Pregnancy and weaning regulate human maternal liver size and function

During pregnancy, the rodent liver undergoes hepatocyte proliferation and increases in size, followed by weaning-induced involution via hepatocyte cell death and stromal remodeling, creating a prometastatic niche. These data suggest a mechanism for increased liver metastasis in breast cancer patients with recent childbirth. It is unknown whether the human liver changes in size and function during pregnancy and weaning. In this study, abdominal imaging was obtained in healthy women at early and late pregnancy and postwean. During pregnancy time points, glucose production and utilization and circulating bile acids were measured. Independently of weight gain, most women’s livers increased in size with pregnancy, then returned to baseline postwean. Putative roles for bile acids in liver growth and regression were observed. Together, the data support the hypothesis that the human liver is regulated by reproductive state with growth during pregnancy and volume loss postwean. These findings have implications for sex-specific liver diseases and for breast cancer outcomes.

Sex-specific differences in liver disease have been attributed to sexual dimorphisms in steroid production, metabolic enzymes, and behavior patterns (1). Whether a pregnancy cycle contributes to sex-specific liver disease remains largely unexplored; however, a previously unrecognized liver biology linked to reproductive status has been reported in rodents (2). This rodent study found that during pregnancy and lactation, hepatocytes proliferated and entered a higher anabolic state accompanied by an overall increase in liver size. Upon weaning, hepatocytes rapidly underwent programmed cell death, liver metabolism shifted toward catabolism, and the liver regressed to its prepregnant size in a process referred to as weaning-induced liver involution (2). In mice, liver involution promoted breast cancer outgrowth in the liver, suggesting a pathophysiological consequence of liver involution (2, 3).Notably, young women diagnosed with breast cancer in the postpartum period were found to be at increased risk for liver metastasis (2). Taken together, these findings suggest that weaning-induced liver involution, which we predict would return the enlarged liver to its prepregnant, prelactational state, may create a prometastatic liver niche in women. However, it is unknown whether the human liver changes in size and function across a reproductive cycle, as expected if the liver is tuned to meet the unique metabolic demands of pregnancy, lactation, and weaning. Such evidence would corroborate findings in rodents and would be foundationally important for future studies of liver health in women.To investigate the impact of reproductive state on liver size and function in women, we conducted a prospective study of healthy pregnant women using magnetic resonance and spectroscopy imaging of the liver and compared findings to a validated rodent model. Here, we show that the human female liver is regulated in both size and function by reproductive state and provide evidence of weaning-induced liver involution in humans. Furthermore, our data provide a hypothesis to explain the increased liver metastasis observed in postpartum breast cancer patients, as well as having potentially broader implications for the understanding of sex-specific liver diseases.     

Identification and characterization of an atypical Gαs-biased β2AR agonist that fails to evoke airway smooth muscle cell tachyphylaxis

G protein–coupled receptors display multifunctional signaling, offering the potential for agonist structures to promote conformational selectivity for biased outputs. For β₂-adrenergic receptors (β₂AR), unbiased agonists stabilize conformation(s) that evoke coupling to Gαs (cyclic adenosine monophosphate [cAMP] production/human airway smooth muscle [HASM] cell relaxation) and β-arrestin engagement, the latter acting to quench Gαs signaling, contributing to receptor desensitization/tachyphylaxis. We screened a 40-million-compound scaffold ranking library, revealing unanticipated agonists with dihydroimidazolyl-butyl-cyclic urea scaffolds. The S-stereoisomer of compound C1 shows no detectable β-arrestin engagement/signaling by four methods. However, C1-S retained Gαs signaling—a divergence of the outputs favorable for treating asthma. Functional studies with two models confirmed the biasing: β₂AR-mediated cAMP signaling underwent desensitization to the unbiased agonist albuterol but not to C1-S, and desensitization of HASM cell relaxation was observed with albuterol but not with C1-S. These HASM results indicate biologically pertinent biasing of C1-S, in the context of the relevant physiologic response, in the human cell type of interest. Thus, C1-S was apparently strongly biased away from β-arrestin, in contrast to albuterol and C5-S. C1-S structural modeling and simulations revealed binding differences compared with unbiased epinephrine at transmembrane (TM) segments 3,5,6,7 and ECL2. C1-S (R2 = cyclohexane) was repositioned in the pocket such that it lost a TM6 interaction and gained a TM7 interaction compared with the analogous unbiased C5-S (R2 = benzene group), which appears to contribute to C1-S biasing away from β-arrestin. Thus, an agnostic large chemical-space library identified agonists with receptor interactions that resulted in relevant signal splitting of β₂AR actions favorable for treating obstructive lung disease.

Most G protein–coupled receptors (GPCRs) are now recognized as multisignal transducers (1, 2). Early concepts of agonist–receptor interactions were based on the idea that there was a single “active” receptor conformation induced by the binding of any agonist, resulting in an interaction with the heterotrimeric G protein and a universal, singular signal. Generally, the α-subunit of the G protein, upon its dissociation, was considered the primary activator (or inhibitor) of the effector, resulting in the intracellular signal. Subsequently, it became clear that multiple signaling outcomes from activation of a given GPCR can occur from a single agonist due to specific molecular determinants of the receptor triggering independent mechanisms (3–5). As these multiple functions were being identified, it was apparent that agonists with different structures could act at a given receptor to preferentially activate one signal with minimal engagement of others, a property later termed signal biasing (6–8). Biased agonists, then, could represent important advantages over nonbiased agonists due to this signal selectivity, activating a specified therapeutic pathway while minimally evoking unnecessary or deleterious signaling. The pathway selectivity of biased agonists is thought to be established by the stabilization of specific conformation(s) of the agonist–receptor complex via a set of interactions that differ from those of unbiased (also called balanced) agonists (9–12). While it is conceivable that small modifications of established cognate agonists might yield such specialized signaling, significant deviation from common agonist structures may be necessary to meet this goal (13).The signals/functions of a given GPCR that might be sought for selective activation are defined by the cell type, disease, and desired final physiologic function. In asthma and chronic obstructive pulmonary disease (COPD), active human airway smooth muscle (HASM) cellular contraction limits airflow, representing a major cause of morbidity and mortality. β₂-adrenergic receptors (β₂ARs) expressed on HASM cells are the targets for binding of therapeutically administered β-agonists, which relax the cells via a cyclic adenosine monophosphate–mediated mechanism (14). β-agonists are used for treating acute bronchospasm as well as for long-term prevention. However, the HASM bronchodilator response to acute β-agonist is attenuated by receptor desensitization (15), with typical treatments of humans, or isolated HASM cells, leading to a loss of receptor function over time (16–18), clinically termed tachyphylaxis.Agonist-promoted desensitization of β₂AR (and other GPCRs) is due to partial uncoupling of the receptor to the G protein, which is initiated by phosphorylation of intracellular Ser/Thr residues of the receptor by G protein–coupled receptor kinases (GRKs) (19, 20). The GRK-phosphorylated β₂AR recruits β-arrestin1 or β-arrestin2 to these receptors, with subsequent interactions that appear to compete with the receptor for its binding to the Gα subunit, thus attenuating the intracellular response (11, 21). Such competition has been strongly inferred for the β₂AR (22, 23) and is compelling for rhodopsin–arrestin interactions (24). In addition, β-arrestin binding to GPCRs can initiate receptor internalization and other events such as receptor activation of ERK1/2 (25) through its multiprotein adapter functions. Thus β-arrestin engagement can be considered an early “second signal” of the β₂AR as well as a desensitization initiator for attenuating the Gs signal. An agonist that is biased toward Gαs coupling (cAMP production and airway smooth muscle [ASM] relaxation) and away from β-arrestin binding (desensitization) would be desirable in treating obstructive lung diseases, since efficacy would not be attenuated acutely, nor would tachyphylaxis be experienced from extended treatment. While biased agonists favoring either G protein or β-arrestin (6) signaling have been described for some GPCRs (such as μ-opioid and type 1 angiotensin II receptors), Gαs biasing has not been apparent from most studies with catecholamine-like compounds for the β₂AR. Thus, we have little information as to whether the two β₂AR pathways can be differentially activated in a selective manner by an efficacious agonist, nor is it apparent from a structural standpoint what strategy might be employed to design agonists biased in this manner for this receptor.In order to find this type of biasing for the β₂AR, we screened a 40-million-compound scaffold ranking (SR) library that was agnostic to known β₂AR agonist structures. We found a scaffold in which substitutions of certain R groups led to individual compounds that are apparently Gαs-biased agonists for β₂AR with no apparent engagement of β-arrestin in model systems. Additional studies in HASM cells revealed a lack of tachyphylaxis of the relaxation effect by the lead compound compared with the most widely utilized β₂AR agonist, albuterol. The structure of this biased agonist is very different from that of catecholamine-like agonists. To ascertain the mechanism that may underlie this biased activity, we used structural modeling and molecular simulations and studied homologous compounds with different R groups and receptor mutagenesis to predict the interaction sites with the activated β₂AR. Such studies uncovered distinct structural characteristics that may be responsible for the biasing effect.     

From competition to co-operation: new economic relationships in the National Health Service

The Labour government has outlined its plans to ‘replace’ the competitive internal market with a more collaborative system based on partnership. Agreement amongst purchasers and providers is to be based on co-operation rather than competition. Longer term agreements covering periods of 3–5 years are to replace annual contracts within this new environment. The aim of this paper is to explore the potential economic implications of these policy changes by drawing on the economics of co-operation and the transaction costs approach to longer term contracting. Issues surrounding the role of trust in contractual relationships are explored and the relevance of experience and evidence from non-health care sectors is considered in the context of the NHS. It is concluded that both theory and empirical evidence suggest that co-operation and trust can play a central role in the efficient organisation of contractual arrangements in circumstances similar to those under which the NHS operates. However, we warn against the expectation that the policy changes will produce automatically the scale of benefits predicted by the Labour government, especially as they will have to find a way of extracting reasonable performance from providers under a system of collaboration and long term agreements. They may find they need to tread a fine line between competition and co-operation in order to reap the benefits of both. © 1998 John Wiley & Sons, Ltd.     

The intranuclear cleft of the intervertebral disk: magnetic resonance imaging

Three cadaver spines, 40 patients who were symptomatic for lumbar disk disease, and ten healthy subjects were examined by MR. T2 weighted spin echo images were used to evaluate the character of an intranuclear cleft. This cleft appears identical to annular tissue both on T2 weighted images and histologically. A 120 msec TE, 3 sec TR image was used to delimit the normal nucleus pulposus from the annulus. The incidence and age distribution of the cleft were calculated. An intranuclear cleft was present in all normal disks in both control and symptomatic subjects who were 30 years of age and older. If present in one disk, it was also present in 94% of the other disks in the same subject. This cleft represents a normal anatomic structure and appears to be a constant feature in subjects 30 years of age or older. Its absence, in the presence of an increased signal intensity within the disk, suggests a pathological process with a long T2 value, such as inflammation.     

Consultant physicians for the future: report from a working party of the Royal College of Physicians and the medical specialties

Workforce planning in medicine is at best an inexact science and at worst a dark art. Over the past year it has become clear that several forces influencing the consultant physician workforce are coming into play at the same time. Many of these forces cannot be easily controlled, but their effects are predictable and thus can be prepared for. Recommendations are made as to how the issues raised should be addressed.     

Considerations arising from a complementary learning systems perspective on hippocampus and neocortex

We discuss a framework for the organization of learning systems in the mammalian brain, in which the hippocampus and related areas form a memory system complementary to learning mechanisms in neocortex and other areas. The hippocampal system stores new episodes and “replays” them to the neocortical system, interleaved with ongoing experience, allowing generalization as cortical memories form. The data to account for include: 1) neurophysiological findings concerning representations in hippocampal areas, 2) behavioral evidence demonstrating a spatial role for hippocampus, 3) and effects of surgical and pharmacological manipulations on neuronal firing in hippocampal regions in behaving animals. We hypothesize that the hippocampal memory system consists of three major modules: 1) an invertible encoder subsystem supported by the pathways between neocortex and entorhinal cortex, which provides a stable, compressed, invertible encoding in entorhinal cortex (EC) of cortical activity patterns, 2) a memory separation, storage, and retrieval subsystem, supported by pathways between EC, dentate gyrus and area CA3, including the CA3 recurrent collaterals, which facilitates encoding and storage in CA3 of individual EC patterns, and retrieval of those CA3 encodings, in a manner that minimizes interference, and 3) a memory decoding subsystem, supported by the Shaffer collaterals from area CA1 to area CA3 and the bi-directional pathways between EC and CA3, which provides the means by which a retrieved CA3 coding of an EC pattern can reinstate that pattern on EC. This model has shown that 1) there is a trade-off between the need for information-preserving, structure-extracting encoding of cortical traces and the need for effective storage and recall of arbitrary traces, 2) long-term depression of synaptic strength in the pathways subject to long-term potentiation is crucial in preserving information, 3) area CA1 must be able to exploit correlations in EC patterns in the direct perforant path synapses. © 1997 Wiley-Liss, Inc.     

GROWTH HORMONE DEFICIENCY FOLLOWING RADIOTHERAPY FOR ORBITAL AND PARAMENINGEAL SARCOMAS

Growth hormone deficiency (GHD) is a recognized late effect of successful treatment of tumors requiring cranial irradiation. Growth after treatment was assessed in 16 patients with sarcomas of the orbital and parameningeal regions. Median age at diagnosis was 6.35 years and median follow-up was 7.2 years. Treatment consisted of combination chemotherapy and radical radiotherapy, conventionally fractionated with a median dose 4500 cGy; the hypothalamic/pituitary region received a median dose of 4163 cGy. Height was measured every 6 months and 13/16 patients underwent tests of GH function. At GH testing median height standard deviation score (SDS) was 0.7, a median decrease of 0.55 since tumor diagnosis. Seven patients were treated with human GH (hGH) at a median of 3.7 years from tumor diagnosis and followed for a median of 2.7 years. Treatment with hGH resulted in a median increase in height SDS of 0.9. Careful surveillance with timely introduction of GH replacement is required for treatment of GHD following treatment of orbital and parameningeal sarcomas.