Impacts of participating in confidential enquiry panels: a qualitative study.

OBJECTIVE: To describe the impacts of participating in confidential enquiry panels for the Confidential Enquiry into Stillbirths and Deaths in Infancy. DESIGN: Qualitative interview study. SETTING: The former northern health region of England. SAMPLE: Eighteen health professionals who had participated in at least one confidential enquiry panel. METHODS: Semistructured one-to-one interviews using purposive sampling; transcripts were analysed by identifying recurring themes. Data were organised and coded using NUD*IST. MAIN OUTCOME MEASURES: Views on the impacts of participation on clinical practice and views on the strengths and limitations of confidential enquiries. RESULTS: Participants valued attendance at panels as a learning experience that provoked reflection on their own clinical practice. Participants felt that taking part had a positive impact on their clinical thinking and practice by increasing their awareness of standards of care. These impacts occurred through both the detailed examination of cases and the interaction with colleagues from different disciplines and hospitals. Learning impacts were cascaded to colleagues through informal discussion and teaching. Concrete examples of changes in practice at the organisational level, stimulated by panel attendance, were reported. CONCLUSIONS: The confidential enquiry approach was supported not only as an effective way of assessing care but also as a valuable learning experience that motivated change in clinical practice. Local benefits of nationally coordinated confidential enquiries should be valued and supported in their future development. Wide multidisciplinary participation in enquiry panels coordinated through regional clinical networks should be promoted.

Risk of congenital anomalies near the Byker waste combustion plant.

BACKGROUND: The aim of this study was to determine whether the risk of congenital anomalies in a population resident close to a waste combustion plant located at Byker in the city of Newcastle upon Tyne, United Kingdom, was higher than in a population resident further away. METHODS: A geographical study was carried out on the prevalence of congenital anomalies in residents living within 3 km (inner zone) of the Byker combustion plant compared with those living 3-7 km (outer zone) from the plant. There were 81255 live births (1985-1999) and 1508 cases with chromosomal and non-chromosomal congenital anomalies. The cases were identified from the Northern Region Congenital Abnormality Survey. RESULTS: After the site commenced operation the estimated rate ratio (inner versus outer zone) was 1.11 (95 per cent confidence interval (CI) 0.96-1.28) adjusted for socio-economic deprivation. There was significant heterogeneity across years and an increasing trend, of marginal significance (p = 0.07), in the rate ratio. The inner zone rate approached or became significantly higher than that in the outer zone in some of the later years. CONCLUSIONS: No significant overall association between the number of congenital anomalies and proximity of residence to the Byker waste combustion plant has been found in this study. Significantly increased rates near the site during the later years may suggest a possible risk but are difficult to interpret. More comprehensive, multi-site investigations around other waste combustion plants are indicated.

Viperin (cig5), an IFN-inducible antiviral protein directly induced by human cytomegalovirus.

Little is known about the mechanism by which IFNs inhibit human cytomegalovirus (HCMV) replication. Indeed, infection of fibroblasts with HCMV initiates the expression of a subset of type I IFN-inducible genes whose role in the infectious process is unclear. We describe here the identification of a cytoplasmic antiviral protein that is induced by IFNs, by HCMV infection, and by the HCMV envelope protein, glycoprotein B (gB). Stable expression of the protein in fibroblasts inhibits productive HCMV infection, down-regulating several HCMV structural proteins (gB, pp28, and pp65) known to be indispensable for viral assembly and maturation. We have named the protein viperin (for virus inhibitory protein, endoplasmic reticulum-associated, interferon-inducible). HCMV infection causes the redistribution of the induced viperin from its normal endoplasmic reticulum association, first to the Golgi apparatus and then to cytoplasmic vacuoles containing gB and pp28. Expression before HCMV infection reduces viperin redistribution from the endoplasmic reticulum to the Golgi apparatus and prevents vacuolar localization, perhaps reflecting the mechanism used by HCMV to evade the antiviral function.

Defective antigen processing in GILT-free mice.

Processing of proteins for major histocompatibility complex (MHC) class II-restricted presentation to CD4-positive T lymphocytes occurs after they are internalized by antigen-presenting cells (APCs). Antigenic proteins frequently contain disulfide bonds, and their reduction in the endocytic pathway facilitates processing. In humans, a gamma interferon-inducible lysosomal thiol reductase (GILT) is constitutively present in late endocytic compartments of APCs. Here, we identified the mouse homolog of GILT and generated a GILT knockout mouse. GILT facilitated the processing and presentation to antigen-specific T cells of protein antigens containing disulfide bonds. The response to hen egg lysozyme, a model antigen with a compact structure containing four disulfide bonds, was examined in detail.

Maintenance of TCR clonality in T cells expressing genes for two TCR heterodimers.

T cell receptor (TCR) allelic exclusion is believed to be primarily mediated by suppression of further recombination at the TCR locus after the expression of a functional TCR protein. Genetic allelic exclusion has been shown to be leaky for the beta chain and, more commonly, for the alpha chain. Here, we demonstrate an additional mechanism by which T cells can maintain monoclonality. T cells from double TCR transgenic mice express only one or the other of the two available TCRs at the cell surface. This "functional allelic exclusion" is apparently due to control of the TCR assembly process because these T cells express RNA and protein for all four transgenic TCR proteins. Lack of cell surface expression of the second TCR may be controlled by a failure to assemble the TCR heterodimer.

Distinct functions and cooperative interaction of the subunits of the transporter associated with antigen processing (TAP).

The ATP-binding cassette (ABC) transporter TAP translocates peptides from the cytosol to awaiting MHC class I molecules in the endoplasmic reticulum. TAP is made up of the TAP1 and TAP2 polypeptides, which each possess a nucleotide binding domain (NBD). However, the role of ATP in peptide binding and translocation is poorly understood. We present biochemical and functional evidence that the NBDs of TAP1 and TAP2 are non-equivalent. Photolabeling experiments with 8-azido-ATP demonstrate a cooperative interaction between the two NBDs that can be stimulated by peptide. The substitution of key lysine residues in the Walker A motifs of TAP1 and TAP2 suggests that TAP1-mediated ATP hydrolysis is not essential for peptide translocation but that TAP2-mediated ATP hydrolysis is critical, not only for translocation, but for peptide binding.

Quality control of transmembrane domain assembly in the tetraspanin CD82.

Retention of misfolded proteins in the endoplasmic reticulum (ER) is a primary mechanism of quality control. To discover whether quality control can monitor assembly inside the hydrophobic ER membrane, we characterized the folding and transport of the tetraspanin glycoprotein CD82. Truncated forms of CD82 that are missing one or more transmembrane segments remain in the ER. A construct (TM 2-4) that is missing the first transmembrane segment remains in the ER, even though its extracellular domain, which is facing the ER lumen, has folded to the native structure. Transport to the cell surface is restored by co-expressing the missing segment (TM 1) as a separate polypeptide. Prior to leaving the ER, CD82 transiently associates with the membrane-bound chaperone calnexin but not with its soluble homolog calreticulin. TM 2-4, in contrast, remains in a prolonged interaction with calnexin that is partially reversed by co-expressing TM 1. These findings establish a simple system to study transmembrane domain assembly, show that ER quality control can directly monitor assembly inside the lipid bilayer and suggest that calnexin may play a role in this process.

Cathepsin S regulates the expression of cathepsin L and the turnover of gamma-interferon-inducible lysosomal thiol reductase in B lymphocytes.

Loading of antigenic peptide fragments on major histocompatibility complex class II molecules is essential for generation of CD4(+) T cell responses and occurs after cathepsin-mediated degradation of the invariant chain chaperone molecule. Cathepsins are expressed differentially in antigen presenting cells, and mice deficient in cathepsin S or cathepsin L exhibit severely impaired antigen presentation in peripheral lymphoid organs and the thymus, respectively. To determine whether these defects are due solely to the block in invariant chain cleavage, we used cathepsin-deficient B cells to examine the role of cathepsins S and B in the degradation of other molecules important in the class II presentation pathway. Our data indicate that neither cathepsin S nor B is critical for H-2M degradation or processing of precursor gamma-interferon-inducible lysosomal thiol reductase (GILT) to a mature thiol reductase, but suggest a role for cathepsin S in the turnover of mature GILT and in regulating levels of mature cathepsin L protein in B cells. Despite the presence of mature cathepsin L protein, no enzyme activity could be detected in B cells or dendritic cells. These experiments suggest a novel mechanism by which these functionally important enzymes may be regulated.

Glycosylation and the immune system.

Almost all of the key molecules involved in the innate and adaptive immune response are glycoproteins. In the cellular immune system, specific glycoforms are involved in the folding, quality control, and assembly of peptide-loaded major histocompatibility complex (MHC) antigens and the T cell receptor complex. Although some glycopeptide antigens are presented by the MHC, the generation of peptide antigens from glycoproteins may require enzymatic removal of sugars before the protein can be cleaved. Oligosaccharides attached to glycoproteins in the junction between T cells and antigen-presenting cells help to orient binding faces, provide protease protection, and restrict nonspecific lateral protein-protein interactions. In the humoral immune system, all of the immunoglobulins and most of the complement components are glycosylated. Although a major function for sugars is to contribute to the stability of the proteins to which they are attached, specific glycoforms are involved in recognition events. For example, in rheumatoid arthritis, an autoimmune disease, agalactosylated glycoforms of aggregated immunoglobulin G may induce association with the mannose-binding lectin and contribute to the pathology.

A role for calnexin in the assembly of the MHC class I loading complex in the endoplasmic reticulum.

Heterodimers of MHC class I glycoprotein and beta(2)-microglobulin (beta(2)m) bind short peptides in the endoplasmic reticulum (ER). Before peptide binding these molecules form part of a multisubunit loading complex that also contains the two subunits of the TAP, the transmembrane glycoprotein tapasin, the soluble chaperone calreticulin, and the thiol oxidoreductase ERp57. We have investigated the assembly of the loading complex and provide evidence that after TAP and tapasin associate with each other, the transmembrane chaperone calnexin and ERp57 bind to the TAP-tapasin complex to generate an intermediate. These interactions are independent of the N:-linked glycan of tapasin, but require its transmembrane and/or cytoplasmic domain. This intermediate complex binds MHC class I-beta(2)m dimers, an event accompanied by the loss of calnexin and the acquisition of calreticulin, generating the MHC class I loading complex. Peptide binding then induces the dissociation of MHC class I-beta(2)m dimers, which can be transported to the cell surface.

Gamma-interferon-inducible lysosomal thiol reductase (GILT). Maturation, activity, and mechanism of action.

We recently identified a gamma-interferon-inducible lysosomal thiol reductase (GILT), constitutively expressed in antigen-presenting cells, that catalyzes disulfide bond reduction both in vitro and in vivo and is optimally active at acidic pH. GILT is synthesized as a 35-kDa precursor, and following delivery to major histocompatibility complex (MHC) class II-containing compartments (MIICs), is processed to the mature 30-kDa form via cleavage of N- and C-terminal propeptides. The generation of MHC class II epitopes requires both protein denaturation and reduction of intra- and inter-chain disulfide bonds prior to proteolysis. GILT may be important in disulfide bond reduction of proteins delivered to MIICs and consequently in antigen processing. In this report we show that, like its mature form, precursor GILT reduces disulfide bonds with an acidic pH optimum, suggesting that it may also be involved in disulfide bond reduction in the endocytic pathway. We also show that processing of precursor GILT can be mediated by multiple lysosomal proteases and provide evidence that the mechanism of action of GILT resembles that of other thiol oxidoreductases.

Interaction of human immunodeficiency virus type 2 Vpx and invariant chain.

Vpx is a virion-associated protein of human immunodeficiency virus type 2 (HIV-2) and simian immunodeficiency viruses. The yeast two-hybrid system was used to identify invariant chain (Ii) as a cellular protein that interacts with HIV-2 Vpx. Vpx-Ii interaction was confirmed in cell-free reactions using bacterially expressed glutathione S-transferase fusion proteins and by coimmunoprecipitation in transfected and infected cells. In chronically infected cells expressing Vpx, Ii levels were markedly decreased, presumably due to enhanced degradation. These findings suggest that Vpx may disrupt major histocompatibility complex class II antigen presentation.

Enzymatic reduction of disulfide bonds in lysosomes: characterization of a gamma-interferon-inducible lysosomal thiol reductase (GILT).

Proteins internalized into the endocytic pathway are usually degraded. Efficient proteolysis requires denaturation, induced by acidic conditions within lysosomes, and reduction of inter- and intrachain disulfide bonds. Cytosolic reduction is mediated enzymatically by thioredoxin, but the mechanism of lysosomal reduction is unknown. We describe here a lysosomal thiol reductase optimally active at low pH and capable of catalyzing disulfide bond reduction both in vivo and in vitro. The active site, determined by mutagenesis, consists of a pair of cysteine residues separated by two amino acids, similar to other enzymes of the thioredoxin family. The enzyme is a soluble glycoprotein that is synthesized as a precursor. After delivery into the endosomal/lysosomal system by the mannose 6-phosphate receptor, N- and C-terminal prosequences are removed. The enzyme is expressed constitutively in antigen-presenting cells and induced by IFN-gamma in other cell types, suggesting a potentially important role in antigen processing.

Intracellular surveillance: controlling the assembly of MHC class I-peptide complexes.

MHC class I molecules bind with high affinity to peptides in the endoplasmic reticulum and display them on the cell surface. Here they are screened by CD8-positive T-lymphocytes for the presence of foreign, pathogen-derived peptides within the mass of self-peptides expressed. MHC class I assembly is a complicated process involving a number of accessory molecules, including specialized components as well as common chaperones. Our understanding of the mechanisms involved, while quite advanced, is far from complete.

Thiol oxidation and reduction in MHC-restricted antigen processing and presentation.

Major histocompatibility complex (MHC) class I molecules are assembled in the endoplasmic reticulum (ER) as a trimer of the class I heavy chain, beta2 microglobulin (beta2m), and a short peptide. Assembly occurs in a complex with additional noncovalently associated proteins, which include the thiol oxidoreductase, ERp57. This molecule facilitates the formation of the correct disulfide bonds in glycoproteins as they fold in the ER and may play a key role in assembling a stable MHC class I-peptide complex. In the endocytic pathway, reduction of protein disulfide bonds is important for the generation of MHC class II-peptide complexes. This process is catalyzed by a gamma-interferon-inducible thiol reductase (GILT). The possible requirement for catalysis of disulfide bond formation in MHC class I-restricted antigen processing and the known requirement for disulfide bond reduction in MHC class II-restricted antigen processing present interesting examples of the adaptation of cellular "housekeeping" functions to facilitate immune responses.

Cytomegalovirus US2 destroys two components of the MHC class II pathway, preventing recognition by CD4+ T cells.

Human cytomegalovirus (HCMV) is a ubiquitous herpesvirus that causes life-threatening disease in patients who are immunosuppressed for bone marrow or tissue transplantation or who have AIDS (ref. 1). HCMV establishes lifelong latent infections and, after periodic reactivation from latency, uses a panel of immune evasion proteins to survive and replicate in the face of robust, fully primed host immunity. Monocyte/macrophages are important host cells for HCMV, serving as a latent reservoir and as a means of dissemination throughout the body. Macrophages and other HCMV-permissive cells, such as endothelial and glial cells, can express MHC class II proteins and present antigens to CD4+ T lymphocytes. Here, we show that the HCMV protein US2 causes degradation of two essential proteins in the MHC class II antigen presentation pathway: HLA-DR-alpha and DM-alpha. This was unexpected, as US2 has been shown to cause degradation of MHC class I (refs. 5,6), which has only limited homology with class II proteins. Expression of US2 in cells reduced or abolished their ability to present antigen to CD4+ T lymphocytes. Thus, US2 may allow HCMV-infected macrophages to remain relatively 'invisible' to CD4+ T cells, a property that would be important after virus reactivation.

The N-terminal region of tapasin is required to stabilize the MHC class I loading complex.

Tapasin mediates the binding of MHC class I molecules to the transporter associated with antigen processing (TAP). Deletion mutants of tapasin were used to examine the effect of tapasin on interactions within the MHC class I complex. Binding to TAP is mediated by the C-terminal region of tapasin. Michaelis-Menten analysis of peptide transport shows that this interaction is sufficient to increase TAP levels without significantly affecting the intrinsic translocation rate. Weak interactions exist between MHC class I molecules and TAP in the absence of tapasin, and between free heavy chains and TAP-tapasin complexes in the absence of beta2-microglobulin. The N-terminal 50 residues of tapasin constitute the key element which converts the sum of these weak interactions into a stable complex.