Control of Membrane Excitability by Potassium and Chloride Leak Conductances

The permeability of the neuronal membrane to different ions determines both resting membrane potential (RMP) and input conductance. These parameters determine the cells response to synaptic input. In this thesis I have examined how the molecular properties of potassium and chloride ion channels can influence neuronal excitability in ways that have not previously been considered. For example, two‐pore domain potassium (K2P) channels open at rest to generate a persistent potassium ion efflux. In addition to its accepted role in setting the RMP, I have tested the hypothesis that this conductance is sufficient to repolarise the membrane during an action potential (AP) in the absence of voltage‐dependent potassium channels (Kv). We tested this prediction using heterologous expression of TASK3 or TREK1 K2P channels combined with conductance injection to simulate the presence of a voltage‐gated sodium conductance. These experiments demonstrated that K2P channels are sufficient to support APs during short and prolonged depolarising current pulses. The membranes permeability to chloride ions can also be affected by extrasynaptic GABAA receptors containing the delta subunit (δ‐GABAARs) that produce a tonic conductance due to their high apparent affinity for GABA. The anaesthetics Propofol and THIP are both believed to alter neuronal excitability by enhancing this persistent chloride flux. We have examined how this anaesthetic action is affected by the steady‐state ambient GABA concentrations that are believed to exist in vivo. Surprisingly, the anaesthetic enhancement of δ‐GABAARs is lost at low ambient GABA concentrations. Therefore, I would suggest that the anaesthetic potency of these drugs is affected by the resting ambient GABA concentration in a manner that has not previously been appreciated. In the current Thesis I have examined the molecular and pharmacological properties of two very different ion channel families that both generate a leak conductance, and I will present models that link the behaviour of these ion channels to their ability to modulate neuronal excitability

Special Low Protein Foods Prescribed in England for PKU Patients: An Analysis of Prescribing Patterns and Cost.

Patients with phenylketonuria (PKU) are reliant on special low protein foods (SLPFs) as part of their dietary treatment. In England, several issues regarding the accessibility of SLPFs through the national prescribing system have been highlighted. Therefore, prescribing patterns and expenditure on all SLPFs available on prescription in England (n = 142) were examined. Their costs in comparison to regular protein-containing (n = 182) and 'free-from' products (n = 135) were also analysed. Similar foods were grouped into subgroups (n = 40). The number of units and costs of SLPFs prescribed in total and per subgroup from January to December 2020 were calculated using National Health Service (NHS) Business Service Authority (NHSBSA) ePACT2 (electronic Prescribing Analysis and Cost Tool) for England. Monthly patient SLPF units prescribed were calculated using patient numbers with PKU and non-PKU inherited metabolic disorders (IMD) consuming SLPFs. This was compared to the National Society for PKU (NSPKU) prescribing guidance. Ninety-eight percent of SLPF subgroups (n = 39/40) were more expensive than regular and 'free-from' food subgroups. However, costs to prescribe SLPFs are significantly less than theoretical calculations. From January to December 2020, 208,932 units of SLPFs were prescribed (excluding milk replacers), costing the NHS £2,151,973 (including milk replacers). This equates to £962 per patient annually, and prescribed amounts are well below the upper limits suggested by the NSPKU, indicating under prescribing of SLPFs. It is recommended that a simpler and improved system should be implemented. Ideally, specialist metabolic dietitians should have responsibility for prescribing SLPFs. This would ensure that patients with PKU have the necessary access to their essential dietary treatment, which, in turn, should help promote dietary adherence and improve metabolic control

Effect of remote ischaemic conditioning on clinical outcomes in patients with acute myocardial infarction (CONDI-2/ERIC-PPCI): a single-blind randomised controlled trial.

BACKGROUND: Remote ischaemic conditioning with transient ischaemia and reperfusion applied to the arm has been shown to reduce myocardial infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). We investigated whether remote ischaemic conditioning could reduce the incidence of cardiac death and hospitalisation for heart failure at 12 months. METHODS: We did an international investigator-initiated, prospective, single-blind, randomised controlled trial (CONDI-2/ERIC-PPCI) at 33 centres across the UK, Denmark, Spain, and Serbia. Patients (age >18 years) with suspected STEMI and who were eligible for PPCI were randomly allocated (1:1, stratified by centre with a permuted block method) to receive standard treatment (including a sham simulated remote ischaemic conditioning intervention at UK sites only) or remote ischaemic conditioning treatment (intermittent ischaemia and reperfusion applied to the arm through four cycles of 5-min inflation and 5-min deflation of an automated cuff device) before PPCI. Investigators responsible for data collection and outcome assessment were masked to treatment allocation. The primary combined endpoint was cardiac death or hospitalisation for heart failure at 12 months in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT02342522) and is completed. FINDINGS: Between Nov 6, 2013, and March 31, 2018, 5401 patients were randomly allocated to either the control group (n=2701) or the remote ischaemic conditioning group (n=2700). After exclusion of patients upon hospital arrival or loss to follow-up, 2569 patients in the control group and 2546 in the intervention group were included in the intention-to-treat analysis. At 12 months post-PPCI, the Kaplan-Meier-estimated frequencies of cardiac death or hospitalisation for heart failure (the primary endpoint) were 220 (8·6%) patients in the control group and 239 (9·4%) in the remote ischaemic conditioning group (hazard ratio 1·10 [95% CI 0·91-1·32], p=0·32 for intervention versus control). No important unexpected adverse events or side effects of remote ischaemic conditioning were observed. INTERPRETATION: Remote ischaemic conditioning does not improve clinical outcomes (cardiac death or hospitalisation for heart failure) at 12 months in patients with STEMI undergoing PPCI. FUNDING: British Heart Foundation, University College London Hospitals/University College London Biomedical Research Centre, Danish Innovation Foundation, Novo Nordisk Foundation, TrygFonden

Bi-allelic Loss-of-Function CACNA1B Mutations in Progressive Epilepsy-Dyskinesia.

The occurrence of non-epileptic hyperkinetic movements in the context of developmental epileptic encephalopathies is an increasingly recognized phenomenon. Identification of causative mutations provides an important insight into common pathogenic mechanisms that cause both seizures and abnormal motor control. We report bi-allelic loss-of-function CACNA1B variants in six children from three unrelated families whose affected members present with a complex and progressive neurological syndrome. All affected individuals presented with epileptic encephalopathy, severe neurodevelopmental delay (often with regression), and a hyperkinetic movement disorder. Additional neurological features included postnatal microcephaly and hypotonia. Five children died in childhood or adolescence (mean age of death: 9 years), mainly as a result of secondary respiratory complications. CACNA1B encodes the pore-forming subunit of the pre-synaptic neuronal voltage-gated calcium channel Cav2.2/N-type, crucial for SNARE-mediated neurotransmission, particularly in the early postnatal period. Bi-allelic loss-of-function variants in CACNA1B are predicted to cause disruption of Ca2+ influx, leading to impaired synaptic neurotransmission. The resultant effect on neuronal function is likely to be important in the development of involuntary movements and epilepsy. Overall, our findings provide further evidence for the key role of Cav2.2 in normal human neurodevelopment.MAK is funded by an NIHR Research Professorship and receives funding from the Wellcome Trust, Great Ormond Street Children's Hospital Charity, and Rosetrees Trust. E.M. received funding from the Rosetrees Trust (CD-A53) and Great Ormond Street Hospital Children's Charity. K.G. received funding from Temple Street Foundation. A.M. is funded by Great Ormond Street Hospital, the National Institute for Health Research (NIHR), and Biomedical Research Centre. F.L.R. and D.G. are funded by Cambridge Biomedical Research Centre. K.C. and A.S.J. are funded by NIHR Bioresource for Rare Diseases. The DDD Study presents independent research commissioned by the Health Innovation Challenge Fund (grant number HICF-1009-003), a parallel funding partnership between the Wellcome Trust and the Department of Health, and the Wellcome Trust Sanger Institute (grant number WT098051). We acknowledge support from the UK Department of Health via the NIHR comprehensive Biomedical Research Centre award to Guy's and St. Thomas' National Health Service (NHS) Foundation Trust in partnership with King's College London. This research was also supported by the NIHR Great Ormond Street Hospital Biomedical Research Centre. J.H.C. is in receipt of an NIHR Senior Investigator Award. The research team acknowledges the support of the NIHR through the Comprehensive Clinical Research Network. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, Department of Health, or Wellcome Trust. E.R.M. acknowledges support from NIHR Cambridge Biomedical Research Centre, an NIHR Senior Investigator Award, and the University of Cambridge has received salary support in respect of E.R.M. from the NHS in the East of England through the Clinical Academic Reserve. I.E.S. is supported by the National Health and Medical Research Council of Australia (Program Grant and Practitioner Fellowship)

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Control of membrane excitability by potassium and chloride leak conductances

The permeability of the neuronal membrane to different ions determines both resting membrane potential (RMP) and input conductance. These parameters determine the cells response to synaptic input. In this thesis I have examined how the molecular properties of potassium and chloride ion channels can influence neuronal excitability in ways that have not previously been considered. For example, two‐pore domain potassium (K2P) channels open at rest to generate a persistent potassium ion efflux. In addition to its accepted role in setting the RMP, I have tested the hypothesis that this conductance is sufficient to repolarise the membrane during an action potential (AP) in the absence of voltage‐dependent potassium channels (Kv). We tested this prediction using heterologous expression of TASK3 or TREK1 K2P channels combined with conductance injection to simulate the presence of a voltage‐gated sodium conductance. These experiments demonstrated that K2P channels are sufficient to support APs during short and prolonged depolarising current pulses. The membranes permeability to chloride ions can also be affected by extrasynaptic GABAA receptors containing the delta subunit (δ‐GABAARs) that produce a tonic conductance due to their high apparent affinity for GABA. The anaesthetics Propofol and THIP are both believed to alter neuronal excitability by enhancing this persistent chloride flux. We have examined how this anaesthetic action is affected by the steady‐state ambient GABA concentrations that are believed to exist in vivo. Surprisingly, the anaesthetic enhancement of δ‐GABAARs is lost at low ambient GABA concentrations. Therefore, I would suggest that the anaesthetic potency of these drugs is affected by the resting ambient GABA concentration in a manner that has not previously been appreciated. In the current Thesis I have examined the molecular and pharmacological properties of two very different ion channel families that both generate a leak conductance, and I will present models that link the behaviour of these ion channels to their ability to modulate neuronal excitability.EThOS - Electronic Theses Online ServiceBiotechnology and Biological Sciences Research CouncilGBUnited Kingdo

Control of membrane excitability by potassium and chloride leak conductances

The permeability of the neuronal membrane to different ions determines both resting membrane potential (RMP) and input conductance. These parameters determine the cells response to synaptic input. In this thesis I have examined how the molecular properties of potassium and chloride ion channels can influence neuronal excitability in ways that have not previously been considered. For example, two‐pore domain potassium (K2P) channels open at rest to generate a persistent potassium ion efflux. In addition to its accepted role in setting the RMP, I have tested the hypothesis that this conductance is sufficient to repolarise the membrane during an action potential (AP) in the absence of voltage‐dependent potassium channels (Kv). We tested this prediction using heterologous expression of TASK3 or TREK1 K2P channels combined with conductance injection to simulate the presence of a voltage‐gated sodium conductance. These experiments demonstrated that K2P channels are sufficient to support APs during short and prolonged depolarising current pulses. The membranes permeability to chloride ions can also be affected by extrasynaptic GABAA receptors containing the delta subunit (δ‐GABAARs) that produce a tonic conductance due to their high apparent affinity for GABA. The anaesthetics Propofol and THIP are both believed to alter neuronal excitability by enhancing this persistent chloride flux. We have examined how this anaesthetic action is affected by the steady‐state ambient GABA concentrations that are believed to exist in vivo. Surprisingly, the anaesthetic enhancement of δ‐GABAARs is lost at low ambient GABA concentrations. Therefore, I would suggest that the anaesthetic potency of these drugs is affected by the resting ambient GABA concentration in a manner that has not previously been appreciated. In the current Thesis I have examined the molecular and pharmacological properties of two very different ion channel families that both generate a leak conductance, and I will present models that link the behaviour of these ion channels to their ability to modulate neuronal excitability.EThOS - Electronic Theses Online ServiceBiotechnology and Biological Sciences Research CouncilGBUnited Kingdo

G(alpha)q-mediated regulation of TASK3 two-pore domain potassium channels: the role of protein kinase C.

The TASK subfamily of two pore domain potassium channels (K2P) gives rise to leak potassium currents, which contribute to the resting membrane potential of many neurons and regulate their excitability. K2P channels are highly regulated by phosphorylation and by G protein-mediated pathways. In this study, we show that protein kinase C (PKC) inhibits recombinant TASK3 channels. Inhibition by PKC is blocked by the PKC inhibitors bisindolylmaleimide 1 hydrochloride (BIM) and 12-(2-cyanoethyl)-6,7,12,13-tetrahydro-13-methyl-5-oxo-5H-indolo(2,3-a)pyrrolo(3,4-c)-carbazole (Gö6976). Gene-silencing experiments with a validated small interfering RNA sequence against PKCalpha ablates the effect of PKC. PKC acts directly on hTASK3 channels to phosphorylate an identified amino acid in the C terminus region (Thr341), thereby reducing channel current. PKC also inhibits mTASK3 channels despite their having a quite different C-terminal structure to hTASK3 channels. Activation of M(3) muscarinic receptors inhibits both hTASK3 channels expressed in tsA-201 cells and standing outward potassium current (IK(SO)) in mouse cerebellar granule neurons through the activation of the G protein Galpha(q), because both effects are abolished by the selective Galpha(q) antagonist YM-254890 (J Biol Chem 279:47438-47445, 2004). This inhibition is not directly transduced through activation of PKC because inhibition persists in mutated PKC-insensitive hTASK3 channels. Instead, inhibition seems to occur through a direct action of Galpha(q) on the channel. Nevertheless, preactivation of PKC blocks muscarinic inhibition of both TASK3 channels and IK(SO). Our results suggest that activation of PKC (via phospholipase C) has a role in opposing inhibition after M(3) receptor activation rather than transducing it and may act as a negative regulator of G protein modulation to prevent prolonged current inhibition

Effect of Noninvasive Respiratory Strategies on Intubation or Mortality Among Patients With Acute Hypoxemic Respiratory Failure and COVID-19: The RECOVERY-RS Randomized Clinical Trial.

Importance Continuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO) have been recommended for acute hypoxemic respiratory failure in patients with COVID-19. Uncertainty exists regarding the effectiveness and safety of these noninvasive respiratory strategies. Objective To determine whether either CPAP or HFNO, compared with conventional oxygen therapy, improves clinical outcomes in hospitalized patients with COVID-19-related acute hypoxemic respiratory failure. Design, Setting, and Participants A parallel group, adaptive, randomized clinical trial of 1273 hospitalized adults with COVID-19-related acute hypoxemic respiratory failure. The trial was conducted between April 6, 2020, and May 3, 2021, across 48 acute care hospitals in the UK and Jersey. Final follow-up occurred on June 20, 2021. Interventions Adult patients were randomized to receive CPAP (n = 380), HFNO (n = 418), or conventional oxygen therapy (n = 475). Main Outcomes and Measures The primary outcome was a composite of tracheal intubation or mortality within 30 days. Results The trial was stopped prematurely due to declining COVID-19 case numbers in the UK and the end of the funded recruitment period. Of the 1273 randomized patients (mean age, 57.4 [95% CI, 56.7 to 58.1] years; 66% male; 65% White race), primary outcome data were available for 1260. Crossover between interventions occurred in 17.1% of participants (15.3% in the CPAP group, 11.5% in the HFNO group, and 23.6% in the conventional oxygen therapy group). The requirement for tracheal intubation or mortality within 30 days was significantly lower with CPAP (36.3%; 137 of 377 participants) vs conventional oxygen therapy (44.4%; 158 of 356 participants) (absolute difference, -8% [95% CI, -15% to -1%], P = .03), but was not significantly different with HFNO (44.3%; 184 of 415 participants) vs conventional oxygen therapy (45.1%; 166 of 368 participants) (absolute difference, -1% [95% CI, -8% to 6%], P = .83). Adverse events occurred in 34.2% (130/380) of participants in the CPAP group, 20.6% (86/418) in the HFNO group, and 13.9% (66/475) in the conventional oxygen therapy group. Conclusions and Relevance Among patients with acute hypoxemic respiratory failure due to COVID-19, an initial strategy of CPAP significantly reduced the risk of tracheal intubation or mortality compared with conventional oxygen therapy, but there was no significant difference between an initial strategy of HFNO compared with conventional oxygen therapy. The study may have been underpowered for the comparison of HFNO vs conventional oxygen therapy, and early study termination and crossover among the groups should be considered when interpreting the findings. Trial Registration isrctn.org Identifier: ISRCTN16912075