Macrophages and Their Organ Locations Shape Each Other in Development and Homeostasis - A Drosophila Perspective

Across the animal kingdom, macrophages are known for their functions in innate immunity, but they also play key roles in development and homeostasis. Recent insights from single cell profiling and other approaches in the invertebrate model organism Drosophila melanogaster reveal substantial diversity among Drosophila macrophages (plasmatocytes). Together with vertebrate studies that show genuine expression signatures of macrophages based on their organ microenvironments, it is expected that Drosophila macrophage functional diversity is shaped by their anatomical locations and systemic conditions. In vivo evidence for diverse macrophage functions has already been well established by Drosophila genetics: Drosophila macrophages play key roles in various aspects of development and organogenesis, including embryogenesis and development of the nervous, digestive, and reproductive systems. Macrophages further maintain homeostasis in various organ systems and promote regeneration following organ damage and injury. The interdependence and interplay of tissues and their local macrophage populations in Drosophila have implications for understanding principles of organ development and homeostasis in a wide range of species.

Renal Function: Guardian of Immune Homeostasis

Microbial cell components from the intestinal microbiota spread systemically in a healthy host, posing the threat of inappropriate immune activation. In this issue of Immunity, Troha et al. identify a key role for renal function in the clearance of circulating Lys-type peptidoglycan, revealing a mechanism that keeps these inflammatory triggers in check to maintain systemic immune homeostasis.

Adult Drosophila Lack Hematopoiesis but Rely on a Blood Cell Reservoir at the Respiratory Epithelia to Relay Infection Signals to Surrounding Tissues

The use of adult Drosophila melanogaster as a model for hematopoiesis or organismal immunity has been debated. Addressing this question, we identify an extensive reservoir of blood cells (hemocytes) at the respiratory epithelia (tracheal air sacs) of the thorax and head. Lineage tracing and functional analyses demonstrate that the majority of adult hemocytes are phagocytic macrophages (plasmatocytes) from the embryonic lineage that parallels vertebrate tissue macrophages. Surprisingly, we find no sign of adult hemocyte expansion. Instead, hemocytes play a role in relaying an innate immune response to the blood cell reservoir: through Imd signaling and the Jak/Stat pathway ligand Upd3, hemocytes act as sentinels of bacterial infection, inducing expression of the antimicrobial peptide Drosocin in respiratory epithelia and colocalizing fat body domains. Drosocin expression in turn promotes animal survival after infection. Our work identifies a multi-signal relay of organismal humoral immunity, establishing adult Drosophila as model for inter-organ immunity.

Effects of an epilepsy-specific Internet intervention (Emyna) on depression: Results of the ENCODE randomized controlled trial

OBJECTIVE

Depression and anxiety are highly prevalent among people with epilepsy (PwE) but often remain unrecognized and treated inadequately. Effective psychosocial treatments such as cognitive behavioral therapy (CBT) are rarely available to most PwE, which is one reason electronically delivered CBT (eCBT) is regarded as promising. This study examined an eCBT intervention, termed Emyna, that was tailored to suit the needs of PwE. It includes CBT-related content on depression, stress and anxiety, seizure triggers and auras, and lifestyle habits. The trial examined the efficacy of Emyna in reducing symptoms of depression (primary outcome) and anxiety as well as improving quality of life.

METHODS

Participants (N = 200) with epilepsy, a diagnosis of a depressive disorder, and at least moderate depressive symptoms were randomized to Emyna or care as usual. At baseline and after 3, 6, and 9 months, participants were invited to complete online questionnaires. The primary outcome was improvement of depressive symptoms at 3 months.

RESULTS

Relative to the control group, intervention group participants experienced significantly greater improvements in depression, anxiety, stress, social-occupational impairment, and epilepsy-related quality of life, in both intention-to-treat (ITT) and per-protocol analyses. In ITT analyses, effects of medium magnitude were observed, as measured by the Patient Health Questionnaire-9 items (Cohen d = 0.54, 95% confidence interval [CI] = 0.25-0.82, P < 0.001) and the Neurological Disorders Depression Inventory for Epilepsy (d = 0.51, 95% CI = 0.23-0.79, P < 0.01). At 3 months, intervention group participants also reported fewer illness-related days off work and fewer days hospitalized over the preceding months, compared to control group participants (P ≤ 0.05), whereas no such differences were present at baseline (P > 0.30).

SIGNIFICANCE

These findings showed that Emyna, used adjunctively to usual care, could help improve mental health, social-occupational functioning, and quality of life among PwE. The program provides an additional treatment option that could produce clinically relevant symptom reductions and reduce key cost drivers (ie, hospitalization rates and illness-related inability to work).

Protocol for the ENCODE trial: evaluating a novel online depression intervention for persons with epilepsy

BACKGROUND

Depression is common among persons with epilepsy (PwE), affecting roughly one in three individuals, and its presence is associated with personal suffering, impaired quality of life, and worse prognosis. Despite the availability of effective treatments, depression is often overlooked and treated inadequately in PwE, in part because of assumed concerns over drug interactions or proconvulsant effects of antidepressants. Internet-administered psychological interventions might complement antidepressant medication or psychotherapy, and preliminary evidence suggests that they can be effective. However, no trial has yet examined whether an Internet intervention designed to meet the needs of PwE can achieve sustained reductions in depression and related symptoms, such as anxiety, when offered as adjunct to treatment as usual.

METHODS/DESIGN

This randomized controlled trial will include 200 participants with epilepsy and a current depressive disorder, along with currently at least moderately elevated depression (Patient Health Questionnaire (PHQ-9) sum score of at least 10). Patients will be recruited via epilepsy treatment centers and other sources, including Internet forums, newspaper articles, flyers, posters, and media articles or advertisements, in German-speaking countries. Main inclusion criteria are: self-reported diagnosis of epilepsy and a depressive disorder, as assessed with a phone-administered structured diagnostic interview, none or stable antidepressant medication, no current psychotherapy, no other major psychiatric disorder, no acute suicidality. Participants will be randomly assigned to either (1) a care-as-usual/waitlist (CAU/WL) control group, in which they receive CAU and are given access to the Internet intervention after 3 months (that is, a CAU/WL control group), or (2) a treatment group that may also use CAU and in addition immediately receives six-month access to the novel, Internet-administered intervention. The primary outcome measure is the PHQ-9, collected at three months post-baseline; secondary measures include self-reported anxiety, work and social adjustment, epilepsy symptoms (including seizure frequency and severity), medication adherence, potential negative treatment effects and health-related quality of life. Measurements are collected online at pre-treatment (T0), three months (T1), six months (T2), and nine months (T3).

DISCUSSION

Results of this trial are expected to extend the body of knowledge with regard to effective and efficient treatment options for PwE who experience elevated depression and anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02791724 . Registered 01 June 2016.

Macrophages and cellular immunity in Drosophila melanogaster

The invertebrate Drosophila melanogaster has been a powerful model for understanding blood cell development and immunity. Drosophila is a holometabolous insect, which transitions through a series of life stages from embryo, larva and pupa to adulthood. In spite of this, remarkable parallels exist between Drosophila and vertebrate macrophages, both in terms of development and function. More than 90% of Drosophila blood cells (hemocytes) are macrophages (plasmatocytes), making this highly tractable genetic system attractive for studying a variety of questions in macrophage biology. In vertebrates, recent findings revealed that macrophages have two independent origins: self-renewing macrophages, which reside and proliferate in local microenvironments in a variety of tissues, and macrophages of the monocyte lineage, which derive from hematopoietic stem or progenitor cells. Like vertebrates, Drosophila possesses two macrophage lineages with a conserved dual ontogeny. These parallels allow us to take advantage of the Drosophila model when investigating macrophage lineage specification, maintenance and amplification, and the induction of macrophages and their progenitors by local microenvironments and systemic cues. Beyond macrophage development, Drosophila further serves as a paradigm for understanding the mechanisms underlying macrophage function and cellular immunity in infection, tissue homeostasis and cancer, throughout development and adult life.

Assaying Blood Cell Populations of the Drosophila melanogaster Larva

In vertebrates, hematopoiesis is regulated by inductive microenvironments (niches). Likewise, in the invertebrate model organism Drosophila melanogaster, inductive microenvironments known as larval Hematopoietic Pockets (HPs) have been identified as anatomical sites for the development and regulation of blood cells (hemocytes), in particular of the self-renewing macrophage lineage. HPs are segmentally repeated pockets between the epidermis and muscle layers of the larva, which also comprise sensory neurons of the peripheral nervous system. In the larva, resident (sessile) hemocytes are exposed to anti-apoptotic, adhesive and proliferative cues from these sensory neurons and potentially other components of the HPs, such as the lining muscle and epithelial layers. During normal development, gradual release of resident hemocytes from the HPs fuels the population of circulating hemocytes, which culminates in the release of most of the resident hemocytes at the beginning of metamorphosis. Immune assaults, physical injury or mechanical disturbance trigger the premature release of resident hemocytes into circulation. The switch of larval hemocytes between resident locations and circulation raises the need for a common standard/procedure to selectively isolate and quantify these two populations of blood cells from single Drosophila larvae. Accordingly, this protocol describes an automated method to release and quantify the resident and circulating hemocytes from single larvae. The method facilitates ex vivo approaches, and may be adapted to serve a variety of developmental stages of Drosophila and other invertebrate organisms.

A systems-level interrogation identifies regulators of Drosophila blood cell number and survival

In multicellular organisms, cell number is typically determined by a balance of intracellular signals that positively and negatively regulate cell survival and proliferation. Dissecting these signaling networks facilitates the understanding of normal development and tumorigenesis. Here, we study signaling by the Drosophila PDGF/VEGF Receptor (Pvr) in embryonic blood cells (hemocytes) and in the related cell line Kc as a model for the requirement of PDGF/VEGF receptors in vertebrate cell survival and proliferation. The system allows the investigation of downstream and parallel signaling networks, based on the ability of Pvr to activate Ras/Erk, Akt/TOR, and yet-uncharacterized signaling pathway/s, which redundantly mediate cell survival and contribute to proliferation. Using Kc cells, we performed a genome wide RNAi screen for regulators of cell number in a sensitized, Pvr deficient background. We identified the receptor tyrosine kinase (RTK) Insulin-like receptor (InR) as a major Pvr Enhancer, and the nuclear hormone receptors Ecdysone receptor (EcR) and ultraspiracle (usp), corresponding to mammalian Retinoid X Receptor (RXR), as Pvr Suppressors. In vivo analysis in the Drosophila embryo revealed a previously unrecognized role for EcR to promote apoptotic death of embryonic blood cells, which is balanced with pro-survival signaling by Pvr and InR. Phosphoproteomic analysis demonstrates distinct modes of cell number regulation by EcR and RTK signaling. We define common phosphorylation targets of Pvr and InR that include regulators of cell survival, and unique targets responsible for specialized receptor functions. Interestingly, our analysis reveals that the selection of phosphorylation targets by signaling receptors shows qualitative changes depending on the signaling status of the cell, which may have wide-reaching implications for other cell regulatory systems.

Efficacy of a psychological online intervention for depression in people with epilepsy: a randomized controlled trial

OBJECTIVE

Depression is the most prevalent psychiatric disorder in persons with epilepsy (PWEs). Despite its major impact on quality of life and risk of suicide, most PWEs are not treated for depression. A current challenge in mental health care is how to close this treatment gap and increase access to psychological services. Psychological online interventions (POIs) have shown efficacy in improving depression among individuals without neurologic disorders. This pilot study aimed to assess the feasibility and efficacy of a psychological online intervention for depression (Deprexis) in PWEs who have symptoms of depression.

METHODS

Participants with self-reported epilepsy and subjective complaints of depressive symptoms were randomized to an intervention condition (Deprexis) or to a waiting list control (WLC) condition. After 9 weeks, participants were invited to complete an online reassessment.

RESULTS

Relative to the waiting list group, program users experienced a significant symptom decline on the Beck Depression Inventory - I (BDI-I, primary outcome) with a moderate effect size in the complete observations analysis and a small effect size in the intention-to-treat analysis. Furthermore, there was a significant improvement with a moderate effect size on the "energy/fatigue" subscale of the Quality of Life In Epilepsy Inventory - 31 (QOLIE-31).

SIGNIFICANCE

The results of this trial suggest that POIs may be a feasible and beneficial tool for PWEs who have comorbid depressive symptoms.

Drosophila as a model for the two myeloid blood cell systems in vertebrates

Fish, mice, and humans rely on two coexisting myeloid blood cell systems. One is sustained by hematopoietic progenitor cells, which reside in specialized microenvironments (niches) in hematopoietic organs and give rise to cells of the monocyte lineage. The other system corresponds to the independent lineage of self-renewing tissue macrophages, which colonize organs during embryonic development and are maintained during later life by proliferation in local tissue microenvironments. However, little is known about the nature of these microenvironments and their regulation. Moreover, many vertebrate tissues contain a mix of both tissue-resident and monocyte-derived macrophages, posing a challenge to the study of lineage-specific regulatory mechanisms and function. This review highlights how research in the simple model organism Drosophila melanogaster can address many of these outstanding questions in the field. Drawing parallels between hematopoiesis in Drosophila and vertebrates, we illustrate the evolutionary conservation of the two myeloid systems across animal phyla. Much like vertebrates, Drosophila possesses a lineage of self-renewing tissue-resident macrophages, which we refer to as tissue hemocytes, as well as a "definitive" lineage of macrophages that derive from hematopoiesis in the progenitor-based lymph gland. We summarize key findings from Drosophila hematopoiesis that illustrate how local microenvironments, systemic signals, immune challenges, and nervous inputs regulate adaptive responses of tissue-resident macrophages and progenitor-based hematopoiesis to maximize fitness of the animal.

Arginine Methylation Initiates BMP-Induced Smad Signaling

Kinase activation and substrate phosphorylation commonly form the backbone of signaling cascades. Bone morphogenetic proteins (BMPs), a subclass of TGF-β family ligands, induce activation of their signaling effectors, the Smads, through C-terminal phosphorylation by transmembrane receptor kinases. However, the slow kinetics of Smad activation in response to BMP suggests a preceding step in the initiation of BMP signaling. We now show that arginine methylation, which is known to regulate gene expression, yet also modifies some signaling mediators, initiates BMP-induced Smad signaling. BMP-induced receptor complex formation promotes interaction of the methyltransferase PRMT1 with the inhibitory Smad6, resulting in Smad6 methylation and relocalization at the receptor, leading to activation of effector Smads through phosphorylation. PRMT1 is required for BMP-induced biological responses across species, as evidenced by the role of its ortholog Dart1 in BMP signaling during Drosophila wing development. Activation of signaling by arginine methylation may also apply to other signaling pathways.

Of blood cells and the nervous system: hematopoiesis in the Drosophila larva

Hematopoiesis is well-conserved between Drosophila and vertebrates. Similar as in vertebrates, the sites of hematopoiesis shift during Drosophila development. Blood cells (hemocytes) originate de novo during hematopoietic waves in the embryo and in the Drosophila lymph gland. In contrast, the hematopoietic wave in the larva is based on the colonization of resident hematopoietic sites by differentiated hemocytes that arise in the embryo, much like in vertebrates the colonization of peripheral tissues by primitive macrophages of the yolk sac, or the seeding of fetal liver, spleen and bone marrow by hematopoietic stem and progenitor cells. At the transition to the larval stage, Drosophila embryonic hemocytes retreat to hematopoietic "niches," i.e., segmentally repeated hematopoietic pockets of the larval body wall that are jointly shared with sensory neurons and other cells of the peripheral nervous system (PNS). Hemocytes rely on the PNS for their localization and survival, and are induced to proliferate in these microenvironments, expanding to form the larval hematopoietic system. In this process, differentiated hemocytes from the embryo resume proliferation and self-renew, omitting the need for an undifferentiated prohemocyte progenitor. Larval hematopoiesis is the first Drosophila model for blood cell colonization and niche support by the PNS. It suggests an interface where innocuous or noxious sensory inputs regulate blood cell homeostasis or immune responses. The system adds to the growing concept of nervous system dependence of hematopoietic microenvironments and organ stem cell niches, which is being uncovered across phyla.

Schnurri regulates hemocyte function to promote tissue recovery after DNA damage

Tissue recovery after injury requires coordinated regulation of cell repair and apoptosis, removal of dead cells and regeneration. A critical step in this process is the recruitment of blood cells that mediate local inflammatory and immune responses, promoting tissue recovery. Here we identify a new role for the transcriptional regulator Schnurri (Shn) in the recovery of UV-damaged Drosophila retina. Using an experimental paradigm that allows precise quantification of tissue recovery after a defined dose of UV, we find that Shn activity in the retina is required to limit tissue damage. This function of Shn relies on its transcriptional induction of the PDGF-related growth factor Pvf1, which signals to tissue-associated hemocytes. We show that the Pvf1 receptor PVR acts in hemocytes to induce a macrophage-like morphology and that this is required to limit tissue loss after irradiation. Our results identify a new Shn-regulated paracrine signaling interaction between damaged retinal cells and hemocytes that ensures recovery and homeostasis of the challenged tissue.

The peripheral nervous system supports blood cell homing and survival in the Drosophila larva

Interactions of hematopoietic cells with their microenvironment control blood cell colonization, homing and hematopoiesis. Here, we introduce larval hematopoiesis as the first Drosophila model for hematopoietic colonization and the role of the peripheral nervous system (PNS) as a microenvironment in hematopoiesis. The Drosophila larval hematopoietic system is founded by differentiated hemocytes of the embryo, which colonize segmentally repeated epidermal-muscular pockets and proliferate in these locations. Importantly, we show that these resident hemocytes tightly colocalize with peripheral neurons and we demonstrate that larval hemocytes depend on the PNS as an attractive and trophic microenvironment. atonal (ato) mutant or genetically ablated larvae, which are deficient for subsets of peripheral neurons, show a progressive apoptotic decline in hemocytes and an incomplete resident hemocyte pattern, whereas supernumerary peripheral neurons induced by ectopic expression of the proneural gene scute (sc) misdirect hemocytes to these ectopic locations. This PNS-hematopoietic connection in Drosophila parallels the emerging role of the PNS in hematopoiesis and immune functions in vertebrates, and provides the basis for the systematic genetic dissection of the PNS-hematopoietic axis in the future.

[Subluxation of hydrophilic acrylate intraocular lenses due to massive capsular fibrosis]

BACKGROUND

Compared with other biomaterials, hydrophilic acrylate provides better uveal biocompatibility, lower adhesion rates of bacteria and silicone oil, and less glare. Because of reduced capsular biocompatibility, increased fibrosis may initiate dislocation of the intraocular lens (IOL).

PATIENTS

In six eyes of four patients, enhanced fibroses led to IOL dislocation, leading to an IOL exchange an average of 40 weeks after implantation of the same hydrophilic acrylate lens type.

DISCUSSION

Predisposing factors were found in 90% of all reported cases of IOL dislocation in the literature, but not in the cases described here. The lens type that was implanted was unable to adapt to the massive fibrosis induced by its hydrophilic biomaterial.

CONCLUSIONS

The pattern of lens opacification should receive attention when one is choosing an IOL type. Eyes showing pseudoexfoliation syndrome as well as post-uveitis eyes might require a hydrophilic IOL for less cellular reaction, whereas a posterior subcapsular cataract might need a hydrophobic IOL to prevent a massive capsular fibrosis. In the case of increased capsular contraction, unreflected YAG laser capsulotomy may result in IOL subluxation when the lens design cannot handle capsule shrinkage, as demonstrated here.

Dynamic switch of negative feedback regulation in Drosophila Akt-TOR signaling

Akt represents a nodal point between the Insulin receptor and TOR signaling, and its activation by phosphorylation controls cell proliferation, cell size, and metabolism. The activity of Akt must be carefully balanced, as increased Akt signaling is frequently associated with cancer and as insufficient Akt signaling is linked to metabolic disease and diabetes mellitus. Using a genome-wide RNAi screen in Drosophila cells in culture, and in vivo analyses in the third instar wing imaginal disc, we studied the regulatory circuitries that define dAkt activation. We provide evidence that negative feedback regulation of dAkt occurs during normal Drosophila development in vivo. Whereas in cell culture dAkt is regulated by S6 Kinase (S6K)–dependent negative feedback, this feedback inhibition only plays a minor role in vivo. In contrast, dAkt activation under wild-type conditions is defined by feedback inhibition that depends on TOR Complex 1 (TORC1), but is S6K–independent. This feedback inhibition is switched from TORC1 to S6K only in the context of enhanced TORC1 activity, as triggered by mutations in tsc2. These results illustrate how the Akt–TOR pathway dynamically adapts the routing of negative feedback in response to the activity load of its signaling circuit in vivo.

The development of multi-cellular organisms depends on the precise choreography of a diverse array of signal transduction pathways. This requires balanced regulation by activating as well as repressing signals. Negative feedback, defined as a signaling response counteracting the stimulus, is a frequently used mechanism to dampen signaling pathway activity. Accordingly, loss of negative feedback is often observed during progression of cancer, while constitutive engagement of negative feedback contributes to chronic loss-of-function phenotypes. Ectopic activation of the Akt–TOR pathway is frequently associated with tumor susceptibility and cancer and contributes to obesity-induced metabolic disease and type II diabetes. Using Drosophila cell culture and the developing fly, we dissect the regulatory circuitry defining negative feedback regulation of dAkt. Our work shows that dAkt activity is regulated by two qualitatively different negative feedback mechanisms and that the activity level of the dAkt pathway dictates which feedback mechanism is utilized. Under normal physiological activity conditions, we observe a feedback mechanism that is dependent on TOR complex 1, but independent of S6K. Under conditions of pathological high pathway activity, we observe an S6K–dependent negative feedback mechanism. Our identification of a quantitative-to-qualitative switch in dAkt–TOR negative feedback signaling might have important implications in the biology of cancer and metabolic diseases.

[Femtosecond laser ablation and scanning microscopy of the internal retinal limiting membrane: an experimental study]

The investigation was undertaken to study whether femtosecond laser ablation and microscopy might be used in the internal retinal borderline membrane. Ablation of internal limiting membrane preparations removed using or not using indocyanine green was made by a low-energy femtosecond laser. Examination of the preparations by laser and electron microscopy revealed precision laser cuts of the internal retinal borderline membrane. The use of indocyanine green during laser ablation reduced laser irradiation parameters as compared to the dye not being applied. Low-energy femtosecond lasers enable precision contactless ablation of the internal borderline membrane to be carried out without collateral damage to the adjacent tissue. The parameters of laser impulses, particularly low ones used in the ablation of indocyanine green-stained preparations, prove the photosensitizing effect of the dye.

[How does the German DRG system differentiate and reimburse vitreoretinal surgery in diabetic patients?]

INTRODUCTION

The German DRG system (G-DRG system) is required to assign medical cases with similar costs correctly into a particular group, each case within the group receiving the same amount of reimbursement. At the same time the system should allow all-inclusive reimbursement, not necessarily reflecting the exact costs of each case. These opposite goals and the so far limited calculation basis raise the question of how the G-DRG system actually processes and reimburses empirically collected in-hospital treatment data.

PATIENTS AND METHODS

In 2005, 112 patients were admitted to the University Eye Hospital, University of the Saarland. All patients had diabetic retinopathy and required at least one vitreoretinal procedure. Demographic and clinical data were collected by using the hospital information system and the coding software KODIP. For statistic evaluation, principal diagnoses, ancillary diagnoses and procedures were each reassigned to particular groups. Reimbursement was calculated based on the case data of the year 2005. Also, the case data were reassigned with respect to calculation of reimbursement for the years 2006 and 2007. The results were compared with federal G-DRG calculation data.

RESULTS

Mean age of the patients was 65.8 +/- 11.1 years, length of stay in-hospital was 9.3 +/- 3.2 days. In the 66 patients requiring general anaesthesia the cumulative length of stay in the operation room was 148.4 +/- 39.5 minutes, the cumulative duration of surgery was 86.3 +/- 34.1 minutes. In the 50 patients requiring local anaesthesia the cumulative length of stay in the operation room was 137.8 +/- 51.8 minutes, the cumulative duration of surgery was 81.6 +/- 43.6 minutes. The patients had 1.9 +/- 0.8 principal diagnoses, 14.4 +/- 5.8 ancillary diagnoses and 3.4 +/- 1.6 procedures. Twenty-five of 112 patients (22.3 %) were assigned to DRG C 03Z (1), 82 of 112 patients (73.2 %) were assigned to DRG C 17Z (2). Five patients were assigned to other DRG. Compared with the federal calculation data, our own data for 2005, 2006 and 2007 showed more high primary clinical complexity levels and a longer duration of in-hospital stay. For each of the three years the amount of reimbursement was equal in about two thirds of the own patients. Reimbursement was only differentiated for outliers beyond the trim point of the duration of in-hospital stay.

CONCLUSIONS

The demographic and clinical G-DRG data of the included patients showed substantial cost-effective inhomogeneities. These inhomogeneities were not sufficiently considered for reimbursement based upon Z-DRG. Specialised departments with higher numbers of difficult cases may be discriminated. Wrong incentives may result in the selection of "low-risk cases".

[Choroidal effusion after uncomplicated cataract surgery]

BACKGROUND

Intake of ACE inhibitors may promote angioedema which can appear months and years after the medication has been stopped. Surgery and local anaesthesia can further aggravate angioedema. A 61-year-old patient with age-related cataract was admitted to our hospital for elective out-patient cataract surgery. A few days after surgery, the patient complained of pain and reduced vision in the operated eye.

RESULTS

Postoperative findings were elevated intraocular pressure (28 mmHg) and a significant reduction of vision. The anterior chamber was shallow. Ophthalmoscopy showed a circumferential choroidal and focal exudative retinal detachment. Local and systemic therapy with antiglaucomatous medications as well as steroids (methylprednisolone) and antibiotics (ciprofloxacin) resulted in control of the eye pressure and an increase of vision. After two weeks, the choroidal detachment disappeared. Important preexisting diseases included a minimal change glomerulonephritis under treatment with low doses of cortisone (4 mg), as well as arterial hypertension. An ACE inhibitor (ramipril) was taken.

CONCLUSIONS

ACE inhibitor intake might be associated with choroidal effusion. A preoperative change to another antihypertensive medication should be considered in patients with a tendency to develop angioedema. A glomerulonephritis might also support edema. Patients with such edema should undergo diagnostic evaluation and receive treatment before cataract surgery.

Lung function in adults with cystic fibrosis at altitude: impact on air travel

Current guidelines for air travel state that patients with chronic respiratory diseases are required to use oxygen if their in-flight arterial oxygen tensions (Pa,O2) drop below 6.6 kPa. This recommendation may not be strictly applicable to cystic fibrosis patients, who may tolerate lower Pa,O2 for several hours without clinical symptoms. Lung function, symptoms, blood gas levels and signs of pulmonary hypertension were studied in 36 cystic fibrosis patients at altitudes of 530 m and, after 7 h, 2,650 m. A hypoxia inhalation test (inspiratory oxygen fraction 0.15) was performed at low altitude in order to predict high-altitude hypoxaemia. Median Pa,O2 dropped from 9.8 kPa at low altitude to 7.0 kPa at high altitude. Mild exercise at a workload of 30 W further decreased Pa,O2. Two-thirds of all patients exhibited Pa,O2 of <6.6 kPa during exercise and, except for one patient, were asymptomatic. Patients were significantly less obstructed at an altitude of 2,650 m. Low forced expiratory volume in one second at baseline was associated with a low Pa,O2 at altitude. It is concluded that cystic fibrosis patients with baseline arterial oxygen tensions of >8.0 kPa safely tolerate an altitude of 2,650 m for several hours under resting conditions. The risk assessment of low in-flight oxygenation should encompass the whole clinical situation of cystic fibrosis patients, with special attention being paid to the presence of severe airway obstruction.

The PDGF/VEGF Receptor Controls Blood Cell Survival in Drosophila

The Drosophila PDGF/VEGF receptor (PVR) has known functions in the guidance of cell migration. We now demonstrate that during embryonic hematopoiesis, PVR has a role in the control of antiapoptotic cell survival. In Pvr mutants, a large fraction of the embryonic hemocyte population undergoes apoptosis, and the remaining blood cells cannibalistically phagocytose their dying peers. Consequently, total hemocyte numbers drop dramatically during embryogenesis, and large aggregates of engorged macrophages carrying multiple apoptotic corpses form. Hemocyte-specific expression of the pan-caspase inhibitor p35 in Pvr mutants eliminates hemocyte aggregates and restores blood cell counts and morphology. Additional rescue experiments suggest involvement of the Ras pathway in PVR-mediated blood cell survival. In cell culture, we demonstrate that PVR directly controls survival of a hemocyte cell line. This function of PVR shows striking conservation with mammalian hematopoiesis and establishes Drosophila as a model to study hematopoietic cell survival in development and disease.

The collagen receptor DDR2 regulates proliferation and its elimination leads to dwarfism

The discoidin domain receptor 2 (DDR2) is a member of a subfamily of receptor tyrosine kinases whose ligands are fibrillar collagens, and is widely expressed in postnatal tissues. We have generated DDR2-deficient mice to establish the in vivo functions of this receptor, which have remained obscure. These mice exhibit dwarfism and shortening of long bones. This phenotype appears to be caused by reduced chondrocyte proliferation, rather than aberrant differentiation or function. In a skin wound healing model, DDR2-/- mice exhibit a reduced proliferative response compared with wild-type littermates. In vitro, fibroblasts derived from DDR2-/- mutants proliferate more slowly than wild-type fibroblasts, a defect that is rescued by introduction of wild-type but not kinase-dead DDR2 receptor. Together our results suggest that DDR2 acts as an extracellular matrix sensor to modulate cell proliferation.

Glycosyltransferase activity of Fringe modulates Notch-Delta interactions

Ligands that are capable of activating Notch family receptors are broadly expressed in animal development, but their activity is tightly regulated to allow formation of tissue boundaries. Members of the fringe gene family have been implicated in limiting Notch activation during boundary formation, but the mechanism of Fringe function has not been determined. Here we present evidence that Fringe acts in the Golgi as a glycosyltransferase enzyme that modifies the epidermal growth factor (EGF) modules of Notch and alters the ability of Notch to bind its ligand Delta. Fringe catalyses the addition of N-acetylglucosamine to fucose, which is consistent with a role in the elongation of O-linked fucose O-glycosylation that is associated with EGF repeats. We suggest that cell-type-specific modification of glycosylation may provide a general mechanism to regulate ligand-receptor interactions in vivo.

EphrinB ligands recruit GRIP family PDZ adaptor proteins into raft membrane microdomains

Transmembrane ephrinB proteins have important functions during embryonic patterning as ligands for Eph receptor tyrosine kinases and presumably as signal-transducing receptor-like molecules. Consistent with "reverse" signaling, ephrinB1 is localized in sphingo-lipid/cholesterol-enriched raft microdomains, platforms for the localized concentration and activation of signaling molecules. Glutamate receptor-interacting protein (GRIP) and a highly related protein, which we have termed GRIP2, are recruited into these rafts through association with the C-terminal PDZ target site of ephrinB1. Stimulation of ephrinB1 with soluble EphB2 receptor ectodomain causes the formation of large raft patches that also contain GRIP proteins. Moreover, a GRIP-associated serine/threonine kinase activity is recruited into ephrinB1-GRIP complexes. Our findings suggest that GRIP proteins provide a scaffold for the assembly of a multiprotein signaling complex downstream of ephrinB ligands.

Signaling by Eph receptors and their ephrin ligands

What are the mechanisms by which Eph receptor tyrosine kinases guide axons and migrating cells? Recent results show that Eph receptors bind some of the well-known effector molecules that are implicated in the organization of the actin cytoskeleton; moreover, biochemical and genetic evidence suggests a signaling role for transmembrane ephrin ligands in axon pathfinding.

Tyrosine phosphorylation of transmembrane ligands for Eph receptors

Axonal pathfinding in the nervous system is mediated in part by cell-to-cell signaling events involving members of the Eph receptor tyrosine kinase (RTK) family and their membrane-bound ligands. Genetic evidence suggests that transmembrane ligands may transduce signals in the developing embryo. The cytoplasmic domain of the transmembrane ligand Lerk2 became phosphorylated on tyrosine residues after contact with the Nuk/Cek5 receptor ectodomain, which suggests that Lerk2 has receptorlike intrinsic signaling potential. Moreover, Lerk2 is an in vivo substrate for the platelet-derived growth factor receptor, which suggests crosstalk between Lerk2 signaling and signaling cascades activated by tyrosine kinases. It is proposed that transmembrane ligands of Eph receptors act not only as conventional RTK ligands but also as receptorlike signaling molecules.

Similarities and differences in the way transmembrane-type ligands interact with the Elk subclass of Eph receptors

The Eph family of receptor tyrosine kinases and their cell surface bound ligands have been implicated in a number of developmental processes, including axon pathfinding and fasciculation, as well as patterning in the central nervous system. To better understand the complex signaling events taking place, we have undertaken a comparative analysis of ligand-receptor interactions between a subset of ligands, those that are tethered to the cell surface via a transmembrane domain, and a subset of Eph receptors, the so-called Elk subclass. Based on binding characteristics, receptor autophosphorylation, and cellular transformation assays, we find that the transmembrane-type ligands Lerk2 and Elf2 have common and specific receptors within the Elk subclass of receptors. The common receptors Cek10 and Elk bind and signal in response to Lerk2 and Elf2, whereas the Myk1 receptor is specific for Elf2. Elf2, however, fails to signal through Cek5 in a cellular transformation assay, suggesting that Lerk2 may be the preferred Cek5 ligand in vivo. A recently identified third transmembrane-type ligand, Elf3, specifically, but weakly, binds Cek10 and only induces focus formation when activated by C-terminal truncation. This suggests that the physiological Elf3 receptor may have yet to be identified. Knowledge regarding functional ligand-receptor interactions as presented in this study will be important for the design and interpretation of in vivo experiments, e.g., loss-of-function studies in transgenic mice.