A comparison of the McGrath videolaryngoscope with direct laryngoscopy for rapid sequence intubation in the operating theatre: a multicentre randomised controlled trial.

Aspiration of gastric contents is a recognised complication during all phases of anaesthesia. The risk of this event becomes more likely with repeated attempts at tracheal intubation. There is a lack of clinical data on the effectiveness of videolaryngoscopy relative to direct laryngoscopy rapid sequence intubation in the operating theatre. We hypothesised that the use of a videolaryngoscope during rapid sequence intubation would be associated with a higher first pass tracheal intubation success rate than conventional direct laryngoscopy. In this multicentre randomised controlled trial, 1000 adult patients requiring tracheal intubation for elective, urgent or emergency surgery were allocated randomly to airway management using a McGrath™ MAC videolaryngoscope (Medtronic, Minneapolis, MN, USA) or direct laryngoscopy. Both techniques used a Macintosh blade. First-pass tracheal intubation success was higher in patients allocated to the McGrath group (470/500, 94%) compared with those allocated to the direct laryngoscopy group (358/500, 71.6%), odds ratio (95%CI) 1.31 (1.23-1.39); p < 0.001. This advantage was observed in both trainees and consultants. Cormack and Lehane grade ≥ 3 view occurred less frequently in patients allocated to the McGrath group compared with those allocated to the direct laryngoscopy group (5/500, 1% vs. 94/500, 19%, respectively; p < 0.001). Tracheal intubation with a McGrath videolaryngoscope was associated with a lower rate of adverse events compared with direct laryngoscopy (13/500, 2.6% vs. 61/500, 12.2%, respectively; p < 0.001). These findings suggest that the McGrath videolaryngoscope is superior to a conventional direct laryngoscope for rapid sequence intubation in the operating theatre.

How the mapping of threshold concepts across a master's programme in health professions education could support the development of mastersness.

INTRODUCTION: Global trends towards the professionalization of Health Professions Education (HPE) have catalyzed the proliferation of degree-awarding programmes in HPE. We apply the theoretical lens of threshold concepts to explore the required levels of Master's in HPE (MHPE) learning and teaching, with a view to determining how students might be supported to engage meaningfully with learning. METHODS: Qualitative data were collected with a series of nominal group discussions. The methodology and data analysis followed a consensus building approach. RESULTS: Four threshold concepts were identified: Being in the HPE world, the nature of HPE knowledge, the nature of HPE practice and the nature of HPE scholarship. We also mapped the threshold concepts to the World Federation for Medical Education (WFME) master's level academic skills and the Scottish Quality Assurance Agency (QAA) facets of mastersness. CONCLUSION: It is envisaged that our findings will enhance alignment between the outcomes and assessment in an MHPE programme, form the basis of understanding feedback received from students, and inform teaching and supervisory practices. The findings also complement the WFME and QAA frameworks by clarifying the depth and complexity of academic skills expected at master's level and informing teaching and learning approaches to support the development of the identified threshold concepts.

Comparison of forces acting on maxillary incisors during tracheal intubation with different laryngoscopy techniques: a blinded manikin study.

Dental trauma is a common complication of tracheal intubation. As existing evidence is insufficient to validly assess the impact of different laryngoscopy techniques on the incidence of dental trauma, the force exerted onto dental structures during tracheal intubation was investigated. An intubation manikin was equipped with hidden force sensors in all maxillary incisors. Dental force was measured while 104 anaesthetists performed a series of tracheal intubations using direct laryngoscopy with a Macintosh blade, and videolaryngoscopy with a C-MAC® , or the hyperangulated GlideScope® or KingVision® laryngoscopes in both normal and difficult airway conditions. A total of 624 tracheal intubations were analysed. The median (IQR [range]) peak force of direct laryngoscopy in normal airways was 21.1 (14.0-32.8 [2.3-127.6]) N and 29.3 (17.7-44.8 [3.3-97.2]) N in difficult airways. In normal airways, these were lower with the GlideScope and KingVision hyperangulated laryngoscopes, with a reduction of 4.6 N (p = 0.006) and 10.9 N (p < 0.001) compared with direct laryngoscopy, respectively. In difficult airways, these were lower with the GlideScope and KingVision hyperangulated laryngoscopes, with a reduction of 9.8 N (p < 0.001) and 17.6 N (p < 0.001) compared with direct laryngoscopy, respectively. The use of the C-MAC did not have an impact on the median peak force. Although sex of anaesthetists did not affect peak force, more experienced anaesthetists generated a higher peak force than less experienced providers. We conclude that hyperangulated videolaryngoscopy was associated with a significantly decreased force exerted on maxillary incisors and might reduce the risk for dental injury in clinical settings.

Comparative usability of modern anaesthesia ventilators: a human factors study.

BACKGROUND: The anaesthesia ventilator represents the key equipment for intraoperative respiratory care. Improper operation of this device may threaten a patient's health. A self-explanatory interface facilitates handling and decreases the risk of operating errors. This study systematically evaluates the usability of user interfaces in four modern anaesthesia ventilators. METHODS: Twenty naïve operators were asked to execute 20 tasks on each of four different anaesthesia ventilators (Avance CS2™, GE Healthcare; Flow-i™, Maquet; and Perseus™ and Primus™, Dräger) in a randomized order. The success of task execution, frequency of requests for assistance, and processing times were recorded. During the tasks, the operators' visual focus was measured via eye-tracking. Additionally, subjective assessments of usability were evaluated by a standardized questionnaire. For comparison, six experienced operators undertook the same protocol. RESULTS: The overall rate of falsely executed tasks was low. Naïve operators requested assistance least when using the Perseus (26). Pooled processing times were shortest for the Perseus (222 s), followed by the Primus (223 s), the Avance (238 s), and the Flow-i (353 s). Task-specific processing times differed considerably between the devices. Eye-tracking analyses revealed associated interface issues that impeded the operators' performance. Operators rated usability best for the Perseus [mean (sd): 67 (17) arbitrary units] and worst for the Flow-i [50 (16) arbitrary units]. Results from experienced operators support these findings by trend. CONCLUSIONS: The usability of modern anaesthesia ventilators differs considerably. Interface issues of specific tasks impair the operator's efficiency. Eliminating the specific usability issues might improve the operator's performance and, as a consequence, the patient's safety.

[Chest pain at 32 weeks' gestation: pregnancy-related spontaneous coronary artery dissection]. / Thorakale Schmerzen in der 32. Schwangerschaftswoche : Spontane Dissektion eines Koronargefäßes in der Schwangerschaft.

A 32-year-old woman at 32 weeks gestation presented with cardiac arrest due to ventricular tachycardia following acute chest pain at home. After immediate defibrillation with return of spontaneous circulation (ROSC), an ST segment elevation myocardial infarction due to coronary artery dissection was confirmed. Two drug-eluting stents were implanted and she was placed on dual antiplatelet therapy (DAPT). The echocardiogram showed akinesis of the apex and anterior wall. The patients risk for stent thrombosis was considered high and therefore DAPT was continued until cesarean section at 35 weeks gestation. Intraoperatively she received two units of packed red blood cells, one platelet concentrate, 4 g fibrinogen and 2 g tranexamic acid. Left ventricular ejection fraction deteriorated 8 days after delivery and the patient developed congestive heart failure.

Identification of acquired coagulation disorders and effects of target-controlled coagulation factor substitution on the incidence and severity of spontaneous intracranial bleeding during veno-venous ECMO therapy.

INTRODUCTION: Intracranial haemorrhage is a redoubtable complication during extracorporeal membrane oxygenation (ECMO) therapy. The underlying mechanisms of haemorrhagic diathesis are still not completely understood. This study was performed to evaluate a coagulation protocol for the regular analysis of acquired coagulation disorders and the systematic substitution of coagulation factors to reach predefined target values. We hypothesised that using this strategy would lead to the identification of acquired bleeding disorders which cannot be monitored with standard coagulation tests and that substitution of the respective factors in a target-controlled approach could have an impact on the incidence and severity of intracranial haemorrhage. METHODS: A protocol for the analysis of acquired coagulation disorders and the subsequent administration of associated factor concentrates was introduced. Previously, coagulation management was mainly based on clinical bleeding signs as the trigger for the administration of blood products. In this investigation, nineteen consecutive patients before (control group) and twenty consecutive patients after the implementation of the protocol (intervention group) have been included in the study. RESULTS: Eighty-eight percent of the patients developed factor XIII deficiency, 79% acquired von Willebrand syndrome, 40% fibrinogen deficiency and 54% of the patients showed a decline in platelet count >20% within the first 24 hours of ECMO therapy. In 6 out of 19 (31%) patients in the control group and in 2 patients out of 20 (10%) in the intervention group, intracranial haemorrhage was detected. Whilst 5 of 6 patients in the control group died because of fatal bleeding, both of the patients in the intervention group recovered with a favourable neurologic outcome. CONCLUSIONS: Veno-venous ECMO therapy leads to thrombocytopenia, factor XIII and fibrinogen deficiency as well as acquired von Willebrand syndrome. The implementation of a coagulation protocol including a standardized determination and target-controlled substitution of coagulation factors may have a beneficial impact on the incidence and severity of intracranial haemorrhage.

[Teaching emergency medicine at the University Medical Center Freiburg: establishment of an integrative concept]. / Lehrveranstaltung Notfallmedizin am Universitätsklinikum Freiburg : Etablierung eines integrativen Gesamtkonzeptes.

Efforts to improve the quality of undergraduate medical education are commonly hampered by limited human and financial resources. This deficiency may be offset by the development of well structured and innovative teaching concepts, which optimize available assets. The newly conceived modular course "Emergency Medicine" at the University Medical Center Freiburg was conducted for the first time in the winter semester 2006/2007. The core of the course is a 3-day practical training period. It provides the possibility to teach a maximum number of medical students with only four lecturers using patient simulators, interactive case scenarios (simulation software MicroSim), and case scenarios with standardized patients. Evaluation of the course revealed standardized patients to be the best of all teaching methods with an overall average grade of 1.1 (patient simulators 1.2, computer simulation 1.4). Of the students, 88% stated that the practical training encouraged their interest in the speciality emergency medicine. The excellent student evaluation results show that the new course "Emergency Medicine" for medical students constitutes a successful balance between the constraint of resource limitation and the goal of excellent medical education.

Changing the Dimensions of Suberin Lamellae of Green Cotton Fibers with a Specific Inhibitor of the Endoplasmic Reticulum-Associated Fatty Acid Elongases.

The fibers of the green lint mutant of cotton (Gossypium hirsutum L.) contain large amounts of wax and are suberized. More than 96% of the bifunctional aliphatic suberin monomers ([alpha],[omega]-alkanedioic acids and [omega]-hydroxyalkanoic acids) have chain lengths of C22 and C24 in green cotton fiber suberin. In fibers grown in the presence of S-ethyl-N,N-dipropylthiocarbamate (EPTC), a specific inhibitor of the endoplasmic reticulum-associated fatty acid elongases, the aliphatic suberin monomers were shortened to chain lengths of C16 and C18. Whereas the amounts of most suberin monomers were not negatively affected by the inhibitor treatment, the amounts of [alpha],[omega]-alkanedioic acids and of glycerol were reduced by more than 80%. Analysis in the transmission electron microscope showed a reduction in suberin content after EPTC treatment. The suberin layers were discontinuous and consisted of fewer lamellae than in the controls. A small proportion (up to 22%) of the electron-translucent suberin lamellae were thinner after EPTC treatment, probably because of the shortening of the aliphatic suberin monomers. A larger proportion of the electron-translucent lamellae were thicker than the lamellae in the controls. Possible explanations for this observation are discussed.

Glycerol is a suberin monomer. New experimental evidence for an old hypothesis

The monomer composition of the esterified part of suberin can be determined using gas chromatography-mass spectroscopy technology and is accordingly believed to be well known. However, evidence was presented recently indicating that the suberin of green cotton (Gossypium hirsutum cv Green Lint) fibers contains substantial amounts of esterified glycerol. This observation is confirmed in the present report by a sodium dodecyl sulfate extraction of membrane lipids and by a developmental study, demonstrating the correlated accumulation of glycerol and established suberin monomers. Corresponding amounts of glycerol also occur in the suberin of the periderm of cotton stems and potato (Solanum tuberosum) tubers. A periderm preparation of wound-healing potato tuber storage parenchyma was further purified by different treatments. As the purification proceeded, the concentration of glycerol increased at about the same rate as that of alpha,omega-alkanedioic acids, the most diagnostic suberin monomers. Therefore, it is proposed that glycerol is a monomer of suberins in general and can cross-link aliphatic and aromatic suberin domains, corresponding to the electron-translucent and electron-opaque suberin lamellae, respectively. This proposal is consistent with the reported dimensions of the electron-translucent suberin lamellae.

Assessment of automated capillary electrophoresis for therapeutic and diagnostic drug monitoring: determination of bupivacaine in drain fluid and antipyrine in plasma.

In an effort to evaluate the use of electrokinetic capillary technology for therapeutic and diagnostic drug monitoring, samples were analysed batchwise with an automated, high-throughput capillary electrophoretic instrument coupled to an inexpensive PC data acquisition and evaluation system. Examples studied included the capillary electrophoretic (HPCE) determination of bupivacaine in drain fluid collected after pulmonary surgery and the micellar electrokinetic capillary chromatographic (MECC) determination of antipyrine in human plasma. Analyses for antipyrine could be accomplished without any sample pretreatment whereas bupivacaine required extraction prior to analysis. Antipyrine determination was effected through external calibration using either peak areas, relative peak areas or peak heights. The intraday and interday reproducibilities (n = 15) of the evaluated concentrations were 1.5-3% and 5-6%, respectively. For bupivacaine, determination based on internal and external calibration employing peak areas and peak heights was investigated. The intraday and interday reproducibilities (n = 5) of bupivacaine concentrations were about 1% and 2%, respectively, for internal calibration and both about 5% for external calibration. The electrokinetic capillary data compared well with data obtained by gas chromatography (bupivacaine) and high-performance liquid chromatography (antipyrine).

A monoclonal antibody directed against the beta 1-adrenergic receptor from turkey erythrocyte membranes.

A monoclonal antibody was raised against the affinity purified beta 1-adrenergic receptor from turkey erythrocytes. This antibody, B120, of the IgG1 isotype, precipitates the photoaffinity-labeled purified receptor and the corresponding binding activity. The antibody recognizes the 42 kDa component of the receptor of erythrocyte membranes, after electrotransfer on nitrocellulose. B120 does not inhibit binding of dihydroalprenolol on membranes and has no effect on the activity of adenylate cyclase. Since specific immunofluorescence was detected only after ethanol treatment of the erythrocytes, the epitope recognized by B120 appears not to be accessible at the cell surface.

Factors affecting the determination of drugs and endogenous low molecular mass compounds in human serum by micellar electrokinetic capillary chromatography with direct sample injection.

Factors influencing the establishment of an analytical window in front of the solubilized proteins in micellar electrokinetic capillary chromatography (MECC) with direct serum injection (DSI) are discussed. Both drugs and endogenous low molecular mass compounds eluting within the analytical window are identified concurrently by multi-wavelength absorption detection. Variables such as the concentration of the micelle forming substance, ionic strength, applied voltage, initial sample zone length, capillary length, selected buffer additives, insufficient renewal of the buffer in the anodic buffer vial and sample matrix are shown to impact MECC of endogenous compounds and model drugs, such as antiepileptics. For two drugs eluting within the analytical window, phenobarbital and ethosuximide, serum levels determined by DSI with external calibration are shown to compare well with levels obtained after liquid-liquid extraction and internal calibration (use of an internal standard). In addition, reproducibility of both assays is excellent. The limit of employing DSI is demonstrated with the determination of the hydrophobic drug phenytoin. Using an automated, commercial instrument and naproxen as model drug, high-speed MECC separations of high reproducibility and with a throughput of 12-15 samples per h are presented.

Assessment of impact of physico-chemical drug properties on monitoring drug levels by micellar electrokinetic capillary chromatography with direct serum injection.

The impact of physico-chemical properties of 25 compounds, including antiepileptic, anti-inflammatory and beta-blocking drugs, on their determination by micellar electrokinetic capillary chromatography (MECC) with direct serum injection (DSI) is discussed. Having a pH 9.2 buffer containing 75 mM sodium dodecyl sulfate (SDS), elution is dependent on hydrophobicity, the order of emergence being basically according to increasing octanol/water partition coefficients (logP values). Peak shape is determined by the dissociation behavior (expressed by pKa) and plasma protein binding (PPB). Sharp peaks are produced by compounds having low PPB and, independently of PPB, by drugs with pKa values which are similar to the buffer pH. Broad or double peaks are established by drugs of low pKa values and significant (> about 40%) PPB. In order to evaluate the effective amount of a protein-bound drug measured by MECC-DSI, serum levels of drugs with different PPB, namely ethosuximide (no PPB), phenobarbital (PPB of about 50%) and naproxen (PPB > 99%) have been determined by both MECC-DSI and MECC with extract injection (MECC-EXI). In each case, with more than 40 sera, there is good agreement between the two sets of data. Thus, employing MECC-DSI, total amounts of drugs are determined, i.e. a complete release of the drugs from the proteins is effected by the impact of dodecyl sulfate on the sampled proteins.

Rapid determination of the antimycotic drug flucytosine in human serum by micellar electrokinetic capillary chromatography with direct sample injection.

The rapid determination of flucytosine (5-FC) in human serum by micellar electrokinetic capillary chromatography (MECC) with direct sample injection is discussed. Minute (nanoliter) quantities of patient sera are applied to the beginning of a fused silica capillary filled with a phosphate/borate buffer (pH 9.2) containing 75 mM sodium dodecyl sulfate. Upon application of an electric field along the capillary, endogenous and drug substances are transported toward the cathode and separated into distinct zones that are detected by on-column ultraviolet absorption. Depending on the capillary and instrument used, 5-FC is shown to elute within 2-3.5 min of current application and free of endogenous interferences. 5-FC becomes also well separated from another often coadministered antimycotic drug, amphotericin B. Thus, quantitation of 5-FC is accomplished without any sample pretreatment. MECC data of 60 patient sera produced on two different automated instruments and 5-FC serum levels obtained by an agar-based bioassay are shown to agree well. For MECC, intraday and interday reproducibility data (80 micrograms/ml level) are shown to be < or = 4.5 and < 7%, respectively. Due to short run times and short capillary equilibration time intervals between runs, a sample throughput of 15/h is feasible. Thus, this technology is suitable for rapid determination of 5-FC serum levels, the time requirement for running a complete calibration, two control sera, and several patient samples being approximately 1 h only.

Determination of phenobarbital, ethosuximide, and primidone in human serum by micellar electrokinetic capillary chromatography with direct sample injection.

The determination of antiepileptic drugs in human serum by micellar electrokinetic capillary chromatography (MECC) with direct sample injection is discussed. Nanoliter quantities of patient sera are applied to the beginning of a fused silica capillary filled with a phosphate/borate buffer (pH 9.2) containing 75 mM sodium dodecylsulfate. Upon application of an electric field along the capillary, endogenous and drug substances are transported toward the cathode and separate into distinct zones which are detected by on-column UV absorption. Phenobarbital, ethosuximide, and primidone are shown to elute in front of the solubilized proteins, thus permitting quantitation of these drugs without any sample pretreatment. For phenobarbital and ethosuximide, MECC data obtained using the external standard method and peak areas as the basis for quantitation are shown to be in excellent agreement with those of nonisotopic immunoassays and, for ethosuximide, also with those of high-performance liquid chromatography. The correlation coefficients (n = 50) are between 0.972 and 0.986. Intraday and interday reproducibility data are 2.0-4.5% and 4.5-8.0%, respectively. For primidone, insufficient samples have been available for a comprehensive comparison of MECC data with those of other analytic techniques.

Capillary electrophoresis for drug analysis in body fluids.

Capillary zone electrophoresis (CZE) and micellar electrokinetic capillary chromatography (MECC) represent attractive methods for the determination of drugs and metabolites in body fluids. In CZE, minute (nanoliter) quantities of samples are applied to the beginning of a fused-silica capillary filled with buffer. On application of a high-voltage DC field, charged solutes begin to separate and are swept through the capillary by the combined action of electrophoresis and electroosmotic bulk flow and are on-column detected toward the capillary end. In MECC, the buffer contains charged micelles (e.g., dodecyl sulfate micelles) and both uncharged and charged solutes separate based on differential partitioning between the micelles and the surrounding buffer and, if charged, also by differential charge effects, including electrophoresis. Based on validated MECC drug assays developed in our laboratory, key aspects of measuring drug levels by MECC, including sample preparation, solute detection and identification, quantitation, reproducibility, and quality assurance are discussed. Drug levels determined by MECC are shown to be in good agreement with those obtained by nonisotopic immunoassays and/or high-performance liquid chromatography (HPLC). Using on-column multi-wavelength detection, this technology is also well suited for toxicological drug screening and confirmation and for the exploration of drug metabolism. Compared with HPLC and gas chromatography, capillary electrophoresis has distinct advantages, including automation, small sample size, minimal sample preparation, use of very small amounts of organic solvents and inexpensive chemicals, ease of buffer change and method development, and low cost of capillary columns. Electrokinetic capillary assays are complementary to the widely employed immunoassays. The state of the art and the pros and cons of capillary electrophoresis for the determination of drugs in body fluids are discussed with the goal of encouraging newcomers to start using this emerging analytical methodology.

Clinical and forensic applications of capillary electrophoresis.

This survey is aimed at giving the readers a short overview of the present state of the art of clinical and forensic applications of capillary electrophoresis. First, the principles associated with electrokinetic capillary separations and instrumentation, sample preparation and solute quantitation are briefly discussed. This is followed by chapters describing the determination of endogenous and exogenous compounds in body fluids and tissue extracts. Finally, a survey of major achievements including reference to fully developed electrokinetic capillary assays is provided. The paper concludes with a brief outlook.

Caffeic acid and glycerol are constituents of the suberin layers in green cotton fibres.

The fibres of the green-lint mutant (Lg) of cotton (Gossypium hirsutum L.) are suberized and contain a large proportion of wax. The unidentified components of the wax were separated into a colourless fluorescent fraction and a yellow pigmented fraction. Using ultraviolet spectroscopy and nuclear-magneticresonance ((1)H-NMR) spectroscopy, esterified trans-caffeic acid was identified as the only phenolic component in the colourless fraction. This fraction was further purified and was shown to contain caffeic acid esterified to fatty acids (mainly ω-hydroxy fatty acids), and glycerol in molar ratios of 4∶5∶5. When 2-aminoindan-2-phosphonic acid (AIP), an inhibitor of phenylalanine ammonia-lyase (EC 4. 3. 1. 5.) was added to ovules cultured in vitro, at the beginning of secondary wall formation, the fibres remained white and the colourless caffeic-acid derivative and the yellow compounds could no longer be detected by ultraviolet spectroscopy. Fibres grown in the presence of AIP were also examined in the electron microscope. Secondary cell walls were present in the treated fibres, but the electron-opaque suberin layers were replaced by apparently empty spaces. This result indicates that cinnamic-acid derivatives are covalently linked to suberin and have a structural role within the polymer or are involved in anchoring the polymer to the cellulosic secondary wall. Purified cell walls of green cotton fibres contained about 1% (of the dry weight) of bound glycerol, 0.9% of the glycerol being extractable with the wax fraction and 0.1% remaining in the cell-wall residue. The corresponding values for white fibres were 0.03% (total), 0.02% (wax), and 0.01% (cell-wall residue). Fibres synthesizing their secondary walls in the presence of AIP contained about normal amounts of bound glycerol in the wax fraction, but glycerol accumulation in the cell-wall residue was inhibited by about 95%. These observations indicate that glycerol is an important constituent of cotton-fibre suberin. Considerable amounts of bound glycerol could also be determined in exhaustively extracted cell walls of the cork layer of potato periderm (1.2%) and smaller amounts in the outer epidermal cell wall of Agave americana L. leaf (0.1%) indicating that the presence of glycerol in suberins and possibly also in cutins may be more widespread than previously thought.

Regulation of intestinal vitamin D receptor expression in experimental uraemia: effects of parathyroidectomy and administration of PTH.

In this study, the effects of PTH on binding of [3H]-1,25-dihydroxyvitamin D3 [1,25(OH)2D3] and on vitamin D receptor (VDR) mRNA concentration were assessed in intestinal mucosa of subtotally nephrectomized rats (Nx) and in intestinal mucosa of sham-operated rats with normal kidney function (Intact). Intestinal 1,25(OH)2D3 binding capacity of Intact remained unchanged (i) after parathyroidectomy (PTx), (ii) after administration of PTH for up to 6 days, and (iii) after PTx and subsequent administration of PTH (n = 4 experiments). In contrast, PTx of subtotally nephrectomized animals (Nx-PTx) decreased 1,25(OH)2D3 binding capacity from 757 +/- 95 fmol/mg protein in Nx to 417 +/- 42 in Nx-PTx (P < 0.01, n = 5). PTH administration had no effect on intestinal 1,25(OH)2D3 binding capacity in Nx. However, PTH administration to Nx-PTx resulted in re-elevation of 1,25(OH)2D3 binding capacity to a level (790 +/- 113 fmol/mg protein) which was comparable to Nx. Kd-values remained unaltered under all experimental conditions. The intestinal VDR mRNA concentration (normalized to beta-actin mRNA) was decreased, on average, by 23% in Nx-PTx (P < 0.05 versus Nx). In further experiments, 1,25(OH)2D3 was administered to Nx-PTx. This resulted in upregulation of 1,25(OH)2D3 binding capacity as compared to vehicle-treated Nx-PTx (562 +/- 90 fmol/mg protein versus 249 +/- 32, P < 0.01). The latter results could indicate that PTH-mediated stimulation of residual renal 1,25(OH)2D3 production was involved in PTH-mediated up-regulation of intestinal 1,25(OH)2D3 binding capacity in Nx-PTx. To rule out this possibility, PTH was administered to totally nephrectomized and parathyroidectomized rats (TNx-PTx). Since PTH caused an approximately 80% increase (P < 0.05) in intestinal 1,25(OH)2D3 binding capacity under those experimental conditions a mediator role of 1,25(OH)2D3 could be excluded. Functional significance of decreased intestinal 1,25(OH)2D3 binding capacity in Nx-PTx as compared to Nx was demonstrated by significantly lower 1,25(OH)2D3-mediated stimulation of intestinal 25(OH)D3-24-hydroxylase activity in Nx-PTx (209 +/- 68 pmol/mg protein) than in Nx (385 +/- 81, P < 0.01). The modulation of intestinal 1,25(OH)2D3 binding capacity was not correlated with changes in calcium, phosphate or 1,25(OH)2D3 serum concentrations under our experimental conditions. Taken together, intact parathyroid gland function was required to maintain adequate intestinal VDR expression in experimental uraemia (but not in normal animals). The mechanism of the modulation of intestinal VDR by PTH remains to be elucidated although an indirect effect of PTH on VDR expression in intestinal mucosa seems most likely.