RESUMEN
BACKGROUND: Virtual implant planning systems integrate (cone beam-) computed tomography data to assess bone quantity and virtual models for the design of the implant-retained prosthesis and drill guides. Five commercially available systems for virtual implant planning were examined regarding the modalities of integration of radiographic data, virtual dental models and the design of drill guides for guided implant surgery. The purpose of this review was to describe the limitations of these available systems regarding the import of imaging data and the design and fabrication of a drill guide. METHODS: The following software systems were examined regarding the import of imaging data and the export of the virtual implant planning for the design and fabrication of a drill guide with the help of two clinical situations requiring dental implant therapy: coDiagnostiX™, DentalWings, Canada (CDX); Simplant Pro™, Dentsply, Sweden (SIM); Smop™, Swissmeda, Switzerland (SMP); NobelClinician™, Nobel Biocare, Switzerland (NC); Implant Studio, 3Shape, Denmark (IST). Assessment criteria included data formats and management as well as the workflow for the design and production of drill guides. RESULTS: All systems have a DICOM-interface ("Digital Imaging and Communication in Medicine") for the import of radiographic data. Imaging artefacts could be reduced but not eliminated by manual data processing. The import of virtual dental models in a universal format (STL: Standard Tesselation Language) was possible with three systems; one system could only be used with a proprietary data format. All systems display three-dimensional surface models or two-dimensional cross-sections with varying orientation for virtual implant planning. Computer aided design and manufacturing (CAD/CAM) of drill guides may be performed by the user with the help of default parameters or solely by the provider of the software and thus without the influence of the clinician. CONCLUSION: Data bases of commonly used implant systems are available in all tested software, however not all systems allow to plan and execute fully guided implant placement. An individual design and in-house manufacturing of the drill guide is only available in some software systems. However, at the time of publication most recent software versions showed flexibility in individual design and in-house manufacturing of drill guides.
Asunto(s)
Implantes Dentales , Cirugía Asistida por Computador , Canadá , Diseño Asistido por Computadora , Tomografía Computarizada de Haz Cónico , Implantación Dental Endoósea , Imagenología Tridimensional , Planificación de Atención al Paciente , Programas Informáticos , Suecia , SuizaRESUMEN
OBJECTIVE: Compared with cone beam computed tomography (CBCT), magnetic resonance imaging (MRI) might be superior for the diagnosis of nerve lesions associated with implant placement. STUDY DESIGN: A patient presented with unilateral pain associated with dysesthesia in the region of the right lower lip and chin after implant placement. Conventional orthopantomography could not identify an association between the position of the inferior alveolar nerve and the implant. For 3-dimensional display of the implant in relation to the surrounding anatomy, CBCT was compared with MRI. RESULTS: MRI enabled the precise depiction of the implant position and its spatial relation to the inferior alveolar nerve, whereas the nerve position and its exact course within the mandible could not be directly displayed in CBCT. CONCLUSION: MRI may be a valuable, radiation-free diagnostic tool for the visualization of intraoral hard and soft tissues, offering an objective assessment of nerve injuries by a direct visualization of the inferior alveolar neurovascular bundle.
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Implantación Dental Endoósea , Implantes Dentales , Imagen por Resonancia Magnética/métodos , Complicaciones Posoperatorias/diagnóstico por imagen , Traumatismos del Nervio Trigémino/diagnóstico por imagen , Traumatismos del Nervio Trigémino/cirugía , Tomografía Computarizada de Haz Cónico , Remoción de Dispositivos , Humanos , Persona de Mediana Edad , Radiografía PanorámicaRESUMEN
There is an urgent need to develop novel treatments to counter Botulinum neurotoxin (BoNT) poisoning. Currently, the majority of BoNT drug development efforts focus on directly inhibiting the proteolytic components of BoNT, i.e. light chains (LC). Although this is a rational approach, previous research has shown that LCs are extremely difficult drug targets and that inhibiting multi-serotype BoNTs with a single LC inhibitor may not be feasible. An alternative approach would target neuronal pathways involved in intoxication/recovery, rather than the LC itself. Phosphorylation-related mechanisms have been implicated in the intoxication pathway(s) of BoNTs. However, the effects of phosphatase inhibitors upon BoNT activity in the physiological target of BoNTs, i.e. motor neurons, have not been investigated. In this study, a small library of phosphatase inhibitors was screened for BoNT antagonism in the context of mouse embryonic stem cell-derived motor neurons (ES-MNs). Four inhibitors were found to function as BoNT/A antagonists. Subsequently, we confirmed that these inhibitors protect against BoNT/A in a dose-dependent manner in human ES-MNs. Additionally, these compounds provide protection when administered in post-intoxication scenario. Importantly, the inhibitors were also effective against BoNT serotypes B and E. To the best of our knowledge, this is the first study showing phosphatase inhibitors as broad-spectrum BoNT antagonists.
Asunto(s)
Toxinas Botulínicas/toxicidad , Células Madre Embrionarias/efectos de los fármacos , Inhibidores Enzimáticos/farmacología , Neuronas Motoras/efectos de los fármacos , Bibliotecas de Moléculas Pequeñas/farmacología , Animales , Toxinas Botulínicas/antagonistas & inhibidores , Relación Dosis-Respuesta a Droga , Evaluación Preclínica de Medicamentos , Células Madre Embrionarias/metabolismo , Humanos , Ratones , Neuronas Motoras/metabolismo , Monoéster Fosfórico Hidrolasas/antagonistas & inhibidores , Proteínas SNARE/metabolismoRESUMEN
Botulinum neurotoxins (BoNTs), the causative agents of botulism, are potent inhibitors of neurotransmitter release from motor neurons. There are currently no drugs to treat BoNT intoxication after the onset of the disease symptoms. In this study, we explored how modulation of key host pathways affects the process of BoNT intoxication in human motor neurons, focusing on Src family kinase (SFK) signaling. Motor neurons derived from human embryonic stem (hES) cells were treated with a panel of SFK inhibitors and intoxicated with BoNT serotypes A, B, or E (which are responsible for >95 % of human botulism cases). Subsequently, it was found that bosutinib, dasatinib, KX2-391, PP1, PP2, Src inhibitor-1, and SU6656 significantly antagonized all three of the serotypes. Furthermore, the data indicated that the treatment of hES-derived motor neurons with multiple SFK inhibitors increased the antagonistic effect synergistically. Mechanistically, the small molecules appear to inhibit BoNTs by targeting host pathways necessary for intoxication and not by directly inhibiting the toxins' proteolytic activity. Importantly, the identified inhibitors are all well-studied with some in clinical trials while others are FDA-approved drugs. Overall, this study emphasizes the importance of targeting host neuronal pathways, rather than the toxin's enzymatic components, to antagonize multiple BoNT serotypes in motor neurons.
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Toxinas Botulínicas/toxicidad , Neuronas Motoras/efectos de los fármacos , Neuronas Motoras/metabolismo , Transducción de Señal/efectos de los fármacos , Familia-src Quinasas/antagonistas & inhibidores , Familia-src Quinasas/metabolismo , Células Madre Embrionarias/citología , Humanos , Proteolisis/efectos de los fármacos , SerogrupoRESUMEN
Synaptosomal-associated protein-25 (SNAP-25) is a component of the soluble NSF attachment protein receptor (SNARE) complex that is essential for synaptic neurotransmitter release. Botulinum neurotoxin serotype A (BoNT/A) is a zinc metalloprotease that blocks exocytosis of neurotransmitter by cleaving the SNAP-25 component of the SNARE complex. Currently there are no licensed medicines to treat BoNT/A poisoning after internalization of the toxin by motor neurons. The development of effective therapeutic measures to counter BoNT/A intoxication has been limited, due in part to the lack of robust high-throughput assays for screening small molecule libraries. Here we describe a high content imaging (HCI) assay with utility for identification of BoNT/A inhibitors. Initial optimization efforts focused on improving the reproducibility of inter-plate results across multiple, independent experiments. Automation of immunostaining, image acquisition, and image analysis were found to increase assay consistency and minimize variability while enabling the multiparameter evaluation of experimental compounds in a murine motor neuron system.
Asunto(s)
Toxinas Botulínicas Tipo A/antagonistas & inhibidores , Proteína 25 Asociada a Sinaptosomas/análisis , Animales , Toxinas Botulínicas Tipo A/metabolismo , Células Cultivadas , Técnica del Anticuerpo Fluorescente/métodos , Ratones , Neuronas Motoras/química , Neuronas Motoras/metabolismo , Reproducibilidad de los Resultados , Proteína 25 Asociada a Sinaptosomas/metabolismoRESUMEN
Rift Valley fever is a potentially fatal disease of humans and domestic animals caused by Rift Valley fever virus (RVFV). Infection with RVFV in ruminants can cause near 100% abortion rates and recent outbreaks in naïve human populations have suggested case fatality rates of greater than thirty percent. To elucidate the roles that host proteins play during RVFV infection, proteomic analysis of RVFV virions was conducted using complementary analytical approaches, followed by functional validation studies of select identified host factors. Coupling the more traditional Gel LC/MS/MS approach (SDS PAGE followed by liquid chromatography tandem mass spectrometry) with an alternative technique that preserves protein complexes allowed the protein complement of these viral particles to be thoroughly examined. In addition to viral proteins present within the virions and virion-associated host proteins, multiple macromolecular complexes were identified. Bioinformatic analysis showed that host chaperones were among over-represented protein families associated with virions, and functional experiments using siRNA gene silencing and small molecule inhibitors identified several of these heat shock proteins, including heat shock protein 90 (HSP90), as important viral host factors. Further analysis indicated that HSP inhibition effects occur during the replication/transcription phase of the virus life cycle, leading to significant lowering of viral titers without compromising the functional capacity of released virions. Overall, these studies provide much needed further insight into interactions between RVFV and host cells, increasing our understanding of the infection process and suggesting novel strategies for anti-viral development. In particular, considering that several HSP90 inhibitors have been advancing through clinical trials for cancer treatment, these results also highlight the exciting potential of repurposing HSP90 inhibitors to treat RVF.
Asunto(s)
Proteínas HSP90 de Choque Térmico/metabolismo , Proteínas de Choque Térmico/metabolismo , Virus de la Fiebre del Valle del Rift/metabolismo , Proteínas Virales/metabolismo , Virión/metabolismo , Silenciador del Gen , Proteínas HSP90 de Choque Térmico/genética , Proteínas de Choque Térmico/genética , Proteómica , ARN Interferente Pequeño , Fiebre del Valle del Rift/virología , Virus de la Fiebre del Valle del Rift/genética , Espectrometría de Masas en Tándem , Proteínas Virales/genética , Virión/genéticaRESUMEN
OBJECTIVES: Common complications associated with dental implant surgery are well recognized and are usually explained to patients during the process of informed consent. For the general dental practitioner, the periodontist, and the oral and maxillofacial surgeon, it is relevant to also be familiar with less frequent complications. This review gathers unusual complications of this surgical procedure and presents unique complications from single case reports. METHOD AND MATERIALS: Studies were located using systematic searches in Medline and the Cochrane Library electronic databases. Key words included the terms "implant", "dental", "oral", "complication", "unusual", and "rare". References from the relevant articles were also double-checked. The review was limited to English and German language articles, published within the last 15 years. RESULTS: 17 different unusual complications were identified. The majority of studies report five different complications: permanent nerve injury, damage to teeth adjacent to the implant, excessive bleeding resulting in hematoma of the floor of the mouth, mandibular fracture, and displacement of implants into the maxillary sinus. Benign paroxysmal positional vertigo and a plunging ranula were reported sporadically. Another 10 complications were only described once in our literature search. CONCLUSION: Unusual complications are challenging. It is important for the dental practitioner to be aware of all the possible complications and to recognize them early so that adequate therapy can immediately be ensured.
Asunto(s)
Implantación Dental Endoósea/efectos adversos , Complicaciones Intraoperatorias , Complicaciones Posoperatorias , HumanosRESUMEN
Botulinum neurotoxins (BoNTs) comprise seven distinct serotypes that inhibit the release of neurotransmitter across neuromuscular junctions, resulting in potentially fatal flaccid paralysis. BoNT serotype A (BoNT/A), which targets synaptosomal-associated protein of 25kDa (SNAP-25), is particularly long-lived within neurons and requires a longer time for recovery of neuromuscular function. There are currently no treatments available to counteract BoNT/A after it has entered the neuronal cytosol. In this study, we examined the ability of small molecule non-peptidic inhibitors (SMNPIs) to prevent SNAP-25 cleavage post-intoxication of neurons. The progressive cleavage of SNAP-25 observed over 5 h following 1 h BoNT/A intoxication was prevented by addition of SMNPIs. In contrast, anti-BoNT/A neutralizing antibodies that strongly inhibited SNAP-25 cleavage when added during intoxication were completely ineffective when added post-intoxication. Although Bafilomycin A1, which blocks entry of BoNT/A into the cytosol by preventing endosomal acidification, inhibited SNAP-25 cleavage post-intoxication, the degree of inhibition was significantly reduced versus addition both during and after intoxication. Post-intoxication application of SMNPIs, on the other hand, was nearly as effective as application both during and after intoxication. Taken together, the results indicate that competitive SMNPIs of BoNT/A light chain can be effective within neurons post-intoxication.
Asunto(s)
Aconitina/análogos & derivados , Toxinas Botulínicas Tipo A/antagonistas & inhibidores , Imidazoles/farmacología , Neuronas Motoras/efectos de los fármacos , Ftalimidas/farmacología , Bibliotecas de Moléculas Pequeñas/farmacología , Aconitina/administración & dosificación , Aconitina/química , Aconitina/farmacología , Animales , Western Blotting , Técnicas de Cultivo de Célula , Células Cultivadas , Embrión de Pollo , Citosol/efectos de los fármacos , Citosol/metabolismo , Imidazoles/administración & dosificación , Imidazoles/química , Macrólidos/administración & dosificación , Macrólidos/farmacología , Estructura Molecular , Neuronas Motoras/metabolismo , Ftalimidas/administración & dosificación , Ftalimidas/química , Bibliotecas de Moléculas Pequeñas/administración & dosificación , Bibliotecas de Moléculas Pequeñas/química , Médula Espinal/citología , Médula Espinal/embriología , Médula Espinal/metabolismo , Proteína 25 Asociada a Sinaptosomas/metabolismo , Sinaptosomas/efectos de los fármacos , Sinaptosomas/metabolismoRESUMEN
Botulinum neurotoxins (BoNTs) inhibit cholinergic synaptic transmission by specifically cleaving proteins that are crucial for neurotransmitter exocytosis. Due to the lethality of these toxins, there are elevated concerns regarding their possible use as bioterrorism agents. Moreover, their widespread use for cosmetic purposes, and as medical treatments, has increased the potential risk of accidental overdosing and environmental exposure. Hence, there is an urgent need to develop novel modalities to counter BoNT intoxication. Mammalian motoneurons are the main target of BoNTs; however, due to the difficulty and poor efficiency of the procedures required to isolate the cells, they are not suitable for high-throughput drug screening assays. Here, we explored the suitability of embryonic stem (ES) cell-derived motoneurons as a renewable, reproducible, and physiologically relevant system for BoNT studies. We found that the sensitivity of ES-derived motoneurons to BoNT/A intoxication is comparable to that of primary mouse spinal motoneurons. Additionally, we demonstrated that several BoNT/A inhibitors protected SNAP-25, the BoNT/A substrate, in the ES-derived motoneuron system. Furthermore, this system is compatible with immunofluorescence-based high-throughput studies. These data suggest that ES-derived motoneurons provide a highly sensitive system that is amenable to large-scale screenings to rapidly identify and evaluate the biological efficacies of novel therapeutics.
Asunto(s)
Antitoxina Botulínica/farmacología , Toxinas Botulínicas/antagonistas & inhibidores , Descubrimiento de Drogas , Evaluación Preclínica de Medicamentos/métodos , Células Madre Embrionarias/efectos de los fármacos , Ensayos Analíticos de Alto Rendimiento/métodos , Neuronas Motoras/efectos de los fármacos , Animales , Toxinas Botulínicas/toxicidad , Diferenciación Celular/efectos de los fármacos , Células Cultivadas , Evaluación Preclínica de Medicamentos/instrumentación , Células Madre Embrionarias/citología , Células Madre Embrionarias/metabolismo , Ensayos Analíticos de Alto Rendimiento/instrumentación , Ratones , Ratones Endogámicos C57BL , Modelos Biológicos , Neuronas Motoras/citología , Neuronas Motoras/metabolismo , Proteína 25 Asociada a Sinaptosomas/metabolismoRESUMEN
A 1,7-bis(alkylamino)diazachrysene-based small molecule was previously identified as an inhibitor of the botulinum neurotoxin serotype A light chain metalloprotease. Subsequently, a variety of derivatives of this chemotype were synthesized to develop structure-activity relationships, and all are inhibitors of the BoNT/A LC. Three-dimensional analyses indicated that half of the originally discovered 1,7-DAAC structure superimposed well with 4-amino-7-chloroquinoline-based antimalarial agents. This observation led to the discovery that several of the 1,7-DAAC derivatives are potent in vitro inhibitors of Plasmodium falciparum and, in general, are more efficacious against CQ-resistant strains than against CQ-susceptible strains. In addition, by inhibiting ß-hematin formation, the most efficacious 1,7-DAAC-based antimalarials employ a mechanism of action analogous to that of 4,7-ACQ-based antimalarials and are well tolerated by normal cells. One candidate was also effective when administered orally in a rodent-based malaria model. Finally, the 1,7-DAAC-based derivatives were examined for Ebola filovirus inhibition in an assay employing Vero76 cells, and three provided promising antiviral activities and acceptably low toxicities.
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Antibacterianos/síntesis química , Antimaláricos/síntesis química , Antivirales/síntesis química , Toxinas Botulínicas Tipo A/antagonistas & inhibidores , Crisenos/síntesis química , Ebolavirus/efectos de los fármacos , Plasmodium falciparum/efectos de los fármacos , Quinolinas/síntesis química , Animales , Anopheles/parasitología , Antibacterianos/química , Antibacterianos/farmacología , Antimaláricos/química , Antimaláricos/farmacología , Antivirales/química , Antivirales/farmacología , Línea Celular , Chlorocebus aethiops , Crisenos/química , Crisenos/farmacología , Hemoproteínas/antagonistas & inhibidores , Malaria/tratamiento farmacológico , Ratones , Modelos Moleculares , Plasmodium berghei , Quinolinas/química , Quinolinas/farmacología , Ratas , Estereoisomerismo , Relación Estructura-ActividadRESUMEN
Botulinum Neurotoxins (BoNTs) are used therapeutically and in cosmetics, providing potential for bioterrorist activity, thus driving the search for small-molecule BoNT inhibitors. This report describes a 70,000-compound screen for inhibition of BoNT/A using a FRET assay to detect proteolysis of a peptide substrate. Hits were confirmed, followed by evaluation to determine compound specificity. Inhibitors fell into three main chemical classes, and on the basis of potency and specificity of inhibition, the activities of two chemotypes were examined further. Compounds exhibited specificity for BoNT/A LC inhibition with respect to other metalloproteases and displayed activity in a neuronal assay for botulinum intoxication.
RESUMEN
Botulinum neurotoxins (BoNTs) are the deadliest of microbial toxins. The enzymes' Zinc(II) metalloprotease, referred to as the light chain (LC) component, inhibits acetylcholine release into neuromuscular junctions, resulting in the disease botulism. Currently, no therapies counter BoNT poisoning post-neuronal intoxication; however, it is hypothesized that small molecules may be used to inhibit BoNT LC activity in the neuronal cytosol. Herein, we describe the pharmacophore-based design and chemical synthesis of potent (non-Zinc(II) chelating) small molecule (non-peptidic) inhibitors (SMNPIs) of the BoNT serotype A LC (the most toxic of the BoNT serotype LCs). Specifically, the three-dimensional superimpositions of 2-[4-(4-amidinephenoxy)-phenyl]-indole-6-amidine-based SMNPI regioisomers (K(i) = 0.600 µM (± 0.100 µM)), with a novel lead bis-[3-amide-5-(imidazolino)-phenyl]-terephthalamide (BAIPT)-based SMNPI (K(i) = 8.52 µM (± 0.53 µM)), resulted in a refined 4-zone pharmacophore. The refined model guided the design of BAIPT-based SMNPIs possessing K(i) values = 0.572 µM (± 0.041 µM) and 0.900 µM (± 0.078 µM).
RESUMEN
Botulism, the disease caused by botulinum neurotoxins (BoNTs), secreted by the spore-forming, anaerobic bacteria Clostridium botulinum, has been associated with food poisoning for centuries. In addition, the potency of BoNTs coupled with the current political climate has produced a threat of intentional, malicious poisoning by these toxins. The ability to detect and measure BoNTs in complex matrixes is among the highest research priorities. However, the extreme potency of these toxins necessitates that assays be capable of detecting miniscule quantities of these proteins. Thus, signal-boosting strategies must be employed. A popular approach uses the proteolytic activity of the BoNT light chain (LC) to catalyze the cleavage of synthetic substrates; reaction products are then analyzed by the analytical platform of choice. However, BoNT LCs are poor catalysts. In this study, the authors used the osmolyte trimethylamine N-oxide (TMAO) to increase the proteolytic activities of BoNT LCs. Their data suggest that concentrated solutions of TMAO induce complete folding of the LCs, resulting in increased substrate affinity and enhanced enzyme turnover. The authors observed increases in catalysis for BoNT serotypes A, B, and E, and this increased proteolytic activity translated into substantial increases in analytical assay sensitivity for these medically relevant toxins.
Asunto(s)
Toxinas Botulínicas Tipo A/metabolismo , Toxinas Botulínicas/metabolismo , Técnicas de Química Analítica/métodos , Metilaminas/farmacología , Secuencia de Aminoácidos , Toxinas Botulínicas/química , Toxinas Botulínicas/efectos de los fármacos , Toxinas Botulínicas Tipo A/química , Toxinas Botulínicas Tipo A/efectos de los fármacos , Activación Enzimática/efectos de los fármacos , Fluorescencia , Análisis de los Alimentos/métodos , Ensayos Analíticos de Alto Rendimiento , Datos de Secuencia Molecular , Concentración Osmolar , Péptido Hidrolasas/química , Péptido Hidrolasas/efectos de los fármacos , Péptido Hidrolasas/metabolismo , Pliegue de Proteína/efectos de los fármacos , Procesamiento Proteico-Postraduccional/efectos de los fármacos , Sensibilidad y Especificidad , Regulación hacia Arriba/efectos de los fármacosRESUMEN
Botulinum neurotoxins (BoNTs) are zinc-metalloproteases that cleave components of the SNARE (soluble N-ethylmaleimide-sensitive factor attachment protein receptor) protein complex, inhibiting acetylcholine release into neuromuscular junctions, resulting in flaccid paralysis and eventual death. The potential for the malicious misuse of these toxins as bioweapons has created an urgent need to develop effective therapeutic countermeasures. Robust cell-based assays will be essential for lead identification and the optimization of therapeutic candidates. In this study, the authors developed novel BoNT serotype A (BoNT/A) cleavage-sensitive (BACS) antibodies that only interact with full-length SNAP-25 (synaptosomal-associated protein of 25 kDa), the molecular target of the BoNT/A serotype. These antibodies exhibit high specificity for full-length SNAP-25, allowing the BoNT/A-mediated proteolysis of this protein to be measured in diverse assay formats, including several variations of enzyme-linked immunosorbent assay and multiple immunofluorescence methods. Assays built around the BACS antibodies displayed excellent sensitivity, had excellent reproducibility, and were amenable to multiwell formats. Importantly, these assays provided novel methods for evaluating BoNT/A activity in cellular models of intoxication and allowed for the high-throughput evaluation of experimental compounds.
Asunto(s)
Anticuerpos/inmunología , Toxinas Botulínicas Tipo A/análisis , Toxinas Botulínicas Tipo A/inmunología , Ensayos Analíticos de Alto Rendimiento/métodos , Secuencia de Aminoácidos , Animales , Afinidad de Anticuerpos/inmunología , Formación de Anticuerpos/inmunología , Especificidad de Anticuerpos/inmunología , Western Blotting , Pollos , Ensayo de Inmunoadsorción Enzimática , Técnica del Anticuerpo Fluorescente , Ensayos Analíticos de Alto Rendimiento/estadística & datos numéricos , Datos de Secuencia Molecular , Neuronas Motoras/citología , Neuronas Motoras/metabolismo , Péptidos/química , Serotipificación , Proteína 25 Asociada a Sinaptosomas/metabolismoRESUMEN
OBJECTIVES: To characterize the clinical features and insulin regulation in infants with hypoglycemia due to prolonged neonatal hyperinsulinism. STUDY DESIGN: Data were collected on 26 infants with hypoglycemia due to neonatal hyperinsulinism that later resolved. Acute insulin response (AIR) tests to calcium, leucine, glucose, and tolbutamide were performed in 11 neonates. Results were compared to children with genetic hyperinsulinism due to mutations of the adenosine triphosphate-dependent potassium (K(ATP)) channel and glutamate dehydrogenase (GDH). RESULTS: Among the 26 neonates, there were significantly more males, small-for-gestational-age infants, and cesarean deliveries. Only 5 of the 26 had no identifiable risk factor. Hyperinsulinism was diagnosed at a median age of 13 days (range, 2 to 180 days) and resolved by a median age of 181 days (range, 18 to 403 days). Diazoxide was effective in 19 of the 21 neonates treated. In the 11 neonates tested, the AIRs to calcium, leucine, glucose, and tolbutamide resembled those in normal controls and differed from genetic hyperinsulinism due to K(ATP) channel and GDH mutations. CONCLUSIONS: We define a syndrome of prolonged neonatal hyperinsulinism that is responsive to diazoxide, persists for several months, and resolves spontaneously. AIR tests suggest that both the K(ATP) channel and GDH have normal function.
Asunto(s)
Antihipertensivos/uso terapéutico , Diazóxido/uso terapéutico , Hiperinsulinismo/terapia , Hipoglucemia/terapia , Calcio/farmacología , Estudios de Casos y Controles , Nutrición Enteral , Ayuno , Femenino , Glucosa/farmacología , Humanos , Hiperinsulinismo/complicaciones , Hiperinsulinismo/diagnóstico , Hipoglucemia/etiología , Hipoglucemiantes/farmacología , Lactante , Recién Nacido , Infusiones Intravenosas , Insulina/sangre , Insulina/metabolismo , Secreción de Insulina , Leucina/farmacología , Masculino , Estudios Prospectivos , Factores de Riesgo , Edulcorantes/farmacología , Tolbutamida/farmacologíaRESUMEN
Infants with congenital hyperinsulinism often require pancreatectomy. Recessive mutations of the ATP-dependent plasma membrane potassium channel (K(ATP)) genes, SUR1 and K(ir)6.2, cause diffuse hyperinsulinism. K(ATP) channel mutations can also cause focal disease through loss of heterozygosity for maternal 11p, resulting in expression of a paternal mutation. This study evaluated whether focal vs. diffuse hyperinsulinism could be diagnosed by acute insulin response (AIR) tests and whether arterial calcium stimulation/venous sampling (ASVS) could localize focal lesions. Fifty infants with diazoxide-unresponsive hyperinsulinism were studied. Focal lesions occurred in 70% of the cases. Positive AIR calcium occurred in 17 of 30 focal and 10 of 13 diffuse cases (P < 0.04). Positive AIR tolbutamide occurred in 27 of 30 focal vs. seven of 13 diffuse cases (P < 0.02); K(ATP) channel mutations were identified in four of the latter. ASVS localized the lesion in 24 of 33 focal cases (73%) but correctly diagnosed diffuse disease in only four of 13 cases. These results indicate that preoperative AIR tests do not distinguish focal vs. diffuse disease because some K(ATP) channel mutations retain responsiveness to tolbutamide. The ASVS test can be used to localize focal lesions in infants. The combination of ASVS, careful intraoperative histologic analysis, and surgical expertise succeeded in correcting hypoglycemia in 86% of the infants with focal hyperinsulinism.