Impact of the Opioid Epidemic on Drug Testing.

BACKGROUND: This review provides a description of how the opioid epidemic has impacted drug testing. METHODS: Four major service areas of drug testing were considered, including emergency response, routine clinical care, routine forensics, and death investigations. RESULTS: Several factors that the opioid epidemic has impacted in drug testing are discussed, including specimens, breadth of compounds recommended for testing, time to result required for specific applications, analytical approaches, interpretive support requirements, and examples of published practice guidelines. CONCLUSIONS: Both clinical and forensic laboratories have adapted practices and developed new testing approaches to respond to the opioid epidemic. Such changes are likely to continue evolving in parallel with changes in both prescription and nonprescription opioid availability and use patterns, as well as emerging populations that are affected by the "waves" of the opioid epidemic.

Demand for Interpretation of a Urine Drug Testing Panel Reflects the Changing Landscape of Clinical Needs; Opportunities for the Laboratory to Provide Added Clinical Value.

BACKGROUND: The direct detection of drugs and metabolites in urine using a targeted panel offers sensitive and specific detection in comparison to the traditional approach to urine drug testing (screen with reflex of samples with positive results to confirmation testing). The purpose of this study was to evaluate changes in clinical demand for the laboratory to provide interpretation of patient adherence and abstinence, based on reconciling laboratory results and individual patient medication information provided by the clinician. The shifts in toxicology testing likely reflect the inherent complexity of the data and associated interpretation. METHODS: Retrospective testing results associated with a targeted urine drug panel and its related interpretation were collected from our laboratory. We examined the associated testing volume and positivity rates of each reported analyte over 5 consecutive years (2015-2019). Requests from clinicians for consultation regarding this test and use of interpretive comments for the most recent year (2019), as well as access to publicly available educational resources over two years (2018-2019) were collected. RESULTS: The changes in test ordering patterns demonstrate shifting of clinical demands for toxicology testing, by increased adoption of a targeted panel for which laboratory-based interpretation is provided. Positivity rates reflect national shifts in controlled substance prescriptions. Several consultative services were accessed by clinicians suggesting interest and need. CONCLUSION: The value of clinical urine drug testing is improved by providing laboratory-based result interpretation and consultative services.

Circulating microRNA as a biomarker of human growth hormone administration to patients.

Circulating microRNAs (miRNAs) in plasma are being studied for use as biomarkers of specific diseases and as markers of administration of pharmaceutical agents. Administration of recombinant human growth hormone (rhGH) is prohibited by sporting authorities, but it continues to be used by athletes attempting to gain an unfair advantage in athletic competition. Current methods for detection of rhGH use rely on immunoassay technology and are limited by a short time-frame in which detection of rhGH is possible. We hypothesized that administration of rhGH would alter expression of circulating miRNAs and that any changes could be detected. To identify potential miRNA targets, we utilized miRNA microarrays for screening. Confirmatory testing used real-time reverse-transcriptase (RT) quantitative PCR (qPCR) assays of selected miRNAs in 35 plasma samples obtained from (1) individuals with no known pituitary disorders, (2) patients with excess GH production, and (3) patients receiving therapeutic replacement doses of rhGH. We identified and confirmed four miRNAs that were differentially expressed in all individuals using therapeutic replacement doses of rhGH when compared to individuals with naturally high levels of GH and normal controls. This study further develops the hypothesis that circulating miRNAs may be used as biomarkers for detection of doping in sports.

A population study of urine glycerol concentrations in elite athletes competing in North America.

Glycerol is an endogenous substance that is on the World Anti-Doping Agency's list of prohibited threshold substances due to its potential use as a plasma volume expansion agent. The WADA has set the threshold for urine glycerol, including measurement uncertainty, at 1.3 mg/mL. Glycerol in circulation largely comes from metabolism of triglycerides in order to meet energy requirements and when the renal threshold is eclipsed, glycerol is excreted into urine. In part due to ethnic differences in postprandial triglyceride concentrations, we investigated urine glycerol concentrations in a population of elite athletes competing in North America and compared the results to those of athletes competing in Europe. 959 urine samples from elite athletes competing in North America collected for anti-doping purposes were analyzed for urine glycerol concentrations by a gas chromatography mass-spectrometry method. Samples were divided into groups according to: Timing (in- or out-of-competition), Class (strength, game, or endurance sports) and Gender. 333 (34.7%) samples had undetectable amounts of glycerol (<1 µg/mL). 861 (89.8%) of the samples had glycerol concentrations ≤20 µg/mL. The highest glycerol concentration observed was 652 µg/mL. Analysis of the data finds the effects of each category to be statistically significant. The largest estimate of the 99.9(th) percentile, from the in-competition, female, strength athlete samples, was 1813 µg/mL with a 95% confidence range from 774 to 4251 µg/mL. This suggests a conservative threshold of 4.3 mg/mL, which would result in a reasonable detection window for urine samples collected in-competition for all genders and sport classes.

Quantification of growth hormone mRNA in blood.

BACKGROUND: Growth hormone (GH) is present in human lymphocytes and the relative concentration of GH mRNA in circulating cells is reportedly increased in patients with acromegaly. No quantitative assay has been described to measure GH in circulating cells. METHODS: To measure GH mRNA, we used real-time reverse-transcriptase (RT) quantitative PCR (qPCR) with nested primers, a synthetic nucleotide standard and SYBR Green I detection. Blood samples from volunteers with and without pituitary disorders were collected in PAXgene Blood RNA tubes. Essential MIQE guidelines were followed during sample preparation and assay development. RESULTS: RT-qPCR assay was specific for GH mRNA and was linear from ≤ 90 to ≥ 90,000 copies of GH mRNA per reaction. Day-to-day imprecision (CV) was 31%-46% at mean concentrations of 3400 and 2630 copies/mL of blood, respectively (n=10). The variability (CV) of results in samples collected from a single individual over a year and assayed in a single run was 28% (n=17 samples). The mean concentrations of GH mRNA in blood were statistically indistinguishable in patients with acromegaly, control subjects, and patients receiving replacement doses of recombinant GH. Moreover, GH mRNA concentrations in blood were not correlated with concentrations of insulin-like growth factor-I in plasma. CONCLUSIONS: The RT-PCR assay quantifies GH mRNA at concentrations present in circulating cells. The present study suggests that the absolute concentration of GH mRNA in circulating cells is not altered in patients with acromegaly.

X-ray structures of the hexameric building block of the HIV capsid.

The mature capsids of HIV and other retroviruses organize and package the viral genome and its associated enzymes for delivery into host cells. The HIV capsid is a fullerene cone: a variably curved, closed shell composed of approximately 250 hexamers and exactly 12 pentamers of the viral CA protein. We devised methods for isolating soluble, assembly-competent CA hexamers and derived four crystallographically independent models that define the structure of this capsid assembly unit at atomic resolution. A ring of six CA N-terminal domains form an apparently rigid core, surrounded by an outer ring of C-terminal domains. Mobility of the outer ring appears to be an underlying mechanism for generating the variably curved lattice in authentic capsids. Hexamer-stabilizing interfaces are highly hydrated, and this property may be key to the formation of quasi-equivalent interactions within hexamers and pentamers. The structures also clarify the molecular basis for capsid assembly inhibition and should facilitate structure-based drug design strategies.

Structure of the antiviral assembly inhibitor CAP-1 complex with the HIV-1 CA protein.

The CA domain of the human immunodeficiency virus type 1 (HIV-1) Gag polyprotein plays critical roles in both the early and late phases of viral replication and is therefore an attractive antiviral target. Compounds with antiviral activity were recently identified that bind to the N-terminal domain of CA (CA N) and inhibit capsid assembly during viral maturation. We have determined the structure of the complex between CA N and the antiviral assembly inhibitor N-(3-chloro-4-methylphenyl)-N'-{2-[({5-[(dimethylamino)-methyl]-2-furyl}-methyl)-sulfanyl]ethyl}-urea) (CAP-1) using a combination of NMR spectroscopy and X-ray crystallography. The protein undergoes a remarkable conformational change upon CAP-1 binding, in which Phe32 is displaced from its buried position in the protein core to open a deep hydrophobic cavity that serves as the ligand binding site. The aromatic ring of CAP-1 inserts into the cavity, with the urea NH groups forming hydrogen bonds with the backbone oxygen of Val59 and the dimethylamonium group interacting with the side-chains of Glu28 and Glu29. Elements that could be exploited to improve binding affinity are apparent in the structure. The displacement of Phe32 by CAP-1 appears to be facilitated by a strained main-chain conformation, which suggests a potential role for a Phe32 conformational switch during normal capsid assembly.

Implications for viral capsid assembly from crystal structures of HIV-1 Gag(1-278) and CA(N)(133-278).

Gag, the major structural protein of retroviruses such as HIV-1, comprises a series of domains connected by flexible linkers. These domains drive viral assembly by mediating multiple interactions between adjacent Gag molecules and by binding to viral genomic RNA and host cell membranes. Upon viral budding, Gag is processed by the viral protease to liberate distinct domains as separate proteins. The first two regions of Gag are MA, a membrane-binding module, and CA, which is a two-domain protein that makes important Gag-Gag interactions, forms the cone-shaped outer shell of the core (the capsid) in the mature HIV-1 particle, and makes an important interaction with the cellular protein cyclophilin A (CypA). Here, we report crystal structures of the mature CA N-terminal domain (CA(N)(133-278)) and a MA-CA(N) fusion (Gag(1-278)) at resolutions/R(free) values of 1.9 A/25.7% and 2.2 A/25.8%, respectively. Consistent with earlier studies, a comparison of these structures indicates that processing at the MA-CA junction causes CA to adopt an N-terminal beta-hairpin conformation that seems to be required for capsid morphology and viral infectivity. In contrast with an NMR study (Tang, C., et al. (2002) Nat. Struct. Biol. 9, 537-543), structural overlap reveals only small relative displacements for helix 6, which is located between the beta-hairpin and the CypA-binding loop. These observations argue against the proposal that CypA binding is coupled with beta-hairpin formation and support an earlier surface plasmon resonance study (Yoo, S., et al. (1997) J. Mol. Biol. 269, 780-795), which concluded that beta-hairpin formation and CypA-binding are energetically independent events.

Ubiquitin recognition by the human TSG101 protein.

The UEV domain of the TSG101 protein functions in both HIV-1 budding and the vacuolar protein sorting (VPS) pathway, where it binds ubiquitylated proteins as they are sorted into vesicles that bud into late endosomal compartments called multivesicular bodies (MVBs). TSG101 UEV-ubiquitin interactions are therefore important for delivery of both substrates and hydrolytic enzymes to lysosomes, which receive proteins via fusion with MVBs. Here, we report the crystal structure of the TSG101 UEV domain in complex with ubiquitin at 2.0 A resolution. TSG101 UEV contacts the Ile44 surface and an adjacent loop of ubiquitin through a highly solvated interface. Mutations that disrupt the interface inhibit MVB sorting, and the structure also explains how the TSG101 UEV can independently bind its ubiquitin and Pro-Thr/Ser-Ala-Pro peptide ligands. Remarkably, comparison with mapping data from other UEV and related E2 proteins indicates that although the different E2/UEV domains share the same structure and have conserved ubiquitin binding activity, they bind through very different interfaces.