Light-induced exchange of nucleotides into coupling factor 1 in spinach chloroplast thylakoids

Identification, expression, and functional analyses of a thylakoid ATP/ADP carrier from Arabidopsis

In plants the chloroplast thylakoid membrane is the site of light-dependent photosynthetic reactions coupled to ATP synthesis. The ability of the plant cell to build and alter this membrane system is essential for efficient photosynthesis. A nucleotide translocator homologous to the bovine mitochondrial ADP/ATP carrier (AAC) was previously found in spinach thylakoids. Here we have identified and characterized a thylakoid ATP/ADP carrier (TAAC) from Arabidopsis.(i) Sequence homology with the bovine AAC and the prediction of chloroplast transit peptides indicated a putative carrier encoded by the At5g01500 gene, as a TAAC. (ii) Transiently expressed TAAC-green fluorescent protein fusion construct was targeted to the chloroplast. Western blotting using a peptide-specific antibody together with immunogold electron microscopy revealed a major location of TAAC in the thylakoid membrane. Previous proteomic analyses identified this protein in chloroplast envelope preparations. (iii) Recombinant TAAC protein specifically imports ATP in exchange for ADP across the cytoplasmic membrane of Escherichia coli. Studies on isolated thylakoids from Arabidopsis confirmed these observations. (iv) The lack of TAAC in an Arabidopsis T-DNA insertion mutant caused a 30-40% reduction in the thylakoid ATP transport and metabolism. (v) TAAC is readily expressed in dark-grown Arabidopsis seedlings, and its level remains stable throughout the greening process. Its expression is highest in developing green tissues and in leaves undergoing senescence or abiotic stress. We propose that the TAAC protein supplies ATP for energy-dependent reactions during thylakoid biogenesis and turnover in plants.

Mitochondrial ATPase

Considerable progress has been made in recent years in our understanding of the phosphorylating apparatus in mitochondria, chloroplasts, and bacteria. It has become clear that the structure and the function of the ATP synthesizing apparatus in these widely divergent organisms is similar if not virtually identical. The subunit composition of F1, its molecular architecture, the location and function of substrate binding sites, as well as putative control sites, understanding of the component parts of the oligomycin-sensitive ATPase complex, and the role of these components in the function of the complex all are under active investigation in many laboratories. The developing information and the new insights provided have begun to permit experimental approaches, at the molecular level, to the mode of action of the ATPase in electron-transport-coupled ATP synthesis.

The decay of the ATPase activity of light plus thiol-activated thylakoid membranes in the dark

Oxidized ATP synthase of spinach thylakoid membranes catalyzes high rates of ATP synthesis in the light, but very low rates of ATP hydrolysis in the dark. Reduction of the disulfide bond in the gamma subunit of the ATP synthase in the light enhances the rate of Mg2+-ATP hydrolysis in the dark. The light plus thiol-activated state decays in a few minutes in the dark after illumination in Tris buffer, but not when Tricine was used in place of Tris. In this paper, it is shown that Tris in the assay mixture is an inhibitor of the light plus thiol-activated ATPase activity of thylakoids, but only after the activated membranes had incubated in the dark. Aminopropanediols and diethanolamine, also selectively inhibited ATPase activity of activated membranes after storage in the dark, whereas NH4Cl and imidazole inhibit the ATPase activity of activated thylakoids almost equally whether they are added directly after the illumination or several minutes later. The fluorescence of 9-amino-6-chloro-2-methoxyacridine (ACMA) is quenched by the establishment of proton gradients by ATP-dependent proton uptake. Addition of ATP to activated membranes results in rapid quenching of ACMA fluorescence. If the activated membranes were incubated in the dark prior to ATP addition, a lag in the ATP-dependent ACMA fluorescence quenching as well as a similar lag in the rate ATP hydrolysis were seen. It is concluded that ADP rebinds to CF1 in the dark following illumination and inhibits the activity of the ATP synthase. Reactivation of the ATP synthase in the dark can occur by the slow generation of proton gradients by ATP hydrolysis in the dark. This reactivation takes place in Tricine buffer, but not in Tris because of its uncoupling action. Whether ADP binding plays a role in the regulation of the activity of the ATP synthase in situ remains to be established.

Rapid purification of membrane extrinsic F1-domain of chloroplast ATP synthase in monodisperse form suitable for 3D-crystallization

A new chromatographic procedure for purification of the membrane extrinsic F1-domain of chloroplast ATP synthase is presented. The purification is achieved by a single anion exchange chromatography step. Determination of the enzyme-bound nucleotides reveals only 1 mole of ADP per complex. The purified enzyme shows a latent Ca(2+)-dependent ATPase activity of 1.0 mumol.mg-1 min-1 and a Mg(2+)-dependent activity of 4.4 mumol.mg-1 .min-1. Both activities are increased up to 8-10-fold after dithiothreitol activation. Analysis of the purified F1-complex by SDS/PAGE, silver staining and immunoblotting revealed that the preparation is uncontaminated by fragmented subunits or ribulose-1,5-bisphosphate carboxylase/oxygenase. Gel filtration experiments indicate that the preparation is homogenous and monodisperse. In order to determine the solubility minimum of the purified F1-complex the isoelectric point of the preparation was calculated from pH mapping on ion exchange columns. In agreement with calculations based on the amino acid sequence, a slightly acidic pI of 5.7 was found. Using ammonium sulphate as a precipitant the purified CF1-complex could be crystallized by MicroBatch.

Energetics of ATP dissociation from the mitochondrial ATPase during oxidative phosphorylation

The dissociation constant (KdATP) for ATP bound in the high affinity catalytic site of membrane-bound beef heart mitochondrial ATPase (F1) was calculated from the ratio of the rate constants for the reverse dissociation step (k-1) and the forward binding step (k+1). k-1 for ATP bound to submitochondrial particles or to submitochondrial particles washed with KCl so as to activate ATPase activity was accelerated by about five orders of magnitude during respiratory chain-linked oxidations of NADH. In the presence of NADH and 0.1 mM ADP, k-1 increased more than six orders of magnitude. These energy-dependent dissociations of ATP were sensitive to the uncoupler carbonyl cyanide p-trifluoromethyloxyphenylhydrazone. Only small changes in k+1 were observed in the presence of NADH or NADH and ADP. KdATP at 23 degrees C in the absence of NADH and ADP was 10(-12) M, in the presence of NADH, 3 microM, and in the presence of NADH and 0.1 mM ADP, 60 microM. Thus, the dissociation of ATP during the transition from non-energized to energized states was, under these conditions, accompanied by observed free energy changes of 8 and 9.7 kcal/mol, respectively.

Proton slip of the chloroplast ATPase: its nucleotide dependence, energetic threshold, and relation to an alternating site mechanism of catalysis

The F-ATPase of chloroplasts couples proton flow to ATP synthesis, but is leaky to protons in the absence of nucleotides. This "proton slip" can be blocked by small concentrations of ADP or by inhibitors of the channel portion, CF0. We studied charge flow through the ATPase by flash spectrophotometry and analyzed the inhibition of proton slip by nucleotides, phosphate/arsenate, and insufficient proton motive force. The following inhibition constants (at given background concentrations) were observed: ADP, 0.2 microM (0.5 mM P(i)); ADP, 13.4 microM (no P(i)); P(i), 43 microM (1 microM ADP); GDP, 2.5 microM (0.5 mM P(i)); ATP, 2 microM. ADP and P(i) mutually lowered their respective inhibition constants. Phosphate could be replaced by arsenate. Proton slip occurred only if the proton motive force exceeded a certain threshold, similar to that for ATP synthesis. The inhibition of proton slip by ADP and GDP qualified the respective nucleotide binding sites as belonging to the subset of two (or three) potentially catalytic sites out of the total of six. We interpreted the ADP-induced transition between different conduction states of the ATPase from "slipping" to "closed" to "coupled" as a consequence of the alternating site mechanism of catalysis. Whereas the proton translocator idles in the absence of nucleotides, the high-affinity binding of the first ADP/P(i) couple to one site clutches proton flow to some (conformational) change that can only be executed after the binding of another ADP/P(i) couple to a second site. From there on these sites alternate in the catalytic cycle. An entropic machine is presented which likewise models proton slip, unisite, and multisite ATP synthesis and hydrolysis.

Energy-dependent changes in the conformation of the chloroplast ATP synthase and its catalytic activity

Chloroplast ATP synthase changes its conformation depending on the transmembrane electrochemical potential difference of protons (delta mu H+). This conformational change is observable by measuring the change in the reactivity of Lys109 of the epsilon subunit of chloroplast-coupling-factor 1. Illumination of thylakoids increased the epsilon-Lys109 reactivity by a factor of 3-4 within 1 s. In the presence of ADP plus Pi, illumination of thylakoids increased the epsilon-Lys109 reactivity by a factor of only 2. Addition of ATP in the post-illumination dark or in the light after prior illumination increased the epsilon-Lys109 reactivity depending on the concentration of coexisting NH4Cl. ATP hydrolysis at high level was observed irrespective of the epsilon-Lys109 reactivity.

Effect of low growth temperature on coupling between electron transport and proton flux in Vicia faba thylakoids

Coupling between electron transport and proton flux has been compared in chloroplasts from Vicia faba (cv. Windsor) plants grown at 20 and 5°C. Proton uptake by warm-grown thylakoids was sensitive to external pH and stimulated by micromolar adenine nucleotide above pH 7.0. Electron transport was modulated by pH, adenine nucleotide and energy transfer inhibitors (triphenyltin and Hg(2+) ). By contrast, proton uptake by cold-grown thylakoids was generally lower and was insensitive to micromolar ATP. The rate of non-phosphorylating electron flow in cold-grown thylakoids was relatively insensitive to pH and Hg(2+) and was not modulated by adenine nucleotides or triphenyltin. Stimulation of electron transport by phosphorylating conditions in cold-grown thylakoids was generally lower and insensitive to pH. It is concluded that the control of proton efflux through CF(0) -CF(1) differs in thylakoids of V. faba grown at warm and cold temperatures.

Photoaffinity labeling of the tight ADP binding site of the chloroplast coupling factor one (CF1): the effect on the CF1-ATPase activity

Chloroplast thylakoid membranes contain tightly bound ADP which is intimately involved in the mechanism of photophosphorylation. The photoaffinity analog 2-azido-ADP binds tightly to spinach thylakoid membrane-bound coupling factor one (CF1) and, in a manner similar to ADP, inhibits the light-triggered ATPase activity (Czarnecki, J.J., Abbott, M.S. and Selman, B.R. (1983) Eur. J. Biochem. 136, 19-24). Ultraviolet irradiation of thylakoid membranes containing noncovalently, tightly bound 2-azido[beta-32P]ADP results in the inactivation of both the methanol-stimulated MgATPase activity of the membrane-bound CF1 and the octylglucoside-dependent MgATPase activity of the solubilized enzyme. There is a linear correlation between the loss of enzyme activity and the covalent incorporation of the photoaffinity analog. Full inactivation of catalytic activity is estimated to occur upon incorporation of 1.07 mol analog and 0.65 mol analog per mol enzyme for the methanol- and octylglucoside-stimulated activities, respectively. Since 2-azido-ADP modifies only the beta subunit of the CF1 and since there are probably three beta subunits per CF1, these results indicate strong cooperativity among beta subunits and between the site of tightly bound nucleotides and the catalytic sites.

Quaternary structure of chloroplast F1-ATPase in solution. Conformational changes in spatial arrangement of subunits upon activation

The hydrodynamic properties of isolated ATPases were studied via their rotational diffusion in buffer solution. Chloroplast F1-ATPase (CF1) and Escherichia coli F1-ATPase (EF1) were covalently labeled with eosinisothiocyanate and then investigated by polarized laser spectroscopy. The rotational correlation time in aqueous buffer of latent (five-subunit) CF1 was 390 ns. Four-subunit (delta-deficient) CF1 showed the same correlation time, however, for three-subunit (delta, epsilon-deficient) CF1 the rotational correlation time was more than eight times larger (3200 ns). The rotational correlation time of activated CF1 was three times larger than the one of latent CF1. These large changes in the rotational correlation times are directly related to changes in the quaternary structure of CF1 upon activation. EF1 was found to behave essentially as activated CF1. Based on the observed rotational correlation times we concluded that the mass distributions of latent CF1 and of delta-deficient CF1 resemble a dimeric arrangement. The structure of delta, epsilon-deficient CF1 more likely resembles a hexagon, the mass centers of the six main subunits lie in one plane. The structure of the activated forms of CF1 can be described best as an intermediate between the dimeric arrangement of latent CF1 and an octahedron. The large changes in the quaternary structure of isolated CF1 are reversed when the activation of the enzyme is reversed.

A regulatory effect of the electron transport chain on the ATP synthase

By the application of different experimental conditions, a variation of the apparent affinity of the chloroplast coupling factors 0-1 (CF0CF1) complex toward nucleotides was observed. This effect was paralleled by varying P/e2 ratios even in presence of millimolar ADP concentrations. This observations indicates that the electron transport system has a regulatory effect on the ATP synthase system. Different effects of mobile ionophores (uncouplers) and channel forming ionophores (gramicidin), respectively, indicated that either membrane-oriented charges--probably protons--or an electric potential difference was involved in the regulatory mechanism. When measuring photosystem II-dependent effects only, no regulation of the CF0CF1 complex could be detected in physiologically intact thylakoid preparations. This means that the regulatory active site must be localized between the 2,5-dibromo-3-methyl-6-isopropyl-p-benzoquinone, (DBMIB) inhibition site and the methylviologen acception site.

Localization of the tight ADP-binding site on the membrane-bound chloroplast coupling factor one

The photoaffinity analog 2-azido-ADP (2-azidoadenosine 5'-diphosphate) was used as a probe of the spinach chloroplast ATP synthase. The analog acted as a substrate for photophosphorylation. Several observations suggested that 2-azido-ADP and ADP bound to the same class of tight nucleotide binding sites: (a) 2-azido-ADP competitively inhibited ADP tight binding (Ki = 1.4 microM); (b) the concentration giving 50% maximum binding, K0.5 for analog tight binding (1 microM) was similar to that observed for ADP (2 microM); (c) nucleotide tight binding required prior membrane energization and was completely reversed by re-energization; (d) the tight binding of 2-azido-[beta-32P]ADP was completely prevented by ADP; (e) the analog inhibited the light-triggered ATPase activity at micromolar concentrations. Ultraviolet irradiation of washed thylakoid membranes containing tightly bound 2-azido-[beta-32P]ADP resulted in the covalent incorporation of the label into the membranes. Denaturing polyacrylamide gel electrophoresis of the labeled membranes demonstrated that the beta subunit of the coupling factor one complex was the only polypeptide in the thylakoid membranes which was labeled. These results identify the beta subunit of the coupling factor as the location of the tightly bound ADP on the thylakoid membranes.

The effects of octylglucoside on the interactions of chloroplast coupling factor 1 (CF1) with adenine nucleotides

The effects of octylglucoside (OcGlc) micelles, which stimulate a Mg-specific ATPase activity in chloroplast coupling factor 1 [Pick, U. and Bassilian, S. (1982) Biochemistry, 21, 6144-6152], on the interactions of the enzyme with adenine nucleotides have been studied. 1. OcGlc specifically accelerates the binding and the release of ADP but not of ATP or adenosine 5'[beta, gamma-imido]triphosphate (AdoPP[NH]P) from the tight-sites. The binding affinity for ADP and for ATP is only slightly decreased (twofold) by the detergent. ATP competitively inhibits the binding of ADP and vice versa in the presence or absence of OcGlc. 2.OcGlc-induced inactivation of CF1-ATPase is correlated with the release of bound nucleotides. In the absence of medium nucleotides ADP X CF1 is rapidly inactivated while ATP X CF1 and AdoPP[NH]P X CF1 are slowly inactivated by OcGlc in parallel with the release of bound nucleotide. In contrast, low concentrations of either ATP or ADP in the medium effectively protect against OcGlc inactivation while AdoPP[NH]P, whose binding to CF1 is inhibited by OcGlc, is ineffective even at millimolar concentrations. The results suggest that the occupancy of the tight-sites protects the enzyme against OcGlc-induced inactivation. 3. Mg ions specifically inhibit the release of bound ADP and the OcGlc-induced inactivation of CF1. High concentrations of medium ATP and ADP (K50 = 100 microM) also inhibit the OcGlc-induced release of bound nucleotides in an EDTA medium. In contrast, in the absence of OcGlc, medium ADP and ATP accelerate the release of bound adenine nucleotides. 4. Mg-ATP in the presence of OcGlc stimulates the release of bound ADP from CF1. Bound ATP is neither released nor hydrolyzed at the tight-sites under these conditions where medium ATP is rapidly hydrolyzed. Mg-ADP stimulates the release of bound ADP only in the presence of inorganic phosphate or of phosphate analogs, e.g. arsenate, pyrophosphate or selenate. 5. It is suggested that: (a) ATP and ADP bind to the same tight-sites, but OcGlc activation specifically accelerates the exchange of bound ADP at the site. (b) CF1 contains low affinity adenine nucleotide binding sites which may be the catalytical sites and which influence the tight-sites by cooperative interactions. (c) Mg-ATP in the presence of OcGlc induces a conformational change at the catalytical site which accelerates the release of ADP from the tight-site. The implications of these results to the role of adenine nucleotides in the regulation and mechanism of ATP hydrolysis by CF1 are discussed.

Further characterization of nucleotide binding sites on chloroplast coupling factor one

The solubilized coupling factor from spinach chloroplasts (CF1) contains one nondissociable ADP/CF1 which exchanges slowly with medium ADP in the presence of Ca2+, Mg2+, or EDTA; medium ATP also exchanges in the presence of Ca2+ or EDTA, but it is hydrolyzed, and only ADP is found bound to CF1. The rate of ATP exchange with heat-activated CF1 is approximately 1000 times slower than the rate of ATP hydrolysis. In the presence of Mg2+, both latent CF1 and heat-activated CF1 bind one ATP/CF1, in addition to the ADP. This MgATP is not removed by dialysis, by gel filtration, or by the substrate CaATP during catalytic turnover; however, it is released when the enzyme is stored several days as an ammonium sulfate precipitate. The photoaffinity label 3'-O-[3-[N-(4-azido-2-nitrophenyl)amino]-propionyl]-ATP binds to the MgATP site, and photolysis results in labeling of the beta subunit of CF1. Equilibrium binding measurements indicate that CF1 has two identical binding sites for ADP with a dissociation constant of 3.9 microM (in addition to the nondissociable ADP site). When MgATP is bound to CF1, one ADP binding site with a dissociation constant of 2.9 microM is found. One ATP binding site is found in addition to the MgATP site with a dissociation constant of 2.9 microM. Reaction of CF1 with the photoaffinity label 3'-O-[3-[N-(4-azido-2-nitrophenyl)amino]propionyl]-ADP indicates that the ADP binding site which is not blocked by MgATP is located near the interface of alpha and beta subunits. No additional binding sites with dissociation constants less than 200 micro M are observed for MgATP with latent CF1 and for CaADP with heat-activated CF1. Thus, three distinct nucleotide binding sites can be identified on CF1, and the tightly bound ADP and MgATP are not at the catalytic site. The active site is either the third ADP and ATP binding site or a site not yet detected.

Nucleotide interactions with the dicyclohexylcarbodiimide-sensitive adenosinetriphosphatase from spinach chloroplasts

The intrinsic nucleotide content of the dicyclohexylcarbodiimide-sensitive ATPase (DSA) from spinach chloroplasts and its interactions with ADP have been studied. Both partially purified and sucrose gradient purified DSA contain at least 1 mol of ADP/mol of enzyme and 1 mol of ATP/mol of enzyme, although considerable variation exists between different preparations. Radioactively labeled ADP is incorporated into DSA in the presence of 5 mM MgCl2 and 10 mM octyl glucoside with a half-life of approximately 30 min. Incorporation of ADP into DSA reconstituted in phospholipid vesicles occurs at about twice this rate, and a slightly slower rate of uptake is observed with [3H]ADP and [3H]ATP in the presence of 2 mM ethylenediaminetetraacetic acid. The [3H]ATP always appears as bound [3H]ADP on the enzyme. Nucleotide analyses indicate that this incorporation represents an exchange with tightly bound ADP. The nucleotide exchange requires binding at another nucleotide site or sites on the enzyme and is essentially a one-turnover process. Even during ATP synthesis less than 20% of incorporated 3H-labeled nucleotide is removed. Binding studies with forced dialysis indicate the presence of a reversible binding site for ADP distinct from the nucleotide exchange. Similar binding isotherms are obtained for the partially purified enzyme stabilized with 10 mM octyl glucoside, the gradient-purified enzyme stabilized with 0.4% sodium cholate, and the reconstituted, partially purified enzyme. The binding stoichiometry is approximately 0.5 mol of ADP/mol of DSA and the dissociation constant is approximately 2 microM, which is similar to the Michaelis constant for ADP estimated from kinetic studies of ATP synthesis.

Relation between the initial kinetics of ATP synthesis and of conformational changes in the chloroplast ATPase studied by external field pulses

ATP formation and the energy-dependent release of tightly bound [14C]-adenine nucleotides from the chloroplast coupling factor CF1 has been studied as a function of the time of energization of the membrane in the range of 500 mus up to 60 ms. The high time resolution was achieved because the energization was generated artificially by external electric field pulses. Applying external electric field pulses to a chloroplast suspension induces an electric potential difference across the thylakoid membrane. The following results were obtained: (1) The amount of ATP generated increases linearly with the time of energization. The steady-state rate of ATP formation is reached in less than 500 mus. (2) A fraction of the adenine nucleotides tightly bound to CF1 is released on energization with a half-rise-time of about 2 ms. The size of the fraction, i.e., the amplitude of the fast phase of the release, increases with the magnitude of the induced transmembrane electric potential difference. A further slow release is superimposed. (3) The initial rate of the release of adenine nucleotides is practically identical with the rate of ATP formation. It is concluded that the release of tightly bound nucleotides monitors an initial conformational change by which the ATPase turns from an inactive into an activated state. For the explanation of the results a reaction scheme is proposed which takes into account a preceding activation of the ATPase.

AMP photophosphorylation and binding by chloroplasts

Stoichiometric amounts of chloroplast thylakoids photophosphorylate free AMP to tightly bound ADP. Free ADP is a poor competitor for this AMP photoreaction, which saturates below 16 micronAMP. The inhibitor, diadenosine pentaphosphate, abolishes AMP photophosphorylation, and inhibits dark ADP binding. Taken together, these data imply that this photoreaction involves the high affinity nucleotide binding site(s) of chloroplast coupling factor CF1, and that little mixing with free nucleotides occurs.

Tentoxin-induced binding of adenine nucleotides to soluble spinach chloroplast coupling factor 1

The effect of tentoxin on the binding of adenine nucleotides to soluble chloroplast coupling factor (CF1) has been studied and the following results have been obtained: 1. Tentoxin (400 micron) increases the maximum attainable tight binding of ADP to CF1. In the absence of tentoxin, the maximal binding observed by the method employed is about 0.3 nmol ADP/mg protein, whereas in the presence of tentoxin this ranges from 1.5 to 2.0 nmol ADP/mg protein. 2. Tentoxin-induced binding of ADP to CF1 is severely inhibited by divalent cations (50% inhibition at about 2 mM) but only weakly inhibited by monovalent cations (less than 50% inhibition at 100 mM). 3. The binding of ADP to CF1 induced by tentoxin is inhibited by ATP and adenylyl imidodiphosphate but is not inhibited by other nucleotides including AMP, GDP, CDP, IDP, or beta, gamma-methylene ATP. 4. The ADP-CF1 complex induced by tentoxin is quite stable. 75% remains bound to CF1 even after passage of the complex through a gel filtration column. An additional 25% can be removed by incubation in the presence of ADP, and all of the bound ADP can be removed only after incubation in the presence of both tentoxin and ADP. The latter result is interpreted as a tentoxin-induced exchange of bound ADP for medium ADP.

Conformational change of the chloroplast ATPase induced by a transmembrane electric field and its correlation to phosphorylation

A prospective clinical study was done on 20 patients referred for computed tomography within 28 hr of a cerebral ischemic event. The patients were scanned before, immediately after, and 3 hr after a high dose of intravenous contrast medium was administered to produce prolonged high blood iodine levels. In seven patients the delayed scan demonstrated a heretofore undescribed type of contrast enhancement which represents the early massive vasogenic edema seen in experimental animals before confluent hemorrhagic infarction. Four of the seven patients developed hemorrhagic infarction. None of the remaining 11 patients with cerebral infarctions and conventional postenhancement CT patterns showed hemorrhage on follow-up CT scans or at autopsy. Two patients with transient ischemic attacks had normal CT scans. It may now be possible to predict patients in whom there is high probability of hemorrhagic infarction before blood appears on CT. Treatment of these patients should probably be aimed at preventing the devastating effects of the vasogenic edema. We speculate that heparinization or bypass surgery to reestablish circulation may be contraindicated in this group.