Cell cycle-dependent Cdc25C phosphatase determines cell survival by regulating apoptosis signal-regulating kinase 1

Cdc25C (cell division cycle 25C) phosphatase triggers entry into mitosis in the cell cycle by dephosphorylating cyclin B-Cdk1. Cdc25C exhibits basal phosphatase activity during interphase and then becomes activated at the G₂/M transition after hyperphosphorylation on multiple sites and dissociation from 14-3-3. Although the role of Cdc25C in mitosis has been extensively studied, its function in interphase remains elusive. Here, we show that during interphase Cdc25C suppresses apoptosis signal-regulating kinase 1 (ASK1), a member of mitogen-activated protein (MAP) kinase kinase kinase family that mediates apoptosis. Cdc25C phosphatase dephosphorylates phospho-Thr-838 in the activation loop of ASK1 in vitro and in interphase cells. In addition, knockdown of Cdc25C increases the activity of ASK1 and ASK1 downstream targets in interphase cells, and overexpression of Cdc25C inhibits ASK1-mediated apoptosis, suggesting that Cdc25C binds to and negatively regulates ASK1. Furthermore, we showed that ASK1 kinase activity correlated with Cdc25C activation during mitotic arrest and enhanced ASK1 activity in the presence of activated Cdc25C resulted from the weak association between ASK1 and Cdc25C. In cells synchronized in mitosis following nocodazole treatment, phosphorylation of Thr-838 in the activation loop of ASK1 increased. Compared with hypophosphorylated Cdc25C, which exhibited basal phosphatase activity in interphase, hyperphosphorylated Cdc25C exhibited enhanced phosphatase activity during mitotic arrest, but had significantly reduced affinity to ASK1, suggesting that enhanced ASK1 activity in mitosis was due to reduced binding of hyperphosphorylated Cdc25C to ASK1. These findings suggest that Cdc25C negatively regulates proapoptotic ASK1 in a cell cycle-dependent manner and may play a role in G₂/M checkpoint-mediated apoptosis.Cell division cycle 25 (Cdc25) phosphatases are dual-specificity phosphatases involved in cell cycle regulation. By removing inhibitory phosphate groups from phospho-Thr and phospho-Tyr residues of cyclin-dependent kinases (CDKs),¹ Cdc25 proteins regulate cell cycle progression in S phase and mitosis. In mammals, three isoforms of Cdc25 phosphatases have been reported: Cdc25A, which controls the G₁/S transition;^{2, 3} Cdc25B, which is a mitotic starter;⁴ and Cdc25C, which controls the G₂/M phase.⁵ Overexpression of Cdc25 phosphatases is frequently associated with various cancers.⁶ Upon exposure to DNA-damaging reagents like UV radiation or free oxygen radicals, Cdc25 phosphatases are key targets of the checkpoint machinery, resulting in cell cycle arrest and apoptosis. The 14-3-3 proteins bind to phosphorylated Ser-216 of Cdc25C and induce Cdc25C export from the nucleus during interphase in response to DNA damage,^{7, 8} but they have no apparent effect on Cdc25C phosphatase activity.^{9, 10} In addition, hyperphosphorylation of Cdc25C correlates to its enhanced phosphatase activity.¹¹ Most studies with Cdc25C have focused on its role in mitotic progression. However, the role of Cdc25C is not clear when it is sequestered in the cytoplasm by binding to 14-3-3.Apoptosis signal-regulating kinase 1 (ASK1), also known as mitogen-activated protein kinase kinase kinase 5 (MAPKKK5), is a ubiquitously expressed enzyme with a molecular weight of 170 kDa. The kinase activity of ASK1 is stimulated by various cellular stresses, such as H₂O₂,^{12, 13} tumor necrosis factor-α (TNF-α),¹⁴ Fas ligand,¹⁵ serum withdrawal,¹³ and ER stress.¹⁶ Stimulated ASK1 phosphorylates and activates downstream MAP kinase kinases (MKKs) involved in c-Jun N-terminal kinase (JNK) and p38 pathways.^{17, 18, 19} Phosphorylation and activation of ASK1 can induce apoptosis, differentiation, or other cellular responses, depending on the cell type. ASK1 is regulated either positively or negatively depending on its binding proteins.^{12, 13, 15, 18, 19, 20, 21, 22, 23, 24, 25}ASK1 is regulated by phosphorylation at several Ser/Thr/Tyr residues. Phosphorylation at Thr-838 leads to activation of ASK1, whereas phosphorylation at Ser-83, Ser-967, or Ser-1034 inactivates ASK1.^{24, 26, 27, 28} ASK1 is basally phosphorylated at Ser-967 by an unidentified kinase, and 14-3-3 binds to this site to inhibit ASK1.²⁴ Phosphorylation at Ser-83 is known to be catalyzed by Akt or PIM1.^{27, 29} Oligomerization-dependent autophosphorylation at Thr-838, which is located in the activation loop of the kinase domain, is essential for ASK1 activation.^{14, 18, 30} Phosphorylation at Tyr-718 by JAK2 induces ASK1 degradation.³¹ Several phosphatases that dephosphorylate some of these sites have been identified. Serine/threonine protein phosphatase type 5 (PP5) and PP2C dephosphorylate phosphorylated (p)-Thr-838,^{28, 32} whereas PP2A and SHP2 dephosphorylate p-Ser-967 and p-Tyr-718, respectively.^{31, 33} Little is known about the kinase or phosphatase that regulates phosphorylation at Ser-1034. Although ASK1 phosphorylation is known to be involved in the regulation of apoptosis, only a few reports show that ASK1 phosphorylation or activity is dependent on the cell cycle.^{21, 34}In this study, we examined the functional relationship between Cdc25C and ASK1 and identified a novel function of Cdc25C phosphatase that can dephosphorylate and inhibit ASK1 in interphase but not in mitosis. Furthermore, we demonstrated that Cdc25C phosphorylation status plays a critical role in the interaction with and the activity of ASK1. These results reveal a novel regulatory function of Cdc25C in the ASK1-mediated apoptosis signaling pathway.     

Effect of ambient air pollution on the incidence of appendicitis

Background

The pathogenesis of appendicitis is unclear. We evaluated whether exposure to air pollution was associated with an increased incidence of appendicitis.

Methods

We identified 5191 adults who had been admitted to hospital with appendicitis between Apr. 1, 1999, and Dec. 31, 2006. The air pollutants studied were ozone, nitrogen dioxide, sulfur dioxide, carbon monoxide, and suspended particulate matter of less than 10 μ and less than 2.5 μ in diameter. We estimated the odds of appendicitis relative to short-term increases in concentrations of selected pollutants, alone and in combination, after controlling for temperature and relative humidity as well as the effects of age, sex and season.

Results

An increase in the interquartile range of the 5-day average of ozone was associated with appendicitis (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.03–1.25). In summer (July–August), the effects were most pronounced for ozone (OR 1.32, 95% CI 1.10–1.57), sulfur dioxide (OR 1.30, 95% CI 1.03–1.63), nitrogen dioxide (OR 1.76, 95% CI 1.20–2.58), carbon monoxide (OR 1.35, 95% CI 1.01–1.80) and particulate matter less than 10 μ in diameter (OR 1.20, 95% CI 1.05–1.38). We observed a significant effect of the air pollutants in the summer months among men but not among women (e.g., OR for increase in the 5-day average of nitrogen dioxide 2.05, 95% CI 1.21–3.47, among men and 1.48, 95% CI 0.85–2.59, among women). The double-pollutant model of exposure to ozone and nitrogen dioxide in the summer months was associated with attenuation of the effects of ozone (OR 1.22, 95% CI 1.01–1.48) and nitrogen dioxide (OR 1.48, 95% CI 0.97–2.24).

Interpretation

Our findings suggest that some cases of appendicitis may be triggered by short-term exposure to air pollution. If these findings are confirmed, measures to improve air quality may help to decrease rates of appendicitis.Appendicitis was introduced into the medical vernacular in 1886.¹ Since then, the prevailing theory of its pathogenesis implicated an obstruction of the appendiceal orifice by a fecalith or lymphoid hyperplasia.² However, this notion does not completely account for variations in incidence observed by age,^3,4 sex,^3,4 ethnic background,^3,4 family history,⁵ temporal–spatial clustering⁶ and seasonality,^3,4 nor does it completely explain the trends in incidence of appendicitis in developed and developing nations.^3,7,8The incidence of appendicitis increased dramatically in industrialized nations in the 19th century and in the early part of the 20th century.¹ Without explanation, it decreased in the middle and latter part of the 20th century.³ The decrease coincided with legislation to improve air quality. For example, after the United States Clean Air Act was passed in 1970,⁹ the incidence of appendicitis decreased by 14.6% from 1970 to 1984.³ Likewise, a 36% drop in incidence was reported in the United Kingdom between 1975 and 1994¹⁰ after legislation was passed in 1956 and 1968 to improve air quality and in the 1970s to control industrial sources of air pollution. Furthermore, appendicitis is less common in developing nations; however, as these countries become more industrialized, the incidence of appendicitis has been increasing.⁷Air pollution is known to be a risk factor for multiple conditions, to exacerbate disease states and to increase all-cause mortality.¹¹ It has a direct effect on pulmonary diseases such as asthma¹¹ and on nonpulmonary diseases including myocardial infarction, stroke and cancer.^11–13 Inflammation induced by exposure to air pollution contributes to some adverse health effects.^14–17 Similar to the effects of air pollution, a proinflammatory response has been associated with appendicitis.^18–20We conducted a case–crossover study involving a population-based cohort of patients admitted to hospital with appendicitis to determine whether short-term increases in concentrations of selected air pollutants were associated with hospital admission because of appendicitis.     

Gut microbiota of healthy Canadian infants: profiles by mode of delivery and infant diet at 4 months

Background:

The gut microbiota is essential to human health throughout life, yet the acquisition and development of this microbial community during infancy remains poorly understood. Meanwhile, there is increasing concern over rising rates of cesarean delivery and insufficient exclusive breastfeeding of infants in developed countries. In this article, we characterize the gut microbiota of healthy Canadian infants and describe the influence of cesarean delivery and formula feeding.

Methods:

We included a subset of 24 term infants from the Canadian Healthy Infant Longitudinal Development (CHILD) birth cohort. Mode of delivery was obtained from medical records, and mothers were asked to report on infant diet and medication use. Fecal samples were collected at 4 months of age, and we characterized the microbiota composition using high-throughput DNA sequencing.

Results:

We observed high variability in the profiles of fecal microbiota among the infants. The profiles were generally dominated by Actinobacteria (mainly the genus Bifidobacterium) and Firmicutes (with diverse representation from numerous genera). Compared with breastfed infants, formula-fed infants had increased richness of species, with overrepresentation of Clostridium difficile. Escherichia–Shigella and Bacteroides species were underrepresented in infants born by cesarean delivery. Infants born by elective cesarean delivery had particularly low bacterial richness and diversity.

Interpretation:

These findings advance our understanding of the gut microbiota in healthy infants. They also provide new evidence for the effects of delivery mode and infant diet as determinants of this essential microbial community in early life.The human body harbours trillions of microbes, known collectively as the “human microbiome.” By far the highest density of commensal bacteria is found in the digestive tract, where resident microbes outnumber host cells by at least 10 to 1. Gut bacteria play a fundamental role in human health by promoting intestinal homeostasis, stimulating development of the immune system, providing protection against pathogens, and contributing to the processing of nutrients and harvesting of energy.^1,2 The disruption of the gut microbiota has been linked to an increasing number of diseases, including inflammatory bowel disease, necrotizing enterocolitis, diabetes, obesity, cancer, allergies and asthma.¹ Despite this evidence and a growing appreciation for the integral role of the gut microbiota in lifelong health, relatively little is known about the acquisition and development of this complex microbial community during infancy.³Two of the best-studied determinants of the gut microbiota during infancy are mode of delivery and exposure to breast milk.^4,5 Cesarean delivery perturbs normal colonization of the infant gut by preventing exposure to maternal microbes, whereas breastfeeding promotes a “healthy” gut microbiota by providing selective metabolic substrates for beneficial bacteria.^3,5 Despite recommendations from the World Health Organization,⁶ the rate of cesarean delivery has continued to rise in developed countries and rates of breastfeeding decrease substantially within the first few months of life.^7,8 In Canada, more than 1 in 4 newborns are born by cesarean delivery, and less than 15% of infants are exclusively breastfed for the recommended duration of 6 months.^9,10 In some parts of the world, elective cesarean deliveries are performed by maternal request, often because of apprehension about pain during childbirth, and sometimes for patient–physician convenience.¹¹The potential long-term consequences of decisions regarding mode of delivery and infant diet are not to be underestimated. Infants born by cesarean delivery are at increased risk of asthma, obesity and type 1 diabetes,¹² whereas breastfeeding is variably protective against these and other disorders.¹³ These long-term health consequences may be partially attributable to disruption of the gut microbiota.^12,14Historically, the gut microbiota has been studied with the use of culture-based methodologies to examine individual organisms. However, up to 80% of intestinal microbes cannot be grown in culture.^3,15 New technology using culture-independent DNA sequencing enables comprehensive detection of intestinal microbes and permits simultaneous characterization of entire microbial communities. Multinational consortia have been established to characterize the “normal” adult microbiome using these exciting new methods;¹⁶ however, these methods have been underused in infant studies. Because early colonization may have long-lasting effects on health, infant studies are vital.^3,4 Among the few studies of infant gut microbiota using DNA sequencing, most were conducted in restricted populations, such as infants delivered vaginally,¹⁷ infants born by cesarean delivery who were formula-fed¹⁸ or preterm infants with necrotizing enterocolitis.¹⁹Thus, the gut microbiota is essential to human health, yet the acquisition and development of this microbial community during infancy remains poorly understood.³ In the current study, we address this gap in knowledge using new sequencing technology and detailed exposure assessments²⁰ of healthy Canadian infants selected from a national birth cohort to provide representative, comprehensive profiles of gut microbiota according to mode of delivery and infant diet.     

Effectiveness of interventions designed to reduce the use of imaging for low-back pain: a systematic review

Background:Rates of imaging for low-back pain are high and are associated with increased health care costs and radiation exposure as well as potentially poorer patient outcomes. We conducted a systematic review to investigate the effectiveness of interventions aimed at reducing the use of imaging for low-back pain.Methods:We searched MEDLINE, Embase, CINAHL and the Cochrane Central Register of Controlled Trials from the earliest records to June 23, 2014. We included randomized controlled trials, controlled clinical trials and interrupted time series studies that assessed interventions designed to reduce the use of imaging in any clinical setting, including primary, emergency and specialist care. Two independent reviewers extracted data and assessed risk of bias. We used raw data on imaging rates to calculate summary statistics. Study heterogeneity prevented meta-analysis.Results:A total of 8500 records were identified through the literature search. Of the 54 potentially eligible studies reviewed in full, 7 were included in our review. Clinical decision support involving a modified referral form in a hospital setting reduced imaging by 36.8% (95% confidence interval [CI] 33.2% to 40.5%). Targeted reminders to primary care physicians of appropriate indications for imaging reduced referrals for imaging by 22.5% (95% CI 8.4% to 36.8%). Interventions that used practitioner audits and feedback, practitioner education or guideline dissemination did not significantly reduce imaging rates. Lack of power within some of the included studies resulted in lack of statistical significance despite potentially clinically important effects.Interpretation:Clinical decision support in a hospital setting and targeted reminders to primary care doctors were effective interventions in reducing the use of imaging for low-back pain. These are potentially low-cost interventions that would substantially decrease medical expenditures associated with the management of low-back pain.Current evidence-based clinical practice guidelines recommend against the routine use of imaging in patients presenting with low-back pain.^1–3 Despite this, imaging rates remain high,^4,5 which indicates poor concordance with these guidelines.^6,7Unnecessary imaging for low-back pain has been associated with poorer patient outcomes, increased radiation exposure and higher health care costs.⁸ No short- or long-term clinical benefits have been shown with routine imaging of the low back, and the diagnostic value of incidental imaging findings remains uncertain.^9–12 A 2008 systematic review found that imaging accounted for 7% of direct costs associated with low-back pain, which in 1998 translated to more than US$6 billion in the United States and £114 million in the United Kingdom.¹³ Current costs are likely to be substantially higher, with an estimated 65% increase in spine-related expenditures between 1997 and 2005.¹⁴Various interventions have been tried for reducing imaging rates among people with low-back pain. These include strategies targeted at the practitioner such as guideline dissemination,^15–17 education workshops,^18,19 audit and feedback of imaging use,^7,20,21 ongoing reminders⁷ and clinical decision support.^22–24 It is unclear which, if any, of these strategies are effective.²⁵ We conducted a systematic review to investigate the effectiveness of interventions designed to reduce imaging rates for the management of low-back pain.     

Inactivation and Disassembly of the Anaphase-Promoting Complex during Human Cytomegalovirus Infection Is Associated with Degradation of the APC5 and APC4 Subunits and Does Not Require UL97-Mediated Phosphorylation of Cdh1

Infection of quiescent cells by human cytomegalovirus (HCMV) elicits severe cell cycle deregulation, resulting in a G₁/S arrest, which can be partly attributed to the inactivation of the anaphase-promoting complex (APC). As we previously reported, the premature phosphorylation of its coactivator Cdh1 and/or the dissociation of the core complex can account for the inactivation. We have expanded on these results and further delineated the key components required for disabling the APC during HCMV infection. The viral protein kinase UL97 was hypothesized to phosphorylate Cdh1, and consistent with this, phosphatase assays utilizing a virus with a UL97 deletion mutation (ΔUL97 virus) indicated that Cdh1 is hypophosphorylated at early times in the infection. Mass spectrometry analysis demonstrated that UL97 can phosphorylate Cdh1 in vitro, and the majority of the sites identified correlated with previously characterized cyclin-dependent kinase (Cdk) consensus sites. Analysis of the APC core complex during ΔUL97 virus infection showed APC dissociation occurring at the same time as during infection with wild-type virus, suggesting that the UL97-mediated phosphorylation of Cdh1 is not required for this to occur. Further investigation of the APC subunits showed a proteasome-dependent loss of the APC5 and APC4 subunits that was temporally associated with the disassembly of the APC. Immediate early viral gene expression was not sufficient for the degradation of APC4 and APC5, indicating that a viral early gene product(s), possibly in association with a de novo-synthesized cellular protein(s), is involved.Human cytomegalovirus (HCMV), a highly prevalent β-herpesvirus, can cause serious birth defects and disease in immunocompromised individuals, and it may be associated with cancer and cardiovascular disease (53). Viral gene expression is temporally regulated and is dependent on many cellular factors for a productive infection. Immediate early (IE) genes are expressed by 2 h postinfection (p.i.) and transactivate the early genes required for viral DNA replication. The expression of the late genes, which encode proteins involved in virion maturation and egress, is dependent on viral DNA replication.The virus has adopted different strategies for altering the cellular environment to make it more conducive to productive infection, including the stimulation of host cell DNA replication pathways, cell cycle deregulation and arrest, immune evasion, and inhibition of apoptosis (53). Although HCMV encodes its own DNA polymerase, it is dependent on other cellular resources for DNA replication. Infection of quiescent cells induces passage toward S phase such that the host cell is stimulated to generate proteins and DNA precursors necessary for genome replication; however, entry into S phase and cellular DNA replication are subsequently blocked and the cell arrests in G₁/S (1, 10, 11, 14, 30, 45). Cellular resources are thereby presumably free to be efficiently utilized for viral replication. Cell cycle arrest by HCMV is achieved in part through the misregulation of several cell cycle proteins, including the phosphorylation and accumulation of the Rb family pocket proteins, upregulation of cyclins E and B and their associated kinase activities, inhibition of cyclin A expression, stabilization of p53, and accumulation of Cdc6 and geminin, which inhibits licensing of the cellular origins of DNA replication (8, 17, 30, 49, 54, 65). Some of these cell cycle defects can be attributed to a deregulation of the anaphase-promoting complex (APC) (8, 72, 79, 80), an E3 ubiquitin ligase that is responsible for the timely degradation of cell cycle proteins and mitotic cyclins to promote cycle progression from mitosis through G₁ to S phase (58, 74). As the APC also appears to be a common target among other viruses, including the chicken anemia virus, adenoviruses, and poxviruses (23, 36, 52, 70), understanding the mechanisms leading to its inactivation during viral infection has been of great interest.As we have previously reported, multiple mechanisms may be involved in disabling the APC during HCMV infection (72), which is not surprising given the complexity of its structure and regulation (for a review, see references 58 and 74). The APC is a large multisubunit complex consisting of at least 11 conserved core subunits, as well as other species-specific subunits. In metazoans, the APC2 and APC11 subunits form the catalytic core, and along with APC10, provide the platform for binding the E2 ubiquitin-conjugating enzyme. Each of the APC3, APC8, APC6, and APC7 subunits contain multiple copies of the tetratricopeptide repeat (TPR) motif and together make up the TPR subcomplex, which provides a platform of protein interaction surfaces for binding the coactivators (i.e., Cdh1 and Cdc20) and various substrates. These two subcomplexes are bridged by the large scaffolding subunit APC1, with the TPR subcomplex tethered to APC1 through APC4 and APC5. The binding between APC1, APC4, APC5, and APC8 is also interdependent, such that the loss of one subunit decreases the association of the other three (71).The APC is activated by either of its coactivators, Cdh1 or Cdc20, which also function in recruiting specific substrates to the APC during different phases of the cell cycle. The phosphorylation of several APC subunits at the onset of mitosis, including APC1 and the TPR subunits, by cyclin B/cyclin-dependent kinase 1 (Cdk1) and Plk1 allows the binding of Cdc20 and subsequent activation of the APC (APC^Cdc20) (19, 37), whereas the binding and activation of the complex by Cdh1 is inhibited through its phosphorylation by cyclin B/Cdk1 (9, 29, 38, 83). As cells pass the spindle assembly checkpoint, APC^Cdc20 ubiquitinates securin (to allow for sister chromatid separation) and cyclin B for degradation by the proteasome (42, 67). The subsequent inactivation of Cdk1 and activation of mitotic phosphatases during late anaphase relieves the inhibitory phosphorylation on Cdh1, presumably by Cdc14 (6, 38, 44), which then allows Cdh1 to bind and activate the APC (APC^Cdh1). APC^Cdh1 ubiquitinates Cdc20 and mitotic cyclins for degradation to facilitate mitotic exit and maintains their low levels, along with S-phase regulators (e.g., Cdc6, geminin, etc.), during G₁ (16, 50, 59, 63). The inactivation of APC^Cdh1 as cells enter S phase may be mediated in part through the phosphorylation of Cdh1 by cyclin A/Cdk2 (46) and Cdh1 binding to the inhibitor Emi1 (25). The inactivation of Cdh1 by phosphorylation has been shown in all organisms studied thus far (e.g., yeast, Drosophila, plants, mammals, etc.), and mutants mimicking constitutively phosphorylated Cdh1 on Cdk consensus sites can neither bind nor activate the APC in vivo or in vitro (9, 29, 38, 69, 83).During HCMV infection of fibroblasts in G₀/G₁, however, Cdh1 becomes prematurely phosphorylated in a Cdk-independent manner and no longer associates with the APC (72). This dissociation does not appear to be due to an overexpression of Emi1 (79). Cdc20 also can no longer associate with the APC (79), suggesting a defect in the APC core. We have further shown that the APC core complex disassembles during the infection, with the TPR subunits (i.e., APC3, APC7, and APC8) and APC10 localizing to the cytosol, while APC1 remains nuclear (72). Interestingly, both the phosphorylation of Cdh1 and the dissociation of the APC occur at similar times during HCMV infection. Although either of these mechanisms could render the APC inactive, it was unclear whether these processes are linked or represent independent (or redundant) pathways. The causative factor(s) in mediating these events and the question of whether such a factor(s) was of cellular or viral origin also remained unresolved.On the basis of the results of several recent studies (26, 32, 62), the viral protein kinase UL97 emerged as a likely candidate for involvement in the phosphorylation of Cdh1. Conserved among herpesviruses, UL97 functions in viral genome replication (7, 32, 81) and in nuclear egress of viral capsids (21, 39, 48). UL97 is present in the tegument of the virus particle (76) and is also expressed de novo with early kinetics (i.e., detectable by 5 h p.i. by Western blot assay), with increased expression at later times of the infection (51, 76, 77). UL97 is a serine/threonine (S/T) protein kinase (22), and recent studies have further characterized it as a Cdkl mimic, with predicted structural similarity to Cdk2 (64) and common substrates. UL97 has been shown to phosphorylate in vitro nuclear lamin A/C (21), the carboxyl-terminal domain of RNA polymerase II (5), the translation elongation factor 1δ (EF1δ) (33), and Rb (26, 62) on sites targeted by Cdks, and there is considerable evidence that UL97 phosphorylates lamin A/C, EF1δ, and Rb on these sites in infected cells as well (21, 26, 33, 62). Given that cyclin A/Cdk2 and cyclin B/Cdk1 complexes normally phosphorylate Cdh1, thus preventing its association with the APC, we hypothesized that UL97 phosphorylates Cdh1 during HCMV infection.In the present study, we provide further mechanistic details of the events and players involved in inactivating the APC during HCMV infection. Evidence that UL97 is the viral factor mediating the phosphorylation of Cdh1 was obtained. However, APC disassembly still occurred at similar times in ΔUL97 and wild-type virus infections, indicating that UL97-mediated phosphorylation of Cdh1 is not required for this event. The inactivation of the APC core complex is further attributed to the loss of the APC5 and APC4 subunits early during the infection. The degradation of these subunits is proteasome dependent and requires de novo synthesis of viral early or cellular proteins. While the primary mechanism of inactivation appears to be the dissociation of the complex and the targeted loss of APC5 and APC4, phosphorylation of Cdh1 may provide a small kinetic advantage and backup mechanism for disabling the APC.     

A Bifunctional Regulatory Element in Human Somatic Wee1 Mediates Cyclin A/Cdk2 Binding and Crm1-Dependent Nuclear Export

Sophisticated models for the regulation of mitotic entry are lacking for human cells. Inactivating human cyclin A/Cdk2 complexes through diverse approaches delays mitotic entry and promotes inhibitory phosphorylation of Cdk1 on tyrosine 15, a modification performed by Wee1. We show here that cyclin A/Cdk2 complexes physically associate with Wee1 in U2OS cells. Mutation of four conserved RXL cyclin A/Cdk binding motifs (RXL1 to RXL4) in Wee1 diminished stable binding. RXL1 resides within a large regulatory region of Wee1 that is predicted to be intrinsically disordered (residues 1 to 292). Near RXL1 is T239, a site of inhibitory Cdk phosphorylation in Xenopus Wee1 proteins. We found that T239 is phosphorylated in human Wee1 and that this phosphorylation was reduced in an RXL1 mutant. RXL1 and T239 mutants each mediated greater Cdk phosphorylation and G₂/M inhibition than the wild type, suggesting that cyclin A/Cdk complexes inhibit human Wee1 through these sites. The RXL1 mutant uniquely also displayed increased nuclear localization. RXL1 is embedded within sequences homologous to Crm1-dependent nuclear export signals (NESs). Coimmunoprecipitation showed that Crm1 associated with Wee1. Moreover, treatment with the Crm1 inhibitor leptomycin B or independent mutation of the potential NES (NESm) abolished Wee1 nuclear export. Export was also reduced by Cdk inhibition or cyclin A RNA interference, suggesting that cyclin A/Cdk complexes contribute to Wee1 export. Somewhat surprisingly, NESm did not display increased G₂/M inhibition. Thus, nuclear export of Wee1 is not essential for mitotic entry though an important functional role remains likely. These studies identify a novel bifunctional regulatory element in Wee1 that mediates cyclin A/Cdk2 association and nuclear export.Despite broad progress in studies of cell cycle control in eukaryotes, advanced models are lacking for the regulation of mitotic entry in human cells. This regulation is pivotal in cell cycle control, and a better understanding of it may be crucial to improving cytotoxic cancer chemotherapy, the mainstay of cancer treatment. Models of mitotic entry in higher eukaryotes revolve around activation of the cyclin B/Cdk1 (cyclin-dependent kinase 1 or Cdc2) complex, which drives the major events of mitosis. A rise in the cyclin B level triggers mitotic entry in Xenopus egg extracts but not in mammalian cells (15, 47). Inhibitory phosphorylation of Cdk1 on the ATP-binding site residue tyrosine 15 (Y15) has been recognized as a key constraint throughout eukaryotes (29, 42). Wee1 and Myt kinases perform this phosphorylation in vertebrate cells, where Wee1 appears to be dominant (34). Kim and Ferrell and others have recently developed an elegant model for ultrasensitive, switch-like inactivation of Wee1 by cyclin B/Cdk1 in a positive feedback loop that contributes to mitotic entry in Xenopus egg extracts (27).Although cyclin A(A2)/Cdk2 is traditionally omitted from models of mitotic entry, accumulating evidence from several different approaches suggests that cyclin A/Cdk complexes play roles. Cyclin A levels rise during S phase and peak in G₂ before falling abruptly in prometaphase of mitosis (60). Microinjection of cyclin A/Cdk2 complexes in human G₂ phase cells was observed to drive mitotic entry (14). Conversely, microinjection of antibodies directed against cyclin A in S-phase cells inhibited mitotic entry without an apparent effect on bulk DNA synthesis (45). In complementary approaches that supported biochemical analyses, cyclin A RNA interference (RNAi) or induction of a dominant negative mutant of Cdk2 (Cdk2-dn), the major cyclin A binding partner, inhibited mitotic entry (13, 15, 21, 37). In these settings, cyclin B/Cdk1 complexes accumulated in inactive, Y15-phosphorylated forms (13, 21, 37). Cdc25 phosphatases, which can reverse this phosphorylation, show reduced activity in this context (37), but increased Cdc25 activity could not readily overcome the arrest (13). RNAi-mediated knockdown of Wee1 was found capable of overriding the arrest mediated by cyclin A RNAi, suggesting that Wee1 is a key rate-limiting factor (13). However, whether and by what mechanisms cyclin A complexes might regulate Wee1 and drive Cdk1 dephosphorylation and mitotic entry have remained unclear.Recently, genetic studies in mice have reinforced these observations while providing evidence for some cell type differences (24). Although Cdk2 is not essential, in its absence Cdk1 binds more cyclin A and E and provides redundant functions (4, 25, 44). Deletion of the cyclin A gene is lethal for embryos and adults (24). Gene deletion in fibroblasts in vitro did not completely abrogate their proliferation but caused S and G₂/M delays. In this setting cyclin E was upregulated, and combined deletion of cyclin E yielded arrest in G₁, S, and G₂/M phases. Cyclin A gene deletion was alone sufficient to block proliferation of hematopoietic stem cells, suggesting that cyclin A is essential for their proliferation.Wee1 is regulated on multiple levels, including inhibitory phosphorylation in the amino-terminal regulatory domain (NRD), residues 1 to 292. This region is predicted to be intrinsically disordered (56), and few functional elements have been identified in it. The cyclin B/Cdk1 complex has been thought to be the principal or exclusive kinase responsible for NRD phosphorylation (18, 27, 28). Two sites in the Xenopus embryonic Wee1 NRD, Thr 104 and Thr 150 (referred to here by the homologous residue, T239, in human somatic Wee1), have been identified as Cdk phosphorylation sites that inhibit Wee1 activity (28). Recent studies of Xenopus somatic Wee1 suggest that T239 phosphorylation may antagonize the function of a surrounding motif, dubbed the Wee box (43). This small, conserved region appears to augment the activity of the carboxy-terminal kinase domain.We show here that cyclin A/Cdk2 complexes directly bind Wee1 as a substrate in human cells. In particular, a conserved cyclin A/Cdk binding RXL motif in the Wee1 NRD is required for efficient T239 phosphorylation. Further analysis revealed that RXL1 is located within a Crm1 binding site that mediates Wee1 export during S and G₂ phases. Cyclin A/Cdk2 activity appears to foster Wee1 export, but this export is not essential for mitotic entry. These findings further define roles of cyclin A/Cdk complexes in regulating Wee1 and mitotic entry in human cells and dissect the mechanisms and consequences of Wee1 redistribution during the run-up to mitosis.     

A qualitative investigation of smoke-free policies on hospital property

Background:

Many hospitals have adopted smoke-free policies on their property. We examined the consequences of such polices at two Canadian tertiary acute-care hospitals.

Methods:

We conducted a qualitative study using ethnographic techniques over a six-month period. Participants (n = 186) shared their perspectives on and experiences with tobacco dependence and managing the use of tobacco, as well as their impressions of the smoke-free policy. We interviewed inpatients individually from eight wards (n = 82), key policy-makers (n = 9) and support staff (n = 14) and held 16 focus groups with health care providers and ward staff (n = 81). We also reviewed ward documents relating to tobacco dependence and looked at smoking-related activities on hospital property.

Results:

Noncompliance with the policy and exposure to secondhand smoke were ongoing concerns. Peoples’ impressions of the use of tobacco varied, including divergent opinions as to whether such use was a bad habit or an addiction. Treatment for tobacco dependence and the management of symptoms of withdrawal were offered inconsistently. Participants voiced concerns over patient safety and leaving the ward to smoke.

Interpretation:

Policies mandating smoke-free hospital property have important consequences beyond noncompliance, including concerns over patient safety and disruptions to care. Without adequately available and accessible support for withdrawal from tobacco, patients will continue to face personal risk when they leave hospital property to smoke.Canadian cities and provinces have passed smoking bans with the goal of reducing people’s exposure to secondhand smoke in workplaces, public spaces and on the property adjacent to public buildings.^1,2 In response, Canadian health authorities and hospitals began implementing policies mandating smoke-free hospital property, with the goals of reducing the exposure of workers, patients and visitors to tobacco smoke while delivering a public health message about the dangers of smoking.^2–5 An additional anticipated outcome was the reduced use of tobacco among patients and staff. The impetuses for adopting smoke-free policies include public support for such legislation and the potential for litigation for exposure to second-hand smoke.^2,4Tobacco use is a modifiable risk factor associated with a variety of cancers, cardiovascular diseases and respiratory conditions.^6–11 Patients in hospital who use tobacco tend to have more surgical complications and exacerbations of acute and chronic health conditions than patients who do not use tobacco.^6–11 Any policy aimed at reducing exposure to tobacco in hospitals is well supported by evidence, as is the integration of interventions targetting tobacco dependence.¹² Unfortunately, most of the nearly five million Canadians who smoke will receive suboptimal treatment,¹³ as the routine provision of interventions for tobacco dependence in hospital settings is not a practice norm.^14–16 In smoke-free hospitals, two studies suggest minimal support is offered for withdrawal, ^17,18 and one reports an increased use of nicotine-replacement therapy after the implementation of the smoke-free policy.¹⁹Assessments of the effectiveness of smoke-free policies for hospital property tend to focus on noncompliance and related issues of enforcement.^17,20,21 Although evidence of noncompliance and litter on hospital property^2,17,20 implies ongoing exposure to tobacco smoke, half of the participating hospital sites in one study reported less exposure to tobacco smoke within hospital buildings and on the property.¹⁸ In addition, there is evidence to suggest some decline in smoking among staff.^18,19,21,22We sought to determine the consequences of policies mandating smoke-free hospital property in two Canadian acute-care hospitals by eliciting lived experiences of the people faced with enacting the policies: patients and health care providers. In addition, we elicited stories from hospital support staff and administrators regarding the policies.     

Relation between fractures and mortality: results from the Canadian Multicentre Osteoporosis Study

Background

Fractures have largely been assessed by their impact on quality of life or health care costs. We conducted this study to evaluate the relation between fractures and mortality.

Methods

A total of 7753 randomly selected people (2187 men and 5566 women) aged 50 years and older from across Canada participated in a 5-year observational cohort study. Incident fractures were identified on the basis of validated self-report and were classified by type (vertebral, pelvic, forearm or wrist, rib, hip and “other”). We subdivided fracture groups by the year in which the fracture occurred during follow-up; those occurring in the fourth and fifth years were grouped together. We examined the relation between the time of the incident fracture and death.

Results

Compared with participants who had no fracture during follow-up, those who had a vertebral fracture in the second year were at increased risk of death (adjusted hazard ratio [HR] 2.7, 95% confidence interval [CI] 1.1–6.6); also at risk were those who had a hip fracture during the first year (adjusted HR 3.2, 95% CI 1.4–7.4). Among women, the risk of death was increased for those with a vertebral fracture during the first year (adjusted HR 3.7, 95% CI 1.1–12.8) or the second year of follow-up (adjusted HR 3.2, 95% CI 1.2–8.1). The risk of death was also increased among women with hip fracture during the first year of follow-up (adjusted HR 3.0, 95% CI 1.0–8.7).

Interpretation

Vertebral and hip fractures are associated with an increased risk of death. Interventions that reduce the incidence of these fractures need to be implemented to improve survival.Osteoporosis-related fractures are a major health concern, affecting a growing number of individuals worldwide. The burden of fracture has largely been assessed by the impact on health-related quality of life and health care costs.^1,2 Fractures can also be associated with death. However, trials that have examined the relation between fractures and mortality have had limitations that may influence their results and the generalizability of the studies, including small samples,^3,4 the examination of only 1 type of fracture,^4–10 the inclusion of only women,^8,11 the enrolment of participants from specific areas (i.e., hospitals or certain geographic regions),^{3,4,7,8,10,12} the nonrandom selection of participants^3–11 and the lack of statistical adjustment for confounding factors that may influence mortality.^3,5–7,12We evaluated the relation between incident fractures and mortality over a 5-year period in a cohort of men and women 50 years of age and older. In addition, we examined whether other characteristics of participants were risk factors for death.     

New Insights into How the Rho Guanine Nucleotide Dissociation Inhibitor Regulates the Interaction of Cdc42 with Membranes

The subcellular localization of the Rho family GTPases is of fundamental importance to their proper functioning in cells. The Rho guanine nucleotide dissociation inhibitor (RhoGDI) plays a key regulatory role by influencing the cellular localization of Rho GTPases and is essential for the transforming activity of oncogenic forms of Cdc42. However, the mechanism by which RhoGDI helps Cdc42 to undergo the transition between a membrane-associated protein and a soluble (cytosolic) species has been poorly understood. Here, we examine how RhoGDI influences the binding of Cdc42 to lipid bilayers. Despite having similar affinities for the signaling-inactive (GDP-bound) and signaling-active (GTP-bound) forms of Cdc42 in solution, we show that when RhoGDI interacts with Cdc42 along the membrane surface, it has a much higher affinity for GDP-bound Cdc42 compared with its GTP-bound counterpart. Interestingly, the rate for the dissociation of Cdc42·RhoGDI complexes from membranes is unaffected by the nucleotide-bound state of Cdc42. Moreover, the membrane release of Cdc42·RhoGDI complexes occurs at a similar rate as the release of Cdc42 alone, with the major effect of RhoGDI being to impede the re-association of Cdc42 with membranes. These findings lead us to propose a new model for how RhoGDI influences the ability of Cdc42 to move between membranes and the cytosol, which highlights the role of the membrane in helping RhoGDI to distinguish between the GDP- and GTP-bound forms of Cdc42 and holds important implications for how it functions as a key regulator of the cellular localization and signaling activities of this GTPase.The Rho family GTPases are a tightly regulated class of signaling proteins that controls a number of important cellular processes. Known most prominently for their ability to remodel the actin cytoskeleton in mammalian cells (1–3), members of this GTPase family have been shown to play essential roles in cell migration, epithelial cell polarization, phagocytosis, and cell cycle progression (4–11). The Rho family member Cdc42 was discovered for its essential role in bud formation in Saccharomyces cerevisiae (12). However, after its identification in higher organisms (13), Cdc42 has been implicated in a diverse array of signaling pathways including those involved in the regulation of cell growth and in the induction of malignant transformation (14). Indeed, point mutations which enable Cdc42 to undergo the spontaneous exchange of GDP for GTP cause NIH3T3 cells to form colonies in soft agar and grow in low serum, two hallmarks of cellular transformation (15). The introduction of activated Cdc42 mutants into nude mice gives rise to tumor formation (16). Moreover, cellular transformation by oncogenic Ras, one of the most commonly mutated proteins in human cancers, requires the activation of Cdc42 (17).At the molecular level, there are a number of mechanisms that possibly contribute to the roles played by Cdc42 in cell growth control and cellular transformation. These include the ability of Cdc42 to activate the c-Jun NH₂-terminal kinase and p38/Mpk2 signaling pathways (18–20) as well as spatially regulate proteins implicated in the establishment of microtubule-dependent cell polarity including glycogen synthase kinase-3β and adenomatous polyposis coli (21), extend the lifetime of epidermal growth factor receptor-signaling activities by sequestering Cbl, a ubiquitin E3 ligase (22), and influence intracellular trafficking events (23, 24). To mediate such a wide range of cellular responses, two parameters must be properly regulated; that is, the activation state of Cdc42 and its subcellular localization. As is the case with other GTPases, the activation of Cdc42 occurs as an outcome of GDP-GTP exchange, which then enables it to undergo high affinity interactions with effector proteins (25–27). Upon the hydrolysis of GTP to GDP, Cdc42 is converted back to a signaling-inactive state. Two families of proteins work in opposing fashion to regulate the GTP-binding/GTPase cycle of Cdc42. GTPase-activating proteins recognize the GTP-bound form of Cdc42 and accelerate the hydrolysis of GTP to GDP, rendering Cdc42 inactive (28, 29). Guanine nucleotide exchange factors (GEFs)² stimulate the dissociation of GDP from Cdc42, thereby promoting the formation of its signaling-active, GTP-bound state (29, 30).Of equal importance to its activation status is the spatial regulation of Cdc42. This is highly contingent on the particular cellular membranes that serve as sites of binding and/or recruitment of Cdc42 (31–33). The vast majority of in vitro studies performed on Cdc42 have been carried out in the absence of lipids, which is an important omission considering that virtually all of the physiological functions of Cdc42 occur on a membrane surface (34). Cdc42, along with most other Rho family GTPases, undergoes a series of carboxyl-terminal modifications which result in the covalent attachment of a 20-carbon geranylgeranyl lipid anchor (35–37). Directly preceding this lipid tail is a sequence of basic residues that further stabilizes the association of Cdc42 with the membrane surface (31, 33, 38). A ubiquitously expressed 22-kDa protein called Rho guanine nucleotide dissociation inhibitor (RhoGDI) was found to form a soluble (cytosolic) complex with Cdc42 and other Rho GTPases and to apparently promote their release from membranes (39, 40). RhoGDI was originally discovered and named for its ability to block the GEF- and EDTA-stimulated nucleotide exchange activity of Rho family GTPases (39, 41, 42) and then subsequently shown to inhibit the GTP-hydrolytic activity of Cdc42 (43) and to be capable of interacting with the GDP- and GTP-bound forms of Cdc42 in solution with equal affinity (44). The x-ray crystal structure of a complex between RhoGDI and Cdc42-GDP revealed two types of binding interactions (45). An amino-terminal regulatory arm of RhoGDI was shown to form a helix-loop-helix motif that binds to both of the switch domains of Cdc42, leading to the inhibition of GTP hydrolysis and GDP dissociation (45, 46). The carboxyl-terminal two-thirds of RhoGDI assumes an immunoglobulin-like domain, forming a hydrophobic pocket that in effect provides a membrane substitute for the geranylgeranyl moiety of Cdc42. After release from membranes, the lipid anchor of Cdc42 binds in the hydrophobic pocket of RhoGDI, thereby helping to maintain Cdc42 in solution (45–47).Prior work from our laboratory has demonstrated an essential role for RhoGDI in Cdc42-mediated cellular transformation. Based on the x-ray crystal structure for the Cdc42·RhoGDI complex, Arg-66 of Cdc42 makes multiple contacts with RhoGDI. When this residue was changed to alanine, Cdc42 was unable to bind to RhoGDI but was still capable of interacting with its other regulatory and effector proteins. Interestingly, when the R66A mutant of Cdc42 was examined in the constitutively active Cdc42(F28L) background, the resulting Cdc42 double mutant was no longer able to transform cells (48). Knocking down RhoGDI by small interfering RNA also blocked transformation by Cdc42. These findings highlighted a key role for RhoGDI in the ability of Cdc42 to stimulate signaling pathways of importance to cellular transformation, presumably by influencing the membrane association of Cdc42 and ensuring its proper cellular localization.In the present study we have set out to better understand how RhoGDI regulates the signaling functions of Cdc42 and, in particular, how RhoGDI affects the association of Cdc42 with membranes. We show how the membrane plays a previously unappreciated role in allowing RhoGDI to distinguish between the signaling-inactive (GDP-bound) and signaling-active (GTP-bound) forms of Cdc42. By assaying the binding of Cdc42 to insect cell membranes and compositionally defined liposomes through different approaches including a sensitive, real-time fluorescence resonance energy transfer (FRET) readout, we have been able to establish how RhoGDI influences the ability of Cdc42 to transition between a membrane-bound and soluble species. This has led us to propose a new mechanism describing how RhoGDI performs its important regulatory function.     

Global Analysis of Cdc14 Dephosphorylation Sites Reveals Essential Regulatory Role in Mitosis and Cytokinesis

Degradation of the M phase cyclins triggers the exit from M phase. Cdc14 is the major phosphatase required for the exit from the M phase. One of the functions of Cdc14 is to dephosphorylate and activate the Cdh1/APC/C complex, resulting in the degradation of the M phase cyclins. However, other crucial targets of Cdc14 for mitosis and cytokinesis remain to be elucidated. Here we systematically analyzed the positions of dephosphorylation sites for Cdc14 in the budding yeast Saccharomyces cerevisiae. Quantitative mass spectrometry identified a total of 835 dephosphorylation sites on 455 potential Cdc14 substrates in vivo. We validated two events, and through functional studies we discovered that Cdc14-mediated dephosphorylation of Smc4 and Bud3 is essential for proper mitosis and cytokinesis, respectively. These results provide insight into the Cdc14-mediated pathways for exiting the M phase.All cells proliferate following a fixed, highly coordinated cycle. Mitosis especially requires elaborate coordination for proper chromosome segregation, mitotic spindle disassembly, and cytokinesis. Much of this activity is facilitated by numerous, diverse phosphorylation and dephosphorylation signals that orchestrate the precise progression of M phase.Prior to mitosis, sister chromatids resulting from DNA replication during S phase are held together by the cohesion complex. Then, during prophase, chromosomes are condensed by the condensin (Smc2/4) complex (1) and microtubules are remodeled to form the mitotic spindle (2). Subsequently, in metaphase, the microtubules of the spindle apparatus attach to the chromosome kinetochores (3) and dissolution of the sister chromatids is triggered by the separase-mediated cleavage of cohesin (4, 5). Finally, Cdc14, Cdh1, and APC/C work together in telophase to degrade the M phase cyclins (6), promote decondensation of chromosomes (7), and finish cytokinesis (8, 9).Cdc14, a dual-specificity phosphatase that removes the phosphate group on both phosphotyrosine and phosphoserine/threonine residues (10), is required for mitosis (11, 12). Specifically, Cdc14 function is essential in late M phase: cells carrying a defective mutation arrest in telophase (13), whereas overexpression of Cdc14 results in G1 arrest (12). Cdc14 triggers mitotic cyclin-dependent kinase (CDK)¹ inactivation, enabling cells to exit mitosis through dephosphorylation and activation of the inhibitors of CDKs. At interphase, Cdc14 is a subunit of the mitotic exit network (14–17), which usually localizes to the nucleolus. However, the Cdc14 early anaphase release network initiates the release of Cdc14 from its inhibitor, Net1/Cfi1 (18), and the mitotic exit network promotes further release of Cdc14 from its inhibitor, allowing it to spread into the nucleus and cytoplasm, where it dephosphorylates its major targets (8, 9), leading to exit from mitosis. In addition to this essential role in late M phrase, Cdc14 substrates have also been identified in other stages of the cell cycle (19).Cdc14 putatively regulates 27 proteins (19–22). Some studies have documented the substrates of Cdc14 via in vitro phosphatase assay, whereas others have provided in vivo evidence. However, dephosphorylation sites have been identified for only five of the target proteins (17, 22–25), suggesting that spurious relationships cannot be ruled out. Also, experiments have not been carried out to demonstrate whether these modifications entail direct or indirect regulation. Therefore, our understanding of Cdc14 function and regulation during mitosis in metazoans is incomplete. Conceivably, Cdc14 may regulate many more substrates involved in aspects of chromosome condensation and cytokinesis. To examine this possibility we performed a systematic phosphoproteomic screen to identify new in vivo pathways regulated by Cdc14. Using this approach, we identified both known and potentially novel substrates of Cdc14, as well as their dephosphorylation sites. Many potentially novel substrates are physically associated with Cdc14 in public databases. We also provide biochemical evidence for direct dephosphorylation of the substrates, characterize the specificity of dephosphorylation in two substrates, Smc4 and Bud3, and further study their regulation and critical role in mitosis and cytokinesis.     

Effectiveness of training family physicians to deliver a brief intervention to address excessive substance use among young patients: a cluster randomized controlled trial

Background:

Brief interventions delivered by family physicians to address excessive alcohol use among adult patients are effective. We conducted a study to determine whether such an intervention would be similarly effective in reducing binge drinking and excessive cannabis use among young people.

Methods:

We conducted a cluster randomized controlled trial involving 33 family physicians in Switzerland. Physicians in the intervention group received training in delivering a brief intervention to young people during the consultation in addition to usual care. Physicians in the control group delivered usual care only. Consecutive patients aged 15–24 years were recruited from each practice and, before the consultation, completed a confidential questionnaire about their general health and substance use. Patients were followed up at 3, 6 and 12 months after the consultation. The primary outcome measure was self-reported excessive substance use (≥ 1 episode of binge drinking, or ≥ 1 joint of cannabis per week, or both) in the past 30 days.

Results:

Of the 33 participating physicians, 17 were randomly allocated to the intervention group and 16 to the control group. Of the 594 participating patients, 279 (47.0%) identified themselves as binge drinkers or excessive cannabis users, or both, at baseline. Excessive substance use did not differ significantly between patients whose physicians were in the intervention group and those whose physicians were in the control group at any of the follow-up points (odds ratio [OR] and 95% confidence interval [CI] at 3 months: 0.9 [0.6–1.4]; at 6 mo: 1.0 [0.6–1.6]; and at 12 mo: 1.1 [0.7–1.8]). The differences between groups were also nonsignificant after we re stricted the analysis to patients who reported excessive substance use at baseline (OR 1.6, 95% CI 0.9–2.8, at 3 mo; OR 1.7, 95% CI 0.9–3.2, at 6 mo; and OR 1.9, 95% CI 0.9–4.0, at 12 mo).

Interpretation:

Training family physicians to use a brief intervention to address excessive substance use among young people was not effective in reducing binge drinking and excessive cannabis use in this patient population. Trial registration: Australian New Zealand Clinical Trials Registry, no. ACTRN12608000432314.Most health-compromising behaviours begin in adolescence.¹ Interventions to address these behaviours early are likely to bring long-lasting benefits.² Harmful use of alcohol is a leading factor associated with premature death and disability worldwide, with a disproportionally high impact on young people (aged 10–24 yr).^3,4 Similarly, early cannabis use can have adverse consequences that extend into adulthood.^5–8In adolescence and early adulthood, binge drinking on at least a monthly basis is associated with an increased risk of adverse outcomes later in life.^9–12 Although any cannabis use is potentially harmful, weekly use represents a threshold in adolescence related to an increased risk of cannabis (and tobacco) dependence in adulthood.¹³ Binge drinking affects 30%–50% and excessive cannabis use about 10% of the adolescent and young adult population in Europe and the United States.^10,14,15Reducing substance-related harm involves multisectoral approaches, including promotion of healthy child and adolescent development, regulatory policies and early treatment interventions.¹⁶ Family physicians can add to the public health messages by personalizing their content within brief interventions.^17,18 There is evidence that brief interventions can encourage young people to reduce substance use, yet most studies have been conducted in community settings (mainly educational), emergency services or specialized addiction clinics.^1,16 Studies aimed at adult populations have shown favourable effects of brief alcohol interventions, and to some extent brief cannabis interventions, in primary care.^19–22 These interventions have been recommended for adolescent populations.^4,5,16 Yet young people have different modes of substance use and communication styles that may limit the extent to which evidence from adult studies can apply to them.Recently, a systematic review of brief interventions to reduce alcohol use in adolescents identified only 1 randomized controlled trial in primary care.²³ The tested intervention, not provided by family physicians but involving audio self-assessment, was ineffective in reducing alcohol use in exposed adolescents.²⁴ Sanci and colleagues showed that training family physicians to address health-risk behaviours among adolescents was effective in improving provider performance, but the extent to which this translates into improved outcomes remains unknown.^25,26 Two nonrandomized studies suggested screening for substance use and brief advice by family physicians could favour reduced alcohol and cannabis use among adolescents,^27,28 but evidence from randomized trials is lacking.²⁹We conducted the PRISM-Ado (Primary care Intervention Addressing Substance Misuse in Adolescents) trial, a cluster randomized controlled trial of the effectiveness of training family physicians to deliver a brief intervention to address binge drinking and excessive cannabis use among young people.     

Cancer cell death induced by novel small molecules degrading the TACC3 protein via the ubiquitin–proteasome pathway

The selective degradation of target proteins with small molecules is a novel approach to the treatment of various diseases, including cancer. We have developed a protein knockdown system with a series of hybrid small compounds that induce the selective degradation of target proteins via the ubiquitin–proteasome pathway. In this study, we designed and synthesized novel small molecules called SNIPER(TACC3)s, which target the spindle regulatory protein transforming acidic coiled-coil-3 (TACC3). SNIPER(TACC3)s induce poly-ubiquitylation and proteasomal degradation of TACC3 and reduce the TACC3 protein level in cells. Mechanistic analysis indicated that the ubiquitin ligase APC/C^CDH1 mediates the SNIPER(TACC3)-induced degradation of TACC3. Intriguingly, SNIPER(TACC3) selectively induced cell death in cancer cells expressing a larger amount of TACC3 protein than normal cells. These results suggest that protein knockdown of TACC3 by SNIPER(TACC3) is a potential strategy for treating cancers overexpressing the TACC3 protein.Inhibitors of microtubule polymerization or depolymerization such as Vinca alkaloids and taxanes, respectively, are widely used as anti-cancer drugs. They arrest cancer cells, inducing mitotic catastrophe and cancer cell death. However, these drugs also affect microtubule function in non-dividing cells and have serious side effects, such as peripheral neuropathy, which limit their utility.¹ Recently, inhibitors of spindle-regulatory proteins, such as mitotic kinases (Aurora kinases and Polo-like kinases) and a motor protein (Eg5/Ksp) have attracted considerable attention, but they have not been developed clinical use yet.^{2, 3}Transforming acidic coiled-coil-3 (TACC3) is another spindle-regulatory protein.^{4, 5} During mitosis, TACC3 localizes to the mitotic spindle and has a critical role in spindle assembly, chromosomal function and mitotic progression.^{6, 7, 8, 9, 10, 11} Studies using microarray and immunohistochemical analysis showed that TACC3 is overexpressed in many human cancers, including ovarian cancer, breast cancer, squamous cell carcinoma and lymphoma.^{12, 13, 14} Depletion of TACC3 results in chromosome alignment defects, multi-polar spindle formation, mitotic cell death and/or a postmitotic cell cycle arrest.^{15, 16, 17, 18, 19, 20} Additionally, conditional disruption of TACC3 has been shown to regress thymic lymphomas in p53-deficient mice without inducing any overt abnormalities in normal tissues.²¹ These findings suggest that TACC3 is a molecular target for anti-cancer drug discovery.The development of a strategy for the selective degradation may be a useful approach to the discovery of novel drugs. Based on the ubiquitin–proteasome system (UPS), we have devised a protein knockdown system for inducing the selective degradation of target proteins by using specifically designed hybrid small compounds.^{22, 23, 24, 25, 26, 27, 28, 29} These compounds, which we have termed SNIPER (Specific and Non-genetic IAP-dependent Protein ERaser), are composed of two different ligands connected by a linker; one is a ligand for cellular inhibitor of apoptosis protein 1 (cIAP1) and the other a ligand for the target protein. Accordingly, SNIPER is expected to crosslink the ubiquitin–ligase cIAP1 and the target protein in the cells, thereby inducing ubiquitylation and, ultimately, proteasomal degradation of the target protein. To date, we have constructed SNIPERs that target cellular retinoic acid binding protein-II (CRABP-II) and nuclear receptors such as estrogen receptor α (ERα) for degradation.^{22, 23, 24, 25, 26, 27, 28} In this study, we designed and synthesized novel SNIPERs targeting TACC3, that is, SNIPER(TACC3)s, that induce proteasomal degradation of the TACC3 protein. We also show that cancer cells expressing a large amount of the TACC3 protein readily undergo cell death as the result of SNIPER(TACC3) treatment.