Biological mechanisms behind clozapine-induced agranulocytosis

Clozapine is the most effective drug in treating therapy-resistant schizophrenia and may even be superior to all other antipsychotics. However, its use is limited by a high incidence (approximately 0.8%) of a severe hematological side effect, agranulocytosis. The exact molecular mechanism(s) of clozapine-induced agranulocytosis is still unknown. We investigated the mechanisms behind responsiveness to clozapine therapy and the risk of developing agranulocytosis by performing an HLA (human leukocyte antigens) association study in patients with schizophrenia. The first group comprised patients defined by responsiveness to first-generation antipsychotics (FGAs) (n= 19). The second group was defined by a lack of response to FGAs but responsiveness to clozapine (n=19). The third group of patients had a history of clozapine-induced granulocytopenia or agranulocytosis (n=26). Finnish healthy blood donors served as controls (n= 120). We found a significantly increased frequency of HLA-A1 among patients who were refractory to FGAs but responsive to clozapine. We also found that the frequency of HLA-A1 was low in patients with clozapine-induced neutropenia or agranulocytosis. These results suggest that HLA-A1 may predict a good therapeutic outcome and a low risk of agranulocytosis and therefore HLA typing may aid in the selection of patients for clozapine therapy. Furthermore, in a subgroup of schizophrenia, HLA-A1 may be in linkage disequilibrium with some vulnerability genes in the MHC (major histocompatibility complex) region on chromosome 6. These genes could be involved in antipsychotic drug response and clozapine-induced agranulocytosis. In addition, we investigated the effect of clozapine on gene expression in granulocytes by performing a microarray analysis on blood leukocytes of 8 schizophrenic patients who had started clozapine therapy for the first time. We identified an altered expression in 4 genes implicated in the maturation or apoptosis of granulocytes: MPO (myeloperoxidase precursor), MNDA (myeloid cell nuclear differentiation antigen), FLT3LG (Fms-related tyrosine kinase 3 ligand) and ITGAL (antigen CD11A, lymphocyte function-associated antigen 1). The altered expression of these genes following clozapine administration may suggest their involvement in clozapine-induced agranulocytosis. Finally, we investigated whether or not normal human bone marrow mesenchymal stromal cells (MSC) are sensitive to clozapine. We treated cultures of human MSCs and human skin fibroblasts with 10 µM of unmodified clozapine and with clozapine bioactivated by oxidation. We found that, independent of bioactivation, clozapine was cytotoxic to MSCs in primary culture, whereas clozapine at the same concentration stimulated the growth of human fibroblasts. This suggests that direct cytotoxicity to MSCs is one possible mechanism by which clozapine induces agranulocytosis.

Benchmark scenarios for the NMSSM

We discuss constrained and semi--constrained versions of the next--to--minimal supersymmetric extension of the Standard Model (NMSSM) in which a singlet Higgs superfield is added to the two doublet superfields that are present in the minimal extension (MSSM). This leads to a richer Higgs and neutralino spectrum and allows for many interesting phenomena that are not present in the MSSM. In particular, light Higgs particles are still allowed by current constraints and could appear as decay products of the heavier Higgs states, rendering their search rather difficult at the LHC. We propose benchmark scenarios which address the new phenomenological features, consistent with present constraints from colliders and with the dark matter relic density, and with (semi--)universal soft terms at the GUT scale. We present the corresponding spectra for the Higgs particles, their couplings to gauge bosons and fermions and their most important decay branching ratios. A brief survey of the search strategies for these states at the LHC is given.

Major histocompatibility complex and coronary artery disease: Special emphasis on Chlamydia pneumoniae, and periodontitis

Most of the genes in the MHC region are involveed in adaptive and innate immunity, with essential function in inflammatory reactions and in protection against infections. These genes might serve as a candidate region for infection and inflammation associated diseases. CAD is an inflammatory disease. The present set of studies was performed to assess whether the MHC region harbors genetic markers for CAD, and whether these genetic markers explain the CAD risk factors: e.g., C. pneumoniae, periodontitis, and periodontal pathogens. Study I was performed using two separate patient materials and age- and sex-matched healthy controls, categorizing them into two independent studies: the HTx and ACS studies. Both studies consistently showed the HLA-A3– B35– DR1 (35 ancestral haplotype) haplotype as a susceptible MHC genetic marker for CAD. HLA-DR1 alone was associated not only with CAD, but also with CAD risk factor diseases, e.g., diabetes mellitus, and hyperlipidemia. The ACS study further showed the HLA-B*07 and -DRB1*15 -related haplotype as a protective MHC haplotype for CAD. Study II showed that patients with CAD showed signs of chronic C. pneumoniae infection when compared to age- and sex-matched healthy controls. HLA-B*35 or -related haplotypes associated with the C. pneumoniae infection markers. Among these haplotype carriers, males and smokers associated with elevated C. pneumoniae infection markers. Study III showed that CAD patients with periodontitis had elevated serum markers of P. gingivalis and occurrence of the pathogen in saliva. LTA+496C strongly associated with periodontitis, while HLA-DRB1*01 with periodontitis and with the elevated serum antibodies of P. gingivalis. Study IV showed that the increased level of C3/C4 ratio was a new risk factor and was associated with recurrent cardiovascular end-points. The increased C3 and decreased C4 concentrations in serum explained the increased level of the C3/C4 ratio. Both the higher than cut-off value (4.53) and the highest quartile of the C3/C4 ratio were also associated with worst survival, increased end-points, and C4 null alleles. The presence of C4 null alleles associated with decreased serum C4 concentration, and increased C3/C4 ratio. In conclusion, the present studies show that the CAD susceptibility haplotype (HLA-A3− B35− DR1 -related haplotypes, Study I) partially explains the development of CAD in patients possessing several recognized and novel risk factors: diabetes mellitus, increased LDL, smoking, C4B*Q0, C. pneumnoiae, periodontitis, P. gingivalis, and complement C3/C4 ratio (Study II, III, and IV).

Effect of compatibilization on mechanical and thermal properties of polypropylene–soy flour composites

A new biobased composite was developed by adding soy flour (SF) to polypropylene (PP). This composite shows an enhanced tensile strength and modulus but decrease in elongation at break. The compatibilizer (coupling agent) appears to have a synergistic effect on tensile strength. The presence of the compatibilizer improves the dispersion of SF in the PP matrix. The addition of glycerol plasticizer to the composite improves the processability resulting in improved performance, as compared to composites without glycerol plasticizer. The optimal compatibilizer content appears to be 6%.

Induced swelling of kaolinitic soil in alkali solution

Unexpected swelling induced in foundation soils can cause distress to structures founded on them. In this paper, the swelling of kaolinitic soils due to interaction with alkali solution has been reported. The induced swelling is attributed to the formation of new minerals, which has been confirmed by X-ray diffraction patters and SEM studies. To understand the effect of alkali concentration and duration of interaction, two series of consolidation experiments have been carried out. In series 1, the specimen were remoulded with water and inundated with alkali solutions and in series 2, the specimen were remoulded and inundated with same alkali solutions. A steep compression during loading cycle and no abnormal swelling during unloading cycle has been noticed for the specimen remoulded with water and inundated with 1 N NaOH solutions. The steep compression is due to the segregation or break down of clay minerals due to alkali interactions. In case of specimen inundated with 4 N NaOH solutions, abnormal swelling has been observed during unloading cycle of the consolidation test. New minerals are formed on interaction of soil with 4 N solution as confirmed by X-ray diffraction patterns. These minerals are known to have very fine pores and possess high water holding capacity. The differences in the amount of swelling of samples remoulded with water and remoulded with alkali solution are due to variations in the concentration of alkali and duration of interaction.

Discrete parameter simulation optimization algorithms with applications to admission control with dependent service times

We propose certain discrete parameter variants of well known simulation optimization algorithms. Two of these algorithms are based on the smoothed functional (SF) technique while two others are based on the simultaneous perturbation stochastic approximation (SPSA) method. They differ from each other in the way perturbations are obtained and also the manner in which projections and parameter updates are performed. All our algorithms use two simulations and two-timescale stochastic approximation. As an application setting, we consider the important problem of admission control of packets in communication networks under dependent service times. We consider a discrete time slotted queueing model of the system and consider two different scenarios - one where the service times have a dependence on the system state and the other where they depend on the number of arrivals in a time slot. Under our settings, the simulated objective function appears ill-behaved with multiple local minima and a unique global minimum characterized by a sharp dip in the objective function in a small region of the parameter space. We compare the performance of our algorithms on these settings and observe that the two SF algorithms show the best results overall. In fact, in many cases studied, SF algorithms converge to the global minimum.

Impact resistance and evaluation of retained strength on geotextiles

Over the last few decades, geotextiles have progressively been incorporated into geotechnical applications, especially in the field of coastal engineering. Geotextile materials often act as separator and a filter layer between rocks laid above and subgrade beneath. This versatile material has gradually substituted traditional granular materials because of its ease of installation, consistent quality and labour costefficiency. However, geotextiles often suffer damage during installation due to high dynamic bulk loading of rock placement. This can degrade geotextiles' mechanical strength. The properties considered in this paper include the impact resistance and retained strength of geotextiles. In general, the greater the impact energy applied to geotextiles, the greater the potential for damage. Results highlight the inadequacy of using index derived values as an indicator to determine geotextile performance on site because test results shows that geotextiles (staple fibre (SF) and continuous filament (CF)) with better mechanical properties did not outperform lower mechanical strength materials. The toughest CF product with a CBR index value of 9696N shows inferior impact resistance compared to SF product with the least CBR strength (2719N) given the same impact energy of 9.02 kJ. Test results also indicated that the reduction of strength for CF materials were much greater (between 20 and 50%) compared to SF materials (between 0 and 5%) when subjected to the same impact energy of 4.52 kJ.

Identifying Genetic Risk Factors in Canine Autoimmune Disorders

Autoimmune diseases are more common in dogs than in humans and are already threatening the future of some highly predisposed dog breeds. Susceptibility to autoimmune diseases is controlled by environmental and genetic factors, especially the major histocompatibility complex (MHC) gene region. Dogs show a similar physiology, disease presentation and clinical response as humans, making them an excellent disease model for autoimmune diseases common to both species. The genetic background of canine autoimmune disorders is largely unknown, but recent annotation of the dog genome and subsequent development of new genomic tools offer a unique opportunity to map novel autoimmune genes in various breeds. Many autoimmune disorders show breed-specific enrichment, supporting a strong genetic background. Furthermore, the presence of hundreds of breeds as genetic isolates facilitates gene mapping in complex autoimmune disorders. Identification of novel predisposing genes establishes breeds as models and may reveal novel candidate genes for the corresponding human disorders. Genetic studies will eventually shed light on common biological functions and interactions between genes and the environment. This study aimed to identify genetic risk factors in various autoimmune disorders, including systemic lupus erythematosus (SLE)-related diseases, comprising immune-mediated rheumatic disease (IMRD) and steroid-responsive meningitis arteritis (SMRA) as well as Addison s disease (AD) in Nova Scotia Duck Tolling Retrievers (NSDTRs) and chronic superficial keratitis (CSK) in German Shepherd dogs (GSDs). We used two different approaches to identify genetic risk factors. Firstly, a candidate gene approach was applied to test the potential association of MHC class II, also known as a dog leukocyte antigen (DLA) in canine species. Secondly, a genome-wide association study (GWAS) was performed to identify novel risk loci for SLE-related disease and AD in NSDTRs. We identified DLA risk haplotypes for an IMRD subphenotype of SLE-related disease, AD and CSK, but not in SMRA, and show that the MHC class II gene region is a major genetic risk factor in canine autoimmune diseases. An elevated risk was found for IMRD in dogs that carried the DLA-DRB1*00601/DQA1*005011/DQB1*02001 haplotype (OR = 2.0, 99% CI = 1.03-3.95, p = 0.01) and for ANA-positive IMRD dogs (OR = 2.3, 99% CI = 1.07-5.04, p-value 0.007). We also found that DLA-DRB1*01502/DQA*00601/DQB1*02301 haplotype was significantly associated with AD in NSDTRs (OR = 2.1, CI = 1.0-4.4, P = 0.044) and the DLA-DRB1*01501/DQA1*00601/DQB1*00301 haplotype with the CSK in GSDs (OR=2.67, CI=1.17-6.44, p= 0.02). In addition, we found that homozygosity for the risk haplotype increases the risk for each disease phenotype and that an overall homozygosity for the DLA region predisposes to CSK and AD. Our results have enabled the development of genetic tests to improve breeding practices by avoiding the production of puppies homozygous for risk haplotypes. We also performed the first successful GWAS for a complex disease in dogs. With less than 100 cases and 100 controls, we identified five risk loci for SLE-related disease and AD and found strong candidate genes involved in a novel T-cell activation pathway. We show that an inbred dog population has fewer risk factors, but each of them has a stronger genetic risk. Ongoing studies aim to identify the causative mutations and bring new knowledge to help diagnostics, treatment and understanding of the aetiology of SLE-related diseases.

Japanese Encephalitis Virus Utilizes the Canonical Pathway To Activate NF-kappa B but It Utilizes the Type I Interferon Pathway To Induce Major Histocompatibility Complex Class I Expression in Mouse Embryonic Fibroblasts

Flaviviruses have been shown to induce cell surface expression of major histocompatibility complex class I (MHC-I) through the activation of NF-kappa B. Using IKK1(-/-), IKK2(-/-), NEMO-/-, and IKK1-/- IKK2-/- double mutant as well as p50(-/-) RelA(-/-) cRel(-/-) triple mutant mouse embryonic fibroblasts infected with Japanese encephalitis virus (JEV), we show that this flavivirus utilizes the canonical pathway to activate NF-kappa B in an IKK2- and NEMO-, but not IKK1-, dependent manner. NF-kappa B DNA binding activity induced upon virus infection was shown to be composed of RelA: p50 dimers in these fibroblasts. Type I interferon (IFN) production was significantly decreased but not completely abolished upon virus infection in cells defective in NF-kappa B activation. In contrast, induction of classical MHC-I (class 1a) genes and their cell surface expression remained unaffected in these NF-kappa B-defective cells. However, MHC-I induction was impaired in IFNAR(-/-) cells that lack the alpha/beta IFN receptor, indicating a dominant role of type I IFNs but not NF-kappa B for the induction of MHC-I molecules by Japanese encephalitis virus. Our further analysis revealed that the residual type I IFN signaling in NF-kappa B-deficient cells is sufficient to drive MHC-I gene expression upon virus infection in mouse embryonic fibroblasts. However, NF-kappa B could indirectly regulate MHC-I expression, since JEV-induced type I IFN expression was found to be critically dependent on it.

The Effects of Reduction Mammaplasty

Symptomatic hypertrophic breasts cause a health burden with physical and psychosocial morbidity. The value of reduction mammaplasty in the treatment of symptomatic breast hypertrophy has been consistently reported by patients and has been well recognised by plastic surgeons for a long time. However, the scientific evidence of the effects of reduction mammaplasty has been weak or lacking. During the design of this study most of the previous studies were retrospective and the few prospective studies had methodological limitations. Therefore, an obvious need for prospective randomised studies was present. Nevertheless, practical and ethical considerations seemed to make this study design impossible, because the waiting time for the operation was several years. The legislation and subsequent introduction of the uniform criteria for access to non-emergency treatment in Finland removed these obstacles, as all patients received their treatment within a reasonable time. As a result, a randomised controlled trial with a six-month follow-up time was designed and conducted. In addition, a follow-up study with two to five years follow-up was also carried out later. The effects of reduction mammaplasty on the patients breast-related symptoms, psychological symptoms, pain and quality of life was assessed. In addition, factors affecting the outcome were investigated. This study was carried out in the Hospital District of Helsinki and Uusimaa, Finland. Eighty-two out of the approximately 300 patients on the waiting list in 2004 agreed to participate in the study. Patients were randomised either to be operated (40 patients) on or to be followed up (42 patients). The follow-up time for both groups was six months. The patients were operated on by plastic surgeons or trainees at the Department of Plastic Surgery at Helsinki University Central Hospital or at the Department of Surgery at Hyvinkää Hospital. The patients completed five questionnaires: the SF-36 and the 15D quality of life questionnaires, the Finnish Breast-Associated Symptoms questionnaire (FBAS), a mood questionnaire (Raitasalo s modification of the short form of the Beck Depression Inventory, RBDI), and a pain questionnaire (The Finnish Pain Questionnaire, FPQ). Sixty-two out of the original 82 patients agreed to participate in the prospective follow-up study. In this study, patients completed the 15D quality of life questionnaire, the Finnish Breast-Associated Symptoms questionnaire, and the RBDI mood questionnaire. After six months follow-up, patients who had undergone reduction mammaplasty had a significantly better quality of life, fewer breast-associated symptoms and less pain, and they were less depressed or anxious when compared to patients who had not undergone surgery. The change in quality of life was more than two times the minimal clinically important difference. The patients preoperative quality of life was significantly inferior when compared to the age-standardised general population. This health burden was removed with reduction mammaplasty. The health loss related to symptomatic breast hypertrophy was comparable to that of patients with major joint arthrosis. In terms of change in quality of life, the intervention effect of reduction mammaplasty was comparable to that of hip joint replacement and more pronounced than that of knee joint replacement surgery. The outcome of reduction mammaplasty was affected more by preoperative psychosocial factors than by changes in breast dimensions. The effects of reduction mammaplasty remained stable at two to five years follow-up. In terms of quality of life, symptomatic breast hypertrophy causes a considerable health loss comparable to that of major joint arthrosis. Patients who undergo surgery have fewer breast-associated symptoms and less pain, and they are less depressed or anxious and have an improved quality of life. The intervention effect is comparable to that of major joint replacement surgery, and it remains stable at two to five years follow-up. The outcome of reduction mammaplasty is affected by preoperative psychosocial factors.

Transfer of F- in the reaction of SF6- with SOF4: Implications for SOF4 production in corona discharges

The temperature (T) and electric field-to-gas pressure (E/P) dependences of the rate coefficientk for the reaction SF 6 � +SOF4rarrSOF 5 � +SF5 have been measured. ForT<270>k approaches a constant of 2.1×10�9 cm3/s, and for 433>T>270 K,k decreases withT according tok (cm3/s)=0.124 exp [�3.3 lnT(K)]. ForE/Pk has a constant value of about 2.5×10�10 cm3/s, and for 130 V/cm·torr>E/P>60 V/cm·torr, the rate is approximately given byk (cm3/s)sim7.0×10�10 exp (�0.022E/P). The measured rate coefficient is used to estimate the influence of this reaction on SOF4 production from negative, point-plane, glow-type corona discharges in gas mixtures containing SF6 and at least trace amounts of O2 and H2O. A chemical kinetics model of the ion-drift region in the discharge gap is used to fit experimental data on SOF4 yields assuming that the SF 6 � +SOF4 reaction is the predominant SOF4 loss mechanism. It is found that the contribution of this reaction to SOF4 destruction falls considerably below the estimated maximum effect assuming that SF 6 � is the predominant charge carrier which reacts only with SOF4. The results of this analysis suggest that SF 6 � is efficiently deactivated by other reactions, and the influence of SF 6 � +SOF4 on SOF4 production is not necessarily more significant than that of other slower secondary processes such as gas-phase hydrolysis

Regulation and Function of GATA Transcription Factors in Adrenocortical Tumors and Granulosa Cells

Transcription factors play a key role in tumor development, in which dysfunction of genes regulating tissue growth and differentiation is a central phenomenon. The GATA family of transcription factors consists of six members that bind to a consensus DNA sequence (A/T)GATA(A/G) in gene promoters and enhancers. The two GATA factors expressed in the adrenal cortex are GATA-4 and GATA-6. In both mice and humans, GATA-4 can be detected only during the fetal period, whereas GATA-6 expression is abundant both throughout development and in the adult. It is already established that GATA factors are important in both normal development and tumorigenesis of several endocrine organs, and expression of GATA-4 and GATA-6 is detected in adrenocortical tumors. The aim of this study was to elucidate the function of these factors in adrenocortical tumor growth. In embryonal development, the adrenocortical cells arise and differentiate from a common pool with gonadal steroidogenic cells, the urogenital ridge. As the adult adrenal cortex undergoes constant renewal, it is hypothesized that undifferentiated adrenocortical progenitor cells reside adjacent to the adrenal capsule and give rise to daughter cells that differentiate and migrate centripetally. A diverse array of hormones controls the differentiation, growth and survival of steroidogenic cells in the adrenal gland and the gonads. Factors such as luteinizing hormone and inhibins, traditionally associated with gonadal steroidogenic cells, can also influence the function of adrenocortical cells in physiological and pathophysiological states. Certain inbred strains of mice develop subcapsular adrenocortical tumors in response to gonadectomy. In this study, we found that these tumors express GATA-4, normally absent from the adult adrenal cortex, while GATA-6 expression is downregulated. Gonadal markers such as luteinizing hormone receptor, anti-Müllerian hormone and P450c17 are also expressed in the neoplastic cells, and the tumors produce gonadal hormones. The tumor cells have lost the expression of melanocortin-2 receptor and the CYP enzymes necessary for the synthesis of corticosterone and aldosterone. By way of xenograft studies utilizing NU/J nude mice, we confirmed that chronic gonadotropin elevation is sufficient to induce adrenocortical tumorigenesis in susceptible inbred strains. Collectively, these studies suggest that subcapsular adrenocortical progenitor cells can, under certain conditions, adopt a gonadal fate. We studied the molecular mechanisms involved in gene regulation in endocrine cells in order to elucidate the role of GATA factors in endocrine tissues. Ovarian granulosa cells express both GATA-4 and GATA-6, and the TGF-β signaling pathway is active in these cells. Inhibin-α is both a target gene for, and an atypical or antagonistic member of the TGF-β growth factor superfamily. In this study, we show that GATA-4 is required for TGF-β-mediated inhibin-α promoter activation in granulosa cells, and that GATA-4 physically interacts with Smad3, a TGF-β downstream protein. Apart from the regulation of steroidogenesis and other events in normal tissues, TGF-β signaling is implicated in tumors of multiple organs, including the adrenal cortex. Another signaling pathway found often to be aberrantly active in adrenocortical tumors is the Wnt pathway. As both of these pathways regulate the expression of inhibin-α, a transcriptional target for GATA-4 and GATA-6, we wanted to investigate whether GATA factors are associated with the components of these signaling cascades in human adrenocortical tumors. We found that the expression of Wnt co-receptors LRP5 and LRP6, Smad3, GATA-6 and SF-1 was diminished in adrenocortical carcinomas with poor outcome. All of these factors drive inhibin-α expression, and their expression in adrenocortical tumors correlated with that of inhibin-α. The results support a tumor suppressor role previously suggested for inhibin-α in the mouse adrenal cortex, and offer putative pathways associated with adrenocortical tumor aggressiveness. Unraveling the role of GATA factors and associated molecules in human and mouse adrenocortical tumors could ultimately contribute to the development of diagnostic tools and future therapies for these diseases.

Experimental evaluation of the aeroacoustic characteristics of a source of pulsating gas flow

Amongv arioums ethodtsh,e t ransmissliionne o r thei mpedantcueb em ethohda sb eenm ospt opulafro r thee xperimenetavla luatioonf thea cousticiaml pedanocef a terminatioTnh. ee xistinmg ethodisn,c luding theo nesre porteeda rlierb, y thea uthorrse quirleo catioonf thes oundp ressumrei nima nd/orm axima, or elsem akeu se0 f somei terativep rocedureTsh. e presenpt aperd ealsw ith a methodo f analysios f standinwga vews hichd oesn otd epenodn anyo f thesein volvepdr ocedureIts i.s applicabtloe thec aseo f stationarays w ella sm ovingm ediaI.t enableosn to evaluatteh e impedancoef anyp assivbel ackb ox,a s well as the aeroacoustcich aracteristicosf a sourceo f pulsatingg asf low, with the leaste xperimentawl ork andc omputatiotinm ea ndw itht hee xtraa dvantagoef usinga givenim pedanctueb ef or wavelengtahss largea s fourt imesit s lengthA. methodo f externaml easuremenntost, involvinugs eo f anyi mpedance tubef, or evaluatintgh ea eroacouscthica racteristoicf as sourcoef pulsatingga sf lowi s alsod ealtw ith, based on the definition of attenuation or insertion loss of a muffler.

HFST—Framework for Compiling and Applying Morphologies

HFST–Helsinki Finite-State Technology ( hfst.sf.net ) is a framework for compiling and applying linguistic descriptions with finite-state methods. HFST currently connects some of the most important finite-state tools for creating morphologies and spellers into one open-source platform and supports extending and improving the descriptions with weights to accommodate the modeling of statistical information. HFST offers a path from language descriptions to efficient language applications in key environments and operating systems. HFST also provides an opportunity to exchange transducers between different software providers in order to get the best out of each finite-state library.

Stochastic Approximation Algorithms for Constrained Optimization via Simulation

We develop four algorithms for simulation-based optimization under multiple inequality constraints. Both the cost and the constraint functions are considered to be long-run averages of certain state-dependent single-stage functions. We pose the problem in the simulation optimization framework by using the Lagrange multiplier method. Two of our algorithms estimate only the gradient of the Lagrangian, while the other two estimate both the gradient and the Hessian of it. In the process, we also develop various new estimators for the gradient and Hessian. All our algorithms use two simulations each. Two of these algorithms are based on the smoothed functional (SF) technique, while the other two are based on the simultaneous perturbation stochastic approximation (SPSA) method. We prove the convergence of our algorithms and show numerical experiments on a setting involving an open Jackson network. The Newton-based SF algorithm is seen to show the best overall performance.