A rodent model for investigating the neurobiology of contralateral neglect.

BACKGROUND: Contralateral neglect is a common and disabling sequela of right hemisphere strokes. Neglect involves attentional and cognitive deficits, including distortions of contralateral spatial and personal awareness. There are no established successful therapies for neglect, and treatment is often complicated by anosognosia. The disturbances associated with neglect are debilitating to patients and their families, and presence of neglect is a strong predictor of poor prognosis for recovery. OBJECTIVE: The present report reviews findings from 20 years of research using a rat model of neglect. In the rat, 2 cortical areas that are linked by corticocortical connections have been identified as having a major role in neglect, and these correspond to frontal and parietal fields in primates. These 2 cortical areas also have convergent projections to the dorsocentral striatum, which has been implicated as a crucial subcortical component of the cortical-striatal-thalamic circuitry involved in directed attention and neglect. We discuss the role of the dorsocentral striatum in neglect and recovery and present evidence that induced axonal sprouting may promote functional recovery following cortical lesions that produce neglect. CONCLUSIONS: The rodent model of neglect captures some of the essential behavioral and anatomic features of neglect in humans. This model has helped reveal the pathophysiology of neglect, has suggested a crucial role of the striatum in recovery from neglect, and is being used to investigate potential therapeutic approaches.

Subcellular compartmentalization and trafficking of the insulin-responsive glucose transporter, GLUT4.

Insulin increases glucose transport into cells of target tissues, primarily striated muscle and adipose. This is accomplished via the insulin-dependent translocation of the facilitative glucose transporter 4 (GLUT4) from intracellular storage sites to the plasma membrane. Insulin binds to the cell-surface insulin receptor and activates its intrinsic tyrosine kinase activity. The subsequent activation of phosphatidylinositol 3-kinase (PI 3-K) is well known to be necessary for the recruitment of GLUT4 to the cell surface. Both protein kinase B (PKB) and the atypical protein kinase C(lambda/zeta) (PKClambda/zeta) appear to function downstream of PI 3-K, but how these effectors influence GLUT4 translocation remains unknown. In addition, emerging evidence suggests that a second signaling cascade that functions independently of the PI 3-K pathway is also required for the insulin-dependent translocation of GLUT4. This second pathway involves the Rho-family GTP binding protein TC10, which functions within the specialized environment of lipid raft microdomains at the plasma membrane. Future work is necessary to identify the downstream effectors that link TC10, PKB, and PKClambda/zeta to GLUT4 translocation. Progress in this area will come from a better understanding of the compartmentalization of GLUT4 within the cell and of the mechanisms responsible for targeting the transporter to specialized insulin-responsive storage compartments. Furthermore, an understanding of how GLUT4 is retained within and released from these compartments will facilitate the identification of downstream signaling molecules that function proximal to the GLUT4 storage sites.

Insulin stimulates actin comet tails on intracellular GLUT4-containing compartments in differentiated 3T3L1 adipocytes.

Incubation of isolated GLUT4-containing vesicles with Xenopus oocyte extracts resulted in a guanosine 5'-[gamma-thio]triphosphate (GTP gamma S) and sodium orthovanadate stimulation of actin comet tails. The in vitro actin-based GLUT4 vesicle motility was inhibited by both latrunculin B and a dominant-interfering N-WASP mutant, N-WASP/Delta VCA. Preparations of gently sheared (broken) 3T3L1 adipocytes also displayed GTP gamma S and sodium orthovanadate stimulation of actin comet tails on GLUT4 intracellular compartments. Furthermore, insulin pretreatment of intact adipocytes prior to gently shearing also resulted in a marked increase in actin polymerization and actin comet tailing on GLUT4 vesicles. In addition, the insulin stimulation of actin comet tails was completely inhibited by Clostridum difficile toxin B, demonstrating a specific role for a Rho family member small GTP-binding protein. Expression of N-WASP/Delta VCA in intact cells had little effect on adipocyte cortical actin but partially inhibited insulin-stimulated GLUT4 translocation. Taken together, these data demonstrate that insulin can induce GLUT4 vesicle actin comet tails that are necessary for the efficient translocation of GLUT4 from intracellular storage sites to the plasma membrane.

Lipid raft microdomain compartmentalization of TC10 is required for insulin signaling and GLUT4 translocation.

Recent studies indicate that insulin stimulation of glucose transporter (GLUT)4 translocation requires at least two distinct insulin receptor-mediated signals: one leading to the activation of phosphatidylinositol 3 (PI-3) kinase and the other to the activation of the small GTP binding protein TC10. We now demonstrate that TC10 is processed through the secretory membrane trafficking system and localizes to caveolin-enriched lipid raft microdomains. Although insulin activated the wild-type TC10 protein and a TC10/H-Ras chimera that were targeted to lipid raft microdomains, it was unable to activate a TC10/K-Ras chimera that was directed to the nonlipid raft domains. Similarly, only the lipid raft-localized TC10/ H-Ras chimera inhibited GLUT4 translocation, whereas the TC10/K-Ras chimera showed no significant inhibitory activity. Furthermore, disruption of lipid raft microdomains by expression of a dominant-interfering caveolin 3 mutant (Cav3/DGV) inhibited the insulin stimulation of GLUT4 translocation and TC10 lipid raft localization and activation without affecting PI-3 kinase signaling. These data demonstrate that the insulin stimulation of GLUT4 translocation in adipocytes requires the spatial separation and distinct compartmentalization of the PI-3 kinase and TC10 signaling pathways.

Using standardized patients as teachers: a concurrent controlled trial.

PURPOSE: To compare two methods of teaching physical assessment, a traditional faculty-taught course and a course with components taught by specially trained standardized patients (SPs), with respect to students' performances and costs. METHOD: Medical students in their second year and without preliminary course work in physical assessment were taught by faculty-led small groups. Students in their first year were taught by faculty-led lecture-demonstrations and exercises led by physical examination teaching associates (PETAs). Both groups of students were tested with a performance-based examination that involved six identical stations. The costs of both courses were calculated using faculty and SP salaries. RESULTS: There was no difference in students' performances on two of the stations, those involving the eye and abdominal examinations. The class that had been taught by PETAs, however, demonstrated a statistically significant performance advantage on the remaining four stations. The cost saving from using the PETAs was conservatively estimated at $24,155. CONCLUSION: Specially trained SPs can effectively teach the normal physical examination to medical students and are a less expensive alternative to traditional faculty small-group teaching methods.

Chiral separations of transition metal complexes using capillary zone electrophoresis.

Several buffer additives that may facilitate chiral separation for optically active transition metal (TM) systems are investigated using capillary zone electrophoresis. The TM complexes evaluated exhibit considerable heterogeneity with respect to total complex charge (0 to 4+), ligand type, and identity of the central metal including Ru2+, Ni2+, Cr3+, and Co3+, threo-D[+]-Isocitrate, potassium antimonyl-d-tartrate and dibenzoyl-L-tartrate are identified as the most efficient chiral selectors. Interestingly, TM complexes exhibiting a (3+) total complex charge exhibit a reversal of enantiomer elution order versus all other complexes when separated using the tartrate additives. Operating parameters including pH, temperature, and capillary length are discussed, and chiral separations of complex mixtures are demonstrated.

Transmembrane domain length determines intracellular membrane compartment localization of syntaxins 3, 4, and 5.

Insulin recruits glucose transporter 4 (GLUT-4) vesicles from intracellular stores to the plasma membrane in muscle and adipose tissue by specific interactions between the vesicle membrane-soluble N-ethylmaleimide-sensitive factor attachment protein target receptor (SNARE) protein VAMP-2 and the target membrane SNARE protein syntaxin 4. Although GLUT-4 vesicle trafficking has been intensely studied, few have focused on the mechanism by which the SNAREs themselves localize to specific membrane compartments. We therefore set out to identify the molecular determinants for localizing several syntaxin isoforms, including syntaxins 3, 4, and 5, to their respective intracellular compartments (plasma membrane for syntaxins 3 and 4; cis-Golgi for syntaxin 5). Analysis of a series of deletion and chimeric syntaxin constructs revealed that the 17-amino acid transmembrane domain of syntaxin 5 was sufficient to direct the cis-Golgi localization of several heterologous reporter constructs. In contrast, the longer 25-amino acid transmembrane domain of syntaxin 3 was sufficient to localize reporter constructs to the plasma membrane. Furthermore, truncation of the syntaxin 3 transmembrane domain to 17 amino acids resulted in a complete conversion to cis-Golgi compartmentalization that was indistinguishable from syntaxin 5. These data support a model wherein short transmembrane domains (< or =17 amino acids) direct the cis-Golgi localization of syntaxins, whereas long transmembrane domains (> or =23 amino acids) direct plasma membrane localization.

A primary care preceptorship for first-year medical students coordinated by an Area Health Education Center program: a six-year review.

In 1991, the University of Florida College of Medicine established a required primary care preceptorship coordinated by the Area Health Education Center (AHEC) Program for all students in the first semester of medical school. Six years' experience with this course, which is entirely community-based and taught by community physicians, provides evidence of the success of the preceptorship. Over the first six years, 97% of students and 92% of preceptors felt strongly that this was an appropriate and valuable experience for students in the first semester of medical school. All believed that the students were capable of interacting with patients in a meaningful fashion and that the course allowed students to gain confidence as health care providers. The course also reinforced the importance of the basic science curriculum and initiated the process of professional development by affirming students' decisions to pursue a career in medicine. The use of content analysis to further evaluate attitudes and behaviors indicated that the students were highly satisfied with their experience and were active participants in the preceptors' practices. Students' approach to patients as people, rather than cases, was positive, and increased from the first to the last day of the preceptorship. After six years, this preceptorship has been demonstrated to have a positive and meaningful impact on medical student education and development.

Insulin-stimulated GLUT4 translocation requires the CAP-dependent activation of TC10.

The stimulation of glucose uptake by insulin in muscle and adipose tissue requires translocation of the GLUT4 glucose transporter protein from intracellular storage sites to the cell surface. Although the cellular dynamics of GLUT4 vesicle trafficking are well described, the signalling pathways that link the insulin receptor to GLUT4 translocation remain poorly understood. Activation of phosphatidylinositol-3-OH kinase (PI(3)K) is required for this trafficking event, but it is not sufficient to produce GLUT4 translocation. We previously described a pathway involving the insulin-stimulated tyrosine phosphorylation of Cbl, which is recruited to the insulin receptor by the adapter protein CAP. On phosphorylation, Cbl is translocated to lipid rafts. Blocking this step completely inhibits the stimulation of GLUT4 translocation by insulin. Here we show that phosphorylated Cbl recruits the CrkII-C3G complex to lipid rafts, where C3G specifically activates the small GTP-binding protein TC10. This process is independent of PI(3)K, but requires the translocation of Cbl, Crk and C3G to the lipid raft. The activation of TC10 is essential for insulin-stimulated glucose uptake and GLUT4 translocation. The TC10 pathway functions in parallel with PI(3)K to stimulate fully GLUT4 translocation in response to insulin.

Intracellular organization of insulin signaling and GLUT4 translocation.

Glucose is cleared from the bloodstream by a family of facilitative transporters (GLUTs), which catalyze the transport of glucose down its concentration gradient and into cells of target tissues, primarily striated muscle and adipose. Currently, there are five established functional facilitative glucose transporter isoforms (GLUT1-4 and GLUTX1), with GLUT5 being a fructose transporter. GLUT1 is ubiquitously expressed with particularly high levels in human erythrocytes and in the endothelial cells lining the blood vessels of the brain. GLUT3 is expressed primarily in neurons and, together, GLUT1 and GLUT3 allow glucose to cross the blood-brain barrier and enter neurons. GLUT2 is a low-affinity (high Km) glucose transporter present in liver, intestine, kidney, and pancreatic beta cells. This transporter functions as part of the glucose sensor system in beta cells and in the basolateral transport of intestinal epithelial cells that absorb glucose from the diet. A new facilitative glucose transporter protein, GLUTX1, has been identified and appears to be important in early blastocyst development. The GLUT4 isoform is the major insulin-responsive transporter that is predominantly restricted to striated muscle and adipose tissue. In contrast to the other GLUT isoforms, which are primarily localized to the cell surface membrane, GLUT4 transporter proteins are sequestered into specialized storage vesicles that remain within the cell's interior under basal conditions. As postprandial glucose levels rise, the subsequent increase in circulating insulin activates intracellular signaling cascades that ultimately result in the translocation of the GLUT4 storage compartments to the plasma membrane. Importantly, this process is readily reversible such that when circulating insulin levels decline, GLUT4 transporters are removed from the plasma membrane by endocytosis and are recycled back to their intracellular storage compartments. Therefore, by establishing an internal membrane compartment as the default localization for the GLUT4 transporters, insulin-responsive tissues are poised to respond rapidly and efficiently to fluctuations in circulating insulin levels. Unfortunately, the complexity of these regulatory processes provides numerous potential targets that may be defective and eventually result in peripheral tissue insulin resistance and possibly diabetes. As such, understanding the molecular details of GLUT4 expression, GLUT4 vesicle compartment biogenesis, GLUT4 sequestration, vesicle trafficking, and fusion with the plasma membrane has become a major focus for many laboratories. This chapter will focus on recently elucidated insulin signal transduction pathways and GLUT4 vesicle trafficking components that are necessary for insulin-stimulated glucose uptake and GLUT4 translocation in adipocytes.

Tensilon and the diagnosis of myasthenia gravis: are we using the Tensilon test too much?

BACKGROUND: Tensilon (edrophonium chloride) is a reversible acetylcholinesterase inhibitor used in the diagnosis of myasthenia gravis, diagnosis and treatment of arrhythmias, detection of early digitalis toxicity, reversal of neuromuscular blockade, and other medical conditions. Toxicity associated with Tensilon use has appeared in the literature for decades. REVIEW SUMMARY: This review discusses the risks of Tensilon and the information practitioners should know before administering the drug. We review the literature regarding serious toxicity of this drug and offer recommendations for its safe use. CONCLUSIONS: A careful medication history should be taken before the administration of Tensilon. Additionally, physicians should be aware of appropriate alternative methods of diagnosis before choosing to administer Tensilon. Physicians should be aware of the clinical situations where the Tensilon test no longer is indicated.

The trimeric GTP-binding protein (G(q)/G(11)) alpha subunit is required for insulin-stimulated GLUT4 translocation in 3T3L1 adipocytes.

To investigate the potential role of trimeric GTP-binding proteins regulating GLUT4 translocation in adipocytes, wild type and constitutively active G(q) (G(q)/Q209L), G(i) (G(i)/Q205L), and G(s) (G(s)/Q227L) alpha subunit mutants were expressed in 3T3L1 adipocytes. Although expression of neither the wild type nor G(i)/Q205L and G(s)/Q227L alpha subunit mutants had any effect on the basal or insulin-stimulated translocation of a co-expressed GLUT4-enhanced green fluorescent protein (EGFP) fusion protein, expression of G(q)/Q209L resulted in GLUT4-EGFP translocation in the absence of insulin. In contrast, microinjection of an inhibitory G(q)/G(11) alpha subunit-specific antibody but not a G(i) or G(s) alpha subunit antibody prevented insulin-stimulated endogenous GLUT4 translocation. Consistent with a required role for GTP-bound G(q)/G(11), expression of the regulators of G protein signaling (RGS4 and RGS16) also attenuated insulin-stimulated GLUT4-EGFP translocation. To assess the relationship between G(q)/G(11) function with the phosphatidylinositol 3-kinase dependent pathway, expression of a dominant-interfering p85 regulatory subunit, as well as wortmannin treatment inhibited insulin-stimulated but not G(q)/Q209L-stimulated GLUT4-EGFP translocation. Furthermore, G(q)/Q209L did not induce the in vivo accumulation of phosphatidylinositol-3,4,5-trisphosphate (PIP(3)), whereas expression of the RGS proteins did not prevent the insulin-stimulated accumulation of PIP(3). Together, these data demonstrate that insulin stimulation of GLUT4 translocation requires at least two independent signal transduction pathways, one mediated through the phosphatidylinositol 3-kinase and another through the trimeric GTP-binding proteins G(q) and/or G(11).

Calmodulin antagonists inhibit insulin-stimulated GLUT4 (glucose transporter 4) translocation by preventing the formation of phosphatidylinositol 3,4,5-trisphosphate in 3T3L1 adipocytes.

It has been previously reported that calmodulin plays a regulatory role in the insulin stimulation of glucose transport. To examine the basis for this observation, we examined the effect of a panel of calmodulin antagonists that demonstrated a specific inhibition of insulin-stimulated glucose transporter 4 (GLUT4) but not insulin- or platelet-derived growth factor (PDGF)-stimulated GLUT1 translocation in 3T3L1 adipocytes. These treatments had no effect on insulin receptor autophosphorylation or tyrosine phosphorylation of insulin receptor substrate 1 (IRS1). Furthermore, IRS1 or phosphotyrosine antibody immunoprecipitation of phosphatidylinositol (PI) 3-kinase activity was not affected. Despite the marked insulin and PDGF stimulation of PI 3-kinase activity, there was a near complete inhibition of protein kinase B activation. Using a fusion protein of the Grp1 pleckstrin homology (PH) domain with the enhanced green fluorescent protein, we found that the calmodulin antagonists prevented the insulin stimulation of phosphatidylinositol 3,4,5-trisphosphate [PI(3,4,5)P3] formation in vivo. Similarly, although PDGF stimulation increased PI 3-kinase activity in in vitro immunoprecipitation assays, there was also no significant formation of PI(3,4,5)P3 in vivo. These data demonstrate that calmodulin antagonists prevent insulin-stimulated GLUT4 translocation by inhibiting the in vivo production of PI(3,4,5)P3 without directly affecting IRS1- or phosphotyrosine-associated PI 3-kinase activity. This phenomenon is similar to that observed for the PDGF stimulation of 3T3L1 adipocytes.

Measuring faculty effort and contributions in medical education.

A national panel on medical education was appointed as a component of the AAMC's Mission-based Management Program and charged with developing a metrics system for measuring medical school faculty effort and contributions to a school's education mission. The panel first defined important variables to be considered in creating such a system: the education programs in which medical school faculty participate; the categories of education work that may be performed in each program (teaching, development of education products, administration and service, and scholarship in education); and the array of specific education activities that faculty could perform in each of these work areas. The panel based the system on a relative value scale, since this approach does not equate faculty performance solely to the time expended by a faculty member in pursuit of a specific activity. Also, a four-step process to create relative value units (RVUs) for education activities was developed. This process incorporates quantitative and qualitative measures of faculty activity and also can measure and value the distribution of faculty effort relative to a school's education mission. When adapted to the education mission and culture of an individual school, the proposed metrics system can provide critical information that will assist the school's leadership in evaluating and rewarding faculty performance in education and will support a mission-based management strategy in the school.

Functional cooperation of two independent targeting domains in syntaxin 6 is required for its efficient localization in the trans-golgi network of 3T3L1 adipocytes.

To identify the targeting domains of syntaxin 6 responsible for its localization to the trans-Golgi network (TGN), we examined the subcellular distribution of enhanced green fluorescent protein (EGFP) epitope-tagged syntaxin 6/syntaxin 4 chimerae and syntaxin 6 truncation/deletion mutants in 3T3L1 adipocytes. Expression of EGFP-syntaxin 6 resulted in a perinuclear distribution identical to endogenous syntaxin 6 as determined both by confocal fluorescence microscopy and subcellular fractionation. Furthermore, both the endogenous and the expressed EGFP-syntaxin 6 fusion protein were localized to a brefeldin A-insensitive but okadaic acid-sensitive compartment characteristic of the TGN. In contrast, EGFP-syntaxin 6 constructs lacking the H2 domain were excluded from the TGN and were instead primarily localized to the plasma membrane. Although syntaxin 4 was localized to the plasma membrane, syntaxin 6/syntaxin 4 chimerae and syntaxin 6 truncations containing the H2 domain of syntaxin 6 were predominantly directed to the TGN. Importantly, the syntaxin 6 H2 domain fused to the transmembrane domain of syntaxin 4 was also localized to the TGN, demonstrating that the H2 domain was sufficient to confer TGN localization. In addition to the H2 domain, a tyrosine-based plasma membrane internalization signal (YGRL) was identified between the H1 and H2 domains of syntaxin 6. Deletion of this sequence resulted in the accumulation of the EGFP-syntaxin 6 reporter construct at the plasma membrane. Together, these data demonstrate that syntaxin 6 utilizes two distinct domains to drive its specific subcellular localization to the TGN.

Neglect and related disorders.

Neglect is a failure to report, respond, or orient to contralateral stimuli that is not caused by an elemental sensorimotor deficit. Subtypes of neglect are distinguished by input (attentional) or output (intentional) demands, the distribution (personal, spatial, and representational), and the means of eliciting the signs (unilateral or bilateral stimuli). In this article we discuss how to assess patients for neglect, the pathophysiology of neglect, and the treatment of neglect.

Mission-based budgeting: removing a graveyard.

Many activities in today's medical schools no longer have medical students' education as their central reason for existence. Faculty are hired primarily to provide clinical service or to make discoveries, with the role of educator of secondary importance. Budgeting in medical schools has not evolved in concert with these changing roles of faculty. The cost of medical students' education is still calculated as if all faculty were hired primarily to teach medical students and their other activities were to support this "central" mission. Most medical schools still mix revenues without regard to intent and cannot accurately determine costs because they confuse expenses with costs. At the University of Florida College of Medicine, a group of administrators, chairpersons, and faculty developed a budgeting process now called mission-based budgeting. This is a three-step process: (1) revenues are prospectively identified for each mission and then aligned with intended purposes; (2) faculty productivity, i.e., faculty effort and its quality, is measured for each of the missions; and (3) productivity is linked to the prospective budget for each mission. This process allows the institution to understand the intent of its revenues, to measure how productive its faculty are, to learn the true costs of its missions, to make wise investment decisions (subsidies), and to justify to various constituents its use of revenues. The authors describe this process, focusing particularly on methods used to develop a comprehensive database for assessment of faculty productivity in education.

Moving a graveyard: how one school prepared the way for continuous curriculum renewal.

From 1991 to 1996, the faculty at the University of Florida College of Medicine initiated several significant changes in its curriculum. These changes, included the introduction of early clinical experience in primary care settings; the enhancement of active learning experiences in small-group settings; production and use of computer-based interactive learning materials; increased clinical teaching in the ambulatory care training in an interdisciplinary primary care clerkship; effective course and faculty evaluation; establishment and use of an assessment center for instruction and performance-based evaluations utilizing standardized patients; creation of a medical education center as the focal point for logistics support of the teaching faculty and education data handling; creation of a faculty development program; and initiation of mission-based budgeting based on the faculty's teaching effort and quality. Because the faculty were relatively conservative, it was important to identify variables that would facilitate the introduction of changes and those that might hinder it. The following factors were most important: interest and support by the dean and clearly defined delegation of authority to an associate dean; introduction of a mission-based budgeting process that allocates education funds on the basis of faculty teaching effort and its quality; a clear understanding of the empowerment of the curriculum committee; and an identification of the principles that should guide educational planning and implementation. These efforts are considered the beginning of the continuous renewal needed to respond to information networking, scientific and technological innovations, and the fundamental changes in health care delivery. As these changes have taken place, a shift toward greater institutional control of the educational program leading to the MD degree has been evident.