In addition to its ability to rapidly alter metabolism, insulin is also able to regulate the expression of numerous genes via activation of the PI3-kinase (PI3-K), MAPK kinase (MEK)-ERK, or p38 pathways. Using differential screening of H4IIE cells, we have identified two members of the Egr zinc-finger transcription factor family of early response genes, Egr-1 and Krox20, whose transcription is induced by insulin treatment. Egr-1 may be involved in insulin's regulation of hepatic gene expression. Krox20 regulation and expression have been primarily studied in neural cells and tissues, but little has been previously reported on the presence of Krox20 in cells of hepatic origin or its regulation by insulin. In the present studies, insulin treatment rapidly increased transcription of both Egr-1 and Krox20. In cells pretreated with a PI3-K inhibitor, there was no reduction in the effect of insulin on Egr-1 and Krox20, but an increase in Egr-1 transcription. The rapid induction of ERK1/2 phosphorylation was completely blocked by pretreatment with a MEK1 inhibitor and was associated with a nearly complete inhibition of insulin-stimulated induction of both Egr-1and Krox20, indicating this pathway is necessary for insulin's effect on these genes. Finally, inhibition of the p38 pathway, followed by insulin addition, caused an additive induction of both Egr-1and Krox20. In conclusion, these genes are induced by insulin via coordinated regulation of the MEK-ERK and p38 pathways and, in the case of Egr-1, the PI3-K pathway.

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Endovascular intervention for obstruction to venous drainage of the head and neck is an established treatment for disorders such as superior vena cava syndrome. Some patients with multiple sclerosis have been observed to have anomalies of the veins draining the head and neck. It is possible that some symptoms associated with multiple sclerosis may be secondary to disturbed venous flow. In an uncontrolled clinical series of 40 patients who had been previously diagnosed with multiple sclerosis, anomalies of the venous drainage of the head and neck were observed, including venous stenoses of the internal jugular veins. In 38 of 40 patients, venous stents were placed with restoration of luminal dimensions and abrogation of the venous pressure gradient. The angiographic and hemodynamic improvement was associated with improvement in symptomatology, most particularly in cognitive and constitutional symptoms that may be related to cerebrovenous flow. Serious complications included death in one subject and stent embolization requiring open heart surgery in another. In conclusion, in this series, endovascular intervention to correct venous stenosis associated with multiple sclerosis was associated with improvement in symptoms possibly related to disturbed venous hemodynamics. However, given the serious adverse events in this small series, a randomized clinical trial is required to confirm these findings, and to determine if the procedure has any effect on the progression of multiple sclerosis, or untoward long-term adverse effects.

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