Antiendomysial and antihuman recombinant tissue transglutaminase antibodies in the diagnosis of coeliac disease: a biopsy-proven European multicentre study

OBJECTIVE: To investigate the value of serum antitissue transglutaminase IgA antibodies (IgA-TTG) and IgA antiendomysial antibodies (IgA-EMA) in the diagnosis of coeliac disease in cohorts from different geographical areas in Europe. The setting allowed a further comparison between the antibody results and the conventional small-intestinal histology. METHODS: A total of 144 cases with coeliac disease [median age 19.5 years (range 0.9-81.4)], and 127 disease controls [median age 29.2 years (range 0.5-79.0)], were recruited, on the basis of biopsy, from 13 centres in nine countries. All biopsy specimens were re-evaluated and classified blindly a second time by two investigators. IgA-TTG were determined by ELISA with human recombinant antigen and IgA-EMA by an immunofluorescence test with human umbilical cord as antigen. RESULTS: The quality of the biopsy specimens was not acceptable in 29 (10.7%) of 271 cases and a reliable judgement could not be made, mainly due to poor orientation of the samples. The primary clinical diagnosis and the second classification of the biopsy specimens were divergent in nine cases, and one patient was initially enrolled in the wrong group. Thus, 126 coeliac patients and 106 controls, verified by biopsy, remained for final analysis. The sensitivity of IgA-TTG was 94% and IgA-EMA 89%, the specificity was 99% and 98%, respectively. CONCLUSIONS: Serum IgA-TTG measurement is effective and at least as good as IgA-EMA in the identification of coeliac disease. Due to a high percentage of poor histological specimens, the diagnosis of coeliac disease should not depend only on biopsy, but in addition the clinical picture and serology should be considered.     

Late results of isolated aortic valve replacement by Bj?rk-Shiley prosthesis. Apropos of 596 cases

Between 1970 and 1985, 596 patients underwent isolated aortic valve replacement with a Bj?rk-Shiley prosthesis: 448 men and 148 women, average age 52 +/- 13 years (range 10-78 years). The valve lesion was aortic stenosis in 158 cases, aortic regurgitation in 218 cases and mixed valve disease in 220 cases. Fifty-four per cent of patients had invalidating cardiac failure (Stage III of the NYHA Classification). Thirteen per cent of patients had an associated non valvular surgical procedure. The hospital mortality was 5.7% and 77% of the early deaths were of cardiac origin. Results were analysed after an average follow-up period of 90 +/- 15 months, a total of 3817 patient-years. The late mortality was 94 (16.7%). Actuarial survival was 87 +/- 1% at 5 years and 79 +/- 2% at 10 years. A prognostic score was established from a multifactorial analysis: Cox = 0.44 (NYHA Stage 1, 2, 3, 4) + 5.29 C/T (absolute value) + 1.15 associated procedure (0.1) + 0.65 (RBBB) (0.1). In the long-term, 84.8% of survivors were asymptomatic (NYHA Stages I and II). The incidence of thrombo-embolism was 0.5/100 patient-years. At 10 years, 95% of patients had no thromboembolic complication. The incidence of ineffective endocarditis was 0.3/100 patient-years and that of complications of anticoagulant therapy was 0.4/100 patient-years. The incidence of valve dehiscence was 0.1/100 patient-years and the reoperation rate was 0.4/100 patient-years but there were no cases of valve dysfunction. The global complication rate in this series was 1.35/100 patient-years. These results confirm the good results of aortic valve replacement with a mechanical prosthesis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Hypoxia drives transient site-specific copy gain and drug-resistant gene expression

Copy number heterogeneity is a prominent feature within tumors. The molecular basis for this heterogeneity remains poorly characterized. Here, we demonstrate that hypoxia induces transient site-specific copy gains (TSSGs) in primary, nontransformed, and transformed human cells. Hypoxia-driven copy gains are not dependent on HIF1α or HIF2α; however, they are dependent on the KDM4A histone demethylase and are blocked by inhibition of KDM4A with a small molecule or the natural metabolite succinate. Furthermore, this response is conserved at a syntenic region in zebrafish cells. Regions with site-specific copy gain are also enriched for amplifications in hypoxic primary tumors. These tumors exhibited amplification and overexpression of the drug resistance gene CKS1B, which we recapitulated in hypoxic breast cancer cells. Our results demonstrate that hypoxia provides a biological stimulus to create transient site-specific copy alterations that could result in heterogeneity within tumors and cell populations. These findings have major implications in our understanding of copy number heterogeneity and the emergence of drug resistance genes in cancer.     

From the Cover: PNAS Plus: Nicastrin functions to sterically hinder γ-secretase–substrate interactions driven by substrate transmembrane domain

γ-Secretase is an intramembrane-cleaving protease that processes many type-I integral membrane proteins within the lipid bilayer, an event preceded by shedding of most of the substrate’s ectodomain by α- or β-secretases. The mechanism by which γ-secretase selectively recognizes and recruits ectodomain-shed substrates for catalysis remains unclear. In contrast to previous reports that substrate is actively recruited for catalysis when its remaining short ectodomain interacts with the nicastrin component of γ-secretase, we find that substrate ectodomain is entirely dispensable for cleavage. Instead, γ-secretase–substrate binding is driven by an apparent tight-binding interaction derived from substrate transmembrane domain, a mechanism in stark contrast to rhomboid—another family of intramembrane-cleaving proteases. Disruption of the nicastrin fold allows for more efficient cleavage of substrates retaining longer ectodomains, indicating that nicastrin actively excludes larger substrates through steric hindrance, thus serving as a molecular gatekeeper for substrate binding and catalysis.Regulated intramembrane proteolysis (RIP) involves the cleavage of a wide variety of integral membrane proteins within their transmembrane domains (TMDs) by a highly diverse family of intramembrane-cleaving proteases (I-CLiPs) (1). I-CLiPs are found in all forms of life and govern many important biological functions, including but not limited to organism development (2), lipid homeostasis (3), the unfolded protein response (4), and bacterial quorum sensing (5). As the name implies, RIP must be tightly regulated to ensure that the resultant signaling events occur only when prompted by the cell and to prevent cleavage of the many nonsubstrate “bystander” proteins present within cellular membranes. Despite this, very little is known about the molecular mechanisms by which I-CLiPs achieve their exquisite specificity. Although traditional soluble proteases maintain substrate specificity by recognizing distinct amino acid sequences flanking the scissile bond, substrates for intramembrane proteases have little to no sequence similarity.Recent work on rhomboid proteases has demonstrated that this family of I-CLiPs achieves substrate specificity via a mechanism that is dependent on the transmembrane dynamics of the substrate rather than its sequence of amino acids (6, 7). Here, rhomboid possesses a very weak binding affinity for substrate and, in a rate-driven reaction, only cleaves those substrates that have unstable TMD helices that have had time to unfold into the catalytic active site, where they are cleaved before they can dissociate from the enzyme–substrate complex. Although it may be tempting to speculate that this is a conserved mechanism for all I-CLiPs, rhomboid is the only family of I-CLiPs that does not require prior activation of substrate through an initial cleavage by another protease (8). Specifically, site-2 protease substrates must be first cleaved by site-1 protease (9), signal peptide peptidase substrates are first cleaved by signal peptidase (10), and ectodomain shedding by α- or β-secretase is required before γ-secretase cleavage of its substrates (11, 12). These facts suggest that the diverse families of I-CLiPs likely have evolved fundamentally different mechanisms by which they recognize and cleave their substrates.Presenilin/γ-secretase is the founding member of the aspartyl family of I-CLiPs. The importance of γ-secretase function in biology and medicine is highlighted by its cleavage of the notch family of receptors, which is required for cell fate determination in all metazoans (2, 13–16), and of the amyloid precursor protein (APP), which is centrally implicated in Alzheimer’s disease (AD) (14, 17). In addition to APP and notch, γ-secretase has over 90 other reported substrates, many of which are involved in important signaling events (12, 18). Despite this, little is known about the mechanism by which γ-secretase binds and cleaves its substrates. Currently, the only known prerequisite for a substrate to be bound and hydrolyzed by γ-secretase is that it be a type-I integral membrane protein that first has most of its ectodomain removed by a sheddase, either α- or β-secretases (11, 12, 19). How γ-secretase selectively recognizes ectodomain-shed substrates and recruits them for catalysis while at the same time preventing cleavage of nonsubstrates remains unsettled.γ-Secretase is a multimeric complex composed of four integral membrane proteins both necessary and sufficient for full activity: presenilin, nicastrin, Aph-1, and Pen-2 (20–24). Presenilin is the proteolytic component, housing catalytic aspartates on TMDs 6 and 7 of its nine TMDs (17, 25, 26). After initial complex formation, the mature proteolytically active complex is formed when presenilin undergoes auto-proteolysis, resulting in N- and C-terminal fragments (NTF and CTF, respectively) (17, 27, 28), a process thought to be stimulated by the three-TMD component Pen-2 (29). The seven-TMD protein Aph-1 is believed to play a scaffolding role in complex formation (30, 31). Nicastrin is a type-I integral membrane protein with a large, heavily glycosylated ectodomain (32–34) that contains multiple stabilizing disulfide bridges (24, 34).The ectodomain of nicastrin is structurally homologous to a bacterial amino peptidase (34). Although nicastrin lacks the specific amino acids required for peptidase activity, it has been proposed to bind the N terminus of ectodomain-shed substrate, thereby directing substrate TMD to the γ-secretase active site for cleavage (35, 36). This mechanism has been suggested to depend on a key binding interaction between the free amine at the N terminus of the shortened substrate ectodomain and E333 of the vestigial amino peptidase domain of nicastrin (35, 36). However, the importance of nicastrin in substrate recognition has been questioned (37, 38), and although an initial high-resolution structure of γ-secretase suggested a role for nicastrin in substrate recognition (24), the most recent structures of the γ-secretase complex and the nicastrin ectodomain reveal that E333 is actually buried within the interior of nicastrin and resides on the opposite side of the complex relative to the active site (39, 40). Although this makes it unlikely that nicastrin is involved in direct substrate binding barring a large, energy-intensive conformational change, the basic mechanism of substrate recognition by γ-secretase remains controversial and requires resolution.Here, we demonstrate that nicastrin functions to sterically exclude substrates based on ectodomain size rather than actively recruit them for catalysis. This blocking mechanism allows γ-secretase to distinguish substrate from nonsubstrate and explains why substrate ectodomain shedding by α- or β-secretases is a prerequisite for γ-secretase catalysis. In contrast to rhomboid, γ-secretase apparently binds substrate TMD tightly, making the nicastrin steric hindrance mechanism necessary to prevent cleavage of nonectodomain-shed substrates and nonsubstrates alike.     

Cardiac structural and functional changes during long-term antihypertensive treatment with lacidipine and atenolol in the European Lacidipine Study on Atherosclerosis (ELSA)

OBJECTIVES: To evaluate and correlate the effects of long-term antihypertensive treatment on left ventricular (LV) mass and carotid structural changes in a large group of essential hypertensive patients, participating in the European Lacidipine Study on Atherosclerosis (ELSA). DESIGN: In four (Brescia, Glasgow, Naples and Pisa) of 23 centres participating in the ELSA study, an echocardiographic examination was performed at baseline and repeated, until the end of the 4-year study, in essential hypertensive patients, followed-up for carotid quantitative ultrasound examination of intima-media thickness (IMT), after random allocation to treatment with either lacidipine or atenolol (and added hydrochlorothiazide, as required for control of blood pressure). METHODS: M-mode, two-dimensional guided echocardiography was used to measure left ventricular (LV) wall thickness and dimensions, from which LV mass was calculated, using an anatomically validated formula (Penn Convention) and indexed to body surface area (left ventricular mass index, LVMI). The echocardiographic tracings were blindly evaluated in a single reading centre (Brescia). Bilateral IMT was measured at the site of common carotid and bifurcation far walls (CBMmax). RESULTS: At baseline, cardiac and carotid ultrasound scans were available in 278 patients (mean age 54 +/- 7 years, 57% males, 22% obese). A significant correlation was observed between baseline LVMI and CBMmax (r = 0.22, P < 0.001), independent of age. In multivariate analysis, CBMmax and mean 24-h pulse pressure were most strongly associated with baseline LVMI. A significant reduction in LVMI was observed both during lacidipine (n = 96) (-12.5% reduction) and atenolol (n = 78) (-13.9% reduction) treatments (up to 4 years) (P < 0.001 for both, without significant differences between treatments). Changes in LVMI were not related to changes in carotid wall thickness. In multivariate analysis, baseline LV mass and mean 24-h systolic blood pressure changes were significantly associated with changes in LV mass. CONCLUSIONS: In this large, long-term controlled study, antihypertensive treatment with atenolol or lacidipine was accompanied by a similar and significant decrease in LV mass. Treatment-induced changes in LV mass were related to baseline LV mass and changes in 24-h mean systolic blood pressure, without any correlation with changes in carotid structure. In the whole ELSA population, carotid IMT changes have been shown to be unrelated to blood pressure reduction, but significantly influenced by the type of antihypertensive treatment.     

Phase Angle and Handgrip Strength Are Sensitive Early Markers of Energy Intake in Hypophagic,Non-Surgical Patients at Nutritional Risk,with Contraindications to Enteral Nutrition

The assessment of nutritional intakes during hospitalization is crucial, as it is known that nutritional status tends to worsen during the hospital stay, and this can lead to the negative consequences of malnutrition. International guidelines recommend the use of parenteral nutrition (PN) in hypophagic, non-surgical patients at nutritional risk, with contraindications to enteral nutrition. However, to date, there are no published data regarding either energy intake or objective measurements associated with it in this patient population. The aim of the present exploratory methodological study was to evaluate whether phase angle (PhA) and handgrip strength normalized for skeletal muscle mass (HG/SMM) are sensitive early markers of energy intake in hypophagic, non-surgical patients at nutritional risk, with contraindications to enteral nutrition. We evaluated 30 eligible patients, who were treated with personalized dietary modifications and supplemental PN for at least one week during hospitalization. In a liner regression model adjusted for age, gender, basal protein intake and the basal value of each variable, a trend toward improvement of PhA and preservation of HG/SMM was observed in patients satisfying the estimated calorie requirements (N = 20), while a significant deterioration of these parameters occurred in those who were not able to reach the target (N = 10). The mean adjusted difference and 95% CI were +1.4° (0.5–2.3) (p = 0.005) for PhA and +0.23 (0.20–0.43) (p = 0.033) for HG/SMM. A significant correlation between PhA and HG/SMM variations was also observed (r = 0.56 (95% CI, 0.23–0.77); p = 0.0023). PhA and HG/SMM were able to distinguish between hypophagic, non-surgical patients at nutritional risk who satisfied their estimated caloric requirements and those who did not after a one-week personalized nutritional support. Clinical studies are warranted, in order to verify these preliminary observations and to validate the role of PhA variations as early markers of anabolic/catabolic fluctuations.     

Bone marrow-resident memory T cells survive pretransplant chemotherapy and contribute to early immune reconstitution of patients with acute myeloid leukemia given mafosfamide-purged autologous bone marrow transplantation

OBJECTIVE: Studies of memory T cells transferred with the graft are relevant to better understand the early immune reconstitution of patients given autologous bone marrow transplantation (A-BMT). A critical question is whether memory T cells resident in bone marrow (BM) of patients with hematological malignancies are resistant to either pretransplant chemotherapy or ex vivo pharmacological purging. PATIENTS AND METHODS: To address these issues, we evaluated the frequency of tetanus-toxoid (TT)-specific proliferating T-cell precursors (TT-PTCp) in BM and peripheral blood (PB) of eight patients with acute myeloid leukemia (AML) given A-BMT after in vitro purging of BM with mafosfamide. Patients were studied at the time of BM harvesting and five of them also after A-BMT. RESULTS: The range of TT-PTCp frequencies found after A-BMT were comparable with those observed in PB and in BM at the time of harvesting and did not differ significantly from those of eight age-matched healthy subjects who donated BM for a human leukocyte antigen-identical sibling. TT-PTCp frequencies in BM, studied before and after ex vivo purging, appeared not to be affected by incubation with mafosfamide. We also compared the T-cell receptor (TCR)-Vbeta-repertoire usage of TT-specific T-cell lines (TT-TCL) in BM of patients at the time of harvesting and in their PB 2 months after transplantation. The same TCR-clonotypes were detected in TT-TCL at time of harvesting and after A-BMT. CONCLUSION: These data indicate that BM-resident memory T cells of patients with AML are resistant to both pretransplant chemotherapy and ex vivo pharmacological purging and may contribute to immune reconstitution after A-BMT.     

Human alloantigen-specific anergic cells induced by a combination of CTLA4-Ig and CsA maintain anti-leukemia and anti-viral cytotoxic responses

The success of allogeneic hematopoietic stem cell transplantation from HLA-disparate donors depends on the development of new strategies for graft-versus-host disease prevention able to target specifically donor antihost alloreactivity, while preserving GVL and antiviral immune surveillance. Recent experimental and clinical work has shown the feasibility of an approach based on induction of anergy to host alloantigens through blockade of B7/CD28 costimulatory signal in donor T cells, but data on the impact of this strategy on the recovery of the immune system are still lacking. We devised an ex vivo method for induction of host alloantigen-specific unresponsiveness based on treatment with the B7/CD28 blocking agent CTLA4-Ig associated with CsA. We then proceeded to assess the maintenance of an effective immune response towards viral pathogens and tumor cells after CTLA4-Ig/CsA treatment, by measuring the frequency of CTL precursors directed against CMV- and EBV-infected targets, and against autologous leukemic blasts. We demonstrated that (1) CTLA4-Ig and CsA can act synergistically in inducing a state of unresponsiveness to alloantigens; (2) the number of leukemia-reactive, EBV-specific and CMV-specific CTLp is not impaired by CTLA4-Ig/CsA treatment. Our data provide the first direct in vitro evidence that it is possible to preserve antiviral and antileukemia effector cells after blockade of CD28/B7 interaction during MLR.