BCL11A intellectual developmental disorder: defining the clinical spectrum and genotype-phenotype correlations.

An increasing number of individuals with intellectual developmental disorder (IDD) and heterozygous variants in BCL11A are identified, yet our knowledge of manifestations and mutational spectrum is lacking. To address this, we performed detailed analysis of 42 individuals with BCL11A-related IDD (BCL11A-IDD, a.k.a. Dias-Logan syndrome) ascertained through an international collaborative network, and reviewed 35 additional previously reported patients. Analysis of 77 affected individuals identified 60 unique disease-causing variants (30 frameshift, 7 missense, 6 splice-site, 17 stop-gain) and 8 unique BCL11A microdeletions. We define the most prevalent features of BCL11A-IDD: IDD, postnatal-onset microcephaly, hypotonia, behavioral abnormalities, autism spectrum disorder, and persistence of fetal hemoglobin (HbF), and identify autonomic dysregulation as new feature. BCL11A-IDD is distinguished from 2p16 microdeletion syndrome, which has a higher incidence of congenital anomalies. Our results underscore BCL11A as an important transcription factor in human hindbrain development, identifying a previously underrecognized phenotype of a small brainstem with a reduced pons/medulla ratio. Genotype-phenotype correlation revealed an isoform-dependent trend in severity of truncating variants: those affecting all isoforms are associated with higher frequency of hypotonia, and those affecting the long (BCL11A-L) and extra-long (-XL) isoforms, sparing the short (-S), are associated with higher frequency of postnatal microcephaly. With the largest international cohort to date, this study highlights persistence of fetal hemoglobin as a consistent biomarker and hindbrain abnormalities as a common feature. It contributes significantly to our understanding of BCL11A-IDD through an extensive unbiased multi-center assessment, providing valuable insights for diagnosis, management and counselling, and into BCL11A's role in brain development.

Investigating the efficacy of integrating video-directly observed therapy (VDOT) in the treatment of tuberculosis (TB): A statewide analysis from Florida.

Objectives: To determine if integrating VDOT into TB therapy demonstrated non-inferiority to direct observation, and if VDOT utilization increased across Florida after the onset of Covid-19. Methods: A statewide programmatic review was conducted of all patients in Florida who initiated tuberculosis treatment between January 2018 - December 2018 and January 2020 - December 2021, as documented by the Florida Department of Health. Results: 1361 patients received treatment within the analysis timeframe. Therapy completion was 97.2% in those utilizing VDOT compared to 92.3% utilizing only DOT (p=<.001). Average duration of therapy was 220.5 days in the DOT-only cohort compared to 211.1 days with VDOT integration (p=.027). A 176.35% increase in VDOT utilization was seen across Florida during Covid-19. Conclusions: This is the first and largest state-wide study evaluating the efficacy of integrating VDOT into TB therapy, finding statistically significant improvements in completion and duration of therapy. Despite increased VDOT utilization since the onset of Covid-19, we suspect that multiple barriers may be hindering further integration. VDOT should be recommended as a cost effective, non-inferior alternative to DOT in monitoring the treatment of tuberculosis.

IASLC grading system predicts distant metastases for resected lung adenocarcinoma.

AIMS: The International Association for the Study of Lung Cancer (IASLC) has proposed a new histological grading system for invasive lung adenocarcinoma (LUAD). However, the efficacy of this grading system in predicting distant metastases in patients with LUAD remains unexplored. This study aims to assess the potential of the IASLC grading system in predicting the occurrence of brain and bone metastases in patients with resectable LUAD, thereby identifying individuals at high risk of post-surgery distant metastasis. METHODS: We retrospectively analysed clinical data and pathological reports of 174 patients with early-stage LUAD who underwent surgical resection between 2008 and 2015 at our cancer center. Patients were monitored for 5 years, and their bone and brain metastasis-free survival rates were determined. RESULTS: 28 out of 174 patients developed distant metastases in 5 years with a median overall survival of 60 months for metastasis-free patients and 38.3 months for patients with distant metastasis. Tumour grading of all samples was evaluated by both IASLC grading and predominant pattern-based grading systems. Receiver operating characteristic (ROC) curves were used to evaluate the predictive capabilities of the IASLC grading system and tumour stage for distant metastasis. Compared with the predominant pattern-based grading system, the IASLC grading system showed a better correlation with the incidence of distant metastasis and lymphovascular invasion. ROC analyses revealed that the IASLC grading system outperformed tumour stage in predicting distant metastasis. CONCLUSIONS: Our study indicates that the IASLC grading system is capable of predicting the incidence of distant metastasis among patients with early-stage invasive LUAD.

Spatial Architecture of Myeloid and T Cells Orchestrates Immune Evasion and Clinical Outcome in Lung Cancer.

Understanding the role of the tumor microenvironment (TME) in lung cancer is critical to improving patient outcomes. We identified four histology-independent archetype TMEs in treatment-naïve early-stage lung cancer using imaging mass cytometry in the TRACERx study (n = 81 patients/198 samples/2.3 million cells). In immune-hot adenocarcinomas, spatial niches of T cells and macrophages increased with clonal neoantigen burden, whereas such an increase was observed for niches of plasma and B cells in immune-excluded squamous cell carcinomas (LUSC). Immune-low TMEs were associated with fibroblast barriers to immune infiltration. The fourth archetype, characterized by sparse lymphocytes and high tumor-associated neutrophil (TAN) infiltration, had tumor cells spatially separated from vasculature and exhibited low spatial intratumor heterogeneity. TAN-high LUSC had frequent PIK3CA mutations. TAN-high tumors harbored recently expanded and metastasis-seeding subclones and had a shorter disease-free survival independent of stage. These findings delineate genomic, immune, and physical barriers to immune surveillance and implicate neutrophil-rich TMEs in metastasis. SIGNIFICANCE: This study provides novel insights into the spatial organization of the lung cancer TME in the context of tumor immunogenicity, tumor heterogeneity, and cancer evolution. Pairing the tumor evolutionary history with the spatially resolved TME suggests mechanistic hypotheses for tumor progression and metastasis with implications for patient outcome and treatment. This article is featured in Selected Articles from This Issue, p. 897.

Reducing Unnecessary Transfusions of RBCs in Inpatients Admitted Across Niagara Health Community Hospitals.

BACKGROUND AND OBJECTIVES: Blood products are scarce resources. Audits on the use of red blood cells (RBCs) in tertiary centers have repeatedly highlighted inappropriate use. Earlier retrospective audit at our local community hospitals has demonstrated that only 85% and 54% of all requests met Choosing Wisely Canada guidelines for pre-transfusion hemoglobin (Hb) of 80 g/L or less and single unit, respectively.We sought to improve RBC utilization by 15% over a period of 12 months (meeting Choosing Wisely Canada criteria of pre-transfusion Hb ≤80g/L by >80% and single-unit transfusion by >65%). METHODS: Following repeated PDSA (Plan-Do-Study-Act) cycles, we implemented educational strategies, prospective transfusion medicine (TM) technologist-led screening of orders, and an RBC order set. RESULTS: The 3-month median percentages of appropriate RBC use for pre-transfusion Hb and single unit (September-November 2021) across all 3 hospitals were 90% and 71%, respectively. Overall, the rate of appropriate RBCs based on pre-transfusion Hb remained above target (>80%), with minimal improvement across all hospitals (median percentage at pre- and post-technologist screening periods of 87% and 90%, respectively). The median percentage of appropriate RBCs based on single-unit transfusion orders has improved across all Niagara Health hospitals with sustained targets (3-month median percentage at pre- and post-technologist screening and most recent time periods of 54%, 56%, and 71%, respectively). CONCLUSIONS: We have taken a collaborative, multifaceted approach to optimizing utilization of RBCs across the Niagara Health hospitals. The rates of appropriate RBC use were comparable with the provincial and national accreditation benchmark standards. In particular, the TM technologist-led screening was effective in producing sustained improvement with respect to single-unit transfusion. One of the balancing outcomes was increasing workload on technologists. Local and provincial efforts are needed to facilitate recruitment and retention of laboratory technologists, especially in community hospitals.

The role of APOBEC3B in lung tumor evolution and targeted cancer therapy resistance.

In this study, the impact of the apolipoprotein B mRNA-editing catalytic subunit-like (APOBEC) enzyme APOBEC3B (A3B) on epidermal growth factor receptor (EGFR)-driven lung cancer was assessed. A3B expression in EGFR mutant (EGFRmut) non-small-cell lung cancer (NSCLC) mouse models constrained tumorigenesis, while A3B expression in tumors treated with EGFR-targeted cancer therapy was associated with treatment resistance. Analyses of human NSCLC models treated with EGFR-targeted therapy showed upregulation of A3B and revealed therapy-induced activation of nuclear factor kappa B (NF-κB) as an inducer of A3B expression. Significantly reduced viability was observed with A3B deficiency, and A3B was required for the enrichment of APOBEC mutation signatures, in targeted therapy-treated human NSCLC preclinical models. Upregulation of A3B was confirmed in patients with NSCLC treated with EGFR-targeted therapy. This study uncovers the multifaceted roles of A3B in NSCLC and identifies A3B as a potential target for more durable responses to targeted cancer therapy.

Vitamin B5 supports MYC oncogenic metabolism and tumor progression in breast cancer.

Tumors are intrinsically heterogeneous and it is well established that this directs their evolution, hinders their classification and frustrates therapy1-3. Consequently, spatially resolved omics-level analyses are gaining traction4-9. Despite considerable therapeutic interest, tumor metabolism has been lagging behind this development and there is a paucity of data regarding its spatial organization. To address this shortcoming, we set out to study the local metabolic effects of the oncogene c-MYC, a pleiotropic transcription factor that accumulates with tumor progression and influences metabolism10,11. Through correlative mass spectrometry imaging, we show that pantothenic acid (vitamin B5) associates with MYC-high areas within both human and murine mammary tumors, where its conversion to coenzyme A fuels Krebs cycle activity. Mechanistically, we show that this is accomplished by MYC-mediated upregulation of its multivitamin transporter SLC5A6. Notably, we show that SLC5A6 over-expression alone can induce increased cell growth and a shift toward biosynthesis, whereas conversely, dietary restriction of pantothenic acid leads to a reversal of many MYC-mediated metabolic changes and results in hampered tumor growth. Our work thus establishes the availability of vitamins and cofactors as a potential bottleneck in tumor progression, which can be exploited therapeutically. Overall, we show that a spatial understanding of local metabolism facilitates the identification of clinically relevant, tractable metabolic targets.

Gastric adenocarcinoma metastasis to the rectum causing complete obstruction, a case report.

Gastric adenocarcinoma is a leading cause of mortality worldwide. The most common sites of metastases are the liver, peritoneum, lungs, and bones. Cases have been described in the colon and rectum, but are very rare. This case report describes a patient in remission from diffuse signet ring cell type gastric adenocarcinoma with resection and chemoradiation close to 10 years prior to presenting with a near-obstructing rectal mass that was consistent with metastatic gastric adenocarcinoma. Gastric cancer spreads via hematogenous, lymphatic, peritoneal seeding, or local recurrence pathways. Given the length of time between initial presentation and eventual metastasis, the theory of dormancy is discussed and proposed as a possible cause in the delay of metastasis to the rectum. This highlights the importance of maintaining a high index of suspicion for recurrence and metastasis in a patient with a history of gastric cancer, who presents with a new obstructing rectal mass.

Endothelial AHR activity prevents lung barrier disruption in viral infection.

Disruption of the lung endothelial-epithelial cell barrier following respiratory virus infection causes cell and fluid accumulation in the air spaces and compromises vital gas exchange function1. Endothelial dysfunction can exacerbate tissue damage2,3, yet it is unclear whether the lung endothelium promotes host resistance against viral pathogens. Here we show that the environmental sensor aryl hydrocarbon receptor (AHR) is highly active in lung endothelial cells and protects against influenza-induced lung vascular leakage. Loss of AHR in endothelia exacerbates lung damage and promotes the infiltration of red blood cells and leukocytes into alveolar air spaces. Moreover, barrier protection is compromised and host susceptibility to secondary bacterial infections is increased when endothelial AHR is missing. AHR engages tissue-protective transcriptional networks in endothelia, including the vasoactive apelin-APJ peptide system4, to prevent a dysplastic and apoptotic response in airway epithelial cells. Finally, we show that protective AHR signalling in lung endothelial cells is dampened by the infection itself. Maintenance of protective AHR function requires a diet enriched in naturally occurring AHR ligands, which activate disease tolerance pathways in lung endothelia to prevent tissue damage. Our findings demonstrate the importance of endothelial function in lung barrier immunity. We identify a gut-lung axis that affects lung damage following encounters with viral pathogens, linking dietary composition and intake to host fitness and inter-individual variations in disease outcome.

Defining the identity and the niches of epithelial stem cells with highly pleiotropic multilineage potency in the human thymus.

Thymus is necessary for lifelong immunological tolerance and immunity. It displays a distinctive epithelial complexity and undergoes age-dependent atrophy. Nonetheless, it also retains regenerative capacity, which, if harnessed appropriately, might permit rejuvenation of adaptive immunity. By characterizing cortical and medullary compartments in the human thymus at single-cell resolution, in this study we have defined specific epithelial populations, including those that share properties with bona fide stem cells (SCs) of lifelong regenerating epidermis. Thymic epithelial SCs display a distinctive transcriptional profile and phenotypic traits, including pleiotropic multilineage potency, to give rise to several cell types that were not previously considered to have shared origin. Using here identified SC markers, we have defined their cortical and medullary niches and shown that, in vitro, the cells display long-term clonal expansion and self-organizing capacity. These data substantively broaden our knowledge of SC biology and set a stage for tackling thymic atrophy and related disorders.

The Candida albicans toxin candidalysin mediates distinct epithelial inflammatory responses through p38 and EGFR-ERK pathways.

The fungal pathogen Candida albicans secretes the peptide toxin candidalysin, which damages epithelial cells and drives an innate inflammatory response mediated by the epidermal growth factor receptor (EGFR) and mitogen-activated protein kinase (MAPK) pathways and the transcription factor c-Fos. In cultured oral epithelial cells, candidalysin activated the MAPK p38, which resulted in heat shock protein 27 (Hsp27) activation, IL-6 release, and EGFR phosphorylation without affecting the induction of c-Fos. p38 activation was not triggered by EGFR but by two nonredundant pathways involving MAPK kinases (MKKs) and the kinase Src, which differentially controlled p38 signaling outputs. Whereas MKKs mainly promoted p38-dependent release of IL-6, Src promoted p38-mediated phosphorylation of EGFR in a ligand-independent fashion. In parallel, candidalysin also activated the EGFR-ERK pathway in a ligand-dependent manner, resulting in c-Fos activation and release of the neutrophil-activating chemokines G-CSF and GM-CSF. In mice, early clearance events of oral C. albicans infection required p38 but not c-Fos. These findings delineate how candidalysin activates the pathways downstream of the MAPKs p38 and ERK that differentially contribute to immune activation during C. albicans infection.

Effect of Echinostoma caproni on Presumptive Lactic Acid Bacteria Abundance and Salmonella enterica Serovar Typhimurium Colonization in the Mouse Gut.

Co-infections of mammalian hosts with intestinal helminths and bacterial pathogens are common, especially in areas with inadequate sanitation. Interactions between co-infecting species and host microbiota can cause significant changes in host immunity, disease severity, and pathogen transmission, requiring unique treatment for each case. A greater understanding of the influences of parasite-bacteria co-infections will improve diagnosis and therapeutic approaches to control infectious diseases. To study the influence of the trematode parasite Echinostoma caproni on commensal and pathogenic bacteria in the mouse gut, we examined the abundance of intestinal lactic acid bacteria and Salmonella enterica serovar Typhimurium in control mice not exposed to E. caproni (P-) or S. Typhimurium (S-), E. caproni-infected (P+S-), S. Typhimurium-infected (P-S+), and E. caproni-S. Typhimurium co-infected (P+S+) mice, and determined bacterial burdens in the livers and spleens of the P-S+ and P+S+ mice. We also examined a subset of P+S- and P+S+ mice for survival and the relative location of E. caproni in the small intestine. The numbers of presumptive lactic acid bacteria were significantly higher in the P+S+ and P-S+ mice compared to the uninfected mice, and S. Typhimurium colonization in the liver and spleen was significantly reduced in the P+S+ mice compared to the P-S+ mice. Echinostoma caproni were located anteriorly in the intestine of P+S- mice, while in the P+S+ mice, the parasites were distributed more posteriorly. Survival of E. caproni was unaffected in either group. The results of our study suggest that E. caproni facilitates a higher abundance of presumptive lactic acid bacteria in the mouse intestine and reduces colonization of S. Typhimurium in the liver and spleen of the co-infected host.

Prospective multicentre cohort study of transthoracic echocardiography provision in the South West of the UK during the first wave of SARS-CoV-2 pandemic.

AIMS: It was predicted internationally that transthoracic echocardiography (TTE) would be vital during the SARS-CoV-2 outbreak. We therefore, designed a study to report the demand for TTE in two large District General Hospitals during the rise in the first wave of the SARS-CoV-2 pandemic in the UK. A primary clinical outcome of 30-day mortality was also assessed. METHODS: The TTE service across two hospitals was reconfigured to maximise access to inpatient scanning. All TTEs of suspected or confirmed SARS-CoV-2 patients over a 3-week period were included in the study. All patients were followed up until at least day 30 after their scan at which point the primary clinical outcome of mortality was recorded. Comparative analysis based on mortality was conducted for all TTE results, biochemical markers and demographics. RESULTS: 27 patients with confirmed SARS-CoV-2 had a TTE within the inclusion window. Mortality comparative analysis showed the deceased group were significantly older (mean 68.4, SD 11.9 vs 60.5, SD 13.0, p=0.03) and more commonly reported fatigue in their presenting symptoms (29.6% vs 71.4%, p=0.01). No other differences were identified in the demographic or biochemical data. Left ventricular systolic dysfunction was noted in 7.4% of patients and right ventricular impairment or dilation was seen in 18.5% patients. TTE results were not significantly different in mortality comparative analysis. CONCLUSION: This study demonstrates an achievable approach to TTE services when under increased pressure. Data analysis supports the limited available data suggesting right ventricular abnormalities are the most commonly identified echocardiographic change in SARS-CoV-2 patients. No association can be demonstrated between mortality and TTE results.

Anti-M-Induced Delayed Hemolytic Transfusion Reaction.

BACKGROUND: Anti-M is most often assumed to be naturally occurring and can be comprised of a mixture of predominantly immunoglobulin(Ig)M with a lesser IgG component. Anti-M-antibodies usually do not react at 37°C and therefore are considered to be of little clinical significance. METHODS: A 28-year-old man presented with hemorrhagic shock from numerous injuries sustained in a motor vehicle collision. The patient received several units of red blood cells (RBCs). The antibody screen, the direct antiglobulin test (DAT), and the RBC genotype were sent for laboratory evaluation. RESULTS: A total of 12 days after the first antibody screening result was negative (7 days after transfusion), the lowest hemoglobin value was 5.5 g per dL, and we observed a positive antibody screening result and DAT with immunoglobulin (Ig)G anti-M identified. After transfusion of 4 units of M antigen-negative RBC, the post-transfusion hemoglobin level increased to 8.9 g per dL. CONCLUSION: Obtaining M antigen-negative compatible RBCs is necessary in patients demonstrating IgG anti-M in plasma.

MCT8 deficiency in Purkinje cells disrupts embryonic chicken cerebellar development.

Inactivating mutations in the human SLC16A2 gene encoding the thyroid hormone transporter monocarboxylate transporter 8 (MCT8) result in the Allan-Herndon-Dudley syndrome accompanied by severe locomotor deficits. The underlying mechanisms of the associated cerebellar maldevelopment were studied using the chicken as a model. Electroporation of an MCT8-RNAi vector into the cerebellar anlage of a 3-day-old embryo allowed knockdown of MCT8 in Purkinje cell precursors. This resulted in the downregulation of the thyroid hormone-responsive gene RORα and the Purkinje cell-specific differentiation marker LHX1/5 at day 6. MCT8 knockdown also results in a smaller and less complex dendritic tree at day 18 suggesting a pivotal role of MCT8 for cell-autonomous Purkinje cell maturation. Early administration of the thyroid hormone analogue 3,5,3'-triiodothyroacetic acid partially rescued early Purkinje cell differentiation. MCT8-deficient Purkinje cells also induced non-autonomous effects as they led to a reduced granule cell precursor proliferation, a thinner external germinal layer and a loss of PAX6 expression. By contrast, at day 18, the external germinal layer thickness was increased, with an increase in presence of Axonin-1-positive post-mitotic granule cells in the initial stage of radial migration. The concomitant accumulation of presumptive migrating granule cells in the molecular layer, suggests that inward radial migration to the internal granular layer is stalled. In conclusion, early MCT8 deficiency in Purkinje cells results in both cell-autonomous and non-autonomous effects on cerebellar development and indicates that MCT8 expression is essential from very early stages of development, providing a novel insight into the ontogenesis of the Allan-Herndon-Dudley syndrome.

Age of Onset of Functional Constipation.

In a review of 538 children with functional constipation, we analyzed ages of presentation and onset, symptom duration, and behavioral/developmental problems. We divided the subjects into quartiles (Q1-Q4) based on age of onset. Median onset age was 2.3 years. The oldest group had the shortest symptom duration before referral at 1.8 ±â€Š1.8 years (compared with Q3 to Q1, P = 0.039, P = 0.001, P < 0.001, respectively). Of the Q4 subjects, 22% had a behavioral/developmental problem (P < 0.001 compared with Q1-Q3). We conclude that most children develop functional constipation as infants and toddlers, but those with later onset are more likely to have behavioral/developmental issues and see a specialist sooner.

A Comparison of Antibiotic Serum Concentrations Drawn Simultaneously from Peripherally Inserted Central Catheters and Peripheral Veins in Children with Respiratory Infection.

The purpose of the study was to evaluate serum concentration of antibiotics drawn from a peripherally inserted central catheter (PICC) compared with a peripheral venipuncture. This prospective comparative study included patients with ages 1month to 21years admitted with a respiratory infection requiring IV vancomycin or IV tobramycin via a newly placed PICC. The difference between the antibiotic levels from the venipuncture and PICC samples was statistically significant for both the peak and trough levels. However, the difference in values was not enough to impact antibiotic dosing and therefore was not clinically significant.

Welcoming Home the Patient with a New Ostomy.

The 5-day average inpatient hospital length-of-stay postostomy limits opportunities for patients and family members to master self-care of the new ostomy prior to discharge. The literature suggests premature discharge, poor care coordination, lack of symptom reporting and follow-up as the primary factors supporting causes of readmissions. Home care nurses are faced with failed handoffs, limited resources, poor care coordination, payor restrictions, and knowledge and skill deficits that negatively impact safe and effective discharge practices of patients with a new ostomy. This article describes an evolving community standard related to nursing care of the patient with a new ostomy as identified by the Baltimore Wound, Ostomy, Continence (WOC) Nursing Affiliate. Case managers, discharge planners, intake team members, and home care nurses benefit from ongoing education from WOC nurse experts to master the skills needed to care for patients with ostomies.