Regulation of alternative VEGF-A mRNA splicing is a therapeutic target for analgesia.

Vascular endothelial growth factor-A (VEGF-A) is best known as a key regulator of the formation of new blood vessels. Neutralization of VEGF-A with anti-VEGF therapy e.g. bevacizumab, can be painful, and this is hypothesized to result from a loss of VEGF-A-mediated neuroprotection. The multiple vegf-a gene products consist of two alternatively spliced families, typified by VEGF-A165a and VEGF-A165b (both contain 165 amino acids), both of which are neuroprotective. Under pathological conditions, such as in inflammation and cancer, the pro-angiogenic VEGF-A165a is upregulated and predominates over the VEGF-A165b isoform. We show here that in rats and mice VEGF-A165a and VEGF-A165b have opposing effects on pain, and that blocking the proximal splicing event - leading to the preferential expression of VEGF-A165b over VEGF165a - prevents pain in vivo. VEGF-A165a sensitizes peripheral nociceptive neurons through actions on VEGFR2 and a TRPV1-dependent mechanism, thus enhancing nociceptive signaling. VEGF-A165b blocks the effect of VEGF-A165a. After nerve injury, the endogenous balance of VEGF-A isoforms switches to greater expression of VEGF-Axxxa compared to VEGF-Axxxb, through an SRPK1-dependent pre-mRNA splicing mechanism. Pharmacological inhibition of SRPK1 after traumatic nerve injury selectively reduced VEGF-Axxxa expression and reversed associated neuropathic pain. Exogenous VEGF-A165b also ameliorated neuropathic pain. We conclude that the relative levels of alternatively spliced VEGF-A isoforms are critical for pain modulation under both normal conditions and in sensory neuropathy. Altering VEGF-Axxxa/VEGF-Axxxb balance by targeting alternative RNA splicing may be a new analgesic strategy.

Influence of active recovery on professional rugby union player's ability to harness postactivation potentiation.

AIM: After postactivation potentiation (PAP) has been induced, current research recommends that, on average, an 8 minute passive recovery period is applied before engaging in subsequent dynamic exercise. However, given the importance of maximizing time usage during the warm-up of elite athletes, it is likely that further exercise would be incorporated into this time frame. This study aimed to examine the effects of passive and active recovery on the ability to utilize PAP. METHODS: In a randomised and counter balanced design, 36 professional rugby union players completed two experimental trials involving a baseline countermovement jump (CMJ), followed by a PAP stimulus (3 x 3 repetitions at 87% of 1-RM back squat) and CMJ retesting after 8 minutes of passive or active recovery. The active recovery involved subjects performing ballistic bench throws (1 x 3 repetitions at 30% 1-RM bench press) 4 minutes after the lower body PAP stimulus. Data presented as mean±SD. RESULTS: Baseline peak power output (PPO) was not different between conditions (P=0.61). CMJ PPO increased from baseline under both conditions, however the delta (mean±SD; passive +161±127 vs. active +116±44 W; P=0.03) and % change (passive 3.3±2.8 vs. active 2.3±0.9 %; P=0.03) in PPO was greater after the passive recovery, when compared to the active recovery. CONCLUSION: In conclusion, the passive and active recovery periods both led to increases in lower-body PPO, nevertheless, the passive recovery elicited the greatest performance changes. However, the active recovery is a more practical option for athletes, as it maximizes time usage during warm-up.

Malignant mesothelioma: facts, myths, and hypotheses.

Malignant mesothelioma (MM) is a neoplasm arising from mesothelial cells lining the pleural, peritoneal, and pericardial cavities. Over 20 million people in the US are at risk of developing MM due to asbestos exposure. MM mortality rates are estimated to increase by 5-10% per year in most industrialized countries until about 2020. The incidence of MM in men has continued to rise during the past 50 years, while the incidence in women appears largely unchanged. It is estimated that about 50-80% of pleural MM in men and 20-30% in women developed in individuals whose history indicates asbestos exposure(s) above that expected from most background settings. While rare for women, about 30% of peritoneal mesothelioma in men has been associated with exposure to asbestos. Erionite is a potent carcinogenic mineral fiber capable of causing both pleural and peritoneal MM. Since erionite is considerably less widespread than asbestos, the number of MM cases associated with erionite exposure is smaller. Asbestos induces DNA alterations mostly by inducing mesothelial cells and reactive macrophages to secrete mutagenic oxygen and nitrogen species. In addition, asbestos carcinogenesis is linked to the chronic inflammatory process caused by the deposition of a sufficient number of asbestos fibers and the consequent release of pro-inflammatory molecules, especially HMGB-1, the master switch that starts the inflammatory process, and TNF-alpha by macrophages and mesothelial cells. Genetic predisposition, radiation exposure and viral infection are co-factors that can alone or together with asbestos and erionite cause MM. J. Cell. Physiol. 227: 44-58, 2012. © 2011 Wiley Periodicals, Inc.

Ovarian VEGF(165)b expression regulates follicular development, corpus luteum function and fertility.

Angiogenesis and vascular regression are critical for the female ovulatory cycle. They enable progression and regression of follicular development, and corpora lutea formation and regression. Angiogenesis in the ovary occurs under the control of the vascular endothelial growth factor-A (VEGFA) family of proteins, which are generated as both pro-(VEGF(165)) and anti(VEGF(165)b)-angiogenic isoforms by alternative splicing. To determine the role of the VEGF(165)b isoforms in the ovulatory cycle, we measured VEGF(165)b expression in marmoset ovaries by immunohistochemistry and ELISA, and used transgenic mice over-expressing VEGF(165)b in the ovary. VEGF(165)b was expressed in the marmoset ovaries in granulosa cells and theca, and the balance of VEGF(165)b:VEGF(165) was regulated during luteogenesis. Mice over-expressing VEGF(165)b in the ovary were less fertile than wild-type littermates, had reduced secondary and tertiary follicles after mating, increased atretic follicles, fewer corpora lutea and generated fewer embryos in the oviduct after mating, and these were more likely not to retain the corona radiata. These results indicate that the balance of VEGFA isoforms controls follicle progression and luteogenesis, and that control of isoform expression may regulate fertility in mammals, including in primates.

Loco-regional treatment in metastatic breast cancer patients: is there a survival benefit?

A number of studies have recently demonstrated a survival benefit in stage IV breast cancer patients following surgical resection of the primary tumor. Here, we investigate the relationship between loco-regional treatment and survival in patients with metastatic breast cancer and evaluate the impact of different loco-regional treatments. We conducted a systematic review of the literature using PubMed to analyze studies with the following criteria: Type of loco-regional treatment (surgery alone or combined with radiation, radiotherapy), overall survival, progression-free survival, selection factors for local treatment, and complication rates. Thirteen studies evaluated the effect of loco-regional treatment on overall survival with overall median survival increasing from a range of 12.6-28.3 months among patients without surgery to a range of 25-42 months among patients with surgery. In addition, six studies reported a 3-year survival benefit of 28-95% and 17-79% in women with and without locoregional therapy respectively. Two studies did not find any improvement in overall survival. One study found an improvement in 5-year breast cancer-specific survival of 27% with negative surgical margins versus 12% with no surgery. Three studies reported an advantage in progression-free survival in the treatment group compared with the non-treatment group. Loco-regional treatment for breast cancer patients with distant metastases at diagnosis is an important issue because of possible improvement of survival or disease-free survival. The possibility of surgery and/or radiotherapy following induction chemotherapy should be weighed and left to individual practice. Participation in randomized controlled trials should be encouraged.

VEGF 165 b, an antiangiogenic VEGF-A isoform, binds and inhibits bevacizumab treatment in experimental colorectal carcinoma: balance of pro- and antiangiogenic VEGF-A isoforms has implications for therapy.

Bevacizumab, an anti-vascular endothelial growth factor (VEGF-A) antibody, is used in metastatic colorectal carcinoma (CRC) treatment, but responses are unpredictable. Vascular endothelial growth factor is alternatively spliced to form proangiogenic VEGF(165) and antiangiogenic VEGF(165)b. Using isoform-specific enzyme-linked immunosorbent assay and quantitative polymerase chain reaction, we found that over 90% of the VEGF in normal colonic tissue was VEGF(xxx)b, but there was a variable upregulation of VEGF(xxx) and downregulation of VEGF(xxx)b in paired human CRC samples. Furthermore, cultured colonic adenoma cells expressed predominantly VEGF(xxx)b, whereas colonic carcinoma cells expressed predominantly VEGF(xxx). However, adenoma cells exposed to hypoxia switched their expression from predominantly VEGF(xxx)b to predominantly VEGF(xxx). VEGF(165)b overexpression in LS174t colon cancer cells inhibited colon carcinoma growth in mouse xenograft models. Western blotting and surface plasmon resonance showed that VEGF(165)b bound to bevacizumab with similar affinity as VEGF(165). However, although bevacizumab effectively inhibited the rapid growth of colon carcinomas expressing VEGF(165), it did not affect the slower growth of tumours from colonic carcinoma cells expressing VEGF(165)b. Both bevacizumab and anti-VEGF(165)b-specific antibodies were cytotoxic to colonic epithelial cells, but less so to colonic carcinoma cells. These results show that the balance of antiangiogenic to proangiogenic isoforms switches to a variable extent in CRC, regulates tumour growth rates and affects the sensitivity of tumours to bevacizumab by competitive binding. Together with the identification of an autocrine cytoprotective role for VEGF(165)b in colonic epithelial cells, these results indicate that bevacizumab treatment of human CRC may depend upon this balance of VEGF isoforms.

Lumbosacral radiculoplexopathy as a manifestation of Epstein-Barr virus infection.

We report the clinical features of five patients with lumbosacral radiculoplexopathy (LSRP) and one patient with a femoral neuropathy, all of whom had serologic evidence of a recent Epstein-Barr virus (EBV) infection. After a thorough investigation, no other etiology was apparent. Pain was a prominent feature in all cases, and the prognosis was generally good, with recovery in weeks to months. We conclude that LSRP may occur as a postinfectious process following recent EBV infection.

Chronic segmental spinal muscular atrophy of upper extremities in identical twins.

We present the 1st report of chronic segmental spinal muscular atrophy confined to the upper extremities in identical male twins. This occurrence in identical twins, together with reports of siblings and parent-child pairs of a disorder phenotypically similar to the more common sporadic form in the literature, suggests a genetic etiology in some cases.

The next phase of healthcare improvement: what can we learn from social movements?

To date, improvement in health care has relied mainly on a "top down" programme by programme approach to service change and development. This has spawned a multitude of different and often impressive improvement schemes and activities. We question whether what has been happening will be sufficient to achieve the desired scale of change within the time scales set. Is it a case of "more of the same" or are there new and different approaches that might now be usefully implemented? Evidence from the social sciences suggests that other perspectives may help to recast large scale organisational change efforts in a new light and offer a different, though complementary, approach to improvement thinking and practice. Particularly prominent is the recognition that such large scale change in organisations relies not only on the "external drivers" but on the ability to connect with and mobilise people's own "internal" energies and drivers for change, thus creating a "bottom up" locally led "grass roots" movement for improvement and change.

Emergency use of uncrossmatched red cells in neonatal intensive care infants.

In very rare situations, a newborn will be delivered with severe unrecognized life-threatening anemia. Two infants with severe anemia with differing etiologies were deemed to require emergency uncrossmatched O-negative blood. In one infant, the blood transfused was incompatible for the minor antigen that had caused the isoimmune hemolytic anemia. We report on the indications, potential risks and benefits in giving uncrossmatched O-negative blood to term infants with life-threatening anemia.

Ranpirnase Interferes with NF-κB Pathway and MMP9 Activity, Inhibiting Malignant Mesothelioma Cell Invasiveness and Xenograft Growth.

The ribonuclease ranpirnase (Onconase) has been used empirically to treat malignant mesothelioma (MM) patients, and some of them had prolonged survivals. The aim of this study was to investigate the mechanisms of the therapeutic function of ranpirnase in MM cells. The effects of ranpirnase were studied in vivo and in vitro on 2 MM cell lines (epithelioid REN and sarcomatoid PPM-Mill). We found that ranpirnase was able to inhibit NF-κB nuclear translocation, evaluated by cell fractionation and immunoblotting as well as by immunofluorescence. Also, MMP9 secretion by MM cells was decreased by ranpirnase treatment, as assessed by the reduction of metalloproteinase activity, evaluated by zymography on culture-conditioned media. Ranpirnase induced apoptosis of MM cells in vitro and in vivo, causing a powerful inhibition of MM tumor growth in SCID xenografts, determined by In Vivo Imaging System (IVIS) of tumor cells engineered by lentiviral transduction of the luciferase gene. Finally, mice treated with ranpirnase showed a significantly prolonged survival. Our data provide a mechanistic rationale to explain the beneficial antitumor activity observed in some patients treated with ranpirnase and demonstrate that ranpirnase interferes with the NF-κB pathway, thus influencing MM tumor cell invasiveness and survival. It is hoped that this information will also facilitate the identification of those patients who are more likely to benefit from this drug and will also open a new frontier for the use of this drug in tumor types other than MM.

(18)F-Choline PET/CT imaging of RECIST measurable lesions in hormone refractory prostate cancer.

PURPOSE: Apply measurability criteria based on the response evaluation criteria in solid tumors (RECIST) to lesions found on (18)F-choline positron emission tomography (PET)/computerized tomography (CT) in patients with hormone refractory prostate cancer. METHODS: Whole-body PET followed by CT or in-line PET/CT using 3.3-4 MBq/kg of (18)F-choline was performed prospectively on 30 patients with prostate cancer, castrate testosterone levels, and rising post-treatment prostate specific antigen (PSA) levels. Lesions demonstrating increased (18)F-choline uptake were classified as measurable or non-measureable based on RECIST. RESULTS: Three patients were known previously to have RECIST measurable lesions, 10 patients had metastatic findings on radionuclide bone scan, and 17 patients had elevated serum PSA level as the only evidence of disease. Lesions demonstrating increased (18)F-choline uptake were found in 28 (93%) patients. Thirty-eight PET/CT lesions from 14 patients were measurable by RECIST. Lymph node maximum standardized uptake value (SUV(max)) correlated with lymph node diameter (Pearson r = 0.44, p < 0. 001). RECIST measurable lymph node SUV(max) was significantly higher than that of non-measurable nodes (8.1 vs. 3.7, p < 0.0001). Detection of skeletal, prostatic, or RECIST-compatible lesions was more likely with a PSA level greater than 4.0 ng/ml (Fisher exact p = 0.0005). CONCLUSION: Lesions detected with (18)F-choline PET/CT are frequently measurable by RECIST at baseline. Therefore, it may be feasible to include comparisons to RECIST in evaluations of (18)F-choline as a therapeutic response marker for hormone refractory prostate cancer.

Stroke in young adults.

Strokes in young adults are uncommon and often a diagnostic challenge. A retrospective study of strokes due to intracerebral hemorrhage, subarachnoid hemorrhage, or cerebral infarction was undertaken. We reviewed the medical records of 113 young patients aged 15-45 years who were admitted to the Medical Center Hospital of Vermont with a diagnosis of stroke between 1982 and 1987. This group comprised 8.5% of patients of all ages admitted for stroke, 2.3 times the proportion observed in the National Survey of Stroke. Nontraumatic intracerebral hemorrhage was diagnosed in 46 young patients (41%); the main causes included aneurysms, arteriovenous malformations, hypertension, and tumors. Subarachnoid hemorrhage was found in 19 young patients (17%); the majority were due to aneurysms. The remaining 48 young patients (42%) had cerebral infarction, the majority due to cardiogenic emboli and premature atherosclerosis. Mitral valve prolapse, the use of oral contraceptives, alcohol drinking, and migraine were infrequent sole causes of cerebral infarction in the absence of other risk factors. The case-fatality rate for this group of young patients with stroke was 20.4% compared with 23.9% for the National Survey of Stroke. Young adults with stroke deserve an extensive but tailored evaluation, which should include angiography and echocardiography.

Clinical correlations of antibodies in pemphigus studied by radioimmunoassay.

Pemphigus antibodies of class G immunoglobulins (IgG) were studied with the use of a solid-phase radioimmunoassay (RIA) that utilizes COLO-16, a squamous cell tumor line, as the substrate. Sera from patients with pemphigus vulgaris and pemphigus vegetans showed greater average binding than did sera from patients with pemphigus foliaceus and pemphigus erythematosus. The patients were subgrouped according to their clinical presentations and were divided into patients with skin lesions only, those with mucous membrane lesions only, and those with both skin and mucous membrane lesions. No significant differences were observed between these groups. There was good correlation between IgG binding in the RIA and both the disease activity and the response to therapy. Blood group antigen absorbable "false positive" anti-intercellular substance antibodies were not detected in the RIA.

Detection of anti-intercellular cement substance and anti-basement membrane zone antibodies by radioimmunoassay using SCaBER tumour cell line as substrate.

IgG autoantibodies present in the serum of pemphigus vulgaris and bullous pemphigoid patients were detected by a solid phase radioimmunoassay, using a squamous cell tumour line, SCaBER, as substrate. This preliminary study shows that the SCaBER cell line displays both pemphigus and bullous pemphigoid antigens. This source of antigens should allow the development of a sensitive assay to measure anti-ICS and anti-BMZ antibodies. Such an assay may have clinical applications and may provide an important tool for studying the mechanisms of autoantibody production in pemphigus and pemphigoid.

Malignant schwannoma of the clitoris in a 1-year-old child.

A 1-year-old infant with von Recklinghausen's neurofibromatosis was seen because of increasing clitoral enlargement over a 7-month period. The mother, who also had neurofibromatosis, was treated 2 years beforehand for an acoustic neuroma. The child was treated by radical clitorectomy. Pathologic examination revealed malignant schwannoma, a tumor not previously described in this site. Vincristine, dactinomycin, and cyclophosphamide chemotherapy was given for 2 years to prevent local recurrence and metastatic spread. The child remains tumor free 2.5 years after diagnosis.

Germline INI1 mutation in a patient with a central nervous system atypical teratoid tumor and renal rhabdoid tumor.

We describe a four-month-old child who presented with an atypical teratoid/rhabdoid tumor of the brain and subsequently developed a renal rhabdoid tumor. Distinct histologic features, immunophenotypic profiles, and deletions of chromosome 22 were supportive of two primary tumors. An identical mutation in exon 7 of the INI1 rhabdoid tumor suppressor gene was identified in both tumors, as well as in normal kidney tissue. We propose that this germline INI1 mutation predisposed the child to the development of both malignancies. These findings lend support to the hypothesis that rhabdoid tumors in all sites have a common genetic etiology.