Sacrolumbar Interbody Fusion (SLIF): Feasibility, Technical Nuances, Biomechanical Assessment, and Clinical Outcomes.

Introduction: S1-L5 transdiscal screw fixation is a direct stabilization technique used for surgical treatment of high-grade (III-IV) L5-S1 spondylolisthesis. It has not been used for nonspondylolisthetic cases or in combination with an interbody cage (IC). This study aimed to develop a novel, direct S1-L5 sacrolumbar interbody fusion (SLIF) technique, a combination of IC and sacrolumbar transdiscal screw. Methods: SLIF was tested in cadaveric, clinical, and finite element analysis settings. Three cadaveric lumbar spines were used to test the SLIF procedure before clinical application. Eight patients underwent the SLIF procedure. Clinical outcomes were evaluated by visual analog score for leg and back pain, short form 36, Oswestry disability index, and neurological examination. CT scans of the lumbar spine were used to assess the hardware placement and subsequent fusion. Finite element analysis was performed on a healthy human CT-based L5-S1 model. Intact segment, unilateral facetectomy and discectomy, SLIF, and transforaminal lumbar interbody fusion (TLIF) procedures were compared in terms of the range of motion (ROM), von Mises stress on hardware, and shear-induced directional deformity. Additionally, the same set of tests were conducted in an osteoporotic model. Results: Excellent hardware placement was feasible in three cadavers and eight patients. Preoperative neurological deficits improved in all patients. Statistically significant improvements were obtained on all self-reported questionnaire scores. All patients developed solid, Bridwell grade I fusions. Biomechanical testing revealed similar outcomes for TLIF and SLIF regarding the ROM. However, the screw's von Mises stress and shear-induced directional deformity were low for SLIF of healthy and osteoporotic bone. Conclusions: SLIF is a feasible, safe, and effective L5-S1 fusion option suitable for all clinical scenarios. It provides several biomechanical advantages, yielding excellent clinical outcomes.

Copy number variations contribute to malignant tumor development in children with serious birth defects.

There are two key signatures of pediatric cancers: (a) higher prevalence of germline alterations and (b) heterogeneity in alteration types. Recent population-based assessments have demonstrated that children with birth defects (BDs) are more likely to develop cancer even without chromosomal anomalies; therefore, explorations of genetic alterations in children with BDs and cancers could provide new insights into the underlying mechanisms for pediatric tumor development. We performed whole-genome sequencing (WGS) on blood-derived DNA for 1556 individuals without chromosomal anomalies, including 454 BD probands with at least one type of malignant tumor, 757 cancer-free children with BDs, and 345 healthy individuals, focusing on copy number variation (CNV) analysis. Roughly half of the children with BD-cancer have CNVs that are not identified in BD-only/healthy individuals, and CNVs are not evenly distributed among these patients. Strong heterogeneity was observed, with a limited number of cancer predisposition genes containing CNVs in more than three patients. Moreover, functional enrichments of genes with CNVs showed that dozens of patients have variations related to the same biological pathways, such as deletions of genes with neurological functions and duplications of immune response genes. Phenotype clustering uncovered recurrences of patients with sarcoma: A notable enrichment was observed involving non-coding RNA regulators, showing strong signals related to growth and cancer regulations in functional analysis. In conclusion, we conducted one of the first genomic studies exploring the impact of CNVs on cancer development in children with BDs, unveiling new insights into the underlying biological processes.

Protocol for the Development and Initial Validation of the COG-IMPACT Tool: A Purpose-Built Unmet Needs Assessment for Cancer-Related Cognitive Impairment.

(1) Background: A significant proportion of cancer survivors report experiencing a cognitive 'fog' that affects their ability to think coherently and quickly, and reason with clarity. This has been referred to as cancer-related cognitive impairment (CRCI). CRCI has extensive impacts on the daily lives of people living with or beyond cancer, including occupational, social, and psychological functioning. Oncology health professionals report feeling under-resourced to effectively assess the needs of an individual with CRCI and then provide optimal care and referral. (2) Methods: The objective of this project is to develop and provide an initial validation of the first purpose-built unmet needs assessment for CRCI: the Unmet Needs Assessment of Cancer-Related Cognitive Impairment Impact (COG-IMPACT). We will use a multiple-stage, co-design, mixed-methods approach to develop and provide an initial validation of the COG-IMPACT. (3) Results: The primary anticipated result of this research is the production of the COG-IMPACT, the first purpose-built unmet needs assessment for CRCI. The assessment could be used by health professionals to understand the unmet needs and facilitate optimal care and referral for cancer survivors, by survivors to elucidate their supportive needs and advocate for their care, and by researchers to examine the correlates of unmet needs relating to CRCI, as well as how best to support people with CRCI.

It's about time: mitigating cancer-related cognitive impairments through findings from computational models of the Wisconsin Card Sorting Task.

BACKGROUND: Many cancer survivors experience cancer-related cognitive impairment (CRCI), often with significant negative consequences across various life domains. Emerging evidence suggests that allowing additional time to process information before acting may be a useful strategy for those with CRCI to mitigate some of its impacts. The Wisconsin Card Sorting Task (WCST), a measure of general cognition, has shown that for some cancer survivors, longer task completion time facilitates similar task performance outcomes to control populations concerning perseveration errors; a key performance metric of the WCST. However, assessing if this strategy may be useful, as well as determining for whom it may be useful, with regard to strengths and weaknesses among select cognitive domains, is challenging due to factors such as the problem of task impurity. Accordingly, this study provides an initial computational and experimental assessment of whether additional time to process information before acting is a useful strategy for those with CRCI. METHODS: We simulated individual cognitive differences observed in humans by varying contributions of executive functioning components (updating, shifting, inhibition) to yield 48 distinct computational models of the WCST. Our main manipulation was then to provide these models with more or less time (at three levels of 20, 40 and 60 cycles) before models executed an action to sort a given card. We compared the number of perseveration errors on the WCST produced by the computational models. Additionally, we determined models that simulated the performance of cancer survivors on the WCST by comparing the number of perseveration errors produced by the models to human data. RESULTS: Additional processing time resulted in the models producing significantly fewer perseveration errors, supporting our hypothesis. In addition, 8 unique models simulated the performance of cancer survivors on the WCST. Additional time appeared to have a positive influence on performance primarily by mitigating the impacts of severe inhibition impairments. For more severe global executive function impairments, a substantial amount of additional time was required to mitigate the impacts of the impairments. For the most severe impairments, additional time was unable to adequately mitigate the impact on performance. CONCLUSION: Additional processing time may be a useful strategy to rectify perseveration errors among cancer survivors with CRCI. Our findings have implications for the development of practical strategies, such as workload and deadline management in occupational settings, which may mitigate the negative effects of CRCI.

Endoscopic-Assisted Presigmoid Approach to the Internal Auditory Canal. A Feasibility Study.

HYPOTHESIS: The retrolabyrinthine (presigmoid) approach has been utilized in various skull base surgeries but has not been fully utilized in the management of internal auditory canal (IAC) lesions, such as vestibular schwannoma (VS). Microsurgical retrolabyrinthine approach provides limited visualization of the IAC, while endoscopic-assisted techniques allow for further lateral exposure with labyrinthine preservation. BACKGROUND: Traditional approaches to the IAC have the disadvantage of hearing sacrifice or retraction of brain tissue. With the introduction of endoscopic techniques and enhanced visualization, access to this region of complex anatomy is possible. METHODS: Radiomorphometric and anatomical dissection was performed on two cadaveric temporal bones. High-resolution computed tomography was used to segment and delineate the volume of the IAC. Projected accessible IAC was compared to actual postdissection data with preservation of the posterior semicircular canal (PSCC) via the retrolabyrinthine corridor. RESULTS: While preserving the PSCC, the 0° and 30° endoscopes visualized 57.1% and 78.6% of the IAC for cadaver 1, and 64.0% and 76.0% of the IAC for cadaver 2, respectively. Sacrificing the PSCC, the 0° and 30° endoscopes provided visualization of 78.6% 85.7% of the IAC for cadaver 1, and 88.0% and 95.1% of the IAC for cadaver 2, respectively. CONCLUSIONS: Retrolabyrinthine approach to resection of VS is a potentially viable hearing-preserving alternative to traditional approaches. This approach provides access to the majority of the IAC, while angled endoscopes or sacrifice of the PSCC can provide additional access toward the fundus. Further studies are needed to determine the clinical feasibility of this approach.

Reconceptualizing mental health in cancer survivorship.

Mental health for cancer survivors in both research and clinical applications has strongly adopted a traditional nosological approach, involving the classification of psychopathology into discrete disorders. However, this approach has recently faced considerable criticism due to issues such as high comorbidity and within-disorder symptom heterogeneity across populations. Moreover, there are additional specific issues impacting the validity of traditional approaches in cancer survivorship populations, including the physiological effects of cancer and its treatments. In response, we provide the case for the hierarchical dimensional approach within psycho-oncology, in particular the Hierarchical Taxonomy of Psychopathology (HiTOP). We discuss not only the potential utility of HiTOP to research and clinical applications within psycho-oncology, but also its limitations, and what is required to apply this approach within cancer survivorship.

CD163+ Macrophages Induce Endothelial-to-Mesenchymal Transition in Atheroma.

BACKGROUND: Cell phenotype switching is increasingly being recognized in atherosclerosis. However, our understanding of the exact stimuli for such cellular transformations and their significance for human atherosclerosis is still evolving. Intraplaque hemorrhage is thought to be a major contributor to plaque progression in part by stimulating the influx of CD163+ macrophages. Here, we explored the hypothesis that CD163+ macrophages cause plaque progression through the induction of proapoptotic endothelial-to-mesenchymal transition (EndMT) within the fibrous cap. METHODS: Human coronary artery sections from CVPath's autopsy registry were selected for pathological analysis. Athero-prone ApoE-/- and ApoE-/-/CD163-/- mice were used for in vivo studies. Human peripheral blood mononuclear cell-induced macrophages and human aortic endothelial cells were used for in vitro experiments. RESULTS: In 107 lesions with acute coronary plaque rupture, 55% had pathological evidence of intraplaque hemorrhage in nonculprit vessels/lesions. Thinner fibrous cap, greater CD163+ macrophage accumulation, and a larger number of CD31/FSP-1 (fibroblast specific protein-1) double-positive cells and TUNEL (terminal deoxynucleotidyl transferase-dUTP nick end labeling) positive cells in the fibrous cap were observed in nonculprit intraplaque hemorrhage lesions, as well as in culprit rupture sections versus nonculprit fibroatheroma sections. Human aortic endothelial cells cultured with supernatants from hemoglobin/haptoglobin-exposed macrophages showed that increased mesenchymal marker proteins (transgelin and FSP-1) while endothelial markers (VE-cadherin and CD31) were reduced, suggesting EndMT induction. Activation of NF-κB (nuclear factor kappa ß) signaling by proinflammatory cytokines released from CD163+ macrophages directly regulated the expression of Snail, a critical transcription factor during EndMT induction. Western blot analysis for cleaved caspase-3 and microarray analysis of human aortic endothelial cells indicated that apoptosis was stimulated during CD163+ macrophage-induced EndMT. Additionally, CD163 deletion in athero-prone mice suggested that CD163 is required for EndMT and plaque progression. Using single-cell RNA sequencing from human carotid endarterectomy lesions, a population of EndMT was detected, which demonstrated significant upregulation of apoptosis-related genes. CONCLUSIONS: CD163+ macrophages provoke EndMT, which may promote plaque progression through fibrous cap thinning.

ICH S1 prospective evaluation study and weight of evidence assessments: commentary from industry representatives.

Industry representatives on the ICH S1B(R1) Expert Working Group (EWG) worked closely with colleagues from the Drug Regulatory Authorities to develop an addendum to the ICH S1B guideline on carcinogenicity studies that allows for a weight-of-evidence (WoE) carcinogenicity assessment in some cases, rather than conducting a 2-year rat carcinogenicity study. A subgroup of the EWG composed of regulators have published in this issue a detailed analysis of the Prospective Evaluation Study (PES) conducted under the auspices of the ICH S1B(R1) EWG. Based on the experience gained through the Prospective Evaluation Study (PES) process, industry members of the EWG have prepared the following commentary to aid sponsors in assessing the standard WoE factors, considering how novel investigative approaches may be used to support a WoE assessment, and preparing appropriate documentation of the WoE assessment for presentation to regulatory authorities. The commentary also reviews some of the implementation challenges sponsors must consider in developing a carcinogenicity assessment strategy. Finally, case examples drawn from previously marketed products are provided as a supplement to this commentary to provide additional examples of how WoE criteria may be applied. The information and opinions expressed in this commentary are aimed at increasing the quality of WoE assessments to ensure the successful implementation of this approach.

Genetic, epigenetic and environmental factors in diverticular disease: systematic review.

BACKGROUND: Diverticulosis is a normal anatomical variant of the colon present in more than 70% of the westernized population over the age of 80. Approximately 3% will develop diverticulitis in their lifetime. Many patients present emergently, suffer high morbidity rates and require substantial healthcare resources. Diverticulosis is the most common finding at colonoscopy and has the potential for causing a significant morbidity rate and burden on healthcare. There is a need to better understand the aetiology and pathogenesis of diverticular disease. Research suggests a genetic susceptibility of 40-50% in the formation of diverticular disease. The aim of this review is to present the hypothesized functional effects of the identified gene loci and environmental factors. METHODS: A systematic literature review was performed using PubMed, MEDLINE and Embase. Medical subject headings terms used were: 'diverticular disease, diverticulosis, diverticulitis, genomics, genetics and epigenetics'. A review of grey literature identified environmental factors. RESULTS: Of 995 articles identified, 59 articles met the inclusion criteria. Age, obesity and smoking are strongly associated environmental risk factors. Intrinsic factors of the colonic wall are associated with the presence of diverticula. Genetic pathways of interest and environmental risk factors were identified. The COLQ, FAM155A, PHGR1, ARHGAP15, S100A10, and TNFSF15 genes are the strongest candidates for further research. CONCLUSION: There is increasing evidence to support the role of genomics in the spectrum of diverticular disease. Genomic, epigenetic and omic research with demographic context will help improve the understanding and management of this complex disease.

Is it time to discard the Diagnostic and Statistical Manual of Mental Disorders (DSM) in psycho-oncology?

The conceptual basis of psychopathology within cancer survivorship is critical, as the chosen conceptualisation informs assessment and explanatory models, as well as interventions and supportive care approaches. The validity of a chosen conceptualisation of psychopathology is therefore paramount for ensuring cancer survivors receive high-quality and efficacious care and support that can be iteratively improved via coordinated research efforts. In this paper, we discuss the traditional diagnostic approach to conceptualising psychopathology within cancer care, including the diagnostic system the 'Diagnostic and Statistical Manual of Mental Disorders' (DSM) [1], and the significant issues it presents within cancer survivorship. We detail and discuss how an alternate conceptualisation of psychopathology may enhance both research and practice within psycho-oncology. We ultimately pose, and provide our perspective, on the question "Is it Time to Discard the DSM in Psycho-Oncology?"

Understanding chronic pain in Neurofibromatosis Type 1 using the Neurofibromatosis Pain Module (NFPM).

Neurofibromatosis Type 1 (NF1) is an autosomal dominant genetic disorder that can cause an individual significant chronic pain (CP). CP affects quality of life and daily functioning, yet there are limited effective treatments for CP within NF1. The current study describes the impact of CP using the Neurofibromatosis Pain Module (NFPM). The NFPM is a self-reported clinical assessment that evaluates the impact of CP across multiple domains (e.g., interference, severity, tolerance, and symptomology) and three prioritized pain regions. A cross-sectional study (N = 242) asked adults with NF1 to describe and rate their pain using the NFPM. The results indicated that they reported moderate pain severity (M = 6.6, SD = 2.0) on a 0-10 scale, that 54% (n = 131) had been in pain at least 24 days in the last 30, for 75% (n = 181) sleep was affected, and 16% reported that nothing was effective in reducing their CP for their primary pain region. The current results extend previously published work on CP within adults with NF1 and indicate that more emphasis on understanding and ameliorating CP is required. The NFPM is a sensitive clinical measure that provides qualitative and quantitative responses to inform medical providers about changes in CP.

High Comorbidity of Pediatric Cancers in Patients with Birth Defects: Insights from Whole Genome Sequencing Analysis of Copy Number Variations.

BACKGROUND: Patients with birth defects (BD) exhibit an elevated risk of cancer. We aimed to investigate the potential link between pediatric cancers and BDs, exploring the hypothesis of shared genetic defects contributing to the coexistence of these conditions. METHODS: This study included 1454 probands with BDs (704 females and 750 males), including 619 (42.3%) with and 845 (57.7%) without co-occurrence of pediatric onset cancers. Whole genome sequencing (WGS) was done at 30X coverage through the Kids First/Gabriella Miller X01 Program. RESULTS: 8211 CNV loci were called from the 1454 unrelated individuals. 191 CNV loci classified as pathogenic/likely pathogenic (P/LP) were identified in 309 (21.3%) patients, with 124 (40.1%) of these patients having pediatric onset cancers. The most common group of CNVs are pathogenic deletions covering the region ChrX:52,863,011-55,652,521, seen in 162 patients including 17 males. Large recurrent P/LP duplications >5MB were detected in 33 patients. CONCLUSIONS: This study revealed that P/LP CNVs were common in a large cohort of BD patients with high rate of pediatric cancers. We present a comprehensive spectrum of P/LP CNVs in patients with BDs and various cancers. Notably, deletions involving E2F target genes and genes implicated in mitotic spindle assembly and G2/M checkpoint were identified, potentially disrupting cell-cycle progression and providing mechanistic insights into the concurrent occurrence of BDs and cancers.

Recommendations for assessing appearance concerns related to plexiform and cutaneous neurofibromas in neurofibromatosis 1 clinical trials.

BACKGROUND/AIMS: Individuals with neurofibromatosis 1 may experience changes in their appearance due to physical manifestations of the disorders and/or treatment sequelae. Appearance concerns related to these physical changes can lead to psychological distress and poorer quality of life. While many neurofibromatosis 1 clinical trials focus on assessing changes in tumor volume, evaluating patients' perspectives on corresponding changes in symptoms such as physical appearance can be key secondary outcomes. We aimed to determine whether any existing patient-reported outcome measures are appropriate for evaluating changes in appearance concerns within neurofibromatosis 1 clinical trials. METHODS: After updating our previously published systematic review process, we used it to identify and rate existing patient-reported outcome measures related to disfigurement and appearance. Using a systematic literature search and initial triage process, we focused on identifying patient-reported outcome measures that could be used to evaluate changes in appearance concerns in plexiform or cutaneous neurofibroma clinical trials in neurofibromatosis 1. Our revised Patient-Reported Outcome Rating and Acceptance Tool for Endpoints then was used to evaluate each published patient-reported outcome measures in five domains, including (1) respondent characteristics, (2) content validity, (3) scoring format and interpretability, (4) psychometric data, and (5) feasibility. The highest-rated patient-reported outcome measures were then re-reviewed in a side-by-side comparison to generate a final consensus recommendation. RESULTS: Eleven measures assessing appearance concerns were reviewed and rated; no measures were explicitly designed to assess appearance concerns related to neurofibromatosis 1. The FACE-Q Craniofacial Module-Appearance Distress scale was the top-rated measure for potential use in neurofibromatosis 1 clinical trials. Strengths of the measure included that it was rigorously developed, included individuals with neurofibromatosis 1 in the validation sample, was applicable to children and adults, covered item topics deemed important by neurofibromatosis 1 patient representatives, exhibited good psychometric properties, and was feasible for use in neurofibromatosis 1 trials. Limitations included a lack of validation in older adults, no published information regarding sensitivity to change in clinical trials, and limited availability in languages other than English. CONCLUSION: The Response Evaluation in Neurofibromatosis and Schwannomatosis patient-reported outcome working group currently recommends the FACE-Q Craniofacial Module Appearance Distress scale to evaluate patient-reported changes in appearance concerns in clinical trials for neurofibromatosis 1-related plexiform or cutaneous neurofibromas. Additional research is needed to validate this measure in people with neurofibromatosis 1, including older adults and those with tumors in various body locations, and explore the effects of nontumor manifestations on appearance concerns in people with neurofibromatosis 1 and schwannomatosis.

"Is My Brain Ever Going to Work Fully Again?": Challenges and Needs of Cancer Survivors with Persistent Cancer-Related Cognitive Impairment.

Many cancer survivors experience cognitive impairments that impact memory, concentration, speed of information processing, and decision making. These impairments, collectively known as cancer-related cognitive impairments (CRCIs), are a key domain of unmet needs and can significantly impact a cancer survivor's identity and quality of life. However, there are no purpose-built, multi-domain, needs assessment tools specifically for CRCI. The development of such tools requires an in-depth understanding of cancer survivors' CRCI-specific challenges and associated needs. This study explored the challenges and associated needs of cancer survivors with persistent CRCI. An in-depth qualitative design using semi-structured interviews with (a) cancer survivors with perceived CRCI (n = 32) and (b) oncology health professionals (n = 19) was utilised. A reflexive thematic analysis of the interviews resulted in five overarching themes: (1) executing regular activities, (2) relational difficulties, (3) occupational functioning, (4) psychological distress, and (5) social functioning, as well as an additional informational needs domain. Ultimately, CRCI was found to directly produce a range of challenges that negatively, and persistently, impact cancer survivors' quality of life. Cancer survivors were also found to have a range of needs associated with these challenges. This research should be used to inform future challenges and needs assessment tools as well as treatment and supportive care priority areas directly relating to CRCI.

The impact of a dedicated social media strategy on enhancing surgical education.

PURPOSE: Social media (SoMe) is increasingly important in surgical education and may be necessary in the current learning environment. Whilst expanding in use and applications, few studies detail the impact of SoMe on measurable outcomes. The goal of this study was to quantify the impact of a dedicated SoMe strategy on engagement metrics for surgical research. METHODS: A retrospective review of a peer-reviewed surgical journal's Twitter microblog platform (@ColorectalDis) was performed from 6/2015 to 4/2021. A formal SoMe strategy was introduced in September 2018. Data were stratified into 2 time periods: pre-intervention (6-2015 to 9-2018) and post-SoMe intervention (9-2018 to 4-2021). The main outcome was the impact of the SoMe strategy on user engagement with the Twitter platform, journal, and traditional journal metrics. Twitter Analytics and Twitonomy were used to analyse engagement. RESULTS: From conception to analysis, the microblog published 1198 original tweets, generating 5 million impressions and 231,000 engagements. Increased account activity (increased tweets published per month-5.51 vs 28.79; p < 0.01) was associated with significant engagement growth, including new monthly followers (213 vs 38; p < 0.01) and interactions with posted articles (4,096,167 vs 269,152; p < 0.01). Article downloads increased twenty-fold post-SoMe intervention (210,449 vs 10,934; p < 0.01), with significant increases in traditional journal metrics of new subscribers (+11%), article submissions (+24%), and impact factor (+0.9) (all p < 0.01). CONCLUSION: SoMe directly impacts traditional journal metrics in surgical research. By examining the patterns of user engagement between SoMe and journal sites, the growing beneficial impact of a structured social media strategy and SoMe as an educational tool is demonstrated.

Exceptionally Mild and High-Yielding Synthesis of Vinyl Esters of Alpha-Ketocarboxylic Acids, Including Vinyl Pyruvate, for Parahydrogen-Enhanced Metabolic Spectroscopy and Imaging.

Metabolic changes often occur long before pathologies manifest and treatment becomes challenging. As key elements of energy metabolism, α-ketocarboxylic acids (α-KCA) are particularly interesting, e.g., as the upregulation of pyruvate to lactate conversion is a hallmark of cancer (Warburg effect). Magnetic resonance imaging with hyperpolarized metabolites has enabled imaging of this effect non-invasively and in vivo, allowing the early detection of cancerous tissue and its treatment. Hyperpolarization by means of dynamic nuclear polarization, however, is complex, slow, and expensive, while available precursors often limit parahydrogen-based alternatives. Here, we report the synthesis for novel 13C, deuterated ketocarboxylic acids, and a much-improved synthesis of 1-13C-vinyl pruvate-d6, arguably the most promising tracer for hyperpolarizing pyruvate using parahydrogen-induced hyperpolarization by side arm hydrogenation. The new synthesis is scalable and provides a high yield of 52%. We elucidated the mechanism of our Pd-catalyzed trans-vinylation reaction. Hydrogenation with parahydrogen allowed us to monitor the addition, which was found to depend on the electron demand of the vinyl ester. Electron-poor α-keto vinyl esters react slower than "normal" alkyl vinyl esters. This synthesis of 13C, deuterated α-ketocarboxylic acids opens up an entirely new class of biomolecules for fast and cost-efficient hyperpolarization with parahydrogen and their use for metabolic imaging.

Inflammatory Activity of Epithelial Stem Cell Variants from Cystic Fibrosis Lungs Is Not Resolved by CFTR Modulators.

Rationale: CFTR (cystic fibrosis transmembrane conductance regulator) modulator drugs restore function to mutant channels in patients with cystic fibrosis (CF) and lead to improvements in body mass index and lung function. Although it is anticipated that early childhood treatment with CFTR modulators will significantly delay or even prevent the onset of advanced lung disease, lung neutrophils and inflammatory cytokines remain high in patients with CF with established lung disease despite modulator therapy, underscoring the need to identify and ultimately target the sources of this inflammation in CF lungs. Objectives: To determine whether CF lungs, like chronic obstructive pulmonary disease (COPD) lungs, harbor potentially pathogenic stem cell "variants" distinct from the normal p63/Krt5 lung stem cells devoted to alveolar fates, to identify specific variants that might contribute to the inflammatory state of CF lungs, and to assess the impact of CFTR genetic complementation or CFTR modulators on the inflammatory variants identified herein. Methods: Stem cell cloning technology developed to resolve pathogenic stem cell heterogeneity in COPD and idiopathic pulmonary fibrosis lungs was applied to end-stage lungs of patients with CF (three homozygous CFTR:F508D, one CFTR F508D/L1254X; FEV1, 14-30%) undergoing therapeutic lung transplantation. Single-cell-derived clones corresponding to the six stem cell clusters resolved by single-cell RNA sequencing of these libraries were assessed by RNA sequencing and xenografting to monitor inflammation, fibrosis, and mucin secretion. The impact of CFTR activity on these variants after CFTR gene complementation or exposure to CFTR modulators was assessed by molecular and functional studies. Measurements and Main Results: End-stage CF lungs display a stem cell heterogeneity marked by five predominant variants in addition to the normal lung stem cell, of which three are proinflammatory both at the level of gene expression and their ability to drive neutrophilic inflammation in xenografts in immunodeficient mice. The proinflammatory functions of these three variants were unallayed by genetic or pharmacological restoration of CFTR activity. Conclusions: The emergence of three proinflammatory stem cell variants in CF lungs may contribute to the persistence of lung inflammation in patients with CF with advanced disease undergoing CFTR modulator therapy.

Genomic variants exclusively identified in children with birth defects and concurrent malignant tumors predispose to cancer development.

Children with birth defects (BD) express distinct clinical features that often have various medical consequences, one of which is predisposition to the development of cancers. Identification of the underlying genetic mechanisms related to the development of cancer in BD patients would allow for preventive measures. We performed a whole genome sequencing (WGS) study on blood-derived DNA samples from 1566 individuals without chromosomal anomalies, including 454 BD probands with at least one type of malignant tumors, 767 cancer-free BD probands, and 345 healthy individuals. Exclusive recurrent variants were identified in BD-cancer and BD-only patients and mapped to their corresponding genomic regions. We observed statistically significant overlaps for protein-coding/ncRNA with exclusive variants in exons, introns, ncRNAs, and 3'UTR regions. Exclusive exonic variants, especially synonymous variants, tend to occur in prior exons locus in BD-cancer children. Intronic variants close to splicing site (< 500 bp from exon) have little overlaps in BD-cancer and BD-only patients. Exonic variants in non-coding RNA (ncRNA) tend to occur in different ncRNAs exons regardless of the overlaps. Notably, genes with 5' UTR variants are almost mutually exclusive between the two phenotypes. In conclusion, we conducted the first genomic study to explore the impact of recurrent variants exclusive to the two distinguished clinical phenotypes under study, BD with or without cancer, demonstrating enrichment of selective protein-coding/ncRNAs differentially expressed between these two phenotypes, suggesting that selective genetic factors may underlie the molecular processes of pediatric cancer development in BD children.