Management of a Rare Mitral Valve Sarcoma Requiring Valve Replacement and Chemotherapy.

A woman with dyspnea is diagnosed with a rare mitral valve primary sarcoma. Patient underwent mechanical mitral valve replacement requiring therapeutic anticoagulation with adjuvant systemic anthracycline-based chemotherapy. The challenges of preventing thromboembolism in a new mechanical prosthesis with risk of bleeding due to cancer and/or its therapies are described.

Cellular adaptation to cancer therapy along a resistance continuum.

Advancements in precision oncology over the past decades have led to new therapeutic interventions, but the efficacy of such treatments is generally limited by an adaptive process that fosters drug resistance1. In addition to genetic mutations2, recent research has identified a role for non-genetic plasticity in transient drug tolerance3 and the acquisition of stable resistance4,5. However, the dynamics of cell-state transitions that occur in the adaptation to cancer therapies remain unknown and require a systems-level longitudinal framework. Here we demonstrate that resistance develops through trajectories of cell-state transitions accompanied by a progressive increase in cell fitness, which we denote as the 'resistance continuum'. This cellular adaptation involves a stepwise assembly of gene expression programmes and epigenetically reinforced cell states underpinned by phenotypic plasticity, adaptation to stress and metabolic reprogramming. Our results support the notion that epithelial-to-mesenchymal transition or stemness programmes-often considered a proxy for phenotypic plasticity-enable adaptation, rather than a full resistance mechanism. Through systematic genetic perturbations, we identify the acquisition of metabolic dependencies, exposing vulnerabilities that can potentially be exploited therapeutically. The concept of the resistance continuum highlights the dynamic nature of cellular adaptation and calls for complementary therapies directed at the mechanisms underlying adaptive cell-state transitions.

Shared features of blastula and neural crest stem cells evolved at the base of vertebrates.

The neural crest is a vertebrate-specific stem cell population that helped drive the origin and evolution of vertebrates. A distinguishing feature of these cells is their multi-germ layer potential, which has parallels to another stem cell population-pluripotent stem cells of the vertebrate blastula. Here, we investigate the evolutionary origins of neural crest potential by comparing neural crest and pluripotency gene regulatory networks of a jawed vertebrate, Xenopus, and a jawless vertebrate, lamprey. We reveal an ancient evolutionary origin of shared regulatory factors in these gene regulatory networks that dates to the last common ancestor of extant vertebrates. Focusing on the key pluripotency factor pou5, we show that a lamprey pou5 orthologue is expressed in animal pole cells but is absent from neural crest. Both lamprey and Xenopus pou5 promote neural crest formation, suggesting that pou5 activity was lost from the neural crest of jawless vertebrates or acquired along the jawed vertebrate stem. Finally, we provide evidence that pou5 acquired novel, neural crest-enhancing activity after evolving from an ancestral pou3-like clade. This work provides evidence that both the neural crest and blastula pluripotency networks arose at the base of the vertebrates and that this may be linked to functional evolution of pou5.

BET activity plays an essential role in control of stem cell attributes in Xenopus.

Neural crest cells are a stem cell population unique to vertebrate embryos that retains broad multi-germ layer developmental potential through neurulation. Much remains to be learned about the genetic and epigenetic mechanisms that control the potency of neural crest cells. Here, we examine the role that epigenetic readers of the BET (bromodomain and extra terminal) family play in controlling the potential of pluripotent blastula and neural crest cells. We find that inhibiting BET activity leads to loss of pluripotency at blastula stages and a loss of neural crest at neurula stages. We compare the effects of HDAC (an eraser of acetylation marks) and BET (a reader of acetylation) inhibition and find that they lead to similar cellular outcomes through distinct effects on the transcriptome. Interestingly, loss of BET activity in cells undergoing lineage restriction is coupled to increased expression of genes linked to pluripotency and prolongs the competence of initially pluripotent cells to transit to a neural progenitor state. Together these findings advance our understanding of the epigenetic control of pluripotency and the formation of the vertebrate neural crest.

Measurement and Application of Incidentally Detected Coronary Calcium: JACC Review Topic of the Week.

Coronary artery calcium (CAC) scoring is a powerful tool for atherosclerotic cardiovascular disease risk stratification. The nongated, noncontrast chest computed tomography scan (NCCT) has emerged as a source of CAC characterization with tremendous potential due to the high volume of NCCT scans. Application of incidental CAC characterization from NCCT has raised questions around score accuracy, standardization of methodology including the possibility of deep learning to automate the process, and the risk stratification potential of an NCCT-derived score. In this review, the authors aim to summarize the role of NCCT-derived CAC in preventive cardiovascular health today as well as explore future avenues for eventual clinical applicability in specific patient populations and broader health systems.

Differentiation signals induce APOBEC3A expression via GRHL3 in squamous epithelia and squamous cell carcinoma.

Two APOBEC (apolipoprotein-B mRNA editing enzyme catalytic polypeptide-like) DNA cytosine deaminase enzymes (APOBEC3A and APOBEC3B) generate somatic mutations in cancer, driving tumour development and drug resistance. Here we used single cell RNA sequencing to study APOBEC3A and APOBEC3B expression in healthy and malignant mucosal epithelia, validating key observations with immunohistochemistry, spatial transcriptomics and functional experiments. Whereas APOBEC3B is expressed in keratinocytes entering mitosis, we show that APOBEC3A expression is confined largely to terminally differentiating cells and requires Grainyhead-like transcription factor 3 (GRHL3). Thus, in normal tissue, neither deaminase appears to be expressed at high levels during DNA replication, the cell cycle stage associated with APOBEC-mediated mutagenesis. In contrast, we show that in squamous cell carcinoma tissues, there is expansion of GRHL3 expression and activity to a subset of cells undergoing DNA replication and concomitant extension of APOBEC3A expression to proliferating cells. These findings indicate a mechanism for acquisition of APOBEC3A mutagenic activity in tumours.

Obesity prevention across the US: A review of state-level policies from 2009 to 2019.

Objective: Uniquely, state legislators may enact obesity prevention policies tailored to each state's needs and take diverse policy approaches to address obesity prevalence. The objective of this study was to identify and describe state-level obesity-related policies between 2009 and 2019. Methods: Using a database of legislation covering 2009-2019, researchers categorized obesity-related legislation by status (proposed/enacted), topic, and environment impacted. Researchers determined the number of policies proposed; enacted, by political party control; obesity prevalence, by states over time. Results: 3256 obesity-related policies were proposed among 50 states and Washington DC between 2009 and 2019. Collectively, 18% (593) of policies were enacted; California (96), New and Jersey (57) enacted the most. Across environment and topics, the most enacted policies categorized in school environment (226) and school nutrition (150) topic area. Most policies were proposed (496) and enacted (77) in 2011. On average, Democrat-controlled states had higher enactment rates than Republican-controlled states, as did states with lower (vs. higher) obesity prevalence. Conclusions: States have actively pursued obesity-related legislation across multiple topics and environments from 2009 to 2019, with mixed enactment rates. Evaluating the impact of these policies, alone and in combination, will be important to determine whether these state-level efforts reduce obesity.

Shared features of blastula and neural crest stem cells evolved at the base of vertebrates.

The neural crest is vertebrate-specific stem cell population that helped drive the origin and evolution of the vertebrate clade. A distinguishing feature of these stem cells is their multi-germ layer potential, which has drawn developmental and evolutionary parallels to another stem cell population-pluripotent embryonic stem cells (animal pole cells or ES cells) of the vertebrate blastula. Here, we investigate the evolutionary origins of neural crest potential by comparing neural crest and pluripotency gene regulatory networks (GRNs) in both jawed ( Xenopus ) and jawless (lamprey) vertebrates. Through comparative gene expression analysis and transcriptomics, we reveal an ancient evolutionary origin of shared regulatory factors between neural crest and pluripotency GRNs that dates back to the last common ancestor of extant vertebrates. Focusing on the key pluripotency factor pou5 (formerly oct4), we show that the lamprey genome encodes a pou5 ortholog that is expressed in animal pole cells, as in jawed vertebrates, but is absent from the neural crest. However, gain-of-function experiments show that both lamprey and Xenopus pou5 enhance neural crest formation, suggesting that pou5 was lost from the neural crest of jawless vertebrates. Finally, we show that pou5 is required for neural crest specification in jawed vertebrates and that it acquired novel neural crest-enhancing activity after evolving from an ancestral pou3 -like clade that lacks this functionality. We propose that a pluripotency-neural crest GRN was assembled in stem vertebrates and that the multi-germ layer potential of the neural crest evolved by deploying this regulatory program.

Cardiovascular disease and chimeric antigen receptor cellular therapy.

Chimeric antigen receptor T-cell (CAR T) therapy is a revolutionary personalized therapy that has significantly impacted the treatment of patients with hematologic malignancies refractory to other therapies. Cytokine release syndrome (CRS) is a major side effect of CAR T therapy that can occur in 70-90% of patients, with roughly 40% of patients at grade 2 or higher. CRS can cause an intense inflammatory state leading to cardiovascular complications, including troponin elevation, arrhythmias, hemodynamic instability, and depressed left ventricular systolic function. There are currently no standardized guidelines for the management of cardiovascular complications due to CAR T therapy, but systematic practice patterns are emerging. In this review, we contextualize the history and indications of CAR T cell therapy, side effects related to this treatment, strategies to optimize the cardiovascular health prior to CAR T and the management of cardiovascular complications related to CRS. We analyze the existing data and discuss potential future approaches.

Gender Differences in Diagnosis, Prevention, and Treatment of Cardiotoxicity in Cardio-Oncology.

Gender differences exist throughout the medical field and significant progress has been made in understanding the effects of gender in many aspects of healthcare. The field of cardio-oncology is diverse and dynamic with new oncologic and cardiovascular therapies approved each year; however, there is limited knowledge regarding the effects of gender within cardio-oncology, particularly the impact of gender on cardiotoxicities. The relationship between gender and cardio-oncology is unique in that gender likely affects not only the biological underpinnings of cancer susceptibility, but also the response to both oncologic and cardiovascular therapies. Furthermore, gender has significant socioeconomic and psychosocial implications which may impact cancer and cardiovascular risk factor profiles, cancer susceptibility, and the delivery of healthcare. In this review, we summarize the effects of gender on susceptibility of cancer, response to cardiovascular and cancer therapies, delivery of healthcare, and highlight the need for further gender specific studies regarding the cardiovascular effects of current and future oncological treatments.

Cancer cell states recur across tumor types and form specific interactions with the tumor microenvironment.

Transcriptional heterogeneity among malignant cells of a tumor has been studied in individual cancer types and shown to be organized into cancer cell states; however, it remains unclear to what extent these states span tumor types, constituting general features of cancer. Here, we perform a pan-cancer single-cell RNA-sequencing analysis across 15 cancer types and identify a catalog of gene modules whose expression defines recurrent cancer cell states including 'stress', 'interferon response', 'epithelial-mesenchymal transition', 'metal response', 'basal' and 'ciliated'. Spatial transcriptomic analysis linked the interferon response in cancer cells to T cells and macrophages in the tumor microenvironment. Using mouse models, we further found that induction of the interferon response module varies by tumor location and is diminished upon elimination of lymphocytes. Our work provides a framework for studying how cancer cell states interact with the tumor microenvironment to form organized systems capable of immune evasion, drug resistance and metastasis.

Assessment of Calories Purchased After Calorie Labeling of Prepared Foods in a Large Supermarket Chain.

Importance: Calorie labels for prepared (ie, ready-to-eat) foods are required in large chain food establishments in the US. Large evaluations in restaurants suggest small declines in purchases of prepared foods after labeling, but to the authors' knowledge, no studies have examined how this policy influences supermarket purchases. Objective: To estimate changes in calories purchased from prepared foods and potential packaged substitutes compared with control foods after calorie labeling of prepared foods in supermarkets. Design, Setting, and Participants: This controlled interrupted time series compared sales 2 years before labeling implementation (April 2015-April 2017) with sales 7 months after labeling implementation (May 2017-December 2017). Data from 173 supermarkets from a supermarket chain with locations in Maine, Massachusetts, New Hampshire, New York, and Vermont were analyzed from March 2020 to May 2022. Intervention: Implementation of calorie labeling of prepared foods in April 2017. Main Outcomes and Measures: Purchased items were classified as prepared foods, potential packaged substitutes for prepared foods, or all other (ie, control) foods. The primary outcome was mean weekly calories per transaction purchased from prepared foods, and the secondary outcome was mean weekly calories per transaction purchased from similar packaged items (for substitution analyses). Analyses of prepared and packaged foods were stratified by food category (bakery, entrées and sides, or deli meats and cheeses). Results: Among the included 173 supermarkets, calorie labeling was associated with a mean 5.1% decrease (95% CI, -5.8% to -4.4%) in calories per transaction purchased from prepared bakery items and an 11.0% decrease (95% CI, -11.9% to -10.1%) from prepared deli items, adjusted for changes in control foods; no changes were observed for prepared entrées and sides (change = 0.3%; 95% CI, -2.5% to 3.0%). Labeling was also associated with decreased calories per transaction purchased from packaged bakery items (change = -3.9%; 95% CI, -4.3% to -3.6%), packaged entrées and sides (change = -1.2%; 95% CI, -1.4% to -0.9%), and packaged deli items (change = -2.1%; 95% CI, -2.4% to -1.7%). Conclusions and Relevance: In this longitudinal study of supermarkets, calorie labeling of prepared foods was associated with small to moderate decreases in calories purchased from prepared bakery and deli items without evidence of substitution to similar packaged foods.

New-Onset Atrial Fibrillation in Patients Hospitalized With COVID-19: Results From the American Heart Association COVID-19 Cardiovascular Registry.

BACKGROUND: New-onset atrial fibrillation (AF) in patients hospitalized with COVID-19 has been reported and associated with poor clinical outcomes. We aimed to understand the incidence of and outcomes associated with new-onset AF in a diverse and representative US cohort of patients hospitalized with COVID-19. METHODS: We used data from the American Heart Association COVID-19 Cardiovascular Disease Registry. Patients were stratified by the presence versus absence of new-onset AF. The primary and secondary outcomes were in-hospital mortality and major adverse cardiovascular events (MACE; cardiovascular death, myocardial infarction, stroke, cardiogenic shock, and heart failure). The association of new-onset AF and the primary and secondary outcomes was evaluated using Cox proportional-hazards models for the primary time to event analyses. RESULTS: Of the first 30 999 patients from 120 institutions across the United States hospitalized with COVID-19, 27 851 had no history of AF. One thousand five hundred seventeen (5.4%) developed new-onset AF during their index hospitalization. New-onset AF was associated with higher rates of death (45.2% versus 11.9%) and MACE (23.8% versus 6.5%). The unadjusted hazard ratio for mortality was 1.99 (95% CI, 1.81-2.18) and for MACE was 2.23 (95% CI, 1.98-2.53) for patients with versus without new-onset AF. After adjusting for demographics, clinical comorbidities, and severity of disease, the associations with death (hazard ratio, 1.10 [95% CI, 0.99-1.23]) fully attenuated and MACE (hazard ratio, 1.31 [95% CI, 1.14-1.50]) partially attenuated. CONCLUSIONS: New-onset AF was common (5.4%) among patients hospitalized with COVID-19. Almost half of patients with new-onset AF died during their index hospitalization. After multivariable adjustment for comorbidities and disease severity, new-onset AF was not statistically significantly associated with death, suggesting that new-onset AF in these patients may primarily be a marker of other adverse clinical factors rather than an independent driver of mortality. Causality between the MACE composites and AF needs to be further evaluated.

Changes in Calorie Content of Menu Items at Large Chain Restaurants After Implementation of Calorie Labels.

Importance: Calorie labeling on menus is required in US chain food establishments with 20 or more locations. This policy may encourage retailers to offer lower-calorie items, which could lead to a public health benefit by reducing customers' calorie intake from prepared foods. However, potential reformulation of restaurant menu items has not been examined since nationwide enforcement of this policy in 2018. Objective: To examine the calorie content of menu items at large chain restaurants before and after implementation of federally mandated menu calorie labels. Design, Setting, and Participants: This pre-post cohort study used restaurant menu data from MenuStat, a database of nutrition information for menu items offered in the largest chain restaurants in the US, collected annually from 2012 to 2019. The study comprised 35 354 menu items sold at 59 large chain restaurants in the US. Statistical analysis was conducted from February 4 to October 8, 2021. Intervention: Nationwide implementation of menu calorie labeling. Main Outcomes and Measures: Changes in menu items' calorie content after restaurant chains implemented calorie labels were estimated, adjusting for prelabeling trends. All menu items, continuously available items, items newly introduced to menus, and items removed from menus were examined separately. Results: Among the 59 restaurant chains included in the study, after labeling, there were no changes in mean calorie content for all menu items (change = -2.0 calories; 95% CI, -8.5 to 4.4 calories) or continuously available items (change = -2.3 calories; 95% CI, -11.5 to 6.3 calories). Items that were newly introduced after labeling, however, had a lower mean calorie content than items introduced before labeling (change = -112.9 calories; 95% CI, -208.6 to -25.2 calories), although there was heterogeneity by restaurant type. Items removed from menus after labeling had similar calorie content as items removed before labeling (change = 0.5 calories; 95% CI, -79.4 to 84.0 calories). Conclusions and Relevance: In this cohort study of large chain restaurants, implementing calorie labels on menus was associated with the introduction of lower-calorie items but no changes in continuously available or removed items.

A Photovoice Study to Reveal Community Perceptions of Highly Processed Packaged Foods in India.

India is experiencing a nutrition transition, with sales of packaged and processed foods rapidly increasing in recent years. This study sought to understand the views and experiences of self-help groups about highly processed, packaged food in Visakhapatnam, India, using the Photovoice method. Participants were able to record, reflect on and critique their environments through participatory analysis, identifying key themes, and offering a critical lens on their food environment and experiences. On an average eight and 14 members participated in the Photovoice workshops held in urban and rural Visakhapatnam respectively. The key themes emerging from the photos and text data are that participants experienced highly processed packaged foods as being: 1) democratic (easily available and consumed by all, affordable and accessible; 2) convenient (easy to prepare) and 3) unhealthy (for human consumption and for environmental sustainability). These data demonstrate the challenges facing public health nutritionists in wishing to shift dietary behaviors to healthy habits: on the surface participants acknowledged their unhealthy characteristics, however these products may now be embedded in dietary culture. Traditional methods for changing dietary habits may not be able to capture the complexity and systems approach is required to explore the most effective entry points for affecting change.

Cancer cell states and emergent properties of the dynamic tumor system.

Phenotypic heterogeneity within malignant cells of a tumor is emerging as a key property of tumorigenesis. Recent work using single-cell transcriptomics has led to the identification of distinct cancer cell states across a range of cancer types, but their functional relevance and the advantage that they provide to the tumor as a system remain elusive. We present here a definition of cancer cell states in terms of coherently and differentially expressed gene modules and review the origins, dynamics, and impact of states on the tumor system as a whole. The spectrum of cell states taken on by a malignant population may depend on cellular lineage, epigenetic history, genetic mutations, or environmental cues, which has implications for the relative stability or plasticity of individual states. Finally, evidence has emerged that malignant cells in different states may cooperate or compete within a tumor niche, thereby providing an evolutionary advantage to the tumor through increased immune evasion, drug resistance, or invasiveness. Uncovering the mechanisms that govern the origin and dynamics of cancer cell states in tumorigenesis may shed light on how heterogeneity contributes to tumor fitness and highlight vulnerabilities that can be exploited for therapy.

Cooperation between melanoma cell states promotes metastasis through heterotypic cluster formation.

Melanomas can have multiple coexisting cell states, including proliferative (PRO) versus invasive (INV) subpopulations that represent a "go or grow" trade-off; however, how these populations interact is poorly understood. Using a combination of zebrafish modeling and analysis of patient samples, we show that INV and PRO cells form spatially structured heterotypic clusters and cooperate in the seeding of metastasis, maintaining cell state heterogeneity. INV cells adhere tightly to each other and form clusters with a rim of PRO cells. Intravital imaging demonstrated cooperation in which INV cells facilitate dissemination of less metastatic PRO cells. We identified the TFAP2 neural crest transcription factor as a master regulator of clustering and PRO/INV states. Isolation of clusters from patients with metastatic melanoma revealed a subset with heterotypic PRO-INV clusters. Our data suggest a framework for the co-existence of these two divergent cell populations, in which heterotypic clusters promote metastasis via cell-cell cooperation.