Developmental expression of vitamin K-dependent gamma-carboxylase activity in zebrafish embryos: effect of warfarin

Vitamin K-dependent gamma-carboxylation is an essential posttranslational modification required for the functional activity of coagulation proteins such as factors VII, IX, X, and prothrombin. Warfarin, an inhibitor of vitamin K-dependent gamma-carboxylation, was used in earlier work on adult zebrafish to provide evidence for the presence of vitamin K-dependent carboxylase in zebrafish. Here we demonstrate the presence of vitamin K-dependent carboxylase activity in zebrafish by directly assaying the microsomal fraction prepared from adult, unfertilized eggs, and embryos from different developmental stages. Gamma-carboxylase activity was detected both before and after fertilization of embryos and the activity levels remained relatively constant from 6 h postfertilization (hpf) through other advanced stages of development. The expression of activity in the early embryos (0-6 hpf) may be due to the presence of maternal protein since the activity was detected even in the unfertilized eggs. Gamma-carboxylase activity in the eggs as well as early embryos suggested that vitamin K-dependent carboxylase is important throughout development. The detection of vitamin K-dependent carboxylase mRNA by RT-PCR and inhibitor studies using warfarin confirmed these activity results. Further, these studies provide a basis for selecting warfarin-resistant zebrafish mutants in order to find genes regulating gamma-carboxylase activity including the yet unidentified vitamin K-epoxide reductase.

Demonstration of the extrinsic coagulation pathway in teleostei: identification of zebrafish coagulation factor VII

It is not known whether the mammalian mechanism of coagulation initiation is conserved in fish. Identification of factor VII is critical in providing evidence for such a mechanism. A cDNA was cloned from a zebrafish (teleost) library that predicted a protein with sequence similarity to human factor VII. Factor VII was shown to be present in zebrafish blood and liver by Western blot analysis and immunohistochemistry. Immunodepletion of factor VII from zebrafish plasma selectively inhibited thromboplastin-triggered thrombin generation. Heterologous expression of zebrafish factor VII demonstrated a secreted protein (50 kDa) that reconstituted thromboplastin-triggered thrombin generation in immunodepleted zebrafish plasma. These results suggest conservation of the extrinsic coagulation pathway between zebrafish and humans and add credence to the zebrafish as a model for mammalian hemostasis. The structure of zebrafish factor VIIa predicted by homology modeling was consistent with the overall three-dimensional structure of human factor VIIa. However, amino acid disparities were found in the epidermal growth factor-2/serine protease regions that are present in the human tissue factor-factor VIIa contact surface, suggesting a structural basis for the species specificity of this interaction. In addition, zebrafish factor VII demonstrates that the Gla-EGF-EGF-SP domain structure, which is common to coagulation factors VII, IX, X, and protein C, was present before the radiation of the teleosts from the tetrapods. Identification of zebrafish factor VII significantly narrows the evolutionary window for development of the vertebrate coagulation cascade and provides insight into the structural basis for species specificity in the tissue factor-factor VIIa interaction.

Paramedic use of endotracheal tube introducers for the difficult airway

OBJECTIVE

To evaluate the ability of paramedics to learn and apply the skill of introducer-aided oral intubation in the setting of the simulated "difficult airway." The authors hypothesized that, following a brief introduction to the device, intubation success rates would not differ for traditional and introducer-aided intubations of an immobilized airway mannequin.

METHODS

During a paramedic recertification class, experienced paramedics were given a brief didactic introduction to the "bougie-like" Flex Guide endotracheal tube introducer (ETTI). The participants were then asked to intubate adult mannequins immobilized in the head-neutral position, with and without the ETTI. "Successful placement" was defined as completion of the procedure within 30 seconds and endotracheal tube position confirmed by the investigator with direct visualization.

RESULTS

For both traditional and ETTI intubations, 34 (97%) of the 35 paramedics successfully intubated within 30 seconds. The two unsuccessful intubation attempts were recognized by the paramedic as esophageal intubations, and correct tube placement was obtained within an additional 30 seconds.

CONCLUSION

In this study, use of the ETTI was mastered by the participants after only a brief didactic introduction to the device, with their ability to intubate an immobilized mannequin using the ETTI being equal to their ability to perform traditional intubation. These results suggest that use of the ETTI is easily learned, and may support the device's role in the prehospital management of the difficult airway.

Claudin-1 is not restricted to tight junctions in the rat epididymis

The blood-epididymal barrier creates a unique microenvironment critical for sperm maturation. There is little information on proteins comprising epididymal tight and adhering junctions or on factors regulating their expression. Claudins are a family of transmembrane proteins reported to be exclusively localized to tight junctions. In the present study the expression of claudin-l (Cl-1) was examined with respect to the different cell types of the epididymis and its various regions as well as its expression during postnatal development and regulation by testicular factors, using both immunocytochemistry and Northern blot analysis. RT-PCR of adult epididymal and testicular RNA (positive control) indicated that Cl-1 messenger RNA (mRNA) transcripts were present in all regions of the epididymis. In the adult, Cl-1 was localized immunocytochemically along the entire length of the lateral plasma membranes between adjacent principal cells, including apical areas containing tight junctions, as well as at the interface between principal and basal cells and along the basal plasma membrane of the epithelium in relation to the basement membrane. Northern blot analysis of adult epididymis with a rat Cl-1 complementary DNA indicated the presence of two hybridizing bands of 4.0 and 1.5 kb. Postnatally, in the caput-corpus and cauda epididymidis, mRNA levels for both transcripts were lowest on day 7. In the caput-corpus epididymidis, mRNA levels for the 1.5-kb transcript increased significantly between 7 and 14 days, whereas the levels of the 4.0-kb transcript were significantly higher by day 21. Postnatal studies revealed that in the initial segment and caput epididymidis, Cl-1 immunostaining was present along the entire length of the lateral plasma membranes of undifferentiated epididymal epithelial cells as early as day 7, including apical areas containing tight junctions. By day 21, staining was identical to that of adult animals, but as this is an age when androgen levels are not at their peak, the data would suggest that they are not a prominent factor regulating Cl-1 expression. Orchidectomy and orchidectomy plus testosterone replacement experiments revealed differences in Cl-1 immunostaining in the initial segment, suggesting that localization of Cl-1 in epididymal tight junctions is androgen dependant. Thus, Cl-1 expression in the initial segment appears to be only partially under the control of androgens. However, in all other epididymal regions, orchidectomy with or without testosterone replacement, revealed no changes to the normal staining pattern, suggesting that androgens do not regulate Cl-1 expression in these regions. Taken together, these studies demonstrate that Cl-1 expression in the epididymis is not localized exclusively to tight junctions, but appears along the entire interfaces of adjacent epithelial cells as well as along the basal plasma membrane, suggesting a role for Cl-1 as an adhesion molecule. The data also suggest that the regulation of Cl-1 in the epididymis is complex and multifactorial.

Antioxidant status of the hypertrophic heart of Dahl hypertensive rat as a model for evaluation of antioxidants

Development of hypertension, myocardial hypertrophy and the cardiac antioxidant status of male Dahl salt-sensitive (DSS) genetically hypertensive rats was evaluated and compared to that of normotensive Dahl salt-resistant (DSR) controls. In order to obtain exaggerated and more severe hypertension, half of the animals (10 per group) were Na loaded (8% NaCl diet) for 6 weeks. The myocardial antioxidant status was estimated in tissue homogenates on the basis of tissue glutathione (GSH), superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px). The results showed that 6 weeks of hypertension resulted in left ventricle myocardial hypertrophy, documented by weight, morphometry and morphological changes. The compromised myocardial antioxidant status of the DSS rats was defined by significantly decreased GSH-Px and glutathione activity (13% and 41%, respectively) as compared to DSR rats. SOD in DSS myocardium was increased by 47% compared to that in DSR myocardium, an effect that is considered a compensatory mechanism to the oxidative stress. All of the above changes were exaggerated by NaCl loading. It was concluded that DSS rats, on either a normal or high NaCl diet, displayed decreased antioxidant capacity, which is most likely genetically determined. Before the Dahl rat can be considered as a suitable model for testing new cardiac antioxidants, a full characterization of the level of cardiac oxygen free radicals is required.

Characterization of zebrafish full-length prothrombin cDNA and linkage group mapping

In this paper, we report the complete cDNA sequence of zebrafish prothrombin. The cDNA sequence predicts that zebrafish prothrombin is synthesized as a pre-proprotein consisting of a Gla domain, two kringle domains, and a two-chain protease domain. Zebrafish prothrombin is structurally very similar to human and other vertebrate prothrombins. Zebrafish and human prothrombin share 53% amino acid identity whereas zebrafish and hagfish prothrombin share 51% identity. Amino acid alignments of various prothrombins identified conservation of many of the functional/structural motifs suggesting that the vertebrate prothrombins may have similar functions. The three-dimensional structure of prothrombin predicted by homology modeling also revealed that the prothrombin fragment 1 and the catalytic domain structures are well conserved except for the insertion of an extra 7-amino-acid loop in the connecting region (CR) between the Gla and kringle I domain of fragment 1. Linkage analysis revealed that the prothrombin gene locus on linkage group 7 in zebrafish is syntenic to the human chromosome 11-prothrombin region suggesting its preservation through evolution. The availability of this cDNA sequence in zebrafish adds to our knowledge of the zebrafish hemostatic system and provides support for the view that similarities between zebrafish and mammalian coagulation exist, thus underscoring the relevance of the zebrafish model for studying human hemostasis.

Haemostatic screening and identification of zebrafish mutants with coagulation pathway defects: an approach to identifying novel haemostatic genes in man

Zebrafish were used as a model to study haemostasis, a vertebrate function of paramount importance. A limitation of the zebrafish model is the difficulty in assaying small amounts of blood to detect coagulation mutants. We report the use of a rapid total coagulation activity (TCA) assay to screen for coagulation defects in individual adult zebrafish. We screened the TCA in 1000 gynogenetic half-tetrad diploids derived from 86 clutches. Each clutch was from a single F1 female offspring of males mutagenized with ethylnitrosourea (ENU). We found 30-50% defective zebrafish among six clutches, consistent with a heritable defect. The assay developed here provided a rapid screen to detect overall coagulation defects. However, because of the limited amounts of plasma, we could not detect defects in specific pathways. Therefore, a novel, ultra-sensitive kinetic method was developed to identify specific pathway defects. To test whether the kinetic assay could be used as a screening tool, 1500 Florida wild-type zebrafish pairs were analysed for naturally occurring coagulation defects. We detected 30 fish with extrinsic pathway defects, but with intact common and intrinsic pathways. We conclude that it is now possible to identify specific coagulation pathway defects in zebrafish.

Remote village survey for agents causing hepatosplenic disease in the Republic of Yemen

The objective of this study was to epidemiologically describe potential infectious agents among rural people in the Republic of Yemen. This would aid clinicians in designing empirical therapy and public health officials in planning disease prevention. We sought to examine evidence for the geographical distribution of pathogens causing human hepatic and splenic disease among villagers and domestic animals living in three remote areas with differing altitudes. In June 1992, a cross-sectional survey was conducted at three survey sites of differing altitudes: 3080, 1440 and 250 m above sea level. Questionnaires, parasitic and serological tests were administered to 627 human volunteers. Additionally 317 domestic animals were studied. Malaria, schistosomiasis, and hepatitis B and C infections were found to be likely causes of human hepatic or splenic disease. Additionally, evidence of human and animal infections with the agents of brucellosis and Q fever was found: IgG antibodies against hepatitis E virus were discovered in two (2.0%) of the 100 volunteers. The prevalence of markers for human and animal disease was often lowest at the village of highest elevation, suggesting that increasing altitude, as a surrogate or a true independent risk factor, was protective against infection with the agents studied.

The Kaiser Permanente prenatal smoking-cessation trial: when more isn't better, what is enough?

INTRODUCTION

The effectiveness of low-cost smoking interventions targeted to pregnant women has been demonstrated, although few gains in absolute cessation rates have been reported in the past decade. Under conditions of typical clinical practice, this study examined whether outcomes achieved with brief counseling from prenatal care providers and a self-help booklet could be improved by adding more resource-intensive cognitive-behavioral programs.

DESIGN

Randomized Clinical Trial.

SETTING

A large-group-model managed care organization.

PARTICIPANTS

390 English-speaking women 18 years of age or older who self-reported to be active smokers at their initial prenatal appointment.

INTERVENTION

Participants were randomized to one of three groups: (1) a self-help booklet tailored to smoking patterns, stage of change, and lifestyle of pregnant smokers; (2) the booklet plus access to a computerized telephone cessation program based on interactive voice response technology; or (3) the booklet plus proactive telephone counseling from nurse educators using motivational interviewing techniques and strategies. No attempt was made to change smoking-related usual care advice from prenatal providers.

MAIN OUTCOME MEASURE

Biochemically confirmed abstinence measured by level of cotinine in urine samples obtained during a routine prenatal visit at approximately the 34th week of pregnancy.

RESULTS

Twenty percent of participants were confirmed as abstinent with no significant differences found between intervention groups. Multivariate baseline predictors of cessation included number of cigarettes smoked per day, confidence in ability to quit, exposure to passive smoke, and educational level. No differential intervention effects were found within strata of these predictors or by baseline stage of readiness to change. Cessation rates among heavier smokers were strikingly low in all intervention groups.

CONCLUSION

Neither a computerized telephone cessation program nor systematic provision of motivational counseling improved cessation rates over a tailored self-help booklet delivered within the context of brief advice from prenatal providers. Innovative strategies need to be developed to increase the effectiveness of existing prenatal smoking interventions. Special attention should be paid to the needs of heavier smokers.

High mutation detection rate in the COL4A5 collagen gene in suspected Alport syndrome using PCR and direct DNA sequencing

Approximately 85% of patients with Alport syndrome (hereditary nephritis) have been estimated to have mutations in the X chromosomal COL4A5 collagen gene; the remaining cases are autosomal with mutations in the COL4A3 or COL4A4 genes located on chromosome 2. In the present work, the promoter sequence and previously unknown intron sequences flanking exons 2 and 37 of COL4A5 were determined. Furthermore, intron sequences flanking the other 49 exons were expanded from 35 to 190 to facilitate mutation analysis of the gene. Using this information, all 51 exons and the promoter region were PCR-amplified and sequenced from DNA of 50 randomly chosen patients with suspected Alport syndrome. Mutations were found in 41 patients, giving a mutation detection rate of 82%. Retrospective analysis of clinical data revealed that two of the cases might be autosomal. Although it could not be determined whether the remaining seven cases (14%) were autosomal or X chromosome-linked, it is likely that some of them were autosomal. It is concluded that PCR amplification and direct DNA sequencing of the promoter and exons is currently the best procedure to detect mutations in COL4A5 in Alport syndrome.

Calciphylaxis mimicking dermatomyositis: ischemic myopathy complicating renal failure

BACKGROUND

Among the complications of chronic renal failure is a syndrome of medial calcification of small- to medium-sized arteries associated with ischemic necrosis of the skin and other organ systems, leading to gangrene and a poor prognosis. The syndrome has been reviewed in the renal, dermatologic, and surgical literature under the term calciphylaxis, which describes a postulated pathogenetic mechanism whereby sensitization to an endogenous or exogenous substance (such as parathyroid hormone) predisposes to calcium deposition after exposure to a challenging agent. Myopathy has rarely been reported as the presenting feature, and the syndrome has not been discussed in the neurologic literature.

METHODS

We report two patients with renal failure and systemic calciphylaxis who presented to our hospital with myopathic complaints and signs suggesting dermatomyositis. We also discuss possible disease mechanisms and treatment.

CONCLUSIONS

Because early treatment (including aggressively lowering the calcium and phosphate levels and parathyroidectomy) may improve the outcome, early recognition of the syndrome of calciphylaxis is essential.

The intubating laryngeal mask. Use in failed and difficult intubation

The use of the intubating laryngeal mask in three patients is described. In two patients for whom tracheal intubation using traditional techniques had failed, the intubating laryngeal mask was used to achieve successful tracheal intubation. The trachea of one of these patients was subsequently re-intubated for a second procedure using the same technique. A third patient with a cervical spine fracture whose trachea was electively intubated using the intubating laryngeal mask is also presented.

Plasma bupivacaine concentrations associated with continuous extradural infusions in babies

The maximum recommended dose for extradural infusions of bupivacaine in children older than 1 month is 0.5 mg kg-1 h-1 but there are few specific reports of the associated blood concentrations during infusions in babies. Toxic symptoms can occur in children at plasma concentrations of bupivacaine as low as 2 micrograms ml-1. We attempted to measure venous plasma concentrations of total and free bupivacaine in babies aged 3-12 months during extradural infusions given at a rate commonly used in our hospital. We studied eight babies (mean age 33 weeks; mean weight 7.8 kg). After a mean initial dose of 1.2 mg kg-1 (range 1.1-1.3 mg kg-1), bupivacaine was infused at a mean rate of 0.38 (0.36-0.39) mg kg-1 h-1 for a mean of 31 (4-44) h. Blood was obtained at 4, 8, 16, 24, 32 and 40 h after starting the infusion and plasma separated by centrifugation. Total plasma bupivacaine concentration was measured using high pressure liquid chromatography (HPLC). Plasma concentrations of total bupivacaine were mostly less than 2 micrograms ml-1. One baby had a concentration of 2.02 micrograms ml-1 at 32 h and showed clear evidence of accumulation of bupivacaine. Babies can accumulate bupivacaine and achieve plasma concentrations above the threshold for toxic side effects, despite infusion rates below the currently accepted maximum. The samples size in our study was small but we believe an extradural infusion rate of 0.375 mg kg-1 h-1 is probably an absolute maximum for babies younger than 12 months.

Evidence of limited capacity and noise reduction with single-element displays in the location-cuing paradigm

Precuing a location facilitates accuracy of identification of a target at that location and reduces noise from other nontarget characters in a multicharacter field. In 5 experiments, evidence for facilitation included higher accuracy with long precue-target intervals than with short intervals and higher accuracy when a precue indicated the correct location than with short intervals and higher accuracy when a precue indicated the correct location than when it indicated the wrong location. These results were found for each target-mask condition used (1 target with 1 mask, 1 target with 4 masks, or 1 target and 3 nontargets with 4 masks) in experienced and inexperienced observers. Evidence for noise reduction was found because accuracy was higher in the 1 target-1 mask condition than in the other conditions on correctly cued trials with short-cue-target intervals and on incorrectly cued trials. Data are related to methodological factors that are important to obtaining these effects and to capacity and noise reduction models.

Evidence of limited capacity and noise reduction with single-element displays in the location-cuing paradigm

Precuing a location facilitates accuracy of identification of a target at that location and reduces noise from other nontarget characters in a multicharacter field. In 5 experiments, evidence for facilitation included higher accuracy with long precue-target intervals than with short intervals and higher accuracy when a precue indicated the correct location than with short intervals and higher accuracy when a precue indicated the correct location than when it indicated the wrong location. These results were found for each target-mask condition used (1 target with 1 mask, 1 target with 4 masks, or 1 target and 3 nontargets with 4 masks) in experienced and inexperienced observers. Evidence for noise reduction was found because accuracy was higher in the 1 target-1 mask condition than in the other conditions on correctly cued trials with short-cue-target intervals and on incorrectly cued trials. Data are related to methodological factors that are important to obtaining these effects and to capacity and noise reduction models.

Home enteral feeding of children in the west of Scotland

Home enteral feeding (HEF) is increasingly used to achieve positive energy and nitrogen balance in children with chronic disease outside hospital. It should be considered when oral feeding cannot or should not be used, and when nutritional support is the sole reason for hospitalisation. In the West of Scotland 156 children (80 male, 76 female) cared for by the Royal Hospital for Sick Children in Glasgow received HEF between 1st September 1994 and 1995. They ranged in age from 0 months to 23 years. Indications for HEF were cystic fibrosis (21), cerebral palsy (17), other neurological disease (29), congenital/metabolic abnormalities (23), chronic renal failure (17), neoplastic disease (17), gastrointestinal/hepatic' disease (12), failure-to-thrive (10), and cardiorespiratory disease (10). Most children received feeds by nasogastric tube (59%) or gastrostomy (41%). One child had a jejunostomy. Feeding regimens were continuous infusion (52%), bolus feeding along (26%), and a combination of bolus and infusion (22%). 73% of patients had infusion pumps. Duration of HEF ranged from one month to 12 years. 78% of children received standard infant or enteral feeds, some receiving energy supplements. The remainder received 'disease-specific' or other special feeds. There was a 23% increase in the number of children receiving HEF during the year of the study. HEF represents an affective way of improving the nutritional status of children with chronic disease at home. It frees hospital beds and nursing resources, is well accepted by children and their families and is growing rapidly as an alternative to hospitalisation.

The Southern California Kaiser-Permanente Chemical Dependency Recovery Program evaluation: results of a treatment outcome study in an HMO setting

This report presents the methodology and outcomes of an evaluation of the Chemical Dependency Recovery Program (CDRP) of Southern California Kaiser-Permanente, a large group model HMO. CDRP treatment includes specialized detoxification inpatient facilities, day treatment and outpatient services. Substance use outcomes in a population of 1,986 patients consecutively entering treatment were obtained via telephone at six and twelve months post intake. For patients who consumed only alcohol at baseline (N = 621), significantly higher six month point prevalence abstinence rates were found among those who remained in treatment for a minimum of three months (89%), compared to those patients who failed to return for treatment after their intake (31%). For polydrug users (N = 1365), as contrasted with patients who utilized services only on their intake date, significantly higher six month point prevalence rates were restricted to those who remained in treatment for a minimum of six months (74% versus 21%). The evaluation documented the need for CDRP services, validated program effectiveness and highlighted areas for systematic improvement.

Identification of 17 mutations in ten exons in the COL4A5 collagen gene, but no mutations found in four exons in COL4A6: a study of 250 patients with hematuria and suspected of having Alport syndrome

Conditions for polymerase chain-reaction amplification of ten exon regions (Exons 3, 7, 11 through 13, and 15 through 19) of the collagen COL4A5 gene and four exon regions (Exons 2, and 12 through 14) of the COL4A6 gene were sequenced and established in this study. These Type IV collagen genes contain 51 and 48 exons, respectively. The sequences of these exons were determined in the two genes in 250 male patients with hematuria and suspected Alport syndrome. Seventeen mutations were found in nine of the ten exons studied in the COL4A5 gene in 17 patients, whereas no mutations were identified in COL4A6. One mutation was identical in two patients known to be unrelated. The results indicate that mutations in COL4A5 that leading to renal failure are more frequent than those involved in classic Alport syndrome, and also that mutations in COL4A6 are not likely to cause this disease. Furthermore, mutations in COL4A5 are distributed quite randomly and no "hot spots" were found.