The unusual transhydrogenase of Entamoeba histolytica

We have expressed and purified a protein fragment from Entamoeba histolytica. It catalyses transhydrogenation between analogues of NAD(H) and NADP(H). The characteristics of this reaction resemble those of the reaction catalysed by a complex of the NAD(H)- and NADP(H)-binding subunits of proton-translocating transhydrogenases from bacteria and mammals. It is concluded that the complete En. histolytica protein, which, along with similar proteins from other protozoan parasites, has an unusual subunit organisation, is also a proton-translocating transhydrogenase. The function of the transhydrogenase, thought to be located in organelles which do not have the enzymes of oxidative phosphorylation, is not clear.

Peripheral intravenous therapy-related phlebitis rates in an adult population

To determine the incidence of peripheral intravenous therapy-related phlebitis in an adult population, 305 peripheral i.v. catheter sites were observed from the time of admission of the patient (or initiation of the first peripheral i.v. catheter) to the time of the participant's discharge from the facility (or 48 hours after the removal of the final catheter). Parameters monitored included patient demographics, diagnosis, i.v. fluids and medications, type of peripheral catheter, dwell time, and dressing integrity. Results showed that of the 10 cases of phlebitis found in nine study subjects, all were associated with catheters indwelling less than 72 hours. In three cases, although the catheter site was clear at the time of catheter removal, postinfusion phlebitis developed within 24 hours. Catheter site locations, diagnoses, medications, and i.v. fluids in these cases were varied.

A comparison of the results of renal transplantation from non-heart-beating, conventional cadaveric, and living donors

BACKGROUND

In an attempt to address the shortage of conventional kidney donors, a non-heart-beating donor (NHBD) organ retrieval program has been established. We compared the results of kidney transplants from NHBDs (N = 77) with those from heart-beating cadaveric (HBD; N = 224) and living donors (LD; N = 49), performed in the same eight-year period.

METHODS

Patients dying after failed attempts at resuscitation in the accident department or after intracerebral hemorrhage/anoxia were considered as potential NHBDs. After death, in situ kidney perfusion and cooling were achieved using an intra-aortic catheter inserted via a femoral artery cut down. Kidney retrieval and transplant operations were performed using standard techniques.

RESULTS

The median (range) warm ischemic time for NHBD kidneys was 25 minutes (5 to 53 min). The initial function rates for NHBD, HBD, and LD transplants were 6.5, 76.3, and 93%, respectively. Primary nonfunction occurred in 5 of 75 evaluable NHBD transplants (7%) compared with only 6 out of 224 (2.7%) HBD and 1 out of 49 (2%) LD transplants (P = NS). Eighty-four percent of NHBD kidney recipients required postoperative dialysis for a median of 19 days. The mean (SD) serum creatinine at 12 months was 179 (73) micromol/L in NHBD kidneys compared with 152 (57) micromol/L for HBD kidneys and 138 (44) micromol/L for LD kidneys. The actuarial five-year graft survival rates for NHBD, HBD, and LD transplants were 79, 75, and 78%, respectively. During the period under study, NHBD organs accounted for 22% of the total renal transplant program.

CONCLUSIONS

Despite being associated with poor initial graft function, the long-term allograft survival of NHBD kidneys does not differ significantly from the results of HBD and LD transplants.

Incidental adult nesidioblastosis after distal pancreatectomy for endocrine microadenoma

Persistent hyperinsulinaemic hypoglycaemia (nesidioblastosis) presenting with hypoglycaemia is extremely rare in adults. The features are suggestive of an insulinoma with a vague presentation and delayed diagnosis. We describe a report of adult nesidioblastosis in association with a pancreatic endocrine microadenoma.

Vascular access for haemodialysis

BACKGROUND

The recent expansion of renal replacement therapy programmes has been associated with an increase in the number and complexity of patients requiring permanent vascular access. The introduction of strategies designed to maximize secondary access patency is, therefore, increasingly important as a means of prolonging patient survival on dialysis, reducing morbidity and reducing the escalating cost of such programmes.

METHODS

A review of the current literature on the planning of vascular access, access surveillance methods and treatment of the most common complications was performed.

RESULTS

Multidisciplinary vascular access planning, increased use of preoperative imaging and the preferential use of autogeneous vein are essential to obtain the best long-term results. While vascular access surveillance, in particular protocols involving direct measurement of access flow, enables the prospective detection and treatment of venous stenosis, the precise indications for treating venous stenosis remain unclear. Surgical revision remains the gold standard for the treatment of failing arteriovenous fistulas, but recent advances in interventional radiological techniques along with the suitability of arteriovenous fistulas for percutaneous intervention may offer an effective alternative. The effect of both these interventions on access patency requires comparison in a randomized trial.

CONCLUSION

The introduction of strategies to improve access patency rates will change vascular access surgical practice away from the construction of new fistulas towards an increase in outpatient percutaneous intervention and surgical revisional procedures. The role of surgical interventions requires clearer definition.

Rapid determination of gemifloxacin in human plasma by high-performance liquid chromatography-tandem mass spectrometry

A method was developed for the determination of gemifloxacin (I) in human plasma using high-performance liquid chromatography-tandem mass spectrometry. Prior to analysis, the protein in plasma samples was precipitated with acetonitrile containing [13C2H3] gemifloxacin (II) to act as an internal standard. The supernatant was injected onto a PLRP-S column without any further clean-up. The mass spectrometer was operated in positive ion mode, employing a heat assisted nebulisation. electrospray interface. Ions were detected in multiple reaction monitoring (MRM) mode. The assay requires 50 microl of plasma and is precise and accurate within the range 10-5,000 ng/ml. The average within-run and between-run coefficients of variation were <11% at 10 ng/ml and greater concentrations. The average accuracy of validation standards was generally within +/-7% of the nominal concentration. There was no evidence of instability of I in human plasma following three complete freeze-thaw cycles and samples can safely be stored for at least 6 months at -20 degrees C. The method proved very robust and was successfully applied to the analysis of clinical samples from patients dosed with gemifloxacin.

Intrahepatic biliary cystadenoma causing luminal common bile duct obstruction

BACKGROUND

Biliary cystadenomas are rare cystic tumours that arise in the liver or less frequently in the extrahepatic biliary system. They are commoner in middle-aged women, their most favoured site is the right hepatic lobe.

METHODS

Case report and review of the literature.

RESULTS

We present only the second case of an intrahepatic cystadenoma causing luminal obstruction of the common bile duct. Clinical presentation is often non-specific and can prove to be a diagnostic challenge.

CONCLUSION

Wide local excision of biliary cystadenomas is recommended, with regular radiological follow-up.

Protein-protein recognition, hydride transfer and proton pumping in the transhydrogenase complex

BACKGROUND

Membrane-bound ion pumps are involved in metabolic regulation, osmoregulation, cell signalling, nerve transmission and energy transduction. How the ion electrochemical gradient interacts with the scalar chemistry and how the catalytic machinery is gated to ensure high coupling efficiency are fundamental to the mechanism of action of such pumps. Transhydrogenase is a conformationally coupled proton pump linking a proton gradient to the redox reaction between NAD(H) and NADP(H). The enzyme has three components; dI binds NAD(H), dII spans the membrane and dIII binds NADP(H).

RESULTS

The first crystal structure of a transhydrogenase dI component (from Rhodospirillum rubrum) has been determined at 2.0 A resolution. The monomer comprises two domains. Both are involved in dimer formation, and one has a Rossmann fold that binds NAD+ in a novel mode. The two domains can adopt different conformations. In the most closed conformation, the nicotinamide ring is expelled from the cleft between the two domains and is exposed on the outside of the protein. In this conformation it is possible to dock the structure of dI/NAD+ with that of a dIII/NADP+ complex to provide the first insights into the molecular basis of the hydride-transfer step.

CONCLUSIONS

Analysis of the model of the dI/dIII complex identifies residues potentially involved in dI/dIII interaction and shows how domain motion in dI results in a shift in position of the nicotinamide ring of NAD+. We propose that this movement is responsible for switching between the forbidden and allowed states for hydride transfer during proton pumping.

Induction of anti-tumor immunity by intrasplenic administration of a carcinoembryonic antigen DNA vaccine

BACKGROUND

We have previously reported that intramuscular, intradermal or epidermal gene gun administration of a plasmid encoding carcinoembryonic antigen (CEA) under transcriptional regulatory control of the cytomegalovirus (CMV) early promoter/enhancer elicits CEA-specific humoral and cellular immune responses in mice with resultant immunoprotection against challenge with syngeneic, CEA-expressing colon adenocarcinoma cells.

METHODS

In the present work, we examine the ability of this DNA vaccine construct (pCEA) to elicit CEA-specific immunity following intrasplenic administration. Groups of mice were immunized with pCEA by intrasplenic or intramuscular injection. Six weeks later, mice were evaluated for the presence of anti-CEA humoral responses and were challenged with syngeneic, CEA-expressing colon carcinoma cells.

RESULTS

Intrasplenic administration of pCEA produced a frequency of CEA-specific antibody responses comparable to that elicited by intramuscular pCEA inoculation. Both intrasplenic and intramuscular administration of pCEA generated IgG2a antibody responses to CEA, consistent with the induction of T helper-1-biased immune responses. In addition, partial immunoprotection against tumor challenge was observed after a single plasmid DNA dose by either route of administration. Subsequent studies revealed that antibody responses to intrasplenic DNA vaccination are dose and schedule dependent.

CONCLUSION

These findings support future investigations of DNA vaccination strategies that specifically promote the uptake of plasmid by splenocytes.

A prospective randomized trial of three different sizes of core-cutting needle for renal transplant biopsy

BACKGROUND

Needle-core biopsy remains one of the most important investigations in cases of renal allograft dysfunction. The size and quality of the biopsy material are likely to be important factors in achieving an accurate diagnosis. The aim of this study was to compare the success and complication rates of renal transplant biopsy procedures using three differently sized needles.

METHODS

One hundred renal allograft recipients undergoing transplant biopsy using an automated needle core method were randomized to a 14, 16, or 18 gauge (G) needle. The size of each biopsy core was measured, and the presence or absence of renal cortical and medullary tissue and the number of glomeruli were recorded. Assessments of the ease with which the procedure was performed, the diagnostic usefulness of the biopsy material, and the discomfort associated with the procedure were made using verbal response and linear analog scales.

RESULTS

Fourteen G biopsy cores (N = 33) were larger than both 16G (N = 33) and 18G (N = 34) cores and contained more gomeruli (mean number for 14G, 16G, and 18G = 15, 11 and 9, respectively). There were no differences in the ease of use of the three needle types, but scores for diagnostic usefulness were higher for 14G versus 18G and 16G versus 18G. The 14G needle was associated with significantly more pain than the two smaller needles when this was assessed using a linear analog score. Macroscopic hematuria occurred in eight patients, but there were no differences in complications rates between the three groups.

CONCLUSIONS

All three needle sizes are safe for use in renal allograft biopsy using a semiautomated biopsy gun. The larger needles provide more tissue and glomeruli and, thus, are more diagnostically useful. Use of a 14G needle may be associated with more pain, and the 16G needle appears to offer the best compromise between diagnostic usefulness and patient acceptability.

Long-term results of arteriovenous fistulas using transposed autologous basilic vein

BACKGROUND

The transposed autologous basilic vein to brachial artery arteriovenous fistula provides vascular access in the absence of adequate superficial vein. The long-term patency and complication rates of this conduit are largely unreported.

PATIENTS AND METHODS

Seventy-four brachiobasilic fistulas were performed in 65 patients. This was a secondary or tertiary access procedure in 84 per cent of patients.

RESULTS

Of the 74 fistulas performed, 50 were successfully used for dialysis (68 per cent) and 24 (32 per cent) were never used, including 13 fistulas that failed without being used for dialysis. Of the 74 fistulas, 46 per cent failed (n = 34), 10 patients died with a functioning fistula (n = 10) and five were transplanted. The 30-day secondary patency was 73 per cent at 1 year, 53 per cent at 2 years and 43 per cent at 3 years rate was 96 per cent. Cumulative secondary patency was 73 per cent at 1 year, 53 per cent at 2 years and 43 per cent at 3 years. Nineteen (26 per cent) fistulas underwent a further 19 operative procedures. Fifty-one (69 per cent) fistulas developed complications. The most common complications were arm oedema (24 per cent), thrombosis (22 per cent) and bleeding (18 per cent).

CONCLUSION

In high-risk patients the autologous transposed brachiobasilic fistula has equivalent patency and lower complication rates than those reported for polytetrafluoroethylene interposition grafts.

Slow NMDA-EPSCs at synapses critical for song development are not required for song learning in zebra finches

Birdsong, like human speech, is learned via auditory experience during a developmentally restricted sensitive period. Within projection neurons of two avian forebrain nuclei, NMDA receptor-mediated EPSCs (NMDA-EPSCs) become fast during song development, a transition posited to limit learning. To discover whether slow NMDA-EPSCs at these synapses are required for learning, we delayed song learning beyond its normal endpoint, post-hatch day (PHD) 65, by raising zebra finches in isolation from song tutors. At PHD45, before learning, isolation delayed NMDA-EPSC maturation, but only transiently. By PHD65, NMDA-EPSCs in isolates were fast and adult-like, yet isolates presented with tutors readily learned song. Thus song learning did not require slow NMDA-EPSCs at synapses critical for song development.

The feasibility of spleen-preserving pancreatectomy for end-stage chronic pancreatitis

BACKGROUND

It is considered difficult to preserve the spleen at the time of distal or total pancreas resection for chronic pancreatitis (CP). The aim of this study was to assess the feasibility of preserving the spleen in patients requiring total or completion pancreatectomy for CP.

METHODS

All patients having total or completion pancreatectomy for CP were evaluated postoperatively in terms of morbidity, mortality, and pain relief. To assess splenic vascularity, all patients underwent abdominal ultrasound and power doppler imaging to assess splenic perfusion and the patency of the remaining splenic vessels.

RESULTS

Of 35 patients having total pancreatectomy, the spleen was preserved in 30 patients (19 women, 11 men; median age 40 years). The etiology of CP was mainly idiopathic (n = 14) or alcohol related (n = 12). All patients presented with chronic abdominal pain (median 5 years) requiring opiate-derived analgesia for pain relief. Fifteen patients (50%) had undergone previous therapeutic intervention for pain relief. The spleen was preserved with either an intact splenic artery and vein in 19 patients and or the short gastric vessels (n = 11). The mean duration of the procedure was 7 hours (range 5 to 11) and mean blood loss was 1,090 mL. The 30-day mortality was 3.8% (n = 1). Five patients had splenic complications (17%). These included splenectomy (n = 2), intrasplenic collection (n = 2), and a wedge splenic infarct (n = 1). Two of these complications were related to intrasplenic islet autotransplants. Follow-up with abdominal ultrasound and power doppler scanning showed no other abnormalities; blood flow was demonstrable in all patients with intact splenic arteries and vein (n = 19). The mean hospital stay was 25 days. Of the 24 patients who were beyond 6 months' follow-up, 82% (n = 20) have complete relief of pain, and 4 still require opiate analgesia.

CONCLUSIONS

Spleen-preserving pancreatectomy is a feasible procedure for chronic pancreatitis, providing complete pain relief in 80% of patients. When the splenic artery and vein cannot be preserved, there is a minimal risk of splenic complications that may require further treatment; but for the majority of patients, splenectomy is avoided.

The NADP(H)-binding component (dIII) of human heart transhydrogenase: crystallization and preliminary crystallographic analysis

Transhydrogenase is a membrane protein which uses the energy of the proton motive force to drive the reduction of NADP(+) by NADH. The enzyme has three domains: dII spans the membrane, while dI and dIII protrude from the membrane and contain the binding sites for NAD(H) and NADP(H), respectively. DIII from human heart transhydrogenase has been expressed in Escherichia coli. The purified protein has been crystallized with bound NADP(+) using the hanging-drop vapour-diffusion method with ammonium sulfate as a precipitant. The crystals belong to the tetragonal space group P4(1)22 or P4(3)22, with unit-cell parameters a = b = 58.1, c = 251.0 A. A 2.1 A resolution native data set has been collected with an R(merge) of 6. 8%.

Anaemia in pregnancy in southern Malawi: prevalence and risk factors

OBJECTIVE

To determine prevalence of anaemia in pregnancy in southern Malawi, and to establish if an 'at risk' group can be identified for targeted intervention.

DESIGN

Prospective cross-sectional study.

SETTING

A semi-urban hospital and a rural health clinic in southern Malawi.

POPULATION

Pregnant women attending the antenatal clinic for their booking visit.

METHODS

Haemoglobin concentration (g/dL) measured from a capillary blood sample (fingerprick) by battery operated HemoCue machine.

RESULTS

In urban Blantyre 57% of women were anaemic by WHO standards (haemoglobin < 11.0 g/dL) and 3.6% were severely anaemic (haemoglobin < 7.0 g/dL). The prevalence was higher in the rural area; 72% and 4.0%, respectively. Primiparae were at slightly increased risk for overall anaemia and severe anaemia but the effect of targeting this group alone for interventions would mean at least 65% of anaemic women and over half of the women with severe anaemia would be excluded. When the effect of age was examined separate from gravidity, adolescents were not found to be at increased risk of anaemia. Anaemia was more prevalent in the wet season and in women who booked late for antenatal care.

CONCLUSION

The prevalence of anaemia in pregnancy in our population is unacceptably high and deserves more attention. Prophylaxis of all women rather than an 'at risk' group based on age or gravidity is recommended.

Dual renal transplant from a non-heart beating donor

In September 1998, a 48 year old male underwent bilateral renal transplantation from a 51 year old non-heart beating donor (NHBD) with ischemic heart disease. The grafts exhibited delayed graft function, otherwise short term results have been good, with a three month serum creatinine of 80 mumol/l, three month GFR of 79 ml/min per 1.73 m2 BSA, and no episodes of acute rejection. We advocate dual transplantation when sub-optimal NHBD kidneys are otherwise in danger of being discarded.

Induction of anti-tumor immunity by intrasplenic administration of a carcinoembryonic antigen DNA vaccine

BACKGROUND

We have previously reported that intramuscular, intradermal or epidermal gene gun administration of a plasmid encoding carcinoembryonic antigen (CEA) under transcriptional regulatory control of the cytomegalovirus (CMV) early promoter/enhancer elicits CEA-specific humoral and cellular immune responses in mice with resultant immunoprotection against challenge with syngeneic, CEA-expressing colon adenocarcinoma cells.

METHODS

In the present work, we examine the ability of this DNA vaccine construct (pCEA) to elicit CEA-specific immunity following intrasplenic administration. Groups of mice were immunized with pCEA by intrasplenic or intramuscular injection. Six weeks later, mice were evaluated for the presence of anti-CEA humoral responses and were challenged with syngeneic, CEA-expressing colon carcinoma cells.

RESULTS

Intrasplenic administration of pCEA produced a frequency of CEA-specific antibody responses comparable to that elicited by intramuscular pCEA inoculation. Both intrasplenic and intramuscular administration of pCEA generated IgG2a antibody responses to CEA, consistent with the induction of T helper-1-biased immune responses. In addition, partial immunoprotection against tumor challenge was observed after a single plasmid DNA dose by either route of administration. Subsequent studies revealed that antibody responses to intrasplenic DNA vaccination are dose and schedule dependent.

CONCLUSION

These findings support future investigations of DNA vaccination strategies that specifically promote the uptake of plasmid by splenocytes.

Surgery for a fractured femur and elective ICU admission at 113 yr of age

Disability and medical dependence increase with age and as the percentage of the population over 80 yr old increases, demands on our healthcare budget will likewise grow. Clinical decision making should always balance the physiological state of the patient against the likely prognosis of the pathological state. Age may influence this decision-making process in an indirect way, as a perceived measure of physiological status, but whether age alone may be used as criteria for the type or degree of clinical intervention is a contentious point. In light of these issues, we present a woman of 113 yr, admitted to hospital with a fractured shaft of femur. The patient underwent surgery and was electively admitted to the intensive care unit for postoperative treatment. She survived surgery and several complications and was subsequently returned to the community where she celebrated her 114th birthday.

The high-resolution structure of the NADP(H)-binding component (dIII) of proton-translocating transhydrogenase from human heart mitochondria

BACKGROUND

Transhydrogenase, located in the inner membranes of animal mitochondria and the cytoplasmic membranes of bacteria, couples the transfer of reducing equivalents between NAD(H) and NADP(H) to proton pumping. The protein comprises three subunits termed dI, dII and dIII. The dII component spans the membrane. The dI component, which contains the binding site for NAD(+)/NADH, and the dIII component, which has the binding site for NADP(+)/NADPH, protrude from the membrane. Proton pumping is probably coupled to changes in the binding affinities of dIII for NADP(+) and NADPH.

RESULTS

The first X-ray structure of the NADP(H)-binding component, dIII, of human heart transhydrogenase is described here at 2.0 A resolution. It comprises a single domain resembling the classical Rossmann fold, but NADP(+) binds to dIII with a reversed orientation. The first betaalphabetaalphabeta motif of dIII contains a Gly-X-Gly-X-X-Ala/Val 'fingerprint', but it has a different function to that in the classical Rossmann structure. The nicotinamide ring of NADP(+) is located on a ridge where it is exposed to interaction with NADH on the dI subunit. Two distinctive features of the dIII structure are helix D/loop D, which projects from the beta sheet, and loop E, which forms a 'lid' over the bound NADP(+).

CONCLUSIONS

Helix D/loop D interacts with the bound nucleotide and loop E, and probably interacts with the membrane-spanning dII. Changes in ionisation and conformation in helix D/loop D, resulting from proton translocation through dII, are thought to be responsible for the changes in affinity of dIII for NADP(+) and NADPH that drive the reaction.

The risks of total pancreatectomy and splenic islet autotransplantation

The intraportal site is the most common site for islet transplantation. Many other sites have been tried experimentally, including the spleen, which has successfully lead to insulin independence in a number of animal models. Nevertheless, there are no detailed reports of total pancreatectomy and splenic islet autotransplantation in humans. Five patients underwent total pancreatectomy and splenic islet autotransplantation for chronic pancreatitis. Four patients had a pylorus-preserving total pancreatectomy and one patient a duodenal-preserving pancreatectomy. In three cases islets were embolized into both the portal vein and spleen. Two patients received splenic islet transplants alone. Islets were transplanted by retrograde venous infusion via the short gastric veins (n = 3), splenic vein stump (n = 1), and the left gastroepiploic vein (n = 1). The total volumes of transplanted pancreatic digest in those receiving combined intraportal and splenic autografts (n = 3) were 15.8, 13.0, and 13.5 ml. The volumes in those receiving a splenic-alone autograft (n = 2) were 12.0 and 5 ml. The mean rise in portal pressure was 18 cm of water. Complications related to the splenic autograft included a wedge splenic infarct, an emergency splenectomy, and a portal vein thrombosis in one patient having a combined intraportal and splenic autograft. Two patients developed insulin independence. two patients were still insulin independent at 1-year follow-up, and all had normal HbA1c levels (mean 5.6, range 5.2-6.3). Splenic islet autotransplantation, after total pancreatectomy, does lead to insulin independence. However, in our experience the combined procedure has a high morbidity because of splenic infarction and venous thrombosis.

Experience of combined endoscopic percutaneous stenting with ultrasound guidance for drainage of pancreatic pseudocycts

The therapeutic options for treatment of pancreatic pseudocysts are numerous. We report our experience of combined endoscopic and ultrasound guided percutaneous stenting for pancreatic pseudocysts. Data were prospectively collected for 20 consecutive patients. All patients had undergone a standard technique of combined endoscopic and ultrasound guided percutaneous placement of double J stents, between a pancreatic pseudocyst and the stomach. Patients age ranged between 25 and 84 years. Thirteen of the pseudocysts were due to acute pancreatitis and 7 were due to chronic pancreatitis. The duration of the combined procedure was mean 50 min (range 30-95 min). The length of hospital stay was mean 5 days (range 2-77 days. Only two patients suffered postoperative complications; one was re-admitted 2 weeks following stenting with acute cholecystitis, the other suffering a perforated duodenal ulcer 3 weeks after stenting. There were two failures early in the series, both due to stent migration, these stents were of a small size, (4.7 French). Following this the stent size was increased to at least 7 French, no further failures occurred. There was no operative mortality for the series. Follow-up ranged between 6 months and 5 years. We conclude that a combined percutaneous and endoscopic cyst-gastrostomy stent is a safe and effective treatment for patients with suitably placed pseudocysts.

Structure and mechanism of proton-translocating transhydrogenase

Recent developments have led to advances in our understanding of the structure and mechanism of action of proton-translocating (or AB) transhydrogenase. There is (a) a high-resolution crystal structure, and an NMR structure, of the NADP(H)-binding component (dIII), (b) a homology-based model of the NAD(H)-binding component (dI) and (c) an emerging consensus on the position of the transmembrane helices (in dII). The crystal structure of dIII, in particular, provides new insights into the mechanism by which the energy released in proton translocation across the membrane is coupled to changes in the binding affinities of NADP(+) and NADPH that drive the chemical reaction.

Xenotransplantation

BACKGROUND

Over the past 10 years xenotransplantation has generated much interest in the hope that it will enable us to overcome the current lack of human organ donors. This review examines the evolution and current therapeutic strategies that have been developed to overcome the predominant problem of graft rejection.

METHODS

A literature review was undertaken using a Medline search from January 1966 to August 1999.

RESULTS AND CONCLUSION

Despite the considerable advances that have been made in molecular biological techniques, xenograft rejection cannot be prevented without significant immunosuppression and toxic side-effects. The problem of delayed rejection, in particular, will probably be very difficult to overcome, although some of the difficulties associated with hyperacute rejection have been resolved. The potential risk of porcine endogenous retrovirus transmission has generated much debate recently, but it is likely that some of the important issues relating to xenotransplantation will never be resolved until carefully regulated clinical trials are allowed to begin.

A novel loop-loop recognition motif in the yeast ribosomal protein L30 autoregulatory RNA complex

The yeast Saccharomyces cerevisiae ribosomal protein L30 negatively autoregulates its production by binding to a helix-loop-helix structure formed in its pre-mRNA and its mRNA. A three-dimensional solution structure of the L30 protein in complex with its regulatory RNA has been solved using NMR spectroscopy. In the complex, the helix-loop-helix RNA adopts a sharply bent conformation at the internal loop region. Unusual RNA features include a purine stack, a reverse Hoogsteen base pair (G11anti-G56syn) and highly distorted backbones. The L30 protein is folded in a three-layer alpha/beta/alpha sandwich topology, and three loops at one end of the sandwich make base-specific contacts with the RNA internal loop. The protein-RNA binding interface is divided into two clusters, including hydrophobic and aromatic stacking interactions centering around G56, and base-specific hydrogen-bonding contacts to A57, G58 and G10-U60 wobble base pair. Both the protein and the RNA exhibit a partially induced fit for binding, where loops in the protein and the internal loop in the RNA become more ordered upon complex formation. The specific interactions formed between loops on L30 and the internal loop on the mRNA constitute a novel loop-loop recognition motif where an intimate RNA-protein interface is formed between regions on both molecules that lack regular secondary structure.

High frequency jet ventilation and gas trapping

We have compared three types of high frequency jet ventilation (HFJV) with conventional positive pressure ventilation in patients recovering from elective coronary artery bypass surgery. Twelve patients were allocated randomly to receive HFJV at ventilatory frequencies of 60, 100, 150 and 200 bpm from a standard jet ventilator at either the proximal or distal airway (HFJV.p and HFJV.d), or from a valveless high frequency jet ventilator acting as a pneumatic piston (VPP). Trapped gas volume (Vtr), cardiac index (CI) and right ventricular ejection fraction (RVEF) were measured. Vtr was related to the type of HFJV used (P < 0.05) and ventilatory frequency (P < 0.05). CI decreased with increasing rate of HFJV (P < 0.05) and there were significant differences between the three types of HFJV (P < 0.05). RVEF showed a linear relationship with ventilatory frequency (P < 0.05) decreasing most with the VPP. The decrease in RVEF was associated with an increase in right ventricular end-systolic volume (P < 0.05) suggesting that an increase in right ventricular afterload was the cause. The same three types of HFJV were compared using a lung model with variable values of compliance and resistance, to assess the impact of lung mechanics on gas trapping (Vtr, ml). Lung model compliance (C) was set at 50 or 25 ml cm H2O-1 and resistance (R) at 5 or 20 cm H2O litre-1 s, where values of 50 and 5, respectively, are normal. Vtr increased with ventilatory frequency for all types of jet ventilation (P < 0.05), varying with the type of jet ventilation used (P < 0.05).

Androgens modulate NMDA receptor-mediated EPSCs in the zebra finch song system

Androgens potently regulate the development of learned vocalizations of songbirds. We sought to determine whether one action of androgens is to functionally modulate the development of synaptic transmission in two brain nuclei, the lateral part of the magnocellular nucleus of the anterior neostriatum (LMAN) and the robust nucleus of the archistriatum (RA), that are critical for song learning and production. We focused on N-methyl-D-aspartate-excitatory postsynaptic currents (NMDA-EPSCs), because NMDA receptor activity in LMAN is crucial to song learning, and because the LMAN synapses onto RA neurons are almost entirely mediated by NMDA receptors. Whole cell recordings from in vitro brain slice preparations revealed that the time course of NMDA-EPSCs was developmentally regulated in RA, as had been shown previously for LMAN. Specifically, in both nuclei, NMDA-EPSCs become faster over development. We found that this developmental transition can be modulated by androgens, because testosterone treatment of young animals caused NMDA-EPSCs in LMAN and RA to become prematurely fast. These androgen-induced effects were limited to fledgling and juvenile periods and were spatially restricted, in that androgens did not accelerate developmental changes in NMDA-EPSCs recorded in a nonsong area, the Wulst. To determine whether androgens had additional effects on LMAN or RA neurons, we examined several other physiological and morphological parameters. In LMAN, testosterone affected alpha-amino-3-hydroxy-5-methyl-4-isoxazoleproprianate-EPSC (AMPA-EPSC) decay times and the ratio of peak synaptic glutamate to AMPA currents, as well as dendritic length and spine density but did not alter soma size or dendritic complexity. In contrast, testosterone did not affect any of these parameters in RA, which demonstrates that exogenous androgens can have selective actions on different song system neurons. These data are the first evidence for any effect of sex steroids on synaptic transmission within the song system. Our results support the idea that endogenous androgens limit sensitive periods for song learning by functionally altering synaptic transmission in song nuclei.

Comparison of the expression of fibrosis-associated genes in glomeruli after renal transplantation between conventional cadaveric and non-heart-beating donors

BACKGROUND

The main difference between cadaveric heart-beating donors and non-heart-beating donors (NHBDs) is the degree of warm ischaemia to which the kidney is subjected. This study was designed to see if this affected the expression of fibrosis-associated genes in the early period after transplantation.

METHODS

A series of 29 cadaveric and 19 NHBD renal transplants was studied. Patients underwent protocol needle-core renal transplant biopsies at 1 week, 3 months and 6 months after transplantation. At least two individual glomeruli were isolated from each biopsy. Messenger RNA was extracted and genes of interest were amplified by reverse transcriptase-polymerase chain reaction, then quantified in an enzyme-linked immunosorbent assay system.

RESULTS

Delayed graft function was common in NHBD (17 of 19) compared with cadaveric transplants (six of 29) (P < 0.0001). Acute rejection rates were similar. The level of tissue inhibitor of metalloproteinase 1, an inhibitor of extracellular matrix degradation, was higher in kidneys from NHBDs at 1 week (P = 0.02). There were no other statistically significant differences in the expression of fibrosis-associated genes between the two groups.

CONCLUSION

Although the increased ischaemic injury in kidneys retrieved from NHBDs leads to a higher rate of delayed graft function, this does not translate into increased expression of fibrosis-associated genes after the first week.

Can an old bird change his tune?

The stereotyped courtship songs of 'age-limited' songbirds, which learn their songs during a specific early period of their lives, were once thought immutable, but recent studies suggest that their maintenance may actually rely on subtle cues provided by auditory feedback.

A comparison of cross sectional surface area densities between adult and juvenile porcine islets of Langerhans

The object of this study was to evaluate differences in islet diameters, their distribution and both cross sectional surface areas and densities of insulin containing islets between adult and juvenile porcine pancreata using a computerised image analysis system (Improvision). Five adult (A) (2-3 yrs) and 5 juvenile (J) (< 12 mths) Large White pancreata were assessed. Biopsies were taken from 5 different regions (posterior lobe, duodenal lobe, along with the head, body and tail regions of the splenic lobe) of the pancreas and tissue sections stained for insulin. In both A and J pancreata islet numbers increased with decreasing islet diameter, showing a skewed distribution. There was no statistical significance between the cross sectional surface area within A (mean 5.04 x 10(3) microm2) or J (mean 5.99 x 10(3) microm2) pancreata. Assuming islets are spherical, extrapolation from pir2 showed that the mean diameter for A was 80 microm and 87 microm in J. These compared with A 77 microm and J 86 microm diameters using conventional microscopic techniques. The percentage islet volume density relative to exocrine tissue, derived from the principle of Delesse (Area density = volume density), did not significantly differ between each of the 5 areas studied, either in A or J. The percentage islet volume densities did show a significant difference between A (mean 1.83%) (P = 0.001) but not between J pancreata (mean 2.13 %). In conclusion poor islet yields can be attributed to differences in islet volume density of islets within porcine pancreata. These results also suggest that the posterior and duodenal lobes should be used along with the splenic lobe in order to improve porcine islet yields. Furthermore, the current practise of reporting porcine islet yields and the isolation index relative to 150 microm (IEQs) needs to be redefined, based on the assumption that the average size of an adult porcine islet is 80 microm.

A novel intubation technique for tracheoesophageal fistula in adults

PURPOSE

To describe a novel technique of tracheal intubation and ventilation in an adult patient with a large tracheoesophageal fistula at the level of the carina.

CLINICAL FEATURES

A 59 yr old woman with squamous cell carcinoma of the esophagus developed a large (2 cm diameter) tracheoesophageal fistula after radiotherapy. The level of her fistula precluded traditional use of a double-lumen endobronchial tube. Intubation and ventilation were managed with two endobronchial tubes. The ability to ventilate or collapse each lung individually was preserved and anesthesia and surgery proceeded uneventfully.

CONCLUSION

Double endobronchial intubation is described to manage anesthesia in an adult patient with a tracheoesophageal fistula at the level of the carina.

Vascularized pancreas allotransplantation--clinical indications and outcome

AIMS

This review examines the status of vascularized pancreas transplantation as a treatment for Type 1 diabetes mellitus (DM).

METHODS

The world literature, with a particular emphasis on data from the International Pancreas Transplant Registry (IPTR), is reviewed and interpreted particularly for clinical indications and outcome.

RESULTS

Over 9000 cases of vascularized pancreas transplant (VPT) have been registered, with insulin dependence approaching 82% at 1 year with 94% patient survival. The majority of transplants are simultaneous pancreas and kidney (SPK) transplants, with far fewer pancreas after kidney (PAK) or pancreas transplants alone (PTA). The success rates differ between the procedures but are generally improving as technical advances, improvements in immunosupression and greater experience are gained. The most obvious advantage is an improved quality of life (QoL) but there are risks associated with the procedure and with the immunosuppression. There is some evidence coming to light of a very slow beneficial effect on microvascular complications.

CONCLUSIONS

VPT is an attractive option to offer Type 1 DM patients who need or already have a renal allograft. Patients have to decide between the increased surgical risk and the risks of long-term immunosuppression and the benefits of improved QoL. In the absense of end-stage renal failure (ESRF) there is no justification for PTA, except where the diabetes itself poses a greater risk to life than the transplantation procedure.

A quantitative analysis of the effect of insulin-like growth factor-1 infusion during mandibular distraction osteogenesis in rabbits

AIM

To quantify, by histomorphometry, the effects of local insulin-like growth factor-1 (IGF-1) during mandibular distraction at various rates.

METHODOLOGY

Mature rabbits underwent bilateral mandibular corticotomy and distraction lengthening. Recombinant IGF-1 was administered to two groups of rabbits via osmotic infusion pumps. Distraction regimes were as follows: Group A, 1 mm/day for 15 days; Group B, as for A plus IGF-1; Group C, 3 mm/day for 5 days; Group D, as for C plus IGF-1; and Group E, sham-operated controls. After a 28-day consolidation period, rabbits were sacrificed and bone deposition quantified using DEXA scanning, three-point bending, histological examination and sampled for histomorphometric analysis.

RESULTS

DEXA scanning and three-point bending failed to detect any effect of distraction rate or of IGF-1 infusion. Histological and histomorphometric analysis suggested 1 mm/day to be the ideal distraction rate, as this was associated with greater osteoblastic activity and consistent bony union. However, IGF-1 infusion significantly enhanced osteoblastic activity at both distraction rates and resulted in bony union when distraction was performed at 3 mm/day.

CONCLUSIONS

Distraction osteogenesis at a rate of 1 mm/day provides greater osteogenic stimulus than 3 mm/day. Exogenous IGF-1 has a positive influence on osteoblastic activity during distraction. Its effect is probably minimised by high levels of endogenous IGF-1.

Physiological values and procedures in the 24 h before ICU admission from the ward

Physiological values and interventions in the 24 h before entry to intensive care were collected for admissions from hospital wards. In a 13-month period, there were 79 admissions in 76 patients who had been in hospital for at least 24 h and had not undergone surgery within 24 h of admission to intensive care. Thirty-four per cent of patients underwent cardiopulmonary resuscitation before intensive care admission. Using Acute Physiology and Chronic Health Evaluation II scoring to quantify abnormal physiology in the group as a whole, a significant deterioration in respiratory function before admission was found. During the 6-h period immediately before intensive care admission, 75% of patients received oxygen, 37% underwent arterial blood gas sampling, and oxygen saturation was measured in 61% of patients, 63% of whom had an oxygen saturation of less than 90%. Overall hospital mortality in the study group was 58%. Information collected on the wards identified seriously ill patients who may have benefited from earlier expert treatment.

Open water scuba diving accidents at Leicester: five years' experience

OBJECTIVES

The aim of this study was to determine the incidence, type, outcome, and possible risk factors of diving accidents in each year of a five year period presenting from one dive centre to a large teaching hospital accident and emergency (A&E) department.

METHODS

All patients included in this study presented to the A&E department at a local teaching hospital in close proximity to the largest inland diving centre in the UK. Our main outcome measures were: presenting symptoms, administration of recompression treatment, mortality, and postmortem examination report where applicable.

RESULTS

Overall, 25 patients experienced a serious open water diving accident at the centre between 1992 and 1996 inclusive. The percentage of survivors (n = 18) with symptoms of decompression sickness receiving recompression treatment was 52%. All surviving patients received medical treatment for at least 24 hours before discharge. The median depth of diving accidents was 24 metres (m) (range 7-36 m). During the study period, 1992-96, the number of accidents increased from one to 10 and the incidence of diving accidents increased from four per 100,000 to 15.4 per 100,000. Over the same time period the number of deaths increased threefold.

CONCLUSIONS

The aetiology of the increase in the incidence of accidents is multifactorial. Important risk factors were thought to be: rapid ascent (in 48% of patients), cold water, poor visibility, the number of dives per diver, and the experience of the diver. It is concluded that there needs to be an increased awareness of the management of diving injuries in an A&E department in close proximity to an inland diving centre.

A preliminary study of the activation of endogenous pancreatic exocrine enzymes during automated porcine islet isolation

The activation of endogenous pancreatic enzymes during automated pancreas digestion may be detrimental to islet isolation. In this report we assessed the activation of trypsin, chymotrypsin, elastase, carboxypeptidases A and B, phospholipase A2, and lipase using a porcine model. Four islet isolations were examined. Duplicate aliquots were taken from the automated circuit at 5-min time intervals up to the completion of pancreas digestion (approx 60 min). One aliquot was activated in vitro with exogenous trypsin in order to convert the enzymes into their active non-"proform," with the exception of trypsinogen, which was activated with exogenous enterokinase. This was done to assess the percentage activation of each individual enzyme (total potentially activatable enzyme release). The extent of activation between isolations was extremely variable. During the closed (recirculating) circuit phase of pancreas digestion there were both gradual and rapid increases in the levels of enzymes released. Peak activity of enzyme activation varied from 13 to 30 min; similarly, total potentially activatable peaks occurred between 13 and 38 min. Lipase and carboxypeptidase B showed greater than 70% activation, chymotrypsin, carboxypeptidase A, and phospholipase A2 between 50% and 70% activation, and trypsin and elastase less than 20%. There were up to 30-fold differences between the four islet preparations. In summary, it is unlikely that poor islet yields are soley explained by variations between collagenases; the variable activation of endogenous pancreatic exocrine enzymes is also likely to be influential to porcine islet yields.

A prospective controlled trial of the efficacy of isopropyl alcohol wipes before venesection in surgical patients

It has previously been suggested that skin preparation before venesection with antiseptic agents is unnecessary. However thousands of doctors and medical students continue to use isopropyl alcohol (IPA) swabs for venesection, at an estimated cost of 10,000 P per annum in a 500 bed hospital. An audit of IPA swab use among junior doctors and medical students at our institution was undertaken; 76% of doctors and 100% of medical students routinely prepared the skin with alcohol before venesection and only one used the swabs correctly. A randomised single-blind controlled trial was conducted of IPA versus no IPA skin preparation before venesection. There were 194 patients in the study, 93 in the IPA group and 101 controls. There was no statistical difference with respect to complications at the venepuncture site between the two groups.