The new field of neuroskeletal biology.

The fields of neuroscience and bone biology have recently converged following the discovery that bone remodeling is directly regulated by the brain. This work has defined bone remodeling as one of the cardinal physiological functions of the body, subject to homeostatic regulation and integrated with the other major physiological functions by the hypothalamus. Central to this discovery was the definition of the adipocyte-derived hormone leptin as a regulator of both arms of bone remodeling, formation and resorption, through its action on the ventromedial hypothalamus and subsequently via the sympathetic nervous system to osteoblasts. The characterization of the sympathetic nervous system as a regulator of bone remodeling has led to several large clinical studies demonstrating a substantial protective effect of beta-blockers, particularly beta1-blockers, on fracture risk. Studies in model organisms have reinforced the role of the central nervous system in the regulation of bone remodeling in vivo by the identification of several additional genes, namely cocaine and amphetamine regulated transcript (Cart), melanocortin 4 receptor (Mc4R), neuropeptide Y (NPY), Y2 receptor, cannabinoid receptor CB1 (Cnbr1), and the genes of the circadian clock. These genes have several common features, including high levels of expression in the hypothalamus and the ability to regulate other major physiological functions in addition to bone remodeling including energy homeostasis, body weight, and reproduction. We review the major pathways that define the new field of neuroskeletal biology and identify further avenues of inquiry.

Identification of a common mutation (Gly194Cys) in both Arab Moslem and Ashkenazi Jewish patients with dihydrolipoamide dehydrogenase (E3) deficiency: possible beneficial effect of vitamin therapy.

Dihydrolipoamide dehydrogenase (E3) deficiency with a clinical phenotype and genotype (Gly194Cys homozygous) previously identified only in Ashkenazi Jewish patients, was diagnosed in two Palestinian Arab siblings and two unrelated Ashkenazi Jewish patients. While three of the four patients died in childhood without specific treatment, the surviving patient at age 18 years may have benefited from long-term daily supplementation with a cocktail of riboflavin, biotin, coenzyme Q and carnitine.

Associations of the collagen type Ialpha1 Sp1 polymorphism with five-year rates of bone loss in older adults.

The collagen type Ialpha1 Sp1 (ColIA1) polymorphism has been associated with reduced bone mineral density (BMD) and increased prevalence of osteoporosis. This study examines associations of the ColIA1 genotype with BMD and 5-year rates of change in BMD in elderly men and women. The 243 subjects, aged 65 years and older, were participants in two consecutive studies lasting a total of 5-years. BMD of the total body, femoral neck, and lumbar spine were made by dual-energy X-ray absorptiometry (DXA). The distribution of the genotypes (155 in the SS genotype, 79 in Ss, and 9 in ss) was proportionately similar to those reported by others. Baseline BMD did not differ significantly at any skeletal site. Unadjusted 5-year percent changes in BMD differed significantly by genotype only at the total body (P = 0.009), where the change was -0.29+/-0.21 (SEM) in the SS genotype, -0.60+/-0.25 in the Ss genotype, and -3.01+/-0.72 in the ss genotype. This 9.4% increase in bone loss of the ss genotype relative to the SS genotype was reduced to an 8.9% increase after adjustment for sex, age, weight, and supplementation group. Results at the femoral neck were directionally similar, but not statistically significant. No effect of genotype on change in spine BMD was observed. In conclusion, bone loss from the total body was significantly greater in elderly men and women who were homozygous for the s allele compared with heterozygotes and SS homozygotes. This finding suggests a possible explanation for the association of the ColIA1 polymorphism with increased rates of osteoporotic fracture, but should be interpreted with caution because of the small number of subjects in the unfavorable ss genotype.

Gene regulation and genetic defects in the pyruvate dehydrogenase complex.

The mammalian pyruvate dehydrogenase complex (PDC) is subject to both short-term (product inhibition and covalent modification) and long-term (increases in total activity and protein mass) regulation mediated by dietary and hormonal treatments. Recent advances in the isolation and characterization of the complementary DNAs as well as genes encoding several components of mammalian PDC have facilitated studies concerning long-term regulation of PDC. Analyses of the promoter-regulatory regions of the two human PDC genes show characteristics of both facultative and housekeeping gene promoters, indicating complex transcriptional regulation. Deficiency of PDC activity causes a wide range of neurological disabilities. A spectrum of genetic defects in PDC components has been reported; however, the most frequent defects are associated with the pyruvate dehydrogenase component. Heterogeneity in pyruvate dehydrogenase deficiency has been shown to occur at both protein and messenger RNA levels, and several mutations in pyruvate dehydrogenase have been identified. Dietary treatments such as ketogenic diets and vitamin supplements as well as dichloroacetate treatment have been utilized to treat PDC deficiency, but their efficacy requires further evaluation.

Primary amino acid sequence and structure of human pyruvate carboxylase.

Pyruvate carboxylase (PC) (pyruvate:carbon dioxide ligase (ADP-forming), EC 6.4.1.1.), a nuclear-encoded mitochondrial enzyme, catalyzes the conversion of pyruvate to oxaloacetate. We have isolated and characterized cDNAs spanning the entire coding region of human PC. The sequence of human PC has an open reading frame of 3537 nucleotides which encodes for a polypeptide with a length of 1178 amino acids. The identity of the cDNA as PC is confirmed by comparison to PC cDNAs of other species and sequenced peptide fragments of mammalian PC. The M(r) of the full length precursor protein is 129,576 and that of the mature apoprotein is 127,370. RNA blot analysis from a variety of human tissues demonstrates that the highest level of PC mRNA is found in liver corresponding to this tissue's high level of PC activity. Based on homology with other biotin-containing proteins, the ATP, pyruvate, and biotin-binding sites can be identified. One of two patients with documented PC deficiency was found to be missing PC mRNA, further confirming the identity of this cDNA.

Problems in the evaluation of alternative medicine.

Evaluation of alternative medicine poses paradigmatic as well as procedural difficulties. Difficulties faced by the scientific community in accepting the 'world view' of acupuncture and homeopathy are described, and possibilities for evaluating alternative medical paradigms are considered. A selection of randomized controlled trials are reviewed and weaknesses in protocol and method identified.

Evaluation of holistic medicine.

As an increasingly informed public becomes more and more disillusioned with the failure of scientific medicine to live up to its promises and to fulfill popular expectations, attention has been turning to 'holistic,' 'traditional,' 'alternative' or 'complementary' medicine. Forms of medical treatment such as acupuncture, homeopathy, and ayurvedic medicine have infrequently been rigorously evaluated. This paper reviews the traditional structures of clinical and economic evaluation of health care, and then describes a particular set of specific problems that would be encountered in applying these techniques to 'holistic' medicine under the headings 'reductionism' (bias from excluding certain categories of effects), 'taxonomic difficulties' (problems inherent in the choice of diagnostic criteria), and the 'logical basis for comparison' (procedural difficulties). Various methods for comparing the results of different schools of medical thought are suggested and evaluated.