bluuebunny/crossref_metadata_2025 huggingface dataset:
Managerial Competencies Engaged in Innovative Actions in Primary Health Care: A Qualitative Study of Brazilian Nurses
Authors: Oliveira Iria Barbara de , Peres Aida Maris , Almeida Bastos Rodrigo , Casey Mary , Timmins Fiona
Published: October 2023

Aim. To explore the managerial competencies engaged in innovative actions among Brazilian nurses working in primary health care. Background. The mobilization of managerial competencies favors environments that are in transformation. There is a lack of studies that recognize the managerial skills which influence the implementation of innovative actions in PHC. Method. A qualitative exploratory descriptive approach was developed in the PHC of a municipality in Brazil. A total of 76 nurses who worked in management and care participated with a semistructured script being applied on innovative actions implemented in the service. The data were processed in IraMuTeQ 0.7 and later analyzed by descending hierarchical classification. Results. The managerial competencies that influenced the development of innovative actions implemented were as follows: communication and teamwork in planning innovative actions, continuing education for application and implementation, and leadership and people management. Conclusions. Managerial competencies were used as strategies by nurses to implement innovative actions and contribute to engagement and generating positive results, emphasizing autonomy and the role of nurses as agents of change. Implications for Nursing Management. The identified management competencies contribute to directing and sustaining innovative actions, as well as to identifying critical nodes that need support and innovation.
Conceptual Design of a Novel Megawatt Molten Salt Reactor Cooled by He-Xe Gas
Authors: Zhao Hongkai , Wu Jianhui , Chen Shuning , Cui Yong , Chen Jingen , Cai Xiangzhou
Published: October 2023

He-Xe gas-cooled micro-molten salt reactor (HX-micro-MSR) is a novel reactor concept that integrates the technologies of molten salt reactor and closed Brayton cycle (CBC), which has a more compact structure compared with the other types of micro-MSRs. The reactor system probed in this paper has a thermal power of 2.5 MWth and consists of the core, fission gas collecting container, and CBC system. The He-Xe gas flows through the coolant channels in the core to transfer the nuclear heat to the CBC for electricity production. To withstand the large pressure difference between the He-Xe gas coolant (7 MPa) and molten salt (nearly atmospheric pressure), the sizes and wall thickness of coolant channels are analyzed and optimized to be 8 mm and 0.5 mm, respectively. In total, 1050 coolant channels are regularly arranged in the core to effectively remove the nuclear heat. The enrichment of U-235 in the fuel UF4 is determined to be 61% to meet the burnup goal of 5 years. To minimize the neutron leakage, the thickness of reflector is selected to be 23 cm. Six control drums with the diameter in 10.5 cm and neutron absorber layer thickness in 1 cm are symmetrically placed in the reflector to realize reactivity control under both normal and accident conditions. Radiation shield is designed and analyzed by varying the thickness of multiple shielding layers, and it is found that a combination of W layer in 14 cm and Mg(BH4)2 layer in 56 cm can satisfy the criterion of radiation dose (<1 mSv/h). The total weight of HX-micro-MSR is estimated to be 35 tonnes and falls into the acceptable range.
Variation of Bulk Modulus, Its First Pressure Derivative, and Thermal Expansion Coefficient with Applied High Hydrostatic Pressure
Authors: Mahammed Manaf A. , Mohammed Hamsa B.
Published: October 2023

Throughout this work, the equations of variation of the isothermal bulk modulus, its first pressure derivative, and the volumetric thermal expansion coefficient as a function of pressure were derived based on the Birch–Murnaghan equation of state (B–M EOS). The bulk modulus and its first derivative at ambient temperature for nine elements were extracted by fitting the published experimental pressure–volume data to B–M EOS, and the results were compared with other published researches, and there was a good agreement. Moreover, those extracted values were used to study the variation of the isothermal bulk modulus, its first pressure derivative, and the isothermal coefficient of thermal expansion as a function of the applied hydrostatic pressure using the equations that were derived from this work.
Effect of Different Cleaning Regimes on Biofilm Formation of Acrylic-Based Removable Orthodontic Appliance: A Randomized Clinical Trial
Authors: Khawwam Safa I. , Al-Groosh Dheaa H.
Published: October 2023

Objectives. This study aimed to evaluate the effects of different cleaning regimes of acrylic-based removable orthodontic appliances on bacterial biofilm formation and whether the surface modification, i.e., polished acrylic fitting surface, reduces biofilm formation. Materials and Methods. This double-blind, parallel, randomized clinical trial involved thirty-nine orthodontic patients indicated for removable orthodontic appliances. The patients were allocated into three groups according to the cleaning method: brushing with a denture brush and chlorhexidine (CHX) toothpaste, Lacalut cleaning tablet, and a combination of both cleaning methods. Each patient wore an upper removable appliance containing eight wells fitted with eight detachable acrylic tiles (four polished and four unpolished) for seven days. Five types of oral microbiota were evaluated using selective growth media and biochemical tests. The biofilm cleaning efficacy was assessed using the colony-forming unit (CFU) and scanning electron microscopy (SEM). Statistical Analysis. Data from the CFU using different cleansing regimes were compared, following log transformation, using one-way analysis of variance (ANOVA). The polished and unpolished tiles were compared for biofilm formation on each cleansing method using an independent t-test. Results. There was no significant difference among the three cleaning methods on the polished or unpolished tiles. However, in polished tiles, streptococci were significantly reduced in all cleaning methods, whereas staphylococci and Staphylococcus aureus were markedly decreased in brushing and combination cleaning methods. However, the total number of anaerobic bacteria was significantly reduced in polished tiles using the combination method only. Conclusions. Polishing the fitting surface of an acrylic-based orthodontic appliance reduced the tested bacterial biofilm formation and may enhance cleaning efficiency. Brushing and combination methods showed superior cleaning effects compared to cleaning tablets. This trial is registered with NCT05707221.
Combined Immunotherapy Improves Outcome for Replication-Repair-Deficient (RRD) High-Grade Glioma Failing Anti–PD-1 Monotherapy: A Report from the International RRD Consortium
Authors: Das Anirban , Fernandez Nicholas R. , Levine Adrian , Bianchi Vanessa , Stengs Lucie K. , Chung Jiil , Negm Logine , Dimayacyac Jose Rafael , Chang Yuan , Nobre Liana , Ercan Ayse B. , Sanchez-Ramirez Santiago , Sudhaman Sumedha , Edwards Melissa , Larouche Valerie , Samuel David , Van Damme An , Gass David , Ziegler David S. , Bielack Stefan S. , Koschmann Carl , Zelcer Shayna , Yalon-Oren Michal , Campino Gadi Abede , Sarosiek Tomasz , Nichols Kim E. , Loret De Mola Rebecca , Bielamowicz Kevin , Sabel Magnus , Frojd Charlotta A. , Wood Matthew D. , Glover Jason M. , Lee Yi-Yen , Vanan Magimairajan , Adamski Jenny K. , Perreault Sebastien , Chamdine Omar , Hjort Magnus Aasved , Zapotocky Michal , Carceller Fernando , Wright Erin , Fedorakova Ivana , Lossos Alexander , Tanaka Ryuma , Osborn Michael , Blumenthal Deborah T. , Aronson Melyssa , Bartels Ute , Huang Annie , Ramaswamy Vijay , Malkin David , Shlien Adam , Villani Anita , Dirks Peter B. , Pugh Trevor J. , Getz Gad , Maruvka Yosef E. , Tsang Derek S. , Ertl-Wagner Birgit , Hawkins Cynthia , Bouffet Eric , Morgenstern Daniel A. , Tabori Uri
Published: October 2023

Immune checkpoint inhibition (ICI) is effective for replication-repair-deficient, high-grade gliomas (RRD-HGG). The clinical/biological impact of immune-directed approaches after failing ICI monotherapy is unknown. We performed an international study on 75 patients treated with anti–PD-1; 20 are progression free (median follow-up, 3.7 years). After second progression/recurrence (n = 55), continuing ICI-based salvage prolonged survival to 11.6 months (n = 38; P < 0.001), particularly for those with extreme mutation burden (P = 0.03). Delayed, sustained responses were observed, associated with changes in mutational spectra and the immune microenvironment. Response to reirradiation was explained by an absence of deleterious postradiation indel signatures (ID8). CTLA4 expression increased over time, and subsequent CTLA4 inhibition resulted in response/stable disease in 75%. RAS–MAPK-pathway inhibition led to the reinvigoration of peripheral immune and radiologic responses. Local (flare) and systemic immune adverse events were frequent (biallelic mismatch-repair deficiency > Lynch syndrome). We provide a mechanistic rationale for the sustained benefit in RRD-HGG from immune-directed/synergistic salvage therapies. Future approaches need to be tailored to patient and tumor biology.

Significance:

Hypermutant RRD-HGG are susceptible to checkpoint inhibitors beyond initial progression, leading to improved survival when reirradiation and synergistic immune/targeted agents are added. This is driven by their unique biological and immune properties, which evolve over time. Future research should focus on combinatorial regimens that increase patient survival while limiting immune toxicity.

This article is featured in Selected Articles from This Issue, p. 201
Potent Personalized Venetoclax Partners for Acute Myeloid Leukemia Identified by Ex Vivo Drug Screening
Authors: Becker Pamela S.
Published: October 2023

High-throughput screens (HTS) have been utilized to assess the efficacy of single drugs against patient tumor samples with the purpose of optimizing precision therapy, but testing the synergy of drug combinations can identify the ideal second drug to add. With novel sophisticated HTS, effective venetoclax combinations can be revealed that provide the cell state, phenotype, and molecular features of the susceptible and resistant cell populations.

See related article by Eide, Kurtz et al., p. 452 (14) .
Concurrent Targeting of HDAC and PI3K to Overcome Phenotypic Heterogeneity of Castration-resistant and Neuroendocrine Prostate Cancers
Authors: Zhang Ailin , Lau Nathan A. , Wong Alicia , Brown Lisha G. , Coleman Ilsa M. , De Sarkar Navonil , Li Dapei , DeLucia Diana C. , Labrecque Mark P. , Nguyen Holly M. , Conner Jennifer L. , Dumpit Ruth F. , True Lawrence D. , Lin Daniel W. , Corey Eva , Alumkal Joshi J. , Nelson Peter S. , Morrissey Colm , Lee John K.
Published: October 2023

Castration-resistant prostate cancer (CRPC) consists of multiple phenotypic subtypes including androgen receptor (AR)-active prostate cancer (ARPC) and neuroendocrine prostate cancer (NEPC). Tumor cells with these phenotypes can coexist between metastases within a patient and within an individual tumor. Treatments that are effective across CRPC subtypes are currently lacking. Histone deacetylation is crucial for the regulation of chromatin structure and maintenance of cancer cell state and activation of the PI3K/AKT/mTOR signaling cascade is a tumor growth–promoting pathway. We therefore investigated combined targeting of histone deacetylase (HDAC) and PI3K using a rationally designed dual inhibitor, fimepinostat, in CRPC subtypes in vitro and in vivo. Dual HDAC1/2 and PI3K/AKT pathway inhibition by fimepinostat led to robust tumor growth inhibition in both ARPC and NEPC models including cell line– and patient-derived xenografts. HDAC1/2 inhibition combined with PI3K/AKT inhibition was more effective than targeting each pathway alone, producing growth inhibitory effects through cell-cycle inhibition and apoptosis. Molecular profiling revealed on-target effects of combined HDAC1/2 and PI3K/AKT inhibition independent of tumor phenotype. Fimepinostat therapy was also associated with the suppression of lineage transcription factors including AR in ARPC and Achaete-scute homolog 1 (ASCL1) in NEPC. Together, these results indicate that fimepinostat represents a novel therapeutic that may be effective against both ARPC and NEPC through CRPC subtype-dependent and -independent mechanisms.

Significance:

CRPC is a heterogeneous disease constituting multiple phenotypic subtypes that often co-occur within tumors or across metastases in patients. Existing targeted therapies for CRPC do not take this into account. Here we show that fimepinostat, a dual HDAC1/2 and PI3K/AKT inhibitor investigated clinically in other cancer types but not prostate cancer, may overcome this heterogeneity by effectively inhibiting both ARPC and NEPC subtypes of CRPC.
Edge Creep: Increased Pigmentation at the Border of Choroidal Melanomas Treated with Plaque Brachytherapy
Authors: Binkley Elaine M. , Rodriguez Sean M. , Hyer Daniel E. , Hinz Connie J. , Boldt H. Culver
Published: October 2023

Introduction: There is an increase in pigmentation that occurs in many tumors following plaque brachytherapy for choroidal melanoma. Correctly distinguishing between increased pigment at the tumor border versus true growth is imperative. We performed a retrospective review of patients treated with I-125 brachytherapy for choroidal melanoma at our institution to study this phenomenon. Methods: Records were reviewed for all patients undergoing plaque brachytherapy for uveal melanoma for a 5-year period (N = 195). Patients with iris and anterior tumors were excluded. Tumors treated more than 31 days after presentation were excluded. Fundus images for patients with increased pigmentation at any of the borders of the tumor at 6-month follow-up that extended beyond the initial pigmented margin were included (N = 20; 8 F, 12 M). Imaging at the last follow-up was reviewed, and it was confirmed that all tumors involuted appropriately with no evidence of local recurrence. The date of initial exam, time to treatment, and follow-up interval were recorded for each included patient. Results: Twenty patients (10%) exhibited increased pigment deposition at any of the borders of the tumor at 6-month follow-up that extended beyond the initial pigmented margin. Average tumor thickness was 3.2 mm (1.3–5.1); average largest tumor basal diameter was 11.6 mm (7–15.5). Average time from diagnosis to treatment was 25 days (17–31). Average length of follow-up was 35 months (16–68). No patient developed recurrence during the duration of follow-up, and 1 patient had developed metastasis. Conclusion: We describe the phenomenon of increased pigment deposition, “edge creep,” at the borders of choroidal melanomas treated with plaque brachytherapy that gave the appearance of initial tumor growth but then subsequently remained stable over time. It is important that treating ocular oncologists be aware of this phenomenon to avoid unnecessary diagnosis of local recurrence.
Update Immunglobulin-A-Vaskulitis
Authors: Neumann Thomas
Published: October 2023

Die Immunglobulin-A-Vaskulitis (IgAV) ist eine systemische Vaskulitis der kleinen Gefäße mit Ig(Immunglobulin)A-Immunkomplexbildung und einem breiten Spektrum klinischer Konstellationen. Typische Manifestationen sind Purpura, Arthralgien oder Arthritiden, Enteritis und Glomerulonephritis. Die IgAV ist die häufigste Vaskulitis im Kindesalter mit meist unkompliziertem und selbstlimitierendem Verlauf. Erwachsene erkranken deutlich seltener an einer IgAV, wobei die Verläufe insbesondere bei renaler oder gastrointestinaler Manifestation komplizierter sind. Verschiedene Trigger der IgAV, darunter Infektionen, wurden beschrieben, wobei eine gestörte Glykosylierung von IgA1 mit konsekutiver Freilegung von Bindungsstellen für Autoantikörper die pathophysiologische Voraussetzung für die Vaskulitis ist. Therapeutische Strategien mit Immunsuppressiva sind bisher mit geringer Evidenz unterlegt, berücksichtigen die Schwere der Organmanifestationen und orientieren sich an den Empfehlungen zur Behandlung anderer Vaskulitiden der kleinen Gefäße. Benigne Verläufe werden symptomatisch behandelt. Die langfristige Prognose der IgAV ist von der renalen Manifestation beeinflusst.
Nivolumab-induzierte Pneumonie bei nicht kleinzelligem Lungenkarzinom: Ein Fallbericht
Authors: Habib Tehmina , Abu-Abaa Mohammad , Kolman-Taddeo Diana
Published: October 2023

Nivolumab ist ein Immuncheckpoint-Inhibitor (ICI), der sich bei der Behandlung bestimmter bösartiger Erkrankungen, einschließlich des nicht kleinzelligen Lungenkarzinoms, als wirksam erwiesen hat. In diesem Fallbericht stellen wir eine 53-jährige Patientin vor, bei der ein metastasierendes nichtkleinzelliges Lungenkarzinom dia­gnostiziert wurde. Nach Bestrahlung (sowohl extern als auch mit Brachytherapie) und Entfernung des Tumors durch bronchoskopische Kryotherapie entwickelte sie unter Nivolumab und Ipilimumab eine initiale Pneumonitis. Diese wurde erfolgreich mit einer Steroidtherapie behandelt, sodass die Monotherapie mit Nivolumab wiederaufgenommen werden konnte. Einige Monate später entwickelte die Patientin jedoch eine organisierende Pneumonie, die zum Abbruch der Immuntherapie und zum Beginn einer Kortikosteroidtherapie führte. Dieser Fall sollte Kliniker daran erinnern, dass ICI zwar eine neue und wirksame Therapie für bestimmte maligne Erkrankungen darstellen, dass aber immunologische Nebenwirkungen kräftezehrend sein und eine Fortsetzung der Immuntherapie verhindern können. Anhand dieses Falles soll hier die Literatur zu dieser seltenen Nebenwirkung der Nivolumab-induzierten Pneumonitis sowie zu den Risikofaktoren, der Diagnose und der Behandlung gesichtet werden.
Concomitant Irradiation to Checkpoint Inhibitor Therapy of Hepatocellular Carcinoma Patients: A Systematic Retrospective, Single-Center Analysis
Authors: Munker Stefan , Roessler Daniel , Öcal Osman , Ben-Khaled Najib , Bernhart Kathrin , Ye Liangtao , Piseddu Ignazio , Vielhauer Jakob , Reiter Florian P. , Rodriguez Isaac , Ricke Jens , Teufel Andreas , De Toni Enrico , Seidensticker Max , Niyazi Maximilian , Corradini Stefanie
Published: October 2023

Introduction: Immunotherapy has been established as the standard treatment option for patients with advanced hepatocellular carcinoma (aHCC). Despite the increased efficacy, disease progression occurs in a relevant proportion of patients even after an objective response. Combination concepts with locoregional therapy are currently under investigation for hepatic disease but are also in discussion for the control of distant metastasis. Radiotherapy is a highly effective treatment modality for local tumor control. It is also thought to increase the efficacy of checkpoint inhibition and sensitize distant lesions to the effects of immunotherapy, but may potentially increase adverse effects. In our center, few patients with aHCC treated with immune checkpoint inhibitors (ICIs) received concomitant radiotherapy for symptom or disease control. The aim of this study was to retrospectively analyze adverse effects and efficacy of concomitant radiotherapy in patients with aHCC treated with checkpoint inhibition. Methods: To this aim, patients who received a combination of ICI and radiotherapy in our institution were retrospectively considered for analysis. The predefined inclusion criterion was radiotherapy after initiated checkpoint inhibition and continuation of ICI therapy for at least 8 weeks. Adverse effects and efficacy measurements were performed according to local standards. Results: The database search of 2016–2021 revealed six consecutive patients fulfilling the predefined criteria for concomitant ICI and radiotherapy. Three patients received high-dose-rate brachytherapy (15 Gy) to treat progredient hepatic lesions. Two patients received stereotactic body radiotherapy (SBRT) (25–30 Gy) for symptom control, and 1 patient received brachytherapy and SBRT to treat metastases. No severe adverse events were reported in the period (<6 months) after concomitant radiotherapy. In 5 out of 6 cases, long-term tumor control could be achieved by this therapeutic combination. Conclusion: A good efficacy of concomitant radiotherapy and checkpoint inhibition has been achieved with no safety concerns. Further investigations should evaluate the safety, appropriate clinical context, and efficacy of this promising approach.
Mild Renal Function Impairment and Long-Term Outcomes in Patients with Three-Vessel Coronary Artery Disease: A Cohort Study
Authors: Zeng Guyu , Yuan Deshan , Wang Peizhi , Li Tianyu , Jiang Lin , Xu Lianjun , Tian Jian , Zhao Xueyan , Feng Xinxing , Wang Dong , Zhang Yin , Sun Kai , Xu Jingjing , Liu Ru , Xu Bo , Zhao Wei , Hui Rutai , Gao Runlin , Song Lei , Yuan Jinqing
Published: October 2023

Introduction: Limited data are available on the long-term impact of mild renal dysfunction (estimated glomerular filtration rate [eGFR] 60–89 mL/min/1.73 m2) in patients with three-vessel coronary disease (3VD). Methods: A total of 5,272 patients with 3VD undergoing revascularization were included and were categorized into 3 groups: normal renal function (eGFR ≥90 mL/min/1.73 m2, n = 2,352), mild renal dysfunction (eGFR 60–89, n = 2,501), and moderate renal dysfunction (eGFR 30–59, n = 419). Primary endpoint was all-cause death. Secondary endpoints included cardiac death and major adverse cardiac and cerebrovascular events (MACCE), a composite of death, myocardial infarction, and stroke. Results: During the median 7.6-year follow-up period, 555 (10.5%) deaths occurred. After multivariable adjustment, patients with mild and moderate renal dysfunction had significantly higher risks of all-cause death (adjusted hazard ratio [HR]: 1.36, 95% confidence interval [CI]: 1.07–1.70; adjusted HR: 2.06, 95% CI: 1.53–2.78, respectively) compared with patients with normal renal function. Patients after coronary artery bypass grafting (CABG) had a lower rate of all-cause death and MACCE than those undergoing percutaneous coronary intervention (PCI) in the normal and mild renal dysfunction group but not in the moderate renal dysfunction group. Results were similar after propensity score matching. Conclusions: In patients with 3VD, even mild renal impairment was significantly associated with a higher risk of all-cause death. The superiority of CABG over PCI diminished in those with moderate renal dysfunction. Our study alerts clinicians to the early screening of mild renal impairment in patients with 3VD and provides real-world evidence on the optimal revascularization strategy in patients with renal impairment.
The Causal Effect of Obesity on the Risk of 15 Autoimmune Diseases: A Mendelian Randomization Study
Authors: Li Xunliang , Zhu Jie , Zhao Wenman , Zhu Yuyu , Zhu Li , Shi Rui , Wang Zhijuan , Pan Haifeng , Wang Deguang
Published: October 2023

Introduction: Observational studies have shown that obesity is a risk factor for various autoimmune diseases. However, the causal relationship between obesity and autoimmune diseases is unclear. Mendelian randomization (MR) was used to investigate the causal effects of obesity on 15 autoimmune diseases. Methods: MR analysis employed instrumental variables, specifically single-nucleotide polymorphisms associated with obesity measures such as body mass index (BMI), waist circumference, hip circumference, and waist-to-hip ratio. The study utilized UK Biobank and FinnGen data to estimate the causal relationship between obesity and autoimmune diseases. Results: Genetically predicted BMI was associated with risk for five autoimmune diseases. The odds ratio per 1-SD increase in genetically predicted BMI, the OR was 1.28 (95% CI, 1.18–1.09; p < 0.001) for asthma, 1.37 (95% CI, 1.24–1.51; p < 0.001) for hypothyroidism, 1.52 (95% CI, 1.27–1.83; p < 0.001) for psoriasis, 1.22 (95% CI, 1.06–1.40; p = 0.005) for rheumatoid arthritis, and 1.55 (95% CI, 1.32–1.83; p < 0.001) for type 1 diabetes. However, after adjusting for genetic susceptibility to drinking and smoking, the correlation between BMI and rheumatoid arthritis was not statistically significant. Genetically predicted waist circumference, hip circumference, and waist and hip circumference were associated with 6, 6, and 1 autoimmune disease, respectively. Conclusion: This study suggests that obesity may be associated with an increased risk of several autoimmune diseases, such as asthma, hypothyroidism, psoriasis, rheumatoid arthritis, and type 1 diabetes.
Chronic Total Occlusion is Not a Risk Factor for Mortality in Patients With Successful Percutaneous Coronary Intervention: A Cohort Study
Authors: Holck Emil N. , Winther Naja S. , Mogensen Lone Juul‐Hune , Christiansen Evald Høj
Published: October 2023

Background

Fifteen percent of patients with coronary artery disease undergoing angiography have a chronic total occlusion (CTO). The current study aimed to investigate the long‐term prognosis after successful and unsuccessful CTO percutaneous coronary intervention (PCI) compared with PCI for non‐CTO lesions.

Methods and Results

The current study was designed as an observational, region‐wide, register‐based cohort study enrolling all patients undergoing PCI in the Central Region of Denmark in 2009 to 2019. Patients were stratified into non‐CTO, successful CTO, and unsuccessful CTO revascularization. Patients were followed until an event or January 1, 2022. The primary end point was all‐cause mortality. In 21 141 patients enrolled, 2108 underwent CTO PCI. Clinical presentation was acute coronary syndrome in 11 879 patients and chronic coronary syndrome in 7887 patients. After a median of 5.7 years (interquartile range, 3.3–8.8), long‐term all‐cause mortality was higher after CTO PCI compared with non‐CTO PCI, but the difference was statistically insignificant when adjusting for clinical factors (unadjusted hazard ratio [HR], 1.19 [95% CI, 1.09–1.29], adjusted HR, 1.08 [95% CI, 0.97–1.20];
P
=0.165). After successful CTO PCI, no difference compared with non‐CTO PCI was observed (unadjusted HR, 0.99 [95% CI, 0.90–1.10], adjusted HR, 0.99 [95% CI, 0.87–1.12];
P
=0.873). After unsuccessful CTO PCI, long‐term all‐cause mortality was higher than non‐CTO PCI (unadjusted HR, 1.82 [95% CI, 1.59–2.08], adjusted HR, 1.35 [95% CI, 1.13–1.63];
P
<0.001).

Conclusions

Patients undergoing PCI for CTO have elevated long‐term mortality compared with patients without CTO. Successful opening of the CTO(s) is associated with equal mortality compared with non‐CTO PCI. In contrast, failed CTO PCI is associated with worse long‐term mortality. These findings suggest the need for CTO programs with high success rates and low complication rates.
Abstract GS.03: Functional Role Of Placental Senescence In Peripartum Cardiomyopathy
Authors: Castro Claire , Yu Andy , Rana Sarosh , Sahul Sajid , Gray Kathryn J , Honigberg Michael C , Ricke-Hoch Melanie , Xia Peng , R. Al Sayed Zeina , Diaz Verdugo Carmen , Kirkland James , Ellinor Patrick T , Karumanchi Ananth A , Arany Zoltan , Hilfiker-Kleiner Denise , Rosenzweig Anthony , Roh Jason D
Published: October 2023

Introduction:
Peripartum cardiomyopathy (PPCM) and preeclampsia (PEC) are leading causes of maternal mortality with limited therapies. Circulating factors in late pregnancy contribute to cardiac dysfunction in PPCM and PEC. We recently identified senescence-associated secretory proteins (SASP), markers of biological aging, as the most highly upregulated circulating proteins in PPCM and PEC. The mechanisms driving this paradoxical aging pathophysiology in these pregnancy-induced heart failure (HF) syndromes are unknown.

Hypothesis:
The placenta becomes markedly senescent by term. We hypothesized that 1) amplified placental senescence causes the increase in circulating SASP in PPCM and PEC, and 2) attenuating placental senescence might improve cardiac function in PPCM.

Methods:
We performed comprehensive senescence assessments in placental samples from women with preeclampsia
vs
. matched pregnant controls. We assessed the effects of placental senescence in human iPSC-derived cardiomyocytes (iPSC-CM) and the PGC1α-KO PPCM murine model.

Results:
Placentas from PEC women displayed multiple markers of amplified senescence, including increased p16 and p21 expression (2 & 4 fold, p<0.03), decreased DNA methylation (-1.7 fold, p<0.04), and increased overall SASP expression (2 fold; p<0.001). In iPSC-CM, PEC plasma induced pathologic gene expression profiles (Nppa, Nppb, Myh7) and increased Activin-A signaling (Fstl3, Serpine1, Ccn2), a key SASP factor that contributes to cardiac dysfunction in PEC and PPCM. The senolytic Fisetin attenuated placental senescence in pregnant PGC1α-KO mice, reducing placental p16 and p21 expression (-2 & -3 fold, p<0.01) and Activin-A levels (-2 fold, p<0.03). Compared to vehicle-treated pregnant PGC1α-KO mice, Fisetin-treated animals had 35% higher left ventricular fractional shortening (31%
vs
. 42%; p<0.001), along with reductions in cardiac Nppa expression and Activin signaling. No changes in cardiac senescence or adverse effects on fetal development were observed with Fisetin.

Conclusion:
We identify amplified placental senescence as part of the core pathobiology underlying PPCM and PEC, and present proof-of-concept evidence for senolytic therapeutic approaches in pregnancy-induced HF.
Abstract P1007: Graph Neural Network Analysis Of Dynamic Temporal Relationships Between Chromatin Accessibility And RNA Expression In The Developing Mouse Heart
Authors: Xu Sidra Y , Galdos Francisco X , Lee Carissa , Wu Sean M
Published: October 2023

Mammalian development is a dynamic process that transforms the epigenetic and transcriptomic landscapes of cells as they differentiate into various cell types and tissues. In vertebrates, the heart is the first functioning organ of the embryo, but its development has yet to be fully understood. Using simultaneous scRNA-seq and scATAQ-seq data from three major timepoints (E8.5, E10.5, E16.5) of murine development, we develop a novel approach to analyze the temporal relationship between chromatin accessibility and gene expression across development using RNA velocity and interpretable graph neural network (GNN) models.

RNA velocity is a powerful splicing kinetics tool for uncovering directed transcriptional dynamics in complex biological systems, and it infers the direction and rate of change of gene expression in single cells over time by comparing the ratio of unspliced to spliced mRNA reads between adjacent cells. We represent the vectors identified through RNA velocity as a directed graph, thereby transforming the single-cell data with the additional simultaneous ATAC-seq information into an input for a GNN. The GNN then learns the temporal epigenetic and transcriptomic dynamics from the node feature information, ie. scATAC-seq, with the graph structure, ie. RNA velocity vectors, to predict the developmental trajectories of cells. After training of the GNN model, we implement an additional GNN explainer model to analyze it and identify subgraphs, ie. networks of DNA regions, that maximize the mutual information associated with its trajectory predictions.

By interpreting the contributions of ATAC peaks in the GNN model, we identify novel regulatory dynamics and trends involved in the separation of distinct cardiac lineages in the developing mouse heart. Ultimately, we provide new insight for future investigation into the temporal relationship between chromatin accessibility and gene expression levels..
Abstract P1038: Role Of Hypomorphic Notch1 Mutations In Cardiomyocyte Signaling And Function In Hypoplastic Left Heart Syndrome
Authors: Saraf Anita , Brent Schlegel , Zaineb Javed , Rao Krithika , Lear Travis , Rajaganapathi Jagannathan , Moulik Mousumi , Nadine Hempel , Shiva Sruti , Rajasundaram Dhivyaa , Kuhn Bernhard , Finkel Toren
Published: October 2023

Background:
Congenital heart disease (CHD) affects is the most common birth defect and affects 1% of births in the United States. Hypoplastic left heart syndrome (HLHS) a complex CHD where left sided structures are malformed during embryonic development. Compound heterozygous mutations in NOTCH1, a developmental transmembrane protein have been implicated HLHS patients. However, the effect of hypomorphic NOTCH1 expression on cardiomyocyte development has not been fully characterized.

Methods:
Using HLHS patient derived induced pluripotent stem cells (iPSCs) with a compound heterozygous NOTCH1 expression and CRISPR-Cas9 gene editing technology we developed multiple iPSCs clones with hypomorphic NOTCH1 expression. We characterized expression of NOTCH1 downstream signaling molecules using transcriptomics of iPSCs and CMs. We further characterized mitochondrial structure, ATP production and sarcomere architecture of the resulting CMs. Lastly, we characterized calcium transients and contractility of the NOTCH1 hypomorphic CMs.

Results:
iPSC-CMs with hypomorphic NOTCH1 expression showed reduced pluripotency and decreased differentiation into cardiomyocytes. Transcriptomics studies showed that hypomorphic clones increasingly differentiated into fibroblasts and smooth muscle cells as compared to wild-type (WT) cells. Multiple signaling pathways associated mitochondrial function, sarcomeric organization, and cardiomyocyte development were dysregulated. Live cell imaging showed abnormal sarcomeric architecture and mitochondrial hyperfission as compared to WT cells. ATP production was also decreased as compared to WT. Lastly, calcium transients in hypomorphic CMs showed a decrease in time to peak and upslope which consequently lead to decreased contractility and relaxation rates of hypomorphic NOTCH1 CMs.

Conclusion:
Hypomorphic expression of NOTCH1 seen in HLHS affects multiple aspects of CM cytoskeletal architecture during CM development. Consequently, NOTCH1 hypomorphic iPSC-CMs have abnormal calcium transients and decreased contractility, likely contributing to the higher incidence of arrhythmia and heart failure seen in HLHS patients.
Abstract P1039: Soluble Extracellular Matrix Protein Induces Senescence In Aortic Valve Interstitial Cells To Up-regulate Valvular Osteogenic Activity
Authors: Yao Qingzhou , Ao Lihua , Fullerton David , Meng Xianzhong
Published: October 2023

Background:
Calcific aortic valve disease (CAVD) is the most prevalent heart valve disease in the elderly, and elevated osteogenic activity of aortic valve interstitial cells (AVICs) play a critical role in CAVD progression to severe aortic valve stenosis. While soluble extracellular matrix (ECM) proteins, including biglycan and matrilin 2, have been found to up-regulate the osteogenic activity in human AVICs, the mechanism underlying the cellular and molecular mechanisms remain unclear. As greater densities of senescent AVICs were observed in human calcified aortic valves, we tested the hypothesis that soluble ECM protein induces senescence in AVICs to up-regulate valvular osteogenic activity.

Methods and Results:
Human AVICs were isolated from normal and CAVD aortic valves. Levels of P16 and P21 were assessed by immunoblotting, and senescent changes is identified using senescence-associated β-galactosidase (SA-β-gal) staining. AVICs from diseased valves displayed higher levels of P16 and P21, greater SA-β-gal staining and active calcium deposition. Soluble matrilin 2 (2.0 μg/ml) up-regulated the expression of P16 and P21, and enhanced SA-β-gal staining in normal AVICs, leading to greater calcium deposition. Further, knockdown of P16 markedly reduced calcium deposition in AVICs exposed to soluble matrilin 2. The impact of soluble matrlin 2 is associated with activation of the M6PR-ERK1/2 pathway. Blocking or knockdown of M6PR (M6P, 10 mM or siRNA, 1.0 nM), or inhibition of ERK1/2 (PD98059, 25 μM) attenuated the effect of soluble matrilin 2 on AVIC senescence and resultant up-regulation of osteogenic activity.

Conclusion:
AVICs from aortic valves of patients with CAVD have higher levels of senescence activity. Soluble matrilin 2, via the M6PR-ERK1/2 pathway, induces AVIC senescence to promote the osteogenic activity. Targeting the D-M6PR-ERK1/2 pathway may suppress AVIC senescence and attenuate aortic valve calcification associated with CAVD progression.
Abstract P1041: Multiplexed Cardiotoxicity And Efficacy Screening Using Kinetic Image Cytometry Of Human Induced Pluripotent Stem Cell-derived Cardiomyocytes
Authors: Basa Ranor Christian B , McDonough Patrick , Pascua Ameena , Harrison Lilian , Wang Ariel , Hilton Jeffrey M , Ingermanson Randall S , Price Jeffrey H
Published: October 2023

Traditionally, cardiotoxicity testing used low-throughput animal models which may not fully recapitulate human physiology. Stem cell technology enables screening in a more physiologically-relevant model system in less time and with less cost, but most current high-throughput screening modalities rely on whole-well or whole-field averaged data, which obfuscate the responses of individual hiPSC-cardiomyocytes (CMs). By measuring individual hiPSC-CMs, heterogenous responses that would otherwise be “averaged out” can be quantified, thus improving sensitivity. We previously published that the single-cell Kinetic Image Cytometry (KIC) methods developed at Vala Sciences predicted arrhythmogenic liability with an accuracy of 90% using intracellular Ca
2+
kinetics as a readout. In this study, we expand upon this methodology by loading metabolically matured hiPSC-CMs with Cal-520 (a green Ca
2+
dye) and BeRST-1 (a far red membrane voltage dye), acquiring interleaved movies of Ca
2+
and membrane potential at 60 Hz (30 Hz per channel). We then created image analysis algorithms to measure Ca
2+
transient (CT) and action potential (AP) kinetics, and to derive contraction measurements from those movies. To validate our approach, we exposed cells to isoproterenol, nifedipine, dofetilide, and butadiene 2-monoxime (BDM) at various concentrations. Isoproterenol increased beat rate, decreased both AP and CT durations, increased CT magnitude, and elicited a lusitropic effect. Nifedipine increased beat rate, decreased AP and CT durations, and reduced CT magnitude and contraction distance. Dofetilide reduced beat rate, prolonged APs and CTs, and increased contraction distance. BDM had multiple inhibitor effects on APs and CTs, and strongly reduced contraction. Thus, this multiplexed assay can quantify multiple effects of drugs on APs, CTs, and contraction, providing an unprecedented suite of information relevant to cardiosafety and efficacy.
Abstract P1050: The Activity Of Autophagy Biomarkers In Acute Myocardial Infarction
Authors: Kong Min Gyu , Suh Jon , Cho Yoonhaeng , Park Hyun Woo , Lee Nae Hee
Published: October 2023

Purpose:
We aimed to evaluate the activity of autophagy in patients with AMI. Furthermore, this study analyzed the associations of autophagy biomarkers with the traditional cardiac biomarkers, echocardiographic left ventricular ejection fraction (LVEF) and the defect size of myocardial SPECT.

Methods:
AMI patients with urgent coronary revascularization and controls who underwent coronary angiography without significant coronary artery stenosis were enrolled prospectively. We obtained the serum of patients from peripheral artery and coronary artery before coronary revascularization. Levels of LC3-II, ATG5, Beclin 1 and M30 were quantified by ELISA in the serum from 71 AMI patients and 46 controls.

Results:
AMI patients had significant higher concentrations of autophagy biomarkers such as LC3-II (217.0±87.5 vs. 58.1±53.2 ng/ml; 218.6±72.4 vs. 58.7±53.7 ng/ml; p<0.001), ATG5 (183.7±100.1 vs. 35.8±34.2; 169.6±85.3 vs. 38.3±43.1; p<0.001), and Beclin 1 (194.9±86.2 vs. 62.0±53.5; 178.0±67.1 vs. 58.7±50.1; p<0.001) in peripheral artery and coronary artery. All autophagy biomarkers in both arteries had strong positive correlations with traditional cardiac biomarkers including CK-MB, Troponin T, and NT-proBNP. Especially, LC3-II in coronary artery was significantly correlated with the defect size (%) on myocardial SPECT (r
s
=0.333, p=0.010) in AMI patients.

Conclusions:
Autophagy biomarkers were significantly higher in AMI patients than in controls. Autophagy biomarkers had significant positive correlations with the traditional cardiac biomarker. LC3-II was significantly correlated with the LV defect size due to myocardial injury in AMI patients.
Abstract P1073: The
Mir-200
Family Modulates Expression Of
Tbx5
,
Gata
4, And
Pitx2
During Early Cardiac Development.
Authors: Leonard Riley J , Sweat Mason , Eliason Steven , Weiss Robert M , Amendt Brad
Published: October 2023

Congenital heart defects (CHDs) may be caused by mutations in genes that drive cardiac development. Cardiac development is also regulated at the transcription level. MicroRNAs (miRs) target the transcripts of genes in numerous cardiac cell types during embryonic development. We and others have shown that the
miR-200
family modulates the transcripts of cardiogenic transcription factors (TFs)
Tbx5
,
Gata4
, and
Pitx2
(
TGP
). However, relationship between these miRs and cardiogenic TFs during cardiac development is poorly understood. To this relationship, we cultured cardiomyocytes (CMs) with reduced
miR-200
expression and found increased expression of Tbx5, Gata4, and Pitx2, providing evidence for targeting in cell-autonomous role.
In vivo,
the
miR-200
family members,
miR-200a
and
-200c
, are highly expressed in the developing heart (e14.5) and reduced in adults (2mo) (Ct Value- 200a: 24.3 ± 0.59 v 38.3 ± 0.21; 200c: 25.0 ± 0.64 v 32.5 ± 0.16). Using our
miR-200
family inhibitor mice models (
I-200
), we have found these miRs are required for cardiac development.
I-200
embryos are found with a membranous ventral septal defect and poor ventricle wall development, which is lethal by e16.5. At e14.5,
I-200
hearts have a significant increase in expression fold change of Tbx5 (5.98 ± 1.51 p ≤ 0.05), Gata4 (3.29 ± 0.61 p ≤ 0.05), and Pitx2 (4.67 ± 0.23 p ≤ 0.05) compared to Wild-Type. With further investigation we discovered the
miR-200
family is required for CMs differentiation.
I-200
CMs have increased expression of cardiac progenitor markers Nkx2.5 and Mef2c compared to Wild-Type. As these cardiogenic transcription factors target DNA elements required for the maintenance of the CM transcriptome and identity, our data suggests the
miR-200
family acts in this process. Concurrent single nuclei multiomics sequencing revealed changes in CM transcription and open chromatin to provided corresponding evidence to support this conclusion.

Conclusions:
The
miR-200
family is a modulator of cardiogenic TFs expression and activity during development. Future directions will determine the role of
miR-
200 in adult cardiac disease, such as ischemic injury. Our work provides new insights into gene dosage, modulated by miRs, that is required and necessary during cardiac development.
Abstract P1074:
In Vitro
Stimulation-conduction Platforms To Mature Induced Pluripotent Stem Cell-derived Cardiomyocytes
Authors: Cook Suh Hee , Twiddy Jack , Daniele Michael A , Gluck Jessica M
Published: October 2023

Figure 1.

Scaffold (i) and bioreactor (ii) viability for iPSC-CM conduction-stimulation platform.Heart disease is the leading cause of death worldwide. Cardiac tissue engineering offers various solutions, frequently employing induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs). iPSC-CMs can be expanded limitlessly and used autologously; however, they are immature compared to healthy, adult cardiomyocytes
in vivo
. We are interested in conductive scaffolds to mature iPSC-CMs by facilitating gap-junctional coupling in the presence of electrical stimulation. We have previously endowed electrospun scaffolds with high conductivity by incorporating carbon nanotubes (CNTs). We differentiated iPSCs into iPSC-CMs with a Wnt inhibitor-directed protocol. We confirmed CNT scaffold biocompatibility by seeding iPSC-CMs onto scaffolds with and without CNTs; 24 hours later, a live/dead assay indicated scaffolds exhibited no cytotoxicity (Fig. 1i). We also confirmed that the application of voltage-controlled electrical stimulation (square wave, 5 ms period, 20% duty cycle) for 5 minutes at magnitudes of 0, 0.1, 1, and 10 V did not introduce cytotoxicity (Fig. 1ii). Furthermore, application of 0.1 V resulted in earlier ultrastructure development and beating. We have developed an upgraded bioreactor which we will use to probe the role of electrical signals in embryonic cardiac development and to explore the ability of CNT scaffolds to electrophysiologically mature iPSC-CMs in the presence of electrical pacing. If successful, this could pave the way for advances in cellular pacemaking, physiologically relevant models, and cardiac tissue regeneration.
Abstract P1077: Transcription Factor Nfya Regulates Mitochondrial Metabolism And Cardiomyocyte Proliferation In The Fetal Heart
Authors: Cui Miao , Bezprozvannaya Svetlana , Hao Tian , Bassel-Duby Rhonda S , Liu Ning , Olson Eric N
Published: October 2023

We previously identified a neonatal cardiomyocyte population that enters the cell-cycle following injury and disappears as the heart loses the ability to regenerate. These regenerative neonatal cardiomyocytes display a unique transcriptional program regulated by NFYA, a subunit of the trimeric complex Nuclear Transcription Factor Y (NFY) that functions as a pioneer factor to promote cell proliferation. To study whether NFYA is required for cardiomyocyte proliferation, we generated mice with cardiomyocyte-specific deletion of
NFYA
using alpha-MHC-Cre.
NFYA
KO mice died before birth; their hearts were smaller in ventricular volumes and developed a distinct cardiac noncompaction phenotype, with hyper trabeculation and reduced cardiomyocyte proliferation. Integration of single-nuclear RNA and ATAC sequencing with spatial transcriptomics identified different embryonic cardiomyocyte subtypes in wildtype and
NFYA
KO hearts, including those from atria, ventricles, trabeculae, and the conduction system. We found that
NFYA
deletion reduced the reservoir of immature regenerative cardiomyocytes in the fetal heart and increased the number of trabecular cardiomyocytes. Mechanistically,
NFYA
deletion reduced the expression of genes regulating oxidative phosphorylation metabolism. The defect in mitochondrial metabolism was further supported by decreased activity of NADH oxidation at mitochondrial membranes and reduced levels of TCA cycle metabolites in
NFYA
KO hearts. Using chromatin immunoprecipitation and reporter assays, we show that NFYA directly regulates the transcription of those mitochondrial metabolic genes as well as cell-cycle genes in cardiomyocytes, thus providing a transcriptional coupling between mitochondrial metabolism and cardiomyocyte proliferation. Our study identified a previously unrecognized transcriptional control mechanism of metabolic genes controlled by NFYA and highlights the importance of oxidative metabolism during fetal heart development and regeneration.