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Genetic Mechanisms of Transcriptional Regulation in Childhood Acute Lymphoblastic Leukemia
Get PDFIntroduction. Advances in genomic profiling and sequencing studies have identified germline and somatic variations that are associated with childhood ALL, improving our understanding of the genetic basis of childhood acute lymphoblastic leukemia (ALL). Recent genome-wide association studies (GWAS) have identified germline genetic variations of ARID5B and, more recently, IGF2BP1 that are associated with susceptibility to ALL. Genome-wide sequencing studies also discovered a new ALL subtype characterized of ZNF384-mediated chromosomal translocations, providing new insights into genetic heterogeneity in childhood ALL. However, the underlying mechanism by which these genetic variants contribute to the transcriptional regulatory circuitries of ALL is still poorly understood. We tested these hypotheses: 1) A low ARID5B expression will increase the relapse risk of ALL, 2) Genetic variants of ARID5B will affect its expression and thus influence susceptibility to childhood ALL, 3) IGF2BP1 is transcriptionally suppressed by ETV6, 4) ZNF384-mediated fusion genes transcriptionally upregulate FLT3 expression as being a therapeutic target. Specific aims in this study include: 1) identifying the causal variant of ARID5B, 2) identifying molecular mechanism underlying drug resistance, 3) identifying molecular mechanism of transcriptional regulation of IGF2BP1 by ETV6, and 4) identifying molecular mechanism of transcriptional regulation of FLT3 by EP300-ZNF384 fusion protein.
Methods. We analyzed association of ARID5B expression in primary human ALL blasts with different molecular subtypes and treatment outcomes. Subsequent mechanistic studies were performed in ALL cell lines by manipulating ARID5B expression isogenically, in which we evaluated drug sensitivity, metabolism, and molecular signaling events. We performed ARID5B targeted sequencing in 5,008 children with ALL and conducted high throughput CRISPR/dCas9 screening in an engineered ARID5B mCherry knock-in cell line. Effects of genetic polymorphism on binding affinity of transcription factor and chromatin accessibility were subsequently assessed. We applied CRISPR/dCas9 to investigate transcriptional regulation of IGF2BP1 by ETV6 in ALL cell lines. We stably knocked down EP300-ZNF384 fusion gene by CRISPR editing in ALL cell line, in which we analyzed FLT3 expression and drug sensitivity.
Results. ARID5B expression varied substantially by ALL subtype, with the highest level being observed in hyperdiploid ALL. Lower ARID5B expression at diagnosis was associated with the risk of ALL relapse, and further reduction was noted at ALL relapse. In isogenic ALL cell models in vitro, ARID5B knockdown led to resistance specific to antimetabolite drugs. ARID5B downregulation significantly inhibited ALL cell proliferation and caused partial cell-cycle arrest partially through upregulating expression the cell-cycle checkpoint regulator p21 (encoded by CDKN1A). Using targeted sequencing in germline DNA of 5,008 children with ALL and high throughput CRISPR/dCas9 screening in an engineered ARID5B mCherry knock-in cell line, we nominated ALL risk variant (rs7090445, P = 1.82 × 10-10) as the causal variant. And its polymorphisms disrupted binding of transcription factor MEF2C and local chromosome accessibility as confirmed by ChIP-Sanger-seq and ATAC-seq. Although it was previously reported that IGF2BP1 expression was significantly higher in ETV6-RUNX1 ALL as well as other cancers, the underlying transcriptional regulatory mechanism remains elusive. In ALL cell models, we identified a cis-regulatory element (CRE) blocking of which by dCas9-KRAB strongly influenced transcription of IGF2BP1. Moreover, we presented a CRISPR-based approach to comprehensively investigate the transcriptional regulatory mechanism of IGF2BP1 by identifying its CREs and upstream transcriptional regulators. In tissue-specific overexpression mouse models, we demonstrated that role of Igf2bp1 in B-cell development was stage-specific. In a novel ALL subtype characterized of ZNF384-mediated rearrangements, for the first time we reported overexpression of FLT3 in this new ALL subtype, providing a novel therapeutic target for ALL patient with high expression of FLT3. Furthermore, we defined EP300-ZNF384 fusion protein as a transcriptional activator of FLT3 gene with direct binding at its 5’UTRand knocking down this fusion gene led to downregulation of FLT3 expression as well as decreased sensitivity to FLT3 inhibitor in vitro.
Conclusions. Our studies have demonstrated that a causal variant of ARID5B affected its transcription in-cis and that a low expression of ARID5B increased ALL relapse risk. As a downstream effector of ETV6, IGF2BP1 expression influenced B-cell development in vivo in a stage-specific manner. Moreover, expression of FLT3 was transcriptionally upregulated by ZNF384-mediated fusion genes. This study sheds light on the underlying mechanism by which genetic variations altered transcriptional programs in childhood ALL and refined our understanding of the genetic basis of childhood ALL, providing new molecular targets which can be harnessed for development of new therapies for patients with ALL
Time to First Blood Glucose Determination and Administration of Intravenous Glucose at Birth in Extremely Low Birth Weight Infants
Get PDFBackground: Extremely low birth weight (ELBW) infants are prone to hypoglycemia unless intravenous glucose is administered within an hour (golden hour) of life. These infants often require resuscitation at birth, but monitoring and intervention for hypoglycemia may be delayed.
Objectives: (1) Study the time to first blood glucose determination and IV glucose administration at birth in ELBW infants, (2) determine the incidence of hypoglycemia, \u3c47mg/dl, and severe hypoglycemia, \u3c40mg/dl, at admission, (3) determine risk factors for hypoglycemia, and (4) compare clinical outcomes at discharge between hypoglycemic and euglycemic infants.
Methods: 244 ELBW (≤1000g birth weight) infants born during Jan 2017- Feb 2020 at the Regional One Health NICU, Memphis, TN were included in the study. Data collected included maternal and infant clinical, demographic, and outcomes at discharge, along with time to first blood glucose determination and IV glucose administration (bolus and/or IV infusion). Blood glucose was measured using the iStat® method at bedside. Data were analyzed for risk factors for hypoglycemia and severe hypoglycemia. Outcomes at discharge of infants who were hypoglycemic or severely hypoglycemic on first blood glucose determination were compared to euglycemic (≥47mg/dl) infants.
Results:Gestational age was 26.2 ±2.4 weeks; birth weight 739 ±161g. The median time (IQR) to first glucose determination was 56 (45-73) min, and the median time for initiation of IV fluids with dextrose or giving bolus dextrose was 88 (60-120) min. Within the golden hour, only 59% of all infants had their first blood glucose determination, and 24% had IV glucose administered, (Figure). 123 infants (50%) had hypoglycemia, and 91(37%) had severe hypoglycemia (\u3c40mg/dL). There was no difference between euglycemic and hypoglycemic infants in time to blood glucose determination or IV glucose infusion. Caesarean delivery, intrauterine growth restriction (IUGR), and maternal β-blocker medications use increased the risk for hypoglycemia and severe hypoglycemia (all p
Conclusion(s): Incidence of hypoglycemia on admission is high among ELBW infants, and administration of IV glucose is delayed beyond an hour of life in majority of these infants. All ELBW infants need to be screened for hypoglycemia and provided iv glucose within an hour after birt
Implications of the quantum DNA model for information sciences
Get PDFThe DNA molecule can be modeled as a quantum logic processor, and this model has been supported by pilot research that experimentally demonstrated non-local communication between cells in separated cell cultures. This modeling and pilot research have important implications for information sciences, providing a potential architecture for quantum computing that operates at room temperature and is scalable to millions of qubits, and including the potential for an entanglement communication system based upon the quantum DNA architecture. Such a system could be used to provide non-local quantum key distribution that could not be blocked by any shielding or water depth, would be simultaneous over any distance, and could not be electromagnetically interfered with or eavesdropped upon. The quantum DNA model also has implications for artificial neural networks and can provide architecture for a system of quantum random number generation
The Impact of the Health Information Technology for Economic and Clinical Health Act on Clinical Pharmacy and Computerized Provider Order Entry
Get PDFThe Health Information Technology for Clinical and Economic Health (HITECH) Act of 2009 encouraged the meaningful use of the electronic health record (EHR) by health care providers in the United States. “Meaningful use” monetary incentives were offered by the Center for Medicare and Medicaid Services (CMS) for health care providers who met standards of documenting in and using the EHR. While clinical pharmacists typically work in clinics and hospitals in the United States, they were not considered eligible professionals who could receive incentives for using the EHR. There is a great deal of literature regarding the use of the EHR by eligible professionals, but not by ineligible professionals like clinical pharmacists. One way that clinical pharmacists assist in meaningful use criteria is by developing computerized provider order entries (CPOEs). The purpose of this study is to assess the perception and use of CPOEs by clinical pharmacists
Exercise Interventions for Adults with Burn Injuries
Get PDFThe purpose of this critically appraised topic (CAT) is to provide the highest quality of evidence available on the implementation of exercise interventions in the early burn rehabilitation phase in adult burn victims. This portfolio contains four peer-reviewed research articles from national and international journals. The study designs include one systematic review and meta analyses, one retrospective cohort study and two randomized control trials. These articles covered three types of exercise interventions including resistance training, mobility training, and physiotherapy. Overall, the clinical bottom line of this CAT is that exercise interventions in early burn rehabilitation may be effective in improving upper extremity function, muscle strength, range of motion, quality of life, and decreasing length of stay and inflammation. Further research is needed to determine the effects of early exercise interventions in adults in the burn ICU
Assessment of Knowledge, Attitude, Perception of Pharmacy Students Towards Telepharmacy
Get PDFTelemedicine is one of the fastest growing area in health care technology and COVID-19 pandemic has changed the way of practicing Telemedicine. Telepharmacy is a part of telemedicine where pharmacy use this technology to provide patient care services. Success of any technology depends on users’ willingness to learn and attitude towards technology. Early assessment of students’ attitude during pharmacy school is important to know in order to assess how receptive students are to accept Telepharmacy in their work setting currently or in future. That will also help to determine success of Telepharmacy implementation. This study will focus on assessing knowledge, attitude and perceptions of student pharmacists towards Telepharmacy
Investigating the Role of ZNF384 Rearrangements in Acute Leukemia
Get PDFChromosomal rearrangements involving ZNF384 are the defining lesion in 5% of pediatric and adult B-cell acute lymphoblastic leukemia and tumors are characterized by aberrant myeloid marker expression. Additionally, ZNF384 rearrangements are the defining lesion in nearly half of pediatric B/myeloid mixed phenotype acute leukemia. These fusions juxtapose full-length ZNF384 to the N terminal portion of a diverse range of partners, most often, transcription factors or epigenetic modifiers. It has been shown that ZNF384-rearranged tumors have a distinct gene expression profile that is consistent between disease groups and N terminal partners. Genomic analyses of patient tumors has shown that ZNF384 fusions arise in hematopoietic stem cells and that expression of the fusion, but not the concomitant genetic alterations, results in lineage aberrancy, however, the mechanistic role of ZNF384 rearrangements has not been formally studied. The goal of this project was to investigate the role of ZNF384 rearrangements, together with concomitant genetic alterations, in leukemogenesis, with an emphasis on characterizing the role of cell-of-origin and lineage of the resulting leukemias. Additionally, I aimed to explore the mechanism that leads to a distinct gene expression profile and immunophenotype.
Using viral overexpression and newly developed genetically engineered mouse models I have shown the effect of ZNF384 fusion expression at multiple stages of hematopoietic development in mouse and human systems. These experiments revealed the hematopoietic skewing toward immature, myeloid differentiation caused by expression of ZNF384 fusions. While expression of ZNF384 fusion oncoproteins in either mouse or human hematopoietic progenitors resulted in hematopoietic expansion, lineage skewing, and for some fusion partners, self-renewal in vitro; co-expression with common concomitant lesions, such as NRAS G12D, was necessary in order to develop a fully penetrant mouse leukemia in vivo. In contrast, ZNF384 fusions alone drive B/myeloid leukemia when expressed in human hematopoietic stem and progenitor cells and transplanted into NSG-SGM3 mice, highlighting the benefits of using human models to investigate human oncogenes. Importantly, these experiments confirm that hematopoietic stem cells are the most sensitive to cellular transformation by ZNF384 fusions. Mechanistic studies integrating gene expression and chromatin occupancy data revealed that fusions bind canonical ZNF384 sites with greater intensity than wild type protein. A subset of regions with increased fusion binding also had increased H3K27Ac and were intronic or intergenic suggesting they are putative enhancer regions.
These findings support that ZNF384 fusions occur in an early hematopoietic stem or progenitor cell which leads to skewed hematopoiesis and leukemic transformation in the presence of additional lesions, proliferative stress, or cytokine stimulation. This is likely caused by inappropriate extended activation of stem and progenitor enhancer regions along with deregulation of lineage-specific genes by altered binding of ZNF384 fusions. Together, these results demonstrate an intersection of cell of origin and expression of fusion oncoproteins as necessary prerequisites for generating lineage ambiguous leukemia
Pain Control: Opioid vs. Nonopioid Analgesia During the Immediate Postoperative Period
Get PDFBackground Opioid analgesia has become the mainstay for acute pain management in the postoperative setting. However, the use of opioid medications comes with significant risks and side effects. Due to increasing numbers of prescriptions to those with chronic pain, opioid medications have become more expensive while becoming less effective due to the buildup of patient tolerance. The idea of opioid-free analgesic techniques has rarely been breached in many hospitals. Emerging research has shown that opioid-sparing approaches have resulted in lower reported pain scores across the board, as well as significant cost reductions to hospitals and insurance agencies. In addition to providing adequate pain relief, the predicted cost burden of an opioid-free or opioid-sparing approach is significantly less than traditional methods.
Methods The following groups were considered in our inclusion criteria: those who speak the English language, all races and ethnicities, male or female, home medications, those who are at least 18 years of age and able to provide written informed consent, those undergoing inpatient or same-day surgical procedures. In addition, our scoping review includes the following exclusion criteria: those who are non-English speaking, those who are less than 18 years of age, those who are not undergoing surgical procedures while admitted, those who are unable to provide numeric pain score due to clinical status, those who are unable to provide written informed consent, and those who decline participation in the study. Data was extracted by one reviewer and verified by the remaining two group members. Extraction was divided as equally as possible among the 11 listed references. Discrepancies in data extraction were discussed between the article reviewer, project editor, and group leader.
Results We identified nine primary sources addressing the use of ketamine as an alternative to opioid analgesia and post-operative pain control. Our findings indicate a positive correlation between perioperative ketamine administration and postoperative pain control. While this information provides insight on opioid-free analgesia, it also revealed the limited amount of research conducted in this area of practice. The strategies for several of the clinical trials limited ketamine administration to a small niche of patients. The included studies provided evidence for lower pain scores, reductions in opioid consumption, and better patient outcomes.
Implications for Nursing Practice Based on the results of the studies’ randomized controlled trials and meta-analyses, the effects of ketamine are shown as an adequate analgesic alternative to opioids postoperatively. The cited resources showed that ketamine can be used as a sole agent, or combined effectively with reduced doses of opioids for multimodal therapy. There were noted limitations in some of the research articles. Not all of the cited studies were able to include definitive evidence of proper blinding techniques or randomization methods. Small sample sizes and the inclusion of specific patient populations identified within several of the studies can skew data in one direction or another; therefore, significant clinical results cannot be generalized to patient populations across the board
Integrating Digital Health Technology to Alleviate Caregiver Burden
Get PDFThe elder population in our country is growing at an exponential pace. Studies have shown that elders who are aged 80 years and older are projected to suffer from age related issues such as Alzheimer’s, dementia, and osteoporosis and will need assistance with Long Term Services and Support (LTSS). Additionally, many elders are also projected to suffer from more severe chronic illnesses such as diabetes, cancer, and heart related illnesses. Because many of these elders are aging in place, residing in their own homes, they will require the services of at home assistance, which high probability will be a neighbor, friend, or family member, serving in the role as an informal caregiver. As the pace of elders increasingly outnumbers informal caregivers, strategic methods must be evaluated, researched, and implemented to ensure caregivers are not becoming overwhelmed and contributing to our chronic health population due to caregiver burden, and to also ensure informal caregivers have the appropriate level of holistic support (emotionally, physically, financially, and spiritually) needed to provide adequate care to our aging population. This paper will focus on the emergence of digital health technology and how it can be beneficial to informal caregivers and care recipients
Intraoperative Dexmedetomidine for Reduction of Postoperative Delirium in the Elderly: A Scoping Review
Get PDFBackground/Purpose: Post-operative delirium leads to significant morbidity in elderly patients, yet there is no regimen to prevent POD. Opioid use in the elderly surgical population is of the most significant risk factors for developing POD. The purpose of this scoping review is to recognize that Dexmedetomidine mitigates cognitive dysfunction secondary to acute pain and the use of narcotic analgesia by decreasing the amount of norepinephrine (an excitatory neurotransmitter) released during times of stress. This mechanism of action also provides analgesia through decreased perception and modulation of pain.
Methods: The authors developed eligibility criteria for inclusion of articles and performed a systematic search of several databases. Each of the authors initially selected five articles for inclusion in the scoping review. We created annotated literature tables for easy screening by co-authors. After reviewing the annotated literature table four articles were excluded, leaving 11 articles for inclusion in the scoping review. There were six level I meta-analysis/systematic reviews, four level II randomized clinical trials, and one level IV qualitative research article. Next, we created a data-charting form on Microsoft Word for extraction of data items and synthesis of results.
Results: Two of the studies found no significant difference in POD between dexmedetomidine groups and control groups. The nine remaining studies noted decreases in the rate, duration, and risk of POD in the groups receiving dexmedetomidine either intraoperatively or postoperatively. Multiple studies found secondary benefits in addition to decreased POD, such as a reduction of tachycardia, hypertension, stroke, hypoxemia, and narcotic use. One study, however, found that the incidence of hypotension and bradycardia were increased among the elderly population.
Implications for Nursing Practice: Surgery is a tremendous stressor in any age group, but especially the elderly population. It has been shown postoperative delirium occurs in 17-61% of major surgery procedures with 30-40% of the cases assumed to be preventable. Opioid administration in the elderly surgical population is one of the most significant risk factors for developing POD. With anesthesia practice already leaning towards opioid-free and opioid-limited anesthetic, the incorporation of dexmedetomidine could prove to be a valuable resource in both reducing opioid use and POD in the elderly surgical population. Although more research is needed, the current evidence is promising