Benefits of Implementing Reflex Genomic Analysis for Nonsmall Cell Lung Cancer

BACKGROUND

Molecular biomarker analysis is standard of care in advanced nonsmall cell lung cancer (NSCLC). Pathologist-driven reflex testing protocols are one approach to initiating this analysis. Two years after insourcing genomic analysis at our institution, a reflex testing protocol for advanced NSCLC was initiated.

METHODS

A retrospective review of the records of 578 NSCLC biopsies was performed to assess the impact of 3 genomic testing workflows (send-out, in-house clinician-ordered, and in-house reflex) on time to initiation of molecular testing [initiation time (IT)], reporting time (RT), proportion of test failures, and test ordering practices. The proportion of test failures by test methodology was also assessed.

RESULTS

IT was lowest for reflex protocol orders (mean weekdays: 30.0 send-out, 27.4 in-house clinician-ordered, 0.95 reflex). Test failure was highest for send-out testing (31.7% vs. 10% each for in-house clinician-ordered and reflex). RT remained consistent across the 3 workflows (mean weekdays: 11.1 send-out, 11.9 in-house clinician-ordered, and 11.4 reflex). Guideline-congruent molecular testing increased upon insourcing genomic analysis and again upon implementing reflex testing with a reduction in nonbiomarker informed care (58.8% send-out, 19.5% in-house clinician-ordered, 11.5% reflex).

CONCLUSIONS

Implementation of reflex in-house genomic analysis for advanced NSCLC ensured consistency in RT and significantly decreased IT and proportion of test failures. Insourcing genomic analysis and thoughtful care pathway design improve equitable access to molecular biomarker analysis and mitigate nonbiomarker informed cancer care in NSCLC.

Intraosseous Spindle Cell Rhabdomyosarcoma with MEIS1::NCOA2 Fusion - Case Report with Substantial Clinical Follow-up and Review of the Literature

Spindle cell/sclerosing rhabdomyosarcoma (SSRMS) is a clinicopathologically and molecularly heterogeneous disease. Gene fusions have been identified in intraosseous SSRMS, consisting predominantly of EWSR1/FUS::TFCP2 and MEIS1::NCOA2. The former often follow an aggressive clinical course; there is limited clinical follow-up available for the latter. We report here a new case of the very rare intraosseous SSRMS with MEIS1::NCOA2 gene fusion and include the detailed treatment course and 52 months of clinical follow-up. SSRMS with MEIS1::NCOA2 gene fusion appears biologically distinct from other intraosseous SSRMS, following a course characterized by local recurrence with rare reports of metastasis to date.

Patterns and trends in insulin intensification among patients with type 2 diabetes: a systematic review

Type 2 diabetes (T2DM) diagnoses are skyrocketing, making treatment of this disease an increasing focus of primary care visits. Guidelines recommend insulin intensification over time to achieve HbA1c targets. We conducted a systematic review regarding patterns and trends of insulin intensification and barriers to intensification. Providers across primary and specialty care settings often did not intensify insulin regimens despite patients' clinical status. Even among progressed patients, HbA1c values remained high. The paucity of available studies prevented a comprehensive understanding of patterns and trends in insulin intensification. Such information is needed to assess the quality of pharmacologic care for patients with T2DM.

Five features of value-based insurance design plans were associated with higher rates of medication adherence

Value-based insurance design (VBID) plans selectively lower cost sharing to increase medication adherence. Existing plans have been structured in a variety of ways, and these variations could influence the effectiveness of VBID plans. We evaluated seventy-six plans introduced by a large pharmacy benefit manager during 2007-10. We found that after we adjusted for the other features and baseline trends, VBID plans that were more generous, targeted high-risk patients, offered wellness programs, did not offer disease management programs, and made the benefit available only for medication ordered by mail had a significantly greater impact on adherence than plans without these features. The effects were as large as 4-5 percentage points. These findings can provide guidance for the structure of future VBID plans.

Infectivity enhancement for adenoviral transduction of canine osteosarcoma cells

The full realization of conditionally replicative adenoviruses (CRAds) for cancer therapy has been hampered by the limited knowledge of CRAd function in vivo and particularly in an immunocompetent host. To address this issue, we previously proposed a canine adenovirus type 2 (CAV2)-based CRAd for clinical evaluation in canine patients with osteosarcoma (OS). In this study, we evaluated infectivity-enhancement strategies to establish the foundation for designing a potent CAV2 CRAd with effective transduction capacity in dog osteosarcoma cells. The results indicate that the native CAV2 fiber-knob can mediate increased binding, and consequently gene transfer, in both canine osteosarcoma immortalized and primary cell lines relative to previously reported Ad5 infectivity-enhancement strategies. Gene delivery was further enhanced by incorporating a polylysine polypeptide onto the carboxy terminus of the CAV2 knob. This vector demonstrated improved gene delivery in osteosarcoma xenograft tumors. These data provide the rationale for generation of infectivity-enhanced syngeneic CAV2 CRAds for clinical evaluation in a dog osteosarcoma model.

Haemolytic anaemia and exercise intolerance due to phosphofructokinase deficiency in related springer spaniels

Phosphofructokinase (PFK) deficiency is an autosomal recessive inherited disorder in dogs causing haemolytic crises and exertional myopathy. The clinical signs may be confused with those of recurrent immune-mediated haemolytic anaemia. The deficiency has been commonly observed in field trial (working) English springer spaniels (ESSPs), but also in the conformation line of ESSPs in the USA over the past two decades. This report documents the first family of ESSPs found with PFK deficiency in Europe. Two related adult ESSPs in Denmark had intermittent signs of pigmenturia after exercise (hunting) and had evidence of a regenerative haemolytic anaemia. Based upon DNA sequencing data, both dogs had the previously described nonsense point mutation in the muscle-type PFK gene (delta2228G-->A). Study of 17 related family members using a simple and accurate PFK-DNA test revealed one additional PFK-deficient dog (with minor exercise intolerance), nine carriers and seven normal (or 'clear') ESSPs. Recently, the authors have also identified PFK carriers and affected ESSPs in the UK. Screening for PFK deficiency is recommended for ESSPs with suspicious clinical signs and before using any for field trials or breeding in order to prevent the further spread of this hereditary disorder.

Utilization of umbilical cords to assess in utero exposure to persistent pesticides and polychlorinated biphenyls

In support of a study to relate developmental and cognitive effects with prenatal exposure to selected environmental toxicants, we developed and applied an analytical method to determine the concentration of two persistent pesticides, hexachlorobenzene (HCB) and p,p'-dichlorodiphenyldichloroethylene (DDE), and 32 specific polychlorinated biphenyl (PCB) congeners in 316 umbilical cords taken in 1986-1987 from women of the Faroe Islands. The analytical method consisted of homogenization of the cords, partitioning, microsilica gel column chromatography for clean-up, and dual-column capillary gas chromatography (DB-5 and DB-1701) with electron capture detection. Several quality control parameters were followed to monitor the performance of the method. Important criteria used before reporting unknown data were the recovery of in vitro-spiked analytes from a bovine umbilical cord (BUC) and the percentage lipid obtained for a Certified Reference Material (CRM)-350 of mackerel oil (MO). Recoveries of analytes that had been spiked at two concentration ranges (0.26-0.95 ng/g whole weight; 0.35-2.42 ng/g whole weight) into bovine cords ranged from 38.5% to 158% and from 50.4% to 145%, respectively, with a median recovery of 77.7%. Measurement of the percentage lipid for CRM-350 ranged from 73.8% to 107% with a median lipid value of 96.0%. The most prevalent analytes detected (%) in unknown umbilical cords were HCB (100), DDE (100), Ballschmiter/Zell PCBs 153 (100), 138 (98), 180 (98), 170 (93), 118 (88), 187 (86), and 146 (83), with corresponding median concentrations (ng/g whole weight) of 0.17, 1.19, 0.38, 0.30, 0.17, 0.11, 0.12, 0.09, and 0.07, respectively. Total PCB--sum of all measurable PCB congeners--had a median concentration of 1.37 ng/g whole weight. The analytes, which were very low in lipid content were also quantified on a lipid-adjusted basis, which provided an analytical challenge in these umbilical cord samples. The gravimetrically measured lipids in the human specimens ranged from 0.01% to 1.43% (median of 0.18%). In the pooled BUCs, our lipid measurements varied from 0.05% to 0.33% with a median value of 0.13%. The utility of using the umbilical cord as a matrix to assess in utero exposure to persistent environmental pollutants, compared with the use of umbilical cord blood or mother's blood, is worthy of debate.

A case-control assessment of risk factors for gallbladder carcinoma

Gallbladder carcinoma is an uncommon, but highly fatal disease. Its symptoms frequently mirror those of gallstone disease, and in most instances, diagnosis is an incidental finding at surgery. While risk factors have been suggested for this cancer, many may in reality simply be a consequence of the older age of the population. This study is one of the few to approach this question by using a case-control study design comparing gallbladder carcinoma patients with a gallstone population, coupled with multivariate analysis to determine age-independent risk factors. Univariate analyses showed gallbladder carcinoma patients to be older than gallstone patients and to have many age-associated diseases. Following multiple regression adjustment for age, this disease was associated with female gender and with a previous history of gallstone symptoms. Carcinoma patients were less likely to have cholesterol gallstones in their gallbladders at surgery. A previous history of smoking was a substantial risk but of borderline statistical significance. Previous studies report associations that may be due to the older age of the gallbladder carcinoma patient. Our results show that after adjusting for age with multivariate analysis, gallbladder cancer subjects were predominantly female, more likely to report previous gallstone symptomology, and to smoke. While gallstones were not universally isolated from carcinoma patients at cholecystectomy, when present, they were less frequently classified as cholesterol gallstones based on visual inspection. Further cohort studies which target these populations will allow us to gain a more solid consensus on the risk factors for this disease.

Flow microsphere immunoassay-based method of virus quantitation

A sensitive assay for adenovirus quantitation in vitro was developed using the flow microsphere immunoassay (FMIA) approach. Polystyrene microspheres were covalently coated with purified anti-adenoviral antibodies and incubated with virus-containing samples. After incubation, the samples were stained with DNA-specific fluorescent dyes, and microsphere-associated fluorescence was quantitated with a flow cytometer. The adsorption of virus to microspheres was examined under different experimental conditions. The flow cytometric assay was determined to be as accurate in detecting adenovirus as titering on 293 cells. The proposed method can be used to quantify virus in viral stocks and in biological samples.

Elucidation of muscle-binding peptides by phage display screening

Muscle makes up the largest tissue volume of the body, yet its size makes muscle-specific therapy difficult. This becomes particularly relevant when approaches to gene therapy for inherited myopathies are evaluated. Thus, a mechanism to target constructs or pharmaceuticals to muscle following intravenous injection would be advantageous. By screening a random phage display library we have identified a heptapeptide sequence, ASSLNIA, with enhanced in vivo skeletal and cardiac muscle binding. Phage carrying this peptide showed a 9- to 20-fold (depending on control tissue) increase in muscle selectivity compared with phage with no insert. When the injected individual phage clone was localized by immunohistochemistry, it was found within focal areas of the membrane of myofibers. Thus, the peptide identified represents a ligand that is capable of accessing skeletal and cardiac muscle from the lumen of blood vessels and could therefore readily be exploited for targeted delivery to muscle cells.

Factors associated with virulence of Mycoplasma synoviae

Virulence mechanisms of six isolates of Mycoplasma synoviae (MS), previously classified as pathogenic (K1968), moderately pathogenic (WVU 1853, K1858, 92D8034, and F10-2AS), and mildly pathogenic (FMT) in chickens, were examined. The most virulent isolate, K1968, had been found to invade systematically and produce lesions following eye-drop inoculation. In the present study, all isolates were evaluated for presence of a possible cytadhesin and for functional attachment to host cells as indicated by hemagglutination and hemadsorption. Three representative isolates, K1968, 92D8034, and FMT, were evaluated for attachment and colonization in cultured chick tracheal rings and tendon cell monolayers by direct transmission electron microscopic examination and by quantitative polymerase chain reaction assay. Ciliostasis was compared in tracheal organ culture. Previously found differences in pathogenicity of these isolates for chickens could not be explained as differences in attachment and were only partially explained by differences in colonization. Pathogenicity of the most virulent isolate of MS was suspected to be multifactorial, involving attachment and colonization of the upper respiratory tract plus additional unidentified factors associated with systemic invasion and lesion production.

Humoral and cellular immune responses of dogs immunized with a nucleic acid vaccine encoding human carcinoembryonic antigen

A nucleic acid vaccine encoding human carcinoembryonic antigen (CEA) was administered to 10 juvenile dogs, 10-15 weeks of age, by four parenteral routes. The routes tested were intramuscular injection using a needle and syringe, intramuscular injection using the Biojector needleless injection device, intradermal injection or intravenous injection. All groups received 150 micrograms of plasmid DNA on weeks 0, 4, 7 and 13. All dogs were bled weekly for 17 weeks and tested for antibody against human CEA. Dogs given plasmid intramuscularly either by needle and syringe or Biojector showed significant antibody responses by week 9 which peaked by week 15. Dogs receiving plasmid intravenously showed slight, unsustained increases in antibody titers while dogs receiving plasmid intradermally had significant titers, but at levels approximately one log less than those induced by intramuscular injection. The five dogs immunized by intramuscular delivery of plasmid DNA were examined for cellular immune responses to human CEA by lymphoblast transformation (LBT) assay. All five showed significant CEA-specific lymphoproliferation when compared with unvaccinated dogs. Physical examination, clinical chemistry, hematology and histopathology examinations revealed no abnormalities associated with nucleic acid immunization.

Nucleic acid immunization protects dogs against challenge with virulent canine parvovirus

Nucleic acid vaccines (NAVs) use expression vectors encoding one or more antigen genes to transfect host cells inducing both humoral and cellular immunity against the expressed antigen. NAV offers major advantages over conventional vaccines for the protection of humans and animals. This study shows that a plasmid DNA (pGT36VP1) encoding the full length VP1 region of canine parvovirus (CPV) induces immunity that protects dogs against challenge with virulent virus. Five dogs without anti-CPV antibodies were injected at 9 months of age with increasing doses of pGT36VP1 or saline. NAV vaccinated dogs showed an increase of serum IgG titer starting 1 week post-injection which peaked at week 2 and remained detectable for at least 14 weeks. A second dose of NAV resulted in an anamnestic response within 1 week. IgG titers peaked at week 3 and 4 after the second injection. All pGT36VP1 vaccinated dogs were protected against infection after virulent CPV challenge regardless of dose and the unvaccinated control dog was fully susceptible. This study demonstrated for the first time that a NAV can protect dogs against an infectious disease.

Variables associated with anticipatory nausea and vomiting in pediatric cancer patients receiving ondansetron antiemetic therapy

Investigated the prevalence of anticipatory nausea and vomiting (ANV) among 59 pediatric cancer patients who had routinely received ondansetron (Zofran) antiemetic therapy and determined patient- and treatment-related factors associated with ANV. Of the sample, 59% indicated at least mild ANV symptoms, suggesting that a significant number of patients report ANV and are bothered by it, despite the use of Zofran. These children were compared to those reporting no ANV symptoms. Most ANV symptomatology was consistent with a traditional classical conditioning model although cognitive processes may also play a role. Children with greater expectations of severe postchemotherapy vomiting and those who were more distressed by nausea and vomiting were more likely to experience ANV symptoms. Implications for psychological and pharmacological treatments of ANV are discussed.

Molecular basis of canine muscle type phosphofructokinase deficiency

Muscle type phosphofructokinase (M-PFK) deficiency is a rare inherited glycogen storage disease in humans that causes exertional myopathy and hemolysis. The molecular basis of canine M-PFK deficiency, the only naturally occurring animal homologue, was investigated. Lack of M-PFK enzyme activity was caused by a nonsense mutation in the penultimate exon of the M-PFK gene, leading to rapid degradation of a truncated (40 amino acids) and therefore unstable M-PFK protein. A polymerase chain reaction-based test was devised to identify M-PFK-deficient and carrier animals. This represents one of only a few inborn errors of metabolism where the molecular defect has been identified in a large animal model which can now be used to develop and assess novel therapeutic strategies.

A cDNA encoding canine muscle-type phosphofructokinase

The canine muscle-type-phosphofructokinase-encoding gene (M-PFK) was sequenced by using a combination of cDNA cloning and RT-PCR amplification. The canine M-PFK sequence shares 88 and 90% identity with rabbit and human M-PFK, respectively. The canine ORF was determined to be 6-bp longer than either human or rabbit M-PFK due to a 6-bp insertion at the end of exon 13.

Nutritional and treatment-related characteristics of pediatric oncology patients referred or not referred for nutritional support

Nutritional problems often result from malignancies and aggressive multimodal treatment. Early identification of reliable risk factors associated with malnutrition and need for nutritional support is necessary for development of preventative approaches. Nutritional and treatment-related characteristics were examined for 173 pediatric oncology patients referred for nutritional support and a comparison sample of 43 patients matched on treatment protocol and/or diagnosis who had never been referred for nutritional support. Abnormally low serum albumin levels, poor oral intake, mucositis, prior radiation therapy, and increased gastrointestinal toxicity were significantly more frequent among referred than non-referred patients. A discriminant function analysis indicated that poor oral intake was the single best predictor of need for nutritional support. Patients with solid tumors were more nutritionally depleted at the time of referral; all bone marrow transplant patients received nutritional support. Patients with central nervous system (CNS) tumors required nutritional support for longer time periods. We conclude that routine documentation of poor oral intake (i.e., observation of change in a child's eating patterns) is the most reliable indicator of children who eventually require nutritional support and who may benefit from interventions that could delay or prevent nutritional problems. Prophylactic interventions should be tailored to meet the specific needs of individual diagnostic groups.

Bovine gallbladder mucin accelerates cholesterol monohydrate crystal growth in model bile

BACKGROUND

Gallbladder mucin accelerates cholesterol crystal nucleation, an early step in the pathogenesis of gallstones. To examine the role of gallbladder mucin in postnucleation gallstone maturation, the influence of mucin on cholesterol monohydrate crystal growth was studied in a novel model system.

METHODS

Cholesterol crystals of a uniform size were incubated in model biles at 37 degrees C with varying cholesterol saturation indices. Crystal size was quantitated by measuring the width and length of individual crystals under polarizing light microscopy and calculating average crystal area.

RESULTS

Crystal growth was dependent on the degree of cholesterol supersaturation of bile. Bovine gallbladder mucin (0.5-8 mg/mL) accelerated crystal growth in supersaturated model bile in a concentration- and time-dependent fashion compared with control incubations with bovine serum albumin or model bile alone (P < 0.05). Cholesterol crystal growth was accompanied by a progressive decrease in cholesterol saturation and an increase in total cholesterol crystal mass. Crystal growth was also accompanied by a decrease in total crystal number, suggesting net transfer of cholesterol to larger crystals.

CONCLUSIONS

The acceleration of cholesterol crystal growth by gallbladder mucin may be of pathophysiological importance in the postnucleation maturation of cholesterol gallstones.

Squamous metaplasia of extrahepatic biliary system in an AIDS patient with cryptosporidia and cholangitis

AIDS-related cholangiopathy is an increasingly recognized syndrome associated with significant morbidity and mortality. The mechanism of cholangiopathy is unknown but is assumed to be related to infectious pathogens such as CMV and cryptosporidia. The case of a Haitian with HIV and long-standing intestinal cryptosporidiosis who presented with cholangitis and protuberant intrabiliary filling defects is reported. Histopathological examination of biliary biopsies revealed previously unreported extensive squamous metaplasia of the bile duct epithelium, and the histogenesis of this condition is discussed. Chronic cryptosporidial infestation may be directly pathogenic resulting in squamous metaplasia that mimics biliary malignancy.

Inherited phosphofructokinase deficiency in an American cocker spaniel

A 3-year-old female American Cocker Spaniel with a chronic hemolytic disorder and hemolytic crises was found to have M-type phosphofructokinase deficiency. This inherited erythroenzymopathy and myopathy is commonly diagnosed in English Springer Spaniels, but the family study of this Cocker Spaniel, although supporting an autosomal recessive mode of inheritance, did not reveal any English Springer Spaniel ancestors. Molecular genetic studies did, however, identify the same mutation in this dog as we previously reported in the English Springer Spaniel breed, suggesting that this mutation originated prior to the separation of these 2 breeds.

Nutritional outcome and pneumonia in critical care patients randomized to gastric versus jejunal tube feedings. The Critical Care Research Team

OBJECTIVE

To compare nutritional status, gastric colonization, and rates of nosocomial pneumonia in ICU patients randomized to gastric tube feeding vs. patients fed by an endoscopically placed jejunal tube.

DESIGN

Randomized, prospective study.

SETTING

Medical and surgical ICUs at Boston City Hospital; surgical ICU at University Hospital.

PATIENTS

Of the 38 study patients, 19 were randomized to gastric tube feeding and 19 were randomized to an endoscopically placed jejunal tube. The two groups were similar in age, sex, race, underlying disease, and type of surgery.

RESULTS

The two patient groups were similar in number of days fed, duration of ICU stay, duration of mechanical ventilation, days of antibiotic therapy, and days with fever. Compared with the gastric group, the jejunal group had more patients with circulatory shock on admission (79% vs. 68.4%), higher admission Acute Physiology Score (24.0 vs. 21.7), and fewer patients with pneumonia at randomization (26.3% vs. 31.6%). The jejunal group received a significantly higher percentage of their daily goal caloric intake (p = .05), and had greater increases in serum prealbumin concentrations (p < .05) than the patients with gastric tube feeding. Although the jejunal tube group had more days of diarrhea (3.3 +/- 6.6 vs. 1.8 +/- 2.9), this difference was not statistically significant. Nosocomial pneumonia was diagnosed clinically in two (10.5%) patients in the gastric tube group and in no patients in the jejunal tube group.

CONCLUSIONS

Patients fed by jejunal tube received a significantly higher proportion of their daily goal caloric intake, had a significantly greater increase in serum prealbumin concentrations, and had a lower rate of pneumonia than patients fed by continuous gastric tube feeding.

Non-mucin proteins in the matrix of human cholesterol gallstones

Human cholesterol gallstones contain a pigmented organic matrix that may originate from biliary sludge. The cholesterol gallstone matrix contains mucin, bile pigments, and calcium salts. The goal of this study was to examine whether non-mucin proteins are present in the matrix of cholesterol gallstones. Matrix was prepared from cholesterol gallstones from 18 patients. Proteins were identified by sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) and by molecular sieve high-performance liquid chromatography (HPLC). Two proteins were present in each gallstone and migrated with or just adjacent to standards of bovine serum albumin on SDS-PAGE. Several additional lower molecular weight proteins were identified, but not in every gallstone. Protein fractions contained visible pigment after chloroform extraction, and pigment co-eluted with proteins on HPLC, suggesting binding of pigments to proteins in the matrix. We conclude that low molecular weight proteins are present in the cholesterol gallstone matrix. The major protein appears to be serum albumin, although definitive identification has not been established. The origin of these matrix proteins and their possible significance in the pathogenesis of cholesterol cholelithiasis is unknown.

Proteins in the fossil bone of the dinosaur, Seismosaurus

Proteins have been successfully extracted from the fossil vertebra of a 150-million-year-old sauropod dinosaur ("Seismosaurus") recently excavated from the Morrison Formation of New Mexico. HCl and guanidine.HCl extracts of the fossil bone and its sandstone matrix were concentrated, demineralized, and resolved into a number of different protein fractions by reversed-phase high-performance liquid chromatography (HPLC). One of these fractions had the same retention time as collagen. Amino acid analysis (Pico-Tag method) of these fractions confirmed they were proteins. Comparison of the correlation coefficients of the amino acid analyses with that of collagen standards indicated that none of the fractions contained significant amounts of collagen. Similar HPLC profiles were obtained for the HCl extracts of fossil bone and its sandstone matrix suggesting they contained the same proteins. However, different HPLC profiles were obtained when these HCl extracts were dried and reextracted with guanidine.HCl. These different fractions represent proteins unique to the fossil and were not found in the sandstone matrix. These differences were confirmed by amino acid analysis. Such information on fossil bone proteins might provide useful knowledge concerning the evolution of skeletal molecules and the fossilization process. Similar information on the proteins from the geological matrix might provide useful fingerprints for reconstructing ancient environments and for assessing sedimentary rocks for fossil fuel exploration.

Characterization of bovine gallbladder mucin. Amino acid sequences of tryptic peptides from the glycosylated domain of the protein core

Gallbladder mucin is a densely glycosylated macro-molecule that promotes cholesterol gallstone formation in experimental animals and in humans. Bovine gallbladder mucin structure was studied after chemical deglycosylation by treatment with anhydrous hydrogen fluoride at 23 degrees C for 3 hours. Deglycosylated mucin contained less than 5% of the amino sugar and neutral hexose content of native mucin. Electrophoretic and molecular sieve chromatographic analyses indicated that significant cleavage of the mucin polypeptide core had occurred during deglycosylation. Deglycosylated mucin was separated into three major fractions by reverse-phase chromatography, one of which was enriched with respect to threonine and proline. Tryptic peptides prepared from this fraction were purified by molecular sieve and reverse-phase chromatography, and the amino acid sequences (8-20 residues) of the four principal tryptic peptides were determined. These peptides contained 65%-75% threonine and proline residues and demonstrated 80%-100% sequence similarity. These data provide the first information on the primary structure of gallbladder mucin and suggest that repeating amino acid sequences occur in this protein. Comparison of gallbladder mucin peptide structure with the consensus repeat sequence of human intestinal mucin showed approximately 60% sequence similarity. It was concluded that mammalian gastrointestinal mucins may be derived from a common ancestral gene.

Gallbladder mucin as a pronucleating agent for cholesterol monohydrate crystals in bile

Mucin is a densely glycosylated macromolecule secreted by the gallbladder epithelium as the principal constituent of gallbladder mucus. Hypersecretion of gallbladder mucus occurs in response to a lithogenic diet in experimental animals, and mucus accumulates as a viscous gel within the gallbladder lumen before gallstone formation. In both animals and man, the initial stage of cholesterol gallstone formation, the nucleation of cholesterol monohydrate crystals, occurs within the mucus gel. Inhibition of mucus secretion with aspirin prevents gallstone formation in the cholesterol-fed prairie dog, indicating the importance of mucus in gallstone formation. Mucin contains domains that bind cholesterol and lecithin transported as vesicles in supersaturated bile. Furthermore, mucin accelerates the nucleation of cholesterol crystals in both supersaturated model and native biles. Binding of cholesterol-enriched vesicles to hydrophobic domains on the mucin protein core appears to be critical for the acceleration of cholesterol crystal nucleation by mucin. Further study of the structure and function of gallbladder mucin should help to elucidate the pathogenesis of cholesterol cholelithiasis.

Isolation and characterization of peptides from the protein core of bovine gallbladder mucin

Gallbladder mucin may promote cholesterol gallstone formation by accelerating cholesterol monohydrate crystal nucleation in supersaturated bile. In this study, peptides were isolated from the mucin protein core by protease digestion and molecular-sieve high-performance liquid chromatography. Tryptic peptides were purified by anion exchange or reverse-phase high-performance liquid chromatography, and amino acid compositions were determined. Tryptic peptides were (a) nonglycosylated, (b) selectively enriched in serine, glutamic acid plus glutamine, and glycine, and (c) depleted in threonine and proline compared with native gallbladder mucin. Bilirubin derivatized with Woodward's reagent K covalently bound to purified mucin. Tryptic digestion of the mucin-bilirubin complex yielded low-molecular-weight nonglycosylated peptides with covalently bound bilirubin. These data indicate that the mucin protein core contains at least two distinct domains. One domain is rich in threonine and proline and contains the majority of covalently bound carbohydrate. A second domain, possibly internally located, is nonglycosylated, enriched in serine, glutamic acid plus glutamine, and glycine, and binds hydrophobic ligands such as bilirubin and 1-anilino-8-naphthalene sulfonate. Hydrophobic domains on the mucin protein core may contribute to the pathogenesis of cholesterol cholelithiasis.

Genes transferred by retroviral vectors into normal and mutant myoblasts in primary cultures are expressed in myotubes

Retroviral vectors were used to transfer genes efficiently into rat and dog myoblasts in primary cultures under conditions which permitted the transduced myoblasts to differentiate into myotubes expressing the transferred genes. The transduced myotubes expressed normal markers of differentiation and were morphologically indistinguishable from uninfected myotubes. Retroviral vector-mediated gene transfer was also used to correct a genetic enzyme deficiency in mutant canine muscle cells.

Addition of N-acetylcysteine to aqueous model bile systems accelerates dissolution of cholesterol gallstones

The organic matrix of cholesterol gallstones contains a macromolecular complex of mucin and bilirubin that may inhibit stone dissolution by limiting contact of desaturated bile with crystalline cholesterol. The goal of this study was to determine if the mucolytic agent N-acetylcysteine could accelerate gallstone dissolution in vitro. Paired gallstones were dissolved in either pure taurocholate (140 mM) or ursodeoxycholate (100 mM), or in bovine bile supplemented with either taurocholate or ursodeoxycholate to achieve the same respective bile-salt concentrations. N-acetylcysteine was added to 1 stone from each pair at a concentration of 500 mM in pure bile salts and 100 mM in supplemented bile. Gallstones dissolved significantly faster in bovine bile supplemented with taurocholate or ursodeoxycholate than in pure solutions of the respective bile salts (n = 30, p less than 0.001). N-acetylcysteine significantly accelerated gallstone dissolution in pure solutions of bile acids (n = 30, p less than 0.001 for each) and in supplemented bovine biles (n = 30, p less than 0.001). N-acetylcysteine also significantly increased the frequency of complete gallstone dissolution in taurocholate-supplemented (66.6% vs. 40.0%) and ursodeoxycholate-supplemented (76.6% vs. 50.0%) bile. These results indicate that the mucolytic agent N-acetylcysteine significantly accelerates in vitro gallstone dissolution. We speculate that adjuvant therapy with an appropriate mucolytic agent may potentially increase the efficacy of clinical gallstone dissolution.

Effect of laser fragmentation of cholesterol and mixed gallstones on in vitro dissolution in methyl tert-butyl ether

This study examined cholesterol and mixed gallstone dissolution in vitro by methyl-tert-butyl ether (MTBE) after gallstone fragmentation. Three morphologically identical gallstones were obtained from 42 patients. One stone from each patient was fragmented with laser energy at a wavelength of 504 nm delivered to the stone surface with a 320-microns quartz fiber. Intact and fragmented stones from the same patient were incubated without stirring in MTBE and dissolution was expressed as the percent of initial stone weight remaining after 2 hr. Stone composition did not correlate with the amount of laser energy required for stone fragmentation. Fragmented stones dissolved faster than intact stones in MTBE with 13.97% +/- 0.37% vs 31.0% +/- 0.51% respectively (mean +/- SEM) of initial stone weight remaining at 2 hr (P less than 0.0001). Initial stone weight and stone matrix content significantly predicted dissolution of intact (P = 0.0033 and P = 0.0483, respectively) and fragmented stones (P = 0.003 and P = 0.0001, respectively) in MTBE. These data suggest that the gallstone matrix may inhibit stone dissolution even after stone fragmentation.

Subunit interactions and physical properties of bovine gallbladder mucin

In this study the interaction of gallbladder mucin subunits was examined by gel permeation chromatography, quasielastic laser light scattering, and viscometry. Purified mucin eluted primarily in the void volume of a Sepharose 2B-Cl column, indicating a molecular weight above 2 x 10(6). Disaggregation of the mucin polymer resulted in the elution of glycoprotein in the included volume of the Sepharose 2B-Cl column. Gallbladder mucin had a hydrodynamic radius of 630 A that was independent of mucin concentration below 2 mg/ml. At mucin concentrations above 2 mg/ml, a concentration-dependent increase in both hydrodynamic radius and apparent viscosity of gallbladder mucin was observed. Mucin demonstrated a strong pH dependence in hydrodynamic radius and viscosity with the maximum occurring at approximately pH 5.5. These findings suggest that noncovalent interactions participate in bovine gallbladder mucin subunit associations. Furthermore, changes that occur in the physicochemical environment of the gallbladder during periods of stasis may enhance the viscoelastic properties of mucin and promote the accumulation of biliary sludge in the gallbladder.

Bovine gallbladder mucin promotes cholesterol crystal nucleation from cholesterol-transporting vesicles in supersaturated model bile

This study examined the ability of purified gallbladder mucin to accelerate the nucleation of cholesterol monohydrate crystals from the cholesterol-transporting particles in supersaturated model bile. Mixed lipid micelles and cholesterol-phosphatidylcholine vesicles in supersaturated model bile were separated by Sephadex G-200 column chromatography. Mixed lipid micelles prepared by column chromatography had a low cholesterol-phosphatidylcholine ratio (0.30) and did not spontaneously nucleate cholesterol monohydrate crystals. In contrast, vesicles prepared by column chromatography had a cholesterol-phosphatidylcholine ratio of 1.00 and nucleated cholesterol crystals rapidly (P less than 0.001). Nucleation of cholesterol crystals was significantly accelerated in a concentration- and time-dependent manner by purified bovine gallbladder mucin in cholesterol containing vesicles, but not in mixed lipid micelles (P less than 0.001). A rapid filtration binding assay demonstrated significant binding of cholesterol and phosphatidylcholine in vesicles to gallbladder mucin but only minimal binding of cholesterol and phosphatidylcholine in mixed micelles. These data indicate that gallbladder mucin binds cholesterol and phosphatidylcholine in vesicles and accelerates the nucleation of cholesterol monohydrate crystals from these cholesterol-transporting particles in supersaturated model bile.

Human gallbladder mucin binds biliary lipids and promotes cholesterol crystal nucleation in model bile

The binding of phosphatidylcholine and cholesterol in model bile to human gallbladder mucin was studied by means of a rapid filtration binding assay and sucrose density gradient ultracentrifugation. Numerous low affinity binding sites for phosphatidylcholine and cholesterol were present on gallbladder mucin. Binding of phosphatidylcholine and cholesterol to mucin increased as a function of cholesterol saturation index. Proteolytic digestion of mucin disaggregated the native mucin polymer and removed hydrophobic domains on the mucin peptide core that bind l-anilino-8-naphthalenesulfonic acid. Proteolytic digestion also resulted in a 91% and 78% decrease, respectively, in the binding of phosphatidylcholine and cholesterol to mucin. The ability of trypsin-treated and native mucin to promote the nucleation of cholesterol monohydrate crystals was compared in a model bile. The incidence of cholesterol monohydrate crystal nucleation with native mucin was significantly greater at 3 days than with trypsin-treated mucin or controls (P less than 0.001). After 3, 6, and 9 days of incubation, samples containing native mucin contained significantly more crystals than controls or trypsin-digested mucin samples (P less than 0.0001 for each). These data indicate that highly purified human gallbladder mucin binds phosphatidylcholine and cholesterol in model bile. Furthermore, this study demonstrates that structural integrity of the native mucin polymer and hydrophobic domains on the peptide core are essential for the nucleation of cholesterol monohydrate crystals by mucin in model bile.

Stargardt's disease: the evolution of a diagnosis

In Stargardt's disease, a gradual loss of vision may precede both the appearance of paracentral or peripheral retinal flecks as well as funduscopically obvious macular changes. This latency delayed a diagnosis of Stargardt's disease in a young girl who underwent neurologic testing for what eventually turned out to be a retinal problem. At one stage in evolution, when retinal flecks and only subtle changes in the maculae were present, a diagnosis of a pure form of fundus flavimaculatus was considered likely. When severe granularity and atrophy of the maculae later developed in the presence of the retinal flecks, a more appropriate diagnosis of Stargardt's disease was made. As the degenerative and atrophic changes in the maculae became more pronounced in early adulthood, the flavimacular retinal flecks had all but disappeared.

Dissolution of cholesterol gallstones in vitro. Gallstone matrix content and diameter, not cholesterol content, predict gallstone dissolution in monooctanoin

The goal of this study was to identify the structural and compositional features of human gallstones that influence in vitro gallstone dissolution in the cholesterol solvent monooctanoin. Gallstones were obtained from 86 consecutive patients who had at least three morphologically similar stones. One stone from each patient was dissolved in ethanol/ether to determine cholesterol and matrix composition. The remaining two matched stones were dissolved in either monooctanoin plus ethanol (n = 86) or monooctanoin plus 2-mercaptoethanol (n = 86). The thiol reducing agent 2-mercaptoethanol has been previously shown to solubilize the isolated gallstone matrix and to accelerate the dissolution of intact, small cholesterol stones. Stone matrix content and initial diameter had the most significant predictive value for stone dissolution (p less than 0.0001 for each), whereas cholesterol content had no predictive value (p = 0.558). Stones incubated in monooctanoin containing 2-mercaptoethanol dissolved more rapidly than those incubated in monooctanoin plus ethanol (16.7% of initial weight per day vs. 13.8% of initial weight per day, p less than 0.0001). Matrix content correlated significantly with the difference in dissolution rate between stones dissolved in monooctanoin plus ethanol or monooctanoin plus 2-mercaptoethanol (p less than 0.0001). These data indicate that the matrix content of human cholesterol gallstones significantly inhibits in vitro stone dissolution in the cholesterol solvent monooctanoin. This finding may be relevant to the clinical dissolution of gallstones.

Interaction between oxygen radicals and gastric mucin

The gastrointestinal epithelium is continuously exposed to reactive oxygen metabolites that are generated within the lumen. In spite of this exposure, the healthy epithelium appears unaffected, suggesting efficient mechanisms for protection against these potentially cytotoxic oxidants. The objective of this study is to characterize the interaction between purified gastric mucin and hydroxyl radicals generated from the interaction between ferric iron and ascorbic acid. We found that both native and pronase-treated mucin effectively scavenged hydroxyl radical and that the scavenging properties were not significantly different. The effective concentration of mucin required for a 50% reduction in malondialdehyde production was approximately 10 mg/ml for both native and pronase-treated mucin. In addition, the iron-ascorbic system produced a dramatic decrease (greater than 50%) in the specific viscosity of mucin that was inhibited by catalase, deferoxamine, and mannitol. Superoxide dismutase had no effect. These data suggest that hydroxyl radicals derived from the iron-catalyzed decomposition of hydrogen peroxide are responsible for the depolymerization of native mucin. We propose that mucin may provide protection to the surface epithelium of the gastrointestinal tract by scavenging oxidants produced within the lumen; however, it does so at the expense of its viscoelastic properties.

Differentiated astrocytoma with osteoblastic skeletal metastases in a child

A 13-year-old boy developed widespread osteoblastic bone metastases, with dissemination throughout the neuraxis, 1 year following treatment of a differentiated (Kernohan and Sayre grade II) astrocytoma of the left parietal cortex. This unusual clinical picture and the possible route of tumour dissemination are discussed.

Identification of gallbladder mucin-bilirubin complex in human cholesterol gallstone matrix. Effects of reducing agents on in vitro dissolution of matrix and intact gallstones

The goals of this study were to isolate and characterize the nonlipid matrix of human cholesterol gallstones. The lipid portion of gallstones was dissolved in ethanol/ether, leaving an insoluble, granular, brown-black matrix that constituted 12.5% of solitary large stones and 3.5% of multiple small stones. The matrix was partially solubilized by sonication and studied by exclusion gel chromatography and density gradient ultracentrifugation. On Sepharose 2B column chromatography, bile pigment eluted with glycoprotein in the void volume, suggesting the presence of a high molecular weight complex (Mr greater than 2 X 10(6)). The identity of mucin in this complex was confirmed by its typical buoyant density during ultracentrifugation. The major bile pigments in the matrix were identified as bilirubin (84%) and bilirubin monoglucuronide (15%) by thin-layer chromatography. Because of their ability to solubilize mucin-type glycoproteins, we tested the ability of the reducing agents 2-mercaptoethanol (2ME) and N-acetylcysteine (NAcCys) to solubilize gallstone matrix. Both reducing agents caused a two- to threefold enhancement of matrix dissolution after 4 d compared to aqueous buffer alone (P less than 0.01). Sepharose 2B chromatography revealed that 2ME released a high molecular weight mucin-bilirubin complex as well as unbound pigment from the insoluble matrix. We also tested the effect of reducing agents on dissolution of matched cholesterol gallstones by monooctanoin, a cholesterol solvent. Both 2ME and NAcCys significantly accelerated gallstone dissolution in monooctanoin. Matched human cholesterol stones (n = 10) incubated for 4 d in monooctanoin plus either 2ME or NAcCys (1 M final concentration) weighed approximately half as much (P less than 0.01 for each) as stones incubated in monooctanoin alone. This study describes, for the first time, the isolation of a bilirubin-mucin complex in the insoluble matrix of human cholesterol gallstones. The ability of reducing agents to dissolve the matrix and thereby accelerate gallstone dissolution by monooctanoin in vitro may be relevant to gallstone dissolution in humans.

Hydrophobic binding properties of bovine gallbladder mucin

Hydrophobic binding properties of purified bovine gallbladder mucin were studied by fluorescence spectroscopy using 1-anilino-8-naphthalene sulfonate (ANS) and N-phenyl-1-naphthylamine. The purified glycoprotein contained 75.5%, dry weight, as carbohydrate, 16.3% as protein, and 3.7% as sulfate; Mr = 2.2 X 10(6) was estimated by chromatography on Sephacryl S-500. Mucin contained a large number of low-affinity binding sites for these hydrophobic ligands. The dissociation constant, KD of mucin-ANS binding was 2.7 X 10(-5); each mucin molecule had approximately 42 binding sites for ANS. These binding sites were deduced to be on the unglycosylated portion of the protein core, as Pronase digestion completely eliminated binding. Reduction of mucin with 2-mercaptoethanol increased the fluorescence yield by formation of subunits with increased binding sites for the ligand. Increasing NaCl concentration (0.125 to 2.0 M) and decreasing pH (9 to 3) progressively increased fluorescence with the charged ligand ANS, suggesting that the binding site may have acidic groups which are shielded at high ionic strength or low pH. The fluorescent yield with N-phenyl-1-naphthylamine, an uncharged ligand, was an order of magnitude higher than with ANS. Bilirubin and bromosulfophthalein inhibited mucin-induced ANS fluorescence, but bile acids did not. Gallbladder mucin contains hydrophobic binding domains in the nonglycosylated peptide core that are involved in polymer formation and binding of biliary lipids and pigment.