Localization and regulation of MuSK at the neuromuscular junction

The receptor tyrosine kinase, MuSK, is required for the formation of the neuromuscular junction (NMJ) where MuSK becomes phosphorylated when exposed to neuronally synthesized isoforms of agrin. To understand better the mechanisms by which MuSK mediates the formation of the NMJ, we have examined how MuSK expression is regulated during development in the embryo, by neuromuscular injury in the adult and by agrin in vitro. Here we show that MuSK is associated with the earliest observable AChR clusters at the developing motor endplate and that MuSK and AChRs codistribute throughout the development of the NMJ. These two proteins are also coordinately regulated on the surfaces of cultured myotubes where MuSK and AChRs colocalize both in spontaneous and agrin-induced clusters. While MuSK is normally restricted to the motor endplate in adult muscle, denervation results in its extrajunctional expression, although a discernible concentration of MuSK remains localized to the motor endplate even 14 days after denervation. Extrajunctional MuSK is first apparent 3 days after denervation and is sharply reduced upon reinnervation. Muscle paralysis also markedly alters the expression of MuSK in adult muscle and results in increased expression of MuSK as well as increased transcription of MuSK mRNA by extrasynaptic myonuclei. Together, these findings demonstrate that MuSK expression is highly regulated by innervation, muscle activity, and agrin, while the distribution of MuSK is precisely coordinated with that of the AChR.

Body mass-specific Na+-K+-ATPase activity in the medullary thick ascending limb: implications for species-dependent urine concentrating mechanisms

In general, the mammalian whole body mass-specific metabolic rate correlates positively with maximal urine concentration (U_max) irrespective of whether or not the species have adapted to arid or mesic habitat. Accordingly, we hypothesized that the thick ascending limb (TAL) of a rodent with markedly higher whole body mass-specific metabolism than rat exhibits a substantially higher TAL metabolic rate as estimated by Na⁺-K⁺-ATPase activity and Na⁺-K⁺-ATPase α1-gene and protein expression. The kangaroo rat inner stripe of the outer medulla exhibits significantly higher mean Na⁺-K⁺-ATPase activity (~70%) compared with two rat strains (Sprague-Dawley and Munich-Wistar), extending prior studies showing rat activity exceeds rabbit. Furthermore, higher expression of Na⁺-K⁺-ATPase α1-protein (~4- to 6-fold) and mRNA (~13-fold) and higher TAL mitochondrial volume density (~20%) occur in the kangaroo rat compared with both rat strains. Rat TAL Na⁺-K⁺-ATPase α1-protein expression is relatively unaffected by body hydration status or, shown previously, by dietary Na⁺, arguing against confounding effects from two unavoidably dissimilar diets: grain-based diet without water (kangaroo rat) or grain-based diet with water (rat). We conclude that higher TAL Na⁺-K⁺-ATPase activity contributes to relationships between whole body mass-specific metabolic rate and high U_max. More vigorous TAL Na⁺-K⁺-ATPase activity in kangaroo rat than rat may contribute to its steeper Na⁺ and urea axial concentration gradients, adding support to a revised model of the urine concentrating mechanism, which hypothesizes a leading role for vigorous active transport of NaCl, rather than countercurrent multiplication, in generating the outer medullary axial osmotic gradient.

Well-being in Residency: Impact of an Online Physician Well-being Course on Resiliency and Burnout in Incoming Residents

BACKGROUND AND OBJECTIVES

Wellness in residency has come to the forefront of national graduate medical education initiatives. Exponential growth in knowledge and skill development occurs under immense pressures, with physical, mental, and emotional stressors putting residents at burnout risk. The Accreditation Council for Graduate Medical Education requires programs to attend to resident wellness, providing the structure, environment, and resources to address burnout. This study's purpose was to evaluate the Andrew Weil Center for Integrative Medicine online Physician Well-being Course (PWC) with incoming postgraduate year-1 (PGY-1) residents in multiple residencies across a single health care system. The PWC teaches the learner strategies for building resilience, managing stress, identifying signs of burnout, and mindfulness practices including a self-selected daily 10-minute resiliency activity (meditation, gratitude journaling, and finding meaning journaling) for 14 days.

METHODS

Incoming PGY-1 residents were enrolled in PWC 1 month prior to 2018 orientation. Validated measures of resiliency, burnout and gratitude were completed pre- and postcourse. We assessed pre/postcourse changes with paired t tests. We asked participants whether they incorporated any wellness behavior changes postcourse.

RESULTS

Almost two-thirds of the incoming trainees completed the course (n=53/87, 61%). We found significant improvements (P<.05) for resiliency and burnout (emotional exhaustion, depersonalization). Gratitude did not change. The personal accomplishment burnout scale declined. The most frequently reported wellness behaviors were in the area of sleep, exercise, and diet.

CONCLUSIONS

Resiliency, emotional exhaustion, and depersonalization improved, personal accomplishment declined, while gratitude remained the same. This project demonstrates an accessible and scalable approach to teaching well-being to incoming residents.

Response of lymphocytes to plant lectins. I. A thymic-dependent lymphoid population responsive to pokeweed mitogen

The response of lymph node, bone marrow, splenic and thymic lymphocytes to phytohaemagglutinin and Pokeweed mitogen has been studied. Depletion of theta positive or recirculating lymphocytes abolished the response to phytohaemagglutinin but did not impair the response to Pokeweed mitogen. Lymphocytes from thymectomized or athymic `nude' mice respond poorly or not at all to phytohaemagglutinin or Pokeweed mitogen.

We conclude that the normal response to Pokeweed mitogen depends upon an intact thymus gland. This despite the fact that one population of Pokeweed mitogen-responsive cells are theta-negative bone marrow-derived cells. This conclusion is based upon: (1) the equal reactivity of theta-positive and theta-negative lymphocytes to Pokeweed mitogen as shown by the normal response to Pokeweed mitogen of anti-theta serum treated lymphoid populations and (2) the impaired response of lymphocytes from nude mice and of lymphocytes from thymectomized, irradiated and bone marrow reconstituted mice to Pokeweed mitogen.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.