Objective: To determine whether tight control of blood pressure with either a beta blocker or an angiotensin converting enzyme inhibitor has a specific advantage or disadvantage in preventing the macrovascular and microvascular complications of type 2 diabetes.Design: Randomised controlled trial comparing an angiotensin converting enzyme inhibitor (captopril) with a beta blocker (atenolol) in patients with type 2 diabetes aiming at a blood pressure of < 150/ < 85 mm Hg.Setting 20 hospital based clinics in England, Scotland, and Northern Ireland.Subjects: 1148 hypertensive patients with type 2 diabetes(mean age 56 years, mean blood pressure 160/94 mm Hg). Of the 758 patients allocated to tight control of blood pressure, 400 were allocated to captopril and 358 to atenolol. 390 patients were allocated to less tight control of blood pressure.Main outcome measures: Predefined clinical end points, fatal and non-fatal, related to diabetes, death related to diabetes, and all cause mortality. Surrogate measures of microvascular and macrovascular disease included urinary albumin excretion and retinopathy assessed by retinal photography.Results: Captopril and atenolol were equally effective in reducing blood pressure to a mean of 144/83 mm Hg and 143/81 mm Hg respectively, with a similar proportion of patients (27% and 31%) requiring three or more antihypertensive treatments. More patients in the captopril group than the atenolol group took the allocated treatment: at their last clinic visit, 78% of those allocated captopril and 65% of those allocated atenolol were taking the drug (P < 0.0001). Captopril and atenolol were equally effective in reducing the risk of macrovascular end points. Similar proportions of patients in the true groups showed deterioration in retinopathy by two grades after nine years (31% in the captopril group and 37% in the atenolol group) and developed clinical grade albuminuria greater than or equal to 300 mg/l (5% and 9%). The proportion of patients with hypoglycaemic attacks was not different between groups, but mean weight gain in the atenolol group was greater (3.4 kg v 1.6 kg).Conclusion: Blood pressure lowering with captopril or atenolol was similarly effective in reducing the incidence of diabetic complications. This study provided no evidence that either drug has any specific beneficial or deleterious effect, suggesting that blood pressure reduction in itself may be more important than the treatment used.

Objective: To determine whether tight control of blood pressure prevents macrovascular and microvascular complications in patients with type 2 diabetes.Design: Randomised controlled trial comparing tight control of blood pressure aiming at a blood pressure of <150/85 mm Hg (with the use of an angiotensin converting enzyme inhibitor captopril or a beta blocker atenolol as main treatment) with less tight control aiming at a blood pressure of <.180/105 mm Hg.Setting 20 hospital based clinics in England, Scotland, and Northern Ireland.Subjects: 1148 hypertensive patients with type 2 diabetes (mean age 56, mean blood pressure at entry 160/94 mm Hg); 758 patients were allocated to tight control of blood pressure and 390 patients to less tight control with a median follow up of 8.4 years.Main outcome measures: Predefined clinical end points, fatal and non-fatal, related to diabetes, deaths related to diabetes, and all cause mortality. Surrogate measures of microvascular disease included urinary albumin excretion and retinal photography.Results: Mean blood pressure during follow up was significantly reduced in the group assigned tight blood pressure control (144/82 mm Hg) compared with the group assigned to less tight control (154/87 mm Hg) (P< 0.0001). Reductions in risk in the group assigned to tight control compared with that assigned to less tight control were 24% in diabetes related end points (95% confidence interval 8% to 38%) (P= 0.0046), 32% in deaths related to diabetes (6% to 51%) (P= 0.019), 44% in strokes (11% to 65%) (P= 0.013), and 37% in microvascular end points (11% to 56%) (P= 0.0092), predominantly owing to a reduced risk of retinal photocoagulation. There was a non-significant reduction in all cause mortality. After nine years of follow up the group assigned to tight blood pressure control also had a 34% reduction in risk in the proportion of patients with deterioration of retinopathy by two steps (99% confidence interval 11% to 50%) (P= 0.0004) and a 47% reduced risk (7% to 70%) (P = 0.004) of deterioration in visual acuity by three lines of the early treatment of diabetic retinopathy study (ETDRS) chart. After nine years of follow up 29% of patients in the group assigned to tight control required three or more treatments to lower blood pressure to achieve target blood pressures.Conclusion: Tight blood pressure control in patients with hypertension and type 2 diabetes achieves a clinically important reduction in the risk of deaths related to diabetes, complications related to diabetes, progression of diabetic retinopathy, and deterioration in visual acuity.

Objectives: To estimate the economic efficiency of tight blood pressure control, with angiotensin converting enzyme inhibitors or beta blockers, compared with less tight control in hypertensive patients with type 2 diabetes.Design: Cost effectiveness analysis incorporating within trial analysis and estimation of impact on life expectancy through use of the within trial hazards of reaching a defined clinical end point Use of resources driven by trial protocol and use of resources in standard clinical practice were both considered.Setting: 20 hospital based clinics in England, Scotland, and Northern Ireland.Subjects: 1148 hypertensive patients with type 2 diabetes from UK prospective diabetes study randomised to tight control of blood pressure (n = 758) or less tight control (n = 390).Main outcome measure: Cost effectiveness ratios based on (a) use of healthcare resources associated with tight control and less tight control and treatment of complications and (b) within trial time free from diabetes related end points, and life years gained.Results: Based an use of resources driven by trial protocol, the incremental cost effectiveness of tight control compared with less tight control was cost saving. Based on use of resources in standard clinical practice, incremental cost per extra year free from end points amounted to pound 1049 (costs and effects discounted at 6'% per year) and pound 434 (costs discounted at 6%, per year and effects not discounted). The incremental cost per life year gained was pound 720 (costs and effects discounted at 6% per year) and pound 291 (costs discounted at 6% per year and effects not discounted).Conclusions: Tight control of blood pressure in hypertensive patients with type 2 diabetes substantially reduced the cost of complications, increased the interval without complications and survival, and had a cost effectiveness ratio that compares favourably with many accepted healthcare programmes.

Control of cell proliferation is dependent on the regulated expression of the cyclin genes. Induction of cyclin B1 gene expression in S phase has been shown to require sequences within the first 90 bp of the proximal promoter region. In this study, we defined the cell cycle regulatory elements within this region and explored the mechanism by which the cyclin B1 gene is activated. A CDE-like element that is important in S-phase regulation of other genes was not required for correct cell cycle expression of cyclin B1. Instead, two CCAAT boxes were essential for S-phase induction of cyclin B1 gene in both NIH3T3 and HeLa cells. Induction of cyclin B1 by cyclin/cyclin-dependent kinase (cdk) complexes were examined by cotransfection of the reporter along with appropriate expression vectors. Complexes of cdk4 with cyclin D1 or cdk2 with cyclin E or A can activate the cyclin B1 promoter, and activation is uniquely dependent on the CCAAT elements in both normal and heterologous contexts. This transcription factor NF-Y binds to both CCAAT elements. These findings suggest that S phase-specific induction of the cyclin B1 promoter is dependent upon NF-Y binding to the CCAAT elements and is correlated with activation by cyclin-dependent kinases.

The promoter of the cell cycle regulated histone FO108 H4 gene is mediated by two in vivo protein/DNA interaction domains, sites I and II. We have shown previously that site II mediates the cell cycle controlled enhancement of H4 gene transcription at the G1/S phase boundary. Here we show that site I, an element containing both G-rich and ATF-like consensus sequences, confers maximal levels of transcription in proliferating cells. By the combined application of gel shift assays with site-directed mutagenesis, DNase I footprinting, oligonucleotide competition, in vitro expression of recombinant proteins, and specific antibody supershift studies, we demonstrate that the proximal G-rich sequence within site I interacts with the transcription factor Sp1, while the distal portion of site I interacts with members of the ATF family of proteins, including ATF-1. In vitro transcription studies as well as expression assays of transiently and stably transfected genes in HeLa cells reveal that the deletion of site I causes a dramatic decrease in expression. Mutation of the Sp1 element, which abolishes Sp1 binding, results in a 6-10-fold reduction in reporter activity. In addition, overexpression of Sp1 in Sp1-deficient cells results in the dramatic activation of the histone promoter. In contrast, mutation of the asymmetric ATF binding site, located distally within site I, has a more limited effect upon expression. Interestingly, the contribution of the Sp1 site to maximal transcription was cell type dependent. Thus, we demonstrate that the Sp1 binding site of the site I histone H4 promoter in particular is critical for maximal expression in living cells and postulate that this site may act to amplify the cell cycle response.

The proximal promoter of the human H4 histone gene FO108 contains two regions of in vivo protein-DNA interaction, Sites I and II, electrophoretic mobility shift assays using a radiolabeled DNA probe revealed that several proteins present in Hela cell nuclear extracts bound specifically to Site 1 (nt-125 to nt-86). The most prominent complex, designated HiNF-C, and a complex of greater mobility, HiNF-C', using were specifically competed by an Sp1 consensus oligonucleotide. Fractionation of HiNF-C using wheat germ agglutinin affinity chromatography suggested that, like Sp1, HiNF-C contains N-acetylglucosamine moieties. Two minor complexes of even greater mobility, designated HiNF-E and F, were competed by ATF consensus oligonucleotides. A DNA probe carrying a site-specific mutation in the distal portion of Site I failed to bind HiNF-E, indicating that this protein associated specifically to this region. UV cross-linking analysis showed that several proteins of different molecular weights interact specifically with Site I. These data indicate that Site I possesses a bipartite structure and that multiple proteins present in HeLa cell nuclear extracts interact specifically with Site I sequences. (C) 1995 Wiley-Liss, Inc.

The proliferation-specific transcription factor complex HiNF-D interacts with sequence specificity in a proximal promoter element of the human H4 histone gene FO108, designated Site II. The occupancy of Site II by HiNF-D has been implicated in proper transcription initiation and as a component of the cell cycle regulation of this gene. In the present study we have investigated the role of the HiNF-D/Site II interaction in controlling the level of H4 histone gene transcription during modifications of normal cellular growth. HiNF-D binding activity is present at high levels in rapidly proliferating cultures of human diploid fibroblasts and is reduced to less than 2% upon the cessation of proliferation induced by serum deprivation of sparsely populated fibroblast cultures. Density-dependent quiescence also abolishes HiNF-D binding activity. Downregulation of transcription from the H4 gene occurs concomitant with the loss of the HiNF-D/Site II interaction, further suggesting a functional relationship between Site II occupancy and the capacity for transcription. Serum stimulation of quiescent preconfluent cells results in an increase in HiNF-D binding activity as the cells are resuming DNA synthesis and H4 histone gene transcription. Density-inhibited quiescent cells respond to serum stimulation with only a minimal increase in the HiNF-D binding activity, 30% of maximal levels. However, H4 histone gene transcription is stimulated to a level equal to that detected in extracts of the sparsely populated serum-stimulated cultures. These results suggest that there is a threshold level of HiNF-D binding activity necessary for the activation of H4 histone gene transcription. Additionally, these findings suggest that there may be a mechanism repressing HiNF-D binding activity in the density-inhibited cultures which is not operative in the sparsely populated, serum-deprived cultures. Density-inhibited cultures may have reached a state analogous to the initial steps of differentiation and have invoked a series of mechanisms to decrease expression of proliferation-specific factors. Serum stimulation is able to overcome the one mechanism downregulating HiNF-D in both sparsely populated and density-inhibited quiescent cultures but is unable to reverse the repression of proliferation-specific factors that occurs in density-inhibited cultures. These results are consistent with the presence of at least two levels of control over the HiNF-D/Site II interaction which are responsive to and reflect the proliferative state of the cell and the extent to which the cell exhibits properties associated with differentiation.

We have identified a nuclear matrix-attachment region within an upstream element of a human H4 histone gene promoter. Nuclear matrix proteins, isolated and solubilized from HeLa S3 cells, were found to interact with sequence specificity at this matrix-attachment region. Several types of assays for protein-DNA interaction showed that the minimal sequence for the nuclear matrix protein-DNA interaction was 5'-TGACGTCCATG-3'; the underlined region corresponds to the core consensus sequence for ATF transcription factor binding. Two proteins with molecular masses of 43 and 54 kDa were identified by UV-crosslinking analysis as integral components of this protein-DNA complex. The molecular masses of these proteins and the ATF-binding site consensus sequence suggest that these proteins are members of the ATF family. Our results provide direct evidence for nuclear matrix localization of sequence-specific DNA-binding factors for an actively transcribed gene. The proximity of a strong positive transcriptional regulatory element to the matrix-attachment region of this gene suggests that the nuclear matrix may serve to localize and concentrate trans-acting factors that facilitate regulation of gene expression.

Regulation of the cell cycle-controlled histone gene promoter factor HiNF-D was examined in vivo. Proliferative activity was measured by DNA replication-dependent histone mRNA levels, and HiNF-D binding activity was found to correlate with cell proliferation in most tissues. Furthermore, HiNF-D is down-regulated during hepatic development, reflecting the onset of differentiation and quiescence. The contribution of transcription to histone gene expression was directly addressed in transgenic mice by using a set of fusion constructs containing a human H4 histone gene promoter linked to three different genes. Transgene expression in both fetal and adult mice paralleled endogenous mouse histone mRNA levels in most tissues, consistent with this promoter conferring developmental, cell growth-related transcriptional regulation. Our results suggest that HiNF-D is stringently regulated in vivo in relation to cell growth and support a primary role for HiNF-D in the proliferation-specific expression of H4 histone genes in the intact animal. Further, the data presented here provide an example in which apparent tissue specificity of gene expression reflects the proliferative state of various tissues and demonstrate that multiple levels of histone gene regulation are operative in vivo.

Osteocalcin, a bone-specific protein and marker of the mature osteoblast, is expressed only in nonproliferating osteoblasts in a mineralizing extracellular matrix, while type I collagen is expressed in proliferating cells. The nuclear proteins encoded by the c-fos and c-jun protooncogenes are expressed during the proliferation period of osteoblast phenotype development. We present evidence that AP-1 (HeLa cell-activating protein 1) sites residing within two promoter elements of the osteocalcin gene bind the Fos-Jun protein complex: the osteocalcin box (OC box; nucleotides -99 to -76), which contains a CCAAT motif as a central element and influences tissue-specific basal levels of osteocalcin gene transcription, and the vitamin D-responsive element (VDRE; nucleotides -462 to -440), which mediates enhancement of osteocalcin gene transcription. Gel electrophoretic mobility-shift analysis demonstrated high AP-1 binding activity in proliferating osteoblasts and dramatic changes in this activity after the down-regulation of proliferation and the initiation of extracellular-matrix mineralization in primary cultures of normal diploid osteoblasts. Methylation interference analysis established at single nucleotide resolution that purified recombinant Fos and Jun proteins bind in a sequence-specific manner to the AP-1 sites within the VDRE and OC box. Similarly, an AP-1 motif within a putative VDRE of the alkaline phosphatase gene, which is also expressed after the completion of proliferation, binds the Fos-Jun complex. These results support a model in which coordinate occupancy of the AP-1 sites in the VDRE and OC box in proliferating osteoblasts may suppress both basal level and vitamin D-enhanced osteocalcin gene transcription as well as transcription of other genes associated with osteoblast differentiation--a phenomenon we describe as phenotype suppression. This model is further supported by binding of the Fos-Jun complex at an AP-1 site in the type alpha I collagen promoter that is contiguous with, but not overlapping, the VDRE. Such a sequence organization in the collagen VDRE motif is compatible with vitamin D modulation of collagen but not with osteocalcin and alkaline phosphatase expression in proliferating osteoblasts.

The proximal promoter of the human H4 histone gene F0108 contains two in vivo protein binding domains, sites I and II. In this report we show that these sequences interact with three nuclear factors: HiNF-D, HiNF-C, and HiNF-A. HiNF-C is a metal ion-requiring protein that binds to an Sp1 consensus binding site. HiNF-C and HiNF-A bind independently to the distally located site I, possibly in conjunction with other proteins, and deletion of site I reduces transcription rates 4- to 6-fold in vitro. Factor HiNF-D binds to an H4 histone-specific element (5'-dGGTPyPyTCAATCNG-GTCCG, where Py indicates pyrimidine) present in site II that has previously been shown to be essential for in vivo expression of this H4 histone gene. All three binding activities are present in human HeLa S3 cells throughout the cell cycle and in exponentially growing mouse C127 and human HL60 cells. This result is consistent with the transcription of H4 histone genes throughout the cell cycle. However, unlike HiNF-A and HiNF-C, HiNF-D is not present in terminally differentiated HL60 cells, in which histone gene transcription is down-regulated. These findings suggest a crucial role for HiNF-D, with an auxiliary role for HiNF-C and possibly HiNF-A, in the regulation of H4 histone gene transcription. Furthermore, the conservation of potential HiNF-D binding sites in mammalian H4 histone gene promoters suggests that HiNF-D has an essential role in the coordinate transcriptional down-regulation of the H4 histone multigene subfamily during the shutdown of proliferation.

The 5' region of a cell cycle regulated human H1 histone gene appears to contain at least six promoter DNA elements that are shared with some, but not all human core (H2A, H2B, H3 and H4) histone genes. We show that two of these elements represent separate binding sites for two distinct, partially purified factors. The first promoter domain contains A/T rich repeats and is involved in the binding of HiNF-A, a nuclear factor previously found to bind to A/T rich direct repeats in the promoters of human H4 and H3 histone genes. The second domain, containing the general promoter element 5' dACCAAT, acts as a binding site for a two component mosaic factor we have designated HiNF-B. These data suggest that coordinate transcriptional regulation of human H1 and core histone genes may involve two classes of trans-acting factors: those specific for histone gene promoters and those that act on a broad spectrum of human gene promoters.

The human H1 histone gene FNC16 resides in a 2.7-kb EcoRI fragment present in a histone gene cluster that also contains one copy of each of the core (H2A, H2B, H3, and H4) histone genes. The cap site for FNC16 H1 mRNA is located 58 nucleotides upstream of the ATG translational start codon, and S1 nuclease protection analysis clearly distinguishes between correctly initiated FNC16 transcripts and transcripts from other nonidentical H1 histone genes. We have observed, using S1 analysis, that the FNC16 H1 histone gene is expressed in a replication-dependent manner in HeLa cells and is expressed in proliferating, but down-regulated in differentiated, HL60 cells. Similar results were found in HeLa S3 and HL60 cells for the cell cycle-dependent human H4 histone gene FO108. Nuclear extracts derived from HeLa S3 cells are capable of directing FNC16 H1 histone gene transcription in vitro. This finding is consistent with previous work that established at least two sites for protein-DNA interaction in vitro in the proximal promoter region of this gene. We have observed a difference in the extent to which the FNC16 H1 histone gene is expressed in HeLa S3 and proliferating HL60 cells, which suggests that this H1 gene is differentially regulated in various cell types. Although results reported for a potentially identical human H1 histone gene designated Hh8C (LaBella, F., Zhong, R., and Heintz, N. (1988) J. Biol. Chem. 263, 2115-2118) support differential regulation of human H1 genes in various cell types, their observations that the Hh8C gene is not expressed in HeLa cells and that the restriction patterns differ indicate that FNC16 and Hh8C are different H1 genes.