Therapeutic drug monitoring of vancomycin in severe sepsis and septic shock.

BACKGROUND: The sudden changes (increase in capillary permeability, edema formation, vasodilation and hypotension) observed in septic patients and the measurements taken in order to revert this situation make vancomycin concentrations difficult to interpret. Therapeutic drug monitoring (TDM) of vancomycin is routinely performed at steady state, target concentrations are peaks between 20 and 40 mg/l and troughs of 5-10 mg/l. Lately, continuous infusion of vancomycin (CIV) has been used as an alternative mode of administration mainly in critically ill patients with sepsis or septic shock. Despite this novel mode of administration, the need of drug monitoring in this population is under discussion. OBJECTIVE: The aim of our study was to test the usefulness of a multi-compartment model in order to understand the rapid changes that occur in critically ill patients. MATERIALS AND METHODS: A prospective, cohort study was carried out in the intensive care unit of the University Hospital. 25 intensive care unit adults patients with severe sepsis or septic shock receiving vancomycin in CIV modality for documented gram-positive infections were included in the study. Once the infusion was started, blood samples were drawn periodically and analyzed by fluorescence polarisation immunoassay (FPIA, TDx, Abbott Laboratories, Chicago, IL, USA). A multi-compartment model was used to predict vancomycin level evolution throughout the treatment of patients with sepsis. RESULTS: High doses of vancomycin were administered in order to rescue patients from septic shock. Plasma drug concentration dropped while clinical condition of patients worsened. Conversely, drug levels increased spontaneously once the infection was reverted. The theoretical model provided greater insight into pharmacokinetic features related with the use of vancomycin in septic patients. CONCLUSIONS: There was consistency between the model based prediction and the experimental data so dose adjustment was performed in order to reach target concentrations above 20 mg/l and an initial dose of 3 grams of vancomycin per day was recommended to reach these levels.

Fixed ceramometallic prostheses over anterior and transzygomatic implants by using the sinus slot technique--report of a case.

Atrophy of the upper jaw poses problems for fixed rehabilitation of implants. Of the different management possibilities that have been developed, transzygomatic implant placement is a good option and affords a high success rate. These implants are positioned in zygomatic bone by using 2 possible techniques. We present a 48-year-old woman with severe posterior maxillary atrophy in which the canine and frontozygomatic prominence were used to place 6 anterior and 2 transzygomatic implants by using the sinus slot technique for fixed bridge rehabilitation. The advantages of the sinus slot technique over the sinus window technique are discussed.

Experimental evolution of propanediol oxidoreductase in Escherichia coli. Comparative analysis of the wild-type and mutant enzymes.

A model for the study of experimental evolution is provided by the novel metabolic system responsible for the progressive utilization of L-1,2-propane-diol by mutants of Escherichia coli (strains 3 and 430). In these mutant strains, propanediol oxidoreductase, which serves as L-lactaldehyde reductase in fucose fermentation by wild-type cells, became a key enzyme for aerobic catabolism of propanediol. In the wild-type strain (strain 1), the enzyme is inducible only anaerobically; in strains 3 and 430, the enzyme is synthesized constitutively even in the presence of air. The propanediol oxidoreductase from all three strains was purified to homogeneity by the same procedure. The enzyme of strain 3 clearly differed from that of strain 1 in several respects: Km and V in both directions of the reaction, energy of activation, thermal stability, pH optimum and substrate specificity. However, no difference in any of the above characteristics was found between the enzymes of strains 3 and 430. All three enzymes presented the same electrophoretic mobility. According to immunological data, all three strains differed in their intracellular enzyme level.

Placenta-specific expression of the rat growth hormone-releasing hormone gene promoter in transgenic mice.

GH-releasing hormone (GHRH) is a hypothalamic peptide that plays a critical role in controlling the synthesis and secretion of GH in the anterior pituitary. Along with many other hypothalamic hormones, GHRH is also expressed in the placenta, although its physiological role in this tissue has not yet been determined. The placental prepro-GHRH is identical to that found in the hypothalamus. However, the placental and hypothalamic GHRH messenger RNAs differ in the region corresponding to the untranslated exon 1. A combined mechanism involving the use of tissue-specific promoters and the differential splicing of exon 1 generates the mature GHRH messenger RNAs in placenta and hypothalamus. As a first step toward the localization of the regulatory elements involved in the placenta-specific expression of the GHRH gene, we have generated transgenic mice containing constructs in which potential regulatory sequences of the rat GHRH gene were fused to the chloramphenicol acetyltransferase (CAT) reporter gene. Construct GHRH-CAT1, which contains 7.5 kilobases of flanking sequences upstream to the placental transcription start site, did not promote CAT expression in the transgenic animals. In contrast, construct GHRH-CAT2, which differs from construct GHRH-CAT1 in having additional sequences located downstream to placental exon 1, exhibited high levels of CAT expression in brain and placenta. Our results show that the sequences included in construct GHRH-CAT2 contain the cis-acting regulatory elements necessary to direct developmentally regulated and cell type-specific expression of the CAT gene in the placenta. Unexpectedly, the expression of the transgene in the brain was detected in glial cells of different areas, but not in the hypothalamus.

Differential splicing of the growth hormone-releasing hormone gene in rat placenta generates a novel pre-proGHRH mRNA that encodes a different C-terminal flanking peptide.

We have isolated and characterized a novel rat placental pre-proGHRH mRNA (pre-proGHRH-2 mRNA). This mRNA is generated by an alternative splicing process which results in the presence of an additional exon of 156 bp (designated exon 4.5) located between exons 4 and 5 of the previously reported hypothalamic and placental pre-proGHRH mRNA (pre-proGHRH-1 mRNA). Since the sequences encoding mature GHRH are included within exons 3 and 4, the processing of pre-proGHRH-2 would not affect the synthesis of mature GHRH but would generate a C-terminal peptide (designated GCTP-2) different from that previously reported in the hypothalamus and placenta (GCTP-1). The putative GCTP-2 has 64 amino acids, and the first 18 N-terminal residues are identical to those present in GCTP-1 (30 amino acids long). Pre-proGHRH-2 mRNA has not been detected in the hypothalamus.

Identification of gcpE as a novel gene of the 2-C-methyl-D-erythritol 4-phosphate pathway for isoprenoid biosynthesis in Escherichia coli.

The 2-C-methyl-D-erythritol 4-phosphate (MEP) pathway for isoprenoid biosynthesis is essential in most eubacteria and plants and has remarkable biotechnological interest. However, only the first steps of this pathway have been determined. Using bioinformatic and genetic approaches, we have identified gcpE as a novel gene of the MEP pathway. The distribution of this gene in bacteria and plants strictly parallels that of the gene encoding 1-deoxy-D-xylulose 5-phosphate reductoisomerase, which catalyses the first committed step of the MEP pathway. Our data demonstrate that the gcpE gene is essential for the MEP pathway in Escherichia coli and indicate that this gene is required for the trunk line of the isoprenoid biosynthetic route.

Expression of catalytically active radish 3-hydroxy-3-methylglutaryl coenzyme A reductase in Escherichia coli.

Two fragments of a cDNA encoding radish 3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGR) were cloned into the vector pET-8c and expressed in Escherichia coli. The large fragment, encoding both the membrane and the cytosolic domains, was expressed at low level, essentially as an insoluble protein without enzymatic activity. In contrast, the fragment encoding only the cytosolic domain was expressed at a high level in a catalytically active form. The amount of soluble active enzyme in cell-free extracts of E. coli dramatically increased when the temperature during the induction was lowered from 37 degrees C to 22 degrees C.

Genetic evidence of branching in the isoprenoid pathway for the production of isopentenyl diphosphate and dimethylallyl diphosphate in Escherichia coli.

An alternative mevalonate-independent pathway for isoprenoid biosynthesis has been recently discovered in eubacteria (including Escherichia coli) and plant plastids, although it is not fully elucidated yet. In this work, E. coli cells were engineered to utilize exogenously provided mevalonate and used to demonstrate by a genetic approach that branching of the endogenous pathway results in separate synthesis of the isoprenoid building units isopentenyl diphosphate (IPP) and its isomer dimethylallyl diphosphate (DMAPP). In addition, the IPP isomerase encoded by the idi gene was shown to be functional in vivo and to represent the only possibility for interconverting IPP and DMAPP in this bacterium.

Multiple changes in chromatin structure precede the transcriptional activation of the human growth hormone locus in placental cells.

In addition to the growth hormone gene (hGH-N) itself, the human growth hormone (hGH) locus contains four related genes, namely hGH-V and hCS-L, -A and -B, which have appeared very recently in evolution and are specifically expressed in placenta. With the aim of identifying the regulatory elements responsible for this placental-specific expression, we have mapped the DNaseI hypersensitive sites present at the hGH gene cluster in a placental cell line (BeWo) that expresses the hGH-V and hCS genes. Our results reveal a complex pattern of hypersensitive sites distributed along the hGH locus, most of which appear to be cell type-specific. Thus, we have identified placental-specific hypersensitive sites within the first intron of the hGH-N and hGH-V genes, but not in the equivalent regions of the hCS genes. In addition, we have found several placental-specific hypersensitive sites downstream of the hCS-L and hCS-A genes, which might reflect the presence of enhancer elements similar to that located downstream of the hCS-B gene (Walker et al. (1990) J. Biol. Chem. 265, 12940). Comparison of BeWo cells with a placental cell line (JEG-3) which does not express the hGH-V and hCS genes revealed a very similar pattern of hypersensitive sites, suggesting that the sites detected are established before the onset of transcription. Our results indicate that the transition to an active hGH locus in placental cells requires multiple alterations in chromatin structure, and provide a framework for the molecular analysis of the regulatory elements and mechanisms mediating such processes.

Identification of the rhaA, rhaB and rhaD gene products from Escherichia coli K-12.

The three structural genes rhaA, rhaB and rhaD, that specify the enzymes rhamnose isomerase, rhamnulose kinase and rhamnulose 1-phosphate aldolase respectively, have been cloned from Escherichia coli K-12. The precise location of the genes has been determined by gene complementation analysis and by enzymatic assays of strains transformed with recombinant plasmids containing different parts of the cloned region. The corresponding gene products have been studied by their expression in maxicells. Protein products of 47 kDa, 52-54 kDa and 32 kDa have been assigned to rhamnose isomerase, rhamnulose kinase and rhamnulose 1-phosphate aldolase respectively.

Detection of unique or low copy number DNA sequences in complex genomes.

The characterization of specific DNA sequences by means of hybridization techniques is of great relevance in the development of molecular biology. Because of its simplicity, the method described by Southern in 1975 (1) is widely used for such purposes. This method, also known as the Southern blot, is based on the hybridization of specific probes to DNA fragments immobilized onto a membrane filter after their separation by agarose gel electrophoresis. The identification of specific DNA fragments is possible since their relative positions are maintained during the transfer from the gel to the filter.

Aspects related to mevalonate biosynthesis in plants.

We purified and characterized a membrane-associated enzyme system from radish (Raphanus sativus L.) that is capable of converting acetyl-CoA into 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA). The enzyme system apparently comprises acetoacetyl-CoA thiolase (EC 2.3.1.9) and HMG-CoA synthase (EC 4.1.3.5). Its activity in vitro can be strongly stimulated by FeII. When ferrous ions are applied chelated with ethylenediaminetetraacetate, citrate or adenosine 5-triphosphate (ATP), the stimulation is further increased. Stimulation is due to a higher catalytic efficiency as indicated by an increase in Vmax, whereas the affinity of the enzyme towards acetyl-CoA remains constant (Km = 6 micro M). A considerable portion of HMG-CoA lyase activity is associated with the same membranes. HMG-CoA lyase (EC 4.1.3.4) is also solubilized and partially co-purified. Its activity requires comparatively high concentrations of Mg2+. The conversion of HMG-CoA to mevalonic acid is catalyzed by HMG-CoA reductase (EC 1.1.1.34) that is associated with the same membranes. By cDNA encoding the Arabidopsis HMG-CoA reductase, we isolated a corresponding gene from a cDNA library newly established from etiolated radish seedlings. This full-length cDNA, referred to as lambda cRS3, encodes a polypeptide 583 amino acids with a molecular mass of about 63 kDa. The hydropathy profile suggests the presence of two hydrophobic membrane-spanning domains within the N-terminal 165 amino acids. The carboxy-terminal part, where the catalytic site resides, is highly conserved in all eukaryotic HMG-CoA reductase genes sequenced so far.

[Diagnosis by DNA analysis in familial isolated growth hormone deficiency type I-A]. / Diagnóstico mediante análisis del DNA de la deficiencia aislada y familiar de hormona de crecimiento tipo I-A.

We show the autoradiograms of DNA from one child affected of familial isolated growth hormone deficiency type I-A. Restriction endonuclease analysis of DNA isolated from leukocytes was done using 32P-labeled human GH cDNA clone as a probe. DNA analysis using the restriction endonuclease Bam HI revealed that the 3.8 kb restriction fragment, which contain the normal hGH-N gene, was absent. Since these deletions preclude production of any GH-N protein, affected individuals tend to be immunologically intolerant to exogenous GH. The child was homozygote and after treatment with exogenous GH developed a high titre of antibodies to GH and growth arrest. This is the first case of this genetic disorder studied in Spain.

GABA(B) receptor antibodies in limbic encephalitis and anti-GAD-associated neurologic disorders.

BACKGROUND: γ-Aminobutyric acid-B receptor antibodies (GABA(B)R-ab) were recently described in 15 patients with limbic encephalitis (LE), associated with small-cell lung cancer (SCLC) or with concurrent glutamic acid decarboxylase (GAD) antibodies. We analyzed the frequency of GABA(B)R-ab in 147 patients with LE or neurologic syndromes associated with GAD-ab. METHODS: We examined the presence of GABA(B)R-ab in 70 patients with LE (33 paraneoplastic with onconeural antibodies, 18 paraneoplastic without onconeural antibodies [5 with Gad-ab], and 19 idiopathic with either GAD-ab [5 patients] or seronegative) and 77 patients with GAD-ab-associated neurologic syndromes other than LE (29 stiff-person syndrome, 28 cerebellar ataxia, 14 epilepsy, and 6 with diverse paraneoplastic neurologic syndromes). GABA(B)R-ab were analyzed in serum or CSF by indirect immunofluorescence on HEK293 cells transfected with GABA(B1) and GABA(B2) receptor subunits. RESULTS: GABA(B)R-ab were detected in 10 of the 70 patients with LE (14%). Eight had SCLC and 2 were idiopathic. One of the 8 patients with LE with SCLC had an additional onconeural antibody (Hu) and 2 GAD-ab. GABA(B)R-ab were identified in 7 (70%) of the 10 patients with LE and SCLC without onconeural antibodies. GABA(B)R-ab antibodies were not found in patients with GAD-ab and stiff-person syndrome, idiopathic cerebellar ataxia, or epilepsy. However, one patient with GAD-ab, paraneoplastic cerebellar ataxia, and anaplastic carcinoid of the thymus also presented GABA(B)R-ab. CONCLUSIONS: GABA(B)R-ab are the most common antibodies found in LE associated with SCLC previously considered "seronegative." In patients with GAD-ab, the frequency of GABA(B)R-ab is low and only observed in the context of cancer.

Rhamnose-induced propanediol oxidoreductase in Escherichia coli: purification, properties, and comparison with the fucose-induced enzyme.

Escherichia coli are capable of growing anaerobically on L-rhamnose as a sole source of carbon and energy and without any exogenous hydrogen acceptor. When grown under such condition, synthesis of a nicotinamide adenine dinucleotide-linked L-lactaldehydepropanediol oxidoreductase is induced. The functioning of this enzyme results in the regeneration of nicotinamide adenine dinucleotide. The enzyme was purified to electrophoretic homogeneity. It has a molecular weight of 76,000, with two subunits that are indistinguishable by electrophoretic mobility. The enzyme reduces L-lactaldehyde to L-1,2-propanediol with reduced nicotinamide adenine dinucleotide as a cofactor. The Km were 0.035 mM L-lactaldehyde and 1.25 mM L-1,2-propanediol, at pH 7.0 and 9.5, respectively. The enzyme acts only on the L-isomers. Strong substrate inhibition was observed with L-1,2-propanediol (above 25 mM) in the dehydrogenase reaction. The enzyme has a pH optimum of 6.5 for the reduction of L-lactaldehyde and of 9.5 for the dehydrogenation of L-1,2-propanediol. The enzyme is, according to the parameters presented in this report, indistinguishable from the propanediol oxidoreductase induced by anaerobic growth on fucose.

Metabolism of L-fucose and L-rhamnose in Escherichia coli: differences in induction of propanediol oxidoreductase.

Escherichia coli is capable of growing on L-fucose or L-rhamnose as a sole source of carbon and energy. When grown under anaerobic conditions on either sugar, a nicotinamide adenine dinucleotide-linked L-lactaldehyde:propanediol oxidoreductase activity is induced. The functioning of this enzyme results in the regeneration of oxidized nicotinamide adenine dinucleotide. Conditions of induction of the enzyme activity were studied and were found to display different characteristics on each sugar. In the rhamnose-grown cells, the increase in enzyme activity detected under inducing conditions was accompanied by the synthesis of propanediol oxidoreductase, as measured by the appearance in the extracts of a protein that reacts with propanediol oxidoreductase antibodies. In contrast, in fucose-grown cells, the level of propanediol oxidoreductase as measured by enzyme antibody-reacting material was high under noninducing and inducing conditions. Thus, the increase in enzyme activity detected in going from noninducing to inducing conditions in fucose-grown cells did not depend on the appearance of the specific protein but on the activation of the propanediol oxidoreductase already present in the cells in an inactive form. The propanediol oxidoreductase of both homologous systems should consequently be regulated by different control mechanisms.

Targeting and topology in the membrane of plant 3-hydroxy-3-methylglutaryl coenzyme A reductase.

The enzyme 3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGR) catalyzes the synthesis of mevalonate. This is the first committed step of isoprenoid biosynthesis. A common feature of all known plant HMGR isoforms is the presence of two highly conserved hydrophobic sequences in the N-terminal quarter of the protein. Using an in vitro system, we showed that the two hydrophobic sequences of Arabidopsis HMGR1S function as internal signal sequences. Specific recognition of these sequences by the signal recognition particle mediates the targeting of the protein to microsomes derived from the endoplasmic reticulum. Arabidopsis HMGR is inserted into the microsomal membrane, and the two hydrophobic sequences become membrane-spanning segments. The N-terminal end and the C-terminal catalytic domain of Arabidopsis HMGR are positioned on the cytosolic side of the membrane, whereas only a short hydrophilic sequence is exposed to the lumen. Our results suggest that the plant HMGR isoforms known to date are primarily targeted to the endoplasmic reticulum and have the same topology in the membrane. This reinforces the hypothesis that mevalonate is synthesized only in the cytosol. The possibility that plant HMGRs might be located in different regions of the endomembrane system is discussed.