Clinical outcomes of patients with diffuse coronary artery disease following physiology-guided treatment strategy: insights from AJIP registry

Background

Physiology-guided treatment strategy improves clinical outcomes of patients with coronary artery disease. However, it has not been fully evaluated whether such guideline-based strategy is useful for patients with diffuse coronary artery disease as well, which is known to be one of the major factors affecting morbidity and mortality.

Purpose

The aim of this study was to clarify clinical outcomes of patients with diffuse coronary artery disease whose treatment strategy was based on coronary physiology.

Methods

From an international multicentre registry of iFR-pullback, consecutive 1067 patients (1185 vessels) with stable angina were included in whom coronary lesions were deferred or revascularized according to the iFR cutoff: 0.89. The physiological pattern of disease was classified according to the iFR-pullback recording as predominantly physiologically diffuse (n=463) or predominantly physiologically focal (n=722). Major adverse cardiovascular events (MACEs), defined as a composite of cardiac death, non-fatal myocardial infarction, and ischemia-driven target lesion revascularization during follow-up period, were compared between diffuse and focal groups, in both deferred and revascularized groups, respectively.

Results

Mean age was 67.1±10.7 years and 75.8% of patients were men. Median iFR was 0.88 (interquartile range: 0.80 to 0.92). At a median follow-up period of 18 months, no significant differences in MACEs were found between diffuse and focal groups, in both iFR-based deferred and revascularized groups. In the deferred group (n=480), MACEs occurred in 6.9% patients (15/217) in the diffuse group and 8.0% patients (21/263) in the focal group (p=0.44). In the revascularized group (n=705), MACEs occurred in 8.9% patients (22/246) in the diffuse group and 7.2% patients (33/459) in the focal group (p=0.49).

Conclusions

Despite potentially higher risks in patients with diffuse coronary artery disease, clinical outcomes of those patients were comparable to those of patients without diffuse disease, as long as treatment strategy was based on the physiology guidance, which is globally recommended by international guidelines.

Funding Acknowledgement

Type of funding source: None

MOB1-YAP1/TAZ-NKX2.1 axis controls bronchioalveolar cell differentiation, adhesion and tumour formation

Mps One Binder Kinase Activator (MOB)1A/1B are core components of the Hippo pathway. These proteins, which coactivate LArge Tumour Suppressor homologue kinases, are also tumour suppressors. To investigate MOB1A/B's roles in normal physiology and lung cancer, we generated doxycycline (Dox)-inducible, bronchioalveolar epithelium-specific, null mutations of MOB1A/B in mice (SPC-rtTA/(tetO)₇-Cre/Mob1a^flox/flox/Mob1b^-/-; termed luMob1DKO mice). Most mutants (70%) receiving Dox in utero (luMob1DKO (E6.5-18.5) mice) died of hypoxia within 1 h post-birth. Their alveolar epithelial cells showed increased proliferation, impaired YAP1/TAZ-dependent differentiation and decreased surfactant protein production, all features characteristic of human respiratory distress syndrome. Intriguingly, mutant mice that received Dox postnatally (luMob1DKO (P21-41) mice) did not develop spontaneous lung adenocarcinomas, and urethane treatment-induced lung tumour formation was decreased (rather than increased). Lungs of luMob1DKO (P21-41) mice exhibited increased detachment of bronchiolar epithelial cells and decreased numbers of the bronchioalveolar stem cells thought to initiate lung adenocarcinomas. YAP1/TAZ-NKX2.1-dependent expression of collagen XVII, a key hemidesmosome component, was also reduced. Thus, a MOB1-YAP1/TAZ-NKX2.1 axis is essential for normal lung homeostasis and expression of the collagen XVII protein necessary for alveolar stem cell maintenance in the lung niche.

A phase II study of bevacizumab with modified OPTIMOX1 as first-line therapy for metastatic colorectal cancer: the TCOG-GI 0802 study

BACKGROUND

Although bevacizumab plus FOLFOX is a standard treatment for metastatic colorectal cancer, oxaliplatin must be withdrawn in many patients because of cumulative neurotoxicity. We postulated that a reduced dose of oxaliplatin and modified treatment schedule would prolong the time to treatment failure and evaluated bevacizumab combined with a modified OPTIMOX1 regimen (mOPTIMOX1, oxaliplatin dose: 85 mg/m(2)).

METHODS

Eligible patients had a histologically confirmed diagnosis of metastatic colorectal cancer and a performance status of 0-1. Patients were excluded if they had grade 1 or higher peripheral sensory neuropathy or had previously received chemotherapy for metastatic colorectal cancer. Patients received bevacizumab plus mFOLFOX6 every 2 weeks for 6 cycles, followed by 12 cycles of a simplified biweekly regimen of leucovorin and fluorouracil (sLV5FU2) plus bevacizumab. Oxaliplatin was then reintroduced, and bevacizumab plus mFOLFOX6 was continued until progressive disease.

RESULTS

The median duration of disease control was 11.7 months (95 % confidence interval [CI], 9.7-13.5 months). The median overall survival was 23.1 months (95 % CI, 18.8-27.9 months). The overall response rate according to both the RECIST and WHO criteria was 51.3 %. The most common grade 3 or 4 toxicities were neutropaenia (32.5 %), hypertension (17.5 %), leukocytopaenia, sensory neuropathy, and diarrhoea (10.0 %). There were no treatment-related deaths.

CONCLUSIONS

Bevacizumab plus mFOLFOX6 was well tolerated, and patients could continue chemotherapy for longer than with conventional FOLFOX regimens. This regimen might be an effective treatment option for patients with metastatic colorectal cancer.

Involvement of JNK in the regulation of autophagic cell death

Programmed cell death is a crucial process in the normal development and physiology of metazoans, and it can be divided into several categories that include type I death (apoptosis) and type II death (autophagic cell death). The Bcl-2 family proteins are well-characterized regulators of apoptosis, among which multidomain pro-apoptotic members (such as Bax and Bak) function as a mitochondrial gateway at which various apoptotic signals converge. Although embryonic fibroblasts from Bax/Bak double-knockout (DKO) mice are resistant to apoptosis, we have previously reported that these cells still die by autophagy in response to various death stimuli. In this study, we found that jun N-terminal kinase (JNK) was activated in etoposide- and staurosporine-treated, but not serum-starved, Bax/Bak DKO cells, and that autophagic cell death was suppressed by the addition of a JNK inhibitor and by a dominant-negative mutant of JNK. Studies with sek1(-/-)mkk7(-/-) cells revealed that disruption of JNK prevented the induction of autophagic cell death. Co-activation of JNK and autophagy induced autophagic cell death. Activation of JNK occurred downstream of the induction of autophagy, and was dependent on the autophagic process. These results indicate that JNK activation is crucial for the autophagic death of Bax/Bak DKO cells.

Antagonistic control of cell fates by JNK and p38-MAPK signaling

During the development and organogenesis of all multicellular organisms, cell fate decisions determine whether cells undergo proliferation, differentiation, or aging. Two independent stress kinase signaling pathways, p38-MAPK, and JNKs, have evolved that relay developmental and environmental cues to determine cell responses. Although multiple stimuli can activate these two stress kinase pathways, the functional interactions and molecular cross-talks between these common second signaling cascades are poorly elucidated. Here we report that JNK and p38-MAPK pathways antagonistically control cellular senescence, oncogenic transformation, and proliferation in primary mouse embryonic fibroblasts (MEFs). Similarly, genetic inactivation of the JNK pathway results in impaired proliferation of fetal hepatoblasts in vitro and defective adult liver regeneration in vivo, which is rescued by inhibition of the p38-MAPK pathway. Thus, the balance between the two stress-signaling pathways, MKK7-JNK and MKK3/6-p38-MAPK, determines cell fate and links environmental and developmental stress to cell cycle arrest, senescence, oncogenic transformation, and adult tissue regeneration.

[Three case reports of effective home palliative chemotherapy with an infuser pump]

We report three cases of home palliative chemotherapy with an infuser pump (IP) for continuous infusion of anticancer drugs, which is as effective as being treated at the hospital. Cases are: A 74-year-old man with intraperitoneal metastasis after rectal operation, a 43-year-old woman with pelvis metastasis after a uterus cervical operation and a 70-year-old man with gastric cancer and massive metastases of the liver. Their performance status (PS) ranged from 3-4. All cases underwent continuous infusion of cisplatin 20-30 mg/w with IP and CPT-11:10-40 mg/w in 1 hour. For case 1/2, 5-FU 1,750 mg/w was carried out continuously, and TS-1 80 mg/day/body was administered for case 3. After 4 courses of chemotherapy, all cases indicated effective changes such as decrease of pain, reduction of metastatic tumor size, decrease of tumor bleeding and tumor makers. Their quality of life (QOL) improved. Palliative chemotherapy to improve QOL can be performed at home if used with IP for poor PS patients.

Activation mechanism and physiological roles of stress-activated protein kinase/c-Jun NH2-terminal kinase in mammalian cells

Stress-activated protein kinase/c-Jun NH2-terminal kinase (SAPK/JNK), which belongs to the family of mitogen-activated protein kinase (MAPK), is activated by many types of cellular stress or extracellular signals. Recent studies, including the analysis with knockout cells and mice, have led towards understanding the molecular mechanism of stress-induced SAPK/JNK activation and the physiological roles of SAPK/JNK in embryonic development and immune responses. Two SAPK/JNK activators, SEK1 and MKK7, are required for full activation of SAPK/JNK, which responds to various stimuli in an all-or-none manner in mouse embryonic stem (ES) cells. SAPK/JNK activation plays essential roles in organogenesis during mouse development by regulating cell proliferation, survival or apoptosis and in immune responses by regulating cytokine gene expression. Furthermore, SAPK/JNK is involved in regulation of mRNA stabilization, cell migration, and cytoskeletal integrity. Thus, SAPK/JNK has a wide range of functions in mammalian cells.

Mild maternal undernutrition in the first half of ovine pregnancy influences placental morphology but not fetal Doppler flow velocity waveforms and fetal heart size

AIMS

We wanted to investigate whether experimental dietary manipulations during early pregnancy influence placental growth and subsequently the cardiovascular system as assessed non-invasively by ultrasonography in the sheep fetus.

METHODS

21 ewes bearing singletons of uniform age were randomly assigned for the first half of pregnancy to one of the following study groups: fed 100% of their nutritional requirements (i.e. controls), global reduction in total intake by 30% (i.e. 70% global) and reduction in protein intake by 30% (i.e. 70% protein).

RESULTS

Placentas from the 70% protein group had significantly more small placentomes, but significantly fewer large placentomes compared to the 70% global group. However, there were no significant differences between the three dietary groups for either the aortic or the umbilical Doppler velocimetry parameters and the fetal heart rate or heart size.

CONCLUSIONS

The present study shows that early mild maternal undernutrition produces subtle changes in cotelydonary weight. However, Doppler and echocardiographic parameters were not affected by these changes.

Visualisation and measurement of tracheal diameter in the sheep fetus: an ultrasound study with stereomicroscopic correlation

OBJECTIVE

There is no information on ultrasonographic visualisation of the upper airways in the sheep fetus, but this species permits to examine the accuracy of ultrasonography in measuring the inner tracheal diameter. This was the aim of our study.

METHODS

Transabdominal ultrasonography to visualise the trachea was attempted in 16 unsedated Welsh Mountain ewes with a singleton pregnancy at 70 (SD 2) days gestation (term 148 days). The ultrasonographically measured inner tracheal diameter was compared with the actual inner tracheal diameter obtained by stereomicroscopy post-mortem.

RESULTS

High-resolution ultrasonography permitted clear imaging of the fetal trachea in 87% (14/16) of the cases analysed. The ultrasound measurements were smaller than the corresponding stereomicroscopic measurements, the mean +/- SD difference between the measurements being 0.40 +/- 0.12 mm.

CONCLUSIONS

Improvements in ultrasound have led to increased interest in the assessment of the trachea in human fetuses. Our study in the ovine fetus at mid gestation shows that optimal views of the fetal trachea allowing accurate measurements can be obtained in almost all the cases.

WSX-1 is required for the initiation of Th1 responses and resistance to L. major infection

WSX-1 is a class I cytokine receptor with homology to the IL-12 receptors. The physiological role of WSX-1, which is expressed mainly in T cells, was investigated in gene-targeted WSX-1-deficient mice. IFN-gamma production was reduced in isolated WSX-1(-/-) T cells subjected to primary stimulation in vitro to induce Th1 differentiation but was normal in fully differentiated and activated WSX-1(-/-) Th1 cells that had received secondary stimulation. WSX-1(-/-) mice were remarkably susceptible to Leishmania major infection, showing impaired IFN-gamma production early in the infection. However, IFN-gamma production during the later phases of the infection was not impaired in the knockout. WSX-1(-/-) mice also showed poorly differentiated granulomas with dispersed accumulations of mononuclear cells when infected with bacillus Calmette-Guerin (BCG). Thus, WSX-1 is essential for the initial mounting of Th1 responses but dispensable for their maintenance.

Impaired synergistic activation of stress-activated protein kinase SAPK/JNK in mouse embryonic stem cells lacking SEK1/MKK4: different contribution of SEK2/MKK7 isoforms to the synergistic activation

Stress-activated protein kinase/c-Jun NH(2)-terminal kinase (SAPK/JNK), which is a member of the mitogen-activated protein kinase (MAPK) family, plays an important role in a stress-induced signaling cascade. SAPK/JNK activation requires the phosphorylation of Thr and Tyr residues in its Thr-Pro-Tyr motif, and SEK1 (MKK4) and MKK7 (SEK2) have been identified as the upstream MAPK kinases. Here we examined the activation and phosphorylation sites of SAPK/JNK and differentiated the contribution of SEK1 and MKK7alpha1, -gamma1, and -gamma2 isoforms to the MAPK activation. In SEK1-deficient mouse embryonic stem cells, stress-induced SAPK/JNK activation was markedly impaired, and this defect was accompanied with a decreased level of the Tyr phosphorylation. Analysis in HeLa cells co-transfected with the two MAPK kinases revealed that the Thr and Tyr of SAPK/JNK were independently phosphorylated in response to heat shock by MKK7gamma1 and SEK1, respectively. However, MKK7alpha1 failed to phosphorylate the Thr of SAPK/JNK unless its Tyr residue was phosphorylated by SEK1. In contrast, MKK7gamma2 had the ability to phosphorylate both Thr and Tyr residues. In all cases, the dual phosphorylation of the Thr and Tyr residues was essentially required for the full activation of SAPK/JNK. These data provide the first evidence that synergistic activation of SAPK/JNK requires both phosphorylation at the Thr and Tyr residues in living cells and that the preference for the Thr and Tyr phosphorylation was different among the members of MAPK kinases.

Dietary restriction in pregnant rats causes gender-related hypertension and vascular dysfunction in offspring

We have investigated the effects of moderate global undernutrition during gestation in the rat on the blood pressure of male and female offspring, and on the development of systemic vascular function. Pregnant Wistar rats were nutritionally restricted (R) by feeding with 70% of the normal gestation-matched dietary intake from 0 to 18 days gestation.R offspring were growth retarded at birth but of similar weight to controls (C) at 20 days. Systolic and/or diastolic and mean arterial blood pressures, measured directly by femoral artery catheter, were elevated from 60 days onward in male R offspring (mean arterial pressure: day 60, P < 0.01; day 100, P < 0.05; day 200, P < 0.005, R vs. C), and from 100 days onward in female R offspring (mean arterial pressure day 100 and day 200, P < 0.05; R vs. C). Maximal constriction to phenylephrine (PE) (P < 0.05) and to noradrenaline (NA) (P < 0.05) was reduced in isolated femoral arteries of day 20 R pups. These differences did not persist into adulthood. In male adult R offspring (200 days), maximal vasoconstriction to the thromboxane A2 mimetic, U46619 (P < 0.05) and sensitivity to potassium (P < 0.01) were enhanced. Moderate maternal undernutrition in rat gestation adversely affects cardiovascular function in the offspring. These abnormalities increase with age and are more pronounced in males.

Effects of undernutrition in early pregnancy on systemic small artery function in late-gestation fetal sheep

OBJECTIVE

The aim of this study was to investigate functional development of small arteries from the skeletal circulation of fetal sheep and to determine whether maternal undernutrition affects responses to vasoconstrictive and vasodilatory agonists in arteries from the late-gestation fetus.

STUDY DESIGN

We investigated vasoconstrictive and vasodilatory responses of isolated small (approximately 300 microm) arteries from the femoral vascular bed of fetal sheep and from late-gestation pregnant ewes. Ewes were fed either 100% of the nutritional requirement throughout pregnancy (control group) or a restricted diet of 85% or 50% of the nutritional requirement for the first 70 days of pregnancy. For the remainder of pregnancy all ewes were fed the complete diet.

RESULTS

Among control group animals vasoconstriction in response to norepinephrine was well developed in fetuses at 0.6 and 0.9 gestation with respect to that in the ewes. When expressed as a percentage of the response to 125-mmol/L potassium (to correct for differences in vessel size and muscle mass), maximum constriction in response to norepinephrine was greater in fetal vessels from 0.9 gestation than in either those at 0.6 gestation or those of the ewes. Endothelium-dependent vasorelaxation responses to acetylcholine and bradykinin were also well developed in fetuses at 0.6 and 0.9 gestation and were similar to those in the ewes. In fetuses at 0.9 gestation the 50% nutritional restriction of the ewe led to blunted endothelium-dependent vasodilatation in response to acetylcholine and blunted endothelium-independent vasodilatation in response to sodium nitroprusside. Responses in the fetuses at 0.9 gestation in which the ewes were fed a restricted diet of 85% were normal.

CONCLUSION

This study shows that from midgestation onward small arteries from the skeletal circulation of the fetal sheep have the functional capacity to respond to norepinephrine and endothelium-dependent vasodilators (eg, acetylcholine and bradykinin). The blunted responses to acetylcholine and sodium nitroprusside in the fetuses at 0.9 gestation among the group of dietarily restricted ewes (restricted diet of 50% group) were indicative of impaired vascular smooth muscle sensitivity to nitric oxide. This defect may contribute to the development of hypertension in later life.

Effect of NO, phenylephrine, and hypoxemia on ductus venosus diameter in fetal sheep

To study the regulation of the ductus venosus (DV) inlet in vivo, we measured the effect of vasoactive substances and hypoxemia on its diameter in nine fetal sheep in utero at 0.9 gestation under ketamine-diazepam anesthesia. Catheters were inserted into an umbilical vein and a fetal common carotid artery, and a flowmeter was placed around the umbilical veins. Ultrasound measurements of the diameter of the fetal DV during normoxic baseline conditions [fetal arterial PO(2) (PaO(2)) 24 mmHg] were compared with measurements during infusion of sodium nitroprusside (SNP; 1.3, 2.6, and 6.5 microg. kg(-1). min(-1)) or the alpha(1)-adrenergic agonist phenylephrine (6.5 microg. kg(-1). min(-1)) into the umbilical vein or during hypoxemia (fetal Pa(O(2)) reduced to 10 mmHg). SNP increased the DV inlet diameter by 23%, but phenylephrine had no effect. Hypoxemia caused a 61% increase of the inlet diameter and a distension of the entire vessel. We conclude that the DV inlet is tonically constricted, because nitric oxide dilates it but an alpha(1)-adrenergic agonist does not potentiate constriction. Hypoxemia causes a marked distension of the entire DV.

Negative regulation of lymphocyte activation and autoimmunity by the molecular adaptor Cbl-b

The signalling thresholds of antigen receptors and co-stimulatory receptors determine immunity or tolerance to self molecules. Changes in co-stimulatory pathways can lead to enhanced activation of lymphocytes and autoimmunity, or the induction of clonal anergy. The molecular mechanisms that maintain immunotolerance in vivo and integrate co-stimulatory signals with antigen receptor signals in T and B lymphocytes are poorly understood. Members of the Cbl/Sli family of molecular adaptors function downstream from growth factor and antigen receptors. Here we show that gene-targeted mice lacking the adaptor Cbl-b develop spontaneous autoimmunity characterized by auto-antibody production, infiltration of activated T and B lymphocytes into multiple organs, and parenchymal damage. Resting cbl-b(-/-) lymphocytes hyperproliferate upon antigen receptor stimulation, and cbl-b(-/-) T cells display specific hyperproduction of the T-cell growth factor interleukin-2, but not interferon-gamma or tumour necrosis factor-alpha. Mutation of Cbl-b uncouples T-cell proliferation, interleukin-2 production and phosphorylation of the GDP/GTP exchange factor Vav1 from the requirement for CD28 co-stimulation. Cbl-b is thus a key regulator of activation thresholds in mature lymphocytes and immunological tolerance and autoimmunity.

The action of a novel vitamin D3 analogue, OCT, on immunomodulatory function of keratinocytes and lymphocytes

Topical vitamin D3 has relatively recently been introduced for the treatment of psoriasis. Synthetic vitamin D3 analogues with a high potential for inducing differentiation of cells, but with a low hypercalcemic effect have recently been developed. One such synthetic analogue of 1,25-dihydroxyvitamin D3 (calcitriol), 22-oxacalcitriol (OCT), is a novel agent for the topical treatment of psoriasis. The activity of OCT in vitro was investigated and compared with that of a series of vitamin D3 analogues as to their ability to inhibit murine T lymphocyte proliferation stimulated by con-A, to suppress IL-6 and IL-8 production by keratinocytes stimulated with IL-1alpha and TNFalpha, and to inhibit AP-1- and NFkappaB-dependent reporter gene expression. OCT inhibited the proliferation of lymphocytes and suppressed IL-8 and IL-6 production by keratinocytes to the same extent as the other vitamin D3 analogues. It also inhibited AP-1- and NFkappaB-controlled luciferase activity to the same extent as the other vitamin D3 analogues, which demonstrates its mechanism of action in the suppression of inflammatory processes.

Mechanisms of noradrenaline-induced vasorelaxation in isolated femoral arteries of the neonatal rat

Isolated arteries from the femoral circulation of Wistar rats mounted on a small vessel myograph demonstrated age related tension development to noradrenaline (NA, 1 x 10(-8) - 5 x 10(-5) M) day 20 greater than day 10 (P<0.005); day 100 greater than day 20 (P<0.001) and depolarizing potassium (125 mM) buffer day 20 greater than day 10 (P<0.001). NA evoked dilatation in femoral arteries from neonatal rats (10 days) when added to unstimulated vessels or to those preconstricted with the thromboxane mimetic, U46619. Relaxation to NA was inhibited by L-NAME (0.1 mM) (P<0.001), endothelial removal (P<0.001) and the alpha2-adrenoceptor antagonist, yohimbine (0.1 microM) (P<0.001). Alpha1- or beta-adrenoceptor antagonism was without effect. Relaxation was evoked in femoral arteries of the 10-day-old rats by the alpha2-adrenoceptor agonist UK14304 (1 x 10(-8) - 5 x 10(-5) M). This relaxation was also abolished by L-NAME (0.1 mM) (P<0.001) or endothelial removal (P<0.001). Alpha2-adrenoceptor-mediated vasorelaxation was the predominant response to NA stimulation in femoral arteries of the neonatal rat. These responses were endothelium-dependent and were NO-mediated.

Goat fetuses disconnected from the placenta, but reconnected to an artificial placenta, display intermittent breathing movements

To investigate whether placental factors are involved in the intermittent breathing movements in goat fetuses, we assessed electrocortical activity (ECoA) and tracheal pressure in 5 fetuses (124-135 days) separated from the placenta and connected for 48 h to an extrauterine fetal incubation system that provided umbilical arteriovenous extracorporeal membrane oxygenation. The fetal physiological condition on this system was almost the same as that in utero for at least 48 h after the preparation. All fetuses showed intermittent low-voltage ECoA and breathing movements. The breathing movements occurred almost exclusively during periods of low- voltage ECoA. The proportions of time spent in low-voltage ECoA and breathing movements were 48-57% and 46-56%, respectively. In conclusion, breathing movements of fetuses on the extrauterine incubation system were episodic, suggesting that intermittent breathing movements are intrinsic to fetuses, independent of placenta-derived factors.

Defective liver formation and liver cell apoptosis in mice lacking the stress signaling kinase SEK1/MKK4

The stress signaling kinase SEK1/MKK4 is a direct activator of stress-activated protein kinases (SAPKs; also called Jun-N-terminal kinases, JNKs) in response to a variety of cellular stresses, such as changes in osmolarity, metabolic poisons, DNA damage, heat shock or inflammatory cytokines. We have disrupted the sek1 gene in mice using homologous recombination. Sek1(−/−)embryos display severe anemia and die between embryonic day 10.5 (E10.5) and E12.5. Haematopoiesis from yolk sac precursors and vasculogenesis are normal in sek1(−/−)embryos. However, hepatogenesis and liver formation were severely impaired in the mutant embryos and E11.5 and E12.5 sek1(−/−)embryos had greatly reduced numbers of parenchymal hepatocytes. Whereas formation of the primordial liver from the visceral endoderm appeared normal, sek1(−/−) liver cells underwent massive apoptosis. These results provide the first genetic link between stress-responsive kinases and organogenesis in mammals and indicate that SEK1 provides a crucial and specific survival signal for hepatocytes.

Activation of c-Jun N-terminal kinase (JNK) by lysophosphatidic acid in Swiss 3T3 fibroblasts

Lysophosphatidic acid (LPA) induced activation of c-Jun N-terminal kinase (JNK) in Swiss 3T3 fibroblasts. This activation reached the maximum at 20 min and required a high concentration of LPA with an EC50 value of approximately 3 microg/ml. LPA-induced activation of JNK was not suppressed by prior treatment of the cells with pertussis toxin, whereas it was completely blocked by suramin, a non-selective inhibitor of ligand-receptor interactions. The kinetics and concentration-dependency of LPA-induced JNK activation were in sharp contrast with those of LPA-induced extracellular signal-regulated kinase (ERK) activation, which reached the maximum within 3 min and occurred with an EC50 of 0.1 microg/ml. The ERK activation was susceptible to pertussis toxin, whereas it was not inhibited by suramin. These results indicate that the signal transduction pathways of LPA-induced JNK and ERK activations are distinct. Thus, this is the first report showing that LPA induces not only ERK activation but also JNK activation, which may be responsible for the induction of DNA synthesis in LPA-stimulated Swiss 3T3 fibroblasts.

Impaired TCR-mediated apoptosis and Bcl-XL expression in T cells lacking the stress kinase activator SEK1/MKK4

The dual specificity kinase SEK1 (MKK4) is a direct activator of stress-activated protein kinases (SAPK/JNK) in response to environmental stresses or mitogenic factors. We show in Sek1(-/-)Rag(-/-) chimeric mice that a Sek1 null mutation augments the susceptibility of peripheral T cells to TCR/CD3 religation-induced apoptosis. Sek1(-/-) T cells failed to induce expression of the death suppressor Bcl-XL in response to Ag receptor activation. The Sek1 mutation did not alter the induction of apoptosis in response to etoposide, cisplatinum, Adriamycin, and gamma-irradiation. Moreover, we show that CD3epsilon activation alone leads to SEK1 activation in Sek1(+/+) T cells. These results suggest that SEK1 transduces cellular survival signals during T cell stimulation.

Molecular mechanism of human CD38 gene expression by retinoic acid. Identification of retinoic acid response element in the first intron

CD38 is a nonlineage-restricted type II transmembrane glycoprotein possessing ecto-NAD+ glycohydrolase activity. Because of its unique expression pattern in lymphocyte differentiation, it appears to function as an immunoregulatory molecule. We previously reported that CD38 was specifically induced by all-trans-retinoic acid (RA) in human promyelocytic leukemia HL-60 cells. Here we studied the molecular mechanism of the RA-dependent induction of human CD38. The expression of CD38 mRNA by RA appeared to be caused by the transcriptional stimulation of the gene, since it was blocked by an RNA synthesis inhibitor, but not by a protein synthesis inhibitor. In search of the RA response element (RARE) possibly present in human CD38 gene promoter, we isolated and sequenced the genomic DNA covering the 5'-flanking region, exon 1, and partial intron 1. Transient transfection experiments revealed that the responsiveness to RA was conferred through an RARE consisting of two direct repeat TGACCT-like hexamer motifs with a 5-nucleotide spacer, which was located in the first intron rather than the 5'-flanking region of the CD38 gene. This RARE interacted with heterodimer composed of RA receptor and retinoid X receptor in vitro. Thus, the RA-induced expression of the human CD38 gene was demonstrated to be mediated through the RARE located in the first intron.

Upper cervical myelopathy associated with low CSF pressure: a complication of ventriculoperitoneal shunt

A patient who had undergone ventriculoperitoneal shunting developed upper cervical myelopathy. His CSF pressure was markedly low, and deformation of the spinal cord and shrinkage of the subarachnoid space at the upper cervical level were found in radiologic examinations. Ligation of the shunt tube resulted in almost complete recovery. The effect of excessive drainage may have caused the abnormalities.

Vav is a regulator of cytoskeletal reorganization mediated by the T-cell receptor

BACKGROUND

Vav is a guanine-nucleotide exchange factor for the Rho-like small GTPases RhoA, Rac1 and Cdc42, which regulate cytoskeletal reorganization and activation of stress-activated protein kinases (SAPK/JNKs). Vav is expressed in hematopoietic cells and is phosphorylated in T and B cells following activation of various growth factor or antigen receptors. Vav interacts with several signaling molecules in T cells, but the functional relevance of these interactions is established only for Slp76: they cooperate to induce activity of the transcription factor NF-AT and interleukin-2 expression. We have investigated the role of Vav in T cells by generating vav-/- mice.

RESULTS

Mice deficient for vav were viable and healthy, but had impaired T-cell development. In vav-/- T cells, in response to activation of the T-cell receptor (TCR), cell cycle progression, induction of NF-ATc1 activity, downregulation of the cell-cycle inhibitor p27Kip1, interleukin-2 production, actin polymerization and the clustering of TCRs into patches and caps--a cytoskeletal reorganization process--were defective. TCR-mediated activation of mitogen-activated protein kinase and SAPK/JNK was unaffected. Ca2+ mobilization was impaired in vav-/- thymocytes and T cells. In wild-type cells, Vav constitutively associated with the cytoskeletal membrane anchors talin and vinculin. In the absence of Vav, phosphorylation of Slp76, Slp76-talin interactions, and recruitment of the actin cytoskeleton to the CD3 zeta chain of the TCR co-receptor were impaired.

CONCLUSIONS

Vav is a crucial regulator of TCR-mediated Ca2+ flux, cytoskeletal reorganization and TCR clustering, and these are required for T-cell maturation, interleukin-2 production and cell cycle progression.

Differential developmental process of respective behavioral states in human fetuses

The presence of behavioral states has been recognized in human fetuses. However, developmental process of fetal behavioral states remains to be clarified. In thirty-one normal pregnant women between 20 and 41 weeks' gestation, fetal movements were examined by using multiple ultrasonic machines. The entire period was divided into eye movement (EM), no eye movement (NEM), and unclassified periods according to the mode of appearance of rapid eye movements. We investigated changes in the ratio of EM and NEM periods and the incidence of various fetal movements in these periods. The ratio of EM periods increased stepwise between 20 and 32 weeks. The difference in the incidence of "startle" and jaw movements between EM and NEM periods was found at 24-27 and 32-35 weeks, respectively. We found a significant decrease in the incidence of total body movements exclusively in NEM periods at 36-39 weeks and a significant increase in the incidence of "rolling" in EM periods at 40-41 weeks. Eye opening was ultrasonographically recognized, providing evidence for awake state in the human fetus. This study revealed the characteristic appearance of fetal movements as related to the presence or absence of EM during the second half of pregnancy, and thereby pointed to differential development process of behavioral states of human fetuses.

Large granular lymphocyte leukemia with pure red cell aplasia in a renal transplant recipient

Neoplastic disorders sometimes accompany a renal transplant. Herein, we report a large granular lymphocyte (LGL) leukemia patient with pure red cell aplasia (PRCA) after renal transplantation. A 36-year-old female was presented to our department with anemia in February 1996. She had undergone hemodialysis because of pregnancy in December 1981. She received a renal transplantation from her mother in April 1986. After the transplantation, she received cyclosporin A (CyA) at 2 mg/kg/day, mizoribine at 1 mg/kg/day, and methylprednisolone at 0.1 mg/kg/day for 8 years. In July 1995, her hemoglobin level dropped to 9.3 g/dl, and anemia developed gradually. In January 1996, her hemoglobin was 5.8 g/dl, and she was given a red blood cell transfusion. Laboratory findings were as follows: RBC 1.46 x 10(12)/L; hemoglobin 5.8 g/dl; hematocrit 17.8%; leucocytes 5.2 x 10(9)/L with 62.4% neutrophils, 34.1% lymphocytes, 2.6% monocytes; platelets 50.8 x 10(10)/L; reticulocytes 0.4%. Bone marrow aspirate smears and biopsy sections revealed normal myeloid and megakaryocyte differentiation with few erythroid precursors. The lymphocytes were of medium size with granules in the cytoplasm. More than 90% of lymphocytes were of the LGL type. Surface markers of peripheral blood mononuclear cells demonstrated increases in the CD2+, CD3+, CD4-, and CD8+ populations. A monoclonal rearrangement of T-cell receptor (TCR)-beta chain gene was found by Southern blot analysis of the mononuclear cells in peripheral blood. A diagnosis of LGL leukemia with PRCA was made. During the next 4 months, she received six red blood cell transfusions, a total of 12 U. In March 1996, the patient was treated with cyclophosphamide (1 mg/kg/day). After 1 month of treatment, serum GPT levels increased to 60 IU/l. The dose of cyclophosphamide was reduced to 0.5 mg/kg/day. Two months after initiation of the therapy, the patient developed reticulocytosis and blood transfusion was not needed thereafter. During remission, the number of CD2+, CD3+, CD4-, and CD8+ lymphocytes decreased. Large granular lymphocytes decreased to less than 10% of peripheral blood. The monoclonal rearrangement of the TCR-beta chain gene in peripheral blood disappeared.

The transcription factor NF-ATc1 regulates lymphocyte proliferation and Th2 cytokine production

NF-ATc1 is a member of a family of genes that encodes the cytoplasmic component of the nuclear factor of activated T cells (NF-AT). In activated T cells, nuclear NF-AT binds to the promoter regions of multiple cytokine genes and induces their transcription. The role of NF-ATc1 was investigated in recombination activating gene-1 (RAG-1)-deficient blastocyst complementation assays using homozygous NF-ATc1-/- mutant ES cell lines. NF-ATc1-/-/RAG-1-/- chimeric mice showed reduced numbers of thymocytes and impaired proliferation of peripheral lymphocytes, but normal production of IL-2. Induction in vitro of Th2 responses, as demonstrated by a decrease in IL-4 and IL-6 production, was impaired in mutant T cells. These data indicate that NF-ATc1 plays roles in the development of T lymphocytes and in the differentiation of the Th2 response.

Activation of stress-activated protein kinases/c-Jun N-terminal protein kinases (SAPKs/JNKs) by a novel mitogen-activated protein kinase kinase

Mitogen-activated protein kinase (MAPK) kinases (MKKs) are dual-specificity protein kinases that phosphorylate and activate MAPK. We have isolated a cDNA encoding a novel protein kinase that has significant homology to MKKs. The novel kinase MKK7 has a nucleotide sequence that encodes an open reading frame of 347 amino acids with 11 kinase subdomains. MKK7 is ubiquitously expressed in all adult and embryonic organs but displays high expression in epithelial tissues at later stages of fetal development. When transiently expressed in 293 cells, MKK7 specifically activated stress-activated protein kinases (SAPKs)/c-Jun N-terminal protein kinases (JNKs) but not extracellular-regulated kinase or p38 kinase. A kinase-negative mutant of MKK7 inhibits interleukin-1beta, lipopolysaccharide, and MEKK1-induced SAPK/JNK activation. Thus, MKK7 is a new member of the MAPK kinase family that functions upstream of SAPK/JNK in the SAPK/JNK signaling pathway.

An evaluation of the system to control blood flow in maintaining goat fetuses on arterio-venous extracorporeal membrane oxygenation: a novel approach to the development of an artificial placenta

We compared various methods to control blood flow for extrauterine incubation of goat fetuses without lung respiration using arterio-venous extracorporeal membrane oxygenation via umbilical vessels to develop a suitable system for a long-term life support system for premature neonates. In twenty-seven consecutive preparations of goat fetuses, 4 designs (System 1, manual flow control without a reservoir; System 2, manual flow control with an arterial open-top reservoir; System 3, semiautomatic flow control with an arterial open top reservoir; and System 4, semiautomatic flow control with a tube occluder and an arterial open top reservoir) were tested in terms of the duration of incubation periods during which fetuses were kept under stable conditions. The incubation periods became prolonged with the advancement of the system (System 1, 5.4 h; System 2, 11.6 h; System 3, 64.8 h; and System 4, 159.8 h medians of the incubation periods). The incubation periods with System 4 were significantly longer compared to those with System 1 and System 2. These results suggest that, for extrauterine incubation of goat fetuses using arterio-venous extracorporeal membrane oxygenation via umbilical vessels, the method to control blood flow is of utmost importance for long-term maintenance, and thus a control system with the fixed vascular resistance of the extracorporeal circuit is applicable to long-term maintenance of premature goat fetuses.

Impaired CD28-mediated interleukin 2 production and proliferation in stress kinase SAPK/ERK1 kinase (SEK1)/mitogen-activated protein kinase kinase 4 (MKK4)-deficient T lymphocytes

The dual specific kinase SAPK/ERK1 kinase (SEK1; mitogen-activated protein kinase kinase 4/Jun NH2 terminal kinase [ JNK] kinase) is a direct activator of stress-activated protein kinases ([SAPKs]/JNKs) in response to CD28 costimulation, CD40 signaling, or activation of the germinal center kinase. Here we show that SEK1(-/-) recombination-activating gene (RAG)2(-/-) chimeric mice have a partial block in B cell maturation. However, peripheral B cells displayed normal responses to IL-4, IgM, and CD40 cross-linking. SEK1(-/-) peripheral T cells showed decreased proliferation and IL-2 production after CD28 costimulation and PMA/Ca2+ ionophore activation. Although CD28 expression was absolutely crucial to generate vesicular stomatitis virus (VSV)-specific germinal centers, SEK1(-/-)RAG2(-/-) chimeras mounted a protective antiviral B cell response, exhibited normal IgG class switching, and made germinal centers in response to VSV. Interestingly, PMA/Ca2+ ionophore stimulation, which mimics TCR-CD3 and CD28-mediated signal transduction, induced SAPK/JNK activation in peripheral T cells, but not in thymocytes, from SEK1(-/-) mice. These results show that signaling pathways for SAPK activation are developmentally regulated in T cells. Although SEK1(-/-) thymocytes failed to induce SAPK/JNK in response to PMA/Ca2+ ionophore, SEK1(-/-)RAG2(-/-) thymocytes proliferated and made IL-2 after PMA/Ca2+ ionophore and CD3/CD28 stimulation, albeit at significantly lower levels compared to SEK1(+/+)RAG2(-/-) thymocytes, implying that CD28 costimulation and PMA/Ca2+ ionophore-triggered signaling pathways exist that can mediate proliferation and IL-2 production independently of SAPK activation. Our data provide the first genetic evidence that SEK1 is an important effector molecule that relays CD28 signaling to IL-2 production and T cell proliferation.

Evidence for an elevation in serum interleukin-2 and tumor necrosis factor-alpha levels before the clinical manifestations of preeclampsia

PROBLEM

The purpose of this study is to clarify whether the disruption of immune regulation occurs in early pregnancy before the clinical manifestations of preeclampsia.

METHOD OF STUDY

The serum concentrations of interleukin-2 (IL-2) and tumor necrosis factor-alpha (TNF-alpha) were determined by using enzyme-linked immunoadsorbent assay (ELISA) in the first trimester of pregnancy in women who had preeclampsia develop after 28 weeks of pregnancy (preeclamptic group) and in women who completed pregnancy uneventfully (control group).

RESULTS

Serum concentrations of both IL-2 and TNF-alpha in the first trimester of the preeclamptic group were significantly higher than those of the control group.

CONCLUSIONS

That the perturbation of feto-maternal immune regulation may precede the clinical manifestations of preeclampsia, which may be of relevance in the development of preeclampsia, is suggested.

Differential clinical courses of pregnancies complicated by diabetes insipidus which does, or does not, pre-date the pregnancy

We present six cases of diabetes insipidus (DI) complicating pregnancy. In three cases, DI was manifested during pregnancy and required the administration of desmopressin acetate (1-desamino-8-D-arginine vasopressin, DDAVP). All these cases exhibited abnormal laboratory data such as an elevation of liver enzymes or a decrease in serum antithrombin III. The remaining three cases had suffered from DI before pregnancy which was well controlled on DDAVP. The clinical courses of these pregnancies were all uneventful subsequent to therapy. If DI is first recognized during pregnancy, attention should be paid to the possibility of abnormal liver function and eclampsia.

Brca2 is required for embryonic cellular proliferation in the mouse

Mutations of the tumor suppressor gene BRCA2 are associated with predisposition to breast and other cancers. Homozygous mutant mice in which exons 10 and 11 of the Brca2 gene were deleted by gene targeting (Brca2(10-11)) die before day 9.5 of embryogenesis. Mutant phenotypes range from severely developmentally retarded embryos that do not gastrulate to embryos with reduced size that make mesoderm and survive until 8.5 days of development. Although apoptosis is normal, cellular proliferation is impaired in Brca2(10-11) mutants, both in vivo and in vitro. In addition, the expression of the cyclin-dependent kinase inhibitor p21 is increased. Thus, Brca2(10-11) mutants are similar in phenotype to Brca1(5-6) mutants but less severely affected. Expression of either of these two genes was unaffected in mutant embryos of the other. This study shows that Brca2, like Brca1, is required for cellular proliferation during embryogenesis. The similarity in phenotype between Brca1 and Brca2 mutants suggests that these genes may have cooperative roles or convergent functions during embryogenesis.

Oscillation of ADP-ribosyl cyclase activity during the cell cycle and function of cyclic ADP-ribose in a unicellular organism, Euglena gracilis

In Euglena gracilis, the activity of ADP-ribosyl cyclase, which produces cyclic ADP-ribose, oscillated during the cell cycle in a synchronous culture induced by a light-dark cycle, and a marked increase in the activity was observed in the G2 phase. Similarly, the ADP-ribosyl cyclase activity rose extremely immediately before cell division started, when synchronous cell division was induced by adding cobalamin (which is an essential growth factor and participates in DNA synthesis in this organism) to its deficient culture. Further, cADPR in these cells showed a maximum level immediately before cell division started. A dose-dependent Ca2+ release was observed when microsomes were incubated with cADPR.

Developmental sequence of human fetal body movements in the second half of pregnancy

To describe fetal body movements precisely and to clarify their developmental sequence in the second half of pregnancy, fetal body movements were observed in 31 normal fetuses between 20 and 41 weeks of pregnancy by using multiple ultrasonic machines. All movements of the whole trunk were able to be classified into six fundamental movements: flexion, stretch, rolling, startle, stepping, and writhing. Startle was always observed as a single movement, but others were more frequently observed as a part of combination rather than as a single movements. The incidence of flexion and stretch peaked at 28-31 weeks, whereas the incidence of startle and stepping lowered at the period. The incidence of rolling and upper half trunk movements increased at 40-41 weeks. Limb movements were frequent and did not exhibit characteristic change in the incidence. In conclusion, we classified fetal body movements into several fundamental movements instead of using the expression of "general movements" by focusing principally on movements of the trunk. In particular, some of the fundamental movements seem to appear in characteristic ways as related to gestational age. In view of that fetal behaviors are closely related to the neural activity, the present findings may contribute to an understanding of the developmental process of the central nervous system.

Stress-signalling kinase Sek1 protects thymocytes from apoptosis mediated by CD95 and CD3

Distinct and evolutionarily conserved signal transduction cascades mediate survival or death in response to developmental and environmental cues. The stress-activated protein kinases, or Jun N-terminal kinases (SAPKs/JNKs), are activated in response to a variety of cellular stresses such as changes in osmolarity and metabolism, DNA damage, heat shock, ischaemia, or inflammatory cytokines. Sek1 (JNKK/MKK4) is a direct activator of SAPKs/JNKs in response to environmental stresses or mitogenic factors. Here we investigate the role of Sek1 in development and apoptosis by deleting sek1 in embryonic stem (ES) cells by homologous recombination. We provide genetic evidence that different stresses utilize distinct signalling pathways for SAPK/JNK activation. sek1(-/-) rag2(-/-) chimaeric mice have normal numbers of mature T cells but fewer immature CD4+CD8+ thymocytes. The sek1 mutation did not affect the induction of apoptosis in response to environmental stresses in ES and T cells: instead, sek1 protected thymocytes from CD95 (Fas)- and CD3-mediated apoptosis. These data indicate that SEK1 mediates survival signals in T-cell development.

Signal transduction via the CD38/NAD+ glycohydrolase

The human cell surface CD38 molecule is a 46-kDa type-II transmembrane glycoprotein with a short N-terminal cytoplasmic domain and a long Cys-rich C-terminal extracellular one. We previously demonstrated that an ecto-form NAD+ glycohydrolase (NADase) activity induced by all-trans retinoic acid in HL-60 cells is due to the extracellular domain of CD38. In the present study, we investigated a possible signal transduction mediated through CD38 in the retinoic acid-differentiated HL-60 cells with anti-CD38 monoclonal antibodies (mAbs). The addition of selected anti-CD38 mAbs to the cells induced rapid tyrosine phosphorylation of the cellular proteins with the molecular weights of 120,000, 87,000 and 77,000; the phosphorylated 120-kDa protein was identified as the c-cbl proto-oncogene product, p120c-cbl. Furthermore, the phosphorylated p 120c-cbl associated with the 85-kDa subunit of phosphatidylinositol 3-kinase. To determine the relationship between the amino acid sequence responsible for the NADase activity and epitopes recognized by the stimulatory mAbs, we produced its carboxy-terminal deletion mutants in COS-7 cells. The mutants with less than 15 amino acids deleted from the carboxyl terminus of the 300-amino acid wild-type molecule still maintained NADase activity, but those with more than 27 amino acids deleted did not. Introduction of site-directed mutation of a cysteine residue (Cys275), located in the 273-285 sequence, completely abolished the NADase activity. These CD38 mutants were also used for an epitope mapping of anti-CD38 mAbs. All the epitopes recognized by the mAbs inducing the tyrosine phosphorylation were mapped on the same Cys275-containing sequence of 273-285. Thus, the discrete carboxy-terminal sequence not only plays a key role in its ecto-NADase activity, but also contains the epitopes of the agonistic anti-CD38 mAbs for the transmembrane signaling. We also found that the agonistic mAbs markedly potentiate superoxide generation induced by the stimulation of G protein-coupled chemotactic receptors. Our results suggested that the stimulation of CD38 might generate an accessory signal(s) to enhance the G protein-mediated signaling, probably though the protein-tyrosine phosphorylation.

Stimulation of ADP-ribosyl cyclase activity of the cell surface antigen CD38 by zinc ions resulting from inhibition of its NAD+ glycohydrolase activity

The lymphocyte cell surface antigen, CD38, which has an amino acid sequence similar to Aplysia ADP-ribosyl cyclase, catalyzes not only the hydrolysis of NAD+ and 1-(5-phospho-beta-D-ribosyl) adenosine 5'-phosphate cyclic anhydride (cyclic ADP-ribose) but also the formation of cyclic ADP-ribose from NAD+. To characterize the bifunctional enzyme properties, we produced the recombinant CD38 fused with a maltose-binding protein (MBP-CD38). Zinc ions stimulated the ADP-ribosyl cyclase activity of MBP-CD38, but inversely inhibited its NAD+ glycohydrolase activity which was approximately 100-fold dominant to the cyclase activity in the absence of Zn2+. Such dual effects of Zn2+ were also observed in the native membrane-bound CD38 of HL-60 cells which had been caused to differentiate by retinoic acid. Zinc ions inhibited the NAD+ glycohydrolase reaction catalyzed by MBP-CD38 in an uncompetitive manner, whereas they enhanced the ADP-ribosyl cyclase reaction without affecting the Km value for NAD+. There was an increase in the fluorescence intensity of a hydrophobic fluorescent probe, 8-anilino-1-naphthalenesulfonate, in the presence of MBP-CD38. The fluorescence increase was further enhanced by the addition of Zn2+ with a shift in the maximum emission wavelength from 484 nm to 470 nm, suggesting that Zn2+ caused conformational changes of MBP-CD38. These results indicate that Zn2+ directly interacts with CD38 to stimulate its ADP-ribosyl cyclase with inhibition of its NAD+ glycohydrolase, probably due to prevention of the access of water molecule to an intermediate of the enzymesubstrate complex.