SummaryObjectiveExposure to chemical warfare nerve agents (CWNAs), such as soman (GD), can induce status epilepticus (SE) that becomes refractory to benzodiazepines when treatment is delayed, leading to increased risk of epileptogenesis, severe neuropathology, and long‐term behavioral and cognitive deficits. Rodent models, widely used to evaluate novel medical countermeasures (MCMs) against CWNA exposure, normally express plasma carboxylesterase, an enzyme involved in the metabolism of certain organophosphorus compounds. To better predict the efficacy of novel MCMs against CWNA exposure in human casualties, it is crucial to use appropriate animal models that mirror the human condition. We present a comprehensive characterization of the seizurogenic, epileptogenic, and neuropathologic effects of GD exposure with delayed anticonvulsant treatment in the plasma carboxylesterase knockout (ES1−/−) mouse.MethodsElectroencephalography (EEG) electrode‐implanted ES1−/− and wild‐type (C57BL/6) mice were exposed to various seizure‐inducing doses of GD, treated with atropine sulfate and the oxime HI‐6 at 1 minute after exposure, and administered midazolam at 15‐30 minutes following the onset of seizure activity. The latency of acute seizure onset and spontaneous recurrent seizures (SRS) was assessed, as were changes in EEG power spectra. At 2 weeks after GD exposure, neurodegeneration and neuroinflammation were assessed.Results GD‐exposed ES1−/− mice displayed a dose‐dependent response in seizure severity. Only ES1−/− mice exposed to the highest tested dose of GD developed SE, subchronic alterations in EEG power spectra, and SRS. Degree of neuronal cell loss and neuroinflammation were dose‐dependent; no significant neuropathology was observed in C57BL/6 mice or ES1−/− mice exposed to lower GD doses.SignificanceThe US Food and Drug Administration (FDA) animal rule requires the use of relevant animal models for the advancement of MCMs against CWNAs. We present evidence that argues for the use of the ES1−/− mouse model to screen anticonvulsant, antiepileptic, and/or neuroprotective drugs against GD‐induced toxicity, as well as to identify mechanisms of GD‐induced epileptogenesis.

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The goal of the Army’s influenza prevention program is to protect all Soldiers, healthcare professionals, and beneficiaries from influenza and its complications to maximize force readiness.  Commanders have the daunting and challenging task of ensuring 100% of Soldiers and Military Treatment Facility (MTF) assigned employees are vaccinated against influenza by a specified timeframe.  Outpatient Pharmacy Services at the MTF are in the perfect position to provide enhanced accessibility to the influenza vaccination to assist in meeting this requirement.  Irwin Army Community Hospital at Fort Riley, Kansas, became the first MTF to offer a pharmacist-administered influenza vaccination program in the outpatient setting, as a walk-in service to all Soldiers, MTF employees, and beneficiaries, in 2016. Since then over 1,500 flu shots have been administered with no documented adverse events, and a potential cost-savings between $23,205 to $61,880.  Here we describe the planning and implementation of such a program, which can easily be reproduced at any MTF outpatient pharmacy with minimal efforts and resources, enabling outpatient pharmacists to provide a convenient and accessible alternative for seasonal flu vaccination, with the ultimate goal of maximizing force readiness. Article Type: Idea Paper

IntroductionWhen treatment of status epilepticus(SE) is delayed, seizures become self‐sustaining and refractory to benzodiazepine therapy. Chemical warfare nerve agents (CWNAs), such as soman(GD), increase acetylcholine through inhibition of acetylcholine sterase and can lead to SE if seizures are not treated quickly and controlled. Prolonged seizures may lead to extensive neuropathology, spontaneous recurrent seizures and long‐term performance deficits. To identify a better treatment against pharmacoresistant seizures caused by GD exposure, we are using combinations of drugs aimed at reversing the effects of maladaptive receptor trafficking that follows CWNA exposure.MethodsRats were implanted with telemetry transmitters for continuous monitoring of EEG, body temperature and activity. After surgical recovery, rats were exposed to 1.2 LD50 GD and treated 1 min later with atropine sulfate and the oxime HI‐6 and then 40 min after seizure onset with the anticonvulsant phenobarbital with or without the NMDA antagonist ketamine (PHE/KET), the benzodiazepine midazolam (PHE/MDZ) or a combination of all three drugs (PHE/KET/MDZ).Two weeks after exposure, rat brains were sectioned and stained for neuropathology assessments.ResultsTriple therapy with PHE/KET/MDZ reduced total time spent in seizures (SE +early recurrent seizures) in the first 72 h and reduced the number of spontaneous recurrent seizures compared to midazolam monotherapy. Tripletherapy also reduced the duration of toxic signs in the hours following GD‐exposure and prevented the development of hyperactivity that occurs in the weeks following exposure compared to GD/MDZ monotherapy. In addition, tripletherapy reduced loss of neurons in the piriform cortex and thalamus compared to GD/MDZ monotherapy.ConclusionTriple therapy with PHE/KET/MDZ hadanticonvulsant, antiepileptic, and neuroprotective effects compared with midazolammonotherapy in GD‐exposed rats. Triple therapy may be a highly effective approach against pharmacoresistant seizures, such as those caused by GD exposure, and may allow for administration of lower doses, resulting in fewer side effects than are often seen with large doses of individual drug therapies.Disclaimer: The views expressed in this abstract are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or the U.S. Government. The experimental protocol was approved by the Animal Care and Use Committee at the United States Army Medical Research Institute of Chemical Defense and all procedures were conducted in accordance with the principles stated in the Guide for the Care and Use of Laboratory Animals and the Animal Welfare Act of 1966 (P.L. 89‐544), as amended.Support or Funding InformationKatieWalker, Erica Kundrick and Sean O'Brien were supported in part by an appointment to the Research Participation Program for the U.S. Army Medical Research and Materiel Command administered by the Oak Ridge Institute for Science and Education through an agreement between the U.S. Department of Energy and U.S. Army Medical Research and Materiel Command. This research was supported by the NIH U01 to Dr. Claude Wasterlain.

IntroductionChemical warfare nerve agents (CWNAs) inhibit acetylcholinesterase (AChE), which leads to status epilepticus (SE), spontaneous recurrent seizures (SRS) and severe neuropathology when treatment is delayed. In addition to binding to AChE, some organophosphorus (OP) CWNAs such as soman (GD) also inhibit carboxylesterase (CaE), which acts as a bioscavenger and can thus reduce the severity of the toxicity of OP agent exposure. Unlike humans, rodents have plasma CaE activity. The CaE knockout (ES1−/−) mouse specifically lacks plasma CaE and might better model human GD exposure compared to wildtype rodents. Delayed treatment of CWNA‐induced SE with midazolam leads to benzodiazepine‐refractory SE. We evaluated combination therapy of midazolam and the NMDA antagonist ketamine in male and female mice for efficacy against soman‐induced lethality, SE and epileptogenesis.MethodsMice implanted with telemetry transmitters for electroencephalography (EEG) seizure identification were exposed to 82 μg/kg GD (~4LD50) and treated with an admix (ip) of atropine sulfate (4 mg/kg) and HI‐6 (50 mg/kg) 1 min after exposure, and with midazolam (3 mg/kg; ip) alone or in combination with ketamine (30 mg/kg, ip) at 40 min after seizure onset. Mice were continuously recorded to evaluate initial seizure duration and SRS and then euthanized 2 weeks after exposure for neuropathology assessment.ResultsDelayed treatment with midazolam resulted in poor survival, was unable to rapidly terminate behavioral or EEG seizure activity and did not prevent the development of SRS or neuronal loss following GD exposure. Combination therapy of midazolam and ketamine resulted in improved outcome, including an increase in survival from 30% to 78% in female and from 57% to 77% in males compared to midazolam monotherapy. In addition, the incidence of epileptogenesis was lower in mice treated with ketamine and midazolam dual therapy compared to midazolam monotherapy.ConclusionsThis study demonstrates that delayed treatment of SE with midazolam is not fully protective against the GD‐induced epileptogenesis and neuropathology, exemplifying the need for adjunct treatment to midazolam to prevent or reduce effects of GD‐induced SE. Ketamine combination with midazolam improves outcome.Support or Funding InformationResearch was supported by the CounterACT Program, NIH OD, and the NINDS (Grant 1R21NS103820‐01 to LA Lumley‐Lange) and by DTRA‐JSTO. Erica Kundrick, Katie Walker, and Sean O'Brien were supported in part by an appointment to the Research Participation Program for the U.S. Army Medical Research and Materiel Command administered by the Oak Ridge Institute for Science and Education through an agreement between the U.S. Department of Energy and U.S. Army Medical Research and Materiel Command.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.