Faculty Bibliography

OBJECTIVE:To examine the associations of LRRK2 p.G2019S, GBA1 p.N409S, polygenic risk scores (PRS), and APOE E4 on PD penetrance, risk, and symptoms. METHODS:We conducted a US-based observational case-control study using data from the 23andMe Inc. and Fox Insight Genetic Substudy (FIGS) databases. The total cohort included 7,586,842 participants (n = 35,163 PD); 8791 LRRK2 p.G2019S carriers (565 with PD), 37,427 GBA1 p.N409S carriers (524 with PD), 244 dual LRRK2/GBA1 carriers (37 with PD), and 7.5 million noncarriers (34,037 with PD). PRS was calculated from the most recently published European genome-wide association study. Survival models estimated the cumulative incidence of PD. Logistic regressions estimated the relative odds of reporting motor and non-motor symptoms according to genetic exposure. RESULTS:By the age of 80 years, the cumulative incidence of PD was 30% for dual carriers, 24% for LRRK2 p.G2019S carriers, 4% for GBA1 p.N409S carriers, and 2% for noncarriers. Higher PRS was associated with increased penetrance of the variants and earlier time to PD diagnosis. GBA1 p.N409S PD was associated with the highest burden of non-motor symptoms, including REM sleep behavior disorder and cognitive/memory deficits, and LRRK2 p.G2019S with the lowest. APOE E4 dosage was associated with greater odds of reporting hallucinations and cognitive impairment in addition to carrier status. INTERPRETATION/CONCLUSIONS:Our findings support the use of genetic screening to enrich candidate selection for neuroprotective trials and better define outcome measures based on genetics.

DNA methylation is a crucial epigenetic mechanism that regulates gene expression. Precise editing of DNA methylation has emerged as a promising tool for dissecting its biological function. However, challenges in delivery have limited most applications of DNA methylation editing to in vitro systems. Here, we develop two transgenic mouse lines harboring an inducible dCas9-DNMT3A or dCas9-TET1 editor to enable tissue-specific DNA methylation editing in vivo. We demonstrate that targeted methylation of the Psck9 promoter in the liver of dCas9-DNMT3A mice results in decreased Pcsk9 expression and a subsequent reduction in serum low-density lipoprotein cholesterol level. Targeted demethylation of the Mecp2 promoter in dCas9-TET1 mice reactivates Mecp2 expression from the inactive X chromosome and rescues neuronal nuclear size in Mecp2^+/- mice. Genome-wide sequencing analyses reveal minimal transcriptional off-targets, demonstrating the specificity of the system. These results demonstrate the feasibility and versatility of methylation editing, to functionally interrogate DNA methylation in vivo.

BACKGROUND/UNASSIGNED:Pyridostigmine bromide is a short-acting carbamate acetylcholinesterase inhibitor that has been shown to acutely augment parasympathetic signaling in cardiovascular disease populations. OBJECTIVE/UNASSIGNED:This study was undertaken to characterize pharmacodynamics, safety, and tolerability of pyridostigmine during repeated dosing in patients with heart failure. METHODS/UNASSIGNED:A prospective ascending-dose, forced titration, double-blind Phase II randomized clinical trial was conducted to compare the effects of pyridostigmine bromide (15, 30, and 60 mg TID over 8 weeks) versus matching placebo on red blood cell (RBC) acetylcholinesterase activity, cholinergic side effects, and physiologic measures of parasympathetic heart rate modulation and sympathovagal balance in ambulatory patients with chronic systolic heart failure. RESULTS/UNASSIGNED:< 0.001 vs placebo). Physiologic measures of parasympathetic heart rate modulation and sympathovagal balance did not differ between treatment groups. In the pyridostigmine bromide group, RBC acetylcholinesterase activity was not significantly associated with postexercise parasympathetic heart modulation. CONCLUSIONS/UNASSIGNED:Pyridostigmine bromide administered over 8 weeks was associated with a significant reduction of RBC acetylcholinesterase activity and relatively mild symptoms of cholinergic excess, but changes in parasympathetic signaling in the sinoatrial node previously reported after acute administration were not observed. Further investigations are needed to delineate pharmacodynamic and pathobiological factors contributing to these findings. ClinicalTrials.gov identifier: NCT01415921.

BACKGROUND/UNASSIGNED:NMOSD. METHODS/UNASSIGNED:NMOSD who received satralizumab for ≥6 months was obtained from US healthcare providers over 28 months. Patient characteristics, examination findings, diagnostic tests, treatment responses, and adverse events were recorded. RESULTS/UNASSIGNED:Of 43 patients, 88% were female and 44% self-identified as Black. Median age was 54 (range, 20-82) years, and time since confirmed NMOSD diagnosis was 8 (1-18) years. Reasons for satralizumab initiation included intolerance/safety concerns with existing therapy (30%), new diagnosis (26%), and inadequate disease control (21%). The median duration of satralizumab treatment was 31 (range, 7-104) months, during which three patients (7%) had radiographically confirmed relapses and 15 (35%) experienced a related adverse event. At data cutoff, 35 patients (81%) were receiving satralizumab. CONCLUSION/UNASSIGNED:Satralizumab was effective and well tolerated in patients with NMOSD, including those who switched from previous treatments due to inadequate disease control and/or intolerance. These real-world outcomes align with long-term safety and efficacy findings from the Phase III SAkura trials.

Aim To compare the clinical outcome and in-hospital complication risk with chemotherapy and without chemotherapy in patients with inflammatory and immune myopathies (IIM). Methods We obtained data for IIM patients admitted to hospitals in the United States from 2017 to 2018 with a primary diagnosis of IIM using a large national database. We determined the rate and pattern of utilization of associated in-hospital outcomes of chemotherapy in this patient population. Results A total of 5,360 patients had IIM, of which 315 (5.8%) received chemotherapy for the underlying malignancies and 5,045 (94.2%) did not. No significant racial or gender discrepancies were observed between the two groups. Patients who received chemotherapy had more in-hospital complications, including sepsis [79 (25.1%) vs. 585 (11.6%), p<0.01] and acute kidney injury [75 (23.8%) vs. 665 (13.2%), p<0.01]. The number of deaths was higher in the chemotherapy group [125 (39.7%) vs. 190 (3.8%)]. Further analysis of patients who died in the chemotherapy group showed that myocardial infarction [20 (6.3%)] and pneumonia [45 (14.3%)] were the leading causes of death. Conclusion In hospitalization complications such as sepsis and acute kidney injury were higher in patients who received chemotherapy in IIM patients; however, patients who died had a higher risk of myocardial infarction and pneumonia, so routine cardiac and pulmonary evaluation should be done during hospitalization of this patient population.

OBJECTIVE:Encephalitis is brain parenchyma inflammation, frequently resulting in seizures which worsens outcomes. Early anti-seizure medication could improve outcomes but requires identifying patients at greatest risk of acute seizures. The SEIZURE (SEIZUre Risk in Encephalitis) score was developed in UK cohorts to stratify patients by acute seizure risk. A 'basic score' used Glasgow Coma Scale (GCS), fever and age; the 'advanced score' added aetiology. This study aimed to evaluate the score internationally to determine its global applicability. DESIGN/METHODS:Patients were retrospectively analysed regionally, and by country, in this international evaluation study. Univariate analysis was conducted between patients who did and did not have inpatient seizures, followed by multivariable logistic regression, hierarchical clustering and analysis of the area under the receiver operating curves (AUROC) with 95% CIs. PARTICIPANTS AND SETTING/METHODS:2032 patients across 13 countries were identified, among whom 1324 were included in SEIZURE score calculations and 970 were included in regression modelling. The involved countries comprised 19 organisations spanning all WHO regions. OUTCOME MEASURES/METHODS:The primary outcome was measuring inpatient seizure rates. RESULTS:Autoantibody-associated encephalitis, low GCS and presenting with a seizure were frequently associated with inpatient seizures; fever showed no association. Globally, the score had limited discriminatory ability (basic AUROC 0.58 (95% CI 0.55 to 0.62), advanced AUROC 0.63 (95% CI 0.60 to 0.66)). The scoring system performed acceptably in western Europe, excluding Spain, with the best performance in Portugal (basic AUROC 0.82 (95% CI 0.69 to 0.94), advanced AUROC 0.83 (95% CI 0.72 to 0.95)). CONCLUSIONS:The SEIZURE score performed best in several countries in Western Europe but performed poorly elsewhere, partly due to differing and unknown aetiologies. In most regions, the score did not reach a threshold to be clinically useful. The Western European results could aid in designing clinical trials assessing primary anti-seizure prophylaxis in encephalitis following further prospective trials. Beyond Western Europe, there is a need for tailored, localised scoring systems and future large-scale prospective studies with optimised aetiological testing to accurately identify high-risk patients.

Clinical decision-making often simplifies continuous risk data into discrete levels using round-number thresholds. These simplifications can distort risk assessments. To systematically uncover these distortions, we develop an interpretable machine learning model that identifies anomalies caused by threshold-based practices. Through simulations, real-world data, and longitudinal studies, we demonstrate how round-number thresholds can lead to discontinuities and counter-causal paradoxes in mortality risk. Despite advances in medicine, these anomalies persist, underscoring the need for dynamic and nuanced risk assessment methods in healthcare. Our findings suggest continuous reassessment of clinical protocols, especially in critical settings like intensive care, to improve patient outcomes by aligning thresholds with the continuous nature of risk.

BACKGROUND:While cognitive processing and brain volume assessments are commonly used in multiple sclerosis (MS) research, they are not routinely incorporated into clinical care. Advances in neuroimaging software now allow for brain volume measurement to be incorporated into standard practice and guide clinical decision-making. METHODS:In this single-center, outpatient, cohort study, pediatric-onset multiple sclerosis (POMS) patients underwent at least two volumetric brain magnetic resonance imagings (MRIs) and two Symbol Digit Modalities Tests (SDMT) at least 6 months apart. Associations were analyzed using Pearson's correlation coefficient and linear regressions. RESULTS:Forty patients with POMS were included. The first volumetric brain MRI occurred at a median of 2.7 years after symptom onset. At the first volumetric MRI, 12% of patients had white matter brain volumes within 1% of normative values (n = 2000 healthy controls). Whole brain volume percentile (r = 0.4, P = 0.01), white matter percentile (r = 0.4, P = 0.01), and white matter lesion volume (r = -0.4, P = 0.005) were associated with SDMT score. Annualized percent brain volume change of the hippocampus (measured a median of 1.6 years apart) significantly correlated with follow-up SDMT (r = 0.4, P = 0.02), and annualized percent brain volume change of the thalamus correlated with annual change in SDMT z-score (r = 0.4, P = 0.009). CONCLUSIONS:Application of new software allows for volumetric assessment to be incorporated into clinical scans and provides clinicians with added data for patient management. This is critical for patients with POMS as the neurological examination often shows few to no abnormalities. Furthermore, a subset of POMS patients have smaller than expected brain volume which links to subsequent poorer cognitive performance.

BACKGROUND:Deep medullary veins (DMVs) play important roles within the cerebrovascular network related to brain drainage and clearance. Although they have been previously correlated with brain volume, it is unknown whether their count is specifically correlated with subcortical or cortical volume changes. PURPOSE/OBJECTIVE:This study aims to better understand the relationship between DMVs, subcortical (lateral ventricle to intracranial volume ratio (ICV)) and cortical atrophy (cortical thickness) to identify whether DMVs can be a predictor of volume changes in these regions. METHODS:We performed a retrospective analysis of 332 cognitively healthy subjects previously followed between 2010 and 2019. Imaging and patient charts were analyzed for baseline demographic and clinical characteristics. Patients underwent a standardized cognitive interview and received a magnetic resonance imaging scan to assess DMVs, cortical thickness, lateral ventricle and global gray matter (GM) volumes, white matter lesions (WMLs) and microbleeds. RESULTS:Among 332 patients (62% female, median age 70), lateral ventricle/ICV was significantly related to DMV count (p<0.001). Similarly, sex stratified analyses confirmed that a larger lateral ventricle/ICV ratio, but not cortical thickness or global GM volumes, was associated with fewer DMVs. In the entire group, subcortical atrophy remained a significant predictor of DMVs even after accounting for baseline characteristics, WMLs, microbleeds and total gray matter volume. CONCLUSIONS:In a large cohort of cognitively unaffected people, subcortical, but not cortical, atrophy was significantly correlated with venous health as measured by DMVs. Reduced DMVs are a strong predictor of ventricular enlargement.

In eukaryotes, each ribosomal subunit includes a ribosomal protein (RP) that is encoded as a fusion protein with ubiquitin (Ub). In yeast, each Ub-RP fusion requires processing by deubiquitylating enzymes (DUBs) to generate ribosome assembly-competent RPs and contribute to the cellular Ub pool. However, how Ub-RP fusions are processed by DUBs in human cells remains unclear. Here, we discovered that Ub-RPs are substrates of the Ub-fusion degradation (UFD) pathway in human cells via lysine 29 and 48 (K29/K48)-specific ubiquitylation and proteasomal degradation. We identified a pool of DUBs that catalytically process Ub-RPs, as well as DUBs that physically occlude Ub-RP interaction with UFD pathway Ub E3 ligases to prevent their degradation in a non-catalytic manner. Our results suggest that DUBs both process and stabilize Ub-RPs, whereas the UFD pathway regulates levels of Ub-RPs that cannot be fully processed by DUBs to fine-tune protein homeostasis.