7/20/17. Objectives. Genetic variation in candidate biomarkers predicts recovery and may affect biomarker utility. Nicole Osier, PhD, RN

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1 Genetic variation in candidate biomarkers predicts recovery and may affect biomarker utility Nicole Osier, PhD, RN TBI* Objectives Describe the state-of-the-science for traumatic brain injury as it relates to understanding pathology and guiding treatment (Tx) BBM* SNPs List 3 promising biomarkers for TBI to date, and how they may guide Tx Define single nucleotide polymorphisms (SNPs) and state how they are assessed. Describe how SNPs could affect recovery and alter circulating biomarker levels Tx* Discuss how genomic and protein data is relevant to the quest for personalized medicines as part of the precision medicine initiative Introduction/State of the Science 1

2 Traumatic Brain Injury (TBI) Causes Acquired injury to the brain Unknown/Other 21%? Falls 35% Assault 10% Struck By/Against 17% Traffic Accident 17% TBI by the Numbers 56,000 Deaths 282,000 Hospitalizations 2,800,000 ED Visits??????? Receive No Care Taylor et a MMWR Surveill Summ 2017;66(9):1-16 TBI s Diverse Symptoms & Deficits Mood/Mental Health Sx - Impulse Control Problems - Loss of Consciousness - Vision and Pupil Changes - Motor/Balance Problems - Speech/Swallow Issues 2

3 ... 7/20/17 FDA-Approved Therapies for TBI (a comprehensive list) TBI Numbers by Severity Mild TBI Moderate TBI Severe TBI Severe TBI (stbi) Signs & Symptoms Glasgow Coma Scale = 3-8 Comatose: no meaningful response/voluntary activities Breathing May require support Eye Opening No response, to pain/speech - Verbal Response No response, and/or incoherent/inappropriate Feeding Assistance Nasogastric, gastric, or other support Motor response No response; decerebrate; decorticate; withdraws 3

4 Biomarkers interest in biomarkers Peripheral samples ideal E.g. blood-based-biomarkers (BBM) A window into TBI pathology Potential to ID the right Rx stbi Protein Changes / Putative Biomarkers Glial Fibrillary Acid Protein (GFAP) Critical to nerve structure and support After TBI, astroglia will GFAP production Ubiquitin C-terminal hydrolase L1 (UCHL1) Enzyme in nerve cells Post-TBI plays a role in degrading damaged cells S100 Calcium Binding Protein B (S100B) Regulates cell process (e.g. mitosis; differentiation) Post-TBI levels in blood/csf are elevated State of the Science Pre-clinical studies identify (ID) BBM BBM Large studies ID/validate BBM Individuals may vary on BBM utility Role of genetic variation is unclear 4

5 We Are Not Quite there Yet! Other Rx Factors to Consider Safety/toxicity Efficacy Dosing/route Long FDA-testing process Individual response to therapy Gap 5

6 Purpose Purpose: explore the association between neurological outcomes assessed at 3-, 6-, 12-, and 24-months post-injury and 18 single nucleotide polymorphisms (SNPs) in genes related to candidate biomarkers stbi Protein Changes / Putative Biomarkers Glial Fibrillary Acid Protein (GFAP) Critical to nerve structure and support After TBI, astroglia will GFAP production 5 SNPs Ubiquitin C-terminal hydrolase L1 (UCHL1) Enzyme in nerve cells Post-TBI plays a role in degrading damaged cells S100 Calcium Binding Protein B (S100B) Regulates cell process (e.g. mitosis; differentiation) Post-TBI levels in blood/csf are elevated 8 SNPs 5 SNPs 6

7 Study Design Pre-Onset: Approval and Consent Recruitment of Parent Study Single Neuro-ICU at a Level I Trauma Center ( ) 7

8 Parent Study Inclusion Criteria Severe TBI Aged at enrollment Ventriculostomy catheter Exclusion Criteria Penetrating TBI Cardiac/respiratory arrest Existing neurological deficit Daughter Study Non-Caucasian -N=63 Screened N=460 No Genotype -N=48 No Outcome -N=44 Final Sample N=305 Sample Collection & DNA Extraction Collection Blood Intravenous catheter or intraarterial catheter CSF Ventriculostomy DNA extraction Centrifugation, buffy coat removal, and salting out Qiamp Midi Kit (Qiagen, Inc., Valencia, CA) 8

9 Blinded Data Collection Timeline GCS GOS GOS GOS GOS Glasgow Coma Scale: Eyes, Verbal, Motor None To Pain/ Pressure To Sound Spontaneous None Sounds Words Confused Oriented None Extension Flexion Flexion with Pain Moves to Pain This sample all severe TBI (GCS 8); Dichotomized as GCS= 3-5 vs. GCS= 6-8 Obeys Commands Glasgow Outcome Scale Severe Disability Moderate Disability Dichotomized as GOS= 1-2 vs. GOS= 3-5 9

10 SNP Genotyping iplex MassARRAY multiplex assay platform Genotype quality control included: Independently double calling genotypes Inclusion of blind duplicates Excluding SNPs with <85% call rate from analyses Statistical Analysis SPSS version 24 software (IBM, Chicago, IL, USA) Screening Univariates Analysis of Variance (ANOVA) for associations with continuous IV (e.g. Age) Chi Squared for associations with categorical IV (e.g. Sex) Multinomial logistic regression controlling for age, sex [& GCS] Relationship between Genotype/Variant Presence and GOS Study Findings 10

11 Sample Demographics Adults with severe TBI (GCS < 8) Mean age 39.1 years (SD= 16.4; range 18-76) All Caucasian (due to demographics/allelic frequency) Due to allelic frequency differences & low minority representation Mostly male: 80.7%, consistent with TBI population GCS univariately predicted GOS at all time points (p<0.05) Variant Allele Presence and GCS S100B SNP Variant allele of rs was associated with higher GCS J after controlling for age & sex GFAP SNP Variant allele of rs was associated with higher GCS J after controlling for age & sex Variant Allele Presence and GOS S100B SNPs The variant allele of 2 SNPs were associated with GOS after controlling for age, sex, and GCS rs variant C associated with reduced odds of dead/vegetative state (J) Held across all time points (3-, 6-, 12-, and 24- months) rs Variant C associated with higher odds of dead/vegetative state at 6 mo (L) GFAP and UCHL1 SNPs No significant associations with GOS after controlling for age, sex, and GCS 11

12 Discussion Genotype Predicts Outcomes First study to report association between genes encoding biomarkers & outcomes Comparison to Existing Publications Variant allele of rs associated with better outcomes on 3, 6, 12, and 24 mo GOS In Alzheimer s disease, wildtype homozygotes had poorer performance on pre-frontal tasks In schizophrenia G wildtype allele associated with poorer spatial ability & mental rotation Variant alleles of both rs and rs associated with poorer outcomes In postmortem samples, a relationship between rs and protein expression Additional exploration is warranted 12

13 Limitations Limited generalizability Crude outcome measures: need more refined assessments Effect of genotype on proteins remains unknown Predictive models with many genes/proteins may be needed This data may be relevant to enhancing interpretation of existing biomarker data, identifying novel biomarkers, and ultimately harnessing this information to improve clinical outcomes. TBI Outcome Predictors TBI Biomarkers Environment Genomics 13

14 TBI Biomarkers: UCHL1 GFAP S100B Genotype Etc. We need drugs that can Prevent secondary injury cascades e.g. neurodegeneration; apoptosis; inflammation; etc. Be tailored to patients based on baseline/recovery profiles e.g. based on biomarkers, demographics and other predictors Address even profound dysfunction Factors Related to TBI Recovery Mechanism/ Cause of Injury Treatment, Supplements, Pharmacogenomics Social Support & Population Characteristics Demographics, Comorbidities, Participation in PT/OT Regimen Timing Considerations (e.g. time til care) Genotype, Protein Expression 14

15 Innovative Research Questions/Methods Numerous Simultaneous Efforts Data Accumulation, Sharing, and Dissemination Law, Policy, & Injury Prevention Efforts Data Replication & Security Therapy Development & Refinement Improved Care, Reduced Costs, Better Outcomes Thank You! Questions? 15

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