Ankyrin-G isoform imbalance and interneuronopathy link epilepsy and bipolar disorder.

ANK3, encoding the adaptor protein Ankyrin-G (AnkG), has been implicated in bipolar disorder by genome-wide association studies. ANK3 has multiple alternative first exons, and a bipolar disorder-associated ANK3 variant has been shown to reduce the expression of exon 1b. Here we identify mechanisms through which reduced ANK3 exon 1b isoform expression disrupts neuronal excitation-inhibition balance. We find that parvalbumin (PV) interneurons and principal cells differentially express ANK3 first exon subtypes. PV interneurons express only isoforms containing exon 1b, whereas excitatory principal cells express exon 1e alone or both 1e and 1b. In transgenic mice deficient for exon 1b, PV interneurons lack voltage-gated sodium channels at their axonal initial segments and have increased firing thresholds and diminished action potential dynamic range. These mice exhibit an Ank3 gene dosage-dependent phenotype including behavior changes modeling bipolar disorder, epilepsy and sudden death. Thus ANK3's important association with human bipolar susceptibility may arise from imbalance between AnkG function in interneurons and principal cells and resultant excessive circuit sensitivity and output. AnkG isoform imbalance is a novel molecular endophenotype and potential therapeutic target.

KCNQ channels mediate IKs, a slow K+ current regulating excitability in the rat node of Ranvier.

Mutations that reduce the function of KCNQ2 channels cause neuronal hyperexcitability, manifested as epileptic seizures and myokymia. These channels are present in nodes of Ranvier in rat brain and nerve and have been proposed to mediate the slow nodal potassium current I(Ks). We have used immunocytochemistry, electrophysiology and pharmacology to test this hypothesis and to determine the contribution of KCNQ channels to nerve excitability in the rat. When myelinated nerve fibres of the sciatic nerve were examined by immunofluorescence microscopy using antibodies against KCNQ2 and KCNQ3, all nodes showed strong immunoreactivity for KCNQ2. The nodes of about half the small and intermediate sized fibres showed labelling for both KCNQ2 and KCNQ3, but nodes of large fibres were labelled by KCNQ2 antibodies only. In voltage-clamp experiments using large myelinated fibres, the selective KCNQ channel blockers XE991 (IC50 = 2.2 microm) and linopirdine (IC50 = 5.5 microm) completely inhibited I(Ks), as did TEA (IC50 = 0.22 mm). The KCNQ channel opener retigabine (10 microm) shifted the activation curve to more negative membrane potentials by -24 mV, thereby increasing I(Ks). In isotonic KCl 50% of I(Ks) was activated at -62 mV. The activation curve shifted to more positive potentials as [K+]o was reduced, so that the pharmacological and biophysical properties of I(Ks) were consistent with those of heterologously expressed homomeric KCNQ2 channels. The ability of XE991 to selectively block I(Ks) was further exploited to study I(Ks) function in vivo. In anaesthetized rats, the excitability of tail motor axons was indicated by the stimulus current required to elicit a 40% of maximal compound muscle action potential. XE991 (2.5 mg kg(-1) i.p.) eliminated all nerve excitability functions previously attributed to I(Ks): accommodation to 100 ms subthreshold depolarizing currents, the post-depolarization undershoot in excitability, and the late subexcitability after a single impulse or short trains of impulses. Due to reduced spike-frequency adaptation after XE991 treatment, 100 ms suprathreshold current injections generated long trains of action potentials. We conclude that the nodal I(Ks) current is mediated by KCNQ channels, which in large fibres of rat sciatic nerve appear to be KCNQ2 homomers.

M channel KCNQ2 subunits are localized to key sites for control of neuronal network oscillations and synchronization in mouse brain.

Mutations in the potassium channel subunit KCNQ2 lead to benign familial neonatal convulsions, a dominantly inherited form of generalized epilepsy. In heterologous cells, KCNQ2 expression yields voltage-gated potassium channels that activate slowly (tau, approximately 0.1 sec) at subthreshold membrane potentials. KCNQ2 associates with KCNQ3, a homolog, to form heteromeric channels responsible for the M current (I(M)) in superior cervical ganglion (SCG) neurons. Muscarinic acetylcholine and peptidergic receptors inhibit SCG I(M), causing slow EPSPs and enhancing excitability. Here, we use KCNQ2N antibodies, directed against a conserved N-terminal portion of the KCNQ2 polypeptide, to localize KCNQ2-containing channels throughout mouse brain. We show that KCNQ2N immunoreactivity, although widespread, is particularly concentrated at key sites for control of rhythmic neuronal activity and synchronization. In the basal ganglia, we find KCNQ2N immunoreactivity on somata of dopaminergic and parvalbumin (PV)-positive (presumed GABAergic) cells of the substantia nigra, cholinergic large aspiny neurons of the striatum, and GABAergic and cholinergic neurons of the globus pallidus. In the septum, GABAergic, purinergic, and cholinergic neurons that contribute to the septohippocampal and septohabenular pathways exhibit somatic KCNQ2 labeling. In the thalamus, GABAergic nucleus reticularis neurons that regulate thalamocortical oscillations show strong labeling. In the hippocampus, many PV-positive and additional PV-negative interneurons exhibit strong somatic staining, but labeling of pyramidal and dentate granule somata is weak. There is strong neuropil staining in many regions. In some instances, notably the hippocampal mossy fibers, evidence indicates this neuropil staining is presynaptic.

Trimethoprim-sulfamethoxazole (TMP-SMZ) dose escalation versus direct rechallenge for Pneumocystis Carinii pneumonia prophylaxis in human immunodeficiency virus-infected patients with previous adverse reaction to TMP-SMZ.

Trimethoprim-sulfamethoxazole (TMP-SMZ) is the most effective Pneumocystis carinii pneumonia (PCP) prophylactic agent, but adverse reactions are common among human immunodeficiency virus (HIV)-infected patients and limit its use. This randomized, double-blind controlled trial compared 2 methods of TMP-SMZ reintroduction, 6-day dose escalation and direct rechallenge, for PCP prophylaxis in HIV-infected patients who had experienced previous treatment-limiting reactions. The primary end point was the ability to take single-strength TMP-SMZ daily for 6 months. Seventy-five percent of the dose-escalation group and 57% of the direct-rechallenge group continued to receive daily single-strength TMP-SMZ for 6 months (P= .014). Among premature discontinuations, 58% of the dose-escalation group and 70% of the direct-rechallenge group were due to adverse reactions. None of these reactions was serious. This study provides evidence that it is possible to successfully reintroduce TMP-SMZ to a significant proportion of HIV-infected patients who have experienced mild-to-moderate treatment-limiting adverse reactions.

Hippocampal heterotopia lack functional Kv4.2 potassium channels in the methylazoxymethanol model of cortical malformations and epilepsy.

Human cortical malformations often result in severe forms of epilepsy. Although the morphological properties of cells within these malformations are well characterized, very little is known about the function of these cells. In rats, prenatal methylazoxymethanol (MAM) exposure produces distinct nodules of disorganized pyramidal-like neurons (e.g., nodular heterotopia) and loss of lamination in cortical and hippocampal structures. Hippocampal nodular heterotopias are prone to hyperexcitability and may contribute to the increased seizure susceptibility observed in these animals. Here we demonstrate that heterotopic pyramidal neurons in the hippocampus fail to express a potassium channel subunit corresponding to the fast, transient A-type current. In situ hybridization and immunohistochemical analysis revealed markedly reduced expression of Kv4.2 (A-type) channel subunits in heterotopic cell regions of the hippocampus of MAM-exposed rats. Patch-clamp recordings from visualized heterotopic neurons indicated a lack of fast, transient (I(A))-type potassium current and hyperexcitable firing. A-type currents were observed on normotopic pyramidal neurons in MAM-exposed rats and on interneurons, CA1 pyramidal neurons, and cortical layer V-VI pyramidal neurons in saline-treated control rats. Changes in A-current were not associated with an alteration in the function or expression of delayed, rectifier (Kv2.1) potassium channels on heterotopic cells. We conclude that heterotopic neurons lack functional A-type Kv4.2 potassium channels and that this abnormality could contribute to the increased excitability and decreased seizure thresholds associated with brain malformations in MAM-exposed rats.

Potassium channels: how genetic studies of epileptic syndromes open paths to new therapeutic targets and drugs.

How can epilepsy gene hunting lead to better care for patients with epilepsy? Lessons may be learned from the progress made by identifying the mutated genes that cause Benign Familial Neonatal Convulsions (BFNC). In 1998, a decade of clinical and laboratory-based genetics work resulted in the cloning of the KCNQ2 potassium channel gene at the BFNC locus on chromosome 20. Subsequently, computer "mining" of public DNA databases allowed the rapid identification of three more brain KCNQ genes. Mutations in each of these additional genes were implicated as causes of human hereditary diseases: epilepsy (KCNQ3), deafness (KCNQ4), and, possibly, retinal degeneration (KCNQ5). Physiologists discovered that the KCNQ genes encoded subunits of the "M-channel," a type of potassium channel known to control repetitive neuronal discharges. Finally, pharmacologists discovered that retigabine, a novel anticonvulsant with a broad but distinctive efficacy profile in animal studies, was a potent KCNQ channel opener. These studies suggest that KCNQ channels may be an important new class of targets for anticonvulsant therapies. The efficacy of retigabine is currently being tested in multicenter clinical trials; identification of its molecular targets will allow it to be more efficiently exploited as a "lead compound." Cloned human KCNQ channels can now be expressed in cultured cells for "high-throughput" screening of drug candidates. Ongoing studies of the KCNQ channels in humans and animal models will refine our understanding of how M-channels control excitability at the cellular, network, and behavioral levels, and may reveal additional targets for therapeutic manipulation.

Colocalization and coassembly of two human brain M-type potassium channel subunits that are mutated in epilepsy.

Acetylcholine excites many central and autonomic neurons through inhibition of M-channels, slowly activating, noninactivating voltage-gated potassium channels. We here provide information regarding the in vivo distribution and biochemical characteristics of human brain KCNQ2 and KCNQ3, two channel subunits that form M-channels when expressed in vitro, and, when mutated, cause the dominantly inherited epileptic syndrome, benign neonatal familial convulsions. KCNQ2 and KCNQ3 proteins are colocalized in a somatodendritic pattern on pyramidal and polymorphic neurons in the human cortex and hippocampus. Immunoreactivity for KCNQ2, but not KCNQ3, is also prominent in some terminal fields, suggesting a presynaptic role for a distinct subgroup of M-channels in the regulation of action potential propagation and neurotransmitter release. KCNQ2 and KCNQ3 can be coimmunoprecipitated from brain lysates. Further, KCNQ2 and KCNQ3 are coassociated with tubulin and protein kinase A within a Triton X-100-insoluble protein complex. This complex is not associated with low-density membrane rafts or with N-methyl-d-aspartate receptors, PSD-95 scaffolding proteins, or other potassium channels tested. Our studies thus provide a view of a signaling complex that may be important for cognitive function as well as epilepsy. Analysis of this complex may shed light on the unknown transduction pathway linking muscarinic acetylcholine receptor activation to M-channel inhibition.

A randomized study of the safety and antiretroviral activity of hydroxyurea combined with didanosine in persons infected with human immunodeficiency virus type 1. American Foundation for AIDS Research Community-Based Clinical Trials Network.

This randomized open-label trial of human immunodeficiency virus type 1-infected persons compared safety and efficacy for 38 patients receiving hydroxyurea/didanosine combination therapy with findings in 42 persons given didanosine monotherapy for 12 weeks, followed by 12 weeks of hydroxyurea/didanosine combination therapy for all patients. Week 12 on-treatment group comparisons showed a mean decrease in virus load between hydroxyurea/didanosine versus didanosine groups of -0.93 versus -0.74 log10 copies/mL (P=.20); a higher percentage of the hydroxyurea/didanosine group below the assay's detection limit (500 copies/mL), 29% versus 7% (P=.017); and median change in CD4 cells for the hydroxyurea/didanosine versus didanosine group of 0 versus 43 cells/mm3 (P=.045), although median change in CD4 percentage was similar (0.9% vs. 1.2%, P=.64). Week 24 virus load reductions and CD4 cell changes were similar in both groups. Intent-to-treat and on-treatment analyses showed similar results. The hydroxyurea/didanosine combination was well tolerated.

Ion channel genes and human neurological disease: recent progress, prospects, and challenges.

What do epilepsy, migraine headache, deafness, episodic ataxia, periodic paralysis, malignant hyperthermia, and generalized myotonia have in common? These human neurological disorders can be caused by mutations in genes for ion channels. Many of the channel diseases are "paroxysmal disorders" whose principal symptoms occur intermittently in individuals who otherwise may be healthy and active. Some of the ion channels that cause human neurological disease are old acquaintances previously cloned and extensively studied by channel specialists. In other cases, however, disease-gene hunts have led the way to the identification of new channel genes. Progress in the study of ion channels has made it possible to analyze the effects of human neurological disease-causing channel mutations at the level of the single channel, the subcellular domain, the neuronal network, and the behaving organism.

Characterization of mutations in the gene doublecortin in patients with double cortex syndrome.

Mutations in the X-linked gene doublecortin, which encodes a protein with no dear structural homologues, are found in pedigrees in which affected females show "double cortex" syndrome (DC; also known as subcortical band heterotopia or laminar heterotopia) and affected males show X-linked lissencephaly. Mutations in doublecortin also cause sporadic DC in females. To determine the incidence of doublecortin mutations in DC, we investigated a cohort of eight pedigrees and 47 sporadic patients with DC for mutations in the doublecortin open reading frame as assessed by single-stranded conformational polymorphism analysis. Mutations were identified in each of the eight DC pedigrees (100%), and in 18 of the 47 sporadic DC patients (38%). Identified mutations were of two types, protein truncation mutations and single amino acid substitution mutations. However, pedigrees with DC displayed almost exclusively single amino acid substitution mutations, suggesting that patients with these mutations may have less of a reproductive disadvantage versus those patients with protein truncation mutations. Single amino acid substitution mutations were tightly clustered in two regions of the open reading frame, suggesting that these two regions are critical for the function of the Doublecortin protein.

Localization of postsynaptic density-93 to dendritic microtubules and interaction with microtubule-associated protein 1A.

Postsynaptic density-93 (PSD-93)/Chapsyn-110 is a member of the membrane-associated guanylate kinase (MAGUK) family of PDZ domain-containing proteins. MAGUKs are widely expressed in the brain and are critical elements of the cytoskeleton and of certain synapses. In the ultrastructural studies that are described here, PSD-93 localizes to both postsynaptic densities and dendritic microtubules of cerebellar Purkinje neurons. The microtubule localization is paralleled by a high-affinity in vivo interaction of PSD-93 via its guanylate kinase (GK) domain with microtubule-associated protein 1A (MAP1A). GK domain truncations that mimic genetically identified mutations of a Drosophila MAGUK, discs-large, disrupt the GK/MAP-1A interaction. Additional biochemical experiments demonstrate that intact MAGUKs do not bind to MAP1A as effectively as do isolated GK domains. This appears to be attributable to an intramolecular inhibition of the GK domain by the PDZs, because GK binding activity of full-length MAGUKs is partially restored by a variety of PDZ ligands, including the C termini of NMDA receptor 2B, adenomatous polyposis coli (APC), and CRIPT. Beyond demonstrating a novel cytoskeletal link for PSD-93, these experiments support a model in which intramolecular interactions between the multiple domains of MAGUKs regulate intermolecular associations and thereby may play a role in the proper targeting and function of MAGUK proteins.

Doublecortin, a brain-specific gene mutated in human X-linked lissencephaly and double cortex syndrome, encodes a putative signaling protein.

X-linked lissencephaly and "double cortex" are allelic human disorders mapping to Xq22.3-Xq23 associated with arrest of migrating cerebral cortical neurons. We identified a novel 10 kb brain-specific cDNA interrupted by a balanced translocation in an XLIS patient that encodes a novel 40 kDa predicted protein named Doublecortin. Four double cortex/X-linked lissencephaly families and three sporadic double cortex patients show independent doublecortin mutations, at least one of them a de novo mutation. Doublecortin contains a consensus Abl phosphorylation site and other sites of potential phosphorylation. Although Doublecortin does not contain a kinase domain, it is homologous to the amino terminus of a predicted kinase protein, indicating a likely role in signal transduction. Doublecortin, along with the newly characterized mDab1, may define an Abl-dependent pathway regulating neuronal migration.

Presynaptic localization of Kv1.4-containing A-type potassium channels near excitatory synapses in the hippocampus.

Mammalian Shaker voltage-gated potassium channels that contain the Kv1.4 subunit exhibit rapid activation and prominent inactivation processes, which enable these channels to integrate brief (approximiately milliseconds) depolarizations over time intervals of up to tens of seconds. In the hippocampus, Kv1.4 immunoreactivity is detected at greatest density in two regions: (1) the middle molecular layer (MML), where perforant path axons synapse with dentate granule cells, and (2) the stratum lucidum (SL) of CA3, where the mossy fibers travel in tight fasciculi and form en passante synapses onto CA3 pyramidal cells. We have studied the localization of Kv1.4 within these regions in detail. First, we compared the distribution of Kv1.4 and synaptophysin (a synaptic vesicle protein primarily localized near termini) under confocal immunofluorescence microscopy. In the MML, Kv1.4 and synaptophysin immunofluorescence appeared to overlap. In the SL, however, Kv1.4 and synaptophysin staining was detected in nonoverlapping, irregular patches ( approximately 5-10 micro m in diameter). Ultrastructural studies of these two regions revealed that Kv1.4 immunoreactivity was absent from the surface membranes of cell bodies and dendrites and occurred prominently on axons, including axonal "necks" near termini. Small excitatory synaptic boutons also were labeled in the MML; by contrast, the mossy fiber synaptic expansions in the SL were not stained. These localizations may enable Kv1.4-containing channels to regulate the process of neurotransmitter release at these excitatory synapses.

Viral load, combination therapy and the eradication of HIV: clarification of the results of the XI International Conference on AIDS. / La carga viral, terapia de combinacion y la erradicacion del VIH: demistificacion de los resultados de la XI Conferencia Internacional del SIDA.

AIDS: Responses to questions on how to interpret the numerous study results that were presented at the XI International Conference on AIDS are provided. The information should be used only as a guide for those who are interested in the progress of HIV/AIDS research. Explanations range from drug treatments to understanding the language of HIV/AIDS. Definitions of viral load, undetectable virus, and the difference between HIV levels in the blood and in lymph nodes are provided. How viral load can determine the development of AIDS, what therapeutic drugs are available, which protease inhibitor is the best, what is meant by combined therapy, and whether there is a cure in sight are answered in the report. Copies of the guidelines are available through the American Foundation for AIDS Research in New York.^ieng

Antiretroviral combination treatment prolongs life in people with HIV/AIDS.

AIDS: Results of ACTG 175 and Delta, large multicenter studies comparing combinations of nucleoside antiretroviral drugs with monotherapy, are reported. ACTG 175 enrolled 2,500 HIV-infected patients (1,000 subjects were AZT naive) over a 3-year period and randomized them to one of four drug regimens: AZT plus ddC, AZT plus ddI, AZT alone, or ddI alone. In moderately immunocompromised patients, the best results are obtained with either combination, or with ddI alone. In patients already on AZT, it is better to add or switch to ddI than to continue AZT monotherapy. The Delta trial enrolled 3,300 subjects and studied the same combinations as in ACTG 175 and AZT monotherapy, but did not study ddI monotherapy. Patients receiving combination therapy did better than those receiving AZT alone. AZT-experienced patients, regardless of the treatment received, experienced similar rates of progression to AIDS or death. This study was ceased prematurely due to the high rate of deaths in AZT-naive subjects receiving AZT alone compared to combination therapies. Other drug combination studies, such as AZT combined with 3TC, show superiority to AZT monotherapy in decreasing viral load and increasing CD4 counts, but do not correlate the results with clinical benefit. Other issues discussed include development and use of non-nucleoside reverse transcriptase inhibitors, studies involving HIV protease inhibitors, and the development of resistance and cross-resistance to various classes of antiviral agents.^ieng

Postexposure chemoprophylaxis: approval criteria for clinical trials.

Five scenarios are proposed that investigators and clinicians might consider in the evaluation of an investigational drug for postexposure chemoprophylaxis. They are (a) safety as the only standard required for an indication for postexposure chemoprophylaxis; (b) efficacy of the drug for treatment of HIV-infected patients as a sufficient criterion for an indication for postexposure chemoprophylaxis; (c) a classic placebo-controlled trial as the basis for evaluation of postexposure chemoprophylaxis; (d) a clinical trial design that evaluates outcome in relation to varying times from exposure to initiation of treatment; and (e) combination therapy. Federal regulations are sufficiently flexible to allow demonstration of safety and efficacy of an investigational drug for this indication. The necessary element is that both safety and efficacy be demonstrated in an objective and reliable manner.

Voltage-sensitive sodium channels: agents that perturb inactivation gating.

In summary, the voltage-sensitive sodium channel from eel electroplax provides an optimal preparation for biochemical and biophysical studies of molecular structure and gating. We have demonstrated that the purified and reconstituted protein is capable of functioning normally, exhibiting, among other properties, voltage-dependent activation and inactivation gating mechanisms. We have been able to recreate the classical electrophysiological studies in which inactivation gating can be removed by proteolytic modification of the cytoplasmic surface of the molecule, and have mapped the probable site of modification to the peptide segment lying between subunit domains III and IV. We have demonstrated that the reconstituted protein undergoes interactions with the lidocaine derivative QX-314 which, at low concentrations, results in paradoxical activation of the channel and a facilitation of modification by oxidizing reagents that remove inactivation gating.

Nonclinical toxicity studies of antiviral drugs indicated for the treatment of non-life-threatening diseases: evaluation of drug toxicity prior to phase 1 clinical studies.

The types of nonclinical toxicity studies conducted during the preclinical research and development of antiviral drugs intended for the treatment of non-life-threatening diseases in humans are reviewed. This guidance also applies to other classes of drugs under development for non-life-threatening diseases that fall under the regulatory responsibility of the Food and Drug Administration's Division of Antiviral Drug Products, including systemic antifungals, antimycobacterials, and immunomodulators.