In situ microwave fixation provides an instantaneous snapshot of the brain metabolome.

Brain glucose metabolism is highly heterogeneous among brain regions and continues postmortem. In particular, we demonstrate exhaustion of glycogen and glucose and an increase in lactate production during conventional rapid brain resection and preservation by liquid nitrogen. In contrast, we show that these postmortem changes are not observed with simultaneous animal sacrifice and in situ fixation with focused, high-power microwave. We further employ microwave fixation to define brain glucose metabolism in the mouse model of streptozotocin-induced type 1 diabetes. Using both total pool and isotope tracing analyses, we identified global glucose hypometabolism in multiple brain regions, evidenced by reduced 13C enrichment into glycogen, glycolysis, and the tricarboxylic acid (TCA) cycle. Reduced glucose metabolism correlated with a marked decrease in GLUT2 expression and several metabolic enzymes in unique brain regions. In conclusion, our study supports the incorporation of microwave fixation for more accurate studies of brain metabolism in rodent models.

Income disparities in mental health: investigating the role of food insecurity by disability status.

OBJECTIVE: To investigate whether food insecurity helps explain the association between income and psychological distress and if its role differs by disability status. DESIGN: Using 2011-2017 National Health Interview Survey cross-sectional data (n 102 543), we conducted linear regression models, fully interacted with disability status, to estimate the association between income-to-poverty ratio (IPR) (<1, 1-<2, 2-<4, ≥4) and psychological distress (Kessler 6 (K6) Scale, range: 0-24). Base models adjusted for socio-demographic factors. We then added food security (secure, low and very low), interacted with disability, and conducted post-estimation adjusted Wald tests. SETTING: USA. PARTICIPANTS: Nationally representative sample of non-institutionalised adults 18 years and older. RESULTS: The association between income and psychological distress was stronger for people with disabilities. Compared to those in the highest income category (IPR ≥4), poor individuals (IPR < 1) with and without disabilities scored 2·10 (95 % CI (1·74, 2·46)) and 0·81 (95 % CI (0·69, 0·93)) points higher on the K6 Scale, respectively. Accounting for food insecurity reduced the estimated income disparity in psychological distress significantly more among individuals with disabilities (0·96 points or 46 %) than without disabilities (0·34 points or 42 %), decreasing the difference in the income disparity between those with and without disabilities by 48 % (0·62 points). Further, food insecurity more strongly predicted psychological distress for individuals with disabilities independent of socio-economic disadvantage. CONCLUSIONS: Food insecurity plays a more important role in shaping patterns of psychological distress for people with disabilities, explaining more of the association between income and psychological distress among those with than without disabilities. Improving food security may reduce mental health disparities.

The Compounded Burden of Poverty on Mental Health for People with Disabilities.

Using 2008-2017 National Health Interview Survey data (N = 127,973), we investigated the relationship between income and psychological distress, measured by the Kessler 6 (K6) Scale (range 0-24), net of education, employment, and other sociodemographic characteristics. Regression models allowed the association to differ by disability status and number of disabilities. Lower income predicted higher psychological distress for those with and without disabilities. However, the adverse association was stronger among people with disabilities. Compared to those with incomes at least four times the poverty threshold, poor individuals with disabilities scored 2.81 (95% CI = 2.55,3.67) points higher on the K6 Scale versus 0.58 (95% CI = 0.48,0.69) points higher for those without disabilities. Differences in associations by number of disabilities were not statistically significant. Nonetheless, those with multiple disabilities were still at increased risk of distress because they were disproportionately poor. People with disabilities who are poor are particularly disadvantaged and should be prioritized in outreach efforts.

Prenatal Treatment of Thyroid Hormone Cell Membrane Transport Defect Caused by MCT8 Gene Mutation.

Background: Mutations of the thyroid hormone (TH)-specific cell membrane transporter, monocarboxylate transporter 8 (MCT8), produce an X-chromosome-linked syndrome of TH deficiency in the brain and excess in peripheral tissues. The clinical consequences include brain hypothyroidism causing severe psychoneuromotor abnormalities (no speech, truncal hypotonia, and spastic quadriplegia) and hypermetabolism (poor weight gain, tachycardia, and increased metabolism, associated with high serum levels of the active TH, T3). Treatment in infancy and childhood with TH analogues that reduce serum triiodothyronine (T3) corrects hypermetabolism, but has no effect on the psychoneuromotor deficits. Studies of brain from a 30-week-old MCT8-deficient embryo indicated that brain abnormalities were already present during fetal life. Methods: A carrier woman with an affected male child (MCT8 A252fs268*), pregnant with a second affected male embryo, elected to carry the pregnancy to term. We treated the fetus with weekly 500 µg intra-amniotic instillation of levothyroxine (LT4) from 18 weeks of gestation until birth at 35 weeks. Thyroxine (T4), T3, and thyrotropin (TSH) were measured in the amniotic fluid and maternal serum. Treatment after birth was continued with LT4 and propylthiouracil. Follow-up included brain magnetic resonance imaging (MRI) and neurodevelopmental evaluation, both compared with the untreated brother. Results: During intrauterine life, T4 and T3 in the amniotic fluid were maintained above threefold to twofold the baseline and TSH was suppressed by 80%, while maternal serum levels remained unchanged. At birth, the infant serum T4 was 14.5 µg/dL and TSH <0.01 mU/L compared with the average in untreated MCT8-deficient infants of 5.1 µg/ and >8 mU/L, respectively. MRI at six months of age showed near-normal brain myelination compared with much reduced in the untreated brother. Neurodevelopmental assessment showed developmental quotients in receptive language and problem-solving, and gross motor and fine motor function ranged from 12 to 25 at 31 months in the treated boy and from 1 to 7 at 58 months in the untreated brother. Conclusions: This is the first demonstration that prenatal treatment improved the neuromotor and neurocognitive function in MCT8 deficiency. Earlier treatment with TH analogues that concentrate in the fetus when given to the mother may further rescue the phenotype.

Functional characterization of ATF1, GREM2 AND WNT10B variants associated with tooth agenesis.

OBJECTIVE: To determine the functional effects of ATF1, WNT10B and GREM2 gene variants identified in individuals with tooth agenesis (TA). SETTINGS AND SAMPLE POPULATION: Stem cells from human exfoliated deciduous teeth (SHED) were used as an in vitro model system to test the effect of TA-associated variants. MATERIALS AND METHODS: Plasmid constructs containing reference and mutant alleles for ATF1 rs11169552, WNT10B rs833843 and GREM2 rs1414655 variants were transfected into SHED for functional characterization of variants. Allele-specific changes in gene transcription activity, protein expression, cell migration and proliferation, and expression of additional tooth development genes (MSX1, PAX9 and AXIN2) were evaluated. Data analyses were performed using Student's t-test. P-values ≤ .05 were considered statistically significant. RESULTS: Mutant variants resulted in significantly decreased transcriptional activity of respective genes (P < 0.05), although no changes in protein localization were noted. Expression of MSX1 was significantly decreased in ATF1- and GREM2-mutant cells, whereas PAX9 or AXIN2 mRNA expression was not significantly altered. Mutant WNT10B had no significant effect on the expression of additional TA genes. ATF1- and GREM2-mutant cells presented increased cell migration. Cell proliferation was also affected with all three mutant alleles. CONCLUSIONS: Our results demonstrate that ATF1, WNT10B and GREM2 mutant alleles have modulatory effects on gene/protein function that may contribute to TA.

Seeking Consensus on the Terminology of Value-Based Transformation Through use of a Delphi Process.

Collaboration among diverse stakeholders involved in the value transformation of health care requires consistent use of terminology. The objective of this study was to reach consensus definitions for the terms value-based care, value-based payment, and population health. A modified Delphi process was conducted from February 2017 to July 2017. An in-person panel meeting was followed by 3 rounds of surveys. Panelists anonymously rated individual components of definitions and full definitions on a 9-point Likert scale. Definitions were modified in an iterative process based on results of each survey round. Participants were a panel of 18 national leaders representing population health, health care delivery, academic medicine, payers, patient advocacy, and health care foundations. Main measures were survey ratings of definition components and definitions. At the conclusion of round 3, consensus was reached on the following definition for value-based payment, with 13 of 18 panelists (72.2%) assigning a high rating (7- 9) and 1 of 18 (5.6%) assigning a low rating (1-3): "Value-based payment aligns reimbursement with achievement of value-based care (health outcomes/cost) in a defined population with providers held accountable for achieving financial goals and health outcomes. Value-based payment encourages optimal care delivery, including coordination across healthcare disciplines and between the health care system and community resources, to improve health outcomes, for both individuals and populations." The iterative process elucidated specific areas of agreement and disagreement for value-based care and population health but did not reach consensus. Policy makers cannot assume uniform interpretation of other concepts underlying health care reform efforts.

An Anatomic and Clinical Study of the Innervation of the Dorsal Midfoot Capsule.

BACKGROUND: Dorsal pain from osteoarthritic midfoot joints is thought to be relayed by branches of the medial and lateral plantar, sural, saphenous, and deep peroneal nerves (DPN). However, there is no consensus on the actual number or pathways of the nervous branches for midfoot joint capsular innervation. This study examined the DPN's terminal branches at the midfoot joint capsules through anatomic dissection and confirmation of their significance in a clinical case series of patients with midfoot pain relief after DPN block. METHODS: Eleven cadaveric lower leg specimens, 6 left and 5 right, were dissected using operative loupe magnification. We preserved the terminal branches and recorded their paths and branching patterns. Joint capsular innervations were individually noted. To confirm our hypothesis of significant dorsal midfoot joint capsular innervation by the DPN, we also performed an institutional review board-approved retrospective chart review of 37 patients with painful dorsal midfoot osteoarthritis who underwent diagnostic local anesthetic injection block of the DPN. The percentage of temporary pain relief after the injection was recorded. RESULTS: Terminal innervation of the DPN branches showed distribution of the second and third tarsometatarsal joints in all specimens. Inconsistent innervation of the naviculocuneiform (9/11), fourth (7/11), first (6/11), and fifth (4/11) tarsometatarsal and calcaneocuboid joints (1/11) were observed. The retrospective review of pain relief in patients with dorsal midfoot pain due to arthritis after diagnostic injection demonstrated a mean of 92.1% improvement. CONCLUSION: Innervation of the dorsal midfoot joint capsule appears to follow a consistent distribution across 3 joints: second and third tarsometatarsal joints and the naviculocuneiform joint. Acute relief of dorsal midfoot arthritic pain after diagnostic injection suggests that dorsal midfoot nociceptive pain is at least partly transmitted by the DPN. LEVEL OF EVIDENCE: Level IV, case series.

Further evidence for the role of WNT10A, WNT10B and GREM2 as candidate genes for isolated tooth agenesis.

OBJECTIVE: To investigate the association of single nucleotide variants in the candidate genes WNT10A, WNT10B and GREM2 with isolated tooth agenesis. SETTING AND SAMPLE POPULATION: A total of 435 Caucasian individuals (88 cases with isolated tooth agenesis and 347 unrelated controls) were ascertained at the University of Texas Health Science Center at Houston School of Dentistry. Clinical and radiographic examination by orthodontists confirmed the diagnosis of tooth agenesis. Genetic evaluation excluded syndromic forms of tooth agenesis. MATERIALS AND METHODS: Saliva samples were collected as source of genomic DNA. Fourteen variants in/nearby WNT10A, WNT10B and GREM2 were genotyped to test for association with tooth agenesis. Genotyping was performed using TaqMan chemistry in a real-time polymerase chain reaction assay. Allelic and haplotype frequencies were compared among cases and controls using chi-square tests as implemented in PLINK v.1.06. Bonferroni correction was used and P ≤ 0.004 indicates statistical differences between groups. RESULTS: Significant associations were found between individual SNPs and SNP combinations in WNT10A, WNT10B and GREM2 SNPs with isolated tooth agenesis (P < 0.004). CONCLUSION: Our findings further support a role for variants in WNT10A, WNT10B and GREM2 genes in the aetiology of isolated tooth agenesis. Functional studies are necessary to investigate the biological effects of these gene variants in tooth agenesis phenotypes.

Effects of Educational Messaging on Urgent and Emergent Care-Seeking Behaviors Among Publicly Insured Populations.

BACKGROUND: The impact of messaging campaigns on influencing urgent care- and emergent care-seeking behaviors, including the use of in-network providers, is not well-understood. Although out-of-network healthcare utilization can have negative financial consequences for patients in narrow network Affordable Care Act plans, individuals with time-sensitive medical conditions, and especially patients visiting the emergency department, may not think about out-of-network issues. Inappropriate or avoidable emergency department visits can also create unnecessary costs for patients. OBJECTIVE: To evaluate the impact of 5 messaging strategies to educate individuals about the use of in-network providers and when care should be sought in the emergency department, urgent care center, or other sites of care. METHODS: Using a retrospective analysis, individuals aged ≥18 years who were enrolled in an individually purchased Affordable Care Act-compliant Humana plan as of July 1, 2015, were randomized to 1 of 5 messaging arms (e-mail, magnet mailer with or without e-mail, and key-tag mailer with or without e-mail) or to a control group. The outreach was implemented and evaluated in 2 distinct, geographically defined populations of Orlando, Palm Beach, and Tampa, Florida (Population 1); and Atlanta, Georgia, and San Antonio and Austin, Texas (Population 2). The relative number of each emergency department, urgent care, and out-of-network visits during follow-up was modeled using negative binomial regression. Cox proportional hazard models were used to calculate the risk for ≥1 of each visit type (assessed separately) and high emergency department utilization (defined as ≥3 visits during follow-up) relative to the control, while accounting for variable follow-up time. RESULTS: The relative numbers of each visit type assessed were not significantly different for any message group compared with the control in either population. The risk for an emergency department visit was 4% lower in the e-mail arm of Population 2 (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.94-0.99; P = .005) and 7% lower in the e-mail/key-tag arm of Population 1 (HR, 0.93; 95% CI, 0.89-0.97; P = .001). The risk for high emergency department utilization was significantly reduced by the key-tag, magnet, and e-mail/key-tag strategies in Population 1, but no impact was found in Population 2. CONCLUSION: Despite the mixed results, the study provides new insights into how different messaging strategies could be used to educate patients and influence healthcare utilization decisions by people with health insurance.

The Changing Landscape in the Genetic Etiology of Human Tooth Agenesis.

Despite much progress in understanding the genetics of syndromic tooth agenesis (TA), the causes of the most common, isolated TA remain elusive. Recent studies have identified novel genes and variants contributing to the etiology of TA, and revealed new pathways in which tooth development genes belong. Further, the use of new research approaches including next-generation sequencing has provided increased evidence supporting an oligogenic inheritance model for TA, and may explain the phenotypic variability of the condition. In this review, we present current knowledge about the genetic mechanisms underlying syndromic and isolated TA in humans, and highlight the value of incorporating next-generation sequencing approaches to identify causative and/or modifier genes that contribute to the etiology of TA.

Colorectal Cancer-Associated Genes Are Associated with Tooth Agenesis and May Have a Role in Tooth Development.

Previously reported co-occurrence of colorectal cancer (CRC) and tooth agenesis (TA) and the overlap in disease-associated gene variants suggest involvement of similar molecular pathways. Here, we took an unbiased approach and tested genome-wide significant CRC-associated variants for association with isolated TA. Thirty single nucleotide variants (SNVs) in CRC-predisposing genes/loci were genotyped in a discovery dataset composed of 440 individuals with and without isolated TA. Genome-wide significant associations were found between TA and ATF1 rs11169552 (P = 4.36 × 10-10) and DUSP10 rs6687758 (P = 1.25 × 10-9), and positive association found with CASC8 rs10505477 (P = 8.2 × 10-5). Additional CRC marker haplotypes were also significantly associated with TA. Genotyping an independent dataset consisting of 52 cases with TA and 427 controls confirmed the association with CASC8. Atf1 and Dusp10 expression was detected in the mouse developing teeth from early bud stages to the formation of the complete tooth, suggesting a potential role for these genes and their encoded proteins in tooth development. While their individual contributions in tooth development remain to be elucidated, these genes may be considered candidates to be tested in additional populations.

Mortality Differences Between Traditional Medicare and Medicare Advantage: A Risk-Adjusted Assessment Using Claims Data.

Medicare Advantage (MA) has grown rapidly since the Affordable Care Act; nearly one-third of Medicare beneficiaries now choose MA. An assessment of the comparative value of the 2 options is confounded by an apparent selection bias favoring MA, as reflected in mortality differences. Previous assessments have been hampered by lack of access to claims diagnosis data for the MA population. An indirect comparison of mortality as an outcome variable was conducted by modeling mortality on a traditional fee-for-service (FFS) Medicare data set, applying the model to an MA data set, and then evaluating the ratio of actual-to-predicted mortality in the MA data set. The mortality model adjusted for clinical conditions and demographic factors. Model development considered the effect of potentially greater coding intensity in the MA population. Further analysis calculated ratios for subpopulations. Predicted, risk-adjusted mortality was lower in the MA population than in FFS Medicare. However, the ratio of actual-to-predicted mortality (0.80) suggested that the individuals in the MA data set were less likely to die than would be predicted had those individuals been enrolled in FFS Medicare. Differences between actual and predicted mortality were particularly pronounced in low income (dual eligibility), nonwhite race, high morbidity, and Health Maintenance Organization (HMO) subgroups. After controlling for baseline clinical risk as represented by claims diagnosis data, mortality differences favoring MA over FFS Medicare persisted, particularly in vulnerable subgroups and HMO plans. These findings suggest that differences in morbidity do not fully explain differences in mortality between the 2 programs.

On the Association Between Repeat Bully Victimizations and Carrying a Firearm: Evidence in a National Sample.

Bullying is a significant public concern. The purpose of the present study is to investigate whether being repeatedly victimized by a bully during childhood and adolescence is associated with gun carrying in adolescence and adulthood. Using data from the National Longitudinal Survey of Youth 1997, we found that just over one fourth of the respondents reported carrying a gun at some point in their lifetime. Respondents experiencing repeat bully victimizations reported higher rates of gun carrying during the last 12 months and the last 30 days. No support was found for the association of repeat bully victimizations and carrying a gun to school. Individuals victimized during childhood (before the age of 12) and during adolescence were found to be at risk of carrying a gun later in the life course. Repeat bully victimizations should be considered a marker for gun-carrying behaviors in adolescence and adulthood.

Structure and ligand-based design of mTOR and PI3-kinase inhibitors leading to the clinical candidates VS-5584 (SB2343) and SB2602.

Phosphoinositide 3-kinases (PI3Ks) and the mammalian target of rapamycin (mTOR) act as critical effectors in a commonly deregulated cell signaling pathway in human cancers. The abnormal activation of the PI3K/mTOR pathway has been shown to play a role in initiation, progression, and metastasis of human tumors. Being one of the most frequently activated pathways in cancer, much effort has been directed toward inhibition of the PI3K/mTOR pathway as a novel oncology therapy. Previous work by a number of groups has revealed several selective PI3K and dual mTOR/PI3K inhibitors. However, there are few reports of therapeutic agents with a pan-PI3K/mTOR inhibitory profile within a narrow concentration range. We therefore initiated a drug discovery project with the aim of discovering dual mTOR/PI3K inhibitors which would equipotently inhibit the 4 isoforms of PI3K, α, ß, γ, and δ, and mTOR a compelling profile for powerful blockage of the PI3K/mTOR pathway. A pharmacophore model was generated and used for designing a series of novel compounds, based on a purine scaffold, which potently inhibited mTOR and PI3Ks. These compounds contained a phenol headgroup essential for binding to the target proteins. Early efforts concentrated on finding replacements for the phenol as it was rapidly conjugated resulting in a short half-life in vivo. Compounds with a variety of headgroups were docked into the PI3Kα and mTOR ATP-binding sites, and aminopyrimidine and aminopyrazine were found to make excellent phenol replacements. Further structure guided optimization of side chains in the 8- and 9-positions of the purine resulted in potent inhibitors with good PKDM properties. As the PI3 kinases play a role in insulin signaling, it is believed that targeting mTOR selectively may give the benefit of blocking the AKT-pathway while avoiding the potential side effects associated with PI3K inhibition. As a result we designed a further series of selective mTOR kinase inhibitors. The project was successfully concluded by progressing both a dual mTOR/PI3K inhibitor, SB2343, and a selective mTOR inhibitor, SB2602, into preclinical development. SB2343 has since entered phase 1 clinical development as VS-5584.

Structure-based design of nitrogen-linked macrocyclic kinase inhibitors leading to the clinical candidate SB1317/TG02, a potent inhibitor of cyclin dependant kinases (CDKs), Janus kinase 2 (JAK2), and Fms-like tyrosine kinase-3 (FLT3).

A high-throughput screen against Aurora A kinase revealed several promising submicromolar pyrimidine-aniline leads. The bioactive conformation found by docking these leads into the Aurora A ATP-binding site had a semicircular shape. Macrocycle formation was proposed to achieve novelty and selectivity via ring-closing metathesis of a diene precursor. The nature of the optimal linker and its size was directed by docking. In a kinase panel screen, selected macrocycles were active on other kinase targets, mainly FLT3, JAK2, and CDKs. These compounds then became leads in a CDK/FLT3/JAK2 inhibitor project. Macrocycles with a basic nitrogen in the linker form a salt bridge with Asp86 in CDK2 and Asp698 in FLT3. Interaction with this residue explains the observed selectivity. The Asp86 residue is conserved in most CDKs, resulting in potent pan-CDK inhibition by these compounds. Optimized macrocycles generally have good DMPK properties, and are efficacious in mouse models of cancer. Compound 5 (SB1317/TG02), a pan-CDK/FLT3/JAK2 inhibitor, was selected for preclinical development, and is now in phase 1 clinical trials.

VS-5584, a novel and highly selective PI3K/mTOR kinase inhibitor for the treatment of cancer.

Dysregulation of the PI3K/mTOR pathway, either through amplifications, deletions, or as a direct result of mutations, has been closely linked to the development and progression of a wide range of cancers. Moreover, this pathway activation is a poor prognostic marker for many tumor types and confers resistance to various cancer therapies. Here, we describe VS-5584, a novel, low-molecular weight compound with equivalent potent activity against mTOR (IC(50) = 37 nmol/L) and all class I phosphoinositide 3-kinase (PI3K) isoforms IC(50): PI3Kα = 16 nmol/L; PI3Kß = 68 nmol/L; PI3Kγ = 25 nmol/L; PI3Kδ = 42 nmol/L, without relevant activity on 400 lipid and protein kinases. VS-5584 shows robust modulation of cellular PI3K/mTOR pathways, inhibiting phosphorylation of substrates downstream of PI3K and mTORC1/2. A large human cancer cell line panel screen (436 lines) revealed broad antiproliferative sensitivity and that cells harboring mutations in PI3KCA are generally more sensitive toward VS-5584 treatment. VS-5584 exhibits favorable pharmacokinetic properties after oral dosing in mice and is well tolerated. VS-5584 induces long-lasting and dose-dependent inhibition of PI3K/mTOR signaling in tumor tissue, leading to tumor growth inhibition in various rapalog-sensitive and -resistant human xenograft models. Furthermore, VS-5584 is synergistic with an EGF receptor inhibitor in a gastric tumor model. The unique selectivity profile and favorable pharmacologic and pharmaceutical properties of VS-5584 and its efficacy in a wide range of human tumor models supports further investigations of VS-5584 in clinical trials.