Longitudinal improvements in clinical and functional outcomes following initiation of elexacaftor/tezacaftor/ivacaftor in patients with cystic fibrosis

Background: The advent of highly effective modulator therapies (HEMTs), including elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA), for treatment of cystic fibrosis (CF) has resulted in remarkable clinical improvement for modulator-naive patients and for those who have been treated with prior modulator therapies. Intranasal micro-optical coherence tomography (muOCT) has detected functional abnormalities in the mucociliary apparatus of people with CF. The objectivewas to characterize the effects of ELX/TEZ/ IVA on nasal mucociliary clearance by muOCT and monitor the clinical changes conferred as a way to understand the effects. Method(s): Of 26 individuals aged 12 and older with at least one F508del mutation recruited, 24 were enrolled and followed over three visits: baseline and 1 (visit 2) and 6 months (visit 4) after initiation of ELX/TEZ/IVA therapy;the COVID-19 pandemic affected visit windows. Intranasal muOCT imaging was conducted at baseline and visit 2 as previously described;additional imaging for 18 months (visit 5) is in progress. Clinical outcomes, including percentage predicted forced expiratory volume in 1 second (FEV1pp) and sweat chloride levels were computed as part of the parent Prospective Study to Evaluate Biological and Clinical Effects of Significantly Corrected CFTR Function (PROMISE study). A blinded investigator team analyzed in vivo muOCT parameters including mucociliary transport (MCT) rate, ciliary beat frequency (CBF), and periciliary liquid depth (PCL) after devising an improved stabilization algorithm. Analysis of airway surface liquid (ASL) depthswas excluded because of the limited number of cases in which the necessary condition for measurement,which is preservation of a clear air layer between the mucus layer and the probe, was satisfied. Result(s): Twenty-three subjects completed visits 1 and 2, and 18 completed visits 1, 2, and 4. Average age at baselinewas 27 +/- 8.7, 69% were female, and 43% were on prior two-drug modulator therapy. No significant change in body mass index was found between the visits. FEV1pp increased significantly (10.9%, 95% CI, 76.1-98.4%) by visit 2 and persisted at visit 4 (10.6%, 95% CI, 87.7-107.0;p < 0.001). Sweat chloride levels decreased significantly at visit 2 (-36.6 mmol/L, 95% CI, 40.9-54.9 mmol/L) and visit 4 (-41.3 mmol/L, 95% CI, 34.9-51.8 mmol/L) at visit 4 ( p < 0.001). Analysis of muOCT images revealed significant improvement in MCT rate (2.8 +/- 1.5 mm/ min at baseline vs 4.0 +/- 1.5 mm/min at visit 2, p = 0.048), although no discernable changes were noted in CBF or PCL. When stratified based on use of prior modulator therapy, no significant differences were found for any muOCT metric. No significant correlations between change in MCT rates and change in FEV1pp or sweat chloride from baseline to visit 2were found. Conclusion(s): Treatment with ELX/TEZ/IVA in people with CF, including those that were treatment naive and those on prior modulator therapy, resulted in significant, sustained improvement in lung function and decreases in sweat chloride levels at ~10 months, consistent with recently published reports. Functional improvements in MCTratewere evident after initiation of ELX/TEZ/IVA therapy, which may partially explain the findings of better whole-lung mucus clearance and reduction in chronic infections reported previously. muOCT imaging in people with CF is sensitive to the treatment effect of HEMT and suggests better mucociliary transport as a mechanism of action underlying the clinical benefits for lung health. Acknowledgements: On behalf of the PROMISE investigatorsCopyright © 2022, European Cystic Fibrosis Society. All rights reserved

Using Synthetic Biology methods to construct a functional estrogen biosensor based on split Nanoluciferase activity

The presence of estrogenic compounds (endocrine-disruptors, EDCs) in the water supply raises concerns about human and aquatic health. Current methods for detecting estrogen contamination require expensive, time-consuming techniques such as liquid chromatography-mass spectrometry and high-performance liquid chromatography. Previously reported estrogen biosensors required multiple cloning and transformation steps for successful detection in bacteria. Synthetic biology allows for the construction of genetic devises composed of DNA sequences modified to be interchangeable and provide novel functions. New tools and devices are constantly needed to enhance the already extensive list of novel genetic parts. Our approach to the design of an estrogen responsive element uses methodology developed in the Wells lab (Elledge et al, 2021) to detect SARS-CoV-2 antibodies. This methodology takes advantage of the split Nanoluciferase (spLUC) protein divided into two functional domains (designated SmBit and LgBit). Based on rational engineering design we express dimerization dependent LgBit and SmBit fused to the Estrogen Receptor alpha protein (ERalpha) in bacteria cells. These two monomeric proteins will dimerize in the presence of estrogen, reconstitute the split luciferase enzyme and reestablish enzyme activity. Cells can be lysed, and luminescence detected to quantify estrogen present in the sample. We present here the construction strategy and proof of concept data demonstrating the efficiency of this dual-functional biosensor and its effectiveness for detection of estrogenic compounds in contaminated water. NSF-REU-1852150, REU Site: A multisite REU in Synthetic Biology, 2019.Copyright © 2023 The American Society for Biochemistry and Molecular Biology, Inc.

A Statewide Surgical Quality Improvement Collaborative's Opioid Data Collection

Introduction: Our statewide surgical quality improvement (QI) collaborative began collecting opioid data to better understand our patients’ pain management and discharge opioid prescriptions. During our pilot there was invalid data requiring variable revision. Collection resumed in 1/2020 and was encouraged during COVID-19, acknowledging that we faced reduced and highly selective operative case volumes with reduced resources. Methods: Institutions from a statewide surgical QI collaborative participated in the revised custom variable opioid data collection. Utilizing the National Surgical Quality Improvement Program (NSQIP) platform, seven custom variable data were collected for 13 general surgery procedures. Variables were abstracted by Surgical Clinical Reviewers from 1/2020-12/2020. Results: 722 cases were performed. 460 (64%) cases had all variable data submitted, 102 (14%) had at least one and 160 (22%) cases had no variables submitted. Postoperative/in-patient opioids and non-opioids administered were the most likely to be submitted (73% and 73%). 489 cases (68%) had submitted data on use of an opioid sparing strategy. 483 (67%) cases had some discharge opioid prescription data, but only 357 cases (49%) had adequate data to standardize for comparison. Conclusion: A significant decrease in collection of the three minimally revised variables was observed. However, from revising the discharge opioid prescription variable from free text to a pre-populated selection, the quality of data improved significantly. This will allow the collaborative to standardize discharge opioid prescribing. Custom variable opioid data collection is feasible and can be utilized to inform collaborative opioid prescribing practices.

Micro Optical Coherence Tomography Demonstrates Ciliated Cell Dysfunction in COVID-19 Patients

RATIONALE: Micro optical coherence tomography (μOCT) is a minimally invasive intranasal imaging technique that can determine cellular and functional dynamics of respiratory epithelia at 1-μm resolution, enabling real time visualization and quantification of ciliary motion, inflammation, and mucus transport. Multiple abnormalities including reduced mucociliary transport were reported in patients with cystic fibrosis (Leung et al., Sci Trans Med 2019). Severe acute respiratory syndrome coronavirus (SARS-CoV-2), causative agent of COVID- 19, binds via ACE2 receptors, highly expressed in the ciliated and secretory cells of the nasal epithelium. We hypothesized that respiratory epithelial cell dysfunction in COVID-19 will manifest as abnormal mucociliary transport due to reduced ciliated cell function, features readily visualized by μOCT. METHODS: Symptomatic outpatients aged ≥ 18 years were recruited within 7 days of symptom onset and known SARS-CoV-2 RT-PCR positivity. Detailed clinical history and nasal swab for PCR quantification of viral RNA were obtained. Subjects were imaged inside a custom designed negative pressure isolation booth to minimize risk of virus transmission. Following inspection with a rhinoscope, the μOCT probe was maneuvered into the inferior meatus while acquiring data from approximately five discrete sites at both turbinate and floor of each nare. Long-term follow up, including clinical outcomes at 21 days were collected. Data was interpreted in comparison to previously imaged healthy controls. RESULTS: Eight subjects underwent imaging without complications, and additional enrollment is in progress. Mean age was 29.4 years (SD 8.2), and average duration of illness from symptom onset to imaging was 8.8 days (SD 4.3). Most common symptoms reported were fatigue (75%), headache, anosmia, fever, and sore throat (50% each). Viral load (mean log10) at time of imaging was 4.3 copies per mL. Imaging abnormalities identified to date (N=5) included denuded epithelium, presence of excessive mucus (Figure.1,B), and increased inflammatory cell counts (Figure.1,C) compared to healthy control (Figure.1,A). Reduced mucociliary transport (2.7 ± 0.3 mm/min COVID-19 vs 11.2 ± 0.8 mm/min healthy controls, P= 0.0016) and diminished periciliary liquid depth (4.3± 0.8 μm COVID-19 vs 6.8 ± 0.3 μm healthy controls, P= 0.028) were evident. CONCLUSION: Subjects with mild but symptomatic COVID-19 exhibit functional abnormalities of the respiratory mucosa, including delayed mucociliary transport. Mucociliary dysfunction in COVID-19, as also seen in Syrian hamsters (See Li Q et al., ATS 2021 Abstract), may increase risk for descending infection and disease progression. μOCT imaging may be a useful tool to evaluate prognosis, disease progression, and monitor emerging therapy.

Comparison between lung function parameters measured using home spirometry and routine office spirometry in stable cystic fibrosis patients

Rationale: Lung function deterioration is a major cause of morbidity and mortality in patients with cystic fibrosis (CF). Spirometry is an important tool for monitoring lung function decline and early detection of exacerbations. The use of tele-services has increased recently and played a pivotal role in healthcare access to the vulnerable populations during the COVID-19 pandemic. The accuracy and reliability of using home spirometry for CF patients remain unclear. We hypothesized that in stable CF patients, lung function measured using home spirometry would correlate with baseline lung function measured by clinic spirometry. Methods: We prospectively enrolled patients with stable CF who received handheld ZEPHYRx® home spirometers from May-December 2020. We analyzed home spirometry efforts that met ATS Standards. Baseline characteristics were retrospectively collected from the electronic health records including baseline lung function-calculated as the average of the best two clinic spirometry efforts, when available. Only home spirometry measurements of patients on stable therapy were included (elexacaftor/tezacaftor/ivacaftor). Pearson's correlation coefficients were performed to evaluate the relationship between baseline lung function and mean home spirometry measures. We measured both point estimates and mean values for home spirometry. Results: We analyzed a cohort of 77 patients, which consisted of 40 (51.9%) females and 76 (98.7%) Non-Hispanic Caucasian. The mean age of patients was 34.3 years (SD 10.9). The average baseline percent predicted FEV1 measured in clinic (FEV1(c)) was 68.7 (SD 23.2) and the average percent predicted FEV1 measured using home spirometry (FEV1(h)) was 66.6 (SD 20.9). The mean baseline percent predicted FVC in clinic (FVC(c)) was 73.5 (SD 21.7) whereas the mean FVC measured using home spirometry (FVC(h)) was 83.5 (SD 18.5). Mean peak expiratory flow rates (PEFR) measured in a subset of patients (n= 48) at baseline in clinic (PEF(c)) was 7.2 l/min (SD 19.1), and mean PEFR measured using home spirometry (PEF(h)) was 7.0 l/min (SD 1.8). A very strong correlation was found between FEV1(c) and FEV1(h) (r = 0.95, P< 0.001). Whereas strong correlations were found between FVC(c) and FVC(h) (r = 0.713, P<0.001) and PEF(c) and PEF(h) (r= 0.895, P<0.001). Conclusion: In a cohort of stable CF patients, the spirometric measures (FEV1, FVC and PEF) using a home spirometry device have stronger or better correlations with the corresponding baseline lung function. Home spirometry is a reliable device in monitoring CF patients. Further studies are ongoing exploring the variability and repeatability of home spirometry measures.

Multicenter assessment of telehealth experience of care in adult people with cystic fibrosis

Background: The 2019 novel coronavirus pandemic (COVID-19) necessitated a rapid shift from conducting multidisciplinary cystic fibrosis (CF) care from in-person to telehealth-based visits. Given infrequent use of telehealth in the CF chronic care model prior to this time, experience of care in this new paradigm for patients is unknown. Objective: To determine experience of telehealth in the care model of patients in adult CF centers and assess barriers to future visits. Methods: Adults across 3 CF centers were issued online surveys via email and text link within one week of the patient's first telehealth visit in fashion under IRB approval. In the survey, patients identified their CF care site and their age range. The survey focused on three themes to assess telehealth experience of care: convenience of the visit, level of concern with absence of usual in-person assessments (pulmonary function testing (PFT), weight, sputum culture, vital signs and physical exam), and the role of telehealth in their future care. Using a 5-point Likert scale of concern, we defined 1 as not concerning and 5 as very concerning. Low level of concern was defined as a score of 2 or less. Results: Between March and June 2020, 90 adults with CF were surveyed at 3 CF centers following telehealth visits. Participants' ages were consistent with usual range of adult CF patients. The majority (71%) had not participated in a telehealth visit before March 2020. During the multidisciplinary visits, MD/DOs were seen most often (91% of visits), followed by advanced practice providers (32%), registered dietitians (31%), registered nurses (13%), and social workers (12%). Nearly all respondents (93%) were satisfied with the overall treatment experience and found utilizing telehealth services convenient. Almost all (96%) felt that their issues and concerns were addressed during the visit. The concern for lack of usual in-person assessments varied: 68% indicated low concern with lack of vital signs and physical exam, 80% indicated low concern with lack of weight measurement, 52% for lack of throat/sputum culture, while only 41% indicated low concern with lack of PFTs. When asked how many future care visits would be preferred to be telehealth, 7% indicated all visits, 35% indicated most visits, 50% indicated some visits, and 8% indicated none. Nearly all respondents (97%) were interested in home lung function assessment. Conclusions: These data show that telehealth is well-received in the adult CF population, despite lacking hallmarks of routine care, such as PFTs and sputum culture. This study supports the notion that multidisciplinary telehealth care should be a key component in the chronic CF care model, even after the COVID-19 pandemic, but provisions for home assessments are needed. Additional survey and longitudinal data for ongoing patient attitude is being analyzed to gain a larger understanding of the necessary components for the role of longitudinal telehealth in the CF chronic care model.