Amyloid-beta antibody binding to cerebral amyloid angiopathy fibrils and risk for amyloid-related imaging abnormalities

Therapeutic antibodies have been developed to target amyloid-beta (Aβ), and some of these slow the progression of Alzheimer's disease (AD). However, they can also cause adverse events known as amyloid-related imaging abnormalities with edema (ARIA-E). We investigated therapeutic Aβ antibody binding to cerebral amyloid angiopathy (CAA) fibrils isolated from human leptomeningeal tissue to study whether this related to the ARIA-E frequencies previously reported by clinical trials. The binding of Aβ antibodies to CAA Aβ fibrils was evaluated in vitro using immunoprecipitation, surface plasmon resonance, and direct binding assay. Marked differences in Aβ antibody binding to CAA fibrils were observed. Solanezumab and crenezumab showed negligible CAA fibril binding and these antibodies have no reported ARIA-E cases. Lecanemab showed a low binding to CAA fibrils, consistent with its relatively low ARIA-E frequency of 12.6%, while aducanumab, bapineuzumab, and gantenerumab all showed higher binding to CAA fibrils and substantially higher ARIA-E frequencies (25-35%). An ARIA-E frequency of 24% was reported for donanemab, and its binding to CAA fibrils correlated with the amount of pyroglutamate-modified Aβ present. The findings of this study support the proposal that Aβ antibody-CAA interactions may relate to the ARIA-E frequency observed in patients treated with Aβ-based immunotherapies.

The MDM2 Inhibitor Navtemadlin Arrests Mouse Melanoma Growth In Vivo and Potentiates Radiotherapy

The tumor suppressor protein p53 is mutated in close to 50% of human tumors and is dysregulated in many others, for instance by silencing or loss of p14^ARF. Under steady-state conditions, the two E3 ligases MDM2/MDM4 interact with and inhibit the transcriptional activity of p53. Inhibition of p53-MDM2/4 interaction to reactivate p53 in tumors with wild-type (WT) p53 has therefore been considered a therapeutic strategy. Moreover, studies indicate that p53 reactivation may synergize with radiation and increase tumor immunogenicity. In vivo studies of most MDM2 inhibitors have utilized immunodeficient xenograft mouse models, preventing detailed studies of action of these molecules on the immune response. The mouse melanoma cell line B16-F10 carries functional, WT p53 but does not express the MDM2 regulator p19^ARF. In this study, we tested a p53-MDM2 protein-protein interaction inhibitor, the small molecule Navtemadlin, which is currently being tested in phase II clinical trials. Using mass spectrometry-based proteomics and imaging flow cytometry, we identified specific protein expression patterns following Navtemadlin treatment of B16-F10 melanoma cells compared with their p53 CRISPR-inactivated control cells. In vitro, Navtemadlin induced a significant, p53-dependent, growth arrest but little apoptosis in B16-F10 cells. When combined with radiotherapy, Navtemadlin showed synergistic effects and increased apoptosis. In vivo, Navtemadlin treatment significantly reduced the growth of B16-F10 melanoma cells implanted in C57Bl/6 mice. Our data highlight the utility of a syngeneic B16-F10 p53^+/+ mouse melanoma model for assessing existing and novel p53-MDM2/MDM4 inhibitors and in identifying new combination therapies that can efficiently eliminate tumors in vivo.

Significance

The MDM2 inhibitor Navtemadlin arrests mouse tumor growth and potentiates radiotherapy. Our results support a threshold model for apoptosis induction that requires a high, prolonged p53 signaling for cancer cells to become apoptotic.

Abstract A79: Inhibition of p53-MDM2 protein interaction reduces tumor growth in a mouse melanoma model

Tumor suppressor protein p53 is mutated in close to 50% of human tumors. Under steady state conditions, the two E3 ligases MDM2 and MDM4 interact with and inhibit the transcriptional activity of p53. Inhibition of p53-MDM2/4 interaction to reactivate p53 has therefore been considered a therapeutic strategy. In this study, we tested p53-MDM2 protein-protein interaction inhibition using the small molecule AMG 232, which is currently being tested in phase 1b/2a clinical trials. In vitro, AMG 232 induced a significant, p53-dependent growth arrest in the mouse melanoma cell line B16-F10. Using mass spectrometry-based proteomics, we identified differential protein expression patterns following AMG 232 treatment of B16-F10 melanoma cells. In vivo, the growth of B16-F10 melanoma cells implanted in WT C57BL/6 mice was significantly reduced by AMG 232 treatment. Our data demonstrate that AMG 232 induces a p53-dependent tumor growth arrest in an immunocompetent mouse model, and we are currently testing whether AMG232 can synergize with checkpoint immunotherapy.

Citation Format: Katrine Ingelshed, Danai Lianoudaki, Dilraj Lama, Silke Sohn, Nicolas Fritz, Long Jiang, Fredrik Wermeling, Mikael Karlsson, David P. Lane, Saikiran K. Sedimbi. Inhibition of p53-MDM2 protein interaction reduces tumor growth in a mouse melanoma model [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2019 Nov 17-20; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2020;8(3 Suppl):Abstract nr A79.

High intracellular stability of the spidroin N-terminal domain in spite of abundant amyloidogenic segments revealed by in-cell hydrogen/deuterium exchange mass spectrometry

Proteins require an optimal balance of conformational flexibility and stability in their native environment to ensure their biological functions. A striking example is spidroins, spider silk proteins, which are stored at extremely high concentrations in soluble form, yet undergo amyloid-like aggregation during spinning. Here, we elucidate the stability of the highly soluble N-terminal domain (NT) of major ampullate spidroin 1 in the Escherichia coli cytosol as well as in inclusion bodies containing fibrillar aggregates. Surprisingly, we find that NT, despite being largely composed of amyloidogenic sequences, showed no signs of concentration-dependent aggregation. Using a novel intracellular hydrogen/deuterium exchange mass spectrometry (HDX-MS) approach, we reveal that NT adopts a tight fold in the E. coli cytosol and in this manner conceals its aggregation-prone regions by maintaining a tight fold under crowded conditions. Fusion of NT to the unstructured amyloid-forming Aβ₄₀ peptide, on the other hand, results in the formation of fibrillar aggregates. However, HDX-MS indicates that the NT domain is only partially incorporated into these aggregates in vivo. We conclude that NT is able to control its aggregation to remain functional under the extreme conditions in the spider silk gland.

Data in support of the identification of neuronal and astrocyte proteins interacting with extracellularly applied oligomeric and fibrillar α-synuclein assemblies by mass spectrometry

α-Synuclein (α-syn) is the principal component of Lewy bodies, the pathophysiological hallmark of individuals affected by Parkinson disease (PD). This neuropathologic form of α-syn contributes to PD progression and propagation of α-syn assemblies between neurons. The data we present here support the proteomic analysis used to identify neuronal proteins that specifically interact with extracellularly applied oligomeric or fibrillar α-syn assemblies (conditions 1 and 2, respectively) (doi: 10.15252/embj.201591397[1]). α-syn assemblies and their cellular partner proteins were pulled down from neuronal cell lysed shortly after exposure to exogenous α-syn assemblies and the associated proteins were identified by mass spectrometry using a shotgun proteomic-based approach. We also performed experiments on pure cultures of astrocytes to identify astrocyte-specific proteins interacting with oligomeric or fibrillar α-syn (conditions 3 and 4, respectively). For each condition, proteins interacting selectively with α-syn assemblies were identified by comparison to proteins pulled-down from untreated cells used as controls. The mass spectrometry data, the database search and the peak lists have been deposited to the ProteomeXchange Consortium database via the PRIDE partner repository with the dataset identifiers PRIDE: PXD002256 to PRIDE: PXD002263 and doi: 10.6019/PXD002256 to 10.6019/PXD002263.

α-synuclein assemblies sequester neuronal α3-Na+/K+-ATPase and impair Na+ gradient

Extracellular α-synuclein (α-syn) assemblies can be up-taken by neurons; however, their interaction with the plasma membrane and proteins has not been studied specifically. Here we demonstrate that α-syn assemblies form clusters within the plasma membrane of neurons. Using a proteomic-based approach, we identify the α3-subunit of Na+/K+-ATPase (NKA) as a cell surface partner of α-syn assemblies. The interaction strength depended on the state of α-syn, fibrils being the strongest, oligomers weak, and monomers none. Mutations within the neuron-specific α3-subunit are linked to rapid-onset dystonia Parkinsonism (RDP) and alternating hemiplegia of childhood (AHC). We show that freely diffusing α3-NKA are trapped within α-syn clusters resulting in α3-NKA redistribution and formation of larger nanoclusters. This creates regions within the plasma membrane with reduced local densities of α3-NKA, thereby decreasing the efficiency of Na+ extrusion following stimulus. Thus, interactions of α3-NKA with extracellular α-syn assemblies reduce its pumping activity as its mutations in RDP/AHC.

AmotL2 disrupts apical-basal cell polarity and promotes tumour invasion

The establishment and maintenance of apical-basal cell polarity is essential for the functionality of glandular epithelia. Cell polarity is often lost in advanced tumours correlating with acquisition of invasive and malignant properties. Despite extensive knowledge regarding the formation and maintenance of polarity, the mechanisms that deregulate polarity in metastasizing cells remain to be fully characterized. Here we show that AmotL2 expression correlates with loss of tissue architecture in tumours from human breast and colon cancer patients. We further show that hypoxic stress results in activation of c-Fos-dependent expression of AmotL2 leading to loss of polarity. c-Fos/hypoxia-induced p60 AmotL2 interacts with the Crb3 and Par3 polarity complexes retaining them in large vesicles and preventing them from reaching the apical membrane. The resulting loss of polarity potentiates the response to invasive cues in vitro and in vivo in mice. These data provide a molecular mechanism how hypoxic stress deregulates cell polarity during tumour progression.

MYC proteins promote neuronal differentiation by controlling the mode of progenitor cell division

The role of MYC proteins in somatic stem and progenitor cells during development is poorly understood. We have taken advantage of a chick in vivo model to examine their role in progenitor cells of the developing neural tube. Our results show that depletion of endogenous MYC in radial glial precursors (RGPs) is incompatible with differentiation and conversely, that overexpression of MYC induces neurogenesis independently of premature or upregulated expression of proneural gene programs. Unexpectedly, the neurogenic function of MYC depends on the integrity of the polarized neural tissue, in contrast to the situation in dissociated RGPs where MYC is mitogenic. Within the polarized RGPs of the neural tube, MYC drives differentiation by inhibiting Notch signaling and by increasing neurogenic cell division, eventually resulting in a depletion of progenitor cells. These results reveal an unexpected role of MYC in the control of stemness versus differentiation of neural stem cells in vivo.

Cxcl12/Cxcr4 signaling controls the migration and process orientation of A9-A10 dopaminergic neurons

CXCL12/CXCR4 signaling has been reported to regulate three essential processes for the establishment of neural networks in different neuronal systems: neuronal migration, cell positioning and axon wiring. However, it is not known whether it regulates the development of A9-A10 tyrosine hydroxylase positive (TH(+)) midbrain dopaminergic (mDA) neurons. We report here that Cxcl12 is expressed in the meninges surrounding the ventral midbrain (VM), whereas CXCR4 is present in NURR1(+) mDA precursors and mDA neurons from E10.5 to E14.5. CXCR4 is activated in NURR1(+) cells as they migrate towards the meninges. Accordingly, VM meninges and CXCL12 promoted migration and neuritogenesis of TH(+) cells in VM explants in a CXCR4-dependent manner. Moreover, in vivo electroporation of Cxcl12 at E12.5 in the basal plate resulted in lateral migration, whereas expression in the midline resulted in retention of TH(+) cells in the IZ close to the midline. Analysis of Cxcr4(-/-) mice revealed the presence of VM TH(+) cells with disoriented processes in the intermediate zone (IZ) at E11.5 and marginal zone (MZ) at E14. Consistently, pharmacological blockade of CXCR4 or genetic deletion of Cxcr4 resulted in an accumulation of TH(+) cells in the lateral aspect of the IZ at E14, indicating that CXCR4 is required for the radial migration of mDA neurons in vivo. Altogether, our findings demonstrate that CXCL12/CXCR4 regulates the migration and orientation of processes in A9-A10 mDA neurons.

RET PLCγ phosphotyrosine binding domain regulates Ca2+ signaling and neocortical neuronal migration

The receptor tyrosine kinase RET plays an essential role during embryogenesis in regulating cell proliferation, differentiation, and migration. Upon glial cell line-derived neurotrophic factor (GDNF) stimulation, RET can trigger multiple intracellular signaling pathways that in concert activate various downstream effectors. Here we report that the RET receptor induces calcium (Ca²⁺) signaling and regulates neocortical neuronal progenitor migration through the Phospholipase-C gamma (PLCγ) binding domain Tyr1015. This signaling cascade releases Ca²⁺ from the endoplasmic reticulum through the inositol 1,4,5-trisphosphate receptor and stimulates phosphorylation of ERK1/2 and CaMKII. A point mutation at Tyr1015 on RET or small interfering RNA gene silencing of PLCγ block the GDNF-induced signaling cascade. Delivery of the RET mutation to neuronal progenitors in the embryonic ventricular zone using in utero electroporation reveal that Tyr1015 is necessary for GDNF-stimulated migration of neurons to the cortical plate. These findings demonstrate a novel RET mediated signaling pathway that elevates cytosolic Ca²⁺ and modulates neuronal migration in the developing neocortex through the PLCγ binding domain Tyr1015.

Dietary sodium modulates the interaction between efferent and afferent renal nerve activity by altering activation of α2-adrenoceptors on renal sensory nerves

Activation of efferent renal sympathetic nerve activity (ERSNA) increases afferent renal nerve activity (ARNA), which then reflexively decreases ERSNA via activation of the renorenal reflexes to maintain low ERSNA. The ERSNA-ARNA interaction is mediated by norepinephrine (NE) that increases and decreases ARNA by activation of renal α(1)-and α(2)-adrenoceptors (AR), respectively. The ERSNA-induced increases in ARNA are suppressed during a low-sodium (2,470 ± 770% s) and enhanced during a high-sodium diet (5,670 ± 1,260% s). We examined the role of α(2)-AR in modulating the responsiveness of renal sensory nerves during low- and high-sodium diets. Immunohistochemical analysis suggested the presence of α(2A)-AR and α(2C)-AR subtypes on renal sensory nerves. During the low-sodium diet, renal pelvic administration of the α(2)-AR antagonist rauwolscine or the AT1 receptor antagonist losartan alone failed to alter the ARNA responses to reflex increases in ERSNA. Likewise, renal pelvic release of substance P produced by 250 pM NE (from 8.0 ± 1.3 to 8.5 ± 1.6 pg/min) was not affected by rauwolscine or losartan alone. However, rauwolscine+losartan enhanced the ARNA responses to reflex increases in ERSNA (4,680 ± 1,240%·s), and renal pelvic release of substance P by 250 pM NE, from 8.3 ± 0.6 to 14.2 ± 0.8 pg/min. During a high-sodium diet, rauwolscine had no effect on the ARNA response to reflex increases in ERSNA or renal pelvic release of substance P produced by NE. Losartan was not examined because of low endogenous ANG II levels in renal pelvic tissue during a high-sodium diet. Increased activation of α(2)-AR contributes to the reduced interaction between ERSNA and ARNA during low-sodium intake, whereas no/minimal activation of α(2)-AR contributes to the enhanced ERSNA-ARNA interaction under conditions of high sodium intake.

The decrease of expression of ryanodine receptor sub-type 2 is reversed by gentamycin sulphate in vascular myocytes from mdx mice

The mdx mouse, a model of the human Duchenne muscular dystrophy, displays impaired contractile function in skeletal, cardiac and smooth muscles. We explored the possibility that ryanodine receptor (RYR) expression could be altered in vascular muscle. The three RYR sub-types were expressed in portal vein myocytes. As observed through mRNA and protein levels, RYR2 expression was strongly decreased in mdx myocytes, whereas RYR3 and RYR1 expression were unaltered. The use of antisense oligonucleotide directed against RYR sub-types indicated that caffeine-induced Ca²⁺ response and Ca²⁺ spark frequency depended on RYR2 and RYR1. In mdx mice, caffeine-induced Ca²⁺ responses were decreased in both amplitude and maximal rate of rise, and the frequency of Ca²⁺ sparks was also strongly decreased. The gentamycin treatment was able to increase both the expression of RYR2 and the caffeine-induced Ca²⁺ response to the same level as that observed in wild-type mice. Taken together, these results confirm that both RYR1 and RYR2 are required for vascular Ca²⁺ signalling and indicate that inhibition of RYR2 expression may account for the decreased Ca²⁺ release from the SR in mdx vascular myocytes. Finally, we suggest that gentamycin can restore the Ca²⁺ signalling in smooth muscle from mdx mice by increasing RYR2 and dystrophin expression. These results may help explain the reduced efficacy of contraction in vascular myocytes of mdx mice and Duchenne muscular dystrophy–afflicted patients. Gentamycin treatment could be a good therapeutic tool to restore the vascular function.

Acetylcholine evokes an InsP3R1-dependent transient Ca2+ signal in rat duodenum myocytes

In smooth muscle myocytes, agonist-activated release of calcium ions (Ca2+) stored in the sarcoplasmic reticulum (SR) occurs via different but overlapping transduction pathways. Hence, to fully study how SR Ca2+ channels are activated, the simultaneous activation of different Ca2+ signals should be separated. In rat duodenum myocytes, we have previously characterized that acetylcholine (ACh) induces Ca2+ oscillations by binding to its M2 muscarinic receptor and activating the ryanodine receptor subtype 2. Here, we show that ACh simultaneously evokes a Ca2+ signal dependent on activation of inositol 1,4,5-trisphosphate (InsP3) receptor subtype 1. A pharmacologic approach, the use of antisense oligonucleotides directed against InsP3R1, and the expression of a specific biosensor derived from green-fluorescent protein coupled to the pleckstrin homology domain of phospholipase C, suggested that the InsP3R1-dependent Ca2+ signal is transient and due to a transient synthesis of InsP3 via M3 muscarinic receptor. Moreover, we suggest that both M2 and M3 signalling pathways are modulating phosphatidylinositol 4,5-bisphosphate and InsP3 concentration, thus describing closely interacting pathways activated by ACh in duodenum myocytes.

RyR1-specific requirement for depolarization-induced Ca2+ sparks in urinary bladder smooth muscle

Ryanodine receptor subtype 1 (RyR1) has been primarily characterized in skeletal muscle but several studies have revealed its expression in smooth muscle. Here, we used Ryr1-null mice to investigate the role of this isoform in Ca2+ signaling in urinary bladder smooth muscle. We show that RyR1 is required for depolarization-induced Ca2+ sparks, whereas RyR2 and RyR3 are sufficient for spontaneous or caffeine-induced Ca2+ sparks. Immunostaining revealed specific subcellular localization of RyR1 in the superficial sarcoplasmic reticulum; by contrast, RyR2 and RyR3 are mainly expressed in the deep sarcoplasmic reticulum. Paradoxically, lack of depolarization-induced Ca2+ sparks in Ryr1–/– myocytes was accompanied by an increased number of cells displaying spontaneous or depolarization-induced Ca2+ waves. Investigation of protein expression showed that FK506-binding protein (FKBP) 12 and FKBP12.6 (both of which are RyR-associated proteins) are downregulated in Ryr1–/– myocytes, whereas expression of RyR2 and RyR3 are unchanged. Moreover, treatment with rapamycin, which uncouples FKBPs from RyR, led to an increase of RyR-dependent Ca2+ signaling in wild-type urinary bladder myocytes but not in Ryr1–/– myocytes.

In conclusion, although decreased amounts of FKBP increase Ca2+ signals in Ryr1–/– urinary bladder myocytes the depolarization-induced Ca2+ sparks are specifically lost, demonstrating that RyR1 is required for depolarization-induced Ca2+ sparks and suggesting that the intracellular localization of RyR1 fine-tunes Ca2+ signals in smooth muscle.

Role of RYR3 splice variants in calcium signaling in mouse nonpregnant and pregnant myometrium

Alternative splicing of ryanodine receptor subtype 3 (RYR3) may generate a short isoform (RYR3S) without channel function and a functional full-length isoform (RYR3L). The RYR3S isoform has been shown to negatively regulate the native RYR2 subtype in smooth muscle cells as well as the RYR3L isoform when both isoforms were coexpressed in HEK-293 cells. Mouse myometrium expresses only the RYR3 subtype, but the role of RYR3 isoforms obtained by alternative splicing and their activation by cADP-ribose during pregnancy have never been investigated. Here, we show that both RYR3S and RYR3L isoforms are differentially expressed in nonpregnant and pregnant mouse myometrium. The use of antisense oligonucleotides directed against each isoform indicated that only RYR3L was activated by caffeine and cADP-ribose in nonpregnant myometrium. These RYR3L-mediated Ca(2+) releases were negatively regulated by RYR3S expression. At the end of pregnancy, the relative expression of RYR3L versus RYR3S and its ability to respond to cADP-ribose were increased. Therefore, our results suggest that physiological regulation of RYR3 alternative splicing may play an essential role at the end of pregnancy.

Ryanodine receptor subtype 2 encodes Ca2+ oscillations activated by acetylcholine via the M2 muscarinic receptor/cADP-ribose signalling pathway in duodenum myocytes

In this study, we characterized the signalling pathway activated by acetylcholine that encodes Ca2+ oscillations in rat duodenum myocytes. These oscillations were observed in intact myocytes after removal of external Ca2+, in permeabilized cells after abolition of the membrane potential and in the presence of heparin (an inhibitor of inositol 1,4,5-trisphosphate receptors) but were inhibited by ryanodine, indicating that they are dependent on Ca2+ release from intracellular stores through ryanodine receptors. Ca2+ oscillations were selectively inhibited by methoctramine (a M2 muscarinic receptor antagonist). The M2 muscarinic receptor-activated Ca2+ oscillations were inhibited by 8-bromo cyclic adenosine diphosphoribose and inhibitors of adenosine diphosphoribosyl cyclase (ZnCl2 and anti-CD38 antibody). Stimulation of ADP-ribosyl cyclase activity by acetylcholine was evaluated in permeabilized cells by measuring the production of cyclic guanosine diphosphoribose (a fluorescent compound), which resulted from the cyclization of nicotinamide guanine dinucleotide. As duodenum myocytes expressed the three subtypes of ryanodine receptors, an antisense strategy revealed that the ryanodine receptor subtype 2 alone was required to initiate the Ca2+ oscillations induced by acetylcholine and also by cyclic adenosine diphosphoribose and rapamycin (a compound that induced uncoupling between 12/12.6 kDa FK506-binding proteins and ryanodine receptors). Inhibition of cyclic adenosine diphosphoribose-induced Ca2+ oscillations, after rapamycin treatment, confirmed that both compounds interacted with the ryanodine receptor subtype 2. Our findings show for the first time that the M2 muscarinic receptor activation triggered Ca2+ oscillations in duodenum myocytes by activation of the cyclic adenosine diphosphoribose/FK506-binding protein/ryanodine receptor subtype 2 signalling pathway.

Efficacy and cognitive side effects of tiagabine and topiramate in patients with epilepsy

OBJECTIVE

Whereas the efficacy of the newer antiepileptic drugs (AEDs) is well established, there remain questions regarding their cognitive side effects. Therefore, we performed a comparative open randomized trial with TPM and TGB as add-on therapy, with particular consideration of cognition, mood, and health-related quality of life (HRQOL).

METHODS

Forty-one patients with refractory epilepsy were randomly assigned to one of the two treatment groups (TPM vs TGB) and received neuropsychological testing at baseline (T1), after titration (3 months, T2), and during the maintenance phase (another 3 months, T3). Tests included measures of intelligence, attention, working memory, episodic memory, language, and self-report questionnaires regarding mood and HRQOL. Twenty patients (8 TPM, 12 TGB) discontinued the trial for different reasons (no group difference).

RESULTS

Seizure outcome (intention-to-treat analysis) was comparably good in both groups (8.1% seizure free, 29.7% seizure reduction>50%). From baseline to after the titration paired sample t tests revealed significant deterioration in verbal fluency, language comprehension, working memory, and visual block tapping under TPM and a deterioration in verbal memory (delayed free recall) in the TGB group. These functions remained stable in the maintenance phase. Self-report measures initially indicated concerns about AED side effects in both groups and concerns about worse cognitive functioning and depression under TPM. In the maintenance phase the TGB group reported feeling a lack of energy, whereas patients on TPM demonstrated improvement on all QOLIE scales on a descriptive level.

CONCLUSION

This study demonstrates the comparable efficacy of TPM and TGB. Consistent with previous reports, TPM but not TGB appears to be associated with persistent negative cognitive side effects on frontal lobe-associated functions, the degree of which may be estimated by the fact that this effect was observed with a very small sample size. In contrast, in patients taking TPM, initially negatively affected HRQOL returns to baseline in the long run on a descriptive level. The latter finding may be interpreted in accordance with the observation that objective performance and subjective self-report under TPM can be dissociated.

Crucial role of type 2 inositol 1,4,5-trisphosphate receptors for acetylcholine-induced Ca2+ oscillations in vascular myocytes

OBJECTIVE

The aim of this study was to correlate the expression of InsP3R subtypes in native vascular and visceral myocytes with specific Ca2+-signaling patterns.

METHODS AND RESULTS

By Western blot and immunostaining, we showed that rat portal vein expressed InsP3R1 and InsP3R2 but not InsP3R3, whereas rat ureter expressed InsP3R1 and InsP3R3 but not InsP3R2. Acetylcholine induced single Ca2+ responses in all ureteric myocytes but only in 50% of vascular myocytes. In the remaining vascular myocytes, the first transient peak was followed by Ca2+ oscillations. By correlating Ca2+ signals and immunostaining, we revealed that oscillating vascular cells expressed both InsP3R1 and InsP3R2 whereas nonoscillating vascular cells expressed only InsP3R1. Acetylcholine-induced oscillations were not affected by inhibitors of ryanodine receptors, Ca2+-ATPases, Ca2+ influx, and mitochondrial Ca2+ uniporter but were inhibited by intracellular infusion of heparin. Using specific antibodies against InsP3R subtypes, we showed that acetylcholine-induced Ca2+ oscillations were specifically blocked by the anti-InsP3R antibody. These data were supported by antisense oligonucleotides targeting InsP3R2, which selectively inhibited Ca2+ oscillations.

CONCLUSIONS

Our results suggest that in native smooth muscle cells, a differential expression of InsP3R subtypes encodes specific InsP3-mediated Ca2+ responses and that the presence of the InsP3R2 subtype is required for acetylcholine-induced Ca2+ oscillations in vascular myocytes.

A prospective randomized comparison of unsedated ultrathin versus standard esophagogastroduodenoscopy in routine outpatient gastroenterology practice: does it work better through the nose?

BACKGROUND AND STUDY AIMS

In an outpatient gastroenterological practice setting, highly effective diagnostic procedures and patient satisfaction play an important role. Ultrathin endoscopy in unsedated patients has been shown to be more cost-effective and time-efficient in comparison with standard endoscopy. A prospective randomized study was carried out in unsedated patients to compare performance, feasibility, safety, and patient tolerance between ultrathin transnasal (UT), ultrathin oral (UO), and standard (SO) esophagogastroduodenoscopy (EGD).

PATIENTS AND METHODS

A total of 200 of 600 eligible patients consented to participate in the study, and were randomly assigned to undergo UT, UO, or SO. Patients reported their tolerance of the procedure (anxiety, pain, gagging, and overall satisfaction; Likert scale 1-10), and the endoscopists reported the effectiveness of the procedure (handling, picture quality, and overall performance; Likert scale 1-10). Statistics were calculated using the Kruskal-Wallis test.

RESULTS

After randomization, 65, 67, and 68 patients were allocated to the UT, UO, and SO groups, respectively. Failure to achieve complete EGD by the intended route occurred in 14 patients (22 %) in the UT group. Compared to the SO group, patients in the UT and UO groups rated anxiety before the procedure as being more intense - median score (10 % quantile estimate; 90 % quantile estimate): UT, 2.0 (1.0; 4.0); UO, 2.0 (1.0; 4.0); SO, 0.0 (0.0; 2.0); p < 0.0001), whereas SO patients experienced a higher level of anxiety during the procedure ( P < 0.0001). Pain during insertion of the endoscope was the least intense in the UO group: UT, 2.0 (1.0; 5.0); UO, 1.0 (1.0; 3.0); SO, 2.0 (1.0; 4.0); P < 0.001). Gagging during insertion was more pronounced in the UO group: UT, 2.0 (1.0; 4.0); UO, 3.0 (1.0; 7.0); SO, 2.0 (1.0; 5.0); P < 0.01). The patients' score for the overall assessment was better in the SO group ( P < 0.0001). The endoscopists' overall assessment for ultrathin EGD was poorer than for standard EGD: UT, 3.0 (2.0; 5.0); UO, 3.0 (2.0; 5.0); SO, 2.0 (1.0; 3.0); P < 0.0001).

CONCLUSIONS

Ultrathin endoscopy through both the transnasal and oral routes has limited use in routine outpatient practice. Techniques for reducing pain and gagging may improve patient tolerance. Further technical improvements are needed to allow routine implementation.

[Compliance with terminology standards in reflux, ulcers, and gastritis: A study of 881 consecutive upper gastrointestinal endoscopy reports]

BACKGROUND

The German version of the Minimal Standard Terminology document for endoscopy was discussed in 1997 and 1998, and finally published at the end of 1999 as one of the German Gastroenterology Society guidelines. The diagnoses and descriptive terms included in this standard terminology are based on the consensus views of a large number of German endoscopists (20 endoscopists based in Munich and 20 elsewhere in Germany). The aim of the present study was to investigate how much spontaneous compliance there is with the descriptive terms included in the standard terminology - both among the members of the consensus discussions, and among colleagues not involved in this project.

METHODS

A total of 881 endoscopy reports with the diagnoses of reflux, ulcer, and gastritis were collected from 11 centers (2 hospitals and 9 private offices, with a total of 26 examiners) over a one-month period. Nine of the 26 examiners were actively involved in the terminology consensus discussion. The rate of occurrence of the descriptive terms contained in the standard terminology was assessed for the diagnoses listed above.

RESULTS

Compliance with the descriptive terms was high (> 90 %) only for basic parameters such as the Savary classification of reflux and the area in which gastroduodenal ulcers were located. Other important parameters, such as the extent (length) of Barrett's esophagus, ulcer size, and circumferential location, were reported in only three-quarters of cases or less. The descriptions of gastritis were inconsistent. There was no difference in the degree of compliance either between endoscopists using free dictation and those using computerized text blocks, or between members of the terminology group and those not involved in preparing the terminology.

CONCLUSIONS

Adherence to standard terminology and its descriptive parameters is poor even among specialized gastroenterologists who have been involved in terminology consensus discussions. Compliance needs to be improved by providing suitable software programs with automatic reporting functions.

A new system for rapid large-caliber percutaneous transhepatic drainage in patients with obstructive jaundice: a prospective randomized trial

BACKGROUND AND STUDY, AIMS: Percutaneous access to the biliary tract is an important diagnostic and therapeutic tool in the management of biliary diseases. It is usually chosen when the endoscopic approach via endoscopic retrograde cholangiopancreatography (ERCP) fails, or is not possible. Once established, the percutaneous tract is then used for the treatment of biliary stones and strictures. To establish a percutaneous tract with a caliber large enough for cholangioscopy to be performed, or for a large-bore permanent drainage tube to be inserted, stepwise dilation up to 14 Fr or 16 Fr is usually required. We present here a new method of rapid dilation using specially designed materials, including a stiffenable guide wire and specially adapted bougies.

PATIENTS AND METHODS

Consecutive patients undergoing percutaneous drainage for biliary diseases were included in this prospective study, over a 19-month period. After establishment of a 10-Fr transpapillary drain, the patients were randomly assigned to either conventional percutaneous transhepatic biliary drainage (PTBD) or stepwise dilation using the new method, aiming at a need for only one further session, using a specially designed stiffenable metal guide wire of 6.6 Fr and plastic bougies. The details of the procedure (duration, materials used, technical ease), initial and later complications, assessment by the patients, and procedural costs were compared between the two groups.

RESULTS

Of the 60 patients included, 29 were randomly assigned to group I (the new method) and 31 to group II (the conventional approach); there were no significant differences between the two groups in terms of clinical data or biliary pathology. The clinical efficacy of PTBD was similar in the two groups, although three patients in group II were switched to the new procedure because of failure of dilation using the conventional approach. The rates of major complications (four of 29 in group I, five of 31 in group II) and patient tolerance were also similar. However, the new procedure led to a significant reduction in the cumulative procedure duration (20.1 minutes vs 30.1 minutes), mean number of sessions (1.1 vs. 1.7), and mean number of hospital days (2.0 vs 5.5), and was therefore also cost-effective, reducing costs from a mean of 5813 to 2581 German marks (DM) per patient.

CONCLUSIONS

The new system for rapid establishment of large-caliber PTBD offers significant advantages in terms of saving hospital resources while maintaining clinical efficacy.

Are guidelines followed in Helicobacter pylori diagnosis and therapy? An inquiry among gastroenterologists, referring physicians and patients in Munich

BACKGROUND AND STUDY AIMS

Attempts to standardize Helicobacter pylori (Hp) diagnosis and therapy have led to the publication of guidelines by various national gastroenterological societies in Europe and the USA. However, little information is available either regarding the compliance of gastroenterologists and referring physicians with these guidelines, or regarding the patients' perspective.

PATIENTS AND METHODS

A retrospective analysis was conducted of all outpatient upper gastrointestinal endoscopy reports for a one-month period in eleven different centers (two university hospitals and nine private practice gastroenterology offices) with a total of 24 gastroenterologists. Endoscopy reports from patients wit the indications of reflux, diarrhea, and tumors were excluded. Diagnoses and treatment recommendations given by gastroenterologists were recorded. Questionnaires concerning Hp diagnosis, treatment indications and performance, and follow-up were sent to referring physicians and patients.

RESULTS

A total of 772 endoscopy reports were included in the study; analyzable questionnaires were returned by 287 referring physicians (47%) and by 265 patients (59%). Gastroenterologists recommended Hp eradication in all ulcers and in 29% of gastritis/nonulcer dyspepsia (NUD) cases. Referring physicians thought that 94% of ulcers should be treated by Hp eradication, which was also considered to be an absolute and relative indication in NUD by 15% and 53% of the referring physicians, respectively. Among the patients who replied, 52% had received Hp eradication regimens; ulcers were found in 22% of the total patient group. Check-up examinations after Hp therapy were considered necessary by 75% of the referring physicians, but only 22% of the responding patients actually underwent some form of check-up (upper gastrointestinal endoscopy in 91%).

CONCLUSIONS

Gastroenterologists and (to a somewhat lesser extent) referring physician appear to be following the current guidelines for Hp treatment. As expected, two thirds of referring physicians consider NUD to be absolute or relative indication for Hp eradication. Check-up examinations are apparently being performed less frequently than recommended.

Biochemical organization of single motor units in two multi-tendoned muscles of the cat distal forelimb

In anesthetized cats single motor units (MUs) of the extensor carpi ulnaris (ECU) and extensor digitorum communis (EDC) muscles were selectively activated by stimulation of cervical ventral root filaments. The distribution of force developed by single MUs at the four distal tendons of the EDC muscle and at three portions of the distal tendon of the ECU muscle was analysed. In general, single MUs of both muscles distributed force over all tendons in a unimodal pattern, with the maximal force levels generated at one specific tendon which was termed the best-tendon. Distributions of force were quantitatively described by a parameter representing the mean direction of force output (output-index) and a further one representing the dispersion of force over the distal tendons (divergence). Generally, these parameters and the best-tendon remained stable when a MU was stimulated at different frequencies, but varied from MU to MU. Despite the general stability of the force distribution, slight systematic changes were regularly found in EDC MUs, when they developed a higher amount of force due to a higher frequency of stimulation: the relative amount of force at the best-tendon increased; e.g. the MUs got more selective for the best-tendon. These changes were partly due to overcoming mechanical cross-coupling between neighbouring compartments of the EDC muscle. Such changes of force distribution were only found in a part of the ECU MUs; other ECU MUs did not change their force distribution at all or became less selective for the best-tendon. The phenomenon that MUs of multi-tendoned muscles distribute their force output to the distal tendons in specific patterns is probably due to mechanical partitioning of the parent muscles: the localization of spatial territories of MUs within different anatomical muscle compartments should correspond to the best-tendon. Complex mechanisms allowing passive transmission of force from limited territories along the transverse axis of both muscles must be assumed in order to explain why most MUs act on all tendons and why force distributions change with increasing stimulus frequency. In addition, specific relations between unit type and force distributions were found within both muscles. Fatigue-resistant EDC MUs have broader force distributions than fatigue-sensitive EDC MUs and slow ECU MUs were found to act predominantly on the most ulnar part of the distal tendon. These biomechanical properties of MUs are discussed as supporting the specific functions of the respective muscles.

Contractile properties of single motor units in two multi-tendoned muscles of the cat distal forelimb

The contractile properties of motor units (MUs) in two multi-tendoned forelimb muscles were investigated. In anesthetized cats single MUs of the extensor carpi ulnaris (ECU) and extensor digitorum communis (EDC) muscles were selectively activated by stimulation of cervical ventral root filaments. MUs were characterized by various tests including single twitches, series of tetanic contractions providing a tension-frequency relation and a fatigue test. They were classified by the parameters contraction time (CT, time-to-peak within unpotentiated single twitches) and fatigue-index (RB, according to Burke). The ECU muscle is composed of 38% type FR MUs (fast, fatigue-sensitive; CT less than 38 ms; RB less than 0.5), 35% type FR MUs (CT less than 38 ms, RB greater than 0.5) and 27% type S MUs (slow; CT greater than 38 ms, RB greater than 0.5). 46% of the EDC MUs were classified as FF (RB less than or equal to 0.25), 29% as FI (fast, intermediately fatiguable; 0.25 less than RB less than 0.75) and 25% as FR/S (fatigue-resistant, fast or slow; RB greater than or equal to 0.75). The latter group was devised since most MUs appeared as fast and the unequivocal presence of slow MUs could neither be demonstrated nor excluded. Normalized tension-frequency relations of fast ECU and EDC MUs were nearly identical and similar to those reported for fast MUs of other muscles. In contrast to this, the tension-frequency relation of slow ECU MUs has a different shape supporting the use of this function to distinguish fast from slow MUs. The distribution of different types of MUs is discussed with regard to the structure and function of the parent muscles and in relation to hindlimb muscles of comparable architecture. As revealed by comparison to EMG data gained in behaving animals (Fritz et al. 1985; Hoffmann et al. 1986, Botterman et al. 1985), the three muscles of the cat distal forelimb investigated so far seem to be adapted to different tasks: the EDC to rapid movements with a high proportion of type FF MUs, flexor carpi radialis to sustained contractions during the body support with a high proportion of fatigue-resistant MUs; the ECU which changes synergism between both muscles has an intermediate composition.

Pattern of monosynaptic Ia connections in the cat forelimb

1. In anaesthetized cats intracellular records were obtained from antidromically identified motoneurones. The motor nuclei to the elbow extensor and flexor muscles and to the muscles innervated by the deep radial, ulnar and median nerves were investigated. The maximum Ia EPSPs from electrical stimulation of various peripheral nerves were measured. The characteristic convergence and projection patterns to each motor nucleus were established from pooled data. 2. The total aggregates of the Ia EPSPs between the different motor nuclei ranged from 3.5 to 11.7 mV. The smallest aggregates were found in the nuclei to the digit muscles. The ratio of the heteronymous versus homonymous EPSP amplitudes varied between 3.9 and 0.5. A general rule which would govern the distribution of the EPSP aggregates, such as a proximo-distal gradient, was not observed. 3. The Ia connections followed a complex but highly organized pattern. Bidirectional and unidirectional pathways were present. In many cases the convergence pattern of a motor nucleus included muscles acting at different joints. The connections of one nucleus were not necessarily restricted to one side of the limb, but could cross the radio-ulnar plane. 4. Muscles with similar actions onto the same joint were interconnected with bidirectional, rather balanced Ia pathways. Such relations were also present between close functional synergists and then often extended across several joints. The relations between the anatomical extensors of wrist and digits were graded according to the neighbourhood of these muscles. It is suggested that this reflects the graded mechanical synergism in the wrist action of these muscles. 5. A large number of unidirectional or strongly skewed bidirectional Ia pathways project from proximal to distal muscles. It is suggested that they may serve a readjustment of distal joints during changes in the position of proximal ones (e.g. stabilization of the position of the radio-ulnar plane during elbow extension in case of the undirectional projections onto supinator and abductor pollicis longus motoneurones). 6. The motor nuclei to some multifunctional muscles display a negative correlation between different heteronymous Ia inputs: motoneurones with a large input from one muscle show a significant tendency to receive a smaller input from another muscle and vice versa. This organization leads to subpopulations of neurones with different convergence patterns within the same motor nucleus. 7. Motor nuclei with bidirectional Ia relations between each other displayed similar convergence and projection patterns. They were combined into 'Ia synergistic groups.' One motor nucleus may belong to several groups.(ABSTRACT TRUNCATED AT 400 WORDS)

Location of motoneurones projecting to the cat distal forelimb. I. Deep radial motornuclei

The position of the motornuclei projecting through the dorsal interosseus (DR) nerve to the distal forelimb muscles has been investigated in the cat. Horseradish peroxidase (HRP) and fluorescent (Fl) compounds have been used as retrograde tracers. They were either injected into forelimb muscles or applied to the proximal end of transected forelimb nerves. Limb muscles that were not investigated have been carefully denervated. HRP was used to trace the position and the architecture of the individual motornuclei. The topographical relations between the nuclei were established with application of up to three F compounds in the same animal. The position of the labeled motornuclei was reconstructed with a computer-assisted approach which is described in the appendix. The DR representation area extends from the caudal C5 to the caudal Th1 segments. In C6 it forms a dorsoventrally oriented narrow region at the lateral border of the ventral horn; in C7 and rostral C8 it forms a broad column in the dorsolateral corner of the ventral horn. In caudal C8 and Th1 this column is shifted into a ventral direction. The motoneurones projecting to the individual DR muscles are not randomly distributed in this area, but arranged in long, slender columns. These motornuclei occupy specific positions with only minimal interindividual variations. Three nuclei (brachioradialis, extensor carpi radialis, and supinator) are located in the C6 and C7 segments. They compose about one-third of the DR cell population. The nuclei to the other radial muscles are all located in C8 and Th1. Thus most of the DR motoneurones are located in these two segments. These results, together with those from the companion paper on the location of the median and ulnar motornuclei, provide important anatomical knowledge for the investigation of the cat brachial enlargement.

Location of motoneurones projecting to the cat distal forelimb. II. Median and ulnar motornuclei

The position of the motornuclei projecting through the median (Mn) and ulnar (Ul) nerves to the cat distal forelimb has been investigated. Horseradish peroxidase (HRP) and fluorescent (Fl) compounds have been used as retrograde tracers. They were either injected into forelimb muscles or applied to the proximal end of transected forelimb nerves. Limb muscles that were not investigated were carefully denervated. The position and the architecture of the individual motornuclei were traced with HRP. The topographical relations between the nuclei were established with application of up to three different Fl compounds in the same animal. The Mn motoneurones had a bimodal distribution in the brachial spinal cord. The motoneurones to the pronator teres and flexor carpi radialis muscles were located in C7 and the other Mn motoneurones were located in C8 and Th1. In C7 the Mn motoneurones occupied a single representation area, which is located some distance medially of the lateral funiculus. In C8 and Th1 two Mn representation areas were found: A dorsal one that contacts the lateral funiculus and is located at the level of the central canal; a ventral one that is located ventrally in the ventral horn. The dorsal area is occupied by the motornuclei projecting to the intrinsic hand muscles and the ventral one by the nuclei projecting to the limb. The Ul motoneurones extend with an unimodal distribution from the caudal C7 to the caudal Th1 segments. They occupy a single, broad representation area. The dorsal part, which contacts the lateral funiculus, is located at the level of the central canal and harbours the nuclei to the intrinsic hand muscles. The other Ul nuclei are located ventromedially deep in the ventral horn. These results, together with those from the companion paper on the location of the deep radial motornuclei, provide important anatomical information for the investigation of the cat brachial enlargement.

Fluorescent compounds as retrograde tracers compared with horseradish peroxidase (HRP). II. A parametric study in the peripheral motor system of the cat

Fluorescent compounds which are currently used as retrograde tracers were tested in the cat peripheral motor system and compared with horseradish peroxidase (HRP). The tracers were either injected into forelimb muscles or applied to the proximal end of transected forelimb nerves. The remaining muscles of the limb has been carefully denervated. Following intramuscular injection all fluorescent compounds labeled spinal cord motoneurons, the DAPI compounds labeled endothelial cells in addition. In the nerve application mode tracer positive motoneurons were only observed when propidium iodide (PI) and the DAPI compounds were used, whereas bisbenzimide (BB), nuclear yellow (NY) and primuline did not label any cells. The fluorescence of BB labeled motoneurons were predominantly located in the cytoplasma. NY positive motoneurons showed a different localization of the fluorescent label between the different neurons of the same motornucleus: in some neurons it was exclusively located in the nucleus, in others predominantly in the cytoplasma, in the majority in both compartments. The intracellular distribution of the BB and the NY label was independent of the pH of the fixation fluid. The fluorescent tracers labeled the motoneuronal cell columns in their complete rostrocaudal extent and in a position identical to the one obtained with HRP. However, some substances (PI, fast blue) labeled less motoneurons of a motornucleus than did HRP, none of the fluorescent tracers labeled more. The results are discussed under several aspects: use of the investigated fluorescent compounds as single tracers; use of several tracers in the same animal to map collateral projections of one and the same neuron; use of several tracers in the same animal to establish the topographical relation between several independent neuronal populations.

Location of median and ulnar motornuclei in the cat

In the cat we used the horseradish peroxidase (HRP) technique to investigate the location of the motor nuclei projecting through the median and the ulnar nerves. Each nucleus is described b its longitudinal extent along the rostro-caudal spinal cord axis and by its dorso-ventral and medio-lateral position within the ventral horn. The topographical relations between different nuclei are, however, only provisionally ascertained with the HRP technique, since the simultaneous use of different fluorescent tracers in the same animal is a more powerful approach to establish the spatial relations between different neuronal populations. One example with the latter technique is reported, which demonstrates the complete overlap of two different nuclei.

Location of dorsal interosseus motor nuclei in the cat

In the cat we have investigated the position of the motor nuclei projecting through the dorsal interosseus nerve to the distal forelimb muscles. Horseradish peroxidase was either injected into single muscles or applied to the central end of a cut nerve. The location of each nucleus is described in two ways: histograms giving the distribution of the labelled motoneurones along the rostro-caudal spinal cord axis; and regions in reconstructed cross-sections of the ventral horn which indicate the area occupied by the motoneurones of one nucleus. The relation between the nuclei was established by superposition of the reconstructed cross-sections. With this procedure we have obtained a map which shows the positions of the centres of the single radial nuclei.