Interconception Care for Adolescent Women During the COVID-19 Pandemic

BACKGROUND AND OBJECTIVE

Interconception care (ICC) is a means of improving health outcomes for women and children by mitigating maternal risks between pregnancies. Within a pediatric medical home ICC is reliant on adherence to well-child visits (WCVs). We hypothesized that a pediatric-based ICC model would remain successful in providing access to services for adolescent women for those seen during the COVID19 pandemic. The objective of this study was to determine if the COVID19 pandemic influenced LARC use and repeat pregnancy for those seen for ICC in a dyadic pediatric medical home.

METHODS

The pre-COVID cohort was comprised of adolescent women seen for ICC from September 2018-October 2019. The COVID cohort was comprised of adolescent women seen for ICC from March 2020-March 2021. The two cohorts were compared across multiple characteristics including sociodemographic factors, age, education, number of visits, contraceptive choice and repeat pregnancy during the study interval.

RESULTS

The COVID cohort were significantly more likely to be primiparous, seen with a younger infant, and attend fewer visits than the pre-COVID cohort. The COVID cohort were equally likely to initiate long-acting reversible contraception but less likely to experience a repeat pregnancy.

CONCLUSIONS

The COVID19 pandemic limited access to routine healthcare and likely impacted access to ICC for many women. ICC provided during WCVs allowed access to care even amid the restrictions of the COVID19 pandemic. Both effective contraception and decreased repeat pregnancy were maintained, highlighting the effectiveness of this approach for ICC within a dyadic pediatric medical home.

How do fluctuating ecological dynamics impact the evolution of hosts and parasites?

Theoretical models of the evolution of parasites and their hosts have shaped our understanding of infectious disease dynamics for over 40 years. Many theoretical models assume that the underlying ecological dynamics are at equilibrium or constant, yet we know that in a great many systems there are fluctuations in the ecological dynamics owing to a variety of intrinsic or extrinsic factors. Here, we discuss the challenges presented when modelling evolution in systems with fluctuating ecological dynamics and summarize the main approaches that have been developed to study host-parasite evolution in such systems. We provide an in-depth guide to one of the methods by applying it to two worked examples of host evolution that have not previously been studied in the literature: when cycles occur owing to seasonal forcing in competition, and when the presence of a free-living parasite causes cycles, with accompanying interactive Python code provided. We review the findings of studies that have explored host-parasite evolution when ecological dynamics fluctuate, and point to areas of future research. Throughout we stress the importance of feedbacks between the ecological and evolutionary dynamics in driving the outcomes of infectious disease systems. This article is part of the theme issue 'Infectious disease ecology and evolution in a changing world'.

Implementing Interconception Care in a Dyadic Adolescent Mother-Child Clinic

INTRODUCTION

The birth of a second child to an adolescent woman worsens the adverse medical, socioeconomic, educational, and parenting outcomes for the woman and her children. Despite the known high efficacy of long-acting reversible contraception (LARC), many postpartum adolescents use less effective or no contraception. Interconception care (ICC) focuses on modifying maternal risks between pregnancies and promoting healthy birth spacing to improve outcomes for women and children. Research shows that women regularly attend their child's health care visits even if they do not seek care for themselves between pregnancies. These visits present a potential opportunity for providers to educate women on available LARC options.

METHODS

In an adolescent mother-child clinic, demographic and ICC screening data were collected on women presenting for well child visits of children age 0-24 months. These data were analyzed using logistic regression models to identify independent predictors of LARC initiation and repeat pregnancy.

RESULTS

Mother-child dyads were screened an average of two times in the study period. Participants with only one visit were less likely to initiate LARC. Of the participants, 5.5% became pregnant again, with patients having only one ICC visit being slightly, but not significantly more likely. Hispanic ethnicity and having ≥ 2 visits were significant independent predictors of LARC initiation. The only independent predictor of repeat pregnancy was not initiating LARC.

CONCLUSIONS

This study suggests that optimal ICC may rely on consistent and frequent touch points with providers and not solely on the medical management during the interconception period, making it adaptable to a traditional pediatric medical home. Tying the worlds of pediatric and maternal healthcare is pivotal for successful ICC.

Health care’s climate footprint: the health sector contribution and opportunities for action

While vastly differing in scale, each nation's health sector directly and indirectly releases greenhouse gases (GHG) through energy consumption, transport, and product manufacture, use, and disposal. Until recently, however, the health sector has not been measured as a coherent segment of the world's climate footprint. A 2019 report by Health Care Without Harm, in collaboration with Arup, provides the most comprehensive global analysis of health care's contribution to climate change to date, based on full global coverage of spending data together with detailed information from 43 countries. It identifies key sources of health care emissions while allowing for comparison between nations and among many regions of the world. Among the report's key findings are that health care's climate footprint is equivalent to 4.4% of global net emissions; that the top three health care emitters-the United States, China, and the European Union-comprise more than half of the global footprint; and that 71% of emissions are derived from the health care supply chain. The findings inform a series of international, national, and subnational policy recommendations for health care climate action, and it identifies opportunities for further research and methodological development to support the health sector in its efforts to understand and address its climate footprint. Additional findings from 2020 will also be presented. Ultimately, these estimates of health care's climate footprint provide the baseline information needed to devise pathways and track progress toward health care de-carbonization across the sector.

Diversity and the maintenance of sex by parasites

The Red Queen hypothesis (RQH) predicts that parasite-mediated selection will maintain sexual individuals in the face of competition from asexual lineages. The prediction is that sexual individuals will be difficult targets for coevolving parasites if they give rise to more genetically diverse offspring than asexual lineages. However, increasing host genetic diversity is known to suppress parasite spread, which could provide a short-term advantage to clonal lineages and lead to the extinction of sex. We test these ideas using a stochastic individual-based model. We find that if parasites are readily transmissible, then sex is most likely to be maintained when host diversity is high, in agreement with the RQH. If transmission rates are lower, however, we find that sexual populations are most likely to persist for intermediate levels of diversity. Our findings thus highlight the importance of genetic diversity and its impact on epidemiological dynamics for the maintenance of sex by parasites.

Agonist-induced internalization and mitogen-activated protein kinase activation of the human prostaglandin EP4 receptor

We examined the pathway of prostaglandin E(2) (PGE(2))-induced internalization of the prostaglandin EP4 receptor in HEK 293 cells. Co-expression of dominant negative beta-arrestin (319-418) or dynamin I (K44A) with the EP4 receptor reduced internalization. The activated receptor co-localized with GFP-arrestin 2 and GFP-arrestin 3, confirming the requirement for beta-arrestins in internalization. Inhibition of clathrin-coated vesicle-mediated internalization resulted in inhibition of sequestration, whereas inhibition of caveola-mediated internalization had no effect. PGE(2) stimulation of the EP4 receptor resulted in rapid mitogen-activated protein (MAP) kinase activation. Examination of an internalization-resistant mutant and co-expression of mutant accessory proteins with EP4 revealed that MAP kinase activation proceeds independently of internalization.

Patterns of cyclic AMP formation by coexpressed D1 and D2L dopamine receptors in HEK 293 cells

Recent studies using immunofluorescence confocal microscopy (Aizman et al., Nature neuroscience (2000) 3, 226-230) present compelling evidence for colocalization of D1 and D2 dopamine receptors on neurons in the striatum and nucleus accumbens. To examine some of the biochemical consequences of colocalization we coexpressed the D1 and D2 dopamine receptors in HEK293 cells. Dopamine D1 and D2 receptors couple to stimulation and inhibition of adenylyl cyclase, respectively. In cells expressing only the D1 receptor, dopamine stimulated cAMP formation with an EC50 of 2.15 nM. In cells expressing only the D2L receptor, dopamine inhibited cAMP formation by 80% with an EC50 of 0.02 nM. The effect of dopamine on the D2L receptor was antagonized by the selective antagonist spiperone with an IC50 of 0.31 nM. In cells coexpressing both the D1 and D2L receptors, dopamine caused an increase in cAMP that was only 20% of that observed with the D1 receptor alone. In this case, increasing concentrations of spiperone caused a change in the dose-response curve from hyperbolic to bell-shaped as the concentration of spiperone was increased. Using pharmacological constants determined from studies on the individually expressed receptors, the curves obtained in cells co-expressing the two receptors could be modeled by kinetic expressions derived by summing the contributions from each receptor. The model leads to a re-interpretation of the pharmacology of dopaminergic ligands. Hence, one consequence of colocalization is that D2 receptor antagonists become functional agonists of cAMP formation.

Determination of D1 and D2 dopamine receptor expression by Ntera-2 cells

There is evidence that D1 and D2 dopamine receptors are co-expressed on some neurons. As a potential model of co-expression we examined Ntera-2 cells using RT-PCR, and showed that they express D2 but not D1 receptors. D2 dopamine receptor expression was confirmed by quinpirole inhibition of forskolin-stimulated cAMP formation. Absence of D1 dopamine receptors was confirmed by the inability of dopamine or SKF 81297 to increase cAMP.

Comparison of agonist-induced internalization of the human EP2 and EP4 prostaglandin receptors: role of the carboxyl terminus in EP4 receptor sequestration

Prostaglandin E(2) (PGE(2)) couples to stimulation of adenylyl cyclase through two distinct G protein-coupled receptors designated EP2 and EP4. Although they have similar affinities for PGE(2), the EP(2) and EP4 receptors have distinct structural characteristics. EP2 is a 358-amino-acid protein with short third intracellular loop and C-terminal domains, whereas EP4 consists of 488 amino acids with a long third intracellular loop and a long cytoplasmic tail. The ability of the HA epitope-tagged receptors to undergo PGE(2)-induced internalization was examined by enzyme-linked immunosorbent assay and immunofluorescence microscopy after expression in human embryonic kidney 293 cells. The EP2 receptor did not internalize, whereas the EP4 receptor underwent rapid internalization. Truncation of the EP4 receptor after amino acid 350, which removes 138 residues, abolished internalization. Truncation after amino acid 369 markedly attenuated internalization, whereas truncation after amino acid 383 had little effect. Serine and threonine residues in the region 350 to 383 were mutated to determine their role in internalization. The mutants S370-382A, a full-length receptor containing six serine-to-alanine mutations in the region 370 to 382, and S354-369A, containing four serine mutations and one threonine mutation in the region 350 to 370, both internalized to the same extent as the wild-type. A further mutant, designated S354-382A, containing amino acid substitutions S354A, S359A, S364A, S366G, T369A, S370A, S371A, S374A, S377A, S379A, and S382A, also internalized to the same extent as the wild-type. We conclude that the C terminus of the EP4 receptor is involved in internalization; however, serine and threonine residues do not seem to be involved.

Distribution of prostaglandin IP and EP receptor subtypes and isoforms in platelets and human umbilical artery smooth muscle cells

Prostaglandins act through specific receptors to stimulate cyclic AMP formation which inhibits platelet activation and relaxes vascular smooth muscle. We have used RT-PCR combined with Southern blot analysis to determine the subtypes of prostaglandin receptor on platelets. Platelets expressed the EP4 rather than the EP2 prostaglandin EP receptor subtype, whereas vascular smooth muscle cells predominantly expressed the EP2 receptor. The IP receptor, which binds prostacyclin and couples to stimulation of adenylyl cyclase, and three isoforms of the inhibitory EP3 receptor were equally expressed in platelets, HEL cells and umbilical artery smooth muscle cells. The EP3-II isoform showed variation in level of expression among the three cell types. As a positive control for the presence of platelet RNA, PCR was performed using primers specific for the alpha chain of the platelet membrane glycoprotein Ib. As a negative control for the absence of T and B cell contamination in the platelet RNA, PCR was performed using primers specific for the cell specific cluster determinants CD2 (a T-cell marker) and CD20 (a B-cell marker). The finding that platelets express both stimulatory and inhibitory prostaglandin receptors provides confirmation of a homeostatic model of regulation of platelet adenylyl cyclase previously proposed.

Agonist-induced desensitization and down-regulation of the human kappa opioid receptor expressed in Chinese hamster ovary cells

In this study, we examined whether the human kappa opioid receptor stably expressed in Chinese hamster ovary cells underwent desensitization and down-regulation after prolonged exposure to the agonist (-)U50,488H. Pretreatment with (-)U50,488H led to a reduction in the magnitude of increase in [35S]GTPgammaS binding by the subsequent application of (-)U50,488H. The extent of desensitization was related to duration of exposure and (-)U50,488H concentration. Pretreatment with (-)U50,488H also reduced the potency of (-)U50,488H in inhibiting forskolin-stimulated adenylate cyclase. In membranes of (-)U50,488H-pretreated cells, the affinity of (-)U50,488H was lower than that in the untreated control, and GTPgammaS had no effect on (-)U50,488H affinity, consistent with the notion of uncoupling of the receptor-G protein complex by (-)U50, 488H treatment. Down-regulation of the kappa opioid receptor also occurred on exposure to (-)U50,488H. Higher (-)U50,488H concentrations and/or longer incubation periods were required for down-regulation than for desensitization. The degree of down-regulation depended on the agonist concentration and incubation time. (-)U50,488H-induced desensitization and down-regulation were blocked by naloxone. (+)U50,488H, an inactive stereoisomer, did not cause desensitization or down-regulation. These results indicate that both processes were receptor-mediated. After incubation with (-)U50,488H and removal of (-)U50,488H, both (-)U50,488H-induced [35S]GTPgammaS binding and receptor number returned to the control level, which indicates that both processes were reversible. Thus, desensitization and down-regulation of the kappa opioid receptor occur after agonist exposure and represent two different adaptation mechanisms.

Co-expression of prostaglandin receptors with opposite effects: a model for homeostatic control of autocrine and paracrine signaling

Prostaglandins are ubiquitous autocrine mediators that exert their effects through a number of G protein-coupled receptors. Many organs and tissues express many of the prostaglandin receptors, and prostaglandins have diverse effects on individual organs and tissues. In some cases, several prostaglandin receptors are expressed on a single cell type. Co-expressed prostaglandin receptors frequently appear to have opposite actions, suggesting homeostatic control of prostaglandin effects. Co-expression of opposing receptors provides a molecular mechanism for weak or partial agonism and explains the action of a drug as a mixed agonist/antagonist. The physiological relevance of co-expressed opposing receptors for a single agonist perhaps can be explained in terms of the difference between endocrine and autocrine mediators. Endocrine hormones are generally produced by cells distant from their site of action so that they are diluted to an elevated but stable concentration by the time they reach their target cells. In contrast, autocoids are produced by the same cell type on which they act and may reach transiently high levels at their sites of action. The presence of a second type of receptor that negates the action of the first receptor would tend to buffer cellular responses to transient extremes of agonist concentration. The slow onset of inhibition would also allow for time-dependent buffering, providing additional control over autocoid release and effect. The mechanism is relevant to other autocrine and paracrine mediators including neurotransmitters, which reach transiently high concentrations in the synaptic cleft.

Molecular basis for ADP-induced platelet activation. I. Evidence for three distinct ADP receptors on human platelets

Acting through cell surface receptors, ADP activates platelets resulting in shape change, aggregation, thromboxane A2 production, and release of granule contents. ADP also causes a number of intracellular events including inhibition of adenylyl cyclase, mobilization of calcium from intracellular stores, and rapid calcium influx in platelets. However, the receptors that transduce these events remain unidentified and their molecular mechanisms of action have not been elucidated. The receptor responsible for the actions of ADP on platelets has been designated the P2T receptor. In this study we have used ARL 66096, a potent antagonist of ADP-induced platelet aggregation, and a P2X ionotropic receptor agonist, alpha,beta-methylene adenosine 5'-triphosphate, to distinguish the ADP-induced intracellular events. ARL 66096 blocked ADP-induced inhibition of adenylyl cyclase, but did not affect ADP-mediated intracellular calcium increases or shape change. Both ADP and 2-methylthio-ADP caused a 3-fold increase in the level of inositol 1,4,5-trisphosphate over control levels which peaked in a similar fashion to the Ca2+ transient. The increase in inositol 1,3,4-trisphosphate was of similar magnitude to that of inositol 1,4,5-trisphosphate. alpha,beta-Methylene adenosine 5'-triphosphate did not cause an increase in either of the inositol trisphosphates. These results clearly demonstrate the presence of two distinct platelet ADP receptors in addition to the P2X receptor: one coupled to adenylyl cyclase and the other coupled to mobilization of calcium from intracellular stores through inositol trisphosphates.

Constitutive activity of human prostaglandin E receptor EP3 isoforms

1. The human EP3 prostaglandin receptor is a seven transmembrane, G protein-coupled receptor that couples to inhibition of adenylyl cyclase. The receptor occurs as at least six isoforms which result from alternative splicing. The isoforms are identical over the first 359 amino acids, comprising the seven transmembrane helices, but differ in the carboxyl terminal tail which ranges in length from 6 to 65 amino acids beyond the common region. 2. We have stably expressed in CHO-K1 cells four of the isoforms (EP3I-EP3IV) and a form of the EP3 receptor (T-359) truncated at the carboxyl-terminal region defined by the alternative splicing site at amino acid number 359. 3. Isoforms EP3I and EP3II showed concentration-dependent inhibition of forskolin-stimulated adenylyl cyclase in CHO-K1 cells by the EP3 receptor agonist, sulprostone. The IC50 calculated for sulprostone inhibition was 0.2 nM for EP3I and 0.15 nM for EP3II. The maximum extent of inhibition was 80% for both isoforms. 4. Isoforms EP3III and EP3IV showed marked constitutive activity, inhibiting forskolin-stimulated adenylyl cyclase in the absence of agonist. EP3IV also displayed some agonist-dependent inhibition whereas EP3III was fully constitutively active. 5. The truncated receptor T-359 was fully constitutively active, inhibiting forskolin-stimulated adenylyl cyclase by about 70% in the absence of agonist, and showed no agonist-dependent inhibition, in agreement with a similar truncation of the mouse EP3 receptor. 6. To confirm that differences in cyclic AMP level between isoforms represent constitutive activity, we treated cells with pertussis toxin for 6 h to abolish Gi function. Pertussis toxin reversed sulprostone-mediated inhibition of cyclic AMP formation in EP3I and EP3II and abolished constitutive activity of EP3III, EP3IV and T-359 so that the level of forskolin-stimulated cyclic AMP produced was the same in all cells and similar to that obtained in mock-transfected cells. In mock-transfected cells, sulprostone had no effect on forskolin-stimulated cyclic AMP formation. 7. For these experiments we chose clones that showed similar expression levels of each isoform, as determined by binding of [3H]-prostaglandin E2 (PGE2) (EP3I, 0.71; EP3II, 1.47; EP3IV, 1.59 pmol mg-1 protein). Mock-transfected cells showed no detectable binding of [3H]-PGE2. In addition, we performed a detailed study of the effects of expression level on constitutive activity. Over a six fold range of expression there was no change in the properties of each isoform with regard to whether it was constitutively active or not. 8. The degree of constitutive activity correlated with the inverse of the length of the C-terminal tail of the isoforms. However, no correlation was found between isoforms from human and mouse: whereas EP3II shows no constitutive activity, its mouse homologue, EP3 gamma, shows almost complete constitutive activity, even though the C-terminal domains of the receptors following the splice site differ in only 7 of 29 amino acids.

The long cytoplasmic carboxyl terminus of the prostaglandin E2 receptor EP4 subtype is essential for agonist-induced desensitization

The 488-amino acid human prostaglandin E2 receptor EP4 subtype, which couples to stimulation of adenylyl cyclase, shares the major structural features of G protein-coupled receptors, having seven putative transmembrane domains, an extracellular amino terminus, and a cytoplasmic carboxyl terminus. The latter is composed of 156 amino acids and contains 38 serine and threonine residues, which are potential phosphorylation sites. The carboxyl terminus may be important in receptor function; in some receptors, truncation of the cytoplasmic tail abolishes desensitization. In others, truncation leads to constitutive activity, and in other receptors, truncation has no effect on receptor function. To investigate the role of the long cytoplasmic tail of the EP4 receptor, we constructed a mutant EP4 that lacks the last 138 amino acids at the carboxyl terminus, including 36 serine and threonine residues. The truncated EP4 receptor was stably expressed in Chinese hamster ovary cells at levels comparable to that of the wild-type receptor and exhibited a Kd value for [3H]PGE2 binding similar to that of the wild-type receptor. PGE2-mediated adenylyl cyclase activity as a function of PGE2 concentration was similar in cells expressing the wild-type and truncated EP4 receptors. Neither the wild-type receptor nor the truncated form showed any constitutive activity. However, the wild-type EP4 receptor underwent PGE2-induced desensitization fully within 15-20 min, whereas the truncated EP4 receptor, lacking 36 of the 38 carboxyl-terminal serines and threonines, displayed a sustained activation. Despite the continuous presence of PGE2, the rate of cAMP synthesis via stimulation of the truncated receptor remained constant over > or = 20 min. These findings suggest that the cytoplasmic tail of EP4 plays an important role in agonist-induced desensitization.

Prostaglandin E2 both stimulates and inhibits adenyl cyclase on platelets: comparison of effects on cloned EP4 and EP3 prostaglandin receptor subtypes

The effects of prostaglandin E2 (PGE2) on platelet cyclic AMP formation were examined and compared with effects on cloned prostaglandin receptors. PGE2 gave a weak stimulation of adenyl cyclase in platelets compared with the PGI2 analog Iloprost. In the presence of the adenyl cyclase stimulator forskolin, the response to PGE2 was amplified in a synergistic manner. By contrast, in the presence of Iloprost, PGE2 inhibited cyclic AMP formation. We postulate that the weak platelet response to PGE2 is due to co-localization of a PGE2 receptor that couples to stimulation of adenyl cyclase with the EP3 prostaglandin receptor that binds PGE2 tightly and inhibits adenyl cyclase. In support of this postulate, we compared the responses obtained with platelets with those of cloned EP4 (stimulatory) and EP3 (inhibitory) prostaglandin receptor subtypes and show similar dose-response curves for stimulation and inhibition of cyclic AMP formation between platelets and cloned receptors.

Molecular cloning of a novel P2 purinoceptor from human erythroleukemia cells

Screening of a human erythroleukemia cell cDNA library with radiolabeled chicken P2Y3 cDNA at low stringency revealed a cDNA clone encoding a novel G protein-coupled receptor with homology to P2 purinoceptors. This receptor, designated P2Y7, has 352 amino acids and shares 23-30% amino acid identity with the P2Y1-P2Y6 purinoceptors. The P2Y7 cDNA was transiently expressed in COS-7 cells: binding studies thereon showed a very high affinity for ATP (37 +/- 6 nM), much less for UTP and ADP (approximately 1300 nM), and a novel rank order of affinities in the binding series studied of 8 nucleotides and suramin. The P2Y7 receptor sequence appears to denote a different subfamily from that of all the other known P2Y purinoceptors, with only a few of their characteristic sequence motifs shared. The P2Y7 receptor mRNA is abundantly present in the human heart and the skeletal muscle, moderately in the brain and liver, but not in the other tissues tested. The P2Y7 receptor mRNA was also abundantly present in the rat heart and cultured neonatal rat cardiomyocytes. The P2Y7 receptor is functionally coupled to phospholipase C in COS-7 cells transiently expressing this receptor. The P2Y7 gene was shown to be localized to human chromosome 14. We have thus cloned a unique member of the P2Y purinoceptor family which probably plays a role in the regulation of cardiac muscle contraction.

Characterization of P2 purinergic receptors on human erythro leukemia cells

We have investigated the nature of the nucleotide receptors on human erythro leukemia (HEL) cells, a cell line with some megakaryocytic properties, using a combination of pharmacological, photoaffinity labeling, and molecular biological techniques. Fura-2 loaded HEL cells responded to 2-methylthio ATP, ATP, 2-methylthio ADP, ADP and UTP with an increase in intracellular calcium. 2 Methylthio ADP was the most potent agonist. When external calcium was chelated with EDTA, calcium responses were observed indicating the mobilization of intracellular stores. These responses showed evidence of both homologous and heterologous receptor desensitization. In photoaffinity labeling experiments, beta-[32P]-AzPET-ADP was incorporated into three protein species with mobilities corresponding to M(r) approximately 55 kDa (doublet) and approximately 43 kDa. Labeling of approximately 55 kDa proteins was specifically inhibited by ADP, while that of the approximately 43 kDa was inhibited specifically by UTP. Nucleotide sequence analysis of the positive clones obtained by screening the HEL cell cDNA library with mouse P2U cDNA revealed that the P2U receptor from HEL cells is identical to the previously cloned human P2U receptor. These experiments suggest that the HEL cells contain a P2Y purinoceptor responding to ADP, in addition to a P2U receptor and possibly also a third P2 purinoceptor with a unique agonist profile.

Protein kinase C activation is not a key step in ADP-mediated exposure of fibrinogen receptors on human platelets

A selective inhibitor of protein kinase C (PKC), Ro 31-8220, blocks pleckstrin (P47) phosphorylation in platelets activated with either ADP, ADP plus synthetic thromboxane agonist U46619 and ADP plus U46619 plus epinephrine, while inducing a weak inhibition of platelet aggregation, and no significant effect on the fibrinogen binding. In platelets activated by U46619 alone, P47 phosphorylation, platelet aggregation, fibrinogen binding and serotonin release are all inhibited by Ro 31-8220. In the presence of an ADP scavenger system, U46619 induces pleckstrin phosphorylation, serotonin release and calcium mobilization but not platelet aggregation and fibrinogen binding, unless epinephrine is added.

IN CONCLUSION

(1) PKC activation is required for ADP secretion; (2) ADP or epinephrine are essential for fibrinogen receptor exposure induced by U46619; (3) fibrinogen receptor exposure induced by ADP is independent of activation of PKC.

Cloning and expression of a prostaglandin E receptor EP3 subtype from human erythroleukaemia cells

Prostaglandins inhibit platelet activation by stimulating intracellular cyclic AMP formation. We have postulated that intracellular cyclic AMP levels in platelets are buffered by a distinct prostaglandin receptor that mediates inhibition of cyclic AMP formation. In order to provide evidence for the model, we have cloned the cDNA coding for a prostaglandin receptor EP3 subtype, which is coupled to inhibition of adenylate cyclase, from the megakaryocytic cell line human erythroleukaemia (HEL) cells. A PCR-generated hybridization probe, produced using primers based on the sequence of the mouse prostaglandin EP3 receptor published by Sugimoto, Namba, Honda, Hayashi, Negishi, Ichikawa and Narumiya [(1992) J. Biol. Chem. 267, 6463-6466], was used to screen a lambda gt11 HEL cell cDNA library. The composite full-length cDNA clone HEP3, generated from the two partial clones pHEP3-7 and pHEP3-5, is 1.6 kb long with an open reading frame coding for 390 amino acids. This clone is 83% identical to the alpha subtype of the mouse EP3 receptor. The full-length construct was transfected into COS-1 cells. The cloned receptor exhibited the properties of a prostaglandin EP3 subtype, inhibiting forskolin-stimulated cyclic AMP formation in response to prostaglandin E2 (PGE2) and binding PGE2 with high specificity and a Kd of 3.2 nM. Radiolabelled PGE2 could be displaced by prostaglandins in the order PGE2 = PGE1 > iloprost = PGD2. Northern blot analysis revealed that the receptor is also present in human kidney.

Molecular cloning and expression of a rat kappa opioid receptor

At least three types of opioid receptors have been identified in the nervous system. In this paper we report molecular cloning and expression of a rat kappa opioid receptor. PCR was performed on double-stranded cDNA derived from poly(A)+ RNA of the rat striatum with primers similar to those of Libert and co-workers [Libert, Parmentier, Lefort, Dinsart, Van Sande, Maenhaut, Simons, Dumont and Vassart (1989) Science 244, 569-572]. One of the PCR products, which had 65% sequence similarity to the mouse delta opioid receptor, was used to screen a rat striatum cDNA library. Two positive clones were isolated and found to be identical. The clone had a 2.1-kb insert, which was termed RKOR-1. RKOR-1 has an open reading frame of 1140 bp and encodes a 380-amino-acid protein. Hydropathy analysis indicates that RKOR-1 has seven putative transmembrane domains with short intra- and extra-cellular loops. Membranes of Cos-7 cells transfected with RKOR-1 exhibited high specific binding for [3H]diprenorphine ([3H]DIP), a non-selective opioid ligand. Naloxone inhibited [3H]DIP binding with stereospecificity. [3H]DIP binding was potently inhibited by selective kappa opioid ligands, with Ki values in the nanomolar or subnanomolar range, but much less potently inhibited by drugs selective for mu or delta receptors. Thus, RKOR-1 represents an opioid receptor with kappa characteristics.

Cyclic AMP does not inhibit collagen-induced platelet signal transduction

The adhesion of platelets to collagen and their activation is the primary event in haemostasis. Following adhesion, platelet aggregation mediated by ADP, thromboxane A2 and thrombin leads to the formation of a platelet plug. It is known that platelet activation by each of these agonists involves an increase in the cytosolic free Ca2+ concentration, and this has been thought to be controlled by cyclic AMP. However, we report here that while signal transduction induced by ADP plus a thromboxane mimetic (U46619), or by thrombin, is inhibited by stimulators of adenylate cyclase such as a prostaglandin I2 (PGI2) analogue (Iloprost), PGD2 and forskolin, elevation of cyclic AMP does not inhibit either platelet adhesion to collagen or the associated Ca2+ mobilization, phosphatidic acid formation or 5-hydroxytryptamine secretion. Furthermore, collagen did not lower elevated levels of cyclic AMP in platelets measured in the presence of both a thromboxane antagonist and an ADP-removing system. The present results are discussed in the context of previous findings.

Comparison of Iloprost, Cicaprost and prostacyclin effects on cyclic AMP metabolism in intact platelets

We have compared the effects of prostacyclin (PGI2) and its stable analogs, Iloprost and Cicaprost, on cyclic AMP metabolism in intact platelets. All three compounds show similar but not identical patterns of prostaglandin concentration-dependent cyclic AMP formation. All three compounds apparently stimulate and inhibit cyclic AMP formation with different concentration dependencies, indicating the presence of distinct stimulatory and inhibitory receptors. Differences in response can be accounted for by slight differences in affinity of stimulatory and inhibitory receptors for the prostaglandins, by the fact that Iloprost contains almost 50% of a relatively inactive isomer, and by the fact that PGI2 is labile in aqueous solution, with a half-life on the order of a few minutes. We conclude 1) stimulation and inhibition of adenylate cyclase is not due to separate effects of 16S- and 16R-stereoisomers of Iloprost because similar patterns were obtained with a single isomeric form of Cicaprost and with authentic PGI2; 2) prostaglandin induced inhibition of adenylate cyclase is readily reversible because inhibition disappears when PGI2 concentration decays below saturation of the inhibitory receptor; 3) the potency of prostaglandins in stimulating platelet adenylate cyclase must be viewed in terms of their effects on both stimulatory and inhibitory receptors.

Prostaglandin-concentration-dependent desensitization of adenylate cyclase in human erythroleukaemia (HEL) cells is abolished by pertussis toxin and enhanced by induction by dimethyl sulphoxide

Prostaglandin-regulated cyclic AMP metabolism in human erythroleukaemia (HEL) cells was similar to that previously described in platelets [Ashby (1989) Mol. Pharmacol. 36, 866-873], displaying prostaglandin-concentration-dependent desensitization that could be explained by the presence of separate stimulatory and inhibitory prostaglandin receptors. Pertussis toxin abolished prostaglandin-concentration-dependent desensitization, indicating that the process is mediated through a pertussis toxin-sensitive GTP-binding protein. Treatment of HEL cells for 4 days with the inducer dimethyl sulphoxide enhanced prostaglandin-concentration-dependent desensitization, but did not alter the initial rate of cyclic AMP synthesis or the amount of Gi2 alpha measured by immunoblotting, suggesting that the inhibitory receptor was selectively induced by changing the cells to a more platelet-like form.

Baseline corrections in experimental and quasi-experimental clinical trials

Three methods of correcting for baseline differences are evaluated for use with randomized experimental designs and nonrandomized quasi-experimental designs. Cases where baseline means differ significantly in spite of random assignment and cases where observed baseline means do not differ significantly in quasi-experimental designs are given special attention. For comparison of treatment-induced change in randomly constituted treatment groups, analysis of covariance (ANCOVA) provides appropriate type I error protection and superior power regardless of the apparent significance of chance baseline differences. Correcting for baseline differences by expressing outcome scores as percentage of the baseline value for each individual produces results that closely approximate ANCOVA under specified conditions. Tests on simple pre-post difference scores are nonconservative when baseline means differ significantly in spite of randomization. In quasi-experimental research where treatment groups represent samples from different predefined populations, ANCOVA and percentage change provide inadequate baseline corrections even when the observed baseline means do not differ significantly. Although no method of baseline correction is entirely satisfactory in the absence of random assignment, tests on simple pre-post difference scores are generally superior for quasi-experimental designs in which treatment groups represent samples from different populations.

Ligands to the platelet fibrinogen receptor glycoprotein IIb-IIIa do not affect agonist-induced second messengers Ca2+ or cyclic AMP

Previous studies have suggested that the platelet glycoprotein complex GPIIb-IIIa, which is the putative fibrinogen receptor, regulates Ca2+ influx into platelets, possibly operating as a Ca2+ channel. We have used RGD-peptides (peptides containing the sequence Arg-Gly-Asp; disintegrins), isolated from snake venoms, that have a high affinity and specificity for the fibrinogen-binding site of GPIIb-IIIa to address the question of whether blocking this site inhibits Ca2+ movement from the extracellular medium to the cytosol. Using fura-2-loaded human platelets, we found that neither disintegrins nor a monoclonal antibody (M148) to the GPIIb-IIIa complex altered the level of cytosolic Ca2+ obtained when the cells were stimulated with various agonists in the presence of either nominal or 1 mM extracellular Ca2+. In the presence of Mn2+, an ion that quenches fura-2 fluorescence, fura-2-loaded platelets were stimulated with thrombin or ADP. Neither disintegrins nor the monoclonal antibody altered the kinetics or the amount of quenching of fura-2 fluorescence by Mn2+. These data indicate that the binding of ligands to the fibrinogen receptor is not associated with an inhibition of Ca2+ movement through a receptor-operated channel. Furthermore, the disintegrins have no effect on platelet cyclic AMP metabolism in either the presence or the absence of phosphodiesterase inhibitors.

Novel mechanism of heterologous desensitization of adenylate cyclase: prostaglandins bind with different affinities to both stimulatory and inhibitory receptors on platelets

Prostaglandins E1, I2, and D2 (PGE1, PGI2, and PGD2) all stimulate and desensitize platelet adenylate cyclase, giving rise to peak and plateau effects in the time course of cyclic AMP metabolism in the intact cell. The peak and plateau effects vary with prostaglandin concentration to a different extent for each prostaglandin. However, at high concentrations, all prostaglandins give rise to the same time course of cyclic AMP formation. Differences in the extent of activation and desensitization can be modeled in terms of distinct stimulatory and slow-acting inhibitory receptors that differ in affinity for each prostaglandin but lead to the same maximum extent of activation and desensitization for all prostaglandins. The affinity for the stimulatory receptor is in the order PGI2 greater than PGE1 much greater than PGD2; the affinity for the inhibitory receptor is in the order of PGE1 greater than PGI2 much greater than PGD2. In addition, the inhibitory receptor binds PGE1 more tightly than the stimulatory receptor, whereas in the case of PGI2 or PGD2, the stimulatory receptor binds agonist more tightly than the inhibitory receptor. It is shown that the model gives rise to heterologous desensitization such that PGE1 readily inhibits PGI2- and PGD2-stimulated cyclic AMP formation, because it has high affinity for the inhibitory receptor. At the same time, because the final steady state concentration of cyclic AMP depends on the fractional occupancy of both the stimulatory and inhibitory receptors, PGE1 can cause either a rise or fall in cyclic AMP level, depending on the concentration of PGI2 or PGD2 used to challenge the platelets before PGE1 addition. The presence of a distinct inhibitory receptor may represent a general mechanism of autocoid desensitization, buffering cellular response against transient localized increases in agonist concentration that may occur when agonists are produced close to their sites of action.

Kinetics of coagulation factor X activation by platelet-bound factor IXa

Thrombin-activated human platelets, in the presence of factors VIIIa and X, have specific, high-affinity (Kd approximately 0.5 nM), saturable binding sites for factor IXa that are involved in factor X activation [Ahmad, S.S., Rawala-Sheikh, R., & Walsh, P.N. (1989) J. Biol. Chem. 264, 3244-3251]. To determine the functional consequences of factor IXa binding to platelets, a detailed kinetic analysis of the effects of platelets, phospholipids, and factor VIII on factor IXa catalyzed factor X activation was done. In the absence of platelets, phospholipids, or factor VIII, the Michaelis constant (Km = 81 microM) was greater than 500-fold higher than the factor X concentration in human plasma. Unactivated platelets and thrombin-activated factor VIII, alone or in combination, had no effect on the kinetic parameters, whereas thrombin-activated platelets caused a major decrease in Km (0.39 microM) with no significant effect on kcat (0.052 min-1) and allowed factor VIIIa to decrease the Km further to a concentration (0.16 microM) near that of factor X in plasma and to increase the kcat 24,000-fold to 1240 min-1. Sonicated mixed phosphatidylserine/phosphatidylcholine vesicles (25/75, mol/mol) had kinetic effects similar to those of activated platelets. When factor IXa binding to thrombin-activated platelets and rates of factor X activation were measured simultaneously at saturating concentrations of factor X and factor VIIIa, the kcat was independent of factor IXa concentration, and the mean kcat value was 2391 min-1. The increase in catalytic efficiency (kcat/Km) in the presence of thrombin-activated platelets and factor VIIIa was (17.4 x 10(6))-fold.

Mechanisms of platelet activation and inhibition

Mechanisms of stimulus-response coupling in platelets are as complex and varied as the compounds that elicit the responses. The complexities are compounded by feedback mechanisms from substances released or synthesized by platelets as well as by "cross-talk" between signal transduction pathways. Examples of cross-talk include the ability of epinephrine to inhibit platelet adenylate cyclase through a G protein-mediated mechanism while causing platelet aggregation by some other mechanism and the ability of cAMP to inhibit thrombin-stimulated diacylglycerol formation. Despite the complexities, certain common threads are beginning to emerge, such as the involvement of G proteins in transducing many receptor-mediated processes, the involvement of relatively few second messenger pathways and the role of calcium in many of events leading to platelet responses, and the common involvement of protein kinases in carrying out second messenger function. The latter offers a useful assay for the effect of many agonists because they lead to the phosphorylation of specific proteins that can readily be detected by radioautography. Indeed, the emphasis has shifted in the past 10 years from relatively crude measurements of platelet function such as aggregation to precise, quantifiable measurement of processes such as protein phosphorylation and calcium release, which are indicators of the fundamental mechanisms involved in platelet function and thus serve as assays of these processes. On the other hand, there are other pathways and regulators yet to be discovered, notably regarding the action of epinephrine and the regulation of phospholipase A2. In addition, certain receptors remain elusive, including those for ADP and eicosanoids. The mechanisms of action of thrombin and cathepsin G, which involve their proteolytic activities, also remain an enigma. The combination of new insights into second messenger function and the techniques of molecular biology will allow many of these problems to be resolved, providing new approaches to therapy of thromboembolic disorders.

Model of prostaglandin-regulated cyclic AMP metabolism in intact platelets: examination of time-dependent effects on adenylate cyclase and phosphodiesterase activities

The kinetics of prostaglandin-regulated cyclic AMP formation by intact human platelets were studied in the presence and absence of phosphodiesterase inhibitors. In the case of iloprost, a chemically stable analogue of prostaglandin I2, the shape of the time course varied with prostaglandin concentration. In the presence of phosphodiesterase inhibitors, low concentrations of iloprost gave a linear rate of cyclic AMP formation. At higher concentrations of iloprost, the initial rate increased as a saturable function of prostaglandin concentration but the curves decayed with time to give new linear rates of cyclic AMP formation with a different prostaglandin concentration dependence from the initial rates. Time courses were simulated using KINSIM [Anal. Biochem. 130: 134-145 (1983)], a kinetic simulation program that employs numerical integration, over a wide range of iloprost concentration (3 nM to 30 microM) by use of a simple model involving rapid activation of adenylate cyclase, followed by slow reversible transition of adenylate cyclase to an inactive form (desensitization) through a distinct inhibitory receptor. The model requires that the affinity for prostaglandins of both the stimulatory and inhibitory receptors declines with prostaglandin concentration, which may be related to the existence of high and low affinity receptor forms depending on the activation state of the appropriate GTP-binding protein. The same two-receptor model can be used to describe cyclic AMP metabolism in the absence of phosphodiesterase inhibitors, giving rise to characteristic peak and plateau effects in the time courses. The putative inhibitory receptor has an apparent affinity for prostaglandin lower than the stimulatory receptor in the case of iloprost and a higher affinity than the stimulatory receptor in the case of prostaglandin E1. The contribution of phosphodiesterase activation to the time course of cyclic AMP formation through phosphorylation by cyclic AMP-dependent protein kinase was assessed. It was shown that phosphodiesterase activation must be rapid. A plausible and perhaps complete description of prostaglandin-regulated cyclic AMP metabolism in platelets is presented.

Platelet receptor-mediated factor X activation by factor IXa. High-affinity factor IXa receptors induced by factor VIII are deficient on platelets in Scott syndrome

We have studied factor IXa binding and factor X activation with normal platelets and with platelets obtained from a patient with a bleeding disorder and an isolated deficiency of platelet procoagulant activity termed Scott syndrome. In the absence of factor VIIIa and factor X, normal, thrombin-treated platelets exposed 560 +/- 35 sites for factor IXa with a Kd of 2.75 +/- 0.27 mM, compared with 461 +/- 60 sites per patient platelet with Kd of 3.2 +/- 0.33 nM. The addition of factor VIIIa and factor X resulted in a decrease in the Kd for normal platelets to 0.68 nM but had no effect on the Kd for patient platelets. The concentrations of factor IXa required for half-maximal rates of factor X activation for normal (0.52 nM) and patient platelets (2.5 nM) were similar to those determined from equilibrium binding studies. Kinetic parameters for factor X activation by factor IXa showed that the Km and Kcat were identical for normal and patient platelets in the absence of factor VIIIa. In the presence of factor VIIIa, and kcat for patient platelets (163 min-1) was only 33% of that for normal platelets (491 min-1): This result can be explained by the difference in affinity for factor IXa between normal and patient platelets in the presence of factor VIIIa, suggesting impaired factor VIIIa binding to Scott syndrome platelets.

Platelet AMP deaminase. Regulation by Mg-ATP2- and inorganic phosphate and inhibition by the transition state analog coformycin

Kinetic studies with platelet AMP deaminase, at pH 7.0 and 100 mM NaC1, gave cooperative initial velocity curves with AMP as substrate, with Mg-ATP2- as an activator, and with Pi as an inhibitor. In the absence of Mg-ATP2-, the s0.5 for AMP was 4.5 mM with a Hill coefficient approaching 2.0. In the presence of saturating Mg-ATP2-, the s0.5 for AMP was reduced to 0.18 mM, the maximum velocity was increased by about 35%, and the Hill coefficient was 1.0. The half-activation constant for Mg-ATP2- varied from 0.7 to 0.07 mM as the concentration of AMP was varied from 0.1 to 5.0 mM and the Hill coefficient for Mg-ATP activation changed from 2.0 to 1.0 over the same range. Phosphate inhibition was competitive with AMP and with Mg-ATP2- (Ki = 2.0 mM) and reversed the activation by Mg-ATP2-. Coformycin inhibited the Mg-ATP-activated enzyme with a Ki less than 0.25 microM. Coformycin inhibition was slow, with a second order rate constant of 6.0 X 10(4) M-1 min-1, suggesting that the compound acts as a transition state analog according to Frieden, C., Kurz, L. C., and Gilbert, H. R. (1980) Biochemistry 19, 5303-5309. The kinetic properties of the enzyme indicate that substantial regulation can occur through changes in AMP concentration acting synergistically to enhance Mg-ATP2- binding and displace Pi from a single type of regulatory site.

Coformycin inhibition of platelet AMP deaminase has no effect on thrombin-induced platelet secretion nor on glycolysis or glycogenolysis

Thrombin-stimulated platelet secretion is accompanied by a 30% reduction in the steady state level of cytosolic ATP, a breakdown that proceeds through ADP, AMP, IMP, and inosine to hypoxanthine. The ATP to hypoxanthine conversion could be blocked at the stage of AMP deamination by incubation of platelet-rich plasma for 6 h with 200 microM coformycin, a transition-state analog inhibitor of AMP deaminase. Abolition of AMP deaminase activity had no effect on thrombin-induced secretion from the dense granules, alpha-granules, or acid hydrolases measured in gel-filtered platelets. Coformycin treatment had no effect on thrombin-stimulated lactate production, even when oxidative phosphorylation was blocked by antimycin A, nor on the rate of thrombin-stimulated glycogenolysis. In addition, although it was clear that the adenylate energy charge was maintained by activation of AMP deaminase following thrombin treatment, the adenylate energy charge was also maintained in coformycin-treated platelets, albeit after a short lag, by stimulated ATP production and equilibration through the adenylate kinase reaction. Hydrogen peroxide brings about similar adenylate degradation which could also be inhibited by coformycin. The results indicate that AMP deamination and secretion, although temporally related, are not coupled. The role of AMP deaminase appears to be to maintain the adenylate energy charge in the absence of stimulation of ATP production or to buffer the adenylate charge before ATP production is stimulated.

Platelet AMP deaminase. Purification and kinetic studies

AMP deaminase has been purified to homogeneity from human platelets by phosphocellulose chromatography. Kinetic studies showed sigmoidal behavior as a function of AMP concentration with the midpoint of the saturation curve (S0.5) at 3.5 and 4.0 mM in NaCl and KCl, respectively, at pH 6.5. Activation by saturating ATP converted the velocity versus substrate plot to hyperbolic with a Michaelis constant of 1.2 mM and the same maximum velocity in either salt. Addition of increasing concentrations of GTP in the presence of NaCl led to activation followed by inhibition whereas GTP in the presence of KCl gave inhibition with no apparent activation.

Immunofluorescent and histochemical localization of AMP deaminase in skeletal muscle

Fluorescent antibody staining experiments with both isolated myofibrils and muscle fibers grown in culture show that AMP deaminase is bound to the myofibril in the A band. The strongest staining occurs at each end of the A band. The approximate width of the fluorescent stripes and their relation to the A band remains constant as a function of sarcomere length. Removal of enzyme from the myofibrils leads to loss of staining, and readdition of purified enzyme restores the original staining pattern. A histoenzymatic method for the detection of AMP deaminase activity in cultured fibers gives comparable localization. The results are consistent with the previous observation (Ashby, B. and C. Frieden. 1977.J. Biol. Chem. 252:1869--1872) that AMP deaminase forms a tight complex in solution with subfragment-2 (S-2) of myosin or with heavy meromyosin (HMM).

Adenylate deaminase. Kinetic and binding studies on the rabbit muscle enzyme

Kinetic studies with adenylate deaminase have been performed by stopped flow methods at 20 degrees C in 0.01 M imidazole/HCl, pH 6.5. The data were analyzed using either the whole time course of the reaction or the initial portion of the full time course. At low KCl concentrations, activation by the product IMP complicates any interpretation. In the presence of 0.15 M KCl, the results are interpreted in terms of three types of purine nucleotide binding sites: an active site, an inhibitory site which appears to be relatively specific for nucleoside triphosphates, and an activating site which shows relatively little specificity for nucleoside phosphates. Nucleotide binding to the activating site weakens binding to the inhibitory site. Sigmoidal kinetic data observed as a function of AMP in the presence of the inhibitor GTP are interpreted in terms of AMP binding to the activating site and weakening GTP binding. A fragment of myosin, subfragement-2, which has previously been shown to form a tight complex with adenylate deaminase (Ashby, B., and Frieden, C. (1977) J. Biol. Chem. 252, 1869--1875) activates the deaminase reaction only slightly. Complex formation, however, makes the reaction less susceptible to inhibition by GTP, although high levels of this nucleotide will disrupt the complex. In the presence of GTP or GTP plus subfragment-2, hysteretic effects are observed.

Interaction of AMP-aminohydrolase with myosin and its subfragments

We have shown that purified rabbit skeletal muscle AMP-aminohydrolase binds to rabbit muscle myosin, heavy meromyosin, and Subfragment 2 but does not bind to light meromyosin nor to Subfragment 1. The dissociation constant for binding to myosin was determined to be 0.14 muM. A new sedimentation boundary, presumably reflecting formation of a complex between AMP-aminohydrolase and heavy meromyosin or Subfragment 2, can be observed using the analytical ultracentrifuge. Binding of AMP-aminohydrolase to myosin, heavy meromyosin, or Subfragment 2 is abolished by phosphate (less than 10 mM), an inhibitor of AMP-aminohydrolase. No other rabbit muscle enzyme tested showed any interaction with myosin under the same conditions and there was no indication of complex formation between AMP-aminohydrolase and phosphofructokinase or phosphocreatine kinase in the analytical ultracentrifuge.