An overview of human single-cell RNA sequencing studies in neurobiological disease.

Neurobiological disorders are highly prevalent medical conditions that contribute to significant morbidity and mortality. Single-cell RNA sequencing (scRNA-seq) is a technique that measures gene expression in individual cells. In this review, we survey scRNA-seq studies of tissues from patients suffering from neurobiological disease. This includes postmortem human brains and organoids derived from peripheral cells. We highlight a range of conditions, including epilepsy, cognitive disorders, substance use disorders, and mood disorders. These findings provide new insights into neurobiological disease in multiple ways, including discovering novel cell types or subtypes involved in disease, proposing new pathophysiological mechanisms, uncovering novel drug targets, or identifying potential biomarkers. We discuss the quality of these findings and suggest potential future directions and areas open for additional research, including studies of non-cortical brain regions and additional conditions such as anxiety disorders, mood disorders, and sleeping disorders. We argue that additional scRNA-seq of tissues from patients suffering from neurobiological disease could advance our understanding and treatment of these conditions.

Mapping nanocrystal orientations via scanning Laue diffraction microscopy for multi-peak Bragg coherent diffraction imaging.

The recent commissioning of a movable monochromator at the 34-ID-C endstation of the Advanced Photon Source has vastly simplified the collection of Bragg coherent diffraction imaging (BCDI) data from multiple Bragg peaks of sub-micrometre scale samples. Laue patterns arising from the scattering of a polychromatic beam by arbitrarily oriented nanocrystals permit their crystal orientations to be computed, which are then used for locating and collecting several non-co-linear Bragg reflections. The volumetric six-component strain tensor is then constructed by combining the projected displacement fields that are imaged using each of the measured reflections via iterative phase retrieval algorithms. Complications arise when the sample is heterogeneous in composition and/or when multiple grains of a given lattice structure are simultaneously illuminated by the polychromatic beam. Here, a workflow is established for orienting and mapping nanocrystals on a substrate of a different material using scanning Laue diffraction microscopy. The capabilities of the developed algorithms and procedures with both synthetic and experimental data are demonstrated. The robustness is verified by comparing experimental texture maps obtained with Laue diffraction microscopy at the beamline with maps obtained from electron back-scattering diffraction measurements on the same patch of gold nanocrystals. Such tools provide reliable indexing for both isolated and densely distributed nanocrystals, which are challenging to image in three dimensions with other techniques.

A dual aurora and lim kinase inhibitor reduces glioblastoma proliferation and invasion.

High rates of recurrence and treatment resistance in the most common malignant adult brain cancer, glioblastoma (GBM), suggest that monotherapies are not sufficiently effective. Combination therapies are increasingly pursued, but the possibility of adverse drug-drug interactions may preclude clinical implementation. Developing single molecules with multiple targets is a feasible alternative strategy to identify effective and tolerable pharmacotherapies for GBM. Here, we report the development of a novel, first-in-class, dual aurora and lim kinase inhibitor termed F114. Aurora kinases and lim kinases are involved in neoplastic cell division and cell motility, respectively. Due to the importance of these cellular functions, inhibitors of aurora kinases and lim kinases are being pursued separately as anti-cancer therapies. Using in vitro and ex vivo models of GBM, we found that F114 inhibits GBM proliferation and invasion. These results establish F114 as a promising new scaffold for dual aurora/lim kinase inhibitors that may be used in future drug development efforts for GBM, and potentially other cancers.

The Emergency Medicine Physician Workforce: Projections for 2030.

STUDY OBJECTIVE: The goals of this study were to determine the current and projected supply in 2030 of contributors to emergency care, including emergency residency-trained and board-certified physicians, other physicians, nurse practitioners, and physician assistants. In addition, this study was designed to determine the current and projected demand for residency-trained, board-certified emergency physicians. METHODS: To forecast future workforce supply and demand, sources of existing data were used, assumptions based on past and potential future trends were determined, and a sensitivity analysis was conducted to determine how the final forecast would be subject to variance in the baseline inputs and assumptions. Methods included: (1) estimates of the baseline workforce supply of physicians, nurse practitioners, and physician assistants; (2) estimates of future changes in the raw numbers of persons entering and leaving that workforce; (3) estimates of the productivity of the workforce; and (4) estimates of the demand for emergency care services. The methodology assumes supply equals demand in the base year and estimates the change between the base year and 2030; it then compares supply and demand in 2030 under different scenarios. RESULTS: The task force consensus was that the most likely future scenario is described by: 2% annual graduate medical education growth, 3% annual emergency physician attrition, 20% encounters seen by a nurse practitioner or physician assistant, and 11% increase in emergency department visits relative to 2018. This scenario would result in a surplus of 7,845 emergency physicians in 2030. CONCLUSION: The specialty of emergency medicine is facing the likely oversupply of emergency physicians in 2030. The factors leading to this include the increasing supply of and changing demand for emergency physicians. An organized, collective approach to a balanced workforce by the specialty of emergency medicine is imperative.

Epigenetic pathways and plasticity in brain tumors.

Clinical studies have shown that treating many primary brain tumors is challenging due in part to the lack of safe and effective compounds that cross the blood brain barrier (BBB) (Tan et al., 2018). However, if we were to imagine that we have ideal BBB penetrant compounds that target brain tumor cells selectively, recent studies suggest that those compounds may still not be effective due to the heterogenous nature of the tumors. In other words, there are many subsets of cells within a brain tumor, and compounds that target all those different populations are needed. This is a considerable challenge. Targeting of the cell-of-origin of these brain tumors is equally important. And yet another impediment we face is that brain tumor cells-of-origin may be protean and are able to differentiate into other cell types to drive recurrence. Therefore, an ideal BBB-penetrant compound targeting a cell-of-origin in a brain tumor may be ineffective due to the cell's ability to differentiate into another resistant cell type. One possible means of combating the plastic nature of these cells is targeting epigenetic pathways used by the cells to differentiate into other cell types along with standard treatment regimens. We summarize here some of the epigenetic pathways that have been shown to be active in three different primary brain tumors, glioblastoma (GBM), medulloblastoma (MB), and diffuse intrinsic pontine glioma (DIPG). We also compare recent single-cell RNA sequencing analyses of these tumors in order to identify common epigenetic pathways to treat the respective cells-of-origin for these tumors. Lastly, we discuss possible combination therapies that may be generalizable for treating these and other brain tumors using multi-omics approaches. While our focus on these three tumor types is not exhaustive and certainly other brain tumors can have similar mechanisms, there has been significant recent evidence linking epigenetics, plasticity, and intratumor heterogeneity in these tumors.

Recommendations for the Implementation of Telehealth in Cardiovascular and Stroke Care: A Policy Statement From the American Heart Association.

The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating the use of telemedicine in cardiovascular and stroke care and to provide consensus policy suggestions. We evaluate the effectiveness of telehealth in advancing healthcare quality, identify legal and regulatory barriers that impede telehealth adoption or delivery, propose steps to overcome these barriers, and identify areas for future research to ensure that telehealth continues to enhance the quality of cardiovascular and stroke care. The result of these efforts is designed to promote telehealth models that ensure better patient access to high-quality cardiovascular and stroke care while striving for optimal protection of patient safety and privacy.

Comprehensive electrocardiogram-to-device time for primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: A report from the American Heart Association mission: Lifeline program.

BACKGROUND: Assessing hospital-related network-level primary percutaneous coronary intervention (PCI) performance for ST-segment elevation myocardial infarction (STEMI) is challenging due to differential time-to-treatment metrics based on location of diagnostic electrocardiogram (ECG) for STEMI. METHODS: STEMI patients undergoing primary PCI at 588 PCI-capable hospitals in AHA Mission: Lifeline (2008-2013) were categorized by initial STEMI identification location: PCI-capable hospitals (Group 1); pre-hospital setting (Group 2); and non-PCI-capable hospitals (Group 3). Patient-specific time-to-treatment categories were converted to minutes ahead of or behind their group-specific mean; average time-to-treatment difference for all patients at a given hospital was termed comprehensive ECG-to-device time. Hospitals were then stratified into tertiles based on their comprehensive ECG-to-device times with negative values below the mean representing shorter (faster) time intervals. RESULTS: Of 117,857 patients, the proportion in Groups 1, 2, and 3 were 42%, 33%, and 25%, respectively. Lower rates of heart failure and cardiac arrest at presentation are noted within patients presenting to high-performing hospitals. Median comprehensive ECG-to-device time was shortest at -9 minutes (25th, 75th percentiles: -13, -6) for the high-performing hospital tertile, 1 minute (-1, 3) for middle-performing, and 11 minutes (7, 16) for low-performing. Unadjusted rates of in-hospital mortality were 2.3%, 2.6%, and 2.7%, respectively, but the adjusted risk of in-hospital mortality was similar across tertiles. CONCLUSIONS: Comprehensive ECG-to-device time provides an integrated hospital-related network-level assessment of reperfusion timing metrics for primary PCI, regardless of the location for STEMI identification; further validation will delineate how this metric can be used to facilitate STEMI care improvements.

Assessment of a rtPCR for the detection of virulent and benign Dichelobacter nodosus, the causative agent of ovine footrot, in Australia.

BACKGROUND: Ovine footrot is a highly contagious bacterial disease of sheep, costing the Australian sheep industry millions of dollars annually. Dichelobacter nodosus, the causative agent of footrot, is a gram-negative anaerobe classed into virulent and benign strains as determined by thermostability of their respective protesases. Current methods for detection of D. nodosus are difficult and time-consuming, however new molecular techniques capable of rapidly detecting and typing D. nodosus have been reported. RESULTS: A competitive real-time PCR (rtPCR) method, based on the ability to detect a 2 nucleotide difference in the aprV2 (virulent) and aprB2 (benign) extracellular protease gene has been tested on Australian samples for determining detection rates, along with clinically relevant cut-off values and performance in comparison to the traditional culturing methods. The rtPCR assay was found to have a specificity of 98.3% for virulent and 98.7% for benign detection from samples collected. Sheep with clinical signs of footrot showed a detection rate for virulent strains of 81.1% and for benign strains of 18.9%. A cut-off value of a Ct of 35 was found to be the most appropriate for use in Victoria for detection of sheep carrying virulent D. nodosus. CONCLUSIONS: In summary, the rtPCR assay is significantly more capable of detecting D. nodosus than culturing, while there is no significant difference seen in virotyping between the two methods.

Blood pressure and in-hospital outcomes in patients presenting with ischaemic stroke.

AIMS: Post-stroke hypertension is associated with poor short-term outcome, although the results have been conflicting. Our objective was to evaluate the association of blood pressure (BP) and in-hospital outcomes in patients with acute ischaemic stroke. METHODS AND RESULTS: Patients in the Get With The Guidelines-Stroke registry with acute ischaemic stroke were included. Admission systolic and diastolic BP was used to compute mean arterial pressure (MAP) and pulse pressure (PP). The outcomes of interest were: in-hospital mortality, not discharged home, inability to ambulate independently at discharge and haemorrhagic complications due to thrombolytic therapy. A total of 309 611 patients with an ischaemic stroke were included. There was a J-shaped/U-shaped relationship between systolic BP and outcomes. Both lower and higher systolic BP values, compared with a central reference value, had higher risk of in-hospital death [e.g. adjusted odds ratio (95% confidence interval) (OR[CI]) = 1.16[1.13-1.20] for 120 vs. 150 mmHg and 1.24[1.19-1.30] for 200 vs. 150 mmHg], not discharged home (OR[CI] = 1.11[1.09-1.13] for 120 vs. 150 mmHg and 1.15[1.12-1.18] for 200 vs. 150 mmHg), inability to ambulate independently at discharge (OR[CI] = 1.16[1.13-1.18] for 120 vs. 150 mmHg and 1.09[1.06-1.11] for 200 vs. 150 mmHg). However, risk of haemorrhagic complications of thrombolytic therapy was lower with lower systolic BP (OR[CI] = 0.89[0.83-0.97] for 120 vs. 150 mmHg), while higher with higher systolic BP (OR[CI] = 1.21[1.11-1.32] for 200 vs. 150 mmHg). The results were largely similar for admission diastolic BP, MAP, and PP. CONCLUSION: In patients hospitalized with ischaemic stroke, J-shaped, or U-shaped relationships were observed between BP variables and short-term outcomes. However, haemorrhagic complications with thrombolytic therapy were lower with lower BP.

Regional Systems of Care Demonstration Project: American Heart Association Mission: Lifeline STEMI Systems Accelerator.

BACKGROUND: Up to 50% of patients fail to meet ST-segment-elevation myocardial infarction (STEMI) guideline goals recommending a first medical contact-to-device time of <90 minutes for patients directly presenting to percutaneous coronary intervention-capable hospitals and <120 minutes for transferred patients. We sought to increase the proportion of patients treated within guideline goals by organizing coordinated regional reperfusion plans. METHODS: We established leadership teams, coordinated protocols, and provided regular feedback for 484 hospitals and 1253 emergency medical services (EMS) agencies in 16 regions across the United States. RESULTS: Between July 2012 and December 2013, 23 809 patients presented with acute STEMI (direct to percutaneous coronary intervention hospital: 11 765 EMS transported and 6502 self-transported; 5542 transferred). EMS-transported patients differed from self-transported patients in symptom onset to first medical contact time (median, 47 versus 114 minutes), incidence of cardiac arrest (10% versus 3%), shock on admission (11% versus 3%), and in-hospital mortality (8% versus 3%; P<0.001 for all comparisons). There was a significant increase in the proportion of patients meeting guideline goals of first medical contact-to-device time, including those directly presenting via EMS (50% to 55%; P<0.001) and transferred patients (44%-48%; P=0.002). Despite regional variability, the greatest gains occurred among patients in the 5 most improved regions, increasing from 45% to 57% (direct EMS; P<0.001) and 38% to 50% (transfers; P<0.001). CONCLUSIONS: This Mission: Lifeline STEMI Systems Accelerator demonstration project represents the largest national effort to organize regional STEMI care. By focusing on first medical contact-to-device time, coordinated treatment protocols, and regional data collection and reporting, we were able to increase significantly the proportion of patients treated within guideline goals.

Emergent Dialysis and its Impact on Quality of Life in Undocumented Patients with End-Stage Renal Disease.

OBJECTIVE: This study aimed to define the ethnographic composition and assess the health-related quality of life (HRQoL) of a large population of undocumented patients with end-stage renal disease (ESRD) seeking emergent dialysis in the emergency department (ED) of a large public hospital in the United States. DESIGN: All ESRD patients presenting to the hospital's main ED were identified during a 4-week consecutive enrollment period. Consenting patients completed two surveys-an ethnographic questionnaire and the validated kidney disease quality of life-36 (KDQOL-36) instrument. SETTING: The study was conducted at a large county hospital in Dallas, Texas. In 2013, the hospital recorded >50,000 ED visits and administered approximately 6,000 dialysis treatments to ED patients. PARTICIPANTS: 88 of 101 unfunded patients presenting to the ED during the study period consented to participate, resulting in an 87.1% response rate. 65 of these patients were undocumented immigrants. MAIN OUTCOME MEASURES: Quantitative scores for the 5 subscales of the KDQOL-36 were calculated for the study population. RESULTS: Measures of physical and mental health in our study population were lower than those published for scheduled dialysis patients. 79.5% of our patients lost employment due to their dialysis requirements. At least 71.4% of the study patients were unaware that they required dialysis before immigrating to the United States. CONCLUSIONS: Quality of life scores were found to be low among our population of undocumented emergent dialysis patients. Our data also provide some evidence that availability of dialysis at no cost is not a primary driver of illegal immigration of ESRD patients to the United States.

Prior Antithrombotic Use Is Associated With Favorable Mortality and Functional Outcomes in Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Antithrombotics are the mainstay of treatment in primary and secondary prevention of stroke, and their use before an acute event may be associated with better outcomes. METHODS: Using data from Get With The Guidelines-Stroke with over half a million acute ischemic strokes recorded between October 2011 and March 2014 (n=540 993) from 1661 hospitals across the United States, we examined the unadjusted and adjusted associations between previous antithrombotic use and clinical outcomes. RESULTS: There were 250 104 (46%) stroke patients not receiving any antithrombotic before stroke; of whom approximately one third had a documented previous vascular indication. After controlling for clinical and hospital factors, patients who were receiving antithrombotics before stroke had better outcomes than those who did not, regardless of whether a previous vascular indication was present or not: adjusted odds ratio (95% confidence intervals) were 0.82 (0.80-0.84) for in-hospital mortality, 1.18 (1.16-1.19) for home as the discharge destination, 1.15 (1.13-1.16) for independent ambulatory status at discharge, and 1.15 (1.12-1.17) for discharge modified Rankin Scale score of 0 or 1. CONCLUSIONS: Previous antithrombotic therapy was independently associated with improved clinical outcomes after acute ischemic stroke. Ensuring the use of antithrombotics in appropriate patient populations may be associated with benefits beyond stroke prevention.

Acute management of stroke patients taking non-vitamin K antagonist oral anticoagulants Addressing Real-world Anticoagulant Management Issues in Stroke (ARAMIS) Registry: Design and rationale.

BACKGROUND: Non-vitamin K antagonist oral anticoagulants (NOACs, dabigatran, rivaroxaban, apixaban, and edoxaban) have been increasingly used as alternatives to warfarin for stroke prophylaxis in patients with atrial fibrillation. Yet there is substantial lack of information on how patients on NOACs are currently treated when they have an acute ischemic stroke and the best strategies for treating intracerebral hemorrhage for those on chronic anticoagulation with warfarin or a NOAC. These are critical unmet needs for real world clinical decision making in these emergent patients. METHODS: The ARAMIS Registry is a multicenter cohort study of acute stroke patients who were taking chronic anticoagulation therapy prior to admission and are admitted with either an acute ischemic stroke or intracerebral hemorrhage. Built upon the existing infrastructure of American Heart Association/American Stroke Association Get With the Guidelines Stroke, the ARAMIS Registry will enroll a total of approximately 10,000 patients (5000 with acute ischemic stroke who are taking a NOAC and 5000 with anticoagulation-related intracerebral hemorrhage who are on warfarin or a NOAC). The primary goals of the ARAMIS Registry are to provide a comprehensive picture of current treatment patterns and outcomes of acute ischemic stroke patients on NOACs, as well as anticoagulation-related intracerebral hemorrhage in patients on either warfarin or NOACs. Beyond characterizing the index hospitalization, up to 2500 patients (1250 ischemic stroke and 1250 intracerebral hemorrhage) who survive to discharge will be enrolled in an optional follow-up sub-study and interviewed at 3 and 6 months after discharge to assess longitudinal medication use, downstream care, functional status, and patient-reported outcomes. CONCLUSION: The ARAMIS Registry will document the current state of management of NOAC treated patients with acute ischemic stroke as well as contemporary care and outcome of anticoagulation-related intracerebral hemorrhage. These data will be used to better understand optimal strategies to care for these complex but increasingly common emergent real world clinical challenges.

The effect of high-risk ST elevation myocardial infarction transfer patients on risk-adjusted in-hospital mortality: A report from the American Heart Association Mission: Lifeline program.

BACKGROUND: Hospital mortality is an important quality measure for acute myocardial infarction care. There is a concern that despite risk adjustment, percutaneous coronary intervention hospitals accepting a greater volume of high-risk ST elevation myocardial infarction (STEMI) transfer patients may have their reported mortality rates adversely affected. METHODS: The STEMI patients in the National Cardiovascular Data RegistryAcute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines from April 2011 to December 2013 were included. High-risk STEMI was defined as having either cardiogenic shock or cardiac arrest on first medical contact. Receiving hospitals were divided into tertiles based on the ratio of high-risk STEMI transfer patients to the total number of STEMI patients treated at each hospital. Using the Action Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines in-hospital mortality risk model, we calculated the difference in risk-standardized in-hospital mortality before and after excluding high-risk STEMI transfers in each tertile. RESULTS: Among 119,680 STEMI patients treated at 539 receiving hospitals, 37,028 (31%) were transfer patients, of whom 4,500 (12%) were highrisk. The proportion of high-risk STEMI transfer patients ranged from 0% to 12% across hospitals. Unadjusted mortality rates in the low-, middle-, and high-tertile hospitals were 6.0%, 6.0%, and 5.9% among all STEMI patients and 6.0%, 5.5%, and 4.6% after excluding high-risk STEMI transfers. However, risk-standardized hospital mortality rates were not significantly changed after excluding high-risk STEMI transfer patients in any of the 3 hospital tertiles (low, -0.04%; middle, -0.05%; and high, 0.03%). CONCLUSIONS: Risk-adjusted in-hospital mortality rates were not adversely affected in STEMI-receiving hospitals who accepted more high-risk STEMI transfer patients when a clinical mortality risk model was used for risk adjustment.

Stroke outcomes measures must be appropriately risk adjusted to ensure quality care of patients: a presidential advisory from the American Heart Association/American Stroke Association.

Because stroke is among the leading causes of death, disability, hospitalizations, and healthcare expenditures in the United States, there is interest in reporting outcomes for patients hospitalized with acute ischemic stroke. The American Heart Association/American Stroke Association, as part of its commitment to promote high-quality, evidence-based care for cardiovascular and stroke patients, fully supports the development of properly risk-adjusted outcome measures for stroke. To accurately assess and report hospital-level outcomes, adequate risk adjustment for case mix is essential. During the development of the Centers for Medicare & Medicaid Services 30-day stroke mortality and 30-day stroke readmission measures, concerns were expressed that these measures were not adequately designed because they do not include a valid initial stroke severity measure, such as the National Institutes of Health Stroke Scale. These outcome measures, as currently constructed, may be prone to mischaracterizing the quality of stroke care being delivered by hospitals and may ultimately harm acute ischemic stroke patients. This article details (1) why the Centers for Medicare & Medicaid Services acute ischemic stroke outcome measures in their present form may not provide adequate risk adjustment, (2) why the measures as currently designed may lead to inaccurate representation of hospital performance and have the potential for serious unintended consequences, (3) what activities the American Heart Association/American Stroke Association has engaged in to highlight these concerns to the Centers for Medicare & Medicaid Services and other interested parties, and (4) alternative approaches and opportunities that should be considered for more accurately risk-adjusting 30-day outcomes measures in patients with ischemic stroke.

Fellowships in international emergency medicine in the USA: a comparative survey of program directors' and fellows' perspectives on the curriculum.

OBJECTIVE: Experts have proposed core curriculum components for international emergency medicine (IEM) fellowships. This study examined perceptions of program directors (PDs) and fellows on whether IEM fellowships cover these components, whether their perspectives differ and the barriers preventing fellowships from covering them. METHODS: From 1 November 2011 to 30 November 2011, a survey was administered to PDs, current fellows and recent graduates of the 34 US IEM fellowships. Respondents quantified their fellowship experience in six proposed core curriculum areas: emergency medicine (EM) systems development, EM education, humanitarian assistance, public health, emergency medical services and disaster medicine. Analysis was performed regarding what per cent of programmes fulfil the six curriculum areas. A paired t test determined the difference between PDs' and fellows' responses. Agreement between PDs and fellows within the same programme was determined using a κ statistic. RESULTS: Only 1/18 (6%) (according to fellows) to 2/24 (8%) (according to PDs) of programmes expose fellows to all six components. PDs consistently reported higher exposure than fellows. The difference in mean score between PDs and fellows was statistically significant (p<0.05) in three of the 6 (50%) core curriculum elements: humanitarian aid, public health and disaster medicine. Per cent agreement between PDs and fellows within each programmes ranged from poor to fair. CONCLUSIONS: While IEM fellowships have varying structure, this study highlights the importance of further discussion between PDs and fellows regarding delineation and objectives of core curriculum components. Transparent curricula and open communication between PDs and fellows may reduce differences in reported experiences.

RAPID resistance to BET inhibitors is mediated by FGFR1 in glioblastoma.

Bromodomain and extra-terminal domain (BET) proteins are therapeutic targets in several cancers including the most common malignant adult brain tumor glioblastoma (GBM). Multiple small molecule inhibitors of BET proteins have been utilized in preclinical and clinical studies. Unfortunately, BET inhibitors have not shown efficacy in clinical trials enrolling GBM patients. One possible reason for this may stem from resistance mechanisms that arise after prolonged treatment within a clinical setting. However, the mechanisms and timeframe of resistance to BET inhibitors in GBM is not known. To identify the temporal order of resistance mechanisms in GBM we performed quantitative proteomics using multiplex-inhibitor bead mass spectrometry and demonstrated that intrinsic resistance to BET inhibitors in GBM treatment occurs rapidly within hours and involves the fibroblast growth factor receptor 1 (FGFR1) protein. Additionally, small molecule inhibition of BET proteins and FGFR1 simultaneously induces synergy in reducing GBM tumor growth in vitro and in vivo. Further, FGFR1 knockdown synergizes with BET inhibitor mediated reduction of GBM cell proliferation. Collectively, our studies suggest that co-targeting BET and FGFR1 may dampen resistance mechanisms to yield a clinical response in GBM.

Natural killer cells associate with epithelial cells in the pancreatic ductal adenocarcinoma tumor microenvironment.

Background: Pancreatic ductal adenocarcinoma (PDAC) is the most common form of pancreatic cancer. PDAC's poor prognosis and resistance to immunotherapy are attributed in part to its dense, fibrotic tumor microenvironment (TME), which is known to inhibit immune cell infiltration. We recently demonstrated that PDAC patients with higher natural killer (NK) cell content and activation have better survival rates. However, NK cell interactions in the PDAC TME have yet to be deeply studied. We show here that NK cells are present and active in the human PDAC TME. Methods: We used imaging mass cytometry (IMC) to assess NK cell content, function, and spatial localization in human PDAC samples. Then, we used CellChat, a tool to infer ligand-receptor interactions, on a human PDAC scRNAseq dataset to further define NK cell interactions in PDAC. Results: Spatial analyses showed for the first time that active NK cells are present in the PDAC TME, and both associate and interact with malignant epithelial cell ducts. We also found that fibroblast-rich, desmoplastic regions limit NK cell infiltration in the PDAC TME. CellChat analysis identified that the CD44 receptor on NK cells interacts with PDAC extracellular matrix (ECM) components such as collagen, fibronectin and laminin expressed by fibroblasts and malignant epithelial cells. This led us to hypothesize that these interactions play roles in regulating NK cell motility in desmoplastic PDAC TMEs. Using 2D and 3D in vitro assays, we found that CD44 neutralization significantly increased NK cell invasion through matrix. Conclusions: Targeting ECM-immune cell interactions may increase NK cell invasion into the PDAC TME.

Triptolide and its prodrug Minnelide target high-risk MYC-amplified medulloblastoma in preclinical models.

Most children with medulloblastoma (MB) achieve remission, but some face very aggressive metastatic tumors. Their dismal outcome highlights the critical need to advance therapeutic approaches that benefit such high-risk patients. Minnelide, a clinically relevant analog of the natural product triptolide, has oncostatic activity in both preclinical and early clinical settings. Despite its efficacy and tolerable toxicity, this compound has not been evaluated in MB. Utilizing a bioinformatic data set that integrates cellular drug response data with gene expression, we predicted that Group 3 (G3) MB, which has a poor 5-year survival, would be sensitive to triptolide/Minnelide. We subsequently showed that both triptolide and Minnelide attenuate the viability of G3 MB cells ex vivo. Transcriptomic analyses identified MYC signaling, a pathologically relevant driver of G3 MB, as a downstream target of this class of drugs. We validated this MYC dependency in G3 MB cells and showed that triptolide exerts its efficacy by reducing both MYC transcription and MYC protein stability. Importantly, Minnelide acted on MYC to reduce tumor growth and leptomeningeal spread, which resulted in improved survival of G3 MB animal models. Moreover, Minnelide improved the efficacy of adjuvant chemotherapy, further highlighting its potential for the treatment of MYC-driven G3 MB.