Development of Potent Mcl-1 Inhibitors: Structural Investigations on Macrocycles Originating from a DNA-Encoded Chemical Library Screen.

Evasion of apoptosis is critical for the development and growth of tumors. The pro-survival protein myeloid cell leukemia 1 (Mcl-1) is an antiapoptotic member of the Bcl-2 family, associated with tumor aggressiveness, poor survival, and drug resistance. Development of Mcl-1 inhibitors implies blocking of protein-protein interactions, generally requiring a lengthy optimization process of large, complex molecules. Herein, we describe the use of DNA-encoded chemical library synthesis and screening to directly generate complex, yet conformationally privileged macrocyclic hits that serve as Mcl-1 inhibitors. By applying a conceptual combination of conformational analysis and structure-based design in combination with a robust synthetic platform allowing rapid analoging, we optimized in vitro potency of a lead series into the low nanomolar regime. Additionally, we demonstrate fine-tuning of the physicochemical properties of the macrocyclic compounds, resulting in the identification of lead candidates 57/59 with a balanced profile, which are suitable for future development toward therapeutic use.

Evaluating the function and psychometric properties of a violence risk screening tool in a community sample of adolescents.

Youth violence continues to be widespread. Despite numerous evidence-based programs that reduce youth violence, objective ways to identify youth in need of services is lacking. Few screening tools are available that enables practitioners or community organizations to predict who may perpetrate serious violence. The Violence Injury Protection and Risk Screen (VIPRS) is a previously validated screening tool providing a framework to address youth violence. The purpose of this study is to evaluate the psychometric properties of the VIPRS in a community sample for use in multiple settings. Youth participating in a community-focused youth violence prevention intervention served as the study subjects. Households with youth ages 10-17 were eligible to participate. Study personnel verbally asked youth survey questions and recorded answers on a laptop. Multiple measures-including risk factors for violent behavior as well as, violence and delinquency scales, were asked. Eleven hundred youth participated. Mean age was 13.3; 53% female, 26% Black, 58% Hispanic, 11% more than 1 race. Twenty percent screened positive on the VIPRS-28% male versus 13% female (p = .000). Violence-related behaviors were common: 33% were in a physical fight, 27% experienced cyberbullying victimization, and 9% perpetrated a minor assault. The VIPRS demonstrated robust criterion validity with significant correlation to multiple violence measures (0.3-0.6). Scoring positive on the VIPRS conveyed increased odds of reporting other violent behaviors, such as perpetrating physical aggression (OR: 7 [95% CI: 5.1-11.5]). Overall, the VIPRS performed well in a community sample of youth further validating its psychometric functioning while demonstrating the potential for use in settings beyond healthcare.

Suicide and Suicide Risk in Adolescents.

Suicide is the second leading cause of death for 10- to 24-year-olds in the United States and is a global public health issue, with a recent declaration of a National State of Emergency in Children's Mental Health by the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children's Hospital Association. This clinical report is an update to the previous American Academy of Pediatrics clinical report, "Suicide and Suicide Attempts in Adolescents." Because pediatricians and pediatric health care providers are at the front line of care for adolescents amid a child and adolescent mental health crisis, and because of the chronic and severe shortage of mental health specialists, it is important that pediatric health care providers become facile with recognizing risk factors associated with suicidality and at-risk populations, screening and further assessment of suicidality as indicated, and evidence-based interventions for patients with suicidal ideation and associated behaviors. Suicide risk can be mitigated by appropriate screening, bolstering of protective factors, indicated treatment, community resources, and referrals to mental health providers when available.

One Step Closer to Safer: Counseling Outcomes from American Academy of Pediatrics Firearm Safe Storage Education Training.

OBJECTIVE: To assess pre and postself-reported counseling outcomes for Safer: Storing Firearms Prevents Harm, an American Academy of Pediatrics universal firearm safe storage counseling training for pediatric clinicians providing health maintenance in outpatient settings. STUDY DESIGN: Safer was developed by a national multidisciplinary committee of firearm injury prevention experts with input from firearm-owning families and launched in June 2021. Pediatric clinicians completed baseline and 1-month posttraining surveys after signing up for the Pedialink course from February through June 2022. Primary outcomes included self-reported measures of counseling self-efficacy and frequency. Wilcoxon matched-pairs signed-rank tests compared outcome distributions at baseline and follow-up. Two adjusted, multilevel mixed-effects regression models were conducted. RESULTS: Of 230 clinicians who completed baseline surveys, 146 (64%) completed 1-month postsurveys. Regional representation included Southeast = 67 (46%), Northeast = 24 (16%), Midwest = 21 (14%), Pacific = 15 (10%), Southwest = 11 (8%), and Rocky Mountain = 8 (5%). At follow-up, there was significant improvement in both the distribution of self-efficacy (median [first Quartile-third Quartile = 50 [20-70] at baseline and 80 [60-85] at follow-up; P < .001) and self-reported counseling frequency (median [first Quartile-third Quartile] = 10 [0-50] at baseline and 50 [10-80] at follow-up; P < .001). Adjusted regression model results suggested that self-efficacy significantly improved from baseline to follow-up (time coefficient 25.3; 95% CI = [21.0, 29.5]; P < .001) as did counseling frequency (time coefficient 13.6; 95% CI = [9.2, 18.0]; P < .001). CONCLUSIONS: Significant improvement in self-reported counseling self-efficacy and frequency was demonstrated 1 month following Safer training.

Intimate Partner Violence: Role of the Pediatrician.

The American Academy of Pediatrics and its members recognize the importance of improving the physician's ability to recognize intimate partner violence (IPV) and understand its effects on child health and development and its role in the continuum of family violence. Pediatricians are in a unique position to identify IPV survivors in pediatric settings, to evaluate and treat children exposed to IPV, and to connect families with available local and national resources. Children exposed to IPV are at increased risk of being abused and neglected and are more likely to develop adverse health, behavioral, psychological, and social disorders later in life. Pediatricians should be aware of these profound effects of exposure to IPV on children and how best to support and advocate for IPV survivors and their children.

Informing Use of the Patient Health Questionnaire-2 to Detect Moderate or Greater Depression Symptoms in Adolescents and Young Adults in Outpatient Primary Care.

OBJECTIVE: We compared the Patient Health Questionnaire (PHQ)-2 to the PHQ-9 and examined the implications of using various cutoff scores on the PHQ-2 to detect moderate or greater depressive symptoms on the PHQ-9. We hypothesized that a cutoff score of ≥2 would be optimal for detecting scores of ≥10 on the PHQ-9. METHODS: Demographic and depression screening data from 3,256 routine preventive visits for patients aged 12-25 years at the adolescent and young adult clinic at Children's Hospital Colorado between March 2017 and July 2019 were collected retrospectively. Patients completed routine depression screening at 2,183 visits which were included for analysis. PHQ-2 scores and PHQ-9 scores were calculated for each included patient visit. Associations between different PHQ-2 cutoff scores and moderate or greater depressive symptoms on the PHQ-9 (≥10) were evaluated. RESULTS: A PHQ-2 score ≥2 had a sensitivity of 89% and specificity of 83% for detecting patients with moderate or greater depressive symptoms on the PHQ-9. On a receiver operating characteristic curve, a PHQ-2 cutoff of ≥2 optimized sensitivity and specificity. Analysis of gender and ethnic/racial subgroups demonstrated the same optimal cutoff score for each group studied. For patients aged 21 years and older a PHQ-2 cutoff of ≥3 was most accurate. DISCUSSION: Lowering the positive PHQ-2 cutoff to ≥2 has several clinical advantages, including increased detection of moderate or greater depressive symptoms and depressive disorders. Providers may increase identification of depression by making this change particularly if they follow a positive PHQ-2 with a full PHQ-9.

Acceptability of Long Versus Short Firearm Safety Education Videos in the Emergency Department: A Pilot Randomized Controlled Trial.

STUDY OBJECTIVE: Safe firearm storage is protective against pediatric firearm injuries. We sought to compare a 3-minute versus 30-second safe firearm storage video in terms of acceptability of video content and use in the pediatric emergency department (PED). METHODS: We conducted a randomized controlled trial in a large PED (from March to September 2021). Participants were English-speaking caregivers of noncritically ill patients. Participants were surveyed about child safety behaviors (including firearm storage), then shown 1 of 2 videos. Both videos described safe storage principles; the 3-minute video included temporary firearm removal and a survivor testimonial. The primary outcome was acceptability, measured by responses on a 5-point Likert scale (strongly disagree to strongly agree). A survey at 3 months evaluated information recall. Baseline characteristics and outcomes were compared between groups using Pearson chi-squared, Fisher exact, and Wilcoxon Mann Whitney tests as appropriate. Absolute risk difference for categoric variables and mean difference for continuous variables are reported with 95% confidence interval (CI). RESULTS: Research staff screened 728 caregivers; 705 were eligible and 254 consented to participate (36%); 4 withdrew. Of 250 participants, most indicated acceptability in terms of setting (77.4%) and content (86.6%), and doctors discussing firearm storage (78.6%), with no difference between groups. More caregivers viewing the longer video felt the length appropriate (99.2%) compared with the shorter video (81.1%, difference 18.1%, 95% CI 11.1 to 25.1). CONCLUSIONS: We show that video-based firearm safety education is acceptable among study participants. This can provide consistent education to caregivers in PEDs and needs further study in other settings.

Utilizing the Electronic Medical Record to Enhance Health Care Provider Delivery of Messages About the Safe Storage of Firearms.

The goal of this project was to determine whether screening youth and parents for firearm presence and imbedding those results in the electronic medical record (EMR) increased health care provider (HCP) documentation of firearms and subsequent delivery of a safe storage message. The study took place in a large adolescent medicine practice. Fifty-six dyads (40% of eligible) were randomized to usual care or the intervention, in which screening results for firearms were imbedded in the EMR. Health care providers delivered a safe storage message to 20% of controls and 51.2% in the intervention (P = .04). When HCPs documented the delivery of a safe storage message, 64% of parents recalled hearing it, compared with only 36% when there was no documentation (P = .012). Therefore, we found that incorporating firearm screening into the EMR increases the attention HCPs give to delivering a firearm safe storage message and correlates with parents recalling having heard a safe storage message.

Implementation of a youth violence prevention programme in primary care.

BACKGROUND AND OBJECTIVES: Youth violence is an alarming public health problem, yet, violence screening and interventions are not systematically offered in primary care (PC). This paper describes data from a pilot effectiveness-implementation trial of an efficacious youth violence prevention programme (SafERteens). METHODS: The study was conducted in two PC clinics: a university-affiliated satellite clinic and a community health centre. In phase 1, we obtained stakeholder feedback to customise the SafERteens package and enrolled a comparison group of adolescents (age 14-18) seeking care in two clinics. In phase 2, clinical staff delivered the SafERteens-PC intervention with adolescents, which is a single, behavioural health therapy session delivered one-on-one from clinic providers to youth patients, followed by text message (TM) reminders. In phase 3, we assessed planned maintenance. All participants reported past-year violent behaviour at intake and completed a 3-month follow-up assessment. RESULTS: Based on stakeholder interviews (n=13), we created a web-based SafERteens-PC programme package, including a three-item past-year violence screen, 30 min motivational interviewing-based brief intervention delivery tool, training videos and 2 months of TM boosters. We enrolled a comparison group (n=49) first, then an intervention group (n=61). Intervention delivery characteristics varied by clinic, including completion of intervention (75.9%; 62.5%), modality (100% delivered via telehealth; 60% via telehealth/40% in-person) and enrolment in TMs (81.8%; 55.0%); 91.8% completed the follow-up. Using an intention-to-treat approach, the intervention group showed significantly greater reductions in severe peer aggression (p<0.05), anxiety (p<0.05) and substance use consequences (p<0.05) relative to the comparison group. Participant and staff feedback were positive and identified challenges to long-term implementation, such as lack of availability of reimbursement for youth violence prevention. CONCLUSIONS: If these challenges could be addressed, routine provision of behavioural health services for violence prevention in PC could have high impact on health outcomes for adolescents.

Discovery of Novel UDP-N-Acetylglucosamine Acyltransferase (LpxA) Inhibitors with Activity against Pseudomonas aeruginosa.

This study describes a novel series of UDP-N-acetylglucosamine acyltransferase (LpxA) inhibitors that was identified through affinity-mediated selection from a DNA-encoded compound library. The original hit was a selective inhibitor of Pseudomonas aeruginosa LpxA with no activity against Escherichia coli LpxA. The biochemical potency of the series was optimized through an X-ray crystallography-supported medicinal chemistry program, resulting in compounds with nanomolar activity against P. aeruginosa LpxA (best half-maximal inhibitory concentration (IC50) <5 nM) and cellular activity against P. aeruginosa (best minimal inhibitory concentration (MIC) of 4 µg/mL). Lack of activity against E. coli was maintained (IC50 > 20 µM and MIC > 128 µg/mL). The mode of action of analogues was confirmed through genetic analyses. As expected, compounds were active against multidrug-resistant isolates. Further optimization of pharmacokinetics is needed before efficacy studies in mouse infection models can be attempted. To our knowledge, this is the first reported LpxA inhibitor series with selective activity against P. aeruginosa.

Adapting Safety Check as a Universal Suicide Prevention Strategy in Pediatric Primary Care.

OBJECTIVE: The presence of unlocked firearms in the home is associated with increased risk of suicide and unintentional injury in youth. We adapted an evidence-based program for promoting safe firearm storage, Safety Check, to enhance its acceptability as a universal suicide prevention strategy in pediatric primary care. METHODS: We applied ADAPT-ITT, an established adaptation framework, to guide iterative program adaptation with ongoing input from key stakeholders. The present study describes 2 phases of ADAPT-ITT: the Production phase (generating adaptations) and the Topical Experts phase (gathering stakeholder feedback on adaptations). After generating proposed program adaptations based on 3 inputs (stakeholder feedback collected in a prior study, the behavioral science literature, and best practices in pediatric medicine), we elicited feedback from stakeholders with firearm expertise. The adaptations included changes such as clarifying firearm ownership will not be documented in the medical record and offering follow-up reminders. We also crowdsourced feedback from 337 parents to select a new name and program logo. RESULTS: Saturation was reached with 9 stakeholders. Feedback confirmed the value of adaptations that: 1) considered context (eg, reason for ownership), 2) promoted parent autonomy in decision-making, and 3) ensured privacy. The most preferred program name was Suicide and Accident prevention through Family Education (SAFE) Firearm. CONCLUSIONS: Guided by an established adaptation framework that prioritized multistage stakeholder feedback, adaptations to the original Safety Check were deemed acceptable. We plan to test the SAFE Firearm program as a universal suicide prevention strategy in pediatric primary care via a hybrid effectiveness-implementation trial.

Risk and Protective Factors Associated with Youth Firearm Access, Possession or Carrying.

Firearm homicide and suicide are the leading causes of violence-related injury deaths among U.S. youth. However, evaluations of the effectiveness of firearm violence prevention programs and strategies to reducing youth firearm violence are limited. To help inform and evaluate such efforts, this study aimed to identify risk and protective factors associated with youth firearm access, possession or carrying (for reasons other than hunting or target shooting) among a sample of U.S. urban youth in the Mountain West. Findings show the influence that youth violence risk (e.g., having friends engaged in delinquency; violence; drug sales; gang fights; exposure to violence; screening positive for violence risk) can have on youth firearm access, possession or carrying. Implications for prevention and intervention are discussed.

Novel Autotaxin Inhibitor for the Treatment of Idiopathic Pulmonary Fibrosis: A Clinical Candidate Discovered Using DNA-Encoded Chemistry.

The activity of the secreted phosphodiesterase autotaxin produces the inflammatory signaling molecule LPA and has been associated with a number of human diseases including idiopathic pulmonary fibrosis (IPF). We screened a single DNA-encoded chemical library (DECL) of 225 million compounds and identified a series of potent inhibitors. Optimization of this series led to the discovery of compound 1 (X-165), a highly potent, selective, and bioavailable small molecule. Cocrystallization of compound 1 with human autotaxin demonstrated that it has a novel binding mode occupying both the hydrophobic pocket and a channel near the autotaxin active site. Compound 1 inhibited the production of LPA in human and mouse plasma at nanomolar levels and showed efficacy in a mouse model of human lung fibrosis. After successfully completing IND-enabling studies, compound 1 was approved by the FDA for a Phase I clinical trial. These results demonstrate that DECL hits can be readily optimized into clinical candidates.

Machine Learning on DNA-Encoded Libraries: A New Paradigm for Hit Finding.

DNA-encoded small molecule libraries (DELs) have enabled discovery of novel inhibitors for many distinct protein targets of therapeutic value. We demonstrate a new approach applying machine learning to DEL selection data by identifying active molecules from large libraries of commercial and easily synthesizable compounds. We train models using only DEL selection data and apply automated or automatable filters to the predictions. We perform a large prospective study (∼2000 compounds) across three diverse protein targets: sEH (a hydrolase), ERα (a nuclear receptor), and c-KIT (a kinase). The approach is effective, with an overall hit rate of ∼30% at 30 µM and discovery of potent compounds (IC50 < 10 nM) for every target. The system makes useful predictions even for molecules dissimilar to the original DEL, and the compounds identified are diverse, predominantly drug-like, and different from known ligands. This work demonstrates a powerful new approach to hit-finding.

State of the science: a scoping review of primary prevention of firearm injuries among children and adolescents.

Intentional and unintentional firearm injury is the second leading cause of death for youth, underscoring the need for effective primary prevention approaches that focus on increasing safe storage by caregivers and decreasing handling/carriage among youth. This article describes the state of the science for prevention of firearm injuries among children and adolescents. We applied PRISMA guidelines to present results from a scoping review using PubMed, Scopus, CINAHL, and CJ Abstracts for original research articles published between January 1, 1985 and March 1, 2018 in the U.S. focusing on primary screening or interventions for primary prevention of pediatric firearm injuries. In total, 46 articles met inclusion criteria: safe storage (23), screening (2), firearm handling/carriage/use (21). Across school, healthcare, and community settings, few evidenced-based programs exist, and data on firearm safety technologies are lacking. Programs have generally not employed rigorous designs, and/or assessed behavioral (e.g., carriage) or injury-related firearm outcomes. Evidenced-based prevention programs are needed to mitigate firearm morbidity and mortality among youth.

Prevention of Firearm Injuries Among Children and Adolescents: Consensus-Driven Research Agenda from the Firearm Safety Among Children and Teens (FACTS) Consortium.

IMPORTANCE: Firearm injuries are the second leading cause of death among US children and adolescents. Because of the lack of resources allocated to firearm injury prevention during the past 25 years, research has lagged behind other areas of injury prevention. Identifying timely and important research questions regarding firearm injury prevention is a critical step for reducing pediatric mortality. OBJECTIVE: The Firearm Safety Among Children and Teens (FACTS) Consortium, a National Institute for Child Health and Human Development-funded group of scientists and stakeholders, was formed in 2017 to develop research resources for the field, including a pediatric-specific research agenda for firearm injury prevention to assist future researchers and funders, as well as to inform cross-disciplinary evidence-based research on this critical injury prevention topic. EVIDENCE REVIEW: A nominal group technique process was used, including 4 key steps (idea generation, round-robin, clarification, and voting and consensus). During idea generation, stakeholders and workgroups generated initial research agenda topics after conducting scoping reviews of the literature to identify existing gaps in knowledge. Agenda topics were refined through 6 rounds of discussion and survey feedback (ie, round-robin, and clarification steps). Final voting (using a 5-point Likert scale) was conducted to achieve consensus (≥70% of consortium ranking items at 4 or 5 priority for inclusion) around key research priorities for the next 5 years of research in this field. Final agenda questions were reviewed by both the stakeholder group and an external panel of research experts not affiliated with the FACTS Consortium. Feedback was integrated and the final set of agenda items was ratified by the entire FACTS Consortium. FINDINGS: Overall, 26 priority agenda items with examples of specific research questions were identified across 5 major thematic areas, including epidemiology and risk and protective factors, primary prevention, secondary prevention and sequelae, cross-cutting prevention factors, policy, and data enhancement. CONCLUSIONS AND RELEVANCE: These priority agenda items, when taken together, define a comprehensive pediatric-specific firearm injury prevention research agenda that will guide research resource allocation within this field during the next 5 years.

Increased Violence Involvement and Other Behavioral and Mental Health Factors Among Youth With Firearm Access.

PURPOSE: The purpose of this study was to examine multiple ways youth may access firearms among a sample of urban, mountain west youth, and explore whether youth reporting various types of violence involvement and other behavioral or mental health factors have differential access to firearms compared with youth who do not report these issues. METHODS: A cross-sectional community-based survey was conducted among adolescents aged 10-17 years and one of their parents. The main outcomes were youth firearm access and possession and associated violence and behavioral and mental health factors. Bivariate and binomial logistic regression, controlling for demographic factors, was used to determine associations and predictors. RESULTS: One thousand one hundred youth and 730 parents participated. Nearly half of youth were male; 58.2% were Hispanic, 24.7% non-Hispanic black, 10.5% multiracial, 3.9% other, and 2.5% white. About 20% were categorized as having potential access to firearms (i.e., youth knows how and/or where to access firearms); 1.9% possessed a firearm. Analyses revealed that being physically aggressive (odds ratio [OR] 2.7), risk for future violence perpetration (OR 2.6), using alcohol (OR 2.0), having internalizing symptoms (OR 1.9), peer problems (OR 1.9), and older age (OR 1.26) predicted youth's possible access to firearms. Marijuana use (OR 9.9), parental gun ownership (OR 6.5), and reported delinquency (OR 8.3) predicted youth's firearm possession. CONCLUSIONS: Youth with potential firearm access demonstrate more violence risk and involvement, and other behavioral or mental health issues than youth without potential firearm access. Parental firearm ownership predicts youth firearm possession. It is important for both health-care providers and parents to recognize these potentially lethal associations to provide appropriate counseling.