Clinical outcomes of patients with diabetes mellitus and acute myocardial infarction treated with primary angioplasty or fibrinolysis

OBJECTIVE

To compare the early and late outcomes of primary percutaneous transluminal coronary angioplasty (PTCA) with fibrinolytic treatment among diabetic patients with acute myocardial infarction (AMI).

DESIGN

Retrospective observational study with data obtained from prospective registries.

SETTING

Tertiary cardiovascular institution with 24 hour acute interventional facilities.

PATIENTS

202 consecutive diabetic patients with AMI receiving reperfusion treatment within six hours of symptom onset.

INTERVENTIONS

Fibrinolytic treatment was administered to 99 patients, and 103 patients underwent primary PTCA. Most patients undergoing PTCA received adjunctive stenting (94.2%) and glycoprotein IIb/IIIa inhibition (63.1%).

MAIN OUTCOME MEASURES

Death, non-fatal reinfarction, and target vessel revascularisation at 30 days and one year were assessed.

RESULTS

Baseline characteristics were similar in these two treatment groups except that the proportion of patients with Killip class III or IV was considerably higher in those treated with PTCA (15.5% v 6.1%, p = 0.03) and time to treatment was significantly longer (103.7 v 68.0 minutes, p < 0.001). Among those treated with PTCA, the rates for in-hospital recurrent ischaemia (5.8% v 17.2%, p = 0.011) and target vessel revascularisation at one year (19.4% v 36.4%, p = 0.007) were lower. Death or reinfarction at one year was also reduced among those treated with PTCA (17.5% v 31.3%, p = 0.02), with an adjusted relative risk of 0.29 (95% confidence interval 0.15 to 0.57) compared with fibrinolysis.

CONCLUSION

Among diabetic patients with AMI, primary PTCA was associated with reduced early and late adverse events compared with fibrinolytic treatment.

Determination of remifentanil in human blood by capillary gas chromatography with nitrogen-selective detection

A validated method for the determination of remifentanil in human blood, applicable to all therapeutic concentrations, using capillary GC with nitrogen-specific detection and fentanyl as the internal standard has been developed. Citrated whole blood samples were extracted into 1-chlorobutane following precipitation of proteins with methanol. The drugs were back extracted into 10 mM HCl and re-extracted into methanol-1-chlorobutane. The extracts were reconstituted in methanol and injected onto a 25-m BPX-5 column. The lower limit of quantitation was 0.2 ng/ml with within- and between-day coefficients of variation of less than 15%.

Bifrontal decompressive craniectomy for acute subdural empyema

INTRODUCTION

Subdural empyema is an uncommon but serious complication of sinusitis. Despite the use of advanced imaging facilities, modern antibiotic therapy and aggressive neurosurgical protocols, this condition still carries significant morbidity and mortality.

CASE REPORT

We report an unusual case of sinusitis-associated acute subdural empyema in a 13-year-old patient, presenting in a catastrophic manner with acutely raised intracranial pressure. Emergency bifrontal decompressive craniectomy was necessary both to reduce the intracranial pressure and to drain the subdural empyema.

RESULTS

The full range of intracranial complications subsequently occurred, including brain abscesses, recurrent subdural empyema and ventriculitis. Despite this, the patient's outcome was good, with minimal intellectual deficits.

CONCLUSION

In cases of severe intracranial infection, we therefore advocate an aggressive surgical approach coupled with appropriate antibiotics to ensure a good outcome.

Peptoid inhibition of trypanothione reductase as a potential antitrypanosomal and antileishmanial drug lead

One route to the design of lead compounds for rational drug design approaches to developing drugs against trypanosomiasis, Chagas' disease and leishmaniasis is to develop novel inhibitors of the parasite-specific enzyme trypanothione reductase. A lead inhibitor based on a peptoid structure was designed in the present study based on the known strong competitive inhibition of trypanothione reductase by N-benzoyl-Leu-Arg-Arg-beta-naphthylamide and N-benzyloxycarbonyl-Ala-Arg-Arg-4-methoxy- beta-naphthylamide. In the target peptoid the arginyl residues were replaced by alkylimidazolium units and the benzyloxycarbonyl group by the benzylaminocarbonyl function. The peptoid was synthesised using t-butoxycarbonyl protection chemistry and couplings were activated by 2-(1H-benzotriazole-1-yl)-1,1,3,3-tetramethyluronium hexafluorophosphate. The resulting peptoid was shown to be a competitive inhibitor of recombinant trypanothione reductase from Trypanosoma cruzi with a K(i) value of 179 microM and with only weak inhibition of human erythrocyte glutathione reductase (the inhibition of glutathione reductase was at least 291-fold weaker than of trypanothione reductase).

Cosmesis in neurosurgery: is the bald head necessary to avoid postoperative infection?

AIM

The aims of this study were to prospectively investigate the incidence of postoperative wound infection following elective cranial surgery, when scalp hair removal was limited to the line of the incision, and to see if there was an increased risk of infection.

MATERIALS AND METHODS

This is an observational study of 57 consecutive adult elective cases operated upon without head shave (between July 1998 and December 1998). The method of scalp preparation is described.

RESULTS

During the follow-up period, there was 1 case (1.75%) of postoperative wound infection. This was compared with retrospective data, and was not found to be statistically significant.

DISCUSSION

In a review of earlier studies and a search into the history of aseptic surgery, no scientific ground for the practice of shaving was found. We suggest that there is no advantage in shaving patients in terms of reducing wound infection rates.

Evaluation of Bioglass/dextran composite as a bone graft substitute

Allogenic and alloplastic bone graft substitutes serve either as bioinert or bioactive osteoconductors. Bioglass is a bioactive osteoconductor and also shows osteoproductive effects due to its high level of bioactivity. However, the material lacks some cohesiveness when used in augmenting certain bony surfaces, i.e. large or pleomorphic defects. The addition of medium molecular weight dextran modifies the particulate to a putty consistency and improves the handling characteristics. The objective of this study is to evaluate the influence of dextran upon the bioactive properties of Bioglass. Standardized bony defects in the lateral femoral condyles in adult New Zealand white rabbits were filled with one of five material groups: (1) autogenous bone; (2) Bioglass particulate; (3) Bioglass particulate mixed with dextran to a putty-like consistency; (4) a mixture of Bioglass and autogenous bone; (5) a mixture of Bioglass putty with autogenous bone. Postoperative healing was observed after periods of 2 days, 1, 2, 3, 6 and 12 weeks. Results showed no evidence of toxicity in the dextran-containing materials, and defects in all test groups showed 100% bony ingrowth within 6 weeks. The addition of medium molecular weight dextran did not appear to alter the bioactive properties of Bioglass and had no adverse influence upon the ingrowth of bone into the defect sites.

Ceramide-mediated apoptosis in lung epithelial cells is regulated by glutathione

Reactive oxygen species (ROS) are mediators of lung injury, and glutathione (GSH) is the major nonprotein antioxidant that protects the cell from oxidative stress. We have recently shown that H(2)O(2) induces ceramide-mediated apoptosis in human lung epithelial cells. We hypothesized that ROS-mediated depletion of GSH plays a regulatory role in ceramide generation, and thus in the induction of apoptosis. Our present studies demonstrate that GSH at physiologic concentrations (1 to 10 mM) inhibits ceramide production in a time- and dose-dependent manner in A549 human alveolar epithelial cells. On the other hand, buthionine-sulfoximine-mediated depletion of intracellular GSH induces elevation of ceramide levels and apoptosis. In addition, GSH blocks H(2)O(2)-mediated induction of intracellular ceramide generation and apoptosis. These effects were not mimicked by oxidized GSH (GSSG) or other thiol antioxidants, such as dithiothreitol and 2-mercaptoethanol. Moreover, increase of intracellular H(2)O(2), mediated by inhibition of catalase by aminotriazole, also induces ceramide generation and apoptosis. These effects were blocked by N-acetylcysteine. Our results suggest that GSH depletion may be the link between oxidative stress and ceramide-mediated apoptosis in the lung.

Specific peptide inhibitors of trypanothione reductase with backbone structures unrelated to that of substrate: potential rational drug design lead frameworks

By introducing cationic charge sites novel peptide lead inhibitor structures for trypanothione reductase have been designed using molecular modelling methods. The inhibitors showed reversible, linear competitive inhibition and the strongest peptide inhibitor to date was found to be N-benzyloxycarbonyl-Ala-Arg-Arg-4-methoxy-beta-naphthylamide with a Ki value of 2.4 microM and a selectivity for parasitic enzyme (trypanothione reductase) over the host enzyme (human glutathione reductase) of over 3 orders of magnitude.

Leg symptoms in peripheral arterial disease: associated clinical characteristics and functional impairment

CONTEXT

Persons with lower-extremity peripheral arterial disease (PAD) are often asymptomatic or have leg symptoms other than intermittent claudication (IC).

OBJECTIVE

To identify clinical characteristics and functional limitations associated with a broad range of leg symptoms identified among patients with PAD.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of 460 men and women with PAD and 130 without PAD, who were identified consecutively, conducted between October 1998 and January 2000 at 3 Chicago-area medical centers.

MAIN OUTCOME MEASURES

Ankle-brachial index score of less than 0.90; scores from 6-minute walk, accelerometer-measured physical activity over 7 days, repeated chair raises, standing balance (full tandem stand), 4-m walking velocity, San Diego claudication questionnaire, Geriatric Depression Score Short-Form, and the Walking Impairment Questionnaire.

RESULTS

All groups with PAD had poorer functioning than participants without PAD. The following values are for patients without IC vs those with IC. Participants in the group with leg pain on exertion and rest (n = 88) had a higher (poorer) score for neuropathy (5.6 vs 3.5; P<.001), prevalence of diabetes mellitus (48.9% vs 26.7%; P<.001), and spinal stenosis (20.8% vs 7.2%; P =.002). The atypical exertional leg pain/carry on group (exertional leg pain other than IC associated with walking through leg pain [n = 41]) and the atypical exertional leg pain/stop group (exertional leg pain other than IC that causes one to stop walking [n = 90]) had better functioning than the IC group. The group without exertional leg pain/inactive (no exertional leg pain in individual who walks </=6 blocks per week [n = 28]) and the leg pain on exertion and rest group had poorer functioning than those with IC. Adjusting for age, sex, race, and comorbidities and compared with IC, participants with atypical exertional leg pain/carry on achieved a greater distance on the 6-minute walk (404.3 vs 328.5 m; P<.001) and were less likely to stop during the 6-minute walk (6.8% vs 36%; P =.002). The group with pain on exertion and rest had a slower time for completing 5 chair raises (13.5 vs 11.9 seconds; P =.009), completed the tandem stand less frequently (37.5% vs 60.0%; P =.004), and had a slower 4-m walking velocity (0.80 vs 0.90 m/s; P<.001).

CONCLUSIONS

There is a wide range of leg symptoms in persons with PAD beyond that of classic IC. Comorbid disease may contribute to these symptoms in PAD. Functional impairments are found in every PAD symptom group, and the degree of functional limitation varies depending on the type of leg symptom.

Total synthesis of the sesquiterpene (+/-)-illudin C via an intramolecular nitrile oxide cycloaddition

[reaction: see text] A convergent total synthesis of illudin C is described. The tricyclic ring system of the natural product was quickly assembled from cyclopropane and cyclopentene precursors via a novel oxime dianion coupling reaction and a subsequent intramolecular nitrile oxide-olefin cycloaddition.

A protein interaction map for cell polarity development

Many genes required for cell polarity development in budding yeast have been identified and arranged into a functional hierarchy. Core elements of the hierarchy are widely conserved, underlying cell polarity development in diverse eukaryotes. To enumerate more fully the protein-protein interactions that mediate cell polarity development, and to uncover novel mechanisms that coordinate the numerous events involved, we carried out a large-scale two-hybrid experiment. 68 Gal4 DNA binding domain fusions of yeast proteins associated with the actin cytoskeleton, septins, the secretory apparatus, and Rho-type GTPases were used to screen an array of yeast transformants that express approximately 90% of the predicted Saccharomyces cerevisiae open reading frames as Gal4 activation domain fusions. 191 protein-protein interactions were detected, of which 128 had not been described previously. 44 interactions implicated 20 previously uncharacterized proteins in cell polarity development. Further insights into possible roles of 13 of these proteins were revealed by their multiple two-hybrid interactions and by subcellular localization. Included in the interaction network were associations of Cdc42 and Rho1 pathways with proteins involved in exocytosis, septin organization, actin assembly, microtubule organization, autophagy, cytokinesis, and cell wall synthesis. Other interactions suggested direct connections between Rho1- and Cdc42-regulated pathways; the secretory apparatus and regulators of polarity establishment; actin assembly and the morphogenesis checkpoint; and the exocytic and endocytic machinery. In total, a network of interactions that provide an integrated response of signaling proteins, the cytoskeleton, and organelles to the spatial cues that direct polarity development was revealed.

Melanoma-associated retinopathy: does autoimmunity prolong survival?

PURPOSE

To discuss the autoimmune basis of melanoma-associated retinopathy (MAR) and its implications for management and prognosis.

METHODS

An unusual history of a woman with melanoma-associated retinopathy is presented in detail. A review of published reports and a summary of 19 reported cases of MAR provide a basis for discussion.

RESULTS

This case report and other published reports highlight a number of points regarding MAR including the male predominance, prolonged survival in several patients and lack of response to immunosuppression.

CONCLUSIONS

Melanoma-associated retinopathy may prolong the survival of patients with metastatic melanoma through the autoimmune response. Therefore, treatment of visual symptoms with immunosuppression needs to be considered carefully.

Cooperative enhancement of specificity in a lattice of T cell receptors

Two of the most important models to account for the specificity and sensitivity of the T cell receptor (TCR) are the kinetic proofreading and serial ligation models. However, although kinetic proofreading provides a means for individual TCRs to measure accurately the length of time they are engaged and signal appropriately, the stochastic nature of ligand dissociation means the kinetic proofreading model implies that at high concentrations the response of the cell will be relatively nonspecific. Recent ligand experiments have revealed the phenomenon of both negative and positive crosstalk among neighboring TCRs. By using a Monte Carlo simulation of a lattice of TCRs, we integrate receptor crosstalk with the kinetic proofreading and serial ligation models and discover that receptor cooperativity can enhance T cell specificity significantly at a very modest cost to the sensitivity of the response.

Microsporidial keratoconjunctivitis in a healthy contact lens wearer without human immunodeficiency virus infection

PURPOSE

To present a rare case of microsporidial keratoconjunctivitis in an otherwise healthy contact lens wearer without human immunodeficiency virus infection who responded to treatment with systemic albendazole and topical fumagillin.

DESIGN

Interventional case report.

METHOD

A cornea epithelial scraping from a man with unilateral keratoconjunctivitis previously treated with topical steroids was evaluated by modified trichome staining.

MAIN OUTCOME MEASURES

The patient was evaluated for his symptoms, visual acuity, clinical observations, and pathologic examination of corneal scrapes.

RESULTS

Modified trichome staining of an epithelial corneal scraping revealed pinkish to red organisms characteristic of microsporidia. Results of a human immunodeficiency virus (HIV) enzyme-linked immunosorbent assay test were negative. The symptoms of ocular discomfort and clinical signs of keratoconjunctivitis resolved after 2 months of treatment with albendazole and topical fumagillin.

CONCLUSIONS

Ocular infection with microsporidia, although classically occurring in patients with HIV infection, may occur rarely in healthy individuals, especially if previously treated with systemic immune suppression or topical steroids. Microsporidial keratoconjunctivitis should be considered in the differential diagnosis of a contact lens wearer with atypical multifocal diffuse epithelial keratitis.

Macrolide resistance in Streptococcus pneumoniae in Hong Kong

Erythromycin resistance rates among penicillin-susceptible Streptococcus pneumoniae were 38 and 92% among penicillin-intermediate and -resistant S. pneumoniae isolates from Hong Kong, respectively, and 27% (43 of 158) of the isolates showed the MLS(B) phenotype, and the majority carried the ermB gene; 73% (115 of 158) displayed the M phenotype, and all possessed the mef gene. The MLS(B) phenotype was predominant in penicillin-susceptible, macrolide-resistant isolates and in penicillin-nonsusceptible isolates of serotype 6B, whilst the M phenotype was predominant in penicillin-intermediate or -resistant isolates belonging to serotype 23F or 19F. Extensive spread of clones of drug-resistant pneumococci has led to the widespread presence of macrolide resistance in S. pneumoniae in Hong Kong.

The role of early tracheostomy in critically ill neurosurgical patients

OBJECTIVE

To determine the value of early tracheostomy (within 7 days) in ventilated neurosurgical patients.

METHODS

Retrospective review of intubated patients in the neurosurgical intensive care unit (NICU) who underwent elective open tracheostomies for prolonged ventilation.

RESULTS

Thirty patients over a 2-year period were analysed. There were 19 males and 11 females, mean age 53.9 +/- 18.1 years (range 14 to 89), and mean Glasgow Coma Scale (GCS) score on admission 7.1 +/- 3.8 (range 3 to 15). The underlying disease aetiology was cerebrovascular disease in 53% of patients, head trauma in 33% and tumour or infection in 13%. Tracheostomy was performed after a mean period of 8.5 +/- 3.5 days (range 2 to 18), with patients requiring ventilation for a mean duration of 13.5 +/- 6.3 days (range 3 to 31). Complications were minimal; 1 wound infection (3.3%) and 4 tube obstructions (13.3%). Patients who underwent elective early tracheostomy (Group 1 = within 7 days) had poorer GCS on admission (6.3 +/- 2.9 versus 7.7 +/- 4.3 in Group 2, P = 0.271). Tracheostomy was performed after a mean of 5.3 +/- 1.7 days in Group I vs. 10.6 +/- 2.7 days in Group 2. Group 1 patients had faster recovery from nosocomial pneumonia (12.3 +/- 6.2 versus 17.9 +/- 12.5 days, P = 0.168), shorter duration of ventilation (9.8 +/- 5.9 versus 16.0 +/- 5.4 days, P = 0.007), and reduced incidence of multibacterial tracheobronchial colonisation (42% versus 72%, P = 0.098). The most prevalent organisms were Acinetobacter baumanii (43.3%), Pseudomonas (40%), methicillin-resistant Staphylococcus aureus (MRSA) (33%), Klebsiella (30%) and Staphylococcus aureus (26.7%).

CONCLUSION

Early tracheostomy in selected neurosurgical patients with poor GCS scores was associated with reduced incidence of tracheobronchial colonisation by multiple pathogens, improvement in chest infections, and rapid weaning from ventilatory support.

Immunocytochemical localization of apolipoprotein D in oligodendrocyte precursor-like cells, perivascular cells, and pericytes in the human cerebral cortex

Apolipoprotein D, a lipocalin transporter of small hydrophobic molecules including sterols, steroid hormones and arachidonic acid, is a widely expressed protein in peripheral and neural tissues. It has been shown to be upregulated in the context of neural injury, and with neuronal degeneration and regeneration. Here we have used light and electron microscopic immunocytochemistry with immunogold labeling to delineate the pattern of expression of apoD in the human brain. Our results confirm previous observations that apoD is a predominantly glial protein in the nervous system. In addition we have found that apoD is present in the cytosol and outer membrane of the nuclear envelope of glial cells in the neuropil. The labeled glial cells were putatively identified as a population of oligodendrocyte precursor cells. Immunoreactivity was also associated with the cytosol of perivascular cells, and lysosomes of pericytes, in the walls of blood vessels. These observations suggest a potential role for glial cells and apoD, in the transport of sterols and small hydrophobic molecules to, or from, blood vessels in the cortex.

Nutritional assessment of the lung transplant patient: body mass index as a predictor of 90-day mortality following transplantation

BACKGROUND

It is well documented that malnourished and/or obese surgical patients have increased morbidity and mortality post-operatively. Only a few studies investigating the effect of nutritional status on mortality are available pertaining to the transplant population. Since limited data are available on the nutritional status and its effects on mortality in the lung transplant population, we sought to ascertain whether there is an association between mortality and preoperative nutritional status.

METHODS

We examined mortality during the first 3 months after transplantation. Patients were grouped by body mass index (BMI) categories as < 17 kg/m(2), 17 to < 20 kg/m(2), 20 to 25 kg/m(2) (reference group), > 25 to 27 kg/m(2), and > 27 kg/m(2). Additional risk factors retrieved from the pre-transplant records included age, gender, diagnosis, energy requirements, protein requirements, protein and caloric intake, and weight history. Logistic regression for univariate and multivariate analysis for mortality used recipient age, gender, disease category, pre-transplant cytomegalovirus (CMV) serology, transplant type (single or bilateral), and donor age, gender, and CMV serology.

RESULTS

The likelihood estimates or odds ratios (ORs) of the risk of death within 90 days of lung transplantation for the BMI categories compared to the reference group were 3.7 for BMI < 17 kg/m(2) (p = 0.085), 1.6 for BMI < 17 to 20 kg/m(2) (p = 0.455), 3.5 for BMI > 25 to 27 kg/m(2) (p = 0.069), and 5.0 for BMI > 27 kg/m(2) (p = 0.003).

CONCLUSIONS

In patients with a pre-transplant BMI < 17 kg/m(2) or > 25 kg/m(2) the risk of dying within 90 days post-transplant was increased. In patients with a pre-transplant BMI of > 27 kg/m(2) the risk was significantly higher in than the reference group.

Cervical assessment at the routine 23-week scan: standardizing techniques

OBJECTIVE

To examine the frequency of curvature of the cervix and to establish the degree of curvature with increasing cervical length. To assess the significance of this phenomenon in terms of the classification of patients as high risk for pre-term delivery.

METHOD

Cervical length was measured prospectively by transvaginal sonography in 301 women at 23 weeks of gestation. The distance between the internal and external os was measured both as a straight line and also as a curved line along the endocervical canal. In addition, a search of our database was made to identify all women who had undergone cervical assessment as part of a policy of routine screening. In those with cervical length of less than 26 mm the thermal images of the cervix were used to obtain straight and curved measurements. The frequency of curved cervix was calculated and the relationship between the ratio of straight to curved measurement to the curved one was determined.

RESULTS

In the prospective study curvature of the cervix was observed in 143 (48%) of the 301 women. Curvature was observed in 51% (135 of 267) with cervical length of 26-55 mm, 25% (8 of 32) with length of 16-25 mm, and none of the two with length of 1-15 mm. The ratio of the straight to the curved measurement decreased with increasing cervical length (r = -0.27, P = 0.001). In the retrospective study curvature of the cervix was found in 72 (15%) of 471 with length of 16-25 mm and in none of the 76 with length of 1-15 mm.

CONCLUSION

Cervical length is influenced by the degree of cervical curvature. The disparity of measurements between the internal and external os taken as a straight line or along the cervical canal increases with cervical length. However, this disparity may not have any clinical implications because at short cervical length (less than 16 mm) the cervix appears to be always straight.

Improved reduction in pain in chronic pancreatitis with combined intraoperative celiac axis plexus block and lateral pancreaticojejunostomy

PURPOSE:Severe abdominal pain secondary to chronic pancreatitis is often multifactorial in origin. Lateral pancreaticojejunostomy (LPJ) is currently the accepted surgical treatment of choice when the main pancreatic duct is dilated. Chemical ablation of the celiac plexus for the treatment of intractable pain in chronic pancreatitis has been used without clear benefit. The aim of this study is to compare treatment outcomes of 2 groups of patients with the diagnosis of chronic pancreatitis and intractable abdominal pain (LPJ alone versus LPJ with intraoperative alcohol celiac ablation).Between 1994 and 1997, 34 patients underwent LPJ to control intractable pain secondary to chronic pancreatitis. These patients were divided into 2 groups, group 1 was LPJ only (16 patients) and group 2 was LPJ and intraoperative celiac ablation with 50% absolute alcohol (18 patients). Preoperative diagnosis and treatment criteria were similar for both groups. The clinical characteristics and outcome of both groups were retrospectively analyzed. Fisher exact test was used for statistical analysis.Demographic characteristics were similar in both groups. Pain control at short- and long-term follow-up was significantly improved in group 2 compared with group 1 (p < 0.035).Intraoperative celiac ablation in addition to LPJ appears to have a better response than does LPJ alone. Even though the number of patients is small, these results provide a basis for pursuing a prospective, randomized study to definitively answer this question.

DsbD-catalyzed transport of electrons across the membrane of Escherichia coli

Dsb proteins catalyze folding and oxidation of polypeptides in the periplasm of Escherichia coli. DsbC reduces wrongly paired disulfides by transferring electrons from its catalytic dithiol motif (98)CGYC. Genetic evidence suggests that recycling of this motif requires at least three proteins, the cytoplasmic thioredoxin reductase (TrxB) and thioredoxin (TrxA) as well as the DsbD membrane protein. We demonstrate here that electrons are transferred directly from thioredoxin to DsbD and from DsbD to DsbC. Three cysteine pairs within DsbD undergo reversible disulfide rearrangements. Our results suggest a novel mechanism for electron transport across membranes whereby electrons are transferred sequentially from cysteine pairs arranged in a thioredoxin-like motif (CXXC) to a cognate reactive disulfide.