The genetic basis of resistance to anticoagulants in rodents

Anticoagulant compounds, i.e., derivatives of either 4-hydroxycoumarin (e.g., warfarin, bromadiolone) or indane-1,3-dione (e.g., diphacinone, chlorophacinone), have been in worldwide use as rodenticides for > 50 years. These compounds inhibit blood coagulation by repression of the vitamin K reductase reaction (VKOR). Anticoagulant-resistant rodent populations have been reported from many countries and pose a considerable problem for pest control. Resistance is transmitted as an autosomal dominant trait although, until recently, the basic genetic mutation was unknown. Here, we report on the identification of eight different mutations in the VKORC1 gene in resistant laboratory strains of brown rats and house mice and in wild-caught brown rats from various locations in Europe with five of these mutations affecting only two amino acids (Tyr139Cys, Tyr139Ser, Tyr139Phe and Leu128Gln, Leu128Ser). By recombinant expression of VKORC1 constructs in HEK293 cells we demonstrate that mutations at Tyr139 confer resistance to warlarin at variable degrees while the other mutations, in addition, dramatically reduce VKOR activity. Our data strongly argue for at least seven independent mutation events in brown rats and two in mice. They suggest that mutations in VKORC1 are the genetic basis of anticoagulant resistance in wild populations of rodents, although the mutations alone do not explain all aspects of resistance that have been reported. We hypothesize that these mutations, apart from generating structural changes in the VKORC1 protein, may induce compensatory mechanisms to maintain blood clotting. Our findings provide the basis for a DNA-based field monitoring of anticoagulant resistance in rodents.

Mechanisms of protease-activated receptor 2-evoked hyperexcitability of nociceptive neurons innervating the mouse colon

Agonists of protease-activated receptor 2 (PAR(2)) evoke hyperexcitability of dorsal root ganglia (DRG) neurons by unknown mechanisms. We examined the cellular mechanisms underlying PAR(2)-evoked hyperexcitability of mouse colonic DRG neurons to determine their potential role in pain syndromes such as visceral hyperalgesia. Colonic DRG neurons were identified by injecting Fast Blue and DiI retrograde tracers into the mouse colon. Using immunofluorescence, we found that DiI-labelled neurons contained PAR(2) immunoreactivity, confirming the presence of receptors on colonic neurons. Whole-cell current-clamp recordings of acutely dissociated neurons demonstrated that PAR(2) activation with a brief application (3 min) of PAR(2) agonists, SLIGRL-NH(2) and trypsin, evoked sustained depolarizations (up to 60 min) which were associated with increased input resistance and a marked reduction in rheobase (50% at 30 min). In voltage clamp, SLIGRL-NH(2) markedly suppressed delayed rectifier I(K) currents (55% at 10 min), but had no effect on the transient I(A) current or TTX-resistant Na(+) currents. In whole-cell current-clamp recordings, the sustained excitability evoked by PAR(2) activation was blocked by the PKC inhibitor, calphostin, and the ERK(1/2) inhibitor PD98059. Studies of ERK(1/2) phosphorylation using confocal microscopy demonstrated that SLIGRL-NH(2) increased levels of immunoreactive pERK(1/2) in DRG neurons, particularly in proximity to the plasma membrane. Thus, activation of PAR(2) receptors on colonic nociceptive neurons causes sustained hyperexcitability that is related, at least in part, to suppression of delayed rectifier I(K) currents. Both PKC and ERK(1/2) mediate the PAR(2)-induced hyperexcitability. These studies describe a novel mechanism of sensitization of colonic nociceptive neurons that may be implicated in conditions of visceral hyperalgesia such as irritable bowel syndrome.

Mechanisms of blunted muscle vasodilation during peripheral chemoreceptor stimulation in heart failure patients

We described recently that systemic hypoxia provokes vasoconstriction in heart failure (HF) patients. We hypothesized that either the exaggerated muscle sympathetic nerve activity and/or endothelial dysfunction mediate the blunted vasodilatation during hypoxia in HF patients. Twenty-seven HF patients and 23 age-matched controls were studied. Muscle sympathetic nerve activity was assessed by microneurography and forearm blood flow (FBF) by venous occlusion plethysmography. Peripheral chemoreflex control was evaluated through the inhaling of a hypoxic gas mixture (10% O-2 and 90% N-2). Basal muscle sympathetic nerve activity was greater and basal FBF was lower in HF patients versus controls. During hypoxia, muscle sympathetic nerve activity responses were greater in HF patients, and forearm vasodilatation in HF was blunted versus controls. Phentolamine increased FBF responses in both groups, but the increase was lower in HF patients. Phentolamine and N-G-monomethyl-L-arginine infusion did not change FBF responses in HF but markedly blunted the vasodilatation in controls. FBF responses to hypoxia in the presence of vitamin C were unchanged and remained lower in HF patients versus controls. In conclusion, muscle vasoconstriction in response to hypoxia in HF patients is attributed to exaggerated reflex sympathetic nerve activation and blunted endothelial function (NO activity). We were unable to identify a role for oxidative stress in these studies. (Hypertension. 2012; 60: 669-676.) . Online Data Supplement

Mass loss and wear mechanisms of HVOF-sprayed multi-component white cast iron coatings

In this work, multi-component white cast iron was applied by HVOF thermal spray process as alternative to other manufacture processes. Effects of substrate type, substrate pre-heating and heat treatment of coating on mass loss have been determined by rubber wheel apparatus in accordance with ASTM G-65. Furthermore, influence of heat treatment of coating on wear mechanisms was also determined by scanning electron microscopy analysis. Heat-treated coatings presented mass loss three times lower than as-sprayed coatings. Furthermore, wear mechanisms of as-sprayed coating are micro-cutting associated with cracks close to unmelted particles and pores. In heat-treated coating, lesser mass loss is due to sintering. (C) 2011 Elsevier B.V. All rights reserved.

Effect of 12 weeks of resistance exercise on post-exercise hypotension in stage 1 hypertensive individuals

Post-exercise hypotension (PEH), the reduction of blood pressure (BP) after a single bout of exercise, is of great clinical relevance. As the magnitude of this phenomenon seems to be dependent on pre-exercise BP values and chronic exercise training in hypertensive individuals leads to BP reduction; PEH could be attenuated in this context. Therefore, the aim of the present study was to investigate whether PEH remains constant after resistance exercise training. Fifteen hypertensive individuals (46 +/- 8 years; 88 +/- 16 kg; 30 +/- 6% body fat; 150 +/- 13/93 +/- 5mm Hg systolic/diastolic BP, SBP/DBP) were withdrawn from medication and performed 12 weeks of moderate-intensity resistance training. Parameters of cardiovascular function were evaluated before and after the training period. Before the training program, hypertensive volunteers showed significant PEH. After an acute moderate-intensity resistance exercise session with three sets of 12 repetitions (60% of one repetition maximum) and a total of seven exercises, BP was reduced post-exercise (45-60 min) by an average of aproximately -22mm Hg for SBP, -8mm Hg for DBP and -13 mm Hg for mean arterial pressure (P<0.05). However, this acute hypotensive effect did not occur after the 12 weeks of training (P>0.05). In conclusion, our data demonstrate that PEH, following an acute exercise session, can indeed be attenuated after 12 weeks of training in hypertensive stage 1 patients not using antihypertensive medication. Journal of Human Hypertension (2012) 26, 533-539; doi:10.1038/jhh.2011.67; published online 7 July 2011

Mechanisms of endothelial dysfunction in obesity-associated hypertension

Obesity is strongly associated with high blood pressure, dyslipidemia, and type 2 diabetes. These conditions synergistically increase the risk of cardiovascular events. A number of central and peripheral abnormalities can explain the development or maintenance of high blood pressure in obesity. Of great interest is endothelial dysfunction, considered to be a primary risk factor in the development of hypertension. Additional mechanisms also related to endothelial dysfunction have been proposed to mediate the development of hypertension in obese individuals. These include: increase in both peripheral vasoconstriction and renal tubular sodium reabsorption, increased sympathetic activity and overactivation of both the renin-angiotensin system and the endocannabinoid system and insulin resistance. The discovery of new mechanisms regulating metabolic and vascular function and a better understanding of how vascular function can be influenced by these systems would facilitate the development of new therapies for treatment of obesity-associated hypertension.

Control of fruit postharvest diseases by thermotherapy: understanding the mechanisms of action by –omics approaches

In recent years the hot water treatment (HW) represents an effective and safe approach for managing postharvest decay. This study reported the effect of an HW (60°C for 60 s and 45°C for 10 min) on brown rot and blue mould respectively. Peaches was found more thermotolerant compared to apple fruit, otherwise Penicillium expansum was more resistant to heat with respect to Monilinia spp. In semi-commercial and commercial trials, the inhibition of brown rot in naturally infected peaches was higher than 78% after 6 days at 0°C and 3 days at 20°C. Moreover, in laboratory trials a 100% disease incidence reduction was obtained by treating artificially infected peaches at 6-12 h after inoculation revealing a curative effect of HW. The expression levels of some genes were evaluated by qRT-PCR. Specifically, the cell wall genes (β-GAL, PL, PG, PME) showed a general decrease of expression level whereas PAL, CHI, HSP70 and ROS-scavenging genes were induced in treated peaches compared to the control ones. Contrarily, HW applied on artificially infected fruit before the inoculum was found to increase brown rot susceptibility. This aspect might be due to an increase of fruit VOCs emission as revealed by PTR-ToF-MS analysis. In addition a microarray experiment was conducted to analyze molecular mechanisms underneath the apple response to heat. Our results showed a largest amount of induced Heat shock proteins (HSPs), Heat shock cognate proteins (HSCs), Heat shock transcription factors (HSTFs) genes found at 1 and 4 hours from the treatment. Those genes required for the thermotolerance process could be involved in induced resistance response. The hypothesis was confirmed by 30% of blue mold disease reduction in artificially inoculated apple after 1 and 4 hours from the treatment. In order to improve peaches quality and disease management during storage, an innovative tool was also used: Da-meter.

Molecular mechanisms of shikonin and its derivatives in cancer therapy

The identification of molecular processes involved in cancer development and prognosis opened avenues for targeted therapies, which made treatment more tumor-specific and less toxic than conventional therapies. One important example is the epidermal growth factor receptor (EGFR) and EGFR-specific inhibitors (i.e. erlotinib). However, challenges such as drug resistance still remain in targeted therapies. Therefore, novel candidate compounds and new strategies are needed for improvement of therapy efficacy. Shikonin and its derivatives are cytotoxic constituents in traditional Chinese herbal medicine Zicao (Lithospermum erythrorhizin). In this study, we investigated the molecular mechanisms underlying the anti-cancer effects of shikonin and its derivatives in glioblastoma cells and leukemia cells. Most of shikonin derivatives showed strong cytotoxicity towards erlotinib-resistant glioblastoma cells, especially U87MG.ΔEGFR cells which overexpressed a deletion-activated EGFR (ΔEGFR). Moreover, shikonin and some derivatives worked synergistically with erlotinib in killing EGFR-overexpressing cells. Combination treatment with shikonin and erlotinib overcame the drug resistance of these cells to erlotinib. Western blotting analysis revealed that shikonin inhibited ΔEGFR phosphorylation and led to corresponding decreases in phosphorylation of EGFR downstream molecules. By means of Loewe additivity and Bliss independence drug interaction models, we found erlotinb and shikonin or its derivatives corporately suppressed ΔEGFR phosphorylation. We believed this to be a main mechanism responsible for their synergism in U87MG.ΔEGFR cells. In leukemia cells, which did not express EGFR, shikonin and its derivatives exhibited even greater cytotoxicity, suggesting the existence of other mechanisms. Microarray-based gene expression analysis uncovered the transcription factor c-MYC as the commonly deregulated molecule by shikonin and its derivatives. As validated by Western blotting analysis, DNA-binding assays and molecular docking, shikonin and its derivatives bound and inhibited c-MYC. Furthermore, the deregulation of ERK, JNK MAPK and AKT activity was closely associated with the reduction of c-MYC, indicating the involvement of these signaling molecules in shikonin-triggered c-MYC inactivation. In conclusion, the inhibition of EGFR signaling, synergism with erlotinib and targeting of c-MYC illustrate the multi-targeted feature of natural naphthoquinones such as shikonin and derivatives. This may open attractive possibilities for their use in a molecular targeted cancer therapy.

Potassium restores vasorelaxation of resistance arterioles in non-hypertensive DOCA/salt fed mice

Potassium-enriched diets exert renal and cardiovascular protective effects, but the underlying mechanisms are largely unknown.

Loss of the high-affinity pentamidine transporter is responsible for high levels of cross-resistance between arsenical and diamidine drugs in African trypanosomes

Treatment of many infectious diseases is under threat from drug resistance. Understanding the mechanisms of resistance is as high a priority as the development of new drugs. We have investigated the basis for cross-resistance between the diamidine and melaminophenyl arsenical classes of drugs in African trypanosomes. We induced high levels of pentamidine resistance in a line without the tbat1 gene that encodes the P2 transporter previously implicated in drug uptake. We isolated independent clones that displayed very considerable cross-resistance with melarsen oxide but not phenylarsine oxide and reduced uptake of [(3)H]pentamidine. In particular, the high-affinity pentamidine transport (HAPT1) activity was absent in the pentamidine-adapted lines, whereas the low affinity pentamidine transport (LAPT1) activity was unchanged. The parental tbat1(-/-) line was sensitive to lysis by melarsen oxide, and this process was inhibited by low concentrations of pentamidine, indicating the involvement of HAPT1. This pentamidine-inhibitable lysis was absent in the adapted line KO-B48. Likewise, uptake of the fluorescent diamidine 4',6-diamidino-2-phenylindole dihydrochloride was much delayed in live KO-B48 cells and insensitive to competition with up to 10 muM pentamidine. No overexpression of the Trypanosoma brucei brucei ATP-binding cassette transporter TbMRPA could be detected in KO-B48. We also show that a laboratory line of Trypanosoma brucei gambiense, adapted to high levels of resistance for the melaminophenyl arsenical drug melarsamine hydrochloride (Cymelarsan), had similarly lost TbAT1 and HAPT1 activity while retaining LAPT1 activity. It seems therefore that selection for resistance to either pentamidine or arsenical drugs can result in a similar phenotype of reduced drug accumulation, explaining the occurrence of cross-resistance.

Mechanisms of Adenovirus-Mediated Autophagy

A patient diagnosed with a glioma, generally, has an average of 14 months year to live after implementation of conventional therapies such as surgery, chemotherapy, and radiation. Glioblastomas are highly lethal because of their aggressive nature and resistance to conventional therapies and apoptosis. Thus other avenues of cell death urgently need to be explored. Autophagy, which is also known as programmed cell death type II, has recently been identified as an alternative mechanism to kill apoptosis- resistant cancer cells. Traditionally, researchers have studied how cells undergo autophagy during viral infection as an immune response mechanism, but recently researchers have discovered how viruses have evolved to manipulate autophagy for their benefit. Extensive studies of viral-induced autophagy provide a rationale to investigate other viruses, such as the adenovirus, which may be developed as part of a therapy against cancers resistant to apoptosis. Despite the present and relatively poor understanding of the mechanisms behind adenoviral-induced autophagy, adenovirus is a promising candidate, because of its ability to efficiently eradicate tumors. A better understanding of how the adenovirus induces autophagy will allow for the development of viruses with increased oncolytic potency. We hypothesized that adenovirus induces autophagy in order to aid in lysis. We found that replication, not infection, was required for adenovirus-mediated autophagy. Loss of function analysis of early genes revealed that, of the early genes tested, no single gene was sufficient to induce autophagy alone. Examination of cellular pathways for their role in autophagy during adenovirus infection revealed a function for the eIF2α pathway and more specifically the GCN2 kinase. Cells lacking GCN2 are more resistant to adenovirus-mediated autophagy in vitro; in vivo we also found these cells fail to undergo autophagy, but display more cell death. We believe that autophagy is a protective mechanism the cell employs during adenoviral infection, and in the in vivo environment, cells cannot recover from virus infection and are more susceptible to death. Congruently, infected cells deficient for autophagy through deletion of ATG5 are not able undergo productive cell lysis, providing evidence that the destruction of the cytoplasm and cell membrane through autophagy is crucial to the viral life cycle. This project is the first to describe a gene, other than a named autophagy gene, to be required for adenovirus- mediated autophagy. It is also the first to examine autophagic cell death as a means to aid in viral-induced cell lysis.

Mechanisms of Adenovirus-Mediated Autophagy

A patient diagnosed with a glioma, generally, has an average of 14 months year to live after implementation of conventional therapies such as surgery, chemotherapy, and radiation. Glioblastomas are highly lethal because of their aggressive nature and resistance to conventional therapies and apoptosis. Thus other avenues of cell death urgently need to be explored. Autophagy, which is also known as programmed cell death type II, has recently been identified as an alternative mechanism to kill apoptosis- resistant cancer cells. Traditionally, researchers have studied how cells undergo autophagy during viral infection as an immune response mechanism, but recently researchers have discovered how viruses have evolved to manipulate autophagy for their benefit. Extensive studies of viral-induced autophagy provide a rationale to investigate other viruses, such as the adenovirus, which may be developed as part of a therapy against cancers resistant to apoptosis. Despite the present and relatively poor understanding of the mechanisms behind adenoviral-induced autophagy, adenovirus is a promising candidate, because of its ability to efficiently eradicate tumors. A better understanding of how the adenovirus induces autophagy will allow for the development of viruses with increased oncolytic potency. We hypothesized that adenovirus induces autophagy in order to aid in lysis. We found that replication, not infection, was required for adenovirus-mediated autophagy. Loss of function analysis of early genes revealed that, of the early genes tested, no single gene was sufficient to induce autophagy alone. Examination of cellular pathways for their role in autophagy during adenovirus infection revealed a function for the eIF2α pathway and more specifically the GCN2 kinase. Cells lacking GCN2 are more resistant to adenovirus-mediated autophagy in vitro; in vivo we also found these cells fail to undergo autophagy, but display more cell death. We believe that autophagy is a protective mechanism the cell employs during adenoviral infection, and in the in vivo environment, cells cannot recover from virus infection and are more susceptible to death. Congruently, infected cells deficient for autophagy through deletion of ATG5 are not able undergo productive cell lysis, providing evidence that the destruction of the cytoplasm and cell membrane through autophagy is crucial to the viral life cycle. This project is the first to describe a gene, other than a named autophagy gene, to be required for adenovirus- mediated autophagy. It is also the first to examine autophagic cell death as a means to aid in viral-induced cell lysis.

Mechanisms of apoptosis in chronic lymphocytic leukemia (CLL)

Chronic lymphocytic leukemia (CLL) is an incurable disease characterized by the accumulation of terminally differentiated, mature B cells that do not progress beyond the G1 stage of cell cycle, suggesting that these cells possess intrinsic defects in apoptosis. Treatment relies heavily on chemotherapy (primarily nucleoside analogs and glucocorticoids) that may initially be effective in patients, but ultimately give rise to refractory, untreatable disease. The purpose of this study was to determine whether key components of the apoptotic machinery were intact in CLL lymphocytes, especially in patients refractory to therapy. ^ Activation of proteases has been shown to be at the core of the apoptotic pathway and this work demonstrates that protease activation is required for glucocorticoid and nucleoside analog-induced apoptosis in CLL cells. Inhibitors of serine proteases as well as caspase inhibitors blocked induced DNA fragmentation, and a peptide inhibitor of the nuclear scaffold (NS) protease completely suppressed both induced and spontaneous apoptosis. However, the NS protease inhibitor actually promoted several pro-apoptotic events, such as caspase activation, exposure of surface phosphatidylserine, and loss of mitochondrial membrane potential. These results suggested that the NS protease may interact with the apoptotic program in CLL cells at two separate points. ^ In order to further investigate the role of the NS protease in CLL, patient isolates were treated with proteasome inhibitors because of previous results suggesting that the ISIS protease might be a β subunit of the proteasome. Proteasome inhibitors induced massive DNA fragmentation in every patient tested, even in those resistant to the effects of glucocorticoid and nucleoside analogs in vitro. Several other features of apoptosis were also promoted by the proteasome inhibitor, including mitochondrial alterations such as release of cytochrome c and drops in mitochondrial membrane potential. Proteasome inhibitor-induced apoptosis was associated with inhibition of NFκB, a proteasome-regulated transcription factor that has been implicated in the suppression of apoptosis in a number of systems. The NS protease inhibitor also caused a decrease in active NFκB, suggesting that the proapoptotic effects of this agent might be due to depletion of NFκB. ^ Given these findings, the role of NFκB, in conferring survival in CLL was investigated. Glucocorticoid hormone treatment was shown to cause decreases in the activity of the transcription factor, while phorbol dibutyrate, which blocks glucocorticoid-induced DNA fragmentation, was capable of upregulating NFκB. Compellingly, introduction of an undegradable form of the constitutive NFκB inhibitor, IκB, caused DNA fragmentation in several patient isolates, some of which were resistant to glucocorticoid in vitro. Transcription of anti-apoptotic proteins by NFκB was postulated to be responsible for its effects on survival, but Bcl-2 levels did not fluctuate with glucocorticoid or proteasome inhibitor treatment. ^ The in vitro values generated from these studies were organized into a database containing numbers for over 250 patients. Correlation of relevant clinical parameters revealed that levels of spontaneous apoptosis in vitro differ significantly between Rai stages. Importantly, in vitro resistance to nucleoside analogs or glucocorticoids predicted resistance to chemotherapy in vivo, and inability to achieve remission. ^

Mechanisms of Ad-p53 induced apoptosis in human malignant glioma

Malignant brain tumors are one of the most challenging cancers affecting society today. In a recent survey, an estimated 17,000 annual cases were recorded with a staggering total of 13,300 deaths. A unique degree of heterogeneity typifies glial tumors and presents a challenge for solitary anti-neoplastic treatments. Tumors subsist as heterogeneous masses that progress through dysplasia to astrocytomas, mixed glioma and glioblastoma multiforme. Although traditional therapeutic approaches have provided increments of success, the median survival time remains 12 months. The urgency to improve upon current clinical protocols has encouraged alternative experimental strategies such as p53 adenoviral gene therapy (Ad-p53). This study addresses the efficacy of Ad-p53 for the treatment of glioma. Our model presents a tumor response that is unique among human cancers. Ad-p53 effectively induces apoptosis in mutant p53 expressing cells yet fails to do so in those with wildtype p53. In order to adopt Adp53 as a standard anti-cancer modality, we characterized the role of the tumor suppressor gene p53 in mediating apoptosis. We demonstrate that altering cellular p53 status through the introduction of a dominant negative mutant p53 (175H, 248W, 273H) sensitized cells to Ad-p53. We discovered that wild-type p53 expressing glioma cells retain the apoptotic machinery necessary to accomplish cell death, but have developed mechanisms that interfere with p53 signaling. Earlier studies have not addressed the mechanisms of Ad-p53 apoptosis nor the resistance exhibited by wild-type p53 glioma. To explain the divergent phenotypes, we identified apoptotic pathways activated and effectors of the response. We illustrated that modulation of the death receptor Fas/APO-1 is a principal means of Ad-p53 signaling that is impaired in wild-type p53 glioma. Moreover, the apoptotic response was found to be a multi-faceted process that engaged several caspases, most notably caspases -1, -3 and -8. Lastly, we assessed the ability of anti-apoptotic molecules Bcl-2 and CrmA to inhibit Ad-p53 apoptosis. These studies revealed that Ad-p53 is a powerful tool for inducing apoptosis that can be delayed but not inhibited by anti-apoptotic means. This work is critical for understanding the development of glioma and the phenotypic and genotypic alterations that account for tumor resistance. ^

Molecular mechanisms of apoptosis induction in chronic lymphocytic leukemia

CLL is the most common adult leukemia in the Western World, yet very little is known about the biology of this disease. CLL cells have very high levels of NF-κB activity. Factors such as CD40 ligation and phorbol ester treatment induce NF-κB activity and also prevent apoptosis. Previous data from our laboratory demonstrated that MG-132, a proteasome inhibitor, blocked NF-κB activation and promoted apoptosis in CLL cells. These data suggested to us that NF-κB mediates survival in CLL. We examined NF-κB activity using two different chemotherapeutic agents, PS-341 and arsenic trioxide. PS-341, a proteasome inhibitor blocked NF-κB in CLL cells. This however, did not correlate with cell death. Resistant patient isolates displayed delayed Smac/DIABLO release in comparison to cytochrome c release. This suggests that IAPs are contributing to CLL cell survival and drug-resistance. Arsenic trioxide did not block NF-κB activity at therapeutic doses. However it was a potent inducer of apoptosis in CLL cells. We identified a novel mechanism by which arsenic induces increases in mitochondrial calcium to induce cytochrome c release and initiate apoptosis. Both PS-341 and arsenic trioxide are currently in Phase II clinical trials at M.D. Anderson Cancer Center. We conclude that NF-κB is not critical for PS-341 or arsenic trioxide-mediated cell death. ^