Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Biological and Clinical Factors contributing to the Metabolic Heterogeneity of Hospitalized Patients with and without COVID-19

The Corona Virus Disease 2019 (COVID-19) pandemic represents an ongoing worldwide challenge. Exploratory studies evaluating the impact of COVID-19 infection on the plasma metabolome have been performed, often with small numbers of patients, and with or without relevant control data; however, determining the impact of biological and clinical variables remains critical to understanding potential markers of disease severity and progression. The present large study, including relevant controls, sought to understand independent and overlapping metabolic features of samples from acutely ill patients (n = 831), testing positive (n = 543) or negative (n = 288) for COVID-19. High-throughput metabolomics analyses were complemented with antigen and enzymatic activity assays on 831 plasma samples from acutely ill patients while in the emergency department, at admission, and during hospitalization. We then performed additional lipidomics analyses of the 60 subjects with the lowest and highest body mass index, either COVID-19 positive or negative. Omics data were correlated to detailed data on patient characteristics and clinical laboratory assays measuring coagulation, hematology and chemistry analytes. Significant changes in arginine/proline/citrulline, tryptophan/indole/kynurenine, fatty acid and acyl-carnitine metabolism emerged as highly relevant markers of disease severity, progression and prognosis as a function of biological and clinical variables in these patients. Further, machine learning models were trained by entering all metabolomics and clinical data from half of the COVID-19 patient cohort and then tested on the other half yielding ~ 78% prediction accuracy. Finally, the extensive amount of information accumulated in this large, prospective, observational study provides a foundation for follow-up mechanistic studies and data sharing opportunities, which will advance our understanding of the characteristics of the plasma metabolism in COVID-19 and other acute critical illnesses.

The novel Mechanical Ventilator Milano for the COVID-19 pandemic

This paper presents the Mechanical Ventilator Milano (MVM), a novel intensive therapy mechanical ventilator designed for rapid, large-scale, low-cost production for the COVID-19 pandemic. Free of moving mechanical parts and requiring only a source of compressed oxygen and medical air to operate, the MVM is designed to support the long-term invasive ventilation often required for COVID-19 patients and operates in pressure-regulated ventilation modes, which minimize the risk of furthering lung trauma. The MVM was extensively tested against ISO standards in the laboratory using a breathing simulator, with good agreement between input and measured breathing parameters and performing correctly in response to fault conditions and stability tests. The MVM has obtained Emergency Use Authorization by U.S. Food and Drug Administration (FDA) for use in healthcare settings during the COVID-19 pandemic and Health Canada Medical Device Authorization for Importation or Sale, under Interim Order for Use in Relation to COVID-19. Following these certifications, mass production is ongoing and distribution is under way in several countries. The MVM was designed, tested, prepared for certification, and mass produced in the space of a few months by a unique collaboration of respiratory healthcare professionals and experimental physicists, working with industrial partners, and is an excellent ventilator candidate for this pandemic anywhere in the world.

Peripheral Tolerance Regulates RBC-specific CD4+ T Cells in a Novel Mouse

T cell tolerance mechanisms towards tissue-restricted antigens are well described and include deletion, anergy, or regulatory cells; however tolerance mechanisms against RBC-restricted antigens are poorly understood. Herein, we utilized the HOD mouse to investigate T cell tolerance to RBC-specific antigens. The HOD mouse expresses a fusion protein consisting of hen egg lysosyme (HEL), ovalbumin (OVA), and human blood group, Duffy driven by an RBC-specific promoter. The HOD mouse was crossed to TCR transgenic OTII mouse to generate HOD mice with autoreactive CD4+ T cells (OTII+HOD+). Young OTII+HOD+ mice do not have detectable autoantibodies, suggesting immune tolerance. Analysis of thymii 8 week-old mice revealed similar numbers of OTII CD4+ SP thymocytes between OTII+HOD+ and OTII+HOD−, suggesting that central tolerance plays little role in RBC specific CD4+ T cells. However, in the periphery, several tolerance mechanisms were identified in OTII+HOD+ mice. Autoreactive splenic CD4+ T cells in OTII+HOD+ mice underwent deletion, expressed higher levels of inhibitory markers PD-1, LAG3, CD5, and had higher numbers of CD25+Foxp3+ regulatory T cells, when compared to OTII+HOD−. Furthermore, CD4+ T cells from OTII+HOD+ had significantly reduced proliferation in response to cognate antigen, suggesting anergy or functional inactivation. Analysis of antigen presenting cells in OTII+HOD+ revealed higher frequencies of myeloid DC, known to express high levels of MHC II and propensity to activate CD4+ T cells. Finally, a break in tolerance was observed in 30% of OTII+HOD+ at 6 months, as indicated by anti-HOD antibodies. Future studies will focus on identifying defective tolerance mechanism that contributed to autoantibody genesis.

Effects of a long-acting GLP-1 mimetic (PF-04603629) on pulse rate and diastolic blood pressure in patients with type 2 diabetes mellitus

PF-04603629, an exendin-transferrin fusion protein, is a long-acting glucagon-like peptide-1 (GLP-1) mimetic. This randomized, double-blind study characterized the safety and pharmacodynamics of a single dose of PF-04603629 (n = 57; 1-70 mg) or placebo (n = 14) in subjects with type 2 diabetes mellitus (T2DM). There were dose-dependent decreases from baseline in day 6 glucose area under the curve following a mixed meal test (-27 ± 12% with 70 mg). Most treatment-related adverse events were gastrointestinal, with nausea and vomiting most frequent at 70 mg. Pulse rate (PR) and diastolic blood pressure (DBP) increased dose dependently within the normal range. At 24 h postdose mean PR increased 23 ± 9 bpm and mean DBP increased 10 ± 5 mmHg with 70 mg. In conclusion, PF-04603629 exhibited efficacy and tolerability consistent with its mechanism of action; however, PR and DBP increased. Similar effects have been reported occasionally with other GLP-1 mimetics. These data underscore the importance of careful assessments of haemodynamic effects in GLP-1 analogues.

Genetic divergence in morphology-performance mapping between Misty Lake and inlet stickleback

Different environments should select for different aspects of organismal performance, which should lead to correlated divergence in morphological traits that influence performance. The result should be genetic divergence in aspects of performance, morphology and associations ('maps') between morphology and performance. Testing this hypothesis requires quantifying performance and morphology in multiple populations after controlling for environmental differences, but this is rarely attempted. We used a common-garden experiment to examine morphology and several aspects of swimming performance within and between the lake and inlet populations of threespine stickleback (Gasterosteus aculeatus) from the Misty system, Vancouver Island, Canada. Controlling for body size, lake stickleback had shallower bodies, larger caudal fins and smaller pelvic girdles. With or without morphological covariates, lake stickleback showed greater performance in both sustained and burst swimming. In contrast, inlet stickleback showed greater manoeuverability than did lake stickleback in some analyses. Morphology-performance relationships were decoupled when considering variation within vs. between populations. Moreover, morphology-performance mapping differed between the two populations. Based on these observations, we advance a hypothesis for why populations adapting to different environments should show adaptive genetic divergence in morphology-performance mapping.

Developing the blueprint for a genetic testing registry

While the number of genetic tests continues to grow, publicly accessible information about the analytic and clinical validity of such tests is lagging. Information gaps impede informed decision making by health care providers and patients. Enhancing the transparency of information about what tests are being offered, for which indications tests are being offered, and the analytic and clinical validity of tests is a key prerequisite to ensuring test quality. A recent government recommendation for a mandatory genetic test registry has received wide stakeholder support but leaves many practical questions unanswered. We propose a 'blueprint' for the creation of a genetic test registry in order to expedite its implementation. We describe the goals of a registry, propose criteria for the inclusion of registrants and tests in the registry, and define the categories of information that should be included for such tests. We discuss the sources of legal authority that empower the government to mandate that a registry be established and identify the federal agencies with the relevant expertise and resources to do so. We conclude that establishing a registry is a critical first step in the development of a more transparent, quality-centered system of oversight that will better inform and protect the public.

E-Learning for Health-Care Workforce Development

Objectives To summarize advances in informatics that contribute to scaling-up the health care workforce.

Method A review of projects and methods in information and communication technologies (ICT) that are having an impact on educating frontline health care workers.

Results and conclusionse-learning is providing innovative approaches for health workforce development, especially in underserved areas.

E-learning for health-care workforce development

OBJECTIVES

To summarize advances in informatics that contribute to scaling-up the health care workforce.

METHOD

A review of projects and methods in information and communication technologies (ICT) that are having an impact on educating frontline health care workers.

RESULTS AND CONCLUSIONS

e-learning is providing innovative approaches for health workforce development, especially in underserved areas.

Expression of PD1 Differs on T Cells from a Pathogenic Versus Nonpathogenic Primate Models of AIDS (43.50)

In most chronic infections antigen specific memory T cells experience a progressive immune exhaustion. Recent reports of HIV infection demonstrate increased expression of PD1 on exhausted T cells correlating with viral loads, and in vitro restoration of function by blockade of PD1 interactions with its ligands. We characterized PD1 in a rhesus macaque model of SIV infection where AIDS develops versus an asymptomatic natural host, sooty mangabeys. Infected animals of both species showed an increase in frequency of total PD1+ CD4+ cells, but not CD8+, which correlated with viral loads in macaques, but not in mangabeys. Furthermore this increase was noted in naïve mangabey CD4+ cells, but central memory macaque CD4+ cells. In macaques, antigen specific CD8+ T cells had increased PD1 expression (MFI) that was reduced with antiviral therapy. While the blockade of PD1-PDL1 interactions in vitro enhanced overall SIV antigen specific responses, individual responses to specific peptides were found enhanced, unchanged or even diminished. These data support a potential for role PD1 in the phenomena of “immune exhaustion” and a rationale for its study using monkey models of AIDS.

Constitutive Cdc25B tyrosine phosphatase activity in adult brain neurons with M phase-type alterations in Alzheimer's disease

The Cdc2/cyclin B kinase is a critical regulator of mitosis that is normally absent from terminally differentiated neurons of adult brain. However, unscheduled expression and activation of Cdc2/cyclin B has been seen in neurons undergoing degeneration in Alzheimer's disease. The presence of this mitotic kinase correlates with accumulation of mitotic phosphoepitopes in protein components of the hallmark neurofibrillary tangles. Of importance to the pathogenic mechanism of Alzheimer's disease is the striking appearance of Cdc2/cyclin B and mitotic phosphoepitopes prior to neurofibrillary tangle formation, which has suggested that a misappropriate mitotic cascade initiates and mediates the neurodegenerative process. To explain the atypical activation of Cdc2/cyclin B in degenerating neurons we have investigated the enzyme responsible for Cdc2/cyclin B activation in mitotic cells, i.e. the Cdc25B tyrosine phosphatase, in Alzheimer's disease brain. Although the enzyme appeared abundant in affected neurons, it was also evident in unaffected neurons of Alzheimer's disease and control brain. Thus, we have found, surprisingly, that Cdc25B is a normal constituent of adult brain neurons, with detectable basal levels of activity. In Alzheimer's disease the levels and activity of the enzyme are elevated, and the active enzyme predominates in the cytoplasmic compartment of neurons. Consistent with these M phase-type changes, Cdc25B displays increased immunoreactivity towards the MPM-2 mitotic phosphoepitope antibody. We propose that aberrant expression of Cdc2/cyclin B in Alzheimer's disease leads to potentiation of mitotic activation mediated by constitutive neuronal Cdc25B activity. As a result, various downstream indices of mitotic events are generated, eventually culminating in neurodegeneration. Our data also suggest that Cdc25B is functional in normal post-mitotic neurons lacking the mitotic Cdc2/cyclin B, but it does not appear to influence the activity of Cdk5, a Cdc2-like kinase that is particularly enriched in brain.

Synergistic effects of glycoprotein 130 binding cytokines in combination with interleukin-1 on cartilage collagen breakdown

OBJECTIVE

To determine whether other glycoprotein 130 (gp130) binding cytokines can mimic the effects of oncostatin M (OSM) in acting synergistically with interleukin-1alpha (IL-1alpha) to induce cartilage collagen breakdown and collagenase expression, and to determine which receptors mediate these effects.

METHODS

The release of collagen and proteoglycan was assessed in bovine and human cartilage explant cultures. Messenger RNA (mRNA) and protein production from immortalized human chondrocytes (T/C28a4) was analyzed by Northern blotting and specific enzyme-linked immunosorbent assays. Collagenase activity was measured by bioassay. Cell surface receptors were detected by flow cytometry.

RESULTS

OSM in combination with IL-1alpha caused a rapid synergistic induction of matrix metalloproteinase 1 mRNA, which was sustained over a 72-hour period. Flow cytometric analyses detected both the OSM-specific receptor and the gp130 receptor at the chondrocyte cell surface, but failed to detect the leukemia inhibitory factor receptor (LIFR). Cartilage degradation assays revealed that, of the gp130 binding cytokines, only OSM and IL-6, in the presence of its soluble receptor (sIL-6R), were able to act synergistically with IL-1alpha to promote collagen release.

CONCLUSION

This study demonstrates that IL-6 can mimic OSM in synergizing with IL-1alpha to induce chondrocyte-mediated cartilage collagen breakdown and collagenase production. In order to have this effect, IL-6 requires the presence of its soluble receptor. The apparent absence of LIFR explains why other gp130 binding cytokines do not act in synergy with IL-1alpha. Since OSM, IL-6, and sIL-6R levels have all been shown to be elevated in the rheumatoid joint, our findings suggest that these cytokines may be key mediators of cartilage collagen catabolism in the inflammatory arthritides.

Measuring quality of care with an inpatient elderly population. The geriatric resource nurse model

Nurses provide health services to an increasing number of older adults in acute care settings. Acute care nurses are committed to giving patients the highest quality care while recognizing the importance of delivering care in a cost-effective manner. In this study, a unit-based, nurse-centered geriatric program is evaluated. The program is designed to enhance the knowledge and skill of staff nurses in providing care to elderly patients. Both quantitative and qualitative methods are used to assess geriatric resource nurses' (GRNs) influence on quality and cost outcomes of the elderly participants. Patients age 65 years and older were randomly selected from two general medical units of a major academic tertiary care center in the southeastern United States. Data were collected during an 18-month period in 1996 and 1997. A total of 129 participants provided data for quantitative analysis. A subset of 34 participants (17 from the unit where GRNs were on staff and 17 from a control unit) was interviewed about their experience during hospitalization. This information was analyzed for common themes and trends using appropriate qualitative techniques. Demographic variables and common measures of illness severity and complexity showed comparable patient populations on the two units. However, results of quantitative analyses indicated significant differences between groups on admission for several of the health status measures. Participants on the unit without GRNs were found to have more problems with pain, incontinence, and mobility. Administrative measures showed the number of patients readmitted to the hospital within 31 days of discharge and the length of stay associated with this initial readmission were significantly lower on the unit with GRNs. The use of vest-type physical restraints was also less frequent on this unit. Elderly patients in both groups indicated they have special needs related to normal aging changes and chronic illnesses, resulting in higher levels of fragility and decreased energy reserves. They identified specific functional areas for which help was needed. These include assistance with bathing, eating, sleeping, mobility, and elimination. Fewer participants on the intervention unit reported decline in activities of daily living (ADL) function during hospitalization than did control participants. Participants in both groups stressed the importance of nurses' demonstrating understanding and caring when working with older individuals.

Multiple roles of the Dcdc42 GTPase during wing development in Drosophila melanogaster

The Rho sub-family of GTPases, comprising Rho, Rac and Cdc42. regulates many biological processes, including morphogenesis, cell polarity, migration, the cell cycle and gene expression. It is important to develop genetic approaches to allow the dissection, in vivo, of the mechanisms of GTPase regulation and signal transmission, and their biological consequences. In this regard, wing development in Drosophila melanogaster is an excellent model system. To investigate the functions of the Drosophila Cdc42 GTPase (Dcdc42), we generated phenotypes during wing development, by expression of the dominant-negative N17 and L89 mutants of Dcdc42. We have identified roles for Dcdc42 in wing growth, and in cell fate choice during the development of the wing veins and the peripheral nervous system. Reduction of Dcdc42 signalling following over-expression of Dcdc42N17 resulted in a broader but more diffuse domain characterised by wing-margin sensory bristles. This was correlated with a broadened stripe of wingless expression along the dorsal-ventral boundary of third-instar wing imaginal discs. Together with genetic interactions with loss- and gain-of-function Notch alleles, these data support a role for wild-type Dcdc42 as a negative regulator of Notch signalling.

The mitotic spindle and DNA damage-induced apoptosis

EM9 Chinese hamster ovary cells cannot rejoin DNA strand breaks induced by alkylating agents. Ethyl methanesulphonate (EMS)-treated EM9cells underwent G2 arrest for a prolonged period followed by entry into mitosis and apoptosis. EM9 cells treated with EMS in G1 entered mitosis 24-36 h after release from synchrony, approximately 12 h after untreated control cells, but the mitoses were morphologically abnormal. The spindle-poison nocodazole reduced apoptosis by greater than 60%, and allowed some cells to complete a second round of DNA replication. We conclude that the assembly of a mitotic spindle, or progression beyond the mitotic checkpoint, is important for apoptosis following DNA strand breakage.

A mitotic spindle requirement for DNA damage-induced apoptosis in Chinese hamster ovary cells

Promiscuously reactive electrophilic agents induce DNA and other cellular damage. DNA repair-defective cells, when compared with genetically matched, repair-proficient parental cells, provide a means to distinguish cellular responses triggered by individual genetic lesions from other macromolecular damage. The Chinese hamster ovary (CHO) cell line EM9 is hypersensitive to the alkylating agent ethyl methanesulfonate (EMS) and is unable efficiently to repair DNA single strand breaks in contrast to parental AA8 cells. EM9 was used to examine how CHO cells couple unrepaired DNA strand breaks to loss of viability. Flow cytometry revealed that EMS-treated EM9 cells underwent prolonged cell cycle arrest in G2, followed by entry into mitosis, micronucleation, and apoptosis. EM9 cells synchronized in G1 prior to EMS treatment entered mitosis 24-36 h after release from synchrony, approximately 12 h after untreated control cells. Mitoses in EMS-treated cells were abnormal, involving multipolar mitotic spindles and elongated and/or incompletely condensed chromosomes. The mitotic spindle poison nocodazole reduced DNA damage-induced apoptosis by >60%, whereas the frequency of micronucleation was similar in the presence or absence of nocodazole. Flow cytometry revealed that nocodazole-treated cells sustained a second round of DNA replication without intervening mitosis. These results demonstrate that nuclear fragmentation and inappropriate DNA replication are insufficient to trigger apoptosis following DNA strand breakage and demonstrate a requirement for mitotic spindle assembly for this process in CHO cells.

Activation of protein kinase B beta and gamma isoforms by insulin in vivo and by 3-phosphoinositide-dependent protein kinase-1 in vitro: comparison with protein kinase B alpha

The regulatory and catalytic properties of the three mammalian isoforms of protein kinase B (PKB) have been compared. All three isoforms (PKBalpha, PKBbeta and PKBgamma) were phosphorylated at similar rates and activated to similar extents by 3-phosphoinositide-dependent protein kinase-1 (PDK1). Phosphorylation and activation of each enzyme required the presence of PtdIns(3,4,5)P3 or PtdIns(3,4)P2, as well as PDK1. The activation of PKBbeta and PKBgamma by PDK1 was accompanied by the phosphorylation of the residues equivalent to Thr308 in PKBalpha, namely Thr309 (PKBbeta) and Thr305 (PKBgamma). PKBgamma which had been activated by PDK1 possessed a substrate specificity identical with that of PKBalpha and PKBbeta towards a range of peptides. The activation of PKBgamma and its phosphorylation at Thr305 was triggered by insulin-like growth factor-1 in 293 cells. Stimulation of rat adipocytes or rat hepatocytes with insulin induced the activation of PKBalpha and PKBbeta with similar kinetics. After stimulation of adipocytes, the activity of PKBbeta was twice that of PKBalpha, but in hepatocytes PKBalpha activity was four-fold higher than PKBbeta. Insulin induced the activation of PKBalpha in rat skeletal muscle in vivo, with little activation of PKBbeta. Insulin did not induce PKBgamma activity in adipocytes, hepatocytes or skeletal muscle, but PKBgamma was the major isoform activated by insulin in rat L6 myotubes (a skeletal-muscle cell line).

Ductal carcinoma in situ of the breast: correlation of pathologic and mammographic features with extent of disease

Optimal treatment of ductal carcinoma in situ (DCIS) of the breast requires an improved understanding of its pathologic extent and propensity for local recurrence. This study was performed to analyze mammographic and pathologic features of DCIS that might predict the extent of disease within the breast and facilitate treatment selection between lumpectomy alone, lumpectomy and radiotherapy, and mastectomy. At our institution, 60 cases of DCIS were diagnosed in 59 patients from June 1985 to February 1995 and form the basis of this retrospective study. Demographic and treatment-related information was obtained from hospital and tumor registry records. Mammograms were reviewed and size estimates of the abnormalities were determined. Pathologic slides from all cases were reviewed and classified according to size group, focality, nuclear grade, necrosis, and histologic subtype. DNA ploidy status and proliferation indices were available for 28 patients. Pathologically, 43 (72%) cases were < 15 mm, 14 (23%) were 16 to 40 mm, and 3 (5%) were > 40 mm. Five (8%) of the lesions were multicentric, 28 (47%) focal, and 27 (45%) multifocal. Thirty-three (55%) patients were treated by mastectomy, 16 (27%) by lumpectomy alone, and 11 (18%) by lumpectomy and radiation therapy. Mammographic size, histologic grade, presence or absence of necrosis, histologic subtype, DNA ploidy, and proliferative index were compared with pathologic size and focality by chi 2 analysis. Mammographic size correlated significantly with pathologic size (chi 2 = 11.3; P = 0.02) but underestimated the extent of disease in 9 cases. Although focality correlated significantly with pathologic size (chi 2 = 15.8; P = 0.003), the remaining histopathologic features did not significantly correlate with pathologic size or focality. Histopathologic features, including DNA studies, do not reliably predict the pathologic extent of DCIS, but mammographic size and focality do significantly correlate with pathologic size. Nevertheless, most cases of DCIS are small focal or multifocal lesions that are amenable to breast conservation approaches; further studies are needed to determine the appropriate use of lumpectomy, radiation therapy, and mastectomy in the treatment of DCIS.

Production and characterization of monoclonal antibodies against the leukemia inhibitory factor low affinity receptor, gp190

Leukemia inhibitory factor (LIF), oncostatin-M (OSM), ciliary neurotrophic factor (CNTF) and cardiotrophin-1 (CT1) act through transmembrane receptors which share the gp190 glycoprotein chain. The understanding of its involvement in the biology of these cytokines is of importance since these systems have recently been shown to participate in major inflammatory and neoplastic processes such as myelomatosis (Rose-John, S., Heinrich, P.C., 1994. Soluble receptors for cytokines and growth factors: generation and biological function. Biochem. J. 300, 281). In addition, this family of receptors also shares the gp130 transducing chain, with the IL6 and IL11 receptors. Because IL6 and gp130 were the first members to be discovered, most of the available reagents are directed at them. In this respect, monoclonal antibodies have played a major role in elucidating these receptor/ligand interactions and exploring the pathophysiological aspects of their biology. So far, no such reagents have been described for the gp190. We now report the production and characterization of 16 monoclonal antibodies directed against human gp190. They were obtained using recombinant chimeric or truncated proteins produced in a eukaryotic CHO cell line. One was able to block the biological activity of LIF. Because gp190 comprises two hematopoietin binding domains, crude epitope mapping was possible using the same reagents. While more of these antibodies are required, the present set validate the technological approach used for their preparation and should improve our understanding of this class of cytokines.

Genetic information and the workplace: legislative approaches and policy changes

The use of genetic information in the workplace poses societal risks that have an impact on employment possibilities, health insurance, and privacy. Individuals who might otherwise believe they can benefit from genetic testing may decline it because of their fear of employment discrimination and lack of privacy in the workplace. As a consequence, the future of research on the benefits and risks of predictive genetic testing may also be compromised. Thus, policy-makers need to evaluate legislative and regulatory strategies to address these concerns. This paper analyzes state and federal legislative approaches to genetic information in the workplace and concludes with a discussion of policy considerations and recommendation.

Identification of altered gene expression in skeletal muscle during sepsis using differential display

Different aspects of muscle metabolism are altered during sepsis and there is evidence that some of these changes may be regulated at the gene level. Differential display is a recently described technique to identify genes whose expression has changed during a biological process. This technique utilizes reverse transcriptase-polymerase chain reaction (RT-PCR) to compare mRNA signals in tissues during two different conditions. We used differential display to test the hypothesis that gene expression is altered in skeletal muscle during sepsis. Sepsis was induced in rats by cecal ligation and puncture (CLP). Control rats were sham-operated. Sixteen hours after CLP or sham operation, extensor digitorum longus muscles were harvested and RNA was extracted. Following differential display, 30 fragments (F1-F30) were identified that appeared to be uniquely expressed in muscles from sham-operated or septic rats. These fragments were reamplified by PCR and used as probes in Northern blot analysis. Messenger RNA levels corresponding to 2 of the 30 fragments (F5 and F24) were confirmed to be increased by Northern blot analysis in septic muscle. Following cloning and sequencing, F5 was found to display significant homology to the gene sequence of the guanine nucleotide releasing protein MSS4. The sequence of F24 did not match any reported gene sequence and may therefore represent a previously unidentified gene. The results support the hypothesis that gene expression is altered in skeletal muscle during sepsis.

Derivation and partial analysis of two highly active myeloma cell transfectants

Vectors have been designed to optimise the expression of heterologous proteins in transfected mouse myeloma cells. The over-ridingly important DNA element contained in these constructs is the classical mouse immunoglobulin heavy chain enhancer. It is shown that even in the absence of a well-known promoter element, the enhancer can drive gene expression in stable cell transfectants and the main transcriptional start site utilized in such situations has been mapped to within the previously defined enhancer region. Using chicken lysozyme as a reporter function in these vectors, two transfected myeloma cell clones have been isolated which secrete this protein at levels 50-100-times as high as those usually obtained with the same vectors and it is shown that in molar terms this is at least as high as endogenous immunoglobulin produced by a related line. Analysis of these lines show that in one case only a single copy, and in the other two to three copies, of the apparently unrearranged vector have integrated at a single locus within the genome. Possible explanations for the high-level expression are discussed.

Sepsis stimulates nonlysosomal, energy-dependent proteolysis and increases ubiquitin mRNA levels in rat skeletal muscle

We tested the role of different intracellular proteolytic pathways in sepsis-induced muscle proteolysis. Sepsis was induced in rats by cecal ligation and puncture; controls were sham operated. Total and myofibrillar proteolysis was determined in incubated extensor digitorum longus muscles as release of tyrosine and 3-methylhistidine, respectively. Lysosomal proteolysis was assessed by using the lysosomotropic agents NH4Cl, chloroquine, leupeptin, and methylamine. Ca(2+)-dependent proteolysis was determined in the absence or presence of Ca2+ or by blocking the Ca(2+)-dependent proteases calpain I and II. Energy-dependent proteolysis was determined in muscles depleted of ATP by 2-deoxyglucose and 2.4-dinitrophenol. Muscle ubiquitin mRNA and the concentrations of free and conjugated ubiquitin were determined by Northern and Western blots, respectively, to assess the role of the ATP-ubiquitin-dependent proteolytic pathway. Total and myofibrillar protein breakdown was increased during sepsis by 50 and 440%, respectively. Lysosomal and Ca(2+)-dependent proteolysis was similar in control and septic rats. In contrast, energy-dependent total and myofibrillar protein breakdown was increased by 172% and more than fourfold, respectively, in septic muscle. Ubiquitin mRNA was increased severalfold in septic muscle. The results suggest that the increase in muscle proteolysis during sepsis is due to an increase in nonlysosomal energy-dependent protein breakdown, which may involve the ubiquitin system.

Identification of Trypanosoma brucei gambiense by PCR amplification of variant surface glycoprotein genes

We have developed a sensitive and specific method to identify Trypanosoma brucei gambiense using the polymerase chain reaction (PCR) to amplify the gene encoding variant surface glycoprotein (VSG) Antat 11.17. The test was capable of distinguishing T. b. gambiense from T. b. brucei in most foci of gambian sleeping sickness and gave positive results with previously well-characterised Type I T. b. gambiense stocks from Ivory Coast, Nigeria, Cameroon, Congo, Zaire and Sudan. The test gave negative results with T. b. rhodesiense from Zambia, Kenya and Uganda, virulent or Type II T. b. gambiense from Ivory Coast and T. b. brucei stocks from East and West Africa. The test was modified for colorimetric detection in dot blot format by using nested biotinylated primers in a two-step reaction. Comparison of DNA sequences of VSG genes from T. b. gambiense and other T. brucei ssp. stocks showed a high level of homology, suggesting recent gene flow.

Role of protein kinase C in induction of gene expression and inhibition of cell proliferation by interferon alpha

Recent studies have suggested that protein kinase C (PKC) may be involved in the mechanism of signal transduction by which members of the interferon (IFN) family regulate gene expression and cell phenotype. We have investigated the role of PKC in the control of cell growth and gene expression by IFN alpha in Daudi cells. Treatment of these cells with two analogues of staurosporine, which are potent inhibitors of PKC, completely blocked the induction by IFN alpha of the mRNA for 2',5'-oligoadenylate synthetase and the 6-16 gene. These compounds also inhibited cell proliferation and thymidine incorporation in this system. In contrast, the protein kinase inhibitor 1-(5-isoquinolinylsulphonyl)-2-methylpiperazine (H7) did not significantly inhibit the induction of these genes by IFN alpha and had no effect on Daudi cell growth or thymidine incorporation in the presence or absence of IFN alpha. No effect of IFN alpha on total PKC activity could be observed, and there were no significant changes in the overall levels of individual PKC isoforms or their mRNA following IFN alpha treatment. In contrast, treatment of Daudi cells with the phorbol ester 12-O-tetradecanoylphorbol 13-acetate, which also inhibits cell proliferation, strongly down-regulated PKC. These data suggest that the activity of a PKC species, or a closely related enzyme, may be required both for continued cell proliferation and the response to IFN alpha in Daudi cells, but that IFN-induced growth inhibition does not involve overall down-regulation or change in activity of PKC.

LCR/MEL: a versatile system for high-level expression of heterologous proteins in erythroid cells

We have used the human globin locus control region (LCR) to assemble an expression system capable of high-level, integration position-independent expression of heterologous genes and cDNAs in murine erythroleukaemia (MEL) cells. The cDNAs are inserted between the human beta-globin promoter and the second intron of the human beta-globin gene, and this expression cassette is then placed downstream of the LCR and transfected into MEL cells. The cDNAs are expressed at levels similar to those of the murine beta-globin in the induced MEL cells. Heterologous genomic sequences can also be expressed at similar levels when linked to to the LCR and beta-globin promoter. In addition we demonstrate that, after induction of differentiation, MEL cells are capable of secreting heterologous proteins over a prolonged time period, making this system suitable for use in continuous production systems such as hollow fibre bioreactors. The utility of the LCR/MEL cell system is demonstrated by the expression of growth hormone at high levels (greater than 100 mg/l) 7 days after induction. Since the expression levels seen do not depend upon gene amplification and are independent of the integration position of the expression cassette, it is possible to obtain clones with stable high-level expression within 3-4 weeks after transfection.

The discharge of elderly patients from an accident and emergency department: functional changes and risk of readmission

Four hundred and fifty patients aged 75 years or older were followed up after discharge from an accident and emergency department. Forty-three per cent of all patients experienced some loss of functional independence. A small number, 5.6%, were readmitted to hospital within 14 days. This group were significantly less able to perform certain activities of daily living than those not readmitted. Attention to functional assessment by casualty staff may help to prevent readmission to hospital of this frail elderly group of patients.

Ultrasound follicle diameter measurement: an assessement of interobserver and intraobserver variation

The intraobserver and interobserver variation of ultrasound measurement of Graafian follicles was assessed. Fourteen follicles from 10 to 30 mm in diameter were each measured three times in three orthogonal planes by three observers. The intraobserver standard deviation (SD) was 0.6 mm and interobserver SD, 1.2 mm, irrespective of follicle diameter. The pooled SD for both variables was 1.2 mm, giving 95% confidence limits of +/- 2.4 mm for any measurement.

Renal vasoconstrictive response to contrast medium. The role of sodium balance and the renin-angiotensin system

The injection of contrast medium into the renal artery causes a biphasic change in renal blood flow, a transient vasodilation followed by a more prolonged vasoconstrictive phase. The role of sodium balance in the vasoconstrictive response to contrast medium was evaluated in sodium-deplete dogs (n = 5) and sodium-replete dogs (n = 5). Contrast medium, 2 ml of diatrizoate solution per 4 sec, was injected into the renal artery in anesthetized dogs. Renal blood flow was 117 +/- 25 ml/min and 173 +/- 12 in the sodium-deplete and sodium-replete dogs, respectively. After the injection of contrast medium and following the transient vasodilation phase, renal blood flow significantly decreased from baseline by 42.2% +/- 4.2 and 12.2% +/- 1.1 in sodium-deplete and sodium-replete dogs, respectively. The duration of the vasoconstriction phase was significantly prolonged in the sodium-deplete dogs, 343 +/- 27 sec vs. 147 +/- 48 in sodium-replete dogs. Blockade of the intrarenal renin-angiotensin system with the renal artery infusion of Sar1-Ala8-All (50 micrograms/kg/min) did not significantly alter the magnitude of vasoconstrictive response to contrast medium in sodium-deplete animals; however, the duration of the vasoconstrictive phase was decreased from 277 +/- 59 sec to 86 +/- 13. We conclude that (1) sodium depletion accentuates both the magnitude and duration of the vasoconstrictive phase of the renal blood flow response to injection of contrast medium and (2) blockade of the intrarenal renin-angiotensin system shortens the duration of this response.

The effect of bezafibrate and clofibrate on cholesterol ester metabolism in rabbit peritoneal macrophages stimulated with acetylated low density lipoproteins

Bezafibrate and clofibrate reduce the quantity of esterified cholesterol, decrease the incorporation of 14C-labeled oleic acid into cholesterol ester and inhibit acyl coenzyme A cholesterol acyltransferase activity in rabbit peritoneal macrophages stimulated with acetylated low density lipoprotein. In all cases, the effect of bezafibrate was more marked than that of clofibrate. The activity of lysosomal cholesterol ester hydrolase in these cells was not affected by these drugs. It is suggested that these drugs exert an anti-atherogenic activity not only by their action on serum lipids, but by influencing cellular cholesterol ester metabolism.

The effect of bezafibrate and clofibrate on microsomal ACAT and lysosomal cholesterol ester hydrolase activity in the cholesterol-fed rabbit aorta

Bezafibrate markedly reduced the activity of fatty acyl CoA:cholesterol acyltransferase (ACAT) in the microsomal fraction of aortas from cholesterol-fed rabbits, while clofibrate was a less potent inhibitor. The activity of lysosomal cholesterol ester hydrolase (LCEH) was not significantly affected by either agent, indicating that inhibition of ACAT rather than stimulation of LCEH is a mechanism whereby these agents may decrease the cholesterol ester content of atherosclerotic aorta.

The effect of bezofibrate and clofibrate on cholesterol accumulation, esterification and removal in cultured 3T3 fibroblasts

3T3 mouse fibroblasts were used to determine the effect of bezafibrate and clofibrate on the cellular metabolism of cholesterol. In cells incubated in normal medium these agents decreased the incorporation of 3H-labelled oleic acid relative to 14C-labelled linoleic acid into the cholesterol ester fraction. When the 3T3 fibroblasts were incubated with cationised low density lipoprotein (LDL) the amount of esterified cholesterol which accumulated in the cells was greatly increased. This accumulation of cholesterol ester was reduced by bezafibrate and clofibrate. These agents decreased the incorporation of both 3H-labelled oleic acid and 14C-labelled linoleic acid into the cholesterol ester fraction of the cells, with a preferential effect on oleic acid as indicated by a reduction in the 3H/14C ratio. When cells which had been preincubated with cationised LDL were reincubated in normal medium, the removal of esterified cholesterol from the cells was increased by both bezafibrate and clofibrate. The mechanism of the effects of these agents on the metabolism of cellular cholesterol is discussed.

Removal of fatty acid labelled cholesterol ester, phospholipid and triglyceride from atherosclerotic rabbit aorta in vitro

An organ culture technique was used to investigate the removal of fatty acids incorporated into various lipid fractions in intimal segments of atherosclerotic rabbit aorta. Segments of aorta were pulse-labelled in vitro with [9,10-3H]oleic acid and [1-14C]linoleic acid for 24 h. The incubation medium was replaced with non-radioactive medium and the removal of the endogenously labelled phospholipid, triglyceride and cholesterol ester was followed for a further period of 10 days. Fatty acids incorporated into phospholipid and triglyceride were removed rapidly from the aortic intima, with fractional half-times of 4--5 days. Cholesterol ester fatty acids were removed more slowly from the aortic intima with fractional half-times of 9--12 days. When the removal rate of oleic acid incorporated into phospholipid, triglyceride and cholesterol ester was compared with that of linoleic acid incorporated into the same lipid fractions, no difference between removal of the two fatty acids could be detected with respect to any of the 3 lipid fractions.

Uptake and metabolism of 3H-fatty acid labelled lecithin by normal and atherosclerotic intima in vivo and in vitro

Following the intravenous injection of tracer doses of 3H-fatty acid labelled lecithin into normally fed rabbits, minimal incorporation into serum cholesterol ester over a 6-hour period was observed. The labelled phospholipid was rapidly removed from the serum primarily by R.E. tissues with little uptake by the aorta. The uptake and metabolism of 3H-fatty acid labelled lecithin by explants of normal and cholesterol-fed rabbit aortas was also investigated in vitro for periods up to 8 days. Low uptake and incorporation into cholesterol ester was observed for the normal aortic explants. The labelled phospholid was taken up to a greater extent by explants from cholesterol-fed rabbit aortas and the fatty acid incorporated into both triglyceride and cholesterol ester in the explants. The incorporation of fatty acid into cholesterol ester from phospholipid was associated with hydrolysis of the phospholipid and re-incorporation of the fatty acid into cholesterol ester, rather than by the action of lecithin cholesterol acyl transferase.