A rare cause of small bowel infarction

We report a rare case of small bowel infarction due to superior mesenteric artery occlusion secondary to cardiac tumour embolism. To our knowledge, this has not been previously reported in the literature. This case highlights a rare case and reviews current knowledge on the subject.

Lanosterol induces mitochondrial uncoupling and protects dopaminergic neurons from cell death in a model for Parkinson's disease

Parkinson's disease (PD) is a neurodegenerative disorder marked by the selective degeneration of dopaminergic neurons in the nigrostriatal pathway. Several lines of evidence indicate that mitochondrial dysfunction contributes to its etiology. Other studies have suggested that alterations in sterol homeostasis correlate with increased risk for PD. Whether these observations are functionally related is, however, unknown. In this study, we used a toxin-induced mouse model of PD and measured levels of nine sterol intermediates. We found that lanosterol is significantly (∼50%) and specifically reduced in the nigrostriatal regions of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-treated mice, indicative of altered lanosterol metabolism during PD pathogenesis. Remarkably, exogenous addition of lanosterol rescued dopaminergic neurons from 1-methyl-4-phenylpyridinium (MPP+)-induced cell death in culture. Furthermore, we observed a marked redistribution of lanosterol synthase from the endoplasmic reticulum to mitochondria in dopaminergic neurons exposed to MPP+, suggesting that lanosterol might exert its survival effect by regulating mitochondrial function. Consistent with this model, we find that lanosterol induces mild depolarization of mitochondria and promotes autophagy. Collectively, our results highlight a novel sterol-based neuroprotective mechanism with direct relevance to PD.

Nursing strategies to reduce the incidence of early childhood caries in culturally diverse populations

In the United States, early childhood caries (ECC) is a major unmet health care need adversely affecting the overall health of young children from diverse ethnic populations. Nurses who work in the newborn nursery, pediatrics, public, and community health centers have a unique opportunity to positively influence a change in this epidemic of ECC. Guided by Leininger's theory of cultural care, these authors describe ways to implement a comprehensive culturally sensitive oral health education program for parents of newborns and infants. Interventions based on the best available evidence for oral health education, a culturally sensitive caries risk assessment, recommendations for fluoride varnish treatments, and ways for parents to establish a dental home for the infant by 12 months old are presented.

Tissue response to the components of a hydroxyapatite-coated composite femoral implant

Bone loss around femoral implants used for THA is a persistent clinical concern. It may be caused by stress shielding, generally attributed to a mismatch in stiffness between the implants and host bone. In this regard, a fatigue resistant, carbon fiber (CF) composite femoral implant with bone-matching stiffness has been developed. This study evaluated the tissue response to the three material components of this implant in normal and textured (blasted with 24 grit alumina) surfaces: the hydroxyapatite (HA) coating, the CF composite and the intermediate crystalline HA particulate composite layer to bond to the HA coating (blended). Sprague-Dawley rats underwent bilateral femoral implantation each receiving two rod-like implants. Bone apposition to the HA (37%) and textured Ti (41%) implants was not significantly different. Bone apposition to the untextured CF (14%) and blended (19%) implants and polished Ti (8%) implants was significantly lower. Bone apposition to the textured CF (9%) and blended (11%) implants was lower (but not statistically from the as received or untextured counterparts). Nearly all sections from femurs containing CF implants presented CF debris. There was no evidence of localized bone loss or any strong immune response associated with any of the implant materials. All materials were well tolerated with minimal inflammation despite the presence of particulate debris. The high degree of bone apposition to the HA-coated composite implants and the lack of short-term inflammation and adverse tissue response to the three material implant component support continued evaluation of this composite technology for use in THA.

Increased haematopoietic progenitor cells are associated with poor outcome in patients with metastatic renal cancer treated with sunitinib

BACKGROUND

Haematopoietic progenitor cells (HPCs) are present in blood in metastatic renal cell cancer (mRCC). We investigate their expression in mRCC patients treated with sunitinib and correlate their expression with plasma growth factor levels [insulin-like growth factor (IGF)-1].

METHODS

Circulating HPCs (CD34(+)/CD45(+)) and plasma IGF-1 levels were measured at specific sequential time points (0, 6, 18 and 28 weeks) in 43 untreated mRCC patients receiving sunitinib (50 mg for 28 days followed by 14-day off treatment). Univariate and multivariate analysis assessed the prognostic significance of HPCs and IGF-1.

RESULTS

HPCs levels were raised in 40 of 43 (93%) of patients. IGF-1 levels were raised in 9 of 43 patients (21%). Univariate and multivariate analysis revealed that high HPCs before treatment were associated with a significantly shorter overall survival (hazard ratio 3.3, 95% confidence interval 1.23-8.8, P=0.01), which was not the case for IGF-1 levels. Both HPC and IGF-1 levels fell with sunitinib (61% and 14% fall, respectively, P <0.05 for both). A positive correlation between the falls in HPC and IGF-1 occurred (P<0.001).

CONCLUSIONS

HPCs are over expressed in the peripheral blood in the majority of patients with mRCC. Higher levels are associated with poor prognosis. A concurrent fall in HPCs and growth factor expression (IGF-1) with sunitinib occurs.

Ministry of Health clinical practice guidelines: Management of Rhinosinusitis and Allergic Rhinitis

The Ministry of Health publishes national clinical practice guidelines to provide doctors and patients in Singapore with evidence-based guidance on managing important medical conditions. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the Ministry of Health clinical practice guidelines on Management of Rhinosinusitis and Allergic Rhinitis, for the information of readers of the Singapore Medical Journal. Chapters, page and figure numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website (http://www.moh.gov.sg/mohcorp/publications.aspx?id=24046). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Analysis of long-term treatment outcomes and toxicty of HL

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Background: Prognosis of patients with Hodgkin lymphoma (HL) has substantially improved but therapy of HL can however contribute to delayed toxicity. Long term treatment outcomes of HL in our local population were evaluated. Methods: Clinical and treatment data was prospectively collected from all patients with a histological diagnosis of HL. Patients were all fully staged with CT scan and bone marrow biopsy. Results: On the basis of 217 patients seen at the National Cancer Centre Singapore between 1990–2008, we found that there was a peak in young adulthood with 103 patients who were diagnosed before the age of 30 (48%), median age of presentation 32 (range 17–84). Patients who were young (< 30 years) were more likely to present with nodular sclerosis HL (p=0.0001). Treatment outcomes were comparable to other published series, 85% of cases received ABVD based treatment. 5 year OS for early stage HL was 92% and 88% for advanced stage HL. Overall FFTF was 93% at 5 years. Of note, comparing patients with early stage (Stage I/ II) HL (n=114) who had ABVD 4 cycles followed by involved field radiotherapy (IFRT) with those who received 6–8 cycles of ABVD, there was no difference in OS, FFTF (p= 0.99, 0.48 respectively). Bulky early stage HL who received 6 cycles of ABVD and IFRT had better FFTF rates than those who had just 4 cycles of ABVD followed by IFRT (p=0.06). In contrast, patients patients with advanced HL (Stage III/ IV) (n=70) who completed 6–8 cycles of ABVD did not benefit from additional IFRT even in the presence of bulky disease (n=15). Acute toxicities included that of bleomycin induced pneumonitis (BIP) seen in 15% of cases. Neither the omission of bleomycin nor the presence BIP adversely affected treatment outcomes. Hematological malignancies were seen in 1% of survivors appearing after a median of 7.3 years. Hypothyroidism was noted in 3% of cases. Conclusions: 1) Epidemiology of HL in Singapore is increasingly similar to that of developed countries with a peak in young adults. 2)Young age was predictive of a nodular sclerosis subtype 3) Abbreviated chemotherapy using 4 cycles of ABVD followed by IFRT performed similarly to 6 cycles of ABVD in early stage HL, but in patients with bulky disease this may not be sufficient. 4) BIP occurred in 15% of cases. BIP and the omission of bleomycin did not adversely affect treatment outcomes.

No significant financial relationships to disclose.

Adjuvant chemotherapy for stage II and stage III colon cancer—What is happening in routine practice?

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Background: Randomised studies have defined adjuvant chemotherapy as standard treatment for stage III colon cancer (SIIICC), with multiple options available. For stage II (SII) disease, the selection of patients for adjuvant treatment remains controversial. There remains limited data on clinician decision making regarding adjuvant chemotherapy in routine clinical practice. Methods: A review of patients treated with SII & IIICC at 4 hospitals, utilising data from BioGrid Australia, where clinician choice and rationale were prospectively documented. Results: 372 patients (37%) with SII and 307 (30%) with SIIICC were identified from 1015 CC patients treated from January 2003 till November 2008. Median age was 68 years, 51% were male; 49% female. 66 (25%) of patients with SIIICC were not offered chemotherapy, predominantly due to advanced age or co-morbidity. Since oxaliplatin and capecitabine became widely available in 2005, 66% of treated patients have received oxaliplatin based therapy, 15% bolus 5-FU alone and 19% capecitabine. For SII disease, overall 81 (26%) pts received adjuvant chemotherapy. Age was the dominant influence on treatment choice with 41% aged 70 (p<0.001) receiving treatment. Patients with high risk features were also more likely to receive adjuvant therapy. (p= 0.006 for those with lymphovascular invasion and p= 0.0068 for those with T4 tumours). Dose reductions and completion rates were similar for SII and III disease, and for older and younger patients. Conclusions: Over 25% of patients with SIIICC do not receive adjuvant chemotherapy in routine practice, with physicians basing non-treatment recommendations predominantly on patient age and co-morbidity. Where treatment is used, oxaliplatin-based therapy is the dominant regimen, except in older patients. In SIICC, adjuvant chemotherapy is used in one in four patients, more frequently in younger patients and those with high risk features.

No significant financial relationships to disclose.

Body mass index and health-related behaviours in a national cohort of 87,134 Thai open university students

BACKGROUND

Thailand is undergoing a health-risk transition with overweight and obesity emerging as an important population health problem. This paper reports on a study of the transition, focusing on "lifestyle" factors such as diet (fried foods, soft drinks, Western-style fast foods) and physical activity (mild, moderate, strenuous exercise, housework/gardening and screen time).

METHODS

A baseline survey was administered to 87 134 adult students from all regions of Thailand attending an open university.

RESULTS

54% of the cohort was female. Participants' median age was 29 years. By self-reported Asian standards, 16% of the sample was obese (body mass index (BMI)>or=25) and 15% overweight at risk (BMI>or=23-24.9). Men were twice as likely as women to be overweight (21% vs 9%) or obese (23% vs 10%). Obesity was associated with urban residence and doing little housework or gardening and with spending more than 4 hours a day watching television or using computers. The latter occurred among 30% of the cohort, with a population attributable fraction (PAF) suggesting that it accounts for 11% of the current problem. Daily consumption of fried food was associated with obesity, and eating fried foods every second day or daily had a PAF of nearly 20%.

CONCLUSIONS

These health-related behaviours underpinning the Thai health transition are associated with increasing obesity. They are modifiable through policies addressing structural issues and with targeted health promotion activities to prevent future obesity gains. Insights into future trends in the Thai health transition can be gained as this student cohort ages.

Systemic Wegener's granulomatosis with severe orbito-ocular involvement

Orbito-ocular involvement in Wegener's granulomatosis is the result of both focal ischaemic vasculitis and granulomatous soft tissue inflammation. Necrotising keratoscleritis and orbital inflammation are two most characteristic ophthalmic presentations. We describe a 56-year-old man with systemic limited Wegener's granulomatosis, presenting with pulmonary fibrosis, pansinusitis and left mastoiditis. This was complicated by the development of a left severe necrotising anterior scleritis, peripheral ulcerative keratitis and orbital apex syndrome. Both c-ANCA and anti-PR3 were positive. Despite mainstay systemic immunosuppressive therapy with cyclophosphamide and prednisolone, the visual prognosis remained very poor. This was largely due to the presence of an irreversible ischaemic optic neuropathy, extensive corneoscleral melt and corneal neovascularisation. This case highlights the possible extent of orbital and ocular surface involvement in Wegener's granulomatosis, and hence the importance of vigilance by the physician.

Long-term outcomes of patients with localized rectal cancer treated with chemoradiation or radiotherapy alone because of medical inoperability or patient refusal

PURPOSE

The standard management of rectal cancer continues to be defined by the results of randomized, clinical trials exploring the optimal timing and use of adjuvant chemotherapy and radiation therapy in relation to surgery. The patient with rectal cancer who is elderly and/or has significant comorbidities and the patient who refuses surgery are clinical contexts for which there is limited current data to guide decision making.

METHODS

A retrospective analysis was performed at six Australian centers of patients with rectal cancer treated with radiation therapy or chemoradiation alone because of excessive operative risk or patient refusal of surgery.

RESULTS

We identified 48 patients treated between August 1998 and June 2005 with a median age of 76 (range, 49-94) years. Twenty-four patients (50 percent) were considered medically inoperable and 24 patients refused surgery. Treatment was with chemoradiation (with 5-fluorouracil) in 36 patients and radiotherapy alone in 12 patients; 93 percent completed the planned therapy. A clinical complete response was seen in 56 percent and a partial response in 30 percent of patients. At a median follow-up of 49 months, 18 patients have disease progression, including 10 of 24 in the medically inoperable group and 8 of 24 in the refused surgery group. Of the 25 deceased patients, 16 died from progressive disease and 9 from noncancer causes.

CONCLUSIONS

Chemoradiation or radiotherapy alone is a safe alternative that results in significant progression-free and overall survival times in patients who are considered medically inoperable or refuse to undergo surgery. Ultimately, however, many patients will progress.

Use of multidimensional separation protocols for the purification of trace components in complex biological samples for proteomics analysis

The routine detection of low abundance components in complex samples for detailed proteomics analysis continues to be a challenge. Whilst the potential of multidimensional chromatographic fractionation for this purpose has been proposed for some years, and was used effectively for the purification to homogeneity of trace components in bulk biological samples for N-terminal sequence analysis, its practical application in the proteomics arena is still limited. This article reviews some of the recent data using these approaches, including the use of microaffinity purification as part of multidimensional protocols for downstream proteomics analysis.

A multicentre analysis of the long-term outcomes of patients with localized rectal cancer treated with chemotherapy and/or radiotherapy alone due to medical inoperability or patient refusal

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Background: The outcome for patients with localized rectal cancer treated with chemoradiotherapy (CMT) or radiotherapy alone (RT) and no planned subsequent surgery is unknown. Insights can be provided by study of patients that do not undergo surgery due to excessive operative risk (medically inoperable) as a result of advanced age and/or co-morbidities, or patient refusal. Methods: A retrospective analysis at 6 Australian centers. Patients with recurrent rectal cancer, metastatic disease or primary tumors that were considered unresectable were excluded from the study. Results: We identified 48 patients treated between August 1998 and June 2005 meeting our criteria. There were 13 females and 35 males with a median age of 76 years (range 49 - 94). 24 patients (50%) were deemed medically inoperable and 24 patients refused surgery (the most common reasons were the desire to avoid a stoma or fear of surgery). Treatment was with standard long course radiation plus 5-FU (either bolus or continuous infusion) in 36 patients (75%) and 12 (25%) received RT alone. A complete clinical response was documented in 23 patients (48%) and a partial clinical response was documented in 14 patients (30%). At a median follow-up of 49 months, 18 patients (37.5%) have documented disease progression including 10 of 24 in the medically inoperable group and 8 of 24 in the refused surgery group. The median progression-free survival for all patients was 30+ months. 7 had local progression only, 7 had distant progression only and 4 patients had both local and distant progression. Of the 23 deceased patients, 16 (70%) died from progressive disease and 7 (30%) from non-cancer causes, including 4 from the refused surgery group. The median survival for all patients was 35 + months. Conclusions: In patients who are not suitable candidates for surgical resection due to advanced age and/or comorbidity CRT or RT alone is a safe alternative that results in significant progression-free and overall survival times, with many patients succumbing to co-morbidities rather than progressive disease. Many of these patients refusing surgery will have long periods of disease control after treatment with CRT or RT.

No significant financial relationships to disclose.

A prospective evaluation of treatment with Selective Internal Radiation Therapy (SIR-spheres) in patients with unresectable liver metastases from colorectal cancer previously treated with 5-FU based chemotherapy

BACKGROUND

To prospectively evaluate the efficacy and safety of Selective Internal Radiation (SIR) spheres in patients with inoperable liver metastases from colorectal cancer who have failed 5FU based chemotherapy.

METHODS

Patients were prospectively enrolled at three Australian centres. All patients had previously received 5-FU based chemotherapy for metastatic colorectal cancer. Patients were ECOG 0-2 and had liver dominant or liver only disease. Concurrent 5-FU was given at investigator discretion.

RESULTS

Thirty patients were treated between January 2002 and March 2004. As of July 2004 the median follow-up is 18.3 months. Median patient age was 61.7 years (range 36-77). Twenty-nine patients are evaluable for toxicity and response. There were 10 partial responses (33%), with the median duration of response being 8.3 months (range 2-18) and median time to progression of 5.3 mths. Response rates were lower (21%) and progression free survival shorter (3.9 mths) in patients that had received all standard chemotherapy options (n = 14). No responses were seen in patients with a poor performance status (n = 3) or extrahepatic disease (n = 6). Overall treatment related toxicity was acceptable, however significant late toxicity included 4 cases of gastric ulceration.

CONCLUSION

In patients with metastatic colorectal cancer that have previously received treatment with 5-FU based chemotherapy, treatment with SIR-spheres has demonstrated encouraging activity. Further studies are required to better define the subsets of patients most likely to respond.

Prospective study of treatment with selective internal radiation therapy spheres in patients with unresectable primary or secondary hepatic malignancies

AIM

To prospectively evaluate the efficacy and safety of Selective Internal Radiation (SIR) Spheres (Sirtex Medical, Sydney, NSW, Australia) in patients with unresectable primary or secondary hepatic malignancies.

METHODS

We report our experience of SIR sphere therapy at three Australian centres. Patients with previously untreated colorectal cancer (CRC) received concurrent 5FU, other patients with CRC received 5-FU at investigator discretion and all other patients received SIR spheres alone.

RESULTS

Forty-six patients were enrolled between January 2002 and June 2003. The majority (32 patients) had metastatic colorectal cancer and five patients had hepatocellular carcinoma. The median age of patients was 64 years (range 46-78 years). Forty-three patients were evaluable for response. There were 12 partial responses, of which 10 were in patients with CRC. The median duration of response for all patients was 8.6 months (range 2-21 months). Overall treatment related toxicity was acceptable. Significant late toxicity included four cases of severe gastric ulceration, despite standard work-up and treatment by experienced interventional radiologists.

CONCLUSION

In this series of patients, treatment with SIR-spheres has demonstrated modest activity, mostly observed in patients with CRC. Toxicity was substantial in a small number of patients.

Contact lens microbial keratitis and prior topical steroid use: a disaster in the making?

INTRODUCTION

To review the best-corrected visual acuity, ulcer size, microbiological profile and morbidity of contact lens-related microbial keratitis with and without prior topical steroid use.

MATERIALS AND METHODS

Retrospective case review of admitted cases of contact lens-related microbial keratitis in a tertiary hospital. Data pertaining to demographics, pre-admission treatment with or without topical steroids, ulcer size, duration of admission, Gram stain and culture results as well as the final best-corrected visual acuity were recorded. Patients are classified into 3 groups: Group 1 received no treatment prior to presentation, Group 2 received topical antibiotics only from their general practitioners and Group 3 prescribed both topical antibiotics and steroids.

RESULTS

Forty-six cases were enrolled in the study, 41.3% had prior topical steroids (all dexamethasone) in combination with antibiotics. None of them had topical steroids alone. Large ulcers were associated with steroid use, odds ratio = 7.74 [95% confidence interval (CI), 1.18-50.56] and positivity of Gram stains odds ratio = 7.74 [95% CI, 1.18-50.56] whereas loss of more than 2 Snellen lines was associated with Pseudomonas aeruginosa infection, odds ratios of 21.70 [95% CI,2.09-225.03] and presence of central ulcer, 13.51 [95% CI, 2.33-78.3]. Prior topical steroid use was associated with longer duration of symptoms prior to admission but not duration of stay or surgical intervention.

CONCLUSION

Patients with prior topical combined antibiotics-steroids present slightly later and with larger ulcers. However, the duration of stay, final visual acuity, treatment failure and complication rates were not statistically different from the non-treated group. This might be due to 1) early presentation and therefore early treatment of contact lens-related microbial keratitis and 2) the short duration of use of combined antibiotic-steroid eye drops.

Novel p21-activated kinase-dependent protrusions characteristically formed at the edge of transformed cells

During long-term culture, certain lines become neoplastic while accumulating changes in cell shape. Early and late cell populations have characteristic shape phenotypes that have been quantified by computerized assay. Phenotypes are determined from variables describing three-dimensional aspects of the subcellular distribution of mass. The features of cells can be recognized by use of latent factors, which are theoretical variables based on the covariance of the primary variables. Factor #7 represented a cell edge feature different from filopodia. We studied the morphological characteristics and morphogenesis of the feature. Brief exposure of cells from rat tracheal epithelium to phorbol 12-myristate 13-acetate (PMA) enhanced #7 values. The time to reach maximal #7 values was prolonged if PMA was administered with calcium ionophore or lysophosphatidic acid (LPA). Factor #7 was elevated during periods of ruffling suppression and stress fiber reorganization. Cells showing high #7 values were examined by scanning electron microscopy (SEM) and found to exhibit strap-shaped and cupola-shaped projections. Because RhoA regulates stress fiber formation, we sought to perturb #7 features by introducing dominant-acting negative and positive constructs of RhoA, RhoA-N19, and RhoA-V14. Neither affected #7 values. Although overexpression of the kinase inhibitory domain of p21-activated kinase 1 (PAK) had no effect on #7 values, they were affected by overexpression of a domain binding PAK-interacting guanine nucleotide exchange factor (PIX). Because a PAK-PIX complex is implicated in the remodeling of focal complexes (FCs) and recycling of PAK to the cytoplasm, the results implicate a component of FCs in the formation of #7 features. The data suggested that feature formation is driven by activated Cdc42-binding kinase (ACK) and Rac. Moreover, they suggested that the #7 protrusions are neurite-like structures and that their development involves FC regulation.

Late onset post-keratoplasty astigmatism in patients with keratoconus

AIM

10 eyes of 10 patients are reported where progression of keratoconus in the host cornea occurred more than 10 years after penetrating keratoplasty with resultant increase in astigmatism. The technique and results of graft refractive surgery in seven eyes are presented.

METHODS

The clinical features and management of these patients were retrospectively analysed. Graft refractive surgery involved an incision at the graft-host junction adjacent to the host thinning with compressive resuturing. Astigmatic changes were calculated using vector analysis.

RESULTS

There were seven men and three women with a mean age of 41.2 years. The average age when undergoing penetrating keratoplasty in the affected eye was 28.4 years and the average time after penetrating keratoplasty until keratoconus appeared in the host cornea defined by host thinning was 13.5 years. The mean cylinder power before host thinning was noted was 5.07 D (SD 2.19) and the mean after host thinning was 11.0 D (2.53). The mean vector calculated disease induced astigmatism magnitude was 7.59 D (3.09). Graft refractive surgery was performed in seven eyes. The mean cylinder power before and after graft refractive surgery was 11.28 D (2.15) and 7.09 D (5.53) respectively. The surgically induced astigmatism vector magnitude was 7.36 D (4.88).

CONCLUSION

Progression of keratoconus in the host cornea late after penetrating keratoplasty is characterised by a large astigmatic change where the flat axis of astigmatism passes through an area of host thinning visible on slit lamp examination. Compressive resuturing performed in the area of host thinning resulted in satisfactory reduction of astigmatism.

Visual rehabilitation with new-age rigid gas-permeable scleral contact lenses--a case series

INTRODUCTION

Primary ectatic corneal diseases usually require rigid gas-permeable (RGP) corneal contact lens wear for visual rehabilitation. As the disease progresses, it becomes increasingly difficult to fit these lenses. RGP scleral contact lenses now provide another treatment option before resorting to surgery.

CLINICAL PICTURE

Two patients with pellucid marginal degeneration and one with advanced keratoconus had failed treatment with conventional lenses.

TREATMENT

They were fitted with RGP scleral lenses.

OUTCOME

Good vision was obtained together with satisfactory fit and comfort.

CONCLUSION

RGP scleral lenses are a viable alternative to surgery in the visual rehabilitation of patients with advanced ectatic corneal disorders.

β1PIX, the PAK-interacting exchange factor, requires localization via a coiled-coil region to promote microvillus-like structures and membrane ruffles

PIX is a Rho-family guanine nucleotide exchange factor that binds PAK. We previously described two isoforms of PIX that differ in their N termini. Here, we report the identification of a new splice variant of βPIX, designated β2PIX, that is the dominant species in brain and that lacks the region of ∼120 residues with predicted coiled-coil structure at the C terminus of β1PIX. Instead, β2PIX contains a serine-rich C terminus. To determine whether these splice variants differ in their cellular function, we studied the effect of expressing these proteins in HeLa cells. We found that the coiled-coil region plays a key role in the localization of β1PIX to the cell periphery and is also responsible for PIX dimerization. Overexpression of β1, but not β2PIX, drives formation of membrane ruffles and microvillus-like structures (via activation of Rac1 and Cdc42, respectively), indicating that its function requires localized activation of these GTPases. Thus, β1PIX, like other RhoGEFs, exerts specific morphological functions that are dependent on its intracellular location and are mediated by its C-terminal dimerization domain.

Randomized clinical trial of Surodex steroid drug delivery system for cataract surgery: anterior versus posterior placement of two Surodex in the eye

OBJECTIVE

To evaluate safety and antiinflammatory efficacy of placing two Surodex (Oculex Pharmaceuticals, Inc., Sunnyvale, CA) in the eye after cataract surgery in comparison with steroid eyedrops and to compare anterior versus posterior chamber placement.

DESIGN

Randomized, masked, controlled trial.

PARTICIPANTS

One hundred four eyes of 104 Asian patients undergoing extracapsular cataract extraction with intraocular lens implantation were examined. Of these, 33 eyes of 33 patients served as control eyes (group A).

INTERVENTION

Two Surodex pellets were inserted in the anterior chamber (AC) of 35 eyes (group B), and two Surodex pellets were inserted in the ciliary sulcus of 36 eyes (group C) at the conclusion of surgery. Control eyes received neither Surodex nor a placebo implant, but were prescribed conventional 0.1% dexamethasone eyedrops four times daily for 4 weeks.

MAIN OUTCOME MEASURES

Anterior chamber flare and cells were graded clinically at the slit lamp. Anterior chamber flare was assessed objectively with the Kowa FC500 Laser Flare Meter (Kowa Co. Ltd, Tokyo, Japan). Intraocular pressure and corneal endothelial specular microscopy with morphometric cell analysis were performed for up to 1 year after surgery.

RESULTS

Lower flare meter readings occurred in both Surodex groups at all postoperative visits, as compared with the dexamethasone eyedrop group, with statistical significance at days 4 (P = 0.001), 8 (P = 0.001), and 15 (P = 0.02). No difference in flare occurred between AC and ciliary sulcus placement. Clinical slit-lamp assessment of anterior chamber flare and cells showed no difference between Surodex-treated eyes and dexamethasone-treated eyes. Nine of 33 eyes (27.3%) in group A required steroid augmentation, as opposed to 4 of 71 eyes (5.6%) in groups B and C. Inflammatory symptoms were reduced in the Surodex-treated eyes, with statistical significance for ocular discomfort (P = 0.001), photophobia (P = 0.04), and lacrimation (P = 0.01). No complications occurred with Surodex-treated eyes, and no significant difference in endothelial cell loss was noted between Surodex-treated eyes and dexamethasone-treated eyes up to 1 year after surgery.

CONCLUSIONS

Intraocular placement of two Surodex is a safe and effective treatment method to reduce intraocular inflammation after cataract surgery and clearly is superior to eyedrops in reducing inflammatory symptoms and aqueous flare as measured with the laser flare meter. No difference in efficacy between AC placement and ciliary sulcus placement of Surodex was detected in this study.

Collapsin response mediator protein switches RhoA and Rac1 morphology in N1E-115 neuroblastoma cells and is regulated by Rho kinase

The formation and directional guidance of neurites involves dynamic regulation of Rho family GTPases. Rac and Cdc42 promote neurite outgrowth, whereas Rho activation causes neurite retraction. Here we describe a role for collapsin response mediator protein (Crmp-2), a neuronal protein implicated in axonal outgrowth and a component of the semaphorin 3A pathway, in switching GTPase signaling when expressed in combination with either dominant active Rac or Rho. In neuroblastoma N1E-115 cells, co-expression of Crmp-2 with dominant active RhoA V14 induced Rac morphology, cell spreading and ruffling (and the formation of neurites). Conversely, co-expression of Crmp-2 with dominant active Rac1 V12 inhibited Rac morphology, and in cells already expressing Rac1 V12, Crmp-2 caused localized peripheral collapse, involving Rho (and Cdc42) activation. Rho kinase was a pivotal regulator of Crmp-2; Crmp-2 phosphorylation was required for Crmp-2/Rac1 V12 inhibition, but not Crmp-2/RhoA V14 induction, of Rac morphology. Thus Crmp-2, regulated by Rho kinase, promotes outgrowth and collapse in response to active Rho and Rac, respectively, reversing their usual morphological effects and providing a mechanism for dynamic modulation of growth cone guidance.

Interferon-gamma counteracts reduced endotoxin responsiveness of whole blood following trauma and cardiopulmonary bypass

Accidental as well as surgical trauma has been reported to cause reduced endotoxin responsiveness of blood in terms of cytokine production. In this study, the effect of interferon-gamma (IFN-gamma) on tumour necrosis factor-alpha (TNF-alpha)-producing capacity of whole blood after severe trauma and cardiac surgery was investigated. Blood samples of severely injured patients were collected at the first day after trauma and of cardiac surgery patients before, 4 h and 2 days after cardiopulmonary bypass (CPB). The blood samples were incubated with INF-gamma (0-100 U/ml) for 20 h and subsequently lipopolysaccharide (LPS)-induced TNF-alpha production was determined. Compared to healthy donors, LPS-induced TNF-alpha production was significantly reduced in blood cultures of trauma patients on day 1 after trauma and 4 h after CPB. Pre-incubation with IFN-gamma in vitro increased endotoxin-induced TNF-alpha production in volunteers' and all patients' blood specimens in a dose-dependent manner. IFN-gamma prompted an elevation of cytokine synthesis in CPB patients' blood which equalled that of volunteers, whereas it caused a lower rise in TNF-alpha production in blood of multiply injured patients, reaching levels of untreated donors only after incubation with 100 U/ml IFN-gamma. These experiments show that hyporesponsiveness of whole blood induced by trauma or cardiac surgery with CPB is not irreversible, but can be counteracted by the immunostimulant IFN-gamma. IFN-gamma, therefore, could be applied clinically in trauma patients or after cardiac surgery to prevent or to resolve infection complications.

Therapeutic use of Bausch & Lomb PureVision contact lenses

PURPOSE

To evaluate the Bausch & Lomb PureVision contact lens as a continuous wear contact lens for therapeutic indications in a prospective open-ended non-randomized clinical trial.

METHODS

Patients with a variety of corneal and ocular surface disease conditions presenting at the Singapore National Eye Centre who required therapeutic continuous contact lens wear were enrolled. Therapeutic indications included pain relief, corneal protection, and enhancement of corneal wound healing. Success or failure of specific treatment indications was assessed in all cases, with evaluation of lens performance and fit characteristics, and the presence of ocular complications or lens-related complications was noted.

RESULTS

There were 54 patients (54 eyes), and the mean duration of continuous contact lens wear was 1.1 months. Conditions treated included post-surgical indications (n = 36) (post-keratoplasty or ocular surface transplantation, post-LASIK or PRK surgery) bullous keratopathy (n = 7), chemical burns (n = 3), epithelial abrasions or recurrent corneal erosion syndromes (n = 3), corneal perforations (n = 3), neurotrophic ulcer (n = 1), and corneal laceration (n = 1). For the indication of corneal healing (40 eyes), improved healing was noted in 38 eyes (96%), with full healing occurring in 33 eyes (83%). For pain relief (28 eyes), 27 patients (96%) had considerable or complete pain relief, and the remaining patient reported partial pain relief. For corneal protection (21 eyes), lens wear was fully protective in all cases. The lens performance and fitting characteristics surpassed any previous therapeutic lenses used by the investigators. Complications related to contact lens wear were limited to one case of a culture-negative corneal infiltrate requiring cessation of therapeutic lens wear and one case of a loosely fit lens.

CONCLUSIONS

Our results show that the PureVision contact lens exhibits good safety and efficacy when utilized as a continuous wear therapeutic lens. With the theoretical advantage of increased oxygen transmissibility reducing the risk of hypoxia-related complications, this new lens may be one step closer to the ideal therapeutic contact lens. The PureVision contact lens is now our primary bandage lens of choice in our corneal, external disease, and refractive surgery services.

High-affinity DNA binding of HU protein from the hyperthermophile Thermotoga maritima

Prokaryotic genomes are compacted by association with small basic proteins, generating what has been termed bacterial chromatin. The ubiquitous DNA-binding protein HU serves this function. DNA-binding properties of HU from the hyperthermophilic eubacterium Thermotoga maritima are shown here to differ significantly from those characteristic of previously described HU homologs. Electrophoretic mobility shift analyses show that T. maritima HU (TmHU) binds double-stranded DNA with high affinity (K(d)=5.6(+/-0.7) nM for 37 bp DNA). Equivalent affinity is observed between 4 degrees C and 45 degrees C. TmHU has higher affinity for DNA containing a set of 4 nt loops separated by 9 bp (K(d)=1.4(+/-0.3) nM), consistent with its introduction of two DNA kinks. Using DNA probes of varying length, the optimal binding site for TmHU is estimated at 37 bp, in sharp contrast to the 9-10 bp binding site reported for other HU homologs. Alignment of >60 HU sequences demonstrates significant sequence conservation: A DNA-intercalating proline residue is almost universally conserved, and it is preceded by arginine and asparagine in most sequences, generating a highly conserved RNP motif; V substitutes for R only in HU from Thermotoga, Thermus and Deinococcus. A fivefold increase in DNA-binding affinity is observed for TmHU in which V is replaced with R (TmHU-V61R; K(d)=1.1(+/-0.2) nM), but a change in the trajectory of DNA flanking the sites of DNA intercalation is inferred from analysis of TmHU-V61R binding to DNA modified with 4 nt loops or with substitutions of 5-hydroxymethyluracil for thymine. Survival in extreme environments places unique demands on protection of genomic DNA from thermal destabilization and on access of DNA to the cellular machinery, demands that may be fulfilled by the specific DNA-binding properties of HU and by the fine structure of the bacterial chromatin.

Defects in pulmonary vasculature and perinatal lung hemorrhage in mice heterozygous null for the Forkhead Box f1 transcription factor

Decreased pulmonary expression of Forkhead Box f1 (Foxf1) transcription factor was associated with lethal alveolar hemorrhage in 55% of the Foxf1 +/- newborn mice. The severity of the pulmonary abnormalities correlates with the levels of Foxf1 mRNA. Defects in alveolarization and vasculogenesis were observed in subsets of the Foxf1 +/- mice with relatively low levels of expression from the normal Foxf1 allele. Lung hemorrhage was coincident with disruption of the mesenchymal-epithelial cell interfaces in the alveolar and bronchiolar regions of the lung parenchyma and was associated with increased apoptosis and reduced surfactant protein B (SP-B) expression. Finally, the lung defect associated with the Foxf1 +/- mutation was accompanied by reduced expression of vascular endothelial growth factor (VEGF), the VEGF receptor 2 (Flk-1), bone morphogenetic protein 4 (Bmp-4), and the transcription factors of the Brachyury T-Box family (Tbx2-Tbx5) and Lung Kruppel-like Factor. Reduction in the level of Foxf1 caused neonatal pulmonary hemorrhage and abnormalities in alveologenesis, implicating this transcription factor in the regulation of mesenchyme-epithelial interaction critical for lung morphogenesis.

alpha2-chimaerin, a Cdc42/Rac1 regulator, is selectively expressed in the rat embryonic nervous system and is involved in neuritogenesis in N1E-115 neuroblastoma cells

Neuronal differentiation involves Rac and Cdc42 GTPases. alpha-Chimaerin, a Rac/Cdc42 regulator, occurs as alpha1- and alternatively spliced Src homology 2 (SH2) domain-containing alpha2-isoforms. alpha2-chimaerin mRNA was highly expressed in the rat embryonic nervous system, especially in early postmitotic neurons. alpha1-chimaerin mRNA was undetectable before embryonic day 16.5. Adult alpha2-chimaerin mRNA was restricted to neurons within specific brain regions, with highest expression in the entorhinal cortex. alpha2-chimaerin protein localized to neuronal perikarya, dendrites, and axons. The overall pattern of alpha2-chimaerin mRNA expression resembles that of cyclin-dependent kinase regulator p35 (CDK5/p35) which participates in neuronal differentiation and with which chimaerin interacts. To determine whether alpha2-chimaerin may have a role in neuronal differentiation and the relevance of the SH2 domain, the morphological effects of both chimaerin isoforms were investigated in N1E-115 neuroblastoma cells. When plated on poly-lysine, transient alpha2-chimaerin but not alpha1-chimaerin transfectants formed neurites. Permanent alpha2-chimaerin transfectants generated neurites whether or not they were stimulated by serum starvation, and many cells were enlarged. Permanent alpha1-chimaerin transfectants displayed numerous microspikes and contained F-actin clusters, a Cdc42-phenotype, but generated few neurites. In neuroblastoma cells, alpha2-chimaerin was predominantly soluble with some being membrane-associated, whereas alpha1-chimaerin was absent from the cytosol, being membrane- and cytoskeleton-associated, paralleling their subcellular distribution in brain. Transient transfection with alpha2-chimaerin mutated in the SH2 domain (N94H) generated an alpha1-chimaerin-like phenotype, protein partitioned in the particulate fraction, and in NGF-stimulated pheochromocytoma cell line 12 (PC12) cells, neurite formation was inhibited. These results indicate a role for alpha2-chimaerin in morphological differentiation for which its SH2 domain is vital.

Blot overlays with 32P-labeled fusion proteins

Proteins labeled with 32P can be used as sensitive "prime" in blot overlays to detect binding proteins or domains. Small G-protein Ras can bind GTP with extremely high affinity (Kd approximately 10(-11)-10(-12) M) in the presence of Mg2+. We have taken advantage of this property of Ras to develop a vector that expresses proteins of interest such as glutathione S-transferase (GST)/Ras fusion proteins for noncovalent labeling with [gamma-32P]GTP. The labeling efficiency of this method is >60% and involves a single short incubation step. We have previously identified several binding proteins for the second SH3 domain of the adaptor Nck using this method. Here we illustrate the overlay method using the GST/Ras system and compare results with the SH3 domain labeled by phosphorylation with [gamma-32P]ATP. Both methods are similarly specific and sensitive; however, we show that signals are dependent primarily on GST-mediated probe dimerization. These dimeric probes allow a more stable probe-target complex similar to immunoglobulin interactions, thus significantly improving the sensitivity of the technique.

Phosphorylation of a novel myosin binding subunit of protein phosphatase 1 reveals a conserved mechanism in the regulation of actin cytoskeleton

The myotonic dystrophy kinase-related kinases RhoA binding kinase and myotonic dystrophy kinase-related Cdc42 binding kinase (MRCK) are effectors of RhoA and Cdc42, respectively, for actin reorganization. Using substrate screening in various tissues, we uncovered two major substrates, p130 and p85, for MRCKalpha-kinase. p130 is identified as myosin binding subunit p130, whereas p85 is a novel related protein. p85 contains N-terminal ankyrin repeats, an alpha-helical C terminus with leucine repeats, and a centrally located conserved motif with the MRCKalpha-kinase phosphorylation site. Like MBS130, p85 is specifically associated with protein phosphatase 1delta (PP1delta), and this requires the N terminus, including the ankyrin repeats. This association is required for the regulation of both the catalytic activities and the assembly of actin cytoskeleton. The N terminus, in association with PP1delta, is essential for actin depolymerization, whereas the C terminus antagonizes this action. The C-terminal effects consist of two independent events that involved both the conserved phosphorylation inhibitory motif and the alpha-helical leucine repeats. The former was able to interact with PP1delta only in the phosphorylated state and result in inactivation of PP1delta activity. This provides further evidence that phosphorylation of a myosin binding subunit protein by specific kinases confers conformational changes in a highly conserved region that plays an essential role in the regulation of its catalytic subunit activities.

The tyrosine kinase ACK1 associates with clathrin-coated vesicles through a binding motif shared by arrestin and other adaptors

One target for the small GTPase Cdc42 is the nonreceptor tyrosine kinase activated Cdc42-associated kinase (ACK), which binds selectively to Cdc42.GTP. We report that ACK1 can associate directly with the heavy chain of clathrin. A central region in ACK1 containing a conserved motif behaves as a clathrin adaptor and competes with beta-arrestin for a common binding site on the clathrin N-terminal head domain. Overexpressed ACK1 perturbs clathrin distribution, an activity dependent on the presence of C-terminal "adaptor" sequences that are also present in the related nonkinase gene 33. ACK1 interacts with the adaptor Nck via SH3 interactions but does not form a trimeric complex with p21-activated serine/threonine kinase, which also binds Nck. Stable low level expression of green fluorescent protein-ACK1 in NIH 3T3 cells has been used to localize ACK1 to clathrin-containing vesicles. The co-localization of ACK1 in vivo with clathrin and AP-2 indicates that it participates in trafficking, underlying an ability to increase receptor-mediated transferrin uptake.

Protein kinases required for segregation of vimentin filaments in mitotic process

Vimentin, one of type III intermediate filament (IF) proteins, is expressed not only in mesenchymal cells but also in most types of tumor cells. In the present study, we introduced several types of vimentin mutated at putative phosphorylation sites in its amino-terminal head domain into type III IF-negative T24 cells. Site-specific mutation induced the formation of an unusually long bridge-like IF structure between the unseparated daughter cells, although these mutants formed the filament network similar to wild type in interphase cells. Together with sites phosphorylated by Rho-kinase and protein kinase C (PKC), vimentin-Ser72, which can not be phosphorylated by any known vimentin kinase, was one of the mutation sites essential for this phenotype. We further demonstrated that vimentin-Ser72 was phosphorylated specifically at the cleavage furrow during cytokinesis. These observations suggest the existence of a novel protein kinase responsible for vimentin filament separation through the cleavage furrow-specific vimentin phosphorylation. We propose that Rho-kinase, PKC, and an unidentified vimentin-Ser72 kinase may play important roles in vimentin filament separation during cytokinesis.

The mechanism of PAK activation. Autophosphorylation events in both regulatory and kinase domains control activity

The p21-activated kinases (PAKs), in common with many kinases, undergo multiple autophosphorylation events upon interaction with appropriate activators. The Cdc42-induced phosphorylation of PAK serves in part to dissociate the kinase from its partners PIX and Nck. Here we investigate in detail how autophosphorylation events affect the catalytic activity of PAK by altering the autophosphorylation sites in both alpha- and betaPAK. Both in vivo and in vitro analyses demonstrate that, although most phosphorylation events in the PAK N-terminal regulatory domain play no direct role in activation, a phosphorylation of alphaPAK serine 144 or betaPAK serine 139, which lie in the kinase inhibitory domain, significantly contribute to activation. By contrast, sphingosine-mediated activation is independent of this residue, indicating a different mode of activation. Thus two autophosphorylation sites direct activation while three others control association with focal complexes via PIX and Nck.

Transcription factors in mouse lung development and function

Development of the mouse lung initiates on day 9.5 postcoitum from the laryngotracheal groove and involves mesenchymal-epithelial interactions, in particular, those between the splanchnic mesoderm and epithelial cells (derived from foregut endoderm) that induce cellular proliferation, migration, and differentiation, resulting in branching morphogenesis. This developmental process mediates formation of the pulmonary bronchiole tree and integrates a terminal alveolar region with an extensive endothelial capillary bed, which facilitates efficient gas exchange with the circulatory system. The major function of the mesenchymal-epithelial signaling is to potentiate the activity or expression of cell type-specific transcription factors in the developing lung, which, in turn, cooperatively bind to distinct promoter regions and activate target gene expression. In this review, we focus on the role of transcription factors in lung morphogenesis and the maintenance of differentiated gene expression. These lung transcription factors include forkhead box A2 [also known as hepatocyte nuclear factor (HNF)-3beta], HNF-3/forkhead homolog (HFH)-8 [also known as FoxF1 or forkhead-related activator-1], HNF-3/forkhead homolog-4 (also known as FoxJ1), thyroid transcription factor-1 (Nkx2.1), and homeodomain box A5 transcription factors, the zinc finger Gli (mouse homologs of the Drosophila cubitus interruptus) and GATA transcription factors, and the basic helix-loop-helix Pod1 transcription factor. We summarize the phenotypes of transgenic and knockout mouse models, which define important functions of these transcription factors in cellular differentiation and lung branching morphogenesis.

Signal therapy for RAS-induced cancers in combination of AG 879 and PP1, specific inhibitors for ErbB2 and Src family kinases, that block PAK activation

BACKGROUND

Both EGF family ligands and ErbB family receptor kinases act upstream of RAS to induce mitogenesis of normal cells, such as NIH 3T3 fibroblasts. However, oncogenically mutated RAS, such as v-Ha-RAS is constitutively activated and therefore no longer requires these ligands or receptors for its activation. Nevertheless, it up-regulates the expression of these EGF family ligands. To understand the biologic significance of RAS-induced up-regulation of these ligands in both RAS-induced PAK activation and malignant transformation, we have conducted the following studies, based on the previous observations that (1) the N-terminal SH3 domain of PIX selectively binds a Pro-rich domain of 18 amino acids of PAKs, CDC42/Rac-dependent Ser/Thr kinase family, and (2) this specific interaction is essential for both PAK activation and membrane ruffling

RESULTS

Using four distinct, cell-permeable, and highly specific inhibitors, namely WR-PAK18, which blocks the PAK-PIX interaction; AG 1478, which inhibits ErbB1 kinase activity; and AG 825 or AG 879, which inhibits ErbB2 kinase activity, we demonstrate that (1) the PAK-PIX interaction is essential for v-Ha-RAS-induced malignant transformation; (2) v-Ha-RAS requires not only ErbB1 but also ErbB2, which are activated through two independent autocrine pathways to induce both the PIX/Rac/CDC42-dependent PAK activation and malignant transformation in vitro; and (3) a combination of AG 879 and the Src family kinase-specific inhibitor PP1 suppresses almost completely the growth of RAS-induced sarcomas in nude mice.

CONCLUSION

These findings not only change our conventional view on the role of these RAS-inducible ligands and ErbB family receptors (serving as RAS activators) but also suggest a new avenue for the treatment of RAS-associated cancers by a combination of inhibitors specific for ERbB, Src, or PAK family kinases.

Optimized analytical method for cyclosporin A by high-performance liquid chromatography-electrospray ionization mass spectrometry

The Micromass Platform LCZ mass detector parameters were optimized for simultaneous recording of the protonated (CsA-H+), sodium adduct (CsA-Na+) and potassium adduct (CsA-K+) of cyclosporin A eluted from a Symmetry Shield RP8 column. The optimized procedure allows a precise analysis of CsA in whole blood or serum without removal of salts prior to analysis. The ratio of the three forms of CsA varied depending on the assay condition and the types of specimens being analyzed. The summation of three ionic forms of CsA detected by LC-ESI-MS is a reliable and simple method to assess CsA concentration in the blood.

Differential expression of forkhead box transcription factors following butylated hydroxytoluene lung injury

The forkhead box (Fox) proteins are a growing family of transcription factors that have important roles in cellular proliferation and differentiation and in organ morphogenesis. The Fox family members hepatocyte nuclear factor (HNF)-3beta (Foxa2) and HNF-3/forkhead homolog (HFH)-8 (FREAC-1, Foxf1) are expressed in adult pulmonary epithelial and mesenchymal cells, respectively, but these cells display only low expression levels of the proliferation-specific HFH-11B gene (Trident, Foxm1b). The regulation of these Fox transcription factors in response to acute lung injury, however, has yet to be determined. We report here on the use of butylated hydroxytoluene (BHT)-mediated lung injury to demonstrate that HFH-11 protein and RNA levels were markedly increased throughout the period of lung repair. The maximum levels of HFH-11 were observed by day 2 following BHT injury when both bronchiolar and alveolar epithelial cells were undergoing extensive proliferation. Although BHT lung injury did not alter epithelial cell expression of HNF-3beta, a 65% reduction in HFH-8 mRNA levels was observed during the period of mesenchymal cell proliferation. HFH-8-expressing cells were colocalized with platelet endothelial cell adhesion molecule-1-positive alveolar endothelial cells and with alpha-smooth muscle actin-positive peribronchiolar smooth muscle cells.