Sporadic primary pulmonary hypertension is associated with germline mutations of the gene encoding BMPR-II, a receptor member of the TGF-beta family

BACKGROUND

Primary pulmonary hypertension (PPH), resulting from occlusion of small pulmonary arteries, is a devastating condition. Mutations of the bone morphogenetic protein receptor type II gene (BMPR2), a component of the transforming growth factor beta (TGF-beta) family which plays a key role in cell growth, have recently been identified as causing familial PPH. We have searched for BMPR2 gene mutations in sporadic PPH patients to determine whether the same genetic defect underlies the more common form of the disorder.

METHODS

We investigated 50 unrelated patients, with a clinical diagnosis of PPH and no identifiable family history of pulmonary hypertension, by direct sequencing of the entire coding region and intron/exon boundaries of the BMPR2 gene. DNA from available parent pairs (n=5) was used to assess the occurrence of spontaneous (de novo) mutations contributing to sporadic PPH.

RESULTS

We found a total of 11 different heterozygous germline mutations of the BMPR2 gene in 13 of the 50 PPH patients studied, including missense (n=3), nonsense (n=3), and frameshift (n=5) mutations each predicted to alter the cell signalling response to specific ligands. Parental analysis showed three occurrences of paternal transmission and two of de novo mutation of the BMPR2 gene in sporadic PPH.

CONCLUSION

The sporadic form of PPH is associated with germline mutations of the gene encoding the receptor protein BMPR-II in at least 26% of cases. A molecular classification of PPH, based upon the presence or absence of BMPR2 mutations, has important implications for patient management and screening of relatives.

Structure of a major immunogenic site on foot-and-mouth disease virus

Attachment of foot-and-mouth disease virus (FMDV) to its cellular receptor involves a long and highly antigenic loop containing the conserved sequence, Arg-Gly-Asp, a motif known to be a recognition element in many integrin-dependent cell adhesion processes. In our original crystal structure of FMDV the Arg-Gly-Asp-containing loop ('the loop'), located between beta-strands G and H of capsid protein VP1, was disordered and hence essentially invisible. We previously surmised that its disorder is enhanced by a disulphide bond linking the base of the loop (Cys 134) to Cys 130 of VP2 (ref. 8). We report here the crystal structure of the virus in which this disulphide is reduced. Reduced virus retains infectivity and serological experiments suggest that some of the loop's internal structure is conserved. But here its structure has become sufficiently ordered to allow us to describe an unambiguous conformation, which we relate to some key biological properties of the virus.

Unicompartmental or total knee replacement

Between 1989 and 1992 we had 102 knees suitable for unicompartmental knee replacement (UKR). They were randomised to receive either a St Georg Sled UKR or a Kinematic modular total knee replacement (TKR). The early results demonstrated that the UKR group had less complications and more rapid rehabilitation than the TKR group. At five years there were an equal number of failures in the two groups but the UKR group had more excellent results and a greater range of movement.

The cases were reviewed by a research nurse at 8, 10 and 12 years after operation. We report the outcome at 15 years follow-up. A total of 43 patients (45 knees) died with their prosthetic knees intact. Throughout the review period the Bristol knee scores of the UKR group have been better and at 15 years 15 (71.4%) of the surviving UKRs and 10 (52.6%) of the surviving TKRs had achieved an excellent score. The 15 years survivorship rate based on revision or failure for any reason was 24 (89.8%) for UKR and 19 (78.7%) for TKR. During the 15 years of the review four UKRs and six TKRs failed.

The better early results with UKR are maintained at 15 years with no greater failure rate. The median Bristol knee score of the UKR group was 91.1 at five years and 92 at 15 years, suggesting little functional deterioration in either the prosthesis or the remainder of the joint. These results justify the increased use of UKR.

Cigarette smoking increases the risk of rheumatoid arthritis. Results from a nationwide study of disease-discordant twins

OBJECTIVE

To test the hypothesis that cigarette smoking is associated with susceptibility to rheumatoid arthritis (RA) by comparing smoking history between twins with RA and their unaffected co-twins.

METHODS

Interview questionnaires on smoking history were administered to 79 identical (monozygotic [MZ]) and 71 same-sex nonidentical (dizygotic, [DZ]) twin pairs who were discordant for RA, recruited from the Arthritis and Rheumatism Council Twin Study. Results were expressed as odds ratios (OR) with 95% confidence intervals (95% CI).

RESULTS

Although most twin pairs were concordant for smoking history, there was a strong association between ever smoking and RA in the MZ pairs (OR 12.0, 95% CI 1.78-513), with a similar trend observed in the DZ pairs (OR 2.5, 95% CI 0.92-7.87).

CONCLUSION

The discordance in cigarette smoking history for individuals who are at presumed identical genetic risk for RA supports other data suggesting the role of smoking in disease susceptibility.

The structure and antigenicity of a type C foot-and-mouth disease virus

BACKGROUND

Picornaviruses are responsible for a wide range of mammalian diseases and, in common with other RNA viruses, show considerable antigenic variation. Foot-and-mouth disease viruses (FMDVs) constitute one genus of the picornavirus family and are classified into seven serotypes, each of which shows considerable intratypic variation. This antigenic variation leads to continuing difficulties in controlling the disease. To date the structure of only one serotype, O, has been reported.

RESULTS

The three-dimensional structure of a serotype C (isolate C-S8c1) FMDV, has been determined crystallographically at 3.5 A resolution. The main chain conformation of the virion is very similar to that of type O1 virus. The immunodominant G-H loop of VP1, the presumed site of cell attachment, is disordered in both types of virus indicating a functional role for flexibility of this region. There are significant changes in the structure of other antigenic loops and in some internal regions involved in protomer-protomer contacts, including the entire amino-terminal portion of VP2, described here for the first time for a picornavirus. Antigenic sites have been identified by genetic and peptide mapping methods, and located on the capsid. The data reveal a major new discontinuous antigenic site (site D) which is located near to the three-fold axis and involves residues of VP1, VP2 and VP3 which lie adjacent to each other on the capsid.

CONCLUSION

In FMDV type C, amino acid substitutions seen in mutants that are resistant to neutralization by monoclonal antibodies (MAbs) map to predominantly surface-oriented residues with solvent-accessible side-chains not involved in interactions with other amino acids, whereas residues which are accessible but not substituted are found to be more frequently involved in protein-protein interactions. This provides a molecular interpretation for the repeated isolation of the same amino acid substitutions in MAb-resistant variants, an observation frequently made with RNA viruses. This first comparison of two FMDV serotypes shows how subtle changes at antigenic sites are sufficient to cause large changes in antigenic specificity between serotypes.

Interferon-alpha does not improve outcome at one year in patients with diffuse cutaneous scleroderma: results of a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To determine whether interferon-alpha (IFNalpha) reduces the severity of skin involvement in early (<3 years) diffuse scleroderma.

METHODS

In a randomized, placebo-controlled, double-blind trial, 35 patients with early scleroderma received subcutaneous injections of either IFNalpha (13.5 x 10(6) units per week in divided doses) or indistinguishable placebo. Outcomes assessed were the modified Rodnan skin score, as determined by a single observer at baseline, 6 months, and 12 months, as well as data on renal, cardiac, and lung function. Pre- and posttreatment skin biopsy samples were analyzed and blood was obtained for assessment of procollagen peptide levels.

RESULTS

There were 11 withdrawals from the IFNalpha group and 3 from the placebo group due to either toxicity, lack of efficacy, or death. In the intent-to-treat analysis, there was a greater improvement in the skin score in the placebo group between 0 and 12 months (mean change IFNalpha -4.7 versus placebo -7.5; P = 0.36). There was also a greater deterioration in lung function in patients receiving active therapy, as assessed by either the forced vital capacity (mean change IFNalpha -8.2 versus placebo +1.3; P = 0.01) or the diffusing capacity for carbon monoxide (mean change IFNalpha -9.3 versus placebo +4.7; P = 0.002). Skin biopsy showed no significant decrease in collagen synthesis in the IFNalpha group, and no significant differences in the levels of procollagen peptides were seen between the 2 groups.

CONCLUSION

This study suggests that IFNalpha is of no value in the treatment of scleroderma, and that it may in fact be deleterious.

A phase II study to evaluate the efficacy of dexmedetomidine for sedation in the medical intensive care unit

OBJECTIVE

To evaluate dexmedetomidine for sedation of patients in the medical ICU.

DESIGN AND SETTING

Prospective observational study in an intensive care unit of a university hospital. PATIENTS. Twelve ventilated patients with median APACHE II score 23 (range 10-26).

INTERVENTIONS

Patients received a loading dexmedetomidine infusion of 1 microg x kg(-1) over 10 min followed by a maintenance infusion rate of 0.2-0.7 microg x kg(-1) x h(-1) for up to 7 days. After experience with the first four patients this maintenance rate of infusion was increased to a maximum of 2.5 microg kg(-1) x h(-1). If required, propofol and morphine provided rescue sedation and analgesia, respectively.

RESULTS

The first four patients with dexmedetomidine infusion at 0.7 microg x kg(-1) x h(-1)all required rescue sedation with a propofol infusion. A protocol amendment allowed the next eight patients to receive higher dexmedetomidine infusions (mean 1.0+/- microg x kg(-1) x h(-1)). Five of the next eight patients did not required propofol, and two patients only required minimal propofol infusions (20-40 mg x h(-1)). A further patient, with hepatic encephalopathy, required a propofol at 50-100 mg x h(-1). Only modest falls in arterial pressure, heart rate and cardiac output were seen, and no rebound sequelae occurred on discontinuation of dexmedetomidine. Adverse cardiovascular events were nearly all confined to the initial loading dose period of dexmedetomidine.

CONCLUSIONS

Sedation with dexmedetomidine is efficacious in critically ill medical patients requiring mechanical ventilation in the intensive care unit. A reduction in loading infusion is advised, but higher maintenance infusions may be required to that seen previously in the postoperative ICU patient.

Dissecting the roles of VP0 cleavage and RNA packaging in picornavirus capsid stabilization: the structure of empty capsids of foot-and-mouth disease virus

Empty capsids of foot-and-mouth disease virus (FMDV) type A22 Iraq 24/64, whose structure has been solved by X-ray crystallography, are unusual for picornaviruses since they contain VP2 and VP4, the cleavage products of the protein precursor VP0. Both the N terminus of VP1 and the C terminus of VP4, which pack together close to the icosahedral threefold symmetry axis where three pentamers associate, are more disordered in the empty capsid than they are in the RNA-containing virus. The ordering of these termini in the presence of RNA strengthens interactions within a single protomer and between protomers belonging to different pentamers. The disorder in the FMDV empty capsid forms a subset of that seen in the poliovirus empty capsid, which has VP0 intact. Thus, VP0 cleavage confers stability on the picornavirus capsid over and above that attributable to RNA encapsidation. In both FMDV and poliovirus empty capsids, the internal disordering uncovers a conserved histidine which has been proposed to be involved in the cleavage of VP0. A comparison of the putative active sites in FMDV and poliovirus suggests a structural explanation for the sequence specificity of the cleavage reaction.

Haloalkane dehalogenases: structure of a Rhodococcus enzyme

The hydrolytic haloalkane dehalogenases are promising bioremediation and biocatalytic agents. Two general classes of dehalogenases have been reported from Xanthobacter and Rhodococcus. While these enzymes share 30% amino acid sequence identity, they have significantly different substrate specificities and halide-binding properties. We report the 1.5 A resolution crystal structure of the Rhodococcus dehalogenase at pH 5.5, pH 7.0, and pH 5.5 in the presence of NaI. The Rhodococcus and Xanthobacter enzymes have significant structural homology in the alpha/beta hydrolase core, but differ considerably in the cap domain. Consistent with its broad specificity for primary, secondary, and cyclic haloalkanes, the Rhodococcus enzyme has a substantially larger active site cavity. Significantly, the Rhodococcus dehalogenase has a different catalytic triad topology than the Xanthobacter enzyme. In the Xanthobacter dehalogenase, the third carboxylate functionality in the triad is provided by D260, which is positioned on the loop between beta7 and the penultimate helix. The carboxylate functionality in the Rhodococcus catalytic triad is donated from E141. A model of the enzyme cocrystallized with sodium iodide shows two iodide binding sites; one that defines the normal substrate and product-binding site and a second within the active site region. In the substrate and product complexes, the halogen binds to the Xanthobacter enzyme via hydrogen bonds with the N(eta)H of both W125 and W175. The Rhodococcusenzyme does not have a tryptophan analogous to W175. Instead, bound halide is stabilized with hydrogen bonds to the N(eta)H of W118 and to N(delta)H of N52. It appears that when cocrystallized with NaI the Rhodococcus enzyme has a rare stable S-I covalent bond to S(gamma) of C187.

Thalamic contributions to attention and consciousness

A tacit assumption since the 19th Century has been that the neocortex serves as the "seat of consciousness." An unexpected challenge to that assumption arose in 1949 with the discovery that high-frequency EEG activation associated with an alert state requires the intactness of the brainstem reticular formation. This discovery became the impetus for nearly three decades of research on what came to be known as the reticular activating system. By the 1970s, however, methodological and philosophical controversies led to the general abandonment of subcortical theories of attention and consciousness, with a return to an almost exclusive focus upon the cortex. With recent advances in the neurosciences the focus is shifting once more, this time to the unique contributions of cortical, thalamic, and brainstem structures in mediating selective attention and perceptual awareness. This paper offers a nontechnical review of the history of these developments up to contemporary interest in the putative role of oscillatory EEG patterns in the integration of perceptual features of experience. It puts forward the thesis that a key to understanding attention and consciousness is an appreciation of the contributions of the thalamus to these cognitive processes.

Effect of a means-end contingency on young children's food preferences

This study showed that a means-end relationship between two snacks exerts a negative influence on preference for the means snack in the contingency. Two snacks ranked of approximately equal medium appeal were individually chosen from an array by each of 86 children (ages 4 years, 4 months to 7 years, 2 months). Children were then assigned to a means-end condition (where one snack was eaten as a means of gaining the other), a temporal order control group (where one snack was presented and eaten before the other), or a mere exposure control group (where the children chose the order in which they ate the two snacks). Post-treatment rankings of the snacks showed that children in the means-end group came to devalue the means snack relative to the reward snack, despite the demonstrably equal prior appeal of the two snacks. Children in the temporal order and mere exposure control groups did not come to prefer the two snacks preferentially. Implications of the finding that adults can affect children's preferences by relatively minor variations in the manner of presentation are discussed.

Crystal structure of the haloalkane dehalogenase from Sphingomonas paucimobilis UT26

The haloalkane dehalogenase from Sphingomonas paucimobilis UT26 (LinB) is the enzyme involved in the degradation of the important environmental pollutant gamma-hexachlorocyclohexane. The enzyme hydrolyzes a broad range of halogenated cyclic and aliphatic compounds. Here, we present the 1.58 A crystal structure of LinB and the 2.0 A structure of LinB with 1,3-propanediol, a product of debromination of 1,3-dibromopropane, in the active site of the enzyme. The enzyme belongs to the alpha/beta hydrolase family and contains a catalytic triad (Asp108, His272, and Glu132) in the lipase-like topological arrangement previously proposed from mutagenesis experiments. The LinB structure was compared with the structures of haloalkane dehalogenase from Xanthobacter autotrophicus GJ10 and from Rhodococcus sp. and the structural features involved in the adaptation toward xenobiotic substrates were identified. The arrangement and composition of the alpha-helices in the cap domain results in the differences in the size and shape of the active-site cavity and the entrance tunnel. This is the major determinant of the substrate specificity of this haloalkane dehalogenase.

Ambulatory 24 hour sleep-wake monitoring in narcolepsy-cataplexy compared to matched controls

Twenty-four hour ambulatory sleep-wake recordings were made in 10 untreated patients with narcolepsy-cataplexy and 10 matched controls. Nocturnal sleep of narcoleptics was similar to descriptions of laboratory based recordings and was characterized by frequent sleep onset REM periods, high variability of REM latency, increased amounts of wakefulness after sleep onset, and low sleep efficiencies. Daytime portions in narcoleptics showed greater drowsiness and sleep than in controls with significantly higher amounts of stages 1A, 1B, 3, 4 and REM, more sleep episodes longer than 1 and longer than 10 min in duration, and high intersubject variability. On average, only 1.2 daytime sleep episodes began with sleep onset REM periods. There was a strong tendency in both groups towards a long mid-afternoon sleep episode often containing slow wave sleep (SWS) and which was significantly longer in narcoleptics. The mean interval between the onset of nocturnal SWS and the main daytime SWS peak was 14.1 h for narcoleptics and 13.6 h for controls. Daytime waking portions in narcoleptics showed significantly less 'active wakefulness' than in controls. There was no correlation between MSLT measures of sleepiness and amount of daytime sleep in ambulant recordings.

Structure of translation initiation factor 5A from Pyrobaculum aerophilum at 1.75 A resolution

BACKGROUND

Translation initiation factor 5A (IF-5A) is reported to be involved in the first step of peptide bond formation in translation, to be involved in cell-cycle regulation and to be a cofactor for the Rev and Rex transactivator proteins of human immunodeficiency virus-1 and T-cell leukemia virus I, respectively. IF-5A contains an unusual amino acid, hypusine (N-epsilon-(4-aminobutyl-2-hydroxy)lysine), that is required for its function. The first step in the post-translational modification of lysine to hypusine is catalyzed by the enzyme deoxyhypusine synthase, the structure of which has been published recently.

RESULTS

IF-5A from the archebacterium Pyrobaculum aerophilum has been heterologously expressed in Escherichia coli with selenomethionine substitution. The crystal structure of IF-5A has been determined by multiwavelength anomalous diffraction and refined to 1.75 A. Unmodified P. aerophilum IF-5A is found to be a beta structure with two domains and three separate hydrophobic cores.

CONCLUSIONS

The lysine (Lys42) that is post-translationally modified by deoxyhypusine synthase is found at one end of the IF-5A molecule in an turn between beta strands beta4 and beta5; this lysine residue is freely solvent accessible. The C-terminal domain is found to be homologous to the cold-shock protein CspA of E. coli, which has a well characterized RNA-binding fold, suggesting that IF-5A is involved in RNA binding.

Activity of an alcohol-based hand gel against human adeno-, rhino-, and rotaviruses using the fingerpad method

OBJECTIVE

To assess the activity against three non-enveloped viruses (an adeno-, a rhino- and a rotavirus) of a gel containing 60% ethanol, using experimentally contaminated thumb- and fingerpads of 12 panelists, as per standard procedure E-1838-96 of the American Society of Testing and Materials.

DESIGN

Each digit received 10 microL of the test virus suspension. The inoculum from the thumbs was eluted immediately with 990 microL of Earle's balanced salt solution (EBSS) to assess the amount of virus on each digit (0-minute control). The inoculum on the fingers was allowed to dry (20-25 minutes), and virus was eluted from two fingerpads to determine the loss in virus infectivity upon drying (baseline titer). Then the dried inoculum on randomly selected fingers was exposed to 1 mL of the test product or standard hard water (200-ppm calcium carbonate) for 20 seconds. The virus remaining was eluted with 1 mL of EBSS, titrated to determine the amounts eliminated, and compared to the baseline titer.

RESULTS

Each digit received at least 10(4) plaque-forming units of virus in 10 microL. The amounts of adeno-, rhino-, and rotaviruses surviving the drying were 30%, 75%, and 42%, respectively. The product reduced the infectivity titers of the three viruses by 3 to >4 log10 when compared to a reduction of < or =1 log10 for the hard-water rinse.

CONCLUSION

The level of virus reduction by gel was statistically significantly higher than that seen with the water control. Evidence for such activity against non-enveloped viruses supports further investigation of the benefits of this product.

Structure of the complex of an Fab fragment of a neutralizing antibody with foot-and-mouth disease virus: positioning of a highly mobile antigenic loop

Data from cryo-electron microscopy and X-ray crystallography have been combined to study the interactions of foot-and-mouth disease virus serotype C (FMDV-C) with a strongly neutralizing monoclonal antibody (mAb) SD6. The mAb SD6 binds to the long flexible GH-loop of viral protein 1 (VP1) which also binds to an integrin receptor. The structure of the virus-Fab complex was determined to 30 A resolution using cryo-electron microscopy and image analysis. The known structure of FMDV-C, and of the SD6 Fab co-crystallized with a synthetic peptide corresponding to the GH-loop of VP1, were fitted to the cryo-electron microscope density map. The SD6 Fab is seen to project almost radially from the viral surface in an orientation which is only compatible with monovalent binding of the mAb. Even taking into account the mAb hinge and elbow flexibility, it is not possible to model bivalent binding without severely distorting the Fabs. The bound GH-loop is essentially in what has previously been termed the 'up' position in the best fit Fab orientation. The SD6 Fab interacts almost exclusively with the GH-loop of VP1, making very few other contacts with the viral capsid. The position and orientation of the SD6 Fab bound to FMDV-C is in accord with previous immunogenic data.

Laser therapy of spider leg veins: clinical evaluation of a new long pulsed alexandrite laser

BACKGROUND

The response of spider leg veins to laser or intense pulsed light therapy has generally been characterized by varying degrees of success and frequently inconsistent clinical response rates.

OBJECTIVE

The purpose of this study was to examine the effectiveness of the 755 nm long pulsed infrared alexandrite (LPA) laser for the treatment of leg telangiectasias.

METHODS

This study was constructed in four phases. Phase I examined 28 patients with variable sized telangiectasias using 5 treatment parameters (15 J/cm2 x 1 pulse, 20 J/cm2 x 1 pulse, 20 J/cm2 x 2 pulses, 20 J/cm2 x 3 pulses, or 30 J/cm2 x 1 pulse). Each patient received 3 treatments at 4 week intervals with the LPA. Patient diaries were obtained to examine the effects of the treatments. Subjective grading was performed at each follow-up visit by the investigators. Blinded objective grading was performed at the conclusion of the study by trained observers. Phase II examined the effects of these treatment parameters on varying vessel diameters. Vessels were grouped into small (<0.4 mm), intermediate (0.4-1.0 mm), and large (1.0-3.0 mm) subsets. Phase III examined the effects of a combination of LPA treatment followed by 23.4% hypertonic saline sclerotherapy. Subjective and blinded objective grading was used to determine improvement after a single treatment with the LPA at 20 J/cm2, single pulsed with a pulse duration of 5 or 10 msec followed by treatment with 23.4% hypertonic saline injected 3, 7, 14, or 28 days after laser therapy. Phase IV involved biopsies after LPA treatment alone at time intervals of immediately posttreatment and 5 and 21 days posttreatment.

RESULTS

These evaluations revealed that the optimal treatment parameters for LPA therapy alone appeared to be 20 J/cm2, double pulsed at a repetition rate of one Hz. After 3 treatments at 4 week intervals, subjective grading indicated a 63% reduction in leg telangiectasias. Medium diameter vessels responded best with small vessel diameters responding poorly, if at all. The addition of 23.4% hypertonic saline sclerotherapy performed 3 to 7 days after laser therapy (LPA at 20 J/cm2, single pulsed with a pulse duration of 5 msec) produced 87% reduction in leg telangiectasias. Biopsies after LPA treatment revealed vessel wall endothelial cell necrosis at 5 days with fibrosis occurring at 3 weeks. The optimal clinical "window" for sclerotherapy seems to coincide with the period of endothelial cell necrosis.

CONCLUSION

LPA therapy is most effective for leg telangiectasias 0.4-3.0 mm in diameter. This LPA technique is significantly improved with the addition of sclerotherapy.