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Xiong L, Pereira De Sa N, Zarnowski R, Huang MY, Mota Fernandes C, Lanni F, Andes DR, Del Poeta M, Mitchell AP. Biofilm-associated metabolism via ERG251 in Candida albicans. PLoS Pathog 2024; 20:e1012225. [PMID: 38739655 DOI: 10.1371/journal.ppat.1012225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/25/2024] [Indexed: 05/16/2024] Open
Abstract
Biofilm formation by the fungal pathogen Candida albicans is the basis for its ability to infect medical devices. The metabolic gene ERG251 has been identified as a target of biofilm transcriptional regulator Efg1, and here we report that ERG251 is required for biofilm formation but not conventional free-living planktonic growth. An erg251Δ/Δ mutation impairs biofilm formation in vitro and in an in vivo catheter infection model. In both in vitro and in vivo biofilm contexts, cell number is reduced and hyphal length is limited. To determine whether the mutant defect is in growth or some other aspect of biofilm development, we examined planktonic cell features in a biofilm-like environment, which was approximated with sealed unshaken cultures. Under those conditions, the erg251Δ/Δ mutation causes defects in growth and hyphal extension. Overexpression in the erg251Δ/Δ mutant of the paralog ERG25, which is normally expressed more weakly than ERG251, partially improves biofilm formation and biofilm hyphal content, as well as growth and hyphal extension in a biofilm-like environment. GC-MS analysis shows that the erg251Δ/Δ mutation causes a defect in ergosterol accumulation when cells are cultivated under biofilm-like conditions, but not under conventional planktonic conditions. Overexpression of ERG25 in the erg251Δ/Δ mutant causes some increase in ergosterol levels. Finally, the hypersensitivity of efg1Δ/Δ mutants to the ergosterol inhibitor fluconazole is reversed by ERG251 overexpression, arguing that reduced ERG251 expression contributes to this efg1Δ/Δ phenotype. Our results indicate that ERG251 is required for biofilm formation because its high expression levels are necessary for ergosterol synthesis in a biofilm-like environment.
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Affiliation(s)
- Liping Xiong
- Department of Microbiology, University of Georgia, Athens, Georgia, United States of America
| | - Nivea Pereira De Sa
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, New York, United States of America
| | - Robert Zarnowski
- Department of Medical Microbiology and Immunology, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Manning Y Huang
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
| | - Caroline Mota Fernandes
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, New York, United States of America
| | - Frederick Lanni
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
| | - David R Andes
- Department of Medical Microbiology and Immunology, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Maurizio Del Poeta
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, New York, United States of America
| | - Aaron P Mitchell
- Department of Microbiology, University of Georgia, Athens, Georgia, United States of America
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
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Xiong L, Goerlich K, Mitchell AP. Regulatory features of Candida albicans hemin-induced filamentation. G3 (Bethesda) 2024; 14:jkae053. [PMID: 38470537 PMCID: PMC11075532 DOI: 10.1093/g3journal/jkae053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 03/14/2024]
Abstract
Candida albicans is a prominent fungal pathogen that can infect the bloodstream and deep tissues. One key pathogenicity trait is the ability to transition between yeast and hyphal growth. Hyphae are critical for the formation of biofilms, which in turn enable device-associated infection. Among signals that drive hypha formation is the presence of hemin, an oxidized Fe(III)-containing heme derivative found in blood. In this study, we asked 4 questions. First, how uniform is the filamentation response to hemin among C. albicans strains? We tested 26 diverse isolates and found that the strength of a strain's filamentation response to hemin reflected its filamentation level in the absence of hemin. Second, does hemin induce biofilm formation? Hemin biofilm induction was evident in 5 out of 10 isolates tested, including most of the weaker biofilm formers tested. Third, what is the gene expression response to hemin? We compared RNA-seq data for type strain SC5314 grown in pH 5.5 minimal media with or without hemin. We also compared that response to SC5314 grown in pH 7.0 minimal media, where it undergoes well-studied pH-dependent filamentation. We found a common set of 72 genes with upregulated RNA levels in response to both signals, including many known hypha-associated genes. Surprisingly, overlap among those 72 genes with 2 recent consensus definitions of hypha-associated genes was limited to only 16 genes. Fourth, which regulators govern hemin-induced filamentation? A mutant survey indicated that the response depends upon filamentation regulators Efg1, Brg1, and Rim101, but not upon heme acquisition regulator Hap1 or its target genes HMX1, RBT5, PGA10, PGA7, and CSA2. These findings argue that hemin induces hypha formation independently of its utilization.
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Affiliation(s)
- Liping Xiong
- Department of Microbiology, University of Georgia, Athens, GA 30602, USA
| | - Katharina Goerlich
- Department of Microbiology, University of Georgia, Athens, GA 30602, USA
| | - Aaron P Mitchell
- Department of Microbiology, University of Georgia, Athens, GA 30602, USA
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Mooghali M, Mohammad A, Wallach JD, Mitchell AP, Ross JS, Ramachandran R. Premarket Evidence and Postmarketing Requirements for Real-Time Oncology Review Indication Approvals. JAMA Netw Open 2024; 7:e249233. [PMID: 38691363 PMCID: PMC11063797 DOI: 10.1001/jamanetworkopen.2024.9233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/02/2024] [Indexed: 05/03/2024] Open
Abstract
This cross-sectional study evaluates the use of the US Food and Drug Administration’s Real-Time Oncology Review (RTOR) program in confirming the effectiveness of cancer drugs.
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Affiliation(s)
- Maryam Mooghali
- Department of Internal Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale Collaboration for Regulatory Rigor, Integrity and Transparency (CRRIT), Yale School of Medicine, New Haven, Connecticut
| | - Ayman Mohammad
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joshua D. Wallach
- Yale Collaboration for Regulatory Rigor, Integrity and Transparency (CRRIT), Yale School of Medicine, New Haven, Connecticut
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Aaron P. Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph S. Ross
- Department of Internal Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale Collaboration for Regulatory Rigor, Integrity and Transparency (CRRIT), Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Health System, New Haven, Connecticut
| | - Reshma Ramachandran
- Department of Internal Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale Collaboration for Regulatory Rigor, Integrity and Transparency (CRRIT), Yale School of Medicine, New Haven, Connecticut
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Mooghali M, Mitchell AP, Skydel JJ, Ross JS, Wallach JD, Ramachandran R. Characterization of accelerated approval status, trial endpoints and results, and recommendations in guidelines for oncology drug treatments from the National Comprehensive Cancer Network: cross sectional study. BMJ Med 2024; 3:e000802. [PMID: 38596814 PMCID: PMC11002412 DOI: 10.1136/bmjmed-2023-000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/24/2024] [Indexed: 04/11/2024]
Abstract
Objectives To evaluate National Comprehensive Cancer Network (NCCN) guideline recommendations for oncology drug treatments that have been granted accelerated approval, and to determine whether recommendations are updated based on the results of confirmatory trials after approval and based on status updates from the US Food and Drug Administration (FDA). Design Cross sectional study. Setting US FDA and NCCN guidelines. Population Oncology therapeutic indications (ie, specific oncological conditions for which the drug is recommended) that have been granted accelerated approval in 2009-18. Main outcome measures NCCN guideline reporting of accelerated approval status and postapproval confirmatory trials, and guideline recommendation alignment with postapproval confirmatory trial results and FDA status updates. Results 39 oncology drug treatments were granted accelerated approval for 62 oncological indications. Although all indications were recommended in NCCN guidelines, accelerated approval status was reported for 10 (16%) indications. At least one postapproval confirmatory trial was identified for all 62 indications, 33 (53%) of which confirmed benefit; among these indications, NCCN guidelines maintained the previous recommendation or strengthened the category of evidence for 27 (82%). Postapproval confirmatory trials failed to confirm benefit for 12 (19%) indications; among these indications, NCCN guidelines removed the previous recommendation or weakened the category of evidence for five (42%). NCCN guidelines reflected the FDA's decision to convert 30 (83%) of 36 indications from accelerated to traditional approval, of which 20 (67%) had guideline updates before the FDA's conversion decision. NCCN guidelines reflected the FDA's decision to withdraw seven (58%) of 12 indications from the market, of which four (57%) had guidelines updates before the FDA's withdrawal decision. Conclusions NCCN guidelines always recommend drug treatments that have been granted accelerated approval for oncological indications, but do not provide information about their accelerated approval status, including surrogate endpoint use and status of postapproval confirmatory trials. NCCN guidelines consistently provide information on postapproval trial results confirming clinical benefit, but not on postapproval trials failing to confirm clinical benefit. NCCN guidelines more frequently update recommendation for indications converted to traditional approval than for those approvals that were withdrawn.
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Affiliation(s)
- Maryam Mooghali
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Yale Collaboration for Regulatory Rigor, Integrity, and Transparency, Yale School of Medicine, New Haven, CT, USA
| | - Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Joseph S Ross
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Yale Collaboration for Regulatory Rigor, Integrity, and Transparency, Yale School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health; and Center for Outcomes Research and Evaluation, Yale New Haven Health System, New Haven, CT, USA
| | - Joshua D Wallach
- Department of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Reshma Ramachandran
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Yale Collaboration for Regulatory Rigor, Integrity, and Transparency, Yale School of Medicine, New Haven, CT, USA
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Mitchell AP, Kinlaw AC, Peacock-Hinton S, Dusetzina SB, Winn AN, Sanoff HK, Lund JL. Commercial Versus Medicaid Insurance and Use of High-Priced Anticancer Treatments. Oncologist 2024:oyae035. [PMID: 38484395 DOI: 10.1093/oncolo/oyae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/16/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Because the markups on cancer drugs vary by payor, providers' financial incentive to use high-price drugs is differential according to each patient's insurance type. We evaluated the association between patient insurer (commercial vs Medicaid) and the use of high-priced cancer treatments. MATERIALS AND METHODS We linked cancer registry, administrative claims, and demographic data for individuals diagnosed with cancer in North Carolina from 2004 to 2011, with either commercial or Medicaid insurance. We selected cancers with multiple FDA-approved, guideline-recommended chemotherapy options and large price differences between treatment options: advanced colorectal, lung, and head and neck cancer. The outcome was a receipt of a higher-priced option, and the exposure was insurer: commercial versus Medicaid. We estimated risk ratios (RRs) for the association between insurer and higher-priced treatment using log-binomial models with inverse probability of exposure weights. RESULTS Of 812 patients, 209 (26%) had Medicaid. The unadjusted risk of receiving higher-priced treatment was 36% (215/603) for commercially insured and 27% (57/209) for Medicaid insured (RR: 1.31, 95% CI: 1.02-1.67). After adjustment for confounders the association was attenuated (RR: 1.15, 95% CI: 0.81-1.65). Exploratory subgroup analysis suggested that commercial insurance was associated with increased receipt of higher-priced treatment among patients treated by non-NCI-designated providers (RR: 1.53, 95% CI: 1.14-2.04). CONCLUSIONS Individuals with Medicaid and commercial insurance received high-priced treatments in similar proportion, after accounting for differences in case mix. However, modification by provider characteristics suggests that insurance type may influence treatment selection for some patient groups. Further work is needed to determine the relationship between insurance status and newer, high-price drugs such as immune-oncology agents.
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Affiliation(s)
- Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Alan C Kinlaw
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sharon Peacock-Hinton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, United States
- Vanderbilt-Ingram Cancer Center, Nashville, TN, United States
| | - Aaron N Winn
- University of Illinois at Chicago, Chicago, IL, United States
| | - Hanna K Sanoff
- Department of Hematology/ Oncology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Jennifer L Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Mitchell AP, Nemirovsky D, Mishra Meza A, Chakraborty N, Persaud S, Farooki A, Morris MJ. Costs to Medicare of Nonrecommended Bone-Modifying Agent Use for Castration-Sensitive Prostate Cancer. JCO Oncol Pract 2024; 20:393-400. [PMID: 38190588 DOI: 10.1200/op.23.00602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/31/2023] [Accepted: 11/14/2023] [Indexed: 01/10/2024] Open
Abstract
PURPOSE Bone-modifying agents (BMAs) do not prevent skeletal-related events among patients with castration-sensitive prostate cancer (CSPC), but many patients receive BMAs unnecessarily. The costs to Medicare from overuse have not been assessed. METHODS We used linked SEER-Medicare data 2011-2015 to measure the frequency and number of doses of zoledronic acid (ZA) and denosumab received during CSPC (between diagnosis and initiation of metastatic, castration resistant prostate cancer therapy). We estimated excess BMA among patients who received BMA therapy for CSPC and did not have an indication for osteoporosis fracture prevention. We used the Medicare fee schedule for drug prices and peer-reviewed sources to estimate adverse event frequencies and costs. RESULTS Median CSPC duration was 387 days (IQR, 253-573), during which time 42% of patients received ≥one dose of denosumab (mean doses, 7) and 18% received ≥one dose of ZA (mean doses, 7). Thirty-eight percent of those receiving denosumab and 47% of those receiving ZA had a history of osteoporosis, osteopenia, spine or hip fracture, or hypercalcemia. The estimated, annual excess BMA cost to Medicare was $44,105,041 in US dollars (USD), composed of $43,303,078 USD and $45,512 USD in drug costs for denosumab and ZA, respectively, and $682,865 USD and $75,585 USD in adverse event costs, respectively. In one-way sensitivity analysis, the estimate was most sensitive to denosumab dosing frequency (estimate range, $28,469,237 USD-$98,830,351 USD) and duration of CSPC (estimate range, $36,823,311 USD-$99,015,908 USD). CONCLUSION BMA overuse in CSPC incurs substantial cost to Medicare, largely because of denosumab drug costs. Excess costs may be reduced by greater adherence to guideline-concordant BMA use.
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Affiliation(s)
- Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Division of Solid Tumor Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David Nemirovsky
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Akriti Mishra Meza
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nirjhar Chakraborty
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sonia Persaud
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Azeez Farooki
- Department of Medicine, Division of Subspecialty Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michael J Morris
- Department of Medicine, Division of Solid Tumor Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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Mitchell AP, Persaud S, Palyca P, Salner A, Farooki A, Ostroff JS, Morris MJ, Chimonas S. Physician knowledge, practice patterns, and barriers encountered regarding guideline-concordant use of bone modifying agents for prostate cancer. Prostate 2024; 84:177-184. [PMID: 37846041 PMCID: PMC10842467 DOI: 10.1002/pros.24636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/25/2023] [Accepted: 09/25/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Guidelines recommend bone-modifying agents (BMAs) for patients with castrate-resistant prostate cancer (CRPC) and bone metastasis, but not for castrate-sensitive prostate cancer (CSPC). Physicians beliefs and practices regarding BMA therapy are poorly understood. METHODS This was a qualitative interview study with embedded Likert-scale elements. Study participants were physicians who treat prostate cancer, located within an academic cancer center or an affiliated community-based network. Participants were asked about their experiences and practice patterns regarding BMA therapy. Participants used Likert-scale items to identify the most common barriers to guideline-concordant BMA use and the most effective potential interventions. Participants were subsequently asked to rank the three most common barriers and the three most effective interventions to reduce underuse (for CRPC) and overuse (for CSPC). RESULTS Nineteen physicians were invited and 15 participated; one physician did not answer some questions as outside of their practice scope. All were aware of the recommendation for BMAs in CRPC. 14% (2/14) were unaware of the recommendation against BMA use for CSPC; an additional 29% (4/14) believed that BMA use could be appropriate for CSPC depending on the metastatic disease burden. 36% (5/14) were unaware of recommendations for screening and treatment of low bone mineral density. The most common barriers (occurring "often" or "sometimes") were obtaining dental clearance (11/15) and insufficient clinic time (6/15). The interventions identified as most effective to reduce underuse were dental navigation (11/15) and electronic medical record (EMR)-based guidance (9/15). The interventions identified as most effective to reduce overuse were peer-to-peer education (14/15) and EMR-based guidance (13/15). CONCLUSIONS Awareness of guideline recommendations for screening and treatment of low bone mineral density and against BMA use for CSPC was good, but not complete. Dental navigation, peer-to-peer education, and EMR-based guidance were preferred intervention strategies to improve guideline-concordant use.
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Affiliation(s)
- Aaron P. Mitchell
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics, New York, NY, USA
- Memorial Sloan Kettering Cancer Center, Department of Medicine, Division of Solid Tumor Oncology, New York, NY, USA
| | - Sonia Persaud
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics, New York, NY, USA
| | - Paul Palyca
- Lehigh Valley Health Network, Lehigh Valley Topper Cancer Institute, Allentown, PA, USA
| | - Andrew Salner
- Hartford HealthCare Cancer Institute, Hartford, CT, USA
| | - Azeez Farooki
- Memorial Sloan Kettering Cancer Center, Department of Medicine, Division of Subspecialty Medicine, New York, NY, USA
| | - Jamie S. Ostroff
- Memorial Sloan Kettering Cancer Center, Department of Psychiatry and Behavioral Sciences, New York, NY, USA
| | - Michael J. Morris
- Memorial Sloan Kettering Cancer Center, Department of Medicine, Division of Solid Tumor Oncology, New York, NY, USA
| | - Susan Chimonas
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics, New York, NY, USA
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Mitchell AP, Imperiale MJ. Full Circle: How ideas unfold. mSphere 2023; 8:e0048523. [PMID: 37850790 PMCID: PMC10732034 DOI: 10.1128/msphere.00485-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023] Open
Affiliation(s)
- Aaron P. Mitchell
- Department of Microbiology, University of Georgia, Athens, Georgia, USA
| | - Michael J. Imperiale
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
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Affiliation(s)
| | - Aaron N Winn
- University of Illinois Chicago, Chicago, IL, USA
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Mitchell AP, Dusetzina SB, Mishra Meza A, Trivedi NU, Bach PB, Winn AN. Pharmaceutical industry payments and delivery of non-recommended and low value cancer drugs: population based cohort study. BMJ 2023; 383:e075512. [PMID: 37879723 PMCID: PMC10599253 DOI: 10.1136/bmj-2023-075512] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE To estimate the association between oncologists' receipt of payments from the pharmaceutical industry and delivery of non-recommended or low value interventions among their patients. DESIGN Cohort study. SETTING Fee-for-service Medicare claims. PARTICIPANTS Medicare beneficiaries with a diagnosis of incident cancer (new occurrence of a cancer diagnosis code in proximity to claims for cancer treatment, and no such diagnosis codes during a ≥1 year washout period) during 2014-19, who met additional requirements identifying them as at risk for one of four non-recommended or low value interventions: denosumab for castration sensitive prostate cancer, granulocyte colony stimulating factors (GCSF) for patients at low risk for neutropenic fever, nab-paclitaxel for cancers with no evidence of superiority over paclitaxel, and a branded drug in settings where a generic or biosimilar version was available. MAIN OUTCOME MEASURES Receipt of the non-recommended or low value drug for which the patient was at risk. The primary association of interest was the assigned oncologist's receipt of any general payments from the manufacturer of the corresponding non-recommended or low value drug (measured in Open Payments) within 365 days before the patient's index cancer date. The two modeling approaches used were general linear model controlling for patients' characteristics and calendar year, and general linear model with physician level indicator variables. RESULTS Oncologists were in receipt of industry payments for 2962 of 9799 patients (30.2%) at risk for non-recommended denosumab (median $63), 76 747 of 271 485 patients (28.3%) at risk for GCSF (median $60); 18 491 of 86 394 patients (21.4%) at risk for nab-paclitaxel (median $89), and 4170 of 13 386 patients (31.2%) at risk for branded drugs (median $156). The unadjusted proportion of patients who received non-recommended denosumab was 31.4% for those whose oncologist had not received payment and 49.5% for those whose oncologist had (prevalence difference 18.0%); the corresponding values for GCSF were 26.6% v 32.1% (5.5%), for nab-paclitaxel were 7.3% v 15.1% (7.8%), and for branded drugs were 88.3% v 83.5% (-4.8%). Controlling for patients' characteristics and calendar year, payments from industry were associated with increased use of denosumab (17.5% (95% confidence interval 15.3% to 19.7%)), GCSF (5.8% (5.4% to 6.1%)), and nab-paclitaxel (7.6% (7.1% to 8.1%)), but lower use of branded drugs (-4.6% (-5.8% to -3.3%)). In physician level indicator models, payments from industry were associated with increased use of denosumab (7.4% (2.5% to 12.2%)) and nab-paclitaxel (1.7% (0.9% to 2.5%)), but not with GCSF (0.4% (-0.3% to 1.1%)) or branded drugs (1.2% (-6.0 to 8.5%)). CONCLUSIONS Within some clinical scenarios, industry payments to physicians are associated with non-recommended and low value drugs. These findings raise quality of care concerns about the financial relationships between physicians and industry.
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Affiliation(s)
- Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10017, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stacie B Dusetzina
- Department of Health Policy and Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Akriti Mishra Meza
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10017, USA
| | | | | | - Aaron N Winn
- University of Illinois Chicago, Chicago, IL, USA
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Cheng Z, Stefani C, Skillman T, Klimas A, Lee A, DiBernardo EF, Brown KM, Milman T, Wang Y, Gallagher BR, Lagree K, Jena BP, Pulido JS, Filler SG, Mitchell AP, Hiller NL, Lacy‐Hulbert A, Zhao Y. MicroMagnify: A Multiplexed Expansion Microscopy Method for Pathogens and Infected Tissues. Adv Sci (Weinh) 2023; 10:e2302249. [PMID: 37658522 PMCID: PMC10602566 DOI: 10.1002/advs.202302249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/29/2023] [Indexed: 09/03/2023]
Abstract
Super-resolution optical imaging tools are crucial in microbiology to understand the complex structures and behavior of microorganisms such as bacteria, fungi, and viruses. However, the capabilities of these tools, particularly when it comes to imaging pathogens and infected tissues, remain limited. MicroMagnify (µMagnify) is developed, a nanoscale multiplexed imaging method for pathogens and infected tissues that are derived from an expansion microscopy technique with a universal biomolecular anchor. The combination of heat denaturation and enzyme cocktails essential is found for robust cell wall digestion and expansion of microbial cells and infected tissues without distortion. µMagnify efficiently retains biomolecules suitable for high-plex fluorescence imaging with nanoscale precision. It demonstrates up to eightfold expansion with µMagnify on a broad range of pathogen-containing specimens, including bacterial and fungal biofilms, infected culture cells, fungus-infected mouse tone, and formalin-fixed paraffin-embedded human cornea infected by various pathogens. Additionally, an associated virtual reality tool is developed to facilitate the visualization and navigation of complex 3D images generated by this method in an immersive environment allowing collaborative exploration among researchers worldwide. µMagnify is a valuable imaging platform for studying how microbes interact with their host systems and enables the development of new diagnosis strategies against infectious diseases.
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Affiliation(s)
- Zhangyu Cheng
- Department of Biological SciencesCarnegie Mellon University4400 Fifth AvenuePittsburghPA15213USA
| | - Caroline Stefani
- Benaroya Research Institute at Virginia Mason1201 9th AveSeattleWA98101USA
| | | | - Aleksandra Klimas
- Department of Biological SciencesCarnegie Mellon University4400 Fifth AvenuePittsburghPA15213USA
| | - Aramchan Lee
- Department of Biological SciencesCarnegie Mellon University4400 Fifth AvenuePittsburghPA15213USA
| | - Emma F. DiBernardo
- Department of Biological SciencesCarnegie Mellon University4400 Fifth AvenuePittsburghPA15213USA
| | - Karina Mueller Brown
- Department of Biological SciencesCarnegie Mellon University4400 Fifth AvenuePittsburghPA15213USA
| | - Tatyana Milman
- Wills Eye Hospital and Jefferson University HospitalPhiladelphiaPA19107USA
| | - Yuhong Wang
- Department of Biological SciencesCarnegie Mellon University4400 Fifth AvenuePittsburghPA15213USA
| | - Brendan R. Gallagher
- Department of Biological SciencesCarnegie Mellon University4400 Fifth AvenuePittsburghPA15213USA
| | - Katherine Lagree
- Department of Biological SciencesCarnegie Mellon University4400 Fifth AvenuePittsburghPA15213USA
| | - Bhanu P. Jena
- Viron Molecular Medicine Institute201 Washington StreetBostonMA02201USA
- Department of PhysiologyWayne State University42 W Warren AveDetroitMI48202USA
- NanoBioScience InstituteWayne State University42 W Warren AveDetroitMI48202USA
- Center for Molecular Medicine & GeneticsSchool of MedicineWayne State University42 W Warren AveDetroitMI48202USA
| | - Jose S. Pulido
- Wills Eye Hospital and Jefferson University HospitalPhiladelphiaPA19107USA
| | - Scott G. Filler
- Lundquist Institute for Biomedical Innovation at Harbor‐UCLA Medical Center1124 W Carson StTorranceCA90502USA
- David Geffen School of Medicine at UCLA10833 Le Conte AveLos AngelesCA90095USA
| | - Aaron P. Mitchell
- Department of Biological SciencesCarnegie Mellon University4400 Fifth AvenuePittsburghPA15213USA
- Department of MicrobiologyUniversity of Georgia210 S Jackson streetAthensGA30602USA
| | - N. Luisa Hiller
- Department of Biological SciencesCarnegie Mellon University4400 Fifth AvenuePittsburghPA15213USA
| | - Adam Lacy‐Hulbert
- Benaroya Research Institute at Virginia Mason1201 9th AveSeattleWA98101USA
| | - Yongxin Zhao
- Department of Biological SciencesCarnegie Mellon University4400 Fifth AvenuePittsburghPA15213USA
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12
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Sharma A, Mitchell AP. Strain variation in gene expression impact of hyphal cyclin Hgc1 in Candida albicans. G3 (Bethesda) 2023; 13:jkad151. [PMID: 37405402 PMCID: PMC10468301 DOI: 10.1093/g3journal/jkad151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/18/2023] [Accepted: 06/20/2023] [Indexed: 07/06/2023]
Abstract
Formation of hyphae is a key virulence trait of the fungal pathogen Candida albicans. Hypha morphogenesis depends upon the cyclin Hgc1, which acts together with cyclin-dependent protein kinase Cdc28 to phosphorylate effectors that drive polarized growth. Hgc1 has also been implicated in gene regulation through its effects on 2 transcription factors, Efg1 and Ume6. Here, we report RNA-sequencing (RNA-seq) analysis of 2 pairs of hgc1Δ/Δ mutants and their respective wild-type strains, which lie in 2 different genetic backgrounds. We find that hgc1Δ/Δ mutations alter expression of 271 genes in both genetic backgrounds and 266 of those genes respond consistently with regard to up- or down-regulation. Consistency is similar to what has been observed with efg1Δ/Δ mutations and greater than observed with nrg1Δ/Δ mutations in these 2 backgrounds. The gene expression response includes genes under Efg1 control, as expected from prior studies. Hgc1-responsive genes also include ergosterol biosynthetic genes and bud neck-related genes, which may reflect interactions between Hgc1 and additional transcription factors as well as effects of Hgc1 on cellular length-to-width ratios.
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Affiliation(s)
- Anupam Sharma
- Department of Microbiology, University of Georgia, Athens, GA 30602, USA
| | - Aaron P Mitchell
- Department of Microbiology, University of Georgia, Athens, GA 30602, USA
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Phan QT, Solis NV, Cravener MV, Swidergall M, Lin J, Huang MY, Liu H, Singh S, Ibrahim AS, Mazzone M, Mitchell AP, Filler SG. Candida albicans stimulates formation of a multi-receptor complex that mediates epithelial cell invasion during oropharyngeal infection. PLoS Pathog 2023; 19:e1011579. [PMID: 37611070 PMCID: PMC10479894 DOI: 10.1371/journal.ppat.1011579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 09/05/2023] [Accepted: 07/25/2023] [Indexed: 08/25/2023] Open
Abstract
Fungal invasion of the oral epithelium is central to the pathogenesis of oropharyngeal candidiasis (OPC). Candida albicans invades the oral epithelium by receptor-induced endocytosis but this process is incompletely understood. We found that C. albicans infection of oral epithelial cells induces c-Met to form a multi-protein complex with E-cadherin and the epidermal growth factor receptor (EGFR). E-cadherin is necessary for C. albicans to activate both c-Met and EGFR and to induce the endocytosis of C. albicans. Proteomics analysis revealed that c-Met interacts with C. albicans Hyr1, Als3 and Ssa1. Both Hyr1 and Als3 are required for C. albicans to stimulate c-Met and EGFR in oral epithelial cells in vitro and for full virulence during OPC in mice. Treating mice with small molecule inhibitors of c-Met and EGFR ameliorates OPC, demonstrating the potential therapeutic efficacy of blocking these host receptors for C. albicans.
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Affiliation(s)
- Quynh T. Phan
- Institute for Infection and Immunity, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Norma V. Solis
- Institute for Infection and Immunity, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Max V. Cravener
- Department of Microbiology, University of Georgia, Athens, Georgia United States of America
| | - Marc Swidergall
- Institute for Infection and Immunity, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Jianfeng Lin
- Institute for Infection and Immunity, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Manning Y. Huang
- Department of Biochemistry and Biophysics, University of California, San Francisco, California, United States of America
| | - Hong Liu
- Institute for Infection and Immunity, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Shakti Singh
- Institute for Infection and Immunity, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Ashraf S. Ibrahim
- Institute for Infection and Immunity, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Massimiliano Mazzone
- Laboratory of Tumor Inflammation and Angiogenesis, Center for Cancer Biology, VIB, Leuven, Belgium
- Laboratory of Tumor Inflammation and Angiogenesis, Center for Cancer Biology, Department of Oncology, KU Leuven, Leuven, Belgium
| | - Aaron P. Mitchell
- Department of Microbiology, University of Georgia, Athens, Georgia United States of America
| | - Scott G. Filler
- Institute for Infection and Immunity, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
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14
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Cheng Z, Stefani C, Skillman T, Klimas A, Lee A, DiBernardo EF, Brown KM, Milman T, Gallagher BR, Lagree K, Jena BP, Pulido J, Mitchell AP, Filler SG, Hiller L, Lacy-Hulbert A, Zhao Y. A New Expansion Microscopy Method Optimized for Microbiology. Microsc Microanal 2023; 29:994. [PMID: 37613535 DOI: 10.1093/micmic/ozad067.498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Affiliation(s)
- Zhangyu Cheng
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | | | | | - Aleksandra Klimas
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Aramchan Lee
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Emma F DiBernardo
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Karina M Brown
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Tatyana Milman
- Wills Eye Hospital and Jefferson University Hospital, Philadelphia, PA, USA
| | - Brendan R Gallagher
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Katherine Lagree
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Bhanu P Jena
- Viron Molecular Medicine Institute, Boston, MAUSA
- Department of Physiology, School of Medicine, Wayne State University, Detroit, MI, USA
- NanoBioScience Institute, School of Medicine, Wayne State University, Detroit, MI, USA
- Center for Molecular Medicine & Genetics, School of Medicine, Wayne State University, Detroit, MI, USA
| | - Jose Pulido
- Wills Eye Hospital and Jefferson University Hospital, Philadelphia, PA, USA
| | - Aaron P Mitchell
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
- Department of Microbiology, University of Georgia, Athens, Georgia, USA
| | - Scott G Filler
- Division of Infectious Diseases, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Luisa Hiller
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | | | - Yongxin Zhao
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
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15
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Serra-Burriel M, Perényi G, Laube Y, Mitchell AP, Vokinger KN. The cancer premium - explaining differences in prices for cancer vs non-cancer drugs with efficacy and epidemiological endpoints in the US, Germany, and Switzerland: a cross sectional study. EClinicalMedicine 2023; 61:102087. [PMID: 37521033 PMCID: PMC10371812 DOI: 10.1016/j.eclinm.2023.102087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 08/01/2023] Open
Abstract
Background High treatment prices of new cancer drugs are a global public health challenge to patients and healthcare systems. Policymakers in the US and Europe are debating reforms to drug pricing. The objective of this study was to assess whether drug efficacy or epidemiological characteristics (prevalence, incidence, mortality) explain the gap in treatment prices between cancer and non-cancer drugs in the US, Germany, and Switzerland. Methods This cross-sectional study identified all new drugs approved in the US, Germany, and Switzerland between 2011 and 2020. Drug efficacy was extracted from pivotal trials, drug prices from public and commercial databases, and epidemiological characteristics from the Global Burden of Disease (GBD) 2019 study. We used regression models to explain drug prices with drug efficacy and epidemiological characteristics (prevalence, incidence, mortality). Findings The cohort included 181 drugs, including 68 (37.5%) drugs approved for treatment of cancer. A significant negative correlation was found between incidence/prevalence and treatment prices, and a significant positive correlation was observed between mortality and treatment prices for both, cancer and non-cancer drugs. A significant association between relative drug efficacy and treatment prices of drugs was observed, however, less pronounced for cancer drugs. Our regression estimates indicated that after adjusting for efficacy and epidemiological characteristics, cancer drugs were on average approximately three times more expensive compared to non-cancer drugs in all three countries, indicating a cancer premium; i.e., treatment prices of cancer drugs were on average USD 74,412 (95% CI [62,810; 86,015]) more expensive in the US compared to non-cancer drugs, USD 37,770 (95% CI [26,175; 49,367]) more expensive in Germany, and USD 32,801 (95% CI [27,048; 38,555]) more expensive in Switzerland. Our model explained 72% of the variance in observed prices (R2). Interpretation Drug pricing reforms should target the cancer premium to improve access of patients to cancer drugs as well as to achieve equity across the different therapeutic areas and sustainability in the health care systems. Funding This study was funded by the Swiss National Science Foundation (SNSF, grant number PCEGP1_194607) and the Swiss Cancer Research Foundation (Krebsforschung Schweiz).
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Affiliation(s)
- Miquel Serra-Burriel
- Institute of Law, University of Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | | | - Yannic Laube
- Institute of Law, University of Zurich, Switzerland
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16
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Larcombe DE, Bohovych IM, Pradhan A, Ma Q, Hickey E, Leaves I, Cameron G, Avelar GM, de Assis LJ, Childers DS, Bain JM, Lagree K, Mitchell AP, Netea MG, Erwig LP, Gow NAR, Brown AJP. Glucose-enhanced oxidative stress resistance-A protective anticipatory response that enhances the fitness of Candida albicans during systemic infection. PLoS Pathog 2023; 19:e1011505. [PMID: 37428810 PMCID: PMC10358912 DOI: 10.1371/journal.ppat.1011505] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 07/20/2023] [Accepted: 06/22/2023] [Indexed: 07/12/2023] Open
Abstract
Most microbes have developed responses that protect them against stresses relevant to their niches. Some that inhabit reasonably predictable environments have evolved anticipatory responses that protect against impending stresses that are likely to be encountered in their niches-termed "adaptive prediction". Unlike yeasts such as Saccharomyces cerevisiae, Kluyveromyces lactis and Yarrowia lipolytica and other pathogenic Candida species we examined, the major fungal pathogen of humans, Candida albicans, activates an oxidative stress response following exposure to physiological glucose levels before an oxidative stress is even encountered. Why? Using competition assays with isogenic barcoded strains, we show that "glucose-enhanced oxidative stress resistance" phenotype enhances the fitness of C. albicans during neutrophil attack and during systemic infection in mice. This anticipatory response is dependent on glucose signalling rather than glucose metabolism. Our analysis of C. albicans signalling mutants reveals that the phenotype is not dependent on the sugar receptor repressor pathway, but is modulated by the glucose repression pathway and down-regulated by the cyclic AMP-protein kinase A pathway. Changes in catalase or glutathione levels do not correlate with the phenotype, but resistance to hydrogen peroxide is dependent on glucose-enhanced trehalose accumulation. The data suggest that the evolution of this anticipatory response has involved the recruitment of conserved signalling pathways and downstream cellular responses, and that this phenotype protects C. albicans from innate immune killing, thereby promoting the fitness of C. albicans in host niches.
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Affiliation(s)
- Daniel E. Larcombe
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
- Medical Research Council Centre for Medical Mycology, University of Exeter, School of Biosciences, Geoffrey Pope Building, Exeter, United Kingdom
| | - Iryna M. Bohovych
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Arnab Pradhan
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
- Medical Research Council Centre for Medical Mycology, University of Exeter, School of Biosciences, Geoffrey Pope Building, Exeter, United Kingdom
| | - Qinxi Ma
- Medical Research Council Centre for Medical Mycology, University of Exeter, School of Biosciences, Geoffrey Pope Building, Exeter, United Kingdom
| | - Emer Hickey
- Medical Research Council Centre for Medical Mycology, University of Exeter, School of Biosciences, Geoffrey Pope Building, Exeter, United Kingdom
| | - Ian Leaves
- Medical Research Council Centre for Medical Mycology, University of Exeter, School of Biosciences, Geoffrey Pope Building, Exeter, United Kingdom
| | - Gary Cameron
- Rowett Institute, School of Medicine Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Gabriela M. Avelar
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Leandro J. de Assis
- Medical Research Council Centre for Medical Mycology, University of Exeter, School of Biosciences, Geoffrey Pope Building, Exeter, United Kingdom
| | - Delma S. Childers
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Judith M. Bain
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Katherine Lagree
- Department of Microbiology, Biosciences Building, University of Georgia, Athens, Georgia, United States of America
| | - Aaron P. Mitchell
- Department of Microbiology, Biosciences Building, University of Georgia, Athens, Georgia, United States of America
| | - Mihai G. Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
- Department for Immunology & Metabolism, Life and Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Lars P. Erwig
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
- Johnson-Johnson Innovation, EMEA Innovation Centre, One Chapel Place, London, United Kingdom
| | - Neil A. R. Gow
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
- Medical Research Council Centre for Medical Mycology, University of Exeter, School of Biosciences, Geoffrey Pope Building, Exeter, United Kingdom
| | - Alistair J. P. Brown
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
- Medical Research Council Centre for Medical Mycology, University of Exeter, School of Biosciences, Geoffrey Pope Building, Exeter, United Kingdom
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17
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Mao Y, Solis NV, Filler SG, Mitchell AP. Functional Dichotomy for a Hyphal Repressor in Candida albicans. mBio 2023; 14:e0013423. [PMID: 36883818 PMCID: PMC10127614 DOI: 10.1128/mbio.00134-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 02/20/2023] [Indexed: 03/09/2023] Open
Abstract
Nrg1 is a repressor of hypha formation and hypha-associated gene expression in the fungal pathogen Candida albicans. It has been well studied in the genetic background of the type strain SC5314. Here, we tested Nrg1 function in four other diverse clinical isolates through an analysis of nrg1Δ/Δ mutants, with SC5314 included as a control. In three strains, nrg1Δ/Δ mutants unexpectedly produced aberrant hyphae under inducing conditions, as assayed by microscopic observation and endothelial cell damage. The nrg1Δ/Δ mutant of strain P57055 had the most severe defect. We examined gene expression features under hypha-inducing conditions by RNA-sequencing (RNA-Seq) for the SC5314 and P57055 backgrounds. The SC5314 nrg1Δ/Δ mutant expressed six hypha-associated genes at reduced levels compared with wild-type SC5314. The P57055 nrg1Δ/Δ mutant expressed 17 hypha-associated genes at reduced levels compared with wild-type P57055, including IRF1, RAS2, and ECE1. These findings indicate that Nrg1 has a positive role in hypha-associated gene expression and that this role is magnified in strain P57055. Remarkably, the same hypha-associated genes affected by the nrg1Δ/Δ mutation in strain P57055 were also naturally expressed at lower levels in wild-type P57055 than those in wild-type SC5314. Our results suggest that strain P57055 is defective in a pathway that acts in parallel with Nrg1 to upregulate the expression of several hypha-associated genes. IMPORTANCE Hypha formation is a central virulence trait of the fungal pathogen Candida albicans. Control of hypha formation has been studied in detail in the type strain but not in other diverse C. albicans clinical isolates. Here, we show that the hyphal repressor Nrg1 has an unexpected positive role in hypha formation and hypha-associated gene expression, as revealed by the sensitized P57055 strain background. Our findings indicate that reliance on a single type strain limits understanding of gene function and illustrate that strain diversity is a valuable resource for C. albicans molecular genetic analysis.
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Affiliation(s)
- Yinhe Mao
- Department of Microbiology, University of Georgia, Athens, Georgia, USA
| | - Norma V. Solis
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Scott G. Filler
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Aaron P. Mitchell
- Department of Microbiology, University of Georgia, Athens, Georgia, USA
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18
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Sharma A, Solis NV, Huang MY, Lanni F, Filler SG, Mitchell AP. Hgc1 Independence of Biofilm Hyphae in Candida albicans. mBio 2023; 14:e0349822. [PMID: 36779720 PMCID: PMC10128054 DOI: 10.1128/mbio.03498-22] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/25/2023] [Indexed: 02/14/2023] Open
Abstract
Biofilm and hypha formation are central to virulence of the fungal pathogen Candida albicans. The G1 cyclin gene HGC1 is required for hypha formation under diverse in vitro and in vivo growth conditions. Hgc1 is required for disseminated infection and is a linchpin in the argument that hyphal morphogenesis itself is required for pathogenicity. We report here that HGC1 is dispensable for hypha formation during biofilm formation both in vitro, under strong inducing conditions, and in vivo, in a mouse oropharyngeal candidiasis model. These findings are validated with two or more C. albicans isolates. Systematic screening of overexpressed cyclin genes indicates that CCN1 and CLN3 can compensate partially for Hgc1 function during biofilm growth. This conclusion is also supported by the severity of the hgc1Δ/Δ ccn1Δ/Δ double mutant biofilm defect. Our results suggest that hypha formation in biofilm is accomplished by combined action of multiple cyclins, not solely by Hgc1. IMPORTANCE The HGC1 gene encodes a cyclin that is required for virulence of the fungal pathogen Candida albicans. It is required to produce the elongated hyphal filaments of free-living planktonic cells that are associated with virulence. Here, we show that HGC1 is not required to produce hyphae in the alternative growth form of a biofilm community. We observe Hgc1-independent hyphae in two infection-relevant situations, biofilm growth in vitro and biofilm-like oropharyngeal infection. Our analysis suggests that hypha formation in the biofilm state reflects combined action of multiple cyclins.
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Affiliation(s)
- Anupam Sharma
- Department of Microbiology, University of Georgia, Athens, Georgia, USA
| | - Norma V. Solis
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Manning Y. Huang
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Frederick Lanni
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Scott G. Filler
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Aaron P. Mitchell
- Department of Microbiology, University of Georgia, Athens, Georgia, USA
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
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19
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Huang MY, Cravener MV, Mitchell AP. Correction: Targeted Genetic Changes in Candida albicans Using Transient CRISPR-Cas9 Expression. Curr Protoc 2023; 3:e715. [PMID: 36892302 DOI: 10.1002/cpz1.715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
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20
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Mitchell AP, Meza AM, Panageas KS, Lipitz-Snyderman A, Farooki A, Morris MJ. Real-world use of bone modifying agents in metastatic, castration-resistant prostate cancer. Prostate Cancer Prostatic Dis 2023; 26:126-132. [PMID: 35798857 PMCID: PMC10251421 DOI: 10.1038/s41391-022-00573-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Bone modifying agents (BMAs) prevent skeletal related events among patients with metastatic, castration-resistant prostate cancer (mCRPC) involving bone and prevent osteoporotic fractures among patients at high risk. BMA utilization for patients with mCRPC has not been well quantified. METHODS We used linked SEER registry and Medicare claims data. We included men diagnosed with stage IV prostate adenocarcinoma during 2007-2015, aged > = 66 at diagnosis, with sufficient continuous enrollment in Medicare Parts A, B, and D, who received androgen deprivation therapy. We limited to those who subsequently received a CRPC-defining treatment (CDT). We identified patients with evidence of bone metastasis using claims. Our primary outcome was receipt of a BMA (zoledronic acid or denosumab) within 180 days of initiating CDT. RESULTS Among 1292 included patients, 1034 (80%) had bone metastasis. BMA use within 180 days of initiating CDT was higher among patients with bone metastases than those without (705/1034 [68%] vs 56/258 [22%]). Among patients without bone metastasis, those with high osteoporotic fracture risk were more likely than those without to receive a BMA (OR = 2.48, 95% CI: 1.17, 5.29); however, only 26% of patients with high fracture risk received a BMA. Among patients who received BMAs, most (62%) first initiated them >90 days before initiating CDT. CONCLUSIONS Two-thirds of patients with mCRPC and bone metastases received BMAs within 180 days after initiating CDT. A greater proportion of patients without bone metastasis may warrant BMA therapy for osteoporotic fracture prevention. Some patients with bone metastasis may be able to delay BMA initiation until CRPC.
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Affiliation(s)
- Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Medicine and Division of Solid Tumor Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Akriti Mishra Meza
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katherine S Panageas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Allison Lipitz-Snyderman
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Azeez Farooki
- Department of Medicine and Division of Subspecialty Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael J Morris
- Department of Medicine and Division of Solid Tumor Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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21
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Phan QT, Solis NV, Cravener MV, Swidergall M, Lin J, Huang MY, Liu H, Singh S, Ibrahim AS, Mazzone M, Mitchell AP, Filler SG. Candida albicans stimulates the formation of a multi-receptor complex that mediates epithelial cell invasion during oropharyngeal infection. bioRxiv 2023:2023.02.23.529756. [PMID: 36865306 PMCID: PMC9980113 DOI: 10.1101/2023.02.23.529756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Fungal invasion of the oral epithelium is central to the pathogenesis of oropharyngeal candidiasis (OPC). Candida albicans invades the oral epithelium by receptor-induced endocytosis but this process is incompletely understood. We found that C. albicans infection of oral epithelial cells induces c-Met to form a multi-protein complex with E-cadherin and the epidermal growth factor receptor (EGFR). E-cadherin is necessary for C. albicans to activate both c-Met and EGFR and to induce the endocytosis of C. albicans . Proteomics analysis revealed that c-Met interacts with C. albicans Hyr1, Als3 and Ssa1. Both Hyr1 and Als3 were required for C. albicans stimulation of c-Met and EGFR in oral epithelial cells in vitro and for full virulence during OPC in mice. Treating mice with small molecule inhibitors of c-Met and EGFR ameliorated OPC, demonstrating the potential therapeutic efficacy of blocking these host receptors for C. albicans . Graphical abstract Highlights c-Met is an oral epithelial cell receptor for Candida albicans C. albicans infection causes c-Met and the epidermal growth factor receptor (EGFR) to form a complex with E-cadherin, which is required for c-Met and EGFR function C. albicans Hyr1 and Als3 interact with c-Met and EGFR, inducing oral epithelial cell endocytosis and virulence during oropharyngeal candidiasis Dual blockade of c-Met and EGFR ameliorates oropharyngeal candidiasis.
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Affiliation(s)
- Quynh T. Phan
- Institute for Infection and Immunity, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Norma V. Solis
- Institute for Infection and Immunity, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Max V. Cravener
- Department of Microbiology, University of Georgia, Athens, Georgia 30602, USA
| | - Marc Swidergall
- Institute for Infection and Immunity, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jianfeng Lin
- Institute for Infection and Immunity, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Manning Y. Huang
- Department of Biochemistry and Biophysics, University of California, San Francisco, CA, USA
| | - Hong Liu
- Institute for Infection and Immunity, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Shakti Singh
- Institute for Infection and Immunity, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Ashraf S. Ibrahim
- Institute for Infection and Immunity, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Massimiliano Mazzone
- 1Laboratory of Tumor Inflammation and Angiogenesis, Center for Cancer Biology, VIB, Leuven B3000, Belgium
- Laboratory of Tumor Inflammation and Angiogenesis, Center for Cancer Biology, Department of Oncology, KU Leuven, Leuven B3000, Belgium
| | - Aaron P. Mitchell
- Department of Microbiology, University of Georgia, Athens, Georgia 30602, USA
| | - Scott G. Filler
- Institute for Infection and Immunity, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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22
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Cravener MV, Do E, May G, Zarnowski R, Andes DR, McManus CJ, Mitchell AP. Reinforcement amid genetic diversity in the Candida albicans biofilm regulatory network. PLoS Pathog 2023; 19:e1011109. [PMID: 36696432 PMCID: PMC9901766 DOI: 10.1371/journal.ppat.1011109] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/06/2023] [Accepted: 01/09/2023] [Indexed: 01/26/2023] Open
Abstract
Biofilms of the fungal pathogen Candida albicans include abundant long filaments called hyphae. These cells express hypha-associated genes, which specify diverse virulence functions including surface adhesins that ensure biofilm integrity. Biofilm formation, virulence, and hypha-associated gene expression all depend upon the transcription factor Efg1. This transcription factor has been characterized extensively in the C. albicans type strain SC5314 and derivatives, but only recently has its function been explored in other clinical isolates. Here we define a principal set of Efg1-responsive genes whose expression is significantly altered by an efg1Δ/Δ mutation across 17 clinical isolates. This principal gene set includes 68 direct Efg1 targets, whose 5' regions are bound by Efg1 in five clinical isolates, and 42 indirect Efg1 targets, whose 5' regions are not detectably bound by Efg1. Three direct Efg1 target genes encode transcription factors-BRG1, UME6, and WOR3 -whose increased expression in an efg1Δ/Δ mutant restores expression of multiple indirect and direct principal targets, as well as biofilm formation ability. Although BRG1 and UME6 are well known positive regulators of hypha-associated genes and biofilm formation, WOR3 is best known as an antagonist of Efg1 in the sexual mating pathway. We confirm the positive role of WOR3 in biofilm formation with the finding that a wor3Δ/Δ mutation impairs biofilm formation in vitro and in an in vivo biofilm model. Positive control of Efg1 direct target genes by other Efg1 direct target genes-BRG1, UME6, and WOR3 -may buffer principal Efg1-responsive gene expression against the impact of genetic variation in the C. albicans species.
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Affiliation(s)
- Max V. Cravener
- Department of Microbiology, University of Georgia, Athens, Georgia, United States of America
| | - Eunsoo Do
- Department of Microbiology, University of Georgia, Athens, Georgia, United States of America
| | - Gemma May
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
| | - Robert Zarnowski
- Department of Medical Microbiology and Immunology, University of Wisconsin, Madison, Wisconsin, United States of America
| | - David R. Andes
- Department of Medical Microbiology and Immunology, University of Wisconsin, Madison, Wisconsin, United States of America
| | - C. Joel McManus
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
| | - Aaron P. Mitchell
- Department of Microbiology, University of Georgia, Athens, Georgia, United States of America
- * E-mail:
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23
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Mitchell AP, Goldstein DA. Cost Savings and Increased Access With Ultra-Low-Dose Immunotherapy. J Clin Oncol 2023; 41:170-172. [PMID: 36265102 PMCID: PMC9839306 DOI: 10.1200/jco.22.01711] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/03/2022] [Accepted: 08/12/2022] [Indexed: 01/19/2023] Open
Affiliation(s)
- Aaron P. Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel A. Goldstein
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Clalit Health Service, Tel Aviv-Yafo, Israel
- Optimal Cancer Care Alliance, Ann Arbor, MI
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24
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de Assis LJ, Bain JM, Liddle C, Leaves I, Hacker C, Peres da Silva R, Yuecel R, Bebes A, Stead D, Childers DS, Pradhan A, Mackenzie K, Lagree K, Larcombe DE, Ma Q, Avelar GM, Netea MG, Erwig LP, Mitchell AP, Brown GD, Gow NAR, Brown AJP. Nature of β-1,3-Glucan-Exposing Features on Candida albicans Cell Wall and Their Modulation. mBio 2022; 13:e0260522. [PMID: 36218369 PMCID: PMC9765427 DOI: 10.1128/mbio.02605-22] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 01/15/2023] Open
Abstract
Candida albicans exists as a commensal of mucosal surfaces and the gastrointestinal tract without causing pathology. However, this fungus is also a common cause of mucosal and systemic infections when antifungal immune defenses become compromised. The activation of antifungal host defenses depends on the recognition of fungal pathogen-associated molecular patterns (PAMPs), such as β-1,3-glucan. In C. albicans, most β-1,3-glucan is present in the inner cell wall, concealed by the outer mannan layer, but some β-1,3-glucan becomes exposed at the cell surface. In response to host signals, such as lactate, C. albicans induces the Xog1 exoglucanase, which shaves exposed β-1,3-glucan from the cell surface, thereby reducing phagocytic recognition. We show here that β-1,3-glucan is exposed at bud scars and punctate foci on the lateral wall of yeast cells, that this exposed β-1,3-glucan is targeted during phagocytic attack, and that lactate-induced masking reduces β-1,3-glucan exposure at bud scars and at punctate foci. β-1,3-Glucan masking depends upon protein kinase A (PKA) signaling. We reveal that inactivating PKA, or its conserved downstream effectors, Sin3 and Mig1/Mig2, affects the amounts of the Xog1 and Eng1 glucanases in the C. albicans secretome and modulates β-1,3-glucan exposure. Furthermore, perturbing PKA, Sin3, or Mig1/Mig2 attenuates the virulence of lactate-exposed C. albicans cells in Galleria. Taken together, the data are consistent with the idea that β-1,3-glucan masking contributes to Candida pathogenicity. IMPORTANCE Microbes that coexist with humans have evolved ways of avoiding or evading our immunological defenses. These include the masking by these microbes of their "pathogen-associated molecular patterns" (PAMPs), which are recognized as "foreign" and used to activate protective immunity. The commensal fungus Candida albicans masks the proinflammatory PAMP β-1,3-glucan, which is an essential component of its cell wall. Most of this β-1,3-glucan is hidden beneath an outer layer of the cell wall on these microbes, but some can become exposed at the fungal cell surface. Using high-resolution confocal microscopy, we examine the nature of the exposed β-1,3-glucan at C. albicans bud scars and at punctate foci on the lateral cell wall, and we show that these features are targeted by innate immune cells. We also reveal that downstream effectors of protein kinase A (Mig1/Mig2, Sin3) regulate the secretion of major glucanases, modulate the levels of β-1,3-glucan exposure, and influence the virulence of C. albicans in an invertebrate model of systemic infection. Our data support the view that β-1,3-glucan masking contributes to immune evasion and the virulence of a major fungal pathogen of humans.
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Affiliation(s)
- Leandro José de Assis
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Judith M. Bain
- Aberdeen Fungal Group, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Corin Liddle
- Bioimaging Unit, University of Exeter, Exeter, United Kingdom
| | - Ian Leaves
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | | | - Roberta Peres da Silva
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Raif Yuecel
- Exeter Centre for Cytomics, University of Exeter, Exeter, United Kingdom
| | - Attila Bebes
- Exeter Centre for Cytomics, University of Exeter, Exeter, United Kingdom
| | - David Stead
- Aberdeen Proteomics Facility, Rowett Institute, University of Aberdeen, Aberdeen, United Kingdom
| | - Delma S. Childers
- Aberdeen Fungal Group, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Arnab Pradhan
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Kevin Mackenzie
- Aberdeen Fungal Group, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Katherine Lagree
- Department of Microbiology, University of Georgia, Athens, Georgia, USA
| | - Daniel E. Larcombe
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Qinxi Ma
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Gabriela Mol Avelar
- Aberdeen Fungal Group, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Mihai G. Netea
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
- Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
- Department for Immunology & Metabolism, Life and Medical Sciences Institute (LIMES), University of Bonn, Bonn, Germany
| | - Lars P. Erwig
- Aberdeen Fungal Group, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
- Johnson-Johnson Innovation, EMEA Innovation Centre, London, United Kingdom
| | - Aaron P. Mitchell
- Department of Microbiology, University of Georgia, Athens, Georgia, USA
| | - Gordon D. Brown
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Neil A. R. Gow
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Alistair J. P. Brown
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
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25
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Case NT, Berman J, Blehert DS, Cramer RA, Cuomo C, Currie CR, Ene IV, Fisher MC, Fritz-Laylin LK, Gerstein AC, Glass NL, Gow NAR, Gurr SJ, Hittinger CT, Hohl TM, Iliev ID, James TY, Jin H, Klein BS, Kronstad JW, Lorch JM, McGovern V, Mitchell AP, Segre JA, Shapiro RS, Sheppard DC, Sil A, Stajich JE, Stukenbrock EE, Taylor JW, Thompson D, Wright GD, Heitman J, Cowen LE. The future of fungi: threats and opportunities. G3 (Bethesda) 2022; 12:jkac224. [PMID: 36179219 PMCID: PMC9635647 DOI: 10.1093/g3journal/jkac224] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/12/2022] [Indexed: 01/13/2023]
Abstract
The fungal kingdom represents an extraordinary diversity of organisms with profound impacts across animal, plant, and ecosystem health. Fungi simultaneously support life, by forming beneficial symbioses with plants and producing life-saving medicines, and bring death, by causing devastating diseases in humans, plants, and animals. With climate change, increased antimicrobial resistance, global trade, environmental degradation, and novel viruses altering the impact of fungi on health and disease, developing new approaches is now more crucial than ever to combat the threats posed by fungi and to harness their extraordinary potential for applications in human health, food supply, and environmental remediation. To address this aim, the Canadian Institute for Advanced Research (CIFAR) and the Burroughs Wellcome Fund convened a workshop to unite leading experts on fungal biology from academia and industry to strategize innovative solutions to global challenges and fungal threats. This report provides recommendations to accelerate fungal research and highlights the major research advances and ideas discussed at the meeting pertaining to 5 major topics: (1) Connections between fungi and climate change and ways to avert climate catastrophe; (2) Fungal threats to humans and ways to mitigate them; (3) Fungal threats to agriculture and food security and approaches to ensure a robust global food supply; (4) Fungal threats to animals and approaches to avoid species collapse and extinction; and (5) Opportunities presented by the fungal kingdom, including novel medicines and enzymes.
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Affiliation(s)
- Nicola T Case
- Department of Molecular Genetics, University of Toronto, Toronto, ON M5G 1M1, Canada
| | - Judith Berman
- Shmunis School of Biomedical and Cancer Research, The George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv 69978, Israel
| | - David S Blehert
- U.S. Geological Survey, National Wildlife Health Center, Madison, WI 53711, USA
| | - Robert A Cramer
- Department of Microbiology & Immunology, Geisel School of Medicine at Dartmouth, Hanover, NH 03755, USA
| | - Christina Cuomo
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Cameron R Currie
- Department of Bacteriology, University of Wisconsin-Madison, Madison, WI 53706, USA
| | - Iuliana V Ene
- Department of Mycology, Institut Pasteur, Université de Paris, Paris 75015, France
| | - Matthew C Fisher
- MRC Centre for Global Infectious Disease Analysis, Imperial College, London W2 1PG, UK
| | | | - Aleeza C Gerstein
- Department of Microbiology and Department of Statistics, University of Manitoba, Winnipeg, MB R3T 2N2, Canada
| | - N Louise Glass
- Plant and Microbial Biology Department, University of California, Berkeley, CA 94720, USA
| | - Neil A R Gow
- Department of Biosciences, University of Exeter, Exeter EX4 4QD, UK
| | - Sarah J Gurr
- Department of Biosciences, University of Exeter, Exeter EX4 4QD, UK
| | - Chris Todd Hittinger
- Laboratory of Genetics, Center for Genomic Science Innovation, J.F. Crow Institute for the Study of Evolution, DOE Great Lakes Bioenergy Research Center, Wisconsin Energy Institute, University of Wisconsin-Madison, Madison, WI 53726, USA
| | - Tobias M Hohl
- Infectious Disease Service, Department of Medicine, and Immunology Program, Sloan Kettering Institute, New York, NY 10065, USA
| | - Iliyan D Iliev
- Department of Microbiology and Immunology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Timothy Y James
- Department of Ecology and Evolutionary Biology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Hailing Jin
- Department of Microbiology and Plant Pathology, Center for Plant Cell Biology, Institute for Integrative Genome Biology, University of California—Riverside, Riverside, CA 92507, USA
| | - Bruce S Klein
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin—Madison, Madison, WI 53706, USA
- Department of Internal Medicine, School of Medicine and Public Health, University of Wisconsin—Madison, Madison, WI 53706, USA
- Department of Medical Microbiology and Immunology, School of Medicine and Public Health, University of Wisconsin—Madison, Madison, WI 53706, USA
| | - James W Kronstad
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
| | - Jeffrey M Lorch
- U.S. Geological Survey, National Wildlife Health Center, Madison, WI 53711, USA
| | | | - Aaron P Mitchell
- Department of Microbiology, University of Georgia, Athens, GA 30602, USA
| | - Julia A Segre
- Microbial Genomics Section, Translational and Functional Genomics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Rebecca S Shapiro
- Department of Molecular and Cellular Biology, University of Guelph, Guelph, ON N1G 2W1, Canada
| | - Donald C Sheppard
- McGill Interdisciplinary Initiative in Infection and Immunology, Departments of Medicine, Microbiology & Immunology, McGill University, Montreal, QC H3A 0G4, Canada
| | - Anita Sil
- Department of Microbiology and Immunology, University of California, San Francisco, San Francisco, CA 94117, USA
| | - Jason E Stajich
- Department of Microbiology and Plant Pathology, Center for Plant Cell Biology, Institute for Integrative Genome Biology, University of California—Riverside, Riverside, CA 92507, USA
| | - Eva E Stukenbrock
- Max Planck Fellow Group Environmental Genomics, Max Planck Institute for Evolutionary Biology, Plön 24306, Germany
- Environmental Genomics, Christian-Albrechts University, Kiel 24118, Germany
| | - John W Taylor
- Department of Plant and Microbial Biology, University of California—Berkeley, Berkeley, CA 94720, USA
| | | | - Gerard D Wright
- M.G. DeGroote Institute for Infectious Disease Research, Department of Biochemistry and Biomedical Sciences, DeGroote School of Medicine, McMaster University, Hamilton, ON L8N 3Z5, Canada
| | - Joseph Heitman
- Department of Molecular Genetics and Microbiology, Medicine, and Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC 27710, USA
| | - Leah E Cowen
- Department of Molecular Genetics, University of Toronto, Toronto, ON M5G 1M1, Canada
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26
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Mitchell AP, Mishra Meza A, Trivedi NU, Bach PB, Gönen M. Physician Payments from Pharmaceutical Companies Related to Cancer Drugs. Oncologist 2022; 27:857-863. [PMID: 35946837 PMCID: PMC9526499 DOI: 10.1093/oncolo/oyac160] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 07/01/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Drug manufacturers claim that the purpose of financial payments to physicians is to facilitate education about new drugs. This claim suggests 2 testable hypotheses: payments should not be associated with drug revenue and payments for each drug should decline over time as physicians become educated. MATERIALS AND METHODS We used open payments data on industry payments. We included payments for cancer drugs without generic/biosimilar competitors and used federal data sources to measure Medicare spending (a proxy for overall drug revenue) and a number of prescribers. We used generalized estimating equations (GEE) to model the drug-level association between industry payments and Medicare spending. Separately, we used GEE to estimate the change in payments with respect to the duration of time since initial FDA approval. RESULTS The sample included 89 drugs and 361 drug-year observations. The total value of industry payments for oncology drugs increased, from $53 333 854 in 2014 to $90 343 731 in 2018. There was no association between log-transformed mean, per-physician industry payments, and per-physician Medicare spending (estimate -0.001, 95%CI, -0.005 to 0.004). Payments for individual drugs decreased over time; estimated payments in the subsequent year for a drug with mean, per-physician payments of $1000 in the index year was: $681* for drugs 0-4 years since approval, $825 for 5-9 years, and $679* for ≥10 years (*P < .05). CONCLUSIONS Although industry-sponsored education may also serve marketing purposes, the absence of association between industry payments and Medicare spending and the decline in payments subsequent to approval are consistent with claims that industry payments function to facilitate physician education.
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Affiliation(s)
- Aaron P Mitchell
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Akriti Mishra Meza
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Mithat Gönen
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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27
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Mao Y, Solis NV, Sharma A, Cravener MV, Filler SG, Mitchell AP. Use of the Iron-Responsive RBT5 Promoter for Regulated Expression in Candida albicans. mSphere 2022; 7:e0030522. [PMID: 35862800 PMCID: PMC9429880 DOI: 10.1128/msphere.00305-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/03/2022] [Indexed: 11/20/2022] Open
Abstract
Engineered conditional gene expression is used in appraisal of gene function and pathway relationships. For pathogens like the fungus Candida albicans, conditional expression systems are most useful if they are active in the infection environment and if they can be utilized in multiple clinical isolates. Here, we describe such a system. It employs the RBT5 promoter and can be implemented with a few PCRs. We validated the system with RBT5 promoter fusions to two genes that promote filamentation and polarized growth, UME6 and HGC1, and with efg1Δ/Δ mutants, which are defective in an activator of filamentous growth. An RBT5 promoter fusion to either gene enabled filamentous growth of an efg1Δ/Δ mutant of strain SC5314 in iron-limited media, including RPMI with serum and yeast extract-peptone-dextrose with bathophenanthrolinedisulfonic acid. The RBT5-UME6 fusion promoted filamentation of efg1Δ/Δ mutants in RPMI with serum of four other clinical C. albicans isolates as well. In a mouse model of disseminated candidiasis, the RBT5-UME6 fusion promoted filamentation of the SC5314 efg1Δ/Δ mutant in kidney tissue, an indication that the RBT5 promoter is active in the iron-limited host environment. The RBT5 promoter expands the conditional expression toolkit for C. albicans genetics. IMPORTANCE Genetic strategies have been vital for mechanistic analysis of biological processes. Here, we describe a genetic tool for the fungal pathogen Candida albicans.
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Affiliation(s)
- Yinhe Mao
- Department of Microbiology, University of Georgia, Athens, Georgia, USA
| | - Norma V. Solis
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Anupam Sharma
- Department of Microbiology, University of Georgia, Athens, Georgia, USA
| | - Max V. Cravener
- Department of Microbiology, University of Georgia, Athens, Georgia, USA
| | - Scott G. Filler
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Aaron P. Mitchell
- Department of Microbiology, University of Georgia, Athens, Georgia, USA
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28
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Phan QT, Solis NV, Lin J, Swidergall M, Singh S, Liu H, Sheppard DC, Ibrahim AS, Mitchell AP, Filler SG. Serum bridging molecules drive candidal invasion of human but not mouse endothelial cells. PLoS Pathog 2022; 18:e1010681. [PMID: 35797411 PMCID: PMC9295963 DOI: 10.1371/journal.ppat.1010681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/19/2022] [Accepted: 06/15/2022] [Indexed: 11/19/2022] Open
Abstract
During hematogenously disseminated candidiasis, blood borne fungi must invade the endothelial cells that line the blood vessels to infect the deep tissues. Although Candida albicans, which forms hyphae, readily invades endothelial cells, other medically important species of Candida are poorly invasive in standard in vitro assays and have low virulence in immunocompetent mouse models of disseminated infection. Here, we show that Candida glabrata, Candida tropicalis, Candida parapsilosis, and Candida krusei can bind to vitronectin and high molecular weight kininogen present in human serum. Acting as bridging molecules, vitronectin and kininogen bind to αv integrins and the globular C1q receptor (gC1qR), inducing human endothelial cells to endocytose the fungus. This mechanism of endothelial cell invasion is poorly supported by mouse endothelial cells but can be restored when mouse endothelial cells are engineered to express human gC1qR or αv integrin. Overall, these data indicate that bridging molecule-mediated endocytosis is a common pathogenic strategy used by many medically important Candida spp. to invade human vascular endothelial cells.
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Affiliation(s)
- Quynh T. Phan
- Institute for Infection and Immunity, Division of Infectious Diseases, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Norma V. Solis
- Institute for Infection and Immunity, Division of Infectious Diseases, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Jianfeng Lin
- Institute for Infection and Immunity, Division of Infectious Diseases, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Marc Swidergall
- Institute for Infection and Immunity, Division of Infectious Diseases, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
- David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Shakti Singh
- Institute for Infection and Immunity, Division of Infectious Diseases, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Hong Liu
- Institute for Infection and Immunity, Division of Infectious Diseases, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Donald C. Sheppard
- Department of Microbiology and Immunology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Ashraf S. Ibrahim
- Institute for Infection and Immunity, Division of Infectious Diseases, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
- David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Aaron P. Mitchell
- Department of Microbiology, University of Georgia, Athens, Georgia, United States of America
| | - Scott G. Filler
- Institute for Infection and Immunity, Division of Infectious Diseases, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
- David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- * E-mail:
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29
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Abstract
BACKGROUND The Prescription Drug User Fee Act (PDUFA) is due for reauthorization in 2022. Beyond creating the user fee program which now generates a majority of the Food and Drug Administration (FDA) Human Drugs Program budget, PDUFA has made numerous additional changes to FDA policy during its 29-year history. FDA's budgetary dependence on user fees may advantage the industry in negotiating favorable policy changes through PDUFA. METHODS The full texts of all prior PDUFA reauthorization bills and all submitted public comments and meeting minutes for the 2022 reauthorization were reviewed. Provisions affecting FDA regulatory authority and processes were identified. FINDINGS PDUFA legislation has instituted a broad range of changes to FDA policy, including evidentiary standards for drug approval, accelerated pathways for approval, industry involvement in FDA decision-making, rules regarding industry information dissemination to providers, and market entry of generic drugs. Negotiations over the 2022 reauthorization suggest that industry priorities include increased application of real-world evidence, regulatory certainty, and increased communication between FDA and industry during the drug application process. CONCLUSIONS The need for PDUFA reauthorization every 5 years has created a recurring legislative vehicle through which far-ranging changes to FDA have been enacted, reshaping the agency's interactions and relationship with the regulated industry. The majority of policy changes enacted through PDUFA legislation have favored industry through decreasing regulatory standards, shortening approval times, and increasing industry involvement in FDA decision-making. FDA's budgetary dependence on the industry, the urgency of each PDUFA reauthorization's passage to maintain uninterrupted funding, and the industry's required participation in PDUFA negotiations may advantage the industry.
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Affiliation(s)
- Aaron P. Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Niti U. Trivedi
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter B. Bach
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
- Delfi Diagnostics, Baltimore, MD
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Affiliation(s)
- Aaron P. Mitchell
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY,Aaron P. Mitchell, MD, MPH, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Ave, New York, NY 10017; e-mail:
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Rahman MW, Trivedi NU, Bach PB, Mitchell AP. Increasing Financial Payments From Industry to Medical Oncologists in the United States, 2014-2017. J Natl Compr Canc Netw 2021; 20:jnccn20125. [PMID: 34965511 PMCID: PMC9309756 DOI: 10.6004/jnccn.2021.7024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 02/02/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Personal payments from the pharmaceutical industry to US physicians are common and are associated with changes in physicians' clinical practice and interpretation of clinical trial results. We assessed temporal trends in industry payments to oncologists, with particular emphasis on payments to authors of oncology clinical practice guideline and on payments related to immunotherapy drugs. METHODS We included US physicians with active National Plan and Provider Enumeration System records and demographic data available in the Centers for Medicare & Medicaid Services Physician Compare system who had a specialty type of medical oncology or general internal medicine. Medical oncologists serving on NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Panels were identified manually. Industry payments, and the subset associated with PD-1/PD-L1 drugs, were identified in Open Payments, the federal repository of all transactions of financial value from industry to physicians and teaching hospitals, from 2014 to 2017. RESULTS There were 13,087 medical oncologists and 85,640 internists who received payments. The mean, annual, per-physician value of payments to oncologists increased from $3,811 in 2014 to $5,854 in 2017, and from $444 to $450 for internists; the median payment increased from $152 to $199 for oncologists and remained at $0 for internists. Oncologists who served on NCCN Guidelines Panels received a greater value in payments and experienced a greater relative increase: mean payments increased from $10,820 in 2014 to $18,977 in 2017, and median payments increased from $500 to $1,366. Among companies marketing PD-1/PD-L1 drugs, mean annual per-oncologist payments associated with PD-1/PD-L1 drugs increased from $28 to $773. Total per-oncologist payments from companies marketing PD-1/PD-L1 drugs experienced a 165% increase from 2014 to 2017, compared with a 31% increase among similar companies not marketing PD-1/PD-L1 drugs. CONCLUSIONS Pharmaceutical industry payments increased for US oncologists from 2014 to 2017 more than for general internists. The increase was greater among oncologists contributing to clinical practice guidelines and among pharmaceutical companies marketing PD-1/PD-L1 drugs. The increasing flow of money from industry to US oncologists supports ongoing concern regarding commercial interests in guideline development and clinical decision-making.
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Affiliation(s)
- Mohammed W Rahman
- 1Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Niti U Trivedi
- 1Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter B Bach
- 1Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aaron P Mitchell
- 1Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
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Mitchell AP, Mishra A, Panageas KS, Lipitz-Snyderman A, Bach PB, Morris MJ. Real-World Use of Bone Modifying Agents in Metastatic Castration-Sensitive Prostate Cancer. J Natl Cancer Inst 2021; 114:419-426. [PMID: 34597380 DOI: 10.1093/jnci/djab196] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/10/2021] [Accepted: 09/24/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Bone modifying agent (BMA) therapy is recommended for metastatic castration-resistant prostate cancer (mCRPC) but not metastatic castration-sensitive prostate cancer (mCSPC). BMA treatment in mCSPC may therefore constitute overuse. METHODS In this retrospective cohort study using linked Surveillance, Epidemiology, and End Results-Medicare data, we included patients diagnosed with stage IV prostate adenocarcinoma from 2007-2015, who were age ≥66 years at diagnosis and received androgen deprivation or antiandrogen therapy. We excluded patients who had previously received BMAs or had existing osteoporosis, osteopenia, hypercalcemia, or prior bone fracture. The primary outcome was receipt of BMA (zoledronic acid or denosumab) within 180 days of diagnosis (emergence of CRPC within this time frame is unlikely). Secondary outcome was BMA within 90 days. Exposures of interest included practice location (physician office vs. hospital outpatient) and specialty (medical oncologist vs. urologist) of treating physician. RESULTS Our sample included 2,627 patients, of which 52.9% were treated by medical oncologists and 47.1% by urologists; 77.7% and 22.3% received care in physician office and hospital outpatient locations, respectively. Overall, 23.6% received a BMA within 180 days; 18.4% did within 90 days. BMA therapy was more common among patients treated by oncologists (odds ratio = 8.23, 95% confidence interval = 6.41 to 10.57) and in physician office locations (odds ratio = 1.33, 95% confidence interval = 1.06 to 1.69). Utilization has increased: 17.3% of patients received BMAs from 2007-2009 (17.3% zoledronic acid, 0% denosumab), and 28.1% from 2012-2015 (8.4% zoledronic acid, 20.3% denosumab). CONCLUSIONS Among mCSPC patients who had no evidence of high osteoporotic fracture risk, over one-quarter received BMAs in recent years. This overuse may lead to excess costs and toxicity.
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Affiliation(s)
- Aaron P Mitchell
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics, New York, NY, USA.,Memorial Sloan Kettering Cancer Center, Department of Medicine, Division of Solid Tumor Oncology, New York, NY, USA
| | - Akriti Mishra
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics, New York, NY, USA
| | - Katherine S Panageas
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics, New York, NY, USA
| | - Allison Lipitz-Snyderman
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics, New York, NY, USA
| | - Peter B Bach
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics, New York, NY, USA
| | - Michael J Morris
- Memorial Sloan Kettering Cancer Center, Department of Medicine, Division of Solid Tumor Oncology, New York, NY, USA
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Mitchell AP, Mishra A, Dey P, Curry MA, Trivedi NU, Haddadin M, Rahman MW, Winn AN, Dusetzina SB, Bach PB. Personal Payments from Pharmaceutical Companies to Authors of Oncology Clinical Practice Guidelines. Oncologist 2021; 26:e1897. [PMID: 34546620 DOI: 10.1002/onco.13983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Mitchell AP, Mishra A, Dey P, Curry MA, Trivedi NU, Haddadin M, Rahman MW, Winn AN, Dusetzina SB, Bach PB. Personal Payments from Pharmaceutical Companies to Authors of Oncology Clinical Practice Guidelines. Oncologist 2021; 26:771-778. [PMID: 33982829 PMCID: PMC8417859 DOI: 10.1002/onco.13823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/30/2021] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Oncologists who author clinical practice guidelines frequently have financial relationships with the pharmaceutical industry. It is unknown whether participation on clinical practice guideline committees is associated with differences in the amounts of industry money received. MATERIALS AND METHODS We conducted a nested case-control study from August 2013 to December 2018. We manually abstracted membership records of National Comprehensive Cancer Network (NCCN) Guidelines committees for the 20 most common cancers and linked to Open Payments. The study sample included medical oncologists selected to join an NCCN Guidelines committee ("joiners") during the study period. Joiners were matched 1:2 to medical oncologists who had no participation on NCCN committees (controls) by gender, NCCN institution, and medical school graduation year. We performed difference-in-differences (DiD) estimation to assess whether selection to an NCCN committee was associated with the dollar value of payments received from industry, using generalized estimating equations to address correlation between matched pairs and between repeated observations of the same pair. RESULTS During the study period, 54 physicians joined an NCCN Guidelines committee. These physicians received more payments than matched controls in the year prior to joining ($11,259 vs. $3,427; p = .02); this difference did not increase in the year after joining (DiD = $731; p = .45). CONCLUSION Medical oncologists selected to NCCN Guidelines committees had greater financial ties to industry than their peers. The potential influence of industry in oncology clinical practice guidelines may be reduced through the selection of committee members with fewer ties to industry. IMPLICATIONS FOR PRACTICE Oncologists who author clinical practice guidelines frequently have financial conflicts of interest with the pharmaceutical industry. This creates concern about the potential for industry influence on guidelines. However, it is unknown whether oncologists who author guidelines have greater industry relationships than their peers. This study compared medical oncologists who were newly selected to join a National Comprehensive Cancer Network (NCCN) Guidelines panel with medical oncologists at the same institutions and at similar career stages. At the time they joined, oncologists joining NCCN Guidelines panels had received more than three times the dollar value of industry payments than their peers. The potential for industry influence may be reduced by the selection of less-conflicted panel members.
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Affiliation(s)
- Aaron P. Mitchell
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Akriti Mishra
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Pranam Dey
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Michael A. Curry
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Niti U. Trivedi
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Michael Haddadin
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
- University of Massachusetts Memorial Medical CenterWorcesterMassachusettsUSA
| | - Mohammed W. Rahman
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
- Hunter College, State University of New YorkNew YorkNew YorkUSA
| | - Aaron N. Winn
- Department of Clinical Sciences, School of Pharmacy, Medical College of WisconsinMilwaukeeWisconsinUSA
| | - Stacie B. Dusetzina
- Department of Health Policy, School of Medicine, Vanderbilt UniversityNashvilleTennesseeUSA
| | - Peter B. Bach
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
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Ichikawa Y, Bruno VM, Woolford CA, Kim H, Do E, Brewer GC, Mitchell AP. Environmentally contingent control of Candida albicans cell wall integrity by transcriptional regulator Cup9. Genetics 2021; 218:iyab075. [PMID: 33989396 PMCID: PMC8864738 DOI: 10.1093/genetics/iyab075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 05/07/2021] [Indexed: 11/14/2022] Open
Abstract
The fungal pathogen Candida albicans is surrounded by a cell wall that is the target of caspofungin and other echinocandin antifungals. Candida albicans can grow in several morphological forms, notably budding yeast and hyphae. Yeast and hyphal forms differ in cell wall composition, leading us to hypothesize that there may be distinct genes required for yeast and hyphal responses to caspofungin. Mutants in 27 genes reported previously to be caspofungin hypersensitive under yeast growth conditions were all caspofungin hypersensitive under hyphal growth conditions as well. However, a screen of mutants defective in transcription factor genes revealed that Cup9 is required for normal caspofungin tolerance under hyphal and not yeast growth conditions. In a hyphal-defective efg1Δ/Δ background, Cup9 is still required for normal caspofungin tolerance. This result argues that Cup9 function is related to growth conditions rather than cell morphology. RNA-seq conducted under hyphal growth conditions indicated that 361 genes were up-regulated and 145 genes were down-regulated in response to caspofungin treatment. Both classes of caspofungin-responsive genes were enriched for cell wall-related proteins, as expected for a response to disruption of cell wall integrity and biosynthesis. The cup9Δ/Δ mutant, treated with caspofungin, had reduced RNA levels of 40 caspofungin up-regulated genes, and had increased RNA levels of 8 caspofungin down-regulated genes, an indication that Cup9 has a narrow rather than global role in the cell wall integrity response. Five Cup9-activated surface-protein genes have roles in cell wall integrity, based on mutant analysis published previously (PGA31 and IFF11) or shown here (ORF19.3499, ORF19.851, or PGA28), and therefore may explain the hypersensitivity of the cup9Δ/Δmutant to caspofungin. Our findings define Cup9 as a new determinant of caspofungin susceptibility.
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Affiliation(s)
- Yuichi Ichikawa
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA 15213, USA
- Division of Cancer Biology, The Cancer Institute of JFCR, Koto-ku, Tokyo 135-8550, Japan
| | - Vincent M Bruno
- Department of Microbiology and Immunology and Institute of Genome Sciences, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Carol A Woolford
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA 15213, USA
| | - Hannah Kim
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA 15213, USA
- Institute for Genomics and Evolutionary Medicine, Temple University, Philadelphia, PA 19122, USA
| | - Eunsoo Do
- Department of Microbiology, University of Georgia, Athens, GA 30602, USA
| | - Grace C Brewer
- Department of Microbiology, University of Georgia, Athens, GA 30602, USA
| | - Aaron P Mitchell
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA 15213, USA
- Department of Microbiology, University of Georgia, Athens, GA 30602, USA
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Winn AN, Mitchell AP, Fergestrom N, Neuner JM, Trogdon JG. The Role of Physician Professional Networks in Physicians' Receipt of Pharmaceutical and Medical Device Industries' Payments. J Gen Intern Med 2021; 36:1858-1866. [PMID: 33904046 PMCID: PMC8298740 DOI: 10.1007/s11606-021-06802-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/03/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Financial relationships between physicians and the pharmaceutical and medical device industries are common, but the factors associated with physicians receiving payments are unknown. OBJECTIVE The objective of this study is to evaluate the influence of physicians' professional networks' characteristics on the receipt of payments among physicians. DESIGN Network analysis of cross-sectional data PARTICIPANTS: US physicians who shared Medicare patients with other physicians in 2015 (N=357,813). EXPOSURE (INTERVENTION) Proportion of a physician's professional network that received industry payments and other network characteristics including number of physician connections, how central the physician is within the network, and the tightness of the referral network in which a physician is located. MAIN OUTCOME MEASURES Relative risk of receiving industry payments. We used modified Poisson regression to control for confounding by gender, time since graduation, practice size, and practice setting (teaching hospital vs. not). We included dummy variables for specialty and hospital referral region level. KEY RESULTS The proportion of a physician's peers in their professional network that received payments was strongly associated with receipt of pharmaceutical or device industry payments by the physician (top vs bottom quartile aRR=1.28, 95%CI=1.25-1.31). Physician's centrality within a network had a small positive effect on receiving payment (top vs bottom quartile aRR=1.02, 95%CI=1.01-1.04). Network density also had a small negative association with receipt of payment (top vs bottom quartile aRR=0.97, 95%CI=0.96-0.98). CONCLUSIONS Network characteristics, particularly the receipt of payments among physicians one shares patients with, are associated with whether a physician receives payments. This finding has implications for institutional regulation of industry payments to physicians and demonstrates how institutional policy may impact not only the physicians within the institution but also physicians outside of the institution.
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Affiliation(s)
- Aaron N Winn
- Department of Clinical Sciences, Medical College of Wisconsin, School of Pharmacy, Milwaukee, WI, USA.
- Cancer Center, Medical College of Wisconsin, Milwaukee, WI, USA.
- Center for the Advancing Population Sciences, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nicole Fergestrom
- Center for the Advancing Population Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
- Section of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Joan M Neuner
- Cancer Center, Medical College of Wisconsin, Milwaukee, WI, USA
- Center for the Advancing Population Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
- Section of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Justin G Trogdon
- Gillings School of Global Public Health, Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
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Wakade RS, Huang M, Mitchell AP, Wellington M, Krysan DJ. Intravital Imaging of Candida albicans Identifies Differential In Vitro and In Vivo Filamentation Phenotypes for Transcription Factor Deletion Mutants. mSphere 2021; 6:e0043621. [PMID: 34160243 PMCID: PMC8265662 DOI: 10.1128/msphere.00436-21] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/07/2021] [Indexed: 01/12/2023] Open
Abstract
Candida albicans is an important cause of human fungal infections. A widely studied virulence trait of C. albicans is its ability to undergo filamentation to hyphae and pseudohyphae. Although yeast, pseudohyphae, and hyphae are present in pathological samples of infected mammalian tissue, it has been challenging to characterize the role of regulatory networks and specific genes during in vivo filamentation. In addition, the phenotypic heterogeneity of C. albicans clinical isolates is becoming increasingly recognized, while correlating this heterogeneity with pathogenesis remains an important goal. Here, we describe the use of an intravital imaging approach to characterize C. albicans filamentation in a mammalian model of infection by taking advantage of the translucence of mouse pinna (ears). Using this model, we have found that the in vitro and in vivo filamentation phenotypes of different C. albicans isolates can vary significantly, particularly when in vivo filamentation is compared to solid agar-based assays. We also show that the well-characterized transcriptional regulators Efg1 and Brg1 appear to play important roles both in vivo and in vitro. In contrast, Ume6 is much more important in vitro than in vivo. Finally, strains that are dependent on Bcr1 for in vitro filamentation are able to form filaments in vivo in its absence. This intravital imaging approach provides a new approach to the systematic characterization of this important virulence trait during mammalian infection. Our initial studies provide support for the notion that the regulation and initiation of C. albicans filamentation in vivo is distinct from in vitro induction. IMPORTANCE Candida albicans is one of the most common causes of fungal infections in humans. C. albicans undergoes a transition from a round yeast form to a filamentous form during infection, which is critical for its ability to cause disease. Although this transition has been studied in the laboratory for years, methods to do so in an animal model of infection have been limited. We have developed a microscopy method to visualize fluorescently labeled C. albicans undergoing this transition in the subcutaneous tissue of mice. Our studies indicate that the regulation of C. albicans filamentation during infection is distinct from that observed in laboratory conditions.
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Affiliation(s)
- Rohan S. Wakade
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Manning Huang
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Aaron P. Mitchell
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
- Department of Microbiology, University of Georgia, Athens, Georgia, USA
| | - Melanie Wellington
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Damian J. Krysan
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Department of Microbiology and Immunology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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Mitchell AP. Industry Payments to Rheumatologists Ought to be Going Down, Not Up. Arthritis Rheumatol 2021; 73:1951-1953. [PMID: 34164949 DOI: 10.1002/art.41898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/08/2021] [Indexed: 11/11/2022]
Abstract
In the current issue of Arthritis & Rheumatology, Putman et al report findings regarding the distribution and temporal trends of industry payments to US rheumatologists [cite ar-21-0182]. Their findings are in line with similar reports from other medical and surgical specialties, and highlight the overarching concern regarding the ability of industry payments to adversely affect care quality within the specific context of rheumatology practice.
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Affiliation(s)
- Aaron P Mitchell
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics.,Memorial Sloan Kettering Cancer Center, Department of Medicine, Division of Solid Tumor Oncology
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Liu H, Xu W, Bruno VM, Phan QT, Solis NV, Woolford CA, Ehrlich RL, Shetty AC, McCraken C, Lin J, Bromley MJ, Mitchell AP, Filler SG. Determining Aspergillus fumigatus transcription factor expression and function during invasion of the mammalian lung. PLoS Pathog 2021; 17:e1009235. [PMID: 33780518 PMCID: PMC8031882 DOI: 10.1371/journal.ppat.1009235] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/08/2021] [Accepted: 03/20/2021] [Indexed: 12/14/2022] Open
Abstract
To gain a better understanding of the transcriptional response of Aspergillus fumigatus during invasive pulmonary infection, we used a NanoString nCounter to assess the transcript levels of 467 A. fumigatus genes during growth in the lungs of immunosuppressed mice. These genes included ones known to respond to diverse environmental conditions and those encoding most transcription factors in the A. fumigatus genome. We found that invasive growth in vivo induces a unique transcriptional profile as the organism responds to nutrient limitation and attack by host phagocytes. This in vivo transcriptional response is largely mimicked by in vitro growth in Aspergillus minimal medium that is deficient in nitrogen, iron, and/or zinc. From the transcriptional profiling data, we selected 9 transcription factor genes that were either highly expressed or strongly up-regulated during in vivo growth. Deletion mutants were constructed for each of these genes and assessed for virulence in mice. Two transcription factor genes were found to be required for maximal virulence. One was rlmA, which is required for the organism to achieve maximal fungal burden in the lung. The other was sltA, which regulates of the expression of multiple secondary metabolite gene clusters and mycotoxin genes independently of laeA. Using deletion and overexpression mutants, we determined that the attenuated virulence of the ΔsltA mutant is due in part to decreased expression aspf1, which specifies a ribotoxin, but is not mediated by reduced expression of the fumigaclavine gene cluster or the fumagillin-pseruotin supercluster. Thus, in vivo transcriptional profiling focused on transcription factors genes provides a facile approach to identifying novel virulence regulators. Although A. fumigatus causes the majority of cases of invasive aspergillosis, the function of most genes in its genome remains unknown. To identify genes encoding transcription factors that may be important for virulence, we used a NanoString nCounter to measure the mRNA levels of A. fumigatus transcription factor genes in the lungs of mice with invasive aspergillosis. The transcriptional profiling data indicate that the organism is exposed to nutrient limitation and stress during growth in the lungs, and that it responds by up-regulating genes that encode mycotoxins and secondary metabolites. In vitro, this response was most closely mimicked by growth in medium that was deficient in nitrogen, iron and/or zinc. Using the transcriptional profiling data, we identified two transcription factors that govern A. fumigatus virulence. These were RlmA, which is governs factors that enables the organism to proliferate maximally in the lung and SltA, which controls the production of mycotoxins and secondary metabolites.
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Affiliation(s)
- Hong Liu
- Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, United States of America
| | - Wenjie Xu
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA, United States of America
| | - Vincent M. Bruno
- Department of Microbiology and Immunology, University of Maryland, Baltimore, MD, United States of America
| | - Quynh T. Phan
- Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, United States of America
| | - Norma V. Solis
- Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, United States of America
| | - Carol A. Woolford
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA, United States of America
| | - Rachel L. Ehrlich
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA, United States of America
| | - Amol C. Shetty
- Institute for Genome Sciences, University of Maryland, Baltimore, MD, United States of America
| | - Carrie McCraken
- Institute for Genome Sciences, University of Maryland, Baltimore, MD, United States of America
| | - Jianfeng Lin
- Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, United States of America
| | - Michael J. Bromley
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Core Technology Facility, and Lydia Becker Institute of Immunology and Inflammation, Biology, Medicine and Health. The University of Manchester, Manchester Academic Health Science Centre, MA, United Kingdom
| | - Aaron P. Mitchell
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA, United States of America
- Department of Microbiology, University of Georgia, Athens, GA, United States of America
- * E-mail: (APM); (SGF)
| | - Scott G. Filler
- Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, United States of America
- David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
- * E-mail: (APM); (SGF)
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Mitchell AP, Trivedi NU, Gennarelli RL, Chimonas S, Tabatabai SM, Goldberg J, Diaz LA, Korenstein D. Are Financial Payments From the Pharmaceutical Industry Associated With Physician Prescribing? : A Systematic Review. Ann Intern Med 2021; 174:353-361. [PMID: 33226858 PMCID: PMC8315858 DOI: 10.7326/m20-5665] [Citation(s) in RCA: 104] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Financial payments from the drug industry to U.S. physicians are common. Payments may influence physicians' clinical decision making and drug prescribing. PURPOSE To evaluate whether receipt of payments from the drug industry is associated with physician prescribing practices. DATA SOURCES MEDLINE (Ovid), Embase, the Cochrane Library, Web of Science, and EconLit were searched without language restrictions. The search had no limiting start date and concluded on 16 September 2020. STUDY SELECTION Studies that estimated the association between receipt of industry payments (exposure) and prescribing (outcome). DATA EXTRACTION Pairs of reviewers extracted the primary analysis or analyses from each study and evaluated risk of bias (ROB). DATA SYNTHESIS Thirty-six studies comprising 101 analyses were included. Most studies (n = 30) identified a positive association between payments and prescribing in all analyses; the remainder (n = 6) had a mix of positive and null findings. No study had only null findings. Of 101 individual analyses, 89 identified a positive association. Payments were associated with increased prescribing of the paying company's drug, increased prescribing costs, and increased prescribing of branded drugs. Nine studies assessed and found evidence of a temporal association; 25 assessed and found evidence of a dose-response relationship. LIMITATION The design was observational, 21 of 36 studies had serious ROB, and publication bias was possible. CONCLUSION The association between industry payments and physician prescribing was consistent across all studies that have evaluated this association. Findings regarding a temporal association and dose-response suggest a causal relationship. PRIMARY FUNDING SOURCE National Cancer Institute.
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Affiliation(s)
- Aaron P. Mitchell
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Niti U. Trivedi
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Renee L. Gennarelli
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Susan Chimonas
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sara M. Tabatabai
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Johanna Goldberg
- Medical Library, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Luis A. Diaz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Deborah Korenstein
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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Tringale KR, Gennarelli RL, Gillespie EF, Mitchell AP, Zelefsky MJ. Association between Site-of-Care and the Cost and Modality of Radiotherapy for Prostate Cancer: Analysis of Medicare Beneficiaries from 2015 to 2017. Cancer Invest 2021; 39:144-152. [PMID: 33416007 PMCID: PMC8285070 DOI: 10.1080/07357907.2020.1865396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 12/13/2020] [Indexed: 10/22/2022]
Abstract
Among 84,447 radiotherapy (RT) courses for Medicare beneficiaries age ≥ 65 with prostate cancer treated with external beam RT (EBRT), brachytherapy, or both, 42,608 (51%) were delivered in hospital-affiliated and 41,695 (49%) in freestanding facilities. Freestanding centers were less likely to use EBRT + brachytherapy than EBRT (OR 0.84 [95%CI 0.84-0.84]; p < .001). Treatment was more costly in freestanding centers (mean difference $2,597 [95%CI $2,475-2,719]; p < .001). Adjusting for modality and fractionation, RT in hospital-affiliated centers was more costly (mean difference $773 [95%CI $693-853]; p < .001). Freestanding centers utilized more expensive RT delivery, but factors unrelated to RT modality or fractionation rendered RT more costly at hospital-affiliated centers.
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Affiliation(s)
- Kathryn R Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Renee L Gennarelli
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Erin F Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michael J Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Swidergall M, Solis NV, Millet N, Huang MY, Lin J, Phan QT, Lazarus MD, Wang Z, Yeaman MR, Mitchell AP, Filler SG. Activation of EphA2-EGFR signaling in oral epithelial cells by Candida albicans virulence factors. PLoS Pathog 2021; 17:e1009221. [PMID: 33471869 PMCID: PMC7850503 DOI: 10.1371/journal.ppat.1009221] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 02/01/2021] [Accepted: 12/05/2020] [Indexed: 12/12/2022] Open
Abstract
During oropharyngeal candidiasis (OPC), Candida albicans invades and damages oral epithelial cells, which respond by producing proinflammatory mediators that recruit phagocytes to foci of infection. The ephrin type-A receptor 2 (EphA2) detects β-glucan and plays a central role in stimulating epithelial cells to release proinflammatory mediators during OPC. The epidermal growth factor receptor (EGFR) also interacts with C. albicans and is known to be activated by the Als3 adhesin/invasin and the candidalysin pore-forming toxin. Here, we investigated the interactions among EphA2, EGFR, Als3 and candidalysin during OPC. We found that EGFR and EphA2 constitutively associate with each other as part of a heteromeric physical complex and are mutually dependent for C. albicans-induced activation. Als3-mediated endocytosis of a C. albicans hypha leads to the formation of an endocytic vacuole where candidalysin accumulates at high concentration. Thus, Als3 potentiates targeting of candidalysin, and both Als3 and candidalysin are required for C. albicans to cause maximal damage to oral epithelial cells, sustain activation of EphA2 and EGFR, and stimulate pro-inflammatory cytokine and chemokine secretion. In the mouse model of OPC, C. albicans-induced production of CXCL1/KC and CCL20 is dependent on the presence of candidalysin and EGFR, but independent of Als3. The production of IL-1α and IL-17A also requires candidalysin but is independent of Als3 and EGFR. The production of TNFα requires Als1, Als3, and candidalysin. Collectively, these results delineate the complex interplay among host cell receptors EphA2 and EGFR and C. albicans virulence factors Als1, Als3 and candidalysin during the induction of OPC and the resulting oral inflammatory response. Oropharyngeal candidiasis occurs when the fungus Candida albicans proliferates in the mouth to a point at which tissue damage occurs. The disease is characterized by fungal invasion of the superficial epithelium and a localized inflammatory response. Two C. albicans virulence factors contribute to the pathogenesis of OPC, Als3 which enables the organism to adhere to and invade host cells, and candidalysin which is a pore-forming toxin that damages host cells. Two epithelial cell receptors, ephrin type-A receptor 2 (EphA2) and the epidermal growth factor receptor (EGFR) are activated by C. albicans. Here, we show that EphA2 and EGFR form part of complex wherein these co-receptors are required to activate each other. Als3 enhances the host cell targeting of candidalysin by stimulating epithelial cell endocytosis of C. albicans, leading to the formation of an endocytic vacuole in which candidalysin accumulates. Thus, Als3 and candidalysin synergize to damage epithelial cells, activate EphA2 and EGFR, and stimulate the production of inflammatory mediators. In the mouse model of OPC, candidalysin elicits of a subset of the oral inflammatory response molecular repertoire. Of the cytokines and chemokines induced by this toxin, some require the activation of EGFR while others are induced independently of EGFR. Collectively, this work provides a deeper understanding of the interactions among C. albicans virulence factors, host cell receptors and immune responses during OPC.
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Affiliation(s)
- Marc Swidergall
- Division of Infectious Diseases, Harbor-UCLA Medical Center, Torrance, California, United States of America
- Institute for Infection and Immunity, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
- David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- * E-mail: (MS); (SGF)
| | - Norma V. Solis
- Division of Infectious Diseases, Harbor-UCLA Medical Center, Torrance, California, United States of America
- Institute for Infection and Immunity, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Nicolas Millet
- Division of Infectious Diseases, Harbor-UCLA Medical Center, Torrance, California, United States of America
- Institute for Infection and Immunity, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Manning Y. Huang
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
| | - Jianfeng Lin
- Division of Infectious Diseases, Harbor-UCLA Medical Center, Torrance, California, United States of America
- Institute for Infection and Immunity, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Quynh T. Phan
- Division of Infectious Diseases, Harbor-UCLA Medical Center, Torrance, California, United States of America
- Institute for Infection and Immunity, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Michael D. Lazarus
- Division of Infectious Diseases, Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Zeping Wang
- Division of Infectious Diseases, Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Michael R. Yeaman
- Division of Infectious Diseases, Harbor-UCLA Medical Center, Torrance, California, United States of America
- Institute for Infection and Immunity, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
- David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- Division of Molecular Medicine, Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Aaron P. Mitchell
- Department of Microbiology, University of Georgia, Athens, Georgia, United States of America
| | - Scott G. Filler
- Division of Infectious Diseases, Harbor-UCLA Medical Center, Torrance, California, United States of America
- Institute for Infection and Immunity, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, United States of America
- David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- * E-mail: (MS); (SGF)
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Abstract
Candida albicans is an opportunistic fungal pathogen responsible for significant disease and mortality. Absent complete mating and other convenient methods, dissection of its virulence factors relies on robust tools to delete, complement, and otherwise modify genes of interest in this diploid organism. Here we describe the design principles and use of CRISPR associated nuclease 9 (Cas9) and single-guide RNAs transiently expressed from PCR cassettes to modify genes of interest, generating homozygous mutants in a single transformation step. © 2021 Wiley Periodicals LLC. Basic Protocol 1: PCR amplification of CRISPR components Basic Protocol 2: Transformation of Candida albicans Basic Protocol 3: Selecting and genotyping transformants Alternate Protocol 1: Deletion with recyclable markers by CRISPR induced marker excision (CRIME) Alternate Protocol 2: Knock-in and combining multiple cassettes with overlapping homology.
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Affiliation(s)
- Manning Y. Huang
- Department of Biochemistry and Biophysics, University of
California San Francisco School of Medicine, San Francisco, California 94518,
USA
| | - Max C. Cravener
- Department of Microbiology, University of Georgia, Athens,
Georgia 30602, USA
| | - Aaron P. Mitchell
- Department of Microbiology, University of Georgia, Athens,
Georgia 30602, USA
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Mitchell AP, Bach PB. Use of Positron Emission Tomography Imaging: Another Nonbiological Source of Racial Disparities in US Cancer Care. J Natl Cancer Inst 2020; 112:1177-1178. [PMID: 32134467 DOI: 10.1093/jnci/djaa035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 02/28/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter B Bach
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Cravener MV, Mitchell AP. Candida albicans Culture, Cell Harvesting, and Total RNA Extraction. Bio Protoc 2020; 10:e3803. [PMID: 33659457 DOI: 10.21769/bioprotoc.3803] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/22/2020] [Accepted: 09/25/2020] [Indexed: 01/04/2023] Open
Abstract
Transcriptional analysis has become a cornerstone of biological research, and with the advent of cheaper and more efficient sequencing technology over the last decade, there exists a need for high-yield and efficient RNA extraction techniques. Fungi such as the human pathogen Candida albicans present a unique obstacle to RNA purification in the form of the tough cell wall made up of many different components such as chitin that are resistant to many common mammalian or bacterial cell lysis methods. Typical in vitro C. albicans cell harvesting methods can be time consuming and expensive if many samples are being processed with multiple opportunities for product loss or sample variation. Harvesting cells via vacuum filtration rather than centrifugation cuts down on time before the cells are frozen and therefore the available time for the RNA expression profile to change. Vacuum filtration is preferred for C. albicans for two main reasons: cell lysis is faster on non-pelleted cells due to increased exposed surface area, and filamentous cells are difficult to pellet in the first place unlike yeast or bacterial cells. Using mechanical cell lysis, by way of zirconia/silica beads, cuts down on time for processing as well as overall cost compared to enzymatic treatments. Overall, this method is a fast, efficient, and high-yield way to extract total RNA from in vitro cultures of C. albicans.
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Affiliation(s)
- Max V Cravener
- Department of Microbiology, University of Georgia, Athens, USA
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Mitchell AP, Tabatabai SM, Dey P, Ohn JA, Curry MA, Bach PB. Association Between Clinical Value and Financial Cost of Cancer Treatments: A Cross-Sectional Analysis. J Natl Compr Canc Netw 2020; 18:1349-1353. [PMID: 33022648 DOI: 10.6004/jnccn.2020.7574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 04/06/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND The cost of cancer treatment has increased significantly in recent decades, but it is unclear whether these costs have been associated with commensurate improvement in clinical value. This study aimed to assess the association between the cost of cancer treatment and 4 of the 5 NCCN Evidence Blocks (EB) measures of clinical value: efficacy of regimen/agent, safety of regimen/agent, quality of evidence, and consistency of evidence. METHODS This is a cross-sectional, observational study. We obtained NCCN EB ratings for all recommended, first-line, and/or maintenance treatments for the 30 most prevalent cancers in the United States and calculated direct pharmacologic treatment costs (drug acquisition, administration fees, guideline-concordant supportive care medications) using Medicare reimbursement rates in January 2019. We used generalized estimating equations to estimate the association between NCCN EB measures and treatment cost with clustering at the level of the treatment indication. RESULTS A total of 1,386 treatments were included. Among time-unlimited treatments (those administered on an ongoing basis without a predetermined stopping point), monthly cost was positively associated with efficacy ($3,036; 95% CI, $1,782 to $4,289) and quality of evidence ($1,509; 95% CI, $171 to $2,847) but negatively associated with safety (-$1,470; 95% CI, -$2,790 to -$151) and consistency of evidence (-$2,003; 95% CI, -$3,420 to -$586). Among time-limited treatments (those administered for a predetermined interval or number of cycles), no NCCN EB measure was significantly associated with treatment cost. CONCLUSIONS An association between NCCN EB measures and treatment cost was inconsistent, and the magnitude of the association was small compared with the degree of cost variation among treatments with the same EB scores. The clinical value of cancer treatments does not seem to be a primary determinant of treatment cost.
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Affiliation(s)
- Aaron P Mitchell
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Sara M Tabatabai
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Pranammya Dey
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; and.,Yale University School of Medicine, New Haven, Connecticut
| | - Jennifer A Ohn
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Michael A Curry
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Peter B Bach
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; and
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Denholm SJ, Brand W, Mitchell AP, Wells AT, Krzyzelewski T, Smith SL, Wall E, Coffey MP. Predicting bovine tuberculosis status of dairy cows from mid-infrared spectral data of milk using deep learning. J Dairy Sci 2020; 103:9355-9367. [PMID: 32828515 DOI: 10.3168/jds.2020-18328] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 06/09/2020] [Indexed: 11/19/2022]
Abstract
Bovine tuberculosis (bTB) is a zoonotic disease in cattle that is transmissible to humans, distributed worldwide, and considered endemic throughout much of England and Wales. Mid-infrared (MIR) analysis of milk is used routinely to predict fat and protein concentration, and is also a robust predictor of several other economically important traits including individual fatty acids and body energy. This study predicted bTB status of UK dairy cows using their MIR spectral profiles collected as part of routine milk recording. Bovine tuberculosis data were collected as part of the national bTB testing program for Scotland, England, and Wales; these data provided information from over 40,500 bTB herd breakdowns. Corresponding individual cow life-history data were also available and provided information on births, movements, and deaths of all cows in the study. Data relating to single intradermal comparative cervical tuberculin (SICCT) skin-test results, culture, slaughter status, and presence of lesions were combined to create a binary bTB phenotype labeled 0 to represent nonresponders (i.e., healthy cows) and 1 to represent responders (i.e., bTB-affected cows). Contemporaneous individual milk MIR spectral data were collected as part of monthly routine milk recording and matched to bTB status of individual animals on the single intradermal comparative cervical tuberculin test date (±15 d). Deep learning, a sub-branch of machine learning, was used to train artificial neural networks and develop a prediction pipeline for subsequent use in national herds as part of routine milk recording. Spectra were first converted to 53 × 20-pixel PNG images, then used to train a deep convolutional neural network. Deep convolutional neural networks resulted in a bTB prediction accuracy (i.e., the number of correct predictions divided by the total number of predictions) of 71% after training for 278 epochs. This was accompanied by both a low validation loss (0.71) and moderate sensitivity and specificity (0.79 and 0.65, respectively). To balance data in each class, additional training data were synthesized using the synthetic minority over sampling technique. Accuracy was further increased to 95% (after 295 epochs), with corresponding validation loss minimized (0.26), when synthesized data were included during training of the network. Sensitivity and specificity also saw a 1.22- and 1.45-fold increase to 0.96 and 0.94, respectively, when synthesized data were included during training. We believe this study to be the first of its kind to predict bTB status from milk MIR spectral data. We also believe it to be the first study to use milk MIR spectral data to predict a disease phenotype, and posit that the automated prediction of bTB status at routine milk recording could provide farmers with a robust tool that enables them to make early management decisions on potential reactor cows, and thus help slow the spread of bTB.
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Affiliation(s)
- S J Denholm
- Scotland's Rural College (SRUC), Peter Wilson Building, Kings Buildings, West Mains Road, Edinburgh EH9 3JG, UK.
| | - W Brand
- Scotland's Rural College (SRUC), Peter Wilson Building, Kings Buildings, West Mains Road, Edinburgh EH9 3JG, UK
| | - A P Mitchell
- Animal and Plant Health Agency (APHA), Woodham Lane, Addlestone, Surrey KT15 3NB, UK
| | - A T Wells
- Scotland's Rural College (SRUC), Peter Wilson Building, Kings Buildings, West Mains Road, Edinburgh EH9 3JG, UK
| | - T Krzyzelewski
- Scotland's Rural College (SRUC), Peter Wilson Building, Kings Buildings, West Mains Road, Edinburgh EH9 3JG, UK
| | - S L Smith
- Scotland's Rural College (SRUC), Peter Wilson Building, Kings Buildings, West Mains Road, Edinburgh EH9 3JG, UK
| | - E Wall
- Scotland's Rural College (SRUC), Peter Wilson Building, Kings Buildings, West Mains Road, Edinburgh EH9 3JG, UK
| | - M P Coffey
- Scotland's Rural College (SRUC), Peter Wilson Building, Kings Buildings, West Mains Road, Edinburgh EH9 3JG, UK
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Dey P, Green AK, Haddadin M, Bach PB, Mitchell AP. Trends in Female Representation on NCCN Guideline Panels. J Natl Compr Canc Netw 2020; 18:1084-1086. [PMID: 32755977 DOI: 10.6004/jnccn.2020.7571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 04/01/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND NCCN produces highly influential disease-specific oncology clinical practice guidelines. Because the number of women in academic oncology has increased, we assessed whether the composition of NCCN Guidelines Panels reflected this trend. METHODS Using historical guidelines requested from NCCN, we investigated time trends for female representation on 21 NCCN Guidelines Panels and analyzed the trends for female-predominant cancers (breast, ovarian, uterine, and cervical) compared with all cancers. RESULTS From 2013 to 2019, there was an increase from 123 women of 541 total panelists (22.7%) to 175 women of 542 panelists (32.3%). Within the 4 female-predominant cancers, the increase was more rapid: from 30 of 101 total panelists (29.7%) to 66 of 118 panelists (56.4%). Excluding female-predominant cancers, increases were minimal. CONCLUSIONS There could be multiple explanations for these differing trends, including the possibility of more rapid increases in the underlying pool of female physician-scientists in female-predominant specialties or more efforts to increase the representation of women in decisions about the standard of care in cancers predominantly affecting women.
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Affiliation(s)
- Pranammya Dey
- Yale University School of Medicine, New Haven, Connecticut; and
| | - Angela K Green
- Department of Epidemiology and Biostatistics, and.,Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael Haddadin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter B Bach
- Department of Epidemiology and Biostatistics, and
| | - Aaron P Mitchell
- Department of Epidemiology and Biostatistics, and.,Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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Mitchell AP, Dey P, Ohn JA, Tabatabai SM, Curry MA, Bach PB. The Accuracy and Usefulness of the National Comprehensive Cancer Network Evidence Blocks Affordability Rating. Pharmacoeconomics 2020; 38:737-745. [PMID: 32201922 PMCID: PMC8357422 DOI: 10.1007/s40273-020-00901-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND The National Comprehensive Cancer Network (NCCN) Guidelines' Evidence Blocks has the broadest scope of the several oncology value assessment frameworks. The Evidence Blocks includes the Affordability criterion, which reflects the financial cost of each treatment on a 1-5 scale. The accuracy of Affordability is unknown. METHODS We calculated Medicare costs for all first-line and maintenance treatments for the 30 cancers with the highest incidence in the USA that had published NCCN Evidence Blocks as of 31 December 2018. We assessed the accuracy and consistency of Affordability across different treatments and cancer types. Among different treatments for the same indication, we determined the frequency with which the Affordability assessment was consistent with calculated treatment costs. RESULTS There were a total of 1386 treatments in our sample. Lower Affordability scores were associated with higher costs. There was significant variation in cost at each level of Affordability; for treatments with Affordability = 1 (very expensive), costs ranged from $US4551 to $US43,794 per month for treatments administered over an undefined time period and from $US2865 to $US500,982 per course of therapy for treatments administered over a defined time period. Among treatments for the same indication, Affordability was discrepant with calculated treatment costs in 7.9% of pairwise comparisons, identifying the higher-cost treatment as being more affordable. Discrepancies were reduced when we reassigned Affordability scores based on calculated treatment costs. CONCLUSIONS Evidence Blocks Affordability generally correlated with treatment costs but contained discrepancies, which may limit its usefulness to clinicians in comparing costs. This study suggests that the Affordability score may be improved by indexing more directly to specified dollar value thresholds.
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Affiliation(s)
- Aaron P Mitchell
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY, USA.
| | - Pranammya Dey
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer A Ohn
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY, USA
| | - Sara M Tabatabai
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY, USA
| | - Michael A Curry
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY, USA
| | - Peter B Bach
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY, USA
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Abstract
The microbial fungus Candida albicans can undergo a change from commensal colonization to virulence that is strongly correlated with its ability to switch from yeast-form growth to hyphal growth. Cells initiating this process become adherent to surfaces as well as to each other, with the resulting development of a biofilm colony. This commonly occurs not only on mucosal tissue surfaces in yeast infections, but also on medical implants such as catheters. It is well known that biofilm cells are resistant to antifungal drugs, and that cells that shed from the biofilm can lead to dangerous systemic infections. Biofilms range from heavily translucent to opaque due to refractive heterogeneity. Therefore, fungal biofilms are difficult to study by optical microscopy. To visualize internal structural, cellular, and subcellular features, we clarify fixed intact biofilms by stepwise solvent exchange to a point of optimal refractive index matching. For C. albicans biofilms, sufficient clarification is attained with methyl salicylate (n = 1.537) to enable confocal microscopy from apex to base in 600 µm biofilms with little attenuation. In this visualization protocol we outline phase contrast refractometry, the growth of laboratory biofilms, fixation, staining, solvent exchange, the setup for confocal fluorescence microscopy, and representative results.
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Affiliation(s)
- Frederick Lanni
- Department of Biological Sciences, Carnegie Mellon University;
| | | | - Manning Y Huang
- Department of Biological Sciences, Carnegie Mellon University
| | - Lan Yan
- Department of Pharmacology, Second Military Medical University
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