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2.
Int J Med Microbiol ; 290(4-5): 421-7, 2000 Oct.
Article in English | MEDLINE | ID: mdl-11111921

ABSTRACT

The lethal toxin of Bacillus anthracis consists of two proteins, PA and LF, which together induce lethal effects in some animal species and cause macrophage lysis. LF is a zinc-binding protein with metalloprotease activity. With a two-hybrid system approach we identified MAP kinase kinases (MAPKKs) Mekl and Mek2 as proteins interacting with LF. LF was shown to cleave Mek1 and Mek2 and an additional MAPKK family member MKK3, within their N-terminal region. We examined macrophage cell lines and primary peritoneal cells with different sensitivities to LF but did not find a direct correlation between MAPKKs cleavage and cell death. On the other hand, sublytic doses of LF cleave MAPKKs and cause a reduction in the LPS/IFNgamma-induced production of proinflammatory mediators. These findings are discussed with respect to the possible role of LF in the initial phase of infection.


Subject(s)
Antigens, Bacterial , Bacillus anthracis/pathogenicity , Bacterial Toxins , Carrier Proteins/toxicity , Macrophages/drug effects , Mitogen-Activated Protein Kinase Kinases/metabolism , Animals , Cell Line , Interferon-gamma/pharmacology , Lipopolysaccharides/pharmacology , Macrophages/metabolism , Mice , Mitogen-Activated Protein Kinase 1/metabolism , Mitogen-Activated Protein Kinase 3 , Mitogen-Activated Protein Kinases/metabolism , Nitric Oxide/biosynthesis , Phosphorylation , Tumor Necrosis Factor-alpha/biosynthesis
3.
Clin Chim Acta ; 291(2): 189-99, 2000 Feb 15.
Article in English | MEDLINE | ID: mdl-10675723

ABSTRACT

The recent determination of their primary sequence has lead to the discovery of the metallo-proteolytic activity of the bacterial toxins responsible for tetanus, botulism and anthrax. The protease domain of these toxins enters into the cytosol where it displays a zinc-dependent endopeptidase activity of remarkable specificity. Tetanus neurotoxin and botulinum neurotoxins type B, D, F and G cleave VAMP, an integral protein of the neurotransmitter containing synaptic vesicles. Botulinum neurotoxins type A and E cleave SNAP-25, while the type C neurotoxin cleaves both SNAP-25 and syntaxin, two proteins located on the cytosolic face of the presynaptic membrane. Such specific proteolysis leads to an impaired function of the neuroexocytosis machinery with blockade of neurotransmitter release and consequent paralysis. The lethal factor of Bacillus anthracis is specific for the MAPkinase-kinases which are cleaved within their amino terminus. In this case, however, such specific biochemical lesion could not be correlated with the pathogenesis of anthrax. The recently determined sequence of the vacuolating cytotoxin of Helicobacter pylori contains within its amino terminal domain elements related to serine-proteases, but such an activity as well as its cytosolic target remains to be detected.


Subject(s)
Bacterial Toxins/metabolism , Endopeptidases/metabolism , Amino Acid Sequence , Animals , Bacterial Toxins/chemistry , Cytosol/metabolism , Humans , Molecular Sequence Data , Sequence Homology, Amino Acid
4.
FEBS Lett ; 462(1-2): 199-204, 1999 Nov 26.
Article in English | MEDLINE | ID: mdl-10580119

ABSTRACT

The lethal toxin of Bacillus anthracis consists of two proteins, PA and LF, which together induce lethal effects in animals and cause macrophage lysis. LF is a zinc-endopeptidase which cleaves two mitogen-activated protein kinase kinases (MAPKKs), Mek1 and Mek2, within the cytosol. Here, we show that also MKK3, another dual-specificity kinase that phosphorylates and activates p38 MAP kinase, is cleaved by LF in macrophages. No direct correlation between LF-induced cell death and cleavage of these MAPKKs was found in macrophage cell lines and primary peritoneal cells exhibiting different sensitivity to LF. However, we present the first evidence that sublytic doses of LF cleave Meks and cause a substantial reduction in the production of NO and tumour necrosis factor-alpha induced by lipopolysaccharide/interferon gamma. We suggest that this effect of LF is relevant during the first stages of B. anthracis infection, when a reduction of the inflammatory response would permit growth and diffusion of the bacterium.


Subject(s)
Antigens, Bacterial , Bacterial Toxins/toxicity , Macrophages/drug effects , Mitogen-Activated Protein Kinase Kinases/metabolism , Nitric Oxide/metabolism , Protein-Tyrosine Kinases/metabolism , Tumor Necrosis Factor-alpha/metabolism , Animals , Bacillus anthracis/metabolism , Bacterial Toxins/metabolism , Cells, Cultured , Drug Interactions , Interferon-gamma/pharmacology , Lipopolysaccharides/pharmacology , MAP Kinase Kinase 2 , MAP Kinase Kinase 3 , Macrophage Activation/drug effects , Macrophages/enzymology , Macrophages/metabolism , Macrophages, Peritoneal/drug effects , Macrophages, Peritoneal/enzymology , Mice
5.
J Appl Microbiol ; 87(2): 288, 1999 Aug.
Article in English | MEDLINE | ID: mdl-10475970

ABSTRACT

The lethal toxin (LeTx) of Bacillus anthracis is the major virulence factor responsible for the death of infected animals and for cytolysis of cultured macrophages. Its catalytic component, LF, contains the characteristic zinc-binding motif of metalloproteases, it binds zinc and indirect evidence suggests that this hydrolytic activity is essential for LeTx cytotoxicity (Limpel et al. 1994; Kochi et al. 1994). To identify substrates of LF, we have used the yeast two-hybrid system, employing an LF inactive mutant as bait. This approach has led to the identification of the MAP kinase kinases (MAPKKs) Mek1 and Mek2 as proteins capable of specific interaction with LF. LF cleaves Mek1 and Mek2 within their N-terminus in vitro and in vivo, hydrolysing a Pro8-Ile9 and a Pro10-Arg11 peptide bond in Mek1 and Mek2, respectively (Vitale et al. 1998), similarly to that found with a different approach by Duesbery et al. (1998). The removal of the amino terminus of MAPKKs eliminates the 'docking site' involved in the specific interaction with MAPKs and interferes with the phospho-activation of the MAPKs ERK1 and ERK2, which become phosphorylated in cultured macrophages following toxin challenge. We are currently investigating the relevance of MAPKKs cleavage for LeTx cytotoxicity and the consequences for the activity of the MAP pathway.

6.
Philos Trans R Soc Lond B Biol Sci ; 354(1381): 259-68, 1999 Feb 28.
Article in English | MEDLINE | ID: mdl-10212474

ABSTRACT

The clostridial neurotoxins responsible for tetanus and botulism are proteins consisting of three domains endowed with different functions: neurospecific binding, membrane translocation and proteolysis for specific components of the neuroexocytosis apparatus. Tetanus neurotoxin (TeNT) binds to the presynaptic membrane of the neuromuscular junction, is internalized and transported retroaxonally to the spinal cord. The spastic paralysis induced by the toxin is due to the blockade of neurotransmitter release from spinal inhibitory interneurons. In contrast, the seven serotypes of botulinum neurotoxins (BoNTs) act at the periphery by inducing a flaccid paralysis due to the inhibition of acetylcholine release at the neuromuscular junction. TeNT and BoNT serotypes B, D, F and G cleave specifically at single but different peptide bonds, of the vesicle associated membrane protein (VAMP) synaptobrevin, a membrane protein of small synaptic vesicles (SSVs). BoNT types A, C and E cleave SNAP-25 at different sites located within the carboxyl-terminus, while BoNT type C additionally cleaves syntaxin. The remarkable specificity of BoNTs is exploited in the treatment of human diseases characterized by a hyperfunction of cholinergic terminals.


Subject(s)
Botulinum Toxins/pharmacology , Metalloendopeptidases/pharmacology , Tetanus Toxin/pharmacology , Animals , Binding Sites , Biological Transport, Active , Botulinum Toxins/pharmacokinetics , Botulinum Toxins/therapeutic use , Cytosol/metabolism , Exocytosis/drug effects , Exocytosis/physiology , Humans , Metalloendopeptidases/metabolism , Metalloendopeptidases/pharmacokinetics , Metalloendopeptidases/therapeutic use , Neurons/drug effects , Neurons/metabolism , Tetanus Toxin/pharmacokinetics , Tetanus Toxin/therapeutic use
7.
Protein Expr Purif ; 15(2): 221-7, 1999 Mar.
Article in English | MEDLINE | ID: mdl-10049679

ABSTRACT

Tetanus neurotoxin (TeNT) consists of two disulfide-linked polypeptide chains, heavy (H) and light (L). The L chain is a zinc endopeptidase protein highly specific for vesicle-associated membrane protein (VAMP), which is an essential component of the exocytosis apparatus. Here we describe the cloning of the L chain of TeNT from Clostridium tetani strain Y-IV-3 (WS 15) and its expression in Escherichia coli as a glutathione S-transferase fusion protein. The full-length recombinant L chain, corresponding to residues 1-457, was obtained as a mixture of proteins of slightly different mass with identical N-terminal ends. To obtain a product useful for structural analysis and crystallization, a COOH-terminally truncated L chain (residues 1-427) was cloned, expressed, and purified with high yield. This truncated L chain is more active than the full-length and wild-type proteins in the hydrolysis of VAMP. Preliminary experiments of crystallization of the truncated recombinant L chain gave encouraging results.


Subject(s)
Metalloendopeptidases/genetics , Tetanus Toxin/genetics , Cloning, Molecular , Crystallization , Escherichia coli , Gene Expression , Humans , Membrane Proteins/metabolism , Metalloendopeptidases/biosynthesis , Metalloendopeptidases/isolation & purification , Metalloendopeptidases/metabolism , Peptide Fragments/biosynthesis , Peptide Fragments/genetics , Peptide Fragments/isolation & purification , Peptide Fragments/metabolism , R-SNARE Proteins , Recombinant Fusion Proteins/biosynthesis , Recombinant Fusion Proteins/genetics , Recombinant Fusion Proteins/isolation & purification , Recombinant Fusion Proteins/metabolism , Spectrometry, Fluorescence , Substrate Specificity , Tetanus Toxin/biosynthesis , Tetanus Toxin/isolation & purification , Tetanus Toxin/metabolism
8.
J Physiol Paris ; 92(2): 135-9, 1998 Apr.
Article in English | MEDLINE | ID: mdl-9782457

ABSTRACT

Botulinum neurotoxins type A and E (BoNT/A and /E) are metalloproteases with a unique specificity for SNAP-25 (synaptosomal-associated protein of 25 kDa), an essential protein component of the neuroexocytotic machinery. It was proposed that this specificity is based on the recognition of a nine-residue sequence, termed SNARE motif, which is common to the other two SNARE proteins: VAMP (vesicle-associated membrane protein) and syntaxin, the only known substrates of the other six clostridial neurotoxins. Here we report on recent studies which provide evidence for the involvement of the SNARE motif present in SNAP-25 in its interaction with BoNT/A and /E by following the kinetics of proteolysis of SNAP-25 mutants deleted of SNARE motifs. We show that a single copy of the motif is sufficient for BoNT/A and /E to recognise SNAP-25. While the copy of the motif proximal to the cleavage site is clearly involved in recognition, in its absence, other more distant copies of the motif are able to support proteolysis. We also report on studies of poisoning human neuromuscular junctions with either BoNT/A or BoNT/E and describe the unexpected finding that the time of recovery of function after poisoning is much shorter in the case of type E with respect to type A intoxication. These data are discussed in terms of the different sites of action of the two toxins within SNAP-25.


Subject(s)
Botulinum Toxins, Type A/pharmacology , Botulinum Toxins/pharmacology , Membrane Proteins , Nerve Tissue Proteins/metabolism , Neuromuscular Junction/drug effects , Neurotoxins/pharmacology , Animals , Botulinum Toxins/toxicity , Botulinum Toxins, Type A/toxicity , Humans , Mice , Mutagenesis , Nerve Tissue Proteins/chemistry , Nerve Tissue Proteins/drug effects , Neuromuscular Junction/pathology , Neuromuscular Junction/physiology , Neurotoxins/toxicity , Recombinant Proteins/chemistry , Recombinant Proteins/drug effects , Recombinant Proteins/metabolism , Sequence Deletion , Synaptosomal-Associated Protein 25
9.
Biochem Biophys Res Commun ; 248(3): 706-11, 1998 Jul 30.
Article in English | MEDLINE | ID: mdl-9703991

ABSTRACT

Lethal factor (LF) is the major virulence factor produced by Bacillus anthracis. LF is sufficient to cause death in laboratory animals and cytolysis of peritoneal macrophages and macrophage cell lines. LF contains the characteristic zinc binding motif of metalloproteases and indirect evidence suggest that this hydrolytic activity is essential for its cytotoxicity. To identify the substrate(s) of LF, we have used the yeast two-hybrid system, employing a LF inactive mutant as bait. This approach has led to the identification of the MAP kinase kinases (MAPKKs) Mek1 and Mek2 as proteins capable of specific interaction with LF. LF cleaves Mek1 and Mek2 within their N-terminus in vitro and in vivo, hydrolyzing a Pro8-Ile9 and a Pro10-Arg11 peptide bond in Mek1 and Mek2 respectively. The removal of the amino terminus of MAPKKs eliminates the "docking site" for the MAPKs ERK1 and ERK2, which become phosphorylated in cultured macrophages following toxin challenge. The possible implications of these findings for the cytolysis of macrophage cells induced by LF are discussed. These results open the way to the design and screening of specific inhibitors of LF.


Subject(s)
Antigens, Bacterial , Bacterial Toxins/metabolism , Bacterial Toxins/pharmacology , Calcium-Calmodulin-Dependent Protein Kinases/metabolism , Macrophages/metabolism , Protein Kinases/metabolism , Amino Acid Sequence , Animals , Bacillus anthracis/pathogenicity , Bacterial Toxins/biosynthesis , Cell Line , Conserved Sequence , Kinetics , MAP Kinase Kinase 1 , MAP Kinase Kinase 2 , Macrophages/drug effects , Metalloendopeptidases/metabolism , Mice , Mitogen-Activated Protein Kinase Kinases , Molecular Sequence Data , Protein Serine-Threonine Kinases/chemistry , Protein Serine-Threonine Kinases/metabolism , Protein-Tyrosine Kinases/chemistry , Protein-Tyrosine Kinases/metabolism , Recombinant Proteins/biosynthesis , Recombinant Proteins/metabolism , Recombinant Proteins/pharmacology , Substrate Specificity , Virulence
10.
Toxicol Lett ; 102-103: 191-7, 1998 Dec 28.
Article in English | MEDLINE | ID: mdl-10022253

ABSTRACT

Tetanus and botulinum neurotoxins are the most potent toxins known and cause tetanus and botulism, respectively. They are zinc-endopeptidases acting in the cytosol, where they cleave SNARE proteins. Here, we report on the assay of their metalloproteolytic activity in vitro on recombinant SNARE proteins. We also describe the assay of their activity in nerve cells in culture using antibodies specific for the SNARE proteins. Together with recent reports from other laboratories, these results show that the toxicity of these powerful neurotoxins can be appropriately assayed in vitro, thus reducing considerably the number of animals currently used in the evaluation of the toxicity of tetanus toxoid vaccine and of the botulinum neurotoxins to be used for human therapy.


Subject(s)
Botulinum Toxins/toxicity , Tetanus Toxin/toxicity , Vesicular Transport Proteins , Animals , Cells, Cultured , Cerebellum/drug effects , Hippocampus/drug effects , Membrane Proteins/metabolism , Membrane Proteins/physiology , Nerve Tissue Proteins/metabolism , R-SNARE Proteins , Rats , SNARE Proteins , Synaptosomal-Associated Protein 25
11.
FEBS Lett ; 418(1-2): 1-5, 1997 Nov 24.
Article in English | MEDLINE | ID: mdl-9414082

ABSTRACT

Botulinum neurotoxins type A and E (BoNT/A and BoNT/E) are metalloproteases with a unique specificity for SNAP-25 (synaptosome-associated protein of 25 kDa), an essential protein component of the neuroexocytotic machinery. It has been suggested that this specificity is directed through the recognition of a nine residue sequence, termed SNARE motif, that is common to the other two SNARE proteins: VAMP (vesicle-associated membrane protein) and syntaxin, the only known substrates of the other six clostridial neurotoxins. Here we analyse the involvement of the four copies of the SNARE motif present in SNAP-25 in its interaction with BoNT/A and BoNT/E by following the kinetics of proteolysis of SNAP-25 mutants deleted of SNARE motifs. We show that a single copy of the motif is sufficient for BoNT/A and BoNT/E to recognise SNAP-25. While the copy of the motif proximal to the cleavage site is clearly involved in recognition, in its absence, other more distant copies of the motif are able to support proteolysis. Also, a non-neuronal isoform of SNAP-25, Syndet, is shown to be sensitive to BoNT/E, but not BoNT/A, whilst the SNAP-25 isoforms from Torpedo marmorata and Drosophila melanogaster were demonstrated not to be substrates of these metalloproteases.


Subject(s)
Botulinum Toxins, Type A/metabolism , Botulinum Toxins/metabolism , Metalloendopeptidases/metabolism , Nerve Tissue Proteins/chemistry , Nerve Tissue Proteins/metabolism , Vesicular Transport Proteins , Amino Acid Sequence , Animals , Binding Sites , Drosophila , Drosophila Proteins , Humans , Kinetics , Membrane Proteins , Mice , Molecular Sequence Data , Mutagenesis, Site-Directed , Recombinant Proteins/chemistry , Recombinant Proteins/metabolism , SNARE Proteins , Sequence Alignment , Sequence Deletion , Sequence Homology, Amino Acid , Substrate Specificity , Synaptosomal-Associated Protein 25 , Torpedo
12.
FEBS Lett ; 409(3): 339-42, 1997 Jun 16.
Article in English | MEDLINE | ID: mdl-9224685

ABSTRACT

Botulinum neurotoxins type D and F are zinc-endopeptidases with a unique specificity for VAMP/synaptobrevin, an essential component of the exocytosis apparatus. VAMP contains two copies of a nine residue motif, termed V1 and V2, which are determinants of the interaction with tetanus and botulinum B and G neurotoxins. Here, we show that V1 plays a major role in VAMP recognition by botulinum neurotoxins D and F and that V2 is also involved in F binding. Site-directed mutagenesis of V1 and V2 indicates that different residues are the determinants of the VAMP interaction with the two endopeptidases. The study of the VAMP-neurotoxins interaction suggest a pairing of the V1 and V2 segments.


Subject(s)
Botulinum Toxins/metabolism , Membrane Proteins/metabolism , Synaptic Vesicles/metabolism , Animals , Botulinum Toxins/chemistry , Membrane Proteins/chemistry , Membrane Proteins/genetics , Mutagenesis, Site-Directed , Osmolar Concentration , Protein Binding , R-SNARE Proteins , Rats , Recombinant Proteins/metabolism , Synaptic Vesicles/chemistry
13.
Biochim Biophys Acta ; 1320(1): 1-7, 1997 May 16.
Article in English | MEDLINE | ID: mdl-9186775

ABSTRACT

A single open reading frame (ORF) encoding cytochrome c oxidase subunit I and II (cox1/2) was identified in the mitochondrial genome of the slime mold Dictyostelium discoideum. The cox1 coding region shares intron positions with its counterparts in fungi and algae. Northern blot analysis, using exon and intron-specific probes, suggests that the cox1/2 gene is transcribed as part of a large, efficiently processed, polycistronic RNA.


Subject(s)
Dictyostelium/enzymology , Electron Transport Complex IV/genetics , RNA/genetics , Amino Acid Sequence , Animals , Base Sequence , Electron Transport Complex IV/chemistry , Molecular Sequence Data , Transcription, Genetic
14.
J Biol Chem ; 271(34): 20353-8, 1996 Aug 23.
Article in English | MEDLINE | ID: mdl-8702770

ABSTRACT

Tetanus and botulinum neurotoxins type B and G are zinc-endopeptidases of remarkable specificity. They recognize and cleave a synaptic vesicle-associated membrane protein (VAMP)/synaptobrevin, an essential protein component of the vesicle docking and fusion apparatus. VAMP contains two copies of a nine-residue motif, also present in SNAP-25 (synaptosomal-associated protein of 25 kDa) and syntaxin, the two other substrates of clostridial neurotoxins. This motif was suggested to be a determinant of the target specificity of neurotoxins. Antibodies raised against this motif cross-react among VAMP, SNAP-25, and syntaxin and inhibit the proteolytic activity of the neurotoxins. Moreover, the various neurotoxins cross-inhibit each other's proteolytic action. The role of the three negatively charged residues of the motif in neurotoxin recognition was probed by site-directed mutagenesis. Substitution of acidic residues in both copies of the VAMP motif indicate that the first one is involved in tetanus neurotoxin recognition, whereas the second one is implicated in binding botulinum B and G neurotoxins. These results suggest that the two copies of the motif have a tandem association in the VAMP molecule.


Subject(s)
Botulinum Toxins/chemistry , Endopeptidases/chemistry , Membrane Proteins/metabolism , Neurotoxins/chemistry , Synaptic Vesicles/metabolism , Tetanus Toxin/chemistry , Vesicular Transport Proteins , Amino Acid Sequence , Animals , Botulinum Toxins/metabolism , Cross Reactions , Endopeptidases/metabolism , Exocytosis , Immunologic Techniques , Molecular Sequence Data , Nerve Tissue Proteins/metabolism , Neurotoxins/metabolism , Protein Binding , Qa-SNARE Proteins , R-SNARE Proteins , Rats , Recombinant Proteins , SNARE Proteins , Structure-Activity Relationship , Synaptosomal-Associated Protein 25 , Tetanus Toxin/metabolism
15.
J Physiol Paris ; 89(1): 43-50, 1995.
Article in English | MEDLINE | ID: mdl-7581298

ABSTRACT

Tetanus and botulinum neurotoxins are produced by several Clostridia and cause the paralytic syndromes of tetanus and botulism by blocking neurotransmitter release at central and peripheral synapses, respectively. They consist of two disulfide-linked polypeptides: H (100 kDa) is responsible for neurospecific binding and cell penetration of L (50 kDa), a zinc-endopeptidase specific for three protein subunits of the neuroexocytosis apparatus. Tetanus neurotoxin and botulinum neurotoxin serotypes B, D, F and G cleave at single sites, which differ for each neurotoxin, VAMP/synaptobrevin, a membrane protein of the synaptic vesicles. Botulinum A and E neurotoxins cleave SNAP-25, a protein of the presynaptic membrane, at two different carboxyl-terminal peptide bonds. Serotype C cleaves specifically syntaxin, another protein of the nerve plasmalemma. The target specificity of these metallo-proteinases relies on a double recognition of their substrates based on interactions with the cleavage site and with a non-contiguous segment that contains a structural motif common to VAMP, SNAP-25 and syntaxin.


Subject(s)
Botulinum Toxins/analysis , Metalloendopeptidases/metabolism , Neurotoxins/analysis , Tetanus Toxin/analysis , Amino Acid Sequence , Animals , Humans , Metalloendopeptidases/analysis , Molecular Sequence Data
16.
Curr Genet ; 25(6): 504-7, 1994 Jun.
Article in English | MEDLINE | ID: mdl-8082200

ABSTRACT

We have determined the nucleotide sequence of a region of the mitochondrial genome of the yeast Saccharomyces douglasii which contains the ATPase subunit 9 gene and part of the intergenic sequences that surround it. The gene is 228 nucleotides long and encodes a polypeptide of 76 aa. A comparison of the coding sequence with that of S. cerevisiae reveals the presence of three silent transitions. A high level of similarity is also found between regions involved in the initiation of transcription and mRNA processing. More interestingly, a region of similarity situated outside the known regulatory regions has been identified. As the intergenic regions are generally highly divergent, the remarkable conservation of these non-coding sequences suggests that their structure may be relevant to the expression of this region of the mitochondrial DNA.


Subject(s)
Adenosine Triphosphatases/genetics , DNA, Fungal/genetics , DNA, Mitochondrial/genetics , Fungal Proteins/genetics , Genes, Fungal , Saccharomyces cerevisiae/genetics , Saccharomyces/genetics , Amino Acid Sequence , Base Composition , Base Sequence , Molecular Sequence Data , RNA Processing, Post-Transcriptional , Sequence Alignment , Sequence Homology , Species Specificity , Transcription, Genetic
17.
CMAJ ; 148(9): 1443-4, 1993 May 01.
Article in English | MEDLINE | ID: mdl-8477356
19.
Can Fam Physician ; 36: 1997-2001, 1990 Nov.
Article in English | MEDLINE | ID: mdl-21233943

ABSTRACT

Growing evidence for the impact of social and economic determinants on the health of Canadians and on current mobidity and mortality trends indicates that graduating family medicine residents lack necessary skills. Current teaching practices and clinical rotations are providing neither the context nor the critical tools that primary care providers in the 1990s will require to make a positive and lasting impact on health and disease prevention.

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