"Risk, respect, responsibility": educational strategies to promote safe medicine use.

Nearly four billion outpatient prescriptions will be dispensed in the United States by 2005. Many people using these medicines will be targeted for educational programs promoting their safe, appropriate use. Such programs have been, or soon will be, developed by virtually all major health care system stakeholders, including: government agencies, the pharmaceutical industry, non-profit organizations and coalitions. After examining changes in 1) health professionals' communication of patient medicine information, and 2) consumers' roles and attitudes, an overview of recent U.S. and international consumer education programs is presented. Despite the proliferation of these programs, most share a weak link in evaluating success and in affecting behavior change. Finally, suggestions for future initiatives are offered, particularly regarding improving evaluation methods.

Validity of generic risk factors and the strain index for predicting nontraumatic distal upper extremity morbidity.

Nine individual generic risk factors, eight combinations of generic risk factors, the presence of any generic risk factor, and the Strain Index were evaluated for 56 jobs by 2 evaluators blinded to morbidity measures. Jobs then were assigned to dichotomous hazard classifications (problem versus safe) according to recommendations from the literature. OSHA 200 logs were used to ascertain historical evidence of distal upper extremity (DUE) morbidity, and jobs were assigned to a dichotomous morbidity classification (positive versus negative) using none versus one or more recorded cases as the criterion. Evidence of association and measures of predictive validity were evaluated by comparing hazard and morbidity classifications using 2 x 2 contingency tables. Five individual generic risk factors, three generic risk factor combinations, and the presence of any generic risk factor were not associated with morbidity classification. The odds ratio estimates among the four individual generic risk factors and the five combinations of generic risk factors associated with DUE morbidity varied from 3.3-36.0. The Strain Index had the largest estimated odds ratio of any exposure factor at 108.3. The exposure methods were grouped according to patterns of predictive validity. With one exception, the individual generic risk factors and their combinations had high sensitivity with low specificity (many false-positives), low sensitivity with high specificity (many false-negatives), or low sensitivity with low specificity. The only generic risk factor that demonstrated reasonable predictive validity was the use of gloves--its sensitivity, specificity, positive predictive value, and negative predictive value were equal to 0.75. The Strain Index performed better than any of the individual or combinations of generic risk factors. Its sensitivity, specificity, positive predictive value, and negative predictive value were all approximately 0.90.

5' flanking sequence of the human immediate early responsive gene ccn1 (cyr61) and mapping of polymorphic CA repeat sequence motifs in the human ccn1 (cyr61) locus.

AIMS: The human ccn1 (hccn; hcyr61) gene has been identified previously at the mRNA and protein level as a 1,25-dihydroxyvitamin D(3) and growth factor regulated gene in human osteoblasts. This study aimed to analyse genomic clones containing the human ccn1 (cyr61) gene and to provide the 5' flanking region. METHODS: Genomic clones were isolated by screening a lambda library and by array filter hybridisations of a genomic library. Sequencing was performed using the dye terminator method. Promoter activity was measured after transient transfection using a beta galactosidase assay. CA repeat motifs were studied by a combined PCR/fragment analysis protocol. RESULTS: The human 5' flanking region of 870 nucleotides contains several stretches with high homology to the mouse promoter as well as CA repeat motifs. This first report on the human 5' flanking sequence of the hccn1 (hcyr61) gene provides important insights into regulation pathways for the expression of this 1,25-dihydroxyvitamin D(3) and growth factor responsive early gene. A genomic clone containing the hccn1 (hcyr61) gene region also yielded a CA sequence located 3' of the ccn1 (cyr61) gene. This CA repeat and one of the CA repeat motifs in the promoter were studied in detail and found to be polymorphic. CONCLUSIONS: The 5' flanking sequence of the hccn1 (hcyr61) gene provides insights into the mechanisms of regulation of this immediate early gene product. The CA repeat polymorphisms within the gene region will be useful in the genetic study of disorders affecting bone metabolism.

Antiangiogenic treatment enhances photodynamic therapy responsiveness in a mouse mammary carcinoma.

Photodynamic therapy (PDT) is a promising cancer treatment that induces localized tumor destruction via the photochemical generation of cytotoxic singlet oxygen. PDT-mediated oxidative stress elicits direct tumor cell damage as well as microvascular injury within exposed tumors. Reduction in vascular perfusion associated with PDT-mediated microvascular injury produces tumor tissue hypoxia. Using a transplantable BA mouse mammary carcinoma, we show that Photofrin-mediated PDT induced expression of the hypoxia-inducible factor-1alpha (HIF-1alpha) subunit of the heterodimeric HIF-1 transcription factor and also increased protein levels of the HIF-1 target gene, vascular endothelial growth factor (VEGF), within treated tumors. HIF-1alpha and VEGF expression were also observed following tumor clamping, which was used as a positive control for inducing tissue hypoxia. PDT treatment of BA tumor cells grown in culture resulted in a small increase in VEGF expression above basal levels, indicating that PDT-mediated hypoxia and oxidative stress could both be involved in the overexpression of VEGF. Tumor-bearing mice treated with combined antiangiogenic therapy (IM862 or EMAP-II) and PDT had improved tumoricidal responses compared with individual treatments. We also demonstrated that PDT-induced VEGF expression in tumors decreased when either IM862 or EMAP-II was included in the PDT treatment protocol. Our results indicate that combination procedures using antiangiogenic treatments can improve the therapeutic effectiveness of PDT.

Photodynamic therapy sensitivity is not altered in human tumor cells after abrogation of p53 function.

Photodynamic therapy (PDT) is an effective local cancer treatment that induces cytotoxicity through the intracellular generation of reactive oxygen species. The current study investigated whether abrogation of wild-type p53 expression modified the sensitivity of tumor cells to PDT-mediated oxidative stress. In these experiments, human colon (LS513) and breast (MCF-7) carcinoma cells exhibiting a wild-type p53 phenotype were directly compared to LS513 and MCF-7 cells with abrogated p53 function induced by stable integration of the human papillomavirus type 16 E6 viral oncoprotein. The effectiveness of this viral oncoprotein to target p53 for degradation was confirmed using a p53 transactivation reporter gene assay. Western analysis also confirmed attenuated expression of p53 in E6-transfected cells. Photosensitivity of PDT-treated cells was measured by a clonogenic assay and found to be equivalent for parental and p53-abrogated cells. PDT-mediated oxidative stress resulted in a rapid shift of pRb from a hyperphosphorylated form to a predominantly underphosphorylated form in parental cells that was not preceded by increases in p53 or p21 expression. Hypophosphorylated pRb was also observed in PDT-treated LS513/E6 and MCF-7/E6 cells, further indicating that p53 was not involved in this process. Delayed expression of p53 and p21 proteins was seen in parental cells 24-48 h after photosensitization. Cell cycle analysis showed that the abrogation of p53 had minimal effects on an observed PDT-induced G1 block. Rapid induction of apoptosis was documented in PDT-treated LS513 cells, whereas LS513/E6 treated cells exhibited reduced apoptosis in response to PDT. The MCF-7 cell lines exhibited a minimal apoptotic response to PDT. These results indicate that p53 expression does not directly modulate tumor cell sensitivity to PDT in either apoptosis-responsive (LS513) or nonresponsive (MCF-7) cells.

Differential photosensitivity in wild-type and mutant p53 human colon carcinoma cell lines.

Tumor sensitivity to cancer therapies may be modulated by the p53 status of the malignant cells. Generally, tumors retaining wild-type p53 are more sensitive to radiotherapy and some chemotherapeutic agents than are tumors with either a mutated or deleted p53 phenotype. The role of p53 in the responsiveness to PDT as a cancer treatment is clinically unknown. In the current study, we evaluated the photosensitivity of two human colon carcinoma cell lines, one expressing wild-type p53 protein and the other expressing mutant p53. Wild-type p53 cells were found to be significantly more sensitive to Photofrin-mediated photodynamic treatment measured by clonogenic assay. Uptake of the photosensitizer was equivalent for both cell lines. Interestingly, sensitivity of the colon carcinoma cell lines to ionizing radiation was similar. These two cell lines represent a useful model for examining p53 involvement in the cellular response to PDT-mediated oxidative stress.

Cellular targets and molecular responses associated with photodynamic therapy.

The positive clinical results associated with photodynamic therapy (PDT) have led to an expanded need to identify the cellular targets and molecular responses associated with this treatment. Increased knowledge regarding the mechanisms of action associated with PDT-mediated cytotoxicity should contribute to the continued advancement of this therapy. This report focuses on recent studies analyzing PDT resistance and examining stress protein and early response gene activation induced by photosensitizer mediated oxidative stress. Recurring observations from these studies indicate that subcellular targets and cellular responses associated with PDT can vary significantly for different photosensitizers.

Photodynamic therapy-mediated oxidative stress can induce expression of heat shock proteins.

Photodynamic therapy (PDT) is an experimental cancer therapy inducing tumor tissue damage via photosensitizer-mediated oxidative cytotoxicity. A previous report indicates that oxidative stress induced by hydrogen peroxide or menadione activates the heat shock transcription factor in mouse cells but does not result in either increased transcription or translation of heat shock proteins (HSPs). Our study documents that photosensitizer-mediated oxidative stress can activate the heat shock factor as well as increase HSP-70 mRNA and protein levels in mouse RIF-1 cells. The cellular heat shock response after PDT varied for the different photosensitizers being examined. Treatments using either a chlorin (mono-L-aspartyl chlorin-e6)- or purpurin (tin etio-purpurin)-based sensitizer induced HSP-70 expression, whereas identical photosensitization conditions with a porphyrin (Photofrin)-based sensitizer failed to induce a cellular HSP response. These sensitizers, which generate singlet oxygen as the primary oxidant during photosensitization, were used in experiments under isoeffective treatment conditions. HSP-70 expression after photosensitization was associated with the concomitant induction of thermotolerance in PDT-treated cells. Interestingly, reverse transcription-PCR demonstrated that in vivo PDT treatments of RIF-1 tumors induce expression of HSP-70 for all photosensitizers including Photofrin. These results indicate that photosensitizer-generated singlet oxygen exposure can induce in vitro and in vivo HSP-70 expression, and that specific subcellular targets of PDT (which can differ for various sensitizers) are determinants for HSP-70 activation after oxidative stress.

Decreased expression and function of alpha-2 macroglobulin receptor/low density lipoprotein receptor-related protein in photodynamic therapy-resistant mouse tumor cells.

Parental and photodynamic therapy (PDT)-resistant mouse, radiation-induced fibrosarcoma cell lines were evaluated using mRNA differential display in an attempt to identify unique transcripts. We detected one transcript that was consistently present in the parental cells but absent in PDT-resistant cells. The transcript was cloned, sequenced, and identified as alpha-2 macroglobulin receptor/low density lipoprotein receptor-related protein (alpha-2 MR/LRP). Northern and Western immunoblot analysis confirmed that receptor expression was present in the parental cell line but barely detectable in PDT-resistant cells. Functionality of the receptor was evaluated by exposing cells to Pseudomonas exotoxin A. alpha-2 MR/LRP is responsible for Pseudomonas exotoxin A internalization, and only the parental cells exhibited toxin-mediated cytotoxicity. The binding and endocytosis of activated alpha-2 macroglobulin and lipoproteins by alpha-2 MR/LRP are consistent with modulating uptake and localization of photosensitizers. Our results demonstrate that PDT-resistant murine tumor cells exhibit minimal alpha-2 MR/LRP activity and suggest that this receptor plays a role in PDT sensitivity by modulating photosensitizer uptake and/or subcellular localization.

Establishment of a Chinese hamster ovary cell line that expresses grp78 antisense transcripts and suppresses A23187 induction of both GRP78 and GRP94.

GRP78, a 78,000 dalton protein residing in the endoplasmic reticulum, is postulated to play important roles in protein folding and cell survival during calcium and other physiological stress. Here we describe the construction of an eukaryotic expression vector for the constitutive expression of grp78 antisense RNA and the creation of a CHO cell line, 78WO, which expresses high levels of the grp78 antisense RNA through amplification of the stably transfected antisense vector. We observed that whereas 78WO maintains a basal level of GRP78 similar to that of control cells, GRP78 is no longer inducible by A23187. The 78WO cells have undergone a compensatory increase in grp78 transcription such that the effects of antisense are cancelled out at the protein level under nonstressed conditions. In these same cells, GRP94, a 94,00 dalton ER protein, is also rendered noninducible by A23187. This provides the first evidence that the regulation of two ER proteins might be coupled such that the failure to induce GRP78 results in the down-regulation of GRP94. The 78WO cell line grows with a doubling time of about 26 hr and exhibits decreased tolerance to A23187, suggesting the GRPs contribute to cell viability under calcium stress. The establishment of this cell line, which can be stably maintained, will provide a useful tool for testing whether the induction of the GRPs is important for protein folding or transport and whether their enhanced synthesis is the cause or consequence of a variety of physiological adaptations.

Glucose regulated protein induction and cellular resistance to oxidative stress mediated by porphyrin photosensitization.

Photodynamic therapy (PDT) utilizes a tumor localizing porphyrin photosensitizer in the clinical treatment of cancer. At a mechanistic level, porphyrin photosensitization generates reactive oxygen species which initiate oxidative damage to a wide spectrum of biomolecules. Cellular stress proteins are also increased following oxidative stress treatments. In the current study, we examined porphyrin photosensitizing parameters associated with induction of the glucose regulated family of stress proteins. Elevated levels of mRNA encoding glucose regulated proteins (GRPs) as well as increases in GRP protein synthesis were observed for mouse radiation induced fibrosarcoma cells exposed to an extended (16-h) porphyrin incubation prior to light exposure. However, a short (1-h) porphyrin incubation prior to light treatment (designed to produce comparable phototoxicity as PDT using the 16-h porphyrin incubation protocol) was associated with only minimal increases in GRP mRNA levels or GRP protein synthesis. The relationship between GRP levels and PDT sensitivity was examined in radiation induced fibrosarcoma cells pretreated with the calcium ionophore A-23187 in order to overexpress GRPs prior to photosensitization. Resistance to PDT was observed in cells overexpressing GRPs only under photosensitizing conditions associated with the extended porphyrin incubation protocol, and this response was not due to changes in cellular porphyrin uptake. In separate experiments, a transient elevation of GRP mRNA levels was observed in transplanted mouse mammary carcinomas following in vivo PDT treatments. Our results indicate that specific targets of oxidative damage (modulated by porphyrin incubation conditions) instead of generalized cellular exposure to reactive oxygen species are correlated with PDT mediated GRP induction. In this regard, GRP induction may be a useful in vivo biochemical marker of PDT mediated injury. These results also support the hypothesis that GRPs may play a role in modulating sensitivity to cellular stresses including certain types of oxidative injury.

Increased transcription and translation of heme oxygenase in Chinese hamster fibroblasts following photodynamic stress or Photofrin II incubation.

Porphyrin mediated photosensitization can enhance the transcription and translation of several oxidative stress genes. In this study, we report on the enhanced expression of the gene encoding for heme oxygenase in Chinese hamster fibroblasts by; (1) incubation in Photofrin II; (2) Photofrin II mediated photosensitization; and (3) photosensitization induced by Rose Bengal. Increased expression of heme oxygenase mRNA was accompanied by a concomitant increase in the synthesis of the 34 kDa heme oxygenase protein. Western blot analysis using antibody to heme oxygenase confirmed the immunoreactivity of the 34 kDa protein induced by Photofrin II and PDT. These results demonstrate that heme oxygenase can be activated by non-metalloporphyrins as well as by photosensitization associated with singlet oxygen mediated subcellular injury.

Intrinsic vasculature of the labyrinthine segment of the facial nerve--implications for site of lesion in Bell's palsy.

Recent studies of the intrinsic vasculature of the cat facial nerve have demonstrated relatively poor blood supply to the labyrinthine segment. In this study, the intrinsic vasculature of the human facial nerve was systematically evaluated in 25 temporal bones and three fresh cadaver nerves. Cross-sectional vessel counts were obtained for the labyrinthine, tympanic, and mastoid segments. Capillary densities for each segment were derived from these data. The labyrinthine segment of the human facial nerve, like that in the cat, contains fewer and smaller intrinsic blood vessels than do the mastoid and tympanic segments. This may indicate that the labyrinthine segment of the facial nerve may be more vulnerable to ischemic damage. In conjunction with the previously demonstrated narrowness of the labyrinthine fallopian canal, these findings support the contention that the labyrinthine segment is a likely site of lesion in Bell's palsy.

Direct comparison of in-vitro and in-vivo Photofrin-II mediated photosensitization using a pulsed KTP pumped dye laser and a continuous wave argon ion pumped dye laser.

A pulsed KTP pumped dye laser (25 kHz repetition rate and 470 nsec pulse width) has been compared to a continuous wave argon ion pumped dye laser as the source of 630 nm light during in-vitro and in-vivo Photofrin-II mediated photosensitization studies. Individual experiments documented the effectiveness of each laser system on a) photosensitizer induced cytotoxicity and induction of stress protein synthesis using Chinese hamster fibroblasts; b) photobleaching of Photofrin-II in aqueous solution; c) Photofrin II mediated photosensitization of normal mouse skin; d) Photofrin II mediated photodynamic therapy of a mouse mammary carcinoma; and e) tumor temperature levels generated during laser exposure. Comparable results were obtained for both laser systems in all experiments.