Scholarship in the medical faculty from the university perspective: retaining academic values.

Academic medicine and research universities have enjoyed a close relationship that has strengthened both, spawning an era of discovery and scholarship in medicine that has earned the U.S. academic medical enterprise a high level of public trust and a deserved leadership position in the world. However, changes in the financing of medical care and in the organization of health care delivery have dramatically affected the medical school-university partnership. The growing emphasis on delivery of clinical services and the concomitant decrease in time for tenured and clinician-educator faculty to teach and do scholarly work jeopardizes both the potential for continued discovery and the education of the next generation of medical scholars. The background of the medical school-university relationship and the factors leading to the development of clinician-educator faculty tracks are reviewed, and recent trends that impact faculty scholarship are discussed. Both tenure-track and clinician-educator medical faculty, as members of the broader university community, should expect from their university colleagues a continued demand for scholarship and educational activity that reflects the underlying philosophy of the parent university. As a corollary, the university, through its medical school, must provide these faculty the time and the financial support necessary to fulfill their academic mission. The size of the clinician-educator faculty should be determined by the academic needs of the medical school rather than by the service demands of its associated health care delivery system. To accomplish this, academic medical centers will have to develop cadres of associated or clinical faculty whose primary focus is on the practice of medicine.

Altered gene expression in steroid-treated denervated muscle.

In rats treated with high-dose corticosteroids, skeletal muscle that is denervated in vivo (steroid-denervated) develops electrical inexcitability similar to that seen in patients with acute quadriplegic myopathy. To determine whether changes in muscle gene transcription might underlie inexcitability of steroid-denervated muscle we performed RNase protection assays to quantitate adult (SkM1) and embryonic (SkM2) sodium channel isoforms and chloride channel (CLC-1) mRNA levels in control, denervated, steroid-innervated, and steroid-denervated skeletal muscle. While SkM1 mRNA levels were relatively unaffected by denervation or steroid treatment, SkM2 mRNA levels were increased by both. These effects were synergistic and high levels of SkM2 mRNA were expressed in denervated muscle exposed to corticosteroids. Skeletal muscle CLC-1 mRNA levels were decreased by denervation. To better understand the marked upregulation of SkM2 in steroid-denervated muscle we examined changes in myogenin and glucocorticoid receptor mRNA levels. However, changes in these mRNA levels cannot account for the upregulation of SkM2 in steroid-denervated muscle.

Dual tandem promoter elements containing CCAC-like motifs from the tetrodotoxin-resistant voltage-sensitive Na+ channel (rSkM2) gene can independently drive muscle-specific transcription in L6 cells.

cis-Elements in the -129/+124 promoter segment of the rat tetrodotoxin-resistant voltage-gated sodium channel (rSkM2) gene that are responsible for reporter gene expression in cultured muscle cells were identified by deletion and scanning mutations. Nested 5' deletion constructs, assayed in L6 myotubes and NIH3T3 cells, revealed that the minimum promoter allowing muscle-specific expression is contained within the -57 to +1 segment relative to the major transcription initiation site. In the context of the -129/+1 construct, however, scanning mutations in the -69/+1 segment failed to identify any critical promoter elements. In contrast, identical mutations in a minimal promoter (-57/+124) showed that all regions except -29/-20 are essential for expression, especially the -57/-40 segment, consistent with the 5' deletion analysis. Further experiments showed that the distal (-129/-58) and proximal promoter (-57/+1) elements can independently drive reporter expression in L6 myotubes, but not in NIH3T3 fibroblasts. This pair of elements is similar in sequence and contains Sp1 sites (CCGCCC), CCAC-like motifs, but no E-boxes or MEF-2 sites. The two segments form similarly migrating complexes with L6 myotube nuclear extracts in gel-shift assays. Critical elements within the distal promoter element were defined by 10 base pair scanning mutations in the -119 to -60 region in the context of the -129/+1 segment containing a mutated -59/-50 segment that inactivates the proximal promoter. Nucleotides in the -119/-90 region, especially -109/-100, were the most important regions for distal promoter function. We conclude that the -129/+1 segment contains two tandem promoter elements, each of which can independently drive muscle-specific transcription. Supershifts with antibodies to Sp1 and myocyte nuclear factor (MNF) implicate the involvement of Sp1, MNF, and other novel factors in the transcriptional regulation of rSkM2 gene expression.

Interaction between the skeletal muscle type 1 Na+ channel promoter E-box and an upstream repressor element. Release of repression by myogenin.

We have defined how four elements that regulate expression of the rat skeletal muscle type 1 sodium channel (SkM1) gene cooperate to yield specific expression in differentiated muscle. A basal promoter region containing within it a promoter E-box (-31/-26) is broadly expressed in many cells, including myoblasts and myotubes; mutations within the promoter E-box that disrupt binding of the myogenic basic helix-loop-helix (bHLH) factors reduce expression in all cell types only slightly. Sequential addition of upstream elements to the wild-type promoter confer increasing specificity of expression in differentiated cells, even though all three upstream elements, including a positive element (-85/-57), a repressor E-box (-90/-85), and upstream repressor sequences (-135/-95), bind ubiquitously expressed transcription factors. Mutations in the promoter E-box that disrupt the binding of the bHLH factors counteract the specificity conferred by addition of the upstream elements, with the greatest interaction observed between the upstream repressor sequences and the promoter E-box. Forced expression of myogenin in myoblasts releases repression exerted by the upstream repressor sequences in conjunction with the wild-type, but not mutant, promoter E-box, and also initiates expression of the endogenous SkM1 protein. Our data suggest that particular myogenic bHLH proteins bound at the promoter E-box control expression of SkM1 by releasing repression exerted by upstream repressor sequences in differentiated muscle cells.

Ion channel mutations affecting muscle and brain.

Voltage-gated ion channels control many aspects of signal transduction in both muscle and nerve. These channels are finely tuned, and either increased or decreased channel activity can adversely affect function. In skeletal muscle, mutations in ion channel genes have been shown to cause both myotonic discharges and episodic paralysis. In cardiac muscle, mutations in related ion channels can produce repolarization defects and fatal arrhythmias. During the past 2 years, a new chapter in the channelopathy story has been opened with the identification of ion channel mutations in the brain that cause disorders ranging from episodic ataxia to epilepsy.

Inactivation and secondary structure in the D4/S4-5 region of the SkM1 sodium channel.

The D4/S4-5 interhelical region plays a role in sodium channel fast inactivation. Examination of S4-5 primary structure in all domains suggests a possible amphipathic helical conformation in which a conserved group of small hydrophobic residues occupies one contiguous surface with a more variable complement of nonpolar and polar residues on the opposite face. We evaluated this potential structure by replacing each residue in D4/S4-5 of the rat SkM1 skeletal muscle sodium channel with substitutions having different side chain properties. Of the 63 mutations analyzed, 44 produced functional channels. P1473 was intolerant of substitutions. Nonpolar substitutions in the conserved hydrophobic region were functionally similar to wild type, while charged mutations in this region before P1473 were nonfunctional. Charged mutations at F1466, M1469, M1470, and A1474, located on the opposite surface of the predicted helix, produced functional channels with pronounced slowing of inactivation, shifted voltage dependence of steady-state inactivation, and increased rate of recovery from inactivation. The substituted-cysteine-accessibility method was used to probe accessibility at each position. Residues L1465, F1466, A1467, M1469, M1470, L1472, A1474, and F1476C were easily accessible for modification by sulfhydryl reagents; L1464, L1468, S1471, and L1475 were not accessible within the time frame of our measurements. Molecular dynamics simulations of residues A1458 to N1477 were then used to explore energetically favorable local structures. Based on mutagenesis, substituted-cysteine-accessibility method, and modeling results, we suggest a secondary structure for the D4/S4-5 region in which the peptide chain is alpha-helical proximal to P1473, bends at this residue, and may continue beyond this point as a random coil. In this configuration, the entire resultant loop is amphipathic; four residues on one surface could form part of the binding site for the inactivation particle.

Two E-boxes are the focal point of muscle-specific skeletal muscle type 1 Na+ channel gene expression.

We have characterized a group of cis-regulatory elements that control muscle-specific expression of the rat skeletal muscle type 1 sodium channel (SkM1) gene. These elements are located within a 3. 1-kilobase fragment that encompasses the 5'-flanking region, first exon, and part of the first intron of SkM1. We sequenced the region between -1062 and +311 and determined the start sites of transcription; multiple sites were identified between +1 and +30. The basal promoter (-65/+11) lacks cell-type specificity, while an upstream repressor (-174/-65) confers muscle-specific expression. A positive element (+49/+254) increases muscle-specific expression. Within these broad elements, two E boxes play a pivotal role. One E box at -31/-26 within the promoter, acting in part through its ability to bind the myogenic basic helix-loop-helix proteins, recruits additional factor(s) that bind elsewhere within the SkM1 sequence to control positive expression of the gene. A second E box at -90/-85 within the repressor controls negative regulation of the gene and acts through a different complex of proteins. Several of these cis-regulatory elements share both sequence and functional similarities with cis-regulatory elements of the acetylcholine receptor delta-subunit; the different arrangement of these elements may contribute to unique expression patterns for the two genes.

Analysis of local structure in the D2/S1-S2 region of the rat skeletal muscle type 1 sodium channel using insertional mutagenesis.

A reporter epitope was inserted at 11 positions in a region encompassing proposed transmembrane segments S1 and S2 in the second repeat domain (D2) of the rat skeletal muscle type 1 sodium channel. All mutations produced full-length membrane-associated protein following transfection into cultured cells, although the level of expression varied with insertion position. Characterization of cognate cRNAs for each mutation in Xenopus oocytes by two-electrode voltage clamp defined a permissive region between the proposed transmembrane regions in which these large insertions did not interfere with channel function. Two of the mutations, in which the point of insertion was within the proposed S1-S2 loop, demonstrated extracellular membrane labeling when studied either by antibody binding in oocytes or by confocal analysis following transfection into primary muscle cells. Our results define the likely boundaries of an extramembrane region linking the S1 and S2 transmembrane segments in D2 and confirm the extracellular location of this S1-S2 loop predicted by current models of channel tertiary structure.

Loss of electrical excitability in an animal model of acute quadriplegic myopathy.

In rats treated with high-dose corticosteroids, skeletal muscle that is denervated in vivo (steroid-denervated [S-D]) develops electrical inexcitability similar to that seen in patients with acute quadriplegic myopathy. In studies of affected muscles in vitro, the majority of S-D fibers failed to generate action potentials in response to intracellular stimulation although the average resting potential of these fibers was no different from that of control denervated muscle. The downregulation of membrane chloride conductance (G[Cl]) seen in normal muscle after denervation did not occur in S-D muscle. Although block of chloride channels in S-D muscle produced high specific membrane resistance, comparable to similarly treated control denervated muscle, and partially restored excitability in many fibers, action potential amplitude was still reduced in S-D fibers, suggesting a concomitant reduction in sodium current. 3H-saxitoxin binding measurements revealed a reduction in the density of the adult muscle sodium channel isoform in S-D muscle, suggesting that a decrease in the number of sodium channels present may play a role in the reduction of sodium current, although altered properties of channels may also contribute. The weakness seen in S-D muscle may involve the interaction of a number of factors that modify membrane excitability, including membrane depolarization, persistence of G(Cl), and reduced voltage-gated sodium currents.

Quality of care in academic neurology departments.

In striving to improve the quality of patient care, today's academic neurology department faces special problems. Factors that are inherent in the department's broader academic mission and in the organization of a major teaching hospital can compromise practice efficiency, reduce ease of access, and undermine cost competitiveness. However, the same environment also provides the opportunity to exploit areas of unique clinical expertise, create value-added services, and develop regional approaches to service-line integration and disease management strategies. A major challenge for the academic department is to validate the quality and efficiency of its current services while assuming a leadership role in the development of new approaches to quality improvement. This challenge must be met without losing sight of the department's equally important parallel commitments to research and education.

Ion channel mutations and diseases of skeletal muscle.

Voltage-gated ion channels play a critical role in coupling excitation at the neuromuscular junction to activation of contractile elements within a muscle fiber. Abnormal channel function can lead to either muscle paralysis or delayed relaxation. Recent advances in the molecular characterization of these ion channels have provided the tools needed to investigate the relationship between channel mutations and disorders of muscle excitability. This article reviews our current understanding of muscle sodium, calcium, and chloride channels and their role in the pathogenesis of myotonia and periodic paralysis.

Paramyotonia congenita mutations reveal different roles for segments S3 and S4 of domain D4 in hSkM1 sodium channel gating.

Mutations in the gene encoding the voltage-gated sodium channel of skeletal muscle (SkMl) have been identified in a group of autosomal dominant diseases, characterized by abnormalities of the sarcolemmal excitability, that include paramyotonia congenita (PC) and hyperkalemic periodic paralysis (HYPP). We previously reported that PC mutations cause in common a slowing of inactivation in the human SkMl sodium channel. In this investigation, we examined the molecular mechanisms responsible for the effects of L1433R, located in D4/S3, on channel gating by creating a series of additional mutations at the 1433 site. Unlike the R1448C mutation, found in D4/S4, which produces its effects largely due to the loss of the positive charge, change of the hydropathy of the side chain rather than charge is the primary factor mediating the effects of L1433R. These two mutations also differ in their effects on recovery from inactivation, conditioned inactivation, and steady state inactivation of the hSkMl channels. We constructed a double mutation containing both L1433R and R1448C. The double mutation closely resembled R1448C with respect to alterations in the kinetics of inactivation during depolarization and voltage dependence, but was indistinguishable from L1433R in the kinetics of recovery from inactivation and steady state inactivation. No additive effects were seen, suggesting that these two segments interact during gating. In addition, we found that these mutations have different effects on the delay of recovery from inactivation and the kinetics of the tail currents, raising a question whether this delay is a reflection of the deactivation process. These results suggest that the S3 and S4 segments play distinct roles in different processes of hSkM1 channel gating: D4/S4 is critical for the deactivation and inactivation of the open channel while D4/S3 has a dominant role in the recovery of inactivated channels. However, these two segments interact during the entry to, and exit from, inactivation states.

Probing sodium channel cytoplasmic domain structure. Evidence for the interaction of the rSkM1 amino and carboxyl termini.

Epitopes for monoclonal antibodies directed against the purified adult rat skeletal muscle sodium channel (rSkM1) were localized using channel proteolysis and fusion proteins. The interactions between these and other monoclonal antibodies with site-specific polyclonal antibodies were used to investigate the spatial relationships among rSkM1 cytoplasmic segments. Competition. between antibodies for binding was performed using a solution-phase assay in which solubilized channel protein retains many of the biophysical characteristics of the rSkM1 protein in vivo. Our results support a model in which: 1) the amino terminus assumes a rigid structure having a fixed orientation with respect to other intracellular segments; 2) the interdomain 2-3 region is centrally located on the cytoplasmic surface of the channel, extends farther into the cytoplasm, and has an intermediate degree of flexibility; 3) the beginning of the amino terminus and end of the carboxyl terminus specifically interact with each other; and 4) domains 1 and 4 are adjacent. The sequences responsible for the interaction of the amino and carboxyl termini were identified by demonstrating the specific binding of a synthetic peptide encompassing the first 30 residues of the rSkM1 amino terminus to a fusion protein containing the rSkM1 carboxyl terminus.

Sodium channel mutations in paramyotonia congenita exhibit similar biophysical phenotypes in vitro.

Mutations in the skeletal muscle voltage-gated Na+ channel alpha-subunit have been found in patients with two distinct hereditary disorders of sarcolemmal excitation: hyperkalemic periodic paralysis (HYPP) and paramyotonia congenita (PC). Six of these mutations have been functionally expressed in a heterologous cell line (tsA201 cells) using the recombinant human skeletal muscle Na+ channel alpha-subunit cDNA hSkM1. PC mutants from diverse locations in this subunit (T1313M, L1433R, R1448H, R1448C, A1156T) all exhibit a similar disturbance in channel inactivation characterized by reduced macroscopic rate, accelerated recovery, and altered voltage dependence. PC mutants had no significant abnormality in activation. In contrast, one HYPP mutation studied (T704M) has a normal inactivation rate but exhibits shifts in the midpoints of steady-state activation and inactivation along the voltage axis. These findings help to explain the phenotypic differences between HYPP and PC at the molecular and biophysical level and contribute to our understanding of Na+ channel structure and function.

Voltage-dependent regulation of modal gating in the rat SkM1 sodium channel expressed in Xenopus oocytes.

The TTX-sensitive rat skeletal muscle sodium channel (rSkM1) exhibits two modes of inactivation (fast vs slow) when the alpha subunit is expressed alone in Xenopus oocytes. In this study, two components are found in the voltage dependence of normalized current inactivation, one having a V1/2 in the expected voltage range (approximately -50 mV, I(N)) and the other with a more hyperpolarized V1/2 (approximately -130 mV, IH) at a holding potential of -90 mV. The I(N) component is associated with the gating mode having rapid inactivation and recovery from inactivation of the macroscopic current (N-mode), while IH corresponds to the slow inactivation and recovery mode (H-mode). These two components are interconvertible and their relative contribution to the total current varies with the holding potential: I(N) is favored by hyperpolarization. The interconversion between the two modes is voltage dependent and is well fit to a first-order two-state model with a voltage dependence of e-fold/8.6 mV and a V1/2 of -62 mV. When the rat sodium channel beta 1-subunit is coinjected with rSkM1, IH is essentially eliminated and the inactivation kinetics of macroscopic current becomes rapid. These two current components and their associated gating modes may represent two conformations of the alpha subunit, one of which can be stabilized either by hyperpolarization or by binding of the beta 1 subunit.