S-adenosylmethionine and nicotinamide riboside therapy in Arts syndrome: A case report and literature review

Phospho-ribosyl-pyrophosphate synthetase 1 (PRPS1) deficiency is secondary to loss of function variants in PRPS1. This enzyme generates phospho-ribosyl-pyrophosphate (PRPP), which is utilized in the synthesis of purines, nicotinamide adenine dinucleotide (NAD), and NAD phosphate (NADP), among other metabolic pathways. Arts syndrome, or severe PRPS1 deficiency, is an X-linked condition characterized by congenital sensorineural hearing loss, optic atrophy, developmental delays, ataxia, hypotonia, and recurrent infections that can cause progressive clinical decline, often resulting in death before 5 years of age. Supplementation of the purine and NAD pathways outside of PRPP-dependent reactions is a logical approach and has been reported in a handful of patients, two with S-adenosylmethionine (SAMe) and one with SAMe and nicotinamide riboside (NR). We present the clinical course of a fourth Arts syndrome patient who was started on therapy and review previously reported patients. All patients had stability or improvement of symptoms, suggesting that SAMe and NR can be a treatment option in Arts syndrome, though further studies are warranted.

Targeted Treatments for Inherited Neuromuscular Diseases of Childhood

In the past decade, the number of genes linked to neuromuscular diseases of childhood has expanded dramatically, and this genetic information is forming the basis for gene-specific and even mutation-specific therapies. At the forefront of these advances are the two recently approved treatments for spinal muscular atrophy: one, an antisense oligonucleotide that modifies splicing of the SMN2 gene, and, the other, a gene therapy vector that delivers the SMN1 gene to motor neurons, both of which are allowing patients to acquire developmental milestones previously unseen in this fatal disease. This review highlights these advances and emerging targeted therapies for Duchenne muscular dystrophy and centronuclear myopathy, while also covering enzyme replacement therapy and small molecule-based targeted therapies for conditions such as Pompe's disease and congenital myasthenic syndromes. With these and other newer techniques for targeted correction of genetic defects, such as CRISPR/Cas9, there is now hope that treatments for many more genetic diseases of the nervous system will follow in the near future.

Autism risk in offspring can be assessed through quantification of male sperm mosaicism

De novo mutations arising on the paternal chromosome make the largest known contribution to autism risk, and correlate with paternal age at the time of conception. The recurrence risk for autism spectrum disorders is substantial, leading many families to decline future pregnancies, but the potential impact of assessing parental gonadal mosaicism has not been considered. We measured sperm mosaicism using deep-whole-genome sequencing, for variants both present in an offspring and evident only in father's sperm, and identified single-nucleotide, structural and short tandem-repeat variants. We found that mosaicism quantification can stratify autism spectrum disorders recurrence risk due to de novo mutations into a vast majority with near 0% recurrence and a small fraction with a substantially higher and quantifiable risk, and we identify novel mosaic variants at risk for transmission to a future offspring. This suggests, therefore, that genetic counseling would benefit from the addition of sperm mosaicism assessment.

A perspective on global access to insulin: a descriptive study of the market, trade flows and prices

AIM

To describe the global insulin market.

METHODS

Market intelligence data, United Nations Commodity Trade Statistics for insulin trade, the International Medical Products Price Guide for prices of human insulin and additional web searches were used as data sources. These sources were combined to gain further insight into possible links among market, trade flows and prices. Descriptive statistics and Spearman's rank order correlation were used for the analysis.

RESULTS

A total of 34 insulin manufacturers were identified. Most countries and territories are reliant on a limited number of supplying countries. The overall median (interquartile range) government procurement price for a 10-ml, 100-IU/ml vial during the period 1996-2013 equivalent was US$4.3 (US$ 3.8-4.8), with median prices in Africa (US$ 4.7) and low- (US$ 6.9) and low- to middle- (US$ 4.7) income countries being higher over this period. The relationships between price and quantity of insulin (Spearman's r=0.046; P>0.1) and number of import links (Spearman's r=0.032; P>0.1) were weak. The links between price and percentage of total insulin from a country where a 'big three' manufacturer produces insulin (Spearman's r=0.294; P<0.05) and total insulin from the main import link (Spearman's r=-0.392; P<0.05) were stronger.

CONCLUSIONS

This research shows the high variability of insulin prices and the reliance on a few sources, both companies and countries, for global supply. In addressing access to insulin, countries need to use existing price data to negotiate prices, and mechanisms need to be developed to foster competition and security of supply of insulin, given the limited number of truly global producers.

Hypoxia-ischemia modifies postsynaptic GluN2B-containing NMDA receptor complexes in the neonatal mouse brain

The N-methyl-d-aspartate-type glutamate receptor (NMDAR)-associated multiprotein complexes are indispensable for synaptic plasticity and cognitive functions. While purification and proteomic analyses of these signaling complexes have been performed in adult rodent and human brain, much less is known about the protein composition of NMDAR complexes in the developing brain and their modifications by neonatal hypoxic-ischemic (HI) brain injury. In this study, the postsynaptic density proteins were prepared from postnatal day 9 naïve, sham-operated and HI-injured mouse cortex. The GluN2B-containing NMDAR complexes were purified by immunoprecipitation with a mouse GluN2B antibody and subjected to mass spectrometry analysis for determination of the GluN2B binding partners. A total of 71 proteins of different functional categories were identified from the naïve animals as native GluN2B-interacting partners in the developing mouse brain. Neonatal HI reshaped the postsynaptic GluN2B interactome by recruiting new proteins, including multiple kinases, into the complexes; and modifying the existing associations within 1h of reperfusion. The early responses of postsynaptic NMDAR complexes and their related signaling networks may contribute to molecular processes leading to cell survival or death, brain damage and/or neurological disorders in term infants with neonatal encephalopathy.

Proteomic Analysis of Mouse Cortex Postsynaptic Density following Neonatal Brain Hypoxia-Ischemia

Proteomics of the synapses and postsynaptic densities (PSDs) have provided a deep understanding of protein composition and signal networks in the adult brain, which underlie neuronal plasticity and neurodegenerative or psychiatric disorders. However, there is a paucity of knowledge about the architecture and organization of PSDs in the immature brain, and how it is modified by brain injury in an early developing stage. Mass spectrometry (MS)-based proteomic analysis was performed on PSDs prepared from cortices of postnatal day 9 naïve mice or pups which had suffered hypoxic-ischemic (HI) brain injury. 512 proteins of different functional groups were identified from PSDs collected 1 h after HI injury, among which 60 have not been reported previously. Seven newly identified proteins involved in neural development were highlighted. HI injury increased the yield of PSDs at early time points upon reperfusion, and multiple proteins were recruited into PSDs following the insult. Quantitative analysis was performed using spectral counting, and proteins whose relative expression was more than 50% up- or downregulated compared to the sham animals 1 h after HI insult were reported. Validation with Western blotting demonstrated changes in expression and phosphorylation of the N-methyl-D-aspartate receptor, activation of a series of postsynaptic protein kinases and dysregulation of scaffold and adaptor proteins in response to neonatal HI insult. This work, along with other recent studies of synaptic protein profiling in the immature brain, builds a foundation for future investigation on the molecular mechanisms underlying developing plasticity. Furthermore, it provides insights into the biochemical changes of PSDs following early brain hypoxia-ischemia, which is helpful for understanding not only the injury mechanisms, but also the process of repair or replenishment of neuronal circuits during recovery from brain damage.

meso-Acetoxymethyl BODIPY dyes for photodynamic therapy: improved photostability of singlet oxygen photosensitizers

Br or I substituted BODIPY photosensitizers for photodynamic therapy bearmeso-acetoxymethyl substitutents for improved photostability to singlet-oxygen damage rendering enhanced¹O₂generation before photodestruction.

Surgical management of medically refractory epilepsy in patients with polymicrogyria

OBJECTIVE

Polymicrogyria (PMG) is a malformation of cortical development characterized by formation of an excessive number of small gyri. Sixty percent to 85% of patients with PMG have epilepsy that is refractory to medication, but surgical options are usually limited. We characterize a cohort of patient with polymicrogyria who underwent epilepsy surgery and document seizure outcomes.

METHODS

A retrospective study of all patients with PMG who underwent epilepsy surgery (focal seizure foci resection and/or hemispherectomy) at our center was performed by review of all clinical data related to their treatment.

RESULTS

We identified 12 patients (7 males and 5 female) with mean age of 18 (ranging from 3 months to 44 years) at time of surgery. Mean age at seizure onset was 8 years, with the majority (83%) having childhood onset. Six patients had focal, five had multifocal, and one patient had diffuse PMG. Perisylvian PMG was the most common pattern seen on magnetic resonance imaging (MRI). Eight patients had other cortical malformations including hemimegalencephaly and cortical dysplasia. Scalp electroencephalography (EEG) often showed diffuse epileptic discharges that poorly lateralized but were focal on intracranial electrocorticography (ECoG). Eight patients underwent seizure foci resection and four underwent hemispherectomy. Mean follow-up was 7 years (ranging from one to 19 years). Six patients (50%) were seizure-free at last follow-up. One patient had rare seizures (Engel class II). Three patients were Engel class III, having either decreased seizure frequency or severity, and two patients were Engel class IV. Gross total resection of the PMG cortex trended toward good seizure control.

SIGNIFICANCE

Our study shows that even in patients with extensive or bilateral PMG malformations, some may still be good candidates for surgery because the epileptogenic zone may involve only a portion of the malformation. Intracranial ECoG can provide additional localizing information compared to scalp EEG in guiding resection of epileptogenic foci.

Fyn in Neurodevelopment and Ischemic Brain Injury

The Src family kinases (SFKs) are nonreceptor protein tyrosine kinases that are implicated in many normal and pathological processes in the nervous system. The SFKs Fyn, Src, Yes, Lyn, and Lck are expressed in the brain. This review will focus on Fyn, as Fyn mutant mice have striking phenotypes in the brain and Fyn has been shown to be involved in ischemic brain injury in adult rodents and, with our work, in neonatal animals. An understanding of Fyn's role in neurodevelopment and disease will allow researchers to target pathological pathways while preserving protective ones.

NR2B phosphorylation at tyrosine 1472 contributes to brain injury in a rodent model of neonatal hypoxia-ischemia

BACKGROUND AND PURPOSE

The NR2B subunit of the N-methyl-d-aspartate (NMDA) receptor is phosphorylated by the Src family kinase Fyn in brain, with tyrosine (Y) 1472 as the major phosphorylation site. Although Y1472 phosphorylation is important for synaptic plasticity, it is unknown whether it is involved in NMDA receptor-mediated excitotoxicity in neonatal brain hypoxia-ischemia (HI). This study was designed to elucidate the specific role of Y1472 phosphorylation of NR2B in neonatal HI in vivo and in NMDA-mediated neuronal death in vitro.

METHODS

Neonatal mice with a knockin mutation of Y1472 to phenylalanine (YF-KI) and their wild-type littermates were subjected to HI using the Vannucci model. Brains were scored 5 days later for damage using cresyl violet and iron staining. Western blotting and immunoprecipitation were performed to determine NR2B tyrosine phosphorylation. Expression of NADPH oxidase subunits and superoxide production were measured in vivo. NMDA-induced calcium response, superoxide formation, and cell death were evaluated in primary cortical neurons.

RESULTS

After neonatal HI, YF-KI mice have reduced expression of NADPH oxidase subunit gp91phox and p47phox and superoxide production, lower activity of proteases implicated in necrotic and apoptotic cell death, and less brain damage when compared with the wild-type mice. In vitro, YF-KI mutation diminishes superoxide generation in response to NMDA without effect on calcium accumulation and inhibits NMDA and glutamate-induced cell death.

CONCLUSIONS

Upregulation of NR2B phosphorylation at Y1472 after neonatal HI is involved in superoxide-mediated oxidative stress and contributes to brain injury.

Effect of day of mixing gestating sows on measures of reproductive performance and animal welfare

Effects of day of mixing sows after breeding were measured for reproduction and welfare on a commercial research farm. Sows (n = 1,436) were weaned into stalls for breeding, and groups of sows were assigned to 1) no mixing and housed in individual stalls (STL), 2) mixed on d 3 to 7 after breeding (D3), 3) mixed on d 13 to 17 after breeding (D14), or 4) mixed 35 d after breeding (D35). Mixed sows were moved into pens (n = 58 sows/pen) with an electronic sow feeding station and maintained as a static group. In the first 12 d after mixing or movement into STL (period 1), sows were assessed for lameness and lesions every 3 d and then every 2 wk until farrowing (period 2). Cortisol and fights were measured in period 1. Conception rates were reduced (P < 0.005) in D3 (87.1%) and D14 (89.2%) compared to D35 (92.2%) and STL (96.2%). Farrowing rates were lower (P < 0.0001) in D3 (82.8%) compared to D35 (90.5%) and STL (96.2%), but litter size was not (P ≥ 0.20) affected by mixing. The proportion of sows bred within 10 d of weaning was reduced (P < 0.05) for D14 compared to STL, but D3 and D35 did not differ among treatments. Number of fights 24 h after mixing was less (P < 0.0001) for D14 compared to D3 and D35 groups, and serum cortisol was greater (P < 0.05) for D35 compared to STL and D3. From period 1 to 2, lameness increased in D3 and decreased in D35 but did not change for D14 and STL (treatment × period, P < 0.05), whereas leg inflammation did not differ (P > 0.10) among treatments. Head and body lesion scores declined from period 1 to 2 in all mix groups, whereas vulva lesions increased in the D3 and D35 but did not change in D14 and STL (treatment × period, P < 0.0001). These results suggest STL can improve most measures of welfare compared to mixing in groups. However, when mixing sows, assessments for reproductive performance and welfare may change from gestation to farrowing. The poorest reproductive performance and welfare was observed when sows were mixed 3 to 7 d after breeding. There were few differences between the D14 and D35 treatments in reproduction or welfare, but D14--not D35--differed from STL in weaned sows rebred. Overall, results of this trial suggest that, even though any of the mixing days can result in acceptable measures of reproduction, there are clear effects of day of mixing on fertility and welfare, and special attention should be focused on the long-term reproductive and welfare consequences.

Enhanced NMDA receptor tyrosine phosphorylation and increased brain injury following neonatal hypoxia-ischemia in mice with neuronal Fyn overexpression

The Src family kinases (SFKs) Src and Fyn are implicated in hypoxic-ischemic (HI) injury in the developing brain. However, it is unclear how these particular SFKs contribute to brain injury. Using neuron-specific Fyn overexpressing (OE) mice, we investigated the role of neuronal Fyn in neonatal brain HI. Wild type (WT) and Fyn OE mice were subjected to HI using the Vannucci model at postnatal day 7. Brains were scored five days later for evaluation of damage using cresyl violet and iron staining. Western blotting with postsynaptic density (PSD)-associated synaptic membrane proteins and co-immunoprecipitation with cortical lysates were performed at various time points after HI to determine NMDA receptor tyrosine phosphorylation and Fyn kinase activity. Fyn OE mice had significantly higher mortality and brain injury compared to their WT littermates. Neuronal Fyn overexpression led to sustained NR2A and NR2B tyrosine phosphorylation and enhanced NR2B phosphorylation at tyrosine (Y) 1472 and Y1252 in synaptic membranes. These early changes correlated with higher calpain activity 24h after HI in Fyn OE mice relative to WT animals. Our findings suggest a role for Fyn kinase in neuronal death after neonatal HI, possibly via up-regulation of NMDA receptor tyrosine phosphorylation.

Developmental localization of NMDA receptors, Src and MAP kinases in mouse brain

Activation of NMDA receptors (NMDAR) is associated with divergent downstream signaling leading to neuronal survival or death that may be regulated in part by whether the receptor is located synaptically or extrasynaptically. Distinct activation of the MAP kinases ERK and p38 by synaptic and extrasynaptic NMDAR is one of the mechanisms underlying these differences. We have recently shown that the Src family kinases (SFKs) play an important role in neonatal hypoxic-ischemic brain injury by regulating NMDAR phosphorylation. In this study, we characterized the distribution of NMDAR, SFKs and MAP kinases in synaptic and extrasynaptic membrane locations in the postnatal day 7 and adult mouse cortex. We found that the NMDAR, SFKs and phospho-NR2B were predominantly at synapses, whereas striatal-enriched protein tyrosine phosphatase (STEP) and its substrates ERK and p38 were much more concentrated extrasynaptically. NR1/NR2B was the main subunit at extrasynaptic membrane with concomitant NR2B phosphorylation at tyrosine (Y) 1336 in the immature brain. STEP expression increased, while p38 decreased with development in the extrasynaptic membrane. These results suggest that SFKs and STEP are poised to differentially regulate NMDAR-mediated signaling pathways due to their distinct subcellular localization, and thus may contribute to the age-specific differences seen in vulnerability, pathology and consequences of hypoxic-ischemic brain injury.

Taking training into your own hands

The Young Diabetologists' Forum (YDF) is a group designed and run by specialist trainees in endocrinology and diabetes that aims to provide high quality educational events. The YDF recognised that not all trainees in the specialty had equitable access to training opportunities and resolved to try and remedy the situation. This article describes the history and evolution of the YDF into an organisation representing over 400 trainees in endocrinology and diabetes, providing up to seven training events per year and with a budget of over pounds 200,000. As well as offering education and training another key purpose of the YDF is to give trainees from around the country the opportunity to meet up and exchange thoughts and ideas. The overall aim of the organisation is to improve the lives of people with diabetes by helping to ensure that future specialists are fully equipped for their role.

41 DETERMINATION OF THE RELATIONSHIP BETWEEN VULVAR SKIN TEMPERATURES AND TIME OF OVULATION IN SWINE USING DIGITAL INFRARED THERMOGRAPHY

Accurate estrus detection is an essential component of a successful AI program in modern swine operations. It is necessary to establish efficacious means of estrus detection and optimize reproductive performance in the herd. Measurement of physiological traits such as body temperature, vaginal electrical resistance, and vulva reddening have been investigated as methods to aid in estrus detection in swine. The relationship between vulvar skin temperature (VST) and ovulation has not been previously investigated. Therefore, the objective of this study was to assess changes in VST that occur during the periovulatory period using digital infrared thermography (IRT). The experiment group consisted of a total of 25 gilts and 27 multiparous sows, and the control group consisted of 30 sows that were 60 days of gestation. All Yorkshire-Landrace females were housed individually in a temperature and humidity controlled environment. VST were measured twice daily at 8-h intervals using the infrared digital thermocamera (Fluke IR FlexCam® Thermal Imager, Fluke Corporation, Everett, WA) while the animals were standing and eating prior to estrus detection. Estrus detection was performed twice daily (at 8-h intervals) with the aid of an adult boar. Once standing estrus was observed, transrectal real-time ultrasound was performed twice daily at 8-h intervals to monitor follicle development and determine the time of ovulation. Ovaries were visualized using an Aloka 500 V ultrasonics machine (Aloka Inc., Tokyo, Japan) fitted with a transrectal 7.5-MHz linear transducer, which was fitted into a rigid, fixed-angle PVC adapter. Average VST and hours were reported in mean ± SEM and compared using an ANOVA and Student’s t-test using SAS software (SAS Institute Inc., Cary, NC, USA). Additionally, pairwise comparisons were performed to compare VST at different times during estrus. Significant differences were reported at P ≤ 0.05. Evidence of CL formation and ovulation was detected at 38 ± 9.3 h after onset of estrus in gilts, and 43 ± 12 h in sows. The mean VST of sows during estrus was significantly higher (P ≤ 0.05) than that of gilts. During estrus, the mean VST of gilts reached a peak of 35.6 ± 0.24°C and then decreased significantly to 33.9 ± 0.32°C 12 h prior to ovulation. This marked change in mean VST was detected between 36 and 12 h prior to ovulation. There was a similar trend in sows with a peak mean VST of 36.1 ± 0.25°C at 24 h prior to ovulation and then dropping to 34.6 ± 0.31°C 12 h prior to ovulation. There was no significant difference (P ≥ 0.05) between VST in gilts and sows at the time of ovulation. This study demonstrated that VST of sows and gilts measured by IRT change significantly during the periovulatory period. Additionally, there are distinct times that VST rises and then falls precipitously in sows compared with gilts. Digital IRT as a predictor for ovulation in swine appears to be a promising tool. Further studies involving predictor models and hormonal assays need to be performed.

Improvement in asthma symptoms and quality of life in pediatric patients through specialty care delivered via telemedicine

Asthma is the most common chronic disease affecting children. Studies have demonstrated improvements in asthma control when care is delivered by specialists compared with generalists. We postulated that specialist care delivered by telemedicine would result in similar improvements in control of symptoms and quality of life as compared with face-to-face encounters with specialists. Seventeen patients with persistent asthma, who were cared for by pediatricians in a rural school-based health clinic, were treated over a 6-month period in an asthma specialty program. Patients had face-to-face encounters at week zero, and then telemedicine follow-up visits at weeks 4, 12, and 24. Patients maintained a symptom diary and reliever medication use log. Spirometry and patient and caregiver quality-of-life questionnaires were completed at each visit. Mean number of symptom free days increased 83% from 2.35 days at week 0 to 4.31 days at week 24 (p < 0.05). There was a 44% reduction in mean symptom scores, from 2.32 at week 0 to 1.31 at week 24 (p < 0.001). Nine patients reported having 7 symptom-free days or 7 days of symptom scores of zero in the preceding seven days at week 24 compared with one patient at week 0 (p < 0.002). FEV(1) increased by > or = 12% in seven patients during the study period. Significant improvements in quality of life were reported by patients at week 4 (p < 0.02) and week 24 (p < 0.01), and by caregivers at week 24 (p < 0.002). Specialty asthma care delivered via telemedicine resulted in improvements in asthma symptom control and quality of life similar to improvements reported in face-to-face encounters provided by specialists.

Audiotapes of oncology consultations: only for the first consultation?

BACKGROUND

Patients value audiotapes of their oncology consultations and letters summarising the discussion, and report improved recall and satisfaction when they receive them. However, studies to date have provided these interventions only after the initial or 'bad news' consultation. This study aimed to evaluate the utility of audiotaping routine follow-up oncology consultations.

PATIENTS AND METHODS

This was a prospective study following a cohort of consecutive patients attending routine follow-up at oncology outpatient appointments with one oncologist. Patients were approached when they attended their appointment and offered the opportunity to be audiotaped. Acceptance rates and reasons for refusal were documented. Two weeks after the consultation, patients were telephoned regarding their response to the tape and were sent a letter summarising the consultation. Two weeks later they received a further telephone call regarding the letter and their perceptions of the comparative value of the two interventions.

RESULTS

Seventy-five per cent of patients were female and for 40% English was not their first language. The patients had attended a median of 14 previous oncology appointments; 52 patients were offered audiotaping, 43 accepted and 30 decided to take home a copy of the audiotape. One patient felt recording had limited the discussion. Patients refused the tape most commonly because they felt no need for this aid, and accepted it most commonly to aid recall or share with family. Twenty-six patients listened to the tape, 14 did so more than once. Twenty had shared it with another person and over 75% thought it was useful. The majority (57%) preferred to receive both the tape and letter, with three preferring the tape alone and seven the letter. Married patients and those receiving bad news were more likely to want the tape.

CONCLUSIONS

Audiotaping follow-up consultations is an inexpensive procedure that is appreciated by the majority of patients. Randomised controlled trials of their impact are warranted.

The integrin-mediated cyclic strain-induced signaling pathway in vascular endothelial cells

The irregular distribution of plaque in the vasculature results from the interaction of local hemodynamic forces with the vessel wall. One well-characterized force is cyclic circumferential strain, the repetitive pulsatile pressure distention on the arterial wall. This review summarizes current research, which has aimed to elicit the signal transduction pathway by which cyclic strain elicits functional and structural responses in endothelial cells; specifically, it summarizes the signaling pathway that begins with the reorganization of integrins. One method by which these extracellular matrix receptors affect signal transduction is through their ability to initiate the process of phosphorylation on tyrosine residues of cytoplasmic protein kinases, including focal adhesion kinase. The strain-induced pathway appears to also involve ras and the mitogen-activated protein kinase family of enzymes, and preliminary data suggests a role for src as well. Ultimately, it is the regulation of gene expression through the modulation of transcription factors that allows endothelial cells to respond to changes in local hemodynamics.

Demonstration of the Activation of Prodrug CB 1954 Using Human DT-Diaphorase Mutant Q104Y-Transfected MDA-MB-231 Cells and Mouse Xenograft Model

The rat form of DT-diaphorase (NAD(P)H: quinone acceptor oxidoreductase; EC 1.6.99.2) is more effective than the human form in activating prodrugs such as CB 1954 (5-(aziridin-1-yl)-2,4-dinitrobenzamide). Our site-directed mutagenesis study has revealed that residue 104 (Tyr in the rat enzyme and Gln in the human enzyme) is an important residue responsible for the catalytic differences between the rat and the human enzymes in the activation of CB 1954 (S. Chen et al., 1997, J. Biol. Chem. 272, 1437-1439). The human mutant Q104Y is capable of reducing CB 1954 at a rate identical to that of the wild-type rat DT-diaphorase. In the present study, we prepared both the wild-type human DT-diaphorase- and the mutant Q104Y-expressing MDA-MB-231 breast cancer cell lines using the cDNA transfection method. The MDA-MB-231 cell line is homozygous for a P187S mutation in the DT-diaphorase gene and has no detectable DT-diaphorase activity. Stable clones for the wild-type transfected cells had the DT-diaphorase activity ranged from 0.1 to 3.8 micromol of DCIP reduced/min/mg of protein and the clones for Q104Y transfected cells had the activity ranged from 0.06 to 1.58 micromol of DCIP reduced/min/mg of protein. Furthermore, in contrast to the cells transfected with only expression vector that were not sensitive to CB 1954 treatment, the wild-type and Q104Y-expressing cells were capable of the reductive activation of CB 1954, resulting in cell eradication. Our data showed that cell killing by CB 1954 followed a dose and incubation-time dependent manner. It was also found that the cell survival upon the treatment of CB 1954 was related to the expressed DT-diaphorase activity in these cells. In the presence of 75 microM CB 1954, a 50% cell killing was achieved in cells containing Q104Y and the wild-type DT-diaphorase with the activity at approximately 0.67 and 3.8 micromol of DCIP reduced/min/mg of protein, respectively. These results agree well with those of the in vitro enzyme assays that show that Q104Y is significantly more active than the wild-type DT-diaphorase in the activation of CB 1954. Finally, the in vivo activation of CB 1954 was demonstrated with a nude mouse model using Q104Y-transfected MDA-MB-231 cells. These studies reveal that DT-diaphorase can activate CB 1954, and human Q104Y mutant enzyme is more active than the wild-type enzyme in the intracellular reductive activation of CB 1954.

Structure-function studies of DT-diaphorase (NQO1) and NRH: quinone oxidoreductase (NQO2)

DT-diaphorase, also referred to as NQO1 or NAD(P)H: quinone acceptor oxidoreductase, is a flavoprotein that catalyzes the two-electron reduction of quinones and quinonoid compounds to hydroquinones, using either NADH or NADPH as the electron donor. NRH (dihydronicotinamide riboside): quinone oxidoreductase, also referred to as NQO2, has a high nucleotide sequence identity to DT-diaphorase and is considered to be an isozyme of DT-diaphorase. These enzymes transfer two electrons to a quinone, resulting in the formation of a hydroquinone product without the accumulation of a dissociated semiquinone. Steady and rapid-reaction kinetic experiments have been performed to determine the reaction mechanism of DT-diaphorase. Furthermore, chimeric and site-directed mutagenesis experiments have been performed to determine the molecular basis of the catalytic differences between the two isozymes and to identify the critical amino acid residues that interact with various inhibitors of the enzymes. In addition, functional studies of a natural occurring mutant Pro-187 to Ser (P187S) have been carried out. Results obtained from these investigations are summarized and discussed.

Telehealth in a rural school-based health center

Telehealth is a new technology for the delivery of health care that allows a provider to deliver health care to a client at a remote setting via full, real-time video and audio interaction (American Nurses' Association, 1996). Telehealth does not change traditional health care standards or practice. School-based health centers are designed specifically for children and offer a continuum of preventive and acute care interventions that few other health care entities can provide (School-Based Adolescent Health Care Program, 1993). Telehealth and a school-based health center were joined together in a pilot project to demonstrate the efficacy of primary care via telehealth and to determine the value of this technology to the school and community. The telehealth capability enhanced the role of the school nurse and increased access to primary care for the students. The students were quick to adapt to the technology. The role of the school nurse was essential to the success of this project.

Molecular characterization of binding of substrates and inhibitors to DT-diaphorase: combined approach involving site-directed mutagenesis, inhibitor-binding analysis, and computer modeling

The molecular basis of the interaction of DT-diaphorase with a cytotoxic nitrobenzamide CB1954 [5-(aziridin-1-yl)-2, 4-dinitrobenzamide] and five inhibitors was investigated with wild-type DT-diaphorase (human and rat) and five mutants [three rat mutants (rY128D, rG150V, rH194D) and two human mutants (hY155F, hH161Q)]. hY155F and hH161Q were generated to evaluate a hypothesis that Tyr155 and His161 participate in the obligatory two-electron transfer reaction of the enzyme. The catalytic properties of hY155F and hH161Q were compared with a naturally occurring mutant, hP187S. Pro187 to Ser mutation disturbs the structure of the central parallel beta-sheet, resulting in a reduction of the binding affinity of the flavin-adenine dinucleotide prosthetic group. With NADH as the electron donor and menadione as the electron acceptor, the k(cat) values for the wild-type human DT-diaphorase, hY155F, hH161Q, and hP187S were measured as 66 +/- 1, 23 +/- 0, 5 +/- 0 and 8 +/- 2 x 10(3) min(-1), respectively. Because hY155F still has significant catalytic activity, the hydroxyl group on Tyr155 may not be as important as proposed. Interestingly, hY155F was found to be 3. 3 times more active than the human wild-type DT-diaphorase in the reduction of CB1954. Computer modeling based on our results suggests that CB1954 is situated in the active site, with the aziridinyl group pointing toward Tyr155 and the amide group placed near a hydrophobic pocket next to Tyr128. Dicoumarol, Cibacron blue, chrysin, 7,8-dihydroxyflavone, and phenindone are competitive inhibitors of the enzyme with respect to nicotinamide coenzymes. The binding orientations of dicoumarol, flavones, and phenindone in the active site of DT-diaphorase were predicted by results from our inhibitor-binding studies and computer modeling based on published X-ray structures. Our studies generated results that explain why dicoumarol is a potent inhibitor and binds differently from flavones and phenindone in the active site of DT-diaphorase.

Immune dysfunction and the pathogenesis of AIDS-associated non-Hodgkin's lymphoma

Much has been learned about how HIV-induced immune dysfunction contributes to B cell hyperactivation, and potentially, to the pathogenesis of AIDS-lymphoma. However, further studies are needed to fully understand how HIV infection and immune dysfunction promote B cell hyperactivation and the development/growth of AIDS-lymphoma. In particular, studies are needed to define the role of HHV8 vIL6, IL6 receptor-expression, and lymphocyte surface stimulatory molecules, in promoting B cell hyperactivation or lymphoma cell growth.

Catalytic properties of NAD(P)H:quinone oxidoreductase-2 (NQO2), a dihydronicotinamide riboside dependent oxidoreductase

Human NAD(P)H:quinone acceptor oxidoreductase-2 (NQO2) has been prepared using an Escherichia coli expression method. NQO2 is thought to be an isoform of DT-diaphorase (EC 1.6.99.2) [also referred to as NAD(P)H:quinone acceptor oxidoreductase] because there is a 49% identity between their amino acid sequences. The present investigation has revealed that like DT-diaphorase, NQO2 is a dimer enzyme with one FAD prosthetic group per subunit. Interestingly, NQO2 uses dihydronicotinamide riboside (NRH) rather than NAD(P)H as an electron donor. It catalyzes a two-electron reduction of quinones and oxidation-reduction dyes. One-electron acceptors, such as potassium ferricyanide, cannot be reduced by NQO2. This enzyme also catalyzes a four-electron reduction, using methyl red as the electron acceptor. The NRH-methyl red reductase activity of NQO2 is 11 times the NADH-methyl red reductase activity of DT-diaphorase. In addition, through a four-electron reduction reaction, NQO2 can catalyze nitroreduction of cytotoxic compound CB 1954 [5-(aziridin-1-yl)-2,4-dinitrobenzamide]. NQO2 is 3000 times more effective than DT-diaphorase in the reduction of CB 1954. Therefore, NQO2 is a NRH-dependent oxidoreductase which catalyzes two- and four-electron reduction reactions. NQO2 is resistant to typical inhibitors of DT-diaphorase, such as dicumarol, Cibacron blue, and phenindone. Flavones are inhibitors of NQO2. However, structural requirements of flavones for the inhibition of NQO2 are different from those for DT-diaphorase. The most potent flavone inhibitor tested so far is quercetin (3,5,7,3',4'-. 6pentahydroxyflavone). It has been found that quercetin is a competitive inhibitor with respect to NRH (Ki = 21 nM). NQO2 is 43 amino acids shorter than DT-diaphorase, and it has been suggested that the carboxyl terminus of DT-diaphorase plays a role in substrate binding (S. Chen et al., Protein Sci. 3, 51-57, 1994). In order to understand better the basis of catalytic differences between NQO2 and DT-diaphorase, a human NQO2 with 43 amino acids from the carboxyl terminus of human DT-diaphorase (i.e., hNQO2-hDT43) has been prepared. hNQO2-hDT43 still uses NRH as an electron donor. In addition, the chimeric enzyme is inhibited by quercetin but not dicumarol. These results suggest that additional region(s) in these enzymes is involved in differentiating NRH from NAD(P)H.

Selective cell ablation in transgenic mice expression E. coli nitroreductase

The gene encoding E. coli nitroreductase (NTR) was expressed in the luminal cells of the mammary gland of transgenic mice using the ovine beta-lactoglobulin promoter. Treatment of NTR expressing animals with the prodrug CB1954 (5-aziridin-1-yl-2-4-dinitrobenzamide) resulted in a rapid and selective killing of this population of cells whereas the closely associated myoepithelial cells were unaffected. NTR-mediated inducible cell ablation offers a number of advantages over the use of HSV1-tk for the selective killing of cells in vivo.

Molecular basis of the catalytic differences among DT-diaphorase of human, rat, and mouse

DT-diaphorase (EC 1.6.99.2), also referred to as NAD(P)H:(quinone-acceptor) oxidoreductase, is involved in the reductive activation process of several cytotoxic antitumor quinones and nitrobenzenes. It has been observed in our and other laboratories that the rat enzyme is significantly more effective in activating these drugs than the human and mouse enzymes. These results indicate that the available cytotoxic drugs are better substrates for the rat enzyme and are not the most ideal prodrugs for activation by DT-diaphorase in human tumors. In this study, using site-directed mutagenesis to replace residues in the rat enzyme with the human sequences and residues in the human enzyme with the rat sequences, we have found that residue 104 (Tyr in the rat enzyme and Gln in the human and mouse enzymes) is an important residue responsible for the catalytic differences between the rat and the human (and mouse) enzymes. With an exchange of a single amino acid, the rat mutant Y104Q behaved like the wild-type human enzyme, and the human mutant Q104Y behaved like the wild-type rat enzyme in their ability to reductively activate the cytotoxic drug CB 1954 (5-(aziridin-1-yl)-2,4-dinitrobenzamide). The study also confirms the conclusion of the x-ray structural analysis of rat enzyme that residue 130 (Thr in the rat enzyme and Ala in the human and mouse enzymes) is positioned near the binding region of the nicotinamide portion of NAD(P)H. This structural information is very important for designing suitable drugs and approaches for human cancer chemotherapy mediated by DT-diaphorase.

Catalytic properties of NAD(P)H:quinone acceptor oxidoreductase: study involving mouse, rat, human, and mouse-rat chimeric enzymes

NAD(P):quinone acceptor oxidoreductase (quinone reductase) (DT-diaphorase, EC 1.6.99.2) is involved in the process of reductive activation of cytotoxic antitumor quinones and nitrobenzenes. In this study, we initially examined the relative abilities of mouse, rat, and human quinone reductases to reduce two prodrugs, CB 1954 [5-(aziridin-1-yl)-2,4-dinitrobenzamide] and EO9 [5-(1-aziridinyl)-3-(hydroxymethyl)-2-(3-hydroxy-1-propenyl)-1- methyl-1H-indole-4,7-dione]. By using Escherichia coli-expressed quinone reductases and evaluating them under identical conditions, we confirmed previous finding showing that the human enzyme is not as effective as the rat enzyme in reducing CB 1954 and EO9, although the two enzymes have similar NAD(P)H-menadione reductase activities. Interestingly, although the amino acid sequence of mouse quinone reductase is more homologous to that of the rat enzyme, we found that the mouse enzyme behaves similarly to the human enzyme in its ability to reduce these compounds and to generate drug-induced DNA damage. To determine the region of quinone reductase that is responsible for the catalytic differences, two mouse-rat chimeric enzymes were generated. MR-P, a chimeric enzyme that has mouse amino-terminal and rat carboxy-terminal segments of quinone reductase, was shown to have catalytic properties resembling those of rat quinone reductase, and RM-P, a chimeric enzyme that has rat amino-terminal and mouse carboxyl-terminal segments of quinone reductase, was shown to have catalytic properties resembling those of mouse quinone reductase. In addition, MR-P and RM-P were found to be inhibited by flavones with Ki values similar to those for rat and mouse quinone reductases, respectively. Based on these results, we propose that the carboxyl-terminal portion of the enzyme plays an important role in the reduction of cytotoxic drugs and the binding of flavones.

A five-year experience with severe injuries in elderly patients

Recent reports of injury in elderly patients document that aggressive care is justified. Our experience indicates that geriatric injury differs from that of other trauma patients. All patients entered into a large urban trauma center registry over a five-year period were analyzed. Variables reviewed included demographics, trauma indices, mechanism of injury, mean number of hospital days, and morbidity and mortality for patients under 60 years old and for geriatric patients defined as those aged 60 and above. There were 3,064 patients in the reviewed group, of whom 243 qualified for geriatric analysis. Blunt injuries in males were the most typical scenario. Failure to use safety belts and alcohol intoxication persist into the geriatric age group (83% and 13%, respectively). Trauma indices including Injury Severity Score (ISS) were slightly greater in the geriatric group (27 versus 23) as compared to younger patients; plus geriatric patients tolerated head injury less well (GCS in those who died 6.7 versus 4.6, respectively; p < 0.001). Mortality in the geriatric group was 31% while being 17.1% in the younger group (p < 0.005). Days in the hospital were 20 for the geriatric compared to 13 for the younger group (p < 0.025). Infections and chest complications were twice as common in the elderly and dysrhythmias were five times more frequent. Elderly patients constitute 8% of the trauma population and suffer a magnitude of injury at least comparable to the general population. Their mortality is approximately 50% above the population as a whole and morbidity twice as common, accounting for the prolonged hospital stay.

Fibrinogen and the albumin-globulin ratio in recurrent stroke

BACKGROUND AND PURPOSE

In following patients initially recruited for a cross-sectional study of blood viscosity in ischemic cerebrovascular disease, it was noted that those having a low albumin-globulin ratio appeared to experience the majority of subsequent vascular events. Accordingly, a prospective study in which subjects were assigned to a high or low albumin-globulin cohort was undertaken to examine the relation between a low albumin-globulin ratio, the presence of clinical risk factors for stroke, and the occurrence of subsequent stroke, myocardial infarction, or vascular death.

METHODS

Three groups of subjects were followed for an average of 1.5 +/- 0.8 years to ascertain vascular end points. Group 1 consisted of 126 patients with acute ischemic stroke; group 2 included 109 subjects matched with group 1 for age, medications, and recognized clinical risk factors for stroke; and group 3 was composed of 84 healthy volunteers, matched for age with groups 1 and 2. The median albumin-globulin ratio for group 1 at enrollment, 1.45, was used to dichotomize patients into two cohorts: all subjects with an albumin-globulin ratio of 1.45 or less were assigned to the "low" albumin-globulin cohort; those whose ratio was greater than 1.45 were assigned to the "high" albumin-globulin cohort. The occurrence of vascular end points was verified during subsequent hospitalizations and outpatient clinic visits and by telephone interviews of patients and providers.

RESULTS

A total of 51 vascular events occurred, including 39 in group 1, 8 in group 2, and 4 in group 3. Subjects in either group 1 or 2 who were in the low albumin-globulin cohort had at least double the risk for a subsequent vascular event compared with their counterparts in the high albumin-globulin cohort (P < .01 and P < .03, respectively). In comparison with the high albumin-globulin cohort, significantly more patients in the low albumin-globulin cohort in group 1 had a history of prior stroke (P < .03). When groups 1 and 2 were combined, both a low albumin-globulin ratio and diabetes had a significant independent association with increased risk for subsequent vascular events in a Cox proportional-hazards model (P < .01 and P < .03, respectively).

CONCLUSIONS

The results of this study indicate that significantly increased risk for subsequent vascular events in stroke patients and in subjects with clinical risk factors for stroke is associated with a shift in the concentrations of blood proteins to a prothrombotic environment characterized by lower levels of albumin and an increased concentration of globulins and fibrinogen.

Steroid use is associated with pneumonia in pediatric chest trauma

A review of pediatric trauma focused on pediatric chest injuries was performed at a trauma center specializing in neurologic trauma. Eighty of 342 (23%) pediatric trauma patients admitted to the center had chest injuries. Age, gender, mechanism of injury, magnitude of injury, incidence of pulmonary infection, chest tube usage, endotracheal intubation, steroid or antibiotic usage, morbidity, and mortality data were reviewed. Sixteen of 78 children (20%) with chest injuries developed pulmonary infections and were compared with the noninfected group. Patients with pneumonia had a higher morbidity with significantly longer mean hospital stay (43.0 vs. 12.7 days; p = 0.001), duration of intubation (8.4 vs. 1.5 days; p = 0.001), and total days with chest tubes, (2.2 vs. 1.4 days; p = 0.02). Pneumonia was significantly associated with longer mean duration of steroid usage (6.4 vs. 0.8 days; p = 0.0001). Duration of steroid administration for the treatment of concomitant brain injury was a significant independent risk factor for the occurrence of pneumonia.

Effect of fat pre-feeding on bile flow and composition in the rat

Studies were conducted in rats to determine if the increase in lymph triacylglycerol output on pre-feeding a 20% glyceryltrioleate diet (Mansbach, C.M., II and Arnold, A. (1986) Am. J. Physiol. 251, G263-269) was due to an increase in phosphatidylcholine output into bile. Rats who were fed chow or pre-fed the 20% fat diet were equipped with biliary and duodenal cannulas and infused with glucose-saline while bile was collected hourly. The next day a taurocholate-glyceryltrioleate infusion was given and bile collected for 5 h. Bile flow, bile acid, phosphatidylcholine and cholesterol output were greater in the chow fed group than controls during the 6 h of the glucose saline period. Outputs were low overnight. During the taurocholate-glyceryltrioleate infusion, bile flow, bile acid, phosphatidylcholine and cholesterol output were all greater in the fat pre-fed group than the chow fed controls. We conclude that fat pre-feeding profoundly influences biliary composition and flow. The 2-fold increase in biliary phosphatidylcholine output during duodenal lipid infusion offers a potential explanation for the increased delivery of triacylglycerol into the lymph in rats on a similar fat pre-feeding program.

Chronic blood hyperviscosity in subjects with acute stroke, transient ischemic attack, and risk factors for stroke

The origin and significance of blood hyperviscosity in subjects with acute stroke has been controversial. It has been argued that viscous abnormalities simply reflect either elevated hematocrit or an acute-phase response to the stroke itself. To address these issues, we measured the factors that determine blood viscosity in a cross-sectional study of 430 subjects, including 135 with acute stroke, 89 with acute transient ischemic attacks of the brain, 115 with recognized risk factors for stroke, and 91 healthy controls. The at-risk group was balanced with the acute stroke group for types of risk factors and medication usage, and all four groups were balanced for age. The viscosity of whole blood at low rates of shear and the plasma viscosity were significantly elevated in both groups with cerebrovascular symptoms and in the at-risk group compared with the healthy controls. The severity of hyperviscosity was stroke group greater than transient ischemic attack group greater than at-risk group greater than healthy controls. Increased viscosity of whole blood was associated with an elevated plasma fibrinogen concentration and with a decreased albumin/globulin ratio. This study provides evidence that blood hyperviscosity is present not only in subjects with acute brain infarction, but also in those with risk factors for stroke, and that these abnormalities are, to a considerable degree, chronic.

Heterotopic lingual brain in the newborn

Heterotopic brain is a rare entity. Histologically, this lesion resembles mature brain and often contains specialized tissues similar to choroid plexus or glia. Specialized neural stains are necessary to differentiate this rare anomaly from other tumors or conditions found in the head and neck. The differential diagnosis includes squamous cell carcinoma, granular cell tumor, hemangioma, lymphangioma, thyroglossal duct cyst, dermoid cyst, hamartoma, rhabdomyosarcoma, and teratoma. We describe a newborn with heterotopic brain tissue occurring on the dorsum of the tongue. We found only one other description of this developmental aberration in the English literature. Our patient was successfully treated with carbon dioxide laser excision of the mass. There has been no evidence of complication or recurrence after one year of follow-up.