Treatment with PB125® Increases Femoral Long Bone Strength in 15-Month-Old Female Hartley Guinea Pigs

Nuclear factor-erythroid 2-related factor-2 (Nrf2) is a transcription factor that serves as a master regulator of anti-inflammatory agents, phase I xenobiotic, and phase II antioxidant enzymes, all of which provide a cytoprotective role during disease progression. We hypothesized that oral administration of a purported phytochemical Nrf2-activator, PB125®, would increase long bone strength in aging Hartley guinea pigs, a model prone to musculoskeletal decline. Male (N = 56) and female (N = 56) guinea pigs were randomly assigned to receive daily oral treatment with either PB125® or vehicle control. Animals were treated for a consecutive 3-months (starting at 2-months of age) or 10-months (starting at 5-months of age) and sacrificed at 5-months or 15-months of age, respectively. Outcome measures included: (1) ANY-maze™ enclosure monitoring, (2) quantitative microcomputed tomography, and (3) biomechanical testing. Treatment with PB125® for 10 months resulted in increased long bone strength as determined by ultimate bending stress in female Hartley guinea pigs. In control groups, increasing age resulted in significant effects on geometric and structural properties of long bones, as well as a trending increase in ultimate bending stress. Furthermore, both age and sex had a significant effect on the geometric properties of both cortical and trabecular bone. Collectively, this work suggests that this nutraceutical may serve as a promising target and preventive measure in managing the decline in bone mass and quality documented in aging patients. Auxiliary to this main goal, this work also capitalized upon 5 and 15-month-old male and female animals in the control group to characterize age- and sex-specific differences on long bone geometric, structural, and material properties in this animal model.

Somatostatin therapy for glomus tumors: a report of two cases

Glomus tumors of the head and neck are benign vascular lesions that often provide dilemmas in management. The presence of somatostatin receptors on the tumor cell surface has facilitated an additional imaging technique in the form of radiolabeled octreotide scanning. The use of the somatostatin analogue, octreotide, also provides a therapeutic option for inoperable or recurrent tumors. We present two patients, one with a surgically inaccessible tumor that recurred after primary radiotherapy and one who underwent incomplete resection because of the tumor's proximity to the internal carotid artery. Neither tumor has shown further growth 5 and 3 years after treatment with octreotide, respectively.

Left ventricular morphology influences mortality after the Norwood operation

BACKGROUND

Within the spectrum of congenital heart disease referred to as hypoplastic left heart syndrome (HLHS), there is variation in the morphology and function of the left ventricle which could influence outcomes after stage I Norwood palliation.

OBJECTIVE

To determine if left ventricular (LV) morphology is associated with outcome after stage I Norwood palliation for HLHS.

METHODS

Echocardiograms were reviewed from 108 patients who had undergone Norwood palliation at our institution over the past 11 years. Total cardiac diameter, thickness of the interventricular septum (IVS), LV area and LV myocardial area were calculated. Competing risk analysis was performed for survival to a stage II operation and to determine potential predictors.

RESULTS

From the Norwood operation up to stage II operation, mortality was predicted by IVS thickness, while the absence of right ventricular (RV) dysfunction was predictive of survival to stage II operation. For the complete pathway, from Norwood to the Fontan operation, mortality was predicted by IVS, a lower RV fractional area change and the presence of significant tricuspid regurgitation. Cardiac transplantation during this period was predicted by a lower RV fractional area change (p = 0.02) and a larger LV area in diastole.

CONCLUSIONS

These results indicate that LV hypertrophy and decreased RV function adversely effect survival after the Norwood operation. They suggest that LV morphology, especially septal hypertrophy, can influence outcomes in HLHS and should be considered when evaluating treatment options.

Evidence for a critical period in the development of excitability and potassium currents in mouse lumbar superficial dorsal horn neurons

The output of superficial dorsal horn (SDH; laminae I-II) neurons is critical for processing nociceptive, thermal, and tactile information. Like other neurons, the combined effects of synaptic inputs and intrinsic membrane properties determine their output. It is well established that peripheral synaptic inputs to SDH neurons undergo extensive reorganization during pre- and postnatal development. It is unclear, however, how membrane properties or the subthreshold whole cell currents that shape SDH neuron output change during this period. Here we assess the intrinsic membrane properties and whole cell currents in mouse SDH neurons during late embryonic and early postnatal development (E15-P25). Transverse slices were prepared from lumbar spinal cord and whole cell recordings were obtained at 32 degrees C. During this developmental period resting membrane potential (RMP) became more hyperpolarized (by approximately 10 mV, E15-E17 vs. P21-P25) and input resistance decreased (1,074 +/- 78 vs. 420 +/- 27 MOmega). In addition, action potential (AP) amplitude and AP afterhyperpolarization increased, whereas AP half-width decreased. Before and after birth (E15-P10), AP discharge evoked by intracellular current injection was limited to a single AP at depolarization onset in many neurons (>41%). In older animals (P11-P25) this changed, with AP discharge consisting of brief bursts at current onset ( approximately 46% of neurons). Investigation of major subthreshold whole cell currents showed the rapid A-type potassium current (I(Ar)) dominated at all ages examined (90% of neurons at E15-E17, decreasing to >50% after P10). I(Ar) expression levels, based on peak current amplitude, increased during development. Steady-state inactivation and activation for I(Ar) were slightly less potent in E15-E17 versus P21-P25 neurons at potentials near RMP (-55 mV). Together, our data indicate that intrinsic properties and I(Ar) expression change dramatically in SDH neurons during development, with the greatest alterations occurring on either side of a critical period, P6-P10.

Recent consensus on the classification of rhinosinusitis — a way forward for research and practice?

Prior classification of rhinitis was into three categories: acute, subacute and chronic rhinosinusitis. The advantages of this classification were obvious but they were offset by some disadvantages. For example, the previous classification did not take account of the mechanisms underlying the condition or the clinical outcome. Hence, there was a need for evidence-based sinusitis classification guidelines. The American Academy of Otolaryngology-Head and Neck Surgery and other related societies published a classification of the condition and suggested clinical research strategies for patients with rhinosinusitis. The main conclusion was that sinusitis should be divided into four categories: acute (bacterial) rhinosinusitis, chronic rhinosinusitis (CRS) without polyps, CRS with polyps, and allergic fungal sinusitis. The aim of this current paper is to discuss the consensus for nomenclature, outline the proposed classification of different types of rhinosinusitis and to suggest some ways that we may audit these guidelines.

Automation of sample mounting for macromolecular crystallography

A standard sample holder and vial for cryocooled macromolecular crystals has been defined for use with robotic sample changers. This SPINE standard sample holder is a modified version, with added features and specifications, of sample holders in common use. In particular, the SPINE standard meets the precision required for automatic sample exchange and includes a cap that is identified by a two-dimensional datamatrix code as well as an optional vial. At the ESRF, the sample holder standard is in use with the EMBL/ESRF/BM14 robotic sample changer (SC3) which is installed on eight beamlines. The SC3 can hold up to 50 crystals stored in five baskets. A datamatrix reader in the SC3 ensures safe management of the sample flow and facilitates fully automatic screening and characterization of samples. Tools for handling and transporting 50 samples in a dry shipping dewar have been developed. In addition to the SC3, the SPINE sample holder is currently compatible with a number of other robotic sample changers.

A comparison of temporal bone fracture classification systems

OBJECTIVES

To compare the traditional and otic capsule classification system of temporal bone fractures for clinical relevance.

DESIGN

A retrospective review of all patients with a radiological diagnosis of a skull-base fracture over a 5-year period.

SETTING

All patients were seen at Beaumont Hospital, the national tertiary referral centre for Neuro-otology.

PARTICIPANTS

Patients with a clinical diagnosis of skull fracture were identified from the hospitals in patient enquiry (HIPE) database. Of 338 patients, 31 (9%) were identified as having a temporal bone fracture on high-resolution CT scanning.

MAIN OUTCOME AND MEASURES

The rate and distribution of each major clinical complications within each classification system to establish if either one was more clinically useful.

RESULTS

Fractures were classified as mixed in 14 (45%), longitudinal in 9 (29%) and horizontal in 8 (26%). Alternatively, 2 (7%) were otic capsule violating and 29 (93%) were otic capsule sparing. Seventeen patients (54.8%) sustained a hearing loss. Seven patients (23%) sustained a facial nerve injury. Four (13%) developed a cerebrospinal fluid (CSF) leak. Of all clinical findings only sensorineural hearing loss occurred significantly more often in the horizontal as opposed to the longitudinal group (P = 0.029) and in the otic violating as opposed to the otic sparing group (P = 0.013).

CONCLUSIONS

We acknowledge that the relatively small size of our cohort diminishes the statistical power of our conclusions. However, we found that the otic capsule-based classification system was not significantly better than the traditional system in predicting the likelihood of sustaining specific injuries from fractures of the temporal bone.

Atrioventricular block after transcatheter closure of perimembranous ventricular septal defects

OBJECTIVE

To look at the presentation, treatment and outcome of patients who developed atrioventricular block after transcatheter closure of a perimembranous ventricular septal defect (PMVSD) with the Amplatzer PMVSD device.

SETTING

Three tertiary referral centres for paediatric cardiology in two countries.

RESULTS

All three patients presented within 10 days of the procedure. All three patients were treated with intravenous steroids. A permanent pacemaker was inserted in all patients but no pacemaker required activation after two months.

CONCLUSION

Complete atrioventricular block occurring in the weeks after device occlusion of a PMVSD appears to resolve quickly. Continued involvement in multicentre device databases is required to monitor safety.

The changing face of lateral sinus thrombosis

Lateral sinus thrombosis is a life threatening complication of middle ear disease, the presentation, diagnosis and management of which has seen many changes in recent times. While the introduction of antibiotics has been associated with a reduction in the incidence and associated morbidity/mortality of this complication, their use has also altered the clinical features of presentation, consequently diagnosis requires a high index of suspicion. Radiological advances, in particular magnetic resonance imaging and magnetic resonance venography, have improved our ability to diagnose this complication pre-operatively, and now are the diagnostic investigations of choice. Intraoperative sigmoid sinus exploration and removal of all necrotic clot are essential steps of surgical management together with appropriate antimicrobial treatment, however the role of anticoagulation therapy remains controversial. We present four recent cases of sigmoid sinus thrombosis and discuss the clinical presentation, investigation and management of this disease.

Induction of nasal hyper-responsiveness by allergen challenge in allergic rhinitis: the role of afferent and efferent nerves

BACKGROUND

Hyper-responsiveness of nasal secretory function and volume changes are features of allergic rhinitis (AR) that are mediated in part by neural mechanisms. The finding of nasal hyper-responsiveness in subjects with AR who are currently symptomatic, but not in those who are currently out of season and asymptomatic, suggests that induction of neural reflexes in allergic subjects occurs as a result of allergic inflammation.

OBJECTIVES

To investigate whether allergen exposure in subjects with asymptomatic seasonal allergic rhinitis (SAR) may lead to induction of neural reflexes, and to investigate the components of the reflexes involved in this induction.

METHODS

Asymptomatic subjects with (out-of-season) SAR underwent a nasal bradykinin challenge, before and 24 h after preceding ipsilateral (n = 11) and contralateral (n = 11) antigen challenge. Challenges were performed and nasal secretions collected using filter paper disks, and changes in nasal minimal cross-sectional area (A(min)) were measured using acoustic rhinometry.

RESULTS

Preceding ipsilateral antigen challenge led to the induction of a contralateral secretory reflex (P = 0.01), which was absent in control experiments (P = 0.34). Ipsilateral secretion weights were also enhanced. Preceding contralateral antigen challenge also induced a contralateral secretory reflex (P = 0.03). Enhancement of the reduction in contralateral A(min) was also seen (P = 0.02). Ipsilateral responses were unchanged.

CONCLUSIONS

Allergen exposure in asymptomatic allergic subjects leads to induction of neural reflexes, resulting in nasal hyper-responsiveness, which persists beyond the resolution of the acute allergic response. Our data suggest that the mechanisms of allergen-induced hyper-responsiveness involve both afferent and efferent components.

An alternative technique for nasal biopsy

OBJECTIVES/HYPOTHESIS

The objective was to investigate the effectiveness of co-phenylcaine as a topical anesthetic agent for nasal mucosal biopsy.

STUDY DESIGN

A prospective study.

METHODS

Nasal mucosal biopsy specimens were taken from a site just anterior to the inferior turbinate following topical anesthesia with co-phenylcaine. All volunteers graded pain according to standard visual analogue scale (0-10) (VAS) scoring, and all were followed up after 24 hours for any epistaxis.

RESULTS

Ninety nasal biopsy specimens were removed from 41 patients in all. Eight-two percent did not report any discomfort following this procedure (VAS score, 0). Ten patients reported mild discomfort (VAS scores ranging between, 1 and 3) and only six reported pain (VAS scores ranging from 5 to 7). However, five of these patients agreed to further biopsy and documented no discomfort during the repeat procedure. Only one patient required immediate intervention for hemorrhage after the procedure. In cases in which bleeding occurred (seven patients) it was documented within the first 6 hours, was minimal in content, and was controlled with local pressure. No systemic side effects were experienced.

CONCLUSION

Co-phenylcaine is a suitable topical anesthetic agent for nasal mucosal biopsy. Removal of nasal tissue from a site anterior to the inferior turbinate can be performed under direct vision and provides sufficient tissue for histological assessment.

The potential of virtual laryngoscopy in the assessment of vocal cord lesions

Virtual laryngoscopy is a useful adjunctive radiological tool in the assessment of laryngeal lesions. A total of 10 patients requiring direct laryngoscopy for the investigation of laryngeal lesions underwent preoperative virtual laryngoscopy using three-dimensional reconstruction of two-dimensional computerized tomography (CT) images. All lesions were correctly diagnosed on virtual laryngoscopy before direct laryngoscopy. Its main advantages are that it does not require general anaesthesia, it allows three-dimensional visualization of the airway beyond areas of narrowing and it gives a highly accurate representation of vocal cord lesions, both in terms of definition and spatial representation. Its disadvantages are that it does not provide histology, it requires an air-mucosa interface to produce an image and it cannot identify functional lesions of the vocal cords.

Intracranial complications of acute frontal sinusitis

Despite advances in the diagnosis and treatment of acute frontal sinusitis, there is still significant occurrence of intracranial complications. Urgent surgical evacuation of any intracranial collection is required; however, the surgical management of the associated sinusitis remains controversial. Ten patients presented to this department over a 12-month period with subdural empyema secondary to acute frontal sinusitis. Four patients had a coexisting Pott's puffy tumour and one patient had a periorbital abscess. Each patient was managed using a multidisciplinary approach. A frontal sinus trephine/drain +/- antral washout was performed at the same time as craniotomy with evacuation of the empyema. With this approach only two patients suffered long-term morbidity in our series, in the form of persistent neurological or cognitive deficit. No patient required a definitive sinus procedure. This study emphasizes the need for the early assessment and intervention of patients with an intracranial complication secondary to acute frontal sinusitis. Further assessment of the underlying sinus disease is indicated during outpatient follow up after the acute episode.

Crystal structures of penicillin acylase enzyme-substrate complexes: structural insights into the catalytic mechanism

The crystal structure of penicillin G acylase from Escherichia coli has been determined to a resolution of 1.3 A from a crystal form grown in the presence of ethylene glycol. To study aspects of the substrate specificity and catalytic mechanism of this key biotechnological enzyme, mutants were made to generate inactive protein useful for producing enzyme-substrate complexes. Owing to the intimate association of enzyme activity and precursor processing in this protein family (the Ntn hydrolases), most attempts to alter active-site residues lead to processing defects. Mutation of the invariant residue Arg B263 results in the accumulation of a protein precursor form. However, the mutation of Asn B241, a residue implicated in stabilisation of the tetrahedral intermediate during catalysis, inactivates the enzyme but does not prevent autocatalytic processing or the ability to bind substrates. The crystal structure of the Asn B241 Ala oxyanion hole mutant enzyme has been determined in its native form and in complex with penicillin G and penicillin G sulphoxide. We show that Asn B241 has an important role in maintaining the active site geometry and in productive substrate binding, hence the structure of the mutant protein is a poor model for the Michaelis complex. For this reason, we subsequently solved the structure of the wild-type protein in complex with the slowly processed substrate penicillin G sulphoxide. Analysis of this structure suggests that the reaction mechanism proceeds via direct nucleophilic attack of Ser B1 on the scissile amide and not as previously proposed via a tightly H-bonded water molecule acting as a "virtual" base.

A thermophilic mini-chaperonin contains a conserved polypeptide-binding surface: combined crystallographic and NMR studies of the GroEL apical domain with implications for substrate interactions

A homologue of the Escherichia coli GroEL apical domain was obtained from thermophilic eubacterium Thermus thermophilus. The domains share 70 % sequence identity (101 out of 145 residues). The thermal stability of the T. thermophilus apical domain (Tm>100 degrees C as evaluated by circular dichroism) is at least 35 degrees C greater than that of the E. coli apical domain (Tm=65 degrees C). The crystal structure of a selenomethione-substituted apical domain from T. thermophilus was determined to a resolution of 1.78 A using multiwavelength-anomalous-diffraction phasing. The structure is similar to that of the E. coli apical domain (root-mean-square deviation 0.45 A based on main-chain atoms). The thermophilic structure contains seven additional salt bridges of which four contain charge-stabilized hydrogen bonds. Only one of the additional salt bridges would face the "Anfinsen cage" in GroEL. High temperatures were exploited to map sites of interactions between the apical domain and molten globules. NMR footprints of apical domain-protein complexes were obtained at elevated temperature using 15N-1H correlation spectra of 15N-labeled apical domain. Footprints employing two polypeptides unrelated in sequence or structure (an insulin monomer and the SRY high-mobility-group box, each partially unfolded at 50 degrees C) are essentially the same and consistent with the peptide-binding surface previously defined in E. coli GroEL and its apical domain-peptide complexes. An additional part of this surface comprising a short N-terminal alpha-helix is observed. The extended footprint rationalizes mutagenesis studies of intact GroEL in which point mutations affecting substrate binding were found outside the "classical" peptide-binding site. Our results demonstrate structural conservation of the apical domain among GroEL homologues and conservation of an extended non-polar surface recognizing diverse polypeptides.

Relationship between intracoronary and peripheral expression of soluble cell adhesion molecules

BACKGROUND

Elevated levels of soluble cell adhesion molecules (sCAMs) have been reported in various coronary artery disease processes. The principle stimulus for expression of sCAMs is believed to be an inflamed atherosclerotic plaque within the coronary vessel. The relationship between levels of sCAMs in the coronary circulation and the peripheral circulation has not been defined. The primary aim of this study was to define the relationship between levels of sCAMs sampled from the systemic circulation and from the coronary circulation. We also set out to document the acute expression of soluble CAMs following coronary angioplasty with or without stent implantation.

METHODS

The coronary sinus was cannulated in patients undergoing LAD angioplasty. Samples were drawn from left coronary ostium (LCO) and coronary sinus (CS) and femoral vein simultaneously before, immediately after and 4 h after the PTCA procedure. Levels of sICAM-1, sVCAM-1, sE-selectin and sP-selectin were measured using ELISA technique.

RESULTS

10 patients (7 male/3 female, 61+/-11 y) entered the study. There was no significant difference in the levels of sICAM-1, sVCAM-1, sE-selectin and sPselectin whether sampled from left coronary ostium, coronary sinus or femoral vein at all time points. There was no significant change in the acute expression of sICAM-1, sVCAM-1 and sE-selectin following coronary angioplasty. Levels of sP-selectin fell significantly during the PTCA procedure (142+/-7 ng/ml to 64+/-6 ng/ml, P<0.001) but then rose again after 4 h and returned toward baseline levels at 24 h.

CONCLUSION

Levels of soluble CAMs sampled in the systemic circulation directly reflect levels in the coronary circulation. Coronary angioplasty results in rapid fall in levels of sP-selectin which returns to normal within 24 h following the procedure.

Structure of RsrI methyltransferase, a member of the N6-adenine beta class of DNA methyltransferases

DNA methylation is important in cellular, developmental and disease processes, as well as in bacterial restriction-modification systems. Methylation of DNA at the amino groups of cytosine and adenine is a common mode of protection against restriction endonucleases afforded by the bacterial methyltransferases. The first structure of an N:6-adenine methyltransferase belonging to the beta class of bacterial methyltransferases is described here. The structure of M. RSR:I from Rhodobacter sphaeroides, which methylates the second adenine of the GAATTC sequence, was determined to 1.75 A resolution using X-ray crystallography. Like other methyltransferases, the enzyme contains the methylase fold and has well-defined substrate binding pockets. The catalytic core most closely resembles the PVU:II methyltransferase, a cytosine amino methyltransferase of the same beta group. The larger nucleotide binding pocket observed in M. RSR:I is expected because it methylates adenine. However, the most striking difference between the RSR:I methyltransferase and the other bacterial enzymes is the structure of the putative DNA target recognition domain, which is formed in part by two helices on an extended arm of the protein on the face of the enzyme opposite the active site. This observation suggests that a dramatic conformational change or oligomerization may take place during DNA binding and methylation.

Nitinol stents: their value in tracheobronchial obstruction

Recurrent tracheobronchial obstruction whether due to a benign or malignant cause is not always amenable to surgery and one is left with the dilemma of what to do for a patient who is slowly asphyxiating. Various modalities have been employed in the past with varying degrees of success. However due to the recent innovations in 'superelastic' biocompatible alloys we present our clinical experience with a new generation of metallic stents made from Nitinol. Over a 12-month period we inserted eight stents in six patients with malignant and benign tracheobronchial obstruction. Almost all patients had dramatic improvement in their symptoms and there was little airway reaction observed up to 18 months after insertion. However, one should exercise caution in inserting them for benign conditions as we regard them as permanent implants. Also evident is the inherent morbidity in this group of patients and this needs to be carefully considered prior to treatment.

Tumor necrosis factor-alpha-induced apoptosis in prostate cancer cells through inhibition of nuclear factor-kappaB by an IkappaBalpha "super-repressor"

Prostate cancer patients experiencing a relapse in disease often express high serum tumor necrosis factor-alpha (TNF-alpha) levels. Many androgen-insensitive prostate cancer cells are TNF-alpha insensitive because of the expression of antiapoptotic genes as part of the nuclear factor-kappaB (NF-kappaB) family of transcription factors. NF-kappaB stimulates gene transcription when expressed in the nucleus; however, in resting cells, this nuclear import is prevented by association with the cytoplasmic inhibitor IkappaBalpha. This cytoplasmic retention of NF-kappaB is uncoupled by many extracellular signals including low levels of TNF-alpha. During normal cell activation, nuclear translocation of NF-kappaB is preceded by phosphorylation and degradation of IkappaBalpha. When phosphorylation is blocked, IkappaBalpha remains intact, thereby blocking NF-kappaB translocation to the nucleus and subsequent activation of antiapoptotic genes that cause TNF-alpha insensitivity. We tested whether a "super-repressor" of NF-kappaB activity could be transfected into prostate cancer cells and make them TNF-alpha sensitive. PC-3 and LNCaP cells were stimulated with TNF-alpha (10 ng/ml) for 24 h in the presence or absence of the IkappaBalpha "super-repressor" (p6R-IkappaB(S32A + S36A)). NF-kappaB activity was measured by electrophoretic mobility shift assay and the steady state levels of the cytoplasmic IkappaBalpha protein were measured by Western blot. Secretory IL-6 and IL-6 mRNA were measured by ELISA. p6R-IkappaB(S32A + S36A) blocked the stimulation of NF-kappaB activity by TNF-alpha in prostate cancer cells. It also subsequently decreased IL-6 production by TNF-alpha. We conclude that these data demonstrate that inhibition of NF-kappaB selectively sensitizes previously insensitive prostate cancer cells to TNF-alpha.

Inhibition of the hepatitis C virus NS3/4A protease. The crystal structures of two protease-inhibitor complexes

The hepatitis C virus NS3 protein contains a serine protease domain with a chymotrypsin-like fold, which is a target for development of therapeutics. We report the crystal structures of this domain complexed with NS4A cofactor and with two potent, reversible covalent inhibitors spanning the P1-P4 residues. Both inhibitors bind in an extended backbone conformation, forming an anti-parallel beta-sheet with one enzyme beta-strand. The P1 residue contributes most to the binding energy, whereas P2-P4 side chains are partially solvent exposed. The structures do not show notable rearrangements of the active site upon inhibitor binding. These results are significant for the development of antivirals.

Crystal structure of delta-chymotrypsin bound to a peptidyl chloromethyl ketone inhibitor

Chymotrypsin is a member of the trypsin family of serine proteases and is one of the first proteins successfully studied by X-ray crystallography. It is secreted into the intestine as the inactive precursor chymotrypsinogen; four sequential cleavages of the peptide bonds following residues 13, 15, 146 and 148 occur to generate the active pi, delta, kappa and alpha forms of chymotrypsin. (13)C NMR has shown [O'Connell & Malthouse (1995). Biochem. J. 307, 353-359] that when the delta form of chymotrypsin is inhibited by 2-(13)C-enriched benzyloxycarbonylglycylglycylphenylalanyl chloromethane, a tetrahedral adduct is formed which is thought to be analogous to the tetrahedral intermediate formed during catalysis. This inhibitor complex has been crystallized as a dimer in space group P4(1)2(1)2. The structure has been refined at 2.14 A resolution to an R value of 21.2% (free R = 25.2%). Conformational differences between delta-chymotrypsin and chymotrypsinogen in the region of the flexible autolysis loop (residues 145-150) were observed. This is the first crystal structure of delta-chymotrypsin and includes two residues which are disordered in previous crystal structures of active chymotrypsin. A difference of 11.3 A(2) between the average B values of the monomers within the asymmetric unit is caused by lattice-disordering effects approximating to rotation of the molecules about a crystallographic screw axis. The substrate-binding mode of the inhibitor was similar to other chymotrypsin peptidyl inhibitor complexes, but this is the first published chymotrypsin structure in which the tetrahedral chloromethyl ketone transition-state analogue is observed. This structure is compared with that of a similar tetrahedral transition-state analogue which does not alkylate the active-site histidine residue.

Head and neck schwannomas--a 10 year review

Schwannomas of the head and neck are uncommon tumours that arise from any peripheral, cranial or autonomic nerve. Twenty-five to 45 per cent of extracranial schwannomas occur in the head and neck region and thus are usually in the domain of the otolaryngologist. They usually present insidiously and thus are often diagnosed incorrectly or after lengthy delays, however, better imaging and cytological techniques have lessened this to some degree more recently. For benign lesions conservative surgical excision is the treatment of choice bearing in mind possible vagal or sympathetic chain injury. Malignant schwannomas are best treated with wide excision where possible. The role of adjuvant therapy remains uncertain and irrespective of treatment modality prognosis is poor with an overall survival of 15 per cent. However, recent advances in ras oncogene inhibitors may hold hope for the future.

MAD data collection - current trends

The multiwavelength anomalous dispersion (MAD) method of protein structure determination is becoming a routine technique in protein crystallography. The increased number of wavelength-tuneable synchrotron beamlines capable of performing challenging MAD experiments, coupled with the widespread availability of charge-coupled device (CCD) based X-ray detectors with fast read-out times have brought MAD structure determination to a new exciting level. Ultrafast MAD data collection is now possible and, with the widespread use of selenium in the form of selenomethionine for phase determination, the method is growing in popularity. Recent developments in crystallographic software are complementing the above advances, paving the way for rapid protein structure determination. An overview of a typical MAD experiment is described, with emphasis on the rates and quality of data acquisition now achievable at third-generation synchrotron sources.

The Westaby T-Y tracheobronchial stent in otolaryngology

The Westaby T-Y tracheobronchial silicone stent can be used for the relief of upper airway obstruction beyond the limit of a standard tracheostomy tube. We report on our experience in the use of the Westaby tube in 10 patients over a five-year period. The general features of the tube, indications for its use, and its method of insertion are described. The versatility and advantages over other stents are discussed. Two cases reports are described and the clinical course and outcomes of the individual patients are outlined.

Sinogenic brain abscess

The otolaryngological contribution to the combined treatment of intracranial suppuration secondary to sinusitis can vary from observation to external approach sinus exploration. Limited surgical intervention using the endoscopic approach, in conjunction with neurosurgical drainage, has recently been adopted at our department as the initial therapeutic strategy in the management of such cases. A retrospective analysis of the otolaryngological input into the treatment of 16 patients with sinogenic brain abscess at the Department of Otolaryngology/Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland is presented. This study reveals that it is generally a disease of young adult males without an antecedent history of sinus disease and that Strep. Milleri is the most common causative organism. It is demonstrated that there is a lack of a consistent approach to the management in the acute phase and that there is an inadequate initial radiologic evaluation of the paranasal sinuses. There are two forms of presentation: 1) an ENT complaint with development of an abscess, and 2) an idiopathic abscess with subsequent identification of a paranasal sinus infective source. Extensive initial intervention seems to be associated with an increased incidence of revision surgery, thus suggesting that a limited endoscopic approach combined with neurosurgical drainage is the optimal course in the first-line management of sinogenic abscess.

Taking MAD to the extreme: ultrafast protein structure determination

Multiwavelength anomalous diffraction data were measured in 23 min from a 16 kDa selenomethionyl substituted protein, producing experimental phases to 2.25 A resolution. The data were collected on a mosaic 3 x 3 charge-coupled device using undulator radiation from the Structural Biology Center 19ID beamline at the Argonne National Laboratory's Advanced Photon Source. The phases were independently obtained semiautomatically by two crystallographic program suites, CCP4 and CNS. The quality and speed of this data acquisition exemplify the opportunities at third-generation synchrotron sources for high-throughput protein crystal structure determination.

Structure of a new crystal form of human Hsp70 ATPase domain

Hsp70 proteins are highly conserved proteins induced by heat shock and other stress conditions. An ATP-binding domain of human Hsp70 protein has been crystallized in two major morphological forms at pH 7.0 in the presence of PEG 8000 and CaCl2. Both crystal forms belong to the orthorhombic space group P212121, but show no resemblance in unit-cell parameters. Analysis of the crystal structures for both forms shows a 1-2 A shift of one of the subdomains of the protein. This conformational change could reflect a 'natural' flexibility of the protein which might be relevant to ATP binding and may facilitate the interaction of other proteins with Hsp70 protein.

Crystallization and preliminary crystallographic analysis of an NADH oxidase that functions in peroxide reduction in Thermus aquaticus YT-1

NADH oxidase from Thermus aquaticus is a thermostable flavoenzyme that is similar in amino-acid sequence and other properties to the flavoenzyme component of the NADH peroxidase systems from Salmonella typhimurium and Amphibacillus xylanus. The enzyme has been isolated from T. aquaticus and crystallized using the hanging-drop method of vapour diffusion with sodium citrate as a precipitant at pH 8.5. The crystals belong to the hexagonal space group P622 with unit-cell dimensions a = b = 89.9, c = 491.6 A, and diffract to 2.5 A resolution.

X-ray crystal structure of the Desulfovibrio vulgaris (Hildenborough) apoflavodoxin-riboflavin complex

The apoprotein of flavodoxin from Desulfovibrio vulgaris forms a complex with riboflavin. The ability to bind riboflavin distinguishes this flavodoxin from other short-chain flavodoxins which require the phosphate of FMN for flavin binding. The redox potential of the semiquinone/hydroquinone couple of the bound riboflavin is 180 mV less negative than the corresponding complex with FMN. To elucidate the binding of riboflavin, the complex has been crystallized and the crystal structure solved by molecular replacement using native flavodoxin as a search model to a resolution of 0.183 nm. Compared to the FMN complex, the hydrogen-bonding network at the isoalloxazine sub-site of the riboflavin complex is severely disrupted by movement of the loop residues Ser58-Ile64 (60-loop) which contact the isoalloxazine by over 0.35 nm, and by a small displacement of the isoalloxazine moiety. The 60-loop movement away from the flavin increases the solvent exposure of the flavin-binding site. The conformation of the site at which 5'-phosphate of FMN normally binds is similar in the two complexes, but in the riboflavin complex a sulphate or phosphate ion from the crystallization buffer occupies the space. This causes small structural perturbations in the phosphate-binding site. The flexibility of the 60-loop in D. vulgaris flavodoxin appears to be a contributing factor to the binding of riboflavin by the apoprotein, and a feature that distinguishes the protein from other 'short chain' flavodoxins. In the absence of the terminal phosphate group, free movement at the 5'-OH group of the ribityl chain can occur. Thus, the 5'-phosphate of FMN secures the cofactor at the binding site and positions it optimally. The structural changes which occur in the 60-loop in the riboflavin complex probably account for most of the positive shift that is observed in the midpoint potential of the semiquinone/hydroquinone couple of the riboflavin complex compared to that of the FMN complex.

Refinement of triclinic hen egg-white lysozyme at atomic resolution

X-ray diffraction data have been collected at both low (120 K) and room temperature from triclinic crystals of hen egg-white lysozyme to 0.925 and 0.950 A resolution, respectively, using synchrotron radiation. Data from one crystal were sufficient for the low-temperature study, whereas three crystals were required at room temperature. Refinement was carried out using the programs PROLSQ, ARP and SHELXL to give final conventional R factors of 8.98 and 10.48% for data with F > 4sigma(F) for the low- and room-temperature structures, respectively. The estimated r.m.s. coordinate error is 0.032 A for protein atoms, 0.050 A for all atoms in the low-temperature study, and 0.038 A for protein atoms and 0.049 A for all atoms in the room-temperature case, as estimated from inversion of the blocked least-squares matrix. The low-temperature study revealed that the side chains of 24 amino acids had multiple conformations. A total of 250 waters, six nitrate ions and three acetate ions, two of which were modelled with alternate orientations were located in the electron-density maps. Three sections of the main chain were modelled in alternate conformations. The room-temperature study produced a model with multiple conformations for eight side chains and a total of 139 water molecules, six nitrate but no acetate ions. The occupancies of the water molecules were refined in both structures and this step was shown to be meaningful when assessed by use of the free R factor. A detailed description and comparison of the structures is made with reference to the previously reported structure refined at 2.0 A resolution.

Modulation of the redox potentials of FMN in Desulfovibrio vulgaris flavodoxin: thermodynamic properties and crystal structures of glycine-61 mutants

Mutants of the electron-transfer protein flavodoxin from Desulfovibrio vulgaris were made by site-directed mutagenesis to investigate the role of glycine-61 in stabilizing the semiquinone of FMN by the protein and in controlling the flavin redox potentials. The spectroscopic properties, oxidation-reduction potentials, and flavin-binding properties of the mutant proteins, G61A/N/V and L, were compared with those of wild-type flavodoxin. The affinities of all of the mutant apoproteins for FMN and riboflavin were less than that of the wild-type apoprotein, and the redox potentials of the two 1-electron steps in the reduction of the complex with FMN were also affected by the mutations. Values for the dissociation constants of the complexes of the apoprotein with the semiquinone and hydroquinone forms of FMN were calculated from the redox potentials and the dissociation constant of the oxidized complex and used to derive the free energies of binding of the FMN in its three oxidation states. These showed that the semiquinone is destabilized in all of the mutants, and that the extent of destabilization tends to increase with increasing bulkiness of the side chain at residue 61. It is concluded that the hydrogen bond between the carbonyl of glycine-61 and N(5)H of FMN semiquinone in wild-type flavodoxin is either absent or severely impaired in the mutants. X-ray crystal structure analysis of the oxidized forms of the four mutant proteins shows that the protein loop that contains residue 61 is moved away from the flavin by 5-6 A. The hydrogen bond formed between the backbone nitrogen of aspartate-62 and O(4) of the dimethylisoalloxazine of the flavin in wild-type flavodoxin is absent in the mutants. Reliable structural information was not obtained for the reduced forms of the mutant proteins, but if the mutants change conformation when the flavin is reduced to the semiquinone, to facilitate hydrogen bonding between N(5)H and the carbonyl of residue 61, then the change must be different from that known to occur in wild-type flavodoxin.

Crystallization and preliminary X-ray crystallographic analysis of the electron-transferring flavoprotein from Megasphaera elsdenii

Electron-transferring flavoprotein from the rumen bacterium Megasphaera elsdenii is a heterodimer (M(r) = 75 kDa) containing FAD as cofactor and functioning solely to mediate electron transfer between the prosthetic groups of other proteins. The enzyme was crystallized by the hanging-drop vapour-diffusion method using polyethylene glycol 4000 as precipitant. The crystals obtained belong to the space group P2(1)2(1)2(1) with unit-cell dimensions of a = 58.75, b = 61.77 and c = 122.27 A. Interestingly the crystals exhibit a low solvent content. Crystals diffracted to beyond 2.5 A using synchrotron radiation.

Recurrent laryngeal nerve dysfunction following carotid endarterectomy

Recurrent laryngeal nerve dysfunction is a significant complication of carotid endarterectomy and vocal cord paralysis is a major source of morbidity. This study prospectively assessed patients undergoing carotid endarterectomy to determine the nature and frequency of vocal cord damage and attempt to identify avoidable factors. Fifty consecutive patients undergoing carotid endarterectomy for symptomatic disease were studied. A standardized surgical technique was used emphasizing identification of the vagus nerve and minimal disturbance of the surrounding tissues. All patients underwent pre-operative and post-operative (day 2) indirect laryngoscopy and videostroboscopy. Pre-operative assessment found asymptomatic compensated vocal cord paralysis in one patient who had previously had a stroke. Post-operative laryngoscopy revealed asymptomatic impaired vocal cord mobility in three patients (6%) all of whom recovered completely. In addition six patients (12%) developed post-operative hoarseness of whom five have fully recovered. The remaining patient (2%) developed vocal cord paralysis which is permanent to date. This prospective study demonstrates that recurrent laryngeal nerve dysfunction is a common but often transient complication of carotid endarterectomy. The incidence of vocal cord paralysis in this group was less than many of the reported series. This could be due to the technique of minimal dissection which may prevent disturbance of the vagal segmental blood supply. Pre-operative vocal cord assessment is essential in all patients undergoing carotid endarterectomy.

Oral terbutaline after parenteral tocolysis: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

Our purpose was to determine whether oral terbutaline, used after successful intravenous tocolysis, will prolong pregnancy and prevent recurrent preterm labor.

STUDY DESIGN

After successful intravenous tocolysis, 203 women with preterm labor at 24 weeks' to 34 weeks 6 days' gestation were randomized to terbutaline (5 mg orally, every 4 hours) or placebo until 37 weeks' gestation. Women with recurrent preterm labor were treated with intravenous magnesium sulfate; if tocolysis was successful, they continued with the initial study medication. The primary outcome was the percentage delivered of their infants within 1 week of beginning oral tocolytic therapy. Latency, recurrent preterm labor, and maternal and neonatal outcomes were also assessed.

RESULTS

Pregnancy outcome data were available in 200 women. There were no differences seen between the two groups in the incidence of delivery at 1 week (18% vs 24%, 95% confidence interval 0.44 to 1.29). In addition, there were no differences regarding median latency, mean gestational age at delivery, or the incidence of recurrent preterm labor (20% vs 16%, 95% confidence interval 0.64 to 2.71). Post hoc evaluation of 96 women enrolled before 32 weeks' gestation suggested pregnancy prolongation with maintenance oral terbutaline (p < 0.01).

CONCLUSIONS

Maintenance oral terbutaline therapy initiated at 24 weeks' to 34 weeks 6 days' gestation after successful parenteral tocolysis is not associated with pregnancy prolongation or a reduction in the incidence of recurrent preterm labor.

Examining the ear: clinical teaching

Although otolaryngology represents up to 20% of the workload of general practitioners, the time allocated in the undergraduate medical curriculum to clinical teaching of ENT disorders is disproportionately small. Many GPs have indicated a desire for further training in ENT, particularly in small groups. This study was carried out on a group of 27 GPs who wished to revise their diagnostic skills in otoscopy by attending a 2-hour teaching session on basic examination of the ear and the recognition and management of common otological conditions. The GPs skill in otoscopy before and after the course was assessed subjectively by means of a self-administered questionnaire and scored objectively by ENT surgeons. Aspects of otoscopy chosen for assessment were technique of examination of the external ear, choosing correct speculum size, techniques of holding the otoscope and pinna, tympanic membrane description and diagnostic ability. An improvement between the objective pre- and post-workshop scores was found for assessment of the external ear, choice of speculum size, description of the tympanic membrane and diagnostic ability. No significant differences in the pre- and post-workshop scores was found for the techniques of holding the otoscope or holding the pinna. The majority of the GPs found the workshop beneficial. Postgraduate teaching of specialist diagnostic skills such as otoscopy to GPs is useful. An improvement in such skills should enable the GPs to manage ENT problems more confidently and refer patients appropriately to the ENT outpatients.

Cervicofacial actinomycosis: an unusual cause of submandibular swelling

Two cases of cervicofacial actinomycosis, resulting in submandibular swelling, are presented. How actinomycosis may present under the guise of malignancy is well demonstrated. Factors predisposing to the condition, difficulties with diagnosis, isolation methods of the causative organism and treatment of the disease, are discussed.

Bacteriology of tonsil and adenoid and sampling techniques of adenoidal bacteriology

The value of pernasal swabs and direct adenoid swabs in chronic adenoid and adenotonsillar disease was assessed in 175 patients. Prior to adenoidectomy (53 patients) or adenotonsillectomy (122 patients), pernasal and direct adenoid swabs were taken. Adenoid currettings and tonsil tissue were cultured. Haemophilus influenzae was the bacterium most frequently isolated from adenoid currettings and from the centre (core) of the resected tonsil. There was a close relationship between the bacteriology of the pernasal swab and the adenoid tissue and tonsil core in 72 and 71% of patients, respectively. There was an identical profile of pathogens in 52 and 49%, respectively. We suggest that in children with adenoiditis or adenotonsillitis and hypertrophy of the adenoid, a pernasal swab should be used in preference to a throat swab in selecting appropriate antimicrobial therapy. Penicillin and ampicillin are not appropriate blind therapy in chronic adenoid and adenotonsillar infections because of the prevalence of beta-lactamase-producing aerobes (40%) in adenoid and tonsil core in these conditions.

Post-tonsillectomy bacteraemia

Post-tonsillectomy bacteraemia is a well recognized aetiological factor in streptococcal endocarditis. Prophylactic penicillin has been recommended to reduce its incidence in susceptible patients undergoing tonsillectomy. Recent studies have shown a change in the microflora and an increase in the number of penicillin resistant organisms in the tonsils of patients undergoing tonsillectomy. The aim of this study has been to assess the incidence of post-tonsillectomy bacteraemia, identify the organisms associated with it and review the suitability of penicillin in prophylactic regimens. Of the 32 patients included in the study, 11 (34.4%) had positive post-tonsillectomy blood cultures. We were surprised at this low incidence of bacteraemia and have postulated a possible reason. Haemophilus influenzae was isolated from 4 (36.4%) of the positive cultures and Streptococcus viridans in only 1 (9%). Rather than using penicillin for prophylaxis a beta-lactamase stable antibiotic would be more appropriate.

Amplitude rise time and the perception of the voiceless affricate/fricative distinction

Variation of amplitude envelope at stimulus onset has been considered to be of primary importance for distinguishing voiceless affricates from fricatives (e.g., [symbol: see text]). In earlier perceptual experiments, however, variation in amplitude rise time was confounded with variation in frication duration. In two experiments, these variables were independently manipulated, and their individual and combined effects for perception of magnitude of [symbol: see text] were examined. Variation in amplitude rise time alone was not sufficient to signal the voiceless affricate/fricative contrast in these experiments, but variation in frication duration alone was sufficient.