[Multicentric prospective randomized study evaluating the interest of intravaginal electro-stimulation at home for urinary incontinence after prior perineal reeducation. Interim analysis]. / Étude prospective multicentrique randomisée évaluant l'intérêt de l'électrostimulation intravaginale à domicile après rééducation périnéale pour incontinence urinaire. Analyse intermédiaire.

OBJECTIVES: Perineal reeducation of stress urinary incontinence is beneficial in 80% of cases. However, patients have to perform self-retraining exercises of the perineal muscles at home, in order to maintain the benefit of the physiotherapy. The aim of this study is to assess the benefit of GYNEFFIK(®), a perineal electro-stimulator, during this home-care phase. PATIENTS AND METHODS: Women with stress urinary incontinence (UI) or with mixed UI (composed predominantly of stress UI) that responded to physiotherapy were included in this study in two parallel groups. The groups followed a self-reeducation program, with or without GYNEFFIK(®) electro-stimulation sessions. The comparison of the two groups was based on the rate of women for whom the benefit of the initial perineal reeducation was maintained (defined as non-worsening ICIQ and Ditrovie scales' score). RESULTS: According to the protocol, an interim analysis was performed on 95 patients (i.e. almost half of the expected sample size) who had had at least one evaluation under treatment, among which 44 patients had finished the study. The therapeutic benefit of the initial perineal reeducation was maintained in 87.8% of the GYNEFFIK(®) patient group, while it was maintained in 52.2% (P=0.0001) in the usual care group (i.e. who did not use electro-stimulation). DISCUSSION AND CONCLUSION: Likewise, patient had a more favorable subjective impression when using GYNEFFIK(®) (83.7% versus 60.0% in the usual care group) as they felt that they improved during the study. In the GYNEFFIK(®) group, no increase in symptoms was reported, whereas almost one out of five patients in the usual care group felt that their condition had worsened.

Improving compliance in oral contraception: 'the reminder card'.

OBJECTIVES: To assess oral contraceptive compliance and to evaluate the reminder card device as a means of improving compliance. The study also aimed to evaluate ease of use of the card and women's attitudes to it after several months of use. METHODS: In France, 975 women requesting oral contraception (whether repeat prescription or first-time use) were asked retrospectively about missed pills during the previous 3 or 6 months. The decision of whether or not to provide a patient with a reminder card at inclusion was left to the gynecologist. Usefulness of and satisfaction with the reminder card were also assessed. RESULTS: Of all study participants, 60% acknowledged missing at least one pill since starting oral contraception. Compliance appeared to be significantly better in card users than non-users (p < 0.001). More than 80% of card users stated that the device had prevented them from forgetting to take the pill on at least one occasion. Forty-six per cent of prevented missed pills occurred during the first week of the cycle. No pregnancies were recorded. Among the card users, 98% found the card easy to use and 97% were satisfied with the card. CONCLUSIONS: Use of the reminder card significantly improved compliance. Users found the reminder card acceptable and easy to use. This type of reminder device could potentially reduce the number of unwanted pregnancies and hence the number of requests for pregnancy termination.

[Improving oral contraception compliance. The "ringing card": memory aid or new ritual?]. / Améliorer l'observance de la contraception orale. La "carte qui sonne": aide-mémoire ou nouveau rituel?

Forgetting to take pills is frequent and induces an avoidable risk of unwanted pregnancy. The integration of the daily use of the pill into a ritual allows to improve compliance. Nine hundred and seventy-five women were retrospectively asked by 180 gynecologists about missed pills in the last three and six months. More than nine out of ten women declare having forgotten at least one pill in the last six months. In 39% of the cases the pill was missed during the first week of 'cycle' in which the risk of pregnancy is theoretically increased. In this survey, 485 women used the compliance card for an average time of 3.5 months. The compliance card is a device that reminds the user to take the pill daily. It is the size of a credit card and can be programmed to ring daily at the same time 21 days out of 28. The efficacy of this device is attested by the great number of women who think that it allowed them avoid forgetting at least one pill in the last three months. Regardless of the age of the women, 91% of the users of the compliance card acknowledged that it allowed them to decrease the number of missed pills. Eighty-four percent think avoided forgetting at least one pill in the last three months, 34% between two and three pills and 17% more than three pills. In practice, 41% of the compliance card users didn't have any failure in taking the pill in the last three months versus 19% among nonusers (P = 0.001). Although women aware of their poor compliance more often think that they benefit from the compliance card, 83% of women who declare themselves as compliant share this opinion. The number of avoided missed pills by the compliance card is greater among women who often fail to take their pill. The mean number of missed pill during the three months preceding the use of the compliance card was 1.6 +/- 1.7 versus 0.9 +/- 1.3 during the three months of use. Among users of the compliance card, 98% think that it is easy to use and 97% like the way it works. The compliance card is an easy and reliable device that improves the compliance of women using oral contraceptives by helping them to establish a ritual.

Insulin-induced activation of phosphatidylinositol (PI) 3-kinase. Insulin-induced phosphorylation of insulin receptors and insulin receptor substrate-1 displaces phosphorylated platelet-derived growth factor receptors from binding sites on PI 3-kinase.

Phosphatidylinositol (PI) 3-kinase is an enzyme that functions in the signaling pathways downstream from multiple cell surface receptors. The p85 regulatory subunit of PI 3-kinase binds to phosphotyrosine residues of various phosphoproteins including the platelet-derived growth factor (PDGF) receptor, the insulin receptor, and insulin receptor substrate-1 (IRS-1). Using NIH-3T3 cells overexpressing the human insulin receptor, we demonstrate that the p85 regulatory subunit of PI 3-kinase binds to phosphorylated PDGF receptor in cells incubated in the absence of insulin. When insulin is added, p85 is released from phosphorylated PDGF receptors and binds to phosphorylated insulin receptors and insulin receptor substrate-1. Moreover, insulin-induced dissociation of PDGF receptors from binding sites on PI 3-kinase requires a functional insulin receptor and is not prevented by vanadate treatment. In contrast, insulin activation does not displace PDGF receptors from binding sites on Ras GTPase-activating protein. This competition for binding to PI 3-kinase provides a mechanism for cross-talk among signaling pathways initiated by distinct peptide hormones and growth factors such as insulin and PDGF.

Insulin-induced activation of phosphatidyl inositol 3-kinase. Demonstration that the p85 subunit binds directly to the COOH terminus of the insulin receptor in intact cells.

Insulin activates the insulin receptor tyrosine kinase to phosphorylate signaling molecules such as insulin receptor substrate-1 (IRS-1). Phosphorylated IRS-1 binds to SH2 domains in the p85 regulatory subunit of phosphatidyl inositol (PI) 3-kinase, thereby stimulating the catalytic activity of PI 3-kinase. For most growth factor receptor tyrosine kinases (including receptors for epidermal growth factor and platelet-derived growth factor), the p85 regulatory subunit of PI 3-kinase binds directly to phosphorylated YXXM motifs contained in the cytoplasmic domain of the receptor itself. Previous studies in cell-free systems have shown that the phosphorylated YHTM sequence (amino acid residues 1322-1325) in the COOH terminus of the insulin receptor has the ability to bind to the p85 subunit of PI 3-kinase, thereby activating the enzyme. In this investigation, we demonstrate the occurrence of the same direct binding interaction in intact cells. Subsequent to insulin-stimulated phosphorylation of the insulin receptor, a complex is formed that contains the insulin receptor and PI 3-kinase. This complex can be immunoprecipitated by antibodies directed against either the insulin receptor or the p85 subunit of PI 3-kinase. The delta 43 mutant insulin receptor that lacks 43 amino acids at the COOH terminus does not bind p85. In addition, the delta 43 truncation impairs the ability of the receptor to mediate the activation of PI 3-kinase. Thus, by binding directly to p85, the phosphorylated YHTM motif in the COOH terminus of the insulin receptor contributes partially to mediating the effect of insulin to activate PI 3-kinase.

Rescue and activation of a binding-deficient insulin receptor. Evidence for intermolecular transphosphorylation.

Binding of insulin to the alpha subunit of the insulin receptor (IR) leads to autophosphorylation of the beta subunit. The reaction proceeds as intramolecular transphosphorylation between alpha beta half-receptors of the heterotetrameric receptor dimer (alpha 2 beta 2). Since IRs are mobile in the plane of the plasma membrane, it is also possible that transphosphorylation may occur between adjacent holoreceptors (alpha 2 beta 2) by an intermolecular reaction. To address this question, we cotransfected NIH-3T3 cells with two IR cDNA constructs: a truncated but functionally normal IR lacking the C-terminal 43 amino acids (delta 43) and a full-length Leu323 mutant receptor that is expressed on the cell surface but that does not bind insulin. A clonal cell line was selected from cells cotransfected with a 1/5 ratio of delta 43 cDNA/Leu323 cDNA. The two homodimers (Leu323 and delta 43) were expressed without detectable formation of hybrid receptors. By using specific antibodies, we demonstrate that in cells coexpressing both homodimers, the Leu323 mutant receptor was phosphorylated in vivo by the delta 43 IR in an insulin-dependent manner. However, when the Leu323 mutant receptor was expressed alone, no phosphorylation was detected. In addition, we demonstrate the association of the phosphorylated Leu323 mutant receptor with insulin receptor substrate-1 and with phosphatidylinositol 3-kinase. These findings indicate that insulin binding is not required for phosphorylation of the Leu323 mutant receptor, that the phosphorylation of the Leu323 mutant receptor occurs by an intermolecular transphosphorylation mechanism, and, finally, that the Leu323 mutant receptor, once phosphorylated, can associate with insulin receptor substrate-1 and phosphatidylinositol 3-kinase.

Structural basis by which a recessive mutation in the alpha-subunit of the insulin receptor affects insulin binding.

Recently, a mutation substituting Leu for Ser323 in the alpha-subunit of the human insulin receptor has been identified in an insulin-resistant patient. The Leu323 mutation leads to a severe impairment in insulin binding without significantly altering the processing or cell surface expression of the receptor. In order to study how alpha beta half-receptors interact to form the insulin-binding site, we cotransfected NIH-3T3 cells with two insulin receptor cDNA constructs: a truncated insulin receptor lacking the C-terminal 43 amino acids (delta 43) and the full-length Leu323 mutant receptor. A clonal cell line from cotransfected cells expresses a hybrid receptor consisting of a Leu323 half-receptor and a delta 43 half-receptor. We demonstrate that the Leu323-delta 43 hybrid receptor binds insulin with high affinity. Furthermore, by cross-linking 125I-insulin to immobilized hybrid receptors, we show that only the alpha beta delta half of the hybrid receptor binds insulin. Since the isolated half-insulin receptor has low affinity for insulin, this suggests that the addition of even a non-binding alpha-subunit can result in high affinity binding to the holoreceptor (alpha alpha mut beta delta beta). Both beta and beta delta-subunits of the Leu323-delta 43 hybrid receptor are phosphorylated in vivo and in vitro in an insulin-dependent manner, suggesting an intramolecular transphosphorylation mechanism and that the presence of the Leu323 mutant receptor that lacks an intrinsic high affinity binding site does not prevent the associated beta-subunit from functioning either as a tyrosine kinase or as a phosphate acceptor in the hybrid insulin receptor molecule (alpha alpha mut beta delta beta). Furthermore, we show that the hybrid receptor can phosphorylate insulin receptor substrate-1 (IRS-1) in response to insulin and can be coimmunoprecipitated together with IRS-1 by anti-IRS-1 antibody.

Mechanisms of hormone resistance: lessons from insulin-resistant patients.

Hormones are secreted by endocrine glands and transported to the target cell at which the hormone acts. The hormone binds to its receptor, thereby eliciting various biological responses within the target cell. Examples of disease mechanisms that function at the different stages in the development of the insulin receptor, and result in insulin resistance, are discussed in this review. Antibodies to insulin can impair delivery of the hormone to the target cell, and can desensitize that target cell to insulin action. In recent years, several genetic diseases have been identified that result from mutations in the genes encoding the relevant receptors. Studies of syndromes of insulin resistance provide illustrations of the multiple types of defects in receptor function that can generally cause hormone resistance (12, 13). For example, mutations in the receptor can decrease the number of receptors on the cell surface by inhibiting receptor biosynthesis, impairing receptor transport to the cell surface, or accelerating the rate of receptor degradation. Alternatively, mutations have been identified that decrease the affinity of insulin binding or inhibit receptor tyrosine kinase activity. In recent years, there has been considerable progress toward elucidating post-receptor mechanisms in the biochemical pathways of hormone action. At present, there are a limited number of examples of mutations in genes encoding proteins that function in this part of the pathway, but it seems likely that additional examples will be discovered in the future. It is likely that these insights into biochemical mechanisms of disease will ultimately lead to an improvement in our ability to treat human disease.

Mutagenesis of Phe381 and Phe382 in the extracellular domain of the insulin receptor: effects on receptor biosynthesis, processing, and ligand-dependent internalization.

Mutations of the extracellular domain of the insulin receptor impair processing and transport of receptors to the plasma membrane. We have previously reported that a mutation substituting Val for Phe382 in the alpha-subunit of the insulin receptor impairs intracellular processing and insulin-induced autophosphorylation of the mutant receptor. In this investigation, we have generated two independent mutations of amino acids Phe381 and Phe382 of the insulin receptor: Val for Phe381 and Leu for Phe382. These substitutions cause a slight impairment of intracellular processing and transport of the mutant receptors. Furthermore, insulin-dependent internalization of the mutant receptors is unaffected by these mutations. Thus, of the three substitutions studied to date, Val for Phe382 is the only mutation of the Phe381-Phe382 sequence that causes a major defect in post-translational processing of the receptor.

Investigation of the mechanism of the dominant negative effect of mutations in the tyrosine kinase domain of the insulin receptor.

Mutations in the tyrosine kinase domain of the insulin receptor cause insulin resistance in a dominant fashion. It has been proposed that formation of hybrid dimers between normal and mutant receptors may explain the dominant negative effect of these mutations. To investigate this mechanism, we expressed two types of human insulin receptors in NIH-3T3 cells; wild type and the tyrosine kinase-deficient Ile1153 mutant. To distinguish the two types of receptors, 43 amino acids were deleted from the C-terminus of the wild type receptor (delta 43 truncation). If mutant and wild type receptors assemble in a random fashion, 50% of the receptors would be hybrid oligomers (alpha 2 beta beta mut). However, alpha 2 beta beta mut hybrids were undetectable. Nevertheless, insulin stimulated the kinase competent delta 43 receptors to transphosphorylate the kinase-deficient Ile1153 mutant receptor in co-transfected cells via an intermolecular mechanism. Furthermore, transphosphorylation of the Ile1153 mutant receptor is sufficient to trigger insulin-stimulated endocytosis. Despite the absence of alpha 2 beta beta mut hybrids, expression of the Ile1153 mutant receptor inhibited the ability of the delta 43 truncated receptor to mediate insulin-stimulated phosphorylation of insulin receptor substrate-1 (IRS-1). Evidence is presented to support the hypothesis that the Ile1153 mutant receptor retains the ability to bind IRS-1, and that sequestration of substrate may explain the dominant negative effect of the mutant receptor to inhibit phosphorylation of IRS-1.

Deletion of C-terminal 113 amino acids impairs processing and internalization of human insulin receptor: comparison of receptors expressed in CHO and NIH-3T3 cells.

We have studied the structure and the function of a truncated human insulin receptor in which 113 amino acids (aa 1231-1343) at the C-terminus of the beta-subunit were deleted. In this study, wild-type and truncated insulin receptors were expressed by stable transfection in NIH-3T3 cells and CHO cells. The mutation impairs post-translational processing of the insulin receptor; proteolytic cleavage is retarded, and degradation of the truncated receptor is accelerated. Furthermore, insulin-stimulated autophosphorylation of the mutant insulin receptor is impaired. This is associated with a defect in insulin-stimulated endocytosis. Finally, in NIH-3T3 cells, the mutant insulin receptor failed to mediate the mitogenic effects of insulin. In CHO cells, transfection of insulin receptor cDNA (either wild-type or mutant) did not alter mitogenic response to insulin. It has previously been shown that deletion of 43 amino acids at the C-terminus of the beta-subunit did not affect insulin receptor tyrosine kinase activity. Our data suggest that the structural domain located 43-113 amino acids from the C-terminus appears to have several functional roles. First, the domain appears to promote folding of receptor into the optimal conformation for post-translational processing. Second, the presence of this domain appears to promote the stability of the receptor beta-subunit in intact cells. Finally, perhaps as a consequence of the effects upon the stability of the receptor, this domain is required in intact cells for insulin-stimulated autophosphorylation and signal transmission.

Streptavidin blotting: a sensitive technique to study cell surface proteins; application to investigate autophosphorylation and endocytosis of biotin-labeled insulin receptors.

Covalent attachment of biotin provides a useful method to label cell surface proteins. Subsequent to biotinylation, the protein can be purified by immunoprecipitation with a specific antibody, followed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. After transfer to a membrane by electroblotting, the biotinylated protein can be detected by probing with labeled streptavidin. This technique has been used to investigate recombinant human insulin receptors expressed on the surface of murine NIH-3T3 cells. Biotinylation of the extracellular domain with an impermeant reagent did not impair the ability of an antibody directed against an epitope in the intracellular domain to immunoprecipitate insulin receptors. In contrast, biotinylation reduced the avidity of a polyclonal antibody directed against the extracellular domain of the receptor. Nevertheless, by increasing the concentration of the antireceptor antibody, it was possible to successfully immunoprecipitate the biotinylated receptor. Furthermore, biotinylated receptors retained the ability to bind insulin and undergo insulin-stimulated autophosphorylation and internalization. The use of enzyme-labeled streptavidin enables the use of chemiluminescence techniques to detect the receptors, thus obviating the need to employ radioactivity. Just as the technique is useful to study cell surface insulin receptors, it can be adapted to investigate other cell surface receptors and proteins.

Paradoxical biological effects of overexpressed insulin-like growth factor-1 receptors in Chinese hamster ovary cells.

One major approach to the study of growth factor receptor action has been to overexpress wild-type or mutant receptors in cultured cells and to evaluate biological responses to exogenous ligand. Studies of this type with insulin and insulin-like growth factor-I (IGF-I) receptors often use Chinese hamster ovary (CHO) cells. We have compared the effect of receptor overexpression in CHO cells and in NIH-3T3 fibroblasts in order to assess the suitability of CHO cells for studies of this nature and the contribution of cell type-specific factors to those responses generally assayed. Overexpression of IGF-I receptors in NIH-3T3 cells resulted in increased sensitivity and maximal responsiveness of thymidine incorporation, 2-deoxyglucose uptake, and phosphatidylinositol-3 (PI3) kinase activation to IGF-I stimulation. In CHO cells, on the other hand, overexpression of either IGF-I or insulin receptors increased the sensitivity of thymidine incorporation to ligand, but maximal responsiveness was unchanged or decreased. Overexpression of the insulin receptor increased sensitivity of glucose uptake and the maximal response of PI3 kinase activation to insulin. Overexpression of the IGF-I receptor did not affect sensitivity or maximal responsiveness of glucose uptake or PI3 kinase activation to IGF-I. These data suggest that IGF-I and insulin signal pathways may differ in CHO cells, and that there may even be divergent IGF-I signaling pathways for short vs. long-term effects. Whether this is a result of differences in the number of endogenous receptors, hybrid receptor formation, or defects in post-receptor signaling, the use of CHO cells to assess receptor function must be approached with caution.

Mutations in the insulin receptor gene in patients with genetic syndromes of insulin resistance and acanthosis nigricans.

Mutations of the insulin receptor gene have been identified in patients with genetic syndromes of insulin resistance associated with acanthosis nigricans. These mutations impair insulin responses by reducing the number of insulin receptors on the surface of target cells, or by reducing the receptor's ability to bind insulin or to undergo insulin-stimulated autophosphorylation, an important step in insulin action. Studies of mutant receptors expressed in transfection systems have contributed to our understanding of the structure-function relationships of the insulin receptor.