Determination of the median effective dose of propofol in combination with different doses of ketamine during gastro-duodenoscopy in children: a randomised controlled trial.

BACKGROUND: Propofol is used to induce deep sedation or general anaesthesia for procedures in children. Adjuvants, such as ketamine, are routinely added to reduce the dose of propofol required and propofol-related adverse events. We conducted a randomised controlled trial to determine the effective bolus dose of propofol in combination with ketamine that induces adequate depth of anaesthesia in 50% of children (ED50) undergoing gastro-duodenoscopy. METHODS: Children were randomised to one of four doses of ketamine: 0 (control), 0.25, 0.5, and 1 mg kg-1, followed by a dose of propofol according to Dixon's up-and-down methodology. Excessive movement, coughing, gagging, or airway obstruction that prevented endoscope insertion was considered a failure. RESULTS: The ED50 of propofol (median, 95% CI) was greater in the ketamine 0, 0.25, and 0.5 mg kg-1 groups compared with the ketamine 1 mg kg-1 group (6.1, 4.1-8.1; 4.5, 2.9-6; 4.7, 3.1-6.2 mg kg-1vs 1.1, 0.5-1.8 mg kg-1, respectively, P<0.008). Total dose of propofol administered during the procedure was reduced with ketamine 1 mg kg-1. The mean arterial pressure was lower in the ketamine 0 mg kg-1 group compared with the 1 mg kg-1 group during and immediately after the procedure. The ketamine 1 mg kg-1 group experienced a higher incidence of nausea and visual disturbances. CONCLUSIONS: Ketamine at 0.5-1 mg kg-1 reduces the dose of propofol required to provide general anaesthesia for gastro-duodenoscopy in children and may reduce the incidence of propofol-related changes in haemodynamics. CLINICAL TRIAL REGISTRATION: NCT 02295553.

Quantum behavior of water nano-confined in beryl.

The proton mean kinetic energy, Ke(H), of water confined in nanocavities of beryl (Be3Al2Si6O18) at 5 K was obtained by simulating the partial vibrational density of states from density functional theory based first-principles calculations. The result, Ke(H) = 104.4 meV, is in remarkable agreement with the 5 K deep inelastic neutron scattering (DINS) measured value of 105 meV. This is in fact the first successful calculation that reproduces an anomalous DINS value regarding Ke(H) in nano-confined water. The calculation indicates that the vibrational states of the proton of the nano-confined water molecule distribute much differently than in ordinary H2O phases, most probably due to coupling with lattice modes of the hosting beryl nano-cage. These findings may be viewed as a promising step towards the resolution of the DINS controversial measurements on other H2O nano-confining systems, e.g., H2O confined in single and double walled carbon nanotubes.

On the mean kinetic energy of the proton in strong hydrogen bonded systems.

The mean atomic kinetic energies of the proton, Ke(H), and of the deuteron, Ke(D), were calculated in moderate and strongly hydrogen bonded (HB) systems, such as the ferro-electric crystals of the KDP type (XH2PO4, X = K, Cs, Rb, Tl), the DKDP (XD2PO4, X = K, Cs, Rb) type, and the X3H(SO4)2 superprotonic conductors (X = K, Rb). All calculations utilized the simulated partial phonon density of states, deduced from density functional theory based first-principle calculations and from empirical lattice dynamics simulations in which the Coulomb, short range, covalent, and van der Waals interactions were accounted for. The presently calculated Ke(H) values for the two systems were found to be in excellent agreement with published values obtained by deep inelastic neutron scattering measurements carried out using the VESUVIO instrument of the Rutherford Laboratory, UK. The Ke(H) values of the M3H(SO4)2 compounds, in which the hydrogen bonds are centro-symmetric, are much lower than those of the KDP type crystals, in direct consistency with the oxygen-oxygen distance ROO, being a measure of the HB strength.

Determining the band gap and mean kinetic energy of atoms from reflection electron energy loss spectra.

Reflection electron energy loss spectra from some insulating materials (CaCO3, Li2CO3, and SiO2) taken at relatively high incoming electron energies (5-40 keV) are analyzed. Here, one is bulk sensitive and a well-defined onset of inelastic excitations is observed from which one can infer the value of the band gap. An estimate of the band gap was obtained by fitting the spectra with a procedure that includes the recoil shift and recoil broadening affecting these measurements. The width of the elastic peak is directly connected to the mean kinetic energy of the atom in the material (Doppler broadening). The experimentally obtained mean kinetic energies of the O, C, Li, Ca, and Si atoms are compared with the calculated ones, and good agreement is found, especially if the effect of multiple scattering is taken into account. It is demonstrated experimentally that the onset of the inelastic excitation is also affected by Doppler broadening. Aided by this understanding, we can obtain a good fit of the elastic peak and the onset of inelastic excitations. For SiO2, good agreement is obtained with the well-established value of the band gap (8.9 eV) only if it is assumed that the intensity near the edge scales as (E - Egap)(1.5). For CaCO3, the band gap obtained here (7 eV) is about 1 eV larger than the previous experimental value, whereas the value for Li2CO3 (7.5 eV) is the first experimental estimate.

Proton dynamics in ice VII at high pressures.

We calculated the proton kinetic energies Ke(H) of ice under high pressures up to 63 GPa by assuming the harmonic approximation. The input measured optical frequencies of vibration, libration, and translation of ice VII versus pressure as well as the H2O geometry and the distances R(OH) necessary for calculating Ke(H) (at 298 K) were taken from the literature. The resulting Ke(H) values were found to decrease gradually with increasing pressure, approaching the region where the H-atom is symmetrically hydrogen bonded between two oxygens in the OH-O system. Interestingly, the Ke(H) results were found to be consistent with those of other materials such as Rb3H(PO4)2 and KH2PO4 having similar R(OH) and R(OO) distances in the OH-O system. Similar calculations were also carried out for D2O.

Regulation of vascular endothelial growth factor (VEGF) expression is mediated by internal initiation of translation and alternative initiation of transcription.

Vascular Endothelial Growth Factor (VEGF) is a very potent angiogenic agent that has a central role in normal physiological angiogenesis as well as in tumor angiogenesis. VEGF expression is induced by hypoxia and hypoglycemia, and thus was suggested to promote neovascularization during tumor outgrowth. Yet, the molecular mechanism that governs VEGF expression is not fully characterized. VEGF induction is attributed in part to increased levels of transcription and RNA stability. Previously, we demonstrated that the 5' Untranslated Region (5' UTR) of VEGF has an important regulatory role in its expression. VEGF has an exceptionally long 5' UTR (1038 bp) which is highly rich in G+C nucleotides. This suggests that secondary structures in the 5' UTR might be essential for VEGF expression through transcriptional and post-transcriptional control mechanisms, as demonstrated for other growth factors. In this communication, we provide evidence that a computer predicted Internal Ribosome Entry Site (IRES) structure is biologically active and is located at the 3' end of the UTR. In addition, the results demonstrate that an alternative transcriptional initiation site for VEGF exists in the 5' UTR of VEGF. This alternative initiation site is 633 bp downstream of the main transcription start site and the resulting 5' UTR includes mainly the IRES structure. Therefore, our results suggest that VEGF is subjected to regulation at either translational level through a mechanism of ribosome internal initiation and/or transcriptional level through alternative initiation.

The mechanism of monensin-mediated cation exchange based on real time measurements.

Monensin is an ionophore that supports an electroneutral ion exchange across the lipid bilayer. Because of this, under steady-state conditions, no electric signals accompany its reactions. Using the Laser Induced Proton Pulse as a synchronizing event we selectively acidify one face of a black lipid membrane impregnated by monensin. The short perturbation temporarily upsets the acid-base equilibrium on one face of the membrane, causing a transient cycle of ion exchange. Under such conditions the molecular events could be discerned as a transient electric polarization of the membrane lasting approx. 200 microseconds. The proton-driven chemical reactions that lead to the electric signals had been reconstructed by numeric integration of differential rate equations which constitute a maximalistic description of the multi equilibria nature of the system (Gutman, M. and Nachliel, E. (1989) Electrochim. Acta 34, 1801-1806). The analysis of the reactions reveals that the ionic selectivity of the monensin (H+ > Na+ > K+) is due to more than one term. Besides the well established different affinity for the various cations, the selectivity is also derived from a large difference in the rates of cross membranal diffusivities (MoH > MoNa > MoK), which have never been detected before. (v) Quantitative analysis of the membrane's crossing rates of the three neutral complexes reveals a major role of the membranal dipolar field in regulating ion transport. The diffusion of MoH, which has no dipole moment, is hindered only by the viscose drag. On the other hand, the dipolar complexes (MoNa and MoK) are delayed by dipole-dipole interaction with the membrane. (vi) Comparison of the calculated dipoles with those estimated for the crystalline conformation of the [MoNa(H2O)2] and [MoK(H2O)2] complexes reveals that the MoNa may exist in the membrane at its crystal configuration, while the MoK definitely attains a structure having a dipole moment larger than in the crystal.

Antibacterial properties of human amniotic membranes.

Amniotic membranes are widely used in a multitude of surgical applications and have been shown to reduce bacterial counts and promote healing in infected wounds. Antibacterial properties of amniotic fluid are well documented and the presence of many potentially antibacterial factors has been demonstrated. No such factors have yet been found in amniotic membranes. We have applied a direct disc-diffusion susceptibility test to try to establish the possible existence of such a factor. Amniotic membranes did not inhibit five bacterial species when tested at 3 X 10(6) and 3 X 10(8) colony forming units/ml. However, complete growth inhibition of all organisms was seen immediately under the amniotic membrane discs. These results support the hypothesis that the antimicrobial effect of amniotic membranes in vitro is due to their close adherence to the wound surface.

Assessment and diagnostic utility of the cytotoxic T-lymphocyte phenotype using the specific markers granzyme-B and TIA-1 in esophageal mucosal biopsies.

Most esophageal intraepithelial lymphocytes (IELs) express T-cell markers. Increased numbers of esophageal IELs have been shown in reflux esophagitis. The cytotoxic potential and activity of esophageal IELs have not as yet been examined. Our objectives were to determine whether esophageal IELs express the recently described cytotoxic T-cell (CTLs) markers, TIA-1 and granzyme-B, and whether the number of CTLs correlates with well-defined endoscopic, clinical, and histological features of esophagitis. In this study, most CD-3+ esophageal IELs exhibit the CD-8+/TIA-1+ T cell with cytotoxic potential phenotype in both histologically normal biopsy specimens and in biopsy specimens with esophagitis. A subpopulation of esophageal IELs that express cytotoxic activity was identified by granzyme-B immunostaining. A significant positive association was found between the number of esophageal IELs seen by light microscopy in biopsy specimens with histological features of reflux (21 IELs/HPF) and Candida esophagitis (31 IELs/HPF) as compared with normal-appearing biopsy specimens (10 IELs/HPF) (P< or =.05). Furthermore, the number of TIA-1 or granzyme-B-positive IELs were significantly increased in biopsy specimens with reflux esophagitis (34 and 15 cells/HPF) and Candida esophagitis (44 and 18 cells/HPF) as compared with normal (11 and 2 cells/HPF) (P< or =.05). Granzyme-B and CD-3-positive IELs were also significantly elevated in biopsy specimens with reflux-associated squamous hyperplasia (P< or =.05). Finally, biopsy specimens of patients with dysphagia and to a lesser extent dyspepsia/heartburn exhibited increased numbers of IELs bearing the cytotoxic phenotype when compared with asymptomatic patients. In conclusion, we provide immunohistochemical evidence that most esophageal IELs exhibit the cytotoxic phenotype and that activated cytotoxic IELs are increased in reflux and Candida esophagitis.

Concomitant aseptic meningitis and bacterial urinary tract infection in young febrile infants.

We evaluated the incidence and implications of coexistent bacterial urinary tract infection and aseptic meningitis in 1629 young febrile infants (age 1 to 60 days) who underwent sepsis work-up. Urinary tract infection was diagnosed in 13.2% and aseptic meningitis in 8.8%. Eleven patients (0.7%) had both infections. In view of possible coinfection initial laboratory results may be insufficient for decision-making regarding treatment in young febrile infants.

Dynamics of cholinergic synaptic mechanisms in rat hippocampus after stress.

Changes in high affinity [3H]choline uptake, newly synthesized [3H]acetylcholine release and [3H]quinuclidinylbenzilate (QNB) binding were characterized in crude synaptosomal preparations from rat hippocampus immediately after different intervals of immobilization stress and at different times following chronic intermittent stress (2h once daily for 5 days). Choline uptake was increased to 125% of unhandled controls after 10 min of stress, after 2 h it returned to control levels and after chronic stress uptake was reduced to 75% of control. Acetylcholine release was enhanced after all stress intervals. Maximal muscarinic (QNB) binding capacity (Bmax) was increased to 135% of control only after chronic stress, with no change in Kd values. Following chronic stress the changes observed in cholinergic synaptic mechanisms all persist for up to 2 days. Recovery occurred only by the 7th post-stress day. We conclude: presynaptic hippocampal cholinergic terminals are rapidly activated by stressful stimuli and this is expressed by an increase in choline uptake and newly synthesized acetylcholine release; after prolonged periods of stress adaptive changes in the cholinergic terminals are expressed by a reduction in choline uptake and an elevation in the number of muscarinic binding sites; and the chronic stress-induced changes are slow to recover. The results demonstrate that the septo-hippocampal cholinergic system is an integral part of the adaptive response to stress.

Stress-induced activation of the hippocampal cholinergic system and the pituitary-adrenocortical axis.

The septo-hippocampal cholinergic system in rats undergoes rapid activation after acute stress. This is expressed by rapid increases both in high affinity choline uptake and newly synthesized acetylcholine release. Administration of ACTH or corticosterone at a high dose led 10 min later to changes comparable to those observed after acute stress. Choline uptake and acetylcholine release were also elevated 2 days after adrenalectomy. The effects of adrenalectomy could be attenuated by corticosterone, but not by ACTH treatment. The results demonstrate that (a) after short term stress the septo-hippocampal cholinergic system is activated secondary to activation of the pituitary-adrenocortical axis and (b) major changes in circulating corticosterone can modulate the activity of the hippocampal cholinergic synapse.

The use of bi-cistronic transfer vectors for the baculovirus expression system.

In this communication, we describe the construction of bi-cistronic transfer vectors for the baculovirus expression system (BVES), which are advantageous over the existing vectors. The new vectors provide a simple way to isolate recombinant viruses. More specifically, the gene of interest and the reporter gene luciferase (LUC), constitute the first and second cistrons, respectively, of the same transcript. Therefore, the LUC activity measured during infection of such a bi-cistronic virus, permits an on-line estimation of the recombinant protein level, a very useful feature for large-scale production of recombinant proteins. To achieve expression of the second cistron, the internal ribosome entry site (IRES) element of the encephalomyocarditis virus (EMCV) was employed. However, this element, which is highly efficient in mammalian systems, did not promote efficient internal translation of the second cistron in various insect cells lines originating from different insect species. The lack of efficient internal translation was not due to baculovirus propagation since the same phenomenon was also observed in a viral-free expression system. It seems that a component essential for efficient EMCV IRES activity is either missing or present in limiting amount in insect cells or not compatible. Nevertheless, LUC placed downstream to the IRES element, or immediately downstream to the first cistron, was expressed to a level that enabled the biotechnological application it was designed for.

Brain acetylcholinesterase after parathion poisoning: a comparative quantitative histochemical analysis post-mortem.

The regional distribution of AChE inhibition by parathion in the human brain was examined in a comparative study of the brains of 2 victims of lethal parathion intoxication and 2 control brains matched for age and sex. AChE activity in discrete brain regions was studied by quantitative histochemistry of 40 microns-thick sagittal or coronal cryostat sections from the 4 brains. The inhibition of human brain AChE by parathion is regionally selective. The biggest decreases were observed in the cerebellum, some thalamic nuclei and cortex. Only a moderate decrease (10-30%) was observed in the substantia nigra and basal ganglia, while no effect at all was seen in white matter regions. Detailed knowledge of the brain regions affected by parathion poisoning may explain some of the clinical manifestations of organophosphate poisoning.

The enigma of parkinsonism in chronic borderline mercury intoxication, resolved by challenge with penicillamine.

A 47 year old female dentist suffered from hemiparkinsonism which had started eighteen months earlier and was manifested mainly by resting tremor and cogwheel rigidity. A baseline quantitative urinary mercury excretion was 46 micrograms/day. The patient was treated with chelating agent d-penicillamine for a week. Chelation therapy resulted in clinical improvement of parkinsonism and in dynamic changes in daily urinary mercury excretion with a prompt increase to 79 micrograms/day, a subsequent decline followed by increase in the mercury urinary excretion. After a week chelation therapy was stopped. During a follow-up period of five years, the neurological status remained unchanged after the initial penicillamine-induced improvement. This case may be evidence, therefore, of a rare clinical variant of elemental mercury intoxication associated with parkinsonism, in the absence of most classical neuropsychiatric signs of chronic mercurialism.

Acute sinusitis: a histopathological and immunohistochemical study.

OBJECTIVE: To provide data on the histopathological and immunohistochemical characteristics of acute sinusitis in humans. STUDY DESIGN: A nonrandomized, retrospective, controlled, qualitative and quantitative study. METHODS: Inflamed sinus mucosal tissues were removed during functional endoscopic sinus surgery from 11 patients with acute sinusitis, of whom 6 had complications with extension of inflammation to the orbit (4) or the meninges (2), 3 had recurrent sinusitis, and 2 had acute exacerbation of chronic sinusitis Normal sinus mucosal tissues were retrieved from four patients with various nasal tumors and served as controls All specimens underwent routine histological processing. Representative sections from each region were stained with hematoxylin and eosin, periodic acid-Schiff, and toluidine blue. Immunohistochemical staining for T and B lymphocytes was also applied. A two-phase examination was designed: low-magnification microscopic assessment (x40) to yield the typical pathological features and high-magnification assessment (x400) to count various inflammatory cells. RESULTS: The lamina propria displayed the most significant changes with edema, extensive infiltration of neutrophils and mononuclear cells, formation of microabscesses, thrombophlebitis, and necrotic foci, whereas the involvement of the epithelial layer in the inflammatory reaction was relatively modest. Immunohistochemistry revealed an increase in the population of T and B lymphocytes. The former were diffusely scattered, whereas the latter also formed distinct clusters: around small venules, adjacent to seromucous glands, and under the epithelium. CONCLUSIONS: The inflammatory reaction of the lamina propria exceeded that of the epithelial layer. It is assumed that the clusters of B lymphocytes around blood vessels may point to the fact that these cells were recruited from the blood during acute sinusitis.

Uvulopalatopharyngoplasty: evaluation of postoperative complications, sequelae, and results.

A study of 71 patients with obstructive sleep apnea syndrome was performed to evaluate the effectiveness, complications, and late sequelae of uvulopalatopharyngoplasty. Postoperative immediate complications were of minor importance. In 96% of the patients, the snoring was improved; it was completely resolved in 48%. The postoperative apnea index remained pathologic in all patients who underwent postoperative polysomnography, although mild improvement was noted. Seventy-four percent of our patients felt a subjective postoperative improvement which was not always confirmed by the polysomnographic examination. A record of improvement was obtained in 64% of the operated patients. Our results establish the beneficial effect of uvulopalatopharyngoplasty, which is the recommended surgical procedure for obstructive sleep apnea syndrome.

Use of human amniotic membrane in otolaryngologic practice.

Human amnion is a readily available allograft with low antigenicity, high antimicrobial potential, and the ability to foster epithelialization. We have used human amniotic membrane in our department for replacing nasal mucosa in Rendu-Osler-Weber disease, as tympanic membrane grafts, and for covering head and neck sites after flap necrosis. Our experience shows moderate success for management of severe epistaxis and excellent results in covering surfaces after flap necrosis. Use of amnion in eardrum perforations was unsuccessful and was discontinued. Properties of human amniotic membrane are listed and its application in the otolaryngologic practice is reviewed.

Characterization of smoking-induced nasopharyngeal lymphoid hyperplasia.

The frequency of smoking-induced nasopharyngeal lymphoid hyperplasia in heavy smokers and its potential clinical implications are still unknown. Precise criteria to differentiate this entity from other types of nasopharyngeal lymphoid hyperplasia are needed. A prospective clinicopathological study of smoking-induced nasopharyngeal lymphoid hyperplasia was conducted in 17 heavy smokers. Ten nonsmoking patients, five of them with chronic sinusitis, three with adult-onset adenoid hypertrophy, and two children with adenoidal hypertrophy served as a control group. Both in smokers and in nonsmokers, lymphocytic infiltration of the mucosa was characterized immunohistochemically as T cells. In smokers, semithin (1 micron) sections revealed deformed and migrating cytotoxic lymphocytes in the nasopharyngeal mucosa. The lymphocytes were attached to epithelial, ciliated, and goblet cells, resulting in cell damage. Transmission electron microscopy of biopsies from smokers revealed emperipolesis, characterized by mucosal invasion and epithelial cell damage by an unusual population of migrating T lymphocytes that penetrate them. These findings confirm a direct effect of smoking on the nasopharyngeal lymphoid tissue, which forms part of the immune system. It is concluded that the diagnostic evaluation and therapeutic approach of heavy smokers with otological and airway symptoms should be based on thorough endoscopic examination of the nasopharynx. When the diagnosis is not clear-cut, selective tele-endoscopic biopsy and electron microscopic examination are recommended. This entity should be added to the list of known clinical manifestations of the smoking habit.