Abducens nerve palsy due to clivus metastasis in a patient with breast carcinoma: A rare case

INTRODUCTION

Breast cancer, comprising 25 % of all diagnosed cancers, predominantly affects women globally. While bone metastasis is common, occurrences at the clivus or skull base are rarely documented. Treatment varies from surgery in early stages to a multifaceted approach for advanced cases, incorporating chemotherapy, radiotherapy, and surgery based on staging and histology.

CLINICAL PRESENTATION

A 40-year-old female presented with a rapidly enlarging lump in her left breast and diplopia on right gaze. Histology was positive for invasive breast cancer (no special type) and Contrast-Enhanced Computed Tomography demonstrated metastatic deposits in multiple vertebrae and bilateral ilium. Further, magnetic resonance imaging of the brain and orbits revealed metastatic deposits in the clivus which extended up-to medial wall of the cavernous sinus, causing compression of the right abducens nerve. Multidisciplinary Tumor Board review recommended chemoradiotherapy.

DISCUSSION

Metastases from breast cancer can occur locally or to distant sites like lymph nodes, bones, lungs, liver, and brain. Unusual symptoms, such as new-onset diplopia, trigger further investigation. Although bone metastases occur in 50-65 % of cases, clivus metastasis is rare. Treatment aims at extending survival, symptom management, and enhancing quality of life through chemotherapy and radiotherapy. Outcomes hinge on metastatic burden and regional therapy responsiveness. Distant metastases substantially reduce the 5-year survival rate from 80 % to approximately 25 %, but cases often improve with regional interventions.

CONCLUSION

Although an extremely rare occurrence, clivus metastasis might be considered in patients with a history of malignancy, in particular, breast malignancy, presenting with new-onset sixth nerve palsy.

Use of Ceftriaxone and Benzylpenicillin in Outpatient Parenteral Antimicrobial Therapy: Spectrum vs Cost

Background

The application of antimicrobial stewardship (AMS) principles may entail increased cost to allow for narrower-spectrum therapy. Prescribing benzylpenicillin (BP) and ceftriaxone (CRO) for outpatient parenteral antimicrobial therapy (OPAT) demonstrates the complex challenge of this principle. The aim of this study is to analyze the use of BP and CRO in our OPAT program, including indications and relative cost.

Methods

We analyzed all adult patients in our OPAT program who received intravenous BP or CRO over 1 year. We identified a "crossover group" of patients who could have received either agent. Economic comparison was based on acquisition cost of the therapy (drug, infuser, and preparation costs).

Results

Of 105 eligible patients, 54 (51%) and 51 (49%) received BP and CRO, respectively. Forty (38%) patients were suitable for either agent; of these, the majority (n = 31, 78%) were treated with BP. Economic analysis demonstrated that the average daily cost of BP therapy was $93.76/d (AUD) vs $1.23/d for CRO. Thus, across our OPAT programs, we had an additional average cost of $92.53/patient/d to use BP instead of CRO. Program-wide the annual additional cost of using BP and thus applying this AMS strategy was $68 386.12.

Conclusions

BP is often selected over CRO by clinicians, where possible, as recommended by the Australian guidelines; however, BP is associated with higher daily acquisition costs. More broadly, a number of narrower-spectrum agents may involve significantly higher costs than comparators; as such, the $92.53/d to prevent CRO exposure can be considered when applying other antimicrobial-substitution AMS interventions in an acute health care setting.

Minimal invasive management of generalized peritonitis as a result of spontaneous ureteral rupture

INTRODUCTION AND IMPORTANCE

Generalized peritonitis following proximal ureteral rupture is a very rare complication. This is about a successfully managed case without open surgical intervention.

CASE PRESENTATION

A lady in her 70s presented with generalized abdominal pain, high spiking fever and low urine output for 3 days. She was haemodynamically unstable on admission and was resuscitated and managed at intensive care unit. CECT abdomen revealed partial anterior ureteral rupture with pyonephrosis. She was managed with percutaneous nephrostomy and subsequent anterograde stenting. Her recovery was uneventful and follow up imaging revealed no features of malignancy.

CLINICAL DISCUSSION

Generalized peritonitis due to renal pathology is very rare and it can be due to urolithiasis or neoplasm. Retroperitoneal infections may lead to irritation of peritoneum or fistulation into the peritoneum leading to generalized peritonitis. This can be managed by various surgical and non-surgical management modalities.

CONCLUSION

There are various pathological causes for acute abdomen. One of the rare causes is spontaneous rupture of ureter in pyonephrotic kidney which can also be managed successfully with minimal intervention.

Impact of water quality on Chronic Kidney Disease of unknown etiology (CKDu) in Thunukkai Division in Mullaitivu District, Sri Lanka

Background

Increase in the number of cases in Chronic Kidney Disease of Unknown etiology (CKDu) in Sri Lanka has become a health issue of national concern. Even though, Northern Province is not identified as a high-risk province, there is an increasing trend of CKDu after the end of civil war in the Northern Province.

Methods

The present study was conducted in Thunukkai Division in Mullaitivu District to investigate the socio demographic and clinical pattern of CKDu patients and to evaluate the quality of their water sources. The samples were selected by using stratified purposive random sampling method which represented 29% of total CKDu patients in Thunukkai Division. Pretested structured questionnaire was administered to collect the data from the CKDu patients. The association between serum creatinine excreted by CKDu patients and the water quality parameters were determined by using linear regression model.

Results

Among the patients, 80% were male with over 68% falling in the age range of 50–70. Majority (90%) were involved in agriculture related occupation. Smoking and alcohol consumption were detected as common habits among 40% of the patients. Secondarily developed, hypertension (60%) and diabetes (34%) were reported as common diseases in the area. Dug wells served as the commonest source of drinking water in the area (90% households) together with few tube wells. Physicochemistry of more than 50% of the water samples revealed higher electric conductivity, salinity, total dissolved solids, total hardness and Na levels compared to drinking water standards in Sri Lanka.

Conclusions

Serum creatinine levels of the CKDu patients were significantly and negatively correlated with phosphate while positively correlated with total dissolved solids (TDS) and arsenic content of the drinking water. Geospatial mapping of TDS and arsenic in drinking water with the occurrence of higher serum creatinine levels confirmed the same trend. Thus, the total dissolved solids and arsenic in drinking water may have positive correlation with the occurrence of CKDu in Thunukkai region in the Mullaitivu District of Sri Lanka.

Circulating human papillomavirus DNA detection in Barrett's dysplasia and esophageal adenocarcinoma

There is evidence to suggest that human papillomaviruses (HPV) are associated with Barrett's dysplasia and esophageal adenocarcinoma. In other HPV-linked cancers such as cervical and oropharyngeal cancer, circulating HPV DNA is a potential biomarker to assist in tumor diagnosis and management. This study aimed to determine whether circulating HPV DNA was detectable in patients with Barrett's dysplasia and esophageal adenocarcinoma, and if so, whether there is any correlation with esophageal tissue HPV status. Plasma from 138 patients representing esophageal adenocarcinoma (N = 41), Barrett's dysplasia (N = 48) and hospital controls (N = 49) were analyzed for the presence of circulating HPV DNA using droplet-digital PCR targeting the E7 gene of HPV types 16 and 18. Circulating HPV DNA was detected in 11/138 (8.0%) study subjects including 1/49 (2.0%) hospital controls, 4/48 (8.3%) Barrett's dysplasia patients, and 6/41 (14.6%) esophageal adenocarcinoma patients. Detection of circulating HPV DNA was higher in patients with HPV-positive esophageal tissue (6/35, 17.1%) compared to those with HPV-negative specimens (5/103; 4.9%) (OR = 4.06; 95% CI 1.15-14.25; P = 0.020). The highest rates of detection occurred in esophageal adenocarcinoma patients, particularly those with invasive tumors that had breached the esophageal submucosa, had regional lymph node involvement or metastatic disease. Circulating HPV DNA was detectable in a subset of Barrett's dysplasia and esophageal adenocarcinoma patients. Detection was associated with tissue HPV positivity and possibly disease severity.

Transforming human papillomavirus infection and the esophageal transformation zone: prime time for total excision/ablative therapy?

High-risk human papillomavirus (hr-HPV) infection is causal for almost all cervical malignancy (both squamous and adenocarcinoma), 90% of anal neoplasia, 70% of penile tumors, and 25% of head and neck cancers. The shared immunogenetics of cervical and esophageal malignancy suggests that HPV infection could well be a common denominator in the etiology of both cancers. In this regard, we have demonstrated that transcriptionally active hr-HPV (genotypes 16 and 18) is strongly associated with Barrett's dysplasia and esophageal adenocarcinoma. Increasing hr-HPV viral load and integration status has been linked with greater disease severity along the Barrett metaplasia-dysplasia-adenocarcinoma sequence as has been demonstrated in cervical intraepithelial neoplasia and cancer. HPV infections in both the cervix and esophagus are both focal, i.e., present in greater quantities at the squamocolumnar junction (SCJ). HPV affinity is to junctional tissue, as basal cells are particularly accessible at the squamocolumnar transformation zone and especially susceptible to this viral infection. We have postulated that progressive acid damage to the esophagus increases the likelihood of mucosal breaks enabling the virus to enter the basal layer of the transformation zone. The SCJ is the transformation zone of the esophagus and is strikingly similar to the transition zone (ectoendocervical SCJ) of the uterine cervix where almost all high-grade cervical lesions and cancers arise including 80% of adenocarcinomas. These transition zone cells exhibit features of squamous epithelium as well as glandular cells, which have been described in both Barrett's esophagus and cervical mucosa. Barrett's esophagus (BE) is derived from a discrete population of embryonic cells residing at the SCJ. There is loss of SCJ immune-phenotype following excision without regeneration at other junctional sites. Prevention of cervical cancer in up to 80-95% of patients with screen-detected CIN is dependent on the excision/ablation of the entire transformation zone. The persistence of hr-HPV 16/18 following eradication of CIN is a significant risk factor for recurrence. Similarly, we have demonstrated that persistent hr-HPV infection 16/18 and p53 overexpression are associated with treatment failure after endoscopic ablation of BD/EAC. Thus, we believe that excision/ablation of the SCJ in patients with BD/intramucosal EAC should be performed to reduce the potential malignant risk. We propose to test this hypothesis by a multicenter randomized controlled trial whereby patients (both HPV positive and those which are virus negative) will be allocated into two arms: complete excision of the SCJ via endoscopic mucosal resection (EMR) in addition to radiofrequency ablation (RFA) ± EMR of BD/intramucosal EAC (experimental arm) versus current standard of care (RFA ± EMR) of said lesions. Treatment efficacy in both groups will be evaluated by comparing disease elimination, regression/progression, and recurrence (if any). All patients would be entered into an intensive endoscopic surveillance protocol (biannually) for at least 2 years with lesional/neosquamous biopsies to compare the recurrence rate of both dysplasia/neoplasia in both arms. Viral (HPV DNA/p16INK4A/E6/E7 mRNA) and host biomarkers (e.g., p53) will be analyzed both at baseline and posttreatment intervals. A positive study would initiate development of tools best suited for SCJ destruction.

Human papillomavirus exposure and sexual behavior are significant risk factors for Barrett's dysplasia/esophageal adenocarcinoma

Given the comparable strains of high-risk human papillomavirus (HPV) present in a subset of Barrett's dysplasia and esophageal adenocarcinoma as in head and neck squamous cell carcinomas and the anatomical proximity of both lesions, we hypothesized that oral sex may increase the risk of Barrett's dysplasia/esophageal adenocarcinoma. Therefore, we compared the sexual behavior of patients with Barrett's dysplasia/esophageal adenocarcinoma and controls (hospital, reflux, and Barrett's metaplasia) to explore a plausible mechanism of viral transmission to the lower esophagus. A hospital-based case-control study involving 36 Barrett's dysplasia/esophageal adenocarcinoma subjects and 55 controls with known HPV DNA status and markers of transcriptional activity i.e p16INK4A and E6/E7 mRNA of the esophageal epithelium was conducted to evaluate differences in sexual history (if any). Barrett's dysplasia/esophageal adenocarcinoma patients were more likely than controls to be positive for HPV DNA (18 of 36, 50% vs. 6/55, 11%, p for trend <0.0001), be male (P = 0.001) and in a relationship (P = 0.02). Viral genotypes identified were HPV 16 (n = 14), 18 (n = 2), 11 (n = 1) and 6 (n = 1). HPV exposure conferred a significantly higher risk for Barrett's dysplasia/esophageal adenocarcinoma as compared with hospital/reflux/Barrett's metaplasia controls (OR = 6.8, 95% CI: 2.1-23.1, adjusted P = 0.002). On univariate analysis, ≥6 lifetime oral sex partners were significantly associated with dysplastic Barrett's esophagus and adenocarcinoma (OR, 4.0; 95% CI: 1.2-13.7, P = 0.046). After adjustment for confounders, HPV exposure and men with ≥2 lifetime sexual partners were at significant risk for Barrett's dysplasia/esophageal adenocarcinoma. If these initial findings can be confirmed in larger studies, it could lead to effective prevention strategies in combating some of the exponential increase in the incidence of esophageal adenocarcinoma in the West.

Barrett's oesophagus in Asians--are ethnic differences due to genes or the environment?

Ethnic differences in the prevalence of gastro-oesophageal reflux disease (GORD) and its complications, including Barrett's oesophagus (BO), are well described in multiracial Asian patient populations. These findings together with familial aggregation of GORD symptoms and twin studies suggest the possibility of a genetic component to GORD. Nevertheless, environmental factors, e.g. Helicobacter pylori infection, abdominal adiposity and metabolic syndrome, could equally account for these differences. Indian (South Asian) race is a risk factor for Barrett' oesophagus. This may be related to the Caucasian genetic make-up of Indians as opposed to an Oriental one as is the case of most other Asians. The HLA-B07 gene commonly found in South Asian and Caucasian populations, but not Orientals, may confer an increased risk for BO. Nevertheless, the high prevalence of H. pylori in South Asians and the consequent atrophic gastritis and hypochlorhydria may partially ameliorate this genetic predisposition to BO. The higher prevalence of obesity and the metabolic syndrome amongst certain Asiatic races may also contribute to the observed increased risk for BO. Future research should target the search for GORD/BO genes, ethnic differences in parietal cell mass and hiatal hernia, H. pylori colonization factors (e.g. MUC1 and MUC2) and adhesion molecules (BabA). Racial differences in lifestyle factors, i.e. abdominal adiposity, consumption of fruit and vegetables as well as smoking, should all be investigated as potential causes for this interethnic variation in GORD and BO. Nature or nurture, the clues are teasing and tantalizing and illustrate the complex relationship between the genetic make-up of man and the environment.

Loss of human leucocyte antigen class I and gain of class II expression are early events in carcinogenesis: clues from a study of Barrett's oesophagus

BACKGROUND

Human leucocyte antigen (HLA) expression is altered in oesophageal carcinomas compared with normal tissue. It is unclear, however, whether this phenotype precedes malignant transformation or results as a consequence of it.

AIM

To investigate HLA class I and II expression in Barrett's oesophagus and normal squamous oesophageal tissue.

METHODS

Asian patients with Barrett's oesophagus (n = 64) and a control group (n = 60) with a normal oesophagus but without reflux symptoms were recruited using endoscopic and histopathological criteria. Tissue samples were stained with monoclonal antibodies specific for HLA-ABC, HLA-DR alpha chain or HLA-DP/DQ/DR, and scored semiquantitatively. The results of immunohistochemical staining were correlated with clinical and histopathological characteristics of patients.

RESULTS

Marked expression of HLA-ABC was observed in 50% of Barrett's oesophagus sections as compared with 68.3% of controls (p = 0.038). HLA-DR staining was seen in 51.6% of Barrett's oesophagus samples versus 11.7% of controls (p<0.001). Expression of HLA-DP/DQ/DR was evident in 73.4% of oesophageal intestinal metaplasia tissue as opposed to 18.3% of controls (p<0.001). Importantly, a total loss of HLA-ABC and a concomitant gain of HLA-DP/DQ/DR expression were seen in 37.5% of patients with Barrett's oesophagus but in none of the controls (p<0.001). Interestingly, this phenotype was associated positively with dysplasia (adjusted p, p* = 0.031) but negatively with non-steroidal anti-inflammatory drug use (p* = 0.004).

CONCLUSIONS

HLA class I expression is down regulated and class II expression is up regulated in Barrett's oesophagus. As these changes predate malignant transformation, altered major histocompatibility complex expression may be a key event in disease progression, possibly in facilitating evasion from immune surveillance.

Human leucocyte antigen determinants of susceptibility to Barrett's oesophagus in Asians--a preliminary study

BACKGROUND

Characteristic immune profiles have been demonstrated in gastro-oesophageal reflux disease. However, the genetic basis of gastro-oesophageal reflux disease remains unclear.

AIM

To investigate whether certain human leucocyte antigen genes are associated with Barrett's oesophagus.

METHODS

Asian patients of Malay, Chinese and Indian descent with Barrett's oesophagus (n = 59) and those without reflux symptoms and a normal oesophagus (n =60) were recruited prospectively using endoscopic and histopathological criteria. Human leucocyte antigen class I and II typing was performed using a polymerase chain reaction sequence-specific primers method.

RESULTS

The HLA-B7 allele was present in 17% (10 of 59) of patients with Barrett's oesophagus when compared with 0% (zero of 60) of controls [P = 0.0006, corrected P = 0.0171, OR = 25.67]. Subgroup analysis revealed that the HLA-B7 allele was confined almost exclusively to Indians with Barrett's oesophagus, 43% (nine of 21) vs. 0% (zero of 19) Indian controls (P = 0.0014, corrected P = 0.0406, OR = 29.64). No class II associations, protective human leucocyte antigens or extended haplotypes for disease susceptibility were identified.

CONCLUSIONS

Barrett's oesophagus in Asians, particularly Indians, is strongly positively associated with HLA-B7; reinforcing a genetic component to gastro-oesophageal reflux disease. A larger sample size and different ethnic populations should be genotyped to further confirm this association and identify possible additional risk factors in the human leucocyte antigen locus.

Ulcerative colitis and motor neurone disease: causal or coincidental?

Neurological involvement associated with inflammatory bowel disease is well established though rarely reported in the literature. The coexistence of motor neurone disease with ulcerative colitis has never been previously documented. The case of a 53-year-old Indian male with distal ulcerative colitis who, two and a half years later, developed dysarthria, dysphagia, a wasted fasciculating tongue and palatal palsy characteristic of bulbar type motor neurone disease is described. Topical and oral steroids together with azathioprine and mesalazine suppositories controlled the bowel symptoms but did not improve the neurological deficit. Subsequently, the antiglutamate agent riluzole improved the mobility of his tongue. The close temporal relationship and relative infrequency of both these conditions in a Malaysian population along with the recognised association between ulcerative colitis and other neurological conditions deserve careful consideration as to whether a common denominator is involved. Documentation of coexistence of both disorders in a single patient is important in case similar associations are reported in future.

Very negative potential for half-inactivation of, and effects of anions on, voltage-dependent sodium currents in acutely isolated rat olfactory receptor neurons

Previous measurements with CsF pipette solutions using whole-cell patch-clamp techniques in dissociated rat olfactory receptor neurons (ORNs) indicated that the sodium currents had very negative inactivation characteristics with the implication that the cell resting potential must also normally have a very negative value. This study supports the conclusions that such an effect was real and not dependent on either the nature of the pipette anions or the recording situation previously used. For all pipette solutions, sodium currents showed a threshold activation approximately -80 mV and half-maximal activation voltages approximately -55 with half-inactivation potential < or =-100 mV, without being significantly affected by the replacement of F(-) by other pipette anions (H(2)PO(-)(4) and acetate(-)) or the addition of nucleotides and glutathione (which did cause a very slight positive shift). F(-), followed by H(2)PO(-)(4) and to a much lesser extent by acetate(-), was the most favorable pipette anion for obtaining good seals and whole-cell sodium currents in these extremely small ORNs. These results implied that resting potentials, for viable responsive cells, should be more negative than about -90 mV, as supported by the observation that action potentials could only be evoked from holding potentials more negative than -90 mV.

Identification of intracellular and extracellular domains mediating signal transduction in the inhibitory glycine receptor chloride channel

Fast synaptic neurotransmission is mediated by transmitter-activated conformational changes in ligand-gated ion channel receptors, culminating in opening of the integral ion channel pore. Human hereditary hyperekplexia, or startle disease, is caused by mutations in both the intracellular or extracellular loops flanking the pore-lining M2 domain of the glycine receptor alpha1 subunit. These flanking domains are designated the M1-M2 loop and the M2-M3 loop respectively. We show that four startle disease mutations and six additional alanine substitution mutations distributed throughout both loops result in uncoupling of the ligand binding sites from the channel activation gate. We therefore conclude that the M1-M2 and M2-M3 loops act in parallel to activate the channel. Their locations strongly suggest that they act as hinges governing allosteric control of the M2 domain. As the members of the ligand-gated ion channel superfamily share a common structure, this signal transduction model may apply to all members of this superfamily.

The glycine receptor

The inhibitory glycine receptor (GlyR) is a member of the ligand-gated ion channel receptor superfamily. The GlyR comprises a pentameric complex that forms a chloride-selective transmembrane channel, which is predominantly expressed in the spinal cord and brain stem. We review the pharmacological and physiological properties of the GlyR and relate this information to more recent insights that have been obtained through the cloning and recombinant expression of the GlyR subunits. We also discuss insights into our understanding of GlyR structure and function that have been obtained by the genetic characterisation of various heritable disorders of glycinergic neurotransmission.

The unique extracellular disulfide loop of the glycine receptor is a principal ligand binding element

A loop structure, formed by the putative disulfide bridging of Cys198 and Cys209, is a principal element of the ligand binding site in the glycine receptor (GlyR). Disruption of the loop's tertiary structure by Ser mutations of these Cys residues either prevented receptor assembly on the cell surface, or created receptors unable to be activated by agonists or to bind the competitive antagonist, strychnine. Mutation of residues Lys200, Tyr202 and Thr204 within this loop reduced agonist binding and channel activation sensitivities by up to 55-, 520- and 190-fold, respectively, without altering maximal current sizes, and mutations of Lys200 and Tyr202 abolished strychnine binding to the receptor. Removal of the hydroxyl moiety from Tyr202 by mutation to Phe profoundly reduced agonist sensitivity, whilst removal of the benzene ring abolished strychnine binding, thus demonstrating that Tyr202 is crucial for both agonist and antagonist binding to the GlyR. Tyr202 also influences receptor assembly on the cell surface, with only large chain substitutions (Phe, Leu and Arg, but not Thr, Ser and Ala) forming functional receptors. Our data demonstrate the presence of a second ligand binding site in the GlyR, consistent with the three-loop model of ligand binding to the ligand-gated ion channel superfamily.

Mutations affecting the glycine receptor agonist transduction mechanism convert the competitive antagonist, picrotoxin, into an allosteric potentiator

Contrary to its effects on the gamma-aminobutyric acid type A receptor, picrotoxin antagonism of the alpha 1 subunit of the human glycine receptor is shown to be competitive, not use-dependent, and nonselective between the picrotoxin components, picrotin, and picrotoxinin. Competitive antagonism and non-use dependence are consistent with picrotoxin binding to a site in the extracellular domain. The mutations Arg-->Leu or Arg-->Gln at residue 271 of the glycine receptor alpha 1 subunit, which are both associated with human startle disease, have previously been demonstrated to disrupt the transduction process between agonist binding and channel activation. We show here that these mutations also transform picrotoxin from an allosterically acting competitive antagonist to an allosteric potentiator at low (0.01-3 microM) concentrations and to a noncompetitive antagonist at higher (> or = 3 microM) concentrations. This demonstrates that arginine 271 is involved in the transduction process between picrotoxin binding and its mechanism of action. Thus, the allosteric transduction pathways of both agonists and antagonists converge at a common residue prior to the activation gate of the channel, suggesting that this residue may act as an integration point for information from various extracellular ligand binding sites.

Molecular mechanisms of inherited startle syndromes

Inherited neurological disorders involving an exaggerated startle response to unexpected sensory stimuli have been identified in mice, cows, dogs, horses and humans. Recent studies of the molecular pathology of a number of these startle syndromes have revealed that they are caused by defects in the inhibitory glycinergic pathways that mediate reciprocal and recurrent inhibition in the spinal cord. These defects arise from various mutations of the receptor for glycine, which either impair its sensitivity to agonists or reduce its expression in vivo. The emergent models of the molecular mechanisms that underlie startle disorders illustrate how diverse mutations can converge physiologically to produce a common phenotype.

Mutation of an arginine residue in the human glycine receptor transforms beta-alanine and taurine from agonists into competitive antagonists

Agonist binding to the inhibitory glycine receptor (GlyR) initiates the opening of a chloride-selective channel that modulates the neuronal membrane potential. Point mutations of the GlyR, substituting Arg-271 with either Leu or Gln, have been shown to underlie the inherited neurological disorder startle disease (hyperekplexia). We show that these substitutions result in the redistribution of GlyR single-channel conductances to lower conductance levels. Additionally, the binding of the glycinergic agonists beta-alanine and taurine to mutated GlyRs does not initiate a chloride current, but instead competitively antagonizes currents activated by glycine. These findings are consistent with mutations of Arg-271 resulting in the uncoupling of the agonist binding process from the channel activation mechanism of the receptor.

Startle disease mutations reduce the agonist sensitivity of the human inhibitory glycine receptor

The receptor for the inhibitory neurotransmitter glycine is a member of the ligand-gated ion channel receptor superfamily. Point mutations in the gene encoding the alpha 1 subunit of the glycine receptor-channel complex (GlyR) have recently been identified in pedigrees with the autosomal dominant neurological disorder, startle disease (hyperekplexia). These mutations result in the substitution of leucine or glutamine for arginine 271. This charged residue is located near the ion channel region and is predicted to affect chloride permeation through the GlyR. We found little evidence for this role from the anion/cation selectivity and lack of pronounced rectification of currents flowing through recombinant human alpha 1 subunit GlyRs containing the startle disease mutations. We reveal, however, that the startle disease mutations profoundly disrupt GlyR function by causing 230-410-fold decreases in the sensitivity of receptor currents activated by the agonist glycine. Additionally, we report corresponding 56- and 120-fold reductions in the apparent binding affinity (Ki) of glycine to the mutant GlyRs, but no change in the binding affinity of the competitive antagonist, strychnine. Thus, startle disease reduces the efficacy of glycinergic inhibitory neurotransmission by producing GlyRs with diminished agonist responsiveness. Our results show that startle disease mutations define a novel receptor activation site.

The extracellular disulfide loop motif of the inhibitory glycine receptor does not form the agonist binding site

Inhibitory (glycine and gamma-aminobutyric acid type A) and excitatory (nicotinic acetylcholine and serotonin 5-hydroxytryptamine type 3) receptors of the ligand-gated ion channel superfamily are related by both structural similarities and primary sequence identity. One invariant feature of all members of this receptor superfamily is the presence of an extracellular disulfide loop motif. This structural motif has been modeled, and Cockcroft et al. [Proteins 8:386-397 (1990)] have suggested that it forms the agonist binding site of the ligand-gated ion channel receptors. Using site-directed mutagenesis of the inhibitory glycine receptor (GlyR), we have specifically tested this hypothesis. The lysine residue at position 143 is proposed to form the binding site for the negatively charged carboxyl group of the agonist glycine. Differing residues at this position in other ligand-gated receptors are proposed to confer agonist specificity. The aspartic acid residue at position 148 is an invariant residue in every known subunit of the ligand-gated ion channel receptor superfamily. This residue has been proposed as the binding site for the positively charged amino group of the various agonists. Mutation of the lysine at position 143 to alanine resulted in essentially unaltered GlyRs, showing only modest decreases in strychnine affinity (Kd, 8.1 +/- 1.4 nM versus 13.4 +/- 1.3 nM), glycine displacement of strychnine binding (Ki, 25 +/- 5 microM versus 49 +/- 9 microM), and glycine activation of chloride currents (EC50, 27 +/- 6 microM versus 114 +/- 14 microM). Thus, we conclude that Lys-143 does not play a major role in either agonist or antagonist binding or agonist activation of the GlyR. Mutation of Asp-148 to either alanine or asparagine disrupted the expression and/or assembly of the receptor, and no binding sites or ion channels were expressed on the cell surface. The conservative mutation of the aspartic acid at position 148 to glutamic acid (D148E) allowed the expression of receptors, although with reduced efficiency. The D148E GlyRs showed a 1 order of magnitude decrease in strychnine affinity (Kd, 8.1 +/- 1.4 nM versus 82 +/- 21 nM), without any change in the glycine displacement of strychnine binding (Ki, 25 +/- 5 microM versus 29 +/- 8 microM) or glycine activation of chloride currents (EC50, 27 +/- 6 microM versus 20 +/- 1 microM).(ABSTRACT TRUNCATED AT 400 WORDS)

Modulation of the development of light-initiated asymmetry in chick thalamofugal visual projections by oestradiol

Thalamofugal visual projections of light-incubated chicks are organised asymmetrically. This asymmetry, which is generated by light stimulation of the embryo during the final days of incubation, is sexually dimorphic, being more pronounced in males than in females. We have shown that the development of the asymmetry can be prevented by elevating circulating levels of 17 beta-oestradiol in the embryo prior to hatching. Light-incubated male chicks were treated 5 days prior to hatching with either one of two doses of 17 beta-oestradiol (1.5 mg or 2.5 mg in a 0.1 ml solution of 10% ethanol in olive oil) or the vehicle only. After hatching the retrogradely labelling fluorescent dyes True Blue and Fluorogold were injected into the left and right side of the hyperstriatal region of the forebrain, consequently labelling the cell bodies of thalamic neurons which project to this region. Although a pronounced asymmetry was present in the control group, it was not present in both of the 17 beta-oestradiol-treated groups. These results suggest that the asymmetrical development of thalamofugal visual projections in response to lateralised light stimulation of the embryo is dependent on circulating levels of steroid hormones, and that compared to the male, the lesser degree of asymmetry found in thalamofugal projections of untreated females may be related to the higher levels of circulating oestradiol present in females prior to hatching.

Asymmetry is present in the thalamofugal visual projections of female chicks

Asymmetry of the thalamofugal visual projections of the chick has been previously reported to exist in males but not females. Using a larger sample size and a double-labelling procedure, projections to the visual Wulst were labelled with the retrograde tracers True Blue and Fluoro-gold and the ratio of contralateral projections to ipsilateral projections was calculated. We found that asymmetry does exist in female chicks, but to a lesser degree than in males.

An analysis of Na+ currents in rat olfactory receptor neurons

Na+ currents were observed in acutely-dissociated adult rat olfactory receptor neurons using the whole-cell recording techniques. The threshold for current activation was near -70 mV and currents were fully activated by -10 mV (midpoint: -45 mV). Steady-state inactivation was complete at potentials more positive than -70 mV and half complete at -110 mV (+/- less than 1, n = 8). Complete recovery from inactivation required one second at -100 mV (n = 7). The addition of 10 microM tetrodotoxin or 1 mM Zn2+ to the external solution was required to completely block the current. The current differs from those in amphibian and cultured neonatal rat olfactory neurons in its unusually negative voltage-dependence and slow recovery. Since mammalian olfactory neurons have very high input resistances, physiological resting potentials cannot usually be measured using whole-cell recording techniques. However, predominantly-capacitatively-coupled spikes activated by depolarisation were frequently observed in cell-attached patches. This indicates that the cells were excitable and implies that they must have had resting potentials more negative than -90 mV in order for this current to underlie the action potential.

Prediction of response to tricyclic antidepressants with a single injection of methyleamphetamine

Twenty five patients of endogenous depression fulfilling Feighner's criteria were selected for this study. It was found that the patients who improved with methylamphetamine responded to imipramine and those who did not improve with methylamphetamine improved with amitriptyline.