Real-world evaluation of CYP2C19 guided antiplatelet therapy in patients undergoing intracranial aneurysm repair.

Aim: To evaluate the feasibility and impact of using CYP2C19 genotype to guide selection of antiplatelet therapy in patients undergoing intracranial aneurysm treatment with a flow diversion stent in a real-world clinical setting.Patients & methods: A single-center, retrospective, observational cohort study was conducted in 112 patients undergoing intracranial aneurysm repair with flow-diversion stenting from 2014 to 2021. Data were abstracted from health records. The frequency of clopidogrel or alternative therapy (ticagrelor or prasugrel) use was compared across CYP2C19 status (intermediate or poor metabolizer [IM/PM] vs. normal, rapid, or ultrarapid metabolizer [NM/RM/UM]).Results: In the study population, CYP2C19 genotype testing was performed on 110 (98.2%) patients; of these, 106 (97.2%) had results available prior to the stent procedure and 28 (25.5%) were IM/PMs. Alternative therapy was used more frequently in IM/PMs compared with NM/RM/UMs (57.1 vs. 8.5%, respectively, p < 0.0001). The frequency of thromboembolic events over 12 months did not significantly differ across clopidogrel-treated IM/PMs, clopidogrel-treated NM/RM/UMs and patients on alternative therapy (p = 0.352); although, event numbers were low.Conclusion: A pre-emptive CYP2C19 genotyping strategy to guide antiplatelet therapy selection in intracranial aneurysm repair patients is feasible in a real-world clinical setting. Larger studies are needed to assess the impact on clinical outcomes.

This study offers new insight into how CYP2C19 genotyping can be used to more precisely select antiplatelet therapy in neurovascular disease patients undergoing intracranial aneurysm repair with flow diversion stenting.

InSeq analysis of defined Legionella pneumophila libraries identifies a transporter-encoding gene cluster important for intracellular replication in mammalian hosts.

Legionella pneumophila is an intracellular bacterial pathogen that replicates inside human alveolar macrophages to cause a severe pneumonia known as Legionnaires' disease. L. pneumophila requires the Dot/Icm Type IV secretion system to deliver hundreds of bacterial proteins to the host cytosol that manipulate cellular processes to establish a protected compartment for bacterial replication known as the Legionella-containing vacuole. To better understand mechanisms apart from the Dot/Icm system that support survival and replication in this vacuole, we used transposon insertion sequencing in combination with defined mutant sublibraries to identify L. pneumophila fitness determinants in primary mouse macrophages and the mouse lung. This approach validated that many previously identified genes important for intracellular replication were critical for infection of a mammalian host. Further, the screens uncovered additional genes contributing to L. pneumophila replication in mammalian infection models. This included a cluster of seven genes in which insertion mutations resulted in L. pneumophila fitness defects in mammalian hosts. Generation of isogenic deletion mutants and genetic complementation studies verified the importance of genes within this locus for infection of mammalian cells. Genes in this cluster are predicted to encode nucleotide-modifying enzymes, a protein of unknown function, and an atypical ATP-binding cassette (ABC) transporter with significant homology to multidrug efflux pumps that has been named Lit, for Legionella infectivity transporter. Overall, these data provide a comprehensive overview of the bacterial processes that support L. pneumophila replication in a mammalian host and offer insight into the unique challenges posed by the intravacuolar environment.IMPORTANCEIntracellular bacteria employ diverse mechanisms to survive and replicate inside the inhospitable environment of host cells. Legionella pneumophila is an opportunistic human pathogen and a model system for studying intracellular host-pathogen interactions. Transposon sequencing is an invaluable tool for identifying bacterial genes contributing to infection, but current animal models for L. pneumophila are suboptimal for conventional screens using saturated mutant libraries. This study employed a series of defined transposon mutant libraries to identify determinants of L. pneumophila fitness in mammalian hosts, which include a newly identified bacterial transporter called Lit. Understanding the requirements for survival and replication inside host cells informs us about the environment bacteria encounter during infection and the mechanisms they employ to make this environment habitable. Such knowledge will be key to addressing future challenges in treating infections caused by intracellular bacteria.

iNaturalist community observations provide valuable data on human-mosquito encounters.

Mosquitoes (Diptera: Culicidae) and the pathogens they transmit represent a threat to human and animal health. Low-cost and effective surveillance methods are necessary to enable sustainable monitoring of mosquito distributions, diversity, and human interactions. This study examined the use of iNaturalist, an online, community-populated biodiversity recording database, for passive mosquito surveillance in the United Kingdom (UK) and Ireland, countries under threat from the introduction of invasive mosquitoes and emerging mosquito-borne diseases. The Mozzie Monitors UK & Ireland iNaturalist project was established to collate mosquito observations in these countries. Data were compared with existing long-term mosquito UK datasets to assess representativeness of seasonal and distribution trends in citizen scientist-recorded observations. The project collected 738 observations with the majority recorded 2020-2022. Records were primarily associated with urban areas, with the most common species Culex pipiens and Culiseta annulata significantly more likely to be observed in urban areas than other species. Analysis of images uploaded to the iNaturalist project also provided insights into human-biting behavior. Our analyses indicate that iNaturalist provides species composition, seasonal occurrence, and distribution figures consistent with existing datasets and is therefore a useful surveillance tool for recording information on human interactions with mosquitoes and monitoring species of concern.

Forecasting and Hindcasting PFAS Concentrations in Groundwater Discharging to Streams near a PFAS Production Facility.

Per- and polyfluoroalkyl substances (PFAS) are known to be highly persistent in groundwater, making it vital to develop new approaches to important practical questions such as the time scale for future persistence of PFAS in contaminated groundwater. In the approach presented here, groundwater from beneath streambeds was analyzed for PFAS and age-dated using SF6 and 3H/3He. The results were coupled with groundwater flux measurements in a convolution approach to estimate past and future PFAS concentrations in groundwater discharge to the streams. At our test site near the Cape Fear River (CFR) of North Carolina, PFAS were detected in groundwater up to 43 years old, suggesting that some PFAS entered groundwater immediately or shortly after fluorochemical production began at the nearby Fayetteville Works. Results are consistent with little to no retardation in groundwater for perfluoroethers such as hexafluoropropylene oxide-dimer acid (HFPO-DA) and perfluoro-2-methoxypropanoic acid (PMPA), the two most abundant PFAS, with mean concentrations of 229 and 498 ng/L, respectively. Future PFAS concentrations in groundwater discharge to streams were estimated to remain above current MCL or health advisory levels through at least 2050 or 2060 (using 3H/3He and SF6, respectively). Recent atmospheric deposition data suggest lower but non-negligible amounts of PFAS may continue to enter groundwater, likely further extending PFAS persistence in groundwater and the adjacent CFR. This approach shows promise for giving an overall perspective on persistence of PFAS in groundwater discharge from a broad contaminated area.

Highly virulent avian brood-parasitic species show elevated embryonic metabolic rates at specific incubation stages compared to less virulent and non-parasitic species.

As the avian embryo grows and develops within the egg, its metabolic rate gradually increases. Obligate avian brood-parasitic birds lay their eggs in the nests of other species to avoid the costs of parental care, and all but one of these brood-parasitic species are altricial at hatching. Yet the chicks of some altricial brood-parasitic species perform the physically demanding task of evicting, stabbing or otherwise killing host progeny within days of hatching. This implies a need for high metabolic rates in the embryo, just as precocial species require. Using flow-through respirometry in situ, we investigated embryonic metabolic rates in diverse avian brood parasite lineages which either kill host offspring (high virulence) or share the nest with host young (low virulence). High-virulence brood parasite embryos exhibited higher overall metabolic rates than both non-parasitic (parental) species and low-virulence parasites. This was driven by significantly elevated metabolic rates around the halfway point of incubation. Additionally, a fine-scale analysis of the embryos of a host-parasitic pair showed faster increases in metabolic rates in the parasite. Together these results suggest that the metabolic patterns of the embryos of high-virulence parasites facilitate their early-life demands.

Genotype-Guided Antiplatelet Therapy: JACC Review Topic of the Week.

The clinical efficacy and safety of antiplatelet agents vary among patients. Consequently, some patients are at increased risk of recurrent ischemic events during treatment. This interindividual variability can be a result of genetic variants in enzymes that play a role in drug metabolism. The field of pharmacogenomics explores the influence of these genetic variants on an individual's drug response. Tailoring antiplatelet treatment based on genetic variants can potentially result in optimized dosing or a change in drug selection. Most evidence supports guiding therapy based on the CYP2C19 allelic variants in patients with an indication for dual antiplatelet therapy. In ticagrelor-treated or prasugrel-treated patients, a genotype-guided de-escalation strategy can reduce bleeding risk, whereas in patients treated with clopidogrel, an escalation strategy may prevent ischemic events. Although the clinical results are promising, few hospitals have implemented these strategies. New results, technological advancements, and growing experience may potentially overcome current barriers for implementation in the future.

The Thoracolumbar Injury Classification and Severity Score Appropriately Predicts Treatment in Children Aged 10 and Under.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: This study aims to assess the validity of the Thoracolumbar Injury Classification and Severity Score (TLICS) in patients ≤10 years-old. SUMMARY OF BACKGROUND DATA: TLICS is a validated measure developed to help facilitate clinical decision-making regarding thoracolumbar spinal trauma in adults. Studies examining the utility of TLICS in children skew towards older pediatric patients, where the spine's biomechanical properties are more similar to adults. Due to differences in a pre-adolescent spine compared to a more mature, adolescent spine, it is unclear if TLICS can be applied to younger patients. METHODS: A single center spine trauma registry was queried for patients ≤10 with an acute, traumatic thoracolumbar fracture treated at a level-1 pediatric trauma center between 2006 and 2020. Test characteristics and Receiver-Operator Curve were used to evaluate TLICS based on TLICS <4=nonsurgical treatment and TLICS >4=surgery recommendation. RESULTS: We identified 94 patients with traumatic thoracolumbar fractures (surgical=20; non-surgical=74). Despite TLICS-suggested operative management in 28 patients with TLICS>4, 9 (32.1%) were initially treated non-operatively. All patients who deviated from TLICS-suggested treatment had flexion-distraction injuries (FDI). Sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 89.2%, 70.4%, and 100%, respectively. The receiver operating characteristic curve demonstrated strong diagnostic ability of TLICS in predicting need for surgery (area under the curve: 0.97, F1-score: 0.86). CONCLUSION: TLICS score <4 showed strong validity and is highly specific in predicting non-operative management for patients ≤10 years-old with thoracolumbar fractures. However, TLICS >4 has more limited specificity in indicating the necessity for surgical intervention, as many FDIs were successfully treated without surgery. Additional factors other than TLICS score may need to be considered for these more severe injuries to optimize management in this age group.

Viral adaptations to alternative hosts in the honey bee pathogen Paenibacillus larvae.

Bacteriophages (phages) that are intended to be used to treat bacterial infections are often improved using genetic engineering or experimental evolution. A protocol called "Appelmans" utilizes evolution in microtiter plates to promote the evolution of phages that can infect nonpermissive hosts. We tested a modification of the Appelmans protocol using the honey bee pathogen, Paenibacillus larvae. Three phages evolved together on four P. larvae strains following the standard Appelmans protocol and a modified version to ensure high phage diversity throughout ten rounds of passaging. The host range of 360 plaques were characterized and six new phage lysis patterns were identified. These new phage lysis patterns included plaque formation on previously nonpermissive, phage-resistant isolates that were used to identify phage types. The modified protocol did not drastically change the rate or number of new phage types observed but did prevent the phage population from being dominated by one phage that tended to rapidly raise in frequency. These findings showed how a minor modification of the Appelmans protocol influenced the development of phages for phage therapy. The method also provided improved phages for the treatment of bacterial infections in honey bees.

A Survey of Post-Graduate Satisfaction With Orthopaedic Residency Training at a Single Institution.

Background: The Accreditation Council for Graduate Medical Education (ACGME) has called for self-study within residency programs. Post-graduate surveys allow the graduate to reflect upon their residency experience after years of autonomous practice. Despite their potential utility, a standardized assessment of residency training from the perspective of orthopaedic alumni does not exist. In this study, we aimed to create, analyze, and share with our alumni a post-graduate survey based on ACGME core competencies. Methods: The survey was developed by full-time orthopaedic faculty and reviewed by a survey methodologist to ensure clarity and an ideal survey format. In May 2020, the survey was emailed to all 90 graduates from 2000 to 2019. Respondents were polled on current clinical practice and satisfaction with program-specific initiatives, residency requirements, and learning environment issues based on a 7-point Likert scale. Respondents were also given the opportunity to provide open-ended responses. Data were collected within the survey platform and subdivided into 3 cohorts based on years since graduation. Results: The response rate was 71% (64/90). The likelihood of fellowship training increased with recency since graduation. Most respondents are in either private or health-system-owned practice but 23% work in an academic center.The oldest cohort had greater variability in clinical practice. Most program-specific initiatives received high satisfaction scores, but graduates within the past 5 years had the lowest satisfaction scores. Instruction of skills included in ACGME competencies received generally favorable reviews, but professional development skills, such as starting a practice and evaluating job opportunities, received low marks.The overall satisfaction with the program was high (86%) but was lowest among most recent graduates. Conclusion: The post-graduate survey demonstrates areas of strength and weakness and highlights dissatisfaction among recent graduates. The data will drive specific curricular changes within our program. The survey will be shared to promote self-study within other programs.

Leveraging bifactor modeling to test prospective direct and indirect effects of adolescent alcohol use and externalizing symptoms on the development of task-general executive functioning.

Adolescence is a period of substantial maturation in brain regions underlying Executive Functioning (EF). Adolescence is also associated with initiation and escalation of Alcohol Use (AU), and adolescent AU has been proposed to produce physiological and neurobiological events that derail healthy EF development. However, support has been mixed, which may be due to (1) failure to consider co-occurring externalizing symptoms (including other drug use) and poor social adaptation, and (2) heterogeneity and psychometric limitations in EF measures. We aimed to clarify the AU-EF association by: (1) distinguishing general externalizing symptoms from specific symptoms (AU, aggression, drug use) using bifactor modeling, (2) testing prospective associations between general externalizing symptoms and specific symptoms, and task-general EF, as indexed by a well-validated computational modeling framework (diffusion decision model), and (3) examining indirect pathways from externalizing symptoms to deficits in task-general EF through poor social adaptation. A high-risk longitudinal sample (N = 919) from the Michigan Longitudinal Study was assessed at four time-points spanning early adolescence (10-13 years) to young adulthood (22-25). Results suggested a critical role of social adaptation within peer and school contexts in promoting healthy EF. There was no evidence that specific, neurotoxic effects of alcohol or drug use derailed task-general EF development.

Weak link or strong foundation? Vulnerability of fine root networks and stems to xylem embolism.

Resolving the position of roots in the whole-plant hierarchy of drought-induced xylem embolism resistance is fundamental for predicting when species become isolated from soil water resources. Published research generally suggests that roots are the most vulnerable organ of the plant vascular system, although estimates vary significantly. However, our knowledge of root embolism excludes the fine roots (< 2 mm diameter) that form the bulk of total absorptive surface area of the root network for water and nutrient uptake. We measured fine root and stem xylem vulnerability in 10 vascular plant species from the major land plant clades (five angiosperms, three conifers, a fern and lycophyte), using standardised in situ methods (Optical Methods and MicroCT). Mean fine root embolism resistance across the network matched or exceeded stems in all study species. In six of these species (one fern, one lycophyte, three conifers and one angiosperm), fine roots were significantly more embolism resistant than stems. No clear relationship was found between root xylem conduit diameter and vulnerability. These results provide insight into the resistance of the plant hydraulic pathway at the site of water and nutrient uptake, and challenge the long-standing assumption that fine roots are more vulnerable than stems.

Estimated incidence of disruptions to event-free survival from non-metastatic cancers in New South Wales, Australia - a population-wide epidemiological study of linked cancer registry and treatment data.

Introduction: Population cancer registries record primary cancer incidence, mortality and survival for whole populations, but not more timely outcomes such as cancer recurrence, secondary cancers or other complications that disrupt event-free survival. Nonetheless, indirect evidence may be inferred from treatment data to provide indicators of recurrence and like events, which can facilitate earlier assessment of care outcomes. The present study aims to infer such evidence by applying algorithms to linked cancer registry and treatment data obtained from hospitals and universal health insurance claims applicable to the New South Wales (NSW) population of Australia. Materials and methods: Primary invasive cancers from the NSW Cancer Registry (NSWCR), diagnosed in 2001-2018 with localized or regionalized summary stage, were linked to treatment data for five common Australian cancers: breast, colon/rectum, lung, prostate, and skin (melanomas). Clinicians specializing in each cancer type provided guidance on expected treatment pathways and departures to indicate remission and subsequent recurrence or other disruptive events. A sample survey of patients and clinicians served to test initial population-wide results. Following consequent refinement of the algorithms, estimates of recurrence and like events were generated. Their plausibility was assessed by their correspondence with expected outcomes by tumor type and summary stage at diagnosis and by their associations with cancer survival. Results: Kaplan-Meier product limit estimates indicated that 5-year cumulative probabilities of recurrence and other disruptive events were lower, and median times to these events longer, for those staged as localized rather than regionalized. For localized and regionalized cancers respectively, these were: breast - 7% (866 days) and 34% (570 days); colon/rectum - 15% (732 days) and 25% (641 days); lung - 46% (552 days) and 66% (404 days); melanoma - 11% (893 days) and 38% (611 days); and prostate - 14% (742 days) and 39% (478 days). Cases with markers for these events had poorer longer-term survival. Conclusions: These population-wide estimates of recurrence and like events are approximations only. Absent more direct measures, they nonetheless may inform service planning by indicating population or treatment sub-groups at increased risk of recurrence and like events sooner than waiting for deaths to occur.

Seasonal and genetic effects on lipid profiles of juvenile Atlantic salmon.

Seasonality can influence many physiological traits requiring optimal energetic capacity for life-history stage transitions. In Atlantic salmon, high-energy status is essential for the initiation of maturation. Earlier studies have linked a genomic region encoding vgll3 to maturation age, potentially mediated via body condition. Vgll3 has also been shown to act as an inhibitor of adipogenesis in mice. Here we investigate the influence of season and vgll3 genotypes associating with early (EE) and late (LL) maturation on lipid profiles in the muscle and liver of juvenile Atlantic salmon. We reared Atlantic salmon for two years from fertilization and sampled muscle and liver during the spring and autumn of the second year (at which time some males were sexually mature). We found no seasonal or genotype effect in the muscle lipid profiles of immature males or females. However, in the liver we detected a triacylglycerol enrichment and a genotype specific direction of change in membrane lipids, phosphatidylcholine and phosphatidylethanolamine, from spring to autumn. Specifically, from spring to autumn membrane lipid concentrations increased in vgll3*EE individuals but decreased in vgll3*LL individuals. This could be explained by 1) a seasonally more stable capacity of endoplasmic reticulum (ER) functions in vgll3*EE individuals compared to vgll3*LL individuals or 2) vgll3*LL individuals storing larger lipid droplets from spring to autumn in the liver compared to vgll3*EE individuals at the expense of ER capacity. This genotype specific seasonal direction of change in membrane lipid concentrations provides more indirect evidence of a potential mechanism linking vgll3 with lipid metabolism and storage.

Learning outcomes for participants in citizen science mosquito surveillance.

Although citizen science initiatives have been increasing globally, there is still a gap in understanding how they can result in sustainable benefits for citizen scientists. This article addresses dual goals of (i) collecting relevant data on potential vector mosquitoes and (ii) delivering learning outcomes among participants in a citizen science mosquito surveillance program. Mozzie Monitors uses an e-entomology approach to collect and identify mosquitoes of medical importance. This study used quantitative, qualitative, and mixed method approaches, comprised of before and after longitudinal surveys, in-depth interviews and descriptive assessment of mosquito attributes to assess participants' educational gains and data collection scalability. Results showed that mosquito abundance and diversity differed in each study location, with Aedes notoscriptus (Skuse) being the most common mosquito reported in all areas. Citizen scientists were predominantly women over 50 and highly educated. The before-and-after analysis showed that participants learned how to identify the most common mosquito species after participating in the program. They also improved their technical skills in mosquito photography, increasing the rates of identifiable photos. Finally, participating in this citizen science program resulted in behavior changes, with participants starting to look for mosquito eggs and larvae in their backyards to manage mosquito populations. The mixed methods used in this research showed increased participants' confidence, self-efficacy, and engagement throughout the trial. Overall, this study demonstrated the potential of Mozzie Monitors to contribute to the dual goals of mosquito data contribution and citizen scientists' educational outcomes for improved public health.

The aryl hydrocarbon receptor and FOS mediate cytotoxicity induced by Acinetobacter baumannii.

Acinetobacter baumannii is a pathogenic and multidrug-resistant Gram-negative bacterium that causes severe nosocomial infections. To better understand the mechanism of pathogenesis, we compare the proteomes of uninfected and infected human cells, revealing that transcription factor FOS is the host protein most strongly induced by A. baumannii infection. Pharmacological inhibition of FOS reduces the cytotoxicity of A. baumannii in cell-based models, and similar results are also observed in a mouse infection model. A. baumannii outer membrane vesicles (OMVs) are shown to activate the aryl hydrocarbon receptor (AHR) of host cells by inducing the host enzyme tryptophan-2,3-dioxygenase (TDO), producing the ligand kynurenine, which binds AHR. Following ligand binding, AHR is a direct transcriptional activator of the FOS gene. We propose that A. baumannii infection impacts the host tryptophan metabolism and promotes AHR- and FOS-mediated cytotoxicity of infected cells.

Isolation and Characterization of a Frog Virus 3 Strain from a Wood Frog (Rana sylvatica) in Wood Buffalo National Park.

Members of the Iridoviridae family, genus Ranavirus, represent a group of globally emerging pathogens of ecological and economic importance. In 2017, an amphibian die-off of wood frogs (Rana sylvatica) and boreal chorus frogs (Pseudacris maculata) was reported in Wood Buffalo National Park, Canada. Isolation and complete genomic sequencing of the tissues of a wood frog revealed the presence of a frog virus 3 (FV3)-like isolate, Rana sylvatica ranavirus (RSR), with a genome size of 105,895 base pairs, 97 predicted open reading frames (ORFs) bearing sequence similarity to FV3 (99.98%) and a FV3-like isolate from a spotted salamander in Maine (SSME; 99.64%). Despite high sequence similarity, RSR had a unique genomic composition containing ORFs specific to either FV3 or SSME. In addition, RSR had a unique 13 amino acid insertion in ORF 49/50L. No differences were found in the in vitro growth kinetics of FV3, SSME, and RSR; however, genomic differences between these isolates were in non-core genes, implicated in nucleic acid metabolism and immune evasion. This study highlights the importance of viral isolation and complete genomic analysis as these not only provide information on ranavirus spatial distribution but may elucidate genomic factors contributing to host tropism and pathogenicity.

Afterload-induced Decreases in Fatty Acid Oxidation Develop Independently of Increased Glucose Utilization.

Background: Metabolic substrate utilization in HFpEF (heart failure with preserved ejection fraction), the leading cause of heart failure worldwide, is pivotal to syndrome pathogenesis and yet remains ill defined. Under resting conditions, oxidation of free fatty acids (FFA) is the predominant energy source of the heart, supporting its unremitting contractile activity. In the context of disease-related stress, however, a shift toward greater reliance on glucose occurs. In the setting of obesity or diabetes, major contributors to HFpEF pathophysiology, the shift in metabolic substrate use toward glucose is impaired, sometimes attributed to the lower oxygen requirement of glucose oxidation versus fat metabolism. This notion, however, has never been tested conclusively. Furthermore, whereas oxygen demand increases in the setting of increased afterload, myocardial oxygen availability remains adequate for fatty acid oxidation (FAO). Therefore, a "preference" for glucose has been proposed. Methods and Results: Pyruvate dehydrogenase complex (PDC) is the rate-limiting enzyme linking glycolysis to the TCA cycle. As PDK4 (PDC kinase 4) is up-regulated in HFpEF, we over-expressed PDK4 in cardiomyocytes, ensuring that PDC is phosphorylated and thereby inhibited. This leads to diminished use of pyruvate as energy substrate, mimicking the decline in glucose oxidation in HFpEF. Importantly, distinct from HFpEF-associated obesity, this model positioned us to abrogate the load-induced shift to glucose utilization in the absence of systemic high fat conditions. As expected, PDK4 transgenic mice manifested normal cardiac performance at baseline. However, they manifested a rapid and severe decline in contractile performance when challenged with modest increases in afterload triggered either by L-NAME or surgical transverse aortic constriction (TAC). This decline in function was not accompanied by an exacerbation of the myocardial hypertrophic growth response. Surprisingly, metabolic flux analysis revealed that, after TAC, fractional FAO decreased, even when glucose/pyruvate utilization was clamped at very low levels. Additionally, proteins involved in the transport and oxidation of FFA were paradoxically downregulated after TAC regardless of genotype. Conclusions: These data demonstrate that cardiomyocytes in a setting in which glucose utilization is robustly diminished and prevented from increasing do not compensate for the deficit in glucose utilization by up-regulating FFA use.

Mitochondrial complex I promotes kidney cancer metastasis.

Most kidney cancers are metabolically dysfunctional1-4, but how this dysfunction affects cancer progression in humans is unknown. We infused 13C-labelled nutrients in over 80 patients with kidney cancer during surgical tumour resection. Labelling from [U-13C]glucose varies across subtypes, indicating that the kidney environment alone cannot account for all tumour metabolic reprogramming. Compared with the adjacent kidney, clear cell renal cell carcinomas (ccRCCs) display suppressed labelling of tricarboxylic acid (TCA) cycle intermediates in vivo and in ex vivo organotypic cultures, indicating that suppressed labelling is tissue intrinsic. [1,2-13C]acetate and [U-13C]glutamine infusions in patients, coupled with measurements of respiration in isolated human kidney and tumour mitochondria, reveal lower electron transport chain activity in ccRCCs that contributes to decreased oxidative and enhanced reductive TCA cycle labelling. However, ccRCC metastases unexpectedly have enhanced TCA cycle labelling compared with that of primary ccRCCs, indicating a divergent metabolic program during metastasis in patients. In mice, stimulating respiration or NADH recycling in kidney cancer cells is sufficient to promote metastasis, whereas inhibiting electron transport chain complex I decreases metastasis. These findings in humans and mice indicate that metabolic properties and liabilities evolve during kidney cancer progression, and that mitochondrial function is limiting for metastasis but not growth at the original site.