Environmental risk scores of persistent organic pollutants associate with higher ALS risk and shorter survival in a new Michigan case/control cohort.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is a fatal, progressive neurogenerative disease caused by combined genetic susceptibilities and environmental exposures. Identifying and validating these exposures are of paramount importance to modify disease risk. We previously reported that persistent organic pollutants (POPs) associate with ALS risk and survival and aimed to replicate these findings in a new cohort. METHOD: Participants with and without ALS recruited in Michigan provided plasma samples for POPs analysis by isotope dilution with triple quadrupole mass spectrometry. ORs for risk models and hazard ratios for survival models were calculated for individual POPs. POP mixtures were represented by environmental risk scores (ERS), a summation of total exposures, to evaluate the association with risk (ERSrisk) and survival (ERSsurvival). RESULTS: Samples from 164 ALS and 105 control participants were analysed. Several individual POPs significantly associated with ALS, including 8 of 22 polychlorinated biphenyls and 7 of 10 organochlorine pesticides (OCPs). ALS risk was most strongly represented by the mixture effects of OCPs alpha-hexachlorocyclohexane, hexachlorobenzene, trans-nonachlor and cis-nonachlor and an interquartile increase in ERSrisk enhanced ALS risk 2.58 times (p<0.001). ALS survival was represented by the combined mixture of all POPs and an interquartile increase in ERSsurvival enhanced ALS mortality rate 1.65 times (p=0.008). CONCLUSIONS: These data continue to support POPs as important factors for ALS risk and progression and replicate findings in a new cohort. The assessments of POPs in non-Michigan ALS cohorts are encouraged to better understand the global effect and the need for targeted disease risk reduction strategies.

Body mass index associates with amyotrophic lateral sclerosis survival and metabolomic profiles.

INTRODUCTION/AIMS: Body mass index (BMI) is linked to amyotrophic lateral sclerosis (ALS) risk and prognosis, but additional research is needed. The aim of this study was to identify whether and when historical changes in BMI occurred in ALS participants, how these longer term trajectories associated with survival, and whether metabolomic profiles provided insight into potential mechanisms. METHODS: ALS and control participants self-reported body height and weight 10 (reference) and 5 years earlier, and at study entry (diagnosis for ALS participants). Generalized estimating equations evaluated differences in BMI trajectories between cases and controls. ALS survival was evaluated by BMI trajectory group using accelerated failure time models. BMI trajectories and survival associations were explored using published metabolomic profiling and correlation networks. RESULTS: Ten-year BMI trends differed between ALS and controls, with BMI loss in the 5 years before diagnosis despite BMI gains 10 to 5 years beforehand in both groups. An overall 10-year drop in BMI associated with a 27.1% decrease in ALS survival (P = .010). Metabolomic networks in ALS participants showed dysregulation in sphingomyelin, bile acid, and plasmalogen subpathways. DISCUSSION: ALS participants lost weight in the 5-year period before enrollment. BMI trajectories had three distinct groups and the group with significant weight loss in the past 10 years had the worst survival. Participants with a high BMI and increase in weight in the 10 years before symptom onset also had shorter survival. Certain metabolomics profiles were associated with the BMI trajectories. Replicating these findings in prospective cohorts is warranted.

Associations of self-reported occupational exposures and settings to ALS: a case-control study.

BACKGROUND: Environmental exposures contribute to the pathogenesis of amyotrophic lateral sclerosis (ALS), a fatal and progressive neurological disease. Identification of these exposures is important for targeted screening and risk factor modification. OBJECTIVE: To identify occupational exposures that are associated with a higher risk of ALS using both survey and standard occupational classification (SOC) coding procedures, and to highlight how exposure surveys can complement SOC coding. METHODS: ALS participants and neurologically healthy controls recruited in Michigan completed a detailed exposure assessment on their four most recent and longest held occupations. Exposure scores were generated from the exposure survey, and occupations were assigned to SOC codes by experienced exposure scientists. RESULTS: This study included 381 ALS and 272 control participants. ALS participants reported higher duration-adjusted occupational exposure to particulate matter (OR = 1.45, 95% CI 1.19-1.78, p < 0.001), volatile organic compounds (OR = 1.22, 95% CI 1.02-1.45, p = 0.029), metals (OR = 1.48, 95% CI 1.21-1.82, p < 0.001), and combustion and diesel exhaust pollutants (OR = 1.20, 95% CI 1.01-1.43, p = 0.041) prior to ALS diagnosis, when adjusted for sex, age, and military service compared to controls. In multivariable models, only occupational exposure to metals remained significant risk (OR = 1.56, 95% CI 1.11-2.20, p = 0.011), although in an adaptive elastic net model, particulate matter (OR = 1.203), pesticides (OR = 1.015), and metals (1.334) were all selected as risk factors. Work in SOC code "Production Occupations" was associated with a higher ALS risk. SOC codes "Building and Grounds Cleaning and Maintenance Occupations", "Construction and Extraction Occupations", "Installation, Maintenance, and Repair Occupations", and "Production Occupations" were all associated with a higher exposure to metals as determined using survey data. DISCUSSION: Occupational exposure to particulate matter, volatile organic compounds, metals, pesticides, and combustion and diesel exhaust and employment in "Production Occupations" was associated with an increased ALS risk in this cohort.

A hierarchical integrative group least absolute shrinkage and selection operator for analyzing environmental mixtures.

Environmental health studies are increasingly measuring multiple pollutants to characterize the joint health effects attributable to exposure mixtures. However, the underlying dose-response relationship between toxicants and health outcomes of interest may be highly nonlinear, with possible nonlinear interaction effects. Existing penalized regression methods that account for exposure interactions either cannot accommodate nonlinear interactions while maintaining strong heredity or are computationally unstable in applications with limited sample size. In this paper, we propose a general shrinkage and selection framework to identify noteworthy nonlinear main and interaction effects among a set of exposures. We design hierarchical integrative group least absolute shrinkage and selection operator (HiGLASSO) to (a) impose strong heredity constraints on two-way interaction effects (hierarchical), (b) incorporate adaptive weights without necessitating initial coefficient estimates (integrative), and (c) induce sparsity for variable selection while respecting group structure (group LASSO). We prove sparsistency of the proposed method and apply HiGLASSO to an environmental toxicants dataset from the LIFECODES birth cohort, where the investigators are interested in understanding the joint effects of 21 urinary toxicant biomarkers on urinary 8-isoprostane, a measure of oxidative stress. An implementation of HiGLASSO is available in the higlasso R package, accessible through the Comprehensive R Archive Network.

Untargeted metabolomics yields insight into ALS disease mechanisms.

OBJECTIVE: To identify dysregulated metabolic pathways in amyotrophic lateral sclerosis (ALS) versus control participants through untargeted metabolomics. METHODS: Untargeted metabolomics was performed on plasma from ALS participants (n=125) around 6.8 months after diagnosis and healthy controls (n=71). Individual differential metabolites in ALS cases versus controls were assessed by Wilcoxon rank-sum tests, adjusted logistic regression and partial least squares-discriminant analysis (PLS-DA), while group lasso explored sub-pathway-level differences. Adjustment parameters included sex, age and body mass index (BMI). Metabolomics pathway enrichment analysis was performed on metabolites selected by the above methods. Finally, machine learning classification algorithms applied to group lasso-selected metabolites were evaluated for classifying case status. RESULTS: There were no group differences in sex, age and BMI. Significant metabolites selected were 303 by Wilcoxon, 300 by logistic regression, 295 by PLS-DA and 259 by group lasso, corresponding to 11, 13, 12 and 22 enriched sub-pathways, respectively. 'Benzoate metabolism', 'ceramides', 'creatine metabolism', 'fatty acid metabolism (acyl carnitine, polyunsaturated)' and 'hexosylceramides' sub-pathways were enriched by all methods, and 'sphingomyelins' by all but Wilcoxon, indicating these pathways significantly associate with ALS. Finally, machine learning prediction of ALS cases using group lasso-selected metabolites achieved the best performance by regularised logistic regression with elastic net regularisation, with an area under the curve of 0.98 and specificity of 83%. CONCLUSION: In our analysis, ALS led to significant metabolic pathway alterations, which had correlations to known ALS pathomechanisms in the basic and clinical literature, and may represent important targets for future ALS therapeutics.

Predictors of urinary and blood Metal(loid) concentrations among pregnant women in Northern Puerto Rico.

Given the potential adverse health effects related to toxic trace metal exposure and insufficient or excessive levels of essential trace metals in pregnant women and their fetuses, the present study characterizes biomarkers of metal and metalloid exposure at repeated time points during pregnancy among women in Puerto Rico. We recruited 1040 pregnant women from prenatal clinics and collected urine, blood, and questionnaire data on demographics, product use, food consumption, and water usage at up to three visits. All samples were analyzed for 16 metal(loid)s: arsenic (As), barium (Ba), beryllium (Be), cadmium (Cd), cobalt (Co), chromium (Cr), cesium (Cs), copper (Cu), mercury (Hg), manganese (Mn), nickel (Ni), lead (Pb), titanium (Ti), uranium (U), vanadium (V), and zinc (Zn). Urine samples were additionally analyzed for molybdenum (Mo), platinum (Pt), antimony (Sb), tin (Sn), and tungsten (W). Mean concentrations of most metal(loid)s were higher among participants compared to the general US female population. We found weak to moderate correlations for inter-matrix comparisons, and moderate to strong correlations between several metal(loid)s measured within each biological matrix. Blood concentrations of Cu, Zn, Mn, Hg, and Pb were shown to reflect reliable biomarkers of exposure. For other metals, repeated samples are recommended for exposure assessment in epidemiology studies. Predictors of metal(loid) biomarkers included fish and rice consumption (urinary As), fish and canned food (blood Hg), drinking public water (blood Pb), smoking (blood Cd), and iron/folic acid supplement use (urinary Cs, Mo, and Sb). Characterization of metal(loid) biomarker variation over time and between matrices, and identification of important exposure sources, may inform future epidemiology studies and exposure reduction strategies.

Estimating Outcome-Exposure Associations when Exposure Biomarker Detection Limits vary Across Batches.

Limit of detection (LOD) issues are ubiquitous in exposure assessment. Although there is an extensive literature on modeling exposure data under such imperfect measurement processes, including likelihood-based methods and multiple imputation, the standard practice continues to be naïve single imputation by a constant (e.g., (Equation is included in full-text article.)). In this article, we consider the situation where, due to the practical logistics of data accrual, sampling, and resource constraints, exposure data are analyzed in multiple batches where the LOD and the proportion of censored observations differ across batches. Compounding this problem is the potential for nonrandom assignment of samples to each batch, often driven by enrollment patterns and biosample storage. This issue is particularly important for binary outcome data where batches may have different levels of outcome enrichment. We first consider variants of existing methods to address varying LODs across multiple batches. We then propose a likelihood-based multiple imputation strategy to impute observations that are below the LOD while simultaneously accounting for differential batch assignment. Our simulation study shows that our proposed method has superior estimation properties (i.e., bias, coverage, statistical efficiency) compared to standard alternatives, provided that distributional assumptions are satisfied. Additionally, in most batch assignment configurations, complete-case analysis can be made unbiased by including batch indicator terms in the analysis model, although this strategy is less efficient relative to the proposed method. We illustrate our method by analyzing data from a cohort study in Puerto Rico that is investigating the relation between endocrine disruptor exposures and preterm birth.

High plasma concentrations of organic pollutants negatively impact survival in amyotrophic lateral sclerosis.

OBJECTIVE: To determine whether persistent organic pollutants (POP) affect amyotrophic lateral sclerosis (ALS) survival. METHODS: ALS participants seen at the University of Michigan (Ann Arbor, MI, USA) provided plasma samples for measurement of POPs. ALS disease and clinical features were collected prospectively from the medical records. Survival models used a composite summary measure of exposure due to multiple POPs (environmental risk score or ERS). RESULTS: 167 participants (40.7% female, n=68) with ALS were recruited, of which 119 died during the study period. Median diagnostic age was 60.9 years (IQR 52.7-68.2), median time from symptom onset to diagnosis was 1.01 years (IQR 0.67-1.67), bulbar onset 28.7%, cervical onset 33.5% and lumbar onset 37.7%. Participants in the highest quartile of ERS (representing highest composite exposure), adjusting for age at diagnosis, sex and other covariates had a 2.07 times greater hazards rate of mortality (p=0.018, 95% CI 1.13 to 3.80) compared with those in the lowest quartile. Pollutants with the largest contribution to the ERS were polybrominated diphenyl ethers 154 (HR 1.53, 95% CI 0.90 to 2.61), polychlorinated biphenyls (PCB) 118 (HR 1.50, 95% CI 0.95 to 2.39), PCB 138 (HR 1.69, 95% CI 0.99 to 2.90), PCB 151 (HR 1.46, 95% CI 1.01 to 2.10), PCB 175 (HR 1.53, 95% CI 0.98 to 2.40) and p,p'-DDE (HR 1.39, 95% CI 1.07 to 1.81). CONCLUSIONS: Higher concentrations of POPs in plasma are associated with reduced ALS survival, independent of age, gender, segment of onset and other covariates. This study helps characterise and quantify the combined effects of POPs on ALS and supports the concept that environmental exposures play a role in disease pathogenesis.

Complete hazard ranking to analyze right-censored data: An ALS survival study.

Survival analysis represents an important outcome measure in clinical research and clinical trials; further, survival ranking may offer additional advantages in clinical trials. In this study, we developed GuanRank, a non-parametric ranking-based technique to transform patients' survival data into a linear space of hazard ranks. The transformation enables the utilization of machine learning base-learners including Gaussian process regression, Lasso, and random forest on survival data. The method was submitted to the DREAM Amyotrophic Lateral Sclerosis (ALS) Stratification Challenge. Ranked first place, the model gave more accurate ranking predictions on the PRO-ACT ALS dataset in comparison to Cox proportional hazard model. By utilizing right-censored data in its training process, the method demonstrated its state-of-the-art predictive power in ALS survival ranking. Its feature selection identified multiple important factors, some of which conflicts with previous studies.

Associations between mixtures of urinary phthalate metabolites with gestational age at delivery: a time to event analysis using summative phthalate risk scores.

BACKGROUND: Preterm birth is a significant public health concern and exposure to phthalates has been shown to be associated with an increased odds of preterm birth. Even modest reductions in gestational age at delivery could entail morbid consequences for the neonate and analyzing data with this additional information may be useful. In the present analysis, we consider gestational age at delivery as our outcome of interest and examine associations with multiple phthalates. METHODS: Women were recruited early in pregnancy as part of a prospective, longitudinal birth cohort at the Brigham and Women's Hospital in Boston, Massachusetts. Urine samples were collected at up to four time points during gestation for urinary phthalate metabolite measurement, and birth outcomes were recorded at delivery. From this population, we selected all 130 cases of preterm birth (< 37 weeks of gestation) as well as 352 random controls. We conducted analysis with both geometric average of the exposure concentrations across the first three visits as well as using repeated measures of the exposure. Two different time to event models were used to examine associations between nine urinary phthalate metabolite concentrations and time to delivery. Two different approaches to constructing a summative phthalate risk score were also considered. RESULTS: The single-pollutant analysis using a Cox proportional hazards model showed the strongest association with a hazard ratio (HR) of 1.21 (95% confidence interval (CI): 1.09, 1.33) per interquartile range (IQR) change in average log-transformed mono-2-ethyl-5-carboxypentyl phthalate (MECPP) concentration. Using the accelerated failure time model, we observed a 1.19% (95% CI: 0.26, 2.11%) decrease in gestational age in association with an IQR change in average log-transformed MECPP. We next examined associations with an environmental risk score (ERS). The fourth quartile of ERS was significantly associated with a HR of 1.44 (95% CI: 1.19, 1.75) and a reduction of 2.55% (95% CI: 0.76, 4.30%) in time to delivery (in days) compared to the first quartile. CONCLUSIONS: On average, pregnant women with higher urinary metabolite concentrations of individual phthalates have shorter time to delivery. The strength of the observed associations are amplified with the risk scores when compared to individual pollutants.

Statistical methods for chemical mixtures: a roadmap for practitioners.

Quantitative characterization of the health impacts associated with exposure to chemical mixtures has received considerable attention in current environmental and epidemiological studies. With many existing statistical methods and emerging approaches, it is important for practitioners to understand when each method is best suited for their inferential goals. In this study, we conduct a review and comparison of 11 analytical methods available for use in mixtures research, through extensive simulation studies for continuous and binary outcomes. These methods fall in three different classes: identifying important components of a mixture, identifying interactions and creating a summary score for risk stratification and prediction. We carry out an illustrative data analysis in the PROTECT birth cohort from Puerto Rico. Most importantly we develop an integrated package "CompMix" that provides a platform for mixtures analysis where the practitioner can implement a pipeline for several types of mixtures analysis. Our simulation results suggest that the choice of methods depends on the goal of analysis and there is no clear winner across the board. For selection of important toxicants in the mixture and for identifying interactions, Elastic net by Zou et al. (Enet), Lasso for Hierarchical Interactions by Bien et al (HierNet), Selection of nonlinear interactions by a forward stepwise algorithm by Narisetty et al. (SNIF) have the most stable performance across simulation settings. Additionally, the predictive performance of the Super Learner ensembling method by Van de Laan et al. and HierNet are found to be superior to the rest of the methods. For overall summary or a cumulative measure, we find that using the Super Learner to combine multiple Environmental Risk Scores can lead to improved risk stratification properties. We have developed an R package "CompMix: A comprehensive toolkit for environmental mixtures analysis", allowing users to implement a variety of tasks under different settings and compare the findings. In summary, our study offers guidelines for selecting appropriate statistical methods for addressing specific scientific questions related to mixtures research. We identify critical gaps where new and better methods are needed.

Avocational exposure associations with ALS risk, survival, and phenotype: A Michigan-based case-control study.

INTRODUCTION: Environmental exposures strongly influence ALS risk and identification is needed to reduce ALS burden. Participation in hobbies and exercise may alter ALS risk and phenotype, warranting an assessment to understand their contribution to the ALS exposome. METHODS: Participants with ALS and healthy controls were recruited from University of Michigan and self-completed a survey to ascertain hobbies, exercise, and avocational exposures. Exposure variables were associated with ALS risk, survival, onset segment, and onset age. RESULTS: ALS (n = 400) and control (n = 287) participants self-reported avocational activities. Cases were slightly older (median age 63.0 vs. 61.1 years, p = 0.019) and had a lower educational attainment (p < 0.001) compared to controls; otherwise, demographics were well balanced. Risks associating with ALS after multiple comparison correction included golfing (odds ratio (OR) 3.48, padjusted = 0.004), recreational dancing (OR 2.00, padjusted = 0.040), performing gardening or yard work (OR 1.71, padjusted = 0.040) five years prior to ALS and personal (OR 1.76, padjusted = 0.047) or family (OR 2.21, padjusted = 0.040) participation in woodworking, and personal participation in hunting and shooting (OR 1.89, padjusted = 0.040). No exposures associated with ALS survival and onset. Those reporting swimming (3.86 years, padjusted = 0.016) and weightlifting (3.83 years, padjusted = 0.020) exercise 5 years prior to ALS onset had an earlier onset age. DISCUSSION: The identified exposures in this study may represent important modifiable ALS factors that influence ALS phenotype. Thus, exposures related to hobbies and exercise should be captured in studies examining the ALS exposome.

Improving prediction models of amyotrophic lateral sclerosis (ALS) using polygenic, pre-existing conditions, and survey-based risk scores in the UK Biobank.

Background and Objectives: Amyotrophic lateral sclerosis (ALS) causes profound impairments in neurological function and a cure for this devastating disease remains elusive. Early detection and risk stratification are crucial for timely intervention and improving patient outcomes. This study aimed to identify predisposing genetic, phenotypic, and exposure-related factors for Amyotrophic lateral sclerosis using multi-modal data and assess their joint predictive potential. Methods: Utilizing data from the UK Biobank, we analyzed an unrelated set of 292 ALS cases and 408,831 controls of European descent. Two polygenic risk scores (PRS) are constructed: "GWAS Hits PRS" and "PRS-CS," reflecting oligogenic and polygenic ALS risk profiles, respectively. Time-restricted phenome-wide association studies (PheWAS) were performed to identify pre-existing conditions increasing ALS risk, integrated into phenotypic risk scores (PheRS). A poly-exposure score ("PXS") captures the influence of environmental exposures measured through survey questionnaires. We evaluate the performance of these scores for predicting ALS incidence and stratifying risk, adjusting for baseline demographic covariates. Results: Both PRSs modestly predicted ALS diagnosis, but with increased predictive power when combined (covariate-adjusted receiver operating characteristic [AAUC] = 0.584 [0.525, 0.639]). PheRS incorporated diagnoses 1 year before ALS onset (PheRS1) modestly discriminated cases from controls (AAUC = 0.515 [0.472, 0.564]). The "PXS" did not significantly predict ALS. However, a model incorporating PRSs and PheRS1 improved prediction of ALS (AAUC = 0.604 [0.547, 0.667]), outperforming a model combining all risk scores. This combined risk score identified the top 10% of risk score distribution with a 4-fold higher ALS risk (95% CI: [2.04, 7.73]) versus those in the 40%-60% range. Discussions: By leveraging UK Biobank data, our study uncovers predisposing ALS factors, highlighting the improved effectiveness of multi-factorial prediction models to identify individuals at highest risk for ALS.

Residential exposure associations with ALS risk, survival, and phenotype: a Michigan-based case-control study.

Background: Environmental exposures impact amyotrophic lateral sclerosis (ALS) risk and progression, a fatal and progressive neurodegenerative disease. Better characterization of these exposures is needed to decrease disease burden. Objective: To identify exposures in the residential setting that associate with ALS risk, survival, and onset segment. Methods: ALS and control participants recruited from University of Michigan completed a survey that ascertained exposure risks in the residential setting. ALS risk was assessed using logistic regression models followed by latent profile analysis to consider exposure profiles. A case-only analysis considered the contribution of the residential exposure variables via a Cox proportional hazards model for survival outcomes and multinomial logistic regression for onset segment, a polytomous outcome. Results: This study included 367 ALS and 255 control participants. Twelve residential variables were associated with ALS risk after correcting for multiple comparison testing, with storage in an attached garage of chemical products including gasoline or kerosene (odds ratio (OR) = 1.14, padjusted < 0.001), gasoline-powered equipment (OR = 1.16, padjusted < 0.001), and lawn care products (OR = 1.15, padjusted < 0.001) representing the top three risk factors sorted by padjusted. Latent profile analysis indicated that storage of these chemical products in both attached and detached garages increased ALS risk. Although residential variables were not associated with poorer ALS survival following multiple testing corrections, storing pesticides, lawn care products, and woodworking supplies in the home were associated with shorter ALS survival using nominal p values. No exposures were associated with ALS onset segment. Conclusion: Residential exposures may be important modifiable components of the ALS susceptibility and prognosis exposome.

Occupational history associates with ALS survival and onset segment.

OBJECTIVE: To identify associations between occupational settings and self-reported occupational exposures on amyotrophic lateral sclerosis (ALS) survival and phenotypes. METHODS: All patients seen in the University of Michigan Pranger ALS Clinic were invited to complete an exposure assessment querying past occupations and exposures. Standard occupational classification (SOC) codes for each job and the severity of various exposure types were derived. Cox proportional hazards models associated all-cause mortality with occupational settings and the self-reported exposures after adjusting for sex, diagnosis age, revised El Escorial criteria, onset segment, revised ALS Functional Rating Scale (ALSFRS-R), and time from symptom onset to diagnosis. Multinomial logistic regression models with three categories, adjusted for age, assessed the association between occupational settings and exposures to onset segment. RESULTS: Among the 378 ALS participants (median age, 64.7 years; 54.4% male), poorer survival was associated with work in SOC code "Production Occupations" and marginally with work in "Military Occupation"; poor survival associated with self-reported occupational pesticide exposure in adjusted models. Among onset segments: cervical onset was associated with ALS participants having ever worked in "Buildings and Grounds Cleaning and Maintenance Occupations," "Construction and Extraction Occupations," and "Production Occupations"; bulbar onset with self-reported occupational exposure to radiation; and cervical onset with exposure to particulate matter, volatile organic compounds, metals, combustion and diesel exhaust, electromagnetic radiation, and radiation. CONCLUSION: Occupational settings and self-reported exposures influence ALS survival and onset segment. Further studies are needed to explore and understand these relationships, most advantageously using prospective cohorts and detailed ALS registries.

The antihelmintic flubendazole inhibits microtubule function through a mechanism distinct from Vinca alkaloids and displays preclinical activity in leukemia and myeloma.

On-patent and off-patent drugs with previously unrecognized anticancer activity could be rapidly repurposed for this new indication given their prior toxicity testing. To identify such compounds, we conducted chemical screens and identified the antihelmintic flubendazole. Flubendazole induced cell death in leukemia and myeloma cell lines and primary patient samples at nanomolar concentrations. Moreover, it delayed tumor growth in leukemia and myeloma xenografts without evidence of toxicity. Mechanistically, flubendazole inhibited tubulin polymerization by binding tubulin at a site distinct from vinblastine. In addition, cells resistant to vinblastine because of overexpression of P-glycoprotein remained fully sensitive to flubendazole, indicating that flubendazole can overcome some forms of vinblastine resistance. Given the different mechanisms of action, we evaluated the combination of flubendazole and vinblastine in vitro and in vivo. Flubendazole synergized with vinblastine to reduce the viability of OCI-AML2 cells. In addition, combinations of flubendazole with vinblastine or vincristine in a leukemia xenograft model delayed tumor growth more than either drug alone. Therefore, flubendazole is a novel microtubule inhibitor that displays preclinical activity in leukemia and myeloma.

Assessing the added value of linking electronic health records to improve the prediction of self-reported COVID-19 testing and diagnosis.

Since the beginning of the Coronavirus Disease 2019 (COVID-19) pandemic, a focus of research has been to identify risk factors associated with COVID-19-related outcomes, such as testing and diagnosis, and use them to build prediction models. Existing studies have used data from digital surveys or electronic health records (EHRs), but very few have linked the two sources to build joint predictive models. In this study, we used survey data on 7,054 patients from the Michigan Genomics Initiative biorepository to evaluate how well self-reported data could be integrated with electronic records for the purpose of modeling COVID-19-related outcomes. We observed that among survey respondents, self-reported COVID-19 diagnosis captured a larger number of cases than the corresponding EHRs, suggesting that self-reported outcomes may be better than EHRs for distinguishing COVID-19 cases from controls. In the modeling context, we compared the utility of survey- and EHR-derived predictor variables in models of survey-reported COVID-19 testing and diagnosis. We found that survey-derived predictors produced uniformly stronger models than EHR-derived predictors-likely due to their specificity, temporal proximity, and breadth-and that combining predictors from both sources offered no consistent improvement compared to using survey-based predictors alone. Our results suggest that, even though general EHRs are useful in predictive models of COVID-19 outcomes, they may not be essential in those models when rich survey data are already available. The two data sources together may offer better prediction for COVID severity, but we did not have enough severe cases in the survey respondents to assess that hypothesis in in our study.

Persistent organic pollutant exposure contributes to Black/White differences in leukocyte telomere length in the National Health and Nutrition Examination Survey.

Despite racial disparities in diseases of aging and premature mortality, non-Hispanic Black Americans tend to have longer leukocyte telomere length (LTL), a biomarker of cellular aging, than non-Hispanic White Americans. Previous findings suggest that exposure to certain persistent organic pollutants (POPs) is both racially-patterned and associated with longer LTL. We examine whether Black/White differences in LTL are explained by differences in exposure to 15 POPs by estimating the indirect effect (IE) of self-reported race on LTL that is mediated through nine polychlorinated biphenyls (PCBs), three furans, and three dioxins, as well as their mixtures. Our study population includes 1,251 adults from the 1999-2000 and 2001-2002 cycles of the cross-sectional National Health and Nutrition Examination Survey. We characterized single-pollutant mediation effects by constructing survey-weighted linear regression models. We also implemented various approaches to quantify a global mediation effect of all POPs, including unpenalized linear regression, ridge regression, and examination of three summary exposure scores. We found support for the hypothesis that exposure to PCBs partially mediates Black/White differences in LTL. In single-pollutant models, there were significant IEs of race on LTL through six individual PCBs (118, 138, 153, 170, 180, and 187). Ridge regression (0.013, CI 0.001, 0.023; 26.0% mediated) and models examining summative exposure scores with linear combinations derived from principal components analysis (0.019, CI 0.009, 0.029; 34.8% mediated) and Toxic Equivalency Quotient (TEQ) scores (0.016, CI 0.005, 0.026; 28.8% mediated) showed significant IEs when incorporating survey weights. Exposures to individual POPs and their mixtures, which may arise from residential and occupational segregation, may help explain why Black Americans have longer LTL than their White counterparts, providing an environmental explanation for counterintuitive race differences in cellular aging.

Variable selection with multiply-imputed datasets: choosing between stacked and grouped methods.

Penalized regression methods are used in many biomedical applications for variable selection and simultaneous coefficient estimation. However, missing data complicates the implementation of these methods, particularly when missingness is handled using multiple imputation. Applying a variable selection algorithm on each imputed dataset will likely lead to different sets of selected predictors. This paper considers a general class of penalized objective functions which, by construction, force selection of the same variables across imputed datasets. By pooling objective functions across imputations, optimization is then performed jointly over all imputed datasets rather than separately for each dataset. We consider two objective function formulations that exist in the literature, which we will refer to as "stacked" and "grouped" objective functions. Building on existing work, we (a) derive and implement efficient cyclic coordinate descent and majorization-minimization optimization algorithms for continuous and binary outcome data, (b) incorporate adaptive shrinkage penalties, (c) compare these methods through simulation, and (d) develop an R package miselect. Simulations demonstrate that the "stacked" approaches are more computationally efficient and have better estimation and selection properties. We apply these methods to data from the University of Michigan ALS Patients Biorepository aiming to identify the association between environmental pollutants and ALS risk. Supplementary materials are available online.

Amyotrophic Lateral Sclerosis Survival Associates With Neutrophils in a Sex-specific Manner.

OBJECTIVE: To determine whether neutrophils contribute to amyotrophic lateral sclerosis (ALS) progression, we tested the association of baseline neutrophil count on ALS survival, whether the effect was sex specific, and whether neutrophils accumulate in the spinal cord. METHODS: A prospective cohort study was conducted between June 22, 2011, and October 30, 2019. Blood leukocytes were isolated from ALS participants and neutrophil levels assessed by flow cytometry. Participant survival outcomes were analyzed by groups (<2 × 106, 2-4 × 106, and >4 × 106 neutrophils/mL) with adjustments for relevant ALS covariates and by sex. Neutrophil levels were assessed from CNS tissue from a subset of participants. RESULTS: A total of 269 participants with ALS within 2 years of an ALS diagnosis were included. Participants with baseline neutrophil counts over 4 × 106/mL had a 2.1 times higher mortality rate than those with a neutrophil count lower than 2 × 106/mL (95% CI: 1.3-3.5, p = 0.004) when adjusting for age, sex, and other covariates. This effect was more pronounced in females, with a hazard ratio of 3.8 (95% CI: 1.8-8.2, p = 0.001) in the >4 × 106/mL vs <2 × 106/mL group. Furthermore, ALS participants (n = 8) had increased neutrophils in cervical (p = 0.049) and thoracic (p = 0.022) spinal cord segments compared with control participants (n = 8). CONCLUSIONS: Higher neutrophil counts early in ALS associate with a shorter survival in female participants. Furthermore, neutrophils accumulate in ALS spinal cord supporting a pathophysiologic correlate. These data justify the consideration of immunity and sex for personalized therapeutic development in ALS. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that in female participants with ALS, higher baseline neutrophil counts are associated with shorter survival.