[Practice variation in the field of suicide prevention in Dutch mental healthcare]. / Praktijkvariatie op het gebied van suïcidepreventie in de Nederlandse ggz.

BACKGROUND: Previous studies found that the implementation of service guideline recommendations can significantly reduce the number of suicides in mental healthcare. Important barriers to suicide prevention guideline implementation are a lack of professionals' knowledge and competence towards the suicide prevention guideline.
AIM: To assess professionals' knowledge of, competence in, and adherence to the suicide prevention guideline in twelve Dutch specialist mental healthcare institutions.
METHOD: In this study, professionals working at crisis teams and outpatient care teams from each of the 12 participating mental healthcare institutions in the network of supranet Care were invited to fill in a questionnaire examining professionals' knowledge of, competence in, and adherence to the suicide prevention guideline (N = 400). Results were analyzed with multilevel regression analysis and adjusted for confounding.
RESULTS: Although professionals scored high on knowledge, competence, and adherence towards the guideline, they did not know to what extent the guideline was implemented within their own team. Outpatient care teams scored significantly lower on professionals' knowledge and reported lower levels of competence. Furthermore, we found significantly higher scores on adherence to the guideline for professionals in crisis teams compared to outpatient care teams. Healthcare professionals also reported practice variation within and across Dutch mental healthcare institutions. CONCLUSIONS Practice variation within and across teams and mental healthcare institutions is undesirable. To reduce this variation, professionals and mental healthcare institutions should share best-practices and learn from each other how the quality of care for suicidal patients can be optimized.

A single hERG mutation underlying a spectrum of acquired and congenital long QT syndrome phenotypes.

The long QT syndrome (LQTS) is a multi-factorial disorder that predisposes to life-threatening arrhythmias. Both hereditary and acquired subforms have been identified. Here, we present clinical and biophysical evidence that the hERG mutation c.1039 C>T (p.Pro347Ser or P347S) is responsible for both the acquired and the congenital phenotype. In one case the genotype remained silent for years until the administration of several QT-prolonging drugs resulted into a full-blown phenotype, that was reversible upon cessation of these compounds. On the other hand the mutation was responsible for a symptomatic congenital LQTS in a Dutch family, displaying a substantial heterogeneity of the clinical symptoms. Biophysical characterization of the p.Pro347Ser potassium channels using whole-cell patch clamp experiments revealed a novel pathogenic mechanism of reciprocal changes in the inactivation kinetics combined with a dominant-negative reduction of the functional expression in the heterozygous situation, yielding a modest genetic predisposition for LQTS. Our data show that in the context of the multi-factorial aetiology underlying LQTS a modest reduction of the repolarizing power can give rise to a spectrum of phenotypes originating from one mutation. This observation increases the complexity of genotype-phenotype correlations in more lenient manifestations of the disease and underscores the difficulty of predicting the expressivity of the LQTS especially for mutations with a more subtle impact such as p.Pro347Ser.

Phenol sulphotransferase SULT1A1*1 genotype is associated with reduced risk of colorectal cancer.

Sulphation is an important detoxification pathway for numerous xenobiotics; however, it also plays an important role in the metabolism and bioactivation of many dietary and environmental mutagens, including heterocyclic amines implicated in the pathogenesis of colorectal and other cancers. A major sulphotransferase (SULT) enzyme in humans, SULT1A1, is polymorphic with the most common variant allele, SULT1A1*2, occurring at a frequency of about 32% in the Caucasian population. This allele codes for an allozyme with low enzyme activity and stability compared to the wild-type (SULT1A1*1) enzyme, and therefore SULT1A1 genotype may influence susceptibility to mutagenicity following exposure to heterocyclic amines and other environmental toxins. Previously, a significant association of SULT1A1*1 genotype with old age has been observed, suggesting a 'chemoprotective' role for the high-activity phenotype. Here we have compared the frequencies of the most common SULT1A1 alleles in 226 colorectal cancer patients and 293 previously described control patients. We also assessed whether SULT1A1 genotype was related to various clinical parameters in the patient group, including Duke's classification, differentiation, site, nodal involvement and survival. There was no significant difference in allele frequency between the control and cancer patient populations, nor was there a significant association with any of the clinical parameters studied. However, when the age-related difference in allele frequency was considered, a significantly reduced risk of colorectal cancer (odds ratio = 0.47; 95% confidence interval = 0.27-0.83; P = 0.009), was associated with homozygosity for SULT1A1*1 in subjects under the age of 80 years. These results suggest that the high activity SULT1A1*1 allozyme protects against dietary and/or environmental chemicals involved in the pathogenesis of colorectal cancer.

Identification of UDP-glucuronosyltransferases involved in the human hepatic metabolism of GV150526, a novel glycine antagonist.

The major metabolic pathway for elimination of GV150526 is by glucuronidation exerted by glucuronosyl transferases (UGTs). Potential exists for the modification of GV150526 pharmacokinetics by drugs capable of inhibiting the glucuronidation of GV150526. Using human liver microsomes, 44 compounds were screened for inhibition of GV150526 glucuronidation. These compounds were selected because they are extensively glucuronidated themselves or are used as concomitant medication in the treatment of acute stroke. For 11 compounds out of the 44, full inhibition kinetics were performed to determine their Ki-value and mechanism of inhibition. To predict possible in vivo drug-drug interactions, the theoretical percentage of inhibition (i) was determined, based on in vitro determined Ki-values, and the expected Cmax plasma levels of GV150526 and the inhibitor. Of the 11 compounds examined, only propofol had an i-value of 6.6; for all other compounds i-values were lower than 2.1. These results indicate that although in vitro inhibition is observed, the likelihood of in vivo drug-drug metabolic interactions occurring is low. The inhibition results suggest that in addition to UGT1A1, also UGT1A3, UGT1A8/9, and UGT2B4 are involved in the glucuronidation of GV150526. The involvement of UGT1A1 and UGT1A8/9 was confirmed from studies using cDNA expressed human UGT cell lines.

Human hepatic metabolism of a novel 2-carboxyindole glycine antagonist for stroke: in vitro-in vivo correlations.

1. The hepatic metabolism of 3-[-2(phenylcarbamoyl) ethenyl]-4,6-dichloroindole-2-carboxylic acid (GV150526), a novel glycine antagonist for stroke, was investigated. 2. After a single intravenous administration of 800 mg GV150526 to healthy volunteers, six metabolites were observed. The major metabolites detected in human plasma have been shown by mass spectrometry to be glucoronides and one sulphate conjugate. 3. After incubation of GV150526 for 6 and 24 h with human liver slices, three glucuronide metabolites were observed. After incubation of GV150526 with pooled human liver microsomes, only one metabolite was observed, with the same molecular weight and HPLC retention time as the synthetic standard GV217053 (GV150526 hydroxylated on the para-position of the phenyl ring). 4. GV150526 hydroxylase enzyme kinetics--a step before sulphation--was determined using pooled human microsomes and was shown to be catalysed by cytochrome P4502C9. Glucuronidation kinetics towards GV150526 using microsomal preparations were also determined. Glucuronidation of GV150526 was observed with UGT1A1 cDNA-expressed protein, but not with UGT1A6. 5. The above enzyme kinetic data were used to calculate intrinsic clearance after scaling-up and hepatic clearance were calculated. Since GV150526 has a high plasma protein binding capacity, the effect of GV150526 binding to microsomal protein was determined. Thus, enzyme kinetic data were corrected, plotting the free (unbound) concentration of GV150526 versus enzymatic velocities: apparent Vmax did not alter significantly but apparent Km was approximately 10-fold lower. Correlation of these corrected enzyme kinetic data to predict clearance with in vivo clearance of GV150526 was good when both fu(plasma) and fu(microsomes) were included in the clearance calculations.

Phenol sulphotransferase SULT1A1 polymorphism: molecular diagnosis and allele frequencies in Caucasian and African populations.

Sulphation, catalysed by members of the sulphotransferase (SULT) enzyme family, is an important component of the body's chemical defence mechanism, but also acts to bioactivate mutagens such as hydroxylated aryl and heterocyclic amines. A major human sulphotransferase, SULT1A1 (P-PST), metabolizes and/or bioactivates many drugs, iodothyronines and hydroxylated aromatic amines. The enzyme activity varies widely within the population and is under genetic control. We have developed an assay detecting a G-->A transition in SULT1A1 that causes an Arg213-->His substitution associated with low SULT activity and altered enzyme properties, and have used it to assess the SULT1A1 genotype in Caucasian (n=293) and African (Nigerian, n=52) populations. We show that the mutant SULT1A1*2 allele is present at frequencies of 0.321 and 0.269 in the Caucasian and African populations respectively. We also demonstrate a significant age-related difference in SULT1A1 genotype within our Caucasian population, with increasing incidence of SULT1A1*1 homozygosity and decreasing incidence of SULT1A1*2 homozygosity with increasing age, indicating a potential association of SULT1A1*1 allozyme(s) with protection against cell and/or tissue damage during aging.

Sulphation of N-hydroxy-4-aminobiphenyl and N-hydroxy-4-acetylaminobiphenyl by human foetal and neonatal sulphotransferase.

Sulphation of the genotoxic compounds N-hydroxy-4-aminobiphenyl (N-OH-4ABP) and N-hydroxy-4-acetylaminobiphenyl (N-OH-4AABP) was determined in cytosolic preparations of human foetal, neonatal and adult liver and foetal and neonatal adrenal gland. Sulphotransferase (ST) activity capable of sulphating these compounds was present in foetal liver and adrenal gland by 14 weeks of gestation. Sulphation of N-OH-4ABP was higher in foetal and neonatal adrenal cytosol than was sulphation of N-OH-4AABP and in general, N-OH-4ABP ST activity was also greater than that towards 1-naphthol. In foetal and neonatal liver cytosol the sulphation of N-OH-4ABP was also higher than that of N-OH-4AABP (approximately 2-fold). In adult liver cytosols, however, N-OH-4AABP ST activity was higher than that for N-OH-4ABP and 1-naphthol sulphation. Aromatic hydroxylamines and hydroxamic acids are known to be converted by sulphotransferase into reactive, electrophilic compounds capable of reacting with DNA. Our data show that the human foetus and neonate have the capacity to sulphate these compounds and thus is able to produce the reactive mutagenic metabolites. Therefore, this class of genotoxic compounds may be bioactivated by humans during development--a time when they are most vulnerable to the effects of genotoxins.

Sulfation of carcinogenic aromatic hydroxylamines and hydroxamic acids by rat and human sulfotransferases: substrate specificity, developmental aspects and sex differences.

Sulfation of the carcinogen N-hydroxy-2-acetylaminofluorene (N-OH-AAF) and structurally related hydroxamic acids by rat and human sulfotransferases was studied. There was a clear sex and age difference in the sulfation of N-OH-AAF and the other hydroxamic acids by rat liver cytosols; adult male rats had the highest sulfation activity. Experiments with purified aryl sulfotransferase IV (AST IV) indicated that the high expression of this enzyme in male rat liver may be responsible for these differences. No such sex or age difference was found for the sulfation of aromatic hydroxylamines. In cytosols of adult human livers, sulfation activity towards aromatic hydroxamic acids and hydroxylamines was clearly present, but activities were much lower than in rat liver cytosols. Sulfation activity towards these compounds was also found in fetal and neonatal liver and adrenals. These compounds probably are sulfated by several different sulfotransferases in humans.

Sulfation of aromatic hydroxamic acids and hydroxylamines by multiple forms of human liver sulfotransferases.

Sulfation activity towards various heterocyclic and homocyclic aromatic hydroxamic acids and hydroxylamines was determined in adult human liver cytosol and with partially purified human liver sulfotransferases (STs). In adult human liver cytosols comparable ST activities towards N-hydroxy-2-acetyl-amino-5-phenylpyridine (N-OH-2AAPP), N-hydroxy-4-acetylaminobiphenyl (N-OH-4AABP) and N-hydroxy-4'fluoro-4-acetylaminobiphenyl (N-OH-4FAABP) were found, while the sulfation rates towards N-hydroxy-2-acetylaminofluorene (N-OH-2AAF), N-hydroxy-2-acetylaminonaphthalene (N-OH-2AAN), N-hydroxy-2-acetylaminophenanthrene (N-OH-2AAP) and N-hydroxy-4-acetylaminostilbene (N-OH-4AAS) were two- to five-fold lower. In adult liver cytosol ST activity was found towards all hydroxylamines tested. No significant differences were found for the various hydroxylamines. In general, the ST activities towards the various hydroxamic acids and hydroxylamines were comparable to phenol ST activity using adult liver cytosols. Partial purification of adult human liver STs was achieved by DEAE-Sepharose chromatography followed by anion exchange FPLC. Two separated protein peaks showing both N-OH-2AAPP and N-OH-2APP ST activities were observed and were designated human hydroxylamine/hydroxamic acid sulfotransferase (hHST) 1 and 2. Immunoblot analysis using an anti-rat estrogen ST antibody demonstrated cross reactivity with both hHSTs at a subunit mol. wt of 32 kDa corresponding to the phenol-sulfating form of phenol ST (P-PST). ST activity towards dopamine was low with both hHSTs, but hHST1 also contained significant capacity to sulfate dehydroepiandrosterone. The highest ST activity towards N-OH-2AAPP and N-OH-2APP was measured at pH 5.5 with both hHSTs. The Km values of the two hHSTs for sulfation of N-OH-2AAPP and N-OH-2APP were comparable, while the Vmax values for sulfation of N-OH-2APP were higher than for N-OH-2AAP with both hHSTs. FPLC anion exchange analysis of human platelet STs demonstrated that sulfation of N-OH-4ABP and N-OH-4AABP was associated with P-PST rather than M-PST (platelets do not possess any significant DHEA ST activity). Our results show that the various hydroxamic acids and hydroxylamines are converted by at least two hHSTs. The results presented here for the human liver hydroxamic acid and hydroxylamine ST activities are discussed in relation to those observed in the rat.

Sulfation of hydroxylamines and hydroxamic acids in liver cytosol from male and female rats and purified aryl sulfotransferase IV.

Sulfation activity towards hydroxamic acids and hydroxylamines was determined in liver cytosols for juvenile and adult males and female rats, as well as in purified rat liver aryl sulfotransferase IV preparations. Sulfation activity towards the hydroxamic acids N-hydroxy-2-acetylaminofluorene, N-hydroxy-2-acetylaminophenanthrene, N-hydroxy-4-acetylaminobiphenyl, N-hydroxy-4'-fluoro-4-acetylaminobiphenyl, N-hydroxy-2-acetylamino-5-phenylpyridine, was higher in cytosols derived from adult males (two or three times) than in those from adult females and juveniles (both sexes). N-Hydroxy-2-acetylamino-3-methyl-5-phenylpyridine (N-OH-2AAMPP), however, was poorly sulfated by any of the cytosols. Sulfation activity towards the hydroxylamines N-hydroxy-2-aminofluorene, N-hydroxy-2-aminophenanthrene, N-hydroxy-4-aminobiphenyl, N-hydroxy-4'-fluoro-4-aminobiphenyl was much lower. N-Hydroxy-2-amino-5-phenylpyridine (N-OH-2APP), however, was sulfated much better than the other hydroxylamines. No higher sulfation activity in adult male cytosols for hydroxylamines was found, except for N-OH-2APP and N-hydroxy-2-amino-3-methyl-5-phenylpyridine (N-OH-2AMPP). Purified aryl sulfotransferase IV (AST IV) converted all hydroxamic acids; N-OH-2AAMPP was a poor substrate. Of the hydroxylamines only N-OH-2APP and N-OH-2AMPP were conjugated. These results suggest that hydroxylamines and hydroxamic acids are converted by different sulfotransferases in the rat in vivo. They also indicate that AST IV may be the major enzyme responsible for sulfation of a variety of aromatic hydroxamic acids in the male rat liver. The results presented here are discussed in relation to the carcinogenic effects of some of these compounds.

Immobilization of solubilized UDP-glucuronosyltransferase from rat liver microsomes to Sepharose 4B.

A method for the covalent binding of rat liver UDP-glucuronosyltransferase to a cyanogen bromide-activated agarose matrix is described. The rat liver microsomal fraction was solubilized with 8 mM 3-[(3-cholamidopropyl)dimethylammonio]-1-propanesulfonate (CHAPS); 90% of the microsomal protein was solubilized. Some 50-60% of this protein became bound covalently to the activated agarose matrix. The immobilized UPD-glucuronosyltransferase remained completely active for 50 days when stored at 4 degrees in a 20% (v/v) glycerol buffer (pH 7.4). The immobilized enzyme has a temperature optimum around 37 degrees, and a broad pH optimum (pH 5-7.4). The enzyme displayed linear kinetics over a period of 1 hr; it conjugates a large variety of substrates.

Bioactivation of the hepatocarcinogen N-hydroxy-2-acetylaminofluorene by sulfation in the rat liver changes during the cell cycle.

Sulfation activity towards N-hydroxy-2-acetylaminofluorene and 4-nitrophenol was determined in male rat liver cytosol at several time points after partial hepatectomy corresponding to G1-, S-, and M-phase. N-hydroxy-2-acetylaminofluorene sulfation activity decreased by 80% when hepatocytes entered the G1-phase. This lower activity was maintained during the S-phase and M-phase, but was restored when hepatocytes entered the G0-phase again. Sulfation activity towards 4-nitrophenol did not alter after hepatectomy. Various other cytosolic enzyme activities were determined after hepatectomy to investigate the specificity of the decrease in sulfation activity. Lactate dehydrogenase and glucose-6-phosphate dehydrogenase activities were increased in the S- and M-phase by maximally 80% and 60%, respectively. Glutathione-S-transferase and glutamate-pyruvate transaminase activity did not alter during the cell cycle. These results indicate that sulfation of N-hydroxy-2-acetylaminofluorene in hepatocytes may depend on the phase of the cell cycle. The relevance of the finding is discussed in relation to the resistance of proliferating (pre)neoplastic hepatocytes to the toxic and mitoinhibitory effects of N-hydroxy-2-acetylaminofluorene.