Myotonia in DNM2-related centronuclear myopathy

Centronuclear myopathy (CNM) is a rare hereditary myopathy characterized by centrally located muscle fiber nuclei. Mutations in the dynamin 2 (DNM2) gene are estimated to account for about 50 % of CNM cases. Electromyographic recordings in CNM may show myopathic motor unit potentials without spontaneous activity at rest. Myotonic discharges, a distinctive electrical activity caused by membrane hyperexcitability, are characteristic of certain neuromuscular disorders. Such activity has been reported in only one CNM case without a known genetic cause. We sequenced the DNM2 gene and the genes associated with myotonia (CLCN1, SCN4A, DMPK and ZNF9) in a sporadic adult patient with CNM and myotonic discharges. Sequencing the entire coding region and exon–intron boundaries revealed a heterozygous c.1106g-a substitution in exon 8, resulting in a R369Q change in the DNM2. Sequencing the CLCN1, SCN4A, DMPK and ZNF9 genes ruled out mutations in these genes. This is the first report of DNM2-related CNM presenting with myotonia. The diagnosis of CNM should be considered in patients with myotonic discharges of an unknown cause.     

Influence of Age on Acute and Chronic GVHD in Children Undergoing HLA-Identical Sibling Bone Marrow Transplantation for Acute Leukemia: Implications for Prophylaxis

Relapse remains the major cause of mortality after hematopoietic cell transplantation (HCT) for pediatric acute leukemia. Previous research has suggested that reducing the intensity of calcineurin inhibitor-based graft-versus-host disease (GVHD) prophylaxis may be an effective strategy for abrogating the risk of relapse in pediatric patients undergoing matched sibling donor (MSD) HCT. We reasoned that the benefits of this strategy could be maximized by selectively applying it to those patients least likely to develop GVHD. We conducted a study of risk factors for GVHD, to risk-stratify patients based on age. Patients age <18 years with leukemia who received myeloablative, T cell-replete MSD bone marrow transplantation and calcineurin inhibitor-based GVHD prophylaxis between 2000 and 2013 and were entered into the Center for International Blood and Marrow Transplant Research registry were included. The cumulative incidence of grade II-IV acute GVHD (aGVHD) was 19%, that of grade II-IV aGVHD 7%, and that of chronic GVHD (cGVHD) was 16%. Compared with age 13 to 18 years, age 2 to 12 years was associated with a lower risk of grade II-IV aGVHD (hazard ratio [HR], .42; 95% confidence interval [CI], .26 to .70; P?=?.0008), grade II-IV aGVHD (HR, .24; 95% CI, .10 to .56; P?=?.001), and cGVHD (HR, .32; 95% CI, .19 to .54; P?<?.001). Compared with 2000-2004, the risk of grade II-IV aGVHD was lower in children undergoing transplantation in 2005-2008 (HR, .36; 95% CI, .20 to .65; P?=?.0007) and in 2009-2013 (HR, .24; 95% CI. .11 to .53; P?=?.0004). Similarly, the risk of grade III-IV aGVHD was lower in children undergoing transplantation in 2005-2008 (HR, .23; 95% CI, .08 to .65; P?=?.0056) and 2009-2013 (HR, .16; 95% CI, .04 to .67; P?=?.0126) compared with those doing so in 2000-2004. We conclude that aGVHD rates have decreased significantly over time, and that children age 2 to 12 years are at very low risk for aGVHD and cGVHD. These results should be validated in an independent analysis, because these patients with high-risk malignancies may be good candidates for trials of reduced GVHD prophylaxis.     

Structure-guided engineering of tick evasins for targeting chemokines in inflammatory diseases

As natural chemokine inhibitors, evasin proteins produced in tick saliva are potential therapeutic agents for numerous inflammatory diseases. Engineering evasins to block the desired chemokines and avoid off-target side effects requires structural understanding of their target selectivity. Structures of the class A evasin EVA-P974 bound to human CC chemokine ligands 7 and 17 (CCL7 and CCL17) and to a CCL8-CCL7 chimera reveal that the specificity of class A evasins for chemokines of the CC subfamily is defined by conserved, rigid backbone–backbone interactions, whereas the preference for a subset of CC chemokines is controlled by side-chain interactions at four hotspots in flexible structural elements. Hotspot mutations alter target preference, enabling inhibition of selected chemokines. The structure of an engineered EVA-P974 bound to CCL2 reveals an underlying molecular mechanism of EVA-P974 target preference. These results provide a structure-based framework for engineering evasins as targeted antiinflammatory therapeutics.

While some proteins exhibit absolute specificity for a unique binding partner, many others display “multispecificity,” whereby they interact with several, but not all, members of a partner protein family (1, 2). Understanding how proteins achieve such selectivity provides a basis for rational engineering to regulate alternative targets. In this study, we investigated the structural basis for multispecific recognition of human proinflammatory chemokines by tick evasin proteins.Chemokines are the master regulators of leukocyte-trafficking, the unifying feature of immune homeostasis and all inflammatory diseases (3). Chemokines stimulate leukocyte migration via activation of chemokine receptors, G protein–coupled receptors expressed on the surfaces of leukocytes. Chemokines are classified into two major families (CCL and CXCL) and two minor families (XCL and CX₃CL) based on the arrangement of conserved cysteine residues near the N termini of their amino acid sequences. Chemokine receptors are classified (CCR, CXCR, XCR, and CX₃CR) based on their chemokine selectivity. The types of leukocytes recruited to specific tissues depend on the array of chemokines expressed in those tissues and the selectivity of those chemokines for the receptors expressed on different leukocyte subsets. For example, in vascular inflammation associated with hypertension, elevated levels of the chemokines CCL2, CCL7, and CCL8 act via the receptor CCR2 (and possibly also CCR1) to stimulate migration of monocytes into the blood vessel wall (4).To suppress leukocyte recruitment in inflammatory diseases, numerous antagonists of specific chemokine receptors have been evaluated in clinical trials. However, these trials have not yielded any new antiinflammatory therapeutics (5), in part because most leukocytes can utilize multiple chemokine receptors, thus circumventing the specific antagonists. The alternative approach of targeting chemokines has not generally been favored, because it would require agents that bind with high affinity to multiple chemokines. However, the natural chemokine-binding proteins of ticks, helminths, and viruses (6–8) display multispecificity for mammalian chemokines, suggesting that they could potentially be deployed as antiinflammatory therapeutics.Evasins are two families of chemokine-binding, antiinflammatory proteins from tick saliva (6). Class A evasins each inhibit multiple CC chemokines of their mammalian hosts but none of the closely related CXC chemokines. Conversely, class B evasins are specific for CXC over CC chemokines but exhibit variable selectivity among CXC chemokines. Typically, each tick species secretes a mixture of evasins, thereby accomplishing broad-spectrum suppression of the host inflammatory response, presumably enabling the tick to feed on the host for extended periods.The in vivo antiinflammatory activity of tick evasins has been demonstrated using a variety of animal models of inflammatory diseases, including lung fibrosis, skin inflammation, arthritis, colitis, pancreatitis, ischemic reperfusion injury, postinfarction myocardial injury, and Leishmania major infection (9–13). However, deploying evasins as effective antiinflammatory therapeutics in humans would require engineering the natural evasins to selectively target the relevant array of chemokines for any given indication while minimizing off-target inhibition (14). Such engineering requires understanding both the specificity of evasins for a single chemokine subfamily and their target preference among chemokines within that subfamily.Previously, only a single structure has been reported for an evasin:chemokine complex, class A evasin EVA-1 bound to CCL3 (15), so it has not been possible to identify the conserved and variable features of the interactions. Nevertheless, the structure revealed that EVA-1 binds to several receptor recognition elements of CCL3, explaining its inhibitory activity. Moreover, limited mutational data (15, 16) have confirmed that residues in the N- and C-terminal regions of EVA-1 and the homologous EVA-4, respectively, contribute to binding affinity, raising the question of whether the structural basis of CC chemokine recognition varies across the class A evasin family.To establish a structure-based platform for engineering the chemokine selectivity of class A evasins, we now report the structures of EVA-P974 (previously called ACA-01) (17, 18), from the Cayenne tick (Amblyomma cajennense), bound to each of two wild-type chemokines and one chimeric CC chemokine. Structural comparisons and extensive evasin and chemokine mutational data revealed the structural basis for CC chemokine specificity and identified several “hotspots” that define target preference among CC chemokines. These insights enabled EVA-P974 to be engineered to modify its target preference. We further verified the molecular basis of the modified selectivity by solving the chemokine-bound structure of the engineered evasin. Finally, by inhibiting a chemokine mixture, we provide proof of principle for applying engineered evasins as multichemokine inhibitors.     

Intermediate and High-Grade Gastric Non-Hodgkin's Lymphoma: A Prospective Study of Non-Surgical Treatment with Primary Chemotherapy, with or without Radiotherapy

The role of surgery as initial treatment in gastric lymphoma remains controversial. We have prospectively evaluated a stomach conservation strategy in histologically aggressive gastric lymphoma, using primary adriamycin-containing chemotherapy, followed by involved-field radiotherapy in patients with limited disease. Twenty-six patients (median age 69 years) were entered in this study; 15 had stage I disease, 7 had stage II disease and 4 had stage IV disease. The chemotherapy combinations were CHOP (18 patients) and ProMACE/MOPP (8 patients). Radiotherapy was given to 11 patients. Of the 24 patients evaluated for response, 18 (75%) achieved endoscopically-confirmed complete response and 4 (17%) partial response. During follow-up (median 22 months), none of the complete responders developed recurrent lymphoma. Gastric resection was performed in 1/26 patients who did not respond to primary chemotherapy. There were no cases of perforation, but three patients (12%) developed acute gastro-intestinal bleeding a few days after the onset of chemotherapy, one of whom required a surgical devascularization procedure. There was no treatment-related mortality. These data further support the non-surgical approach in histologically aggressive gastric lymphoma, using primary chemotherapy with or without radiation therapy.     

Direct inhibitory effect of erythromycin on human alimentary tract smooth muscle

BACKGROUND: Erythromycin was found to stimulate motor activity in the upper gastrointestinal tract. However, in several smooth muscle preparations, it also elicited an inhibitory effect. Our aim was to study the effect of erythromycin in various human alimentary tract smooth muscles. METHODS: Using force measurements, we assessed the effect of erythromycin on electrically and chemically evoked contractions of isolated muscle strips of human gallbladder, small intestine, and colon. RESULTS: The muscarinic receptor agonist carbachol evoked contraction in gallbladder, ileum, and colonic smooth muscle that were reduced by erythromycin at 10(-4) M to 72% +/- 24%, 77% +/- 22%, and 76% +/- 22% of control values, respectively. Erythromycin did not affect contractions evoked by noncholinergic agents. Erythromycin's inhibitory effects were not altered by nerve blockade, indicating a direct muscle effect. Eryrthromycin also reduced contractions evoked by electrical stimulation at frequencies of 5, 10, and 20 Hz in the human gallbladder, ileum, and colon preparations. These contractions were reduced by erythromycin in a reversible and dose-dependent manner. CONCLUSIONS: Erythromycin antagonized direct cholinergic effects on various smooth muscles from the human alimentary tract in a concentration-dependent manner.