The impact of an electronic reminder on the use of alarms after separation from cardiopulmonary bypass

INTRODUCTION

During cardiopulmonary bypass (CPB) monitor alarms are routinely disabled. Failure to reactivate these alarms after CPB may jeopardize patient safety. We have produced an electronic reminder that automatically alerts clinicians to reactivate alarms after CPB and have evaluated the alarm reactivation rate after its implementation.

METHODS

We developed and implemented an algorithm that identifies separation from CPB by the return of pulsatile flow and of mechanical ventilation, and checks alarm status (activated, disabled or silenced). If alarms have not been reactivated after separation from CPB, an electronic reminder appears. Data were collected during three time periods: Stage I (304 patients)--baseline period before implementation of the electronic reminder; Stage II (256 patients)--after implementation; Stage III-(435 patients) after a single educational departmental meeting, at the end of Stage II. Incidence of proper alarm reactivation and the number of electronic reminders per patient were compared among stages.

RESULTS

The rate of alarm reactivation at baseline (Stage I) was 22%, increased to 63% (Stage II), and again to 83% during Stage III (P < 0.001). The spontaneous alarm reactivation rate before the appearance of the electronic reminder on the anesthesia information management system screen increased from 19% at Stage II to 42% at stage III (P < 0.001).

CONCLUSION

Introducing an automatic electronic reminder significantly increased the rate of alarm reactivation after separation from CPB. Real-time computerized decision-support tools can be developed within anesthesia information management system and may be useful for improving safety during anesthesia.

DNA-free recombinant SV40 capsids protect mice from acute renal failure by inducing stress response, survival pathway and apoptotic arrest

Viruses induce signaling and host defense during infection. Employing these natural trigger mechanisms to combat organ or tissue failure is hampered by harmful effects of most viruses. Here we demonstrate that SV40 empty capsids (Virus Like Particles-VLPs), with no DNA, induce host Hsp/c70 and Akt-1 survival pathways, key players in cellular survival mechanisms. We postulated that this signaling might protect against organ damage in vivo. Acute kidney injury (AKI) was chosen as target. AKI is critical, prevalent disorder in humans, caused by nephrotoxic agents, sepsis or ischemia, via apoptosis/necrosis of renal tubular cells, with high morbidity and mortality. Systemic administration of VLPs activated Akt-1 and upregulated Hsp/c70 in vivo. Experiments in mercury-induced AKI mouse model demonstrated that apoptosis, oxidative stress and toxic renal failure were significantly attenuated by pretreatment with capsids prior to the mercury insult. Survival rate increased from 12% to >60%, with wide dose response. This study demonstrates that SV40 VLPs, devoid of DNA, may potentially be used as prophylactic agent for AKI. We anticipate that these finding may be projected to a wide range of organ failure, using empty capsids of SV40 as well as other viruses.

Activation and transposition of endogenous retroviral elements in hypomethylation induced tumors in mice

Genomewide DNA hypomethylation is a consistent finding in human tumors, but the importance of this change for human tumorigenesis remains an open question. We have previously reported that mice carrying a hypomorphic allele for the maintenance DNA methyltransferase (Dnmt1(chip/-)) are hypomethylated and develop thymic lymphomas, demonstrating that genomewide DNA hypomethylation can induce tumors. Hypomethylated cells exhibit inherent chromosomal instability, which is revealed in the lymphomas as a consistent trisomy of chromosome 15. We now report another aspect of the molecular basis for tumor development upon DNA hypomethylation. Seven out of 16 hypomethylation-induced lymphomas were found to contain an intracisternal A particle (IAP) somatic insertion in the middle of the Notch1 genomic locus, leading to generation of an oncogenic form of Notch1 in the tumors. This finding suggests that the molecular basis for hypomethylation-induced tumors in this model involves chromosomal instability events accompanied by activation of endogenous retroviral elements. Our findings validate the proposed role of DNA methylation in suppression of transposable elements in mammalian cells and demonstrate the importance of DNA methylation for normal cell function as well as the potential consequences of spontaneously occurring or chemically induced DNA hypomethylation.

The implementation of an anesthesia information management system

BACKGROUND AND OBJECTIVE

Anaesthesia information management systems, though still not used widely, will inevitably replace handwritten records and may eventually serve as a core for the development of computerized decision support. We investigated staff expectations and the accuracy of data entry in a recently implemented commercially available anaesthesia information management system.

METHODS

A structured questionnaire was administered to the staff before and 1 week and 3 months after implementation in order to assess their opinion. The quality of manual data entry, and of automatic data record was evaluated by looking for missing data and the prevalence of artefacts.

RESULTS

Despite initial fears the users quickly accepted the system. Both automatic and manual data entry were found to be accurate and reliable while the prevalence of artefacts was relatively low.

CONCLUSIONS

A commercially available anaesthesia information management system can be easily implemented and used instead of paper charts.

The effects of intrathecal morphine on patients undergoing minimally invasive direct coronary artery bypass surgery

OBJECTIVE

To evaluate the effects of intrathecal morphine (ITM) on the perioperative use of opiates and the fast-track pathway in patients undergoing minimally invasive direct coronary artery bypass grafting (MIDCAB).

DESIGN

Retrospective cohort study.

SETTINGS

University teaching hospital.

PARTICIPANTS

Twenty-two elective consecutive patients who underwent MIDCAB surgery.

INTERVENTIONS

Eleven patients received an intrathecal injection of morphine, 7 microg/kg (ITM group, n=11), and the control group (n=11) received standard anesthesia care.

MEASUREMENTS AND MAIN RESULTS

The intraoperative dose of fentanyl was 0.55+/-0.2 mg in the ITM group and 1.1+/-0.2 mg in the control group (p<0.0001). Four patients in the ITM group and none in the control group were extubated in the operating room. Extubation time was 3.2+/-4.7 hours in the ITM group and 6.3+/-3.4 hours in the control group (p=0.016). Morphine requirements in 24 hours after surgery were 2.0+/-3.5 mg in the ITM and 16.1+/-4.8 mg in the control group (p<0.0001). There were no differences in ischemic time, intraoperative fluid requirements, postoperative blood loss, and duration of surgical procedure. Hospital length of stay was shorter in the ITM group compared with the control group (3.9+/-1.7 days v 4.9+/-1.4 days, respectively, p=0.047).

CONCLUSIONS

ITM has to be considered in MIDCAB surgery as an effective component of the perioperative analgesia. The safety and effects of ITM in the patients recovery after MIDCAB surgery should be evaluated in further prospective studies.

Lack of association between B19 or V9 erythrovirus infection and ANCA-positive vasculitides: a case-control study

OBJECTIVES

To examine the potential association of human B19 or V9 erythrovirus infection and onset of ANCA-positive vasculitides.

METHODS

We tested the sera of 13 adults with newly diagnosed ANCA-positive vasculitides. Each was age- and sex-matched to three sera obtained from healthy controls. All samples were tested for B19- and V9-specific immunoglobulin (Ig) G and IgM antibodies (Ab) (third-generation ELISA), and B19 or V9 DNA was sought with the polymerase chain reaction. Statistical analysis was performed by conditional logistic regression.

RESULTS

Patient diagnoses comprised six cases of Wegener's granulomatosis, six of microscopic polyangiitis and one of Churg-Strauss syndrome. IgG Ab to B19 were detected equally in patient and control sera (77 and 79% respectively) (odds ratio=0.84, P=0.84). All 13 cases and 39 controls were negative for IgM Ab and viral DNA.

CONCLUSION

These results suggest that neither acute nor chronic B19 or V9 infection is an aetiological factor in ANCA-associated vasculitides.

Airway management by physicians wearing anti-chemical warfare gear: comparison between laryngeal mask airway and endotracheal intubation

BACKGROUND AND OBJECTIVE

To evaluate the ease with which successful insertion of a laryngeal mask airway can be performed in comparison with endotracheal intubation by medical personnel wearing chemical protective equipment.

METHODS

Anaesthetists and non-anaesthetists (each n = 20) participated in the prospective comparative trial in an animal laboratory. The time and success rates of laryngeal mask airway vs. endotracheal tube insertions were measured as performed on anaesthetized monkeys.

RESULTS

The results showed that the laryngeal mask airway was inserted more rapidly than the endotracheal tube by both groups (3.6 s and 28.6 s, P < 0.0001). Failed intubation occurred in 35% (anaesthetists) vs. 55% (non-anaesthetists) (P = 0.17).

CONCLUSIONS

In view of the 100% success rate of insertion even in unfavourable conditions, the possible role of the laryngeal mask airway in the scenario of a toxic mass casualty event should be considered.

Quantitation of soluble and skeletal alkaline phosphatase, and insoluble alkaline phosphatase anchor-hydrolase activities in human serum

BACKGROUND

The current studies were intended to compare the circulating levels of total and anchorless (soluble) skeletal and hepatic ALP isoenzyme activities, and insoluble ALP anchor-hydrolase activity in serum of postmenopausal women.

METHODS

Preliminary studies of the insoluble ALP anchor-hydrolase activity in serum revealed a pH optimum of pH 5-6.5, a sensitivity to inactivation by heat at temperatures >45 degrees C (t(1/2)=8-9 min at 60 degrees C), and an apparent K(M) (at pH 7.5) of 40-45 mU/ml of insoluble skeletal ALP activity.

RESULTS

Serum analyses showed that 94.5+/-0.5% (mean+/-SEM) of the ALP activity in serum was in the anchorless, soluble form. The data were also consistent with the notion that the amount of insoluble ALP anchor-hydrolase activity in serum, 52.8+/-0.8 U/l (mean+/-SEM), was sufficient for the conversion of anchor-intact (insoluble) ALP into the anchorless, soluble form, assuming activation by serum lipids and/or bile salts. Distributions of results for total, skeletal, hepatic, and insoluble ALP anchor-hydrolase activity were skewed toward the higher range and leptokurtotic (p<0.01 for each). Total ALP activity ranged from 42% to 208% of the group mean value; skeletal, hepatic, and insoluble ALP anchor-hydrolase activities ranged from 5% to 306%, 33% to 277%, and 2% to 325%, respectively. In contrast, the soluble ALP fraction only ranged from 71% to 106% of the group mean value.

CONCLUSIONS

The correlations between the total and both skeletal (r=0.711, p<0.001) and hepatic (r=0.782, p<0.001) ALP isoform activities were predictive. Although correlations were also observed between insoluble ALP anchor-hydrolase activity and total (r=0.197, p<0.001), hepatic (r=0.184, p<0.001) and skeletal ALP activities (r=0.118, p<0.05), those relationships were not predictive (r(2)<0.04).

Induced neuronal differentiation of human embryonic stem cells

Human embryonic stem (ES) cells are pluripotent cells capable of forming differentiated embryoid bodies (EBs) in culture. We examined the ability of growth factors under controlled conditions to increase the number of human ES cell-derived neurons. Retinoic acid (RA) and nerve growth factor (betaNGF) were found to be potent enhancers of neuronal differentiation, eliciting extensive outgrowth of processes and the expression of neuron-specific molecules. Our findings show that human ES cells have great potential to become an unlimited cell source for neurons in culture. These cells may then be used in transplantation therapies for neural pathologies.

Involvement of branched-chain amino acid aminotransferases in the production of fusel alcohols during fermentation in yeast

Organoleptic compounds produced by yeast during the fermentation of wort have a great impact on beer smell and taste. Among them, fusel alcohols are the major abundant volatile compounds. The availability of Saccharomyces cerevisiae mutants in which the genes coding for the two branched-chain amino acid aminotransferases have been deleted offers the possibility of further defining the role of these enzymes in the formation of higher alcohols. Comparing the production profiles of different strains, it is clear that they are not all influenced in the same way by branched-chain amino acid aminotransferase mutations. First of all, as propanol is synthesised from alpha-ketobutyrate, the first metabolic intermediate in the anabolic pathway of isoleucine, neither the eca39 nor eca40 mutations have any effect on the production of this higher alcohol. On the other hand, it can be concluded that the eca40 mutation has a drastic effect on the production of isobutanol. To a certain extent, the same conclusion can be made for the production of active amyl alcohol and isoamyl alcohol, although the results suggest that another route could lead to the formation of these two higher alcohols.

Differentiation of human embryonic stem cells into embryoid bodies compromising the three embryonic germ layers

BACKGROUND

Embryonic stem (ES) cells are lines of cells that are isolated from blastocysts. The murine ES cells were demonstrated to be true pluripotent cells as they differentiate into all embryonic lineages. Yet, in vitro differentiation of rhesus ES cells was somewhat inconsistent and disorganized. The recent isolation of human ES cells calls for exploring their pluripotential nature.

MATERIALS AND METHODS

Human ES cells were grown in suspension to induce their differentiation into embryoid bodies (EBs). The differentiation status of the human ES cells and EBs was analyzed by following the expression pattern of several lineage-specific molecular markers using reverse transcription polymerase chain reaction (RT-PCR) and in situ hybridization.

RESULTS

Here we report the induction in vitro of cystic embryoid bodies from human ES cells. Our findings demonstrate induction of expression of cell-specific genes during differentiation of the human ES cells into EBs. In the human EBs, we could show a characteristic regional expression of embryonic markers specific to different cellular lineages, namely, zeta-globin (mesoderm), neurofilament 68Kd (ectoderm), and alpha-fetoprotein (endoderm). Moreover, we present a synchronously pulsing embryoid body that expresses the myocardium marker alpha-cardiac actin. In addition, dissociating the embryoid bodies and plating the cells as monolayers results in multiple morphologies, among them cells with neuronal appearance that express neurofilament 68Kd chain.

CONCLUSION

Human ES cells can reproducibly differentiate in vitro into EBs comprising the three embryonic germ layers. The ability to induce formation of human embryoid bodies that contain cells of neuronal, hematopoietic and cardiac origins will be useful in studying early human embryonic development as well as in transplantation medicine.

Involvement of branched-chain amino acid aminotransferase (Bcat1/Eca39) in apoptosis

The branched-chain amino acid aminotransferase, Bcat1/Eca39, catalyzes the first step of branched-chain amino acid catabolism. Bcat1/Eca39 was originally isolated from a c-myc-induced tumor and was proven to be a direct target for c-Myc regulation. The gene is highly conserved in evolution and disruption of its yeast homolog affects cell growth. To assess the role of Bcat1/Eca39 in mammalian cells, we overexpressed Bcat1/Eca39 in murine cells and studied effects on cell growth. Overexpression of Bcat1/Eca39 had no apparent effect on the proliferation of cells grown with high serum concentrations, but under serum deprivation conditions, led to a decrease in cell viability. Cell death under these conditions displayed apoptotic features. The branched-chain keto acid, alpha-ketoisocaproate, a metabolite of leucine catabolism produced by BCAT1/ECA39, was previously found to inhibit cell growth. We show that alpha-ketoisocaproate can induce rapid apoptotic cell death. This observation suggests that the growth inhibitory effect of BCAT1/ECA39 and its apoptosis promoting effect may be mediated by the levels of the products of BCAT1/ECA39 activity, namely, branched-chain keto acids.

Characterization of a branched-chain amino-acid aminotransferase from Schizosaccharomyces pombe

The Saccharomyces cerevisiae genes for the cytosolic and mitochondrial branched-chain amino-acid aminotransferases (BCAT) were isolated recently. These genes show significant homology to mammalian ECA39, originally isolated as a gene regulated by the c-myc oncogene. We now report the isolation of the Schizosaccharomyces pombe eca39/BCAT gene. The S. pombe protein shows 47-52% identity to other eukaryotic BCAT proteins isolated from S. cerevisiae, nematode, mouse and man. A genetic growth assay for BCAT activity was established using an S. cerevisiae strain disrupted in both BCAT isoenzymes. Consequently, the activity of the S. pombe BCAT was demonstrated by genetic and biochemical means. Possible applications of BCAT-encoding genes as selection markers in yeast transformation are proposed.

Erythroblastic inclusions in dominantly inherited beta thalassemias

While the precipitation of unstable variant beta-globin chains has been implicated as a major pathogenic mechanism in dominantly inherited beta thalassemia, their instability and presence in intra-erythroblastic inclusions have not been conclusively shown. We report the investigation of two cases of dominantly inherited beta thalassemia due to heterozygosity for the beta-codon 121 G-T mutation. In one case, we were able to demonstrate the presence of an abnormal beta-globin chain in both peripheral blood reticulocytes and bone marrow erythroblasts, and to assess its stability in relation to the substantial amounts of mutant beta mRNA transcript. The serum transferrin receptor (TfR) level was markedly increased, an indication of increased erythropoietic activity. In both cases, we could show by immunoelectron microscopy that the intra-erythroblastic inclusion bodies, a prominent feature of diseases in this category, contained not only precipitated alpha-globin chains, but also beta chains. The data confirm previous suggestions that the cellular pathology underlying this group of beta thalassemias is related to the synthesis of highly unstable beta-globin chain variants, which fail to form functional tetramers and precipitate intracellularly with the concomitant excess alpha chains, leading to increased ineffective erythropoiesis.

Two yeast homologs of ECA39, a target for c-Myc regulation, code for cytosolic and mitochondrial branched-chain amino acid aminotransferases

ECA39 was isolated as a target gene for c-Myc regulation in mice. We identified two homologs for the murine ECA39 in the yeast Saccharomyces cerevisiae, ECA39 and ECA40, as well as two human homologs. These genes show a significant homology to prokaryotic branched-chain amino acid aminotransferase (BCAT) (EC). To understand the function of eukaryotic ECA39 and ECA40, we deleted either gene from the yeast genome. Activity of branched-chain amino acid aminotransferase was measured in the wild-type and mutants with either leucine, isoleucine, or valine as substrates. The results demonstrate that in S. cerevisiae ECA39 and ECA40 code for mitochondrial and cytosolic branched-chain amino acid aminotransferases, respectively. ECA39 is highly expressed during log phase and is down-regulated during the stationary phase of growth, while ECA40 shows an inverse pattern of gene expression. In agreement with these results, while we previously showed that deletion of ECA39 affected the cell cycle in proliferating cells, we do not observe a growth phenotype in eca40Delta cells. We suggest that BCAT is a target for c-Myc activity and discuss the evolutionary conservation of prokaryotic and eukaryotic BCATs and their possible involvement in regulation of cell proliferation.

ECA39, a conserved gene regulated by c-Myc in mice, is involved in G1/S cell cycle regulation in yeast

The c-myc oncogene has been shown to play a role in cell proliferation and apoptosis. The realization that myc oncogenes may control the level of expression of other genes has opened the field to search for genetic targets for Myc regulation. Recently, using a subtraction/coexpression strategy, a murine genetic target for Myc regulation, called EC439, was isolated. To further characterize the ECA39 gene, we set out to determine the evolutionary conservation of its regulatory and coding sequences. We describe the human, nematode, and budding yeast homologs of the mouse ECA39 gene. Identities between the mouse ECA39 protein and the human, nematode, or yeast proteins are 79%, 52%, and 49%, respectively. Interestingly, the recognition site for Myc binding, located 3' to the start site of transcription in the mouse gene, is also conserved in the human homolog. This regulatory element is missing in the ECA39 homologs from nematode or yeast, which also lack the regulator c-myc. To understand the function of ECA39, we deleted the gene from the yeast genome. Disruption of ECA39 which is a recessive mutation that leads to a marked alteration in the cell cycle. Mutant haploids and homozygous diploids have a faster growth rate than isogenic wild-type strains. Fluorescence-activated cell sorter analyses indicate that the mutation shortens the G1 stage in the cell cycle. Moreover, mutant strains show higher rates of UV-induced mutations. The results suggest that the product of ECA39 is involved in the regulation of G1 to S transition.