Exagamglogene Autotemcel for Transfusion-Dependent ß-Thalassemia.

BACKGROUND: Exagamglogene autotemcel (exa-cel) is a nonviral cell therapy designed to reactivate fetal hemoglobin synthesis through ex vivo clustered regularly interspaced short palindromic repeats (CRISPR)-Cas9 gene editing of the erythroid-specific enhancer region of BCL11A in autologous CD34+ hematopoietic stem and progenitor cells (HSPCs). METHODS: We conducted an open-label, single-group, phase 3 study of exa-cel in patients 12 to 35 years of age with transfusion-dependent ß-thalassemia and a ß0/ß0, ß0/ß0-like, or non-ß0/ß0-like genotype. CD34+ HSPCs were edited by means of CRISPR-Cas9 with a guide mRNA. Before the exa-cel infusion, patients underwent myeloablative conditioning with pharmacokinetically dose-adjusted busulfan. The primary end point was transfusion independence, defined as a weighted average hemoglobin level of 9 g per deciliter or higher without red-cell transfusion for at least 12 consecutive months. Total and fetal hemoglobin concentrations and safety were also assessed. RESULTS: A total of 52 patients with transfusion-dependent ß-thalassemia received exa-cel and were included in this prespecified interim analysis; the median follow-up was 20.4 months (range, 2.1 to 48.1). Neutrophils and platelets engrafted in each patient. Among the 35 patients with sufficient follow-up data for evaluation, transfusion independence occurred in 32 (91%; 95% confidence interval, 77 to 98; P<0.001 against the null hypothesis of a 50% response). During transfusion independence, the mean total hemoglobin level was 13.1 g per deciliter and the mean fetal hemoglobin level was 11.9 g per deciliter, and fetal hemoglobin had a pancellular distribution (≥94% of red cells). The safety profile of exa-cel was generally consistent with that of myeloablative busulfan conditioning and autologous HSPC transplantation. No deaths or cancers occurred. CONCLUSIONS: Treatment with exa-cel, preceded by myeloablation, resulted in transfusion independence in 91% of patients with transfusion-dependent ß-thalassemia. (Supported by Vertex Pharmaceuticals and CRISPR Therapeutics; CLIMB THAL-111 ClinicalTrials.gov number, NCT03655678.).

Exagamglogene Autotemcel for Severe Sickle Cell Disease.

BACKGROUND: Exagamglogene autotemcel (exa-cel) is a nonviral cell therapy designed to reactivate fetal hemoglobin synthesis by means of ex vivo clustered regularly interspaced short palindromic repeats (CRISPR)-Cas9 gene editing of autologous CD34+ hematopoietic stem and progenitor cells (HSPCs) at the erythroid-specific enhancer region of BCL11A. METHODS: We conducted a phase 3, single-group, open-label study of exa-cel in patients 12 to 35 years of age with sickle cell disease who had had at least two severe vaso-occlusive crises in each of the 2 years before screening. CD34+ HSPCs were edited with the use of CRISPR-Cas9. Before the exa-cel infusion, patients underwent myeloablative conditioning with pharmacokinetically dose-adjusted busulfan. The primary end point was freedom from severe vaso-occlusive crises for at least 12 consecutive months. A key secondary end point was freedom from inpatient hospitalization for severe vaso-occlusive crises for at least 12 consecutive months. The safety of exa-cel was also assessed. RESULTS: A total of 44 patients received exa-cel, and the median follow-up was 19.3 months (range, 0.8 to 48.1). Neutrophils and platelets engrafted in each patient. Of the 30 patients who had sufficient follow-up to be evaluated, 29 (97%; 95% confidence interval [CI], 83 to 100) were free from vaso-occlusive crises for at least 12 consecutive months, and all 30 (100%; 95% CI, 88 to 100) were free from hospitalizations for vaso-occlusive crises for at least 12 consecutive months (P<0.001 for both comparisons against the null hypothesis of a 50% response). The safety profile of exa-cel was generally consistent with that of myeloablative busulfan conditioning and autologous HSPC transplantation. No cancers occurred. CONCLUSIONS: Treatment with exa-cel eliminated vaso-occlusive crises in 97% of patients with sickle cell disease for a period of 12 months or more. (CLIMB SCD-121; ClinicalTrials.gov number, NCT03745287.).

Defining curative endpoints for sickle cell disease in the era of gene therapy and gene editing.

A growing number of gene therapy- and gene editing-based treatments for patients with sickle cell disease (SCD) are entering clinical trials. These treatments, designed to target the underlying cause of SCD, have the potential to provide functional cures, which until now were possible only through allogeneic hematopoietic stem cell transplant. However, as these novel approaches advance from early- to late-stage clinical trials, it is essential to identify physiologically and clinically relevant endpoints that can demonstrate the achievement of a functional cure for SCD. Here, we present an overview of the pathophysiology of SCD and current treatment options, review ongoing SCD clinical trials using gene therapy or gene editing approaches, and identify the most relevant endpoints for demonstrating the attainment of a functional cure for SCD.

Defining curative endpoints for transfusion-dependent ß-thalassemia in the era of gene therapy and gene editing.

ß-thalassemia is a monogenic disease that results in varying degrees of anemia. In the most severe form, known as transfusion-dependent ß-thalassemia (TDT), the clinical hallmarks are ineffective erythropoiesis and a requirement of regular, life-long red blood cell transfusions, with the development of secondary clinical complications such as iron overload, end-organ damage, and a risk of early mortality. With the exception of allogeneic hematopoietic cell transplantation, current treatments for TDT address disease symptoms and not the underlying cause of disease. Recently, a growing number of gene addition and gene editing-based treatments for patients with TDT with the potential to provide a one-time functional cure have entered clinical trials. A key challenge in the design and evaluation of these trials is selecting endpoints to evaluate if these novel genetic therapies have a curative versus an ameliorative effect. Here, we present an overview of the pathophysiology of TDT, review emerging gene addition or gene editing therapeutic approaches for TDT currently in clinical trials, and identify a series of endpoints that can quantify therapeutic effects, including a curative outcome.

For living well, behaviors and circumstances matter just as much as psychological traits.

In 2004 through 2016, three studies in the national Midlife in the United States (MIDUS) project asked participants the open-ended question "What do you do to make life go well?". We use verbatim responses to this question to evaluate the relative importance of psychological traits and circumstances for predicting self-reported, subjective well-being. The use of an open-ended question allows us to test the hypothesis that psychological traits are more strongly associated with self-reported well-being than objective circumstances because psychological traits and well-being are similarly self-rated-meaning that they both ask respondents to decide how to place themselves on provided and unfamiliar survey scales. For this, we use automated zero-shot classification to score statements about well-being without training on existing survey measures, and we evaluate this scoring through subsequent hand-labeling. We then assess associations of this measure and closed-ended measures for health behaviors, socioeconomic circumstances, biomarkers for inflammation and glycemic control, and mortality risk over follow-up. Although the closed-ended measures were far more strongly associated with other multiple-choice self-ratings, including Big 5 personality traits, the closed- and open-ended measures were similarly associated with relatively objective indicators of health, wealth, and social connectedness. The findings suggest that psychological traits, when collected through self-ratings, predict subjective reports of well-being so strongly because of a measurement advantage-and that circumstance matters just as much when assessed using a fairer comparison.

Safety and efficacy of classical complement pathway inhibition with sutimlimab in chronic immune thrombocytopenia.

Chronic/refractory immune thrombocytopenia (ITP) is a rare and pathophysiologically heterogeneous disorder with variable responsiveness to available treatments. Sutimlimab, a first-in-class humanized monoclonal anti-C1s IgG4 antibody, selectively inhibits the classical pathway. This phase 1 study (NCT03275454) assessed the safety, efficacy, pharmacokinetics, and pharmacodynamics of biweekly sutimlimab in patients with chronic/refractory ITP with an inadequate response to ≥2 therapies (platelet count ≤ 30 × 109/L). Twelve patients (median age 42 years) received sutimlimab for a median of 20.5 weeks followed by a median 2-week washout period (part A). In part B, 7 of the 12 eligible patients received sutimlimab retreatment for a median of 113 weeks. In part A, the mean (standard deviation) platelet count increased from 25 × 109/L (17) to 54 × 109/L (60) 24 hours after starting sutimlimab, maintaining ≥50 × 109/L throughout part A. Five patients (42%) achieved durable platelet count responses (≥50 × 109/L in ≥50% of follow-up visits) and 4 achieved complete response (platelet count ≥100 × 109/L). The mean platelet count returned to baseline during washout and increased upon retreatment in part B. The mean platelet count improvements accompanied the rapid inhibition of the classical pathway. There were 74 treatment-emergent adverse events in part A (n = 10) and 70 in part B (n = 6). Five serious adverse events were observed; 1 event (migraine) was assessed by the investigator as related to sutimlimab. These results demonstrated that in some patients with ITP, autoantibodies activate the classical complement pathway, accelerating platelet destruction or impairing platelet production and contributing to treatment failure. Thus, C1s inhibition may be a safe and beneficial therapeutic approach for patients with chronic/refractory ITP.

Sutimlimab improves quality of life in patients with cold agglutinin disease: results of patient-reported outcomes from the CARDINAL study.

Patients with cold agglutinin disease (CAD) experience fatigue and poor quality of life. However, previous CAD-related studies have not explored patient-reported outcomes such as the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue. Sutimlimab, a C1s complement inhibitor, has been shown to halt haemolysis in CAD. Here, we present 26-weeks' patient-reported data from CARDINAL Part A (ClinicalTrials.gov, NCT03347396), which assessed efficacy and safety of sutimlimab in patients with CAD and recent history of transfusion. Aside from measuring changes in haemolytic markers, FACIT-Fatigue was measured at the treatment assessment timepoint (TAT; average of weeks 23, 25, and 26). Exploratory endpoints included the change in EuroQol 5-dimension 5-level questionnaire (EQ-5D-5L) and the 12-Item Short Form Health Survey (SF-12) at TAT, and Patient Global Impression of Change (PGIC), and Patient Global Impression of (fatigue) Severity (PGIS) at week 26. Mean (range) FACIT-Fatigue scores increased from 32.5 (14.0-47.0) at baseline (a score indicative of severe fatigue) to 44.3 (28.0-51.0) at TAT. Considerable improvements were reported for EQ-5D-5L at TAT, SF-12 scores at TAT, and PGIC and PGIS scores at week 26. Sutimlimab treatment resulted in sustained improvements in symptoms of fatigue and overall quality of life in patients with CAD. NCT03347396. Registered 20 November, 2017.

Online engagement with 2020 election misinformation and turnout in the 2021 Georgia runoff election.

Following the 2020 general election, Republican elected officials, including then-President Donald Trump, promoted conspiracy theories claiming that Joe Biden's close victory in Georgia was fraudulent. Such conspiratorial claims could implicate participation in the Georgia Senate runoff election in different ways-signaling that voting doesn't matter, distracting from ongoing campaigns, stoking political anger at out-partisans, or providing rationalizations for (lack of) enthusiasm for voting during a transfer of power. Here, we evaluate the possibility of any on-average relationship with turnout by combining behavioral measures of engagement with election conspiracies online and administrative data on voter turnout for 40,000 Twitter users registered to vote in Georgia. We find small, limited associations. Liking or sharing messages opposed to conspiracy theories was associated with higher turnout than expected in the runoff election, and those who liked or shared tweets promoting fraud-related conspiracy theories were slightly less likely to vote.

A baseline of copper associated with antifouling paint in marinas within a large fjord estuary.

Marinas have been shown to contribute elevated concentrations of copper (Cu) to marine waters. The Cu can come primarily from antifouling paints which are designed to discourage biofouling of boat hulls. Legislation in Washington State, USA is being developed to limit or regulate the amount and rate of diffusion of Cu from antifouling paints. This study provides baseline data for Cu in five marinas of different configuration and size within Puget Sound, a large fjord estuary. Samples were collected over a year from multiple environmental media. We find strong evidence that Cu accumulates inside marinas to higher concentrations than outside marinas. Marinas that are more enclosed accumulated higher concentrations of Cu than more open marinas. Using a power analysis, we assessed the adequacy of the baseline dataset to measure progress as a result of future legislation towards the reduction of Cu to Puget Sound from marinas.

Exploring watershed effects on nutrient concentrations in shallow lakes through stable isotope analysis.

Biogeochemistry patterns in shallow lakes are influenced by both in-lake factors such as ecosystem state as well as watershed-level factors such as land use, but the relative importance of in-lake versus watershed factors is poorly known. This knowledge gap makes it difficult for lake mangers to prioritize efforts on watershed versus in-lake strategies for stabilizing the clear-water state. We studied 48 shallow lakes in Minnesota, USA to assess the relative influence of lake size, land use in watersheds, and ecosystem state (turbid versus clear) on water column total nitrogen (TN) and total phosphorus (TP), as well as δ15N and δ13C in three species of fish. Our land use categories included natural areas, row crop agriculture, and all agriculture (row crops plus alfalfa). A model selection approach revealed different control mechanisms on the behavior of stable isotopes and nutrients. δ13C ratios in fish were most strongly influenced by lake size, while δ15N ratios were influenced by all agriculture in watersheds. In contrast, water column TN and TP concentrations were influenced by the in-lake factor of ecosystem state, with both nutrients lower in the clear state. We detected no effects of land use on TN or TP concentrations, likely due to strong effects of ecosystem state masking watershed effects. However, the strong relationship between agriculture and δ15N in fish indicated that watersheds did influence nutrient processing in shallow lakes, and that effects are not a legacy from past watershed events. Collectively, these observations indicate that lake managers should minimize agricultural intensity in shallow lake watersheds to facilitate the clear-water state, which will, in turn reduce water-column TN and TP relative to the turbid state.

COVID-19 increased censorship circumvention and access to sensitive topics in China.

Crisis motivates people to track news closely, and this increased engagement can expose individuals to politically sensitive information unrelated to the initial crisis. We use the case of the COVID-19 outbreak in China to examine how crisis affects information seeking in countries that normally exert significant control over access to media. The crisis spurred censorship circumvention and access to international news and political content on websites blocked in China. Once individuals circumvented censorship, they not only received more information about the crisis itself but also accessed unrelated information that the regime has long censored. Using comparisons to democratic and other authoritarian countries also affected by early outbreaks, the findings suggest that people blocked from accessing information most of the time might disproportionately and collectively access that long-hidden information during a crisis. Evaluations resulting from this access, negative or positive for a government, might draw on both current events and censored history.

Sutimlimab in Cold Agglutinin Disease.

BACKGROUND: Cold agglutinin disease is a rare autoimmune hemolytic anemia characterized by hemolysis that is caused by activation of the classic complement pathway. Sutimlimab, a humanized monoclonal antibody, selectively targets the C1s protein, a C1 complex serine protease responsible for activating this pathway. METHODS: We conducted a 26-week multicenter, open-label, single-group study to assess the efficacy and safety of intravenous sutimlimab in patients with cold agglutinin disease and a recent history of transfusion. The composite primary end point was a normalization of the hemoglobin level to 12 g or more per deciliter or an increase in the hemoglobin level of 2 g or more per deciliter from baseline, without red-cell transfusion or medications prohibited by the protocol. RESULTS: A total of 24 patients were enrolled and received at least one dose of sutimlimab; 13 patients (54%) met the criteria for the composite primary end point. The least-squares mean increase in hemoglobin level was 2.6 g per deciliter at the time of treatment assessment (weeks 23, 25, and 26). A mean hemoglobin level of more than 11 g per deciliter was maintained in patients from week 3 through the end of the study period. The mean bilirubin levels normalized by week 3. A total of 17 patients (71%) did not receive a transfusion from week 5 through week 26. Clinically meaningful reductions in fatigue were observed by week 1 and were maintained throughout the study. Activity in the classic complement pathway was rapidly inhibited, as assessed by a functional assay. Increased hemoglobin levels, reduced bilirubin levels, and reduced fatigue coincided with inhibition of the classic complement pathway. At least one adverse event occurred during the treatment period in 22 patients (92%). Seven patients (29%) had at least one serious adverse event, none of which were determined by the investigators to be related to sutimlimab. No meningococcal infections occurred. CONCLUSIONS: In patients with cold agglutinin disease who received sutimlimab, selective upstream inhibition of activity in the classic complement pathway rapidly halted hemolysis, increased hemoglobin levels, and reduced fatigue. (Funded by Sanofi; CARDINAL ClinicalTrials.gov number, NCT03347396.).

Using a lake sediment record to infer the long-term history of cyanobacteria and the recent rise of an anatoxin producing Dolichospermum sp.

Lakes that experience recurrent toxic cyanobacterial harmful algae blooms (cyanoHABS) are often subject to cultural eutrophication, where landscape development and upland activities increase the nutrient inputs to the water column and fuel cyanoHABS. Few studies have focused on the response of a lake to nutrient inputs for which the natural geomorphic setting predisposes a nutrient-rich water column to already support abundant cyanobacteria. Here, we present a sediment core record from a lake surrounded by parkland that experiences recurrent cyanoHABs which produce dangerous levels of the neurotoxin, anatoxin-a, impacting the recreational use of the lake and park. Using photoautotrophic pigments in the sediment record, we establish cyanobacteria have long been part of the diverse and abundant phytoplankton community within the lake. Despite this long record, shotgun metagenome and other DNA analyses of the sediment record suggest that the current anatoxin-a producer Dolichospermum sp. WA102 only emerged to dominate the cyanobacterial community in the mid-1990s. A period of lakeshore farming that finished in the 1950s-1960s and possibly the stocking of rainbow trout fry (1970-2016) coincide with a progressive shift in primary production, together with a change in bacterial communities. Based on the history of the lake and contemporary ecology of Dolichospermum, we propose that the legacy of nutrient inputs and changes in nutrient cycling within the lake has encouraged the development of an ecosystem where the toxin producing Dolichospermum sp WA102 is highly competitive. Understanding the historical presence of cyanobacteria in the lake provides a context for current-day management strategies of cyanoHABs.

Prevalence and persistence of microcystin in shoreline lake sediments and porewater, and associated potential for human health risk.

Midlatitude waterbodies are experiencing increased cyanobacteria blooms that necessitate health advisories to protect waterbody users. Although surface waters may contain cyanotoxins such as microcystin (MC), at concentrations that pose potential public health risks, little is known about MC contamination of shoreline sediments. Based on growing evidence that lake and reservoir sediments can accumulate MCs, we hypothesized that shoreline sediments (i.e., recreational beaches) may accumulate MCs and thereby pose a potential health risk to recreational users even if people stay out of contaminated water. We sampled nearshore surface water, shoreline sediment, and porewater from seven Washington State, USA, lakes/reservoirs recreational beaches to determine MC presence/absence during or immediately following cyanobacteria blooms. We found MCs in shoreline sediments at all waterbodies using ELISA and LC-MS/MS. MC concentrations in shoreline sediments and porewaters persisted for 20 days following dissipation of cyanobacteria blooms when MC concentrations were near analytical reporting limits in corresponding surface waters. A human health risk assessment based on potential MC exposure through incidental ingestion of porewaters and sediments found, even when very high MC concentrations occur in surface waters (i.e., >11,000 µg/L), estimated ingestion doses are below MC World Health Organization tolerable daily intake and U.S. Environmental Protection Agency's risk reference dose. While our findings suggest MCs in Washington State recreational beaches in 2018 did not present a significant human health risk, future blooms with higher MC concentrations could pose human health risks via the shoreline sediment/porewater exposure pathway.

Toxic Burdens of Freshwater Biofilms and Use as a Source Tracking Tool in Rivers and Streams.

Biofilms, composed of periphyton, bacteria, and organic detritus, are the base of the food web in many streams and rivers. This media adsorbs and actively sequesters organic and inorganic contaminants from the water column. Here, we demonstrate the utility of using the contaminant concentrations in the biofilm matrix as an environmental media in source tracking and understanding biological impacts at higher trophic levels. Physical partitioning of polychlorinated biphenyl (PCB) and polybrominated diphenyl ether congeners is the dominant mode of uptake from water to biofilm and bioaccumulation factor: log Kow relationships suggest that PCB uptake is often near equilibrium between log Kow 5-7. We show that the concentrations of metals in biofilms are more effective at delineating and recording spatial and temporal differences in metal inputs than bed sediments and water samples. The burden of metals in the biofilm matrix explained adverse impacts and variability in periphyton metrics and ecological integrity in macroinvertebrates. This work provides new insights into the partitioning of organic chemicals onto biofilms and shows clear linkages between metals in the biofilm matrix and ecological health of invertebrates that depend on biofilms as a food source.

Freshening by glacial meltwater enhances melting of ice shelves and reduces formation of Antarctic Bottom Water.

Strong heat loss and brine release during sea ice formation in coastal polynyas act to cool and salinify waters on the Antarctic continental shelf. Polynya activity thus both limits the ocean heat flux to the Antarctic Ice Sheet and promotes formation of Dense Shelf Water (DSW), the precursor to Antarctic Bottom Water. However, despite the presence of strong polynyas, DSW is not formed on the Sabrina Coast in East Antarctica and in the Amundsen Sea in West Antarctica. Using a simple ocean model driven by observed forcing, we show that freshwater input from basal melt of ice shelves partially offsets the salt flux by sea ice formation in polynyas found in both regions, preventing full-depth convection and formation of DSW. In the absence of deep convection, warm water that reaches the continental shelf in the bottom layer does not lose much heat to the atmosphere and is thus available to drive the rapid basal melt observed at the Totten Ice Shelf on the Sabrina Coast and at the Dotson and Getz ice shelves in the Amundsen Sea. Our results suggest that increased glacial meltwater input in a warming climate will both reduce Antarctic Bottom Water formation and trigger increased mass loss from the Antarctic Ice Sheet, with consequences for the global overturning circulation and sea level rise.

Dimethyl fumarate increases fetal hemoglobin, provides heme detoxification, and corrects anemia in sickle cell disease.

Sickle cell disease (SCD) results from a point mutation in the ß-globin gene forming hemoglobin S (HbS), which polymerizes in deoxygenated erythrocytes, triggering recurrent painful vaso-occlusive crises and chronic hemolytic anemia. Reactivation of fetal Hb (HbF) expression ameliorates these symptoms of SCD. Nuclear factor (erythroid derived-2)-like 2 (Nrf2) is a transcription factor that triggers cytoprotective and antioxidant pathways to limit oxidative damage and inflammation and increases HbF synthesis in CD34+ stem cell-derived erythroid progenitors. We investigated the ability of dimethyl fumarate (DMF), a small-molecule Nrf2 agonist, to activate γ-globin transcription and enhance HbF in tissue culture and in murine and primate models. DMF recruited Nrf2 to the γ-globin promoters and the locus control region of the ß-globin locus in erythroleukemia cells, elevated HbF in SCD donor-derived erythroid progenitors, and reduced hypoxia-induced sickling. Chronic DMF administration in SCD mice induced HbF and increased Nrf2-dependent genes to detoxify heme and limit inflammation. This improved hematological parameters, reduced plasma-free Hb, and attenuated inflammatory markers. Chronic DMF administration to nonanemic primates increased γ-globin mRNA in BM and HbF protein in rbc. DMF represents a potential therapy for SCD to induce HbF and augment vasoprotection and heme detoxification.

Watershed vs. within-lake drivers of nitrogen: phosphorus dynamics in shallow lakes.

Research on lake eutrophication often identifies variables affecting amounts of phosphorus (P) and nitrogen (N) in lakes, but understanding factors influencing N:P ratios is important given its influence on species composition and toxin production by cyanobacteria. We sampled 80 shallow lakes in Minnesota (USA) for three years to assess effects of watershed size, proportion of watershed as both row crop and natural area, fish biomass, and lake alternative state (turbid vs. clear) on total N : total P (TN : TP), ammonium, total dissolved phosphorus (TDP), and seston stoichiometry. We also examined N:P stoichiometry in 20 additional lakes that shifted states during the study. Last, we assessed the importance of denitrification by measuring denitrification rates in sediment cores from a subset of 34 lakes, and by measuring seston δ15 N in four additional experimental lakes before and after they were experimentally manipulated from turbid to clear states. Results showed alternative state had the largest influence on overall N:P stoichiometry in these systems, as it had the strongest relationship with TN : TP, seston C:N:P, ammonium, and TDP. Turbid lakes had higher N at given levels of P than clear lakes, with TN and ammonium 2-fold and 1.4-fold higher in turbid lakes, respectively. In lakes that shifted states, TN was 3-fold higher in turbid lakes, while TP was only 2-fold higher, supporting the notion N is more responsive to state shifts than is P. Seston δ15 N increased after lakes shifted to clear states, suggesting higher denitrification rates may be important for reducing N levels in clear states, and potential denitrification rates in sediment cores were among the highest recorded in the literature. Overall, our results indicate lake state was a primary driver of N:P dynamics in shallow lakes, and lakes in clear states had much lower N at a given level of P relative to turbid lakes, likely due to higher denitrification rates. Shallow lakes are often managed for the clear-water state due to increased value as wildlife habitat. However, our results indicate lake state also influences N biogeochemistry, such that managing shallow lakes for the clear-water state may also mitigate excess N levels at a landscape scale.