Etomidate uniquely modulates the desensitization of recombinant α1ß3δ GABA(A) receptors.

Central GABA(A) receptors mediate GABAergic phasic and tonic inhibition. While synaptic αßγ GABA(A) receptors primarily mediate phasic inhibition, extrasynaptic αßδ receptors play an important role in mediating tonic inhibition. Etomidate is a general anesthetic that produces its effects by enhancing GABA(A) receptor activity. We previously showed that etomidate modulates the gating of oocyte-expressed αßγ and αßδ receptors with similar overall allosteric impact, but different pharmacological patterns. In αßγ receptors, etomidate enhances apparent GABA sensitivity (reduces GABA EC50), modestly increases maximal GABA efficacy, and slows current deactivation without affecting desensitization (Zhong et al., 2008). In αßδ receptors characterized by low GABA efficacy, etomidate dramatically increases responses to both low and maximal GABA. The effects of etomidate on desensitization and deactivation of αßδ receptors are unknown. To investigate the kinetic effects of etomidate on α1ß3δ receptors of defined subunit arrangement, we expressed concatenated trimer (ß3-α1-δ) and dimer (ß3-α1) GABA(A) receptor subunit assemblies in human embryonic kidney (HEK)293T cells and recorded whole-cell voltage-clamp currents during rapid external solution exchanges. As expected, etomidate substantially increased maximal GABA-induced currents and prolonged deactivation. Moreover, desensitization was significantly decreased by etomidate. During prolonged GABA applications, etomidate enhanced steady-state currents more than peak currents. Thus, etomidate enhances tonic GABAergic inhibition through extrasynaptic αßδ receptors by both augmenting gating and reducing desensitization.

Etomidate produces similar allosteric modulation in α1ß3δ and α1ß3γ2L GABA(A) receptors.

BACKGROUND AND PURPOSE: Neuronal GABA(A) receptors are pentameric chloride ion channels, which include synaptic αßγ and extrasynaptic αßδ isoforms, mediating phasic and tonic inhibition respectively. Although the subunit arrangement of αßγ receptors is established as ß-α-γ-ß-α, that of αßδ receptors is uncertain and possibly variable. We compared receptors formed from free α1, ß3 and δ or γ2L subunits and concatenated ß3-α1-δ and ß3-α1 subunit assemblies (placing δ in the established γ position) by investigating the effects of R-(+)-etomidate (ETO), an allosteric modulator that selectively binds to transmembrane interfacial sites between ß3 and α1. EXPERIMENTAL APPROACH: GABA-activated receptor-mediated currents in Xenopus oocytes were measured electrophysiologically, and ETO-induced allosteric shifts were quantified using an established model. KEY RESULTS: ETO (3.2 µM) similarly enhanced maximal GABA (1 mM)-evoked currents in oocytes injected with 5 ng total mRNA and varying subunit ratios, for α1ß3(1:1), α1ß3δ(1:1:1) and α1ß3δ(1:1:3), but this potentiation by ETO was significantly greater for ß3-α1-δ/ß3-α1(1:1) receptors. Reducing the amount of α1ß3δ(1:1:3) mRNA mixture injected (0.5 ng) increased the modulatory effect of ETO, matching that seen with ß3-α1-δ/ß3-α1(1:1, 1 ng). ETO similarly reduced EC50s and enhanced maxima of GABA concentration-response curves for both α1ß3δ and ß3-α1-δ/ß3-α1 receptors. Allosteric shift parameters derived from these data depended on estimates of maximal GABA efficacy, and the calculated ranges overlap with allosteric shift values for α1ß3γ2L receptors. CONCLUSION AND IMPLICATIONS: Reducing total mRNA unexpectedly increased δ subunit incorporation into receptors on oocyte plasma membranes. Our results favour homologous locations for δ and γ2L subunits in α1ß3γ2/δ GABA(A) receptors.

Effect of an aggressive lipid-lowering strategy on progression of atherosclerosis in the left main coronary artery from patients in the post coronary artery bypass graft trial.

BACKGROUND: The Post Coronary Artery Bypass Graft Trial, designed to compare the effects of two lipid-lowering regimens and low-dose anticoagulation versus placebo on progression of atherosclerosis in saphenous vein grafts of patients who had had CABG surgery, demonstrated that aggressive lowering of LDL cholesterol levels to a mean yearly cholesterol level from 93 to 97 mg/dL compared with a moderate reduction to a level of 132 to 136 mg/dL decreased the progression of atherosclerosis in saphenous vein grafts. Low-dose anticoagulation did not affect progression. This secondary analysis tested the hypothesis that a similar decrease in progression of atherosclerosis would also be present in native coronary arteries as measured in the left main coronary artery (LMCA). METHODS AND RESULTS: A sample of 402 patients was randomly selected from 1102 patients who had baseline and follow-up views of the LMCA suitable for analysis. Patients treated with the aggressive lipid-lowering strategy had less progression of atherosclerosis in the LMCA as measured by changes in minimum (P=0.0003) lumen diameter or the maximum percent stenosis (P=0.001), or the presence of substantial progression (P=0.008), or vascular occlusion (P=0.005) when compared with the moderate strategy. CONCLUSIONS: A strategy of aggressive lipid lowering results in significantly less atherosclerosis progression than a moderate approach in LMCAs.

Nonhalogenated alkane anesthetics fail to potentiate agonist actions on two ligand-gated ion channels.

BACKGROUND: Although ether, alcohol, and halogenated alkane anesthetics potentiate agonist actions or increase the apparent agonist affinity of ligand-gated ion channels at clinically relevant concentrations, the effects of nonhalogenated alkane anesthetics on ligand-gated ion channels have not been studied. The current study assessed the abilities of two representative nonhalogenated alkane anesthetics (cyclopropane and butane) to potentiate agonist actions or increase the apparent agonist affinity of two representative ligand-gated ion channels: the nicotinic acetylcholine receptor and y-aminobutyric acid type A (GABA(A)) receptor. METHODS: Nicotinic acetylcholine receptors were obtained from the electroplax organ of Torpedo nobiliana, and human GABA(A) receptors (alpha1beta2gamma2L) were expressed in human embryonic kidney 293 cells. The Torpedo nicotinic acetylcholine receptors apparent agonist affinity in the presence and absence of anesthetic was assessed by measuring the apparent rates of desensitization induced by a range of acetylcholine concentrations. The GABA(A) receptor's apparent agonist affinity in the presence and absence of anesthetic was assessed by measuring the peak currents induced by a range of GABA concentrations. RESULTS: Neither cyclopropane nor butane potentiated agonist actions or increased the apparent agonist affinity (reduced the apparent agonist dissociation constant) of the Torpedo nicotinic acetylcholine receptor or GABA(A) receptor. At clinically relevant concentrations, cyclopropane and butane reduced the apparent rate of Torpedo nicotinic acetylcholine receptor desensitization induced by low concentrations of agonist. CONCLUSIONS: Our results suggest that the in vivo central nervous system depressant effects of nonhalogenated alkane anesthetics do not result from their abilities to potentiate agonist actions on ligand-gated ion channels. Other targets or mechanisms more likely account for the anesthetic activities of nonhalogenated alkane anesthetics.

The gamma subunit determines whether anesthetic-induced leftward shift is altered by a mutation at alpha1S270 in alpha1beta2gamma2L GABA(A) receptors.

BACKGROUND: A major action of volatile anesthetics is enhancement of gamma-aminobutyric acid receptor type A (GABA(A)R) currents. In recombinant GABA(A)Rs consisting of several subunit mixtures, mutating the alpha1 subunit serine at position 270 to isoleucine [alpha1(S270I)] was reported to eliminate anesthetic-induced enhancement at low GABA concentrations. In the absence of studies at high GABA concentrations, it remains unclear whether alpha1(S270I) affects enhancement versus inhibition by volatile anesthetics. Furthermore, the majority of GABA(A)Rs in mammalian brain are thought to consist of alpha1, beta2, and gamma2 subunits, and the alpha1(S270I) mutation has not been studied in the context of this combination. METHODS: Recombinant GABA(A)Rs composed of alpha1beta2 or alpha1beta2gamma2L subunit mixtures were studied electrophysiologically in whole Xenopus oocytes in the voltage clamp configuration. Currents elicited by GABA (0.03 microM to 1 mM) were measured in the absence and presence of isoflurane or halothane. Anesthetic effects on GABA concentration responses were evaluated for individual oocytes. RESULTS: In wild-type alpha1beta2gamma2L GABA(A), anesthetics at approximately 2 minimum alveolar concentration (MAC) shifted GABA concentration response curves to the left approximately threefold, decreased the Hill coefficient, and enhanced currents at all GABA concentrations. The alpha1(S270I) mutation itself rendered the GABA(A)R more sensitive to GABA and reduced the Hill coefficient. At low GABA concentrations (EC5), anesthetic enhancement of peak current was much smaller in alpha1(S270I)beta2gamma2L versus wild-type channels. Paradoxically, the leftward shift of the whole GABA concentration-response relation by anesthetics was the same in both mutant and wild-type channels. At high GABA concentrations, volatile anesthetics reduced currents in alpha1(S270I)beta2gammaL GABA(A)Rs. In parallel studies on alpha1beta2 (gamma-less) GABA(A)Rs, anesthetic-induced leftward shifts in wild-type receptors were more than eightfold at 2 MAC, and the alpha1(S270I) mutation nearly eliminated anesthetic-induced leftward shift. CONCLUSIONS: The results support a role for alpha1S270 in alpha1beta2gamma2L GABA(A)R gating and sensitivity to inhibition by volatile anesthetics. The alpha1S270 locus also modulates anesthetic enhancement in alpha1beta2 GABA(A)R. The presence of the gamma2L subunit reduces anesthetic-induced left shift of wild-type GABA(A)R and nullifies the impact of the alpha1(S2701) mutation on anesthetic modulation. Thus, the gamma2L subunit plays a significant role in GABA(A)R modulation by volatile anesthetic compounds.

Butanol effects on gamma-amino butyric acid concentration-responses in human alpha1beta2gamma2L gamma-amino butyric acid type A receptors with a mutation at alpha1S270.

Alcohol enhancement of gamma-amino butyric acid type A receptor (GABA(A)R) gating at low GABA is reduced by a serine-to-isoleucine mutation at residue alphaS270, suggesting that alphaS270 forms an enhancement site. However, whether the alphaS270I mutation strengthens alcohol inhibition of GABA(A)Rs remains unexplored. Furthermore, alphaS270 mutations have not been studied in the most prevalent form of mammalian GABA(A)Rs consisting of alpha1, beta2, and gamma2 subunits. In voltage-clamped Xenopus oocytes expressing recombinant alpha1beta2gamma2L GABA(A)Rs, electrophysiological analysis of GABA concentration-responses demonstrates that the alpha1(S270I) mutation increases apparent GABA affinity and significantly reduces the Hill coefficient of GABA(A)R activation. Butanol-induced leftward-shifts in GABA concentration-responses for both wild-type alpha1beta2gamma2L and alpha1(S270I)beta2gamma2L GABA(A)Rs are equal. At high GABA, butanol neither enhances nor inhibits alpha1(S270I)beta2gamma2L responses. Thus, in the dominant mammalian GABA(A)R isoform, the alphaS270I mutation affects neither enhancement nor inhibition by butanol, but alters the gating mechanism by reducing cooperativity, producing an apparent reduction in alcohol enhancement at low GABA.

The n-alcohol site in the nicotinic receptor pore is a hydrophobic patch.

Alcohols and volatile anesthetics inhibit peripheral nicotinic acetylcholine receptors noncompetitively, primarily via an open-channel block mechanism. Analysis of hydrophobic mutations near the middle of the pore-forming M2 domains suggested that alcohols interact with the pore in this vicinity. To establish the extent of this inhibitory site, we created a series of hydrophobicity-altering mutations scanning most of the alpha subunit M2 domain. Using both single-channel and rapid patch perfusion electrophysiology, we measured how these mutations affect nAChR sensitivity to ethanol and hexanol. We find a near-contiguous series of amino acids in alpha-M2, extending from alphaL250 (8') to alphaV255 (13'), where mutagenesis strongly influences inhibition by alcohols. These results support the existence of a large inhibitory patch in the nAChR pore lining where interactions with alcohols are primarily due to hydrophobic forces. Ethanol appears to interact with deeper regions of this site than does hexanol. Because alcohols apparently act as open-channel blockers, we infer from our results that most of the residues between alphaL250 and alphaV255 are exposed to the aqueous environment of the pore when the channel is open. The location and extent of this site can explain why small alcohols occupy the nAChR pore at the same time as larger alcohols or charged blockers, while two large alcohols bind in a mutually exclusive manner.

High-risk population health management--achieving improved patient outcomes and near-term financial results.

OBJECTIVE: A managed care organization sought to achieve efficiencies in care delivery and cost savings by anticipating and better caring for its frail and least stable members. STUDY DESIGN: Time sequence case study of program intervention across an entire managed care population in its first year compared with the prior baseline year. PATIENTS AND METHODS: Key attributes of the intervention included predictive registries of at-risk members based on existing data, relentless focus on the high-risk group, an integrated clinical and psychosocial approach to assessments and are planning, a reengineered care management process, secured Internet applications enabling rapid implementation and broad connectivity, and population-based outcomes metrics derived from widely used measures of resource utilization and functional status. RESULTS: Concentrating on the highest-risk group, which averaged just 1.1% prevalence in the total membership, yielded bottom line results. When the year before program implementation (July 1997 through June 1998) was compared with the subsequent year, the total population's annualized commercial admission rate was reduced 5.3%, and seniors' was reduced 3.0%. A claims-paid analysis exclusively of the highest-risk group revealed that their efficiencies and savings overwhelmingly contributed to the membershipwide effect. This subgroup's costs dropped 35.7% from preprogram levels of $2590 per member per month (excluding pharmaceuticals). During the same time, patient-derived cross-sectional functional status rose 12.5%. CONCLUSIONS: A sharply focused, Internet-deployed case management strategy achieved economic and functional status results on a population basis and produced systemwide savings in its first year of implementation.

Nicotinic receptor pore mutations create a sensitive inhibitory site for ethanol.

BACKGROUND: Ethanol (EtOH) inhibition and enhancement of ligand-gated ion channel functions may be due to direct interactions with sites on these membrane proteins. Peripheral nicotinic receptors have pore sites that long-chain alcohols inhibit but EtOH does not, either because of weak binding (low affinity) or inability to impair ion translocation (low efficacy). We tested whether nicotinic pore mutations that increase hydrophobicity and/or size can create a site where EtOH inhibits at physiological concentrations. METHODS: We studied recombinant expressed mouse muscle receptors with patch-clamp electrophysiology to measure EtOH effects both on single-channel conductance and on multichannel currents elicited with rapid agonist superfusion. We studied pairs of mutants with similar residue sizes but different hydrophobicitics at position alpha252 to determine if size or hydrophobicity determines EtOH sensitivity. RESULTS: Inhibition of wild-type currents is seen at EtOH concentrations >300 mM. Receptors that contain the alphaS252I (serine to isoleucine) mutation are significantly inhibited by 100 mM EtOH. Adding a second homologous mutation on the beta subunit (betaT263I) further enhances sensitivity and creates receptors that are inhibited significantly by 50 mM EtOH. The open-state conductance of single nicotinic channels is reduced in the presence of EtOH, which closely parallels EtOH inhibition of multichannel currents. In two isosteric mutant pairs at position alpha252, only hydrophobic side-chains significantly increase receptor sensitivity to EtOH. CONCLUSIONS: Wild-type nicotinic receptors have a very low affinity for EtOH, but only one or two mutations in the pore site create receptors inhibited by physiological EtOH concentrations. Ethanol inhibition is due primarily to channel interactions in the open state. At amino acid alpha252, side-chain hydrophobicity, not size, determines receptor sensitivity to EtOH inhibition. We propose that similar sites may exist within the pores of other EtOH-sensitive ion channels, such as NMDA receptors and neuronal nicotinic receptors.

Long-term effects on clinical outcomes of aggressive lowering of low-density lipoprotein cholesterol levels and low-dose anticoagulation in the post coronary artery bypass graft trial. Post CABG Investigators.

BACKGROUND: The Post Coronary Artery Bypass Graft Trial, designed to compare the effects of 2 lipid-lowering regimens and low-dose anticoagulation versus placebo on progression of atherosclerosis in saphenous vein grafts of patients who had had CABG surgery, demonstrated that aggressive lowering of LDL cholesterol (LDL-C) levels to <100 mg/dL compared with a moderate reduction to 132 to 136 mg/dL decreased the progression of atherosclerosis in grafts. Low-dose anticoagulation did not significantly affect progression. METHODS AND RESULTS: Approximately 3 years after the last trial visit, Clinical Center Coordinators contacted each patient by telephone to ascertain the occurrence of cardiovascular events and procedures. The National Death Index was used to ascertain vital status for patients who could not be contacted. Vital status was established for all but 3 of 1351 patients. Information on nonfatal events was available for 95% of surviving patients. A 30% reduction in revascularization procedures and 24% reduction in a composite clinical end point were observed in patients assigned to aggressive strategy compared with patients assigned to moderate strategy during 7.5 years of follow-up, P=0. 0006 and 0.001, respectively. Reductions of 35% in deaths and 31% in deaths or myocardial infarctions with low-dose anticoagulation compared with placebo were also observed, P=0.008 and 0.003, respectively. CONCLUSIONS: -The long-term clinical benefit observed during extended follow-up in patients assigned to the aggressive strategy is consistent with the angiographic findings of delayed atherosclerosis progression in grafts observed during the trial. The apparent long-term benefit of low-dose warfarin remains unexplained.

A hydrophobic photolabel inhibits nicotinic acetylcholine receptors via open-channel block following a slow step.

3-(Trifluoromethyl)-3-(m-iodophenyl)diazirine (TID) is a hydrophobic inhibitor of nicotinic acetylcholine receptors (nAChRs) and a photolabel that incorporates both at the lipid-protein interface and within the gated pore. On the basis of Torpedo vesicle studies, TID is thought to selectively inhibit the closed nAChR state. The nAChR site(s) mediating TID inhibition is unknown. We investigated the state dependence and kinetics of TID inhibition electrophysiologically using rapidly superfused membrane patches expressing mouse muscle nAChRs. Currents from patches simultaneously exposed to ACh and TID show no inhibition of peak currents relative to acetylcholine (ACh) alone but demonstrate slow (10 s(-1)) TID inhibition. Patch preexposure to TID before ACh results in a burst of current followed by rapid [TID]-dependent inhibition at a bimolecular rate of 1.8 x 10(8) M(-1) s(-1), indicating that TID selectively inhibits open channels. We also determined sensitivity to TID in two nAChRs containing mutations in their pore-forming M2 domains. The alphaL251T mutation eliminates sensitivity to TID inhibition, while the alphaS252I mutation enhances this sensitivity 4-fold compared to wild type. These results indicate that TID inhibition of nAChRs follows two distinct kinetic steps. The rate-limiting step, which shows features suggesting a diffusion barrier, precedes rapid open-state-dependent TID binding to an inhibition site near the putative nAChR gate.

Synthesis and properties of 3-(2-hydroxyethyl)-3-n-pentyldiazirine, a photoactivable general anesthetic.

To overcome the difficulties of locating the molecular sites of general anesthetic action, we synthesized a novel photoactivable general anesthetic, 3-(2-hydroxyethyl)-3-n-pentyldiazirine (3-diazirinyloctanol), which anesthetized tadpoles with an ED(50) of 160 microM. Subanesthetic concentrations of 3-diazirinyloctanol enhanced GABA-induced currents in GABA(A) receptors, an effect that has been implicated in general anesthetic action. It also enhanced [(3)H]muscimol binding to this receptor. In muscle nicotinic acetylcholine receptors (nAcChoR), it inhibited the response to acetylcholine with an IC(50) of 33 microM. 3-Diazirinyloctanol's pharmacological actions were comparable to those of octanol. 3-(2-Hydroxyethyl)-3-[4,5-(3)H(2)]-n-pentyldiazirine photoincorporated into Torpedo nAcChoR-rich membranes mainly in the alpha subunit with 70% being in a proteolytic fragment containing the M4 transmembrane segment. Agonist enhanced the photolabeling 10-fold in a fragment containing the M1, M2, and M3 transmembrane segments. Thus, 3-diazirinyloctanol is a novel general anesthetic that acts on, and can be photoincorporated into, postsynaptic receptors.

Aggressive cholesterol lowering delays saphenous vein graft atherosclerosis in women, the elderly, and patients with associated risk factors. NHLBI post coronary artery bypass graft clinical trial. Post CABG Trial Investigators.

BACKGROUND: The NHLBI Post Coronary Artery Bypass Graft trial (Post CABG) showed that aggressive compared with moderate lowering of low-density lipoprotein-cholesterol (LDL-C) decreased obstructive changes in saphenous vein grafts (SVGs) by 31%.1 Using lovastatin and cholestyramine when necessary, the annually determined mean LDL-C level ranged from 93 to 97 mg/dL in aggressively treated patients and from 132 to 136 mg/dL in the others (P<0.001). METHODS AND RESULTS: The present study evaluated the treatment effect in subgroups defined by age, gender, and selected coronary heart disease (CHD) risk factors, ie, smoking, hypertension, diabetes mellitus, high-density lipoprotein cholesterol (HDL-C) <35 mg/dL, and triglyceride serum levels >/=200 mg/dL at baseline. As evidenced by similar odds ratio estimates of progression (lumen diameter decrease >/=0.6 mm) and lack of interactions with treatment, a similar beneficial effect of aggressive lowering was observed in elderly and young patients, in women and men, in patients with and without smoking, hypertension, or diabetes mellitus, and those with and without borderline high-risk triglyceride serum levels. The change in minimum lumen diameter was in the same direction for all subgroup categories, without significant interactions with treatment. CONCLUSIONS: Aggressive LDL-C lowering delays progression of atherosclerosis in SVGs irrespective of gender, age, and certain risk factors for CHD.

Novel modulation of a nicotinic receptor channel mutant reveals that the open state is stabilized by ethanol.

Ethanol enhances the gating of a family of related ligand-gated ion channels including nicotinic acetylcholine, serotonin type 3, gamma-aminobutyric acid-A, and glycine receptors. This common action may reflect shared molecular and kinetic mechanisms. In all of these receptors, ethanol enhances multichannel currents elicited with low agonist concentrations, but not with high agonist concentrations. A single mutation in the nicotinic receptor beta subunit, betaT263I, causes ethanol to enhance multichannel currents elicited with both low and high acetylcholine concentrations. Based on the ratios of acetylcholine EC50s in the presence and absence of ethanol, this mutant's sensitivity to enhancement is similar to wild type. Ethanol enhancement of betaT263I receptor activation shows no voltage dependence. In the presence of ethanol, the apparent single-channel conductance of the betaT263I receptor is reduced and the apparent channel lifetime is lengthened. Both the 28% increase in maximal current and the 2-fold reduction in EC50 observed at 300 mM ethanol are quantitatively predicted by simulation of a simple kinetic scheme in which ethanol increases by 4-fold the ratio of microscopic opening rate (beta) to closing rate (alpha) for acetylcholine-bound betaT263I receptors. We conclude that ethanol enhancement of betaT263I currents reflects stabilization of its open-channel state relative to agonist-bound closed states. Ethanol effects in wild-type receptors can also be explained by this mechanism.

Factors influencing clinical outcomes after revascularization in the asymptomatic cardiac ischemia pilot (ACIP). ACIP Study Group.

BACKGROUND AND AIM: The Asymptomatic Cardiac Ischemia Pilot is the first randomized trial where revascularization involved choice of either coronary bypass or angioplasty used in an early or a delayed symptom-driven approach. One-year outcomes were favorable (reduced recurrent ischemia and adverse outcomes) for an early revascularization strategy (within 4 weeks), compared with an early medical strategy when revascularization was delayed until symptom-driven. This ancillary study examined variables influencing outcomes after these 2 revascularization approaches (early vs. delayed until symptom-driven). METHODS: Participants were clinically stable coronary disease patients with stress-induced and daily life ischemia who underwent revascularization. Characteristics associated with clinical outcomes occurring within the year following revascularization were examined using Cox regression analysis. RESULTS: A total of 262 patients received revascularization; 170 in the early approach and 92 in the delayed symptom-driven approach. Thirty-three patients had adverse outcomes (death, nonfatal myocardial infarction, or repeat revascularization) during 1-year follow-up. The most important independent predictor of improved outcome during the follow-up year was attempted revascularization of > or = 66% of vessels with significant stenosis for the early (risk ratio [RR] 0.25, 95% confidence interval [CI] 0.09-0.67) and the delayed (RR 0.21, CI 0.08-0.58) approaches. Factors such as age, stress test results, and coronary angiographic findings did not predict clinical outcome. CONCLUSIONS: Our findings are important in the planning of a large trial with longer follow-up.

Nonanesthetic volatile drugs obey the Meyer-Overton correlation in two molecular protein site models.

BACKGROUND: Nonanesthetic volatile compounds fail to inhibit movement in response to noxious stimulation at concentrations predicted to induce anesthesia from their oil-water partitioning. Thus they represent tools to determine whether molecular models behave like the targets that mediate in vivo anesthetic actions. The effects of volatile anesthetics and nonanesthetics were examined in two experimental models in which anesthetics interact directly with proteins: the pore of the nicotinic acetylcholine receptor and human serum albumin. METHODS: Wild-type mouse muscle nicotinic receptors and receptors containing pore mutations (alphaS252I + betaT263I) were studied electrophysiologically in membrane patches from Xenopus oocytes. Patch currents evoked by brief pulses of acetylcholine were measured in the presence of enflurane and two nonanesthetics, 1,2-dichlorohexafluorocyclobutane and 2,3-dichlorooctafluorobutane. Nonanesthetic interactions with human serum album were assessed by quenching of intrinsic protein fluorescence. RESULTS: Both anesthetic and nonanesthetic volatile compounds inhibited wild-type and alphaS252I + betaT263I mutant nicotinic channels but displayed different selectivity for open versus resting receptor states. Median inhibitory concentrations (IC50s) in wild-type nicotinic receptors were 870+/-20 microM for enflurane, 37+/-3 microM for 1,2-dichlorohexafluorocylcobutane, and 11.3+/-5.6 microM for 2,3-dichlorooctafluorobutane. For all three drugs, ratios of wild-type IC50s to mutant IC50mut ranged from 7-10, and ratios of wild-type IC50s to predicted anesthetic median effective concentrations (EC50s) ranged from 1.8-2.3. 1,2-Dichlorohexafluorocyclobutane quenched human serum albumin with an apparent dissociation constant (Kd) of 160+/-11 microM. The ratios of dissociation constants to predicted EC50s for the nonanesthetics were within a factor of two of the dissociation constant:EC50 ratios calculated for halothane and chloroform from previous published results. CONCLUSIONS: In two models in which anesthetics bind to protein sites, both anesthetic and nonanesthetic volatile drugs cause similar steady state effects with potencies that are predicted by hydrophobicity. These protein sites do not sterically discriminate between anesthetic and nonanesthetic drugs. However, differential state-selective actions on ion channel targets may underlie the distinct in vivo effects of anesthetics and nonanesthetics.

Identification, functional characterization, and developmental expression of two nonallelic parathyroid hormone (PTH)/PTH-related peptide receptor isoforms in Xenopus laevis (Daudin).

Complementary DNAs encoding two nonallelic PTH/PTH-related peptide (PTHrP) receptor (PPR) isoforms, xPPR-A and xPPR-B, were isolated from a kidney complementary DNA library of the tetraploid African clawed frog Xenopus laevis. Both isoforms differ in their coding region by 19 amino acids, and lack the region corresponding to the mammalian exon E2. When expressed in mammalian COS-7 cells, both receptor isoforms bound radiolabeled PTH-(1-34) and PTHrP-(1-36) analogs with comparable affinity, and both unlabeled peptides equivalently stimulated the accumulation of cAMP. xPPR-A also mediated inositol phosphate turnover in COS cells and stimulated channel-mediated current changes in voltage clamp experiments after injection into oocytes. Using ribonuclease protection analysis, significant xPPR-A messenger RNA expression was first detected in neurula stage embryos, which subsequently increased approximately 30-fold during tadpole development. Expression reached a maximum at the metamorphotic climax, when isoform B also became detectable at significant levels, and subsequently declined in postmetamorphotic froglets. In the adult frog, xPPR-A was prominently expressed in lung, brain, small bowel, and skin, whereas isoform B was highest in lung, heart, and brain. Using an xPPR-A antisense riboprobe for in situ hybridization, expression appeared during metamorphosis at all sites of chondrogenesis, specifically in the maturing zone of the amphibian growth plate. xPPR-A expression was also seen in a subpopulation of mononuclear cells, possibly representing osteoblasts that line perichondral bone and diaphyseal bone trabeculae. Our findings suggest that xPPRs serve a prominent role in amphibian skeletal development and possibly other functions during embryonal and early larval development.

Direct interactions of anesthetics and nonanesthetics with the nicotinic acetylcholine receptor pore.

(1) We review evidence that anesthetics inhibit peripheral nAChR cation translocation by binding directly to a protein site in the transmembrane pore. (2) This site is near the middle of the pore-forming M2 domains on alpha and beta subunits, but further from the homologous portions of gamma and delta subunits. (3) Interactions between both anesthetics and nonanesthetics with the nAChR pore site are determined primarily by hydrophobic forces rather than steric factors. (4) Anesthetics and nonanesthetics display different state-dependent accessibility to this site, suggesting a mechanism for the different in vivo actions of these two classes of drugs.

Clinical improvement with bottom-line impact: custom care planning for patients with acute and chronic illnesses in a managed care setting.

A fully capitated, integrated healthcare delivery system endeavored to improve the care of its sickest members. A computer algorithm severity index that encompassed a 1-year history of hospitalization and adjusted for inclusion of a variety of chronic conditions was calculated on the basis of clinical and administrative claims databases for the entire membership of the healthcare system. Monthly updated lists were produced to find patients with acute and chronic illnesses. These patients accounted for one-fourth of hospital admissions and almost half of inpatient days, but they numbered less than 1% of system membership. Each listed person, regardless of age or diagnosis, had a custom care plan formulated by nurses in consultation with the primary care physician and involved specialists. Plan development featured in-home assessments in most instances and incorporated a variety of ancillary services, telephone and home-care follow-up, and strategies to increase continuity and access to care. Patient-reported functional status was obtained at establishment of the care plan and periodically thereafter in expectation of raising the cross-sectional mean values of the population. Three months after initiation of the program, the expected winter hospitalization peak did not occur, and utilization tended to be lower in subsequent months. Inpatient admissions among members with acute and chronic illnesses decreased 20%, and inpatient days decreased 28% from baseline levels. Among the subset of seniors in the population, inpatient days decreased 37%. Net financial impact was a medical expenditure decrease of more than 5% from 1995 levels. On a population basis, functional status was raised, and the acuity of patients' conditions and need for inpatient hospital care were reduced.