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PURPOSE Despite the high frequency of EGFR genetic alterations in glioblastoma (GBM), EGFR-targeted therapies have not had success in this disease. To improve the likelihood of efficacy, we targeted adult patients with recurrent GBM enriched for EGFR gene amplification, which occurs in approximately half of GBM, with dacomitinib, a second-generation, irreversible epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor that penetrates the blood-brain barrier, in a multicenter phase II trial. PATIENTS AND METHODS We retrospectively explored whether previously described EGFR extracellular domain (ECD)–sensitizing mutations in the context of EGFR gene amplification could predict response to dacomitinib, and in a predefined subset of patients, we measured post-treatment intratumoral dacomitinib levels to verify tumor penetration. RESULTS We found that dacomitinib effectively penetrates contrast-enhancing GBM tumors. Among all 56 treated patients, 8 (14.3%) had a clinical benefit as defined by a duration of treatment of at least 6 months, of whom 5 (8.9%) remained progression free for at least 1 year. Presence of EGFRvIII or EGFR ECD missense mutation was not associated with clinical benefit. We evaluated the pretreatment transcriptome in circulating extracellular vesicles (EVs) by RNA sequencing in a subset of patients and identified a signature that distinguished patients who had durable benefit versus those with rapid progression. CONCLUSION While dacomitinib was not effective in most patients with EGFR-amplified GBM, a subset experienced a durable, clinically meaningful benefit. Moreover, EGFRvIII and EGFR ECD mutation status in archival tumors did not predict clinical benefit. RNA signatures in circulating EVs may warrant investigation as biomarkers of dacomitinib efficacy in GBM.

Background:Military and nonmilitary organizations need the capability to support their expeditionary forces by selecting a temporary base of operations that projects a minimal footprint and reduces logistical burdens. For example, strategically sited temporary bases anticipate impacts on the local context and its population of siting and operating temporary bases.Objective:This paper describes a methodology to assess the practicality of incorporating local construction materials when planning for contingency operations in a given region. While the assessment methodology was originally developed for military planners, the principles and methods are applicable to any organization that is considering building and operating temporary locations in foreign nations.Method:The methodology assesses factors such as population densities, main building types, geographical regions, port locations, railroad locations, road networks, airport locations, flood-risk areas, and construction materials. The methodology optimizes all factors to yield the best material-based solution for site selection. To demonstrate the developed methodology, two hypothetical case studies are described–Dhaka in Bangladesh for its high-population density and Maiduguri in Nigeria for its low-population density and potential for disruption.Results:This methodology provides a contingency site selection process that does not currently exist and will assist in the reduction of materiel demand, minimize footprint, and reduce the risk to personnel. The methodology captures factors such as population densities, main building types, geographical regions, port locations, railroad locations, road networks, airport locations, flood-risk areas, and construction materials and optimizes all factors to yield the best material-based solution for site selection.Conclusion:This methodology provides a contingency site selection process that does not currently exist for mission planners. It is designed to produce a methodology with a goal of developing a GIS-based decision support tool to assist in siting bases of operations.

OBJECTIVES: Vancomycin-resistant Enterococcus faecium is a leading cause of MDR hospital infection. Two genetically definable populations of E. faecium have been identified: hospital-adapted MDR isolates (clade A) and vancomycin-susceptible commensal strains (clade B). VanN-type vancomycin resistance was identified in two isolates of E. faecium recovered from blood and faeces of an immunocompromised patient. To understand the genomic context in which VanN occurred in the hospitalized patient, the risk it posed for transmission in the hospital and its origins, it was of interest to determine where these strains placed within the E. faecium population structure. METHODS: We obtained the genome sequence of the VanN isolates and performed comparative and functional genomics of the chromosome and plasmid content. RESULTS: We show that, in these strains, VanN occurs in a genetic background that clusters with clade B E. faecium, which is highly unusual. We characterized the chromosome and the conjugative plasmid that carries VanN resistance in these strains, pUV24. This plasmid exhibits signatures of in-host selection on the vanN operon regulatory system, which are associated with a constitutive expression of vancomycin resistance. VanN resistance in clade B strains may go undetected by current methods. CONCLUSIONS: We report a case of vancomycin resistance in a commensal lineage of E. faecium responsible for an atypical bacteraemia in an immunocompromised patient. A reservoir of transferable glycopeptide resistance in the community could pose a concern for public health.

The polysaccharide capsule of Streptococcus pneumoniae is required for nasopharyngeal colonization and for invasive disease in the lungs, blood, and meninges. In contrast, the vast majority of conjunctival isolates are acapsular. The first serotype-specific gene in the capsule operon, cpsE , encodes the initiating glycosyltransferase and is one of the few serotype-specific genes that can tolerate null mutations. This report characterizes a spontaneously arising TIGR4 mutant exhibiting a reduced capsule, caused by a 6-nucleotide duplication in cpsE which results in duplication of Ala and Ile at positions 45 and 46. This strain (AI45dup) possessed more exposed phosphorylcholine and was hypersusceptible to C3 complement deposition compared to the wild type. Accordingly, the mutant was significantly better at forming abiotic biofilms and binding epithelial cells in vitro but was avirulent in a sepsis model. In vitro serial passaging of the wild-type strain failed to reproduce the AI45dup mutation but instead led to a variety of mutants with reduced capsule harboring single nucleotide polymorphisms (SNPs) in cpsE . A single passage in the sepsis model after high-dose inoculation readily yielded revertants of AI45dup with restored wild-type capsule level, but the majority of SNP alleles of cpsE could not revert, suppress, or bypass. Analysis of cpsE in conjunctival isolates revealed a strain with a single missense mutation at amino acid position 377, which was responsible for reduced encapsulation. This study supports the hypothesis that spontaneous, nonreverting mutations in cpsE serve as a form of adaptive mutation by providing a selective advantage to S. pneumoniae in niches where expression of capsule is detrimental. IMPORTANCE While the capsule of Streptococcus pneumoniae is required for colonization and invasive disease, most conjunctival isolates are acapsular by virtue of deletion of the entire capsular operon. We show that spontaneous acapsular mutants isolated in vitro harbor mostly nonrevertible single nucleotide polymorphism (SNP) null mutations in cpsE , encoding the initiating glycosyltransferase. From a small collection of acapsular conjunctival isolates, we identified one strain with a complete capsular operon but containing a SNP in cpsE that we show is responsible for the acapsular phenotype. We propose that acapsular conjunctival isolates may arise initially from such nonreverting SNP null mutations in cpsE , which can be followed later by deletion of portions or all of the cps operon.

The increase in obesity in the Unites States and around the world in the last decade is overwhelming. The number of overweight adults in the world surpassed 1 billion in 2008. Health hazards associated with obesity are serious and include heart disease, sleep apnea, diabetes, and cancer. Although lifestyle modifications are the most straightforward way to control weight, a large portion of the population may not be able to rely on this modality alone. Thus, the development of anti-obesity therapeutics represents a major unmet medical need. Historically, anti-obesity pharmacotherapies have been unsafe and minimally efficacious. A better understanding of the biology of appetite and metabolism provides an opportunity to develop drugs that may offer safer and more effective alternatives for weight management. This review discusses drugs that are currently on the market and in development as anti-obesity therapeutics based on their target and mechanism of action. It should serve as a roadmap to establish expectations for the near future for anti-obesity drug development.

UnlabelledOver the past decade, the Department of Veterans Affairs (VA) Pharmacy Benefits Management Services (PBM) has enhanced its formulary management activities and added programs to ensure that the national drug plan continues to meet the pharmacy needs of veterans and to promote safe and appropriate drug therapy in the face of rising medication expenditures. This article describes the broad range of services provided by the VA PBM that work in partnership to deliver a high-quality and sustainable pharmacy benefit for veterans. In support of formulary management, VA PBM pharmacists prepare extensive clinical guidance documents (e.g., drug monographs and criteria for use) that are used by physicians and pharmacists with operational and clinical oversight of the VA national formulary. The VA PBM has utilized various contracting techniques and continually evaluates drug utilization data to identify opportunities for potential savings. Remarkably, since before 2004, the average acquisition cost for a 1-month supply of medication has remained fairly stable at approximately $13-$15. Two new VA PBM programs are the VA Center for Medication Safety (VA MedSAFE) and the Clinical Pharmacy Practice Office (CPPO). VA MedSAFE is a comprehensive pharmacovigilance program focused on the detection, assessment, and prevention of adverse drug events, and CPPO is dedicated to improving safe and appropriate medication use by supporting and expanding clinical pharmacy practice. Moving forward, the VA PBM will consider new initiatives to stay at the forefront of providing quality care while maintaining economic viability.DisclosuresNo outside funding supported this research. This work was supported by VA Pharmacy Benefits Management Services (VA PBM), Hines, Illinois, and VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania. Glassman is co-director of the VA Center for Medication Safety, which is part of the VA PBM. He is also part of the Medical Advisory Panel for the VA PMB. All other authors are employed by the VA PBM. The views expressed in this article are those of the authors, and no official endorsement by the U.S. Department of Veteran Affairs or the U.S. government is intended or should be inferred. Study concept and design were contributed by Valentino, Cunningham, Good, Aspinall, and Sales. Calabrese and Ourth took the lead in data collection, along with Good, Cunningham, Aspinall, Sales, Burk, Moore, Neuhauser, and Golterman. Data interpretation was performed by Burk, Newhauser, and Golterman, along with Glassman, Calabrese, Moore, and Ourth. The manuscript was written by Aspinall and Sales, along with Burk, Newhauser, Golterman, Ourth, and Cunningham. Good, Glassman, and Moore revised the manuscript, along with Calabrese, Valentino, and Aspinall.

Background The 2013 American College of Cardiology/American Heart Association cholesterol management guidelines represented a paradigm shift from the National Cholesterol Education Program Adult Treatment Panel III guidelines, replacing low-density lipoprotein cholesterol targets with a risk assessment model to guide statin therapy. Our objectives are to compare provider prescription of high-intensity statin therapy in patients hospitalized with acute coronary syndrome (ACS) or cerebrovascular accident (CVA) before and after the publication of the 2013 cholesterol guidelines, determine potential predictors of high-intensity statin utilization, and identify targets for improvement in cardiovascular risk reduction among these high-risk populations. Methods A single-center retrospective cohort study of 695 patients discharged with a diagnosis of ACS or CVA in the 6 months before (n = 359) and after (n = 336) the release of the 2013 American College of Cardiology/American Heart Association cholesterol guidelines. Patient characteristics were compared using analysis of variance and χ2 tests. Multivariable logistic regression models were used to assess clinical predictors of provider utilization of high-intensity statins. Results After the 2013 cholesterol guidelines, the rate of prescribing high-intensity statins was greater for statin-naive patients compared with those already on statin therapy (odds ratio [OR] 0.51, P = .02). Prescription of high-intensity statins was higher for patients with ACS compared with CVA (OR 8.4, P Conclusions Physicians were more likely to prescribe high-intensity statins in statin-naive patients as compared with intensifying existing statin therapy, and their prescription pattern was lower after CVA vs ACS.

Intestinal enteroendocrine cells are critical to central regulation of caloric consumption, since they activate hypothalamic circuits that decrease appetite and thereby restrict meal size by secreting hormones in response to nutrients in the gut. Although guanylyl cyclase and downstream cGMP are essential regulators of centrally regulated feeding behavior in invertebrates, the role of this primordial signaling mechanism in mammalian appetite regulation has eluded definition. In intestinal epithelial cells, guanylyl cyclase 2C (GUCY2C) is a transmembrane receptor that makes cGMP in response to the paracrine hormones guanylin and uroguanylin, which regulate epithelial cell dynamics along the crypt-villus axis. Here, we show that silencing of GUCY2C in mice disrupts satiation, resulting in hyperphagia and subsequent obesity and metabolic syndrome. This defined an appetite-regulating uroguanylin-GUCY2C endocrine axis, which we confirmed by showing that nutrient intake induces intestinal prouroguanylin secretion into the circulation. The prohormone signal is selectively decoded in the hypothalamus by proteolytic liberation of uroguanylin, inducing GUCY2C signaling and consequent activation of downstream anorexigenic pathways. Thus, evolutionary diversification of primitive guanylyl cyclase signaling pathways allows GUCY2C to coordinate endocrine regulation of central food acquisition pathways with paracrine control of intestinal homeostasis. Moreover, the uroguanylin-GUCY2C endocrine axis may provide a therapeutic target to control appetite, obesity, and metabolic syndrome.

Francisella tularensis is a Gram-negative intracellular bacterium that is the causative agent of tularaemia. Concerns regarding its use as a bioterrorism agent have led to a renewed interest in the biology of infection, host response and pathogenesis. A robust T-cell response is critical to confer protection against F. tularensis. However, characterization of the cellular immune response has been hindered by the paucity of tools to examine the anti-Francisella immune response at the molecular level. We set out to combine recent advances of genomics with solid-phase antigen delivery coupled with a T-cell functional assay to identify T-cell epitopes. A subset of clones, encoding serological targets, was selected from an F. tularensis SchuS4 ordered genomic library and subcloned into a bacterial expression vector to test the feasibility of this approach. Proteins were expressed and purified individually employing the BioRobot 3000 in a semi-automated purification method. The purified proteins were coupled to beads, delivered to antigen-presenting cells for processing, and screened with Francisella-specific T-cell hybridomas of unknown specificity. We identified cellular reactivity against the pathogenicity protein IglB, and the chaperone proteins GroEL and DnaK. Further analyses using genetic deletions and synthetic peptides were performed to identify the minimal peptide epitopes. Priming with the peptide epitopes before infection with F. tularensis LVS increased the frequency of antigen-specific CD4 T cells as assessed by intracellular interferon-γ staining. These results illustrate the feasibility of screening an arrayed protein library that should be applicable to a variety of pathogens.

Heat-stable toxins (STs) produced by enterotoxigenic bacteria cause endemic and traveler’s diarrhea by binding to and activating the intestinal receptor guanylyl cyclase C (GC-C). Advances in understanding the biology of GC-C have extended ST from a diarrheagenic peptide to a novel therapeutic agent. Here, we summarize the physiological and pathophysiological role of GC-C in fluid-electrolyte regulation and intestinal crypt-villus homeostasis, as well as describe translational opportunities offered by STs, reflecting the unique characteristics of GC-C, in treating irritable bowel syndrome and chronic constipation, and in preventing and treating colorectal cancer.

Introduction Breast cancer is the most prevalent cancer in women, with approximately 250,000 diagnoses per year in the US. Non-invasive detection of breast cancer is of critical importance but has proven challenging due to the rate of false-positive diagnoses with current tests. Liquid biopsies including circulating tumor cells (CTCs) or cell-free DNA (cfDNA) have struggled with the detection of early stage disease. For example, a recent multi-analyte (cfDNA+protein) analysis, ‘cancerSEEK', achieved a sensitivity of just 33% in breast cancer, highlighting the challenges facing the development of more sensitive and specific diagnostics for this disease. Exosome-based liquid biopsy is a promising approach for minimally-invasive and highly sensitive diagnostics and it has been demonstrated that combining exosomal RNA and cfDNA greatly enhances mutation detection compared to profiling cfDNA alone. While most liquid biopsies profile mutations, studying RNA abundance in exosomes adds a new dimension to these non-invasive diagnostics. To date, much of the focus on exosomal RNA expression profiling has been on the small-RNA fraction. Here we demonstrate that whole-transcriptome profiling of mRNAs and lincRNAs greatly expands the landscape of potential biomarkers to clinically actionable genes. Results We have developed a novel platform designed to perform long-RNA sequencing on transcripts obtained from exosomes. We used this platform to compare expression profiles of total plasma exosomes versus subpopulations enriched for breast cancer-derived exosomes (CDE) versus depleted of non-cancer exosomes (NCE). The NCE-depleted and CDE-enriched exosomes equally outperformed total plasma exosomes, each detecting significantly more genes exhibiting breast cancer vs. healthy expression differences. We performed NCE-depletion on 1.5 mL of input plasma from 15 stage I & II ER+/Her2- breast cancer patients and 12 healthy women matched for age & menopausal-status. RNA-seq data from these samples detected over 10,000 mRNAs and over 1,000 lincRNAs. Of these, we observed significantly increased abundance in over 100 mRNAs and lincRNAs in these early stage breast cancer patients. These mRNAs are enriched for gene-sets including those previously implicated in ‘breast cancer', ‘chromatin remodeling', and ‘immune response'. We also performed RNA-seq on formalin-fixed paraffin-embedded (FFPE) samples from healthy and matched breast cancer tissue. The >100 genes found to be more abundant in breast cancer plasma exosomes significantly (p Conclusions This preliminary analysis highlights the exciting potential of exosomal long RNA based liquid biopsy for non-invasive early-stage detection of breast cancer. The platform is readily applicable to other disease areas and other biofluids such as urine or CSF. Citation Format: Sudipto K. Chakrabortty, Robert R. Kitchen, Christine M. Coticchia, Vasisht R. Tadigotla, Erez Eitan, Elena Castellanos-Rizaldos, Lisa Bedford, Sunita Badola, Michael D. Valentino, Nicholas Colafemina, Hidefumi Uchiyama, Mario Morken, Miguel Williams, Sylvie Vincent, Hadi Danaee, Seth Yu, Johan Skog. Exosomal liquid biopsy reveals mRNA and lincRNA biomarkers in early stage breast cancer patient plasma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr LB-226.

Obesity has emerged as one of the principal worldwide health concerns of the modern era, and there exists a tremendous unmet clinical need for safe and effective therapies to combat this global pandemic. The prevalence of obesity and its associated comorbidities, including cardiovascular and metabolic diseases, has focused the attention of those in drug discovery and development on generating effective modalities for the treatment and prevention of obesity. Early efforts in the field of obesity pharmacotherapy centered on the development of agents with indeterminate mechanisms of action. This led to treatment paradigms characterized by significant off-target effects. In the past two decades, new insights have been made into the physiologic regulation of energy balance and the subordinate central and peripheral circuits coordinating appetite, metabolism, and lipogenesis. These studies have revealed previously unrecognized molecular targets for controlling appetite and managing weight from which has emerged a new wave of targeted pharmacotherapies to prevent and control obesity. Clinical Pharmacology & Therapeutics (2010) 87 6, 652–662. doi: 10.1038/clpt.2010.57

Francisella tularensis is a Gram-negative intracellular bacterium that is the causative agent of tularemia. Small mammals such as rodents and rabbits, as well as some biting arthropods, serve as the main vectors for environmental reservoirs of F. tularensis. The low infectious dose, ability to aerosolize the organism, and the possibility of generating antibiotic resistant strains make F. tularensis a prime organism for use in bioterrorism. As a result, some strains of F. tularensis have been placed on the CDC category A select agent list. T cell immune responses are thought to be a critical component in protective immunity to this organism. However, investigation into the immune responses to F. tularensis has been hampered by the lack of molecularly defined epitopes. Here we report the identification of a major CD4+ T cell epitope in C57Bl/6 (B6) mice. The murine model of F. tularensis infection is relevant as mice are a natural host for F. tularensis LVS and exhibit many of the same features of tularemia seen in humans. Using T cell hybridomas derived from B6 mice that had either been inoculated with F. tularensis and allowed to clear the infection or which had been immunized by conventional means using purified recombinant protein in adjuvant, we have identified amino acids 86–99 of the lipoprotein Tul4 (RLQWQAPEGSKCHD) as an immunodominant CD4 T cell epitope in B6 mice. This epitope is a major component of both the acute and memory responses to F. tularensis infection and can constitute as much as 20% of the responding CD4 T cells in an acute infection. Reactive T cells can also effectively enter the long-term memory T cell pool. The identification of this epitope will greatly aid in monitoring the course of F. tularensis infection and will also aid in the development of effective vaccine strategies for F. tularensis.

The identification and characterization of epitopes is essential for modern immunologic studies. Here, we describe a novel methodology we have developed to identify T cell epitopes exploiting the phenomenon of cross presentation. Particulate antigens, in the form of beads, are very effective in delivering exogenous antigen to both the class I and class II pathways. We will review our efforts to screen entire genomes of pathogens for T cell epitopes taking advantage of the advances in genomics using Francisella tularensis as a model. By automating aspects of this technology we will be able to functionally screen the entire genome of F. tularensis for T cell epitopes. This technology should be applicable not only to F. tularensis, but also to many other pathogens as well.

Long-term studies of macrophyte beds growing near streams in Conesus Lake, New York, have revealed a high biomass and continuing dominance of the invasive rooted species Eurasian watermilfoil (Myriophyllum spicatum). We tested whether agricultural best management practices (BMPs) designed to reduce tributary nutrient and soil loss from the watershed could reduce populations of Eurasian watermilfoil downstream in the lake littoral. Six macrophyte beds were monitored during a 3-year baseline period (2001–2003) prior to the implementation of BMPs and for a 4-year experimental period after a variety of agricultural BMPs were implemented in three sub-watersheds. For three macrophyte beds downstream from sub-watersheds managed as part of our project, quadrat biomass decreased by 30–50% and was statistically lower than Pre-BMP baseline values in 7 of 11 experimental sample years. Biomass loss primarily in the form of the dominant Eurasian watermilfoil ranged from 6.2 to 10 t wet weight for each bed. The...

The patient is a 27-year old Hispanic female who was brought to the ER from the airport by the Drug Enforcement Agency (DEA) on suspicion of “body packing” (illicit drug smuggling via ingestion). An abdominal X-ray (Figures 1a,b) was obtained in the ER which showed multiple radiopaque foreign bodies which were uniform in size measuring 5 cm x 2 cm throughout her colon. The patient then admitted to ingesting numerous heroin pellets. She subsequently had a CT Abdomen/Pelvis performed (Figure 2) which again showed numerous tubular radiopaque foreign bodies throughout the gastrointestinal tract. She was admitted to the medical intensive care unit (MICU) under police escort. She was treated with oral laxatives to accelerate passage of the pellets, and she was monitored for signs of opiate intoxication due to pellet rupture. Surgery was consulted in the event of pellet rupture and resultant drug toxicity uncontrolled with pharmacologic therapy as well other potential complications including intestinal obstruction and/ or perforation. She had serial abdominal x-rays performed to monitor for passage of all of the heroin pellets. All heroin pellets were collected by the DEA as evidence. During her hospitalization, the patient was able to pass all of the heroin pellets without any adverse events and was discharged into police custody.

Growing research in oncology implicates exosomes in cell-to-cell communication and various cancer patho-physiologies. Vesicle-mediated signaling is thought to occur via both protein and RNA transport. However, there is a fundamental lack of understanding regarding the long RNA cargo within exosomes. Previous RNASeq studies on exosomes have largely focused on the small RNA fraction, although the clinical biomarker space remains dominated by mRNA. These studies have reported a relatively small proportion and poor transcript coverage of long RNA which has led many to conclude that exosomes only carry short fragments of mRNA and ncRNA. To address this, we have developed a novel platform specifically designed to perform RNASeq on long RNA from exosomes to efficiently interrogate these as RNA biomarkers. Paired-end sequencing revealed the presence of a wider diversity of annotated mRNA and ncRNAs than previously recognized in exosomes. Employing our whole transcriptome unique molecular indexing strategy, we were able to accurately quantify the number of unique RNA molecules. We detected a total of over 1.4 million unique RNA molecules in our libraries, with 271,308 mapped to protein-coding regions from as little as 2 ml of plasma. We observed that even at a shallow sequencing depth (15 million read pairs), we could detect more than 10,000 genes, composed of 40,000 mRNA and 37,000 ncRNA annotated transcripts. ERCC spike-in analysis indicates that our RNASeq platform is highly sensitive, detecting as few as 8 copies of RNA. Long non-coding RNAs dominated the ncRNA classes and accounted for over 95% of all uniquely detected ncRNAs. We also observed a bimodal distribution of transcript coverage, similar to cellular and tissue derived RNA. In excess of 15,000 transcripts were detected with ≥80% coverage and of these high-coverage transcripts, more than 25% were over 1kb in length, the longest being 17.6kb. Taken together, these findings suggest exosomes harbor more than just small RNA transcripts and short fragments of mRNAs as was previously thought and is a treasure trove of RNA biomarkers. Current research in the liquid biopsy space has been limited to variant detection in cell-free DNA and circulating tumor cells but transcriptional dysregulation is also an important feature of cancer. Our results shed new light on the biology of exosomes and indicate that, in addition to well-recognized small RNA cargo, plasma exosomes carry an abundance of long RNAs that can be interrogated by our optimized workflow. As exosomes provide a rich and protected source of RNA in biofluids, sequencing both long and small RNA from exosomes has the potential to identify biomarkers without the need for invasive tissue biopsies and allow us to have a more complete picture of how the RNA transcriptome in plasma changes in health and disease. Citation Format: Sudipto K. Chakrabortty, Lisa Bedford, Hidefumi Uchiyama, Vasisht Tadigotla, Michael D. Valentino, Dominik Grimm, Dalin Chan, Sunita Badola, Graham Brock, Johan Skog. Long RNA sequencing of human plasma exosomes reveals full coverage of diverse protein coding and long non coding RNA [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 5686. doi:10.1158/1538-7445.AM2017-5686

Staphylococcus aureus is a leading cause of both community- and hospital-acquired infections that are increasingly antibiotic resistant. The emergence of S. aureus resistance to even last-line antibiotics heightens the need for the development of new drugs with novel targets. We generated a highly saturated transposon insertion mutant library in the genome of S. aureus and used Tn-seq analysis to probe the entire genome, with unprecedented resolution and sensitivity, for genes of importance in infection. We further identified genes contributing to fitness in various infected compartments (blood and ocular fluids) and compared them to genes required for growth in rich medium. This resulted in the identification of 426 genes that were important for S. aureus fitness during growth in infection models, including 71 genes that could be considered essential for survival specifically during infection. These findings highlight novel as well as previously known genes encoding virulence traits and metabolic pathways important for S. aureus proliferation at sites of infection, which may represent new therapeutic targets., IMPORTANCE Staphylococcus aureus continues to be a leading cause of antibiotic-resistant community and nosocomial infection. With the bacterium’s acquisition of resistance to methicillin and, more recently, vancomycin, the need for the development of new drugs with novel targets is urgent. Applying a highly saturated Tn-seq mutant library to analyze fitness and growth requirements in a murine abscess and in various infection-relevant fluids, we identified S. aureus traits that enable it to survive and proliferate during infection. This identifies potential new targeting opportunities for the development of novel therapeutics.

In 1995, the Department of Veterans Affairs (VA) established its Pharmacy Benefits Management Strategic Healthcare Group (PBM-SHG) to provide an integrated, comprehensive, portable, high-quality national drug plan for veterans. In the 12 years since then, PBM-SHG has matured into a pharmacy plan that has garnered national and international attention for maintaining a generous drug benefit at a very low cost. Indeed, the success of the VA’s pharmacy benefit plan has led many to suggest that it be a model for other integrated pharmacy plans, including Medicare Part D. The success of the VA prescription drug program has also been a concern for some, resulting in critical publications in the lay press, at times with misleading information. We describe the VA’s pharmacy benefit and outline some of the strategies that have helped the organization achieve a high-quality benefit while keeping pharmacy costs at a level that is almost certainly the lowest in the United States.

Vagococci are usually isolated from marine hosts and occasionally from endodontic infections. Using 16S rRNA gene comparison, the closest relatives are members of the genera Enterococcus and Carnobacterium. A draft sequence of Vagococcus lutrae was generated to clarify the relationship of Vagococcus to these and other related low-G+C Gram-positive bacteria., National Institute of Allergy and Infectious Diseases (U.S.) (contract HSN272200900018C), United States. National Institutes of Health (AI072360)

There is an emerging link between body mass and intestinal malignancies, and obese patients have ~20-60% greater risk of, and ~2-fold greater mortality from, colorectal cancer. Although this epidemiological relationship is established, mechanisms that link obesity and colorectal tumorigenesis, and their reversibility, remain incompletely defined. Here, we explore the novel hypothesis that obesity and colorectal cancer are mechanistically linked through dysregulation of paracrine and endocrine hormone axes mediated by GUCY2C. GUCY2C is the receptor for the paracrine hormones guanylin in the colorectum and uroguanylin in small intestine. These paracrine hormones are the most commonly lost gene products in sporadic colorectal cancer, and their universal loss early in neoplasia is required for tumor initiation and progression in mice and humans. In that context, GUCY2C regulates intestinal homeostasis, and its silencing by hormone loss accelerates proliferation and the cell cycle, increases DNA damage, and reprograms cellular metabolism, which increases genetic- and carcinogen-induced colorectal cancer in mice. Beyond its role in colorectal tumor suppression, GUCY2C and uroguanylin comprise a novel gut-brain endocrine axis, evolutionarily conserved from invertebrates to humans, that regulates appetite, body mass and metabolism. Elimination of this endocrine axis in mice results in hyperphagia, obesity, diabetes and the metabolic syndrome. Unexpectedly, recent studies revealed that GUCY2C paracrine hormone expression in colon is eliminated by diet-induced obesity in mice and humans. Indeed, hormone expression appears to be reversibly modulated by ingested calories, rather than by the endocrine, adipokine or inflammatory milieu associated with obesity. Moreover, enforced expression of GUCY2C paracrine hormone by intestinal epithelial cells eliminates tumorigenesis induced by obesity. These observations suggest a model of cancer risk in which ingested calories contributing to obesity recapitulate mechanisms underlying sporadic colorectal cancer by suppressing paracrine hormone expression, silencing the GUCY2C tumor suppressor and disrupting epithelial homeostasis. They define a previously unrecognized mechanism linking diet and obesity to colorectal cancer and identify silencing of the GUCY2C tumor suppressor as a link between reversible risk factors like ingested calories and molecular mechanisms underlying cancer development. Moreover, they offer strategies for countering these risks, including calorie restriction and oral hormone therapy.

Obesity is a world-wide pandemic and its incidence is on the rise along with associated comorbidities. Currently, there are few effective therapies to combat obesity. The use of lifestyle modification therapy, namely, improvements in diet and exercise, is preferable over bariatric surgery or pharmacotherapy due to surgical risks and issues with drug efficacy and safety. Although they are initially successful in producing weight loss, such lifestyle intervention strategies are generally unsuccessful in achieving long-term weight maintenance, with the vast majority of obese patients regaining their lost weight during followup. Recently, various compensatory mechanisms have been elucidated by which the body may oppose new weight loss, and this compensation may result in weight regain back to the obese baseline. The present review summarizes the available evidence on these compensatory mechanisms, with a focus on weight loss-induced changes in energy expenditure, neuroendocrine pathways, nutrient metabolism, and gut physiology. These findings have added a major focus to the field of antiobesity research. In addition to investigating pathways that induce weight loss, the present work also focuses on pathways that may instead prevent weight regain. Such strategies will be necessary for improving long-term weight loss maintenance and outcomes for patients who struggle with obesity.

Epitopes are a hallmark of the antigen specific immune response. The identification and characterization of epitopes is essential for modern immunologic studies, from investigating cellular responses against tumors to understanding host/pathogen interactions especially in the case of bacteria with intracellular residence. Here, we have utilized a novel approach to identify T cell epitopes exploiting the exquisite ability of particulate antigens, in the form of beads, to deliver exogenous antigen to both MHC class I and class II pathways for presentation to T cell hybridomas. In the current study, we coupled this functional assay with two distinct protein expression libraries to develop a methodology for the characterization of T cell epitopes. One set of expression libraries containing single amino acid substitutions in a defined epitope sequence was interrogated to identify epitopes with enhanced T cell stimulation for a MHC class I epitope. The second expression library is comprised of the majority of open reading frames from the intracellular pathogen and potential biowarfare agent, Francisella tularensis. By automating aspects of this technology, we have been able to functionally screen and identify novel T cell epitopes within F. tularensis. We have also expanded upon these studies to generate a novel expression vector that enables immunization of recombinant protein into mice, which has been utilized to facilitate T cell epitope discovery for proteins that are critically linked to Francisella pathogenicity. This methodology should be applicable to a variety of systems and other pathogens.

Obesity has escalated into a pandemic over the past few decades. In turn, research efforts have sought to elucidate the molecular mechanisms underlying the regulation of energy balance. A host of endogenous mediators regulate appetite and metabolism, and thereby control both short- and long-term energy balance. These mediators, which include gut, pancreatic and adipose neuropeptides, have been targeted in the development of anti-obesity pharmacotherapy, with the goal of amplifying anorexigenic and lipolytic signaling or blocking orexigenic and lipogenic signaling. This article presents the efficacy and safety of these anti-obesity drugs.

With the eruption of the obesity pandemic over the past few decades, much research has been devoted to understanding the molecular mechanisms by which the human body regulates energy balance. These studies have revealed several mediators, including gut/pancreatic/adipose hormones and neuropeptides that control both short- and long-term energy balance by regulating appetite and/or metabolism. These endogenous mediators of energy balance have been the focus of many anti-obesity drug-development programs aimed at either amplifying endogenous anorexigenic/lipolytic signaling or blocking endogenous orexigenic/lipogenic signaling. Here, we discuss the efficacy and safety of targeting these pathways for the pharmacologic treatment of obesity.

These guidelines outline the recommended processes and techniques for formulary system management and describe the pharmacist’s responsibilities and roles in managing the formulary system in partnership with other health care professionals. These guidelines also provide assistance to pharmacists

Tomales Bay, a graben structure along the San Andreas Fault, was selected for modeling ecosystem nutrient dynamics because of its linear, one-dimensional morphology and relatively pristine state. Groundwater is a potentially important term in the nutrient budget. The geologic complexities created by the San Anreas Fault, however, complicate the hydrogeology and require the area to be subdivided into three regions: granite to the west, Franciscan Formation to the east, and alluvial fill in the trough. Nutrient concentrations in the groundwater were determined through extensive well sampling; groundwater discharge was estimated using both Darcy's Law calculations and a soil moisture budget. Results indicate that groundwater discharge is of the same order of magnitude as summer streamflow into the Bay, while being significantly less than other freshwater inputs in winter. Dissolved nutrient (phosphate, nitrate + nitrite, ammonium, silica and DIC) concentrations in groundwater were consistently higher (by as much as an order of magnitude) than in surface water discharges. During the summer months, groundwater flow contributes about as much nutrient load to the bay as does streamflow. During the winter, the groundwater contribution to nutrient loading is about 20% of the streamflow contribution. Our findings indicate that groundwater is a significant component of terrestrial nutrient and freshwater loading to Tomales Bay, particularly so during the summer months. However, neither groundwater nor streamflow nutrient fluxes are large in comparison to the mixing flux at the bay mouth or the flux of N2 gas across the air-water interface.

Staphylococcus aureus is capable of infecting nearly every organ in the human body. In order to infiltrate and thrive in such diverse host tissues, staphylococci must possess remarkable flexibility in both metabolic and virulence programs. To investigate the genetic requirements for bacterial survival during invasive infection, we performed a transposon sequencing (TnSeq) analysis of S. aureus during experimental osteomyelitis. TnSeq identified 65 genes essential for staphylococcal survival in infected bone and an additional 148 mutants with compromised fitness in vivo. Among the loci essential for in vivo survival was SrrAB, a staphylococcal two-component system previously reported to coordinate hypoxic and nitrosative stress responses in vitro. Healthy bone is intrinsically hypoxic, and intravital oxygen monitoring revealed further decreases in skeletal oxygen concentrations upon S. aureus infection. The fitness of an srrAB mutant during osteomyelitis was significantly increased by depletion of neutrophils, suggesting that neutrophils impose hypoxic and/or nitrosative stresses on invading bacteria. To more globally evaluate staphylococcal responses to changing oxygenation, we examined quorum sensing and virulence factor production in staphylococci grown under aerobic or hypoxic conditions. Hypoxic growth resulted in a profound increase in quorum sensing-dependent toxin production, and a concomitant increase in cytotoxicity toward mammalian cells. Moreover, aerobic growth limited quorum sensing and cytotoxicity in an SrrAB-dependent manner, suggesting a mechanism by which S. aureus modulates quorum sensing and toxin production in response to environmental oxygenation. Collectively, our results demonstrate that bacterial hypoxic responses are key determinants of the staphylococcal-host interaction., Author Summary Staphylococcus aureus is a leading cause of infectious death, yet is also capable of harmlessly colonizing healthy individuals. These disparate observations imply that S. aureus can modulate its growth and virulence in response to different host environments. To characterize the staphylococcal genetic programs required to sustain invasive infection, we applied a technique known as TnSeq to experimental osteomyelitis. Osteomyelitis is one of the most common invasive manifestations of staphylococcal infection, and a better understanding of the bacterial factors required to colonize and destroy bone will aid in vaccine and antimicrobial development. TnSeq identified more than 200 genes important for invasive staphylococcal infection of bone. Two of these genes encode a bacterial two-component system, SrrAB, which is known to help S. aureus survive in low oxygen. Consistent with this finding, we discovered that oxygen levels in bone decrease during osteomyelitis. Furthermore, we discovered that staphylococcal virulence is augmented by environmental oxygen levels, suggesting one strategy by which S. aureus can respond to different host environments. Collectively, our results define the genetic and metabolic programs required for S. aureus to sustain invasive infection.

The Department of Veterans Affairs (VA) Pharmacy Benefits Management Strategic Healthcare Group (VA PBM) oversees the formulary for the entire VA system, which serves more than 4 million veterans and provides more than 108 million prescriptions per year. Since its establishment in 1995, the VA PBM has managed pharmaceuticals and pharmaceutical-related policies, including drug safety and efficacy evaluations, pharmacologic management algorithms, and criteria for drug use. These evidence-based practices promote, optimize, and assist VA providers with the safe and appropriate use of pharmaceuticals while allowing for formulary decisions that can result in substantial cost savings. The VA PBM also has utilized various contracting techniques to standardize generic agents as well as specific drugs and drug classes (eg, antihistamines, angiotensin-converting enzyme inhibitors, alpha-blockers, and 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors [statins]). These methods have enabled the VA to save approximately dollar 1.5 billion since 1996 even as drug expenditures continued to rise from roughly dollar 1 billion in fiscal year (FY) 1996 to more than dollar 3 billion in FY 2003. Furthermore, the VA PBM has established an outcomes research section to undertake quality-improvement and safety initiatives that ultimately monitor and determine the clinical impact of formulary decisions on the VA system nationwide. The experiences of this pharmacy benefits program, including clinical and contracting processes/procedures and their impact on the VA healthcare system, are described.

SummaryMatrix metalloproteinases (MMPs) play an important role in many biological and pathological processes including tissue remodeling, wound healing, inflammation, atherosclerosis, and cancer. Numerous publications have supported the concept that activated MMP-2 enhances agonist-induced platelet aggregation and activated MMP-9 inhibits platelet aggregation. In this study, we demonstrated that the organomercurial compound, 4-aminophenyl mercuric acetate (APMA), which is routinely employed to activate latent MMPs at a concentration of 1000 μ M, induces platelet aggregation at low concentration (5 μ M) and inhibits agonist-induced platelet aggregation at concentrations ≥ 50 μ M. Activated MMP-2, MMP-1, and MMP-9, following removal of APMA by ultrafiltration through an anisotropic membrane, exert no independent effect on platelet aggregation. Acetylsalicylic acid and BAPTA inhibited APMA-induced platelet aggregation indicating that the APMA mediated pathway of platelet activation is dependent upon thromboxane and calcium signaling. Zinc chelation with 1,10-phenanthroline, which inhibits zincdependent proteins including metalloproteinases, also abrogated platelet functional responses to APMA. Additional studies will be required to clarify the mechanism of the biphasic effect of APMA on platelet aggregation.

The chemokine CXCL12 (SDF-1) and its receptor, CXCR4, have been implicated in organ-specific metastases of several malignancies. Head and neck squamous cell carcinoma (HNSCC) predominantly metastasizes to lymph nodes, and recent evidence has shown that CXCL12 stimulates HNSCC migration. We explored the potential role of CXCR4 in mediating other metastatic processes in HNSCC cells. CXCR4 mRNA and cell-surface expression was assessed in HNSCC cell lines. CXCR4 mRNA expression was detected in five HNSCC cell lines. Cell-surface CXCR4 was also detected in each of the HNSCC cell lines and in resected HNSCC tissues. CXCL12 induced rapid intracellular calcium mobilization in a metastatic HNSCC cell line (HN), as well as rapid phosphorylation of ERK-1/2. HNSCC cell adhesion to fibronectin and collagen was increased by CXCL12 treatment, while the addition of an inhibitor of ERK-1/2 signaling, PD98059, reduced the effects of CXCL12. CXCL12 also increased the active matrix metalloproteinase (MMP)-9 secreted. Thus, HNSCC cells express functional CXCR4 receptors that induce rapid intracellular signaling upon binding to CXCL12. Such binding leads to increased HNSCC cell adhesion and MMP secretion, suggesting that CXCR4 may be a novel regulator of HNSCC metastatic processes.

We describe, in rheumatoid arthritis (RA), abnormalities in the expression and distribution of heat shock protein (hsp) and dendritic cells (DCs) that are conducive to cross-priming and DC cross-talk. As detected by ELISA, inducible (i)hsp70 was dramatically increased in RA synovial fluid (RASF) vs normal human and RA sera and osteoarthritis and gout synovial fluid. Immunoblot analysis of fresh RASF cells revealed marked increases in ihsp70 and activation of its transcription factor heat shock factor-1, compared with fresh normal peripheral blood cells. Flow cytometry and microscopy demonstrated high levels of ihsp70 on the surface of RASF myeloid DCs (but not normal myeloid DCs) that occurred concurrently with hspRs (CD91/CD14). ihsp70 present in RASF exhibited chaperoning potential, as indicated by the capture of ihsp70 present in RASF on the surface of normal DCs. Binding was partially competitively inhibited by excess α2-macroglobulin, indicating that hspRs in addition to CD91 participate in the capture process. These data indicate that ihsp70 may chaperone autologous Ags into immature RASF DCs via hspRs, and that cross-talk between DCs coexpressing hsp/hspRs reflects a disease process in RA. The induction of surface ihsp70 on normal cells after sublethal heat stress and the release of ihsp70 from normal DCs after inflammatory stress also suggest that the pattern of ihsp70 expression in RASF occurs in response to sustained stress.

Streptococcus pneumoniae, an inhabitant of the upper respiratory mucosa, causes respiratory and invasive infections as well as conjunctivitis. Strains that lack the capsule, a main virulence factor and the target of current vaccines, are often isolated from conjunctivitis cases. Here we perform a comparative genomic analysis of 271 strains of conjunctivitis-causing S. pneumoniae from 72 postal codes in the United States. We find that the vast majority of conjunctivitis strains are members of a distinct cluster of closely related unencapsulated strains. These strains possess divergent forms of pneumococcal virulence factors (such as CbpA and neuraminidases) that are not shared with other unencapsulated nasopharyngeal S. pneumoniae. They also possess putative adhesins that have not been described in encapsulated pneumococci. These findings suggest that the unencapsulated strains capable of causing conjunctivitis utilize a pathogenesis strategy substantially different from that described for S. pneumoniae at other infection sites.

Guanylyl cyclase C (GCC) is the receptor expressed by intestinal cells for the paracrine hormones guanylin and uroguanylin that coordinate mucosal homeostasis and its silencing contributes to intestinal transformation. It orchestrates proliferative and metabolic circuits by limiting the cell cycle and programming metabolic transitions central to regeneration along the crypt-villus axis. Mice deficient in GCC are more susceptible to colon cancer induced by germline mutations or carcinogens. Moreover, guanylin and uroguanylin are the most commonly lost gene products in colon cancer. The role of GCC as a tumor suppressor and the universal loss of its hormones in transformation suggest a paradigm in which colorectal cancer is a disease of paracrine hormone insufficiency. Indeed, GCC signaling reverses the tumorigenic phenotype of human colon cancer cells by regulating proliferation and metabolism. These data suggest a pathophysiological hypothesis in which GCC is a tumor suppressor coordinating proliferative homeostasis whose silencing through hormone loss initiates transformation. The correlative therapeutic hypothesis suggests that colorectal cancer is a disease of hormone insufficiency that can be prevented or treated by oral hormone replacement therapy employing GCC ligands.

The Veterans Health Administration (VHA) runs the largest integrated healthcare system in the nation. Formulary management within VHA primarily involves 3 national groups: the Medical Advisory Panel, the Veterans Integrated Service Network Formulary Leaders, and the Pharmacy Benefits Management Strategic Healthcare Group. Together, these groups manage the VHA national drug formulary with a goal of providing a comprehensive, safe, and cost-effective pharmacy benefit for veterans. Traditionally, VHA has relied on cost-minimization analyses in formulary decisions. More recently, VHA has emphasized the use of cost-effectiveness data, especially for newer, costly drugs. In addition to including this data in drug monographs, the VHA has begun requiring formal cost-effectiveness analysis from manufacturers of selected pharmaceuticals. VHA has also requested that clinically relevant information such as quality of life plus mortality benefit be made available from industry so that internal cost analyses can be performed. It is hoped that by setting the expectation that cost-effectiveness will be formally considered in all VHA formulary decisions, the pharmaceutical industry and others will be stimulated to collect and report data that enables these analyses. We believe that if other organizations also place an emphasis on economic evaluations, industry and the public will be more accepting of decisions that incorporate cost considerations.