Design cas témoins apparié sur score de risque : un outil méthodologique original pour une étude de l'efficacité vaccinale et des conséquences médicales de l'hospitalisation pour COVID-19 en France

Introduction

L’étude de l'efficacité vaccinale d'une part, et des conséquences médicales du COVID-19 d'autre part, nécessitent généralement la mise en place de deux designs spécifiques. La construction d'un cas témoins apparié sur un score de risque d'hospitalisation pour COVID-19 est un design original visant à répondre à ces deux objectifs.

Méthodes

A partir des données du Système national des données de santé (SNDS), nous avons construit pour les 67 millions de résidents, un score individuel de risque d'hospitalisation pour COVID-19 à partir d'un modèle de Cox prenant en compte l’âge, le genre, la région, l'indice de défavorisation, 50 facteurs de risque médicaux, et la prise d'immunosuppresseurs ou de corticoïdes. Ce score a été discrétisé en 20 classes de même effectif, basées sur la répartition de ce score chez les cas d'hospitalisation pour COVID-19 survenus entre le 01/06/2022 et le 15/10/2022. Chaque cas d'hospitalisation a ensuite été apparié sur l'année de naissance, le genre, le département et sa tranche de score de risque, à 1-10 témoins non hospitalisés pour COVID-19. Le schéma vaccinal (base SI-VAC) et les résultats des tests (SI-DEP), ont été chainés.

Résultats

La quasi-totalité des 39 059 cas a pu être appariée à ≥1 individu non hospitalisé comparables en termes de facteurs médicaux: respectivement 24 % versus 25 % de diabète, 19 % de maladies respiratoires chroniques, 65% d'hypertension artérielle et 1 % de cancer du poumon dans les deux groupes, etc. L'administration d'une dose additionnelle de vaccin (3e ou 4e dose) comparativement à des patients vaccinés ne bénéficiant pas de cette dose additionnelle, non récemment infectés, permettait de réduire de 50 % le risque d'hospitalisation sur une durée de 4 mois.

Discussion/Conclusion

L'appariement sur le score de risque a permis de prendre en compte un grand nombre de facteurs de confusion. A partir de ce design original, nous avons pu étudier l'efficacité vaccinale et nous étudierons lors d'un suivi longitudinal les conséquences médicales de l'hospitalisation pour COVID-19 dans un contexte de prédominance du sous-lignage BA5 du variant Omicron.

Mots-clés

Covid-19 ; Score de risque ; Vaccination ; Efficacité ; SNDS

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Caractéristiques sociodémographiques et médicales associées au risque d’échec d'un schéma vaccinal deux doses contre la COVID-19 en France

Contexte

Bien qu'il ait été démontré une efficacité majeure des vaccins contre la COVID-19 pour prévenir les formes sévères de la maladie, il se pose la question d'une meilleure compréhension des facteurs de risque d'échec des vaccins.

Objectif

Identifier les caractéristiques sociodémographiques et médicales associées au risque d'hospitalisation et/ou de décès hospitalier pour COVID-19 en France après un schéma vaccinal complet.

Méthodes

L'étude porte sur les données de la base nationale de vaccination COVID-19 VAC-SI couplées au Système national des données de santé (SNDS). L'ensemble des personnes présentant un schéma vaccinal complet en France au 31 juillet 2021 de deux injections vaccinales par mRNA BNT162b2 (Pfizer©), mRNA-1273 (Moderna©), ou ChAdOx1 nCoV-19 (Astrazeneca©), ou d'une unique injection lors d'un diagnostic d'infection préalable au SARS-COV-2, ont été incluses et suivies jusqu'au 31 août 2021. Des modèles de Cox ont été utilisés pour estimer les Hasards Ratios ajustés (HRa) d'hospitalisation et de décès hospitalier pour COVID-19 associés à l'âge, au sexe, à l'indice de défavorisation sociale, aux comorbidités et à la prise de traitements immunosuppresseurs ou de corticoïdes oraux 14 jours après un schéma vaccinal complet.

Résultats

Un total de 28 031 641 personnes avec un schéma vaccinal complet ont été incluses et suivies pendant en moyenne 80 jours (médiane de 67 jours, IQR 48-105). Au cours de ce suivi, 5 345 (19 pour 100 000) ont été hospitalisées et 996 (4 pour 100 000) sont décédées à l'hôpital pour COVID-19. Dans cette population de sujets vaccinés, les risques respectifs d'hospitalisation et de décès hospitalier pour COVID-19 étaient associés à l'âge (85-89 ans versus 45-54 ans : HRa 4,0 [3,5- 4,7] et HRa 38 [19-75]), au genre masculin (HRa 1,6 [1,5-1,7] et HRa 2,0 [1,7-2,3]) et au niveau de défavorisation sociale (communes les plus défavorisées vs les plus favorisées : HRa 1,3 [1,2-1,4] et HRa 1,5 [1,2-1,9]). Les 47 affections chroniques testées étaient positivement associées à des risques accrus à l'exception de la dyslipidémie. Les associations les plus fortes étaient retrouvées pour la transplantation rénale (HRa 32 [28-37] et 34 [24-47]), la transplantation du poumon (HRa 14 [8,1-23] et 11 [1,5-88]), l'insuffisance rénale en dialyse (HRa 7,0 [5,9-8,2] et HRa 8,6 [6,3-12]), la trisomie 21 (HRa 3,9 [2,1- 7,3] et 45 [16-127]), le retard mental (HRa 3,6 [2,5-5,0] et 3,1 [1,0-10]) et le cancer actif du poumon (HRa 3,5 [2,7-4,4] et 6,5 [4,2-10]). Les risques étaient également augmentés chez les personnes vaccinées traitées par immunosuppresseurs (HRa 3,3 [2,8-3,8] et 2,4 [1,7-3,5]) ou corticoïdes oraux (HRa 2,8 [2,5-3,1] et 4,1 [3,3-5,1]). Moins de 10 % des personnes hospitalisées et 2 % des personnes décédées à l'hôpital ne présentaient aucune comorbidité. Après ajustement, les risques d'hospitalisation et de décès hospitalier augmentaient fortement avec le nombre de comorbidités, atteignant chez les personnes présentant au moins 5 comorbidités des risques multipliés par 10 (HRa 10 [9,0- 11]) et 18 (HRa 18 [11- 27]) respectivement.

Conclusion

Bien que la vaccination ait très fortement réduit la fréquence des formes sévères de COVID-19, un risque résiduel persistait en particulier dans les populations âgées, immunodéprimées et/ou polypathologiques. Des mesures de prévention complémentaires (gestes barrières) restent nécessaires pour réduire le risque résiduel de formes sévères de COVID-19.

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Morphometric Analysis of Platelets in Bernard-Soulier Syndrome: Size and Configuration in Patients and Carriers

Quantitative ultrastructural morphometric analysis has been carried out on thin sections of platelets from two Bernard-Soulier sisters and their parents. Measurements were made for the major and minor axes, axial ratios, cross-sectional circumference and cross-sectional area. Platelets were collected either into CPD anticoagulant or directly into glutaraldehyde. The results confirm that Bemard-Soulier platelets are significantly larger than normals (p <0.05) in all the parameters mentioned and indicate (I) that the morphology of platelets from Bernard-Soulier patients is affected by the presence of anticoagulant, and (II) a more spherocytic configuration is characteristic of Bemard-Soulier disease both in patients and carriers.

Characterization of MENX-associated pituitary tumours

AIMS

The aim of this study is to evaluate the pathological features, serum hormone levels and ex vivo cultures of pituitary adenomas that occur in rats affected by MENX syndrome. MENX is multiple endocrine neoplasia syndrome caused by a germline mutation in the cell cycle inhibitor p27. Characterization of MENX adenomas is a prerequisite to exploit this animal model for molecular and translational studies of pituitary adenomas.

METHODS

We investigated MENX pituitary adenomas with immunohistochemistry, double immunofluorescence, electron microscopy, reverse transcription polymerase chain reaction (RT-PCR), measurement of serum hormone levels and ex vivo cultures.

RESULTS

Adenomas in MENX rats belong to the gonadotroph lineage. They start from 4 months of age as multiple neoplastic nodules and progress to become large lesions that efface the gland. Adenomas are composed of chromophobic cells predominantly expressing the glycoprotein alpha-subunit (αGSU). They show mitotic activity and high Ki67 labelling. A few neoplastic cells co-express gonadotropins and the transcription factor steroidogenic factor 1, together with growth hormone or prolactin and Pit-1, suggesting that they are not fully committed to one cell lineage. Ex vivo cultures show features similar to the primary tumour.

CONCLUSIONS

Our results suggest that p27 function is critical to regulate gonadotroph cells growth. The MENX syndrome represents a unique model to elucidate the physiological and molecular mechanisms mediating the pathogenesis of gonadotroph adenomas.

Phenotypic homogeneity and genotypic variability in a large series of congenital isolated ACTH-deficiency patients with TPIT gene mutations

CONTEXT

Congenital isolated ACTH deficiency (IAD) is a rare disease characterized by low plasma ACTH and cortisol levels and preservation of all other pituitary hormones. This condition was poorly defined before we identified TPIT, a T-box transcription factor with a specific role in differentiation of the corticotroph lineage in mice and humans, as its principal molecular cause.

OBJECTIVE

We have enlarged our series of IAD patients to better characterize the phenotype and the genotype of this rare disease.

DESIGN

Each exon of the TPIT gene was amplified and sequenced in IAD patients without any identified cause. A functional analysis of each new TPIT mutation was performed.

RESULTS

We described the largest series of 91 IAD patients and identified three distinct groups: neonatal onset complete or partial IAD or late onset IAD. We did not identify any TPIT mutation in patients with partial or late-onset IAD. However, we found a TPIT mutation in 65% of patients with neonatal-onset complete IAD. These patients are homozygous or compound heterozygous for TPIT mutations, and their parents are healthy heterozygous carriers. We identified nine new mutations: four missense, one one-nucleotide deletion, three splice-site mutations, and one large deletion. TPIT mutations lead to loss of function by different mechanisms, such as non-sense-mediated mRNA decay, abnormal mRNA splicing, loss of TPIT DNA binding or protein-protein interaction defects.

CONCLUSION

TPIT mutations are responsible for two thirds of neonatal-onset complete IAD but can not be detected in partial or late-onset IAD.

Expression and mutation analysis of Tpit in the canine pituitary gland and corticotroph adenomas

Pituitary-dependent hyperadrenocorticism (PDH) in dogs is caused by a pituitary corticotroph adenoma. Although PDH is a common disorder in dogs, little is known about the underlying pathogenesis. In the pituitary glands of humans and mice, the pro-opiomelanocortin (POMC)-expressing cell lineages, the corticotrophs and melanotrophs, have a specific marker in common, the T-box transcription factor Tpit (Tbx19), which is obligate for POMC expression. Tpit also regulates the late differentiation of the corticotrophs and melanotrophs, and therefore may contribute to the pathogenesis of the corticotroph adenomas. The aim of this study was to perform an expression and mutation analysis of Tpit in the normal canine pituitary and in corticotroph adenomas. The distribution of the Tpit protein in the pituitary gland was studied with immunohistochemistry and the expression of the gene with RT-PCR. The coding region of Tpit cDNA from 14 dogs with PDH was screened for mutations. Tpit was expressed in corticotroph and melanotroph cells of the normal and adenomatous canine pituitary, and remained present in non-adenomatous corticotrophs of pituitaries from PDH dogs. No tumor-specific mutation in the Tpit cDNA from the corticotroph adenomas was found. However, a missense polymorphism in the highly conserved DNA-binding domain, the T-box, was discovered in one dog. It is concluded that Tpit can be used as a reliable marker for the corticotroph and melanotroph cells in the canine pituitary tissue and that mutations in the Tpit gene are unlikely to play a major role in the pathogenesis of canine corticotroph adenomas.

Of old and new diseases: genetics of pituitary ACTH excess (Cushing) and deficiency

The pituitary gland orchestrates our endocrine environment: it produces hormones in response to hypothalamic factors that integrate neural inputs and its activity is balanced by the feedback action of peripheral hormones. Disruption of this equilibrium has severe consequences that affect multiple systems and may be fatal. Genetic analysis of pituitary function led to discovery of critical transcription factors that cause hormone deficiencies when mis-expressed. This review will summarize recent findings that led to the first complete clinical description of inherited, isolated corticotropin (ACTH) deficiency (IAD) and to the first molecular mechanism for excessive ACTH production in Cushing's disease. Indeed, mutations in TPIT, a positive or negative regulator of cell fates for different pituitary lineages, cause neonatal IAD, a condition considered anecdotic before discovery of this transcription factor. Cushing's disease is caused by corticotroph adenomas that produce excess ACTH as a result of resistance to glucocorticoids (Gc). Molecular investigation of the normal mechanism of Gc feedback led to identification of two essential proteins for pro-opiomelanocortin repression that are often mis-expressed in corticotroph adenomas thus providing a molecular explanation for Gc resistance. These two proteins, Brg1 and histone deacetylase 2 (HDAC2), are involved in chromatin remodeling and may also participate in the tumorigenic process, as Brg1 is a tumor suppressor. These recent advances have provided improved diagnosis and opened new perspectives for patient management and therapies.

A multinational evaluation of the efficacy, safety and acceptability of the Protectaid contraceptive sponge

OBJECTIVE

The Protectaid sponge (Gefar Pharma, Switzerland) is a new feminine barrier contraceptive method containing three low-dose spermicidal agents. In order to evaluate its efficacy and safety profiles, an international, multicenter study has been conducted in four countries.

METHODS

Healthy, presumably fertile and sexually active women were enrolled in this study and were followed at 15 days, 3, 6, 9 and 12 months. Contraceptive efficacy was assessed by a pregnancy test, while safety was evaluated by performing gynecological examinations as well as reporting adverse events. The 'acceptability' of the sponge by the women was assessed through a standard questionnaire.

RESULTS

A total of 129 women were enrolled in the study, generating 1182 cycles of use of the sponge. The overall efficacy rate was 77%, with no significant influence of age or parity. Acceptability was high, with 85% of subjects being symptom- or problem-free while using the sponge. Finally, the safety profile was very good, with no clinically significant evidence of local or systemic adverse reactions.

CONCLUSION

The new Protectaid sponge is a safe and effective non-hormonal contraceptive method for women.

Characterization of a partial prostaglandin endoperoxide H synthase-1 deficiency in a patient with a bleeding disorder

Thromboxane A2 (TXA2), synthesized in platelets, is a powerful aggregating agent and vasoconstrictor. To induce platelet aggregation, the platelets' enzyme, prostaglandin endoperoxide H synthase-1 (PGHS-1), first converts arachidonic acid (AA) into prostaglandin H2 (PGH2). PGH2 is then converted by the enzyme thromboxane synthase into TXA2. Finally, TXA2 is secreted and can activate the TXA2 receptor on the platelet surface. The importance of TXA2 in haemostasis has been demonstrated by the presence of a bleeding tendency in patients showing an inherited defect in the TXA2 production pathway. We studied an 18-year-old woman with a lifelong bleeding disorder, moderate thrombocytopenia (55-71 x 109/l) and a prolonged bleeding time (12.5 min). Her platelets aggregated in the presence of both PGH2 and a stable TXA2 analogue, but did not aggregate in the presence of AA. The activity of PGHS-1 in platelets, measured using thin-layer chromatography and radioactive counting of TXA2 formation from [14C]-AA, was reduced to 13% of the activity measured in control subjects. PGHS-1 protein levels, measured using Western blot analysis, were also markedly reduced to 10% of control values. Such levels of PGHS-1 enzyme were too low to sustain platelet aggregation in the patient, even if the enzyme was active. The PGHS-1 protein level was also reduced in the patient's immortalized B lymphocytes, suggesting a systemic expression defect. Northern blot analysis was then carried out with poly (A)+ RNA extracted from the patient's immortalized B lymphocytes. PGHS-1 mRNA was detected as a 2.8-kb band in both the patient and control. The intensity of the band representing the patient's PGHS-1 mRNA was similar to that of the control subject. The Northern blot result suggests a normal transcriptional rate of the PGHS-1 gene for the patient. Therefore, the defect responsible for the reduced levels of PGHS-1 protein is probably post-transcriptional.

Opposite ability of pre-TCR and alpha beta TCR to induce apoptosis

In early CD4(-)CD8(-) pro-thymocytes, signaling through the pre-TCR is crucial for survival and differentiation into CD4(+)CD8(+) cells. At this more mature stage, interactions between alphabetaTCR and self-Ag/MHC complexes in turn lead either to cell survival and differentiation (positive selection) or to cell death (negative selection). Intrinsic differences must therefore exist between pre-TCR signals in CD4(-)CD8(-) thymocytes and alphabetaTCR signals in CD4(+)CD8(+) cells, since only the latter can mediate a death signal. In this work, we directly compared the capability of pre-TCR and alphabetaTCR to induce apoptosis in a CD4(-)CD8(-) thymoma cell line following receptor cross-linking with mAbs. Cross-linking of alphabetaTCR triggered high levels of programmed cell death, mimicking the negative selection signal usually induced in CD4(+)CD8(+) thymocytes. In contrast, pre-TCR was very inefficient at inducing apoptosis upon cross-linking, despite similar levels of surface receptor expression. Importantly, inefficient apoptosis induction by the pre-TCR did not result from its weak association with TCRzeta chain, since TCRs containing alpha-pTalpha chimeric chains, binding weakly to TCRzeta, were still able to induce apoptosis. Although similar tyrosine phosphorylation and calcium influx were induced after either pre-TCR or alphabetaTCR cross-linking, the two pathways diverged at the level of Fas ligand induction. Among putative transcription factors involved in Fas ligand mRNA induction, Nur77 and NFAT transcriptional activities were readily induced after alphabetaTCR, but not pre-TCR, stimulation. Together, these results support the view that the structure of the pre-TCR and alphabetaTCR directly influences their apoptosis-inducing capabilities by activating distinct signaling pathways.

Pitx3 activates mouse tyrosine hydroxylase promoter via a high-affinity binding site

Tyrosine hydroxylase (TH) is the rate-limiting enzyme of dopamine and (nor)adrenaline biosynthesis. Regulation of its gene expression is complex and different regulatory mechanisms appear to be operative in various neuronal lineages. Pitx3, a homeodomain-containing transcription factor, has been cloned from neuronal tissues and, in the CNS, mouse Pitx3 is exclusively expressed in midbrain dopaminergic (MesDA) neurons from embryonic day 11 (E11). TH appears in these neurons at E11.5, consistent with a putative role of Pitx3 in TH transcription. We show that Pitx3 activates the TH promoter through direct interaction with a single high-affinity binding site within the promoter and that this site is sufficient for Pitx3 responsiveness. In contrast, we did not observe an effect of Nurr1, an orphan nuclear receptor essential for normal development of MesDA neurons, on TH promoter activity. Pitx3 activation of TH promoter activity appears to be cell-dependent suggesting that Pitx3 action may be modulated by other(s) regulatory mechanism(s) and factor(s).

A pituitary cell-restricted T box factor, Tpit, activates POMC transcription in cooperation with Pitx homeoproteins

The pituitary gland has provided unique insight into molecular mechanisms and regulatory factors controlling both differentiation and gene transcription. We identified Tpit, a novel T box factor only present in the two pituitary POMC-expressing lineages, the corticotrophs and melanotrophs, and apparently in no other tissue, including hypothalamic POMC neurons. In pituitary cells, Tpit activation of POMC gene transcription requires cooperation with Pitx1, the two factors binding to contiguous sites within the same regulatory element. In gain-of-function experiments, Tpit induces POMC expression in undifferentiated pituitary cells, indicating that it can initiate differentiation into POMC-expressing lineages. TPIT gene mutations were found in patients with isolated deficiency of pituitary POMC-derived ACTH, in support of an essential role of Tpit for differentiation of the pituitary POMC lineage.

Effects of low-impact, moderate-intensity exercise training with and without wrist weights on functional capacities and mood states in older adults

This study examined the effects of low-impact, moderate-intensity exercise training with and without wrist weights (0.68 kg.wrist-1) on functional capacities and mood states in older adults (age 68.6 +/- 5.6, mean +/- SD). Twenty-three senior citizens residing in the community were randomly assigned to wrist weight (WW; n = 12) and no-wrist weight (NW; n = 11) exercise groups while 11 matched subjects served as non-exercise controls (NE). Exercise training was performed for 10 weeks, 3 days/week, for 60 min/session and consisted of low-impact aerobic dance (50-70% of maximal heart rate) combined with exercises to promote muscular fitness, flexibility, and balance. Before and after the intervention, each participant's aerobic fitness, muscular strength, flexibility, static and dynamic balance, skinfold thickness, and psychological mood states were assessed under standardized testing conditions. Exercise training resulted in significant improvements in peak oxygen uptake, lower extremity muscle strength, and psychological vigor (p < 0.05) but did not affect other fitness components (p > 0.05). There were no differences between the WW and NW exercise groups for any of the same variables studied (p > 0.05). No significant pre- to post-test changes were found for the NE control group (p > 0.05). It is concluded that 10 weeks of low-impact, moderate-intensity exercise training of the type that can be considered well-rounded in nature provides a sufficient stimulus to augment aerobic fitness, beneficially affects leg strength, and increases feelings of vigor in older adults. The present observations indicate that the use of light wrist weights has no beneficial or adverse effects on the measured training outcomes.

Repression of virus-induced interferon A promoters by homeodomain transcription factor Ptx1

Interferon A (IFN-A) genes are differentially expressed after virus induction. The differential expression of individual IFN-A genes is modulated by substitutions in the proximal positive virus responsive element A (VRE-A) of their promoters and by the presence or absence of a distal negative regulatory element (DNRE). The functional feature of the DNRE is to specifically act by repression of VRE-A activity. With the use of the yeast one-hybrid system, we describe here the identification of a specific DNRE-binding protein, the pituitary homeobox 1 (Ptx1 or Pitx1). Ptx1 is detectable in different cell types that differentially express IFN-A genes, and the endogenous Ptx1 protein binds specifically to the DNRE. Upon virus induction, Ptx1 negatively regulates the transcription of DNRE-containing IFN-A promoters, and the C-terminal region, as well as the homeodomain of the Ptx1 protein, is required for this repression. After virus induction, the expression of the Ptx1 antisense RNA leads to a significant increase of endogenous IFN-A gene transcription and is able to modify the pattern of differential expression of individual IFN-A genes. These studies suggest that Ptx1 contributes to the differential transcriptional strength of the promoters of different IFN-A genes and that these genes may provide new targets for transcriptional regulation by a homeodomain transcription factor.

Specific protein-protein interaction between basic helix-loop-helix transcription factors and homeoproteins of the Pitx family

Homeoproteins and basic helix-loop-helix (bHLH) transcription factors are known for their critical role in development and cellular differentiation. The pituitary pro-opiomelanocortin (POMC) gene is a target for factors of both families. Indeed, pituitary-specific transcription of POMC depends on the action of the homeodomain-containing transcription factor Pitx1 and of bHLH heterodimers containing NeuroD1. We now show lineage-restricted expression of NeuroD1 in pituitary corticotroph cells and a direct physical interaction between bHLH heterodimers and Pitx1 that results in transcriptional synergism. The interaction between the bHLH and homeodomains is restricted to ubiquitous (class A) bHLH and to the Pitx subfamily. Since bHLH heterodimers interact with Pitx factors through their ubiquitous moiety, this mechanism may be implicated in other developmental processes involving bHLH factors, such as neurogenesis and myogenesis.

Transcriptional properties of Ptx1 and Ptx2 isoforms

The Ptx (Pitx) family of homeobox transcription factors comprises Ptx1, Ptx2 and Ptx3. Ptx1 and Ptx2 are expressed in the stomodeum and its derivatives including the pituitary, as well as in mesodermal derivatives, whereas Ptx3 is expressed in one neuronal lineage of the brain and in the eyes. A large set of downstream target genes have been identified for Ptx1 in the pituitary gland where it acts as a pan-pituitary regulator of transcription. In particular, Ptx1 contributes to promoter- and lineage-specific transcription by interaction with cell-restricted factors such as SF-1, Egr-1, Pit1, and the basic helix-loop-helix heterodimer NeuroD1/Pan1. We describe the cloning from pituitary cells and the characterization of a Ptx1 isoform, named Ptx1b, generated by alternative promoter usage. The two Ptx1 and two Ptx2 isoforms have similar in vitro DNA binding specificities and they all activate transcription driven by a panel of pituitary promoters, including those for proopiomelanocortin, alphaGSU, LHbeta, FSHbeta, GnRH-R, TSHbeta, PRL, and GH. Also like Ptx1, the Ptx1b, Ptx2a, and Ptx2b transcription factors synergize with the structurally unrelated factors SF-1, Egr-1, Pit1, and NeuroD1/Pan1 to activate promoter-specific transcription. In conclusion, the pituitary transcriptional activities of the four Ptx isoforms do not appear to be dependent on the variant N-termini of these factors.

Burch colposuspension: long-term results and review of published reports

OBJECTIVES

To review our long-term results with the Burch colpocystourethropexy, compare our results with those in recently published reports, and define factors that may influence the long-term outcome of this procedure.

METHODS

A group of 79 patients who underwent Burch colposuspension as modified by Tanagho between January 1985 and January 1991 were studied retrospectively. Preoperative investigation consisted of clinical history, physical examination, cystourethroscopy, multichannel urodynamic evaluation, including pressure-flow studies, and static and dynamic urethral pressure profile analysis. A postal survey was sent to all patients to evaluate their symptoms and the impact on their quality of life.

RESULTS

The mean follow-up was 7.6 years (range 5.3 to 10.8). Forty-four percent of patients were considered cured (responders), 25% significantly improved (partial responders), and 31% failures (nonresponders). The success rate was higher among patients who had not undergone previous continence surgery (75%) or hysterectomy (78%) than among those who had previously undergone continence surgery (59%) or hysterectomy (65%). Seventy-five percent of the patients were responders or partial responders if the bladder was stable preoperatively, as opposed to 70% when the bladder was unstable before surgery. Analysis of the postal questionnaire indicated a statistically significant difference in terms of irritative symptoms between the responder and partial responder groups combined and the nonresponder group.

CONCLUSIONS

More than two thirds (69.6%) of our patients who underwent a Burch-Tanagho colpocystourethropexy had a favorable long-term outcome (mean 7.6 years). Previously failed continence procedures, unstable bladder preoperatively, and previous or concomitant hysterectomy had a negative influence on the final outcome in the long term from the clinical point of view, even if, statistically, the difference was not significant. The incidence of irritative symptoms and nocturia were significantly higher among nonresponders than among responders and partial responders. More attention paid to these symptoms during the post-operative follow-up should increase the perception of success by the patient after retropubic colpocystourethropexy.

Heterodimerization between members of the Nur subfamily of orphan nuclear receptors as a novel mechanism for gene activation

We have recently shown that the orphan nuclear receptor Nur77 (NGFI-B) is most active in transcription when it is interacting with a cognate DNA sequence as a homodimer. Further, we have shown that the target for Nur77 dimers, the Nur response element (NurRE), is responsive to physiological stimuli in both endocrine and lymphoid cells, whereas other DNA targets of Nur77 action are not. The Nur77 subfamily also includes two related receptors, Nur-related factor 1 (Nurr1) and neuron-derived orphan receptor 1 (NOR-1). Often, more than one member of this subfamily is induced in response to extracellular signals. We now show that Nur77 and Nurr1 form heterodimers in vitro in the presence or absence of NurRE, and we have documented interactions between these proteins in vivo by using a two-hybrid system in mammalian cells. These heterodimers synergistically enhance transcription from NurRE reporters in comparison to that seen with homodimers. The naturally occurring NurRE from the pro-opiomelanocortin gene preferentially binds and activates transcription in the presence of Nur77 homo- or heterodimers, while a consensus NurRE sequence does not show this preference. Taken together, the data indicate that members of the Nur77 subfamily are most potent as heterodimers and that different dimers exhibit target sequence preference. Thus, we propose that a combinatorial code relying on specific NurRE sequences might be responsible for the activation of subsets of target genes by one of the members of the Nur77 subfamily of transcription factors.

Ptx1 regulates SF-1 activity by an interaction that mimics the role of the ligand-binding domain

Ptx1 (Pitx1) is a bicoid-related homeobox transcription factor expressed from the onset of pituitary development. It was shown to cooperate with cell-restricted factors, such as Pit1, NeuroD1/PanI and steroidogenic factor 1 (SF-1), to establish a combinatorial code conferring lineage- and promoter-specific gene transcription in the pituitary. Transcriptional synergism between Ptx1 and SF-1 on two SF-1 target genes, pituitary luteinizing hormone beta and Müllerian-inhibiting substance (MIS), requires SF-1 binding to DNA and appears to result from direct physical interaction between these two proteins. The interaction between the C-terminus of Ptx1 and the N-terminal half of SF-1 results in transcriptional enhancement that equals the activity of a constitutively active SF-1 mutant and that may mimic the effect of a still unidentified SF-1 ligand. Thus, the unmasking of SF-1 activity by Ptx1 may represent a developmental mechanism to alleviate the need for SF-1 ligand in transcription and, possibly, at critical times during organogenesis.

Hindlimb patterning and mandible development require the Ptx1 gene

The restricted expression of the Ptx1 (Pitx1) gene in the posterior half of the lateral plate mesoderm has suggested that it may play a role in specification of posterior structures, in particular, specification of hindlimb identity. Ptx1 is also expressed in the most anterior ectoderm, the stomodeum, and in the first branchial arch. Ptx1 expression overlaps with that of Ptx2 in stomodeum and in posterior left lateral plate mesoderm. We now show that targeted inactivation of the mouse Ptx1 gene severely impairs hindlimb development: the ilium and knee cartilage are absent and the long bones are underdeveloped. Greater reduction of the right femur size in Ptx1 null mice suggests partial compensation by Ptx2 on the left side. The similarly sized tibia and fibula of mutant hindlimbs may be taken to resemble forelimb bones: however, the mutant limb buds appear to have retained their molecular identity as assessed by forelimb expression of Tbx5 and by hindlimb expression of Tbx4, even though Tbx4 expression is decreased in Ptx1 null mice. The hindlimb defects appear to be, at least partly, due to abnormal chondrogenesis. Since the most affected structures derive from the dorsal side of hindlimb buds, the data suggest that Ptx1 is responsible for patterning of these dorsal structures and that as such it may control development of hindlimb-specific features. Ptx1 inactivation also leads to loss of bones derived from the proximal part of the mandibular mesenchyme. The dual role of Ptx1 revealed by the gene knockout may reflect features of the mammalian jaw and hindlimbs that were acquired at a similar time during tetrapod evolution.

Egr-1 is a downstream effector of GnRH and synergizes by direct interaction with Ptx1 and SF-1 to enhance luteinizing hormone beta gene transcription

Pituitary gonadotropins are critical regulators of gonadal development and function. Expression and secretion of the mature hormones are regulated by gonadotropin-releasing hormone (GnRH), which is itself secreted from the hypothalamus. GnRH stimulation of gonadotropin expression and secretion occurs through the G-protein-linked phospholipase C/inositol triphosphate intracellular signaling pathway, which ultimately leads to protein kinase C (PKC) activation and increased intracellular calcium levels. Transcription factors mediating the effects of GnRH-induced signals on transcription of gonadotropin genes have not yet been identified. Recent studies have identified key factors involved in luteinizing hormone beta (LHbeta) gonadotropin gene transcription: the nuclear receptor SF-1, the bicoid-related homeoprotein Ptx1 (Pitx1), and the immediate-early Egr-1 gene. We now show that GnRH is a potent stimulator of Egr-1, but not Ptx1 or SF-1, expression. Further, Egr-1 activation of the LHbeta promoter is specifically enhanced by PKC, in agreement with a role for Egr-1 in mediating a GnRH effect on transcription. Egr-1 interacts directly with Ptx1 and with SF-1, leading to an enhancement of Ptx1- and SF-1-induced LHbeta transcription. Thus, Egr-1 is a likely transcriptional mediator of GnRH-induced signals for activation of the LHbeta gene.

Pituitary homeobox 1 (Ptx1) is differentially expressed during pituitary development

Pituitary homeobox 1 (Ptx1) is a homeodomain-containing transcription factor acting on transcription of all pituitary hormone genes. Its expression is first detected in the stomodeal ectoderm and is maintained in all derivatives of this structure, including Rathke's pouch. We now show that Ptx1 is expressed in all pituitary cells but that it is differentially expressed in different lineages at both the messenger RNA and protein levels. On day 12.5 of mouse embryonic development, cells expressing the highest levels of Ptx1 are restricted to the forming pars tuberalis, also called the rostral tip, a region where the first alpha-glycoprotein subunit-expressing cells appear. Coimmunolocalization studies reveal that alpha-glycoprotein subunit-positive cells express the highest levels of Ptx1 throughout development and in the adult gland. The quantitative differences in Ptx1 expression in pituitary cell lineages may relate to a role in cell proliferation, lineage commitment, and/or the control of organ development.

Neuroendocrine dysplasia in mice lacking protein tyrosine phosphatase sigma

Protein tyrosine phosphatase sigma (PTP-sigma, encoded by the Ptprs gene) is a member of the LAR subfamily of receptor-like protein tyrosine phosphatases that is highly expressed during mammalian embryonic development in the germinal cell layer lining the lateral ventricles of the developing brain, dorsal root ganglia, Rathke's pouch, olfactory epithelium, retina and developing lung and heart. On the basis of its expression and homology with the Drosophila melanogasterorthologues DPTP99 and DPTP100A (refs 5,6), which have roles in the targeting of axonal growth cones, we hypothesized that PTP-sigma may also have a modulating function in cell-cell interactions, as well as in axon guidance during mammalian embryogenesis. To investigate its function in vivo, we generated Ptprs-deficient mice. The resulting Ptprs-/-animals display retarded growth, increased neonatal mortality, hyposmia and hypofecundity. Anatomical and histological analyses showed a decrease in overall brain size with a severe depletion of luteinizing hormone-releasing hormone (LHRH)-immunoreactive cells in Ptprs-/- hypothalamus. Ptprs-/- mice have an enlarged intermediate pituitary lobe, but smaller anterior and posterior lobes. These results suggest that tyrosine phosphorylation-dependent signalling pathways regulated by PTP-sigma influence the proliferation and/or adhesiveness of various cell types in the developing hypothalamo-pituitary axis.

The PTX family of homeodomain transcription factors during pituitary developments

A subfamily of bicoid-related homeodomain factors was recently discovered through its involvement in transcription of pituitary-specific genes. We isolated the first member of this family, Ptxl (pituitary homeobox 1), through its DNA binding properties whereas a second related gene, Ptx2 (RIEG), was identified by positional cloning as the causative gene for Rieger's syndrome. The mechanisms of Ptx action on its target genes as well as its putative roles during development are reviewed with particular emphasis on its role in pituitary function.

Transient dwarfism and hypogonadism in mice lacking Otx1 reveal prepubescent stage-specific control of pituitary levels of GH, FSH and LH

Genetic and molecular approaches have enabled the identification of regulatory genes critically involved in determining cell types in the pituitary gland and/or in the hypothalamus. Here we report that Otx1, a homeobox-containing gene of the Otx gene family, is postnatally transcribed and translated in the pituitary gland. Cell culture experiments indicate that Otx1 may activate transcription of the growth hormone (GH), follicle-stimulating hormone (betaFSH), luteinizing hormone (betaLH) and alpha-glycoprotein subunit (alphaGSU) genes. Analysis of Otx1 null mice indicates that, at the prepubescent stage, they exhibit transient dwarfism and hypogonadism due to low levels of pituitary GH, FSH and LH hormones which, in turn, dramatically affect downstream molecular and organ targets. Nevertheless, Otx1−/− mice gradually recover from most of these abnormalities, showing normal levels of pituitary hormones with restored growth and gonadal function at 4 months of age. Expression patterns of related hypothalamic and pituitary cell type restricted genes, growth hormone releasing hormone (GRH), gonadotropin releasing hormone (GnRH) and their pituitary receptors (GRHR and GnRHR) suggest that, in Otx1−/− mice, hypothalamic and pituitary cells of the somatotropic and gonadotropic lineages appear unaltered and that the ability to synthesize GH, FSH and LH, rather than the number of cells producing these hormones, is affected. Our data indicate that Otx1 is a new pituitary transcription factor involved at the prepubescent stage in the control of GH, FSH and LH hormone levels and suggest that a complex regulatory mechanism might exist to control the physiological need for pituitary hormones at specific postnatal stages.

Novel mechanism of action for Nur77 and antagonism by glucocorticoids: a convergent mechanism for CRH activation and glucocorticoid repression of POMC gene transcription

Whereas orphan nuclear receptors of the Nur77 (NGFI-B) subfamily were previously known to act on transcription as monomers or as heterodimers with RXR, we have recently shown that Nur77 homodimers potently activate transcription upon interaction with a novel palindromic response element, the NurRE. In fact, reporter plasmids containing the NurRE respond to physiological stimuli in conditions where the NBRE, a binding site for Nur77 monomers, does not. Nur77 and its related receptors were shown to be important mediators for control of apoptosis induced by the T-cell receptor, and they also mediate the effect of the hypothalamic hormone CRH on transcription of the pituitary pro-opiomelanocotin (POMC) gene. In both systems, glucocorticoids antagonize the stimulatory effects of Nur77 on transcription by a mechanism that involves protein:protein interactions. Thus, the Nur77 signalling pathway appears to be a point of convergence for stimulatory signals and glucocorticoid repression in both endocrine and lymphoid systems.

The pan-pituitary activator of transcription, Ptx1 (pituitary homeobox 1), acts in synergy with SF-1 and Pit1 and is an upstream regulator of the Lim-homeodomain gene Lim3/Lhx3

The Ptx1 (pituitary homeobox 1) homeobox transcription factor was isolated as a transcription factor of the pituitary POMC gene. In corticotrope cells that express POMC, cell-specific transcription is conferred in part by the synergistic action of Ptx1 with the basic helix-loop-helix factor NeuroD1. Since Ptx1 expression precedes pituitary development and differentiation, we investigated its expression and function in other pituitary lineages. Ptx1 is expressed in most pituitary-derived cell lines and as is the related Ptx2 (Rieger) gene. However, Ptx1 appears to be the only Ptx protein in corticotropes and the predominant one in gonadotrope cells. Most pituitary hormone-coding gene promoters are activated by Ptx1. Thus, Ptx1 appears to be a general regulator of pituitary-specific transcription. In addition, Ptx1 action is synergized by cell-restricted transcription factors to confer promoter-specific expression. Indeed, in the somatolactotrope lineage, synergism between Ptx1 and Pit1 is observed on the PRL promoter, and strong synergism between Ptx1 and SF-1 is observed in gonadotrope cells on the betaLH promoter but not on the alphaGSU (glycoprotein hormone alpha-subunit gene) and betaFSH promoters. Synergism between these two classes of factors is reminiscent of the interaction between the products of the Drosophila genes Ftz (fushi tarazu) and Ftz-F1. Antisense RNA experiments performed in alphaT3-1 cells that express the alphaGSU gene showed that expression of endogenous alphaGSU is highly dependent on Ptx1 whereas many other genes are not affected. Interestingly, the only other gene found to be highly dependent on Ptx1 for expression was the gene for the Lim3/Lhx3 transcription factor. Thus, these experiments place Ptx1 upstream of Lim3/Lhx3 in a cascade of regulators that appear to work in a combinatorial code to direct pituitary-, lineage-, and promoter-specific transcription.

A homeodomain gene Ptx3 has highly restricted brain expression in mesencephalic dopaminergic neurons

The mesencephalic dopaminergic (mesDA) system regulates behavior and movement control and has been implicated in psychiatric and affective disorders. We have identified a bicoid-related homeobox gene, Ptx3, a member of the Ptx-subfamily, that is uniquely expressed in these neurons. Its expression starting at E11.5 in the developing mouse midbrain correlates with the appearance of mesDA neurons. The number of Ptx3-expressing neurons is reduced in Parkinson patients, and these neurons are absent from 6-hydroxydopamine-lesioned rats, an animal model for this disease. Thus, Ptx3 is a unique transcription factor marking the mesDA neurons at the exclusion of other dopaminergic neurons, and it may be involved in developmental determination of this neuronal lineage.

NeuroD1/beta2 contributes to cell-specific transcription of the proopiomelanocortin gene

NeuroD1/beta2 is a basic helix-loop-helix (bHLH) factor expressed in the endocrine cells of the pancreas and in a subset of neurons as they undergo terminal differentiation. We now show that NeuroD1 is expressed in corticotroph cells of the pituitary gland and that it is involved in cell-specific transcription of the proopiomelanocortin (POMC) gene. It was previously shown that corticotroph-specific POMC transcription depends in part on the action of cell-restricted bHLH factors that were characterized as the CUTE (corticotroph upstream transcription element) (M. Therrien and J. Drouin, Mol. Cell. Biol. 13:2342-2353, 1993) complexes. We now demonstrate that these complexes contain NeuroD1 in association with various ubiquitous bHLH dimerization partners. The NeuroD1-containing heterodimers specifically recognize and activate transcription from the POMC promoter E box that confers transcriptional specificity. Interestingly, the NeuroD1 heterodimers activate transcription in synergy with Ptx1, a Bicoid-related homeodomain protein, which also contributes to corticotroph specificity of POMC transcription. In the adult pituitary gland, NeuroD1 transcripts are detected in POMC-expressing corticotroph cells. Taken together with the restricted pattern of Ptx1 expression, these results suggest that these two factors establish the basis of a combinatorial code for the program of corticotroph-specific gene expression.

Novel dimeric Nur77 signaling mechanism in endocrine and lymphoid cells

Within the nuclear receptor family, Nur77 (also known as NGFI-B) distinguishes itself by its ability to bind a target sequence (the NBRE) as a monomer and by its role in T-cell receptor (TCR)-induced apoptosis in T cells. We now report on a novel mechanism of Nur77 action that is mediated by homodimers. These dimers bind a Nur77 response element (NurRE), which has been identified as a target of CRH-induced Nur77 in the pro-opiomelanocortin (POMC) gene promoter. Both halves of the palindromic NurRE are required for responsiveness to physiological signals, like CRH in pituitary-derived AtT-20 cells. Similarly, in T-cell hybridomas, TCR activation induced NurRE but not NBRE reporters. The in vivo signaling function of Nur77 thus appears to be mediated by dimers acting on a palindromic response element of unusual spacing between its half-sites. This mechanism may represent the biologically relevant paradigm of action for this subfamily of orphan nuclear receptors.

Antagonism between Nur77 and glucocorticoid receptor for control of transcription

Two important functions of glucocorticoids (Gc), namely, suppression of immune system function and feedback repression of the hypothalamo-pituitary-adrenal (HPA) axis, are mediated through repression of gene transcription. Previous studies have indicated that this repression is exerted in part through antagonism between the glucocorticoid receptors (GR) and the AP-1 family of transcription factors. However, this mechanism could not account for repression of the pro-opiomelanocortin (POMC) gene, an important regulator of the HPA axis. Our recent identification of the orphan nuclear receptor Nur77 as a mediator of CRH induction of POMC transcription led us, in the present work, to show that Gc antagonize this positive signal at two levels. First, Gc partly blunt the CRH induction of Nur77 mRNA, and second, they antagonize Nur77-dependent transcription. GR repression is exerted by antagonism of Nur77 action on the NurRE element of the POMC gene. Gc antagonism of NurRE activity was observed in response to physiological stimuli in both endocrine (CRH induction of POMC) and lymphoid (T-cell receptor activation) cells. In transfection experiments, transcriptional activation by Nur77 and the repressor activity of liganded GR titrated each other on their cognate DNA target. In vitro binding experiments as well as mutation analysis of GR suggest that the mechanism of GR antagonism of Nur77 is very similar to that of the antagonism between GR and AP-1. The convergence of positive signals mediated by Nur77 (and also probably by related family members) and negative signals exerted by GR appears to be a general mechanism for control of transcription, since it is active in both endocrine and lymphoid cells.

The bicoid-related homeoprotein Ptx1 defines the most anterior domain of the embryo and differentiates posterior from anterior lateral mesoderm

Ptx1 is a member of the small bicoid family of homeobox-containing genes; it was isolated as a tissue-restricted transcription factor of the pro-opiomelanocortin gene. Its expression during mouse and chick embryogenesis was determined by in situ hybridization in order to delineate its putative role in development. In the head, Ptx1 expression is first detected in the ectoderm-derived stomodeal epithelium at E8.0. Initially, expression is only present in the stomodeum and in a few cells of the rostroventral foregut endoderm. A day later, Ptx1 mRNA is detected in the epithelium and in a streak of mesenchyme of the first branchial arch, but not in other arches. Ptx1 expression is maintained in all derivatives of these structures, including the epithelia of the tongue, palate, teeth and olfactory system, and in Rathke's pouch. Expression of Ptx1 in craniofacial structures is strikingly complementary to the pattern of goosecoid expression. In addition, Ptx1 is expressed early (E6.8) in posterior and extraembryonic mesoderm, and in structures that derive from these. The restriction of expression to the posterior lateral plate is later evidenced by exclusive labelling of the hindlimb but not forelimb mesenchyme. In the anterior domain of expression, the stomodeum was shown by fate mapping to derive from the anterior neural ridge (ANR) which represents the most anterior domain of the embryo. The concordance between these fate maps and the stomodeal pattern of Ptx1 expression supports the hypothesis that Ptx1 defines a stomodeal ectomere, which lies anteriorly to the neuromeres that have been suggested to constitute units of a segmented plan directing head formation.

Identification of novel factor VIII inhibitor epitopes using synthetic peptide arrays

OBJECTIVES

Mapping the antibody-binding sites on the factor VIII (FVIII) protein opens the prospect of studying the development of FVIII inhibitors and the alteration of inhibitor specificities over time. This paper describes a novel approach to the mapping of FVIII antibody-binding sites.

METHODS

Immobilized synthetic peptide arrays covering 80% of the complete 2351 amino acid sequence of factor VIII (FVIII) were used to determine epitope specificity of 6 alloantibodies and 3 autoantibodies inhibitory to FVIII activity. This detailed assessment was carried out using a modified enzyme-linked immunosorbent assay with plasma from normal persons or hemophilia A patients without inhibitors as negative controls.

RESULTS

Antibody-combining sites could be differentiated in both a qualitative and quantitative manner and were patient-specific. Highly reactive peptides were restricted to specific sites in the A1-A3 and C1-C2 domains and were not proximal to known proteolytic cleavage sites. Free peptides incubated in vitro with the plasmas of 3 patients significantly reduced residual inhibitor titers in a dose-dependent manner.

CONCLUSION

This technique permits the study of the development and specificity of FVIII inhibitors, can detect and differentiate between inhibitory and noninhibitory antibodies using immobilized or free peptides respectively, permits correlation of antibody-combining sites with inhibition of FVIII activity and provides a basis for the development of inhibitor adsorption or neutralization technology.

Human and murine PTX1/Ptx1 gene maps to the region for Treacher Collins syndrome

Ptx1 belongs to an expanding family of bicoid-related vertebrate homeobox genes. These genes, like their Drosophila homolog, seem to play a role in the development of anterior structures and, in particular, the brain and facies. We report the chromosomal localization of mouse Ptx1, and the cloning, sequencing, and chromosomal localization of the human homolog PTX1. The putative encoded proteins share 100% homology in the homeodomain and are 88% and 97% conserved in the N- and C-termini respectively. Intron/exon boundaries are also conserved. Murine Ptx1 was localized, by interspecific backcrossing, to Chr 13 within 2.6 cM of Caml. The gene resides centrally on Chromosome (Chr) 13 in a region syntenic with human Chr 5q. Subsequent analysis by fluorescent in situ hybridization places the human gene, PTX1, on 5q31, a region associated with Treacher Collins Franceschetti Syndrome. Taken together with the craniofacial expression pattern of Ptx1 during early development, the localization of the gene in this chromosomal area is consistent with an involvement in Treacher Collins Franceschetti Syndrome.

An autosomal dominant, qualitative platelet disorder associated with multimerin deficiency, abnormalities in platelet factor V, thrombospondin, von Willebrand factor, and fibrinogen and an epinephrine aggregation defect

Multimerin is a massive soluble, multimeric protein found in platelets and endothelial cells. Recent studies identified multimerin as a specific coagulation factor V binding protein, complexed with platelet, but not plasma, factor V. These findings led us to investigate individuals with inherited factor V deficiencies for possible multimerin abnormalities. Platelet proteins were evaluated using immunoassays, sodium dodecyl sulfate-polyacrylamide gel electrophoresis, immunoblotting, immunoprecipitation, and direct binding studies. Patients with factor V Quebec, a disorder with abnormal platelet factor V, had a quantitative deficiency in multimerin (n = 11 tested; mean, 12.5%; range, 5% to 27% of the normal pool; normal range, 45% to 214%) with a normal multimer pattern. Quantitative and qualitative abnormalities were detected in their platelet factor V. An unrelated patient who was deficient in platelet and plasma factor V had normal platelet multimerin. The levels of platelet beta-thromboglobulin, von Willebrand factor, thrombospondin, and fibrinogen antigen were normal in the factor V Quebec patients. However, proteins with abnormal mobility were detected in their platelet lysate and releasate, and their platelet thrombospondin, von Willebrand factor, and fibrinogen showed evidence of proteolytic degradation. Platelet counts of the factor V Quebec patients ranged from mildly thrombocytopenic to low normal (mean, 159 x 10(9)/L; range, 104 to 198 x 10(9)/L). In addition, their platelets failed to aggregate in response to 6 to 10 micromol/L epinephrine despite normal numbers of platelet alpha 2-adrenergic receptors. These data indicate that patients with factor V Quebec have an inherited bleeding disorder distinct from other platelet disorders and associated with multiple abnormalities, including multimerin deficiency, abnormal platelet factor V, thrombospondin, von Willebrand factor, and fibrinogen, and an epinephrine aggregation defect.

Ptx1, a bicoid-related homeo box transcription factor involved in transcription of the pro-opiomelanocortin gene

The pituitary gland contains six distinct hormone-producing cell types that arise sequentially during organogenesis. The first cells to differentiate are those that express the pro-opiomelanocortin (POMC) gene in the anterior pituitary lobe. The other lineages, which appear later, include cells that are dependent on the POU factor Pit-1 and another POMC-expressing lineage in the intermediate pituitary lobe. Using AtT-20 cells as a model for early expression of POMC in the anterior pituitary, we have defined a regulatory element conferring cell specificity of transcription and cloned a cognate transcription factor. This factor, Ptx1 (pituitary homeo box 1), contains a homeo box related to those of the anterior-specific genes bicoid and orthodenticle in Drosophila, and Otx-1 and Otx-2 in mammals. Ptx1 activates transcription upon binding a sequence related to the Drosophila bicoid target sites. Ptx1 is the only nuclear factor of this DNA-binding specificity that is detected in AtT-20 cells, and it is expressed at high levels in a subset of adult anterior pituitary cells that express POMC. However, Ptx1 is expressed in most cells of Rathke's pouch at an early time during pituitary development and before final differentiation of hormone-producing cells. Thus, Ptx1 may have a role in differentiation of pituitary cells, and its early expression pattern suggests that it may have a role in pituitary formation. In the adult pituitary gland, Ptx1 appears to be recruited for cell-specific transcription of the POMC gene.

Defective thrombin-induced calcium changes and aggregation of Bernard-Soulier platelets are not associated with deficient moderate-affinity receptors

Cloning of the moderate-affinity, serpentine thrombin receptor has helped clarify the mechanism of thrombin-induced platelet activation. Proteolytic cleavage by thrombin generates a new amino terminal that autostimulates the receptor, leading to activation of multiple signaling pathways and the platelet response. The function of other thrombin receptors, such as high-affinity glycoprotein Ib (GPIb), on platelets and their relationships to the moderate-affinity receptor remain unclear. The present study examined the role of the moderate-affinity thrombin receptor in Bernard-Soulier syndrome (BSS) platelets, which contain low amounts of GPIb. Platelets from four BSS subjects displayed normal aggregation profiles and cytosolic calcium changes in response to moderate or high concentrations of thrombin. In contrast, the BSS platelet aggregation response was delayed and calcium changes were absent in response to low thrombin concentrations. Platelets from an asymptomatic BSS heterozygote displayed an activation profile similar to those of control individuals. Specific activation of the moderate-affinity receptor by a synthetic peptide caused similar aggregation in platelets from all individuals. The synthetic peptide also elicited calcium responses in BSS platelets. Platelets from the BSS subjects and from an individual with the May-Hegglin anomaly showed increased expression of the moderate-affinity thrombin receptor by flow-cytometric analyses. These results suggest that BSS platelets possess high levels of a functional moderate-affinity thrombin receptor, probably due to large platelet size, and provide indirect evidence that a high-affinity thrombin receptor is associated with GPIb.