An M-CAT binding factor and an RSRF-related A-rich binding factor positively regulate expression of the alpha-cardiac myosin heavy-chain gene in vivo.

Cardiac muscle-restricted expression of the alpha-myosin heavy-chain (alpha-MHC) gene is regulated by multiple elements in the proximal enhancer/promoter. Within this region, an M-CAT site and an A-rich site were identified as potential regulatory elements. Site-specific mutations in each site, individually, reduced activity from the wild-type promoter by approximately 85% in the adult rat heart, demonstrating that these sites were positive regulatory elements. alpha-MHC, beta-MHC, and chicken cardiac troponin T (cTnT) M-CAT sites interacted with an M-CAT-binding factor (MCBF) from rat heart nuclear extracts that was immunologically related to transcriptional enhancer factor 1, a factor that binds within the simian virus 40 enhancer. The factor that bound the A-rich region (ARF) was antigenically related to the RSRF family of proteins, ARF was distinct from myocyte-specific enhancer factor 2 (MEF-2) on the basis of DNA-binding specificity and developmental expression. Like MEF-2, ARF DNA-binding activity was present in the heart and brain; however, no ARF activity was detected in extracts from skeletal muscle or C2C12 myotubes. MCBF and ARF DNA-binding activities were developmentally regulated with peak levels in the 1- to 2-day neonatal heart. The activity of both factors increased nearly fivefold in adult rat hearts subjected to a pressure overload. By comparison, the levels of alpha-MHC binding factor 2 did not change during hypertrophy. Binding sites for MCBF and ARF are present in several genes that are upregulated during cardiac hypertrophy. Our results suggest that these factors participate in the alterations in gene expression that occur during cardiac development and hypertrophy.

Transcription factor GATA-4 regulates cardiac muscle-specific expression of the alpha-myosin heavy-chain gene.

The alpha-myosin heavy-chain (alpha-MHC) gene is the major structural protein in the adult rodent myocardium. Its expression is restricted to the heart by a complex interplay of trans-acting factors and their cis-acting sites. However, to date, the factors that have been shown to regulate expression of this gene have also been found in skeletal muscle cells. Recently, transcription factor GATA-4, which has a tissue distribution limited to the heart and endodermally derived tissues, was identified. We recently found two putative GATA-binding sites within the proximal enhancer of the alpha-MHC gene, suggesting that GATA-4 might regulate its expression. In this study, we establish that GATA-4 interacts with the alpha-MHC GATA sites to stimulate cardiac muscle-specific expression. Mutation of the GATA-4-binding sites either individually or together decreased activity by 50 and 88% in the adult myocardium, respectively. GATA-4-dependent enhancement of activity from a heterologous promoter was mediated through the alpha-MHC GATA sites. Coinjection of an alpha-MHC promoter construct with a GATA-4 expression vector permitted ectopic expression in skeletal muscle but not in fibroblasts. Thus, the lack of alpha-MHC expression in skeletal muscle correlates with a lack of GATA-4. GATA-4 DNA binding activity was significantly up-regulated in triiodothyronine- or retinoic acid-treated cardiomyocytes. Putative GATA-4-binding sites are also found in the regulatory regions of other cardiac muscle-expressed structural genes. This indicates a mechanism whereby triiodothyronine and retinoic acid can exert coordinate control of the cardiac phenotype through a trans-acting regulatory factor.

The transcription factor GATA4 is activated by extracellular signal-regulated kinase 1- and 2-mediated phosphorylation of serine 105 in cardiomyocytes.

The zinc finger-containing transcription factor GATA4 has been implicated as a critical regulator of multiple cardiac-expressed genes as well as a regulator of inducible gene expression in response to hypertrophic stimulation. Here we demonstrate that GATA4 is itself regulated by the mitogen-activated protein kinase signaling cascade through direct phosphorylation. Site-directed mutagenesis and phospho-specific GATA4 antiserum revealed serine 105 as the primary site involved in agonist-induced phosphorylation of GATA4. Infection of cultured cardiomyocytes with an activated MEK1-expressing adenovirus induced robust phosphorylation of serine 105 in GATA4, while a dominant-negative MEK1-expressing adenovirus blocked agonist-induced phosphorylation of serine 105, implicating extracellular signal-regulated kinase (ERK) as a GATA4 kinase. Indeed, bacterially purified ERK2 protein directly phosphorylated purified GATA4 at serine 105 in vitro. Phosphorylation of serine 105 enhanced the transcriptional potency of GATA4, which was sensitive to U0126 (MEK1 inhibitor) but not SB202190 (p38 inhibitor). Phosphorylation of serine 105 also modestly enhanced the DNA binding activity of bacterially purified GATA4. Finally, induction of cardiomyocyte hypertrophy with an activated MEK1-expressing adenovirus was blocked with a dominant-negative GATA4-engrailed-expressing adenovirus. These results suggest a molecular pathway whereby MEK1-ERK1/2 signaling regulates cardiomyocyte hypertrophic growth through the transcription factor GATA4 by direct phosphorylation of serine 105, which enhances DNA binding and transcriptional activation.

The cardiac tissue-restricted homeobox protein Csx/Nkx2.5 physically associates with the zinc finger protein GATA4 and cooperatively activates atrial natriuretic factor gene expression.

Specification and differentiation of the cardiac muscle lineage appear to require a combinatorial network of many factors. The cardiac muscle-restricted homeobox protein Csx/Nkx2.5 (Csx) is expressed in the precardiac mesoderm as well as the embryonic and adult heart. Targeted disruption of Csx causes embryonic lethality due to abnormal heart morphogenesis. The zinc finger transcription factor GATA4 is also expressed in the heart and has been shown to be essential for heart tube formation. GATA4 is known to activate many cardiac tissue-restricted genes. In this study, we tested whether Csx and GATA4 physically associate and cooperatively activate transcription of a target gene. Coimmunoprecipitation experiments demonstrate that Csx and GATA4 associate intracellularly. Interestingly, in vitro protein-protein interaction studies indicate that helix III of the homeodomain of Csx is required to interact with GATA4 and that the carboxy-terminal zinc finger of GATA4 is necessary to associate with Csx. Both regions are known to directly contact the cognate DNA sequences. The promoter-enhancer region of the atrial natriuretic factor (ANF) contains several putative Csx binding sites and consensus GATA4 binding sites. Transient-transfection assays indicate that Csx can activate ANF reporter gene expression to the same extent that GATA4 does in a DNA binding site-dependent manner. Coexpression of Csx and GATA4 synergistically activates ANF reporter gene expression. Mutational analyses suggest that this synergy requires both factors to fully retain their transcriptional activities, including the cofactor binding activity. These results demonstrate the first example of homeoprotein and zinc finger protein interaction in vertebrates to cooperatively regulate target gene expression. Such synergistic interaction among tissue-restricted transcription factors may be an important mechanism to reinforce tissue-specific developmental pathways.

Analysis of mRNA synthesis following induction of the Escherichia coli SOS system.

Escherichia coli responds to impairment of DNA synthesis by inducing a system of DNA repair known as the SOS response. Specific genes are derepressed through proteolytic cleavage of their repressor, the lexA gene product. Cleavage in vivo requires functional RecA protein in a role not yet understood. We used mRNA hybridization techniques to follow the rapid changes that occur with induction in cells with mutations in the recA operator or in the repressor cleavage site. These mutations allowed us to uncouple the induction of RecA protein synthesis from its role in inducing the other SOS functions. Following induction with ultraviolet light, we observed increased rates of mRNA synthesis from five SOS genes within five minutes, maximum expression ten to 20 minutes later and then a later decline to near the initial rates. The presence of a recA operator mutation did not significantly influence these kinetics, whereas induction was fully blocked by an additional mutation in the repressor cleavage site. These experiments are consistent with activation of RecA protein preceding repressor cleavage and derepression of SOS genes. The results also suggest that the timing and extent of induction of individual SOS genes may be different.

Clofibrate prevents the development of hypertension in Dahl salt-sensitive rats.

We have reported that cytochrome P-450-dependent omega-hydroxylation of arachidonic acid is reduced in microsomes prepared from the renal outer medulla of Dahl salt-sensitive (SS/Jr) rats, but the functional significance of this observation is unknown. The present study examined whether long-term induction of renal fatty acid omega-hydroxylase with clofibrate would alter the development of hypertension in Dahl SS/Jr rats. Dahl SS/Jr rats were placed on a high salt diet (8.0% NaCl) and given either vehicle or clofibrate (80 mg/day) in their drinking water. After 4 weeks of a high salt diet, mean arterial pressure averaged 170 +/- 3 mm Hg in vehicle-treated (n = 17) and 127 +/- 2 mm Hg in clofibrate-treated (n = 19) SS/Jr rats. Clofibrate had no effect on arterial pressure in Dahl salt-resistant rats. The antihypertensive effect of clofibrate was reversible. Mean arterial pressure rose from 131 +/- 4 to 182 +/- 8 mm Hg in the first week after clofibrate treatment (n = 6) was discontinued. Clofibrate had no effect on arterial pressure in SS/Jr rats (n = 9) in which hypertension was already established by feeding the rats a high salt diet for 4 weeks before the study. In clofibrate-treated SS/Jr rats (n = 12), the omega-hydroxylation of arachidonic and lauric acids by renal cortical and outer medullary microsomes was greater than that seen in vehicle-treated rats (n = 9).(ABSTRACT TRUNCATED AT 250 WORDS)

Child abuse intervention: conflicts in current practice and legal theory.

Recent litigation of child abuse cases indicates that two contradictory policies compete for court approval. One policy would reduce the amount of intervention into abusive families on grounds of privacy. The other seeks to maintain and expand channels of investigation and treatment. While attempting to prescribe a comprehensive approach to child abuse, these conflicting policies, in fact, address different problems in child protection. Without a treatment formulation that focuses on the separate issues raised by each policy, it is not clear that clinicians will be able to sustain child abuse investigatory and protective authority against the privacy attack. This treatment synthesis must entail development of standards that maximize protection of the child from caretakers at the earliest stages of risk and protection from administrative procrastination in case resolution. Protecting the child rather than the family institution should provide the central focus of policy formulation.

Selective opportunistic screening for hypercholesterolemia in primary care practice.

OBJECTIVES: To assess the performance of selective opportunistic screening in a primary care group practice. DESIGN: Cross-sectional survey of coronary heart disease risk factors and retrospective chart audit of cholesterol testing. SETTING: Capitation-funded primary care group practice in Ontario, Canada. SUBJECTS: 7785 enrolled patients between the ages of 20 and 69 years. INTERVENTION: Protocol-based selective opportunistic screening program for hypercholesterolemia of 45 months duration. MAIN OUTCOME MEASURES: Targeting (proportion of screening tests that were appropriate), coverage (proportion of those meeting screening criteria who had a screening test performed), over-screening (proportion of those not meeting screening criteria who had a screening test performed), and screening ratio (likelihood that a screening test was performed on an individual who met screening criteria rather than one who failed to meet screening criteria). RESULTS: 64.7% of patients tested met the practice criteria for screening. 37.7% of patients who met the practice screening criteria were tested and 24.9% of those not meeting practice screening criteria had a cholesterol test performed. The screening ratio was 1.52. CONCLUSION: Our findings bring into question the effectiveness of opportunistic approaches to preventive care.

Casting the screening net: separating big fish from little fish.

Screening tests are a rapidly growing part of medical practice. If we are going to make the best use of resources, screening tests need to be considered in terms of effectiveness, efficiency and equity. We present a framework as a way to think about screening programmes. The framework expands on existing literature that recognizes two categories of screening: universal and opportunistic. By adding the dimension of 'selectivity', we identify four categories of screening: active non-selective (universal or mass screening), active selective, opportunistic non-selective and opportunistic selective. We illustrate the framework by categorizing screening recommendations for high serum cholesterol levels. We conclude there is no one ideal strategy for screening that simultaneously satisfies criteria of effectiveness, efficiency and equity. However, our framework allows a systematic consideration and balancing of these objectives in the development and assessment of screening programs. In this way, it may assist decision-makers by making this trade-off more explicit.

Health years equivalents as a measurement of preferences for dental interventions.

OBJECTIVE: To test the feasibility and importance of measuring preferences among treatment choices using Healthy Years Equivalents (HYE). DESIGN: Development of scenarios for alternative approaches to caries treatment. Completion of category rating and standard gamble questions elicited in personal interviews. SETTING: The provision of dental care to children in a public-funded dental health clinic. PARTICIPANTS: Random sample of the adult population of Hamilton, Ontario. MAIN OUTCOME MEASURES: The percentage of the sample unable to complete the interviews, time taken to perform interviews, ease of understanding of interviews, correlation between rank ordering and HYE scores. RESULTS: Ninety-six per cent of the sample were able to complete the HYE exercise. Inconsistencies between HYE scores and rank orders implying preference reversal occurred in 6% of those completing HYE scores for the two scenarios. The additional time taken by the HYE was of the order of 17 minutes but increased with the age of the subject. Where problems occurred, they were related to the method of measurement or the sensitivity of the chosen scale as opposed to additional requirements of the HYE. There was some evidence that HYEs and QALYs produced different scores even in the context of chronic constant health states. CONCLUSIONS: HYEs are a feasible and important practical method of measuring preferences among interventions. Alternative utility-based approaches, such as willingness to pay, may be required to detect differences in modest improvements in temporary health states.

Screening for hypercholesterolaemia in primary care: randomised controlled trial of postal questionnaire appraising risk of coronary heart disease.

OBJECTIVES: To validate a self administered postal questionnaire appraising risk of coronary heart disease. To determine whether use of this questionnaire increased the percentage of people at high risk of coronary heart disease and decreased the percentage of people at low risk who had their cholesterol concentration measured. DESIGN: Validation was by review of medical records and clinical assessment. The questionnaire appraising risk of coronary heart disease encouraged those meeting criteria for cholesterol measurement to have a cholesterol test and was tested in a randomised controlled trial. The intervention group was sent the risk appraisal questionnaire with a health questionnaire that determined risk of coronary heart disease without identifying the risk factors as related to coronary heart disease; the control group was sent the health questionnaire alone. SETTING: One capitation funded primary care practice in Canada with an enrolled patient population of about 12 000. SUBJECTS: Random sample of 100 participants in the intervention and control groups were included in the validation exercise. 5686 contactable patients aged 20 to 69 years who on the basis of practice records had not had a cholesterol test performed during the preceding 5 years were included in the randomised controlled trial. 2837 were in the intervention group and 2849 were in the control group. MAIN OUTCOME MEASURES: Sensitivity and specificity of assessment of risk of coronary heart disease with risk appraisal questionnaire. Rate of cholesterol testing during three months of follow up. RESULTS: Sensitivity of questionnaire appraising coronary risk was 87.5% (95% confidence interval 73.2% to 95.8%) and specificity 91.7% (81.6% to 97.2%). Of the patients without pre-existing coronary heart disease who met predefined screening criteria based on risk, 45 out of 421 in the intervention group (10.7%) and 9 out of 504 in the control group (1.8%) had a cholesterol test performed during follow up (P<0.0001). Of the patients without a history of coronary heart disease who did not meet criteria for cholesterol testing, 30 out of 1128 in the intervention group (2.7%) and 18 out of 1099 in the control group (1.6%) had a cholesterol test (P=0.175). Of the patients with pre-existing coronary heart disease, 1 out of 15 in the intervention group (6.7%) and 1 out of 23 in the control group (4.3%) were tested during follow up (P=0.851, one tailed Fisher's exact test). CONCLUSIONS: Although the questionnaire appraising coronary risk increased the percentage of people at high risk who obtained cholesterol testing, the effect was small. Most patients at risk who received the questionnaire did not respond by having a test.

Diagnostic perceptions and diagnostic behavior in a family practice unit.

Results of a pilot study with nine physicians in a model Family Practice Unit are described in this report. It was hypothesized that decisions regarding treatment priorities would lead to the "undertreatment" of ailments for which the physicians felt relatively ineffective and that feelings of efficacy would be greater for primarily organic than for primarily psychological ailments. Physician interviews and examination of the Unit's diagnostic file provided the data for this study. A treatment bias as a function of the degree to which an ailment had a psychological compenent was not demonstrated. However, the physicians did feel less effective (less comfortable) in treating problems that were significantly psychological and also felt that methods of intervention for such ailments were less clear-cut. Physician comfort level was greater when there were few alternative treatment methods generally used for the ailment and when the ailment was recorded frequently. A suggestion is made that medical curricula include more practical experience in treating ailments which have notable psychological components in order to increase physician comfort and probably physician effectiveness.

Review of the multi-hospital arrangements literature: benefits, disadvantages and lessons for implementation.

The multi-hospital arrangements literature is reviewed for Canada and the United States. There is a notable lack of evaluations on the outcomes of these arrangements, especially in the Canadian context. For evaluations that do make it to the literature, generalizability of conclusions is difficult because most is based on case studies and relates to "for-profit" U.S. hospitals. We are forced to conclude, however, that there is little definitive evidence that quality of care is improved by multi-hospital arrangements or to support or refute the claims of better human resources deployment. The most striking organizational benefit appears to be that institutions considering merger or other arrangements are forced into explicit considerations of their mission and goals. Many of the potential disadvantages of multi-hospital arrangements may be ameliorated with appropriate strategic planning and attention to detail during negotiation of the arrangement. As new multi-institutional arrangements may cause harm as well as reap benefits, careful evaluation is needed.

Influence of chromosome integrity on Escherichia coli cell division.

The antitumor agent cis-platinum(II)diamminodichloride (PDD) caused wild-type and recA+ deoxyribonucleic acid (DNA) repair-deficient mutant cells of Escherichia coli K-12 to grow as long, multinucleated filaments. At 5 micrograms/ml, the times required for reduction of viability to 37% for wild-type, polA, recB,C, uvrA, and recA organisms were > 200, 200, 120, 25, and 5 min, respectively. Only recA cells exhibited @reckless" degradation of DNA at this concentration of PDD. As shown by sedimentation in alkaline sucrose gradients, generation of single-strand breaks in DNA of the remaining organisms was a major consequence of growth in PDD. Upon incubation in fresh medium after removal of the compound and storage for 4 h at 4 degrees C, a respective lag of 3, 4, 6, and 9 h occurred before filaments of wild-type, polA, recB,C, and uvrA cells commenced cell division. Maintenance at 4 degrees C, which evidently delayed postshift initiation of chromosome replication, was only essential for fragmentation of uvrA filaments. In all cases, these periods of division delay corresponded to those required for restoration of normal chromosomal molecular weight as determined in alkaline sucrose gradients.

Myocyte-specific enhancer-binding factor (MEF-2) regulates alpha-cardiac myosin heavy chain gene expression in vitro and in vivo.

A myocyte-specific enhancer-binding factor (MEF-2) DNA binding site was identified in the rat alpha-myosin heavy chain (MHC) gene adjacent to the E-box binding site for alpha-MHC binding factor-2 (BF-2). Mutation of the MEF-2 site, within the context of the full-length promoter, reduced activity by 85 and 80% in neonatal cardiomyocytes and the adult heart, respectively. Mutation of the BF-2 site reduced activity approximately 70% in both models. A MEF-2/BF-2 double mutant gave significantly less activity than the BF-2 mutant but not the MEF-2 mutant, suggesting the possibility that BF-2 and MEF-2 interact. Mutations in MEF-2, which decreased functional activity, also abolished MEF-2 DNA binding activity. MEF-2 DNA binding activity was present in the developing heart, reached a peak in the late fetal and early neonatal stages, and then declined to low levels in the adult heart. The adult levels were sufficient to support alpha-MHC gene expression. MEF-2 activity was increased 2-3-fold in the adult heart subjected to a pressure or volume overload. Two working models are proposed as possible explanations of the antithetic relationship between MEF-2 levels and alpha-MHC gene expression.

p300 Functions as a coactivator of transcription factor GATA-4.

Transcription factor GATA-4 plays critical roles in controlling heart development and cardiac hypertrophy. To understand how GATA-4 functions under diverse conditions, we sought to identify its coactivators. We tested p300 as a coactivator in GATA-4-dependent transient transcription assays in NIH3T3 cells and found that p300 synergistically activated GATA-4-dependent transcription on both synthetic and natural promoters. Direct physical interactions between the N- and C-zinc finger domains of GATA-4 and the cysteine/histidine-rich region 3 (C/H3) of p300 were identified in immunoprecipitation and glutathione S-transferase pull-down experiments. Deletion of the C/H3 region of p300 abolished its coactivator activity indicating that the physical interaction was required for functional synergy. Through the use of a series of GATA-4 zinc finger mutants, the amino acids WRR in the C finger were identified as critical to the interaction. The adenoviral E1A protein or a peptide encoding the C/H3 region of p300 could inhibit GATA-4-dependent transcription, presumably by competing for p300 binding. Furthermore, deletion of the region of p300 encoding the histone acetyltransferase activity abolished its effect on GATA-4-dependent transcriptional activity. These results establish that p300 acts as a GATA-4 coactivator and that the p300 histone acetyltransferase activity is necessary for the functional interaction.

Is small really beautiful? Some thoughts on the 1995 federal budget.

The 1995 federal budget meets the financial markets' expectations by proposing deep funding cuts and defining a smaller federal presence in several sectors of Canadian society. The most significant aspect of the budget for health care is the creation of the Canada Health and Social Transfer, which merges federal funding for health, post-secondary education and social assistance into one block grant. Provinces will be free to shift funds among these programs.

Physiology of the SOS response: kinetics of lexA and recA transcriptional activity following induction.

The products of the lexA and recA genes play central roles in the regulation of the Escherichia coli SOS response. We have measured the rate of mRNA synthesis from each gene at intervals following various inducing treatments in order to obtain a more precise timing of the induction process. Further, we provide quantitative evidence for kinetics of decay from fully induced levels of mRNA synthesis to basal levels as the cells shut down the SOS response which are in agreement with previously published data on the expression of specific SOS functions. The induction kinetics of lexA and recA gene expression are parallel except for nalidixic acid (NAL) treatment, with the actual levels of lexA mRNA synthesis being about 10-fold lower than that of recA. Reestablishment of repression from RecA commenced over 30 min earlier than from lexA. These results are fully consistent with the model that the functions result from the increased gene expression.