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Archive for December, 2013

Genomics of Incident Ischemic Stroke Events, Stroke and Cardiovascular Disease

Reporter: Aviva Lev-Ari, PhD, RN

 

Associations Between Incident Ischemic Stroke Events and Stroke and Cardiovascular Disease-Related Genome-Wide Association Studies Single Nucleotide Polymorphisms in the Population Architecture Using Genomics and Epidemiology Study

Cara L. Carty, PhD, Petra Bůžková, PhD, Myriam Fornage, PhD, Nora Franceschini, MD, Shelley Cole, PhD, Gerardo Heiss, MD, PhD, Lucia A. Hindorff, PhD, MPH, Barbara V. Howard, PhD, Sue Mann, MPH, Lisa W. Martin, MD, Ying Zhang, PhD, Tara C. Matise, PhD, Ross Prentice, PhD, Alexander P. Reiner, MD, MS and Charles Kooperberg, PhD

Author Affiliations

From the Public Health Sciences, Fred Hutchinson Cancer Research Center (C.L.C., S.M., R.P., C.K.); Department of Biostatistics, University of Washington, Seattle, WA (P.B.); Institute of Molecular Medicine, University of Texas Health Sciences Center at Houston, Houston, TX (M.F.); Division of Epidemiology, School of Public Health, University of Texas Health Sciences Center, Houston, TX (M.F.); Department of Epidemiology, University of North Carolina, Chapel Hill, NC (N.F., G.H.); Department of Genetics, Texas Biomedical Research Institute, San Antonio, TX (S.C.); Office of Population Genomics, National Human Genome Research Institute, Bethesda, MD (L.A.H.); Medstar Health Research Institute, Washington, DC (B.V.H.); George Washington University School of Medicine, Washington, DC (B.V.H., L.W.M.); University of Oklahoma Health Sciences Center, Oklahoma City, OK (Y.Z.); Department of Genetics, Rutgers University, Piscataway, NJ (T.C.M.); Department of Epidemiology, University of Washington, Seattle, WA (A.P.R.).

Correspondence to Dr Cara L. Carty, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N./M3-A410, Seattle, WA 98109. E-mail ccarty@fhcrc.org

Abstract

Background—Genome-wide association studies (GWAS) have identified loci associated with ischemic stroke (IS) and cardiovascular disease (CVD) in European-descent individuals, but their replication in different populations has been largely unexplored.

Methods and Results—Nine single nucleotide polymorphisms (SNPs) selected from GWAS and meta-analyses of stroke, and 86 SNPs previously associated with myocardial infarction and CVD risk factors, including blood lipids (high density lipoprotein [HDL], low density lipoprotein [LDL], and triglycerides), type 2 diabetes, and body mass index (BMI), were investigated for associations with incident IS in European Americans (EA) N=26 276, African-Americans (AA) N=8970, and American Indians (AI) N=3570 from the Population Architecture using Genomicsand Epidemiology Study. Ancestry-specific fixed effects meta-analysis with inverse variance weighting was used to combine study-specific log hazard ratios from Cox proportional hazards models. Two of 9 stroke SNPs (rs783396 and rs1804689) were associated with increased IS hazard in AA; none were significant in this large EA cohort. Of 73 CVD risk factor SNPs tested in EA, 2 (HDL and triglycerides SNPs) were associated with IS. In AA, SNPs associated with LDL, HDL, and BMI were significantly associated with IS (3 of 86 SNPs tested). Out of 58 SNPs tested in AI, 1 LDL SNP was significantly associated with IS.

Conclusions—Our analyses showing lack of replication in spite of reasonable power for many stroke SNPs and differing results by ancestry highlight the need to follow up on GWAS findings and conduct genetic association studies in diverse populations. We found modest IS associations with BMI and lipids SNPs, though these findings require confirmation.

SOURCE:

Circulation: Cardiovascular Genetics.2012; 5: 210-216

 

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Strong Lipid Gene Contribution But No Evidence for Common Genetic Basis for Clustering of Metabolic Syndrome Traits: Genome-Wide Screen for Metabolic Syndrome Susceptibility Loci Reveals

Reporter: Aviva Lev-Ari, PhD, RN

Genome-Wide Screen for Metabolic Syndrome Susceptibility Loci Reveals Strong Lipid Gene Contribution But No Evidence for Common Genetic Basis for Clustering of Metabolic Syndrome Traits

Kati Kristiansson, PhD, Markus Perola, MD, PhD, Emmi Tikkanen, MSc, Johannes Kettunen, PhD, Ida Surakka, MSc, Aki S. Havulinna, DSc (Tech.), Alena Stančáková, MD, PhD, Chris Barnes, PhD, Elisabeth Widen, MD, PhD, Eero Kajantie, MD, PhD,Johan G. Eriksson, MD, DMSc, Jorma Viikari, MD, PhD, Mika Kähönen, MD, PhD,Terho Lehtimäki, MD, PhD, Olli T. Raitakari, MD, PhD, Anna-Liisa Hartikainen, MD, PhD, Aimo Ruokonen, MD, PhD, Anneli Pouta, MD, PhD, Antti Jula, MD, PhD, Antti J. Kangas, MSc, Pasi Soininen, PhD, Mika Ala-Korpela, PhD, Satu Männistö, PhD, Pekka Jousilahti, MD, PhD, Lori L. Bonnycastle, PhD, Marjo-Riitta Järvelin, MD, PhD,Johanna Kuusisto, MD, PhD, Francis S. Collins, MD, PhD, Markku Laakso, MD, PhD,Matthew E. Hurles, PhD, Aarno Palotie, MD, PhD, Leena Peltonen, MD, PhD*Samuli Ripatti, PhD and Veikko Salomaa, MD, PhD

Correspondence to Dr Kati Kristiansson, National Institute for Health and Welfare, University of Helsinki, Biomedicum, PL 104, FI-00251 Helsinki, Finland. E-mailkati.kristiansson@thl.fi

Abstract

Background—Genome-wide association (GWA) studies have identified several susceptibility loci for metabolic syndrome (MetS) component traits, but have had variable success in identifying susceptibility loci to the syndrome as an entity. We conducted a GWA study on MetS and its component traits in 4 Finnish cohorts consisting of 2637 MetS cases and 7927 controls, both free of diabetes, and followed the top loci in an independent sample with transcriptome and nuclear magnetic resonance-based metabonomics data. Furthermore, we tested for loci associated with multiple MetS component traits using factor analysis, and built a genetic risk score for MetS.

Methods and Results—A previously known lipid locus, APOA1/C3/A4/A5 gene cluster region (SNP rs964184), was associated with MetS in all 4 study samples (P=7.23×10−9 in meta-analysis). The association was further supported by serum metabolite analysis, where rs964184 was associated with various very low density lipoprotein, triglyceride, and high-density lipoprotein metabolites (P=0.024–1.88×10−5). Twenty-two previously identified susceptibility loci for individual MetS component traits were replicated in our GWA and factor analysis. Most of these were associated with lipid phenotypes, and none with 2 or more uncorrelated MetS components. A genetic risk score, calculated as the number of risk alleles in loci associated with individual MetS traits, was strongly associated with MetS status.

Conclusions—Our findings suggest that genes from lipid metabolism pathways have the key role in the genetic background of MetS. We found little evidence for pleiotropy linking dyslipidemia and obesity to the other MetS component traits, such as hypertension and glucose intolerance.

 SOURCE:

Circulation: Cardiovascular Genetics.2012; 5: 242-249

Published online before print March 7, 2012,

doi: 10.1161/ CIRCGENETICS.111.961482

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New Functional Apolipoprotein B Variant Influencing Oxidized Low-Density Lipoprotein Levels But Not Cardiovascular Events: Genome-Wide Association Study

Reporter: Aviva Lev-Ari, PhD, RN

 

Genome-Wide Association Study Pinpoints a New Functional Apolipoprotein B Variant Influencing Oxidized Low-Density Lipoprotein Levels But Not Cardiovascular Events

AtheroRemo Consortium

Kari-Matti Mäkelä, BM, BSc, Ilkka Seppälä, MSc, Jussi A. Hernesniemi, MD, PhD, Leo-Pekka Lyytikäinen, MD, Niku Oksala, MD, PhD, DSc, Marcus E. Kleber, PhD, Hubert Scharnagl, PhD, Tanja B. Grammer, MD, Jens Baumert, PhD, Barbara Thorand, PhD,Antti Jula, MD, PhD, Nina Hutri-Kähönen, MD, PhD, Markus Juonala, MD, PhD, Tomi Laitinen, MD, PhD, Reijo Laaksonen, MD, PhD, Pekka J. Karhunen, MD, PhD, Kjell C. Nikus, MD, PhD, Tuomo Nieminen, MD, PhD, MSc, Jari Laurikka, MD, PhD, Pekka Kuukasjärvi, MD, PhD, Matti Tarkka, MD, PhD, Jari Viik, PhD, Norman Klopp, PhD,Thomas Illig, PhD, Johannes Kettunen, PhD, Markku Ahotupa, PhD, Jorma S.A. Viikari, MD, PhD, Mika Kähönen, MD, PhD, Olli T. Raitakari, MD, PhD, Mahir Karakas, MD, Wolfgang Koenig, MD, PhD, Bernhard O. Boehm, MD, Bernhard R. Winkelmann, MD, Winfried März, MD and Terho Lehtimäki, MD, PhD

Correspondence to Kari-Matti Mäkelä, Department of Clinical Chemistry, Finn-Medi 2, PO Box 2000, FI-33521 Tampere, Finland. E-mail kari-matti.makela@uta.fi

Abstract

Background—Oxidized low-density lipoprotein may be a key factor in the development of atherosclerosis. We performed a genome-wide association study on oxidized low-density lipoprotein and tested the impact of associated single-nucleotide polymorphisms (SNPs) on the risk factors of atherosclerosis and cardiovascular events.

Methods and Results—A discovery genome-wide association study was performed on a population of young healthy white individuals (N=2080), and the SNPs associated with a P<5×10–8 were replicated in 2 independent samples (A: N=2912; B: N=1326). Associations with cardiovascular endpoints were also assessed with 2 additional clinical cohorts (C: N=1118; and D: N=808). We found 328 SNPs associated with oxidized low-density lipoprotein. The genetic variant rs676210 (Pro2739Leu) in apolipoprotein B was the proxy SNP behind all associations (P=4.3×10–136, effect size=13.2 U/L per allele). This association was replicated in the 2 independent samples (A and B, P=2.5×10–47 and 1.1×10–11, effect sizes=10.3 U/L and 7.8 U/L, respectively). In the meta-analyses of cohorts A, C, and D (excluding cohort B without angiographic data), the top SNP did not associate significantly with the age of onset of angiographically verified coronary artery disease (hazard ratio=1.00 [0.94–1.06] per allele), 3-vessel coronary artery disease (hazard ratio=1.03 [0.94–1.13]), or myocardial infarction (hazard ratio=1.04 [0.96–1.12]).

Conclusions—This novel genetic marker is an important factor regulating oxidized low-density lipoprotein levels but not a major genetic factor for the studied cardiovascular endpoints.

SOURCE:

Circulation: Cardiovascular Genetics.2013; 6: 73-81

Published online before print December 17, 2012,

doi: 10.1161/ CIRCGENETICS.112.964965

 

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Lemtrada (alemtuzumab) for the treatment of relapsing forms of multiple sclerosis – Biologics License Application: FDA – Not ready for approval!

Reporter: Aviva Lev-Ari, PhD, RN

 

Genzyme Receives Complete Response Letter from FDA on LemtradaTM (alemtuzumab) Application 

Paris, France – December 30, 2013 – Sanofi (EURONEXT: SAN and NYSE: SNY) and its subsidiary Genzyme announced today that it has received a Complete Response Letter from the U.S. Food and Drug Administration (FDA) for its supplemental Biologics License Application seeking approval of Lemtrada (alemtuzumab) for the treatment of relapsing forms of multiple sclerosis.

A Complete Response Letter informs companies that an application is not ready for approval. FDA has taken the position that Genzyme has not submitted evidence from adequate and well-controlled studies that demonstrate the benefits of Lemtrada outweigh its serious adverse effects. Genzyme understands that the conclusion is related to the design of the completed Phase 3 active comparator studies of Lemtrada in relapsing-remitting MS patients. FDA has also taken the position that one or more additional active comparator clinical trials of different design and execution are needed prior to the approval of Lemtrada.

Genzyme strongly disagrees with the FDA’s conclusions and plans to appeal the agency’s decision.

“We are extremely disappointed with the outcome of the review and the implications for patients in the U.S. suffering with multiple sclerosis who remain in need of alternative therapies to manage a devastating disease,” said Genzyme President and CEO, David Meeker, M.D. “We strongly believe that the clinical development program, which was designed to demonstrate how Lemtrada compares against an active comparator as opposed to placebo, provides robust evidence of efficacy and a favorable benefit-risk profile. This evidence was also the basis for the approvals of Lemtrada by other regulatory agencies around the world.”

Lemtrada is approved in the European Union, Canada, and Australia, and additional marketing applications for Lemtrada are under review by regulatory agencies around the world.

Sanofi does not anticipate that the CVR milestone of U.S. approval of Lemtrada by March 31, 2014 will be met.

About Lemtrada™ (alemtuzumab) 

The Lemtrada clinical development program included two pivotal randomized Phase III studies comparing treatment with Lemtrada to Rebif® (high-dose subcutaneous interferon beta-1a) in patients with RRMS who had active disease and were either new to treatment (CARE-MS I) or who had relapsed while on prior therapy (CARE-MS II), as well as an ongoing extension study. In CARE-MS I, Lemtrada was significantly more effective than Rebif at reducing annualized relapse rates; the difference observed in slowing disability progression did not reach statistical significance. In CARE-MS II, Lemtrada was significantly more effective than interferon beta-1a at reducing annualized relapse rates, and accumulation of disability was significantly slowed in patients given Lemtrada vs. interferon beta-1a.

The most common side effects of Lemtrada are infusion associated reactions, infections (upper respiratory tract and urinary tract), lymphopenia and leukopenia. Serious autoimmune conditions can occur in patients receiving Lemtrada. A comprehensive risk management program will support early detection and management of these autoimmune events. 2/3

 

Alemtuzumab is a monoclonal antibody that selectively targets CD52, a protein abundant on T and B cells. Treatment with alemtuzumab results in the depletion of circulating T and B cells thought to be responsible for the damaging inflammatory process in MS. Alemtuzumab has minimal impact on other immune cells. The acute anti-inflammatory effect of alemtuzumab is immediately followed by the onset of a distinctive pattern of T and B cell repopulation that continues over time, rebalancing the immune system in a way that potentially reduces MS disease activity.

Genzyme holds the worldwide rights to alemtuzumab and has primary responsibility for its development and commercialization in multiple sclerosis. Bayer HealthCare holds the right to co-promote alemtuzumab in MS in the United States. Upon commercialization, Bayer will receive contingent payments based on global sales revenue.

About Genzyme, a Sanofi Company 

Genzyme has pioneered the development and delivery of transformative therapies for patients affected by rare and debilitating diseases for over 30 years. We accomplish our goals through world-class research and with the compassion and commitment of our employees. With a focus on rare diseases and multiple sclerosis, we are dedicated to making a positive impact on the lives of the patients and families we serve. That goal guides and inspires us every day. Genzyme’s portfolio of transformative therapies, which are marketed in countries around the world, represents groundbreaking and life-saving advances in medicine. As a Sanofi company, Genzyme benefits from the reach and resources of one of the world’s largest pharmaceutical companies, with a shared commitment to improving the lives of patients. Learn more at http://www.genzyme.com.

About Sanofi 

Sanofi, an integrated global healthcare leader, discovers, develops and distributes therapeutic solutions focused on patients’ needs. Sanofi has core strengths in the field of healthcare with seven growth platforms: diabetes solutions, human vaccines, innovative drugs, consumer healthcare, emerging markets, animal health and the new Genzyme. Sanofi is listed in Paris (EURONEXT: SAN) and in New York (NYSE: SNY).

Genzyme® is a registered trademark and LemtradaTM is a trademark of Genzyme Corporation. Rebif® is a registered trademark of EMD Serono, Inc.

Sanofi Forward Looking Statements 

This press release contains forward-looking statements as defined in the Private Securities Litigation Reform Act of 1995, as amended. Forward-looking statements are statements that are not historical facts. These statements include projections and estimates and their underlying assumptions, statements regarding plans, objectives, intentions and expectations with respect to future financial results, events, operations, services, product development and potential, and statements regarding future performance. Forward-looking statements are generally identified by the words “expects”, “anticipates”, “believes”, “intends”, “estimates”, “plans” and similar expressions. Although Sanofi’s management believes that the expectations reflected in such forward-looking statements are reasonable, investors are cautioned that forward-looking information and statements are subject to various risks and uncertainties, many of which are difficult to predict and generally beyond the control of Sanofi, that could cause actual results and developments to differ materially from those expressed in, or implied or projected by, the forward-looking information and statements. These risks and uncertainties include among other things, the uncertainties inherent in research and development, future clinical data and analysis, including post marketing, decisions by regulatory authorities, such as the FDA or the EMA, regarding whether and when to approve any drug, device or biological application that may be filed for any such product candidates as well as their decisions regarding labeling and other matters that could affect the availability or commercial potential of such product candidates, the absence of guarantee that the product candidates if approved will be commercially successful, the future approval and commercial success of therapeutic alternatives, the Group’s ability to benefit from external growth opportunities, trends in exchange rates and prevailing interest rates, the impact of cost containment policies and subsequent changes thereto, the average number of shares outstanding as well as those discussed or identified in the public filings with the SEC and the AMF made by Sanofi, including those listed under “Risk Factors” and “Cautionary Statement Regarding Forward-Looking Statements” in Sanofi’s annual report on Form 20-F for the year ended December 31, 2012. Other than as required by applicable law, Sanofi does not undertake any obligation to update or revise any forward-looking information or statements. 

SOURCE

http://en.sanofi.com/Images/35285_20131230_Lemtrada_en.pdf

 

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Larry H Bernstein, MD, Reviewer and Content Advisor
Stephen Williams, PhD, Cancer Editor
http://pharmaceuticalintelligence.com/2013-12-24/larryhbern/
Ecdysteroid-Dioxolanes-as-MDR-Modulators-in Cancer

This article is a presentation on drug research and development in cancer therapeutics
introducing structure activity relationships of a novel class of oncotherapeutic drugs –
ecdysteroid dioxolanes as MDR modulators. Ecdysteroids are the molting hormones
of insects, and they have nonsteroidal activity in mammals. However, they have been
found to have an effect on certain derivatives on the ABCB1 transporter mediated
multidrug resistance (MDR) of a transfected murine leukemia cell line. The following
study focused on the apolar dioxolane derivatives of 20-hydroxyecdysone.

Synthesis and Structure-Activity Relationships of
Novel 
Ecdysteroid Dioxolanes as MDR Modulators in Cancer

Ana Martins 1,2,†,*, József Csábi 3,†, Attila Balázs 4, Diána Kitka 1,
Leonard Amaral 5, József Molnár 1, András Simon 6, Gábor Tóth 6
and Attila Hunyadi 3,*

1 Department of Medical Microbiology and Immunobiology,
University of Szeged, Szeged Hungary;
2 Unidade de Parasitologia e Microbiologia Médica, Institute of
Hygiene and Tropical Medicine, Universidade Nova de Lisboa,
Lisbon, Portugal
3 Institute of Pharmacognosy, Faculty of Pharmacy, University
of Szeged, Szeged, Hungary;
Ubichem Research Ltd., Budapest, Hungary;
4 Center for Malaria and Other Tropical Diseases (CMDT),
Institute of Hygiene and Tropical Medicine, Universidade Nova
de Lisboa, Lisbon,
Portugal;
5 Department of Inorganic and Analytical Chemistry, Budapest
University of Technology and 
Economics, Budapest, Hungary;
*correspondence; E-Mails: martins.a@pharm.u-szeged.hu (A.M.);
hunyadi.a@pharm.u-szeged.hu (A.H.);

Molecules 2013, 18, 15255-15275;
 http://dx.doi.org/10.3390/molecules181215255

Keywords: 
ecdysteroids; 20-hydroxyecdysone; acetonide; dioxolane;
stereochemistry; cancer; multi-drug resistance;
P-glycoprotein; ABCB1 transporter; efflux pump

Abstract:
Ecdysteroids, molting hormones of insects, can exert several mild, 

  • non-hormonal bioactivities in mammals,

including humans. In a previous study, we found a significant effect of 

  • derivatives on the ABCB1 transporter mediated multi-drug resistance

of a transfected murine leukemia cell line. In this paper, we present

  • a structure-activity relationship study of the apolar dioxolane
    derivatives of 20-hydroxyecdysone.

Semi-synthesis and bioactivity of a total of 32 ecdysteroids,
including 20 new compounds, is presented
, supplemented

  • with their complete 1H- and 13C-NMR signal assignment.

1. Introduction

Ecdysteroids represent a large family of steroid hormones that play a crucial role in
arthropods’physiology. The most abundant representative of these compounds,

  • 20-hydroxyecdysone (20E), regulates
    • the reproduction,
    • embryogenesis,
    • diapause and
    • molting of arthropods [1].

Their role in plants is still to be fully understood, but it had been suggested that
they have importance in

  • several plants as defensive agents against non-adapted herbivores [2].

An estimated 5%–6% of the terrestrial plant species

  • accumulate detectable levels of ecdysteroids, among which
    • Ajuga, Serratula and Silene spp.,
  • containing high amounts of these compounds, are
    • good sources of  ecdysteroids of herbal origin [3].

Ecdysteroids generally retain the cholesterol-originated side-chain, typically

  • contain 27–29 carbon atoms and
    • are substituted with 4–8 hydroxyl groups.
  • their A/B ring junction is usually cis, and
    • a characteristic 7-en-6-one

(α,β-unsaturated ketone) chromophore group is present in their B-ring [4].

Due to their significantly different structure as compared to the
vertebrate steroid hormones, these compounds

  • have no hormonal effects in humans [5].

On the other hand, a number of beneficial 

  • metabolic effects are attributed to them [4–6], which has
  • encouraged the production and worldwide marketing of food supplements,
  • mainly containing the isolated ecdysteroid compound 20E [6].

In our recent studies, we found that certain ecdysteroid derivatives significantly

  • decrease the resistance of a multi-drug resistant (MDR) murine leukemia cell line
  • expressing the human ABCB1 transporter to doxorubicin,
    • a chemotherapeutic agent and a
    • substrate of the ABCB1 transporter, and

we discussed the possible mechanisms that might be involved in this activity [7].
Based on the observed structure-activity relationships 

  • of the isolated and semi-synthesized ecdysteroids, 
  • 20-hydroxyecdysone 2,3;20,22-diacetonide (1)
was chosen as the most promising lead. Although 
  • the acetonide moiety is generally utilized as
  • a protecting group for vicinal diols
    (which needs a strong acidic environment for removal),
  • and it is also an important structural element of certain drugs, 

such as triamcinolone acetonide (

not a pro-drug for triamcinolone but

has),
having

different pharmacological and pharmacokinetical properties [8].
Based on our previous work,

we have synthesized

  • additional dioxolane derivatives and
  • thoroughly discussed their structure elucidation and stereochemistry [9].
In 

the study reported herein we present the

  • synthesis,
  • structure and
  • MDR-modulating activity

of 32  ecdysteroid dioxolanes, including 20 new derivatives, and

  • provide insights on
    • their structure-activity relationships 

2. Results and Discussion

2.1. Semi-Synthesis

Having a common protecting group of vicinal diols, the acetonide,

  • 32 compounds containing one or two dioxolane rings were
  • synthesized from 20-hydroxyecysone
  • with various aldehydes and ketones
    • in the presence of phosphomolybdic acid.

A summary of the reactions performed and their product structures are presented
in Figure 1.

Figure 1. Semi-synthetic transformations of 20E
and structures of the products obtained.

Substituents of the reagent oxo-compound (X1/X2 and X3/X4) 

  • typically correspond to R1/R2 and R2/R3respectively, 

except for compounds 18 and 19, where the reagent was methyl-ethyl ketone. C-15
was obtained as a side product in the synthesis of 23.
1H- and 13C-NMR data of the
new compounds 
are presented in Tables 1–3.  To facilitate the comparison between

  • the NMR signals of structurally analogous hydrogen and carbon atoms
    • in the different dioxolane compounds,

we applied a special numbering system

  • for the central atoms (C-28 and C-29) of
    • the 2,3- and 20,22-dioxolane structures.

Compounds containing similar number of carbon atoms are presented
in one table, and

  • compounds with the highest structural similarity are presented
    in neighbouring columns.
Martins + Amaral molecules-18-15255  MDR modulators in tumor cells  Fig 1
Table 1. 1H- and 13C-NMR shifts of compounds 4, 6, 22, 30, 33, 9 and 10; in ppm, in methanol-d4.
(go to source)
Table 2. 1H- and 13C-NMR shifts of compounds 16–20 and 26–27; in ppm, in methanol-d4.
(go to source)
Table 3. 1H- and 13C-NMR shifts of compounds 11–14; 31 and 32; in ppm, in methanol-d4.
(go to source)

As published before [9], the 20,22-diol moiety of 20E 

  • is more reactive than the 2,3-diol, probably
  • due tothe free rotation of the 20,22-bond of 20E that
  • allows the 20,22-dioxolane ring to form with less strain.

This allowed us to selectively obtain the 20,22-mono-dioxolane derivatives 2–14,
or, depending on the amount of reagent and the reaction time, the

  • 2,3;20,22-bis-homo-dioxolanes 17 and 21–25.

By utilizing the 20,22-monodioxolane ecdysteroids, another aldehyde or ketone

  • could be coupled to position 2,3, resulting in  
  • several bis-hetero-dioxolane derivatives 26–33

For this, however,  gradually decreasing reactivity with the increase of 

  • the size of the reagent was a limiting factor: larger aldehydes or ketones
    (mainly those containing a substituted aromatic ring) 
  • could not be coupled at the 2,3-position

The 2,3-monodioxolane derivatives also appeared to be present 

  • as minor side-products of the reactions,

and as a consequence of their low amount, only one such compound (C-15) was isolated
and studied. 
To selectively obtain this kind of a compound (16) in a more reasonable
yield, another, 
three-step approach was successfully applied:

  1. after protecting the 20,22-diol with phenylboronic acid,
  2. the 2,3-acetonide could be prepared, and
  3. removal of the 20,22 protecting group

afforded the desired 2,3-monoacetonide in a one-pot procedure.

In the case of the reactions with aldehydes or asymmetric ketones, the new

  • C-28 and C-29 central atoms of the  dioxolane rings  are stereogenic centers
  • two possible diastereomers can be formed at both diols.

Their configuration was elucidated by

  • two-dimensional ROESY or
  • selective one-dimensional ROESY experiments,

e.g., in the doubly substituted dioxolane derivative 22
(R1 = R4 = n-Bu, R2 = R3 = H) the unambiguous differentiation of the

  • 1H and 13C signals of the two n-butyl groups 

was achieved in the following way (see Figure 2).

Figure 2. Stereostructure of 22. 

Martins + Amaral molecules-18-15255  MDR modulators in tumor cells  Fig. 3_page_007

Red arrows indicate the detected ROESY steric proximities, the blue numbers
give the characteristic 1H, and the black numbers the 13C chemical shifts.

Assignment of the H-C(28) atoms (δ = 4.93/105.9 ppm) was supported by

  • the H-2/C-28 and H-3/C-28 HMBC correlations, and
  • that of H-C(29) (δ = 4.91/105.6 ppm) by the H-22/C-29 cross peak

The selective  ROESY experiment irradiating at 4.93 ppm

  • showed contacts with the Hα-2 and Hα-3 atoms 
  • proving the α position of the R2 = H atom. 

The ROESY response obtained irradiating H = R3 signal (δ = 4.91) on H-22 (δ = 3.64 ppm) 

  • revealed their cis arrangement and the R configuration around C-29.
  • assignments of the signals of the two n-butyl groups R1 and R4  

    • were achieved by selective TOCSY experiments
      (irradiation at δ = 4.93 and 4.91, respectively).

In case of the C-28-epimers, typically an approximately 1:1 yield was obtained, and a good
separation was  achieved by simple  chromatographic  methods (see below). On the other hand,
possibly due to steric reasons,

  • the longer chain of the reagent was highly selective in the α-position
    • in the 20,22-dioxolane moiety.

This selectivity was, however, decreased in cases

  • when larger moieties were present in the reagent,

such as substituted aromatic rings, resulting in the appearance of the other epimers
These epimer pairs (compounds 11-12 and 13-14) required high-performance liquid
chromatography (HPLC) for their successful separation. C-10  was isolated by HPLC
as a minor product from the preparation of C-9; this compound, considering

  • the vicinal coupling constant of the olefinic hydrogen atoms
    (J = 11.8 Hz) contains a Z double bond,

and most likely originated from an impurity in the trans-cinnamic aldehyde reagent used.
C-18 and C-19  were the only cases where one of the dioxolane rings was formed with

  • the elimination of ethanol instead of water, losing an 
  • ethyl group from the reagent methyl ethyl ketone.
2.2. Anti-Proliferative Effect of Ecdysteroid Derivatives on
PAR and MDR Mouse Lymphoma Cells 

The anti-proliferative activity of the derivatives was determined by

  • incubation of each of the cell lines with
      • serial dilutions of  the  compounds.

Inhibitory concentrations (IC50) were calculated and are presented in Table 4.

Table 4. IC50 values of the ecdysteroid derivatives and fluorescence activity ratio (FAR)

values determined in presence of 2 and 20 μM of compound. IC50—inhibitory concentration
(concentration of compound that inhibits 50% of cell growth); IC50 values are presented as
the average of 3 independent experiments ± the standard error of the mean (SEM);
*— the compound showed cytotoxicity at this concentration and it was not possible to
calculate the FAR value; FAR values of the positive control verapamil (20.4 μM) and the negative
control DMSO (0.2%) were 5.73 and 0.72, respectively.

As seen from the table, several compounds

  • exert much lower anti-proliferative activity on the MDR cell line
    as  compared to the parental one,

while other compounds show similar activities on both cell lines.

2.3. Inhibition of the ABCB1 Pump of MDR Mouse Lymphoma Cells
(Rhodamine 123 Accumulation Assay)

Accumulation of rhodamine 123 by MDR mouse lymphoma cells
was evaluated by flow cytometry
 

  • in the presence of the newly described compounds
  • in order to study their capacity to inhibit the ABCB1 pump and
  • therefore prevent the efflux of the dye,

which was consequentially retained inside the MDR cell.
Parental mouse lymphoma cells were used as control 

  • for dye retention inside the cell 
  • while MDR cells alone do not retain rhodamine 123 at
    the concentration employed

The efflux pump inhibitor (EPI) verapamil was used as positive control.
All the 
compounds were dissolved in DMSO, which was also evaluated for 

  • any effect on the retention of the fluorochrome.

DMSO concentration in the assay was 0.2%. For each compound, 

  • the fluorescence activity ratio (FAR), which measures
  • the  amount of rhodamine 123 accumulated by the cell 
  • in presence of the compound was calculated as follows:

FAR = (FLMDRtreated/FLMDRuntreated)/(FLPARtreated/FLPARuntreated) (1)

where FL is the mean of the fluorescence. The obtained results are shown by Table 4.

Martins + Amaral molecules-18-15255  MDR modulators in tumor cells  Table 4_page_009

As seen from the table, the compounds

  • showed marked differences according to their capacity to inhibit the efflux of rhodamine 123 in this bioassay:

from the practically inactive (compounds 5, 7, 9, 10, 12 and 20) to the very strong (compounds 6, 8, 14 and 25),
various activities were observed.
Most interestingly, these results did not always conform to those obtained from the combination studies, for example,
no significant differences can be observed

  • between the combination indices of compounds 20 and 25, and
  • compound 3, very weak in this assay, was able to act in a rather significant synergism with doxorubicin (see below). 

These observations seem to support our initial theory, that 

  • these compounds are not or not exclusively acting as EPIs

but other mechanisms may also be involved in their activity [7].2.4. Combination Studies: Effect of Ecdysteroid Derivatives on the Activity of Doxorubicin on MDR Mouse Lymphoma Cells

Effect of the newly synthesized derivatives was evaluated on checkerboard 96-cell plates with different concentrations of
doxorubicin and compound after  48 h of  incubation of the cells, similarly to our previous approach [7]. Combination
indices for the  different constant ratios of  compound vs.doxorubicin were determined by using the CompuSyn software  to plot four to five data points to each ratio. CI values were calculated by means of the median-effect equation [10], where

CI < 1, CI = 1, and CI > 1  represent

  1. synergism,
  2. additive effect (i.e., no interaction), and
  3. antagonism, respectively.

The CI values are presented on Table 5. Combination index plots (or Fa-CI plots, where Fa is the fraction affected) were
also generated for each compound using serial deletion analysis in order to determine variability of the data [10]. An example
of Fa-CI plot is given by Figure 3 for compounds 1, 5 and 15.

Figure 3. Fraction affected (Fa) vs. combination index (CI) value plot for compounds 5 and 15, in comparison with the original lead compound 1. 

Martins + Amaral molecules-18-15255  MDR modulators in tumor cells  Fig 3

Table 5. 

Combination index (CI) values at different drug ratios (compound vs. doxorubicin, respectively) at 50, 75 and 90% of growth inhibition (ED50, ED75
and ED90, respectively); CIavg— weighted average CI value; CIavg = (CI50 + 2CI75 + 3CI90)/6. CI < 1, CI = 1, and CI > 1 represent

  • synergism,
  • additivity, and
  • antagonism, respectively.

Dm, m, and r represent antilog of the x-intercept, slope, and

  •  linear correlation coefficient of the median-effect plot, respectively.

As seen from Table 5, all compounds acted synergistically with doxorubicin and their behavior followed our previous observation,

Error bars represent 95% confidence intervals by means of serial deletion analysis performed with the CompuSyn software.
The 2,3-mono-dioxolane derivative 15 represents significantly

  • stronger synergism with doxorubicin than the corresponding 20,22-dioxolane derivative 5 at practically all activity levels,  and above Fa = 0.7 (which, in case of cancer, matters the most [10])
  • it is also stronger than compound 1.  
    • in case of all ecdysteroids there seems to be an “ideal” compound vs. doxorubicin ratio 
      • where the strongest synergistic effect occurs. 

Based on the variability of the mono-, homo-di- and hetero-di-substituted compounds, as well as

  • that of the coupled substituents at R1–R4, several novel structure-activity relationships (SARs) were observed.

According to this, we followed our previous approach [7]—for each compound, the strongest activity by

  • means of the weighted average CI values was primarily considered for comparison,

regardless of the  compound vs. doxorubicin ratio where this activity was found.

  1. the 2,3-dioxolane moiety is far more important for a strong activity, than the one at  positions 20,22.  compound 15, monosubstituted at position 2,3, was the only ecdysteroid derivative that was able to exert a stronger activity at its best ratio than our original lead, the diacetonide
    compound 1 (Figure 3). 
  2. A very interesting SAR was revealed by comparing the activity of the C-28 and C-29 epimer pairs:
    at C-28, the larger substituent needs to take the α‐position 
    (24 vs. 25), while at C-29 the β-position
    for a stronger activity (cf. 11 vs. 12 and 13 vs. 14). 
  3. As concerns the 20,22-monodioxolanes, increasing the length of the side chains coupled to C-29 lead to a significant increase in the synergistic activity with doxorubicin 

till the length  of three carbon  atoms  (compound 3), however a longer alkyl substituent (compound 4) 

appeared to be less preferable. Introducing larger aromatic groups did not lead to a breakthrough, although  further substituents on the aromatic ring (compounds 11, 13) were able to increase activity as compared to the
case when a non-substituted phenyl group was present (compound 7).
Addition of a β-methyl group to C-29 could significantly improve the activity as compared to that of

  • the 29α-phenyl substituted derivative  (cf. 8 vs. 7, respectively).

The observed structure-activity relationships are summarized in Figure 4.

Figure 4. SAR summary for compounds 1–33.

Martins + Amaral molecules-18-15255  MDR modulators in tumor cells  Fig. 2

“Greater than” symbols denote stronger synergistic activities, i.e., lower weighted average CI values
when applied together with doxorubicin.

3. Experimental

3.1 General Information

The starting material 20E (90%, originated from the roots of Cyanotis arachnoidea) was purchased
from Shaanxi KingSci Biotechnology Co., Ltd. (Shanghai, China), and further purified by crystallization
from ethyl acetate–methanol (2:1, v/v), so that purity of 20E utilized for the semi-syntheses was 97.8%,
by means of HPLC-DAD, maximum absorbance within the range of 220–400 nm. Mono- and disubstituted
ecdysteroid  dioxolanes were synthesized as published before [9]. Briefly, the starting compound was
reacted with the aldehyde  or ketone  to be coupled to positions 20,22 and/or 2,3 in the presence of
phosphomolybdic acid (Lach-Ner, Neratovice, Czech Republic) at room temp. for 5–60 min depending  on the target compound. The reaction was terminated by neutralizing the pH with a 5% aqueous solution  of NaHCO3 (Merck, Munich, Germany), methanol was evaporated until only water was present, and the
product(s) were extracted with methylene chloride. Column chromatography (CC), rotational planar
chromatography (RPC) and/or crystallization was used for purification, as detailed below. Solvent system
compositions are given in v/v%. For RPC, a Chromatotron device  (Harrison Research, Palo Alto)
was used.  The separation was monitored with thin layer chromatography (TLC) on silica gel 60 F254
(0.25 μm, Merck). HPLC purification of compounds 9–14 was performed on a gradient system of two
Jasco PU2080 pumps connected to a Jasco MD-2010 Plus photodiode – array detector, on a Zorbax
XDB-C8 column (5 μm, 9.6 × 250 mm) at a flow rate of 3 mL/min. Mass spectra were recorded on an
API 2000 triple quadrupole tandem mass spectrometer (AB SCIEX, Foster City, CA) in positive mode with
atmospheric pressure chemical ionization  (APCI) ion source except for compound 29 which was measured
with electron-spray ionization (ESI). 1H- (500.1) and 13C- (125.6) MHz 
NMR spectra were recorded at  room temperature on an Avance 500 spectrometer (Bruker, Billerica, MA). For the examples of compounds
 3, 5, 7, 8, 15, 21, 23–25, 28 and 29, structure elucidation of ecdysteroid dioxolanes by comprehensive one-
and two-dimensional NMR methods 
has recently been discussed in detail elsewhere, including experimental
details for the aforementioned compounds [9]. Regarding the new compounds, amounts of approximately
1–10 mg were dissolved in 0.1 mL of methanol-d4 and transferred to a 2.5 mm Bruker MATCH NMR sample
tube. Chemical shifts are given on the δ-scale and are referenced to the solvent (MeOH-d4: δC = 49.1 and δH =
3.31 ppm).  Pulse programs of all experiments (1H, 13C, DEPTQ, DEPT-135, sel-TOCSY, sel-ROE, sel-NOE,
gradient-selected (gs) 1H, 1H-COSY, edited gs-HSQC, gs-HMBC, ROESY) were taken from the Bruker software
library.  Most 1H assignments were accomplished  using general knowledge of chemical shift dispersion with
the aid of the proton-proton coupling pattern (1H-NMR spectra).

3.2. Semi-Synthesis and Purification of Monosubstituted Ecdysteroid Dioxolane Derivatives 2–16

20E was dissolved in methanol (10 mL, Merck) to a final concentration of 100 mM or 25 mM in case of compounds
9, 10, 13, 14, and the corresponding reagent (3: butyraldehyde, 4: valeraldehyde, 5: 3-pentanone, 6: methyl isobutyl
ketone, 10 equivalents each; 7: benzaldehyde,  5 g; 8: acetophenone, 6 g; 9, 10: cinnamaldehyde, 11, 12: vanillin, 13, 14:
4-benzyloxybenzaldehyde, 10 equivalents each; 15: 3-pentanone, 100 equivalents; (compound 15 was obtained from the
synthesis of 25, see below) was added to the solution.  Phosphomolybdic acid (1.00 g) was added (except in the  case  of  the synthesis of 9 and 10, when 0.50 g were added) and the mixture was stirred at room temp. for 10 min (except for  7: 5 min, 8: 60 min, 15: 30 min). In the case of compound 16, 20E was dissolved in methanol (10 mL) to a final
concentration  of 100 mM, and after adding phenylboronic acid (1 equivalent), the mixture was stirred for 30 min.
Acetone (500 equivalents) and phoshomolybdic acid (0.5 g) were added to the mixture, and after 1 h stirring a solution
of NaOH and H2O2 was added in order to remove the phenyl-boronate group. Then, the reaction was worked up as
described above. Compounds 3, 4, 7, 8, a mixture of 9-10, and compounds 15 and 16 were obtained from RPC on silica
gel with appropriate solvent systems of ethyl acetate-ethanol-water (3, 4) or cyclohexane-ethyl acetate (7, 8, 9-10, 15, 16).
The purification of compounds 11-12 and 13-14 started with CC by using solvent systems of ethyl acetate-ethanol-water.
Isomer pairs 9-10, 11-12 and 13-14 were isolated by RP-HPLC (9, 10: 75% CH3OH aq., 3 mL/min; 11, 12: 70% CH3OH
aq., 3 mL/min;  13, 14: 80%  CH3OH aq., 3 mL/min). Compounds 2, 5 and 6 were recrystallized from acetonitrile without
chromatographic purification. The yields were:
2 (236.6 mg, 45.43%), 3 (116.2 mg, 21.7%), 4 (142.8 mg, 26.0%), 5 (183.5 mg, 33.4%), 6 (71.9 mg, 25.2%), 7 (292.5 mg, 51.4%),
8 (196.8 mg, 33.8%), 9 (27.0 mg, 18.5%), 10 (13.9 mg, 9.4%), 11 (156.3 mg, 25.4%), 12 (67.0 mg, 10.9%), 13 (67.3 mg, 39.9%),
14 (33.7 mg, 20.0%), 15 (27.4 mg, 5.0%), 16 (13.3 mg, 10.2%).

3.3. Semi-Synthesis and Purification of Disubstituted Ecdysteroid Derivatives 17–25 in One-Step

20E (17–20: 200 mg; 21–25: 480 mg) was dissolved in methyl-ethyl ketone (20 mL, compounds 17–20) or methanol (10 mL)
and the reagent was added to the solution  (21: butyraldehyde, 100 equivalents, 22: valeraldehyde, 100 equivalents, 23: 3-pentanone,
100 equivalents, 24, 25: benzaldehyde, 5 g).  Phosphomolybdic acid was added (17–20: 20 mg; 21–25: 0.50 g), and the mixture was
stirred at room temperature for 5 (17–20, 24–25) or 30 (21–23) min. The reactions were worked up as described above, and the
products were isolated by RPC using the appropriate n-hexane-acetone (17–20) or cyclohexane-ethyl acetate-ethanol (21–25) solvent
systems. As a side-product of the reaction of 20E with methyl ethyl ketone, 20 was obtained as a 20,22-onodioxolane derivative. The
yields were:
17 (15.5 mg, 6.3%), 18 (4.9 mg, 2.1%), 19  (8.4 mg, 3.6%),  20 (4.46 mg, 2.0%) 21 (242.4 mg, 41.2%), 22 (134.5 mg, 21.8%),
23 (42.3 mg, 6.9%), 24 (36.1 mg, 5.5%), 25 (43.8 mg, 6.7%).

3.4. Semi-Synthesis and Purification of Disubstituted Ecdysteroid Derivatives 26–33 in Two-Steps

Previously obtained 20,22-monosubstituted compounds (2, 20.7 mg; 3, 40.0 mg; 5, 40.7 mg; 6, 50.0 mg; 7, 57.0 mg; 8, 87.3 mg; 2, 104.0 mg)
were dissolved in methyl ethyl ketone (2 mL, 26 and 27) or in methanol (5 mL) and the reagent (28–32: acetone, 500 equivalents; 33: butyraldehyde,
500 equivalents) was added to the solution. Phosphomolybdic acid (26, 27: 20 mg; 28–32: 0.5 g) was added to the solution, and the mixture was
stirred at room  temperature for 5 (26, 27) or 60 (28–33) min. The reactions were terminated and the products were purified as described above for
the disubstituted derivatives. The yields were: 26 (5.1 mg, 23.1%), 27 (5.1 mg, 23.1%), 28 (10.9 mg, 25.4%), 29 (15.8 mg, 36.2%), 30 (15.5 mg, 28.9%),
31 (24.8 mg, 40.6%), 32 (38.7 mg, 41.5%), 33 (53.0 mg, 46.2%).

3.5. Further Experimental Data for the New Compounds

(see Archival supplement)

3.6. Preparation of the Compounds for the Bioassays

Each compound was dissolved in 99.5% DMSO (Sigma, Munich, Germany). In each protocol DMSO was always tested
as solvent control and no activity was observed.

3.7. Cell Lines

Two mouse lymphoma cell lines were used in this work: a parental (PAR) cell line, L5178 mouse T-cell lymphoma cells (ECACC
catalog no.87111908,  U.S. FDA, Silver Spring, MD); and a multi-drug resistant (MDR) cell line derived from PAR by transfection
with pHa  MDR1/A  retrovirus [11]. MDR cell line was selected by culturing the infected cells with 60 μg/L colchicine. Both cell
lines were cultured in McCoy’s 5A  medium supplemented with 10% heat inactivated horse serum, L-glutamine, and antibiotics
(penicillin and streptomycin) at 37 °C and 5% CO2 atmosphere [12].

Medium, horse serum, and antibiotics were purchased from Difco (Detroit, MI).

3.8. Anti-proliferative Assay

Anti-proliferative activities on PAR and MDR cell lines were performed as described before [7].  Briefly, 6 × 103 cells/well were
incubated with serial dilutions of each compound (n = 3) in McCoy’s 5 A medium for 72 h at 37 °C, 5% CO2. Then, MTT (Sigma) [13]
was added to  each well  at  a final concentration of 0.5 mg/mL per well) and after 4 h of incubation, 100 μL of SDS 10% (Sigma) in
0.01 M HCl was added to each well. Plates were further incubated overnight and optical density at 540 and 630 nm using an ELISA
reader (Multiskan EX, Thermo Labsystem, Milford, MA). Fifty percent inhibitory concentrations (IC50) were calculated using non-linear regression curve fitting of log(inhibitor) vs. response and variable slope  with a least squares (ordinary) fit of GraphPad Prism 5
software (GraphPad Software, San Diego, CA,).

3.9. Inhibition of ABCB1 Pump of MDR Mouse Lymphoma Cells (Rhodamine 123 Accumulation Assay)

Inhibition of ABCB1 was evaluated using rhodamine 123, a fluorescent dye, which retention inside the cells was evaluated by flow cytometry (14).
Briefly, 2 × 106 cells/mL were treated with 2 and 20 μM of each compound. After 10 min incubation, rhodamine 123 (Sigma) was added to a final
concentration of 5.2 μM and the samples were incubated at 37 °C in water bath for 20 min. Samples were centrifuged (2,000 rpm, 2 min) and washed
twice with phosphate buffer saline (PBS, Sigma). The final samples were re-suspended in 0.5 mL PBS and its fluorescence measured with a  Partec  CyFlow flow cytometer (Partec, Münster, Germany). Verapamil (Sanofi-Synthelabo, Budapest, Hungary) at 20.4 μM was used as positive control.

3.10. Combination Assays

The combined activity of doxorubicin (Teva, Budapest, Hungary) and the ecdysteroids was determined using the checkerboard microplate method, as
described before [7]. Briefly, 5 × 104 cells/well were incubated with doxorubicin and the compound to be tested for 48 h at 37 °C under 5% CO2. Cell
viability rate was determined through MTT staining, as described above. The interaction was evaluated using the CompuSyn software (CompuSyn Inc.,
Paramus, NJ) at each constant ratio of compound vs. doxorubicin (M/M), and combination index (CI) values were obtained for 50%, 75%, and 90% of
growth inhibition.

4. Conclusions

In the present study, we have prepared 32 semi-synthetic derivatives of 20-hydroxy- ecdysone,following our previously observed structure-activity  relationships on the strong synergistic activity of ecdysteroid dioxolanes with doxorubicin on a murine MDR cancer cell line expressing the human ABCB1
transporter. By utilizing the different reactivity of the 2,3 and 20,22 vicinal diol moieties, various bis-homo- and bis-hetero-dioxolanes were synthesized,
as well as  several 20,22- and two 2,3-monodioxolane derivatives. In addition to these, two epimer pairs were also obtained.  Twenty compounds are reported  for the first time; their chemical structures were thoroughly investigated by comprehensive 1 and 2D-NMR methods, based on which complete signal
assignments are provided.  The compounds showed mild to very strong synergistic effects with doxorubicin  against the aforementioned MDR cancer cell  line, and the diversity of the substituents allowed us to observe several new structure-activity relationships. Among these, the importance of the 2,3-dioxolane substitution and the observations concerning the role of stereochemistry at C-28 and C-29 are the most interesting results. Apparently, ecdysteroids can be engineered to become strong MDR modulators only by decreasing the polarity at the A-ring, while the polar side-chain can be kept, providing the  possibility for designing such compounds with a reasonable water solubility and high drug-likeness.

Considering the high importance of the 2,3-dioxolane group in our compounds and the fact that exactly this part is the most sensitive to an  acidic environment,
per os application of these compounds requires an appropriate formulation; development of such delivery systems is currently in process,  investigation on their  activity against MDR cancer xenografts is going to be reported in the near future.

Acknowledgments

The authors acknowledge the support from the European Union co-funded by the European Social Fund (TÁMOP 4.2.2/B-10/1-2010-0012,
TÁMOP 4.2.2.A-11/1/KONV-2012-0035) and the Fundação para a Ciência e a Tecnologia (FCT), Portugal (PEsT-OE/SAU/UI0074/2011).  A. Martins was supported by the grant SFRH/BPD/81118/2011, FCT, Portugal. The work presented here was performed within the framework
of COST Action CM1106, Chemical Approaches to Targeting Drug Resistance in Cancer Stem Cells. The authors thank Nikoletta Jedlinszki for
the mass spectroscopic measurements, Imre Ocsovszki, supported by the grant TÁMOP-4.2.1/B-09/KONV-2010-0005, for the flow cytometry  measurements and Ibolya Hevérné Herke for the semi-synthetic preparation and purification of compounds 17–20.

The authors declare no conflict of interest.

References

1. Karlson, P. Mode of Action of Ecdysones. In Invertebrate Endocrinology and Hormonal Heterophylly; Burdette, W.B., Ed.; Springer:
Berlin/Heidelberg, Germany, 1974; pp. 43–54.

2. Zeleny, J.; Havelka, J.; Sláma, K. Hormonally mediated insect-plant relationships: Arthropod populations associated with ecdysteroid-containing plant, Leuzea carthamoides (Asteraceae). Eur J. Entomol. 1997, 94, 183–198.

3. Dinan, L. A strategy for the identification of ecdysteroid receptor agonists and antagonists from plants. Eur. J. Entomol. 1995, 92, 271–283.

4. Tóth, N.; Hunyadi, A.; Báthori, M.; Zádor, E. Phytoecdysteroids and vitamin D analogues—Similarities in structure and mode of action.
Curr. Med. Chem. 2010, 17, 1974–1994.

5. Báthori, M.; Tóth, N.; Hunyadi, A.; Márki, Á.; Zádor, E. Phytoecdysteroids and anabolic- androgenic steroids. Structure and
effects on humans.  Curr. Med. Chem. 2008, 15, 75–91.

6. Dinan, L. The Karlson lecture. Phytoecdysteroids: What use are they? Arch. Arch. Insect Biochem. Physiol. 2009, 72, 126–141.

7. Martins, A.; Tóth, N.; Ványolós, A.; Béni, Z.; Zupkó, I.; Molnár, J.; Báthori, M.; Hunyadi, A. Significant activity of ecdysteroids on
the resistance to doxorubicin in mammalian cancer cells expressing the human ABCB1 transporter J. Med. Chem. 2012, 55, 5034–5043.

8. Möllmann, H.; Rohdewald, P.; Schmidt, E.W.; Salomon, V.; Derendorf, H. Pharmacokinetics of triamcinolone acetonide and its
phosphate ester. Eur. J. Clin. Pharmacol. 1985, 29, 85–89.

9. Balázs, A.; Hunyadi, A.; Csábi, J.; Jedlinszki, N.; Martins, A.; Simon, A.; Tóth, G. 1H- and 13C-NMR investigation of 20-hydroxyecdysone
dioxolane  derivatives, a novel group of MDR modulator agents. Magn. Reson. Chem. 2013, 51, 830−836.

10. Chou, T.-C. Theoretical basis, experimental design, and computerized simulation of synergism and antagonism in drug combination studies.
Pharmacol. Rev. 2006, 58, 621−681.

11. Pastan, I.; Gottesman, M.M.; Ueda, K.; Lovelace, E.; Rutherford, A.V.; Willingham, M.C. A retrovirus carrying an MDR1 cDNA confers
multidrug resistance and polarized expression of P-glycoprotein in MDCK cells. Proc. Natl. Acad. Sci. USA 1988, 85, 4486−4490.

12. Choi, K.; Frommel, T.O.; Stern, R.K.; Perez, C.F.; Kriegler, M.; Tsuruo, T.; Roninson, I.B. Multidrug resistance after retroviral transfer of
the human MDR1 gene correlates with P-glycoprotein density in the plasma membrane and is not affected by cytotoxic selection.

13. Proc. Natl. Acad. Sci. USA 1991, 88, 7386−7390. 13. Mosmann, T. Rapid colorimetric assay for cellular growth and survival: Application to
proliferation and cytotoxicity assays. J. Immunol. Methods 1983, 65, 55−63.

Sample Availability: Samples of the compounds 1–33 are available from the authors.
© 2013 by the authors; licensee MDPI, Basel, Switzerland. This article is an open access article

Archival Supplement

29α-Butyl-20,22-O-methylidene-20-hydroxyecdysone (4): white needle-like crystals; mp 197–199 °C; for 1H- and 13C-NMR data, see
Table 1; APCI-MS, m/z (Irel, %): 549 [M+H]+, 531 [M+H-H2O]+, 445, 427, 409.

29α-I-butyl-29β-methyl-20,22-O-methylidene-20-hydroxyecdysone (6): white needle-like crystals; mp 198–199 °C; for 1H- and 13C-NMR
data, see Table 1; APCI-MS, m/z (Irel, %): 563 [M+H]+, 545 [M+H-H2O]+, 445, 427, 409.

29α-E-ethenylbenzyl-20,22-O-methylidene-20-hydroxyecdysone (9): white solid; mp. 161–163 °C; for 1H- and 13C-NMR data, see Table 1,
in addition to this, the vicinal coupling constant of the olefinic hydrogen atoms (J = 16.0 Hz) proved the E configuration of the double bond;
APCI-MS, m/z (Irel, %): 595 [M+H]+, 577 [M+H-H2O]+, 445, 427, 409.

29α-Z-ethenylbenzyl-20,22-O-methylidene-20-hydroxyecdysone (10): white solid; mp 138–140 °C; for 1H- and 13C-NMR data, see
Table 1; APCI-MS, m/z (Irel, %): 595 [M+H]+, 577 [M+H-H2O]+, 445, 427, 409.

29α-(3-Methoxy-4-hydroxyphenyl)-20,22-O-methylidene-20-hydroxyecdysone (11): white solid; mp 163–165 °C; for 1H- and 13C-NMR
data, see Table 3; APCI-MS, m/z (Irel, %): 615 [M+H]+, 597 [M+H-H2O]+, 445, 427, 409.

29β-(3-Methoxy-4-hydroxyphenyl)-20,22-O-methylidene-20-hydroxyecdysone (12): white solid; mp 157–159 °C; for 1H- and 13C-NMR
data, see Table 3; APCI-MS, m/z (Irel, %): 615 [M+H]+, 597 [M+H-H2O]+, 445, 427, 409.

29α-(4-Benzyloxyphenyl)-20,22-O-methylidene-20-hydroxyecdysone (13): white solid; mp 144–146 °C; for 1H- and 13C-NMR data, see
Table 3; APCI-MS, m/z (Irel, %): 675 [M+H]+, 445, 427, 409.

29β-(4-Benzyloxyphenyl)-20,22-O-methylidene-20-hydroxyecdysone (14): white solid; mp 139–141 °C; for 1H- and 13C-NMR data, see
Table 3; APCI-MS, m/z (Irel, %): 675 [M+H]+, 445, 427, 409.

20-Hydroxyecdysone 2,3-acetonide (16): white solid; mp 124–126 °C; for 1H- and 13C-NMR data, see Table 2; APCI-MS, m/z (Irel, %):
553 [M+H+MeOH]+, 535, 503, 485, 467, 409.

28α,29α-Diethyl-28β,29β-dimethyl-2,3;20,22-bis-O-methylidene-20-hydroxyecdysone (17): white solid; mp 98–100 °C; for 1H- and
13C-NMR data, see Table 2; APCI-MS, m/z (Irel, %): 589 [M+H]+, 571 [M+H-H2O]+, 499, 481, 409.

28α,29α-Dimethyl-28β-ethyl-2,3;20,22-bis-O-methylidene-20-hydroxyecdysone (18): white solid; mp 99–101 °C; for 1H- and 13C-
NMR data, see Table 2; APCI-MS, m/z (Irel, %): 561 [M+H]+, 543 [M+H-H2O]+, 499, 481, 409.

28β,29β-Dimethyl-29α-ethyl-2,3;20,22-bis-O-methylidene-20-hydroxyecdysone (19): white solid; mp 79–81 °C; for 1H- and 13C-
NMR data, see Table 2; APCI-MS, m/z (Irel, %): 561 [M+H]+, 543 [M+H-H2O]+, 471, 453, 409.

29α-Ethyl-29β-methyl-20,22-O-methylidene-20-hydroxyecdysone (20): white solid; mp 140–142 °C; for 1H- and 13C-NMR data, see
Table 2; APCI-MS, m/z (Irel, %): 535 [M+H]+, 517 [M+H-H2O]+, 445, 427, 409.

28β,29α-Dibutyl-2,3;20,22-bis-O-methylidene-20-hydroxyecdysone (22): transparent crystals; mp 186–187 °C; for 1H- and 13C-NMR
data, see Table 1; APCI-MS, m/z (Irel, %): 617 [M+H]+, 599 [M+H-H2O]+, 513, 495, 409.

28β,29,29-Trimethyl-2,3;20,22-bis-O-methylidene-20-hydroxyecdysone (26): white solid; mp 100–102 °C; for 1H- and 13C-NMR data,
see Table 2; APCI-MS, m/z (Irel, %): 547 [M+H]+, 517, 499, 467, 409.

28α,29,29-Trimethyl-28β-ethyl-2,3;20,22-bis-O-methylidene-20-hydroxyecdysone (27) white solid; mp 360–362 °C; for 1H- and 13C-
NMR data, see Table 2; APCI-MS, m/z (Irel, %): 575 [M+H]+, 557 [M+H-H2O]+, 499, 481, 409.

28,28,29β-Trimethyl-29α-i-buthyl-2,3;20,22-bis-O-methylidene-20-hydroxyecdysone (30): transparent solid; mp 114–115 °C; for 1H-
and 13C-NMR data, see Table 1; APCI-MS, m/z (Irel, %): 603 [M+H]+, 585 [M+H-H2O]+, 485, 467, 409.

28,28-Dimethyl-29α-phenyl-2,3;20,22-bis-O-methylidene-20-hydroxyecdysone (31): white solid; mp 114–117 °C; for 1H- and 13C-NMR
data, see Table 3; APCI-MS, m/z (Irel, %): 641 [M+H+MeOH]+, 623, 517, 485, 467, 409.

28,28,29β-Trimethyl-29α-phenyl-2,3;20,22-bis-O-methylidene-20-hydroxyecdysone (32): white solid; mp 126–128 °C; for 1H- and 13C-
NMR data, see Table 3; APCI-MS, m/z (Irel, %): 623 [M+H]+, 605 [M+H-H2O]+, 485, 467, 409.

28β-Propyl-29,29-dimethyl-2,3;20,22-bis-O-methylidene-20-hydroxyecdysone (33): transparent solid; mp 109–111 °C; for 1H- and 13C-
NMR data, see Table 1; APCI-MS, m/z (Irel, %): 575 [M+H]+, 557 [M+H-H2O]+, 499, 481.

Read Full Post »

2013 – Personal Perspectives on Revolutionizing Medicine and Top Stories in Cardiology

Reporter: Aviva Lev-Ari, PhD, RN

Article ID #94: 2013 as A Year of Revolutionizing Medicine and Top 11 Cardiology Stories. Published on 12/24/2013

WordCloud Image Produced by Adam Tubman

Topol Reviews 2013: A Year of Revolutionizing Medicine

 Medscape > Eric Topol on Medscape

Director, Scripps Translational Science Institute; Chief Academic Officer, Scripps Health; Professor of Genomics, The Scripps Research Institute, La Jolla, California; Editor-in-Chief, Medscape

Disclosure: Eric J. Topol, MD, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: AltheaDX; Biological Dynamics; Cypher Genomics (Co-founder); Dexcom; Genapsys; Gilead Sciences, Inc.; Portola Pharmaceuticals; Quest Diagnostics; Sotera Wireless; Volcano. Received research grant from: National Institutes of Health; Qualcomm Foundation

December 11, 2013

Practice Changers: Lab Innovations and Genetic Testing

It was almost a year ago that I signed on as Editor-in-Chief of Medscape, and I’m extremely grateful for the opportunity and for the extensive input so many of you have provided. In my last monthly newsletter for the year, I would like to expound on why I think this is the most exciting time ever in the history of medicine and how it will be imminently practice-changing.

Looking at the Laboratory

Let me first turn to laboratories, a big part of how we practice. We send our patients to the clinic or hospital lab, or a central facility, to get their blood drawn. Typically, multiple tubes of blood are obtained; the costs are not transparent; and perhaps even worse, the results are not easily or routinely accessible for most patients. Last month, I highlighted a new entity on the scene — Theranos — and interviewed Elizabeth Holmes, the young CEO.

Theranos will be in all Walgreens stores before long, leveraging microfluidic technology to do hundreds of assays with a droplet of blood, with a fully transparent cost list, and ultimately with results directly going to both the patient and doctor. After 60 years of unchanged laboratory medicine practice, this new, innovative model will help drive disruption — just the kind of shake-up that we have needed.

Second, while touching on labs, recently there has been a big flap between 23andMe, a direct-to-consumer genomics company, and the US Food and Drug Administration (FDA).[1]This was probably attributable to a prolonged lapse of communication on the part of the company, concurrent with aggressive marketing of the product. 23andMe has temporarily stopped providing health-related genetic testing, such as disease susceptibility, carrier state, and pharmacogenomics. Their intention is to work things out with the FDA and get their full $99 panel back up in the months ahead. Why is this an important issue? A Nature editorial[2] posited, “so even if regulators or doctors want to, they will not be able to stand between ordinary people and their DNA for very long.”

Genetic Tests and the “Angelina Effect”

In May of this year, Angelina Jolie published her “My Medical Choice” op-ed,[3] signaling her decision to not only get her BRCA 1,2 genes sequenced but to also undergo bilateral mastectomy.The impact of the so-called “Angelina effect” has been felt worldwide, with a large spike in BRCA testing driven by consumers, and challenges to prevailing cultural norms in places such as Israel, where there is a very high rate of pathogenic BRCA mutations but close to the lowest rate of preventive surgery.[4]

The issue at hand is the availability of genetic tests to patients, which didn’t exist before. Pregnant women can now, in their first trimester, have a single tube of blood drawn to screen for multiple chromosomal aberrations. Amniocentesis is quickly becoming a bygone procedure.[5] The power of genetic testing in practice is just starting to be felt and will be increasingly transformative in the years ahead.

Restructuring and Digitizing Medicine

The Out-of-Hospital Experience

Third, the structural icons of medicine are undergoing reassessment. What do we do with hospitals and clinics in a digital medicine world? George Halvorson, the outgoing CEO of Kaiser Permanente, has weighed in on this by saying that we should start delivering healthcare “farther and farther” from the hospital setting and “even out of doctors’ offices.”[6]

Cisco did a large consumer survey and found that over 70% of patients would prefer a virtual rather than a physical office visit.[7] A tweet that I put out in response to a Fast Company article[8] that said “the idea of going down to your doctor’s office is going to feel as foreign as going to the video store” attracted considerable attention.

Just this week, a large Intel poll of 12,000 consumers found that most believe that hospitals as we know them today will be “obsolete in the near future.”[9] The fact that we are even now questioning what to do with our hospitals and clinics is telling in itself and reflects the profound forthcoming changes in medicine.

Tracking the Human Body 

What Made Medical News in 2013?

Fourth and finally, the explosion of sensors is especially worth noting. This year, the FDA approval of smartphone ECGs and digitized pills heralded the beginning of many more novel digital ways that we will be tracking patients in the future. A watch that passively and continuously captures blood pressure from every heartbeat is just around the corner. We don’t even know what “normal” blood pressure is when it can be assessed 24/7, throughout the night, and during any time of stress, and this is representative of what the era of wireless sensor tracking will bring.

I hope that I have convinced you, with just a few examples, that this is an extraordinary time in medicine. We are all lucky to be a part of it, to see it go through its major reconfiguration and refinement. I will continue to post the links to anything that I think is particularly interesting on a daily basis via Twitter, and you are welcome to follow me @EricTopol.

Wishing you and your family all the best in the New Year. Despite some counterforces, let’s hope that 2014 takes medicine to new heights, with ever more palpable changes and improvements in the way that we render healthcare for our patients.

Eric J. Topol, MD

Editor-in-Chief, Medscape

References

  1. The FDA and thee. The Wall Street Journal. November 25, 2013.http://online.wsj.com/news/articles/SB10001424052702304465604579220003539640102 Accessed December 10, 2013.
  2. The FDA and me. Nature. December 3, 2013. http://www.nature.com/news/the-fda-and-me-1.14289 Accessed December 10, 2013.
  3. Jolie A. My medical choice. The New York Times. May 14, 2013.http://www.nytimes.com/2013/05/14/opinion/my-medical-choice.html Accessed December 10, 2013.
  4. Rabin RC. In Israel, a push to screen for cancer gene leaves many conflicted. The New York Times. November 26, 2013. http://www.nytimes.com/2013/11/27/health/in-israel-a-push-to-screen-for-cancer-gene-leaves-many-conflicted.html Accessed December 10, 2013.
  5. Topol EJ. Topol predicts genomic screening will replace amniocentesis. Medscape. November 11, 2013.http://www.medscape.com/viewarticle/814052 Accessed December 10, 2013.
  6. Friedman B. The future of healthcare: virtual physician visits & bedless hospitals. Lab Soft News. April 1, 2013.http://labsoftnews.typepad.com/lab_soft_news/2013/04/the-future-of-healthcare-less-emphasis-on-hospital-visits.html Accessed December 10, 2013.
  7. Cisco. Cisco study reveals 74 percent of consumers open to virtual doctor visit. March 4, 2013.http://newsroom.cisco.com/release/1148539/Cisco-Study-Reveals-74-Percent-of-Consumers-Open-to-Virtual-Doctor-Visit Accessed December 11, 2013.
  8. Fast Company. Could ePatient networks become the superdoctors of the future?http://www.fastcoexist.com/1680617/could-epatient-networks-become-the-superdoctors-of-the-future
  9. Fisher N. Global study finds majority believe traditional hospitals will be obsolete in the near future. Forbes. December 9, 2013. http://www.forbes.com/sites/theapothecary/2013/12/09/global-study-finds-majority-believe-traditional-hospitals-will-be-obsolete-in-the-near-future/ Accessed December 10, 2013.

SOURCE

http://www.medscape.com/viewarticle/817648_1

John Mandrola’s Top 11 Cardiology Stories of 2013

by John M. Mandrola, MD

Clinical Electrophysiologist, Baptist Medical Associates, Louisville, Kentucky

Disclosure: John M. Mandrola, MD, has disclosed the following relevant financial relationships:
Served as a speaker or member of a speakers bureau for: Biosense/Webster

In Medscape Cardiology, December 20, 2013

 

1. Obamacare/Affordable Care Act

The reforms that sweep in with the tidal waves of Obamacare will transform the landscape of cardiology. Things look differently already, but even more change is coming. Optimism is healthier than pessimism, so my assessment is: Obamacare will be associated with better heart disease outcomes.

Here’s why: What single factor limits improvement of outcomes in heart disease? It’s surely not a lack of access to echocardiograms, or new antiplatelet drugs, or LAA occlusion devices. Rather, it’s the lack of patients’ adherence to healthy lifestyles choices. Cardiologists have reached a therapeutic threshold. Gains in the treatment of heart disease have become and will likely stay incremental. The next big jump in heart disease outcomes will require patients’ actions — not doctors’.

The chief strength of Obamacare is that it ushers in the era of cost-shifting to patients. People will pay more for care. This, I believe, will favor the adoption of healthy lifestyles. Skin in the game, will, on the whole, do great things for heart health. The car analogy: We get our oil changed in our car because preventative maintenance is cost-effective. If you never had to pay for a new car, there’d be little incentive not to trash your current one.

I can hear the naysayers. Placing more of the costs on patients will keep them from getting care. Yes, in isolated cases, which will surely be amplified — this might be true. But overall, 3 arguments refute this thinking: First is that in the past decade, both deaths from heart disease and number of cardiology procedures have declined. Patients are doing better while we do less. Second is the observation that countries that do far fewer procedures boast better CV outcomes. Third, you don’t really believe that doctors control outcomes, do you?

2. The George Bush Stent Case

More than 2 decades ago, a mentor at Indiana taught me that squishing a high-grade coronary lesion did not reduce the risk for heart attack or death. I still remember where I was when I heard that. It was that counterintuitive. The notion that the vulnerable plaque is not the one that looks like a baddie on an angiogram has been proven time and time again. What’s truly remarkable is the resistance of the cardiology community to accept it. Perchance, our visceral reactions to angiograms have clouded our interpretation of science.

Cynics would believe that the overuse of stents — in the face of contrary clinical evidence — is due to financial incentives. They point to examples of outrageous behavior on the part of a tiny few outliers behaving very badly. I can’t deny that incentives don’t play a role, but I think this story has more to do with the cognitive bias stemming from the success of acute primary angioplasty. It’s tempting to merge the stunning benefits of intervening in an acute MI situation to the nonacute situations.

The George Bush story is big because the media attention forced us to look again at the science of the COURAGE trial.[1] What’s more, this story gave strength to those who question the entrenched paradigm of ischemia-guided revascularization. Imagine the implications for cardiology if there was little reason to look for asymptomatic ischemia.

3. Cholesterol Guidelines: Who Decides the “Need” for a Statin?

The cholesterol guidelines[2] had some obvious practice-changing revelations: (1) the end of nonstatin cholesterol-lowering drugs; (2) cessation of treating to numbers; (3) the notion of using statins as cardiovascular risk reducers, rather than cholesterol-lowering drugs; (4) the fight over where CV risk warrants statin intervention.

These are big issues, but I don’t see them as the biggest part of the 2013 cholesterol guideline story. I think what makes this a tipping point in clinical cardiology is the notion that the ultimate decision to take a statin falls with the patient.

Writing to patients in Forbes, Dr. Harlan Krumholz says:

It is your decision. Your doctors can guide you, but you deserve to be informed about the decision and make the choice that feels most comfortable to you. You do not know if you will be the person who avoids a heart attack or will suffer a side effect. You should have the information about what you are likely to gain by taking the medication — and what risks you are incurring. The decision to take the drug should mean that you believe that you are more likely to benefit from the drug than to be harmed by it. And even if a drug has a benefit for you, you have a right to decide whether it is right for you.

This is huge because it brings patient-centered, shared decision-making to the mainstream. Before the cholesterol guidelines, shared decision-making was something you read about in academic journals. But now, across doctors’ offices throughout the United States, low-risk patients will have to decide whether their 1-in-100 chance of preventing a heart attack is worth the 1-in-100 chance of developing diabetes or other statin side effects. Getting patients to see tradeoffs, NNTs, and aligning care with their goals isn’t just a story of 2013; it’s a story of the decade.

JNC-8, Obesity and AF, and NOACs

4. High Blood Pressure Guidelines

I often tell this story to patients: When I was a younger doctor, I would take my 94-year-old grandfather around to see the best doctors in town. We both held to the fantasy that doctors could “fix” him. Mostly he had age-related problems. He did, however, own one shining beacon of good health: He had perfect blood pressure, without medication. My message to patients is that my grandfather lived to 94 because of those BP readings.

What I learned from my grandfather’s case, which has now been borne out in the new JNC 8 guidelines,[3] is that it matters how one achieves good blood pressure. The new guidelines, chaired by a family medicine professor (how cool is that?), continues to disrupt the concept that more drug treatment leads to better outcomes.

It is indeed striking what can be found when one looks carefully and systematically at absolute benefits of treatments from randomized clinical trials. Truthfully, did you know that there was essentially no evidence that treating mild high blood pressure in patients younger than 60 improves outcomes? I didn’t.

Here the affect heuristic looms large. I find great pleasure in the idea that the medical establishment is now poised to embrace common sense. Namely, that modifying a single risk factor with a chemical that surely has multiple system-wide effects does not necessarily improve outcomes.

5. In Electrophysiology, Treat the Underlying Cause of AF

There are a few landmark studies I keep around the exam room for show-and-tell. 2013 brought another keeper. Dr. Prashanthan Sanders and colleagues (from Adelaide, Australia) are authors of the most impactful study in all of cardiology in 2013.[4]

Here is the story: Atrial fibrillation is increasing exponentially. Electrophysiologists see patients at the end of the disease spectrum. Rate control, rhythm control, and anticoagulation are each important treatment strategies, but they don’t address the root cause of AF. In previous work in animal models, this group of researchers showed that obesity increases the susceptibility to AF.

The hypothesis was that weight loss (and aggressive attention to other cardiometabolic risk factors) would reduce AF burden. They randomly assigned patients on their waiting list for AF ablation to 2 groups: (1) a physician-led aggressive program that targeted primarily weight loss, but also hypertension, sleep apnea, glucose control, and alcohol reduction; or (2) standard care with lifestyle counseling.

The findings were striking. Compared with the group of patients receiving standard care, patients in the physician-directed program lost weight, reported less AF symptoms, and had fewer AF episodes recorded. Most impressive were the structural effects noted on echocardiograms. Patients in the intervention group had regression of left ventricular hypertrophy and reduction in left atrial size.

Though this is a small trial, it is practice-changing for cardiology. It shows that treating modifiable risk factors remodels the heart and in so doing reduces the burden of AF. In an interview in JAMA, Dr. Sanders says aggressive risk factor treatment should be a standard of care. I agree. Right now, AF ablation is too often thought of in terms of a supraventricular tachycardia ablation — a fix for a fluke of nature. It’s not that way. In the majority of AF cases, the same excesses that cause atherosclerosis also cause AF. Rather than make 50 burns in the atria, it makes much more sense to address the root cause.

NOACs

6. Novel Anticoagulants Face Value-Based Headwinds

Tell me you haven’t been in this situation: You are making rounds on a patient with newly diagnosed AF, admitted the night before. She has multiple risk factors for stroke. Her heart rate has been controlled and her symptoms improved. There are now 2 choices for anticoagulation: (1) Start warfarin, and while waiting for an adequate INR, cover with IV-heparin (days in hospital) or low-molecular-weight heparin (teaching- and dollar-intensive); or (2) Begin a novel oral anticoagulant (NOAC) and discharge the patient that day. It’s so much easier to use NOAC drugs.

But then what happens when the “starter” kits run out and the patient faces a massive bill at the pharmacy, or her third-party payer denies payment? Now our patient has a problem. She is in AF and has risk factors for stroke. A gap in anticoagulation is not desirable.

At the heart of this issue is the value and superiority of NOAC drugs compared with warfarin. At the 2013 American Heart Association Sessions, the ENGAGE-AF trial showed that the newest NOAC drug, edoxaban, compared favorably to warfarin.[5] All 4 clinical trials of NOAC drugs vs warfarin looked strikingly similar — namely, that in absolute benefits (stroke reduction) and harm (bleeding), NOAC drugs and warfarin performed similarly, within 1% of each other. In the cost-conscious, evidence-based climate of 2013, NOAC drugs are increasingly recognized as overvalued. Warfarin, with all its imperfections, remains steady.

Transparency, End-of-Life Care, and TACT

7. The Sunshine Act

Cardiology is a drug- and device-intensive field. Collaboration with industry is necessary. Skillful use of stents, ICDs, ablation, and pharmaceutical agents has enhanced and saved the lives of millions of patients. Yet, there is clear evidence of overuse and misuse of expensive technology. Look no further than studies that show huge geographic practice variation,[6] which I wrote about here.

The 2013 Sunshine Act has changed the landscape of cardiology education and influence. The upside of transparency is that knowing the financial relationships of investigators is an important part of judging science. Perhaps more important, though, is the possibility that the Sunshine Act will help remove those with financial relationships from guideline writing. Given the influence of guidelines, it’s important that writers be free of conflicts.

The potential downsides of too much Sunshine are noteworthy. After being interviewed in the Wall Street Journal this August,[7] I wrote the following on my blog:

Doctors are a conservative lot. Concern over perception will surely decrease physicians’ interactions with industry, both the useful and not so useful ones. The effect on physician education might suffer. Though the Ben Goldacres of the world rightly emphasize bias when industry entwines itself with medical education, I can attest to have learned a lot from industry-sponsored programs. And this too: one thing that happens when industry sponsors a learning session is that doctors come to it. They talk; they share cases; they come together face-to-face. Such interactions are critical. Will the disappearance of sponsored sessions decrease the amount of face-to-face learning?

We shall soon learn whether all this sunshine enhances health or causes burns.

8. Compassionate Care of the Elderly

Cardiologists are programmed to see death as the enemy. This is a very good thing when treating diseases like STEMI. But a side effect of improving life-prolonging interventions is that patients live long enough to develop other problems. Cardiologists are increasingly asked to treat the elderly and the frail. And this is a challenge because in these patients, treating death as if it’s avoidable is perilous. Delaying death is not the same as prolonging life. Treating a disease is not the same as treating a person.

It’s possible that 2013 will be the year in which things changed for the better in the care of the elderly. And if it is, we will have Katy Butler, an author and investigative journalist, to thank. Ms. Butler’s 2013 book, Knocking on Heaven’s Door, poignantly chronicles the difficulties that both her parents struggled with as they approached the end of life.[8] In both cases, suffering occurred because of disconnect with cardiologists who behaved as if death were optional.

Writing in the Wall Street Journal this September, Ms. Butler describes her mother’s decision to forego aggressive intervention for valvular heart disease.[9] Despite being cared for in one of the nation’s elite heart hospitals, Mrs. Butler’s mother was forced to fight hard for her right to self-determination. Perhaps she mustered the strength to fight for a good death because of the lessons she learned as a caregiver for her chronically ill husband, whose death was tragically prolonged at the hands of paternalistic cardiologists. In Ms. Butler’s father’s case, which she describes in this award-winning New York Times Magazine essay, cardiologists implanted an unnecessary pacemaker and then refused to deactivate it, against the family’s wishes.[10]

As the American College of Cardiology begins an awareness campaign for aortic stenosis, and transcutaneous approaches to valvular disease begin their long road to clinical utility, no topic could be timelier than compassionate patient-centered care for the elderly. 2013 is the year that the oath of Maimonides — “Oh, God, Thou has appointed me to watch over the life and death of Thy creatures” — becomes even more relevant to cardiologists, the guardians of technology.

9. Chelation Therapy

Nothing has become more virtuous in the practice of medicine than clinical evidence. We have set out the rules: The scientific method will determine the best treatments for our patients. One group gets treatment A and the other treatment B. Then we measure outcomes — the simpler the better. These are the rules of the game; they can’t be changed when we don’t like how the game turns.

The TACT investigators have followed the rules. They compared 322 diabetic patients with coronary heart disease who were treated with chelation vs 311 similarly matched patients treated with placebo infusions.[11] The primary endpoint, a composite of death, MI, stroke, revascularization, and hospitalization for angina, occurred in 80 of 322 (25%) treated with chelation and 117 (38%) on placebo. That’s an absolute — not relative — reduction of 13%, and an astounding NNT of 7. For comparison, statin drugs for primary prevention, or NOAC drugs vs warfarin in patients with AF, have NNTs greater than 100.

What makes chelation in diabetics a top story of the year is more than just the data. By the authors’ own account, these findings need to be replicated. What’s really big here is the voracity of opposition from the establishment. I re-read what I said in my opinion piece from November. I’m sticking to it: “It would be a huge mistake to dismiss this science because chelation does not conform to preconceived notions or because it is practiced outside the mainstream of medicine. Let’s not forget about the patients with this terrible disease. It’s not as if we have good treatments for them.”

EMRs and the Blogosphere

10. EMR and the Danger It Poses to the Patient-Doctor Connection

Among Mr. Obama’s broken promises (if you like your insurance plan…) was that the efficiency inherent in electronic medical records (EMRs) would solve the growing cost of healthcare.

In 2013, nearly every doctor is being forced to adopt an EMR. Medicine is replete with examples of good ideas gone awry. There is no better example of this than medical EMR systems. The list is long: EMRs interface poorly with users (doctors). Completing a medical record on an encounter for a common heart rhythm ailment requires me to click more than 25 times. (Fact: EMRs either decrease the number of patients one can see, or worse, they cause a doctor to spend less face time with each patient.) EMRs don’t talk to each other — and in their current form, never will. There is not a shred of evidence that they improve real outcomes. EMRs function more as a billing invoice than a useful medical record.

Doctors are the end-users but not the customers of EMR companies, so our feedback carries little weight. EMR companies effectively answer to no one. And talk about conflict of interest: Anointed EMR companies have become immensely profitable. Even the New York Times took notice.[12]

None of this is the worst part. The worst aspect of EMR systems (in their current form) is that they threaten to remove the humanity from something that at its heart should be human: the patient-doctor connection. In 2013, EMR is one of the many forces that threaten the patient-doctor relationship. If this situation improves in 2014, I’ll report it; but I’m not optimistic. (Full disclosure: I love computers.)

11. Social Media

The American College of Cardiology, the Heart Rhythm Society, the BMJ, and the New England Journal of Medicine are all actively engaged in social media and blogging. I gave a talk at an Indiana University medical student leadership conference this year. Nearly every medical student was on Twitter. So is the president of the ACC and SCAI, as are millions of patients.

The democracy of information on social media enhances patient involvement in medical decision-making. When patients have information, decisions improve. AF patient Mellanie True Hills has made her Website, StopAfib, a go-to resource for patients, a place where influential academic leaders in electrophysiology have taken the time to be interviewed. Social media empowers patient advocates.

Social media is also transforming influence. In the past, the only influencers in cardiology were academic leaders — those who have access to medical journals. That is changing. Look at me: I am a nobody in the academic world, yet Dr. Rich Fogel, the former president of the Heart Rhythm Society (HRS), put me on the same stage with Dr. Douglas Zipes, Dr. Brian Olshansky, and Dr. Anne Curtis at the 2013 HRS sessions to speak about ICDs.

Finally, this is speculative, but I believe that social media has the power to transform medical education. This year, the biggest electrophysiology story from the 2013 European Society of Cardiology Congress was the Echo-CRT trial.[13] This was a practice changer because it put a stop to implanting CRT devices in patients destined to be nonresponders. Dr. Jay Schloss (Christ Hospital, Cincinnati, Ohio), writing on his personal blog, provided clear and useful coverage for free, without the need for registration. Another example: I think IV-diltiazem is overused and misused. In the academic literature, you cannot find a contemporary piece to support this view. But you can on social media.

This is my top 11 for 2013. I invite you to use the comments section to share your top cardiology picks.

 SOURCE

http://www.medscape.com/viewarticle/818115_1

 

 

 

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Joy Is in the Air!

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Ca2+-Stimulated Exocytosis:  The Role of Calmodulin and Protein Kinase C in Ca2+ Regulation of Hormone and Neurotransmitter

Article XIII Ca2+-Stimulated Exocytosis The Role of Calmodulin and Protein Kinase C in Ca2+ Regulation of Hormone and Neurotransmitter

Writer and Curator: Larry H Bernstein, MD, FCAP
and
Curator and Content Editor: Aviva Lev-Ari, PhD, RN

This article is Part V in a series of TWELVE articles, listed at the end of this article,  on the

  1. cytoskeleton,
  2. calcium calmodulin kinase signaling,
  3. muscle and nerve transduction, and
  4. calcium,
  5. Na+-K+-ATPase,
  6. neurohumoral activity and vesicles vital and essential for all functions related to
  • cell movement,
  • migration, and
  • contraction.

Calmodulin and Protein Kinase C Increase Ca–stimulated Secretion by Modulating
Membrane-attached Exocytic Machinery

YA Chen, V Duvvuri, H Schulmani, and RH.Scheller‡
From the ‡Howard Hughes Medical Institute, Department of Molecular and Cellular Physiology,
and the Department of Neurobiology, Stanford University School of Medicine, Stanford, CA

The molecular mechanisms underlying the Ca2+ regulation of hormone and neurotransmitter release
are largely unknown.

Using a reconstituted [3H]norepinephrine release assay in permeabilized PC12 cells, we found

  • essential proteins that support the triggering stage of Ca2+-stimulated exocytosis
  • are enriched in an EGTA extract of brain membranes.
Fractionation of this extract allowed purification of two factors that stimulate secretion
  • in the absence of any other cytosolic proteins.
These are calmodulin and protein kinase Ca (PKCa). Their effects on secretion were
  • confirmed using commercial and recombinant proteins.
Calmodulin enhances secretion

  • in the absence of ATP, whereas
  • PKC requires ATP to increase secretion, suggesting that
  • phosphorylation is involved in PKC-mediated stimulation
  • but not calmodulin mediated stimulation.
  • Both proteins modulate
    • The half-maximal increase was elicited by
      3 nM PKC and 75 nM calmodulin.
These results suggest that calmodulin and PKC increase Ca2+-activated exocytosis by
  • directly modulating the membrane- or cytoskeleton-attached exocytic machinery
    downstream of Ca2+ elevation.

The abbreviations used are:

NE, norepinephrine; PKC, protein kinase C; CaM, calmodulin; SNAP-25, synaptosome-associated protein of 25 kDa; CAPS, calcium-dependent activator protein for secretion; SNARE, SNAP (soluble N-ethylmaleimide-sensitive factor attachment proteins) receptor; CaMK, Ca2+/calmodulin-dependent protein kinase; PAGE, polyacrylamide gel electrophoresis; AMP-PNP, adenosine 59-(b,g- imido) triphosphate;  HA, hydroxyapatite

*This work was supported in part by Conte Center Grant MH48108. The costs of publication of
this article were defrayed in part by the payment of page charges. This article has been marked
“advertisement” in accordance with 18 U.S.C. Section 1734.

The molecular mechanisms of presynaptic vesicle release have been extensively examined
by a combination of

  • biochemical,
  • genetic, and
  • electrophysiological techniques.

A series of protein-protein interaction cascades have been proposed to lead to vesicle
docking and fusion
(1–3). The SNARE protein family, including

  • syntaxin, SNAP-25, and vesicle-associated membrane protein
    (VAMP, also called synaptobrevin),
  • plays an essential role in promoting membrane fusion, and
  • is thought to comprise the basic fusion machinery (4, 5).

In Ca2+-stimulated exocytosis, many additional proteins are important in the Ca2+ regulation
of the basic membrane trafficking apparatus.
Calcium

  • not only triggers rapid fusion of release-competent vesicles, but is also involved in
  • earlier processes which replenish the pool of readily releasable vesicles (6).

Furthermore, it appears to be critical in initiating several forms of synaptic plasticity including

  • post-tetanic potentiation (7).

The molecular mechanisms by which Ca2+ regulates these processes is not well understood.


PC12 cells have often been utilized to study Ca2+-activated exocytosis
, as

  • they offer a homogeneous cell population that possesses the same basic exocytic machinery as neurons (8).

In this study, we used an established cracked cell assay, in which

  • [3H]norepinephrine (NE)1 labeled PC12 cells are
  • permeabilized by mechanical “cracking” and
  • then reconstituted for secretion of NE in the presence of test proteins (9).

Transmitter-filled vesicles and intracellular cytoskeletal structures

  • remain intact in these cells,
  • while cytosolic proteins leak out (10).

These cracked cells readily release NE upon addition of

  • ATP,
  • brain cytosol, and
  • 1 mM free Ca2+
    • at an elevated temperature.

We term this a “composite assay,” as

  • all essential components are added into one reaction mixture.

Alternatively, cracked cells can be

  • first primed with cytosol and ATP, washed, then
  • reconstituted for NE release with cytosol and Ca2+ (11).

This sequential priming-triggering protocol is useful

  • for determining whether a protein acts early or late in the exocytic pathway, and
  • whether its effect is dependent on Ca2+ or ATP.

This semi-intact cell system serves as

  • a bridge between an in vitro system comprised of purified components, and
  • electro-physiological systems that monitor release in vivo.
  • It provides information on protein functions in a cell with an intact membrane infrastructure while being easily manipulatable.

Ca2+ regulation by membrane depolarization is no longer a concern, as
intra-cellular Ca2+ concentration can be controlled by a buffered solution.

  • Indirect readout of neurotransmitter release using a postsynaptic cell is replaced by
  • direct readout of [3H]NE released into the buffer.

Complications associated with interpreting overlapping

  • exo- and endocytotic signals are also eliminated as only one round of exocytosis is measured.

Finally, concentration estimates are likely to be accurate, since

  • added compounds do not need to diffuse long distances along axons and dendrites to their sites of action.

Using this assay, several proteins required for NE release have been purified from rat brain cytosol, including

  • phosphatidyl-inositol transfer protein (12),
  • phosphatidylinositol-4-phosphate 5-kinase (13), and
  • calcium-dependent activator protein for secretion (CAPS) (9).

The validity of the cracked cell system is confirmed by the finding that

  • phosphatidylinositol transfer protein and CAPS are mammalian homologues of
    • yeast SEC14p (12) and
    • nematode UNC31p, respectively (14),
  • both proteins involved in membrane trafficking (15, 16).

Calmodulin is the most ubiquitous calcium mediator in eukaryotic cells, yet its involvement in membrane trafficking has not been well established. Some early studies showed

  • that calmodulin inhibitors (17–19), anti-calmodulin antibodies (20,21),

or

  • calmodulin binding inhibitory peptides (22) inhibited Ca2+-activated exocytosis.

However, in other studies, calmodulin-binding peptides and an anti-calmodulin antibody led to the conclusion that

  • calmodulin is only involved in endocytosis,
  • not exocytosis (23).

More recently, it was reported that

  1. Ca2+/ calmodulin signals the completion of docking and
  2. triggers a late step of homotypic vacuole fusion in yeast,
  • thus suggesting an essential role for Ca2+/calmodulin in constitutive intracellular membrane fusion (24).

If calmodulin indeed plays an important role in exocytosis,

  • a likely target of calmodulin is
  • Ca2+/calmodulin-dependent protein kinase II (CaMKII),
    • a multifunctional kinase that is found on synaptic vesicles (25) and
    • has been shown to potentiate neurotransmitter release (26, 27).

Another Ca2+ signaling molecule, PKC, has also been implicated in regulated exocytosis.
In various cell systems, it has been shown that

  • the phorbol esters stimulate secretion (28, 29).

It is usually assumed that phorbol esters effect on exocytosis is

  • through activation of PKC,
  • but Munc13-1 was recently shown to be a presynaptic phorbol ester receptor that enhances neurotransmitter release (30, 31),

which complicates the interpretation of some earlier reports. The mode of action of PKC remains controversial. There is evidence

  • that PKC increases the intracellular Ca2+ levels by modulating plasma membrane Ca2+ channels (32, 33),
  • that it increases the size of the release competent vesicle pool (34, 35), or
  • that it increases the Ca2+ sensitivity of the membrane trafficking apparatus (36).

no consensus on these issues has been reached.

PKC substrates that have been implicated in exocytosis include

  1. SNAP-25 (37),
  2. synaptotagmin (28),
  3. CAPS (38), and
  4. nsec1 (39).

It is believed that upon phosphorylation, these PKC substrates might

  • interact differently with their binding partners, which, in turn,
  • leads to the enhancement of exocytosis.

In addition, evidence is accumulating that PKC and calmodulin interfere with each others actions, as

  • PKC phosphorylation sites are embedded in the calmodulin-binding domains of substrates such as
  • neuromodulin and
  • neurogranin (40).

It is therefore possible that PKC could modulate exocytosis via

  • a calmodulin-dependent pathway by synchronously releasing calmodulin from storage proteins.

In this study, we fractionated an EGTA extract of brain membranes in order to identify active components that could reconstitute release in the cracked cell assay system. We identified calmodulin and PKC as two active factors. Thus, we demonstrate that

  • calmodulin and PKC play a role in the Ca2+ regulation of exocytosis, and provide further insight into the mechanisms of their action.

DISCUSSION

 In this study, we first identified an EGTA extract of brain membranes as a protein source
  •  capable of reconstituting Ca2+- activated exocytosis in cracked PC12 cells.
EGTA only extracts a small pool of Ca2+-dependent membrane-associating proteins,
  • it served as an efficient initial purification step.
Further protein chromatography led to the identification of two active factors in the starting extract,
  • calmodulin and PKC,
  • which together accounted for about half of the starting activity.
Upon confirmation with commercially obtained proteins, this result unambiguously demonstrated
  • that calmodulin and PKC mediate aspects of Ca2+-dependent processes in exocytosis.
The finding that brain membrane EGTA extract alone is able
  • to replace cytosol in supporting Ca2+-triggered NE secretion
 in PC12 cells is somewhat surprising. We suggest that the likely explanation is 2-fold.
  1. some cytosolic proteins essential for exocytosis have a membrane-bound pool
    within permeabilized cells, whose activity might be sufficient for a normal level of exocytosis.
  2. although the 100,000 3 g membrane pellet was washed to remove as many cytosolic proteins as possible,
  • some cytosolic proteins that associate with membranes in a
    • Ca2+-independent manner are probably present in the membrane EGTA extract.
  • these proteins likely constitute only a small percentage of the proteins in the extract, as
    • the characteristics of the activity triggered by the membrane extract
    • are quite different to that of cytosol (Fig. 2).
 Using an unbiased biochemical purification method, we demonstrated that
  •  calmodulin and PKC directly modulate the exocytotic machinery downstream of Ca2+ entry
  • they signal through membrane-attached molecules to increase exocytosis.
 These targets include integral and peripheral membrane proteins, and cytosolic proteins that have a significant
membrane-bound pool.  The modest stimulation by calmodulin and PKC on secretion might suggest a regulatory
role. However, it is also possible that some intermediates in their signaling pathways are in limiting amounts in the
cell ghosts, so that their full effects were not observed. Half-maximal stimulation was obtained at
  • about 3 nM for PKC and
  • at about 75 nM for calmodulin.
This is consistent with an enzymatic role for PKC, and predicts a high-affinity interaction between
  • calmodulin and its substrate protein.
 Ca2+ regulates exocytosis at many different levels. Prior studies indicated that Ca2+ signaling occurs in

  • the priming steps as well
  • as in triggering steps (49, 50).
Our priming triggering protocol 
  1. does not allow Ca2+-dependent priming events to be assayed, as EGTA is present in the priming reaction.
  2. a different approach revealed the existence of both high and low Ca2+-dependent processes (Fig. 2).
  3. this analysis indicated that late triggering events require high [Ca2+], whereas
  4. early priming events require low [Ca2+]. If, as proposed, there is
a pronounced intracellular spatial and temporal [Ca2+] gradient from
  • the point of Ca2+ entry during depolarization (51),
  • perhaps triggered events occur closer to the point of Ca2+ entry,
  • while Ca2+-dependent priming events occur further away from the point of Ca2+ entry.
Fig 2A. measurements of range of [Ca2+]total - average [Ca2+]free values._page_004
Fig. 2B. measurements of range of [Ca2+] total - average [Ca2+]free values_edited-1
Distinct Ca2+ sensors at these stages might be appropriately tuned to different [Ca2+] to handle different tasks.
By analyzing the Ca2+ sensitivity of calmodulin-and PKC-stimulated release, we addressed the question of
  • whether calmodulin and PKC plays an early or a late role in vesicle release.
  •  they both require relatively high [Ca2+] (Fig. 8B),
  • implying that calmodulin and PKC both mediate late triggering events, consistent with some earlier reports
    (34, 52, 53).

In addition, it is interesting to note that PKC does not alter the calcium sensitivity of release in cracked cells, in contrast

to observations from the chick ciliary ganglion (36). Therefore, in contrast to previous electrophysiological studies (28),
we are able to limit the possible modes of PKC action in our system to an increase in the readily releasable vesicle pool or
release sites, or an enhancement of the probability of release of individual vesicles upon Ca2+ influx.
The experiments assaying the calcium sensitivity of release (Figs. 2, 5, and 8) demonstrated
  • a drop in release at very high [Ca2+].

FIG. 5 calmodulin action_page_005

FIG. 8. PKC and calmodulin stimulate... the late triggering reaction_page_006
This decline in release at high [Ca2+] has been previously reported (49, 51), and may represent
  • the true Ca2+ sensitivity of the Ca2+-sensing mechanism inside cells.

However, in our system, it could also be due to the activation of a variety of Ca2+ -activated proteases, as experiments are usually performed in the presence of crude extracts, which include unsequestered proteases.

What might the molecular targets of PKC and calmodulin be? An obvious calmodulin target molecule is CaMKII.
  • but calmodulin’s effect on exocytosis is ATP-independent, rendering the involvement of a kinase unlikely.
 Calmodulin has also been shown to associate with
  • synaptic vesicles in a Ca2+-dependent fashion through synaptotagmin (54),
  • probably by binding to its C-terminal tail (55), and to promote Rab3A dissociation from synaptic vesicles (56).
  • However, there was little calcium-dependent binding of calmodulin to synaptotagmin
    • either on synaptic vesicles, in a bead binding assay with recombinant proteins,
    • or in a calmodulin overlay (data not shown).

In addition, using immobilized calmodulin, we did not see

  • significant Ca2+-dependent pull-down of synaptotagmin or Rab3A from rat brain extract (data not shown).
Recent work has suggested three other candidate targets for calmodulin, Munc13, Pollux, and CRAG (57).
  • Pollux has similarity to a portion of a yeast Rab GTPase-activating protein, while
  • CRAG is related to Rab3 GTPase exchange proteins.
Further work is required to investigate the role of their interactions with calmodulin in vivo.
The recent report that calmodulin mediates yeast vacuole fusion (24) is intriguing, as it raises the possibility that
  • calmodulin, a highly conserved ubiquitous molecule,
    • may mediate many membrane trafficking events.

It is not yet known if

  • the effector molecule of calmodulin is conserved or variable across species and different trafficking steps.

It is enticing to propose a model for Ca2+ sensing whereby

  • calmodulin is a high affinity Ca2+ sensor for both constitutive and regulated membrane fusion.
  1. In the case of constitutive fusion, calmodulin may be the predominant Ca2+ sensor.
  2. In the case of slow, non-local exocytosis of large dense core granules, an additional requirement for
  3. the concerted actions of other molecule(s) that are better tuned to intermediate rises in [Ca2+] might exist.
At the highly localized sites of fast exocytosis of small clear vesicles where high [Ca2+] is reached,
  • specialized low affinity sensor(s) are likely required
  • in addition to calmodulin to achieve membrane fusion.

Therefore, although calmodulin participates in multiple types of vesicle fusion,

  • the impact of Ca2+ sensing by calmodulin on vesicle release likely varies.
Due to the fact that calmodulin binding to some proteins can be modulated by PKC phosphorylation, one might suspect
  • PKC action on exocytosis proceeds through a calmodulin-dependent pathway.
  • but the effects of calmodulin and PKC are additive within our system,
    • suggesting that PKC does not act by releasing calmodulin from a substrate
      • that functions as a calmodulin storage protein.
How Ca2+ regulates presynaptic vesicle release has been an open question for many years. By

  • identifying calmodulin and PKC as modulators of Ca21-regulated exocytosis and clarifying their functions,
  • we have extended our knowledge of the release process.

While the basic machinery of membrane fusion is becoming better understood,

  • the multiple effects of Ca2+ on exocytosis remain to be elucidated at the molecular level.

In addition, the ways that Ca2+ regulation may be important to

  • the mechanisms of synaptic plasticity in the central nervous system

EXPERIMENTAL PROCEDURES

Materials
Rat Brain Cytosol Preparation
Membrane EGTA Extract Preparation

Cracked Cell Assay

PC12 cells were maintained and [3H]NE labeled as described previously (11). Labeled cells were harvested by pipetting with ice-cold potassium glutamate buffer (50 mM Hepes, pH 7.2, 105 mM potassium glutamate, 20 mM potassium acetate, 2 mM EGTA) containing 0.1% bovine serum albumin. Subsequent manipulations were carried out at 0–4 °C. Labeled cells (1–1.5 ml/dish) were mechanically permeabilized passage through a stainless steel homogenizer. The cracked cells were adjusted to 11 mM EGTA and

  • incubated on ice for 0.5–3 h, followed by three washes in which
  • the cells were centrifuged at 800 3 g for 5 min and
  • resuspended in potassium glutamate buffer containing 0.1% bovine serum albumin.

Composite Assay 

Each release reaction contains 0.5–1 million cracked cells, 1.5 mM free Ca2+, 2 mM MgATP,
and the protein solution to be tested in potassium glutamate buffer. Release reactions were initiated
by incubation at 30 °C and terminated by returning to ice. The supernatant of each reaction was
isolated by centrifugation at 2,500 3 g for 30 min at 4 °C, and the

  • released [3H]NE was quantified by scintillation counting (Beckman LS6000IC).

Cell pellets were dissolved in 1% Triton X-100, 0.02% azide and similarly counted. NE release

  • was calculated as a percentage of total [3H] in the supernatant.

Priming Assay

A priming reaction contains about

  • 1–2 million cracked cells,
  • 2 mM MgATP, and
  • the protein solution to be tested.
  • Ca2+ is omitted.

The primed cells were spun down, washed once with fresh potassium glutamate buffer, and

  • distributed into two triggering reactions, each containing
  • rat brain cytosol and free Ca2+
  • The triggering reaction was performed at 30 °C for 3 min, and
  • the NE release was measured
    • as in a composite assay.

Triggering Assay

Cracked cells were primed …, centrifuged, washed …, and

distributed into triggering reactions containing

  • 1.5 mM free Ca2+ and the protein solution 

To inhibit any ATP dependent activity in the triggering reaction,  an

  • ATP depletion system of
    1. hexokinase
    2. MgCl2,
    3. glucose or
  • a non-hydrolyzable ATP analogue AMPPNP

was added into the triggering reaction. NE release was measured as above.

Free Ca2+ Concentration Determination

The range of Ca2+free in the release reaction (Fig. 2B) was achieved

  • by adding Ca2+ into potassium glutamate buffer to reach final [Ca2+] total values of
    • 0.8, 1.0, 1.2, 1.4, 1.6, 1.8, 1.9, and 2.0 mM.
  • The pH of the reaction was 7.24 when no Ca2+ was added and
  • 7.04 when 2.0 mM Ca2+ was added
    • in the absence of protein extracts or cracked cells.
Fig. 2B. measurements of range of [Ca2+] total - average [Ca2+]free values_edited-1
Fig. 2B.   The range of [Ca21]free in the release reaction (Fig. 2B)
Free Ca2+ concentrations were determined using video microscopic
measurements of fura-2 fluorescence
 (41). [Ca2+]free was calculated from the equation
  • [Ca2+]free 5 Kd*3 (R 2 Rmin)/(Rmax 2 R) (42).
The values of Rmin, Rmax, and Kd* were determined in the following solutions: 
potassium glutamate buffer (PGB) containing
  • 8 x 3 10^6 cracked cells/ml, 2 mM MgATP (PGB+CC)
1) Rmin:  PGB+CC and 10 mM additional EGTA;
2) Rmax: PBG+CC, and 10 mM total Ca2+;
3) Kd*: PGB+CC, 28 mM additional EGTA, and 18 mM total Ca2+, pH 7.2
([Ca2+]free 5 = 169 nM, determined in the absence of cells and MgATP
  • based on fura-2 calibration in cell-free solutions).
These solutions were
  1. incubated at 37 °C ,
  2. mixed with fura-2 pentapotassium salt
    (100 mM; Molecular Probes, Eugene, OR), and
  3. imaged.
This procedure allowed us to take into account
  • changes in fura-2 properties
  • caused by the presence of
    • permeabilized cells.
Duplicate measurements of the above range of [Ca2+] total gave
  • the following average [Ca2+] free values:
  • 106, 146, 277, 462, 971, 1468, 1847, and 2484 nM.

Purification of Active Proteins

All procedures were carried out at 4 °C or on ice. Membrane
EGTA extract of one or two bovine brain(s) was

  1. filtered through cheesecloth and
  2. loaded overnight onto a column packed with DEAE-Sepharose
    CL-6B beads (Amersham Pharmacia Biotech).

The column was then

  1. washed with
    (20 mM Hepes, pH 7.5, 0.25 mM sucrose, 2 mM EGTA, 1 mM dithiothreitol) and 
  2. step eluted with 10 column volumes of elution buffer
    (20 mM Hepes, pH 7.5, 2 mM EGTA, 400 mM KCl, 1 mM dithiothreitol).
    100 ml of every other fraction was
  3. dialyzed overnight into PGB, and
  4. tested in a composite release assay for activity.
  • The active fractions were pooled and dialyzed into zero salt buffer
    (20 mM Hepes, pH 7.5, 2 mM EGTA) and
  • batch bound to 10 ml of Affi-Gel Blue beads (Bio-Rad) or DyeMatrex-Green A beads (Amicon)

Blue beads were used in earlier experiments, and Green beads were used later to

  • specifically deplete CAPS, which was known to bind to Green beads (9).

The unbound material was

  1. collected,
  2. concentrated to about 2 ml using a Centriprep-10 (Amicon), and
  3. loaded onto a 120-ml HiPrep Sephacryl S-200 gel filtration column
    (Amersham Pharmacia Biotech).
Samples were run on the S-200 column in PGB at a flow rate of 7 ml/h.
  • 10–50 ml of every other fraction was tested for
    • activity in the cracked cell composite assay, and
  • two peaks of activity were observed (Fig. 3).

FIG. 3. Gel filtration chromatography reveals two stimulatory_page_004

The first peak of activity had a predicted molecular mass of 85 kDa.
The corresponding material was

  • adjusted to 10 mM potassium phosphate concentration (pH 7.2) and
  • loaded onto a 1-ml column packed with hydroxyapatite Bio-Gel HT
    (Bio-Rad).

The bound material was

  • eluted with a linear K-PO4 gradient from 10 to 500 mM (pH 7.2)
  •  at a flow rate of about 0.1 ml/min, and
  • 0.4–0.5-ml fractions were collected.
  •  each fraction was dialyzed into PGB and
  • tested for activity.

The fractions were also analyzed by

  • SDS-PAGE and silver staining (Sigma silver stain kit).

The active material was concentrated and resolved

  • on an 8% poly-acrylamide gel.

Two Coomassie-stained protein bands that matched the activity profile (Fig. 6)

  • were excised from the gel,
  • sequenced by the Stanford PAN facility.

FIG. 6. Purification of the high molecular weight active factor_page_001

The two polypeptide sequences obtained from the upper band were:

  1. LLNQEEGEYYNVPIXEGD
  2. IRSTLNPRWDESFT.

The only bovine protein that contains both polypeptides is PKCa.
The four polypeptide sequences obtained from the lower band were:

  1. YELTGKFERLIVGLMRPPAY,
  2. LIEILASRTNEQIHQLVAA,
  3. MLVVLLQGTREEDDVVSEDL, and
  4. EMSGDVRDVFVAIVQSVK.

Based on these sequences, the protein band was

  • unambiguously identified to be bovine annexin VI.

The second S-200 peak has a predicted molecular mass of 25 kDa.
The corresponding material was

  • dialyzed into zero salt buffer
    (20 mM Tris, pH 7.5, 1 mM EGTA) and
  • injected onto a Mono-Q HR 5/5 FPLC column
    (Pharmacia).

The FPLC run was performed at 18 °C at 1 ml/min and

  • 1-ml fractions were collected
  • with a linear salt gradient from 0 to 1 M KCl over 71 ml.

The fractions containing proteins (determined by A280) were

  • dialyzed into PGB and
  • tested in the cracked cell assay.

Western Blot

Anti-calmodulin antibody and anti-PKC antibody were used, and

  • ECL (Amersham) was used for detection.

RESULTS

A Membrane EGTA Extract Supports NE Release 

Brain cytosol, prepared as the supernatant of the brain homogenate,
  • effectively stimulates NE release
  • in the cracked cell assay (Fig. 1)
    as previously shown (9). 

Fig. 1 EGTA extract can support NE release_page_003_edited-2

We wondered whether crude extracts other than cytosol
  • could support NE release, and we focused on
  • extractable peripheral membrane proteins.
We found that a salt or EGTA extract of brain membranes,
membranes defined as the
  • 100,000 3 g pellet of the crude homogenate,
  • reconstituted secretion in the absence of cytosol.
  • the salt extract only slightly enhanced NE release
    above background (data not shown), the 
EGTA extract not only stimulated NE release to a high level,
  • similar to that supported by cytosol, but also
  • had a higher specific activity than cytosol (Fig. 1). 
Fig. 1 EGTA extract can support NE release_page_003_edited-3
FIG. 1. The EGTA extract of brain membranes can support NE release in the absence of cytosol. Rat brain membrane EGTA extract (closed triangles) and rat brain cytosol (closed squares) were prepared as described under “Experimental Procedures.” NE release was measured in a composite reaction mixture of cracked cells, MgATP, Ca2+, and the indicated amount of crude extracts.
The ability of the membrane EGTA extract to support secretion is consistent with the fact that
  • following cracking, the cells are immediately extracted with EGTA, and are presumably
  • devoid of most membrane EGTA-extractable factors.

This also suggests that these factors, some of which are probably

  • Ca2+-dependent membrane-associating proteins,
  • participate in Ca2+- triggered exocytosis.

The Membrane EGTA Extract Is Enriched in Triggering Fators

NE release in cracked cells can be resolved into two sequential stages,
  • an ATP-dependent priming stage and
  • an ATP-independent Ca21-dependent triggering stage (11), and
  • proteins can be tested for activity in either stage.
An effect in priming indicates
  1. an early role for the protein, and
  2. an effect in triggering a late ATP-independent role.
Since the protein composition of the
  • membrane EGTA extract and cytosol are different,
we tested whether they had different activities
  • in the priming stage versus the triggering stage.
We found that the membrane EGTA extract is enriched in factors that
  • act during triggering stage of NE releaseas
  • the same amount of protein from the membrane EGTA extract as cytosol
  • gave a higher stimulation in the triggering assay, but
  • not in the priming assay (Fig. 2A). 

Fig 2A. measurements of range of [Ca2+]total - average [Ca2+]free values._page_004

Regular cytosol is prepared in a buffer containing 2 mM EGTA, and thus

  • presumably contains some of the proteins present in the membrane EGTA extract.
Cytosol prepared in the absence of EGTA showed an even lower specific activity
  • in the triggering assay compared with regular cytosol (Fig. 2A).

Identification of Calmodulin as an Active Triggering Factor in the EGTA Extract

Biochemical fractionation of the bovine brain membrane EGTA extract was carried out

  • to identify the active components capable of reconstituting NE release.

Activity was assayed in a composite reaction mixture containing

  • cracked cells,
  • ATP,
  • Ca2+, and
  • the test protein(s).

Except for the presence of bovine serum albumin in the basal buffer,

  • no other proteins were added to the cell ghosts except for the test protein(s).

Initial tests indicated that at least

  1. part of the activity in the membrane EGTA extract binds to and
  2. can be efficiently eluted from an anion exchanger and hydroxyapatite resin,
  3. but does not bind to Amicon color resins.

The starting material was, therefore, sequentially purified using

  • DEAE, Affi-Gel Blue (or Matrex Green-A), and gel filtration chromotography.

Gel filtration fractionation indicated the presence of two peaks of activity with

  • predicted molecular masses of 25 and 85 kDa, respectively (Fig. 3).

FIG. 3. Gel filtration chromatography reveals two stimulatory_page_004

FIG. 3. Gel filtration chromatography reveals two stimulatory factors in the membrane EGTA extract.

In order to purify the active component(s) in the membrane EGTA extract, the crude extract from one bovine brain was fractionated chromatographically (see Experimental Procedures” for details). Fractions from a Sephacryl S-200 gel filtration column were tested for their activity in stimulating NE release in the composite assay. The two activity peaks have predicted molecular masses of 85 and 25 kDa, respectively. The arrows indicate the retention volume of standard proteins run on the same column.

The low molecular weight active factor was purified to homogeneity, as judged by a

  • Coomassie-stained SDS-PAGE gel, after a subsequent Mono-Q fractionation (Fig. 4).

FIG. 4. The low molecular weight active factor is calmodulin_page_004

FIG. 4. The low molecular wen.ight active factor is calmodulin

A, the  membrane EGTA extract from one bovine brain (Start) was subjected to sequential fractionation on DEAE, Blue A, and
Sephacryl S-200 columns. The pooled material containing the activity after each chromotographic step was analyzed by SDS-
PAGE and Coomassie staining. The arrowheads indicate the presence of calmodulin in all the lanes. Calmodulin shows a
mobility shift depending on whether or not Ca2+ is present during electrophoresis (see panel C).
B, the active material  pooled from Sephacryl S-200 was fractionated on a Mono-Q FPLC column and the fractions
(5 ml/fraction) were tested for activity in a composite assay. The activity peak is shown.
C, the active Mono-Q fractions (5 ml/fraction) were subjected to SDS-PAGE in the presence of 1 mM EGTA or 0.1 mM Ca2+,
and the gels stained with Coomassie Blue.
D, fraction 47 (1 ml) was probed by Western blotting with a monoclonal anti-calmodulin antibody. No Ca2+ or EGTA was
added during SDS-PAGE.

We reasoned that the protein might be calmodulin (43) based on the following:

1) It is a relatively small protein (14–18 kDa) that is abundant in the
starting extract (Fig. 4A).
2) It elutes at a very high salt concentration (0.41 M KCl) on the
Mono-Q column.
3) It stains negatively in silver stain (data not shown).
4) Its electrophoretic mobility shifts depending on the presence or
absence of Ca21 (Fig. 4C).

A Western blot with an anti-calmodulin monoclonal antibody gave a
positive signal (Fig. 4D), confirming our prediction.

Properties of Calmodulin-stimulated Exocytosis

We used commercial calmodulin or bacterially expressed recombinant calmodulin to confirm our purification result; both sources of authentic calmodulin stimulated NE release as expected. Moreover, we found that calmodulin stimulates secretion in a triggering assay as well as in a composite assay (Fig. 5A).

FIG. 5A calmodulin action_page 5

The half-maximal increase was at 75 nM (250 ng/200 ml) final calmodulin concentration. This is within the broad
range of affinities between calmodulin and its various targets and suggests that the interaction between
calmodulin and its target molecule in exocytosis is in the physiological range. When the triggering reaction was
performed at different Ca2+ concentrations, calmodulin increased NE release only at high [Ca2+] (0.4 – 2 mM)
similar to the crude EGTA extract (Fig. 5B),

FIG. 5B calmodulin action_page_5

suggesting that calmodulin contributes to the triggering activity of the membrane EGTA extract.  Calmodulin’s affinity for Ca2+ has
been  reported to be around 1 mM (25),

  • consistent with the Ca2+ requirement for
  • calmodulin-stimulated secretion that we observed.

FIG. 5 calmodulin action_page_005

FIG. 5. Calmodulin stimulates NE release in the triggering stage.
A, calmodulin (obtained from Sigma) increased NE release in the
triggering assay in a dose-dependent fashion, in the absence of ATP
or any other cytosolic proteins. In this particular experiment, the
maximal release achieved by addition of rat brain cytosol was 46.5%.

B, the triggering assay was performed with different concentrations
of free Ca2+. Calmodulin (3 mg bacterially expressed recombinant
protein; closed squares) increased NE release with a similar Ca2+
sensitivity to rat brain membrane EGTA extract (10 mg; closed
triangles), as compared with conditions in which no protein was
added (open squares).

Western analysis with commercial protein as standards indicated that calmodulin 

  •  constitutes about 5% of total proteins in the rat brain membrane EGTA extract
  • and about 2% of total proteins in the rat brain cytosol (data not shown).

In addition, a significant amount of calmodulin appears to be left

  • in the washed cell ghosts (data not shown).

Based on the activity of saturating levels of

  • pure calmodulin (releasing 6–10% of total [3H]NE)
  • and crude EGTA extract (releasing ;45% of total [3H]NE),

we estimated that

  • calmodulin accounts for 13–22% of total activity of the extract.

Consistent with this,

  • a high affinity calmodulin-binding peptide
    (CaMKIIa(291–312) (44), used at 5 mM) and
  • an anti-calmodulin antibody (2 mg/200 ml)
  • inhibited about 20% of the membrane EGTA extract-stimulated release
    (6.7 mg of extract added; data not shown).

We showed that calmodulin increased NE release

  • in the triggering stage.

Since regular triggering reactions were performed

  • in the absence of any added ATP,

this suggests that

  • calmodulin enhanced secretion in an ATP-independent fashion.

Furthermore, residual ATP in the cell ghosts did not play a role, since

  •  addition of a hexokinase ATP depletion system that
  • can deplete millimolar concentrations of ATP
    • within a few minutes (11) had little effect, as did
    • addition of 5 mM AMPPNP,
  • which blocks ATP-dependent enzymatic activity (Fig.8A).

Therefore, we ruled out the possibility that a kinase mediates calmodulin’s effect.

FIG. 8. PKC and calmodulin stimulate... the late triggering reaction_page_006

FIG. 8. PKC and calmodulin stimulate the late triggering reaction in
an ATP-dependent and ATP-independent manner respectively.
A, triggering assays were performed to test the activity of calmodulin
(recombinant; black bars) and PKC (purified rat brain PKC from
Calbiochem; shaded bars) in the absence of ATP. A regular triggering
assay is done in the absence of ATP (2ATP). To deplete residual ATP
in the cells, hexokinase-based ATP depletion was employed (1Hexo).
Alternatively, 5 mM AMP-PNP (1AMP-PNP) was added in the triggering
reaction. Under all three conditions, calmodulin increased release
as compared with the background (buffer only; white bars), whereas
PKC did not.
B, NE release in a composite assay was measured with varying
concentrations of free Ca2+ in the presence of 10 mg of calmodulin
(recombinant; closed triangles), 70 ng of PKC  (purified rat brain PKC
from Calbiochem; closed squares), or buffer only (open squares).

A series of calmodulin mutants from Paramecium and chicken were tested

  • for their ability to enhance Ca2+-stimulated secretion, and
  • none of the mutations abolished the calmodulin effect (data not shown).

These mutations include

  • S101F, M145V, E54K, G40E/D50N, V35I/D50N within Paramecium
  • calmodulin (45), and M124Q, M51A/V55A, and M51A/V55A/L32A
    within chicken calmodulin (46, 47).

The Paramecium calmodulin mutants are the result of

  • naturally occurring mutations that result in aberrations in their behavior.

These mutants can be grouped into two categories according to their
behavior, reflecting their loss of either

  1. a Ca2+-dependent Na1 current
     (calmodulin N-terminal lobe mutants: E54K, G40E/D50N, and
     V35I/D50N) or
  2. a Ca21-dependent K1 current
    (calmodulin C-terminal lobe mutants: S101F and M145V) (45).

The chicken calmodulin mutants have been shown to

  • differentially activate myosin light chain kinase
    (M124Q, M51A/V55A, and M51A/V55A/L32A),
    CaMKII (M124Q),  
    and CaMKIV (M124Q),

and the mutated residues are thought to be important in

  • defining calmodulin’s binding specificity (46, 47).

Our finding that these mutant calmodulins can stimulate exocytosis suggests that

  • calmodulin-binding domains similar to those of Paramecium Ca2+/calmodulin-dependent
    ion channels, myosin light chain kinase, CaMKII, and CaMKIV,
  • are unlikely to mediate release utilizing the conserved SNARE fusion machinery, as they
  • could be completely abolished by addition of exogenous syntaxin H3 domains (data not shown).
  • the same molecular pathway was not activated, since their effects were additive (data not shown).

 

Acknowledgments
We thank Diana Bautista and Dr. Richard S.Lewis for generous help
with [Ca21]free determination; Dr. Ching Kung for providing the Paramecium calmodulin
mutants, and Dr. Anthony R. Means for providing the chicken calmodulin mutants. We also
thank Dr. Jesse C. Hay for the initial setup of the cracked cell assay, and Dr. Suzie J.
Scales for helpful comments on the manuscript.

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5. Chen, Y. A., Scales, S. J., Patel, S. M., Doung, Y.-C., and Scheller, R. H. (1999) Cell 97, 165–174
6. Neher, E., and Zucker, R. S. (1993) Neuron 10, 21–30
7. Kamiya, H., and Zucker, R. S. (1994) Nature 371, 603–606
SOURCE

Other related articles published in this Open Access Online Scientific Journal include the following:

The role of ion channels in Na(+)-K(+)-ATPase: regulation of ion transport across the plasma membrane has been studies by our Team in 2012 and 2013. Chiefly, our sources of inspiration were the following:

1. 2013 Nobel work on vesicles and calcium flux at the neuromuscular junction Machinery Regulating Vesicle Traffic, A Major Transport System in our Cells The 2013 Nobel Prize in Physiology or Medicine is awarded to Dr. James E. Rothman, Dr. Randy W. Schekman and Dr. Thomas C. Südhof

  • for their discoveries of machinery regulating vesicle traffic,
  • a major transport system in our cells.

This represents a paradigm shift in our understanding of how the eukaryotic cell, with its complex internal compartmentalization, organizes

  • the routing of molecules packaged in vesicles
  • to various intracellular destinations,
  • as well as to the outside of the cell

Specificity in the delivery of molecular cargo is essential for cell function and survival.

http://www.nobelprize.org/nobel_prizes/medicine/laureates/2013/advanced-medicineprize2013.pdf

Synaptotagmin functions as a Calcium Sensor: How Calcium Ions Regulate the fusion of vesicles with
cell membranes during Neurotransmission

Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

http://pharmaceuticalintelligence.com/2013/09/10/synaptotagmin-functions-as-a-calcium-sensor-
how-calcium-ions-regulate-the-fusion-of-vesicles-with-cell-membranes-during-neurotransmission/

2. Perspectives on Nitric Oxide in Disease Mechanisms

available on Kindle Store @ Amazon.com

http://www.amazon.com/dp/B00DINFFYC

http://pharmaceuticalintelligence.com/biomed-e-books/series-a-e-books-on-cardiovascular-diseases/
perspectives-on-nitric-oxide-in-disease-mechanisms-v2/

3. Professor David Lichtstein, Hebrew University of Jerusalem, Dean, School of Medicine

Lichtstein’s main research focus is the regulation of ion transport across the plasma membrane of eukaryotic cells.

His work led to the discovery that specific steroids that have crucial roles, as

  • the regulation of cell viability,
  • heart contractility,
  • blood pressure and
  • brain function.

His research has implications for the fundamental understanding of body functions,

  • as well as for several pathological states such as
    • heart failure, hypertension
    • and neurological and psychiatric diseases.

Physiologist, Professor Lichtstein, Chair in Heart Studies at The Hebrew University elected
Dean of the Faculty of Medicine at The Hebrew University of Jerusalem

Reporter: Aviva Lev-Ari, PhD, RN

http://pharmaceuticalintelligence.com/2013/12/18/physiologist-professor-lichtstein-chair-in-heart-studies-
at-the-hebrew-university-elected-dean-of-the-faculty-of-medicine-at-the-hebrew-university-of-jerusalem/

4. Professor Roger J. Hajjar, MD at Mount Sinai School of Medicine

Calcium Cycling (ATPase Pump) in Cardiac Gene Therapy: Inhalable Gene Therapy for Pulmonary Arterial Hypertension
and Percutaneous Intra-coronary Artery Infusion for Heart Failure: Contributions by Roger J. Hajjar, MD

Aviva Lev-Ari, PhD, RN

http://pharmaceuticalintelligence.com/2013/08/01/calcium-molecule-in-cardiac-gene-therapy-inhalable-gene-therapy-for-
pulmonary-arterial-hypertension-and-percutaneous-intra-coronary-artery-infusion-for-heart-failure-contributions-by-roger-j-hajjar/

5.            Seminal Curations by Dr. Aviva Lev-Ari on Genetics and Genomics of Cardiovascular Diseases with a focus on Conduction and Cardiac Contractility

Aviva Lev-Ari, PhD, RN

Aviva Lev-Ari, PhD, RN

Aviva Lev-Ari, PhD, RN and Larry H. Bernstein, MD, FCAP

Justin Pearlman, MD, PhD, FACC, Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

6. Atherosclerosis Independence: Genetic Polymorphisms of Ion Channels Role in the Pathogenesis of Coronary Microvascular Dysfunction and Myocardial Ischemia (Coronary Artery Disease (CAD))

Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

http://pharmaceuticalintelligence.com/2013/12/21/genetic-polymorphisms-of-ion-channels-have-a-role-in-the-pathogenesis-of-coronary-microvascular-dysfunction-and-ischemic-heart-disease/

This study presents  the possible correlation between Myocardial Ischemia (Coronary Artery Disease (CAD)) aka Ischemic Heart Disease (IHD) and single-nucleotide polymorphisms (SNPs) genes encoding several regulators involved in Coronary Blood Flow Regulation (CBFR), including

  • ion channels acting in vascular smooth muscle and/or
  • endothelial cells of coronary arteries.

They completely analyzed exon 3 of both KCNJ8 and KCNJ11 genes (Kir6.1 and Kir6.2 subunit, respectively) as well as

  • the whole coding region of KCN5A gene (Kv1.5 channel).

The work suggests certain genetic polymorphisms may represent a non-modifiable protective factor that could be

  • used to identify individuals at relatively low-risk for cardiovascular disease
    • an independent protective role of the
    • rs5215_GG against developing CAD and
    • a trend for rs5219_AA to be associated with protection against coronary microvascular dysfunction

Other related articles published on this Open Access Online Scientific Journal include the following:

ION CHANNEL and Cardiovascular Diseases

http://pharmaceuticalintelligence.com/?s=Ion+Channel

Calcium Role in Cardiovascular Diseases

Part I: Identification of Biomarkers that are Related to the Actin Cytoskeleton
Larry H Bernstein, MD, FCAP
http://pharmaceuticalintelligence.com/2012/12/10/identification-of-biomarkers-
that-are-related-to-the-actin-cytoskeleton/

Part II: Role of Calcium, the Actin Skeleton, and Lipid Structures in Signaling and Cell Motility
Larry H. Bernstein, MD, FCAP, Stephen Williams, PhD and Aviva Lev-Ari, PhD, RN
http://pharmaceuticalintelligence.com/2013/08/26/role-of-calcium-the-actin-
skeleton-and-lipid-structures-in-signaling-and-cell-motility/

Part III: Renal Distal Tubular Ca2+ Exchange Mechanism in Health and Disease
Larry H. Bernstein, MD, FCAP, Stephen J. Williams, PhD
and Aviva Lev-Ari, PhD, RN
http://pharmaceuticalintelligence.com/2013/09/02/renal-distal-tubular-ca2-
exchange-mechanism-in-health-and-disease/

Part IV: The Centrality of Ca(2+) Signaling and Cytoskeleton Involving Calmodulin Kinases and
Ryanodine Receptors in Cardiac Failure, Arterial Smooth Muscle, Post-ischemic Arrhythmia,
Similarities and Differences, and Pharmaceutical Targets
Larry H Bernstein, MD, FCAP, Justin Pearlman, MD, PhD, FACC and Aviva Lev-Ari, PhD, RN
http://pharmaceuticalintelligence.com/2013/09/08/the-centrality-of-ca2-signaling-and-cytoskeleton-
involving-calmodulin-kinases-and-ryanodine-receptors-in-cardiac-failure-arterial-smooth-muscle-
post-ischemic-arrhythmia-similarities-and-differen/

Part V: Ca2+-Stimulated Exocytosis:  The Role of Calmodulin and Protein Kinase C in Ca2+ Regulation of Hormone and Neurotransmitter

Larry H Bernstein, MD, FCAP
and
Aviva Lev-Ari, PhD, RN

http://pharmaceuticalintelligence.com/2013/12/23/calmodulin-and-protein-kinase-c-drive-the-ca2-regulation-of-hormone-and-neurotransmitter-release-that-triggers-ca2-stimulated-exocytosis/

Part VI: Calcium Cycling (ATPase Pump) in Cardiac Gene Therapy: Inhalable Gene Therapy for Pulmonary

Arterial Hypertension and Percutaneous Intra-coronary Artery Infusion for Heart Failure: Contributions by Roger J. Hajjar, MD
Aviva Lev-Ari, PhD, RN
http://pharmaceuticalintelligence.com/2013/08/01/calcium-molecule-in-cardiac-gene-therapy-inhalable-gene-therapy-
for-pulmonary-arterial-hypertension-and-percutaneous-intra-coronary-artery-infusion-for-heart-failure-contributions-by-roger-j-hajjar/

Part VII: Cardiac Contractility & Myocardium Performance: Ventricular Arrhythmias and Non-ischemic Heart Failure –
Therapeutic Implications for Cardiomyocyte Ryanopathy (Calcium Release-related Contractile Dysfunction) and Catecholamine Responses
Justin Pearlman, MD, PhD, FACC, Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
http://pharmaceuticalintelligence.com/2013/08/28/cardiac-contractility-myocardium-performance-ventricular-arrhythmias-
and-non-ischemic-heart-failure-therapeutic-implications-for-cardiomyocyte-ryanopathy-calcium-release-related-contractile/

Part VIII: Disruption of Calcium Homeostasis: Cardiomyocytes and Vascular Smooth Muscle Cells:
The Cardiac and Cardiovascular Calcium Signaling Mechanism
Justin Pearlman, MD, PhD, FACC, Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
http://pharmaceuticalintelligence.com/2013/09/12/disruption-of-calcium-homeostasis-cardiomyocytes-and-vascular-smooth-
muscle-cells-the-cardiac-and-cardiovascular-calcium-signaling-mechanism/

Part IX: Calcium-Channel Blockers, Calcium Release-related Contractile Dysfunction
(Ryanopathy) and Calcium as Neurotransmitter Sensor
Justin Pearlman, MD, PhD, FACC, Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
http://pharmaceuticalintelligence.com/2013/09/16/calcium-channel-blocker-calcium-as-neurotransmitter-sensor-
and-calcium-release-related-contractile-dysfunction-ryanopathy/

Part X: Synaptotagmin functions as a Calcium Sensor: How Calcium Ions Regulate the fusion of
vesicles with cell membranes during Neurotransmission
Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
http://pharmaceuticalintelligence.com/2013/09/10/synaptotagmin-functions-as-a-calcium-sensor-how-calcium-ions-
regulate-the-fusion-of-vesicles-with-cell-membranes-during-neurotransmission/

Part XI: Sensors and Signaling in Oxidative Stress
Larry H. Bernstein, MD, FCAP
http://pharmaceuticalintelligence.com/2013/11/01/sensors-and-signaling-in-oxidative-stress/

Part XII: Atherosclerosis Independence: Genetic Polymorphisms of Ion Channels Role in the Pathogenesis of Coronary Microvascular Dysfunction and Myocardial Ischemia (Coronary Artery Disease (CAD))

Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

http://pharmaceuticalintelligence.com/2013/12/21/genetic-polymorphisms-of-ion-channels-have-a-role-in-the-pathogenesis-of-coronary-microvascular-dysfunction-and-ischemic-heart-disease/

 

Mitochondria and its Role in Cardiovascular Diseases

Mitochondria and Oxidative Stress Role in Cardiovascular Diseases Reversal of Cardiac Mitochondrial Dysfunction
Larry H. Bernstein, MD, FCAP
http://pharmaceuticalintelligence.com/2013/04/14/reversal-of-cardiac-mitochondrial-dysfunction/

Calcium Signaling, Cardiac Mitochondria and Metabolic Syndrome
Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
http://pharmaceuticalintelligence.com/2013/11/09/calcium-signaling-cardiac-mitochondria-and-metabolic-syndrome/

Mitochondrial Dysfunction and Cardiac Disorders
Larry H. Bernstein, MD, FCAP
http://pharmaceuticalintelligence.com/2013/04/14/mitochondrial-dysfunction-and-cardiac-disorders/

Mitochondrial Metabolism and Cardiac Function
Larry H. Bernstein, MD, FCAP
http://pharmaceuticalintelligence.com/2013/04/14/mitochondrial-metabolism-and-cardiac-function/

Mitochondria and Cardiovascular Disease: A Tribute to Richard Bing
Larry H. Bernstein, MD, FCAP
http://pharmaceuticalintelligence.com/2013/04/14/chapter-5-mitochondria-and-cardiovascular-disease/

MIT Scientists on Proteomics: All the Proteins in the Mitochondrial Matrix Identified
Aviva Lev-Ari, PhD, RN
http://pharmaceuticalintelligence.com/2013/02/03/mit-scientists-on-proteomics-all-the-proteins-
in-the-mitochondrial-matrix-identified/

Mitochondrial Dynamics and Cardiovascular Diseases
Ritu Saxena, Ph.D.
http://pharmaceuticalintelligence.com/2012/11/14/mitochondrial-dynamics-and-cardiovascular-diseases/

Mitochondrial Damage and Repair under Oxidative Stress
Larry H Bernstein, MD, FCAP
http://pharmaceuticalintelligence.com/2012/10/28/mitochondrial-damage-and-repair-under-oxidative-stress/

Nitric Oxide has a Ubiquitous Role in the Regulation of Glycolysis -with a Concomitant Influence on Mitochondrial Function
Larry H. Bernstein, MD, FACP
http://pharmaceuticalintelligence.com/2012/09/16/nitric-oxide-has-a-ubiquitous-role-in-the-regulation-of-
glycolysis-with-a-concomitant-influence-on-mitochondrial-function/

Mitochondrial Mechanisms of Disease in Diabetes Mellitus
Aviva Lev-Ari, PhD, RN
http://pharmaceuticalintelligence.com/2012/08/01/mitochondrial-mechanisms-of-disease-in-diabetes-mellitus/

Mitochondria Dysfunction and Cardiovascular Disease – Mitochondria: More than just the “Powerhouse of the Cell”
Ritu Saxena, PhD
http://pharmaceuticalintelligence.com/2012/07/09/mitochondria-more-than-just-the-powerhouse-of-the-cell/

Read Full Post »

See on Scoop.itCardiovascular and vascular imaging

A $14 million funding infusion will help SynCardia Systems double down on efforts to develop a smaller, next-generation version of its artificial heart for children and smaller adults, as well as expand the use of its existing implant on both sides…

See on www.fiercemedicaldevices.com

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SensiCardiac for iPhone Supercharges Electronic Stethoscopes (w/video)

Reporter: Aviva Lev-Ari, PhD, RN

 

See on Scoop.itCardiovascular and vascular imaging

SensiCardiac out of Stellenbosch, South Africa has released a free iPhone app that turns your now old and boring electronic stethoscope into a powerful au

See on www.medgadget.com

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