Second and third year oral health and dental student perceptions of future professional work

OBJECTIVES

To explore and compare the ways dental and oral health students characterise their future professional work (FPW) at the end of their second and third professional years.

MATERIALS AND METHODS

Questionnaires were given to a cohort group of 48 dental students and 31 oral health students at the end of their second and third professional years at the University of Otago. Students' characterisations of their FPW were identified using an inductive approach, and the emphasis on each characterisation was confirmed using a 'weighted' table.

RESULTS

Dental student response rates were 92% (in 2010) and 85% (in 2011); and oral health student response rates were 100% (in 2011) and 97% (in 2011). Students characterised their FPW in ten broad ways: in reference to treatment-related concerns, patient-related concerns, oral health promotion, oral health education, disease prevention and monitoring, communication, teamwork, maintaining an ideal clinical environment, maintaining a sense of self and improving quality of life. In both years, dental students emphasised treatment-related concerns as central to their FPW and dealing with patient-related concerns as a primary source of difficulty. Oral health students emphasised oral health promotion, oral health education, disease prevention and monitoring and restorative tasks as central to their FPW and dealing with patient-related concerns as a primary source of difficulty.

CONCLUSION

Students' broad perceptions of their FPW changed little as they progressed through their programmes; however, their responses suggested the need for greater attention within their programmes to patient management and teamwork.

Array comparative genomic hybridisation analysis of boys with X linked hypopituitarism identifies a 3.9 Mb duplicated critical region at Xq27 containing SOX3

INTRODUCTION

Array comparative genomic hybridisation (array CGH) is a powerful method that detects alteration of gene copy number with greater resolution and efficiency than traditional methods. However, its ability to detect disease causing duplications in constitutional genomic DNA has not been shown. We developed an array CGH assay for X linked hypopituitarism, which is associated with duplication of Xq26-q27.

METHODS

We generated custom BAC/PAC arrays that spanned the 7.3 Mb critical region at Xq26.1-q27.3, and used them to search for duplications in three previously uncharacterised families with X linked hypopituitarism.

RESULTS

Validation experiments clearly identified Xq26-q27 duplications that we had previously mapped by fluorescence in situ hybridisation. Array CGH analysis of novel XH families identified three different Xq26-q27 duplications, which together refine the critical region to a 3.9 Mb interval at Xq27.2-q27.3. Expression analysis of six orthologous mouse genes from this region revealed that the transcription factor Sox3 is expressed at 11.5 and 12.5 days after conception in the infundibulum of the developing pituitary and the presumptive hypothalamus.

DISCUSSION

Array CGH is a robust and sensitive method for identifying X chromosome duplications. The existence of different, overlapping Xq duplications in five kindreds indicates that X linked hypopituitarism is caused by increased gene dosage. Interestingly, all X linked hypopituitarism duplications contain SOX3. As mutation of this gene in human beings and mice results in hypopituitarism, we hypothesise that increased dosage of Sox3 causes perturbation of pituitary and hypothalamic development and may be the causative mechanism for X linked hypopituitarism.

Audit of 'crash' emergency caesarean sections due to cord prolapse in terms of response time and perinatal outcome

OBJECTIVE

The objective was to audit 'crash' emergency caesarean sections (CS) with respect to response time (the diagnosis to delivery interval [DDI]) and perinatal outcome.

MATERIALS AND METHODS

The computerised database at the Singapore General Hospital (SGH) delivery suite was used to identify all cases of 'crash' emergency CS activated for the diagnosis of cord prolapse from 1992 to 2002. Patients' case notes and neonatal charts were reviewed and the following variables were evaluated: parity, gestational age at the time of delivery and the DDI. Neonatal outcome was measured by Apgar scores at 1 and 5 minutes, cord pH and admission to the neonatal intensive care unit (NICU).

RESULTS

A total of 34 cases of umbilical cord prolapse were identified from 29,867 deliveries, giving an incidence of 0.11% (1 in 900). The median gestational age was 38.5 weeks (range, 25 to 41 weeks). The median time from diagnosis to delivery was 20 minutes (range, 10 to 40 minutes). Seventy-six percent (19/30) were delivered within 30 minutes. The time of diagnosis was not recorded for 5 cases. Sixty-three percent of neonates had an Apgar score < or = 7 at 1 minute of life, increasing to 97% at 5 minutes. There were 3 NICU admissions for reasons of prematurity. There was no perinatal mortality. Cord pH was not performed for 47% of (14/30) neonates. Among the remaining 16 neonates, an umbilical cord pH of < or = 7.20 was found in 62% (10/16). There was poor correlation between the DDI and umbilical cord pH.

CONCLUSION

Three-quarters of our 'crash' emergency CS for cord prolapse were performed within 30 minutes with a good perinatal outcome. However, we have identified areas for improvement to optimise further the operational efficiency of 'crash' emergency CS.

Changing trends in indications for caesarean sections in a tertiary hospital

OBJECTIVES

To study the caesarean section rate and the trends in indications for caesarean delivery at the Singapore General Hospital (SGH) during two study periods of 6 months each.

MATERIALS AND METHODS

The percentages of caesarean sections attributable to specific indications were computed for the first 6 months of 1998 and the last 6 months of 2001. Subgroup analysis of "less common indications" was performed.

RESULTS

In the first half of 1998, 170 caesarean sections were performed giving a rate of 16.77%. 54.12% of women were multiparous. The main indication for caesarean section was dystocia (4.24% of deliveries). Two hundred and sixty caesarean sections were performed in the later half of 2001 giving a caesarean section rate of 25.10%. 53.46% of women were multiparous. The main indication for caesarean section was dystocia (5.41% of deliveries). Increase in caesarean section rate in 2001 was attributed to statistically significant increase in caesarean section for previous caesarean section and placenta previa major. Other changes in practice included shorter operating time which may be related to decision not to perform peritoneal closure.

CONCLUSION

Studying indications for caesarean section are useful for hospitals, clinicians and researchers in determining strategies to lower primary and repeat caesarean section rate.

The glucose challenge test for screening gestational diabetes in pregnant women with no risk factors

AIM OF STUDY

To evaluate the 50 g glucose challenge test as a screening tool for gestational diabetes in pregnant women with no risk factors, to determine the prevalence of gestational diabetes in this population and to determine the perinatal outcomes of pregnancy according to the glucose challenge test.

METHODOLOGY

A descriptive prospective study. A total of 146 patients with no risk factors who booked a particular obstetrician and delivered between May 1996 and April 1997 were recruited. Pregnancy outcomes were assessed by the gestation and mode of delivery, neonatal outcomes included birth weights, apgar scores and other neonatal complications.

RESULTS

The detected incidence of gestational diabetes was 8.2%. With the threshold plasma glucose level at 7.1 mmol/l, 53 women or 36% needed to undergo the 75 g oral glucose tolerance test and 12 women were found to have gestational diabetes. The diagnostic yield was 22.6%. With 7.8 mmol/l as the threshold value, 28 women or 20% needed the oral glucose tolerance test and eight women with gestational diabetes were detected. The diagnostic yield was 28.6%. Perinatal outcome for these diabetic women who were well-controlled during pregnancy was similar to the rest of the women with normal glucose challenge test.

CONCLUSIONS

The 50 g glucose challenge test is a useful screening test for diabetes in Singaporean women with no risk factors. A threshold value at 7.8 mmol/l with a smaller number of women requiring the 75 g oral glucose challenge test may be more acceptable.

Clinical management of PCOS

The polycystic ovary syndrome (PCOS) is a heterogeneous condition with genetic predisposition. It is characterized by a myriad of symptoms including oligomenorrhea or amenorrhea, anovulation or infertility, hirsutism or acne. Insulin resistance appears to be an important factor in PCOS though the lack of an etiology has led to symptom oriented therapy which includes lifestyle modification, the use of cyclical progestagens and antiandrogens. Ovulation induction by drug therapy and ovarian drilling aims to treat subfertility in women with PCOS. Therapeutic approaches to PCOS remain an ongoing source of debate. Insulin sensitizing agents may bring new hope in therapy. Future research is aimed at shedding light on the pathophysiology so as to optimize treatment of women with PCOS.

Perioperative management of a patient with congenital myasthenia gravis for elective caesarean section

Congenital disorders of neuromuscular transmission are commonly referred to as congenital myasthenia gravis because of their clinical similarity to the immune-mediated disease. Differentiation between the immune-mediated and congenital forms of the disease is important, because therapy established for the former may not be appropriate for patients with the latter presentation. The course of this rare neuromuscular disorder during pregnancy and its influence on anaesthesia remain largely unknown. We report on the case of a 32-year-old parturient suffering from congenital myasthenia gravis scheduled for elective caesarean section. The perioperative management of this patient who underwent the operation under spinal anaesthesia was reviewed. The effects of anaesthetic agents and techniques on the course of congenital myasthenic patients may need further review in the light of latest findings in the electrophysiology, genetic and therapeutic studies of this syndrome.

Relationship between gestational age and frequency of fetal trophoblasts and nucleated erythrocytes in maternal peripheral blood

The relationship between gestational age and frequency of fetal cells in the maternal blood was studied in order to determine the optimal time for cell recovery. The immunomagnetic colloid system was used to enrich nucleated erythrocytes (NRBCs) and trophoblasts from 20 ml maternal blood samples obtained between 9 and 35 weeks' gestation (n=41). Nested polymerase chain reaction (PCR) for the Y chromosome of enriched NRBCs and trophoblasts showed decreasing negative predictive values with increasing gestational age. The sensitivity and the overall frequency for correct fetal gender diagnosis were the lowest in the third trimester. Fluorescence in situ hybridisation (FISH) using XY DNA-specific probes was used to determine the fetal gender of the trophoblast-enriched fraction. The fetal origin of enriched NRBCs was determined using simultaneous immunophenotyping for fetal hemoglobin and FISH with XY probes. The mean number and mean percentage purity for both fetal trophoblasts and NRBCs showed decreasing values with increasing gestational age. However, statistical analysis showed no relationship between gestational age and frequency of fetal cells even though more fetal cells tend to exist during the first trimester. Nevertheless, the first trimester appears to offer the most optimal time for fetal cell recovery from maternal blood for the purpose of prenatal diagnosis.

Retroperitoneal Castleman's disease in the perinephric space--imaging appearance: a case report and a review of the literature

INTRODUCTION

Castleman's disease (CD) is a rare lymphoid tumour usually found in the mediastinum. Extrathoracic sites are uncommon. Its radiological findings may be similar to other retroperitoneal tumours, making diagnosis difficult.

CLINICAL PICTURE

A 54-year-old female was found to have an incidental hypoechoic mass in the left posterior perinephric space on routine ultrasound. Abdominal computed tomography (CT) scan demonstrated an isodense mass which enhanced brightly with intravenous contrast. Angiogram confirmed a hypervascular mass.

TREATMENT

The retroperitoneal mass was excised.

OUTCOME

Histology revealed CD of hyaline-vascular type.

CONCLUSION

CD should be considered in the differential diagnosis of a retroperitoneal mass, which demonstrates homogeneous and intense enhancement.

Overview of legislation and tobacco control in Singapore

Legislative measures against smoking in Singapore began in the early 1970s, and can be said to have been the start of a comprehensive smoking control programme. With the launch of the National Smoking Control Programme (NSCP) in 1986, a National Smoking Control Coordinating Committee was set up to look into legislation and fiscal measures. To further increase the dimension and impact of the programme, a Civic Committee on Smoking Control was formed in 1996. This committee also looks into and recommends legislative measures. The NSCP is an ongoing programme that aims to reduce smoking rates through a combination of strategies, including education, establishment of no-smoking areas and increasing taxation and legislative measures. Existing legislation is regularly and systematically reviewed and revised, and new laws are recommended to strengthen our smoking control efforts. Concurrently, penalties and ways to improve enforcement of the legislation are also updated. The legislative measures that have been implemented in Singapore over the years include prohibition of tobacco advertising and promotion, restrictions on the sale of tobacco products, licensing of sales outlets, use of health warnings on cigarette packets, controlling and labelling of tar and nicotine contents, restriction of smoking in public places and prohibition of smoking in public by the under-eighteens. Several factors have helped make legislative measures work in Singapore. These include political will and support, starting legislation early, comprehensive legislative measures, enforcement measures and continuous review. To sustain these efforts, Singapore needs to continue to stay abreast of world-wide measures on smoking control.

Superoxide produced by activated neutrophils efficiently reduces the tetrazolium salt, WST-1 to produce a soluble formazan: a simple colorimetric assay for measuring respiratory burst activation and for screening anti-inflammatory agents

Activation of the respiratory burst of granulocytes and macrophages by invading microorganisms is a key first line cellular defence against infection. Failure to generate this response leads to persistent life-threatening infection unless appropriate antibiotic treatment is given. The respiratory burst of neutrophils is usually measured spectrophotometrically by following ferricytochrome c reduction, and histologically by using the tetrazolium salt, nitroblue tetrazolium, which is reduced intracellularly to an insoluble formazan. In both assays, reduction is mediated by superoxide generated via NADPH oxidase. Because ferricytochrome c has a high molecular mass and high background absorbance at 550 nm, the assay lacks sensitivity and is not ideally suited to microplate measurement. We have circumvented these limitations by using the cell-impermeable, sulfonated tetrazolium salt, WST-1, which exhibits very low background absorbance and is efficiently reduced by superoxide to a stable water-soluble formazan with high molar absorptivity. This has permitted adaptation of the WST-1 assay to microplate format while retaining sensitivity. Reduction of WST-1 by activated human peripheral blood neutrophils correlated closely with ferricytochrome c reduction across a range of PMA concentrations and with time of activation by PMA and fMLP. Reduction of WST-1 was inhibited by 98% by superoxide dismutase (20 microg/ml) and by 88% by the NADPH oxidase inhibitor, diphenyleneiodinium (10 microM) but was resistant to catalase, azide and the NADH oxidase inhibitor, resiniferatoxin. WST-1 and ferricytochrome c reduction were also compared using xanthine/xanthine oxidase to generate superoxide. Under optimised assay conditions, both WST-1 and ferricytochrome c reduction were directly proportional to added xanthine. WST-1 generated approximately 2-fold greater increase in absorbance than ferricytochrome c at their respective wavelengths, and this translated into increased assay sensitivity. Addition of the intermediate electron acceptor, 1-methoxy phenazine methosulfate, increased the background of the neutrophil assay but did not affect the overall magnitude of the response. We have used the WST-1 assay to assess human neutrophil dysfunction and to compare anti-inflammatory activity.

Cell-surface NAD(P)H-oxidase: relationship to trans-plasma membrane NADH-oxidoreductase and a potential source of circulating NADH-oxidase

The surface of mammalian cells faces an oxidizing environment that has the potential to damage proteins, lipids, and carbohydrates to which it is exposed. In contrast, the cytoplasm is reducing and its redox state is tightly regulated. Trans-plasma membrane oxidoreductases that shift electrons from cytosolic NADH to external electron acceptors such as oxygen are widely involved in cellular redox control. They reduce oxygen to water and may generate reactive oxygen species such as superoxide and hydrogen peroxide. In addition, external NAD(P)H-oxidases have been demonstrated on intact cells and as eluted proteins, but the relationship between trans-plasma membrane NADH-oxidoreductases and cell-surface NAD(P)H-oxidases is not known. To investigate further the relationship between plasma membrane NAD(P)H-oxidoreductases, and to gain insight into the physiological functions of these redox active membrane proteins, we have adapted a simple colorimetric assay for measuring the trans-plasma membrane NADH-oxidoreductase activity of viable cells to measure NAD(P)H-oxidase at the cell surface in real time. Using the cell-impermeable tetrazolium salt WST-1 in the presence of NADH or NADPH, but in the absence of an intermediate electron acceptor, we show that cell-surface NAD(P)H-oxidase is widely expressed on mammalian cells, being more abundant on rapidly proliferating cells than on resting neutrophils and spleen cells. The ratio of cofactor dependence of NAD(P)H-oxidase (NADH:NADPH) varied widely between different cells (0.7-5.2), suggesting a family of cell surface oxidases or that the activity of these enzymes may be modulated in various ways. Comparison of NAD(P)H-oxidase on the surface of viable cells with trans-membrane NADH-oxidoreductase, measured with WST-1 in the presence of 1-methoxy PMS, showed that cell-surface NAD(P)H-oxidase was differentially inhibited by the cell-impermeable thiol-blocking agent pCMBS, but was unaffected or stimulated by other thiol blocking agents. Capsaicin, which inhibits trans-plasma membrane NADH-oxidoreductase activity, stimulated surface NAD(P)H-oxidase. Metabolic inhibitors had little effect on surface NAD(P)H-oxidase activity but inhibited trans-plasma membrane activity. These results do not support the view the surface NAD(P)H-oxidase is a terminal oxidase for trans-plasma membrane NADH-oxidoreductase.

High-capacity redox control at the plasma membrane of mammalian cells: trans-membrane, cell surface, and serum NADH-oxidases

The high capacity of proliferating mammalian cells to transfer electrons from cytosolic NADH to extracellular electron acceptors like oxygen is poorly understood and not widely recognized. Nevertheless, trans-plasma membrane electron transport (plasma membrane redox control) probably ranks alongside the Na+/H+ antiport system (pH control) and glucose transport in facilitating cellular responses to physiological stimuli. These plasma membrane transport systems are acutely responsive to receptor ligation by growth factors, polypeptide hormones, and other cell activators. A novel tetrazolium-based cell proliferation assay that we have shown to measure an NADH-oxidoreductase component of the trans-plasma membrane electron transport system has allowed direct comparisons with NADH:ferricyanide-oxidoreductase and respiratory burst NADPH-oxidoreductase. In addition, an NAD(P)H-oxidase at the cell surface and an NADH-oxidase activity in body fluids can be measured by modifying the basic cell proliferation assay. As determined by reduction of the cell-impermeable tetrazolium reagent, WST-1, electron transfer across the plasma membrane of dividing cells can exceed that of fully activated human peripheral blood neutrophils. Cellular reduction of WST-1 is dependent on the presence of an intermediate electron acceptor and is inhibited by superoxide dismutase (SOD) and by oxygen, implying indirect involvement of superoxide in WST-1 reduction. Cell-surface NAD(P)H-oxidase and serum NADH-oxidase are shown to be distinct from trans-plasma membrane NADH-oxidoreductase by their differential sensitivity to capsaicin and pCMBS. The glycolytic metabolism of cancer cells may be linked to changes in trans-plasma membrane NADH:WST-1-oxidoreductase activity and to increased serum NADH-oxidase in cancer.

Acute regulation of glucose transport after activation of human peripheral blood neutrophils by phorbol myristate acetate, fMLP, and granulocyte-macrophage colony-stimulating factor

Activation of human peripheral blood neutrophils by pathogens or by phorbol myristate acetate (PMA), fMLP, or myeloid growth factors generates a respiratory burst in which superoxide production plays an important role in killing invading microorganisms. Although the increased energy demands of activated neutrophils would be expected to be associated with increased glucose uptake and utilization, previous studies have shown that PMA inhibits 2-deoxyglucose (2-DOG) uptake. In this study, we show that PMA activation of neutrophils, isolated by methods not involving hypotonic lysis, increases the rate of 2-DOG uptake and results in a 1.6-fold to 2.1-fold increase in transporter affinity for glucose without changing Vmax. Increased transporter affinity in response to PMA was also observed with 3-O-methyglucose, which is not phosphorylated, and inclusion of glucose in the activation medium further increased respiratory burst activity. Increased 2-DOG uptake and increased transporter affinity for glucose were also observed with the peptide activator, fMLP, and with granulocyte-macrophage colony-stimulating factor (GM-CSF). The protein kinase C (PKC) inhibitor, calphostin C, and the tyrosine kinase inhibitor, genistein, inhibited both PMA- and fMLP-stimulated 2-DOG uptake. In contrast, genistein inhibited fMLP-induced superoxide production, but had little effect on the PMA-induced response, while staurosporine differentially inhibited PMA-induced superoxide production. These results show that neutrophil activation involves increased glucose transport and intrinsic activation of glucose transporter molecules. Both tyrosine kinases and PKC are implicated in the activation process.

Does a prenatal diagnosis of congenital heart disease alter short-term outcome?

Congenital heart disease (CHD) is the most common fatal congenital anomaly in the first year after birth. Fetal echocardiography has become accepted as a method of diagnosing CHD in utero, but the benefits of prenatal diagnosis have not been evaluated. We performed a cohort analysis of neonates with CHD in the absence of other life-threatening conditions. One group (I) consisted of neonates who had been diagnosed as fetuses to have CHD and who were delivered at Yale-New Haven Hospital. The other group (II) consisted of neonates who were not diagnosed to have CHD until after birth, and were either delivered at, or transferred to, the same hospital. Costs of initial hospitalization, length of hospitalization, and survival to discharge home with the parents were primary outcome measures. Our primary hypothesis was that all outcome measures would be improved by prenatal diagnosis. We also examined secondary hypotheses that these same measures would be improved among selected subgroups, including those requiring univentricular management, those amenable to biventricular repair, those with ductal dependent lesions, and those requiring any surgery during the primary admission. From January 1, 1991 to June 30, 1996 we identified 45 antenatal cases and 54 postnatal cases of CHD that met the study entry criteria. The median length (+/- SE) of initial hospitalization was 16 +/- 3.8 days in group I, and 11 +/- 3.8 days in group II (p < 0.08). The median cost of initial hospitalization was $57,678 +/- 12,340 vs. $53,604 +/- 7249 (not significant). Eighty percent of group I survived to hospital discharge compared with 67% of group II (p = 0.14). There was no difference in survival among those requiring univentricular management (64 vs. 44%), but costs and length of hospitalization were greater in group I, regardless of whether or not surgery was performed postnatally. Surgery was undertaken more often among the prenatal diagnosis group with univentricular hearts (86 vs. 56%, p < 0.05). Among those fetuses amenable to biventricular repair, survival was better (96 vs. 76%, p < 0.05) and the cost of hospitalization was lower ($30,277 +/- 16,869 vs. $64,616 +/- 9441, p = 0.06) in the prenatal diagnosis group. Prenatal diagnosis of CHD does not result in the expected savings in cost, length of hospitalization or survival in the overall group of patients. The prenatal diagnosis group showed a skew towards single ventricle physiology. Within that group a high rate of pregnancy termination results in a group of parents who are likely to choose postnatal surgery despite high short- and long-term mortality risks.

The hemopoietic growth factor, interleukin-3, promotes glucose transport by increasing the specific activity and maintaining the affinity for glucose of plasma membrane glucose transporters

Most mammalian cells rely on an external supply of glucose for survival, proliferation, and function. Glucose enters cells through specific transporter molecules at the plasma membrane by a facilitative process that does not expend energy. Regulation of glucose transport into cells is thought to occur largely through transporter expression at the cell surface, but the extent to which the intrinsic properties of glucose transporters are regulated is at present controversial. Using a bone marrow-derived cell line that responds to the hemopoietic growth factor, interleukin-3 (IL-3), we investigated IL-3 regulation of glucose transport. IL-3 significantly increased 2-deoxyglucose (2-DOG) uptake within 1 h (26 +/- 8.0%, n = 11) with a maximum 73% increase after 6 h. Withdrawal of IL-3 resulted in decreased uptake within 1 h and this continued to decline to 43% of initial uptake by 16 h. To determine whether these changes in 2-DOG uptake were associated with corresponding changes in glucose transporter expression, subtype-specific antisera against Glut-1 and Glut-3 were used. Little change in membrane expression of these transporters was observed prior to 16 h. Fractionation of cell membranes on Nycodenz gradients showed that the majority of each transporter subtype was associated with the plasma membrane (63-93%) and that transporter distribution did not change markedly in response to addition or withdrawal of IL-3. These results demonstrate that IL-3 regulates glucose uptake by modulating the intrinsic transporting ability of glucose transporters. Decreased transporter affinity for 2-DOG and 3-O-methylglucose was observed following IL-3 withdrawal. Similar affinity changes were observed with 2-DOG following exposure of IL-3-stimulated cells to the protein kinase inhibitors, genistein and staurosporine. In contrast, the tyrosine phosphatase inhibitor, vanadate, acted like IL-3 to increase transporter affinity for glucose. Together these results demonstrate that IL-3 acts to maintain the intrinsic transport properties of glucose transporters without markedly affecting their expression or translocation.

Patient education in the management of diabetes mellitus

AIM

A patient education programme in the management of diabetes mellitus (DM) was piloted in a government polyclinic. This study aimed to evaluate the effectiveness of the education programme in improving knowledge of DM and skills in self-care in order to achieve long term control of DM.

METHOD

The study was carried out on an intervention group of 183 diabetic patients who completed the education programme and a control group of 95 diabetic patients who attended the clinic during the period of the study. The patients were assessed on their knowledge of diabetes and their practice for good control of the disease (dietary practice, compliance, home monitoring) through a questionnaire. Long term control was assessed by their glycosylated haemoglobin levels. The education programme comprised individual counselling using a diabetes education guide, talks, videoshows and food displays.

RESULTS

The intervention group showed a significant and greater improvement in the knowledge of the disease and self-care and in the dietary practice (taking more unpolished rice/high fibre food, reducing calories intake and cutting down oily/fatty food) when compared to the control group. Compliance with medication and the mean HbA1c levels were also improved in the intervention group.

CONCLUSION

In this study the educational intervention was observed to have improved the diabetic patients' knowledge of the disease and self-care and the long term control of the disease. Patient education is thus an important component in the management of diabetes mellitus.

Is maternal thyrotropin releasing hormone administration safe in the pregnant woman with preeclampsia?

Maternal intravenous administration of thyrotropin releasing hormone (TRH) is associated with rapid elevations of blood pressure potentially causative of cerebrovascular accidents. We report a case in which peak blood pressure of 220/120 mm Hg was attained from a baseline of 132/80 mm Hg following TRH administration in a preeclamptic patient.

CD95 (Fas/Apo-1)-induced apoptosis results in loss of glucose transporter function

Treatment of activated human T cells with CD95 (Fas/Apo-1) ligand or Abs against CD95 results in apoptotic cell death. Although cellular responses to CD95 ligation have been described in some detail, the early molecular events that result in T cell death are only now beginning to be elucidated. Using Jurkat cells as a model of activated human T cells, we have investigated the effects of CD95 ligation on glucose transport and on glucose transporter function. We show that within minutes of CD95 activation, the ability to transport glucose across the plasma membrane is compromised and that transient exposure to Abs against CD95 for as little as 3 min results in reduced glucose transport and 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) responses measured at 16 h. The effects of CD95 ligation on glucose transport are shown to be associated with loss of affinity of glucose transporters for glucose without altered maximum velocity and without changes in the cell surface expression of Glut 1, the predominant glucose transporter isotype on Jurkat cells. These results support a model of CD95 induced cell death that, at least in its early stages, does not depend on signaling to the nucleus or on macromolecular synthesis. Acute regulation of glucose transport is proposed to be an early effector mechanism in CD95-induced apoptotic cell death.

CD95 (Fas/Apo-1)-induced apoptosis results in loss of glucose transporter function

Treatment of activated human T cells with CD95 (Fas/Apo-1) ligand or Abs against CD95 results in apoptotic cell death. Although cellular responses to CD95 ligation have been described in some detail, the early molecular events that result in T cell death are only now beginning to be elucidated. Using Jurkat cells as a model of activated human T cells, we have investigated the effects of CD95 ligation on glucose transport and on glucose transporter function. We show that within minutes of CD95 activation, the ability to transport glucose across the plasma membrane is compromised and that transient exposure to Abs against CD95 for as little as 3 min results in reduced glucose transport and 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) responses measured at 16 h. The effects of CD95 ligation on glucose transport are shown to be associated with loss of affinity of glucose transporters for glucose without altered maximum velocity and without changes in the cell surface expression of Glut 1, the predominant glucose transporter isotype on Jurkat cells. These results support a model of CD95 induced cell death that, at least in its early stages, does not depend on signaling to the nucleus or on macromolecular synthesis. Acute regulation of glucose transport is proposed to be an early effector mechanism in CD95-induced apoptotic cell death.

Evidence that cell survival is controlled by interleukin-3 independently of cell proliferation

Hemopoietic cell proliferation is controlled by a set of polypeptide growth factors and regulatory molecules that bind to cell surface receptors inducing cellular responses. Maintenance of a viable state, cell growth, DNA synthesis and mitosis are basic properties of proliferating cells, but links between growth factor receptors and each of these cellular outcomes are poorly understood. Most studies have monitored DNA synthesis as a measure of progression through the cell cycle or directly measured viable cell numbers, but cell survival per se as an output of receptor activation by ligand, has received little attention. In this study we have used a bone marrow-derived murine cell line that is dependent on interleukin-3 for growth, to investigate the relationship between DNA synthesis and a biochemical marker of cell survival, reduction of the tetrazolium salt, MTT. We show that at times up to 6 hr, continued DNA synthesis, RNA synthesis, protein synthesis, and mitochondrial respiration are not necessary for background or IL-3-stimulated MTT reduction. Furthermore, dibutyryl cyclic AMP promoted background and IL-3-dependent MTT reduction while simultaneously inhibiting DNA synthesis. These results provide evidence that IL-3 controls events involved in MTT reduction and cell survival independently of DNA synthesis.

Interleukin-3 facilitates glucose transport in a myeloid cell line by regulating the affinity of the glucose transporter for glucose: involvement of protein phosphorylation in transporter activation

Growth factors promote cell survival and proliferation by activating signal transduction pathways that result in progression through the cell cycle and differential gene expression. Uptake of simple sugars needed for basal cell metabolism, and for macromolecular synthesis necessary for cell growth and proliferation, is thought to follow as a consequence of signal transduction to the nucleus. However, in the presence of inhibitors of DNA synthesis and respiration, growth factors can still promote cell survival responses in the short term, raising the possibility that they may also regulate critical membrane and cytosolic processes necessary for cell survival. We have tested this hypothesis directly by investigating the role of the haemopoietic growth factor, interleukin-3 (IL-3), in the regulation of glucose transport in the bone marrow-derived cell line, 32D. We show that IL-3 promotes glucose transport by actively maintaining the affinity of the plasma membrane, glucose transporter for glucose (Km 1.35 +/- 0.15 mM, n = 4). Withdrawal of IL-3 for 1 h resulted in reduced affinity for glucose (Km 2.96 +/- 0.28 mM, n = 4) without an associated change in Vmax. Furthermore, glucose transporter molecules as the cell surface, as determined by cytochalasin B binding to isolated plasma membranes, did not differ significantly between control and IL-3-treated cells. Inhibition of DNA synthesis with mitomycin C or with the respiratory poison, sodium azide, did not affect the ability of IL-3 to promote glucose transport. In contrast, the tyrosine kinase inhibitors genistein and erbstatin extensively inhibited control and IL-3-stimulated glucose transport, some preference of IL-3-stimulated glucose transport, some preference for IL-3-stimulated responses being observed at low inhibitor concentrations. The light-activated protein kinase C inhibitor, calphostin C, also inhibited control and IL-3-stimulated glucose transport but without preference for IL-3 responses. Additionally, the tyrosine phosphatase inhibitor, orthovanadate, stimulated control and IL-3-dependent glucose transport by 50-80% while the protein kinase A inhibitor, KT5720, inhibited glucose transport by about 20% at plateau values. These results indicate that IL-3 is involved in continuous maintenance of glucose transporter activity by a mechanism that involves tyrosine kinases and protein kinase C, and demonstrate that this activation is not dependent on respiration or signal transduction to the nucleus.

Characterization of the cellular reduction of 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT): subcellular localization, substrate dependence, and involvement of mitochondrial electron transport in MTT reduction

The MTT assay, which is widely used to measure cell proliferation and to screen for anticancer drugs, is based on reduction of the tetrazolium salt, MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) by actively growing cells to produce a blue formazan product. Despite broad acceptance of this assay, neither the subcellular localization, nor the biochemical events involved in MTT reduction are known. Mitochondrial involvement in MTT reduction has been inferred from studies with respiratory inhibitors using succinate as a substrate, but the contribution of this activity to overall cellular MTT reduction is unknown. Using the bone marrow-derived cell line, 32D, we investigated the subcellular localization of MTT reduction using succinate, NADH, and NADPH as substrates. At optimum substrate concentrations, MTT reduction by whole cell homogenates was greatest with NADH and least with succinate, which accounted for less than 10% of the combined activities. Using succinate, 96% of recoverable MTT reducing activity was in particulate fractions of the cell and 77% in the mitochondrial and light mitochondrial/lysosomal fractions. When NADH and NADPH were used as substrates, increased amounts of MTT reducing activity were associated with soluble fractions of the cell and association with mitochondrial fractions was less pronounced. To further characterize MTT reduction by the mitochondrial fraction, respiratory chain inhibitors were used to explore involvement of electron transport in MTT reduction. Succinate-dependent mitochondrial MTT reduction was inhibited by 80% with chlorpromazine, 70% by antimycin A, and 85-90% by thenoyltrifluoracetone (TTFA), but inhibition was not observed with rotenone at < or = 2 microM, Amytal, or azide. These results suggest that when succinate is used as an electron donor, 70-80% of mitochondrial MTT reduction occurs subsequent to transfer of electrons from cytochrome c to cytochrome oxidase, but prior to the point of azide inhibition. In contrast to succinate, NADPH-dependent mitochondrial MTT reduction was not affected by any of the respiratory inhibitors tested, and NADH-dependent reduction was only inhibited by chlorpromazine (40-50% at plateau concentrations). These results suggest that most cellular MTT reduction occurs outside the mitochondrial inner membrane and involves NADH and NADPH-dependent mechanisms that are insensitive to respiratory chain inhibitors. This interpretation is supported by whole cell studies in which rotenone failed to affect basal and interleukin-3-stimulated MTT reduction at times up to 4 h but strongly inhibited DNA synthesis. We conclude that most cellular reduction of MTT occurs extramitochondrially and probably involves the pyridine nucleotide cofactors NADH and NADPH.

Isolation and characterization of two immunochemically distinct alkaline phosphatases from Pseudomonas aeruginosa

We have isolated two alkaline phosphatases (H-AP and L-AP, for high and low molecular mass, respectively) from Pseudomonas aeruginosa PA01. These two enzymes were found to differ in mobility on sodium dodecyl sulphate polyacrylamide gels (H-AP, M(r) = 51,000 and L-AP, M(r) = 39,500), amino-terminal amino acid sequence and did not cross-react. Both enzymes were active as phosphomonoesterases while only L-AP demonstrated any phosphodiesterase activity. Both enzymes were purified from P. aeruginosa grown in phosphate limiting conditions using the same protocol and were identified in both periplasmic and extracellular locations. A low level of H-AP was produced constitutively whereas L-AP was produced only after induction by reduced phosphate concentration in the growth medium. An L-AP-like enzyme has been previously described, however, this is the first report of a second P. aeruginosa alkaline phosphatase.

Cyclic adenosine monophosphate promotes cell survival and retards apoptosis in a factor-dependent bone marrow-derived cell line

Hemopoietic growth factors promote cell survival, proliferation and differentiation, but whether these processes, which often occur in concert, are mediated through the same or different receptor signaling mechanisms is not known. Using the bone marrow-derived IL-3-dependent cell line, 32D, we show that dibutyryl cyclic adenosine monophosphate (dbcAMP) retards the rapid loss of viable cells seen in the absence of IL-3. This effect is shown to be concentration-dependent and detectable within 16 hours of culture and is not associated with cell differentiation. At earlier times (2 to 7 hours), when no significant changes in cell numbers were observed, dbcAMP stimulated the reduction of dimethylthiazoldiphenyl tetrazolium bromide (MTT), and this effect was indistinguishable from that seen with IL-3. In contrast, control cells deprived of growth factor showed a decline in MTT response over this period. The effect of dbcAMP in maintaining cell viability and MTT responsiveness was associated with a concentration-dependent inhibition of 3H-thymidine incorporation into DNA, and retardation of the intranucleosomal cleavage of DNA that is associated with apoptosis. These results suggest that in 32D cells, cAMP can act to promote cell survival and retard apoptosis, quite independently of cell proliferation, by stimulating the activity of mitochondrial enzymes involved in MTT reduction.

The protein kinase C inhibitor, calphostin C, inhibits succinate-dependent mitochondrial reduction of MTT by a mechanism that does not involve protein kinase C

The light-activated protein kinase C inhibitor, calphostin C, is shown to inhibit the ability of IL-3-dependent 32D cells to reduce the tetrazolium salt, MTT. To determine whether this inhibition was mediated through mitochondria which have been implicated in MTT reduction, isolated mitochondria were treated with calphostin C in the presence of various substrates for mitochondrial electron transport and EDTA (to exclude PKC involvement). Calphostin C extensively inhibited succinate-dependent MTT reduction (IC50 = 110nM) but had little effect on either NADH- or NADPH-dependent MTT reduction. An alternative protein kinase C inhibitor, H7, did not affect succinate-dependent mitochondrial MTT reduction, and the protein kinase A inhibitor, KT5720, had little effect on either cellular or mitochondrial MTT reduction. These results show that in addition to its role as a PKC inhibitor, calphostin C is also a potent inhibitor of succinate-dependent mitochondrial electron transport.

Monoclonal antibodies that bind to hemopoietic stem cells: characterization and immunohistochemical localization of cells expressing gp50-65

The cell surface of hemopoietic stem cells has been shown to express several antigens in common with more mature hemopoietic cells. One set of stem cell antigens is defined by a group of three monoclonal antibodies (13C6, 1C10, and 1A9), selected on the basis of binding to subpopulations of spleen colony-forming stem cells (CFU-S). These antibodies are shown to recognize cell surface glycoproteins of 50-65 kd (gp50-65) that occur widely on hemopoietic cells. Each cell type investigated shows a distinctive pattern of expression of these glycoproteins. To further investigate the presence of gp50-65 on stem cells, low-density bone marrow cells were labeled with 1C10 and sorted according to fluorescence intensity. Most (73%) of the stem cells (CFU-S10) were recovered in the two most highly fluorescent fractions containing 2.6% of starting marrow cells. Immunohistochemistry of frozen sections of normal spleen and spleens during repopulation after lethal irradiation and bone marrow transplantation showed that the most strongly 1C10-labeled cells occurred under the splenic capsule and along trabeculae. Although many of these cells were also alpha-naphthylacetate esterase positive and Mac-1 positive, indicating cells of the monocyte-macrophage lineage, a distinctive population of singular cells were stained with 1C10 alone. These cells were negative for surface Ig and closely corresponded with a small population of cells in a similar location that were doubly labeled with 1C10 and anti-Thy-1. These results show that stem cells express high levels of gp50-65 and suggest that stem cells can be identified by immunohistochemical methods using dual labeling procedures.

Expression of specific high-affinity binding sites for erythropoietin on rat and mouse megakaryocytes

Considerable experimental and clinical evidence suggests a relationship between erythropoiesis and thrombopoiesis. This is supported by observations that erythropoietin (Epo), the primary regulator of erythropoiesis, can affect platelet production when injected into animals. In this study we provide experimental evidence for a direct effect of Epo on thrombopoiesis by demonstrating that 125I-labeled recombinant human Epo binds to rat and mouse bone marrow megakaryocytes. Thus, autoradiographic analysis using cold competition to measure specific binding has been used to demonstrate that Epo binding to megakaryocytes increases with megakaryocyte maturation. When corrected for cell size, Epo binding sites per unit surface area increase from Stage I megakaryoblasts to Stage II megakaryocytes, and then remain approximately constant throughout further megakaryocyte maturation. Receptor density on megakaryocytes is similar to that on pronormoblasts in the rat, and in mice is 60% that on pronormoblasts. No binding of Epo to platelets or to naked megakaryocyte nuclei was detected. Equilibrium binding studies with partially purified rat megakaryocytes (20%-40% pure), where megakaryocytes are the only significant Epo binding cell population, showed a single class of saturable, high-affinity binding sites present on average at 6500 binding sites per megakaryocyte with a KD of 287 pM. Binding of [125I]Epo to rat megakaryocytes was inhibited with an antiserum against murine erythroblasts. These results suggest that the effects of Epo on thrombopoiesis may be directly mediated through specific, high-affinity binding sites for Epo on the surface of maturing megakaryocytes.

Polymorphic glycoprotein-1 on mouse platelets: possible role of Pgp-1 and LFA-1 in antibody-dependent platelet cytotoxicity involving complement

The presence of the Pgp-1 glycoprotein on mouse platelets is demonstrated by antibody-binding techniques, by immunoprecipitation, and by transblotting using the monoclonal antibody (MoAb) C71/26 against Pgp-1. C71/26 immunoprecipitates as a broad band of mol wt 87,000 to 100,000 as determined by radioiodination of the platelet cell surface and by the 3H-sodium borohydride labeling technique. Immunoblotting showed Pgp-1 expression on platelets to be quantitatively similar to its presence on macrophages and resolved platelet Pgp-1 into two bands of mol wt 87,000 and 97,000 whereas Pgp-1 on parasite-elicited peritoneal macrophages showed 82,000 and 87,000 mol wt species. Platelets and monocyte/macrophage cells from either peripheral blood or from the peritoneal cavity showed homogeneous binding of Pgp-1 antibody to greater than 97% of cells by flow cytometry. In contrast, lymphocytes from peripheral blood or from the spleen showed a heterogeneous binding pattern with 20% to 30% of cells being negative, and the majority weakly positive. In functional studies, MoAbs against CR1 and CR3 substantially inhibited platelet immune adherence, whereas C71/26 showed only marginal inhibitor. In contrast, C71/26 and other MoAbs against Pgp-1 inhibited platelet-dependent cytotoxicity of antibody-coated sheep erythrocytes in the presence of C5-deficient mouse plasma whereas M1/70 against CR3 showed no effect. In this assay, MoAbs against the alpha- and beta-subunits of leukocyte functional molecule LFA-1 also inhibited platelet cytotoxicity. These results show that the platelet cell surface moieties Pgp-1 and LFA-1 are involved in or closely associated with antibody-dependent cellular cytotoxicity by platelets.

Cell-lineage antigens of the stem cell-megakaryocyte-platelet lineage are associated with the platelet IIb-IIIa glycoprotein complex

The stem cell-platelet lineage is uniquely defined by platelet cell-lineage antigens. These antigens are present on all stem cells measured by the spleen colony assay and become restricted to the platelet cell lineage as differentiation proceeds. In this study, anti-platelet serum (APS) has been used to identify cells in the bone marrow that express platelet cell-lineage antigens and to identify platelet cell surface molecules expressing these antigens. Anti-platelet IgG extensively absorbed with brain, thymus, and peritoneal cells bound selectively to stem cells, megakaryocyte progenitor cells (Mk-CFC), and megakaryocytes in CBA mouse bone marrow and to blood platelets. No other hemopoietic cell type, tissue, cell line, or tumor cell bound significant amounts of antibody against platelet cell-lineage antigens as determined by ability to absorb the anti-stem cell activity in APS. Studies with lactoperoxidase-labeled platelets showed that two major iodinated proteins of Mr = 114,000 and 138,000 were immunoprecipitated with APS and with antiserum that had been extensively absorbed. These proteins correspond to the platelet IIb-IIIa glycoprotein complex, which is known to express receptors for collagen and fibrinogen, molecules known to influence hemopoietic cell proliferation and tumor cell growth. A panel of six monoclonal antibodies against human IIb-IIIa inhibited spleen colony formation by 17% to 100%, J15 and A5.15 also being cytotoxic for granulocyte-macrophage progenitor cells and Mk-CFC. Other platelet monoclonal antibodies did not inhibit spleen colony formation. Although APS inhibited fibrinogen binding to platelets and platelet aggregation, these activities were greatly reduced with absorbed antiserum. Furthermore, fibrinogen treatment of bone marrow did not block the anti-stem cell activity in APS. Thus the evidence is consistent with expression of platelet cell-lineage antigens on the platelet IIb-IIIa glycoprotein complex at a site removed from the fibrinogen binding site.

Binding of monoclonal antibodies that inhibit spleen colony formation to leukemic cell lines

Clonogenic tumor cells and normal stem cells share the property of extensive proliferative potential. Normal stem cells are under stringent growth restraint and respond to appropriate differentiation signals, whereas tumor stem cells have lost the ability to respond normally to these controls. In an attempt to define cell surface molecules involved in the control of hemopoietic cell proliferation and differentiation, we have produced 5 monoclonal antibodies against antigens held in common between hemopoietic stem cells and the Abelson virus-induced pre-B-lymphoma cells from which they were derived. Four of these monoclonal antibodies produced greater than 90% reduction of spleen colony-forming cells, whereas the other bound to a subpopulation (60 to 70%) of spleen colony-forming cells at plateau values. The expression of antigens recognized by these and two other anti-stem cell monoclonal antibodies has been shown to correlate with the differentiation status of a panel of tumor cell lines, with greater expression being observed on cells more closely resembling the pluripotent stem cell than mature hemopoietic cells. Immunoperoxidase staining of bone marrow showed that these antigens are mainly expressed by monocytes and blast cells. Treatment of bone marrow cells with those antibodies which extensively inhibited spleen colony formation and with rabbit complement abolished the ability of progenitor cells to form colonies in soft agar. Quantitative absorption studies distinguished the antigens recognized by two of the anti-stem cell monoclonal antibodies from those detected by anti-H-2k 11-4.1 monoclonal antibody. These observations suggest that the antigens involved may play a role in the regulation of growth and differentiation of stem cells and undifferentiated leukemic cells.

Changes in cell surface antigens during stem cell ontogeny

A panel of monoclonal antibodies that bind to the murine pluripotential stem cell CFU-s was used to examine the antigenic profile of the stem cell during ontogeny. The results show that the stem cell surface changes dramatically during development. One group of three independently derived monoclonal antibodies binds to subpopulations (50%-70%) of stem cells at plateau values, and these populations increase marginally during development. A second group of four monoclonal antibodies, including anti-H-2Kk (11-4.1), define stem cell antigens that increase from low levels in the fetal liver to high levels in adult bone marrow. The presence of these two classes of antigens on adult splenic stem cells was in general similar to that observed on adult bone marrow. Antigens defined by the first group of monoclonal antibodies were present in similar amounts on CBA, C57B1/6, and Balb/c bone marrow stem cells, whereas antigens of the second group showed mouse strain variations. Quantitative absorption analysis was used to distinguish H-2Kk (11-4.1) from 9F6, which showed a similar developmental profile. Monoclonal antibodies recognizing subpopulations of stem cells were shown to be distinct by complementation studies and recognized antigens not present on brain tissue.