An Interpretive Description of Drug Withdrawal Among Pregnant Women in Jail

OBJECTIVE

To explore the experience of drug withdrawal among pregnant women in jail.

DESIGN

A qualitative interpretive descriptive approach.

SETTING/PROBLEM

The care of incarcerated pregnant women constitutes a complex and significant public health problem. Many have substance use disorder (SUD) and cycle in and out of jails in their community, resulting in repeated experiences of drug withdrawal. Most jails do not provide medication-assisted therapy for management of withdrawal, a situation that violates standards of care set by leading health organizations. The experience of drug withdrawal among pregnant women in jail has not been qualitatively explored in the literature.

PARTICIPANTS

Five women completed interviews for the study.

INTERVENTION

In-depth, qualitative interviews.

RESULTS

Five themes with subthemes emerged from the interviews: Framing the Story Through Life History: I Need You to Know Where I Come From, Patterns of Thinking About Substance Use, The Manifestations of Withdrawal: Body and Mind, Perceived Punishment for Drug Use During Pregnancy, and Mixed Perceptions of Withdrawal Treatment.

CONCLUSION

Participants told a story beyond that of the physical withdrawal symptoms, revealing new insights into their maternal distress and the need for compassionate, nonstigmatized care to address physical and mental symptoms, as well as advocacy for the provision of an evidence-based standard of care. Nurses who care for pregnant women with SUD in the jail setting could benefit from collaborative relationships with other health care professionals in the community to reduce disparate health outcomes for this vulnerable population.

How do young people with a hereditary cancer predisposition syndrome understand and experience cancer survivorship? "With Li-Fraumeni syndrome, it's just an intermission"

OBJECTIVES

Adolescents and young adult (AYA) cancer survivors face unique medical and psychosocial sequalae, including chronic health conditions, late effects of treatment and fear of recurrence. The meaning of cancer survivorship may be further complicated for AYAs with hereditary cancer predisposition syndromes. This study used a patient-centered framework to investigate how AYAs with Li-Fraumeni syndrome (LFS) consider cancer survivorship.

METHODS

An interprofessional team conducted 30 semi-structured interviews with AYAs (aged 18-41, mean 31 years) enrolled in the National Cancer Institute's LFS Study (NCT01443468). Twenty had experienced at least one cancer diagnosis. Interview data were thematically analyzed by an inter-professional team using interpretive description and grounded theory methods.

FINDINGS

Participants viewed "survivorship" as a period marked by no evidence of formerly diagnosed disease. By contrast, participants felt the label "survivor" was tenuous since LFS is characterized by multiple primary malignancies and uncertainty about intervals between one diagnosis and the next. Many AYAs viewed survivorship as requiring a high degree of suffering. Though many personally rejected "survivor" identities, almost all articulated its various functions including positive, negative, and more complicated connotations. Instead, they chose language to represent a range of beliefs about survival, longevity, prognosis, and activism.

CONCLUSIONS

AYAs with LFS struggle with the term "survivor" due to their multi-organ cancer risk, short intervals between malignancies, and evolving identities. Loved ones' cancer-related suffering informed perspectives on survivorship. Survivorship care for AYAs with cancer risk syndromes requires interprofessional interventions that address their unique biomedical and psychosocial needs.

Induction of expression of branched-chain aminotransferase and alpha-keto acid dehydrogenase in rat tissues during lactation

This study was designed to determine the effect of lactation and weaning on the gene expression of branched-chain aminotransaminase (BCAT) and branched-chain alpha-keto acid dehydrogenase (BCKD) in different tissues of the lactating rat. BCAT activity increased in mammary tissue during lactation and was 6-fold higher than in virgin rats. This increase was associated with an increase in protein levels measured by immunoblot analysis, and with an increase in BCAT mitochondrial (BCATm) mRNA concentration. Twenty-four hours after weaning, BCAT activity, protein concentration, and mRNA levels in the dam decreased. BCAT activity, protein enzyme levels, and BCATm mRNA concentration in muscle were higher in weaning rats than in lactating rats. BCAT cytosolic (BCATc) mRNA was not expressed in mammary tissue, and there was no BCATc enzyme detected by Western blot in any physiological state. Mammary tissue BCKD activity increased and was active (dephosphorylated) during the lactation period. The level of enzyme also increased and the mRNA level for the E2 subunit in mammary tissue was 10-fold higher than the virgin values. Hepatic enzyme activity increased during weaning, and this was associated with the protein level and with the mRNA level of the E2 subunit. Muscle BCKD activity and protein content were the lowest of all tissues, and the E2 subunit mRNA level was barely detected by Northern blot analysis. The results suggest gene regulation of the two main catabolic enzymes of the branched-chain amino acid metabolism during lactation.

Structure and function of branched chain aminotransferases

Branched chain aminotransferases (BCATs) catalyze transamination of the branched chain amino acids (BCAAs) leucine, isoleucine, and valine. Except for the Escherichia coli and Salmonella proteins, which are homohexamers arranged as a double trimer, the BCATs are homodimers. Structurally, the BCATs belong to the fold type IV class of pyridoxal phosphate (PLP) enzymes. Other members are D-alanine aminotransferase and 4-amino-4-deoxychorismate lyase. Catalysis is on the re face of the PLP cofactor, whereas in other classes, catalysis occurs from the si face of PLP. Crystal structures of the fold type IV proteins show that they are distinct from the fold type I aspartate aminotransferase family and represent a new protein fold. Because the fold type IV enzymes catalyze diverse reactions, it is not surprising that the greatest structural similarities involve residues that participate in PLP binding rather than residues involved in substrate binding. The BCATs are widely distributed in the bacterial kingdom, where they are involved in the synthesis/degradation of the BCAAs. Bacteria contain a single BCAT. In eukaryotes there are two isozymes, one is mitochondrial (BCATm) and the other is cytosolic (BCATc). In mammals, BCATm is in most tissues, and BCATm is thought to be important in body nitrogen metabolism. BCATc is largely restricted to the central nervous system (CNS). Recently, BCATc has been recognized as a target of the neuroactive drug gabapentin. BCATc is involved in excitatory neurotransmitter glutamate synthesis in the CNS. Ongoing structural studies of the BCATs may facilitate the design of therapeutic compounds to treat neurodegenerative disorders involving disturbances of the glutamatergic system.

Role of specific aminotransferases in de novo glutamate synthesis and redox shuttling in the retina

In this study aminotransferase inhibitors were used to determine the relative importance of different aminotransferases in providing nitrogen for de novo glutamate synthesis in the retina. Aminooxyacetate, which inhibits all aminotransferases, blocked de novo glutamate synthesis from H(14)CO(3)(-) by more than 60%. Inhibition of neuronal cytosolic branched chain amino acid transamination by gabapentin or branched chain amino acid transport by the L-system substrate analog, 2-amino-bicyclo-(2,2,1)-heptane-2-carboxylic acid, lowered total de novo synthesis of glutamate by 30%, suggesting that branched chain amino acids may account for half of the glutamate nitrogen contributed by transamination reactions. L-cycloserine, an inhibitor of alanine aminotransferase, inhibited glutamate synthesis less than 15% when added in the presence of 5 mM pyruvate but 47% in the presence of 0.2 mM pyruvate. Although high levels of pyruvate blunted the inhibitory effectiveness of L-cycloserine, the results indicate that, under physiological conditions, alanine as well as branched chain amino acids are probably the predominant sources of glutamate nitrogen in ex vivo retinas. The L-cycloserine results were also used to evaluate activity of the malate/aspartate shuttle. In this shuttle, cytosolic aspartate (synthesized in mitochondria) generates cytosolic oxaloacetate that oxidizes cytosolic NADH via malate dehydrogenase. Because L-cycloserine inhibits cytosolic but not mitochondrial aspartate aminotransferase, L-cycloserine should prevent the utilization of aspartate but not its generation, thereby increasing levels of (14)C-aspartate. Instead, L-cycloserine caused a significant decline in (14)C-aspartate. The results suggest the possibility that shuttle activity is low in retinal Müller cells. Low malate/aspartate shuttle activity may be the molecular basis for the high rate of aerobic glycolysis in retinal Müller cells.

The structure of human mitochondrial branched-chain aminotransferase

X-ray crystal structures of three forms of human mitochondrial branched-chain aminotransferase (BCAT) were solved by molecular-replacement methods, using Escherichia coli BCAT as the search model. The enzyme is a homodimer and the polypeptide chain of each monomer has two domains. The small domain is composed of residues 1--175 and the large domain is composed of residues 176--365. The active site is close to the dimer interface. The 4'-aldehyde of the PLP cofactor is covalently linked to the epsilon-amino group of the active-site lysine, Lys202, via a Schiff-base linkage in two of the structures. In the third structure, the enzyme is irreversibly inactivated by Tris. The overall fold of the dimer in human mitochondrial BCAT is similar to the structure of two bacterial enzymes, E. coli BCAT and D-amino acid aminotransferase (D-AAT). The residues lining the putative substrate-binding pocket of human BCAT and D-AAT are completely rearranged to allow catalysis with substrates of opposite stereochemistry. In the case of human mitochondrial branched-chain aminotransferase, a hydrogen-bond interaction between the guanidinium group of Arg143 in the first monomer with the side-chain hydroxyl of Tyr70 in the second monomer is important in the formation of the substrate-binding pocket.

Distribution of key enzymes of branched-chain amino acid metabolism in glial and neuronal cells in culture

Transamination of branched-chain amino acids (BCAAs) catalyzed by the branched chain aminotransferase isoenzymes (BCATs) is believed to play an important role in nitrogen shuttling and excitatory neurotransmitter glutamate metabolism in brain. Recently, we have shown that the mitochondrial isoenzyme (BCATm) is the predominant form found in cultured astrocytes. In this study we used immunocytochemistry to examine the distribution of BCAT isoenzymes in cultured rat neurons and microglial cells. The cytoplasm of neurons displayed intense staining for the cytosolic isoenzyme (BCATc), whereas BCATm staining was not detectable in neurons. In contrast, microglial cells expressed BCATm in high concentration. BCATc appeared to be absent in this cell type. The second and committed step in the BCAA catabolic pathway is oxidative decarboxylation of the alpha-keto acid products of BCAT catalyzed by the branched-chain alpha-keto acid dehydrogenase (BCKD) enzyme complex. Because the presence of BCKD should provide an index of the ability of a cell to oxidize BCAA, we have also immunocytochemically localized BCKD in neuron and glial cell cultures from rat brain. Our results suggest ubiquitous expression of this BCKD enzyme complex in cultured brain cells. BCKD immunoreactivity was detected in neurons and in astroglial and microglial cells. Therefore, the expression of BCAT isoenzymes shows cell-specific localization, which is consistent with the operation of an intercellular nitrogen shuttle between neurons and astroglia. On the other hand, the ubiquitous expression of BCKD suggests that BCAA oxidation can probably take place in all types of brain cells and is most likely regulated by the activity state of BCKD rather than by its cell-specific localization.

Purification and cloning of the mitochondrial branched-chain amino acid aminotransferase from sheep placenta

This paper presents the first purification of the mitochondrial branched-chain amino acid aminotransferase (BCATm) from sheep placenta. It is a homodimer with an apparent subunit molecular mass of 41 kDa. The enzyme differs from those of the rat and human as it appears to form at least one intermolecular disulfide bond. The sheep BCATm cDNA (1.4 kb) encodes a mature polypeptide of 366 amino acids with a calculated molecular mass of 41 329 Da and a partial mitochondrial targeting sequence of seven amino acids. The sheep BCATm sequence shares higher identity with other mammalian BCATm isoenzymes (82-85%) than with the cytosolic isoenzymes (60%). By Northern blot analysis, a message of 1.7 kb was detected in sheep placenta and skeletal muscle. Measurements of BCAT activity, mRNA and BCATm protein in sheep placenta and skeletal muscle revealed that BCATm is the sole BCAT isoenzyme expressed in placenta, whereas it contributes 57 and 71% of the BCAT activity in tensor fascia latae and masseter muscles from weaned lambs respectively. Skeletal muscle, the main site of branched-chain amino acid transamination, exhibits significantly lower BCAT activity in sheep than in rat. Our results suggest that the low BCATm mRNA level probably accounts for the low BCAT activity in sheep skeletal muscle, and that the metabolic scheme for branched-chain amino acid catabolism is specific to each species.

Processing and expression of rat and human clotting factor-X-encoding cDNAs

The cDNA encoding clotting factor X, which participates in the middle stage of the blood coagulation cascade was cloned from a rat liver cDNA library. Sequencing of the rat factor-X-encoding cDNA revealed that this vitamin-K-dependent protein has a dibasic Arg-Arg sequence at the propeptide cleavage site, as occurs in other vitamin-K-dependent proteins. Although the human and rat deduced amino acid sequences are remarkably similar (76% identical), they do significantly differ in that human factor-X contains a unique Thr-Arg sequence at the propeptide cleavage site [Fung et al., Proc. Natl. Acad. Sci. USA 82 (1985) 3591-3595], where a dibasic sequence would normally be expected. This specific site is the recognition motif for the endoprotease, furin, which is located in the Golgi apparatus. Both rat and human cDNAs expressed in Cos-1 cells resulted in secretion of a mixture of single- and two-chain forms of factor X. The two-chain forms were devoid of the propeptide and were produced at similar rates by the transfected cells. The efficient processing of human factor X, when compared to rat factor X, may indicate that an additional protease(s), which recognizes the Thr-Arg motif, may be involved in proteolytic processing of the human enzyme.

Evidence for competition between vitamin K-dependent clotting factors for intracellular processing by the vitamin K-dependent gamma-carboxylase

This study demonstrates an apparent competition between newly synthesized precursors of prothrombin and factor X for binding to and processing by the gamma-carboxylase in the ER membrane of hepatocytes. The precursor of factor X appears to exhibit a strong affinity for the carboxylase than the prothrombin precursor. This conclusion is supported by the findings that 1) in normal hepatocytes, the factor X precursor prevents increased prothrombin precursor binding to the ER membrane, 2) increased prothrombin binding to the ER membrane was measured in H4-II-E-C3 Reuber H-35 cells where factor X synthesis is suppressed. The variations in the concentrations of the prothrombin and the factor X precursors that were as associated with the ER membrane correlated with the available prothrombin and factor X substrate pools for the gamma-carboxylase.

Vitamin K-dependent carboxylation. Evidence that at least two microsomal dehydrogenases reduce vitamin K1 to support carboxylation

It has been shown that NAD(P)H dehydrogenase (EC 1.6.99.2) reduces vitamin K1 and can support the [vitamin K1 + NADH]-dependent carboxylation reaction in rat liver microsomes (Wallin, R., Gebhardt, O., and Prydz, H. (1978) Biochem. J. 169, 95-101). Antibodies were raised in rabbits against the purified enzyme from liver cytosol and used to study the importance of NAD(P)H dehydrogenase in the vitamin K-dependent carboxylation reaction. The antibodies neutralized the warfarin-sensitive NAD(P)H dehydrogenase activity in Triton X-100-solubilized microsomes; however, they neutralized only 45% of the total [vitamin K1 + NADH]-dependent carboxylation activity. Chromatography on protein A-sepharose showed that the remaining carboxylase activity was not the result of soluble antigen-antibody complexes. The data presented support the conclusion that the microsomal preparation also contains a non-warfarin-sensitive dehydrogenase(s) that, in addition to NAD(P)H dehydrogenase, can reduce vitamin K1 to support the carboxylation reaction.