cGMP phosphodiesterase inhibition improves the vascular and metabolic actions of insulin in skeletal muscle.

There is considerable support for the concept that insulin-mediated increases in microvascular blood flow to muscle impact significantly on muscle glucose uptake. Since the microvascular blood flow increases with insulin have been shown to be nitric oxide-dependent inhibition of cGMP-degrading phosphodiesterases (cGMP PDEs) is predicted to enhance insulin-mediated increases in microvascular perfusion and muscle glucose uptake. Therefore, we studied the effects of the pan-cGMP PDE inhibitor zaprinast on the metabolic and vascular actions of insulin in muscle. Hyperinsulinemic euglycemic clamps (3 mU·min(-1)·kg(-1)) were performed in anesthetized rats and changes in microvascular blood flow assessed from rates of 1-methylxanthine metabolism across the muscle bed by capillary xanthine oxidase in response to insulin and zaprinast. We also characterized cGMP PDE isoform expression in muscle by real-time PCR and immunostaining of frozen muscle sections. Zaprinast enhanced insulin-mediated microvascular perfusion by 29% and muscle glucose uptake by 89%, while whole body glucose infusion rate during insulin infusion was increased by 33% at 2 h. PDE2, -9, and -10 were the major isoforms expressed at the mRNA level in muscle, while PDE1B, -9A, -10A, and -11A proteins were expressed in blood vessels. Acute administration of the cGMP PDE inhibitor zaprinast enhances muscle microvascular blood flow and glucose uptake response to insulin. The expression of a number of cGMP PDE isoforms in skeletal muscle suggests that targeting specific cGMP PDE isoforms may provide a promising avenue for development of a novel class of therapeutics for enhancing muscle insulin sensitivity.

Effects of central administration of insulin or l-NMMA on rat skeletal muscle microvascular perfusion.

AIM: Intracerebroventricular (ICV) administration of a nitric oxide synthase (NOS) inhibitor to rats has been reported to raise blood pressure (BP) and cause insulin resistance, suggestive of a central effect of insulin that is NO dependent. Herein we test whether ICV insulin has peripheral haemodynamic and metabolic effects and whether peripheral effects of systemic insulin are affected by the ICV administration of the NOS inhibitor N(G) -methyl-l-arginine (l-NMMA). METHODS: Anaesthetized rats were fitted with an ICV cannula for insulin, artificial cerebrospinal fluid (aCSF) or l-NMMA infusion. Rats receiving ICV l-NMMA (500 µg) underwent systemic insulin clamp (10 mU/min/kg) or saline treatment for 70 min and were compared with animals receiving an equal amount of l-NMMA infused systemically. RESULTS: ICV aCSF or insulin (135 mU/min/kg brain) for 70 min or systemic l-NMMA (500 µg) had no effect on BP, heart rate (HR), femoral blood flow (FBF), glucose infusion rate, muscle 2-deoxyglucose uptake, microvascular perfusion or plasma insulin. However, ICV l-NMMA reduced systemic insulin-mediated increases in FBF (2.05 ± 0.08 to 1.55 ± 0.15 ml/min), 2-deoxyglucose uptake (17.7 ± 0.15 to 10.0 ± 0.03 µg/g/min) and microvascular perfusion (10.5 ± 0.5 to 6.6 ± 1.1 mol/min) (each mean ± SE, p < 0.05); plasma insulin, HR and BP were unaffected. CONCLUSIONS: Central insulin administration had no effect on skeletal muscle haemodynamics or glucose metabolism. However, systemic insulin-mediated increases in limb blood flow, muscle microvascular perfusion and glucose uptake may be regulated by a central pathway that is NO dependent.

Local hindlimb antioxidant infusion does not affect muscle glucose uptake during in situ contractions in rat.

There is evidence that reactive oxygen species (ROS) contribute to the regulation of skeletal muscle glucose uptake during highly fatiguing ex vivo contraction conditions via AMP-activated protein kinase (AMPK). In this study we investigated the role of ROS in the regulation of glucose uptake and AMPK signaling during low-moderate intensity in situ hindlimb muscle contractions in rats, which is a more physiological protocol and preparation. Male hooded Wistar rats were anesthetized, and then N-acetylcysteine (NAC) was infused into the epigastric artery (125 mg.kg(-1).h(-1)) of one hindlimb (contracted leg) for 15 min before this leg was electrically stimulated (0.1-ms impulse at 2 Hz and 35 V) to contract at a low-moderate intensity for 15 min. The contralateral leg did not receive stimulation or local NAC infusion (rest leg). NAC infusion increased (P<0.05) plasma cysteine and cystine (by approximately 360- and 1.4-fold, respectively) and muscle cysteine (by 1.5-fold, P=0.001). Although contraction did not significantly alter muscle tyrosine nitration, reduced (GSH) or oxidized glutathione (GSSG) content, S-glutathionylation of protein bands at approximately 250 and 150 kDa was increased (P<0.05) approximately 1.7-fold by contraction, and this increase was prevented by NAC. Contraction increased (P<0.05) skeletal muscle glucose uptake 20-fold, AMPK phosphorylation 6-fold, ACCbeta phosphorylation 10-fold, and p38 MAPK phosphorylation 60-fold, and the muscle fatigued by approximately 30% during contraction and NAC infusion had no significant effect on any of these responses. This was despite NAC preventing increases in S-glutathionylation with contraction. In conclusion, unlike during highly fatiguing ex vivo contractions, local NAC infusion during in situ low-moderate intensity hindlimb contractions in rats, a more physiological preparation, does not attenuate increases in skeletal muscle glucose uptake or AMPK signaling.

Graves ophthalmopathy.

Graves ophthalmopathy (GO) is an autoimmune disease that typically affects the thyroid gland and the orbit. The roles of the thyroid stimulating hormone receptor and cellular and humoral immunity in the pathogenesis of GO are being investigated. Investigators are gaining insights into the epidemiology of GO as it relates to other ocular and autoimmune diseases. Several possible tools for assessing GO disease activity are being studied. Medical and radiation therapy for GO recently have been evaluated prospectively. Orbital surgeons continue to refine orbital decompression techniques to improve patient outcomes and minimize surgical complications.

Radiation-induced meningiomas involving the orbit.

PURPOSE: To review the clinical features and outcomes of patients with radiation-induced meningiomas involving the orbit. DESIGN: Retrospective case series. PARTICIPANTS: Eight patients with radiation-induced meningiomas affecting the orbit. METHODS: Clinical and pathologic data of the patients were reviewed. MAIN OUTCOME MEASURES: Age at diagnosis, mean interval between radiation therapy and meningioma diagnosis, tumor recurrence, histologic atypia, and mean follow-up time after initial diagnosis. RESULTS: The mean age at diagnosis was 42 years (range, 21 years to 70 years). The mean interval between radiation therapy and meningioma diagnosis was 26 years (range, 3 years to 54 years). All patients underwent gross total resection or subtotal resection of the meningioma. Five tumors (62.5%) recurred, based on clinical findings and CT imaging. The mean interval between resection of the meningioma and recurrence was 3 years (range, 9 months to 9 years). Three patients (37.5%) had atypical meningiomas. One patient (12.5%) had multiple tumors. The mean follow-up interval was 7 years after initial diagnosis of the meningioma (range, 15 months to 19 years). CONCLUSIONS: This series of radiation-induced meningiomas, the first in the ophthalmic literature, illustrates the aggressive nature of this tumor.

Adrenocortical carcinoma metastatic to the orbit.

PURPOSE: To describe the clinical course and histopathologic features of a patient with adrenocortical carcinoma metastatic to the orbit. METHODS: Case report and literature review. RESULTS: A 24-year-old man first came to medical attention because of symptoms referable to a 4.47-kg, nonfunctioning carcinoma of the left adrenal cortex. Several metastases ensued, including a large tumor to the right superior lateral bony orbit with extension to the brain, temporalis fossa, and orbit proper. The tumor was resected with the use of a combined neurosurgical, ophthalmic, and craniofacial approach. The patient died of widespread metastatic disease 15 months after the orbital operation. CONCLUSIONS: Metastasis to the orbit from adrenocortical carcinoma is rare. Surgical resection is the treatment of choice, with adjunctive radiation therapy and chemotherapy in some cases. The prognosis is poor.

Surgical correction of blepharoptosis in patients with myasthenia gravis.

PURPOSE: To describe the results of surgical correction of blepharoptosis in a series of patients with myasthenia gravis (MG). METHODS: In this retrospective case series, we reviewed the medical records of all patients with MG who did not respond to medical therapy and underwent surgical correction for blepharoptosis at the Mayo Clinic between 1985 and 1999. The primary outcome measure was change in interpalpebral eyelid fissure height. RESULTS: Sixteen blepharoptosis procedures were performed on 10 patients with MG. Eight of the 10 patients had ocular MG. Two of the 10 patients had systemic MG. Of the 16 procedures performed, 9 were external levator advancements (ELA), six were frontalis slings, and one was a tarsomyectomy. Patients were followed postoperatively for an average of 34 months (range, 14-126 months). The amount of ptosis was quantified pre- and postoperatively for seven of the nine eyelids that underwent ELA. For these seven eyelids (five patients), there was a statistically significant improvement in the mean interpalpebral eyelid fissure height from 3.7 mm preoperatively to 7.8 mm postoperatively, with a mean difference of 4.1 mm (95% confidence interval 1.9 mm to 6.25 mm, p = 0.0038). Postoperative complications included worsened diplopia in one patient with ELA and exposure keratopathy in one patient with frontalis sling. Two of the ELA eyelids developed recurrent ptosis requiring additional surgery more than 2 years after the initial procedure. CONCLUSIONS: Blepharoptosis surgery can achieve eyelid elevation in patients who have failed to respond to medical therapy for MG. Potential complications include worsened diplopia and exposure keratopathy.

Surgical correction of blepharoptosis in patients with myasthenia gravis.

PURPOSE: To describe the results of surgical correction of blepharoptosis in a series of patients with myasthenia gravis. METHODS: We reviewed the medical records of all patients with myasthenia gravis who underwent surgical correction for blepharoptosis at the Mayo Clinic between 1985 and 1999. The primary outcome measure was change in interpalpebral eyelid fissure height. RESULTS: Eighteen blepharoptosis procedures were performed on 11 patients with myasthenia gravis. Eight of the 11 patients had ocular myasthenia gravis, and 3 had systemic myasthenia gravis. Of the 18 procedures performed, 11 were external levator advancements (ELA), 6 were frontalis slings, and 1 was a tarsomyectomy. Patients were followed up postoperatively for an average of 34 months (range, 9 to 126 months). The amount of ptosis was quantified preoperatively and postoperatively for 9 of the 11 eyelids that underwent ELA. For these eyelids, there was a statistically significant improvement in the mean interpalpebral eyelid fissure height, from 4.2 mm preoperatively to 8.1 mm postoperatively, with a mean difference of 3.9 mm (95% confidence interval, 2.3 to 5.5 mm; P = .0005). Postoperative complications included worsened diplopia in 1 patient who underwent ELA and exposure keratopathy in 1 patient who underwent a frontalis sling procedure. Two of the eyelids that underwent ELA developed recurrent ptosis, requiring additional surgery more than 2 years after the initial procedure. CONCLUSION: Surgical correction of blepharoptosis is an appropriate treatment option in patients with myasthenia gravis who fail medical therapy. Potential complications include worsened diplopia and exposure keratopathy.

Transcatheter uterine artery embolisation to treat large uterine fibroids.

Bilateral uterine artery embolisation was performed to treat eight women with symptomatic large fibroids requiring treatment. Uterine volume was quantitatively assessed by magnetic resonance imaging. Both uterine arteries were occluded effectively in all women, and the procedure was well tolerated, with a 24-36 hour admission for pain relief. The level of pain experienced was variable, but well controlled. Some women experienced intermittent vaginal discharge and pain following the procedure. Improvement of symptoms occurred in six of the seven women and the eighth woman conceived. There were no significant complications. At three months four women had a uterine volume of < 350 cm3. Embolisation appears to be a good alternative to surgery, but longer follow up is required to evaluate the long term effects and to determine those patients for whom the procedure is suitable.

Transcaheter uterine artery embolisation to treat large uterine fibroids with MRI quantitative assessment

Fibroids are benign tumours of the uterus which occur more commonly and earlier in black women. We do not know what causes the fibroids to grow, but their growth seems to be hormone dependant. Some women may have asymptomatic fibroids and be unaware of their presence. However, many others seek help from gynaecologists due to menorrhagia, sometimes leading to anaemia and pressure symptoms leading to pain, sciatica, urinary infrequency and constipation. Fibroids may also contribute towards infertility and cause problems in pregnancy. Treatment of fibroids is notoriously difficult. Drug treatment has proved unsuccessful in the long term treatment of fibroids and has been reserved for preoperative treatment. Myomectomy is a difficult operation for women which may require blood transfusions, unacceptable to Jehovah's Witnesses and rarely lead to hysterectomy due to uncontrollable bleeding. Women above child bearing age are usualy offered hysterectomy, but many women are unhappy to loose their uterus as this has cultural and social implications. At St. Thomas' and Guy's Hospital we have pioneered a new treatment for fibroids whereby the uterine arteries are embolised bilaterally and by cutting off the blood supply to the fibroids, they shrink in size and degenerate. An interventional radiologist inserts a catheter into the femoral artery in the groin and passes a guide wire under x-ray control into the uterine artery. Non-biodegradable particles are introduced into the artery until flow is reduced or stopped. This is repeated on the second side. The procedure is performed under sedation and takes about an hour. The patients are admitted for 24-36 hours for analgesia. Ten women have been treated to date, nine were Afro-Caribbean and we have three month follow-up on eight. MRI scans were performed before the procedure and at three months to obtain quantitative assessment of reduction in volume. The uterine volume reduced by a mean of 51 percent and further shrinkage is expected. All but one of the patients noticed improvement in one or all of their symptoms. Patient satisfaction was high. The main side effects of the procedure were pain, controlled with simple analgesia and vaginal discharge. This seems a good treatment for women with symptomatic fibroids who are not suitable for or unwilling to undergo surgery. It avoids a general anaesthetic major surgery and blood transfusions. The procedure is tolerated well and has good symptomatic cure rates.(AU)

A study of the physiological mechanisms contributing to neurotensin-induced hypothermia.

Although central administration of neurotensin is known to produce marked hypothermia in the rat, there are no studies which have investigated the effects of neurotensin on oxygen consumption and heat exchange, the physiological mechanisms which are the principal contributors to changes in body temperature. We report a significant correlation between dose and the duration and degree of post-injection heat loss following central administration of neurotensin. Oxygen consumption does not appear to be affected by neurotensin. We suggest that it is this dose-dependent, post-injection heat loss which is responsible for neurotensin-induced hypothermia. Furthermore, the hypothermia does not appear to reflect a change in set point.

Modeling the structure of Pyrococcus furiosus rubredoxin by homology to other X-ray structures.

The three-dimensional structure of rubredoxin from the hyperthermophilic archaebacterium, Pyrococcus furiosus, has been modeled from the X-ray crystal structures of three homologous proteins from Clostridium pasteurianum, Desulfovibrio gigas, and Desulfovibrio vulgaris. All three homology models are similar. When comparing the positions of all heavy atoms and essential hydrogen atoms to the recently solved crystal structure (Day, M. W., et al., 1992, Protein Sci. 1, 1494-1507) of the same protein, the homology model differ from the X-ray structure by 2.09 A root mean square (RMS). The X-ray and the zinc-substituted NMR structures (Blake, P. R., et al., 1992b, Protein Sci. 1, 1508-1521) show a similar level of difference (2.05 A RMS). On average, the homology models are closer to the X-ray structure than to the NMR structures (2.09 vs. 2.42 A RMS).

Investigations of the thermostability of rubredoxin models using molecular dynamics simulations.

The affects of differences in amino acid sequence on the temperature stability of the three-dimensional structure of the small beta-sheet protein, rubredoxin (Rd), was revealed when a set of homology models was subjected to molecular dynamics simulations at relatively high temperatures. Models of Rd from the hyperthermophile, Pyrococcus furiosus (Pf), an organism that grows optimally at 100 degrees C, were compared to three mesophilic Rds of known X-ray crystal structure. Simulations covering the limits of known Rd thermostabilities were carried out at temperatures of 300 K, 343 K, 373 K, and 413 K. They suggest that Rd stability is correlated with structural dynamics. Because the dynamic behavior of three Pf Rd models was consistently different from the dynamic behavior of the three mesophilic Rd structures, detailed analysis of the temperature-dependent dynamic behavior was carried out. The major differences between the models of the protein from the hyperthermophile and the others were: (1) an obvious temperature-dependent transition in the mesophilic structures not seen with the Pf Rd models, (2) consistent AMBER energy for the Pf Rd due to differences in nonbonded interaction terms, (3) less variation in the average conformations for the Pf Rd models with temperature, and (4) the presence of more extensive secondary structure for the Pf Rd models. These unsolvated dynamics simulations support a simple, general hypothesis to explain the hyperthermostability of Pf Rd. Its structure simplifies the conformational space to give a single minimum accessible over an extreme range of temperatures, whereas the mesophilic proteins sample a more complex conformational space with two or more minima over the same temperature range.

BK virus.

BK virus is a human polyoma virus that infects the renal epithelium and remains latent until immunosuppression triggers reactivation. After reactivation, BK virus can be detected in the urine by methods currently available in the clinical laboratory. Correlations can be made between BK viruria and the occurrence of both renal and hepatic pathologies. BK virus is emerging as a significant pathogen in transplant patients. Additionally, the presence of BK virus DNA in primary brain and pancreatic tumors suggests that it may have oncogenic potential. Thus far, attempts to treat BK virus infection have been ineffective, though research has opened new avenues for treatment possibilities. Prevention of BK virus and other latent viral reactivation remains a challenge to viral research.

Murine typhus: forgotten but not gone.

An occasional patient presents the classical symptoms of a disease that has become uncommon. Typhus is an example of such a disease, since it is now well contained through control of its rodent reservoir. It is readily treated with tetracycline or one of its long-acting analogues, doxycycline or minocycline. Because typhus is infrequently encountered, the physician may not initially include it in his differential diagnosis. Our case serves as a remainder that with the increasingly frequent movement of persons from one geographic area to another, the uncommon rickettsial infection, murine typhus, should continue to be in the differential of a febrile patient. Furthermore, our case underscores the importance of including typhus in the differential of typhoid fever.

Williams' syndrome in adulthood: a case study focusing on psychological and psychiatric aspects.

The present authors report on the history and the psychiatric, psychological and social status of a 43-year-old man recently identified as having Williams' syndrome.