A Practical Approach to the Diagnosis and Management of Thrombocytopenia Associated with Glycoprotein IIb/IIIa Receptor Inhibitors

The introduction of drugs that inhibit the GP IIb/IIIa receptor represents one of the most important new developments in the field of cardiovascular pharmacotherapeutics of the past decade. Thrombocytopenia associated with a GP IIb/IIIa inhibitor can occur in up to 5% of patients and is associated with poor clinical outcomes. Monitoring of the platelet count early after administration of these drugs is recommended and further assessment of the platelet count should be performed with long-term oral administration. Confirmation of true thrombocytopenia and an investigation of other potential etiologies are crucial initial diagnostic steps that should be taken when a platelet count of <100,000/cm³ is encountered. In patients receiving concomitant heparin, identification of heparin-induced thrombocytopenia using an enzyme-linked immunosorbent assay to detect anti-heparin-PF4 antibodies is preferred. Treatment recommendations depend upon the severity of thrombocytopenia and presence of bleeding. In general, GP IIb/IIIa inhibitor therapy should be stopped; conventional critical care instituted; and platelet transfusions considered if the platelet count is <10,000/cm³, if there is severe bleeding, or if an emergency invasive procedure is required. Readministration of GP IIb/IIIa inhibitors may be associated with an increased risk of thrombocytopenia in selected circumstances, and caution is advised if the patient had previously experienced a significant decline in the platelet count or developed drug-induced antibodies following prior use. Future areas of research should target the mechanism(s) of thrombocytopenia, more accurate diagnostic methods, and the risk of thrombocytopenia when these drugs are combined with other antiplatelet and anticoagulant agents.     

Somatostatin and insulin secretion in man. IV. The role of calcium

In this study we evaluated the influence of changes in serum calcium concentration upon somatostatin-mediated inhibition of insulin secretion in man. For this purpose, we investigated the effect of somatostatin in a group of subjects with hypoparathyroidism before and after correction of hypocalcemia and in normal subjects made hypercalcemic by exogenous calcium administration. In the presence of hypocalcemia, somatostatin caused an almost total inhibition of glucose-induced insulin secretion. In addition, somatostatin significantly decreased glucose tolerance in those hypocalcemic patients who exhibited normal tolerance under basal conditions [glucose utilization (kG), 1.44 +/- 0.13 before vs. 0.68 +/- 0.14 during somatostatin; P < 0.02]. Glucose tolerance was unaltered in those subjects who had a decreased glucose tolerance under basal conditions (kG, 1.01 +/- 0.1 before vs. 0.88 +/- 0.16 during somatostatin; P = NS). Under normocalcemic conditions, the insulin response to glucose and glucose tolerance were significantly greater than values measured during hypocalcemia. However, somatostatin blunted the insulin response to glucose and significantly decreased glucose utilization. These inhibitory effects of somatostatin upon insulin secretion and glucose tolerance were not reversed by a concurrent infusion of calcium (serum calcium, 6.9 +/- 0.3 meq/liter) in a group of normal subjects. Our data confirm the reduced insulin secretion and glucose tolerance in hypoparathyroidism and demonstrate that the suppressive effect of somatostatin upon glucose-stimulated insulin secretion is independent of changes in serum calcium concentration over a wide range.     

Hemodynamic effects of somatostatin in insulin-dependent diabetic subjects

Summary The aim of the present study was to evaluate possible hemodynamic effects of somatostatin in insulin-dependent diabetic subjects. For this purpose, 7 insulin-requiring juvenile-onset diabetics were submitted to a short-term infusion of cyclic somatostatin (250 μg/h, over 2 h) or saline in randomized order. Somatostatin infusion resulted in a progressive and significant decrease in heart rate, stroke volume, cardiac index and velocity circumferential fiber; on the other hand, left ventricular ejection time was augmented by somatostatin. None of these effects was seen in the saline control study. We conclude that somatostatin exerts a negative inotropic effect in insulin-dependent diabetes.     

Effects of a treatment adherence enhancement program on health literacy, patient-provider relationships, and adherence to HAART among low-income HIV-positive Spanish-speaking Latinos

The impact of an adherence enhancement program for low income HIV-infected Spanish-speaking Latinos on health literacy, patient-provider relationships, and adherence to HAART was examined. Evaluations were conducted at baseline, 6 weeks, and 6 months for participants (n = 85) randomly assigned to either the intervention group or a comparison group; 69 (81%) remained in the study for the entire 6-month duration. The intervention group scored significantly better than the comparison group on 3 of 5 measures of HIV health literacy at 6 weeks and on 2 of 5 measures, at 6 months. While there was a weak trend for the intervention group to report an increase in self-efficacy of medication adherence management, baseline to 6 weeks, no other changes were significant. Perceptions of the quality of relationship and communications with their HIV-treating physicians improved both at 6 weeks (p = 0.04) and at 6 months (p < 0.001). The comparison group showed little change baseline to 6 weeks and baseline to 6 months. While there was a trend for the pilot group to report better medication adherence, these differences were not statistically significant. Further evaluation of the impact of this adherence enhancement program is needed.     

Role of free fatty acids on cardiac autonomic nervous system in noninsulin-dependent diabetic patients: effects of metabolic control

Decreased heart rate variability (HRV) is a risk factor for cardiovascular mortality. Elevated plasma free fatty acid (FFA) levels decrease HRV in healthy subjects. Thus, we investigated the effect of changes in plasma FFA levels on HRV, in non-insulin-dependent diabetes (NIDDM) patients. Thirty NIDDM patients free from diabetic neuropathy volunteered for a study made by two phases. In study A, changes in HRV along a 10% lipid emulsion infusion + heparin (n = 15) or saline infusion (control study; n = 15) were investigated. In study B, all patients (n = 30) underwent further determination of HRV after 3 months of improved metabolic control achieved by intensified insulin treatment. In study A, lipid emulsion infusion increased plasma FFA (P < 0.001) and catecholamine concentrations (P < 0.005), mean arterial blood pressure (P < 0.005), low frequency/high frequency (LF/HF) ratio (P < 0.001). Delta plasma FFA levels correlated with delta LF/HF ratio (r = 0.57; P < 0.02). Along with saline infusion, metabolic and cardiovascular parameters remained unchanged throughout the test. In study B, improved metabolic control lowered fasting plasma glucose (P < 0.005), FFA (P < 0.001), norepinephrine (P < 0.02), epinephrine (P < 0.04), and glycosylated hemoglobin levels (P < 0.001), mean arterial blood pressure(P < 0.05), and LF/HF ratio (P < 0.001). Again percent decline in plasma FFA correlated with the percent change in LF/HF ratio (r = 0.72; P < 0.001). In a multivariate analysis, percent changes in LF/HF ratio were associated with percent changes in plasma FFA independently of gender and percent changes in body mass index, waist/hip ratio, plasma norepinephrine, epinephrine, glycosylated hemoglobin, and daily insulin therapy. Our study demonstrates that changes in plasma FFA levels may have a parallel effect on cardiac sympathetic/parasympathetic nervous system balance in NIDDM patients.     

Development and characterization of a 99mTc‐labeled Neuropeptide Y short analog with potential application in breast cancer imaging

The aim of this work was to develop and evaluate a ^99mTc‐labeled neuropeptide Y derivative with affinity toward Y1‐receptor. The selected amino acid sequence included nine amino acids derived from the C‐terminal portion of the NPY complemented with the addition of one cysteine‐mercaptoacetic acid moiety to bind the radiometal. Labeling was achieved through the preparation of a 3 + 1 nitrido complex. Physicochemical evaluation, cell uptake, internalization and externalization studies, and competitive assays were performed. Biodistribution experiments were carried out in normal and tumor‐bearing mice. A single product with radiochemical purity >90% and high stability was obtained. In vitro analysis showed specific cellular uptake, IC₅₀ of 73.2 nM, and a high internalization rate (80%). Biodistribution studies showed low blood and renal uptake and combined hepatobiliary and urinary elimination. Preliminary studies in mice bearing induced breast tumors rendered promising uptake values.     

Quantum dots functionalized with gH625 attenuate QDs oxidative stress and lethality in Caenorhabditis elegans: a model system

Ecotoxicology - Nanomaterials have revolutionized many scientific fields and are widely applied to address environmental problems and to develop novel health care strategies. However, their...     

First structure of full-length mammalian phenylalanine hydroxylase reveals the architecture of an autoinhibited tetramer

Improved understanding of the relationship among structure, dynamics, and function for the enzyme phenylalanine hydroxylase (PAH) can lead to needed new therapies for phenylketonuria, the most common inborn error of amino acid metabolism. PAH is a multidomain homo-multimeric protein whose conformation and multimerization properties respond to allosteric activation by the substrate phenylalanine (Phe); the allosteric regulation is necessary to maintain Phe below neurotoxic levels. A recently introduced model for allosteric regulation of PAH involves major domain motions and architecturally distinct PAH tetramers [Jaffe EK, Stith L, Lawrence SH, Andrake M, Dunbrack RL, Jr (2013) Arch Biochem Biophys 530(2):73–82]. Herein, we present, to our knowledge, the first X-ray crystal structure for a full-length mammalian (rat) PAH in an autoinhibited conformation. Chromatographic isolation of a monodisperse tetrameric PAH, in the absence of Phe, facilitated determination of the 2.9 Å crystal structure. The structure of full-length PAH supersedes a composite homology model that had been used extensively to rationalize phenylketonuria genotype–phenotype relationships. Small-angle X-ray scattering (SAXS) confirms that this tetramer, which dominates in the absence of Phe, is different from a Phe-stabilized allosterically activated PAH tetramer. The lack of structural detail for activated PAH remains a barrier to complete understanding of phenylketonuria genotype–phenotype relationships. Nevertheless, the use of SAXS and X-ray crystallography together to inspect PAH structure provides, to our knowledge, the first complete view of the enzyme in a tetrameric form that was not possible with prior partial crystal structures, and facilitates interpretation of a wealth of biochemical and structural data that was hitherto impossible to evaluate.Mammalian phenylalanine hydroxylase (PAH) (EC 1.14.16.1) is a multidomain homo-multimeric protein whose dysfunction causes the most common inborn error in amino acid metabolism, phenylketonuria (PKU), and milder forms of hyperphenylalaninemia (OMIM 261600) (1). PAH catalyzes the hydroxylation of phenylalanine (Phe) to tyrosine, using nonheme iron and the cosubstrates tetrahydrobiopterin and molecular oxygen (2, 3). A detailed kinetic mechanism has recently been derived from elegant single-turnover studies (4). PAH activity must be carefully regulated, because although Phe is an essential amino acid, high Phe levels are neurotoxic. Thus, Phe allosterically activates PAH by binding to a regulatory domain. Phosphorylation at Ser16 potentiates the effects of Phe, with phosphorylated PAH achieving full activation at lower Phe concentrations than the unphosphorylated protein (5, 6). Allosteric activation by Phe is accompanied by a major conformational change, as evidenced by changes in protein fluorescence and proteolytic susceptibility, and by stabilization of a tetrameric conformer (3).There are >500 disease-associated missense variants of human PAH; the amino acid substitutions are distributed throughout the 452-residue protein and among all its domains (Fig. 1A) (7–9). Of those disease-associated variants that have been studied in vitro (e.g., ref. 10), some confound the allosteric response, and some are interpreted as structurally unstable. We also suggest that the activities of some disease-associated variants may be dysregulated by an altered equilibrium among conformers having different intrinsic levels of activity, arguing by analogy to the enzyme porphobilinogen synthase (PBGS) and its porphyria-associated variants (11). Consistent with this notion, we have recently established that PAH can assemble into architecturally distinct tetrameric conformers (12), and propose that these conformers differ in activity due to differences in active-site access. This idea has important implications for drug discovery, as it implies that small molecules could potentially modulate the conformational equilibrium of PAH, as has already been demonstrated for PBGS (e.g., ref. 13). Deciphering the relationship among PAH structure, dynamics, and function is a necessary first step in testing this hypothesis.Open in a separate windowFig. 1.The structure of PAH. (A) The annotated domain structure of mammalian PAH. (B) The 2.9 Å PAH crystal structure in orthogonal views, colored as in part A, subunit A is shown in ribbons; subunit B is as a Cα trace; subunit C is in sticks; and subunit D is in transparent spheres. In cyan, the subunits are labeled near the catalytic domain (Top); in red, they are labeled near the regulatory domain (Bottom). The dotted black circle illustrates the autoregulatory domain partially occluding the enzyme active site (iron, in orange sphere). (C) Comparison of the subunit structures of full-length PAH and those of the composite homology model; the subunit overlay aligns residues 144–410. The four subunits of the full-length PAH structure (the diagonal pairs of subunits are illustrated using either black or white) are aligned with the two subunits of 2PAH (cyan) and the one subunit of 1PHZ (orange). The catalytic domain is in spheres, the regulatory domain is in ribbons, and the multimerization domain is as a Cα trace. The arrow denotes where the ACT domain and one helix of 2PAH conflict.Numerous crystal structures are known for one- and two-domain constructs of mammalian PAH (14).

Table S1.

Mammalian PAH structures available in the PDB (August 2015)