[Osteonecrosis of the jaws and bisphosphonates]

Widely prescribed, bisphosphonates inhibit bone resorption. They are not metabolised and have long half-lives. Two cases of osteonecrosis of the jaws have recently been attributed to bisphosphonates at the University Hospital of Geneva. The recent literature reveals more than a hundred similar cases throughout the world. Bone exposure appears spontaneously or after dental care. Treatment of the osteonecrosis is controversial and cure very difficult. This pathology is usually seen in patients on chemotherapy, steroids and i.v. bisphosphonates, but is sometimes seen with low-dose p.o. bisphosphonates. In view of the strong association between bisphosphonate therapy and osteonecrosis of the jaw, specialists have recommended dental and oral evaluation during bisphosphonate therapy as well as for several years after drug discontinuation.

[Early detection in prostate cancer and shared decision making]

Screening of prostate cancer with PSA is a challenge for the aid to decision. Beside the rather mediocre characteristics of the screening test, there the additional problem of the peculiar biology of this cancer, with its late development and its ability to remain latent for a prolonged period. On the other hand, the treatment (surgery, irradiation) is associated with important side-effects: impotence and urinary leakage. Several studies, which appear to be a form of aid to information than aid to shared decision, have been carried out to analyse the effect of various modes of information on the behaviour of potential candidates to screening of prostate cancer, with the following results: better knowledge of the problem, lower rate of acceptance of PSA testing and trend towards watchful waiting rather than surgery in case of discovery of cancer.

[The PROVE IT-TIMI-22 study or the biter being bit]

The importance of statins in secondary prevention is well established since the 4S, CARE and LIPID studies, their indications being now applied to even normocholesterolemic patients. To date, it is still unclear which statin to choose, and at what dose. A recent study entitled "PROVE IT-TIMI-22" has compared 80 mg of atorvastatin/day to 40 mg of pravastatin/day in early secondary prevention. It appears that the intensive treatment with atorvastatin has been more effective on the LDL-cholesterol levels and has had a more favourable effect on the clinical evolution based on a composite score. We herein propose a critical review of this study and recommend a somewhat cautious attitude before giving high doses of atorvastatin in the secondary prevention of all the patients with coronary heart disease.

[Application of evidence based medicine to the individual patient: the role of decision analysis]

INTRODUCTION

The objective of evidence based medicine (EBM) is to contribute to medical decision making by providing the best possible information in terms of validity and relevance. This allows evaluation in a specific manner of the benefits and risks of a decision.

METHODS

The limitations and hazards of this approach are discussed in relation to a clinical case where the diagnosis of pulmonary embolism was under consideration. The individual details and the limited availability of some technical procedures illustrate the need to adapt the data of EBM to the circumstances. The choice between two diagnostic tests (d-dimers and ultrasound of the legs) and their optimal timing is analysed with integration of the consequences for the patient of the treatments proposed. This allows discussion of the concept of utility and the use of sensitivity analysis.

CONCLUSIONS

If EBM is the cornerstone of rational and explicit practise it should also allow for the constraints of real life. Decision analysis, which depends on the same critical demands as EBM but can also take account of the individual features of each patient and test the robustness of a decision, gives a unique opportunity reconcile rigorous reasoning with individualisation of management.

Prospective evaluation of patients with syncope: a population-based study

PURPOSE

To determine the diagnostic yield of a standardized sequential evaluation of patients with syncope in a primary care teaching hospital.

PATIENTS AND METHODS

All consecutive patients who presented to the emergency department with syncope as a chief complaint were enrolled. Their evaluation included initial and routine clinical examination, including carotid sinus massage, as well as electrocardiography and basic laboratory testing. Targeted tests, such as echocardiography, were used when a specific entity was suspected clinically. Other cardiovascular tests (24-hour Holter monitoring, ambulatory loop recorder ECG, upright tilt test, and signal-averaged electrocardiography) were performed in patients with unexplained syncope after the initial steps. Electrophysiologic studies were performed in selected patients only as clinically appropriate. Follow-up information on recurrence and mortality were obtained every 6 months for as long as 18 months for 94% (n = 611) of the patients.

RESULTS

After the initial clinical evaluation, a suspected cause of syncope was found in 69% (n = 446) of the 650 patients, including neurocardiogenic syncope (n = 234, 36%), orthostatic hypotension (n = 156, 24%), arrhythmia (n = 24, 4%), and other diseases (n = 32, 5%). Of the 67 patients who underwent targeted tests, suspected diagnoses were confirmed in 49 (73%) patients: aortic stenosis (n = 8, 1%), pulmonary embolism (n = 8, 1%), seizures/stroke (n = 30, 5%), and other diseases (n = 3). Extensive cardiovascular workups, which were performed in 122 of the 155 patients in whom syncope remained unexplained after clinical assessment, provided a suspected cause of syncope in only 30 (25%) patients, including arrhythmias in 18 (60%), all of whom had abnormal baseline ECGs. The 18-month mortality was 9% (n = 55, including 8 patients with sudden death); syncope recurred in 15% (n = 95) of the patients.

CONCLUSION

The diagnostic yield of a standardized clinical evaluation of syncope was 76%, greater than reported previously in unselected patients. Electrocardiogram-based risk stratification was useful in guiding the use of specialized cardiovascular tests.

Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score

OBJECTIVE

To develop a simple standardized clinical score to stratify emergency ward patients with clinically suspected pulmonary embolism (PE) into groups with a high, intermediate, or low probability of PE to improve and simplify the diagnostic approach.

METHODS

Analysis of a database of 1090 consecutive patients admitted to the emergency ward for suspected PE in whom diagnosis of PE was ruled in or out by a standard diagnostic algorithm. Logistic regression was used to predict clinical parameters associated with PE.

RESULTS

A total of 296 (27%) of 1090 patients were found to have PE. The optimal estimate of clinical probability was based on 8 variables: recent surgery, previous thromboembolic event, older age, hypocapnia, hypoxemia, tachycardia, band atelectasis, or elevation of a hemidiaphragm on chest x-ray film. A probability score was calculated by adding points assigned to these variables. A cutoff score of 4 best identified patients with low probability of PE. A total of 486 patients (49%) had a low clinical probability of PE (score </=4), of which 50 (10.3%) had a proven PE. The prevalence of PE was 38% in the 437 patients with an intermediate probability (score of 5-8; n = 437) and 81% in the 63 patients with a high probability (score >/=9).

CONCLUSIONS

This clinical score, based on easily available and objective variables, provides a standardized assessment of the clinical probability of PE. Applying this score to emergency ward patients suspected of having PE could allow a more effective diagnostic process.

Predicting adverse outcome in patients with acute pulmonary embolism: a risk score

Reliable prediction of adverse outcomes in acute pulmonary embolism may help choose between in-hospital and ambulatory treatment. We aimed to identify predictors of adverse events in patients with pulmonary embolism and to generate a simple risk score for use in clinical settings. We prospectively followed 296 consecutive patients with pulmonary embolism admitted through the emergency ward. Logistic regression was used to predict death, recurrent thromboembolic event, or major bleeding at 3 months. Thirty patients (10.1%) had one or more adverse events during the 3-month follow-up period: 25 patients (8.4%) died, thromboembolic events recurred in 10 patients (3.4%), and major bleeding occurred in 5 patients (1.7%). Factors associated with an adverse outcome in multivariate analysis were cancer, heart failure, previous deep vein thrombosis, systolic blood pressure <100 mmHg, arterial PaO2 <8 kPa, and presence of deep vein thrombosis on ultrasound. A risk score was calculated by adding 2 points for cancer and hypotension, and 1 point each for the other predictors. A score of 2 best identified patients at risk of an adverse outcome in a receiver operating characteristic curve analysis. Of 180 low-risk patients (67.2%) (score < or =2), only 4 experienced an adverse outcome (2.2%), compared to 23 (26.1%) of 88 high-risk patients (score > or =3). A simple risk score based on easily available variables can accurately identify patients with pulmonary embolism at low risk of an adverse outcome. Such a score may be useful for selecting patients with pulmonary embolism eligible for outpatient care.

[Evidence-based medicine: an approach without any weakness?]

Evidence-based medicine is a methodological approach giving access to the best information derived from clinical research for an individual patient. It requires the formulation of a question, a strategy to search for the best information, the selection of the latter, its critical appraisal and its application to the patient. The qualities, but also the limitations of this approach are discussed.

Reactive oxygen metabolites increase mitochondrial calcium in endothelial cells: implication of the Ca2+/Na+ exchanger

In endothelial cells, a bolus of hydrogen peroxide (H2O2) or oxygen metabolites generated by hypoxanthine-xanthine oxidase (HX-XO) increased the mitochondrial calcium concentration [Ca2+]m. Both agents caused a biphasic increase in [Ca2+]m which was preceded by a rise in cytosolic free calcium concentration [Ca2+]c (18 and 6 seconds for H2O2 and HX-XO, respectively). The peak and plateau elevations of [Ca2+] were consistently higher in the mitochondrial matrix than in the cytosol. In Ca2+-free/EGTA medium, the plateau phase of elevated [Ca2+] evoked by H2O2 due to capacitative Ca2+ influx was abolished in the cytosol, but was maintained in the mitochondria. In contrast to H2O2 and HX-XO, ATP which binds the P2Y purinoceptors induced an increase in [Ca2+]m that was similar to that of [Ca2+]c. When cells were first stimulated with inositol 1,4, 5-trisphosphate-generating agonists or the Ca2+-ATPase inhibitor cyclopiazonic acid (CPA), subsequent addition of H2O2 did not affect [Ca2+]c, but still caused an elevation of [Ca2+]m. Moreover, the specific inhibitor of the mitochondrial Ca2+/Na+ exchanger, 7-chloro-3,5-dihydro-5-phenyl-1H-4.1-benzothiazepine-2-on (CGP37157), did not potentiate the effects of H2O2 and HX-XO on [Ca2+]m, while causing a marked increase in the peak [Ca2+]m and a significant attenuation of the rate of [Ca2+]m efflux upon addition of histamine or CPA. In permeabilized cells, H2O2 mimicked the effects of CGP37157 causing an increase in the basal level of matrix free Ca2+ and decreased efflux. Dissipation of the electrochemical proton gradient by carbonylcyanide p-(trifluoromethoxy) phenylhydrazone (FCCP), and blocade of the Ca2+ uptake by ruthenium red prevented [Ca2+]m increases evoked by H2O2. These results demonstrate that the H2O2-induced elevation in [Ca2+]m results from a transfer of Ca2+ secondary to increased [Ca2+]c, and an inhibition of the Ca2+/Na+ electroneutral exchanger of the mitochondria.

Should there be systematic screening of coronary heart disease in asymptomatic patients with risk factors alone? A decision analysis approach

The problem of choosing between detection of asymptomatic coronary heart disease (CHD) in patients at risk and primary prevention was assessed in a decision analysis model. Most of the relevant data were derived from the WOSCOP study, which evaluated the effects of statins in asymptomatic hypercholesterolaemic subjects. This study is considered to be a model of primary prevention measurement. Over a 5-year period, 10% of control subjects had events related to CHD, with a 20% mortality rate which was reduced by 33% under statin administration. A decision tree was used to compare these two sets of data (controls and treated patients) with those of a third option in which an exercise test, 201Tl scintigraphy and, in certain cases, coronary arteriography were used to detect and treat CHD at an asymptomatic stage. The test characteristics and outcomes correspond as closely as possible to previously reported data, concerning what can be expected in this particular situation. Over a wide range of CHD probabilities, screening appeared to be better than primary prevention. This result is robust since it was not modified by sensitivity analysis for most of the data. A sharp decrease in the sensitivity of the first two tests and a marked increase in the effectiveness of primary prevention would alter the decision in favour of primary prevention, whereas an increased death rate from CHD and higher CHD probability would favour the utility of screening. As the cost-effectiveness of screening compares favourably with that of primary prevention, it may be useful to assess the validity of this model in a prospective controlled study.

Hydrogen peroxide-induced DNA damage is independent of nuclear calcium but dependent on redox-active ions

In cells undergoing oxidative stress, DNA damage may result from attack by .OH radicals produced by the Fenton reaction, and/or by nucleases activated by nuclear calcium. In the present study, the participation of these two mechanisms was investigated in HeLa cells. Nuclear-targeted aequorin was used for selectively monitoring Ca2+ concentrations within the nuclei ([Ca2+]n), in conjunction with the cell-permeant calcium chelator bis-(o-aminophenoxy)ethane-N,N,N', N'-tetraacetic acid acetoxymethyl ester (BAPTA/AM), the lipid-soluble broad-spectrum metal chelator with low affinity for Ca2+ and Mg2+ N,N,N',N'-tetrakis(2-pyridylmethyl)ethylenediamine (TPEN), and the high-affinity iron/copper chelator 1, 10-phenanthroline (PHE). In Ca2+-containing medium, H2O2 induced extensive DNA strand breaks and an increase in [Ca2+]n that was almost identical to that observed in the cytosol ([Ca2+]c). In cells bathed in Ca2+-free/EGTA medium, in which the increases in [Ca2+]n and [Ca2+]c due to H2O2 were significantly reduced, similar levels of DNA fragmentation also occurred. In cells preloaded with BAPTA/AM or TPEN, the small increase of [Ca2+]n normally elicited by H2O2 in Ca2+-free medium was completely buffered, and DNA damage was largely prevented. On the other hand, pretreatment with PHE did not affect the calcium response in the nuclei, but completely prevented DNA strand breakage induced by H2O2. Re-addition of 100 microM CuSO4 and 100 microM FeSO4 to TPEN- and PHE-treated cells prior to H2O2 challenge reversed the effect of TPEN and PHE, whereas 1 mM was necessary to negate the effect of BAPTA/AM. The levels of DNA strand breakage observed, however, did not correlate with the amounts of 8-hydroxy 2'-deoxyguanosine (8-OHdG): H2O2 did not produce 8-OHdG, whereas PHE alone slightly increased 8-OHdG levels. CuSO4 and FeSO4 enhanced the effects of PHE, particularly in the presence of H2O2. Exposure of cells to a mixture of CuSO4/FeSO4 also resulted in a significant increase in 8-OHdG levels, which was prevented in cells preloaded with BAPTA/AM. Similar results were obtained in a cell-free system using isolated calf thymus DNA exposed to CuSO4/FeSO4, regardless of whether H2O2 was present or not. These results suggest that BAPTA/AM prevents H2O2-induced DNA damage by acting as an iron/copper chelator. These data also indicate that caution must be exercised in using Ca2+ chelating agents as evidence for a role in cellular Ca2+ levels in experimental conditions in which transition-metal-ion-mediated oxidant production is also occurring.

Predictors of inappropriate hospital days in a department of internal medicine

BACKGROUND

This study aimed to identify predictors of inappropriate hospital days in a department of internal medicine, as a basis for quality improvement interventions.

METHODS

The appropriateness of 5665 hospital days contributed by 500 patients admitted to the Department of Internal Medicine, Geneva University Hospitals, Switzerland, was assessed by means of the Appropriateness Evaluation Protocol. Predictor variables included patient's age and sex, manner of admission and discharge, and characteristics of hospital days (weekend, holiday, sequence).

RESULTS

Overall, 15% of hospital admissions and 28% of hospital days were rated as inappropriate. In multivariate models, inappropriate hospital days were more frequent among patients whose admission was inappropriate (odds ratio [OR] = 5.3, 95% CI: 3.1-8.4) and among older patients (80-95 years: OR = 3.6, 95% CI: 1.7-7.0, versus <50 years). The likelihood of inappropriateness also increased with each subsequent hospital day, culminating on the day of discharge, regardless of the total length of stay.

CONCLUSIONS

This study identified both the admission and the discharge processes as important sources of inappropriate hospital use in a department of internal medicine. The oldest patients were also at high risk of remaining in the hospital inappropriately. Surprisingly, long hospital stays did not generate a higher proportion of inappropriate days than short hospital stays. This information proved useful in developing interventions to improve the hospitalization process.

Preventing stroke recurrence in patients with patent foramen ovale: antithrombotic therapy, foramen closure, or therapeutic abstention? A decision analytic perspective

Emphasis on the role of patent foramen ovale as a potential risk factor for ischemic paradoxical stroke has recently increased. Current therapeutic options for secondary stroke prevention include long-term antithrombotic therapies and invasive closure of the defect, but selective indications have not been evaluated. Therefore we developed a Markov-based decision analysis model for a hypothetical cohort of patients 55 years of age with presumed paradoxical embolism, measuring for each therapy the risks of stroke recurrence, treatment-related complications, and death after 5 years and the quality-adjusted life-years. Over a wide range of stroke risk recurrence (0.8% per year to 7% per year), the gain provided by closure of the defect exceeded the one obtained by other therapeutic options. When the risk exceeded 0.8% per year and 1.4% per year, respectively, this was also verified for anticoagulation and antiplatelet therapies compared with therapeutic abstention. Therapeutic abstention was the preferred strategy under 0.8% per year. Sensitivity analyses identified key parameters influencing the choice of therapy. These included estimates of stroke recurrence, bleeding rates, surgery-related case fatality rates, and age. Considering the risks of treatment and the devastating consequences of a recurrent stroke, our model suggests that if the estimated risk of paradoxical stroke recurrence is > 0.8% per year, therapeutic abstention becomes the worst option. Above this threshold secondary stroke prevention with anticoagulation therapy or surgical closure of the defect is the preferred strategy, and assessment of both the risk of stroke recurrence and the risk related to therapeutic options should guide individual therapeutic decision making.

Modulation of the DNA binding activity of transcription factors CREP, NFkappaB and HSF by H2O2 and TNF alpha. Differences between in vivo and in vitro effects

Human endothelial cells exposed to H2O2 showed reduced CREP DNA binding activity, enhanced HSF activation, and no induction of NFkappaB binding activity. Interestingly, H2O2 was able to induce NFkappaB subunit p65 translocation in the nucleus. In contrast, cells exposed to TNF alpha showed enhanced CREP binding activity, activation of NFkappaB and no induction of HSE-HSF complex. Addition of H2O2, diamide and iodoacetic acid to the binding reaction mixture markedly reduced the DNA binding ability of the three transcription factors. Thus free sulfhydryls were important in DNA binding activity of CREP, NFkappaB and HSF, and the lack of induction of NFkappaB by H2O2 in intact cells was likely caused by oxidation on a thiol, and not by a deficiency in the activation pathway.

Hyperoxia, unlike phorbol ester, induces glutathione peroxidase through a protein kinase C-independent mechanism

Human selenium-dependent glutathione peroxidase (GP) is implicated as a mechanism of resistance against oxygen free radicals. The 5' flanking sequence upstream from the coding region of GP contained an oxygen-responsive element termed ORE1 that is responsive to hypoxia, as well as several copies of the activator protein-1 (AP-1)- and AP-1-like-binding sites. In this study, we sought to define the molecular events that lead to GP gene transcription in response to hyperoxia in human umbilical-vein endothelial cells, and asked whether such induction is mimicked and sustained by activation of protein kinase C (PKC) by phorbol esters. Treatment of cells with 100 nM phorbol 12,13-dibutyrate (PdBu) induced a delayed (24-48 h) but significant (2-fold) increase in steady-state GP mRNA levels. Steady-state GP mRNA levels also rose after exposure to 95% O2, again after considerable delay (48-72 h). For both PdBu and oxygen, induction was transcriptionally regulated, as demonstrated by nuclear run-on experiments. The simulations by PdBu and oxygen were additive. In contrast with PdBu, hyperoxia did not stimulate translocation of PKC from the cytosol to the particulate fraction, although the specific activity of both cytosolic and particulate-associated PKC was increased 2-fold in cells exposed to 95% O2 for 5 days. In addition, gel mobility-shift assays using double-stranded tumour-promoting-agent-responsive element (TRE) and nuclear extracts derived from phorbol- and oxygen-treated cells revealed that PdBu, but not hyperoxia, increased AP-1 DNA-binding activity. On the other hand, the up-regulation of GP expression by oxygen could not be accounted for by the ORE1 core sequence, since no specific protein-DNA binding activity could be detected using nuclear extracts from hyperoxic cells and ORE1. Taken together, these results suggest that there may be different molecular mechanisms controlling GP expression. After exposure to PdBu, GP undergoes transcriptional activation via a process that can be readily explained by a classic AP-1 interaction with the TRE sites in the GP promoter. During hyperoxia, GP also undergoes transcriptional activity, but via a process that appears to involve neither TRE nor ORE1.

Risk factors for a medically inappropriate admission to a Department of Internal Medicine

OBJECTIVE

To identify patient- and admission-related risk factors for a medically inappropriate admission to a department of internal medicine.

METHODS

Cross-sectional study of a systematic sample of 500 admissions to the department of internal medicine of an urban teaching hospital. The appropriateness of each admission and reasons for inappropriate admissions were assessed using the Appropriateness Evaluation Protocol. Risk factors included the time (day of week and holidays) and manner (through emergency department or direct admission) of admission, patient age and sex, health status of patient and spouse, living arrangements, formal home care services, and informal support from family or friends.

RESULTS

Overall, 76 (15.2%) hospital admissions were rated as medically inappropriate by the Appropriateness Evaluation Protocol. In multivariate analysis, the likelihood of an inappropriate admission was increased by better physical functioning of the patient (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1-2.1 [for 1 SD in Physical Functioning scores]), lower mental health status of the patient's spouse (OR, 2.6; 95% CI, 1.3-5.6), receipt of informal help from family or friends (OR, 3.3; 95% CI, 1.5-7.2), and hospitalization by one's physician (OR, 3.6; 95% CI, 1.7-7.5). Receiving formal adult home care was not associated with inappropriateness of hospitalization.

CONCLUSIONS

Inappropriate admissions to internal medicine wards are determined by a mix of factors, including the patient's health and social environment. In addition, the private practitioners' discretionary ability to hospitalize their patients directly may also favor medically inappropriate admissions.

Detecting acute thoracic aortic dissection in the emergency department: time constraints and choice of the optimal diagnostic test

STUDY OBJECTIVES

To compare diagnostic strategies for the emergency assessment of patients with suspected acute thoracic aortic dissection and to measure the effect of delays related to the availability of these tests on the selection of the most appropriate one.

METHODS

We carried out a decision analysis representing the risks of performing one or two sequential tests, the tests' accuracy, the risks and benefits of treatment, and the time-dependent mortality rate in untreated patients with dissection (1%/hour). Data were drawn from a Medline search. Our subjects were patients who presented to the emergency department with chest pain in whom acute thoracic aortic dissection was suspected. For different clinical probabilities of aortic dissection, we compared the risks and benefits of testing using the following procedures (alone and in combinations): aortography, computed tomography (CT), magnetic resonance imaging (MRI), and both transesophageal (TEE) and transthoracic echocardiography (TTE). We then measured the effect of delays in these tests on the selection of the appropriate procedure. The outcome studied was 30-day survival.

RESULTS

We determined that the "threshold" clinical probability of aortic dissection above which the benefits of testing outweigh its risks is low. It ranges from 2% with the most reliable procedure (MRI) to 9% with the least (TTE). At low probability of dissection (< 15%), the accuracy of all tests except TTE is sufficient to rule out dissection. Delays have negligible effect on these results. When the likelihood of dissection is higher, the preferred option is to order a second diagnostic test if the results of the first are negative. The threshold probabilities above which to order a second test range from 15% (CT, then aortography) to 35% (MRI, then aortography). Excessive delays may affect the selection of tests when the likelihood of dissection is high (eg, 50%). Thus, although it is less accurate, a CT scan obtained within 2 hours or a TEE obtained within 6 hours of presentation to the ED yields a higher survival rate than an MRI obtained within 9 hours. Similarly, the benefits of ordering a second test, if the result of the first are negative, outweigh the risks only if the delay in obtaining the test does not exceed 10 hours.

CONCLUSION

All patients in whom aortic dissection is suspected, even if the index of suspicion is very low, should undergo one of the available diagnostic procedures (except TTE). A patient with a moderate to high probability of disease should undergo a second investigation if the findings of the first are negative. When the probability of dissection is high, the physician must consider delays in obtaining specific diagnostic tests and order those that will be the most quickly available.

Role of oxygen free radicals in cancer development

In aerobic life, oxidative stress arises from both endogenous and exogenous sources. Despite antioxidant defence mechanisms, cell damage from oxygen free radicals (OFR) is ubiquitous. OFR-related lesions that do not cause cell death can stimulate the development of cancer. This review discusses the effects of oxidative stress at the different stages of carcinogenesis. Mutagenesis through oxidative DNA damage is widely hypothesised to be a frequent event in the normal human cell. A large body of evidence suggests important roles of OFR in the expansion of tumour clones and the acquisition of malignant properties. In view of these facts, OFR may be considered as an important class of carcinogens. Therefore, the ineffectiveness of preventive antioxidant treatments, as documented in several recent clinical trials, is surprising. However, the difficulties of antioxidant intervention are explained by the complexity of both free radical chemistry and cancer development. Thus, reducing the avoidable endogenous and exogenous causes of oxidative stress is, for the present, the safest option. In the near future, new insights in the action of tumour suppressor genes and the DNA repair mechanisms may lead the way to additional tools against carcinogenesis from OFR.

Effects of oxidative stress and Ca2+ agonists on molecular chaperones in human umbilical vein endothelial cells

Endothelial cell dysfunction is a key factor in oxidative stress-related pathology. Disruption of Ca2+ homeostasis is thought to be responsible for much of the endothelial cell dysfunction in oxidative stress. The expression of molecular chaperones (MC), which stabilize protein structures in normal and in stress conditions, reflects the Ca(2+)-dependent and -independent stress effects in the different cell compartments. By two-dimensional (2-D) gel electrophoresis combined with immunoblotting or microsequencing, we have identified 12 major MC in human umbilical vein endothelial cells (HUVEC): (i) the endoplasmic reticulum-located MC GRP78, GRP94, protein disulfide isomerase, and calreticulin; (ii) the mitochondrial MC HSP65 and GRP75; and (iii) the cytosolic/nuclear MC HSP27, HSC70, HSP70, HSP90, cyclophilin, and ubiquitin. To differentiate oxidative stress- and Ca(2+)-mediated effects, HUVEC were exposed to 1) xanthine oxidase plus hypoxanthine to generate oxidative stress, 2) ionomycin plus ethylene glycol-bis(beta-aminoethylether)-N,N,N', N'-tetraacetic acid (EGTA) to deplete intracellular Ca2+ stores, or 3) thrombin to increase cytosolic Ca2+. De novo protein synthesis after exposure was quantified by the incorporation of [35S]methionine. Image processing with the MELANIE system was used to create and compare the 2-D maps of [35S]methionine-labeled proteins under conditions 1)-3) with those of the controls. In a total of 24 2-D gels, 9 different MC were detected in at least 5 out 6 experimental replicates and were subjected to numeric analysis. The statistics showed a > 10% increase in GRP78 (p < 0.05), HSP27, cyclophilin, and ubiquitin after oxidative stress.(ABSTRACT TRUNCATED AT 250 WORDS)