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Supplementary Figure S2. Genetic tools used for dissecting Il6/Stat3/Myc signaling. (A) Scheme of conditional alleles and PCR primers used for assessing the recombination of Pten/ Trp53 genes. (B) Senescence-specific ß-gal staining is detected after Pten loss but not after Pten/Trp53 co-deletion. Scale Bar, 200 μm.

Supplementary Figure S1. Copy Number Alteration analysis of human prostate cancer confirms loss of PTEN and TP53 genes as a genetic hallmark of metastatic prostate cancer. (A) Co-deletion frequency for PTEN and TP53 in metastatic and primary prostate cancer samples. (B) Co-deletion frequency for PTEN and TP53 in metastatic and primary prostate cancer samples. (C) Co-deletion frequency for PTEN and TP53 in metastatic prostate cancer samples . (D) Gene maps of the conditional alleles used for ablation of Pten/ Trp53 genes and activation of tdTomato. Cre leads to recombination of loxP sites in the Pten/Trp53 genes and excision of a STOP cassette that leads to activation of the fluorescence protein tdTomato. (E) Analysis of tdTomato-positive cells using Guava flow cytometry system show that AdCre leads to activation of tdTomato in over 95% percent of cells without the need for selection. (F) Activation of tdTomato can be easily visualized using fluorescence microscopy.

Supplementary Figure S7. Pathway to Pten/ Trp53 deficient prostate metastasis and therapy resistance. Pten-loss triggers PIP3 signaling to activate AKT, which prompts activation of the p53/ p21/ p16 tumor suppressors and senescence arrest. Suppression and loss of p53 in this context results in cell proliferation and Il6 secretion. Il6 signals both auto and paracrine to activate Myc via the Jak/Stat pathway. Myc induces the Phlpp2 phosphatase which creates a negative feedback loop by dampening Akt activation. Metastases (and castration-resistant tumors) select for increased Myc expression (and gene amplification, and Akt inactivation, demonstrating that Myc supersedes the need for Akt in lethal prostate cancer.

Supplementary Figure S3. Tools used for targeting of Il6 and Stat3. (A) Il6 neutralizing antibody specifically decreases the proliferation of Pten/ Trp53 deficient primary MEFs. ANOVA, Dunnett's post-hoc test, **p

Supplementary Figure S4. Activation of Stat3/Myc signaling is specific to Ptenpc-/-; Trp53pc-/-prostate and leads to stromal expansion. (A) H&E analysis of prostates from all studied genotypes reveals massive stromal expansion after co-deletion of Pten and Trp53. IHC analysis confirms stromal pStat3/ Myc activation specifically in Ptenpc-/-; Trp53pc-/- prostate. Note that pAkt activation is restricted to gland, consistent with triggering paracrine Il6/Stat3/Myc activation. Scale Bars, 100 μm. (B) Pten is present in the stroma of Ptenpc-/-; Trp53pc-/- prostates confirming that the expansion of stroma is not driven by spurious Pten/Trp53 recombination. (C) Proliferation in the Ptenpc-/- glands correlates with Akt activation, in contrast to Ptenpc-/-; Trp53pc-/- glands, where it correlates with Stat3/ Myc staining.

Supplementary Figure S6. Ar expression in primary and metastatic tumors. (A) IHC analysis of the Ar status in RapidCaP lesions shows no significant Ar staining (left panel) while most prostate glands show strong nuclear Ar staining. (B) The wild type and mutant prostates from Probasin-Cre animals show strong Ar staining.

Supplementary Figure Legends from MYC Drives Pten/Trp53-Deficient Proliferation and Metastasis due to IL6 Secretion and AKT Suppression via PHLPP2

BACKGROUND: Haematological malignancies and their treatments are likely to affect SARS-CoV-2 vaccine efficacy. We aimed to evaluate serological response to BNT162b2 vaccine in patients with haematological malignancies by type of treatment. METHODS: Our national prospective cohort study was done in Lithuania and assessed serological response to one and two BNT162b2 (Comirnaty, Pfizer-BioNTech) vaccine doses in healthy health-care workers and in patients with haematological malignancies. Eligible participants were aged 18 years or older, had received both vaccine doses, and had available biobanked blood samples from before vaccination and after the second dose. Biobanked samples and health data were obtained from Vilnius University Hospital Santaros Klinikos Biobank. Abbott Architect SARS-CoV-2 IgG Quant II chemiluminescent microparticle assay was used to quantify serum anti-SARS-CoV-2-S1 IgG antibody (anti-S1 IgG antibody) concentrations 0-10 days before the first BNT162b2 vaccine, on the day of second immunisation (around day 21), and 7 to 21 days after the second immunisation. Adverse events were assessed by a standardised questionnaire. Breakthrough infections were characterised clinically and by SARS-CoV-2 genotyping whenever possible. This study is registered with ClinicalTrials.gov, NCT04871165. FINDINGS: Between Jan 8 and April 21, 2021, 885 participants with haematological malignancies were included in the study. 857 patients were anti-S1 IgG seronegative at timepoint 0 and constituted the main analysis cohort. The age-matched comparison was made between 315 patients with haematological malignancies who were aged 18-60 years and 67 healthy health-care workers in the same age group. Patients aged 18-60 years with haematological malignancies had lower median anti-S1 IgG antibody responses after two BNT162b2 vaccine doses than did health-care workers of the same age group (median 6961 AU/mL [IQR 1292-20 672] vs 21 395 AU/mL [14 831-33 553]; p

Background: Patients with active haematological malignancies (HM) have been excluded from clinical trials evaluating vaccines against SARS-CoV-2. Both HM and their treatments are commonly immunosuppressive and are likely to impact COVID-19 vaccine efficacy. Methods: We performed a study assessing serological response to one and two BNT162b2 vaccine doses in healthy healthcare workers (HCWs) and in patients with HM. Peripheral blood samples were collected at three time points: 0-10 days before the first BNT162b2 vaccine jab, on the day of second jab (around day 21) and 7 to 21 days after the second jab. Abbott Architect SARS-CoV-2 IgG Quant II assay was used to quantify serum anti-SARS-CoV-2-S1 IgG antibody (anti-S1 IgG) levels. HM individuals were stratified into groups by current or most recent treatment, latency since treatment and anti-S1 IgG seroconversion status before the first jab. Results: 653 anti-S1 IgG negative participants with HM (median age 64 years, IQR 53 - 72, 52% female) and 69 healthy HCWs (40 [32 - 53] years, 83% female) were included in the study. 18-60 year-old HM patients had lower median anti-S1 IgG response (median 6810 [IQR 635 - 20574] vs 21394 [14289 - 33322], p

The high frequency of somatic mutations in myelodysplastic syndromes (MDS) provides an additional biomarker modality for MDS diagnosis. This has significant potential in the investigation of cytopenias particularly in cases with All patient samples referred for unexplained cytopenia or suspected MDS to the Haematological Malignancy Diagnostic Service in the UK over a 2-year period (July 2014-2016) were included. Samples were analysed using established diagnostic assays (morphology, flow cytometry, cytogenetics) and in parallel subjected to targeted sequencing of 27 genes commonly mutated in myeloid malignancies. Outcome data was captured including serial blood count data, subsequent diagnoses and overall survival. A subgroup of 37 mutation negative samples underwent extended genotyping of 126 genes. A total of 2089 samples passed QC for targeted sequencing. Of these, 538 had a confirmed diagnosis (26%), the majority of which were diagnosed with a myeloid malignancy (449/538; 83%). Mutations were commonly identified in the latter with ≥1 somatic mutation +/or karyotypic abnormality detected in 91% of patients. Importantly, mutations were also detected in 28% of non-diagnostic (ND) samples (412/1496). The spectrum of mutations was similar between ND and MDS samples, though varied in frequency. In ND samples TET2, SRSF2 and DNMT3A mutations predominated (47%, 22%, 19% respectively) while SF3B1, TET2 and ASXL1 were most frequently mutated in MDS (25%, 24%, 24% respectively). The number of mutations detected per sample and the variant allele fraction (VAF) was also significantly lower in ND samples (median no. of mutations 1 vs 2; median VAF 17.7% vs 35.1%; p To determine the clinical significance of mutations, correlation was made with subsequent diagnoses and clinical outcome. Follow-up bone marrow samples were received in 205 ND samples and 82 of these had a confirmed diagnosis of which 61 had a myeloid malignancy. The presence of a mutation at baseline was strongly associated with a subsequent myeloid diagnosis (NDmut vs NDunmut ;13% vs 0.5%; p1 mutation; p Importantly the presence of a mutation impacted significantly on survival in the ND group (odds ratio=1.59; p By analysing a large unselected cohort of cytopenic patients, this study has demonstrated the power of mutation analysis to predict both a subsequent myeloid diagnosis and clinical outcome in those without a confirmed diagnosis. While standard techniques will identify some of these patients over time, crucially, those at highest risk can remain undetected. Identifying these patients would ensure close clinical follow-up and provide an opportunity for early intervention. Ultimately this will facilitate the development of predictive models and refine diagnostic algorithms and this work is ongoing. Disclosures Cargo: Celgene: Research Funding. Evans:Diaceutics: Honoraria; Novartis: Honoraria. Papaemmanuil:Celgene: Research Funding.

Summary Background Several new treatments for Clostridium difficile infections have been investigated. We aimed to compare and rank treatments for non-multiply recurrent infections with C difficile in adults. Methods We did a random effects network meta-analysis within a frequentist setting to obtain direct and indirect comparisons of trials. We searched MEDLINE, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov for published and unpublished trials from the creation of these databases until June 30, 2017. We included randomised controlled trials of treatments for non-multiply recurrent infections with confirmed C difficile in adults (at least 18 years) that reported both primary cure and recurrence rates, and we used the Cochrane Risk of Bias tool to appraise trial methods. For our analysis, we extracted the total numbers of patients with primary cure and recurrence from published and unpublished reports. The primary outcome was sustained symptomatic cure, defined as the number of patients with resolution of diarrhoea minus the number with recurrence or death. Findings Of 23 004 studies screened, 24 trials, which comprised 5361 patients and 13 different treatments, were included in the analysis. The overall quality of evidence was rated as moderate to low. For sustained symptomatic cure, fidaxomicin (odds ratio 0·67, 95% CI 0·55–0·82) and teicoplanin (0·37, 0·14–0·94) were significantly better than vancomycin. Teicoplanin (0·27, 0·10–0·70), ridinilazole (0·41, 0·19–0·88), fidaxomicin (0·49, 0·35–0·68), surotomycin (0·66, 0·45–0·97), and vancomycin (0·73, 0·56–0·95) were better than metronidazole. Bacitracin was inferior to teicoplanin (0·22, 0·06–0·77) and fidaxomicin (0·40, 0·17–0·94), and tolevamer was inferior to all drugs except for LFF571 (0·50, 0·18–1·39) and bacitracin (0·67, 0·28–1·58). Global heterogeneity of the entire network was low (Cochran's Q=15·70; p=0·47). Interpretation Among the treatments for non-multiply recurrent infections by C difficile , the highest quality evidence indicates that fidaxomicin provides a sustained symptomatic cure most frequently. Fidaxomicin is a better treatment option than vancomycin for all patients except those with severe infections with C difficile and could be considered as a first-line therapy. Metronidazole should not be recommended for treatment of C difficile . Funding None.

Several articles have concluded that associations between high cholesterol and premature death are lacking and advocate revision of current guidance advising low consumption (

In post-Soviet countries, where medical practice largely relies on experience alone, the incorporation of the best research evidence in clinical practice is limited. In order to promote the awareness and utilization of evidence-based medicine (EBM) among Lithuanian doctors, we organized EBM conferences in each of the two Lithuanian medical schools. More than 500 medical professionals and students attended the conferences in Vilnius (2013) and Kaunas (2014) demonstrating that there is a high demand for formal EBM teaching. Building on the success of these seminal conferences, and to start addressing the lack of EBM practice in the country, the first Lithuanian Centre for Evidence-Based Medicine was established at Vilnius University Medical Faculty in 2014. The Centre will focus on the implementation of EBM teaching in medical school curriculum, formulating management guidelines, writing systematic reviews and supporting Lithuanian authors in doing so.

Persistently raised blood pressure is one of the major risk factors for diseases such as myocardial infarction and stroke. Uncontrolled hypertension is also associated with high rates of mortality, particularly in middle and high-income countries. Lifestyle factors such as poor diet, obesity, physical inactivity and smoking are all thought to contribute to the development of hypertension. As a result, the management of hypertension should begin with modifying these lifestyle factors. Beyond this, drug interventions are used as the predominant form of management. However, adherence to medications can be highly variable, medication side effects are common, and may require regular monitoring or, in some individuals may be ineffective. Therefore, additional non-pharmacologic interventions that lower blood pressure may be advantageous when combined with lifestyle modifications. Such interventions may include relaxation therapies such as slow breathing exercises, which can be initiated by means of specific devices. The technique of device-guided breathing (DGB) has been considered by guideline developers in the management of hypertension. One specific device, the Resperate, has received US FDA and UK NHS approval over the last few years. In this review, we summarise the evidence base on efficacy and find that although some clinical trials exist that demonstrate a BP-lowering effect, others do not. There is currently insufficient evidence from pooled data to recommend the routine use of device-guided breathing in hypertensive patients.

We have recently recapitulated metastasis of human PTEN/TP53–mutant prostate cancer in the mouse using the RapidCaP system. Surprisingly, we found that this metastasis is driven by MYC, and not AKT, activation. Here, we show that cell–cell communication by IL6 drives the AKT–MYC switch through activation of the AKT-suppressing phosphatase PHLPP2, when PTEN and p53 are lost together, but not separately. IL6 then communicates a downstream program of STAT3-mediated MYC activation, which drives cell proliferation. Similarly, in tissues, peak proliferation in Pten/Trp53–mutant primary and metastatic prostate cancer does not correlate with activated AKT, but with STAT3/MYC activation instead. Mechanistically, MYC strongly activates the AKT phosphatase PHLPP2 in primary cells and prostate cancer metastasis. We show genetically that Phlpp2 is essential for dictating the proliferation of MYC-mediated AKT suppression. Collectively, our data reveal competition between two proto-oncogenes, MYC and AKT, which ensnarls the Phlpp2 gene to facilitate MYC-driven prostate cancer metastasis after loss of Pten and Trp53. Significance: Our data identify IL6 detection as a potential causal biomarker for MYC-driven metastasis after loss of PTEN and p53. Second, our finding that MYC then must supersede AKT to drive cell proliferation points to MYC inhibition as a critical part of PI3K pathway therapy in lethal prostate cancer. Cancer Discov; 5(6); 636–51. ©2015 AACR. This article is highlighted in the In This Issue feature, p. 565

The sporadic transition from indolent to metastatic disease is a hallmark of prostate cancer (PC) and frequently involves deletion of PTEN and TP53. We recently recapitulated metastasis of Pten/ Trp53-mutant PC in mouse using the RapidCaP system and surprisingly, we found that it is driven by Myc, rather than Akt activation. Here, we show that cell-cell communication by Il6 drives this Akt-Myc switch through activation of the Akt-inactivating phosphatase Phlpp2. Primary cells revealed that loss of Pten/ Trp53 triggers secretion of the Il6 cytokine when these genes are deleted together, but not separately. Il6 then communicates a downstream program of Stat3-mediated Myc activation, which drives cell proliferation. Abrogation of Myc activity by Myc inhibition with the JQ1 bromodomain inhibitor, Myc-RNAi, and Myc-CRISPR/ Cas9 approaches inhibited proliferation. We validated these findings in vivo, where peak proliferation in Pten/ Trp53 mutant primary and metastatic PC did not correlate with activated Akt, but with Stat3/ Myc activation instead. Most notably, we found that Myc strongly activates the Akt phosphatase Phlpp2 in primary cells and RapidCaP metastasis, and showed genetically that Phlpp2 is essential for dictating proliferation and Myc-mediated suppression of Akt. Collectively, our data reveal competition between two proto-oncogenes: Myc and Akt, which ensnarls the Phlpp2 gene to facilitate Myc-driven metastasis. Citation Format: Dawid G. Nowak, Hyejin Cho, Tali Herzka, Victoria M.Y. Wang, Serif Senturk, Daniel V. DeMarco, David Ding, Christof Fellmann, Tumas Beinortas, David Kleinman, Kaitlin Watrud, Muhan Chen, John E. Wilkinson, Mireia Castillo-Martin, Carlos Cordon-Cardo, Brian D. Robinson, Lloyd C. Trotman. Myc drives Pten/ p53-deficient proliferation and metastasis due to Il6-secretion and Akt-suppression via Phlpp2. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2258. doi:10.1158/1538-7445.AM2015-2258

Background Currently available chronic myeloid leukaemia (CML) survival reports have originated from more affluent countries. Herein we report the entire country data on incidence and survival of CML, as well as penetrance of tyrosine kinase inhibitors (TKIs) in Lithuania. Methods We analyzed all patients (N = 601) from the national haematological disease monitoring system who were diagnosed with CML between 2000 and 2013. Crude (CR) and age-standardized (weighted) (ASW(R)) incidence and mortality rates, as well as 1-, 5-, and 10-year relative survival rates (RSR) were calculated. Information on TKI penetration is also reported. Results Throughout the entire 2000–2013 period the median age at diagnosis of CML patients was 62 years. The respective incidence and mortality CRs were 1.28 and 0.78, both characterized by decreasing trends over the observation period. A 5-year RSR increased from 0.33 [95 % CI, 0.27–0.40] in 2000–2004 to 0.55 [95 % CI, 0.47–0.63] in 2005–2009. However, the respective 5-year RSRs for patients aged 65–74 and ≥75 were only 0.33 [95 % CI, 0.24–0.42] and 0.18 [95 % CI 0.07–0.23] during the entire study period. TKI penetrance for CML patients grew from 1.5 % in 2000–2004 to 30.6 % in 2005–2009 and 69.1 % in 2010–2013. TKI penetrance was low in the older age groups (60 % for the 65–74 and 19 % for the ≥75 patient group, in 2010–2013). Conclusion Relative CML survival in Lithuania steadily improved and paralleled the increase in TKI treatment availability. Patients above 64 years rarely received TKIs and their relative survival remained low throughout the observation period. The latency of TKI availability may have influenced the survival trends. Electronic supplementary material The online version of this article (doi:10.1186/s12885-016-2238-9) contains supplementary material, which is available to authorized users.