An immune-protein score combining TRAIL, IP-10 and CRP for predicting severe COVID-19 disease

COVID-19 patients are oftentimes over- or under-treated due to a deficit in predictive management tools. This study reports derivation of an algorithm that integrates the host levels of TRAIL, IP-10, and CRP into a single numeric score that is an early indicator of severe outcome for COVID-19 patients and can identify patients at-risk to deteriorate. 394 COVID-19 patients were eligible; 29% meeting a severe outcome (intensive care unit admission/non-invasive or invasive ventilation/death). The score's area under the receiver operating characteristic curve (AUC) was 0.86, superior to IL-6 (AUC 0.77; p = 0.033) and CRP (AUC 0.78; p < 0.001). Likelihood of severe outcome increased significantly (p < 0.001) with higher scores. The score differentiated severe patients who further deteriorated from those who improved (p = 0.004) and projected 14-day survival probabilities (p < 0.001). The score accurately predicted COVID-19 patients at-risk for severe outcome, and therefore has potential to facilitate timely care escalation and de-escalation and appropriate resource allocation.

Interferon gamma-induced protein 10 (IP-10) for the early prognosis of the risk for severe respiratory failure and death in COVID-19 pneumonia

OBJECTIVES

Elevated concentrations of soluble urokinase plasminogen activator receptor (suPAR) predict progression to severe respiratory failure (SRF) or death among patients with COVID-19 pneumonia and guide early anakinra treatment. As suPAR testing may not be routinely available in every health-care setting, alternative biomarkers are needed. We investigated the performance of C-reactive protein (CRP), interferon gamma-induced protein-10 (IP-10) and TNF-related apoptosis-inducing ligand (TRAIL) for predicting SRF or death in COVID-19.

METHODS

Two cohorts were studied; one discovery cohort with 534 patients from the SAVE-MORE clinical trial; and one validation cohort with 364 patients from the SAVE trial including also 145 comparators. CRP, IP-10 and TRAIL were measured by the MeMed Key® platform in order to select the biomarker with the best prognostic performance for the early prediction of progression into SRF or death.

RESULTS

IP-10 had the best prognostic performance: baseline concentrations 2000 pg/ml or higher predicted equally well to suPAR (sensitivity 85.0 %; negative predictive value 96.6 %). Odds ratio for poor outcome among anakinra-treated participants of the SAVE-MORE trial was 0.35 compared to placebo when IP-10 was 2,000 pg/ml or more. IP-10 could divide different strata of severity for SRF/death by day 14 in the validation cohort. Anakinra treatment decreased this risk irrespective the IP-10 concentrations.

CONCLUSIONS

IP-10 concentrations of 2,000 pg/ml or higher are a valid alternative to suPAR for the early prediction of progression into SRF or death the first 14 days from hospital admission for COVID-19 and they may guide anakinra treatment.

TRIAL REGISTRATION

CLINICALTRIALS

gov, NCT04680949 and NCT04357366.

32. Host Immune-Protein Signature Combining TRAIL, IP-10 and CRP for Early and Accurate Prediction of Severe COVID-19 Outcome

Background

Accurately identifying COVID-19 patients at-risk to deteriorate remains challenging. Dysregulated immune responses impact disease progression and development of life-threatening complications. Tools integrating host immune-protein expression have proven useful in determining infection etiology and hold potential for prognosticating disease severity.

Methods

Adults with COVID-19 were enrolled at medical centers in Israel, Germany, and the United States (Figure 1). Severe outcome was defined as intensive care unit admission, non-invasive or invasive ventilation, or death. Tumor necrosis factor related apoptosis inducing ligand (TRAIL), interferon gamma inducible protein-10 (IP-10) and C-reactive protein (CRP) were measured using an analyzer providing values within 15 minutes (MeMed Key®). A signature indicating the likelihood of severe outcome was derived generating a score (0-100).

Description of derivation cohort

RT-PCR, reverse transcription polymerase chain reaction.

Results

Between March and November 2020, 518 COVID-19 patients were enrolled, of whom 394 were eligible, 29% meeting a severe outcome. Age ranged between 19-98 (median 61.5), with 59.1% male. Patients meeting severe outcomes exhibited higher levels of CRP and IP-10 and lower levels of TRAIL (Figure 2; p < 0.001). Likelihood of severe outcome increased significantly (p < 0.001) with higher scores. The signature’s area under the receiver operating characteristic curve (AUC) was 0.86 (95% confidence interval: 0.81-0.91). Performance was not confounded by age, sex, or comorbidities and was superior to IL-6 (AUC 0.77; p = 0.033) and CRP (AUC 0.78; p < 0.001). Clinical deterioration proximal to blood draw was associated with higher signature score. Scores of patients meeting a first outcome over 3 days after blood draw were significantly (p < 0.001) higher than scores of non-severe patients (Figure 3). Moreover, the signature differentiated patients who further deteriorated after meeting a severe outcome from those who improved (p = 0.004) and projected 14-day survival probabilities (p < 0.001; Figure 4).

TRAIL, IP-10, CRP and the severity signature score are differentially expressed in severe and non-severe COVID-19 infection

Dots represent patients and boxes denote median and interquartile range (IQR)

The signature score of patients meeting a severe outcome on or after the day of blood draw is significantly (p < 0.001) higher than the signature score of non-severe patients.

Dots represents patients and boxes denote median and IQR

Kaplan-Meier survival estimates for signature score bins

Conclusion

The derived signature combined with a rapid measurement platform has potential to serve as an accurate predictive tool for early detection of COVID-19 patients at risk for severe outcome, facilitating timely care escalation and de-escalation and appropriate resource allocation.

Disclosures

Alon Angel, n/a, MeMed (Employee, Shareholder) Niv Samuel Mastboim, BSc, MeMed (Employee, Shareholder) Oded Shaham, PhD, MeMed (Employee, Shareholder) Tahel Ilan Ber, MD, MeMed (Employee, Shareholder) Roy Navon, MSc, MeMed (Employee, Shareholder) Einav Simon, PhD, MeMed (Employee, Shareholder) Michal Rosenberg, PhD, MeMed (Employee) Yael Israeli, PhD, MeMed (Employee) Mary Hainrichson, PhD, MeMed (Employee, Shareholder) Noa Avni, PhD, MeMed (Employee) Eran Reiner, MD, MeMed (Employee) Kfir Oved, MD, PhD, MeMed (Board Member, Employee, Shareholder) Ilya Kagan, MD, MeMed (Scientific Research Study Investigator) Shaul Lev, M.D, MeMed (Scientific Research Study Investigator) Dror Diker, MD, MeMed (Scientific Research Study Investigator) Amir Jarjou’i, MD, MeMed (Scientific Research Study Investigator) Ramzi Kurd, MD, MeMed (Scientific Research Study Investigator) Guy Danziger, MD, MeMed (Scientific Research Study Investigator) Cihan Papan, MD, MeMed (Scientific Research Study Investigator) Sergey Motov, MD, MeMed (Scientific Research Study Investigator) Maanit Shapira, Ph.D, MeMed (Scientific Research Study Investigator) Tanya Gottlieb, PhD, MeMed (Employee, Shareholder) Eran Eden, PhD, MeMed (Board Member, Employee, Shareholder)

Using heated humidified high-flow nasal cannulas for premature infants may result in an underestimated amount of water reaching the airways

AIM

Condensation often occurs when providing humidified respiratory support. We examined conditions conducive to excess water formation in heated humified high-flow nasal cannula (HHHFNC).

METHODS

An HHHFNC device, at 35 or 37°C, was attached with a nasal cannula to a reservoir and tested in five ambient conditions and flows. For Group A, tubing and collection bottle remained at room temperature (23°C). Group B, tubing and reservoir remained inside an incubator (31°C). Group C, tubing and reservoir remained at 33°C. In Group D, the HHHFNC was set to 35°C, the reservoir remained at 33°C, and the nasal cannula and tubing remained at 23°C. Group E, same as D, with HHHFNC at 37°C.

RESULTS

The largest amounts of collected water were in groups A and E. Both had highest temperature differences. Median (range) was 4.9°C (4.1-6.9) and 4.0°C, collecting 38.4 (26.4-50.4) and 26.4 (19.2-50.4) ml/24 h, respectively. Smallest amounts of water were seen with lower temperature differences as in groups B, C, and D with 2.7 (1.9-4.7), 1.6 (1.2-2.1), and 2.0°C with 8.4 (0.0-33.6), 2.4 (0.0-14.4), and 9.6 (4.8-16.8) ml/24 h, respectively.

CONCLUSION

HHHFNC devices may produce clinically significant amounts of water reaching the upper airways. This may be prevented with appropriate device set-up.

[GETTING READY FOR THE FIRST MINUTE OF LIFE - THE DEVELOPMENT AND ORGANIZATION OF NEONATAL RESUSCITATION IN ISRAEL]

The recognition of the newborn as a separate patient with special unique needs and rights began relatively late compared to other medical disciplines. This process occurred concomitantly with the development of modern neonatology in the country and the establishment of special care nurseries. The process included organization of skilled teams, standardization of treatment methods, introduction of standardized language and practices, and teamwork optimization. The importance of providing support to a newborn in distress after birth - in the first minute, and as needed for the first hour of his life, coined as "The Golden Hour", is highlighted in the training sessions in the program. These principles are conveyed today in multiple simulation-based training courses of multidisciplinary teams taking place in most Israeli hospitals, based on the recommendations of the leading organizations in the field and following the consensus statements outlined by the International Liaison Committee for Resuscitation (ILCOR). This article describes the processes that enabled present achievements, and the goals for further future improvements in the outcomes of newborn resuscitation in Israel.

Paediatric Visits to Community Emergency Departments: Outcomes from Referrals and Unscheduled Return Visits to a Paediatric Centre

BACKGROUND: Approximately 85% of children in Canada who seek emergency care do so in a general emergency department (ED), yet also have access to a dedicated pediatric ED (PED) within reasonable range. Existing pediatric literature describing return visits to the ED for the same medical complaint – an important quality indicator of ED performance – has yet to report on patient flow patterns from general EDs to a PED.

OBJECTIVES: We sought to measure the proportion of children seen at general EDs who subsequently present to a PED for further care. We also sought to elucidate the reasons behind this pattern of revisits, and to describe the clinical management provided at the subsequent visit.

DESIGN/METHODS: A retrospective cohort study was conducted combining linked administrative databases and health records review. We reviewed all pediatric visits (&lt;17 years of age) at 5 general EDs in Vancouver, linking visits between general EDs and the PED based on clincally compatible presentations. Our primary outcome measure was the proportion of general ED visits with a subsequent visit to a PED (within 7 days) during the 2012-13 fiscal year. Secondary outcomes included reasons for PED consultation, the clinical services accessed, and disposition at the PED.

RESULTS: During the study period, 582/17,824 (3.3%) children seen at GEDs subsequently presented to the PED within 7 days. The top 3 diagnoses among these were: fracture, viral infection, and musculoskeletal complaints. Of the 582 children with a visit to the PED, 167 (28.7%) were referred to the PED for a consultation, while the rest were family-initiated. Referred visits were more frequently associated with pediatric subspecialist consultation than family-initiated visits (41.3% versus 21.7%, p&lt;0.01). The referred group more frequently resulted in a surgical procedure (12.0% versus 3.6%, p&lt;0.01) or hospital admission (48.5% versus 11.6%, p&lt;0.01).

CONCLUSION: Knowing the proportion, management, and outcomes of children that are treated in a general ED and subsequently at a PED may provide an important quality measure and opportunities to improve the management of common pediatric emergencies in the community.

Persistent organochlorine compounds in human milk collected in Croatia over two decades

The distribution and time trend of organochlorine pesticide (OCP), polychlorinated biphenyl (PCB), and polychlorinated dibenzo-p-dioxin/polychlorinated dibenzofuran (PCDD/PCDF) concentrations in human milk samples from Croatia collected in 1981-2003 are presented. Between 1981/1982 and 1987/1989, the concentrations of HCB, beta-HCH, DDE, and total PCBs decreased about 50%, while for the last decade, the concentrations have been decreasing very slowly. In 2002/2003 the range of PCB congeners and OCPs was from below the limit of determination to 332 ng g(-1) milk fat. PCDD/PCDF concentrations in human milk samples collected in 1981-2000 ranged between 5.2 and 26.7 pg I-TEQ g(-1) milk fat and showed a decreasing trend.

Esterases in schistosomes: reaction with substrates and inhibitors

Studies were made (at 37 degrees, pH 7.6) on the interaction of some organophosphorus compounds and carboxylic acid esters with cholinesterases (EC 3.1.1.7 and EC 3.1.1.8) and A-esterases (EC 3.1.1.2) in homogenates of Schistosoma mansoni (adults and cercariae) and Schistosoma haematobium (adults). The results are compared with those obtained from the same reactions in other parasitic helminths and in mammalian tissues. Metrifonate (0,0-dimethyl-2,2,2-trichloro-1-hydroxyethyl phosphonate) does not seem to react with cholinesterases from parasites or mammals. Dichlorvos (0,0-dimethyl-2,2-dichlorovinyl phosphate) is a phosphorylating inhibitor; the rate constants of inhibition of cholinesterases from schistosomes are in the order of 10(5) M-1 min.-1. Similar or lower rate constants (10(4) M-1 min.-1) are found for cholinesterase inhibition in other parasitic helminths and mammals. S. mansoni and S. haematobium hydrolyse carboxylic acid esters (10 mM) in decreasing order: phenylacetate (about 2 mumol per hour per mg protein), acetylthiocholine, propionylthiocholine, butyrylthiocholine. Dichlorvos (10 mM) is hydrolysed by S. mansoni and S. haematobium at about the same rate as by mammalian erythrocytes and human sera (about 10 mumol per hour per gram wet weight). Neither paraoxon (0,0-diethyl-4-nitrophenyl phosphate) nor methyl-paraoxon are hydrolysed by S. mansoni and S. haematobium, although both compounds are good substrates for mammalian A-esterases. The stability of metrifonate and dichlorvos in buffer solutions was also determined (at 37 degrees). Metrifonate is about equally stable in bicarbonate buffer (pH 7.6) and phosphate buffer (pH 7.4) (t 1/2 = 1.5 and 2.6 hrs, respectively), while dichlorvos is considerably more stable in bicarbonate (t 1/2 = (36 hrs) than in phosphate buffer (t 1/2 = 2.9 hrs).

Organophosphorus compounds and esterases: current research topics concerning the toxicity of and protection against organophosphates

This brief review describes the reactions of organophosphorus compounds with cholinesterases, neuropathy target esterase, and phosphoric triester hydrolases with respect to their toxicity. It also describes antidotes, protectors, and decontaminating agents against organophosphates.

Activated clotting time as a screening test prior to catheter-based cardiovascular procedures

The activated clotting time (ACT) was investigated as a rapid, inexpensive, point-of-service screening test for coagulation abnormalities prior to catheter-based procedures. A total of 963 patients were screened by obtaining a history, standard coagulation profile, and activated coagulation time. The prevalence of normal patients (normal ACT and coagulation profile) was 94% (sensitivity = 91%; specificity = 27%). A normal ACT had a positive predictive value of 95%. The ACT was an acceptable screening test due to its ability to predict positively a low rate of bleeding complication and normal coagulation studies. Patients with ACT > 150 sec should be further evaluated with a screening coagulation panel. Additionally, given its low specificity, coagulation studies should be obtained in high-risk patients since an abnormal ACT does not effectively correlate with abnormal coagulation studies.

Organochlorine compounds in human milk and food of animal origin in samples from Croatia

Human milk and food of animal origin (milk, meat, and fish) have been analysed over several decades for the DDT-complex, PCBs, HCB, and HCH-isomers. Human milk has also been analysed for PCDDs and PCDFs. Human milk samples were collected in six inland sites and one island, and food samples in marketplaces and individual households throughout Croatia. All human milk samples contained DDE and PCBs, and almost all food samples contained the DDT-complex. All analysed pools of human milk contained PCDDs and PCDFs. Levels of most analysed compounds show a decreasing trend over the past decade. The obtained data were the basis for the calculation of the daily intake of organochlorine compounds in breast-fed infants and adults.

Serum paraoxonase activities in hemodialyzed uremic patients: cohort study

AIM

To determine whether paraoxonase activity, paraoxonase phenotypes, and lipid status are altered in uremic patients on long-term hemodialysis treatment as compared to healthy population.

METHODS

Patients (n = 69) and control subjects (n = 145) were from the area of Slavonski Brod, Croatia. Paraoxon was used as a substrate for measuring basal or sodium chloride-stimulated (NaCl-stimulated) paraoxonase activity, and phenylacetate for measuring arylesterase activity. The double substrate method was used to assign phenotypes. Cholesterol, triglycerides, and high-density lipoprotein cholesterol (HDL-cholesterol) were determined by methods routinely used in medical-biochemical laboratories. Enzyme activities are expressed as international units per liter of serum or per mmol of HDL-cholesterol (HDL-standardized activities).

RESULTS

Basal and NaCl-stimulated paraoxonase activity, as well as arylesterase activity expressed per serum volume, were significantly lower in the hemodialyzed uremic patients compared to the controls; 69% (p < 0.001), 73% (p < 0.001) and 49%, (p < 0.001), respectively. However, basal and NaCl-stimulated paraoxonase activity standardized for HDL-cholesterol concentrations were not significantly reduced in the hemodialyzed uremic patients as compared to controls (86%, p = 0.614 and 87%, p = 0.720, respectively), contrary to arylesterase activity, which remained significantly lower (72%, p < 0.001). The distribution of paraoxonase phenotypes in hemodialyzed uremic patients and controls was as follows: AA 45% and 39%, AB 37% and 48%, BB 18%, and 13%, respectively.

CONCLUSION

Patients on long-term hemodialysis have decreased paraoxonase/arylesterase activity, which might indicate a greater risk of premature atherogenesis.

Cholinesterase: substrate inhibition and substrate activation

The relationship between activities and substrate concentrations (pS-curves) was analysed for reactions of acetylcholinesterase (EC 3.1.1.7) and butyrylcholinesterase (EC 3.1.1.8). Catalytic constants Km, Kss, Vm, n and b were calculated from the Michaelis, Haldane, Hill and Webb equations in order to assess whether a given substrate also acts as an inhibitor or activator. It is suggested that the term substrate inhibition should only be attributed to substrates revealing bell-shaped pS-curves, while the terms apparent substrate inhibition or apparent substrate activation should relate to calculated values of the catalytic constants.

Comparison of protocols for measuring activities of human blood cholinesterases by the Ellman method

This paper presents a protocol for routine assays of human blood cholinesterase activities which separates erythrocytes from plasma by centrifugation and measures acetylcholinesterase activity in unwashed erythrocytes and butyrylcholinesterase activity in the plasma. The recommended substrate for both enzymes is 1.0 mM acetylthiocholine. The protocol is compared with other two recommended protocols for the activity measurements of the two enzymes using the Ellman method. The paper discusses the advantages and disadvantages of each and concludes with a proposal for an international agreement between laboratories for the evaluation of a standardized protocol.

Amino acid residues involved in the interaction of acetylcholinesterase and butyrylcholinesterase with the carbamates Ro 02-0683 and bambuterol, and with terbutaline

In order to identify amino acids involved in the interaction of acetylcholinesterase (AChE; EC 3.1.1.7) and butyrylcholinesterase (BChE; EC 3.1.1.8) with carbamates, the time course of inhibition of the recombinant mouse enzymes BChE wild-type (w.t.), AChE w.t. and of 11 site-directed AChE mutants by Ro 02-0683 and bambuterol was studied. In addition, the reversible inhibition of cholinesterases by terbutaline, the leaving group of bambuterol, was studied. The bimolecular rate constant of AChE w.t. inhibition was 6.8 times smaller by Ro 02-0683 and 16000 times smaller by bambuterol than that of BChE w.t. The two carbamates were equipotent BChE inhibitors. Replacement of tyrosine-337 in AChE with alanine (resembling the choline binding site of BChE) resulted in 630 times faster inhibition by bambuterol. The same replacement decreased the inhibition by Ro 02-0683 ten times. The difference in size of the choline binding site in the two w.t. enzymes appeared critical for the selectivity of bambuterol and terbutaline binding. Removal of the charge with the mutation D74N caused a reduction in the reaction rate constants for Ro 02-0683 and bambuterol. Substitution of tyrosine-124 with glutamine in the AChE peripheral site significantly increased the inhibition rate for both carbamates. Substitution of phenylalanine-297 with alanine in the AChE acyl pocket decreased the inhibition rate by Ro 02-0683. Computational docking of carbamates provided plausible orientations of the inhibitors inside the active site gorge of mouse AChE and human BChE, thus substantiating involvement of amino acid residues in the enzyme active sites critical for the carbamate binding as derived from kinetic studies.

3-Hydroxyquinuclidinium derivatives: synthesis of compounds and inhibition of acetylcholinesterase

Four compounds were prepared: 3-hydroxy-1-methylquinuclidinium iodide (I), 3-(N,N-dimethylcarbamoyloxy)-1-methylquinuclidinum iodide (II), and two conjugates of I and II with 2-hydroxyiminomethyl-3-methylimidazole in which two parts of the molecule were linked by -CH2-O-CH2- (III and IV). III and IV are new compounds and their synthesis and physical data were given. All compounds were tested as inhibitors of human erythrocyte acetylcholinesterase (EC 3.1.1.7, AChE). The enzyme activity was measured in 0.1 M phosphate buffer (pH 7.4) at 10 and 37 degrees C with acetylthiocholine (ATCh) as the substrate. The obtained enzyme/inhibitor dissociation constants were between 0.05 and 0.5 mM at 10 degrees C and between 0.2 and 0.6 mM at 37 degrees C. At both temperatures compounds III and IV had higher affinities for the enzyme than compounds I and II and this difference was more pronounced at 10 than at 37 degrees C. The carbamates II and IV were also progressive AChE inhibitors. For compound II the rate constants of inhibition were 6300 and 2020 M(-1) min(-1) at 37 and 10 degrees C, respectively. Compound IV was a very weak carbamoylating agent with rate constants of inhibition of 100 and 63 M(-1) min(-1) at 37 and 10 degrees C, respectively. The oxime group in compounds III and IV hydrolyzed ATCh at rates of 23 and 3.2 M(-1) min(-1) at 37 and 10 degrees C, respectively.

Reversible inhibition of acetylcholinesterase and butyrylcholinesterase by 4,4'-bipyridine and by a coumarin derivative

Inhibition of recombinant mouse wild type AChE (EC 3.1.1.7) and BChE (EC 3.1.1.8), and AChE peripheral site-directed mutants and human serum BChE variants by 4,4'-bipyridine (4,4'-BP) and the coumarin derivative 3-chloro-7-hydroxy-4-methylcoumarin (CHMC) was studied. The enzyme activity was measured with acetylthiocholine as substrate. Enzyme-inhibitor dissociation constants for the catalytic and peripheral sites were evaluated from the apparent dissociation constants as a function of the substrate concentration. Inhibition by 4,4'-BP of AChE, BChE and the AChE mutant Y72N/Y124Q/W286A, was consistent with inhibitor binding to both catalytic and peripheral sites. The dissociation constants for the peripheral site were about 3.5-times higher than for the catalytic site. The competition between CHMC and substrate displayed two binding sites on the AChE mutants Y72N, Y124Q, W286A and W286R, and on the atypical and fluoride-resistant BChE variants. The dissociation constants for the peripheral site were on average two-times higher than for the catalytic site. CHMC displayed binding only to the catalytic site of Y72N/Y124Q/W286A mutant and only to the peripheral site of w.t. AChE and the human usual BChE. Modelling of the 4,4'-BP and CHMC binding to wild type mouse AChE substantiated the difference between the inhibitors in their mode of binding which was revealed in the kinetic studies.

Paraoxonase and arylesterase activities in the serum of two hyperlipoproteinaemic patients after repeated extracorporal lipid precipitation

The effect of heparin-induced extracorporal lipid precipitation (HELP) on the activities of paraoxonase (EC 3.1.8.1) and arylesterase (EC 3.1.1.2) was studied in serum of a patient with hyperlipoproteinaemia (A) and of a patient with non-insulin dependent diabetes mellitus and hyperlipoproteinaemia (B). The enzyme activities were measured spectrophotometrically (Tris-HCl buffer, pH 7.4, 37 degrees C) with paraoxon and phenylacetate as substrates of paraoxonase and arylesterase, respectively. Both patients underwent HELP applications once a week over a period of 7 weeks. Over that period no overall change was observed either in enzyme activities or in the lipid and protein content of the sera. However, each HELP session caused an immediate decrease of EDTA-insensitive arylesterase activity (on average 56% in A and 42% in B), while EDTA-sensitive arylesterase remained almost unaltered. Paraoxonase remained unchanged in A, but decreased in B (approximately 60%). Of the atherogenic lipoprotein parameters, the most pronounced decrease was found in VLDL-cholesterol and in triglycerides (on average 45% in A and 32% in B), while the anti-atherogenic HDL-cholesterol decreased < 10%. Possible implications of the effect of HELP on the enzyme activities studied remain to be explained.

Catalytic parameters for the hydrolysis of butyrylthiocholine by human serum butyrylcholinesterase variants

Catalysed hydrolysis of butyrylthiocholine (BTCh) by the usual (UU), fluoride-resistant (FS), AK, AJ and atypical (AA) human serum butyrylcholinesterase (EC 3.1.1.8) variants was measured in phosphate buffer pH 7.4 at 25 degrees C. pS-curves for all phenotypes were S-shaped; the activities rose to a plateau with increasing substrate concentration except at 100 mM where there was a small decrease. To obtain the catalytic constants, three equations were applied: Michaelis-Menten equation (Eq. 1), Hill equation (Eq. 2) and an equation which assumes simultaneous binding of the substrate to the catalytic site and to a peripheral site on the enzyme (Eq. 3). Over a range from 0.01 to 50 mM BTCh, the activity versus substrate concentration relationship deviated from Michaelis-Menten kinetics (Eq. 1) while data fitted well with Eqs. 2 and 3. The Michaelis-Menten equation was applied separately to two BTCh concentration ranges: the corresponding Km constants for the UU, FS, AK, AJ and AA phenotypes ranged from 0.1 to 0.2 mM (at 0.01-1.0 mM BTCh) and from 0.3 to 2.0 mM (at 1.0-50 mM BTCh). Hill coefficients (nH) calculated from Eq. 2 were similar for all phenotypes (nH approximately 0.5). The dissociation constants K1 and K2 calculated from Eq. 3 for two sites on the enzyme fell between 0.02 and 0.12 mM (K1) and 0.89 and 4.9 mM (K2) for the five phenotypes. Experimental data support the assumption that the phenotypes studied have two substrate binding sites.

Organochlorine pesticides and PCBs in human milk collected from mothers nursing hospitalized children

Organochlorine compounds in milk were analyzed in samples collected over a nine-year period (1987-1995) from nursing mothers (N = 139) whose children were hospitalized for various disorders. All samples contained p,p'-DDE and PCBs; the median concentrations were 318 micrograms/kg milk fat and 220 micrograms/kg milk fat resp. Higher levels were found in mothers (N = 12) nursing neonates with impaired neurodevelopmental competencies or an inappropriate arousal reaction. No difference was observed between mothers nursing children with respiratory or gastrointestinal diseases, urinary tract infections or other infectious diseases, anemias, prolonged neonatal hyperbilirubinaemias or when children were with dermatological findings, congenital malformations or healthy.

Quinuclidinium-imidazolium compounds: synthesis, mode of interaction with acetylcholinesterase and effect upon Soman intoxicated mice

Four compounds were prepared: 3-oxo-1-methylquinuclidinium iodide (I), 2-hydroxyiminomethyl-1,3-dimethylimidazolium iodide (II) and two conjugates of I and II linked by -(CH2)3- (III) and -CH2-O-CH2- (IV). The aim was to evaluate separately the properties of I and II as opposed to III and IV, which contain both moieties in the same molecule. All four compounds were reversible inhibitors of acetylcholinesterase (AChE; EC 3.1.1.7). The enzyme/inhibitor dissociation constants for the catalytic site ranged from 0.073 mM (II) to 1.6 mM (I). The dissociation constant of I for the allosteric (substrate inhibition) site was 4.8 mM. Possible binding of the other compounds to the allosteric site could not be measured because II, III and IV reacted with the substrate acetylthiocholine (ATCh) and at high ATCh concentrations the non-enzymic reaction interfered with the enzymic hydrolysis of ATCh. The rate constants for the non-enzymic ATCh hydrolysis were between 23 and 37 l/mol per min. All four compounds protected AChE against phosphorylation by Soman and VX. The protective index (PI) of I (calculated from binding of I to both, catalytic and allosteric sites in AChE) agreed with the measured PI; this confirms that allosteric binding contributes to the decrease of phosphorylation rates. The PI values obtained with III and IV were higher than those predicted by the assumption of their binding to the AChE catalytic site only. The toxicity (i.p. LD50) of compounds I, II, III and IV for mice was 0.21, 0.68, 0.49 and 0.77 mmol/kg body wt. respectively. All four compounds protected mice against Soman when given (i.p.) together with atropine 1 min after Soman (s.c.). One-quarter of the LD50 dose fully protected mice (survival of all animals) against 2.52 (IV), 2.00 (I and III) and 1.58 (II) LD50 doses of Soman.

Identification of the contents and the shelf-life of indicator tubes from field kits for detection of organophosphorus compounds in the air

Indicator tubes from field kits for detection of organophosphorus compounds in the air were found on the territory of Croatia, in barracks liberated during the war years of 1991/1992, and were analysed during 1993/95. The detection kit consisted of glass indicator tubes with two sealed vials within each tube, a device for opening the tubes and breaking the vials, and an air sampling pump. The tubes were marked with serial numbers and expiry dates (1974-1992), but the description as to their contents was unavailable. The aim of this study was to identify the contents of the indicator tubes and to establish whether they were still suitable for detection of organophosphorus compounds. One vial was found to contain a cholinesterase (EC 3.1.1.7) preparation, while the other vial contained a non-thiocholine substrate and a pH-sensitive indicator (most probably cresol red). Applying DDVP as an organophosphorus cholinesterase inhibitor, it was found that all sets of indicator tubes were suitable for use regardless of the indicated expiry dates. Furthermore, the same tubes were found suitable for detection of organophosphorus compounds in water.

Catalytic properties and distribution profiles of paraoxonase and cholinesterase phenotypes in human sera

Paraoxonase activities (322 healthy subjects) measured in the absence of ethylenediaminetetraacetic acid (EDTA) had a polymodal distribution profile with 60% of the subjects in the low activity mode; the activity measured in the presence of EDTA had a unimodal skewed distribution. Cholinesterase (ChE) activities (365 healthy subjects) had a unimodal, slightly skewed distribution. Patients with dementia (74) and patients with hyperlipidaemia (159) had different median paraoxonase and ChE activities than healthy subjects and all activity profiles had a higher skewness. The ChE variants usual (UU), fluoride resistant (FS) and atypical (AA) had the same affinity for the studied charged and uncharged ligands. The variants differed in rates of inhibition by the charged organophosphates and carbamates.

Catalytic properties of rabbit serum esterases hydrolyzing esterified monosaccharides

Rabbit serum and one enzyme fraction isolated from rabbit serum by column chromatography (Fraction II) were used as catalysts in regioselective hydrolysis of radiolabelled pivaloylated monosaccharides (Piv = Me3CCO). The hydrolysis of 14C-labelled methyl 2-O-pivaloyl-(2-MP)-, 6-O-pivaloyl (6-MP)-, 2,6-di-O-pivaloyl-(2,6-DP) alpha-D- glucopyranosides and methyl 2-acetamido-2-deoxy-3,6- di-O-pivaloyl-(3,6-DPNAc) alpha-D-glucopyranosides, was studied, as well as that of the non-sugar substrates butyrylthiocholine, thiophenylbutyrate, phenylacetate and paraoxon. The specific activities of 2,6-DP, 3,6-DPNAc, butyrylthiocholine and thiophenylbutyrate were higher in Fraction II than in native sera, while those of phenylacetate and paraoxon were lower. Inhibition studies were done using the substrates mentioned and five different inhibitors, namely bis(p-nitrophenyl phosphate) (BNPP), eserine, paraoxon, HgCl2 and EDTA. The hydrolysis of 2,6-DP and 3,6-DPNAc was not inhibited by HgCl2 and only slightly by EDTA. Paraoxon, eserine and BNPP were progressive inhibitors of the hydrolysis of the two sugar substrates, and the pattern of inhibition resembled closely the inhibition of butyrylthiocholine and thiophenylbutyrate hydrolysis. This result applied to both, native serum and Fraction II. It was concluded that esterases in rabbit serum which hydrolyze pivaloylated sugar substrates belong to the category of serine esterases. Kinetic parameters (KM and Vmax), effects of temperature and pH on activity of esterases from Fraction II were also determined for the hydrolysis of sugar substrates.

Differentiation of esterases reacting with organophosphorus compounds

The hydrolysis of paraoxon (POX), phenylacetate (PA) and beta-naphthylacetate (BNA) was studied in human serum. Based upon correlations between enzyme activities, upon reversible inhibition by EDTA and upon progressive inhibition by iso-OMPA, tabun, eserine and bis-4 nitrophenylphosphate, the following conclusions were drawn about the number and specificity of enzymes involved in the hydrolysis. Two paraxonases hydrolyse paraoxon: one sensitive and the other insensitive to EDTA. The EDTA-sensitive paraoxonase also hydrolysed BNA. The EDTA-insensitive hydrolysis of BNA and PA was attributed to a serine esterase. The EDTA-sensitive hydrolysis of PA is probably due to more than one enzyme, which might be an arylesterase and a carboxylesterase.

Hydrolysis of some organophosphorus dichlorophenyl esters by hen brain homogenates and rabbit serum compared with hydrolysis of paraoxon

The hydrolysis of four organophosphorus dichlorophenyl esters and of paraoxon was studied in hen brain homogenates and in rabbit serum. All compounds were hydrolysed by both preparations, but the rates were different in the two preparations. EDTA inhibited the hydrolysis almost completely in rabbit serum, but had only a small effect on the hydrolysis in hen brain homogenates.

Serum paraoxonase and cholinesterase activities in individuals with lipid and glucose metabolism disorders

In patients with hyperlipaemia, serum paraoxonase activities were polymodally distributed with 75% individuals in the low activity mode. In the same patients the distribution of serum cholinesterase activities was unimodal, but asymmetrical. Patients with impaired glucose tolerance or non-insulin-dependent diabetes mellitus had slightly higher cholinesterase activities than patients with hyperlipaemia only.

A field-test for detecting organophosphorus compounds in water

An enzyme test has been worked out for detecting organophosphorus compounds in water. The test is based on the inhibition of cholinesterase. The detection limits for the "nerve gases" are (microgram/L): Soman 0.12, VX 5.9, Sarin 9.9 and Tabun 26. The detection limit for the organophosphorus pesticide dichlorvos is 50 micrograms/L.

Interaction of imidazolium and pyridinium dioximes with human erythrocyte acetylcholinesterase

Two pyridinium and two imidazolium dioximes were tested as reversible inhibitors of human erythrocyte acetylcholinesterase (AChE), as protectors of the enzyme against phosphorylation and as reactivators of the phosphorylated AChE. All four dioximes reversibly inhibited AChE, protected the enzyme against phosphorylation by soman and tabun and reactivated AChE after phosphorylation by sarin, VX and tabun. From the experimental results the enzyme/dioxime dissociation constants were evaluated for the catalytically active enzyme and for phosphorylated enzyme. The evaluation constants have shown that all four dioximes have about the same affinity for the catalytically active as for the phosphylated AChE. Obtained results also indicate that imidazolium dioximes probably bind only to the allosteric, while pyridinium dioximes bind to both, the catalytic and the allosteric site of the enzyme.

Role of the peripheral anionic site on acetylcholinesterase: inhibition by substrates and coumarin derivatives

Propidium has been demonstrated in previous studies to be a selective ligand for the peripheral anionic site on acetylcholinesterase (EC 3.1.1.7). Its association with this site can be advantageously monitored by direct fluorescent titration. We have measured the ability of acetylcholine, acetylthiocholine, haloxon [di-(2-chloroethyl)3-chloro-4-methylcoumarin-7-ylphosphate] , and a coumarin derivative (3-chloro-7-hydroxy-4-methylcoumarin) to dissociate propidium from the peripheral anionic site of Torpedo californica acetylcholinesterase. Measurements were made by back-titration of propidium after complete inhibition of the active center with diisopropylfluorophosphate. Both acetylcholine and acetylthiocholine show substrate inhibition at high substrate concentrations. The concentrations required for occupation of the peripheral site, as ascertained by competition with propidium, correlated well with the concentration dependence for the kinetics of substrate inhibition. These observations are consistent with substrate inhibition being due to binding of acetylcholine or acetylthiocholine at a peripheral anionic site. Displacement of propidium by haloxon and coumarin indicated that these inhibitors also bind to the peripheral anionic site. The dissociation constants ascertained from peripheral site occupation are in agreement with the constants obtained from inhibition kinetics. Evidence is presented that competition with propidium obtained by direct fluorescence titrations, when combined with inhibition kinetics, provides a more reliable means for ascertaining site selectivity of various inhibitors than does a kinetic analysis alone.

Inhibition of serum cholinesterase by trialkylphosphorothiolates

The kinetics of inhibition of horse serum cholinesterase (EC 3.1.1.8) by six trialkylphosphorothiolates was studies (25 degrees C, pH 7.4). The compounds were : OOS-trimethylphosphorothiolate (OOS-Me), OSS-trimethylphosphorodithiolate (OSS-Me), SSS-trimethylphosphorotrithiolate (SSS-Me) and their corresponding ethyl analogues (OOS-Et, OSS-Et, SSS-Et). The second order rate constants of inhibition ranged from 7.2 to 2128 mol-1 1 min-1, of inhibition ranged from 7.2 to 2128 mol-1 1 min-1, and the enzyme/inhibitor dissociation constants from 0.079 to 1.5 mM. The ethyl esters were better inhibitors than their methyl analogues and the OSS-compounds were better inhibitors than the OOS- or SSS-compounds. The same structure-activity relationship is known to hold for the reaction of the compounds with acetylcholinesterase (EC 3.1.1.7).

Residues of polychlorinated-dibenzodioxins, -dibenzofurans and -biphenyls in human milk samples collected in a continental town in Croatia, Yugoslavia

The levels of several polychlorinated-dibenzodioxins (PCDDs), polychlorinated-dibenzofurans (PCDFs) and total polychlorinated-biphenyls (PCBs) were determined in pooled human milk samples. The samples were collected in a continental town of Croatia, Yugoslavia, during the years 1981/82 and 1985. The concentrations of seven PCDDs and nine PCDFs were within the range less than 0.2-116 ng/kg milk fat; the total PCBs were 0.47 and 0.32 mg/kg milk fat. The levels determined were about the same as those reported for the general population in other countries.

Kinetics of heat inactivation of phenyl valerate hydrolases from hen and rat brain

Heat inactivation was studied at 45, 50, 55, and 60 degrees for all of the phenyl valerate hydrolases (PVase), including neurotoxic esterase (NTE) and inhibitor-resistant esterase (IRE), in homogenates of hen or rat brain or in preparations of hen brain microsomal membranes. Hen and rat brain homogenates were prepared in buffer (50 mM Tris/0.20 mM EDTA, pH 8.00, at 25 degrees). Hen brain microsomes were suspended either in buffer or in aqueous dimethyl sulfoxide (DMSO, 40%, w/v), or solubilized either in aqueous Triton X-100 (0.10%, w/v) or in 40% (w/v) DMSO. Enzyme activities were measured at 37 degrees using phenyl valerate as substrate. Each enzyme activity in all of the preparations exhibited biphasic heat inactivation kinetics. Apparent rate constants were calculated for the fast (kf) and slow (ks) reactions, along with the relative amounts of activity in each component (Af, As) expressed as percentages of the total activity. For a given preparation and temperature, respective values of kf or ks were similar for PVase, NTE, and IRE, with a mean kf/ks ratio of 52 across all preparations. Af and As were a function of temperature. Mean values of the apparent activation energies (Ea) for all activities and preparations were 44 and 25 kcal/mol for the fast and slow inactivation reactions respectively. These results indicate that all phenyl valerate hydrolases in hen and rat brain undergo a common heat-induced structural change leading to loss of enzymic activity.

Levels of beta-HCH, HCB, p,p'-DDE, p,p'-DDT and PCBs in human milk from a continental town in Croatia, Yugoslavia

Concentrations of beta-HCH, HCB, p,p'-DDE, p,p'-DDT and PCBs were determined by gas chromatography in 50 human milk samples collected from the general population during 1981/1982 in a continental town in Croatia (Yugoslavia). The samples were collected between one and 22 weeks after delivery from mothers breast-feeding one child only. The mothers' age was 18 to 31 years, and they were nursing their first or second child. All 50 samples contained beta-HCH, HCB, p,p'-DDE and PCBs, whereas p,p'-DDT was present in 37 samples. The concentrations of beta-HCH, HCB, p,p'-DDE, p,p'-DDT and PCBs expressed on a whole milk basis were (median in microgram/kg): 11, 7.1, 67, 7.3 and 22 respectively, and expressed on a fat basis (median in mg/kg): 0.28, 0.21, 1.9, 0.18 and 0.62 respectively. The fat content was 3.7% (median). PCBs were present in a mixture containing penta-, hexa- and heptachlorobiphenyls.

An enzyme test for determining isomalathion impurities in water-dispersible powders of malathion

An enzyme test for determining isomalathion (O,S-dimethyl-S-(1,2-dicarbethoxyethyl) phosphorodithioate) impurities in water-dispersible powders of malathion (WDP malathion) is described. The test is based on inhibition of acetylcholinesterase (EC 3.1.1.7) by isomalathion extracted from WDP malathion. The lower limit of detection of the test is 0.01% (w/w) isomalathion. For 18 samples of WDP malathion there was good correlation between the levels of isomalathion found using the enzyme test and those obtained by thin-layer chromatography.

Binding sites on acetylcholinesterase for reversible ligands and phosphorylating agents. A theoretical model tested on haloxon and phosphostigmine

The reaction of acetylcholinesterase (EC 3.1.1.7; human erythrocytes) with phosphostigmine, haloxon and VX was studied, and the effect of three reversible ligands (TMA, edrophonium, coumarin) and of acetylthiocholine upon the time-dependent and time-independent (reversible) inhibition by the organophosphates was evaluated. The three ligands and acetylthiocholine decreased the second-order rate constant of phosphorylation by a factor proportional to the enzyme-ligand dissociation constant, or to both Km and Kss (Michaelis constant and the substrate-inhibition constant for acetylthiocholine) irrespective of the organophosphate. However, the time-independent inhibitions by phosphostigmine and haloxon were differently affected. Acetylthiocholine affected the time-independent inhibition by phosphostigmine by a factor proportional to Km, and that by haloxon by a factor proportional to Kss. Coumarin had no effect on the time-independent inhibition by phosphostigmine, while TMA and edrophonium displaced phosphostigmine from its complex. Coumarin displaced haloxon from its complex with the enzyme, while TMA and edrophonium had no effect. We conclude that phosphostigmine and haloxon bind reversibly to different sites on the enzyme and the experiments agree with a theoretical model that haloxon binds reversibly to a peripheral site on acetylcholinesterase, and phosphostigmine to the catalytic site.

The identification and characterization of two separate carboxylesterases in guinea-pig serum

The esterase activity of guinea-pig serum was investigated. A 3-fold purification was achieved by removing the serum albumin by Blue Sepharose CL-6B affinity chromatography. The partially purified enzyme preparation had carboxylesterase and cholinesterase activities of 1.0 and 0.22 mumol of substrate/min per mg of protein respectively. The esterases were labelled with [3H]di-isopropyl phosphorofluoridate (DiPF) and separated electrophoretically on sodium dodecyl sulphate/polyacrylamide gels. Two main labelled bands were detected: band I had Mr 80 000 and bound 18-19 pmol of [3H]DiPF/mg of protein, and band II had Mr 58 000 and bound 7 pmol of [3H]DiPF/mg of protein. Bis-p-nitrophenyl phosphate (a selective inhibitor of carboxylesterase) inhibited most of the labelling of bands I and II. The residual labelling (8%) of band I but not band II (4%) was removed by preincubation of partially purified enzyme preparation with neostigmine (a selective inhibitor of cholinesterase). Paraoxon totally prevented the [3H]DiPF labelling of the partially purified enzyme preparation. Isoelectrofocusing of [3H]DiPF-labelled and uninhibited partially purified enzyme preparation revealed that there were at least two separate carboxylesterases, which had pI3.9 and pI6.2, a cholinesterase enzyme (pI4.3) and an unidentified protein that reacts with [3H]DiPF and has a pI5.0. Sodium dodecyl sulphate/polyacrylamide-gel electrophoresis of these enzymes showed that the carboxylesterase enzymes at pI3.9 and pI6.2 corresponded to the 80 000-Mr subunit (band I) and 58 000-Mr subunit (band II). The cholinesterase enzyme was also composed of 80 000-Mr subunits (i.e. the residual labelling in band I after bis-p-nitrophenyl phosphate treatment). The unidentified protein at pI5.0 corresponded to the residual labelling in band II (Mr 58 000), which was insensitive to neostigmine and bis-p-nitrophenyl phosphate. These studies show that the carboxylesterase activity of guinea-pig serum is the result of at least two separate and distinct enzymes.

[Orthotic device with partial decompression of the lower leg - technic and indication]

The orthopedic-technical way of production of a foot-and lower leg-orthosis with partial decompression is demonstrated. The possibilities of clinical application are analysed by classical indications and results of control examinations. We found an important increase of gait-performance, active and passive motion and circulation. It seems to be very important that 8 of 20 patients were able to work soon after application of the orthosis and could even do hard work.

Rehabilitation of micturition by transurethral electrostimulation of the bladder in patients with incomplete spinal cord lesions

The effect of direct transurethral electrostimulation of the saline-filled bladder in 29 patients with bladder dysfunction after incomplete spinal cord injury is described. Following investigation by cystourethrography and cystomanometry, treatment was started from 14 days to 8 months after injury (average 3 months after injury). The method was considered to be very helpful in the rehabilitation of micturition. Twenty-six out of 29 patients gained normal bladder sensation, 25 achieved satisfactory detrusor contractions and 29 had low residual urines. Seventeen patients developed perfect bladder control and ten more were socially dry without the need for appliances.

Dimethylphosphorothioates. Reaction with malathion and effect on malathion toxicity

Five dimethylphosphorothioates were tested for their toxicity to rats, potentiation of malathion toxicity in rats, inhibition of carboxylesterase in vitro, and reaction with malathion in vitro. The compounds were: potassium salts of (CH3S)2P(O)O-(I), (CH3O)(CH3S)P(O)S-(II), (CH3O)2P(O)S-(III), (CH3O)2P(S)S-(IV), and (CH3O)(CH3S)P(O)O-(V). The dimethylphosphorothioates are not toxic to rats (up to 1 g/kg, orally), they do not potentiate malathion toxicity in rats, and do not inhibit carboxylesterase activity in vitro (up to 1 mM concentrations). However, when the S-acid diesters (II, III, IV) are incubated with malathion for serveral days at room temperature or for several hours at 50 degrees C they become methylated forming the trimethylphosphorothioates OSS-trimethyl phosphorodithioate, OOS-trimethyl phosphorothioate and OOS-trimethyl phosphorodithioate respectively, which potentiate malathion toxicity. Furthermore, these same acid diesters increase the rate of isomerization of malathion into OS-dimethyl-S-(1,2-dicarbethoxyethyl) phosphorodithioate (isomalathion) particularly, diester IV. The formation of the trimethylphosphorothioates and isomalathion from the interaction of the S-acid diesters with malathion was determined by thin layer chromatography (TLC), gas chromatography and mass spectrometry and could be detected by in vitro inhibition of carboxylesterase. TLC methods can detect 1 mg of the trimethylphosphorothioates and isomalathion per gram malathion.