Hospital Careful Hand Feeding Program Reduced Feeding Tube Use in Patients with Advanced Dementia.

OBJECTIVES: Tube feeding is prevalent among patients with advanced dementia despite empirical data that suggest its lack of benefit. To provide an alternative to tube feeding for end-of-life patients, a careful hand feeding program was launched in a Hong Kong geriatric convalescent hospital in February 2017. We aim to compare the rates of feeding tube insertion before and after program implementation and determine risk factors for feeding tube insertion. For patients on careful hand feeding, we evaluated their sustainability on oral feeding and the rates of hospital readmissions compared with tube feeding patients over the next 12 months. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Advanced dementia patients ≥60 years with indication for tube feeding due to feeding problems admitted from January 2015-June 2019. METHODS: Data was collected on demographic and clinical variables, initial feeding mode (careful hand feeding vs. tube feeding), subsequent feeding mode changes, and hospital admissions over the next 12 months. Rates of feeding tube insertion, sustainability on oral feeding, and hospital readmissions were compared using Chi-square test. Risk factors for feeding tube insertion were assessed using logistic regression models. RESULTS: Among 616 advanced dementia patients admitted with feeding problems, feeding tube insertion rate declined significantly after careful hand feeding program implementation (72% vs 51% p<.001). Independent risk factors for feeding tube insertion were admission prior to program implementation, presence of dysphagia alone, dysphagia combined with poor intake, and lack of advance care planning. Among patients on careful hand feeding, 91% were sustained on oral feeding over the next twelve months and did not differ significantly before or after careful hand feeding program implementation (p=.67). There was no significant difference in hospital readmission rates between careful hand feeding patients and tube feeding patients before (83% vs 86%, p=.55) and after careful hand feeding program implementation (87% vs 85%, p=.63). CONCLUSIONS AND IMPLICATIONS: A hospital careful hand feeding program significantly reduced the feeding tube insertion rate among advanced dementia patients with feeding problems. The vast majority of patients on careful hand feeding were sustained on oral feeding over the next 12 months but their rate of hospital readmissions remained similarly high after program implementation.

The intermolecular disulfide bridge of human glial cell line-derived neurotrophic factor: its selective reduction and biological activity of the modified protein.

Recombinant human glial cell line-derived neurotrophic factor has been implicated to have therapeutic potential in the treatment of neurodegenerative diseases. The mature protein is a single polypeptide of 134 amino acid residues and functions as a disulfide-linked dimer. Reduction of the protein with dithiothreitol at pH 7.0 and in the absence of denaturant showed that the single intermolecular cystine bridge was reduced preferentially. Direct alkylation of the generated free sulfhydryl group using iodoacetamide or iodoacetate without denaturant was incomplete. Unfolding the protein in 6 M guanidine hydrochloride prior to the modification showed rapid disulfide scrambling. However, the sulfhydryl-modifying reagent N-ethylmaleimide was able to label quantitatively the free cysteinyl residue in the absence of any added chaotropic agent. By a combination of peptide mapping, Edman degradation, and mass spectrometric analysis, the labeled residue was identified to be Cys101, hence verifying the location of the intermolecular disulfide bond. The modified protein behaved as a noncovalent dimer when chromatographed through a Superdex 75 column under nondenaturing conditions and was comparable in biological activity to an unmodified control sample. The results therefore indicate that the intermolecular disulfide bridge of the protein is not essential for its biological function.

Applications of in-source fragmentation of protein ions for direct sequence analysis by delayed extraction MALDI-TOF mass spectrometry.

In matrix-assisted laser desorption/ionization of proteins, there exists a certain amount of fast metastable decay immediately after laser irradiation. The fragment ions thus formed can be resolved and their m/z values measured accurately by employing delayed extraction linear time-of-flight mass spectrometry. At higher than threshold laser fluences, proteins exhibit a series of fragment ions providing useful sequence information. We also observe that when moderate amounts of salts are present in the sample with sinapinic acid being the matrix, the intensities of cn ions (N-terminal fragments) are enhanced compared to other types of fragment ions. This enhancement in cn ion signals allows direct sequencing of proteins. The cn ions are completely absent when Xxx-Pro bonds are encountered and are of lower intensity when Xxx-Gly bonds are involved. Further, the cn ion series is interrupted at Xxx-Cys, when the cysteine is involved in a disulfide bond. Upon reduction of the disulfide bonds, the series continues and information is available for longer stretches. Using 10-20 pmol of recombinant proteins, sometimes contiguous sequence information up to 70 residues is obtained in a matter of minutes. Applications of the technique to some recombinant proteins with intra- or interchain disulfide linkages are presented.

Identification of Asp95 as the site of succinimide formation in recombinant human glial cell line-derived neurotrophic factor.

Human glial cell line-derived neurotrophic factor is a single polypeptide of 134 amino acids and functions as a disulfide-linked dimer. Incubation of the protein in pH 5.0 and at 37 degreesC for 1 week showed that 5% of the material was converted to a form that eluted after the major protein peak on a cation-exchange column. The modified component gave an average molecular mass of 30367.0 u (theoretical = 30384.8 u). Within measurement error, this 17.8-u decrease in mass indicated the loss of a water molecule. This observation, together with the protein's behavior on cation-exchange chromatography and the mode of incubation used to generate the modification, was consistent with cyclic imide (succinimide) formation at an aspartyl residue. Hence, only a monomer of the dimeric protein was modified. The modified monomer was purified and subjected to peptic degradation. By a combination of N-terminal analysis and mass spectrometry, the region containing Asp95-Lys96 was identified to be modified. This was further confirmed by carboxypeptidase Y digestion of the modified peptide where the modified region was found to be resistant to further enzymatic degradation. Furthermore, incubation of the modified monomer in pH 8. 5 for 2 h yielded two peaks, in agreement with the succinimide model where the cyclic imide was hydrolyzed into a mixture of isoaspartate and aspartate. Tryptic mapping of the isoaspartyl-containing protein showed that Asp95 was refractory to Edman degradation, confirming it was in the isoaspartate form. Hence, the modification observed was due to succinimide formation at Asp95. This is the first report of succinimide formation at an Asp-Lys linkage.

Determination of disulfide structure in agouti-related protein (AGRP) by stepwise reduction and alkylation.

The agouti-related protein gene (Agrp) plays an important role in body weight regulation. The mature human protein is a single polypeptide chain of 112 amino acid residues, consisting of an N-terminal acidic region and a unique C-terminal cysteine-rich domain. The disulfide structure of recombinant human AGRP was determined by chemical methods using partial reduction with tris(2-carboxyethyl)phosphine under acidic conditions, followed by direct alkylation with N-ethylmaleimide or fluorescein-5-maleimide. Partial reduction and alkylation provided several forms of AGRP that were modified in a stepwise fashion. The resulting proteins were characterized by peptide mapping, sequence analysis, and mass spectrometry, showing that AGRP contained a highly reducible disulfide bond, C85-C109, followed by less reactive ones, C90-C97, C74-C88, C67-C82, and C81-C99, respectively. The chemically defined disulfide connectivity of the recombinant human AGRP was homologous to that of omega-agatoxin IVB except for an additional disulfide bond, C85-C109.

Selective deamidation of recombinant human stem cell factor during in vitro aging: isolation and characterization of the aspartyl and isoaspartyl homodimers and heterodimers.

During in vitro aging, deamidation of recombinant human stem cell factor produced in Escherichia. coli was detected by HPLC analysis and by the release of soluble ammonia. The deamidation rate is very slow in buffers at low pH or at low temperatures; however, the rate is significantly accelerated in alkaline buffers such as sodium bicarbonate in combination with elevated temperatures. HPLC isolation of various deamidated forms followed by peptide mapping and mass spectrometric analyses revealed that the deamidation involves Asn10 in the sequence -T9NNV- near the N-terminus of the protein. Following peptide mapping analysis, significant amounts of aspartyl and isoaspartyl peptides were identified, indicating the conversion of asparagine into both aspartate and isoaspartate residues. As a result of spontaneous association-dissociation of stem cell factor dimer, a total of five deamidated forms, including two homodimers and three heterodimers, were detected and isolated. Cell proliferation assays showed that two rhSCF heterodimeric species, derived from dimerization between isoaspartyl and other stem cell factor monomers, retain only approximately half of the biological activity. The homodimer with isoaspartic acid in place of Asn10 is 50-fold less potent, while the aspartyl homodimer, either isolated during deamidation experiments or recombinantly prepared by site-directed mutagenesis (e.g., N10D and N10D/N11D variants), exhibits higher activity than the standard molecule. In comparison, synthetic N10A and N10E variants, though missing the deamidation site, are significantly less active. All these variants lacking the Asn10 deamidation site are relatively more stable than those containing the asparagine residue. The results indicate that the biological function and chemical stability of stem cell factor are influenced by the nature of the residue at position 10.

Liquid chromatography and mass spectrometry for the speciation of arsenic animal feed additives.

A number of analytical techniques have been investigated for the determination of arsenic animal feed additive compounds. More specifically, liquid chromatography methods have been developed for the separation of these arsenicals. Micro liquid chromatography, which is a relatively new technique, shows a number of advantages for these analyses, especially when interfaced to mass spectrometers. Improved limits of detection, low solvent consumption, reduced amounts of stationary phase, as well as flow-rates easily accommodated by continuous-flow liquid secondary ion mass spectrometry and direct liquid introduction mass spectrometry, are some of the advantages we have observed when fabricating and using these columns. The off-line combination of micro liquid chromatography and electrothermal atomic absorption spectrometry improves the limit of detection for arsenic and shows potential for on-line coupling. Further use of the methods developed here may allow for a more detailed understanding of the fate and interactions of arylarsenicals in biological and environmental systems.

A mass spectrometry-based approach for probing enzyme active sites: identification of Glu 127 in Cellulomonas fimi exoglycanase as the residue modified by N-bromoacetyl cellobiosylamine.

We have identified the residue in Cellulomonas fimi exoglycanase modified by N-bromoacetyl cellobiosylamine as Glu 127 using a new combination of experimental approaches. The enzyme was quantitatively inhibited with the affinity label N-bromoacetyl cellobiosylamine and cleaved with pepsin. The N-acetyl cellobiosylamine-modified peptide was identified by comparative peptide mapping of the digests derived from labeled and unlabeled proteins by reverse-phase high-performance liquid chromatography connected online to an electrospray ionization mass spectrometer. The modified residue in the labeled peptide was determined by using a novel protein sequencing chemistry which is based on monitoring the amino acid derivatives released by stepwise peptide degradation using electrospray ionization mass spectrometry. Tandem mass spectrometry was used for further structural characterization of the cleaved residue. We show that the residue modified by N-bromoacetyl cellobiosylamine is Glu 127. This residue has been identified previously as the acid-base catalyst by using a combination of mutagenic and kinetic analyses. Our results therefore demonstrate the usefulness of this type of affinity label in identifying important catalytic residues in glycosidases and suggest that this new experimental approach can be applied generally to any labeled protein in which the mass of the label is known and thus represents an alternative approach to the current methods used to identify labeled residues within proteins.

Characterization of the cleavage specificity of a subtilisin-like serine proteinase from Ophiostoma piceae by liquid chromatography/mass spectrometry and tandem MS.

A proteinase secreted by the sapstaining fungus Ophiostoma piceae is thought to be necessary for the primary retrieval of nitrogen from wood proteins. By using mass spectrometry (MS) techniques, we have established the cleavage specificity of this subtilisin-like serine proteinase. This work demonstrated the potential of MS in determining cleavage specificities of newly isolated proteinases in a relatively short time frame, and determined that the O. piceae proteinase showed a substrate specificity similar to that of proteinase K. Primary cleavage of the insulin B-chain occurred between Leu15 and Tyr16. In addition numerous secondary cleavage sites occurred after hydrophobic, polar, and charged amino acids indicating a broad specificity.

Synthesis of the protein-sequencing reagent 4-(3-pyridinylmethylaminocarboxypropyl) phenyl isothiocyanate and characterization of 4-(3-pyridinylmethylaminocarboxypropyl) phenylthiohydantoins.

We report the synthesis and structural characterization of the novel Edman-type protein-sequencing reagent 4-(3-pyridinylmethylaminocarboxypropyl) phenyl isothiocyanate. A panel of thiohydantoins prepared from this reagent were found stable during liquid chromatography-electrospray mass spectrometry and were detectable at the low femtomole sensitivity level. Furthermore, the signal detected for these compounds in the mass spectrometer was linear from the low femtomole to the low picomole range. The derivatives showed uv absorbance spectra comparable to their phenylthiohydantoin counterparts. The extinction coefficient for the 4-(3-pyridinylmethylaminocarboxypropyl) phenyl thiohydantoin tyrosine was determined by adsorptive sequence analysis of a synthetic pentapeptide featuring an N-terminal 125I-labeled tyrosine. The sequence data suggest that the reagent will be useful for extended sequence analysis of proteins and peptides using commercially available gas-liquid-phase sequencers.

Liquid chromatography-electrospray ionization mass spectrometry of 4-(3-pyridinylmethylaminocarboxypropyl) phenylthiohydantoins.

We report the separation of 4-(3-pyridinylmethylaminocarboxypropyl) phenylthiohydantoins by microbore reverse-phase high-performance liquid chromatography and their detection by on-line electrospray ionization mass spectrometry. These compounds are the products of the chemical stepwise degradation of polypeptides using 4-(3-pyridinylmethylaminocarboxypropyl) phenyl isothiocyanate. We describe chromatographic conditions for on-column concentration of the analytes and for baseline separation of the isobaric amino acid derivatives of leucine and isoleucine. A commercially available protein sequencer was readily interfaced with the described analytical system and used for adsorptive sequence analysis of a panel of synthetic peptides containing collectively all 20 naturally occurring amino acids. On-line mass analysis of derivatives generated by automated sequencing confirmed that the derivatives were of the predicted mass and were detectable at comparable signal strength and sensitivity. Finally, we demonstrate that the additional selectivity in data interpretation provided by mass analysis dramatically improves the signal-to-noise ratio and therefore enhances the ability to conclusively interpret protein and peptide sequence data.

Pleiotrophin stimulates fibroblasts and endothelial and epithelial cells and is expressed in human cancer.

Previously we reported the purification of the heparin-binding growth factor pleiotrophin (PTN) from supernatants of the human breast cancer cell line MDA-MB-231. To investigate further the biological activities of PTN and its potential role in cancer, we cloned a PTN cDNA and expressed the gene in a human kidney and in a human adrenal carcinoma cell line (SW-13). The supernatants harvested from cells transfected with PTN contained a heparin-binding specific protein of an apparent molecular mass of 18 kDa. These supernatants stimulated the proliferation of endothelial cells as well as the anchorage-independent growth of SW-13 cells and of normal rat kidney fibroblasts. Furthermore, SW-13 cells transfected with PTN acquired autonomous growth in soft agar and were tumorigenic in athymic nude mice. In contrast to these results with PTN from human cells, PTN obtained from insect cells (Sf9) using recombinant baculovirus as a vector was biologically inactive. We detected high levels of PTN mRNA in 16 of 27 primary human breast cancer samples (62%) as well as in 8 of 8 carcinogen-induced rat mammary tumors. Furthermore, 9 of 34 human tumor cell lines of different origin showed detectable PTN mRNA. We conclude that PTN may function as a tumor growth and angiogenesis factor in addition to its role during embryonic development.