The end of the human chromosome is protected by telomeres which contain a special tandem guanine-rich DNA sequence, 5’-TTAGGG. The length of telomeres is shortened during cell replications, and its length limits the replication capacity of cells. Telomerase is over-expressed in 85–90% of cancer cells, responsible for extending the telomere length in cancer cells. Guanine-rich DNA sequence can self-assemble into unique G-quadruplex structures that interfere with the extension of telomeres by telomerase. Therefore, DNA G-quadruplex has recently received much attention because of its important regulatory functions in telomerase-mediated cancerization. The formation of G-quadruplex requires monovalent cations (Na+ and K+) or small molecules known as G-quadruplex ligands. In the present work, we developed a serial of G-quadruplex ligands by tethering side-chains to two core structures: 1,10-phenanthroline (Phen) and thiazole orange (TO). Biophysical studies including DNA thermal denaturation monitored by fluorescence orcircular dichroism, fluorometric titration, and ESI-MS spectrometry reveal that the binding of the synthesized ligands to G-quadruplex is side-chain dependent. The arylsulfanyl side chains significantly improve the binding affinity and selectivity of 1,10-phenanthroline towards G-quadruplex over duplex DNA. The polyamine side chains are a suitable structural motif for remarkable G-quadruplex binding affinity based on the results from both Phen and TO derivatives. These ligands greatly inhibit the telomerase activity in vitro, determined by a modified telomeric repeat amplification protocol (TRAP) assay. Amongst these promising telomerase inhibitors, a thiazole orange derivative containing a side chain of spermine shows an outstanding telomerase inhibition effect at nanomolar concentrations, which is comparable to the most effective synthetic telomerase inhibitors, BRACO-19.

Evaluation of the Pulmonary Ambulatory Care Clinic at David Grant Medical Center was an attempt to explore several questions that surround the care of patients with chronic obstructive pulmonary disease (COPD) and to assess the role and impact of pharmacists providing pharmaceutical care in an Air Force Medical Center. Four experimental designs were implemented. Thirty-eight ambulatory patients with COPD were randomized into a control group or into a program where pharmacists resolved drug-related problems (DRPs) and educated patients about optimal drug use and management of exacerbations. The groups were evaluated prospectively at baseline, three months and six months for the presence of DRPs, quality of life (QOL) scores, and health care resource utilization (HCRU) parameters. Significant improvements in Health Status Questionnaire scores of study group were at three (F = 4.56, p = 0.04) and six months (F = 3.84, p = 0.05). Chronic Respiratory Disease Index questionnaire scores significantly improved in study group at three months in fatigue category (F = 5.35, p = 0.02). Disease State Knowledge Test scores significantly improved at three (F = 3.90, p = 0.04) and six months (F = 13.37, p = 0.001) in study group. Twenty-two DRPs were resolved. The study group realized significant reductions in mean numbers of physician visits (F = 8.12, p $<$ 0.05), and emergency room visits (F = 5.41, p $<$ 0.05) at three and six months respectively. Mean number of physician visits in study group during six-month period was significantly lower prospectively than retrospectively (T = 3.56, p = 0.003) in the single subject design study. Retrospective study of seventy patients showed that mean numbers of chronic medications (F = 6.57, p $<$ 0.05) and pulmonary hospitalizations (F = 4.08, p $<$ 0.05) were significantly lower in mild patients than severe patients. These results of this four-part study design, showed that patient education and resolution of DRPs improved patients' QOL and increased their knowledge about their disease states. Teaching patients how to manage exacerbation resulted in a decrease in health care visits in this patient population. Categorization of severity by pulmonologist coincided with patients' utilization of HCRs.

This cross-sectional study used a weighted sample of ED visits contained in the 2010-2015 years of the National Hospital Ambulatory Care Survey-Emergency Department (NHAMCS-ED) dataset. The purpose of this study was to: 1) identify differences in predisposing, enabling, and need characteristics, and ED use and medication prescribing characteristics between homeless and nonhomeless ED users; 2) assess the association between housing status and medication prescribing at ED discharge, and identify variables contributing to the disparity in medication prescribing between homeless and nonhomeless ED users; and 3) assess the predisposing, enabling, need, and ED use characteristics that predict medication prescribing at ED discharge among homeless ED users. This research is guided by the Andersen-Gelberg Behavioral Model for Vulnerable Populations. There were a total of 502,614,359 visits to EDs located within a MSA made by homeless and nonhomeless adults 18 years of age and older. About 0.9% of these visits were made by homeless individuals. Age, mental health diagnosis, substance use diagnosis, primary payer, and patient-reported pain differed significantly between homeless and nonhomeless ED users. A significantly greater proportion of homeless ED users arrived to the ED via ambulance, and was seen in the last 72 hours. Homeless ED users tended to have longer ED visits, and ED disposition differed significantly between homeless and nonhomeless ED users. A significantly smaller proportion of homeless ED users were prescribed a medication at ED discharge, and an opioid medication at ED discharge. There was no difference in the likelihood of medication prescribing at ED discharge between homeless and nonhomeless ED users after controlling for predisposing, enabling, need, and ED use characteristics. ED diagnosis was the greatest contributor to the disparity in medication prescribing at ED discharge between homeless and nonhomeless ED users. Among homeless ED users, visits covered by Medicare and other payers were significantly more likely to result in medication prescribing at ED discharge compared to nonhomeless ED users covered by private insurance. Homeless ED users with no substance use condition diagnosis were significantly more likely to be prescribed a medication at ED discharge compared to those with a substance use condition diagnosis.

INTRODUCTION: Diabetes mellitus is one of the most prevalent and costly chronic diseases in the United States (US). The healthcare and drug cost of diabetes has risen steadily and the increase in patients’ out-of-pocket drug expenditures are associated with a reduction in treatment adherence. The objectives of this study were to assess trends in insulin products prices in the period January 1983-July 2019, and to compare the price, acquisition costs and reimbursement amount of insulins available in the US. DATA AND METHODS: Data of insulin products marketed in the US during the period January 1983-July 2019 was derived from the FDA databases, the RedBook online, Medicaid.gov, the Department of Veterans Affairs, and the Centers for Medicare & Medicaid Services. Prices were adjusted using the consumer price index (CPI). The compounded average group rate (CAGR) was calculated for each insulin product. Data was analyzed by summary descriptive statistics. RESULTS: Human insulins had a CPI-adjusted AWP CAGR ranging 4.89%-8.89% from the first AWP effective date to July 2019 and insulin analogues had a CPI-adjusted AWP CAGR ranging 9.5%- 9.75%. The 2 follow-on (biosimilar) insulins; long-acting insulin glargine and rapid-acting insulin lispro experienced a negative adjusted CAGR (-1.20%, -33.70%, respectively). Insulin acquisition cost and reimbursement amounts showed a large variation when compared with the average wholesale (AWP) prices. The wholesale acquisition cost (WAC) was typically set at 83.33% of the AWP. Community pharmacies acquired insulins and analogues at a median of 80.27% of the AWP. Significant reductions in AWP were observed for Medicare Part D (78.80% of the AWP), and Federal Supply Schedule (FSS) /Big4 (25.89%). CONCLUSION: Manufacturer prices of insulins and analogues increased significantly during the period of 1983- July 2019. There are significant differences in the manufacturer prices, pharmacy acquisition costs and reimbursement rates of insulins and analogues.

Background: Staphylococcus aureus is an aerobic, Gram positive commensal organism that is capable of causing a wide spectrum of disease. This study contributes to previously published literature regarding daptomycin versus vancomycin use in S. aureus bacteremia (SAB). Methods: Adult patients admitted between 2010 and 2014, billed for ICD-9 code V09.0, 038.11, 038.12, 041.11, or 041.12, and received vancomycin and daptomycin were included in this retrospective analysis. Patients were stratified by time to change in antibiotics from vancomycin to daptomycin to the early switch (1-3 days), intermediate switch (4-7 days), or late switch (8 days or later) group. The primary outcome was treatment failure defined as 30-day recurrence, 60-day all-cause mortality, and 90-day all-cause readmission. Results: 193 patients were enrolled in the final cohort. The overall treatment failure rate was 18% with no differences between early switch, intermediate switch, and late switch (P=0.72) groups. Independent predictors of treatment success were length of stay (OR=1.035) and time to positive culture (OR=0.961). Conclusions: Results of this study did not demonstrate a difference in treatment failure based on time to switch from vancomycin to daptomycin. Future research should focus on optimizing use of vancomycin and daptomycin and medical management of SAB.

A key cardiovascular signaling molecule involved in both physiologic and pathologic regulation of cardiomyocytes is the small molecular weight G-protein, Ras. Differential effects of Ras are mediated by multiple effector molecules, including the RalGEFs which activate Ral. Studies performed in cardiomyocytes have indicated a role for Ral in cardiac hypertrophic signaling and the RalGEF family member, Rgl2, was shown to specifically interact with Ras in the heart. Therefore, I hypothesized that Rgl2 was an important Ras effector that would regulate cardiomyocyte signaling. To elucidate the potential importance of Rgl2 in regulating cardiomyocyte signaling, a gain-of-function approach was utilized in which NRVMs were infected with an adenovirus to increase Rgl2 expression. Using this approach, I found that Rgl2 increased Ral-GTP levels, Ras-GTP levels, and PI3-kinase-Akt signaling, but decreased ERK phosphorylation. Overall, my results suggest a model in which Rgl2 disrupts Ras-Raf and Ras-RasGAP interaction to decrease ERK phosphorylation and increase Ras-GTP, respectively. Furthermore, Rgl2-induced Ral activation promotes the enhanced PI3- kinase-Akt signaling. The physiologic consequence of Rgl2 signaling is difficult to predict, but the increase in PI3-kinase-Akt signaling would be expected to promote cardiomyocyte survival and enhance cardiac function, both of which are characteristic of physiologic hypertrophy.

Blackberries are rich in polyphenols including anthocyanins. Polyphenols are hypothesized to have biological activities that impact positively on human health. The purpose of these studies was to develop phenolic extracts from selected cultivars of blackberries currently grown in Kentucky as potential Botanical Drug Products for the treatment and prevention of cancer and inflammatory diseases. An ultrasound-assisted ethanol extraction method was employed to obtain anthocyanin-containing extracts (ACEs) from puree or powder (lyophilized puree) of blackberries. ACEs were analyzed for total anthocyanin and phenolics content, polymeric color, and total antioxidant capacity (TAC). The influence of water content in the extraction system was evaluated. A 90 day stability study of the extract and a 48 h stability study of the extract in biologically relevant buffers were completed. HPLC-MS results showed the anthocyanins in ACE were mainly cyanidin-based. As compared to powder-derived ACEs, puree-derived ACEs contained similar amounts of anthocyanins, but greater levels of phenolics and increased TAC. The in vitro antiproliferative effects of ACEs were evaluated in human leukemia (HL- 60), colon (HT-29), and breast (MCF-7) cancer cells. The anticancer mechanism involving reactive oxygen species (ROS) generation was investigated. It was found puree-derived ACEs significantly enhanced production of H2O2 and cytotoxicity in all cell lines as compared to powder-derived ACEs. Cyanidin 3-glucoside exerted anticancer effect by acting synergistically or additively with other active components in the extracts. Furthermore, the phenolic-enriched fractions were separated from non-phenolic fractions in ACEs and found to have potent antioxidant and antiproliferative activities. Pureederived ACE and corresponding phenolic-enriched methanol fraction (MF) induced cell death through ROS-independent caspase 3 pathway whereas the cytotoxicity induced by powder-derived ACE and corresponding MF is related to ROS mechanisms. The in vitro anti-inflammatory studies showed ACEs inhibited Lipid A-induced Interleukin-12 (IL-12) release from mouse dendritic cells, and modulated lipopolysaccharide (LPS)-induced secretion of tumor necrosis factor-α (TNF-α) and Interleukin-6 (IL-6) from murine macrophages. These studies have important implications for the potential use of blackberry extracts for the treatment and prevention of cancer and inflammation diseases and provide essential information for the development of Botanical Drug Products from extracts derived from blackberries and other fruits.

Microneedles are a minimally invasive method for delivering drugs through the impermeable skin layers, and have been used to deliver a variety of compounds including macromolecules, vaccines, and naltrexone. Microneedles can be applied to the skin once, creating micropores that allow for drug delivery into the underlying circulation from a drug formulation. The utility of this technique, however, is blunted by rapid micropore closure. This research project sought to: 1) characterize micropore lifetime and re-sealing kinetics, and 2) prolong micropore lifetime via inhibition of the skin’s barrier restoration processes. Impedance spectroscopy was used as a surrogate technique in animals and humans to measure micropore formation and lifetime. A proof of concept study in humans, using impedance spectroscopy, demonstrated that diclofenac (a topical anti-inflammatory) applied to microporated skin resulted in slower re-sealing kinetics compared to placebo, in agreement with previous animal studies. The clinical feasibility of prolonging micropore lifetime with diclofenac was confirmed via 7-day delivery of naltrexone through microneedle treated skin in humans (compared to 72 hour delivery with placebo). Lastly, naltrexone gels with calcium salts were applied to microneedle treated skin (hairless guinea pigs) to restore the altered epidermal calcium gradient; this method did not significantly extend micropore lifetime.

OBJECTIVE:To compare and contrast patients that receive treatment following an osteoporotic fracture to those patients that do not. METHODS:Data were taken from the Medical Expenditures Panel Survey (MEPS). Subjects who reported a wrist, vertebral, or hip fracture were identified. Prescription data were assessed for these subjects and two groups were identified: those who received treatment following a fracture and those who did not. RESULTS:The final sample consisted of n=129 subjects. Of these subjects, only 38% received treatment following an osteoporotic fracture. The only variable showing significant effects on treatment were type of insurance coverage. There was evidence of a relationship for other variables: race, inability to obtain necessary prescription medicines, family income, vertebral fracture and patient's perceived health.CONCLUSIONS: Overall treatment rates following a fracture remain low. Substantial efforts should be made to close the gap between guideline recommendations and clinical practice.

Background: Alzheimer’s disease (AD) is the most common form of dementia and is characterized by a progressive loss of memory, judgment, and thinking in older adults. The current treatment is cholinesterase inhibitors, which increase acetylcholine at the synapse. Medications with anticholinergic (AC) activity are given for a variety reasons including for the treatment of comorbid conditions or side effects of cholinesterase inhibitors (ChEIs). These drugs inhibit acetylcholine in the brain. Studies have shown the detrimental outcomes of using AC medications with ChEIs in older adults. Moreover, older patients take more medications and have an increased risk of developing AC toxicity as these effects are additive. The association between AC burden with functional, cognitive, and behavioral outcomes bears further evaluation. Methods: This study is a retrospective observational study that investigated the effect of AC medications on function, cognition, and behavior. Data was collected from charts on dementia patients who resided at Piedmont Geriatric Hospital. Descriptive statistics and GEE regression were performed using MS Excel 2007 and SPSS 18.0. Results: There were a total of 83 subjects included in this study with a median age of 77 years old and with a median length of stay of 536 days. 33.7% of the patients were taking cognitive-enhancing medications. The analysis found that AC burden was not a significant predictor of functional, cognitive or behavioral decline. Conclusion: The minimal amount of literature on this association, suggests that AC burden may have negative consequences on function, cognition and behavior in dementia patients. The study results provided inconclusive evidence about the association of AC burden on poorer functional, cognitive and behavioral outcomes. Future research in this field is needed to determine if there is a true association between worsening outcomes and AC burden.