Diffuse midline glioma (DMG) is a devastating brain tumor with a median overall survival (OS) of 11 months. Although more patients are now participating in precision medicine clinical trials, DMGs often lack clearly druggable genomic targets, limiting effective treatment options. To address this gap, we performed integrative proteogenomic analyses on 210 tumor and control samples, including DMGs and pediatric high-grade gliomas (pHGG). Whole-genome sequencing (90X) of these 210 samples (112 H3.3K27M DMGs, 19 H3.1K27M DMGs, 7 H3-WT DMGs, 31 pHGGs, and 41 normal controls) identified recurrent driver alterations in genes associated with DNA damage response (71%), PI3K/mTOR (24%), RTK (18%), and MAPK (12%) pathways. Among pHGGs, 15 tumors lacked any known DMG driver mutations, while 16 harbored two or more canonical DMG drivers, highlighting biological overlap between these tumors. Despite comprehensive profiling, FDA-approved therapies could only be matched to 38% of samples, with just 17% of variants deemed targetable, underscoring the need for alternative strategies. Hence, we performed complementary proteomic profiling to uncover targetable signaling vulnerabilities not evident at the genomic level. Proteomics of H3.3K27M DMG cell lines (UON-DMG-05 and SU-DIPG-XIII), one of which harbors a known targetable mutation (UON-DMG-05, PDGFRA:D842V), identified elevated activity of ATM and PI3K-Akt signaling, suggesting convergent, actionable dependencies. In vivo validation confirmed the therapeutic potential of targeting these pathways. Monotherapy with avapritinib (30 mg/kg/day; PDGFRAi) or paxalisib (5 mg/kg/day; PI3Ki) extended OS to 57 and 59 days, respectively, compared to 51 days in untreated controls (P<0.01). Combined avapritinib/paxalisib treatment further improved OS to 64.5 days (P<0.0001). Currently, we are testing a novel sequential treatment regimen in PDXs model, combining upfront radiotherapy with ATM inhibition (WSD0628), followed by avapritinib/paxalisib consolidation. Further analysis and proteogenomic integration of all 210 tumor samples is underway, with the aims of overcoming current therapeutic limitations.

Alterations in the FMS-like tyrosine kinase 3 (FLT3) gene are the most frequent driver mutations in acute myeloid leukaemia (AML), linked to a high risk of relapse in patients with internal tandem duplications (FLT3-ITD). Tyrosine kinase inhibitors (TKIs) targeting the FLT3 protein are approved for clinical use, yet resistance often emerges. This resistance is mainly seen following the acquisition of additional point mutations in the tyrosine kinase domain (TKD), resulting in a double mutant FLT3-ITD/TKD, which sustains cell signalling and survival despite the presence of FLT3 inhibitors. Here, we developed a FLT3-mutant AML model with adaptive resistance to type II TKIs, sorafenib, and quizartinib by in vitro drug selection. Through global multiomic profiling, we identified upregulation of proteins involved in reactive oxygen species (ROS) production, particularly NADPH-oxidases, driving cellular 'ROS-addiction', with resistant cells relying on ROS for survival, and genome fidelity preserved by ATM-driven DNA repair. Transcriptomic analysis of adult and paediatric AML (pAML) patients identified high ATM expression as a biomarker for shorter median overall survival in both the de novo and relapsed settings. Inhibition of ATM with clinically relevant therapy WSD-0628 effectively killed TKI- and chemotherapy-resistant AML cells in vitro and significantly extended the survival of mice with sorafenib- and quizartinib-resistant FLT3-ITD AML in vivo. We propose a new treatment strategy to improve survival of patients who develop resistance to sorafenib and quizartinib, as well as relapsed and refractory pAML, exploiting resistance mechanisms to precision therapies and cell-intrinsic features of high-risk cases, highlighting a clinically relevant salvage strategy. ### Competing Interest Statement The authors have declared no competing interest.

Abstract BACKGROUND Diffuse midline glioma (DMG) is a devastating pediatric high-grade glioma (pHGG) located along the midline structures of the brain and spine. Palliative radiotherapy is the only approved treatment outside of clinical trials, with patients given 9–11-months survival post-diagnosis. Over the last 10-years, it has become common for patients to be prescribed precision therapies targeting genetic alterations, however largely, DMG harbor genetic alterations that are untargetable. METHODS To improve DMG patient outcomes, we are performing multi-omic analysis on 210 DMG, normal controls and other pHGG samples to functionally characterize the genomic landscape of these tumors and understand the protein-controlled functional consequences of recurring somatic alterations. RESULTS Genomic sequencing has been performed on 40/210 pHGG samples, identifying 290 unique mutations and several recurrent chromosomal alterations. Additionally, proteomic/phosphoproteomic profiling identified both unique and similar features of post-translational landscapes across genotypes. Examining H3.3K27M DMG cell-lines, SU-DIPG-XIII and UON-VIBE5, genomic sequencing identified 11 and 6 mutations respectively, however, only UON-VIBE5 possessed a genomically-predicted target, a PDGFRA-D842V mutation, potentially targetable by Avapritinib. Conversely, investigation of proteomes/phosphoproteomes revealed several potential therapeutic vulnerabilities. SU-DIPG-XIII possessed high enrichment of HDAC/BRD and CDK pathways and UON-VIBE5, ATM-centric pathways. In vitro proliferation assays of Avapritinib treated UON-VIBE5 failed to elicit a response at clinically relevant doses, while all proteomically-predicted therapies (HDAC – Fimepinostat, BRD – JQ1, CDK – Ribociclib and ATM – WSD-0628) successfully influenced tumor cell growth whilst leaving microglia controls cells unaffected. Avapritinib and WSD-0628 (CNS-active ATM inhibitor) drug predictions were further validated in the RA055 DMG model, which possesses similar genomic and proteomic features to UON-VIBE5. Avapritinib alone failed to influence tumor growth, while WSD-0628 notably reduced cell proliferation. The combination of these drugs, however, synergistically inhibited RA055 proliferation. CONCLUSIONS These findings thus provide preliminary evidence supporting the need to take a multi-omic approach in treating DMGs.

Diffuse midline gliomas (DMGs) diagnosed in the pons (DIPG) are universally fatal central nervous system tumors and are the leading cause of cancer-related death in children. Palliative radiotherapy is the only recognized treatment, with median overall survival just 9-11 months. The brain-penetrant, small molecule, ONC201, shows early-stage clinical trial efficacy, extending survival by ~9-11 months compared to historic controls. However, studies to determine the mechanisms behind the temporary clinical response to ONC201 are needed. Here, we have used a systems-biological approach to investigate whether genomic features influenced ONC201 response. DMGs harboring PIK3CA mutations were more sensitive to ONC201, whereas those harboring TP53 mutations were less sensitive. Quantitative proteogenomics identified that ONC201 elicits potent agonism of the mitochondrial protease, ClpP, driving proteolysis of electron transport chain and tricarboxylic acid proteins, leading to mitochondrial dysfunction. However, metabolic adaptation to ONC201 is promoted by the spare redox-signaling capacity of cells harboring WT-PIK3CA that was counteracted using the brain-penetrant PI3K/Akt/mTOR inhibitor, paxalisib. ONC201 and paxalisib combinations extended survival of orthotopic DIPG xenograft mouse models (SU-DIPG-VI, p=0.0027; SF8626, p=0.0002; HSJD-DIPG-007, p=< 0.0001). The combination in the first three recorded patients; two at progression following re-irradiation, and one at diagnosis following the completion of radiation, resulted in dramatic reductions in tumor area, dramatically extending overall survival for all three patients (25 months, 30 and 31 months continuing). The DIPG patient receiving the combination since diagnosis, remains in progression free survival (MR axial diagnosis scan = 1554 mm2, current tumour area = 306 mm2, ~80% reduction). The patient continuing to receive the combination at progression and following reirradiation also experienced a marked decrease in tumor size (MR axial diagnosis scan = 1248 mm2, current tumour area = 315 mm2, ~75% reduction), 10 months following radiological detection of progression. These data inform the phase II clinical trial (NCT05009992).

Abstract Diffuse midline gliomas (DMGs) diagnosed in the pons (DIPG) are universally fatal central nervous system tumors and are the leading cause of cancer-related death in children. Palliative radiotherapy is the only recognized treatment, with median overall survival just 9-11 months. The brain-penetrant, small molecule, ONC201, shows early-stage clinical trial efficacy, extending survival by ~9-11 months compared to historic controls. However, studies to determine the mechanisms behind the temporary clinical response to ONC201 are needed. Here, we have used a systems-biological approach to investigate whether genomic features influenced ONC201 response. DMGs harboring PIK3CA mutations were more sensitive to ONC201, whereas those harboring TP53 mutations were less sensitive. Quantitative proteogenomics identified that ONC201 elicits potent agonism of the mitochondrial protease, ClpP, driving proteolysis of electron transport chain and tricarboxylic acid proteins, leading to mitochondrial dysfunction. However, metabolic adaptation to ONC201 is promoted by the spare redox-signaling capacity of cells harboring WT-PIK3CA that was counteracted using the brain-penetrant PI3K/Akt/mTOR inhibitor, paxalisib. ONC201 and paxalisib combinations extended survival of orthotopic DIPG xenograft mouse models (SU-DIPG-VI, p=0.0027; SF8626, p=0.0002; HSJD-DIPG-007, p=< 0.0001). The combination in the first three recorded patients; two at progression following re-irradiation, and one at diagnosis following the completion of radiation, resulted in dramatic reductions in tumor area, dramatically extending overall survival for all three patients (25 months, 30 and 31 months continuing). The DIPG patient receiving the combination since diagnosis, remains in progression free survival (MR axial diagnosis scan = 1554 mm2, current tumour area = 306 mm2, ~80% reduction). The patient continuing to receive the combination at progression and following reirradiation also experienced a marked decrease in tumor size (MR axial diagnosis scan = 1248 mm2, current tumour area = 315 mm2, ~75% reduction), 10 months following radiological detection of progression. These data inform the phase II clinical trial (NCT05009992).

All Supplementary Figures and their captions.

Global high-throughput phosphoproteomic profiling is increasingly being applied to cancer specimens to identify the oncogenic signaling cascades responsible for promoting disease initiation and disease progression; pathways that are often invisible to genomics analysis. Hence, phosphoproteomic profiling has enormous potential to inform and improve individualized anti-cancer treatment strategies. However, to achieve the adequate phosphoproteomic depth and coverage necessary to identify the activated, and hence, targetable kinases responsible for driving oncogenic signaling pathways, affinity phosphopeptide enrichment techniques are required and often coupled with offline high-pressure liquid chromatographic (HPLC) separation prior to nanoflow liquid chromatography–tandem mass spectrometry (nLC-MS/MS). These complex and time-consuming procedures, limit the utility of phosphoproteomics for the analysis of individual cancer patient specimens in real-time, and restrict phosphoproteomics to specialized laboratories often outside of the clinical setting. To address these limitations, here we have optimized a new protocol, phospho-heavy-labeled-spiketide FAIMS stepped-CV DDA (pHASED), that employs online phosphoproteome deconvolution using high-field asymmetric waveform ion mobility spectrometry (FAIMS) and internal phosphopeptide standards to provide accurate label-free quantitation (LFQ) data in real-time. Compared with traditional single-shot LFQ phosphoproteomics workflows, pHASED provided increased phosphoproteomic depth and coverage (phosphopeptides = 4617 pHASED, 2789 LFQ), whilst eliminating the variability associated with offline prefractionation. pHASED was optimized using tyrosine kinase inhibitor (sorafenib) resistant isogenic FLT3-mutant acute myeloid leukemia (AML) cell line models. Bioinformatic analysis identified differential activation of the serine/threonine protein kinase ataxia-telangiectasia mutated (ATM) pathway, responsible for sensing and repairing DNA damage in sorafenib-resistant AML cell line models, thereby uncovering a potential therapeutic opportunity. Herein, we have optimized a rapid, reproducible, and flexible protocol for the characterization of complex cancer phosphoproteomes in real-time, a step towards the implementation of phosphoproteomics in the clinic to aid in the selection of anti-cancer therapies for patients.

Acute myeloid leukemia (AML) is the most common and aggressive form of acute leukemia, with a 5-year survival rate of just 24%. Over a third of all AML patients harbor activating mutations in kinases, such as the receptor tyrosine kinases FLT3 (receptor-type tyrosine-protein kinase FLT3) and KIT (mast/stem cell growth factor receptor kit). FLT3 and KIT mutations are associated with poor clinical outcomes and lower remission rates in response to standard-of-care chemotherapy. We have recently identified that the core ki-nase of the non-homologous end joining DNA repair pathway, DNA-PK (DNA-dependent protein kinase), is acti-vated downstream of FLT3; and targeting DNA-PK sensitized FLT3-mutant AML cells to standard-of-care therapies. Herein, we investigated DNA-PK as a possible therapeutic vulnerability in KIT mutant AML, using isogenic FDC-P1 mouse myeloid progenitor cell lines transduced with onco-genic mutant KIT (V560G and D816V) or vector control. Tar-geted quantitative phosphoproteomic profiling identified phosphorylation of DNA-PK in the T2599/T2605/S2608/ S2610 cluster in KIT mutant cells, indicative of DNA-PK activation. Accordingly, proliferation assays revealed that KIT mutant FDC-P1 cells were more sensitive to the DNA-PK inhibitors M3814 or NU7441, compared with empty vector controls. DNA-PK inhibition combined with inhibition of KIT signaling using the kinase inhibitors dasatinib or ibrutinib, or the protein phosphatase 2A activators FTY720 or AAL(S), led to synergistic cell death. Global phosphoproteomic analysis of KIT-D816V cells revealed that dasatinib and M3814 single -agent treatments inhibited extracellular signal-regulated kinase and AKT (RAC-alpha serine/threonine-protein ki-nase)/MTOR (serine/threonine-protein kinase mTOR) activ-ity, with greater inhibition of both pathways when used in combination. Combined dasatinib and M3814 treatment also synergistically inhibited phosphorylation of the transcrip-tional regulators MYC and MYB. This study provides insight into the oncogenic pathways regulated by DNA-PK beyond its canonical role in DNA repair and demonstrates that DNA-PK is a promising therapeutic target for KIT mutant cancers.

Stallions experience transient fluctuations in fertility throughout the breeding season. Considering pregnancy diagnoses cannot be ascertained until similar to 14 days postbreeding, the timely detection of decreases in stallion fertility would enhance industry economic and welfare outcomes. Therefore, this study aimed to identify the proteomic signatures reflective of short-term fertility fluctuations and to determine the biological mechanisms governing such differences. Using liquid chromatography-mass spectrometry (LC-MS/MS), we compared the proteomic profile of semen samples collected from commercially "fertile" stallions, during high- and low-fertility periods. A total of 1702 proteins were identified, of which, 38 showed a significant change in abundance (P < 0.05). Assessment of intra- and interstallion variability revealed that caseins (namely kappa , alpha-S1-, and alpha-S2-casein) were significantly more abundant during "high-fertility" periods, while several epididymal, and seminal plasma proteins (chiefly, epididymal sperm binding protein 1 [ELSPbP1], horse seminal plasma protein 1 [HSP-1], and clusterin), were significantly more abundant during "low-fertility" periods. We hypothesized that an increased abundance of caseins offers greater protection from potentially harmful seminal plasma proteins, thereby preserving cell functionality and fertility. In vitro exposure of spermatozoa to casein resulted in decreased levels of lipid scrambling (Merocyanine 540), higher abundance of sperm-bound caseins (alpha-S1-,alpha-S2-, and K-casein), and lower abundance of sperm-bound HSP-1 (P <= 0.05). This study demonstrates key pathways governing short-term fertility fluctuations in the stallion, thereby providing a platform to develop robust, fertility assessment strategies into the future. [GRAPHICS] .

Diffuse midline gliomas (DMGs), including those of the pons (diffuse intrinsic pontine glioma - DIPG), are pediatric CNS tumors recognized as the most lethal of all children’s cancers. Palliative radiotherapy remains the only approved treatment, with survival just 9-11 months post-diagnosis. The brain-penetrant small molecule therapy, ONC201, shows preclinical and emerging efficacy in early-stage clinical trials. However, patients invariably develop resistance, with some patients and models completely refractory to treatment. Using a powerful combination of pharmacology, proteomics, genomics, epigenetics, in vitro and in vivo modeling, across ten international laboratories, we have uncovered mechanisms underpinning resistance to ONC201. We find ONC201 elicits antagonism of the Dopamine receptor D2 (DRD2), whilst also causing mitochondrial degradation through potent agonism of the mitochondrial protease CLPP. This drives proteolysis of the electron transport chain (ETC) proteins including Succinate dehydrogenase A (SDHA) and the critical mitochondrial tricarboxylic acid (TCA) cycle regulator, Isocitrate dehydrogenase 3B (IDH3B). Loss of TCA activity reduces α-ketoglutarate and inhibits lysine demethylation, increasing methylation of H3K4me3 and H3K27me3, thus, altering the epigenome of DIPG. Mitochondrial disruption elicited redox-activated RAS-PI3K/AKT signaling, counteracted using the PI3K/AKT inhibitor paxalisib. The combination of ONC201 and paxalisib synergistically extended survival of two aggressive DIPG PDX models (SU-DIPG-VI vehicle=73 vs. combination=100-days, p=0.0027; SF8626 vehicle=36 vs. combination=43-days, p=0.0002). Compassionate access to this combination (n=2 patients; immediately post-RT and following re-RT) resulted in dramatic reductions in tumor volume, extending overall survival for the patient at diagnosis and the patient at progression (e.g., MR axial diagnosis scan = 1554 mm2, following twelve months on the combination, current tumor volume = 464 mm2 (~70% reduction), patient remains in progression free survival, 15 months since diagnosis). The clinical utility of our preclinical data is currently under investigation in the PNOC022 clinical trial (NCT05009992).

Diffuse midline gliomas (DMG), including those of the brainstem (diffuse intrinsic pontine glioma - DIPG), are pediatric CNS tumors recognized as the most lethal of all children’s cancers. Palliative radiotherapy is the only approved treatment, with survival just 9-11–months post-diagnosis. ONC201 shows preclinical and emerging clinical efficacy in early-stage clinical trials, extending survival of DIPG patients by ~9-11–months compared to historic controls. However, patients invariably develop resistance, with some patients completely refractory to treatment. Using a multi-omics approach, including pharmacology, proteomics, genomics, epigenetics, in vitro and in vivo modeling, across ten international laboratories, we have uncovered the inherent mechanisms of resistance to ONC201. We find ONC201 elicits antagonism of the Dopamine receptor D2 (DRD2), whilst also causing mitochondrial degradation through potent agonism of the Mitochondrial protease CLPP, that drives proteolysis of the electron transport chain (ETC) protein Succinate dehydrogenase A (SDHA) and degradation of critical mitochondrial tricarboxylic acid (TCA) cycle regulator Isocitrate dehydrogenase 3B (IDH3B). Loss mitochondrial respiration increased hypoxia and reduced α-ketoglutarate, inhibiting lysine demethylation, increasing methylation of H3K4me3 and H3K27me3, thus altering the epigenome of primary DIPG cells. Loss of SDHA caused oxidation of succinate forming superoxide driving redox regulated PI3K/AKT signaling, counteracted using the PI3K/AKT inhibitor paxalisib. The combination of ONC201 and paxalisib synergically extended survival of two aggressive DIPG PDX models (SU-SIPG-VI vehicle=73 vs. combination=100-days, p=0.0027; SF8626 vehicle=36 vs. combination=43-days, p=0.0002). Compassionate access to this combination (n=2 patients; immediately post-RT and following re-RT) resulted in reductions in tumor volume and complete resolution of disease symptoms, extending overall survival (e.g., diagnosis patient MR axial scan=1554 mm2 , following eight months on the combination, current tumor volume=464 mm2 (<70%), patient remains on treatment). Our findings harness the powerful anti-DMG/DIPG pharmacokinetic/dynamic properties of ONC201 and paxalisib, a combination that is currently in clinical trials (NCT05009992).

ABSTRACT Global high-throughput profiling of oncogenic signaling pathways by phosphoproteomics is increasingly being applied to cancer specimens. Such quantitative unbiased phosphoproteomic profiling of cancer cells identifies oncogenic signaling cascades that drive disease initiation and progression; pathways that are often invisible to genomics sequencing strategies. Therefore, phosphoproteomic profiling has immense potential for informing individualized anti-cancer treatments. However, complicated and extensive sample preparation protocols, coupled with intricate chromatographic separation techniques that are necessary to achieve adequate phosphoproteomic depth, limits the clinical utility of these techniques. Traditionally, phosphoproteomics is performed using isobaric tagged based quantitation coupled with TiO 2 enrichment and offline prefractionation prior to nLC-MS/MS. However, the use of isobaric tags and offline HPLC limits the applicability of phosphoproteomics for the analysis of individual patient samples in real-time. To address these limitations, here we have optimized a new protocol, p hospho- H eavy-l a beled-spiketide FAIM S St e pped-CV D DA (pHASED). pHASED maintained phosphoproteomic coverage yet decreased sample preparation time and complexity by eliminating the variability associated with offline prefractionation. pHASED employed online phosphoproteome deconvolution using high-field asymmetric waveform ion mobility spectrometry (FAIMS) and internal phosphopeptide standards to provide accurate label-free quantitation data. Compared with our traditional tandem mass tag (TMT) phosphoproteomics workflow and optimized using isogenic FLT3-mutant acute myeloid leukemia (AML) cell line models (n=18/workflow), pHASED halved total sample preparation, and running time (TMT=10 days, pHASED=5 days) and doubled the depth of phosphoproteomic coverage in real-time (phosphopeptides = 7,694 pHASED, 3,861 TMT). pHASED coupled with bioinformatic analysis predicted differential activation of the DNA damage and repair ATM signaling pathway in sorafenib-resistant AML cell line models, uncovering a potential therapeutic opportunity that was validated using cytotoxicity assays. Herein, we optimized a rapid, reproducible, and flexible protocol for the characterization of complex cancer phosphoproteomes in real-time, highlighting the potential for phosphoproteomics to aid in the improvement of clinical treatment strategies.

Pediatric high-grade gliomas (pHGG) are the leading cause of cancer-related death in children and young adults. Current treatment strategies are centered on maximal safe resection, followed by radiotherapy, and interrogation of the tumor genome to identify targetable mutations. Unfortunately, we are yet to see an improvement in patient outcomes with a median overall survival remaining 15-months. To improve patient outcomes, we have begun to characterize the genome, proteome, and phosphoproteome of 168 pHGGs to better understand the functional consequences of their somatic alterations as well as their influence of the tumor microenvironment. Employing a novel ‘pharmaco-phospho-proteo-genomics’ pipeline, we have analyzed pHGG cell lines and tumor tissue specimens at diagnosis, relapse (partial resection congenital glioblastoma), and autopsy. Genomic profiling was conducted utilizing the 523-gene TruSight Oncology 500 (TSO500) next-generation sequencing panel. Simultaneously, tumor proteomes and phosphoproteomes were characterized using our high-throughput global phospho-proteomic profiling technique termed pHASED (phospho Heavy-labelled-spiketide FAIMS StEpped-CV DDA). High-fidelity tumor proteomic and phospho-proteomic data were identified and compared to normal control brain samples. Across 40 pHGG samples, we identified 290 unique somatic alterations with a high predicted impact severity and quantified 7,345 unique proteins and 3,327 phosphoproteins. Gene panel sequencing of a critical pediatric glioblastoma patient sample identified 18 somatic alterations, eight of which had a high predicted impact severity, however, none were targetable. Conversely, phosphoproteomic profiling identified enriched MAPK and PRKCB signaling, relative to normal brain tissues, thereby encouraging the use of the TGA/FDA approved therapies trametinib (MAPKs) and enzastaurin (PRKCB). In vitro investigations confirmed the utility of these treatment approaches and in vivo patient derives xenograft mouse models for this sample are under investigation. This pilot study provides critical data to support the benefit of interrogating the genome, proteome, and phospho-proteome of these devastating tumours to aid in the selection/development of effective treatment strategies.

EXECUTIVE SUMMARY Accountable care organizations (ACOs) need confidence in their return on investment to implement changes in care delivery that prioritize seriously ill and high-cost Medicare beneficiaries. The objective of this study was to characterize spending on seriously ill beneficiaries in ACOs with Medicare Shared Savings Program (MSSP) contracts and the association of spending with ACO shared savings. The population included Medicare fee-for-service beneficiaries identified with serious illness (N = 2,109,573) using the Medicare Master Beneficiary Summary File for 100% of ACO-attributed beneficiaries linked to MSSP beneficiary files (2014-2016). Lower spending for seriously ill Medicare beneficiaries and risk-bearing contracts in ACOs were associated with achieving ACO shared savings in the MSSP. For most ACOs, the seriously ill contribute approximately half of the spending and constitute 8%-13% of the attributed population. Patient and geographic (county) factors explained $2,329 of the observed difference in per beneficiary per year spending on seriously ill beneficiaries between high- and low-spending ACOs. The remaining $12,536 may indicate variation as a result of potentially modifiable factors. Consequently, if 10% of attributed beneficiaries were seriously ill, an ACO that moved from the worst to the best quartile of per capita serious illness spending could realize a reduction of $1,200 per beneficiary per year for the ACO population overall. Though the prevalence and case mix of seriously ill populations vary across ACOs, this association suggests that care provided for seriously ill patients is an important consideration for ACOs to achieve MSSP shared savings.

Estrogenic compounds enter waterways via effluents from wastewater treatment works (WWTW), thereby indicating a potential risk to organisms inhabiting adjacent receiving waters. However, little is known about the loads or concentrations of estrogenic compounds that enter Australian WWTWs, the efficiency of removing estrogenic compounds throughout the various stages of tertiary WWTW processes (which are common in Australia), nor the concentrations released into estuarine or marine receiving waters, and the associated risk for aquatic taxa residing in these environments. Therefore, seven estrogenic compounds, comprising the natural estrogens estrone (E1), 17 beta-estradiol (E2) and estriol (E3), the synthetic estrogen (EE2), and the industrial chemicals bisphenol A (BPA), 4-t-octyl phenol (4-t-OP) and 4-nonyl phenol (4-NP), in wastewater samples were quantified via liquid chromatographic-mass spectrometry (LC-MS) after solid-phase extraction at different stages of wastewater treatment and associated receiving waters. The concentrations of the target compounds in wastewater ranged from < LOQ (limit of quantification) to 158 ng/L for Tanilba Bay WWTW and < LOQ to 162 ng/L for Belmont WWTW. Most target compounds significantly declined after the secondary treatment phase. Appreciable removal efficiency throughout the treatment process was observed with removal from 39.21 to 99.98% of influent values at both WWTWs. The reduction of the natural estrogens (E1, E2 and E3) and 4-t-OP were significantly greater than EE2, BPA, and 4-NP in both WWTWs. Risk quotients (RQs) were calculated to assess potential ecological risks from individual estrogenic compounds. In predicted diluted effluents, no targeted compounds showed any ecological risk (RQ <= 1.65 x 10(-2)) at both WWTWs. Similarly, all RQs for shore samples at both WWTWs were below 1. Finally, the hazard index (HI), which represents combined estrogenic contaminants' ecological risk, indicated no mentionable risk for predicted diluted effluents (HI = 0.0097 to 0.0218) as well as shoreline samples (HI = 0.393 to 0.522) in the receiving estuarine or marine waters. (C) 2021 Elsevier Ltd. All rights reserved.

Release and rechlorination of chlorine atoms on the benzene ring have been observed during advanced oxidation processes (AOPs), while the dechlorination on the side chain of the benzene ring has not been fully investigated previously. The degradation and dechlorination processes of chloramphenicol (i.e., thiamphenicol (TAP) and florfenicol (FFC)) were assessed through generation of the sulfate radical from Co(II)-mediated activation of peroxymonosulfate (PMS). High-resolution mass spectrometry (HRMS) analysis detected a few chlorinated and dechlorinated products during the Co2+/PMS reaction. The low efficiency of total organic carbon (TOC) removal in conjunction with slightly decreased absorbable organic halogen (AOX) values with high degradation rates, indicate that TAP and FFC could be degraded via the destruction of a small portion of the carbon moiety rather than through complete mineralization. The possible degradation pathways of TAP and FFC are proposed. All experimental results and further quantum chemistry calculations indicate dechlorination on the side chain of the benzene ring is more difficult than that directly on the benzene ring. This suggests organic pollutants containing chlorine atoms on the side chain of the benzene ring will be more resistant to oxidative attack and deserve more attention.

Background For Australians living with cystic fibrosis (CF), increased longevity means greater consideration needs to be given to long-term endocrine sequelae such as CF-related bone disease. Deficits in bone mass accrual are most likely to occur during childhood and adolescence. Current guidelines in Australia suggest repeat dual-energy X-ray absorptiometry (DXA) scans every 2 years. This study aims to stratify clinical factors that determine future bone health in the Australian CF population and use this to guide a more streamlined approach to bone health screening. Methods This study was a retrospective audit of all patients diagnosed with CF who were treated at the Royal Children's Hospital Melbourne, Australia from 2000 to 2016 (n = 453). Two hundred and two patients had a DXA scan in the study period (191 with height-adjusted data) and 111 patients had more than one scan (108 with height-adjusted data). An investigation into the associations between bone mineral density (BMD) Z score and potential risk factors was conducted using DXA and historical data. Results The main predictor of future BMD was the previous BMD Z score (p < .001). Other factors found to be determinants of BMD included nutritional status, lung function (FEV1), age, history of previous fracture, oral corticosteroid use, and the number of hospital admissions. However, after adjusting for previous BMD, evidence of an association remained only with nutritional status, FEV1, and number of hospital admissions. Conclusion Second yearly scans may be unnecessary in children with an adequate DXA score on the initial scan who remain clinically stable. However, clinical deterioration in those whose BMD was previously normal, may require closer monitoring of bone health. We propose a guideline for the frequency of DXA monitoring in relation to clinical risk factors.

Abstract Background Diffuse intrinsic pontine glioma (DIPG) is a fatal childhood brainstem tumor for which radiation is the only treatment. Case studies report a clinical response to ONC201 for patients with H3K27M-mutant gliomas. Oncoceutics (ONC201) is only available in the United States and Japan; however, in Germany, DIPG patients can be prescribed and dispensed a locally produced compound—ONC201 German-sourced ONC201 (GsONC201). Pediatric oncologists face the dilemma of supporting the administration of GsONC201 as conjecture surrounds its authenticity. Therefore, we compared GsONC201 to original ONC201 manufactured by Oncoceutics Inc. Methods Authenticity of GsONC201 was determined by high-resolution mass spectrometry and nuclear magnetic resonance spectroscopy. Biological activity was shown via assessment of on-target effects, in vitro growth, proliferation, and apoptosis analysis. Patient-derived xenograft mouse models were used to assess plasma and brain tissue pharmacokinetics, pharmacodynamics, and overall survival (OS). The clinical experience of 28 H3K27M+ mutant DIPG patients who received GsONC201 (2017–2020) was analyzed. Results GsONC201 harbored the authentic structure, however, was formulated as a free base rather than the dihydrochloride salt used in clinical trials. GsONC201 in vitro and in vivo efficacy and drug bioavailability studies showed no difference compared to Oncoceutics ONC201. Patients treated with GsONC201 (n = 28) showed a median OS of 18 months (P = .0007). GsONC201 patients who underwent reirradiation showed a median OS of 22 months compared to 12 months for GsONC201 patients who did not (P = .012). Conclusions This study confirms the biological activity of GsONC201 and documents the OS of patients who received the drug; however, GsONC201 was never used as a monotherapy.