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Zocor

By X. Lester. Flagler College. 2018.

At its functional end 40mg zocor sale, lipoate contains a disulfide group that accidental or intentional arsenic poisoning accepts electrons when it binds the acyl fragment of -ketoglutarate cheap zocor 10 mg mastercard. It can thus act requires high doses and involves arsenate like a long flexible -CH2- arm of the enzyme that reaches over to the decarboxylase (AsO 2 ) and arsenite (AsO2 ) order 40mg zocor with amex. Arsenite purchase zocor 20mg otc, to pick up the acyl fragment from thiamine and transfer it to the active site contain- 4 which is 10 times more toxic than arsenate, ing bound CoASH. It then swings over to dihydrolipoyl dehydrogenase to transfer binds to neighboring sulfhydryl groups, electrons from the lipoyl sulfhydryl groups to FAD. FAD AND DIHYDROLIPOYL DEHYDROGENASE keto acid dehydrogenase complexes and in succinic dehydrogenase. Arsenate weakly FAD on dihydrolipoyl dehydrogenase accepts electrons from the lipoyl sulfhydryl inhibits enzymatic reactions involving phos- groups and transfers them to bound NAD. FAD thus accepts and transfers elec- phate, including the enzyme glyceraldehyde trons without leaving its binding site on the enzyme. The direction of the reaction 3-P dehydrogenase in glycolysis (see Chap- is favored by interactions of FAD with groups on the enzyme, which change its ter 22). Thus both aerobic and anaerobic ATP reduction potential and by the overall release of energy from cleavage and oxida- production can be inhibited. ENERGETICS OF THE TCA CYCLE rather than direct toxicity. Like all metabolic pathways, the TCA cycle operates with an overall net negative G0 (Fig 20. The conversion of substrates to products is, therefore, energeti- O cally favorable. However, some of the reactions, such as the malate dehydrogenase CH2 CH2 CH2 C reaction, have a positive value. CH2 CH CH2 CH2 N lysine– H transacylase S S enzyme Lipoamide Acetyl CoA (oxidized) CoA Oxaloacetate TPP–intermediate + –7. Lipoate is Succinate CO Succinyl 2 attached to the -amino group on the lysine CoA side chain of the tranacylase enzyme (E2). The GTP Pi GDP oxidized lipoate disulfide form is reduced as it accepts the acyl group from thiamine Fig. Approximate G0 values for the reactions in the TCA cycle, given for the for- pyrophosphate (TPP) attached to E. The reactions with large negative G0 values are shown in blue. The stan- 1 example shown is for the -ketoglutarate dard free energy ( G0 ) refers to the free energy change for conversion of 1 mole of substrate dehydrogenase complex. Energy Yield of the TCA Cycle The reactions of the TCA cycle are extremely efficient in converting energy in the kcal/mole chemical bonds of the acetyl group to other forms. The total amount of energy avail- 3 NADH: 3 53 159 able from the acetyl group is about 228 kcal/mole (the amount of energy that could 1 FAD(2H) 41 be released from complete combustion of 1 mole of acetyl groups to CO in a bomb 1 GTP 7 2 Sum 207 calorimeter). The products of the TCA cycle (NADH, FAD(2H), and GTP) contain about 207 kcal (Table 20. Thus, the TCA cycle reactions are able to conserve Chapter 19 explains the values given for energy yield from NADH and FAD(2H). Thermodynamically and Kinetically Reversible and The net standard free energy change for the TCA cycle, G0 , can Irreversible reactions be calculated from the sum of the 0 0 Three reactions in the TCA cycle have large negative values for G that strongly G values for the individual reactions. The favor the forward direction: the reactions catalyzed by citrate synthase, isocitrate G0 , 13 kcal, is the amount of energy lost dehydrogenase, and -ketoglutarate dehydrogenase (see Fig. It can be considered the amount of cycle, these reactions are physiologically irreversible for two reasons: the products energy spent to ensure that oxidation of the do not rise to high enough concentrations under physiological conditions to over- acetyl group to CO2 goes to completion. This come the large negative G0 values, and the enzymes involved catalyze the reverse value is surprisingly small. However, oxida- tion of NADH and FAD(2H) in the electron reaction very slowly. These reactions make the major contribution to the overall neg- 0 transport chain helps to make acetyl oxida- ative G for the TCA cycle, and keep it going in the forward direction.

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It is not possible at present to replace a defective Receptor Coreceptor gene with a normal gene at its usual location in the genome of the appropriate cells buy discount zocor 20mg online. Cell membrane However order zocor 40 mg on-line, as long as the gene is expressed at the appropriate time and produces ade- quate amounts of the protein to return the person to a normal state cheap zocor 10 mg otc, the gene does not have to integrate into the precise place in the genome zocor 10 mg lowest price. Sometimes the gene does Endosome not even have to be in the cells that normally contain it. Retroviruses were the first vectors used to introduce genes into human cells. Normally, retroviruses enter target cells, their RNA genome is copied by reverse Therapeutic transcriptase, and the double-stranded DNA copy is integrated into the host cell protein genome (see Fig. This process works only when the human host cells are undergo- ing division, so it has limited applicability. Other problems with this technique are RNA/DNA that it can only be used with small genes ( 8 kb), and it may disrupt other genes because the insertion point is random, thereby possibly resulting in cancer. RNase H Nuclear A defect in the adenosine deaminase (ADA) gene causes severe combined membrane immunodeficiency syndrome (SCID). When ADA is defective, deoxyadenosine DNA and dATP accumulate in rapidly dividing cells, such as lymphocytes, and prove mRNA toxic to these cells. Cells of the immune system cannot proliferate at a normal rate, and Host-cell Therapeutic children with SCID usually die at an early age because they cannot combat infections. To genome gene survive, they must be confined to a sterile, environmental “bubble. Use of retroviruses for gene ther- In 1990, a 4-year-old girl, for whom no donor was available, was treated with infu- apy. The retrovirus carries an RNA copy of the sions of her own lymphocytes that had been treated with a retrovirus containing a nor- therapeutic gene into the cell. Although she had not responded to previous therapy, she improved sig- that contains the virus dissolves, and the RNA nificantly after this attempt at gene therapy. This disease is still being treated with gene and viral reverse transcriptase are released. This enzyme copies the RNA, making a dou- ble-stranded DNA that integrates into the host In familial hypercholesterolemia, a condition associated with a high incidence cell genome. Transcription and translation of of heart attacks, the low-density lipoprotein (LDL) receptor is deficient. After ply because its genes were removed and these dividing cells were infected with a retrovirus containing the gene for the LDL recep- replaced by the RNA copy of the therapeutic tor, they were reinfused into the hepatic portal vein of the patient. CHAPTER 17 / USE OF RECOMBINANT DNA TECHNIQUES IN MEDICINE 313 Adenoviruses, which are natural human pathogens, can also be used as vectors. Adenoviral vectors have been used As in retroviral gene therapy, the normal viral genes required for synthesis of viral in a aerosal spray to deliver normal particles are replaced with the therapeutic genes. The advantages to using an aden- copies of the CFTR (cystic fibrosis transmembrane conductance regulator) ovirus are that the introduced gene can be quite large (~36 kb), and infection does gene to cells of the lung. Some cells took up not require division of host cells. The disadvantage is that genes carried by the ade- this gene, and the patients experienced novirus do not stably integrate into the host genome, resulting in only transient moderate improvement. However, stable expression of the therapeutic proteins (but preventing disruption of host genes). Another problem with adenovi- not occur, and cells affected by the disease ral gene therapy is that the host can mount an immune response to the pathogenic other than those in the lung (e. Nevertheless, this To avoid the problems associated with viral vectors, researchers are employing approach marked a significant forward step treatment with DNA alone or with DNA coated with a layer of lipid (i. Adding a ligand for a receptor located on the target cells could aid delivery of the liposomes to the appropriate host cells. Many problems still plague the field In an attempt to treat ornithine transcarbamoylase deficiency (a of gene therapy. In many instances, the therapeutic genes must be targeted to the disorder of nitrogen metabolism) cells where they normally function—a difficult task at present. Deficiencies in dom- using adenoviral vectors, a volunteer died of inant genes are more difficult to treat than those in recessive genes, and the expres- a severe immune response to the vector.

While doing periosteal elevation over the sacrum and L5 buy discount zocor 40 mg line, care should be taken to avoid opening the sacroiliac joints or violating the pos- terior sacroiliac ligaments order zocor 10 mg overnight delivery, as these will have significant bleeding cheap zocor 10 mg on line. Identify the crest of the posterosuperior iliac spine and then make a longitudinal incision down the midline of the crest to the inferior as- pect of the posterosuperior iliac spine (Figure S2 buy zocor 10mg with mastercard. Subperiosteally strip the lateral aspect of the ilium anterior and inferior. Use a packing sponge; dissect inferior toward the sciatic notch and the posterosuperior iliac spine. Clean the inferior two-thirds of the posterosuperior iliac spine so its medial and lateral border and caudal edge are visible clearly. Insert the drill guide hook into the sciatic notch and align the drill insertion point at the inferior aspect of the posterosuperior iliac spine. Before drilling, make sure that the drill guide is held into the apex of the sciatic notch with its lateral border being flat against the ilium. Also, before drilling, mark the drill bit so that it will protrude 1 to 2 cm past the distal end of the drill guide (Figure S2. Drill the hole into the pelvis to, or just past, the mark on the drill bit. Always be careful to stabilize the drill guide in the proper position (Figure S2. Using a wire or a thin probe, document that the drillhole is entirely within bone. Repeat the same procedure on the iliac crest on the opposite side. Pack Gelfoam into the drillholes to prevent bone bleeding. Pack the lateral side of the iliac crest with a sponge to prevent bleed- ing. These sponges have to be inserted completely over the edge of the iliac crest or they will become entangled in the rod or wires. These sponges will be removed just before wound closure. Remove the sponge packs from the prior exposure of the spine, and clean each vertebra so that all the soft tissue is removed from the tips 2. In the thoracic spine, cut vertically approximately 1 cm distal to the superior aspect of the lamina. By proper removal of the spinous processes, the spinal interspace is opened. It is important never to violate the superior bor- der of the posterior elements, as this is where the strength for wire fixation occurs. In the lumbar spine, the spinous processes should be transected transversely at their base (Figure S2. In the lumbar area, the spinous process is cut horizonally; then at the thora- columbar junction they are cut at 45°, and in the thoracic area the process are cut off vertically (Figure S2. Use a rongeur with a serrated end to remove the ligamentum flavum (Figure S2. If more bone removal is indicated, remove the bone from the inferior aspect of the spinous process base and lamina only. Never remove bone from the superior aspect of the lamina be- cause this is the aspect of the lamina that provides strength for the wire (Figure S2. Complete the spinal interspace opening with a curette, making sure that the ligamentum flavum is cut a sufficient distance on either side so wire can be passed (Figure S2. If epidural bleeding occurs during this time, the interspace should be packed gently with Gelfoam and a neural sponge. There may be substantial bleeding from these epidural veins; however, it is almost impossible to cau- terize them without an extremely large exposure that destroys the lamina.

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Woofter and Manyam (87) reported on a 74-year-old man with PD who was treated with LD and whose malignant melanoma was later discovered buy cheap zocor 20 mg online. Prior to the diagnosis of melanoma order 40mg zocor, it was estimated that the patient received 5 order 20mg zocor fast delivery. The patient continued with LD treatment for more than 10 years cheap zocor 10mg fast delivery, with an additional 4. They concluded that withholding LD therapy for fear of accelerating melanoma was unwarranted (87). Thus, despite the continued warning appearing in the prescribing literature for LD, there appears to be no causal relationship between LD therapy in PD and the occurrence of malignant melanoma. A history of melanoma in a PD patient should not prohibit the use of LD. LEVODOPA CHALLENGE TEST It can be difficult to accurately differentiate PD from other forms of parkinsonism, especially during early presentation. LD administration can be used for diagnostic purposes as PD patients respond more frequently and robustly to LD compared with other forms of parkinsonism. Clarke and Davies recently published a review of 13 studies that examined whether an acute LD or apomorphine challenge test could aid in Copyright 2003 by Marcel Dekker, Inc. Four studies examined de novo patients and nine examined patients with clinically established idiopathic PD. Although there was significant variability in the methodologies employed, abstracted sensitivity and specificity data were summarized from the studies and the two challenge tests compared as to their ability to accurately predict patients’ diagnosis. The sensitivity for the diagnosis of established PD for apomorphine was 0. The specificity for the diagnosis of established PD was apomorphine 0. The number of patients positive for each test divided by the number with clinically diagnosed de novo disease was apomorphine 0. Twenty-one chronic LD patients described as having positive response were initially negative via acute LD. The authors concluded that the accuracy of the acute levodopa and apomorphine tests was similar but not superior than that of chronic levodopa therapy and that these were not more accurate than the established accuracy of clinical diagnosis of PD (75–80% accuracy). In addition, given the additional costs and adverse effects associated with their use, they could not recommend using the challenge tests. Motor responses to the acute administration of LD and apomorphine were analyzed in a series of 134 parkinsonian patients (83 with a clinical diagnosis of idiopathic PD, 28 patients with multiple system atrophy, 6 with progressive supranuclear palsy and 17 unclassified patients). The duration of disease or the clinical stage of the patients was not described. Patients received LD/AADI (250/25 mg) or subcutaneous apomorphine (1. UPDRS motor scores were evaluated 1 hour following LD administration and 20 minutes after apomorphine injection. The motor evaluation was matched with the clinical diagnosis and the response to chronic LD therapy. Those patients who had improvement of at least 16% on their UPDRS were more likely to have PD when compared to non-PD patients. When comparing PD with MSA patients, those who improved at least 18% on their UPDRS were more likely to have PD rather than MSA. If a patient responded to the challenge test with at least 14. The authors conclude that use of the challenge test was helpful in making treatment decisions regarding long- term LD therapy (91). It appears that an acute LD test is not very useful in Copyright 2003 by Marcel Dekker, Inc. Questions remain about its use in making treatment decisions. ACKNOWLEDGMENTS This work was supported by the Riley Family Chair of Parkinson’s Disease (SAF), The Phyllis Dake Neurosciences Fellowship (AJS), and the Albany Medical College Parkinson’s Research Fund. Parkinson’s disease: initial treatment with levodopa or dopamine agonists. Report of a Survey by the Matheson Commission, New York, Columbia University Press, 1939.

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Even in normal individuals buy zocor 20mg line, somatic mutations result in of genetic defects of the proteins in respira- a decline of oxidative phosphorylation capacity with age (accumulation of somatic tory chain complexes have buy zocor 20mg fast delivery, therefore buy cheap zocor 20mg online, been classified together as “congenital lactic mutations with age) zocor 40mg online. At some stage, the ATP-generating capacity of a tissue falls acidosis. In general, symptoms of these defects would appear in one or more of the tissues with A patient experienced sponta- the highest ATP demands: nervous tissue, heart, skeletal muscle, and kidney. Other Genetic Disorders of Oxidative Phosphorylation progressed over 10 years to include debili- tating myoclonus, neurosensory hearing Genetic mutations also have been reported for mitochondrial proteins encoded by loss, dementia, hypoventilation, and mild nuclear DNA. Most of the estimated 1,000 proteins required for oxidative phospho- cardiomyopathy. Energy metabolism was rylation are encoded by nuclear DNA, whereas mtDNA encodes only 13 subunits of affected in the central nervous system, the oxidative phosphorylation complexes (including ATP synthase). Nuclear DNA heart, and skeletal muscle, resulting in lactic encodes the additional 70 or more subunits of the oxidative phosphorylation com- acidosis. A history indicated that the plexes, as well as adenine nucleotide translocase (ANT) and other anion transloca- patient’s mother, her grandmother, and two tors. Coordinate regulation of expression of nuclear and mtDNA, import of proteins maternal aunts had symptoms involving into the mitochondria, assembly of the complexes, and regulation of mitochondrial either nervous or muscular tissue (clearly a fission are nuclear encoded. However, no Nuclear DNA mutations differ from mtDNA mutations in several important other relative had identical symptoms. The symptoms and history of the patient are respects. These mutations do not show a pattern of maternal inheritance but are usu- those of myoclonic epileptic ragged red fiber ally autosomal recessive. The mutations are uniformly distributed to daughter cells disease (MERRF). The affected tissues (cen- and therefore are expressed in all tissues containing the allele for a particular tissue- tral nervous system and muscle) are two of specific isoform. However, phenotypic expression still will be most apparent in tis- the tissues with the highest ATP require- sues with high ATP requirements. Most cases of MERRF are caused by a point mutation in mitochondrial tRNAlys (mtRNAlys). COUPLING OF ELECTRON TRANSPORT AND muscle biopsy, are enlarged and show ATP SYNTHESIS abnormal patterns of cristae. The electrochemical gradient couples the rate of the electron transport chain to the rate of ATP synthesis. Because electron flow requires proton pumping, electron flow cannot occur faster than protons are used for ATP synthesis (coupled oxidative How does shivering generate heat? The nuclear respiratory factors (NRF-1 and NRF-2) are nuclear transcription fac- tors that bind to and activate promotor regions of the nuclear genes encoding subunits of the respiratory chain complexes, including cytochrome c. They also activate the transcription of the nuclear gene for the mitochondrial transcription factor (mTF)-A. The protein product of this gene translocates into the mitochondrial matrix, where it stimulates transcription and replication of the mitochondrial genome. CHAPTER 21 / OXIDATIVE PHOSPHORYLATION AND MITOCHONDRIAL FUNCTION 391 A. Regulation through Coupling Shivering results from muscular contraction, which increases the As ATP chemical bond energy is used by energy-requiring reactions, ADP and Pi rate of ATP hydrolysis. The more ADP present to bind to the ATP synthase, the quence of proton entry for ATP synthesis, greater will be proton flow through the ATP synthase pore, from the intermembrane the electron transport chain is stimulated. Thus, as ADP levels rise, proton influx increases, and the elec- Oxygen consumption increases, as does the trochemical gradient decreases (Fig 21. The proton pumps of the electron trans- amount of energy lost as heat by the elec- port chain respond with increased proton pumping and electron flow to maintain the tron transport chain. The increased oxidation of NADH in the electron transport chain and the increased concentration of ADP stimulate the pathways of fuel oxidation, such as the TCA cycle, to supply more NADH and FAD(2H) to the electron transport chain. For example, during NADH – exercise, we use more ATP for muscle contraction, consume more oxygen, oxidize e 5 more fuel (which means burn more calories), and generate more heat from the elec- NAD+ tron transport chain. If we rest, and the rate of ATP utilization decreases, proton H+ influx decreases, the electrochemical gradient increases, and proton “back- O2 3 pressure” decreases the rate of the electron transport chain. NADH and FAD(2H) 4 H2O cannot be oxidized as rapidly in the electron transport chain, and consequently, their build-up inhibits the enzymes that generate them.

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