[Improvement of medication safety by identification of genetically predisposed subjects. Personalized clinical strategies and regulatory advices]. / Erhöhung der Arzneimitteltherapiesicherheit durch Identifizierung genetisch prädisponierter Personen. Personalisierte klinische Ansätze und regulatorische Maßnahmen.

BACKGROUND: Because adverse drug events (ADEs) have a high socio-economic impact there is an urgent need for effective prevention. In addition to process-related avoidable errors personalised approaches for the prevention of ADEs should also focus on genetic polymorphisms as potential causative agents. AIM: Using five case reports as examples therapeutic modalities are described to illustrate the clinical impact of prospective testing aimed at estimating the individual risk of susceptible subjects. MATERIAL AND METHODS: The role of the HLA system, the cytochrome P450 family, other metabolic enzymes and transport proteins are described to illustrate the broad range of genetic susceptibility. It is shown, why, when and for whom pretherapeutic tests on genetic polymorphisms are recommended to reduce the risk of ADEs. RESULTS: The determination of genetic susceptibility is already implemented in clinical practice prior to (1) carbamazepine therapy in south-east Asians and (2) treatment with abacavir independent of ethnicity. Before prescribing carbamazepine or abacavir, it is recommended that therapeutic decisions be based on these test results. CONCLUSION: The broad application of personalised medicine used as an effective tool for minimizing ADE risks is limited by the evidence-based benefit for the patient on the one hand and the costs of the test on the other hand.

[Integrity/demyelination of the optic radiation, morphology of the papilla, and contrast sensitivity in glaucoma patients]. / Integrität/Demyelinisierung der Radiatio optica, Morphologie der Papille und Kontrastsensitivität bei Glaukompatienten.

BACKGROUND: In primary open angle glaucoma (POAG) and its non-barotraumatic subgroup, normal tension glaucoma (NTG), the pathophysiological differences are not clear. A participation of the 4th neuron of the visual pathway (optic radiation) appears possible on the basis of related experimental studies. The goal of the present study was the evaluation of the optic radiation by diffusion tensor imaging (DTI), which is based on the magnetic resonance imaging. The diffusion and anisotropy parameters of the optic radiation as a marker of axonal integrity and demyelination/damage of glial cells, respectively, were used to investigate the relation between the morphology of the papilla (BLDF, linear discriminant function of Burk) and the contrast sensitivity (FDT, frequency doubling test). PATIENTS AND METHODS: In this prospective observational study 13 POAG patients, 13 NTG patients, and 7 control patients of the same mean age were included. For segmentation of the optic radiation a semi-automated algorithm was applied and the diffusion and anisotropy parameters were calculated. The importance of the covariates age, BLDF, and FDT for the DTI parameters was determined using partial correlation analysis. RESULTS: Analysis of the covariates partially showed a clear autocorrelation. The correlations between the DTI parameters and BLDF were significant in all groups after correction of the measurement values for the covariates. FDT correlated with DTI parameters in controls and POAG. The NTG group did not show this correlation due to a strong spreading of the FDT values. CONCLUSION: After statistical elimination of the autocorrelation of the covariates age, BLDF, and FDT the morphology of the papilla correlated with the axonal integrity and demyelination/glia cell impairment of the optic radiation in controls and glaucoma. In NTG the impaired contrast sensitivity is highly variable and is not associated with the condition of the 3rd or 4th neuron, respectively, as compared to POAG. The autocorrelation between individual covariates represents an important element for the judgement of the visual pathway.

[Validation of telemedical fundus images from patients with retinopathy]. / Validierung von telemedizinischen Fundusaufnahmen bei Patienten mit Retinopathie.

BACKGROUND: The degree of retinal microangiopathy is important foran estimation of the vascular risk and for the optimisation of therapy in hypertensive and diabetic patients. Retinal microangiopathy may be determined by examination of the retinal fundus. We examined the reliability of the ophthalmoscopic diagnosis and of the telemedical judgement of fundus images in relation to the presence and the degree of retinopathy. PATIENTS AND METHODS: This comparative observational study included 47 inpatient hypertensive and/or diabetic subjects. The fundus was judged ophthalmoscopically and subsequently, a fundus image was generated by use of a KOWA camera. The images were sent to the Interdisciplinary Center of Ophthalmologic Preventive Medicine. The reliability of the two diagnostic methods was calculated for one of the two eyes, which was selected by a random generator. RESULTS: The largest concordance of the two diagnosis methods was achieved, in descending order, for retinal bleeding, stage of diabetic retinopathy and the papilla findings. Additionally, there were no differences for the stage of hypertensive retinopathy und tortuosity. The reliability of arterio-venous nicking related to the right and the left eye was low or absent, respectively. CONCLUSIONS: The teleophthalmologic diagnosis achieves good results as compared to the ophthalmoscopic judgement in relation to retinopathy assessment criteria.

[Prevalence of glaucomatous optic nerve atrophy among a working population in Germany diagnosed by a telemedical approach]. / Telemedizinische Erfassung der Prävalenz der glaukomatösen Optikusatrophie in einer arbeitenden Bevölkerungsgruppe.

PURPOSE: The aim of this study was to determine the prevalence of glaucomatous optic nerve atrophy among a working population in Germany by secondary evaluation of a study conducted to estimate the prevalence of retinal microangiopathic abnormalities by telemedical examination of the retina. PATIENTS AND METHODS: From August 2002 until January 2004 the retina and optic nerve head were examined in 19,294 Caucasians using a non-mydriatic fundus camera (Kowa, nonmyd-alpha 45), which produces colour images with 45 degrees. The images of the retina and optic nerve head were evaluated telemedically by glaucoma specialists in respect to optic nerve pathologies and microangiopathic abnormalities by a standardised procedure. Glaucomatous optic nerve atrophy was diagnosed when specific glaucomatous morphological alterations of the optic nerve head were present. A complete medical history including reported elevated intraocular pressure (IOP) and blood pressure was obtained. RESULTS: The intra-observer and inter-observer reliability were 0.884 and 0.740, respectively. Cronbach's alpha for two evaluation cycles each of two observers was 0.870. The prevalences of glaucomatous optic nerve atrophy in the different age groups were 0.07 % (45 - 49 years), 0.40 % (50 - 54 years), 0.45 % (55 - 59 years) and 0.82 % (60 - 64 years). Age could be established as an important risk factor for glaucomatous optic nerve atrophy, while no influence of gender or family history was found. CONCLUSION: Telemedical evaluation of colour images of the retina and optic nerve acquired by a non-mydriatic fundus camera allows a fast and efficient screening of many subjects with medium reliability.

Cold stimulation induces different responses of ophthalmic artery blood flow velocity depending on baseline blood pressure and gender.

Earlier, we have introduced the spectral index (SI), which was derived from the harmonic content of the blood flow velocity envelope of the ophthalmic artery. SI changed in dependency on the baseline blood pressure (bBP). We now examined SI during sympathetic activation by cold stimulation for 300 s in dependency on bBP to investigate the response to sympathetic neural activity in arterial hypertension. Ten men and 12 women with normal bBP (age, 60.5+/-4.6 years and 61.9+/-7.2 years) and age-adjusted men and women with increased bBP underwent the cold pressor test, including a periodical measurement of blood pressure and blood flow velocity in the ophthalmic artery, the latter by pulsed Doppler sonography. From this, the course of the SI was calculated. During cold stimulation men with increased bBP achieved their SI peak and their systolic blood pressure peak earlier than those with normal bBP (P=0.002 and P=0.035, respectively) and their SI slope was steeper than in normotensive men (P=0.002). Multiple testing showed that the difference of SI decrease between men with normal and increased bBP occurs on average 60 s after the beginning of cold stimulation (P=0.018). These differences were not found between female blood pressure groups, but the results in women may be influenced by antihypertensive treatment of some of the hypertensive women. In conclusion, the SI is useful to evaluate the response to sympathetic activation in hypertensive men but a larger study population should confirm the study results in women.

Up-regulation of the human serum and glucocorticoid-dependent kinase 1 in glomerulonephritis.

Glomerulonephritis is paralleled by excessive formation of transforming growth factor-beta (TGF-beta), which participates in the pathophysiology of the disease. Recently, a novel downstream target of TGF-beta has been identified, i.e. the human serum and glucocorticoid-dependent kinase 1 (hSGK1), a serine/threonine kinase participating in the regulation of Na(+) transport. The present study was performed to elucidate transcriptional regulation of hSGK1 in glomerulonephritis. To this end, in situ hybridization was performed in biopsies from patients with clinical diagnosis of glomerulonephritis. hSGK1 transcript levels were moderately enhanced in 5 out of 9 patients and strongly enhanced in 4 out of 9 patients. Distal nephron epithelial cell hSGK1 transcript levels were low or absent in 7 of the 9 patients but markedly enhanced in 2 of the 9 patients. In conclusion, glomerulonephritis leads to glomerular and in some cases to epithelial up-regulation of hSGK1 transcription.

Cerebral localization and regulation of the cell volume-sensitive serum- and glucocorticoid-dependent kinase SGK1.

The serum- and glucocorticoid-dependent kinase SGK1 is regulated by alterations of cell volume, whereby cell shrinkage increases and cell swelling decreases the transcription, expression and activity of SGK1. The kinase is expressed in all human tissues studied including the brain. The present study was performed to localize the sites of SGK1 transcription in the brain, to elucidate the influence of the hydration status on SGK1 transcription and to explore the functional significance of altered SGK1 expression. Northern blot analysis of human brain showed SGK1 to be expressed in all cerebral structures examined: amygdala, caudate nucleus, corpus callosum, hippocampus, substantia nigra, subthalamic nucleus and thalamus. In situ hybridization and immunohistochemistry in the rat revealed increased expression of SGK1 in neurons of the hippocampal area CA3 after dehydration, compared with similar slices from brains of euvolaemic rats. Additionally, several oligodendrocytes, a few microglial cells, but no astrocytes, were positive for SGK1. The abundance of SGK1 mRNA in the temporal lobe, including hippocampus, was increased by dehydration and SGK1 transcription in neuroblastoma cells was stimulated by an increase of extracellular osmolarity. Co-expression studies in Xenopus laevis oocytes revealed that SGK1 markedly increased the activity of the neuronal K+ channel Kv1.3. As activation of K+ channels modifies excitation of neuronal cells, SGK1 may participate in the regulation of neuronal excitability.

Cell volume regulatory mechanisms in progression of renal disease.

One of the striking morphological features of renal failure is an increase of cell volume. This review explores the role of cell volume regulatory mechanisms in the pathophysiology of progressive renal disease. The case is made that TGF-beta, a major cytokine involved in the development of progressive renal failure, upregulates the transcription of the serum and glucocorticoid-dependent kinase hSGK1, involved in cell volume regulation. Excessive extracellular glucose concentrations stimulate TGF-beta1 expression and thus similarly enhance hSGK1-transcription. The kinase stimulates two mechanisms important for cell volume regulation, i.e. the renal epithelial Na+ channel ENaC and the thick ascending limb Na+,K+,2Cl- cotransporter BSC1. On the one hand, stimulation of renal tubular transport leads to renal retention of Na+, which favours the development of hypertension. On the other, the increase of cell volume stimulates protein synthesis and inhibits protein degradation, contributing to the enhanced net formation and deposition of matrix proteins. At later stages, the increase of cell volume may be reversed to atrophy, and cell death may lead to loss of functional tissue. In conclusion, progressive renal disease is paralleled by deranged cell volume regulatory mechanisms.

Serum- and glucocorticoid-dependent kinase, cell volume, and the regulation of epithelial transport.

Ample pharmacological evidence points to a role of kinases in the regulation of cell volume. Given the limited selectivity of most inhibitors, however, the specific molecules involved have remained largely elusive. The search for cell volume regulated genes in liver HepG2 cells led to the discovery of the human serum- and glucocorticoid-dependent serine/threonine kinase hsgk1. Transcription and expression of hsgk1 is markedly and rapidly upregulated by osmotic and isotonic cell shrinkage. The effect of osmotic cell shrinkage on hsgk1 is mediated by p38 kinase. Further stimuli of hsgk1 transcription include glucocorticoids, aldosterone, TGF-beta1, serum, increase of intracellular Ca2+ and phorbolesters, whereas cAMP downregulates hsgk1 transcription. The hsgk1 protein is expressed in several epithelial tissues including human pancreas, intestine, kidney, and shark rectal gland. Co-expression of hsgk1 with the renal epithelial Na+-channel ENaC or the Na+/K+/2Cl(-)-cotransporter NKCC2 (BSC1) in Xenopus oocytes, accelerates insertion of the transport proteins into the cell membrane and thus, stimulates channel or transport activity. Thus, hsgk1 participates in the regulation of transport by steroids and secretagogues increasing intracellular Ca2+-activity. The stimulation of hsgk1 transcription by TGF-beta1 may further bear pathophysiological relevance.

Expression of cell volume-regulated kinase h-sgk in pancreatic tissue.

Transcript levels of the human serine/threonine kinase h-sgk have been found to be highest in pancreas. In the present study, localization and regulation of h-sgk transcription in pancreatic tissue were elucidated. As was apparent from radioactive in situ hybridization, most pancreatic acinar cells expressed high levels of h-sgk mRNA. h-sgk mRNA-positive cells were also found in ductal epithelia but not in pancreatic islets. In biopsy specimens from patients with pancreatitis, h-sgk mRNA levels were decreased in acinar cells but abundant in numerous mononuclear interstitial cells within areas of pancreatic necrosis and fibrosis. As shown by Northern blotting, h-sgk transcription in DAN-G pancreatic tumor cells is upregulated by osmotic cell shrinkage, serum, phorbol esters (phorbol 12,13-didecanoate), and Ca(2+) ionophore A-23187 and decreased by staurosporine and cAMP. In conclusion, h-sgk transcription is regulated not only by cell volume but also by serum, protein kinase C stimulation, cAMP, and increase of intracellular Ca(2+) activity. The kinase may participate not only in normal function of exocrine pancreas but also in fibrosing pancreatitis.

Deranged transcriptional regulation of cell-volume-sensitive kinase hSGK in diabetic nephropathy.

Transforming growth factor beta (TGF-beta) has been shown to participate in the pathophysiology of diabetic complications. As shown most recently, TGF-beta stimulates the expression of a distinct serine/threonine kinase (hSGK) which had previously been cloned as an early gene transcriptionally regulated by cell volume alterations. The present study was performed to elucidate transcription and function of hSGK in diabetic nephropathy. As shown by Northern blotting, an increase of extracellular glucose concentration increased hSGK mRNA levels in cultured cells, an effect qualitatively mimicked by osmotic cell shrinkage or treatment with TGF-beta (2 microgram/liter), phorbol 12,13-didecanoate (1 microM), or the Ca(2+) ionophore ionomycin (1 microM) and blunted by high concentrations of nifedipine (10 and 100 microM). In situ hybridization revealed that hSGK transcription was markedly enhanced in diabetic nephropathy, with particularly high expression in mesangial cells, interstitial cells, and cells in thick ascending limbs of Henle's loop and distal tubules. According to voltage clamp and tracer flux studies in Xenopus oocytes expressing the renal epithelial Na(+) channel ENaC or the mouse thick ascending limb Na(+),K(+),2Cl(-) cotransporter BSC-1, coexpression with hSGK stimulated ENaC and BSC-1 11-fold and 6-fold, respectively, effects reversed by kinase inhibitors staurosporine (1 microM) and chelerythrine (1 microM) and not elicited by inactive hSGK. In conclusion, excessive extracellular glucose concentrations enhance hSGK transcription, which in turn stimulates renal tubular Na(+) transport. These observations disclose an additional element in the pathophysiology of diabetic nephropathy.

Effect of urea and osmotic cell shrinkage on Ca2+ entry and contraction of vascular smooth muscle cells.

The present study was performed to elucidate the effects of urea on vascular smooth muscle cells (SMC). Addition of urea (20, 50, 100 mM) to physiological salt solution blunted the vasoconstrictory effect of phenylephrine (by 17, 25 and 30%, respectively) and of an increased extracellular K+ concentration (by 7, 14 and 19%, respectively) without affecting the basal tone of rabbit arterial rings. According to Fura-2 fluorescence in cultured SMC (A7r5), urea had no effect on basal intracellular calcium activity ([Ca2+]i), but significantly blunted the increase of [Ca2+]i following an increase of extracellular K+. Whole-cell patch-clamp studies revealed that the Ca2+ current through voltage-sensitive Ca2+ channels is significantly inhibited in the presence of urea. As evident from calcein fluorescence, addition of urea leads to sustained cell shrinkage. The effects of urea on vascular tone, [Ca2+]i activity, voltage-gated Ca2+ channels and cell volume are mimicked by addition of raffinose or NaCl. However, the cell shrinkage induced by urea is sustained, whereas the addition of equiosmolar NaCl is only transient and followed by a regulatory cell volume increase. Moreover, hypertonic NaCl increases, whereas urea decreases, the transcription of cell-volume-regulated kinase hsgk. In conclusion, urea leads to sustained shrinkage of vascular smooth muscle cells, which is followed by inhibition of voltage-gated Ca2+ channels, a decrease of [Ca2+]i and thus blunts the vasoconstrictory action of phenylephrine and increased extracellular K+ concentration.