Atherosclerosis--multi-organ involvement the rule rather than the exception

Atherosclerosis is a systemic disorder and significant lesions often occur in organ systems other than the symptomatic area. Three groups of patients, those admitted to hospital with either coronary artery disease, carotid artery stenosis or peripheral vascular disease, were examined for concomitant atherosclerotic lesions. Non-invasive tests, namely duplex scanning of the carotid arteries, arm ergometer exercise testing, and segmental pressure of the limbs, were used during evaluation. A clear association between ischaemic heart disease, carotid artery stenosis and femoropopliteal disease was found. Women appear to be more prone to multi-organ involvement than men; their higher average age on admission to hospital is a possible explanation for this in some cases, but not all.     

L-arginine, the precursor of nitric oxide, abolishes the effect of estrogens on bleeding time in experimental uremia.

We have reported previously that conjugated estrogens that are effective in shortening the prolonged bleeding time in uremic patients are also effective on bleeding time in a rat model of uremia. Using such a rat model we have recently demonstrated that nitric oxide (NO), an endothelium-derived vasodilator, is involved in mediating the bleeding tendency of uremia. With the present study we wanted to investigate whether conjugated estrogen mixture or its active component, 17 beta-estradiol, reduce uremic bleeding by interfering with the NO pathway. Our results showed that the shortening effect of conjugated estrogen and 17 beta-estradiol on bleeding time of uremic rats was completely reversed by giving the animals the NO precursor L-arginine, but not D-arginine, which is not a precursor of NO. Dexamethasone which at variance to progesterone inhibits the process of induction of NO-forming enzyme, shortened the prolonged bleeding time of uremic rats within 4 hours from injection. This effect was eliminated by L-arginine but not D-arginine administration. The glucocorticoid receptor antagonist cortexolone prevented the shortening of bleeding time induced by dexamethasone, suggesting that a receptor-mediated mechanism is involved in the hemostatic effect of dexamethasone as previously reported for estrogens. Unlike conjugated estrogens and dexamethasone, progesterone had no effect on bleeding time. All these findings would indicate that the effect of estrogens and dexamethasone on primary hemostasis in uremia might be mediated by changes in NO synthetic pathway.     

Time course and localization of endothelin-1 gene expression in a model of renal disease progression.

Experimental and human proteinuric glomerulopathies are associated with tubulo-interstitial injury that correlates with the decline of renal function even better than glomerular lesions do. Mechanism(s) leading to tubulo-interstitial damage are unknown. It has been proposed that excessive reabsorption of filtered proteins activates renal cells to produce vasoactive and inflammatory molecules including endothelin-1. The aim of the present study was twofold: we first evaluated the cellular origin of excessive renal endothelin-1 production in the renal mass reduction model and then related endothelin-1 distribution to the development of kidney lesions. Four groups of renal mass reduction (n = 15) and four groups of control rats (n = 5) were studied at 7, 14, 21, and 28 days after surgery. Urinary proteins in renal mass reduction rats were comparable with controls at day 7 but became significantly higher thereafter. Renal mass reduction rats first developed tubulo-interstitial changes, which were already evident at day 14 in the majority of them. At 28 days, renal mass reduction rats also developed glomerulosclerosis. A parallel increase of renal endothelin-1 gene expression and synthesis of the corresponding peptide in renal mass reduction rats versus controls was observed from day 14. Nonradioactive in situ hybridization confirmed a pattern of endothelin-1 mRNA consistent with the distribution of lesions. At day 14, endothelin-1 staining was stronger in renal mass reduction than in control kidneys and mainly localized to the cytoplasm of tubular cells, whereas glomeruli were negative. At day 28, endothelin-1 expression further increased in renal mass reduction rats as compared with controls, and the staining was apparent also in glomeruli. Thus, in renal mass reduction, a progressive up-regulation of endothelin-1 occurs during the development of renal injury, that first involves the tubules and, only in a subsequent phase, the glomeruli.     

Closing the gap between clinic and cage: Sensori-motor and cognitive behavioural testing regimens in neurotoxin-induced animal models of Parkinson's disease

Animal models that make use of chemical toxins to adversely affect the nigrostriatal dopaminergic pathway of rodents and primates have contributed significantly towards the development of symptomatic therapies for Parkinson's disease (PD) patients. Although their use in developing neuro-therapeutic and -regenerative compounds remains to be ascertained, toxin-based mammalian and a range of non-mammalian models of PD are important tools in the identification and validation of candidate biomarkers for earlier diagnosis, as well as in the development of novel treatments that are currently working their way into the clinic. Toxin models of PD have and continue to be important models to use for understanding the consequences of nigrostriatal dopamine cell loss. Functional assessment of these models is also a critical component for eventual translational success. Sensitive behavioural testing regimens for assessing the extent of dysfunction exhibited in the toxin models, the degree of protection or improvement afforded by potential treatment modalities, and the correlation of these findings with what is observed clinically in PD patients, ultimately determines whether a potential treatment moves to clinical trials. Here, we review existing published work that describes the use of such behavioural outcome measures associated with toxin models of parkinsonism. In particular, we focus on tests assessing sensorimotor and cognitive function, both of which are significantly and progressively impaired in PD.     

Diversity of patient preparation activities before initiation of antiretroviral therapy in Cape Town,South Africa

Objective  To investigate patient education and counseling activities prior to the initiation of antiretroviral therapy (ART) at public sector services across Cape Town, South Africa. Methods  Key informant interviews and programme reviews were conducted with government bodies and non‐governmental organisations involved in patient preparation activities. Results  All 11 organisations in Cape Town involved in training and managing personnel to prepare patients for ART during 2010 participated. Each organisation reported a different approach to patient preparation within public sector clinics and in each aspect of patient preparation activities. The number of patient education sessions ranged from 3 to 7, and the delays to ART initiation introduced by patient preparation ranged from 3 to 6 weeks. Different patient education materials (pamphlets, posters and flipcharts) were used by various programmes, and all programmes reported that shortages in materials meant that patient preparation often took place without any educational materials. Each programme also reported attention to mental illness and alcohol/substance use disorders, but none employed formal screening tools consistently, and the handling of patients with potential mental health‐ or substance‐related problems varied. Conclusion  Approaches to prepare patients before ART initiation are wide ranging in one part of South Africa. Their relative value requires investigation, as there is little evidence for the impact of varying approaches. Moreover, the risks associated with delayed ART initiation may outweigh any benefits of patient education before the start of treatment.     

Development,validity and reliability of a new pressure air biofeedback device (PAB) for measuring isometric extension strength of the lumbar spine

This study describes the development of a new portable muscle testing device, using air pressure as a biofeedback and strength testing tool. For this purpose, a pressure air biofeedback device (PAB^®) was developed to measure and record the isometric extension strength of the lumbar multifidus muscle in asymptomatic and low back pain (LBP) persons. A total of 42 subjects (age 47.58 years, ±18.58) participated in this study. The validity of PAB^® was assessed by comparing a selected measure, air pressure force in millibar (mb), to a standard criterion; calibrated weights in kilograms (kg) during day-to-day tests. Furthermore, clinical trial-to-trial and day-to-day tests of maximum voluntary isometric contraction (MVIC) of L5 lumbar multifidus were done to compare air pressure force (mb) to electromyography (EMG) in microvolt (μV) and to measure the reliability of PAB^®. A highly significant relationship were found between air pressure output (mb) and calibrated weights (kg). In addition, Pearson correlation calculations showed a significant relationship between PAB^® force (mb) and EMG activity (μV) for all subjects (n?=?42) examined, as well as for the asymptomatic group (n?=?24). No relationship was detected for the LBP group (n?=?18). In terms of lumbar extension strength, we found that asymptomatic subjects were significantly stronger than LBP subjects. The results of the PAB^® test differentiated between LBP and asymptomatic subject’s lumbar isometric extension strength without any risk to the subjects and also indicate that the lumbar isometric extension test with the new PAB^® device is reliable and valid.     

Mitochondrial Abnormality Associates with Type-Specific Neuronal Loss and Cell Morphology Changes in the Pedunculopontine Nucleus in Parkinson Disease

Cholinergic neuronal loss in the pedunculopontine nucleus (PPN) associates with abnormal functions, including certain motor and nonmotor symptoms. This realization has led to low-frequency stimulation of the PPN for treating patients with Parkinson disease (PD) who are refractory to other treatment modalities. However, the molecular mechanisms underlying PPN neuronal loss and the therapeutic substrate for the clinical benefits following PPN stimulation remain poorly characterized, hampering progress toward designing more efficient therapies aimed at restoring the PPN''s normal functions during progressive parkinsonism. Here, we investigated postmortem pathological changes in the PPN of PD cases. Our study detected a loss of neurons producing gamma-aminobutyric acid (GABA) as their output and glycinergic neurons, along with the pronounced loss of cholinergic neurons. These losses were accompanied by altered somatic cell size that affected the remaining neurons of all neuronal subtypes studied here. Because studies showed that mitochondrial dysfunction exists in sporadic PD and in PD animal models, we investigated whether altered mitochondrial composition exists in the PPN. A significant up-regulation of several mitochondrial proteins was seen in GABAergic and glycinergic neurons; however, cholinergic neurons indicated down-regulation of the same proteins. Our findings suggest an imbalance in the activity of key neuronal subgroups of the PPN in PD, potentially because of abnormal inhibitory activity and altered cholinergic outflow.CME Accreditation Statement: This activity (“ASIP 2013 AJP CME Program in Pathogenesis”) has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Society for Clinical Pathology (ASCP) and the American Society for Investigative Pathology (ASIP). ASCP is accredited by the ACCME to provide continuing medical education for physicians.The ASCP designates this journal-based CME activity (“ASIP 2013 AJP CME Program in Pathogenesis”) for a maximum of 48 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.CME Disclosures: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose.Patients with Parkinson disease (PD) present with a multitude of motor-related disabilities, including progressive resting tremor, rigidity, bradykinesia/akinesia, gait disturbances, and postural instability. In addition, it is recognized increasingly that various nonmotor functions are also left impaired, including mood, cognition, sleep, autonomic nervous system functions, and sensory functions.¹ A neuropathological signature of PD is the progressive deterioration of dopamine-producing neurons in the substantia nigra pars compacta (SNpc).² Although the precise cellular and molecular mechanisms underlying this neuronal death remain unknown, several reports implicate an underlying mitochondrial dysfunction, relating to energy deficits, enhanced production of free-radical species with concomitant oxidative stress,³ proteasomal deregulation,⁴ and neuronal excitotoxicity.⁵Evidence for a mitochondrial-related cause in PD stems from studies reporting on the use of human postmortem brains of patients with PD, which found a deficiency of complex I of the mitochondrial respiratory chain in the SNpc.⁶ Furthermore, outside the central nervous system a mitochondrial respiratory chain complex I deficiency has also been detected in the blood platelets of patients with PD, with some patients who also displayed defects of mitochondrial respiratory chain complexes II and III.⁷ In this regard, Gu et al⁸ found that a mitochondrial DNA (mtDNA) abnormality may underlie this mitochondrial defect in at least a proportion of patients with PD. By contrast, data reporting on mitochondrial respiratory chain defects in skeletal muscle cells of patients with PD remain somewhat more controversial. In this regard, Penn et al⁹ performed 31P magnetic resonance spectroscopy on the resting muscles of patients with PD, to report detecting defects in oxidative phosphorylation in the patients'' musculature, compared with healthy control cases. However, a study by Taylor et al¹⁰ was unable to validate this result. It has been proposed that the conflicting results that report on skeletal mitochondrial defects in patients with PD may relate to either methodological variation for assessing this biochemical defect or may be a reflection of the heterogeneity of the disease.¹¹Further evidence for an association between PD and a mitochondrial defect was obtained from the use of experimental neurotoxins such as rotenone and 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine. Use of such toxins mimic parkinsonism in animals to a remarkably accurate extent, with studies showing that the pathological substrate for this defect may be due to the ability of such toxins to inhibit complex I of the mitochondrial respiratory chain.^12,13 Finally, disordered mitochondrial function, including defects in oxidative phosphorylation, are also seen in rare, young-onset genetic forms of PD, such as in patients who harbor mutations in genes such as Parkinson protein 2, E3 ubiquitin protein ligase [parkin (official symbol, PARK2)], parkinson protein 7 [DJ-1, (official symbol, PARK7)], and PTEN (phosphatase and tensin homologue) induced putative kinase 1 (PINK1), where loss of function of the respective protein products associate with deregulation of the mitochondrial quality control pathways of the cells.¹⁴Although the principal motor features of PD stem from reduced dopaminergic innervation of the striatum because of a substantial loss of SNpc dopaminergic neurons, recognition is growing that PD symptoms could result from disruption to multiple neural regions and systems.¹⁵ Although the loss of neurons is most conspicuous in the SNpc, neuronal loss and the presence of intracytoplasmic Lewy bodies (LBs) and Lewy neurites (LNs), composed of aggregation-prone proteins such as α-synuclein (αSYN) form an additional neuropathological hallmark of PD¹⁶ and have been observed in brain regions as diverse as the dorsal motor nucleus of vagus of the medulla, the locus ceruleus in the pons, the raphe nucleus, the basal forebrain, and allocortical regions such as the hippocampus and amygdala.¹⁷ Such widespread distribution of PD pathology could correlate with the variety of motor and nonmotor symptoms observed in patients with PD.¹⁸ PD-related pathologies that affect regions other than the dopaminergic-rich SNpc suggest that, although treatments that target only the nigrostriatal dopaminergic system could substantially benefit patients with PD, they are unlikely to completely resolve the PD-related deficit.¹⁹One particular brain region, the pedunculopontine nucleus (PPN), located within the lateral tegmental region and spanning the pontine midbrain isthmus, has been deemed critically important for regulating some of the physiological functions that fail during progressive PD. Such functions include regulating the activity of the reticular activating system for controlling rapid eye movement (REM) sleep.²⁰ Interestingly, patients with PD frequently present with abnormal REM muscle tone and concomitant REM sleep behavior disorder (RBD),²¹ which may be due to a loss of PPN cells and their concomitant functions during progressive PD. Moreover, PPN axons project toward and receive input from a variety of brain regions, including the thalamus, SN (both the compacta and reticular part), cortical regions, and spinal cord, all of which are involved in regulating aspects of voluntary motor function.^22–30 The PPN was assigned a role in the onset and progression of PD because of reports that the nucleus undergoes degenerative changes, principally affecting the resident cholinergic neurons.^31,32 The loss of these cells is believed to provide the cellular basis for the gait and postural deficits that patients with PD experience³³ and nonhuman primates rendered parkinsonian via cytotoxic lesions.^34,35 In addition, LBs and LNs are seen within the remaining PPN neurons in the postmortem brains of patients with PD.³⁶ Such findings provided the rationale for the commencement of therapeutic trials of deep brain stimulation of the PPN, with trial results reporting a reduction in gait and postural dysfunction in patients with PD after receiving PPN deep brain stimulation.^37,38Here, we used serially cut sections taken from the postmortem PPN of patients with PD and compared this with elderly, healthy control persons, who died without known neurological or psychiatric deficit. After confirming a decreased number of cholinergic neurons in PD-affected PPNs, as previously reported,^31,32 we studied whether the remaining cholinergic neurons undergo somatic cell size alterations. Because it is unknown whether other, noncholinergic neurons are also lost in the PPN of patients with PD, we next determined whether glycinergic and GABAergic neurons in the PPN also degenerate as a result of PD, and whether the remaining neurons undergo structural alterations. In an attempt to explain the altered cell numbers and cellular structural changes seen in the PPN of the present study''s cohort of patients with PD compared with controls, and consistent with the wide amount of literature that suggests an association between PD and mitochondrial dysfunction, we determined whether the loss of different neuronal subpopulations in the PPN is linked to mitochondrial abnormalities.     

Increased appearance rate of 27-hydroxycholesterol in vivo in hypercholesterolemia: a possible compensatory mechanism

Background and aimsThe first step in the alternative pathway of bile acid biosynthesis is the 27-hydroxylation of cholesterol, which takes place both in liver and extrahepatic tissues. This pathway is believed to play a role in peripheral cholesterol degradation. Aim of this study was to investigate the impact of hyperlipidemia on 27-hydroxycholesterol appearance rate, and to assess the effects induced by treatment with statins.Methods and resultsSeven patients with familial hypercholesterolemia and eight patients with familial combined hyperlipidemia underwent determination of 27-hydroxylation rates in vivo by i.v. infusion of deuterated 27-hydroxycholesterol. Isotope enrichment was assayed by gas chromatography-mass spectrometry, allowing to calculate 27-hydroxycholesterol appearance rates. Six normocholesterolemic subjects were regarded as controls. In some hypercholesterolemic patients the infusions were repeated during treatment with atorvastatin or rosuvastatin. Hydroxylation rates were higher in hypercholesterolemic patients (8.7 ± 2.5 mg/h; controls, 3.4 ± 2.0 mg/h; combined hyperlipidemia, 4.4 ± 1.6 mg/h; mean ± SD, P < 0.01 vs both). After statin treatment, both plasma cholesterol levels and hydroxylation rates dropped by nearly 50%. No difference was detectable between the two statins. A linear correlation was shown between plasma cholesterol and 27-hydroxylation rates.ConclusionHypercholesterolemia associates with increased 27-hydroxycholesterol appearance rates, which decrease during hypocholesterolemic treatment. The correlation with cholesterol levels supports the view that 27-hydroxylation may act as a compensatory mechanism in a condition of larger plasma cholesterol pool. A regulatory role for hepatic and extrahepatic nuclear receptors seems reasonable. These data prompt novel pharmacological approaches for the management of hypercholesterolemia and the prevention of atherosclerosis.     

Impact of MammaPrint on Clinical Decision‐Making in South African Patients with Early‐Stage Breast Cancer

The aim of the study was to evaluate the impact of MammaPrint on treatment decision‐making in patients with breast cancer. Clinicopathologic information of all breast cancer patients referred for MammaPrint testing in South Africa was collected from 2007 until 2014. A total of 107 patients (109 tumors) with estrogen receptor/progesterone receptor positive and human epidermal growth factor receptor‐2 negative tumors were selected with tumors ≥10 mm, or when 1–3 nodes were involved without extra‐nodal extension. None of the clinical indicators correlated significantly with the MammaPrint risk classification, which changed the decision for adjuvant chemotherapy in 52% of patients. Of 60 patients who were clinically high risk, 62% had a low‐risk MammaPrint result and of the 47 clinically low ‐risk patients 40% had a high‐risk MammaPrint result. This study indicates that MammaPrint could reduce the need for adjuvant chemotherapy by 17% using the selection criteria stipulated. The significant impact on treatment decisions confirmed the clinical utility of MammaPrint independent of standard clinicopathologic risk factors as supported by long‐term clinical outcome studies.     

Shiga Toxin Promotes Podocyte Injury in Experimental Hemolytic Uremic Syndrome via Activation of the Alternative Pathway of Complement

Shiga toxin (Stx)–producing Escherichia coli is the offending agent of postdiarrhea-associated hemolytic uremic syndrome (HUS), a disorder of glomerular ischemic damage and widespread microvascular thrombosis. We previously documented that Stx induces glomerular complement activation, generating C3a responsible for microvascular thrombosis in experimental HUS. Here, we show that the presence of C3 deposits on podocytes is associated with podocyte damage and loss in HUS mice generated by the coinjection of Stx2 and LPS. Because podocyte adhesion to the glomerular basement membrane is mediated by integrins, the relevance of integrin-linked kinase (ILK) signals in podocyte dysfunction was evaluated. Podocyte expression of ILK increased after the injection of Stx2/LPS and preceded the upregulation of Snail and downregulation of nephrin and α-actinin-4. Factor B deficiency or pretreatment with an inhibitory antibody to factor B protected mice against Stx2/LPS-induced podocyte dysregulation. Similarly, pretreatment with a C3a receptor antagonist limited podocyte loss and changes in ILK, Snail, and α-actinin-4 expression. In cultured podocytes, treatment with C3a reduced α-actinin-4 expression and promoted ILK-dependent nuclear expression of Snail and cell motility. These results suggest that Stx-induced activation of the alternative pathway of complement and generation of C3a promotes ILK signaling, leading to podocyte dysfunction and loss in Stx-HUS.