Pediatrics and Genetics

Pancreatic DuctalAdenocarcinoma (PDAC) is one of the most lethalmalignancies, with limited treatment options. Altered lipid metabolism,including dysregulated eicosanoid pathways, plays a role in PDAC progressionand therapy resistance. In this study, we investigated the impactof a treatment with polymeric hydroxychloroquine (PCQ), a novel macromolecularderivative of hydroxychloroquine (HCQ), on tumor lipid metabolismin a syngeneic mouse model of PDAC. Using a validated LC-MS/MS method,we quantified 72 eicosanoids in tumors to assess the metabolic changesinduced by PCQ and HCQ treatment. Our findings revealed significantPCQ-mediated downregulation of multiple protumorigenic eicosanoids,including PGD2, PGJ2, LTE4, LTB4, and HETEs, and upregulation of antitumorresolvins. This was further confirmed by Partial Least Squares DiscriminantAnalysis (PLS-DA) and heatmap analysis. The parent compound HCQ showedminimal impact on eicosanoid concentrations in the tumors, with nosignificant alterations at 24-h and modulation of only six eicosanoidsdownregulated at 72-h post treatment. Overall, our data highlighta novel role of PCQ in modulating tumor lipid metabolism, suggestinga unique mechanism of action and its potential as an adjuvant agentin the therapy of PDAC.

SUMMARYModification by ubiquitination governs the half-lives of thousands of proteins that are fated for elimination by either the proteasome or autophagy pathways, depending on the intricate architectures of ubiquitin modification. This system mediates quality control for individual proteins, protein complexes, and organelles, as well as myriad purely regulatory functions. Here we provide a comprehensive survey of the ubiquitin-proteasome system (UPS), the scope of which is at present poorly defined. The UPS, with the inclusion of pathways involving ubiquitin-like modifiers, comprises in our estimate over 1400 distinct proteins in humans, a vast set of activities whose collective impact on the biology of the cell is pervasive. The UPS is an integral component of the proteostasis network (PN), the remainder of which we have also surveyed in recent studies. With the addition of molecular chaperones, proteins from autophagy-lysosome pathway, and related activities, the PN includes in total over 3100 components by our estimates. Comprehensive and systematic definition of these pathways should support a range of ongoing investigations in the areas of genomics, proteomics, biochemistry, cell biology, and disease research.

Abstract We tested state-of-the-art LLMs under clinical-scale workloads using two designs: a single agent handling all tasks and a multi-agent orchestrator assigning each task to a dedicated worker. Across retrieval, extraction, and dosing tasks, batch sizes ranged from 5–80. Multi-agent accuracy remained high (90.6% at 5 tasks; 65.3% at 80), while single-agent accuracy collapsed (73.1% to 16.6%; p < 0.01). Multi-agent runs used up to 65-fold fewer tokens and limited latency growth. These findings show that lightweight orchestration preserves accuracy and efficiency under mixed-task clinical loads.

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Base editors enable precise genome modification but are constrained by bystander edits that limit their applicability. Existing strategies to enhance precision often compromise efficiency and remain highly sequence dependent. Here we present a parallel engineering approach that optimizes both guide RNAs and the deaminase enzyme to minimize bystander editing without sacrificing activity. We designed a library of 3'-extended guide RNAs and identified context-dependent variants that improved specificity. Using a precision-driven phage-assisted evolution system and protein language models, we evolved adenine base editor variants two- to threefold more precise than adenine base editor ABE8e while maintaining high efficiency across a library of thousands of human pathogenic contexts in vitro. Our findings establish a scalable framework for precision engineering of base editors, addressing a major challenge in genome editing.

BackgroundAlzheimer's disease (AD) exhibits significant genetic heterogeneity, with no single model fully explaining its inheritance pattern. Structural variants (SVs) may contribute to the missing heritability of AD, particularly in disease pathology and familial AD, which remain largely unexplored.MethodStructural variants (SVs) were analyzed in unrelated 1,162 individuals from the ROSMAP study (687 cognitively normal (CN), 475 AD patients), as well as 197 Non‐Hispanic White (NHW) families (926 individuals, 58.5% with AD) and 214 Caribbean Hispanic (CH) families (1,340 individuals, 59.17% with AD). Large insertions and deletions were identified using Manta, Absinthe, and MELT from whole‐genome sequencing, supplemented by Sniffles2 and external SV call sets. This approach generated a unified VCF file containing 45,251 insertions and 76,566 deletions. After filtering for missingness rate and allele counts, a total of 9,290 insertions and 9,529 deletions were retained for analysis. Genome‐wide SV analyses were performed with AD‐related metrics in ROSMAP, adjusting for age, sex, and principal components, and validated in an independent ADSP replication cohort comprising 29,055 unrelated individuals (17,110 CN and 11,945 AD patients).ResultWe identified nine SVs (one insertion and eight deletions) segregating in AD families. An insertion near PDCD10 in NHW families reached genome‐wide significance (p <5×10‐8) for AD risk in the replication cohort. Two deletions in KIF26B and SPHKAP were found in both CH and NHW families, while five appeared only in NHW and one in CH. All eight deletions showed genome‐wide significance for AD risk. SV GWAS on AD pathologies in ROSMAP revealed an insertion in INPP4B with the strongest association to global brain pathology (β=0.19; p = 2.32×10‐5), also linked to pathological AD, diffuse plaques, and Braak staging. A deletion near ADGRB1 (β=1.53; p = 5.05×10‐6) was associated with neuritic plaques, and another near ARMC2 (β=1.66; p = 2.17×10‐6) was linked to diffuse plaques. All three SVs associated with AD (p <5×10‐6) in replication.ConclusionOur findings reveal numerous SVs segregating in familial AD across both CH and NHW families, as well as additional SVs linked to sporadic AD. Prioritizing these SVs based on their potential effects on gene function and expression will provide deeper insight into their contributions to both familial and sporadic AD.

IntroductionIn the United States, limited English proficiency (LEP) and provider-patient language discordance are associated with poorer medical outcomes compared with English-proficient, language-concordant patients. Asian American and Pacific Islander (AAPI) populations have higher-than-average rates of LEP and may be more vulnerable to adverse outcomes. The authors of this study examined differences in risk factors, medical care, and delivery outcomes between AAPI individuals who gave birth and spoke English at home versus those who spoke an AAPI language at home.MethodsDe-identified birth and death certificate data from January 1, 2005, to December 31, 2018, were obtained from the Kansas Department of Health and Environment (N = 17,067). Risk factors, medical care, and delivery outcomes were compared between AAPI language speakers and English speakers using likelihood chi-square and Fisher exact tests.ResultsNon-English speakers initiated prenatal care later (p <0.0001) and received less adequate prenatal care (p <0.0001). They also had higher rates of forceps- and vacuum-assisted deliveries (p <0.0001), and third- or fourth-degree perineal lacerations (p <0.0001) compared with English speakers. Neonatal outcomes largely were similar between groups.ConclusionsWithin the AAPI community in Kansas, speakers of AAPI languages experienced poorer maternal delivery outcomes, specifically higher rates of assisted deliveries and severe perineal lacerations, compared with English speakers. These disparities may reflect patient-provider language discordance, which can limit patient autonomy and influence decision-making in urgent or emergent situations, as well as broader structural determinants of health.

Background:Diagnostic delay is common in mitochondrial disease, and its drivers remain unclear despite advances in molecular diagnostics.Methods:We retrospectively analyzed 58 individuals with molecularly confirmed mitochondrial disease at the Mount Sinai Mitochondrial Disease Clinic, diagnosed after 2016. Diagnostic delay was partitioned into intervals from symptom onset to clinical suspicion, and from suspicion to molecular diagnosis. Demographic, phenotypic, and genetic data were abstracted from health records, and Human Phenotype Ontology terms were compared before and after diagnosis using ClinPhen.Results:Most delays occurred between symptom onset and clinical suspicion (mean 8.17 years) rather than after suspicion (mean 0.63 years), yielding a mean total delay of 8.8 years (median 3.0). Delay decreased sharply by year of birth (r = −0.99, p < 1.5 × 10^–48) and symptom onset (r = −0.98, p < 1.4 × 10^–36), but showed no meaningful trend with year of diagnosis. Developmental delay predicted shorter diagnostic intervals. Canonical features such as seizures, hypotonia, and stroke were frequently documented years before suspicion, underscoring missed opportunities.Conclusions:Diagnostic delay reflects missed recognition rather than testing limitations. Systematic capture of early phenotypes and AI/NLP-based mining of electronic health records could proactively flag patients for reflexive sequencing, shortening diagnostic delay.

Previous studies have shown that regional anesthesia (RA) use versus placebo control is associated with less postsurgical opioid requirements and improved pain scores. This trial compared a novel combination of bilateral pecto-intercostal fascial plane and unilateral rectus sheath blocks to an active comparator of surgeon-administered local anesthetic wound infiltration in children undergoing septal defect repair. The study tested the hypothesis that RA use would result in less opioid use and lower pain intensity compared to wound infiltration. This double-blind, randomized, parallel group, single-center trial included children (<18 years) undergoing primary atrial septal defect (ASD) or ventricular septal defect (VSD) repair. Participants were randomized to RA consisting of ultrasound-guided pecto-intercostal fascial plane and rectus sheath blocks or no-block, consisting of local anesthetic wound infiltration. Both groups received 1.5 mL/kg of ropivacaine 0.2% for the intervention. The primary outcome was opioid use (oral morphine milligram equivalents [MME]/kg) 0-12 hours after surgery. Secondary outcomes were opioid use at additional time points, pain (0-10 scale) between 0 and 48 hours (area under the curve [AUC]), and hospital length of stay (LOS). Data analysis included 42 children (24 RA, 18 infiltration), age 3.3 ± 2.7 years (mean ± standard deviation [SD]; median, 3; range, 4 months-10 years). Opioid use (MME/kg mean ± SD) 0-12 hours after surgery was 0.44 ± 0.19 in the RA group compared to 0.83 ± 0.39 in the infiltration group (mean difference -0.39; 95% confidence interval [CI], -0.59 to -0.18; P = .001). Total postoperative opioid use from 0 to 48 hours after surgery was 0.95 ± 0.40 in the RA group compared to 1.57 ± 0.75 in the infiltration group (mean difference -0.64; 95% CI, -1.02 to -0.22, P = .004). Pain intensity AUC (0-48 hours) was 45.0 ± 26.8 in the RA group compared to 94.5 ± 55.7 in the infiltration group (mean difference -49.5 [-78.9 to -20.1]; P = .002). Opioid use between 12 and 48 hours and hospital LOS was not different between groups. This single-center study showed that the combined pecto-intercostal fascial plane and rectus sheath blocks were opioid-sparing and provided superior pain control compared to contemporary practice of local anesthetic infiltration in children following septal defect repair. This investigation strengthens the evidence to support RA use to improve postoperative pain in this population.