Experiences of hereditary cancer care among transgender and gender diverse people: "It's gender. It's cancer risk it's everything".

Transgender and gender diverse (TGD) individuals are a significant yet underrepresented population within genetic counseling research and broader LGBTQI+ health studies. This underrepresentation perpetuates a cycle of exclusion from the production of medical knowledge, impacting the quality and equity of care received by TGD individuals. This issue is particularly poignant in cancer genetic counseling, where TGD individuals with elevated cancer risk receive risk assessment, counseling, and referral to support based on risk figures and standards of care developed for cisgender individuals. The experiences of TGD individuals navigating inherited cancer syndromes remain largely undocumented in medical literature, posing challenges to the provision of inclusive care by genetics providers. To bridge this knowledge gap, we conducted a cross-sectional qualitative study. Nineteen semi-structured interviews were held with gender diverse adults having hereditary cancer syndromes, family histories of such syndromes, or personal histories of chest cancer. Our study employed thematic analysis using combined inductive and deductive methods to illuminate how hereditary cancer care intersects with participants' gender identities, gender expression, and gender-affirming care experiences. Participants reflected on care experiences that felt affirming or triggered gender dysphoria. Participants also discussed the interplay between risk-reducing mastectomy and top surgery, exploring co-emergent dynamics between cancer risk management and gender expression. Significantly, participants identified actionable strategies for healthcare providers to enhance support for gender diverse patients, including the mindful use of gendered language, collaborative decision-making, and conveying allyship. These findings offer valuable insights into tailoring genetic counseling to meet the unique needs of TGD individuals, advancing the path toward inclusive and appropriate care for LGBTQI+ individuals with hereditary cancer syndromes.

Circulating cell-free methylated DNA reveals tissue-specific, cellular damage from radiation treatment.

Radiation therapy is an effective cancer treatment, although damage to healthy tissues is common. Here we analyzed cell-free, methylated DNA released from dying cells into the circulation to evaluate radiation-induced cellular damage in different tissues. To map the circulating DNA fragments to human and mouse tissues, we established sequencing-based, cell-type-specific reference DNA methylation atlases. We found that cell-type-specific DNA blocks were mostly hypomethylated and located within signature genes of cellular identity. Cell-free DNA fragments were captured from serum samples by hybridization to CpG-rich DNA panels and mapped to the DNA methylation atlases. In a mouse model, thoracic radiation-induced tissue damage was reflected by dose-dependent increases in lung endothelial and cardiomyocyte methylated DNA in serum. The analysis of serum samples from patients with breast cancer undergoing radiation treatment revealed distinct dose-dependent and tissue-specific epithelial and endothelial responses to radiation across multiple organs. Strikingly, patients treated for right-sided breast cancers also showed increased hepatocyte and liver endothelial DNA in the circulation, indicating the impact on liver tissues. Thus, changes in cell-free methylated DNA can uncover cell-type-specific effects of radiation and provide a readout of the biologically effective radiation dose received by healthy tissues.

Evaluation of an Integrated Intervention to Address Clinical Care and Social Needs Among Patients with Type 2 Diabetes.

BACKGROUND: The Providence Diabetes Collective Impact Initiative (DCII) was designed to address the clinical challenges of type 2 diabetes and the social determinants of health (SDoH) challenges that exacerbate disease impact. OBJECTIVE: We assessed the impact of the DCII, a multifaceted intervention approach to diabetes treatment that employed both clinical and SDoH strategies, on access to medical and social services. DESIGN: The evaluation employed a cohort design and used an adjusted difference-in-difference model to compare treatment and control groups. PARTICIPANTS: Our study population consisted of 1220 people (740 treatment, 480 control), aged 18-65 years old with a pre-existing type 2 diabetes diagnosis who visited one of the seven Providence clinics (three treatment and four control) in the tri-county area of Portland, Oregon, between August 2019 and November 2020. INTERVENTIONS: The DCII threaded together clinical approaches such as outreach, standardized protocols, and diabetes self-management education and SDoH strategies including social needs screening, referral to a community resource desk, and social needs support (e.g., transportation) to create a comprehensive, multi-sector intervention. MAIN MEASURES: Outcome measures included SDoH screens, diabetes education participation, HbA1c, blood pressure, and virtual and in-person primary care utilization, as well as inpatient and emergency department hospitalization. KEY RESULTS: Compared to patients at the control clinics, patients at DCII clinics saw an increase in diabetes education (15.5%, p<0.001), were modestly more likely to receive SDoH screening (4.4%, p<0.087), and had an increase in the average number of virtual primary care visits of 0.35 per member, per year (p<0.001). No differences in HbA1c, blood pressure, or hospitalization were observed. CONCLUSIONS: DCII participation was associated with improvements in diabetes education use, SDoH screening, and some measures of care utilization.

Health care workers' perspectives on care for patients with injection drug use associated infective endocarditis (IDU-IE).

BACKGROUND: Despite high morbidity and mortality, patients with injection drug use associated infective endocarditis (IDU-IE) lack standardized care, and experience prolonged hospitalization and variable substance use disorder (SUD) management. Our study's objective was to elicit perspectives of health care workers (HCWs) who deliver care to this population by understanding their perceived patient, provider, and system-level resources and barriers. METHODS: This qualitative study included interviews of HCWs providing care to patients with IDU-IE from January 2017 to December 2019 at a single Midwest academic center. Based on electronic medical record queries to determine high and low rates of referral to SUD treatment, HCWs were selected using stratified random sampling followed by convenience sampling of non-physician HCWs and a patient. Study participants were recruited via email and verbal consent was obtained. The final sample included 11 hospitalists, 3 specialists (including 2 cardiovascular surgery providers), 3 case managers, 2 social workers, 1 nurse, and 1 patient. Qualitative semi-structured interviews explored challenges and resources related to caring for this population. Qualitative Data Analysis (QDA) Minor Lite was used for thematic data using an inductive approach. RESULTS: Three major thematic categories emerged relative to patient-level barriers (e.g., pain control, difficult patient interactions, social determinants of health), provider-level barriers (e.g., inequity, expectations for recovery, varying levels of hope, communication style, prescribing medication for SUD), and system-level barriers (e.g., repeat surgery, placement, resources for SUD and mental health). The need to address underlying SUD was a prominent theme. CONCLUSION: Practical steps we can take to improve treatment for this population include training and coaching HCWs on a more person-centered approach to communication and transparent decision-making around pain management, surgery decisions, and expectations for SUD treatment.

A Retrospective Analysis of Sacroiliac Joint Pain Interventions: Intraarticular Steroid Injection and Lateral Branch Radiofrequency Neurotomy.

BACKGROUND: Sacroiliac joint (SIJ) pain is a common etiology of chronic lower back pain. Treatment of persistent sacroiliac joint pain may entail intraarticular steroid injections and lateral branch radiofrequency neurotomy. OBJECTIVES: This study evaluates the efficacy of SIJ intervention treatments by comparing intraarticular steroid injections with lateral branch radiofrequency neurotomy. STUDY DESIGN: Retrospective cohort study. SETTING: We reviewed electronic medical records of patients with SIJ pain at Massachusetts General Hospital from 2006  through 2016 and identified 354 patients who received 930 SIJ intraarticular  injections and 19 patients who received 41 SIJ lateral branch radiofrequency neurotomies. METHODS: The Numeric Rating Scale (NRS) score for pain and the Eastern Cooperative Oncology Group (ECOG) Performance Status were measured prior to intervention and on follow-up. A mixed effects model was used to evaluate the duration of treatment effect. RESULTS: Patients who received an SIJ intraarticular steroid injection reported lower pain scores following treatment with a mean (standard deviation) NRS reduction from 6.77 (2.25) to 2.72 (2.81). SIJ lateral branch radiofrequency neurotomy resulted in NRS reduction from 5.96 (2.39) to 3.54 (3.14). A linear mixed model analysis suggests SIJ intraarticular steroid injections provided an estimated mean (CI 95%) of 38 (30-46.3) days of pain relief. Lateral branch radiofrequency neurotomy provided 82 (39.4-124.8) days of pain relief. The mean preprocedure ECOG score was 1.22 for both interventions and trended toward improvement with a post SIJ intraarticular injection score of 1.05 and SIJ lateral branch radiofrequency neurotomy score of 1.03. LIMITATIONS: There was variable follow-up reporting among patients. The small size of the lateral branch radiofrequency cohort limited intergroup comparisons. CONCLUSION: Both SIJ intraarticular steroid injections and SIJ lateral branch radiofrequency neurotomy demonstrated significant pain relief for patients with SIJ pain. SIJ lateral branch radiofrequency neurotomy provided a longer duration of pain relief (82 days) versus SIJ intraarticular steroid injection (38 days).

N6-Methyladenine in Eukaryotic DNA: Tissue Distribution, Early Embryo Development, and Neuronal Toxicity.

DNA methylation is one of the most important epigenetic modifications and is closely related with several biological processes such as regulation of gene transcription and the development of non-malignant diseases. The prevailing dogma states that DNA methylation in eukaryotes occurs essentially through 5-methylcytosine (5mC) but recently adenine methylation was also found to be present in eukaryotes. In mouse embryonic stem cells, 6-methyladenine (6mA) was associated with the repression and silencing of genes, particularly in the X-chromosome, known to play an important role in cell fate determination. Here, we have demonstrated that 6mA is a ubiquitous eukaryotic epigenetic modification that is put in place during epigenetically sensitive periods such as embryogenesis and fetal development. In somatic cells there are clear tissue specificity in 6mA levels, with the highest 6mA levels being observed in the brain. In zebrafish, during the first 120 h of embryo development, from a single pluripotent cell to an almost fully formed individual, 6mA levels steadily increase. An identical pattern was observed over embryonic days 7-21 in the mouse. Furthermore, exposure to a neurotoxic environmental pollutant during the same early life period may led to a decrease in the levels of this modification in female rats. The identification of the periods during which 6mA epigenetic marks are put in place increases our understanding of this mammalian epigenetic modification, and raises the possibility that it may be associated with developmental processes.

Cancer Cell Invasion and Metastasis in Zebrafish Models (Danio rerio).

Cancer cell vascular invasion and extravasation at metastatic sites are hallmarks of malignant progression of cancer and associated with poor disease outcome. Here we describe an in vivo approach to study the invasive ability of cancer cells into the vasculature and their hematogenous metastatic seeding in zebrafish (Danio rerio). In one approach, extravasation of fluorescently labeled cancer cells is monitored in zebrafish embryos whose vasculature is marked by a contrasting fluorescent reporter. After injection into the precardiac sinus of 2-day-old embryos, cancer cells can extravasate from the vasculature into tissues over the next few days. Extravasated cancer cells are identified and counted in live embryos via fluorescence microscopy. In a second approach, intravasation of cancer cells can be evaluated by changing their injection site to the yolk sac of zebrafish embryos. In addition to monitoring the impact of drivers of malignant progression, candidate inhibitors can be studied in this in vivo model system for their efficacy as well as their toxicity for the host.

Cardiomyocyte-specific circulating cell-free methylated DNA in esophageal cancer patients treated with chemoradiation.

Thoracic high dose radiation therapy (RT) for cancer has been associated with early and late cardiac toxicity. To assess altered rates of cardiomyocyte cell death due to RT we monitored changes in cardiomyocyte-specific, cell-free methylated DNA (cfDNA) shed into the circulation. Eleven patients with distal esophageal cancer treated with neoadjuvant chemoradiation to 50.4 Gy (RT) and concurrent carboplatin and paclitaxel were enrolled. Subjects underwent fasting blood draws prior to the initiation and after completion of RT as well as 4-6 months following RT. An island of six unmethylated CpGs in the FAM101A locus was used to identify cardiomyocyte-specific cfDNA in serum. After bisulfite treatment this specific cfDNA was quantified by amplicon sequencing at a depth of >35,000 reads/molecule. Cardiomyocyte-specific cfDNA was detectable before RT in the majority of patient samples and showed some distinct changes during the course of treatment and recovery. We propose that patient-specific cardiac damages in response to the treatment are indicated by these changes although co-morbidities may obscure treatment-specific events.

MicroRNA-193b-3p represses neuroblastoma cell growth via downregulation of Cyclin D1, MCL-1 and MYCN.

Neuroblastoma is the most common diagnosed tumor in infants and the second most common extracranial tumor of childhood. The survival rate of patients with high-risk neuroblastoma is still very low despite intensive multimodal treatments. Therefore, new treatment strategies are needed. In recent years, miRNA-based anticancer therapy has received growing attention. Advances in this novel treatment strategy strongly depends on the identification of candidate miRNAs with broad-spectrum antitumor activity. Here, we identify miR-193b as a miRNA with tumor suppressive properties. We show that miR-193b is expressed at low levels in neuroblastoma cell lines and primary tumor samples. Introduction of miR-193b mimics into nine neuroblastoma cell lines with distinct genetic characteristics significantly reduces cell growth in vitro independent of risk factors such as p53 functionality or MYCN amplification. Functionally, miR-193b induces a G1 cell cycle arrest and cell death in neuroblastoma cell lines by reducing the expression of MYCN, Cyclin D1 and MCL-1, three important oncogenes in neuroblastoma of which inhibition has shown promising results in preclinical testing. Therefore, we suggest that miR-193b may represent a new candidate for miRNA-based anticancer therapy in neuroblastoma.

Ultrasmall Superparamagnetic Iron Oxide Imaging Identifies Tissue and Nerve Inflammation in Pain Conditions.

Objective: Correlation between radiologic structural abnormalities and clinical symptoms in low back pain patients is poor. There is an unmet clinical need to image inflammation in pain conditions to aid diagnosis and guide treatment. Ferumoxytol, an ultrasmall superparamagnetic iron oxide (USPIO) nanoparticle, is clinically used to treat iron deficiency anemia and showed promise in imaging tissue inflammation in human. We explored whether ferumoxytol can be used to identify tissue and nerve inflammation in pain conditions in animals and humans. Methods: Complete Freud's adjuvant (CFA) or saline was injected into mice hind paws to establish an inflammatory pain model. Ferumoxytol (20 mg/kg) was injected intravenously. Magnetic resonance imaging (MRI) was performed prior to injection and 72 hours postinjection. The changes in the transverse relaxation time (T2) before and after ferumoxytol injection were compared between mice that received CFA vs saline injection. In the human study, we administered ferumoxytol (4 mg/kg) to a human subject with clinical symptoms of lumbar radiculopathy and compared the patient with a healthy subject. Results: Mice that received CFA exhibited tissue inflammation and pain behaviors. The changes in T2 before and after ferumoxytol injection were significantly higher in mice that received CFA vs saline (20.8 ± 3.6 vs 2.2 ± 2.5, P = 0.005). In the human study, ferumoxytol-enhanced MRI identified the nerve root corresponding to the patient's symptoms, but the nerve root was not impinged by structural abnormalities, suggesting the potential superiority of this approach over conventional structural imaging techniques. Conclusions: Ferumoxytol-enhanced MRI can identify tissue and nerve inflammation and may provide a promising diagnostic tool in assessing pain conditions in humans.

The Fit Family Challenge: A Primary Care Childhood Obesity Pilot Intervention.

BACKGROUND: Childhood obesity has increased dramatically over several decades, and the American Academy of Pediatrics has recommended primary care practices as ideal sites for the identification, education, and implementation of therapeutic interventions. The objective of this study was to describe the implementation and results for the Fit Family Challenge (FFC), a primary care-based childhood obesity intervention. METHODS: A single-intervention pilot project that trains primary care practices on childhood obesity guidelines and implementation of a family-focused behavior modification curriculum. A total of 29 family medicine and pediatric community practices in Colorado participated. Participants included 290 patients, aged 6 to 12 years, with a body mass index (BMI) above the 85th percentile. The main outcome measure included the feasibility of implementation of a childhood obesity program in primary care; secondary outcomes were changes in BMI percentile, BMI z-scores, blood pressure, and changes in lifestyle factors related to childhood obesity. RESULTS: Implementation of FFC is feasible, statically significant changes were seen for decreases in BMI percentile and BMI z-scores for participants who completed 9 to 15 months of follow-up; lifestyle factors related to childhood obesity in proved Spanish-speaking families and food insecurity were associated with less follow-up time (P < .01). CONCLUSIONS: A primary care-based childhood obesity intervention may result in significant clinical and lifestyle changes.

Next generation sequencing of microRNAs from isogenic neuroblastoma cell lines isolated before and after treatment.

Neuroblastoma is a pediatric cancer of the developing sympathetic nervous system. High risk neuroblastoma patients typically undergo an initial remission in response to treatment, followed by recurrence of aggressive tumors that have become refractory to further treatment. Recent works have underlined the involvement of microRNAs (miRNAs) in neuroblastoma development and evolution of drug resistance. In this study we have used deep sequencing technology to identify miRNAs differentially expressed in neuroblastoma cell lines isolated from 6 patients at diagnosis and at relapse after intensive treatments. This approach revealed a panel of 42 differentially expressed miRNAs, 8 of which were upregulated and 34 were downregulated. Most strikingly, the 14q32 miRNA clusters encode 22 of the downregulated miRNAs. Reduced expression of 14q32 miRNAs in tumors associated with poor prognosis factors was confirmed in a cohort consisting of 226 primary neuroblastomas. In order to gain insight into the nature of the genes that may be affected by the differentially expressed miRNAs we utilized Ingenuity Pathway Analysis (IPA). This analysis revealed several biological functions and canonical pathways associated with cancer progression and drug resistance. The results of this study contribute to the identification of miRNAs involved in the complex processes of surviving therapeutic treatment and developing drug resistance in neuroblastoma.

Exosome-like Extracellular Vesicles from MYCN-amplified Neuroblastoma Cells Contain Oncogenic miRNAs.

BACKGROUND: In recent years, evidence has accumulated indicating that both normal and cancer cells communicate via the release and delivery of macromolecules packed into extracellular membrane vesicles. MATERIALS AND METHODS: We isolated nano-sized extracellular vesicles from MYCN-amplified neuroblastoma cell lines using ultracentrifugation and exosome precipitation (Exoquick) protocols. These vesicles were characterized by transmission electron microscopy (TEM), nanoparticle tracking analysis and western blotting. Exosomal miRNA profiles were obtained using a reverse transcription-polymerase chain reaction (RT-PCR) ready-to-use panel measuring a total of 742 miRNAs. RESULTS: In this study, we showed that MYCN-amplified neuroblastoma cell lines secrete populations of miRNAs inside small exosome-like vesicular particles. These particles were shown to be taken-up by recipient cells. By profiling the miRNA content, we demonstrated high expression of a group of established oncomirs in exosomes from two MYCN-amplified neuroblastoma cell lines. Despite the fact that other studies have demonstrated the ability of exosomal miRNAs both to repress mRNA targets and to stimulate Toll-like receptor-8 (TLR8) signaling in recipient cells, we did not observe these effects with exosomes from MYCN-amplified neuroblastoma cells. However, functional enrichment analysis reveals that mRNA targets of highly expressed exosomal miRNAs are associated with a range of cellular and molecular functions related to cell growth and cell death. CONCLUSION: MYCN-amplified neuroblastoma cell lines secrete exosome-like particles containing oncogenic miRNAs. This work showed for the first time that neuroblastoma cells secrete exosome-like particles containing miRNAs with potential roles in cancer progression. These findings indicate a new way for MYCN-amplified neuroblastoma cells to interact with the tumor environment.

Sub-chronic lead exposure alters kidney proteome profiles.

The current study examined the impact of sub-chronic lead (Pb)-exposure upon global protein profile in rodent kidney (blood Pb levels ~50 µg/dL; 5 weeks oral Pb-acetate exposure). Utilizing 2D SDS-PAGE for kidney protein separation, greater than 500 protein spots were analyzed by densitometry following background noise removal, spot alignment, and intensity filtering. Approximately 100 protein spots were identified by ESI-MS/MS with mitochondrial, chaperone, antioxidant, and Pb-binding proteins included. Forty-eight protein spots exhibited significant alterations in abundance (18 identified by ESI-MS/MS) including the increased protein abundance of ketohexokinase, enolase, protein disulfide-isomerase, lamda crystallin, lactamase, and glycerol-3-phosphate dehydrogenase. Decreased protein abundances were observed for α-2 microglobulin, glutamate cysteine ligase, prohibitin, homogentisate 1,2-dioxygenase, alpha-ETF, argininosuccinate synthetase and ATP synthase (H+ transporting). These data support the hypothesis that protein profiles in the kidney are altered following sub-chronic physiologically relevant Pb-exposure.