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Abstract Neuromelanin-pigmented neurons of the substantia nigra are selectively lost during the progression of Parkinson’s disease. These neurons accumulate iron in the disease state, and iron-mediated neuron damage is implicated in cell death. Animal models of Parkinson’s have evidenced iron loading inside the nucleoli of nigral neurons, however the nature of intranuclear iron deposition in the melanised neurons of the human substantia nigra is not understood. Here, scanning transmission x-ray microscopy (STXM) is used to probe iron foci in relation to the surrounding ultrastructure in melanised neurons of human substantia nigra from a confirmed Parkinson’s case. In addition to the expected neuromelanin-bound iron, iron deposits are also associated with the edge of the cell nucleolus. Speciation analysis confirms these deposits to be ferric (Fe3+) iron. The function of intranuclear iron in these cells remains unresolved, although both damaging and protective mechanisms are considered. This finding shows that STXM is a powerful label-free tool for the in situ, nanoscale chemical characterisation of both organic and inorganic intracellular components. Future applications are likely to shed new light on incompletely understood biochemical mechanisms, such as metal dysregulation and morphological changes to cell nucleoli, that are important in understanding the pathogenesis of Parkinson’s.

Abstract Alzheimer’s disease (AD) and other tauopathies are characterized by the aggregation of tau into soluble and insoluble forms (including tangles and neuropil threads). In humans, a fraction of both phosphorylated and non-phosphorylated N-terminal to mid-domain tau species, are secreted into cerebrospinal fluid (CSF). Some of these CSF tau species can be measured as diagnostic and prognostic biomarkers, starting from early stages of disease. While in animal models of AD pathology, soluble tau aggregates have been shown to disrupt neuronal function, it is unclear whether the tau species present in CSF will modulate neural activity. Here, we have developed and applied a novel approach to examine the electrophysiological effects of CSF from patients with a tau-positive biomarker profile. The method involves incubation of acutely-isolated wild-type mouse hippocampal brain slices with small volumes of diluted human CSF, followed by a suite of electrophysiological recording methods to evaluate their effects on neuronal function, from single cells through to the network level. Comparison of the toxicity profiles of the same CSF samples, with and without immuno-depletion for tau, has enabled a pioneering demonstration that CSF-tau potently modulates neuronal function. We demonstrate that CSF-tau mediates an increase in neuronal excitability in single cells. We then observed, at the network level, increased input–output responses and enhanced paired-pulse facilitation as well as an increase in long-term potentiation. Finally, we show that CSF-tau modifies the generation and maintenance of hippocampal theta oscillations, which have important roles in learning and memory and are known to be altered in AD patients. Together, we describe a novel method for screening human CSF-tau to understand functional effects on neuron and network activity, which could have far-reaching benefits in understanding tau pathology, thus allowing for the development of better targeted treatments for tauopathies in the future. Graphical Abstract

# Background Little is known about changes in kinetics or kinematics following a 10 km training run. This information has implications on risk of running-related injury. # Purpose The purpose of this study was to examine the effect of a 10 km run on running kinematics and kinetics in a sample of experienced runners. # Study Design Cross-Sectional Study # Subjects Nineteen runners ages 18-48 (7 female, 12 male) consented to participate including eight (3 female, 5 male) ultra-runners, and 11 (4 female, 7 male) recreational runners. # Methods Following collection of demographic data and completion of a short running survey, participants did a 6-minute run at their self-selected running speed to acclimate to the instrumented treadmill. Reflective markers were placed over designated anatomical landmarks on both sides of the pelvis as well as the left lower extremity and marked with a skin pen. Subjects then ran on the treadmill and 30 seconds of video data were recorded at 240 frames/sec using a high-speed camera for the sagittal plane and the frontal plane. Simultaneously, ground reaction forces (GRFs) were recorded at 1200 Hz through the treadmill's embedded force plates. Each runner then ran 10 km on a paved trail at their self-selected pace. Immediately following the run, reflective markers were reattached, guided by markings placed before the run, and a 30-second post-run trial of the video and GRF data were recorded. Video data were analyzed using Kinovea software to measure the kinematic variables of interest. Paired t-tests with Bonferroni corrections were used to find if significant differences existed between pre- and post-run data for all kinematic and kinetic variables. # Results No significant or clinically relevant differences existed between the pre- and post-run measurements for the kinematic or kinetic variables. The only significant difference noted between the ultra-runners and recreational runners was that the ultra-runners had significantly higher cadence (p=0.045). # Conclusions A 10 km run at a self-selected pace did not result in change in the mean kinematic or kinetic variables in this group of experienced runners. Ultra-runners employ higher cadence than recreational runners, but their kinematics and kinetics are similar. # Level of Evidence Level 3

Wall et al. describe the selective activation of an adenosine A1 receptor-mediated intracellular pathway that provides potent analgesia in the absence of sedation or cardiorespiratory depression, paving the way for novel medicines based on the far-reaching concept of selective Gα agonism.

As cities become more populated and the density of urban development increases, local biodiversity is threatened. Urban greenspaces have the capacity to preserve pollinator biodiversity, but the quality of support they provide depends on greenspace landscape attributes, including the availability of pollinator habitat and foraging resources. Wild native bees provide important pollination services to urban ecosystems, yet relatively little is known about how urban landscape management influences pollinator community composition and diversity. Our study explores how wild bee communities are affected by greenspace and landscape-level features like pollinator management practices, in urban greenspaces in and around Appleton Wisconsin: a mid-sized urban community spanning more than 100 sq. km. We sampled and identified native bees periodically between late-May 2017 and mid-September of 2018 using standardized arrays of pan traps at 15 sites around the city. We classified greenspaces based on their level of development (urban or suburban) and whether they were managed or unmanaged for increasing wild pollinator diversity. We quantified floral species diversity, floral color diversity, tree species diversity, and proximity of sites to open water for each site and used remotely sensed satellite data from both the USGS National Land Cover Database (NLCD) and the Normalized Difference Vegetation Index (NDVI). All variables were tested as potential correlates of wild bee abundance and species richness. Active pollinator management sites supported higher levels of bee abundance and richness. Notably, active greenspace management (e.g. planting native wildflowers) was a stronger correlate of bee abundance and richness than greenspace size and other landscape-level attributes. Within-greenspace attributes such as floral diversity, tree diversity, and proximity to open water contributed positively to both bee abundance and richness. Based on these findings, we suggest that urban greenspaces may be managed more efficiently and cost-effectively by focusing resources on active management by planting wildflowers, removing invasive species, creating nesting habitat, and providing water resources, rather than simply expanding in area.

Hill et al. examine the effects of full-length or truncated human recombinant tau on the excitability of hippocampal pyramidal neurons in mice. Their results suggest that effects seen with full-length tau oligomers can be dissected apart using tau truncations and highlights a tau-mediated alteration in voltage-gated sodium channel currents.

Salmonella enterica serovar Typhi is the etiologic agent of typhoid fever, a major public health problem in the developing world. Moving toward and adhering to the intestinal epithelium represents key initial steps of infection by S. Typhi. We examined the role of the S. Typhi yrbE gene, which encodes an inner membrane phospholipid transporter, in these interactions with epithelial cells. Disruption of yrbE resulted in elevated expression of flagellin and a hypermotile phenotype. It also significantly reduced the ability of S. Typhi to adhere to the HeLa epithelial cell line and to polarized primary epithelial cells derived from human ileal organoids. Interestingly, the yrbE-deficient strain of S. Typhi induced higher production of interleukin-8 from the primary human ileal epithelial cell monolayers compared to the wild-type bacteria. Deletion of the flagellin gene (fliC) in the yrbE-deficient S. Typhi inhibited motility and attenuated interleukin-8 production, but it did not correct the defect in adhesion. We also disrupted yrbE in S. Typhimurium. In contrast to the results in S. Typhi, the deficiency of yrbE in S. Typhimurium had no significant effect on flagellin expression, motility or adhesion to HeLa cells. Correspondingly, the lack of yrbE also had no effect on association with the intestine or the severity of intestinal inflammation in the mouse model of S. Typhimurium infection. Thus, our results point to an important and serovar-specific role played by yrbE in the early stages of intestinal infection by S. Typhi.

Screening for drugs that disrupt embryonic development in zebrafish can help identify treatments that suppress metastasis.

Abstract Background Documentation and diagnosis of childhood obesity in primary care is poor and providers are often unfamiliar with guidelines. This lack of knowledge may be attributed to insufficient training in medical school and residency; however, no studies have evaluated medical students’ knowledge of recommendations. Methods We distributed a modified version of the Physician Survey of Practice on Diet, Physical Activity, and Weight Control to medical students at a single university. Descriptive analyses assessed knowledge and attitudes of childhood obesity and diabetes. Results Of the 213 participating students, 74% indicated being unfamiliar with obesity screening recommendations. Few correctly identified BMI percentile cut-points for child overweight (21.2%), obesity (23.7%), and normal weight (29.4%). They reported screening glucose 4.5 years earlier in patients with risk factors compared to those without (p

Background: Patient-derived xenograft (PDX) models have significantly enhanced cancer research, and often serve as a robust model. However, enhanced growth rate and altered pathological phenotype with serial passages have repeatedly been shown in adenoid cystic carcinoma (ACC) PDX tumors, which is a major concern. Methods: We evaluated the fidelity of ACCs in their natural habitat by performing ACC orthotopic xenotransplantation (PDOX) in salivary glands. Findings: Our PDOX model enabled solid tumors to integrate within the local epithelial, stromal and neuronal environment. Over serial passages, PDOX tumors maintained their stereotypic MYB-NFIB translocation, and FGFR2 and ATM point mutations. Tumor growth rate and histopathology were retained, including ACCs hallmark presentations of cribriform, tubular, solid areas and innervation. We also demonstrate that the PDOX model retains its capacity as a tool for drug testing. Interpretation: Unlike the precedent PDX model, our data shows that the PDOX is a superior model for future cancer biology and therapy research. Fund: This work was supported by the National Institutes of Health (NIH)/National Institute of Dental and Craniofacial Research (NIDCR) grants DE022557, DE027034, and DE027551. Keywords: Adenoid cystic carcinoma, Salivary gland, Orthotopic PDX model, Fidelity, Neural invasion, Drug treatment

Summary: Understanding how epithelial progenitors within exocrine glands establish specific cell lineages and form complex functional secretory units is vital for organ regeneration. Here we identify the transcription factor Sox10 as essential for both the maintenance and differentiation of epithelial KIT+FGFR2b+ progenitors into secretory units, containing acinar, myoepithelial, and intercalated duct cells. The KIT/FGFR2b-Sox10 axis marks the earliest multi-potent and tissue-specific progenitors of exocrine glands. Genetic deletion of epithelial Sox10 leads to loss of secretory units, which reduces organ size and function, but the ductal tree is retained. Intriguingly, the remaining duct progenitors do not compensate for loss of Sox10 and lack plasticity to properly form secretory units. However, overexpression of Sox10 in these ductal progenitors enhances their plasticity toward KIT+ progenitors and induces differentiation into secretory units. Therefore, Sox10 controls plasticity and multi-potency of epithelial KIT+ cells in secretory organs, such as mammary, lacrimal, and salivary glands. : In this manuscript, Lombaert and colleagues discovered that transcription factor Sox10 is not only essential to maintain epithelial progenitors in exocrine glands, but also acts as a master regulator to induce plasticity toward secretory units. These results provide new avenues for directed differentiation and engineering of secretory units in vitro and/or in vivo. Keywords: SOX10, secretory unit, cell fate, stem/progenitor cell, exocrine glands, salivary gland, mammary gland, lacrimal gland, KIT

Summary: This protocol provides two independent methods to functionally detect the neuronal expression of CO2-sensitive hemichannels. These hemichannels (consisting of connexins 26 or 30) are directly gated by CO2, independent of pH changes and until recently were thought to be only expressed by glia. This protocol outlines a method to change the concentration of CO2 without changing pH, using isohydric solutions and then utilizing this to detect opening and closing of functional hemichannels using whole-cell patch clamp recording and dye loading.For complete details on the use and execution of this protocol, please refer to Hill et al. (2020).

Tau is a predominantly neuronal protein that is normally bound to microtubules, where it acts to modulate neuronal and axonal stability. In humans, pathological forms of tau are implicated in a range of diseases that are collectively known as tauopathies. Kinases and phosphatases are responsible for maintaining the correct balance of tau phosphorylation to enable axons to be both stable and labile enough to function properly. In the early stages of tauopathies, this balance is interrupted leading to dissociation of tau from microtubules. This leaves microtubules prone to damage and phosphorylated tau prone to aggregation. Initially, phosphorylated tau forms oligomers, then fibrils, and ultimately neurofibrillary tangles (NFTs). It is widely accepted that the initial soluble oligomeric forms of tau are probably the most pathologically relevant species but there is relatively little quantitative information to explain exactly what their toxic effects are at the individual neuron level. Electrophysiology provides a valuable tool to help uncover the mechanisms of action of tau oligomers on synaptic transmission within single neurons. Understanding the concentration-, time-, and neuronal compartment-dependent actions of soluble tau oligomers on neuronal and synaptic properties are essential to understanding how best to counteract its effects and to develop effective treatment strategies. Here, we briefly discuss the standard approaches used to elucidate these actions, focusing on the advantages and shortcomings of the experimental procedures. Subsequently, we will describe a new approach that addresses specific challenges with the current methods, thus allowing real-time toxicity evaluation at the single-neuron level.

Summary: The substantia nigra (SN) and ventral tegmental area (VTA) are vital for the control of movement, goal-directed behavior, and encoding reward. Here we show that the firing of specific neuronal subtypes in these nuclei can be modulated by physiological changes in the partial pressure of carbon dioxide (PCO2). The resting conductance of substantia nigra dopaminergic neurons in young animals (postnatal days 7–10) and GABAergic neurons in the VTA is modulated by changes in the level of CO2. We provide several lines of evidence that this CO2-sensitive conductance results from connexin 26 (Cx26) hemichannel expression. Since the levels of PCO2 in the blood will vary depending on physiological activity and pathology, this suggests that changes in PCO2 could potentially modulate motor activity, reward behavior, and wakefulness.

Connexins can assemble into either gap junctions (between two cells) or hemichannels (from one cell to the extracellular space) and mediate cell-to-cell signalling. A subset of connexins (Cx26, Cx30, Cx32) are directly sensitive to CO2 and fluctuations in the level within a physiological range affect their open probability, and thus, change cell conductance. These connexins are primarily found on astrocytes or oligodendrocytes, where increased CO2 leads to ATP release, which acts on P2X and P2Y receptors of neighbouring neurons and changes excitability. CO2-sensitive hemichannels are also found on developing cortical neurons, where they play a role in producing spontaneous neuronal activity. It is plausible that the transient opening of hemichannels allows cation influx, leading to depolarisation. Recently, we have shown that dopaminergic neurons in the substantia nigra and GABAergic neurons in the VTA also express Cx26 hemichannels. An increase in the level of CO2 results in hemichannel opening, increasing whole-cell conductance, and decreasing neuronal excitability. We found that the expression of Cx26 in the dopaminergic neurons in the substantia nigra at P7-10 is transferred to glial cells by P17-21, displaying a shift from being inhibitory (to neuronal activity) in young mice, to potentially excitatory (via ATP release). Thus, Cx26 hemichannels could have three modes of signalling (release of ATP, excitatory flickering open and shut and inhibitory shunting) depending on where they are expressed (neurons or glia) and the stage of development.

Background: Age-related declines in physical function lead to decreased independence and higher healthcare costs. Individuals who meet the endurance and resistance exercise recommendations can improve their physical function and overall fitness, even into their ninth decade. However, most older adults do not exercise regularly, and the majority of those who do only perform one type of exercise, and in doing so are not getting the benefits of endurance or resistance exercise. Herein we present the study protocol for a randomized clinical trial that will investigate the potential for high-intensity interval training (HIIT) to improve maximal oxygen consumption, muscular power, and muscle volume (primary outcomes), as well as body composition, 6-min walk distance, and muscular strength and endurance (secondary outcomes).Methods and Analysis: This is a single-site, single-blinded, randomized clinical trial. A minimum of 24 and maximum of 30 subjects aged 60–75 that are generally healthy but insufficiently active will be randomized. After completion of baseline assessments, participants will be randomized in a 1:1:1 ratio to participate in one of three 12-week exercise programs: stationary bicycle HIIT, stationary bicycle moderate-intensity continuous training (MICT), or resistance training. Repeat assessments will be taken immediately post intervention.Discussion: This study will examine the potential for stationary bicycle HIIT to result in both cardiorespiratory and muscular adaptations in older adults. The results will provide important insights into the effectiveness of interval training, and potentially support a shift from volume-driven to intensity-driven exercise strategies for older adults.Clinical Trial Registration: This trial is registered with ClinicalTrials.gov (registration number: NCT03978572, date of registration June 7, 2019).

Seawater rare earth element (REE) concentrations are increasingly applied to reconstruct water mass histories by exploiting relative changes in the distinctive normalised patterns. However, the mechanisms by which water masses gain their patterns are yet to be fully explained. To examine this, we collected water samples along the Extended Ellett Line (EEL), an oceanographic transect between Iceland and Scotland, and measured dissolved REE by offline automated chromatography (SeaFAST) and ICP-MS. The proximity to two continental boundaries, the incipient spring bloom coincident with the timing of the cruise, and the importance of deep water circulation in this climatically sensitive gateway region make it an ideal location to investigate sources of REE to seawater and the effects of vertical cycling and lateral advection on their distribution. The deep waters have REE concentrations closest to typical North Atlantic seawater and are dominated by lateral advection. Comparison to published seawater REE concentrations of the same water masses in other locations provides a first measure of the temporal and spatial stability of the seawater REE signal. We demonstrate the REE pattern is replicated for Iceland-Scotland Overflow Water (ISOW) in the Iceland Basin from adjacent stations sampled 16 years previously. A recently published Labrador Sea Water (LSW) dissolved REE signal is reproduced in the Rockall Trough but shows greater light and mid REE alteration in the Iceland Basin, possibly due to the dominant effect of ISOW and/or continental inputs. An obvious concentration gradient from seafloor sediments to the overlying water column in the Rockall Trough, but not the Iceland Basin, highlights release of light and mid REE from resuspended sediments and pore waters, possibly a seasonal effect associated with the timing of the spring bloom in each basin. The EEL dissolved oxygen minimum at the permanent pycnocline corresponds to positive heavy REE enrichment, indicating maximum rates of organic matter remineralisation and associated REE release. We tentatively suggest a bacterial role to account for the observed heavy REE deviations. This study highlights the need for fully constrained REE sources and sinks, including the temporary nature of some sources, to achieve a balanced budget of seawater REE.

Few advances in the treatment of advanced epithelial ovarian cancer have improved patient overall survival. However, the incorporation of intraperitoneal administration of platinum based chemotherapy to standard treatment was one such advancement. It is understood that the intraperitoneal regimen is associated with increased toxicity when compared to intravenous administration alone; however, information regarding the specific risk of ototoxicity is lacking in the literature. We report a case of almost complete sensorineural hearing loss after one cycle of intraperitoneal cisplatin. Three days after receiving an intravenous 24 h paclitaxel at 135 mg/m2 and subsequent intraperitoneal infusion of cisplatin at 75 mg/m2, the patient presented with profound bilateral sensorineural hearing loss. The patient experienced no recovery of hearing despite an aggressive systemic steroid taper and change in chemotherapy regimen to alternative agents. She is currently under consideration for cochlear device implantation. Generally, cisplatin related ototoxicity during treatment of epithelial ovarian cancer is gradual, limited to high-frequency ranges and dose-related; however, the toxicity with only one standard dose can be profound and irreversible. This risk should be addressed when counseling patients prior to initiation of treatment.

In this study, the psychometric properties of the Classroom Observation of Engagement, Disrespectful and Disruptive Behavior (COEDD), a systematic direct observation coding protocol designed to assess common school-based behavioral targets, were examined. Interobserver agreement and criterion-related validity were evaluated in a sample of 155 kindergarten- through third-grade students. Interobserver agreement was high across categories and criterion-related validity was supported by correlations between the COEDD categories and teacher ratings of student behavior on well-established teacher rating scales. Together these findings support continued study of the COEDD as a tool for quantifying student classroom behavior.

AbstractThe peripheral immune system has a key pathophysiologic role in Frontotemporal degeneration (FTD). We sought a comprehensive transcriptome-wide evaluation of gene expression alterations unique to the peripheral immune system in FTD compared to healthy controls and amyotrophic lateral sclerosis.Nineteen subjects with FTD with 19 matched healthy controls and 9 subjects with amyotrophic lateral sclerosis underwent isolation of peripheral blood mononuclear cells (PBMCs) which then underwent bulk ribonucleic acid sequencing.There was increased expression in genes associated with CD19+ B-cells, CD4+ T-cells, and CD8+ T-cells in FTD participants compared to healthy controls. In contrast, there was decreased expression in CD33+ myeloid cells, CD14+ monocytes, BDCA4+ dendritic cells, and CD56+ natural killer cells in FTD and healthy controls. Additionally, there was decreased expression is seen in associated with 2 molecular processes: autophagy with phagosomes and lysosomes, and protein processing/export. Significantly downregulated in PBMCs of FTD subjects were genes involved in antigen processing and presentation as well as lysosomal lumen formation compared to healthy control PBMCs.Our findings that the immune signature based on gene expression in PBMCs of FTD participants favors adaptive immune cells compared to innate immune cells. And decreased expression in genes associated with phagosomes and lysosomes in PBMCs of FTD participants compared to healthy controls.

BackgroundFragile X-associated tremor/ataxia syndrome (FXTAS) is a neurodegenerative disorder characterized by intention tremor, cerebellar ataxia, and executive dysfunction in carriers of a CGG repeat expansion premutation (55-200 repeats) in the fragile X mental retardation 1 (FMR1) gene. Given reports of poor insight in FXTAS, we postulated that patients with FXTAS would be less likely to exhibit placebo response.ObjectiveTo analyze placebo response from the first randomized controlled trial in FXTAS that evaluated cognitive and motor outcomes after 1 year of treatment with memantine.MethodsData from the placebo arm of the first randomized controlled trial in FXTAS were analyzed. There were 2 coprimary outcomes. Based on studies in Parkinson's disease, placebo responders were defined as individuals with an improvement of at least 50% in the coprimary outcomes. Improvements of 20% and 30% served as secondary cutoff values based on the suggested magnitude of placebo response in other movement disorders.ResultsA total of 36 participants in the placebo group completed baseline and follow-up evaluations. The average age was 66 ± 7 years, and 60% were men. Average CGG repeat size was 86 ± 18. A total of 19 participants had stage 3 disease. Only 1 patient showed 50% improvement in both coprimary outcomes. At 30% and 20% improvement, there were 2 and 3 patients showing placebo response in the coprimary outcomes, respectively.ConclusionsPatients with FXTAS exhibited low rates of placebo response in a randomized controlled trial. Further studies on the relationship between baseline insight and placebo responsivity are applicable to FXTAS and other disorders exhibiting cognitive impairment.

Ongoing biomarker development programs have been designed to identify serologic or imaging signatures of clinico-pathologic entities, assuming distinct biological boundaries between them. Identified putative biomarkers have exhibited large variability and inconsistency between cohorts, and remain inadequate for selecting suitable recipients for potential disease-modifying interventions. We launched the Cincinnati Cohort Biomarker Program (CCBP) as a population-based, phenotype-agnostic longitudinal study. While patients affected by a wide range of neurodegenerative disorders will be deeply phenotyped using clinical, imaging, and mobile health technologies, analyses will not be anchored on phenotypic clusters but on bioassays of to-be-repurposed medications as well as on genomics, transcriptomics, proteomics, metabolomics, epigenomics, microbiomics, and pharmacogenomics analyses blinded to phenotypic data. Unique features of this cohort study include (1) a reverse biology-to-phenotype direction of biomarker development in which clinical, imaging, and mobile health technologies are subordinate to biological signals of interest; (2) hypothesis free, causally- and data driven-based analyses; (3) inclusive recruitment of patients with neurodegenerative disorders beyond clinical criteria-meeting patients with Parkinson's and Alzheimer's diseases, and (4) a large number of longitudinally followed participants. The parallel development of serum bioassays will be aimed at linking biologically suitable subjects to already available drugs with repurposing potential in future proof-of-concept adaptive clinical trials. Although many challenges are anticipated, including the unclear pathogenic relevance of identifiable biological signals and the possibility that some signals of importance may not yet be measurable with current technologies, this cohort study abandons the anchoring role of clinico-pathologic criteria in favor of biomarker-driven disease subtyping to facilitate future biosubtype-specific disease-modifying therapeutic efforts.

Implementing and integrating an Enterprise Resource Planning (ERP) system into an organization is an enormous undertaking that requires substantial cash outlays, time commitments, and skilled IT and business personnel. It requires careful and detailed planning, thorough testing and training, and a change management process that creates a supporting culture. In rare circumstances is a company required to implement an ERP twice in two years. This teaching case documents the business process changes and ERP system related events that occurred to a pharmaceutical manufacturing facility when it was involved in an acquisition; and then, a second acquisition in less than a three year time period.