Saturation genome editing of DDX3X clarifies pathogenicity of germline and somatic variation.

Loss-of-function of DDX3X is a leading cause of neurodevelopmental disorders (NDD) in females. DDX3X is also a somatically mutated cancer driver gene proposed to have tumour promoting and suppressing effects. We perform saturation genome editing of DDX3X, testing in vitro the functional impact of 12,776 nucleotide variants. We identify 3432 functionally abnormal variants, in three distinct classes. We train a machine learning classifier to identify functionally abnormal variants of NDD-relevance. This classifier has at least 97% sensitivity and 99% specificity to detect variants pathogenic for NDD, substantially out-performing in silico predictors, and resolving up to 93% of variants of uncertain significance. Moreover, functionally-abnormal variants can account for almost all of the excess nonsynonymous DDX3X somatic mutations seen in DDX3X-driven cancers. Systematic maps of variant effects generated in experimentally tractable cell types have the potential to transform clinical interpretation of both germline and somatic disease-associated variation.

The NIH childhood adversity portfolio: unmet needs, emerging challenges.

Despite the significant increase in pediatric funding, an important question is whether recent changes in the burden of disease and conditions (child and adolescent mortality and nonfatal health loss) are reflected in the National Institutes of Health's (NIH) allocation process. As it sets future priorities, NIH acknowledges "a need to scan the landscape for unmet needs and emerging challenges" so that supported "research translates into meaningful health benefits." Our focus is to scan the pediatric budgetary landscape, report research funding for childhood adversity and adverse childhood experiences, and to illuminate gun violence, suicide, and drug abuse/overdose as prime examples of pediatric unmet needs and emerging challenges. Our findings suggest that pediatric researchers must reconceptualize gun violence as a form of childhood adversity and adverse childhood experiences, as we also need to do for other leading causes of child and adolescent mortality such as suicide and drug abuse/overdose. As it relates to the leading cause of death for children and adolescents, pediatric-related gun violence research spending remains only 0.0017% of the NIH pediatric portfolio. IMPACT: New data on NIH spending on ACEs and childhood adversity. New data to assess the relationship of spending to pediatric burden of disease. New data on pediatrics-related gun violence, suicide and drug abuse/overdose spending.

The state and future of pediatric research-an introductory overview : The state and future of pediatric research series.

IMPACT: This is an introduction to an article series devoted to the current state and future of pediatric research. The role of public-private partnerships, influencing factors, challenges, and recent trends in pediatric research are described, with emphasis on funding, drug and device development, physician-scientist training, and diversity. Potential solutions and advocacy opportunities are discussed.

Making the case for pediatric research: a life-cycle approach and the return on investment.

There is unmistakable evidence of increased NIH funding for pediatric and perinatal research, but there is much work to be done. To further promote NIH-funded pediatric and perinatal research, we advocate for a life-cycle approach in which the return on the investment continues over the lifespan. Although elected policymakers have short-time horizons, pediatric and perinatal researchers must provide novel evidence and theoretical arguments demonstrating the long-term health benefits for the adults of tomorrow by improving the health of our current pediatric populations. Child health researchers must communicate the role of early developmental events on childhood and adult disease, including those that are prenatal and gestational so that its importance is understood by the public and policymakers.

Gain-of-function factor H-related 5 protein impairs glomerular complement regulation resulting in kidney damage.

Genetic variation within the factor H-related (FHR) genes is associated with the complement-mediated kidney disease, C3 glomerulopathy (C3G). There is no definitive treatment for C3G, and a significant proportion of patients develop end-stage renal disease. The prototypical example is CFHR5 nephropathy, through which an internal duplication within a single CFHR5 gene generates a mutant FHR5 protein (FHR5mut) that leads to accumulation of complement C3 within glomeruli. To elucidate how abnormal FHR proteins cause C3G, we modeled CFHR5 nephropathy in mice. Animals lacking the murine factor H (FH) and FHR proteins, but coexpressing human FH and FHR5mut (hFH-FHR5mut), developed glomerular C3 deposition, whereas mice coexpressing human FH with the normal FHR5 protein (hFH-FHR5) did not. Like in patients, the FHR5mut had a dominant gain-of-function effect, and when administered in hFH-FHR5 mice, it triggered C3 deposition. Importantly, adeno-associated virus vector-delivered homodimeric mini-FH, a molecule with superior surface C3 binding compared to FH, reduced glomerular C3 deposition in the presence of the FHR5mut. Our data demonstrate that FHR5mut causes C3G by disrupting the homeostatic regulation of complement within the kidney and is directly pathogenic in C3G. These results support the use of FH-derived molecules with enhanced C3 binding for treating C3G associated with abnormal FHR proteins. They also suggest that targeting FHR5 represents a way to treat complement-mediated kidney injury.

The uncertain fate of the National Institutes of Health (NIH) pediatric research portfolio.

BACKGROUND: The amount of federal dollars allocated to improving the health of our pediatric population can serve as an indicator of the priority placed on child well-being. Although Congress has established novel mechanisms that marginally increase pediatric research funding, the pediatric research portfolio is facing an increasingly uncertain fate. METHODS: This work examines pediatric, perinatal and pediatric research initiative (PRI) spending using data collected by the NIH that uses the novel research, condition and disease categorization system. Further, this work reports on recent policy developments in pediatric biomedical research and offers recommendations to insulate this portfolio from future uncertainty. RESULTS: Federal support for pediatric research has declined with average annual growth rates of NIH pediatric spending dropping from 12.8% (FY 1998-2003) to 1.7% (FY 2004-2015). After taking into account Biomedical Research and Development Price Index growth, the pediatric research portfolio's purchasing power has declined by 15.9% (FY 2004-2015). CONCLUSION: Federal support for pediatric biomedical research has plateaued in nominal terms and declined significantly in real terms. Future congressional action will be necessary to protect gains and to expand the capacity of the pediatric portfolio.

The Fragile State of the National Institutes of Health Pediatric Research Portfolio, 1992-2015: Doing More With Less?

In this article, we examine the status of the National Institutes of Health (NIH) pediatric research portfolio between start of federal fiscal year (FY) 1992 and end of FY 2015. The NIH experienced the greatest mean annual growth rate during the "doubling era" (FY 1998-2003): both the NIH budget (13.5%) and pediatric research portfolios (11.5%) increased annually by double digits. However, in the "postdoubling" era (FY 2004-2009), both the NIH (2.0%) and pediatric (-0.2%) mean annual growth rates decreased dramatically. In the most recent era (FY 2010-2015), the NIH mean annual growth rate has been flat (-0.1%) and pediatric research funding has posted very modest gains (3.5%) without accounting for 1-time increases under the 2009 American Recovery and Reinvestment Act. We offer recommendations to protect against further erosion of the pediatric research portfolio because continuation of these trends will have a negative effect on the health of children during their childhood and as adults. As capacity to conduct basic and applied research is further constrained, it will be a challenge for pediatric researchers to do more with less and less.

Designing and implementing a comparative effectiveness study of two strategies for delivering high quality CHD prevention: methods and participant characteristics for the Heart to Health study.

BACKGROUND: Although lifestyle and medications are effective for coronary heart disease (CHD) risk reduction, few studies have examined the comparative effectiveness of various strategies for delivering high quality CHD risk reduction. In this paper, we report on the design and baseline characteristics of participants for just such a trial. METHODS: We conducted a randomized trial of the same lifestyle and medication intervention delivered in two alternate formats: counselor-delivered or web-based. The trial was conducted at 5 diverse practices in a family medicine research network and included men and women age 35-79 who were at high risk of CHD events based on 10-year predicted Framingham risk of ≥10% or a known history of cardiovascular disease. After individual-level randomization, participants in both arms received a decision aid plus four intensive intervention visits and 3 maintenance visits over 12 months. The primary outcome was change in 10-year predicted CHD risk among patients without prior cardiovascular disease. Secondary outcomes, measured among all participants, included changes in CHD risk factors, cost-effectiveness, and acceptability at 4 and 12-month follow-up. RESULTS: We randomized 489 eligible patients: 389 without and 100 with a known history of cardiovascular disease. Mean age was 62.3. 75% were white, 25% African-American. 45% had a college education. 88% had health insurance. Mean 10-year predicted CHD risk was 16.9%. CONCLUSION: We have successfully recruited a diverse sample of practices and patients that will provide a rich sample in which to test the comparative effectiveness of two strategies to implement high quality CHD prevention.

Isocitrate dehydrogenase (IDH) mutations promote a reversible ZEB1/microRNA (miR)-200-dependent epithelial-mesenchymal transition (EMT).

Mutations in the genes encoding isocitrate dehydrogenase 1 and 2 (IDH1/2) occur in a variety of tumor types, resulting in production of the proposed oncometabolite, 2-hydroxyglutarate (2-HG). How mutant IDH and 2-HG alter signaling pathways to promote cancer, however, remains unclear. Additionally, there exist relatively few cell lines with IDH mutations. To examine the effect of endogenous IDH mutations and 2-HG, we created a panel of isogenic epithelial cell lines with either wild-type IDH1/2 or clinically relevant IDH1/2 mutations. Differences were noted in the ability of IDH mutations to cause robust 2-HG accumulation. IDH1/2 mutants that produce high levels of 2-HG cause an epithelial-mesenchymal transition (EMT)-like phenotype, characterized by changes in EMT-related gene expression and cellular morphology. 2-HG is sufficient to recapitulate aspects of this phenotype in the absence of an IDH mutation. In the cells types examined, mutant IDH-induced EMT is dependent on up-regulation of the transcription factor ZEB1 and down-regulation of the miR-200 family of microRNAs. Furthermore, sustained knockdown of IDH1 in IDH1 R132H mutant cells is sufficient to reverse many characteristics of EMT, demonstrating that continued expression of mutant IDH is required to maintain this phenotype. These results suggest mutant IDH proteins can reversibly deregulate discrete signaling pathways that contribute to tumorigenesis.

Child health research funding and policy: imperatives and investments for a healthier world.

Although pediatric research enjoyed significant benefits during the National Institutes of Health (NIH) doubling era, the proportion of the NIH budget devoted to the pediatric-research portfolio has declined overall. In light of this declining support for pediatric biomedical research, the Federation of Pediatric Organizations held a topic symposium at the 2009 Pediatric Academic Societies annual meeting as a forum for discussion of the past and future states of funding, the rationale for directing public funds toward the understanding of child health and disease, and new programs and paradigms for promoting child health research. This report of the symposium is intended to disseminate more broadly the information presented and conclusions discussed to encourage those in the child health research community to exert influence with policy makers to increase the allocation of national funding for this underfunded area.

That sinking feeling, again? The state of National Institutes of Health pediatric research funding, fiscal year 1992-2010.

This review article examines the National Institutes of Health's (NIH) overall budget and its pediatric research funding across three time periods: predoubling [fiscal year (FY) 1992-1997]; doubling (FY 1998-2003); and postdoubling (FY 2004-2009). The average annual NIH appropriations increased by 5.4%, 13.4%, and 1.3% in each period, respectively. The average annual pediatric research funding (actual grants, contracts, intramural research, and other mechanisms of support) increased much less, by 4.7%, 11.5%, and 0.3% in each period, respectively. Between FY 2004 and FY 2007, the average NIH budget increase has nearly flattened, to only 1.96%. During this period, average pediatric research funding has dropped markedly lower, to 0.57%; estimated FY 2008 pediatric funding is at negative 0.5%. Although pediatric research enjoyed significant benefits of the NIH doubling era, the proportion of the NIH budget devoted to the pediatric research portfolio has declined overall. The most recent period has wiped out the annual gains of the doubling era for both pediatric and overall NIH research funding. We offer recommendations to protect against further erosion of pediatric research funding and to implement several unfulfilled commitments to strengthen the federal pediatric research portfolio in the coming decade.

Stretch-induced injury in organotypic hippocampal slice cultures reproduces in vivo post-traumatic neurodegeneration: role of glutamate receptors and voltage-dependent calcium channels.

The relationship between an initial mechanical event causing brain tissue deformation and delayed neurodegeneration in vivo is complex because of the multiplicity of factors involved. We have used a simplified brain surrogate based on rat hippocampal slices grown on deformable silicone membranes to study stretch-induced traumatic brain injury. Traumatic injury was induced by stretching the culture substrate, and the biological response characterized after 4 days. Morphological abnormalities consistent with traumatic injury in humans were widely observed in injured cultures. Synaptic function was significantly reduced after a severe injury. The N-methyl-D-aspartate (NMDA) receptor antagonist MK-801 attenuated neuronal damage, prevented loss of microtubule-associated protein 2 immunoreactivity and attenuated reduction of synaptic function. In contrast, the NMDA receptor antagonists 3-[(R)-2-carboxypiperazin-4-yl]-propyl-1-phosphonic acid (CPP) and GYKI53655, were neuroprotective in a moderate but not a severe injury paradigm. Nifedipine, an L-type voltage-dependent calcium channel antagonist was protective only after a moderate injury, whereas omega-conotoxin attenuated damage following severe injury. These results indicate that the mechanism of damage following stretch injury is complex and varies depending on the severity of the insult. In conclusion, the pharmacological, morphological and electrophysiological responses of organotypic hippocampal slice cultures to stretch injury were similar to those observed in vivo. Our model provides an alternative to animal testing for understanding the mechanisms of post-traumatic delayed cell death and could be used as a high-content screen to discover neuroprotective compounds before advancing to in vivo models.

New directions for public health care purchasers? Responses to looming challenges.

State public employee health plans (PEHPs) provide health benefits for millions of state and local workers, retirees, and their dependents nationwide. This paper explores major issues and challenges that PEHP leaders and state policymakers are addressing. These include the perennial challenge of funding benefits for a diverse and aging workforce; new accounting standards affecting public employers; and the changing relationship between states, retired public employees, and the Medicare program. Interviews with PEHP executives explored whether these are incremental challenges to which states can effectively adapt, or whether these challenges will catalyze broader and lasting change in the public employee and retiree health benefits arena.

Did a rising tide lift all boats? The NIH budget and pediatric research portfolio.

This paper examines National Institutes of Health (NIH) pediatric research spending in absolute terms and relative to the doubling of the NIH overall budget between fiscal years 1998 and 2003. Pediatric spending increased by an average annual rate of 12.8 percent during the doubling period (almost on par with the NIH average annual growth rate of 14.7 percent). However, the proportion of the total NIH budget devoted to the pediatric portfolio declined from 12.3 to 11.3 percent. We offer recommendations for implementing existing commitments to strengthen the pediatric research portfolio and to protect the gains of the doubling period.