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Ruiter FAA, Sidney LE, Kiick KL, Segal JI, Alexander C, Rose FRAJ. The electrospinning of a thermo-responsive polymer with peptide conjugates for phenotype support and extracellular matrix production of therapeutically relevant mammalian cells. Biomater Sci 2021; 8:2611-2626. [PMID: 32239020 DOI: 10.1039/c9bm01965k] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Current cell expansion methods for tissue engineering and regenerative medicine applications rely on the use of enzymatic digestion passaging and 2D platforms. However, this enzymatic treatment significantly reduces cell quality, due to the destruction of important cell-surface proteins. In addition, culture in 2D results in undesired de-differentiation of the cells caused by the lack of 3D similarity to the natural extracellular matrix (ECM) environment. Research has led to the development of thermo-responsive surfaces for the continuous culture of cells. These thermo-responsive materials properties can be used to passage cells from the surface when the cell culture temperature is reduced. Here we report the development of a PLA/thermo-responsive (PDEGMA) blend 3D electrospun fibre-based scaffold to create an enzymatic-free 3D cell culture platform for the expansion of mammalian cells with the desired phenotype for clinical use. Human corneal stromal cells (hCSCs) were used as an exemplar as they have been observed to de-differentiate to an undesirable myo-fibroblastic phenotype when cultured by conventional 2D cell culture methods. Scaffolds were functionalised with a cell adherence peptide sequence GGG-YIGSR by thiol-ene chemistry to improve cell adherence and phenotype support. This was obtained by functionalising the thermo-responsive polymer with a thiol (PDEGMA/PDEGSH) by co-polymerisation. These incorporated thiols react with the norbornene acid functionalised peptide (Nor-GGG-YIGSR) under UV exposure. Presence of the thiol in the scaffold and subsequent peptide attachment on the scaffolds were confirmed by fluorescence labelling, ToF-SIMS and XPS analysis. The biocompatibility of the peptide containing scaffolds was assessed by the adhesion, proliferation and immuno-staining of hCSCs. Significant increase in hCSC adherence and proliferation was observed on the peptide containing scaffolds. Immuno-staining showed maintained expression of the desired phenotypic markers ALDH, CD34 and CD105, while showing no or low expression of the undesired phenotype marker α-SMA. This desired expression was observed to be maintained after thermo-responsive passaging and higher when cells were cultured on PLA scaffolds with 10 wt% PDEGMA/4 mol% PDEGS-Nor-GGG-YIGSR. This paper describes the fabrication and application of a first generation, biocompatible peptide conjugated thermo-responsive fibrous scaffold. The ease of fabrication, successful adherence and expansion of a therapeutically relevant cell type makes these scaffolds a promising new class of materials for the application of cell culture expansion platforms in the biomaterials and tissue engineering field.
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Affiliation(s)
- F A A Ruiter
- School of Pharmacy, University of Nottingham, UK.
| | - L E Sidney
- Division of Clinical Neuroscience, University of Nottingham, UK.
| | - K L Kiick
- Department of Material Science and Engineering, University of Delaware, USA.
| | - J I Segal
- Faculty of Engineering, University of Nottingham, UK.
| | - C Alexander
- School of Pharmacy, University of Nottingham, UK.
| | - F R A J Rose
- School of Pharmacy, University of Nottingham, UK.
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Shah K, Vasileva D, Karadaghy A, Zustiak SP. Development and characterization of polyethylene glycol–carbon nanotube hydrogel composite. J Mater Chem B 2015; 3:7950-7962. [DOI: 10.1039/c5tb01047k] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Polyethylene–glycol–carbon nanotube composite was developed where carbon nanotubes altered the hydrogel mechanical and physical properties and aided neuronal cell viability.
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Affiliation(s)
- K. Shah
- Department of Biomedical Engineering
- Saint Louis University
- St Louis
- USA
| | - D. Vasileva
- Department of Biomedical Engineering
- Saint Louis University
- St Louis
- USA
| | - A. Karadaghy
- Department of Biomedical Engineering
- Saint Louis University
- St Louis
- USA
| | - S. P. Zustiak
- Department of Biomedical Engineering
- Saint Louis University
- St Louis
- USA
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Schularick NM, Clark JJ, Hansen MR. Primary culture of human vestibular schwannomas. J Vis Exp 2014. [PMID: 25079666 DOI: 10.3791/51093] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Vestibular schwannomas (VSs) represent Schwann cell (SC) tumors of the vestibular nerve, compromising 10% of all intracranial neoplasms. VSs occur in either sporadic or familial (neurofibromatosis type 2, NF2) forms, both associated with inactivating defects in the NF2 tumor suppressor gene. Treatment for VSs is generally surgical resection or radiosurgery, however the morbidity of such procedures has driven investigations into less invasive treatments. Historically, lack of access to fresh tissue specimens and the fact that schwannoma cells are not immortalized have significantly hampered the use of primary cultures for investigation of schwannoma tumorigenesis. To overcome the limited supply of primary cultures, the immortalized HEI193 VS cell line was generated by transduction with HPV E6 and E7 oncogenes. This oncogenic transduction introduced significant molecular and phenotypic alterations to the cells, which limit their use as a model for human schwannoma tumors. We therefore illustrate a simplified, reproducible protocol for culture of primary human VS cells. This easily mastered technique allows for molecular and cellular investigations that more accurately recapitulate the complexity of VS disease.
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Affiliation(s)
- Nathan M Schularick
- Department of Otolaryngology-Head and Neck, University of Iowa Hospitals and Clinics
| | - J Jason Clark
- Department of Otolaryngology-Head and Neck, University of Iowa Hospitals and Clinics
| | - Marlan R Hansen
- Department of Otolaryngology-Head and Neck, University of Iowa Hospitals and Clinics;
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Olbertz L, Langohr I, Werner J, Pessoa L, Kiupel M, Agnew D, Montiani-Ferreira F. Anterior uveal spindle cell tumor in a blue-eyed mixed-breed dog. Vet Ophthalmol 2013; 16 Suppl 1:135-40. [DOI: 10.1111/vop.12018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Letícia Olbertz
- Department of Veterinary Medicine; Federal University of Paraná; Curitiba PR Brazil
- Rua dos Funcionários; Laboratório de Oftalmologia Comparada; Hospital Veterinário; Curitiba PR Brazil
| | - Ingeborg Langohr
- Diagnostic Center for Population and Animal Health; Michigan State University; Lansing MI USA
| | - Juliana Werner
- Werner & Werner Laboratory; Curitiba PR Brazil
- Rua Tomazina, subsolo, Ahú; Curitiba PR Brazil
| | - Lenita Pessoa
- Clínica Veterinária Aconchego; Rua Presidente Campos Salles; Joinville SC Brazil
| | - Matti Kiupel
- Diagnostic Center for Population and Animal Health; Michigan State University; Lansing MI USA
| | - Dalen Agnew
- Diagnostic Center for Population and Animal Health; Michigan State University; Lansing MI USA
| | - Fabiano Montiani-Ferreira
- Department of Veterinary Medicine; Federal University of Paraná; Curitiba PR Brazil
- Department of Small Animal Clinical Sciences; Michigan State University; East Lansing MI USA
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Wippold FJ, Lubner M, Perrin RJ, Lämmle M, Perry A. Neuropathology for the neuroradiologist: Antoni A and Antoni B tissue patterns. AJNR Am J Neuroradiol 2007; 28:1633-8. [PMID: 17893219 PMCID: PMC8134199 DOI: 10.3174/ajnr.a0682] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Histologic patterns of cellular architecture often suggest a tissue diagnosis. Distinctive histologic patterns seen within the peripheral nerve sheath tumor schwannoma include the Antoni A and Antoni B regions. The purpose of this report is to review the significance of Antoni regions in the context of schwannomas.
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Affiliation(s)
- F J Wippold
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO 63110, USA.
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Abstract
OBJECTIVE To establish primary vestibular schwannoma (VS) cultures that selectively favor the growth of schwannoma cells. BACKGROUND The lack of a suitable in vitro model of human VS cells has directly limited the progress of research on tumorigenesis and therapy. The problems of establishing pure VS culture include control of fibroblast proliferation. Current efforts to extend VS cell life span using viral oncogenes, by conferring the ability to proliferate in vitro, will yield cells intrinsically different from in vivo VS tumors. Much more desirable is the ability to culture VS cells without cellular transformation. METHODS Tumor specimens from 17 patients were processed for cell culture and grown at 37 degrees C with 5% CO2 and 100% humidity. Key modifications limiting fibroblast proliferation included using selective medium without L-valine, supplemented by Nu-Serum for at least a week; the use of cytosine arabinoside to kill contaminating fibroblasts; and using the Dulbecco modified medium, supplemented with brain-derived neurotrophic factor and 10% fetal calf serum after the initial serum-free period. RESULTS Twelve of 17 VS were successfully cultured. The presence of schwannoma cells and the absence of fibroblasts were confirmed immunohistochemically using S100 and CD90 markers, respectively. Scanning and transmission electron microscopy demonstrated typical spindle-shaped cells and the presence of "fibrous long-spacing collagen." CONCLUSION We describe a method for obtaining short-term, essentially fibroblast-free, primary VS cultures. Such pure VS cultures, retaining in vivo characteristics, are extremely useful as an in vitro model to study the pathobiology of schwannoma cells.
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Affiliation(s)
- Salil Nair
- Department of Surgery, University of Newcastle, Framlington Place, Newcastle Upon Tyne, UK.
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Huang HY, Park N, Erlandson RA, Antonescu CR. Immunohistochemical and Ultrastructural Comparative Study of External Lamina Structure in 31 Cases of Cellular, Classical, and Melanotic Schwannomas. Appl Immunohistochem Mol Morphol 2004; 12:50-8. [PMID: 15163020 DOI: 10.1097/00129039-200403000-00010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Unlike most soft tissue tumors, schwannoma is characterized by the presence of distinct linear, frequently duplicated external lamina (EL). Although electron microscopy remains the gold standard for demonstrating this unique feature and distinguishing its morphologic variants from mimickers, the use of two anti-EL antibodies, laminin and type IV collagen, appears to supersede electron microscopy in terms of current practice. To determine whether immunohistochemical expression correlates with ultrastructural findings, 10 cellular schwannomas, 18 classic schwannomas, and 3 melanotic schwannomas were evaluated ultrastructurally and immunohistochemically using antibodies to type IV collagen and laminin. Immunohistochemically, a moderate to strong intensity in more than 50% of tumor cells was detected using either antibody in most cases of cellular schwannomas (70%), the Antoni A areas of classic schwannomas (78%), and melanotic schwannomas (67%). Ultrastructurally, the presence of diffusely continuous, duplicated EL was observed in 30% of cellular schwannomas and 56% of classic schwannomas, while 50% of cellular schwannomas and 22% of classic schwannomas showed either continuous simple EL or discontinuous but duplicated EL alone. In addition, two cellular schwannomas (20%) and four classic schwannomas (22.2%) had only a simple layer of EL in focal areas. In contrast to the distinct immunostaining surrounding individual cells seen in the former two subtypes, all three melanotic schwannomas displayed a biphasic-staining pattern of the EL (ie, individual cell and nested), which was confirmed at the ultrastructural level. The authors found a significant difference in intensity between the Antoni A and B areas of classic schwannomas using both laminin and type IV collagen. In addition, the intensities of laminin and type IV collagen in the Antoni A areas of classic schwannomas were significantly stronger compared with those of cellular schwannomas. Nevertheless, there was no significant difference either between two antibodies or between cellular and classic variants with regard to the extent of immunoreaction. Only in classic schwannomas did the extent of immunoreaction against both laminin and type IV collagen correlate significantly with the ultrastructural EL distribution pattern (diffusely continuous vs. discontinuous). However, this association was not detected in cases of cellular schwannomas. On the other hand, the intensities of laminin and type IV collagen did not correlate with the ultrastructural thickness of EL, irrespective of the morphologic subtypes. In conclusion, both type collagen IV and laminin are still reliable markers of EL in various types of schwannomas. Schwannomas exhibiting a monolayered EL are as strong in immunoreaction as those displaying reduplicated/thickened EL, indicating that a single layer of EL is thick enough to be identified by both antibodies with sufficient sensitivity. The peculiar biphasic EL pattern seen in melanotic schwannoma remains under-recognized, which may lead to misdiagnosis as malignant melanomas, especially in limited biopsy specimens.
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Affiliation(s)
- Hsuan-Ying Huang
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Chafik D, Bear D, Bui P, Patel A, Jones NF, Kim BT, Hung CT, Gupta R. Optimization of Schwann cell adhesion in response to shear stress in an in vitro model for peripheral nerve tissue engineering. TISSUE ENGINEERING 2003; 9:233-41. [PMID: 12740086 DOI: 10.1089/107632703764664701] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The design of nerve guidance channels (NGCs) is evolving to produce a favorable environment for neural regeneration. We created an in vitro model to evaluate the interactions between three centrally important components of this altered host environment: (1). Schwann cells, (2). substrate, and (3). sustained mechanical stimulus in the form of shear stress with laminar fluid flow. Preconfluent Schwann cells were plated on slides coated either with laminin, poly-D-lysine, type IV collagen, or fibronectin. These slides were placed into custom-designed, parallel-plate, flow chambers and were administered laminar fluid flow at a rate of 15 mL/min for 2 h. Schwann cell adhesion assays demonstrated that laminin (mean, 86.1%; SEM, 4.47%) and fibronectin (mean, 81.7%; SEM, 3.24%) were statistically superior to collagen type IV (mean, 57.7%; SEM, 3.96%) and poly-D-lysine (mean, 58.0%; SEM, 4.97%) (p < 0.001). Fibronectin (mean, 12.20%; SEM, 0.374%) induced statistically greater Schwann cell proliferation than did laminin (mean, 8.14%; SEM, 0.682%) (p < 0.001). Therefore, we recommend that fibronectin should be used as an important component of NGCs with further in vivo studies. As mechanical stress is an integral part of the host environment, our study is the first to incorporate this factor into an in vitro model for peripheral nerve tissue engineering.
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Affiliation(s)
- Dara Chafik
- Department of Orthopedic Surgery, University of California, Irvine, Irvine, California 92657, USA
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Sundarraj N, Fite D, Belak R, Sundarraj S, Rada J, Okamoto S, Hassell J. Proteoglycan distribution during healing of corneal stromal wounds in chick. Exp Eye Res 1998; 67:433-42. [PMID: 9820791 DOI: 10.1006/exer.1998.0540] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Proteoglycan distribution during corneal stromal healing in growing corneas of young chicks were histologically and immunohistochemically analysed. Single linear incisions to produce partial-thickness wounds were made in the corneas of 5 day old chicks. The corneas were harvested at different times after wounding and processed for either histochemical analyses using periodic acid-Schiff's reaction (PAS) or for indirect immunofluorescence analyses of lumican, keratocan, keratan sulfate, perlecan and laminin. Linear corneal stromal incisions were completely covered by migrated stratified epithelium by day 2 post wounding and resulted in a gaping wound with a thinner stroma. New stromal scar tissue formed between the epithelium and the original stroma that resulted in partial restoration of stromal thickness. During the first two to three weeks of healing, the stromal tissue filling the depression formed from the gaping wound, was hypercellular and PAS positive, indicating significantly higher levels of glycoprotein content but no new Bowman's membrane was formed. By four weeks, the scar tissue occupied a 2-3 mm wide region. Immunofluorescence analyses indicated that other major differences in the healing and normally growing stroma were the increased synthesis and deposition of perlecan and laminin. No differences were evident in the immunofluorescence for keratocan or keratan sulfate in the scar tissue, but the scar tissue did contain markedly decreased levels of lumican. Thus, the regulation of proteoglycan and glycoprotein synthesis is altered in the keratocytes that are recruited to the wounded regions in the growing corneal stroma of post-hatched young chicks. While synthesis and deposition of adhesive molecules including laminin and perlecan are elevated, the synthesis of one of the keratan sulfate proteoglycans, lumican, is reduced in the scar tissue as compared to the normally growing stroma.
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Affiliation(s)
- N Sundarraj
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Matsuoka T, Hirakawa K, Chung YS, Yashiro M, Nishimura S, Sawada T, Saiki I, Sowa M. Adhesion polypeptides are useful for the prevention of peritoneal dissemination of gastric cancer. Clin Exp Metastasis 1998; 16:381-8. [PMID: 9626817 DOI: 10.1023/a:1006573732238] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We examined the effect of adhesion polypeptides on the adhesion and invasiveness of gastric cancer cell lines. We previously reported the establishment of an extensively peritoneal-seeding cell line, OCUM-2MD3, from a poorly seeding human scirrhous gastric carcinoma cell line, OCUM-2M. Both alpha2beta1 and alpha3beta1 integrin expression was markedly increased on OCUM-2MD3 cells compared with OCUM-2M cells, and the ability of OCUM-2MD3 cells to bind to the extracellular matrix (ECM) was also significantly higher than that of OCUM-2M cells. The adhesion polypeptides, YIGSR and RGD, and two RGD derivatives significantly inhibited the adhesion of OCUM-2MD3 cells to the submesothelial ECM, while not inhibiting the adhesiveness of OCUM-2M cells and two well differentiated human gastric cell lines, MKN-28 and MKN-74. The YIGSR and RGD peptides also significantly inhibited the invasiveness of OCUM-2MD3 cells. The survival of nude mice with peritoneal dissemination given YIGSR sequence intraperitoneally was obviously longer than that of untreated mice. The survival of mice treated with RGD was also improved, and this effect was increased using the RGD derivatives, poly(CEMA-RGDS) and CM-chitin RGDS. These polypeptides appear to block the binding of integrins, which are expressed on OCUM-2MD3 cells, to the submesothelial ECM, and consequently inhibit peritoneal implantation. The peritoneal injection of adhesion polypeptides may be a new therapy against the dissemination of scirrhous gastric cancer, and may be useful for the prevention of dissemination in high-risk patients.
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Affiliation(s)
- T Matsuoka
- First Department of Surgery, Osaka City University Medical School, Osaka, Japan
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Feldman EL, Sullivan KA, Kim B, Russell JW. Insulin-like growth factors regulate neuronal differentiation and survival. Neurobiol Dis 1997; 4:201-14. [PMID: 9361296 DOI: 10.1006/nbdi.1997.0156] [Citation(s) in RCA: 149] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Insulin-like growth factor I (IGF-I) and IGF-II are potent trophic factors for motor and sensory neurons and glial cells. The actions of IGF-I and IGF-II are mediated via the IGF-I receptor (IGF-IR). IGF:IGF-IR binding activates distinct signaling cascades, which in turn mediate the trophic effects of the IGFs. We discuss three main IGF coupled events: growth cone motility, long-term neurite outgrowth, and neuroprotection. Our data suggest that IGF-I enhances growth cone motility by promoting reorganization of actin and activation of focal adhesion proteins via the phosphatidylinositol-3 kinase (Pl-3K) pathway. Long-term treatment with IGF-I activates the mitogen-activated protein (MAP) kinase cascade and promotes neurite outgrowth. A separable, but likely linked, action of the IGFs via Pl-3K is protection of neurons from apoptosis. These pleotrophic effects of IGFs suggest that this family of growth factors may have potential clinical utility in the treatment of neurological disorders.
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Affiliation(s)
- E L Feldman
- Department of Neurology, University of Michigan, Ann Arbor 48109, USA
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Abstract
Schwann cells (SCs) are the myelin producing cells of the peripheral nervous system. During development, SCs cease proliferation and differentiate into either a myelin-forming or non-myelin forming mature phenotype. We are interested in the role of insulin-like growth factor-I (IGF-I) in SC development. We have shown previously SCs proliferate in response to IGF-I in vitro. In the current study, we investigated the role of IGF-I in SC differentiation. SC differentiation was determined by morphological criteria and expression of myelin proteins. Addition of 1 mM 8-bromo cyclic AMP (cAMP) or growth on Matrigel matrix decreased proliferation and induced differentiation of SCs. IGF-I enhanced both cAMP and Matrigel matrix-induced SC differentiation, as assessed by both morphological criteria and myelin gene expression. Cultured SCs also express IGF binding protein-5 (IGFBP-5), which can modulate the actions of IGF-I. We examined the expression of IGFBP-5 during SC differentiation. Both cAMP and Matrigel matrix treatment enhanced IGFBP-5 protein expression and cAMP increased IGFBP-5 gene expression five fold. These findings suggest IGF-I potentiates SC differentiation. The concomitant up-regulation of IGFBP-5 may play a role in targeting IGF-I to SCs and thus increase local IGF-I bioavailability.
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Affiliation(s)
- H L Cheng
- Department of Neurology, University of Michigan, Ann Arbor 48109, USA
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Singleton JR, Dixit VM, Feldman EL. Type I insulin-like growth factor receptor activation regulates apoptotic proteins. J Biol Chem 1996; 271:31791-4. [PMID: 8943217 DOI: 10.1074/jbc.271.50.31791] [Citation(s) in RCA: 131] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Activation of the type I insulin-like growth factor receptor (IGF-IR) blocks osmotic mediated programmed cell death (PCD) in neurons. We speculated that IGF-IR activation could afford neuroprotection either by effecting the negative regulators of the death pathway, Bcl-2 and Bcl-xL, or by altering activity of the ced-3/ICE-like proteases. Here we report that osmotic stress decreases total neuronal Bcl-2 by 4-fold and that hyperosmotic PCD correlates with proteolytic processing of neuronal ced-3/ICE-like proteases. IGF-IR activation maintains normal Bcl-2 levels, and signaling via the IGF-IR:phosphatidylinositol 3-kinase pathway prevents ICE/LAP-3 and Yama/CPP32 processing. Finally, increased neuronal IGF-IR expression enhances the negative death regulator Bcl-xL. We suggest that IGF-IR signaling exerts its short-term inhibitory effects upon PCD "upstream" of both Bcl proteins and ced-3/ICE-like proteases, while chronic increased IGF-IR expression may modulate susceptibility to death signals by mediating the negative death regulator, Bcl-xL.
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Affiliation(s)
- J R Singleton
- Department of Neurology, University of Michigan, Ann Arbor, Michigan 48109, USA.
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