Self-intoxication with morphine obtained from an infusion pump

A 36-year-old Caucasian male was found unresponsive by his wife. He had white foam around his mouth and was pronounced dead shortly thereafter. He had a history of back pain and was treated with intrathecal morphine because of his previous addiction to oral opiate medications. Because of crimping of the pump catheter, it was replaced 4 days before his death. Toxicological findings included urine screen positive for amitriptyline, nortriptyline, opiates, hydrocodone metabolites, ibuprofen, acetaminophen, caffeine, nicotine, and metabolite. Drug concentrations were as follows: blood, 0.260 mg/L amitriptyline, 0.160 mg/L nortriptyline, 0.460 mg/L unconjugated morphine, and 0.624 mg/L total morphine; vitreous humor, 0.034 mg/L unconjugated morphine and 0.080 mg/L total morphine; and cerebrospinal fluid, 0.099 mg/L unconjugated morphine and 0.095 mg/L total morphine. Shortly after death, the volume of the residual pump reservoir was only 8 mL instead of the expected 17 mL. Testing by the FDA showed that the pump was functional. The residual content of the pump accounted for only 230 mg instead of the expected 488 mg. The high blood-morphine concentrations did not correlate with the intrathecal infusion dose. The symptoms were consistent with opiate overdose, possibly by injection of morphine withdrawn from the pump reservoir. The cause of death was determined to be fatal morphine self-intoxication, and the manner of death was accidental. This case is intended to alert regulatory agencies, pain management health professionals, pathologists, and toxicologists to the abuse potential of one of the newer analgesic-delivery systems.

Morphological and functional association of Sec22b/ERS-24 with the pre-Golgi intermediate compartment

Yeast Sec22p participates in both anterograde and retrograde vesicular transport between the endoplasmic reticulum (ER) and the Golgi apparatus by functioning as a v-SNARE (soluble N-ethylmaleimide-sensitive factor [NSF] attachment protein receptor) of transport vesicles. Three mammalian proteins homologous to Sec22p have been identified and are referred to as Sec22a, Sec22b/ERS-24, and Sec22c, respectively. The existence of three homologous proteins in mammalian cells calls for detailed cell biological and functional examinations of each individual protein. The epitope-tagged forms of all three proteins have been shown to be primarily associated with the ER, although functional examination has not been carefully performed for any one of them. In this study, using antibodies specific for Sec22b/ERS-24, it is revealed that endogenous Sec22b/ERS-24 is associated with vesicular structures in both the perinuclear Golgi and peripheral regions. Colabeling experiments for Sec22b/ERS-24 with Golgi mannosidase II, the KDEL receptor, and the envelope glycoprotein G (VSVG) of vesicular stomatitis virus (VSV) en route from the ER to the Golgi under normal, brefeldin A, or nocodazole-treated cells suggest that Sec22b/ERS-24 is enriched in the pre-Golgi intermediate compartment (IC). In a well-established semi-intact cell system that reconstitutes transport from the ER to the Golgi, transport of VSVG is inhibited by antibodies against Sec22b/ERS-24. EGTA is known to inhibit ER-Golgi transport at a stage after vesicle/transport intermediate docking but before the actual fusion event. Antibodies against Sec22b/ERS-24 inhibit ER-Golgi transport only when they are added before the EGTA-sensitive stage. Transport of VSVG accumulated in pre-Golgi IC by incubation at 15 degreesC is also inhibited by Sec22b/ERS-24 antibodies. Morphologically, VSVG is transported from the ER to the Golgi apparatus via vesicular intermediates that scatter in the peripheral as well as the Golgi regions. In the presence of antibodies against Sec22b/ERS-24, VSVG is seen to accumulate in these intermediates, suggesting that Sec22b/ERS-24 functions at the level of the IC in ER-Golgi transport.

Prevalence and prediction of difficult intubation in Chinese women

We conducted a prospective, blind observational study to investigate the prevalence and prediction of difficult intubation in Chinese women. Two groups of Chinese women were studied (151 pregnant and 260 non-pregnant). The prevalence of difficult intubation was 1.99% in the pregnant and 1.54% in the non-pregnant group. The difference was not statistically significant. Predictive variables for difficult intubation, including modified Mallampati class, thyromental distance and atlanto-occipital extension, had high sensitivity but low positive predictive value when used alone. A shorter thyromental distance had to be used as the criterion for prediction in Chinese women. Combination of predictive variables could improve the positive predictive value.

Otorrhea after grommet insertion for middle ear effusion in patients with nasopharyngeal carcinoma

PURPOSE

To document the incidence of complications after myringotomy and grommet insertion in patients with nasopharyngeal carcinoma. The focus is on the incidence of otorrhea and perforation. The possible risk factors for these conditions and treatment response were studied.

MATERIALS AND METHODS

We reviewed the records on 206 ears of 163 patients who suffered from nasopharyngeal carcinoma and underwent myringotomy and grommet insertion in a 7-year period. The follow-up period ranged from 4 weeks to 78 months (median, 9 months).

RESULTS

The overall incidence of otorrhea in these ears was 38%. Patients with nasopharyngeal carcinoma (NPC) had a significantly high incidence of postoperative discharge (chi2 test, P<.0001) compared with other patients who underwent myringotomy and grommet insertion. The mean interval between myringotomy and otorrhea was 19.8 weeks. Forty-seven per cent of the ears with a discharge developed otorrhea within 1 month. In 42%, the otorrhea responded to treatment and the ears became dry. After extrusion of the grommet, 29% of those ears with otorrhea ended with an eardrum perforation, and 24% of the ears showed recurrent effusion.

CONCLUSIONS

For patients with NPC who underwent myringotomy, there was a significant risk of otorrhea (49%) and persistent perforation (29%), and these complications were difficult to manage. We conclude that myringotomy and grommet insertion should not be routinely offered to NPC patients with middle ear effusion.

GS32, a novel Golgi SNARE of 32 kDa, interacts preferentially with syntaxin 6

Syntaxin 1, synaptobrevins or vesicle-associated membrane proteins, and the synaptosome-associated protein of 25 kDa (SNAP-25) are key molecules involved in the docking and fusion of synaptic vesicles with the presynaptic membrane. We report here the molecular, cell biological, and biochemical characterization of a 32-kDa protein homologous to both SNAP-25 (20% amino acid sequence identity) and the recently identified SNAP-23 (19% amino acid sequence identity). Northern blot analysis shows that the mRNA for this protein is widely expressed. Polyclonal antibodies against this protein detect a 32-kDa protein present in both cytosol and membrane fractions. The membrane-bound form of this protein is revealed to be primarily localized to the Golgi apparatus by indirect immunofluorescence microscopy, a finding that is further established by electron microscopy immunogold labeling showing that this protein is present in tubular-vesicular structures of the Golgi apparatus. Biochemical characterizations establish that this protein behaves like a SNAP receptor and is thus named Golgi SNARE of 32 kDa (GS32). GS32 in the Golgi extract is preferentially retained by the immobilized GST-syntaxin 6 fusion protein. The coimmunoprecipitation of syntaxin 6 but not syntaxin 5 or GS28 from the Golgi extract by antibodies against GS32 further sustains the preferential interaction of GS32 with Golgi syntaxin 6.

Identification and molecular characterization of Charybdis feriatus tropomyosin, the major crab allergen

BACKGROUND

Crab sensitivity is one of the most common seafood allergies. However, to date, there has been no report on the molecular characterization of crab allergens and no comparative analysis with other seafood allergens.

OBJECTIVE

This study was undertaken to clone, identify, and determine the primary structure of a major IgE-reactive molecule in crab.

METHODS

We constructed an expression cDNA library from a common crab, Charybdis feriatus. This library was then screened with the use of sera from subjects with a well-documented history of type I hypersensitivity reactions upon ingestion of crab. An IgE-reactive clone was chosen and subcloned into plasmids for nucleotide sequence determination and expression in Escherichia coli.

RESULTS

We identified a 1-kb cDNA designated as Cha f 1. Expression of Cha f 1 produces a 34-kd recombinant protein reactive to the IgE antibodies from patients with crab allergies but not from control subjects. Cha f 1 has an opening reading frame of 264 amino acids and demonstrates marked homology to the shrimp tropomyosin Met e 1. Absorption of allergic sera with Cha f I removes IgE reactivity to crab extract. Moreover, absorption of allergic sera with recombinant shrimp Met e 1 tropomyosin removes IgE reactivity to Cha f 1.

CONCLUSIONS

This 34-kd protein, designated as Cha f 1, is the first identified major allergen of crab. Nucleotide and amino acid comparison shows that this protein is the crab tropomyosin. The molecular basis of shrimp and crab allergy is readily demonstrated at the nucleotide and amino acid level.

A novel synaptobrevin/VAMP homologous protein (VAMP5) is increased during in vitro myogenesis and present in the plasma membrane

cDNA clones encoding a novel protein (VAMP5) homologous to synaptobrevins/VAMPs are detected during database searches. The predicted 102-amino acid VAMP5 harbors a 23-residue hydrophobic region near the carboxyl terminus and exhibits an overall amino acid identity of 33% with synaptobrevin/VAMP1 and 2 and cellubrevin. Northern blot analysis reveals that the mRNA for VAMP5 is preferentially expressed in the skeletal muscle and heart, whereas significantly lower levels are detected in several other tissues but not in the brain. During in vitro differentiation (myogenesis) of C2C12 myoblasts into myotubes, the mRNA level for VAMP5 is increased approximately 8- to 10-fold. Immunoblot analysis using antibodies specific for VAMP5 shows that the protein levels are also elevated approximately 6-fold during in vitro myogenesis of C2C12 cells. Indirect immunofluorescence microscopy and immunoelectron microscopy reveal that VAMP5 is associated with the plasma membrane as well as intracellular perinuclear and peripheral vesicular structures of myotubes. Epitope-tagged versions of VAMP5 are similarly targeted to the plasma membrane.

Alpha-SNAP but not gamma-SNAP is required for ER-Golgi transport after vesicle budding and the Rab1-requiring step but before the EGTA-sensitive step

N-ethylmaleimide-sensitive factor (NSF) and soluble NSF attachment proteins (SNAPs) have been implicated in diverse vesicular transport events; yet their exact role and site of action remain to be established. Using an established in vitro system, we show that antibodies against alpha-SNAP inhibit vesicle transport from the ER to the cis-Golgi and that recombinant alpha-SNAP enhances/stimulates the process. Cytosol immunodepleted of alpha-SNAP does not support normal transport unless supplemented with recombinant alpha-SNAP but not gamma-SNAP. In marked contrast, cytosol immunodepleted of gamma-SNAP supports ER-Golgi transport to the normal level. Neither antibodies against gamma-SNAP nor recombinant gamma-SNAP have any effect on ER-Golgi transport. These results clearly establish an essential role for alpha-SNAP but not gamma-SNAP in ER-Golgi transport. When the transport assay is performed with cytosol immunodepleted of alpha-SNAP, followed by incubation with cytosol immunodepleted of a COPII subunit, normal transport is achieved. In marked contrast, no transport is detected when the assay is first performed with cytosol depleted of the COPII subunit followed by alpha-SNAP-depleted cytosol, suggesting that alpha-SNAP is required after a step that requires COPII (the budding step). In combination with cytosol immunodepleted of Rab1, it is seen that alpha-SNAP is required after a Rab1-requiring step. It has been shown previously that EGTA blocks ER-Golgi transport at a step after vesicle docking but before fusion and we show here that alpha-SNAP acts before the step that is blocked by EGTA. Our results suggest that alpha-SNAP may be involved in the pre-docking or docking but not the fusion process.

A 29-kilodalton Golgi soluble N-ethylmaleimide-sensitive factor attachment protein receptor (Vti1-rp2) implicated in protein trafficking in the secretory pathway

Expressed sequence tags coding for a potential SNARE (soluble N-ethylmaleimide-sensitive factor attachment protein receptor) were revealed during data base searches. The deduced amino acid sequence of the complete coding region predicts a 217-residue protein with a COOH-terminal hydrophobic membrane anchor. Affinity-purified antibodies raised against the cytoplasmic region of this protein specifically detect a 29-kilodalton integral membrane protein enriched in the Golgi membrane. Indirect immunofluorescence microscopy reveals that this protein is mainly associated with the Golgi apparatus. When detergent extracts of the Golgi membrane are incubated with immobilized glutathione S-transferase alpha soluble N-ethylmaleimide-sensitive factor attachment protein (GST-alpha-SNAP), this protein was specifically retained. This protein has been independently identified and termed Vti1-rp2, and it is homologous to Vti1p, a yeast Golgi SNARE. We further show that Vti1-rp2 can be qualitatively coimmunoprecipitated with Golgi syntaxin 5 and syntaxin 6, suggesting that Vti1-rp2 exists in at least two distinct Golgi SNARE complexes. In cells microinjected with antibodies against Vti1-rp2, transport of the envelope protein (G-protein) of vesicular stomatitis virus from the endoplasmic reticulum to the plasma membrane was specifically arrested at the Golgi apparatus, providing further evidence for functional importance of Vti1-rp2 in protein trafficking in the secretory pathway.

Endobrevin, a novel synaptobrevin/VAMP-like protein preferentially associated with the early endosome

Synaptobrevins/vesicle-associated membrane proteins (VAMPs) together with syntaxins and a synaptosome-associated protein of 25 kDa (SNAP-25) are the main components of a protein complex involved in the docking and/or fusion of synaptic vesicles with the presynaptic membrane. We report here the molecular, biochemical, and cell biological characterization of a novel member of the synaptobrevin/VAMP family. The amino acid sequence of endobrevin has 32, 33, and 31% identity to those of synaptobrevin/VAMP-1, synaptobrevin/VAMP-2, and cellubrevin, respectively. Membrane fractionation studies demonstrate that endobrevin is enriched in membrane fractions that are also enriched in the asialoglycoprotein receptor. Indirect immunofluorescence microscopy establishes that endobrevin is primarily associated with the perinuclear vesicular structures of the early endocytic compartment. The preferential association of endobrevin with the early endosome was further established by electron microscopy (EM) immunogold labeling. In vitro binding assays show that endobrevin interacts with immobilized recombinant alpha-SNAP fused to glutathione S-transferase (GST). Our results highlight the general importance of members of the synaptobrevin/VAMP protein family in membrane traffic and provide new avenues for future functional and mechanistic studies of this protein as well as the endocytotic pathway.

Standards of laboratory practice: analgesic drug monitoring. National Academy of Clinical Biochemistry

Analgesics are the most commonly consumed over-the-counter preparations in the United States. They are used in the treatment of various pain syndromes and other medical conditions. Although analgesics are generally perceived to be safe agents, serious toxicity may occur in the setting of acute overdose, chronic abuse, or overuse. The indications for therapeutic drug monitoring in patients using these medications appropriately is as yet not well defined. The emphasis of this discussion, therefore, is on recommendations for monitoring in situations where toxicity is suspected. Preanalytical, analytical, and practice issues including drug interactions, frequency of monitoring, pertinent ancillary tests, reporting, and special patient groups at risk for toxicity are reviewed. Recent information from a major manufacturer of evacuated tubes arguing against the use of gel tubes for blood collection for drug monitoring is included. Colorimetric/enzymatic/immunoassays for the routine/stat monitoring of acetaminophen and salicylate and diflunisal cross-reactivity with most of the currently used salicylate assays are presented. Achiral and chiral chromatographic assays and newly introduced columns such as restricted access media and/or automated chromatographic systems are reviewed for the analysis of ibuprofen, naproxen, and the recently introduced tramadol. Finally, concepts regarding future directions including drug chirality and chiral analysis are presented.

Local recurrence of carcinoma of the tongue after glossectomy: patient prognosis

We conducted a retrospective review of the prognosis for patients with local recurrence after surgical treatment of carcinoma of the tongue. Glossectomy for squamous cell carcinoma of the tongue was performed in 167 patients. Local recurrence developed in 32 patients including 21 with local recurrence alone, 10 with locoregional recurrence and one with locodistant recurrence. The incidence of local recurrence increased with tumor stage (from 16% of T1 tumors to 46% of T4 carcinomas). Eleven (34%) patients underwent surgical salvage for local recurrence, with only one (9%) patient surviving free of carcinoma at 43 months post-surgical salvage. All of the remaining 21 patients with local recurrence were treated palliatively and all died within one year. Patients who underwent surgical salvage had significantly higher survival rates compared to those treated palliatively. Close follow-up after glossectomy is important for early detection of local recurrence amenable to surgical salvage. However, the overall prognosis for patients with local recurrence was poor, with a three-year actuarial survival rate of only 3%. Therefore, prevention of local recurrence with adequate initial surgical treatment is essential.

Influence of fluid intake pattern on short-term recovery from prolonged, submaximal running and subsequent exercise capacity

The aim of this study was to examine if the pattern of fluid intake with a carbohydrate-electrolyte solution during 4 h recovery from prolonged, submaximal running would influence the subsequent endurance capacity. Seven well-trained athletes aged 19.8 +/- 0.3 years (mean +/- s(mean)) took part in the study, which had university ethical committee approval. They ran at 70% VO2 max on a level treadmill for 90 min (T1), or until volitional fatigue, whichever came first, on two occasions, at least 7-10 days apart. Four hours later, the subjects ran at the same speed for as long as possible (T2), as a measure of their endurance capacity. During the 4 h rehydration recovery period, the runners were allowed to drink a carbohydrate-electrolyte solution (6.9% Lucozade-Sport; sodium, 24 mmol l(-1); potassium, 2.6 mmol l(-1); calcium, 1.2 mmol l(-1); osmolality, 300 mOsm kg(-1)) ad libitum on one occasion. On the other occasion, the volume of the same fluid was prescribed from calculations of the body mass loss during T1 (2.6% of pre-exercise body mass). All subjects completed the 90 min run during T1 on both trials. However, during T2, in the prescribed intake trial, the exercise time to exhaustion was 16% longer (P< 0.05) than during T2 in the ad libitum trial (69.9 +/- 9.1 vs 60.2 +/- 10.2 min). Although there was no difference between conditions in the total volume ingested (1499 +/- 155 vs 1405 +/- 215 ml), the volume of carbohydrate-electrolyte solution ingested in the fourth hour of the rehydration recovery period was greater in the prescribed intake trial than in the ad libitum trial (258 +/- 52 vs 78 +/- 34 ml; P< 0.05). The amount of glucose ingested in this period during the prescribed intake trial was also greater than during the ad libitum trial (17.8 +/- 3.6 vs 5.4 +/- 2.4 g; P< 0.05). There was a higher blood lactate concentration at the start of T2 in the prescribed intake trial than in the ad libitum trial (1.12 +/- 0.20 vs 0.94 +/- 0.09 mmol l(-1); P< 0.05), but there were no differences in blood glucose, plasma insulin, free fatty acid concentrations or urine volume between trials. The results of this study suggest that drinking a prescribed volume of a carbohydrate-electrolyte solution after prolonged exercise, calculated to replace the body fluid losses, restores endurance capacity to a greater extent than ad libitum rehydration during 4 h of recovery, even though the total volumes ingested were the same between trials.

Syntaxin 7, a novel syntaxin member associated with the early endosomal compartment

Members of the syntaxin family are key molecules involved in diverse vesicle docking/fusion events. We report here the molecular, biochemical, and cell biological characterizations of a novel member (syntaxin 7) of the syntaxin family. Syntaxin 7 is structurally related to all known syntaxins. Within a 79-residue region preceding the C-terminal hydrophobic tail, syntaxin 7 is 35, 34, 34, 34, 25, and 19% identical to syntaxins 1, 2, 3, 4, 5, and 6, respectively. Northern blot analysis showed that syntaxin 7 is widely expressed. Indirect immunofluorescence microscopy revealed that syntaxin 7 is primarily associated with the early endosome. In vitro binding assays established that syntaxin 7 in membrane extracts interacts with immobilized recombinant alpha-soluble N-ethylmaleimide-sensitive factor attachment proteins fused to glutathione S-transferase. Our results highlight the general importance of members of the syntaxin family in protein trafficking and provide new avenues for future functional and mechanistic studies of this first endosomal syntaxin as well as the endocytotic pathway.

The mammalian protein (rbet1) homologous to yeast Bet1p is primarily associated with the pre-Golgi intermediate compartment and is involved in vesicular transport from the endoplasmic reticulum to the Golgi apparatus

Yeast Bet1p participates in vesicular transport from the endoplasmic reticulum to the Golgi apparatus and functions as a soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) associated with ER-derived vesicles. A mammalian protein (rbet1) homologous to Bet1p was recently identified, and it was concluded that rbet1 is associated with the Golgi apparatus based on the subcellular localization of transiently expressed epitope-tagged rbet1. In the present study using rabbit antibodies raised against the cytoplasmic domain of rbet1, we found that the majority of rbet1 is not associated with the Golgi apparatus as marked by the Golgi mannosidase II in normal rat kidney cells. Rather, rbet1 is predominantly associated with vesicular spotty structures that concentrate in the peri-Golgi region but are also present throughout the cytoplasm. These structures colocalize with the KDEL receptor and ERGIC-53, which are known to be enriched in the intermediate compartment. When the Golgi apparatus is fragmented by nocodazole treatment, a significant portion of rbet1 is not colocalized with structures marked by Golgi mannosidase II or the KDEL receptor. Association of rbet1 in cytoplasmic spotty structures is apparently not altered by preincubation of cells at 15 degrees C. However, upon warming up from 15 to 37 degrees C, rbet1 concentrates into the peri-Golgi region. Furthermore, rbet1 colocalizes with vesicular stomatitis virus G-protein en route from the ER to the Golgi. Antibodies against rbet1 inhibit in vitro transport of G-protein from the ER to the Golgi apparatus in a dose-dependent manner. This inhibition can be neutralized by preincubation of antibodies with recombinant rbet1. EGTA is known to inhibit ER-Golgi transport at a stage after vesicle docking but before the actual fusion event. Antibodies against rbet1 inhibit ER-Golgi transport only when they are added before the EGTA-sensitive stage. These results suggest that rbet1 may be involved in the docking process of ER-derived vesicles with the cis-Golgi membrane.

A SNARE involved in protein transport through the Golgi apparatus

In eukaryotic cells, the Golgi apparatus receives newly synthesized proteins from the endoplasmic reticulum (ER) and delivers them after covalent modification to their destination in the cell. These proteins move from the inside (cis) face to the plasma-membrane side (trans) of the Golgi, through a stack of cisternae, towards the trans-Golgi network (TGN), but very little is known about how proteins are moved through the Golgi compartments. In a model known as the maturation model, no special transport process was considered necessary, with protein movement along the Golgi being achieved by maturation of the cisternae. Alternatively, proteins could be transported by vesicles or membrane tubules. Although little is known about membrane-tubule-mediated transport, the molecular mechanism for vesicle-mediated transport is quite well understood, occurring through docking of SNAREs on the vesicle with those on the target membrane. We have now identified a protein of relative molecular mass 27K which is associated with the Golgi apparatus. The cytoplasmic domain of this protein or antibodies raised against it quantitatively inhibit transport in vitro from the ER to the trans-Golgi/TGN, acting at a stage between the cis/medial- and the trans-Golgi/TGN. This protein, which behaves like a SNARE and has been named GS27 (for Golgi SNARE of 27K), is identical to membrin, a protein implicated earlier in ER-to-Golgi transport. Our results suggest that protein movement from medial- to the trans-Golgi/TGN depends on SNARE-mediated vesicular transport.

Use of transtympanic round window electrocochleography for threshold estimations in children

OBJECTIVE

This study aimed to evaluate the efficacy of round window electrocochleography for the estimation of hearing thresholds in difficult-to-test children.

STUDY DESIGN

The study was a retrospective analysis.

SETTING

A standard day-stay operating room was used.

PATIENTS

Round window electrocochleography was performed on 198 children between January 1993 and January 1996.

INTERVENTION

The intervention was diagnostic.

MAIN OUTCOME MEASURE

Clinically reliable pure-tone audiograms were obtained in 101 patients (50.9%) for comparisons of electrocochleography and behavioral thresholds.

RESULTS

The mean differences between electrocochleography and behavioral thresholds at 0.5, 1, 2, and 4 kHz were less than 6 dB. Ninety-seven percent of the results were within +30 to -30 dB, and approximately 86% of the results were within +20 to -20 dB. Good correlation coefficients of 0.83, 0.84, 0.91 and 0.88 were found between electrocochleography and behavioral thresholds at 0.5, 1, 2, and 4 kHz, respectively. Only 2 of 395 ears were complicated postoperatively by suppurative otitis media. There were no anesthetic complications.

CONCLUSION

Round window electrocochleography can be used in conjunction with other audiometric methods for threshold estimations in the difficult-to-test children and as part of the preoperative assessment for cochlear implantation.

GS15, a 15-kilodalton Golgi soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) homologous to rbet1

Bet1p plays an essential role in vesicular transport from the endoplasmic reticulum (ER) to the Golgi in yeast, and it functions as a vesicle soluble N-ethylmaleimide-sensitive factor protein receptor (v-SNARE). A mammalian protein related to Bet1p has been reported previously and was referred to as rbet1. We have now identified a new mammalian protein that is homologous to rbet1 (28% amino acid identity). mRNA for this rbet1 homologue is widely expressed in rat tissues. Affinity-purified polyclonal antibodies raised against recombinant protein specifically recognized a 15-kilodalton integral membrane protein highly enriched in Golgi membranes. Indirect immunofluorescence microscopy revealed that this protein is specifically associated with the Golgi apparatus in diverse cell types. Biochemical characterization established that this protein behaves like a SNARE and was named GS15 (Golgi SNARE with a size of 15 kilodaltons). These properties raise the possibility that GS15 is a novel SNARE mediating a yet to be defined transport event associated with the Golgi apparatus.

Surgical excision of intracranial arteriovenous malformations after preoperative embolisation with N-butylcyanoacrylate

The aim of this study was to determine the usefulness of preoperative embolisation of intracranial arteriovenous malformations (AVMs) with N-Butylcyanoacrylate (NBCA) since the introduction of this interventional neuroradiology technique in March 1994 at Tan Tock Seng Hospital, Singapore. Twenty-one patients who underwent complete surgical excision of their AVMs (proven on postoperative angiograms) were studied. Eight patients had preoperative embolisation with NBCA prior to surgical excision of their AVMs. Thirteen patients had excision of their AVMs without preoperative embolisation and these were used as the control group. The parameters studied were the patient's AVM characteristics, the amount of blood loss and the length of operative time. Statistically significant reduction in blood loss occurred in Spetzler and Martin Grade 3 and 4 AVMs but not in Grade 1 and 2 AVMs undergoing preoperative embolisation with NBCA. Operative time was reduced in Grade 3 and 4 AVMs but not in Grade 1 and 2 AVMs, although this was not statistically significant. Preoperative embolisation of AVMs is hence a useful and important adjunct in the management of patients with Grade 3 and 4 AVMs of the brain undergoing conventional open microneurosurgery.

Long-term results of voice rehabilitation after total laryngectomy using primary tracheoesophageal puncture in Chinese patients

PURPOSE

Prosthetic voice restoration is an increasingly popular method of postlaryngectomy voice rehabilitation. Despite its success in non-tonal languages, the efficacy of tracheoesophageal speech in tonal languages was largely unknown. The aim of the present study was to evaluate the long-term results of voice rehabilitation using a Blom-Singer valve (BSV) in the tonal language of Cantonese.

PATIENTS AND METHODS

The records of 159 patients who underwent total laryngectomy and primary tracheoesophageal puncture (TEP) between May 1985 and December 1994 were retrospectively reviewed. Tracheoesophageal speech was regarded as functional if effective communication could be made during face-to-face conversation and telephone conversation. Any TEP-related complications were noted. Perioperative factors that might contribute to nonfunctional speech were subjected to statistical analysis.

RESULTS

Six hospital mortalities were excluded from speech analysis. Of the remaining 153 patients, the median follow-up was 25 months, ranging from 3 to 113 months. Seventy-three patients had closure of tracheosophageal fistulae (TEF), and the main causes were ineffective voice production, dislodgment, and tracheostomal stenosis. Only 15 of them acquired functional speech before closure. The other 80 patients used a BSV as the chief modality of voice rehabilitation, with functional results achieved in 64 patients. None of the perioperative factors were found to be statistically significant in relation to nonfunctional speech.

CONCLUSION

Primary TEP is an established method of voice rehabilitation after total laryngectomy. In our series, 52% patients achieved functional tracheoesophageal speech using a BSV.

Prospective Randomized Study of Thrice Weekly Six-Month and Nine-Month Chemotherapy for Cervical Tuberculous Lymphadenopathy

The aim of this study is to compare the efficacy of a thrice weekly 6-month regimen, 4S3H3R3Z3/2H3R3 (which consists of an initial 4 months of streptomycin ( S), isoniazid ( H), rifampicin ( R), and pyrazinamide ( Z) followed by 2 months of isoniazid and rifampicin), with a thrice weekly 9-month regimen, 4S3H3R3Z3/5H3R3 (which consists of an initial 4 months of streptomycin, isoniazid, rifampicin, and pyrazinamide followed by 5 months of isoniazid and rifampicin), in the treatment of cervical tuberculous lymphadenopathy. A total of 113 patients were recruited between August 1987 and December 1993. Twenty-two patients were excluded from the analysis because of defaulting treatment or modification of regimen. Ninety-one patients were included in the analysis. Forty-three patients were given the 6-month regimen, and 48 patients were given the 9-month regimen. Two (5%) patients of the 6-month regimen and one (2%) patient of the 9-month regimen had primary failure after completion of treatment (relative risk, 2.23; 95% confidence interval, 0.21 to 23.76). Of the 88 patients who had initial clinical remission after completion of treatment, the 5-year actuarial remission rates were 89% for the 6-month regimen and 90% for the 9-month regimen (Wilcoxon, p = 0.44). There were no significant differences of both primary failure rate and 5-year actuarial remission rate of the two regimens. The 6-month regimen is recommended as the initial treatment of tuberculous lymphadenopathy.

Prospective randomized study of thrice weekly six-month and nine-month chemotherapy for cervical tuberculous lymphadenopathy

The aim of this study is to compare the efficacy of a thrice weekly 6-month regimen, 4S3H3R3Z3/2H3R3 (which consists of an initial 4 months of streptomycin (S), isoniazid (H), rifampicin (R), and pyrazinamide (Z) followed by 2 months of isoniazid and rifampicin), with a thrice weekly 9-month regimen, 4S3H3R3Z3/5H3R3 (which consists of an initial 4 months of streptomycin, isoniazid, rifampicin, and pyrazinamide followed by 5 months of isoniazid and rifampicin), in the treatment of cervical tuberculous lymphadenopathy. A total of 113 patients were recruited between August 1987 and December 1993. Twenty-two patients were excluded from the analysis because of defaulting treatment or modification of regimen. Ninety-one patients were included in the analysis. Forty-three patients were given the 6-month regimen, and 48 patients were given the 9-month regimen. Two (5%) patients of the 6-month regimen and one (2%) patient of the 9-month regimen had primary failure after completion of treatment (relative risk, 2.23; 95% confidence interval, 0.21 to 23.76). Of the 88 patients who had initial clinical remission after completion of treatment, the 5-year actuarial remission rates were 89% for the 6-month regimen and 90% for the 9-month regimen (Wilcoxon, p = 0.44). There were no significant differences of both primary failure rate and 5-year actuarial remission rate of the two regimens. The 6-month regimen is recommended as the initial treatment of tuberculous lymphadenopathy.

Assessment of tracheoesophageal speech in a tonal language. A prospective study

BACKGROUND

Tracheoesophageal puncture followed by insertion of a voice prosthesis is an increasingly popular method for voice rehabilitation after total laryngectomy.

OBJECTIVE

To perform a functional assessment of voice produced by means of the Blom-Singer valve in a tonal language (Cantonese).

DESIGN

Prospective study.

SETTING

Hospital referral center.

MAIN OUTCOME MEASURE

A 5-point scoring scale was adopted for 15 test items of speech assessment grouped into 4 categories: phonatory skills, articulation, additional factors, and general judgment. The sum of the scores for the 15 items was the final speech score. The final speech score was rated as poor, satisfactory, or excellent if it was in the range of less than 30, 31 to 45, or 46 to 75, respectively.

RESULTS

Forty-four users of the Blom-Singer valve who had undergone total laryngectomy and primary tracheoesophageal puncture were available for functional assessment. The final speech score was poor in 2 patients (5%), satisfactory in 4 (9%), and excellent in 38 (86%).

CONCLUSION

Chinese patients can speak satisfactory tonal language with the Blom-Singer voice prosthesis.

Totally automated analysis by robotized PrepStation and liquid chromatography: direct-sample analysis of felbamate

A totally automated analysis of felbamate was developed by using a robotized PrepStation for extraction, followed by automated liquid chromatographic (LC) analysis and data reduction. This is one of the newer direct-sample analysis approaches by LC. Felbamate was a previously approved antiepileptic agent used to treat partial seizures with and without generalization and to treat Lennox-Gastaut syndrome in pediatric patients. However, due to the reported incidences of aplastic anemia, its clinical application was recently restricted to the treatment of the latter syndrome. The automated assay using Bench Supervisor, PrepStation, and LC, based on a previously developed manual method, used 200 microliters of serum standards, quality control, or patients' plasma. These were mixed with 600 microliters of internal standard (IS) W509 dissolved in acetonitrile for protein precipitation. After axial centrifugation and standing, aliquots of the clear supernatant were transferred and washed with hexane. Aliquots of the supernatant were transferred and injected into a high-performance liquid chromatograph (HPLC). HPLC parameters included an mu Bondapak C-18 column, phosphate/acetonitrile (8:2) as mobile phase, and detection at 214 nm. Retention times were 2.9 and 4.2 min for felbamate and IS, respectively. Calibration was linear for concentrations from 10 to 200 mg/L with r > 0.994. Precision studies showed coefficients of variation ranging from 2.7% to 8.8%. Correlation with the manual method showed that r = 0.934, slope = 1.048, intercept = -2.642, and n = 21. Phenobarbital coeluted with the IS. This study demonstrated the feasibility of using a robotized, automated method for monitoring felbamate, readily extended to monitoring other antiepileptic drugs with minimal modification.