The Kindlin2-p53-SerpinB2 signaling axis is required for cellular senescence in breast cancer

In cancer, cellular senescence is a complex process that leads to inhibition of proliferation of cells that may develop a neoplastic phenotype. A plethora of signaling pathways, when dysregulated, have been shown to elicit a senescence response. Two well-known tumor suppressor pathways, controlled by the p53 and retinoblastoma proteins, have been implicated in maintaining the cellular senescence phenotype. Kindlin-2, a member of an actin cytoskeleton organizing and integrin activator proteins, has been shown to play a key role in the regulation of several hallmarks of several cancers, including breast cancer (BC). The molecular mechanisms whereby Kindlin-2 regulates cellular senescence in BC tumors remains largely unknown. Here we show that Kindlin-2 regulates cellular senescence in part through its interaction with p53, whereby it regulates the expression of the p53-responsive genes; i.e., SerpinB2 and p21, during the induction of senescence. Our data show that knockout of Kindlin-2 via CRISPR/Cas9 in several BC cell lines significantly increases expression levels of both SerpinB2 and p21 resulting in the activation of hallmarks of cellular senescence. Mechanistically, interaction between Kindlin-2 and p53 at the promotor level is critical for the regulated expression of SerpinB2 and p21. These findings identify a previously unknown Kindlin-2/p53/SerpinB2 signaling axis that regulates cellular senescence and intervention in this axis may serve as a new therapeutic window for BCs treatment.

Abstract LB-082: The Kindlin2-p53-SerpinB2 signaling axis is required for the regulation of cellular senescence in breast cancer

Physiological cellular senescence is defined as the irreversible arrest of cell proliferation. However, in cancer, pathological aberrations of signaling pathways that regulate specific oncogenes and tumor suppressor genes, can also lead to senescence in cancer cells. In both physiological and pathological settings, senescence is regulated by at least two well-defined pathways; i.e. the p53/p21 and p16INK4a/pRB pathways. In cancer, it is now well established that senescence is a driver of hyperplastic pathology. Kindlin-2 (FERMT2) belongs to the FERM domain-containing family of intracellular proteins that have been established as playing a key role in the activation of integrins. Several recent studies, including those from our group, have associated Kindlin-2 with the pathology of cancers originating from different organs, including breast cancer (BC). For example, we have shown that Kindlin-2 is involved in the regulation of the tumor microenvironment in BC by recruiting macrophages to the tumor site and their polarization to a pro-tumorigenic state. We have also established Kindlin-2 as a major regulator of the EMT process in BC. The role of Kindlin-2 in senescence in BC is, however, not well understood. Our RNA-Seq analyses determined that loss of Kindlin-2 expression in several BC cell lines resulted in a significant increase (at least 30-fold) in SerpinB2 and p21 expression levels, both known associated with cancer cell senescence, compared to the control cells, using RT-PCR, western blot analyses, and by immunostaining of mouse tumors xenografts derived from Kindlin-2-deficient MDA-MB-231 and 4T1 BC cells. Concomitant with the increase of SerpinB2 and p21 expression, we observed a significant increase of β-galactosidase staining, a marker for senescence, in both the Kindlin-2-defficient cells as well as senescent cells, clearly implicating Kindlin-2 in cancer cell senescence via the regulation of expression of senescence-specific genes. Further investigations revealed that Kindlin-2 can be found in nuclear immunocomplexes that also contain p53 in non-senescent cells; and to a much lesser extent in senescent cells. This latest observation led us to hypothesize that binding of Kindlin-2 to p53 may have an inhibitory effect on the function of p53 as a senescence-inducer gene by inhibiting the binding of p53 to the promoter of SerpinB2 and p21. This hypothesis was confirmed by chromatin immunoprecipitation analyses which showed that Kindlin-2, like p53, can bind to the promoters of both SerpinB2 and p21. The binding of Kindlin-2 to SerpinB2 and p21 promoters was, however, weakened in senescent cells. More importantly, in the Kindlin-2-deficient cancer cells, the binding of p53 to the promoters of both SerpinB2 and p21 was significantly much stronger, further supporting our hypothesis that Kindlin-2, by being present in the same immunocomplexes as p53, inhibits the binding of p53 to SerpinB2 and promoters to induce their expression and, therefore, cancer cell senescence. Collectively, our data provide the underpinnings of a new signaling axis (Kindlin-2/p53/SerpinB2-p21), in which Kindlin-2 regulates cancer cell senescence through its binding to p53 and modulating the p53-mediated regulation of expression of senescence-specific genes, thereby identifying a novel role of Kindlin-2 in the regulation of BC progression and metastasis.

Citation Format: Khalid Sossey-Alaoui, Elzbieta Pluskota, Dorota Szpak, Edward F. Plow. The Kindlin2-p53-SerpinB2 signaling axis is required for the regulation of cellular senescence in breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr LB-082.

The Kindlin-2 regulation of epithelial-to-mesenchymal transition in breast cancer metastasis is mediated through miR-200b

Metastasis is the main cause of death in cancer patients, including breast cancer (BC). Despite recent progress in understanding the biological and molecular determinants of BC metastasis, effective therapeutic treatments are yet to be developed. Among the multitude of molecular mechanisms that regulate cancer metastasis, the epithelial-to-mesenchymal transition (EMT) program plays a key role in the activation of the biological steps leading to the metastatic phenotype. Kindlin-2 has been associated with the pathogenesis of several types of cancers, including BC. The role of Kindlin-2 in the regulation of BC metastasis, and to a lesser extent in EMT is not well understood. In this study, we show that Kindlin-2 is closely associated with the development of the metastatic phenotype in BC. We report that knockout of Kindlin-2 in either human or mouse BC cells, significantly inhibits metastasis in both human and mouse models of BC metastasis. We also report that the Kindlin-2-mediated inhibition of metastasis is the result of inhibition of expression of key molecular markers of the EMT program. Mechanistically, we show that miR-200b, a master regulator of EMT, directly targets and inhibits the expression of Kindlin-2, leading to the subsequent inhibition of EMT and metastasis. Together, our data support the targeting of Kindlin-2 as a therapeutic strategy against BC metastasis.

αMβ2 Is Antiatherogenic in Female but Not Male Mice

Atherosclerosis is a complex inflammatory process characterized by monocyte recruitment into the arterial wall, their differentiation into macrophages, and lipid accumulation. Because integrin α_Mβ₂ (CD11b/CD18) mediates multiple diverse functions of leukocytes, we examined its role in atherogenesis. α_M^-/-/ApoE^-/- and ApoE^-/- mice were fed a control or high fat diet for 3 or 16 wk to induce atherogenesis. Unexpectedly, α_M deficiency accelerated development of atherosclerosis in female but not in male mice. The size of aortic root lesions was 3-4.5-fold larger in female α_M^-/-/ApoE^-/- than in ApoE^-/- mice. Monocyte and macrophage content within the lesions was increased 2.5-fold in female α_M^-/-/ApoE^-/- mice due to enhanced proliferation. α_Mβ₂ elimination promoted gender-dependent foam cell formation due to enhanced uptake of cholesterol by α_M^-/-/ApoE^-/- macrophages. This difference was attributed to enhanced expression of lipid uptake receptors, CD36 and scavenger receptor A1 (SR-A1), in female mice. Macrophages from female α_M^-/-/ApoE^-/- mice showed dramatically reduced expression of FoxM1 transcription factor and estrogen receptors (ER) α and β. As their antagonists inhibited the effect of 17β-estradiol (E₂), E₂ decreased CD36, SR-A1, and foam cell formation in ApoE^-/- macrophages in an ERα- and ERβ-dependent manner. However, female α_M^-/-/ApoE^-/- macrophages failed to respond to E₂ and maintained elevated CD36, SR-A1, and lipid accumulation. FoxM1 inhibition in ApoE^-/- macrophages reduced ERs and enhanced CD36 and SR-A1 expression, whereas FoxM1 overexpression in α_M^-/-/ApoE^-/- macrophages reversed their proatherogenic phenotype. We demonstrate a new, surprising atheroprotective role of α_Mβ₂ in female ApoE^-/- mice. α_Mβ₂ maintains ER expression in macrophages and E₂-dependent inhibition of foam cell formation.

Kindlin-2 interacts with endothelial adherens junctions to support vascular barrier integrity

KEY POINTS

A reduction in Kindlin-2 levels in endothelial cells compromises vascular barrier function. Kindlin-2 is a previously unrecognized component of endothelial adherens junctions. By interacting directly and simultaneously with β- or γ-catenin and cortical actin filaments, Kindlin-2 stabilizes adherens junctions. The Kindlin-2 binding sites for β- and γ-catenin reside within its F1 and F3 subdomains. Although Kindlin-2 does not associate directly with tight junctions, its downregulation also destabilizes these junctions. Thus, impairment of both adherens and tight junctions may contribute to enhanced leakiness of vasculature in Kindlin-2^+/- mice.

ABSTRACT

Endothelial cells (EC) establish a physical barrier between the blood and surrounding tissue. Impairment of this barrier can occur during inflammation, ischaemia or sepsis and cause severe organ dysfunction. Kindlin-2, which is primarily recognized as a focal adhesion protein in EC, was not anticipated to have a role in vascular barrier. We tested the role of Kindlin-2 in regulating vascular integrity using several different approaches to decrease Kindlin-2 levels in EC. Reduced levels of Kindlin-2 in Kindlin-2^+/- mice aortic endothelial cells (MAECs) from these mice, and human umbilical ECs (HUVEC) treated with Kindlin-2 siRNA showed enhanced basal and platelet-activating factor (PAF) or lipopolysaccharide-stimulated vascular leakage compared to wild-type (WT) counterparts. PAF preferentially disrupted the Kindlin-2^+/- MAECs barrier to BSA and dextran and reduced transendothelial resistance compared to WT cells. Kindlin-2 co-localized and co-immunoprecipitated with vascular endothelial cadherin-based complexes, including β- and γ-catenin and actin, components of adherens junctions (AJ). Direct interaction of Kindlin-2 with β- and γ-catenin and actin was demonstrated in co-immunoprecipitation and surface plasmon resonance experiments. In thrombin-stimulated HUVECs, Kindlin-2 and cortical actin dissociated from stable AJs and redistributed to radial actin stress fibres of remodelling focal AJs. The β- and γ-catenin binding site resides within the F1 and F3 subdomains of Kindlin-2 but not the integrin binding site in F3. These results establish a previously unrecognized and vital role of Kindlin-2 with respect to maintaining the vascular barrier by linking Vascuar endothelial cadherin-based complexes to cortical actin and thereby stabilizing AJ.

Kindlin-2 Regulates the Growth of Breast Cancer Tumors by Activating CSF-1-Mediated Macrophage Infiltration

Interplay between tumor cells and host cells in the tumor microenvironment dictates the development of all cancers. In breast cancer, malignant cells educate host macrophages to adopt a protumorigenic phenotype. In this study, we show how the integrin-regulatory protein kindlin-2 (FERMT2) promotes metastatic progression of breast cancer through the recruitment and subversion of host macrophages. Kindlin-2 expression was elevated in breast cancer biopsy tissues where its levels correlated with reduced patient survival. On the basis of these observations, we used CRISPR/Cas9 technology to ablate Kindlin-2 expression in human MDA-MB-231 and murine 4T1 breast cancer cells. Kindlin-2 deficiency inhibited invasive and migratory properties in vitro without affecting proliferation rates. However, in vivo tumor outgrowth was inhibited by >80% in a manner associated with reduced macrophage infiltration and secretion of the macrophage attractant and growth factor colony-stimulating factor-1 (CSF-1). The observed loss of CSF-1 appeared to be caused by a more proximal deficiency in TGFβ-dependent signaling in Kindlin-2-deficient cells. Collectively, our results illuminate a Kindlin-2/TGFβ/CSF-1 signaling axis employed by breast cancer cells to capture host macrophage functions that drive tumor progression. Cancer Res; 77(18); 5129-41. ©2017 AACR.

Brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF) blood levels in patients with acute carbon monoxide poisoning - a preliminary observations

BACKGROUND

Neurotrophins are the family of proteins which stimulate and regulate the process of neurogenesis. Several factors belong to the family, mainly nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), neurotrophin-3 (NT 3), and neurotrophin-4/5 (NT-4/5). Acute poisoning with carbon monoxide (CO), which usually is accompanied by neurologic symptoms, can potentially change the secretion profile of neurotrophins. Aim of the study. The main goal of the study is to assess the changes of NGF and BDNF plasma levels during an acute phase of CO poisoning as well as immediately after recovery. Additionally, the relationship among neurotrophin levels and selected aspects of clinical course of CO poisoning were studied.

MATERIALS AND METHODS

The study group consisted of 18 patients (mean age: 31.8±10.3 years) hospitalized in Toxicology Department of University Hospital in Cracow because of acute CO poisoning. There were 10 women (mean age: 30.2±6.9 years) and 8 men (mean age 33.9±13.7 years) in the group. The levels of NGF and BDNF were evaluated using immunoenzymatic method (ELISA) in plasma samples taken thrice in each patient. The sample 1. was taken during hospital admission, the sample 2. about 12-36 hours after admission, and the sample 3. just before the hospital discharging (usually, on the 3rd-4th day). The clinical data were collected from patients’ anamnesis, physical examination and neuropsychological evaluation. The statistical analysis were performed using tools comprised in STATISTICA 12.0 PL (StatSoft Polska, Cracow, Poland) software.

RESULTS

The majority of NGF plasma levels were less than 14 pg/mL (values below the limit of quantification), contrary to the sole case of 34.3 pg/mL. BDNF plasma levels ranged from 4.8 ng/mL to above 48 ng/mL, i.e. they were higher than the upper limit of measurement range for the plasma dilution which had been used. The comparison of NGF and BDNF plasma levels in the study group with their analogues in healthy volunteers taken from the literature indicates that NGF level declines and BDNF level rises in patients with CO poisoning. The profile of BDNF concentrations in the majority of patients formed the characteristic pattern: BDNF sample 1. > BDNF sample 2. < BDNF sample 3. Taking all the values of BDNF higher than 48 ng/mL as equal to 48 ng/ mL, the statistically significant difference among 3 sample series was found according to BDNF levels. Maintaining the above mentioned assumption, the statistically significant negative correlation between the number of higher cognitive functions disturbed in one patient at the same time and the BDNF levels in sample series 2 was discovered, as well as the weak correlations between BDNF level in sample series 1 and carboxyhaemoglobin or lactate level. Moreover, weak but statistically significant correlations were present between the duration of CO exposure and BDNF levels in each sample series.

CONCLUSIONS

The NGF plasma level is probably declined, while the BDNF plasma level is increased in patients with acute CO poisoning. The concentration–time curve for the plasma BDNF may sometimes undergo fluctuations with two peaks on its course. Plasma BDNF level may serve as a biological marker of disturbed higher cognitive functions in acute CO poisoning. Some clinical aspects of CO poisoning (duration of exposure, HbCO and lactate blood levels) may influence BDNF level.

[Structure of poison xenobiotic based on results of toxicological analysis from Toxicological Laboratory in Krakow in years 2003 and 2013]

The aim of the study was to present changes in structure of toxicological analysis performed for hospitals in south-east Poland in last decennium. Material for the study were data from Toxicological Laboratory in Krakow in years 2003 and 2013. Total number of toxicological analysis decreased by about 30% in the period. The decline was related to analysis of ethanol, drugs of abuse (amphetamines, opiates, THC) and medicines. The number of determinations of acetylocholinoesterase activity (AChE)--marker of exposition to organophosphate and carbamate pesticides and carboxyhemoglobin (COHb)--marker of exposition to carbon monoxide also declined. The number of analysis of toxic alcohols (methanol and ethylene glycol) raised. The demand for determinations of new toxic substances (new drugs of abuse, "spices") appeared in the studied period. Advanced analytical methods (gas chromatography (GC), high performance liquid chromatography (HPLC), atomic absorption spectrometry (AAS) came into use in day-to-day routine. Changes in structure and numbers of determinations performed in regional toxicology laboratory reflects different trends. Prevalence of rapid tests for determination of drugs of abuse and alcohol in general medical laboratories caused decrease of number of the analysis in specialized toxicology laboratory. On the other hand growing demand for specialized analysis: new drugs of abuse, spices, new drugs, toxic alcohols and heavy metals was observed in last decennium.

Dual role of the leukocyte integrin αMβ2 in angiogenesis

Polymorphonuclear neutrophils (PMNs) and macrophages are crucial contributors to neovascularization, serving as a source of chemokines, growth factors, and proteases. α(M)β(2)(CD11b/CD18) and α(L)β(2)(CD11a/CD18) are expressed prominently and have been implicated in various responses of these cell types. Thus, we investigated the role of these β2 integrins in angiogenesis. Angiogenesis was analyzed in wild-type (WT), α(M)-knockout (α(M)(-/-)), and α(L)-deficient (α(L)(-/-)) mice using B16F10 melanoma, RM1 prostate cancer, and Matrigel implants. In all models, vascular area was decreased by 50-70% in α(M)(-/-) mice, resulting in stunted tumor growth as compared with WT mice. In contrast, α(L) deficiency did not impair angiogenesis and tumor growth. The neovessels in α(M)(-/-) mice were leaky and immature because they lacked smooth muscle cell and pericytes. Defective angiogenesis in the α(M)(-/-) mice was associated with attenuated PMN and macrophage recruitment into tumors. In contrast to WT or the α(L)(-/-) leukocytes, the α(M)(-/-) myeloid cells showed impaired plasmin (Plm)-dependent extracellular matrix invasion, resulting from 50-75% decrease in plasminogen (Plg) binding and pericellular Plm activity. Surface plasmon resonance verified direct interaction of the α(M)I-domain, the major ligand binding site in the β(2) integrins, with Plg. However, the α(L)I-domain failed to bind Plg. In addition, endothelial cells failed to form tubes in the presence of conditioned medium collected from TNF-α-stimulated PMNs derived from the α(M)(-/-) mice because of severely impaired degranulation and secretion of VEGF. Thus, α(M)β(2) plays a dual role in angiogenesis, supporting not only Plm-dependent recruitment of myeloid cells to angiogenic niches, but also secretion of VEGF by these cells.

Kindlin-3 enhances breast cancer progression and metastasis by activating Twist-mediated angiogenesis

The FERM domain containing protein Kindlin-3 has been recognized as a major regulator of integrin function in hematopoietic cells, but its role in neoplasia is totally unknown. We have examined the relationship between Kindlin-3 and breast cancer in mouse models and human tissues. Human breast tumors showed a ∼7-fold elevation in Kindlin-3 mRNA compared with nonneoplastic tissue by quantitative polymerase chain reaction. Kindlin-3 overexpression in a breast cancer cell line increased primary tumor growth and lung metastasis by 2.5- and 3-fold, respectively, when implanted into mice compared with cells expressing vector alone. Mechanistically, the Kindlin-3-overexpressing cells displayed a 2.2-fold increase in vascular endothelial growth factor (VEGF) secretion and enhanced β1 integrin activation. Increased VEGF secretion resulted from enhanced production of Twist, a transcription factor that promotes tumor angiogenesis. Knockdown of Twist diminished VEGF production, and knockdown of β1 integrins diminished Twist and VEGF production by Kindlin-3-overexpressing cells, while nontargeting small interfering RNA had no effect on expression of these gene products. Thus, Kindlin-3 influences breast cancer progression by influencing the crosstalk between β1 integrins and Twist to increase VEGF production. This signaling cascade enhances breast cancer cell invasion and tumor angiogenesis and metastasis.

Tobacco smoke exposure and endothelial dysfunction in patients with advanced coronary artery disease

INTRODUCTION

 Exposure to tobacco smoke is associated with a higher cardiovascular risk, especially in patients with coronary artery disease (CAD). 

OBJECTIVES

 The aim of the study was to evaluate the effect of active and passive tobacco smoking on the activity of endothelial markers in advanced atherosclerosis.

PATIENTS AND METHODS

 We studied 181 consecutive patients with advanced CAD (53 women and 128 men) aged 60 ±8 years, including 102 active self‑declared smokers (56.3%). We determined plasma asymmetric dimethylarginine (ADMA), thrombomodulin (TM), and plasminogen activator inhibitor‑1 (PAI‑1) levels, along with serum cotinine concentrations as a marker of tobacco smoking. 

RESULTS

 Plasma ADMA levels were higher in active smokers compared with nonsmokers (0.60 ±0.09 μmol/l vs. 0.49 ±0.08 μmol/l, P <0.001). There were similar intergroup differences in TM (4.60 ±2.11 ng/ml vs. 3.0 ±1.7 ng/ml, P <0.0001) and PAI‑1 levels (30.3 ±12.4 ng/ml vs. 23.6 ±11.3 ng/ml, P <0.0001). We observed positive correlations between cotinine and ADMA (r = 0.71, P <0.0001), TM (r = 0.53, P <0.0001), and PAI‑1 (r = 0.58, P <0.0001). In 21 patients (26.6%) who declared to be nonsmokers, cotinine levels (mean, 6.30 ±22.5 ng/ml) significantly correlated with ADMA, TM, and PAI‑1 (all P <0.001). A multivariate regression analysis showed that cotinine was an independent predictor of ADMA, TM, and PAI‑1 in the whole patient group. 

CONCLUSIONS

 Despite long‑lasting endothelial injury in advanced CAD, continued cigarette smoking is able to further enhance endothelial damage by increasing ADMA levels and resultant inhibition of fibrinolysis.

[Osteopontin level in the serum of patients with alcoholic liver disease, treated for alcohol withdrawal syndrome--a preliminary report]

Alcoholic liver disease (ALD) is consequence of alcohol addiction, that increase morbidity and mortality of those group of patients. Induction of the inflammatory process in alcohol injured liver is a turning point in ALD, can cause acute liver damage symptoms or cirrhosis with increase of hepatic fibrosis intensity and portal hypertension. Osteopontin (OPN)--a protein associated with early inflammatory process and remodeling of damaged tissues with intensification of hepatic fibrogenesis process, is considered to be a biomarker of hepatic inflammation and fibrosis. A group of 12 patients with mean age--44 years, mean alcohol addiction time--16 years, hospitalized because of alcohol withdrawal symptoms were examined in the preliminary report. ALD was diagnosed in all patients, steatosis--in 4, inflammatory--in 3, cirrhosis--in 5. Control group were 19 healthy patients with no alcohol addiction and liver disease in medical history. Serum OPN level was measured by ELISA method using reagents from Raybiotech. Serum OPN level in control group ranged 0-35,955 pg/ml, in examined group ranged 0-338,280 pg/ml. OPN levels in serum of patients with hepatic steatosis were under limit of detection (< 50 pg/ml). OPN serum level increase was correlated to ALD progression. The highest OPN levels (> 100,000 pg/ml) were observed in patients with symptoms of the liver decompensation due to severe hepatitis and advanced cirrhosis.

[Acute clozapine poisonings in years 2007 - 2010 in material of Clinic of Toxicology in Kraków]

18 patients with acute clozapine poisoning, 6 female and 12 male, were analyzed. The mean age was 42.8 years. Six patients were intoxicated only clozapine. Mixed poisoning (clozapine and other factor) was diagnosed in nine cases. Among the additional factors dominated psychotropic drugs. According to the Poisoning Severity Score (PSS) criteria in the study group was only a one mild intoxication. Acute pneumonia developed in 3 patients, acute bronchitis and rabdomyolysis were reported in one case. The most common symptoms included: agitation, confusion (83.3%), tachycardia (77.8%), CNS depression (66.7%), excessive mucus production in bronchi, hypersalivation (44.4%), miosis (50%). Disordered breathing requiring intubation or mechanical ventilation occurred in 27.7% of poisoned. The average duration of hospitalization was less than 7 days.

[Sulpiride poisoning--case report confirmed with the quantitative determination of the xenobiotic serum level]

Despite above 40 years the presence of sulpride on the pharmaceutical market, the acute poisonings are poorly reported in the medical literature. The discussed case of sulpiride intoxication concerns ingestion probably dose of 12 g, that exceeded 10-fold maximum therapeutic dose. 16-year-old girl, with no previous sulpiride treatment, was admitted to the Toxicology Department about 3 hours after ingestion. In clinical picture she presented quantitative consciousness disturbances with maximum 10 scores in GCS scale, with tendency to low BP (minimum 88/45 mmHg) and episode of orthostatic hypotension. The ECG demonstrated: normogram, sinus tachycardia with a heart rate of 125 beats/min, PQ = 120 ms, QRS = 80 ms, prolongation of QTc to 519,6 ms and unspecific changes of ST-T syndrome. The qualitative toxicological test confirmed the presence of chlorprothixene in urine, but the serum therapeutic concentration (0.126 microg/ml) excluded the overdose. The quantitative determination of sulpiride serum concentration confirmed acute sulpiride poisoning. The measured sulpiride toxic concentration on admission and in the consecutive hours were from 13.2 to 8.2 microg/ml. Sulpiride toxicokinetic parameters such as t max = about 3 h, t 1/2 = 24.02 h, k(el) = 0.029 h(-1) were also estimated. They point out that the absorption rate is similar and the elimination is prorogated in sulpiride acute poisoning compared to therapeutic doses.

[Side effects of the HMG-CoA reductase inhibitors (statins). Lupus erythematosus induced by Atorvastatin therapy]

The paper describes the case of 56 years old woman admitted to the Toxicology Department because of skin lesions, joint and muscle pain and elevated activity of transaminases and creatine phosfokinase as well in biochemical analysis. The symptoms occurred after 6 days of the Atorvastatin therapy. The clinical picture indicated side effects of the hipolipemic therapy, but the presence of the skin lesions suggested drug induced collagenosis (lupus erythrematosus, dermatomyositis). Immunological studies confirmed association with antinuclear antibodies (ANA) and anti-Mi-2 autoantibodies in the serum. Immunosuppressive therapy was ordered with clinical and biochemical improvement.

Carbamazepine intoxication in alcohol dependent epileptic patients

Carbamazepine is frequently administrated to alcohol addict patients. The aim of this study was to evaluate the influence of alcohol addiction on carbamazepine pharmacokinetics and severity of drug intoxication. The total of 158 carbamazepine intoxicated patients participated in the study (76 non-alcohol-dependent, and 82 alcohol-dependent subjects). The results of the study indicate that the level of unconsciousness depends on carbamazepine concentration. The frequency of anticholinergic toxidrome was higher in alcohol-dependent patients (88.6% - alcohol-abused subjects, and 78.3% - alcoholics in abstinency) comparing to non-alcohol-dependent epileptics (67.1%). The average biological half-life of carbamazepine in non-addicted epileptics was 41.5 h, 43.5 h for alcohol-dependent patients during abstinency, and 38.6 in abused patients. It may be concluded that ethanol doesn't influence the pharmacokinetic and pharmacodynamic of carbamazepine in acute drug intoxication.

[The review of acute risperidone poisoning]

Risperidone (RIS) is a benzisoxazole derivative, an atypical neuroleptic used in the treatment of schizophrenia and other psychoses. The therapeutic action of RIS depends not only on the parent compound but also its major active metabolite, 9-hydroxyrisperidone (9-OH-RIS), and the pharmacokinetics is modified by the genetic polymorphism of CYP2D6, the main site o RIS metabolism. Diverse symptoms of an acute RIS poisoning result from its interaction with multiple receptors, i.e. serotoninergic 5-HT2A and 5-HT7, dopaminergic D2, adrenergic alpha1 and alpha2, as well as histamine H1. The clinical picture of acute RIS poisoning consists predominantly of central nervous system and cardiovascular effects and the most severe symptoms are: hypotension, dysrrhythmias, consciousness disturbances, seizures and respiratory failure. No specific antidote for RIS poisoning is known and the treatment is only symptomatic and supportive. Quantitative determination of RIS blood concentration seems to be helpful in confirmation and monitoring of acute poisoning, nevertheless further investigations are needed to evaluate the relation between drug concentration and clinical symptoms.

[Toxicity of sulpiride]

Sulpiride is a benzamide neuroleptic used in the treatment of some psychiatric and gastroenterological disorders. Its antipsychotic, antiautistic, activizing and antidepressive properties result from antagonistic action to dopaminergic D2, D3 and D4 receptors in the central nervous system (CNS). The oral bioavailability of sulpiride is poor and it does not appear to have an extensive first-pass metabolism, nor is it extensively protein-bound. Elimination of sulpiride appears to depend primarily on the kidneys. The acute sulpiride poisoning includes mainly neuropsychiatric (i.e., agitation, hallucinations, and CNS depression) as well as cardiac effects (i.e., hypotension, dysrhythmias, and sinus tachycardia). The life-threatening conditions with sometimes fatal outcome after sulpiride poisoning are prolongation of QTc interval with consequent torsade de pointes (TdP) and neuroleptic malignant syndrome (NMS). The quantitative methods for the measurement of sulpiride blood concentration are not routinely available and the toxic blood concentration is probably higher than 2 mg/L. Treatment of acute sulpiride poisoning includes standard protocols of gastrointestinal decontamination and further symptomatic and supportive measures, among them TdP (magnesium sulphate, isoproterenol, electrotherapy) and NMS treatment (benzodiazepines, bromocriptine, dantrolene, physical cooling).

[Acute lethal poisoning with venlafaxine]

The case of acute venlafaxine poisoning with fatal outcome is shown. The 52-year-old woman with depression disorder ingested 56 pills of Symfaxin ER 150 venlafaxine as a suicidal attempt. Initially she was observed in the Neurology Department because of seizures, but after her husband found empty packages of medicine she was sent to the Toxicology Department being suspected of venlafaxine poisoning. The qualitative toxicological test confirmed the presence of venlafaxine in urine. In the course of poisoning rhabdomiolysis, hypotension and consecutive acute renal failure were observed. Finally, severe ventricular tachyarrhythmia occurred leading do cardiac arrest. Despite intensive symptomatic and supportive treatment the patient died.

[Amanitin determination in mushroom poisoning diagnostics]

There are some serious poisonings with toxic mushroom species in Poland every year. Good prognostics in the cases is correlated to short time from mushroom consumption to hospitalization, correct distinguish not specific gastrointestinal and Amanita phalloides syndrome and immediately specific treatment. The purpose of the paper was to make appraisal of usefulness of amanitin blood and urine determination and transaminases activity determination (ALT, AST) in diagnostics of mushroom poisoned patients up to three days after mushroom consumption. The material was twenty two retrospective histories of mushroom poisoned patients treated in the years 2007-2008. Amanitin blood and urine determinations were made by ELISA method. Urine amanitin results in samples collected within 40 h from mushroom consuming were positive in all Amanita phalloides syndrome cases. Serum amanitin determination was not useful for the diagnostics. Trans-aminases activity determinations let to distinguish Amanita phalloides syndrome on the second and the third day after mushroom consumption. In the first poisoning phase (within 24 h), the ALT and AST activities were in normal ranges and only amanitin urine determination let to confirm or exclude Amanita phalloides poisoning. Amanitin urine determinations were useful to take fast decision about specific treatment and avoid internal organs dysfunctions.

Neutrophil apoptosis: selective regulation by different ligands of integrin alphaMbeta2

Neutrophils undergo spontaneous apoptosis, but their survival can be extended during inflammatory responses. alpha(M)beta(2) is reported either to delay or accelerate neutrophil apoptosis, but the mechanisms by which this integrin can support such diametrically opposed responses are poorly understood. The abilities of closely related alpha(M)beta(2) ligands, plasminogen and angiostatin, derived from plasminogen, as well as fibrinogen and its two derivative alpha(M)beta(2) recognition peptides, P1 and P2-C, differed markedly in their effects on neutrophil apoptosis. Plasminogen, fibrinogen, and P2-C suppressed apoptosis via activation of Akt and ERK1/2 kinases, while angiostatin and P1 failed to activate these prosurvival pathways and did not prevent neutrophil apoptosis. Using cells transfected with alpha(M)beta(2) or its individual alpha(M) or beta(2) subunits, and purified receptors and its constituent chains, we show that engagement of both subunits with prosurvival ligands is essential for induction of the prosurvival response. Hence, engagement of a single integrin by closely related ligands can induce distinct signaling pathways, which can elicit distinct cellular responses.

The influence of carbamazepine plasma level on blood pressure and some ECG parameters in patients with acute intoxication

BACKGROUND

Carbamazepine (CBZ) is an antiepileptic drug with tricyclic structure which implies its potential cardinotxic properties, especially in acute poisoning.

AIM

To evaluate some cardiovascular effects connected with CBZtoxicity and tofind the relation between them and CBZ plasma level.

MATERIAL AND METHODS

34 patients (18 males, 16 females; median age 24.5) hospitalized in our Department in 1996-1997 and 2005-2006 due to acute CBZ poisoning. Analysis included following parameters: systolic (SBP) and diastolic (DBP) blood pressure, ECG parameters: heart rate (HR), duration of QRS complex, PQ interval and corrected QT interval (QTc) calculated with Bazett's (QTc(B)) and Hodges's (QTc(H)) formulas. These parameters were compared with reference values for general population available in the literature. Relations between above mentioned parameters and CBZ plasma level were studied by means of Generalized Additive Model (GAM).

RESULTS

The reference values were exceeded most often for QRS (62%), DBP and QTc(B) (53%, both) and SBP (50%). The mean number of parameters with exceeded norms was 3.1 per patient (SD = 1.71). We failed to find any significant correlation between CBZ plasma level and any of the studied parameters. Positive correlation between SBP and DBP (r = 0.68; p < 0.001) and negative correlation between QRS and HR (r = -0.50; p = 0.003) were found.

CONCLUSION

CBZ could affect different cardiovascular parameters which should be monitored in cases of acute drug poisonings.

Mechanism and effect of thrombospondin-4 polymorphisms on neutrophil function

High-throughput genomic technology identified an association between a single nucleotide polymorphism (SNP), a proline (P387) rather than the predominant alanine (A387) at position 387 in thrombospondin-4 (TSP-4) and premature myocardial infarction. The inflammatory hypothesis of atherosclerosis invokes a prominent role of leukocytes and cytokines in pathogenesis. As the expression of TSP-4 by vascular cells permits its exposure to circulating leukocytes, the interactions of human neutrophils (polymorphonuclear leukocytes [PMNs]) with both TSP-4 variants were investigated. Phorbol 12-myristate 13-acetate (PMA)-stimulated PMNs adhered and migrated well and equally on the TSP-4 variants. Integrin alpha(M)beta2 was identified as the TSP-4 receptor mediating these responses, and the 3 epidermal growth factor (EGF)-like domains of TSP-4 harboring the SNPs interacted with the alpha(M)I-domain. Despite the similarity in these responses, the P387 variant induced more robust tyrosine phosphorylation of the stress-related mitogen-activated protein kinases (MAPKs): p38MAPK and c-Jun NH2-terminal kinase (JNK), as well as signal transducer and activator of transcription-1 (STAT1) and heat shock protein 27 (HSP27) than the A387 variant. Additionally, cells adherent to P387 TSP-4 variant released 4-fold more H2O2 and secreted 2-fold more interleukin 8 (IL-8) as compared with the A387. H2O2 release and p38MAPK activation were totally inhibited by blockade of alpha(M)beta2. Thus, alpha(M)beta2 plays a central role in proinflammatory activities of TSP-4 (P387) and may contribute to the prothrombotic phenotype associated with this variant.

[Cardiotoxic plants]

In statistics from Poison Information Center in Kraków plant poisonings comprise 2% of the total registered poisonings. In toxicology cardiac glycosides poisonings existing in common foxglove plant, lilies of the valley, oleander are essential. Species of cardiotoxic plants which may cause a danger in Poland are presented in the research. The toxic mechanisms of cardiac glycosides are specified.

Comparison of fluorescence polarization immunoassay and high performance liquid chromatography for determination of carbamazepine concentration in blood of poisoned patients

Carbamazepine is an antiepileptic drug widely used by neurological and psychiatric patients. Because of it's low therapeutic index and increasing number of acute carbamazepine intoxications there is a need of routine serum carbamazepine assay in toxicological laboratories. Determinations of serum carbamazepine concentrations are 5.3% of all toxicological analysis carried on in Department of Analytical Toxicology and Therapeutic Drug Monitoring, Collegium Medicum, Jagiellonian University in Kraków. The goal of the study was comparison of two analysis methods: FPIA and HPLC-DAD for the diagnostics of patients intoxicated with carbamazepine. Material for analysis were 21 samples of blood collected from poisoned patients treated in Department of Clinical Toxicology in Kraków. Measurements of serum carbamazepine concentration by FPIA method and carbamazepine and it's main active metabolite carbamazepine-10,11-epoxide concentrations by HPLC-DAD method were made. Statistical analysis showed that serum carbamazepine concentrations measured by FPIA method were higher than serum carbamazepine concentrations measured by HPLC-DAD method (t21 = 2.21, p = 0.0384). The mean difference of serum carbamazepine concentrations measured by the two methods was 2.67 mg/l (SD = 5.69 mg/l) and didn't depend on the carbamazepine concentration measured by FPIA method (r = -0.137, p = 0.5431). There was no statistical difference between serum carbamazepine concentration measured by FPIA method and the sum of serum carbamazepine and carbamazepine-10,11-epoxide concentrations measured by HPLC-DAD method (t21 = 1.42, p = 0.1690).

[Clinical course of acute poisoning with olanzapine]

Olanzapine is a new atypical antipsychotic drug acting on different receptors. A variety of pharmacologic effects are responsible for toxicity and the variety of clinical symptoms seen in overdose: tachycardia, agitation or aggression, dysarthria, extrapyramidal dystonic effects, sedation or coma, small pupils, blurred vision, respiratory depression, hypotension. A retrospective analysis of clinical course of eight acute olanzapine intoxication treated at the Department of Clinical Toxicology Jagiellonian University Medical College is presented. CNS symptoms manifested in fluctuations between somnolence/coma and agitation/aggression and miosis were observed in most of the patients. Increased CPK activity was stated in the most of patients. All of the patients recovered, poisoning severity according PSS was moderate and severe.

[Acute poisoning with nifedipine and acebutol: two cases]

In this paper the case of intoxication in two women (19-year-old and 23-year-old), who in suicide attempts ingested at the same time different doses of nifedipine and acebutol. In 23-year-old woman 4 hours post ingestion cardiorespiratory arrest was stated. Resuscitation procedures were ineffective, she died. Acebutol concentration in postmortem blood was 24.1 mg/l and nifedipine-1.8 mg/l. The second one (19-year-old) was treated successfully, only mild cardiac disturbances were observed. Acebutol concentration in blood was 1.8 mg/l, nifedipine was not stated.

[Severe mixed poisoning with diltiazem, potassium and magnesium: a case report]

We report the case of 52-year-old woman, who ingested 3.6 g of diltiazem, 16 g of potassium chloride and 6.5 g of magnesium, in a suicide attempt 4 hours before admission. She developed cardiorespiratory failure, with severe hypotonia and acute renal failure, in ECG third degree atrioventricular block was stated. The highest potassium concentration was 8.0 mmol/l, magnesium 2.15 mmol/l. As a result of multiple pharmacologic intervention, including intravenous fluids, calcium, glucagon, dopamine, dobutamine, norepinephrine, transvenous pacing and peritoneal dialysis (haemodynamic instability makes haemodialysis noneffective) the haemodynamic stabilization of cardiovascular system and normalization of potassium and magnesium concentration were achieved. The diltiazem concentration was measured using liquid chromatography, the result was 0.89 microgram/ml. She was discharged in a good clinical condition on day 26th.

[Cardiotoxicity of amantadine in acute poisoning: a case report]

We report the case of an adolescent, 15-year-old woman, who ingested 4.0 g of amantadine in a suicide attempt 2 hours before admission. She developed central nervous system symptoms including confusion and psychomotor agitation. The main cardiovascular symptoms were due to disturbances in atrioventricular conduction and propagation of stimuli in sinus node. All cardiovascular symptoms disappearanced after 12 hours of admission, CNS symptoms were observed 48 hours. No other systems were involved. She was discharged in a good state on day 5th.

[Cardiovascular disturbances in acute poisoning--mechanisms and management]

The authors present the most common in clinical toxicology cardiovascular disturbances and mechanism of action the selected drugs (tricyclic antidepressants, cardiac glycosides, beta-blocking agents and calcium channel blockers). General management in acute poisoning with these drugs is also presented, concerning their toxicodynamics.

Usefulness of rest and forced perfusion scintigraphy (SPECT) to evaluate cardiotoxicity in acute carbon monoxide poisoning

The aim of the study was to evaluate myocardial perfusion in acute carbon monoxide poisoned patients using rest and stress Tc 99m-MIBI SPECT scintigraphy. There were 29 study patients (15 men and 14 women) aged from 14 to 46 years poisoned acutely with CO at home. Measurement of COHb, blood lactate level, duration of exposure and ECG examination were performed on admission to the Clinic. The enzymes activity (ALT, AST, CBK) were evaluated after 24 hours. The first rest Tc99m-MIBI SPECT was performed in all patients two to five days after intoxication. Fifteen of the patients underwent the control examination: stress and rest scintigraphy six months after CO exposure. Moving track exercise according to the Bruce protocol was used in each the patients. The control rest scintigraphy was performed 48 hours after exercise. Abnormal, differently intensified scans were noted in all the subjects: 5 patients had a I degree of pathological changes, 7 patients had II degree, 16--III degree and 1 patient had a IV degree of pathological changes. In 14 of the patients with pathological scintigraphic scans the normal EKG curves were noted. The mean COHb level was 35.0 +/- 7.22%, the blood lactate concentration was 4.4 +/- 3.7 mmol/L. The average duration of exposure was 108.4 +/- 163.9 min. Effort related ischemia was not noted in 10 of the patients who underwent control examination. An improvement in rest scintigraphic scans was stated in 12, and no changes were observed in 3 of the controlled patients. Deterioration was not found in any patient. No correlation between ECG results and scintigraphic image of myocardium was found. Tc 99m-MIBI SPECT scintigraphy is a more sensitive method than electrocardiography and measurement of enzymes activity for the evaluation of CO cardiotoxicity in acute poisoning. The method enables evaluation of the localization and disease extent.

The influence of acute poisoning with an organophosphate compound on the regulation of breathing and the respiratory system efficiency

The female patient, aged 40, was admitted to the Department of Toxicology about fifteen hours after she had drunk 50 ml Basudin 25 EC (diazinon contents 25%) in a suicidal attempt. On admission the patients state was described as moderately severe (9 points). Starting with the first day after the poisoning, the functional state of the respiratory system was monitored. Ventilation efficiency was determined on the basis of the results from a flow-volume curve, spirometry and the measurements of the respiratory tract resistance (Rrs) in a computerised system Lungtest-MES company (Poland). Respiratory regulation was evaluated by means of synchronic measurements of the respiratory pattern and occlusion pressure. The results obtained from a respiratory pattern and P 0.1 were refereed to normal values. In the examination carried out directly after the poisoning slight obturation of the central bronchi and elevation in resistance of respiratory tract was noted. After a week, obturation was not noted and the resistance value was better. Also the respiratory pattern parameters and value of occlusion pressure were better. It seems that in this case the increase in resistance values in the respiratory tract should be related to the increased activity in the parasympathetic system. Basic, traditional spirometric even in the examination on the first day after the poisoning, were within normal limits, while the parameters of respiratory pattern, occlusion pressure and respiratory resistance were beyond the norm. The results obtained from the measurements of respiratory pattern parameters correlated well with the clinical condition of the patient and with the results of biochemical and enzymatic measurements.

Thermoregulatory dysfunction secondary to acute ethanol poisoning

Acute ethanol poisoning followed by drugs of abuse and psychiatric disorders is the most common cause of hypothermia. An attempt to evaluate the ethanol poisoning degree considering body temperature, serum osmolality, osmolal gap and ethanol concentration measurements was the aim of study. The lowest body temperature measured using infrared tympanic thermometer--First Temp Genius, Sherwood Medical was noted in the severely poisoned patients and was well correlated with the serum osmolality and with the osmolal gap.

The assessment of the condition of the liver in patients chronically exposed to mercury compounds in the place of settlement

Problems with the assessment of organ damage caused by toxic substances in places of residence have recently appeared with increasing frequency. In spite of this there have been so far no uniform, objective research methods which could allow their accurate evaluation. This is why the attempt has been made to assess morphological and functional condition of the liver in patients chronically exposed to mercury compounds in the place of settlement. The research group consisted of 62 patients exposed to metallic mercury at a yearly rate exceeding 24 kg for average duration of 16 years. Patients with the liver or biliary tract diseases, symptoms of chronic circulatory insufficiency, Australia (HBs+) antigen carriers and alcoholics were excluded from the research group. The control group consisted of 29 males. AST and ALT activity, prothrombin level, bilirubin and protein concentration in blood serum were measured and scintigraphic and USG examinations of the liver were performed. Mercury concentrations were also established. Scintigraphic examination yielded an abnormal image of the liver in 52% of the exposed patients. The differences in frequency and intensity of scintigraphic changes in comparison with the control group were of statistical significance. No pathological changes were found in USG examination. Significantly higher ALT activity and bilirubin concentration and significantly lower total protein concentration were found in the exposed group. The correlation between the intensity of scintigraphic changes and mercury concentration were noted. Liver scintigraphic examination combined with biochemical analysis allows an assessment of the liver condition in chronic exposure to mercury compounds in the place of settlement.