35 Characterization of the promoter region of ZNFO, an oocyte-specific gene in cattle

Maternal factors are essential aspects of oocyte competence, which orchestrate early embryonic development. ZNFO is a Krüppel-associated box domain (KRAB) containing zinc finger transcription factor, which is exclusively expressed in bovine oocyte. Previous studies have demonstrated that ZNFO is essential for early embryonic development. However, the mechanisms regulating ZNFO transcription remain elusive. The objective of present study is to elucidate regulatory mechanisms of ZNFO transcription invitro, and specifically to identify putative core promoter and transcription factor(s) regulating ZNFO expression. 5′ Random amplification of cDNA ends (RACE) was performed using RNA isolated from 100 germinal vesicle (GV) stage oocytes to identify the transcription start site (TSS) of ZNFO. To elucidate the molecular mechanisms of ZNFO transcription, a 1.7-kb fragment of the 5′ regulatory region was obtained and cloned into pGL4.14 promoterless vector. The luciferase reporter assay was performed to confirm the promoter activity of the regulatory region. To further identify the core promoter region of the putative ZNFO promoter, a series of 5′ deletions in the ZNFO promoter followed by luciferase reporter assay was performed. The luciferase results indicated that the core promoter region of ZNFO was located within a region 57 to 31bp upstream of the transcription start site. Bioinformatics analysis indicated that a putative USF1/USF2 binding site (GGTCTCGTGACC) is located within the core promoter region. USF1 is a basic helix–loop–helix leucine zipper transcription factor, which regulates the expression of various maternal genes, which are essential for oocyte maturation and early embryonic development in cattle. To confirm that USF1 regulated ZNFO expression, bovine USF1 open reading frame (ORF) was cloned into pcDNA3.1A-HA vector, generating a USF1 overexpression construct. Overexpression of USF1 by transfecting USF1 plasmid enhanced ZNFO promoter activity within HEK293 cells, confirming that ZNFO expression is regulated by USF1. From these results, we conclude that USF1 activates the ZNFO promoter by binding to its target site, GGTCTCGTGACC.

84 Characterization of agouti-signalling protein expression within the bovine ovary and early embryo

Factors present in the oocyte and surrounding follicular cells aid in the attainment of oocyte competence. Agouti-signalling protein (ASIP) is a known regulator of melanocyte function through binding to melanocortin receptors including MC1R and MC4R. Additionally, ASIP has been classified as an adipokine due to a link with insulin resistance and obesity in humans. In mice, expression is limited to hair follicles where ASIP regulates hair pigmentation. In cattle, however, ASIP mRNA has been detected in a variety of tissues, including adipose, skin, heart, testis, and the ovary. Despite ovarian expression, the role of ASIP in reproduction remains undetermined. Bovine ASIP is a secreted protein consisting of 133 amino acids. The aim of this experiment was to provide a detailed description of the ASIP expression profile within the bovine ovary and during early embryonic development. Reverse transcription PCR (RT-PCR) was conducted to analyse ASIP, MC1R, and MC4R mRNA expression. Samples examined included fetal ovaries from gestational day 90 to 250, adult ovary, fetal testis, adult testis, and 12 somatic tissues including adrenal, cerebral cortex, gut, heart, intestine, kidney, liver, lung, muscle, pituitary, stomach, and thymus. Amplification of ribosomal protein L19 (RPL19) served as a positive control for all samples. Expression of ASIP was detected in the fetal testis, 9 somatic tissues, and the fetal and adult ovary. In the fetal ovary, ASIP was detected as early as 90 days of gestation and continued throughout gestation. Expression of the ASIP receptors, MC1R and MC4R, were detected exclusively in the fetal ovary. To further characterise ASIP expression, quantitative real-time PCR (RT-qPCR) was utilised to examine samples including germinal vesicle and MII oocytes (pool of 10 oocytes), invitro-produced embryos ranging from the 2-cell to blastocyst stages (pool of 10 embryos), and cumulus and granulosa cells collected from a pool from 5 cumulus–oocyte complexes (COCs) and follicles, respectively. Theca cells from a single follicle were analysed. Samples with cycle threshold values below 35 were considered to express the gene of interest. Of the follicular cells examined, ASIP expression was present in theca, granulosa, and cumulus cells. ASIP expression was detected in both GV and MII oocytes. Early embryonic expression of ASIP was detected in the 2-cell embryo and continued to the blastocyst stage of development. In conclusion, ASIP is present in the bovine adult and fetal ovary, follicular cells including cumulus, granulosa, and theca cells, GV and MII oocytes, and invitro-produced embryos from the 2-cell to blastocyst stages. Future research will focus on identifying the function of ovarian and early embryonic ASIP in cattle.

135 Differential gene expression of bovine long noncoding RNAs in single oocytes aspirated from small and large follicles

In mammals, maternal mRNAs accumulate in the oocyte and play important roles during early embryogenesis in embryonic genome activation. Proper development is dependent upon regulation of these maternal transcripts while simultaneously activating the embryonic genome. Long noncoding RNAs (lncRNAs) regulate various cellular processes, including modulation of gene expression and epigenetic status. Recently, lncRNAs have been functionally characterised as key regulators of embryonic genome activation in humans and mice. Our laboratory identified 1535 lncRNAs in bovine oocytes using RNA-sequencing. The objective of this study was to verify our RNA-seq data and if present, characterise the expression of six highly abundant lncRNAs (2160.1, 5379.1, 18208.1, 23721, 25823.1, and 34876.2) in single oocytes aspirated from varying size follicles at different developmental stages. Single oocytes were aspirated from small (<4mm) and presumably oestrogen active (6–18mm) follicles and were denuded at the germinal vesicle (GV) or MII stage. MII stage was determined by cumulus expansion and the extrusion of the first polar body. Real-time quantitative PCR analysis, using RPL-19 as a housekeeping gene analysed using the standard curve method, revealed detectable expression for each lncRNA in single oocytes from small (SF) and presumably oestrogen active (EA) follicles at both stages. Average expression of each lncRNA from SF was used as a calibrator in normalization. Effect of follicle size and maturity stage and their interaction on the lncRNA expression were examined using a two-factorial ANOVA followed by Tukey’s HSD post hoc test. In five lncRNAs (2160.1, 5379.1, 18208.1, 25823.1, and 34876.2), maturity stage was significant (P<0.05). Moreover, we found significant interaction of stage and size in expression of lncRNA 25823.1 (P<0.05). SF oocytes at the GV stage had the highest relative expression of lncRNA 25823.1. Specific differences were detected between SF MII and SF GV oocytes, indicating higher expression in the earlier developmental stage (P<0.05). The SF oocytes at MII had a 0.63-fold decrease in relative expression with respect to the SF oocytes at GV. In addition, we found a tendency for significant interaction between maturity stage and follicle size in the expression of lncRNA 5379.1 (P<0.1). LncRNA 5379.1 exhibited the same expression pattern as lncRNA 25823.1 with SF oocytes at MII having a 0.75-fold decrease in relative expression relative to SF oocytes at GV. In summary, both lncRNA 25823.1 and 5379.1 had higher expression in oocytes aspirated from small follicles during the earlier developmental stage. The literature indicates that follicle size can be an indicator of oocyte quality and that RNAs accumulated or degraded during maturation are crucial to achieve developmental competence. Therefore, lncRNAs 25823.1 and 5379.1 shows promise to be linked with oocyte quality.

AN EXPERIMENTAL STUDY OF OXALURIA, WITH SPECIAL REFERENCE TO ITS FERMENTATIVE ORIGIN

1. As varying amounts of calcium oxalate may be held in solution in the urine, conclusions based upon the presence or number of calcium oxalate crystals found therein are of no real value as an indication of the quantity of oxalic acid present. 2. Unless the utmost care is exercised, the results obtained by quantitative estimation of oxalic acid are subject to large percentages of error. This is especially true in the use of Neubauer's or Shultzen's methods, in which the calcium oxalate is precipitated in an alkaline solution. 3. An ordinary mixed diet regularly contains traces of oxalic acid or its salts. 4. A portion of the oxalic acid ingested with the food may be absorbed and reappear unchanged in the urine. 5. The normal daily excretion of oxalic acid in the urine fluctuates with the amount taken in the food, and varies from a few milligrammes to two or three centigrammes, being usually below ten milligrammes. 6. In health, no oxalic acid, or only a trace, is formed in the body, but that present in the urine has been ingested with the food. 7. In certain clinical disturbances which in some of the cases studied above were associated with absence of free hydrochloric acid from the gastric juice, oxalic acid is formed in the organism. 8. This formation in the organism is connected with fermentative activity in the alimentary canal. (a) The prolonged feeding of dogs with excessive quantities of glucose, together with meat, leads eventually to a state of oxaluria. (6) This experimental oxaluria is associated with a mucous gastritis, and with absence of free hydrochloric acid in the gastric contents. (c) The oxaluria and the accompanying gastritis are referable to fermentation induced by the excessive feeding with sugar. (d) The experimental gastritis from fermentation is associated with the formation of oxalic acid in the gastric contents. 9. The symptoms attributed to an oxalic acid diathesis, with the exception of those due to local irritation in the genitourinary tract, do not appear to be due to the presence in the system of soluble oxalates, but are more likely to depend on other products of fermentation and putrefaction.

Developmental modulation of immunity: changes within the feeding period of the fifth larval stage in the defence reactions of Manduca sexta to infection by Photorhabdus

In insect pathogen interactions, host developmental stage is among several factors that influence the induction of immune responses. Here, we show that the effectiveness of immune reactions to a pathogen can vary markedly within a single larval stage. Pre-wandering fifth-stage (day 5) larvae of the model lepidopteran insect Manduca sexta succumb faster to infection by the insect pathogenic bacterium Photorhabdus luminescens than newly ecdysed fifth-stage (day 0) caterpillars. The decrease in insect survival of the older larvae is associated with a reduction in both humoral and cellular defence reactions compared to less developed larvae. We present evidence that older fifth-stage larvae are less able to over-transcribe microbial pattern recognition protein and antibacterial effector genes in the fat body and hemocytes. Additionally, older larvae show reduced levels of phenoloxidase (PO) activity in the cell-free hemolymph plasma as well as a dramatic decrease in the number of circulating hemocytes, reduced ability to phagocytose bacteria and fewer melanotic nodules in the infected tissues. The decline in overall immune function of older fifth-stage larvae is reflected by higher bacterial growth in the hemolymph and increased colonization of Photorhabdus on the basal surface of the insect gut. We suggest that developmentally programmed variation in immune competence may have important implications for studies of ecological immunity.

The role of corticotropin-releasing factor in behavioural responses to stress

Corticotropin-releasing factor (CRF), when administered directly into the CNS, can have activating properties on behaviour and can enhance behavioural responses to stress. CRF injected intraventricularly produces a dose-dependent increase in locomotor activity and increased responsiveness to an acoustic startle stimulus. However, this profile of activation changes to enhanced suppression of behaviour in stressful situations and includes increased freezing, increased conditioned suppression, increased conflict, decreased feeding and decreased behaviour in a novel open field. These effects of CRF are independent of the pituitary-adrenal axis and can be reversed by the CRF antagonist alpha-helical CRF(9-41). More importantly, the CRF antagonist can also reverse many behavioural responses to stressors. alpha-Helical CRF(9-41) reverses stress-induced fighting behaviour, stress-induced freezing, stress-induced suppression of feeding, stress-induced decreases in exploration of an elevated plus maze, fear-potentiated startle and the development of conditioned suppression. Intracerebral microinjections suggest that the amygdala may be an important site for the anti-stress effects of alpha-helical CRF(9-41). These results suggest that endogenous CRF systems in the CNS may have a role in mediating behavioural responses to stress and further suggest that CRF in the brain may function as a fundamental behavioural activating system. This CRF system may be particularly important in situations where an organism must mobilize not only the pituitary-adrenal system but also the CNS in response to environmental challenge.

Rescuing the N-cadherin knockout by cardiac-specific expression of N- or E-cadherin

Cell-cell adhesion mediated by some members of the cadherin family is essential for embryonic survival. The N-cadherin-null embryo dies during mid-gestation, with multiple developmental defects. We show that N-cadherin-null embryos expressing cadherins using muscle-specific promoters, alpha- or beta-myosin heavy chain, are partially rescued. Somewhat surprisingly, either N-cadherin or E-cadherin was effective in rescuing the embryos. The rescued embryos exhibited an increased number of somites, branchial arches and the presence of forelimb buds; however, in contrast, brain development was severely impaired. In rescued animals, the aberrant yolk sac morphology seen in N-cadherin-null embryos was corrected, demonstrating that this phenotype was secondary to the cardiac defect. Dye injection studies and analysis of chimeric animals that have both wild-type and N-cadherin-null cells support the conclusion that obstruction of the cardiac outflow tract represents a major defect that is likely to be the primary cause of pericardial swelling seen in null embryos. Although rescued embryos were more developed than null embryos, they were smaller than wild-type embryos, even though the integrity of the cardiovascular system appeared normal. The smaller size of rescued embryos may be due, at least in part, to increased apoptosis observed in tissues not rescued by transgene expression, indicating that N-cadherin-mediated cell adhesion provides an essential survival signal for embryonic cells. Our data provide in vivo evidence that cadherin adhesion is essential for cell survival and for normal heart development. Our data also show that E-cadherin can functionally substitute for N-cadherin during cardiogenesis, suggesting a critical role for cadherin-mediated cell-cell adhesion, but not cadherin family member-specific signaling, at the looping stage of heart development.

Hyperopic photorefractive keratectomy with the erodible mask and axicon system: two year follow-up

PURPOSE

To evaluate efficacy and long-term stability of hyperopic photorefractive keratectomy (H-PRK) using the erodible mask and Axicon system.

SETTING

Department of Ophthalmology, St. Thomas' Hospital, London, England.

METHODS

Forty-three patients (43 eyes), with a mean preoperative refraction (spherical equivalent) of +4.54 diopters (D) (range +1.75 to +7.50 D), were treated using an Apex Plus(R) excimer laser (Summit Technology). This uses an erodible mask to ablate a 6. 50 mm diameter hyperopic correction and an Axicon to fashion a 1.50 mm blend zone around the correction. The overall ablation diameter was 9.50 mm. Follow-up was 2 years.

RESULTS

At 2 years, the mean manifest refraction was +0.16 D (range +4.125 to -4.000 D), with the induced correction appearing stable after 9 months. Based on the Munnerlyn algorithm, predictability was acceptable for corrections up to +4.50 D, with 68% of eyes within +/-1.00 D of the predicted correction. It was poorer for +6.00 D corrections, with 33% of eyes within +/-1.00 D of that expected. Patient satisfaction was high. Forty eyes (93%) had an improvement in uncorrected near visual acuity and 37 (86%), an improvement in uncorrected distance acuity. A peripheral ring of haze, 6.5 mm in diameter, appeared in all eyes 1 month postoperatively. Its intensity was maximal at 3 to 9 months and then diminished over time. There were no significant differences in measurements of the central corneal transparency at 12 and 24 months and those preoperatively. Measurements of flicker contrast sensitivity, forward light scatter (glare), and scotopic halos showed no significant differences between preoperative values and those measured after 6 months.

CONCLUSIONS

Achieved H-PRK corrections with the erodible mask and Axicon system agreed closely with the Munnerlyn algorithm, with refractive stability after 9 months. Predictability was acceptable for corrections up to +4.50 D. Axial corneal transparency was not compromised and visual performance, in terms of best spectacle-corrected visual acuity, forward light scatter, and night halos, was not impaired.

Temporally regulated expression patterns following in utero adenovirus-mediated gene transfer

Developmental patterns of gene expression were determined following intravascular administration of adenovirus in utero, during sequential stages of murine development. Replication-deficient adenovirus (AdCMV.LacZ) was injected into yolk sac vessels of mouse embryos 12, 13, 15 and 18 days post-conception (d.p.c.). beta-Galactosidase (beta-gal) expression was evaluated 24-48 h after injection, at birth, and 5 weeks following normal delivery. Gene expression was detected in myocardial cells, endothelial cells of heart, lung, kidney, adrenal, gut, and in hepatocytes. The patterns of expression were distinct for each stage of virus administration and time-point of analysis. Intensity of individual organ expression varied with injection time-point, with the largest number of organs express- ing the transgene when embryos were injected at 15 d.p.c. beta-Gal activity was detected in only a subset of cells expressing the murine coxsackievirus and adenovirus receptor (CAR), indicating factors other than receptor distribution were responsible for the pattern of transgene expression observed. These studies begin to define critical parameters affecting intravascular gene delivery in utero and indicate that intrinsic developmental regulatory mechanisms may control exogenous gene expression. Intravenous administration of adenovirus provides a unique approach for in utero gene transduction and will be a useful adjunct in evaluating genes which have early lethal mutations.

Finasteride in the treatment of men with frontal male pattern hair loss

BACKGROUND

Finasteride, a specific inhibitor of type II 5alpha-reductase, decreases serum and scalp dihydrotestosterone and has been shown to be effective in men with vertex male pattern hair loss.

OBJECTIVE

This study evaluated the efficacy of finasteride 1 mg/day in men with frontal (anterior/mid) scalp hair thinning.

METHODS

This was a 1-year, double-blind, placebo-controlled study followed by a 1-year open extension. Efficacy was assessed by hair counts (1 cm2 circular area), patient and investigator assessments, and global photographic review.

RESULTS

There was a significant increase in hair count in the frontal scalp of finasteride-treated patients (P < .001), as well as significant improvements in patient, investigator, and global photographic assessments. Efficacy was maintained or improved throughout the second year of the study. Finasteride was generally well tolerated.

CONCLUSION

In men with hair loss in the anterior/mid area of the scalp, finasteride 1 mg/day slowed hair loss and increased hair growth.

Mast cells in pathological and surgical scars

AIM

To investigate the role of mast cells in surgical and pathological scar reactions by their identification and quantification using immunohistochemistry.

METHODS

Surgical scars and pathological scar reactions were stained immunohistochemically for tryptase to identify mast cells. These were quantified in the scar tissue and surrounding dermis. Statistical analyses were performed to test the hypothesis that mast cell numbers were different in the varying types of scar reaction.

RESULTS

A significant difference was found between the mean number of mast cells in periocular scars compared with keloids, hypertrophic scars, and surgical scars from other sites (p < 0.05). No significant difference was found in mast cell numbers between the other scar types either within the lesions or surrounding dermis. There were significantly more mast cells in the dermis than in the scar tissue itself, except for the small group of periocular scars. The ratio of mast cells in the lesion compared with the dermis was not significantly different between the scar types, except for the periocular scars.

CONCLUSIONS

Mast cell numbers are similar in and around keloid, hypertrophic, and surgical scars. The increased number of mast cells at periocular scar sites was contrary to expectation since keloids are rare at this site. Absolute mast cell numbers may not be an accurate measure of tissue concentrations of active mast cell products. Further comparisons between immunological characteristics of keloid and periocular scars may elucidate specific immunological abnormalities of keloid scars, and this has implications for the development of immunotherapy.

The role of corticotropin-releasing factor in the anxiogenic effects of ethanol withdrawal

In summary, endogenous CRF has been demonstrated to play an important role in the endocrine but also autonomic and behavioral responses to a stressor and to mediate some of the signs and symptoms observed in human affective and anxiety disorders. These findings led to the hypothesis that the anxiety that characterizes drug withdrawal, such as ethanol withdrawal in humans, may be related in part to the action of CRF-producing neurons in the CNS. Indeed, rats made dependent on an ethanol liquid diet showed significant signs of enhanced stress responsiveness that was blocked by intracerebral administration of a CRF antagonist. At this time little is known about the specific site of action for endogenous CRF. However, recent studies using local administration of CRF antagonist and in vivo CRF microdialysis suggest that the central nucleus of the amygdala may be an important site for the increases in CRF activity associated with the anxiogenic effects of ethanol withdrawal. Although preliminary, these results propound that ethanol dependence may involve a prolonged dysregulation of the CRF system in the basal forebrain that may contribute to the increased motivational effect of ethanol withdrawal.

Relapsing polychondritis: case report and review of the literature

A 65-year-old man who experienced the acute onset of pain, redness, and swelling of his right ear was treated with antibiotics for erysipelas. Subsequently, the other ear and both eyes became inflammed. Relapsing polychondritis was diagnosed and treatment with prednisone was successful. Relapsing polychondritis, a rare multisystem disease, presents most commonly with auricular chondritis. Other clinical manifestations include arthritis, nasal chondritis, scleritis, damage to tracheal and bronchial cartilage, and aortic, cardiac, and renal involvement. The cause is autoimmune. Recurrent episodes of progressive inflammation result in destruction of cartilage. Treatment consists of administration of corticosteroids and other anti-inflammatory and immunosuppressive drugs.

High plasma vitamin C associated with high plasma HDL- and HDL2 cholesterol

High plasma vitamin C may lower risk of cardiovascular disease as indicated by direct association with plasma high-density-lipoprotein (HDL) cholesterol and HDL2 cholesterol. Plasma lipids and vitamin C were determined in 316 women and 511 men (aged 19-95 y). After adjustment for age, sex, obesity, and smoking, plasma vitamin C was directly associated with HDL- (P = 0.01) and HDL2 cholesterol (P = 0.0002). When men and women with diseases that might affect lipids were excluded, associations between plasma vitamin C and HDL- and HDL2 cholesterol persisted, though the relationships were strongest in older men. Comparisons of diets in a subset (n = 485) who completed 7-d diet records were made. Total fat, saturated fatty acids, energy from fat, and cholesterol intakes were not associated with plasma vitamin C. Mean intakes of vitamin C were well above recommended dietary allowances. These findings suggest that high plasma concentrations of vitamin C may lower atherogenic risk.

Long-term longitudinal measurements of plasma dehydroepiandrosterone sulfate in normal men

Dehydroepiandrosterone sulfate (DS) was measured by direct tritium RIA in longitudinal plasma specimens from 97 normal healthy male participants in the Baltimore Longitudinal Study of Aging. Fasting blood was collected at regular visits (approximately 1.5 yr apart) over an average 13 yr of adulthood (cumulative age range: 32-83 yr). DS was measured in 3-4 widely spaced specimens from each subject. A decline in DS was found in 65 (67%) subjects, 13 subjects (13%) showed no change, and increases were found in the 19 remaining subjects during the study period. A plot of individual data points revealed the same pattern we had obtained previously from a cross-sectional study of a different normal male population. A plot of DS values vs. age among subjects whose DS increased during the study also revealed an age-related decline. Thus, the longitudinal decrease in circulating DS, long inferred from cross-sectional data, is confirmed for normal men in the present study. A more detailed study of every specimen collected during the study period from 12 of the Baltimore Longitudinal Study of Aging subjects (4 whose values tended to be low, 4 whose values tended to be high, and 4 whose values were near the mean) failed to reveal any patterns of variation that could be correlated with changes in life circumstances, health status, or any other discernible factors. Hence, the wide variability seen in DS among individuals within normal populations remains unexplained.

Anxiolytic activity of steroid anesthetic alphaxalone

The synthetic steroid anesthetic alphaxalone (3 alpha-hydroxy-5 alpha-pregnane-11,20-dione) was studied in two behavioral paradigms known to be sensitive to anxiolytic drugs. In an elevated plus maze, alphaxalone produced an anxiolytic profile, significantly increasing the percentage of entries made into the open arms as well as the percentage of time spent on the open arms. In the conflict test, alphaxalone (6 and 8 mg/kg) produced a significant dose-dependent increase in punished responding and a decrease (8 mg/kg) in unpunished responding. The pattern of responding was similar to that observed with the benzodiazepine agonist chlordiazepoxide (2-8 mg/kg). The increase in punished responding was not altered by the benzodiazepine antagonist Ro 15-1788 and only partially blocked by the picrotoxinin receptor ligand isopropylbicyclophospate (10 and 15 micrograms/kg). The gamma-aminobutyric acid agonists picrotoxin (1 mg/kg) and bicuculline (1 mg/kg) also failed to suppress the rate-increasing effects of alphaxalone in the conflict test. Chronic administration of alphaxalone for 1 week produced no tolerance to the anxiolytic behavioral effects. In addition, no changes in pain threshold were noted with alphaxalone (8 mg/kg) in the tail-flick analgesia test. These results suggest that the pharmacologic substrates for the anxiolytic actions of alphaxalone may be independent of either the benzodiazepine or picrotoxinin binding sites of the gamma-aminobutyric acid/benzodiazepine receptor complex.

Gadolinium-DTPA enhancement of a recurrent intramedullary ependymoma: a case report

Magnetic resonance images enhanced with the paramagnetic contrast agent gadolinium-DTPA accurately differentiated a recurrent intramedullary spinal cord ependymoma from surrounding postoperative and postirradiation spinal cord tissue changes, thereby facilitating total excision of the lesion. The illustrative case and the merits of enhanced magnetic resonance imaging are presented.

Combined trimipramine/phenelzine treatment of depression: case report

Trimipramine was found safe, effective, and free of complications when used in combination with the MAOI phenelzine in the treatment of a case of refractory depression. Trimipramine co-administration with phenelzine may be an efficacious alternative pharmacotherapy for selected cases when synergistic antidepressant therapies are indicated.