DETERMINING INSULIN DOSE AT THE TIME OF DISCHARGE IN A HIGH-RISK POPULATION: IS THERE ROOM FOR IMPROVEMENT?

OBJECTIVE: To evaluate the adequacy of the insulin dose prescribed at hospital discharge in a high-risk population and assess patient characteristics that influence insulin dose requirement in the immediate postdischarge period. METHODS: This was a retrospective study conducted at Parkland Health System. We included all patients admitted to a medical floor who received an insulin prescription at discharge and had at least one follow-up visit within 6 months of discharge. All data were extracted by a detailed manual review of each electronic medical record. RESULTS: At the postdischarge follow-up (N = 797, median 33 days from discharge), 60% of patients required an insulin dose adjustment; 47% of the patients required a dose decrease. Significant predictors of a decrease insulin requirement postdischarge included (multiple regression beta coefficient [95% confidence interval]): newly diagnosed diabetes, -12.7 (-17.7, -7.7); ketosis-prone diabetes, -8.4 (-15, -1.8); glycated hemoglobin A1c (HbA1c), <10% (86 mmol/mol) -7.0 (-11.4, -2.6); discharge insulin total daily dose, -5.3 (-9.3, -1.3); and metformin prescription, -4.9 (-8.4, -1.3). CONCLUSION: An insulin dose adjustment (most commonly a decrease) was necessary shortly after discharge in more than half of our patients. A better model to estimate insulin dose at discharge is needed along with short-term follow-up after discharge for insulin titration. A pre-emptive insulin dose reduction at discharge should be considered for patients with newly diagnosed diabetes, ketosis-prone diabetes, metformin prescription, and those with HbA1c <10% at presentation. ABBREVIATIONS: DKA = diabetic ketoacidosis; HbA1c = glycated hemoglobin A1c; KPDM = ketosis-prone diabetes mellitus; TDD = total daily dose.

FcR-independent effects of IgE and IgG autoantibodies in bullous pemphigoid.

Bullous pemphigoid (BP) is a subepidermal blistering disease characterized by IgE and IgG class autoantibodies specific for 180-kDa BP Ag 2 (BP180), a protein involved in cell-substrate attachment. Although some direct effects of BP IgG have been observed on keratinocytes, no study to date has examined direct effects of BP IgE. In this study, we use primary cultures of human keratinocytes to demonstrate Ag-specific binding and internalization of BP IgE. Moreover, when BP IgE and BP IgG were compared, both isotypes stimulated FcR- independent production of IL-6 and IL-8, cytokines critical for BP pathology, and elicited changes in culture confluence and viability. We then used a human skin organ culture model to test the direct effects of these Abs on the skin, whereas excluding the immune inflammatory processes that are triggered by these Abs. In these experiments, physiologic concentrations of BP IgE and BP IgG exerted similar effects on human skin by stimulating IL-6 and IL-8 production and decreasing the number of hemidesmosomes localized at the basement membrane zone. We propose that the Ab-mediated loss of hemidesmosomes could weaken attachment of basal keratinocytes to the basement membrane zone of affected skin, thereby contributing to blister formation. In this article, we identify a novel role for IgE class autoantibodies in BP mediated through an interaction with BP180 on the keratinocyte surface. In addition, we provide evidence for an FcR-independent mechanism for both IgE and IgG class autoantibodies that could contribute to BP pathogenesis.

Characterization of soy-based changes in Wnt-frizzled signaling in prostate cancer.

BACKGROUND: A soy-based diet has been associated with a decreased risk of prostate cancer through its anti-androgenic effects. Because the Wnt/beta catenin pathway has been associated with aggressive prostate cancer, we have sought to further evaluate this pathway with respect to soy protein and prostate cancer. MATERIALS AND METHODS: Previously we have treated rat and human prostate cancer cell lines with soy protein isolates or purified genistein and used gene expression profiling and cross species analysis to identify genes with similar expression changes. One pathway that was identified included the Wnt/beta-cantenin pathway. Here the initial data are evaluated and extended with immunohistochemistry in human prostate cancer, and Western blotting, small interfering ribonucleic acid (siRNA) inhibition and bromodeoxyuridine (BrDU) labeling in prostate cancer cell lines. RESULTS: The Wnt/beta-catenin pathway is modulated by both soy protein isolates and genistein in the genomic results. Immunohistochemistry demonstrated staining of Wnt pathway component molecules, in particular frizzled 3, glycogen synthase kinase 3 (GSK-3), and beta-catenin, in prostate tumors. Western blotting noted increased GSK3 and decreased expression of beta-catenin in soy treated prostate cancer PC3 cells. Supporting this finding, siRNA blocking of GSK3 accelerated growth whereas inhibition of frizzled 3 suppressed growth based on growth curves and BrDU labeling. CONCLUSION: Soy protein appears to regulate prostate cancer via the Wnt/beta-catenin pathway. These data demonstrate that the effect of soy protein effect on prostate cancer may occur through the frizzled 3 receptor with activation of GSK3 leading to increased degradation of beta-catenin and cell growth.

Use of cross species genomic profiling identifies pathways and genes differentially regulated in prostate cancer cells treated with soy protein isolates or purified genistein.

BACKGROUND: The main purified compound from soy protein isolates is genistein, but this purified phytoestrogen fails to recapitulate all the features of the soy-based diet that is associated with lower incidence of prostate cancer. MATERIALS AND METHODS: Rat and human prostate cancer cell lines were treated with either soy protein isolates or purified genistein. In vitro cell growth was correlated with the associated genomic expression profiles using cDNA arrays. The data was subsequently bioinformatically analyzed within and across species to identify common changes in expression profiles associated with the soy protein or genistein treatments. RESULTS: Gene expression profiling and data mining noted genes specific to soy; however, biological pathways showed the same gene regulation profiles between genistein and soy. CONCLUSION: Genistein is likely the major contributor to the effect of soy proteins on cellular pathways; however, the expression of different genes using soy protein isolates suggests complexity in the many compounds found in whole soy protein.

Perlecan, a candidate gene for the CAPB locus, regulates prostate cancer cell growth via the Sonic Hedgehog pathway.

BACKGROUND: Genetic studies associated the CAPB locus with familial risk of brain and prostate cancers. We have identified HSPG2 (Perlecan) as a candidate gene for CAPB. Previously we have linked Perlecan to Hedgehog signaling in Drosophila. More recently, we have demonstrated the importance of Hedgehog signaling in humans for advanced prostate cancer. RESULTS: Here we demonstrate Perlecan expression in prostate cancer, and its function in prostate cancer cell growth through interaction and modulation of Sonic Hedgehog (SHH) signaling. Perlecan expression in prostate cancer tissues correlates with a high Gleason score and rapid cell proliferation. Perlecan is highly expressed in prostate cancer cell lines, including androgen insensitive cell lines and cell lines selected for metastatic properties. Inhibition of Perlecan expression in these cell lines decreases cell growth. Simultaneous blockade of Perlecan expression and androgen signaling in the androgen-sensitive cell line LNCaP was additive, indicating the independence of these two pathways. Perlecan expression correlates with SHH in tumor tissue microarrays and increased tumor cell proliferation based on Ki-67 immunohistochemistry. Inhibition of Perlecan expression by siRNA in prostate cancer cell lines decreases SHH signaling while expression of the downstream SHH effector GLI1 rescues the proliferation defect. Perlecan forms complexes with increasing amounts of SHH that correlate with increasing metastatic potential of the prostate cancer cell line. SHH signaling also increases in the more metastatic cell lines. Metastatic prostate cancer cell lines grown under serum-starved conditions (low androgen and growth factors) resulted in maintenance of Perlecan expression. Under low androgen, low growth factor conditions, Perlecan expression level correlates with the ability of the cells to maintain SHH signaling. CONCLUSION: We have demonstrated that Perlecan, a candidate gene for the CAPB locus, is a new component of the SHH pathway in prostate tumors and works independently of androgen signaling. In metastatic tumor cells increased SHH signaling correlates with the maintenance of Perlecan expression and more Perlecan-SHH complexes. Perlecan is a proteoglycan that regulates extracellular and stromal accessibility to growth factors such as SHH, thus allowing for the maintenance of SHH signaling under growth factor limiting conditions. This proteoglycan represents an important central regulator of SHH activity and presents an ideal drug target for blocking SHH effects.

Inhibition of prostate cancer proliferation by interference with SONIC HEDGEHOG-GLI1 signaling.

Prostate cancer is the most common solid tumor in men, and it shares with all cancers the hallmark of elevated, nonhomeostatic cell proliferation. Here we have tested the hypothesis that the SONIC HEDGEHOG (SHH)-GLI signaling pathway is implicated in prostate cancer. We report expression of SHH-GLI pathway components in adult human prostate cancer, often with enhanced levels in tumors versus normal prostatic epithelia. Blocking the pathway with cyclopamine or anti-SHH antibodies inhibits the proliferation of GLI1+/PSA+ primary prostate tumor cultures. Inversely, SHH can potentiate tumor cell proliferation, suggesting that autocrine signaling may often sustain tumor growth. In addition, pathway blockade in three metastatic prostate cancer cell lines with cyclopamine or through GLI1 RNA interference leads to inhibition of cell proliferation, suggesting cell-autonomous pathway activation at different levels and showing an essential role for GLI1 in human cells. Our data demonstrate the dependence of prostate cancer on SHH-GLI function and suggest a novel therapeutic approach.