Cardiopulmonary exercise testing and cardiopulmonary morbidity in patients undergoing major head and neck surgery.

Cardiopulmonary exercise testing (CPET) is used as a risk stratification tool for patients undergoing major surgery. In this study, we investigated the role of CPET in predicting day five cardiopulmonary morbidity in patients undergoing head and neck surgery. This observational cohort study included 230 adults. We recorded preoperative CPET variables and day five postoperative cardiopulmonary morbidity. Full data from 187 patients were analysed; 43 patients either had incomplete data sets or declined surgery/CPET. One hundred and nineteen patients (63.6%) developed cardiopulmonary morbidity at day five. Increased preoperative heart rate and duration of surgery were independently associated with day five cardiopulmonary morbidity. Those with such morbidity also had lower peak V̇O2 11.4 (IQR 8.4-18.0) vs 16.0 (IQR 14.0-19.7) ml.kg-1.min-1, P<0.0001 and V̇O2 at AT 10.6 (IQR 9.1-13.1) vs 11.5 (IQR 10.5-13.0) ml.kg-1.min-1, p=0.03. Logistic regression model containing peak V̇O2 and duration of surgery demonstrated that increased peak V̇O2 was associated with a reduction in the likelihood of cardiopulmonary complications OR 0.92 (95%CI 0.87 to 0.96), p=0.001. The area under the receiver operating characteristic curve for this model was 0.75(95%CI 0.68 to 0.82), p<0.0001, 64% sensitivity, 81% specificity. CPET can help to predict day five cardiopulmonary morbidity in the patients undergoing head and neck surgery. A model containing peak V̇O2 allowed identification of those with such complications.

Anaphylaxis during general anaesthesia: experience from a drug allergy centre in the UK.

BACKGROUND: Anaphylaxis during general anaesthesia is rare but often severe. Identification of the cause of anaphylaxis and recommendation of a range of drugs or agents likely to be safer for future surgery is a collaborative venture between the allergists and the anaesthesiologists, but it often poses a significant challenge. METHODS: A total of 31 patients who attended the Drug Allergy Unit at University College London Hospital with suspected perioperative anaphylaxis between March 2013 and January 2016 were reviewed retrospectively. RESULTS: The culprit drug was identified in 21 patients (67.7%): antibiotics (n = 11, 52.3%), neuromuscular blocking agents (n = 8, 38.1%), morphine (n = 1, 4.8%) and gelofusine (n = 1, 4.8%). No cause was identified in six patients (19.4%), and four patients (12.9%) had non-allergic reactions. CONCLUSION: Our results confirm that antibiotics and neuromuscular blocking agents are common causative agents of perioperative anaphylaxis in the United Kingdom.

Tracheostomies for the non-expert 1: indications and techniques.

Recent reports have emphasized shortcomings in routine and emergency care leading to adverse outcomes in patients with tracheostomies. This two-part article provides a guide to the principles of care for staff looking after adult patients with tracheostomies in the hospital. The first part looks at indications and techniques.

Tracheostomies for the non-expert 2: routine and emergency care.

Recent reports have emphasized shortcomings in routine and emergency care leading to adverse outcomes in patients with tracheostomies. This two-part article provides a guide to the principles of care for staff looking after adult patients with tracheostomies in the hospital. The second part looks at routine and emergency care.

Perioperative anaesthetic practice for head and neck free tissue transfer -- a UK national survey.

BACKGROUND: Anaesthetic management of microvascular head and neck free flap surgery is based on physiological principles, but data on how these affect clinical outcomes in this challenging group are limited. There are no evidence-based guidelines available in this area. METHODS: To establish current perioperative anaesthetic practice by surveying all UK centres performing head and neck free flap surgery. Anaesthetists from 73 centres performing head and neck microvascular reconstructive surgery in the UK were asked to complete a structured online survey. The survey included general questions, a hypothetical clinical scenario with multiple choice questions and questions about perioperative management. The main outcomes measured were protocols of pre-operative assessment, perioperative fluid and blood pressure strategies, monitoring and post-operative management. RESULTS: Seventy-three units were contacted, and fifty-five responded (75%). Most respondents performed up to two cases per month. Opinion was divided as to how best to manage intra-operative blood pressure, fluid balance, pre-operative assessment and monitoring. Notably 52% preferred crystalloid infusion to increase blood pressure, while 35% stated crystalloids were contraindicated. CONCLUSIONS: Currently in the UK, anaesthetic perioperative management for head and neck free flap transfer is varied, reflecting the paucity of high-quality data in this area; but some techniques, in particular avoidance of excessive crystalloid use, is associated with improved flap outcome.

Randomized controlled trial of the A.P. Advance, McGrath, and Macintosh laryngoscopes in normal and difficult intubation scenarios: a manikin study.

BACKGROUND: Several videolaryngoscopes are available which may facilitate tracheal intubation in difficult airways. We compared the McGrath(®) Series 5 and the Venner™ A.P. Advance™ (APA) videolaryngoscopes with a Macintosh laryngoscope by studying the performance of experienced anaesthetists using manikins in normal and difficult airway scenarios. METHODS: We recruited 48 anaesthetists into a randomized trial. Each performed tracheal intubation with each laryngoscope in one easy and one difficult laryngoscopy scenario. The primary endpoint was time to intubation. Other endpoints were time to best glottic visualization, grade of view, and number of glottic advances. RESULTS: There were no dropouts. In the easy scenario, the time to intubation was greater using the McGrath [median time 40.7 s, inter-quartile range (IQR) 31.0, 57.4, P<0.001] than the other devices. In the difficult scenario, the time to intubation using the APA with Difficult Airway Blade (DAB) was less (median time 23.2 s, IQR 19.8, 29.0, P<0.001) than the other devices. Time to glottic visualization was reduced using the McGrath and the APA with DAB. Glottic advances were fewer using the APA with DAB. CONCLUSIONS: Experienced anaesthetists required a longer time for intubation in a standard manikin using a McGrath compared with other laryngoscopes, but a shorter time for intubation in a difficult manikin using an APA with DAB, and with fewer glottic advances, compared with other laryngoscopes.

Mechanisms of adaptation of glucose transporters to changes in the oxidative chain of muscle and fat cells.

Cells in which glucose uptake is rate limiting respond to hypoxic insults with an increase in glucose transport activity. To understand the underlying cellular mechanisms involved in this adaptive response, the effects of an uncoupler of oxidative phosphorylation, 2,4-dinitrophenol (DNP), and of an inhibitor of the electron transport chain, rotenone, were compared with the effect of hypoxia in L6 muscle cells and 3T3-L1 adipocytes. All three conditions (DNP, rotenone, and 3% oxygen) elevated hexose uptake by approximately twofold in 4 h relative to control cells. All three insults decreased cellular ATP levels rapidly. A subsequent recovery was observed within 1-2 h in the presence of DNP or 3% oxygen, probably as a result of anaerobic production of ATP through increased glucose uptake and glycolysis. DNP and rotenone elevated the content of GLUT-1 protein in isolated plasma membranes and decreased it in intracellular light microsomes, suggestive of translocation of this transporter isoform. No change in GLUT-4 protein distribution was detected. In contrast, 3% oxygen caused a marked specific increase in GLUT-1 protein in both plasma membranes and microsomes. Consistently, cycloheximide had no effect on the hexose transport responses to DNP or rotenone, but prevented the response to hypoxia. However, GLUT-1 mRNA and the total cell content of GLUT-1 protein were elevated by all three treatments. It is proposed that within the time frame studied, reductions in the energy charge may activate the glucose transport system in L6 myotubes and 3T3-L1 adipocytes by GLUT-1 protein biosynthesis and translocation. When both responses exist, the biosynthetic pathway is dispensable, and posttranslational mechanisms, including transporter translocation suffice to sustain the adaptive elevation in glucose transport activity for several hours.

Insulin induces the translocation of GLUT4 from a unique intracellular organelle to transverse tubules in rat skeletal muscle.

Skeletal muscle surface membrane is constituted by the PM domain and its specialized deep invaginations known as TTs. We have shown previously that insulin induces a rapid translocation of GLUT4s from an IM pool to the PM in rat skeletal muscle (6). In this study, we have investigated the possibility that insulin also stimulates the translocation of GLUT4 proteins to TTs, which constitute the largest area of the cell surface envelope. PM, TTs, and IM components of control and insulinized skeletal muscle were isolated by subcellular fractionation. The TTs then were purified further by removing vesicles of SR origin by using a Ca-loading procedure. Ca-loading resulted in a five- to sevenfold increase in the purification of TTs in the unloaded fraction relative to the loaded fraction, assessed by immunoblotting with an anti-DHP-receptor monoclonal antibody. In contrast, estimation of the content of Ca(2+)-ATPase protein (a marker of SR) with a specific polyclonal antibody revealed that most, if not all, SR vesicles were recovered in the Ca-loaded fraction. Western blotting with an anti-COOH-terminal GLUT4 protein polyclonal antibody revealed that acute insulin injection in vivo (30 min) increased the content of GLUT4 (by 90%) in isolated PMs and markedly enhanced (by 180%) GLUT4 content in purified TTs. Importantly, these insulin-dependent changes in GLUT4 content of PM and purified TTs were seen in the absence of changes in the alpha 1-subunit of the Na(+)-K(+)-ATPase, a surface membrane marker.(ABSTRACT TRUNCATED AT 250 WORDS)

Glucose transport in human skeletal muscle cells in culture. Stimulation by insulin and metformin.

Primary human muscle cell cultures were established and the regulation of glucose transport was investigated. Primary cultures were allowed to proceed to the stage of myotubes through fusion of myoblasts or were used for clonal selection based on fusion potential. In clonally selected cultures, hexose (2-deoxy-glucose) uptake into myotubes was linear within the time of study and inhibitable by cytochalasin B (IC50 = 400 nM). Cytochalasin B photolabeled a protein(s) of 45,000-50,000 D in a D-glucose-protectable manner, suggesting identity with the glucose transporters. In the myotube stage, the cells expressed both the GLUT1 and GLUT4 glucose transporter protein isoforms at an average molar ratio of 7:1. Preincubation in media of increasing glucose concentrations (range 5-25 mM) progressively decreased the rate of 2-deoxyglucose uptake. Insulin elevated 2-deoxyglucose uptake in a dose-dependent manner, with half maximal stimulation achieved at 3.5 nM. Insulin also stimulated the transport of the nonmetabolizable hexose 3-O-methylglucose, as well as the activity of glycogen synthase, responsible for nonoxidative glucose metabolism. The oral antihyperglycemic drug metformin stimulated the cytochalasin B-sensitive component of both 2-deoxyglucose and 3-O-methylglucose uptake. Maximal stimulation was observed at 8 h of exposure to 50 microM metformin, and this effect was not prevented by incubation with the protein-synthesis inhibitor cycloheximide. The relative effect of metformin was higher in cells incubated in 25 mM glucose than in 5 mM glucose, consistent with its selective action in hyperglycemic conditions in vivo. Metformin (50 microM for 24 h) was more effective than insulin (1 microM for 1 h) in stimulating hexose uptake and the hormone was effective on top of the stimulation caused by the biguanide, suggesting independent mechanisms of action.

Regulation of glucose transport and GLUT1 glucose transporter expression by O2 in muscle cells in culture.

The effect of varying cellular oxygenation on L6 muscle cell 2-deoxy-D-glucose transport, glucose utilization, lactate production, and expression of GLUT1 and GLUT4 transport proteins was investigated. Incubation of L6 myotubes in 3% O2 (mimicking a state of hypoxia) elevated glucose uptake by 6.5-fold over 48 h relative to cells incubated in 21% O2 (normoxia). Incubation of L6 cells in hyperoxic conditions (50% O2) significantly depressed glucose uptake by 0.4-fold. These effects were fully reversible. Incubation in 3% O2 also caused lactate accumulation and enhanced glucose consumption from the medium. Hypoxia elevated 2-deoxy-D-glucose transport even when the concentration of glucose in the medium was kept constant, suggesting that glucose deprivation alone was not responsible for increased cellular glucose uptake. Incubation in 3% O2 also elevated 3-O-methylglucose uptake but not amino acid uptake. Cycloheximide prevented the hypoxia-induced increase in glucose uptake, indicating that de novo synthesis of glucose transport-related proteins was the major means by which cells increased glucose uptake. The content of GLUT1 glucose transporter was significantly elevated in total membranes of cells incubated in 3% O2 and depressed in membranes from cells incubated in hyperoxic conditions, whereas GLUT4 expression was not affected. These results indicate that hypoxia induces an adaptive response of increasing cellular glucose uptake through elevated expression of GLUT1 in an attempt to maintain supply of glucose for utilization by nonoxidative pathways.

Differential expression of the GLUT1 and GLUT4 glucose transporters during differentiation of L6 muscle cells.

Skeletal muscle is the main tissue responsible for glucose utilization in the fed state, and it expresses the ubiquitous GLUT1 glucose transporter and the muscle/fat specific GLUT4 glucose transporter. Here we investigated the expression of these transporters during muscle cell differentiation in vitro. Rat L6 muscle cells were grown to the stages of myoblasts, alignment and fused myotubes. Glucose (2-deoxy-D-glucose) transport was higher in myoblasts, decreasing with the progression of alignment and cell fusion. Conversely, insulin-stimulated glucose uptake was negligible in myoblasts, and increased with cell alignment and fusion. The cellular content of GLUT1 transporters decreased and that of GLUT4 transporters increased with cell fusion. Insulin rapidly stimulated glucose uptake in fused myotubes maintained in 2% serum but not in 10% serum. In 10% serum, basal glucose uptake increased as did the cellular content of GLUT1 transporters, while GLUT4 transporter content did not change. These results indicate that both transporters are regulated oppositely during muscle cell differentiation, and that high serum concentrations override the capacity of insulin to regulate transport by inducing overexpression of the GLUT1 transporter.

Differential regulation of the GLUT-1 and GLUT-4 glucose transport systems by glucose and insulin in L6 muscle cells in culture.

The regulation by glucose and insulin of the muscle-specific facilitative glucose transport system GLUT-4 was investigated in L6 muscle cells in culture. Hexose transport activity, mRNA expression, and the subcellular localization of the GLUT-4 protein were analyzed. As observed previously (Walker, P. S., Ramlal, T., Sarabia, V., Koivisto, U.-M., Bilan, P. J., Pessin, J. E., and Klip, A. (1990) J. Biol. Chem. 265, 1516-1523), 24 h of glucose starvation and 24 h of insulin treatment each increase glucose transport activity severalfold. Here we report a differential regulation of the GLUT-4 and GLUT-1 transport systems under these conditions. (a) The level of GLUT-4 mRNA was not affected by glucose starvation and was diminished by prolonged (24 h) administration of insulin; in contrast, the level of GLUT-1 mRNA was elevated under both conditions. (b) Glucose starvation and prolonged insulin administration increased the amount of both GLUT-4 and GLUT-1 proteins in the plasma membrane. (c) In intracellular membranes, glucose starvation elevated, and prolonged insulin administration reduced, the GLUT-4 protein content. In contrast, the GLUT-1 protein content in these membranes decreased with glucose starvation and increased with insulin treatment. Glucose transport was rapidly curbed upon refeeding glucose to glucose-starved cells, with half-maximal reversal after 30 min and maximal reversal after 4 h. This was followed by a marked decrease in the levels of GLUT-1 mRNA without major changes in GLUT-4 mRNA. Neither 2-deoxy-D-glucose nor 3-O-methyl-D-glucose could substitute for D-glucose in these effects. It is proposed that glucose and insulin differentially regulate the two glucose transport systems in L6 muscle cells and that the rapid down-regulation of hexose transport activity by glucose is regulated by post-translational mechanisms.

Characterization of glucose transporter-enriched membranes from rat skeletal muscle: assessment of endothelial cell contamination and presence of sarcoplasmic reticulum and transverse tubules.

The subcellular origin of membranes from rat skeletal muscle that contain insulin-responsive glucose transporters was investigated. Rat skeletal muscle membranes were prepared by isopycnic centrifugation in sucrose gradients. In vivo insulin treatment increased the content of GLUT-4 glucose transporters in the 25% sucrose fraction (enriched in the plasma membrane marker 5'-nucleotidase) and decreased it in the 35% sucrose fraction (devoid of plasma membrane markers). The possibility of endothelial cell membrane contamination in these fractions was investigated using a mouse monoclonal antibody, MRC OX-43, raised against a cell surface protein specific to rat vascular endothelium. MRC OX-43 did not react with any of the muscle membrane fractions, but did recognize a protein of around 100 kDa in extracts of human endothelial cells and rat aorta. An antibody to the dihydropyridine receptor of skeletal muscle, IIC12, was used to determine the presence of transverse tubules in these fractions. IIC12 reacted positively with a 180-kDa protein in purified rat transverse tubules. In contrast, this antibody did not cross-react with the 25% or 35% sucrose fractions. The 25% sucrose fraction was devoid of calsequestrin and ryanodine receptor, cisternal sarcoplasmic reticulum markers. However, small amounts of these proteins were detected in the 35% sucrose fraction. The results suggest that the 25% sucrose fraction represents plasma membranes, while the 35% sucrose fraction is an insulin-sensitive intracellular fraction that contains, but is not enriched in, sarcoplasmic reticulum cisternae. The results further show that insulin-induced recruitment of GLUT-4 transporters in skeletal muscles can be demonstrated independently of GLUT-4 recruitment in endothelial cells.

Effect of GTP gamma S on insulin binding and tyrosine phosphorylation in liver membranes and L6 muscle cells.

Guanosine 5'-O-(3-thiotriphosphate) (GTP gamma S), a specific activator of G proteins, did not change the Kd nor total binding of [125I]insulin in plasma membranes from rat liver. Insulin did not alter GTP gamma 35S binding nor polypeptide ADP ribosylation in crude and plasma membranes catalyzed either intrinsically or by cholera toxin. In L6 muscle cells, insulin caused tyrosine phosphorylation of a polypeptide of Mr 160,000. Cell electroporation enabled testing of G protein action in this cellular system. Phosphorylation of the Mr 160,000 polypeptide in these permeabilized cells was insulin and ATP dependent but other small molecules or ionic gradients were not essential. The reaction could not be mimicked by the G protein agonist GTP gamma S nor inhibited by the G protein antagonist guanosine 5'-O-(2-thiodiphosphate) (GDP beta S). However, GTP gamma S effectively decreased insulin-mediated phosphorylation of this polypeptide. This suggests that the tyrosine kinase activity of the insulin receptor can be modulated by G protein agonists. It is concluded that cross talk between the insulin receptor and G proteins could not be demonstrated in isolated membranes by strategies that detect interactions between beta-adrenergic receptors and G proteins. In contrast, in permeabilized cells, G protein-mediated regulation of the insulin receptor kinase activity could be detected.

Exofacial regions of the glucose transporter of human erythrocytes: detection with polyclonal antibodies.

The glucose transporter of human erythrocytes is a glycoprotein of 492 amino acids with a Mr of 55,000. From hydrophobicity plots based on the transporter's amino acid sequence, it has been proposed that exofacially, there are only a segment of 34 residues and the glycosylating carbohydrate branch. To detect changes in the number of glucose transporters during metabolic regulation in intact cells, one should obtain antibodies directed to exofacial sites of the transporter. Antibodies to the purified glucose transporter (Band 4.5), intact or deglycosylated with endoglycosidase F, were raised in rabbits. These antibodies, when purified by column chromatography on protein A-Sepharose and by adsorption onto erythrocyte membranes, cross-reacted with the glycosylated glucose transporter on Western blots. The reactivity of the polyclonal antibodies with intact cells was tested by incubating these cells with the antibody, followed by a centrifugation and a subsequent reaction with 125I-labelled goat-antirabbit immunoglobulin G. Intact human erythrocytes reacted positively with the anti-Band 4.5 antibodies but not with nonimmune sera. Reaction with human erythrocytes was about 10 times greater than with pig erythrocytes, which lack glucose transporters. The reaction with intact cells was not due to contamination with broken cells since under the conditions used, broken (freeze-thawed) cells or membranes did not sediment. Reaction with human erythrocyte membranes was more than fivefold higher than with pig erythrocyte membranes. Rat L6 muscle cells reacted with anti-Band 4.5 antibodies; there were about 10 times more binding sites in any one cell in L6 cells than in human erythrocytes, roughly paralleling their relative content of glucose transporters.(ABSTRACT TRUNCATED AT 250 WORDS)

Insulin-induced decrease in 5'-nucleotidase activity in skeletal muscle membranes.

Insulin releases inositol phosphoglycans from myocytes in culture [(1986) Science 233, 967-972], which display insulinomimetic activity. Because 5'-nucleotidase is anchored to the membrane through inositol-containing phospholipid glycans, we investigated whether insulin could release the enzyme from the membrane. Membranes prepared from hindquarter muscles of rats perfused with insulin showed a 23% decrease in 5'-nucleotidase activity. Isolated membranes from muscle exposed to insulin in vitro also showed a small but reproducible decrease (9%) in 5'-nucleotidase activity relative to unexposed controls. Phospholipase C from Staphylococcus aureus released 60% of the membrane-bound 5'-nucleotidase. We propose that insulin may activate an endogenous phospholipase C that cleaves phospholipid-glycan-anchored proteins.

Distribution of glucose transporters and insulin receptors in the plasma membrane and transverse tubules of skeletal muscle.

The distribution of glucose transporters and of insulin receptors on the surface membranes of skeletal muscle was studied, using isolated plasma membranes and transverse tubule preparations. (i) Plasma membranes from rabbit skeletal muscle were prepared according to Seiler and Fleischer (1982, J. Biol. Chem. 257, 13862-13871), and transverse tubules from rabbit skeletal muscle were prepared according to Rosemblatt et al. (1981, J. Biol. Chem. 256, 8140-8148) as modified by Hidalgo et al. (1983, J. Biol. Chem. 258, 13937-13945). The membranes were identified by the abundance of nitrendipine receptors in the transverse tubules, and their relative absence from the plasma membranes. (ii) Plasma membranes and transverse tubules were also isolated from rat skeletal muscle, according to a novel procedure that isolates both fractions from the same common homogenate. (iii) Glucose transporters were detected by D-glucose protectable binding of the specific inhibitor [3H]cytochalasin B, and insulin receptors were detected by saturable binding of 125I-insulin. The concentration of glucose transporters was about threefold (rabbit) or fivefold (rat) higher in the transverse tubule membrane compared to the plasma membrane, whereas the insulin receptor concentration was about the same in both membranes. These results indicate that the glucose transporters on the surface of the muscle are preferentially segregated to the transverse tubules, and this poses interesting consequences on the functional response of glucose transport to insulin in skeletal muscle.