Do shorter-acting neuromuscular blocking drugs or opioids associate with reduced intensive care unit or hospital lengths of stay after coronary artery bypass grafting? CABG Clinical Benchmarking Data Base Participants

BACKGROUND

The authors hypothesized that shorter-acting opioid and neuromuscular blocking drugs would be associated with reductions in duration of intubation, length of stay (LOS) in the intensive care unit (ICU) after tracheal extubation, or postoperative (exclusive of ICU) LOS, and that shorter durations of intubation would be associated with reduced ICU LOS after extubation and postoperative (exclusive of ICU) LOS.

METHODS

One-thousand ninety-four patients undergoing primary coronary artery bypass graft surgery at 40 academic health centers were studied. Multiple patient-related factors were included in multivariate models for hypothesis testing.

RESULTS

The duration of tracheal intubation, ICU LOS after extubation, and postoperative (exclusive of ICU) LOS all varied significantly by site. There was no difference between vecuronium and pancuronium in duration of intubation, ICU LOS after extubation, or postoperative (exclusive of ICU) LOS. Use of sufentanil rather than fentanyl was associated with a significant (P=0.045) reduction of 1.9 h (95% CI, 0.04 to 4.1 h) in duration of tracheal intubation but had no significant effect on ICU LOS after extubation, total ICU LOS, postoperative (exclusive of ICU) LOS, or total postoperative LOS. The authors' best model predicts a complex association between increasing duration of intubation and both ICU LOS after tracheal extubation and postoperative (exclusive of ICU) LOS, which was associated with an increase in those measures when duration of intubation exceeded 7.3 or 3 h, respectively.

CONCLUSIONS

The LOS measures varied considerably among the institutions. Use of shorter-acting opioid and neuromuscular blocking drugs had no association with ICU LOS after tracheal extubation or with postoperative (exclusive of ICU) LOS. Only when the duration of intubation exceeded threshold values was it associated with increased LOS measures.

Con: calcium is not routinely indicated during separation from cardiopulmonary bypass

Severe hypocalcemia is uncommon in adult cardiac surgery patients; the nearly ubiquitous mild hypocalcemia does not impair myocardial performance. Clinicians should recognize that in certain circumstances, calcium may interact negatively with catecholamines such as epinephrine or dobutamine. Lastly, evidence suggests that calcium influx during ischemia-reperfusion contributes to myocardial dysfunction after CPB. Therefore, there appears to be no justification for the practice of routinely administering large doses of calcium salts to adult cardiac surgery patients after CPB.

Selective alterations of cerebrospinal fluid amino acids in dogs with congenital portosystemic shunts

Numerous studies suggest that modifications in concentrations of both excitatory and inhibitory amino acids are implicated in the pathophysiology of portal-systemic encephalopathy (PSE), a neuropsychiatric disorder associated with chronic liver disease in humans. In this study, amino acid levels were measured by High Performance Liquid Chromatography (HPLC) in Cerebrospinal Fluid (CSF) of 10 dogs (age range: 3 mo.- 3 yr 4 mo.) exhibiting a congenital portal-systemic shunt, either intra or extra-hepatic, and 8 age-matched control dogs who showed no signs of hepatic or neurologic disorders. Dogs with congenital shunts manifested signs of encephalopathy such as disorientation, head pressing, vocalization, depression, seizures and coma. CSF from dogs with congenital shunts contained significantly increased amounts of glutamate (2 to 3-fold increase, p<0.01), glutamine (6-fold increase, p<0.05) and aromatic amino acids (phenylalanine, tyrosine and tryptophan) compared to CSF of control dogs. Concentrations of GABA and branched chain amino acids (valine, leucine, isoleucine) were within normal limits. Modifications of brain glutamate (an excitatory amino acid) as well as tryptophan (the precursor of serotonin) could contribute to the neurological syndrome characteristic of congenital PSE in dogs.

Cerebral emboli during cardiac surgery in children

BACKGROUND

Microemboli occur commonly during cardiac surgery in adults, and, when present, increase the risk of neuropsychological deficits. Their incidence and significance during correction of congenital heart disease is unknown. The authors hypothesized that microemboli would occur before bypass with right-to-left cardiac shunts and would also occur in large numbers when the aortic crossclamp was released in children during repair of congenital heart defects.

METHODS

In 25 children studied with carotid artery Doppler, embolic signals were counted and timed in relation to 13 intraoperative events. Patients were classified as either at high risk (obligate right-to-left shunt or uncorrected transposition of the great arteries) or at low risk (net left-to-right shunt or simple obstructive lesions) for paradoxical (venous to arterial) emboli.

RESULTS

The median number of emboli detected was 122 (range, 2-2,664). Forty-two percent of all emboli were detected within 3 min of release of the aortic crossclamp. The high-risk group had significantly more emboli (median, 66; range, 0-116) during the time interval before cardiopulmonary bypass than did the low-risk group (median, 8; range, 0-73), with P < 0.01. There was no significant difference between the high- and low-risk groups in the total number of emboli detected. There was no apparent association between number of emboli and gross neurologic deficits.

CONCLUSIONS

Microemboli can be detected in the carotid arteries of children undergoing repair of congenital heart disease and are especially prevalent immediately after release of the aortic crossclamp. The role of emboli in causing neurologic injury in children undergoing repair of congenital heart disease remains to be determined.

Structure-affinity relationships and stereospecificity of several homologous series of local anesthetics for the beta2-adrenergic receptor

Local anesthetics inhibit binding of ligands to beta2-adrenergic receptors (beta2ARs), and, as a consequence, inhibit intracellular cAMP production. We hypothesized that among homologous local anesthetics, their avidity at inhibiting binding of tritiated dihydroalprenolol (3H-DHA) to beta2ARs would increase with increasing length of alkyl substituents and would demonstrate stereospecificity. Specific binding of 3H-DHA to human beta2ARs was assayed in the presence of six different members of the 1-alkyl-2,6-pipecoloxylidide class of local anesthetics (including mepivacaine, ropivacaine, and bupivacaine), the R(+) and S(-) bupivacaine enantiomers, lidocaine, prilocaine, etidocaine, procaine, and tetracaine. Avidity of binding to beta2ARs increased with increasing length of the alkyl chain (pKi values = 2.4, 3.6, 4.3, 4.1, 4.1, 5.9 for the methyl [mepivacaine], ethyl, S(-)propyl [ropivacaine], butyl [bupivacaine], pentyl, and octyl derivatives, respectively). We found no evidence for bupivacaine stereospecificity (pKi values = 4.3 and 4.9 for the S(-) and R(+) isomers, respectively). Other amide and ester local anesthetics also showed increasing potency with increasing length of alkyl substituents (pKi values = 3.6, 3.8, and 4.3 for lidocaine, prilocaine, and etidocaine; 4.2 and 5.6 for procaine and tetracaine, respectively). The correlation between increased inhibition of beta2AR binding and alkyl chain length resembles the correlation between local anesthetic potency at nerve block and increased alkyl chain length. The lack of clear stereospecificity is consistent with the relatively low potency these agents demonstrate at inhibition of beta2AR binding. Finally, the relatively potent inhibition of beta2ARs by etidocaine, tetracaine, and bupivacaine suggests that their propensity for cardiovascular depression after accidental intravenous overdose could result from beta2AR or beta1AR blockade and inhibition of cAMP production.

IMPLICATIONS

Local anesthetics demonstrate a rank order of avidity for displacing ligands from beta2-adrenergic receptors such that larger molecules displace ligands at lower concentrations than smaller local anesthetic molecules. This relationship between molecular size and receptor avidity could explain the greater propensity for cardiovascular toxicity of relatively large local anesthetics such as bupivacaine.

Clinical pathways for the high-risk patient

The goal of managed health care is to reduce health care costs while maintaining or improving the quality of care given to patients. Clinical pathways, which outline the services and therapies planned for a typical patient admitted with a specific diagnosis, may provide a way to control costs and improve patient outcome. These pathways are under development by medical centers and managed-care organizations nationwide, with the aim of planning, managing, documenting, and evaluating multidisciplinary care. A coordinated care plan can take a number of approaches. Time lines identify predictable clinical landmarks and time intervals for a specific medical episode or illness within a given diagnostic-related group or set of diagnostic-related groups. Case-management plans and case managers coordinate a patient's care throughout an episode, eg, an operation, enabling patients to reach defined time points in the course of their care at the expected time. Critical pathways are the favored method of documenting the patient's progress according to the predicted time schedule. This report discusses ways to successfully implement a care plan, highlighting the commitment and effort needed from a multidisciplinary staff to achieve the goal of optimizing efficiency and quality of patient care.

Protective effect of L-carnitine in ammonia-precipitated encephalopathy in the portacaval shunted rat

L-carnitine administration prevents the neurological symptoms of acute ammonia toxicity. To further evaluate its efficacy in the prevention of hepatic encephalopathy in hyperammonemic conditions, L-carnitine (16 mmol/kg, intraperitoneally [i.p.] was administered 1 hour before ammonium acetate (NH4OAc) (8.5 mmol/kg, subcutaneously) to portacaval shunted (PCS) rats. Cerebrospinal fluid (CSF) ammonia, lactate, and amino acid levels were measured in relation to deteriorating neurological status in these animals. None of 35 L-carnitine-treated animals showed neurological deterioration after NH4OAC administration compared with saline-treated controls; the latter manifested severe encephalopathy progressing through loss of righting reflex to coma. Survival rate was 100% in the L-carnitine-treated group compared with 5% in saline-treated controls. Following NH4OAC administration to PCS rats, CSF ammonia increased to 0.93 +/- 0.15 mmol/L and 1.24 +/- 0.15 mmol/L at precoma and coma stages of encephalopathy (P < .01) respectively. Treatment with L-carnitine reduced CSF ammonia at both precoma and coma stages; the time-course of this protective effect paralleled blood and CSF L-carnitine accumulation. CSF alanine and lactate increases following NH4OAC administration to PCS rats were significantly attenuated following L-carnitine treatment. However, L-carnitine treatment did not lead to significant reductions in plasma ammonia nor CSF or brain glutamine in these animals. These findings show the therapeutic efficacy of L-carnitine in ammonia-precipitated coma in PCS rats and suggest that this protective effect is centrally mediated involving improved mitochondrial respiration. L-carnitine could be of therapeutic benefit in the prevention of hepatic encephalopathy precipitated by ammoniagenic conditions in humans with chronic liver disease.

Failure of meperidine to anesthetize human median nerve. A blinded comparison with lidocaine and saline

BACKGROUND AND OBJECTIVES

Although meperidine safely produces clinical spinal anesthesia, the responsible mechanism is unknown. This study was undertaken to test the possibility that this drug acts as a local anesthetic by investigating its ability to inhibit conduction in a human peripheral nerve.

METHODS

In a blinded fashion, the abilities of 5-mL injections of meperidine (0.5% and 1.5%), lidocaine (0.25%), and saline to produce median nerve block were tested in eight volunteer subjects, and these four solutions were compared with standard local anesthetic solutions that had been tested in previous studies. The extent of local anesthesia was measured objectively by electrodiagnostic tests, namely, compound motor action potentials (CMAPs) and sensory nerve action potentials (SNAPs), as well as by qualitative tests of sensation.

RESULTS

Lidocaine (0.25%) prolonged median SNAP latency from 3.1 ms to 3.3 ms (P < .015) and prolonged mean CMAP latency from 4.1 ms to 4.7 ms (P < .002). The SNAP amplitude trended downward after lidocaine (0.25%), but the decrease did not reach statistical significance (35 microV to 25 microV, P < .19). Neither meperidine solution (0.5% or 1.5%) nor saline inhibited SNAP or CMAP amplitudes or prolonged SNAP or CMAP latencies. Also, in contrast to previous findings with more potent local anesthetic solutions (eg, lidocaine 1%, mepivacaine 1%, and bupivacaine 0.33%), none of the four solutions tested in this study altered subjective sensations of hot, cold, or pinprick. Meperidine 1.5% produced systemic side effects, including vertigo, nausea, and flushing, in all subjects.

CONCLUSIONS

Meperidine produced no signs of local anesthesia, even when given at a dose (75 mg) and concentration (1.5%) that consistently produced systemic side effects. Thus, the coequivalent ability of meperidine and lidocaine to produce spinal anesthesia contrasts with their discordant ability to produce local anesthesia. This disparity suggests that meperidine may produce spinal anesthesia through mechanisms other than inhibition of sodium channel function.

Neuroactive amino acids and glutamate (NMDA) receptors in frontal cortex of rats with experimental acute liver failure

It has been proposed that alterations of excitatory and inhibitory amino acids play a role in the pathogenesis of hepatic encephalopathy in acute liver failure. To evaluate this possibility, in vivo cerebral microdialysis was used to sample extracellular concentrations of amino acids in the frontal cortex of unanesthetized rats at various times during the progression of encephalopathy resulting from acute liver failure. Liver failure was induced by portacaval anastomosis followed 24 hours later by hepatic artery ligation. Dialysate concentrations of amino acids were measured by high-performance liquid chromatography (HPLC) with fluorescence detection. Deterioration of neurological status was accompanied by two- to four-fold increases in extracellular glutamate, glutamine, and glycine; concentrations of gamma-aminobutyric acid (GABA) and taurine were unchanged. Densities of binding sites for the glutamate (N-methyl-D-aspartate [NMDA]) receptor ligand 3H-MK801, assessed using quantitative receptor autoradiography, however, were unchanged in the frontal cortex of rats at coma stages of ischemic liver failure. Increased extracellular glutamate concentrations were positively correlated with the severity of encephalopathy and with arterial ammonia concentrations. Such changes may result from an ammonia-induced reduction in the capacity for astrocytes to uptake glutamate. Increased extracellular glutamate in brain, together with increases in concentrations of glycine, a positive allosteric modulator of glutamate (NMDA) receptors, are consistent with increased NMDA-related glutamatergic neurotransmission in this model of acute liver failure. Increased extracellular glutamate, therefore, could contribute to the pathogenesis of hepatic encephalopathy and brain edema in acute liver failure.

"This is your meeting": a qualitative study of person-centered planning

Participant observation and in-depth interviews were conducted to determine processes involved in person-centered planning. Initial planning meetings of 6 individuals were studied in connection with a project to assist young adults in transition from school to adult life. The organization and structure, facilitation process, participation of families, professionals, friends, and the focal individual were described. Although the major goal of the project was to assure that this was the individual's own meeting, implementation of this principle was constrained in several ways, including facilitators' tendency to behave according to prior roles and training. Six months following initiation, several positive outcomes could be attributed to the planning process. Further, many unplanned positive outcomes appeared to result from person-centered planning.

Selecting an inotrope for the cardiac surgery patient

Although a wide variety of positive inotropic agents have been administered to cardiac surgery patients, few of them have been carefully studied in controlled clinical trials, in surgical patient populations. The limited data available suggest that one of the more widely used agents, calcium, may lack efficacy and possibly inhibit the actions of catecholamines. Dopamine, dobutamine, and dopexamine are highly effective agents, but more prone to produce tachycardia than epinephrine. Amrinone is an effective agent by itself, but is especially useful in combination with a beta-adrenergic agonist for patients with severe left-ventricular dysfunction.

Inhibition of brain cell excitability by lidocaine, QX314, and tetrodotoxin: a mechanism for analgesia from infused local anesthetics?

Local anesthetic infusions have been used to provide analgesia in a variety of painful conditions. The mechanism for this drug effect remains unknown. To better define the electrical effects of lidocaine concentrations comparable to those obtained during analgesic infusions, lidocaine (0.05-3 mmol.l-1), QX314 (an obligatorily charged, quaternary lidocaine derivative applied within the cells), and tetrodotoxin (10 mmol.l-1) were applied to rat hippocampal pyramidal cells. The three drugs, which inhibit Na+ currents by varying mechanisms, produced tonic increases in (firing) current threshold, and decreases in the amplitude of action potentials measured using an intracellular microelectrode technique. Lidocaine inhibited action potential spikes and increased current threshold in a concentration-dependent fashion. Lidocaine 50 and 100 mumol.l-1 did not inhibit action potentials, but increased firing threshold by nearly 100%. Lidocaine 1-3 mmol.l-1 significantly inhibited action potential amplitude and increased threshold by as much as 800%. Similarly, QX314 and tetrodotoxin produced greater increases in current threshold than in action potential amplitude. QX314 produced phasic (or frequency-dependent) block during trains of stimuli at 1 Hz, even when almost no tonic block was present. Lidocaine produced less phasic block than QX314, and required both greater tonic block and more frequent stimulation to produce the phenomenon. Tetrodotoxin demonstrated no phasic block. Increases in current threshold occurred in lidocaine concentrations associated with analgesia and toxicity; inhibition of action potentials occurred scarcely at all at these concentrations. Thus, tonic increases in current threshold may underlie analgesia and supplementation of general anesthesia by intravenous lidocaine.

Sustained focal effects of low-dose intramuscular succinylcholine

We studied low-dose intramuscular succinylcholine in 9 subjects as part as an ongoing investigation of its potential to predict responses to botulinum toxin. We measured compound muscle action potentials (CMAPs) from the extensor digitorum brevis (EDB) muscles in each foot before and after intramuscular injections of 2.5 mg of succinylcholine into the EDB. Succinylcholine reduced mean CMAP amplitudes to 42% of baseline; the maximal reduction occurred at 19 +/- 6 (mean +/- standard deviation) minutes. Recovery to 73% of the baseline CMAP amplitude (approximately 50% recovery from block) occurred at 105 +/- 49 minutes after injection. Repetitive (train-of-four) stimulation at 2 Hz produced mild CMAP decrements (5-25%), but only during the recovery phase. Varying the succinylcholine concentrations (10, 20, or 50 mg/mL) while holding the total drug dose constant did not change the rate of onset or the extent of block. No systemic complications occurred. We conclude that: (1) 2.5 mg intramuscular succinylcholine can safely induce selective muscle weakness with a time course that differs from intravenously administered succinylcholine; and (2) further clinical studies comparing intramuscular succinylcholine and botulinum toxin are warranted.

Enzyme activities in relation to pH and lactate in postmortem brain in Alzheimer-type and other dementias

Phosphate-activated glutaminase, glutamic acid decarboxylase, pyruvate dehydrogenase, succinic dehydrogenase, pH, and lactate were measured in frontal cortex and caudate nucleus of postmortem brains from cases of Alzheimer-type dementia (ATD), Down's syndrome, Huntington's disease, and one case of Pick's disease, as well as from sudden death and agonal controls. Lactate levels were higher and pH, phosphate-activated glutaminase, and glutamic acid decarboxylase levels were lower in the agonal controls than in the sudden death controls. Phosphate-activated glutaminase and glutamic acid decarboxylase were correlated with tissue pH and lactate, and also were reduced by in vitro acidification, suggesting that the low activities of these enzymes in agonal controls were related to decreased pH consequent upon lactate accumulation. Compared with control tissues at the same pH, phosphate-activated glutaminase and glutamic acid decarboxylase were unaltered in ATD and Down's frontal cortex and reduced in Huntington's caudate nucleus, and glutamic acid decarboxylase was reduced in Huntington's frontal cortex. These data suggest that GABAergic neurons are not affected in ATD and confirm the GABAergic defect in Huntington's disease. Pyruvate dehydrogenase and succinic dehydrogenase activities were the same in agonal controls and sudden death controls and were unaffected by acid pH and lactate in vitro, and pyruvate dehydrogenase was not correlated with pH or lactate. Reduced pyruvate dehydrogenase in frontal cortex of individual ATD, Down's, and Pick's cases, and in the caudate nucleus of Huntington's and Down's cases, was accompanied by gliosis/neuron loss. We conclude that decreased pyruvate dehydrogenase reflects neuronal loss.

Postmortem human brain pH and lactate in sudden infant death syndrome

Lactate and pH were measured in frontal and temporal cortex, cingulate gyrus, and caudate nucleus in brains from sudden infant death syndrome (SIDS) cases, control infants, and control adults. Both the lactate levels and the pH values were significantly correlated (p less than 0.001) between the four brain areas, whereas lactate and pH values were significantly correlated within each brain area (p less than 0.001) with a value of pH 7.2 for zero lactate. The lactate concentration in heart blood was significantly correlated with brain lactate (p less than 0.001). Adult sudden death cases (heart attacks) had low lactate and high pH values, whereas agonal state cases had high lactate and low pH values. Control infants who had died because of accidents also had low lactate and high pH values, but infants who might have been exposed to hypoxia before death had high lactate and low pH values. SIDS cases fell into two groups: the first, consisting of all victims over 30 weeks of age and about one-half to two-thirds of those aged less than 30 weeks, had low lactate and high pH values; the second group, consisting of about one-third to one-half of those less than 30 weeks old, had high lactate and low pH values. The changes in lactate levels and pH values indicate that the majority of SIDS cases had died suddenly, but that a sizeable minority had been exposed to hypoxia prior to death.

Negative comments

The clinical feature on anaesthetic nurses (Nursing Standard October 31) made depressing reading. At a time when the NATN and the British Association of ODA's are coming together to further establish the working relationship between theatre staff, Mrs Cooks comments are wholly negative.

Changes in nine enzyme markers for neurons, glia, and endothelial cells in agonal state and Huntington's disease caudate nucleus

Enzymes considered to be markers for neurons (angiotensin converting enzyme, thermolysin-like metalloendopeptidase, alanine aminopeptidase, and glutamate-oxaloacetate transaminase), glia (glutamine synthetase, pyruvate carboxylase, and beta-glucuronidase), and endothelial cells (alkaline phosphatase and plasminogen activator) were measured in caudate nucleus from 10 sudden death controls, eight agonal state controls, and 16 Huntington's disease patients. Glutamate-oxaloacetate transaminase was slightly reduced by agonal state. The four enzymes with a neuronal distribution were all correlatively reduced in Huntington's disease caudate nucleus. Glutamine synthetase activity was reduced and beta-glucuronidase mean activity increased over twofold in Huntington's disease caudate nucleus, with the two enzyme activities being inversely related. Pyruvate carboxylase was markedly affected by agonal state and was very variable in Huntington's disease caudate nucleus. The two endothelial enzymes were unaltered in Huntington's disease caudate nucleus. The findings are indicative of neuronal loss, an increased proportion of altered glia, and also of maintained vasculature in Huntington's disease caudate nucleus. Measurement of enzyme activities can help to delineate the types of cell altered in Huntington's disease.

Prolinase and non-specific dipeptidase of human kidney

Human kidney prolinase, assayed with Pro-Ala, and non-specific dipeptidase, assayed with Gly-Leu, were purified by using DEAE-cellulose, gel-filtration, metal-ion-chelate, hydrophobic and adsorption chromatography and chromatofocusing. Both enzymes gave single peaks of activity that were congruent and the ratio of their activities was constant throughout the purification. Gel filtration indicated an Mr of 100 000 and chromatofocusing a pI of 5.4. Ni2+-chelate chromatography demonstrated the presence of exposed histidine residues on the enzyme and was an effective separative procedure. Polyacrylamide-gel electrophoresis of the final preparation showed the two enzyme activities to be coincident. Both enzyme activities decayed at the same rate at 53 degrees C and were inhibited to the same extent by p-hydroxymercuribenzoate. Of six non-specific dipeptidase substrates tested Gly-Leu gave the highest activity, and of six prolinase substrates Pro-Leu had the highest activity. Gly-Leu was hydrolysed at double the rate of Pro-Leu. Pro-Ala was a competitive inhibitor of activity towards Gly-Leu, and Gly-Leu was a competitive inhibitor of activity towards Pro-Ala. Mixed-substrate studies strongly suggested that Gly-Leu and Pro-Ala were hydrolysed at a common active site. The data are consistent with prolinase and non-specific dipeptidase activity in human kidney being due to a single enzyme.

Distribution of phosphate-activated glutaminase, succinic dehydrogenase, pyruvate dehydrogenase and gamma-glutamyl transpeptidase in post-mortem brain from Huntington's disease and agonal cases

The activity of phosphate-activated glutaminase was reduced throughout the brain of cases with longstanding illnesses (agonal controls) compared to cases dying suddenly. The reduction was less marked in cortical than sub-cortical areas, with the caudate nucleus occupying an intermediate position. In control brains succinic dehydrogenase and pyruvate dehydrogenase were little affected by the ante-mortem clinical state. Of 9 brain areas studied, only the caudate nucleus showed a reduction of phosphate-activated glutaminase and succinic dehydrogenase in Huntington's disease greater than in agonal controls. The levels of succinic dehydrogenase and pyruvate dehydrogenase were highly correlated in frontal cortex and in caudate nucleus of Huntington's disease and control brains. There was a significant reduction in pyruvate dehydrogenase mean activity and a significant increase in gamma-glutamyl transpeptidase mean activity in Huntington's disease caudate nucleus. The level of pyruvate dehydrogenase significantly decreased and the level of gamma-glutamyl transpeptidase significantly increased with increasing duration of illness, possibly due to a progressive loss of neurons and increase in the density of glia in Huntington's disease caudate nucleus.

Presence in human cells and tissues of two prolidases and their alteration in prolidase deficiency

Two forms of prolidase can be separated for all the human cells and tissues examined by DEAE-cellulose column chromatography or batch methods. Serum had a very low prolidase activity eluting as a single peak prior to tissue peak I prolidase. Analysis of the two peaks can readily be carried out using white blood cells, cultured skin fibroblasts and amniotic fluid cells. Dialysis inactivated peak II prolidase although the loss can be prevented by the presence of dithiothreitol. The two peaks differed in their response to Mn(2+), substrate specificity, heat stability and inhibition by p-hydroxymercuribenzoate. In two unrelated cases of prolidase deficiency, fibroblast peak I was markedly reduced, although still detectable, whereas peak II was active against all the substrates, except for a 90% reduction against glycyl-L-proline. The properties of peak II were altered in the disease. The results imply that the two forms of prolidase are structurally related.

Substrate specificity of manganese-activated prolidase in control and prolidase-deficient cultured skin fibroblasts

Skin fibroblasts have a single enzyme, Mn2+-activated prolidase, that hydrolyses a range of amino acid-proline dipeptides. Two cases of prolidase deficiency showed a marked loss of activity against glycyl-proline irrespective of Mn2+ conditions. However, the abnormal enzyme showed only moderate reductions in activity against phenylalanyl-, alanyl-, and leucyl-proline following preincubation with Mn2+ or addition of Mn2+ with the substrate. Control prolidase was stable to prolonged preincubation with Mn2+, whereas the abnormal prolidase was progressively inactivated. The findings indicate, for at least the present two cases, that prolidase deficiency results from an altered rather than a marked reduction in the amount of normal enzyme.

Phosphate-activated glutaminase in relation to Huntington's disease and agonal state

Involvement of phosphate-activated glutaminase in Huntington's disease and agonal state was investigated in caudate nucleus and frontal cortex from postmortem brains. In Huntington's disease the activities of phosphate-activated glutaminase, glutamic acid decarboxylase, succinic dehydrogenase, choline acetyltransferase, and acetylcholinesterase were significantly reduced in the caudate nucleus, but not in the frontal cortex. The activity of phosphate-activated glutaminase, and to a lesser extent of glutamic acid decarboxylase, was reduced in cases of terminal illness, as compared with cases of sudden death. Succinic dehydrogenase and choline acetyltransferase were reduced only in the few cases of prolonged and severe terminal illness. Enzyme activities of the caudate nucleus were more affected by agonal state than were those of frontal cortex. Results indicate that phosphate-activated glutaminase could be a useful marker of neuronal damage due to agonal state, and that phosphate-activated glutaminase and succinic dehydrogenase are reduced in Huntington's disease.

Fluorimetric assay of phosphate-activated glutaminase

A fluorimetric assay for the estimation of phosphate-activated glutaminase is presented. The liberated glutamate is separated from glutamine using a Dowex centrifugation technique allowing multiple samples to be rapidly analyzed. Glutamate is estimated fluorimetrically by reaction with o-phthaldialdehyde. Parameters for the assay were worker out based upon characterization of human frontal cortex glutaminase. High phosphate-activated glutaminase was found in cultured human skin fibroblasts and amniotic fluid cells and rat frontal cortex and striatum. Human caudate nucleus and frontal cortex activity was variable, but related in an exponential manner. Human and rat liver activity was markedly lower than brain activity.

Effects of Econazole, Fungizone and Pimafucin on cell growth, lysosomal enzyme activity and sulphate metabolism of cultured human skin fibroblasts and amniotic fluid cells

Human skin fibroblasts and amniotic fluid cells showed sensitivity to antifungal agents in the order Econazole less than Pimafucin less than Fungizone, with the last initially reducing cell growth 10-20%, even at the level recommended for cell culture. The activities of the lysosomal enzymes alpha-L-fucosidase, beta-D-glucuronidase and alpha-D-mannosidase were unaffected, even by high concentrations of all three antifungal agents. Sulphate incorporation by cultured fibroblasts was increased by removal of sulphate salts and Crystamycin (contains streptomycin sulphate) from the culture medium. Sulphate incorporation into and degradation from macromolecules was only slightly reduced by antifungal agents. Human skin fibroblasts and amniotic fluid cells can be cultured long term in the presence of Econazole or Fungizone and used for lysosomal enzyme assay and sulphate kinetic studies.

Susceptibility to neuraminidase of alpha-L-fucosidase and N-acetyl-beta-D-glucosaminidase of cystic fibrosis, I-cell and neuraminidase-deficient fibroblasts

Intracellular alpha-L-fucosidase and hexosaminidase showed similar isoelectro-focusing patterns in control, cystic fibrosis and neuraminidase-deficient fibroblasts and were unaffected by neuraminidase treatment. An I-cell strain excreted these two enzymes at 3-4 times the rate of the three other cell types. I-cell and neuraminidase-deficient cells excreted more of the electronegative forms of these enzymes than control and cystic fibrosis cells. Extracellular hexosaminidase A and B were both sensitive to neuraminidase for the four cell types. Extracellular alpha-L-fucosidase consisted of a pH 6.1 form insensitive to neuraminidase and other forms that were sensitive and changed to a pI 7.0-7.1 form. Cystic fibrosis extracellular alpha-L-fucosidase and hexosaminidase behaved as for control fibroblasts.

Intracellular and extracellular alpha-D-mannosidase activity of cultured skin fibroblasts: relationship to cystic fibrosis

Fibroblast intracellular alpha-D-mannosidase was inactivated by 30--50% after 120 min at 50 degrees C. Separation of alpha-D-mannosidase by isoelectrofocusing and wheat germ lectin-Sepharose into neutral and acid components showed the former to be heat labile and the cause of the observed loss. Fetal calf serum acid alpha-D-mannosidase could be inactivated at 60 degrees C if kept at pH 9.0. Fibroblast extracellular alpha-D-mannosidase was inactivated by 50--70% after 120 min at 50 degrees C, reflecting the greater level of the neutral component. Control and cystic fibrosis alpha-D-mannosidase showed no difference.

Comparison of the substrate 4-methylumbelliferyl-alpha-l-iduronide with phenyl-alpha-L-iduronide for the diagnosis of Hurler's disease in cultured cells

4-Methylumbelliferyl-alpha-l-iduronide provided a more sensitive method than phenyl-alpha-l-iduronide for the estimation of alpha-l-iduronidase in cultured cells and could be used to diagnose Hurler's disease. The 4-methylumbelliferyl derivative was no more useful than the phenyl derivative for the detection of heterozygotes. All ten lysosomal enzymes tested could be used as reference enzymes when cell extracts were prepared by freeze/thawing in formate buffer pH 3.5 containing 150 mmol/l sodium chloride.

Carboxypeptidase B activity of cultured skin fibroblasts and relationship to cystic fibrosis

Enzyme activity against hippuryl-L-arginine was studied in cultured skin fibroblasts from controls and cystic fibrosis patients. The enzyme had a lysosomal distribution and an acid optimum of pH 4.5 with little or no activity present above pH 7.0. Dithiothreitol was required for full activity and the kinetics of thiol activation were different for the control and cystic fibrosis enzyme. The properties and lysosomal distribution of the enzyme indicated that it was a carboxypeptidase B. Substrate affinity, thermolability, pH stability, the fall and rise in activity with subculture, the cyclical pattern of activity through serial passage and the level of activity were similar for the control and cystic fibrosis enzyme.

Primary amniotic fluid cell, skin fibroblast and liver alpha-L-fucosidase and its relation to cystic fibrosis

Cultured skin fibroblast and primary amniotic fluid cell alpha-L-fucosidase had a double optimum of pH 5.0 and 6.0. Alpha-L-fucosidase was largely bound as a single peak to DEAE-cellulose at pH 6.6. Sucrose density isoelectric focusing revealed up to seven components with pI values of 4.9, 5.2, 5.4, 5.8, 6.1, 6.5 and 7.1 with their apparent KM values (77--500 mumol/l) being higher than that (57 mumol/l) of the unfocused enzyme. Liver, skin fibroblast and amniotic fluid cell alpha-L-fucosidase was separated into two peaks by gel filtration. Peak one was more active and stable at low pH and more thermostable at 50 degrees C than peak two, while both peaks had an apparent KM of 52 mumol/l. Apart from the different proportions of the peaks separated by gel filtration, the results for the three tissues were similar. The properties of alpha-L-fucosidase studied were similar for control and cystic fibrosis liver or skin fibroblasts.

Low arylsulphatase A activity in a family without metachromatic leukodystrophy

A low arylsulphatase A activity was noted in the leukocytes and cultured skin fibroblasts of a child without any other symptoms of metachromatic leukodystrophy. Although the mother had a level of arylsulphatase commensurate with heterozygosity for the classical metachromatic leukodystrophy gene, the father had a variant gene giving an unusually low in vitro level of this enzyme. In combination (the proband), these two genes gave rise to a very low in vitro activity without any apparent disease. In screening for metachromatic leukodystrophy, a low arylsulphatase A level is not necessarily indicative of this disease, if a clinically normal parent shows an unusually low level of this enzyme.

Gaucher's disease. Factors affecting the 4-methylum-belliferyl-beta-D-glucosidase activity of cultured skin fibroblasts

Phosphate-buffered saline was found to inhibit acid beta-glucosidase activity of cultured cells. This effect was attributable to both the pH and the chloride content of the phosphate-buffered saline. Washing the cells in sucrose (0.25M) to remove residual phosphate-buffered saline effectively eliminated this inhibition.

Acid beta-glucosidase and the diagnosis of Gaucher's disease in liver and spleen

Variable amounts of residual 4-methylumbelliferyl-beta-glucosidase activity gave rise to difficulties in the diagnosis of Gaucher's disease using spleen and particularly liver. Soluble and particulate components of beta-glucosidase, which interfere with the diagnosis, may be eliminated by preincubation of homogenates at pH 3.0 or with 100 mM sodium chloride at pH 4.0. After either of these treatments the optimum of acid beta-glucosidase was pH 4.5 and diagnosis of Gaucher's disease could be more easily made using homogenates of spleen and liver. There was residual acid beta-glucosidase activity in one of the Gaucher livers.

Carboxypeptidase A activity of cultured skin fibroblasts and relationship to cystic fibrosis

Properties of carboxypeptidase A of cultured skin fibroblasts from control and cystic fibrosis patients were studied using alpha-N-carbobenzoxy-L-glutamyl-L-tyrosine as substrate. Carboxypeptidase A was inhibited by thiomersal, cyanide, iodoacetate and N-ethylmaleimide in a similar manner for control and cystic fibrosis fibroblasts. Both trypsin and dithiothreitol treatment activated the enzyme, but 1,10-phenanthroline inhibited only in the presence of dithiothreitol. Both Zn2+ and Co2+ reversed this inhibition. Trypsin treatment of carboxypeptidase A produced a form of the enzyme having a higher KM value for both control and cystic fibrosis fibroblasts. Dithiothreitol treatment of control fibroblasts resulted in a form with similar properties to the trypsin activated form, but cystic fibrosis fibroblasts yielded a variant form with even higher KM and Vmax values. Since other properties were similar, it seems likely that this difference reflected binding of a molecule to the enzyme rather than of a defect in the enzyme.

Pompe's disease: diagnosis in kidney and leucocytes using 4-methylumbelliferyl-alpha-D-glucopyranoside

The diagnosis of Pompe's disease by the assay of acid alpha-glucosidase in kidney and leucocytes was not previously possible because of the presence of another component which had activity at pH 4.0, but was not deficient in the disease. This problem was resolved either by the use of the inhibitors, turanose, maltose and citrate, or by isoelectric precipitation at pH 5.0, which enabled the estimation of acid alpha glucosidase in kidney and leucocytes.