The cis-acting gibberellin response complex in high pI alpha-amylase gene promoters. Requirement of a coupling element for high-level transcription

In cereal alpha-amylase gene promoters the cis-acting gibberellin response element (GARE) is required for increased transcription in the presence of gibberellin. In low-isoelectric point (pI) alpha-amylase gene promoters a second type of cis element, termed a coupling element, must also be present in a specific position near the GARE; otherwise, the level of transcription in the presence of gibberellin is only a few percent of maximum. The coupling element may help determine where and when in development high-level, hormonally regulated transcription will occur. Such coupling elements have not yet been shown to be necessary for high-level transcription from high-pI alpha-amylase gene promoters. Here we use quantitative transient expression assays to show that a high-pI promoter truncated to -300 is a weak promoter due to the absence of a functional coupling element in the vicinity of the GARE. Gibberellin-induced transcription increases substantially when coupling element function is provided, either by appending upstream regions normally attached to the promoter or by inserting a defined coupling element from a low-pI promoter. Thus, in a second type of gibberellin-regulated promoter coupling element function was found to be crucial for hormone regulation to result in high-level transcription.

Purification and initial characterization of a potential plant vacuolar targeting receptor

Clathrin-coated vesicles are known to be involved in the transport of proteins from the Golgi to the vacuole in plant cells. The mechanisms by which proteins are directed into this pathway are not known. Here we identify an integral membrane protein of approximately 80 kDa, extracted from clathrin-coated vesicles of developing pea (Pisum sativum L.) cotyledons, that bound at neutral pH to an affinity column prepared with the N-terminal targeting determinant of the vacuolar thiol protease, proaleurain, and eluted when the pH was lowered to 4. The protein was not retained on a control column prepared with the N-terminal sequence of a homologous, secreted thiol protease, endopeptidase B. The 80-kDa protein also accumulated in a membrane fraction that is less dense than clathrin-coated vesicles. In vitro studies demonstrated a binding constant of 37 nM between the approximately 80 kDa protein and the proaleurain targeting determinant. A peptide with a vacuolar targeting determinant from prosporamin weakly competed for binding to the approximately-80 kDa protein, while a peptide carrying a single amino acid substitution known to abolish prosporamin vacuolar targeting had no measurable binding affinity for the protein. The binding protein is a glycoprotein with a transmembrane orientation in which the C terminus is exposed to the cytoplasm. The binding domain is located in the N-terminal luminal portion of the protein. These properties of the binding protein are consistent with the function of a receptor that would select proteins in the trans-Golgi for sorting to clathrin-coated vesicles and delivery to the vacuole.

What did the doctor do? When physicians and patients disagree

OBJECTIVE

A serendipitous finding in a study of routine clinical encounters was that physicians and patients frequently gave discrepant reports of what had happened during a clinic visit. This report examines the conditions under which these discrepant perceptions occurred.

DESIGN

Five experienced physicians and 189 patients completed postencounter questionnaires immediately following visits to an academic family practice clinic. After each encounter, the physician and patient estimated the duration of the visit and reported whether each of seven clinical events had occurred.

RESULTS

The most common disagreements concerned whether the physician had provided counseling or performed a treatment procedure. Multiple regression analyses suggest that patient characteristics contributed to specific forms of physician-patient disagreement but that overall discrepancy was greatest in cases in which the physician minimized the importance of psychosocial issues and/or felt relatively confident about understanding the patient's problem.

CONCLUSIONS

Although correlation need not imply causality, the results raise the possibility that physicians can promote shared physician-patient understanding by paying more attention to psychosocial factors and being more circumspect in drawing conclusions about patients' problems.

Evaluation of physician decision making with the use of prior probabilities and a decision-analysis model

OBJECTIVES

To determine whether treatment decisions could be influenced by supplying probabilities and whether these decisions would be consistent with a decision-analysis model.

DESIGN

Survey with case scenarios and a computerized decision-analysis model.

SETTING

Family practice residency program.

PARTICIPANTS

Forty family practice residents and faculty in the experimental group and six controls.

INTERVENTIONS

Twelve cases scenarios of patients with hypertension and coexisting diseases were developed. Family practice physicians were asked to rank their drugs of choice for each case. In the second phase, six case scenarios included probabilities for efficacy and adverse reactions of step 1 antihypertensives. These drug selections were compared with a computerized decision-analysis model.

MAIN OUTCOME MEASURES

Frequencies of matches between the drug selections of physicians and the computer model.

RESULTS

The frequency of matches before probabilities were provided to physicians was low (45.6%) and there was a significant increase when probabilities were supplied (71.3%). Regardless of experience level, physicians increased their consistency with the computer model after probabilities were supplied.

CONCLUSIONS

This study demonstrated that physician decision making for antihypertensive therapy can be influenced by patient-specific probability estimates. Probability data can help less experienced residents make decisions that are comparable to those of attending physicians. This study was conducted in one residency program and the generalizability to the practicing physician is unknown. These findings would suggest that educational efforts in residency programs, health maintenance organizations, or group practices may benefit from patient-specific probabilities that assist with decisions for drug therapy interventions.

Improving prescription documentation in the ambulatory setting

Use of a standard prescription pad, although it adequately meets the needs of drug delivery, requires the physician to document prescribed medications separately in the medical record. Failure to do so may lead to under-recognition of problems of potential drug interactions and adverse drug reactions, delays in prescription refills, and other areas of quality of care, especially in a setting where multiple physicians may be involved in the care of a patient. Of 83 prescriptions written in a primary care clinic, only 11 (13%) were noted on the chart medication form when physicians used prescription pads. Implementation of a "one-write" noncarbon prescription form that generated an instant copy increased prescription documentation to 83% (49 of 59 prescriptions) (x2 = 68.86; p < 0.005) over a one-week period. In a follow-up study conducted approximately 3.5 years after the initial intervention, use of the "one-write" form had maintained at 82% prescription documentation (32 of 39) prescriptions) (x2 = 52.05; p < 0.005). A "one-write" copy system could improve clinical care by improving medication documentation in the medical record.

Definition and functional implications of gibberellin and abscisic acid cis-acting hormone response complexes

The mechanisms by which cis-acting hormone response elements affect transcription is unclear. In this study, we demonstrated that a second "coupling element," identified as O2S, must be present to allow a single copy of either the gibberellin response element (GARE) or the abscisic acid response element (ABRE) to mediate their hormonal effects in the barley Amy32b alpha-amylase gene promoter. The interactive effects of the O2S and the GARE are constrained positionally and spatially; thus, together they form a gibberellin response complex (GARC). The absolute requirement of the O2S for function of the ABRE demonstrates that these together form an abscisic acid response complex (ABRC). A second copy of the GARE can substitute for the O2S in the GARC, but only in one orientation. By expressing the GARC-containing and ABRC-containing promoters in developing aleurone tissue, we showed that hormonal effects prevent alpha-amylase gene expression during the second half of grain development, but other mechanisms suppress expression earlier. Our results suggest that the specific sequence serving as a coupling element in a given gene promoter will greatly affect where and when the GARE or ABRE will be able to regulate transcription.

Definition and functional implications of gibberellin and abscisic acid cis-acting hormone response complexes

The mechanisms by which cis-acting hormone response elements affect transcription is unclear. In this study, we demonstrated that a second "coupling element," identified as O2S, must be present to allow a single copy of either the gibberellin response element (GARE) or the abscisic acid response element (ABRE) to mediate their hormonal effects in the barley Amy32b alpha-amylase gene promoter. The interactive effects of the O2S and the GARE are constrained positionally and spatially; thus, together they form a gibberellin response complex (GARC). The absolute requirement of the O2S for function of the ABRE demonstrates that these together form an abscisic acid response complex (ABRC). A second copy of the GARE can substitute for the O2S in the GARC, but only in one orientation. By expressing the GARC-containing and ABRC-containing promoters in developing aleurone tissue, we showed that hormonal effects prevent alpha-amylase gene expression during the second half of grain development, but other mechanisms suppress expression earlier. Our results suggest that the specific sequence serving as a coupling element in a given gene promoter will greatly affect where and when the GARE or ABRE will be able to regulate transcription.

Dicyclomine for medical management of persistent anal fissure with associated spasm of the internal sphincter

The case of a 43-year-old woman with persistent anal fissure responsive to dicyclomine is described. Associated spasm of the internal sphincter had precluded fissure healing. The spasm of the internal sphincter relaxed within 24 hours of dicyclomine administration and subsequently allowed healing. Surgery was avoided.

Differences between patient and physician perceptions of predicted compliance

One approach to improving patient compliance is for physicians to adapt their behaviour to fit patients' psychological characteristics. Previous university-based research has suggested that physician adaptation to patients' locus of control interferes with patient-physician congruence on expected compliance, but not with congruence on satisfaction with their relationship. This study was conducted in a community practice to clarify the relationship between the physician's adaptation to locus of control and likelihood of and commitment to compliance, and satisfaction with the doctor-patient match. One physician saw 148 patients with a variety of illnesses after they had completed the Health Locus of Control (HLC) questionnaire. The physician altered how he spoke with a patient based on whether the patient scored internally or externally on the HLC. After the encounter, both patient and physician rated the patient's likelihood of and commitment to complying with each of the three recommendations. The physician and each patient also rated their satisfaction with the match between them. Patients' ratings of commitment, likelihood, and satisfaction were significantly higher than those of the physician. Unlike earlier results, there were strong correlations between the patients' and physician's estimates of compliance (commitment and likelihood). Just as with the previous study, there was no correlation between the levels of physician and patient satisfaction with their match. This study indicates that physician adaptation to patients' locus of control does not interfere with compliance outcomes of doctor-patient encounters. Whether such adaptation will improve compliance outcomes is yet to be determined.

Purification and characterization of aleurain : a plant thiol protease functionally homologous to Mammalian cathepsin h

Barley (Hordeum vulgare L. cv Himilaya) aleurain is a vacuolar thiol protease originally isolated as a cDNA with 65% derived amino acid sequence identity with cathepsin H (JC Rogers, D Dean, GR Heck [1985] Proc Natl Acad Sci USA 82: 6512-6516). We purified aleurain from barley leaves to homogeneity (>1000-fold) and characterized its activity against a number of substrates. Aleurain is best described as an aminopeptidase; it hydrolyzes three different aminopeptidase substrates with similar catalytic efficiency but is less efficient at hydrolyzing an NH(2)-blocked substrate analog and azocasein. Our values for K(m) and k(cat) for three substrates (arginine 4-methyl-7-coumarylamide, l-arginine beta-naphthylamide, and N-alpha-benzoyl-l-arginine beta-naphthylamide) and specific activity with azocasein are all within a threefold range of those previously reported for human cathepsin H for these substrates (WN Schwartz, AJ Barrett [1980] Biochem J 191: 487-497). Aleurain also shows a number of other similarities to cathepsin H including heterogeneity of charge forms, position of the NH(2)-terminus of the mature protein, and pH-activity profile. The similar properties of aleurain and cathepsin H suggest that these enzymes have a similar function(s) that is required by both plant and animal cells. The availability of a plant system may permit functional ablation experiments in the future to clarify the role of this enzyme in higher eukaryotes.

Can experts predict health risk from family genograms?

BACKGROUND

The family genogram is sometimes used to aid diagnostic, therapeutic, and preventive care decisions. This study evaluated the efficacy of genograms for predicting health risk in comparison to predictions made using demographic and chart review data.

METHODS

Six physicians with expertise in using genograms were asked to evaluate 20 actual patient cases and use three methods to predict the patients' chances, over the next three months, of: a) experiencing illness causing at least one disability day, b) making an unexpected physician visit for a new problem, or c) requiring hospitalization. The three methods were genogram evaluation, review of patient demographics, and review of patients' charts. Predictions from demographic data were always made first; the other two methods were used in varied order. Three months later, actual patient outcomes were reviewed and compared to predictions.

RESULTS

Over the next three months, 44% of subjects experienced a disability day, 35% made an unexpected clinic visit, and none required hospitalization. Predictions of these events with genograms were no more accurate than predictions generated from chart review. The six genogram experts did not predict outcomes at better than chance levels.

CONCLUSIONS

Genograms may be no more accurate than standard clinical chart review for predicting short-term (three month) health outcomes.

Proaleurain vacuolar targeting is mediated by short contiguous peptide interactions

Targeting of soluble proteins to the plant vacuole is mediated by determinants that reside in the polypeptide. We identified the vacuolar targeting determinant of aleurain, a plant vacuolar thiol protease, by incorporating different sequences from proaleurain into the secreted thiol protease, proendoproteinase B (proEP-B), and vice versa. The targeting fates of the chimeric proteins were analyzed by transient expression in electroporated tobacco protoplasts. The targeting determinant SSSSFADSNPIR is positioned at the N terminus of the aleurain propeptide, and its substitution into the propeptide of EP-B caused vacuolar targeting of the resulting chimeric protein. This determinant can be divided into two smaller determinants, SSSSFADS and SNPIR, each of which is sufficient to target proEP-B chimeras to the vacuole, but with lower efficiency. These smaller determinants interact in a positive manner because the combined determinant SSSSFADSNPIR targeted proEP-B with an efficiency greater than each of the smaller determinants alone. Accordingly, the efficiency of aleurain targeting was decreased when either of the smaller determinants was disrupted by replacement with similarly positioned proEP-B sequences. Further experiments on proaleurain identified an additional determinant, VTDRAAST, adjacent to the SSSSFADSNPIR determinant that is also necessary for efficient vacuolar targeting. Our results provide evidence that efficient vacuolar targeting of this thiol protease in plant cells is mediated by the combined action of smaller contiguous determinants; two of these alone are sufficient for vacuolar targeting.

A gibberellin response complex in cereal alpha-amylase gene promoters

The Amy32b gene is a representative member of a closely related family of alpha-amylase genes expressed under hormonal control in aleurone layers of barley grains. Transcription of this gene is induced by gibberellin (GA) and suppressed by abscisic acid. In this study, we functionally defined the promoter elements of the Amy32b gene that govern the developmental and hormonal control of its expression in aleurone. Two functionally distinct yet physically associated elements are essential: a gibberellin response element mediates regulation by GA and abscisic acid, and an Opaque-2 binding sequence (O2S) is thought to interact with a barley homolog of the maize endosperm-specific transcriptional regulator Opaque-2. An additional element CCTTTT, which with the O2S forms part of a canonical "endosperm box," is important in modulating the absolute level of expression of the Amy32b promoter, as is another separate, highly conserved element TATCCATGCAGTG.

Assistive technology device use in patients with rheumatic disease: a literature review

Occupational therapists often prescribe assistive technology devices (ATDs) to assist persons with disabilities in performing daily living tasks. Estimates suggest that although most ATDs are used, a substantial proportion are never used or are discarded shortly after they are obtained. A review of the literature on ATDs was carried out to identify factors that contribute to ATD use and disuse. The review focused on persons with osteoarthritis and rheumatoid arthritis, because such persons are frequent users of ATDs. Although the literature review highlighted person-, environment-, and ATD-related factors as relevant to ATD use, it also underscored the dearth of scientific study of the prescription, provision, and use of ATDs. A model is proposed to guide empirical research aimed at identifying non-device users from the outset of treatment so that interventions to improve ATD use may be initiated or alternative interventions implemented. The variables comprising the model pertain to the patient, the patient's living environment, the therapist prescribing the device, and the device itself.

A gibberellin response complex in cereal alpha-amylase gene promoters

The Amy32b gene is a representative member of a closely related family of alpha-amylase genes expressed under hormonal control in aleurone layers of barley grains. Transcription of this gene is induced by gibberellin (GA) and suppressed by abscisic acid. In this study, we functionally defined the promoter elements of the Amy32b gene that govern the developmental and hormonal control of its expression in aleurone. Two functionally distinct yet physically associated elements are essential: a gibberellin response element mediates regulation by GA and abscisic acid, and an Opaque-2 binding sequence (O2S) is thought to interact with a barley homolog of the maize endosperm-specific transcriptional regulator Opaque-2. An additional element CCTTTT, which with the O2S forms part of a canonical "endosperm box," is important in modulating the absolute level of expression of the Amy32b promoter, as is another separate, highly conserved element TATCCATGCAGTG.

Occupational therapy diagnostic reasoning: a component of clinical reasoning

The occupational therapy process involves the assessment and treatment of problems in occupational status. Assessment entails the sensing and defining of patients' problems and is accomplished through diagnosis. As a process, diagnosis involves the creation of a clinical image of the patient through cue acquisition, hypothesis generation, cue interpretation, and hypothesis evaluation. This sequence of cognitive activities is called diagnostic reasoning. As a product, diagnosis summarizes a patient's occupational deficits in terms of occupational role performance, occupational performance, and the components of occupational performance. To serve adequately as a basis for planning intervention, the occupational therapy diagnosis describes the problem, explains the potential cause of the problem, gives the cues whereby the problem is recognized, and names the pathologic agent. Occupational therapy assessment is broader than diagnosis and includes a delineation of the patient's assets as well as deficits. In the resolution of problems in occupational status, assets may be used to offset deficits. The clinical image represents a balanced view of occupational status by reflecting assets and deficits.

The SAGE-PAGE trial: do family genograms make a difference?

BACKGROUND

Despite enthusiastic promotion of family genograms, the impact of routine use of this tool on clinical practice has not been systematically examined. The present study investigated whether doing a genogram, or having one available, makes physicians more sensitive to psychosocial issues or in other ways affects the physician-patient relationship or the process of clinical care.

METHODS

In a randomized clinical trial, patients visiting 5 physicians at an academic family practice center (n = 189) received a physician-administered genogram (PAGE); a self-administered genogram (SAGE), which the patient completed before seeing the physician; or no genogram. A fourth (baseline) group was tested without genograms prior to the randomized trial.

RESULTS

Analyses of patients' and physicians' postencounter questionnaires showed no impact of genograms on how physicians think about and deal with clinical problems or how patients view the encounter with their physicians. Compared with control groups, neither patient- nor physician-administered genograms increased the physician's (self-defined) understanding of the patient or the importance the physician attached to psychosocial issues in the case. A positive finding was that physicians considered genograms more relevant when they did them themselves. On the other hand, physician-administered genograms also increased the length of the encounter and were substantially less complete (conveying less information) than genograms completed by patients.

CONCLUSIONS

THe results leave open the possibility that genograms do make a difference when used routinely by residents or experts or in difficult cases when family assessment is indicated. While enthusiasm about genogram applications in family medicine is understandable, the clinical utility of this tool remains to be demonstrated scientifically.

cis-acting DNA elements responsive to gibberellin and its antagonist abscisic acid

We have used a transient expression assay in aleurone protoplasts of barley to delineate hormone response elements of the abscisic acid (ABA)-responsive rice gene Rab16A and of the gibberellin A3 (GA3)-responsive barley alpha-amylase gene Amy 1/6-4. Our approach used transcriptional fusions between their 5' upstream sequences and a bacterial chloramphenicol acetyltransferase reporter gene. A chimeric promoter containing six copies of the -181 to -171 region of Rab 16A fused to a minimal promoter conferred ABA-responsive expression on the reporter gene. Transcription from this ABA response element (GTACGTGGCGC) was unaffected by GA3. A chimeric promoter containing six copies of the -148 to -128 sequence of Amy 1/6-4 fused to the minimal promoter conferred GA3-responsive expression on the reporter gene. Transcription from this GA3 response element (GGCCGATAACAAACTCCGGCC) was repressed by ABA. The effect on transcription from both hormone response elements was orientation-independent, indicating that they function as inducible enhancers in their native genes.