Lessons from early life: understanding development to expand stem cells and treat cancers.

Haematopoietic stem cell (HSC) self-renewal is a process that is essential for the development and homeostasis of the blood system. Self-renewal expansion divisions, which create two daughter HSCs from a single parent HSC, can be harnessed to create large numbers of HSCs for a wide range of cell and gene therapies, but the same process is also a driver of the abnormal expansion of HSCs in diseases such as cancer. Although HSCs are first produced during early embryonic development, the key stage and location where they undergo maximal expansion is in the foetal liver, making this tissue a rich source of data for deciphering the molecules driving HSC self-renewal. Another equally interesting stage occurs post-birth, several weeks after HSCs have migrated to the bone marrow, when HSCs undergo a developmental switch and adopt a more dormant state. Characterising these transition points during development is key, both for understanding the evolution of haematological malignancies and for developing methods to promote HSC expansion. In this Spotlight article, we provide an overview of some of the key insights that studying HSC development have brought to the fields of HSC expansion and translational medicine, many of which set the stage for the next big breakthroughs in the field.

Identification and characterization of in vitro expanded hematopoietic stem cells.

Hematopoietic stem cells (HSCs) cultured outside the body are the fundamental component of a wide range of cellular and gene therapies. Recent efforts have achieved > 200-fold expansion of functional HSCs, but their molecular characterization has not been possible since the majority of cells are non-HSCs and single cell-initiated cultures have substantial clone-to-clone variability. Using the Fgd5 reporter mouse in combination with the EPCR surface marker, we report exclusive identification of HSCs from non-HSCs in expansion cultures. By directly linking single-clone functional transplantation data with single-clone gene expression profiling, we show that the molecular profile of expanded HSCs is similar to proliferating fetal HSCs and reveals a gene expression signature, including Esam, Prdm16, Fstl1, and Palld, that can identify functional HSCs from multiple cellular states. This "repopulation signature" (RepopSig) also enriches for HSCs in human datasets. Together, these findings demonstrate the power of integrating functional and molecular datasets to better derive meaningful gene signatures and opens the opportunity for a wide range of functional screening and molecular experiments previously not possible due to limited HSC numbers.

Simultaneous neutralization and innate immune detection of a replicating virus by TRIM21.

Tripartite motif-containing 21 (TRIM21) is a cytosolic immunoglobulin receptor that mediates antibody-dependent intracellular neutralization (ADIN). Here we show that TRIM21 potently inhibits the spreading infection of a replicating cytopathic virus and activates innate immunity. We used a quantitative PCR (qPCR)-based assay to measure in vitro replication of mouse adenovirus type 1 (MAV-1), a virus that causes dose-dependent hemorrhagic encephalitis in mice. Using this assay, we show that genetic ablation of TRIM21 or chemical inhibition of either the AAA ATPase p97/valosin-containing protein (VCP) or the proteasome results in a >1,000-fold increase in the relative level of infection in the presence of immune serum. Moreover, the TRIM21-mediated ability of antisera to block replication was a consistent feature of the humoral immune response in immunized mice. In the presence of immune sera and upon infection, TRIM21 also activates a proinflammatory response, resulting in secretion of tumor necrosis factor alpha (TNF-α) and interleukin-6 (IL-6). These results demonstrate that TRIM21 provides a potent block to spreading infection and induces an antiviral state.

Regulation of virus neutralization and the persistent fraction by TRIM21.

Despite a central role in immunity, antibody neutralization of virus infection is poorly understood. Here we show how the neutralization and persistence of adenovirus type 5, a prevalent nonenveloped human virus, are dependent upon the intracellular antibody receptor TRIM21. Cells with insufficient amounts of TRIM21 are readily infected, even at saturating concentrations of neutralizing antibody. Conversely, high TRIM21 expression levels decrease the persistent fraction of the infecting virus and allows neutralization by as few as 1.6 antibody molecules per virus. The direct interaction between TRIM21 and neutralizing antibody is essential, as single-point mutations within the TRIM21-binding site in the Fc region of a potently neutralizing antibody impair neutralization. However, infection at high multiplicity can saturate TRIM21 and overcome neutralization. These results provide insight into the mechanism and importance of a newly discovered, effector-driven process of antibody neutralization of nonenveloped viruses.

Complementary and alternative medicine education in the United States, China, and Taiwan.

As public demand for complementary and alternative medicine increases,it is important for physical medicine and rehabilitation physicians to have some basic understanding of complementary and alternative medicine or at least to appreciate some of the approved indications so that appropriate referrals can be made. Because the concept of evidence-based medicine is essential for a successful physical medicine and rehabilitation practice in either academic or private facilities, well-developed research projects, such as randomized, controlled trials of large sample size, are needed to investigate the efficacy and safety of complementary and alternative medicine therapy.

Applications of monoclonal anti-human inhibin alpha subunit in endometrial curettings.

AIMS: Using archival material, we studied the immunoreactivity and utility of monoclonal anti-human inhibin alpha subunit in the identification of chorionic villi (CV) and trophoblastic subpopulations in endometrial curettings (EC) from patients who had intra-uterine, ectopic, molar and, particularly, probable intra-uterine pregnancies. We also compared its expression with those of betaHCG, HPL and CAM 5.2. METHODS: The four groups of EC investigated included: Group 1, 15 patients with intra-uterine pregnancies (IUP); Group 2, 15 patients with tubal pregnancies (TP); Group 3, 15 patients with hydatidiform moles (HM); and Group 4, 20 patients with purported history of intra-uterine pregnancies (PIUP). Positive and negative control cases were from Groups 1 and 3 and Group 2, respectively. The test cases were from Group 4. Immunohistochemistry was performed on each case testing for expression of inhibin alpha, betaHCG, HPL and CAM 5.2. RESULTS: Trophoblastic populations, which included syncytiotrophoblast (ST), cytotrophoblast (CT) and intermediate trophoblast (IT), were absent in all 15 negative control cases (Group 2). The 30 positive control cases (Groups 1 and 3) revealed the following: (a) ST, CT and IT were identified in all cases and were positive for CAM 5.2, (b) inhibin alpha, betaHCG and HPL (except one case) were reactive for all cases with ST, but not CT, and (c) IT positivity for betaHCG, HPL and inhibin alpha was 67, 80-93 and 100%, respectively. From the 20 test cases (Group 4), the findings were: (a) CT was absent in all cases, (b) scattered ST cells, which were identified only in 10 cases, were positive for all antibodies, (c) scattered IT cells were present in 17 cases and showed 100% CAM 5.2 positivity, and (d) IT positivity for betaHCG, inhibin alpha and HPL was 58.8% (10/17), 76.5% (13/17) and 82.4% (14/17), respectively. Background staining was observed in 22 of 65 cases (33.8%) stained with betaHCG and HPL; half of these cases came from Group 3. Inhibin alpha and CAM 5.2 staining did not show this problem. CONCLUSIONS: We suggest that inhibin alpha is a useful antibody in diagnosing IUP and HM and in documenting intra-uterine gestations in cases with PIUP because it is a sensitive marker in immunolabelling IT and ST. Combined application of inhibin alpha and CAM 5.2 might be more useful than betaHCG and HPL because the latter showed background staining in one third of the cases.

Early myocardial fibrosis is associated with depletion of vasoactive intestinal peptide in rat heart.

In this study we sought to determine whether early myocardial fibrosis is associated with depletion of vasoactive intestinal peptide (VIP) in the heart, thereby suggesting a possible pathogenetic role for depletion of myocardial VIP levels in the development of fibrosis in the heart. Spontaneously hypertensive rats (SHRs) and normotensive control Wistar-Kyoto rats (WKYs) were assigned randomly to low, intermediate or high sodium diets and their blood pressure was recorded twice weekly for 4 weeks. At the end of this period the rats were anaesthetised, blood was sampled for plasma VIP concentration and the hearts were harvested for histology and determination of the concentration of VIP in the heart. The degree of myocardial fibrosis increased with increasing dietary sodium intake in both the WKYs (P < 0.001) and the SHRs (P < 0.01). Myocardial VIP concentration decreased with increasing dietary sodium intake in the WKYs (P < 0.01) and in the SHRs (P < 0.01). There was a negative correlation between myocardial VIP concentration and the degree of myocardial fibrosis in both the WKYs (P < 0.0005) and the SHRs (P < 0.005). Dietary sodium intake induces myocardial fibrosis in a dose-dependent manner. Further, in early myocardial fibrosis resulting from increasing dietary sodium intake in both normotensive and hypertensive rats the concentration of VIP in the heart was negatively correlated with the degree of fibrosis. This suggests a possible role for depletion of VIP in the myocardium in the pathogenesis of myocardial fibrosis.

Catalytic and binding poly-reactivities shared by two unrelated proteins: The potential role of promiscuity in enzyme evolution.

It is generally accepted that enzymes evolved via gene duplication of existing proteins. But duplicated genes can serve as a starting point for the evolution of a new function only if the protein they encode happens to exhibit some activity towards this new function. Although the importance of such catalytic promiscuity in enzyme evolution has been proposed, little is actually known regarding how common promiscuous catalytic activities are in proteins or their origins, magnitudes, and potential contribution to the survival of an organism. Here we describe a pattern of promiscuous activities in two completely unrelated proteins-serum albumins and a catalytic antibody (aldolase antibody 38C2). Despite considerable structural dissimilarities-in the shape of the cavities and the position of catalytic lysine residues-both active sites are able to catalyze the Kemp elimination, a model reaction for proton transfer from carbon. We also show that these different active sites can bind promiscuously an array of hydrophobic negatively charged ligands. We suggest that the basic active-site features of an apolar pocket and a lysine residue can act as a primitive active site allowing these promiscuous activities to take place. We also describe, by modelling product formation at different substrate concentrations, how promiscuous activities of this kind- inefficient and rudimentary as they are-can provide a considerable selective advantage and a starting point for the evolution of new functions.

Biofeedback via telehealth: a new frontier for applied psychophysiology.

Psychophysiological diagnostic and therapeutic methods, to include biofeedback, have been found to be empirically effective in the treatment of a variety of physical disorders. In many areas of the country, however, certified biofeedback practitioners are not well distributed, limiting patient access to this treatment modality. Psychologists at Tripler Army Medical Center have pioneered efforts to develop and provide these needed services via a telehealth venue. Such capability significantly improves access to care, particularly for patient's located at considerable distance from the provider. As the telecommunications infrastructure in rural and remote areas is often quite basic, such a system must be capable of operating within these limited parameters. The system developed by the authors provides real-time video and audio interactivity and allows the therapist to monitor and control biofeedback equipment located at the remote site. The authors discuss the clinical applications, the technology, and relevant practical and ethical issues.

Biofeedback using telemedicine: clinical applications and case illustrations.

Telecommunications technology is dramatically changing our world, allowing healthcare professionals to offer medical healthcare, in the form of consultation, assessment, and treatment, through the use of new communications media. In behavioral medicine, advances in telecommunications have brought about new ways of offering services by expanding healthcare to patients located all over the world and simultaneously reducing costs and improving outcome efficacy. This article describes the use of biofeedback to treat various pain and psychophysiological disorders through telemedicine technology. The authors provide a description of "off-the-shelf," low-cost, and low-bandwidth telemedicine equipment used to deliver clinical biofeedback treatment when the patient and provider are in two different locations. In addition, the authors discuss practical issues of behavioral telehealth.

Acute and post-traumatic stress disorder after spontaneous abortion.

When a spontaneous abortion is followed by complicated bereavement, the primary care physician may not consider the diagnosis of acute stress disorder or post-traumatic stress disorder. The major difference between these two conditions is that, in acute stress disorder, symptoms such as dissociation, reliving the trauma, avoiding stimuli associated with the trauma and increased arousal are present for at least two days but not longer than four weeks. When the symptoms persist beyond four weeks, the patient may have post-traumatic stress disorder. The symptoms of distress response after spontaneous abortion include psychologic, physical, cognitive and behavioral effects; however, patients with distress response after spontaneous abortion often do not meet the criteria for acute or post-traumatic stress disorder. After spontaneous abortion, as many as 10 percent of women may have acute stress disorder and up to 1 percent may have post-traumatic stress disorder. Critical incident stress debriefing, which may be administered by trained family physicians or mental health practitioners, may help patients who are having a stress disorder after a spontaneous abortion.

A conceptual overview of a proactive health psychology service: the Tripler Health Psychology Model.

The military patient population, the demanding environment in which medical services are provided, and the rigors of the operational environment create a unique challenge for service members as well as military health care providers. Within the military medical system, the subspecialty of clinical health psychology may provide patient care and consultation interventions necessary to meet the demands of the unique Army medical and military communities. As funding and other resources decrease, military health psychologists can provide high-quality care to difficult-to-manage patients while increasing outcome efficacy and decreasing costs to the hospital. This paper provides a definition of clinical health psychology and a description of its unique interventions and applications and how these unique skills augment medical services. Moreover, we offer a conceptual model for an innovative health psychology program that will assist other military treatment facilities in designing programs to increase outcome efficacy and concurrently reduce costs and utilization of services.

The Tripler LE3AN Program: a two-year follow-up report.

This paper provides a review of 2-year follow-up data on the Tripler Army Medical Center LE3AN Program. The LE3AN Program (emphasizing healthy Lifestyles, reasonable Exercise, realistic Expectations, Emotions, and Attitudes, and Nutrition) provides active duty service members a treatment strategy that involves a reasonable low-intensity exercise regimen, behavior modification, intensive nutritional counseling healthy meal planing, relapse prevention strategies, cognitive coping strategies, and healthy lifestyle principals to lose weight and maintain weight loss. Based on the 2-year data and additional clinical findings, we expand upon earlier preliminary reports. The 2-year follow-up data suggest that the program is a safe and efficacious treatment program.

1.9 A structure of the therapeutic antibody CAMPATH-1H fab in complex with a synthetic peptide antigen.

CAMPATH-1 antibodies have a long and successful history in the treatment of leukaemia, autoimmune disease and transplant rejection. The first antibody to undergo "humanisation", CAMPATH-1H, permits treatment with limited patient anti-globulin response. It recognises the CD52 antigen which is a small glycosylphosphatidylinositol(GPI)-anchored protein expressed on lymphocytes and mediates cell depletion. We present the 1.9 A structure of the CAMPATH-1H Fab complexed [corrected] with an analogue of the antigenic determinant of CD52. Analysis of the CAMPATH-1H binding site reveals that in contrast to most antibodies CDR L3 plays a dominant role in antigen binding. Furthermore CDR H3, which is essential for effective antigen recognition in most antibodies, participates in only two main-chain interactions in CAMPATH-1H. The CAMPATH-1H binding site is highly basic; ionic interaction with the enthanolamine phosphate of the CD52 GPI anchor has long been hypothesised to be important in antigen binding. The structure reveals a number of important specific ionic interactions, including Lys53H but not Lys52bH as had previously been suggested. Prolonged treatment with CAMPATH-1H can lead to patient anti-idiotype responses which may be exacerbated by the unusually high number of basic residues in the antibody. This suggests that a strategy where redundant basic residues are replaced with neutral counterparts may be effective in further reducing the immunogenicity of this versatile and widely used antibody.

Clinical applications of hypnotherapy in a medical setting.

Since 1958, hypnosis has been recognized by the American Medical Association as a legitimate form of medical treatment when administered by an appropriately trained practitioner. With the prevalence of certification societies and international organizations, the specialty has increased its level of professionalism and clinical applications. However, in spite of increased exposure and utilization of this unique clinical application, its use within medical settings varies considerably. The purpose of this article is to provide an understanding of clinical hypnosis and offer clinical applications, with the goal of increasing its exposure and utilization within medical settings.

The Tripler Tobacco-Cessation Program: predictors for success and improved efficacy.

This study analyzed differences in baseline, course of treatment, and post-quit variables of participants in a tobacco-cessation program to identify factors predictive of outcome that could be used as a focus for intervention. The program offered a 10-week course of transdermal nicotine replacement combined with education and cognitive/behavioral therapy in a group format at a major military medical center. Demonstrated differences were found among abstainers, early relapsers, and late relapsers in age-initiated tobacco use, use of liquor, levels of exhaled carbon monoxide at intake, tobacco use during the program, and perceived reasons for relapse. The abstinence rate at follow-up was 27%. Based on our findings, we discuss recommendations to improve treatment. This information is offered as a model to evaluate and improve the efficacy of established clinic-based tobacco-cessation programs.

The Tripler Army Medical Center LEAN Program: a healthy lifestyle model for the treatment of obesity.

This paper provides an overview of the Tripler Army Medical Center LEAN Program for the treatment of obesity, hypercholesterolemia, and essential hypertension. The LEAN Program, a multi-disciplinary prevention program, emphasizes healthy Lifestyles, Exercise and Emotions, Attitudes, and Nutrition for active duty service members. The treatment model offers a medically healthy, emotionally safe, and reasonable, low-intensity exercise program to facilitate weight loss. We will discuss the philosophy behind the LEAN Program and the major components. Thereafter, we will briefly discuss the preliminary results.

Suicide prevention in an army infantry division: a multi-disciplinary program.

This article is intended to provide an overview of the 25th Infantry Division (Light) Suicide Prevention Program. A multidisciplinary intervention model, it outlines the role of chaplains and division mental health officers as well as indicators or warning signs relevant to army personnel who have committed suicide. Prevention strategies applicable to the military community, including Crisis Intervention Command Consultations, will be recommended. It is hoped that this information will not only assist professionals in identifying personnel at risk for suicide, but aid in the development of other suicide prevention programs.

EEG biofeedback as a treatment for chronic fatigue syndrome: a controlled case report.

EEG neurofeedback has been identified as a potential diagnostic and treatment protocol with chronic fatigue syndrome (CFS) symptoms. In the present case study, the authors applied an EEG neurofeedback biofeedback paradigm as a treatment modality with a CFS patient. Baseline data were acquired using the Wechsler Adult Intelligence Scale-Revised and qualitative and subjective ratings of cognitive improvement. Test results and clinical findings revealed improvements in the patient's cognitive abilities, functional skill level, and quality of life. The patient showed significant differences in pre- and posttest levels on the Wechsler scale.