Murine Factor H Co-Produced in Yeast With Protein Disulfide Isomerase Ameliorated C3 Dysregulation in Factor H-Deficient Mice

Recombinant human factor H (hFH) has potential for treating diseases linked to aberrant complement regulation including C3 glomerulopathy (C3G) and dry age-related macular degeneration. Murine FH (mFH), produced in the same host, is useful for pre-clinical investigations in mouse models of disease. An abundance of FH in plasma suggests high doses, and hence microbial production, will be needed. Previously, Pichia pastoris produced useful but modest quantities of hFH. Herein, a similar strategy yielded miniscule quantities of mFH. Since FH has 40 disulfide bonds, we created a P. pastoris strain containing a methanol-inducible codon-modified gene for protein-disulfide isomerase (PDI) and transformed this with codon-modified DNA encoding mFH under the same promoter. What had been barely detectable yields of mFH became multiple 10s of mg/L. Our PDI-overexpressing strain also boosted hFH overproduction, by about tenfold. These enhancements exceeded PDI-related production gains reported for other proteins, all of which contain fewer disulfide-stabilized domains. We optimized fermentation conditions, purified recombinant mFH, enzymatically trimmed down its (non-human) N-glycans, characterised its functions in vitro and administered it to mice. In FH-knockout mice, our de-glycosylated recombinant mFH had a shorter half-life and induced more anti-mFH antibodies than mouse serum-derived, natively glycosylated, mFH. Even sequential daily injections of recombinant mFH failed to restore wild-type levels of FH and C3 in mouse plasma beyond 24 hours after the first injection. Nevertheless, mFH functionality appeared to persist in the glomerular basement membrane because C3-fragment deposition here, a hallmark of C3G, remained significantly reduced throughout and beyond the ten-day dosing regimen.

Implementation of a psychodermatology clinic at a major health system in Detroit

The association between psychiatric and dermatologic disorders has been well characterized in the present literature with estimates of up to 40% of dermatology patients having concomitant psychiatric problems that are often related to their skin condition. Here, we present our experience regarding the implementation of a psychodermatology clinic in Detroit, Michigan. The most commonly referred conditions were delusions of parasitosis, neurotic excoriations, and isotretinoin initiation for patients with a history of psychiatric conditions. Seventy-three percent of referred patients were female. By creating a monthly clinic for patients who are diagnosed with skin conditions and associated psychiatric disorders or psychological symptoms, we are able to meet the needs of these patients with a synergistic relationship between health care providers.

An Engineered Complement Factor H Construct for Treatment of C3 Glomerulopathy

Background C3 glomerulopathy (C3G) is associated with dysregulation of the alternative pathway of complement activation, and treatment options for C3G remain limited. Complement factor H (FH) is a potent regulator of the alternative pathway and might offer a solution, but the mass and complexity of FH makes generation of full-length FH far from trivial. We previously generated a mini-FH construct, with FH short consensus repeats 1-5 linked to repeats 18-20 (FH1-5^18-20), that was effective in experimental C3G. However, the serum t1/2 of FH1-5^18-20 was significantly shorter than that of serum-purified FH.Methods We introduced the oligomerization domain of human FH-related protein 1 (denoted by R1-2) at the carboxy or amino terminus of human FH1-5^18-20 to generate two homodimeric mini-FH constructs (FHR1-2^1-5^18-20 and FH1-5^18-20^R1-2, respectively) in Chinese hamster ovary cells and tested these constructs using binding, fluid-phase, and erythrocyte lysis assays, followed by experiments in FH-deficient Cfh-/- mice.Results FHR1-2^1-5^18-20 and FH1-5^18-20^R1-2 homodimerized in solution and displayed avid binding profiles on clustered C3b surfaces, particularly FHR1-2^1-5^18-20 Each construct was >10-fold more effective than FH at inhibiting cell surface complement activity in vitro and restricted glomerular basement membrane C3 deposition in vivo significantly better than FH or FH1-5^18-20 FH1-5^18-20^R1-2 had a C3 breakdown fragment binding profile similar to that of FH, a >5-fold increase in serum t1/2 compared with that of FH1-5^18-20, and significantly better retention in the kidney than FH or FH1-5^18-20Conclusions FH1-5^18-20^R1-2 may have utility as a treatment option for C3G or other complement-mediated diseases.

Disease-linked mutations in factor H reveal pivotal role of cofactor activity in self-surface-selective regulation of complement activation

Spontaneous activation enables the complement system to respond very rapidly to diverse threats. This activation is efficiently suppressed by complement factor H (CFH) on self-surfaces but not on foreign surfaces. The surface selectivity of CFH, a soluble protein containing 20 complement-control protein modules (CCPs 1-20), may be compromised by disease-linked mutations. However, which of the several functions of CFH drives this self-surface selectivity remains unknown. To address this, we expressed human CFH mutants in Pichia pastoris We found that recombinant I62-CFH (protective against age-related macular degeneration) and V62-CFH functioned equivalently, matching or outperforming plasma-derived CFH, whereas R53H-CFH, linked to atypical hemolytic uremic syndrome (aHUS), was defective in C3bBb decay-accelerating activity (DAA) and factor I cofactor activity (CA). The aHUS-linked CCP 19 mutant D1119G-CFH had virtually no CA on (self-like) sheep erythrocytes (E_S) but retained DAA. The aHUS-linked CCP 20 mutant S1191L/V1197A-CFH (LA-CFH) had dramatically reduced CA on E_S but was less compromised in DAA. D1119G-CFH and LA-CFH both performed poorly at preventing complement-mediated hemolysis of E_S PspCN, a CFH-binding Streptococcus pneumoniae protein domain, binds CFH tightly and increases accessibility of CCPs 19 and 20. PspCN did not improve the DAA of any CFH variant on E_S Conversely, PspCN boosted the CA, on E_S, of I62-CFH, R53H-CFH, and LA-CFH and also enhanced hemolysis protection by I62-CFH and LA-CFH. We conclude that CCPs 19 and 20 are critical for efficient CA on self-surfaces but less important for DAA. Exposing CCPs 19 and 20 with PspCN and thus enhancing CA on self-surfaces may reverse deficiencies of some CFH variants.

Fibrin Glue Injections: A Minimally Invasive and Cost-Effective Treatment for Post-Renal Transplant Lymphoceles and Lymph Fistulas

Pelvic lymphoceles/lymph fistulas are commonly observed after kidney allotransplantation, especially when the kidney is placed in a retroperitoneal position. While the majority are <5 cm in diameter and resolve without intervention, some may continue to enlarge, and cause local or systemic symptoms or graft dysfunction. Among 1662 recipients of both living and deceased donor kidney transplants between January 2003 and July 2014, we found 46 (2.7%) patients with symptomatic lymphoceles requiring intervention. We studied the clinical outcomes and charges for three treatment modalities including open surgical drainage (22), laparoscopic surgical drainage (11), and percutaneous fibrin glue injections into the drained lymphocele cavity (13). The patient demographics and clinical characteristics were comparable for each treatment group, although maintenance immunosuppressive drugs differed by era. We found fibrin glue injections resulted in significantly lower (p = 0.04) rates of recurrence (1; 7.7%) than either laparoscopic (6; 54%) or open surgical drainage (6; 27.3%). In addition, fibrin glue injections generated significantly (p < 0.001) lower median ($4559) charges compared to either laparoscopic ($26,330) or open surgical drainage ($23,758). Fibrin glue treatment has the advantage of being an outpatient procedure, performed with the patient under local anesthesia, and does not incur the expense of an operative procedure or hospital admission associated with laparoscopic or open surgery.

Complement Evasion Mediated by Enhancement of Captured Factor H: Implications for Protection of Self-Surfaces from Complement

In an attempt to evade annihilation by the vertebrate complement system, many microbes capture factor H (FH), the key soluble complement-regulating protein in human plasma. However, FH is normally an active complement suppressor exclusively on self-surfaces and this selective action of FH is pivotal to self versus non-self discrimination by the complement system. We investigated whether the bacterially captured FH becomes functionally enhanced and, if so, how this is achieved at a structural level. We found, using site-directed and truncation mutagenesis, surface plasmon resonance, nuclear magnetic resonance spectroscopy, and cross-linking and mass spectrometry, that the N-terminal domain of Streptococcus pneumoniae protein PspC (PspCN) not only binds FH extraordinarily tightly but also holds it in a previously uncharacterized conformation. Functional enhancement arises from exposure of a C-terminal cryptic second binding site in FH for C3b, the activation-specific fragment of the pivotal complement component, C3. This conformational change of FH doubles its affinity for C3b and increases 5-fold its ability to accelerate decay of the binary enzyme (C3bBb) responsible for converting C3 to C3b in an amplification loop. Despite not sharing critical FH-binding residues, PspCNs from D39 and Tigr4 S. pneumoniae exhibit similar FH-anchoring and enhancing properties. We propose that these bacterial proteins mimic molecular markers of self-surfaces, providing a compelling hypothesis for how FH prevents complement-mediated injury to host tissue while lacking efficacy on virtually all other surfaces. In hemolysis assays with 2-aminoethylisothiouronium bromide–treated erythrocytes that recapitulate paroxysmal nocturnal hemoglobinuria, PspCN enhanced protection of cells by FH, suggesting a new paradigm for therapeutic complement suppression.

Effects of poor glucose handling on arterial stiffness and left ventricular mass in normal children

AIM

Cardiovascular risk factors can be present in children and young adults. We previously found abnormal microvascular function in children who had glucose intolerance and insulin resistance. The aim of the present study was to investigate whether they also have abnormalities in left ventricular mass (LVM) and arterial stiffness.

METHODS

We measured heart dimensions and LVM using echocardiography, and arterial stiffness using pulse wave analysis in 23 children with good glucose handling (postfeeding glucose: 3.9 to 5 mmol/L) and 21 with poor glucose handling (7.7 to 11.4 mmol/L).

RESULTS

The time to pulse reflection was slightly shorter in the poorer glucose handlers (mean+/-SD: 143+/-10 vs 153+/-20 ms, P=0.04), suggestive of increased arterial stiffness. Also in this group, there were significant relationships between intraventricular septal thickness, blood pressure and body mass index, but not in the normal glucose handlers.

CONCLUSIONS

We have found that normal children who are in the lowest quintile of glucose tolerance in comparison with their peers are exhibiting the first signs of arterial stiffening. In addition, we have seen the beginnings of a relationship between blood pressure, body mass index and left ventricular enlargement in this group. While these changes may not yet be clinically significant, their emergence might be further evidence of early predisposition to cardiovascular disease.

Pinpoint papular variant of polymorphous light eruption: clinical and pathological correlation

BACKGROUND

Polymorphous light eruption (PMLE) is the most common chronic idiopathic photodermatosis usually manifesting as a papular eruption along with several other morphological variants including a pinpoint papular variant.

METHODS AND MATERIALS

Between June 1998 and August 2003, 10 PMLE patients presented to the Department of Dermatology at Henry Ford Hospital with complaints of a pruritic pinpoint papular eruption associated with sun exposure. In six patients skin biopsies were performed along with a detailed history and complete skin examination. We correlated the histology with the clinical course of disease corresponding to acute and subacute disease presentation. We also performed immunohistochemistry on three cases to study the immunophenotype in PMLE.

RESULTS

The clinical, histologic and immunostain findings are summarized. Acute: Clinically pinpoint papules and vesicles, some with erythematous base, were seen. Histology showed focal vesicle formation, spongiosis, oedema, red blood cells extravasation, and superficial and deep perivascular and interstitial lymphocytic infiltrate with occasional eosinophils. Subacute: Clinically pinpoint papules with or without erythema were seen. Histology of the pinpoint lesion showed a nodular collection of lymphocytes and histiocytes with claw-like extension of epidermal rete ridges at the lateral boundaries of the lesion. Overlying epidermal atrophy with adjacent spongiosis, exocytosis, oedema and a superficial perivascular lymphocytic infiltrate and parakeratosis was also observed. The histologic differential diagnosis included lichen nitidus. Immunohistochemical stains revealed the following results: CD8, CD68 positive, CD4 variable (strongly positive to negative) and S-100 negative.

CONCLUSION

(i) Pinpoint papular variant of PMLE is a distinct entity, which shows characteristic histology corresponding to the clinical course of the disease (acute and subacute). (ii) The histologic and immunophenotypic differential diagnosis of this variant during the subacute phase includes lichen nitidus.

Unmet need in osteoporosis

OBJECTIVE

To audit the management of females presenting to Accident and Emergency department with a diagnosis of low impact Colles fracture.

DESIGN

Telephone questionnaire of 50 patients who attended A & E in 1998 with diagnosis of Colles fracture

SETTING

Glasgow Royal Infirmary within North Glasgow catchment area.

SUBJECTS

Women between 45-79 years of age who attended Accident and Emergency Department in 1998 with a diagnosis of low impact Colles fracture.

RESULTS

Mean age was 63 years (range 44-78): ninety percent were post menopausal and 40% of the total group were smokers. Twenty six percent had a positive family history of osteoporosis, 24% had undergone hysterectomy and 88% took no part in any load bearing exercise. Ten percent (n = 5) were on treatment (1 alendronate, 3 etidronate with calcium, 1 hormone replacement therapy)

CONCLUSION

A significant proportion of our study population have multiple risk factors for osteoporosis which are not being addressed. Raising awareness in orthopaedic surgeons, family doctors and patients is urgently required.

Spondyloarthropathy and human immunodeficiency virus infection in Zambia

OBJECTIVE

To explore the relationship between spondyloarthropathy (SpA) and infection with the human immunodeficiency virus (HIV) in black Zambians.

METHODS

Consecutive patients attending an arthritis clinic in a 30 month period were assessed clinically and tested for the presence of antibodies to HIV. HLA-B27 gene was investigated by polymerase chain reaction and T cell subsets were tested in selected subgroups.

RESULTS

Of 595 new attendees, 272 were diagnosed with SpA [130 reactive arthritis (ReA), 128 undifferentiated SpA (uSpA), 13 psoriatic arthritis (PsA), 1 ankylosing spondylitis] and 146 with a reactive type arthritis alone (AA) without preceding clinical trigger infection or SpA features. HIV seroprevalence was 98% in uSpA, 94% PsA, 87% ReA, 64% AA; vs approximately 50% among hospital outpatients and 30% of the adult urban population. Prevalence of SpA is calculated at approximately 180/100,000 in HIV positive and approximately 15/100,000 in HIV negative in the general population. Dysentery was the most common identified trigger. Positive HIV status correlated strongly with SpA features and aggressive sustained disease. At onset 80% of patients were in WHO clinical stage 1 (no disease or lymphadenopathy alone), with a mean CD4+ count of 279/microl. Stage 4 patients had a mean CD4+ count of 60/microl and inactive arthritis. The B27 gene was absent in 30 patients tested.

CONCLUSION

ReA is the most common inflammatory joint disorder in black Zambians and is closely linked to HIV infection and not B27, even though our subjects had clinical and radiological characteristics similar to those reported in HLA-B27 positive Caucasians. The changing epidemiology of SpA in this region has important practical and educational implications.

Women's awareness of, and attitudes towards, hormone replacement therapy: ethnic differences and effects of age and education

To investigate ethnic differences and the effect of age and education on awareness and attitudes of women towards hormone replacement therapy (HRT), we conducted a questionnaire survey of 180 women attending a gynaecology clinic, of whom 152 (84.4%) responded. Seventy-one of the women had heard of HRT. Awareness of HRT was higher in the 50-59 year age group and in women with higher education, but lower in Indo-Asian women than in white and black/Afro-Caribbean women. Friends, relatives and the media were important sources of information (apart from the doctor), especially among the younger age groups. The women themselves ranked their overall understanding of HRT as 'low'; 78% felt they did not know enough about the subject. A distorted perception of benefits/risks associated with HRT was also noted--cardiovascular protection was not appreciated, whereas there was an excessive fear of breast cancer. Twenty-eight per cent of the menopausal, postmenopausal and hysterectomised women surveyed were current HRT users. We conclude that factors such as ethnicity, age and educational level have an impact on women's awareness of and attitudes towards HRT. Some confusion about the real benefits/risks still exists, which probably accounts for low acceptance of this treatment, and suggests that clinicians prescribing HRT need to be aware of these problems.

Nucleotide sequence and molecular analysis of the rhesus cytomegalovirus immediate-early gene and the UL121-117 open reading frames

Cytomegalovirus (CMV) has been isolated from many nonhuman primates, including rhesus macaques (Macaca mulatta). To better understand the molecular biology of rhesus CMV (RhCMV), a 9.2-kb DNA restriction fragment spanning the immediate-early (IE) gene has been molecularly cloned and sequenced. Open reading frames (ORF) have been identified and transcripts mapped for regions corresponding to exons 1, 2, 3, and 4 of the IE1 protein of human CMV (HCMV) and to exons 1, 2, 3, and 5 of IE2. The predicted RhCMV IE1 protein was 29 and 40% identical with the HCMV and African green monkey (AGM) CMV IE1 proteins, respectively, and the predicted RhCMV IE2 protein was 48 and 65% identical with the HCMV and AGM CMV IE2 proteins, respectively. Five additional ORF 3' to the RhCMV IE gene were identified which contained significant homologies with the HCMV UL121-UL117 ORF. The predicted translation products ranged from 29 to 47% identical with, and 52 to 66% similarity to the corresponding ORF of HCMV. Conservation of nucleic and amino acid sequences, and colinearity of genes, between primate CMV genomes contribute to a better understanding of primate CMV evolution, regulation, and pathogenesis.

Advanced breast cancer: a phase II trial with gemcitabine

PURPOSE

In this phase II study, the efficacy and tolerability of gemcitabine were studied in 44 patients with locally advanced or metastatic breast cancer.

PATIENTS AND METHODS

Of 40 patients assessable for response, 14 were chemotherapy-naive, seven had received adjuvant chemotherapy, and 19 had received one prior chemotherapy regimen for metastatic disease. Gemcitabine was administered as a 30-minute intravenous infusion once a week for 3 weeks followed by a 1-week rest every 4 weeks. The mean number of completed cycles administered was 2.7 and the mean dosage delivered was 725 mg/m2 per injection. Eighty-one percent of doses were delivered as scheduled.

RESULTS

There were three complete responses and seven partial responses, for an overall response rate of 25.0% (95% confidence interval [CI], 12.7% to 41.2%). Four patients were not assessable for efficacy (one had insufficient therapy, two had no bidimensionally measurable disease, and one had neither). All responses were independently validated by an external oncology review board. Responses were observed early in treatment, with a median time to response of 1.9 months. The median survival duration for all 40 assessable patients was 11.5 months. Hematologic toxicity was generally mild, with World Health Organization (WHO) grade 3 and 4 leukopenia occurring in 6.8% and 2.3% of patients and neutropenia in 23.3% and 7.0%, of patients, respectively. The only other grade 4 toxicities were infection and nausea and vomiting in one patient each. One patient was withdrawn due to shortness of breath, possibly drug-related. Flu-like symptoms, which were mild, transient, and treatable with acetominophen, were reported in 6.8% of patients. Only one patient developed alopecia of severity greater than WHO grade 2.

CONCLUSION

In view of the single-agent activity seen in advanced breast cancer, modest toxicity profile, and novel mechanism of action, gemcitabine deserves evaluation in breast cancer and is an ideal candidate for combination therapy.

OKT 3 reaction in a renal transplant patient

In this case, the intended patient outcomes were achieved. Nursing was clearly able to take a very proactive role in providing the necessary emergency patient care to prevent further patient compromise. Once the immediate physiologic danger of respiratory decompensation was treated, nursing moved on to intervene in the less-serious complications associated with OKT 3 reaction to assure maximal patient comfort. Finally, patient teaching was done both to assess the learning needs associated with the OKT 3 reaction, as well as to prepare the patient and family for administration of additional doses of OKT 3. These nursing actions resulted in a very favorable outcome for both the patient and family.

Seroepidemiologic studies of cytomegalovirus infection in a breeding population of rhesus macaques

A protein immunoblot (western blot) assay was developed for detection of IgG and IgM antibodies to cytomegalovirus (CMV) in banked serum and was used to study the epidemiology of infection in a breeding population of rhesus macaques. All juveniles and adults were antibody-positive to CMV. Repeated samples from 1990-born infants (n = 28) over a 12-month period allowed retrospective assessment of CMV seroconversion. Most infants (23 of 25 seroconversions) were apparently exposed to CMV during their first year of life. The IgM testing permitted identification of seroconversion time points in eight infants. Risk factors that significantly affected seroconversion probabilities in the study population were not found. Cytomegalovirus-free rhesus macaques are potentially valuable for viral teratology and pathogenesis research projects; however, present epidemiologic findings suggest that establishment of CMV-free colonies will be difficult in conventional settings.

Drug sensitivity of non small cell carcinoma of lung by clonogenic assay in several media

Lung tumours of non small cell pathology were cultured by clonogenic assay in several media. Culture was successful in spleen conditioned medium, but only 57% grew and low plating efficiencies (PE) meant that only 23% of the original number produced significant drug results. Comparison of rat erythrocyte lysate (REL) medium with serum free defined medium (HITES) and HITES + 10% FBS demonstrated clear enhancement of PE in REL although growth was 100% successful in all these media. Ninety-three percent of samples tested against drugs in REL produced significant results. A later comparison of REL with McCoy's 5A + rbc +/- hydrocortisone produced relatively poor culture success for these 3 media and equivocal growth patterns. Low PE was attributed to age of rats used for rbc. Vindesine and cis-platinum cytotoxicity in spleen conditioned medium were 61% and 15% sensitivity respectively. These do not concur with clinical experience but the figures for overt resistance, at 39% and 69%, correspond with expected non-responders to these regimes. Drug testing in REL produced figures correlating more closely with clinical performance at 45% sensitivity to platinum and 36% of patients sensitive to both drugs, but the vindesine sensitivity at 55% is again discrepant with performance of this drug as a single agent.

Urinary infection caused by Micrococcus subgroup 3

The laboratory findings and clinical presentations in urinary infections in 23 nurses, 10 caused by Micrococcus subgroup 3 and 13 by Escherichia coli, were studied, and the symptoms and possible predisposing factors compared. There were no important differences between the two groups. The infections caused by Micrococcus subgroup 3 were symptomatically severe, as were those caused by Escherichia coli.