were conducted within each cohort, separately. Results indicated that the A+T+ classification was best predicted, cross-sectionally, by the recency ratio (Rr), indexing how much of the end of the story was forgotten between initial learning and delayed assessment. Rr outperformed traditional scores and discriminated between A+T+ and A+T-/A-T-, in both cohorts. Overall, this study confirms that serial position analysis of LMT and CST data, and particularly Rr as an index of recency loss, is a valuable tool for the identification of in vivo tau pathology in individuals free of dementia. Diagnostic considerations are discussed. |
| 850 | Rebecca Langhough | WAI | langhough@wisc.edu | Longitudinal plasma phosphorylated-tau217 and other related biomarkers in a non-demented Alzheimer's risk-enhanced sample. | Understanding longitudinal change in key plasma biomarkers will aid in detecting presymptomatic Alzheimer's disease (AD). Serial plasma samples from 424 Wisconsin Registry for Alzheimer's Prevention participants were analyzed for phosphorylated-tau217 (p-tau217; ALZpath) and other AD biomarkers, to study longitudinal trajectories in relation to disease, health factors, and cognitive decline. Of the participants, 18.6% with known amyloid status were amyloid positive (A+); 97.2% were cognitively unimpaired (CU). In the CU, amyloid-negative (A-) subset, plasma p-tau217 levels increased modestly with age but were unaffected by body mass index and kidney function. In the whole sample, average p-tau217 change rates were higher in those who were A+ (e.g., simple slopes(se) for A+ and A- at age 60 were 0.232(0.028) and 0.038(0.013))). High baseline p-tau217 levels predicted faster preclinical cognitive decline. p-tau217 stands out among markers for its strong association with disease and cognitive decline, indicating its potential for early AD detection and monitoring progression. Phosphorylated-tau217 (p-tau217) trajectories were significantly different in people who were known to be amyloid positive. Subtle age-related trajectories were seen for all the plasma markers in amyloid-negative cognitively unimpaired. Kidney function and body mass index were not associated with plasma p-tau217 trajectories. Higher plasma p-tau217 was associated with faster preclinical cognitive decline. |
| 851 | Rebecca Langhough | WAI | langhough@wisc.edu | The role of cognitive reserve and depression on executive function in older adults: A 10-year study from the Wisconsin Registry for Alzheimer's Prevention. | Objective: The current study examined the longitudinal relationship between cognitive reserve (CR), depression, and executive function (EF) in a cohort of older adults. Methods: 416 participants were selected from the Wisconsin Registry for Alzheimer's Prevention. They were native English speakers, aged ≥50+, and cognitively unimpaired at baseline, with no history of neurological or other psychiatric disorders aside from depression. Depression was assessed with the 20-item Center for Epidemiologic Studies Depression Scale (CES-D). A composite score, based on the premorbid IQ (WRAT-3 Reading subtest) and years of education was used to estimate CR. Another composite score from four cognitive tests was used to estimate EF. A moderation analysis was performed to evaluate the effects of CR and Depression on EF at follow-up after controlling for age, gender, and APOE risk score. Moreover, a multinomial logistic regression was used to predict conversion to Mild Cognitive Impairment (MCI) from the healthy baseline. Results: The negative relationship between depression and EF was stronger in individuals with higher CR levels, suggesting a possible floor effect at lower CR levels. In the multinomial regression, the interaction between CR and depression predicted conversion to MCI status, indicating that lower CR paired with more severe depression at baseline was associated with a higher risk of subsequent impairment. Conclusions: This study sheds light on the intricate relationship between depression and EF over time, suggesting that the association may be influenced by varying levels of CR. Further studies may replicate these findings in clinical populations. |
| 852 | Rebecca Langhough | WAI | langhough@wisc.edu | Alzheimer's disease genetic risk and changes in brain atrophy and white matter hyperintensities in cognitively unimpaired adults. | Reduced brain volumes and more prominent white matter hyperintensities on MRI scans are commonly observed among older adults without cognitive impairment. However, it remains unclear whether rates of change in these measures among cognitively normal adults differ as a function of genetic risk for late-onset Alzheimer's disease, including APOE-ɛ4, APOE-ɛ2 and Alzheimer's disease polygenic risk scores (AD-PRS), and whether these relationships are influenced by other variables. This longitudinal study examined the trajectories of regional brain volumes and white matter hyperintensities in relationship to APOE genotypes (N = 1541) and AD-PRS (N = 1093) in a harmonized dataset of middle-aged and older individuals with normal cognition at baseline (mean baseline age = 66 years, SD = 9.6) and an average of 5.3 years of MRI follow-up (max = 24 years). Atrophy on volumetric MRI scans was quantified in three ways: (i) a composite score of regions vulnerable to Alzheimer's disease (SPARE-AD); (ii) hippocampal volume; and (iii) a composite score of regions indexing advanced non-Alzheimer's disease-related brain aging (SPARE-BA). Global white matter hyperintensity volumes were derived from fluid attenuated inversion recovery (FLAIR) MRI. Using linear mixed effects models, there was an APOE-ɛ4 gene-dose effect on atrophy in the SPARE-AD composite and hippocampus, with greatest atrophy among ɛ4/ɛ4 carriers, followed by ɛ4 heterozygouts, and lowest among ɛ3 homozygouts and ɛ2/ɛ2 and ɛ2/ɛ3 carriers, who did not differ from one another. The negative associations of APOE-ɛ4 with atrophy were reduced among those with higher education (P < 0.04) and younger baseline ages (P < 0.03). Higher AD-PRS were also associated with greater atrophy in SPARE-AD (P = 0.035) and the hippocampus (P = 0.014), independent of APOE-ɛ4 status. APOE-ɛ2 status (ɛ2/ɛ2 and ɛ2/ɛ3 combined) was not related to baseline levels or atrophy in SPARE-AD, SPARE-BA or the hippocampus, but was related to greater increases in white matter hyperintensities (P = 0.014). Additionally, there was an APOE-ɛ4 × AD-PRS interaction in relation to white matter hyperintensities (P = 0.038), with greater increases in white matter hyperintensities among APOE-ɛ4 carriers with higher AD-PRS. APOE and AD-PRS associations with MRI measures did not differ by sex. These results suggest that APOE-ɛ4 and AD-PRS independently and additively influence longitudinal declines in brain volumes sensitive to Alzheimer's disease and synergistically increase white matter hyperintensity accumulation among cognitively normal individuals. Conversely, APOE-ɛ2 primarily influences white matter hyperintensity accumulation, not brain atrophy. Results are consistent with the view that genetic factors for Alzheimer's disease influence atrophy in a regionally specific manner, likely reflecting preclinical neurodegeneration, and that Alzheimer's disease risk genes contribute to white matter hyperintensity formation. |
| 853 | Maria Mora Pinzon | GERI | mmora2@wisc.edu | Comparison of sample characteristics of Wisconsin Alzheimer's Disease Research Center participants with the Wisconsin state population-An evaluation of the recruitment effort. | Understanding how a research sample compares to the population from which it is drawn can help inform future recruitment planning. We compared the Wisconsin Alzheimer's Disease Research Center (WADRC) participant sample to the Wisconsin state population (WI-pop) on key demographic, social exposome, and vascular risk measures. The WADRC sample included 930 participants. Population statistics were estimated using several national and state data sources. We compared WADRC to WI-pop for two age groups, 45-64 years and ≥65 years, separately. Compared to WI-pop, WADRC participants were older and included more women, more Black and American Indian individuals, and fewer Hispanic and Asian individuals. WADRC participants had higher levels of educational attainment, consisted of smaller proportions living in rural areas and disadvantaged neighborhoods, and showed lower vascular risks. Greater differences between WADRC and WI-pop were found for most metrics in the ≥65 group compared to the 45-64 group. The findings revealed opportunities to increase enrollment from the Hispanic/Latino and Asian American populations, to include participants from a broader range of educational backgrounds, and to enroll more residents from rural areas and disadvantaged neighborhoods, which may lead to a broader distribution of cardiovascular risk factors. Expanding sociodemographic and health profiles represented in the participant candidate pool for study selection and including those who are underrepresented in research may potentially reduce selection bias but not eliminate it. Statistical approaches can be applied to address bias and generalize findings from a study sample to its target population by adjusting for their differences in the joint distribution of covariates. Although research centers have different regional populations and specific recruitment focuses for scientific reasons, evaluating their participant characteristics may help plan engagement efforts to improve the inclusion of underrepresented groups and collaboratively support generalizable research nationwide. We compared the characteristics of Wisconsin Alzheimer's Disease Research Center (WADRC) participants with the Wisconsin population.Metrics of comparison included demographics, social exposomes, and vascular risks.WADRC participants are different from the Wisconsin population.We explored the implications and causes of the differences.We discussed strategies for engaging and recruiting underrepresented groups. |
| 854 | Maria Mora Pinzon | GERI | mmora2@wisc.edu | Understanding the experience of Latinas in medical education: A qualitative study. | Despite increased recruitment of Latina medical students, the percentage of Latina physicians has remained stagnant, suggesting unique retentive barriers affecting this population. Discriminatory experiences involving bias may contribute to difficulties in the retention and advancement of Latinas in medicine. This qualitative analysis aimed to explore thematic barriers prevalent among Latinas throughout their medical training in the United States. An anonymous online survey was distributed to Latinas in the continental United States from June 22 to August 12, 2022. Eligibility criteria included self-identifying as Hispanic/Latina, female/woman, and being currently enrolled in or graduated from medical school, residency, or fellowship in the United States in the past 10 years. Content and thematic analyses were done on 602 responses across seven open-ended survey questions. Data were categorized into three main themes: (1) barriers stemming from limited social, cultural, and financial capital; (2) experiences of discrimination, bias, and perceptions of being undervalued; and (3) burdens resulting in notable mental health challenges such as depression and anxiety. Many women questioned their place in medicine throughout training and the value of the sacrifice and trauma endured. This is the first qualitative study evaluating the experiences of Latinas throughout medical training, revealing that they experience disproportionate barriers and discriminatory experiences from both colleagues and patients. Despite calls to enhance institutional climates of diversity, there continues to be an acute need for the reform of medical education to promote an inclusive culture and provide adequate mentorship to marginalized trainees. |
| 855 | Maria Mora Pinzon | GERI | mmora2@wisc.edu | Understanding Healthcare Barriers for Latino/a/e/x Families with Alzheimer's Disease: Insights from Primary Care Provider interviews. | Alzheimer's Disease and Related dementias (ADRD) are disproportionately underdiagnosed, misdiagnosed, and undertreated in Latino/a/e/x populations living in the U.S. Latino/a/e/x families also experience low access to ADRD caregiver support services and high levels of depression. Primary care providers (PCPs) are the first point of contact for patients and their families, and they are critical in understanding the factors associated with disparities in accessing services. This project aims to reflect on the barriers that Latino/a/e/x families experience in accessing and using healthcare services from the perspective of PCPs. The data was collected through structured interviews with 23 diverse PCPs across the US via videoconference or phone calls. Participants were recruited via snowball sampling. Two reviewers used an inductive coding approach to conduct qualitative thematic analysis. The Rigorous and Accelerated Data Reduction (RADaR) technique was used to extract relevant data and organize it into relevant categories. Some of the themes identified reflect the experiences of individuals in the diagnostic process and subsequent care: 1) Family members are usually the first ones to notice the symptoms, 2) Delays in seeking care might be partially influenced by denial from individuals and their families, 3) Language congruency promotes the disclosure of symptoms, 4) Care that is linguistically and literacy appropriate requires additional support of patients and families, and 5) Caregiving expectations and preferences by Latino/a/e/x families do not shield caregivers from feeling burnout. Overall, PCPs reflected that the experiences of individuals are highly influenced by socioeconomic factors, which also influence their care plans. Most Latino/a/e/x older adults with ADRD will be cared for by a PCP at some point during their disease, which means that they require additional support and resources at primary care appointments to address the barriers to accessing care services and enhance health equity in Latino/a/e/x communities. |
| 856 | Maria Mora Pinzon | GERI | mmora2@wisc.edu | Implementation of a Social Media Strategy for Public Health Promotion in Black, American Indian or Alaska Native, and Hispanic or Latino Communities During the COVID-19 Pandemic: Cross-Sectional Study. | Individuals identifying as Black, American Indian or Alaska Native, or Hispanic or Latino lack access to culturally appropriate accurate information and are the target of disinformation campaigns, which create doubt in science and health care providers and might play a role in sustaining health disparities related to the COVID-19 pandemic. This study aims to create and disseminate culturally and medically appropriate social media messages for Black, Latino, and American Indian or Alaska Native communities in Wisconsin and evaluate their reach and effectiveness in addressing the information needs of these communities. Our team identified relevant COVID-19 topics based on feedback from their respective community, developed lay format materials, and translated materials into culturally appropriate social media messages that community advocates delivered across their respective communities. Social media metrics (reach, engagement, and impressions) were collected using Sprout Social and Facebook Analytics. We hosted 9 focus groups with community members to learn about their social media use. These data were analyzed using an inductive approach, using NVivo software (release 1.7) to code content. Between August 2021 and January 2023, we created 980 unique social media posts that reached 88,790 individuals and gathered >6700 engagements. Average reach per post was similar across the 3 communities, despite differences in the number of posts and followers on each page: 119.46 (Latino individuals), 111.74 (Black individuals), and 113.11 (Oneida Nation members). The type of posts that had higher engagement rate per reached person (ERR) varied across communities and platforms, with the highest being live videos for the Latino community on Facebook (ERR 9.4%), videos for the Black community on Facebook (ERR 19.53%), and social media messages for the Oneida Nation community (ERR 59.01%). Our project presents a unique and effective model for health messages and highlights the need for tailoring social media messages and approaches for minoritized audiences (eg, age, gender, race, and ethnicity). Further research studies are needed to explore how specific types of information affect the dissemination of information and the implications for health communications. |
| 857 | Maria Mora Pinzon | GERI | mmora2@wisc.edu | Latinas in medicine: evaluating and understanding the experience of Latinas in medical education: a cross sectional survey. | The percentage of physicians identifying as Latina has not improved despite improvements in recruitment of Latina medical students, suggesting barriers to retention and career advancement. Discriminatory experiences and mental health inflictions throughout training may contribute to difficulties in recruitment, retainment, and advancement of Hispanic/Latinx trainees, a notably understudied population. An anonymous, online survey was distributed to Latinas in the continental U.S. between June 22 to August 12, 2022. Eligibility criteria included: self-identifying as Hispanic/Latina, female/woman, and completing or have completed medical school, residency, or fellowship in the continental U.S. in the past 10 years. Recruitment was done via the Twitter account @LatinasInMed and outreach to Latino Medical Student Association chapters. Descriptive statistics summarized the self-reported experiences. The survey included 230 Hispanic/Latinx women, mostly medical students (46.9%). A majority (54.5%) reported negative ethnicity-based interactions from patients and/or patients' families; 71.8%, from others in the medical field. High rates of depression (76.2%) and anxiety (92.6%) during training were reported by Latinas, especially medical students. Feelings of imposter syndrome and burnout were high at 90.7% and 87.4%, respectively. This is the first study evaluating the unique experiences of Latinas in medicine, who reported discrimination and mental health struggles, specifically during medical school, at alarmingly high rates. Our findings could aid in creating the needed interventions to support Latinas in medical training to reduce the existing exodus of Latinas from medicine. |
| 858 | Maria Mora Pinzon | GERI | mmora2@wisc.edu | Factors Influencing Eye Screening Adherence Among Latinx Patients With Diabetes: A Qualitative Study. | Latinx populations have the highest rates of visual impairment and blindness of any ethnic group in the United States, with most cases of diabetic retinopathy remaining undiagnosed. We aimed to identify factors influencing adherence with diabetic eye screening in Latinx communities. We conducted semistructured individual interviews with adult Latinx patients in Dane County, WI. Interviews were transcribed verbatim, translated from Spanish to English, and analyzed using QSR NVivo software. We performed both inductive open coding and deductive coding using the National Institute on Minority Health and Health Disparities Research Framework, as well as the Campbell and Egede Model. All participants (n = 20) self-identified as Latinx and were diagnosed with type 2 diabetes. The mean age was 61.5 years (range 33-79 years). Most participants were uninsured (60%), self-reported low or moderate health literacy (60%), and preferred to speak Spanish during their clinic appointments (75%). Individual-level barriers to diabetic eye screening included limited eye health literacy, lack of insurance coverage, and low self-efficacy with diabetes management. Health system-level facilitators included a recommendation to obtain eye screening from a primary care provider and the use of nonwritten forms of patient education. Community-level barriers included social isolation, concerns about inconveniencing others, machismo, and immigration status. We identified several health system- and community-level factors, in addition to individual-level factors, influencing adherence with diabetic eye screening in Latinx communities. Strategies addressing these factors may enhance the effectiveness of interventions to prevent blindness from diabetes and contribute to advancing health equity in Latinx communities. |
| 859 | Maria Mora Pinzon | GERI | mmora2@wisc.edu | Perspectives of Latinx Patients with Diabetes on Teleophthalmology, Artificial Intelligence-Based Image Interpretation, and Virtual Care: A Qualitative Study. | Latinx populations in the United States bear a disproportionate burden of diabetic eye disease. Teleophthalmology with and without artificial intelligence (AI)-based image interpretation are validated methods for diabetic eye screening, but limited literature exists on patient perspectives. This study aimed at understanding the perspectives of Latinx patients with diabetes on teleophthalmology, AI-based image interpretation, and general virtual care to prevent avoidable blindness in this population. We conducted semi-structured, individual interviews with 20 Latinx patients with diabetes at an urban, federally qualified health center in Madison, WI. Interviews were transcribed verbatim, professionally translated from Spanish to English, and analyzed using both inductive open coding and deductive coding. Most participants had no prior experience with teleophthalmology but did have experience with virtual care. Participants expressed a preference for teleophthalmology compared with traditional in-person dilated eye exams but were willing to obtain whichever method of screening was recommended by their primary care clinician. They also strongly preferred having human physician oversight in image review compared with having images interpreted solely using AI. Many participants preferred in-person clinic visits to virtual health care due to the ability to have a more thorough physical exam, as well as for improved non-verbal communication with their clinician. Leveraging primary care providers' recommendations, human oversight of AI-based image interpretation, and improving communication may enhance acceptance and utilization of teleophthalmology, AI, and virtual care by Latinx patients. Understanding Latinx patient perspectives may contribute toward the development of more effective telemedicine interventions to enhance health equity in Latinx communities. |
| 860 | Maria Mora Pinzon | GERI | mmora2@wisc.edu | Understanding Attitudes, Beliefs, Behaviors, and Barriers to Hearing Loss Care Among Hispanic Adults and Caregivers. | Introduction: While 9.5 million U.S. Hispanic adults have hearing loss, limited research has focused on their hearing care experiences. This study examines the attitudes, beliefs, behaviors, and barriers to hearing care among Hispanic adult patients with hearing loss (HL) and their caregivers. Methods: In a qualitative study, participants were recruited through community organizations, social media, and word of mouth. Participants were interviewed through virtual platforms and audio recorded. The recording was then transcribed verbatim in Spanish, translated to English, and analyzed using a hybrid deductive and inductive content approach. Results: The 12 participants (age 35-92, 83.3% female) comprised seven individuals with HL and three family caregivers. Most participants attributed HL to aging and genetics, and most shared a stigmatized community attitude toward HL that silenced any discussion of it. Barriers to hearing care included high cost, lack of insurance, and language barriers. These resulted in negative experiences with providers and poor access to hearing tests and auditory devices. Conclusions: The study's findings suggest a need to improve access to comprehensive low-cost hearing services and education in the Hispanic community. Additionally, unique challenges of this community should be addressed to promote hearing health and self-management. |
| 861 | Maria Mora Pinzon | GERI | mmora2@wisc.edu | Addressing the disparities in dementia risk, early detection and care in Latino populations: Highlights from the second Latinos & Alzheimer's Symposium. | The Alzheimer's Association hosted the second Latinos & Alzheimer's Symposium in May 2021. Due to the COVID-19 pandemic, the meeting was held online over 2 days, with virtual presentations, discussions, mentoring sessions, and posters. The Latino population in the United States is projected to have the steepest increase in Alzheimer's disease (AD) in the next 40 years, compared to other ethnic groups. Latinos have increased risk for AD and other dementias, limited access to quality care, and are severely underrepresented in AD and dementia research and clinical trials. The symposium highlighted developments in AD research with Latino populations, including advances in AD biomarkers, and novel cognitive assessments for Spanish-speaking populations, as well as the need to effectively recruit and retain Latinos in clinical research, and how best to deliver health-care services and to aid caregivers of Latinos living with AD. |
| 862 | Maria Mora Pinzon | GERI | mmora2@wisc.edu | The Wisconsin Alzheimer's Institute Dementia Diagnostic Clinic Network: A community of practice to improve dementia care. | The Wisconsin Alzheimer's Institute (WAI) Dementia Diagnostic Clinic Network is a community of practice formed in 1998 as a collaboration of community-based clinics from various healthcare systems throughout the state. Its purpose is to promote the use of evidence-based strategies to provide high quality care throughout Wisconsin for people with dementia. The purpose of this study is to describe the use of a community of practice to facilitate education of healthcare providers on best practices in dementia care, and the implementation of an interprofessional approach to diagnose and manage dementia and related disorders. Cross-sectional study of the members of the WAI's Dementia Diagnosis Clinic Network. Characteristics of clinics and healthcare teams, learners' participation in educational events and educational outcomes were collected from evaluation forms. Number and characteristics of patients seen in the memory clinics were collected from de-identified data forms submitted by members to a centralized location for data analysis. The clinic network currently has 38 clinics affiliated with 26 different healthcare systems or independent medical groups in 21 of 72 Wisconsin counties. Most (56%) are based in primary care, 15% in psychiatry, and 29% in neurology. Between 2018 and 2021, we received data on 4710 patients; 92% were ≥65 years old, 60% were female, and 92% were white. Network members meet in-person twice a year to learn about innovations in the field of dementia care and to share best practices. Educational events associated with the network are shown to be relevant, useful, and improve knowledge and skills of participants. Communities of practice provide added value via shared best practices and educational resources, continuing education of the health workforce, continuous quality improvement of clinical practices, and adoption of new diagnostic and management approaches in dementia care. |
| 863 | Justine Yang Bruce | HEM/ONC | jybruce@medicine.wisc.edu | Safety and toxicity of Iopofosine I 131 (CLR 131) with external beam radiation therapy in recurrent or metastatic head and neck cancer: results of a phase 1 single-centre, open-label, single-arm, dose escalation and dose expansion study. | Re-irradiation of recurrent head and neck cancer (HNC) is often limited by tumour adherence to critical structures and/or radiation tolerance of critical normal tissues. Iopofosine I 131 (CLR 131) is a targeted small molecular phospholipid ether (PLE) drug conjugate that delivers iodine-131 selectively to tumour cells. We conducted a phase 1, single-centre, open-label study to determine whether CLR 131 given with reduced dose of external beam radiation therapy (EBRT) would be tolerable and feasible. All participants received previous curative intent treatment with radiotherapy as primary or adjuvant treatment. Eligible participants demonstrated uptake of CLR 131 as indicated via single photon emission CT/CT (SPECT/CT) imaging following CLR 131 test dose. Participants received two therapeutic doses of CLR 131 (days 1 and 8) with SPECT/CT imaging performed to quantitate the biodistribution of CLR 131. Participants subsequently received EBRT to achieve the designated radiation dose (60-70 Gy). The primary endpoint was safety. This trial was registered with ClinicalTrials.gov, NCT04105543, and enrolment and follow-up are complete. Twelve participants completed treatment with CLR 131 and EBRT. Eight participants experienced grade 4 non-DLT haematologic toxicities (2 anaemia, 8 leukopenia, 5 thrombocytopenia) at least probably attributed to CLR 131, consistent with the expected toxicity profile. Haematologic toxicities occurred during weeks 6-8 from the first dose of CLR 131 and resolved within three weeks without sequelae. There were no treatment-related grade 3-4 non-haematologic toxicities. CLR 131 in combination with EBRT did not confer any safety concerns, and was tolerable in participants with recurrent/metastatic HNC. Myelosuppression was consistent with the known toxicity profile of CLR 131. National Institutes of HealthP50 DE026787, National Cancer InstituteP30 CA014520, National Institutes of Health1UL1TR002373, Cellectar, NCT04105543. |
| 864 | Justine Yang Bruce | HEM/ONC | jybruce@medicine.wisc.edu | Phase II Trial of Enfortumab Vedotin in Patients With Previously Treated Advanced Head and Neck Cancer. | Despite advances in immunotherapy, unresectable recurrent/metastatic head and neck cancer (HNC) carries a poor prognosis, and effective treatments are needed. As nectin-4 is widely expressed in HNC, enfortumab vedotin (EV), a nectin-4-directed antibody-drug conjugate, was explored in HNC in EV-202 (ClinicalTrials.gov identifier: NCT04225117). This open-label, multicohort, phase II study evaluated intravenous EV 1.25 mg/kg on days 1, 8, and 15 of each 28-day cycle. In the HNC cohort, eligible patients had recurrent/metastatic HNC and had received platinum-based therapy for locally advanced/metastatic disease and a PD-1/PD-L1 inhibitor. The primary end point was investigator-assessed confirmed objective response rate (ORR) per RECIST version 1.1. Secondary end points were investigator-assessed duration of response (DOR), disease control rate (DCR), and progression-free survival (PFS); overall survival (OS); and safety. The primary analysis included 46 patients; all received EV (median follow-up, 9.3 months). Most patients (52.2%) had ≥3 previous lines of systemic therapy in the metastatic setting. Confirmed ORR was 23.9%, DCR was 56.5%, and median DOR was not reached (median DOR was 9.4 months at a later data cutoff [median follow-up, 11.3 months]). Median PFS and OS were 3.9 and 6.0 months, respectively. Treatment-related adverse events (TRAEs) occurring in >20% of patients were alopecia (28.3%), fatigue (26.1%), and peripheral sensory neuropathy (23.9%). Sixteen patients (34.8%) experienced grade ≥3 TRAEs; anemia and decreased neutrophil count occurred in ≥1 patient (both n = 2; 4.3%). EV demonstrated antitumor activity in heavily pretreated HNC. Safety was consistent with the known safety profile of EV; no new safety signals were identified. These data support further evaluation of EV for advanced HNC not amenable to definitive local therapy. |
| 865 | Justine Yang Bruce | HEM/ONC | jybruce@medicine.wisc.edu | Sinonasal Tumors: What the Multidisciplinary Cancer Care Board Wants to Know. | Sinonasal neoplasms are a remarkably heterogeneous group, reflecting the numerous tissue types present in the nasal cavity and paranasal sinuses. These entities can be relatively benign (ie, respiratory epithelial adenomatoid hamartoma) or can be exceedingly aggressive (ie, NUT carcinoma). Certain sinonasal tumors have a propensity to spread through local invasion and destruction, while others have a high likelihood of perineural spread. The genetic and molecular mechanisms underlying sinonasal tumor behavior have recently become better understood, and new tumor types have been described using these genetic and molecular data. This has prompted an expansion in the number of tumors included in the World Health Organization fifth edition classification system for head and neck tumors, along with a new classification structure. Radiologists' familiarity with this classification structure is crucial to understanding the expected behavior of these tumors and to collaboration with the multidisciplinary cancer care board in making decisions for optimal patient care. ©RSNA, 2024. |
| 866 | Justine Yang Bruce | HEM/ONC | jybruce@medicine.wisc.edu | Advances in Organ Preservation for Laryngeal Cancer. | At the University of Wisconsin, all treatment of head and neck cancer patients begins with discussion at our multi-disciplinary tumor board. Most patients with T4 disease, with existing laryngeal dysfunction, considered unlikely to complete definitive CRT or who have a high risk of persistent aspiration after non-operative management undergo total laryngectomy. A laryngeal sparing approach is attempted on most other patients. Radiotherapy is delivered over 6.5 weeks, preferably with concurrent weekly cisplatin. If the patient is hesitant of chemotherapy or has contraindications to cisplatin, concurrent cetuximab may be offered. Patients treated with RT alone are often treated to the same dose, but via an accelerated schedule by adding a 6th fraction per week. The 6th fraction is given by delivering two treatments at least 6 h apart on a weekday of the patient's choosing. We consider the following to be major risk factors for clinically significant weight loss during treatment: a 10% or greater loss of weight in the 6 months prior to starting treatment, delivery of concurrent cisplatin, and treatment of the bilateral neck with radiation. Patients who have 2-3 of these characteristics are often given gastrostomy tubes prophylactically. Patients are seen 2 weeks after completion of therapy, and then every 3 months after completion for 2 years. A CT neck and PET-CT are performed at the first 3-month visit. They are seen twice in year three, and then yearly until years 5-7. At each of these visits, we have a low threshold to present the patient at our multidisciplinary tumor board for consideration of salvage laryngectomy if there are signs of progression. |
| 867 | Justine Yang Bruce | HEM/ONC | jybruce@medicine.wisc.edu | A Phase Ib Study of Axitinib in Combination with Crizotinib in Patients with Metastatic Renal Cell Cancer or Other Advanced Solid Tumors. | The combination of axitinib and crizotinib has a manageable safety and tolerability profile, consistent with the profiles of the individual agents when administered as monotherapy.The antitumor activity reported here for the combination axitinib/crizotinib does not support further study of this combination treatment in metastatic renal cell carcinoma given the current treatment landscape. Vascular endothelial growth factor (VEGF) inhibitors have been successfully used to treat metastatic renal cell carcinoma (mRCC); however, resistance eventually develops in most cases. Tyrosine protein kinase Met (MET) expression increases following VEGF inhibition, and inhibition of both has shown additive effects in controlling tumor growth and metastasis. We therefore conducted a study of axitinib plus crizotinib in advanced solid tumors and mRCC. This phase Ib study included a dose-escalation phase (starting doses: axitinib 3 mg plus crizotinib 200 mg) to estimate maximum tolerated dose (MTD) in patients with solid tumors and a dose-expansion phase to examine preliminary efficacy in treatment-naïve patients with mRCC. Safety, pharmacokinetics, and biomarkers were also assessed. No patients in the dose-escalation phase (n = 22) experienced dose-limiting toxicity; MTD was estimated to be axitinib 5 mg plus crizotinib 250 mg. The most common grade ≥3 adverse events were hypertension (18.2%) and fatigue (9.1%). In the dose-expansion phase, overall response rate was 30% (95% confidence interval [CI], 11.9-54.3), and progression-free survival was 5.6 months (95% CI, 3.5-not reached). The combination of axitinib plus crizotinib, at estimated MTD, had a manageable safety profile and showed evidence of modest antitumor activity in mRCC. 经验总结 • 阿西替尼联合克唑替尼具有可控的安全性和耐受性特性，与单一疗法用药时的个体药物特征相一致。 • 鉴于当前的治疗环境，本文中所报告的阿西替尼/克唑替尼联合疗法的抗肿瘤活性不支持将此联合疗法用于转移性肾细胞癌的进一步研究。 摘要 背景。血管内皮生长因子 (VEGF) 抑制剂已成功用于治疗转移性肾细胞癌 (mRCC)；然而，大多数情况下最终会产生耐药性。在抑制VEGF后，酪氨酸蛋白激酶 Met (MET) 的表达增加，且两者的抑制作用在控制肿瘤生长和转移方面显现出附加效应。因此，我们对阿西替尼联合克唑替尼治疗晚期实体瘤和转移性肾细胞癌的效果进行了研究。 方法。此项 IB 期研究包括剂量递增阶段(起始剂量:阿西替尼 3 mg，加上克唑替尼 200 mg)，以评估实体瘤患者的最大耐受剂量 (MTD)；剂量扩展阶段，以检验对mRCC治疗无效患者的初步疗效。此外，还对安全性、药代动力学和生物标志物进行了评估。 结果。在剂量递增阶段(n=22)，无患者出现剂量限制性毒性；预估的MTD为:阿西替尼 5 mg，加上克唑替尼 250 mg。最常见的≥ 3 级不良事件为高血压 (18.2%) 和疲劳 (9.1%)。在剂量扩展阶段，总体反应率为 30% [95% 置信区间 (CI)，11.9‐54.3]，无进展生存期为 5.6 个月(95% CI，3.5‐ 未达到)。 结论。在达到预估的MTD时，阿西替尼联合克唑替尼疗法具有可管理的安全特性，且有证据表明，对治疗mRCC显示出适度的抗肿瘤活性。 |
| 868 | Justine Yang Bruce | HEM/ONC | jybruce@medicine.wisc.edu | Pharmacodynamic study using FLT PET/CT in advanced solid malignancies treated with a sequential combination of X-82 and docetaxel. | A sequential approach, synchronizing cell-cycle specific chemotherapy during VEGFR-TKI treatment breaks, may improve the therapeutic index of this combination therapy. In this study we investigate the safety/tolerability and pharmacodynamic effects of docetaxel used in sequential combination with the novel VEGFR-TKI X-82. Patients with advanced solid malignancies underwent 21-day treatment cycles with X-82 administered daily on days 1-14, a treatment break on days 15-20, and docetaxel administered on day 21. Randomization was 1:1 to either a low-dose X-82 (200 mg) or high-dose X-82 (400 mg) arm. Patients were scheduled to undergo four 3'-deoxy-3'-18F-fluorothymidine (FLT) PET/CT scans to assess changes in tumor cell proliferation. PET standardized uptake values (SUV) were summarized for tumors and changes were assessed using mixed effects models. 14 patients were enrolled and treated with median 3.5 cycles (range 0-12). Three patients in the high-dose cohort (50%) and three patients in the low-dose cohort (38%) experienced at least one grade 3 adverse event during the study (infections, cytopenias, electrolyte abnormalities, and vascular complications). Four patients with 13 metastatic tumors underwent FLT PET/CT scanning. During the cycle 1 X-82 exposure period, tumor SUVmax decreased by - 11% (p = 0.04). After administration of docetaxel and the cycle 2 X-82 exposure period, tumor SUVmax decreased - 44% (p = 0.03). The sequential combination of X-82 and docetaxel was safe and led to diminished FLT uptake. Further, decrease in FLT uptake during cycle 2 (X-82 plus docetaxel) was greater than in cycle 1 (X-82 alone), suggesting sequential chemotherapy enhances the pharmacodynamic effect of therapy. |
| 869 | Justine Yang Bruce | HEM/ONC | jybruce@medicine.wisc.edu | (18)F-FLT PET/CT imaging in patients with advanced solid malignancies treated with axitinib on an intermittent dosing regimen. | This study utilizes FLT PET/CT imaging to characterize changes in tumor cell proliferation and vasculature during intermittent treatment with VEGR-TKI axitinib. Patients with metastatic solid malignancies underwent 3-week treatment cycles with axitinib (7 and 5 mg BID for safety and pharmacodynamic cohorts, respectively). Cycles consisted of 2 weeks of treatment (dosing period) followed by a 1-week treatment break (washout period). Patients in the pharmacodynamic cohort had up to six FLT PET/CT scans (three scans in each cycle 1 and cycle 3) and had plasma VEGF concentrations measured at imaging timepoints. Changes in tumor SUVs and VEGF within and across drug cycles were investigated. Eight patients enrolled in the safety cohort where it was determined 7 mg axitinib was not tolerable due to severe adverse events, including three patients who experienced significant hypertension and thrombovascular effects. Sixteen patients enrolled in the pharmacodynamic cohort demonstrated significant decreases in SUVs and increases in VEGF during dosing periods. This was followed by significant increases in SUVs and decreases in VEGF during drug washout periods. No significant differences in SUVs or VEGF were found when comparing cycle 1 with cycle 3. A mixed effects model demonstrated significant negative correlation between SUV and VEGF. Response to axitinib included diminished FLT uptake during dosing periods followed by increased FLT uptake during drug washout periods. These changes were not different when comparing treatment cycle 1 versus cycle 3, suggesting that the pharmacodynamic effect of intermittent axitinib is similar across multiple drug cycles. |
| 870 | Justine Yang Bruce | HEM/ONC | jybruce@medicine.wisc.edu | A pharmacodynamically guided dose selection of PF-00337210 in a phase I study in patients with advanced solid tumors. | PF-00337210 is an oral, highly selective vascular endothelial growth factor receptor (VEGFR) inhibitor. We evaluated a composite of biomarkers in real time to identify the recommended phase 2 dose (RP2D) and preliminary anticancer activity of PF-00337210. Patients (Pts) with advanced cancers were treated once (QD) or twice daily (BID) with escalating doses. Acute effects on tumor perfusion and vascularity were assessed using DCE-MRI, weekly BP readings, soluble VEGFR-2, and hemoglobin levels. Forty-six pts were treated with 0.67-9 mg QD and 4-6 mg BID of PF-00337210. Nineteen pts (41%) previously received VEGF/VEGFR inhibitors. Two pts had dose-limiting toxicity (DLT) at 9 mg QD (troponin I increase and hypertension). The MTD at QD dose was 8 mg. Common drug-related adverse events were hypertension, fatigue, proteinuria, and nausea. Hypertension incidence and intensity corresponded with dose, but was well controlled with medication. Two confirmed partial responses and minor regressions (>10 to <30% reduction in target lesions) were noted. Complete DCE-MRI was acquired in 21 pts (20 evaluable for vascular response). Ten pts were vascular responders, including 5/6 pts at BID doses. Greatest modulation of soluble VEGFR-2 was at 6 mg BID. The maximum change from baseline in diastolic BP was higher at BID doses. There were no significant differences for systolic BP and hemoglobin levels. PF-00337210 has profound VEGFR inhibition effects at well-tolerated doses. Antitumor activity and VEGF inhibition effects were observed across BID doses. The RP2D was 6 mg BID. |
| 871 | Justine Yang Bruce | HEM/ONC | jybruce@medicine.wisc.edu | Pharmacodynamic study of axitinib in patients with advanced malignancies assessed with (18)F-3'deoxy-3'fluoro-L-thymidine positron emission tomography/computed tomography. | Rapid disease progression associated with increased tumor proliferation has been observed during withdrawal of anti-angiogenic therapy. We characterize the dynamics of withdrawal flare for axitinib. Thirty patients with metastatic solid malignancies received axitinib for 2 weeks, followed by a 1-week drug holiday. Twenty patients suitable for PET imaging received scans with (18)F-3'deoxy-3'fluoro-L-thymidine (FLT), a marker of proliferation. Plasma VEGF and axitinib pharmacokinetic levels were also assessed at specified time points. During axitinib withdrawal, significant increases in both SUVmax (+22 %; p = 0.006) and SUVmean (+20 %; p = 0.001) were observed. Significant increases relative to peak axitinib concentration were observed at day 2 withdrawal for SUVmax and SUVmean, with no further significant increase from day 2 to day 7 of withdrawal. No significant change in SUVmax or SUVmean was observed during the treatment period, relative to baseline. VEGF concentration significantly increased when on drug (p < 0.001) and decreased back to a level indistinguishable from baseline by day 7 of drug washout (p = 0.448). No correlation between change in VEGF and change in imaging metrics was observed. A significant increase in tumor proliferation was observed during withdrawal of axitinib therapy, and this flare occurred within 2 days of axitinib withdrawal. An exploratory analysis indicated that this flare may be associated with poor clinical outcome. |
| 872 | Justine Yang Bruce | HEM/ONC | jybruce@medicine.wisc.edu | A phase I pharmacodynamic trial of sequential sunitinib with bevacizumab in patients with renal cell carcinoma and other advanced solid malignancies. | Sunitinib treatment results in a compensatory increase in plasma VEGF levels. Acute withdrawal of sunitinib results in a proliferative withdrawal flare, primarily due to elevated VEGF levels. Concurrent sunitinib plus bevacizumab is poorly tolerated with high (37 %) incidence of microangiopathic hemolytic anemia (MAHA). We evaluated a sequential design administering bevacizumab during the sunitinib treatment break to suppress the sunitinib withdrawal flare. Patients with no prior VEGF treatment were enrolled in this study. All patients had target lesions amenable to serial FLT PET/CT imaging. Sunitinib 37.5 mg was given on days 1-28 every 6 weeks with bevacizumab 5 mg/kg on day 29. If safe and tolerable, sunitinib increased to 50 mg. FLT PET/CT scans would be obtained at baseline (D1), week 4, and week 6 to evaluate pharmacodynamics of the sequential combination. Sunitinib pharmacokinetics and total, free, and bound VEGF levels were obtained on each cycle at D1, pre-bevacizumab (D29), 4 h post-bevacizumab (D29H4), and day 42 (D42). Six patients enrolled in the safety cohort of sunitinib 37.5 mg plus bevacizumab (see Table). One patient experienced grade 1 MAHA, and after discussion with the Cancer Therapy Evaluation Program (CTEP), the trial was closed to further accrual. No imaging scans were obtained due to early closure. Total and free VEGF levels during cycle 1 Cycle 1 Total VEGF (pg/mL) Mean ± SD Free VEGF (pg/mL) Mean ± SD D1 80 ± 70 51 ± 47 D29 150 ± 62 103 ± 35 D29H4 10 ± 12 2 ± 5 D42 177 ± 34 97 ± 18 CONCLUSIONS: Subclinical MAHA was seen despite using sequential sunitinib with low-dose bevacizumab, and this combination was not feasible for further development. As predicted, VEGF levels increased during sunitinib exposure followed by a rapid decline after bevacizumab. Due to the long half-life of bevacizumab, we expected VEGF ligand suppression through D42, but instead observed a complete rebound in total/free VEGF levels by D42. The increase in VEGF at D42 was unexpected based on sunitinib alone and contrary to the hypothesis that we would block VEGF flare with low-dose bevacizumab. VEGF ligand production may increase as a result of bevacizumab, implying a robust host compensatory mechanism to VEGF signaling pathway inhibition. A greater understanding of the compensatory mechanism would aid future sequencing strategies of new agents. |
| 873 | Victoria J Williams | GERI | vwilliams@medicine.wisc.edu | Cognitive and Alzheimer's disease biomarker effects of oral nicotinamide riboside (NR) supplementation in older adults with subjective cognitive decline and mild cognitive impairment. | Age-associated depletion in nicotinamide adenine dinucleotide (NAD+) concentrations has been implicated in metabolic, cardiovascular, and neurodegenerative disorders. Supplementation with NAD+ precursors, such as nicotinamide riboside (NR), offers a potential therapeutic avenue against neurodegenerative pathologies in aging, Alzheimer's disease, and related dementias. A crossover, double-blind, randomized placebo (PBO) controlled trial was conducted to test the safety and efficacy of 8 weeks' active treatment with NR (1 g/day) on cognition and plasma AD biomarkers in older adults with subjective cognitive decline and mild cognitive impairment. The primary efficacy outcome was the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Secondary outcomes included plasma phosphorylated tau 217 (pTau217), glial fibrillary acidic protein (GFAP), and neurofilament light chain (NfL). Exploratory outcomes included Lumosity gameplay (z-scores) for cognition and step counts from wearables. Mixed model for repeated measures was used for between-group comparisons; paired t-tests were used for within-individual comparisons. Forty-six participants aged over 55 were randomized to NR-PBO or PBO-NR groups; 41 completed baseline visits, and 37 completed the trial. NR supplementation was safe and well tolerated with no differences in adverse events reported between NR and PBO treatment phases. For the between-group comparison, there was a 7% reduction in pTau217 concentrations after taking NR, while an 18% increase with PBO (p = 0.02). No significant between-group differences were observed for RBANS, other plasma biomarkers(GFAP and NfL), Lumosity gameplay scores or step counts. For the within-individual comparison, pTau217 concentrations significantly decreased during the NR phase compared to the PBO (p = 0.02), while step counts significantly increased during the NR phase than PBO (p = 0.04). Eight weeks NR supplementation is safe and lowered pTau217 concentrations but did not alter cognition as measured by conventional or novel digital assessments. Further research is warranted to validate NR's efficacy in altering pathological brain aging processes. The integrated study design combines a two-arm parallel trial with a crossover phase, offering the opportunity to enhance sample size for within-individual analysis and assess carryover effects.NR is safe but did not alter cognition as measured by multi-modal assessments in SCD/MCI.For between-group comparison, pTau217 levels decreased with NR and increased with PBO at 8-week follow-up.For within-individual comparison, step counts increased after NR and decreased after PBO.A larger, longer study with pharmacodynamic and pathophysiological biomarkers is needed to assess NR's disease-modifying effects. |
| 874 | Victoria J Williams | GERI | vwilliams@medicine.wisc.edu | Midlife and late-life environmental exposures on dementia risk in the Wisconsin Longitudinal Study: The modifying effects of ApoE. | Late-life air pollution exposure is associated with an increased risk for dementia, with this effect exacerbated among apolipoprotein E-4 (ApoE-4) carriers. However, whether midlife occupational exposures likewise influence dementia outcomes, and varies as a function of ApoE-4 status is unknown. Using data from 3814 participants in the Wisconsin Longitudinal Study (WLS), we employed weighted logistic regression to evaluate associations between midlife occupational respiratory exposures and late-life air pollution on all-cause dementia risk, stratified by ApoE-4 status. Midlife occupational exposure was associated with increased odds of all-cause dementia preferentially among ApoE-4 noncarriers (odds ratio [OR] = 1.59, p = 0.01), whereas higher late-life urban air pollution exposure was associated with increased dementia risk among ApoE-4 carriers (OR = 1.258, p = 0.029). Associations between environmental exposures and dementia risk vary based on the timing of exposure and ApoE-4 status. While late-life environmental exposures are associated with dementia among ApoE-4 carriers, for noncarriers midlife environmental exposure confers the greatest risk. The effect of adult environmental respiratory exposures on subsequent dementia risk varies as a function of both ApoE-4 carrier status and exposure timing. Midlife occupational exposure to respiratory hazards is preferentially associated with increased dementia odds among ApoE-4 noncarriers. Late-life exposure to ambient air pollution is associated with dementia risk, but only among ApoE-4 carriers. While higher exposure to PM2.5 increases the risk for dementia, higher exposure to ozone was associated with reduced risk for dementia among ApoE-4 carriers. |
| 875 | Victoria J Williams | GERI | vwilliams@medicine.wisc.edu | Biological effects of sodium phenylbutyrate and taurursodiol in Alzheimer's disease. | Sodium phenylbutyrate and taurursodiol (PB and TURSO) is hypothesized to mitigate endoplasmic reticulum stress and mitochondrial dysfunction, two of many mechanisms implicated in Alzheimer's disease (AD) pathophysiology. The first-in-indication phase 2a PEGASUS trial was designed to gain insight into PB and TURSO effects on mechanistic targets of engagement and disease biology in AD. The primary clinical efficacy outcome was a global statistical test combining three endpoints relevant to disease trajectory (cognition [Mild/Moderate Alzheimer's Disease Composite Score], function [Functional Activities Questionnaire], and total hippocampal volume on magnetic resonance imaging). Secondary clinical outcomes included various cognitive, functional, and neuropsychiatric assessments. Cerebrospinal fluid (CSF) biomarkers spanning multiple pathophysiological pathways in AD were evaluated in participants with both baseline and Week 24 samples (exploratory outcome). PEGASUS enrolled 95 participants (intent-to-treat [ITT] cohort); cognitive assessments indicated significantly greater baseline cognitive impairment in the PB and TURSO (n = 51) versus placebo (n = 44) group. Clinical efficacy outcomes did not significantly differ between treatment groups in the ITT cohort. CSF interleukin-15 increased from baseline to Week 24 within the placebo group (n = 34). In the PB and TURSO group (n = 33), reductions were observed in core AD biomarkers phosphorylated tau-181 (p-tau181) and total tau; synaptic and neuronal degeneration biomarkers neurogranin and fatty acid binding protein-3 (FABP3); and gliosis biomarker chitinase 3-like protein 1 (YKL-40), while the oxidative stress marker 8-hydroxy-2-deoxyguanosine (8-OHdG) increased. Between-group differences were observed for the Aβ42/40 ratio, p-tau181, total tau, neurogranin, FABP3, YKL-40, interleukin-15, and 8-OHdG. Additional neurodegeneration, inflammation, and metabolic biomarkers showed no differences between groups. While between-group differences in clinical outcomes were not observed, most likely due to the small sample size and relatively short treatment duration, exploratory biomarker analyses suggested that PB and TURSO engages multiple pathophysiologic pathways in AD. Proteostasis and mitochondrial stress play key roles in Alzheimer's disease (AD).Sodium phenylbutyrate and taurursodiol (PB and TURSO) targets these mechanisms.The PEGASUS trial was designed to assess PB and TURSO effects on biologic AD targets.PB and TURSO reduced exploratory biomarkers of AD and neurodegeneration.Supports further clinical development of PB and TURSO in neurodegenerative diseases. |
| 876 | Victoria J Williams | GERI | vwilliams@medicine.wisc.edu | Associations Between Midlife Menopausal Hormone Therapy Use, Incident Diabetes, and Late Life Memory in the Wisconsin Longitudinal Study. | Prior research suggests a link between menopausal hormone therapy (MHT) use, memory function, and diabetes risk. The menopausal transition is a modifiable period to enhance long-term health and cognitive outcomes, although studies have been limited by short follow-up periods precluding a solid understanding of the lasting effects of MHT use on cognition. We examined the effects of midlife MHT use on subsequent diabetes incidence and late life memory performance in a large, same-aged, population-based cohort. We hypothesized that the beneficial effects of MHT use on late life cognition would be partially mediated by reduced diabetes risk. 1,792 women from the Wisconsin Longitudinal Study (WLS) were included in analysis. We employed hierarchical linear regression, Cox regression, and causal mediation models to test the associations between MHT history, diabetes incidence, and late life cognitive performance. 1,088/1,792 women (60.7%) reported a history of midlife MHT use and 220/1,792 (12.3%) reported a history of diabetes. MHT use history was associated with better late life immediate recall (but not delayed recall), as well as a reduced risk of diabetes with protracted time to onset. Causal mediation models suggest that the beneficial effect of midlife MHT use on late life immediate recall were at least partially mediated by diabetes risk. Our data support a beneficial effect of MHT use on late life immediate recall (learning) that was partially mediated by protection against diabetes risk, supporting MHT use in midlife as protective against late life cognitive decline and adverse health outcomes. |
| 877 | Victoria J Williams | GERI | vwilliams@medicine.wisc.edu | Associations of the Lifestyle for Brain Health index with longitudinal cognition and brain amyloid beta in clinically unimpaired older adults: Findings from the Wisconsin Registry for Alzheimer's Prevention. | Modifiable health and lifestyle factors increase risk of dementia, but whether modifiable factors, when measured in late-midlife, impact the emergence or progression of Alzheimer's disease (AD) pathophysiologic or cognitive changes remains unresolved. In initially cognitively unimpaired, late middle-aged participants (N = 1215; baseline age, M [standard deviation] = 59.3 [6.7] years) from the Wisconsin Registry for Alzheimer's Prevention (WRAP), we investigated the influence of the Lifestyle for Brain Health (LIBRA) index, a lifestyle-based dementia risk score, on AD-related cognitive trajectories and amyloid beta (Aβ) plaque accumulation. Overall, lower baseline LIBRA, denoting healthier lifestyle and lower dementia risk, was related to better overall cognitive performance, but did not moderate apolipoprotein E ε4 or Aβ-related longitudinal cognitive trajectories. LIBRA was not significantly associated with Aβ accumulation or estimated age of Aβ onset. In WRAP, late-midlife LIBRA scores were related to overall cognitive performance, but not AD-related cognitive decline or Aβ accumulation in the preclinical timeframe. The Lifestyle for Brain Health (LIBRA) index was associated with cognitive performance in late-midlife.LIBRA did not moderate apolipoprotein E ε4 or amyloid-related cognitive decline.LIBRA was not associated with the onset or accumulation of amyloid plaques. |
| 878 | Victoria J Williams | GERI | vwilliams@medicine.wisc.edu | Assessing Dementia Prevalence in the Wisconsin Longitudinal Study: Cohort Profile, Protocol, and Preliminary Findings. | There is growing consensus that non-genetic determinants of dementia can be linked to various risk- and resiliency-enhancing factors accumulating throughout the lifespan, including socioeconomic conditions, early life experiences, educational attainment, lifestyle behaviors, and physical/mental health. Yet, the causal impact of these diverse factors on dementia risk remain poorly understood due to few longitudinal studies prospectively characterizing these influences across the lifespan. The Initial Lifespan's Impact on Alzheimer's Disease and Related Dementia (ILIAD) study aims to characterize dementia prevalence in the Wisconsin Longitudinal Study (WLS), a 60-year longitudinal study documenting life course trajectories of educational, family, occupational, psychological, cognitive, and health measures. Participants are surveyed using the modified Telephone Interview for Cognitive Status (TICS-m) to identify dementia risk. Those scoring below cutoff undergo home-based neuropsychological, physical/neurological, and functional assessments. Dementia diagnosis is determined by consensus panel and merged with existing WLS data for combined analysis. Preliminary findings demonstrate the initial success of the ILIAD protocol in detecting dementia prevalence in the WLS. Increasing age, hearing issues, lower IQ, male sex, APOE4 positivity, and a steeper annualized rate of memory decline assessed in the prior two study waves, all increased likelihood of falling below the TICS-m cutoff for dementia risk. TICS-m scores significantly correlated with standard neuropsychological performance and functional outcomes. We provide an overview of the WLS study, describe existing key lifespan variables relevant to studies of dementia and cognitive aging, detail the current WLS-ILIAD study protocol, and provide a first glimpse of preliminary study findings. |
| 879 | Danielle McCarthy | GIM | demccarthy@ctri.wisc.edu | Specialty Tobacco Treatment Implementation in Oncology: A Qualitative Study. | In 2017, the National Cancer Institute (NCI) funded the Cancer Center Cessation Initiative (C3I) to implement and expand tobacco treatment programs in routine oncology care. Many C3I programs developed specialty care programs staffed by tobacco treatment specialists (TTSs) to deliver evidence-based treatment to adult patients who smoke. People involved in specialty tobacco treatment programs can help to identify implementation strategies and adaptations that may enhance tobacco treatment reach and effectiveness in cancer care and help more patients with cancer quit using tobacco. We conducted semistructured interviews with TTSs from 21 C3I-funded cancer centers and applied content analysis to interview transcripts from 37 TTSs and 17 respondents in other program roles. We used the Consolidated Framework for Implementation Research to code interview data. We identified final themes and implementation strategies and adaptations recommended by respondents on the basis of these codes. Respondents shared that implementation of specialty tobacco treatment programs in cancer care settings could be facilitated by training staff to provide patient connection to services, incorporating prescription of no- or low-cost cessation medications, hiring additional staff to deliver tobacco treatment, allocating space to the program, and automating electronic health record workflows. TTSs and others involved in specialty tobacco treatment in NCI-designated cancer centers identified ways to improve tobacco treatment access, use, and effectiveness by (1) adapting specialty tobacco treatment delivery to meet patient needs; (2) facilitating referrals and pharmacotherapy coordination; and (3) committing staffing, space, and support resources to tobacco treatment programs. Key program participants suggested that these approaches would help more oncology patients connect with evidence-based tobacco treatment and quit smoking. |
| 880 | Danielle McCarthy | GIM | demccarthy@ctri.wisc.edu | Tobacco Quitline Retreatment Interventions Among Adults With Socioeconomic Disadvantage: A Factorial Randomized Clinical Trial. | A single round of standard tobacco quitline treatment may not be sufficient to sustain abstinence, particularly among people experiencing socioeconomic disadvantage. Adaptive retreatment may help more individuals with socioeconomic disadvantage achieve abstinence and reduce disparities in smoking cessation outcomes. To evaluate 4 evidence-based strategies for adults with limited education, no insurance, or Medicaid eligibility who continued smoking after quitline treatment. A factorial randomized clinical trial with 4 factors adapting quitline strategies was conducted for participants enrolled from June 7, 2018, to January 25, 2023, with 6-month follow-up. Adults using the Wisconsin Tobacco Quit Line who were smoking cigarettes 3 to 6 months after prior quitline treatment who were uninsured, Medicaid insured, or had no more than a high school education were included. Quitline retreatment strategies were (1) increased counseling intensity (4 calls vs 1 call), (2) increased nicotine replacement therapy intensity (4 weeks of combination nicotine patch plus nicotine lozenge vs 2 weeks of nicotine patch), (3) text-message support (National Cancer Institute SmokefreeTXT program vs none), and (4) financial incentives for engagement in counseling and SmokefreeTXT ($30/call and/or 6-week SmokefreeTXT retention vs no incentives). Primary outcome was 7-day point-prevalence biochemically confirmed abstinence 26 weeks after the target quit day. Intention-to-treat analysis was performed. Of 6019 people assessed for eligibility, 1316 (21.9%) participants were randomized (mean [SD] age, 53.1 [11.9] years; 760 [57.8%] women), and 919 (69.8%) provided final follow-up. Intention-to-treat analyses showed 162 participants (12.3%) had biochemically confirmed abstinence at 26 weeks (368 [28.0% self-reported abstinence]). There were no significant main effects for the primary outcome: 1 call (11.6% [77 of 662]) vs 4 calls (13.0% [85 of 654]) (odds ratio [OR], 1.04; 95% CI, 0.88-1.24), 2-week patch (11.2% [73 of 654]) vs 4-week combination nicotine replacement therapy (13.4% [89 of 662]) (OR, 1.12; 95% CI, 0.94-1.34), no SmokefreeTXT (13.4% [88 of 657]) vs SmokefreeTXT (11.2% [74 of 659]) (OR, 0.88; 95% CI, 0.74-1.05), and no financial incentives (12.8% [85 of 662]) vs financial incentives (11.8% [77 of 654]) (OR, 0.94; 95% CI, 0.78-1.11). In this randomized clinical trial evaluating enhancements to tobacco quitlines for adults with socioeconomic disadvantage who were smoking after quitline treatment, none of the adaptive treatment strategies robustly improved long-term abstinence. Strategies are needed to enhance quitline retreatment effectiveness for adults with socioeconomic disadvantage. ClinicalTrials.gov Identifier: NCT03538938. |
| 881 | Danielle McCarthy | GIM | demccarthy@ctri.wisc.edu | Cost-Effectiveness of a Comprehensive Primary Care Smoking Treatment Program. | Smoking is the leading preventable cause of death and disease in the U.S. This study evaluates the cost-effectiveness from a healthcare system perspective of a comprehensive primary care intervention to reduce smoking rates. This pragmatic trial implemented electronic health record prompts during primary care visits and employed certified tobacco cessation specialists to offer proactive outreach and smoking cessation treatment to patients who smoke. The data, analyzed in 2022, included 10,683 patients in the smoking registry from 2017 to 2020. Pre-post analyses compared intervention costs to treatment engagement, successful self-reported smoking cessation, and acute health care utilization (urgent care, emergency department visits, and inpatient hospitalization). Cost per quality-adjusted life year was determined by applying conversion factors obtained from the tobacco research literature to the cost per patient who quit smoking. Tobacco cessation outreach, medication, and counseling costs increased from $2.64 to $6.44 per patient per month, for a total post-implementation intervention cost of $500,216. Smoking cessation rates increased from 1.3% pre-implementation to 8.7% post-implementation, for an incremental effectiveness of 7.4%. The incremental cost-effectiveness ratio was $628 (95% CI: $568, $695) per person who quit smoking, and $905 (95% CI: $822, $1,001) per quality-adjusted life year gained. Acute health care costs decreased by an average of $42 (95% CI: -$59, $145) per patient per month for patients in the smoking registry. Implementation of a comprehensive and proactive smoking cessation outreach and treatment program for adult primary care patients who smoke meets typical cost-effectiveness thresholds for healthcare. |
| 882 | Danielle McCarthy | GIM | demccarthy@ctri.wisc.edu | Explaining COVID-19 related mortality disparities in American Indians and Alaska Natives. | American Indian and Alaska Native (AI/AN) individuals are more likely to die with COVID-19 than other groups, but there is limited empirical evidence to explain the cause of this inequity. The objective of this study was to determine whether medical comorbidities, area socioeconomic deprivation, or access to treatment can explain the greater COVID-19 related mortality among AI/AN individuals. The design was a retrospective cohort study of harmonized electronic health record data of all inpatients with COVID-19 from 21 United States health systems from February 2020 through January 2022. The mortality of AI/AN inpatients was compared to all Non-Hispanic White (NHW) inpatients and to a matched subsample of NHW inpatients. AI/AN inpatients were more likely to die during their hospitalization (13.2% versus 7.1%; odds ratio [OR] = 1.98, 95% confidence interval [CI] = 1.48, 2.65) than their matched NHW counterparts. After adjusting for comorbidities, area social deprivation, and access to treatment, the association between ethnicity and mortality was substantially reduced (OR 1.59, 95% CI 1.15, 2.22). The significant residual relation between AI/AN versus NHW status and mortality indicate that there are other important unmeasured factors that contribute to this inequity. This will be an important direction for future research. |
| 883 | Danielle McCarthy | GIM | demccarthy@ctri.wisc.edu | Using information technology to integrate tobacco use treatment in routine oncology care: Lessons learned from the U.S. Cancer Center Cessation Initiative Cancer Centers. | Cancer patients who receive evidence-based tobacco-dependence treatment are more likely to quit and remain abstinent, but tobacco treatment programs (TTPs) are not consistently offered. In 2017, the U.S. National Cancer Institute, through the Cancer Moonshot, funded the Cancer Center Cessation Initiative (C3I). C3I supports 52 cancer centers to implement and expand evidence-based tobacco treatment in routine oncology care. Integration into routine care involves the use of health information technology (IT), including modifying electronic health records and clinical workflows. Here, we examine C3I cancer centers' IT leadership involvement and experiences in tobacco-dependence treatment implementation. This qualitative study of C3I-funded cancer centers integrated data from online surveys and in-person, semistructured interviews with IT leaders. We calculated descriptive statistics of survey data and applied content analysis to interview transcripts. Themes regarding IT personnel included suggestions to involve IT early, communicate regularly, understand the roles and influence of the IT team, and match program design with IT funding and resources. Themes regarding electronic health record (EHR) modifications included beginning modifications early to account for long lead time to make changes, working with IT to identify and adapt existing EHR tools for TTP or designing tools that will support a desired workflow developed with end-users, and working with IT personnel to make sure TTPs comply with system and state policies (e.g., privacy laws). The experiences of C3I cancer centers regarding the use of health IT to enhance tobacco-dependence treatment program implementation can guide cancer centers and community oncology practices to potentially enhance TTP implementation and patient outcomes. Almost a quarter of patients first diagnosed with cancer report current cigarette smoking. There are tobacco treatment programs (TTPs) that effectively help patients quit smoking to improve cancer treatment response, survival, and quality-of-life. In 2017, the U.S. National Cancer Institute (NCI) funded the Cancer Center Cessation Initiative (C3I) and supported 52 cancer centers to implement these TTPs. A key component of these programs is the information technology (IT) necessary to refer patients to the program and document their progress. As coordinators of C3I, our team conducted interviews with IT leaders at these cancer centers to learn about the implementation of the programs. IT leaders suggested that IT teams be involved early in the program implementation process and that leaders communicate with the IT team regularly to address necessary changes to referral and documentation systems. IT teams are important to involve early and regularly throughout the TTP implementation process because they have unique knowledge of how funding, policy, and existing technological tools will impact the implementation and success of the program. Our findings emphasize the importance of involving IT teams early in the planning process for such programs. Studies such as this focusing on the experiences and knowledge of specific team members, such as the IT team, enhance tobacco-dependence treatment program implementation and can guide cancer centers and community oncology practices to implement these programs to improve patient outcomes. |
| 884 | Danielle McCarthy | GIM | demccarthy@ctri.wisc.edu | Factors associated with 60-day readmission among inpatients with COVID-19 at 21 United States health systems. | Identifying patients at risk for readmission after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection could facilitate care planning and prevention. This retrospective cohort study of 60-day readmission included 105 543 COVID-19 patients at 21 US healthcare systems who were discharged alive between February 2020 and November 2021. Generalized linear mixed regression analyses tested predictors of 60-day readmission and severity. The all-cause readmission rate was 15% (95% confidence interval [CI] = 10%-21%), with 22% (95% CI = 18%-26%) of readmitted patients needing intensive care, and 6% (95% CI = 05%-07%) dying. Factors associated with readmission included male sex, government insurance, positive smoking history, co-morbidity burden, longer index admissions, and diagnoses at index admission (e.g., cancer, chronic kidney disease, and liver disease). Death and intensive care rates at readmission declined postvaccine availability. Receiving at least two COVID-19 vaccine doses, which were more common among older patients and those with comorbid conditions, was not independently associated with readmission but predicted a reduced risk of death at readmission. This retrospective cohort study identified factors associated with all-cause readmission for patients re-admitted to the same health system after hospitalization with SARS-CoV-2 infection. Patients who are male, who smoke, who have a higher comorbidity burden, and have government insurance may benefit from additional postacute care planning. |
| 885 | Danielle McCarthy | GIM | demccarthy@ctri.wisc.edu | Observational study of organisational responses of 17 US hospitals over the first year of the COVID-19 pandemic. | The COVID-19 pandemic has required significant modifications of hospital care. The objective of this study was to examine the operational approaches taken by US hospitals over time in response to the COVID-19 pandemic. This was a prospective observational study of 17 geographically diverse US hospitals from February 2020 to February 2021. We identified 42 potential pandemic-related strategies and obtained week-to-week data about their use. We calculated descriptive statistics for use of each strategy and plotted percent uptake and weeks used. We assessed the relationship between strategy use and hospital type, geographic region and phase of the pandemic using generalised estimating equations (GEEs), adjusting for weekly county case counts. We found heterogeneity in strategy uptake over time, some of which was associated with geographic region and phase of pandemic. We identified a body of strategies that were both commonly used and sustained over time, for example, limiting staff in COVID-19 rooms and increasing telehealth capacity, as well as those that were rarely used and/or not sustained, for example, increasing hospital bed capacity. Hospital strategies during the COVID-19 pandemic varied in resource intensity, uptake and duration of use. Such information may be valuable to health systems during the ongoing pandemic and future ones. |
| 886 | Danielle McCarthy | GIM | demccarthy@ctri.wisc.edu | An Examination of Cardiac Vagal Control Indices and Cognitive Stress Appraisal in Cigarette Smokers. | Identifying factors that influence how individuals who smoke cigarettes respond to stress is important as stress is a risk factor for smoking and its maintenance. This study examined the modulatory role of cardiac vagal control (CVC), a physiological correlate of self-regulation, on cognitive stress appraisal processes of adults who smoke. Sixty daily cigarette smokers were randomized to receive positive or negative feedback during a modified Trier Social Stress Test. Pre- and post-task stress appraisals were assessed and resting and reactivity CVC measures were computed. Moderated regression models assessed if the relation between feedback condition and post-task stress appraisal varied as a function of CVC. We hypothesized that participants receiving negative feedback would report greater post-task stress appraisal compared to participants receiving positive feedback, and the strength of the effect of both feedback groups would be greater at higher levels of CVC. All models showed significant main effects of feedback condition (b = - 0.42, p = 0.01; b = - 0.45, p = 0.01) on post-task stress appraisal: participants receiving negative feedback reported greater post-task stress appraisal. No significant main or interactive effects of CVC and feedback condition on post-task stress appraisal were observed. This study demonstrates that stress appraisals of daily cigarette smokers are sensitive to social feedback, but are not moderated by individual differences in CVC. Future investigations are needed to clarify whether this finding is explained by smoking-specific impairments in CVC as well as the distinct and interactive effects of physiological and psychological processes implicated in stress and smoking risk. |
| 887 | Danielle McCarthy | GIM | demccarthy@ctri.wisc.edu | Missing Out: Underutilization of Primary Care by Wisconsin Patients Who Smoke and Its Implications for Tobacco Treatment Access. | Tobacco dependence treatment is usually offered in primary care settings. Yet, if many patients who smoke do no not access primary care, cessation interventions may be missing those who most need them. This study describes Wisconsin adults' health care utilization by smoking status. Data were analyzed from 1726 individuals participating in a population-based, cross-sectional, in-person health survey of Wisconsin residents (2014-2016). Demographic characteristics were compared across smoking status using Wald chi-square tests weighted for the complex survey design. Odds ratios were calculated using multivariate logistic regression models. Of 1726 respondents, 15.3% reported current smoking, 25.4% former smoking, and 59.4% never smoking. Those currently smoking were more likely than former- or never-smoking respondents to report emergency departments as their "usual place to go when sick" (12% vs 3%) or report they had "no place to go when sick" (16% vs 7%). People who currently smoke also reported more emergency department visits during the past year (mean = 1.4 visits) than did others (mean = 0.4, P< 0.01). Among those currently smoking, 18% reported that they "needed health care but didn't get it" over the past year, compared to 6% of others (P< 0.01). Those currently smoking also were more likely to report a "delay in getting care" (16% vs 9%, P = 0.02) and were less likely to have had a "general health checkup" within the past year (58% vs 70%, P< 0.02). These relationships persisted in logistic regression models controlling for variables related to smoking status and health care utilization, including health insurance. These findings suggest that more than a quarter of Wisconsin adults who smoke do not receive primary care every year and that they delay care or seek care in emergency departments more frequently than do those who never smoked or who quit smoking. As a result, such individuals may be missing out on evidence-based tobacco cessation treatment. |
| 888 | Danielle McCarthy | GIM | demccarthy@ctri.wisc.edu | A comprehensive electronic health record-enabled smoking treatment program: Evaluating reach and effectiveness in primary care in a multiple baseline design. | Effective treatments for smoking cessation exist but are underused. Proactive chronic care approaches may enhance the reach of cessation treatment and reduce the prevalence of smoking in healthcare systems. This pragmatic study evaluated a population-based Comprehensive Tobacco Intervention Program (CTIP) implemented in all (6) adult primary care clinics in a Madison, Wisconsin, USA healthcare cooperative, assessing treatment reach, reach equity, and effectiveness in promoting smoking cessation. CTIP launched in 3 waves of 2 clinics each in a multiple baseline design. Electronic health record (EHR) tools facilitated clinician-delivered pharmacotherapy and counseling; guiding tobacco care managers in phone outreach to all patients who smoke; and prompting multimethod bulk outreach to all patients on a smoking registry using an opt-out approach. EHR data were analyzed to assess CTIP reach and effectiveness among 6894 adult patients between January 2018 and February 2020. Cessation treatment reach increased significantly after CTIP launch in 5 of 6 clinics and was significantly higher when clinics were active vs. inactive in CTIP [Odds Ratio (OR) range = 2.0-3.0]. Rates of converting from current to former smoking status were also higher in active vs. inactive clinics (OR range = 2.2-10.5). Telephone treatment reach was particularly high in historically underserved groups, including African-American, Hispanic, and Medicaid-eligible patients. Implementation of a comprehensive, opt-out, chronic-care program aimed at all patients who smoke was associated with increases in the rates of pharmacotherapy and counseling delivery and quitting smoking. Proactive outreach may help reduce disparities in treatment access. |
| 889 | Michael Fiore | GIM | mcf@ctri.wisc.edu | Validity of the E-Cigarette Wisconsin Inventory of Smoking Dependence Motives (e-WISDM) in Exclusive E-Cigarette Users: Evidence from a Laboratory Self-Administration Study. | Prior research suggests that the e-Cigarette Wisconsin Inventory of Smoking Dependence Motives (e-WISDM) distinguishes primary (e-PDM) and secondary dependence (e-SDM), however, there is little research on these e-WISDM dimensions and prior research comprised dual users (using cigarettes and e-cigarettes) and those using older generations of e-cigarettes. Those exclusively using contemporary e-cigarettes (N = 164) completed the e-WISDM and a laboratory self-administration session and rated pre-use expectancies and post-use experiences. Only a 1-factor model limited to the primary scales (Automaticity, Tolerance, Craving, Loss of Control) achieved good model fit. The e-PDM was correlated with the Penn State Electronic Cigarette Dependence Index (PS-ECDI), r = .79, p < .001. The e-PDM and PS-ECDI were similarly correlated with use topography and self-reported measures. Analyses of motive profiles identified Taste, Tolerance, and Automaticity as the most strongly endorsed motives in the full sample. Subgroup analyses indicated primary motives were more elevated in in daily vs. non-daily e-cigarette users and participants with vs. without a history of smoking cigarettes. Taste motives were stronger in users of 3rd vs. 4th generation e-cigarettes. These findings suggest that the four e-PDM subscales are a concise, reliable, and valid measure of core e-cigarette dependence motives that are related to meaningful dependence attributes. Electronic cigarettes (e-cigarettes) are dependence-producing. Instruments that measure e-cigarette dependence are necessary to identify users who may have difficulty quitting e-cigarettes and who are at risk for use-related harms. The four subscales of the e-WISDM PDM index self-reported heavy e-cigarette use, craving, automatic or mindless use, and perceived loss of control over use. The current research supports the validity of the e-WISDM PDM as a measure of core e-cigarette dependence in users of today's e-cigarette devices. |
| 890 | Michael Fiore | GIM | mcf@ctri.wisc.edu | Cigarette smoking status and COVID-19 hospitalization in the context of cannabis use: An electronic health record cohort study in northern California. | Research investigating the association between cigarette smoking and COVID-19 outcomes has yielded mixed results, often overlooking cannabis use. This study examined the association between cigarette smoking and COVID-19 hospitalization with consideration of cannabis use. We used electronic health record data from adult patients with COVID-19 (2/1/2020 to 2/3/2022) at a northern California academic medical center. The outcome was COVID-19 hospitalization. We conducted three multivariable logistic models to examine the relationship between cigarette smoking and hospitalization. Model 1 included cigarette smoking status and other covariates; Model 2 added cannabis use status to Model 1; Model 3 added interaction term of cigarette and cannabis use to Model 2, followed by a post-hoc analysis. Of the 14,440 patients, 8.5 % had COVID-19 hospitalization, 4.9 % and 24.1 % currently and formerly smoked cigarettes, respectively; 7.2 % currently used cannabis, 62.8 % had unknown cannabis use status. Both current and former cigarettes smoking were associated with hospitalization (Models 1-2). In Model 3, the cigarette-cannabis interaction was significant. Former cigarette smoking had higher odds for hospitalization (adjusted odds ratio [AOR] = 1.36; 95 % confidence interval [CI] 1.09-1.70) only among people who did not currently use cannabis. Current cigarette smoking yielded higher odds of hospitalization (AOR = 1.47; 95 % CI 1.02-2.12) among people whose cannabis use was unknown. Cigarette smoking status was not associated with hospitalization among people who currently used cannabis. Cigarette smoking's associations with COVID-19 hospitalization varied by cannabis use. Future research should include both cigarette and cannabis use in understanding risk factors for COVID-19 outcomes. |
| 891 | Michael Fiore | GIM | mcf@ctri.wisc.edu | Correlates of improved outcomes in patients with COVID-19 treated in US emergency departments. | The COVID-19 pandemic was managed in part by the rapid development of vaccines, diagnostics, and therapeutics including antiviral agents and advances in emergency airway and ventilatory management. The impact of these therapeutic advances on clinically pertinent metrics of emergency care have not been well-studied. We abstracted data from emergency department (ED) visits made to 21 US health systems during the first two years of the pandemic, from February 1, 2020 to January 31, 2022. These health systems were participants in the NIH-supported COVID EHR Cohort, in which the University of Wisconsin served as the coordinating site. Limited patient-level data files were submitted monthly. Data elements included demographic and clinical variables, as well as standard measures of ED outcomes including 72-h returns, 72-h returns leading to readmission, and in-hospital mortality. Multivariable models were fitted to identify correlates of each of the dependent variables. A test for trend was used to detect changes in outcomes over time. During the two-year period, 150,357 individuals aged 18 years or older visited the ED. The median age was 45.4 years (IQR 27), 58.1 % were female, 49 % were White, 18.3 % Hispanic/Latino, and 45 % were publicly insured or uninsured. The prevalence of 72-h ED returns, readmissions, and in-hospital mortality significantly declined across the two-year period. SARS-CoV-2 vaccination was associated with reduced ED returns and mortality. Therapeutic agents were associated with increased mortality risk but were likely confounded by unmeasured covariates. Operational and clinical outcomes of ED-based treatment of individuals with COVID-19 improved in the first two years of the pandemic. This improvement is likely multifactorial and includes the development and deployment of SARS-CoV-2-specific vaccines, therapeutic agents, and improved healthcare delivery in the ED and elsewhere addressing management of airway and ventilatory status, as well as increased innate immunity in the general population. |
| 892 | Michael Fiore | GIM | mcf@ctri.wisc.edu | Specialty Tobacco Treatment Implementation in Oncology: A Qualitative Study. | In 2017, the National Cancer Institute (NCI) funded the Cancer Center Cessation Initiative (C3I) to implement and expand tobacco treatment programs in routine oncology care. Many C3I programs developed specialty care programs staffed by tobacco treatment specialists (TTSs) to deliver evidence-based treatment to adult patients who smoke. People involved in specialty tobacco treatment programs can help to identify implementation strategies and adaptations that may enhance tobacco treatment reach and effectiveness in cancer care and help more patients with cancer quit using tobacco. We conducted semistructured interviews with TTSs from 21 C3I-funded cancer centers and applied content analysis to interview transcripts from 37 TTSs and 17 respondents in other program roles. We used the Consolidated Framework for Implementation Research to code interview data. We identified final themes and implementation strategies and adaptations recommended by respondents on the basis of these codes. Respondents shared that implementation of specialty tobacco treatment programs in cancer care settings could be facilitated by training staff to provide patient connection to services, incorporating prescription of no- or low-cost cessation medications, hiring additional staff to deliver tobacco treatment, allocating space to the program, and automating electronic health record workflows. TTSs and others involved in specialty tobacco treatment in NCI-designated cancer centers identified ways to improve tobacco treatment access, use, and effectiveness by (1) adapting specialty tobacco treatment delivery to meet patient needs; (2) facilitating referrals and pharmacotherapy coordination; and (3) committing staffing, space, and support resources to tobacco treatment programs. Key program participants suggested that these approaches would help more oncology patients connect with evidence-based tobacco treatment and quit smoking. |
| 893 | Michael Fiore | GIM | mcf@ctri.wisc.edu | Tobacco Quitline Retreatment Interventions Among Adults With Socioeconomic Disadvantage: A Factorial Randomized Clinical Trial. | A single round of standard tobacco quitline treatment may not be sufficient to sustain abstinence, particularly among people experiencing socioeconomic disadvantage. Adaptive retreatment may help more individuals with socioeconomic disadvantage achieve abstinence and reduce disparities in smoking cessation outcomes. To evaluate 4 evidence-based strategies for adults with limited education, no insurance, or Medicaid eligibility who continued smoking after quitline treatment. A factorial randomized clinical trial with 4 factors adapting quitline strategies was conducted for participants enrolled from June 7, 2018, to January 25, 2023, with 6-month follow-up. Adults using the Wisconsin Tobacco Quit Line who were smoking cigarettes 3 to 6 months after prior quitline treatment who were uninsured, Medicaid insured, or had no more than a high school education were included. Quitline retreatment strategies were (1) increased counseling intensity (4 calls vs 1 call), (2) increased nicotine replacement therapy intensity (4 weeks of combination nicotine patch plus nicotine lozenge vs 2 weeks of nicotine patch), (3) text-message support (National Cancer Institute SmokefreeTXT program vs none), and (4) financial incentives for engagement in counseling and SmokefreeTXT ($30/call and/or 6-week SmokefreeTXT retention vs no incentives). Primary outcome was 7-day point-prevalence biochemically confirmed abstinence 26 weeks after the target quit day. Intention-to-treat analysis was performed. Of 6019 people assessed for eligibility, 1316 (21.9%) participants were randomized (mean [SD] age, 53.1 [11.9] years; 760 [57.8%] women), and 919 (69.8%) provided final follow-up. Intention-to-treat analyses showed 162 participants (12.3%) had biochemically confirmed abstinence at 26 weeks (368 [28.0% self-reported abstinence]). There were no significant main effects for the primary outcome: 1 call (11.6% [77 of 662]) vs 4 calls (13.0% [85 of 654]) (odds ratio [OR], 1.04; 95% CI, 0.88-1.24), 2-week patch (11.2% [73 of 654]) vs 4-week combination nicotine replacement therapy (13.4% [89 of 662]) (OR, 1.12; 95% CI, 0.94-1.34), no SmokefreeTXT (13.4% [88 of 657]) vs SmokefreeTXT (11.2% [74 of 659]) (OR, 0.88; 95% CI, 0.74-1.05), and no financial incentives (12.8% [85 of 662]) vs financial incentives (11.8% [77 of 654]) (OR, 0.94; 95% CI, 0.78-1.11). In this randomized clinical trial evaluating enhancements to tobacco quitlines for adults with socioeconomic disadvantage who were smoking after quitline treatment, none of the adaptive treatment strategies robustly improved long-term abstinence. Strategies are needed to enhance quitline retreatment effectiveness for adults with socioeconomic disadvantage. ClinicalTrials.gov Identifier: NCT03538938. |
| 894 | Michael Fiore | GIM | mcf@ctri.wisc.edu | Helping Black Patients in Wisconsin Quit Smoking: A Call for Clinical Action. | |
| 895 | Michael Fiore | GIM | mcf@ctri.wisc.edu | COVID-19 outcomes among patients with dementia and age-matched controls who were hospitalized in 21 US health-care systems. | COVID-19 had devastating impacts worldwide. However, most research examining the impact of dementia on COVID-19 outcomes has been conducted in Europe and Asia and has not examined dementia subtypes. A retrospective analysis of electronic health record data from 21 US health-care systems examined relationships of all-cause dementia, Alzheimer's disease (AD), and vascular dementia with in-hospital mortality, intensive care unit (ICU) admission, and hospital stay duration. All-cause dementia, but not AD or vascular dementia independently, was associated with increased mortality risk, the inclusion of discharge to hospice as a mortality equivalent increased risk for mortality for all-cause dementia, and AD and vascular dementia. Patients with all-cause dementia and AD were less likely to be admitted to the ICU than patients without. Patients with any form of dementia had longer hospital stays than patients without. Dementia was associated with increased mortality or hospice discharge, decreased ICU admissions, and longer hospital stays. Only all-cause dementia was associated with increased mortality risk. This risk was lower than what has been published in previous research. Combining mortality and hospice discharge increased risk for all dementia subtypes. All-cause and Alzheimer's disease (AD) dementia were associated with decreased intensive care unit admissions. All-cause, vascular, and AD dementia were associated with longer hospital stays. |
| 896 | Michael Fiore | GIM | mcf@ctri.wisc.edu | What to do after smoking relapse? A sequential multiple assignment randomized trial of chronic care smoking treatments. | To compare effects of three post-relapse interventions on smoking abstinence. Sequential three-phase multiple assignment randomized trial (SMART). Eighteen Wisconsin, USA, primary care clinics. A total of 1154 primary care patients (53.6% women, 81.2% White) interested in quitting smoking enrolled from 2015 to 2019; 582 relapsed and were randomized to relapse recovery treatment. In phase 1, patients received cessation counseling and 8 weeks nicotine patch. Those who relapsed and agreed were randomized to a phase 2 relapse recovery group: (1) reduction counseling + nicotine mini-lozenges + encouragement to quit starting 1 month post-randomization (preparation); (2) repeated encouragement to quit starting immediately post-randomization (recycling); or (3) advice to call the tobacco quitline (control). The first two groups could opt into phase 3 new quit treatment [8 weeks nicotine patch + mini-lozenges plus randomization to two treatment factors (skill training and supportive counseling) in a 2 × 2 design]. Phase 2 and 3 interventions lasted ≤ 15 months. The study was powered to compare each active phase 2 treatment with the control on the primary outcome: biochemically confirmed 7-day point-prevalence abstinence 14 months post initiating phase 2 relapse recovery treatment. Exploratory analyses tested for phase 3 counseling factor effects. Neither skill training nor supportive counseling (each on versus off) increased 14-month abstinence rates; skills on versus off 9.3% (14/151) versus 5.2% (8/153), P = 0.19; support on versus off 6.6% (10/152) versus 7.9% (12/152), P = 0.73. Phase 2 preparation did not produce higher 14-month abstinence rates than quitline referral; 3.6% (8/220) versus 2.1% [3/145; risk difference = 1.5%, 95% confidence interval (CI) = -1.8-5.0%, odds ratio (OR) = 1.8, 95% CI = 0.5-6.9]. Recycling, however, produced higher abstinence rates than quitline referral; 6.9% (15/217) versus 2.1% (three of 145; risk difference, 4.8%, 95% CI = 0.7-8.9%, OR = 3.5, 95% CI = 1.0-12.4). Recycling produced greater entry into new quit treatment than preparation: 83.4% (181/217) versus 55.9% (123/220), P < 0.0001. Among people interested in quitting smoking, immediate encouragement post-relapse to enter a new round of smoking cessation treatment ('recycling') produced higher probability of abstinence than tobacco quitline referral. Recycling produced higher rates of cessation treatment re-engagement than did preparation/cutting down using more intensive counseling and pharmacotherapy. |
| 897 | Michael Fiore | GIM | mcf@ctri.wisc.edu | Economic Evaluation of Enhanced vs Standard Varenicline Treatment for Tobacco Cessation. | Smoking is the leading preventable cause of death and illness in the US. Identifying cost-effective smoking cessation treatment may increase the likelihood that health systems deliver such treatment to their patients who smoke. To evaluate the cost-effectiveness of standard vs enhanced varenicline use (extended varenicline treatment or varenicline in combination with nicotine replacement therapy) among individuals trying to quit smoking. This economic evaluation assesses the Quitting Using Intensive Treatments Study (QUITS), which randomized 1251 study participants who smoked into 4 conditions: (1) 12-week varenicline monotherapy (n = 315); (2) 24-week varenicline monotherapy (n = 311); (3) 12-week varenicline combination treatment with nicotine replacement therapy patch (n = 314); or (4) 24-week varenicline combination treatment with nicotine replacement therapy patch (n = 311). Study enrollment occurred in Madison and Milwaukee, Wisconsin, between November 11, 2017, and July 2, 2020. Statistical analysis took place from May to October 2023. The primary outcome was 7-day point prevalence abstinence (biochemically confirmed with exhaled carbon monoxide level ≤5 ppm) at 52 weeks. The incremental cost-effectiveness ratio (ICER), or cost per additional person who quit smoking, was calculated using decision tree analysis based on abstinence and cost for each arm of the trial. Of the 1251 participants, mean (SD) age was 49.1 (11.9) years, 675 (54.0%) were women, and 881 (70.4%) completed the 52-week follow-up. Tobacco cessation at 52 weeks was 25.1% (79 of 315) for 12-week monotherapy, 24.4% (76 of 311) for 24-week monotherapy, 23.6% (74 of 314) for 12-week combination therapy, and 25.1% (78 of 311) for 24-week combination therapy, respectively. The total mean (SD) cost was $1175 ($365) for 12-week monotherapy, $1374 ($412) for 12-week combination therapy, $2022 ($813) for 24-week monotherapy, and $2118 ($1058) for 24-week combination therapy. The ICER for 12-week varenicline monotherapy was $4681 per individual who quit smoking and $4579 per quality-adjusted life-year (QALY) added. The ICER for 24-week varenicline combination therapy relative to 12-week monotherapy was $92 000 000 per additional individual who quit smoking and $90 000 000 (95% CI, $15 703 to dominated or more costly and less efficacious) per additional QALY. This economic evaluation of standard vs enhanced varenicline treatment for smoking cessation suggests that 12-week varenicline monotherapy was the most cost-effective treatment option at the commonly cited threshold of $100 000/QALY. This study provides patients, health care professionals, and other stakeholders with increased understanding of the health and economic impact of more intensive varenicline treatment options. |
| 898 | Michael Fiore | GIM | mcf@ctri.wisc.edu | Cost-Effectiveness of a Comprehensive Primary Care Smoking Treatment Program. | Smoking is the leading preventable cause of death and disease in the U.S. This study evaluates the cost-effectiveness from a healthcare system perspective of a comprehensive primary care intervention to reduce smoking rates. This pragmatic trial implemented electronic health record prompts during primary care visits and employed certified tobacco cessation specialists to offer proactive outreach and smoking cessation treatment to patients who smoke. The data, analyzed in 2022, included 10,683 patients in the smoking registry from 2017 to 2020. Pre-post analyses compared intervention costs to treatment engagement, successful self-reported smoking cessation, and acute health care utilization (urgent care, emergency department visits, and inpatient hospitalization). Cost per quality-adjusted life year was determined by applying conversion factors obtained from the tobacco research literature to the cost per patient who quit smoking. Tobacco cessation outreach, medication, and counseling costs increased from $2.64 to $6.44 per patient per month, for a total post-implementation intervention cost of $500,216. Smoking cessation rates increased from 1.3% pre-implementation to 8.7% post-implementation, for an incremental effectiveness of 7.4%. The incremental cost-effectiveness ratio was $628 (95% CI: $568, $695) per person who quit smoking, and $905 (95% CI: $822, $1,001) per quality-adjusted life year gained. Acute health care costs decreased by an average of $42 (95% CI: -$59, $145) per patient per month for patients in the smoking registry. Implementation of a comprehensive and proactive smoking cessation outreach and treatment program for adult primary care patients who smoke meets typical cost-effectiveness thresholds for healthcare. |
| 899 | Timothy Baker | GIM | tbb@ctri.wisc.edu | Validity of the E-Cigarette Wisconsin Inventory of Smoking Dependence Motives (e-WISDM) in Exclusive E-Cigarette Users: Evidence from a Laboratory Self-Administration Study. | Prior research suggests that the e-Cigarette Wisconsin Inventory of Smoking Dependence Motives (e-WISDM) distinguishes primary (e-PDM) and secondary dependence (e-SDM), however, there is little research on these e-WISDM dimensions and prior research comprised dual users (using cigarettes and e-cigarettes) and those using older generations of e-cigarettes. Those exclusively using contemporary e-cigarettes (N = 164) completed the e-WISDM and a laboratory self-administration session and rated pre-use expectancies and post-use experiences. Only a 1-factor model limited to the primary scales (Automaticity, Tolerance, Craving, Loss of Control) achieved good model fit. The e-PDM was correlated with the Penn State Electronic Cigarette Dependence Index (PS-ECDI), r = .79, p < .001. The e-PDM and PS-ECDI were similarly correlated with use topography and self-reported measures. Analyses of motive profiles identified Taste, Tolerance, and Automaticity as the most strongly endorsed motives in the full sample. Subgroup analyses indicated primary motives were more elevated in in daily vs. non-daily e-cigarette users and participants with vs. without a history of smoking cigarettes. Taste motives were stronger in users of 3rd vs. 4th generation e-cigarettes. These findings suggest that the four e-PDM subscales are a concise, reliable, and valid measure of core e-cigarette dependence motives that are related to meaningful dependence attributes. Electronic cigarettes (e-cigarettes) are dependence-producing. Instruments that measure e-cigarette dependence are necessary to identify users who may have difficulty quitting e-cigarettes and who are at risk for use-related harms. The four subscales of the e-WISDM PDM index self-reported heavy e-cigarette use, craving, automatic or mindless use, and perceived loss of control over use. The current research supports the validity of the e-WISDM PDM as a measure of core e-cigarette dependence in users of today's e-cigarette devices. |
| 900 | Timothy Baker | GIM | tbb@ctri.wisc.edu | Tobacco Quitline Retreatment Interventions Among Adults With Socioeconomic Disadvantage: A Factorial Randomized Clinical Trial. | A single round of standard tobacco quitline treatment may not be sufficient to sustain abstinence, particularly among people experiencing socioeconomic disadvantage. Adaptive retreatment may help more individuals with socioeconomic disadvantage achieve abstinence and reduce disparities in smoking cessation outcomes. To evaluate 4 evidence-based strategies for adults with limited education, no insurance, or Medicaid eligibility who continued smoking after quitline treatment. A factorial randomized clinical trial with 4 factors adapting quitline strategies was conducted for participants enrolled from June 7, 2018, to January 25, 2023, with 6-month follow-up. Adults using the Wisconsin Tobacco Quit Line who were smoking cigarettes 3 to 6 months after prior quitline treatment who were uninsured, Medicaid insured, or had no more than a high school education were included. Quitline retreatment strategies were (1) increased counseling intensity (4 calls vs 1 call), (2) increased nicotine replacement therapy intensity (4 weeks of combination nicotine patch plus nicotine lozenge vs 2 weeks of nicotine patch), (3) text-message support (National Cancer Institute SmokefreeTXT program vs none), and (4) financial incentives for engagement in counseling and SmokefreeTXT ($30/call and/or 6-week SmokefreeTXT retention vs no incentives). Primary outcome was 7-day point-prevalence biochemically confirmed abstinence 26 weeks after the target quit day. Intention-to-treat analysis was performed. Of 6019 people assessed for eligibility, 1316 (21.9%) participants were randomized (mean [SD] age, 53.1 [11.9] years; 760 [57.8%] women), and 919 (69.8%) provided final follow-up. Intention-to-treat analyses showed 162 participants (12.3%) had biochemically confirmed abstinence at 26 weeks (368 [28.0% self-reported abstinence]). There were no significant main effects for the primary outcome: 1 call (11.6% [77 of 662]) vs 4 calls (13.0% [85 of 654]) (odds ratio [OR], 1.04; 95% CI, 0.88-1.24), 2-week patch (11.2% [73 of 654]) vs 4-week combination nicotine replacement therapy (13.4% [89 of 662]) (OR, 1.12; 95% CI, 0.94-1.34), no SmokefreeTXT (13.4% [88 of 657]) vs SmokefreeTXT (11.2% [74 of 659]) (OR, 0.88; 95% CI, 0.74-1.05), and no financial incentives (12.8% [85 of 662]) vs financial incentives (11.8% [77 of 654]) (OR, 0.94; 95% CI, 0.78-1.11). In this randomized clinical trial evaluating enhancements to tobacco quitlines for adults with socioeconomic disadvantage who were smoking after quitline treatment, none of the adaptive treatment strategies robustly improved long-term abstinence. Strategies are needed to enhance quitline retreatment effectiveness for adults with socioeconomic disadvantage. ClinicalTrials.gov Identifier: NCT03538938. |
| 901 | Timothy Baker | GIM | tbb@ctri.wisc.edu | Understanding the motivational mechanisms for smoking and vaping among dual users and exclusive smokers. | Understanding the motivational processes that influence e-cigarette use in a laboratory setting may help elucidate mechanisms that support long-term ecigarette use, which could have significant clinical and public health consequences. Secondary analyses were conducted on data from exclusive smokers (N=47) and dual users (N=88) who underwent a laboratory ad lib use session. Participants were given 10minutes to smoke (exclusive smokers) or vape (dual users) as much as they wanted. Withdrawal was assessed pre- and post-use. Smoking and vaping behavior was coded from session videos. Person-level predictors included cigarette/ecigarette craving-relief expectancies, demographics, and cigarette/e-cigarette use and dependence. Smoking and vaping status was assessed at Year 1 using self-reported 30-day point prevalence. Data were analyzed using general linear models and logistic regressions. Both groups reported reductions in withdrawal after product use, including cigarette craving. Baseline e-cigarette craving-relief expectancies, pre-session ecigarette craving, heaviness of e-cigarette use, and relative e-cigarette dependence were significant univariate predictors of continued vaping in dual users at Year 1 (ORs>1.04, ps.16). E-cigarette use alleviated withdrawal, including cigarette and e-cigarette craving, in dual users. Laboratory use behavior did not differ between dual users using e-cigarettes and exclusive smokers using cigarettes. Greater e-cigarette craving-relief expectancies, e-cigarette craving, heaviness of e-cigarette use, and morning product use pattern ('relative dependence') may reflect mechanisms that sustain e-cigarette use. |
| 902 | Timothy Baker | GIM | tbb@ctri.wisc.edu | Helping Black Patients in Wisconsin Quit Smoking: A Call for Clinical Action. | |
| 903 | Timothy Baker | GIM | tbb@ctri.wisc.edu | COVID-19 outcomes among patients with dementia and age-matched controls who were hospitalized in 21 US health-care systems. | COVID-19 had devastating impacts worldwide. However, most research examining the impact of dementia on COVID-19 outcomes has been conducted in Europe and Asia and has not examined dementia subtypes. A retrospective analysis of electronic health record data from 21 US health-care systems examined relationships of all-cause dementia, Alzheimer's disease (AD), and vascular dementia with in-hospital mortality, intensive care unit (ICU) admission, and hospital stay duration. All-cause dementia, but not AD or vascular dementia independently, was associated with increased mortality risk, the inclusion of discharge to hospice as a mortality equivalent increased risk for mortality for all-cause dementia, and AD and vascular dementia. Patients with all-cause dementia and AD were less likely to be admitted to the ICU than patients without. Patients with any form of dementia had longer hospital stays than patients without. Dementia was associated with increased mortality or hospice discharge, decreased ICU admissions, and longer hospital stays. Only all-cause dementia was associated with increased mortality risk. This risk was lower than what has been published in previous research. Combining mortality and hospice discharge increased risk for all dementia subtypes. All-cause and Alzheimer's disease (AD) dementia were associated with decreased intensive care unit admissions. All-cause, vascular, and AD dementia were associated with longer hospital stays. |
| 904 | Timothy Baker | GIM | tbb@ctri.wisc.edu | Prevalence and Trends in Cigarette Smoking With and Without Tobacco Use Disorder Among Adults in the United States: 2010-2021. | Objective: Few national estimates are available on the prevalence of tobacco use disorder (TUD) in the United States (US), and most trials exclusively assess daily smoking rather than TUD. We examined the prevalence and trends in cigarette smoking with vs without TUD among adults. Methods: Data came from the 2010-2021 National Survey on Drug Use and Health (n = 483,982), a cross sectional, US representative dataset. A TUD composite variable was created based on established definitions (eg, DSM-5 symptoms). Weighted prevalence of past 30-day cigarette smoking, daily smoking (30/30 days) and nondaily smoking (<30/30 days) with and without TUD, was calculated annually. Results: In 2021, the prevalence of past 30- day overall cigarette smoking was 17%; 11% reported daily cigarette smoking, whereas 6% reported nondaily cigarette smoking. Only 1% of the population reported daily smoking without TUD, whereas 10% reported daily smoking with TUD. Two percent of the population reported nondaily smoking without TUD, and 4% of the population reported nondaily smoking with TUD. Daily smoking with TUD and nondaily smoking with and without TUD decreased significantly from 2010 to 2021 (all P's < .001). US adults reporting TUD symptoms (vs not) were more likely to be older, identify as White, have lower income and less education, and have a substance use disorder. Conclusions: The prevalence of daily cigarette smoking with TUD was 10× higher than the prevalence of daily cigarette smoking without TUD. Twice as many US adults with nondaily smoking reported TUD than no TUD, illustrating that daily smoking is not necessary for TUD. |
| 905 | Timothy Baker | GIM | tbb@ctri.wisc.edu | Cannabis, Tobacco Use, and COVID-19 Outcomes. | It is unclear whether cannabis use is associated with adverse health outcomes in patients with COVID-19 when accounting for known risk factors, including tobacco use. To examine whether cannabis and tobacco use are associated with adverse health outcomes from COVID-19 in the context of other known risk factors. This retrospective cohort study used electronic health record data from February 1, 2020, to January 31, 2022. This study included patients who were identified as having COVID-19 during at least 1 medical visit at a large academic medical center in the Midwest US. Current cannabis use and tobacco smoking, as documented in the medical encounter. Health outcomes of hospitalization, intensive care unit (ICU) admission, and all-cause mortality following COVID-19 infection. The association between substance use (cannabis and tobacco) and these COVID-19 outcomes was assessed using multivariable modeling. A total of 72 501 patients with COVID-19 were included (mean [SD] age, 48.9 [19.3] years; 43 315 [59.7%] female; 9710 [13.4%] had current smoking; 17 654 [24.4%] had former smoking; and 7060 [9.7%] had current use of cannabis). Current tobacco smoking was significantly associated with increased risk of hospitalization (odds ratio [OR], 1.72; 95% CI, 1.62-1.82; P < .001), ICU admission (OR, 1.22; 95% CI, 1.10-1.34; P < .001), and all-cause mortality (OR, 1.37, 95% CI, 1.20-1.57; P < .001) after adjusting for other factors. Cannabis use was significantly associated with increased risk of hospitalization (OR, 1.80; 95% CI, 1.68-1.93; P < .001) and ICU admission (OR, 1.27; 95% CI, 1.14-1.41; P < .001) but not with all-cause mortality (OR, 0.97; 95% CI, 0.82-1.14, P = .69) after adjusting for tobacco smoking, vaccination, comorbidity, diagnosis date, and demographic factors. The findings of this cohort study suggest that cannabis use may be an independent risk factor for COVID-19-related complications, even after considering cigarette smoking, vaccination status, comorbidities, and other risk factors. |
| 906 | Timothy Baker | GIM | tbb@ctri.wisc.edu | What to do after smoking relapse? A sequential multiple assignment randomized trial of chronic care smoking treatments. | To compare effects of three post-relapse interventions on smoking abstinence. Sequential three-phase multiple assignment randomized trial (SMART). Eighteen Wisconsin, USA, primary care clinics. A total of 1154 primary care patients (53.6% women, 81.2% White) interested in quitting smoking enrolled from 2015 to 2019; 582 relapsed and were randomized to relapse recovery treatment. In phase 1, patients received cessation counseling and 8 weeks nicotine patch. Those who relapsed and agreed were randomized to a phase 2 relapse recovery group: (1) reduction counseling + nicotine mini-lozenges + encouragement to quit starting 1 month post-randomization (preparation); (2) repeated encouragement to quit starting immediately post-randomization (recycling); or (3) advice to call the tobacco quitline (control). The first two groups could opt into phase 3 new quit treatment [8 weeks nicotine patch + mini-lozenges plus randomization to two treatment factors (skill training and supportive counseling) in a 2 × 2 design]. Phase 2 and 3 interventions lasted ≤ 15 months. The study was powered to compare each active phase 2 treatment with the control on the primary outcome: biochemically confirmed 7-day point-prevalence abstinence 14 months post initiating phase 2 relapse recovery treatment. Exploratory analyses tested for phase 3 counseling factor effects. Neither skill training nor supportive counseling (each on versus off) increased 14-month abstinence rates; skills on versus off 9.3% (14/151) versus 5.2% (8/153), P = 0.19; support on versus off 6.6% (10/152) versus 7.9% (12/152), P = 0.73. Phase 2 preparation did not produce higher 14-month abstinence rates than quitline referral; 3.6% (8/220) versus 2.1% [3/145; risk difference = 1.5%, 95% confidence interval (CI) = -1.8-5.0%, odds ratio (OR) = 1.8, 95% CI = 0.5-6.9]. Recycling, however, produced higher abstinence rates than quitline referral; 6.9% (15/217) versus 2.1% (three of 145; risk difference, 4.8%, 95% CI = 0.7-8.9%, OR = 3.5, 95% CI = 1.0-12.4). Recycling produced greater entry into new quit treatment than preparation: 83.4% (181/217) versus 55.9% (123/220), P < 0.0001. Among people interested in quitting smoking, immediate encouragement post-relapse to enter a new round of smoking cessation treatment ('recycling') produced higher probability of abstinence than tobacco quitline referral. Recycling produced higher rates of cessation treatment re-engagement than did preparation/cutting down using more intensive counseling and pharmacotherapy. |
| 907 | Timothy Baker | GIM | tbb@ctri.wisc.edu | Economic Evaluation of Enhanced vs Standard Varenicline Treatment for Tobacco Cessation. | Smoking is the leading preventable cause of death and illness in the US. Identifying cost-effective smoking cessation treatment may increase the likelihood that health systems deliver such treatment to their patients who smoke. To evaluate the cost-effectiveness of standard vs enhanced varenicline use (extended varenicline treatment or varenicline in combination with nicotine replacement therapy) among individuals trying to quit smoking. This economic evaluation assesses the Quitting Using Intensive Treatments Study (QUITS), which randomized 1251 study participants who smoked into 4 conditions: (1) 12-week varenicline monotherapy (n = 315); (2) 24-week varenicline monotherapy (n = 311); (3) 12-week varenicline combination treatment with nicotine replacement therapy patch (n = 314); or (4) 24-week varenicline combination treatment with nicotine replacement therapy patch (n = 311). Study enrollment occurred in Madison and Milwaukee, Wisconsin, between November 11, 2017, and July 2, 2020. Statistical analysis took place from May to October 2023. The primary outcome was 7-day point prevalence abstinence (biochemically confirmed with exhaled carbon monoxide level ≤5 ppm) at 52 weeks. The incremental cost-effectiveness ratio (ICER), or cost per additional person who quit smoking, was calculated using decision tree analysis based on abstinence and cost for each arm of the trial. Of the 1251 participants, mean (SD) age was 49.1 (11.9) years, 675 (54.0%) were women, and 881 (70.4%) completed the 52-week follow-up. Tobacco cessation at 52 weeks was 25.1% (79 of 315) for 12-week monotherapy, 24.4% (76 of 311) for 24-week monotherapy, 23.6% (74 of 314) for 12-week combination therapy, and 25.1% (78 of 311) for 24-week combination therapy, respectively. The total mean (SD) cost was $1175 ($365) for 12-week monotherapy, $1374 ($412) for 12-week combination therapy, $2022 ($813) for 24-week monotherapy, and $2118 ($1058) for 24-week combination therapy. The ICER for 12-week varenicline monotherapy was $4681 per individual who quit smoking and $4579 per quality-adjusted life-year (QALY) added. The ICER for 24-week varenicline combination therapy relative to 12-week monotherapy was $92 000 000 per additional individual who quit smoking and $90 000 000 (95% CI, $15 703 to dominated or more costly and less efficacious) per additional QALY. This economic evaluation of standard vs enhanced varenicline treatment for smoking cessation suggests that 12-week varenicline monotherapy was the most cost-effective treatment option at the commonly cited threshold of $100 000/QALY. This study provides patients, health care professionals, and other stakeholders with increased understanding of the health and economic impact of more intensive varenicline treatment options. |
| 908 | Timothy Baker | GIM | tbb@ctri.wisc.edu | Cost-Effectiveness of a Comprehensive Primary Care Smoking Treatment Program. | Smoking is the leading preventable cause of death and disease in the U.S. This study evaluates the cost-effectiveness from a healthcare system perspective of a comprehensive primary care intervention to reduce smoking rates. This pragmatic trial implemented electronic health record prompts during primary care visits and employed certified tobacco cessation specialists to offer proactive outreach and smoking cessation treatment to patients who smoke. The data, analyzed in 2022, included 10,683 patients in the smoking registry from 2017 to 2020. Pre-post analyses compared intervention costs to treatment engagement, successful self-reported smoking cessation, and acute health care utilization (urgent care, emergency department visits, and inpatient hospitalization). Cost per quality-adjusted life year was determined by applying conversion factors obtained from the tobacco research literature to the cost per patient who quit smoking. Tobacco cessation outreach, medication, and counseling costs increased from $2.64 to $6.44 per patient per month, for a total post-implementation intervention cost of $500,216. Smoking cessation rates increased from 1.3% pre-implementation to 8.7% post-implementation, for an incremental effectiveness of 7.4%. The incremental cost-effectiveness ratio was $628 (95% CI: $568, $695) per person who quit smoking, and $905 (95% CI: $822, $1,001) per quality-adjusted life year gained. Acute health care costs decreased by an average of $42 (95% CI: -$59, $145) per patient per month for patients in the smoking registry. Implementation of a comprehensive and proactive smoking cessation outreach and treatment program for adult primary care patients who smoke meets typical cost-effectiveness thresholds for healthcare. |
| 909 | Marin Schweizer | ID | mschweizer@medicine.wisc.edu | Low-quality evidence on practices to prevent transmission of resistant organisms calls for rigorous trials and a paradigm shift. | |
| 910 | Marin Schweizer | ID | mschweizer@medicine.wisc.edu | Healthcare worker attitudes on routine non-urological preoperative urine cultures: a qualitative assessment. | Many preoperative urine cultures are of low value and may even lead to patient harms. This study sought to understand practices around ordering preoperative urine cultures and prescribing antibiotic treatment. Open-ended, semi-structured qualitative interviews. 5 Veterans Affairs hospitals. Interviews with 14 surgeons (9 surgeons, 5 surgical leaders), 7 infectious disease physicians, 8 surgical advanced practice providers (APPs), 1 surgical nurse manager, 3 infectious disease pharmacists, 1 hospitalist, and 1 lab manager. We interviewed participants using a qualitative semi-structured interview guide. Collected data was coded inductively and with the Dual Process Model (DPM) using MAXQDA software. Data in the "Testing Decision-Making" code was further reviewed using the concept of perceived risk as a sensitizing concept. We identified themes relating to surgeons' concerns about de-implementing preoperative urine cultures to detect asymptomatic bacteriuria (ASB) in patients undergoing non-urological procedures: (1) anxiety and uncertainty surrounding missing infection signs spanned surgical specialties, (2) there were perceived risks of negative consequences associated with omitting urine cultures and treatment prior to specific procedure sites and types, and additionally, (3) participants suggested potential routes for adjusting these perceived risks to facilitate de-implementation acceptance. Notably, participants suggested that leadership support and peer engagement could help improve surgeon buy-in. Concerns about perceived risks sometimes outweigh the evidence against routine preoperative urine cultures to detect ASB. Evidence from trusted peers may improve openness to de-implementing preoperative urine cultures. |
| 911 | Marin Schweizer | ID | mschweizer@medicine.wisc.edu | Obesity in Refugees post-resettlement in a high-income country: a meta-analysis. | Refugees have a high prevalence of obesity post resettlement, but few studies have compared their risk of obesity to those of the host population. We systematically investigated the association between refugee status and obesity after resettlement in a high-income nation. We searched PubMed, Embase, OpenGrey and bibliographies of retrieved articles, with no date, location, and language restrictions, for observational studies assessing obesity rates in resettled refugees compared to the host population. Nine studies were analyzed. We found no evidence of increased risk of obesity among refugees compared to the host population, with significant heterogeneity across studies. However, the risk of obesity among refugee men were significantly lower than the host population. The heterogeneity between studies calls for more high-quality research to examine the risk of obesity among refugees compared to the host population in high-income countries. This will enable results to be pooled to provide more decisive evidence about obesity trends among refugees post migration in a high-income nation. |
| 912 | Marin Schweizer | ID | mschweizer@medicine.wisc.edu | Implementing nasal povidone-iodine decolonization to reduce infections in hemodialysis units: a qualitative assessment. | A substantial proportion of patients undergoing hemodialysis carry Staphylococcus aureus in their noses, and carriers are at increased risk of S. aureus bloodstream infections. Our pragmatic clinical trial implemented nasal povidone-iodine (PVI) decolonization for the prevention of bloodstream infections in the novel setting of hemodialysis units. We aimed to identify pragmatic strategies for implementing PVI decolonization among patients in outpatient hemodialysis units. Qualitative descriptive study. Outpatient hemodialysis units affiliated with five US academic medical centers. Units varied in size, patient demographics, and geographic location. Sixty-six interviewees including nurses, hemodialysis technicians, research coordinators, and other personnel. We conducted interviews with personnel affiliated with all five academic medical centers and conducted thematic analysis of transcripts. Hemodialysis units had varied success with patient recruitment, but interviewees reported that patients and healthcare personnel (HCP) found PVI decolonization acceptable and feasible. Leadership support, HCP engagement, and tailored patient-focused tools or strategies facilitated patient engagement and PVI implementation. Interviewees reported both patients and HCP sometimes underestimated patients' infection risks and experienced infection-prevention fatigue. Other HCP barriers included limited staffing and poor staff engagement. Patient barriers included high health burdens, language barriers, memory issues, and lack of social support. Our qualitative study suggests that PVI decolonization would be acceptable to patients and clinical personnel, and implementation is feasible for outpatient hemodialysis units. Hemodialysis units could facilitate implementation by engaging unit leaders, patients and personnel, and developing education for patients about their infection risk. |
| 913 | Marin Schweizer | ID | mschweizer@medicine.wisc.edu | Research agenda for transmission prevention within the Veterans Health Administration, 2024-2028. | |
| 914 | Marin Schweizer | ID | mschweizer@medicine.wisc.edu | Population and hospital-level COVID-19 measures are associated with increased risk of hospital-onset COVID-19. | A review of hospital-onset COVID-19 cases revealed 8 definite, 106 probable, and 46 possible cases. Correlations between hospital-onset cases and both HCW and inpatient cases were noted in 2021. Rises in community measures were associated with rises in hospital-onset cases. Measures of community COVID-19 activity might predict hospital-onset cases. |
| 915 | Marin Schweizer | ID | mschweizer@medicine.wisc.edu | Propensity Score-Weighted Analysis of Postoperative Infection in Patients With and Without Preoperative Urine Culture. | Although recent guidelines recommend against performance of preoperative urine culture before nongenitourinary surgery, many clinicians still order preoperative urine cultures and prescribe antibiotics for treatment of asymptomatic bacteriuria in an effort to reduce infection risk. To assess the association between preoperative urine culture testing and postoperative urinary tract infection (UTI) or surgical site infection (SSI), independent of baseline patient characteristics or type of surgery. This cohort study analyzed surgical procedures performed from January 1, 2017, to December 31, 2019, at any of 112 US Department of Veterans Affairs (VA) medical centers. The cohort comprised VA enrollees who underwent major elective noncardiac, nonurological operations. Machine learning and inverse probability of treatment weighting (IPTW) were used to balance the characteristics between those who did and did not undergo a urine culture. Data analyses were performed between January 2023 and January 2024. Performance of urine culture within 30 days prior to surgery. The 2 main outcomes were UTI and SSI occurring within 30 days after surgery. Weighted logistic regression was used to estimate odds ratios (ORs) for postoperative infection based on treatment status. A total of 250 389 VA enrollees who underwent 288 858 surgical procedures were included, with 88.9% (256 753) of surgical procedures received by males and 48.9% (141 340) received by patients 65 years or older. Baseline characteristics were well balanced among treatment groups after applying IPTW weights. Preoperative urine culture was performed for 10.5% of surgical procedures (30 384 of 288 858). The IPTW analysis found that preoperative urine culture was not associated with SSI (adjusted OR [AOR], 0.99; 95% CI, 0.90-1.10) or postoperative UTI (AOR, 1.18; 95% CI, 0.98-1.40). In analyses limited to orthopedic surgery and neurosurgery as a proxy for prosthetic implants, the adjusted risks for UTI and SSI were also not associated with preoperative urine culture performance. This cohort study found no association between performance of a preoperative urine culture and lower risk of postoperative UTI or SSI. The results support the deimplementation of urine cultures and associated antibiotic treatment prior to surgery, even when using prosthetic implants. |
| 916 | Marin Schweizer | ID | mschweizer@medicine.wisc.edu | Comparative effectiveness of daptomycin versus vancomycin among patients with methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections: A systematic literature review and meta-analysis. | In the treatment of methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSIs), vancomycin stands as the prevalent therapeutic agent. Daptomycin remains an alternative antibiotic to treat MRSA BSIs in cases where vancomycin proves ineffective. However, studies have conflicted on whether daptomycin is more effective than vancomycin among patients with MRSA BSI. To compare the effectiveness of daptomycin and vancomycin for the prevention of mortality among adult patients with MRSA BSI. Systematic searches of databases were performed, including Embase, PubMed, Web of Science, and Cochrane Library. The Newcastle Ottawa Scale (NOS) and Revised Cochrane risk-of-bias tool for randomized trials (RoB 2) were used to assess the quality of individual observational and randomized control studies, respectively. Pooled odd ratios were calculated using random effects models. Twenty studies were included based on a priori set inclusion and exclusion criteria. Daptomycin treatment was associated with non-significant lower mortality odds, compared to vancomycin treatment (OR = 0.81; 95% CI, 0.62, 1.06). Sub-analyses based on the time patients were switched from another anti-MRSA treatment to daptomycin demonstrated that switching to daptomycin within 3 or 5 days was significantly associated with 55% and 45% decreased odds of all-cause mortality, respectively. However, switching to daptomycin any time after five days of treatment was not significantly associated with lower odds of mortality. Stratified analysis based on vancomycin minimum inhibitory concentration (MIC) revealed that daptomycin treatment among patients infected with MRSA strains with MIC≥1 mg/L was significantly associated with 40% lower odds of mortality compared to vancomycin treatment. Compared with vancomycin, an early switch from vancomycin to daptomycin was significantly associated with lower odds of mortality. In contrast, switching to daptomycin at any time only showed a trend towards reduced mortality, with a non-significant association. Therefore, the efficacy of early daptomycin use over vancomycin against mortality among MRSA BSIs patients may add evidence to the existing literature in support of switching to daptomycin early over remaining on vancomycin. More randomized and prospective studies are needed to assess this association. |
| 917 | Marin Schweizer | ID | mschweizer@medicine.wisc.edu | Intravenous Diltiazem Versus Metoprolol in Acute Rate Control of Atrial Fibrillation/Flutter and Rapid Ventricular Response: A Meta-Analysis of Randomized and Observational Studies. | Atrial fibrillation (AF) and/or atrial flutter (AFL) with rapid ventricular response (RVR) is a condition that often requires urgent treatment. Although guidelines have recommendations regarding chronic rate control therapy, recommendations on the best choice for acute heart rate (HR) control in RVR are unclear. A systematic search across multiple databases was performed for studies evaluating the outcome of HR control (defined as HR less than 110 bpm and/or 20% decrease from baseline HR). Included studies evaluated AF and/or AFL with RVR in a hospital setting, with direct comparison between intravenous (IV) diltiazem and metoprolol and excluded cardiac surgery and catheter ablation patients. Hypotension (defined as systolic blood pressure less than 90 mmHg) was measured as a secondary outcome. Two authors performed full-text article review and extracted data, with a third author mediating disagreements. Random effects models utilizing inverse variance weighting were used to calculate odds ratios (OR) and 95% confidence intervals (CI). Heterogeneity was assessed using the I2 test. A total of 563 unique titles were identified through the systematic search, of which 16 studies (7 randomized and 9 observational) were included. In our primary analysis of HR control by study type, IV diltiazem was found to be more effective than IV metoprolol for HR control in randomized trials (OR 4.75, 95% CI 2.50-9.04 with I2 = 14%); however, this was not found for observational studies (OR 1.26, 95% CI 0.89-1.80 with I2 = 55%). In an analysis of observational studies, there were no significant differences between the two drugs in odds of hypotension (OR 1.12, 95% CI 0.51-2.45 with I2 = 18%). While there was a trend toward improved HR control with IV diltiazem compared with IV metoprolol in randomized trials, this was not seen in observational studies, and there was no observed difference in hypotension between the two drugs. |
| 918 | Marin Schweizer | ID | mschweizer@medicine.wisc.edu | Examining barriers to implementing a surgical-site infection bundle. | Surgical-site infections (SSIs) can be catastrophic. Bundles of evidence-based practices can reduce SSIs but can be difficult to implement and sustain. We sought to understand the implementation of SSI prevention bundles in 6 US hospitals. Qualitative study. We conducted in-depth semistructured interviews with personnel involved in bundle implementation and conducted a thematic analysis of the transcripts. The study was conducted in 6 US hospitals: 2 academic tertiary-care hospitals, 3 academic-affiliated community hospitals, 1 unaffiliated community hospital. In total, 30 hospital personnel participated. Participants included surgeons, laboratory directors, clinical personnel, and infection preventionists. Bundle complexity impeded implementation. Other barriers varied across services, even within the same hospital. Multiple strategies were needed, and successful strategies in one service did not always apply in other areas. However, early and sustained interprofessional collaboration facilitated implementation. The evidence-based SSI bundle is complicated and can be difficult to implement. One implementation process probably will not work for all settings. Multiple strategies were needed to overcome contextual and implementation barriers that varied by setting and implementation climate. Appropriate adaptations for specific settings and populations may improve bundle adoption, fidelity, acceptability, and sustainability. |
| 919 | Toby Campbell | HEM/ONC | tcc@medicine.wisc.edu | Utilizing Simulated Telemedicine Encounters to Conduct Nationwide Studies of Physician Communication Practices. | Introduction: High-quality communication and shared decision making (SDM) are crucial elements of effective patient care. SDM conversations are intimate and logistically challenging to capture. Evaluating alternative methods to effectively observe how physicians conduct these conversations may improve research efforts in this core discipline of medicine. Methods: In two distinct qualitative studies (A and B), subspecialist physicians participated in a telemedicine encounter with a simulated patient facing a high-stakes treatment decision. Results: Thirty-seven transplant hematologists (A) and 21 medical oncologists (B) from across the United States successfully completed a telemedicine encounter with a trained actor, allowing for qualitative analysis of their SDM conversations. Discussion: Simulated telemedicine encounters are a feasible method for studying how a broad sample of subspecialty physicians conduct difficult conversations, such as emotionally fraught SDM conversations. This model could improve understanding of the current practice of SDM, identify opportunities for improvement, and serve as a framework for ongoing research of physician communication practices. |
| 920 | Toby Campbell | HEM/ONC | tcc@medicine.wisc.edu | Associations between physicians' personal preferences for end-of-life decisions and their own clinical practice: PROPEL survey study in Europe, North America, and Australia. | Physicians have significant influence on end-of-life decisions. Therefore, it is important to understand the connection between physicians' personal end-of-life care preferences and clinical practice, and whether there is congruence between what they prefer for themselves and for patients. Study to what extent physicians believe their personal end-of-life preferences impact their clinical practice and to what extent physicians' personal treatment option preferences differ from what they prefer for their patients. A cross-sectional survey was conducted from May 2022 to February 2023. Eight jurisdictions: Belgium, Italy, Canada, USA (Oregon, Wisconsin, and Georgia), and Australia (Victoria and Queensland). Three physician types were included: general practitioners, palliative care physicians, and other medical specialists. We analyzed 1157 survey responses. Sixty-two percent of physicians acknowledge considering their own preferences when caring for patients at the end of life and 29.7% believe their personal preferences impact the recommendations they make. Palliative care physicians are less likely to consider their own preferences when caring for and making recommendations to patients. Congruence was found between what physicians prefer for patients and themselves with cardiopulmonary resuscitation considered "not a good option for both" by 99.1% of physicians. Incongruence was found with physicians considering some options "not good for the patient, but good for themselves"-palliative sedation (8.3%), physician-assisted suicide (7.0%), and euthanasia (11.6%). Physicians consider their own preferences when providing care and their preferences impact the recommendations they make to patients. Incongruence exists between what physicians prefer for themselves and what they prefer for patients. |
| 921 | Toby Campbell | HEM/ONC | tcc@medicine.wisc.edu | DARES: A Phase II Trial of Durvalumab and Ablative Radiation in Extensive-Stage Small Cell Lung Cancer. | Immunotherapy in combination with chemotherapy is first-line treatment for patients with extensive-stage small-cell lung cancer (ES-SCLC). Growing evidence suggests that radiation, specifically stereotactic body radiation therapy (SBRT), may enhance the immunogenic response as well as cytoreduce tumor burden. The primary objective of the study is to determine the progression free survival for patients with newly diagnosed ES-SCLC treated with combination multisite SBRT and chemo-immunotherapy (carboplatin, etoposide, and durvalumab). This is a multicenter, single arm, phase 2 study. Patients with treatment-naïve, ES-SCLC will be eligible for this study. Patients will receive durvalumab 1500mg IV q3w, carboplatin AUC 5 to 6 mg/mL q3w, and etoposide 80 to 100 mg/m2 on days 1 to 3 q3w for four cycles, followed by durvalumab 1500mg IV q4w until disease progression or unacceptable toxicity. Ablative radiation will be delivered 1 to 4 extracranial sites in 3 or 5 fractions, determined by location, during cycle 2. The primary endpoint is progression-free survival, measured from day 1 of chemoimmunotherapy. Secondary endpoints include grade ≥3 toxicity by CTCAE v5.0 within three months of RT, overall survival, response rate, time to second line systemic therapy, and time to new distant progression. Now that immunotherapy is an established part of ES-SCLC management, it is important to further optimize its use and effect. This study will investigate the progression-free survival of combined SBRT and chemo-immunotherapy in patients with ES-SCLC. In addition, the data from this study may further inform the immunogenic role of SBRT with chemo-immunotherapy, as well as identify clinical, biological, or radiomic prognostic features. |
| 922 | Toby Campbell | HEM/ONC | tcc@medicine.wisc.edu | Embedding an Education Intervention about Shared Decision Making into an RCT: Ensuring competency and fidelity. | To describe the outcomes of training nephrology clinicians and clinical research participants, to use the Best Case/Worst Case Communication intervention, for discussions about dialysis initiation for patients with life-limiting illness, during a randomized clinical trial to ensure competency, fidelity to the intervention, and adherence to study protocols and the intervention throughout the trial. We enrolled 68 nephrologists at ten study sites and randomized them to receive training or wait-list control. We collected copies of completed graphic aids (component of the intervention), used with study-enrolled patients, to measure fidelity and adherence. We trained 34 of 36 nephrologists to competence and 27 completed the entire program. We received 60 graphic aids for study-enrolled patients for a 73% return rate in the intervention arm. The intervention fidelity score for the graphic aid reflected completion of all elements throughout the study. We successfully taught the Best Case/Worst Case Communication intervention to clinicians as research participants within a randomized clinical trial. Decisions about dialysis are an opportunity to discuss prognosis and uncertainty in relation to consideration of prolonged life supporting therapy. Our study reveals a strategy to evaluate adherence to a communication intervention in real time during a clinical study. |
| 923 | Toby Campbell | HEM/ONC | tcc@medicine.wisc.edu | Telehealth vs In-Person Early Palliative Care for Patients With Advanced Lung Cancer: A Multisite Randomized Clinical Trial. | Numerous studies show that early palliative care improves quality of life and other key outcomes in patients with advanced cancer and their caregivers, although most lack access to this evidence-based model of care. To evaluate whether delivering early palliative care via secure video vs in-person visits has an equivalent effect on quality of life in patients with advanced non-small cell lung cancer (NSCLC). Randomized, multisite, comparative effectiveness trial from June 14, 2018, to May 4, 2023, at 22 US cancer centers among 1250 patients within 12 weeks of diagnosis of advanced NSCLC and 548 caregivers. Participants were randomized to meet with a specialty-trained palliative care clinician every 4 weeks either via video visit or in person in the outpatient clinic from the time of enrollment and throughout the course of disease. The video visit group had an initial in-person visit to establish rapport, followed by subsequent virtual visits. Equivalence of the effect of video visit vs in-person early palliative care on quality of life at week 24 per the Functional Assessment of Cancer Therapy-Lung questionnaire (equivalence margin of ±4 points; score range: 0-136, with higher scores indicating better quality of life). Participants completed study questionnaires at enrollment and at weeks 12, 24, 36, and 48. By 24 weeks, participants (mean age, 65.5 years; 54.0% women; 82.7% White) had a mean of 4.7 (video) and 4.9 (in-person) early palliative care encounters. Patient-reported quality-of-life scores were equivalent between groups (video mean, 99.7 vs in-person mean, 97.7; difference, 2.0 [90% CI, 0.1-3.9]; P = .04 for equivalence). Rate of caregiver participation in visits was lower for video vs in-person early palliative care (36.6% vs 49.7%; P < .001). Study groups did not differ in caregiver quality of life, patient coping, or patient and caregiver satisfaction with care, mood symptoms, or prognostic perceptions. The delivery of early palliative care virtually vs in person demonstrated equivalent effects on quality of life in patients with advanced NSCLC, underscoring the considerable potential for improving access to this evidence-based care model through telehealth delivery. ClinicalTrials.gov Identifier: NCT03375489. |
| 924 | Toby Campbell | HEM/ONC | tcc@medicine.wisc.edu | Beyond Chemoimmunotherapy in Advanced Non-Small Cell Lung Cancer: New Frontiers, New Challenges. | Chemoimmunotherapy is currently the preferred first-line treatment option for the majority of patients with advanced non-small cell lung cancer without driver genetic alterations. Most of these patients, however, will experience disease progression within the first year after treatment initiation and both patients and their physicians will be confronted with the dilemma of the optimal second-line treatment. Identification of molecular targets, such as KRASG12C, BRAFV600X, METexon14, and human epidermal growth factor receptor 2 mutations, and RET rearrangements offer therapeutic opportunities in pretreated patients with corresponding alterations. For those tumors that do not harbor oncogenic drivers, second-line treatment with docetaxel remains the current standard of care despite modest efficacy. Strategies to challenge docetaxel include the combination of immune checkpoint inhibitors (ICIs) with tyrosine inhibitors of multiple kinases or with DNA damage response inhibitors, antibody-drug conjugates, and locoregional treatments for oligoprogressive disease. Next-generation immunotherapy strategies, such as T-cell engagers, immune-mobilizing monoclonal T-cell receptors, chimeric antigen receptor cell therapy, tumor infiltrating lymphocytes, and T-cell receptor cell therapy are being currently investigated in the quest to reverse resistance to ICIs. Importantly, the advent of these new agents heralds a novel spectrum of toxicities that require both the physician's and the patient's education. Herein, we review current and future strategies aiming to outperform docetaxel after chemoimmunotherapy failure, and we provide practical information on how to best communicate to our patients the unique toxicity aspects associated with immunotherapy. |
| 925 | Toby Campbell | HEM/ONC | tcc@medicine.wisc.edu | Balancing risks and rewards: How hematologists discuss uncertainty in allogeneic hematopoietic cell transplantation outcomes. | Allogeneic hematopoietic cell transplant (alloHCT) offers many patients with blood cancers a chance of cure but carries risks. We characterized how hematologists discuss the high-risk, high-reward concept of alloHCT. Qualitative analysis of video-recorded virtual encounters of hematologists who routinely perform alloHCT with actors portraying an older man recently diagnosed with high-risk myelodysplastic syndrome. Hematologists (n = 37) were a median age of 44 years, 65% male, and 68% white. They frequently used "teeter-totter" language that juxtaposed alloHCT's risks and rewards in a dynamic, quickly alternating fashion and communicated uncertainty in transplant outcomes. This dialogue oscillated between encouragement about alloHCT's potential for cure and caution about its risks and occurred within single speech turns and in exchanges between hematologist and patient. Fewer hematologists outlined their big-picture stance on transplant's risks and benefits early in the conversation. Meanwhile, hematologists varied in how they counseled patients to manage transplant-related uncertainty and consider treatment decision making. Hematologists use "teeter-totter" language to express hope and concern, confidence and uncertainty, and encouragement and caution about the high-risk, high-reward nature of alloHCT. Teeter-totter language may help frame big-picture content about alloHCT's risks and benefits that is essential for patient education and decision making. |
| 926 | Toby Campbell | HEM/ONC | tcc@medicine.wisc.edu | Renaming Palliative Cancer Therapies: Call It What It Is. | This commentary explores the language choices that oncology providers make when discussing cancer therapy goals. |
| 927 | Toby Campbell | HEM/ONC | tcc@medicine.wisc.edu | Communication Strategies of Transplant Hematologists in High-Risk Decision-Making Conversations. | Shared decision making (SDM) is essential to empower patients with blood cancers to make goal-concordant decisions about allogeneic hematopoietic cell transplantation. This study characterizes communication strategies used by hematologists to discuss treatment options and facilitate SDM with patients in this high-risk, high-reward setting. We recruited US hematologists who routinely perform allogeneic hematopoietic cell transplant through email. Participants conducted up to an hour-long video-recorded encounter with an actor portraying a 67-year-old man with recently diagnosed high-risk myelodysplastic syndrome. We transcribed and qualitatively analyzed video-recorded data. The mean age of participants (N = 37) was 44 years, 65% male, and 68% White. Many hematologists included similar key points in this initial consultation, although varied in how much detail they provided. Their discussion of treatment options included transplant and chemotherapy and less commonly supportive care or clinical trials. They often emphasized transplant's potential for cure, discussed transplant chronologically from pretransplant considerations through the post-transplant course, and outlined risks, complications, and major outcomes. Hematologists referred to several elements that formed the basis of treatment decision making. The strength of their treatment recommendations ranged from strong recommendations for transplant or chemotherapy to deferrals pending more information. Hematologists also varied in the extent to which they indicated the decision was physician-driven, patient-led, or shared. The transplant decision-making discussion is complex. Identification of similar content areas used by hematologists can be used as the basis for a communication tool to help hematologists discuss allogeneic hematopoietic cell transplant with patients. |
| 928 | Toby Campbell | HEM/ONC | tcc@medicine.wisc.edu | Combining Dual Checkpoint Immunotherapy with Ablative Radiation to All Sites of Oligometastatic Non-Small Cell Lung Cancer: Toxicity and Efficacy Results of a Phase 1b Trial. | Ablative local treatment of all radiographically detected metastatic sites in patients with oligometastatic non-small cell lung cancer (NSCLC) increases progression-free survival (PFS) and overall survival (OS). Prior studies demonstrated the safety of combining stereotactic body radiation therapy (SBRT) with single-agent immunotherapy. We investigated the safety of combining SBRT to all metastatic tumor sites with dual checkpoint, anticytotoxic T-lymphocyte-associated protein 4 (anti-CTLA-4), and anti-programmed cell death ligand 1 (anti-PD-L1) immunotherapy for patients with oligometastatic NSCLC. We conducted a phase 1b clinical trial in patients with oligometastatic NSCLC with up to 6 sites of extracranial metastatic disease. All sites of disease were treated with SBRT to a dose of 30 to 50 Gy in 5 fractions. Dual checkpoint immunotherapy was started 7 days after completion of radiation using anti-CTLA-4 (tremelimumab) and anti-PD-L1 (durvalumab) immunotherapy for a total of 4 cycles followed by durvalumab alone until progression or toxicity. Of the 17 patients enrolled in this study, 15 patients received at least 1 dose of combination immunotherapy per protocol. The study was closed early (17 of planned 21 patients) due to slow accrual during the COVID-19 pandemic. Grade 3+ treatment-related adverse events were observed in 6 patients (40%), of which only one was possibly related to the addition of SBRT to immunotherapy. Median PFS was 42 months and median OS has not yet been reached. Delivering ablative SBRT to all sites of metastatic disease in combination with dual checkpoint immunotherapy did not result in excessive rates of toxicity compared with historical studies of dual checkpoint immunotherapy alone. Although the study was not powered for treatment efficacy results, durable PFS and OS results suggest potential therapeutic benefit compared with immunotherapy or radiation alone in this patient population. |
| 929 | Brian Williams | PEDS | bswillia@medicine.wisc.edu | Correlates of improved outcomes in patients with COVID-19 treated in US emergency departments. | The COVID-19 pandemic was managed in part by the rapid development of vaccines, diagnostics, and therapeutics including antiviral agents and advances in emergency airway and ventilatory management. The impact of these therapeutic advances on clinically pertinent metrics of emergency care have not been well-studied. We abstracted data from emergency department (ED) visits made to 21 US health systems during the first two years of the pandemic, from February 1, 2020 to January 31, 2022. These health systems were participants in the NIH-supported COVID EHR Cohort, in which the University of Wisconsin served as the coordinating site. Limited patient-level data files were submitted monthly. Data elements included demographic and clinical variables, as well as standard measures of ED outcomes including 72-h returns, 72-h returns leading to readmission, and in-hospital mortality. Multivariable models were fitted to identify correlates of each of the dependent variables. A test for trend was used to detect changes in outcomes over time. During the two-year period, 150,357 individuals aged 18 years or older visited the ED. The median age was 45.4 years (IQR 27), 58.1 % were female, 49 % were White, 18.3 % Hispanic/Latino, and 45 % were publicly insured or uninsured. The prevalence of 72-h ED returns, readmissions, and in-hospital mortality significantly declined across the two-year period. SARS-CoV-2 vaccination was associated with reduced ED returns and mortality. Therapeutic agents were associated with increased mortality risk but were likely confounded by unmeasured covariates. Operational and clinical outcomes of ED-based treatment of individuals with COVID-19 improved in the first two years of the pandemic. This improvement is likely multifactorial and includes the development and deployment of SARS-CoV-2-specific vaccines, therapeutic agents, and improved healthcare delivery in the ED and elsewhere addressing management of airway and ventilatory status, as well as increased innate immunity in the general population. |
| 930 | Brian Williams | PEDS | bswillia@medicine.wisc.edu | Addressing Substance Use in the Adolescent Transplant Population. | Adolescence is a unique period of physical and psychosocial changes as youth transition, over many years, to adulthood. The psychosocial changes that accompany adolescence include emotional separation from parents, greater influence of peer groups, an interest in self-identification and autonomy, and increased risk-taking behaviors. Substance use is a common form of risk-taking behavior in the adolescent developmental stage. Alcohol, nicotine, and cannabis are the most common types of substances used in the United States. In the adolescent transplant population, rates of substance use appear to be at, or slightly below, their peer counterparts. Substance use can lead to deleterious health outcomes for adolescent transplant patients as a result of impaired decision-making, reduction in medication and clinic visit compliance, increases in mental health disorders, and risk for developing dependence and a substance use disorder. Given the close relationship that many pediatric transplant providers have with their patients and families, transplant care teams are in an excellent position to help their patients by addressing adolescent substance use. This narrative review describes how providers can use proactive standardized approaches to identify and intervene with substance use behavior. |
| 931 | Brian Williams | PEDS | bswillia@medicine.wisc.edu | Factors associated with 60-day readmission among inpatients with COVID-19 at 21 United States health systems. | Identifying patients at risk for readmission after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection could facilitate care planning and prevention. This retrospective cohort study of 60-day readmission included 105 543 COVID-19 patients at 21 US healthcare systems who were discharged alive between February 2020 and November 2021. Generalized linear mixed regression analyses tested predictors of 60-day readmission and severity. The all-cause readmission rate was 15% (95% confidence interval [CI] = 10%-21%), with 22% (95% CI = 18%-26%) of readmitted patients needing intensive care, and 6% (95% CI = 05%-07%) dying. Factors associated with readmission included male sex, government insurance, positive smoking history, co-morbidity burden, longer index admissions, and diagnoses at index admission (e.g., cancer, chronic kidney disease, and liver disease). Death and intensive care rates at readmission declined postvaccine availability. Receiving at least two COVID-19 vaccine doses, which were more common among older patients and those with comorbid conditions, was not independently associated with readmission but predicted a reduced risk of death at readmission. This retrospective cohort study identified factors associated with all-cause readmission for patients re-admitted to the same health system after hospitalization with SARS-CoV-2 infection. Patients who are male, who smoke, who have a higher comorbidity burden, and have government insurance may benefit from additional postacute care planning. |
| 932 | Brian Williams | PEDS | bswillia@medicine.wisc.edu | Smoking Status, Nicotine Medication, Vaccination, and COVID-19 Hospital Outcomes: Findings from the COVID EHR Cohort at the University of Wisconsin (CEC-UW) Study. | Available evidence is mixed concerning associations between smoking status and COVID-19 clinical outcomes. Effects of nicotine replacement therapy (NRT) and vaccination status on COVID-19 outcomes in smokers are unknown. Electronic health record data from 104 590 COVID-19 patients hospitalized February 1, 2020 to September 30, 2021 in 21 U.S. health systems were analyzed to assess associations of smoking status, in-hospital NRT prescription, and vaccination status with in-hospital death and ICU admission. Current (n = 7764) and never smokers (n = 57 454) did not differ on outcomes after adjustment for age, sex, race, ethnicity, insurance, body mass index, and comorbidities. Former (vs never) smokers (n = 33 101) had higher adjusted odds of death (aOR, 1.11; 95% CI, 1.06-1.17) and ICU admission (aOR, 1.07; 95% CI, 1.04-1.11). Among current smokers, NRT prescription was associated with reduced mortality (aOR, 0.64; 95% CI, 0.50-0.82). Vaccination effects were significantly moderated by smoking status; vaccination was more strongly associated with reduced mortality among current (aOR, 0.29; 95% CI, 0.16-0.66) and former smokers (aOR, 0.47; 95% CI, 0.39-0.57) than for never smokers (aOR, 0.67; 95% CI, 0.57, 0.79). Vaccination was associated with reduced ICU admission more strongly among former (aOR, 0.74; 95% CI, 0.66-0.83) than never smokers (aOR, 0.87; 95% CI, 0.79-0.97). Former but not current smokers hospitalized with COVID-19 are at higher risk for severe outcomes. SARS-CoV-2 vaccination is associated with better hospital outcomes in COVID-19 patients, especially current and former smokers. NRT during COVID-19 hospitalization may reduce mortality for current smokers. Prior findings regarding associations between smoking and severe COVID-19 disease outcomes have been inconsistent. This large cohort study suggests potential beneficial effects of nicotine replacement therapy on COVID-19 outcomes in current smokers and outsized benefits of SARS-CoV-2 vaccination in current and former smokers. Such findings may influence clinical practice and prevention efforts and motivate additional research that explores mechanisms for these effects. |
| 933 | Brian Williams | PEDS | bswillia@medicine.wisc.edu | Trends in E-cigarette Use in Callers to the Wisconsin Tobacco Quit Line. | E-cigarette use has been increasing for years with a limited understanding of how to help users quit. Quit lines are a potential resource for e-cigarette cessation. Our objective was to characterize e-cigarette users who call state quit lines and to examine trends in e-cigarette use by callers. This retrospective study examined data from adult callers to the Wisconsin Tobacco Quit Line from July 2016 through November 2020, including demographics, tobacco product use, motivations for use, and intentions to quit. Descriptive analyses were performed by age group with pairwise comparisons. A total of 26,705 encounters were handled by the Wisconsin Tobacco Quit Line during the study period. E-cigarettes were used by 11% of callers. Young adults aged 18-24 had the highest rates of use at 30%, and their use rose significantly from 19.6% in 2016 to 39.6% in 2020. E-cigarette use among young adult callers peaked at 49.7% in 2019, coinciding with an outbreak of e-cigarette-related lung injury. Only 53.5% of young adult callers used e-cigarettes to "cut down on other tobacco," compared to 76.3% of adult callers aged 45-64 (P <0.05). Of all callers using e-cigarettes, 80% were interested in quitting. E-cigarette use among callers to the Wisconsin Tobacco Quit Line has increased, driven largely by young adults. Most e-cigarette users who call the quit line want to quit. Thus, quit lines can serve an important role in e-cigarette cessation. A better understanding of strategies to help e-cigarette users quit is needed, particularly in young adult callers. |
| 934 | Brian Williams | PEDS | bswillia@medicine.wisc.edu | Relations of Current and Past Cancer with Severe Outcomes among 104,590 Hospitalized COVID-19 Patients: The COVID EHR Cohort at the University of Wisconsin. | There is mixed evidence about the relations of current versus past cancer with severe COVID-19 outcomes and how they vary by patient and cancer characteristics. Electronic health record data of 104,590 adult hospitalized patients with COVID-19 were obtained from 21 United States health systems from February 2020 through September 2021. In-hospital mortality and ICU admission were predicted from current and past cancer diagnoses. Moderation by patient characteristics, vaccination status, cancer type, and year of the pandemic was examined. 6.8% of the patients had current (n = 7,141) and 6.5% had past (n = 6,749) cancer diagnoses. Current cancer predicted both severe outcomes but past cancer did not; adjusted odds ratios (aOR) for mortality were 1.58 [95% confidence interval (CI), 1.46-1.70] and 1.04 (95% CI, 0.96-1.13), respectively. Mortality rates decreased over the pandemic but the incremental risk of current cancer persisted, with the increment being larger among younger vs. older patients. Prior COVID-19 vaccination reduced mortality generally and among those with current cancer (aOR, 0.69; 95% CI, 0.53-0.90). Current cancer, especially among younger patients, posed a substantially increased risk for death and ICU admission among patients with COVID-19; prior COVID-19 vaccination mitigated the risk associated with current cancer. Past history of cancer was not associated with higher risks for severe COVID-19 outcomes for most cancer types. This study clarifies the characteristics that modify the risk associated with cancer on severe COVID-19 outcomes across the first 20 months of the COVID-19 pandemic. See related commentary by Egan et al., p. 3. |
| 935 | Brian Williams | PEDS | bswillia@medicine.wisc.edu | The first 20 months of the COVID-19 pandemic: Mortality, intubation and ICU rates among 104,590 patients hospitalized at 21 United States health systems. | There is limited information on how patient outcomes have changed during the COVID-19 pandemic. This study characterizes changes in mortality, intubation, and ICU admission rates during the first 20 months of the pandemic. University of Wisconsin researchers collected and harmonized electronic health record data from 1.1 million COVID-19 patients across 21 United States health systems from February 2020 through September 2021. The analysis comprised data from 104,590 adult hospitalized COVID-19 patients. Inclusion criteria for the analysis were: (1) age 18 years or older; (2) COVID-19 ICD-10 diagnosis during hospitalization and/or a positive COVID-19 PCR test in a 14-day window (+/- 7 days of hospital admission); and (3) health system contact prior to COVID-19 hospitalization. Outcomes assessed were: (1) mortality (primary), (2) endotracheal intubation, and (3) ICU admission. The 104,590 hospitalized participants had a mean age of 61.7 years and were 50.4% female, 24% Black, and 56.8% White. Overall risk-standardized mortality (adjusted for age, sex, race, ethnicity, body mass index, insurance status and medical comorbidities) declined from 16% of hospitalized COVID-19 patients (95% CI: 16% to 17%) early in the pandemic (February-April 2020) to 9% (CI: 9% to 10%) later (July-September 2021). Among subpopulations, males (vs. females), those on Medicare (vs. those on commercial insurance), the severely obese (vs. normal weight), and those aged 60 and older (vs. younger individuals) had especially high mortality rates both early and late in the pandemic. ICU admission and intubation rates also declined across these 20 months. Mortality, intubation, and ICU admission rates improved markedly over the first 20 months of the pandemic among adult hospitalized COVID-19 patients although gains varied by subpopulation. These data provide important information on the course of COVID-19 and identify hospitalized patient groups at heightened risk for negative outcomes. ClinicalTrials.gov Identifier: NCT04506528 (https://clinicaltrials.gov/ct2/show/NCT04506528). |
| 936 | Brian Williams | PEDS | bswillia@medicine.wisc.edu | The 2020 Pandemics: Lessons Learned in Academic Surgery and Beyond. | 2020 was a significant year because of the occurrence of two simultaneous public health crises: the coronavirus pandemic and the public health crisis of racism brought into the spotlight by the murder of George Floyd. The coronavirus pandemic has affected all aspects of health care, particularly the delivery of surgical care, surgical education, and academic productivity. The concomitant public health crisis of racism and health inequality during the viral pandemic highlighted opportunities for action to address gaps in surgical care and the delivery of public health services. At the 2021 Academic Surgical Congress Hot Topics session on flexibility and leadership, we also explored how our military surgeon colleagues can provide guidance in leadership during times of crisis. The following is a summary of the issues discussed during the session and reflections on the important lessons learned in academic surgery over the past year. |
| 937 | Brian Williams | PEDS | bswillia@medicine.wisc.edu | Development of a Pharmacist-Led Opt-Out Cessation Treatment Protocol for Combustible Tobacco Smoking Within Inpatient Settings. | Background: Although people who smoke cigarettes are overrepresented among hospital inpatients, few are connected with smoking cessation treatment during their hospitalization. Training, accountability for medication use, and monitoring of all patients position pharmacists well to deliver cessation interventions to all hospitalized patients who smoke. Methods: A large Midwestern University hospital implemented a pharmacist-led smoking cessation intervention. A delegation protocol for hospital pharmacy inpatients who smoked cigarettes gave hospital pharmacists the authority to order nicotine replacement therapy (NRT) during hospitalization and upon discharge, and for referral to the Wisconsin Tobacco Quit Line (WTQL) at discharge. Eligible patients received the smoking cessation intervention unless they actively refused (ie, "opt-out"). The program was pilot tested in phases, with pharmacist feedback between phases, and then implemented hospital-wide. Interviews, surveys, and informal mechanisms identified ways to improve implementation and workflows. Results: Feedback from pharmacists led to changes that improved workflow, training and patient education materials, and enhanced adoption and reach. Refining implementation strategies across pilot phases increased the percentage of eligible smokers offered pharmacist-delivered cessation support from 37% to 76%, prescribed NRT from 2% to 44%, and referred to the WTQL from 3% to 32%. Conclusion: Hospitalizations provide an ideal opportunity for patients to make a tobacco quit attempt, and pharmacists can capitalize on this opportunity by integrating smoking cessation treatment into existing inpatient medication reconciliation workflows. Pharmacist-led implementation strategies developed in this study may be applicable in other inpatient settings. |
| 938 | Brian Williams | PEDS | bswillia@medicine.wisc.edu | Smoke Exposure Disclosure: Parental Perspectives of Screening in the Inpatient Setting. | Current screening questions for pediatric tobacco smoke exposure are suboptimal. Factors influencing screening accuracy, particularly in the pediatric inpatient setting, are unknown. Our objective was to identify facilitators of and barriers to parental disclosure of smoke exposure when screened during their child's hospitalization and strategies to promote accurate disclosure. This qualitative study was conducted with a convenience sample of parents of children admitted to the medical and surgical unit of a Midwest tertiary care children's hospital. Eligible parents included those with documented disclosure of smoke exposure in the child's electronic health record. A researcher trained in qualitative methods conducted semistructured, in-depth interviews with parents regarding their experiences with smoke exposure screening in the inpatient pediatric setting. Two researchers independently identified concepts directed at barriers, facilitators, and strategies for effective screening, which were compared and reconciled by a third researcher. Facilitators of disclosing their child's smoke exposure included the following: (1) the caregiver's internal characteristic(s) promoting disclosure, (2) perceived relevance of the screening question to the child's health, and (3) the questioner being viewed positively. Barriers included the following: (1) fear of negative consequences, (2) a vague question, (3) lack of knowledge, (4) guilt, and (5) unconducive environment and timing. The strategies parents suggested to improve screening for smoke exposure included the following: (1) communicate preemptively, (2) provide specific exposure examples, (3) improve questioner-caregiver rapport, and (4) improve screening environment and timing. Parents identified various mechanisms to improve tobacco smoke exposure screening. The facilitators, barriers, and strategies provide opportunities to improve the inpatient pediatric screening process. |
| 939 | Sara Westergaard | HOSP | swesterga@medicine.wisc.edu | Big brother or big opportunity? Utilization of EHR use metadata in the inpatient setting: A mixed methods study at 16 organizations. | Clinician electronic actions within the electronic health record (EHR) are captured seamlessly in real-time during regular work activities in all major EHRs. Analysis of this EHR use metadata, such as audit log data, is increasingly used to understand the impact of work design on critical patient, workforce, and organizational outcomes. Understand experiences and perspectives influencing the use and implementation of audit log data into practice. Mixed methods design utilizing focus groups and embedded survey with hospitalist group leaders attending a national society special interest group. Themes and subthemes were identified. Seven semistructured virtual focus groups were held with 16 individuals from 16 different organizations on December 12, 2023, with a 100% survey response rate. Survey results highlighted the lack of familiarity with audit log data, the lack of tools and training for use, and the lack of established protocols to respond to insights, with some concerns for the accuracy of the data. Four themes and multiple subthemes were identified and included: (1) Limited, but widely variable use of audit log data driven by a lack of access, resources, skills, and knowledge, (2) mistrust and skepticism about the data, including concerns about potential misuse and a lack of best practices and standards, (3) perspectives around audit log data are culture and context driven, and (4) excitement for the many potential use cases. Despite all major EHRs having audit log data, participants had limited access, training, and knowledge. Although there was mistrust, many opportunities were identified. |
| 940 | Sara Westergaard | HOSP | swesterga@medicine.wisc.edu | Optimizing learners on direct care teaching services: A qualitative study of hospitalist clinicians at 26 sites. | Academic medical centers are experiencing rapid clinical growth which has outpaced traditional teaching services. Learners such as medical students, advanced practice provider fellows, and residents may be placed onto direct care teaching services (i.e., inpatient services where attendings provide both direct care to patients and supervise learners) creating potential challenges for attending physicians due to clinical demands. Characterize the hospitalist experience with direct care teaching services. Embedded mixed methods study with a 16-question survey and semistructured focus groups using rapid qualitative methods. Virtual focus groups in the Hospital Medicine Reengineering Network (HOMERuN). Qualitative themes. Thirty-eight hospitalist clinicians from 26 hospital systems across five geographic regions participated in the focus groups. Thirty-four (89%) of participants responded to the survey and were predominantly physicians (97%). Most participants preferred traditional teaching services compared with direct care teaching services with 82% replying somewhat or to a great extent. Thematic analysis identified three themes: (1) Hospitalists prefer traditional teaching services in part due to a time and workload mismatch in direct care teaching services; (2) Adaptations can support attending physicians in direct care teaching services such as adjusting workloads based on the level of learners; and (3) Direct care teaching services were perceived to serve an important role by providing direct and personalized teaching, and offering teaching opportunities. Direct care teaching services pose challenges given clinical workloads, time constraints for educational activities. Addressing these challenges may make these types of services more sustainable. |
| 941 | Sara Westergaard | HOSP | swesterga@medicine.wisc.edu | Academic hospitalist perspectives on the benefits and challenges of secure messaging: A mixed methods analysis. | Hospitals and patients rely on effective clinician communication. Asynchronous electronic secure messaging (SM) systems are a common way for hospitalists to communicate, but few studies have evaluated how hospitalists are navigating the adoption of SM and the benefits and challenges they are encountering. The objective of this study is to assess academic hospitalist perspectives on SM to guide future research and quality improvement initiatives. This was a mixed methods study utilizing an embedded REDCap survey and six virtual semistructured focus groups. It took place during a Hospital Medicine ReEngineering Network Zoom meeting on October 13, 2023. Rapid qualitative methods were used to define major themes. There were 28 hospitalists and one patient representative across 24 separate academic institutions. There was a 71% survey completion rate (N = 20). SM was felt to be an effective and efficient communication modality but was associated with a large amount of multitasking and interruptions. Perspectives around SM clustered around three main themes: SM has been widely but variably adopted; there is a lack of institutional guidance about how to best engage with SM; and SM is changing the landscape of hospitalist work by increasing ease but decreasing depth of communication, increasing cognitive load, and changing interpersonal relationships. Recommendations for SM improvements included the need for institutions to work with frontline workers to develop and implement clear usage guidelines. SM is likely contributing to both positive and negative effects for clinicians and patients. Understanding hospitalist perspectives on SM will help guide future research and quality improvement initiatives. |
| 942 | Sara Westergaard | HOSP | swesterga@medicine.wisc.edu | Identifying and Measuring Administrative Harms Experienced by Hospitalists and Administrative Leaders. | Administrative harm (AH), defined as the adverse consequences of administrative decisions within health care that impact work structure, processes, and programs, is pervasive in medicine, yet poorly understood and described. To explore common AHs experienced by hospitalist clinicians and administrative leaders, understand the challenges that exist in identifying and measuring AH, and identify potential approaches to mitigate AH. A qualitative study using a mixed-methods approach with a 12-question survey and semistructured virtual focus groups was held on June 13 and August 11, 2023. Rapid qualitative methods including templated summaries and matrix analysis were applied. The participants included 2 consortiums comprising hospitalist clinicians, researchers, administrative leaders, and members of a patient and family advisory council. Quantitative data from the survey on specific aspects of experiences related to AH were collected. Focus groups were conducted using a semistructured focus group guide. Themes and subthemes were identified. Forty-one individuals from 32 different organizations participated in the focus groups, with 32 participants (78%) responding to a brief survey. Survey participants included physicians (91%), administrative professionals (6%), an advanced practice clinician (3%), and those in leadership roles (44%), with participants able to select more than one role. Only 6% of participants were familiar with the term administrative harm to a great extent, 100% felt that collaboration between administrators and clinicians is crucial for reducing AH, and 81% had personally participated in a decision that led to AH to some degree. Three main themes were identified: (1) AH is pervasive and comes from all levels of leadership, and the phenomenon was felt to be widespread and arose from multiple sources within health care systems; (2) organizations lack mechanisms for identification, measurement, and feedback, and these challenges stem from a lack of psychological safety, workplace cultures, and ambiguity in who owns a decision; and (3) organizational pressures were recognized as contributors to AHs. Many ideas were proposed as solutions. The findings of this study suggest that AH is widespread with wide-reaching impact, yet organizations do not have mechanisms to identify or address it. |
| 943 | Sara Westergaard | HOSP | swesterga@medicine.wisc.edu | Virtual hospital care development and deployment: A rapid qualitative study of frontline clinicians and leaders. | Virtual hospitalist programs are rapidly growing in popularity due to worsening clinician shortages and increased pressure for flexible work options. These programs also have the potential to establish sustainable staffing models across multiple hospitals optimizing cost. We aimed to explore the current state of virtual hospitalist services at various health systems, challenges and opportunities that exist in providing virtual care, and future opportunities for these types of services. To identify perspectives on design and implementation of virtual hospitalist programs from academic hospitalist leaders. We conducted focus groups with United States academic hospitalist leaders. Semistructured interviews explored experiences with virtual hospitalist programs. Using rapid qualitative methods including templated summaries and matrix analysis, focus group recordings were analyzed to identify key themes. We conducted four focus groups with 13 participants representing nine hospital systems across six geographic regions and range of experience with virtual hospital medicine care. Thematic analysis identified three themes: (1) a broad spectrum of virtual care delivery; (2) adoption and acceptance of virtual care models followed the stages of diffusion of innovation; and (3) sustainability and scalability of programs were affected by unclear finances. Hospitalist leader perspectives revealed complex factors influencing virtual care adoption and implementation. Addressing concerns about care quality, financing, and training may accelerate adoption. Further research should clarify the best practices for sustainable models optimized for access, hospitalist experience, patient safety, and financial viability. |
| 944 | Sara Westergaard | HOSP | swesterga@medicine.wisc.edu | Collaborative research: The power of multiorganizational affinity groups and adaptive research methods. | |
| 945 | Sara Westergaard | HOSP | swesterga@medicine.wisc.edu | Impact of billing reforms on academic hospitalist physician and advanced practice provider collaboration: A qualitative study. | Medicare previously announced plans for new billing reforms for inpatient visits that are shared by physicians and advanced practice providers (APPs) whereby the clinician spending the most time on the patient visit would bill for the visit. To understand how inpatient hospital medicine teams utilize APPs in patient care and how the proposed billing policies might impact future APP utilization. We conducted focus groups with hospitalist physicians, APPs, and other leaders from 21 academic hospitals across the United States. Utilizing rapid qualitative methods, focus groups were analyzed using a mixed inductive and deductive method at the semantic level with templated summaries and matrix analysis. Thirty-three individuals (physicians [n = 21], APPs [n = 10], practice manager [n = 1], and patient representative [n = 1]) participated in six focus groups. Four themes emerged from the analysis of the focus groups, including: (1) staffing models with APPs are rapidly evolving, (2) these changes were felt to be driven by staffing shortages, financial models, and governance with minimal consideration to teamwork and relationships, (3) time-based billing was perceived to value tasks over cognitive workload, and (4) that the proposed billing changes may create unintended consequences impacting collaboration and professional satisfaction. Physician and APP collaborative care models are increasingly evolving to independent visits often driven by workloads, financial drivers, and local regulations such as medical staff rules and hospital bylaws. Understanding which staffing models produce optimal patient, clinician, and organizational outcomes should inform billing policies rather than the reverse. |
| 946 | Sara Westergaard | HOSP | swesterga@medicine.wisc.edu | Documenting a Decade of Exponential Growth in Employer Demand for Peer Support Providers. | The past decade has seen peer support providers increasingly incorporated as part of a recovery-oriented approach to behavioral health (BH) services for mental illness and substance use disorder. Despite this, there are few data sources to track this sector of the BH workforce, and understanding of peer support provider supply, demand, distribution, and associated factors is limited. In this retrospective, observational study, the authors analyzed job postings from 2010 to 2020 to assess employer demand for peer support providers and the factors associated with its growth, using a labor market data set from Emsi Burning Glass. The authors identified peer support job postings using a three-pronged, stepwise approach. Then, bivariate regression analyses using robust standard errors were conducted to examine state-level relationships between the number of peer support job postings per 100,000 population and Medicaid policies and indicators of states' BH infrastructure. The authors identified approximately 35,000 unique postings, finding the number increased 17-fold between 2010 and 2020. Bivariate analysis found significant state-level associations between peer support job postings and Medicaid expansion, as well as states' mean number of mental health facilities. This analysis represents the first to quantify employer demand for peer support providers, clearly demonstrating robust growth over time. Findings underscore the importance of continuing to develop data on this workforce to better understand factors driving its growth. |
| 947 | David Feldstein | GIM | df2@medicine.wisc.edu | Ambulatory antibiotic prescription rates for acute respiratory infection rebound two years after the start of the COVID-19 pandemic. | During the COVID-19 pandemic, acute respiratory infection (ARI) antibiotic prescribing in ambulatory care markedly decreased. It is unclear if antibiotic prescription rates will remain lowered. We used trend analyses of antibiotics prescribed during and after the first wave of COVID-19 to determine whether ARI antibiotic prescribing rates in ambulatory care have remained suppressed compared to pre-COVID-19 levels. Retrospective data was used from patients with ARI or UTI diagnosis code(s) for their encounter from 298 primary care and 66 urgent care practices within four academic health systems in New York, Wisconsin, and Utah between January 2017 and June 2022. The primary measures included antibiotic prescriptions per 100 non-COVID ARI encounters, encounter volume, prescribing trends, and change from expected trend. At baseline, during and after the first wave, the overall ARI antibiotic prescribing rates were 54.7, 38.5, and 54.7 prescriptions per 100 encounters, respectively. ARI antibiotic prescription rates saw a statistically significant decline after COVID-19 onset (step change -15.2, 95% CI: -19.6 to -4.8). During the first wave, encounter volume decreased 29.4% and, after the first wave, remained decreased by 188%. After the first wave, ARI antibiotic prescription rates were no longer significantly suppressed from baseline (step change 0.01, 95% CI: -6.3 to 6.2). There was no significant difference between UTI antibiotic prescription rates at baseline versus the end of the observation period. The decline in ARI antibiotic prescribing observed after the onset of COVID-19 was temporary, not mirrored in UTI antibiotic prescribing, and does not represent a long-term change in clinician prescribing behaviors. During a period of heightened awareness of a viral cause of ARI, a substantial and clinically meaningful decrease in clinician antibiotic prescribing was observed. Future efforts in antibiotic stewardship may benefit from continued study of factors leading to this reduction and rebound in prescribing rates. |
| 948 | David Feldstein | GIM | df2@medicine.wisc.edu | Barriers to Implementing Registered Nurse-Driven Clinical Decision Support for Antibiotic Stewardship: Retrospective Case Study. | Up to 50% of antibiotic prescriptions for upper respiratory infections (URIs) are inappropriate. Clinical decision support (CDS) systems to mitigate unnecessary antibiotic prescriptions have been implemented into electronic health records, but their use by providers has been limited. As a delegation protocol, we adapted a validated electronic health record-integrated clinical prediction rule (iCPR) CDS-based intervention for registered nurses (RNs), consisting of triage to identify patients with low-acuity URI followed by CDS-guided RN visits. It was implemented in February 2022 as a randomized controlled stepped-wedge trial in 43 primary and urgent care practices within 4 academic health systems in New York, Wisconsin, and Utah. While issues were pragmatically addressed as they arose, a systematic assessment of the barriers to implementation is needed to better understand and address these barriers. We performed a retrospective case study, collecting quantitative and qualitative data regarding clinical workflows and triage-template use from expert interviews, study surveys, routine check-ins with practice personnel, and chart reviews over the first year of implementation of the iCPR intervention. Guided by the updated CFIR (Consolidated Framework for Implementation Research), we characterized the initial barriers to implementing a URI iCPR intervention for RNs in ambulatory care. CFIR constructs were coded as missing, neutral, weak, or strong implementation factors. Barriers were identified within all implementation domains. The strongest barriers were found in the outer setting, with those factors trickling down to impact the inner setting. Local conditions driven by COVID-19 served as one of the strongest barriers, impacting attitudes among practice staff and ultimately contributing to a work infrastructure characterized by staff changes, RN shortages and turnover, and competing responsibilities. Policies and laws regarding scope of practice of RNs varied by state and institutional application of those laws, with some allowing more clinical autonomy for RNs. This necessitated different study procedures at each study site to meet practice requirements, increasing innovation complexity. Similarly, institutional policies led to varying levels of compatibility with existing triage, rooming, and documentation workflows. These workflow conflicts were compounded by limited available resources, as well as an implementation climate of optional participation, few participation incentives, and thus low relative priority compared to other clinical duties. Both between and within health care systems, significant variability existed in workflows for patient intake and triage. Even in a relatively straightforward clinical workflow, workflow and cultural differences appreciably impacted intervention adoption. Takeaways from this study can be applied to other RN delegation protocol implementations of new and innovative CDS tools within existing workflows to support integration and improve uptake. When implementing a system-wide clinical care intervention, considerations must be made for variability in culture and workflows at the state, health system, practice, and individual levels. ClinicalTrials.gov NCT04255303; https://clinicaltrials.gov/ct2/show/NCT04255303. |
| 949 | David Feldstein | GIM | df2@medicine.wisc.edu | Feasibility Study of a Low-Carbohydrate/Time-Restricted Eating Protocol for Insulin-Using Type 2 Diabetic Patients. | Low-carbohydrate diets and time-restricted eating are methods to improve hemoglobin A1C in patients with type 2 diabetes. However, insulin-using patients are often counseled against these practices due to hypoglycemia concerns. This observational study evaluated a protocol utilizing both methods coupled with proactive insulin titration. To evaluate the safety and feasibility of a timed eating protocol for insulin-using patients and to assess its impact on outcomes, including insulin use and hemoglobin A1C. Participants included insulin-using adults ages 49 to 77 years with type 2 diabetes. They were counseled to eat 2 meals per day in a 6- to 8-hour window of their choosing, with a goal intake of ≤ 30 grams of carbohydrates per day. Glucose was closely monitored, and insulin was adjusted per study protocol. Primary outcomes included hypoglycemic events and compliance with timed eating. Insulin use, hemoglobin A1C, body mass index, blood pressure, and quality of life also were measured. Nineteen of the 20 participants completed the 6-month study. No hypoglycemic events requiring urgent medical care occurred. Symptomatic episodes with glucose between 47 and 80 mg/dl were reported by 37% (7/19) of participants. Average daily insulin use decreased by 62.2 U (P < 0.001) and insulin was discontinued for 14 participants. Average hemoglobin A1C remained unchanged. Average body mass index decreased by 4.0 (P = 0.01), systolic blood pressure decreased by 9.9 mm Hg (P = 0.02), and diabetes-related quality-of-life metrics improved significantly. These results demonstrate that a time-restricted eating protocol is feasible and safe for insulin-using patients with type 2 diabetes when paired with a proactive insulin titration. |
| 950 | David Feldstein | GIM | df2@medicine.wisc.edu | Reducing prescribing of antibiotics for acute respiratory infections using a frontline nurse-led EHR-Integrated clinical decision support tool: protocol for a stepped wedge randomized control trial. | Overprescribing of antibiotics for acute respiratory infections (ARIs) remains a major issue in outpatient settings. Use of clinical prediction rules (CPRs) can reduce inappropriate antibiotic prescribing but they remain underutilized by physicians and advanced practice providers. A registered nurse (RN)-led model of an electronic health record-integrated CPR (iCPR) for low-acuity ARIs may be an effective alternative to address the barriers to a physician-driven model. Following qualitative usability testing, we will conduct a stepped-wedge practice-level cluster randomized controlled trial (RCT) examining the effect of iCPR-guided RN care for low acuity patients with ARI. The primary hypothesis to be tested is: Implementation of RN-led iCPR tools will reduce antibiotic prescribing across diverse primary care settings. Specifically, this study aims to: (1) determine the impact of iCPRs on rapid strep test and chest x-ray ordering and antibiotic prescribing rates when used by RNs; (2) examine resource use patterns and cost-effectiveness of RN visits across diverse clinical settings; (3) determine the impact of iCPR-guided care on patient satisfaction; and (4) ascertain the effect of the intervention on RN and physician burnout. This study represents an innovative approach to using an iCPR model led by RNs and specifically designed to address inappropriate antibiotic prescribing. This study has the potential to provide guidance on the effectiveness of delegating care of low-acuity patients with ARIs to RNs to increase use of iCPRs and reduce antibiotic overprescribing for ARIs in outpatient settings. ClinicalTrials.gov Identifier: NCT04255303, Registered February 5 2020, https://clinicaltrials.gov/ct2/show/NCT04255303 . |
| 951 | David Feldstein | GIM | df2@medicine.wisc.edu | Disseminating child abuse clinical decision support among commercial electronic health records: Effects on clinical practice. | The use of electronic health record (EHR)-embedded child abuse clinical decision support (CA-CDS) may help decrease morbidity from child maltreatment. We previously reported on the development of CA-CDS in Epic and Allscripts. The objective of this study was to implement CA-CDS into Epic and Allscripts and determine its effects on identification, evaluation, and reporting of suspected child maltreatment. After a preimplementation period, CA-CDS was implemented at University of Wisconsin (Epic) and Northwell Health (Allscripts). Providers were surveyed before the go-live and 4 months later. Outcomes included the proportion of children who triggered the CA-CDS system, had a positive Child Abuse Screen (CAS) and/or were reported to Child Protective Services (CPS). At University of Wisconsin (UW), 3.5% of children in the implementation period triggered the system. The CAS was positive in 1.8% of children. The proportion of children reported to CPS increased from 0.6% to 0.9%. There was rapid uptake of the abuse order set.At Northwell Health (NW), 1.9% of children in the implementation period triggered the system. The CAS was positive in 1% of children. The child abuse order set was rarely used. Preimplementation, providers at both sites were similar in desire to have CA-CDS system and perception of CDS in general. After implementation, UW providers had a positive perception of the CA-CDS system, while NW providers had a negative perception. CA-CDS was able to be implemented in 2 different EHRs with differing effects on clinical care and provider feedback. At UW, the site with higher uptake of the CA-CDS system, the proportion of children who triggered the system and the rate of positive CAS was similar to previous studies and there was an increase in the proportion of cases of suspected abuse identified as measured by reports to CPS. Our data demonstrate how local environment, end-users' opinions, and limitations in the EHR platform can impact the success of implementation. When disseminating CA-CDS into different hospital systems and different EHRs, it is critical to recognize how limitations in the functionality of the EHR can impact the success of implementation. The importance of collecting, interpreting, and responding to provider feedback is of critical importance particularly with CDS related to child maltreatment. |
| 952 | David Feldstein | GIM | df2@medicine.wisc.edu | Clinical Decision Support for Child Abuse: Recommendations from a Consensus Conference. | |
| 953 | David Feldstein | GIM | df2@medicine.wisc.edu | Clinician Attitudes and Beliefs Associated with More Aggressive Diagnostic Testing. | Variation in clinicians' diagnostic test utilization is incompletely explained by demographics and likely relates to cognitive characteristics. We explored clinician factors associated with diagnostic test utilization. We used a self-administered survey of attitudes, cognitive characteristics, and reported likelihood of test ordering in common scenarios; frequency of lipid and liver testing in patients on statin therapy. Participants were 552 primary care physicians, nurse practitioners, and physician assistants from practices in 8 US states across 3 regions, from June 1, 2018 to November 26, 2019. We measured Testing Likelihood Score: the mean of 4 responses to testing frequency and self-reported testing frequency in patients on statins. Respondents were 52.4% residents, 36.6% attendings, and 11.0% nurse practitioners/physician assistants; most were white (53.6%) or Asian (25.5%). Median age was 32 years; 53.1% were female. Participants reported ordering tests for a median of 20% (stress tests) to 90% (mammograms) of patients; Testing Likelihood Scores varied widely (median 54%, interquartile range 43%-69%). Higher scores were associated with geography, training type, low numeracy, high malpractice fear, high medical maximizer score, high stress from uncertainty, high concern about bad outcomes, and low acknowledgment of medical uncertainty. More frequent testing of lipids and liver tests was associated with low numeracy, high medical maximizer score, high malpractice fear, and low acknowledgment of uncertainty. Clinician variation in testing was common, with more aggressive testing consistently associated with low numeracy, being a medical maximizer, and low acknowledgment of uncertainty. Efforts to reduce undue variations in testing should consider clinician cognitive drivers. |
| 954 | David Feldstein | GIM | df2@medicine.wisc.edu | Clinician Conceptualization of the Benefits of Treatments for Individual Patients. | Knowing the expected effect of treatment on an individual patient is essential for patient care. To explore clinicians' conceptualizations of the chance that treatments will decrease the risk of disease outcomes. This survey study of attending and resident physicians, nurse practitioners, and physician assistants was conducted in outpatient clinical settings in 8 US states from June 2018 to November 2019. The survey was an in-person, paper, 26-item survey in which clinicians were asked to estimate the probability of adverse disease outcomes and expected effects of therapies for diseases common in primary care. Estimated chance that treatments would benefit an individual patient. Of 723 clinicians, 585 (81%) responded, and 542 completed all the questions necessary for analysis, with a median (interquartile range [IQR]) age of 32 (29-44) years, 287 (53%) women, and 294 (54%) White participants. Clinicians consistently overestimated the chance that treatments would benefit an individual patient. The median (IQR) estimated chance that warfarin would prevent a stroke in the next year was 50% (5%-80%) compared with scientific evidence, which indicates an absolute risk reduction (ARR) of 0.2% to 1.0% based on a relative risk reduction (RRR) of 39% to 50%. The median (IQR) estimated chance that antihypertensive therapy would prevent a cardiovascular event within 5 years was 30% (10%-70%) vs evidence of an ARR of 0% to 3% based on an RRR of 0% to 28%. The median (IQR) estimated chance that bisphosphonate therapy would prevent a hip fracture in the next 5 years was 40% (10%-60%) vs evidence of ARR of 0.1% to 0.4% based on an RRR of 20% to 40%. The median (IQR) estimated chance that moderate-intensity statin therapy would prevent a cardiovascular event in the next 5 years was 20% (IQR 5%-50%) vs evidence of an ARR of 0.3% to 2% based on an RRR of 19% to 33%. Estimates of the chance that a treatment would prevent an adverse outcome exceeded estimates of the absolute chance of that outcome for 60% to 70% of clinicians. Clinicians whose overestimations were greater were more likely to report using that treatment for patients in their practice (eg, use of warfarin: correlation coefficient, 0.46; 95% CI, 0.40-0.53; P < .001). In this survey study, clinicians significantly overestimated the benefits of treatment to individual patients. Clinicians with greater overestimates were more likely to report using treatments in actual patients. |
| 955 | David Feldstein | GIM | df2@medicine.wisc.edu | Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testing. | Accurate diagnosis is essential to proper patient care. To explore practitioner understanding of diagnostic reasoning. In this survey study, 723 practitioners at outpatient clinics in 8 US states were asked to estimate the probability of disease for 4 scenarios common in primary care (pneumonia, cardiac ischemia, breast cancer screening, and urinary tract infection) and the association of positive and negative test results with disease probability from June 1, 2018, to November 26, 2019. Of these practitioners, 585 responded to the survey, and 553 answered all of the questions. An expert panel developed the survey and determined correct responses based on literature review. A total of 553 (290 resident physicians, 202 attending physicians, and 61 nurse practitioners and physician assistants) of 723 practitioners (76.5%) fully completed the survey (median age, 32 years; interquartile range, 29-44 years; 293 female [53.0%]; 296 [53.5%] White). Pretest probability was overestimated in all scenarios. Probabilities of disease after positive results were overestimated as follows: pneumonia after positive radiology results, 95% (evidence range, 46%-65%; comparison P < .001); breast cancer after positive mammography results, 50% (evidence range, 3%-9%; P < .001); cardiac ischemia after positive stress test result, 70% (evidence range, 2%-11%; P < .001); and urinary tract infection after positive urine culture result, 80% (evidence range, 0%-8.3%; P < .001). Overestimates of probability of disease with negative results were also observed as follows: pneumonia after negative radiography results, 50% (evidence range, 10%-19%; P < .001); breast cancer after negative mammography results, 5% (evidence range, <0.05%; P < .001); cardiac ischemia after negative stress test result, 5% (evidence range, 0.43%-2.5%; P < .001); and urinary tract infection after negative urine culture result, 5% (evidence range, 0%-0.11%; P < .001). Probability adjustments in response to test results varied from accurate to overestimates of risk by type of test (imputed median positive and negative likelihood ratios [LRs] for practitioners for chest radiography for pneumonia: positive LR, 4.8; evidence, 2.6; negative LR, 0.3; evidence, 0.3; mammography for breast cancer: positive LR, 44.3; evidence range, 13.0-33.0; negative LR, 1.0; evidence range, 0.05-0.24; exercise stress test for cardiac ischemia: positive LR, 21.0; evidence range, 2.0-2.7; negative LR, 0.6; evidence range, 0.5-0.6; urine culture for urinary tract infection: positive LR, 9.0; evidence, 9.0; negative LR, 0.1; evidence, 0.1). This survey study suggests that for common diseases and tests, practitioners overestimate the probability of disease before and after testing. Pretest probability was overestimated in all scenarios, whereas adjustment in probability after a positive or negative result varied by test. Widespread overestimates of the probability of disease likely contribute to overdiagnosis and overuse. |
| 956 | David Feldstein | GIM | df2@medicine.wisc.edu | Dissemination of child abuse clinical decision support: Moving beyond a single electronic health record. | Child maltreatment is a leading cause of pediatric morbidity and mortality. We previously reported on development and implementation of a child abuse clinical decision support system (CA-CDSS) in the Cerner electronic health record (EHR). Our objective was to develop a CA-CDSS in two different EHRs. Using the CA-CDSS in Cerner as a template, CA-CDSSs were developed for use in four hospitals in the Northwell Health system who use Allscripts and two hospitals in the University of Wisconsin health system who use Epic. Each system had a combination of triggers, alerts and child abuse-specific order sets. Usability evaluation was done prior to launch of the CA-CDSS. Over an 18-month period, a CA-CDSS was embedded into Epic and Allscripts at two hospital systems. The CA-CDSSs vary significantly from each other in terms of the type of triggers which were able to be used, the type of alert, the ability of the alert to link directly to child abuse-specific order sets and the order sets themselves. Dissemination of CA-CDSS from one EHR into the EHR in other health care systems is possible but time-consuming and needs to be adapted to the strengths and limitations of the specific EHR. Site-specific usability evaluation, buy-in of multiple stakeholder groups and significant information technology support are needed. These barriers limit scalability and widespread dissemination of CA-CDSS. |
| 957 | Jessica Tischendorf | ID | jtischen@medicine.wisc.edu | Skin Color Representation in Infectious Disease Textbooks. | Darker skin is underrepresented in medical textbooks. This may contribute to inequity in our system. We assessed skin color representation in infectious disease textbooks and compared diseases associated with social stigma to those not stigmatized. Images depicting conditions associated with social stigma were significantly more common on darker skin. |
| 958 | Jessica Tischendorf | ID | jtischen@medicine.wisc.edu | Emphasis of Diversity, Equity, and Inclusion on US Adult Infectious Disease Fellowship Program Websites in the Era of Virtual Recruitment. | Women and underrepresented-in-medicine applicants value a climate for diversity when selecting graduate medical education training programs. Climate may not be accurately represented during virtual recruitment. Optimizing program websites may help overcome this barrier. We reviewed websites for adult infectious disease fellowships that participated in the 2022 National Resident Matching Program for emphasis on diversity, equity, and inclusion (DEI). Fewer than half expressed DEI language in their mission statement or had a dedicated DEI statement or webpage. Programs should consider emphasizing their commitment to DEI prominently on their websites, which may help recruit candidates from diverse backgrounds. |
| 959 | Jessica Tischendorf | ID | jtischen@medicine.wisc.edu | Gender influences resident physicians' perception of an employee-to-employee recognition program: a mixed methods study. | Burnout is prevalent in medical training. While some institutions have implemented employee-to-employee recognition programs to promote wellness, it is not known how such programs are perceived by resident physicians, or if the experience differs among residents of different genders. We used convergent mixed methods to characterize how residents in internal medicine (IM), pediatrics, and general surgery programs experience our employee-to-employee recognition ("Hi-5″) program. We collected Hi-5s received by residents in these programs from January 1, 2021-December 31, 2021 and coded them for recipient discipline, sex, and PGY level and sender discipline and professional role. We conducted virtual focus groups with residents in each training program. We compared Hi-5 receipt between male and female residents; overall and from individual professions. We submitted focus group transcripts to content analysis with codes generated iteratively and emergent themes identified through consensus coding. Over a 12-month period, residents received 382 Hi-5s. There was no significant difference in receipt of Hi-5s by male and female residents. Five IM, 3 surgery, and 12 pediatric residents participated in focus groups. Residents felt Hi-5s were useful for interprofessional feedback and to mitigate burnout. Residents who identified as women shared concerns about differing expectations of professional behavior and communication based on gender, a fear of backlash when behavior does not align with gender stereotypes, and professional misidentification. The "Hi-5" program is valuable for interprofessional feedback and promotion of well-being but is experienced differently by men and women residents. This limitation of employee-to-employee recognition should be considered when designing equitable programming to promote well-being and recognition. |
| 960 | Jessica Tischendorf | ID | jtischen@medicine.wisc.edu | Factors Associated With Infectious Disease Fellowship Fill Rate: An Analysis of 2019, 2020, and 2021 Match Cycles. | Historically, there has been a relative paucity of applicants to infectious disease fellowships. This leads to a significant number of programs being unfilled in the fellowship match. We sought to identify predictors of a program filling all positions offered in the match through retrospective review of available match and program data for the 2019-2021 match cycles. In the 2021 match, hospital and research rankings were associated with filling, as were offering specialized training tracks and having an active Twitter account. Knowledge of these associations can help programs direct resources to optimize recruitment and enrichment of infectious disease fellows. |
| 961 | Jessica Tischendorf | ID | jtischen@medicine.wisc.edu | Feasibility of a pharmacy-led intervention to de-implement non-guideline-concordant proton pump inhibitor use. | Proton pump inhibitors (PPIs) are among the most prescribed medications and are often used unnecessarily. PPIs are used for the treatment of heartburn and acid-related disorders. Emerging evidence indicates that PPIs are associated with serious adverse events, such as increased risk of Clostridioides difficile infection. In this study, we designed and piloted a PPI de-implementation intervention among hospitalized non-intensive care unit patients. Using the Systems Engineering Initiative for Patient Safety (SEIPS) model as the framework, we developed an intervention with input from providers and patients. On a bi-weekly basis, a trainee pharmacist reviewed a random sample of eligible patients' charts to assess if PPI prescriptions were guideline-concordant; a recommendation to de-implement non-guideline-concordant PPI therapy was sent when applicable. We used convergent parallel mixed-methods design to evaluate the feasibility and outcomes of the intervention. During the study period (September 2019 to August 2020), 2171 patients with an active PPI prescription were admitted. We randomly selected 155 patient charts for review. The mean age of patients was 70.9 ± 9 years, 97.4% were male, and 35% were on PPIs for ≥5 years. The average time (minutes) needed to complete the intervention was as follows: 5 to assess if the PPI was guideline-concordant, 5 to provide patient education, and 7 to follow-up with patients post-discharge. After intervention initiation, the week-to-week mean number of PPI prescriptions decreased by 0.5 (S<0.0001). Barriers and facilitators spanned the 5 elements of the SEIPS model and included factors such as providers' perception that PPIs are low priority medications and patients' willingness to make changes to their PPI therapy if needed, respectively. Ready access to pharmacists was another frequently reported facilitator to guideline-concordant PPI. Providers recommended a PPI de-implementation intervention that is specific and tells them exactly what they need to do with a PPI treatment. In a busy inpatient setting, we developed a feasible way to assess PPI therapy, de-implement non-guideline-concordant PPI use, and provide follow-up to assess any unintended consequences. We documented barriers, facilitators, and provider recommendations that should be considered before implementing such an intervention on a large scale. |
| 962 | Jessica Tischendorf | ID | jtischen@medicine.wisc.edu | Are Fluoroquinolones or Macrolides Better for Treating Legionella Pneumonia? A Systematic Review and Meta-analysis. | The Infectious Diseases Society of America recommends either a fluoroquinolone or a macrolide as a first-line antibiotic treatment for Legionella pneumonia, but it is unclear which antibiotic leads to optimal clinical outcomes. We compared the effectiveness of fluoroquinolone versus macrolide monotherapy in Legionella pneumonia using a systematic review and meta-analysis. We conducted a systematic search of literature in PubMed, Cochrane, Scopus, and Web of Science from inception to 1 June 2019. Randomized controlled trials and observational studies comparing macrolide with fluoroquinolone monotherapy using clinical outcomes in patients with Legionella pneumonia were included. Twenty-one publications out of an initial 2073 unique records met the selection criteria. Following PRISMA guidelines, 2 reviewers participated in data extraction. The primary outcome was mortality. Secondary outcomes included clinical cure, time to apyrexia, length of hospital stay (LOS), and the occurrence of complications. The review and meta-analysis was registered with PROSPERO (CRD42019132901). Twenty-one publications with 3525 patients met inclusion criteria. The mean age of the population was 60.9 years and 67.2% were men. The mortality rate for patients treated with fluoroquinolones was 6.9% (104/1512) compared with 7.4% (133/1790) among those treated with macrolides. The pooled odds ratio assessing risk of mortality for patients treated with fluoroquinolones versus macrolides was 0.94 (95% confidence interval, .71-1.25, I2 = 0%, P = .661). Clinical cure, time to apyrexia, LOS, and the occurrence of complications did not differ for patients treated with fluoroquinolones versus macrolides. We found no difference in the effectiveness of fluoroquinolones versus macrolides in reducing mortality among patients with Legionella pneumonia. |
| 963 | Jessica Tischendorf | ID | jtischen@medicine.wisc.edu | Bridging Undergraduate and Graduate Medical Education: A Resident-as-Educator Curriculum Embedded in an Internship Preparation Course. | Many graduate medical education programs have implemented curricula to develop trainees into the next generation of medical teachers; however, coordination of in-person teaching curricula is challenging due to full trainee schedules. To address limited in-person time, we developed a largely asynchronous resident-as-educator curriculum. Our elective curricular activities are embedded within the fourth-year internship preparation course at the University of Wisconsin School of Medicine and Public Health and include trainees from internal medicine, family medicine, and pediatrics. Trainee self-assessment of teaching skills improved after our curriculum, and students evaluated resident sessions favorably. Trainees can be effective teachers in an internship preparation course after a brief, asynchronous teaching curriculum. To disseminate our curriculum, we designed a resident-as-educator curriculum website. |
| 964 | Jessica Tischendorf | ID | jtischen@medicine.wisc.edu | Evaluation of a successful fluoroquinolone restriction intervention among high-risk patients: A mixed-methods study. | We conducted a quality improvement initiative to restrict fluoroquinolone prescribing on two inpatient units housing high-risk patients and applied a human factors approach to understanding the barriers and facilitators to success of this intervention by front-line providers. This was a mixed-methods, quasi-experimental study. This study was conducted on two inpatient units at a tertiary care academic medical center: the medical-surgical intensive care and abdominal solid organ transplant units. Unit-level data were collected retrospectively for 24 months pre- and post- fluoroquinolone restriction intervention, implemented in July 2016, for all admissions to the study units. Our restriction intervention required antimicrobial stewardship pre-approval for fluoroquinolone prescribing. We explored barriers and facilitators to optimal fluoroquinolone prescribing using semi-structured interviews attending, fellow and resident physicians, advanced practice providers and pharmacists on these units. Hospital-onset C. difficile infection did not decrease significantly, but fluoroquinolone use declined significantly from 111.6 to 19.8 days of therapy per 1000 patient-days without negatively impacting length of stay, readmissions or mortality. Third generation cephalosporin and aminoglycoside use increased post-restriction. Providers identified our institution's strong antimicrobial stewardship program and pharmacy involvement in antimicrobial decision making as key facilitators of fluoroquinolone optimization and patient complexity, lack of provider education and organizational culture as barriers to optimal prescribing. Fluoroquinolones can be safely restricted even among high-risk patients without negatively impacting length of stay, readmissions or mortality. Our study provides a framework for successful antimicrobial stewardship interventions informed by perceptions of front line providers. |
| 965 | Jessica Tischendorf | ID | jtischen@medicine.wisc.edu | Research Agenda for Microbiome Based Research for Multidrug-resistant Organism Prevention in the Veterans Health Administration System. | |
| 966 | Jessica Tischendorf | ID | jtischen@medicine.wisc.edu | On the hands of patients with Clostridium difficile: A study of spore prevalence and the effect of hand hygiene on C difficile removal. | The prevalence of Clostridium difficile spores was assessed in 48 observations of infected inpatients. Participants were randomized to hand hygiene with either alcohol-based handrub or soap and water. C difficile was recovered in 14.6% of pre-hand hygiene observations. It was still present on 5 of these 7 participants after hand hygiene (3/3 using alcohol-based handrub; 2/4 using soap and water). |
| 967 | Aurora Pop-Vicas | ID | popvicas@medicine.wisc.edu | The Functional Consequences of Long COVID Need to Be Addressed by Occupational Therapists. | Long COVID-persistent health complications after recovery from coronavirus disease 2019 infection-is associated with activity limitations in nearly 48 million U.S. adults, affecting work, leisure, family, and community functioning. Occupational therapists are experts in customizing interventions to maximize performance of daily routines, and often treat individuals who experience similar functional impacts to those observed in long COVID. The large number of people experiencing new disability, as well as a lack of medical treatment options, make occupational therapy a crucial component of long-COVID research and multidisciplinary management. In this column, we discuss actionable steps occupational therapists can take to place them at the forefront of maximizing functional and quality-of-life outcomes for people with long COVID. |
| 968 | Aurora Pop-Vicas | ID | popvicas@medicine.wisc.edu | A scoping review of bacterial resistance among inpatients amidst the COVID-19 pandemic. | The COVID-19 pandemic disrupted antimicrobial stewardship and infection prevention operations worldwide, raising concerns for an acceleration of antimicrobial resistance (AMR). Therefore, we aimed to define the scope of peer reviewed research comparing AMR in inpatient bacterial clinical cultures before and after the start of the COVID-19 pandemic. We conducted a scoping review and searched PubMed, Scopus, and Web of Science through 15 June 2023. Our inclusion criteria were: (1) English language, (2) primary evidence, (3) peer-reviewed, (4) clinical culture data from humans, (5) AMR data for at least one bacterial order/species, (6) inpatient setting, (7) use of statistical testing to evaluate AMR data before and during the COVID-19 pandemic. Reviewers extracted country, study design, type of analysis, study period, setting and population, number of positive cultures or isolates, culture type(s), method of AMR analysis, organisms, and AMR results. Study results were organised by organism and antibiotic class or resistance mechanism. AMR results are also summarised by individual study and across all studies. In total, 4805 articles were identified with 55 papers meeting inclusion criteria. Acinetobacter baumannii, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus aureus were the most commonly studied organisms. There were 464 bacterial AMR results across all studies with 82 (18%) increase, 71 (15%) decrease, and 311 (67%) no change results. The literature examining the impact of COVID-19 on AMR among inpatients is diverse with most results reflecting no change pre/post pandemic. Ongoing inquiry is needed into evolving patterns in AMR post COVID-19. |
| 969 | Aurora Pop-Vicas | ID | popvicas@medicine.wisc.edu | A severe acute respiratory coronavirus virus 2 (SARS-CoV-2) nosocomial cluster with inter-facility spread: Lessons learned. | Despite infection control guidance, sporadic nosocomial coronavirus disease 2019 (COVID-19) outbreaks occur. We describe a complex severe acute respiratory coronavirus virus 2 (SARS-CoV-2) cluster with interfacility spread during the SARS-CoV-2 δ (delta) pandemic surge in the Midwest. This study was conducted in (1) a hematology-oncology ward in a regional academic medical center and (2) a geographically distant acute rehabilitation hospital. We conducted contact tracing for each COVID-19 case to identify healthcare exposures within 14 days prior to diagnosis. Liberal testing was performed for asymptomatic carriage for patients and staff. Whole-genome sequencing was conducted for all available clinical isolates from patients and healthcare workers (HCWs) to identify transmission clusters. In the immunosuppressed ward, 19 cases (4 patients, 15 HCWs) shared a genetically related SARS-CoV-2 isolate. Of these 4 patients, 3 died in the hospital or within 1 week of discharge. The suspected index case was a patient with new dyspnea, diagnosed during preprocedure screening. In the rehabilitation hospital, 20 cases (5 patients and 15 HCWs) positive for COVID-19, of whom 2 patients and 3 HCWs had an isolate genetically related to the above cluster. The suspected index case was a patient from the immune suppressed ward whose positive status was not detected at admission to the rehabilitation facility. Our response to this cluster included the following interventions in both settings: restricting visitors, restricting learners, restricting overflow admissions, enforcing strict compliance with escalated PPE, access to on-site free and frequent testing for staff, and testing all patients prior to hospital discharge and transfer to other facilities. Stringent infection control measures can prevent nosocomial COVID-19 transmission in healthcare facilities with high-risk patients during pandemic surges. These interventions were successful in ending these outbreaks. |
| 970 | Aurora Pop-Vicas | ID | popvicas@medicine.wisc.edu | Understanding clinical implementation coordinators' experiences in deploying evidence-based interventions. | The fluoroquinolone restriction for the prevention of Clostridioides difficile infection (FIRST) trial is a multisite clinical study in which sites carry out a preauthorization process via electronic health record-based best-practice alert (BPA) to optimize the use of fluoroquinolone antibiotics in acute care settings. Our research team worked closely with clinical implementation coordinators to facilitate the dissemination and implementation of this evidence-based intervention. Clinical implementation coordinators within the antibiotic stewardship team (AST) played a pivotal role in the implementation process; however, considerable research is needed to further understand their role. In this study, we aimed to (1) describe the roles and responsibilities of clinical implementation coordinators within ASTs and (2) identify facilitators and barriers coordinators experienced within the implementation process. We conducted a directed content analysis of semistructured interviews, implementation diaries, and check-in meetings utilizing the conceptual framework of middle managers' roles in innovation implementation in healthcare from Urquhart et al. Clinical implementation coordinators performed a variety of roles vital to the implementation's success, including gathering and compiling information for BPA design, preparing staff, organizing meetings, connecting relevant stakeholders, evaluating clinical efficacy, and participating in the innovation as clinicians. Coordinators identified organizational staffing models and COVID-19 interruptions as the main barriers. Facilitators included AST empowerment, positive relationships with staff and oversight/governance committees, and using diverse implementation strategies. When implementing healthcare innovations, clinical implementation coordinators facilitated the implementation process through their roles and responsibilities and acted as strategic partners in improving the adoption and sustainability of a fluoroquinolone preauthorization protocol. |
| 971 | Aurora Pop-Vicas | ID | popvicas@medicine.wisc.edu | Predictors of persistent symptoms after severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection among healthcare workers: Results of a multisite survey. | |
| 972 | Aurora Pop-Vicas | ID | popvicas@medicine.wisc.edu | A Perfect Storm: COVID-19 and Antimicrobial Resistance. | |
| 973 | Aurora Pop-Vicas | ID | popvicas@medicine.wisc.edu | Surgeons' mental models of surgical site infection: Insights into adherence with complex prevention bundles. | Of 10 surgeons interviewed in a descriptive qualitative study, 6 believed that surgical site infections are inevitable. Bundle adherence was felt to be more likely with strong evidence-based measures developed by surgical leaders. The intrinsic desire to excel was viewed as the main adherence motivator, rather than "pay-for-performance" models. |
| 974 | Aurora Pop-Vicas | ID | popvicas@medicine.wisc.edu | Characterization of bacterial composition of surgical site infections after gynecologic surgery. | |
| 975 | Aurora Pop-Vicas | ID | popvicas@medicine.wisc.edu | Hospital-acquired Legionella pneumonia outbreak at an academic medical center: Lessons learned. | An outbreak of Legionella pneumonia occurred at a university hospital using copper-silver ionization for potable water disinfection. We present the epidemiological and laboratory investigation of the outbreak, and associated case-control study. Cases were defined by syndrome compatible with Legionella pneumonia with laboratory-confirmed Legionella infection. The water circuit and disinfection system were assessed, and water samples collected for Legionella culture. Whole genome multi-locus sequence typing (wgMLST) was used to compare the genetic similarity of patient and environmental isolates. A case-control study was conducted to identify risk factors for Legionella pneumonia. We identified 13 cases of hospital-acquired Legionella. wgMLST revealed >99.9% shared allele content among strains isolated from clinical and water samples. Smoking (P= .008), steroid use (P= .007), and documented shower during hospitalization (P= .03) were risk factors for Legionella pneumonia on multivariable analysis. Environmental assessment identified modifications to the hospital water system had occurred in the month preceding the outbreak. Multiple mitigation efforts and application of point of use water filters stopped the outbreak. Potable water system Legionella colonization occurs despite existing copper-silver ionization systems, particularly after structural disruptions. Multidisciplinary collaboration and direct monitoring for Legionella are important for outbreak prevention. Showering is a modifiable risk factor for nosocomial Legionella pneumonia. Shower restriction and point-of-use filters merit consideration during an outbreak. |
| 976 | Aurora Pop-Vicas | ID | popvicas@medicine.wisc.edu | Risk Factors and Mortality for Atypical Presentation of COVID-19 Infection in Hospitalized Patients - Lessons From the Early Pandemic. | To assess the clinical epidemiology and outcomes of patients hospitalized with COVID-19 who did not experience fever and cough during the early pandemic. Retrospective cohort of all patients admitted during March 13, 2020 through May 13, 2020 with laboratory-confirmed COVID-19 to 3 tertiary-care hospitals. Patient-level data (demographic, clinical manifestations, comorbid illnesses, inpatient treatment) were analyzed. The main outcome variable was atypical presentation, defined as any hospitalized patient with COVID-19 infection who did not experience both fever and cough. We identified risk factors for atypical presentation on univariate and multivariate analyses and assessed 30-day mortality differences via survival analysis. Of 163 patients in the study, 39 (24%) were atypical. On univariate analysis, atypical cases were significantly more likely to be older, reside in a long-term-care facility (LTCF), and have underlying diabetes mellitus, stroke, or cardiac disease; present without dyspnea or myalgia, have lower C-reactive proteins (CRP) and higher beta-natriuretic peptides. They were less likely to receive intensive care unit care or specific COVID-19 treatments (P < .05). The incidence of acute respiratory failure was not significantly different between the groups. On logistic regression, atypical cases were significantly more likely to be LTCF residents (P = 0.003) and have a lower average CRP (P = 0.01). Atypical cases had significantly higher 30-day mortality (hazard ratio 3.4 [95% CI, 1.6 - 7.2], P = 0.002). During the first pandemic surge, COVID-19 patients without inflammatory signs and symptoms were more likely to be LTCF residents and had higher mortality. Timely recognition of these atypical presentations may have prevented spread and improved clinical outcomes. |
| 977 | Joseph McBride | ID | jmcbride@medicine.wisc.edu | Multiple Lactobacillus Infections Caused by Probiotics at Pediatric and Adult Academic Medical Centers. | Probiotics are synthetic oral supplements containing live bacterial and fungal species hypothesized to help with various gastrointestinal conditions. However, they can cause infection if the organism spreads outside of the gastrointestinal tract. The aim of this study was to identify and describe patients who experienced systemic infections caused by probiotic use. This study was a retrospective chart review of pediatric and adult patients at academic medical centers who received probiotics and subsequently developed positive cultures from a sterile site for probiotic-related species. Two individuals completed the chart reviews to determine if the probiotic was the true cause of the infection. Lactobacillus, Bifidobacterium, and Saccharomyces cultures were reviewed, with a total of 71, 8, and 2 cultures isolated from sterile sites for each organism, respectively. Further review revealed 23 Lactobacillus cultures from 13 unique patients who were taking Lactobacillus-containing probiotics. Four patients without gastrointestinal tract compromise were included in the final analysis, including 1 patient whose culture was confirmed as identical to the probiotic. Types of infections included meningitis and bacteremia. Targeted antimicrobial therapy included ampicillin, ampicillin-sulbactam, and piperacillin-tazobactam, with total durations of therapy ranging from 10 to 22 days. No patients had mortality attributed to Lactobacillus infection. Probiotics are not harmless supplements as they come with risk of serious infection as demonstrated in this review. Before use, the risks of probiotics should be considered carefully for each individual patient. Clinicians should consider avoiding probiotics in hospitalized patients, especially those with vascular or extra-ventricular access devices. |
| 978 | Joseph McBride | ID | jmcbride@medicine.wisc.edu | Performance characteristics of "lollipop" swabs for the diagnosis of infection with SARS-CoV-2. | Common biologic samples used to diagnose COVID-19 include nasopharyngeal, nasal, or oropharyngeal swabs, and salivary samples. The performance characteristics of a sucked "lollipop" swab to detect SARS-CoV-2 virus is assessed in four small sub-studies. In each sub-study, a flocked swab was sucked for 20 s and submitted for PCR detection of SARS-CoV-2 virus. Across all studies, 52 of 69 (75.4%) COVID-19 positive participants had positive "lollipop" swabs. Twelve of the 17 COVID-19 positive participants with negative "lollipop" swabs had known corresponding cycle threshold values of >37 from their nasal/nasopharyngeal swabs, an indication of low viral load at time of sampling. In a paired samples sub-study, the sensitivity and specificity of the "lollipop" swabs were 100% and 98%. "Lollipop" swabs performed satisfactorily especially in individuals with acute infection of COVID-19. "Lollipop" swabs are a simple method of sample collection for detecting SARS-CoV-2 virus and warrants additional consideration. |
| 979 | Joseph McBride | ID | jmcbride@medicine.wisc.edu | Validation of Thermal Imaging and the ALT-70 Prediction Model to Differentiate Cellulitis From Pseudocellulitis. | Cellulitis is misdiagnosed in up to 30% of cases due to mimic conditions termed pseudocellulitis. The resulting overuse of antibiotics is a threat to patient safety and public health. Surface thermal imaging and the ALT-70 (asymmetry, leukocytosis, tachycardia, and age ≥70 years) prediction model have been proposed as tools to help differentiate cellulitis from pseudocellulitis. To validate differences in skin surface temperatures between patients with cellulitis and patients with pseudocellulitis, assess the optimal temperature measure and cut point for differentiating cellulitis from pseudocellulitis, and compare the performance of skin surface temperature and the ALT-70 prediction model in differentiating cellulitis from pseudocellulitis. This prospective diagnostic validation study was conducted among patients who presented to the emergency department with acute dermatologic lower extremity symptoms from October 11, 2018, through March 11, 2020. Statistical analysis was performed from July 2020 to March 2021 with additional work conducted in September 2023. Temperature measures for affected and unaffected skin were obtained. Cellulitis vs pseudocellulitis was assessed by a 6-physician, independent consensus review. Differences in temperature measures were compared using the t test. Logistic regression was used to identify the temperature measure and associated cut point with the optimal performance for discriminating between cellulitis and pseudocellulitis. Diagnostic performance characteristics for the ALT-70 prediction model, surface skin temperature, and both combined were also assessed. The final sample included 204 participants (mean [SD] age, 56.6 [16.5] years; 121 men [59.3%]), 92 (45.1%) of whom had a consensus diagnosis of cellulitis. There were statistically significant differences in all skin surface temperature measures (mean temperature, maximum temperature, and gradients) between cellulitis and pseudocellulitis. The maximum temperature of the affected limb for patients with cellulitis was 33.2 °C compared with 31.2 °C for those with pseudocellulitis (difference, 2.0 °C [95% CI, 1.3-2.7 °C]; P < .001). The maximum temperature was the optimal temperature measure with a cut point of 31.2 °C in the affected skin, yielding a mean (SD) negative predictive value of 93.5% (4.7%) and a sensitivity of 96.8% (2.3%). The sensitivity of all 3 measures remained above 90%, while specificity varied considerably (ALT-70, 22.0% [95% CI, 15.8%-28.1%]; maximum temperature of the affected limb, 38.4% [95% CI, 31.7%-45.1%]; combination measure, 53.9% [95% CI, 46.5%-61.2%]). In this large diagnostic validation study, significant differences in skin surface temperature measures were observed between cases of cellulitis and cases of pseudocellulitis. Thermal imaging and the ALT-70 both demonstrated high sensitivity, but specificity was improved by combining the 2 measures. These findings support the potential of thermal imaging, alone or in combination with the ALT-70 prediction model, as a diagnostic adjunct that may reduce overdiagnosis of cellulitis. |
| 980 | Joseph McBride | ID | jmcbride@medicine.wisc.edu | Recommendations for SARS-CoV-2 Testing in Children With Disabilities and Medical Complexity. | Schools provide important services that cannot be provided virtually to children with medical complexity and children with intellectual and developmental disabilities, yet these children are among the most at risk from coronavirus disease 2019 (COVID-19). To keep schools open for children with medical complexity and/or intellectual and developmental disabilities during the COVID-19 pandemic, we implemented severe acute respiratory syndrome coronavirus 2 testing at 3 sites across the United States. We evaluated testing strategies for staff and students at each site, including specimen source (nasopharyngeal or saliva), test type (polymerase chain reaction or rapid antigen), and frequency and type (screening versus exposure/symptomatic) of testing provided. Among the greatest barriers to severe acute respiratory syndrome coronavirus 2 testing in these schools was the engagement of caregivers and challenges navigating legal guardianship for consenting adult students. Additionally, variability in testing strategies nationally and in the community, as well as surges in viral transmission across the United States during the course of the pandemic, led to testing hesitancy and variable participation rates. Essential to the successful implementation of testing programs is building a trusted relationship with school administrators and guardians. Leveraging our experiences with COVID-19 and forming lasting school partnerships can help keep schools for vulnerable children safe in future pandemics. |
| 981 | Joseph McBride | ID | jmcbride@medicine.wisc.edu | In-Home COVID-19 Testing for Children With Medical Complexity: Feasibility and Association With School Attendance and Safety Perceptions. | The REstarting Safe Education and Testing program for children with medical complexity was implemented in May 2021 at the University of Wisconsin to evaluate the feasibility of in-home rapid antigen COVID-19 testing among neurocognitively affected children. Parents or guardians administered BinaxNOW rapid antigen self-tests twice weekly for three months and changed to symptom and exposure testing or continued surveillance. In-home testing was feasible: nearly all (92.5%) expected tests were conducted. Symptomatic testing identified seven of nine COVID-19 cases. School safety perceptions were higher among those opting for symptom testing. Clinical Trials.gov identifier: NCT04895085. (Am J Public Health. 2022;112(S9):S878-S882. https://doi.org/10.2105/AJPH.2022.306971). |
| 982 | Joseph McBride | ID | jmcbride@medicine.wisc.edu | COVID-19 Vaccination Coverage Among People Experiencing Homelessness in a Highly Vaccinated Midwest County-Dane County, Wisconsin, 2021. | People experiencing homelessness (PEH) are at increased risk for coronavirus disease 2019 (COVID-19) infection. This study assessed COVID-19 vaccination coverage among vaccine-eligible PEH (5 years and older) stratified by demographic characteristics. PEH were less likely to complete a primary vaccination series than the Dane County population (32.0%; 95% confidence interval [CI], 30.3%-33.8% vs 82.4%; 95% CI, 82.3%-82.5%) and were less likely to have received a booster when eligible (30.8%; 95% CI, 27.8%-33.9% vs 67.2%; 95% CI, 67.1%-67.4%). Vaccination rates were lowest among young PEH and PEH of color. |
| 983 | Joseph McBride | ID | jmcbride@medicine.wisc.edu | COVID-19 Vaccination Intentions for Children With Medical Complexity. | The chronic conditions and functional limitations experienced by children with medical complexity (CMC) place them at disproportionate risk for COVID-19 transmission and poor outcomes. To promote robust vaccination uptake, specific constructs associated with vaccine hesitancy must be understood. Our objective was to describe demographic, clinical, and vaccine perception variables associated with CMC parents' intention to vaccinate their child against COVID-19. We conducted a cross-sectional survey (June-August 2021) for primary caregivers of CMC between ages 5 to 17 at an academic medical center in the Midwest. Multivariable logistic regression examined associations between vaccination intent and selected covariates. Among 1330 families, 65.8% indicated vaccination intent. In multivariable models, demographics had minimal associations with vaccination intent; however, parents of younger children (1 complex chronic condition (vs 1), had higher adjusted odds of vaccination intent (1.82 [1.14-2.92] and 1.77 [1.16-2.71], respectively). Vaccine perceptions associated with vaccine intention included "My doctor told me to get my child a COVID-19 vaccine" (2.82 [1.74-4.55]); and "I'm concerned about my child's side effects from the vaccine" (0.18 [0.12-0.26]). One-third of CMC families expressed vaccine hesitation; however, constructs strongly associated with vaccination intent are potentially modifiable. Pediatrician endorsement of COVID-19 vaccination and careful counseling on side effects might be promising strategies to encourage uptake. |
| 984 | Joseph McBride | ID | jmcbride@medicine.wisc.edu | Comparing skin surface temperature to clinical documentation of skin warmth in emergency department patients diagnosed with cellulitis. | To compare clinical documentation of skin warmth to patient report and quantitative skin surface temperatures of patients diagnosed with cellulitis in the emergency department (ED). Adult patients (≥18 years) presenting to the ED with an acute complaint involving visible erythema of the lower extremity were prospectively enrolled. Those diagnosed with cellulitis were included in this analysis. Participant report of skin warmth was recorded and skin surface temperature values were obtained from the affected and corresponding unaffected area of skin using thermal cameras. Average temperature (Tavg) was extracted from each image and the difference in Tavg between the affected and unaffected limb was calculated (Tgradient). Clinical documentation of skin warmth was compared to patient report and measured skin warmth (Tgradient >0°C). Among 126 participants diagnosed with cellulitis, 110 (87%) exhibited objective warmth (Tgradient >0°C) and 58 (53%) of these cases had warmth documented in the physical examination. Of those with objective warmth, 86 (78%) self-reported warmth and 7 (6%) had warmth documented in their history of present illness (HPI) (difference = 72%, 95% confidence interval [CI]: 62%-82%; P < 0.001). A significant difference was observed for Tavg affected when warmth was documented (32.1°C) versus not documented (31.0°C) in the physical examination (difference = 1.1°C, 95% CI: 0.29-1.94; P = 0.0083). No association was found between Tgradient and patient-reported or HPI-documented warmth. The majority of ED-diagnosed cellulitis exhibited objective warmth, yet significant discordance was observed between patient-reported, clinician-documented, and measured warmth. This raises concerns over inadequate documentation practices and/or the poor sensitivity of touch as a reliable means to assess skin surface temperature. Introduction of objective temperature measurement tools could reduce subjectivity in the assessment of warmth in patients with suspected cellulitis. |
| 985 | Joseph McBride | ID | jmcbride@medicine.wisc.edu | Clinical Manifestations and Outcomes in Immunocompetent and Immunocompromised Patients With Blastomycosis. | Blastomyces is a dimorphic fungus that infects persons with or without underlying immunocompromise. To date, no study has compared the clinical features and outcomes of blastomycosis between immunocompromised and immunocompetent persons. A retrospective study of adult patients with proven blastomycosis from 2004-2016 was conducted at the University of Wisconsin. Epidemiology, clinical features, and outcomes were analyzed among solid-organ transplantation (SOT) recipients, persons with non-SOT immunocompromise (non-SOT IC), and persons with no immunocompromise (NIC). A total of 106 cases met the inclusion criteria including 74 NIC, 19 SOT, and 13 non-SOT IC (malignancy, HIV/AIDS, idiopathic CD4+ lymphopenia). The majority of patients (61.3%) had at least 1 epidemiologic risk factor for acquisition of Blastomyces. Pneumonia was the most common manifestation in all groups; however, immunocompromised patients had higher rates of acute pulmonary disease (P = .03), more severe infection (P = .007), respiratory failure (P = .010), and increased mortality (P = .02). Receipt of SOT primarily accounted for increased severity, respiratory failure, and mortality in immunosuppressed patients. SOT recipients had an 18-fold higher annual incidence of blastomycosis than the general population. The rate of disseminated blastomycosis was similar among NIC, SOT, and non-SOT IC. Relapse rates were low (5.3-7.7%). Immunosuppression had implications regarding the acuity, severity, and respiratory failure. The rate of dissemination was similar across the immunologic spectrum, which is in sharp contrast to other endemic fungi. This suggests that pathogen-related factors have a greater influence on dissemination for blastomycosis than immune defense. |
| 986 | Joseph McBride | ID | jmcbride@medicine.wisc.edu | Impact of COVID-19 Quarantine and School Cancelation on Other Common Infectious Diseases. | Coronavirus disease 2019 lead to wide-spread quarantines and cancelations. The impact of these measures on other, noncoronavirus disease 2019, infectious diseases was analyzed within Dane County, Wisconsin. The incidence of streptococcal pharyngitis and acute otitis media decreased during quarantine while gonorrhea increased. Quarantine had the expected result for infections spread via the respiratory route but a different effect from those transmitted through sexual activity. |
| 997 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Widening access to recombinant zoster vaccination in IBD. | |
| 998 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Non-colorectal Cancer Screening and Vaccinations in Patients with Inflammatory Bowel Disease: Expert Review. | The aim of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) is to provide best practice advice (BPA) statements for gastroenterologists and other health care providers who provide care to patients with inflammatory bowel disease (IBD). The focus is on IBD-specific screenings (excluding colorectal cancer screening, which is discussed separately) and vaccinations. We provide guidance to ensure that patients are up to date with the disease-specific cancer screenings, vaccinations, as well as advice for mental health and general wellbeing. This expert review was commissioned and approved by the AGA CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. The BPA statements were drawn from reviewing existing literature combined with expert opinion to provide practical advice on the screening for non-colorectal cancers and vaccinations in patients with IBD. Because this was not a systematic review, formal rating of the quality of evidence or strength of the presented considerations was not performed. BPA 1. All adult patients with IBD should receive age-appropriate cancer screening. BPA 2. Adult women with IBD should follow age-appropriate screening for cervical dysplasia. Data are insufficient to determine whether patients receiving combined immunosuppression or thiopurines require more frequent screening. Shared decision making and individual risk stratification are encouraged. BPA 3. All adult patients with IBD should follow skin cancer primary prevention practices by avoiding excessive exposure to the sun's ultraviolet radiation. Patients on immunomodulators, anti-tumor necrosis factor (anti-TNF) biologic agents, or small molecules should undergo yearly total body skin exam (TBSE). Patients with any history of thiopurine use should continue with yearly TBSE even after thiopurine cessation. BPA 4. At every colonoscopy, a thorough perianal and anal examination should be performed. Special attention should be made to inspection of the anal canal of patients with perianal Crohn's disease, anal stricture, human papilloma virus (HPV), human immunodeficiency virus (HIV), and those who engage in anoreceptive intercourse. BPA 5. Gastroenterology clinicians should discuss age-appropriate vaccines with adult patients who have IBD and share responsibility with primary care providers for administering these vaccines. Patients with IBD should follow the adult immunization schedule recommended by the Centers for Disease Control and Prevention (CDC) for all vaccines with the exception of live vaccines; Patients receiving immune modifying agents should be counseled against receiving live vaccines. Immunization history to the two live pediatric vaccines, varicella and measles, mumps, and rubella (MMR) vaccine series is presumptive evidence of immunity; All adults 18-26 years should receive HPV vaccine series and those between 27-45 years should be vaccinated if they are likely to have a new sexual partner. BPA 6. Inactivated vaccines are safe in patients with IBD and their administration are not associated with exacerbation of IBD activity. We suggest patients receive vaccines at the earliest opportunity and preferably off corticosteroids or at the lowest tolerable corticosteroid dose. BPA 7. All adult patients with IBD should be evaluated for latent hepatitis B infection. Patients who have previously completed a full hepatitis B vaccine series but are not seroprotected (anti-HBs < 10 mIU/mL) should receive a single challenge dose of hepatitis B vaccine; Four to eight weeks after this challenge dose, their hepatitis B surface antibody (anti-HBs) levels should be measured to evaluate for an amnestic response; An amnestic response, indicated by an anti-HBs level ≥ 10 mIU/mL (seroprotection), suggests immunologic memory and no further doses are needed; If no amnestic response is observed, the patient should complete a second full two or three dose series of hepatitis B vaccination. BPA 8. All adult patients with IBD should receive an annual inactivated influenza vaccine; Patients receiving anti-TNF monotherapy or who have undergone a solid organ transplant can benefit from a high dose influenza vaccine; Older adults 65 years of age and older should receive a high dose, recombinant, or adjuvanted influenza vaccine. Live attenuated intranasal vaccines should be avoided. BPA 9. All adult patients with IBD aged 19-64 years should receive an initial pneumococcal vaccine, with an subsequent second pneumococcal vaccine administered at 65 years of age and older. BPA 10. All adult patients with IBD who are 60 years of age and older should receive a respiratory syncytial virus (RSV) vaccine. There is no preference for any of the available RSV vaccines. BPA 11. All adult patients 19 years of age and older receiving immune-modifying therapies, or with plans to initiate immune-modifying therapies, should receive a recombinant herpes zoster (RZV) vaccine series, regardless of their prior varicella vaccination status. BPA 12. Bone densitometry should be considered in patients with IBD, regardless of age, when risk factors for osteopenia and osteoporosis are present. These risk factors include low body mass index (BMI; <20), greater than 3 months of cumulative corticosteroid exposure, current smoking, post-menopausal status, or hypogonadism. In the absence of other factors, bone densitometry should be considered for post-menopausal women and men 65 years or older. BPA 13. All adult patients with IBD should be screened for depression and anxiety annually. Patients who screen positive for depression or anxiety should be referred to the appropriate specialist, be it their primary care physician or a mental health specialist. |
| 999 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Editorial: Updated COVID-19 Boosters-Tailoring Protection for Patients With IBD. | |
| 1.000 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Letter: Enhancing the Rigor of Research on Herpes Zoster Risk in IBD Patients Post-SARS-CoV2: Recommendations for Global and Detailed Analyses-Authors' Reply. | |
| 1.001 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Inadvertent live vaccine administration in adult patients with inflammatory bowel disease on immunosuppressive therapy. | Live vaccines are contraindicated in patients on immunosuppressive therapy. We conducted a retrospective study evaluating the administration of a live vaccine in patients with IBD on immunosuppressive therapy. The primary outcome was to determine clinical or disseminated disease episodes within three months of vaccine administration in patients who inadvertently received a live vaccine. Thirty-five patients met the inclusion criteria. Twenty-two received the measles, mumps, and varicella (MMR) vaccine, nine received the live zoster vaccine, and one received the varicella vaccine (VAR). Three patients received both the MMR and VAR. The majority of our cohort (20, 57 %) were on anti-tumor necrosis factor, followed by azathioprine (12, 34 %) and vedolizumab (3, 9 %). Although live vaccines are contraindicated in patients on immunosuppressive therapy, none of the patients in this study reported any infections after inadvertent immunization. Further studies are required to address the safety and effectiveness of live vaccine administration in this population. |
| 1.002 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Patients with Inflammatory Bowel Disease are at Increased Risk for Complications of Herpes Zoster. | Patients with inflammatory bowel disease (IBD) are at an increased risk for vaccine-preventable diseases, such as herpes zoster (HZ). The aim of this study was to determine whether complications of HZ are more frequent in patients with IBD than in non-IBD controls. This was a retrospective, cohort study using the Optum Research Database. Patients with IBD were matched 1:1 to non-IBD controls based on age, sex, and index year, which was defined as the diagnosis of HZ. We then identified the complications of HZ that occurred up to 90 days after the index date. We compared patients with IBD with non-IBD controls and evaluated the 90-day risk of HZ complications. We used a composite primary outcome for any HZ complication. Secondary outcomes were risk factors for complications. A total of 4756 patients with IBD met the inclusion criteria and were matched to the controls. Patients with IBD were more likely to have complications of HZ than controls (738 [15.52%] vs 595 [12.51%]; P < .0001). Patients with IBD with higher comorbidity scores were more likely to develop complications (1.86 vs 1.18; P < .0001). In the logistic regression analysis of patients with IBD having a higher comorbidity score, above 50 years of age, on anti-tumor necrosis factor (TNF) or corticosteroids were all at increased risk of a complication of HZ. Patients with IBD are more likely to have complications of HZ than controls. Efforts are needed to increase HZ vaccine uptake to reduce the morbidity of HZ. |
| 1.003 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Utility of a Third Heplisav-B Dose in Patients With Inflammatory Bowel Disease Without Immunity After 2-Dose Heplisav-B Vaccination. | Hepatitis B virus (HBV) vaccination is recommended in patients with inflammatory bowel disease (IBD). Although the 2-dose Heplisav-B vaccine has proven effective, more than 20% of patients with IBD do not seroconvert. We prospectively evaluated the effectiveness of a third Heplisav-B dose in patients with IBD lacking HBV immunity despite 2-dose vaccination. Adults with IBD who had received 2-dose Heplisav-B vaccination between 2018 and 2023 were identified. Seroconversion was defined as hepatitis B surface antibody (HBsAb) ≥ 10 IU/L measured at ≥4 weeks after vaccination. Patients who did not seroconvert were prospectively offered a third Heplisav-B dose, followed by repeat HBsAb measurement. Demographic, clinical, medication, and vaccination data were compared between those who did and did not seroconvert. Of 192 patients identified, 71.9% (138/192) seroconverted after 2-dose Heplisav-B vaccination. The 54 patients (28.1%) who did not seroconvert were more likely to be male, have diabetes, chronic kidney disease, or elevated Charlson Comorbidity Index. Of the 54 patients, 30 (55.6%) elected to receive a third Heplisav-B dose, with 56.7% (17/30) achieving seroconversion (median HBsAb titer 376 IU/L, IQR 47-1,000 IU/L) despite a median intervaccination time of 416 days (IQR 90.8-667.8). No differences were noted between patients who did vs did not seroconvert after third-dose vaccination. In patients with IBD lacking HBV immunity despite 2-dose Heplisav-B vaccination, administration of a third dose resulted in a 56.7% seroconversion rate. Our results suggest that administration of an additional Heplisav-B dose may be an effective strategy in patients lacking immunity despite primary 2-dose vaccination. |
| 1.004 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Safety of Rotavirus Vaccination in Infants That Were Exposed to Biologics In Utero: A Systematic Review. | In infants that were exposed to biologics in utero, gastroenterology societal guidelines have either recommended against administration of the live rotavirus vaccine until 6-12 months of age or until serum biologic levels are undetectable. We performed a systematic review to evaluate the safety of rotavirus vaccination in biologic-exposed infants. EMBASE, PubMed, Scopus, and Cochrane databases were searched from 2006 to 2024 for original data reporting on the safety of rotavirus vaccination in infants that were exposed to anti-tumor necrosis factors (TNFs) (ie, infliximab, adalimumab, golimumab, certolizumab) and non-TNF biologics (ie, vedolizumab, ustekinumab, rizankizumab, mirikizumab) in utero. A database search yielded 7185 screening results of which 10 studies met inclusion criteria. There were over 300 instances of rotavirus vaccination in biologic-exposed infants (n = 162 exposed to anti-TNFs, n = 142 exposed to non-TNF biologics). Biologic-exposed infants were not at an increased risk of severe adverse events or adverse events of any severity related to rotavirus vaccination. Administration of the live rotavirus vaccine appears to be safe in biologic-exposed infants. As such, with careful examination of the risks and benefits, there may be a role for rotavirus vaccination in this population. We performed a systematic review evaluating the safety of rotavirus vaccination in infants that were exposed to anti-TNFs and non-TNF biologics in utero. There was no increased risk of adverse events associated with rotavirus vaccination in this population. |
| 1.005 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Hepatitis B-CpG Vaccine Series for Healthcare Workers Who Are Hepatitis B Vaccine Nonresponders. | This prospective study enrolled healthcare workers (HCWs) who were nonresponders following at least 5 doses of aluminum-adjuvanted hepatitis B vaccine who received the 2-dose Heplisav-B (HepB-CpG) (Dynavax Technologies Corporation, Emeryville, CA) series. After 2 doses of HepB-CpG, 43/47 (91%) participants, and with 1 dose, 41/49 (84%) responded. HepB-CpG could be the preferred vaccine in HCW nonresponders. Clinical Trials Registration. Clinicaltrials.gov NCT04456504. |
| 1.006 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | High Rates of Seroprotection to Hepatitis B After a Hepatitis B Challenge Dose in Previously Vaccinated Patients with Inflammatory Bowel Disease on Immunosuppressive Therapy. | Healthy populations have high rates of sustained vaccine-induced seroprotection to hepatitis B virus, but previous studies in immunosuppressed patients with inflammatory bowel disease (IBD) have shown suboptimal seroprotection rates. A challenge dose of hepatitis B vaccine (HepB) is recommended in previously vaccinated individuals who are seronegative to elicit an anamnestic response and determine if they are seroprotected. The aim of our study was to determine sustained seroprotection rates to hepatitis B vaccine (HepB) in patients with IBD. This was a single-center prospective study of patients with IBD previously vaccinated with a three dose HepB series. Patients had a hepatitis B surface antibody (anti-HBs) drawn; if it was below 10 mIU/mL, they received a challenge dose of the HepB vaccine to assess for anamnestic response and sustained seroprotection. The primary outcome was to determine the rate of sustained seroprotection (anti-HBs ≥ 10). A total of 168 patients met inclusion criteria, mean age 35.7 years ± 13.6 standard deviation (SD). Initially 120 (71.4%) had anti-HBs ≥ 10 mIU/mL, with median anti-HBs of 37 mIU/mL (interquartile range 0-234); 48 (28.6%) needed a challenge dose, of which 34 responded with anti-HBs ≥ 10 mIU/mL. In total, 154 (91.7%) demonstrated sustained seroprotection to HepB. Those not seroprotected were more likely to have been vaccinated on immunosuppressive therapy or after their diagnosis of IBD. Most vaccinated patients with IBD maintain sustained seroprotection to HepB despite prolonged exposure to immunosuppression. This contradicts prior studies and shows that immunosuppression does not lead to loss of seroprotection. |
| 1.007 | Michael Lucey | GI | mrl@medicine.wisc.edu | Faecal proteomics links neutrophil degranulation with mortality in patients with alcohol-associated hepatitis. | Patients with alcohol-associated hepatitis (AH) have a high mortality. Alcohol exacerbates liver damage by inducing gut dysbiosis, bacterial translocation and inflammation, which is characterised by increased numbers of circulating and hepatic neutrophils. In this study, we performed tandem mass tag (TMT) proteomics to analyse proteins in the faeces of controls (n=19), patients with alcohol-use disorder (AUD; n=20) and AH (n=80) from a multicentre cohort (InTeam). To identify protein groups that are disproportionately represented, we conducted over-representation analysis using Reactome pathway analysis and Gene Ontology to determine the proteins with the most significant impact. A faecal biomarker and its prognostic effect were validated by ELISA in faecal samples from patients with AH (n=70), who were recruited in a second and independent multicentre cohort (AlcHepNet). Faecal proteomic profiles were overall significantly different between controls, patients with AUD and AH (principal component analysis p=0.001, dissimilarity index calculated by the method of Bray-Curtis). Proteins that showed notable differences across all three groups and displayed a progressive increase in accordance with the severity of alcohol-associated liver disease were predominantly those located in neutrophil granules. Over-representation and Reactome analyses confirmed that differentially regulated proteins are part of granules in neutrophils and the neutrophil degranulation pathway. Myeloperoxidase (MPO), the marker protein of neutrophil granules, correlates with disease severity and predicts 60-day mortality. Using an independent validation cohort, we confirmed that faecal MPO levels can predict short-term survival at 60 days. We found an increased abundance of faecal proteins linked to neutrophil degranulation in patients with AH, which is predictive of short-term survival and could serve as a prognostic non-invasive marker. |
| 1.008 | Michael Lucey | GI | mrl@medicine.wisc.edu | Video introduction: Special issue on alcohol use disorder and liver disease. | |
| 1.009 | Michael Lucey | GI | mrl@medicine.wisc.edu | Therapy of alcohol use disorder in liver transplant recipients. | |
| 1.010 | Michael Lucey | GI | mrl@medicine.wisc.edu | Metabolic dysfunction and alcohol-related liver disease (MetALD): Position statement by an expert panel on alcohol-related liver disease. | In this position statement, we explore the intricate relationship between alcohol intake and metabolic dysfunction in the context of the 2023 nomenclature update for steatotic liver disease (SLD). Recent and lifetime alcohol use should be accurately assessed in all patients with SLD to facilitate classification of alcohol use in grams of alcohol per week. Alcohol biomarkers (i.e., phosphatidylethanol), use of validated questionnaires (i.e. AUDIT-C [alcohol use disorders identification test consumption]), and collateral information from friends and relatives could help facilitate differentiation between alcohol-related liver disease (ALD) per se and liver disease with both metabolic and alcohol-related components (MetALD). Heavy alcohol use can contribute to cardiometabolic risk factors such as high blood pressure, hypertriglyceridaemia, and hyperglycaemia. As a result, caution should be exercised in the application of only one metabolic dysfunction criterion to diagnose MASLD, as suggested in the 2023 nomenclature document, particularly in individuals exceeding weekly alcohol use thresholds of 140 g for women and 210 g for men. This is particularly important in those individuals with isolated high blood pressure, hypertriglyceridaemia, or hyperglycaemia, where the disease process may be driven by alcohol itself. Additionally, metabolic dysfunction and alcohol use should be reassessed over time, especially after periods of change in risk factor exposure. This approach could ensure a more accurate prognosis and effective management of SLD, addressing both metabolic and alcohol-related factors. |
| 1.011 | Michael Lucey | GI | mrl@medicine.wisc.edu | Is there a safe limit for consumption of alcohol? | In order to understand and curb the harms related to alcohol, it will be necessary to think beyond patterns of use that meet criteria for a diagnosis of alcohol use disorder or addiction. Current research suggests that regular daily alcohol use does not confer a health benefit, and, for many persons, even relatively low consumption is associated with a health risk. Determining a safe limit for alcohol consumption is challenging both for the individual person and for society. We conclude that excessive drinking is always risky. We provide a list of circumstances, such as chronic illness, driving a vehicle, or pregnancy where persons should be advised to abstain from alcohol. We recognise the need to encourage less consumption of alcohol, particularly in young adults and older adults with co-morbid conditions (especially if taking multiple medications). Finally, we offer the modest proposal that, for persons without the contributing negative influences described above, consumption which adheres to one drink per session, with interspersed abstinent days, does not constitute a meaningful risk to health. |
| 1.012 | Michael Lucey | GI | mrl@medicine.wisc.edu | Viral antibody response predicts morbidity and mortality in alcohol-associated hepatitis. | Alcohol-associated hepatitis (AH) is associated with very high mortality despite abstinence from alcohol; up to 40% of patients die within 6 months of diagnosis. Patients with AH are especially prone to infections, which can lead to multiorgan dysfunction and poorer prognosis. We performed comprehensive serological profiling of the viral and bacterial infection history of 36 healthy controls, 48 patients with alcohol use disorder, and 224 patients with AH from 2 multicenter observational studies. We used systematic viral and bacterial epitope scanning by VirScan, a phage-display immunoprecipitation and sequencing technology that detects the peptides recognized by antibodies in patient sera, to comprehensively analyze antiviral and antibacterial antibodies and identify serologic biomarkers to predict patient outcomes. We found significant differences in the serological profiles of the 3 populations. The number of serum antibody epitopes in patients with alcohol use disorder during abstinence was increased compared with during active alcohol use. A decreased number and diversity of viral and bacterial antibody targets were detected in the sera of patients with AH, particularly those with a higher Child-Pugh score. In patients with AH, a decrease in the serum antiviral, but not antibacterial, antibody repertoire was associated with decompensation and mortality. Ninety-day mortality in AH could be predicted using a serum viral epitope signature. Abstinence from alcohol is associated with a significant increase in serum viral and bacterial antibody response. Decreased serum antiviral antibody repertoire is predictive of decompensation of liver disease and mortality in patients with AH. |
| 1.013 | Michael Lucey | GI | mrl@medicine.wisc.edu | Designing clinical trials to address alcohol use and alcohol-associated liver disease: an expert panel Consensus Statement. | Most patients with alcohol-associated liver disease (ALD) engage in heavy drinking defined as 4 or more drinks per day (56 g) or 8 (112 g) or more drinks per week for women and 5 or more drinks per day (70 g) or 15 (210 g) or more drinks per week for men. Although abstinence from alcohol after diagnosis of ALD improves life expectancy and reduces the risk of decompensation of liver disease, few studies have evaluated whether treatment of alcohol use disorders will reduce progression of liver disease and improve liver-related outcomes. In November 2021, the National Institute of Alcohol Abuse and Alcoholism commissioned a task force that included hepatologists, addiction medicine specialists, statisticians, clinical trialists and members of regulatory agencies to develop recommendations for the design and conduct of clinical trials to evaluate the effect of alcohol use, particularly treatment to reduce or eliminate alcohol use in patients with ALD. The task force conducted extensive reviews of relevant literature on alcohol use disorders and ALD. Findings were presented at one in-person meeting and discussed over the next 16 months to develop the final recommendations. As few clinical trials directly address this topic, the 28 recommendations approved by all members of the task force represent a consensus of expert opinions. |
| 1.014 | Michael Lucey | GI | mrl@medicine.wisc.edu | Relationship between updated MELD and prognosis in alcohol-associated hepatitis: Opportunities for more efficient trial design. | Alcohol-associated hepatitis (AH) is associated with significant mortality. Model for End-Stage Liver Disease (MELD) score is used to predict short-term mortality and aid in treatment decisions. MELD is frequently updated in the course of AH. However, once the most updated MELD is known, it is uncertain if previous ones still have prognostic value, which might be relevant for transplant allocation and trial design. We aimed to investigate the predictive performance of updated MELDs in a prospectively collected cohort of patients with AH by the InTeam consortium. Three hundred seven patients (with 859 MELD values within 60 d of admission) fulfilled the inclusion criteria. The main endpoint was time to death or transplant up to 90 days. We used a joint model approach to assess the predictive value of updated MELDs. Updated MELD measurements had a strong prognostic value for death/transplant (HR: 1.20, 95% CI: 1.14-1.27) (p < 0.0001). Previous MELD values did not add predictive value to the most current MELD. We also showed that MELD at day 28 (MELD28) had a significant predictive value for subsequent mortality/transplant in a landmark analysis (HR: 1.18, 95% CI: 1.12-1.23). We show that the use of an ordinal scale including death, transplant, and MELD28 as a trial outcome could substantially reduce the sample size required to demonstrate short-term benefit of an intervention. We show that updated MELDs during the trajectory of AH predict subsequent mortality or the need for transplant. MELD28 inclusion in an ordinal outcome (together with death or transplant) could increase the efficiency of randomized controlled trials. |
| 1.015 | Michael Lucey | GI | mrl@medicine.wisc.edu | Early Liver Transplant for Alcohol-associated Liver Disease Has Excellent Survival but Higher Rates of Harmful Alcohol Use. | Early liver transplantation (LT) for alcohol-associated liver disease (ALD) has increased worldwide. Short-term outcomes have been favorable, but data on longer-term outcomes are lacking. Single-center retrospective study of primary LT recipients between 2010 and 2020, with follow-up through July 1, 2022. Survival analysis was performed using log rank, Cox models, and Kaplan-Meier method. Cox models were created to identify variables associated with mortality; logistic regression to identify variables associated with post-LT alcohol use. Of 708 patients who underwent LT, 110 (15.5%) had ALD and abstinence 6 months (SLT), and 364 (51.4%) had non-ALD diagnoses. Median follow-up was 4.6 years (interquartile range, 2.6-7.3 years). ELT recipients were younger (P = .001) with median abstinence pre-LT of 61.5 days. On adjusted Cox model, post-LT survival was similar in ELT and SLT (hazard ratio [HR], 1.31; P = .30) and superior to non-ALD (HR, 1.68; P = .04). Alcohol use (40.9% vs 21.8%; P < .001) and harmful alcohol use (31.2% vs 16.0%; P = .002) were more common in ELT recipients. Harmful alcohol use was associated with post-LT mortality on univariate (HR, 1.69; P = .03), but not multivariable regression (HR, 1.54; P = .10). Recurrence of decompensated ALD trended toward more common in ELT (9.1% vs 4.4%; P = .09). Greater than 6 months pre-LT abstinence was associated with a decreased risk of harmful alcohol use (odds ratio, 0.42; P = .001), but not in a multivariable model (odds ratio, 0.71; P = .33). Patients who undergo ELT for ALD have similar or better survival than other diagnoses in the first 10 years after LT despite a higher incidence of post-LT alcohol use. |
| 1.016 | Michael Lucey | GI | mrl@medicine.wisc.edu | The Survival Benefit of Reabstinence After Harmful Alcohol Use Following Early Liver Transplant for Severe Alcohol-Associated Hepatitis: A Multicenter ACCELERATE Study. | Early (i.e., without mandated period of abstinence) liver transplant (LT) for alcohol-associated hepatitis is the fastest-growing indication for LT in the United States and Europe. Harmful alcohol use after LT is associated with poor outcomes, but the distinction of establishing abstinence after return to drinking (i.e., reabstinence) is understudied. This study aims to characterize the survival outcomes of achieving reabstinence after post-LT harmful alcohol use. We analyzed early LT recipients from 12 US LT centers between 2006 and 2021. Post-LT alcohol use was characterized as harmful using criteria of "binge" (≥5 [men] or ≥4 [women] drinks in 20 ng/mL. Reabstinence was defined as ≥12 consecutive months without harmful alcohol use after harmful alcohol use. Among 347 LT recipients (64% male, median age 43, median Model for End-Stage Liver Disease-Sodium score 38) with median post-LT follow-up of 2.2 years (interquartile interval 1.1-3.6), 276 (80%) recipients had no evidence of harmful alcohol use, 35 (10%) recipients had reabstinence, and 36 (10%) recipients had continued harmful alcohol use without reabstinence. Five-year predicted survival, adjusted for age, sex, and Model for End-Stage Liver Disease-Sodium score, was lowest among LT recipients with continued harmful alcohol use (77%), but similar among those with no harmful use (93%) and reabstinence (94%). Achieving reabstinence after post-LT harmful alcohol use is associated with similar 5-year post-LT survival compared with those without evidence of post-LT harmful alcohol use. Our findings highlight the importance of early detection and treatment of post-LT alcohol use. |
| 1.017 | Margarita German | GI | mgerman@medicine.wisc.edu | Lessons Learned From the Liver About the Undergraduate to Graduate Medical Education Transition. | The burden of cirrhosis and chronic liver disease is growing, yet there is a projected worsening deficit in hepatology providers. As such, cirrhosis and liver disease have been important inclusions within the core curricula of Internal Medicine. Formal assessments of provider preparedness resulting from the curriculum are lacking though. Prior studies have demonstrated that exposure to cirrhosis in undergraduate medical education is insufficient, as are learner comfort and self-reported knowledge levels. These findings are further corroborated by a multicenter survey of incoming Internal Medicine interns showing that subjective comfort with and objective knowledge of various liver disease topics are lacking compared to other common Internal Medicine topics. This paper also demonstrates how similar surveys may be used to identify additional topics that may require adjustments for curricular improvement. |
| 1.018 | Margarita German | GI | mgerman@medicine.wisc.edu | Portal Hypertensive Gastropathy and MELD-Na Score Predict Recurrent Gastrointestinal Bleeding After TIPSS: An ALTA Group Study. | Transjugular intrahepatic portosystemic shunt (TIPSS) is highly effective for treatment of variceal bleeding; however, factors contributing to rebleeding complications remain unclear. In this study, we aim to determine risk factors for recurrent portal hypertensive gastrointestinal bleeding following TIPSS. Utilising the Advancing Liver Therapeutic Approaches multicentre database, we retrospectively identified adult patients who underwent TIPSS for secondary prophylaxis of variceal bleeding and had a gastrointestinal rebleeding event within 1 year. We developed multivariable logistic regression models to identify clinical/procedural characteristics associated with rebleeding. We identified 476 patients, predominately middle-aged (mean age 57), male (62%) and White (65%), with mean MELD-Na 16. 16% (n = 77) had a rebleeding event; these patients were more likely to be male (p = 0.016), with higher serum creatinine (p = 0.005), MELD-Na (p = 0.0002), portal hypertensive gastropathy on pre-TIPSS upper endoscopy (p = 0.000) and with higher incidence of TIPSS revision (p = 0.000). There were no significant differences in type of TIPSS endoprosthesis, concurrent embolotherapy, and post-TIPSS pressure gradients between those who experienced rebleeding and those who did not. After adjusting for TIPSS revision, multivariable analysis revealed MELD-Na and presence of portal hypertensive gastropathy on pre-TIPSS endoscopy were independently associated with rebleeding. In this retrospective analysis of a multicentre, nationally representative database, we found that apart from TIPSS-related factors, high MELD-Na and portal hypertensive gastropathy on pre-TIPSS endoscopy were independent predictors of rebleeding within 1 year following TIPSS. These variables may be used to identify high-risk patients who may require additional monitoring following TIPSS. |
| 1.019 | Margarita German | GI | mgerman@medicine.wisc.edu | Designing clinical trials to address alcohol use and alcohol-associated liver disease: an expert panel Consensus Statement. | Most patients with alcohol-associated liver disease (ALD) engage in heavy drinking defined as 4 or more drinks per day (56 g) or 8 (112 g) or more drinks per week for women and 5 or more drinks per day (70 g) or 15 (210 g) or more drinks per week for men. Although abstinence from alcohol after diagnosis of ALD improves life expectancy and reduces the risk of decompensation of liver disease, few studies have evaluated whether treatment of alcohol use disorders will reduce progression of liver disease and improve liver-related outcomes. In November 2021, the National Institute of Alcohol Abuse and Alcoholism commissioned a task force that included hepatologists, addiction medicine specialists, statisticians, clinical trialists and members of regulatory agencies to develop recommendations for the design and conduct of clinical trials to evaluate the effect of alcohol use, particularly treatment to reduce or eliminate alcohol use in patients with ALD. The task force conducted extensive reviews of relevant literature on alcohol use disorders and ALD. Findings were presented at one in-person meeting and discussed over the next 16 months to develop the final recommendations. As few clinical trials directly address this topic, the 28 recommendations approved by all members of the task force represent a consensus of expert opinions. |
| 1.020 | Margarita German | GI | mgerman@medicine.wisc.edu | The rise of multidisciplinary clinics in hepatology: A practical, how-to-guide, and review of the literature. | Multidisciplinary clinics (MDCs) are gaining momentum throughout the medical field, having initially been pioneered in oncology clinics due to their inherent ability to streamline complex care and improve both patient outcomes and the patient care experience. Liver transplant and hepatobiliary tumor clinics are examples of established MDCs in hepatology. With the changing landscape of liver disease in regard to etiology and patient complexity and acuity, there is a clear need for efficient, highly coordinated care. These changes highlight opportunities for hepatology MDCs in alcohol-associated liver disease, metabolic dysfunction-associated steatotic liver disease, and palliative care. This review provides practical advice in navigating the complex logistics of establishing and maintaining a hepatology MDC while also reviewing the emerging evidence on clinical outcomes for patients seen in these MDCs. As hepatology looks to the future, establishment of MDCs in key clinical areas will be the cornerstone of patient care. |
| 1.021 | Margarita German | GI | mgerman@medicine.wisc.edu | Making the best use of testing for blood phosphatidylethanol. | |
| 1.022 | Margarita German | GI | mgerman@medicine.wisc.edu | Testing a Digital Health App for Patients With Alcohol-Associated Liver Disease: Mixed Methods Usability Study. | Alcohol-associated liver disease (ALD) is increasingly common and associated with serious and costly health consequences. Cessation of drinking can improve ALD morbidity and mortality; however, support for cessation is not routinely offered to those diagnosed with ALD, and continued drinking or resumption of drinking after diagnosis is common. Mobile health (mHealth) has the potential to offer convenient and scalable support for alcohol cessation to those diagnosed with ALD, but mHealth interventions for alcohol cessation have not been designed for or evaluated in a population with ALD. This study aims to understand how individuals with ALD would perceive and use an mHealth tool for alcohol cessation and to gather their perspectives on potential refinements to the tool that would allow it to better meet their needs. We interviewed 11 individuals who attended clinic visits related to their ALD to elicit their needs related to support for alcohol cessation and views on how mHealth could be applied. After completing initial interviews (pre), participants were provided with access to an mHealth app designed for alcohol cessation, which they used for 1 month. Afterward, they were interviewed again (post) to give feedback on their experiences, including aspects of the app that met their needs and potential refinements. We applied a mixed methods approach, including a qualitative analysis to identify major themes from the interview transcripts and descriptive analyses of use of the app over 1 month. First, we found that a diagnosis of ALD is perceived as a motivator to quit drinking but that patients had difficulty processing the overwhelming amount of information about ALD they received and finding resources for cessation of alcohol use. Second, we found that the app was perceived as usable and useful for supporting drinking recovery, with patients responding favorably to the self-tracking and motivational components of the app. Finally, patients identified areas in which the app could be adapted to meet the needs of patients with ALD, such as providing information on the medical implications of an ALD diagnosis and how to care for their liver as well as connecting individuals with ALD to one another via a peer-to-peer support forum. Rates of app use were high and sustained across the entire study, with participants using the app a little more than half the days during the study on average and with 100% (11/11) of participants logging in each week. Our results highlight the need for convenient access to resources for alcohol cessation after ALD diagnosis and support the potential of an mHealth approach to integrate recovery support into care for ALD. Our findings also highlight the ways the alcohol cessation app should be modified to address ALD-specific concerns. |
| 1.023 | Margarita German | GI | mgerman@medicine.wisc.edu | Change in Platelet Count after Transjugular Intrahepatic Portosystemic Shunt Creation: An Advancing Liver Therapeutic Approaches (ALTA) Group Study. | To evaluate recovery of platelet count after transjugular intrahepatic portosystemic shunt (TIPS) creation and patient factors predicting platelet recovery after TIPS creation. Adults with cirrhosis who underwent TIPS creation at 9 U.S. hospitals from 2010 to 2015 were included in this retrospective analysis. Change in platelets from before TIPS to 4 months after TIPS creation was characterized. Logistic regression was used to assess factors associated with top quartile percentage platelet increase after TIPS. Subgroup analyses were performed among patients with a pre-TIPS platelet count of ≤50 ×109/L. A total of 601 patients were included. The median absolute change in platelets was 1 × 109/L (-26 × 109/L to 25 × 109/L). Patients with top quartile percent platelet increase experienced ≥32% platelet increase. In multivariable analysis, pre-TIPS platelet counts (odds ratio [OR], 0.97 per 109/L; 95% CI, 0.97-0.98), age (OR, 1.24 per 5 years; 95% CI, 1.10-1.39), and pre-TIPS model for end-stage liver disease (MELD) scores (OR, 1.06 per point; 95% CI, 1.02-1.09) were associated with top quartile (≥32%) platelet increase. Ninety-four (16%) patients had a platelet count of ≤50 × 109/L before TIPS. The median absolute platelet change was 14 × 109/L (2 × 109/L to 34 × 109/L). Fifty-four percent of patients in this subgroup were in the top quartile for platelet increase. In multivariable logistic regression, age (OR, 1.50 per 5 years; 95% CI, 1.11-2.02) was the only factor associated with top quartile platelet increase in this subgroup. TIPS creation did not result in significant platelet increase, except among patients with a platelet count of ≤50 × 109/L before TIPS. Lower pre-TIPS platelet counts, older age, and higher pre-TIPS MELD scores were associated with top quartile (≥32%) platelet increase in the entire cohort, whereas only older age was associated with this outcome in the patient subset with a pre-TIPS platelet count of ≤50 × 109/L. |
| 1.024 | Margarita German | GI | mgerman@medicine.wisc.edu | Alcohol use disorder: Recognition, testing, and initial management strategies. | |
| 1.025 | Margarita German | GI | mgerman@medicine.wisc.edu | The impact of right atrial pressure on outcomes in patients undergoing TIPS, an ALTA group study. | Single-center studies in patients undergoing TIPS suggest that elevated right atrial pressure (RAP) may influence survival. We assessed the impact of pre-TIPS RAP on outcomes using the Advancing Liver Therapeutic Approaches (ALTA) database. Total 883 patients in ALTA multicenter TIPS database from 2010 to 2015 from 9 centers with measured pre-TIPS RAP were included. Primary outcome was mortality. Secondary outcomes were 48-hour post-TIPS complications, post-TIPS portal hypertension complications, and post-TIPS inpatient admission for heart failure. Adjusted Cox Proportional hazards and competing risk model with liver transplant as a competing risk were used to assess RAP association with mortality. Restricted cubic splines were used to model nonlinear relationship. Logistic regression was used to assess RAP association with secondary outcomes.Pre-TIPS RAP was independently associated with overall mortality (subdistribution HR: 1.04 per mm Hg, 95% CI, 1.01, 1.08, p =0.009) and composite 48-hour complications. RAP was a predictor of TIPS dysfunction with increased odds of post-90-day paracentesis in outpatient TIPS, hospital admissions for renal dysfunction, and heart failure. Pre-TIPS RAP was positively associated with model for end-stage liver disease, body mass index, Native American and Black race, and lower platelets. Pre-TIPS RAP is an independent risk factor for overall mortality after TIPS insertion. Higher pre-TIPS RAP increased the odds of early complications and overall portal hypertensive complications as potential mechanisms for the mortality impact. |
| 1.026 | Margarita German | GI | mgerman@medicine.wisc.edu | Out With the Old, in With the New: Replacing the "6-Month Abstinence Rule" With Integrated Care for Alcohol-Associated Liver Disease. | |
| 1.027 | Sumona Saha | GI | ssaha@medicine.wisc.edu | Safety of Rotavirus Vaccination in Infants That Were Exposed to Biologics In Utero: A Systematic Review. | In infants that were exposed to biologics in utero, gastroenterology societal guidelines have either recommended against administration of the live rotavirus vaccine until 6-12 months of age or until serum biologic levels are undetectable. We performed a systematic review to evaluate the safety of rotavirus vaccination in biologic-exposed infants. EMBASE, PubMed, Scopus, and Cochrane databases were searched from 2006 to 2024 for original data reporting on the safety of rotavirus vaccination in infants that were exposed to anti-tumor necrosis factors (TNFs) (ie, infliximab, adalimumab, golimumab, certolizumab) and non-TNF biologics (ie, vedolizumab, ustekinumab, rizankizumab, mirikizumab) in utero. A database search yielded 7185 screening results of which 10 studies met inclusion criteria. There were over 300 instances of rotavirus vaccination in biologic-exposed infants (n = 162 exposed to anti-TNFs, n = 142 exposed to non-TNF biologics). Biologic-exposed infants were not at an increased risk of severe adverse events or adverse events of any severity related to rotavirus vaccination. Administration of the live rotavirus vaccine appears to be safe in biologic-exposed infants. As such, with careful examination of the risks and benefits, there may be a role for rotavirus vaccination in this population. We performed a systematic review evaluating the safety of rotavirus vaccination in infants that were exposed to anti-TNFs and non-TNF biologics in utero. There was no increased risk of adverse events associated with rotavirus vaccination in this population. |
| 1.028 | Sumona Saha | GI | ssaha@medicine.wisc.edu | Characterization of idiopathic chronic diarrhea and associated intestinal inflammation and preliminary observations of effects of vagal nerve stimulation in a non-human primate. | Diarrhea is commonly associated with irritable bowel syndrome, inflammatory bowel disease, microscopic colitis, and other gastrointestinal dysfunctions. Spontaneously occurring idiopathic chronic diarrhea is frequent in rhesus macaques, but has not been used as a model for the investigation of diarrhea or its treatment. We characterized this condition and present preliminary data demonstrating that left vagal nerve stimulation provides relief. Stool consistency scores were followed for up to 12 years. Inflammation was assessed by plasma C-reactive protein, [18F]fluorodeoxyglucose (FDG) uptake, measured by positron emission tomography (PET), multiplex T cell localization, endoscopy and histology. The vagus was stimulated for 9 weeks in conscious macaques, using fully implanted electrodes, under wireless control. Macaques exhibited recurrent periods of diarrhea for up to 12 years, and signs of inflammation: elevated plasma C-reactive protein, increased bowel FDG uptake and increased mucosal T helper1 T-cells. The colon and distal ileum were endoscopically normal, and histology revealed mild colonic inflammation. Application of vagal nerve stimulation to conscious macaques (10 Hz, 30 s every 3 h; 24 h a day for 9 weeks) significantly reduced severity of diarrhea and also reduced inflammation, as measured by FDG uptake and C-reactive protein. These macaques exhibit spontaneously occurring diarrhea with intestinal inflammation that can be reduced by VNS. The data demonstrate the utility of this naturally occurring primate model to study the physiology and treatments for chronic diarrhea and the neural control circuits influencing diarrhea and inflammation that are not accessible in human subjects. |
| 1.029 | Sumona Saha | GI | ssaha@medicine.wisc.edu | Micronutrient Deficiencies in Patients With Inflammatory Bowel Disease. | Inflammatory bowel disease (IBD) can cause micronutrient deficiencies that have cutaneous manifestations. Dermatologists may be the first to identify an undiagnosed micronutrient deficiency in the affected population. The approach to monitoring and repleting a micronutrient deficiency may be impacted by factors such as IBD activity and potential interactions between supplements and medications used to treat IBD. In this article, we review the most common micronutrient deficiencies observed in patients with IBD and their associated cutaneous manifestations. We also provide guidance for monitoring and supplementing each micronutrient discussed. |
| 1.030 | Sumona Saha | GI | ssaha@medicine.wisc.edu | Structural brain morphometry differences and similarities between young patients with Crohn's disease in remission and healthy young and old controls. | Crohn's disease (CD), one of the main phenotypes of inflammatory bowel disease (IBD), can affect any part of the gastrointestinal tract. It can impact the function of gastrointestinal secretions, as well as increasing the intestinal permeability leading to an aberrant immunological response and subsequent intestinal inflammation. Studies have reported anatomical and functional brain changes in Crohn's Disease patients (CDs), possibly due to increased inflammatory markers and microglial cells that play key roles in communicating between the brain, gut, and systemic immune system. To date, no studies have demonstrated similarities between morphological brain changes seen in IBD and brain morphometry observed in older healthy controls.. For the present study, twelve young CDs in remission (M = 26.08 years, SD = 4.9 years, 7 male) were recruited from an IBD Clinic. Data from 12 young age-matched healthy controls (HCs) (24.5 years, SD = 3.6 years, 8 male) and 12 older HCs (59 years, SD = 8 years, 8 male), previously collected for a different study under a similar MR protocol, were analyzed as controls. T1 weighted images and structural image processing techniques were used to extract surface-based brain measures, to test our hypothesis that young CDs have different brain surface morphometry than their age-matched young HCs and furthermore, appear more similar to older HCs. The phonemic verbal fluency (VF) task (the Controlled Oral Word Association Test, COWAT) (Benton, 1976) was administered to test verbal cognitive ability and executive control. On the whole, CDs had more brain regions with differences in brain morphometry measures when compared to the young HCs as compared to the old HCs, suggesting that CD has an effect on the brain that makes it appear more similar to old HCs. Additionally, our study demonstrates this atypical brain morphometry is associated with function on a cognitive task. These results suggest that even younger CDs may be showing some evidence of structural brain changes that demonstrate increased resemblance to older HC brains rather than their similarly aged healthy counterparts. |
| 1.031 | Sumona Saha | GI | ssaha@medicine.wisc.edu | 2022 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. | The objective is to update recommendations for prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) for patients with rheumatic or nonrheumatic conditions receiving >3 months treatment with glucocorticoids (GCs) ≥2.5 mg daily. An updated systematic literature review was performed for clinical questions on nonpharmacologic, pharmacologic treatments, discontinuation of medications, and sequential therapy. Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the certainty of evidence. A Voting Panel achieved ≥70% consensus on the direction (for or against) and strength (strong or conditional) of recommendations. For adults beginning or continuing >3 months of GC treatment, we strongly recommend as soon as possible after initiation of GCs, initial assessment of fracture risks with clinical fracture assessment, bone mineral density with vertebral fracture assessment or spinal x-ray, and Fracture Risk Assessment Tool if ≥40 years old. For adults at medium, high, or very high fracture risk, we strongly recommend pharmacologic treatment. Choice of oral or intravenous bisphosphonates, denosumab, or parathyroid hormone analogs should be made by shared decision-making. Anabolic agents are conditionally recommended as initial therapy for those with high and very high fracture risk. Recommendations are made for special populations, including children, people with organ transplants, people who may become pregnant, and people receiving very high-dose GC treatment. New recommendations for both discontinuation of osteoporosis therapy and sequential therapies are included. This guideline provides direction for clinicians and patients making treatment decisions for management of GIOP. These recommendations should not be used to limit or deny access to therapies. |
| 1.032 | Sumona Saha | GI | ssaha@medicine.wisc.edu | 2022 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. | The objective is to update recommendations for prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) for patients with rheumatic or nonrheumatic conditions receiving >3 months treatment with glucocorticoids (GCs) ≥2.5 mg daily. An updated systematic literature review was performed for clinical questions on nonpharmacologic, pharmacologic treatments, discontinuation of medications, and sequential therapy. Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the certainty of evidence. A Voting Panel achieved ≥70% consensus on the direction (for or against) and strength (strong or conditional) of recommendations. For adults beginning or continuing >3 months of GC treatment, we strongly recommend as soon as possible after initiation of GCs, initial assessment of fracture risks with clinical fracture assessment, bone mineral density with vertebral fracture assessment or spinal x-ray, and Fracture Risk Assessment Tool if ≥40 years old. For adults at medium, high, or very high fracture risk, we strongly recommend pharmacologic treatment. Choice of oral or intravenous bisphosphonates, denosumab, or parathyroid hormone analogs should be made by shared decision-making. Anabolic agents are conditionally recommended as initial therapy for those with high and very high fracture risk. Recommendations are made for special populations, including children, people with organ transplants, people who may become pregnant, and people receiving very high-dose GC treatment. New recommendations for both discontinuation of osteoporosis therapy and sequential therapies are included. This guideline provides direction for clinicians and patients making treatment decisions for management of GIOP. These recommendations should not be used to limit or deny access to therapies. |
| 1.033 | Sumona Saha | GI | ssaha@medicine.wisc.edu | Higher Cell-Mediated Immune Responses in Patients With Inflammatory Bowel Disease on Anti-TNF Therapy After COVID-19 Vaccination. | Some patients with inflammatory bowel disease (IBD) on immunosuppressive therapies may have a blunted response to certain vaccines, including the messenger RNA (mRNA) coronavirus disease 2019 (COVID-19) vaccines. However, few studies have evaluated the cell-mediated immune response (CMIR), which is critical to host defense after COVID-19 infection. The aim of this study was to evaluate the humoral immune response and CMIR after mRNA COVID-19 vaccination in patients with IBD. This prospective study (HERCULES [HumoRal and CellULar initial and Sustained immunogenicity in patients with IBD] study) evaluated humoral immune response and CMIR after completion of 2 doses of mRNA COVID-19 vaccines in 158 IBD patients and 20 healthy control (HC) subjects. The primary outcome was the CMIR to mRNA COVID-19 vaccines in patients with IBD. The secondary outcomes were a comparison of (1) the CMIR in patients with IBD and HC subjects, (2) CMIR and humoral immune response in all participants, and (3) correlation between CMIR and humoral immune response. The majority (89%) of patients with IBD developed a CMIR, which was not different vs HC subjects (94%) (P = .6667). There was no significant difference (P = .5488) in CMIR between immunocompetent (median 255 [interquartile range, 146-958] spike T cells per million peripheral blood mononuclear cells) and immunosuppressed patients (median 377 [interquartile range, 123-1440]). There was no correlation between humoral and cell-mediated immunity after vaccination (P = .5215). In univariable analysis, anti-tumor necrosis factor therapy was associated with a higher CMIRs (P = .02) and confirmed in a multivariable model (P = .02). No other variables were associated with CMIR. Most patients with IBD achieved CMIR to a COVID-19 vaccine. Future studies are needed evaluating sustained CMIR and clinical outcomes. Antibody and T cell responses to coronavirus disease 2019 vaccines in patients with inflammatory bowel disease do not correlate. Most patients with inflammatory bowel disease mount a T cell response despite being on biologic therapies, those on anti-tumor necrosis factor may have a higher T cell response. Anti-tumor necrosis factor therapy has been associated with a lower antibody response to coronavirus disease 2019 vaccines, but the T cell response is augmented. |
| 1.034 | Sumona Saha | GI | ssaha@medicine.wisc.edu | Tutorial on adult enteral tube feeding: Indications, placement, removal, complications, and ethics. | Enteral nutrition, generally preferred to parenteral nutrition, is indicated when patients cannot meet their energy and metabolic demands. Gastrostomy tubes are placed directly into the stomach (either endoscopically, surgically, or radiologically) through the abdominal wall. Routine gastrostomy tube care is important to maintain well-functioning tubes. Postpyloric feeding tubes are preferable to gastric feeding tubes if patients have a history of aspiration, gastroesophageal reflux, severe gastroparesis, and/or recurrent nausea and vomiting. Feeding jejunostomy tubes are placed surgically and are indicated if gastric feeding is unsafe or impossible. Dual-lumen gastrojejunostomy tubes are used when both gastric decompression and feeding are desired. The general risks of enteral tube feeding include diarrhea, metabolic derangements, and aspiration. Additional complications for gastrostomy tubes, which can arise at any time, include tube dysfunction (clogging or deterioration), infection, bleeding, peristomal leakage, ulceration, gastric outlet obstruction, and accidental removal. After percutaneous endoscopic gastrostomy placement, there are also early or late complications that may occur. Multiple factors should be considered in the decision-making process for feeding tube placement. It is important to be realistic about the patient's prognosis and goals and to discuss the risks and benefits ahead of time. Consultation with palliative care or clinical ethics specialists should be considered in certain clinical scenarios. |
| 1.035 | Sumona Saha | GI | ssaha@medicine.wisc.edu | Everything that You Always Wanted to Know About the Management of Percutaneous Endoscopic Gastrostomy (PEG) Tubes (but Were Afraid to Ask). | |
| 1.036 | Sumona Saha | GI | ssaha@medicine.wisc.edu | Humoral Immunogenicity of 3 COVID-19 Messenger RNA Vaccine Doses in Patients With Inflammatory Bowel Disease. | Herein, we evaluated the humoral immunogenicity of a third coronavirus disease 2019 messenger RNA vaccine dose in patients with inflammatory bowel diseases. All patients displayed a humoral immune response, and median antibody concentrations were higher after the third dose than after completion of the 2-dose series. |
| 1.037 | Kerstin Austin | GI | keaustin@medicine.wisc.edu | Diagnosis and Management of Celiac Disease. | This JAMA Clinical Guidelines Synopsis summarizes the American College of Gastroenterology’s 2023 guideline update on diagnosis and management of celiac disease. |
| 1.038 | Kerstin Austin | GI | keaustin@medicine.wisc.edu | Tutorial on adult enteral tube feeding: Indications, placement, removal, complications, and ethics. | Enteral nutrition, generally preferred to parenteral nutrition, is indicated when patients cannot meet their energy and metabolic demands. Gastrostomy tubes are placed directly into the stomach (either endoscopically, surgically, or radiologically) through the abdominal wall. Routine gastrostomy tube care is important to maintain well-functioning tubes. Postpyloric feeding tubes are preferable to gastric feeding tubes if patients have a history of aspiration, gastroesophageal reflux, severe gastroparesis, and/or recurrent nausea and vomiting. Feeding jejunostomy tubes are placed surgically and are indicated if gastric feeding is unsafe or impossible. Dual-lumen gastrojejunostomy tubes are used when both gastric decompression and feeding are desired. The general risks of enteral tube feeding include diarrhea, metabolic derangements, and aspiration. Additional complications for gastrostomy tubes, which can arise at any time, include tube dysfunction (clogging or deterioration), infection, bleeding, peristomal leakage, ulceration, gastric outlet obstruction, and accidental removal. After percutaneous endoscopic gastrostomy placement, there are also early or late complications that may occur. Multiple factors should be considered in the decision-making process for feeding tube placement. It is important to be realistic about the patient's prognosis and goals and to discuss the risks and benefits ahead of time. Consultation with palliative care or clinical ethics specialists should be considered in certain clinical scenarios. |
| 1.039 | Kerstin Austin | GI | keaustin@medicine.wisc.edu | Controversy in Nutrition Recommendations for Short Bowel Syndrome: How Type of SBS Impacts Response. | This review examines the current recommendations for dietary management of patients living with short bowel syndrome (SBS) and outlines the need for future research to provide optimal care for this unique group of patients. Providers caring for patients with SBS lack sufficient data to help guide recommendations regarding diet. The majority of studies are conducted at a single medical institution on a small number of anatomically diverse patients. Multi-center studies would allow for inclusion of a larger number of patients and may lead to more individualized dietary recommendations. Patients with short bowel syndrome should be evaluated on an individual basis by a multidisciplinary team including physicians, dieticians, pharmacists, and nurses specializing in the care of these complex patients. Tailoring both medical and nutritional therapy will help realize the overarching goal for these patients of maintaining adequate nutrition with diet and medications, and achieving independence from parenteral support. |
| 1.040 | Kerstin Austin | GI | keaustin@medicine.wisc.edu | Ketogenic Diet: from the Historical Records to Use in Elite Athletes. | To review the available literature/evidence on low carbohydrate/high fat (LCHF) and low carbohydrate ketogenic (LCKD) diets' effects on human athletic performance and to provide a brief review of the physiology and history of energy systems of exercise. Multiple studies have been conducted in an attempt to answer this question, many within the last 3-5 years. Studies are heterogenous in design, intervention, and outcome measures. Current available data show that LCHF and LCKD do not significantly enhance or impair performance in endurance or strength activities. However, there is a trend towards improved body composition (greater percent lean body mass) across multiple studies. While this may not translate to enhanced performance in the primarily laboratory conditions in the reviewed studies, there could be a benefit in sports in which an athlete's strength-to-weight ratio is a significant determinant of outcome. |
| 1.041 | Kerstin Austin | GI | keaustin@medicine.wisc.edu | Premixed vs Compounded Parenteral Nutrition: Effects of Total Parenteral Nutrition Shortage on Clinical Practice. | Drug shortages continue to impact our patients with intestinal failure and their ability to receive nutrition. ASPEN guidelines address the management of certain shortages in compounded total parenteral nutrition (TPN); however, some institutions have utilized premixed total parenteral nutrition (pTPN) in place of TPN. Premixed TPN appears to be as safe, if not safer, as compounded TPN when comparing the risk of bloodstream infection. However, there is an increased use of supplemental electrolytes to meet patient needs. Cost-effectiveness depends on multiple factors and should be evaluated by each institution when considering the use of TPN. In light of the published information on the use of pTPN compared to TPN, institutions and nutrition clinicians should consider their current practice and opportunities to consider when pTPN may be beneficial for their patients, not only from a safety perspective, but also considering cost savings. However, close monitoring and individual patient needs should be considered as these formulas may not meet all patient nutritional and electrolyte needs. |
| 1.042 | Kerstin Austin | GI | keaustin@medicine.wisc.edu | Musculoskeletal Injuries Are Commonly Reported Among Gastroenterology Trainees: Results of a National Survey. | Endoscopy-related musculoskeletal injuries are increasingly recognized among gastroenterologists. While injury rates and risk factors have been studied among practicing gastroenterologists, little is known about rates among trainees during fellowship. This study analyzes the prevalence of endoscopy-related overuse injuries and risk factors for injuries among a national sample of gastroenterology (GI) fellows. We also surveyed GI fellowship program directors and fellows about perceptions of overuse injuries during GI training. We distributed a 29-item electronic survey to GI fellows at accredited programs in the USA in April 2016. Survey items included demographic information, questions pertaining to injuries, and level of agreement on the importance of ergonomics training in GI fellowship. Additionally, we distributed a 7-item electronic survey to fellowship program directors evaluating perception of overuse injuries and prevention during fellowship training. Fisher's exact test determined factors associated with sustaining an injury. An estimated 1509 fellows received the survey. Eleven percent (n = 165) of gastroenterology fellows completed the survey. Twenty percent reported having a musculoskeletal injury. Female gender was the only factor associated with a higher rate of reported injury (p < 0.01). The most common injuries reported were thumb and other hand-related pain (n = 28 [64%]). Musculoskeletal injuries may affect up to 20% of GI fellows. Female fellows more frequently report injuries and may be at particularly high risk which has not been found in previously reported surveys of practicing gastroenterologists. Standardized curricula on ergonomic considerations and injury prevention are needed to enhance GI fellowship training and reduce injury rates. |
| 1.043 | Kerstin Austin | GI | keaustin@medicine.wisc.edu | Hyperemesis Gravidarum. | Nausea and vomiting of pregnancy affect the majority of pregnancies, while the most severe version, hyperemesis gravidarum (HG), affects a much smaller subset of women. Despite the prevalence of nausea and vomiting of pregnancy and the severe consequences of HG, the pathophysiology of these conditions is not fully understood. Currently, it is thought that a combination of hormonal factors accounts for their development. Multiple treatments have been described for nausea and vomiting of pregnancy and HG with varying levels of success. In this paper we describe the epidemiology of nausea and vomiting of pregnancy and HG, the recommended workup, their proposed etiologic factors, treatments, and their potential impact on mother and baby. |
| 1.044 | Kerstin Austin | GI | keaustin@medicine.wisc.edu | Influence of previous night call and sleep deprivation on screening colonoscopy quality. | There are few studies evaluating the influence of sleep deprivation on endoscopic outcomes. To evaluate the effect of a previous night call on the quality of screening colonoscopies performed the following day. Average-risk patients undergoing screening colonoscopies were included. Quality metrics were retrospectively compared between two groups of post-call colonoscopies and colonoscopies performed by the same individuals not on call the night before: those performed by gastroenterologists who were only on call the night prior and those performed by gastroenterologists who performed emergent on-call procedures the night prior. Between 1 July 2010 and 31 March 2012, 447 colonoscopies were performed by gastroenterologists who were on call only the night prior, 126 colonoscopies were performed by gastroenterologists who had completed on-call emergent procedures the night prior, and 8,734 control colonoscopies were completed. There was a lower percent of patients who were screened with adenomas detected in procedures performed by endoscopists who had performed emergent on-call procedures the night prior compared with the controls (30 vs. 39%, respectively; P=0.043). The mean withdrawal time for these colonoscopies was significantly longer than that for the control procedures (15.5 vs. 14.0 min; P=0.025). For the colonoscopies performed by endoscopists who were on call only the night prior, there was no significant difference in the percent of patients screened with adenomas detected compared with controls (42 vs. 39%, respectively; P=0.136). (1) Despite longer withdrawal times, being on call the night prior and performing an emergent procedure lead to a significant 24% decrease in the adenoma detection rates. (2) It is imperative for screening physicians to be aware of the influence of sleep deprivation on procedural outcomes and to consider altering their practice accordingly. |
| 1.045 | Peter Rahko | CVM | psr@medicine.wisc.edu | Takotsubo Cardiomyopathy: New Insights Into Long-Term Outcomes. | |
| 1.046 | Peter Rahko | CVM | psr@medicine.wisc.edu | Relationship of TAPSE Normalized by Right Ventricular Area With Pulmonary Compliance, Exercise Capacity, and Clinical Outcomes. | While tricuspid annular plane systolic excursion (TAPSE) captures the predominant longitudinal motion of the right ventricle (RV), it does not account for ventricular morphology and radial motion changes in various forms of pulmonary hypertension. This study aims to account for both longitudinal and radial motions by dividing TAPSE by RV area and to assess its clinical significance. We performed a retrospective analysis of 71 subjects with New York Heart Association class II to III dyspnea who underwent echocardiogram and invasive cardiopulmonary exercise testing (which defined 4 hemodynamic groups: control, isolated postcapillary pulmonary hypertension, combined postcapillary pulmonary hypertension, and pulmonary arterial hypertension). On the echocardiogram, TAPSE was divided by RV area in diastole (TAPSE/RVA-D) and systole (TAPSE/RVA-S). Analyses included correlations (Pearson and linear regression), receiver operating characteristic, and survival curves. On linear regression analysis, TAPSE/RVA metrics (versus TAPSE) had a stronger correlation with pulmonary artery compliance (r=0.48-0.54 versus 0.38) and peak VO2 percentage predicted (0.23-0.30 versus 0.18). Based on the receiver operating characteristic analysis, pulmonary artery compliance ≥3 mL/mm Hg was identified by TAPSE/RVA-D with an under the curve (AUC) of 0.79 (optimal cutoff ≥1.1) and by TAPSE/RVA-S with an AUC of 0.83 (optimal cutoff ≥1.5), but by TAPSE with only an AUC of 0.67. Similarly, to identify peak VO2 <50% predicted, AUC of 0.66 for TAPSE/RVA-D and AUC of 0.65 for TAPSE/RVA-S. Death or cardiovascular hospitalization at 12 months was associated with TAPSE/RVA-D ≥1.1 (HR, 0.38 [95% CI, 0.11-0.56]) and TAPSE/RVA-S ≥1.5 (HR, 0.44 [95% CI, 0.16-0.78]), while TAPSE was not associated with adverse outcomes (HR, 0.99 [95% CI, 0.53-1.94]). Among 31 subjects with available cardiac magnetic resonance imaging, RV ejection fraction was better correlated with novel metrics (TAPSE/RVA-D r=0.378 and TAPSE/RVA-S r=0.328) than TAPSE (r=0.082). In a broad cohort with suspected pulmonary hypertension, TAPSE divided by RV area was superior to TAPSE alone in correlations with pulmonary compliance and exercise capacity. As a prognostic marker of right heart function, TAPSE/RVA-D <1.1 and TAPSE/RVA-S <1.5 predicted adverse cardiovascular outcomes. |
| 1.047 | Peter Rahko | CVM | psr@medicine.wisc.edu | Evaluation of inter-observer variability regarding aortic and mitral valve findings on transesophageal echocardiograms ordered for suspected endocarditis. | Transesophageal echocardiography (TEE) is the gold standard for the detection of valvular vegetations (VV). Differentiating small VV from degenerative changes is challenging and prone to inter-observer variability. We evaluated inter-observer agreement regarding aortic (AV) and mitral valve (MV) findings on TEEs ordered for suspected infective endocarditis (IE). A total of 349 consecutive TEEs were evaluated. Studies were classified as "definite, possible, or no" IE with valve masses classified further by morphology. Nine faculty echocardiographers scored randomly selected TEEs of the AV (N = 38) and MV (N = 35). Inter-reader variability was calculated using the Fleiss/Scott Kappa (Kf). Positive blood cultures were present in 81% and 45% had definite IE by the modified Duke criteria. There was moderate reader agreement regarding the presence of a valvular mass for both the AV (Kf = .41, 95% CI [.30-.53]) and MV (Kf = .49, 95% CI [.34-.65]). For diagnosis of IE, there was fair agreement for the AV (Kf = .29, 95% CI [.18-.42]) and moderate agreement for the MV (Kf = .53, 95% CI [.36-.70]). Masses described as large, multi-lobulated, or pedunculated were more frequently categorized as clinical IE, (p < .006, both valves), however those with filamentous lesions were not (p < .001, both valves). In a large academic center, the inter-observer agreement for the presence of a left sided valvular mass was moderate and agreement regarding the final diagnosis of IE was fair to moderate, with better agreement among readers evaluating the MV. Lesion morphology is associated with the clinical diagnosis of IE. |
| 1.048 | Peter Rahko | CVM | psr@medicine.wisc.edu | Interventional Transesophageal Echocardiography: Background and Coding Review: A Publication from the ASE Advocacy Committee. | |
| 1.049 | Peter Rahko | CVM | psr@medicine.wisc.edu | Technical and clinical study of x-ray-based surface echo probe tracking using an attached fiducial apparatus. | Several types of structural heart intervention (SHI) use information from multiple imaging modalities to complete an interventional task. For example, in transcatheter aortic valve replacement (TAVR), placement and deployment of a bioprosthetic aortic valve in the aorta is primarily guided by x-ray fluoroscopy (XRF), and echocardiography provides visualization of cardiac anatomy and blood flow. However, simultaneous interpretation of independent x-ray and echo displays remains a challenge for the interventionalist. The purpose of this work was to develop a novel echo/x-ray co-registration solution in which volumetric transthoracic echo (TTE) is transformed to the x-ray coordinate system by tracking the three-dimensional (3D) pose of a probe fiducial attachment from its appearance in two-dimensional (2D) x-ray images. A fiducial attachment for a commercial TTE probe consisting of rings of high-contrast ball bearings was designed and fabricated. The 3D pose (position and orientation) of the fiducial attachment is estimated from a 2D x-ray image using an algorithm in which a virtual point cloud model of the attachment is iteratively rotated, translated, and forward-projected onto the image until the average sum-of-squares of grayscale values at the projected points is minimized. Fiducial registration error (FRE) and target registration error (TRE) of this approach were evaluated in phantom studies using TAVR-relevant gantry orientations and four standard acoustic windows for the TTE probe. A patient study was conducted to assess the clinical suitability of the fiducial attachment prototype during TTE imaging of patients undergoing SHI. TTE image quality for the task of guiding a transcatheter procedure was evaluated in a reviewer study. The 3D FRE ranged from 0.32 ± 0.03 mm (mean ± SD) to 1.31 ± 0.05 mm, depending on C-arm orientation and probe acoustic window. The 3D TRE ranged from 1.06 ± 0.03 mm to 2.42 ± 0.06 mm. Fiducial pose estimation was stable when >75% of the fiducial markers were visible in the x-ray image. A panel of reviewers graded the presentation of heart valves in TTE images from 48 SHI patients. While valve presentation did not differ significantly between acoustic windows (P > 0.05), the mitral valve did achieve a significantly higher image quality compared to the aortic and tricuspid valves (P < 0.001). Overall, reviewers perceived sufficient image quality in 76.5% of images of the mitral valve, 54.9% of images of the aortic valve, and 48.6% of images of the tricuspid valve. Fiducial-based tracking of a commercial TTE probe is compatible with clinical SHI workflows and yields 3D target registration error of less than 2.5 mm for a variety of x-ray gantry geometries and echo probe acoustic windows. Although TTE image quality with respect to target valve anatomy was sufficient for the majority of cases examined, prescreening of patients for sufficient TTE quality would be helpful. |
| 1.050 | Peter Rahko | CVM | psr@medicine.wisc.edu | A Rare Case of Primary Pericardial Schwannoma. | Schwannomas are typically benign, indolent neoplasms. Primary pericardial schwannomas are extremely rare and arise from the cardiac plexus and vagus nerve innervating the heart. Few case reports have been documented to date. Pericardial schwannomas are difficult to diagnose at plain radiography or transthoracic echocardiography, often leading to further characterization with either CT or MRI. Biopsy is required for definitive diagnosis. A case of primary pericardial schwannoma of the posterior pericardium with concerns for compression of the left atrium and left ventricle is presented. © RSNA, 2021. |
| 1.051 | Peter Rahko | CVM | psr@medicine.wisc.edu | Usefulness of Focused Screening Echocardiography for Collegiate Athletes. | Sudden cardiac death in a young healthy athlete is a rare but catastrophic event. The American Heart Association preparticipation screening guidelines recommend a focused history and physical without routine imaging or electrocardiogram screening. We hypothesized that a focused echocardiogram can identify structural abnormalities that may lead to sudden cardiac death in athletes, which might otherwise go undetected by history and physical. We retrospectively reviewed the charts of all incoming collegiate athletes at a single university from 2005 to 2013, all of whom had undergone a focused, 5-minute echocardiogram along with a guideline-based preparticipation history and physical (PPS H&P). Abnormal findings prompted further testing or referral. We report the prevalence of abnormal findings and the relation between an abnormal PPS H&P and screening echocardiogram. A total of 2,898 athletes were screened and 159 (5%) had findings. Forty athletes underwent further testing and evaluation. Of these athletes, 3 had newly diagnosed abnormalities that warranted restriction of participation: 1 apical-variant hypertrophic cardiomyopathy, 1 large bidirectional atrial septal defect with right ventricular dysfunction, and 1 dilated ascending aorta. Two of these athletes had a normal PPS H&P. Conversely, of the 661 athletes with an abnormal PPS H&P, only 1 (0.15%) had an abnormal screening echocardiogram. In conclusion, although the overall number was low, the 5-minute screening echocardiogram detected athletes at risk for sudden cardiac death not discovered on PPS H&P. |
| 1.052 | Peter Rahko | CVM | psr@medicine.wisc.edu | Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography. | |
| 1.053 | Peter Rahko | CVM | psr@medicine.wisc.edu | Acute Heart Failure in the Emergency Department: What Is the Prognosis? | |
| 1.054 | Peter Rahko | CVM | psr@medicine.wisc.edu | Comparison of Outcomes of Atrial Fibrillation in Patients With Reduced Versus Preserved Left Ventricular Ejection Fraction. | Patients with newly diagnosed atrial fibrillation (AF) and a rapid ventricular response may present with a reduced left ventricular ejection fraction (LVEF). We compared long-term outcomes of these patients with those with preserved LVEF. This retrospective cohort study included 385 consecutive adults with newly diagnosed AF with rapid ventricular response, presenting to a single medical center from January 2006 to August 2014. Patients with a history of coronary artery disease or known cardiomyopathy were excluded. Patients were divided into 2 groups: those with an LVEF ≤55% (n = 147) (REF) and those with an LVEF >55% (n = 238) (PEF). Echocardiographic parameters, all-cause mortality, cardiovascular mortality, and stroke rates were compared between both groups at baseline and a minimum of 1-year follow-up. The mean age of patients was 68 ± 1.1 in REF versus 60 ± 7.4 in PEF (p = 0.39). There were no significant differences in baseline co-morbidities between both groups. The mean LVEF during the index admission was 47.7 ± 0.8% in REF versus 65.5 ± 0.3% in PEF. The average duration of follow-up was 2.8 years. Patients with REF had higher all-cause mortality (32.7% REF vs 20.6% PEF, odds ratio 2.17, p = 0.008). Patients with REF had higher rates of subsequent clinic or ER visits for AF with a rapid ventricular response (32% REF vs 22.7% PEF, p = 0.044). The incidence of stroke was similar between both groups (17% REF vs 18.9% PEF, p = 0.639). Of the patients with REF, 64% had subsequent EF recovery and had similar outcomes compared with patients with PEF. Baseline LV end-diastolic diameter predicted all-cause mortality (odds ratio 1.14, p = 0.003) in the REF group. None of the echocardiographic parameters predicted EF recovery. In conclusion, in patients with new AF with rapid ventricular response, REF was associated with higher long-term all-cause mortality. Those with subsequent LVEF recovery after medical therapy appear to have a similar prognosis compared with those with initial PEF. |
| 1.055 | Didier Mandelbrot | NEPH | damandel@medicine.wisc.edu | The UW Experience: Feasibility of De Novo Letermovir for Primary Prophylaxis After Abdominal Solid Organ Transplant. | Letermovir is approved for primary prophylaxis of cytomegalovirus (CMV) in high-risk kidney transplant recipients. However, many experts suggest the drug be reserved as a second-line agent when valganciclovir is not tolerated or fails. The purpose of this study was to describe the feasibility of a de novo letermovir prophylactic approach for CMV high-risk and seropositive abdominal solid organ transplant patients. Retrospective review of abdominal transplant recipients who required CMV prophylaxis between June 6, 2023, and June 6, 2024. The purpose was to evaluate feasibility of universal letermovir prophylaxis and prophylaxis success. 278 patients required CMV prophylaxis and 207 obtained letermovir (74% success). Mean time from transplant to drug approval was 10.5 ± 27 days. Mean out of pocket patient cost was $10.19 ± $36.06 per 28-day supply of letermovir and $55.69 ± $311.48 per 30-day supply of valganciclovir (P = 0.0419). For patients who obtained letermovir, 107 (52%) required prior authorization; 32 (16%) required insurance appeal after denial of prior authorization. Forty-two patients (20%) used Merck copay assistance program while 23 (11%) used the Merck Access patient assistance program to obtain drug. There were no episodes of prophylaxis failure due to breakthrough replication necessitating termination. De novo use of letermovir for CMV primary prophylaxis after abdominal transplant was found to be feasible with a high rate of success in obtaining the drug in a timely manner posttransplant and without significant out-of-pocket cost to the patient. |
| 1.065 | Brad Astor | NEPH | bcastor@medicine.wisc.edu | Predicting kidney graft function and failure among kidney transplant recipients. | Graft loss is a major health concern for kidney transplant (KTx) recipients. It is of clinical interest to develop a prognostic model for both graft function, quantified by estimated glomerular filtration rate (eGFR), and the risk of graft failure. Additionally, the model should be dynamic in the sense that it adapts to accumulating longitudinal information, including time-varying at-risk population, predictor-outcome association, and clinical history. Finally, the model should also properly account for the competing risk by death with a functioning graft. A model with the features above is not yet available in the literature and is the focus of this research. We built and internally validated a prediction model on 3,893 patients from the Wisconsin Allograft Recipient Database (WisARD) who had a functioning graft 6 months after kidney transplantation. The landmark analysis approach was used to build a proof-of-concept dynamic prediction model to address the aforementioned methodological issues: the prediction of graft failure, accounted for competing risk of death, as well as the future eGFR value, are updated at each post-transplant time. We used 21 predictors including recipient characteristics, donor characteristics, transplant-related and post-transplant factors, longitudinal eGFR, hospitalization, and rejection history. A sensitivity analysis explored a less conservative variable selection rule that resulted in a more parsimonious model with reduced predictors. For prediction up to the next 1 to 5 years, the model achieved high accuracy in predicting graft failure, with the AUC between 0.80 and 0.95, and moderately high accuracy in predicting eGFR, with the root mean squared error between 10 and 18 mL/min/1.73m2 and 70%-90% of predicted eGFR falling within 30% of the observed eGFR. The model demonstrated substantial accuracy improvement compared to a conventional prediction model that used only baseline predictors. The model outperformed conventional prediction model that used only baseline predictors. It is a useful tool for patient counseling and clinical management of KTx and is currently available as a web app. |
| 1.066 | Brad Astor | NEPH | bcastor@medicine.wisc.edu | Renal Arteriosclerosis in kidney biopsies associated with higher 10-year atherosclerotic cardiovascular disease in lupus nephritis. | Patients with lupus nephritis (LN), including those below age 50, face significantly higher risk of atherosclerotic cardiovascular disease (ASCVD) vs. peers. This highlights the need for identifying specific ASCVD risk factors in LN. Renal arteriosclerosis in kidney biopsies (subclinical arteriosclerosis) may be able to predict future clinical ASCVD events. However, renal arteriosclerosis is under-reported in LN biopsies and is not taken into consideration when ASCVD risk is calculated. Therefore, we aimed to systematically grade renal arteriosclerosis in kidney biopsies at LN diagnosis and examined associations with 10- & 20-year ASCVD occurrence. Adults with biopsy proven LN were included. Clinical ASCVD, including fatal & non-fatal events, were adjudicated. Utilizing standard Banff grading criteria, all biopsies at LN diagnosis were re-read to grade renal arteriosclerosis. Covariables (e.g., socio-demographics, comorbidities, med exposure) were abstracted. Using Cox models, factors (including renal arteriosclerosis) associated with 10- & 20-year clinical ASCVD were examined. Among 209 patients, 36 & 49 clinical ASCVD occurred within 10 & 20 years. Renal arteriosclerosis (>25%) was associated with 3x higher 10-year ASCVD. High area deprivation index (>80) & longer angiotensin converting enzyme inhibitor (ACEi) exposure were associated with 4x higher & 0.65x lower ASCVD occurrence. Adding renal arteriosclerosis >25% improved model performance for 10-year ASCVD risk estimation from 65% to 80%. Similar associations were seen with 20-year ASCVD. Renal arteriosclerosis >25%, area deprivation, ACEi exposure could inform ASCVD risk stratification in LN. Prospective studies should validate findings and inform clinical use. |
| 1.067 | Brad Astor | NEPH | bcastor@medicine.wisc.edu | Low 25-Hydroxyvitamin D Post-Kidney Transplant Is Associated with Increased Risk of BK Polyomavirus-Associated Nephropathy. | BK viremia (BKPyV-DNAemia) and nephropathy (BKPyVAN) are significant causes of morbidity and mortality in kidney transplant recipients (KTRs). Vitamin D supports immune function, yet low 25-hydroxyvitamin D [25(OH)D] is common among KTRs. The association between serum 25(OH)D, measured 61 days to 2 years post-transplant, and subsequent incident BKPyV-DNAemia and BKPyVAN was examined in KTRs without previous BKPyV-DNAemia or BKPyVAN, respectively. Out of 3308 KTRs, 399 (12%) were vitamin D deficient [25(OH)D ≤ 20 ng/mL], and 916 (27.7%) were insufficient [25(OH)D 21-29 ng/mL]. A total of 184 KTRs developed BKPyV-DNAemia and 44 developed BKPyVAN. The incidence rate (/100 person-years) for BKPyV-DNAemia was 2.88 in the 25(OH)D sufficient group, 2.22 in the insufficient group, and 2.37 in the deficient group. The incidence rate (/100 person-years) for BKPyVAN was 0.30 in the 25(OH)D sufficient group, 0.75 in the insufficient group, and 1.28 in the deficient group. Vitamin D deficiency (adjusted hazard ratio [aHR] compared to 25(OH)D sufficiency: 3.92; 95% CI: 1.66-9.23) and insufficiency (aHR: 2.22; 95% CI: 1.11-4.45) remained significantly associated with the incidence of BKPyVAN after adjustment for baseline characteristics. Low serum 25(OH)D was associated with an increased risk of BKPyVAN but not BKPyV-DNAemia. |
| 1.068 | Brad Astor | NEPH | bcastor@medicine.wisc.edu | Therapeutic Hydroxychloroquine Blood Levels Are Associated With Fewer Hospitalizations and Possible Reduction of Health Disparities in Lupus. | Nonadherence to receiving hydroxychloroquine (HCQ) is associated with a three-fold higher risk of lupus-related hospitalization. Monitoring HCQ blood levels could improve adherence to receiving HCQ and efficacy. Yet, HCQ level monitoring is not routinely done partially due to cost and coverage concerns. To establish HCQ level monitoring cost-effectiveness, we reported the following: (1) risk of acute care by HCQ blood levels, and (2) cost of HCQ monitoring versus acute care visits. HCQ blood levels were measured during routine lupus visits. HCQ levels were categorized as follows: (1) subtherapeutic (1,200 ng/mL). All lupus-related acute care visits (emergency room visits/hospitalizations) after the index clinic visit until next follow-up were abstracted. In our primary analysis, we examined associations between HCQ levels and time to first acute care visit in all patients and subgroups with higher rates of acute care. A total of 39 lupus-related acute care visits were observed in 181 patients. Therapeutic HCQ blood levels were associated with 66% lower rates of acute care. In our cohort, two groups, Black or Hispanic patients and those with public insurance, faced three to four times higher rates of acute care. Levels within 750 to 1,200 ng/mL were associated with 95% lower rates of acute care use in subgroups with higher acute care use. HCQ blood levels within 750 to 1,200 ng/mL are associated with lower rates of acute care in all patients with lupus, including groups with higher rates of acute care. Future clinical trials should establish the causal association between HCQ level monitoring and acute care in patients with lupus. |
| 1.069 | Brad Astor | NEPH | bcastor@medicine.wisc.edu | CKD Management in the Age of Telenephrology: An Observational Analysis of a Hybrid Telenephrology System within a Veteran's Affairs Medical Center. | Nephrology has seen an uptake in transition to remote care delivery. The impact of telenephrology care on chronic kidney disease (CKD) progression is not well defined. We analyzed data from patients naturally selected for telenephrology versus standard, in-person visits. Patients were seen across 4,230 visits over a 2-year period at a nephrology clinic within the Veterans Affairs health system. Baseline characteristics and health profile data were assessed based on grouping of individuals to the telenephrology group (>50% virtual visits) or in-person group (≤50% virtual visits). The slope of eGFR change over time was estimated for each patient using a random effects regression model and compared across groups using weighted linear regression models. A total of 1,098 patients comprised the final analysis. The groups were similar across baseline demographics and health profiles, although more cardiovascular disease, congestive heart failure, and diabetes mellitus were present in the in-person group. There was no significant difference in eGFR decline between groups, though those in telenephrology group trended toward less steep decline compared to those seen predominately in-person (telenephrology slope versus in-person slope; difference = 0.81mL/min/1.73 m2; 95% CI: -0.447, 2.08; p=0.21). Those seen primarily in-person had a similar degree of proteinuria compared to those in telenephrology (p=0.12). All-cause mortality and incidence of outpatient renal replacement therapy initiation was similar. Telenephrology patients had an average of 1.3 fewer emergency department visits per individual compared to their in-person counterpart (2.17 versus 3.44, p<0.001), as well as fewer hospital admissions (1.59 versus 2.08, p=0.02). Those in the in-person group were more often prescribed SGLT-2 inhibitors, statins, NSAIDs, and potassium supplements. Data from this observational study within a VA healthcare system suggests that medically complex, multi-morbid CKD patients can expect a similar rate of eGFR decline when care is delivered via a hybrid system that includes a majority of telenephrology when compared to those managed in face-to-face visits. Further studies are needed to corroborate findings and ensure generalizability outside of this VA system. |
| 1.070 | Brad Astor | NEPH | bcastor@medicine.wisc.edu | Risk Factors for Early Post-transplant Weight Changes Among Simultaneous Pancreas-kidney Recipients and Impact on Outcomes. | There are limited data about the risk factors for weight changes and the association of significant weight changes with graft and metabolic outcomes after simultaneous pancreas and kidney (SPK) transplantation. We included all SPK recipients with both allografts functioning for at least 6 mo post-transplant and categorized them based on the weight changes from baseline to 6 mo post-transplant. We analyzed risk factors for significant weight gain (SWG) and significant weight loss (SWL) over 6 mo post-transplant, as well as outcomes including pancreas uncensored graft failure, pancreas death-censored graft failure (DCGF), composite pancreas graft outcomes of DCGF, use of an antidiabetic agent, or hemoglobin A1C >6.5%, and kidney DCGF. Of 280 SPK recipients, 153 (55%) experienced no significant weight change, 57 (20%) SWG, and 70 (25%) SWL. At 6 mo post-transplant, mean weight changes were 1.2% gain in the no significant weight change group, 13.4% gain in SWG, and 9.6% loss in the SWL groups. In multivariate analysis, the only factor associated with decreased risk for weight gain was older recipient age (aOR, 0.97; 95% confidence intervals, 0.95-0.99). Importantly, SWG or SWL were not associated with pancreas graft failure, P-DCGF, or K-DCGF. Interestingly in the adjusted model, SWG at 6 mo was associated with a lower risk for composite outcomes (HR, 0.35; 95% confidence intervals, 0.14-0.85). Forty-five percent of SPK recipients had significant weight changes by 6 mo post-transplant, but only 20% exhibited SWG. Likely because of proper management, weight changes were not associated with poor outcomes post-SPK transplant. |
| 1.071 | Brad Astor | NEPH | bcastor@medicine.wisc.edu | Simultaneous Pancreas-Kidney Transplant Outcomes Stratified by Autoantibodies Status and Pretransplant Fasting C-peptide. | Pancreatic beta cell function and islet autoantibodies classically distinguish types of diabetes (type 1 diabetes mellitus [DM] or type 2 DM). Here, we sought to evaluate simultaneous pancreas-kidney (SPK) transplant outcomes stratified by the presence or absence of beta cell function and autoantibodies. SPK recipients were eligible if pretransplant autoantibodies were measured against insulin, islet cell, or glutamic acid decarboxylase 65-kD isoform. Recipients were categorized as A+ or A- based on the detection of ≥1 autoantibodies. Recipients were similarly categorized on the basis of detectable pretransplant fasting C-peptide of ≥2 ng/mL (β+) or 6.5. One hundred eighty-three SPK recipients were included: A+β- (n = 72), A-β- (n = 42), A-β+ (n = 49), and A+β+ (n = 20). We did not detect a statistical difference in non-death-censored pancreas graft failure for A+β- recipients compared with other groups: A-β- (adjusted hazard ratio [aHR]: 0.44; 95% confidence interval [CI], 0.14-1.42), A-β+ (aHR: 1.02; 95% CI, 0.37-2.85), and A+β+ (aHR: 0.67; 95% CI, 0.13-3.33) in adjusted analyses. Similar outcomes were observed for other outcomes. In SPK recipients, outcomes were similar among recipients with classic features of type 1 DM and various other types of DM. |
| 1.072 | Brad Astor | NEPH | bcastor@medicine.wisc.edu | Extreme Humid-Heat Exposure and Mortality Among Patients Receiving Dialysis. | Exposure to extreme heat events has been linked to increased morbidity and mortality in the general population. Patients receiving maintenance dialysis may be vulnerable to greater risks from these events, but this is not well understood. We characterized the association of extreme heat events and the risk of death among patients receiving dialysis in the United States. Retrospective cohort study. Data from the US Renal Data System were used to identify adults living in US urban settlements prone to extreme heat who initiated maintenance dialysis between 1997 and 2016. An extreme heat event, defined as a time-updated heat index (a humid-heat metric) exceeding 40.6°C for≥2 days or 46.1°C for≥1day. Death. Cox proportional hazards regression to estimate the elevation in risk of death during a humid-heat event adjusted for age, sex, year of dialysis initiation, dialysis modality, poverty level, and climate region. Interactions between humid-heat and these same factors were explored. Among 945,251 adults in 245 urban settlements, the mean age was 63 years, and 44% were female. During a median follow-up period of 3.6 years, 498,049 adults were exposed to at least 1 of 7,154 extreme humid-heat events, and 500,025 deaths occurred. In adjusted models, there was an increased risk of death (hazard ratio 1.18 [95% CI, 1.15-1.20]) during extreme humid-heat exposure. The relative mortality risk was higher among patients living in the Southeast (P<0.001) compared with the Southwest. Possibility of exposure misclassification, did not account for land use and air pollution co-exposures. This study suggests that patients receiving dialysis face an increased risk of death during extreme humid-heat exposure. Patients who receive dialysis are vulnerable to extreme weather events, and rising global temperatures may bring more frequent extreme heat events. We sought to determine whether extreme heat exposure was associated with an increased risk of death in urban-dwelling patients receiving dialysis across the United States. We found that people receiving dialysis were more likely to die during extreme humid-heat events, defined by a heat index exceeding 40.6°C (105°F) for≥2 days or 46.1°C (115°F) for≥1day. These findings inform the nephrology community about the potential importance of protecting patients receiving maintenance dialysis from the risks associated with extreme heat. |
| 1.073 | Brad Astor | NEPH | bcastor@medicine.wisc.edu | Microvascular Inflammation of Kidney Allografts and Clinical Outcomes. | The heterogeneous clinical presentation of graft microvascular inflammation poses a major challenge to successful kidney transplantation. The effect of microvascular inflammation on allograft outcomes is unclear. We conducted a cohort study that included kidney-transplant recipients from more than 30 transplantation centers in Europe and North America who had undergone allograft biopsy between 2004 and 2023. We integrated clinical and pathological data to classify biopsy specimens according to the 2022 Banff Classification of Renal Allograft Pathology, which includes two new diagnostic categories: probable antibody-mediated rejection and microvascular inflammation without evidence of an antibody-mediated response. We then assessed the association between the newly recognized microvascular inflammation phenotypes and allograft survival and disease progression. A total of 16,293 kidney-transplant biopsy specimens from 6798 patients were assessed. We identified the newly recognized microvascular inflammation phenotypes in 788 specimens, of which 641 were previously categorized as specimens with no evidence of rejection. As compared with patients without rejection, the hazard ratio for graft loss was 2.1 (95% confidence interval [CI], 1.5 to 3.1) among patients with microvascular inflammation without evidence of an antibody-mediated response and 2.7 (95% CI, 2.2 to 3.3) among patients with antibody-mediated rejection. Patients with a diagnosis of probable antibody-mediated rejection had a higher risk of graft failure beyond year 5 after biopsy than those without rejection (hazard ratio, 1.7; 95% CI, 0.8 to 3.5). Patients with a diagnosis of either newly recognized microvascular inflammation phenotype had a higher risk of progression of transplant glomerulopathy during follow-up than patients without microvascular inflammation. Microvascular inflammation in kidney allografts includes distinct phenotypes, with various disease progression and allograft outcomes. Our findings support the clinical use of additional rejection phenotypes to standardize diagnostics for kidney allografts. (Funded by OrganX. ClinicalTrials.gov number, NCT06496269.). |
| 1.074 | Brad Astor | NEPH | bcastor@medicine.wisc.edu | Competing and Noncompeting Risk Models for Predicting Kidney Allograft Failure. | Prognostic models are becoming increasingly relevant in clinical trials as potential surrogate endpoints, and for patient management as clinical decision support tools. However, the impact of competing risks on model performance remains poorly investigated. We aimed to carefully assess the performance of competing risk and noncompeting risk models in the context of kidney transplantation, where allograft failure and death with a functioning graft are two competing outcomes. We included 11,046 kidney transplant recipients enrolled in 10 countries. We developed prediction models for long-term kidney graft failure prediction, without accounting (i.e., censoring) and accounting for the competing risk of death with a functioning graft, using Cox, Fine-Gray, and cause-specific Cox regression models. To this aim, we followed a detailed and transparent analytical framework for competing and noncompeting risk modelling, and carefully assessed the models' development, stability, discrimination, calibration, overall fit, clinical utility, and generalizability in external validation cohorts and subpopulations. More than 15 metrics were used to provide an exhaustive assessment of model performance. Among 11,046 recipients in the derivation and validation cohorts, 1,497 (14%) lost their graft and 1,003 (9%) died with a functioning graft after a median follow-up post-risk evaluation of 4.7 years (IQR 2.7-7.0). The cumulative incidence of graft loss was similarly estimated by Kaplan-Meier and Aalen-Johansen methods (17% versus 16% in the derivation cohort). Cox and competing risk models showed similar and stable risk estimates for predicting long-term graft failure (average mean absolute prediction error of 0.0140, 0.0138 and 0.0135 for Cox, Fine-Gray, and cause-specific Cox models, respectively). Discrimination and overall fit were comparable in the validation cohorts, with concordance index ranging from 0.76 to 0.87. Across various subpopulations and clinical scenarios, the models performed well and similarly, although in some high-risk groups (such as donors over 65 years old), the findings suggest a trend towards moderately improved calibration when using a competing risk approach. Competing and noncompeting risk models performed similarly in predicting long-term kidney graft failure. |
| 1.075 | Sandesh Parajuli | NEPH | sparajuli@medicine.wisc.edu | Low 25-Hydroxyvitamin D Post-Kidney Transplant Is Associated with Increased Risk of BK Polyomavirus-Associated Nephropathy. | BK viremia (BKPyV-DNAemia) and nephropathy (BKPyVAN) are significant causes of morbidity and mortality in kidney transplant recipients (KTRs). Vitamin D supports immune function, yet low 25-hydroxyvitamin D [25(OH)D] is common among KTRs. The association between serum 25(OH)D, measured 61 days to 2 years post-transplant, and subsequent incident BKPyV-DNAemia and BKPyVAN was examined in KTRs without previous BKPyV-DNAemia or BKPyVAN, respectively. Out of 3308 KTRs, 399 (12%) were vitamin D deficient [25(OH)D ≤ 20 ng/mL], and 916 (27.7%) were insufficient [25(OH)D 21-29 ng/mL]. A total of 184 KTRs developed BKPyV-DNAemia and 44 developed BKPyVAN. The incidence rate (/100 person-years) for BKPyV-DNAemia was 2.88 in the 25(OH)D sufficient group, 2.22 in the insufficient group, and 2.37 in the deficient group. The incidence rate (/100 person-years) for BKPyVAN was 0.30 in the 25(OH)D sufficient group, 0.75 in the insufficient group, and 1.28 in the deficient group. Vitamin D deficiency (adjusted hazard ratio [aHR] compared to 25(OH)D sufficiency: 3.92; 95% CI: 1.66-9.23) and insufficiency (aHR: 2.22; 95% CI: 1.11-4.45) remained significantly associated with the incidence of BKPyVAN after adjustment for baseline characteristics. Low serum 25(OH)D was associated with an increased risk of BKPyVAN but not BKPyV-DNAemia. |
| 1.076 | Sandesh Parajuli | NEPH | sparajuli@medicine.wisc.edu | Early clearance of BK polyomavirus-DNAemia among kidney transplant recipients may lead to better graft survival. | BK polyomavirus (BKPyV)-DNAemia is a common complication in kidney transplant recipients (KTRs). The significance of achieving viral clearance at different time intervals is not well understood. All adult KTRs transplanted between January 1, 2015 and December 31, 2017 who developed BKPyV-DNAemia were included. Outcomes were analyzed based on persistent clearance of BKPyV-DNAemia at 3-month intervals up to 2 years after initial detection, and for recipients with persistent BKPyV-DNAemia at last follow-up. Uncensored graft failure, death-censored graft failure (DCGF), and a composite outcome of DCGF or fall in estimated glomerular filtration rate (eGFR) by ≥50% from the time of initial BKPyV-DNAemia were outcomes of interest. Of 224 KTRs with BKPyV-DNAemia, 58 recipients (26%) achieved viral clearance by 3 months after initial detection, 105 (47%) by 6 months, 120 (54%) by 9 months, 141 (63%) by 12 months, 155 (69%) by 15 months, 167 (75%) by 18 months, 180 (80%) by 21 months, and 193 (86%) by 24 months. Nine recipients (4%) had persistent BKPyV-DNAemia at last follow-up. Compared to recipients who achieved viral clearance by 3 months, those who achieved clearance by 6 months (adjusted odds ratio [aOR]: 3.15; 95% confidence interval [CI]: 1.22-8.12; p = .02) and 9 months (aOR: 3.69; 95% CI: 1.02-13.43; p = .04) had significantly increased risk for uncensored graft failure. There was no significant association between time to viral clearance and DCGF or composite outcomes. We found a trend of increased risk for uncensored graft failure among those who cleared BKPyV-DNAemia more slowly. Aiming to clear viremia early, without risking rejection, may be beneficial for allograft function and patient morbidity and mortality. |
| 1.077 | Sandesh Parajuli | NEPH | sparajuli@medicine.wisc.edu | Changes in Donor-Derived Cell-Free DNA Before and After Rejection and De Novo DSA Detection in Primary and Repeat Kidney Transplant Recipients. | Serial monitoring of dd-cfDNA and change from baseline can provide meaningful information beyond absolute thresholds. We describe dd-cfDNA trajectories from the baseline before and after acute rejection (AR) and de novo donor-specific antibodies (dnDSA) detection in kidney transplant recipients (KTRs). We included KTR from 02/2019 to 03/2022 with serial dd-cfDNA. The primary analysis compared the time-varying change in dd-cfDNA from baseline in KTR first AR on biopsy [AR] to patients with no-AR on biopsy [no-AR]. 151 KTR were analyzed (AR = 56 KTR, no-AR = 95 KTRs). In the AR group, dd-cfDNA rose ahead of diagnosis: median rise from baseline was 75% at -3 months, 32% at -2 months, and 325% at -1 month before biopsy. At the time of biopsy, the median rise in dd-cfDNA from baseline was 291% (IQR [interquartile range] 88%-1081%) in AR and 17% (IQR 0%- 194%) in no-AR (p < 0.0001). Following treatment, dd-cfDNA values fell in the AR group with a median change from baseline of 94.7% at +1 month, 10.5% at +2 months, and 0% at +3 months. These trajectories were not observed in the no-AR group. Similarly, there were no significant differences in eGFR (estimated glomerular filtration rate) trajectories between the two groups. The median change from baseline to dnDSA detection was 141% (IQR 112%-574%). In KTRs with persistent rejection, median dd-cfDNA was 0.95% (IQR 0.44-1.8) compared to 0.19% (IQR 0.12-0.31) in subjects with no rejection on follow-up (p < 0.001). The significant changes from baseline observed before and after AR show how serial monitoring enhances dd-cfDNA utility and allows for earlier identification of evolving injury and monitoring treatment response. |
| 1.078 | Sandesh Parajuli | NEPH | sparajuli@medicine.wisc.edu | Risk Factors for Early Post-transplant Weight Changes Among Simultaneous Pancreas-kidney Recipients and Impact on Outcomes. | There are limited data about the risk factors for weight changes and the association of significant weight changes with graft and metabolic outcomes after simultaneous pancreas and kidney (SPK) transplantation. We included all SPK recipients with both allografts functioning for at least 6 mo post-transplant and categorized them based on the weight changes from baseline to 6 mo post-transplant. We analyzed risk factors for significant weight gain (SWG) and significant weight loss (SWL) over 6 mo post-transplant, as well as outcomes including pancreas uncensored graft failure, pancreas death-censored graft failure (DCGF), composite pancreas graft outcomes of DCGF, use of an antidiabetic agent, or hemoglobin A1C >6.5%, and kidney DCGF. Of 280 SPK recipients, 153 (55%) experienced no significant weight change, 57 (20%) SWG, and 70 (25%) SWL. At 6 mo post-transplant, mean weight changes were 1.2% gain in the no significant weight change group, 13.4% gain in SWG, and 9.6% loss in the SWL groups. In multivariate analysis, the only factor associated with decreased risk for weight gain was older recipient age (aOR, 0.97; 95% confidence intervals, 0.95-0.99). Importantly, SWG or SWL were not associated with pancreas graft failure, P-DCGF, or K-DCGF. Interestingly in the adjusted model, SWG at 6 mo was associated with a lower risk for composite outcomes (HR, 0.35; 95% confidence intervals, 0.14-0.85). Forty-five percent of SPK recipients had significant weight changes by 6 mo post-transplant, but only 20% exhibited SWG. Likely because of proper management, weight changes were not associated with poor outcomes post-SPK transplant. |
| 1.079 | Sandesh Parajuli | NEPH | sparajuli@medicine.wisc.edu | Simultaneous Pancreas-Kidney Transplant Outcomes Stratified by Autoantibodies Status and Pretransplant Fasting C-peptide. | Pancreatic beta cell function and islet autoantibodies classically distinguish types of diabetes (type 1 diabetes mellitus [DM] or type 2 DM). Here, we sought to evaluate simultaneous pancreas-kidney (SPK) transplant outcomes stratified by the presence or absence of beta cell function and autoantibodies. SPK recipients were eligible if pretransplant autoantibodies were measured against insulin, islet cell, or glutamic acid decarboxylase 65-kD isoform. Recipients were categorized as A+ or A- based on the detection of ≥1 autoantibodies. Recipients were similarly categorized on the basis of detectable pretransplant fasting C-peptide of ≥2 ng/mL (β+) or 6.5. One hundred eighty-three SPK recipients were included: A+β- (n = 72), A-β- (n = 42), A-β+ (n = 49), and A+β+ (n = 20). We did not detect a statistical difference in non-death-censored pancreas graft failure for A+β- recipients compared with other groups: A-β- (adjusted hazard ratio [aHR]: 0.44; 95% confidence interval [CI], 0.14-1.42), A-β+ (aHR: 1.02; 95% CI, 0.37-2.85), and A+β+ (aHR: 0.67; 95% CI, 0.13-3.33) in adjusted analyses. Similar outcomes were observed for other outcomes. In SPK recipients, outcomes were similar among recipients with classic features of type 1 DM and various other types of DM. |
| 1.080 | Sandesh Parajuli | NEPH | sparajuli@medicine.wisc.edu | High Post-Kidney Transplant Serum Uric Acid Levels Are Associated with Detrimental Outcomes. | The potential effects of post-transplant serum uric acid (SUA) levels and outcomes pose a variety of risks among kidney transplant (KTR) recipients. The association between post-transplant SUA and major detrimental outcomes among KTRs remains uncertain. We evaluated all adult kidney transplant recipients (KTRs) transplanted between 1/1/2000 and 12/31/2019. Recipients were included if they had a functioning allograft without any cardiovascular events (CVE) before their earliest SUA measurement within 5-13 months post-transplant.Survival analyses were performed regarding CVEs, CVE-related mortality, death-censored graft failure (DCGF), and uncensored graft failure, within 10 years after transplantation. A total of 3808 eligible KTRs were followed for a median of 7.5 years after transplantation. Recipients with post-transplant SUA > 6.8 mg/dl had significantly higher risk of congestive heart failure (CHF) than those with SUA <6 mg/dl (adjusted hazard ratio [aHR] = 1.55, 95% CI: 1.10-2.19; p = 0.01); uncensored graft failure (aHR = 1.18, 95% CI: 1.02-1.36; p = 0.03), and DCGF (aHR = 1.28, 95% CI: 1.01-1.61; p = 0.04), after adjustment for multiple variables, including kidney graft function. No statistically significant association was found between SUA levels and other CVEs. There was no statistically significant risk for other outcomes of interest when comparing SUA < 6 mg/dl versus 6-6.8 mg/dl. Elevated early post-transplant SUA levels were associated with detrimental post-transplant outcomes, leading to increased morbidity and mortality through CHF, graft failure, and overall death. |
| 1.081 | Sandesh Parajuli | NEPH | sparajuli@medicine.wisc.edu | Delayed graft function has comparable associations with early outcomes in primary and repeat transplant among deceased-donor kidney transplant recipients. | Delayed graft function (DGF) is a common complication and is associated with worse outcomes among kidney transplant recipients (KTRs). There are various risk factors for DGF including previous transplant. We hypothesized that DGF among KTRs undergoing repeat transplant has a greater impact on outcomes compared to primary KTRs. All deceased-donor KTRs between 01/2000 and 12/2020 at our center were included. Recipients were categorized as primary KTR or repeat KTR (any number of previous kidney transplants). Outcomes of interest included acute rejection, death-censored graft failure, and patient mortality within 12 months post-transplant. A total of 3137 deceased-donor KTRs were included; 2498(80%) were primary KTRs and 639(20%) were repeat KTRs. The rates of DGF were similar between the groups at 29% and 28%, respectively. Compared to KTRs without DGF, DGF was associated with a greater incidence of death and graft failure in both primary and repeat transplants; however, the risk of rejection was not significantly higher in repeat KTRs (p = 0.72). Comparing primary and repeat KTRs, there were no significant differences in either acute rejection (p-interaction = 0.11), death-censored graft failure (p-interaction = 0.38), or death (p-interaction = 0.37). In subgroup analysis among repeat KTRs with DGF, a repeat transplant with no prior DGF was associated with increased risk for death-censored graft failure and death but not for acute rejection. DGF in the prior transplant was protective against death-censored graft failure (HR: 0.07, 95% CI 0.005-0.98, p = 0.05) (p-interaction = 0.04), but this was not significantly associated with acute rejection or death. DGF is associated with similar detrimental outcomes among primary and repeat KTRs. |
| 1.082 | Sandesh Parajuli | NEPH | sparajuli@medicine.wisc.edu | Can Blood Gene Expression Profile and Donor-Derived Cellfree DNA Guide Postrejection Management among Kidney Transplant Recipients? | |
| 1.083 | Sandesh Parajuli | NEPH | sparajuli@medicine.wisc.edu | Analysis of Rejection, Infection and Surgical Outcomes in Type I Versus Type II Diabetic Recipients After Simultaneous Pancreas-Kidney Transplantation. | Given the increasing frequency of simultaneous pancreas-kidney transplants performed in recipients with Type II diabetes and CKD, we sought to evaluate possible differences in the rates of allograft rejection, infection, and surgical complications in 298 Type I (T1D) versus 47 Type II (T2D) diabetic recipients of simultaneous pancreas-kidney transplants between 2006-2017. There were no significant differences in patient or graft survival. The risk of biopsy-proven rejection of both grafts was not significantly different between T2D and T1D recipients (HRpancreas = 1.04, p = 0.93; HRkidney = 0.96; p = 0.93). Rejection-free survival in both grafts were also not different between the two diabetes types (ppancreas = 0.57; pkidney = 0.41). T2D had a significantly lower incidence of de novo DSA at 1 year (21% vs. 39%, p = 0.02). There was no difference in T2D vs. T1D recipients regarding readmissions (HR = 0.77, p = 0.25), infections (HR = 0.77, p = 0.18), major surgical complications (HR = 0.89, p = 0.79) and thrombosis (HR = 0.92, p = 0.90). In conclusion, rejection, infections, and surgical complications after simultaneous pancreas-kidney transplant are not statistically significantly different in T2D compared to T1D recipients. |
| 1.084 | Sandesh Parajuli | NEPH | sparajuli@medicine.wisc.edu | Reflecting on the Past and Looking Toward the Future: A Brief History of University of Wisconsin Transplant Program. | |
| 1.085 | Fahad Aziz | NEPH | faziz@wisc.edu | Shaping the Future of Medicine Through Mentorship. | |
| 1.086 | Fahad Aziz | NEPH | faziz@wisc.edu | Risk Factors for Early Post-transplant Weight Changes Among Simultaneous Pancreas-kidney Recipients and Impact on Outcomes. | There are limited data about the risk factors for weight changes and the association of significant weight changes with graft and metabolic outcomes after simultaneous pancreas and kidney (SPK) transplantation. We included all SPK recipients with both allografts functioning for at least 6 mo post-transplant and categorized them based on the weight changes from baseline to 6 mo post-transplant. We analyzed risk factors for significant weight gain (SWG) and significant weight loss (SWL) over 6 mo post-transplant, as well as outcomes including pancreas uncensored graft failure, pancreas death-censored graft failure (DCGF), composite pancreas graft outcomes of DCGF, use of an antidiabetic agent, or hemoglobin A1C >6.5%, and kidney DCGF. Of 280 SPK recipients, 153 (55%) experienced no significant weight change, 57 (20%) SWG, and 70 (25%) SWL. At 6 mo post-transplant, mean weight changes were 1.2% gain in the no significant weight change group, 13.4% gain in SWG, and 9.6% loss in the SWL groups. In multivariate analysis, the only factor associated with decreased risk for weight gain was older recipient age (aOR, 0.97; 95% confidence intervals, 0.95-0.99). Importantly, SWG or SWL were not associated with pancreas graft failure, P-DCGF, or K-DCGF. Interestingly in the adjusted model, SWG at 6 mo was associated with a lower risk for composite outcomes (HR, 0.35; 95% confidence intervals, 0.14-0.85). Forty-five percent of SPK recipients had significant weight changes by 6 mo post-transplant, but only 20% exhibited SWG. Likely because of proper management, weight changes were not associated with poor outcomes post-SPK transplant. |
| 1.087 | Fahad Aziz | NEPH | faziz@wisc.edu | Simultaneous Pancreas-Kidney Transplant Outcomes Stratified by Autoantibodies Status and Pretransplant Fasting C-peptide. | Pancreatic beta cell function and islet autoantibodies classically distinguish types of diabetes (type 1 diabetes mellitus [DM] or type 2 DM). Here, we sought to evaluate simultaneous pancreas-kidney (SPK) transplant outcomes stratified by the presence or absence of beta cell function and autoantibodies. SPK recipients were eligible if pretransplant autoantibodies were measured against insulin, islet cell, or glutamic acid decarboxylase 65-kD isoform. Recipients were categorized as A+ or A- based on the detection of ≥1 autoantibodies. Recipients were similarly categorized on the basis of detectable pretransplant fasting C-peptide of ≥2 ng/mL (β+) or 6.5. One hundred eighty-three SPK recipients were included: A+β- (n = 72), A-β- (n = 42), A-β+ (n = 49), and A+β+ (n = 20). We did not detect a statistical difference in non-death-censored pancreas graft failure for A+β- recipients compared with other groups: A-β- (adjusted hazard ratio [aHR]: 0.44; 95% confidence interval [CI], 0.14-1.42), A-β+ (aHR: 1.02; 95% CI, 0.37-2.85), and A+β+ (aHR: 0.67; 95% CI, 0.13-3.33) in adjusted analyses. Similar outcomes were observed for other outcomes. In SPK recipients, outcomes were similar among recipients with classic features of type 1 DM and various other types of DM. |
| 1.088 | Fahad Aziz | NEPH | faziz@wisc.edu | Outcomes of Deceased Donor Kidney Recipients From the Same Donor Based on Donor-Recipient Sex Discordance. | Outcomes of deceased donor kidney transplant (DDKT) recipients from the same donor with donor-recipient sex discordance have been studied with inconsistent results. Adult DDKT where both kidneys from the same donor occurred at our center in two different recipients of different sexes were included. Outcomes were analyzed separately for male and female donors, based on the concordance or discordance between donor-recipient sex: Male-male (M-m) versus Male to female (M-f) or vice versa, F-f versus F-m. Acute rejection (AR) and uncensored graft failure were primary outcomes of interest. The univariate and multivariate risks for AR and graft failure were conducted using the Cox proportional hazards model and log-rank tests. A total of 130 donors, 84 male and 46 female fulfilled our selection criteria and were transplanted in 260 recipients. With respect to the concordant groups (M-m or F-f), sex discordance was not significantly associated with the risk of rejection in multivariate analysis (M-f vs. M-m HR 1.15 [0.53-2.53, P = 0.72]; F-m vs. F-f HR 1.77 [0.71-4.39, P = 0.23]). Sex discordance was also not significantly associated with graft failure in multivariate analysis. Interestingly, risk factors for AR differed among male donors and female donors. The higher calculated panel reactive antibodies (cPRA) and nonwhite recipients were at increased risk for AR in F-m, but not in M-f. Donor-recipient sex discordance was not significantly associated with AR or graft failure. Risk factors for AR may differ across male and female donors. |
| 1.089 | Fahad Aziz | NEPH | faziz@wisc.edu | Thriving in Your First Year of Medical Training. | |
| 1.090 | Fahad Aziz | NEPH | faziz@wisc.edu | Oxalate Nephropathy After Kidney Transplantation: Risk Factors and Outcomes of Two Phenotypes. | Describing risk factors and outcomes in kidney transplant recipients with oxalate nephropathy (ON) may help elucidate the pathogenesis and guide treatment strategies. We used a large single-center database to identify patients with ON and categorized them into delayed graft function with ON (DGF-ON) and late ON. Incidence density sampling was used to select controls. A total of 37 ON cases were diagnosed between 1/2011 and 1/2021. DGF-ON (n = 13) was diagnosed in 1.05% of the DGF population. Pancreatic atrophy on imaging (36.4% vs. 2.9%, p = 0.002) and gastric bypass history (7.7% vs. 0%; p = 0.06) were more common in DGF-ON than with controls with DGF requiring biopsy but without evidence of ON. DGF-ON was not associated with worse graft survival (p = 0.98) or death-censored graft survival (p = 0.48). Late ON (n = 24) was diagnosed after a mean of 78.2 months. Late ON patients were older (mean age 55.1 vs. 48.4 years; p = 0.02), more likely to be women (61.7% vs. 37.5%; p = 0.03), have gastric bypass history (8.3% vs. 0.8%; p = 0.02) and pancreatic atrophy on imaging (38.9% vs. 13.3%; p = 0.02). Late ON was associated with an increased risk of graft failure (HR 2.0; p = 0.07) and death-censored graft loss (HR 2.5; p = 0.10). We describe two phenotypes of ON after kidney transplantation: DGF-ON and late ON. Our study is the first to our knowledge to evaluate DGF-ON with DGF controls without ON. Although limited by small sample size, DGF-ON was not associated with adverse outcomes when compared with controls. Late ON predicted worse allograft outcomes. |
| 1.091 | Fahad Aziz | NEPH | faziz@wisc.edu | Avascular Necrosis in Kidney Transplant Recipients is Associated With an Increased Risk of Patient Death. | Introduction: Avascular necrosis is a debilitating osseous complication in transplant recipients. Project Aim: This program evaluation sought to describe risk factors and adverse outcomes of avascular necrosis in kidney transplant recipients. Design: This was a retrospective evaluation of all recipients of kidneys and simultaneous pancreas and kidneys between 2001 and 2018 from a single center. Controls were selected based on the incidence density, sampling at a 1:3 ratio based on the post-transplant interval. Outcomes of interest were acute rejection, death-censored graft failure, and patient mortality. Results: A total of 88 kidney recipients had avascular necrosis and were compared with 257 controls. Most of the recipient's and donors' baseline characteristics were similar between the groups, except calcineurin inhibitor-based immunosuppression was more prevalent, and non-white donors were less prevalent in the control group. Looking for risk factors for avascular necrosis, calcineurin inhibitor-based immunosuppression was associated with a lower risk for avascular necrosis in the univariate analysis, but this was not found after adjustment of multiple variables. In multivariate analysis, avascular necrosis was associated with an increased risk for patient death (hazard ratio: 1.68; 95% confidence interval: 1.16-2.44; P = .008) but not for acute rejection or death censored graft failure. Conclusion: Although limited by small sample size, this evaluation found avascular necrosis to be associated with an increased risk of patient death. This finding may be useful for the provider taking care of the patients and discussing the various outcomes after the transplant. |
| 1.092 | Fahad Aziz | NEPH | faziz@wisc.edu | The Art of Peer Review. | |
| 1.093 | Fahad Aziz | NEPH | faziz@wisc.edu | Compassionate Care Through the Lens of Generational Understanding. | |
| 1.094 | Fahad Aziz | NEPH | faziz@wisc.edu | Advanced Practice Providers' Wellness Essential for Health Care Organizations. | |
| 1.095 | Michael Eberlein | APCC-Pulm | meberlein@medicine.wisc.edu | Right- versus left-first implantation in off-pump sequential double-lung transplantation: physiology and size matter? | |
| 1.096 | Michael Eberlein | APCC-Pulm | meberlein@medicine.wisc.edu | Lung transplantation from donation after cardiocirculatory death: a systematic review and meta-analysis. | Lung transplantation (LTx) can extend life expectancy and enhance the quality of life for select patients with end-stage lung disease. In the setting of donor lung shortage and waiting list mortality, the interest in donation after cardiocirculatory death (DCD) is increasing. We performed a systematic review and meta-analysis to compare outcomes between DCD and conventional donation after brain death (DBD). PubMed, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and ClinicalTrials.gov were searched. We identified original research studies with 1-year post-transplant survival data involving >5 DCD transplants. We performed meta-analyses examining 1-year survival, primary graft dysfunction, and acute rejection after LTx. We identified 519 citations; 11 observational cohort studies met our inclusion criteria for systematic review, and 6 met our inclusion criteria for meta-analysis. There were no differences found in 1-year mortality after LTx between DCD and DBD cohorts in individual studies or in the meta-analysis (DCD [n = 271] vs DBD [n = 2,369], relative risk [RR] 0.88, 95% confidence interval [CI] 0.59-1.31, p = 0.52, I(2) = 0%). There was also no difference between DCD and DBD in a pooled analysis of 5 studies reporting on primary graft dysfunction (RR 1.09, 95% CI 0.68-1.73, p = 0.7, I(2) = 0%) and 4 studies reporting on acute rejection (RR 0.72, 95% CI 0.49-1.05, p = 0.09, I(2) = 0%). Survival after LTx from DCD is comparable to survival after LTx from DBD in observational cohort studies. DCD appears to be a safe and effective method to expand the donor pool. |
| 1.097 | Carrie Johnson | APCC-Pulm | cjohnson1@medicine.wisc.edu | Right- versus left-first implantation in off-pump sequential double-lung transplantation: physiology and size matter? | |
| 1.098 | Carrie Johnson | APCC-Pulm | cjohnson1@medicine.wisc.edu | Elizabethkingia anophelis: Clinical Experience of an Academic Health System in Southeastern Wisconsin. | In late 2015 and early 2016, 11 patients were identified with cultures positive for Elizabethkingia anophelis in our health system. All patients had positive blood cultures upon admission. Chart review showed that all had major comorbidities and recent health care exposure. The attributable mortality rate was 18.2%. |
| 1.099 | Carrie Johnson | APCC-Pulm | cjohnson1@medicine.wisc.edu | Chemotherapy-induced peripheral neuropathy: a review of recent findings. | Chemotherapy-induced peripheral neuropathy (CIPN) is a common, frequently chronic condition characterized by pain and decreased function. Given the growing number of cancer survivors and an increasing recognition of opioid therapy limitations, there is a need for critical analysis of the literature in directing an informed and thoughtful approach for the management of painful CIPN. A PubMed search for 'chemotherapy-induced peripheral neuropathy AND pain' identifies 259 publications between 1 January 2016 and 31 March 2017. Based on review of this literature, we aim to present a clinically relevant update of painful CIPN. Notably, the use of duloxetine as a first-line agent in treatment of CIPN is confirmed. Moreover, clinical trials focus on nonpharmacologic strategies for managing painful CIPN. Despite the volume of recent publications, there are limited preventive or therapeutic strategies for CIPN supported by high-level evidence. Duloxetine remains the only pharmacologic agent with demonstrated benefit; its clinical use should be routinely considered. Moving forward, nonopioid analgesic therapies will likely play an increasing role in CIPN treatment, but further research is necessary to confirm their utility. Promising therapies include vitamin B12 supplementation, physical therapy, and various forms of neuromodulation. |
| 1.100 | Robert Guzy | APCC-Pulm | rdguzy@medicine.wisc.edu | Right- versus left-first implantation in off-pump sequential double-lung transplantation: physiology and size matter? | |
| 1.101 | Robert Guzy | APCC-Pulm | rdguzy@medicine.wisc.edu | Androgen signaling restricts glutaminolysis to drive sex-specific Th17 metabolism in allergic airway inflammation. | Female individuals have an increased prevalence of many Th17 cell-mediated diseases, including asthma. Androgen signaling decreases Th17 cell-mediated airway inflammation, and Th17 cells rely on glutaminolysis. However, it remains unclear whether androgen receptor (AR) signaling modifies glutamine metabolism to suppress Th17 cell-mediated airway inflammation. We show that Th17 cells from male humans and mice had decreased glutaminolysis compared with female individuals, and that AR signaling attenuated Th17 cell mitochondrial respiration and glutaminolysis in mice. Using allergen-induced airway inflammation mouse models, we determined that females had a selective reliance upon glutaminolysis for Th17-mediated airway inflammation, and that AR signaling attenuated glutamine uptake in CD4+ T cells by reducing expression of glutamine transporters. In patients with asthma, circulating Th17 cells from men had minimal reliance upon glutamine uptake compared to Th17 cells from women. AR signaling thus attenuates glutaminolysis, demonstrating sex-specific metabolic regulation of Th17 cells with implications for Th17 or glutaminolysis targeted therapeutics. |
| 1.102 | Robert Guzy | APCC-Pulm | rdguzy@medicine.wisc.edu | Implementation of a prospective screening strategy to identify adults with a telomere biology disorder among those undergoing lung transplant evaluation for interstitial lung disease. | Patients with interstitial lung disease (ILD) secondary to telomere biology disorders (TBD) experience increased morbidity after lung transplantation. Identifying patients with TBD may allow for personalized management to facilitate better outcomes. However, establishing a TBD diagnosis in adults is challenging. A TBD screening questionnaire was introduced prospectively into the lung transplant evaluation. Patients with ILD screening positive were referred for comprehensive TBD phenotyping and concurrent telomere length measurement and germline genetic testing. Of 98 patients, 32 (33%) screened positive. Eight patients (8% of total; 25% of patients with a positive screen) met strict TBD diagnostic criteria, requiring either critically short lymphocyte telomeres (<1st percentile) (n = 4), a pathogenic variant in a TBD-associated gene (n = 1), or both (n = 3) along with a TBD clinical phenotype. Additional patients not meeting strict diagnostic criteria had histories consistent with TBD along with telomere lengths <10th percentile and/or rare variants in TBD-associated genes, highlighting a critical need to refine TBD diagnostic criteria for this patient population. A TBD phenotype screening questionnaire in patients with ILD undergoing lung transplant evaluation has a diagnostic yield of 25%. Additional gene discovery, rare variant functional testing, and refined TBD diagnostic criteria are needed to realize the maximum benefit of testing for TBD in patients undergoing lung transplantation. |
| 1.103 | Robert Guzy | APCC-Pulm | rdguzy@medicine.wisc.edu | Antigenic responses are hallmarks of fibrotic interstitial lung diseases independent of underlying etiologies. | Interstitial lung diseases (ILD) are heterogeneous conditions that may lead to progressive fibrosis and death of affected individuals. Despite diversity in clinical manifestations, enlargement of lung-associated lymph nodes (LLN) in fibrotic ILD patients predicts worse survival. Herein, we revealed a common adaptive immune landscape in LLNs of all ILD patients, characterized by highly activated germinal centers and antigen-activated T cells including regulatory T cells (Tregs). In support of these findings, we identified serum reactivity to 17 candidate auto-antigens in ILD patients through a proteome-wide screening using phage immunoprecipitation sequencing. Autoantibody responses to actin binding LIM protein 1 (ABLIM1), a protein highly expressed in aberrant basaloid cells of fibrotic lungs, were correlated with LLN frequencies of T follicular helper cells and Tregs in ILD patients. Together, we demonstrate that end-stage ILD patients have converging immune mechanisms, in part driven by antigen-specific immune responses, which may contribute to disease progression. |
| 1.104 | Erin Lowery | APCC-Pulm | emlowery@medicine.wisc.edu | Right- versus left-first implantation in off-pump sequential double-lung transplantation: physiology and size matter? | |
| 1.105 | Erin Lowery | APCC-Pulm | emlowery@medicine.wisc.edu | Successful Medical Management of Pulmonary Gangrene in a Transplanted Lung. | Pulmonary gangrene (PG) is a potentially devastating complication of necrotizing pneumonia. We describe successful nonsurgical management of PG in a lung transplant recipient. The patient presented with symptoms and imaging consistent with pneumonia. Bronchoalveolar lavage cultures demonstrated polymicrobial growth and antibiotic treatments were tailored. Imaging demonstrated a large cavitary lesion with intracavitary lung tissue consistent with PG. Prolonged antibiotic therapy resulted in clinical improvement and radiographic resolution. |
| 1.106 | Erin Lowery | APCC-Pulm | emlowery@medicine.wisc.edu | Lung Transplantation from hepatitis C+ donor lungs: Reassuring midterm outcomes. | The development of modern antiviral therapy for hepatitis C virus (HCV) has allowed for the transplantation of HCV nucleic acid amplification testing-positive (NAT+) donor lungs with acceptable short-term outcomes. We sought to evaluate trends and midterm outcomes of lung transplant recipients of HCV NAT+ donor allografts. All adults undergoing isolated lung transplantation in the United Network for Organ Sharing database from January 2016 to December 2022 were included in the study. Lung transplant recipients were stratified based on donor HCV status (HCV NAT+ vs NAT-). Propensity score matching was used to adjust for differences between groups. Several outcomes, including acute rejection by 1 year, early (30-day and in-hospital) mortality, and both 1- and 3-year survival, were compared between matched groups. A total of 16,725 patients underwent lung transplantation during the study period, with 489 (3%) receiving HCV NAT+ donor lungs. Regions 1 (18%) and 6/8 (both 0%) had the highest and lowest proportions, respectively, of HCV NAT+ donor transplants. Utilization of HCV NAT+ donors increased throughout the study period from 2 (0.1%) in 2016 to a peak of 117 (5%) in 2019. Donors who were HCV NAT+ were younger (34 vs 36 years, p < 0.001), more often female (44% vs 39%, p < 0.01), and more commonly died due to drug intoxication (56% vs 15%, p < 0.001). Recipients of HCV NAT+ donor lungs were similar in age (62 vs 62 years, p = 0.69) and female gender (43% vs 39%, p = 0.15) but had lower lung allocation scores (38 vs 41, p < 0.001) compared to others. Rates of acute rejection (13% vs 17%, p = 0.09), early mortality (30-day: 2% vs 1%, p = 0.59, in-hospital: 3% vs 4%, p = 0.38), as well as 1-year (90% vs 92%, p = 0.29) and 3-year survival (69% vs 75%, p = 0.13) were not significantly different between matched groups. Lung transplant recipients of HCV NAT+ donor allografts experience similar rates of acute rejection, early mortality, and 3-year survival compared to all other lung recipients. Increased use of HCV NAT+ donor allografts may help to expand the donor pool and alleviate donor shortages. |
| 1.107 | Erin Lowery | APCC-Pulm | emlowery@medicine.wisc.edu | Implementation of a prospective screening strategy to identify adults with a telomere biology disorder among those undergoing lung transplant evaluation for interstitial lung disease. | Patients with interstitial lung disease (ILD) secondary to telomere biology disorders (TBD) experience increased morbidity after lung transplantation. Identifying patients with TBD may allow for personalized management to facilitate better outcomes. However, establishing a TBD diagnosis in adults is challenging. A TBD screening questionnaire was introduced prospectively into the lung transplant evaluation. Patients with ILD screening positive were referred for comprehensive TBD phenotyping and concurrent telomere length measurement and germline genetic testing. Of 98 patients, 32 (33%) screened positive. Eight patients (8% of total; 25% of patients with a positive screen) met strict TBD diagnostic criteria, requiring either critically short lymphocyte telomeres (<1st percentile) (n = 4), a pathogenic variant in a TBD-associated gene (n = 1), or both (n = 3) along with a TBD clinical phenotype. Additional patients not meeting strict diagnostic criteria had histories consistent with TBD along with telomere lengths <10th percentile and/or rare variants in TBD-associated genes, highlighting a critical need to refine TBD diagnostic criteria for this patient population. A TBD phenotype screening questionnaire in patients with ILD undergoing lung transplant evaluation has a diagnostic yield of 25%. Additional gene discovery, rare variant functional testing, and refined TBD diagnostic criteria are needed to realize the maximum benefit of testing for TBD in patients undergoing lung transplantation. |
| 1.108 | Erin Lowery | APCC-Pulm | emlowery@medicine.wisc.edu | Internal and External Validation of an Alcohol Biomarker for Screening in Trauma. | We aimed to examine biomarkers for screening unhealthy alcohol use in the trauma setting. Self-report tools are the practice standard for screening unhealthy alcohol use; however, their collection suffers from recall bias and incomplete collection by staff. We performed a multi-center prospective clinical study of 251 adult patients who arrived within 24 hours of injury with external validation in another 60 patients. The Alcohol Use Disorders Identification Test served as the reference standard. The following biomarkers were measured: (1) PEth; (2) ethyl glucuronide; (3) ethyl sulfate; (4) gamma-glutamyl-transpeptidase; (5) carbohydrate deficient transferrin; and (6) blood alcohol concentration (BAC). Candidate single biomarkers and multivariable models were compared by considering discrimination (AUROC). The optimal cutpoint for the final model was identified using a criterion for setting the minimum value for specificity at 80% and maximizing sensitivity. Decision curve analysis was applied to compare to existing screening with BAC. PEth alone had an AUROC of 0.93 [95% confidence interval (CI): 0.92-0.93] in internal validation with an optimal cutpoint of 25 ng/mL. A 4- variable biomarker model and the addition of any single biomarker to PEth did not improve AUROC over PEth alone ( P > 0.05). Decision curve analysis showed better performance of PEth over BAC across most predicted probability thresholds. In external validation, sensitivity and specificity were 76.0% (95% CI: 53.0%-92.0%) and 73.0% (95% CI: 56.0%-86.0%), respectively.Conclusion and Relevance: PEth alone proved to be the single best biomarker for screening of unhealthy alcohol use and performed better than existing screening systems with BAC. PEth may overcome existing screening barriers. |
| 1.109 | Erin Lowery | APCC-Pulm | emlowery@medicine.wisc.edu | A Case Report of Cystic Fibrosis Plus Tuberous Sclerosis: A Cautionary Tale Regarding Lung Transplantation. | Cystic fibrosis (CF) and tuberous sclerosis complex (TSC) are 2 rare genetic diseases that often affect the lungs. Pulmonary compromise in TSC or CF can be severe enough to require lung transplantation. In rare instances patients with CF undergo pneumonectomy to control recurrent lung infections and lung necrosis affecting one lung more than the other. Lung transplantation in these patients is exceedingly rare because preexistent pneumonectomy increases the risk of lung transplant-associated morbidity and mortality. We present the case of a young woman with co-occurrence of TSC and CF, who underwent left-sided pneumonectomy and, approximately 2 years later, right-sided single lung transplant. The posttransplant clinical course was complicated by phrenic nerve injury, ventilator dependency, Aspergillus endocarditis with embolic shower, and death. Pretransplant pneumonectomy, Aspergillus colonization, and posttransplant phrenic nerve injury contributed to the complex postoperative course, ventilatory dependence, and poor outcome. This cautionary case should alert physicians on the challenges associated with single lung transplant in patients with preexistent pneumonectomy. |
| 1.110 | Erin Lowery | APCC-Pulm | emlowery@medicine.wisc.edu | Cystic fibrosis foundation consensus statements for the care of cystic fibrosis lung transplant recipients. | Cystic fibrosis (CF) is the indication for transplantation in approximately 15% of recipients worldwide, and Cystic Fibrosis Lung Transplant Recipients (CFLTRs) have excellent long-term outcomes. Yet, CFLTRs have unique comorbidities that require specialized care. The objective of this document is to provide recommendations to CF and lung transplant clinicians for the management of perioperative and underlying comorbidities of CFLTRs and the impact of transplantation on these comorbidities. The Cystic Fibrosis Foundation (CFF) organized a multidisciplinary committee to develop CF Lung Transplant Clinical Care Recommendations. Three workgroups were formed to develop focused questions. Following a literature search, consensus recommendations were developed by the committee members based on literature review, committee experience and iterative revisions, and in response to public comment. The committee formulated 32 recommendation statements in the topics related to infectious disease, endocrine, gastroenterology, pharmacology, mental health and family planning. Broadly, the committee recommends close coordination of care between the lung transplant team, the cystic fibrosis care center, and specialists in other disciplines with experience in the care of CF and lung transplant recipients. These consensus statements will help lung transplant providers care for CFLTRs in order to improve post-transplant outcomes in this population. |
| 1.111 | Dominic O Co | PEDS | doco@wisc.edu | Recent Advances in Juvenile Dermatomyositis: Moving toward Integration of Myositis-Specific Antibody Clinical Phenotypes, IFN-Driven Pathogenesis, and Targeted Therapies. | Juvenile dermatomyositis (JDM), the most common pediatric inflammatory myopathy, is associated with significant morbidity despite therapeutic advances. Distinct clinical phenotypes have emerged, which can correlate with myositis-specific antibodies. Because translational data solidify the role of type I IFNs in JDM disease pathogenesis, integration of clinical and molecular phenotyping may impact the choice of targeted therapy. This paper reviews clinical and molecular phenotyping in JDM and translational insights into immune pathogenesis that have created emerging options for targeted therapy. |
| 1.112 | Dominic O Co | PEDS | doco@wisc.edu | Interleukin (IL)-1/IL-6-Inhibitor-Associated Drug Reaction With Eosinophilia and Systemic Symptoms (DReSS) in Systemic Inflammatory Illnesses. | After introducing IL-1/IL-6 inhibitors, some patients with Still and Still-like disease developed unusual, often fatal, pulmonary disease. This complication was associated with scoring as DReSS (drug reaction with eosinophilia and systemic symptoms) implicating these inhibitors, although DReSS can be difficult to recognize in the setting of systemic inflammatory disease. To facilitate recognition of IL-1/IL-6 inhibitor-DReSS in systemic inflammatory illnesses (Still/Still-like) by looking at timing and reaction-associated features. We evaluated outcomes of stopping or not stopping IL-1/IL-6 inhibitors after DReSS reaction began. In an international study collaborating primarily with pediatric specialists, we characterized features of 89 drug-reaction cases versus 773 drug-exposed controls and compared outcomes of 52 cases stopping IL-1/IL-6 inhibitors with 37 cases not stopping these drugs. Before the reaction began, drug-reaction cases and controls were clinically comparable, except for younger disease-onset age for reaction cases with preexisting cardiothoracic comorbidities. After the reaction began, increased rates of pulmonary complications and macrophage activation syndrome differentiated drug-reaction cases from drug-tolerant controls (P = 4.7 × 10-35 and P = 1.1 × 10-24, respectively). The initial DReSS feature was typically reported 2 to 8 weeks after initiating IL-1/IL-6 inhibition. In drug-reaction cases stopping versus not stopping IL-1/IL-6-inhibitor treatment, reaction-related features were indistinguishable, including pulmonary complication rates (75% [39 of 52] vs 76% [28 of 37]). Those stopping subsequently required fewer medications for treatment of systemic inflammation, had decreased rates of macrophage activation syndrome, and improved survival (P = .005, multivariate regression). Resolution of pulmonary complications occurred in 67% (26 of 39) of drug-reaction cases who stopped and in none who continued inhibitors. In systemic inflammatory illnesses, recognition of IL-1/IL-6-inhibitor-associated reactions followed by avoidance of IL-1/IL-6 inhibitors significantly improved outcomes. |
| 1.113 | Dominic O Co | PEDS | doco@wisc.edu | Childhood-Onset Systemic Lupus Erythematosus. | |
| 1.114 | Dominic O Co | PEDS | doco@wisc.edu | Executive summary: Consensus treatment guidelines for the use of methotrexate for inflammatory skin disease in pediatric patients. | |
| 1.115 | Dominic O Co | PEDS | doco@wisc.edu | Disease Course, Treatments, and Outcomes of Children With Systemic Juvenile Idiopathic Arthritis-Associated Lung Disease. | Systemic juvenile idiopathic arthritis-associated lung disease (SJIA-LD) is a life-threatening disease complication. Key questions remain regarding clinical course and optimal treatment approaches. The objectives of the study were to detail management strategies after SJIA-LD detection, characterize overall disease courses, and measure long-term outcomes. This was a prospective cohort study. Clinical data were abstracted from the electronic medical record, including current clinical status and changes since diagnosis. Serum biomarkers were determined and correlated with presence of LD. We enrolled 41 patients with SJIA-LD, 85% with at least one episode of macrophage activation syndrome and 41% with adverse reactions to a biologic. Although 93% of patients were alive at last follow-up (median 2.9 years), 37% progressed to requiring chronic oxygen or other ventilator support, and 65% of patients had abnormal overnight oximetry studies, which changed over time. Eighty-four percent of patients carried the HLA-DRB1*15 haplotype, significantly more than patients without LD. Patients with SJIA-LD also showed markedly elevated serum interleukin-18 (IL-18), variable C-X-C motif chemokine ligand 9 (CXCL9), and significantly elevated matrix metalloproteinase 7. Treatment strategies showed variable use of anti-IL-1/6 biologics and addition of other immunomodulatory treatments and lung-directed therapies. We found a broad range of current clinical status independent of time from diagnosis or continued biologic treatment. Multidomain measures of change showed imaging features were the least likely to improve with time. Patients with SJIA-LD had highly varied courses, with lower mortality than previously reported but frequent hypoxia and requirement for respiratory support. Treatment strategies were highly varied, highlighting an urgent need for focused clinical trials. |
| 1.116 | Dominic O Co | PEDS | doco@wisc.edu | Bilateral Rasmussen Encephalitis: Good Outcome Following Hemispherotomy. | Bilateral Rasmussen encephalitis is a rare variant of a debilitating, typically unihemispheric disease with limited treatment options. Few cases with bilateral histopathology have been reported, all with poor seizure control following surgery. Here we report a favorable outcome following hemispherotomy in a four-year-old male with biopsy-confirmed bilateral disease. The patient presented with right hemispheric focal seizures with behavioral arrest and over a year progressed to left lower extremity clonic seizures, epilepsia partialis continua, and loss of ambulation, with transient response to steroids and tacrolimus. Histopathology confirmed bilateral disease. The patient developed super-refractory status epilepticus and underwent right functional hemispherotomy 4.5 years after initial presentation. In a 2.5-year follow-up period, an Engel 1D outcome classification was observed with substantially improved quality of life. Previous reports of bilateral Rasmussen encephalitis describe universally poor outcomes, and hemispherotomy is often considered contraindicated. However, hemispherotomy in a patient with bilateral Rasmussen encephalitis may have a good outcome if seizures are unihemispheric. |
| 1.117 | Dominic O Co | PEDS | doco@wisc.edu | Acquired Demyelinating Syndromes. | Acquired demyelinating syndromes (ADS) are a heterogenous group of inflammatory demyelinating conditions that include presentations of optic neuritis, transverse myelitis, and acute demyelinating encephalomyelitis. They can be monophasic or can develop into relapsing episodes of the initial demyelinating event or evolve to include other types of demyelination. Significant progress has been made in differentiating subtypes of ADS that differ in their tendency to relapse and in which anti-inflammatory therapies are effective. Differentiating between these subtypes is important for the optimal management of these patients. Clinical features, labs (especially autoantibodies), and MRI findings can help to differentiate between the different ADS. |
| 1.118 | Dominic O Co | PEDS | doco@wisc.edu | Methotrexate for inflammatory skin disease in pediatric patients: Consensus treatment guidelines. | Methotrexate (MTX) is a readily accessible drug, first used in 1948 and employed for a wide variety of indications since then. However, despite widespread off-label use, FDA labeling does not include approved indications for the use of MTX for many inflammatory skin diseases in pediatric patients, including morphea, psoriasis, atopic dermatitis, and alopecia areata, among others. Without published treatment guidelines, some clinicians may be hesitant to use MTX off-label, or uncomfortable prescribing MTX in this population. To address this unmet need, an expert consensus committee was convened to develop evidence- and consensus-based guidelines for use of MTX to treat pediatric inflammatory skin disease. Clinicians with experience and expertise in clinical research, drug development, and treating inflammatory skin disease in pediatric patients with MTX were recruited. Five committees were created based on major topic areas: (1) indications and contraindications, (2) dosing, (3) interactions with immunizations and medications, (4) adverse effects (potential for and management of), and (5) monitoring needs. Pertinent questions were generated and addressed by the relevant committee. The entire group participated in a modified Delphi process to establish agreement on recommendations for each question. The committee developed 46 evidence- and consensus-based recommendations, each with >70% agreement among members, across all five topics. These are presented in tables and text, along with a discussion of supporting literature, and level of evidence. These evidence- and consensus-based recommendations will support safe and effective use of MTX for the underserved population of pediatric patients who may benefit from this valuable, time-honored medication. |
| 1.119 | Dominic O Co | PEDS | doco@wisc.edu | Autoimmune Encephalitis: Distinguishing Features and Specific Therapies. | Autoimmune encephalitis is characterized by subacute onset of the altered mental status that can rapidly progress to autonomic instability and refractory seizures requiring intensive care. It is mediated by autoantibodies that bind to synaptic surface proteins and alter their function. In contrast to many autoimmune CNS diseases, there is often little detectable inflammatory damage to the brain making it difficult to diagnose. Early engagement of a multidisciplinary team is essential to obtaining a complete diagnostic workup and instituting definitive therapy as early as possible to optimize outcomes. Diagnosis, treatment, and monitoring for this devastating condition continue to evolve. Pathogenesis, diagnosis and both current and emerging therapies are reviewed. |
| 1.120 | Dominic O Co | PEDS | doco@wisc.edu | T Cell Interactions in Mycobacterial Granulomas: Non-Specific T Cells Regulate Mycobacteria-Specific T Cells in Granulomatous Lesions. | Infections with pathogenic mycobacteria are controlled by the formation of a unique structure known as a granuloma. The granuloma represents a host-pathogen interface where bacteria are killed and confined by the host response, but also where bacteria persist. Previous work has demonstrated that the T cell repertoire is heterogenous even at the single granuloma level. However, further work using pigeon cytochrome C (PCC) epitope-tagged BCG (PCC-BCG) and PCC-specific 5CC7 RAG-/- TCR transgenic (Tg) mice has demonstrated that a monoclonal T cell population is able to control infection. At the chronic stage of infection, granuloma-infiltrating T cells remain highly activated in wild-type mice, while T cells in the monoclonal T cell mice are anergic. We hypothesized that addition of an acutely activated non-specific T cell to the monoclonal T cell system could recapitulate the wild-type phenotype. Here we report that activated non-specific T cells have access to the granuloma and deliver a set of cytokines and chemokines to the lesions. Strikingly, non-specific T cells rescue BCG-specific T cells from anergy and enhance the function of BCG-specific T cells in the granuloma in the chronic phase of infection when bacterial antigen load is low. In addition, we find that these same non-specific T cells have an inhibitory effect on systemic BCG-specific T cells. Taken together, these data suggest that T cells non-specific for granuloma-inducing agents can alter the function of granuloma-specific T cells and have important roles in mycobacterial immunity and other granulomatous disorders. |
| 1.121 | Amy K Taylor | HEM/ONC | ataylor@medicine.wisc.edu | Clinical cell-surface targets in metastatic and primary solid cancers. | Therapies against cell-surface targets (CSTs) represent an emerging treatment class in solid malignancies. However, high-throughput investigations of CST expression across cancer types have been reliant on data sets of mostly primary tumors, despite therapeutic use most commonly in metastatic disease. We identified a total of 818 clinical trials of CST therapies with 78 CSTs. We assembled a data set spanning RNA-seq and microarrays in 7,927 benign samples, 16,866 primary tumor samples, and 6,124 metastatic tumor samples. We also utilized single-cell RNA-seq data from 36 benign tissues and 558 primary and metastatic tumor samples, and matched RNA versus protein expression in 29 benign tissue samples, 1,075 tumor samples, and 942 cell lines. High RNA expression accurately predicted high protein expression across CST therapies in benign tissues, tumor samples, and cell lines. We compared metastatic versus primary tumor expression, identified potential opportunities for repositioning, and matched cell lines to tumor types based on CST and global RNA expression. We evaluated single-cell heterogeneity across tumors, and identified rare normal cell subpopulations that may contribute to toxicity. Finally, we identified combinations of CST therapies for which bispecific approaches could improve tumor specificity. This study helps better define the landscape of CST expression in metastatic and primary cancers. |
| 1.122 | Amy K Taylor | HEM/ONC | ataylor@medicine.wisc.edu | Same People, Different Results: Categorizing Cancer Registry Cases Across the Rural-Urban Continuum. | Many rural-urban indexes are utilized in cancer research. This variation introduces inconsistencies between studies. Recommendations on index use have prioritized geographical unit over feasibility of inclusion in analysis. We evaluated rural-urban indexes and recommend one for use to increase comparability across studies. We assessed 9 US rural-urban indexes regarding their respective rural and urban code ranges; geographical unit, land area, and population distributions; percent agreement; suitability for analysis; and integration feasibility for national, state, and local cancer research. We referenced 1569 Wisconsin Pancreatic Cancer Registry patients to demonstrate how index choice affects patient categorization. Six indexes categorized rural and urban areas. Indexes agreed on binary rural-urban designation for 88.8% of the US population. As ternary variables, they agreed for 83.4%. For cancer registry patients, this decreased to 73.4% and 60.4% agreement, respectively. Rural-Urban Continuum Codes (RUCC) performed the best in differentiating metropolitan, micropolitan, and rural counties; availability for retrospective and prospective studies; and continuous coding for analysis. Urban/rural patient categorization changed with index selection. We conclude that RUCC is an appropriate and feasible rural-urban index to include in cancer research, as it is standardly available in national cancer registries, can be matched to patient's county of residence for local research, and it had the least amount of fluctuation of the indices analyzed. Utilizing RUCC as a continuous variable across studies with a rural-urban component will increase reproducibility and comparability of results and eliminate rural-urban index choice as a potential source of discrepancy between studies. |
| 1.123 | Amy K Taylor | HEM/ONC | ataylor@medicine.wisc.edu | A platform-independent AI tumor lineage and site (ATLAS) classifier. | Histopathologic diagnosis and classification of cancer plays a critical role in guiding treatment. Advances in next-generation sequencing have ushered in new complementary molecular frameworks. However, existing approaches do not independently assess both site-of-origin (e.g. prostate) and lineage (e.g. adenocarcinoma) and have minimal validation in metastatic disease, where classification is more difficult. Utilizing gradient-boosted machine learning, we developed ATLAS, a pair of separate AI Tumor Lineage and Site-of-origin models from RNA expression data on 8249 tumor samples. We assessed performance independently in 10,376 total tumor samples, including 1490 metastatic samples, achieving an accuracy of 91.4% for cancer site-of-origin and 97.1% for cancer lineage. High confidence predictions (encompassing the majority of cases) were accurate 98-99% of the time in both localized and remarkably even in metastatic samples. We also identified emergent properties of our lineage scores for tumor types on which the model was never trained (zero-shot learning). Adenocarcinoma/sarcoma lineage scores differentiated epithelioid from biphasic/sarcomatoid mesothelioma. Also, predicted lineage de-differentiation identified neuroendocrine/small cell tumors and was associated with poor outcomes across tumor types. Our platform-independent single-sample approach can be easily translated to existing RNA-seq platforms. ATLAS can complement and guide traditional histopathologic assessment in challenging situations and tumors of unknown primary. |
| 1.124 | Amy K Taylor | HEM/ONC | ataylor@medicine.wisc.edu | Association of Neighborhood Disadvantage with Short- and Long-Term Outcomes After Pancreatectomy for Pancreatic Ductal Adenocarcinoma. | While lower socioeconomic status has been shown to correlate with worse outcomes in cancer care, data correlating neighborhood-level metrics with outcomes are scarce. We aim to explore the association between neighborhood disadvantage and both short- and long-term postoperative outcomes in patients undergoing pancreatectomy for pancreatic ductal adenocarcinoma (PDAC). We retrospectively analyzed 243 patients who underwent resection for PDAC at a single institution between 1 January 2010 and 15 September 2021. To measure neighborhood disadvantage, the cohort was divided into tertiles by Area Deprivation Index (ADI). Short-term outcomes of interest were minor complications, major complications, unplanned readmission within 30 days, prolonged hospitalization, and delayed gastric emptying (DGE). The long-term outcome of interest was overall survival. Logistic regression was used to test short-term outcomes; Cox proportional hazards models and Kaplan-Meier method were used for long-term outcomes. The median ADI of the cohort was 49 (IQR 32-64.5). On adjusted analysis, the high-ADI group demonstrated greater odds of suffering a major complication (odds ratio [OR], 2.78; 95% confidence interval [CI], 1.26-6.40; p = 0.01) and of an unplanned readmission (OR, 3.09; 95% CI, 1.16-9.28; p = 0.03) compared with the low-ADI group. There were no significant differences between groups in the odds of minor complications, prolonged hospitalization, or DGE (all p > 0.05). High ADI did not confer an increased hazard of death (p = 0.63). We found that worse neighborhood disadvantage is associated with a higher risk of major complication and unplanned readmission after pancreatectomy for PDAC. |
| 1.125 | Amy K Taylor | HEM/ONC | ataylor@medicine.wisc.edu | PARP inhibitors in metastatic prostate cancer. | Poly-ADP ribose polymerase inhibitors (PARPi) are an emerging therapeutic option for the treatment of prostate cancer. Their primary mechanism of action is via induction of synthetic lethality in cells with underlying deficiencies in homologous recombination repair (HRR). In men with metastatic castrate-resistant prostate cancer (mCRPC) and select HRR pathway alterations, PARPi treatment has been shown to induce objective tumor responses as well as improve progression free and overall survival. Presently, there are two PARPi, olaparib and rucaparib, that are FDA approved in the treatment of mCRPC. Ongoing research is focused on identifying which HRR alterations are best suited to predict response to PARPi so that these therapies can be most effectively utilized in the clinic. While resistance to PARPi remains a concern, combination therapies may represent a mechanism to overcome or delay resistance. |
| 1.126 | Amy K Taylor | HEM/ONC | ataylor@medicine.wisc.edu | Treatment Inequity: Examining the Influence of Non-Hispanic Black Race and Ethnicity on Pancreatic Cancer Care and Survival in Wisconsin. | We investigated race and ethnicity-based disparities in first course treatment and overall survival among Wisconsin pancreatic cancer patients. We identified adults diagnosed with pancreatic adenocarcinoma in the Wisconsin Cancer Reporting System from 2004 through 2017. We assessed race and ethnicity-based disparities in first course of treatment via adjusted logistic regression and overall survival via 4 incremental Cox proportional hazards regression models. The study included 8,490 patients: 91.3% (n = 7,755) non-Hispanic White; 5.1% (n = 437) non-Hispanic Black, 1.8% (n = 151) Hispanic, 0.6% Native American (n = 53), and 0.6% Asian (n = 51) race and ethnicities. Non-Hispanic Black patients had lower odds of treatment than non-Hispanic White patients for full patient (OR, 0.52; 95% CI, 0.41-0.65) and Medicare cohorts (OR, 0.40; 95% CI, 0.29-0.55). Non-Hispanic Black patients had lower odds of receiving surgery than non-Hispanic White patients (full cohort OR, 0.67 [95% CI, 0.48-0.92]; Medicare cohort OR, 0.57 [95% CI, 0.34-0.93]). Non-Hispanic Black patients experienced worse survival than non-Hispanic White patients in the first 2 incremental Cox proportional hazard regression models (model II HR, 1.18; 95% CI, 1.06-1.31). After adding insurance and treatment course, non-Hispanic Black and non-Hispanic White patients experienced similar survival (HR, 0.98; 95% CI, 0.88-1.09). Non-Hispanic Black patients were almost 50% less likely to receive any treatment and 33% less likely to receive surgery than non-Hispanic White patients. After including treatment course, non-Hispanic Black and non-Hispanic White patient survival was similar. Increasing non-Hispanic Black patient treatment rates by addressing structural factors affecting treatment availability and employing culturally humble approaches to treatment discussions may mitigate these disparities. |
| 1.127 | Marina Sharifi | HEM/ONC | msharifi@medicine.wisc.edu | Personalized Medicine: Leave no Patient Behind; Report From the 2024 Coffey-Holden Prostate Cancer Academy Meeting. | The 11th Annual 2024 Coffey - Holden Prostate Cancer Academy (CHPCA) Meeting, was themed "Personalized Medicine: Leave No Patient Behind," and was held from June 20 to 23, 2024 at the University of California, Los Angeles, Luskin Conference Center, in Los Angeles, CA. The CHPCA Meeting is an academy-styled annual conference organized by the Prostate Cancer Foundation, to focus discussion on the most critical emerging research that have the greatest potential to advance knowledge of prostate cancer biology and treatment. The 2024 CHPCA Meeting was attended by 75 academic investigators and included 37 talks across 8 sessions. The meeting sessions focused on: novel human, mouse and systems biology research models, novel immunotherapies for prostate cancer, efforts to overcome treatment resistance, the role of metabolism and diet in prostate cancer biology and as a therapeutic target, mechanisms that drive differentiation into neuroendocrine cancer subtypes, the evolving prostate cancer epigenome in disease progression and treatment resistance, and machine learning and advanced computational approaches for precision oncology. This article summarizes the presentations and discussions from the 2024 CHPCA Meeting. We hope that sharing this knowledge will inspire and accelerate research into new discoveries and solutions for prostate cancer. |
| 1.128 | Marina Sharifi | HEM/ONC | msharifi@medicine.wisc.edu | Dynamic reciprocal interactions between activated T cells and tumor associated macrophages drive macrophage reprogramming and proinflammatory T cell migration within prostate tumor models. | Tumor-associated macrophages (TAMs) have been implicated as a tumor microenvironment (TME) cell population, which may be playing a vital role in the inhibition of effective T cell responses in the prostate TME. In this manuscript, we leverage a novel microscale cell culture platform, known as Stacks, to investigate mono-, co-, and tri-culture TME models comprised of prostate tumor cell lines, primary macrophages, and autologous T cells from patients with prostate cancer. Through multiplexed analysis of these multi-cellular prostate tumor models, we capture a dynamic interaction between primary TAMs and activated T cells that resulted in reciprocal proinflammatory activation of both cell populations upon interaction. These findings suggest that activated T cells are capable of reprogramming immunosuppressive TAMs in the context of prostate tumor models and that TAM reprogramming may play a key supportive role in restoring proinflammatory T cell tumor responses in the prostate TME. |
| 1.129 | Marina Sharifi | HEM/ONC | msharifi@medicine.wisc.edu | A phenocopy signature of TP53 loss predicts response to chemotherapy. | In preclinical studies, p53 loss of function impacts chemotherapy response, but this has not been consistently validated clinically. We trained a TP53-loss phenocopy gene expression signature from pan-cancer clinical samples in the TCGA. In vitro, the TP53-loss phenocopy signature predicted chemotherapy response across cancer types. In a clinical dataset of 3003 breast cancer samples treated with neoadjuvant chemotherapy, the TP53-loss phenocopy samples were 56% more likely to have a pathologic complete response (pCR), with a significant association between TP53-loss phenocopy and pCR in both ER positive and ER negative tumors. In an independent clinical validation in the I-SPY2 trial (N = 987), we confirmed the association with neoadjuvant chemotherapy pCR and found higher rates of chemoimmunotherapy response in TP53-loss phenocopy tumors compared to non-TP53-loss phenocopy tumors (64% vs. 28%). The TP53-loss phenocopy signature predicts chemotherapy response across cancer types in vitro, and in a proof-of-concept clinical validation is associated with neoadjuvant chemotherapy response across multiple clinical breast cancer cohorts. |
| 1.130 | Marina Sharifi | HEM/ONC | msharifi@medicine.wisc.edu | Clinical cell-surface targets in metastatic and primary solid cancers. | Therapies against cell-surface targets (CSTs) represent an emerging treatment class in solid malignancies. However, high-throughput investigations of CST expression across cancer types have been reliant on data sets of mostly primary tumors, despite therapeutic use most commonly in metastatic disease. We identified a total of 818 clinical trials of CST therapies with 78 CSTs. We assembled a data set spanning RNA-seq and microarrays in 7,927 benign samples, 16,866 primary tumor samples, and 6,124 metastatic tumor samples. We also utilized single-cell RNA-seq data from 36 benign tissues and 558 primary and metastatic tumor samples, and matched RNA versus protein expression in 29 benign tissue samples, 1,075 tumor samples, and 942 cell lines. High RNA expression accurately predicted high protein expression across CST therapies in benign tissues, tumor samples, and cell lines. We compared metastatic versus primary tumor expression, identified potential opportunities for repositioning, and matched cell lines to tumor types based on CST and global RNA expression. We evaluated single-cell heterogeneity across tumors, and identified rare normal cell subpopulations that may contribute to toxicity. Finally, we identified combinations of CST therapies for which bispecific approaches could improve tumor specificity. This study helps better define the landscape of CST expression in metastatic and primary cancers. |
| 1.131 | Marina Sharifi | HEM/ONC | msharifi@medicine.wisc.edu | A prostate cancer gastrointestinal transcriptional phenotype may be associated with diminished response to AR-targeted therapy. | Prostate cancer is a heterogenous disease, but once it becomes metastatic it eventually becomes treatment resistant. One mechanism of resistance to AR-targeting therapy is lineage plasticity, where the tumor undergoes a transformation to an AR-indifferent phenotype, most studied in the context of neuroendocrine prostate cancer (NEPC). However, activation of additional de- or trans-differentiation programs, including a gastrointestinal (GI) gene expression program, has been suggested as an alternative method of resistance. In this study, we explored the previously identified GI prostate cancer phenotype (PCa-GI) in a large cohort of metastatic castration-resistant prostate cancer (mCRPC) patient biopsy samples. We analyzed a dataset of 634 mCRPC samples with batch effect corrected gene expression data from the West Coast Dream Team (WCDT), the East Coast Dream Team (ECDT), the Fred Hutchinson Cancer Research Center (FHCRC) and the Weill Cornell Medical center (WCM). Survival data was available from the WCDT and ECDT cohorts. We calculated a gene expression GI score using the sum of z-scores of genes from a published set of PCa-GI-defining genes (N=38). Survival analysis was performed using the Kaplan-Meier method and Cox proportional hazards regression with endpoint overall survival from time of biopsy to death of any cause. We found that the PCa-GI score had a bimodal distribution, identifying a distinct set of tumors with an activated GI expression pattern. Approximately 35% of samples were classified as PCa-GI high, which was concordant with prior reports. Liver metastases had the highest median score but after excluding liver samples, 29% of the remaining samples were still classified as PCa-GI high, suggesting a distinct phenotype not exclusive to liver metastases. No correlation was observed between GI score and proliferation, AR signaling, or NEPC scores. Furthermore, the PCa-GI score was not associated with genomic alterations in AR, FOXA1, RB1, TP53 or PTEN. However, tumors with MYC amplifications showed significantly higher GI scores (p=0.0001). Patients with PCa-GI tumors had a shorter survival (HR=1.5 [1.1-2.1], p=0.02), but this result was not significant after adjusting for the liver as metastatic site (HR=1.2 [0.82-1.7], p=0.35). Patients with PCa-GI low samples had a better outcome after androgen receptor signaling inhibitors (ASI, abiraterone or enzalutamide) than other therapies (HR=0.37 [0.22-0.61], p=0.0001) while the benefit of ASI was smaller and non-significant for PCa-GI high samples (HR=0.55 [0.29-1.1], p=0.07). A differential pathway analysis identified FOXA2 signaling to be upregulated PCa-GI high tumors (FDR = 3.7 × 10-13). The PCa-GI phenotype is prevalent in clinical mCRPC samples and may represent a distinct biological entity. PCa-GI tumors may respond less to ASI and could offer a strategy to study novel therapeutic targets. |
| 1.132 | Marina Sharifi | HEM/ONC | msharifi@medicine.wisc.edu | A platform-independent AI tumor lineage and site (ATLAS) classifier. | Histopathologic diagnosis and classification of cancer plays a critical role in guiding treatment. Advances in next-generation sequencing have ushered in new complementary molecular frameworks. However, existing approaches do not independently assess both site-of-origin (e.g. prostate) and lineage (e.g. adenocarcinoma) and have minimal validation in metastatic disease, where classification is more difficult. Utilizing gradient-boosted machine learning, we developed ATLAS, a pair of separate AI Tumor Lineage and Site-of-origin models from RNA expression data on 8249 tumor samples. We assessed performance independently in 10,376 total tumor samples, including 1490 metastatic samples, achieving an accuracy of 91.4% for cancer site-of-origin and 97.1% for cancer lineage. High confidence predictions (encompassing the majority of cases) were accurate 98-99% of the time in both localized and remarkably even in metastatic samples. We also identified emergent properties of our lineage scores for tumor types on which the model was never trained (zero-shot learning). Adenocarcinoma/sarcoma lineage scores differentiated epithelioid from biphasic/sarcomatoid mesothelioma. Also, predicted lineage de-differentiation identified neuroendocrine/small cell tumors and was associated with poor outcomes across tumor types. Our platform-independent single-sample approach can be easily translated to existing RNA-seq platforms. ATLAS can complement and guide traditional histopathologic assessment in challenging situations and tumors of unknown primary. |
| 1.133 | Marina Sharifi | HEM/ONC | msharifi@medicine.wisc.edu | Is the Androgen Receptor a Viable Target in Triple Negative Breast Cancer in 5 Years? | Triple negative breast cancer (TNBC) is characterized by high rates of disease recurrence after definitive therapy, and median survival of less than 18 months in the metastatic setting. Systemic therapy options for TNBC consist primarily of cytotoxic chemotherapy-containing regimens, and while recently FDA-approved chemo-immunotherapy combinations and antibody-drug conjugates such as Sacituzumab govitecan have improved clinical outcomes, there remains an unmet need for more effective and less toxic therapies. A subset of TNBC expresses the androgen receptor (AR), a nuclear hormone steroid receptor that activates an androgen-responsive transcriptional program, and gene expression profiling has revealed a TNBC molecular subtype with AR expression and luminal and androgen responsive features. Both preclinical and clinical data suggest biologic similarities between luminal AR (LAR) TNBC and ER+ luminal breast cancer, including lower proliferative activity, relative chemoresistance, and high rates of oncogenic activating mutations in the phosphatidylinositol-3-kinase (PI3K) pathway. Preclinical LAR-TNBC models are sensitive to androgen signaling inhibitors (ASIs), and particularly given the availability of FDA-approved ASIs with robust efficacy in prostate cancer, there has been great interest in targeting this pathway in AR+ TNBC. Here, we review the underlying biology and completed and ongoing androgen-targeted therapy studies in early stage and metastatic AR+ TNBC. |
| 1.134 | Marina Sharifi | HEM/ONC | msharifi@medicine.wisc.edu | A clinical-grade liquid biomarker detects neuroendocrine differentiation in prostate cancer. | BackgroundNeuroendocrine prostate cancer (NEPC) is an aggressive subtype, the presence of which changes the prognosis and management of metastatic prostate cancer.MethodsWe performed analytical validation of a Circulating Tumor Cell (CTC) multiplex RNA qPCR assay to identify the limit of quantification (LOQ) in cell lines, synthetic cDNA, and patient samples. We next profiled 116 longitudinal samples from a prospectively collected institutional cohort of 17 patients with metastatic prostate cancer (7 NEPC, 10 adenocarcinoma) as well as 265 samples from 139 patients enrolled in 3 adenocarcinoma phase II trials of androgen receptor signaling inhibitors (ARSIs). We assessed a NEPC liquid biomarker via the presence of neuroendocrine markers and the absence of androgen receptor (AR) target genes.ResultsUsing the analytical validation LOQ, liquid biomarker NEPC detection in the longitudinal cohort had a per-sample sensitivity of 51.35% and a specificity of 91.14%. However, when we incorporated the serial information from multiple liquid biopsies per patient, a unique aspect of this study, the per-patient predictions were 100% accurate, with a receiver-operating-curve (ROC) AUC of 1. In the adenocarcinoma ARSI trials, the presence of neuroendocrine markers, even while AR target gene expression was retained, was a strong negative prognostic factor.ConclusionOur analytically validated CTC biomarker can detect NEPC with high diagnostic accuracy when leveraging serial samples that are only feasible using liquid biopsies. Patients with expression of NE genes while retaining AR-target gene expression may indicate the transition to neuroendocrine differentiation, with clinical characteristics consistent with this phenotype.FundingNIH (DP2 OD030734, 1UH2CA260389, R01CA247479, and P30 CA014520), Department of Defense (PC190039 and PC200334), and Prostate Cancer Foundation (Movember Foundation - PCF Challenge Award). |
| 1.135 | Marina Sharifi | HEM/ONC | msharifi@medicine.wisc.edu | Longitudinal Molecular Profiling of Circulating Tumor Cells in Metastatic Renal Cell Carcinoma. | Liquid biopsies in metastatic renal cell carcinoma (mRCC) provide a unique approach to understand the molecular basis of treatment response and resistance. This is particularly important in the context of immunotherapies, which target key immune-tumor interactions. Unlike metastatic tissue biopsies, serial real-time profiling of mRCC is feasible with our noninvasive circulating tumor cell (CTC) approach. We collected 457 longitudinal liquid biopsies from 104 patients with mRCC enrolled in one of two studies, either a prospective cohort or a phase II multicenter adaptive immunotherapy trial. Using a novel CTC capture and automated microscopy platform, we profiled CTC enumeration and expression of HLA I and programmed cell death-ligand 1 (PD-L1). Given their diametric immunological roles, we focused on the HLA I to PD-L1 ratio (HP ratio). Patients with radiographic responses showed significantly lower CTC abundances throughout treatment. Furthermore, patients whose CTC enumeration trajectory was in the highest quartile (> 0.12 CTCs/mL annually) had shorter overall survival (median 17.0 months v 21.1 months, P < .001). Throughout treatment, the HP ratio decreased in patients receiving immunotherapy but not in patients receiving tyrosine kinase inhibitors. Patients with an HP ratio trajectory in the highest quartile (≥ 0.0012 annually) displayed significantly shorter overall survival (median 18.4 months v 21.2 months, P = .003). In the first large longitudinal CTC study in mRCC to date to our knowledge, we identified the prognostic importance of CTC enumeration and the change over time of both CTC enumeration and the HP ratio. These insights into changes in both tumor burden and the molecular profile of tumor cells in response to different treatments provide potential biomarkers to predict and monitor response to immunotherapy in mRCC. |
| 1.136 | Marina Sharifi | HEM/ONC | msharifi@medicine.wisc.edu | A phase I study of talazoparib (BMN 673) combined with carboplatin and paclitaxel in patients with advanced solid tumors (NCI9782). | Inhibitors of poly(ADP-ribose) polymerase (PARP) proteins potentiate antitumor activity of platinum chemotherapy. This study sought to determine the safety and tolerability of PARP inhibitor talazoparib with carboplatin and paclitaxel. We conducted a phase I study of talazoparib with carboplatin AUC5-6 and paclitaxel 80 mg/m2 days 1, 8, 15 of 21-day cycles in patients with advanced solid tumors. Patients enrolled using a 3 + 3 design in two cohorts with talazoparib for 7 (schedule A) or 3 days (schedule B). After induction with 4-6 cycles of triplet therapy, patients received one of three maintenance options: (a) continuation of triplet (b) carboplatin/talazoparib, or (c) talazoparib monotherapy. Forty-three patients were treated. The MTD for both schedules was talazoparib 250mcg daily. The main toxicity was myelosuppression including grade 3/4 hematologic treatment-related adverse events (TRAEs). Dose modification occurred in 87% and 100% of patients for schedules A and B, respectively. Discontinuation due to TRAEs was 13% in schedule A and 10% in B. Ten out of 22 evaluable patients in schedule A and 5/16 patients in schedule B had a complete or partial response. Twelve out of 43 patients received ≥6 cycles of talazoparib after induction, with a 13-month median duration of maintenance. We have established the recommended phase II dose of Talazoparib at 250mcg on a 3- or 7-day schedule with carboplatin AUC6 and paclitaxel 80 mg/m2 on days 1, 8, 15 of 21-day cycles. This regimen is associated with significant myelosuppression, and in addition to maximizing supportive care, modification of the chemotherapy component would be a consideration for further development of this combination with the schedules investigated in this study. |
| 1.137 | Dustin Deming | HEM/ONC | ddeming@medicine.wisc.edu | Phase I/II Trial of Perioperative Avelumab in Combination With Chemoradiation in the Treatment of Stage II/III Resectable Esophageal and Gastroesophageal Junction Cancer. | Standard treatment of patients with stage II/III esophageal or gastroesophageal junction (E/GEJ) cancer involves neoadjuvant chemoradiation (nCRT), resection, and immunotherapy. Our trial evaluated the addition of perioperative avelumab to standard treatments. Patients with resectable E/GEJ cancers received avelumab with nCRT and adjuvant avelumab after resection. Primary endpoints for phase I and II portions were safety and pathologic complete response (pCR) rate, respectively. Secondary endpoints included recurrence-free survival (RFS), surgical complication prevalence, and R0 resection rate. Twenty-two patients enrolled in the study. Median follow-up during data cutoff was 23.9 months. There were no dose-limiting toxicities during the run-in phase. Nineteen patients (86.4%) underwent resection with R0 resection rate of 78.9% and with pCR rate of 26%. Most common treatment-related adverse events (TRAE) were cytopenias from chemoradiation. Aside from one grade ≥ 3 avelumab-related hypersensitivity, no grade ≥ 3 avelumab TRAEs were seen. Median RFS was not reached, and 1-year RFS and overall survival were 71% and 81%, respectively. The study was terminated before full planned accrual due to standard practice change based on the CheckMate 577 trial. The addition of perioperative avelumab to nCRT was tolerable and demonstrated promising outcomes. |
| 1.138 | Dustin Deming | HEM/ONC | ddeming@medicine.wisc.edu | Development of KRAS Inhibitors and Their Role for Metastatic Colorectal Cancer. | Colorectal cancer (CRC) is a heterogeneous group of diseases comprising several molecular subtypes. Comprehensive DNA sequencing is now standard practice to identify these subtype. Until recently, KRAS mutation status in metastatic CRC was primarily used as a biomarker to predict resistance to EGFR inhibition. However, with up to 40% of CRC cases harboring KRAS mutations, therapeutic targeting of RAS has been an area of great need. The development of KRASG12C inhibitors has led to the FDA approval of drugs for treating non-small cell lung cancer. Recently, these and other newly developed inhibitors have been investigated as monotherapies and in combination for metastatic KRASG12C-mutant CRC. This review examines the development of these inhibitors and highlights data supporting the inclusion of sotorasib and adagrasib, in combination with either panitumumab or cetuximab, in the NCCN Guidelines for CRC for the treatment of refractory metastatic disease. |
| 1.139 | Dustin Deming | HEM/ONC | ddeming@medicine.wisc.edu | The dichotomous roles of microbial-modified bile acids 7-oxo-DCA and isoDCA in intestinal tumorigenesis. | The gut microbiota has a significant impact on the development and function of intestinal epithelial cells (IECs) by modifying bile acid (BA) metabolites. Recently, specific gut microbiome-derived BAs, such as 7-oxo-deoxycholic acid (7-oxo-DCA) and isodeoxycholic acid (isoDCA), have been identified to be shifted inversely in colitis and hepatic liver diseases. Although the responsible gut microbes have been identified, metabolites' effects on IECs remain largely unclear. We found that although high-fat diet treatment in mice elevated both 7-oxo-DCA and isoDCA levels, during intestinal tumorigenesis, 7-oxo-DCA levels rise while isoDCA levels decrease. Interestingly, 7-oxo-DCA promotes cancer cell growth, while isoDCA suppresses it. Moreover, 7-oxo-DCA promotes whereas isoDCA inhibits the proliferation of intestinal stem cells in organoids derived from WT and APCMin/+ mice, as well as in patient-derived colon cancer organoids. The APCMin/+ mice administered with 7-oxo-DCA heightened gut permeability and increased tumor burden, whereas isoDCA protected gut barrier and reduced tumor loads. Both BAs reshape the BA pool and shifted gut microbiome. Mechanistically, we identified 7-oxo-DCA as a natural antagonist of Farnesoid X Receptor (FXR) to downregulate FXR signaling, as opposed to isoDCA, which is a potent FXR agonist to upregulate FXR signaling. In conclusion, we unveiled the opposing roles of 7-oxo-DCA and isoDCA to promote or inhibit intestinal tumorigenesis, respectively. Manipulating the BA-FXR axis during tumor initiation and progression holds great promise for developing innovative diagnostic and therapeutic approaches for the treatment of colorectal cancer. |
| 1.140 | Dustin Deming | HEM/ONC | ddeming@medicine.wisc.edu | Cancer-Associated Fibroblast Proteins as Potential Targets against Colorectal Cancers. | In colorectal cancer (CRC), attempts to identify cancer cell-specific markers to guide antibody-mediated therapeutics have failed to uncover markers that are both exclusive to cancer tissues and abundant across CRCs. Alternatively, cancer-associated fibroblasts (CAFs), which are abundant in the tumor microenvironment and upregulate unique surface markers, are not found in healthy tissues. Here, we evaluated the expression patterns of CAF-associated proteins α-smooth muscle actin (αSMA), fibroblast activation protein (FAP), podoplanin (PDPN), matrix metalloproteinase-2 (MMP2), transgelin (TAGLN), and THY1. While αSMA and THY1 were abundant in cancer tissues, high abundance in normal tissues limited their targeting potential. FAP was present in 94.5% of primary and metastatic CRC tissues and absent in 93.7% of adjacent normal colon and liver tissues assessed. These results indicate that FAP is a promising target for antibody conjugates with potential for broad application in CRC. Co-expression analyses showed that CRCs simultaneously expressing high levels of PDPN, MMP2, and THY1 were enriched for immune-related signatures, indicating potential for antibody-mediated immune engagers. Overall, this work highlights the potential of CAF proteins to act as therapeutic targets for novel anticancer agents and become important therapeutic biomarkers. |
| 1.141 | Dustin Deming | HEM/ONC | ddeming@medicine.wisc.edu | Carboplatin and Paclitaxel Chemoradiation for Localized Anal Cancer in Patients Not Eligible for Mitomycin and 5-Fluorouracil. | Although squamous cell carcinoma of the anus (SCCA) is a relatively uncommon malignancy in the United States, it continues to increase in incidence. Treatment for locoregional disease includes mitomycin and 5-fluorouracil with radiation. This combination is associated with significant toxicity, limiting its use in patients who are older or have certain comorbidities. Carboplatin and paclitaxel (C/P) is an accepted treatment regimen for metastatic SCCA. We aim to evaluate the efficacy and toxicity of weekly C/P given with radiation for patients unable to receive standard chemoradiation for SCCA. From our cancer registry, adult patients who received weekly intravenous C/P concurrent with standard-dose radiation for localized SCCA were included in this study. Clinical response was determined based on the evidence of disease on imaging and/or anoscopy. Toxicities were graded according to the CTCAE v5. Ten patients were included; eight were female, and the median age was 75.5 years (54-87). Six had T2 disease, and four had T3 tumors. Four had node-positive disease. The majority (70%) of patients were dosed at standard C (AUC 2) and P (50 mg/m2), with a limited subset requiring dose reduction for baseline performance status. Patients completed a mean of 78.3% (40-100%) of the intended treatments. A total of 89% of the patients achieved a complete clinical response. With a median follow-up of 25.8 months (3.4-50.4 months), 67% of the patients are alive and without recurrence. Two patients have had local recurrence, and one patient had metastatic progression. The most common toxicities of any grade included leukopenia (100%), anemia (100%), radiation dermatitis (100%), diarrhea (100%), and fatigue (100%). Grade 3 or higher toxicities included neutropenic fever (20%), neutropenia (30%), and anemia (30%). This study demonstrates promising tolerability and efficacy for weekly C/P chemoradiation for patients with anal cancer unable to receive mitomycin and 5-fluorouracil. This regimen merits further investigation in prospective clinical trials. |
| 1.142 | Dustin Deming | HEM/ONC | ddeming@medicine.wisc.edu | Cellpose as a reliable method for single-cell segmentation of autofluorescence microscopy images. | Autofluorescence microscopy uses intrinsic sources of molecular contrast to provide cellular-level information without extrinsic labels. However, traditional cell segmentation tools are often optimized for high signal-to-noise ratio (SNR) images, such as fluorescently labeled cells, and unsurprisingly perform poorly on low SNR autofluorescence images. Therefore, new cell segmentation tools are needed for autofluorescence microscopy. Cellpose is a deep learning network that is generalizable across diverse cell microscopy images and automatically segments single cells to improve throughput and reduce inter-human biases. This study aims to validate Cellpose for autofluorescence imaging, specifically from multiphoton intensity images of NAD(P)H. Manually segmented nuclear masks of NAD(P)H images were used to train new Cellpose models. These models were applied to PANC-1 cells treated with metabolic inhibitors and patient-derived cancer organoids (across 9 patients) treated with chemotherapies. These datasets include co-registered fluorescence lifetime imaging microscopy (FLIM) of NAD(P)H and FAD, so fluorescence decay parameters and the optical redox ratio (ORR) were compared between masks generated by the new Cellpose model and manual segmentation. The Dice score between repeated manually segmented masks was significantly lower than that of repeated Cellpose masks (p0.9) between Cellpose and manually segmented masks for the ORR, mean NAD(P)H lifetime, and mean FAD lifetime across 2D and 3D cell culture treatment conditions. Masks generated from Cellpose and manual segmentation also maintain similar means, variances, and effect sizes between treatments for the ORR and FLIM parameters. Overall, Cellpose provides a fast, reliable, reproducible, and accurate method to segment single cells in autofluorescence microscopy images such that functional changes in cells are accurately captured in both 2D and 3D culture. |
| 1.143 | Dustin Deming | HEM/ONC | ddeming@medicine.wisc.edu | State-of-the-Art Management of Colorectal Cancer: Treatment Advances and Innovation. | Colorectal cancer (CRC) remains a significant global health challenge, ranking among the leading causes of cancer-related morbidity and mortality worldwide. Recent advancements in molecular characterization have revolutionized our understanding of the heterogeneity within colorectal tumors, particularly in the context of tumor sidedness. Tumor sidedness, referring to the location of the primary tumor in either the right or left colon, has emerged as a critical factor influencing prognosis and treatment responses in metastatic CRC. Molecular underpinnings of CRC, the impact of tumor sidedness, and how this knowledge guides therapeutic decisions in the era of precision medicine have led to improved outcomes and better quality of life in patients. The emergence of circulating tumor DNA as a prognostic and predictive tool in CRC heralds promising advancements in the diagnosis and monitoring of the disease. This innovation facilitates better patient selection for exploration of additional treatment options. As the field progresses, with investigational agents demonstrating potential as future treatments for refractory metastatic CRC, new avenues for enhancing outcomes in this challenging disease are emerging. |
| 1.144 | Dustin Deming | HEM/ONC | ddeming@medicine.wisc.edu | Modified FOLFOX6 plus bevacizumab with and without nivolumab for first-line treatment of metastatic colorectal cancer: phase 2 results from the CheckMate 9X8 randomized clinical trial. | Standard first-line therapies for metastatic colorectal cancer (mCRC) include fluoropyrimidine-containing regimens with oxaliplatin and/or irinotecan and a biologic agent. Immunotherapy may enhance antitumor activity in combination with standard therapies in patients with mCRC. Here, we present phase 2 results of nivolumab plus standard-of-care therapy (SOC; 5-fluorouracil/leucovorin/oxaliplatin/bevacizumab) versus SOC in the first-line treatment of patients with mCRC (CheckMate 9X8). CheckMate 9X8 was a multicenter, open-label, randomized, phase 2/3 trial. Eligible patients were at least 18 years of age with unresectable mCRC and no prior chemotherapy for metastatic disease. Patients were randomized 2:1 to receive nivolumab 240 mg plus SOC or SOC alone every 2 weeks. The primary endpoint was progression-free survival (PFS) by blinded independent central review (BICR) per Response Evaluation Criteria in Solid Tumors V.1.1. Secondary endpoints included PFS by investigator assessment; objective response rate (ORR), disease control rate, duration of response, and time to response, all by BICR and investigator assessments; overall survival; and safety. Preplanned exploratory biomarker analyses were also performed. From February 2018 through April 2019, 310 patients were enrolled, of which 195 patients were randomized to nivolumab plus SOC (n=127) or SOC (n=68). At 21.5-month minimum follow-up, PFS with nivolumab plus SOC versus SOC did not meet the prespecified threshold for statistical significance; median PFS by BICR was 11.9 months in both arms (HR, 0.81 (95% CI, 0.53 to 1.23); p=0.30). Higher PFS rates after 12 months (18 months: 28% vs 9%), higher ORR (60% vs 46%), and durable responses (median 12.9 vs 9.3 months) were observed with nivolumab plus SOC versus SOC. Grade 3-4 treatment-related adverse events were reported in 75% versus 48% of patients; no new safety signals were identified. The CheckMate 9X8 trial investigating first-line nivolumab plus SOC versus SOC in patients with mCRC did not meet its primary endpoint of PFS by BICR. Nivolumab plus SOC showed numerically higher PFS rates after 12 months, a higher response rate, and more durable responses compared with SOC alone, with acceptable safety. Further investigation to identify subgroups of patients with mCRC that may benefit from nivolumab plus SOC versus SOC in the first-line setting is warranted. NCT03414983. |
| 1.145 | Dustin Deming | HEM/ONC | ddeming@medicine.wisc.edu | Exceptional Response to Crizotinib With Subsequent Response to Cabozantinib in Metastatic, ROS1-GOPC Fusion-Mutated Breast Cancer. | |
| 1.146 | Dustin Deming | HEM/ONC | ddeming@medicine.wisc.edu | Clinical utility of a regional precision medicine molecular tumor board and challenges to implementation. | Molecular tumor boards provide precision treatment recommendations based on cancer genomic profile. However, practical barriers limit their benefits. We studied the clinical utility of the precision medicine molecular tumor board (PMMTB) and described challenges with PMMTB implementation. An observational cohort study included patients reviewed by the PMMTB between September 2015 to December 2017. Patients who had consented to the registry study were included. The primary endpoint of this study was time on treatment (ToT) ratio. Clinical utility was established if the primary endpoint had least 15% of patients achieving a ToT ratio of ≥1.3. Overall, 278 patients were presented to the PMMTB and 113 cases were included in the final analysis. The PMMTB identified at least one nonstandard of care (SOC) clinically actionable mutation for 69.0% (78/113) of cases. In patients who received non-SOC treatment, 43.8% (7/16) achieved a ToT ratio of 1.3 or more (p < 0.001). Fifty-nine patients did not receive non-SOC recommendations. Reasons for not pursuing treatment included 35.6% having response to current treatment, 20.3% died prior to starting or considering PMMTB recommendations, 13.6% pursued other treatment options based on clinician discretion, another 10.2% pursued other treatment options because clinical trials recommended were not geographically accessible, 8.5% had rapid decline of performance status, 6.8% lacked of financial support for treatment, and 5.1% were excluded from clinical trials due to abnormal laboratory values. The regional PMMTB non-SOC recommendations benefitted a majority of patients and additional processes were implemented to assist with non-SOC treatment accessibility. |
| 1.147 | Mark Benson | GI | mb4@medicine.wisc.edu | Top tips for the management of iatrogenic colon perforations. | |
| 1.148 | Mark Benson | GI | mb4@medicine.wisc.edu | Sedation reversal trends at outpatient ambulatory endoscopic center vs in-hospital ambulatory procedure center using a triage protocol. | Routine outpatient endoscopy is performed across a variety of outpatient settings. A known risk of performing endoscopy under moderate sedation is the potential for over-sedation, requiring the use of reversal agents. More needs to be reported on rates of reversal across different outpatient settings. Our academic tertiary care center utilizes a triage tool that directs higher-risk patients to the in-hospital ambulatory procedure center (APC) for their procedure. Here, we report data on outpatient sedation reversal rates for endoscopy performed at an in-hospital APC vs at a free-standing ambulatory endoscopy digestive health center (AEC-DHC) following risk stratification with a triage tool. To observe the effect of risk stratification using a triage tool on patient outcomes, primarily sedation reversal events. We observed all outpatient endoscopy procedures performed at AEC-DHC and APC from April 2013 to September 2019. Procedures were stratified to their respective sites using a triage tool. We evaluated each procedure for which sedation reversal with flumazenil and naloxone was recorded. Demographics and characteristics recorded include patient age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, procedure type, and reason for sedation reversal. There were 97366 endoscopic procedures performed at AEC-DHC and 22494 at the APC during the study period. Of these, 17 patients at AEC-DHC and 9 at the APC underwent sedation reversals (0.017% vs 0.04%; P = 0.06). Demographics recorded for those requiring reversal at AEC-DHC vs APC included mean age (53.5 ± 21 vs 60.4 ± 17.42 years; P = 0.23), ASA class (1.66 ± 0.48 vs 2.22 ± 0.83; P = 0.20), BMI (27.7 ± 6.7 kg/m2 vs 23.7 ± 4.03 kg/m2; P = 0.06), and female gender (64.7% vs 22%; P = 0.04). The mean doses of sedative agents and reversal drugs used at AEC-DHC vs APC were midazolam (5.9 ± 1.7 mg vs 8.9 ± 3.5 mg; P = 0.01), fentanyl (147.1 ± 49.9 μg vs 188.9 ± 74.1 μg; P = 0.10), flumazenil (0.3 ± 0.18 μg vs 0.17 ± 0.17 μg; P = 0.13) and naloxone (0.32 ± 0.10 mg vs 0.28 ± 0.12 mg; P = 0.35). Procedures at AEC-DHC requiring sedation reversal included colonoscopies (n = 6), esophagogastroduodenoscopy (EGD) (n = 9) and EGD/colonoscopies (n = 2), whereas APC procedures included EGDs (n = 2), EGD with gastrostomy tube placement (n = 1), endoscopic retrograde cholangiopancreatography (n = 2) and endoscopic ultrasound's (n = 4). The indications for sedation reversal at AEC-DHC included hypoxia (n = 13; 76%), excessive somnolence (n = 3; 18%), and hypotension (n = 1; 6%), whereas, at APC, these included hypoxia (n = 7; 78%) and hypotension (n = 2; 22%). No sedation-related deaths or long-term post-sedation reversal adverse outcomes occurred at either site. Our study highlights the effectiveness of a triage tool used at our tertiary care hospital for risk stratification in minimizing sedation reversal events during outpatient endoscopy procedures. Using a triage tool for risk stratification, low rates of sedation reversal can be achieved in the ambulatory settings for EGD and colonoscopy. |
| 1.149 | Mark Benson | GI | mb4@medicine.wisc.edu | Gastroenterology Providers and the Electronic Health Record. | |
| 1.150 | Mark Benson | GI | mb4@medicine.wisc.edu | Outcomes of colon self-expandable metal stents for malignant vs benign indications at a tertiary care center and review of literature. | Endoscopic placement of a self-expandable metal stent (SEMS) is a minimally invasive treatment for use in malignant and benign colonic obstruction. However, their widespread use is still limited with a nationwide analysis showing only 5.4% of patients with colon obstruction undergoing stent placement. This underutilization could be due to perceived increase risk of complications with stent placement. To review long- and short-term clinical success of SEMS use for colonic obstruction at our center. We retrospectively reviewed all the patients who underwent colonic SEMS placement over a eighteen year period (August 2004 through August 2022) at our academic center. Demographics including age, gender, indication (malignant and benign), technical success, clinical success, complications (perforation, stent migration), mortality, and outcomes were recorded. Sixty three patients underwent colon SEMS over an 18-year period. Fifty-five cases were for malignant indications, 8 were for benign conditions. The benign strictures included diverticular disease stricturing (n = 4), fistula closure (n = 2), extrinsic fibroid compression (n = 1), and ischemic stricture (n = 1). Forty-three of the malignant cases were due to intrinsic obstruction from primary or recurrent colon cancer; 12 were from extrinsic compression. Fifty-four strictures occurred on the left side, 3 occurred on the right and the rest in transverse colon. The total malignant case (n = 55) procedural success rate was 95% vs 100% for benign cases (P = 1.0, NS). Overall complication rate was significantly higher for benign group: Four complications were observed in the malignant group (stent migration, restenosis) vs 2 of 8 (25%) for benign obstruction (1-perforation, 1-stent migration) (P = 0.02). When stratifying complications of perforation and stent migration there was no significant difference between the two groups (P = 0.14, NS). Colon SEMS remains a worthwhile option for colonic obstruction related to malignancy and has a high procedural and clinical success rate. Benign indications for SEMS placement appear to have similar success to malignant. While there appears to be a higher overall complication rate in benign cases, our study is limited by sample size. When evaluating for perforation alone there does not appear to be any significant difference between the two groups. SEMS placement may be a practical option for indications other that malignant obstruction. Interventional endoscopists should be aware and discuss the risk for complications in setting of benign conditions. Indications in these cases should be discussed in a multi-disciplinary fashion with colorectal surgery. |
| 1.151 | Mark Benson | GI | mb4@medicine.wisc.edu | Electronic Health Record Work Demands for Gastroenterology and Hepatology Providers: A Prospective Use Analysis and Survey Study. | There is a paucity of research on the use of the electronic health record (EHR) by gastroenterology and hepatology providers and its effect on work-life balance. Our aim was to study the after-hour EHR work completed among providers within a multispecialty academic practice. Time spent completing EHR tasks during evening hours (7p-7a) and days off was prospectively recorded for 35 providers over six consecutive months at a single center. Type and time of EHR tasks completed were compared based on subspecialty, academic degree, academic track category, identified gender, and number of weekly assigned clinical days worked. Prior to the data collection, providers filled out a survey regarding EHR use, work hours, and work-life balance. All providers used EHR during evening hours and during days off. The total mean after-hours time spent completing EHR tasks was 18.4 m (± 13.0) per day and 45.0 m (± 25.8) during days off. There was significant variation in the daily mean after-hours time spent completing EHR tasks among subspecialties, range 45.3 m (± 27.1) (advanced endoscopy)-28.7 m (± 22.7) (hepatology), and among providers who work clinically > 7.5 days per week versus those who do not, 42.1 m (± 25.7) vs 30.0 m (± 14.0). The most common after-hours EHR task was note completion. 83% providers reported being unable to complete EHR tasks during allotted workday time and 87% report that EHR tasks interfered with family life; 74% with social life. Gastroenterology and hepatology providers spend a significant amount of after-hour time completing EHR tasks which is perceived to interfere with family/social life. |
| 1.152 | Mark Benson | GI | mb4@medicine.wisc.edu | Individualized feedback on colonoscopy skills improves group colonoscopy quality in providers with lower adenoma detection rates. | Background and study aims Colonoscopy inspection quality (CIQ) assesses skills (fold examination, cleaning, and luminal distension) during inspection for polyps and correlates with adenoma detection rate (ADR) and serrated detection rate (SDR). We aimed to determine whether providing individualized CIQ feedback with instructional videos improves quality metrics performance. Methods We prospectively studied 16 colonoscopists who already received semiannual benchmarked reports of quality metrics (ADR, SDR, and withdrawal time [WT]). We randomly selected seven colonoscopies/colonoscopist for evaluation. Six gastroenterologists graded CIQ using an established scale. We created instructional videos demonstrating optimal and poor inspection techniques. Colonoscopists received the instructional videos and benchmarked CIQ performance. We compared ADR, SDR, and WT in the 12 months preceding ("baseline") and following CIQ feedback. Colonoscopists were stratified by baseline ADR into lower (≤ 34 %) and higher-performing (> 34 %) groups. Results Baseline ADR was 38.5 % (range 26.8 %-53.8 %) and SDR was 11.2 % (2.8 %-24.3 %). The proportion of colonoscopies performed by lower-performing colonoscopists was unchanged from baseline to post-CIQ feedback. All colonoscopists reviewed their CIQ report cards. Post-feedback, ADR (40.1 % vs 38.5 %, P = 0.1) and SDR (12.2 % vs. 11.2 %, P = 0.1) did not significantly improve; WT significantly increased (11.4 vs 12.4 min, P < 0.01). Among the eight lower-performing colonoscopists, group ADR (31.1 % vs 34.3 %, P = 0.02) and SDR (7.2 % vs 9.1 %, P = 0.02) significantly increased post-feedback. In higher-performing colonoscopists, ADR and SDR did not change. Conclusions CIQ feedback modestly improves ADR and SDR among colonoscopists with lower baseline ADR but has no effect on higher-performing colonoscopists. Individualized feedback on colonoscopy skills could be used to improve polyp detection by lower-performing colonoscopists. |
| 1.153 | Mark Benson | GI | mb4@medicine.wisc.edu | Probe-based confocal laser endoscopy and primary sclerosing cholangitis: Is seeing actually believing? | |
| 1.154 | Mark Benson | GI | mb4@medicine.wisc.edu | Cecal retroflexion is infrequently performed in routine practice and the retroflexed view is of poor quality. | As right colon polyps are challenging to detect, a retroflexed view of right colon (RV) may be useful. However, cecal retroflexion (CR) without a RV to the hepatic flexure (HF) is inadequate. We aimed to determine the frequency of CR and quality of the RV in routine practice. This prospective observational study performed at an academic medical center assessed colonoscopy inspection technique of endoscopists who had performed ≥ 100 annual screening colonoscopies. We video recorded ≥ 28 screening/surveillance colonoscopies per endoscopist and randomly evaluated 7 videos per endoscopist. Six gastroenterologists blindly reviewed the videos to determine if CR was performed and HF withdrawal time (cecum to HF time, excluding ileal/polypectomy time). Reviewers assessed 119 colonoscopies performed by 17 endoscopists. The median HF withdrawal time was 3 min and 46 s. CR was performed in 31% of colonoscopies. CR frequency varied between endoscopists with 9 never performing CR and 2 performing CR in all colonoscopies. When performed, nearly half (43%) of RVs did not extend to the HF with median RV duration of 16 s (IQR 9-30 s). Three polyps were identified in the RV (polyp detection rate of 8.1%), all identified prior to a forward view. CR is performed infrequently in routine practice. When CR is performed, the RV is of low quality with a very short inspection duration and insufficient ascending colon examination. Further education is required to educate endoscopists in optimal technique to improve overall colonoscopy quality. |
| 1.155 | Mark Benson | GI | mb4@medicine.wisc.edu | Colorectal Cancer Screening After Changes in US Preventive Services Task Force Guidelines With Increased Screening Options. | In 2016, the US Preventive Services Task Force (USPSTF) added multitarget stool DNA and computed tomography colonography (CTC) as accepted colorectal cancer screening modalities to the already recommended tests: fecal immunochemical test (FIT), sigmoidoscopy, and colonoscopy. The aim of our study was to determine trends in screening after the USPSTF update, with the effect of additional tests on the use of existing colorectal cancer screening modalities and overall screening rates. We prospectively compared monthly colorectal cancer overall screening rates and the mean total numbers of patients screened by multitarget stool DNA, colonoscopy, sigmoidoscopy, CTC, and FIT 6 months prior to the new USPSTF guidelines until 30 months after. At completion of the study, 72,202 patients were eligible for screening. The overall rate of eligible patients screened for colorectal cancer did not change (80.9% vs 81.3%; P = 0.287). There was a significant increase in the percent of patients screened with multitarget stool DNA (1.6% to 15.6%; P = .001) and a significant decrease in the percent of patients screened using CTC (3.8 % to 1.5%; P = .004), FIT (9.3% to 4.9%; P = .003), and sigmoidoscopy (2.4% to 1.5%, P = .024). There was a nonsignificant decrease in the percent use of screening colonoscopy, from 82.9 % to 76.5% (P = .313). While the overall colorectal cancer screening rate did not increase after the USPSTF update with additional recommended screening tests, practice patterns did change with a shift in the type of screening test used. |
| 1.156 | Mark Benson | GI | mb4@medicine.wisc.edu | Prospective Comparison of Moderate Conscious Sedation and Anesthesia Assistance for the Performance of Endoscopic Retrograde Cholangiopancreatography (ERCP). | Recent trends have favored the use of anesthesia personnel more frequently for advanced endoscopic procedures. We hypothesize a selective sedation approach based on patient and procedural factors using either moderate conscious sedation (MCS) or general anesthesia (GA) will result in similar outcomes and safety with significant cost savings. A 12-month prospective study of all adult endoscopic retrograde cholangiopancreatography (ERCPs) performed at a tertiary medical center was enrolled. Technical success, cannulation rates, procedural related complications, procedure time, and cost were compared between MCS and GA. A total of 876 ERCPs were included in the study with 74% performed with MCS versus 26% with GA. The intended intervention was completed successfully in 95% of cases with MCS versus 96% cases with GA (p = 0.59). Cannulation success rates with MCS were 97.5 versus 97.8% with GA (p = 0.81). Overall, adverse event rates were similar in both groups (MCS: 6.6% vs. GA: 9.2%, p = 0.21). Mean procedure time was less for MCS versus GA, 18.3 and 26 minutes, respectively (p < 0.0001). Selective use of MCS vs. universal sedation with GA resulted in estimated savings of $8,190 per case and $4,735,202 per annum. Preselection of ERCP sedation of moderate conscious sedation versus general anesthesia based upon patient risk factors and planned therapeutic intervention allows for the majority of ERCPs to be completed with MCS with similar rates of technical success and improvement in resource utilization and cost savings compared to performing ERCPs universally with anesthesia assistance. |
| 1.157 | Patrick Pfau | GI | prp@medicine.wisc.edu | Top tips for EUS-guided celiac plexus block and neurolysis. | |
| 1.158 | Patrick Pfau | GI | prp@medicine.wisc.edu | Sedation reversal trends at outpatient ambulatory endoscopic center vs in-hospital ambulatory procedure center using a triage protocol. | Routine outpatient endoscopy is performed across a variety of outpatient settings. A known risk of performing endoscopy under moderate sedation is the potential for over-sedation, requiring the use of reversal agents. More needs to be reported on rates of reversal across different outpatient settings. Our academic tertiary care center utilizes a triage tool that directs higher-risk patients to the in-hospital ambulatory procedure center (APC) for their procedure. Here, we report data on outpatient sedation reversal rates for endoscopy performed at an in-hospital APC vs at a free-standing ambulatory endoscopy digestive health center (AEC-DHC) following risk stratification with a triage tool. To observe the effect of risk stratification using a triage tool on patient outcomes, primarily sedation reversal events. We observed all outpatient endoscopy procedures performed at AEC-DHC and APC from April 2013 to September 2019. Procedures were stratified to their respective sites using a triage tool. We evaluated each procedure for which sedation reversal with flumazenil and naloxone was recorded. Demographics and characteristics recorded include patient age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, procedure type, and reason for sedation reversal. There were 97366 endoscopic procedures performed at AEC-DHC and 22494 at the APC during the study period. Of these, 17 patients at AEC-DHC and 9 at the APC underwent sedation reversals (0.017% vs 0.04%; P = 0.06). Demographics recorded for those requiring reversal at AEC-DHC vs APC included mean age (53.5 ± 21 vs 60.4 ± 17.42 years; P = 0.23), ASA class (1.66 ± 0.48 vs 2.22 ± 0.83; P = 0.20), BMI (27.7 ± 6.7 kg/m2 vs 23.7 ± 4.03 kg/m2; P = 0.06), and female gender (64.7% vs 22%; P = 0.04). The mean doses of sedative agents and reversal drugs used at AEC-DHC vs APC were midazolam (5.9 ± 1.7 mg vs 8.9 ± 3.5 mg; P = 0.01), fentanyl (147.1 ± 49.9 μg vs 188.9 ± 74.1 μg; P = 0.10), flumazenil (0.3 ± 0.18 μg vs 0.17 ± 0.17 μg; P = 0.13) and naloxone (0.32 ± 0.10 mg vs 0.28 ± 0.12 mg; P = 0.35). Procedures at AEC-DHC requiring sedation reversal included colonoscopies (n = 6), esophagogastroduodenoscopy (EGD) (n = 9) and EGD/colonoscopies (n = 2), whereas APC procedures included EGDs (n = 2), EGD with gastrostomy tube placement (n = 1), endoscopic retrograde cholangiopancreatography (n = 2) and endoscopic ultrasound's (n = 4). The indications for sedation reversal at AEC-DHC included hypoxia (n = 13; 76%), excessive somnolence (n = 3; 18%), and hypotension (n = 1; 6%), whereas, at APC, these included hypoxia (n = 7; 78%) and hypotension (n = 2; 22%). No sedation-related deaths or long-term post-sedation reversal adverse outcomes occurred at either site. Our study highlights the effectiveness of a triage tool used at our tertiary care hospital for risk stratification in minimizing sedation reversal events during outpatient endoscopy procedures. Using a triage tool for risk stratification, low rates of sedation reversal can be achieved in the ambulatory settings for EGD and colonoscopy. |
| 1.159 | Patrick Pfau | GI | prp@medicine.wisc.edu | Gastrointestinal Bleeding and the Endoscopist. | |
| 1.160 | Patrick Pfau | GI | prp@medicine.wisc.edu | 2 AM in the Intensive Care Unit: What Could Go Wrong? | |
| 1.161 | Patrick Pfau | GI | prp@medicine.wisc.edu | Gastroenterology Providers and the Electronic Health Record. | |
| 1.162 | Patrick Pfau | GI | prp@medicine.wisc.edu | A Combined DNA/RNA-based Next-Generation Sequencing Platform to Improve the Classification of Pancreatic Cysts and Early Detection of Pancreatic Cancer Arising From Pancreatic Cysts. | We report the development and validation of a combined DNA/RNA next-generation sequencing (NGS) platform to improve the evaluation of pancreatic cysts. Despite a multidisciplinary approach, pancreatic cyst classification, such as a cystic precursor neoplasm, and the detection of high-grade dysplasia and early adenocarcinoma (advanced neoplasia) can be challenging. NGS of preoperative pancreatic cyst fluid improves the clinical evaluation of pancreatic cysts, but the recent identification of novel genomic alterations necessitates the creation of a comprehensive panel and the development of a genomic classifier to integrate the complex molecular results. An updated and unique 74-gene DNA/RNA-targeted NGS panel (PancreaSeq Genomic Classifier) was created to evaluate 5 classes of genomic alterations to include gene mutations (e.g., KRAS, GNAS, etc.), gene fusions and gene expression. Further, CEA mRNA ( CEACAM5 ) was integrated into the assay using RT-qPCR. Separate multi-institutional cohorts for training (n=108) and validation (n=77) were tested, and diagnostic performance was compared to clinical, imaging, cytopathologic, and guideline data. Upon creation of a genomic classifier system, PancreaSeq GC yielded a 95% sensitivity and 100% specificity for a cystic precursor neoplasm, and the sensitivity and specificity for advanced neoplasia were 82% and 100%, respectively. Associated symptoms, cyst size, duct dilatation, a mural nodule, increasing cyst size, and malignant cytopathology had lower sensitivities (41-59%) and lower specificities (56-96%) for advanced neoplasia. This test also increased the sensitivity of current pancreatic cyst guidelines (IAP/Fukuoka and AGA) by >10% and maintained their inherent specificity. PancreaSeq GC was not only accurate in predicting pancreatic cyst type and advanced neoplasia but also improved the sensitivity of current pancreatic cyst guidelines. |
| 1.163 | Patrick Pfau | GI | prp@medicine.wisc.edu | Outcomes of colon self-expandable metal stents for malignant vs benign indications at a tertiary care center and review of literature. | Endoscopic placement of a self-expandable metal stent (SEMS) is a minimally invasive treatment for use in malignant and benign colonic obstruction. However, their widespread use is still limited with a nationwide analysis showing only 5.4% of patients with colon obstruction undergoing stent placement. This underutilization could be due to perceived increase risk of complications with stent placement. To review long- and short-term clinical success of SEMS use for colonic obstruction at our center. We retrospectively reviewed all the patients who underwent colonic SEMS placement over a eighteen year period (August 2004 through August 2022) at our academic center. Demographics including age, gender, indication (malignant and benign), technical success, clinical success, complications (perforation, stent migration), mortality, and outcomes were recorded. Sixty three patients underwent colon SEMS over an 18-year period. Fifty-five cases were for malignant indications, 8 were for benign conditions. The benign strictures included diverticular disease stricturing (n = 4), fistula closure (n = 2), extrinsic fibroid compression (n = 1), and ischemic stricture (n = 1). Forty-three of the malignant cases were due to intrinsic obstruction from primary or recurrent colon cancer; 12 were from extrinsic compression. Fifty-four strictures occurred on the left side, 3 occurred on the right and the rest in transverse colon. The total malignant case (n = 55) procedural success rate was 95% vs 100% for benign cases (P = 1.0, NS). Overall complication rate was significantly higher for benign group: Four complications were observed in the malignant group (stent migration, restenosis) vs 2 of 8 (25%) for benign obstruction (1-perforation, 1-stent migration) (P = 0.02). When stratifying complications of perforation and stent migration there was no significant difference between the two groups (P = 0.14, NS). Colon SEMS remains a worthwhile option for colonic obstruction related to malignancy and has a high procedural and clinical success rate. Benign indications for SEMS placement appear to have similar success to malignant. While there appears to be a higher overall complication rate in benign cases, our study is limited by sample size. When evaluating for perforation alone there does not appear to be any significant difference between the two groups. SEMS placement may be a practical option for indications other that malignant obstruction. Interventional endoscopists should be aware and discuss the risk for complications in setting of benign conditions. Indications in these cases should be discussed in a multi-disciplinary fashion with colorectal surgery. |
| 1.164 | Patrick Pfau | GI | prp@medicine.wisc.edu | Electronic Health Record Work Demands for Gastroenterology and Hepatology Providers: A Prospective Use Analysis and Survey Study. | There is a paucity of research on the use of the electronic health record (EHR) by gastroenterology and hepatology providers and its effect on work-life balance. Our aim was to study the after-hour EHR work completed among providers within a multispecialty academic practice. Time spent completing EHR tasks during evening hours (7p-7a) and days off was prospectively recorded for 35 providers over six consecutive months at a single center. Type and time of EHR tasks completed were compared based on subspecialty, academic degree, academic track category, identified gender, and number of weekly assigned clinical days worked. Prior to the data collection, providers filled out a survey regarding EHR use, work hours, and work-life balance. All providers used EHR during evening hours and during days off. The total mean after-hours time spent completing EHR tasks was 18.4 m (± 13.0) per day and 45.0 m (± 25.8) during days off. There was significant variation in the daily mean after-hours time spent completing EHR tasks among subspecialties, range 45.3 m (± 27.1) (advanced endoscopy)-28.7 m (± 22.7) (hepatology), and among providers who work clinically > 7.5 days per week versus those who do not, 42.1 m (± 25.7) vs 30.0 m (± 14.0). The most common after-hours EHR task was note completion. 83% providers reported being unable to complete EHR tasks during allotted workday time and 87% report that EHR tasks interfered with family life; 74% with social life. Gastroenterology and hepatology providers spend a significant amount of after-hour time completing EHR tasks which is perceived to interfere with family/social life. |
| 1.165 | Patrick Pfau | GI | prp@medicine.wisc.edu | Electrohydraulic lithotripsy pancreatoscopy: Crush and remove stones-yes! Help our patients-maybe? | |
| 1.166 | Patrick Pfau | GI | prp@medicine.wisc.edu | Hemosuccus Pancreaticus Following Acute Pancreatitis in a 12-years-old Boy Secondary to Pancreatic Pseudoaneurysm Treated With Endovascular Coil Embolization. | Hemosuccus pancreaticus is a very rare cause of upper gastrointestinal bleeding in children. It is defined as bleeding from the pancreatic or peripancreatic vessels into the main pancreatic duct and may be life-threatening. We present the case of a 12-year-old boy with hematemesis and severe anemia that developed following an episode of acute pancreatitis. Upper endoscopy did not reveal a bleeding source. An endoscopic retrograde cholangiopancreatography performed for the evaluation of common bile duct obstruction identified bleeding from the pancreatic duct. Subsequently, the bleeding source, a pseudoaneurysm of the splenic artery, was identified by conventional angiography and occluded with coil embolization. The diagnosis of hemosuccus pancreaticus may be difficult in children due to rare occurrence and the unusual anatomical site; hence, a high index of suspicion is needed in a patient with a history of pancreatitis who presents with intermittent upper gastrointestinal bleeding and normal upper endoscopy. |
| 1.167 | Deepak Gopal | GI | dvg@medicine.wisc.edu | Sedation reversal trends at outpatient ambulatory endoscopic center vs in-hospital ambulatory procedure center using a triage protocol. | Routine outpatient endoscopy is performed across a variety of outpatient settings. A known risk of performing endoscopy under moderate sedation is the potential for over-sedation, requiring the use of reversal agents. More needs to be reported on rates of reversal across different outpatient settings. Our academic tertiary care center utilizes a triage tool that directs higher-risk patients to the in-hospital ambulatory procedure center (APC) for their procedure. Here, we report data on outpatient sedation reversal rates for endoscopy performed at an in-hospital APC vs at a free-standing ambulatory endoscopy digestive health center (AEC-DHC) following risk stratification with a triage tool. To observe the effect of risk stratification using a triage tool on patient outcomes, primarily sedation reversal events. We observed all outpatient endoscopy procedures performed at AEC-DHC and APC from April 2013 to September 2019. Procedures were stratified to their respective sites using a triage tool. We evaluated each procedure for which sedation reversal with flumazenil and naloxone was recorded. Demographics and characteristics recorded include patient age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, procedure type, and reason for sedation reversal. There were 97366 endoscopic procedures performed at AEC-DHC and 22494 at the APC during the study period. Of these, 17 patients at AEC-DHC and 9 at the APC underwent sedation reversals (0.017% vs 0.04%; P = 0.06). Demographics recorded for those requiring reversal at AEC-DHC vs APC included mean age (53.5 ± 21 vs 60.4 ± 17.42 years; P = 0.23), ASA class (1.66 ± 0.48 vs 2.22 ± 0.83; P = 0.20), BMI (27.7 ± 6.7 kg/m2 vs 23.7 ± 4.03 kg/m2; P = 0.06), and female gender (64.7% vs 22%; P = 0.04). The mean doses of sedative agents and reversal drugs used at AEC-DHC vs APC were midazolam (5.9 ± 1.7 mg vs 8.9 ± 3.5 mg; P = 0.01), fentanyl (147.1 ± 49.9 μg vs 188.9 ± 74.1 μg; P = 0.10), flumazenil (0.3 ± 0.18 μg vs 0.17 ± 0.17 μg; P = 0.13) and naloxone (0.32 ± 0.10 mg vs 0.28 ± 0.12 mg; P = 0.35). Procedures at AEC-DHC requiring sedation reversal included colonoscopies (n = 6), esophagogastroduodenoscopy (EGD) (n = 9) and EGD/colonoscopies (n = 2), whereas APC procedures included EGDs (n = 2), EGD with gastrostomy tube placement (n = 1), endoscopic retrograde cholangiopancreatography (n = 2) and endoscopic ultrasound's (n = 4). The indications for sedation reversal at AEC-DHC included hypoxia (n = 13; 76%), excessive somnolence (n = 3; 18%), and hypotension (n = 1; 6%), whereas, at APC, these included hypoxia (n = 7; 78%) and hypotension (n = 2; 22%). No sedation-related deaths or long-term post-sedation reversal adverse outcomes occurred at either site. Our study highlights the effectiveness of a triage tool used at our tertiary care hospital for risk stratification in minimizing sedation reversal events during outpatient endoscopy procedures. Using a triage tool for risk stratification, low rates of sedation reversal can be achieved in the ambulatory settings for EGD and colonoscopy. |
| 1.168 | Deepak Gopal | GI | dvg@medicine.wisc.edu | Gastroenterology Providers and the Electronic Health Record. | |
| 1.169 | Deepak Gopal | GI | dvg@medicine.wisc.edu | Outcomes of colon self-expandable metal stents for malignant vs benign indications at a tertiary care center and review of literature. | Endoscopic placement of a self-expandable metal stent (SEMS) is a minimally invasive treatment for use in malignant and benign colonic obstruction. However, their widespread use is still limited with a nationwide analysis showing only 5.4% of patients with colon obstruction undergoing stent placement. This underutilization could be due to perceived increase risk of complications with stent placement. To review long- and short-term clinical success of SEMS use for colonic obstruction at our center. We retrospectively reviewed all the patients who underwent colonic SEMS placement over a eighteen year period (August 2004 through August 2022) at our academic center. Demographics including age, gender, indication (malignant and benign), technical success, clinical success, complications (perforation, stent migration), mortality, and outcomes were recorded. Sixty three patients underwent colon SEMS over an 18-year period. Fifty-five cases were for malignant indications, 8 were for benign conditions. The benign strictures included diverticular disease stricturing (n = 4), fistula closure (n = 2), extrinsic fibroid compression (n = 1), and ischemic stricture (n = 1). Forty-three of the malignant cases were due to intrinsic obstruction from primary or recurrent colon cancer; 12 were from extrinsic compression. Fifty-four strictures occurred on the left side, 3 occurred on the right and the rest in transverse colon. The total malignant case (n = 55) procedural success rate was 95% vs 100% for benign cases (P = 1.0, NS). Overall complication rate was significantly higher for benign group: Four complications were observed in the malignant group (stent migration, restenosis) vs 2 of 8 (25%) for benign obstruction (1-perforation, 1-stent migration) (P = 0.02). When stratifying complications of perforation and stent migration there was no significant difference between the two groups (P = 0.14, NS). Colon SEMS remains a worthwhile option for colonic obstruction related to malignancy and has a high procedural and clinical success rate. Benign indications for SEMS placement appear to have similar success to malignant. While there appears to be a higher overall complication rate in benign cases, our study is limited by sample size. When evaluating for perforation alone there does not appear to be any significant difference between the two groups. SEMS placement may be a practical option for indications other that malignant obstruction. Interventional endoscopists should be aware and discuss the risk for complications in setting of benign conditions. Indications in these cases should be discussed in a multi-disciplinary fashion with colorectal surgery. |
| 1.170 | Deepak Gopal | GI | dvg@medicine.wisc.edu | Electronic Health Record Work Demands for Gastroenterology and Hepatology Providers: A Prospective Use Analysis and Survey Study. | There is a paucity of research on the use of the electronic health record (EHR) by gastroenterology and hepatology providers and its effect on work-life balance. Our aim was to study the after-hour EHR work completed among providers within a multispecialty academic practice. Time spent completing EHR tasks during evening hours (7p-7a) and days off was prospectively recorded for 35 providers over six consecutive months at a single center. Type and time of EHR tasks completed were compared based on subspecialty, academic degree, academic track category, identified gender, and number of weekly assigned clinical days worked. Prior to the data collection, providers filled out a survey regarding EHR use, work hours, and work-life balance. All providers used EHR during evening hours and during days off. The total mean after-hours time spent completing EHR tasks was 18.4 m (± 13.0) per day and 45.0 m (± 25.8) during days off. There was significant variation in the daily mean after-hours time spent completing EHR tasks among subspecialties, range 45.3 m (± 27.1) (advanced endoscopy)-28.7 m (± 22.7) (hepatology), and among providers who work clinically > 7.5 days per week versus those who do not, 42.1 m (± 25.7) vs 30.0 m (± 14.0). The most common after-hours EHR task was note completion. 83% providers reported being unable to complete EHR tasks during allotted workday time and 87% report that EHR tasks interfered with family life; 74% with social life. Gastroenterology and hepatology providers spend a significant amount of after-hour time completing EHR tasks which is perceived to interfere with family/social life. |
| 1.171 | Deepak Gopal | GI | dvg@medicine.wisc.edu | What lies in-between: C3 glomerulopathy with non-hemolytic renal microangiopathy and an ultra-rare C3 variant. | We report a 36-year-old female with mixed nephritic-nephrotic syndrome and recurrent pancreatitis. Kidney biopsy showed a crescentic membranoproliferative glomerulonephritis with dominant C3 staining on immunofluorescence (IF) but only scant deposits on electron microscopy (EM) and instead, evidence of severe acute and chronic microangiopathy - endothelial swelling, sub-endothelial fluff, and segmental basement membrane remodeling. Her serum C3 was normal, Factor Ba, and serum Membrane attack complex (sMAC) levels were elevated, and Properdin was low. Genetic testing revealed a heterozygous ultra rare C3 variant of unknown significance (c.4838G>T, p.Gly1613Val) as well as a heterozygous deletion of CFHR3-CFHR1. She showed an initial response to terminal complement blockade with eculizumab, but her renal disease progressed in the next year. Notably, our patient never demonstrated microangiopathic hemolysis, yet pancreatitis of unclear etiology recurred periodically. Our case suggests the existence of a "C3G/aHUS overlap" clinicopathologic syndrome and highlights the challenges of treating complement-mediated kidney disease. |
| 1.172 | Deepak Gopal | GI | dvg@medicine.wisc.edu | Retrograde Balloon-Assisted Deep Enteroscopy in the Diagnosis of Metastatic Melanoma. | A 74-year-old male with a history of metastatic melanoma presents with persistently abnormal small bowel findings on PET-CT scan. The patient had persistent FDG uptake near the ileocolic junction on imaging, concerning for metastatic melanoma. Capsule endoscopy demonstrated ulcerated mucosa in the distal ileum. This area was biopsied and tattooed via retrograde double-balloon enteroscopy to confirm the diagnosis of metastatic melanoma and facilitate subsequent small bowel resection. The case illustrates a unique case of metastatic melanoma to the small bowel and the utility of capsule endoscopy and balloon-assisted enteroscopy to assist in diagnosis and management of metastatic disease. |
| 1.173 | Deepak Gopal | GI | dvg@medicine.wisc.edu | Percutaneous Transhepatic Single-Operator Cholangioscopy-Guided Intraductal Stone Therapy in a Liver Transplant Patient With Ischemic Cholangiopathy. | Ischemic cholangiopathy is a feared complication after liver transplantation. We present a 68-year-old man who is status postorthotopic liver transplant from a donation after cardiac death. His posttransplant course was complicated by the development of a biliary anastomotic stricture, ischemic cholangiopathy, biloma, recurrent cholangitis, and intrahepatic stones. Through the use of antegrade cholangioscopy with a single-operator cholangioscope (SpyGlass 2; Boston Scientific, Boston, MA) passed through a percutaneous sheath, we were able to visualize impacted stones within the left intrahepatic system and treat them using electrohydraulic lithotripsy for stone fragmentation and removal. |
| 1.174 | Deepak Gopal | GI | dvg@medicine.wisc.edu | Prospective Comparison of Moderate Conscious Sedation and Anesthesia Assistance for the Performance of Endoscopic Retrograde Cholangiopancreatography (ERCP). | Recent trends have favored the use of anesthesia personnel more frequently for advanced endoscopic procedures. We hypothesize a selective sedation approach based on patient and procedural factors using either moderate conscious sedation (MCS) or general anesthesia (GA) will result in similar outcomes and safety with significant cost savings. A 12-month prospective study of all adult endoscopic retrograde cholangiopancreatography (ERCPs) performed at a tertiary medical center was enrolled. Technical success, cannulation rates, procedural related complications, procedure time, and cost were compared between MCS and GA. A total of 876 ERCPs were included in the study with 74% performed with MCS versus 26% with GA. The intended intervention was completed successfully in 95% of cases with MCS versus 96% cases with GA (p = 0.59). Cannulation success rates with MCS were 97.5 versus 97.8% with GA (p = 0.81). Overall, adverse event rates were similar in both groups (MCS: 6.6% vs. GA: 9.2%, p = 0.21). Mean procedure time was less for MCS versus GA, 18.3 and 26 minutes, respectively (p < 0.0001). Selective use of MCS vs. universal sedation with GA resulted in estimated savings of $8,190 per case and $4,735,202 per annum. Preselection of ERCP sedation of moderate conscious sedation versus general anesthesia based upon patient risk factors and planned therapeutic intervention allows for the majority of ERCPs to be completed with MCS with similar rates of technical success and improvement in resource utilization and cost savings compared to performing ERCPs universally with anesthesia assistance. |
| 1.175 | Deepak Gopal | GI | dvg@medicine.wisc.edu | Safety and Efficacy of Moderate Sedation in Super Obese Patients Undergoing Lower and Upper GI Endoscopy: a Case-Control Study. | Obesity is a disease of increasing prevalence. There is minimal research on the safety of sedation for general endoscopic procedures among super obese patients (BMI ≥ 50). The aim of our study was to evaluate the safety of moderate sedation and endoscopic procedural outcomes for super obese patients in a case-control study. We completed an age and sex-matched case-control study comparing 132 super obese patients with 132 non-obese controls. We assessed intra-procedure adverse events, delayed adverse events, doses of sedation medication used, and procedure duration at a tertiary care setting. The mean BMI for the obese cohort was 55.6 compared with 22.5 for the controls (P < 0.001). The mean intra-procedure fentanyl and midazolam dose was higher for the obese patients compared with the controls, fentanyl 180 mcg, midazolam 7.7 mg vs fentanyl 148 mcg, midazolam 6.4 mg, respectively (P < 0.001). There was a significantly higher percentage of brief intra-procedure hypoxia (oxygen blood saturation < 90%) for the obese patients compared with the controls, 5% vs 0% (P = 0.02). There was no difference in delayed adverse events with 2% of the cases and 2% of the controls having delayed adverse events (P = 1.0). Procedure completion rates were 100% for both cases and controls. General endoscopic procedures can be safely and effectively performed in super obese patients with moderate sedation. Brief intra-procedure hypoxia more commonly occurs in super obese patients, and higher medication doses are required. |
| 1.176 | Deepak Gopal | GI | dvg@medicine.wisc.edu | Endoscopic Ultrasound in Guiding Local Resection and Ampullary Preservation of a High-Risk Periampullary GIST. | Gastrointestinal stromal tumors (GISTs) typically develop in the stomach or small intestine and rarely involve the ampulla of Vater, with only 13 cases reported in the world literature since 2004. Most authors advocate performing pancreaticoduodenectomy for such lesions. However, this operation can carry higher rates of morbidity and mortality compared to local resection. We present a case of a high-risk, invasive periampullary GIST and the multidisciplinary management approach to local resection with the aid of endoscopic ultrasound. In addition, this case shows no local recurrence at 3 months and a favorable clinical outcome at 1 year. |
| 1.177 | Adnan Said | GI | axs@medicine.wisc.edu | Portal Hypertensive Gastropathy and MELD-Na Score Predict Recurrent Gastrointestinal Bleeding After TIPSS: An ALTA Group Study. | Transjugular intrahepatic portosystemic shunt (TIPSS) is highly effective for treatment of variceal bleeding; however, factors contributing to rebleeding complications remain unclear. In this study, we aim to determine risk factors for recurrent portal hypertensive gastrointestinal bleeding following TIPSS. Utilising the Advancing Liver Therapeutic Approaches multicentre database, we retrospectively identified adult patients who underwent TIPSS for secondary prophylaxis of variceal bleeding and had a gastrointestinal rebleeding event within 1 year. We developed multivariable logistic regression models to identify clinical/procedural characteristics associated with rebleeding. We identified 476 patients, predominately middle-aged (mean age 57), male (62%) and White (65%), with mean MELD-Na 16. 16% (n = 77) had a rebleeding event; these patients were more likely to be male (p = 0.016), with higher serum creatinine (p = 0.005), MELD-Na (p = 0.0002), portal hypertensive gastropathy on pre-TIPSS upper endoscopy (p = 0.000) and with higher incidence of TIPSS revision (p = 0.000). There were no significant differences in type of TIPSS endoprosthesis, concurrent embolotherapy, and post-TIPSS pressure gradients between those who experienced rebleeding and those who did not. After adjusting for TIPSS revision, multivariable analysis revealed MELD-Na and presence of portal hypertensive gastropathy on pre-TIPSS endoscopy were independently associated with rebleeding. In this retrospective analysis of a multicentre, nationally representative database, we found that apart from TIPSS-related factors, high MELD-Na and portal hypertensive gastropathy on pre-TIPSS endoscopy were independent predictors of rebleeding within 1 year following TIPSS. These variables may be used to identify high-risk patients who may require additional monitoring following TIPSS. |
| 1.178 | Adnan Said | GI | axs@medicine.wisc.edu | Predictors of long-term clinical outcomes after TIPS: An ALTA group study. | While TIPS is traditionally considered a bridge to liver transplant (LT), some patients achieve long-term transplant-free survival (TFS) with TIPS alone. Prognosis and need for LT should not only be assessed at time of procedure, but also re-evaluated in patients with favorable early outcomes. Adult recipients of TIPS in the multicenter advancing liver therapeutic approaches retrospective cohort study were included (N=1127 patients; 2040 person-years follow-up). Adjusted competing risk regressions were used to assess factors associated with long-term post-TIPS clinical outcomes at the time of procedure and 6 months post-TIPS. MELD-Na at TIPS was significantly associated with post-TIPS mortality (subdistribution hazards ratio of death 1.1 [ p =0.42], 1.3 [ p =0.04], and 1.7 [ p <0.01] for MELD-Na 15-19, 20-24, and ≥25 relative to MELD-Na 3 points from TIPS to 6 months post-TIPS was significantly associated with long-term mortality, regardless of initial MELD-Na score (subdistribution hazards ratio of death 1.8, p <0.01). For patients with long-term post-TIPS TFS, rates of complications of the TIPS or portal hypertension were low. Among patients with early post-TIPS TFS, prognosis and need for LT should be reassessed, informed by postprocedure changes in MELD-Na and clinical status. For selected patients, "destination TIPS" without LT may offer long-term survival with freedom from portal hypertensive complications. |
| 1.179 | Adnan Said | GI | axs@medicine.wisc.edu | Dietary macro and micronutrients associated with MASLD: Analysis of a national US cohort database. | Our objective was to measure and compare the intake of macro and micronutrients in a cohort of individuals with Metabolic Syndrome Associated Steatotic Liver Disease (MASLD) compared with matched controls to identify areas of further research in this area; we identified nutrition-associated associations with MASLD in the United States general population. We used the 2017 - 2018 NHANES dataset. Elastography Controlled Attenuation Parameter (CAP score>280) in the absence of other liver disease was defined as MASLD in adults (>18). Advanced fibrosis was defined by transient elastography >10 kPa. Controls were adults without liver disease. 1648 MASLD cases (11.4 % advanced fibrosis) and 2527 controls were identified. MASLD cases were older (P<0.001), more likely males (P = 0.01), less likely to have a college education (P = 0.04) and more likely married (P = 0.002). MASLD cases were more likely to be of Mexican American or Hispanic ethnicity (P = 0.002), have higher BMI, and have higher prevalence of diabetes, hyperlipidemia and hypertension (P<0.001 for all). MASLD cases had higher hs-CRP (P = 0.02) and ferritin (P = 0.02). MASLD cases had lower total (P = 0.004) and added vitamin E in their diet (P = 0.002), lower vitamin K intake (P = 0.005), and higher selenium intake (P = 0.03). Caloric intake (P = 0.04), carbohydrate intake (P = 0.02), cholesterol intake (P = 0.03) and saturated fatty acid intake (P = 0.05) were higher in MASLD. Individuals with MASLD were more likely to be on a diet (P<0.001), sedentary (P = 0.008) and less likely to participate in moderate or vigorous recreational activities (P<0.001). The deficiencies of micronutrients and excess of macronutrients point to oxidative stress, pro-inflammatory state, and lipotoxicity as pathways linking the US diet to MASLD. MASLD patients are more often on special diets, which may reflect prior provider counseling on diet changes to improve health. |
| 1.180 | Adnan Said | GI | axs@medicine.wisc.edu | Change in Platelet Count after Transjugular Intrahepatic Portosystemic Shunt Creation: An Advancing Liver Therapeutic Approaches (ALTA) Group Study. | To evaluate recovery of platelet count after transjugular intrahepatic portosystemic shunt (TIPS) creation and patient factors predicting platelet recovery after TIPS creation. Adults with cirrhosis who underwent TIPS creation at 9 U.S. hospitals from 2010 to 2015 were included in this retrospective analysis. Change in platelets from before TIPS to 4 months after TIPS creation was characterized. Logistic regression was used to assess factors associated with top quartile percentage platelet increase after TIPS. Subgroup analyses were performed among patients with a pre-TIPS platelet count of ≤50 ×109/L. A total of 601 patients were included. The median absolute change in platelets was 1 × 109/L (-26 × 109/L to 25 × 109/L). Patients with top quartile percent platelet increase experienced ≥32% platelet increase. In multivariable analysis, pre-TIPS platelet counts (odds ratio [OR], 0.97 per 109/L; 95% CI, 0.97-0.98), age (OR, 1.24 per 5 years; 95% CI, 1.10-1.39), and pre-TIPS model for end-stage liver disease (MELD) scores (OR, 1.06 per point; 95% CI, 1.02-1.09) were associated with top quartile (≥32%) platelet increase. Ninety-four (16%) patients had a platelet count of ≤50 × 109/L before TIPS. The median absolute platelet change was 14 × 109/L (2 × 109/L to 34 × 109/L). Fifty-four percent of patients in this subgroup were in the top quartile for platelet increase. In multivariable logistic regression, age (OR, 1.50 per 5 years; 95% CI, 1.11-2.02) was the only factor associated with top quartile platelet increase in this subgroup. TIPS creation did not result in significant platelet increase, except among patients with a platelet count of ≤50 × 109/L before TIPS. Lower pre-TIPS platelet counts, older age, and higher pre-TIPS MELD scores were associated with top quartile (≥32%) platelet increase in the entire cohort, whereas only older age was associated with this outcome in the patient subset with a pre-TIPS platelet count of ≤50 × 109/L. |
| 1.181 | Adnan Said | GI | axs@medicine.wisc.edu | Baseline Features and Reasons for Nonparticipation in the Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) Study, a Colorectal Cancer Screening Trial. | The Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) randomized clinical trial sought to recruit 50 000 adults into a study comparing colorectal cancer (CRC) mortality outcomes after randomization to either an annual fecal immunochemical test (FIT) or colonoscopy. To (1) describe study participant characteristics and (2) examine who declined participation because of a preference for colonoscopy or stool testing (ie, fecal occult blood test [FOBT]/FIT) and assess that preference's association with geographic and temporal factors. This cross-sectional study within CONFIRM, which completed enrollment through 46 Department of Veterans Affairs medical centers between May 22, 2012, and December 1, 2017, with follow-up planned through 2028, comprised veterans aged 50 to 75 years with an average CRC risk and due for screening. Data were analyzed between March 7 and December 5, 2022. Case report forms were used to capture enrolled participant data and reasons for declining participation among otherwise eligible individuals. Descriptive statistics were used to characterize the cohort overall and by intervention. Among individuals declining participation, logistic regression was used to compare preference for FOBT/FIT or colonoscopy by recruitment region and year. A total of 50 126 participants were recruited (mean [SD] age, 59.1 [6.9] years; 46 618 [93.0%] male and 3508 [7.0%] female). The cohort was racially and ethnically diverse, with 748 (1.5%) identifying as Asian, 12 021 (24.0%) as Black, 415 (0.8%) as Native American or Alaska Native, 34 629 (69.1%) as White, and 1877 (3.7%) as other race, including multiracial; and 5734 (11.4%) as having Hispanic ethnicity. Of the 11 109 eligible individuals who declined participation (18.0%), 4824 (43.4%) declined due to a stated preference for a specific screening test, with FOBT/FIT being the most preferred method (2820 [58.5%]) vs colonoscopy (1958 [40.6%]; P < .001) or other screening tests (46 [1.0%] P < .001). Preference for FOBT/FIT was strongest in the West (963 of 1472 [65.4%]) and modest elsewhere, ranging from 199 of 371 (53.6%) in the Northeast to 884 of 1543 (57.3%) in the Midwest (P = .001). Adjusting for region, the preference for FOBT/FIT increased by 19% per recruitment year (odds ratio, 1.19; 95% CI, 1.14-1.25). In this cross-sectional analysis of veterans choosing nonenrollment in the CONFIRM study, those who declined participation more often preferred FOBT or FIT over colonoscopy. This preference increased over time and was strongest in the western US and may provide insight into trends in CRC screening preferences. |
| 1.182 | Adnan Said | GI | axs@medicine.wisc.edu | The impact of right atrial pressure on outcomes in patients undergoing TIPS, an ALTA group study. | Single-center studies in patients undergoing TIPS suggest that elevated right atrial pressure (RAP) may influence survival. We assessed the impact of pre-TIPS RAP on outcomes using the Advancing Liver Therapeutic Approaches (ALTA) database. Total 883 patients in ALTA multicenter TIPS database from 2010 to 2015 from 9 centers with measured pre-TIPS RAP were included. Primary outcome was mortality. Secondary outcomes were 48-hour post-TIPS complications, post-TIPS portal hypertension complications, and post-TIPS inpatient admission for heart failure. Adjusted Cox Proportional hazards and competing risk model with liver transplant as a competing risk were used to assess RAP association with mortality. Restricted cubic splines were used to model nonlinear relationship. Logistic regression was used to assess RAP association with secondary outcomes.Pre-TIPS RAP was independently associated with overall mortality (subdistribution HR: 1.04 per mm Hg, 95% CI, 1.01, 1.08, p =0.009) and composite 48-hour complications. RAP was a predictor of TIPS dysfunction with increased odds of post-90-day paracentesis in outpatient TIPS, hospital admissions for renal dysfunction, and heart failure. Pre-TIPS RAP was positively associated with model for end-stage liver disease, body mass index, Native American and Black race, and lower platelets. Pre-TIPS RAP is an independent risk factor for overall mortality after TIPS insertion. Higher pre-TIPS RAP increased the odds of early complications and overall portal hypertensive complications as potential mechanisms for the mortality impact. |
| 1.183 | Adnan Said | GI | axs@medicine.wisc.edu | A Case of Progressive Cholestatic Drug-Induced Liver Injury Due to Terbinafine. | Terbinafine is commonly prescribed for onychomycosis. It rarely leads to severe, prolonged cholestatic drug-induced liver injury. Clinicians should remain vigilant for this complication. A 62-year-old woman was started on terbinafine and developed mixed hepatocellular and cholestatic drug-induced liver injury, confirmed on liver biopsy. The injury became predominantly cholestatic. Unfortunately, she developed coagulopathy with elevated international normalized ratio and progressive drug-induced liver injury with severely elevated alkaline phosphatase and total bilirubin, requiring repeat liver biopsy. Fortunately, she did not develop acute liver failure. Prior case reports and series have documented severe cholestatic drug-induced liver injury (although with lesser degree of bilirubin elevation) due to terbinafine, which has very rarely been associated with acute liver failure, need for liver transplantation, and/or death. Non-acetaminophen drug-induced liver injury is idiosyncratic. Complications including acute liver failure and vanishing bile duct syndrome can be slow to develop, so monitoring for them is important over longitudinal follow-up. |
| 1.184 | Adnan Said | GI | axs@medicine.wisc.edu | Immunotherapy for HCC: limitations in patients with NASH. | |
| 1.185 | Adnan Said | GI | axs@medicine.wisc.edu | Staging Liver Fibrosis by Fibroblast Activation Protein Inhibitor PET in a Human-Sized Swine Model. | Current methods of staging liver fibrosis have notable limitations. We investigated the utility of PET in staging liver fibrosis by correlating liver uptake of 68Ga-labeled fibroblast activation protein inhibitor (FAPI) with histology in a human-sized swine model. Methods: Five pigs underwent baseline 68Ga-FAPI-46 (68Ga-FAPI) PET/MRI and liver biopsy, followed by liver parenchymal embolization, 8 wk of oral alcohol intake, endpoint 68Ga-FAPI PET/MRI, and necropsy. Regions of interest were drawn on baseline and endpoint PET images, and SUVmean was recorded. At the endpoint, liver sections corresponding to regions of interest were identified and cut out. Fibrosis was histologically evaluated using a modified METAVIR score for swine liver and quantitatively using collagen proportionate area (CPA). Box-and-whisker plots and linear regression were used to correlate SUVmean with METAVIR score and CPA, respectively. Results: Liver 68Ga-FAPI uptake strongly correlated with CPA (r = 0.89, P < 0.001). 68Ga-FAPI uptake was significantly and progressively higher across F2 and F3/F4 fibrosis stages, with a respective median SUVmean of 2.9 (interquartile range [IQR], 2.7-3.8) and 7.6 (IQR, 6.7-10.2) (P < 0.001). There was no significant difference between 68Ga-FAPI uptake of baseline liver and endpoint liver sections staged as F0/F1, with a respective median SUVmean of 1.7 (IQR, 1.3-2.0) and 1.7 (IQR, 1.5-1.8) (P = 0.338). Conclusion: The strong correlation between liver 68Ga-FAPI uptake and the histologic stage of liver fibrosis suggests that 68Ga-FAPI PET can play an impactful role in noninvasive staging of liver fibrosis, pending validation in patients. |
| 1.186 | Adnan Said | GI | axs@medicine.wisc.edu | Microwave Ablation as Bridging to Liver Transplant for Patients with Hepatocellular Carcinoma: A Single-Center Retrospective Analysis. | To evaluate the efficacy and safety of microwave (MW) ablation as first-line locoregional therapy (LRT) for bridging patients with hepatocellular carcinoma (HCC) to liver transplant. This retrospective study evaluated 88 patients who received percutaneous MW ablation for 141 tumors as first-line LRT for HCC and who were listed for liver transplantation at a single medical center between 2011 and 2019. The overall survival (OS) rate statuses after liver transplant, waitlist retention, and disease progression were evaluated using the Kaplan-Meier techniques. Among the 88 patients (72 men and 16 women; mean age, 60 years; Model for End-Stage Liver Disease score, 11.2) who were listed for transplant, the median waitlist time was 9.4 months (interquartile range, 5.5-18.9). Seventy-one (80.7%) patients received transplant after a median waitlist time of 8.5 months. Seventeen (19.3%) patients were removed from the waitlist; of these, 4 (4.5%) were removed because of tumors outside of the Milan criteria (HCC-specific dropout). No difference in tumor size or alpha-fetoprotein was observed in the transplanted versus nontransplanted patients at the time of ablation (2.1 vs 2.1 cm and 34.4 vs 34.7 ng/mL for transplanted vs nontransplanted, respectively; P > .05). Five (5.1%) of the 88 patients experienced adverse events after ablation; however, they all recovered. There were no cases of tract seeding. The local tumor progression (LTP) rate was 7.2%. The OS status after liver transplant at 5 years was 76.7%, and the disease-specific survival after LTP was 89.6%, with a median follow-up of 61 months for all patients. MW ablation appears to be safe and effective for bridging patients with HCC to liver transplant without waitlist removal from seeding, adverse events, or LTP. |
| 1.187 | Vaishalee Kenkre | HEM/ONC | vpkenkre@medicine.wisc.edu | Measurable Residual Disease Testing Following Nonintensive Chemoimmunotherapy is Predictive of Need for Maintenance Therapy in Previously Untreated Mantle Cell Lymphoma: A Wisconsin Oncology Network Study. | Obinutuzumab is hypothesized to improve progression-free survival (PFS) combined with bendamustine induction in mantle cell lymphoma (MCL). Measurable-residual disease (MRD) testing may predict benefit from maintenance therapy. Adults (≥ 18 years) with untreated MCL ineligible for intensive therapies received 4 to 6 cycles of bendamustine + obinutuzumab (BO) followed by consolidation obinutuzumab (CO). Restaging after CO included MRD assessment by next-generation sequencing of bone marrow aspirate (BMA) and peripheral blood (PB). Maintenance obinutuzumab (MO) was omitted for patients with imaging complete response (CR) and MRD-negativity in PB/BMA. All other patients received 8 cycles MO. Primary endpoint is PFS; secondary endpoints are response rates, overall survival, and estimation of MRD status. Twenty-one patients enrolled, with median age 70 years and stage IV disease in 95%. Twenty patients completed BO; 10 patients received MO per protocol. Six patients did not complete MO due to progression (n = 4), infection (n = 1) and carcinoma (n = 1). Overall response is 95% (75% CR, 20% partial response). Concordance rate between post-consolidation MRD testing in PB and BMA was 70%. After a median follow-up of 43.9 months, median PFS is 46.5 months. The observed difference between 2-year PFS in groups receiving MO versus observation was not statistically significant (HR 0.45, 95% CI, 0.10-1.91). Most common grade 3/4 toxicities were neutropenia, leukopenia, and infections. BO is a tolerable induction regimen with higher rates of CR compared with historical rates with bendamustine + rituximab. Omission of MO did not worsen outcomes in patients achieving MRD-negative status after nonintensive induction/consolidation therapy. |
| 1.188 | Vaishalee Kenkre | HEM/ONC | vpkenkre@medicine.wisc.edu | Maintenance low-dose fixed duration lenalidomide and rituximab following bendamustine and rituximab induction in previously untreated chronic lymphocytic leukemia and small lymphocytic lymphoma. | Lenalidomide (LEN) and rituximab (RTX) have independently improved progression-free survival (PFS) in CLL, leading to interest in use of LEN + RTX (R2) following induction chemoimmunotherapy. Patients with previously untreated CLL received bendamustine + RTX (BR) for 6 cycles, then 24 cycles of R2. LEN dosing was 5-10 mg daily; RTX was given odd cycles (12 doses). The primary endpoint is PFS; secondary endpoints are response and overall survival. Thirty-six patients enrolled, median age 64.5 years. Twenty-nine received R2; 12 completed a full course R2 (33.3%), 5 completed R2 with premature discontinuation of LEN. Dose reductions/holds were most often for neutropenia. Complete response was achieved in 33.3%. After median >4 years follow-up, 2-year and 3-year PFS were 86.1% and 69.4%. Five-year overall survival was 92.3%. R2 maintenance may improve PFS after BR induction, and a lower dose of 5 mg/day and ≤1 year of R2 may be most tolerable (NCT00974233). |
| 1.189 | Vaishalee Kenkre | HEM/ONC | vpkenkre@medicine.wisc.edu | Autologous transplant vs. CAR-T therapy in patients with DLBCL treated while in complete remission. | In patients with relapsed DLBCL in complete remission (CR), autologous hematopoietic cell transplantation (auto-HCT) and CAR-T therapy are both effective, but it is unknown which modality provides superior outcomes. We compared the efficacy of auto-HCT vs. CAR-T in patients with DLBCL in a CR. A retrospective observational study comparing auto-HCT (2015-2021) vs. CAR-T (2018-2021) using the Center for International Blood & Marrow Transplant Research registry. Median follow-up was 49.7 months for the auto-HCT and 24.7 months for the CAR-T cohort. Patients ages 18 and 75 with a diagnosis of DLBCL were included if they received auto-HCT (n = 281) or commercial CAR-T (n = 79) while in a CR. Patients undergoing auto-HCT with only one prior therapy line and CAR-T patients with a previous history of auto-HCT treatment were excluded. Endpoints included Progression-free survival (PFS), relapse rate, non-relapse mortality (NRM) and overall survival (OS). In univariate analysis, treatment with auto-HCT was associated with a higher rate of 2-year PFS (66.2% vs. 47.8%; p < 0.001), a lower 2-year cumulative incidence of relapse (27.8% vs. 48% ; p < 0.001), and a superior 2-year OS (78.9% vs. 65.6%; p = 0.037). In patients with early (within 12 months) treatment failure, auto-HCT was associated with a superior 2-year PFS (70.9% vs. 48.3% ; p < 0.001), lower 2-year cumulative incidence of relapse (22.8% vs. 45.9% ; p < 0.001) and trend for higher 2-year OS (82.4% vs. 66.1% ; p = 0.076). In the multivariable analysis, treatment with auto-HCT was associated with a superior PFS (hazard ratio 1.83; p = 0.0011) and lower incidence of relapse (hazard ratio 2.18; p < 0.0001) compared to CAR-T. In patients with relapsed LBCL who achieve a CR, treatment with auto-HCT is associated with improved clinical outcomes compared to CAR-T. These data support the consideration of auto-HCT in select patients with LBCL achieving a CR in the relapsed setting. |
| 1.190 | Vaishalee Kenkre | HEM/ONC | vpkenkre@medicine.wisc.edu | JAK inhibition enhances checkpoint blockade immunotherapy in patients with Hodgkin lymphoma. | Unleashing antitumor T cell activity by checkpoint inhibitor immunotherapy is effective in cancer patients, but clinical responses are limited. Cytokine signaling through the Janus kinase (JAK)-signal transducer and activator of transcription (STAT) pathway correlates with checkpoint immunotherapy resistance. We report a phase I clinical trial of the JAK inhibitor ruxolitinib with anti-PD-1 antibody nivolumab in Hodgkin lymphoma patients relapsed or refractory following checkpoint inhibitor immunotherapy. The combination yielded a best overall response rate of 53% (10/19). Ruxolitinib significantly reduced neutrophil-to-lymphocyte ratios and percentages of myeloid suppressor cells but increased numbers of cytokine-producing T cells. Ruxolitinib rescued the function of exhausted T cells and enhanced the efficacy of immune checkpoint blockade in preclinical solid tumor and lymphoma models. This synergy was characterized by a switch from suppressive to immunostimulatory myeloid cells, which enhanced T cell division. |
| 1.191 | Vaishalee Kenkre | HEM/ONC | vpkenkre@medicine.wisc.edu | Impact of race and social determinants of health on outcomes in patients with aggressive B-cell NHL treated with CAR-T therapy. | Chimeric antigen receptor (CAR) T-cell (CAR-T) immunotherapy is an effective therapy for relapsed/refractory B-cell non-Hodgkin lymphoma (r/r B-NHL). However, data are limited on the impact of the convergence of race and social determinants of health on outcomes for patients treated with CAR-T therapy. We examined the impact of interactions between race and insurance type on health care use and outcomes in patients treated with CAR-T therapy for aggressive B-NHL. Adult patients with r/r B-NHL treated with CD19 CAR-Ts were identified between 2015 and 2021 across 13 US academic centers. Insurance type, demographic, and clinical data were collected and analyzed. In total, 466 adult patients were included in our analysis. Median follow-up after CAR-T therapy was 12.7 months. Median progression-free survival (mPFS) was longer for Caucasians (11.5 months) than for African Americans (3.5 months; hazard ratio [HR], 1.56 [1.03-2.4]; P = .04) or Asians (2.7 months; HR, 1.7 [1.02-2.67]; P = .04). Differences in median overall survival (mOS) were not significant. For Medicare (n = 206) vs Medicaid (n = 33) vs private insurance (n = 219) vs self-pay (n = 7): mPFS was 15.9 vs 4.2 vs 6.0 vs 0.9 months (P < .001), respectively; and mOS was 31.2 vs 12.8 vs 21.5 vs 3.2 months (P < .001), respectively. Our multicenter retrospective analysis showed that race and insurance status can affect outcomes for patients treated with CAR-T therapy. |
| 1.192 | Vaishalee Kenkre | HEM/ONC | vpkenkre@medicine.wisc.edu | Subsequent malignant neoplasms in patients previously treated with anti-CD19 CAR T-cell therapy. | |
| 1.193 | Vaishalee Kenkre | HEM/ONC | vpkenkre@medicine.wisc.edu | Safety and efficacy of zandelisib plus zanubrutinib in previously treated follicular and mantle cell lymphomas. | The combination of the phosphatidylinositol 3-kinase delta (PI3Kδ) inhibitor zandelisib with the Bruton's tyrosine kinase (BTK) inhibitor zanubrutinib was hypothesized to be synergistic and prevent resistance to single-agent therapy. This phase 1 study (NCT02914938) included a dose-finding stage in patients with relapsed/refractory (R/R) B-cell malignancies (n = 20) and disease-specific expansion cohorts in follicular lymphoma (FL; n = 31) or mantle cell lymphoma (MCL; n = 19). The recommended phase 2 dose was zandelisib 60 mg on Days 1-7 plus zanubrutinib 80 mg twice daily continuously in 28-day cycle. In the total population, the most common adverse events (AEs; all grades/grade 3-4) were neutropenia (35%/24%), diarrhoea (33%/2%), thrombocytopenia (32%/8%), anaemia (27%/8%), increased creatinine (25%/0%), contusion (21%/0%), fatigue (21%/2%), nausea (21%/2%) and increased aspartate aminotransferase (24%/6%). Three patients discontinued due to AEs. The overall response rate was 87% (complete response [CR] = 33%) for FL and 74% (CR = 47%) for MCL. The median duration of response and progression-free survival (PFS) were not reached in either group. The estimated 1-year PFS was 72.3% (95% confidence interval [CI], 51.9-85.1) for FL and 56.3% (95% CI, 28.9-76.7) for MCL (median follow-up: 16.5 and 10.9 months respectively). Zandelisib plus zanubrutinib was associated with high response rates and no increased toxicity compared to either agent alone. |
| 1.194 | Vaishalee Kenkre | HEM/ONC | vpkenkre@medicine.wisc.edu | Overall survival of patients with cHL who progress after autologous stem cell transplant: results in the novel agent era. | In the pre-novel agent era, the median postprogression overall survival (PPS) of patients with classic Hodgkin lymphoma (cHL) who progress after autologous stem cell transplant (ASCT) was 2 to 3 years. Recently, checkpoint inhibitors (CPI) and brentuximab vedotin (BV) have improved the depth and durability of response in this population. Here, we report the estimate of PPS in patients with relapsed cHL after ASCT in the era of CPI and BV. In this multicenter retrospective study of 15 participating institutions, adult patients with relapsed cHL after ASCT were included. Study objective was postprogression overall survival (PPS), defined as the time from posttransplant progression to death or last follow-up. Of 1158 patients who underwent ASCT, 367 had progressive disease. Median age was 34 years (range, 27-46) and 192 were male. Median PPS was 114.57 months (95% confidence interval [CI], 91-not achieved) or 9.5 years. In multivariate analysis, increasing age, progression within 6 months, and pre-ASCT positive positron emission tomography scan were associated with inferior PPS. When adjusted for these features, patients who received CPI, but not BV, as first treatment for post-ASCT progression had significantly higher PPS than the no CPI/no BV group (hazard ratio, 3.5; 95% CI, 1.6-7.8; P = .001). Receipt of allogeneic SCT (Allo-SCT) did not improve PPS. In the era of novel agents, progressive cHL after ASCT had long survival that compares favorably with previous reports. Patients who receive CPI as first treatment for progression had higher PPS. Receipt to Allo-SCT was not associated with PPS in this population. |
| 1.195 | Vaishalee Kenkre | HEM/ONC | vpkenkre@medicine.wisc.edu | EGR1-mediated metabolic reprogramming to oxidative phosphorylation contributes to ibrutinib resistance in B-cell lymphoma. | The use of Bruton tyrosine kinase inhibitors, such as ibrutinib, to block B-cell receptor signaling has achieved a remarkable clinical response in several B-cell malignancies, including mantle cell lymphoma (MCL) and diffuse large B-cell lymphoma (DLBCL). Acquired drug resistance, however, is significant and affects the long-term survival of these patients. Here, we demonstrate that the transcription factor early growth response gene 1 (EGR1) is involved in ibrutinib resistance. We found that EGR1 expression is elevated in ibrutinib-resistant activated B-cell-like subtype DLBCL and MCL cells and can be further upregulated upon ibrutinib treatment. Genetic and pharmacological analyses revealed that overexpressed EGR1 mediates ibrutinib resistance. Mechanistically, TCF4 and EGR1 self-regulation induce EGR1 overexpression that mediates metabolic reprogramming to oxidative phosphorylation (OXPHOS) through the transcriptional activation of PDP1, a phosphatase that dephosphorylates and activates the E1 component of the large pyruvate dehydrogenase complex. Therefore, EGR1-mediated PDP1 activation increases intracellular adenosine triphosphate production, leading to sufficient energy to enhance the proliferation and survival of ibrutinib-resistant lymphoma cells. Finally, we demonstrate that targeting OXPHOS with metformin or IM156, a newly developed OXPHOS inhibitor, inhibits the growth of ibrutinib-resistant lymphoma cells both in vitro and in a patient-derived xenograft mouse model. These findings suggest that targeting EGR1-mediated metabolic reprogramming to OXPHOS with metformin or IM156 provides a potential therapeutic strategy to overcome ibrutinib resistance in relapsed/refractory DLBCL or MCL. |
| 1.196 | Vaishalee Kenkre | HEM/ONC | vpkenkre@medicine.wisc.edu | TCR-α/β and CD19 depleted stem cell grafts from haploidentical donors for allogeneic transplantation in patients with relapsed lymphoma: a single-center experience. | |
| 1.197 | Parag Tipnis | CVM | pt2@medicine.wisc.edu | Technical and clinical study of x-ray-based surface echo probe tracking using an attached fiducial apparatus. | Several types of structural heart intervention (SHI) use information from multiple imaging modalities to complete an interventional task. For example, in transcatheter aortic valve replacement (TAVR), placement and deployment of a bioprosthetic aortic valve in the aorta is primarily guided by x-ray fluoroscopy (XRF), and echocardiography provides visualization of cardiac anatomy and blood flow. However, simultaneous interpretation of independent x-ray and echo displays remains a challenge for the interventionalist. The purpose of this work was to develop a novel echo/x-ray co-registration solution in which volumetric transthoracic echo (TTE) is transformed to the x-ray coordinate system by tracking the three-dimensional (3D) pose of a probe fiducial attachment from its appearance in two-dimensional (2D) x-ray images. A fiducial attachment for a commercial TTE probe consisting of rings of high-contrast ball bearings was designed and fabricated. The 3D pose (position and orientation) of the fiducial attachment is estimated from a 2D x-ray image using an algorithm in which a virtual point cloud model of the attachment is iteratively rotated, translated, and forward-projected onto the image until the average sum-of-squares of grayscale values at the projected points is minimized. Fiducial registration error (FRE) and target registration error (TRE) of this approach were evaluated in phantom studies using TAVR-relevant gantry orientations and four standard acoustic windows for the TTE probe. A patient study was conducted to assess the clinical suitability of the fiducial attachment prototype during TTE imaging of patients undergoing SHI. TTE image quality for the task of guiding a transcatheter procedure was evaluated in a reviewer study. The 3D FRE ranged from 0.32 ± 0.03 mm (mean ± SD) to 1.31 ± 0.05 mm, depending on C-arm orientation and probe acoustic window. The 3D TRE ranged from 1.06 ± 0.03 mm to 2.42 ± 0.06 mm. Fiducial pose estimation was stable when >75% of the fiducial markers were visible in the x-ray image. A panel of reviewers graded the presentation of heart valves in TTE images from 48 SHI patients. While valve presentation did not differ significantly between acoustic windows (P > 0.05), the mitral valve did achieve a significantly higher image quality compared to the aortic and tricuspid valves (P < 0.001). Overall, reviewers perceived sufficient image quality in 76.5% of images of the mitral valve, 54.9% of images of the aortic valve, and 48.6% of images of the tricuspid valve. Fiducial-based tracking of a commercial TTE probe is compatible with clinical SHI workflows and yields 3D target registration error of less than 2.5 mm for a variety of x-ray gantry geometries and echo probe acoustic windows. Although TTE image quality with respect to target valve anatomy was sufficient for the majority of cases examined, prescreening of patients for sufficient TTE quality would be helpful. |
| 1.198 | Matthew Tattersall | CVM | mtattersall@medicine.wisc.edu | Oncostatin-M Is Produced by Human Eosinophils and Expression Is Increased in Uncontrolled Severe Asthma. | |
| 1.199 | Matthew Tattersall | CVM | mtattersall@medicine.wisc.edu | Proteomic Analysis of Asthma Airway Inflammation Post-Allergen Challenge: A Heterogeneous Response. | |
| 1.200 | Matthew Tattersall | CVM | mtattersall@medicine.wisc.edu | Influenza Vaccine Immune Response in Patients With High-Risk Cardiovascular Disease: A Secondary Analysis of the INVESTED Randomized Clinical Trial. | High-dose trivalent compared with standard-dose quadrivalent influenza vaccine did not significantly reduce all-cause mortality or cardiopulmonary hospitalizations in patients with high-risk cardiovascular disease in the INVESTED trial. Whether humoral immune response to influenza vaccine is associated with clinical outcomes is unknown. To examine the antibody response to high-dose trivalent compared with standard-dose quadrivalent inactivated influenza vaccine and its associations with clinical outcomes. This secondary analysis is a prespecified analysis of the immune response substudy of the randomized, double-blind, active-controlled INVESTED trial, which was conducted at 157 sites in the United States and Canada over 3 influenza seasons between September 2016 and January 2019. Antibody titers were determined by hemagglutination inhibition assays at randomization and 4 weeks during the 2017-2018 and 2018-2019 seasons. Eligibility criteria included recent acute myocardial infarction or heart failure hospitalization and at least 1 additional risk factor. Data were analyzed from February 2023 to June 2023. Mean antibody titer change, seroprotection (antibody titer level ≥1:40) and seroconversion (≥4-fold increase in titer) at 4 weeks, and the association between seroconversion status and the risk for adverse clinical outcomes. High-dose trivalent or standard-dose quadrivalent inactivated influenza vaccine, with revaccination up to 3 seasons. Antibody data were available for 658 of 5260 randomized participants (12.5%; mean [SD] age, 66.2 [11.4] years; 507 male [77.1%], 151 female [22.9%]; 348 with heart failure [52.9%]). High-dose vaccine was associated with an increased magnitude in antibody titers for A/H1N1, A/H3N2, and B-type antigens compared with standard dose. More than 92% of all participants achieved seroprotection for each of the contained antigens, while seroconversion rates were higher in participants who received high-dose vaccine. Seroconversion for any antigen was not associated with the risk for cardiopulmonary hospitalizations or all-cause mortality (hazard ratio, 1.09; 95% CI, 0.79-1.53; P = .59), irrespective of randomized treatment (P = .38 for interaction). High-dose vaccine elicited a more robust humoral response in patients with heart failure or prior myocardial infarction enrolled in the INVESTED trial, with no association between seroconversion status and the risk for cardiopulmonary hospitalizations or all-cause mortality. Vaccination to prevent influenza remains critical in high-risk populations. ClinicalTrials.gov Identifier: NCT02787044. |
| 1.201 | Matthew Tattersall | CVM | mtattersall@medicine.wisc.edu | Asthma and cardiovascular disease: embracing disease heterogeneity is required. | |
| 1.202 | Matthew Tattersall | CVM | mtattersall@medicine.wisc.edu | Systemic Inflammation in Asthma: What Are the Risks and Impacts Outside the Airway? | Airway inflammation in asthma has been well recognized for several decades, with general agreement on its role in asthma pathogenesis, symptoms, propensity toward exacerbation, and decline in lung function. This has led to universal recommendation in asthma management guidelines to incorporate the use of inhaled corticosteroid as an anti-inflammatory therapy for all patients with persistent asthma symptoms. However, there has been limited attention paid to the presence and potential impact of systemic inflammation in asthma. Accumulating evidence from epidemiological observations and cohort studies points to a host of downstream organ dysfunction in asthma especially among patients with longstanding or more severe disease, frequent exacerbations, and underlying risk factors for organ dysfunction. Most studies to date have focused on cognitive impairment, depression/anxiety, metabolic syndrome, and cardiovascular abnormalities. In this review, we summarize some of the evidence demonstrating these abnormalities and highlight the proposed mechanisms and potential benefits of treatment in limiting these extrapulmonary abnormalities in patients with asthma. The goal of this commentary is to raise awareness of the importance of recognizing potential extrapulmonary conditions associated with systemic inflammation of asthma. This area of treatment of patients with asthma is a large unmet need. |
| 1.203 | Matthew Tattersall | CVM | mtattersall@medicine.wisc.edu | Incidental Coronary Artery Calcium on Chest CT in Persons Without Known Atherosclerotic Cardiovascular Disease. | This cross-sectional study examines the expected prevalence of coronary artery calcium (CAC) on chest computed tomography (CT) in people without clinical atherosclerotic cardiovascular disease (ASCVD) by age, sex, and race and ethnicity. |
| 1.204 | Matthew Tattersall | CVM | mtattersall@medicine.wisc.edu | Temporal Association Among Influenza-Like Illness, Cardiovascular Events, and Vaccine Dose in Patients With High-Risk Cardiovascular Disease: Secondary Analysis of a Randomized Clinical Trial. | Influenza-like illness (ILI) activity has been associated with increased risk of cardiopulmonary (CP) events during the influenza season. High-dose trivalent influenza vaccine was not superior to standard-dose quadrivalent vaccine for reducing these events in patients with high-risk cardiovascular (CV) disease in the Influenza Vaccine to Effectively Stop Cardio Thoracic Events and Decompensated Heart Failure (INVESTED) trial. To evaluate whether high-dose trivalent influenza vaccination is associated with benefit over standard-dose quadrivalent vaccination in reducing CP events during periods of high, local influenza activity. This study was a prespecified secondary analysis of INVESTED, a multicenter, double-blind, active comparator randomized clinical trial conducted over 3 consecutive influenza seasons from September 2016 to July 2019. Follow-up was completed in July 2019, and data were analyzed from September 21, 2016, to July 31, 2019. Weekly Centers for Disease Control and Prevention (CDC)-reported, state-level ILI activity was ascertained to assess the weekly odds of the primary outcome. The study population included 3094 patients with high-risk CV disease from participating centers in the US. Participants were randomized to high-dose trivalent or standard-dose quadrivalent influenza vaccine and revaccinated for up to 3 seasons. The primary outcome was the time to composite of all-cause death or CP hospitalization within each season. Additional measures included weekly CDC-reported ILI activity data by state. Among 3094 participants (mean [SD] age, 65 [12] years; 2309 male [75%]), we analyzed 129 285 person-weeks of enrollment, including 1396 composite primary outcome events (1278 CP hospitalization, 118 deaths). A 1% ILI increase in the prior week was associated with an increased risk in the primary outcome (odds ratio [OR], 1.14; 95% CI, 1.07-1.21; P < .001), CP hospitalization (OR, 1.13; 95% CI, 1.06-1.21; P .99). High-dose compared with standard-dose vaccine did not significantly reduce the primary outcome, even when the analysis was restricted to weeks of high ILI activity (OR, 0.88; 95% CI, 0.65-1.20; P = .43). Traditionally warmer months in the US were associated with lower CV risk independent of local ILI activity. In this secondary analysis of a randomized clinical trial, ILI activity was temporally associated with increased CP events in patients with high-risk CV disease, and a higher influenza vaccine dose did not significantly reduce temporal CV risk. Other seasonal factors may play a role in the coincident high rates of ILI and CV events. ClinicalTrials.gov Identifier: NCT02787044. |
| 1.205 | Matthew Tattersall | CVM | mtattersall@medicine.wisc.edu | In Vivo Adaptive Bayesian Regularized Lagrangian Carotid Strain Imaging for Murine Carotid Arteries and Its Associations With Histological Findings. | Non-invasive methods for monitoring arterial health and identifying early injury to optimize treatment for patients are desirable. The objective of this study was to demonstrate the use of an adaptive Bayesian regularized Lagrangian carotid strain imaging (ABR-LCSI) algorithm for monitoring of atherogenesis in a murine model and examine associations between the ultrasound strain measures and histology. Ultrasound radiofrequency (RF) data were acquired from both the right and left common carotid artery (CCA) of 10 (5 male and 5 female) ApoE tm1Unc/J mice at 6, 16 and 24 wk. Lagrangian accumulated axial, lateral and shear strain images and three strain indices-maximum accumulated strain index (MASI), peak mean strain of full region of interest (ROI) index (PMSRI) and strain at peak axial displacement index (SPADI)-were estimated using the ABR-LCSI algorithm. Mice were euthanized (n = 2 at 6 and 16 wk, n = 6 at 24 wk) for histology examination. Sex-specific differences in strain indices of mice at 6, 16 and 24 wk were observed. For male mice, axial PMSRI and SPADI changed significantly from 6 to 24 wk (mean axial PMSRI at 6 wk = 14.10 ± 5.33% and that at 24 wk = -3.03 ± 5.61%, p < 0.001). For female mice, lateral MASI increased significantly from 6 to 24 wk (mean lateral MASI at 6 wk = 10.26 ± 3.13% and that at 24 wk = 16.42 ± 7.15%, p = 0.048). Both cohorts exhibited strong associations with ex vivo histological findings (male mice: correlation between number of elastin fibers and axial PMSRI: rs = 0.83, p = 0.01; female mice: correlation between shear MASI and plaque score: rs = 0.77, p = 0.009). The results indicate that ABR-LCSI can be used to measure arterial wall strain in a murine model and that changes in strain are associated with changes in arterial wall structure and plaque formation. |
| 1.206 | Matthew Tattersall | CVM | mtattersall@medicine.wisc.edu | Cardiovascular and Pulmonary Responses to Acute Use of Electronic Nicotine Delivery Systems and Combustible Cigarettes in Long-Term Users. | The acute cardiovascular and pulmonary effects of contemporary electronic nicotine delivery systems (ENDS) in long-term users are not known. What are the cardiovascular and pulmonary responses to an acute 15-min product use challenge with ENDS and combustible cigarettes in regular nicotine-containing product users compared with control participants who do not use tobacco or vape? Observational challenge study before and after nicotine-containing product use of 395 individuals who used ENDS exclusively (n = 164; exhaled carbon monoxide level, 5 ppm; positive urine NicCheck I results), and control participants (n = 114; carbon monoxide level, < 5 ppm; negative urine NicCheck I results). During the 15-min product challenge, cigarette users took a median of 14.0 puffs (interquartile range [IQR], 9.3 puffs); ENDS users took 9.0 puffs (IQR, 7.5 puffs; P < .001). After product challenge, compared with control participants, ENDS users showed greater increases in adjusted mean differences in systolic BP (5.6 mm Hg [95% CI, 4.4-6.8 mm Hg] vs 2.3 mm Hg [95% CI, 0.8-3.8 mm Hg]; P = .001), diastolic BP (4.2 mm Hg [95% CI, 3.3-5.0 mm Hg] vs 2.0 mm Hg [95% CI, 1.1-3.0 mm Hg; P = .003), and heart rate (4.8 beats/min [95% CI, 4.0-5.6 beats/min] vs -1.3 beats/min [95% CI, -2.2 to -0.3 beats/min]; P < .001) and greater reductions in brachial artery diameter (-0.011 cm [95% CI, -0.013 to 0.009 cm] vs -0.006 cm [95% CI, -0.004 to -0.009 cm]; P = .003), time-domain heart rate variability (-7.2 ms [95% CI, -10.5 to -3.7 ms] vs 3.6 ms [95% CI, 1.6-9.3 ms]; P = .001), and FEV1 (ENDS: -4.1 [95% CI, -5.4 to -2.8] vs control participants: -1.1 [95% CI, -2.7 to 0.6]; P = .005) with values similar to those of cigarette users. ENDS users performed worse than control participants on all exercise parameters, notably metabolic equivalents (METs; adjusted mean difference, 1.28 METs [95% CI, 0.73-1.83 METs]; P < .001) and 60-s heart rate recovery (adjusted mean difference, 2.9 beats/min [95% CI, 0.7-5.0 beats/min]; P = .008). ENDS users had acute worsening of blood pressure, heart rate, and heart rate variability, as well as vasoconstriction, impaired exercise tolerance, and increased airflow obstruction after vaping, compared to control participants. ClinicalTrials.gov; No.: NCT03863509; URL: www. gov. |
| 1.207 | Matthew Tattersall | CVM | mtattersall@medicine.wisc.edu | Changes in carotid artery texture by ultrasound and elastin features in a murine model. | In humans, arterial grayscale ultrasound texture features independently predict adverse cardiovascular disease (CVD) events and change with medical interventions. We performed this study to examine how grayscale ultrasound texture features and elastin fibers change in plaque-free segments of the arterial wall in a murine model prone to atherosclerosis. A total of 10 Apoetm1Unc/J mice (n = 5 male, n = 5 female) were imaged at 6, 16, and 24 weeks of age. Two mice were euthanized at 6 and 16 weeks and the remaining mice at 24 weeks. Texture features were extracted from the ultrasound images of the distal 1.0 mm of the common carotid artery wall, and elastin measures were extracted from histology images. Two-way analysis of variance was used to evaluate associations between week, sex, and grayscale texture features. Texture feature and elastin number comparisons between weeks were conducted using the sex-by-week two-way interaction contrasts. Sex-specific correlations between the number of elastin fibers and grayscale texture features were analyzed by conducting non-parametric Spearman's rank correlation analyses. Arterial wall homogeneity changed significantly in male mice from 6 to 24 weeks, with a mean (SD) of 0.14 (0.03) units at 6 weeks and 0.18 (0.03) units at 24 weeks (p = 0.026). Spatial gray level dependence matrices-homogeneity (SGLD-HOM) also correlated with carotid artery plaque score (rs = 0.707, p = 0.033). Elastin fibers in the region of interest decreased from 6 to 24 weeks for both male and female mice, although only significantly in male mice. The mean (SD) number of elastin fibers for male mice was 5.32 (1.50) at 6 weeks and 3.59 (0.38) at 24 weeks (p = 0.023). For female mice, the mean (SD) number of elastin fibers was 3.98 (0.38) at 6 weeks and 3.46 (0.19) at 24 weeks (p = 0.051). Grayscale ultrasound texture features that are associated with increased risk for CVD events in humans were used in a murine model, and the grayscale texture feature SGLD-HOM was shown to change in male mice from 6 weeks to 24 weeks. Structural alterations of the arterial wall (change in elastin fiber number) were observed during this time and may differ by sex. |
| 1.208 | Daniel J Jackson | PEDS | djj@medicine.wisc.edu | Controversies in Allergy: Are Biologic Treatment Responses in Severe Asthma the Same in Adults and Children? | The availability of biologic agents for patients with severe asthma has increased dramatically over the last several decades. The absence of direct head-to-head comparative data and relative lack of biomarkers to predict response can make it difficult to choose the right biologic medication for a given patient. Selecting a biologic agent for the pediatric population presents further challenges due to more limited approved biologic agents and fewer clinical trials in children. In addition, the outcome data that are currently available suggest that treatment responses for a given biologic may be different between adult and pediatric patients. To better understand this possible difference in treatment response, this review focuses on the available efficacy data for biologics evaluated in adult and pediatric patients with severe asthma in addition to other considerations when choosing a biologic agent. Finally, this review discusses how asthma phenotypes differ across age groups and their contributions to the responses to biologic treatment across age groups. Keywords: Biologics; Severe asthma. |
| 1.209 | Farhan Raza | CVM | fraza@medicine.wisc.edu | Relationship of TAPSE Normalized by Right Ventricular Area With Pulmonary Compliance, Exercise Capacity, and Clinical Outcomes | Background: While tricuspid annular plane systolic excursion (TAPSE) captures the predominant longitudinal motion of the right ventricle (RV), it does not account for ventricular morphology and radial motion changes in various forms of pulmonary hypertension. This study aims to account for both longitudinal and radial motions by dividing TAPSE by RV area and to assess its clinical significance. Methods: We performed a retrospective analysis of 71 subjects with New York Heart Association class II to III dyspnea who underwent echocardiogram and invasive cardiopulmonary exercise testing (which defined 4 hemodynamic groups: control, isolated postcapillary pulmonary hypertension, combined postcapillary pulmonary hypertension, and pulmonary arterial hypertension). On the echocardiogram, TAPSE was divided by RV area in diastole (TAPSE/RVA-D) and systole (TAPSE/RVA-S). Analyses included correlations (Pearson and linear regression), receiver operating characteristic, and survival curves. Results: On linear regression analysis, TAPSE/RVA metrics (versus TAPSE) had a stronger correlation with pulmonary artery compliance (r=0.48-0.54 versus 0.38) and peak VO2 percentage predicted (0.23-0.30 versus 0.18). Based on the receiver operating characteristic analysis, pulmonary artery compliance ≥3 mL/mm Hg was identified by TAPSE/RVA-D with an under the curve (AUC) of 0.79 (optimal cutoff ≥1.1) and by TAPSE/RVA-S with an AUC of 0.83 (optimal cutoff ≥1.5), but by TAPSE with only an AUC of 0.67. Similarly, to identify peak VO2 <50% predicted, AUC of 0.66 for TAPSE/RVA-D and AUC of 0.65 for TAPSE/RVA-S. Death or cardiovascular hospitalization at 12 months was associated with TAPSE/RVA-D ≥1.1 (HR, 0.38 [95% CI, 0.11-0.56]) and TAPSE/RVA-S ≥1.5 (HR, 0.44 [95% CI, 0.16-0.78]), while TAPSE was not associated with adverse outcomes (HR, 0.99 [95% CI, 0.53-1.94]). Among 31 subjects with available cardiac magnetic resonance imaging, RV ejection fraction was better correlated with novel metrics (TAPSE/RVA-D r=0.378 and TAPSE/RVA-S r=0.328) than TAPSE (r=0.082). Conclusions: In a broad cohort with suspected pulmonary hypertension, TAPSE divided by RV area was superior to TAPSE alone in correlations with pulmonary compliance and exercise capacity. As a prognostic marker of right heart function, TAPSE/RVA-D <1.1 and TAPSE/RVA-S <1.5 predicted adverse cardiovascular outcomes. Keywords: ROC curve; exercise tolerance; pulmonary arterial hypertension; pulmonary artery; right ventricular function. |
| 1.210 | Steven Ewer | CVM | smewer@medicine.wisc.edu | Abdominal STEMI: Ileus Presenting as Acute Coronary Syndrome | No abstract available |
| 1.211 | Ryan Kipp | CVM | rtkipp@medicine.wisc.edu | Pacemaker-mediated reentrant arrhythmia facilitated by an atrial-tracking leadless pacemaker | Introduction: Pacemaker-mediated tachycardia is a known arrhythmia in patients with dual chamber pacemakers and defibrillators and intact ventriculoatrial (VA) conduction. We report a case of pacemaker-mediated reentrant arrhythmia (PMRA) in a patient with an atrioventricular (AV) synchronous leadless pacemaker. Methods and results: A 91-year-old female presented with 2:1 AV conduction and received an AV synchronous leadless pacemaker. She had atrial mechanical sense-ventricular paced beats between heart rates of 80-100 bpm more than 80% of the time. She was found to have a new cardiomyopathy and was referred for placement of biventricular pacemaker. At the time of device implantation, her electrocardiogram showed ventricular pacing with a short RP interval and superiorly directed P waves. Changes in the ventricular pacing rate resulted in changes in the atrial rate. Following device placement, her heart rate decreased to the lower rate limit of her pacemaker. The atrial mechanical sense impulse most likely was generated by a retrograde conducted P wave resulting in near incessant PMRA. Conclusion: PMRA may occur in patients who receive an AV synchronous leadless pacemaker with intact VA conduction and sinoatrial node dysfunction. Due to the lower rates of PMRA, this arrhythmia may be underrecognized. Interventions for and implications of PMRA need further investigation. Keywords: AV synchronous leadless pacemaker; complete heart block; leadless pacemaker; pacemaker arrhythmia; pacemaker malfunction. |
| 1.212 | Sumona Saha | GI | ssaha@medicine.wisc.edu | Tutorial on adult enteral tube feeding: Indications, placement, removal, complications, and ethics | Enteral nutrition, generally preferred to parenteral nutrition, is indicated when patients cannot meet their energy and metabolic demands. Gastrostomy tubes are placed directly into the stomach (either endoscopically, surgically, or radiologically) through the abdominal wall. Routine gastrostomy tube care is important to maintain well-functioning tubes. Postpyloric feeding tubes are preferable to gastric feeding tubes if patients have a history of aspiration, gastroesophageal reflux, severe gastroparesis, and/or recurrent nausea and vomiting. Feeding jejunostomy tubes are placed surgically and are indicated if gastric feeding is unsafe or impossible. Dual-lumen gastrojejunostomy tubes are used when both gastric decompression and feeding are desired. The general risks of enteral tube feeding include diarrhea, metabolic derangements, and aspiration. Additional complications for gastrostomy tubes, which can arise at any time, include tube dysfunction (clogging or deterioration), infection, bleeding, peristomal leakage, ulceration, gastric outlet obstruction, and accidental removal. After percutaneous endoscopic gastrostomy placement, there are also early or late complications that may occur. Multiple factors should be considered in the decision-making process for feeding tube placement. It is important to be realistic about the patient's prognosis and goals and to discuss the risks and benefits ahead of time. Consultation with palliative care or clinical ethics specialists should be considered in certain clinical scenarios. Keywords: GI access; enteral access; enteral nutrition; gastroenterology. |
| 1.213 | John Rice | GI | jrice@medicine.wisc.edu | Early Liver Transplant for Alcohol-associated Liver Disease Has Excellent Survival but Higher Rates of Harmful Alcohol Use | Background & aims: Early liver transplantation (LT) for alcohol-associated liver disease (ALD) has increased worldwide. Short-term outcomes have been favorable, but data on longer-term outcomes are lacking. Methods: Single-center retrospective study of primary LT recipients between 2010 and 2020, with follow-up through July 1, 2022. Survival analysis was performed using log rank, Cox models, and Kaplan-Meier method. Cox models were created to identify variables associated with mortality; logistic regression to identify variables associated with post-LT alcohol use. Results: Of 708 patients who underwent LT, 110 (15.5%) had ALD and abstinence 6 months (SLT), and 364 (51.4%) had non-ALD diagnoses. Median follow-up was 4.6 years (interquartile range, 2.6-7.3 years). ELT recipients were younger (P = .001) with median abstinence pre-LT of 61.5 days. On adjusted Cox model, post-LT survival was similar in ELT and SLT (hazard ratio [HR], 1.31; P = .30) and superior to non-ALD (HR, 1.68; P = .04). Alcohol use (40.9% vs 21.8%; P < .001) and harmful alcohol use (31.2% vs 16.0%; P = .002) were more common in ELT recipients. Harmful alcohol use was associated with post-LT mortality on univariate (HR, 1.69; P = .03), but not multivariable regression (HR, 1.54; P = .10). Recurrence of decompensated ALD trended toward more common in ELT (9.1% vs 4.4%; P = .09). Greater than 6 months pre-LT abstinence was associated with a decreased risk of harmful alcohol use (odds ratio, 0.42; P = .001), but not in a multivariable model (odds ratio, 0.71; P = .33). Conclusions: Patients who undergo ELT for ALD have similar or better survival than other diagnoses in the first 10 years after LT despite a higher incidence of post-LT alcohol use. Keywords: Alcohol Use Disorder; Cirrhosis; End-stage Liver Disease; Liver Failure. |
| 1.214 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | A Practical Update on COVID-19 and Inflammatory Bowel Disease: COVID-19 Disease Risk and Vaccine Safety and Efficacy | The COVID-19 pandemic introduced significant uncertainty regarding the care of patients with inflammatory bowel disease (IBD). Substantial research efforts have made progress in answering many of the questions that arose, but the constantly shifting paradigm of COVID-19-related research and recommendations has made it challenging for IBD clinicians to remain up-to-date. The goal of this article is to provide a concise and practical summary of the literature evaluating COVID-19 disease risk in addition to COVID-19 vaccine safety, immunogenicity, real-world effectiveness, and uptake among patients with IBD. Keywords: COVID-19; Inflammatory bowel disease; cell-mediated immunity; humoral immunogenicity; uptake; vaccine. |
| 1.215 | Freddy Caldera | GI | fcaldera@medicine.wisc.edu | Patients With Inflammatory Bowel Disease Are at Increased Risk of Hospitalization Due to Respiratory Syncytial Virus | Introduction: Patients with inflammatory bowel disease (IBD) are at increased risk of developing respiratory infections. Respiratory syncytial virus (RSV) is a common respiratory virus with adverse outcomes in older adults. This study aimed to determine whether patients with IBD are at increased risk of a serious infection due to RSV. Methods: We conducted a retrospective study using the multi-institutional research network TriNetX to assess the risk of hospitalization in a cohort of patients with IBD compared with that in a non-IBD control cohort with RSV infection from January 1, 2007, to February 27, 2023. One-to-one (1:1) propensity score matching was performed for demographic variables and RSV risk factors between the 2 cohorts. Risk was expressed as adjusted odds ratio (aOR) with 95% confidence interval (CI). Results: There were 794 patients in the IBD-RSV cohort and 93,074 patients in the non-IBD-RSV cohort. The mean age of the IBD-RSV cohort was 55.6 ± 20 years, 59% were female, 80% were White, and 56.9% had Crohn's disease. The IBD-RSV cohort was at an increased risk of hospitalization (aOR 1.30, 95% CI 1.06-1.59). There was no difference in the risk (aOR 0.83, 95% CI 0.58-1.19) of a composite outcome of hospitalization-related complications between the 2 cohorts. Recent systemic corticosteroid use (<3 months) was associated with an increased risk of hospitalization (aOR 1.86, 95% CI 1.30-2.59) in the IBD-RSV cohort. Discussion: We found that adult patients with IBD and RSV infection are at an increased risk of hospitalization and may benefit from the new RSV vaccine recommended for adults aged 60 years and older. |
| 1.216 | Caldera, Freddy | GI | fcaldera@medicine.wisc.edu | Racial, Ethnic, and Geographic Disparities in Immunization Rates Among Patients With Inflammatory Bowel Disease | Background and aims: Racial and ethnic disparities exist in the treatment of IBD. These disparities exist in adult vaccine uptake among the general population and may extend to patients with IBD. The primary aim of this study was to determine whether racial, ethnic, or geographic disparities existed in influenza vaccine uptake among patients with IBD. Methods: We performed a multicenter, retrospective cohort study evaluating adult vaccine uptake among patients with IBD seen at two tertiary referral centers between September 2019 and February 2020. The primary outcome was to determine if racial/ethnic and geographic disparities existed in influenza vaccine uptake for the two prior seasons. Our secondary outcomes were to determine if disparities existed for pneumococcal, zoster, or hepatitis B vaccines. Results: Among the 2453 patients who met the inclusion criteria, most identified as non-Hispanic White (89.9%), were on immunosuppressive therapy (74.5%), and received the influenza vaccine in both seasons (56.0%). Older age (prevalence ratio (PR) 0.98; 95% confidence interval (95%CI) 0.98-0.99; P < .001) and non-Hispanic White patients (PR 0.76, 95%CI 0.59-0.98, P < 0.03) were significantly more likely to be immunized. Black patients (PR 1.37; 95%CI 1.18-1.59; P < .001) and those living in underserved geographic areas (PR 1.35; 95%CI 1.17-1.56; P < 0.001) were less likely to be immunized. Racial/ethnic and geographic disparities were identified for pneumococcal, zoster, and hepatitis B vaccine uptake. Conclusions: Racial and ethnic vaccination uptake disparities exist among patients with IBD; patients from medically underserved areas are also vulnerable to these disparities Studies identifying patient, provider, and system-level opportunities to address these disparities are needed. Keywords: inflammatory bowel diseases; influenza vaccine; pneumococcal vaccines; recombinant zoster vaccine. |
| 1.217 | Thomas C Friedrich | PATHBIO SCI | tfriedri@wisc.edu. | Persistent SARS-CoV-2 infection: significance and implications | SARS-CoV-2 causes persistent infections in a subset of individuals, which is a major clinical and public health problem that should be prioritised for further investigation for several reasons. First, persistent SARS-CoV-2 infection often goes unrecognised, and therefore might affect a substantial number of people, particularly immunocompromised individuals. Second, the formation of tissue reservoirs (including in non-respiratory tissues) might underlie the pathophysiology of the persistent SARS-CoV-2 infection and require new strategies for diagnosis and treatment. Finally, persistent SARS-CoV-2 replication, particularly in the setting of suboptimal immune responses, is a possible source of new, divergent virus variants that escape pre-existing immunity on the individual and population levels. Defining optimal diagnostic and treatment strategies for patients with persistent virus replication and monitoring viral evolution are therefore urgent medical and public health priorities. |
| 1.218 | Christopher Saddler | ID | csaddler@medicine.wisc.edu | Infective endocarditis is rare in patients with hematologic malignancy and neutropenia | Background: Infective endocarditis (IE) is a serious complication of bloodstream infections (BSIs) that occurs at variable rates depending on the pathogen and clinical setting. There is a paucity of data describing the risk of IE in patients with hematologic malignancy who develop bacteremia while neutropenic. Methods: Adult patients on the hematology ward from January 2018 to December 2020 with hematologic malignancy and bacteremia were evaluated retrospectively for endocarditis by applying the 2023 Duke-ISCVID criteria. Charts of possible cases were evaluated 90 days after the initial BSI for new infectious complications that could indicate missed IE. Descriptive statistics compared patients admitted for hematopoietic stem cell transplantation (HSCT) to those admitted for alternative reasons (non-HSCT). Results: Among the 1005 positive blood cultures initially identified, there were 66 episodes in 65 patients with hematologic malignancy and at least grade 3 neutropenia for a mean duration of 11.4 days during their admission. Transthoracic echocardiography (TTE) was performed in 34.8% of BSIs, and transesophageal echocardiography (TEE) in 6.1%. There were no new infectious complications in possible cases 90 days after their initial BSI. No cases of endocarditis were identified. Conclusions: Endocarditis is rare amongst patients with hematologic malignancy, bacteremia, and neutropenia, and no cases were identified in this cohort. The use of routine TTE in this setting seems unwarranted, and the addition of TEE is unlikely to improve patient-centered outcomes. Keywords: Duke's criteria; endocarditis; hematopoietic stem cell transplantation (HSCT); neutropenia. |
| 1.219 | Matthew M. Kalscheur | CVM | mmkalsch@medicine.wisc.edu | Evaluation of an adaptive, rule-based dosing algorithm to maintain therapeutic anticoagulation during atrial fibrillation ablation | Background: Cerebral thromboembolism during atrial fibrillation (AF) ablation is an infrequent (0.17%) complication in part owing to strict adherence to intraprocedural anticoagulation. Failure to maintain therapeutic anticoagulation can lead to an increase in events, including silent cerebral ischemia. Objective: To evaluate a computerized, clinical decision support system (CDSS) to dose intraprocedural anticoagulation and determine if it leads to improved intraprocedural anticoagulation outcomes during AF ablation. Methods: The Digital Intern dosing algorithm is an adaptive, rule-based CDSS for heparin dosing. The initial dose is calculated from the patient's weight, baseline activated clotting time (ACT), and outpatient anticoagulant. Subsequent recommendations adapt based on individual patient ACT changes. Outcomes from 50 cases prior to algorithm introduction were compared to 139 cases using the algorithm. Results: Procedures using the dosing algorithm reached goal ACT (over 300 seconds) faster (17.6 ± 11.1 minutes vs 33.3 ± 23.6 minutes pre-algorithm, P < .001). ACTs fell below goal while in the LA (odds ratio 0.20 [0.10-0.39], P 80.3 excellent). Preprocedure anticoagulant, weight, baseline ACT, age, sex, and renal function were potential predictors of heparin dose to achieve ACT >300 seconds and final infusion rate. Conclusion: A heparin dosing CDSS based on rules and adaptation to individual patient response improved maintenance of therapeutic ACT during AF ablation and was rated highly by nurses for usability. Keywords: Anticoagulation; Atrial fibrillation; Catheter ablation; Clinical decision support system; Implementation; Quality improvement. |
| 1.220 | Jennifer Wright | CVM | jmwright@medicine.wisc.edu | Wolff-Parkinson-White pattern in the setting of antibody-mediated rejection after heart transplant | No abstract available |
| 1.221 | Christie Bartels | Rheum | cb4@medicine.wisc.edu | Multiplicative Impact of Adverse Social Determinants of Health on Outcomes in Lupus Nephritis: A Meta-analysis and Systematic Review | Objective: Social determinants of health (SDoH) likely contribute to outcome disparities in lupus nephritis (LN). Understanding the overall burden and contribution of each domain could guide future health equity-focused interventions to improve outcomes and reduce disparities in LN. Objectives of this meta-analysis were to 1) determine the association of overall SDoH and specific SDoH domains on LN outcomes and 2) develop a framework for the multidimensional impact of SDoH on LN outcomes. Methods: We performed a comprehensive search of studies measuring associations between SDoH and LN outcomes. We examined pooled odds of poor LN outcomes including death, end-stage kidney disease, or cardiovascular disease in patients with and without adverse SDoH. Additionally, we calculated the pooled odds ratios of outcomes by four SDoH domains: individual (eg, insurance), health care (eg, fragmented care), community (eg, neighborhood socioeconomic status), and health behaviors (eg, smoking). Results: Among 531 screened studies, 31 meeting inclusion criteria and 13 with raw data were included in meta-analysis. Pooled odds of poor outcomes were 1.47-fold higher in patients with any adverse SDoH. Patients with adverse SDoH in individual and health care domains had 1.64-fold and 1.77-fold higher odds of poor outcomes. We found a multiplicative impact of having two or more adverse SDoH on LN outcomes. Black patients with public insurance and fragmented care had 12-fold higher odds of poor LN outcomes. Conclusion: Adverse SDoH is associated with poor LN outcomes. Having two or more adverse SDoH, specifically in different SDoH domains, had a multiplicative impact leading to worse LN outcomes, widening disparities. |
| 1.222 | Jane Churpek | HEM/ONC | jchurpek@wisc.edu | Implementation of a prospective screening strategy to identify adults with a telomere biology disorder among those undergoing lung transplant evaluation for interstitial lung disease | Introduction: Patients with interstitial lung disease (ILD) secondary to telomere biology disorders (TBD) experience increased morbidity after lung transplantation. Identifying patients with TBD may allow for personalized management to facilitate better outcomes. However, establishing a TBD diagnosis in adults is challenging. Methods: A TBD screening questionnaire was introduced prospectively into the lung transplant evaluation. Patients with ILD screening positive were referred for comprehensive TBD phenotyping and concurrent telomere length measurement and germline genetic testing. Results: Of 98 patients, 32 (33%) screened positive. Eight patients (8% of total; 25% of patients with a positive screen) met strict TBD diagnostic criteria, requiring either critically short lymphocyte telomeres (<1st percentile) (n = 4), a pathogenic variant in a TBD-associated gene (n = 1), or both (n = 3) along with a TBD clinical phenotype. Additional patients not meeting strict diagnostic criteria had histories consistent with TBD along with telomere lengths <10th percentile and/or rare variants in TBD-associated genes, highlighting a critical need to refine TBD diagnostic criteria for this patient population. Conclusion: A TBD phenotype screening questionnaire in patients with ILD undergoing lung transplant evaluation has a diagnostic yield of 25%. Additional gene discovery, rare variant functional testing, and refined TBD diagnostic criteria are needed to realize the maximum benefit of testing for TBD in patients undergoing lung transplantation. Keywords: Lung transplant; Pulmonary fibrosis; Telomere biology disorder. |
| 1.223 | Jane Churpek | HEM/ONC | jchurpek@wisc.edu | Implementation of and Systems-Level Barriers to Guideline-Driven Germline Genetic Evaluation in the Care of Patients With Myelodysplastic Syndrome and Acute Myeloid Leukemia | Purpose: Knowledge of an inherited predisposition to myelodysplastic syndrome (MDS) and AML has important clinical implications for treatment decisions, surveillance, and care of at-risk relatives. National Comprehensive Cancer Network (NCCN) guidelines recently incorporated recommendations for germline genetic evaluation of patients with MDS/AML on the basis of personal and family history features, but the practicality of implementing these recommendations has not been studied. Methods: A hereditary hematology quality improvement (QI) committee was formed to implement these guidelines in a prospective cohort of patients diagnosed with MDS/AML. Referral for germline genetic testing was recommended for patients meeting NCCN guideline criteria. Referral patterns and genetic evaluation outcomes were compared with a historical cohort of patients with MDS/AML. Barriers to evaluation were identified. Results: Of the 90 patients with MDS/AML evaluated by the QI committee, 59 (66%) met criteria for germline evaluation. Implementation of the QI committee led to more referrals for germline evaluation in accordance with NCCN guidelines (31% v 14%, P = .03). However, the majority of those meeting criteria were never referred due to high medical acuity or being deceased or in hospice at the time of QI committee recommendations. Despite this, two (17%) of the 12 patients undergoing genetic testing were diagnosed with a hereditary myeloid malignancy syndrome. Conclusion: Current NCCN guidelines resulted in two thirds of patients with MDS/AML meeting criteria for germline evaluation. A hereditary hematology-focused QI committee aided initial implementation and modestly improved NCCN guideline adherence. However, the high morbidity and mortality and prolonged inpatient stays associated with MDS/AML challenged traditional outpatient genetic counseling models. Further improvements in guideline adherence require innovating new models of genetic counseling and testing for this patient population. |
| 1.224 | Nataliya Uboha | HEM/ONC | nvuboha@medicine.wisc.edu | Targeted Agents in Esophagogastric Cancer Beyond Human Epidermal Growth Factor Receptor-2 | Gastroesophageal cancers are highly diverse tumors in terms of their anatomic and molecular characteristics, making drug development challenging. Recent advancements in understanding the molecular profiles of these cancers have led to the identification of several new biomarkers. Ongoing clinical trials are investigating new targeted agents with promising results. CLDN18.2 has emerged as a biomarker with established activity of associated targeted therapies. Other targeted agents, such as bemarituzumab and DKN-01, are under active investigation. As new agents are incorporated into the treatment continuum, the questions of biomarker overlap, tumor heterogeneity, and toxicity management will need to be addressed. Keywords: Biomarker; CLDN18.2; DKN-01; Esophageal cancer; FGFR2b; Gastric cancer; Gastroesophageal junction adenocarcinoma; Receptor tyrosine kinases. |
| 1.225 | Nataliya Uboha | HEM/ONC | nvuboha@medicine.wisc.edu | Current and Future Biomarkers in Esophagogastric Adenocarcinoma | Purpose: Biomarker-based therapies have shown improved patient outcomes across various cancer types. The purpose of this review to summarize our knowledge of current and future biomarkers in esophagogastric adenocarcinoma (EGA). Methods: In this publication, we will review current standard biomarkers in patients with upper GI cancers. We will also discuss novel biomarkers that are under investigations and their associated therapies that are currently in clinical trials. Results: EGAa are a group of heterogeneous diseases, both anatomically and molecularly. There are several established biomarkers (HER2, PD-L1, microsattelite instability or mismatch repair protein expression) that allow for individualized treatments for patients with these cancers. There are also several emerging biomarkers for EGA, some of which have clinically relevant associated therapies. Claudin 18.2 is the furthest along among these. Anti-claudin antibody, zolbetuximab, improved overall survival in biomarker select patients with advanced GEA in two phase 3 studies. Other novel biomarkers, such as FGFR2b and DKN01, are also in the process of validation, and treatments based on the presence of these biomarkers are currently in clinical studies. Conclusion: Ongoing efforts to identify novel biomarkers in EGA have led to enhanced subclassification of upper GI cancers. These advances, coupled with the strategic application of targeted therapies and immunotherapy when appropriate, hold promise to further improve patients outcomes. Keywords: Biomarker; Claudin 18.2; DKK1; DKN-01; Esophageal cancer; FGFR2b; Gastric cancer; Gastroesophageal junction adenocarcinoma; HER2; MMR; Microsatellite instability; PDL1 CPS. |
| 1.226 | Vincent Cryns | ENDO | vlcryns@medicine.wisc.edu | Nuclear Phosphoinositide Signaling Initiates the DNA Damage Response | Phosphoinositides (PIPn) lipids are known to accumulate at DNA damage sites suggesting a critical role in DNA damage repair. Nuclear phosphatidylinositol transfer proteins (PITPs) were recently shown to supply the stressinduced nuclear PIPn pools maintaining cellular homeostasis through Akt activation. PITPs can offer an enhanced platform to investigate the connections between the DNA damage response (DDR) and PIPns through their largely unconsidered role in the nucleus. The goal of this study is to investigate the role of PITP-dependent nuclear PIPn signaling in DNA damage response and repair mechanisms. Non-targeting and PITPα/β specific siRNA were used as a control and for PITPα/β knockdown in breast cancer cells. Cisplatin was used to induce genotoxic stress. Immunoprecipitation and proximity ligation assay was used to investigate protein-protein interactions and protein-lipid linkages. Protein-lipid complexes were further validated by fluorescent Western Blot. We show the correlation between the nuclear PI(4,5)P2 pool and the DDR marker, γ-Η2Α.Χ. Additionally, these nuclear PI(4,5)P2 puncta colocalize with phosphorylated ATM, ATR, and DNA-PK, which initiate the DDR. Class I PITP α/β, which are necessary to generate PIPn pools in the nucleus, mediate the generation of γ-Η2Α.Χ upon genotoxic stress in multiple cancer cell lines. Individual knockdown of either PITPα or PITPβ decreases Η2Α.Χ phosphorylation but increases cisplatin-induced DNA damage as determined by comet assay. These effects were dramatically augmented by combined knockdown of PITPα/β. Intriguingly, PIPns tightly bind to key components of the DDR, including PARP1 and Ku80, which recruit DDR kinases to sites of DNA damage, and these interactions are enhanced by genotoxic stress effecting downstream functions. These results expound upon the functional relationship between the DDR and nuclear PIPns and describe the first connection between PITPs and DNA damage signaling further validating a critical role for PITPs in the nucleus. Mechanistically, these data demonstrate that the stress-induced and PITP-dependent nuclear PIPn pool correlates with DDR machinery and tightly associates with DDR components effecting repair capacity. As such, they point to PITPs as novel drug targets in cancer to disrupt the DDR and enhance chemotherapeutic-induced genotoxic stress. |
| 1.227 | Nathan Sandbo | APCCM | nsandbo@medicine.wisc.edu | The Role of Bromodomain-Containing Protein 4 (Brd4) in myofibroblast differentiation by Transforming Growth Factor Beta 1 | Rationale: Idiopathic Pulmonary Fibrosis (IPF) is a progressive and deadly lung disease characterized by excessive accumulation of extracellular matrix (ECM), which leads to lung tissue stiffening and impaired function. Recent studies have highlighted the role of Brd4, an epigenetic reader that regulates profibrotic gene expression, in IPF pathogenesis. In this study, we employed both in vivo and in vitro models to investigate Brd4’s involvement in lung fibrosis. For in vivo experiments, we used transgenic mice with inducible Brd4 knockout, either globally or in PDGFRβ+ mesenchymal cells, to assess Brd4's role in bleomycin-induced lung fibrosis. In vitro, we utilized primary lung fibroblasts to examine Brd4’s role in fibroblast activation, proliferation, and ECM production. This combined approach offers a comprehensive evaluation of Brd4’s contribution to the fibrotic processes in IPF. Methods: Mice expressing tamoxifen-inducible Cre-recombinase either globally (B6.129-Gt(ROSA)26Sortm1(cre/ERT2)Tyj/J) or specifically in PDGFRβ+ mesenchymal cells (B6.Cg-Pdgfrbtm1.1(cre/ERT2)Csln/J) were utilized. We crossed these mouse lines with the Brd4f,f line to generate Rosa-Cre/Brd4f,f and PDGFRβ-Cre/Brd4f,f lines, enabling either global or PDGFRβ+ lineage-specific Brd4 knockout. Mice (10-14 weeks old) were treated with a single intratracheal bleomycin dose (1U/kg) to induce fibrosis or normal saline as control. Fourteen days later, Lung and tail samples were collected for genotyping, gene, and protein analysis. Ashcroft scores were assigned to trichrome-stained lung sections to quantify collagen deposition. In vitro, we used siRNA-mediated Brd4 knockdown in human lung fibroblasts treated with Transforming Growth Factor Beta 1 (TGF-β1) to investigate Brd4’s role in fibroblast activation. Statistical analyses were performed using one-way ANOVA. Results: We successfully generated Rosa-Cre/Brd4f,f mice, confirming temporally controlled Cre-induced Brd4 knockout. We show that PDGFRβ-positive mesenchyme expands by day 14 post-bleomycin injury and that mice lacking Brd4 in PDGFRβ+ cells demonstrated a decrease in fibrotic markers, including the marker of synthetic mesenchyme, CTHRC1. Some Ashcroft scoring indices suggested an improvement in lung fibrosis post-bleomycin treatment in mice lacking Brd4 in PDGFRβ+ mesenchyme. In fibroblast cultures, Brd4 knockdown inhibited TGF-β1-induced myofibroblast differentiation, as evidenced by decreased α-SMA expression, a key marker of myofibroblast activation. In addition, reduced phalloidin signal by ICC in Brd4 knockout cells suggested the diminished F-actin polymerization and impaired cytoskeletal reorganization in TGFβ induced cells. Conclusion: Our findings suggest that Brd4 plays a significant role in both PDGFRβ+ mesenchymal cells and primary human lung fibroblasts in the development of lung fibrosis. By utilizing temporally controlled and lineage-specific Brd4 knockouts, we provide evidence that targeting Brd4 in mesenchymal cells may represent a promising therapeutic strategy for IPF. |
| 1.228 | John P Sheehan | HEM/ONC | jps@medicine.wisc.edu | Collagen IV and Heparin-binding Sites Independently Contribute to the Extravascular Binding and Activity of Human Factor IX(a) | Introduction: Factor IX (FIX) is unique among vitamin K-dependent coagulation factors in that a substantial portion is bound to extravascular sites. The extravascular compartment of the hemophilia B (HemB) mouse binds ~3-fold more FIX than is present in the plasma compartment. This extensive extravascular binding is responsible for the poor plasma recovery observed during FIX replacement therapy in hemophilia B patients. Extravascular FIX also appears to make significant contributions to in vivo hemostasis. Methods: Purified recombinant human FIX variants with decreased (K5A) or increased (K5R) collagen IV binding (Gla domain) were evaluated alone or in combination with the reduced heparin affinity variant K126A/K132A (protease domain) to assess effects on extravascular binding of FIX(a). FIX variants were expressed in VKOR-293 cells and purified to homogeneity. Zymogen activation by FXIa, enzymatic characterization of protease, coagulant activity and tissue factor (TF)-triggered plasma thrombin generation were evaluated as previously described (Westmark et al. J.Throm Haem 2015). Pharmacokinetics (PK) of FIX and FIXa variants were characterized in HemB and HemA mice, respectively, following tail vein injection (N=5- 10 mice/variant), retro-orbital blood sampling and determination of FIX(a) concentration by human FIX(a)- specific ELISA. PK of FIX(a) variants were fit to a 2-compartment model and plasma volume of 40 ml/kg BW. Results: FIXa variants all had similar catalytic efficiency (kcat/Km) for peptide substrate. FIXa-FVIIIa affinity ranked FIXa variants as follows: K5R > WT > K5R/K126A/K132A > K5A > K126A/K132A > K5A/K126A/K132A; with Kd(app) ranging 0.9 to13.3 nM and similar Bmax for all (~25-27 nM/min). FX activation showed similar Km (14-24 nM) and kcat (2.9-5.3 sec-1) for all FIXa variants. FIX/FIXa coagulant activity was: WT 100/100%, K5A 44/48%, K5R 87/201%, K126A/K132A 16/14%, K5A/K126A/K132A 5.2/6.3% and K5R/K126A/K132A 24/39%. TF-triggered (0.2 pM) peak thrombin values for 90 nM FIX variants in FIX deficient plasma were: WT 72 nM, K5A 71nM, K5R 182 nM, K126A/K132A 23 nM, K5A/K126A/K132A 22 nM and K5R/K126A/K132A 60 nM. FIX (HemB mice) and FIXa (HemA mice) WT demonstrated biphasic clearance with poor plasma recovery at 2 min. FIX WT demonstrated ~15% recovery of the total dose in the plasma. FIX K5A enhanced (39%) and FIX K5R reduced (8%) plasma recovery. The FIX K126A/K132A heparin-binding variant increased (37%) plasma recovery, FIX K5A/K126A/K132A showed an additive increase (60%), while FIX K5R/K126A/K132A reduced (25%) recovery relative to FIX K126A/K132A. In HemA mice, FIXa WT recovery (16%) at 2 min was similar to zymogen. FIXa K5A (42%), K5R (29%) and K126A/K132A (40%) all enhanced protease recovery. FIXa K5A/K126A/K132A (76%) and FIXa K5R/K126A/K132A (54%) variants demonstrated additive effects on protease recovery. Conclusions: Gla domain K5A/R substitutions in the collagen IV site had opposing effects on cofactor affinity, coagulant activity and thrombin generation, either alone or combined with the K126A/K132A protease domain variant. PK of FIX(a) variants demonstrated biphasic clearance and poor recovery of WT proteins, consistent with extravascular binding of both zymogen and protease. Disruption of collagen (Gla domain) and heparin (protease domain) binding sites had additive effects on plasma redistribution, emphasizing the extensive interaction of FIX(a) with the extravascular compartment. Unexpectedly, the FIX(a) K5R zymogen demonstrated decreased plasma recovery, while the protease showed increased recovery, suggesting a conformational effect. These results demonstrate the potential importance of extravascular binding of human FIX(a) in the local regulation of both hemostasis and thrombosis. |
| 1.229 | Toby Campbell | HEM/ONC | tcc@medicine.wisc.edu | One shot to get it right: the experiences of donation request specialists and donor families with donation conversations | Introduction: Although public awareness of organ donation and transplantation is relatively high, there remains a significant gap in understanding the complexities of the donation process, the lived experiences of the healthcare teams, and the challenging conversations required to help a family say “Yes” to donating an organ. The present study is part of a larger health dissemination project that aims to highlight the lived experiences of everyone involved in the donation and transplantation process through a documentary-style podcast. The goal of this study is to provide an in-depth examination of strategies used by donation request specialists (DRS) when approaching donor families and the experiences of families with these interactions. Methods: Two DRS recruited from a major organ procurement organization and three donor family dyads participated in separate unstructured interviews designed to uncover the communication strategies used by DRS to obtain donor families consent for donation and understand the families’ experiences with these strategies. Interviews were audiorecorded, transcribed verbatim, and analyzed using an inductive thematic analytic approach. Results: Analysis of DRS interviews revealed a three-step approach to obtaining consent: Preparation before the request, Making the request, and Decision support after the request. Specifically, Preparation includes understanding the donor family’s background, family dynamics, and their readiness for the conversation before the meeting. Making the Request includes a gradual time-sensitive approach that focuses on creating a supportive environment, assessing the family’s needs and acknowledging their emotions, gathering information on the donor and their wishes, educating families on the donation process and benefits of donation, and addressing their questions. Decision support after the Request includes maintaining open communication with requesters, encouraging families to reflect on their personal values and the implications of their decision, and messages focused on praise and positive reinforcement for the family. Donor families' experience with the organ request was very positive. They appreciated DRS's compassion and supportive communication style. Other aspects that families valued include the ability to contact DRS with questions at any time, being given adequate time to make a decision, and the positive remarks made by staff throughout the process. Discussion: The present study provides a detailed examination of effective strategies used by DRS and their impact on donor families’ donation experience. These strategies can be adopted in other healthcare settings that aim to provide compassionate care for families and donors. Future studies need to evaluate the impact of the podcast content on the public’s knowledge about donation and their willingness to become donors. |
| 1.230 | Alexey Glukhov | CVM | aglukhov@medicine.wisc.edu | SK channel enhancement suppresses atrial ectopy and normalizes heart rhythm in calsequestrin 2 null mouse model of AF | Proarrhythmic atrial ectopy which triggers atrial fibrillation (AF), the most common form of abnormal cardiac rhythm, has been linked to Ca2+ mishandling due to leaky ryanodine receptors. Recent findings indicate that enhancement of small conductance Ca2+ activated K+ (SK) channels located at mitochondrial membrane (mSKs) attenuates sarcoplasmic reticulum Ca2+ leak via suppression of Ca2+ leak‑induced mitochondrial reactive oxygen species (ROS) production. Here, we determined whether SK channel enhancement suppresses Ca2+-dependent pro-arrhythmic atrial ectopy in calsequestrin 2 null (Casq2−/−) mouse model of AF (PMID:25384790). High-resolution optical mapping of electrical activity was performed from isolated atrial preparations of 12-months-old wild type (WT, n=9) and Casq2−/− mice, at baseline and after isoproterenol stimulation (ISO, 50 nM) without and with pre-treatment with SK channel enhancer NS309 (2 mM). At baseline, Casq2−/− mice demonstrated a slower spontaneous atrial beating rate compared to WT mice (349±20 bpm vs. 425±25 bpm, P=0.029) which was associated with significantly elevated beat-to-beat heart rate variability and enhanced atrial ectopy (arrhythmia index, AI: 1.0±0.3 in WT vs. 1.7±0.2 in Casq2−/−, P=0.056). During sympathetic stimulation, Casq2−/− mice showed a blunted beating rate response (550±21 bpm vs. 640±21 bpm in WT, P=0.025), with a trend for a higher atrial ectopy (AI: 3.2±0.5 in Casq2−/− vs. 1.9±0.6 in WT, P=0.057). NS309 abolished the difference in heart rhythm between groups, both at baseline and under sympathetic stimulation, and decreased heart rhythm variability and significantly suppressed arrhythmogenic atrial ectopy in Casq2−/− mice (AI: 0.7±0.3 after NS309+ISO vs. 3.2±0.5 after ISO alone, P=0.006). In conclusion, SK channel enhancement could suppress pro-arrhythmic atrial ectopy and normalize heart rhythm in the setting of pathologically leaky ryanodine receptors. Our findings support a potential cross-talk between mitochondrial ROS and sarcoplasmic reticulum Ca2+ leak, highlighting mitochondrial SK channels as a potential target for atrial arrhythmia treatment. |
| 1.231 | Sandesh Parajuli | NEPH | sparajuli@medicine.wisc.edu | The Association of 25-Hydroxyvitamin D Levels with BK Viremia and Nephropathy in Kidney Transplant Recipients | Introduction. BK virus reactivation and subsequent viremia (BKPyV) and nephropathy (BKPyVAN) are significant causes of morbidity and mortality in kidney transplant recipients (KTRs). Limited treatment options make these complications particularly detrimental. Vitamin D supports immune function, yet low 25-hydroxyvitamin D [25(OH)D] is common among KTRs. The association between 25(OH)D and BKPyV and BKPyVAN in KTRs remains undefined. Methods. The association between serum 25(OH)D, measured 61 days to 2 years post-transplant, and subsequent incident BKPyV and BKPyVAN was examined in 2938 and 3308 KTRs without previous BKPyV or BKPyVAN, respectively. The study population was selected from the Wisconsin Allograft Recipient Database (WisARD), including recipients who received kidney only transplants from 2000 to 2020. KTRs were followed from their first eligible 25(OH)D measurement until the first instance of BKPyV or BKPyVAN or for a maximum of 3 years. Results. Out of 3308 KTRs, 399 (12%) were vitamin D deficient [25(OH)D S20 ng/ml] and 916 (27.7%) were insufficient [25(OH)D 21-29 ng/ml]. A total of 184 KTRs developed BKPyV and 44 developed BKPyVAN. The incidence rate (/100 person-years) of BKPyV was 2.88 in the 25(OH)D sufficient group, 2.22 in the insufficient group, and 2.37 in the deficient group. Vitamin D deficiency or insufficiency was not significantly associated with incidence of BKPyV after adjustment for baseline characteristics. In contrast, the incidence rate of BKPyVAN was 0.30 in the 25(OH)D sufficient group, 0.75 in the insufficient group, and 1.28 in the deficient group. 25(OH)D deficiency (adjusted hazard ratio [aHR] compared to 25[OH]D sufficiency: 3.92; 95% Cl: 1.66-9.23) and insufficiency (aHR: 2.22; 95% Cl: 1.11-4.45) were significantly associated with increased risk for BKPyVAN in adjusted models. Discussion. Low 25(OH)D level after kidney transplantation is associated with increased risk of BKPyVAN but not BKPyV. These findings reinforce the role of vitamin D in immune function, highlighting the importance of further research to explore the significance of vitamin D levels in transplant recipients and the effects of vitamin D supplements to mitigate complications associated with BKPyVAN. |
| 1.232 | Michelle E Kimple | ENDO | mkimple@medicine.wisc.edu | Gαz Regulates Islet Hormone Secretion in a Mouse Model of Type 1 Diabetes | Type 1 diabetes (T1D) is a disease of decreased functional beta-cell mass and impaired hormone secretion following immune infiltration to the pancreatic islet. Beta-cell proliferation, survival, and insulin secretion are regulated by G protein coupled receptors (GPCRs) that act through specific G proteins to regulate cellular second messenger levels like cyclic adenosine monophosphate (cAMP). Beta-cell cAMP potentiates insulin secretion and enhances proliferation and survival. Beta-cell cAMP production is stimulated by Glucagon-like peptide-1 receptor (GLP-1R) via Gs activity and inhibited by Prostaglandin EP3 receptor (EP3) via Gz activity. Previous work with the non-obese diabetic (NOD) mouse model of T1D revealed Gz contributes to disease progression, as mice lacking the catalytic alpha subunit Gɑz are protected from developing diabetes. Presence or absence of Gɑz does not impact glucose-stimulated insulin secretion (GSIS), but in female NOD mice Gɑz loss partially restores a defect in the potentiating effect of a GLP-1R agonist on GSIS. Delta-cells within the islet express GLP-1R, and GLP-1R activity potentiates glucose-stimulated somatostatin secretion (GSSS). Notably, islets from Gɑz-null mice exhibit greater GLP-1R agonist potentiation of GSSS compared to WT controls. This finding may be due to increased delta-cell GLP-1R expression in Gɑz-null mice compared to WT: a hypothesis we are testing by immunofluorescence experiments. Alternatively, Gɑz may be expressed in the delta-cell and have direct effects on somatostatin secretion: a hypothesis supported by previous immunohistochemical analyses. Regardless of the underlying mechanisms our experiments have revealed a critical role for Gɑz in regulating islet hormone secretion and susceptibility to T1D. |
| 1.233 | Sally Jolles | ID | sajolles@medicine.wisc.edu | Surveying Antibiotic Risk: Results from a Survey Exploring Negative Health Symptoms and Quality of Life Following Antibiotic Use among adult patients with Ehlers-danlos syndromes & Hypermobility spectrum disorders in Wisconsin | Introduction: The adverse effects of fluoroquinolone (FQ) antibiotic toxicity on musculoskeletal tissue has been well-documented, indicating a heightened risk of tendinitis, tendon rupture, and aortic aneurysm. In 2008, the US Food and Drug Administration (FDA) began documenting these risks in black box warnings including a 2018 warning advising against prescribing FQ to patients with “certain genetic conditions such as Marfan syndrome and Ehlers-Danlos syndrome.” Despite these warnings, research into the prevalence at which FQ are prescribed or the impact of adverse effects of FQ within Ehlers-Danlos syndromes (EDS) or Hypermobility spectrum disorders (HSD) communities remains extremely limited. To answer these research questions, we conducted a cross-sectional observational survey of EDS and HSD patients in Wisconsin. Methods: The study team developed a survey using a systematic literature review on FQ and connective tissue disorders3 and iterative patient stakeholder feedback. Wisconsin adults (>18 years) with self-confirmed EDS or Hypermobility spectrum disorder (HSD) diagnoses were recruited using non-probability convenience snowball sampling from a Wisconsin-based online patient and family support group. Using an online survey, Participants were asked using an online survey how often they had been prescribed antibiotics (including FQ), whether they had experienced any negative health symptoms, and asked to describe their symptoms, the types of health care utilized, and the impact on their quality of life. Results: 97 participants completed the survey. 76% of participants were diagnosed with Hypermobile EDS, 17% with HSD, 6% with Classical EDS, and 1% with Cardiac-valvular EDS. Demographics for participants are described in Table 1. 89% (n=85) of participants who completed the survey reported receiving antibiotics in their lifetime while 11% (n=11) had not. Of the 87 participants that received antibiotics, 55% (n=48) reported being prescribed a FQ while 45% (n=39) had been prescribed non-FQs only and 70% (n=61) experienced negative health symptoms to at least one antibiotic. 46% (n=22) of the 48 participants who had been prescribed a FQ reported experiencing negative health symptoms after taking at least one FQ. Participants who experienced negative health symptoms after taking a FQ, were prescribed 4.5 FQs on average in their lifetime, with 1.7 FQs of those causing negative health symptoms. 26% (n=5) of participants stated that their experience related to taking a FQ had a severe or major impact on their quality of life (QOL), 37% (n=7) of participants stated it had a moderate impact, while 21% (n=4) of participants said their experience had a minimal impact. 16% (n=3) stated that their experience taking a FQ had no impact on their QOL. Discussion: The findings from our survey of adults with EDS and HSD living in Wisconsin highlight a potentially concerning prevalence of adverse health effects associated with FQ use that warrants further investigation. While the majority of participants experienced moderate to severe impacts on their QOL, the variability in response suggests potential underlying factors. A future analysis will explore whether certain types of adverse reactions and FQs are associated with QOL severity scores. Given the high prevalence of antibiotic reactions reported by participants, future research should also explore the mechanisms underlying adverse responses to both FQ and non-FQ antibiotics. Further studies are also needed to investigate the long-term outcomes of repeated FQ use in individuals with EDS and HSD. |
| 1.234 | Michael Eberlein | APCCM | meberlein@medicine.wisc.edu | Chest Wall Strapping in a Porcine Model: A Model for the Physiology of the Oversized Lung Allograft | Introduction: Restrictive lung disease (RLD) is the leading indication for lung transplantation. Donor-to-recipient size matching is challenging in RLD, especially oversizing. Chest-Wall-Strapping (CWS) is a technique forcing the lung to operate at lower volumes. Methods: We developed a porcine model of CWS to investigate limits of oversizing. Farm-raised pigs were intubated and mechanically ventilated. Computer tomography (CT) Scans were obtained in control and CWS-conditions. Results: CT volumetry demonstrated that Total Lung Volume (TLV) at 25cmH2O end-expiratory pressure was 1204mL at baseline. Application of increasing doses of CWS reduced TLV to 879mL (CWS-cuff inflated to 35mmHg) and reduced TLV to 620mL (CWS-cuff inflated to 50mmHg), Figure 1. At 50mmHg of CWS (50% TLV reduction) atelectasis of the lung bases was evident. Lung elastance was increased with CWS. CT lung-density at 35mmHg CWS (30% reduction in TLV) was normal for the inflation state of the lung. Discussion: Physiological limits of oversizing should be considered for optimal lung function. In future studies, the identification of a possible defined inflection-point for the physiological limits and characterization of the lung structure-function relationship and gas exchange efficiency when forcing the lung to operate at lower volumes via CWS could further inform acceptable ranges for size matching in lung transplantation. |
| 1.235 | Priyanka Pophali | HEM/ONC | ppophali@medicine.wisc.edu | Palliative care and hospice utilization in patients with refractory or relapsed diffuse B-cell lymphoma in the era of novel therapies | Background: Around 40% of patients with diffuse large-B cell lymphoma (DLBCL) experience relapsed/refractory (r/r) disease and have very poor prognosis. Since 2018, the availability of chimeric antigen receptor T-cells (CART) and other therapies targeting CD19, CD20, and CD79b have expanded treatment options for patients with r/r DLBCL. Despite this, most patients with r/r DLBCL die from their disease and palliative care (PC)/hospice remain integral to their care. This study aimed to assess the changes in PC/hospice utilization before and after the introduction of CART at our institution (1/1/2018). Methods: Electronic medical records at a single center were retrospectively reviewed for deceased patients with r/r DLBCL. Patients were excluded if they died without active lymphoma or if they were referred to PC/hospice for a reason unrelated to lymphoma diagnosis. Demographic, clinical, and PC and hospice utilization characteristics were extracted and compared using descriptive statistics. Results: We identified 87 patients who had first r/r DLBCL between 1/1/2010 – 12/31/2017 (pre-CART era) and 95 patients between 1/1/2018 – 9/10/2024 (post-CART era). There were no differences in age, gender, stage, LDH, CNS involvement, IPI score at diagnosis or lines of therapy received in the pre- and post-CART era (p > 0.05). PC referral/consult rates were 57.5% in the pre-CART era and 68.4% in the post-CART era (p-value = 0.715). In the pre-CART era, 78.2% had hospice referral/consult compared with 80% in the post-CART era (pvalue = 0.433). Median time from last treatment to death was 95 (IQR 44-278) days in the pre- CART era and 51 (IQR 18-132) days in the post-CART era (p = 0.001). Conclusions: Overall rates of PC and hospice utilization at our institution have remained similar for patients with r/r DLBCL before and after the availability of CART and novel therapies. The time from last treatment to death is shorter in the post-CART era, reflecting the increase in treatment options for r/r DLBCL. While most patients received PC and hospice referrals, 20-30% of patients were not referred to these services, demonstrating a continued need to optimize end of life services to improve quality of life in patients with r/r DLBCL. |
| 1.236 | Jacqueline Kruser | APCCM | jkruser@wisc.edu | ICU Transfer Through the COVID-19 Pandemic: Characterizing an Informal ICU Transfer Network From 2018 Through 2024 | INTRODUCTION: The transfer of critically ill patients relies on informal networks and relationships between institutions,1 many of which have been interrupted by the COVID-19 pandemic and its aftermath. Barriers to timely transfer appear to disproportionately impact rural “sending” hospitals over similarly sized urban facilities.2 In order to better identify factors affecting the transfer of critically ill patients, we sought to characterize the evolution of transfer traffic during and after the COVID-19 pandemic. METHODS: Utilizing a dataset of 2276 ICU-level transfers to a Midwest academic medical center from January 2018 through July 2024, we identified geographic & demographic characteristics of sending faculties requesting transfer of patients. We further identified cases of respiratory failure requiring mechanical ventilation and requests for ECMO candidacy consideration to define the pre- and post-pandemic burden. RESULTS: During the study period 118 facilities transferred critically ill patients to the receiving center (RC), with the majority of patients arriving from only 13 hospitals (1,154 of 2276, 50.7%), and 64.8% from the top 20 sending hospitals. 12 of these 20 hospitals are within census designated rural areas,3 and 3 designated as critical access hospitals by Centers for Medicare & Medicaid Services (CMS). Transfers for ECMO support of respiratory failure were rare (50/2276), although requests rose through the COVID-19 pandemic (6 in 2019 to 89 in 2021). Though requests for ECMO support arrived from a more diverse cohort of hospitals, the majority of patients accepted (29/50, 58%) arrived from the sites comprising the 20 most frequent sending facilities. During and after the COVID-19 pandemic, overall transfer traffic declined significantly with significant changes between referring centers. DISCUSSION: The transfer patterns of the studied midwestern academic medical center exhibit patterns consistent with a network that is only partially formalized, suggesting that a combination of geographic, organizational, and historical factors drive transfer traffic. This analysis identifies trends among sending facilities and changes since the COVID- 19 pandemic that may be studied further in order to identify clinician and health-system level barriers to inter-ICU transfer. |
| 1.237 | Nathan Sandbo | APCCM | nsandbo@medicine.wisc.edu | Knockdown of GFPT2 in Human Lung Fibroblasts Reduces Myofibroblast Gene Signature and Decreases Matrix Protein Expression | Introduction: Idiopathic pulmonary fibrosis is a deadly and progressive disease affecting three million people worldwide, and is characterized by fibroblast to myofibroblast transitioning as well as excess extracellular matrix deposition (ECM). The Hexosamine Biosynthetic Pathway (HBP) plays a crucial role in ECM remodeling. Glutamine-fructose-6-phosphate transaminase 2 (GFPT2) is a rate-limiting enzyme in the HBP which results in the addition of the GlcNAc post translational modification. GlcNAcylation is known to modulate protein function, and in particular, ECM proteins. We hypothesize that knockdown of GFPT2 will downregulate ECM protein expression. Methods: Human lung fibroblasts (HLFs) were treated with or without transforming growth factor-beta1 (TGF-β1), a known pro-fibrotic activator of fibroblasts, and knockdown of GFPT2 in HLFs was facilitated by treatment with shRNA lentivirus. Matrix protein gene expression was characterized using RT-qPCR by probing for fibronectin (FN) and collagen (Col1a1), classical markers of ECM. Myofibroblast associated gene expression was characterized using RT-qPCR for the following genes: alpha smooth muscle actin (⍺SMA), tenascin-C (TNC), a known matrix adhesion protein CD44, and an essential gene in the fibroblast-myofibroblast transition TNS1. Matrix protein expression was characterized via western blotting for FN. Results: GFPT2 knockdown in HLFs resulted in statistically significant decreases in fibronectin and collagen expression as measured by qPCR. Additionally, we found that ⍺SMA, TNC, and TNS1 were all also significantly down with GFPT2 knockdown as determined by qPCR. We also found that fibronectin protein expression was decreased as measured by western blot analysis. Conclusion: Human lung fibroblasts treated with GFPT2 shRNA showed decreased matrix protein gene expression such as FN and collagen. These data suggest that there is a direct link between GFPT2 expression and matrix proteins and, given the importance of these two ECM proteins in IPF, GFPT2 modulation could serve as a potential therapeutic target. |
| 1.238 | Farhan Raza | DOM | fraza@medicine.wisc.edu | Effect of Sirolimus in Preventing Pulmonary Hypertension Post-Heart Transplant | Introduction: Pulmonary hypertension (PH) is a common complication following heart transplantation, contributing to significant morbidity and mortality. Preclinical studies suggest that inhibitors of mTOR (mechanistic target of rapamycin) signaling pathway can prevent PH by reducing pulmonary vascular remodeling. In this study, we define the effect of mTOR inhibitor Sirolimus on cardiopulmonary hemodynamics in heart transplant recipients using serial right heart catheterization (RHC) measurements. Methods: In this retrospective cohort study, 25 heart transplant recipients were included who were started on Sirolimus post-transplant and had three serial RHC procedures (1. baseline study before Sirolimus start, 2. One-year post-sirolimus, 3. Two-years post-sirolimus). The median (IQR) time from transplant to sirolimus start was 459 (271) days. The median time from sirolimus start to the first RHC was 290 (145) days and the second RHC was 685 (490) days. Results: Age (mean±SD) was 55±10 years and 28% were female. The prevalence of significant comorbidities were: diabetes 48%, chronic kidney disease 84%, hyperlipidemia 68%, chronic obstructive lung disease 4%, interstitial lung disease 4% and obstructive sleep apnea 4%. On baseline RHC, mean pulmonary artery pressure (mPAP) was 26.4±6.4 mmHg, pulmonary artery wedge pressure (PAWP) was 16.0±4.6 mmHg, cardiac index (CI) 2.9±0.5 (L/min) and pulmonary vascular resistance (PVR) was 1.9±0.6 Woods unit (WU). First follow-up RHC (nearly 1-year follow-up) revealed mPAP 25.9±5.8 mmHg, PAWP 15.8±5.3 mmHg, CI 3.0±0.5 L/min, and PVR 1.8±0.6 WU. There was a median decrease of mPAP= -0.2 mmHg (IQR -2.8). Second follow-up RHC (nearly 2-years follow-up) revealed mPAP 26.5±6.2 mmHg, PAWP 16.3±5.3 mmHg, CI 2.8±0.5 L/min and PVR 1.8±0.5 WU. The median decrease in mPAP from baseline RHC was -1.5 mmHg (IQR -4.5). Conclusion: Sirolimus appears to exert a stabilizing effect on pulmonary pressures post-heart transplant, with minimal progression of mPAP over time. This suggests that sirolimus may prevent worsening PH and pulmonary vascular remodeling. |
| 1.239 | Dustin Deming | HEM/ONC | ddeming@medicine.wisc.edu | Alpha-2-macroglobulin in the tumor microenvironment of pancreatic ductal adenocarcinoma to regulate versican proteolysis | Introduction: Versican (VCAN), a large chondroitin sulfate matrix proteoglycan upregulated in pancreatic ductal adenocarcinoma (PDAC), plays an immunosuppressive role whereas the VCAN V1 isoform cleavage product (cleaved by ADAMTS proteases 1, 4, 5, 9, 15 and 20) versikine is known to be immunostimulatory. PDAC displays poor VCAN proteolysis and CD8+ T-cell infiltration, but interestingly overexpresses ADAMTS proteases. Alpha-2-macroglobulin (A2M) may be overexpressed in the PDAC tumor microenvironment and a potential mechanism of inhibition of ADAMTS proteases, which is investigated here. Methods: The PDAC TCGA PanCancer Atlas dataset was used to compare relative levels of ADAMTS protease expression at the bulk RNA seq level and a Tumor-Normal-Metastasis (TNM) plot was used to compare levels of ADAMTS proteases between normal adjacent (NA) and tumor tissues. Patient-derived tissue microarrays (TMAs) (n=66) were used to correlate VCAN proteolysis, ADAMTS 4 and 5 as well as A2M expression. To explore the causative link between A2M and VCAN proteolysis, a major drawback of the well-studied Pan02 injectable model of PDAC is the lack of intense desmoplasia seen in the TME of human PDAC. To overcome this limitation, KPC tumor organoids and cancer-associated fibroblasts (1:10) were co-allografted into the flanks of B6 mice, followed by validation of cytokeratin-17/19 and alpha-smooth muscle actin expression using immunohistochemistry. Results: ADAMTS 1, 4 and 9 have similar relative levels of expression in PDAC; ADAMTS 5 and 15 slightly lower [median RSEM log2(value+1) = 10.2, 9.91, 9.54, 7.25, 5.33] and ADAMTS 20 is almost absent. ADAMTS 4, 5, 9 and 15 have significantly higher expression in PDAC tumor tissue versus (vs) normal adjacent (NA) pancreas tissue (log2FC= 2.16, 1.9, 1.57, 1.4, p-values <0.05). In patient-derived TMAs, PDAC tumors show higher levels of ADAMTS 4 expression vs. NA pancreas tissue (58.42% vs 44.12% of samples are ADAMTS 4hi). ADAMTS 5 expression is high in both tumor and NA tissue (90.5% vs 90%) which may be attributed to residual tumor tissue in the NA samples. Both ADAMTS 4 and 5 correlate with poor VCAN proteolysis. A2M RNA (log2FC= 2.09, p-value <0.05) and protein levels are significantly higher in tumor tissue vs. NA pancreas (67.41% vs 33.33% of samples are A2Mhi) and correlate with poor VCAN proteolysis. The murine co-allograft model resembles the human PDAC TME closely as evidenced by the pattern of cytokeratin-17/19 staining on epithelial cells and alpha-smooth muscle actin on cancer-associated fibroblasts. Discussion: High A2M expression correlates with high ADAMTS 4/5 expression and poor VCAN proteolysis, indicating a potential for A2M to aid in VCAN accumulation in the TME. The co-allograft model will be used to explore the role of A2M further in the PDAC TME. |
| 1.240 | Lindsay Clark | GERI | lrclark@medicine.wisc.edu | Remote digital memory assessment in middle-aged and older adults: Feasibility, reliability, and construct validity | Introduction: Although Alzheimer’s disease (AD) pathophysiology begins 10-20 years before clinical diagnosis, studies suggest a substantial proportion of missed or delayed diagnosis, resulting in delayed access to treatment, less time for advanced planning, and higher costs of care. With the rising adoption of mobile consumer technologies, including by older age groups, novel remote digital cognitive assessments may represent a means to address limited accessibility to cognitive screening or monitoring for older adults including those from underserved groups. Our objective was to evaluate the feasibility, reliability, and construct validity of digital memory tasks for memory screening in late middle-aged and older adults. Methods: Participants were recruited from longitudinal aging cohorts to complete medial temporal lobe-based memory paradigms (Object-In-Room Recall [ORR], Mnemonic Discrimination for Objects and Scenes [MDT-OS], Complex Scene Recognition [CSR]) using the neotiv application on a smartphone or tablet at repeated intervals over one year. Feasibility metrics included recruitment, enrollment, retention, adherence, and user acceptability. Intraclass correlation coefficients (ICC) assessed test-retest reliability over an 8-week period. Analysis of covariance (ANCOVA) models including covariates of demographics, device type, and task schedule were used to evaluate relationships between neotiv performance and traditional memory scores (Rey Auditory Verbal Learning Test [RAVLT]; Preclinical Alzheimer’s Cognitive Composite [PACC]). Results: Of 279 potentially eligible adults, n=179 consented (64% participation rate). Of 179 consented, n=132 completed at least one remote session and n=103 completed all remote sessions (retention rate=58% for all consented and 78% for all completed 1+ session). For the n=132 who completed at least one session, the overall adherence rate was 92% (number sessions completed / 18 total sessions). Greater than 90% of users felt the application was easy to use, instructions were understood, and the frequency and length of remote sessions were appropriate. 60% enjoyed completing the tasks (34% felt neutral) and 40% preferred mobile tests to traditional cognitive testing (42% felt neutral). Test-retest reliability was moderate (ICC=0.54-0.70). Remote memory tasks (MDT-OS, CSR, and ORR) were significantly associated with traditional memory task performances (RAVLT, PACC) (p’s <.001). Discussion: Challenges to participation occurred primarily during enrollment; future studies may allocate additional support facilitating registration and initial task completion within the application. User acceptability of the mobile tasks was high, the digital memory paradigms exhibited moderate test-retest reliability and were significantly related to gold-standard cognitive tests. Overall, findings support preliminary feasibility, reliability, and validity of the remote digital memory tasks in assessing memory function in cognitively healthy older adults. |
| 1.241 | Dawn Belt Davis | ENDO | dbd@medicine.wisc.edu | Gender Disparities in Sodium-Glucose Co-Transporter 2 Inhibitor Prescribing: Insights from an Academic Endocrinology Clinic | Background: Sodium-Glucose Co-Transporter 2 inhibitors (SGLT2i) improve outcomes in type 2 diabetes (T2DM) with atherosclerotic cardiovascular disease, heart failure (HF), or chronic kidney disease (CKD). However, women are prescribed SGLT2i less often than men, potentially leading to worse clinical outcomes. Objectives: To evaluate gender-based disparities in SGLT2i prescribing and identify any clinical or provider-related barriers within an academic endocrinology clinic. Methods: We retrospectively analyzed electronic health record data for patients aged ≥18 with T2DM and comorbid CKD, coronary artery disease (CAD), or HF seen in an academic endocrinology clinic from September 2023 to September 2024 as part of a quality improvement initiative. Exclusions included end-stage renal disease (ESRD), type 1 diabetes, diabetic ketoacidosis, or recent genital or urinary infections. Prescribing patterns by gender were analyzed using chi-squared tests. An electronic cross-sectional survey of 19 prescribers was conducted to assess potential barriers, with a response rate of 68%. Results: Among 2,653 patients (1,356 males; 1,297 females), 44.9% were on an SGLT2i: 50.8% of males versus 38.6% of females (p < 0.0001). Gender differences were significant among patients aged 40+ (males 51.5%, females 39.2%; p < 0.0001) and across CKD (males 16.8%, females 12.9%; p = 0.038), CAD (males 51.5%, females 41.9%; p = 0.0016), and HF (males 57.9%, females 43.2%; p < 0.0001). In the survey, 77% reported implicit bias 'slightly' or 'moderately' affects prescribing; concerns about side effects in females influenced prescribing 'sometimes' or more often in 77% of respondents. Conclusion: Women were less likely than men to receive SGLT2i therapy across subgroups, consistent with prior research. Prescriber bias, possibly due to concerns about a higher risk of adverse effects in females, may contribute to this difference. Limitations include reliance on aggregate data and single-center design, preventing multivariable adjustment and limiting generalizability. These findings will guide provider education and strategies to promote equitable prescribing. Future research should examine this disparity and its underlying factors across diverse healthcare settings. |
| 1.242 | Sameer K. Mathur | APCCM | skmathur@wisc.edu | Associations Between Absolute Eosinophil Counts and Cardiovascular Diseases | Introduction Elevated blood absolute eosinophil counts (AECs) have previously been associated with cardiovascular disease (CVD), but whether eosinophils are causative is unknown. We investigated associations between AECs and CVD and the impact of anti-eosinophil therapy. Methods We performed retrospective analyses of 264,590 medical records from 2019 through 2023 at the University of Wisconsin. Chi-squared analyses were performed to evaluate associations between blood AECs (stratified by ≥ 300 and < 300 cells/μL) and prevalent CVDs (hypertension [HTN], coronary heart disease [CHD], and stroke). Separately, retrospective patient-level blood pressure (BP) data on 85 patients treated with benralizumab, mepolizumab, or reslizumab were analyzed using paired t-tests to assess for pre- and post-treatment differences in BP. Results The high AEC group was significantly associated (p < 0.001) with a higher prevalence of HTN (23.0% vs. 22.2%), CHD (9.5% vs. 8.3%), and stroke (2.7% vs. 2.5%). Analysis of the 85 patients (mean age 63.6 years, 40% male) treated with anti-eosinophil therapy did not demonstrate significant differences in pre- and post-treatment systolic (p = 0.441) or diastolic BP (p = 0.464). Discussion Our findings suggest elevated blood AECs are associated with several CVDs. Our preliminary analysis did not find an effect of anti-eosinophil therapy on BP in a small sample of patients. Future analyses will compare rates of incident CVD in patients with high AECs and explore whether anti-eosinophil therapy impacts outcomes. |
| 1.243 | Nilay Kumar | HOSP MED | nkumar@medicine.wisc.edu | Incidence and Predictors of 30-day Readmissions following Hospitalization for COVID-19 | Background COVID-19 continues to strain healthcare systems worldwide, with post-discharge complications leading to readmissions that impact both patient outcomes and resource allocation. This study aims to determine the incidence and causes of 30-day readmissions following COVID-19 hospitalizations, as well as identify clinical, hospital-level, and socioeconomic risk factors associated with these readmissions. By understanding these patterns, we seek to improve post-discharge care and reduce the burden of readmissions. Methods We analyzed data from the 2020 Nationwide Readmissions Database (NRD), which contains approximately 17 million discharge records. The database provided information on sociodemographic variables, comorbidities, procedures performed during hospitalization, and hospital characteristics. National-level estimates were calculated using the weighing, stratification, and clustering variables included in the database. Results An estimated 668,567 index admissions for COVID-19 were identified, with a 30-day readmission rate of 11.4%. Notably, COVID-19 itself accounted for 40.4% of these readmissions, followed by sepsis (14.8%). Risk-adjusted odds ratios (OR) revealed several significant predictors of readmission: • Age over 65 (OR 1.171, p<0.001) • Male sex (OR 1.21, p<0.001) • Higher Charlson Comorbidity Index (OR 1.190, p<0.001) • Chronic lung disease (OR 1.093, p<0.001) • Hypertension with complications (OR 1.280, p<0.001) • Hypertension without complications (OR 1.096, p<0.001) • Lowest income quartile compared to highest (OR 1.099, p<0.001) Conclusions The high rate of COVID-19-related readmissions highlights the ongoing impact of the disease on patient health and healthcare systems. The identification of significant predictors such as age, comorbidities, and socioeconomic status provides valuable insights for targeted interventions. These findings can guide discharge planning strategies to reduce readmission rates, ultimately improving patient outcomes and alleviating the burden on healthcare resources. |
| 1.244 | Mark Benson | GASTRO | mb4@medicine.wisc.edu | CARE INEQUALITY: QUALITY OF COLONOSCOPY BOWEL PREPARATION AMONG INCARCERATED INDIVIDUALS | Background: Disparities in health equity have broadly been observed among incarcerated people in the United States. Our tertiary care academic medical center provides access to endoscopy for every correctional facility in our state. We have anecdotally observed that the quality of colonoscopy bowel preparation (bowel prep) is relatively poor for those who are incarcerated. There does not yet exist any published literature pertaining to the incarcerated population and bowel prep. The aim of our study was to evaluate the quality of bowel prep among incarcerated individuals compared to age- and sex- matched controls. Methods: We performed a cohort study evaluating bowel prep adequacy among incarcerated people undergoing screening and diagnostic colonoscopy. All outpatient colonoscopies performed between 07/2023-06/2024 for patients from state correctional facilities were analyzed. A control group comprised of patients from the local population who had outpatient colonoscopies during the same timeframe were identified and matched to age, sex, procedure classification, and sedation type. Endoscopist-measured bowel prep quality was recorded. Adequate bowel preps were defined as those that allowed for detection of polyps ≥ 6mm in size using Aronchick or Boston Bowel Prep Scales. The primary outcome was rate of adequate bowel prep. Results: We identified 130 incarcerated individuals who had a colonoscopy performed at our institution during the study period who were matched to a group of age- and sex-matched controls (Table 1). The median age was 53 years, and the majority of the patients were male (98.5%). Most of the colonoscopies were performed for screening purposes (59.2%). The most common ASA was II, and this classification was similar between both groups (P=0.46). The rate of adequate bowel prep was significantly lower for incarcerated individuals compared to controls, 63.8% vs 96.2% (P<0.001). The relative risk of inadequate bowel prep for an incarcerated person was 25 (95% CI 3.44-181.79) with a number needed to harm of 5.42 (95% CI 3.94-8.68). There was no significant difference in the quality of bowel prep among the 17 correctional facilities included. The adenoma detection rate was lower among those who were incarcerated compared to the control population, 47.7% vs 53.8% (P=0.38). Conclusion: Incarcerated individuals have a significantly lower rate of adequate bowel prep compared to age- and sex- matched controls. Our observed bowel prep adequacy rate of 80.8% falls significantly below the ≥90% performance target proposed in the recently published colonoscopy quality guidelines, identifying a gap and disparity in care quality. Collaborating with state correctional facilities to improve bowel prep adequacy is of paramount importance to lead to acceptable patient care. |
| 1.245 | Alexey Glukhov | CVM | aglukhov@medicine.wisc.edu | Sex-, Age- and Disease-Dependent Chronotropic Response of the Heart to Atrial Stretch in Mice and Rats | Background: Mechanical load is a fundamental regulator of cardiac function, including heart rhythm. Alterations in cardiac preload/afterload influence cardiac performance to coordinate cardiac output with venous return and arterial blood supply, in autonomous fashion. This autoregulatory mechanism might be diminished over age and during pathological conditions. Methods: We aimed to determine changes in heart rhythm upon mechanical stretch in young (10-12 weeks old) and old (12-14 months old) wild type mice (n=5/4 young and n=6/3 old male/female) and rats (n=6/5 young and n=3/5 old male/female) as well as spontaneously hypertensive rats (SHR, 12-14 months old; n=2/3 male/female). Stretch was modelled by right atrial volume overload in Langendorff-perfused hearts by increasing (from 0 cm H2O to 30 cm H2O) the pulmonary outflow fluid column in the setting of caval and coronary sinus occlusion (Fig. 1A, B). Electrocardiogram was used to monitor heart rhythm. Changes in cardiomyocyte and ECM size were visualized by using caveolin-3 (for cardiomyocyte size), WGA (for ECM composition) and α-actinin (for sarcomere elongation) immunofluorescent analysis. Results: In accordance with previous studies, atrial overload increased heart rhythm in both mice and rats, with more pronounced response in mice (22-28% in mice vs. 9-15% in rats). We found a sex-specific response in young rats (8.6 ± 1.6% in males vs. 14.8 ± 1.4% in female, P=0.021) with this trend appeared to be preserved in old and SHR rats. Our preliminary data indicate a similar sex-specific response in young mice. We did not reveal a decline in sinoatrial node response to stretch in old and SHR rats (11.9 ± 2.5% and 16.5 ± 2.5% in male and female rats, respectively, and 11.3 ± 4.9% and 13.5 ± 2.9% in male and female SHR, respectively). WGA/Caveolin3 immunofluorescence staining confirmed significant increase in young male cardiomyocyte width (36%, p < 0.0001) and length (23%, p < 0.001) upon stretch (Fig. 1C). Discussion: Our preliminary studies demonstrate stretch-mediated positive chronotropic response in both mice and rats. We also reviewed sex-dependent differences when female animals are more sensitive to stretch than males. The response and sex-specific differences seem to be conserved across aged and hypertensive animals. Preliminary results indicate a notable, sex-dependent and disease/age-resilient positive chronotropic response to mechanical stretch, which may allow for understanding of cardiac autoregulation under physiological and pathological conditions. |
| 1.246 | Michael Eberlein | APCCM | meberlein@medicine.wisc.edu | Chest Wall Strapping dilates airways and increases airway homogeneity in COPD | Rationale: Chest wall strapping (CWS) is a technique that restricts the chest wall to induce breathing at lower lung volumes. CWS increases lung elastic recoil and expiratory airflows. In imaging studies CWS dilates small airways in healthy and COPD-subjects. The timecourse and a possible lasting effect of CWS on airway function remains unclear. Volumetric capnography and plethysmography allow for repeated measurements of the lung structure function relationship. Objectives: We hypothesized that CWS causes an increase in dead space of COPD-subjects via CWS induced increase in airway dimensions. Secondly, we hypothesized that CWS increases airway homogeneity. Methods: Male participants with COPD were recruited (n=5) and healthy, sex-matched controls (n=5). After performing baseline measurements (ventilation parameters, plethysmography, and volumetric capnography), participants underwent CWS. Measurements were repeated every 15 minutes for one hour following CWS. After CWS-removal measurements were repeated every 15 minutes for an additional hour. We related anatomic dead space, alveolar dead space, VD/VT, and slope of the capnogram to lung volume and tracked their changes over time. Results: COPD-subjects were breathing at higher lung volumes than control-subjects over the entire experiment (p < 0.001). Moving from unstrapped to the CWS and to post-CWS condition, we saw an overall increase in the anatomic dead space (a surrogate with the size of the airway tree) for both groups with CWS and post-CWS (p=0.001, Figure A). Post-CWS had a large effect on both groups causing a decrease in the slope of the capnogram to lung volume ratio (p=0.03, Figure B). Conclusion: CWS dilates airways quantified by the increase in dead space. The increase in airway homogeneity persists at least 45 minutes after strapping is removed. This indicates lasting benefits of CWS on airway function. CWS should be further investigated as a novel non-pharmacological treatment for COPD. |
| 1.247 | Andrea Galmozzi | ENDO | agalmozzi@medicine.wisc.edu | Investigating the role of adipose tissue Phosphoenolpyruvate Carboxykinase 1 (PCK1) in systemic lipid homeostasis | White adipose tissue (WAT) stores excess lipids and regulates systemic lipid homeostasis in response to endocrine signals. Impaired lipid storage in adipose tissue, often exacerbated by chronic consumption of a high-calorie Western diet, leads to dyslipidemia and ectopic lipid deposition. Modulating lipid storage pathways in adipose tissue might offer a new avenue to reduce these risks. In adipocytes, fatty acids (FA) and glycerol are stored as triglycerides (TG). Lipolysis is stimulated under catabolic conditions like fasting, breaking down TGs into FAs and glycerol. TG synthesis and lipolysis occur simultaneously and are together known as the lipid cycle, which is thought to play key roles in energy balance and lipid metabolism. Murine models with genetic disruption of TG synthesis enzymes exhibit lipodystrophy, and in some instances, hypercholesterolemia. However, shifting the balance away from TG synthesis towards lipid oxidation may reduce lipid accumulation. Glycerol-3-phosphate (G3P), the backbone of TGs, is produced through glycolysis, glyceroneogenesis, or direct phosphorylation of the glycerol. In contrast to mutations in enzymes directly involved in TG synthesis, disruption of G3P synthesis does not result in adipose tissue dysfunction, while still presenting altered lipid homeostasis. PCK1 is the rate-limiting enzyme for glyceroneogenesis in adipose tissue. To delve deeper into the role of PCK1 in adipose tissue, we generated PCK1 Adipose-specific KnockOut (PAKO) mice. We found that PCK1 knockout results in a 50% reduction of G3P in white adipocytes and increased oxygen consumption in brown adipocytes. Under high-fat diet, male PAKO mice show reduced body weights and fat mass together with lower serum glycerol levels. However, PAKO mice exhibit no difference in glucose and insulin tolerance tests. These results indicate that deletion of PCK1 in adipose tissue results in resistance to diet-induced obesity without affecting glucose handling. PAKO mice under standard chow diet exhibit lower fat weight after acute cold challenge, suggesting that PCK1 knockout promotes lipid mobilization in adipose tissue in response to cold exposure. Taken together, we show that modulating PCK1-mediated glyceroneogenesis in adipose tissue protects mice from diet-induced obesity by altering systemic lipid metabolism. Completion of this work may reveal novel therapeutic targets for metabolic syndromes like diet-induced obesity. |
| 1.248 | Katie Raffel | HOSP MED | katie.raffel@cuanschutz.edu | Assessing Organizational Readiness to Pursue Diagnostic Excellence Collaboration | Introduction Diagnostic error may occur in up to 5% of all adult hospitalizations, leading to prolonged length of stay, higher cost and significant morbidity and mortality. Improving diagnostic safety requires measurement, analysis, and learning accelerated by dissemination. While safety is at the forefront of hospital priorities, organizational readiness to address diagnostic safety lacks consistent deployment and monitoring. Methods Achieving Diagnostic Excellence through Prevention and Teamwork (ADEPT) is a 16-hospital, AHRQ-funded national study seeking to reduce diagnostic error among adult inpatient medicine patients. These geographically distributed sites primarily represent academic medical centers. The ADEPT team developed a 37-item novel organizational assessment instrument distributed via email to leads at each site in early 2023. Data captured included multiple choice and free text response about case analysis, safety, and work around diagnostic improvement. Results Site leads at all sites completed the assessment, reporting 87% of sites having structured mortality review and 37% having structured review of cases with care escalation, such as ICU transfer. While diagnostic error discussion may arise in these reviews, less than half (43%) of programs incorporated diagnostic error into their existing patient safety and quality infrastructure. Half of the sites had begun to measure diagnostic error through triggered case review. One site had developed a dedicated system for sharing diagnostic opportunity, “Diagnostic Error Reporting System (DERS).” In terms of interventions to improve diagnostic safety, some sites reported improving culture of feedback and building a diagnostic reasoning curriculum. One site focused on teamwork, including improving interprofessional communication tools and psychological safety training. Another site emphasized patient engagement through promotion of electronic patient access to medical records. Many sites reported barriers to diagnostic improvement, including complexity and diversity of diagnosis in hospital medicine, limited financial support, the need for leadership development, and lack of institutional prioritization. Conclusions There is large variation in structure, process, and support around measuring, tracking, and learning from diagnostic opportunity, likely representing broader uncertainty around the best way to organize and coordinate a diagnostic excellence program. As the evidence for methods to reduce diagnostic error grows, it will be necessary to establish best practices around how to structure and adequately resource dedicated diagnostic safety programs, including patient and interprofessional engagement strategies, and building leadership commitment. |
| 1.249 | Mariana Pehar | GERI | mapehar@medicine.wisc.edu | A Role for NR1D1 Signaling in the Development of Neuroinflammation During Aging | Neuroinflammation has been associated with the aging process and contributes to the onset and progression of neurodegenerative diseases. Astrocytes, an abundant glial type with important homeostatic functions, play a key role in the regulation of the innate immune response in the central nervous system. NR1D1 is a member of the nuclear receptor superfamily and it is an essential component of the molecular clock in mammals. It functions as a transcriptional repressor downregulating the expression of multiple genes involved in inflammatory and metabolic processes. NR1D1 is considered a key regulator of fatty acid-binding protein 7 (FABP7) expression, a protein that is upregulated by astrocytes in multiple pathological conditions. Accordingly, we previously showed that in primary mouse astrocyte cultures, silencing NR1D1 increases the expression of FABP7. Moreover, we showed that the upregulation of FABP7 induces a pro-inflammatory phenotype in astrocytes. Here we investigate a potential role for NR1D1 in the regulation of neuroinflammation during aging. Western blot analysis showed decreased NR1D1 expression in the cerebral cortex of 2-year-old mice, when compared to young 3-month-old animals. By immunostaining, we observed that the decrease in NR1D1 expression is observed in astrocytes and neurons. In addition, we observed that FABP7 expression increases in a subpopulation of astrocytes in the aging brain. Remarkably, astrocytes expressing high FABP7 levels also have higher expression of the inflammatory markers, NOS2 and COX2. Together, our results suggest a potential role for NR1D1 in the regulation of astrocyte-mediated neuroinflammation during aging. |
| 1.250 | Nathan Sandbo | APCCM | nsandbo@medicine.wisc.edu | Fibronectin-targeting PET probe non-invasively detects reduction in lung fibrosis disease activity upon TNS1 knockout | Introduction: Extracellular matrix deposition is one of the hallmarks of fibrotic disorders, including idiopathic pulmonary fibrosis (IPF). Tensin1 (TNS1), a beta1-integrin-interacting protein, is required by myofibroblasts to assemble de novo fibronectin and collagen extracellular matrix. In this study, we analyzed the effects of conditional deletion of TNS1 in the bleomycin-induced model of pulmonary fibrosis including the use of a fibronectin-targeting positron emission tomography (PET) imaging probe for non-invasive assessment of active disease. Methods: TNS1floxed,floxed (TNS1f,f) mouse line was bred to tamoxifen-induced ubiquitous Cre-reporter strain (B6.129-Gt(ROSA)26Sortm1(cre/ERT2)Tyj/J, Jackson Laboratories) to enable whole mouse TNS1 conditional knockout in Rosa-Cre/TNS1f,f mice. Rosa-Cre/TNS1f,f mice and controls were treated with daily tamoxifen (100mg/kg) for seven days to induce TNS1 deletion, which was confirmed by RT-qPCR and western blot. Bleomycin (1U/kg) or 0.9% normal saline was delivered intratracheally to 9-12 week old Rosa-Cre/TNS1f,f mice and controls. Fourteen days after bleomycin treatment, lungs from one mouse cohort were harvested to assess total collagen content. Another mouse cohort at the same time point was administered a single dose of radiolabeled PEGylated fibronectin-targeting peptide probe [64Cu]Cu-PEG-FUD and imaged via micro PET/CT 24 hours later ahead of tissue and image analysis. Tissue uptake was further quantified through ex vivo biodistribution studies. Lung radiodensity (Hounsfield units of CT scans) and radiotracer uptake (%ID/g in PET scans) were determined in Imalytics software by manually drawing regions of interest. One-way ANOVA and correlation analyses were utilized for statistical comparisons between groups of interest and to determine a relationship between μPET and μCT-based signal in lungs from mice treated with [64Cu]Cu-PEG-FUD, respectively. Results: TNS1 knockout was confirmed by RNA and protein. We found that TNS1 knockout mice developed significantly less fibrosis compared to wild type controls, as evident by reduced hydroxyproline content in the lungs 14 days post-bleomycin. Furthermore, we demonstrated reduced uptake of the fibronectin-targeting PET probe, [64Cu]Cu-PEG-FUD, in the TNS1 knockout mice in comparison to the wild type controls treated with bleomycin. This finding was further confirmed by ex vivo gamma counting of lung tissue at this time point. Finally, we found a correlative relationship between μCT radiodensity and [64Cu]Cu-PEG-FUD uptake in this mouse cohort. Conclusions: These data reveal that TNS1 is protective against the development of bleomycin-induced fibrosis and that our fibronectin-targeting PET probe is capable of non-invasively detecting changes in disease activity in real-time. |
| 1.251 | Lindsay Taylor | ID | ltaylor@medicine.wisc.edu | Use of Statewide All-Payers' Claims Data to Create Outpatient Antibiotic Use Dashboards: A Public Health Stewardship Initiative | Background: The Centers for Disease Control and Prevention (CDC) Core Elements of Antibiotic Stewardship for Health Departments includes tracking and reporting of antibiotic use (AU). To support outpatient AU tracking and reporting, the Wisconsin Department of Health Services (DHS) leveraged all-payers claims data to create health care organization-specific outpatient AU dashboards with benchmarked measures. Methods: DHS contracted with the Wisconsin Health Information Organization’s to access their database to review all payers’ claims data from 2018–2023, which included medical encounter and pharmaceutical claims. Visits were included if they occurred at a clinic (in-person or virtual), urgent care, or emergency department in Wisconsin. Antibiotic visits were defined as an outpatient visit associated with a filled oral, systemic antibiotic prescription ordered up to three days after the encounter. Antibiotic visits were normalized by all outpatient visits as a rate per 1,000 visits. A quality measure of antibiotic visits for respiratory tract infection (RTI) was developed using the CDC’s tier 3 ICD-10 codes representing cough, upper RTI, or bronchitis without cooccurring ICD-10 code for other infection. Antibiotic visit rates were then summarized at the health care organization level, with additional stratification by place of service, diagnosis, patient age, and provider type. Results: From 2018–2023, there were over 59 million outpatient visits in Wisconsin by over 20,000 different clinicians from 57 organizations. Statewide benchmarks were developed for all diagnoses and RTI antibiotic visit rates (Table 1). Visits by surgeons and advanced practitioners had the highest rates of antibiotic prescribing for tier 3 RTIs; rates were similar across places of service. Rates per individual prescriber were visually compared to the statewide and organization benchmarks within dashboards (Figure 1). Conclusion: All-payers' claims data provides a statewide data source to develop antibiotic visit rates, including a quality measure for visits associated with RTI. Overlying statewide and organizational medians provides a benchmark to identify outliers for further stewardship interventions. Piloting these dashboards will help improve access to AU data. |
| 1.252 | Farah Acher Kaiksow | Medical Student, General Internal Medicine | fkaiksow@medicine.wisc.edu | Diagnostic equity: measuring the association between diagnostic errors and neighborhood disadvantage | Introduction Patients who reside in areas of high neighborhood disadvantage have poorer health outcomes; the mechanisms for this disparity are complex. We sought to determine if there was an association between neighborhood disadvantage and diagnostic error among a cohort of adult inpatients who experienced either an ICU transfer or in-hospital death. Methods Our study population (n=527) comes from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study, a retrospective cohort study of a randomly selected population of adult patients who were admitted to participating hospitals with a medical admission diagnosis and were transferred to the ICU, died, or both during the study period. Each patient case was reviewed to assess for the presence and severity of diagnostic error. Using the Neighborhood Atlas, we used the ZIP+4 code from the UPSIDE data set to link each patient to their appropriate Area Deprivation Index (ADI) score based on 2020 U.S. Census data. We used multivariate logistic regression to examine the relationship between neighborhood disadvantage and DE rate. Results In our study population, 15.7% of patients (n=87) came from the most disadvantaged neighborhoods. Overall, 18.3% of patients experienced a diagnostic error. There was no significant difference in DE rate between the two ADI groups (19.5% among the most disadvantaged, 18.0% among the less disadvantaged, p = .97). No association was observed between ADI decile and DE rate. Discussion In contrast to previous studies that found differences in hospital care based on socioeconomic status, we found no difference in diagnostic error rate between patients based on neighborhood disadvantage. Although we know that ADI negatively impacts health, our data suggests that neighborhood disadvantage may influence a patient's health over the long term, rather than by directly altering acute care systems that define the inpatient diagnostic process. We hypothesize that the impacts of socioeconomic status on health may be found in other areas, such as delays in care and limited English language proficiency, which should be the focus of future study. |
| 1.253 | Andrea Galmozzi | ENDO | agalmozzi@medicine.wisc.edu | Dissecting the Heterogeneity of Adipocyte Progenitors in White and Brown Adipose Tissue | Obesity and type 2 diabetes are significant contributors to pathologic morbidity and mortality in developed nations. Dysfunctional white (WAT) and brown (BAT) adipose tissues often serve as early indicators of metabolic dysregulation. Therefore, creating a detailed map of adipose tissue in the healthy state and understanding how it transforms during the onset of dysfunction remains a critical aim in biomedical and translational research. Modern single-cell characterization techniques underscore the remarkable heterogeneity of adipose depots, both anatomically and physiologically. While multiple studies have reproducibly identified distinct lineages of adipocyte precursor cells (APCs), the functional importance of this diversity is only beginning to elucidate. In this study, we employed an in vitro model of APCs and integrated multiple datasets from primary WAT and BAT). Single-cell RNA sequencing of WAT and BAT adipose precursor cells from P0 were analyzed for differentially expressed genes, developmental trajectories, biological pathway analysis, gene regulatory network inferences, and a comprehensive comparison between the two depots. Our findings reveal that the heterogeneity within these tissues can be broadly distilled into two principal identities: (1) Committed Adipogenic Progenitors (CAPs) and (2) Fibro-Adipogenic-Like Progenitors (FAPL). Biological and differential expression testing showed parallel expression patterns across both depots in these 2 fates. Notably, we observed a striking degree of similarity in form and function among FAPL populations across both WAT and BAT when BAT and WAT datasets were combined. These subpopulation identities were also recapitulated in in vivo public datasets, confirming the validity of our in silico approach. These results provide new insight into the fundamental architecture of adipocyte precursor subtypes and lay the groundwork for future investigations into how these progenitors may contribute to both metabolic health and disease. |
| 1.254 | Nicole Rogus-Pulia | GERI | npulia@wisc.edu | Stuck on the Tuck: Examining and Maximizing Clinician Practices and Nomenclature for Head and Neck Flexion | Introduction: Postural maneuvers are crucial to management of dysphagia (i.e., disordered swallowing), as they provide an opportunity to acutely optimize flow of food and liquid through the pharynx. While head flexion (commonly referred to as a “chin tuck”) and neck flexion (commonly referred to as “chin down”) are widely researched, their distinction in the literature has been inconsistent, leaving both strategies vulnerable to being viewed as one in the same among clinicians. As such, we aimed to determine how clinicians perceive, refer to, and implement these two strategies in clinical practice. Methods: A 23-item survey was developed and distributed over two months via Qualtrics to licensed US-based clinicians evaluating and treating dysphagia. Validation of data obtained included use of Captcha, as well as specific validation questions to ensure respondent legitimacy. The survey consisted of the following sections: 1) Demographics, 2) Open-ended prompt for nomenclature, 3) Prevalence of use, 4) Training in the strategies, 5) Future directions. Results: A total of 354 survey responses were included in the analysis. The majority of respondents (328/354; 93%) referred to neck flexion as “chin tuck.” 13% (40/318) referred to head flexion as chin tuck; however, 78% of these same respondents also referred to neck flexion as “chin tuck,” thus indicating no distinction in terminology. 51% of respondents (161/318) did not recognize head flexion as a strategy at all; “retraction” was the most commonly reported alternative term for head flexion. 23% (80/354) did not report distinguishing between neck and head flexion, while 49% (175/354) reported distinguishing between the two but only trialing chin down during instrumental assessment. More education and updated terminology were the most voted approaches to maximizing distinction (Table 1). Fifty-two percent (122/234) supported a shift in terminology to use of chin retraction for head flexion and chin down for neck flexion. Discussion: Findings showed that clinicians are inconsistent in their distinction between head and neck flexion, with most respondents not recognizing head flexion as a strategy to trial during instrumental assessment. Results support the need for improved distinction between these two strategies, including more education on differential effects of these strategies as well as a shift in common terminology toward head flexion as “chin retraction”, neck flexion as “chin down”, and “chin tuck” as an umbrella term. |
| 1.255 | Vincent Ma | HEM/ONC | vtma@medicine.wisc.edu | Circulating tumor DNA (ctDNA) dynamics during anti-PD-1 based therapy may predict clinical outcomes in advanced stage melanoma: a multicenter retrospective study. | Introduction: ctDNA has shown promise as a prognostic biomarker for disease relapse in resected tumors. The significance of ctDNA changes in the advanced or metastatic disease setting for predicting treatment response and survival characteristics is still under investigation. In our study, we evaluated the association between early ctDNA changes after anti-PD-1 based therapy initiation and clinical outcomes in patients with advanced stage melanoma. Methods: We performed a multicenter, retrospective analysis using a personalized, tumor-informed ctDNA assay (Natera) on prospectively collected plasma samples from patients with unresectable stage III/IV melanoma treated with anti-PD-1 based therapy. Baseline ctDNA levels were assessed prior to the start of treatment and at 6-8 weeks. Patients were divided into 3 cohorts based on ctDNA changes: ctDNA clearance (6-8 week level undetectable or 0 MTM/mL), ctDNA decrease (6-8 week level decreased from baseline but detectable), or ctDNA increase (6-8 week level increased from baseline). Logistic regression models were used to evaluate the odds of disease control based on the change in ctDNA levels between both time points. Cox proportional hazard models were used to study the effects of ctDNA changes on progression-free survival (PFS) and overall survival (OS). Results: We identified 95 patients with unresectable stage III (18%; n = 17) or stage IV (82%; n = 78) melanoma with cutaneous (72%; n = 68), uveal (12%; n = 11), mucosal (8%; n = 8), or unknown (8%; n = 8) primaries who were treated with dual anti-PD-1/anti-CTLA-4 (60%; n = 57), dual anti-PD-1/anti-LAG-3 (17%; n = 16), or anti-PD-1 monotherapy (23%; n = 22). At baseline, median age was 75, median baseline ctDNA was 363 mTM/ml, and median follow up was 13.1 months; 29% (n = 28) had liver metastases, 26% (n = 25) had brain metastases. Using ctDNA clearance (n = 40) as reference, patients with ctDNA decrease (n = 23) had lower odds of disease control (OR = 0.09, 95% CI 0.01-0.85, p = 0.035), and shorter PFS (HR = 5.15, 2.25-11.79, p < 0.001), and OS (HR = 5.72, 1.52-21.56, p = 0.010); patients with ctDNA increase (n = 32) had even lower odds of disease control (OR = 0.01, 0.00-0.09, p < 0.001) and even shorter PFS (HR = 5.67, CI 2.62-12.24, p < 0.001) and OS (HR = 8.76, CI 2.55-30.11, p = 0.001). 12-month PFS for ctDNA clearance, ctDNA decrease, and ctDNA increase were 94.3%, 63.0%, and 48.2%, respectively. 12-month OS for ctDNA clearance, ctDNA decrease, and ctDNA increase were 95.4%, 64.6%, and 50.5% respectively. Discussion: ctDNA dynamics after 6-8 weeks of anti-PD-1 therapy in patients with advanced stage melanoma may be predictive of disease control, progression-free survival, and overall survival. ctDNA clearance is associated with favorable clinical outcomes. Larger studies are needed to validate the role of ctDNA as an early response biomarker in advanced disease. |
| 1.256 | Mark Benson | GASTRO | mb4@medicine.wisc.edu | Maximum Recall: A Novel Advanced Endoscopy Interactive Tool Improves Education Outcomes for Gastroenterology Fellows | Introduction: Spaced repetition is an evidence-based learning method leading to improved longterm knowledge retention. Novel mobile or web-based spaced repetition flashcard algorithms have been used to teach medical students and residents and have been shown to be effective and convenient. There have been no previous studies on the use of these learning methods for internal medicine fellowship education. Methods: A slide deck of mobile interactive flashcards, Anki, were developed based on board style gastroenterology topics about advanced endoscopy, pancreas and hepatobiliary diseases. General GI fellows rotating on the advanced endoscopy service were given access to the mobile deck and completed the deck during their time on the rotation. The fellows were given a pre-test on the first day of the 2-week rotation and a post-test when the slide deck was completed. The tests included 20 gastroenterology board style questions on advanced endoscopy topics and pancreaticobiliary diseases. Results: 8 gastroenterology fellows completed the program (4 first year, 2 second year, 2 third year). There was a significant increase in the pre vs post test scores after completing the mobile deck, 13.4(±3.0)/20, 67 % vs 16.4(±3.7)/20, 82 %, P=0.019. There was no significant difference in the rates of improvement between the years of fellowship training. On the survey, 50 % of the fellows reported individual reading/studying and 38 % reported lectures as their preferred learning method. Despite this, 75% were interested or very interested in using this type of mobile learning for other gastroenterology and hepatology topics. 75 % of the fellows enjoyed their experience with the novel educational format. Conclusion: 1) Novel spaced repetition mobile interactive flashcards are an effective method of teaching complex advanced endoscopy topics to gastroenterology fellows. 2) This unique convenient method can improve educational outcomes for all levels of fellowship training. 3) This type of educational technique should be applied to other areas within gastroenterology and hepatology training to improve long-term knowledge retention. |
| 1.257 | Dudley Lamming | ENDO | dlamming@medicine.wisc.edu | Prior history of dietary amino acid composition epigenetically marks a persistent metabolic signature | Restriction of dietary protein or specific amino acids, including the branched-chain amino acids (BCAAs; i.e. leucine, isoleucine and valine), rapidly restores metabolic health to diet-induced obese (DIO) mice. However, for humans dietary adherence is often transitory, and followed by a return to a Western diet (WD). Therefore, we created a study using DIO mice studying the long-term effects of a short-term diet. We placed mice on 12 weeks of WD to induce obesity before placing them on a BCAA-restricted mice for 3 weeks before returning them back to a WD for 12 weeks. Over the 27-weeek study, we assessed their metabolic health and collected tissues at the end of each diet phase for tissue analysis. Here, we find that specific restriction of dietary BCAAs for just three weeks not only rapidly improves metabolic health, but that benefits of BCAA restriction persist following a return to a normal WD. These benefits include persistent increases in energy expenditure and glucose regulation, and reduced fat mass and hepatic steatosis as compared to a constant WD diet. Epigenetic analyses (transcriptomics and histone proteomics) revealed that transient BCAA restriction and subsequent return to WD yielded a novel chromatin landscape that featured higher transcriptional fidelity where lowly expressed genes in WD were silenced after BCAA-restriction and upon return to WD. We find that the increased energy expenditure of previously BCAA-restricted mice is partially dependent on FGF21 but is also mediated by persistent brown adipose thermogenesis. Finally, we find that methionine restriction leads to persistent metabolic and molecular effects distinct from those induced by BCAA restriction. In conclusion, we show not only that BCAA restriction can have long-term benefits following cessation of restriction, but more broadly suggest that diet history, including the specific amino acid composition of foods eaten months prior, can impact current metabolic health through persistent chromatin alterations that metabolism. |
| 1.258 | Vincent Cryns | ENDO | vlcryns@medicine.wisc.edu | Lipid Transfer Proteins Initiate Nuclear Phosphoinositide Signaling | Background: The canonical membrane-localized phosphatidylinositol (PI) 3-kinase (PI3K)/Akt pathway regulates many biological processes and is aberrantly activated in cancer. Recent studies reveal a distinct PI3K/Akt pathway operating in the nucleus and involving p53-polyphosphoinositide (PIPn) complexes which are modified to recruit and activate Akt. Importantly, this mechanism involves the two most commonly mutated pathways in all cancers, p53 and PI3K/Akt, relying on nuclear PIPn pools to participate in signaling events. The canonical and nuclear pathways overlap in their prerequisite of PI, however, nuclear PIPns have an unknown origin and remain poorly characterized resulting in the nuclear pathway remaining uninhibited by clinical therapeutics that target cytosolic PI 3-kinases. Methods: We use immunofluorescent staining of MDA-MB-231 cells to assess the nuclear PIPn pools that allow nuclear PIPn signaling. Moreover, we use a combination of immunoprecipitation, proximity ligation assays, and fluorescent Western blot to define a new protein interaction for p53, as well as a means of investigating protein-PIPn linkages. Lastly, we demonstrate the therapeutic relevance of this pathway on oncogenic phenotypes using crystal violet staining and transwell migration analysis. Results: In the membrane pathway, PI transfer proteins (PITPs) transport PI, the precursor of PIPns, to endomembranes to enable PIPn synthesis and stress signaling. Our results indicate class I PITPs (α/β) are compensatory, stress responsive, and nuclear translocating proteins that regulate the induction of PIPn pools in the non-membranous nucleoplasm. PITPα/β interact with p53 in the nucleus in response to stress where they facilitate p53-PIPn complex formation and regulate p53 stability. Moreover, PITPα/β appear to regulate PIPn linkages to many targets beyond p53 indicating a broad role for these proteins. Targeting PITPα/β in cancer cells conveyed chemosensitivity and decrease migratory potential supporting a translational opportunity that warrants further exploration. Conclusions: The nuclear PI3K/Akt pathway, centered around p53-PIPn complexes, provides an alternate mechanism to activate Akt that may compensate for clinical targeting of cytosolic PI3Ks. PITPα/β were previously thought to be cytosolic and homeostatic in nature. However, we have shown PITPα/β contribute to nuclear PIPn signaling through a stress responsive interaction with p53 in the nucleus that facilitates p53- and other protein-PIPn linkages. Taken together, this data indicates PITPα/β present an unexpected and powerful tool to further investigate nuclear PIPn pools and an overlapping target for both the cytosolic and nuclear PI3K/Akt pathways for developing cancer therapeutics. |
| 1.259 | Heidi Twedt | Section of Applied Clinical Informatics, Division of General Internal Medicine | htwedt@wisc.edu | Variation in utilization of patient education materials by medical specialty | Introduction: We identified significant variation in utilization of patient education materials by medical specialty. We found that emergency medicine (EM) providers utilized vendor-provided patient education materials (Ignite Healthwise, LLC) at a higher rate of 58.6% relative to 20.9% of urgent care (UC), 10.2% of primary care (PC) and 2.6% of outpatient specialty (OPS) providers. Methods: Using a human factors engineering approach, we created a survey assessing perspectives on the ease of use and value of available educational materials. This survey was distributed to physicians and advanced practice providers (APPs) across 23 medical specialties. We collected, analyzed and reported the quantitative and qualitative results of the survey. Additionally, we conducted unstructured interviews with EM and PC providers to understand workflows for providing patients with education materials and to identify possible reasons for variable utilization of electronic health record (EHR) integrated content. Results: A total of 138 physicians and APPs completed the survey. Of respondents, 56% were PC providers, 35% OPS, 5% EM/UC and 5% inpatient. Across all specialties, 48% of providers were occasional users of educational materials and 64% reported materials were generally useful and with valuable content. Additionally, 38% reported difficulty accessing materials and 46% reported too many clicks were required to access the materials. Of respondents, 80% reported that they would be more likely to use the materials if the workflow allowed relevant educational materials to be automatically suggested based on the diagnosis entered. When evaluating by specialty category, 83% of EM and UC providers agreed that it was easy to find relevant materials and disagreed that it took too many clicks to access these materials. While 49% of PC providers agreed that it was easy to access relevant materials, only 13% of OPS providers agreed with this statement. Most PC and OPS providers agreed that it takes too many clicks or too much time to find relevant materials (42% and 60%, respectively). Discussion: EM providers reported using an EHR vendor (Epic) designed workflow that automatically suggests patient education materials based on discharge diagnosis and allows providers to add these materials to the after visit summary (AVS) with just one click. In contrast, most PC and OPS providers access these materials through manual search processes that they described as “cumbersome” and “time-consuming” due to the many clicks and less user-friendly design. This discrepancy likely contributes to the higher utilization of these resources among EM/UC providers. Additionally, some providers described the educational materials as “unhelpful” and “nonspecific,” and many providers stated that they preferred to use educational materials they personally developed or retrieved from non-EHR integrated sources like professional societies. Automatic suggestion of relevant materials (i.e. using structured data or AI to harvest key terms) and a more user-friendly workflow represent important next steps to encourage greater use of educational resources across all specialties. Conclusion: In summary, multiple factors contributed to variation in provider use of patient education materials. A streamlined workflow for adding these materials to the AVS likely contributed to higher utilization among EM and UC providers relative to PC and OPS providers who use a more time-consuming cumbersome workflow. Additionally, many providers cited concerns about the value of the content in these materials and preferred using other resources. |
| 1.260 | Michelle E. Kimple | ENDO | mkimple@medicine.wisc.edu | G⍺z Regulates β-cell Cholecystokinin Expression by Direct and Indirect Mechanisms | The gut-derived peptide hormone cholecystokinin (CCK) is produced in pancreatic β-cells during stress conditions and acts in an autocrine manner to promote β-cell survival. While several transcription factors may promote Cck expression, cyclic adenosine monophosphate (cAMP) response element binding protein (CREB) is known to occupy the Cck promoter and promote Cck transcription. The prostaglandin EP3 receptor (EP3)-coupled G⍺z protein has been wellcharacterized as a negative regulator of β-cell cAMP production, limiting the ability of the β-cell to survive in response to metabolic stress. Previous work from our lab revealed the EP3 agonist, sulprostone, reduces INS-1E β-cell cAMP production and Cck expression, suggesting a link between β-cell CCK and G⍺z signaling. To test this, we developed and validated an INS-1 (832/13) cell line stably overexpressing human G⍺z. We treated parental or G⍺z-overexpressing INS-1 (832/13) cells with sulprostone or vehicle control for 24 h, collecting mRNA and protein samples for downstream analysis. When G⍺z is overexpressed, Cck and Cckar expression is significantly increased as compared to parental INS-1 (832/13) cells. The addition of sulprostone significantly reduced expression of Cckar in G⍺z overexpressing cells. While suprostone significantly decreased cAMP levels, we did not observe changes in p-CREB, suggesting a cAMPindependent effect of sulprostone on Cck and Cckar expression. Preliminary findings in streptozotocin-treated cells suggest a link with cell stress pathways. To study the impact of loss of G⍺z on Cck expression in the context of β-cell stress, we turned to the non-diabetic obese C57BL/6J LeptinOb (Ob) mouse model. As expected, none of the Ob mice from either genotype were diabetic, and G⍺z loss had no impact on fasting blood glucose levels. During obesity, islet Cck expression was increased 60-fold in wild-type Ob mice as compared to lean controls, consistent with previous studies linking obesity-driven metabolic stress to increased Cck gene expression. G⍺z loss affected Cck expression depending on metabolic state. In lean mouse islets, where Cck expression is already low/undetectable, G⍺z loss did not have an effect. However, compensatory upregulation of Cck transcription was significantly blunted in islets from G⍺z-null Ob mice as compared to wild-type Ob mice. Combined, our results from cell lines and mouse models suggest that G⍺z regulates Cck expression through both direct (i.e., cAMP-mediated) and indirect (i.e., cell stress-mediated) mechanisms. |
| 1.261 | Monica Yun Liu | APCCM | mliu@medicine.wisc.edu | Establishing Organoids from Patient BAL as a New Model for Lung Transplant Rejection | INTRODUCTION: Acute cellular rejection (ACR) is a common complication experienced by lung transplant recipients that injures the transplanted lung and worsens long-term outcomes. Since the underlying mechanisms of ACR are not well understood, treatment involves nonspecific immunosuppressive therapy, which carries many adverse effects. We established lung organoids from patients’ bronchoalveolar lavage fluid (BAL) as a new experimental model to uncover mechanisms of lung epithelial injury in ACR. METHODS: BAL was obtained from lung transplant patients with and without a history of ACR at the University of Wisconsin Hospital and Brigham and Women’s Hospital. From previously established methods, cells from fresh and cryopreserved BAL were plated with media promoting stem cell proliferation and selecting for airway or alveolar epithelial cells. We quantified organoid numbers, size, and growth rate over multiple passages, then performed single-cell RNA-sequencing (scRNA-seq) to reveal transcriptomic changes in rejection. RESULTS: 31 fresh and 9 thawed human BAL samples yielded airway and alveolar organoids. 19/40 (47.5%) samples had a history of ACR. The samples with a history of ACR demonstrated higher initial organoid forming efficiencies (OFE, number of organoids per live cells plated) compared to those without. Work is ongoing to compare organoid numbers and growth over time, as well as the capacity of epithelial stem cells to differentiate in culture. The scRNA-seq data from samples with a history of rejection revealed preliminary trends suggesting an upregulation of inflammatory and apoptosis pathways, alongside a downregulation of cell cycle and DNA repair pathways. DISCUSSION: Our BAL-derived organoid models provide an entirely new way of studying ACR using patients’ primary cells. We are starting to identify cellular and molecular mechanisms of ACR, which may ultimately help to develop more targeted therapies and improve patient outcomes. Future work includes further analysis of scRNA-seq data, validation of our results using additional patient samples, and applying our organoid models to other understudied lung diseases. |
| 1.262 | David Sonetti | APCCM | dsonetti@medicine.wisc.edu | Safety of ultrasound-guided tunneled pleural catheter placement in patients on therapeutic anticoagulation. | For patients who are on therapeutic anticoagulation and require a non-urgent procedure, current guidelines recommend holding anticoagulation therapy prior to a low-to-moderate-bleed-risk procedure such as bronchoscopy +/- biopsy.ⁱ For a minimal-bleeding-risk procedure such as thoracentesis or pacemaker placement, however, evidence demonstrates that it is safe to continue full-dose anticoagulation.ⁱⁱ, ⁱⁱⁱ The bleeding risk for ultrasound-guided tunneled pleural catheter (TPC) placement is not clearly defined. We retrospectively reviewed our experience placing ultrasound-guided TPCs at an academic institution by trained interventional pulmonologists between November 1, 2021 and December 2024. Of 215 TPC placements, 80 patients (35.5%) were on anticoagulation, 34 (15.8%) of which were completed while on full- dose anticoagulation. No bleeding complications of any type were encountered in the group of patients undergoing ultrasound-guided TPC on full-dose anticoagulation. The risk of bleeding complications from ultrasound-guided TPC placement in the setting of full-dose anticoagulation appears low when completed by expert interventional pulmonologists. More research in a prospective and multicenter fashion is recommended to confirm these results. |
| 1.263 | Andrea Galmozzi | ENDO | agalmozzi@medicine.wisc.edu | BCAA catabolism regulates brown adipose tissue function via heme biosynthesis. | A defining feature of obesity and type II diabetes is elevated levels of circulating metabolites such as glucose and branched chain amino acids (BCAAs). Therapies that promote uptake and clearance of these metabolites from circulation reduce disease severity and progression. Active brown adipose tissue (BAT) has been identified as a major “sink” for circulating metabolites, including BCAAs. Glucose and fatty acids readily feed BAT thermogenesis via oxidation and entry into the TCA cycle. Conversely, only a small fraction of BCAA-derived carbon is consumed through the TCA cycle in stimulated BAT, suggesting that BCAAs play a role in thermogenesis and energy expenditure beyond serving as oxidative fuels. The distinctive color of BAT is due to its high content of heme-rich mitochondria. Despite this, how BAT regulates intracellular heme levels remains largely unexplored. Here, we demonstrate for the first time that endogenous biosynthesis is the primary source of heme in brown adipocytes. We identified a novel interaction between Pcca and the Alas1-containing heme metabolon that enables channeling of BCAA-derived carbons via propionyl-CoA to feed heme synthesis. Furthermore, this interaction is dynamic and increases upon increased heme demand and in response to oxidative stress and adrenergic stimulation. Inhibition of heme biosynthesis leads to accumulation of the BCAAs valine and isoleucine, along with downstream metabolic intermediates in BCAA catabolism including propionyl-CoA. Despite no impairment in adipocyte differentiation, heme synthesis-deficient brown adipocytes display reduced mitochondrial respiration and Ucp1 levels compared to wild-type. Additionally, loss of heme biosynthesis increases the demand on the glutathione system to compensate for the loss of heme-dependent catalase and peroxidase activity. While supplementing exogenous heme normalizes intracellular heme levels and restores mitochondrial function, Ucp1 downregulation persists due to the accumulation of propionyl-CoA, which is sufficient to repress Ucp1 transcription. This observed metabolite-dependent transcriptional regulation is linked to epigenetic remodeling, and specifically, an increase in histone propionylation in heme synthesis-deficient cells. Finally, disruption of heme biosynthesis in BAT results in significant whitening, impairs thermogenic response, and hinders the cold-induced clearance of circulating BCAAs by BAT in female mice in a sex-hormone-dependent manner. These findings establish adipose heme biosynthesis as an important regulator of thermogenesis and sex-dependent BCAA homeostasis. Ongoing efforts aim to identify appropriate therapeutic targets and assess the efficacy of increasing adipose heme biosynthesis to protect against obesity and metabolic dysfunction via browning. |
| 1.264 | Michael Eberlein | APCCM | meberlein@medicine.wisc.edu | Chest Wall Strapping in a Porcine Model: Dynamcic Dysanapsis dilates airways for optimized function of the “oversized” lung | Introduction: Chest-Wall-Strapping (CWS), a technique forcing the lung to operate at low volumes, is a model for an oversized lung allograft in lung transplantation. Dynamic-dysanapsis describes airway dilation mediated by increased elastic recoil from CWS. We hypothesized that dynamic-dysanapsis can be quantified via the dysanapsis-ratio, defined as the airway-size to lung-volume ratio. Methods: Farm-raised pigs were mechanically ventilated. Stepwise CT-images throughout the lung deflation limb in control and CWS conditions were analyzed quantifying airway dimensions and lung volume. Results: CWS (30%-reduction in lung-volume) was associated with a significant increase in the Dysanapsis-Ratio (p<0.001), Figure 1. CWS increased airway distensibility at the 6th major branch of the right lower airway (27±8% vs. 38±7%; p=0.04), Figure 2. Discussion: The dysanapsis-ratio allows to quantify dynamic-dysanapsis with CWS. Dynamic-dysanapsis appears to be a compensatory mechanism to preserve pulmonary gas exchange by airway dilation, when the lung is forced to operate at lower lung volumes. Dynamic-dysanapsis furthers the understanding of oversized allografts in lung transplantation. |
| 1.265 | Loren Denlinger | APCCM | lcd@medicine.wisc.edu | Acute Biomarkers of Sustained Loss of Lung Function After Recovery from Asthma Exacerbations | Introduction: Among patients with severe asthma, those with baseline elevations in both sputum eosinophils and neutrophils have the greatest risk of longitudinal loss of lung function. Several eicosanoid mediators have both bronchoconstrictive and chemotactic properties. We hypothesized that during asthma exacerbations, individuals with acutely high sputum eosinophils and neutrophils would have the largest decline in lung function at recovery, and that measurements of acute levels of eicosanoids might serve as a noninvasive biomarker of this risk. Methods: This was a secondary analysis of an IRB-approved study that has been previously described. 21 participants at the University of Wisconsin had complete data for nasal lavage, sputum, and lung function measurements at baseline, acute, and recovery visits surrounding exacerbations. Samples with negative viral testing at the time of acute visit were excluded. Changes in lung function were compared to the baseline visit after bronchodilator response. Sputum samples were processed by the Severe Asthma Research Program protocol, with percentages counted from review of 300 cells after staining. Nasal lavage samples were analyzed for eicosanoid levels including thromboxane B2 (TXB2) and prostaglandin E2 (PGE2) via ELISA and EIA protocols per the manufacturer. Participants were stratified by asthma severity defined according to ATS/ERS guidelines. Multivariate modeling was performed using a stepwise approach and significance established at p<0.05. Results: Increased sputum eosinophils at the time of exacerbation were significantly correlated with reduced post-bronchodilator FEV1 (p=0.05) and FVC (p<0.05) at the recovery visit, when controlled for baseline spirometry. There was no observed relationship between recovery lung function and sputum neutrophils at the acute visit. Increased TXB2 from nasal lavage at the acute visit was correlated with reduced FEV1/FVC (p<0.01), and increased PGE2 was correlated with a near significant reduction in FEV1/FVC (p=0.07) at the acute visit. Discussion: Among a cohort of patients with severe asthma, higher acute sputum eosinophil count was correlated with reduced lung function at the recovery visit, however, sputum neutrophils did not significantly impact lung function at the acute or recovery visit. Additionally, higher nasal oxylipin TXB2 and PGE2 levels were associated with reduced lung function at the acute visit only. This suggests that characterization of exacerbation sputum and nasal fluid, easily accessible at the time of an acute visit, may aid in identifying patients at risk for progressive lung function decline. Further investigation of other exacerbation covariates via multivariate modeling may further define at-risk individuals. |
| 1.266 | Francisco J. Alvarado | CVM | falvarad@medicine.wisc.edu | Mice with phospho-substitutions at a novel ARVC-associated residue in ryanodine receptor 2 show normal calcium handling. | Background: Ryanodine receptor 2 (RyR2) is a critical Ca2+ ion channel located in the sarcoplasmic reticulum (SR) of the cardiomyocyte. It is a critical component for excitation-contraction (EC) coupling where electrical signals are transduced into mechanical force. Post-translational modifications of RyR2 such as phosphorylation have been shown to regulate the channel in healthy and diseased hearts. Recently, a novel RyR2 phosphorylation site, T2810, was identified in a mouse model of arrhythmogenic right ventricular cardiomyopathy (ARVC). This study aims at understanding the impact of the T2810 phosphorylation site on cardiac function and RyR2 regulation. Methods: We generated two novel mouse models with phosphoablated (T2810A) and phosphomimetic (T2810D) substitutions in RyR2 channels. Additionally, recombinant channels with the same substitutions were expressed in HEK293 cells. To assess the site’s potential contribution to cardiac function, Ca2+ handling, and RyR2 activity, we employed electrocardiography, confocal Ca2+ imaging, and [3H]ryanodine binding assays. Finally, we crossed the T2810A mouse an ARVC mouse model (phakophilin-2 conditional knockout, PKP2cKO) to assess the role of this site in disease progression. Results: [3H]ryanodine binding assays in recombinant RyR2 channels revealed no differences in the Ca2+ sensitivity or maximum activity in T2810A or T2810D channels. In vivo, T2810A mice showed no significant differences in electrocardiographic parameters under basal conditions or following a pharmacological arrhythmia challenge (2mg/kg epinephrine and 120mg/kg caffeine). Studies on T2810D are ongoing. Confocal imaging in isolated ventricular myocytes revealed no significant differences in Ca2+ transients (1-3 Hz stimulation) or in the sarcoplasmic reticulum Ca2+ load following a pulse of 10 mM caffeine. Interestingly, double-mutant PKP2cKO-T2810A mice showed longer lifespan than PKP2cKO animals following induction of the knockout. Discussion: T2810 is located within the region of RyR2 commonly referred to as the “phosphorylation hotspot,” alongside well-studied phosphorylation sites S2808 and S2814. Our data suggests that while T2810 may not be critical to regulate cardiac function or RyR2 activity in basal conditions or during adrenergic stimulation, it may play a role in ARVC pathology. Further studies are being conducted to investigate cardiac function, Ca2+ handling, and RyR2 activity in the PKP2cKO-T2810A model. |
| 1.267 | Chris Crnich | ID | cjc@medicine.wisc.edu | Air Monitoring to Detect Communicable Respiratory Viruses in Long-term Care Facilities | Introduction: Respiratory viral outbreaks are a major cause of nursing home (NH) resident morbidity and mortality. A substantial number of outbreaks in NHs are seeded by infected staff who have minimal or no symptoms at the beginning of their illness. Serial testing of asymptomatic employees was effective for controlling SARS-CoV-2 spread in NHs during the COVID-19 pandemic but is an unsustainable practice in the post-pandemic era. We conducted a pilot to develop a novel population surveillance method based on monitoring facility air and assess if it can accurately predict healthcare worker infections caused by common respiratory viruses. Methods: AerosolSense air instruments (Thermo Fisher Scientific) were placed in the Madison VA Community Living Center (CLC) – one in the unit entryway hallway and another at a nursing station. Air samples were collected daily (Su-Th) from Oct 2024 through Jan 2025. A commercial reverse transcription PCR (qRT-PCR) platform was used to test samples on-site, and its validity was assessed through parallel testing of the sample on a laboratory-based qRT-PCR assay. Research staff prospectively identified cases of acute respiratory illness (ARI) among CLC staff and compared them to air sample results to assess the predictive value of air monitoring. Results: Analyses of 127 paired air samples demonstrated moderate levels of agreement (Kappa = 0.46) between the on-site and laboratory-based PCR assays (Figure 1). Six CLC staff developed an ARI during the study period, all of which tested positive for SARS-CoV-2 by antigen testing. Air samples collected from the entryway sampler were frequently positive and, while highly sensitive (100.0%) for the subsequent identification of a staff ARI, lacked specificity (68.3%; Figure 2). In contrast, air samples collected at the nursing station were less frequently positive and demonstrated good sensitivity (83.3%) and excellent specificity (93%; Figure 2). The average time interval between a positive air sample and a staff case of ARI was 2.8 days (range: 1 – 5 days). Discussion: A laboratory-based qRT-PCR test was more sensitive than on-site qRT-PCR testing for detection of respiratory viruses in air samples although overall level of agreement between the platforms was acceptable. Air sampler location played an important role in the accuracy of air monitoring, and our results suggest placement in/near nursing stations is superior to placement at unit entryways. Air monitoring appears to predict subsequent cases of ARI among staff with good accuracy and lead time although further studies to validate its utility as an environmental surveillance system and how this technology can be integrated into an effective respiratory virus prevention program are needed. |
| 1.268 | David Andes | ID | dra@medicine.wisc.edu | Blastomyces dermatitidis titers decline rapidly in severe disease and azole monitoring levels stabilize over time with less variability in older patients | Introduction: Our work aims to inform interpretation of antigen titers in blastomycosis as a knowledge gap exists regarding their utility. The Clinical Practice Guidelines for the Management of Blastomycosis were last updated by the Infectious Diseases Society of America in 2008; at that time, the guidelines noted that antigen detection may be helpful in monitoring treatment response and predicting recurrence. No knowledge is currently available regarding the rates of decline in titers in relation to azole monitoring levels; we therefore investigated changes in titer levels and azole monitoring levels across a unified time scale to gain insight into their clinical significance. Methods: We analyzed clinical data for adults diagnosed with blastomycosis at the University of Wisconsin Hospital and Clinics. Analyses were performed using R version 4.4.1 which was used to fit a Bayesian gamma regression model to assess the effects of disease severity, location of disease, immunocompetence, and time on titer levels. We fit a generalized linear mixed-effects model to assess the effects of patient age, disease severity, azole type, and time on azole levels, capturing non-linear time trends. Results: We analyzed 218 patients with blastomycosis (64% male, 68% White, 67% living in Wisconsin) with mean age 57 years. The most rapid decline in titers occurred in patients with severe disease requiring intensive care compared to those with mild disease (0.17, 95% CI: [0.06, 0.47]). Immunocompromised patients had higher titers (2.03, 95% CI: [1.05, 4.01]). Titers varied significantly across individuals with a multiplicative factor of variability estimated at 3.63 (95% CI: [2.44, 6.36]). Regarding azole levels, time trends were significantly non-linear; azole levels initially rapidly declined and then plateaued. Lower variability in azole levels was observed in older patients compared to younger patients (p < 0.02). Discussion: Titers decline more rapidly in patients with severe disease compared to those with mild disease, possibly due to higher initial levels; immunocompromise may predispose patients to higher titers; and, regarding azole levels, time trends are significantly non-linear. Levels rapidly decline and then plateau, and lower variability occurs in older patients, possibly in part due to adherence. Future research will aim to further delineate the role of antigen titers and azole monitoring levels in guiding the treatment of blastomycosis. |
| 1.269 | Adnan Said | GASTRO | axs@medicine.wisc.edu | Nutrient Composition and Weight Loss Diets in MASLD: An Analysis of the U.S. Population | Background Despite advancements in therapeutic options for Metabolic Dysfunction Associated Steatotic Liver Disease (MASLD), dietary intervention remains the cornerstone of management. Dietary patterns to improve hepatic steatosis include weight loss and reduced caloric intake. However, the specific characteristics of these diets are often poorly defined in the literature. Furthermore, it is unclear if self-elected dietary interventions differ significantly between individuals with or without MASLD or from those with MASLD not following specific diets. This population-based cross-sectional study compares self-reported dietary patterns between individuals with and without MASLD in the US population. Methods We conducted a cross-sectional analysis using data from the 2017-2018 National Health and Nutrition Examination Survey (NHANES) to compare the self-reported low-calorie dietary patterns of adult MASLD subjects with those of non-MASLD individuals and with the diet patterns of those with MASLD not following a specific diet. Dietary intake was recorded using self-reported 24-hour recall. Categorical variables were analyzed with the Chi-square test, and continuous variables were analyzed with the Student’s t-test. A p-value of 0.05 was considered statistically significant. Results The NHANES survey included 8704 subjects, and 18% (1566) were diagnosed with MASLD. Among MASLD participants, 12.3% (175/1426) reported adherence to a low-calorie diet compared to 8% (180/2246) of non-MASLD controls (p < 0.001). In this low-calorie group, total caloric intake was higher in the MASLD group (2159 ± 912 Calories) compared to controls (1883 ± 871 Calories) (p = 0.004) with greater consumption of carbohydrates (242g ± 109g vs. 205g ± 103g, p <0.001) and total fat (90g ± 48g vs. 76g ± 44g, p = 0.04) in the MASLD population. When comparing MASLD patients following a low-calorie diet to those not following a diet, no significant difference in total caloric intake was observed (2,205 ± 1,005 Calories vs. 2,159 ± 912 Calories; p = 0.545). However, the group not following a diet reported higher total sugar intake (114g ± 79g vs. 93g ± 56g; p = 0.01). Conclusion This study highlights that MASLD individuals consume higher calories derived from fats and carbohydrates than non-MASLD individuals, even when reporting adherence to a low-calorie diet. MASLD patients had no significant difference in nutrient profiles regardless of whether they reported following a specific diet. Due to the impact of diet on outcomes in MASLD, this variability in diet composition could account for some of the variability in placebo response rates in clinical trials of MASLD therapies. Accurately measuring dietary compliance and diet composition should be prioritized in MASLD therapeutic trials. Further research is warranted to validate these findings. |
| 1.270 | Andrea Galmozzi | ENDO | agalmozzi@medicine.wisc.edu | Polyamines regulate cancer-induced loss of adipose tissue in a PDAC model. | Introduction: Cancer-associated cachexia (CC) affects about 80% of patients with advanced cancer and directly contributes to up to 20% of cancer-related deaths. This metabolic disorder is characterized by the involuntary loss of body weight, specifically skeletal muscle and adipose tissue. Current therapeutic strategies, which primarily rely on nutritional supplementation to combat weight loss, are palliative and demonstrate limited efficacy. There is no pharmacologic therapy that is currently recommended as standard of care for CC, largely due to the poor understanding of its underlying pathophysiology. Therefore, as a first step to developing effective interventions for this disease, there is a dire need to identify the molecular pathways triggered by the tumor that reprogram host metabolism to drive CC progression. We hypothesize that cancerderived polyamines mediate, at least in part, adipocyte dysfunction and promote adipose tissue waste in the early stages of cachexia. The objective of this work is to characterize the role and mechanism of action of cancer-derived polyamines in adipose tissue dysfunction and the progression of cancer cachexia. Methods: Lipolytic activity in primary adipocytes was measured by assessing glycerol release into the media and monitoring Hormone Sensitive Lipase (HSL) phosphorylation via Western Blot after exposure to conditioned media (CM) from different cancer cells. We developed a cachectic mouse pancreatic cancer model, by injecting FVB mice with 65671-KPC cells subcutaneously. The characterization of the model included monitoring body weight, body composition, and food consumption weekly. After euthanizing the mice, we harvested adipose depots, weighed them, and quantified the adipocytes’ size using Fiji software. Statistical analysis was performed on GraphPad using Student’s t-test for comparisons between two groups and one-way ANOVA with multiple comparisons for assessment of more than two groups. Results: We classified several cancer cell lines as “pro-cachectic” or “non-cachectic” based on the effects of their conditioned media (CM) on adipocyte lipolysis. Initial analysis of factors secreted by cancer cells revealed significantly elevated polyamine levels in pro-cachectic CM compared to non-cachectic CM. Notably, exposure of adipocytes to polyamines alone phenocopied pro-cachectic CM. Moreover, inhibition of polyamine production in cancer cells using DFMO, a selective ODC1 inhibitor, was sufficient to block the pro-lipolytic properties of their CM. Body composition of our in vivo PDAC model showed a significant reduction in fat mass of tumorbearing mice compared to sham-operated mice, which contrasted with comparable lean mass between groups, indicating that fat waste precedes muscle loss in this model. In addition, we determined that the body fat percentage negatively correlated with serum polyamine levels. Mechanistically, we determined that both in vitro and in vivo, adipocytes subjected to tumorsecreted polyamines showed increased hypusination, a unique posttranslational modification, spermidine dependent, and only described in eukaryotic translation initiation factor 5A (eIF5A). Finally, we showed that inhibiting the hypusination process by treating the adipocytes with GC7, a Deoxyhypusine Synthase (DHPS) inhibitor, prevents the lipolytic activity of the CM. Discussion: This study sheds light on tumor-adipose tissue crosstalk and identifies cancerderived polyamines as key drivers of cachexia. Specifically, polyamines promote the hyperhypusination of eIF5A, thereby enhancing lipolysis. These findings lay the groundwork for developing anti-cachectic therapies that target polyamine-dependent hypusination of eIF5A, potentially improving the quality of life and clinical outcomes for cancer patients suffering from cachexia. |
| 1.271 | Bolajoko Fayoda | NEPH | ? | UNTANGLING THROMBECTOMY FAILURES: HOW COMPLEX STENOSIS AND TREATMENT CHOICES INFLUENCE RECURRENCE AND ACCESS LOSS RISK | Background Arteriovenous accesses (AV) are the preferred standard of care for ESRD patients requiring hemodialysis. Often, these AV accesses whether native or graft fail due to thrombosis. This can lead to dependence on catheters. Therefore, swift endovascular interventions remain the best approach to remove thrombus and restore flow in the circuit. Despite the widespread use of chemical thrombectomy agents like Alteplase and Heparin, and introduction of mechanical thrombectomy devices like Cleaner, Penumbra and Angiojet, there is risk of thrombectomy failure and recurrent thrombosis. This study looks at the risk factors associated with thrombectomy failure or instant recurrence. Methods This is a retrospective chart review of patients presenting to the interventional nephrology suite for thrombectomy of their thrombosed dialysis access from June 1st, 2021, and May 30th, 2024. Unsuccessful thrombectomy was defined as the failure to restore the blood flow at the end of the procedure, need to place a dialysis catheter during the procedure, or return of the patient for repeat thrombectomy or dialysis catheter placement before getting any outpatient dialysis session after the reviewed procedure. Access loss in 90 days was defined as abandonment of the access due to inability to use the access for any further dialysis, resulting in placement of a catheter or a new access placement. Demographics, underlying co-morbidities, access type, anatomy and history, and thrombectomy procedure related factors were compared between the two groups. Results A total of 98 patients underwent thrombectomy. 47% met the definition of unsuccessful thrombectomy. There was no difference between successful and unsuccessful thrombectomies in terms of the type of access, vintage, use of anticoagulation, or previous interventions on the accesses. However, unsuccessful thrombectomy cases presented with greater initial stenosis severity (mean 90% vs. 80% in successful cases, p=0.03), higher residual stenosis post-procedure (mean 46% vs. 10%, p<0.001), and received smaller balloon sizes (mean size 6.0 mm vs. 8.0 mm, p=0.002). Additionally, the use of adjunctive agents, such as TPA (Alteplase) and Heparin, was significantly lower in unsuccessful cases (Alteplase usage: 63.0% vs. 86.5%, p=0.007; Heparin usage: 67.4% vs. 90.4%, p=0.005), highlighting procedural variations between the groups. Outcome analysis indicated a substantial disparity in recurrence risk within 30 days, with unsuccessful thrombectomy cases showing a 54.3% recurrence rate compared to 25.0% in successful cases (p=0.003). Similarly, the likelihood of access loss within 90 days was significantly higher in the unsuccessful group, with a rate of 71.7% compared to 19.2% (p<0.001). Conclusion The study demonstrates that unsuccessful thrombectomy is closely associated with severe lesions difficult to address with standard angioplasty, particularly when larger balloons or thrombolytic agents are not employed. These findings underscore the challenge posed by more complex, treatment-resistant lesions. It emphasizes the utility of thrombolytic agents. These cases are linked to an increased risk of both short-term recurrence and long-term access loss, emphasizing the need for tailored intervention strategies in managing severe stenosis cases. |
| 1.272 | Maria Mora Pinzon | GERI | mmora2@wisc.edu | Combating Survey Fraud Through Enhanced Security Protocols: A Comprehensive Approach Beyond CAPTCHA | Introduction: Sophisticated bots and AI technologies increasingly threaten online survey data integrity, rendering traditional security measures like CAPTCHA insufficient. This abstract presents preliminary results from a multi-layered security framework combining automated and human detection strategies in online healthcare survey research. Methods: We implemented a hybrid security process for a cross-sectional survey of healthcare providers via Qualtrics (November 2024-May 2025). Recruitment occurred via email listservs, personal invitations, QR codes, and social media. Participants completed a screening form before receiving individualized survey links, creating a two-tier security barrier. Our process integrated technical indicators including geolocation checks, Qualtrics Fraud Scores, Rapid Submissions, Regular Wave Patterns, and Suspicious Email Pattern analysis. Using R programming, we developed a fraud detection workflow that followed these steps: (1) entries were automatically disqualified based on both eligibility criteria (e.g., non-healthcare providers, age requirements) and definitive fraud indicators (e.g., non-US submissions, duplicate emails); (2) remaining submissions underwent manual review where entries with 2+ indicators received brief verification of fraudulent status; and (3) entries with fewer than 2 indicators underwent comprehensive examination including credential verification. This approach ensured no entries were classified as fraudulent based on a single non-definitive indicator. Results: We received 5,886 responses through March 2025. The process automatically disqualified 2,895 (49.2%) submissions based on eligibility criteria and definitive fraud indicators, while 2,991 (50.8%) underwent manual review. Of these, 2,224 (74.4%) contained two or more indicators requiring only brief verification of fraudulent status, whereas 767 (25.6%) needed a more comprehensive examination. Ultimately, this combined automated and manual process identified only 40 legitimate entries (0.7%) with 5,846 submissions (99.3%) classified as fraudulent. The most prevalent indicators included Regular Wave Patterns at 75.6%, defined as submissions occurring in batches within 5-minute windows with consistent intervals; High Qualtrics Fraud Score at 27.4%, triggered when scores reached or exceeded 30; Rapid Submission at 22.3%, identified as three or more submissions occurring in the same minute; and Suspicious Email Pattern at 17.4% which included nonsensical structures such as unusual character combinations, excessive number sequences, and low vowel-to-consonant ratios. Discussion: Maintaining online survey integrity requires implementing multi-faceted security approaches beyond basic measures like CAPTCHAs. Our findings demonstrate that combining automated detection with strategic human oversight effectively identifies sophisticated fraud attempts, ensuring data reliability as fraudulent techniques continue to evolve. |
| 1.273 | Jeremy D Kratz | HEM/ONC | jdkratz@medicine.wisc.edu | Physiologic Epidermal Growth Factor Modeling Improves Sensitivity of KRASG12D Inhibitor MRTX1133 | Background: Pancreatic Ductal Adenocarcinoma (PDAC) remains a formidable cancer type with a median 5-year survival rate of 13%, largely due to ineffective systemic therapy. MRTX1133 is an emerging small molecule inhibitor of KRASG12D which has been shown to be effective across multiple treatment settings. Epidermal growth factor (EGF) is often integrated at supraphysiologic levels in models of luminal cancer types. Here, we evaluate KRASG12D targeting as a function of EGF supplementation to understand both sensitivity and selectivity across EGFR signaling. Methods: Organoids were seeded in low volume 10uL 96 well plate (Ibidi, Inc) with a density of 500 cells per microliter across experimental groups. Organoids were treated with MRTX1133 in serial dilutions with either standard EGF concentrations (50 ug/mL) or physiological (0.5 ug/mL). Brightfield imaging was captured using time course data from 0h to 144h via Cytation 5. Viability was assessed 144 hours post treatment via Cell-Titer Glo assay, to calculate IC50 of MRTX1133 (n= 8). Response to MRTX1133 was tracked via effect size Glass’s Delta, which is defined by difference between the mean of control and treatment group normalized to the standard deviation of the control. Protein analysis was performed by western blot for MAP kinase effector signaling. Results: Removal of EGF in media lead to growth arrest over the course of 5 weeks (+17.8% v. + 120% in control; GD = 0.64 ). Indicating that its addition is required for proper organoid propagation. When established across 5 weeks, physiologic levels of EGF in cultures did not impact the growth of KRASG12D pancreatic organoids (+101.3% v. 102% in control; GD = 0.005). However, the use of physiologic EGF had improved sensitivity to MRTX1133 (IC50 0.46± 11.03 nM) when compared to standard media (IC50=33.6±3.40 nM), which shows a 60-fold decrease in sensitivity. At lower concentrations of MRTX1133 (0.5nM), resistance was observed in standard EGF conditions (+133.8% v. +106.4% in control; GD = 0.437), in comparison to physiological EGF media which reduced proliferation (+55.8% v. +85.7% in control; GD= -0.47). Western blot analysis revealed few changes between standard media conditions and physiologic when probing for effectors in Ras signaling, such as AKT and EGFR. Treatment of MRTX1133 (10nM) over 72 hours, also did not yield improved inhibition at either media conditions. Conclusion: Physiologic EGF stimulation yielded improved sensitivity to MRTX1133 in a manner independent of organoid growth rate. While resistance to MRTX1133 can be observed in organoid models, understanding this as a function of accurate EGF stimulation remains a critical need particularly at informing relevant resistance mechanisms. Future work includes evaluating this across a diversity of KRASG12D cancer models and comparing physiologic EGF across therapeutic screening applications in combination. |
| 1.274 | Mark Benson | GASTRO | mb4@medicine.wisc.edu | Prolonged Duration, Enhanced Outcomes: Evaluating Outpatient Endoscopy Quality and Diagnostic Yield at the Digestive Health Center | BACKGROUND: With more than 6 million esophagogastroduodenoscopies (EGDs) completed annually in the United States it is of upmost importance to follow procedure quality metrics like those for colonoscopy. Best-practice advisory on high-quality EGD recommend sufficient inspection time, 7 minutes, for a thorough endoscopic evaluation. There is a paucity of research evaluating the influence of procedure time on EGD outcomes in the United States. Our study evaluated how procedure time affects endoscopic outcomes and adherence to recommended quality metrics for EGDs completed at the Digestive Health Center. METHODS: 1000 consecutive EGDs completed by multispecialty endoscopists at the Digestive Health Center at the University of Wisconsin from 1/1/23-4/27/23 were reviewed. Patient demographics, sedation type, procedure indication, procedure time, endoscopist subspeciality, intra-procedure findings, maneuvers and photos, recommended procedure quality metrics, biopsy location and pathology results were compared for procedures completed in less than 7 minutes to those procedures completed for greater than 7 minutes. RESULTS: The overall mean EGD procedure time for the entire cohort was 5.76 (±3.4) minutes. Mean patient age was 51 (±16.5) years old, 45 % male. Only 28% of the procedures were ≥ 7 minutes. There was no significant difference in the patient demographics, sedation type and procedure indication between the two procedure groups compared. There was a significant increase in the detection of Barretts mucosa for EGDs completed for ≥ 7 minutes compared to those < 7 minutes, 12.3 % vs 5.9 %, P < 0.001. There was a two-fold increase in esophageal cancer detection, 0.8% vs 0.4%, P=0.32, and three-fold increase in gastric cancer detection, 1.2% v 0.4%, P=0.14, between the groups. There was a significant difference in the mean EGD procedure times for the 31 subspecialty endoscopists studied, ranging from 4.4 min. to 9.6 min. P<0.0001. The mean procedure times for the subspecialties were: Esophagology, 5.5 min., Advanced Endoscopy, 5.6 min., IBD, 5.4 min., General GI, 6.3 min. and Hepatology, 6.9 min. CONCLUSIONS: EGDs completed in ≥ 7 minutes are associated with a significantly higher pathology detection rate as well as higher detection esophageal and gastric cancer. There is a significant variation in mean EGD procedure times and poor compliance with recommended quality procedure metrics. This implementation of strict multi-society US EGD quality standards is of paramount importance to ensure comprehensive high quality patient care. Future studies on educational interventions to improve EGD quality are needed. |
| 1.275 | Farhan Raza | CVM | fraza@medicine.wisc.edu | Does Pericardiotomy with Cardiac Surgery Relieve Pericardial Restraint and Elevated Left Heart Pressures in Pre-capillary Pulmonary Hypertension? | Background Pericardial restraint may contribute to elevated left heart pressure, particularly with compression of a dilated right ventricle, leading to HFpEF physiology. Preclinical studies have demonstrated that removal of pericardial restraint by surgical pericardiotomy can lead to sustained reduction in left heart pressures. In thus study, we report trends of left heart pressures in patients undergoing cardiac surgery with pericardiotomy vs. those with intact pericardium. Methods: This retrospective study included 204 participants who underwent invasive cardiopulmonary exercise testing (iCPET) and left ventricular ejection fraction ≥50%. The overall cohort was subdivided into two groups: 1. Post-pericardiotomy (prior cardiac surgery), and 2. Intact pericardium. A chi‐square analysis was performed to compare the incidence of HFpEF (defined by an abnormal pulmonary artery wedge pressure: PAWP >15 mmHg) between patients with and without pericardiotomy. Using a similar approach, a sub-analysis was also conducted in participants with pulmonary vascular resistance (PVR) > 2.0 woods unit (n=134). Results Out of 204 participants, 51 had a pericardiotomy history with 26 among those with PAWP>15 mmHg (51%). Among the rest with intact pericardium (n=153), 70 had PAWP >15 mmHg (46%; p=0.44). In the subgroup analysis including only participants with PVR>2 (n=134), incidence of HFpEF was comparable in post-pericardiotomy (54%) vs intact pericardium group (46%, p=0.42). Although statistically insignificant, repeat analyses using lower PAWP cutoff (>12 mmHg) revealed lower incidence of elevated left heart pressures among postpericardiotomy vs intact pericardium groups (69% and 76% p=0.34). The findings in the elevated PVR group were similar (71% and 80% p= 0.31). Conclusion In this study, prior history of pericardiotomy did not demonstrate lower rates of elevated left heart pressures. However, we plan additional analyses including impact of comorbidities increasing intra-thoracic pressure (obesity, sleep apnea) and myocardial structure (quantitative echo data for ventricular interdependence) as next steps to more definitively assess the impact of pericardiotomy on left heart pressures in HFpEF. |
| 1.276 | Lixin Rui | HEM/ONC | lrui@medicine.wisc.edu | DNMT3B functions as a tumor suppressor in Mantle Cell Lymphoma | Introduction: Lymphoma is the most prevalent blood cancer, causing over 20,000 deaths annually in the United States and non-Hodgkin lymphoma constitutes approximately 90% of all lymphoma cases. DNMT3B, a member of the DNA methyltransferase (DNMT) family, is crucial for normal B-cell development and differentiation, alongside DNMT3A and DNMT1. Research indicates that DNMTs are involved in hematological malignancies. Specifically, the expression of DNMT1 and DNMT3B is strongly linked to advanced clinical stages and poor responses to chemotherapy or radiotherapy. DNMT3A has been associated with drug resistance in mantle cell lymphoma (MCL) by mediating oxidative phosphorylation. However, the precise role of DNMT3B in lymphomagenesis remains unclear, underscoring the need to further explore DNMT3B-dependent regulatory networks. Methods: In this study, we applied both cellular and genomic experiments to reveal the role of DNMT3B in mantle cell lymphoma, generated DNMT3B knockout and overexpression cell lines and performed RNA sequencing for DNMT3B knockout or wild-type cell lines. Differentially expressed genes and pathways were revealed by bioinformatics analysis. Motif enrichment analysis of chromatin immunoprecipitation sequencing (ChIP-seq) data revealed the binding sites of DNMT3B. Immunohistochemical staining (IHC) of tissue microarrays for diffuse large B cell lymphoma (DLBCL) and MCLwas conducted. Antibodies for DNMT3B and PAX5 were used to detect the different expression levels between normal and tumor tissues. Immunoprecipitation (IP) experiments were used to detect the interaction between DNMT3B and PAX5. We will use patient-derived xenograft mouse models to validate our cell line and in vitro findings. Results: The IHC analysis of 58 MCL and 57 DLBCL samples revealed significantly lower DNMT3B protein levels in tumor tissues compared to lymph nodes and tonsils, suggesting that DNMT3B is downregulated in both tumor types, which may point to a potential role of DNMT3B loss in lymphomagenesis (Fig. A). To verify these findings in vitro, we developed a DNMT3B knockout system in MCL cell lines (Z138 and Mino). Doxycycline was used to induce sgRNA expression. cell numbers on day 20 were normalized to the control group. The result revealed a significant increase in cell count in the doxycycline-treated groups for the Z138 pool and Mino pool cell lines, consistent with our expectations (Fig. B). To determine the molecular mechanism underlying increased cell proliferation following DNMT3B knockout, I performed RNA-seq and ChIP-seq analyses on Z138 cells using DNMT3B KO cells as a control. Gene set enrichment analysis revealed that 22 gene sets were significantly upregulated in the DNMT3B KO group, while 28 gene sets were downregulated in the control group. Among these 50 gene sets, I noted a marked upregulation of MYC-target gene sets in the KO group (Fig. C). In the ChIP-seq analysis, I identified a total of 4,027 peaks in the WT group (Fig. D). Subsequently, I performed motif analysis to explore potential protein interactions at the same binding sites as those of DNMT3B. This analysis highlighted PAX5 as the top-ranked protein, indicating a significant association with DNMT3B binding sites. The identification of PAX5 in this context suggests a potential interaction between DNMT3B and PAX5, which may play a crucial role in the regulatory network governing gene expression in lymphoma. To investigate the interaction between PAX5 and DNMT3B, I conducted an IP experiment. Plasmids encoding Flag-PAX5 and HA-DNMT3B were co-transfected into 293T cells to facilitate the expression of both proteins. Western blotting was then performed to detect the presence of the respective proteins in the immunoprecipitated samples. The Western blot results demonstrated the presence of the PAX5 band in the IP sample with DNMT3B (Fig. E). IHC staining on TMA for PAX5 and DNMT3B observed PAX5 upregulation in tumor tissues. Additionally, correlation analysis revealed a significant negative correlation between PAX5 and DNMT3B, suggesting a potential antagonistic relationship between these two proteins. Discussion: In this study, immunohistochemistry analysis revealed reduced DNMT3B expression in MCL and DLBCL samples compared to normal lymphoid tissues. In vitro experiments indicated the suppressive function of DNMT3B. My RNA-seq analysis of an MCL cell line demonstrated that MYC and cell cycle signature genes were enriched following DNMT3B knockout by a small guide RNA (sgRNA). ChIP-seq and IP results revealed the potential interaction between DNMT3B and PAX5. These findings prompted me to investigate the molecular mechanisms underlying the oncogenic cooperation between DNMT3B loss and PAX5 overexpression, which remain poorly understood. |
| 1.277 | Farhan Raza | CVM | fraza@medicine.wisc.edu | Phenotypic clustering of HFpEF using cardiac magnetic resonance imaging | Background: Improved understanding of the high-risk features associated with HFpEF may facilitate risk stratification. Cardiac magnetic resonance (CMR)-based strain and structural data can define detailed myocardial structure, which can be leveraged to define heterogenous HFpEF phenotypes. This study used phenotypic clustering integrating CMR-based strain and structural data to identify a high-risk HFpEF phenotype. Methods: Retrospective analyses of 48 HFpEF participants, who underwent cardiac MRI and invasive cardiopulmonary exercise testing (median time between the two studies=40 days), was performed. We conducted unsupervised and unbiased K-means clustering analyses using CMR-based strain and myocardial structural variables. We associated two identified clusters with mortality using Cox proportional hazards modeling and constructed Kaplan-Meier survival curves. A p-value was considered significant if < 0.05. Results: We identified a low (n=32) and high-risk (n=16) cluster. Patients in the identified clusters had similar ages and comorbidities. The high-risk cluster had more male participants and hemodynamically had a higher exercise mPAP/CO and PAWP/CO slope, which are metrics of pulmonary vascular disease. The high-risk cluster displayed greater LV mass, worse biventricular longitudinal strain, decreased right ventricular ejection fraction, and greater interventricular septal angle (all P<0.05) as characterized by CMR as compared to the low-risk cluster (Table 1, Figure 1A). Mortality for the high-risk cluster was 5.43 times that for the low-risk cluster at 12 months (95% CI 1.69-17.42, Figure 1B). Conclusions: Using clustering analyses with CMR strain and structural variables, we identified a high-risk HFpEF phenotype with increased LV mass, reduced biventricular strain, and reduced RV ejection fraction. |
| 1.278 | Sterling Johnson | GERI | scj@medicine.wisc.edu | Longitudinal evaluation of 18F-MK-6240 in patients with Alzheimer’s disease dementia or mild cognitive impairment compared to healthy volunteers. | Purpose/Background: Understanding the rate of fibrillar tau progression is critical for staging and monitoring progression of Alzheimer’s Disease (AD) and for designing clinical trials, as it provides essential insights into neuropathology trajectory and the potential efficacy window for therapeutic interventions. While 18F-MK-6240 PET imaging has shown utility in tracking tau pathology, longitudinal data on its accumulation rates are limited. In this study, we addressed this gap in knowledge by evaluating longitudinal changes in tau deposition using 18F-MK-6240 PET imaging in individuals across stages of cognitive impairment. We investigated the rate of change in specific regions to provide evidence for potential reporting regions for future clinical trials using tau PET as an outcome. Additionally, we analyzed the observed rates of change at 6, 12, and 24 months in the selected reporting region to inform the design of future trials. Methods: This study was a longitudinal, observational, open-label study of investigating changes in the non-treatment radiotracer 18F-MK-6240 which recruited 27 participants (13 F/14M; AVG Age 72.62, STD 5.90) with varying cognitive statuses: 6 participants who were cognitively unimpaired healthy volunteers (HV; 2/6 Amyloid+), 8 participants with mild cognitive impairment (MCI; 8/8 A+), and 13 participants with AD dementia (13/13A+). Amyloid PET imaging using 11C-labeled Pittsburgh Compound-B (11C-PIB; dynamic imaging from 0-70 minutes post-injection) was used to determine amyloid positivity at baseline. Participants underwent 18F-MK-6240 PET imaging at baseline, 6, 12, and 24 months with additional 18 and 30 month timepoints for COVID-19 pandemic related flexibility reasons. Tau PET data were analyzed as standardized uptake value ratios (SUVRs) in regions of interest corresponding to Braak neuropathological staging as well as two composite ROIs: meta-temporal composite (MTC) and an early tau composite (EFAH). Cognitive testing was done using Mini-Mental State Exam (MMSE), Clinical Dementia Rating Scale (CDR), and the Alzheimer’s Disease Assessment Scale (ADAS-Cog) at each timepoint. Raw and annualized rates of change in SUVR were estimated and compared between cognitive status groups using Kruskal-Wallis tests. Correlations between change in SUVR and cognitive outcomes were estimated using Spearman’s rho. Results: At the baseline timepoint, visual reads of tau deposition, as measured by 18F-MK-6240 PET imaging, demonstrated a clear progression across cognitive groups, with minimal signal in CU participants, signal localized to the medial temporal lobe in MCI participants, and signal spanning the inferolateral temporal lobe and extending posteriorly along the ventral cortex and into the posterior parietal cortex and cingulate in dementia participants. We observed a correlation between amyloid burden and tau deposition; those with higher PiB levels had an associated elevated 18F-MK-6240 signal in the MTC region, our primary composite ROI. Longitudinal analysis over two years showed that the percent change in tau deposition in this region was -0.59% in HV participants, +12% in the MCI group, and +9% in the dementia group. In addition, tau accumulation in this region was significantly associated with cognitive decline as measured by ADAS-11 score (ρ=0.43). The results from this study support the utility of these regions, in particular the MTC, as ROIs in clinical trials using 18F-MK-6240 as an imaging biomarker. Conclusion: This study supports the use of 18F-MK-6240 PET imaging to track tau accumulation over time and provides preliminary evidence that these changes correlate with cognitive decline. The findings align with the established Braak staging methods, demonstrating progressive tau deposition in an expanding spatial distribution over the course of AD. |
| 1.279 | Jessica Tischendorf | ID | jtischen@medicine.wisc.edu | Perceptions of Bias and Discrimination Among Antimicrobial Stewardship Providers | Background: Bias and discrimination influence the experience of many in healthcare, and antimicrobial stewardship providers are no exception as demonstrated by work documenting differential uptake of recommendations made by men and women stewards. In this mixed method study, we explored the perceptions and experiences of bias and discrimination among antimicrobial stewards. Methods: We conducted a nationwide survey of stewardship providers including physicians, pharmacists, advanced practice providers and trainees. Participants were recruited via convenience sampling using X and professional listservs during May and June 2023. We solicited steward and program demographics and responses to statements exploring bias and discrimination in the execution of stewardship duties through a 67- item electronic survey (Qualtrics). Statistical analysis using chi-squared, ANOVA, student t-tests were performed in STATA. We further explored these experiences through semi-structured interviews. Results: 209 surveys were collected including 135 Female (65%) and 52 non-white or multi-race (24.8%). The average age of respondents was 38 years and practicing >10 years in stewardship. Female stewards reported their gender negatively influenced their experiences with primary teams (29.2%) and health system (29.6%). Among the youngest cohort of stewards, almost half perceived their seniority negatively influences their interactions with primary teams and the greater health system (49.2%, 48.7%). Non-white stewards (16.1%) report a negative influence of their race and/or ethnicity with the health systems compared to white respondents (3.6%). Themes from our 16 interviews illuminated sources of perceived bias against stewards, the impact they had, and strategies to mitigate the influence of these biases. Conclusions: Bias and discrimination are felt disproportionately by women and junior antimicrobial stewardship providers and can lead to poor job satisfaction and lack of perceived effectiveness. Acknowledging these experiences and equipping stewards with strategies to mitigate the harmful personal, professional and programmatic effects of bias and discrimination should be a priority of institutions and professional societies. |
| 1.280 | Dudley Lamming | ENDO | dlamming@medicine.wisc.edu | Protein restriction improves metabolic health but not lifespan in aged C57BL/6J mice | Aging individuals often face conflicting dietary advice regarding the protein content of their diets. High protein diets are often recommended to aging individuals to combat age-related diseases such as sarcopenia and frailty. However, there is increasing evidence that low protein diets are associated with reduced weight, increased glucose tolerance, and reduced mortality in mice when used as a lifelong intervention. Many studies analyze the impacts of these diets as an early onset, lifelong dietary pattern, so it remains unclear how these diets may influence health and lifespan when introduced as a late-life intervention in aged animals. To study this, we assigned male and female C57BL/6J mice to isocaloric diets composed of either 7% (Low Protein, LP), 21% (Medium Protein, MP), or 36% (High Protein, HP) kilocalories from protein starting at 21 months of age. We then investigated markers of metabolic health via glucose and insulin tolerance tests, measured functional strength via rotarod and inverted cling tests, quantified metabolic activity with CLAMS metabolic chambers, and performed routine frailty assessment and MRI analysis of body composition. Our data reveal that aged male mice on an LP diet have reduced body weight and adiposity despite consuming more food, while also exhibiting improved glucose tolerance, improved insulin sensitivity, and reduced frailty compared to those consuming an HP diet. Aged female mice on LP diet have decreased body weights and improved glucose tolerance, but do not exhibit improvements in insulin sensitivity or frailty. Additionally, LP fed mice have elevated energy expenditures and respiratory exchange rates than MP and HP fed mice. Counterintuitively, LP diet males exhibit longer rotarod endurance compared to HP diet, though ANCOVA analysis suggests this is attributable to differences in body weights. Dietary protein content did not impact lifespan, suggesting that these interventions may not be potent enough to alter lifespan in aged animals. Together, these data suggest that low protein diets may be effective in improving the metabolic and functional health of aged individuals, while a high protein diet may actually accelerate aging phenotypes when used as a late-life dietary model. |
| 1.281 | Mariana Pehar | GERI | mapehar@medicine.wisc.edu | Therapeutic potential of FABP7 in a mouse model of Alzheimer's disease | Background: Multiple lines of evidence indicate that the activation of inflammatory processes has an early and important involvement in Alzheimer’s disease (AD) pathology. However, clinical trials with anti-inflammatory agents have so far failed to show conclusive results. We previously showed that fatty acid-binding protein 7 (FABP7) upregulation induces a proinflammatory phenotype in human and mouse astrocytes in culture. In addition, FABP7 is upregulated in the brain of AD patients and mouse models, most prominently in astrocytes surrounding amyloid plaques. FABP7 regulates the inflammatory response by simultaneously targeting different signaling pathways in astrocytes. Here, we performed a preclinical study to evaluate the therapeutic potential of targeting FABP7 in APP/PS1 mice, a widely used AD mouse model. Methods: We used a viral vector to knockdown astrocytic FABP7 in APP/PS1 mice and 5 months later evaluated histopathological hallmarks of the disease by Western blot and immunostaining. In addition, cognitive performance was evaluated using pre-pulse inhibition (PPI) and fear-conditioning tests. Results: Downregulation of FABP7 expression decreased glial reactivity in the brain of APP/PS1 mice. This effect was particularly evident in the vicinity of amyloid plaques. In addition, FABP7 downregulation attenuated the accumulation of phosphorylated-Tau at Ser396 (PHF13), a phosphorylation site that has been identified in paired helical filaments from the brain of AD patients. Lastly, we observed beneficial effects in cognitive performance. Conclusion: Collectively, our findings support the therapeutic potential of targeting astrocytic FABP7 to reduce the deleterious effects of chronic neuroinflammation observed in AD. |
| 1.282 | Barbara B. Bendlin | GERI | bbb@medicine.wisc.edu | Investigating the Relationship Between Neuropsychological Testing and Synaptic Density | Post-mortem studies show that synaptic loss is a feature of Alzheimer’s disease dementia (Scheff et al. 2006). The [C-11]UCB-J PET tracer, which binds to synaptic vesicle glycoprotein 2A on presynaptic terminals, now allows for the in vivo measurement of synaptic density (Finnema et al. 2016). This project examines the relationship between cognitive performance, as measured by the Montreal Cognitive Assessment (MoCA) and the Rey Auditory Verbal Learning Test (RAVLT), and in vivo synaptic density measured by PET UCB-J distribution volume ratios (DVR). Methods: Participants were recruited from the Wisconsin Alzheimer’s Disease Research Center, the Wisconsin Registry for Alzheimer’s Prevention, and the community for participation in a brain synapse imaging study. Individuals who completed [C-11]UCB-J PET and neuropsychological testing were included in this analysis (N=86). Synaptic density was quantified from [C-11]UCB-J scans using Logan Graphical Analysis (whole cerebellar reference region) and regions of interest (hippocampus, entorhinal cortex, amygdala, inferior parietal lobule, parahippocampal gyrus, and precuneus) were defined using FreeSurfer T1-weighted MRI parcellation. We used multiple regression to examine the relationship between performance on the MoCA total raw score, RAVLT Delayed Recall, and RAVLT Immediate Recall with UCB-J DVR in the 6 identified ROIs. All models adjusted for age, sex, years of education, and diagnosis (unimpaired vs impaired) and a Benjamini-Hochberg false discovery rate correction was applied. Results: Hippocampal UCB-J DVR was significantly associated with RAVLT Immediate (β = 0.002, SE = 0.0006, p = 0.02) and RAVLT Delayed Recall (β = 0.006, SE = 0.002, p = 0.02), however these associations did not survive multiple comparison correction. The MoCA total score was not associated with UCB-J DVR in any of the 6 brain regions. Discussion: Although associations between RAVLT Immediate and Delayed Recall with hippocampal UCB-J DVR did not remain statistically significant after p-value correction, the positive correlation is still noteworthy. As expected, lower immediate and delayed recall scores (indicative of impaired verbal learning and memory) were associated with lower DVR scores, suggesting that reduced synaptic density in the hippocampus may play a role in learning and memory, consistent with previous findings (Moradi et al, 2016). |
| 1.283 | Ksenija Bernau | APCCM | kbernau@medicine.wisc.edu | Fibronectin-targeting peptide PET probe uptake in fibrogenesis correlates with lung function decline during the established fibrosis phase in murine pulmonary fibrosis | Introduction: Progressive forms of interstitial lung diseases, including idiopathic pulmonary fibrosis, are devastating disorders characterized by rampant extracellular matrix (ECM) deposition, respiratory failure and mortality. There are no biomarkers that serve to non-invasively assess disease progression in real time and predict upcoming fibrotic burden. Fibronectin (FN), an ECM glycoprotein, is abundantly upregulated and critical for fibrogenesis. Due to the role of FN in ECM elaboration, we are targeting it with a PEGylated FN binding peptide (PEG-FUD), to elucidate the ability of this novel PET-based probe to detect early disease activity and predict upcoming fibrosis. Methods: To induce pulmonary fibrosis, 10-week-old male and female C57Bl6/J mice were administered a single, intratracheal dose of bleomycin (1U/kg) or normal saline (NS). Each week thereafter, this single cohort of mice was intravenously administered [64Cu]Cu-PEG-FUD 24 hours before computed tomography (CT) and positron emission tomography (PET) imaging for 4 consecutive weeks post-bleomycin administration. On week 4, lung function and mechanic measurements, including compliance and inspiratory capacity (IC), were collected using flexiVent. PET/CT data was analyzed using Imalytics Preclinical software. Furthermore, 150 radiomic features were computed for both CT and PET to reveal distinct patterns and correlations between models. Results: PET/CT imaging revealed a differential distribution of CT and PET signals over the course of bleomycin induced pulmonary fibrosis. CT voxel distribution analysis indicated a rightward shift toward increased Hounsfield unit values 2-4 weeks post-bleomycin, indicating increased radiodensity and fibrosis compared to NS-treated controls. In contrast, PET image voxel distribution from [64Cu]Cu-PEG-FUD was the most right shifted 1 week post-bleomycin compared to NS, suggesting greatest probe uptake occurs early. However, 2-4 weeks post-bleomycin, PET distribution began shifting back toward NS, revealing lower signal intensity. Finally, measures of lung function decline, including compliance and IC, at week 4 post-bleomycin correlated with PET uptake at week 1. Discussion: We show that PET probe uptake precedes detection of lung fibrosis by CT imaging, suggesting that PEG-FUD may be used for early detection of fibrotic disease activity. Furthermore, the correlative relationship between probe uptake 1 week post-bleomycin (fibrogenesis) and measures of declining lung function 4 weeks post-bleomycin (established fibrosis) indicate that our probe has the capacity to predict the upcoming fibrotic burden during early phases of the disease. Thus, radiolabeled PEG-FUD peptide holds promise to serve as a PET-based molecular imaging probe for assessment of pulmonary fibrosis progression, offering clinical providers a real-time insight into patients’ disease status and the need for therapeutic intervention. |
| 1.284 | Jeremy Kratz | HEM/ONC | jdkratz@medicine.wisc.edu | Optimization of CRISPR-Cas9 library screens in pancreatic cancer organoid models targeting KRASG12D | Introduction: Pancreatic ductal adenocarcinoma (PDAC) has a critical need in systemic therapeutic development, with hallmark activation of the mitogen-activated protein kinase pathway. Novel mutant-specific KRAS inhibitors have been developed, however no method to date can predict patient-specific resistance mechanisms. Here, we optimize a CRISPR-Cas9 lentivirus screen in 3D patient-derived cancer organoids (PCOs) to study resistance mechanisms and guide combination therapy using the KRASG12D inhibitor MRTX1133. Methods: PDAC PCOs were derived from surgical specimens. Puromycin (puro) dose-response curves were established using cell viability assays. PCOs were transfected with a lentiviral-based ‘druggable genome’ CRISPR-Cas9 library of 2,292 unique targets (Millipore-Sigma) overnight (18h) in a liquid phase with the addition of polybrene (5ug/mL). Puro selection was compared for efficiency at 6 days and 12 days. Western blotting was used to confirm Cas9 expression. Multiplicity of infection (MOI) optimization was performed by digital droplet PCR (ddPCR) on selected cells to measure lentiviral genome copy number efficiency. MOI was compared across traditional cell viability assays using CellTiterGlo (CTG, 50% v/v) and cell counting methods. Results: Molecular profiling of the PDAC PCO line confirmed KRASG12D mutant by DNA sequencing (SureSelect Cancer, Agilent). Puro dose was selected at 2 mM to exceed the IC90 of 1.95 ± 0.1 μM. Western blots confirmed Cas9 presence in selected cells. The KRASG12D inhibitor MRTX1133 revealed an IC50 of 11.16 ± 0.36 nM. The 1:5 cell-to-lentivirus ratio after 6 days of puro selection was selected based on copy number analysis by ddPCR (0.93 ± 0.01). The control, 1:2, and 1:10 ratios after 6 days of selection exhibited copy numbers of 0 ± 0, 0.53 ± 0.13, and 1.52 ± 0.38, respectively. Selection for 12 days yielded higher copy numbers (1.13 ± 0.38 at 1:2, 1.19 ± 0.11 at 1:5, and 1.72 ± 0.43 at 1:5) compared to the 6 day puro selection. Increased selection time also revealed reduced viability compared to the 6 day selection. The 1:5 ratio showing 16.8% (p<0.0001) and 22.65% (p<0.0001) viability, respectively. Post-selection, the viability of puro-selected, non-transfected cells was 0%, confirming selection efficiency. Discussion: Here, we demonstrate the optimization of CRISPR-Cas9 screening with 3D PDAC PCOs using ddPCR to validate the efficiency of transfection. Importantly, the degree of puro selection and lentivirus transfection did confer multiplicity in viral transfections. The ongoing work is aimed at understanding the time course dynamics of gene editing between early (14 day) and late (28 day) resistance to KRASG12D inhibition using the Model-based Analysis of the Genome-wide CRISPR/Cas9 Knockout (MAGeCK) method. This work extends the efficiency of novel gene editing technologies for screening applications in organoid models of pancreatic cancer. |
| 1.285 | Chris Crnich | ID | cjc@medicine.wisc.edu | Results of a Statewide Survey of the Antibiotic Tracking and Reporting Inventory (ATARI) in Wisconsin Nursing Homes | Introduction Antibiotic tracking and reporting are core components of nursing home (NH) antibiotic stewardship programs. Nevertheless, how NHs conduct these essential activities remains poorly understood. The objectives of this study were to understand how NHs capture information on antibiotic use (AU) and characterize how AU is reported in Wisconsin NHs. Methods: The Antibiotic Tracking and Reporting Inventory (ATARI), a survey instrument designed to characterize the structure and process of antibiotic tracking and reporting in NHs was developed and piloted through a mixed methods approach. The instrument is organized into three sections: facility demographics, structure and process of AU data collection, and types of AU measures reported and methods of generation. After coding into REDCap, the ATARI instrument was distributed to Wisconsin NHs (n = 328) in partnership with the Wisconsin Department of Health Services. Descriptive statistics were utilized to summarize information regarding antibiotic data collection, AU reporting, and NH characteristics. Results: One hundred and thirty-two responses were received, of which 98 completed the instrument in its entirety for a response rate of approximately 30%. 21.5% of NHs reported a bed size of >100, 60% reported a bed size between 50-100 beds, while 19.5% of NHs reported having less than 50 beds. NHs reported devoting approximately 10 hours per week to completing surveillance line listing activities and 18 hours per month in developing and disseminating reports (Table 1). NHs employed a variety of tools including Excel-based tools (69%), followed by paper (39%), EMR-embedded or infection control software (29%), and others (2%) to conduct line listing activities (Table 1), with 32 NHs employing more than one tool for this purpose. A majority, approximately 84%, of NHs reported at least one measure of antibiotic initiation although there was variation in whether facilities employed starts, courses, and treatment measures (Table 2). Nineteen NHs utilize one or more report tools. A majority of NHs employed rate adjustment and stratification of their initiation measure by indication as well as appropriateness in their reports. In contrast, a minority, 39%, of NHs reported a treatment duration measure (Table 2). Discussion: Wisconsin NHs devote a considerable amount of time to tracking and reporting of AU and employ a variety of low-tech tools for this purpose. There is considerable variability in the types of AU measures monitored in NHs with a majority focused on antibiotic initiation measures and lesser focus on measuring duration of therapy. These results suggest a need for standardization of AU measures in NHs as well as information systems that improve the efficiency of their collection and reporting. |
| 1.286 | Anupama Joseph | CVM | atjoseph2@wisc.edu | Community-Engaged Cardiovascular Health in the Forest County Potawatomi Tribe: A Qualitative Study | Background: More than one in three American Indians (AI) will die from premature atherosclerotic cardiovascular disease (ASCVD), nearly 2.5 times the rate seen in non-Hispanic White individuals; 80% of these deaths are preventable. Community-centered ASCVD prevention programs, which empower Indigenous voices and promote sustainable change, are necessary, but have been underutilized in AI populations. The Forest County Potawatomi (FCP) tribe (Crandon, WI) experiences disparate rates of ASCVD risk factors, particularly obesity, type 2 diabetes mellitus (T2DM) and commercial tobacco use. We aimed to understand FCP perspectives surrounding cardiovascular health and health programming as a foundational step to enhance ASCVD prevention efforts within the tribe. Methods: Two separate advisory boards were recruited, the first (FCP-CAB) made up of seven tribal Elders, and the second (Prov-AB) comprised of 12 FCP Clinic providers and staff. With the help of two expert facilitators from WINRS, five alternating semi-structured group discussions were audio recorded, transcribed and edited for clarity and to remove identifiers. Discussion transcripts were coded by a research team (AJ, LH, MM) using NVivo 14 (Lumivero, 2023) using inductive thematic analysis. Reorganization, coding distribution and frequent meetings ensured coding concordance. Results: The FCP-CAB, initially tasked with identifying 1-2 ASCVD risk factors to prioritize for intervention, immediately described their perception of the interconnectedness of all aspects of health (physical, emotional, spiritual and mental). Reflecting this, although there were areas of overlap, six discrete themes were identified from the broad parent coding, subcategorization and text segment analysis (Table 1). Participant validation was solicited to ensure the resonance of these themes with the FCP-CAB. Members discussed ASCVD risk factors (particularly T2DM) and clinical ASCVD as separate entities. They highlighted prior elimination of opioid-related overdoses as an example of community capacity to sustain meaningful change. FCP-CAB and Prov-AB members noted that interventions should be community-centered, inclusive, rooted in traditions and youth-focused to improve cardiovascular health. Discussion: This qualitative study elicited novel insights into the FCP’s perception of cardiovascular health and identified six themes that will be leveraged as a framework to co-design ASCVD risk reduction programs within the FCP tribe. |
| 1.287 | Danielle E. McCarthy | UW Center for Tobacco Research and Intervention, General Internal Medicine | demccarthy@ctri.wisc.edu | Bringing NCI’s Moonshot Cancer Center Cessation Initiative to UW Carbone Cancer Center: A Pilot Proactive Outreach Approach to Offer Tobacco Treatment for Patients with Cancer | Abstract Introduction: Cigarette smoking is far too rarely addressed during cancer care, despite strong evidence that quitting smoking can benefit patients with cancer by contributing to improved survival and quality of life. Many barriers that contribute to the undertreatment of smoking are challenges in all care contexts (e.g., lack of clinician time, inefficient workflows), while others are heightened in the context of cancer care (e.g., stigma, fatalism, stress). Systems change that promotes smoking treatment for all patients with cancer who smoke can increase the reach of evidence-based treatment. We conducted a pilot study of an innovative, proactive tobacco treatment outreach approach that addresses many translational barriers to implementing evidence-based tobacco treatment in practice. Methods: Quarterly reports from electronic health records (EHR) identified UW Carbone Cancer Center adult patients who had select cancer diagnoses (head, neck, lung, skin, bladder) in the past 3 years, had received cancer care at a participating clinic within the past year, and had current tobacco use documented in the EHR. Patients were mailed a letter providing information on how to opt-out of the program. A centralized Tobacco Treatment Specialist proactively called all patients who did not opt-out and provided information about how to access evidence-based smoking cessation treatment. Patients were offered a referral to the Wisconsin Tobacco Quitline or enrollment in a pilot comparative effectiveness clinical trial evaluating standard smoking cessation treatment (2w nicotine patch + 3 counseling calls + NCI Smokefree.gov information) versus enhanced treatment (12w varenicline + 7 cancer-targeted counseling calls + NCI Smokefree.gov information). Results: Of the 574 patients who were initially identified by EHR as eligible or referred by their provider, 9.2% (53/574) initiated evidence-based smoking treatment through the opt-out referral program. In sensitivity analyses accounting for possible EHR data inaccuracy (e.g., over-estimation of smoking prevalence, undocumented deaths), 13.1% (53/406) of potentially eligible patients initiated smoking treatment. Only 3.5% (20/574) of patients proactively called to opt-out of the program and an additional 12.7% (73/574) asked to be removed from future call lists during an outreach call. The trial (N=52) showed the treatments were both feasible and acceptable to patients. The majority of patients assigned to each condition completed at least 1 counseling call (standard care: 96.2%; enhanced care: 92.3%) and completed a high percentage of available counseling calls (standard care: M=2.2 calls, 71.8% of available calls; enhanced condition: M=4.5 calls, 65% of available calls). Patients rated treatment satisfaction in key domains (1= not at all, to 7=extremely): overall choices of smoking treatment (standard care: M=5.3, SD=2.1; enhanced care: M=6.1, SD=1.0), counseling (standard care: M=4.9, SD=2.6; enhanced care: M=6.3, SD=1.2), and medication (standard care: M=4.4, SD=2.4; enhanced care: M=6.1, SD=1.4). Discussion: This pilot study demonstrated the feasibility, acceptability, and reach of a novel centralized proactive outreach approach to offer evidence-based tobacco treatment to UW Carbone Cancer Center patients. This approach holds promise regarding its scalability and sustainability to ensure all patients with cancer receive tobacco treatment as an essential and routine component of cancer care. |
| 1.288 | Farhan Raza | CVM | fraza@medicine.wisc.edu | Capturing Interventricular Dyssynchrony and Interdependence with Cardiac MRI-based Strain Analyses in HFpEF and Pre-capillary Pulmonary Hypertension | Background: In HFpEF and pulmonary hypertension (PH), interventricular dyssynchrony can lead to cardiac inefficiency. We use cardiac MRI (CMR)-based strain analyses (longitudinal, circumferential, radial strain, time-to-peak strain) to report a new method to quantify ventricular dyssynchrony and interdependence. Methods: We conducted retrospective analyses of 73 participants who underwent CMR and invasive cardiopulmonary exercise testing (CPET). Using unsupervised K-means clustering approach with CMR-based strain data as input, two distinct HFpEF clusters were identified: cluster#1 (n=36), cluster#2 (n=12), while pre-capillary PH (n=25) was used as a comparison group. p-value<0.05 labeled as *. Results: Among 3 groups (HFpEF cluster#1, cluster#2, pre-capillary PH), age (65.9±9.4 years, 69.9±11.1 years, 60.9±11.6 years) and female sex distributions (46%, 42%, 58%) were similar. Notable higher comorbidity trends in HFpEF cluster#2 included higher incidence of atrial fibrillation (37%, 67%, 8%) and sleep-disordered breathing (40%, 67%, 29%). On hemodynamics, rest pulmonary vascular resistance (PVR) was: 2.6±1.7 WU, 3.7±2.0 WU, 5.8±2.6 WU and mean pulmonary artery pressure/cardiac output slope with exercise: 6.2±6.9 mmHg/L/min, 9.9±9.8 mmHg/L/min, 6.4±3.9 mmHg/L/min. On CPET, peak VO2 was 15.3±5.1 mL/Kg/min, 12.9±5.4 mL/Kg/min, 15.6±5.5 mL/Kg/min and VE/VCO2 slope was 33.6±5.6, 37.3±11.4, 37.7±10.4. In comparison to cluster#1 (Figure), cluster#2 had lower right ventricular (RV) ejection fraction*, higher RV:LV (left ventricular) ratios*, and increased circumferential time-to-peak strain (ttps) for RV in relation to LV*. Hence, cluster#2 had increased dyssynchrony and poor RV function, best captured by circumferential ttps. These metrics were worse in cluster#2, even compared to pre-capillary PH patients who had higher rest and exercise PVR. Additional CMR data among 3 groups (HFpEF cluster#1, cluster#2, pre-capillary PH) included LV indexed volumes (end-diastolic: 69.4±21.9 mL/m2, 61.2±14.5 mL/m2, 63.1±15.7 mL/m2; end-systolic: 33.8±19.6 mL/m2, 24.8±7.4 mL/m2, 30.3±15.3 mL/m2), RV indexed volumes (end-diastolic: 72.5±18.8 mL/m2, 94.5±15.3 mL/m2, 83.2±28.2 mL/m2; end-systolic volumes: 37.3±14.9 mL/m2, 58.63±12.7 mL/m2, 50.8±28.3 mL/m2). Circumferential strain for LV was -15.4±3.4%, -15.2±2.9%, -16.0±4.9% and for RV was -13.0±3.7%, -10.9±2.5%, -11.3±6.3%. Conclusion: RV-minus-LV ttps captures interventricular dyssynchrony. Unsupervised clustering approach in HFpEF using CMR-based strain analyses identified 2 distinct HFpEF phenotypes with normal (cluster #1) vs. abnormal (cluster #2) interventricular synchrony and RV function. |
| 1.289 | Jane Churpek | HEM/ONC | jchurpek@wisc.edu | Detection of TERT promoter mutations in patients with Telomere Biology Disorders using long-read amplicon sequencing | Background: Telomere Biology Disorders (TBDs) are inherited bone marrow failure syndromes that arise due to germline mutations in genes involved in telomere maintenance. The symptoms seen in patients with these disorders are often aging-associated phenotypes and are the consequence of accelerated telomere shortening and dysfunction leading to premature senescence. Highly proliferative tissue, like the bone marrow, is under immense pressure to circumvent this phenomenon, and patients with TBDs often develop clonal hematopoiesis. Acquired variants in the telomerase (TERT) promoter have been well characterized in the context of cancer and have only recently been described in blood cell populations in patients with TBDs. However, because these mutations can occur at extremely low variant allele frequencies, and because the TERT promoter region is 85% GC-rich, these mutations have been very difficult to detect. Methods: To overcome these challenges, we have developed a long-read amplicon sequencing pipeline that incorporates deepSNV for highly sensitive variant calling to detect TERT promoter mutations in patients with TBD features. Our pipeline was validated using a dilution series and was then applied to patient samples from our TBD population (n=51). DNA was extracted from peripheral blood and bone marrow tissue and amplicons were generated using standard PCR protocol tailored for amplification of GC-rich regions. Results: After successful PCR amplification of the TERT promoter region (amplicon = 474bp), a dilution series was conducted by generated variant allele frequencies ranging from 0.5%-50%. The dilution series was submitted as quadruplicates and successfully identified TERT promoter mutations in all samples with a VAF of 1% and higher and in 2/4 samples with a VAF of 0.5%. We then selected 51 patients with TBD features from our patient panel at UW-Madison to undergo sequencing, and our analysis thus far has detected 7 hotspot mutations with VAFs ranging from 0.61% to 33%. The average depth at these locations is 8500, with even coverage across the GC-rich regions and no evidence of strand bias. Of the patients that meet diagnostic criteria, we have identified a hotspot mutation rate of 14%. Conclusion: Our data therefore identifies long-read amplicon sequencing as a sensitive, cost-effective, and relatively simple method for detection of TERT promoter mutations that emerge at extremely low variant allele frequencies. With accurate detection of these variants, we can then determine if TERT promoter mutations confer any prognostic insight for patients with TBDs and can evaluate the utility of incorporating TERT promoter variant identification as evidence for diagnosis. This method can also be expanded to other amplicons for both germline and somatic mutation detection. |
| 1.290 | Dudley Lamming | ENDO | dlamming@medicine.wisc.edu | Protein restriction ameliorates ovariectomy-induced metabolic dysfunction by inhibition of Mtorc1 | Consuming a high protein diet has been shown to increase the risk of type 2 diabetes. In contrast, lifelong protein restriction (PR) has been shown to increase lifespan, decrease frailty, and improve metabolic health in a variety of model organisms. In mice, PR has sex-specific metabolic and molecular effects, with males exhibiting a stronger response than females. The role that sex organs and sex hormones play in the response to PR remains to be determined and is important when considering medical recommendations for protein intake in older adults. To study the role sex plays in responding to PR, we placed intact males, castrated males, intact females, and ovariectomized female mice on either a protein restricted diet (7%) or a normal (21%) protein diet from 8 until 20 weeks of age. Our studies reveal that the metabolic benefits of PR in males are entirely independent of the sex organ, however the blunted metabolic benefits of PR in females are ablated by ovariectomy. Across all groups a low protein diet decreases body weight gain, despite increased food consumption. Intact females do not exhibit a decrease in adiposity like males, but ovariectomized PR mice exhibit a significant decrease in adiposity. PR improves glycemic control, as determined by improvements in glucose tolerance and insulin sensitivity. This study reveals that the mammalian target of rapamycin (mTOR) nutrient signaling pathway is downregulated in certain tissues and may be responsible for the metabolic health improvements in PR ovariectomized mice. Together this data shows that ovariectomy-induced metabolic dysfunction can be ameliorated by PR. |
| 1.291 | Jeremy D. Kratz | HEM/ONC | jdkratz@medicine.wisc.edu | Dysregulating transcription and epigenetic remodeling using dual BRD4 and CDK9 inhibition in pancreatic ductal adenocarcinoma | Background: Pancreatic ductal adenocarcinoma (PDAC) is the most common cause of mortality for pancreatic cancers with a five-year survival rate of only 13%. These malignancies acquire resistance to therapeutics through dysregulation of epigenomic and transcriptional signals, however few investigations have considered combination therapies to disrupt these pathways. BRD4 and CDK9 are both promising targets playing key roles in epigenomic and transcription regulation and are both upregulated in PDAC. Here, we evaluate the potential of dual BRD4 and CDK9 inhibition as a strategy to disrupt global transcriptional and epigenomic regulation in PDAC. Methods: PDAC patient-derived cancer organoids (PCOs) were established from live tissue samples. PCOs were treated with single agents, VIP152 and ZEN3694, or the combination. ZEN3694 was treated continuously while VIP152 was removed after 24 hours to mimic in vivo pharmacokinetics. Western blotting was used to analyze phosphorylation of RNA polymerase II at serine 2 (pRPB1-s2) and anti-apoptotic proteins after 24 hours of treatment. Differential expression and peak calls were made on bulk mRNA and CUT&Tag sequencing (RNA-seq and CUT&Tag) performed on treated PCOs. PCOs were collected after 144 hours of treatment for RNA-seq and 48 hours for CUT&Tag. gProfiler was used for pathway analysis for both sequencing sets. Results: Western blot analysis revealed combination therapy achieved downregulation of pRPB1-s2 and anti-apoptotic proteins compared to single agents. RNA-seq yielded no pathway dysregulation for VIP152 treated PCOs across 2 unique PDAC lines. The number of dysregulated pathways increased in the combination treated group compared to ZEN3694 in PDAC2 (ZEN3694 n=156, combination n=235), however this was not seen in PDAC1 (ZEN3694 n=69, combination n=37). Pathway analysis from CUT&Tag of PDAC1 for pRPB1-s2 revealed significant pathway dysregulation in the combination (n=186) with no single agent disruption. These pathways included biologically relevant gene sets such as ‘Pancreatic Cancer Subtypes’ (adj p<0.001), ‘response to stimulus’ (adj p<0.001), and ‘signal transduction’ (adj p<0.001) across both sequencing sets. CUT&Tag also revealed a significant decrease in pRPB1-s2 binding across all matched significant differential peak calls (VIP152=-0.21, ZEN3694=-0.23, combination=-0.74 p<0.001), and a decrease in open chromatin markers (H3K4me3=-0.64 p<0.001 and H3K27ac=-0.56 p<0.001) compared to both single agents (VIP152=-0.15 and -0.20; ZEN3694=-0.15 and -0.14). Conclusion: Here, we show preclinical evidence that combination treatment of VIP152 and ZEN3694 synergistically dysregulates PDAC transcription and remodels the epigenomic landscape. Future directions will include exploring Myc amplified subtype specific selectivity and in vivo validation of toxicity and efficacy. |
| 1.292 | Jennifer Weiss | GASTRO | jmw@medicine.wisc.edu | Unveiling the Lived Experience of Lynch Syndrome and Polyposis Syndrome Patients: A Comparison | Background: The two most common hereditary colon cancer syndromes are Lynch syndrome (LS) and polyposis syndromes (PS) (e.g., Familial Adenomatous Polyposis). Both syndromes share increased lifetime risks for intestinal and extra-intestinal cancers and require frequent surveillance and surgical interventions, yet their life experiences are varied. Comparing and contrasting the life experiences of individuals with these syndromes is crucial for improving patient support, interventions, and resource allocation. Methods: Narrative data was collected from 44 semi-structured, in-depth, qualitative interviews with individuals living with elevated risk for hereditary cancer (colon and breast) as part of a collaborative research initiative to elicit and analyze real-life experiences of diverse patients across the United States. Participants were recruited using maximum variation sampling with respect to age, gender, sexual identities, geographic location, and selfreported race/ethnicity. Recruitment occurred through cancer genetic clinics at three academic medical centers and through community-based recruitment. This study draws from participants with Lynch syndrome and polyposis syndromes. Interview transcripts were analyzed with NVivo software utilizing a deductive approach based on an adapted integrated framework for living well with chronic illness, as well as specific models for living with illnesses such as diabetes and Crohn’s disease. Results: 21 patients were included in the analysis (14 with LS, 7 with PS). A common theme across both groups was the need to educate both themselves and members of their healthcare teams about their diagnoses. Multiple contrasting themes were identified across both groups (Figure 1). In general, PS patients identified more negative experiences with family, insurance, and their healthcare team compared to LS patients. They also described more changes to daily life, difficulty coping with current symptoms, and feelings of fear and sadness about their diagnosis, as opposed to LS patients who described a better ability to cope and willingness to seize each day. Conclusions: Patients with hereditary colon cancer syndromes (Lynch syndrome and polyposis syndromes) describe a common issue with lack of knowledge of these diseases from their primary healthcare teams. Differences in life experiences across the groups exist with respect to support networks, coping skills, and feelings towards life after their diagnoses with more negative experiences in PS patients. This illustrates a need for different resource allocation across these two groups such as ensuring access to health psychology and social work in GI genetics clinics, particularly for individuals with polyposis syndromes. |
| 1.293 | Lynn M. Schnapp | APCCM | lschnapp@medicine.wisc.edu | Insights into Transcriptomic Variation Between Pericytes in Lung and Skin | Rationale. Pericytes are stromal cells that closely associate with the microvasculature and play an essential role in normal angiogenesis and vascular homeostasis in the lung and other organs. However, with injury, lung pericytes are involved in the inflammatory response and can transdifferentiate to the myofibroblastic cells that typify fibrosis. Little is known about the functional differences in pericytes among organs. Both skin and lung serve barrier functions and are constantly exposed to external challenges. In addition, both organs are often significantly impacted in systemic fibrotic diseases. We asked whether the biology of pericytes derived from skin differed from pericytes derived from lung. To address this question, we took an unbiased approach to characterize the transcriptome of pericytes from normal skin compared to normal lung by RNA sequencing (RNA-seq) and full systems level analysis. Methods. Tissue from normal lungs and abdominal skin (n = 4/group) was mechanically disrupted and enzymatically digested, then cultured in specialized pericyte medium. Pericytes were further enriched by selection for the pericyte marker PDGFRb. RNA was extracted from the cells and analyzed by RNA-seq. Differential expression analysis was performed using the DEseq2 package followed by a systems level analysis on iPathwayGuide (Advaita). Data were validated by qPCR and functional assays. Results. 1,461 differentially expressed genes were identified in skin pericytes compared to lung pericytes, using a p-adjusted value of <0.05 and a minimum log2-fold change of 0.6. Perturbation of several major pathways was observed, including cytokine-cytokine receptor interaction, TNF signaling, chemokine signaling, and extracellular matrix-receptor interaction. Our data showed significant downregulation of multiple chemokines and cell adhesion molecules, including CXCL1, CXCL2, IL6, and VCAM1, in skin pericytes. We also found decreased gene expression of collagens I, III, and IV. RT-PCR analysis of independent isolates of skin and lung pericytes confirmed that skin pericytes exhibited lower baseline expression of chemokines compared to lung pericytes. In addition, skin pericytes showed a dampened response to in vitro stimulation by various inflammatory agents in comparison to lung pericytes. Conclusions. The transcriptome of normal skin pericytes significantly differs from that of normal lung pericytes, suggesting that these cells are also functionally different. Lung pericytes appear to be more activated at baseline and poised to respond more readily to inflammatory and profibrotic stimuli than skin pericytes. Our future work will continue to explore the pathways that differ between skin and lung pericytes and determine how these pathways impact inflammation and fibrosis. |
| 1.294 | Vincent L. Cryns | ENDO | vlcryns@medicine.wisc.edu | Regulation of the MDM2 Oncoprotein by a Nuclear Phosphoinositide Complex | Background: The tumor suppressor p53 maintains genome stability in the setting of cellular stress and is frequently mutated in cancer. The stability of p53 is regulated by its interaction with the oncoprotein MDM2, an ubiquitin E3 ligase. Our previous data showed that the type I phosphatidylinositol phosphate kinase (PIPKIα) and its product phosphatidylinositol-4,5-bisphosphate (PIP2) regulates the stability of p53. Here, we demonstrate an unexpected role for nuclear phosphoinositides and sHSPs in controlling MDM2 stability and its function, providing a novel therapeutic strategy for targeting this pathway in cancer. Methods: To analyze binding between MDM2 and PIP2, we perfumed Microscale Thermophoresis assays (MST) to calculate binding affinity, liposome sedimentation, and in vitro binding assay to quantitate the direct binding between them. To investigate association between MDM2 and PIP2, we proceed Co-IP western blot, Immunofluorescent staining to check co-localization, and proximity ligation assay (PLA) to evaluate proximity between MDM2 with phosphoinositide kinases and small heat shock proteins (sHSPs). Functional analysis was conducted to investigate how PIPn and sHSPs regulate the stability and function of MDM2. Results: MST and liposome sedimentation indicate that MDM2 binds to multiple phosphoinositides with the highest affinity for PIP2. Co-IP western blot confirm that MDM2 also associates with PIP2 in various cell lines. Additionally, MDM2 interacts with phosphoinositide kinases including PIPKIα, which generates MDM2-PIP2 complex. Interestingly, MDM2 also interacts with small Heat Shock Proteins (sHSPs). According to the in vitro binding assay, PIP2 regulates the formation of MDM2-sHSPs complexes and the interaction of MDM2 with p53. In addition, the MDM2-PIP2-sHSPs complex regulates the stability and function of MDM2. Conclusions: Our data demonstrate that PIPKIα and its product PIP2 interact with MDM2 oncoprotein and it regulates association with sHSPs. The MDM2-PIP2-sHSPs complex controls MDM2 stability and its ubiquitination function. |
| 1.295 | Timothy Kamp | CRB | tjk@medicine.wisc.edu | Chamber-Specific hiPSC-CMs for Disease Modeling Brugada Syndrome | Introduction. Brugada Syndrome (BrS) is a genetic disorder causing arrhythmias and sudden cardiac death, commonly linked to mutations in the SCN5A gene encoding the cardiac sodium channel Nav1.5. These mutations are identified in about 11–28% of cases. Clinically, BrS is characterized by a coved-type ST-segment elevation in leads V1–V3, frequently originating from the right ventricular outflow tract (RVOT). The RVOT is vulnerable to arrhythmias due to reduced sodium current (INa) and predominant transient outward potassium current (Ito), creating steep repolarization gradients. Embryologically, RVOT arises from the second heart field (SHF), distinct from the left ventricular (LV) myocardium derived from the first heart field (FHF). Our laboratory recently developed hPSC-differentiation protocols to generate FHF-and SHF-derived, chamber specific cardiomyocytes (CMs), enabling detailed studies of RV-specific disorders like BrS. Objectives. 1. Compare electrophysiological properties of RV and LV hiPSC-CMs produced using chamber-specific differentiation protocols. 2. Determine the impact of the SCN5A p.D356N mutation, associated with BrS, on sodium current (INa) and action potentials in hiPSC-CMs. Results. Ongoing comparisons of RV vs. LV differentiation protocols revealed preliminary distinctions. WT hiPSC-CMs differentiated via RV protocol displayed longer action potential duration at 90% repolarization (APD90) compared to LV-derived cells (209.2±79.1 vs. 156.6±53.4 ms). RV-derived cells also exhibited greater capacitance (112.5 ± 45.9 vs. 69.4±16.0 pF). Resting membrane potential, AP amplitude, and dV/dt were not significantly affected by differentiation protocol. Notably, WT cells exhibited higher INa density in RV-derived cells than LV-derived cells (−52.0±23.7 vs. −25.3±11.0 pA/pF). Using the LV-specific (GiWi) protocol, we evaluated electrophysiological effects of the SCN5A p.D356N mutation by patch-clamp recordings in human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs). BrS hiPSC-CMs showed a significant fourfold reduction in peak sodium current (INa) compared to isogenic BrS-corrected cells (−11.6±3.2 vs. −43.1±19.4 pA/pF). The BrS cells’ INa density was approximately half that of wild-type (WT) hiPSC-CMs (−11.6±3.2 vs. −25.3± pA/pF). Action potential (AP) maximum upstroke velocity (dV/dt) confirmed these findings, with values ranked as BrS-corrected (312.5±149.1 V/s) > WT (201.1±46.8 V/s) > BrS (84.4±36.27 V/s). No significant differences appeared in resting membrane potential, AP amplitude and APD. Optical mapping in monolayer cultures revealed conduction velocity (CV) differences. BrS-corrected hiPSC-CMs showed higher CV than BrS cells (10.0±0.7 vs. 8.7±1.2 cm/s) but remained below WT (16.3±2.0 cm/s), despite increased INa and dV/dt. Conclusion. Differentiated RV hiPSC-CMs have longer APD90, increased capacitance, and greater INa density compared to LV-derived cells. The BrS-associated SCN5A p.D356N mutation significantly reduces INa in hiPSC-CMs, and INa rescue is validated in isogenic corrected controls. |
| 1.296 | Nicole Rogus-Pulia | GERI | npulia@wisc.edu | Impact of Hydrocolloid Type on Rheology of Thickened Liquids Used in Dysphagia Treatment | Abstract: Introduction: The International Dysphagia Diet Standardization Initiative (IDDSI) provides a standardized method to differentiate the thickness of liquids; however, this method may not capture variations in fluid flow behavior relevant to swallowing. Thickened fluids at the same IDDSI level can exhibit differences in shear thinning behavior, extensional viscosity, and surface tension that influence how they behave during swallowing. The purpose of this study was to rheologically characterize variations in flow behavior across fluids with different thickener types. Methods: Twelve hydrocolloids (modified starch, konjac gum, methylcellulose, carboxymethylcellulose, hydroxypropyl methylcellulose, sodium caseinate, iota carrageenan, sodium alginate, tara gum, xanthan gum, guar gum, and high methoxy pectin) were prepared to an apparent viscosity of 300 cP at a shear rate of 30 s-1 (IDDSI Level 2), seen in Figure 1. Shear thinning behavior was measured through a shear rate sweep from 0.1-1000 s-1 and modeled using a power law. Surface tension evaluated through a pendant drop method. Extensional viscosity was measured using a capillary break-up method, extracted at Hencky strain = 5, 5.5, 6, 6.5, 7 and 7.5. Rheological metrics were compared between fluids using linear mixed models, with Tukey’s HSD post-hoc analysis (ɑ=0.05). Results: Extensional viscosity and capillary break-up times, shown in Figure 2, varied based on hydrocolloid type (p<0.001). Specifically, extensional viscosity of modified starch, iota carrageenan, xanthan gum, and methylcellulose all differed (p<0.01), with modified starch showing the highest values and methylcellulose the lowest extensional viscosity. For capillary break-up time, differences between modified starch and methylcellulose were observed (p<0.001), representing the lowest and highest times, respectively. Intermediate break-up times from hydrocolloids including konjac and xanthan gum were also statistically differentiable (p<0.001). Gums displayed the greatest shear thinning, while cellulosics demonstrated longer capillary break-up times and higher extensional viscosity. Discussion: We observed differences in shear thinning and extensional viscosity across a broad range of thickened fluids with comparable apparent shear viscosity. These findings will inform thickener selection for subsequent swallow studies to determine the implications of rheological properties on fluid flow during swallowing. |
| 1.297 | Dudley Lamming | ENDO | dlamming@medicine.wisc.edu | Isoleucine as a regulator of plasma cholesterol in mice | Excess cholesterol is a major risk underlying many cardiac and vascular diseases process as leading causes of death, including atherosclerosis, heart attack and stroke. The risk of hypercholesterolemia significantly increases with age, as metabolism changes. We found dietary Isoleucine restriction significantly lowers plasma cholesterol in mice. To determine which fractions contribute to the drop in total cholesterol, we run the pooled plasma samples collected from the 67% Isoleucine restriction and control groups from male mice through FPLC. We found Isoleucine restriction was able to decrease both LDL-cholesterol and HDL-cholesterol, and the decrease in LDL-cholesterol was especially prominent. This finding is of particular interest to us as LDL-cholesterol was considered detrimental to cardiac health in humans. Then to tell what’s contributing to lower cholesterol on restriction, we did a p-407 assay in mice. Upon the inhibition of peripheral lipolysis, plasma cholesterol increased slower in restriction group, and the difference was in LDL-cholesterol but not VLDL-cholesterol. Since the transition of VLDL to LDL was stopped by p-407, the result validates that the decreased LDL-cholesterol level was not from decreased liver VLDL production, but from increased reuptake of LDL-cholesterol. In accordance with the physiological observations, we saw decreased PCSK9 and increased LDLR protein level in restriction livers, indicating higher liver LDL reuptake. To test it we’ll check if Isoleucine restriction also decreases plasma LDL-cholesterol in LDLR-KO mice, also to explore if there’s a role of liver direct LDL secretion in play. As for the question of how Isoleucine restriction caused the cholesterol metabolism changes in liver, we cultured AML-12 cells in Isoleucine depletion media to explore if it’s cell autonomous, and saw time-dependent molecular changes upon Isoleucine depletion. This indicates we could possibly take advantage of certain timepoints to use AML-12 cells as a model system to further explore the molecular mechanism of how Isoleucine restriction changes mouse liver cholesterol metabolism. These findings shed light on the opportunity for future research to potentially use a moderate Isoleucine restriction diet to treat male patients for risk of hyperlipidemia with metabolic dysfunctions, including older population. |
| 1.298 | Lixin Rui | HEM/ONC | lrui@medicine.wisc.edu | PRMT5 inhibition sensitizes B-cell lymphoma cells to ferroptosis. | Background: Protein arginine methyltransferase 5 (PRMT5) catalyzes the symmetric dimethylation of arginine residues on histone and non-histone proteins to regulate gene expression. PRMT5-mediated gene regulation is involved in the progression and survival of many cancers. Our research, along with other studies, has shown that PRMT5 expression is upregulated in B-cell non-Hodgkin lymphomas, including the most common diffuse large B-cell lymphoma (DLBCL) and the currently incurable mantle cell lymphoma (MCL). Ferroptosis is a form of regulated cell death driven by the accumulation of iron-dependent lipid reactive oxygen species (ROS) on cellular membranes, distinguishing it from other types of cell death. This process is initially triggered by the inhibition of system Xc- or GPX4 activity, which ultimately leads to cell death. Lymphoma-related pathways, such as the p53 pathway, MYC, and the PI3K–AKT–mTOR signaling pathway, are involved in the regulation of ferroptosis. We and others have shown that upregulated PRMT5 enhances cell proliferation and survival in lymphoma cells by activating various mechanisms, including the PI3K-AKT signaling pathway and MYC target genes. However, whether PRMT5 is involved in ferroptosis in B-cell lymphoma remains unknown. Therefore, understanding and targeting ferroptosis in B-cell lymphoma is an urgent clinical need. Methods: To elucidate the phenomenon and mechanism by which PRMT5 modulates ferroptosis in B-cell lymphoma cells, we employed a comprehensive approach, which included RNA-seq, flow cytometric assays (Lipid Peroxidation Sensor), dual-luminescence-based reporter gene assays, chromatin immunoprecipitation in DLBCL and MCL cell lines, as well as xenograft mouse models and patient-derived xenograft MCL models. In addition, we conducted the CellTiter-Glo assay to detect the combination effect of the PRMT5 inhibitor GSK3326595 and ferroptosis inducers, including dimethyl fumarate (DMF), RSL3, and Erastin. Results: Our lab previously performed PRMT5 knockout RNA sequencing. Re-analysis of the RNA-seq data revealed several metabolic-related pathways affected by PRMT5 knockout in both OCI-Ly7 and TMD8 cells, including the fatty acid metabolism pathway. Treatment of DLBCL and MCL cells with various PRMT5 inhibitors or genetic knockdown alone did not induce lipid peroxidation but enhanced DMF-induced lipid peroxide accumulation. Interestingly, PRMT5 knockout or inhibition in DLBCL and MCL cells increased sensitivity to DMF treatment. Moreover, the combination of DMF and GSK3326595 exhibited a significant synergistic effect. Mechanistically, PRMT5 inhibition reduced system Xc- expression by targeting the PI3K–AKT–MYC signaling pathway. To determine whether PRMT5 inhibition promotes lipid peroxidation in various cell lines in response to DMF and other ferroptosis-inducing agents (FINs), we treated multiple DLBCL and MCL cell lines with different concentrations of the GPX4 inhibitor RSL3 and the SLC7A11 inhibitor Erastin, both alone and in combination with the PRMT5 inhibitor GSK3326595. Both RSL3 and Erastin demonstrated significant synergistic effects across different DLBCL and MCL cell lines. More importantly, a combination of GSK3326695 and DMF achieved a greater anti-tumor effect compared with either drug alone in patient-derived xenograft MCL models. Conclusions: In summary, we demonstrate that targeting PRMT5 through pharmacological inhibition and genetic knockdown sensitizes DLBCL and MCL cells to DMF-induced lipid peroxidation and ferroptosis. These findings provide a rationale for developing a new therapeutic strategy that induces ferroptotic cell death to treat lymphoma patients with relapsed or refractory disease. |
| 1.299 | Jane Churpek | HEM/ONC | jchurpek@wisc.edu | Clonal hematopoiesis prevalence years before and after a thyroid cancer diagnosis: A case-control study | Introduction: After diagnosis and treatment, individuals with thyroid cancer have the highest prevalence of clonal hematopoiesis (CH) among cancer patients (Coombs, 2017). Treatment with radioactive iodine (RAI) has been associated with an increased odds of CH in this population (Boucai, 2018). However, whether CH is present prior to their cancer diagnosis and treatment or only afterward and whether germline cancer susceptibility contributes to this process is not known. Methods: We designed a retrospective case-control study using a population-based biobank, the Personalized Medicine Research Project (PMRP) (Marshfield, Wisconsin, United States) to determine whether individuals destined to develop thyroid cancer more frequently have CH prior to their cancer or a germline cancer susceptibility pathogenic variant than matched controls. Cases were healthy upon enrollment but subsequently developed an incident thyroid cancer. Controls were age- and self-reported race-matched individuals who were never diagnosed with cancer. Clinical and laboratory data were abstracted from electronic medical records and PMRP enrollment surveys. We performed whole-exome sequencing (WES) to 125-fold depth of coverage on peripheral blood (PB) and curated variants in 204 inherited cancer susceptibility and 155 CH-associated genes. Somatic variants were considered CH if the variant allele frequency (VAF) was between 0.05 and 0.25. A subset of both groups was recontacted ~20 years after initial enrollment and underwent repeat WES. Multivariate logistic regression was used to evaluate associations between case-control status and CH or germline variants in cancer susceptibility genes at baseline. Results: 63 cases and 125 controls were included. Median age at baseline PB sampling was 46 and 45 years in cases and controls, respectively (p=0.88), and 53 years at thyroid cancer diagnosis in cases. 87% had papillary thyroid carcinoma. 98% had surgery to treat their thyroid cancer, and 71% received RAI. Overall, we identified CH in three (5%) cases and four (3%) controls. After adjusting for age at enrollment, sex, and race, those with CH had a 1.51 odds (0.31-7.33, p=0.61) of developing a thyroid cancer diagnosis versus those without CH. DNMT3A was the most frequently mutated gene in both groups (5/7 of CH events), followed by PHIP and TET2. We detected likely pathogenic/pathogenic (LP/P) germline variants in 11% of cases and 7% of controls. CHEK2 accounted for 71% and 56% of germline variants in cases and controls, respectively. Other genes affected included BRCA1 and POT1 in cases, and ATM, SDHC, and SEC23B in controls. None of the subjects with a LP/P germline variant had CH detected in their baseline PB sample. After enrollment, two cases developed hematologic malignancies, whereas none of the controls did. They did not have CH at baseline. Next, we successfully recontacted seven cases and seven controls, none of whom had CH previously. We found that three (43%) cases and two (29%) controls developed CH. The genes affected in controls were consistent with aging-related CH (DNMT3A, DNMT3B, and TET2), while cases had CH in genes more often described in CH in cancer (CHEK2 and KMT2D). All cases who developed CH had been treated with RAI. Both controls who developed CH had evidence of these variants in their enrollment PB sample, whereas only one of three cases did. All of these variants were at a VAF not meeting our threshold, suggesting expansion with age. Discussion: We demonstrate that individuals destined to develop early-stage, predominantly papillary thyroid cancers do not have CH months to years before their diagnosis more often than age- and race-matched individuals who do not develop cancer. Additionally, our data show that the timeline of CH acquisition in cases can occur years before diagnosis, very close to the time of diagnosis, or after thyroid cancer diagnosis and treatment. |
| 1.300 | Sameer Mathur | APCCM | skmathur@wisc.edu | Dupilumab Leads to Improvement of Fibrotic and Inflammatory Features in Patients with Eosinophilic Esophagitis | Introduction Dupilumab is the first biologic to treat eosinophilic esophagitis (EoE), approved by the FDA in 2022. This study aimed to determine the endoscopic, histologic, and symptomatic effects of dupilumab in patients with EoE in clinical practice. Methods We conducted a retrospective study of EoE patients prescribed dupilumab for clinical care. Patient demographics, clinical characteristics, EoE history, procedural data, histologic data, and symptom history were extracted from the medical record. Endoscopic severity was assessed using the EoE Endoscopic Reference Score (EREFS) using a scale from 0 to 9. We broke this down further into fibrotic features of the EREFS (rings and strictures) and inflammatory features of the EREFS (edema, exudates, furrows). Paired t tests were used to compare the most recent pre-dupilumab EGDs with post-dupilumab EGDs. Symptomatic changes were evaluated per subjective reports from patients. Results We identified 23 patients with EoE who were treated with dupilumab with EREFS scores before and after treatment and 50 patients who reported symptoms before and after treatment. EREFS and peak eosinophil counts decreased significantly after dupilumab treatment. Total EREFS decreased from 3.87 to 1.65, score specific to fibrotic features decreased from 1.78 to 1.04, and score specific to inflammatory features decreased from 1.96 to 0.74 (P < .001 for all). Peak eosinophil count also decreased significantly from 51.4 to 4.58 (P < .001). Out of 50 patients with EoE who were treated with dupilumab, 88% reported overall symptom improvement and 82% were able to wean off of or stop other therapies including proton pump inhibitors and/or swallowed steroids. Conclusion Dupilomab led to endoscopic, histologic, and symptomatic improvement in most patients with treatment refractory EoE. Furthermore, dupilumab provides benefits to both fibrotic and inflammatory phenotypes of EoE. This shows real-world efficacy of dupilumab for EoE. |
| 1.301 | Jane E. Mahoney | GERI | jm2@medicine.wisc.edu | Enhancing the Community-Academic Aging Research Network (CAARN) to Support Assistive Technology Research for Safe and Healthy Aging | Introduction: Assistive technology (AT) has the potential to maintain or improve the health, well-being and function of older adults, however, multiple barriers, such as perceived stigma, financial costs, high complexity and perceived threats to privacy, impact older adult acceptance and use of AT. AT development occurs in silos with little, if any, input from older adults and other disciplines (clinicians, social scientists, healthcare providers), thus limiting innovation and new ways of thinking about AT use and the needs of older adults. The long-term goal of the Community-Academic Aging Research Network (CAARN) is to increase the number and reach of effective AT interventions designed to improve the health and function of older adults and increase aging in place. Methods: In 2024, CAARN, which has been funded by the NIH for over 10 years to facilitate community-engaged aging research, received 5-years of renewal funding from the National Institute on Aging to enhance research to develop new or refine existing AT to improve health and function of older adults. CAARN partners with the Schools of Medicine and Public Health, Nursing, Pharmacy, and Education, the College of Engineering and Dept. of Computer Science. CAARN’s community and clinical partners include the African American Health Network of Dane County, the Center for Community Engagement in Milwaukee, the Wisconsin Institute for Healthy Aging, which serves older adults in all Wisconsin counties and tribes, and MetaStar, a quality improvement organization working with health care organizations across Wisconsin. CAARN’s methods to support AT research include: 1) an annual AT summit with community members, clinicians, and UW Madison investigators; 2) an annual peer-reviewed and community-reviewed pilot award program, providing funding for 1-2 new AT research projects ($50,000 each) to engage older adults in iterative cyles of prototype development; 3) facilitation of new community partnerships for research teams. Results: Since 2024, CAARN has facilitated community collaboration with UW investigators for three research projects, resulting in three proposals submitted for NIH funding: 1) Robot-assisted food delivery for rural seniors ( Zhu and Kuo, UW Engineering and Nursing); 2) OptiGait technology to improve gait monitoring (Jiang and King, UW Engineering and Nursing; 3) Driving decisions for dementia care (Hansmann, SMPH). Four applications have been submitted for Round One of the AT pilot award program, with peer-review and funding decision to follow. The AT Summit, planned for April and May, 2025, will engage 30-50 older adults, investigators, clinicians, and UW faculty in identifying older adults’ needs related to AT (Session 1) and forming collaborative teams to utilize user-centered design cycles to develop and refine new AT to meet older adults’ needs (Session 2). CAARN MPIs (Mahoney, Farrar-Edwards, King, and Jiang) and Community Research Associates (CRAs) are developing a two-part training for new investigators. The gerontology section is developed and will be led by MPIs King and Mahoney and include topics such as heterogeneity of older adult populations, normal changes in aging, geriatric syndromes, and social issues (e.g. isolation, transportation, housing). CRAs, with oversight by MPIs Mahoney and Farrar-Edwards will develop and lead training on principles of community engagement and collaboration in research. Discussion: To our knowledge this new direction for CAARN represents one of the first uses of a community-academic partnership to design AT for older adults. Building on CAARN’s existing partnerships, we are engaging community members in a new direction centering their input in an Annual AT Summit, including community members as external reviewers for AT pilot awards, and including older adults on AT teams. We anticipate this enhanced CAARN infrastructure will support new transdisciplinary, community-engaged teams to develop innovations in AT for older adults. |
| 1.302 | Michelle Kimple | ENDO | mkimple@medicine.wisc.edu | Elucidating the role of GLP-1R signaling in the protective effect of Gɑz loss on high-fat diet-induced type 2 diabetes | G Protein Coupled Receptors (GPCRs) alternatively regulate beta-cell cyclic AMP (cAMP) levels through stimulatory, Gɑs, or inhibitory, Gɑi, signaling. Agonists of the Gɑs-coupled GLP-1 receptor (GLP-1R) are gold-standard T2D therapeutics well-known to stimulate beta-cell function, replication, and survival. In previous studies, we used the high-fat diet (HFD)-induced mouse model of type 2 diabetes (T2D) to determine the effect of ablating cAMP-inhibitory Gɑz signaling on beta-cell function and mass. HFD-fed Gɑz-null C57Bl/6N mice were protected from T2D due to a significant increase in functional beta-cell mass, and islets from these mice had increased GLP-1-potentiated insulin secretion, with a coordinate decrease in basal glucagon secretion. We performed immunofluorescence experiments on pancreas slide sections from control-diet and HFD-fed wild-type (WT) and Gɑz-null mice, revealing HFD feeding reduced the percentage of GLP-1 producing alpha-cells in WT islets, with Gɑz loss partially ameliorating this effect. These results raise the question of whether the protective effect of Gɑz loss requires GLP-1R signaling. To test this hypothesis, I will surgically implant control diet-fed and HFD-fed WT and Gɑz-null mice with mini-osmotic pumps continuously releasing the GLP-1R antagonist, exendin 9-39, quantifying the effects of GLP-1R antagonism on beta-cell function, replication, and mass. We predict exendin 9-39-treated Gɑz-null HFD-fed mice will be glucose intolerant and have reduced beta-cell replication and mass as compared to vehicle-treated HFD-fed Gɑz-null mice. If our studies are successful, our results will provide strong support for the pursuit of the Gɑz signaling pathway as a novel therapeutic target for T2D. This study was supported by NIH grants R01 DK137505 and R01 DK102598 (to M.E.K.) and Department of Veterans Affairs grants IK6 BX006804, I01 BX005804, and I01 BX003700 (to M.E.K.) |
| 1.303 | Marina Sharifi | DOM | msharifi@medicine.wisc.edu | Circulating Tumor Cell Analysis Reveals Expression Patterns of Cell Surface Targets in Metastatic Prostate Cancer | Background: Treatment resistance to first-line Androgen Receptor Pathway Inhibitors (ARPI) in metastatic castrate resistant prostate cancer (mCRPC) is universal and can be driven by androgen receptor (AR) alterations driving constitutive AR signaling, or lineage state transitions that bypass AR and culminate in small cell/neuroendocrine PC (NEPC). Recent advances with cell surface targeted therapies, including antibody drug conjugates and targeted radioligand therapies, shows promise for treatment of mCRPC. Circulating tumor cells (CTCs) are a minimally-invasive source of tumor material to track these known and novel targets for therapeutic development. We report differential expression of cell surface targets using the largest CTC RNA sequencing cohort of patients with mPC across lineage states and clinical outcomes. Methods: We isolated CTCs using automated microfluidic technology on a 273-sample cohort from patients with histologically confirmed mPC. CTCs were purified via anti-EpCAM conjugated magnetic beads and analyzed via RNA-seq. We examined CTC gene expression of cell surface targets, including PSMA, TROP2, B7H3, DLL3, stratified by subgroups: disease category (mCSPC, mCRPC or NEPC), metastatic site (bone +/- lymph nodes, liver, other visceral), and prior ARPI treatment. Results: CTCs from patients with mCRPC showed high expression of canonical adenocarcinoma cell surface targets STEAP1, KLK2 and FOLH1 (PSMA) and epithelial TACSTD2 (TROP2), intermediate tumor immune checkpoint cell surface protein CD276 (B7H3), and low expression of neuroendocrine targets DLL3 and SSTR2. NEPC CTCs, as expected, demonstrated lower expression of most adenocarcinoma targets and a trend towards higher DLL3 and SSTR2 and associated with worse OS regardless of disease site in multivariate analysis (HR 4.76 [1.09-8.44], p=0.011). CTCs from patients with mCSPC showed highest expression of TACSTD2 (p=0.00758) as well as a trend towards lower DLL3 expression. When comparing metastatic sites, CTCs from non-NEPC mCRPC with liver metastases had significantly higher expression of DLL3 (p=0.0116) compared to mCRPC with only bone or non-liver visceral metastases and can be detected in highrisk adenocarcinomas though expression is heterogeneous. Conversely, CTCs from mCRPC with liver metastases had lower expression of TACSTD2 (p=0.0391). Prior ARPI therapy associated with lower TACSTD2 (p=0.0248) and a trend toward higher DLL3 in patients with early evidence of lineage transitions. Conclusions: We report differential cell surface target expression across lineage states and sites of disease using novel CTC RNA-seq and single CTC phenotyping. Expression of these targets associates with response to targeted therapies, though altered target expression can be observed in PC lineage transitions. Future studies will utilize these biomarkers to explore mechanisms of response and resistance. |
| 1.304 | Dudley Lamming | ENDO | dlamming@medicine.wisc.edu | A Plasma Metabolomic and Lipidomic Signature of mTORC1-specific Inhibition | Rapamycin, an inhibitor of mechanistic Target Of Rapamycin Complex 1 (mTORC1), extends lifespan and shows strong potential for the treatment of age-related diseases. However, rapamycin exerts undesirable metabolic and immunological side eCects mediated by oC-target inhibition of a second mTOR-containing complex, mTOR complex 2 (mTORC2). Although rapamycin dosing regimens involving intermittent dosing result in reduced side eCects in mice while still extending lifespan, there is currently no way to ascertain if these types of regimens are specifically inhibiting mTORC1 in a given animal without a detailed molecular analysis of biopsied tissue. Here, we report the identification of AV448 and AV805, novel rapamycin analogs with enhanced selectivity for mTORC1. We find that both AV448 and AV805 inhibit mTORC1 in vivo in male C57BL/6J mice, without impairing mTORC2-mediated glucose and lipid homeostasis. Animals treated with either compound display significantly improved glucose and pyruvate tolerance compared to rapamycin-treated mice, while rapamycin, but not AV805, elevates cholesterol and triglyceride levels. Furthermore, both AV448 and AV805 robustly inhibit the mTORC1-dependent phosphorylation of S6 S240/S244 in skeletal muscle, liver and heart, with limited impact on the mTORC2-mediated phosphorylation of AKT S473. Finally, we find that rapamycin and the novel rapamycin analogs induce distinct plasma metabolomic and lipidomic signatures. Our results demonstrate that selective pharmacological inhibition of mTORC1 induces a plasma metabolomic and lipidomic signature that is distinct from that resulting from the dual inhibition of both mTOR complexes by rapamycin. These results suggest that levels of circulating metabolites and lipids are candidate biomarkers for monitoring mTOR complex inhibition in individuals treated with mTOR inhibitors. |
| 1.305 | Mats Johansson | CVM; APCCM | mwj@medicine.wisc.edu | Associations Between Absolute Blood Eosinophil Count and Subclinical Atherosclerotic Plaque in the Multi-Ethnic Study of Atheroscclerosis (MESA) | Background: Prior studies have demonstrated associations between eosinophil activation products and incident stroke. We sought to investigate associations between blood eosinophil count and imaging markers of atherosclerosis (carotid artery plaque [CAP] and coronary artery calcium [CAC]) in the Multi-Ethnic Study of Atherosclerosis (MESA). Methods: The MESA enrolled adults aged 45-84 years, free of atherosclerotic cardiovascular disease (ASCVD) at baseline. ASCVD risk factors, blood eosinophils, CAP presence and score (0-12) and CAC presence and Agatston score were measured at exam 5. Logistic and linear regression models were employed to test the association of blood eosinophils, CAP and CAC presence and score (log[score+1]) adjusted for biologic confounders. Results: The 2,166 participants were a mean (standard deviation (SD]) 69.6 (9.3) years old, 53% female, 29% Hispanic, 28% Black, 1 % Chinese. The median (interquartile range) eosinophil count was 0.1 (0.1, 0.2)x1 0E3/uL, CAP score= 2 (0,4) and CAC score= 45 (0, 292) Agatston units. In risk-factor adjusted models (Table 1; model 5), increased blood eosinophil count (per 1 SD (0.15 x10E3/uL]) was associated with CAP (13 = 0.05 [95% Cl 0.02-0.08, p = 0.001) and CAC (13 = 0.11 , [95% Cl: 0.01-0.21], p = 0.03) score. Similar associations were seen with eosinophils and CAP (Odds ratio (OR] = 1.12, [95% Cl: 1.01-1.25], p = 0.03) and CAC (OR = 1.15, [95% Cl: 1.02-1 .30], p = 0.02) presence. Conclusions: In a large, contemporary, multiethnic, U.S. cohort, blood eosinophils were strongly associated with imaging measures of atherosclerosis even after adjustment for ASCVD risk factors. These data suggest potential roles of T2/eosinophilic inflammation in atherosclerosis |
| 1.306 | Nathan Sandbo | APCCM | nsandbo@medicine.wisc.edu | Macrophages cocultured with human lung fibroblasts preferentially polarize towards an alternatively activated macrophage | Introduction: Idiopathic pulmonary fibrosis is a disease characterized by excess extracellular matrix (ECM) accumulation and tissue remodeling. Macrophages are implicated in disease progression and tissue remodeling, and macrophage-fibroblast interaction has been shown to create a pro-fibrotic niche. However, it remains unclear how macrophage-fibroblast interactions influence macrophage phenotypes and gene-expression. We hypothesized that the interaction of macrophages with lung fibroblasts leads to macrophage polarization. Methods: Mice were treated with bleomycin intratracheally (1U/kg) to induce pulmonary fibrosis. Starting on day 3 until endpoint on day 14 post-bleomycin, mice were treated daily with a fibronectin (FN) assembly inhibitor, PEG-FUD. Paraffin-embedded lung sections were immuno-stained with various macrophage markers and subsequently quantified. THP-1 cells were seeded with human lung fibroblasts (HLFs) and differentiated to macrophages via phorbol 12-myristate 13-acetate and then polarized with either LPS or IL-4/IL-13 or vehicle control for 24h to 120h. Results: Reduction of FN in murine bleomycin-induced pulmonary fibrosis leads to reduced collagen content and numbers of alternatively activated macrophages (AAMs) in the lung, identified by the presence of CD206, compared to controls in vivo. THP-1 macrophages cocultured with established HLFs exhibit an AAM phenotype, marked by increased MRC1 and IL10 expression, as opposed to pro-inflammatory markers IL1B and TNFA. This pattern was detected 24h in coculture and continued to increase over the course of 72h. By 72h, the polarization effect of the coculture was stronger than that of IL-4/IL-13. This effect was not replicated in concurrent cocultures or when macrophages were plated on FN or collagen. Additionally, the observed effect was independent of matrix substrate stiffness. When plated on cell-free, cell-derived matrix, THP-1 cells did not display similar polarization, however, pro-inflammatory genes were still inhibited. Conclusions: Our data suggests that exposure of macrophages to established lung fibroblasts and surrounding cell-derived matrix results in very robust polarization of macrophages towards an AAM phenotype. Isolated cell or ECM cues do not recapitulate this effect suggesting the possibility of a multifactorial effect related to cell-cell/ECM interactions. These findings imply that macrophages may have a stereotypic polarization response in the fibrotic niche and may be a driver of the aberrant wound-healing process characteristic of IPF. |
| 1.307 | Alexey V. Glukhov | CVM | aglukhov@medicine.wisc.edu | Role of sphingomyelinase in mechanical regulation of cardiac function and remodeling via ROS/PKA pathways | Background: Neutral sphingomyelinase (nSMase) is a membrane-bound hydrolase enzyme that breaks down sphingomyelin into ceramide and phosphocholine. nSMase activation can lead to the production of reactive oxygen species (ROS) and the regulation of Ca2+ signaling while its effects on cardiac electrophysiology remains unclear. Methods and results: Optical mapping of electrical activity in Langendorff-perfused mouse hearts (n=22) was used to study the electrophysiological effects of nSMase activation mimicked by application of a bacterial SMase (bSMase, 5 mU/ml) for 15-minutes followed by a washing with a bSMase-free Tyrode's solution. bSMase treatment resulted in a significant prolongation of the action potential duration (APD) and slowing of ventricular conduction velocity, accompanied by an increase in the pacing threshold and the development of ventricular quiescence after ~30 mins of bSMase washing out. Nonselective ROS scavenger dithiothreitol (DTT, 2 μM) prevented bSMase-induced conduction slowing and APD prolongation, while sarcolemmal NADPH oxidase (NOX)-specific inhibitors DPI and VAS2870 only partially prevented conduction slowing, with marginal effects on APD. In contrast, mitochondria-targeted ROS scavenging by MitoTempo prevented bSMase-induced conduction slowing, but not APD prolongation. Among these agents, only MitoTempo and DTT prolonged the time when the hearts developed electrical quiescence after bSMase treatment. Since it was shown that both bSMase and ROS activate a depolarizing current ICl,swell, we pre-treated the hearts with a specific ICl,swell inhibitor DCPIB (50 μM) before bSMase application. Notably, ICl,swell inhibition prevented conduction slowing, APD prolongation and ventricular quiescence. Confocal imaging of Ca2+ activity in isolated cardiomyocytes showed that bSMase prolongs Ca2+ transient duration and increases spontaneous Ca2+ spark activity, promoting the reduction of sarcoplasmic reticulum (SR) Ca2+ load. DTT prevented Ca2+ transient duration prolongation but did not reduce Ca2+ spark activity. Interestingly, selective PKA inhibition with H-89, but not CaMKII by KN93, significantly reduced Ca2+ spark frequency after bSMase perfusion. Conclusions: Our findings suggest that nSMase activation stimulates ROS production and PKA activity leading to SR Ca2+ leak and activation of ICl,swell which suppress cardiac activity and may promote arrhythmias and mechanical dysfunction during chronic cardiac overload. |
| 1.308 | Ryan Powell | GERI | rpowell@medicine.wisc.edu | Association of Life Course Factory Production Work and Lewy Body Dementia | Introduction: Work as a determinant of health and related disparities may be an important source of occupational exposures, yet its role in influencing the biological underpinnings of Alzheimer’s Disease and Related Dementias (ADRD) is limited. Identifying harmful exposures is a critical step towards understanding the role that work plays in the pathogenesis of ADRD, allowing for effective design of disease prevention and intervention strategies for the most efficient allocation of resources. Methods: Decedents donating to two Alzheimer's Disease Research Center (ADRC) brain banks from 1986 to 2018, with neuropathologist categorized Lewy body dementia presence, were included (n = 1079). Donor occupational histories derived from archival public records went through a multi-step process to assign a 6-digit occupation Standardized Occupation Codes (SOC) for each occupation using established protocols. Using generalized logistic regression, we modeled the presence of Lewy bodies association with having worked in “Production Occupations” adjusting for age, sex, and death year with site clustered standard errors. Results: Donors with a history of “Production Occupations” face a 20% increased odds of having Lewy Bodies (OR=1.20, 95% CI=1.16-1.25) after adjusting for age, sex, and death. Discussion: This is the first study, to our knowledge, to find increased levels of verified Lewy body neuropathology in those with “Production Occupations”—i.e., donors who reported working as factory workers, foremen, assemblers, etc. in their work histories. Additional precision categorizing industrial production and manufacturing exposure in their occupational histories, duration of occupational exposure, and dosage of exposure, is needed to identify specific drivers behind this association, which may include the direct exposure to environmental hazards including heavy metals exposure. |
| 1.309 | Robert Striker | ID | rtstriker@wisc.edu | Innovations in Cancer Screening: Machine Learning to Incorporate Immune Parameters in Anal Cancer Screening Decision Making | Background: The recent ANCHOR study from 2024 definitively shows that treating precancerous high-grade intraepithelial lesions (HSIL) anal dysplasia prevents anal cancer, yet this study does not provide: (1) the best screening methods for anal cancer dysplasia and (2) the percentage of patients at risk for anal cancer who should be screened for anoscopy. While anoscopies are not limited at UW Health, they are not available for most patients who are at high risk for HSIL, and it is unclear when and how anoscopies should be utilized. While there are many parallels between anal cancer and cervical cancer, there are also many differences. Both cancer types are preceded and caused by an oncogenic HPV infection; however, the presence of high-risk HPV in the anus is roughly 10-fold higher in men who have sex with men. The presence of high-risk HPV is insufficient as a single time point to warrant invasive preventative action unlike with cervical cancer screening. Evidence from UW and other groups agree that abnormal immune parameters (particularly low CD4/CD8 ratios) precede most anal cancer by months to years. Furthermore, small immune abnormalities are linked to dysplasia, with a correlation between time of immune parameter abnormality and the worsening degree of dysplasia. There is a need for prediction models based on risk that includes more than age, but it is unclear if immune parameters are powerful enough to be used to alter clinical decisionmaking. Methods: From 2000 to 2020, over 400 UW Health patients with HIV have been evaluated by anal paps, anoscopy with biopsies, or biopsies obtained without anoscopy. All were virally suppressed at the time of anal disease assessment. CD4/CD8 ratios within 6 months of assessment and immune health grades (IHGs) were calculated and used with biological age to develop Machine Learning models (Random Forest and Naive Bayes). Seventy percent of the cohort was used for model building and the rest for assessment of model prediction. To build the models, we programmed in python using tools from Google Collaboratory. Both models were trained and tested on (1) CD4/CD8 ratio, (2) IHG, (3) age, and (4) all previous parameters plus CD4 count and CD8 count. The models were then tested with data from the testing set to assess the accuracy of predictions. Results: Random Forest was more accurate for (2) and (4), yet Naive Bayes was more accurate for (1) and (3). While the Random Forest model explored model accuracy when trained using various feature combinations, it was not able to determine how a patient might transition between stages. The Naive Bayes Model was used to better understand what impact bucketization of features (such as age and ratio) had on the overall accuracy when trying to make a prediction as to what stage the patient might belong to. Discussion: To determine the utility of AI models in anal cancer/dysplasia prediction, more immune parameter data is needed, likely including immune data that proceeds the assessment. Future work will incorporate years of immune parameter data proceeding assessment as well as data from the Emory CFAR and Epic Cosmos. A key goal is determining how much of past immune parameter data should be included in order to have the most accurate predictions. |
| 1.310 | Freddy Caldera | Internal Med | fcaldera@medicine.wisc.edu | Humoral and Cell Mediated Immunogenicity of Recombinant Zoster Vaccine in Patients with Inflammatory Bowel Disease Treated with Anti-Tumor Necrosis Factor Agents or Vedolizumab | Introduction: Herpes zoster (HZ) is potentially preventable with a recombinant herpes zoster vaccine (RZV), which is recommended for all adults aged ≥ 19 years who are at an increased risk of HZ. This study aimed to evaluate the humoral and cell-mediated immunity of RZV in patients with IBD receiving anti-tumor necrosis factor (TNF) therapy compared with those receiving vedolizumab. Methods: This single-center prospective study evaluated the immunogenicity of RZV in patients with IBD receiving either vedolizumab or anti-TNF monotherapy. Serum samples were collected for varicella antibody concentrations at pre-immunization, 90, 240, and 425 days. Antibody concentrations in sera were measured by ELISA using the optical density (OD). The primary outcome was to evaluate the immunogenicity of RZV in patients with IBD receiving vedolizumab compared with those receiving anti-TNF monotherapy. Secondary outcomes included: 1) sustained response to RZV at 6 and 12 months post-immunization; 2) change in VZV antibody concentration from pre-immunization to one month post-immunization, and the area under curve (AUC) as a measure of antibody concentration over time; and 3) adverse events following immunization. Results: 33 patients were enrolled in the study, with four lost to follow-up and two in each group. Sixteen patients who received vedolizumab monotherapy and 17 who received anti-TNF therapy were included. Antibody concentrations as OD were available for 14 patients receiving anti-TNF therapy and 12 patients receiving vedolizumab. Patients mounted an antibody response to the vaccine series. (pre-immunization median 42.3 Optical density (OD); interquartile range (IQR) 37.2-49.1 vs 90 days median 77.1 mIU/ml; IQR 65.5-81.7 p<0.001). No significant difference in antibody concentration was observed between the anti-TNF and vedolizumab groups at 90 days (77.0 vs. 77.1 OD; p=0.58). (Figure ) Pre-immunization to 90-day antibody response between vedolizumab and antiTNF groups was not significant (antiTNF median 37.1 OD/ml; vs vedolizumab 24.8 OD/ml; p=0.45). (Table 2) At 240 days post vaccine series, the antibody concentrations in the two groups were not different (antiTNF group median 71.5OD/ml; vs vedo group median 62.4 OD/ml; p=0.26). At day 425, the groups again had similar antibody concentrations (antiTNF group median 68.3 OD/ml; IQR 59.1-73.9 vs vedo group median 75.9 OD/ml; IQR 67.1-88.1; p=0.12). The antibody AUC was also not different between the groups (antiTNF 32528 OD days/ml; IQR 24255-35004 vs. vedo 31982 ODdays/ml; IQR 30157-35259. p=0.78) (Cell mediated immunity will be presented at DDW). No IBD flares were observed after the RZV vaccine. Discussion: Patients with IBD who received the RZV series developed antibodies regardless of whether they were taking anti-TNFs or vedolizumab. The antibody response was similar between both treatment groups. |
| 1.311 | Maria Mora Pinzon | GERI | mmora2@wisc.edu | Budgeting for Success: Understanding the Costs of Community-Engaged Research for Latino Older Adults | Background: Community-engaged research (CER) is essential for addressing the health needs of older adults. However, the financial implications of such research are often underestimated, particularly when targeting groups underrepresented in research, such as Latino older adults. This study aims to provide an overview of the activities required for successfully hosting outreach and engagement activities, and the associated costs. We present examples from health fairs, educational sessions, and workshops. The goal of this analysis is to provide better planning and resource allocation and provide other investigators with practical advice. Methods: We conducted a cost analysis of various CER activities. Costs were calculated based on direct expenses (e.g., registration fees, mileage, supplies) and staff time used for planning, preparation, and execution of the activities (including fringe and benefits). Data was collected through detailed budget reviews. The activities evaluated included health fairs, educational outreach or sessions, and participation in conferences or one-day events that were hosted or co-hosted with community organizations serving Latino older adults. Results: The analysis revealed that participating in a health fair can cost an average of $12,177.51, with the cost per participant being approximately $113.40. Workshops, which require an average of 264.5 hours, have an average cost of $11,137.24, and a cost per participant/per session of $150.84. Educational events (such as lectures) required approximately 45.25 hours for planning and execution, costing $2,835.98 on average, with a cost per participant of $147.28. When the events are hosted by the academic partner, these costs increase as they do not synergize with other existing initiatives. For example, our non-partnership event had a cost of $13,392.57, which included the need to coordinate transportation for attendees, resulting in a cost of $318.87 per participant. Overall, over 60% of the cost is related to adequate staffing of events and does not include indirect costs (e.g. administrative staff), or the time invested in relationship building. Conclusion: Effective CER requires careful consideration of all cost elements and the involvement of multiple individuals to ensure successful outcomes. This study underscores the importance of collaborative efforts with community organizations to optimize resource allocation and impact. Future projects should incorporate these insights to enhance efficiency and effectiveness. |
| 1.312 | Dawn Belt Davis | ENDO | dbd@medicine.wisc.edu | Cholecystokinin Expression in Islets Under Hyperglycemic Stress | Introduction: Although cholecystokinin (CCK) is a canonical gut hormone, it is produced and secreted from pancreatic islets. Our group has demonstrated that islets secrete CCK in response to metabolic stressors, such as hyperglycemia, which prevents beta cell apoptosis. Previous work demonstrated that Cck is expressed in beta cells, but has not characterized if its production results in dedifferentiation, a known consequence of beta cell dysfunction. The goal of this study is to determine the location and the characteristics of islet cells that express Cck under metabolic stress in order to understand the hormone’s role on beta cell dedifferentiation. We hypothesized that Cck expression would be greatest in dedifferentiated beta cells. Methods: We generated triple transgenic mice using Rosa26-H2BmCherry with Ins1-Cre driver and Cck-eGFP (LTCCK). This genetic makeup allows for lineage-tracing of beta cells through mCherry labeling and visualization with GFP where Cck is expressed. In combination with immunofluorescent staining of Ucn3, this facilitates the quantification of dedifferentiated beta cells, Cck expressing cells, and their overlap. To determine the relationship between beta cell dedifferentiation and Cck expression, we treated mice with insulin receptor antagonist (S961) for one week to induce hyperglycemic stress. Pacreata were dissected, fixed and mounted on slides, then stained for GFP and Ucn3. We evaluated Cck expression, beta cell lineage, and Ucn3 expression as a marker of differentiated beta cells in confocal images using FIJI. Results: We successfully induced expression of Cck by S961 treatment in 6.4% of islet cells. Cck expression was not exclusive to beta cells. We discovered that Cck-eGFP positive cells were enriched in dedifferentiated beta cells (19.3% of mCherry+, Ucn3- cells) compared to mature beta cells (7.7% of mCherry+, Ucn3+ cells). However, Cck-eGFP negative cells were more abundant than Cck-eGFP positive cells in both populations.There was evidence of Ucn3+/mCherry-/Cck-eGFP- cells (13% of total cells), suggesting there could be evidence of transdifferentiation or incomplete lineage tracing of beta cells in this model. Discussion: Cck expression is induced by metabolic stress in islets and occurs in both beta and non-beta cells. Based on our finding that few Cck positive cells were dedifferentiated beta cells, it is unlikely that CCK production results in beta cell dedifferentiation as the mechanism to protect from apoptosis. Further analysis will examine spatial relationships to determine if paracrine action of CCK may impart benefits to neighboring cells. |
| 1.313 | Majid Afshar | APCCM | mafshar@medicine.wisc.edu | Retrieval-Augmented Generation for Antibiotic Timeline Extraction from Clinical Notes | Introduction: While large language models (LLMs) have demonstrated promising capabilities in clinical question answering and summarization, the sheer length of text in electronic health records (EHRs) presents significant challenges for efficient and comprehensive reasoning. Retrieval-augmented generation (RAG) addresses these limitations by first searching through patient notes to find the most relevant information for the task at hand, then feeding just those sections to the LLM, potentially improving both efficiency and accuracy. In this study, we evaluate the effectiveness of a RAG-based approach for accurately extracting antibiotic treatment timelines from clinical notes. This task aims to emulate the work performed by Infectious Diseases (ID) clinicians in documenting the antibiotic regimen for the active infection of concern, requiring synthesizing information scattered across multiple documents and performing reasoning over which antibiotics to include. Methods: We constructed a dataset of 200 patient encounters from the UW-Madison hospital where there was a consultation with Infectious Diseases. The antibiotic timelines manually written in the consult note serve as our ground truth labels with annotated antibiotic names and dates active for that hospital encounter. Unlike the structured medication data in the EHR, these timelines identify only antibiotics used to treat the major infection necessitating the consultation and exclude prophylactics and those used to treat other conditions. We processed the clinical notes that occurred prior to the consultation into 128-token long segments and used the BAAI General Embeddings (BGE-en-large-v1.5) model to turn these text chunks into vector representations for semantic search. RAG was performed in a two step process: 1) We retrieved relevant portions of clinical notes prior to the consultation by their semantic similarity to the embedding for the query “What antibiotics has the patient taken?” 2) The retrieved text is presented alongside instructions to the LLM Gemma 2 (27B) to generate a list of medications and the date ranges they were administered. We evaluated results using the Jaccard index, calculating the time overlap between the generated timelines against the ground truth from ID consult notes, which ranges from 0 (no overlap in the date range, missing a medication entirely, or adding a medication not present in the gold standard) to 1 (exact date range match). These values are then averaged. We evaluated three approaches to extracting antibiotic timelines. As a baseline, we used a rule-based approach of directly extracting the time ranges for all administered medications of the “anti-infective” therapeutic class from the MAR (medication administration record) in the EHR. We also evaluated a non-RAG LLM approach of providing Gemma 2 with as many recent clinical notes as possible within its 8K token context limit. Finally, we tested the RAG approach by providing the model with the 20-, 40-, and 60-most relevant note chunks identified by our retrieval method, where the use of 60 chunks in combination with the instruction approaches the context window limitations of Gemma 2. Results: The rule-based baseline resulted in an average Jaccard index of 0.465. The known shortcoming of this method is the inclusion of antibiotics not considered therapeutically relevant to the infection of concern. The non-RAG approach of using as many recent notes as possible results in a performance of 0.381. We found RAG to provide substantial improvement over this, where providing the LLM with the 20 most relevant text chunks produced antibiotic timeline lists with an average Jaccard index of 0.482. Increasing the provided information to the top 40 and 60 text chunks yielded additional incremental improvement (0.504 and 0.514, respectively). We conducted an error analysis of the generated medication lists for 70 randomly selected encounters to identify failure modes of the RAG-based approach using 20 retrieved text passages. In 41.8% of error cases, the LLM's inability to reason correctly over the provided context contributed to the inaccuracy, such as overlooking a medication that was mentioned or using the wrong date. Retrieval failures contributed to 34.7% of errors, where additional needed information existed in the full notes but wasn't selected during the retrieval phase of RAG. In 28.1% of the gold medications analyzed, the information needed to generate the gold standard medication and exact timespan is not present in the full clinical notes, which presents a limitation in this task. Some causes of this lack of information include the precise start/end dates being unclear from the notes or the timestamp metadata of notes reflecting a delayed filing time, rather than when it was written. Discussion: These findings demonstrate that by selectively targeting information in the EHR, RAG can significantly improve the extraction of antibiotic treatment timelines from clinical notes compared to a naive LLM approach using as many notes as the LLM can incorporate based on context-length limitations, while also improving efficiency. While this approach shows promising results in the application of RAG to more precisely target relevant information, the error analysis shows an opportunity for further refinement in the retrieval method and demonstrates limitations in the tested LLM’s reasoning capability. |
| 1.314 | Sandesh Parajuli | NEPHRO | sparajuli@medicine.wisc.edu | Delayed Graft Function among Simultaneous Pancreas-Kidney Transplant Recipients Is Associated with an Increased Risk of Urinary Tract Infections and Kidney Rejections | Introduction: Kidney delayed graft function (K-DGF) is associated with various detrimental outcomes among simultaneous pancreas and kidney (SPK) recipients. However, its potential risk associated with infection and rejection remains unclear. Methods: We compared recipients with K-DGF to those without K-DGF among all adult SPK recipients transplanted at our center between 01/2010 and 12/2022 who had pancreas graft survival of more than 2 weeks. Outcomes of interest included urinary tract infections (UTI) and pneumonia, along with pancreas and kidney graft rejections, within one-year post-transplant. Results: 543 SPK recipients were included, of whom 47 (8.7%) developed K-DGF. A total of 89 recipients had UTI, 33 had pneumonia, 77 had pancreas rejection and 21 had kidney rejection within one-year post-transplant. Recipients with K-DGF experienced a higher incidence of UTI. This association remained after adjustment for baseline characteristics (adjusted Hazard Ratio [aHR]: 3.06; 95% CI: 1.46-6.42; p=0.003). Similarly, K-DGF was associated with increased risk for kidney rejection in the unadjusted and adjusted models (aHR: 5.47; 95% CI: 1.98-15.1, p=0.001). K-DGF was not associated with pneumonia or pancreas rejection. Conclusion: K-DGF among SPK recipients is associated with an increased risk for UTI and kidney allograft rejection, likely related to dysregulation of the immune system. Close monitoring and appropriate management are warranted in these unique patient populations. |
| 1.315 | Alexey Glukhov | CVM | aglukhov@medicine.wisc.edu | Hypertension-mediated decrease in myocardium elasticity augments atrial mechanosensitivity and contributes to stretch-induced arrhythmogenesis in spontaneously hypertensive rats | Background: Initiation of atrial tachyarrhythmias is frequently linked to discrete regions, including the pulmonary veins (PV) and superior vena cava (SVC). Risk of atrial tachyarrhythmias is significantly increased during hypertension, and mechano-electrical feedback (MEF) has been proposed to contribute to arrhythmia initiation in those specific atrial regions. Moreover, we previously revealed a significant augmentation of PV and SVC mechanosensitivity in spontaneously hypertensive rats (SHR), however, the underlying mechanisms are unclear. Methods: We utilized RNA-sequencing to compare gene expression for normotensive (NTR) and hypertensive (SHR) rat (12-14 months old males, n=4 rats/group) SVC and right atrial appendage (RAA) tissues. Fibrosis content, elastin expression, and the level of apoptosis were evaluated in SVC and RAA by using Masson Trichrome, Verhoeff, and cleaved-caspase 3 staining, respectively (n=3-4 rats/group). Results: RNA-seq identified significant differences in genes related to mechanosensitivity between the SVC and RAA regions, with SVC showing significantly elevated expression of genes associated with MEF mechanisms. At the same time, the genes related to MEF were not significantly changed in during chronic hypertension. RNA-seq also revealed a significant upregulation of genes linked with apoptosis and inflammation as well as extracellular matrix composition in SVC. Indeed, histological analysis confirmed a significantly increased fibrosis content in SHR SVC compared to NTR (72.5 %). Interestingly, despite augmented fibrogenesis, SHR SVC demonstrated a significant downregulation of elastin expression (-45.9 %). As extracellular matrix remodeling may affect the stiffness and thus mechano-sensitivity of the heart, our data suggests that hypertension-induced extracellular matrix remodeling increases the hypersensitivity of the SVC to mechanical stretch, as observed in our previous electrophysiological studies. Conclusions: Our RNA-sequencing data confirms that the SVC possesses a significantly different molecular foundation, with many differences in mechano-sensitive mRNAs compared to RAA, potentially underlying the SVC’s susceptibility to arrythmia generation in pathological conditions. |
| 1.316 | Heidi Twedt | GIM | htwedt@wisc.edu | Usability Assessment of our EHR’s Rooming Navigator using Keystroke Level Modeling (KLM) and the System Usability Scale (SUS) | Background The EHR rooming navigator is cluttered with redundant/rarely used features, leading to staff inefficiencies and dissatisfaction. To support a redesign, we established baseline usability metrics using Keystroke Level Modeling (KLM) and the System Usability Scale (SUS). Methods An informatics fellow recruited rooming staff from ambulatory clinics. Participants performed a scripted mock rooming process, with workflow metrics captured by the EHR's KLM workflow analyzer. After task completion, participants completed the SUS questionnaire. Spearman rank correlation evaluated relationships between SUS scores, task duration, and experience. Results 35 participants from five ambulatory departments completed the study. KLM workflow analyzer showed a median rooming duration of 47 s, with 9 screen/keyboard transitions, 50 keypresses/mouse clicks, and a SUS score of 89. Correlation between SUS score, task duration, and experience was not significant. Conclusion Baseline KLM metrics reveal mouse clicks and scrolling significantly impact task duration. High SUS scores indicate the navigator is user-friendly, with minimal correlation between satisfaction, task duration, and experience. |
| 1.317 | Nathan Sandbo | APCCM | nsandbo@medicine.wisc.edu | Glutamine-fructose-6 phosphate transaminase 2, a rate limiting enzyme of the Hexosamine Biosynthetic Pathway, is increased in cultured human precision cut lung slices, an ex vivo model of human lung fibrosis | Introduction: Idiopathic Pulmonary Fibrosis (IPF) is a progressive and terminal lung disease affecting over three million people worldwide. It is characterized by irreversible excessive extracellular matrix (ECM) deposition in the lung leading to loss of oxygen exchange and eventually death. ECM is a complex web of macromolecules, including fibronectin and collagen, many of which are regulated by O-GlcNAcylation (a post-translational modification involving the addition of N-acetylglucosamine (GlcNAc) to serine or threonine residues on proteins). Glutamine-fructose-6-phosphate transaminase 2 (GFTP2) is a rate limiting enzyme in the Hexosamine Biosynthetic Pathway, a metabolic pathway that converts glucose into UDP-GlcNAc, the substrate for downstream O-GlcNAcylation. GFTP2 expression is increased in both the lungs of IPF and our bleomycin induced mouse model of fibrosis. We hypothesize that GFPT2 expression will be increased in cultured human precision cut lung slices (PCLS) treated with pro-fibrotic compounds, an ex vivo model of fibrosis. Methods: Human PCLS are derived from human lungs rejected for transplant. These lungs are inflated with warm agarose, cooled to harden the agarose and provide lung rigidity, core samples are taken, and the cores are sectioned into 500-micron slices with a Leica vibratome. PCLS are subjected to a 30-minute agarose wash out period in culture media (DMEM with 0.1% FBS containing streptomycin, penicillin, and amphotericin B, and L-glutamine) at 37°C with 5% CO2. After this wash out period, PCLS are either taken immediately for RNA analysis and fixed in formalin for immunohistochemistry (IHC) or they are cultured for 5 days in culture media with or without 5 ng/ml transforming growth factor beta 1 (TGF-β1) or fibrotic cocktail (5 ng/ml TGF- β1, 10 ng/ml tumor necrosis factor alpha (TNFα), 5 μM platelet-derived growth factor alpha beta (PDGFαβ), 5 μM lysophosphatidic acid (LPA)). After 48 hours the culture media with or without pro-fibrotic additives are replenished and the PCLS are incubated for 72 more hours before being harvested for RNA or fixed in formalin for IHC. RNA was isolated from PCLS, cDNA was synthesized, and RT-qPCR was utilized to measure the gene expression of GFPT2, fibronectin, collagen as well as other markers of fibrosis and enzymes in the HBP. For the fixed PCLS, IHC was performed to stain for Masson’s Trichrome, GFTP2, fibronectin, and pro-collagen. Results: We found that GFPT2 gene and protein expression levels in the human PCLS were significantly increased with both TGF- β1 alone and with the fibrotic cocktail as compared to culture media without pro-fibrotic additives, with the fibrotic cocktail causing a more robust increase. Interestingly, the GFPT2 expression of the non-cultured human PCLS was low in comparison to all cultured PCLS conditions. The levels of fibronectin mRNA and protein were significantly increased with TGF- β1 alone. We found that the level of fibronectin protein expression was similarly increased under the stimulation of the fibrotic cocktail. Similar to fibronectin, the levels of collagen mRNA were significantly increased with TGF- β1 alone, but no increase was seen with the fibrotic cocktail. Interestingly, while we detected a trend toward increased pro-collagen protein expression with TGF- β1 stimulation, these changes were not observed with fibrotic cocktail. At the mRNA level, there were significant increases in both alpha smooth muscle actin (αSMA) and collagen triple helix repeat containing 1 (CTHRC1), both additional markers of fibrosis, with TGF- β1 alone, and variable effects with fibrotic cocktail. Conclusions: Taken together, it is evident that the expression of GFPT2 is increased in our ex vivo fibrotic lung model. The observation that GFPT2 expression was low in the non-cultured human PCLS compared with the 5-day cultured PCLS suggests that GFTP2 may be impacted by the potential trauma of PCLS generation. The validity of the cultured human PCLS as a model of fibrosis is corroborated by the increased levels of pro-fibrotic markers, fibronectin, collagen, αSMA, and CTHRC1. This data, along with more investigation, uncovers a novel potential and critically needed target for the therapeutic intervention for IPF, GFPT2. |
| 1.318 | Nathan Sandbo | APCCM | nsandbo@medicine.wisc.edu | Elucidating the Mechanisms glutamine fructose-6-phosphate transaminase 2 via 5-Aminoimidazole-4-carboxamide ribonucleoside in Human Lung Fibroblasts | Introduction: Idiopathic Pulmonary Fibrosis (IPF) is a disease of excessive lung scarring caused by aberrant extracellular matrix (ECM) assembly by lung fibroblasts, which accounts for about 30% of all restrictive lung disease (RLD) cases. ECM is a complex system of macromolecules, produced and modulated by a myriad of enzymes within the fibroblasts. Fibroblasts, when differentiated into myofibroblasts, have a robust profibrotic phenotype. The Hexosamine Biosynthetic Pathway (HBP) is made up of enzymes involved in the differentiation of myofibroblasts, as well as the regulation and production of ECM macromolecules. The HBP is essential for the production of uridine diphosphate N-acetylglucosamine (UDP-GlcNAc), a vital component of N- linked and O-linked glycosylation, which are posttranslational modifications of proteins, many that are known to play a role in the regulation of ECM. We have found elevated expression of glutamine fructose-6-phosphate transaminase 2 (GFPT2), a rate limiting enzyme of the HBP, in IPF and mouse models of lung fibrosis, and differences in its expression directly impact the function of the HBP. GFPT2 expression can be modulated by phosphorylation events via AMP kinase. We hypothesize that the downregulation of GFPT2 via 5-Aminoimidazole-4-carboxamide ribonucleoside (AICAR), an AMP Kinase activator, will result in a reduction in profibrotic ECM. Methods: Human lung fibroblasts (HLFs) were plated in culture media (DMEM, 10% FBS, 1% antibiotic, 1% L-glutamine) overnight and replaced the next day with starve media(DMEM, 0.1% BSA, 1% antibiotic, 1% L-glutamine) containing 1 μM AICAR or vehicle control and 30 minutes later with or without transforming growth factor beta 1 (TGF-β1), used to initiate stimulation of myofibroblast differentiation. Cells were incubated for 24-72 hours. RNA was isolated, cDNA was synthesized, and RT-qPCR was utilized to measure the gene expression of GFPT2, fibronectin, as well as other markers of fibrosis and enzymes in the HBP. Protein expression was characterized using western blotting for the same targets. Results: At the gene expression level, ECM markers of fibrosis were significantly decreased when stimulated with TGF-β1 and AICAR compared to TGF-β1 alone, including but not limited to fibronectin, collagen, and alpha smooth muscle actin. Most of the enzymes of the were also significantly decreased at the gene expression level when stimulated with TGF-β1 and AICAR compared to TGF-β1 alone. Interestingly, we found that fibronectin increased more after 72 hours compared to 24 hours. However, GFPT2 was significantly increased at 24 hours only The Sirtuin 1 gene was used as a marker of AICAR effectiveness and significantly increased when stimulated with TGF-β1 and AICAR. Discussion: Based on these results, AICAR worked as expected given the results of Sirtuin 1 gene expression and the significant increase in GFPT2 expression at 24 hours only suggests that compensatory mechanisms might take place. AICAR significantly decreases ECM markers of fibrosis and markers of the HBP, however future directions will determine if this is a result of the subsequent downregulation of GFPT2. Our hope is to elucidate the role of GFPT2 in fibrosis and its viability as a therapeutic target for IPF or other RLD diseases |
| 1.319 | Adam Konopka | GERI | akonopka@medicine.wisc.edu | Aging Attenuates Exercise-Induced Proteostatic Maintenance in Skeletal Muscle | Aging is marked by a progressive decline in skeletal muscle mass and function, known as sarcopenia, which compromises mobility and overall health. The mechanistic target of rapamycin complex 1 (mTORC1) plays a pivotal role in maintaining proteostasis by coordinating protein synthesis and degradation. While mTORC1 is essential for skeletal muscle homeostasis, its chronic activation with aging disrupts protein quality control mechanisms. Exercise is a potent modulator of mTORC1 and remains the most effective intervention for preserving muscle integrity. However, the ability of exercise to restore proteostasis when initiated later in life remains unclear. To address this, adult (5-monthold) and aged (22-month-old) female C57BL/6J mice (N=12–16/group) completed 8- weeks of sedentary control or Progressive Weighted Wheel Running (PoWeR). During PoWeR, adult mice averaged ~8 km/day, whereas aged mice covered ~3 km/day. Gastrocnemius muscles were collected 24 hours post-exercise to evaluate mTORC1 signaling, protein quality control mechanisms, and the distribution of soluble proteins susceptible to protein turnover and insoluble proteins prone to be resistant to turnover. Compared to adults, aged muscle had elevated basal mTORC1 signaling and attenuated activation of mTORC1 signaling after PoWeR. In the detergent-insoluble protein fraction, aged muscle exhibited elevated levels of p62 and total ubiquitinated proteins, suggesting an accumulation of misfolded and aggregated proteins. While PoWeR enhanced markers of autophagy-mediated protein clearance in adult mice, as evidenced by increased soluble p62 and reduced insoluble p62; the age-related accumulation of p62 accumulation in both soluble and insoluble protein fractions remained refractory to PoWeR. Similarly, PoWeR reduced K48-linked ubiquitinated proteins tagged for proteasomal degradation in the insoluble fraction in adult but not older mice. The impairment in autophagy and proteasomal markers of proteostasis in aged mice was accompanied by impaired collagen remodeling, which is essential for muscle integrity and adaptability. Both old sedentary and PoWeR mice exhibited increased pepsin-insoluble and crosslinked collagen indicated by crosslinking enzyme lysyl oxidase (LOX). The agerelated reduction in pepsin-soluble collagen content was modestly improved with PoWeR. Our findings indicate that while PoWeR promotes proteostatic maintenance in adult muscle, it fails to restore proteostatic imbalance in aged skeletal muscle when initiated later in life. These results may indicate the need for complementary gerotherapeutic interventions to augment the efficacy of exercise in reversing age-associated impairments in protein homeostasis. |
| 1.320 | Sterling C. Johnson | GERI | scj@medicine.wisc.edu | Plasma pTau217 levels and conversion to MCI in the Wisconsin Registry for Alzheimer’s Prevention and the Wisconsin ADRC | Introduction: As the evidence base supporting the accuracy and reliability of plasma pTau217 assays continues to grow, attention has shifted towards establishing their diagnostic and clinical utility. The aim of the current study was to examine the association between plasma pTau217 levels and conversion to MCI in a preclinical cohort. Method: We selected 1943 participants from the Wisconsin Registry for Alzheimer’s Prevention and the Wisconsin ADRC for whom Quanterix HD-X plasma pTau217 data was available. Participants were classified as being plasma pTau217 negative (≤ 40 pg/ml, n=1402) or positive (> 40 pg/ml, n=541), with the positive group also being subdivided into moderately positive (> 0.40 & ≤ 0.63 pg/ml, n=308) and strongly positive (> 0.63 pg/ml, n=233). Incident MCI was defined using varying levels of stringency and definitions included (1) conversion from CDR 0 to CDR 0.5 at two consecutive visits (n=638, median 3 visits, mean FU 6.6 years; definition 1), (2) a clinical diagnosis of MCI from multidisciplinary consensus review (n=1076, median 5 visits, mean FU 5.6 years; definition 2) and (3) performance below the 7th conditional centile on the PACC-3 for two consecutive visits (n=716, median 3 visits, mean FU 7.7 years; definition 3). Results: The mean age of the included participants was 63 years (SD8.1). 68% of participants were female, 35% of participants were APOE e4 carrier and 83% of participants were non-Hispanic white. Rates of conversion in the total cohort were < 1% per year (1.5% overall; average time to conversion 5.1 years) for definition 1, 1.1% per year (6.4% overall; average time to conversion 7.3 years) for definition 2 and <1.0% per year (3.9% overall; average time to conversion 5.7 years) for definition 3. Rates of conversion in the subset of pTau217 positive participants ranged from <1.0% to 4.7% per year. Those with strongly positive plasma levels showed the highest rates of conversion. Discussion: Rates of conversion to MCI in this largely preclinical cohort ranged from < 1% to 1.1% per year in the total cohort and from <1% to 4.7% per year in the subset of participants that were plasma pTau217 positive. |
| 1.321 | Edmond Ramly; Susan Nordman-Oliveira | ID | ramly@wisc.edu; susan.nordmanoliveira@wisc.edu | Trends in Falls and Falls with Injury in Assisted Living Communities: Data from the Quality Improvement with Data (QID) group and the Wisconsin Coalition for Collaborative Excellence in Assisted Living (WCCEAL) | Introduction: Nursing homes residents experience over 800,000 falls a year [1]. Despite similar populations, there are limited data available on falls in assisted living communities (ALCs)[2]. This study aims to characterize falls incidence and outcomes across different ALC resident populations. Methods: We conducted a analyses using data from the Wisconsin Coalition for Collaborative Excellence in Assisted Living (WCCEAL) system created by the Quality Improvement with Data (QID) group. These data were collected from over 300 ALCs quarterly from 2019 to 2023. In this period, over 300 ALCs reported quarterly resident population makeup, fall incidence, and injury rates. In addition to a longitudinal analysis, we compared our assisted living results to corresponding nursing home data from published reports. Results: We found disparities between ALC resident population types in reported falls. Communities primarily serving Irreversible Dementia & Alzheimer’s residents experienced 114 falls per 10,000 resident-days, with 8.88% resulting in injury. For communities with other primary populations, there were fewer falls on average (38.2 falls per 10,000 resident-days) and higher rates of injury (12.56%). Overall, 11.64% of falls in ALCs resulted in injury from 2019 to 2023. Comparatively, nursing home residents report fewer falls (approx. 9.47 falls per 10,000 resident-days) and higher injury rates (26-48%) [3, 4]. Conclusions: ALC residents experience more falls and lower injury rates than nursing home residents, emphasizing the distinct care needs and fall risks of ALC and nursing home populations. Unique falls risk factors for ALC residents must be better understood to reduce falls in long-term care settings. |
| 1.322 | Farah Acher Kaiksow | HOSP MED | fkaiksow@medicine.wisc.edu | Healing behind bars: Differential use of a hospital prison unit | Introduction The United States (US) is a world leader in incarceration, both per capita and as an absolute number.1 As the population of older incarcerated adults – and their health care needs – both rapidly increase, heath care systems must determine how to best care for this vulnerable group.2 The use of locked prison units in community-based hospitals is one model for care, though little information exists describing how these units are used. Methods We created a database that included all male incarcerated patient admissions to the UW Hospital from 2010-2019; admissions to critical care or psychiatry services were excluded as these patients were not eligible for placement in the hospital’s locked unit. Admissions to the locked unit and to regular patient rooms were compared based on average age, length of stay (LOS), admitting service, Charlson Comorbidity Index (CCI), and race. We used Mann-Whitney U tests for age, LOS, and CCI, while chi-square tests were used for race and admitting service. Additionally, a disproportionality index was calculated to determine if there were racial inequities in who was admitted to the hospital compared to the overall state Department of Corrections population during the study period. Results There were statistically significant differences in the age, LOS, admitting service, and race between admissions to the locked unit compared to admissions to regular patient rooms; patients admitted to the locked unit were younger, had longer LOS, were more likely to be on surgical services compared to medical services, and were more likely to be Black/African American. There was no statistically significant difference in CCI. Overall, admissions for Black/African American incarcerated patients were disproportionately low compared to the overall population; this difference was not explained by differences in illness severity. Discussion In this large academic hospital, incarcerated patients admitted to the locked unit were slightly younger and had slightly longer LOS compared to those admitted to regular patient rooms. Black/African American patients were more likely to be admitted to the locked unit, despite having the same level of illness severity as other racial groups. Additionally, Black/African American patients were admitted to the hospital less than would be expected based on their total proportion of the incarcerated population over the study period. These racial disparities should be investigated further to determine if they could be due to bias or other structural barriers. |
| 1.323 | Heidi Twedt | DOM Clinical Informatics | htwedt@wisc.edu | Challenges of Implementing Social Determinants of Health Screening in a Low Vision Clinic | Abstract Patients in a low vision clinic have unique challenges when completing online patient portal questionnaires. The implementation of EHR-based screening of social determinants of health in a primary care setting has been previously studied. We aim to describe and address the challenges of implementation in a unique community ophthalmology clinic that primarily treats low vision patients. Methods We implemented an EHR patient portal-based screening using evidence-based questions to evaluate a patient’s risk in various categories of SDOH. This was piloted in an ophthalmology clinic that serves low vision patients and a general primary care clinic. We gathered data on survey completion for SDOH as part of a pre-visit questionnaire sent to the patient portal over a month. We reviewed demographic data within and between clinic locations to identify barriers to screening. We also interviewed nurses, providers, and ophthalmology technicians on perceived barriers to screening. Additional qualitative data will be collected via a survey to patients about their experience with the health screening. Results The survey was completed in 15.2% of patients in the ophthalmology clinic as compared to 43% of patients in the primary care clinic. Social connection was the most common high-risk domain with 49.9% of patients in the primary care clinic and 26.2% of patients in the ophthalmology clinic reporting a lack of social connection. Nurses and ophthalmology technicians identified inability to read the health questionnaire as a barrier to screening, and providers noted that they were unaware of where to find SDOH data after it is entered. Discussion The results of this study indicate a disparity in access for patients reporting SDOH screening information. Some disparities might be due to lack of knowledge of technical accessibility features for low vision. This can be mitigated by identifying low-vision patients and administration of in-person forms via font-adjusted tablet or accessible font and format-adjusted paper forms, along with targeted education about accessibility technology features. We additionally anticipate that patients may not complete SDOH screening as they may not believe it is relevant, may not believe that their provider would review it, or would not feel comfortable disclosing personal financial and socioeconomic indicators to their vision specialist. |
| 1.324 | Carmen R. Valdivia; Francisco J. Alvarado | CVM | crvaldivia@medicine.wisc.edu, falvarad@medicine.wisc.ed | Novel RyR2 mutation linked to Long QT Syndrome | Background: Long QT syndrome (LQTS) is a severe cardiac disorder characterized by impaired cardiac repolarization, leading to a prolonged QT interval on the electrocardiogram (ECG). Patients with LQTS are at risk for malignant ventricular tachyarrhythmias, syncope, and sudden cardiac death. Recent reports have linked mutations in ryanodine receptor 2 (RyR2), the primary Ca2+ release channel of the sarcoplasm reticulum in the heart and a critical component of excitation-contraction (e-c) coupling, to LQTS. However, the molecular and cellular mechanisms by which RyR2 dysfunction triggers LQTS remain poorly understood. This study aims to investigate how the novel mutation RyR2-R2920Q may lead to LQTS. Methods: Our approach includes a combination of in vivo and ex vivo electrophysiological studies in mice harboring the mutation R2920Q, associated with LQTS in humans. Wild type (WT), heterozygous (Het) and homozygous (Homo) littermates were analyzed. Surface ECGs were examined to assess changes in the QTc interval. Simultaneous current-clamp and confocal Ca2+ imaging were performed to evaluate alterations on Ca2+ handling and excitation-contraction coupling in isolated left ventricle myocytes. Results: Both Het and Homo RyR2-R2920Q mice exhibited significantly prolonged QTc interval compared to WT mice (WT, 50±2, Het, 60±3, and Homo, 71±1 ms). Myocytes from Het and Homo mice showed increased action potential duration (APD) at 30%, 70%, and 90% repolarization compared to WT myocytes (APD 30,70,90%: WT: 1.6 ± 0.3, 48 ± 9, and 168 ± 1 ms; Het: 2.4 ± 0.4, 68 ± 1, and 216 ± 3 ms; Homo: 3.2 ± 0.5, 132 ± 22, and 348 ± 33 ms). Homozygous myocytes also displayed increased APD variability and a higher incidence of early after-depolarizations (EADs) compared to WT controls. These electrophysiological changes were associated with prolonged decay of Ca²⁺ transients (WT: 158 ± 18 ms; Het: 133 ± 15 ms; Homo: 176 ± 11 ms). Application of Ca²⁺ chelators (EGTA and BAPTA) shortened APD in all genotypes and completely abolished EADs without affecting action potential amplitude or resting membrane potential. Discussion: Using a novel mouse model harboring the RyR2-R2920Q mutation, we identified electrophysiological alterations compatible with LQTS syndrome, including prolonged QTc, APD prolongation, variability of APD and heightened propensity for EADs. Our findings demonstrate that sarcoplasmic reticulum Ca²⁺ release plays a critical role in APD prolongation and EAD generation. This study provides the first evidence of LQTS in a mouse model caused by an RyR2 mutation. Further research is needed to elucidate the underlying mechanisms linking RyR2 dysfunction to LQTS pathogenesis. |
| 1.325 | Deepak Gopal | GASTRO | dvg@medicine.wisc.edu | OPTIMIZING COMMUNICATION AND STREAMLINING SEDATION PLAN FOR ERCPS: A QUALITY IMPROVEMENT APPROACH TO TRANSITION FROM ANESTHESIA-GUIDED TO MODERATE SEDATION AMIDST LIMITED ANESTHESIA RESOURCES AND STAFFING CONSTRAINTS | OPTIMIZING COMMUNICATION AND STREAMLINING SEDATION PLAN FOR ERCPS: A QUALITY IMPROVEMENT APPROACH TO TRANSITION FROM ANESTHESIA-GUIDED TO MODERATE SEDATION AMIDST LIMITED ANESTHESIA RESOURCES AND STAFFING CONSTRAINTS Oscar Ramirez-Ramirez, Mark E. Benson, Patrick Pfau, Annette Dopp, Jeff Pothof, Christopher Turner, Michelle Bishop, Ashley Ring, Sarah Missig, Dana Ley, Anurag Soni, Jennifer Weiss, Peter Stadmeyer, Antonio Bosch , Deepak Gopal. Introduction: Most endoscopic retrograde cholangiopancreatography (ERCP) procedures are performed using general anesthesia (GA) or monitored anesthesia care (MAC); however, select centers with procedural team experience with sedation and airway management can offer moderate conscious sedation (MCS) based on case complexity to optimize patient care and access. Unplanned same-day conversions from GA or MAC to MCS for ERCPs can negatively impact patient experience, procedural flow, workload, and resource capacity. These challenges are aggravated by growing anesthesia demands. This quality improvement (QI) initiative aimed to reduce unplanned sedation conversions by enhancing multi-team communication and decision-making through evidence-based process improvements Methods: Using the Plan-Do-Study-Act (PDSA) QI process, a multidisciplinary team of proceduralists, anesthesiologists, nursing care leaders was convened to identify causes of unplanned ERCP conversions. Current state contributing to challenges, were systematically identified in 2023 to develop targeted interventions. Root-cause analysis identified key issues: limited anesthesia resources and after-hours availability, prioritizing urgent weekends cases, demand exceeding capacity, insufficient team communication, and staff unfamiliar with MCS protocols. Proposed interventions included scheduling non-emergent weekend cases to earlier in the week, reserving slots for ERCP add-ons, establishing a 3 PM huddle to triage later cases, optimizing case sequencing, and improving communication with procedure teams and patients to ensure care plan alignment Results: Baseline data from 01/01/2023 to 12/31/2023 included 871 ERCPs performed by six proceduralists with varying experience levels (2–25 years, each performing over 100 cases annually). 71 cases (8%) utilized MCS performed with fentanyl, midazolam with or without diphenhydramine. Of the 107 cases after-hours (weekends or after 5 PM), 61 cases (57%) utilized MCS. During the initial implementation of this (QI) process, data from 01/01/2024 to 10/31/2024 were analyzed. 537 ERCPs were performed, with 22 (4%) under MCS. Of the 76 cases conducted after-hours, 16 (21%) utilized MCS. Statistically significant reductions were observed in both total conversions (8% vs. 4%, p= 0.0047) and after-hours conversions (57% vs. 21%, p<0.001), see table 1. No sedation related adverse events occurred with MCS. Conclusion: Targeted interventions, such as improved communication among multidisciplinary teams and organized case triage, can effectively reduce unplanned sedation conversions. These measures enhance efficiency, optimize resource utilization, and improve the experiences of both patients and staff. This QI initiative highlights the significance of collaboration and structured processes in overcoming operational challenges, especially during times of staffing shortages |
| 1.326 | Francisco Alvarado | CVM | falvarad@medicine.wisc.edu | Compensatory Mechanisms Regulating Cardiac Excitation-Contraction Coupling Under Decreased Ryanodine Receptor 2 Expression | ABSTRACT Introduction: Excitation-contraction coupling (ECC) is a critical process for correct heart function. ECC relies on the coordinated activity of specific components that translate an electrical signal into motion. The ryanodine receptor 2 (RyR2) plays a main role during ECC by bridging the action potential with cardiac contraction. RyR2 dysfunction is associated with several cardiac arrhythmias that may lead to sudden cardiac death. Interestingly, RyR2 expression is often decreased in heart disease, but the pathophysiological relevance of this reduction remains unclear. Our laboratory and others have shown that RyR2 expression can be reduced by 50-80% and the heart remains functional. This suggests that despite RyR2’s critical role in ECC, the system possesses plasticity. How ECC function is preserved upon significant reduction of RyR2 remains to be elucidated. The main goal of this project is to identify the mechanisms preserving ECC stability upon RyR2 depletion. Methods: To identify these mechanisms, we have developed an innovative approach to correlate cellular electrophysiology and Ca2+ homeostasis with RyR2 expression. We performed simultaneous patch-clamp, Ca2+ imaging, Western blot, immunostaining and single-cell RNA-seq (scRNAseq) experiments in cardiomyocytes from a conditional RyR2 knock-out (RyR2cKO) mouse that expresses different levels of RyR2 in a time-dependent manner. Results: Following induction of the RyR2cKO we observe a biphasic survival response. While some mice die within 12 days, there is stable survival and limited mortality until 3-4 weeks after induction. During this timeframe, mice do not display an overt phenotype when compared to the control group. This suggests that compensation after RyR2 depletion can stabilize ECC and preserve cardiac function. Remarkably, we found an increase in calcium transient amplitude and rate of rise, and a decrease in decay time after one-week post-KO. Interestingly, these parameters returned to control levels at 2- and 3-weeks post-KO. These effects occur in the absence of any structural remodeling or altered heart function as evidenced by echocardiography. To further elucidate possible compensatory mechanisms, we measured the expression of ECC proteins using Western blots. Similar to the changes in Ca2+ handling, the expression of the Na+/Ca2+ exchanger (NCX) was upregulated at one-week but returned to control levels at later time points, suggesting that RyR2 and NCX may be coregulated in the early stages of RyR2 depletion. scRNAseq data suggests a transient transcriptomic adaptation only present during the first week after KO induction. Discussion: RyR2 expression is compensated by a homeostatic network involving the coregulation of ECC key molecules. We hypothesize that these early functional and transcriptomic changes are necessary to compensate for acute depletion of RyR2 within the first week post-KO. In later stages, however, homeostatic plasticity of ECC maintains function without structural or transcriptomic remodeling. Further analysis of scRNAseq will allow us to identify molecular pathways activated during the loss of RyR2 that either trigger sudden death or help stabilize ECC functionality. |
| 1.327 | Maria Mora Pinzon | GERI | mmora2@wisc.edu | Adapting the Brain Health Community Registry to Enhance Latino/a/e/x Enrollment and Retention: A FRAME Framework Approach | Background: To enhance Latino enrollment in aging and Alzheimer’s disease-related studies and ensure inclusive and representative results, adaptations to existing trials might be necessary. The Brain Health Community Registry (BHR) is a longitudinal registry that connects individuals to research opportunities related to brain health, dementia, and caregiving, while also sharing information about brain health and providing connections to resources that address unmet needs. The purpose of this study is to describe the process of adapting the BHR to increase Latino/a/e/x enrollment and participant retention. Methods: Adaptations were organized using the FRAME framework, which categorized changes by what was modified, the nature of the adaptation, the step in the process, and the reasoning behind each change. Researchers developed a graphical representation of the adaptation process and iteratively reviewed BHR participant-facing materials and internal standard operating procedures to identify potential modifications. Adaptations were reviewed and advanced based on available funding, IRB approval, and feasibility of integration within existing infrastructure or scope. Revised materials were translated and reviewed by a community advisory board to ensure accessibility and cultural relevance. Results: Thirteen changes were proposed; seven were accepted (five content-related and two implementation-related), while six were deferred (two content-related, three implementation-related, and one contextual-related). Accepted changes included renaming the study from “brain health” to “memory health,” revising language related to caregiving, and adjusting sensitive questions. Additionally, we transitioned intake forms from REDCap to Qualtrics, which provides enhanced language support and additional security measures for a two-step enrollment process. Changes that required additional monetary resources (e.g., increased remuneration) were deferred due to a lack of funding. Other rejected changes included the use of a short informed consent form for individuals with lower literacy, which was rejected due to IRB recommendations, and the use of WhatsApp to communicate with study participants. Since implementing these changes, we have identified a lack of understanding of the term “registry” and confusion regarding study activities within the Latino/a/e/x community. Conclusion: The next steps involve revisiting previously rejected or deferred adaptations to enhance registry recruitment while ensuring long-term sustainability. We will also explore additional adaptations to address newly identified concerns, increase recruitment, and diversify the study sample. |
| 1.328 | David Harris; Dawn Davis | ENDO | daharris6@wisc.edu; dbd@medicine.wisc.edu | Low Protein Diet Potentiates the Effects of Vertical Sleeve Gastrectomy | Vertical Sleeve Gastrectomy (VSG) is an effective surgery to treat obesity and Type 2 Diabetes (T2D), both of which contribute to age-related disease and mortality. Currently, it is recommended that patients consume a high protein diet following VSG, however, data from non-surgical models show that a low protein diet is beneficial for weight loss and insulin sensitivity. We hypothesize that consumption of a low protein diet after VSG will potentiate weight loss and improvements to glycemia. To test this, we fed C57Bl6/J mice a Western style diet for 14 weeks to induce obesity and hyperglycemia. We then performed either VSG or sham surgeries, and mice were transitioned to one of three isocaloric diets with 7% (low), 21% (medium), or 36% (high) kCal from protein. Low protein diet led to increased weight loss and improved insulin sensitivity in both the sham and VSG mice. Low protein intake potentiated the effects of VSG causing the VSG mice consuming it to lose more weight and be more insulin sensitive than VSG mice on medium or high protein diets. VSG improved glucose tolerance in all three diet groups compared to shams, but diet did not impact the glucose tolerance between VSG mice. Diet had no impact on GIP secretion in sham mice, but high protein diet greatly increased GIP secretion from VSG mice, suggesting a synergistic effect from the combination of VSG and high protein diet. VSG modestly elevated GIP secretion from medium and low protein fed mice compared to shams. Isolated pancreatic islets from VSG mice secreted the same amount of insulin as sham islets in high glucose media, but secreted significantly more insulin with the addition of GIP into the media. This suggests that VSG islets are more sensitive to GIP. Addition of a GLP-1 receptor antagonist blunted this effect, indicating that the increased sensitivity to GIP is dependent on signaling through the GLP-1 receptor. In conclusion, these data show that a low protein diet can potentiate weight loss and improvements to insulin sensitivity after VSG compared to a high protein diet. VSG patients will have to modify their diet to recover from surgery by consuming liquid and soft foods, this creates a suitable opportunity to introduce a low protein dietary intervention since patients will already have to transition away from their typical diet. |
| 1.329 | Rebecca Langhough | GERI | langhough@wisc.edu | Association of COVID-19 Positivity with Biomarkers of Alzheimer's Disease and Cognitive Test Performance | Background The amyloid cascade that causes Alzheimer’s disease (AD) is associated in part with neuroinflammation, which may be affected by peripheral disease. COVID-19 has been implicated in cognitive change, though its effect on AD biomarkers is unclear. We leverage a cohort with biomarker and cognitive data pre- and post-COVID-pandemic to examine these relationships. Methods Data was obtained from the Wisconsin Registry for Alzheimer’s Prevention. Participants return biennially for cognitive and biomarker testing. We used the data from the most recent pre-pandemic visit, compared with the first post-pandemic visit, to examine biomarker and cognitive change. One-way ANOVA was used to examine annualized biomarker change as a function of both pTau217 positivity (0.46 pg/mL or greater) and participant-reported prior COVID test-positivity (pTau217-/COVID-; pTau217-/COVID+; pTau217+/COVID-; pTau217+/COVID+). Baseline-adjusted cognitive scores on tests measuring cognitive processes previously reported to be affected by COVID (trails B, animal naming, and letter fluency tests, memory and Preclinical Alzheimer’s Cognitive Composite-3 composite scores) were compared using two-tailed, unpaired t-tests (COVID- vs COVID+). The significance level for all tests was p<0.05. Results The pTau217+/COVID- group differed from both the pTau217-/COVID- and pTau217-/COVID+ groups, but these differences did not survive correction for multiple comparisons. The biomarkers did not show any other significant differences between COVID+ and COVID- groups. The cognitive testing results trended towards the opposite relationship found in past studies, with those who were COVID+ averaging non-significantly higher percentile scores. Participants who tested positive for COVID-19 were more likely to be vaccinated, likely due to the increase in positive tests after vaccines were available. Conclusions Overall, we did not find significant associations between COVID-19, cognitive test scores, or biomarker levels. Our data may be less robust given the high percentage of vaccinations among COVID-19 positive cases and that vaccination decreases infection severity. It is also possible that the slightly younger age of the COVID+ group acted as a confounding variable. Strengths of our study include comparison of individual biomarker data before and after the spread of COVID-19, interpretation of individual cognitive test scores relative to previous performance, and a large cohort size enriched with Alzheimer’s disease risk factors. |
| 1.330 | Freddy Caldera | GASTRO | fcaldera@medicine.wisc.edu | Incidence of Herpes Zoster in Pediatric Patients with Inflammatory Bowel Disease | Background: Herpes zoster (HZ) is caused by reactivation of the varicella zoster virus (VZV). Those who have had varicella, and less commonly those who have received the live VZV vaccine, are at risk of HZ. Patients with IBD, especially those treated with thiopurines, anti-tumor necrosis factor (anti-TNF) agents, and steroids, are at increased risk. Vaccination with the recombinant zoster vaccine is recommended for adults ≥ 50 years in addition to adults ≥ 18 years who are immunocompromised. The aim of our study was to establish incidence of HZ and risk of complications among pediatric patients with IBD. We hypothesized that those with IBD would be at increased. Methods: We performed a retrospective case-control study using Optum’s Clinformatics Data Mart Database. We analyzed data from January 1, 2007 to March 31, 2022. Patients ≤21 years at time of the index date were eligible. Index date was defined as time of first IBD prescription. Patients with IBD were identified using the following criteria: (1) at least two IBD-related inpatient or outpatient visits between 2007-2022; and (2) ≥2 outpatient pharmacy claims for a distinct IBD treatment group (e.g., aminosalicylates, anti-TNFs, vedolizumab). Each patient with IBD was matched to a randomly selected non-IBD control according to age, sex, race/ethnicity, and region. Variables including demographics, IBD type, IBD treatments, and diagnosis of HZ including complications were extracted. The primary outcome was HZ incidence. Secondary outcomes included complicated HZ (e.g., ophthalmic, neurologic), hospitalization, and death. Results: Five thousand three hundred sixty-eight patients with IBD were identified (Table 1). Fifty-three (1%) of patients with IBD developed HZ, with incidence rate 3.041 (95% CI: 2.324-3.981) per 1000 person-years. In contrast, 24 (0.5%) controls developed HZ, with incidence rate 1.430 (95% CI: 0.958-2.133) per 1000 person-years (incidence rate ratio for IBD vs. control: 2.127 (95% CI: 1.313 – 3.445, p=0.002)) (Figure 1). Multivariable Cox proportional hazards model showed that IBD and age were associated with a greater risk of HZ. Seven IBD patients with HZ had complicated HZ (vs. one control). Two IBD patients were hospitalized within one month of HZ (vs. no controls). There were no deaths within one month of HZ. Nested case-control analysis revealed that combination therapy with anti-TNF and an antimetabolite was associated with an increased risk of HZ. Conclusion: Pediatric patients with IBD are at low but relatively increased risk of HZ compared to their non-IBD counterparts. Treatment with combination of anti-TNF with an antimetabolite portends an increased risk. Patients with IBD may be at greater risk of complicated HZ and hospitalization, although these findings are hypothesis-generating. These findings highlight the importance of vaccinating against varicella and herpes zoster plus screening for immunity in this patient population. |
| 1.331 | Marin Schweizer | ID | mschweizer@medicine.wisc.edu | Early Implementation of a New Bronchoalveolar Lavage PCR Panel in Lung Transplant Recipients; a Perspective from Diagnostic Stewardship | Introduction: Lung transplant (LTx) recipients are a high-risk population requiring lifelong immunosuppression and close monitoring for respiratory infections and graft rejection. A new PCR panel for lower respiratory samples from bronchoalveolar lavage (BAL) fluid able to identify multiple bacterial and viral pathogens along with select antibiotic resistance genes was implemented at the UWHealth microbiology lab in early 2023. While this test identifies multiple potential pathogens rapidly before culture results, it is uncertain if the PCR panel leads to excessive antimicrobial prescribing or inappropriate reduction in immunosuppression. Methods: This cross-sectional study included adult lung transplant recipients at the University of Wisconsin from February 2023 to October 2023 who had a BAL PCR pathogen panel. Patients without a BAL culture at the same time as the PCR were excluded. Our primary analysis compared the proportion of PCR panels sent from bronchoscopies for surveillance for rejection to those for diagnostic indications. Secondary analyses explored factors associated with having a positive BAL PCR by logistic regression, the rate of PCR-culture concordance – defined as both methods identifying the same bacterial pathogens targeted by PCR, and how frequently the antimicrobials and mycophenolate dosing was changed after the BAL. R version 4.4.1 was used for statistical analysis. Results: We included 95 LTx recipients [mean age 58.2 years, 20% single lung transplant, 93.7% basaliximab induction, 85.3% transplanted in 2015 or later, 10.5% diagnosed with rejection in prior 90 days]. 43.2% of bronchoscopies were done inpatient, 10.5% while the patient was intubated in the ICU. The indication was for rejection surveillance in 39/95 (41.1%) and for diagnosis of a new problem in 56/95 (58.9%). Diagnostic indications included inpatient evaluation for pneumonia or acute hypoxic respiratory failure (24/56; 42.9%), change in spirometry (28/56; 50%), and outpatient evaluation of new imaging abnormalities (e.g. pulmonary nodules) (4/56; 7.1%). Of all bronchoscopies 35.8% had a positive PCR and 31.6% had a positive culture. There was no difference in PCR positivity between surveillance or diagnostic bronchoscopies (33.3% v 37.5%; p=0.842). There were no significant factors associated with PCR positivity in the logistic regression (Table), antimicrobials were more frequently broadened after a positive PCR than a negative PCR (52.9% vs 18.0%; p=0.002), and there was no difference in the frequency of decreasing mycophenolate dosing after a positive PCR than a negative (5.9% vs 3.3% p = 0.942). PCR-culture concordance was high 86.3%. Pseudomonas aeruginosa was identified by PCR in 10 patients and isolated in culture in 6 of those 10. PCR identified a virus in 21.1%. Discussion: This BAL PCR panel was sent frequently on patients undergoing bronchoscopy for rejection surveillance (41.1%), it was positive frequently in this group (33.3%), it identified more Pseudomonas aeruginosa than BAL cultures, and a positive PCR result seems to be associated with broader antimicrobial therapy. While LTx recipients are at high risk for pulmonary infection, unmonitored implementation of a new molecular test may lead to unanticipated changes antimicrobial prescribing. Though we did not collect patient or graft outcomes, these results question the practice of sending this PCR panel from bronchoscopies for rejection surveillance without acute concern for infection. Diagnostic stewardship evaluates the implementation, interpretation, and impact of new tests on patient care. Data should guide our multidisciplinary teams when balancing the risks and benefits of antimicrobial therapy in our high-risk patients. |
| 1.332 | Dustin Deming | HEM/ONC | ddeming@medicine.wisc.edu | Versican status in the tumor microenvironment heterogeneously impacts immune infiltration and inflammatory pathway expression | Background: Versican (VCAN) and its proteolysis product, Versikine (Vkine), have been shown to regulate CD8+ T-cell infiltration in cancers. Here, we evaluate the impact of VCAN proteolysis and accumulation on immune infiltration and immune-related pathway expression across cancer types. Methods: RNA expression (Z-score) signatures of VCANhi/ADAMTS4hi/TIMP3lo and VCANhi/ADAMTS4lo/TIMP3hi were used to identify VCAN proteolytic predominant (VPP) and weak (VPW) cohorts, respectively, from TCGA Pan-cancer Atlas datasets. Gene-set enrichment analysis was performed between VPP and VPW cohorts for each cancer type. 10 tissue microarrays (TMAs, UW Carbone Cancer Center Translational Science Biocore and TissueArray.com) were used to evaluate VCAN, Vkine, and CD8+ tumor infiltrating lymphocytes (TILs) by immunohistochemistry (IHC). VCAN and Vkine stromal intensity was scored from 0-3+. Cancers were categorized by IHC as VPP (VCAN low, Vkine high), VVL (VCAN low, Vkine low), and VPW (all others). CD8+ TILs were quantified per high-powered field (HPF). Results: Patients (n = 4664) were evaluated across 9 cancer types [breast, esophageal (EsC), gastric, kidney (KC), lung, melanoma, endometrial (EnC), bladder (BlC), and colorectal (CRC)], of which 400 were VPP or VPW. In ≥ 6 cancer types with VPP status, E2F targets and TNFα signaling via NFκB were enriched in (q < 0.001). In ≥ 2 cancer types with VPW status, myogenesis, coagulation, IFNα response, and epithelial mesenchymal transition were enriched (q < 0.05). IL6 (average log2 fold change 2.33), CSF3 (2.26), CXCL2 (1.76), CXCL3 (1.71), XCL1 (1.47), CXCL8 (1.42) were upregulated across all VPP groups. SPP1 (0.96), PPP1R3C (0.95), and COMP (0.84) were upregulated across most VPW groups. IHC was performed on BlCs, KCs, EsCs, EnCs, triple-negative breast cancers (TNBCs), non-TNBCs, pancreatic ductal adenocarcinomas (PDACs), non-small cell lung cancers, and mismatch repair deficient (dMMR) and proficient (pMMR) CRCs. The most prevalent phenotype was VPP for EnCs (46.3%) and EsCs (52.0%), VPW for TNBCs (63.9%), pMMR CRCs (64.8%), PDACs (80.7%) and non-TNBCs (84.5%), and VVL for BlCs (78.6%) and KCs (85.9%). There were 0 VPP PDACs. CD8+ TILs were higher in VPP than VPW KCs (VPP average 16.3 CD8+ TILs/HPF = 16.3, VPW 13.7), EsC (39.9, 16.8), EnC (13.8, 9.8), dMMR CRC (31.5, 3.1), pMMR CRC (16.4, 2.2), and TNBC (37.0, 7.3). Cancers with < 5 average CD8+ TILs/HPF included VPW dMMR CRCs (3.1), pMMR CRCs (2.2), and PDACs (0.7) as well as VVL PDACs (2.9) and VPP non-TNBCs (4.5). Conclusion: VCAN proteolysis is associated with CD8+ TIL abundance, especially in EsCs, EmCs, dMMR and pMMR CRCs, and TNBCs, and expression of inflammatory genes and pathways. Further insight into VCAN prevalence and interactions with inflammatory pathways and other TME components is necessary to establish its potential as a pan-cancer biomarker for immunotherapy response. |
| 1.333 | Jacqueline Kruser | APCCM | jkruser@wisc.edu | The Potential of Interprofessional Team Coaching to Promote Human-Centered ICU Environments | Introduction: ICU’s require interprofessional roles to work as a team to provide patient care in a setting that is highly technical and fast paced. Unfortunately, conflict is common among these teams; animosity, mistrust and communication gapes are reportedly the most severe conflict causing behaviors (1). Our research uses team coaching in the MICU to assist the team in examining their behaviors, to identify what they want to change, and how those changes will improve their work together and support each other for the betterment of everyone in the MICU. Methods: A certified professional coach conducts three 90 minute sessions during the lunch hour for the MICU team. Each session has a topic specifically designed to build trust by breaking down assumptions built up over time. The list of topics are: Role Identification, Impact oof End of Life Care, and The Practice of Showing Dignity and Respect to Patients, Families, and Each Other. Reflection periods are built into the sessions to offer participants time to assess awareness resulting from the session, and how they will incorporate that into their behavior / patterns while working in the MICU. Results: Managers of each role in the interprofessional team were eager to schedule and protect time for a representative to attend the sessions (example, RNs, RTs, Chaplains, and Program Directors). Pre survey data reported that most participants (81%) reported a need for more human centered interprofessional training, which dropped to 28% following team coaching sessions. Participants reported that the program increased their awareness of other team members’ experiences and struggles and improved their interprofessional relationships. Finally, we noticed a decrease in confidence from 78% to 71% on the post survey for the question, “I currently promote and provide optimal human-centered care.” This indicates the team coaching discussions shifted what they thought was human centered care, and how they think about it after the sessions. Discussion: The MICU is a technology driven environment, which can unintentionally create a dehumanizing atmosphere for those working in it. Since we know MICU teams encounter conflict, we believe team coaching is the correct intervention to break down assumptions, offering space for them to agree upon human centered care behaviors that unify rather than separate them. The reduction in their confidence about their old practice of human centered care, tells us that spending 270 minutes exploring personal behavior has taught them something new. And since 100% of the participants (n=33) would highly recommend the program (some recommend it be incorporated into onboarding practices), we also know it’s a highly valued new knowledge. |
| 1.334 | Adam Gepner | CVM | agepner@medicine.wisc.edu | Hemodynamic Changes with Preload Augmentation Maneuvers and Heart Rate Variability Indices in Older Adults | Introduction: A blunted heart rate (HR) response to stress has been associated with both reduced heart rate variability (HRV) and cardiovascular disease. The relationship between HRV and practical in-office preload augmentation strategies such as passive leg raise (PLR) and nitroglycerin (NTG) administration have not been studied in older adults. Methods: Veterans ≥ 60 years old without known cardiovascular disease (CVD) were included in this analysis (N=142). At baseline, ECG monitoring was used to obtain HRV time-domain indices for 10-15 minutes (Atcor Medical). Bioimpedance electrodes and a brachial blood pressure cuff (Baxter Medical) were used to measure hemodynamic parameters and changes from pre-PLR (10 minutes) to active PLR (3 minutes) and pre-NTG (10 minutes) to post-NTG (3 minutes). Multiple linear regression was used to assess associations between changes in hemodynamic parameters during PLR and NA with HRV parameters. Results: Veterans were (mean ± SD) 70.5 ± 8 years old, 27% female, and 90% with self-reported white race. CVD risk factors included hypertension (64%), diabetes (19%), and current tobacco use (9%). Average baseline HR was 60.9 ± 8.3 bpm and increased to 61.6 ± 8.3 bpm with PLR and to 63.6 ± 9.3 with NTG. Baseline mean arterial blood pressure (MABP) was 95.4 ± 10.8 mmHg and increased to 98.3 ± 10.9 mmHg with PLR while decreasing to 92.9 ± 10.5 with NTG. An increased HR response to PLR was significantly associated with lower HRV indices including the standard deviation of the R-R intervals (SDNN) (β = -0.21, p = 0.018), the root mean square difference of the successive normal R-R interval (RMSSD) (β = -0.22, p = 0.009), and the HRV triangular index (HRVI) (β = -0.21, p = 0.018) after adjustment for age, sex, race, body surface area, hypertension, diabetes, and tobacco use status. A larger decrease in MABP after NTG was associated with lower SDNN (β = 0.15, p = 0.057) and HRVTI (β = 0.15, p = 0.058). There were no associations between HRV indices and cardiac output or total peripheral resistance changes during PLR or NTG (Table). Conclusion: An increased HR response to PLR and larger MABP drop in response to NTG are associated with lower resting HRV indices. These findings suggest additional information about autonomic dysfunction can be detected with preload augmentation. Further study is warranted to assess if these hemodynamic changes correlate with adverse cardiovascular outcomes in older adults. |
| 1.335 | Dudley Lamming | ENDO | dlamming@medicine.wisc.edu | Optimal late life protein intake may be dependent on early to mid-life protein intake | Current medical guidelines call for protein intake to make up 10-35% of an individual’s daily caloric intake. In aged individuals, medical professionals recommend increased protein intake to combat sarcopenia and suggest that aged individuals consume 30-35% of their daily calories as protein. However, there are a lot of conflicting studies describing the optimal protein intake for both health and longevity. We have previously shown that protein restriction (PR) improves metabolic health and longevity without increasing physical frailty when started early in life, and late life PR is also improves metabolic health in mice. As such, it is important to know the role that early to mid-life protein intake has on the optimal late-life protein intake. Male C57BL/6J were placed onto one of three diets at 2 months of age: low protein (LP; 7% protein), medium protein (MP; 21% protein), and high protein (HP; 36% protein). Mice are maintained on these diets until 20 months of age, at which point they will be randomly assigned to one of the three diets, resulting in 9 groups: LP to LP, LP to MP, LP to HP, MP to LP, MP to MP, MP to HP, HP to LP, HP to MP, and HP to HP. During both the pre- and post-switch periods, metabolic health, cognition, physical performance, and frailty will be assessed. During the pre-switch period, mice on the MP diet exhibit the greatest body weight gain, despite increased food intake in LP-fed mice and no change in food intake in HP-fed mice. However, only LP-fed mice have decreased adiposity. Improvements in body weight and adiposity in LP-fed mice may be in part due to changes in energy expenditure, which is increased compared to both MP- and HP-fed mice. Finally, all groups exhibit progressive age-related impairments in glucose homeostasis, which is blunted by LP diet. These results suggest that a diet low in protein content is the best option for improved body weight, adiposity, and metabolic health during early- to mid-life, but it is still unknown how these contribute to late-life outcomes. |
| 1.336 | Nathan Sandbo | APCCM | nsandbo@medicine.wisc.edu | Does Knockdown of PGM3 by siRNA Attenuate Myofibroblast Differentiation in Primary Human Lung Fibroblasts? | Introduction: Idiopathic pulmonary fibrosis, a disease partly characterized by the overactivity of myofibroblasts, affects approximately three million people worldwide. The hexosamine biosynthetic pathway is a proven contributor when it comes to idiopathic pulmonary fibrosis as the pathway’s output, 5′-diphosphate-N-acetyl-d-glucosamine, is upregulated in pulmonary fibrosis. The amount of this output has been shown to be influenced by phosphoglucomutase 3 (PGM3), one of the genes in the pathway; therefore, we knocked down the PGM3 gene to determine if PGM3 knockdown could attenuate myofibroblast differentiation. Methods: We used small-interfering RNA (siRNA) to knockdown PGM3 in primary human lung fibroblasts and conducted analysis on the RNA and protein amounts in the cells in different conditions to determine the effectiveness of the attenuation. More specifically, qPCR and western blots to determine the level of differentiation in the primary human fibroblasts in cells with TGF-β. Results: Preliminary results show the ability to knockdown the PGM3 gene in primary human fibroblasts. While we are still yet to analyze the RNA and proteins, we expect to see lower amounts of gene expression in genes related to myofibroblast differentiation, such as glutamine-fructose-6-phosphate transaminase 2, smooth muscle actin, fibronectin, and more. Discussion: Lower gene expression of genes related to myofibroblast differentiation would lead to the conclusion that PGM3 helps to attenuate myofibroblast differentiation and could possibly be used to develop a strategy to treat fibrosis in the future. Consequently, more research could be done on the effectiveness of siRNA on fibrosis in the growing field of siRNA therapeutics if the attenuation is successful. |
| 1.337 | Richard B. Halberg | GASTRO | rbhalberg@medicine.wisc.edu | Generation of a Novel Mouse Model to Assess the Impact of Senescence on Colorectal Cancer: | Introduction Advanced age is a well-established risk factor for colorectal cancer (CRC), with patients between the ages of 65 and 74 diagnosed most frequently in the United States. Retrospective studies have shown that age also impacts patient survival, with patients diagnosed before age 50 surviving twice as long as those aged 80 years old or more. Senescent cells, which have stopped proliferating but still interact with the surrounding microenvironment by secreting proteins, accumulate with age and have been shown to impact CRC tumorigenesis. However, the precise mechanisms remain unclear. We have generated a novel mouse model in which adenoma formation is induced by administration of tamoxifen (TAM), and in which senescent cells can be visualized in vivo and selectively cleared following administration of ganciclovir (GCV). Methods The CANp16 mouse model (ApcFlox/Flox; CDX2-CreERT2; p16-3MR) was generated through two rounds of breeding. In the presence of tamoxifen, CRE recombinase is activated in the colon and triggers the loss of APC, thereby initiating tumor formation. The specificity of CDX2-CreERT2 activity was assessed by administering a single dose of either TAM at 70 μg per g body weight or an equivalent volume of vehicle control to animals at 60 days of age, followed by colonoscopies conducted every two weeks to observe tumor formation. Two additional doses of TAM, 35 μg/g and 7 μg/g, were also assessed to determine the optimal dose for additional experiments. To confirm activity of the p16-3MR trimodality reporter in CANp16 mice, aged animals underwent bioluminescent imaging pre- and post-exposure to 5.5 Gy of total body irradiation (TBI) to induce senescence. Results Specificity studies using 70 μg per g body weight TAM or vehicle control found that CANp16 animals hemizygous for CDX2-CreERT2 rapidly formed tumors following TAM treatment (21 days on average; n=6 p16-3MR carriers and n=6 p16-3MR non-carriers), whereas TAM-treated non-carriers and animals of any genotype treated with vehicle did not form any tumors. Total tumor burden in the colon and cecum of TAM-treated CDX2-CreERT2 animals was not significantly different between p16-3MR carriers and non-carriers (p=0.5238; 110 and 84 tumors on average, respectively), however p16-3MR carriers formed fewer cecal tumors (p=0.0095; 23 tumors on average in p16-3MR carriers compared to 55 in non-carriers). Histopathology analysis of the colon and cecum collected from one animal found at least 2 tubular adenomas with high-grade dysplasia, an intramucosal carcinoma, and an invasive carcinoma – indicating that the CANp16 model can develop both adenomas and carcinomas. Survival analysis of animals hemizygous for CDX2-CreERT2 treated with the three different doses of TAM (70, 35, and 7 μg/g) found no significant improvement in animal survival when the dose was decreased from 70 to 35 μg/g. Bioluminescent imaging of CANp16 animals pre- and post-TBI indicates that the 3MR trimodality reporter protein is functional. Discussion Work performed confirms high specificity of tumor formation in the CANp16 model following TAM administration and supports previous studies indicating that tumor burden in ApcFlox/Flox mice is dose-dependent (in progress). We are now conducting a follow-up study in which both aged and young CANp16 animals will be exposed to 5.5 Gy of TBI to induce senescence, then treated 60 days later with either GCV at 25 μg per g body weight or vehicle control. This study will confirm that i) senescent cell elimination following GCV is shown via bioluminescent imaging and ii) robust GCV-induced clearance of senescent cells is observed in the colon and cecum of animals (identified via triplex immunofluorescent staining for ICAM1/γH2A.x/Ki-67 and immunohistochemistry for cleaved-caspase 3). Following completion of this work, we plan to utilize the CANp16 mouse model to assess the impact of senescent cell burden on colorectal tumorigenesis. Our expectation is that the number of tumors and stage of disease is directly related to the number of senescent cells. If correct, we also plan to perform spatial transcriptomic analysis on tumors collected from animals treated with both GCV and vehicle control to determine how the presence of senescent cells influences gene expression within these tumors affecting formation and progression. |
| 1.338 | Elizabeth A. Townsend | APCCM | eatownsend@wisc.edu | Flavin Mononucleotide: A Novel Biomarker for Early Detection of Asthma Exacerbations | Background: Asthma exacerbations present a significant health risk, especially without early interventions. These exacerbations involve increased resting energy expenditure, reactive oxygen species production, inflammation and nitric oxide production. Mitochondrial dysfunction is linked to severe asthma but its role during acute exacerbations is not well understood. Additionally, there are no easy tests to assess mitochondrial stress during acute illness. Flavin mononucleotide (FMN), a fluorescent product of riboflavin metabolism, is crucial for mitochondrial complex I and is a cofactor for inducible nitric oxide synthase. Studies on brain ischemia/reperfusion injury show FMN levels as dynamic biomarkers of injury severity. Although data on FMN in asthma is limited, one study in 30 children found that urine levels of reduced FMN helped identify corticosteroid responders and non-responders.1 We hypothesize that FMN levels decrease during acute asthma exacerbations, reflect mitochondrial stress, and can be used to predict disease outcomes. Methods: A subset of adults with asthma in the Severe Asthma Research Program 3, a multicenter, longitudinal, observational study, participated in a UW-Madison, IRB-approved ancillary study on acute exacerbation and recovery. Serum from healthy individuals and asthmatic individuals were collected at baseline. Participants were followed longitudinally and instructed to contact coordinators during an increase in asthma symptoms and/or upper respiratory symptoms associated with an upper respiratory infection (URI). Serum was collected during this acute period and once participants felt better, deemed recovery. Samples were loaded into a black 96-well plate and a standard curve was constructed using Riboflavin 5’-monophosphate sodium salt. Fluorescence was measured with excitation at 485 nm and emission at 528 nm. FMN levels at each timepoint were compared to healthy controls using 1-way ANOVA. Additionally, paired t-tests were used to compare within each timepoint for the samples from asthmatic individuals. Pearsons’s correlation was used to assess FMN levels and other variables including acute exacerbation symptom scores, the ASSESS score, and lung function decline. Significance was established at p<0.05 with correction for repeated measures. Results: Flavin mononucleotide was present in all samples at all timepoints. There was no significant difference in FMN levels from healthy controls (455.7± 42.6 ng/mL, n=15) and individuals with asthma (344.8 ± 31 ng/mL, n=10) measured at baseline during a period of stability. FMN levels from individuals with asthma collected during exacerbation (282.7 ± 14.4 ng/mL, n=10) demonstrated a significant decrease compared to healthy individuals. Additionally, in paired analysis, there was a dynamic decrease from baseline (p<0.06, n=10) with subsequent significant increase back to baseline levels at the recovery timepoint (p=0.02, n=10). Those requiring oral corticosteroids (OCS) for an acute exacerbation had lower FMN levels compared to those who did not require OCS (257.7± 15.5 ng/mL vs 307.7 ± 19.4 ng/mL, n=5 in each group, p=0.07). FMN levels during acute exacerbation correlated with longitudinal lung function decline (p<0.05, R2=0.68, n=7) and the ASSESS score, a measure of asthma severity (p=0.07, R2=0.346, n=10). Conclusions: We demonstrate a novel, dynamic, serum biomarker that correlates with acute asthma exacerbations, while also correlating with longitudinal variables including asthma severity and lung function decline. To our knowledge, this is the first readout with the potential to quantify mitochondrial stress during asthma exacerbations using a simple blood test. This represents a potential new diagnostic tool and potential therapeutic target. Further collaboration is necessary to validate observed levels of FMN in individuals with asthma at baseline and during acute and convalescent phases of disease, to draw correlations between FMN levels and phenotypic markers including T2 vs non-T2 disease, and to understand the contribution of diet and nutrient supplementation on FMN levels in individuals during asthma exacerbations. |
| 1.339 | Matthew C. Tattersall | CVM | mtattersall@medicine.wisc.edu | Carotid Artery Ultrasound Grayscale Median and Incident Dementia: The Multi-Ethnic Study of Atherosclerosis (MESA) | Introduction: Because vascular contributions to cognitive impairment and dementia are potentially modifiable, early detection of reversible arterial injury may improve risk stratification and enable treatment monitoring. We hypothesized that carotid ultrasound grayscale-median (GSM), a novel imaging biomarker of early arterial injury, would predict incident all-cause dementia in the Multi-Ethnic Study of Atherosclerosis (MESA). Methods: The MESA enrolled adults (45-84 years old) who were free of atherosclerotic cardiovascular disease at baseline. Common carotid artery GSM was measured at baseline. Incident all-cause dementia events were identified by hospital and death records and centrally adjudicated. Cox proportional hazards models with natural cubic splines allowing for non-linear effects, adjusted for biologic confounders, were used to investigate the association of carotid GSM and all-cause dementia. Results: The 1,788 participants were a mean (SD) 63.1 (10.3) years-old; 53% were female (32% White, 28% Black, 23% Hispanic, 17% Chinese). Over a median follow-up of 13.7 years, 157 all-cause dementia events occurred. In models adjusted for age, sex, race/ethnicity, blood pressure, lipids, body-mass index, diabetes mellitus, education, and carotid artery wall thickness, lower (worse) carotid GSM independently predicted incident all-cause dementia (HR 1.45, 95% CI 1.11-1.90, p=0.021). Furthermore, analysis of image contrast using gray level difference statistics demonstrated a consistent direction of the point in risk-factor adjusted analyses (HR 1.28, 95% CI 0.99-1.67, p=0.06) Conclusions: Lower GSM independently predicts all-cause dementia in a multi-ethnic population free of prevalent atherosclerotic vascular disease at baseline. This novel carotid artery ultrasound measure provided additional predictive data beyond carotid IMT, an established predictor of incident cognitive decline and dementia. Carotid GSM may serve as an early marker of dementia risk. |
| 1.340 | David Sterken | HOSP MED | sterken@wisc.edu | Components of "Against Medical Advice" Discharge Forms and Their Implications | Introduction It is common practice in the US to have patients sign a form when they choose to discharge from the hospital against medical advice (“AMA”). Such forms are institution-specific and not publicly accessible, however, so their contents may vary. This variance may have important clinical, ethical, and legal implications, yet the contents of forms currently in use in the United States have not been described in the literature. Methods I performed a qualitative document analysis on 10 AMA discharge forms from acute care hospitals around the country, obtained via crowdsourcing. I evaluated each document for the presence of specific sections, adapted from the “Required Components of a Comprehensive AMA Form and Discharge Instructions” enumerated by Levy et al (1). I also characterized the source hospitals based on US Census Bureau regions and CMS-defined hospital ownership. Results 5 hospitals were from the West, 4 from the Midwest, 1 from the Southeast, and 0 from the Northeast. 4 were non-profit private hospitals, 2 were non-profit “other” hospitals (both were university-affiliated), 3 were government hospitals, and 1 was a Veterans Administration hospital. All 10 forms contained an attestation by the patient and staff that an informed consent discussion was conducted, all 10 included the formalities of signatures by both parties, and 9 of the forms included an exculpatory contract (i.e., a “waiver of liability”) ostensibly releasing the hospital and medical providers from legal liability related to the discharge. Only 5 forms had a section where patient-specific risks and consequences could be documented. 4 forms mentioned decisional capacity, although none contained a formal capacity evaluation. 3 forms provided instructions for subsequent care such as primary care follow-up or when to return to the Emergency Department. Conclusions Based on their contents, AMA forms more frequently address the legal components of an AMA discharge than the clinical ones. Most notably, 90% of forms contained exculpatory contracts, which are all legally unenforceable because 1) some states like Wisconsin (2) categorically do not enforce exculpatory contracts, and more importantly, 2) a patient’s right to leave the hospital (i.e., their bodily autonomy) is not contingent on signing any form and therefore patients do not receive any benefit from signing these contracts, which makes the contracts unenforceable based on the legal concept of lacking consideration by both parties. Having patients sign a legally unenforceable contract is misleading and unethical; therefore, hospitals should revise their AMA discharge forms to focus less on legal maneuvering and more on improving clinical outcomes, as has been successfully done by Henson et al (3). |
| 1.341 | Vincent Cryns | ENDO | vlcryns@medicine.wisc.edu | Lipid Transfer Proteins Mediate Chromatin Remodeling through PARP1-GCN5 Axis | Introduction Triple-negative breast cancers (TNBC) account for 10–20% of all breast cancers and lack therapeutic targets that are used to combat other breast cancers necessitating further exploration of therapeutic avenues in TNBCs. Interestingly, TNBCs are highly resistant to genotoxic therapies but often rely on error-prone DNA repair pathways like non-homologous end joining (NHEJ) due to defects in homologous recombination (HR). Poly(ADPRibose) Polymerase 1(PARP) is a key DNA damage sensor that facilitates repair through poly(ADP-ribosyl)ation (PARylation), which helps coordinate chromatin remodeling in increase DNA repair efficiency. Chromatin remodeling and efficient DNA repair is supported by PARP1 via recruitment of chromatin-modifying enzymes such as the lysine acetyltransferase GCN5 to promote histone acetylation and chromatin relaxation at damage sites. While PARP inhibitors (PARPi) exploit this vulnerability, their clinical utility is limited by toxicity and resistance. Phosphoinositides (PIPns) are lipid second messengers that participate in a wide array of cellular processes including DNA repair. In the nucleus, they modulate cell survival and gene expression by influencing transcription, RNA processing, epigenetic modifications, and p53 signaling. Their nuclear localization is tightly controlled by class I phosphatidylinositol transfer proteins (PITPs) which shuttle cytosolic PIPns into the nucleus for signaling. Emerging evidence suggests that targeting the PITPs in TNBCs prevents efficient or effective DNA damage repair in response to chemotherapeutic stress. However, nuclear PIPn regulation of PARP1, as well as their connections to chromatin remodeling through GCN5, remain to be elucidated and may offer a therapeutic window to treat TNBCs. Methods Parental and PITP knockout (PITPKO) MDA-MB-231 cells were used to compare basal and nuclear PIPndeficient conditions, respectively. H2O2 and ionizing radiation were used to induce genotoxic stress, and cellular fractionation was used to begin defining the impact of chromatin machinery. A combination of immunoprecipitation, western blot, immunofluorescence microscopy and proximity ligation assays were then used to define protein-protein and protein-lipid phenotypes in the varying conditions. Results PITPKO cells revealed a dramatic inhibition of protein PARylation excluding PARylation of histones suggesting PARP1 activity is regulated by PITPs with high specificity. Furthermore, these PITPKO cells lose the established interaction between PARP1 and GCN5. A reduction of histone acetylation at preferred residues of GCN5 was also observed aligning with the notion of a PITP-PARP1-GCN5 pathway. This pathway has clinical relevance as PITPKO cells are more sensitive to chemotherapeutic stress than parental MDA-MB-231 cells. Conclusions While nuclear PIPns connection to DNA damage and repair have been previously observed, this work establishes a mechanism by which nuclear PIPns directly contribute to efficient DNA repair processes. PITPdependent PARylation of GCN5 identifies a previously unknow function of nuclear PIPns in chromatin remodeling. Moreover, the PITP-PARP1-GCN5 axis provides mechanistic insights as to how PITPs impact the DNA damage response. These findings could create avenues for new combinatorial strategies targeting DNA repair vulnerabilities in TNBC, potentially improving treatment outcomes for patients with this aggressive breast cancer subtype. |
| 1.342 | Sean Ronnekleiv-Kelly | HEM/ONC | ronnekleiv-kelly@surgery.wisc.edu | Targeting transcriptional regulation using CDK7 and CDK9 inhibition as a novel combination therapy in fibrolamellar carcinoma | Background: Fibrolamellar carcinoma (FLC) is a rare liver cancer with a 5-year survival rate between 35-40%. FLC typically affects a younger patient population, the majority receiving a diagnosis between the ages of 10-35. There are currently no curative systemic therapies and an unmet need for novel and effective therapeutics to improve survival. A unique molecular hallmark of FLC is a fusion event between heat shock protein 40 (DNAJB1) and the catalytic subunit alpha of protein kinase A (PRKACA). This event creates the FLC specific oncoprotein (DNAJ-PKAc) which has been shown to promote FLC tumor formation. Downstream signaling of DNAJ-PKAc remains unknown, however, this fusion protein has been shown to cause enhancer remodeling to upregulate FLC specific drivers of proliferation. Methods: Western blot analysis was performed on patient tumors, normal tissue, and patient derived organoids (PDOs) for active RPB1, including phosphorylation of serine 2, serine 5, and serine 7 (pRBP1-s2, s5, s7). Single agent activity of SY5609 was assessed at 144 hours in PDOs. Synergy was assessed at 144 hours using a dose titration grid. SynergyFinder 3.0 was used to produce Highest Single Agent (HSA) synergy scores. Viability was determined using CellTiterGlo (CTG, 50% v/v). RNA was extracted from PDOs for qPCR to measure relative FLC specific driver gene expression, including SLC16A14 and LINC00473. SY5609 was treated continuously while VIP152 was removed after 24 hours to mimic in vivo pharmacokinetics. Results: Relative to normal tissue, FLC tumors had an increase in pRPB1-s5 (6.38, p<0.05) and pRPB1-s7 (5.82, p<0.05) compared to cholangiocarcinoma (CCA) (2.42, n.s.; 1.10, n.s.) and hepatocellular carcinoma (HCC) (2.61, n.s.; 0.95, n.s.). CDK7 inhibition with SY5609 in FLC PDOs had a 9x greater selectivity than normal liver PDOs and 216x greater than CCA PDOs with IC50=0.39nM, 3.14nM, and 84.22nM, respectively. FLC PDOs treated with physiologic concentrations of SY5609 showed downregulation of FLC specific enhancer driven gene SLC16A14 but not LINC00473 with fold changes of 0.51 and 0.84. SY5609 did not regulate SLC16A14 in CCA PDOs (fold change=2.78) and LINC00473 was undetectable in all samples. The addition of CDK9 inhibition with VIP152 was synergistic in FLC PDOs (HSA=8.79) which was not seen in CCA PDOs (HSA=-1.82). Combination treatment synergistically downregulated FLC specific driver gene LINC00473 (fold change=0.41), and decreased pRBP1-s2, 5, and 7 shown via western blot. Conclusion: Here, we show FLC has an increase in phosphorylated RPB1 specifically at s5 and s7, and a unique sensitivity to CDK7 inhibition with SY5609. The addition of CDK9 inhibition using VIP152 is synergistic at downregulating FLC specific driver genes and decreasing activated RPB1 and viability. Ongoing work is validating this combination in animal models to assess toxicity and in vivo efficacy. |
| 1.343 | Sameer K. Mathur | APCCM | skmathur@wisc.edu | Real-World Analysis Of Tezepelumab-Ekko For Severe Persistent Asthma And Comparison To Other Biologic Therapies | Introduction/Rationale: Of approved biologics for severe persistent asthma, Tezepelumab-Ekko is currently the only biologic with no phenotype or biomarker limitation. We previously evaluated local outcomes of anti-IL5 biologics and Dupilumab. We seek to compare the patient populations and health outcomes for Tezepelumab-Ekko. Methods: An IRB-approved retrospective chart review was performed on patients with severe asthma on anti-IL5 biologics, Dupilumab, or Tezepelumab-Ekko for one year before/after initiation. Demographics data, including prior systemic steroid and alternate biologic therapy, was collected. Asthma control markers (rescue inhaler use, asthma control test (ACT), steroid bursts, medical visits, spirometry) were examined. Data was analyzed by t-test and ANOVA. Results/Discussion: Fifteen patients on Tezepelumab-Ekko were evaluated and compared to forty-nine on anti-IL5 biologics and twenty on Dupilumab. Of these, ten previously failed another biologic, two required dual-biologic therapy, three discontinued due to financial barriers, and one discontinued for alternate biologic therapies. Patients on Tezepelumab-Ekko had on average 4.5 asthma-related comorbidities compared to 2.9 (anti-IL5) and 3.6 (Dupilumab) (p=0.74). Tezepelumab-Ekko had significant reduction in steroid bursts/year from 2.5+/-2.0 to 1.1+/-1.6 (p<0.05) vs anti-IL5 4.3+/-3.1 to 1.7+/-1.8 (p<0.001) vs Dupilumab 3.6+/-3.3 to 1.0+/-2.0 (p<0.01). There was no significant difference between rescue inhaler use, ACT, steroid bursts, medical visits, or spirometry. In prior analyses, significant improvements were seen in all metrics for anti-IL5 biologics and in ACT, steroid bursts, and spirometry for Dupilumab. Conclusions: Preliminary analysis suggests that patients receiving Tezepelumab-Ekko have more difficult to control asthma compared to our prior biologic populations studied. Despite this, Tezepelumab-Ekko has demonstrated reduction in steroid bursts needed. |
| 1.344 | Joshua Lang | HEM/ONC | jmlang@medicine.wisc.edu | Investigating Relationships amongst Intrinsic and Acquired Genomic Alterations on Overall Survival in Metastatic Prostate Cancer | Introduction: Resistance to Androgen Receptor Pathway Inhibitors (ARPI) in metastatic prostate cancer (mPC) is universal and can be driven by complex genomic alterations. The evolution of lineage state transitions from adenocarcinomas to neuroendocrine prostate cancer (NEPC) has also been shown to drive treatment resistance and poor survival. Identifying the timing and association of genomic mutations with lineage state transitions has been limited by the requirement of serial tumor biopsies. We report an integrated analysis of clinical next-generation sequencing (NGS) data and mPC lineage states with a novel circulating tumor cell (CTC) RNA sequencing methodology. Methods: We collected 273 samples from 117 unique patients with mPC in a prospective biomarker trial. CTCs were purified via immunomagnetic capture on an automated microfluidic technology and analyzed via RNA-seq. A subset of patients had a clinical grade genetic test performed on a contemporary metastatic tissue biopsy. We compared CTC gene expression for lineage states (luminal A, luminal B, NEPC) with somatic gene mutation subtypes known to confer resistance to ARPIs (AR, p53, RB, PTEN, HRR genes) and overall survival (OS). Results: Single sample pathway analysis of high CTC purity samples identified four transcriptional phenotypes: luminal A-like (LumA), luminal B-like (LumB), low proliferation (LP), and neuroendocrine (NE). Compared to patients with low CTC burden/purity (median OS not reached), patients with LumA and LP phenotypes had similar survival, patients with LumB and NE CTC phenotypes had shorter survival (LumB: median OS 6m, HR 9.1[3.8-21.8], p<0.0001, NE: median OS 3.7m, HR 11.8[2.4-57.2], p=0.0019). AR alterations were found in samples with prior ARPI exposure and at similar frequencies across all CTC phenotypes but NE where they were absent. RB mutations were enriched in the unfavorable CTC phenotypes (LumB, NE; p=0.0288). Integrating CTC phenotype with presence or absence of at least one high risk genomic alteration (AR, RB, TP53, PTEN), patients with favorable CTC phenotype (Low burden, LP and LumA) and no high risk alterations had the longest median survival (median OS NR), followed by patients with favorable phenotype but a high risk alteration (median OS 12.7m), patients with an unfavorable phenotype (LumB, NE) but no high risk alteration (median OS 8m), and unfavorable phenotype with a high risk alteration (median OS 4m). Conclusions: Somatic mutations in mCRPC influence lineage state acquisitions and treatment resistance. Lineage state transitions themselves are associated with poor outcomes and decreased survival which is worsened in the presence of high-risk genetic mutations including RB. This data presents potentially targetable patient populations that would benefit from treatment intensification and early disease monitoring for more aggressive mCRPC subtypes. |
| 1.345 | Matthew Churpek | APCCM | mchurpek@medicine.wisc | Early vs Late Failure of High Flow Nasal Cannula in Acute Hypoxic Respiratory Failure; A Propensity Matched Analysis | Introduction: High flow nasal cannula (HFNC) is a frequently used treatment for patients with acute hypoxic respiratory failure (AHRF). Studies show up to 30 to 50% of patients fail HFNC and require intubation, but it is unclear whether late failure (>24 hours) is associated with worse outcomes compared to patients intubated in the first 24 hours. Therefore, we aimed to compare patient outcomes between early versus late initiation of mechanical ventilation in patients who fail HFNC. Methods: Adult inpatients hospitalized at seven hospitals in four health systems who received HFNC and later required intubation were eligible for inclusion. Patients were excluded if they were intubated prior to first HFNC initiation or began HFNC, experienced death, or intubation in a location other than the wards, intermediate care, emergency department, or intensive care unit. Patients were divided by time on HFNC prior to intubation of ≤24 hours or >24 hours (early vs. late intubation). Propensity matching was used to adjust for confounding between the two groups and included patient demographics, vital signs, site, and lab values. The primary outcome was in-hospital mortality, and the secondary outcomes were hospital length of stay (LOS) since admission and time on mechanical ventilation. Results: Of the 2,819 eligible patients in the unmatched cohort, 1,852 were included in the study after propensity matching. In the propensity-matched cohort, the primary outcome occurred in 361/926 (38.9%) for patients with early intubation compared to 478/926 (51.6%) for patients with late intubation (OR 1.41 [1.16 – 1.71], P Value = <0.001). The mean total hospital LOS for those intubated early was 474 (366 – 582) hours compared to 651 (433 - 868) hours for patients intubated late (P Value = 0.002). The mean duration of mechanical ventilation was 235 (201 - 269) hours in patients intubated early vs 269 (201 - 338) hours in patients intubated late (P Value = 0.051). Conclusions: Our study indicates that prolonged HFNC prior to intubation in patients with AHRF is associated with worse outcomes, including increased mortality, longer hospital LOS, and possibly extended duration of mechanical ventilation. The identification of patients likely to fail HFNC paired with early intubation may improve outcomes in patients hospitalized with AHRF. Prospective randomized trials are needed to further validate these results. |
| 1.346 | Jennifer Weiss | GASTRO | jmw@medicine.wisc.edu | Creating Multi-Level Interventions to Address Significant Screening Colonoscopy Wait Times in the Aftermath of the COVID-19 Pandemic | `Background: Colorectal cancer (CRC) is a leading cause of cancer-related deaths in the United States, and early detection is crucial for improving patient outcomes. In response to a backlog of care delays as a result of the COVID-19 pandemic and the more recent change in nationally adopted CRC screening guidelines that now include individuals ≥45 years old for routine screening – the American healthcare system has experienced heightened demand for colonoscopy and significant delays in access. Addressing the continually expanding backlog of colonoscopy cases requires targeted interventions across multiple levels of the healthcare delivery system to ensure continued access for high-risk patients and minimization of inefficiency and unnecessary screening. This study outlines a systems-based framework for identifying solutions to various factors that prolong screening wait times. Aim: Develop a multipronged approach to decreasing colonoscopy wait times that targets multiple levels of the patient care delivery system within a large academic health center with an open access endoscopy unit. Methods: A quality improvement task force was convened to identify a comprehensive set of factors impacting colonoscopy screening rates and leading to increased demand via a root cause analysis. A systematic framework grounded in research from industrial and systems engineering, organizational behavior, and health system redesign was used to identify stress points at each level of the healthcare delivery system and design interventions to address these points of stress. The potential impact of each intervention was estimated by change in colonoscopy capacity over the following year based on existing procedure templates and provider caseloads. Results: The baseline colonoscopy screening queue consisted of 15,065 cases. On a background of overall rising incidence of early onset CRC and a significant number of cases delayed as a result of the COVID-19 pandemic, three overarching categories of stress points were identified: (1) prior to entering the colonoscopy screening queue, (2) need for increased capacity, and (3) opportunities to reduce the existing screening queue. Within these categories, six specific stress points were delineated and interventions to address these issues with their appropriate healthcare system-level targets were proposed. If successfully implemented, we expect the interventions to result in a decrease in the colonoscopy screening queue of approximately 12,400-13,300 cases. Conclusions: Wait times for screening colonoscopies have drastically increased since the COVID-19 pandemic, the effect compounded by age-based screening guidelines and already high demand. Our approach demonstrates the utility of a human-centered, systems-based framework to identify multilevel solutions for high stress points that contribute to delayed CRC screening. |
| 1.347 | Jennifer Weiss | GASTRO | jmw@medicine.wisc.edu | Learning from the best: Successful colorectal cancer screening strategies among high-performing clinics across multiple healthcare systems | Background: Our prior work evaluating colorectal cancer (CRC) screening rates has shown that many primary care clinics are struggling to reach the National Colorectal Cancer Roundtable goal of 80% screening in every community. To design effective interventions, we need to learn from practices in high-performing clinics. Aim: To identify effective CRC screening strategies among high-performing primary care clinics in multiple healthcare systems across Wisconsin. Methods: EHR data from 1/1/2008 to 12/31/2018 were reviewed from 278 primary care clinics in 19 health systems to identify high-performing clinics (CRC screening rate >80%). CRC screening completion was defined as: (1) FOBT/FIT within 1 yr, (2) multi-target stool DNA (mtsDNA) within 3 yrs, (3) sigmoidoscopy/CT colonography within 5 yrs, or (4) colonoscopy within 10 yrs. Multiple healthcare personnel (primary care providers (PCP), nurses, medical assistants (MA), clinic managers) from high-performing clinics were invited to participate in 45- 60 minute semi-structured, virtual interviews. The interview guide was based on Taplin and Rodgers five steps of the CRC screening process (Table 1). Transcripts were analyzed utilizing a deductive approach based on the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model, a human factors framework for studying and improving the work of healthcare professionals and patients. Transcripts were coded to identify common themes across clinics on the components of the SEIPS model (people, tasks, tools and technology, physical environment, and organization factors) necessary for each step of the CRC screening process. Results: Nine high-performing clinics (7 urban, 2 rural) participated in the interviews. The data generated common practices across five CRC screening steps (Table 1). All clinics recommended colonoscopy as the preferred screening method with 7 recommending mt-sDNA as back-up and 2 clinics recommending FIT. PCPs and MAs were the primary staff involved in the CRC screening process at the primary care clinics. All clinics rely on the health maintenance feature in the EHR to identify eligible patients and 6 clinics use the same EHR as the specialists providing colonoscopies ensuring easy access to results. Multiple clinics have access to quality metrics via the EHR and 5 clinics reported organizational commitment to regularly measuring CRC screening rates. Conclusions: Several common CRC screening strategies were identified in high-performing clinics: offer both colonoscopy and stool-based test options, utilize MAs during multiple steps of the screening process, and take advantage of multiple features of the EHR. Next steps include working with lower-performing clinics to examine the feasibility of operationalizing these strategies to improve CRC screening rates in every community. |
| 1.348 | Maria Mora Pinzon | GERI | mmora2@wisc.edu | Social Media and Healthcare: Evaluating Message Content and Readability for Black, Latino, and Native American Communities | Introduction: Creating and evaluating social media content tailored for Black, Latino, and Native American communities is crucial for several reasons. These communities have historically faced underrepresentation and misrepresentation in mainstream media, leading to a lack of culturally relevant and accurate information. By developing content that resonates with their unique experiences and perspectives, we can foster a more inclusive and equitable digital space. This project aims to evaluate the readability, content, and delivery of social media messages created for these underrepresented communities, and to assess how these characteristics affect the reach and engagement of the messages delivered. Methods: Our team identified relevant COVID-19 topics based on feedback from their respective communities, developed lay format materials, and translated these materials into culturally appropriate social media messages that community advocates delivered. Social media metrics (Reach, Engagement, Impressions) were collected using Sprout Social and Facebook Analytics. Posts were included in an Excel database and manually coded to classify them according to the presence of scientific terms, plain language, calls to action, and references to cultural or religious elements. Additionally, readability was calculated using Microsoft Word and Syllable Counter to measure the number of words, syllables, and paragraph structure, which were then used to calculate the Flesch-Kincaid Grade Level. Results: This study evaluated 604 posts created between August 2020 and January 2023. Posts were on average seen by 144 unique individuals and received 12 engagements (e.g., likes, comments, or shares). A preliminary analysis of a small number of posts showed that the average number of sentences per paragraph was 7, the average number of words per sentence was 24, and the average character count per word was 5. The average Flesch-Kincaid Grade Level was 9.2375. Posts with a Flesch-Kincaid Grade Level less than 10 had higher impressions and reach than other posts, although no differences in engagement rates were observed. Conclusions: Our project presents the key components of social media messages delivered to Black, Latino, and Native American communities and highlights the need for tailoring messages and approaches for a variety of audiences. Future work aims to analyze the relationships between readability statistics and message effectiveness in these communities. |
| 1.349 | Richard A. Anderson; Vincent L. Cryns | ENDO | raanders@wisc.edu; vlcryns@medicine.wisc.edu | A Comprehensive Phosphoinositide Signaling Pathway Coupled to Star-PAP | Introduction: Speckle-targeted PIPKIa regulated-poly(A) polymerase (Star-PAP) is a noncanonical poly(A) polymerase that controls gene expression. Star-PAP was previously reported to bind the phosphoinositide (PI) kinase PIPKI⍺ (PIP5K1A) and its product phosphatidylinositol 4,5-bisphosphate (PI(4,5)P2), which regulate Star-PAP activity. Recent studies have revealed a nuclear PI signaling pathway in which the PI transfer proteins PITP⍺/β, PI kinases and phosphatases bind nuclear proteins to sequentially modify phosphatidylinositol phosphates (PIPns) that are linked to the target protein and regulate its function. Methods: We utilized immunoprecipitation (IP), Immunofluorescence-Western Blot (IF-WB), proximity ligation assay (PLA), and isotope labeling to study the in vivo interactions between Star-PAP, PIPs, PI transfer proteins, kinases, phosphatases, and sHSPs under stress signals. In vitro binding assays and microscale thermophoresis (MST) were used to investigate direct interactions and quantitate binding affinities. Results: Here we demonstrate that multiple PIPns, including phosphatidylinositol 4-monophosphate (PI(4)P), PI(4,5)P2, and phosphatidylinositol 3,4,5-trisphosphate (PI(3,4,5)P3) are coupled to Star-PAP in response to stress. PITP⍺/β bind Star-PAP and combined PITP⍺/β knock down (KD) inhibits PI(4)P and PI(4,5)P2 coupling to Star-PAP. Moreover, the PI kinases PI4KII⍺, PIPKI⍺, and IPMK and the 3-phosphatase PTEN associate with Star-PAP and regulate the interconversion of the Star-PAP-coupled PIPns. PIPn coupling to Star-PAP enhances the association of the small heat shock proteins (sHSPs) HSP27 and ⍺B-crystallin with Star-PAP. KD of PITP⍺, PITPβ, and HSP27 reduce the expression of the Star-PAP poly(A) targets HO-1 and BIK. Our results demonstrate a nuclear Star-PAP-PI complex composed of PITPs, PI kinases/phosphatases and sHSPs that dynamically regulate PI coupling and Star-PAP activity in response to stress. Discussion: Our data indicate the stress-related functions of Star-PAP is mediated by a PIP stress signaling pathway, where PI transfer proteins, kinases, phosphatases, and small heat shock proteins form PIP complexes on Star-PAP that regulate its function. |
| 1.350 | CVM | Effects of mTOR inhibition on LMNA-associated dilated cardiomyopathy: a very personal example of personalized medicine. | Introduction: Mutations in the rod-domain of the LMNA gene are associated with an aggressive autosomal dominant familial dilated cardiomyopathy (LMNA-DCM), leading to progressive heart failure, conduction system disease, and malignant ventricular arrhythmias that respond poorly to conventional, FDA-approved medical therapy and result in premature death or the need for cardiac transplantation typically in the 4th or 5th decade of life.1,2 The senior author is LMNA-DCM patient (LMNA N195K) s/p heart/kidney transplant with multiple affected family members. Prior studies have demonstrated rapamycin improves cardiac function and prolongs survival in murine models of LMNA-DCM (lmna-/- and lmnaH222P/H222P). We sought to confirm these findings in a murine model of my family’s mutation (lmnaN195K/N195K) and extend these observations in induced cardiomyocytes differentiated from patient-derived induced pluripotent stem cells (LMNA N915K iPSC-iCM) Methods: Homozygous lmna N195K mice were a gift from Colin Stewart, and faithfully recapitulate the human familial dilated cardiomyopathy phenotype demonstrating cardiac enlargement and dysfunction, conduction system disease and ventricular arrhythmias and premature death at 7 – 8 weeks of age.5 Wild-type littermates were used as controls, and were treated with vehicle. Rapamycin (8 mg/kg) or vehicle control was injected once a week starting at 3 weeks of age until sacrifice at 6 weeks for biochemical and histologic studies, or death for survival studies. Transthoracic echocardiography was performed to measure left ventricular dimensions and cardiac function. Wild-type and patient (MRW)-derived LMNA N195K-DCM human iPSCs were previously obtained under a UW Institutional Review Board-approved protocol. CRISPR-edited isogenic control LMNA iPSCs were generated by the Waisman Center. Mutant and control iPSC-iCMs have been differentiated using the previously described UW GiWi small molecule-directed monolayer differentiation protocol.13 Preliminary studies characterizing morphology and function of these iPSC-iCMs have been performed and studies examining the effects of rapamycin in this human iPSC-ICM disease model are underway. Rapamycin (8 mg/kg/IP/week) beginning at age 3 weeks significantly prolonged survival and improved left ventricular ejection fraction in the murine lmnaN195K/N195K model of LMNA-DCM compared to vehicle-treated mutant mice. Morphologic and functional analysis of patient-derived N195K LMNA-DCM induced cardiomyocytes (IPSC-iCMs). Mutant nuclear were smaller and mis-shapened compared to normal controls, while sarcomeric structure was grossly similar (A,B). Profound nuclear abnormalities, including blebbing, are apparent in mutant nuclei after minimal pacing stress (C, 1 Hz for 4 hours, not observed in WT IPSCiCMs). Caspase 3/7 activity as a measure of apoptosis pathway activation was increased, while H2O2 levels as a measure of reductive stress were reduced in mutant IPSC-iCMs (D, Promega Caspase Glo and ROS-Glo assays). Discussion: Rapamycin prolongs survival and improved cardiac function in a murine model of LMNA N195K DCM. If similar positive effects of rapamycin are observed in the LMNA iPSC-iCM model, and given the favorable safety profile of rapamycin, our data would support a phase II human clinical trial for this disease. 0 20 40 60 80 100 0 50 Survival | ||
| 1.351 | Nicole M. Rogus-Pulia | GERI | npulia@wisc.edu | Effects of Radiation Therapy on Salivary Flow, Viscosity, and Swallowing Efficiency in Patients with Head and Neck Cancer | Vertical Sleeve Gastrectomy (VSG) is an effective surgery to treat obesity and Type 2 Diabetes (T2D), both of which contribute to age-related disease and mortality. Currently, it is recommended that patients consume a high protein diet following VSG, howe |
| 1.352 | Dudley Lamming | ENDO | dlamming@medicine.wisc.edu | Sex- and Strain-Specific Roles of FGF21 in Modulating Metabolic Responses to Isoleucine Restriction in Mice | The restriction of branched-chain amino acids (BCAAs) has shown promise as a potential intervention for promoting health and longevity. Our lab has identified isoleucine (Ile) as the primary driver of the beneficial effects associated with BCAA restriction, including improved glucose tolerance, enhanced insulin sensitivity, and reduced body weight. Additionally, an Ile-restricted (IleR) diet promotes the expression of fibroblast growth factor 21 (FGF21), a hormone previously linked to increased insulin sensitivity and energy expenditure. However, the role of FGF21 in the metabolic response to Ile restriction has not been fully explored. Here, we directly examined the role of FGF21 in metabolic response to a low isoleucine diet by feeding FGF21-/- and wild-type control mice—both male and female—from two different strains, C57BL/6J and DBA/2J, with either a control diet or a 33% Ile diet for 12 weeks. We find that while FGF21 is not essential for the body weight improvements induced by isoleucine, it does affect food consumption and energy expenditure in both sexes and genotypes. FGF21 is largely dispensable for the effects of IleR on glycemic control in male mice. In DBA males, the absence of FGF21 leads to a greater metabolic response and attenuates IleR-induced changes in beiging of white adipose tissue (WAT) and thermogenic gene expression compared to other groups. These results provide new insights into the molecular mechanisms underlying the benefits of a low Ile diet and probe into the sex- and strain-specific roles of FGF21 in regulating metabolism. |
| 1.353 | Lynn M. Schnapp | APCCM | lschnapp@medicine.wisc.edu | Deficiency of the collagen endocytic receptor MRC2 alters collagen organization: Findings from second harmonic generation imaging | Introduction: Mannose receptor C type 2 (MRC2) is primarily expressed in stromal cells and functions as a key receptor for the degradation and internalization of collagens. Mrc2 expression declines with aging and is implicated in the development of pulmonary fibrosis. In a previous study, we demonstrated that lung fibroblasts from Mrc2-/- mice exhibit impaired internalization of collagens. In addition, Mrc2-/- mice have stiffer lungs at baseline without changes in total hydroxyproline content. Therefore, we asked if the loss of MRC2 impacts the structure of matrix collagen. In this study, we utilized second harmonic generation (SHG) imaging technology to examine changes in the organization of the deposited collagen from lung fibroblasts isolated from Mrc2-/- mice. Methods: Mouse lung fibroblasts were harvested from age- and sex-matched Mrc2-/- and wild-type mice. Fibroblasts were cultured for 14 days on chamber slides and treated with ascorbic acid ±TGF-β. Collagen structural changes in the ECM were evaluated using SHG imaging. Fiber length and width were measured from the images using the CT-FIRE program. Results: We observed that the collagen produced by Mrc2-/- MLFs exhibited increased image brightness and higher entropy in the gray-level co-occurrence matrix, indicating a disruption of matrix cohesiveness compared to WT (Forward entropy: p=0.01; Backward entropy: p=0.02). Furthermore, compared to WT, collagen fibers in the Mrc2-/-group remained elongated without fragmentation and increased in thickness, while the overall forward:backward SHG emission ratio, a measure of fibril organization, stayed the same. These findings suggest qualitative changes in collagen deposition within the ECM, accompanied by structural alterations, but relatively normal fibril packing. Discussion: These findings suggest that the absence of MRC2 in lung fibroblast causes qualitative changes in collagen organization. Such structural alterations in collagen, a key ECM component, may play a significant role in pulmonary fibrosis development. In future studies, we will use similar in vitro-derived matrices from WT and Mrc2-/- fibroblasts to analyze the effect of abnormal collagen organization on the behavior of exogenously added cells. |
| 1.354 | Gihan Dawood | ENDO | gedawood@medicine.wisc.edu | Enhancing Dental Health Documentation for Diabetic Patients | Introduction Despite American Diabeks Association (ADA) recommendations for regular dental e\'aluations, documentation of dental care for diabetic patients in the University of Wisconsin Hoopital and Clinics' e lectronic medical record (E~tR) remains inconsistent. This gap may result in missed opportunities for early intervention in oral health, a critical component of diabetes management. Strengthening documentation prac.tic.es could enhance comprehensive diabetes care and improve patient outcomes. Mtthodll We conducted a baseline EMR review to assess the frequency of documented dental discussions and recent dental visits among diabetic patients. Patients were categorized by provider type (Attendin~, Advanced Practice Providers, and Fellows). An intervention was introduced, prompting providers to include a dedicated dental health section in patient notes, aligned with ADA guidelines. Results Following the intervention, dental visit doc.umentation improved from 19% to 54% (p < 0.OO0L). Compared to a 202 l study where 6L % of diabetic patients nationwide had a dental visit, 76% of our c.linic's diabetic patients had seen a dentist in the past year (p < 0.0001). A provider survey identified key barriers to discussing dental health during diabetes visits, including time constraints (91 .7%) and competing medical priorities (41.7°/4). \\'hile 83.3°1. of providers felt comfortable addressing dental health, challenges included work.0ow inefficiencies (41.'r/o), the absence of a dedicated EMR field (41 .7%), and ftnanc.ial barriers for patients (83.3%). Additional concerns induded provider percc:ptions of patient difficulty in finding a dentist (25%) and dental an.1:iety (16.7°/.). Oiscunion The significant improvement in dental health documentation underscores the effectiveness of our inten.•ention. Despite higher dental visit rates in our clinic compared to national averages, a substantial proportion of patients still lack regular dental care. Addressing financ.ia~ logistical, and awareness barriers remains essential to further improving oral health access and overall outcomes for diabetic patients. |
| 1.355 | Dudley Lamming | ENDO | dlamming@medicine.wisc.edu | Ketogenesis is dispensable in the metabolic adaptation to caloric restriction | Introduction: Caloric restriction (CR) is an effective therapy that enhances metabolic health and extends the lifespan of mice. Daily fasting contributes significantly to CR protocols, however, the role of fasting-induced ketogenesis in CR-driven metabolic benefits remains unclear. Methods: To investigate this, we generated a mouse model with a full-body knockout of Hmgcs2, the rate-limiting enzyme for the synthesis of the main ketone body β-hydroxybutyrate (βHB). The mice underwent a CR regimen with 30% reduction in calories intake. The mice were then evaluated extensively for metabolic adaptations. Results: We found that despite the lack of ketogenesis, Hmgcs2-KO mice experienced similar metabolic benefits under CR, including reduced weight gain, increased leanness, improved glucose tolerance, enhanced insulin sensitivity, and increased feeding-driven energy expenditure and respiratory exchange ratio. Surprisingly, Hmgcs2-WT mice on CR did not express high levels of circulating βHB, suggesting minimal reliance on ketogenesis. To further understand this phenomenon, we measured the fasting βHB levels in a separate cohort over the initial 8 weeks of CR adaptation. Interestingly, the CR mice quickly became metabolically habituated to the daily feeding schedule and exhibited reduced ketogenesis in response to fasting. Discussion: These findings suggest that CR-fed mice downregulate ketogenesis as a part of their physiological adaptation to regular fasting, leaving Hmgcs2 largely dispensable for the metabolic response to CR. |
| 1.356 | Brad C. Astor | NEPH | bcastor@medicine.wisc.edu | Association of Post-transplant Circulating 25-Hydroxyvitamin D and Long-term Survival among Kidney Transplant Recipients | Introduction Long-term survival after kidney transplantation remains suboptimal. While vitamin D inadequacy is common among kidney transplant recipients (KTR), the association of circulating 25-hydroxyvitamin D [25(OH)D] and long-term survival remains uncertain. Methods Data from adult kidney-only transplant recipients at our center from 2005-2020 who survived with a functioning graft at least 12 months after transplantation were analyzed. Baseline serum 25(OH)D level was identified as the earliest measurement from 5 to 13 months post-transplant. Eligible recipients were followed from 12 months post-transplant until graft failure (i.e., resumption of dialysis, re-transplant, or death) or August, 2023, whichever came first. Cox proportional hazards models were fitted for overall graft failure, death-censored graft failure (DCGF), death with a functioning graft (DWFG) and cause-specific mortality. Longitudinal analyses of eGFR trajectory in 5 years after transplantation were conducted via linear mixed models. Models adjusted for recipient age at transplant, sex, race, body mass index (BMI) at transplant, cause of end-stage kidney disease, donor status, delayed graft function, prior kidney transplant, human leukocyte antigens (HLA)-mismatch, induction and maintenance immunosuppression, acute rejection within 12 months post-transplant, transplant year, season of 25(OH)D measurement, baseline urine protein-creatinine ratio (UPCR), serum albumin, and estimated glomerular filtration rate (eGFR). Results A total of 2509 recipients who maintained a functioning graft for over 12 months were included in our analysis. 872 overall graft failures occurred during a median follow-up of 6.8 years. Vitamin D deficiency (≤20 ng/ml) was associated with a 43% higher hazard of overall graft failure (95% confidence interval [CI]: 1.15, 1.77), a 2.26-fold higher hazard of DCGF (95% CI: 1.62, 3.14) and a 2.09-fold higher hazard (95% CI: 1.37, 3.19) of infection-related mortality compared with vitamin D sufficiency (≥30 ng/ml). It was also associated with a 0.99 ml/min/1.73m2/year faster (95% CI: -1.55, -0.42) annual decline rate of eGFR compared with sufficiency. No association was detected for DWFG, or other cause-specific mortality. Discussion Post-transplant vitamin D deficiency is independently associated with a higher risk of DCGF, infection-related mortality and a faster decline of graft function in KTRs. These results highlight the potential of vitamin D as a modifiable risk factor for long-term survival among stable KTRs. |
| 1.357 | Francisco J. Alvarado | CVM | falvarad@medicine.wisc.edu | Ryanodine Receptor 2 Dysfunction Triggers Cardiac Muscle Loss and Fibrofatty Infiltrations Consistent with Arrhythmogenic Cardiomyopathy in a Rabbit Model | Background: Ryanodine receptor 2 (RyR2) dysfunction occurs early in Arrhythmogenic Cardiomyopathy (ACM), contributing to ventricular arrhythmia, but its role in subsequent structural remodeling remains unclear. While RyR2 mutations have been linked to ACM, this association has been disputed due to conflicting clinical data and the lack of appropriate animal models. Here, we present a RyR2-V2475F rabbit model that exhibits hallmark ACM features. Methods: RyR2-V2475F New Zealand white rabbits were generated via CRISPR-Cas9. Cardiac function and structure changes were assessed in vivo and in vitro using histology, telemetry, echocardiography, Ca2+ imaging, and single-nucleus RNA sequencing (snRNA-seq). Results: Sudden death (SD) occurred in 33% (28/84) of homozygous (Homo) rabbits, whereas no wild-type or heterozygotes littermates were affected. Hearts from SD rabbits exhibited right ventricular (RV)-dominant muscle loss and fibrofatty infiltration, initiating epicardially and progressing transmurally, closely resembling ACM. Ventricular tachycardia (100%, 20/20) and SD (25%, 7/28) occurred even before structural remodeling was evident. Echocardiography revealed early biventricular dilation, followed by RV specific contractile dysfunction, indicated by reduced tricuspid annular plane systolic excursion (TAPSE, 0.62 ± 0.06 vs 0.45 ± 0.10, p = 0.03). Isolated Homo cardiomyocytes (CMs) exhibited increased Ca2+ leak, reduced Ca2+ transient amplitude, and prolonged time to peak and decay. snRNA-seq identified early CM metabolic defects, including increased fatty acid uptake and impaired mitochondrial function, shifting toward inflammation and advanced disease stages. Fibroblasts (FBs) were initially proliferative but later transitioned to a fibrosis-producing phenotype, particularly in the RV, contributing to increased fibrosis. Conclusion: The RyR2-V2475F rabbit is the first animal model of RyR2-induced ACM with RV-dominant muscle loss, fibrofatty infiltration, and lethal arrhythmias. RyR2 dysfunction and Ca2+ mishandling drive not only early arrhythmias but also progressive structural remodeling. Metabolic defects in CMs and RV-specific FB activation contribute to disease progression, providing mechanistic insights that may guide therapeutic strategies. |
| 1.358 | Sandesh Parajuli | NEPH | sparajuli@medicine.wisc.edu | Post-Kidney Transplant Delayed Graft Function Outcomes are not Worsened by Deceased Donor Type | Introduction Post-Kidney Transplant (KT) Delayed graft function (DGF) is more common with donation after cardiac death (DCD) donors in comparison to donation after brain death (DBD). To better understand the consequences of post-transplant DGF across donor types, we reviewed our center experience between the two groups. Methods We analyzed all adult deceased donor kidney transplant recipients (DDKTR) at our center between 2005-2019, stratified by donor type (DBD vs. DCD). We assessed risk factors for DGF, acute rejection (AR), and graft failure (GF), along with the interaction between types of donors for those complications. Results Among 2543 DDKTRs, 804 (31%) were from DCD donors. 20.9% of DBD and 46.6% of DCD recipients experienced DGF. Older donor age, higher recipient BMI, and receipt of a depleting induction agent were associated with increased risk for DGF in both DBD and DCD recipients, while preemptive transplant and female recipient gender were associated with reduced risk. Additional risk factors in DBD, but not in DCD recipients, included higher donor terminal serum creatinine, higher KDPI, right donor kidney, and prolonged cold ischemia time (CIT). Female donors were associated with a reduced risk of DGF only among DCD donors. While DGF was associated with higher AR and GF, with no significant differences across donor types, DBD vs DCD (AR: aHR 2.22 vs 2.37, p-interaction=0.65; GF: 3.04 vs 2.56; p-interaction=0.47). Conclusion Despite higher DGF rates in DCD-KTs, early adverse outcomes after DGF were similar between deceased donor types. Higher DGF rates alone should not deter the utilization of DCD kidneys. |
| 1.359 | Dudley Lamming | ENDO | dlamming@medicine.wisc.edu | Methionine restriction improves metabolic health and has sex-specific benefits for lifespan in HET3 mice | Methionine is one of nine essential amino acids in mammals, and plays a vital role in proteostasis, metabolism, autophagy, and epigenetic modulation. Reduced methionine intake has been shown to promote glucose homeostasis, improve insulin sensitivity, reduce hepatic lipogenesis, increase energy expenditure, and promote longevity in rats and mice. Methionine auxotrophy is also of therapeutic interest in cancer treatment and prevention. Previous studies of methionine restriction (MR) on the lifespan of rodents used homogeneous inbred strains, with various degrees of methionine restriction and duration, and often focused on a single sex, resulting in incongruent findings. Here, we placed genetically diverse HET3 mice on either a MR diet (0.23% Met for 2 weeks followed by 0.15% Met, 0% Cys) or a control diet (0.67% Met, 0.72% Cys) starting at 6 months of age. We found that mice on methionine restriction had lower body weight despite increased food consumption and an overall reduction in adiposity associated with an increase in energy expenditure. The male mice also showed improved glycemic control, with improved glucose tolerance and insulin sensitivity. While consuming less of an essential amino acid, methionine restricted male mice actually had higher muscle strength compared to their controlfed counterparts. So far, mice fed the MR diet seemed to show lower cancer occurrence in both sexes and increased survival in males. Overall, we find that methionine restriction improves metabolic health and survival in HET3 mice, suggesting that diet low in methionine may be a useful way to promote healthy aging in humans. |
| 1.360 | Mark R. Albertini | HEM/ONC | mra@medicine.wisc.edu | A 10-color full spectrum flow cytometry panel for immunophenotyping canine PBMC including activated and regulatory T cells | Introduction Canine malignant melanoma provides a clinically relevant, large animal parallel patient population to study the GD2-reactive hu14.18-IL2 immunocytokine (IC) as it is like human melanoma and expresses GD2. Murine preclinical studies have shown that intratumoral (IT) injection of IC (IT-IC) in combination with local radiation therapy (RT) can convert the injected tumor into an effective in situ tumor vaccine. To study the immunological aspects of IT-IC treatment, we optimized a multi-color flow cytometry panel for subsequent immunophenotypic analysis of cryopreserved peripheral blood mononuclear cells (PBMCs) of dogs with spontaneous melanoma treated with RT and IT-IC. Further, as immune checkpoint blockade is now available in the canine using a caninized anti-PD-1 antibody, we assessed PD-1 expression on canine lymphocytes. We initially designed the panel for acquisition on a conventional 5-laser cytometer (BD Biosciences LSR Fortessa II) and have now optimized the panel for data collection on a 5-laser full spectrum Cytek Aurora (Cytek Biosciences). Methods Multi-color flow cytometry was performed using previously cryopreserved healthy canine PBMCs. Commercially available fluorochrome-conjugated dog-specific antibodies (n=6) and anti-human cross-reactive antibodies (n=3) were used. A fixable viability dye was used to exclude dead cells and fluorescent Minus One (FMO) controls were used to inform gate placement for rare and dim populations, as well as those expressed on a continuum. Optimization of this panel, and conversion from a conventional to a full spectral platform, involved several steps: i) antibody and live/dead reagent titration; ii) evaluation of optimal spectral reference controls (SRC); iii) evaluation of unmixing of fully stained sample; and iv) evaluation of marker resolution. Data were acquired on a Cytek Auora or BD LSR II Fortessa and analyzed with SpectroFlo and FlowJo software. Results A full spectrum 10-color (9 markers + live/dead) color immunophenotyping panel for flow cytometry (CD3, CD5, CD4, CD8, CD14, CD21, CD25, FoxP3, and PD-1) was optimized using cryopreserved healthy canine PBMC. Optimization demonstrated: i) reagent concentrations used to stain cells for acquisition on the Cytek were either comparable to (n=2) or 2- to 8-fold lower than (n=8) concentrations for the LSR II; ii) singlestained (SS) cells were required as SRCs for 5 fluorochromes, whereas SS compensation beads were acceptable for the other 5 fluorochromes; iii) the selected SRCs successfully unmixed the fully-stained (FS) sample; and iv) comparing marker resolution in the FS sample to SS cell controls revealed resolution loss for 2 markers in the FS sample. The ability to identify the population of interest was not affected for CD14 and required no modification, whereas PD1 exhibited a loss of signal which was improved by increasing the titer 2- fold. Resolution of some populations was improved on the Cytek compared to the LSR II. Conclusions In summary, we optimized a backbone immunophenotyping full spectrum flow cytometry panel for analysis of cryopreserved canine PBMCs. As the availability of canine reactive antibodies increases, the panel can be expanded and adapted. Moreover, the panel is amenable for use with fresh PBMC and other tissues, e.g., tumor, spleen, lymph node, with the addition of an anti-CD45 antibody. Markers can be added or changed when reagents become available and/or to address additional questions. |
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