Combined aortic and mitral stenosis in mucopolysaccharidosis type I-S (Ullrich-Scheie syndrome)

The genetic mucopolysaccharidosis syndromes (MPS) are autosomal recessive inborn errors of metabolism. Heart valve involvement in MPS is not uncommon but only a few case reports of successful cardiac surgery are available. In particular, reports of combined aortic and mitral stenosis associated with MPS type I-S are very rare. Both type I and type VI MPS are associated with significant left sided valvar heart disease that requires surgical valve replacement because of irregular valve thickening, fibrosis, and calcification. A 35 year old man had severe mitral valve stenosis after successful surgical replacement of a stenotic aortic valve. Valvar heart disease was investigated by cardiac ultrasound and left heart catheterisation. Histomorphological characterisation of the affected mitral valve was performed. The case illustrates typically associated clinical features of cardiac and extracardiac abnormalities found in MPS type I-S.

Preclinical antitumor efficacy of analogs of XK469: sodium-(2-[4-(7-chloro-2-quinoxalinyloxy)phenoxy]propionate

A series of quinoxaline analogs of the herbicide Assure was found to have selective cytotoxicity for solid tumors of mice in a disk-diffusion-soft-agar-colony-formation-assay compared to L1210 leukemia. Four agents without selective cytotoxicity and 14 agents with selective cytotoxicity were evaluated in vivo for activity against a solid tumor. The four agents without selective cytotoxicity in the disk-assay were inactive in vivo (T/C > 42%). Thirteen of the fourteen agents with selectivity in the disk-assay were active in vivo (T/C < 42%). Five of the agents had curative activity. These five agents had a halogen (F, Cl, Br) in the 7-position (whereas Assure had a CI in the 6 position). All agents with curative activity were either a carboxylic acid, or a derivative thereof, whereas Assure is the ethyl ester of the carboxylic acid. All other structural features were identical between Assure and the curative agents. Assure had no selective cytotoxicity for solid tumors in the disk-assay, and was devoid of antitumor activity. The analog XK469 is in clinical development.

Genetic and environmental influences on subtypes of conduct disorder behavior in boys

Oppositional and conduct disorders are a heterogeneous collection of disruptive behaviors associated with diverse risk factors and varying outcomes. Data from males in the Virginia Twin Study of Adolescent Behavioral Development (VTSABD) are used to explore the relative importance of genetic and environmental influences on four previously described disruptive subtypes: property violations, status violations, oppositional behavior, and aggression. Striking differences between results according to mother and child ratings are found, indicating the need to consider carefully the origin of rater differences. Child ratings indicate support for a general genetic liability, with greatest influence on property violations, oppositional behavior and aggression. Maternal ratings suggest that the genetic factors influencing conduct disorder behavior are more specific to the behavioral area, with the stronger genetic influence on property violations and aggression.

Calculation of left ventricular outflow tract area using three-dimensional echocardiography. Influence on quantification of aortic valve stenosis

In 23 patients with aortic valve stenosis (14 male, 9 female, mean age 66 +/- 21.5 years) left ventricular outflow tract cross-sectional area was determined in planimetric fashion using three-dimensional echocardiography. The 3-D data-set for each patient had been acquired in the course of a multiplane transesophageal examination. Aortic valve area was determined using the continuity equation. Results obtained were compared to those calculated by continuity equation using to the conventionally determined LVOT area (a = pi [d/2]2). As reference method the results were compared to invasive measurements. 3-D planimetric determination of LVOT cross-sectional area was possible in 20 of 23 patients. In three patients, this method failed due to artefacts. The mean difference to the conventionally calculated LVOT area amounted to 0.18 cm2 (SD = 0.46). The comparison of AVA determined by continuity equation and by invasive measurement showed a mean difference of -0.074 cm2 (SD = 0.21) for the conventionally calculated LVOT area; for the planimetrically determined LVOT area the mean difference of AVA amounted to -0.03 cm2 (SD = 0.14) (p < 0.05). Planimetric determination of LVOT area using 3-D echocardiography improves the agreement of the continuity equation with invasive measurement.

Pacemaker therapy in premature children with high degree AV block

The smallest pacemaker pulse generator and a steroid-eluting bipolar epicardial lead were implanted in two premature children with symptomatic AV block. Stable capture threshold and high amplitude evoked response electrogram resulted in normal function of the pacemaker Autocapture algorithm, which adjusts output 0.3 V above the measured capture threshold. Autocapture had previously been used only with endocardial leads. Longer-term observation is required.

Mapping of the ICAM-5 (telencephalin) gene, a neuronal member of the ICAM family, to a location between ICAM-1 and ICAM-3 on human chromosome 19p13.2

Intercellular adhesion molecule 5 (ICAM-5, telencephalin) is a cell adhesion molecule expressed on neurons in the most rostral segment of the mammalian brain, the telencephalon. Antibody studies in rodents and rabbits have demonstrated expression of this molecule on the cell body and dendrites of these neurons. We have examined the expression pattern in human brain by Northern blot analysis of 16 human brain segments. This analysis has confirmed the unique expression pattern of this ICAM in human. In addition, we report the mapping of the human ICAM-5 gene to an 80-kb region on chromosome 19p13.2 that also contains ICAM-1 and ICAM-3.

Short CAG repeats within the hSKCa3 gene associated with schizophrenia: results of a family-based study

In a family-based association study we investigated transmission of a multiallelic CAG repeat in a novel neuronal potassium channel gene, hSKCa3, in 59 parent/ offspring trios. In contrast to recent reports of an association of moderately large repeats with schizophrenia in case-control studies, our findings indicate that short CAG repeats (< or=19 repeats) are transmitted at an increased frequency to schizophrenic offspring (p=0.014), particularly among familial cases (p=0.007). No evidence for a parent-of-origin effect was found. Multiallelic TDT procedure showed no association of individual CAG repeats to schizophrenia. Further studies using family-based designs should clarify whether hSKCa3 is a susceptibility factor to schizophrenia or co-segregates with a major disease gene in tight linkage.

Heterologous biosynthesis and characterization of the [2Fe-2S]-containing N-terminal domain of Clostridium pasteurianum hydrogenase

The primary structure of Clostridium pasteurianum hydrogenase I appears to be composed of modules suggesting that the various iron-sulfur clusters present in this enzyme might be segregated in structurally distinct domains. On the basis of this observation, a gene fragment encoding the 76 N-terminal residues of this enzyme has been expressed in Escherichia coli. The polypeptide thus produced contains a [2Fe-2S]n+ cluster of which the oxidized level (n = 2) has been monitored by UV-visible absorption, circular dichroism, and resonance Raman spectroscopy. This cluster can be reduced by dithionite or electrochemically to the n = 1 level which has been investigated by EPR and by low-temperature magnetic circular dichroism. The redox potential of the +2 to +1 transition is -400 mV (vs the normal hydrogen electrode). The spectroscopic and redox results indicate a [2Fe-2S]2+/+ chromophore coordinated by four cysteine ligands in a protein fold similar to that found in plant- and mammalian-type ferredoxins. Among the five cysteines present in the N-terminal hydrogenase fragment, four (in positions 34, 46, 49, and 62) are conserved in other sequences and are therefore the most likely ligands of the [2Fe-2S] site. The fifth cysteine, in position 39, can be dismissed on the grounds that the Cys39Ala mutation does not alter any of the properties of the iron-sulfur cluster. The spectroscopic signatures of this chromophore are practically identical with some of those reported for full-size hydrogenase. This confirms that C. pasteurianum hydrogenase I contains a [2Fe-2S] cluster and indicates that the polypeptide fold around the metal site of the N-terminal fragment is very similar, if not identical, to that occurring in the full-size protein. The N-terminal sequence of this hydrogenase is homologous to sequences of a number of proteins or protein domains, including a subunit of NADH-ubiquinone oxidoreductase of respiratory chains. From that, it can be anticipated that the structural domain isolated and described here is a building block of electron transfer complexes involved in various bioenergetic processes.

Is atrial sensing of ventricular far-field signals important in single-lead VDD pacing?

In single-lead VDD pacing the atrial sensitivity frequently is programmed to sensitive values. Atrial sensing of ventricular far-field signals should be reduced by differential atrial sensing. The aim of the study was to evaluate the effectiveness of this approach.

METHODS

The study included 10 patients with a single-lead VDD pacemaker (Thera 8948, Lead 5032). The atrial sensitivity was set to its most sensitive value of 0.18 mV and the telemetered intraatrial EGM was continuously recorded. After atrial tracked ventricular pacing, VVI pacing was performed with pacing rates from 100 to 160 beats/min in steps of 10 beats/min and up to 165 beats/min. The peak-to-peak amplitudes of P waves (P) and ventricular far-field signals (VFFS) were measured from the recordings. The ratio P/VFFS that defines the atrial signal-to-noise ratio was calculated, and the time from stimulus to maximum of the far-field signals amplitude (Tmax) was measured.

RESULTS

P measured 0.98 +/- 0.76 mV. A VFFS was visible in the atrial channel in all patients with an amplitude of 0.45 +/- 0.25 mV (range 0.01-1.0 mV), independent of the pacing rate. The ratio P/VFFS was 3.9 +/- 4.2 (range 0.9-21.0). Tmax measured 99.4 +/- 15.2 ms during sinus rhythm. A rate dependent shortening of Tmax to 92.7 +/- 11.2 ms at 140 beats/min was observed (P = 0.001). At rates above 140 beats/min no further shortening occurred.

CONCLUSION

Ventricular far-field signals are measurable in the atrial channel of VDD systems and may reach considerable amplitudes, which are not rate dependent. Although differential sensing provides favorable P waves to ventricular far-field signal ratios, refractory periods are needed to avoid far-field sensing. The rate dependent shortening of the ventricular signal can be detected in the atrial channel in VDD pacing.

[The official American guidelines for prevention of nosocomial pneumonia. U. S. Centers for Disease Control]

The official German guidelines for prevention of nosocomial pneumonia were published by the Bundesgesundheitsamt, now called Robert-Koch-Institut, twelve years ago. The recently published official "guidelines for prevention of nosocomial pneumonia" of the Centers for Disease Control and Prevention (CDC) are categorized according to scientific evidence. The American guidelines are very detailed and differ in some aspects from the official German guidelines. The purpose of the present paper is to inform the German anaesthesiologist about the official CDC guidelines and to provide a renewed background for the prevention of nosocomial pneumonia.

Thoracoscopic interruption of patent ductus arteriosus compromises cardiopulmonary function in newborn pigs

Interruption of patent ductus arteriosus (PDA) using video-assisted thoracoscopic surgery (VATS) has recently been introduced into clinical practice. To study cardiovascular and pulmonary function during VATS, we treated 16 newborn pigs (weight 1421+/-44 g) with PDA with conventional surgical interruption (CSI; n = 7) or interruption via VATS (n = 9). Measurements of hemodynamics and gas exchange were performed before, during, and after surgery. Systemic perfusion was calculated using Fick's equation. Stress hormones (ACTH, epinephrine, and norepinephrine) were determined before and after surgery. The duration of the surgical procedure was 41+/-8 min for CSI and 49+/-9 min for VATS (mean+/-SEM). With VATS, PaO2 decreased during and after surgery (P < 0.05), whereas alveolar-arterial PO2 difference (PA-aO2) and PaCO2 were increased (P < 0.05). Compared with CSI after surgery, PaO2 with VATS was decreased (130+/-10 vs 171+/-12 mm Hg; P < 0.05). Systemic perfusion was lower during VATS (76.7% of baseline) than during CSI (107% of baseline; P < 0.05). Heart rate, mean arterial pressure, and right ventricular end-diastolic pressure remained unchanged with both treatments. Stress hormones were comparable between groups. We conclude that systemic perfusion and oxygenation were impaired during VATS compared with CSI. Therefore, VATS may be contraindicated in pediatric patients with minor cardiopulmonary reserve.

IMPLICATIONS

We studied the cardiopulmonary effects of endoscopic interruption of the patent ductus arteriosus in an animal model of newborn pigs. Gas exchange and systemic perfusion were impaired compared with conventional interruption of the patent ductus arteriosus after thoracotomy.

How reliable is atrial sensing in single-lead VDD pacing: comparison of three systems

This study evaluated the reliability of atrial sensing, expressed as AV synchronous stimulation, in three VDD systems with the atrial sensitivity (AS) programmed to a conventional value with a 2:1 safety margin compared to most-sensitive values. We studied 34 sex- and age-matched patients with 3 VDD systems: 14 with Unity 292-07, 10 with Saphir 600, and 10 with Thera VDD (5 model 8948 and 5 model 8968i). Two 24-hour Holters were performed on consecutive days. The AS was programmed in a randomized order to its most-sensitive value or to a 2:1 safety margin. All other parameters were programmed identically. The patients underwent a myopotential oversensing test and a daily life activity protocol. A beat-to-beat analysis of the Holters was performed to determine AV synchrony. For the entire group AV synchrony with conventional AS was 98.63% +/- 2.57%, compared to 99.80% +/- 0.43% with most-sensitive values (p = 0.002). There was no difference between the three systems with conventional AS. With the most-sensitive AS, AV synchrony was: Unity 99.99% +/- 0.03%, Saphir 99.42% +/- 0.60% (P = 0.002), Thera 99.81% +/- 0.35% (ns). In the Saphir system with an atrial blanking period of 150 ms, ventricular far-field sensing could be demonstrated in 5 of 10 patients. This reduced the percentage of AV synchrony due to an unwanted mode-switch to a nontracking mode. Myopotential oversensing was not detected in any patient.

CONCLUSION

The VDD systems tested under identical conditions showed reliable P wave sensing at the most-sensitive atrial sensing setting without myopotential oversensing. Ventricular far-field sensing reduced AV synchrony and must be avoided by appropriate refractory periods.

First experience with an automatic sensing algorithm in single-lead VDD stimulation

An "Autosensing" algorithm available in SSI(R) and DDR(R) pacemakers automatically adapts the device's sensitivity to changing intracardiac signals. The atrial sensing function of this algorithm was tested for the first time with a VDD pacing system in which large variations of the atrial signal may occur because the atrial electrodes float in the atrial blood pool.

METHODS

15 patients with a VDD pacing system were studied (Unity 292-07, lead 425; Sulzer Intermedics). The atrial sensing threshold was measured, and the atrial sensitivity was programmed with a 2:1 safety margin. The autosensing algorithm and sensitivity profile were temporarily activated, and an ambulatory ECG with continuous marker annotation was recorded. All patients underwent a 30-minute daily life activities protocol. A beat-to-beat analysis of the ambulatory ECG was correlated with the changes in atrial sensitivity.

RESULTS

The algorithm changed the baseline sensitivity from 0.57 +/- 0.23 mV during the test to 0.39 +/- 0.20 mV after the final rest period (P < 0.05). During the test 12.6 +/- 10.2 adaptations of the sensitivity occurred (range 0-33). In eight patients atrial undersensing occurred in 4.4% +/- 7.5% of the cycles (4-458 unsensed P waves). In these patients, the algorithm continuously adjusted the sensitivity towards more sensitive values, operating 19.1 +/- 18.3 changes compared with 5.4 +/- 7.3 changes in patients without undersensing (P = 0.009). Oversensing did not occur.

CONCLUSION

The autosensing algorithm effectively optimized atrial sensitivity in VDD pacing. In patients with atrial undersensing the algorithm continuously remained near the most sensitive settings, thus reacting as intended. A faster sensitivity adjustment of the system would be desirable.

Clinical profile of saruplase: angiographic findings

Saruplase is a relatively new fibrinolytic drug. Dose finding studies indicated that 70-80 mg saruplase given intravenously results in a high perfusion rate. With a 20 mg bolus followed by a 60 mg infusion over 1 h, a rapid and complete restoration of blood flow can be achieved in a fairly high number of patients. This dose regimen was used in subsequent studies comparing saruplase with other thrombolytic agents. The PRIMI (Pro-urokinase In Myocardial Infarction) study compared saruplase with streptokinase. Early patency rate at 60 min (TIMI grade 2 and 3 flow) was significantly higher with saruplase (71.8%) than with streptokinase (48.0%). In the SESAM (Study in Europe with Saruplase and Alteplase in Myocardial Infarction) study comparing saruplase with alteplase, at 60 min patency rate was 79.9% versus 75.3%, respectively, and at 90 min the rate was 79.9% versus 81.4%, respectively. In the LIMITS (Liquemin in Myocardial Infarction during Thrombolysis with Saruplase) study a heparin bolus of 5000 IU was shown to have an important impact on patency rate. Both heparin and acetylsalicylic acid are recommended as adjunctive therapy before fibrinolysis with saruplase. The reocclusion rates within 24-40 h were between 0.9% and 2.4% in the saruplase studies. There is some variation in estimating whether patency rates are higher with anterior or with inferior infarctions. Saruplase appears to be equally effective in the treatment of infarction in both locations.

Paroxysmal atrial fibrillation and high degree AV block: use of single-lead VDDR pacing with mode switching

Dual chamber rate responsive pacing incorporating a mode switching option is increasingly used in patients with chronic paroxysmal atrial fibrillation and high degree AV block. Single-lead VDDR pacemakers have rarely used for this indication. The purpose of this study was to determine their reliability of atrial sensing during atrial fibrillation, the percentage of atrial synchronous ventricular pacing, and the behavior of the sinus rate outside the phases of atrial fibrillation. We studied ten patients with a single-lead VDDR pacemaker implanted for this indication. Follow-up visits were performed at predischarge and after 1, 3, 6, 12, 18, and 24 months. During the mean follow-up period of 18.9 +/- 6.9 months, the atrial sensing thresholds in sinus rhythm remained stable. Atrial synchronous ventricular stimulation was achieved in 68.7 +/- 31.2% (median 82.5%) of the whole follow-up time. All patients showed an adequate atrial rate response during sinus rhythm. Atrial fibrillation was detected by the pacemakers in 24.0 +/- 29.8% of time. In 3 of 10 patients the duration of atrial fibrillation showed a steady increase from visit to visit. The sensed amplitudes of atrial fibrillation ranged from 0.1-1.0 mV. A programmed atrial sensitivity of 0.1 mV was necessary to achieve complete sensing of atrial fibrillation. None of the patients experienced tachycardias with optimized pacemaker programming. Single-lead VDDR pacing incorporating a mode-switching option is useful in patients with high degree AV block and paroxysmal atrial fibrillation, since it provides atrial synchronous ventricular pacing in more than two-thirds of follow-up time. In a subgroup of patients, a progressive increase of the time during atrial fibrillation was demonstrated. A reliable detection of paroxysmal atrial fibrillation requires the programming of the atrial sensitivity to its most sensitive value.

Unit-based acute confusion resource nurse: an educational program to train staff nurses

Despite the high prevalence of acute confusion among elders and the importance of its early detection, there are few reports of systematic efforts to increase staff competence. This article describes the development and evaluation of an 8-hour educational program designed to prepare staff nurses to perform in a new role, the unit-based acute confusion Resource Nurse (ACRN). Pre- and posttest scores were obtained for the 80 registered nurses who participated in the program. Paired t tests showed that knowledge and confidence significantly increased for participants as a result of their participation in the educational program. This program can serve as an effective model for geriatric staff education.

[Flow quantification of intracardiac shunt volumes using MR phase contrast technique in the breath holding phase]

PURPOSE

Comparison of a breath-hold, velocity-encoded, phase-difference magnetic resonance (MR) sequence for intracardiac shunt flow measurement with the invasive shunt size determination by oximetry.

PATIENTS AND METHODS

10 patients with different cardiac shunts (6 ASD/3 VSD/1 PDA) and four healthy individuals were investigated using a 1.5 Tesla Siemens Vision system. For flow measurements a breath-hold, velocity-encoded, phase-difference magnetic resonance (MR) sequence was used ('through plane', FLASH 2D-sequence, TR/TE 110/5 ms, 'velocity encoding' 250 cm/s). Mean flow (ml/R-R interval) in the ascending aorta, the pulmonary trunk, and the right and left pulmonary arteries was determined. The ratio of the mean flow in the pulmonary circulation (Qp: sum of the mean flows in the right and left pulmonary arteries) and the systemic circulation (Qs: mean flow in the proximal aorta) was compared with the Qp/Qs ratios determined by the invasive oxymetric technique. Oximetry was performed within 24 hours after MR imaging.

RESULTS

In the 4 healthy individuals MR flow measurement yielded a Qp/Qs ratio of 0.96 +/- 0.15. In the 10 patients with the various shunt defects, the non-invasive shunt determination by MR gave a Qp/Qs ratio of 2.09 +/- 0.67. The percentage of the calculated shunt sizes was 47.05 +/- 17.45%. In the comparison with the results determined by the invasive oxymetric technique, the MR data showed a strong correlation of r = 0.87.

CONCLUSIONS

Breath-hold, velocity-encoded, phase-difference MR-technique enables a reliable quantification of cardiac shunts within a short acquisition time.

Impact of routine angiographic follow-up after angioplasty

BACKGROUND

There is an ongoing controversy as to whether repeat coronary angiography should be routinely performed after successful percutaneous transluminal coronary angioplasty (PTCA).

METHODS

We examined the 10-year outcome in 400 patients who had or had not undergone an angiographic control 6 months after successful PTCA and a subsequent event-free 6-month period. Our comparison was based on data gathered by questionnaire and telephone interview in 315 patients with (group A) and 85 patients without (group B) a routine 6-month angiographic control. Multivariate analysis (Cox model) was performed to identify predictors of adverse events.

RESULTS

During the 10-year follow-up period, 22 (7%) of the 315 patients in group A died, compared with 16 (19%) patients in group B (P= .003). In groups A and B, respectively, acute myocardial infarction occurred in 28 (9%) and 10 (12%) patients (not significant [NS]); coronary artery bypass grafting (CABG) was performed in 42 (13%) and 14 (16%) patients (NS); repeat PTCA was performed in 89 (28%) and 11 (13%) patients (P= .012); and serious adverse events (death, myocardial infarction, CABG) occurred in 76 (24%) and 32 (38%) patients (P= .02). Absence of a 6-month angiographic follow-up was identified as an independent predictor of death associated with a 2.7 times higher mortality rate during the 10-year follow-up period. Previous myocardial infarction increased the risk of death 2.5 times. Any increase of residual diameter stenosis by 10% was combined with a 1.4 times higher mortality rate. The chance of bypass surgery was higher in patients with multivessel disease (2.9 times), in patients with unstable angina (2.1 times), and in case of an increase of residual diameter stenosis by 10% (1.3 times). No predictor for the risk of myocardial infarction was found. Angiographic follow-up increased the likelihood of PTCA 2.5 times.

CONCLUSIONS

A routinely performed angiographic control 6 months after successful PTCA is associated with a significantly higher rate of repeat PTCA but, most important, is correlated with a significantly lower mortality rate during the 10-year follow-up period.

Changes of neurohumoral parameters and endothelin-1 in response to exercise in patients with mild to moderate congestive heart failure

Plasma endothelin levels are increased in patients with moderate and severe CHF. Conflicting data exist about the endothelin-1 (ET) level in patients with mild to moderate CHF and the effect of maximal exercise on plasma ET levels.

METHODS AND RESULTS

We determined the plasma levels of ET and various neurohumoral parameters in 93 patients with CHF in functional class II and III of the NYHA classification at rest and after maximal bicycle exercise. Baseline ET level was increased compared to an age-matched healthy volunteer group (6.95+/-0.31 vs 3.29+/-0.17 pg/ml, mean+/-S.E.M., P<0.05), without significant differences between NYHA class II and III patients. Maximal exercise did not increase the ET level. In contrast, the neurohumoral parameters were significantly increased with maximal exercise. In conclusion, plasma levels of ET are increased in patients with mild to moderate CHF. However, no further increase in response to exercise was observed. Thus, it is highly unlikely that exercise capacity may be limited by ET-mediated peripheral vasoconstriction.

The alpha-chemokine, stromal cell-derived factor-1alpha, binds to the transmembrane G-protein-coupled CXCR-4 receptor and activates multiple signal transduction pathways

The alpha-chemokine stromal cell-derived factor (SDF)-1alpha binds to the seven transmembrane G-protein-coupled CXCR-4 receptor and acts to modulate cell migration and proliferation. The signaling pathways that mediate the effects of SDF-1alpha are not well characterized. We studied events following SDF-1alpha binding to CXCR-4 in a model murine pre-B cell line transfected with human CXCR-4. There was enhanced tyrosine phosphorylation and association of components of focal adhesion complexes such as the related adhesion focal tyrosine kinase, paxillin, and Crk. We also observed activation of phosphatidylinositol 3-kinase. Wortmannin, a selective inhibitor of phosphatidylinositol 3-kinase, partially inhibited the SDF-1alpha-induced migration and tyrosine phosphorylation of paxillin. SDF-1alpha treatment selectively activated p44/42 mitogen-activated protein kinase (Erk 1 and Erk 2) and its upstream kinase mitogen-activated protein kinase kinase but not p38 mitogen-activated protein kinase, c-Jun amino-terminal kinase or mitogen activated protein kinase kinase. We also observed that SDF-1alpha treatment increased NF-kappaB activity in nuclear extracts from the CXCR-4 transfectants. Taken together, these studies revealed that SDF-1alpha activates distinct signaling pathways that may mediate cell growth, migration, and transcriptional activation.