Nasogastric tube feeding in line with new dietetic guidelines for the treatment of anorexia nervosa in a specialist children and adolescent inpatient unit: a case series.

BACKGROUND: The present study reports a case series where three adolescent patients with anorexia nervosa (AN) (two cases with typical AN and one case atypical AN) received nasogastric tube feeding under restraint in line with new dietetic clinical guidelines. METHODS: Three cases were chosen out of 61 admitted patients over the period of 1 year who were fed via a nasogastric tube under restraint in a specialist eating disorders unit for children and adolescents. These cases were chosen to highlight a range of clinical scenarios that clinicians may encounter. They also represent clinical scenarios where decisions to feed patients under restraint were rendered more complex by additional concerns. RESULTS: Despite the complexity of the cases, all patients tolerated the feeds well and were discharged home eating solid food. CONCLUSIONS: The decision to feed a patient against their will is never an easy one. Sadly, there have been some recent high-profile deaths of adult patients on medical wards where treatment opinion was not considered, and the patient received no or minimal nutrition when awaiting specialist treatment. Dietetic guidelines have been published to help inform clinicians for whom feeding under restraint may be out of the scope of their daily practice. This case series highlights clinical scenarios that illustrate the utility of the guidelines, which we hope will support clinicians when making, potentially lifesaving decisions in children and young people.

The development of consensus-based guidelines for dietetic practice in nasogastric tube feeding under restraint for patients with anorexia nervosa using a modified Delphi process.

INTRODUCTION: Nasogastric tube feeding against a person's will, under restraint, can be a lifesaving intervention for patients with severe anorexia nervosa. Dietetic guidelines have been developed to support dietitians in this specialised area. METHODS: A modified Delphi process was used in the development of the guidelines; stage 1, initial stakeholders created a draft; stage 2, creation of the working group; stage 3, comments and feedback on draft; stage 4, final draft agreed; stage 5, external review from Psychiatrists, patients and carers; stage 6, endorsement. Specialist mental health dietitians working in both adult and Child and Adolescent Mental Health Services (CAMHS) across four countries contributed to the development of the consensus guidelines. RESULTS: New guidance is outlined specifically for NGT feeding under restraint, which details the process, rate and volume of feed to comply with lawful guidance. CONCLUSIONS: Clinical guidelines were developed for dietitians treating patients with anorexia nervosa, using a modified Delphi process, incorporating both expert opinion and all available evidence. The guidance provides new information to dietitians and clinicians in how to enterally feed patients under restraint where none previously existed.

The P2X7 receptor antagonist Brilliant Blue G reduces serum human interferon-γ in a humanized mouse model of graft-versus-host disease.

Graft-versus-host disease (GVHD) remains a major problem after allogeneic haematopoietic stem cell transplantation, a curative therapy for haematological malignancies. Previous studies have demonstrated a role for the adenosine triphosphate (ATP)-gated P2X7 receptor channel in allogeneic mouse models of GVHD. In this study, injection of human peripheral blood mononuclear cells (PBMCs) into immunodeficient non-obese diabetic-severe combined immunodeficiency-interleukin (NOD-SCID-IL)-2Rγnull (NSG) mice established a humanized mouse model of GVHD. This model was used to study the effect of P2X7 blockade in this disease. From five weeks post-PBMC injection, humanized mice exhibited clinical signs and histopathology characteristic of GVHD. The P2X7 antagonist, Brilliant Blue G (BBG), blocked ATP-induced cation uptake into both murine and human cells in vitro. Injection of BBG (50 mg/kg) into NSG mice did not affect engraftment of human leucocytes (predominantly T cells), or the clinical score and survival of mice. In contrast, BBG injection reduced circulating human interferon (IFN)-γ significantly, which was produced by human CD4+ and CD8+ T cells. BBG also reduced human T cell infiltration and apoptosis in target organs of GVHD. In conclusion, the P2X7 antagonist BBG reduced circulating IFN-γ in a humanized mouse model of GVHD supporting a potential role for P2X7 to alter the pathology of this disease in humans.

Russian wheat aphids (Diuraphis noxia) in China: native range expansion or recent introduction?

In this study, we explore the population genetics of the Russian wheat aphid (RWA) (Diuraphis noxia), one of the world's most invasive agricultural pests, in north-western China. We have analysed the data of 10 microsatellite loci and mitochondrial sequences from 27 populations sampled over 2 years in China. The results confirm that the RWAs are holocyclic in China with high genetic diversity indicating widespread sexual reproduction. Distinct differences in microsatellite genetic diversity and distribution revealed clear geographic isolation between RWA populations in northern and southern Xinjiang, China, with gene flow interrupted across extensive desert regions. Despite frequent grain transportation from north to south in this region, little evidence for RWA translocation as a result of human agricultural activities was found. Consequently, frequent gene flow among northern populations most likely resulted from natural dispersal, potentially facilitated by wind currents. We also found evidence for the long-term existence and expansion of RWAs in China, despite local opinion that it is an exotic species only present in China since 1975. Our estimated date of RWA expansion throughout China coincides with the debut of wheat domestication and cultivation practices in western Asia in the Holocene. We conclude that western China represents the limit of the far eastern native range of this species. This study is the most comprehensive molecular genetic investigation of the RWA in its native range undertaken to date and provides valuable insights into the history of the association of this aphid with domesticated cereals and wild grasses.

The human P2X7 receptor and its role in innate immunity.

The human P2X7 receptor is a two-transmembrane ionotropic receptor which has a ubiquitous distribution and is most highly expressed on immune cells. In macrophages and similar myeloid cells primed by lipopolysaccharide (LPS), activation of P2X7 by extracellular ATP opens a cation channel/pore allowing massive K+ efflux associated with processing and secretion of pro-inflammatory cytokines interleukin (IL)-1ß and IL-18. A variety of other downstream effects follows P2X7 activation over several minutes including shedding of certain surface molecules, membrane blebbing, microvesicle/exosome release and apoptosis of the cell. High concentrations of ATP (>100 µM) are required to activate P2X7 but it remains unclear where these levels exist, other than in inflammatory foci or confined spaces such as in bone. A variety of potent selective antagonists of P2X7 activation have recently become available, allowing clinical trials to be undertaken in inflammatory and immune-mediated disorders. Proteomic studies have shown that P2X7 exists as a large multiprotein complex which includes non-muscle myosin heavy chain and other elements of the cytoskeleton. In the absence of its ATP ligand and serum, P2X7 has an alternate function in the recognition and phagocytosis of non-opsonized foreign particles, including bacteria and apoptotic cells. The P2RX7 gene has many polymorphic variants and isoforms which increase or decrease function of the receptor. Genetic association studies have linked loss-of-function polymorphisms with reactivation of latent tuberculosis as well as symptomatic infection with certain other obligate intracellular pathogens. The many roles involving P2X7 suggest that this receptor is essential to fundamental aspects of the innate immune response.

Evidence for associations between the purinergic receptor P2X(7) (P2RX7) and toxoplasmosis.

Congenital Toxoplasma gondii infection can result in intracranial calcification, hydrocephalus and retinochoroiditis. Acquired infection is commonly associated with ocular disease. Pathology is characterized by strong proinflammatory responses. Ligation of ATP by purinergic receptor P2X(7), encoded by P2RX7, stimulates proinflammatory cytokines and can lead directly to killing of intracellular pathogens. To determine whether P2X(7) has a role in susceptibility to congenital toxoplasmosis, we examined polymorphisms at P2RX7 in 149 child/parent trios from North America. We found association (FBAT Z-scores +/-2.429; P=0.015) between the derived C(+)G(-) allele (f=0.68; OR=2.06; 95% CI: 1.14-3.75) at single-nucleotide polymorphism (SNP) rs1718119 (1068T>C; Thr-348-Ala), and a second synonymous variant rs1621388 in linkage disequilibrium with it, and clinical signs of disease per se. Analysis of clinical subgroups showed no association with hydrocephalus, with effect sizes for associations with retinal disease and brain calcifications enhanced (OR=3.0-4.25; 0.004

Ozonolysis of maleic acid aerosols: effect upon aerosol hygroscopicity, phase and mass.

The hygroscopicity and mass loss of aerosols initially composed of maleic acid have been investigated before and after reaction with ozone. The phase of the aerosol, solid or aqueous, during the reaction with ozone strongly affects the composition of the processed aerosol. Furthermore the loss of aerosol mass, via the production of volatile ozonolysis products, does not occur until the processed aerosol has existed as an aqueous phase aerosol. The loss rate of the aerosol mass appears to follow unimolecular first order kinetics which is consistent with the rate determining step being the cleavage of a weak hydroperoxide, or peroxide, bond (approximately 104 kJ mol(-1)). This speculative rate determining step, which is not based on chemical analysis, is possibly a universal feature in the ozonolysis of organic aerosol containing the alkene functionality.

The amyloid protein precursor of Alzheimer's disease is a mediator of the effects of nerve growth factor on neurite outgrowth.

The beta A4 protein, the major component of the amyloid deposition characterizing Alzheimer's disease, derives from the amyloid protein precursor (APP), an integral membrane protein with soluble derivatives. The function of APP is unknown. Both soluble and membrane-associated human brain APP (10(-10) M) significantly increased (P less than 0.025) neurite length and branching in pheochromocytoma PC12 cells, but did not affect the number of neurites per cell. At higher concentrations, APP was cytotoxic, with a half-maximal concentration of 5 x 10(-9) M. Nerve growth factor (NGF) is known to affect APP expression in vivo and in vitro. Antibodies to APP specifically diminished the effects of NGF on neurite length and branching. Thus APP may act to mediate neurite outgrowth promotion by NGF.

Glycogen synthase kinase 3 (GSK3) in the heart: a point of integration in hypertrophic signalling and a therapeutic target? A critical analysis.

Glycogen synthase kinase 3 (GSK3, of which there are two isoforms, GSK3alpha and GSK3beta) was originally characterized in the context of regulation of glycogen metabolism, though it is now known to regulate many other cellular processes. Phosphorylation of GSK3alpha(Ser21) and GSK3beta(Ser9) inhibits their activity. In the heart, emphasis has been placed particularly on GSK3beta, rather than GSK3alpha. Importantly, catalytically-active GSK3 generally restrains gene expression and, in the heart, catalytically-active GSK3 has been implicated in anti-hypertrophic signalling. Inhibition of GSK3 results in changes in the activities of transcription and translation factors in the heart and promotes hypertrophic responses, and it is generally assumed that signal transduction from hypertrophic stimuli to GSK3 passes primarily through protein kinase B/Akt (PKB/Akt). However, recent data suggest that the situation is far more complex. We review evidence pertaining to the role of GSK3 in the myocardium and discuss effects of genetic manipulation of GSK3 activity in vivo. We also discuss the signalling pathways potentially regulating GSK3 activity and propose that, depending on the stimulus, phosphorylation of GSK3 is independent of PKB/Akt. Potential GSK3 substrates studied in relation to myocardial hypertrophy include nuclear factors of activated T cells, beta-catenin, GATA4, myocardin, CREB, and eukaryotic initiation factor 2Bvarepsilon. These and other transcription factor substrates putatively important in the heart are considered. We discuss whether cardiac pathologies could be treated by therapeutic intervention at the GSK3 level but conclude that any intervention would be premature without greater understanding of the precise role of GSK3 in cardiac processes.

Regulation of mitogen-activated protein kinases in cardiac myocytes through the small G protein Rac1.

Small guanine nucleotide-binding proteins of the Ras and Rho (Rac, Cdc42, and Rho) families have been implicated in cardiac myocyte hypertrophy, and this may involve the extracellular signal-related kinase (ERK), c-Jun N-terminal kinase (JNK), and/or p38 mitogen-activated protein kinase (MAPK) cascades. In other systems, Rac and Cdc42 have been particularly implicated in the activation of JNKs and p38-MAPKs. We examined the activation of Rho family small G proteins and the regulation of MAPKs through Rac1 in cardiac myocytes. Endothelin 1 and phenylephrine (both hypertrophic agonists) induced rapid activation of endogenous Rac1, and endothelin 1 also promoted significant activation of RhoA. Toxin B (which inactivates Rho family proteins) attenuated the activation of JNKs by hyperosmotic shock or endothelin 1 but had no effect on p38-MAPK activation. Toxin B also inhibited the activation of the ERK cascade by these stimuli. In transfection experiments, dominant-negative N17Rac1 inhibited activation of ERK by endothelin 1, whereas activated V12Rac1 cooperated with c-Raf to activate ERK. Rac1 may stimulate the ERK cascade either by promoting the phosphorylation of c-Raf or by increasing MEK1 and/or -2 association with c-Raf to facilitate MEK1 and/or -2 activation. In cardiac myocytes, toxin B attenuated c-Raf(Ser-338) phosphorylation (50 to 70% inhibition), but this had no effect on c-Raf activity. However, toxin B decreased both the association of MEK1 and/or -2 with c-Raf and c-Raf-associated ERK-activating activity. V12Rac1 cooperated with c-Raf to increase expression of atrial natriuretic factor (ANF), whereas N17Rac1 inhibited endothelin 1-stimulated ANF expression, indicating that the synergy between Rac1 and c-Raf is potentially physiologically important. We conclude that activation of Rac1 by hypertrophic stimuli contributes to the hypertrophic response by modulating the ERK and/or possibly the JNK (but not the p38-MAPK) cascades.

Stimulation of adult rat ventricular myocyte protein synthesis and phosphoinositide hydrolysis by the endothelins.

The effects of endothelin-1 (ET-1) on protein synthesis and phosphoinositide (PI) hydrolysis were investigated in ventricular myocytes isolated by collagenase digestion of adult rat hearts. The maximum stimulation of protein synthesis by ET-1 was about 35% and the EC50 value was about 0.3 nM. The stimulation was exerted at the translational stage since it was insensitive to inhibition by actinomycin D. The maximum stimulation of PI hydrolysis by ET-1 as measured by the formation of [3H]inositol phosphates was about 11-fold and the EC50 value was about 0.7 nM. The ET-1 analogue sarafotoxin-6b stimulated protein synthesis by a maximum of 27% and stimulated PI hydrolysis about 8- to 9-fold. The EC50 values were 1.6 nM and 0.6 nM, respectively. Other endothelins stimulated protein synthesis and PI hydrolysis in the following order of potency: ET-1 approximately ET-2 > ET-3. This order of potency suggests that the stimulation of both protein synthesis and PI hydrolysis is mediated through the ETA receptor. Although both angiotensin II and [Arg]vasopressin stimulated PI hydrolysis significantly, the stimulation was less than 60%, i.e., much less than the stimulation by ET-1 and its analogues. Neither insulin nor substance P stimulated PI hydrolysis. Stimulation of protein synthesis by ET-1 and its analogues correlated strongly with the stimulation of PI hydrolysis and we suggest that the stimulation of protein synthesis may be dependent on the stimulation of PI hydrolysis. We hypothesize that the mechanism may involve a protein kinase C-mediated increase in intracellular pH.

The amyloid precursor protein of Alzheimer disease in human brain and blood.

Studies of the metabolism and function of the amyloid precursor protein (APP) and its proteolytic fragment A beta in cultured cells, transgenic mice, and post-mortem brain tissue have advanced our understanding of Alzheimer disease (AD). However, the molecular pathogenesis of the disease is still not clear, and we are a long way from finding a cure for the disease. Studies carried out on human platelets and leukocytes have also helped shed light on APP and A beta metabolism and function. Platelet and leukocyte APP isoforms are processed using mechanisms similar to those in neuronal cells to generate A beta and soluble forms of APP. The activation of platelets and leukocytes leads to the secretion of APP and A beta, resulting in higher levels of these proteins in serum. APP and A beta in the circulation may be involved in the regulation of platelet function and in the modulation of immune responses. Because human platelets and lymphocytes produce all forms of APP and secrete amyloidogenic A beta peptides, these tissues may be useful in monitoring responses to therapeutic interventions directed at APP metabolism. Although not of neuronal origin, further studies on the more accessible ex vivo tissues, including platelets and leukocytes and other blood components, may reveal potential peripheral markers for AD and will further our understanding of the molecular pathogenesis of AD.

G alpha 13 stimulates gene expression and increases cell size in cultured neonatal rat ventricular myocytes.

OBJECTIVES: Constitutively-active G alpha 13 causes permissive cell types to proliferate or undergo phenotypic transformation implying a role for G13 in the control of cell growth. Cardiac myocytes are terminally-differentiated cells which respond to growth stimuli by increasing in size rather than by cell division. The objective of this study was to determine whether constitutively-active G alpha 13 is able to induce a hypertrophic phenotype in cardiac myocytes. METHODS: Cultured neonatal rat ventricular myocytes were transiently transfected with an expression vector (pRC/RSV) encoding wild-type G alpha 13 or constitutively-active G alpha 13Q226L. Effects on transcription were monitored by co-transfected luciferase (LUX) reporter genes under the control of promoters responsive to hypertrophic stimuli. Cell size was determined by planimetry. RESULTS: Transfection of neonatal myocytes with G alpha 13Q226L, but not wild-type G alpha 13, stimulated ANF638LUX and ANF3003LUX expression to 3.0 +/- 0.3- and 4.3 +/- 0.6-fold of the control, respectively. Likewise, G alpha 13Q226L stimulated vMLC250LUX and vMLC2700LUX expression to 3.9 +/- 1.0- and to 7.7 +/- 1.7-fold of controls, respectively, but there was relatively little effect of G alpha 13Q226L on c-fos-SRE- and beta-MHC promoter activity. The effects of G alpha 13Q226L on ANF3003LUX were inhibited by expression of C3 exoenzyme. Wild-type G alpha 13 and G alpha 13Q226L increased myocyte area from 869 +/- 43 micron 2 in control tranfections to 1287 +/- 64 micron 2 and 1278 +/- 59 microns, respectively. CONCLUSION: We conclude that G alpha 13Q226L is able to induce gene expression and morphological changes associated with a hypertrophic response in cardiac myocytes and that the transcriptional effects may be mediated through a Rho-dependent mechanism.

Stimulation of protein synthesis, glucose uptake and lactate output by insulin and adenosine deaminase in the rat heart.

In the anterogradely perfused rat heart, physiological concentrations of insulin stimulated the rates and efficiencies of protein synthesis in both ventricles and atria. Half-maximal stimulation of ventricular protein synthesis was obtained at about 35 microU/ml. Glucose uptake and lactate release were also stimulated over this range of insulin concentrations. Adenosine deaminase increased protein synthesis rates in ventricles and atria in the presence of submaximally stimulating insulin concentrations (40 microU/ml) but had no effect in the absence of insulin or in the presence of maximally stimulating concentrations. The insulin sensitivities of glucose uptake and lactate release were also increased by adenosine deaminase. Adenosine may be a modulator of insulin sensitivity in the heart.

Protein synthesis in rat cardiac myocytes is stimulated at the level of translation by phorbol esters.

12-O-Tetradecanoylphorbol 13-acetate acutely stimulated the rate of protein synthesis maximally by about 43% in terminally differentiated myocytes freshly isolated from adult rat hearts. Stimulation was rapidly expressed (within 20 min). The relative effects of four phorbol esters on protein synthesis was consistent with a specific effect on protein kinase C. Inhibition of transcription with actinomycin D had no effect on the absolute stimulation of the protein synthesis rate by 12-O-tetradecanoylphorbol 13-acetate. We conclude that protein kinase C may be involved in the regulation of the translational process.

Stimulation of protein synthesis by raised extracellular pH in cardiac myocytes and perfused hearts.

Protein synthesis was stimulated in freshly-isolated rats cardiac myocytes by increasing the extracellular pH of Hepes-buffered Tyrode's solutions over the range pH 7.4-8.4. The maximal stimulation was about 45%. Protein synthesis in anterogradely-perfused rat hearts was stimulated by 11% by increasing the pH of the bicarbonate-containing perfusion medium from pH 7.4 to 7.8. This manoeuvre increased intracellular pH by 0.12 units. A concomitant increase in phosphocreatine concentration was observed. These findings are consistent with the hypothesis that intracellular pH may exert profound effects on tissue protein synthesis rates.

Classical, novel and atypical isoforms of PKC stimulate ANF- and TRE/AP-1-regulated-promoter activity in ventricular cardiomyocytes.

Cultured neonatal rat ventricular myocytes were co-transfected with expression plasmids encoding protein kinase C (PKC) isoforms from each of the PKC subfamilies (classical PKC-alpha, novel PKC-epsilon or atypical PKC-zeta) together with an atrial natriuretic factor (ANF) reporter plasmid. Each PKC had been rendered constitutively active by a single Ala-->Glu mutation or a small deletion in the inhibitory pseudosubstrate site. cPKC-alpha, nPKC-epsilon or aPKC-zeta expression plasmids each stimulated ANF-promoter activity and expression of a reporter gene under the control of a 12-O-tetradecanoylphorbol 13-acetate-response element (TRE). Upregulation of the ANF promoter is characteristic of the hypertrophic response in the heart ventricle and a TRE is present in the ANF promoter. Thus all subfamilies of PKC may have the potential to contribute to hypertrophic response in cardiomyocytes.

Gelatinase A possesses a beta-secretase-like activity in cleaving the amyloid protein precursor of Alzheimer's disease.

The ability of the 72 kDa gelatinase A to cleave the amyloid protein precursor (APP) was investigated. HeLa cells were transfected with an APP695 plasmid. The cells were incubated with gelatinase A, which cleaved the 110 kDa cell-surface APP, releasing a 100 kDa form of the protein. A peptide homologous to the beta-secretase site was cleaved by gelatinase A adjacent to a glutamate residue at position -3 (beta A4 numbering system). A peptide homologous to the alpha-secretase site was not cleaved. The results demonstrate that 72 kDa gelatinase A is not an alpha-secretase, but that it may have a beta-secretase activity.

Platelet-rich plasma reduces postoperative blood loss after cardiopulmonary bypass.

To study the effect of plasma sequestration and reinfusion of platelet-rich plasma on blood loss after cardiopulmonary bypass, 18 patients undergoing heart operations were randomly selected either to have collected or not to have collected approximately 250 ml of platelet-rich plasma before initiating cardiopulmonary bypass with the use of the Haemonetics Plasma Saving System (Haemonetics Corporation, Braintree, Mass.). All patients had standardized anesthesia and cardiopulmonary bypass. After reversal of heparin, autologous platelet-rich plasma was reinfused in nine patients. Thrombocyte counts, hemoglobin, and hematocrit were calculated before, during, and after cardiopulmonary bypass, and 24 and 48 hours postoperatively. Blood loss and total number of transfusions were recorded. Although 9% of the total platelet volume was removed, there were no hemodynamic complications related to the use of the Haemonetics Plasma Saving System. In both groups, significant low levels of thrombocytes, hemoglobin, and hematocrit were seen after cardiopulmonary bypass. Platelet-rich plasma-reinfused patients had a significantly higher number of platelets after heparin reversal. They also had significantly less blood loss after the operation, necessitating 65% less banked blood products (p less than 0.05). We concluded that reinfusion of autologous platelet-rich plasma may serve as an effective and safe way to restore some of the hematologic derangements after cardiopulmonary bypass.

Genetic engineering of cardiac muscle cells: in vitro and in vivo.

Over the last few years many of the difficulties encountered in applying molecular biology techniques to cardiac muscle have been addressed. Although continuous cardiac cell lines are still, as yet, unavailable, progress in embryonic stem cell systems and in our fundamental understanding of the critical steps that lead to cessation of cardiac myocyte cell division suggests that one may soon emerge. The cis-acting promoter elements and transacting factors responsible for cardiac specificity and inducible expression of cardiac genes are being characterized at a rapid pace. Transgenic models of cardiac disease are being generated and new insights are being made towards the goal of gene therapy in the heart. As the repertoire of techniques for transferring DNA into heart cells continues to expand, so the prospect for efficient and long-term expression of exogenous DNA in heart cells improves. The recent rapid rate of progress promises that ideas once fanciful may ultimately be within our reach.