[Coordination to assist with hospital-to-home discharge after cerebral hemorrhage--perspectives of a patient's family and nurse]

Discharge support, although provided for a limited time, is of vital importance in the acute phase care period. Such support is necessary to ensure continuity of care and treatment even after being discharged from the hospital. I acquired both the viewpoints of the family and the nurse of a patient who was about to be discharged from the hospital after cerebral hemorrhage. However, the patient's family and I were not able to decide on a home care plan or hospital-to-home transfer ahead of time because of the unstable condition of the patient, limited care power of the family, and varying discharge plans among the family members. I intended to help in the decision-making process, taking into consideration the patient's best interest. I evaluated the viewpoint of the family and was able to understand situations in which a family member, who assumes the role of a primary care giver, would need guidance in providing home care to the patient.

[Does the nutritional care plan and report upon discharge under the health care system substitute the nutrition support team summary at patient discharge?]

Our nutrition support team (NST) designed the NST summary for cooperation among personnel providing medical care for nutritional management of high-need patients in our area. After the introduction of the NST fee under the health care system, the number of summary publications decreased. The requested NST fee is necessary for publication of a nutritional care plan and report upon patient discharge. We hypothesized that the nutritional care plan and discharge report were being substituted for the NST summary at the time of patient discharge. We retrospectively investigated 192 cases with NST fee. There were only 13 cases of overlapping publication, and the NST summary was necessary for 107 of 179 cases in which no NST summary had been prepared. Since the space on the report form is limited, it can provide only limited information. However, the NST summary can convey detailed supplementary information. Therefore, there is a high need for the NST summary, and publication of NST summaries for the appropriate cases must continue.

[A regional alliance in nutritional management-ten years of collaboration with an nutrition support team network]

Ten years has passed since we began the nutrition support team(NST)to make a regional alliance between local institutions for construction of the NST network. The network was formed with the following aims: 1) regional joint conferences for learning about nutrition with family doctors, facilities, and hospitals; 2) open general meetings for information about nutrition within the suburbs of our city; 3) preparing and sending an NST manual about parenteral nutrition(PN)and enteral nutrition(EN); and 4) preparation of an NST summary of patient malnutrition to foster mutual understanding. We produced a questionnaire summarizing the completion of nutritional management in patients. The following positive benefits were observed: 1) improved nutritional motivation and technique; 2) reduced nutritional confusion after discharge from our hospital; and 3) lower levels of anxiety in the facilities, the patient, and among the patient's family. In addition, follow-upinquiries allowed us to estimate whether our nutritional strategy was adequate. A more widely open regional alliance is needed in the future to strengthen patient nutrition following hospital discharge.

[Home-based infusion therapy by Broviac catheter after total parenteral nutrition therapy in a patient with a severe skin condition]

In collaboration between the in-hospital nutrition support team and infection control team, we attempted to standardize the management of infusion therapy. We report on a simple and effective at-home infusion therapy, after total parenteral nutrition(TPN)therapy, by using a Broviac catheter in a discharged patient with a severe skin condition. The patient was a man in his 50s who had amyloidosis. Because of dysphagia and complications of the digestive organs, TPN was chosen as the method for nutritional management. At the beginning the patient repeated infection and a trouble of the skin, but the insertion site was managed by the existing standardized manual. However, switching to a Broviac catheter improved the existing disease. Dermatopathy was improved and there was no catheter-related bloodstream infection under the new management method. Furthermore, the patient is now able to feed orally. Patients should be evaluated individually, and for the case that is hard to care with a manual, it is necessary to choose the best possible method.

[A survey on nutritional management planning for patients attending an another institute after discharge]

We sent the reports and plans concerning nutritional management to the 81 facilities, such as a hospital, nursing home, or clinic of home care, and carried out the questionnaire to determine their level of understanding and utilization of the reports. Sixty-nine % understood the purpose of the survey, with 74% noting that the report served as a reference. The purpose of the report was relatively well understood in the hospital or nursing home environments, but was not sufficiently understood in the clinics. In addition, it became clear that several facilities involved with one patient. Therefore, it was necessary to send a report to each facility. The interest in the report concerning nutritional management was very high in a range of various medical workers. Sections such as "matters that require attention, a characteristic in the nourishment management", "dysphagia ", and "a nourishment management method" were considered useful by these workers. The nutritional evaluation of patients discharged may be difficult; therefore, information from reports on nutritional management may help to make a more informed decision on future nutritional management.

[The trend of nutritional management in a survey of nutrient intake, via gastrostomy, in patients following an acute hospital stay]

In our hospital, the nutrition support team(NST)deepened relations with the local medical institution for sequential nutritional management following patient discharge. We began to process additional reports about patient nutritional management that could be passed onto any other institute for subsequent nutritional therapy. Three months following discharge, the main method of nutritional management was examined in 109 patients who were discharged between April 2008 and July 2010 and who were receiving the majority of nutrients via gastrostomy. Ten of these patients could feed orally. We choose the best methods at that time according to the patient condition, the medical treatment environment, and the patients' family. A change in those aspects following discharge will lead to a change in nutritional management methods. Observing the current nutritional therapy methods in patients after discharge is beneficial and allows us to produce a summary of this information to send to the local medical institute and to provide guidelines for the most appropriate procedures for nutritional management via gastrostomy.

[Local communalization of clinical records between the municipal community hospital and local medical institutes by using information technology]

We introduced the electronic health record system in 2002. We produced a community medical network system to consolidate all medical treatment information from the local institute in 2010. Here, we report on the present status of this system that has been in use for the previous 2 years. We obtained a private server, set up a virtual private network(VPN)in our hospital, and installed dedicated terminals to issue an electronic certificate in 50 local institutions. The local institute applies for patient agreement in the community hospital(hospital designation style). They are then entitled to access the information of the designated patient via this local network server for one year. They can access each original medical record, sorted on the basis of the medical attendant and the chief physician; a summary of hospital stay; records of medication prescription; and the results of clinical examinations. Currently, there are approximately 80 new registrations and accesses per month. Information is provided in real time allowing up to date information, helping prescribe the medical treatment at the local institute. However, this information sharing system is read-only, and there is no cooperative clinical pass system. Therefore, this system has a limit to meet the demand for cooperation with the local clinics.

[Hemiparkinsonism due to a solitary infarction of the right external segment of the globus pallidus: a case report]

Three months prior to presentation, a 76-year-old woman suffered from insomnia and was prescribed some antidepressants and hypnotics. At that time, brain MRI showed no cerebral infarcts. Having developed an action tremor of the left hand, bradykinesia, and unstable gait, she visited our hospital. Neurological examination revealed rigidity of the neck and left limbs, clumsiness of the left hand, action tremor, and decreasing swing of the left arm while walking. 123I-metaiodobenzylguanidine scintigraphy showed no decrease of the heart/mediastinum ratio. The second MRI showed an old cerebral infarct located just in the right external segment of the globus pallidus. Since drug-induced parkinsonism was suspected, paroxetine and trazodone were discontinued, but her symptoms did not improve. We concluded that her hemiparkinsonism was due to the cerebral infarct in the right external segment of the globus pallidus, because her symptoms did not respond to dopamine agonist and L-dopa therapy, and the onset of symptoms corresponded with the time of appearance of the cerebral infarct. This is a rare case that is important for understanding the mechanism of parkinsonism.

[The importance of Dysphagia management during the peri-operative period to home elderly care]

Dysphagia is usually a major problem for the elderly to go home after a surgical treatment for the bone fracture of the thigh bone cervix or trochanter part in the leg. We analyzed each clinical course with regard to a change of the oral intake and the nutritional status, the activity of daily living(ADL)and a nutritional management and the place after the patient was discharged. According to our results, about 20% of the patients among those surgical cases were pointed with dysphagia, and there were many cases that ADL was ultimately gotten worse. We took care of disphagia by doing a best practice of changing in feedings and deglutition function. However, some of the patients with the problem finally moved to another elderly health care institute against their primary wishes to go home. Furthermore, 55% of the disphagia patients became dementia. It seems that dementia might be a high risk factor of disphagia. We should do more better job for managing disphargia during a peri-operative period just after admission.

[Two elderly case reports of renal excretion type drug poisoning caused by dehydration that was due to poor eating in home care]

The elderly patients are susceptible to acute renal failure due to dehydration or infection. Therefore, the drug should be administered with caution. We report two cases of acute renal failure from dehydration that led to a subsequent drug poisoning. Case 1: An 85-year-old woman with a history of colorectal cancer surgery was admitted to our emergency department for appetite loss and weakness. Because she was given a normal amount of drugs under the condition of poor oral intake, she was hospitalized by digitalism. Case 2: A 72-year-old woman was admitted to our emergency department for disturbance of consciousness and appetite loss. The medication given by a staff in geriatric health services facility appeared to have caused a pilsicainide poisoning. As the elderly patients were given a normal amount of drugs under the poor oral intake condition, blood levels of renal excretion type drug had increased in both cases. Medication management for the elderly should be comprehensively considered the background of the individual.

[The follow-up study of patients with NST discharge summary for a continuous nutritional management]

The nutritional management of a patient discharged from a primary hospital will not end just there. The nutritional management information issued by the primary hospital is required when a patient moves to a next institute.We,the Nutritional Support Team(NST), make a nutrition summary report in addition to letters written by the doctor and the ward in charge. We investigated a total of 64 patients three months after their discharge, and followed them for a year since April 2008. On some patients, the nutritional care had to be changed in accordance with the facility and the patients' primary disease status.In order for the nutrition management to be continued, a bidirectional communication exchange between the primary hospital and acute phase hospital is essential. In other words, a seamless nutritional management for patients has to be executed. When the disease condition of the patient has changed, the host institution must consult with us about the new nutritional care to the patient. On the other hand, we should keep in touch to reduce a communication distance in the region.

[A case of severe obese patient complicated with type-2 diabetes--transition from Very Low Calorie Diet(VLCD) therapy to Low Calorie Diet(LCD)therapy]

A 6 0-year-old woman with severe obese and type-2 diabetes was hospitalized due to poorly controlled glycemia by worsening osteoarthritis of both knees. Although a diet therapy(1,200 kcal/day)was initially offered, but the body weight did not decrease. Thus, we changed VLCD therapy to LCD therapy sequentially. The weight loss made her possible not only to walk with a walker but it also improved a glycemic control. Because it was thought to be necessary to reduce her economic burden in order to continue the LCD therapy after was discharged, an inexpensive LCD menu was devised based on meal and auxiliary nutrients including trace elements. To support the LCD therapy at home, it is important to propose a simple and sustainable approach with a consideration of economic aspects as well as home environment.

[The use of total enteral formula with enriched nutrient in home Low Calorie Diet(LCD)therapy based on regular meal]

We made a low calorie diet(LCD)menu which added two commercial supporting nutritional supplements to a meal. Because a conventional formula food is very expensive, the patient was not able to afford it at home. Those supplements are a total enteral formula with enriched nutrient(ACURE EN800)and vitamin-mineral rich drink(V CRESC). The contents of vitamin and mineral in this menu satisfied the dietary reference intakes, though protein was a little low. However, we could keep the price low compared to the formula food. The patient was able to switch over to home LCD therapy with the menu.

Human catalase gene is regulated by peroxisome proliferator activated receptor-gamma through a response element distinct from that of mouse

Oxidative stress has been implicated as a causal role in atherosclerosis, microvascular complications of diabetes as well as in beta cell failure in type 2 diabetes. PPARgamma agonists not only improve insulin sensitivity but also eliminate oxidative stress. In mouse, catalase, a major antioxidant enzyme, is directly regulated by PPARgamma through two PPARgamma binding elements in its promoter. This study examined the regulatory mechanisms of catalase expression in human. Expression of catalase was significantly upregulated in human primary adipocytes upon treatment with a PPARgamma agonist. However, the mouse PPARgamma response elements are not functionally conserved in human catalase promoter. In luciferase reporter assay containing human catalase promoter, PPARgamma /RXRalpha, in combination of a PPARgamma agonist significantly transactivated 19 kb of promoter and this was mediated via a novel PPARgamma response element (PPRE) at -12 kb from transcription initiation site of human catalase gene. Electrophoretic mobility shift assay showed direct binding of PPARgamma to this PPRE. Together, our results indicate that PPARgamma regulates the expression of catalase gene in human through a PPRE distinct from that of mouse, and could explain, at least in part, the observed inhibitory effects of PPARgamma on oxidative stress in human.

Dysregulated glutathione metabolism links to impaired insulin action in adipocytes

Oxidative stress plays an important role in obesity-related metabolic diseases. Glutathione peroxidase (GPX) is an antioxidant enzyme downregulated in adipose tissue of obese mice. However, the role of GPX in adipocytes remains elusive. The objective of this study was to clarify the pathophysiological changes in GPX activity and glutathione metabolism and their roles in the pathogenesis of insulin resistance in adipocytes. To achieve this goal, we measured cellular GPX activity, glutathione (GSH) contents, GSH/GSSG ratio, and mRNA expression of gamma-glutamylcysteine synthetase (gamma-GCS), a rate-limiting enzyme for de novo GSH synthesis, in adipose tissue of control and ob/ob mice and in 3T3-L1 adipocytes treated with insulin, H(2)O(2), free fatty acid (FFA), or TNFalpha. Furthermore, we investigated the effects of GPX inhibition with a specific GPX inhibitor or RNA interference against GPX, H(2)O(2), and reduced GSH on insulin signaling in 3T3-L1 adipocytes. ob/ob Mice showed not only a decrease in cellular activity of GPXs (GPX1, -4, and -7) but also an increase in gamma-GCS expression, resulting in increased GSH contents in adipose tissue. These alterations in glutathione metabolism were also observed during differentiation of 3T3-L1 cells and their exposure to insulin, FFA, or H(2)O(2). Inhibition of GPX activity, addition of GSH, and H(2)O(2) resulted in impaired insulin signaling in 3T3-L1 adipocytes. These results suggest that decreased GPX activity and increased gamma-GCS expression lead to overaccumulation of GSH, which might be involved in the pathogenesis of insulin resistance in obesity.

Identification of a novel distal enhancer in human adiponectin gene

Adiponectin is exclusively expressed in adipose tissue and secreted from adipocytes, and shows anti-diabetic and anti-atherogenic properties. However, the precise transcriptional mechanism of adiponectin remains elusive. In this study, the 5' flanking promoter region of human adiponectin gene was analyzed using UCSC genome browser, and a 10 390-bp fragment, containing an evolutionally conserved region among species, was investigated. The luciferase reporter assay using this fragment identified a novel distal enhancer of human adiponectin gene. Promoter constructs with the distal enhancer exhibited high promoter activities in 3T3-L1 mature adipocytes. However, no such activity was observed in other types of cell lines. The distal enhancer is highly conserved, and contains two completely conserved CCAAT boxes. In 3T3-L1 mature adipocytes, deletion or each point mutation of these CCAAT boxes markedly reduced luciferase activity driven by adiponectin promoter. Knockdown of CCAAT/enhancer-binding protein alpha (CEBPA; also known as C/EBPalpha) using small interfering RNA diminished adiponectin mRNA expression and luciferase activity driven by adiponectin promoter with the distal enhancer. However, adiponectin promoter with each mutation of two CCAAT boxes in the distal enhancer did not respond to knockdown of CEBPA expression. Furthermore, CEBPA bound to the distal enhancer both in vitro and in vivo. We also identified a proximal promoter region responsible for transcriptional activation by the distal enhancer in human adiponectin gene. Our results indicate that CEBPA plays a pivotal role in the transcription of human adiponectin gene via the distal enhancer and proximal region in its promoter.

Obesity causes a shift in metabolic flow of gangliosides in adipose tissues

Obesity is associated with insulin resistance and a mild chronic inflammation in adipose tissues. Recent studies suggested that GM3 ganglioside mediates dysfunction in insulin signaling. However, it has not been determined the ganglioside profiling in adipose tissues of obese animals. Here, we for the first time examined semi-quantitative ganglioside profiles in the adipose tissues of high fat- and high sucrose-induced obese, diabetic C57BL/6J mice by TLC and HPLC/mass spectrometry. In control adipose tissues GM3 dominated with traces of GM1 and GD1a; obesity led to a dramatic increase in GM2, GM1, and GD1a with the GM3 content unchanged. Similar results were obtained in KK and KKAy mice. Adipocytes separated from stromal vascular cells including macrophages contained more of those gangliosides in KKAy mice than in KK mice. These results underscore those gangliosides in the pathophysiology of obesity-related diseases.

Effects of statins on adipose tissue inflammation: their inhibitory effect on MyD88-independent IRF3/IFN-beta pathway in macrophages

OBJECTIVE

Macrophage-mediated chronic inflammation of adipose tissue is causally linked to insulin resistance in obesity. The beneficial effects of 3-hydroxy-3-methylglutaryl (HMG) coenzyme A (CoA) reductase inhibitors (statins) on glucose metabolism have been suggested, but the effects of these agents on adipose tissue inflammation are unclear. The aim of the present study is to define the effects of statins on adipose tissue inflammation and macrophages.

METHODS AND RESULTS

Pravastatin or pitavastatin treatment of obese mice attenuated an increase in mRNA expressions of proinflammatory genes, including MCP1 and IL6, in adipose tissue. The supernatant of TLR4-stimulated RAW264 macrophages strongly induced the expression of these genes in 3T3-L1 adipocytes, which was inhibited by pretreatment of macrophages with either statin. Statins inhibited TLR4-mediated activation of interferon (IFN) regulatory factor (IRF)3 by either lipopolysaccharide (LPS) or palmitic acid, resulting in suppression of IFN-beta expression, but not that of NF-kappaB or JNK. Moreover, statins strongly downregulated TLR3-mediated gene expressions by poly(I:C), but not TLR2-stimulation by zymosan A. Neutralization of IFN-beta attenuated proinflammatory activities of the macrophage supernatant.

CONCLUSIONS

Statins partially attenuated the development of adipose tissue inflammation in obese mice, which might be associated with an inhibitory effect of statins on TLR4-triggered expression of IFN-beta via MyD88-independent signaling pathway in macrophages.

Effect of pravastatin on the development of diabetes and adiponectin production

In the West of Scotland Coronary Prevention Study (WOSCOPS), treatment of hypercholesterolemic men with pravastatin, an inhibitor of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, reduced their likelihood to progress to diabetes mellitus by 30%. However, the mechanism of this effect of pravastatin has not been investigated. In the current study, we examined the effect of pravastatin on the development of diabetes in obese diabetic mice, and on the insulin-induced glucose uptake and adiponectin production. Pravastatin treatment attenuated the development of diabetes in db/db and high fat/high sucrose diet-fed C57BL/6J mice. An in vivo glucose transport assay showed that pravastatin upregulated glucose uptake in adipose tissue. Insulin-stimulated glucose uptake was enhanced in primary adipocytes isolated from pravastatin-treated mice. Pravastatin treatment increased adiponectin production in 3T3-L1 adipocytes. Plasma adiponectin levels were significantly increased in pravastatin-treated mice. Analyses of plasma samples from the WOSCOPS biobank indicated a significant increase of plasma adiponectin levels with pravastatin treatment (placebo -0.28+/-0.34 microg/ml versus pravastatin +1.47+/-0.33 microg/ml, p=0.0003). Taken together, our findings suggest that pravastatin may have beneficial effects on adipose tissue, which may partly explain the reduction of the development of diabetes by pravastatin treatment.

Adipose expression of catalase is regulated via a novel remote PPARgamma-responsive region

In adipose tissue of obese mice, the expression of catalase, an anti-oxidant enzyme, significantly decreases, which may cause insufficient elimination of hydrogen peroxide, but it does not in liver or skeletal muscle. However, the precise regulatory mechanism of catalase expression in adipocytes has not been fully defined. Here, we demonstrated that adipose tissues highly expressed catalase on the level comparable to liver and kidney, and treatment of mice with PPARgamma agonist significantly enhanced catalase expression in adipose tissue but not in liver. In 3T3-L1 cells, mRNA expression of catalase was up-regulated by the induction for adipose differentiation, and down-regulated by TNFalpha, in parallel with alterations in PPARgamma expression. PPARgamma agonist significantly enhanced catalase mRNA and activity. Furthermore, we newly identified a remote enhancer region containing two functional PPARgamma binding sites in mouse catalase gene. Collectively, our findings suggest that PPARgamma plays a crucial role in the expression of catalase in adipocytes.

Nitric oxide dysregulates adipocytokine expression in 3T3-L1 adipocytes

Obesity is associated with infiltration of macrophages into adipose tissue, and macrophages are an important source of nitric oxide (NO). Dysregulated production of fat-derived secretory factor, adipocytokine, leads to obesity-linked metabolic disorders. However, it has not been fully determined whether NO might have direct effects on adipocytokine expressions. Here, we show that NO donor treatment downregulated gene expression and secretion of adiponectin, and upregulated mRNA levels of PAI-1 and IL-6. NO donor reduced promoter activity of adiponectin through PPARgamma responsive element. Moreover, NO donor activated JNK and NF-kappaB pathways, and inhibitors of these pathways rescued NO-mediated upregulation of PAI-1 and IL-6. Analysis of adipose tissue of high-fat-fed obese mice showed upregulation of PAI-1 and IL-6 expression, increased synthesis of NO, and downregulation of adiponectin. Our results suggest that increased NO synthesis might be partly responsible for dysregulation of adipocytokines in adipose tissue.

Visfatin is released from 3T3-L1 adipocytes via a non-classical pathway

Visfatin is a secretory protein which exerts insulin mimetic and proinflammatory effects, also functioning as an intracellular enzyme to produce NAD. Plasma visfatin levels and visfatin mRNA expression in adipose tissues are increased in obese subjects. Visfatin does not have a decent cleavable signal sequence, and the mechanism, that mediates release of visfatin from adipocytes, remains poorly understood. In this study, we demonstrate that visfatin is released abundantly into culture medium from 3T3-L1 adipocytes. Subcellular fractionation analysis showed that visfatin was localized in the cytosol, but not in nucleus, membrane, vesicles, or mitochondria fractions. Visfatin release was not reduced by Brefeldin A and Monensin, inhibitors of endoplasmic reticulum (ER)-Golgi-dependent secretion. In addition, visfatin was not released on microvesicles. These results suggest that visfatin should be released from 3T3-L1 adipocytes via an ER-Golgi or microvesicles independent pathway.

Adipose tissue hypoxia in obesity and its impact on adipocytokine dysregulation

Obesity is linked to a variety of metabolic disorders, such as insulin resistance and atherosclerosis. Dysregulated production of fat-derived secretory factors, adipocytokines, is partly responsible for obesity-linked metabolic disorders. However, the mechanistic role of obesity per se to adipocytokine dysregulation has not been fully elucidated. Here, we show that adipose tissue of obese mice is hypoxic and that local adipose tissue hypoxia dysregulates the production of adipocytokines. Tissue hypoxia was confirmed by an exogenous marker, pimonidazole, and by an elevated concentration of lactate, an endogenous marker. Moreover, local tissue hypoperfusion (measured by colored microspheres) was confirmed in adipose tissue of obese mice. Adiponectin mRNA expression was decreased, and mRNA of C/EBP homologous protein (CHOP), an endoplasmic reticulum (ER) stress-mediated protein, was significantly increased in adipose tissue of obese mice. In 3T3-L1 adipocytes, hypoxia dysregulated the expression of adipocytokines, such as adiponectin and plasminogen activator inhibitor type-1, and increased the mRNAs of ER stress marker genes, CHOP and GRP78 (glucose-regulated protein, 78 kD). Expression of CHOP attenuated adiponectin promoter activity, and RNA interference of CHOP partly reversed hypoxia-induced suppression of adiponectin mRNA expression in adipocytes. Hypoxia also increased instability of adiponectin mRNA. Our results suggest that hypoperfusion and hypoxia in adipose tissues underlie the dysregulated production of adipocytokines and metabolic syndrome in obesity.

Angiopoietin-like protein3 regulates plasma HDL cholesterol through suppression of endothelial lipase

OBJECTIVE

A low level of high-density lipoprotein (HDL) in plasma has been recognized as an aspect of metabolic syndrome and as a crucial risk factor of cardiovascular events. However, the physiological regulation of plasma HDL levels has not been completely defined. Current studies aim to reveal the contribution of angiopoietin-like protein3 (angptl3), previously known as a plasma suppressor of lipoprotein lipase, to HDL metabolism.

METHODS AND RESULTS

Angptl3-deficient mice showed low plasma HDL cholesterol and HDL phospholipid (PL), and which were increased by ANGPTL3 supplementation via adenovirus. In vitro, ANGPTL3 inhibited the phospholipase activity of endothelial lipase (EL), which hydrolyzes HDL-PL and hence decreases plasma HDL levels, through a putative heparin-binding site in the N-terminal domain of ANGPTL3. Post-heparin plasma in Angptl3-knockout mice had higher phospholipase activity than did that in wild-type mice, suggesting that the activity of endogenous EL is elevated in Angptl3-deficient mice. Furthermore, we established an ELISA system for human ANGPTL3 and found that plasma ANGPTL3 levels significantly correlated with plasma HDL cholesterol and HDL-PL levels in human subjects.

CONCLUSIONS

Angptl3 acts as an inhibitor of EL and may be involved in the regulation of plasma HDL cholesterol and HDL-PL levels in humans and rodents.

Visfatin in adipocytes is upregulated by hypoxia through HIF1alpha-dependent mechanism

Obesity is associated with metabolic disorders, such as insulin resistance. Visfatin is an adipose-derived secretory factor to exert insulin-mimetic effects. Plasma visfatin levels and mRNA levels of visfatin in adipose tissues are increased in obesity. However, the mechanism that mediates induction of visfatin mRNA in adipose tissue of obesity remains unknown. Recent studies have reported that fat tissue is hypoxia in obesity. In this study, we investigated the effects of hypoxia on mRNA expression of visfatin in adipocytes. Hypoxia increased visfatin mRNA expression. Desferoxamine and Cobaltous chloride, two hypoxia mimetic compounds, also increased visfatin mRNA levels. Dimethyloxallyl glycine, a stabilizer of hypoxia-inducible factor 1alpha (HIF1alpha), mimicked the hypoxia-mediated upregulation of visfatin, and YC1, an inhibitor of HIF1 cancelled the hypoxia-induced upregulation of visfatin mRNA. We identified two functional hypoxia responsive elements (HRE) in mouse visfatin promoter. Hypoxic treatment and overexpression of HIF1alpha increased the promoter activity, and mutation of the HRE blunted hypoxia-induced activation of visfatin promoter. Our results suggest that visfatin mRNA expression is upregulated in the fat tissue of obesity through the activation of HIF1alpha pathway due to hypoxia.

Familial massive tendon xanthomatosis with decreased high-density lipoprotein-mediated cholesterol efflux

We experienced a family with novel massive tendon xanthomatosis which can be excluded from known disease causing xanthomatosis. The proband was a 58-year-old man who had necrosis in his massive Achilles tendon xanthoma. Three of 5 brothers including him and his nephew had the same clinical phenotype. The systemic tendon xanthomatosis became apparent around 30 years of their age. The proband and his elder brother had mild elevations of serum total cholesterol level (251 and 228 mg/dL, respectively). The low-density lipoprotein receptor activity of the proband's lymphocytes was normal. Neither plant sterol nor cholestanol level was increased in the proband's plasma. Magnetic resonance image of the proband's Achilles tendon demonstrated a massive expansion of the soft tissue with salami sausage-like appearance in his heels (50 mm in thickness). The physiological function of macrophages (MPhi) from the patients was investigated to clarify the mechanism for the formation of xanthomatosis. There was no significant difference in the uptake of oxidized low-density lipoprotein between the proband's MPhi and the control. High-density lipoprotein 3-mediated cholesterol efflux from the patients' MPhi (n = 2) was significantly reduced compared with the controls (n = 3), whereas there was no difference in apolipoprotein (apo) A-I-mediated cholesterol efflux between the patients' MPhi and the controls. Furthermore, there was no reduction of the messenger RNA levels of ATP-binding cassette transporter 1 (ABCA1), which is involved in apo A-I-mediated cholesterol efflux, in the proband's MPhi compared with the control. The present study demonstrates that the mechanism for the formation of novel familial massive tendon xanthomatosis may be, at least in part, associated with decreased high-density lipoprotein 3, but not free apo A-I-mediated cholesterol efflux from MPhi in vivo.

Liver-specific mRNA for Insig-2 down-regulated by insulin: implications for fatty acid synthesis

Insig-1 and -2 are closely related proteins of the endoplasmic reticulum (ER) that block proteolytic activation of sterol regulatory element-binding proteins (SREBPs), transcription factors that activate the synthesis of cholesterol and fatty acids in liver and other organs. When cellular cholesterol levels are high, Insig proteins bind and trap SREBP cleavage-activating protein (SCAP), retaining it in the ER and preventing it from escorting SREBPs from ER to the site of proteolytic activation in the Golgi complex. Here, we report the discovery of a liver-specific transcript of Insig-2, designated Insig-2a. This transcript and the ubiquitous transcript, designated Insig-2b, differ through the use of different promoters that produce different noncoding first exons that splice into a common second exon. Although the Insig-2a and -2b mRNAs encode identical proteins, they differ in patterns of regulation. Insig-2a is the predominant transcript in livers of fed animals, and it is selectively down-regulated by insulin. Insig-2a mRNA increases when mice are fasted, and it declines when they are refed. The transcript also increases in livers of rats whose insulin-secreting pancreatic beta cells have been destroyed by streptozotocin, and it is reduced when insulin is injected. The insulin-mediated fall in Insig-2a may allow SREBP-1c to be processed, thereby allowing insulin to stimulate fatty acid synthesis, even under conditions in which hepatic cholesterol levels are elevated.

Role of adiponectin in preventing vascular stenosis. The missing link of adipo-vascular axis

Obesity is more linked to vascular disease, including atherosclerosis and restenotic change, after balloon angioplasty. The precise mechanism linking obesity and vascular disease is still unclear. Previously we have demonstrated that the plasma levels of adiponectin, an adipose-derived hormone, decreases in obese subjects, and that hypoadiponectinemia is associated to ischemic heart disease. In current the study, we investigated the in vivo role of adiponectin on the neointimal thickening after artery injury using adiponectin-deficient mice and adiponectin-producing adenovirus. Adiponectin-deficient mice showed severe neointimal thickening and increased proliferation of vascular smooth muscle cells in mechanically injured arteries. Adenovirus-mediated supplement of adiponectin attenuated neointimal proliferation. In cultured smooth muscle cells, adiponectin attenuated DNA synthesis induced by growth factors including platelet-derived growth factor, heparin-binding epidermal growth factor (EGF)-like growth factor (HB-EGF), basic fibroblast growth factor, and EGF and cell proliferation and migration induced by HB-EGF. In cultured endothelial cells, adiponectin attenuated HB-EGF expression stimulated by tumor necrosis factor alpha. The current study suggests an adipo-vascular axis, a direct link between fat and artery. A therapeutic strategy to increase plasma adiponectin should be useful in preventing vascular restenosis after angioplasty.

Diet-induced insulin resistance in mice lacking adiponectin/ACRP30

Here we investigated the biological functions of adiponectin/ACRP30, a fat-derived hormone, by disrupting the gene that encodes it in mice. Adiponectin/ACRP30-knockout (KO) mice showed delayed clearance of free fatty acid in plasma, low levels of fatty-acid transport protein 1 (FATP-1) mRNA in muscle, high levels of tumor necrosis factor-alpha (TNF-alpha) mRNA in adipose tissue and high plasma TNF-alpha concentrations. The KO mice exhibited severe diet-induced insulin resistance with reduced insulin-receptor substrate 1 (IRS-1)-associated phosphatidylinositol 3 kinase (PI3-kinase) activity in muscle. Viral mediated adiponectin/ACRP30 expression in KO mice reversed the reduction of FATP-1 mRNA, the increase of adipose TNF-alpha mRNA and the diet-induced insulin resistance. In cultured myocytes, TNF-alpha decreased FATP-1 mRNA, IRS-1-associated PI3-kinase activity and glucose uptake, whereas adiponectin increased these parameters. Our results indicate that adiponectin/ACRP30 deficiency and high TNF-alpha levels in KO mice reduced muscle FATP-1 mRNA and IRS-1-mediated insulin signaling, resulting in severe diet-induced insulin resistance.

PPARgamma ligands increase expression and plasma concentrations of adiponectin, an adipose-derived protein

Insulin resistance and its dreaded consequence, type 2 diabetes, are major causes of atherosclerosis. Adiponectin is an adipose-specific plasma protein that possesses anti-atherogenic properties, such as the suppression of adhesion molecule expression in vascular endothelial cells and cytokine production from macrophages. Plasma adiponectin concentrations are decreased in obese and type 2 diabetic subjects with insulin resistance. A regimen that normalizes or increases the plasma adiponectin might prevent atherosclerosis in patients with insulin resistance. In this study, we demonstrate the inducing effects of thiazolidinediones (TZDs), which are synthetic PPARgamma ligands, on the expression and secretion of adiponectin in humans and rodents in vivo and in vitro. The administration of TZDs significantly increased the plasma adiponectin concentrations in insulin resistant humans and rodents without affecting their body weight. Adiponectin mRNA expression was normalized or increased by TZDs in the adipose tissues of obese mice. In cultured 3T3-L1 adipocytes, TZD derivatives enhanced the mRNA expression and secretion of adiponectin in a dose- and time-dependent manner. Furthermore, these effects were mediated through the activation of the promoter by the TZDs. On the other hand, TNF-alpha, which is produced more in an insulin-resistant condition, dose-dependently reduced the expression of adiponectin in adipocytes by suppressing its promoter activity. TZDs restored this inhibitory effect by TNF-alpha. TZDs might prevent atherosclerotic vascular disease in insulin-resistant patients by inducing the production of adiponectin through direct effect on its promoter and antagonizing the effect of TNF-alpha on the adiponectin promoter.

SREBP cleavage-activating protein (SCAP) is required for increased lipid synthesis in liver induced by cholesterol deprivation and insulin elevation

In liver, the synthesis of cholesterol and fatty acids increases in response to cholesterol deprivation and insulin elevation, respectively. This regulatory mechanism underlies the adaptation to cholesterol synthesis inhibitors (statins) and high calorie diets (insulin). In nonhepatic cells, lipid synthesis is controlled by sterol regulatory element-binding proteins (SREBPs), membrane-bound transcription factors whose active domains are released proteolytically to enter the nucleus and activate genes involved in the synthesis and uptake of cholesterol and fatty acids. SCAP (SREBP cleavage-activating protein) is a sterol-regulated escort protein that transports SREBPs from their site of synthesis in the endoplasmic reticulum to their site of cleavage in the Golgi. Here, we produced a conditional deficiency of SCAP in mouse liver by genomic recombination mediated by inducible Cre recombinase. SCAP-deficient mice showed an 80% reduction in basal rates of cholesterol and fatty acid synthesis in liver, owing to decreases in mRNAs encoding multiple biosynthetic enzymes. Moreover, these mRNAs failed to increase normally in response to cholesterol deprivation produced by a cholesterol synthesis inhibitor and to insulin elevation produced by a fasting-refeeding protocol. These data provide in vivo evidence that SCAP and the SREBPs are required for hepatic lipid synthesis under basal and adaptive conditions.

ER stress induces cleavage of membrane-bound ATF6 by the same proteases that process SREBPs

ATF6 is a membrane-bound transcription factor that activates genes in the endoplasmic reticulum (ER) stress response. When unfolded proteins accumulate in the ER, ATF6 is cleaved to release its cytoplasmic domain, which enters the nucleus. Here, we show that ATF6 is processed by Site-1 protease (S1P) and Site-2 protease (S2P), the enzymes that process SREBPs in response to cholesterol deprivation. ATF6 processing was blocked completely in cells lacking S2P and partially in cells lacking S1P. ATF6 processing required the RxxL and asparagine/proline motifs, known requirements for S1P and S2P processing, respectively. Cells lacking S2P failed to induce GRP78, an ATF6 target, in response to ER stress. ATF6 processing did not require SCAP, which is essential for SREBP processing. We conclude that S1P and S2P are required for the ER stress response as well as for lipid synthesis.

Decreased expression of a member of the Rho GTPase family, Cdc42Hs, in cells from Tangier disease - the small G protein may play a role in cholesterol efflux

Cholesterol efflux (CE) is the initial and important step of reverse cholesterol transport (RCT), a major protective system against atherosclerosis. However, most of the molecular mechanism for CE still remains to be clarified. In the present study, cDNA subtraction revealed that the expression of a member of the Rho GTPase family, Cdc42Hs, was markedly decreased in both passaged fibroblasts and macrophages (Mφ) from patients with Tangier disease (TD), a rare lipoprotein disorder with reduced CE. This small G protein is known to have many cell biological activities such as rearrangement of actin cytoskeleton and vesicular transport, however the association between this molecule and lipid transport has never been reported. We demonstrate that MDCK cells expressing the dominant negative form of Cdc42Hs had reduced CE, inversely ones expressing the dominant active form had increased CE. From these observations, we would like to raise a novel hypothesis that this type of small G protein may play a role in some steps of CE. To our knowledge, the present study is the first demonstration that the expression of this molecule is altered in cells from human disease.

Involvement of Rho and Rac small G proteins and Rho GDI in Ca2+-dependent exocytosis from PC12 cells

BACKGROUND

The Rho small G protein family, which includes the Rho, Rac and Cdc42 subfamilies, is implicated in various cell functions such as cell shape change, cell motility and cytokinesis, through the reorganization of actin filaments. Rho GDI is an inhibitory regulator of the Rho small G protein family and inhibits the Rho family dependent cell functions. Reorganization of actin filaments is also known to regulate Ca2+-dependent exocytosis.

RESULTS

We have examined here whether the Rho family members are also involved in Ca2+-dependent exocytosis. We have found, by the use of the human growth hormone (GH) co-expression assay system on PC12 cells, that overexpression of Rho GDI inhibits high K+-induced, Ca2+-dependent GH release. This inhibitory action of Rho GDI is restored by co-expression of a dominant active mutant of RhoA or Rac1, but not of a dominant active mutant of Cdc42. C3 transferase, known to ADP-ribosylate Rho and to inhibit its function, also inhibits this GH release. Overexpression of a dominant active mutant of RhoA or Rac1 alone shows only a small effect on GH release. Moreover, immunocytochemical studies show that the overexpression of Rho GDI prevents a partial disruption of the cortical actin network which accompanies exocytosis.

CONCLUSIONS

These results suggest that RhoA, Rac1 and Rho GDI are involved in Ca2+-dependent exocytosis at least partly through the reorganization of actin filaments, and that the activation of RhoA or Rac1 alone is not sufficient for this reaction.

Doc2 enhances Ca2+-dependent exocytosis from PC12 cells

We previously isolated a new protein having two C2-like domains which interacted with Ca2+ and phospholipid and named Doc2 (Double C2). Because Doc2 was abundantly expressed in brain where it was highly concentrated on the synaptic vesicle fraction, we have examined here whether Doc2 is involved in Ca2+-dependent exocytosis from cultured PC12 cells. For this purpose, we took advantage of the growth hormone (GH) co-expression assay system of PC12 cells in which GH is stored in dense core vesicles and released in response to high K+ in an extracellular Ca2+-dependent manner. Northern and Western blot analyses indicated that Doc2 is present in PC12 cells. Overexpression of hemagglutinin-tagged Doc2 stimulated the Ca2+-dependent, high K+-induced release of co-expressed GH without affecting the basal release. In the PC12 cells transfected with a plasmid with the coding sequence of Doc2 in the antisense orientation, the high K+-induced release of co-expressed GH was inversely inhibited. The Doc2 mutant expressing an N-terminal fragment or a C-terminal fragment containing two C2-like domains inhibited the high K+-induced release of co-expressed GH. These results indicate that Doc2 enhances Ca2+-dependent exocytosis of dense core vesicles from PC12 cells.

Involvement of rabphilin-3A in Ca2+-dependent exocytosis from PC12 cells

Rabphilin-3A, a putative target molecule of Rab3A small GTP-binding protein implicated in Ca2+-dependent exocytosis, consists of two functionally different domains: the N-terminal Rab3A-binding domain and the C-terminal two C2-like domains (C2A and C2B domains) interacting with Ca2+ and phospholipid. Here, we used the growth hormone (GH) co-expression assay system of PC12 cells in which expressed GH is released in response to high K+. Reduction of endogenous rabphilin-3A inhibited the Ca2+-dependent, high K+-induced GH release. Various rabphilin-3A mutants expressing an N-terminal, C-terminal, or C2B fragment, but not the rabphilin-3A mutant expressing a C2A fragment, inhibited the high K+-induced GH release. These results indicate that rabphilin-3A is involved at least in Ca2+-dependent exocytosis from PC12 cells and that the C2A and C2B domains have different functions.

Doc2: a novel brain protein having two repeated C2-like domains

Two repeated C2-like domains interacting with Ca2+ and phospholipid are found in synaptotagmin and Rabphilin-3A which are implicated in neurotransmitter release. Here we have isolated a cDNA encoding a novel protein having two repeated C2-like domains from a human brain cDNA library. The isolated cDNA encodes a protein with 400 amino acids and a M(r) of 44,071. The purified recombinant protein indeed interacts with Ca2+ and phospholipid. We have named this protein Doc2 (Double C2). Doc2 is exclusively expressed in brain and is highly concentrated in the synaptic vesicle fraction. These results suggest that Doc2 is a novel brain protein and serves as a Ca2+ sensor in neurotransmitter release.