Retrospective evaluation of the efficacy of fluconazole for the treatment of coccidioidomycosis in dogs: 49 cases (2015-2020).

OBJECTIVE: To characterize the clinical course and therapeutic response in dogs with coccidioidomycosis treated with fluconazole. ANIMALS: 49 client-owned dogs with coccidioidomycosis that were treated with fluconazole and had ≥ 2 follow-up examinations. PROCEDURES: Medical records were retrospectively searched to identify dogs in which coccidioidomycosis was diagnosed between January 2015 and May 2020. Data recorded from each dog included signalment, clinical signs, diagnostic test results, and treatment. RESULTS: Dogs were treated with fluconazole at a median initial dosage of 19.7 mg/kg/d. Median treatment duration was 298.5 days, with 26 of the 49 dogs completing treatment during the study period. Respiratory signs, lethargy, and hyporexia were the most common clinical signs. Frequency of lethargy decreased after 30 days, whereas frequency of hyporexia and respiratory signs decreased after 90 days. Median IgG titer at diagnosis was 1:32 and was significantly decreased, compared with baseline titer, at all recheck intervals after 90 days. Hyperglobulinemia, monocytosis, and neutrophilia were the most common clinicopathologic abnormalities. Hyperglobulinemia resolved within 30 days, neutrophilia resolved within 90 days, and monocytosis resolved after 180 days. CLINICAL RELEVANCE: Improvements in clinical signs, titers, and clinicopathologic abnormalities were observed after initiation of treatment with fluconazole. Improvement began as early as the first 3 months of treatment, but some variables did not resolve until after 6 to 9 months of treatment. This information provides clinical guidance and describes expectations when prescribing fluconazole to treat coccidioidomycosis in dogs.

Efficient and Precise Processing of the Optimized Primary Artificial MicroRNA in a Huntingtin-Lowering Adeno-Associated Viral Gene Therapy In Vitro and in Mice and Nonhuman Primates.

Huntington's disease is a fatal neurodegenerative disorder caused by an inherited mutation in the huntingtin (HTT) gene comprising an expanded cytosine-adenine-guanine (CAG) trinucleotide repeat sequence that results in a pathogenic huntingtin protein. Adeno-associated viral (AAV) gene therapy containing a primary artificial microRNA (pri-amiRNA) specifically targeting HTT messenger RNA (mRNA) has the potential to provide long-lasting therapeutic benefit, through durable reduction of mutant HTT expression after a single administration. The efficiency and precision of processing of the pri-amiRNA precursor to the mature guide (G) strand by transduced cells are critical for specific and potent HTT mRNA lowering. The selection of the optimized pri-amiRNA comprised a series of in vitro studies followed by in vivo studies in small and then large mammals. Our studies demonstrate the predictivity of certain cell culture systems and rodent models for nonhuman primates with respect to some, but not all key features of pri-amiRNA processing. In addition, our results show that the processing of pri-amiRNAs to the mature guide strand can differ greatly across different scaffolds and sequences while providing the same levels of target lowering. Importantly, our data demonstrate that there is a combinatorial effect of guide and passenger (P) strand sequences, together with the scaffold, on pri-amiRNA processing, with different guide and passenger strand sequences within the same scaffold dramatically altering pri-amiRNA processing. Taken together, our results highlight the importance of optimizing not only target lowering but also the efficiency and precision of pri-amiRNA processing in vitro, in rodents and in large mammals to identify the most potent and selective AAV gene therapy that harnesses the endogenous microRNA (miRNA) biogenesis pathway for target lowering without perturbing the endogenous cellular miRNA profile. The optimized pri-amiRNA was selected with this focus on efficiency and precision of pri-amiRNA processing in addition to its pharmacological activity on HTT mRNA lowering and general tolerability in vivo.

Clinical features, treatment, and outcome of dogs with Coccidioides osteomyelitis.

OBJECTIVE: To describe signalment, clinical signs, serologic test results, treatment, and outcome of dogs with Coccidioides osteomyelitis (COM) and to compare those findings with findings for dogs with osteosarcoma (OSA). ANIMALS: 14 dogs with COM and 16 dogs with OSA. PROCEDURES: Data were retrospectively gathered from electronic medical records. RESULTS: Dogs with COM were younger and weighed less than dogs with OSA. Six dogs with COM had appendicular lesions, 5 had axial lesions, and 3 had both appendicular and axial lesions; 9 had monostotic disease, and 5 had polyostotic disease. Axial lesions and nonadjacent polyostotic disease were more common in dogs with COM than in dogs with OSA, but radiographic appearance was not different between the 2 groups. Median IgG titer at diagnosis of COM was 1:48 and was significantly decreased after 6 and 12 months of treatment. Percentage of dogs with COM that had clinical signs was significantly decreased after 1, 3, 6, and 12 months of treatment. One year after initiation of treatment, 9 of 9 dogs were still receiving fluconazole and 8 of 9 dogs had positive results for serum IgG titer testing. CLINICAL RELEVANCE: Dogs with COM typically had a rapid improvement in clinical signs after initiating treatment with fluconazole but required long-term antifungal treatment. Dogs with COM differed from dogs with OSA, but radiographic features had a great degree of overlap between groups, confounding the ability to make a diagnosis on the basis of diagnostic imaging alone.

Small Molecule Targets TMED9 and Promotes Lysosomal Degradation to Reverse Proteinopathy.

Intracellular accumulation of misfolded proteins causes toxic proteinopathies, diseases without targeted therapies. Mucin 1 kidney disease (MKD) results from a frameshift mutation in the MUC1 gene (MUC1-fs). Here, we show that MKD is a toxic proteinopathy. Intracellular MUC1-fs accumulation activated the ATF6 unfolded protein response (UPR) branch. We identified BRD4780, a small molecule that clears MUC1-fs from patient cells, from kidneys of knockin mice and from patient kidney organoids. MUC1-fs is trapped in TMED9 cargo receptor-containing vesicles of the early secretory pathway. BRD4780 binds TMED9, releases MUC1-fs, and re-routes it for lysosomal degradation, an effect phenocopied by TMED9 deletion. Our findings reveal BRD4780 as a promising lead for the treatment of MKD and other toxic proteinopathies. Generally, we elucidate a novel mechanism for the entrapment of misfolded proteins by cargo receptors and a strategy for their release and anterograde trafficking to the lysosome.

Investigation and characterization of Brucella canis infections in pet-quality dogs and associated human exposures during a 2007-2016 outbreak in Michigan.

OBJECTIVE To estimate Brucella canis seropositivity rates for purebred dogs being bred by noncommercial breeders, describe epidemiological findings in infected commercial dog-production facilities, and characterize B canis infection in pet dogs and the risk to human health. DESIGN Retrospective descriptive study. SAMPLE 2,799 canine specimens submitted to the Michigan State University Veterinary Diagnostic Laboratory for B canis testing and records of B canis reports provided to the Michigan Department of Agriculture and Rural Development from 2007 through 2016. PROCEDURES Results of B canis laboratory tests and epidemiological findings for reported cases of B canis were reviewed and summarized. Federal and state public health officials were interviewed regarding human B canis infection. State veterinarians were interviewed regarding canine brucellosis reporting and control procedures. RESULTS Estimated B canis seropositivity was 0.4% among purebred Michigan dogs owned by noncommercial breeders. Infection was confirmed in dogs from 17 commercial dog-production facilities, 3 shelters, and 1 rescue agency. Estimated infection prevalence in production facilities ranged from 2 of 22 (9%) to 5 of 6 (83%). Transfer of infected dogs involved 22 Michigan counties and 11 states. Seven of 20 privately owned infected dogs had diskospondylitis; I also had uveitis. Fifty-three veterinary hospital or diagnostic laboratory personnel had inadvertent exposure to the pathogen. Brucella canis was isolated from 1 commercial production facility owner. CONCLUSIONS AND CLINICAL RELEVANCE B canis was uncommon in purebred dogs being bred by noncommercial breeders but endemic in Michigan commercial facilities producing dogs destined to become household pets. Infected pet dogs caused human B canis exposure, and several pet dogs had debilitating disease not associated with the reproductive system.

Corrigendum: An immunogenic personal neoantigen vaccine for patients with melanoma.

This corrects the article DOI: 10.1038/nature22991.

An immunogenic personal neoantigen vaccine for patients with melanoma.

Effective anti-tumour immunity in humans has been associated with the presence of T cells directed at cancer neoantigens, a class of HLA-bound peptides that arise from tumour-specific mutations. They are highly immunogenic because they are not present in normal tissues and hence bypass central thymic tolerance. Although neoantigens were long-envisioned as optimal targets for an anti-tumour immune response, their systematic discovery and evaluation only became feasible with the recent availability of massively parallel sequencing for detection of all coding mutations within tumours, and of machine learning approaches to reliably predict those mutated peptides with high-affinity binding of autologous human leukocyte antigen (HLA) molecules. We hypothesized that vaccination with neoantigens can both expand pre-existing neoantigen-specific T-cell populations and induce a broader repertoire of new T-cell specificities in cancer patients, tipping the intra-tumoural balance in favour of enhanced tumour control. Here we demonstrate the feasibility, safety, and immunogenicity of a vaccine that targets up to 20 predicted personal tumour neoantigens. Vaccine-induced polyfunctional CD4+ and CD8+ T cells targeted 58 (60%) and 15 (16%) of the 97 unique neoantigens used across patients, respectively. These T cells discriminated mutated from wild-type antigens, and in some cases directly recognized autologous tumour. Of six vaccinated patients, four had no recurrence at 25 months after vaccination, while two with recurrent disease were subsequently treated with anti-PD-1 (anti-programmed cell death-1) therapy and experienced complete tumour regression, with expansion of the repertoire of neoantigen-specific T cells. These data provide a strong rationale for further development of this approach, alone and in combination with checkpoint blockade or other immunotherapies.

Development and Validation of a Mass Spectrometry-Based Assay for the Molecular Diagnosis of Mucin-1 Kidney Disease.

Mucin-1 kidney disease, previously described as medullary cystic kidney disease type 1 (MCKD1, OMIM 174000), is an autosomal dominant tubulointerstitial kidney disease recently shown to be caused by a single-base insertion within the variable number tandem repeat region of the MUC1 gene. Because of variable age of disease onset and often subtle signs and symptoms, clinical diagnosis of mucin-1 kidney disease and differentiation from other forms of hereditary kidney disease have been difficult. The causal insertion resides in a variable number tandem repeat region with high GC content, which has made detection by standard next-generation sequencing impossible to date. The inherently difficult nature of this mutation required an alternative method for routine detection and clinical diagnosis of the disease. We therefore developed and validated a mass spectrometry-based probe extension assay with a series of internal controls to detect the insertion event using 24 previously characterized positive samples from patients with mucin-1 kidney disease and 24 control samples known to be wild type for the variant. Validation results indicate an accurate and reliable test for clinically establishing the molecular diagnosis of mucin-1 kidney disease with 100% sensitivity and specificity across 275 tests called.

Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council.

UNLABELLED: Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence. PERSPECTIVE: This guideline, on the basis of a systematic review of the evidence on postoperative pain management, provides recommendations developed by a multidisciplinary expert panel. Safe and effective postoperative pain management should be on the basis of a plan of care tailored to the individual and the surgical procedure involved, and multimodal regimens are recommended in many situations.

Getting personal with neoantigen-based therapeutic cancer vaccines.

Despite years of preclinical efforts and hundreds of clinical studies, therapeutic cancer vaccines with the routine ability to limit or eliminate tumor growth in humans have been elusive. With advances in genome sequencing, it is now possible to identify a new class of tumor-specific antigens derived from mutated proteins that are present only in the tumor. These "neoantigens" should provide highly specific targets for antitumor immunity. Although many challenges remain in producing and testing neoantigen-based vaccines customized for each patient, a neoantigen vaccine offers a promising new approach to induce highly focused antitumor T cells aimed at eradicating cancer cells.

An exploratory study of combination buspirone and melatonin SR in major depressive disorder (MDD): a possible role for neurogenesis in drug discovery.

We used in vitro neurogenesis-based human neural stem cell (hNSCs) assays and rodent in vivo behavioral assays to identify potential novel antidepressants. A combination of buspirone and melatonin displayed antidepressant activity in these assays whereas neither buspirone nor melatonin alone showed any antidepressant-like profile. After evaluating numerous combination ratios, we determined that low dose buspirone 15 mg combined with melatonin-SR 3 mg yielded optimal antidepressant efficacy in our pre-clinical platform. The low dose of buspirone suggested that antidepressant efficacy might be achieved with only minimal adverse event liability. Based on these data, we conducted an exploratory 6-week, multi-center, double-blind, randomized, placebo- and comparator-controlled study of the combination of buspirone and melatonin in subjects with acute Major Depressive Disorder (MDD). The combination treatment revealed a significant antidepressant response in subjects with MDD on several measures (Clinical Global Impression of Severity and Improvement, Inventory of Depressive Symptomatology) compared to either placebo or buspirone 15 mg monotherapy. These preliminary findings have clinical implications and suggest that a platform of pre-clinical neurogenesis matched with confirmatory behavioral assays may be useful as a drug discovery strategy.

Fluoxetine rescues impaired hippocampal neurogenesis in a transgenic A53T synuclein mouse model.

The accumulation of alpha-synuclein in Lewy bodies and Lewy neurites of different neuronal populations is one of the neuropathological hallmarks in Parkinson disease (PD). Overexpression of human wildtype or mutant alpha-synuclein affects the generation of new neurons in the adult dentate gyrus (DG) of the hippocampus in models of PD. Hippocampal dysfunction with reduced neurogenesis plays an important role in the pathogenesis of depression, an important non-motor symptom in PD. Moreover, effective antidepressant treatment is still an unmet need in PD. The present study explored if impaired hippocampal neurogenesis in the A53T transgenic animal model of PD may be restored by chronic oral application of the selective serotonin reuptake inhibitor (SSRI) fluoxetine. First, we determined the expression pattern of transgenic mutant A53T synuclein in developing DG neurons and showed early expression of the transgene linked to a severely impaired neurogenesis. After chronic fluoxetine treatment we observed an increased adult neurogenesis in the hippocampus of more than threefold in treated A53T mice compared with controls. The pro-neurogenic effect of chronic fluoxetine application is predominantly related to an increased proliferation of neural precursor cells in the DG, and to a lesser extent by induction of differentiation into mature neurons. Analysis of the underlying mechanisms revealed an induction of brain-derived and glial cell-derived neurotrophic factor levels as a result of fluoxetine treatment. This study underlines the large potential of SSRI-dependent mechanisms to stimulate adult hippocampal neurogenesis in alpha-synuclein models and may lead to novel means to improve neuropsychiatric symptoms in PD.

Identification of N-(5-tert-butyl-isoxazol-3-yl)-N'-{4-[7-(2-morpholin-4-yl-ethoxy)imidazo[2,1-b][1,3]benzothiazol-2-yl]phenyl}urea dihydrochloride (AC220), a uniquely potent, selective, and efficacious FMS-like tyrosine kinase-3 (FLT3) inhibitor.

Treatment of AML patients with small molecule inhibitors of FLT3 kinase has been explored as a viable therapy. However, these agents are found to be less than optimal for the treatment of AML because of lack of sufficient potency or suboptimal oral pharmacokinetics (PK) or lack of adequate tolerability at efficacious doses. We have developed a series of extremely potent and highly selective FLT3 inhibitors with good oral PK properties. The first series of compounds represented by 1 (AB530) was found to be a potent and selective FLT3 kinase inhibitor with good PK properties. The aqueous solubility and oral PK properties at higher doses in rodents were found to be less than optimal for clinical development. A novel series of compounds were designed lacking the carboxamide group of 1 with an added water solubilizing group. Compound 7 (AC220) was identified from this series to be the most potent and selective FLT3 inhibitor with good pharmaceutical properties, excellent PK profile, and superior efficacy and tolerability in tumor xenograft models. Compound 7 has demonstrated a desirable safety and PK profile in humans and is currently in phase II clinical trials.

Arylcarboxyamino-substituted diaryl ureas as potent and selective FLT3 inhibitors.

A series of diaryl ureas with an amide substitution at the 4-position was prepared and found to be potent and selective FLT3 inhibitors with good oral bioavailability and efficacy in a tumor xenograft model.

The critical care air transport program.

BACKGROUND: The critical care air transport team program is a component of the U.S. Air Force Aeromedical Evacuation system. A critical care air transport team consists of a critical care physician, critical care nurse, and respiratory therapist along with the supplies and equipment to operate a portable intensive care unit within a cargo aircraft. DISCUSSION: This capability was developed to support rapidly mobile surgical teams with high capability for damage control resuscitation and limited capacity for postresuscitation care. The critical care air transport team permits rapid evacuation of stabilizing casualties to a higher level of care. The aeromedical environment presents important challenges for the delivery of critical care. All equipment must be tested for safety and effectiveness in this environment before use in flight. The team members must integrate the current standards of care with the limitation imposed by stresses of flight on their patient. SUMMARY: The critical care air transport team capability has been used successfully in a range of settings from transport within the United States, to disaster response, to support of casualties in combat.

Off-label use of recombinant human bone morphogenetic protein-2 (rhBMP-2) for reconstruction of mandibular bone defects in humans.

PURPOSE: The off-label use of recombinant human bone morphogenetic protein-2 (rhBMP-2) for the treatment of mandibular bone defects was evaluated in 5 patients. The rhBMP-2 was used as an alternative to autogenous bone grafting. PATIENTS AND METHODS: A total of 5 patients had mandibular defects reconstructed with rhBMP-2, 1.5 mg/mL, soaked collagen sponges alone or in combination with bone marrow cells and allogenic cancellous bone chips. Four of the patients had mandibular continuity defects and the fifth patient had 2 large bone cavities following removal of dentigerous cysts. Radiographs and clinical examinations were used to evaluate healing. The longest patient follow-up was 22 months after reconstruction. RESULTS: Radiographic and clinical assessments revealed bone regeneration and restoration of the mandibular defects in 3 of the 5 patients. The rhBMP-2 failed in 2 patients with continuity defects. Both patients with failed rhBMP-2 grafts were successfully repaired using autogenous harvested from the iliac crest. CONCLUSION: Mandibular bone defects can be successfully reconstructed using rhBMP-2 soaked sponges with and without including bone marrow cells and allogenic bone. Further studies are needed to determine the ideal combination of components that will predictably and reliably regenerate bone in different types of bone defects.