James A. Haley Veterans' Hospital

BACKGROUND: The incidence and severity of herpes zoster and postherpetic neuralgia increase with age in association with a progressive decline in cell-mediated immunity to varicella-zoster virus (VZV). We tested the hypothesis that vaccination against VZV would decrease the incidence, severity, or both of herpes zoster and postherpetic neuralgia among older adults. METHODS: We enrolled 38,546 adults 60 years of age or older in a randomized, double-blind, placebo-controlled trial of an investigational live attenuated Oka/Merck VZV vaccine ("zoster vaccine"). Herpes zoster was diagnosed according to clinical and laboratory criteria. The pain and discomfort associated with herpes zoster were measured repeatedly for six months. The primary end point was the burden of illness due to herpes zoster, a measure affected by the incidence, severity, and duration of the associated pain and discomfort. The secondary end point was the incidence of postherpetic neuralgia. RESULTS: More than 95 percent of the subjects continued in the study to its completion, with a median of 3.12 years of surveillance for herpes zoster. A total of 957 confirmed cases of herpes zoster (315 among vaccine recipients and 642 among placebo recipients) and 107 cases of postherpetic neuralgia (27 among vaccine recipients and 80 among placebo recipients) were included in the efficacy analysis. The use of the zoster vaccine reduced the burden of illness due to herpes zoster by 61.1 percent (P<0.001), reduced the incidence of postherpetic neuralgia by 66.5 percent (P<0.001), and reduced the incidence of herpes zoster by 51.3 percent (P<0.001). Reactions at the injection site were more frequent among vaccine recipients but were generally mild. CONCLUSIONS: The zoster vaccine markedly reduced morbidity from herpes zoster and postherpetic neuralgia among older adults.

BACKGROUND: Aberrant DNA methylation, which results in leukemogenesis, is frequent in patients with myelodysplastic syndromes (MDS) and is a potential target for pharmacologic therapy. Decitabine indirectly depletes methylcytosine and causes hypomethylation of target gene promoters. METHODS: A total of 170 patients with MDS were randomized to receive either decitabine at a dose of 15 mg/m2 given intravenously over 3 hours every 8 hours for 3 days (at a dose of 135 mg/m2 per course) and repeated every 6 weeks, or best supportive care. Response was assessed using the International Working Group criteria and required that response criteria be met for at least 8 weeks. RESULTS: Patients who were treated with decitabine achieved a significantly higher overall response rate (17%), including 9% complete responses, compared with supportive care (0%) (P < .001). An additional 12 patients who were treated with decitabine (13%) achieved hematologic improvement. Responses were durable (median, 10.3 mos) and were associated with transfusion independence. Patients treated with decitabine had a trend toward a longer median time to acute myelogenous leukemia (AML) progression or death compared with patients who received supportive care alone (all patients, 12.1 mos vs. 7.8 mos [P = 0.16]; those with International Prognostic Scoring System intermediate-2/high-risk disease, 12.0 mos vs. 6.8 mos [P = 0.03]; those with de novo disease, 12.6 mos vs. 9.4 mos [P = 0.04]; and treatment-naive patients, 12.3 mos vs. 7.3 mos [P = 0.08]). CONCLUSIONS: Decitabine was found to be clinically effective in the treatment of patients with MDS, provided durable responses, and improved time to AML transformation or death. The duration of decitabine therapy may improve these results further.

BACKGROUND: Coronary-artery bypass grafting (CABG) has traditionally been performed with the use of cardiopulmonary bypass (on-pump CABG). CABG without cardiopulmonary bypass (off-pump CABG) might reduce the number of complications related to the heart-lung machine. METHODS: We randomly assigned 2203 patients scheduled for urgent or elective CABG to either on-pump or off-pump procedures. The primary short-term end point was a composite of death or complications (reoperation, new mechanical support, cardiac arrest, coma, stroke, or renal failure) before discharge or within 30 days after surgery. The primary long-term end point was a composite of death from any cause, a repeat revascularization procedure, or a nonfatal myocardial infarction within 1 year after surgery. Secondary end points included the completeness of revascularization, graft patency at 1 year, neuropsychological outcomes, and the use of major resources. RESULTS: There was no significant difference between off-pump and on-pump CABG in the rate of the 30-day composite outcome (7.0% and 5.6%, respectively; P=0.19). The rate of the 1-year composite outcome was higher for off-pump than for on-pump CABG (9.9% vs. 7.4%, P=0.04). The proportion of patients with fewer grafts completed than originally planned was higher with off-pump CABG than with on-pump CABG (17.8% vs. 11.1%, P<0.001). Follow-up angiograms in 1371 patients who underwent 4093 grafts revealed that the overall rate of graft patency was lower in the off-pump group than in the on-pump group (82.6% vs. 87.8%, P<0.01). There were no treatment-based differences in neuropsychological outcomes or short-term use of major resources. CONCLUSIONS: At 1 year of follow-up, patients in the off-pump group had worse composite outcomes and poorer graft patency than did patients in the on-pump group. No significant differences between the techniques were found in neuropsychological outcomes or use of major resources. (ClinicalTrials.gov number, NCT00032630.).

OBJECTIVES: Chronic subjective tinnitus is a prevalent condition that causes significant distress to millions of Americans. Effective tinnitus treatments are urgently needed, but evaluating them is hampered by the lack of standardized measures that are validated for both intake assessment and evaluation of treatment outcomes. This work was designed to develop a new self-report questionnaire, the Tinnitus Functional Index (TFI), that would have documented validity both for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus (responsiveness) and that would provide comprehensive coverage of multiple tinnitus severity domains. DESIGN: To use preexisting knowledge concerning tinnitus-related problems, an Item Selection Panel (17 expert judges) surveyed the content (175 items) of nine widely used tinnitus questionnaires. From those items, the Panel identified 13 separate domains of tinnitus distress and selected 70 items most likely to be responsive to treatment effects. Eliminating redundant items while retaining good content validity and adding new items to achieve the recommended minimum of 3 to 4 items per domain yielded 43 items, which were then used for constructing TFI Prototype 1.Prototype 1 was tested at five clinics. The 326 participants included consecutive patients receiving tinnitus treatment who provided informed consent-constituting a convenience sample. Construct validity of Prototype 1 as an outcome measure was evaluated by measuring responsiveness of the overall scale and its individual items at 3 and 6 mo follow-up with 65 and 42 participants, respectively. Using a predetermined list of criteria, the 30 best-functioning items were selected for constructing TFI Prototype 2.Prototype 2 was tested at four clinics with 347 participants, including 155 and 86 who provided 3 and 6 mo follow-up data, respectively. Analyses were the same as for Prototype 1. Results were used to select the 25 best-functioning items for the final TFI. RESULTS: Both prototypes and the final TFI displayed strong measurement properties, with few missing data, high validity for scaling of tinnitus severity, and good reliability. All TFI versions exhibited the same eight factors characterizing tinnitus severity and negative impact. Responsiveness, evaluated by computing effect sizes for responses at follow-up, was satisfactory in all TFI versions.In the final TFI, Cronbach's alpha was 0.97 and test-retest reliability 0.78. Convergent validity (r = 0.86 with Tinnitus Handicap Inventory [THI]; r = 0.75 with Visual Analog Scale [VAS]) and discriminant validity (r = 0.56 with Beck Depression Inventory-Primary Care [BDI-PC]) were good. The final TFI was successful at detecting improvement from the initial clinic visit to 3 mo with moderate to large effect sizes and from initial to 6 mo with large effect sizes. Effect sizes for the TFI were generally larger than those obtained for the VAS and THI. After careful evaluation, a 13-point reduction was considered a preliminary criterion for meaningful reduction in TFI outcome scores. CONCLUSIONS: The TFI should be useful in both clinical and research settings because of its responsiveness to treatment-related change, validity for scaling the overall severity of tinnitus, and comprehensive coverage of multiple domains of tinnitus severity.

There continues to be debate about the long-term neuropsychological impact of mild traumatic brain injury (MTBI). A meta-analysis of the relevant literature was conducted to determine the impact of MTBI across nine cognitive domains. The analysis was based on 39 studies involving 1463 cases of MTBI and 1191 control cases. The overall effect of MTBI on neuropsychological functioning was moderate (d = .54). However, findings were moderated by cognitive domain, time since injury, patient characteristics, and sampling methods. Acute effects (less than 3 months postinjury) of MTBI were greatest for delayed memory and fluency (d = 1.03 and .89, respectively). In unselected or prospective samples, the overall analysis revealed no residual neuropsychological impairment by 3 months postinjury (d = .04). In contrast, clinic-based samples and samples including participants in litigation were associated with greater cognitive sequelae of MTBI (d = .74 and .78, respectively at 3 months or greater). Indeed, litigation was associated with stable or worsening of cognitive functioning over time. The implications and limitations of these findings are discussed.

OBJECTIVES: This report examines the frequency, type, and prognostic factors of medical (nonneurologic) complications after subarachnoid hemorrhage in a large, prospective study. The influences of contemporary neurosurgical, neurological, and critical care practice on mortality and morbidity rates after aneurysmal subarachnoid hemorrhage are evaluated. DESIGN: A study of medical complications observed in the placebo limb of a large, randomized, controlled trial of the calcium antagonist, nicardipine, after subarachnoid hemorrhage. SETTING: Patients were recruited from 50 hospitals in 41 neurosurgical centers in the United States and Canada. PATIENTS: A total of 457 patients with subarachnoid hemorrhage, > or = 18 yrs of age, were randomly assigned to the placebo group. All patients arrived at the participating center within 7 days (mean 1.0 +/- 1.8 [SD] days) of rupture of an angiographically documented saccular aneurysm. MEASUREMENTS AND MAIN RESULTS: The frequency rates of symptomatic vasospasm, rebleeding, and total mortality rate after subarachnoid hemorrhage at 3-month follow-up were 46%, 7%, and 19%, respectively. The frequency of having at least one severe (life-threatening) medical complication was 40%. The proportion of deaths from medical complications was 23%. This value was comparable with the proportion of deaths attributed to the direct effects of the initial hemorrhage (19%), rebleeding (22%), and vasospasm (23%) after aneurysmal rupture. The frequency of life-threatening cardiac arrhythmias was 5%; less ominous rhythm disturbances occurred in 30% of the patients. There was an increased frequency of cardiac arrhythmias on the day of, or day after, aneurysm surgery. Pulmonary edema occurred in 23% of the patients, with a 6% occurrence rate incidence of severe pulmonary edema. There was a wide variation from center to center, with the greatest frequency on days 3 through 7. There was a nonsignificant association of pulmonary edema with the use of hypertensive hypervolemic therapy (p = .10), and a significant association with the timing of surgery (p < .05). Some degree of hepatic dysfunction was noted in 24% of patients, the majority with only mild abnormalities of hepatic enzymes with no clinical accompaniment (4% frequency of severe hepatic dysfunction). Thrombocytopenia occurred in 4% of patients, usually in the setting of sepsis. Renal dysfunction was reported in 7% of the patients, with 15% of that figure deemed to be of life-threatening severity. There was an association (p = .001) with antibiotic therapy. CONCLUSIONS: Potentially preventable medical complications after ruptured cerebral aneurysm add to the total mortality rate of patients, and may increase length of hospital stay in the critical care setting. The proportion of deaths after subarachnoid hemorrhage from medical complications equals those deaths from either direct effects, rebleeding, or vasospasm individually. Pulmonary complications are the most common nonneurologic cause of death. Cardiac arrhythmia, although frequent, was not associated with significant mortality. The frequency of cardiac arrhythmia and pulmonary edema increased on the day of, or day after, aneurysm surgery. Renal and hepatic dysfunction, and blood dyscrasias, were also observed, underscoring the need for meticulous monitoring for metabolic and hematologic derangements.

The protective/neurotoxic role of fractalkine (CX3CL1) and its receptor CX3C chemokine receptor 1 (CX3CR1) signaling in neurodegenerative disease is an intricate and highly debated research topic and it is becoming even more complicated as new studies reveal discordant results. It appears that the CX3CL1/CX3CR1 axis plays a direct role in neurodegeneration and/or neuroprotection depending on the CNS insult. However, all the above studies focused on the role of CX3CL1/CX3CR1 signaling in pathological conditions, ignoring the relevance of CX3CL1/CX3CR1 signaling under physiological conditions. No approach to date has been taken to decipher the significance of defects in CX3CL1/CX3CR1 signaling in physiological condition. In the present study we used CX3CR1⁻/⁻, CX3CR1⁺/⁻, and wild-type mice to investigate the physiological role of CX3CR1 receptor in cognition and synaptic plasticity. Our results demonstrate for the first time that mice lacking the CX3CR1 receptor show contextual fear conditioning and Morris water maze deficits. CX3CR1 deficiency also affects motor learning. Importantly, mice lacking the receptor have a significant impairment in long-term potentiation (LTP). Infusion with IL-1β receptor antagonist significantly reversed the deficit in cognitive function and impairment in LTP. Our results reveal that under physiological conditions, disruption in CX3CL1 signaling will lead to impairment in cognitive function and synaptic plasticity via increased action of IL-1β.

Although widely touted as a replacement for glass slides and microscopes in pathology, digital slides present major challenges in data storage, transmission, processing and interoperability. Since no universal data format is in widespread use for these images today, each vendor defines its own proprietary data formats, analysis tools, viewers and software libraries. This creates issues not only for pathologists, but also for interoperability. In this paper, we present the design and implementation of OpenSlide, a vendor-neutral C library for reading and manipulating digital slides of diverse vendor formats. The library is extensible and easily interfaced to various programming languages. An application written to the OpenSlide interface can transparently handle multiple vendor formats. OpenSlide is in use today by many academic and industrial organizations world-wide, including many research sites in the United States that are funded by the National Institutes of Health.

Abstract This paper is devoted to the development of a composite model of limb praxis processing that is supported by a series of dissociations noted in the performance of apraxic patients. These dissociations include die separability of praxis production from praxis reception, the selectivity of input modalities, an “assembled” route of praxis imitation, and the possible fragmentation of semantics into an action and a nonaction system.

There is increasing interest in the potential neuropsychological impact of sports-related concussion. A meta-analysis of the relevant literature was conducted to determine the impact of sports-related concussion across six cognitive domains. The analysis was based on 21 studies involving 790 cases of concussion and 2014 control cases. The overall effect of concussion (d = 0.49) was comparable to the effect found in the non-sports-related mild traumatic brain injury population (d = 0.54; Belanger et al., 2005). Using sports-concussed participants with a history of prior head injury appears to inflate the effect sizes associated with the current sports-related concussion. Acute effects (within 24 hr of injury) of concussion were greatest for delayed memory, memory acquisition, and global cognitive functioning (d = 1.00, 1.03, and 1.42, respectively). However, no residual neuropsychological impairments were found when testing was completed beyond 7 days postinjury. These findings were moderated by cognitive domain and comparison group (control group versus preconcussion self-control). Specifically, delayed memory in studies utilizing a control group remained problematic at 7 days. The implications and limitations of these findings are discussed.

FoxO transcription factors are important targets of insulin action. To better understand the role of FoxO proteins in the liver, we created transgenic mice expressing constitutively active FoxO1 in the liver using the alpha1-antitrypsin promoter. Fasting glucose levels are increased, and glucose tolerance is impaired in transgenic (TGN) versus wild type (WT) mice. Interestingly, fasting triglyceride and cholesterol levels are reduced despite hyperinsulinemia, and post-prandial changes in triglyceride levels are markedly suppressed in TGN versus WT mice. Activation of pro-lipogenic signaling pathways (atypical protein kinase C and protein kinase B) and the ability to suppress beta-hydroxybutyrate levels are not impaired in TGN. In contrast, de novo lipogenesis measured with (3)H(2)O is suppressed by approximately 70% in the liver of TGN versus WT mice after refeeding. Gene-array studies reveal that the expression of genes involved in gluconeogenesis, glycerol transport, and amino acid catabolism is increased, whereas genes involved in glucose utilization by glycolysis, the pentose phosphate shunt, lipogenesis, and sterol synthesis pathways are suppressed in TGN versus WT. Studies with adenoviral vectors in isolated hepatocytes confirm that FoxO1 stimulates expression of gluconeogenic genes and suppresses expression of genes involved in glycolysis, the shunt pathway, and lipogenesis, including glucokinase and SREBP-1c. Together, these results indicate that FoxO proteins promote hepatic glucose production through multiple mechanisms and contribute to the regulation of other metabolic pathways important in the adaptation to fasting and feeding in the liver, including glycolysis, the pentose phosphate shunt, and lipogenic and sterol synthetic pathways.

BACKGROUND: The literature on family caregiving for stroke patients is reviewed with the goals of (1) evaluating the effects of stroke caregiving on caregivers' well-being, (2) outlining deficiencies and methodological limitations of current research, and (3) outlining policy and practice implications of current studies. SUMMARY OF REVIEW: A total of 20 published stroke caregiving research articles were included in this review. Across studies, the effects of stroke caregiving on caregivers' well-being and the significant predictors of caregivers' depression were analyzed. Current evidence suggests that stroke caregivers have elevated levels of depression at both the acute stroke phase and the chronic stroke phase. However, major gaps are apparent in this literature, with few studies addressing such areas as caregiver physical health, ethnicity, and caregiver interventions. CONCLUSIONS: Given the increasing prevalence of stroke as well as the increasing pressures on families to provide care, more research is needed to guide policy and practice in this understudied topic.

Specific Immunotherapy for respiratory allergy is used since about one century and there is now solid documentation of its efficacy. Nevertheless, the methods and experimental designs used in clinical trials are quite heterogeneous and there is no unanimously accepted methodological standard. Many studies are planned with study designs that may not confirm the clinical value of SIT as an effective treatment to reduce disease severity. To ensure that patients are treated based on sound scientific evidence and to minimize the risk of misusing limited financial resources for scientific studies, the World Allergy Organization (WAO) convened a group of experts to provide guidelines for the methodology of future immunotherapy studies. This document summarizes the recommendations for study design, patients' selection, appropriate outcomes and statistical treatment to be used in planning and performing clinical trials with specific immunotherapy.

Insulin provoked rapid increases in enzyme activity of immunoprecipitable protein kinase C-ζ (PKC-ζ) in rat adipocytes. Concomitantly, insulin provoked increases in32P labeling of PKC-ζ both in intact adipocytes and during in vitro assay of immunoprecipitated PKC-ζ; the latter probably reflected autophosphorylation, as it was inhibited by the PKC-ζ pseudosubstrate. Insulin-induced activation of immunoprecipitable PKC-ζ was inhibited by LY294002 and wortmannin; this suggested dependence upon phosphatidylinositol (PI) 3-kinase. Accordingly, activation of PI 3-kinase by a pYXXM-containing peptide in vitro resulted in a wortmannin-inhibitable increase in immunoprecipitable PKC-ζ enzyme activity. Also, PI-3,4-(PO4)2, PI-3,4,5-(PO4)3, and PI-4,5-(PO4)2 directly stimulated enzyme activity and autophosphoralytion in control PKC-ζ immunoprecipitates to levels observed in insulin-treated PKC-ζ immunoprecipitates. In studies of glucose transport, inhibition of immunoprecipitated PKC-ζ enzyme activity in vitro by both the PKC-ζ pseudosubstrate and RO 31-8220 correlated well with inhibition of insulin-stimulated glucose transport in intact adipocytes. Also, in adipocytes transiently expressing hemagglutinin antigen-tagged GLUT4, co-transfection of wild-type or constitutive PKC-ζ stimulated hemagglutinin antigen-GLUT4 translocation, whereas dominant-negative PKC-ζ partially inhibited it. Our findings suggest that insulin activates PKC-ζ through PI 3-kinase, and PKC-ζ may act as a downstream effector of PI 3-kinase and contribute to the activation of GLUT4 translocation. Insulin provoked rapid increases in enzyme activity of immunoprecipitable protein kinase C-ζ (PKC-ζ) in rat adipocytes. Concomitantly, insulin provoked increases in32P labeling of PKC-ζ both in intact adipocytes and during in vitro assay of immunoprecipitated PKC-ζ; the latter probably reflected autophosphorylation, as it was inhibited by the PKC-ζ pseudosubstrate. Insulin-induced activation of immunoprecipitable PKC-ζ was inhibited by LY294002 and wortmannin; this suggested dependence upon phosphatidylinositol (PI) 3-kinase. Accordingly, activation of PI 3-kinase by a pYXXM-containing peptide in vitro resulted in a wortmannin-inhibitable increase in immunoprecipitable PKC-ζ enzyme activity. Also, PI-3,4-(PO4)2, PI-3,4,5-(PO4)3, and PI-4,5-(PO4)2 directly stimulated enzyme activity and autophosphoralytion in control PKC-ζ immunoprecipitates to levels observed in insulin-treated PKC-ζ immunoprecipitates. In studies of glucose transport, inhibition of immunoprecipitated PKC-ζ enzyme activity in vitro by both the PKC-ζ pseudosubstrate and RO 31-8220 correlated well with inhibition of insulin-stimulated glucose transport in intact adipocytes. Also, in adipocytes transiently expressing hemagglutinin antigen-tagged GLUT4, co-transfection of wild-type or constitutive PKC-ζ stimulated hemagglutinin antigen-GLUT4 translocation, whereas dominant-negative PKC-ζ partially inhibited it. Our findings suggest that insulin activates PKC-ζ through PI 3-kinase, and PKC-ζ may act as a downstream effector of PI 3-kinase and contribute to the activation of GLUT4 translocation. The atypical protein kinase C (PKC), 1The abbreviations used are: PKC, protein kinase C; DAG, diacylglycerol; PI, phosphatidylinositol; KRP, Krebs-Ringer phosphate; TPA, tetradecanoylphorbol-13-acetate; HA, hemagglutinin antigen; 2-DOG, [3H]2-deoxyglucose. PKC-ζ, is ubiquitously expressed, but little is known about its activation or actions. This ignorance partly derives from the fact that PKC-ζ is not activated by membrane-associated diacylglycerol (DAG) or phorbol esters, generally does not translocate appreciably from cytosol to membrane when activated, and is not depleted by prolonged phorbol ester treatment. Consequently, methods used to evaluate DAG-sensitive conventional (α, β, and γ) and novel (δ, ε, η, and θ) PKCs are not relevant to PKC-ζ and other DAG-insensitive, atypical PKCs. Although not activated by DAG, PKC-ζ is activated in vitro by phosphatidylserine and polyphosphoinositides, including D3-PO4 derivatives of phosphatidylinositol (PI) (1Nakanishi H. Brewer K.A. Exton J.H. J. Biol. Chem. 1993; 268: 13-16Abstract Full Text PDF PubMed Google Scholar, 2Palmer R.H. Dekker L.V. Woscholski R. Le Good J.A. Gigg R. Parker P.J. J. Biol. Chem. 1995; 270: 22412-22416Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar). Because of its activation by polyphosphoinositides, PKC-ζ has been suspected to operate downstream of PI 3-kinase; however, direct experimental evidence for this suspicion is lacking, particularly in intact cells. Since insulin increases total polyphosphoinositide levels (3Farese R.V. Larson R.E. Sabir M.A. J. Biol. Chem. 1982; 257: 4042-4045Abstract Full Text PDF PubMed Google Scholar, 4Farese R.V. Barnes D.E. Davis J.S. Standaert M.L. Pollet R. J. Biol. Chem. 1984; 259: 7094-7100Abstract Full Text PDF PubMed Google Scholar, 5Farese R.V. Davis J.S. Barnes D.E. Standaert M.L. Babischkin J.S. Hock R. Rosic N.K. Pollet R.J. Biochem. J. 1985; 231: 269-278Crossref PubMed Scopus (98) Google Scholar, 6Pennington S.R. Martin B.R. J. Biol. Chem. 1985; 260: 11039-11045Abstract Full Text PDF PubMed Google Scholar), probably largely through PI 3-kinase activation (7Ruderman N.B. Kapeller R. White M.F. Cantley L.C. Proc. Natl. Acad. Sci. U. S. A. 1990; 87: 1411-1415Crossref PubMed Scopus (395) Google Scholar), we examined the possibility that insulin activates PKC-ζ by a PI 3-kinase-dependent mechanism. To this end, we assayed immunoprecipitable PKC-ζ (a) following treatment of intact adipocytes with insulin in the presence and absence of PI 3-kinase inhibitors; (b) following PI 3-kinase activation in vitro by a pYXXM-containing peptide; and (c) in response to polyphosphoinositides added directly to the assay of PKC-ζ in vitro. Also, since PI 3-kinase appears to be required for insulin-stimulated GLUT4 translocation and subsequent glucose transport, we questioned whether PKC-ζ, as an effector of PI 3-kinase, may play a role in this process. To this end, we used PKC-ζ inhibitors and examined the effects of transiently transfected wild-type, constitutive, and dominant-negative PKC-ζ in adipocytes co-transfected with hemagglutinin antigen (HA)-tagged GLUT4. As described (8Standaert M.L. Avignon A. Yamada K. Bandyopadhyay G. Farese R.V. Biochem. J. 1996; 313: 1039-1045Crossref PubMed Scopus (60) Google Scholar), rat adipocytes were prepared from epididymal fat pads of 200–250-g male Sprague-Dawley rats. For acute incubations, the cells were suspended and incubated in glucose-free Krebs-Ringer phosphate (KRP) buffer containing 1% bovine serum albumin with or without insulin (Elanco), tetradecanoylphorbol-13-acetate (TPA; Sigma), wortmannin (Sigma), LY294002 (Biomol), RO 31-8820 (Alexis), and/or myristoylated PKC-ζ or PKA pseudosubstrate peptides (Quality Controlled Biochemicals) as indicated in the text. For overnight incubations, the cells were suspended in Dulbecco's modified Eagle's medium (Life Technologies, Inc.) containing 1% bovine serum albumin, 5 mm glucose, and other indicated treatments; after overnight incubations, the cells were transferred to glucose-free KRP for acute treatments. Following acute treatments, glucose transport was assayed by measurement of [3H]2-deoxyglucose (2-DOG; 0.1 mm; NEN Life Science Products) uptake over 1 min as described (8Standaert M.L. Avignon A. Yamada K. Bandyopadhyay G. Farese R.V. Biochem. J. 1996; 313: 1039-1045Crossref PubMed Scopus (60) Google Scholar), or PKC-ζ enzyme activity was assayed as described below. In some experiments, adipocytes were co-transfected by electroporation (as described by Quon et al. (9Quon M.J. Butte A.J. Zarnowski M. Sesti G. Cushman S.W. Taylor S.I. J. Biol. Chem. 1994; 269: 27920-27924Abstract Full Text PDF PubMed Google Scholar, 10Quon M.J. Guerre-Millo M. Zarnowski M.J. Butte A.J. Em M. Cushman S.W. Taylor S.I. Proc. Natl. Acad. Sci. U. S. A. 1994; 9: 5587-5591Crossref Scopus (87) Google Scholar)) in the presence of (a) pCIS2 eukaryotic expression vector containing cDNA encoding HA-tagged GLUT4 (kindly supplied by Drs. Michael Quon and Simeon Taylor) and (b) pCDNA3 eukaryotic expression vector alone (vector) or pCDNA3 containing cDNA encoding either (i) various forms of PKC-ζ (wild-type and dominant-negative forms of PKC-ζ were described previously (11Bandyopadhyay B. Standaert M.L. Zhao L. Yu B. Avignon A.M. Galloway L. Karnam P. Moscat J. Farese R.V. J. Biol. Chem. 1997; 272: 2551-2558Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar), and the constitutive form of PKC-ζ was generated by mutating Ala119 in the pseudosubstrate region to Asp119 (i.e. GCC to GAC) using a Transformer™ Site-Directed Mutagenesis Kit from CLONTECH; the sequence of this construct was confirmed by sequence analysis) or (i) a dominant-negative mutant form of the Δp85 subunit of PI 3-kinase (Δp85; kindly supplied by Drs. Wataru Ogawa and Masato Kasuga). These cells were incubated overnight in Dulbecco's modified Eagle's medium containing 25 mmHepes, 200 nm(−N)-N 6-(2-phenylisopropyl)-adenosine, and 5% bovine serum albumin to allow time for expression of the inserts. Cells were then washed and resuspended in glucose-free KRP medium and treated with or without 10 nm insulin for 30 min prior to the of mm and of the translocation of HA-tagged GLUT4 to the as described (9Quon M.J. Butte A.J. Zarnowski M. Sesti G. Cushman S.W. Taylor S.I. J. Biol. Chem. 1994; 269: 27920-27924Abstract Full Text PDF PubMed Google Scholar, 10Quon M.J. Guerre-Millo M. Zarnowski M.J. Butte A.J. Em M. Cushman S.W. Taylor S.I. Proc. Natl. Acad. Sci. U. S. A. 1994; 9: 5587-5591Crossref Scopus (87) Google Scholar). This treatment was using and to of GLUT4 containing the To PKC-ζ enzyme as described previously (11Bandyopadhyay B. Standaert M.L. Zhao L. Yu B. Avignon A.M. Galloway L. Karnam P. Moscat J. Farese R.V. J. Biol. Chem. 1997; 272: 2551-2558Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar), the were by KRP and cells were washed and in mm mm mm 1 1 mm 1 mm and 1 mm were for 10 min to and the fat and mm were then added to the total after 30 min or from Life Technologies, or were a sequence and was added to containing of overnight immunoprecipitates were protein by and suspended in mm 5 mm 1 mm and were then incubated for min 30 in of containing of Life Science of and a for PKC-ζ A. H. J. 1993; Scholar). In some experiments, or or PI-4,5-(PO4)2 was added as a to the were by of 10 of 5% of the were washed in 5% and were from with serum or from in the presence of PKC-ζ pseudosubstrate and were from total to were with to time and were upon of phosphatidylserine but not or Insulin treatment not either the of PKC-ζ in immunoprecipitates or the of total was in the and this was not by the of a of As previously (11Bandyopadhyay B. Standaert M.L. Zhao L. Yu B. Avignon A.M. Galloway L. Karnam P. Moscat J. Farese R.V. J. Biol. Chem. 1997; 272: 2551-2558Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar), PKC-ζ immunoprecipitates β, or ε, are known to be in rat adipocytes A. Standaert M.L. Yamada K. H. B. Farese R.V. Biochem. J. 1995; PubMed Scopus Google Scholar). The dependence of enzyme activity phosphatidylserine suggested that protein kinase and protein kinase were from PKC-ζ since immunoprecipitable and are of L. L. P. G. J. and R. In experiments, control and treated cells were from the of and were assayed in of treatment were to the control of observed in control and insulin-stimulated PKC-ζ immunoprecipitates in an is in of In some of immunoprecipitated PKC-ζ, was and labeling of PKC-ζ was after its by to and in the were as described (11Bandyopadhyay B. Standaert M.L. Zhao L. Yu B. Avignon A.M. Galloway L. Karnam P. Moscat J. Farese R.V. J. Biol. Chem. 1997; 272: 2551-2558Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar), that used for and were from were in a PI 3-kinase activity in was as described previously (8Standaert M.L. Avignon A. Yamada K. Bandyopadhyay G. Farese R.V. Biochem. J. 1996; 313: 1039-1045Crossref PubMed Scopus (60) Google Scholar). Insulin provoked rapid increases in the enzyme activity in PKC-ζ immunoprecipitates prepared from total were observed a treatment with 10 nm but the increases to be with and 10 and were insulin of In increases in immunoprecipitable PKC-ζ enzyme activity 10 min of 10 nm insulin treatment were from to This to in but in the of the may in As in increases in immunoprecipitable PKC-ζ were not in incubated adipocytes but in adipocytes that were incubated overnight prior to acute insulin treatment. As the of DAG-sensitive PKCs (α, and by overnight treatment to or insulin-stimulated immunoprecipitable PKC-ζ enzyme activity and in some other insulin-stimulated uptake was partly by in the activity of the insulin or other by activation of DAG-sensitive PKCs that in some for overnight treatment in in A. Standaert M.L. Yamada K. H. B. Farese R.V. Biochem. J. 1995; PubMed Scopus Google These with the fact that PKC-ζ immunoprecipitates little or or B. Standaert M.L. Zhao L. Yu B. Avignon A.M. Galloway L. Karnam P. Moscat J. Farese R.V. J. Biol. Chem. 1997; 272: 2551-2558Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar), (a) evidence for the of the used PKC-ζ enzyme (b) that and be from glucose transport effects of insulin in the rat and (c) that PKC-ζ is activated by acute insulin treatment in adipocytes that are either used directly or and incubated overnight with or without To whether PKC-ζ may be activated by a PI 3-kinase-dependent we used we used but inhibitors of PI 3-kinase. In that PI 3-kinase and insulin effects glucose transport, both LY294002 and wortmannin inhibited insulin effects PKC-ζ activation in intact adipocytes in inhibitors not PKC-ζ enzyme activity when added directly to PKC-ζ immunoprecipitates we used a peptide by of its activates the of PI 3-kinase White M.F. J. Biol. Chem. 1995; 270: Full Text Full Text PDF PubMed Scopus Google Scholar). of this peptide with control was a activation of immunoprecipitable PKC-ζ this activation was by nm that it was by PI 3-kinase activation that PI 3-kinase activity in was by pYXXM-containing peptide and was by LY294002 we added polyphosphoinositides PI-3,4,5-(PO4)3, and directly to control and insulin-stimulated PKC-ζ immunoprecipitates. As in of polyphosphoinositides, in to be in other experiments, stimulated enzyme activity of control PKC-ζ immunoprecipitates but a or insulin-stimulated PKC-ζ polyphosphoinositides or the in enzyme activity control and insulin-stimulated immunoprecipitates. These findings suggested that PI 3-kinase is not required for activation of immunoprecipitable PKC-ζ in rat adipocytes through its for this of PI 3-kinase in vitro by pYXXM-containing peptide a wortmannin-inhibitable increase in immunoprecipitable PKC-ζ enzyme activity. was prepared by control adipocytes in containing mm to of and incubated for 10 min with indicated of peptide in the presence of mm mm mm mm and PI, with or without nm wortmannin as PKC-ζ was immunoprecipitated and assayed for enzyme activity. are of in the is an of PI 3-kinase-dependent labeling of that in response to indicated of peptide this was that increases in PI 3-kinase activity were and enzyme activity was largely by the PI 3-kinase LY294002 of PI-3,4-(PO4)2, PI-3,4,5-(PO4)3, and PI-4,5-(PO4)2 control and insulin-stimulated immunoprecipitable PKC-ζ enzyme activity. were treated for 10 min with or without 10 nm and PKC-ζ was immunoprecipitated from total and assayed for enzyme activity in the absence or presence of 10 10 or 1 were to be in other are of evidence (8Standaert M.L. Avignon A. Yamada K. Bandyopadhyay G. Farese R.V. Biochem. J. 1996; 313: 1039-1045Crossref PubMed Scopus (60) Google Scholar, M.L. Pollet R.J. Farese R.V. 1990; Full Text PDF PubMed Scopus Google Scholar, H. Biochem. J. 1994; PubMed Scopus Google that a protein kinase to PI 3-kinase (8Standaert M.L. Avignon A. Yamada K. Bandyopadhyay G. Farese R.V. Biochem. J. 1996; 313: 1039-1045Crossref PubMed Scopus (60) Google Scholar, Le J. Biol. Chem. 1993; 268: Full Text PDF PubMed Google may be required for insulin effects translocation and glucose Insulin effects are to inhibitors in the required of inhibitors (8Standaert M.L. Avignon A. Yamada K. Bandyopadhyay G. Farese R.V. Biochem. J. 1996; 313: 1039-1045Crossref PubMed Scopus (60) Google Scholar, M.L. Pollet R.J. Farese R.V. 1990; Full Text PDF PubMed Scopus Google Scholar, H. Biochem. J. 1994; PubMed Scopus Google required to conventional and novel DAG-sensitive PKCs. it may be that are inhibitors of conventional PKCs but PKC-ζ G. H. G. H. J. Biol. Chem. 1993; 268: Full Text PDF PubMed Google Scholar, Parker P.J. J.S. Biochem. J. 1993; PubMed Scopus Google Scholar), and this was to be the for the RO inhibited forms of and with of and we that the inhibition of enzyme activity in PKC-ζ vitro the inhibition of insulin-stimulated glucose transport observed in intact adipocytes in response to of RO 31-8220 for inhibition of both were of RO 31-8220 for of PKC-ζ in immunoprecipitates for that in may in of RO 31-8220 enzyme In other we that RO 31-8220 not activation of PI 3-kinase (8Standaert M.L. Avignon A. Yamada K. Bandyopadhyay G. Farese R.V. Biochem. J. 1996; 313: 1039-1045Crossref PubMed Scopus (60) Google or PI 3-kinase-dependent activation of or RO 31-8220 does not insulin that PI 3-kinase. that that conventional PKCs (α, β, γ) but not novel or atypical not insulin-stimulated glucose transport in to not of PKC-ζ enzyme activity and insulin-stimulated uptake by RO 31-8220 and the PKC-ζ pseudosubstrate in rat adipocytes. To and uptake in adipocytes were for min with RO 31-8220 or for min this time was with myristoylated PKC-ζ or PKA prior to treatment with 10 nm insulin for 30 of over 1 min was then of inhibitors PKC-ζ enzyme activity and were in PKC-ζ immunoprecipitates prepared from insulin-treated adipocytes. In C and effects of RO 31-8220 and PKC-ζ pseudosubstrate insulin-stimulated uptake and PKC-ζ enzyme activity are as of the insulin or are of in In to RO the J. J. Biol. Chem. 1993; 268: Full Text PDF PubMed Google Scholar), myristoylated PKC-ζ pseudosubstrate but not the myristoylated PKA pseudosubstrate inhibited insulin-stimulated glucose transport in a and in intact adipocytes Full inhibition was min of treatment with PKC-ζ pseudosubstrate and the was that treatment and were in studies of inhibition by a myristoylated pseudosubstrate in cells J. J. Biol. Chem. 1993; 268: Full Text PDF PubMed Google enzyme activity of immunoprecipitated PKC-ζ in vitro was inhibited by of PKC-ζ pseudosubstrate that were to required for inhibition of glucose transport in intact cells in other we that the PKC-ζ pseudosubstrate does not immunoprecipitated and is not the PKC-ζ protein kinase that is required for glucose As to the possibility that PKC-ζ may play a role in insulin of glucose transport, we co-transfected HA-tagged GLUT4 and various forms of PKC-ζ rat adipocytes. overnight to allow time for expression by HA-tagged PKC-ζ with HA-tagged GLUT4 in some we that wild-type PKC-ζ to a constitutive PKC-ζ HA-tagged GLUT4 translocation and effects of insulin HA-tagged GLUT4 translocation were observed in cells expressing wild-type and constitutive PKC-ζ, the of increases in HA-tagged GLUT4 translocation, were in cells. In to observed effects of wild-type and constitutive PKC-ζ, a dominant-negative form of PKC-ζ B. Standaert M.L. Zhao L. Yu B. Avignon A.M. Galloway L. Karnam P. Moscat J. Farese R.V. J. Biol. Chem. 1997; 272: 2551-2558Abstract Full Text Full Text PDF PubMed Scopus (276) Google to HA-tagged GLUT4 translocation, but in about of the experiments, it inhibited insulin-stimulated HA-tagged GLUT4 translocation and by this inhibition was that observed in adipocytes transfected with dominant-negative was in about of the from an in forms of PKC-ζ and Δp85 were used in (i.e. in the of are in from are in increases in HA-tagged GLUT4 translocation to expression of wild-type and constitutive PKC-ζ were and this may be with insulin-stimulated increases of that in the translocation of HA-tagged GLUT4 not be by in its expression in cells co-transfected with various forms of PKC-ζ or in as with PKC-ζ, increases in HA-tagged GLUT4 translocation were observed in adipocytes expressing a constitutive form of PKC-ζ in (i.e. the was Although it was not to directly in transiently transfected we observed effects of transfected wild-type PKC-ζ co-transfected HA-tagged GLUT4 that a of transfected wild-type PKC-ζ was without insulin of transiently wild-type constitutive and dominant-negative PKC-ζ control and insulin-stimulated translocation in rat adipocytes. Cells were suspended in Dulbecco's modified Eagle's medium and co-transfected with pCIS2 containing cDNA encoding HA-tagged GLUT4 and with pCDNA3 alone or pCDNA3 containing cDNA encoding wild-type, constitutive, or dominant-negative PKC-ζ or dominant-negative overnight the cells were for min in glucose-free KRP medium with or without nm and then incubated for 30 min with or without 10 nm as was then and were examined for and of HA-tagged GLUT4 by of in and are of from were observed in other experiments, that was some in and effects of for of HA-tagged GLUT4 translocation observed in for findings in that were by expressing of treated cells as of observed in the in cells transfected with GLUT4 and pCDNA3 of expression of wild-type, constitutive, or dominant-negative PKC-ζ translocation of HA-tagged GLUT4 to the membrane in control and insulin-stimulated rat in of adipocytes were co-transfected with pCIS2 containing cDNA encoding HA-tagged GLUT4 as indicated with either pCDNA3 alone or pCDNA3 containing cDNA encoding wild-type PKC-ζ, constitutive PKC-ζ, or dominant-negative were as described in the to are observed in experiments, in that in in dominant-negative PKC-ζ was the for cells were from observed in cells. for of to various in in of in a adipocytes were co-transfected with pCIS2 containing cDNA encoding HA-tagged GLUT4 as indicated with either pCDNA3 alone or pCDNA3 containing cDNA encoding wild-type PKC-ζ, constitutive PKC-ζ, or dominant-negative were as described in the to are observed in experiments, in that in in dominant-negative PKC-ζ was the for cells were from observed in cells. for of to various in Since PKC-ζ be to operate downstream of PI 3-kinase in the activation of glucose transport, it was of to whether wortmannin GLUT4 translocation. As in nm wortmannin insulin effects HA-tagged GLUT4 translocation but not the effects of constitutive the activated form of PKC-ζ to operate or downstream of PI 3-kinase. In to increases in enzyme insulin provoked rapid increases in labeling of immunoprecipitable PKC-ζ in cells that been incubated in the presence for prior to insulin is to activity during a Standaert M.L. H. J. H. Zhao L. Farese R.V. Biochem. J. 1993; PubMed Scopus Google This evidence that the activation of PKC-ζ observed in vitro reflected an activation of PKC-ζ in intact cells. the other it may be that increases in32P labeling of PKC-ζ 5 and this was from the of increases in PKC-ζ enzyme activity 10 and In to labeling of PKC-ζ in intact insulin provoked increases in labeling of PKC-ζ that during the in vitro assay of immunoprecipitated PKC-ζ this suggested that PKC-ζ in vitro in response to insulin treatment in intact and this was confirmed by the that the PKC-ζ pseudosubstrate inhibited labeling of PKC-ζ in vitro to a labeling of PKC-ζ in control but not insulin-treated PKC-ζ immunoprecipitates These findings suggested that both insulin and D3-PO4 polyphosphoinositides both the enzyme activity and of The for PI 3-kinase in activation of PKC-ζ in intact adipocytes and the direct effects of both PI 3-kinase and PKC-ζ enzyme activity in that PI 3-kinase is both and for PKC-ζ The for PKC-ζ activation is not but since added polyphosphoinositides stimulated control but not insulin-treated immunoprecipitates and since added polyphosphoinositides or the in enzyme activity control and insulin-stimulated PKC-ζ it that polyphosphoinositides may largely for increases in enzyme activity observed in insulin-stimulated PKC-ζ immunoprecipitates. In this increases in either D3-PO4 polyphosphoinositides and/or other or that are in response to increases in polyphosphoinositides of were over the PKC-ζ are in to evaluate In with the possibility that PI 3-kinase may been for activation of PKC-ζ, both and the enzyme activity of control PKC-ζ immunoprecipitates. PI-4,5-(PO4)2 was in this and effects of PI-4,5-(PO4)2 were observed a of 1 whereas were a 10 is to that insulin rapid increases in the levels of total polyphosphoinositides (3Farese R.V. Larson R.E. Sabir M.A. J. Biol. Chem. 1982; 257: 4042-4045Abstract Full Text PDF PubMed Google Scholar, 4Farese R.V. Barnes D.E. Davis J.S. Standaert M.L. Pollet R. J. Biol. Chem. 1984; 259: 7094-7100Abstract Full Text PDF PubMed Google Scholar, 5Farese R.V. Davis J.S. Barnes D.E. Standaert M.L. Babischkin J.S. Hock R. Rosic N.K. Pollet R.J. Biochem. J. 1985; 231: 269-278Crossref PubMed Scopus (98) Google Scholar, 6Pennington S.R. Martin B.R. J. Biol. Chem. 1985; 260: 11039-11045Abstract Full Text PDF PubMed Google this largely increases in D3-PO4 polyphosphoinositides, with little or in not the PI-4,5-(PO4)2 N.B. J. Biol. Chem. 1993; 268: Full Text PDF PubMed Google Scholar). to the possibility that may modified PKC-ζ enzyme activity during insulin it be that the of labeling of PKC-ζ in intact adipocytes to a time when enzyme activity the of the activation This the possibility that some PKC-ζ may either or an PKC-ζ enzyme activity. Accordingly, it is that are PKC-ζ, with various effects enzyme activity. studies PKC-ζ be required to evaluate this possibility and the for in intact adipocytes. The findings that the PKC-ζ pseudosubstrate and RO 31-8220 provoked effects immunoprecipitated PKC-ζ enzyme activity and insulin-stimulated glucose transport suggested that PKC-ζ or a kinase may be required for glucose transport effects of DAG-sensitive for the PKC-ζ pseudosubstrate and RO be as required for insulin of glucose transport, as suggested by the fact that phorbol of and and the conventional not insulin of glucose this was by the fact that effects of RO 31-8220 insulin-stimulated glucose transport the inhibition of PKC-ζ and required to and As to does not to be the PKC-ζ protein kinase that is required for insulin-stimulated glucose This does not that is not required for insulin-stimulated glucose transport, but it that or a protein kinase is with In this as DAG-sensitive PKCs to be is to suggest that PKC-ζ and/or atypical is the PKC-ζ kinase that is required for insulin of glucose we the possibility that the PKC-ζ as well as RO may to and of other but protein The activation of GLUT4 translocation by wild-type PKC-ζ, and by constitutive PKC-ζ, in transiently transfected adipocytes evidence that PKC-ζ may in the activation of GLUT4 translocation by insulin or other forms of constitutive PKC-ζ, in the pseudosubstrate region and in the was were as as insulin in HA-tagged GLUT4 translocation. as with the that of wild-type and constitutive PKC-ζ to increases in HA-tagged GLUT4 translocation be as increases (i.e. over that be to activation of a of and other the inhibition of insulin-stimulated glucose transport by dominant-negative PKC-ζ suggested that PKC-ζ may be required for this but this inhibition may in other in cells transfected with this PKC-ζ other experimental be to evaluate the of PKC-ζ in insulin-stimulated glucose may be that the findings activation of PKC-ζ and its role in the activation of GLUT4 translocation and glucose transport in rat adipocytes are in with findings in and in with pCDNA3 containing cDNA encoding wild-type and dominant-negative PKC-ζ to increases and of glucose transport (11Bandyopadhyay B. Standaert M.L. Zhao L. Yu B. Avignon A.M. Galloway L. Karnam P. Moscat J. Farese R.V. J. Biol. Chem. 1997; 272: 2551-2558Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar). we that PKC-ζ is activated by insulin in G. Standaert M.L. Galloway L. Moscat J. Farese R.V. 1997; Google and rat it is to suggest that PKC-ζ is activated by insulin and may in glucose transport in a of In findings suggest that insulin activates PKC-ζ in rat adipocytes largely through PI 3-kinase-dependent increases in Our findings suggest that PKC-ζ may be required for and may in the translocation of GLUT4 and the activation of glucose transport in rat adipocytes. studies are to

BACKGROUND: This double-blind, multicenter, placebo-controlled study determined the efficacy and safety of dofetilide in converting atrial fibrillation (AF) or atrial flutter (AFl) to sinus rhythm (SR) and maintaining SR for 1 year. METHODS AND RESULTS: Patients with AF or AFl (n=325) were randomized to 125, 250, or 500 microgram dofetilide or placebo twice daily. Dosages were adjusted for QTc response and, after 105 patients were enrolled, for calculated creatinine clearance (Cl(Cr)). Pharmacological cardioversion rates for 125, 250, and 500 microgram dofetilide were 6.1%, 9.8%, and 29.9%, respectively, versus 1.2% for placebo (250 and 500 microgram versus placebo; P=0.015 and P<0.001, respectively). Seventy percent of pharmacological cardioversions with dofetilide were achieved in 24 hours and 91% in 36 hours. For the 250 patients who successfully cardioverted pharmacologically or electrically, the probability of remaining in SR at 1 year was 0.40, 0.37, 0.58 for 125, 250, and 500 microgram dofetilide, respectively, and 0.25 for placebo (500 microgram versus placebo, P=0.001). Two cases of torsade de pointes occurred, 1 on day 2 and the other on day 3 (0.8% of all patients given active drug); 1 sudden cardiac death, classified as proarrhythmic, occurred on day 8 (0.4% of all patients given active drug). CONCLUSIONS: Dofetilide, a new class III antiarrhythmic agent, is moderately effective in cardioverting AF or AFl to SR and significantly effective in maintaining SR for 1 year. In-hospital initiation and dosage adjustment based on QTc and Cl(Cr) are necessary to minimize a small but nonnegligible proarrhythmic risk.

This article aimed to provide a descriptive review of the psychometric properties and conceptual dimensions of published health literacy measurement tools. PsycINFO and PubMed search from 1999 through 2013, review of the grey literature, and an environmental scan was conducted to identify health literacy measurement tools. For each tool, we evaluated the conceptual dimensions assessed, test parameters, and psychometric properties. Of the 51 tools identified, 26 measured general health literacy, and 15 were disease or content specific, and 10 aimed at specific populations. Most tools are performance based, require in-person administration, and are exclusively available in a pencil and paper testing mode. The tools assess 0 (proxy measure) to 9 of the 11 defined dimensions of health literacy. Reported administration times vary, from less than 1 to 60 minutes. Validation procedures for most of the tools are limited by inadequate power to ensure reliability across subgroups (i.e., race, age, ethnicity, and gender). The health literacy measurement tools currently available generally represent a narrow set of conceptual dimensions with limited modes of administration. Most of the tools lack information on key psychometric properties. Significant work is needed to establish important aspects of the construct, convergent, and predictive validity for many tools. As researchers develop new measures, inclusion of a full range of conceptual dimensions of health literacy, more representative sampling for testing, and additional modes of administration will allow a more refined and flexible approach to research in this field.

OBJECTIVE: Traumatic brain injury (TBI) is a recognized risk factor for later development of neurodegenerative disease. However, the mechanisms contributing to neurodegeneration following TBI remain obscure. METHODS: In this study, we have utilized a novel mild TBI (mTBI) model to examine the chronic neurobehavioral and neuropathological outcomes following single and repetitive mTBI at time points from 6 to 18 months following injury. RESULTS: Our results reveal that at 6, 12, and 18 months after injury, animals exposed to a single mTBI have learning impairments when compared to their sham controls without exhibiting spatial memory retention deficits. In contrast, animals exposed to repetitive injury displayed persistent cognitive deficits, slower rate of learning, and progressive behavioral impairment over time. These deficits arise in parallel with a number of neuropathological abnormalities, including progressive neuroinflammation and continuing white matter degradation up to 12 months following repetitive injury. Neither single nor repetitive mTBI was associated with elevated brain levels of amyloid beta or abnormal tau phosphorylation at 6 or 12 months after injury. INTERPRETATION: Importantly, these data provide evidence that, although a single mTBI produces a clinical syndrome and pathology that remain static in the period following injury, repetitive injuries produce behavioral and pathological changes that continue to evolve many months after the initial injuries. As such, this model recapitulates many aspects described in human studies of TBI, providing a suitable platform on which to investigate the evolving pathologies following mild TBI and potential strategies for therapeutic intervention.

BODEN, WILLIAM E.; O'ROURKE, ROBERT A.; CRAWFORD, MICHAEL H.; BLAUSTEIN, ALVIN S.; DEEDWANIA, PRAKASH C.; ZOBLE, ROBERT G.; WEXLER, LAURA F.; KLEIGER, ROBERT E.; PEPINE, CARL J.; FERRY, DAVID R.; CHOW, BRUCE K. PHILIP W. LAVORI FOR THE VETERANS AFFAIRS NON-Q-WAVE INFARCTION STRATEGIES IN HOSPITAL (VANQWISH) TRIAL INVESTIGATORS Author Information

BACKGROUND: Cutaneous tumor metastasis may be the first manifestation of cancer, but more often is a harbinger of advanced disease that portends an ominous prognosis. All skin accessions over the past 10 years from a large Veterans Administration (VA) hospital were reviewed. METHODS: Archived histories, glass slides, and the immunohistochemical battery (IHC), were assessed to determine diagnostic accuracy. RESULTS: Of the 100,453 cases reviewed, there were a total of 77 cases (75 males and 2 females) of cutaneous metastasis from the lungs (28.6%), metastatic melanoma (18.2%), gastrointestinal tract (14.2%), genitourinary tract (10.4%), head and neck (9.1%), hematologic (5.2%), breast (5.2%), and miscellaneous (<2%). Metastasis represented the first indication of an internal malignancy in 7.8% of cases. The cutaneous sites of involvement included the head and neck (28%), the trunk (40%), the extremities (18%), and multiple sites (14%). The age range was 38-83 years, with a mean of 62 years. The average time interval between diagnosis of internal malignancy and cutaneous presentation was 33 months (range: <1 month-22 years), and the average survival following diagnosis was 7.5 months (range: <1 month-8 years). In a cohort of subjects, a truncated immunohistochemical battery consisting of CK-7, CK-20, and S-100 was consistent with the expected staining pattern of the primary source of cutaneous metastasis in 83.33% of the patients. CONCLUSIONS: Excluding the potential for age and gender bias in this study conducted in a VA setting, cutaneous metastases represent an uncommon, deadly, and late-developing occurrence in many patients. Compared with previous studies, lung carcinoma remains the most common of the cutaneous metastases, with a relative rise in the incidence of metastatic melanoma. The immunohistochemical battery of CK-7, CK-20, and S-100 is a helpful adjunct in narrowing the differential diagnosis of the primary site of a large proportion of cutaneous metastases, particularly tumors with an epithelioid appearance such as carcinomas and melanomas.

Anaphylaxis is an acute and potentially lethal multi-system allergic reaction. Most consensus guidelines for the past 30 years have held that epinephrine is the drug of choice and the first drug that should be administered in acute anaphylaxis. Some state that properly administered epinephrine has no absolute contraindication in this clinical setting. A committee of anaphylaxis experts assembled by the World Allergy Organization has examined the evidence from the medical literature concerning the appropriate use of epinephrine for anaphylaxis. The Committee strongly believes that epinephrine is currently underutilized and often dosed suboptimally to treat anaphylaxis, is under-prescribed for potential future self-administration, that most of the reasons proposed to withhold its clinical use are flawed, and that the therapeutic benefits of epinephrine exceed the risk when given in appropriate i.m. doses.