Insights into urticaria in pediatric and adult populations and its management with fexofenadine hydrochloride

OBJECTIVE

The present narrative review provides a comprehensive update of the current knowledge on urticaria, both in adult and pediatric populations, and on the safety and efficacy of fexofenadine hydrochloride (HCl) as a treatment option.

DATA SOURCE

A literature search was conducted on Embase and Medline.

STUDY SELECTION

Clinical studies published in English and published between 1999 and 2020 were selected.

RESULTS

Although the exact pathogenesis of urticaria is not fully understood, multiple pathways of mast cell activation are discussed to explain the existence of phenotypically different clinical manifestations of urticaria. An overview of the worldwide prevalence of chronic urticaria, including disease burden and patient's quality of life is provided. The impact of urticaria on patient's life differs on the basis of whether its form is acute or chronic, but pharmacological approaches are most often needed to control the disabling symptoms. A summary of the current management of urticaria recommended by different guidelines across countries (Global; European; American; Australian; Asian; Japanese) is presented. Non-sedating, second-generation H₁-antihistamines are the preferred choice of treatment across several guidelines worldwide. Herein, the efficacy and safety of fexofenadine HCl, a representative second-generation H₁-antihistamine approved for the treatment of urticaria, is discussed. The occurrence of urticaria manifestations in COVID-19 patients is also briefly presented.

CONCLUSION

The burden of acute and chronic urticaria is high for patients. Second generation anti-histamines such as fexofenadine HCl can help managing the symptoms.

WAO-ARIA consensus on chronic cough - Part III: Management strategies in primary and cough-specialty care. Updates in COVID-19

Background

Chronic cough management necessitates a clear integrated care pathway approach. Primary care physicians initially encounter the majority of chronic cough patients, yet their role in proper management can prove challenging due to limited access to advanced diagnostic testing. A multidisciplinary approach involving otolaryngologists and chest physicians, allergists, and gastroenterologists, among others, is central to the optimal diagnosis and treatment of conditions which underly or worsen cough. These include infectious and inflammatory, upper and lower airway pathologies, or gastro-esophageal reflux. Despite the wide armamentarium of ancillary testing conducted in cough multidisciplinary care, such management can improve cough but seldom resolves it completely. This can be due partly to the limited data on the role of tests (eg, spirometry, exhaled nitric oxide), as well as classical pharmacotherapy conducted in multidisciplinary specialties for chronic cough. Other important factors include presence of multiple concomitant cough trigger mechanisms and the central neuronal complexity of chronic cough. Subsequent management conducted by cough specialists aims at control of cough refractory to prior interventions and includes cough-specific behavioral counseling and pharmacotherapy with neuromodulators, among others. Preliminary data on the role of neuromodulators in a proof-of-concept manner are encouraging but lack strong evidence on efficacy and safety.

Objectives

The World Allergy Organization (WAO)/Allergic Rhinitis and its Impact on Asthma (ARIA) Joint Committee on Chronic Cough reviewed the recent literature on management of chronic cough in primary, multidisciplinary, and cough-specialty care. Knowledge gaps in diagnostic testing, classical and neuromodulator pharmacotherapy, in addition to behavioral therapy of chronic cough were also analyzed.

Outcomes

This third part of the WAO/ARIA consensus on chronic cough suggests a management algorithm of chronic cough in an integrated care pathway approach. Insights into the inherent limitations of multidisciplinary cough diagnostic testing, efficacy and safety of currently available antitussive pharmacotherapy, or the recently recognized behavioral therapy, can significantly improve the standards of care in patients with chronic cough.

WAO-ARIA consensus on chronic cough - Part 1: Role of TRP channels in neurogenic inflammation of cough neuronal pathways

BACKGROUND

Cough features a complex peripheral and central neuronal network. The function of the chemosensitive and stretch (afferent) cough receptors is well described but partly understood. It is speculated that chronic cough reflects a neurogenic inflammation of the cough reflex, which becomes hypersensitive. This is mediated by neuromediators, cytokines, inflammatory cells, and a differential expression of neuronal (chemo/stretch) receptors, such as transient receptor potential (TRP) and purinergic P2X ion channels; yet the overall interaction of these mediators in neurogenic inflammation of cough pathways remains unclear.

OBJECTIVES

The World Allergy Organization/Allergic Rhinitis and its Impact on Asthma (WAO/ARIA) Joint Committee on Chronic Cough reviewed the current literature on neuroanatomy and pathophysiology of chronic cough. The role of TRP ion channels in pathogenic mechanisms of the hypersensitive cough reflex was also examined.

OUTCOMES

Chemoreceptors are better studied in cough neuronal pathways compared to stretch receptors, likely due to their anatomical overabundance in the respiratory tract, but also their distinctive functional properties. Central pathways are important in suppressive mechanisms and behavioral/affective aspects of chronic cough. Current evidence strongly suggests neurogenic inflammation induces a hypersensitive cough reflex marked by increased expression of neuromediators, mast cells, and eosinophils, among others. TRP ion channels, mainly TRP V1/A1, are important in the pathogenesis of chronic cough due to their role in mediating chemosensitivity to various endogenous and exogenous triggers, as well as a crosstalk between neurogenic and inflammatory pathways in cough-associated airways diseases.

WAO-ARIA consensus on chronic cough - Part II: Phenotypes and mechanisms of abnormal cough presentation - Updates in COVID-19

BACKGROUND

Chronic cough can be triggered by respiratory and non-respiratory tract illnesses originating mainly from the upper and lower airways, and the GI tract (ie, reflux). Recent findings suggest it can also be a prominent feature in obstructive sleep apnea (OSA), laryngeal hyperresponsiveness, and COVID-19. The classification of chronic cough is constantly updated but lacks clear definition. Epidemiological data on the prevalence of chronic cough are informative but highly variable. The underlying mechanism of chronic cough is a neurogenic inflammation of the cough reflex which becomes hypersensitive, thus the term hypersensitive cough reflex (HCR). A current challenge is to decipher how various infectious and inflammatory airway diseases and esophageal reflux, among others, modulate HCR.

OBJECTIVES

The World Allergy Organization/Allergic Rhinitis and its Impact on Asthma (WAO/ARIA) Joint Committee on Chronic Cough reviewed the current literature on classification, epidemiology, presenting features, and mechanistic pathways of chronic cough in airway- and reflux-related cough phenotypes, OSA, and COVID-19. The interplay of cough reflex sensitivity with other pathogenic mechanisms inherent to airway and reflux-related inflammatory conditions was also analyzed.

OUTCOMES

Currently, it is difficult to clearly ascertain true prevalence rates in epidemiological studies of chronic cough phenotypes. This is likely due to lack of standardized objective measures needed for cough classification and frequent coexistence of multi-organ cough origins. Notwithstanding, we emphasize the important role of HCR as a mechanistic trigger in airway- and reflux-related cough phenotypes. Other concomitant mechanisms can also modulate HCR, including type2/Th1/Th2 inflammation, presence or absence of deep inspiration-bronchoprotective reflex (lower airways), tissue remodeling, and likely cough plasticity, among others.

Metallothionein-3 Is a Component of a Multiprotein Complex in the Mouse Brain

Metallothlonein (MT)-3, originally called growth inhibitory factor (GIF), was initially identified through its ability to Inhibit the growth of neuronal cells in the presence of brain extract. MT-3 is the brain specific isoform of the MT family whose specific biological activity associates it with neurological disorders. Indeed, studies report that MT-3 is decreased by ~30% in brains of patients with Alzheimer disease (AD). Furthermore, many lines of evidence suggest that MT-3 engages in specific protein interactions. To address this, we conducted Immunoaffinity chromatography experiments using an immobilized anti-mouse MT-3 antibody. We identified five associated proteins from the pool of sixteen recovered using mass spectrometry and tandem mass spectrometry after in-gel trypsin digestion of bands from the affinity chromatography. The proteins identified were: heat shock protein 84 (HSP84), heat shock protein 70 (HSP70), dihydropyrimidinase-like protein-2 (DRP-2), creatine kinase (CK) and β-actin. Coimmunoprecipitation experiments, also conducted on whole mouse brain extract using the anti-mouse MT-3 antibody along with commercially available antibodies against HSP84 and CK, confirmed that these three proteins were in a single protein complex. Immunohistochemical experiments were then conducted on the perfused mouse brain that confirmed the in situ colocallzation of CK and MT-3 in the hippocampus region. These data provide new Insights into the involvement of MT-3 in a multiprotein complex, which will be used to understand the biological activity of MT-3 and its role in neurological disease.

Implications of venom hypersensitivity for a deploying soldier

Venom immunotherapy (VIT) is a life-saving medical treatment for individuals allergic to Hymenoptera species. Delivery of VIT is a complex process that requires proper extract preparation, shipping, storage, refrigeration, and administration by qualified medical personnel in a facility that can manage a life-threatening allergic emergency (anaphylaxis). Successful VIT requires 3 to 5 years of uninterrupted maintenance injections, which may be difficult to maintain during deployments, particularly in combat operations. The complexity of VIT has resulted in service members being deemed nondeployable and has led to interruption or discontinuation of VIT for deployed service members in the past. We report the case of a 34-year-old Army National Guard soldier who successfully received maintenance VIT while deployed to Operation Iraqi Freedom. This case demonstrates that, with proper coordination and appropriate risk assessment, continuation of complex medical care, such as VIT, can be supported in a combat zone.

A comparison of two single-headed and two multi-headed allergen skin test devices

Given the potential differences in performance of skin test devices, the purpose of this study was to prospectively assess the performance of two single-headed and two multiheaded devices for allergy skin testing in terms of wheal size, sensitivity, specificity, intradevice variability, and pain level. Two single-headed devices (Greer Pick, Duotip-Test) and two multiheaded devices (Multi-Test II, OMNI) were tested in 15 subjects in a prospective partially blind fashion looking at wheal reactions and pain using histamine and glycerol-saline on the arms and back. Differences among devices in wheal size and pain were noted. Sensitivity, specificity, and intradevice variability were calculated. Differences between corner and interior heads in multiheaded devices were analyzed. No significant differences were observed in wheal size between Greer Pick (7.1+/-1.4 mm) and Duotip-Test (7.2+/-1.6 mm). Multiheaded devices were significantly different in wheal size compared with each other and to the single-headed devices (Multi-Test II, 5.4+/-1.7 mm; OMNI, 3.3+/-1.2 mm). Single-headed devices were more sensitive (100% each, 95% CI of 92-100%) than the multiheaded devices. Multi-Test II was significantly more sensitive (83%, 95% CI of 78-87%) than OMNI (57%, 95% CI of 51-62%). There was significant intradevice variability for the multiheaded devices with corner heads being significantly more sensitive than interior heads. Specificities for all devices were equally good (-97%). Pain was greater for multiheaded devices than single-headed devices but was generally mild. In conclusion, this study supports the idea that single-headed devices may be more sensitive and consistent than multiheaded devices. Multi-Test II is more sensitive than OMNI. In multiheaded devices, corner heads are more sensitive than interior heads.

Absence of oropharyngeal vaccinia virus after vaccinia (smallpox) vaccination

BACKGROUND

With the resumption of the vaccinia (smallpox) vaccination, questions regarding transmission risk prompted this study to determine whether vaccinia virus could be detected in the oropharynx of adults recently vaccinated with vaccinia (smallpox) vaccine. German, Russian, and American studies on the oropharyngeal presence of vaccinia virus revealed conflicting results in different age groups.

OBJECTIVE

To measure vaccinia viral particle or antigen presence in the oropharynx of adult health care workers after vaccination with vaccinia (smallpox) vaccine using viral culture and high-sensitivity assays (polymerase chain reaction [PCR] and electrochemiluminescence) and to determine whether there is an association between the presence of vaccinia virus and adverse reactions.

METHODS

A total of 155 adults (primary vaccinees and revaccinees) were enrolled for 1 baseline and 5 subsequent throat swabs. The swabs were evaluated using viral culture, PCR, and electrochemiluminescence.

RESULTS

Of the 155 participants, 144 had more than 2 throat swabs in the 2 weeks after vaccination. Of the 801 specimens evaluated, there were no positive results by culture, PCR, or electrochemiluminescence except in the control samples (n = 6), which were positive by all 3 methods.

CONCLUSIONS

Based on the absence of detectable vaccinia virus in this study population, one can be 95% certain that the true rate of vaccinia virus in the oropharynx of adults during the 2 weeks after vaccination with vaccinia (smallpox) vaccine is 0% to 3.3%. These data should be reassuring to the medical community and support the Advisory Committee on Immunization Practice guidelines that respiratory precautions are not necessary after vaccinia (smallpox) vaccination in healthy adults.

Asthma in pregnancy

Asthma, one of the most common serious medical problems to complicate pregnancy, affects 3-8% of pregnancies in the United States. The goals of therapy in the pregnant asthmatic patient do not differ from those in non-pregnant patients. Inhaled corticosteroids (ICS) are preferred in the management of all levels of persistent asthma in pregnant patients, because these agents have been shown to reduce asthma exacerbations during pregnancy. Asthma in pregnancy is often undertreated due to physician and patient concerns over the effects of asthma medications on the fetus. However, undertreatment leads to loss of asthma control and increases in maternal morbidity, perinatal mortality, preeclampsia, preterm birth, and low birth weight infants. Recent prospective clinical cohort studies with active asthma management by NAEPP guidelines show no evidence of increased maternal or fetal morbidity or mortality. Therefore, it is critical for the mother to understand that failure to control asthma during pregnancy may lead to poor outcomes. A case study follows to highlight clinical pearls and pitfalls in the management of asthma in the pregnant patient.

Airway hyperresponsiveness by methacholine challenge testing following negative exercise challenge

BACKGROUND

Exercise challenge testing (ECT) to diagnose exercise-induced bronchospasm has been demonstrated to be an insensitive screening test to demonstrate the presence or absence of airway hyperreactivity. Previous studies have not compared this procedure to methacholine challenge testing (MCT) in a clinical setting.

OBJECTIVE

To determine the frequency of positive MCT in subjects with exertional dyspnea, normal baseline spirometry, and negative ECT.

METHODS

Observational study of 215 military patients at an Army Community Hospital referred for evaluation of exertional dyspnea with normal baseline spirometry. Subjects were further evaluated with ECT on a graded treadmill with pre- and postexercise spirometry. Those without evidence of bronchial hyperreactivity as defined by a 15% decrease in FEV1 postexercise were evaluated with methacholine challenge testing (MCT).

RESULTS

Two hundred ten military subjects were evaluated. Eighty-two patients underwent ECT as the only method of bronchoprovocation testing with 25 positive tests (57 were negative but not referred for further testing). The remaining 128 patients with a negative ECT underwent MCT. Seventy-six (59%) had a negative MCT and 52 (41%) had a positive MCT. Of the positive MCT studies, 74% were positive at a methacholine concentration of 2.5 mg/mL or less.

CONCLUSIONS

Our study demonstrates that a significant number of patients being evaluated for exertional dyspnea will have a positive MCT after a negative ECT. Our findings lead us to question the utility of ECT as an initial diagnostic test for the exercise-induced bronchospasm.

A novel connexin 26 gene mutation associated with features of the keratitis-ichthyosis-deafness syndrome and the follicular occlusion triad

We report the case of a congenitally deaf white male with mild palmoplantar keratoderma, ichthyosiform scaling, follicular hyperkeratosis, and mild keratitis, features consistent with keratitis-ichthyosis-deafness syndrome. His major problem was severe, disfiguring, inflammatory dissecting folliculitis of the scalp, hidradenitis suppurativa, and cystic acne, features comprising the follicular occlusion triad. This unusual phenotype is associated with a novel heterozygous point mutation (C119T) in the gap junction beta2 gene that substitutes a valine for alanine at codon 40 (A40V) in the connexin 26 protein. Through Xenopus oocyte expression studies, this mutant protein was shown to significantly disrupt the function of the specialized gap junctions connecting the cytoplasm of adjacent cells critical for tissue homeostasis. Mutations within the connexin 26 protein are associated with syndromes involving both sensorineural deafness and hyperkeratotic skin disorders. This is the first report of an association between a connexin 26 protein mutation, follicular hyperkeratosis of keratitis-ichthyosis-deafness syndrome, and severe follicular occlusion triad.

Adverse reactions to vaccines

(The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.) Immunization healthcare is becoming increasingly complex as the number and types of vaccines have continued to expand. Like all prescription drugs, vaccines may be associated with adverse events. The majority of these reactions are self-limited and not associated with prolonged disability. The media, Internet and public advocacy groups have focused on potentially serious vaccine-associated adverse events with questions raised about causal linkages to increasing frequencies of diseases such as autism and asthma. Despite a lack of evidence of a causal relationship to a variety of vaccine safety concerns, including extensive reviews by the Institute of Medicine, questions regarding vaccine safety continue to threaten the success of immunization programs. Risk communication arid individual risk assessment is further challenged by the public health success of vaccine programs creating the perception that certain vaccines are no longer necessary or justified because of the rare reaction risk. There is a need for improved understanding of true vaccine contraindications and precautions as well as host factors and disease threat in order to develop a patient specific balanced risk communication intervention. When they occur, vaccine related adverse events must be treated, documented and reported through the VAERS system. The increasing complexity of vaccination health care has led the Center of Disease Control and Prevention (CDC) to identify Vaccine Safety Assessment and Evaluation as a potential new specialty.

Hypaxial muscle migration during primary myogenesis in Xenopus laevis

In contrast to many vertebrates, the ventral body wall muscles and limb muscles of Xenopus develop at different times. The ventral body wall forms in the tadpole, while limb (appendicular) muscles form during metamorphosis to the adult frog. In organisms that have been examined thus far, a conserved mechanism has been shown to control migratory muscle precursor specification, migration, and differentiation. Here, we show that the process of ventral body wall formation in Xenopus laevis is similar to hypaxial muscle development in chickens and mice. Cells specified for the migratory lineage display an upregulation of pax3 in the ventro-lateral region of the somite. These pax3-positive cells migrate ventrally, away from the somite, and undergo terminal differentiation with the expression of myf-5, followed by myoD. Several other genes are selectively expressed in the migrating muscle precursor population, including neural cell adhesion molecule (NCAM), Xenopus kit related kinase (Xkrk1), and Xenopus SRY box 5 (sox5). We have also found that muscle precursor migration is highly coordinated with the migration of neural crest-derived melanophores. However, by extirpating neural crest at an early stage and allowing embryos to develop, we determined that muscle precursor migration is not dependent on physical or genetic interaction with melanophores.

Identification of the t-type calcium channel (Ca(v)3.1d) in developing mouse heart

During cardiac development, there is a reciprocal relationship between cardiac morphogenesis and force production (contractility). In the early embryonic myocardium, the sarcoplasmic reticulum is poorly developed, and plasma membrane calcium (Ca(2+)) channels are critical for maintaining both contractility and excitability. In the present study, we identified the Ca(V)3.1d mRNA expressed in embryonic day 14 (E14) mouse heart. Ca(V)3.1d is a splice variant of the alpha1G, T-type Ca(2+) channel. Immunohistochemical localization showed expression of alpha1G Ca(2+) channels in E14 myocardium, and staining of isolated ventricular myocytes revealed membrane localization of the alpha1G channels. Dihydropyridine-resistant inward Ba(2+) or Ca(2+) currents were present in all fetal ventricular myocytes tested. Regardless of charge carrier, inward current inactivated with sustained depolarization and mirrored steady-state inactivation voltage dependence of the alpha1G channel expressed in human embryonic kidney-293 cells. Ni(2+) blockade discriminates among T-type Ca(2+) channel isoforms and is a relatively selective blocker of T-type channels over other cardiac plasma membrane Ca(2+) handling proteins. We demonstrate that 100 micromol/L Ni(2+) partially blocked alpha1G currents under physiological external Ca(2+). We conclude that alpha1G T-type Ca(2+) channels are functional in midgestational fetal myocardium.

In vitro effect of retinoids on calcineurin activity

Calcineurin was shown previously to be inhibited by members of the tyrphostin family of tyrosine kinase inhibitors, with the most effective inhibition suggested to be caused by the presence of a conjugated side chain (Martin BL, Biochem Pharmacol 56: 483-488, 1998). Retinoids are a family of naturally occurring biomolecules having non-aromatic ring structures and conjugated side chains as substituents on the ring. Three oxidation states of the all-trans configuration of retinoids (retinol, retinal, and retinoic acid) were tested as effectors of calcineurin. Only retinoic acid was found to inhibit calcineurin effectively, with an IC(50) value of approximately 50 microM. Retinol and retinal caused less than 30% inhibition at concentrations up to 100 microM. All three retinoids caused some precipitation of reaction components: retinoic acid and retinal above 50 microM, and retinol above 250 microM. Bacterial alkaline phosphatase was not inhibited by the retinoids, indicating that metal centers alone are insufficient for significant inhibition by retinoic acid. An aromatic ring was not required for inhibition and may not provide additional inhibition, inasmuch as an aromatic analog of retinoic acid (acitretin) showed less effective inhibition. These data are consistent with the presence of conjugated, unsaturated groups enhancing the inhibition of calcineurin.

Differences between Mg(2+) and transition metal ions in the activation of calcineurin

Exogenous metal ion activation of calcineurin catalyzed hydrolysis of para-nitrophenyl phosphate was kinetically characterized at 20, 25, 30, and 37 degrees C. Analysis yielded estimates for thermodynamic parameters for the activation of calcineurin by each of the metal ions. Values for DeltaG(Me)( degrees ) were varied with the best activators resulting in more stable enzyme-metal ion complexes and with DeltaG(Me)( degrees ) dominated by the entropic component. Mg(2+) was the only nontransition metal ion which supported significant activity and showed some distinct characteristics including a negative DeltaS(Me)( degrees ), suggesting that activation by Mg(2+) may have resulted in a unique enzyme-metal ion form. Circular dichroism showed that metal ions increased the alpha-helical content of calcineurin, but little significant differences in the spectra were identified between using activating and nonactivating metal ions. Activating Mg(2+), but not nonactivating Ca(2+), did cause changes in the Fourier transform infrared photoacoustic spectrum of calcineurin compared to the spectrum of calcineurin with Mn(2+). Other metal ions, Co(2+) and Ni(2+), also caused no changes in the infrared spectrum. Possible explanations for these differences between Mg(2+) and transition metal ions in the activation of calcineurin are discussed.

Arginine to citrulline replacement in substrates of phosphorylase kinase

Synthetic peptides based on residues 9 to 18 of glycogen phosphorylase were prepared containing citrulline at position 10 or 16, or at both positions 10 and 16. The peptides were compared as substrates for a recombinant, truncated form of the catalytic subunit of phosphorylase kinase (residues 1-300). The peptide having citrulline at position 10 was phosphorylated the same as the parent peptide. Both the peptides with a single citrulline at position 16 and with two citrullines were phosphorylated less effectively than the parent peptide; k(cat)/K(m) values were approximately 20% the value with the parent peptide. Incorporation of the second citrulline had little change in the effectiveness of the peptide as a substrate although the kinetic parameters with the citrulline peptides did show differences. The change in peptide phosphorylation did not seem to result from a change in peptide structure. Two-dimensional nuclear magnetic resonance studies of di-citrulline peptide are reported and showed no change in the solution structure of the peptide compared to the parent peptide. Thus, the change in kinetic parameters with the modified peptides seemed an effect of arginine replacement and was likely a consequence of the loss of charge inasmuch as the size of arginine and citrulline are similar. Arginine-16 was concluded to be more important for phosphorylase kinase recognition than arginine-10. These findings were consistent with the earlier studies using alanine replacement of arginine in synthetic peptides as substrates for the holoenzyme form of phosphorylase kinase.

Effect of substitution inert metal complexes on calcineurin

As a substitute for M(H2O)2+6, Co(NH3)3+6 was found to activate calcineurin with para-nitrophenyl phosphate as substrate. Kinetics for calcineurin catalyzed hydrolysis of para-nitrophenyl phosphate at pH 7.0 with Mn2+, Mg2+, Co2+, and Co(NH3)3+6 were compared. Although kcat and Km were different with the metals, values of kcat/Km were nearly identical for Mn2+ and Mg2+, but lower for Co2+ and Co(NH3)3+6. The concentration of each metal providing half-maximal activation, designated Kact, was evaluated as 15.9 mM for Co(NH3)3+6, compared to Kact = 0.17 mM for Mn2+ and Co2+ and 6.3 mM for Mg2+, respectively. Comparing kcat/Kcat showed that Co(NH3)3+6 was a 170-fold poorer activator of calcineurin than was Mn2+, but only 1.5-fold poorer than Mg2+. Activation by Co(NH3)3+6 indicated that activation of calcineurin by exogenous metal ions can proceed via an outer coordination sphere reaction mechanism with no requirement for the direct coordination of substrate by metal. Because Co(NH3)3+6 was found to support calcineurin activity, the related compound [Co-(ethylenediamine)3]3+ (or Co(en)3+3) was tested as a possible activator. Co(en)3+3 did not support calcineurin activity but did inhibit calcineurin. Co(en)3+3 showed competitive inhibition kinetics with either Mn2+ or pNPP as the varied ligand and the other at a fixed, subsaturating concentration. Inorganic phosphate was used as a known competitive inhibitor to pNPP (B. L. Martin and D. J. Graves, J. Biol. Chem. 261, 14545-14550, 1986) and showed uncompetitive inhibition with Mn2+ as the varied ligand. These patterns are consistent with the mechanism of ligand binding to calcineurin being ordered with metal preceding substrate. Prior formation of a metal-substrate complex was not required for association with calcineurin.

Localized structural effects of electrostatic interactions in a thermostable enzyme

The sequence and resolved structure of thermotrophic isopropylmalate dehydrogenase (IPMDH) and a related protein, mesotrophic isocitrate dehydrogenase (IDH), were compared emphasizing clusters of charged residues identified from X-ray crystallographic studies (Wallon, G., Kryger, G., Lovett, S. T., Oshima, T., Ringe, D., and Petsko, G. A. (1997) J. Mol. Biol. 266, 1016-1031). Mesotrophic isocitrate dehydrogenase was used for comparison because crystallographic data for a mesotrophic form of IPMDH was not available in the database. The structural features in the region of these clusters were compared and localized conformational differences were found in the thermotroph compared to the mesotroph. Because the overall topology of the two proteins is similar, it was concluded that these localized structural differences induced by electrostatic interactions between charged residues in the thermotrophic enzyme were responsible for the enhanced thermal stability of proteins from thermotroph.

Comparison of the reaction progress of calcineurin with Mn2+ and Mg2+

Activation of calcineurin by Mn2+ and Mg2+ was compared using a heavy atom isotope analogue of the substrate p-nitrophenyl phosphate (pNPP). Heavy atom isotope effects were measured for Mg2+ activation and compared to published results of the isotope effects with Mn2+ as the activating metal. Isotope effects were measured for the kinetic parameter Vmax/Km at the nonbridging oxygen atoms [18(V/K)nonbridge]; at the position of bond cleavage in the bridging oxygen atom [18(V/K)bridge]; and at the nitrogen atom in the nitrophenol leaving group [15(V/K)]. The isotope effects increased in magnitude upon changing from an optimal pH to a nonoptimal pH; the 18(V/K)bridge effect increased from 1.0154 (+/-0.0007) to 1.0198 (+/-0.0002), and the 15(V/K) effect increased from 1.0018 (+/-0. 0002) to 1.0021 (+/-0.0003). The value for 18(V/K)nonbridge is 0. 9910 (+/-0.0003) at pH 7.0. As with Mn2+, the 18(V/K)nonbridge isotope effect indicated that the dianion was the substrate for catalysis, and that a dissociative transition state was operative for the phosphoryl transfer. Comparison to results for Mn2+ activation suggested that chemistry was more rate-limiting with Mg2+ than with Mn2+. Changing the activating metal concentration showed opposite trends with increasing Mg2+ increasing the commitment factor and seemingly making the chemistry less rate-limiting. The influence of viscosity was evaluated as well to gauge the role of chemistry. The activation of calcineurin-catalyzed hydrolysis of pNPP1 by Mg2+ or Mn2+ at pH 7.0 was compared in the presence of viscogens, glycerol and poly(ethylene glycol). Increasing glycerol caused different effects with the two activators. With Mn2+ as the activator, calcineurin activity showed a normal response with kcat and kcat/Km decreasing with viscosity. There was an inverse response with Mg2+ as the activator as values of kcat/Km increased with viscosity. From values of the normalized kcat/Km with Mn2+, the chemistry was found to be partially rate-limiting, consistent with previous heavy atom isotope studies (22). The effect observed for Mg2+ seems consistent with a change in the rate-limiting step for the two different metals at pH 7.0.

Urticaria and angioedema: diagnostic and treatment considerations

Urticaria and angioedema are common--and commonly frustrating--problems for physicians and patients alike. Patients often are in considerable distress with pruritus and uncomfortable lesions. They are frightened about their condition and frustrated when modern medicine cannot pinpoint the cause of the symptoms. Both urticaria and angioedema may be categorized as acute and chronic conditions. The dividing line between acute and chronic forms is relatively arbitrarily set at 6 weeks. A thorough history and physical examination may provide clues to the underlying cause, but in the majority of patients, the cause is rarely identified. One is more likely to discover the cause of acute than of chronic urticaria. A multitude of laboratory tests can be performed, but they often do not provide a diagnosis. It is not appropriate to do a large "screening" battery of laboratory tests. The dermal mast cells and their mediators play a central role in chronic urticaria. Chronic urticaria may have an autoimmune aspect. Recent evidence reveals that 50% of patients with chronic urticaria have a cutaneous autoimmune disorder mediated by autoantibodies to the high-affinity IgE receptor on mast cells. Biopsy may be necessary and may help with treatment.

Skin manifestations of food allergies

The role of dietary factors in chronic skin diseases has been a subject of controversy, but several investigators have shown the effectiveness of elimination diets in the management of some patients with atopic dermatitis. Chronic skin diseases are common, complex, and often difficult to treat; therefore, the physician should consider all possible causes. More people consider themselves to have food allergies than can actually be documented to have an immunologic reaction to foods. Six foods--egg, peanut, cow's milk, soy, fish, and wheat--account for most skin reactions to food in children, with egg, peanut, and cow's milk being most common. Elimination of the offending food can be an effective form of treatment, but it must be done with caution, and while ensuring that the patient maintains adequate nutrition.

Urticaria and angioedema: Diagnostic and treatment considerations

Urticaria and angioedema are common-and commonly frustrating-problems for physicians and patients alike. Patients often are in considerable distress with pruritus and uncomfortable lesions. They are frightened about their condition and frustrated when modem medicine cannot pinpoint the cause of the symptoms. Both urticaria and angioedema may be categorized as acute and chronic conditions. The dividing line between acute and chronic forms is relatively arbitrarily set at 6 weeks. A thorough history and physical examination may provide clues to the underlying cause, but in the majority of patients, the cause is rarely identified. One is more likely to discover the cause of acute than of chronic urticaria. A multitude of laboratory tests can be performed, but they often do not provide a diagnosis. It is not appropriate to do a large "screening" battery oflaboratory tests. The dermal mast cells and their mediators playa central role in chronic urticaria. Chronic urticaria may have an autoimmune aspect. Recent evidence reveals that 50% of patients with chronic urticaria have a cutaneous autoimmune disorder mediated by autoantibodies to the high-affinity IgE receptor on mast cells. Biopsy may be necessary and may help with treatment.

Skin manifestations of food allergies

The role of dietary factors in chronic skin diseases has been a subject of controversy, but several investigators have shown the effectiveness of elimination diets in the management of some patients with atopic dermatitis. Chronic skin diseases are common, complex, and often difficult to treat; therefore, the physician should consider all possible causes. More people consider themselves to have food allergies than can actually be documented to have an immunologic reaction to foods. Six foods--egg, peanut, cow's milk, soy, fish, and wheat-account for most skin reactions to food in children, with egg, peanut, and cow's milk being most common. Elimination of the offending food can be an effective form of treatment, but it must be done with caution, and while ensuring that the patient maintains adequate nutrition.

Effect of citrulline for arginine replacement on the structure and turnover of phosphopeptide substrates of protein phosphatase-1

Phosphorylated and nonphosphorylated forms of a decapeptide corresponding to residues 9 to 18 of glycogen phosphorylase were compared using two-dimensional nuclear magnetic resonance with assignment of both peptides done by the sequential method. Both forms had little secondary structure, but there was evidence for an interaction between arginine-16 and phosphorylated serine at position 14. A change in the chemical shift for the epsilon-nitrogen hydrogen of arginine in position 16 was observed in the spectrum of the phosphorylated peptide and was not evident in a phosphopeptide having citrulline in place of arginine-16. Hydrolysis catalyzed by protein phosphatase-1 was decreased with the citrulline-containing phosphopeptide compared to the arginine-containing phosphopeptide with effects observed on both kcat and Km of the phosphatase reaction. Alkaline phosphatase hydrolyzed these peptides and a di-citrulline peptide equally well. These results are consistent with arginine being favorable in the recognition of substrates by phosphatase-1, possibly recognition as an arginine-phosphoserine complex. As a model study, arginine and two analogs, citrulline and canavanine, were examined for association with inorganic phosphate by nuclear magnetic resonance spectrometry. 31P-NMR measurements showed that arginine and canavanine caused a shift in the phosphate resonance at 20 degreesC. Citrulline caused no change. Changes in chemical shift were measured over the pH range 5-9 with arginine and canavanine both causing a slight decrease in the apparent pKa of inorganic phosphate (DeltapKa approximately 0.15). NaCl, NH4Cl, and guanidine hydrochloride showed little effect on the resonance signal position of inorganic phosphate at pH 6.5, consistent with selectivity for the guanidino group. Temperature (6 degrees, 20 degrees, and 37 degreesC) caused little change in the effect of arginine, but there was some dependency with canavanine, decreasing with temperature. Citrulline caused no change in the chemical shift of phosphate at any temperature. It was concluded that hydrogen bonded complexes were formed between the dianion of phosphate and the protonated form of arginine or canavanine with a bifurcated structure having preference for the omega-hydrogens.

Inhibition of calcineurin by the tyrphostin class of tyrosine kinase inhibitors

Because of their similarity to tyrosine, members of the tyrphostin family of tyrosine kinase inhibitors were tested as possible inhibitors of the protein serine/threonine phosphatase calcineurin. Calcineurin was inhibited by tyrphostins A8 (also designated AG10), A23 (AG18), and A48 (AG112) with p-nitrophenyl phosphate as substrate. The IC50 values estimated with this substrate were 21, 62, and 30 microM for A8, A23, and A48, respectively. Two other tyrphostins, A46 (AG99) and A63 (AG13), did not inhibit calcineurin at concentrations up to 200 microM. Similar inhibition was observed with tyrphostins A8 and A23 using a phosphopeptide substrate (1.0 mM). Tyrphostin A8 showed competitive inhibition against p-nitrophenyl phosphate as the substrate, with an inhibition constant of 18 microM, comparable to the IC50 value. Possible chemical and structural features influencing inhibition are discussed based on a comparison of the structures of the tyrphostins tested.

Activation of calcineurin by the trivalent metal terbium

As a possible probe for metal activation of calcineurin, Tb3+ was tested for effects on calcineurin activity. Calcineurin was activated by Tb3+ with the following kinetic parameters estimated: k(cat) = 0.78 +/- 0.02 sec(-1), Km(pNPP) = 32.6 +/- 1.8 mM, and K(act)(Tb3+) = 0.08 +/- 0.03 mM. Terbium luminescence was demonstrated in the presence of the heterodimer of calcineurin and exploited to localize the binding of exogenous metal to the enzyme active site. Exogenous Mn2+ reduced luminescence, although the affinity of calcineurin for Tb3+ seemed to be greater. Putative active-site ligands, such as para-nitrophenol and a synthetic peptide from the autoinhibitory region, reduced the luminescence of terbium. Collectively, these data suggested that Tb3+ was binding directly at the active site of calcineurin, with the corollary that exogenous activating metal (Mn2+) binds at the active site of the enzyme. These data support the hypothesis that activating, exogenous divalent metal participates directly in catalysis.

Selective activation of calcineurin by dipicolinic acid

Calcineurin was activated at 30 degrees C by incubation with dipicolinic acid, a metal chelator, in the absence of activating, exogenous Mn2+. The activation reached a plateau after 90 min with 8- to 12-fold higher activity. Inclusion of the activating metal Mn2+ (1.0 mM) in the incubation mixture slightly lessened the activation induced by dipicolinic acid. The chelator 1,10-phenanthroline had no effect on the activity of calcineurin in concurrent experiments. Activation by dipicolinic acid was reversed by the addition of Zn2+ or Fe3+. The reversal occurred within 30 min after the addition of either metal and returned the activity of calcineurin to its initial level. Atomic absorption spectrometry analysis showed no loss of iron or zinc from calcineurin after activation (2 h) by dipicolinic acid. Because there seemed to be no interaction between dipicolinic acid and exogenous metal, the effect of dipicolinic acid was concluded to result from masking of at least one intrinsic metal. Calcineurin incubated with 1.0 mM Mn2+ (saturating levels) also did not show any loss of intrinsic metal by atomic absorption analysis. The consequences of these data concerning the role(s) of intrinsic metals in calcineurin catalysis are discussed.

Isotope effect studies on the calcineurin phosphoryl-transfer reaction: transition state structure and effect of calmodulin and Mn2+

The hydrolysis of p-nitrophenyl phosphate (pNPP) catalyzed by calcineurin has been studied by measurement of heavy-atom isotope effects in the substrate. The isotope effects were measured at the nonbridging oxygen atoms [18(V/K)nonbridge], at the position of bond cleavage in the bridging oxygen atom [18(V/K)bridge], and at the nitrogen atom in the nitrophenol leaving group [15(V/K)]. The isotope effects increased in magnitude upon moving from the pH optimum of 7.0 to 8.5; 18(V/K)bridge increased from 1.0072 to 1.0115, and 15(V/K) from 1.0006 to 1.0014. The value for 18(V/K)nonbridge is 0.9942 at pH 8.5. These data are consistent with P-O bond cleavage being partially rate-limiting at the pH optimum and more so at the higher pH. The 18(V/K)nonbridge isotope effect indicates that the dianion is the substrate for catalysis, and a dissociative transition state is operative for phosphoryl transfer. Increasing the concentration of the activating metal ion Mn2+ at pH 7.0 from 1 mM to 5 mM increases the magnitude of the isotope effects by an amount similar to that observed with the shift in pH from 7.0 to 8.5, indicative of a change in the commitment factor in the kinetic mechanism so as to make the chemical step more rate-limiting.

A survey of outpatient visits in a United States Army forward unit during Operation Desert Shield

Reports suggest that deployed soldiers during Operations Desert Shield and Desert Storm remained healthy, but primary care data are limited. We reviewed the outpatient visit surveillance data from the 3d Armored Cavalry Regiment to obtain information regarding soldiers' health in the field. Nontraumatic orthopedic problems accounted for the highest incidence of primary health care visits, followed by unintended injuries, gastrointestinal, respiratory, and dermatologic conditions. Visits for heat injuries, sexually transmitted diseases, unexplained fever, and psychiatric problems were low, probably due to preventive measures. These results suggest that increased prevention to decrease orthopedic problems and unintended injuries may substantially reduce outpatient visits during future deployments. Medical surveillance during future deployments can be improved by taking advantage of current advances in technology to facilitate patient data retrieval and provide timely information to first- and second-echelon medical personnel.

A firearm safety program for children: they just can't say no

The purpose of this study was to compare children's play and aggressive behavior with firearms before and after an information-based intervention. Correlates of aggression and gun play were also analyzed. Subjects were 24 pairs of preschool children videotaped for 10 minutes in a structured play setting, in which they had access to a variety of toys and to real and toy guns. One child from each dyad was then exposed to an information-based intervention and told not to play with guns. The children were again videotaped in the same setting approximately 1 week later. Results indicated that the intervention was ineffective in modifying the behavior of the children. Regression analyses revealed that access to a parent's firearm was correlated with gun play and that gun play and handling of firearms in the home were correlated with aggressive behavior. The findings in this study represent the first systematic attempt to decrease gun play in children and suggest that information provision alone is an insufficient intervention.

Intracellular accumulation of beta-amyloid in cells expressing the Swedish mutant amyloid precursor protein

beta-Amyloid (beta A) is a normal metabolic product of the amyloid precursor protein (APP) that accumulates in senile plaques in Alzheimer's disease. Cells that express the Swedish mutant APP (Sw-APP) associated with early onset Alzheimer's disease overproduce beta A. In this report, we show that expression of Sw-APP gives rise to cell-associated beta A, which is not detected in cells that express wild-type APP. Cell-associated beta A is rapidly generated, is trypsin-resistant, and is not derived from beta A uptake, indicating that it is generated from intracellular processing of Sw-APP. Intracellular and secreted beta A are produced with different kinetics. The generation of intracellular beta A is partially resistant to monensin and a 20 degrees C temperature block but is completely inhibited by brefeldin A, suggesting that it occurs in the Golgi complex. Monensin, brefeldin A, and a 20 degrees C temperature block almost completely inhibit beta A secretion without causing increased cellular retention of beta A, suggesting that secreted beta A is generated in a post-Golgi compartment. These results suggest that the metabolism of Sw-APP gives rise to intracellular and secreted forms of beta A through distinct processing pathways. Pathological conditions may therefore alter both the level and sites of accumulation of beta A. It remains to be determined whether the intracellular form of beta A plays a role in the formation of amyloid plaques.

Enzymatic deimination of glycogen phosphorylase and a peptide of the phosphorylation site: identification of modification and roles in phosphorylation and activity

The functional role of arginine residues in glycogen phosphorylase b was probed by enzymatic modification by using peptidylarginine deiminase, which converts arginine residues to citrulline. A peptide with sequence LysArgLysGlnIleSerValArgGlyLeu, corresponding to the phosphorylation site of serine-14 in phosphorylase, was a substrate for the deiminase. Although both arginine residues could be converted to citrulline, modification of arginine-16 occurred more rapidly than modification of arginine-10. Previous studies have implicated a role for arginine, notably arginine-16, in determining phosphorylase kinase activity with the peptide. Deimination altered the phosphorylation of the peptide. Monodeimination of the peptide at arginine-16 slowed down the phosphorylation reaction, but did not diminish the total amount of phosphorylation that could be obtained. Deimination of both arginines produced a peptide that could not be phosphorylated. Modification of phosphorylase b resulted in activation or inactivation of enzyme activity depending on the extent of reaction with peptidylarginine deiminase. A low level of deiminase causes inactivation initially, but after prolonged incubation activation occurs. With high level of deiminase only activation can be observed. Because changes in activity are seen only at subsaturating AMP concentrations (50-100 microM), inactivation and activation are likely due to changes in affinity of the enzyme for AMP. The protein modified with the high level of deiminase has multiple sites of deimination. Arginine 16 was established as a major site of modification. Only protein modified with the high level of deiminase showed modification of arginine-16 and effects on the phosphorylation of phosphorylation b. As with the modified peptide substrate, the reaction was slower with modified phosphorylase in comparison with native phosphorylase b. The results show the importance of the guanidino group of arginine-16 of the protein substrate in modulating the phosphorylase kinase reaction.

Concurrent purification of type-1 and type-2A protein phosphatase catalytic subunits

We describe a simple purification scheme for the active catalytic subunits of both protein phosphatases type-1 and type-2A. The advantage of this procedure over others is that it produces intact proteins with high yield and specific activity and is suitable for either kilograms of tissue or a dish of cells. Type-1 and type-2A phosphatases from rabbit skeletal muscle were resolved on polylysine-agarose and subsequently obtained in homogeneous form. The phosphatases demonstrated characteristic properties. The phosphatase-1 catalytic subunit was inhibited by inhibitor-2 and phosphoinhibitor-1 whereas phosphatase-2A was not. The phosphatase activities were stable for years at -20 degrees C when stored in the presence of Mg2+ and glycerol. Based on the predicted sequence of the carboxyl terminus of each phosphatase, antibodies specific for phosphatases-1 and -2A were produced in rabbits using synthetic peptides as immunogens. Immunoblots showed complete specificity of these antibodies for their respective phosphatases and confirmed that the purified phosphatases has intact carboxyl termini. The purified catalytic subunits and antibodies will be useful for examining the regulation and the physiological roles of these protein phosphatases in cellular physiology.

Isotope effects on the mechanism of calcineurin catalysis: kinetic solvent isotope and isotope exchange studies

The reaction scheme of calcineurin was examined with kinetic and physical approaches. Proton inventory studies of the calcineurin-catalyzed hydrolysis of para-nitrophenyl phosphate were done to probe the role of proton transfer in the mechanism. Control experiments determined that the solvent did not cause the irreversible inactivation of the enzyme and had no effect on the dependence on metal ion or calmodulin. A solvent isotope effect was observed on the Vmax/Km term, but not the Vmax term. The isotope effect was modest with a value of 1.35. Proton inventory data could be fit by multiple parameter sets. The parameter sets yielded fractionation factors of 0.73 for a one-proton transfer or 0.85 for a two-proton transfer. These values compare to the value of 0.69 for reactions involving a water molecule or hydroxide coordinated to metal ion. A chemical mechanism consistent with the proton inventory data and other information about calcineurin catalysis is presented. The simplest model for catalysis involves a single proton transfer from water coordinated to metal that is reasoned to occur during association of the substrate with calcineurin. Questions about the reaction intermediate were also addressed. Attempts to monitor a phosphate-water exchange reaction with 31P nuclear magnetic resonance spectroscopy were unsuccessful. Failure to observe an exchange reaction suggests that no phosphoryl enzyme is formed during the progress of the reaction. Together these data are explained by a model in which cleavage of the phosphate ester bond is catalyzed by a water (hydroxide) molecule coordinated to a divalent metal ion without the formation of a covalent intermediate.

Hydrolysis of trifluoroethyl phosphate as evidence that the serine and tyrosine phosphatase activities of calcineurin share the same specificity determinant

Calcineurin is shown to hydrolyze 2,2,2-trifluoroethyl phosphate. The time course of hydrolysis showed a lag period. The lag was present at all substrate concentrations used and was dependent on substrate concentration. Evaluation of the kinetic constants from the steady state portion of the enzymatic reaction indicated that hydrolysis of this compound fit the Bronsted relationship determined previously for Vmax/Km term for the hydrolysis of aromatic phosphate esters. Moreover, a Bronsted relationship for the Vmax was developed for the substrates containing leaving groups that are more basic than 2,3,4,5-tetrafluorotyrosine. The hydrolysis of 2,3,4,5-tetrafluorotyrosine phosphate did not fit this relationship implying a change in the rate limiting step with this substrate. The significance of these data to the serine and tyrosine phosphatase activities of calcineurin is discussed. A rationale for understanding the determinant of both activities of calcineurin is presented.

Regulation of protein serine-threonine phosphatase type-2A by tyrosine phosphorylation

Extracellular signals that promote cell growth activate cascades of protein kinases. The kinases are dephosphorylated and deactivated by a single type-2A protein phosphatase. The catalytic subunit of type-2A protein phosphatase was phosphorylated by tyrosine-specific protein kinases. Phosphorylation was enhanced in the presence of the phosphatase inhibitor okadaic acid, consistent with an autodephosphorylation reaction. More than 90% of the activity of phosphatase 2A was lost when thioadenosine triphosphate was used to produce a thiophosphorylated protein resistant to autodephosphorylation. Phosphorylation in vitro occurred exclusively on Tyr307. Phosphorylation was catalyzed by p60v-src, p56lck, epidermal growth factor receptors, and insulin receptors. Transient deactivation of phosphatase 2A might enhance transmission of cellular signals through kinase cascades within cells.