Development and IND-enabling studies of a novel Cas9 genome-edited autologous CD34+ cell therapy to induce fetal hemoglobin for sickle cell disease.

Sickle cell disease (SCD) is a common, severe genetic blood disorder. Current pharmacotherapies are partially effective and allogeneic hematopoietic stem cell transplantation (HSCT) is associated with immune toxicities. Genome editing of patient hematopoietic stem cells (HSCs) to reactivate fetal hemoglobin (HbF) in erythroid progeny offers an alternative potentially curative approach to treat SCD. Although the FDA released guidelines for evaluating genome editing risks, it remains unclear how best to approach pre-clinical assessment of genome-edited cell products. Here we describe rigorous pre-clinical development of a therapeutic γ-globin gene promoter editing strategy that supported an investigational new drug (IND) application cleared by the FDA. We compared γ-globin promoter and BCL11A enhancer targets, identified a potent HbF-inducing lead candidate, and tested our approach in mobilized CD34+ HSPCs from SCD patients. We observed efficient editing, HbF induction to predicted therapeutic levels, and reduced sickling. With single-cell analyses, we defined the heterogeneity of HbF induction and HBG1/HBG2 transcription. With CHANGE-seq for sensitive and unbiased off-target discovery followed by targeted sequencing, we did not detect off-target activity in edited HSPCs. Our study provides a blueprint for translating new ex vivo HSC genome editing strategies towards clinical trials for treating SCD and other blood disorders.

Breaking the Cycle: A Qualitative Study of Factors That Mitigate Impostor Phenomenon Among Internal Medicine Residents.

Background Impostor phenomenon (IP) describes feelings of inadequacy often experienced by individuals struggling to internalize success despite evidence to the contrary. IP is common in medicine and can be experienced as a cycle following exposure to an achievement-focused task, leading to fear of being found out as an impostor. Prior research describes IP characteristics, yet few studies have identified factors that mitigate IP among medical residents. Objective To understand factors that moderate IP among internal medicine (IM) residents. Methods We conducted a qualitative study using one-on-one semistructured interviews with 28 IM residents at a single academic health center from May to June 2020. To ascertain the prevalence of IP, informants completed a 20-item Clance Impostor Phenomenon Scale (CIPS) questionnaire. Using a constructivist thematic approach investigators independently coded transcripts to identify factors mitigating IP. Results Twenty-eight of 53 (53%) eligible residents participated in the study. Most informants were female (21 of 28, 75%) and in their second postgraduate year of training (12 of 28, 43%). The mean CIPS score was 63. When faced with an achievement-focused task, informants describe feelings of inadequacy, avoidance behaviors, distortion of feedback, and attribution beliefs. Internal factors found to moderate IP include (1) reframing attribution beliefs; (2) accepting feedback; and (3) acknowledging strengths. External factors include (1) mentors, coaches, and role models; (2) formal opportunities to share IP experiences; and (3) growth-oriented learning environments. Conclusions This qualitative study describes internal and external factors that potentially mitigate impostor feelings, thereby interrupting the cyclical nature of IP among IM residents.

Commitment to inclusion: The importance of collaboration in gender equity work.

Despite decades of faculty professional development programs created to prepare women for leadership, gender inequities persist in salary, promotion, and leadership roles. Indeed, men still earn more than women, are more likely than women to hold the rank of professor, and hold the vast majority of positions of power in academic medicine. Institutions demonstrate commitment to their faculty's growth by investing resources, including creating faculty development programs. These programs are essential to help prepare women to lead and navigate the highly matrixed, complex systems of academic medicine. However, data still show that women persistently lag behind men in their career advancement and salary. Clearly, training women to adapt to existing structures and norms alone is not sufficient. To effectively generate organizational change, leaders with power and resources must commit to gender equity. This article describes several efforts by the Office of Faculty in the Johns Hopkins University School of Medicine to broaden inclusivity in collaborative work for gender equity. The authors are women and men leaders in the Office of Faculty, which is within the Johns Hopkins University School of Medicine dean's office and includes Women in Science and Medicine. Here, we discuss potential methods to advance gender equity using inclusivity based on our institutional experience and on the findings of other studies. Ongoing data collection to evaluate programmatic outcomes in the Johns Hopkins University School of Medicine will be reported in the future.

Cascade genetic testing for hereditary cancer syndromes: a review of barriers and breakthroughs.

Germline genetic sequencing is now at the forefront of cancer treatment and preventative medicine. Cascade genetic testing, or the testing of at-risk relatives, is extremely promising as it offers genetic testing and potentially life-saving risk-reduction strategies to a population exponentially enriched for the risk of carrying a cancer-associated pathogenic variant. However, many relatives do not complete cascade testing due to barriers that span individual, relationship, healthcare community, and societal/policy domains. We have reviewed the published research on cascade testing. Our aim is to evaluate barriers to cascade genetic testing for hereditary cancer syndromes and explore strategies to mitigate these barriers, with the goal of promoting increased uptake of cascade genetic testing.

Inspiring and Preparing Our Future Leaders: Evaluating the Impact of the Early Career Women's Leadership Program.

Purpose: The number of women in high-level leadership in academic medicine remains disproportionately low. Early career programs may help increase women's representation in leadership. We evaluated the Early Career Women's Leadership Program (ECWLP). We hypothesized that participants would rate themselves as having increased confidence in their leadership potential, improved leadership skills, and greater alignment between their goals for well-being and leading after the program. We also explored the participants' aspirations and confidence around pursuing high-level leadership before and after the program. Methods: We surveyed women physicians and scientists before and after they participated in the 2023 ECWLP, consisting of 11 seminars over six months. We analyzed pre- and post-program data using Wilcoxon signed-rank tests. We analyzed answers to open-ended questions with a content analysis approach. Results: 47/51 (92%) participants responded, and 74% answered pre- and post-program questionnaires. Several metrics increased after the program, including women's confidence in their ability to lead (p<0.001), negotiate (p<0.001), articulate their career vision (p<0.001), reframe obstacles (p<0.001), challenge their assumptions (p<0.001), and align their personal and professional values (p=0.002). Perceptions of conflict between aspiring to lead and having family responsibilities (p=0.003) and achieving physical well-being (p=0.002) decreased. Perceived barriers to advancement included not being part of influential networks, a lack of transparency in leadership, and a competitive and individualistic culture. In the qualitative analysis, women described balancing internal factors such as self-doubt with external factors like competing professional demands when considering leadership. Many believed that becoming a leader would be detrimental to their well-being. Beneficial ECWLP components included support for self-reflection, tactical planning to pursue leadership, and creating a safe environment. Conclusion: The ECWLP improved women's confidence and strategic plans to pursue leadership in a way that supported their work-life integration. Early career leadership programs may encourage and prepare women for high-level leadership.

Bone-marrow-homing lipid nanoparticles for genome editing in diseased and malignant haematopoietic stem cells.

Therapeutic genome editing of haematopoietic stem cells (HSCs) would provide long-lasting treatments for multiple diseases. However, the in vivo delivery of genetic medicines to HSCs remains challenging, especially in diseased and malignant settings. Here we report on a series of bone-marrow-homing lipid nanoparticles that deliver mRNA to a broad group of at least 14 unique cell types in the bone marrow, including healthy and diseased HSCs, leukaemic stem cells, B cells, T cells, macrophages and leukaemia cells. CRISPR/Cas and base editing is achieved in a mouse model expressing human sickle cell disease phenotypes for potential foetal haemoglobin reactivation and conversion from sickle to non-sickle alleles. Bone-marrow-homing lipid nanoparticles were also able to achieve Cre-recombinase-mediated genetic deletion in bone-marrow-engrafted leukaemic stem cells and leukaemia cells. We show evidence that diverse cell types in the bone marrow niche can be edited using bone-marrow-homing lipid nanoparticles.