Clinical crossroads: a 45-year-old man with low back pain.
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Humans↗
Biomedical subjects
J P Johnson
Publications and source records attributed to J P Johnson.
Human ether-à-go-go-related gene K+ channel gating probed with extracellular ca2+. Evidence for two distinct voltage sensors.
Human ether-à-go-go-related gene (HERG) encoded K+ channels were expressed in Chinese hamster ovary (CHO-K1) cells and studied by whole-cell voltage clamp in the presence of varied extracellular Ca2+ concentrations and physiological external K+. Elevation of external Ca2+ from 1.8 to 10 mM resulted in a reduction of whole-cell K+ current amplitude, slowed activation kinetics, and an increased rate of deactivation. The midpoint of the voltage dependence of activation was also shifted +22.3 +/- 2.5 mV to more depolarized potentials. In contrast, the kinetics and voltage dependence of channel inactivation were hardly affected by increased extracellular Ca2+. Neither Ca2+ screening of diffuse membrane surface charges nor open channel block could explain these changes. However, selective changes in the voltage-dependent activation, but not inactivation gating, account for the effects of Ca2+ on Human ether-à-go-go-related gene current amplitude and kinetics. The differential effects of extracellular Ca2+ on the activation and inactivation gating indicate that these processes have distinct voltage-sensing mechanisms. Thus, Ca2+ appears to directly interact with externally accessible channel residues to alter the membrane potential detected by the activation voltage sensor, yet Ca2+ binding to this site is ineffective in modifying the inactivation gating machinery.
Algorithms↗
Modulation of HERG potassium channels by extracellular magnesium and quinidine.
Torsades de pointes is a polymorphic ventricular arrhythmia resulting from congenital or drug-induced (acquired) QT prolongation. Pharmacologic suppression of repolarizing potassium currents is one mechanism causing the acquired long QT (LQT) syndrome. Recent studies have linked mutations in a gene encoding a potassium channel subunit (HERG) to the LQT syndrome. Clinical experience indicates that intravenous magnesium sulfate is effective in reversing torsades de pointes, but the molecular basis of this effect is not understood. This study was designed to investigate the effects of extracellular magnesium (Mg2+) on HERG potassium currents. HERG potassium channels were expressed in Xenopus oocytes and in a human cell line and were examined by voltage-clamp methods. Extracellular Mg2+ (0.3-10 mM) caused a concentration-dependent shift in the membrane-potential dependence of HERG channel opening, causing a reduction in K+ current. This effect was much greater than that observed in another human delayed rectifier K+ channel, hKv1.5, suggesting a specific interaction with the HERG channel. Quinidine is an antiarrhythmic drug that also causes torsades de pointes under certain conditions. Quinidine (3 microM) inhibited HERG currents expressed in oocytes by 32.1 +/- 3.2% (n = 5), whereas 1 microM quinidine inhibited HERG currents in tsA201 cells by 75.8 +/- 2.4% (n = 12). Increasing extracellular Mg2+ did not relieve the inhibition by quinidine, but caused additional suppression. These results indicate that extracellular Mg2+ exerts a direct action on HERG potassium channels, resulting in suppression of outward repolarizing potassium current. It is concluded that modulation of this important K+ current is not the mechanism by which intravenous magnesium terminates drug-induced LQT and torsades de pointes. Potent suppression of HERG channel current by quinidine, compared with that of I(Ks) and I(Na), is a likely contributor to torsades de pointes arrhythmias.
Animals↗
Universal calibration of surgical instruments for spinal stereotaxy.
PURPOSE: To describe new software applications and interchangeable instrumentation enabling the use of standard surgical instruments with image-guided systems for stereotactic spinal procedures. CONCEPT: The ability to adapt essentially any surgical instrument for stereotactic procedures will improve the safety and accuracy of image-guided spinal surgery. RATIONALE: Using universal dynamic registration hardware and software, standard surgical instruments are adapted for real-time image-guided surgery. The Radionics Optical Tracking System (Radionics, Inc., Burlington, MA) has custom software applications and universal hardware adaptation devices for spinal stereotaxy that allows the use of standard instruments for intraoperative guidance. An array of light-emitting diodes can be attached to essentially any rigid instrument with a definable tip and can then be calibrated to the system for intraoperative use. Stereotactic guidance of a drill, tap, and screwdriver may improve screw placement accuracy in spinal surgery because every step of the procedure can be monitored in real time. DISCUSSION: Most stereotactic systems have only a standard probe or limited instruments for localization, targeting, and tracking a procedure. The surgeon then resumes the operation using standard surgical instruments without the benefit of image guidance for the key steps of the procedure. Because each surgical step for screw placement in the spine has a potential for error, use of multiple instruments that can be interchanged for real-time image-guided spinal surgery may increase the accuracy and safety of spinal instrumentation procedures. These techniques can also be applied to intracranial image-guided surgery.
Bone Screws↗
Carboxylmethylation of the beta subunit of xENaC regulates channel activity.
The action of aldosterone to increase apical membrane permeability in responsive epithelia is thought to be due to activation of sodium channels. Aldosterone stimulates methylation of a 95-kDa protein in apical membrane of A6 cells, and we have previously shown that methylation of a 95-kDa protein in the immunopurified Na+ channel complex increases open probability of these channels in planar lipid bilayers. We report here that aldosterone stimulates carboxylmethylation of the beta subunit of xENaC in A6 cells. In vitro translated beta subunit, but not alpha or gamma, serves as a substrate for carboxylmethylation. Carboxylmethylation of ENaC reconstituted in planar lipid bilayers leads to an increase in open probability only when beta subunit is present. When the channel complex is immunoprecipitated from A6 cells and analyzed by Western blot with antibodies to the three subunits of xENaC, all three subunits are recognized as constituents of the complex. The results suggest that Na+ channel activity in A6 cells is regulated, in part, by carboxylmethylation of the beta subunit of xENaC.
Aldosterone↗
Cervical-disk herniation.
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Cervical Vertebrae↗
Hyperkalemia in hospitalized patients: causes, adequacy of treatment, and results of an attempt to improve physician compliance with published therapy guidelines.
BACKGROUND: Hyperkalemia is a common, potentially life-threatening disorder. Electrocardiograms are considered to be sensitive indicators of the presence of hyperkalemia. Since the treatment of hyperkalemia involves relatively few maneuvers and because its success can be objectively scored, we investigated how physicians manage this disorder and how successful their prescribed therapy is. We also sought to determine whether treatment could be improved by providing the treating physicians with therapy guidelines on a real-time basis. METHODS: Consecutive patients with hyperkalemia were identified by review of laboratory records. During the observation-only phase of the study, demographic data, contributing causes, electrocardiogram findings, treatments used, compliance with prescribing guidelines, and patient outcome were recorded. During the subsequent notification phase of the study, treatment recommendations were sent to the patient's ward when the elevated potassium value was noted. The same outcome data were collected. RESULTS: There were 127 episodes of hyperkalemia during the observation-only phase and 115 during the notification phase. No patients died or had life-threatening cardiac arrhythmias. Electrocardiographic abnormalities consistent with hyperkalemia were observed in only 14% of episodes. Renal failure (77%), drugs (63%), and hyperglycemia (49%) contributed to most episodes. Treatments used were exchange resin (51%), insulin (46%), calcium (36%), bicarbonate (34%), and albuterol (4%). The agents were equally efficacious. The time to first treatment was shorter in patients with potassium levels of 6.5 mmol/L or more than in patients with lower values (2.1 +/- 2.2 vs 2.8 +/- 2.4 hours; P<.05). Treatment was better in the intensive care unit than on regular wards. Only 39% of episodes during the observation-only period met the predetermined criteria for monitoring and diagnosis, initial treatment, and follow-up. During the notification period, physician performance was no better; only 42% of episodes met all criteria. The laboratory transmitted a copy of the guidelines to the patient's ward only 38% of the time. In a separate analysis of these episodes, there was no improvement in treatment. Physicians who did not receive the notification fulfilled all treatment criteria more often than physicians who did (50% vs 30%; P<.05). CONCLUSIONS: Although treatment of hyperkalemia was frequently suboptimal, no serious arrhythmias and no deaths complicated management of 242 episodes of severe hyperkalemia. A narrowly targeted effort to improve physician management of a disorder with discrete treatment options did not improve therapy.
Adolescent↗
Influence of triple-marker screen risk versus a priori risk in decision for amniocentesis in women of advanced maternal age.
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Amniocentesis↗
De novo expression of the cell adhesion molecule E-selectin on gastric cancer endothelium.
BACKGROUND AND AIMS: Angiogenesis and the molecular phenotype of the tumor vasculature determine tumor growth and metastasis. PATIENTS/METHODS: In a series of 58 gastric cancer patients, vascular density and the antigenic profile of endothelial cells in normal, inflamed and malignant gastric tissues were compared using immunohistochemistry. RESULTS: In both benign gastric mucosa and primary gastric cancer vascular density was inflammation-independent. However, increased vascularity in primary tumors was positively associated with a high tumor cell density suggesting tumor-induced angiogenesis (P=0.00001 ). P-selectin was expressed in most of the gastric mucosa samples on a small fraction of vessels and increased in the presence of moderate to strong leukocyte infiltrate. VCAM-1 positive mucosal vessels were rare and showed no association with inflammation. E-selectin and the EN 7/44 antigen defining budding vessels were absent on normal and inflamed endothelium. In contrast, in primary gastric cancer de novo expression of both E-selectin and the EN 7/44 antigen was observed. E-selectin positive vessels were preferentially found in vascular-rich tumor areas (P=0.0043) independently of leukocyte infiltration. Upregulation of VCAM-1 on tumor-associated endothelium was closely related to inflammation (P=0.019), while P-selectin expression resembled that in benign mucosa. CONCLUSIONS: Differentially expressed vascular molecules may influence the functional characteristics of extravasating leukocytes and represent new targets in anti-gastric cancer therapy.
Capillaries↗
Costello syndrome: phenotype, natural history, differential diagnosis, and possible cause.
We describe 8 patients affected with Costello syndrome including an affected sib pair and review the literature on 29 previously reported cases. We emphasize an association with advanced parental age, which is consistent with autosomal dominant inheritance with germline mosaicism. The pathogenesis appears to involve metabolic dysfunction, with growth disturbance, storage disorder appearance, acanthosis nigricans, hypertrophic cardiomyopathy, and occasional abnormalities of glucose metabolism. Although the cause is currently unknown, Costello syndrome is interesting because of a potential genetic-metabolic etiology.
Acanthosis Nigricans↗
Impact of acute renal failure on mortality in end-stage liver disease with or without transplantation.
BACKGROUND: Acute renal failure (ARF) is traditionally considered a poor prognostic factor in end-stage liver disease and is associated with a mortality approaching 90%. While the increased use of orthotopic liver transplantation (OLTX) has changed the outcome for patients with end-stage liver disease (ESLD), it is not clear whether this has affected the outcome of patients with ESLD and ARF. METHODS: We prospectively followed the course of ARF in 177 patients with ESLD being evaluated for OLTX. Of these patients 111 received OLTX. In-hospital mortality was compared to that of 316 ESLD patients without ARF, of these 196 received OLTX. Variables include severity of illness as assessed by APACHE II, co-morbid conditions, oliguria, need for renal replacement therapy, and etiologies of ESLD and ARF. These variables were evaluated with respect to the outcome in-hospital mortality by multiple regression analysis for patients with ARF. RESULTS: Mortality was significantly higher in oliguric versus non-oliguric patients and in patients who required renal replacement therapy. Mortality correlated strongly with the number of co-morbid conditions, especially sepsis, encephalopathy, respiratory failure, and DIC. For OLTX recipients who developed ARF, no significant difference in survival occurred whether the ARF was pre-OLTX or post-OLTX. CONCLUSION: ARF was associated with an increased mortality consistent with the known adverse prognostic effect of ARF in ESLD. However, the effect of ARF on mortality was remarkably reduced in patients who received a functioning OLTX. Since expected mortality generated from APACHE II scores was higher in the ARF groups, it is not clear that there is an additional effect of ARF beyond the physiologic derangements captured by APACHE II. ARF per se should not necessarily be a contraindication to liver transplant.
Acute Kidney Injury↗
Diffusive vs. convective therapy: effects on mediators of inflammation in patient with severe systemic inflammatory response syndrome.
OBJECTIVE: To compare two forms of continuous renal replacement therapy, continuous venovenous hemofiltration (CVVH) vs. continuous venovenous hemodialysis (CVVHD), in terms of the removal of inflammatory mediators from the blood of patients with systemic inflammatory response syndrome and acute renal failure. DESIGN: Randomized crossover, clinical study. SETTING: University teaching hospital. PATIENTS: Thirteen patients with systemic inflammatory response syndrome and acute renal failure receiving continuous renal replacement therapy. INTERVENTION: Patients were randomized to receive either convective clearance using CVVH or diffusive clearance using CVVHD for the first 24 hrs, followed by the other modality for 24 hrs. All treatments utilized AN69 hemofilters. CVVH was performed with an ultrafiltration rate of 2 L/hr and CVVHD with a dialysis outflow rate of 2 L/hr. MEASUREMENTS AND MAIN RESULTS: Plasma and ultrafiltrate concentrations of tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-10, and sL-selectin were measured at 0, 1, 3, 6, 12, and 24 hrs by radioimmunoassay. Plasma endotoxin concentrations were also measured at 0, 12, and 24 hrs by chromogenic assay. CVVH was associated with a 13% decrease in plasma TNF-alpha concentrations compared with a 23% increase while on CVVHD (p < .05). Mean plasma concentrations of IL-6, IL-10, and sL-selectin were unchanged over time and between therapies. Only minimal amounts of mediators were recovered in the effluents with either therapy except for IL-6. The clearances for IL-6 were different between therapies, 1.9+/-0.8 (SD) mL/min for CVVHD and 3.3+/-1.5 mL/min for CVVH, (p< .01). Plasma endotoxin concentrations were not different between therapies. CONCLUSION: CVVH resulted in a decrease in plasma TNF-alpha concentrations as compared with CVVHD, while the type of transport mechanism used did not influence plasma concentrations of IL-6, IL-10, soluble L-selectin, or endotoxin. Differences in clearance for IL-6 between CVVH and CVVHD did not translate into significant changes in circulating IL-6 concentrations.
Acute Kidney Injury↗
Heterogeneous patterns of constitutive and heat shock induced expression of HLA-linked HSP70-1 and HSP70-2 heat shock genes in human melanoma cell lines.
The heat shock response, which is characterized by the induction of heat shock proteins, is known to affect the ability of tumour cells to cope with potentially adverse conditions such as hypoxia, glucose starvation and cytotoxic immune reactions. To assess the heat shock response of melanoma cells, spontaneous and heat shock induced expression of heat shock proteins was analysed in a panel of 17 human melanoma cell lines. Constitutive expression of HSP27, HSP70, HSC70, HSP90alphabeta and GRP94 proteins was found in all the melanoma cell lines, and HSP70 and HSC70 were also induced by heat shock. The major heat inducible HLA-linked HSP70-1 and HSP70-2 genes were analysed at the mRNA level. Basal expression and inducibility varied between the different melanoma cell lines. In addition, in situ hybridization demonstrated heterogeneous expression of these genes among single cells of a given cell line. In general, each melanoma cell line appears to exhibit an individual type of HSP70 expression that might reflect selection during tumour progression and therapy.
Antibodies, Monoclonal↗
A family with mental retardation, variable macrocephaly and macro-orchidism, and linkage to Xq12-q21.
A family with X linked inheritance of mental retardation (XLMR) is presented. There are 10 mentally retarded males and two affected females in two generations. There are four obligatory carriers, one of whom is described as "slow". Most affected males show macrocephaly and macro-orchidism, which are typical signs of the fragile X syndrome, but have been tested cytogenetically and by analysis of the FMR1 gene and do not have this syndrome. However, some normal males in the family also exhibit macro-orchidism and macrocephaly. Linkage analysis using markers derived from the X chromosome indicates that the causative gene in this family is located in the proximal long arm of the X chromosome, in the interval Xp11-q21. Maximum lod scores of 2.96 with no recombination were found at three loci in Xq13-q21: DXS1111, DXS566, and DXS986. Recombination was observed with DXS1002 (Xq21.31) and DXS991 (Xp11.2), loci separated by about 30 Mb. Although isolation of the gene in this family will be difficult because of the size of the region involved, the localisation should be helpful in investigating other similar families with XLMR, macrocephaly, and macro-orchidism not attributable to FMR1.
Adolescent↗
Acceptance of amniocentesis by women in the state of Montana (USA) who are screen positive for Down's syndrome.
OBJECTIVE: To assess factors influencing uptake of amniocentesis after a positive Down's syndrome screening result. METHODS: Interviews of 53 Montana women with screening risks > or = 1 in 300 after delivery. RESULTS: Thirty had accepted amniocentesis ("yes" group) and 23 had declined ("no" group) (57% uptake). Age at delivery was significantly higher (p = 0.02) for the "no" than the "yes" group (mean 35.3 nu 31.7 years). The mean risk of Down's syndrome ascertained by screening was 1 in 190 for the "no" group and 1 in 115 for the "yes" group (p = 0.05). Statistically significant differences (p < or = 0.05) between opinions in the two groups included: (a) desire to know if the fetus had Down's syndrome; (b) perception of the burden of care for an affected child; (c) support of doctor, spouse, and relatives for choice about amniocentesis; (d) attitudes toward abortion; (e) importance of religion; and (f) concerns about the amniocentesis procedure. The most important factor for those choosing amniocentesis was knowing if the fetus had Down's syndrome, and for those not choosing amniocentesis, attitude about abortion. CONCLUSION: Our results show the need for prescreening education to enable pregnant women to make informed decisions about screening for Down's syndrome and diagnostic testing.
Adult↗
A second enzyme protecting mineralocorticoid receptors from glucocorticoid occupancy.
We have confirmed that A6 cells (derived from kidney of Xenopus laevis), which contain both mineralocorticoid and glucocorticoid receptors, do not normally possess 11 beta-hydroxysteroid dehydroxgenase (11 beta-HSD1 or 11 beta-HSD2) enzymatic activity and so are without apparent "protective" enzymes. A6 cells do not convert the glucocorticoid corticosterone to 11-dehydrocorticosterone but do, however, possess steroid 6 beta-hydroxylase that transforms corticosterone to 6 beta-hydroxycorticosterone. This hydroxylase is cytochrome P-450 3A (CYP3A). We have now determined the effects of 3 alpha,5 beta-tetrahydroprogesterone and chenodeoxycholic acid (both inhibitors of 11 beta-HSD1) and 11-dehydrocorticosterone and 11 beta-hydroxy-3 alpha,5 beta-tetrahydroprogesterone (inhibitors of 11 beta-HSD2) and carbenoxalone, which inhibits both 11 beta-HSD1 and 11 beta-HSD2, on the actions and metabolism of corticosterone and active Na+ transport [short-circuit current (Isc)] in A6 cells. All of these 11 beta-HSD inhibitory substances induced a significant increment in corticosterone-induced Isc, which was detectable within 2 h. However, none of these agents caused an increase in Isc when incubated by themselves with A6 cells. In all cases, the additional Isc was inhibited by the mineralocorticoid receptor (MR) antagonist, RU-28318, whereas the original Isc elicited by corticosterone alone was inhibited by the glucocorticoid receptor antagonist, RU-38486. In separate experiments, each agent was shown to significantly inhibit metabolism of corticosterone to 6 beta-hydroxycorticosterone in A6 cells, and a linear relationship existed between 6 beta-hydroxylase inhibition and the MR-mediated increase in Isc in the one inhibitor tested. Troleandomycin, a selective inhibitor of CYP3A, inhibited 6 beta-hydroxylase and also significantly enhanced corticosterone-induced Isc at 2 h. These experiments indicate that the enhanced MR-mediated Isc in A6 cells may be related to inhibition of 6 beta-hydroxylase activity in these cells and that this 6 beta-hydroxylase (CYP3A) may be protecting the expression of corticosterone-induced active Na+ transport in A6 cells by MR-mediated mechanism(s).
11-beta-Hydroxysteroid Dehydrogenases↗
A critical appraisal of syrinx cavity shunting procedures.
OBJECT: This study was conducted to evaluate the results of shunting procedures for syringomyelia. METHODS: In a follow-up analysis of 42 patients in whom shunts were placed in syringomyelic cavities, the authors have demonstrated that 21 (50%) developed recurrent cyst expansion indicative of shunt failure. Problems were encountered in patients with syringomyelia resulting from hindbrain herniation, spinal trauma, or inflammatory processes. A low-pressure cerebrospinal fluid state occurred in two of 18 patients; infection was also rare (one of 18 patients), but both are potentially devastating complications of shunt procedures. Shunt obstruction, the most common problem, was encountered in 18 patients; spinal cord tethering, seen in three cases, may account for situations in which the patient gradually deteriorated neurologically, despite a functioning shunt. CONCLUSIONS: Placement of all types of shunts (subarachnoid, syringoperitoneal, and syringopleural) may be followed by significant morbidity requiring one or more additional surgical procedures.
Cerebrospinal Fluid Pressure↗
Traumatic lumbar pseudomeningocele occurring with spina bifida occulta.
Pseudomeningocele in the lumbar spine due to spinal fractures or surgical procedures are well-recognized complications. We treated a 24-year-old man who fell from a horse, landing on his buttocks, and developed headaches, back pain, and a large lumbar subcutaneous fluid collection. Plain radiographs and magnetic resonance (MR) imaging revealed a midline defect in the sacral lamina and a large fluid collection in the subcutaneous space consistent with cerebrospinal fluid (CSF). He was treated conservatively, his symptoms resolved, and follow-up MR imaging showed resolution of the CSF accumulation. To our knowledge, there have been no cases of traumatic pseudomeningocele related to spina bifida occulta reported in the literature. The authors postulate that congenital defects in the neural arch contribute to the occurrence of this entity, and nonsurgical treatment should be the initial course.
Adult↗