Impact of a passive clinical decision support tool on potentially inappropriate medications (PIM) use in older adult patients.

BACKGROUND: Medication related clinical decision support (CDS) interventions may improve patient safety. In older patient populations, there has been effort placed in reducing exposure to potentially inappropriate medications (PIMs). After years of reducing exposure of older adults in our hospitals to PIMs through multi-component interventions, our system chose to expand the scope and attempt a new strategy to lessen alert burden for providers and pharmacists. Based on the American Geriatric Society Beers Criteria and internal data, a passive CDS approach, termed "geriatric context" was established to recommend appropriate medication selection including lower dosage amounts and frequency of administration in older adults. METHODS: Retrospective descriptive study examining change in a pre and post implementation analysis of medication usage patterns between two 9-month time periods in 2019 and 2021 in patients age ≥65 years across an 8-hospital health system. The primary endpoint is the percentage of each medication intervened with an ordered dose and frequency outside of alignment with recommended context parameters. Secondary endpoints include total daily dose (TDD) and average dose (AD) per patient of the individual PIMs. Exploratory endpoints include frequency of active alerts fired by the CPOE and overridden by providers. RESULTS: A total of 62,738 older adult hospital admissions are included in the overall study period, with 32,969 pre-implementation and 29,769 post-implementation. Haloperidol showed the greatest reduction in inappropriate doses from 41.5% to 21.4% (p < 0.001) of orders, followed by reduction in inappropriate frequencies in orders for diphenhydramine from 57.2% to 39.7% (p < 0.001). Secondary endpoints showed favorable reductions across 11 of the 16 medications in both TDD and AD administered. Exploratory analysis with select medications showed reductions in frequency of alerts fired and overridden. CONCLUSIONS: Utilization of a passive CDS positively influences prescribing patterns for older adults and reduces the alert burden to ordering providers.

Predicting TCR-Epitope Binding Specificity Using Deep Metric Learning and Multimodal Learning.

Understanding the recognition of specific epitopes by cytotoxic T cells is a central problem in immunology. Although predicting binding between peptides and the class I Major Histocompatibility Complex (MHC) has had success, predicting interactions between T cell receptors (TCRs) and MHC class I-peptide complexes (pMHC) remains elusive. This paper utilizes a convolutional neural network model employing deep metric learning and multimodal learning to perform two critical tasks in TCR-epitope binding prediction: identifying the TCRs that bind a given epitope from a TCR repertoire, and identifying the binding epitope of a given TCR from a list of candidate epitopes. Our model can perform both tasks simultaneously and reveals that inconsistent preprocessing of TCR sequences can confound binding prediction. Applying a neural network interpretation method identifies key amino acid sequence patterns and positions within the TCR, important for binding specificity. Contrary to common assumption, known crystal structures of TCR-pMHC complexes show that the predicted salient amino acid positions are not necessarily the closest to the epitopes, implying that physical proximity may not be a good proxy for importance in determining TCR-epitope specificity. Our work thus provides an insight into the learned predictive features of TCR-epitope binding specificity and advances the associated classification tasks.

Targeted exon skipping with AAV-mediated split adenine base editors.

Techniques for exclusion of exons from mature transcripts have been applied as gene therapies for treating many different diseases. Since exon skipping has been traditionally accomplished using technologies that have a transient effect, it is particularly important to develop new techniques that enable permanent exon skipping. We have recently shown that this can be accomplished using cytidine base editors for permanently disabling the splice acceptor of target exons. We now demonstrate the application of CRISPR-Cas9 adenine deaminase base editors to disrupt the conserved adenine within splice acceptor sites for programmable exon skipping. We also demonstrate that by altering the amino acid sequence of the linker between the adenosine deaminase domain and the Cas9-nickase or by coupling the adenine base editor with a uracil glycosylase inhibitor, the DNA editing efficiency and exon-skipping rates improve significantly. Finally, we developed a split base editor architecture compatible with adeno-associated viral packaging. Collectively, these results represent significant progress toward permanent in vivo exon skipping through base editing and, ultimately, a new modality of gene therapy for the treatment of genetic diseases.

Erratum: Author Correction: Targeted exon skipping with AAV-mediated split adenine base editors.

[This corrects the article DOI: 10.1038/s41421-019-0109-7.].

Single-Cell Transcriptomics Reveals Spatial and Temporal Turnover of Keratinocyte Differentiation Regulators.

Keratinocyte differentiation requires intricately coordinated spatiotemporal expression changes that specify epidermis structure and function. This article utilizes single-cell RNA-seq data from 22,338 human foreskin keratinocytes to reconstruct the transcriptional regulation of skin development and homeostasis genes, organizing them by differentiation stage and also into transcription factor (TF)-associated modules. We identify groups of TFs characterized by coordinate expression changes during progression from the undifferentiated basal to the differentiated state and show that these TFs also have concordant differential predicted binding enrichment in the super-enhancers previously reported to turn over between the two states. The identified TFs form a core subset of the regulators controlling gene modules essential for basal and differentiated keratinocyte functions, supporting their nomination as master coordinators of keratinocyte differentiation. Experimental depletion of the TFs ZBED2 and ETV4, both predicted to promote the basal state, induces differentiation. Furthermore, our single-cell RNA expression analysis reveals preferential expression of antioxidant genes in the basal state, suggesting keratinocytes actively suppress reactive oxygen species to maintain the undifferentiated state. Overall, our work demonstrates diverse computational methods to advance our understanding of dynamic gene regulation in development.

CRISPR-SKIP: programmable gene splicing with single base editors.

CRISPR gene editing has revolutionized biomedicine and biotechnology by providing a simple means to engineer genes through targeted double-strand breaks in the genomic DNA of living cells. However, given the stochasticity of cellular DNA repair mechanisms and the potential for off-target mutations, technologies capable of introducing targeted changes with increased precision, such as single-base editors, are preferred. We present a versatile method termed CRISPR-SKIP that utilizes cytidine deaminase single-base editors to program exon skipping by mutating target DNA bases within splice acceptor sites. Given its simplicity and precision, CRISPR-SKIP will be broadly applicable in gene therapy and synthetic biology.