[Intravenous beta-2-adrenergic agonists for tocolytic therapy in pre-eclampsia: two cases of acute pulmonary edema]. / Bêta 2-mimétiques intraveineux pour tocolyse au cours de la prééclampsie: deux cas d'oedème aigu du poumon.

Two cases of pulmonary oedema during beta 2-adrenergic agonist therapy in pre-eclampsia pregnant patients are reported. In our first case, the pulmonary oedema was exceptionally severe, because the patient (twins at 26 SA) had to be intubated and ventilated, but the caesarean section was performed only 6 weeks later. These two clinical observations underline the fact that B2 adrenergic agonist are not indicated for the treatment of preeclampsy. Furthermore they suggest that such patients should be rapidly admitted to intensive care units.

[The measurement of end-tidal carbon dioxide (PETCO2) is not a significant parameter to monitor in patients with severe traumatic brain injury]. / La pression télé expiratoire en CO2 n'est pas un paramètre pertinent de surveillance d'un traumatisme crânien grave.

PURPOSE: To evaluate the agreement between end-tidal carbon dioxide (PETCO2) and arterial CO2 (PaCO2) in patients with traumatic brain injury and to document the course of the (PaCO2-PETCO2) gradient over time. METHODS: Twenty one traumatic brain injury patients (Coma Glasgow Scale < or = 8) were included in this prospective observational study over a period of six months. Simultaneous determinations of PaCO2 and PETCO2 (by infrared capnometry) were recorded. Agreement between PaCO2 and PETCO2 was determined by the statistical method described by Bland and Altman. Changes in PETCO2 over time were compared with changes in PaCO2. Factors likely to explain a gradient superior to +/- 4 mmHg were explored. RESULTS: One hundred and eleven data pairs were obtained. The bias was 5.5 mmHg with a precision of 5.1 mmHg and limits of agreement ranged from -4.5 mmHg to 15.5 mmHg. The latter exceeded the predefined limits of agreement established to determine interchangeability between methods (+/- 4 mmHg). PETCO2 and PoCO2 changed in opposite directions in 20% of 90 consecutive measurements. Only the duration of ventilation was found to be significantly associated with a gradient superior to +/- 4 mmHg. CONCLUSIONS: In this selected population of patients with severe traumatic brain injury, measurements of PETCO2 and PaCO2 are not interchangeable. Further the PoCO2-PETCO2 gradient is not stable over time and cannot predict variations of PaCO2. The use of PETCO2 instead of PaCO2 could be deleterious in patients in whom strict control of PaCO2 values is required.

Evidence for the need of bedside accuracy of pulse oximetry in an intensive care unit.

OBJECTIVE: To compare pulse oximetry saturation (Spo2 with arterial blood gas saturation (SaO2) obtained during clinical routine to determine the optimal lowest reliable value of SpO2 in ventilator-dependent patients before setting up a nurse-directed protocol of FIO2 titration. DESIGN: Prospective clinical study. SETTING: Surgical intensive care unit in a university hospital. PATIENTS: Thirty-three patients with a pulse oximeter probe in whom arterial blood gas was measured with a radial artery line. INTERVENTIONS: SPO2 was recorded by the nurses and compared with SaO2 obtained by blood gas analysis with a co-oximeter. Two sensors currently used in our surgical intensive care unit and connected to a monitor (HP OmniCare M1165/66A; Hewett Packard, Andover, MA) were tested. In group I, the Durensor DS 100A (Nellcor Puritan Bennett, Pleasanton, CA), a reusable sensor, was used. In group II, the Oxisensor D25L (Nellcor Puritan Bennett), a nonreusable sensor, was used. MEASUREMENTS AND MAIN RESULTS: In group 1, 64 data pairs were obtained. In this group, SaO2 ranged from 87 to 98% and SpO2 ranged from 92 to 100%. The bias was -1.90% and the limits of agreement ranged from -5.56 to 1.76%. In group 11, 47 data pairs were obtained. In this group, SaO2 ranged from 87 to 99% and SpO2 ranged from 92 to 100%. The bias was -2.49% and the limits of agreement ranged from -6.62 to 1.64%. CONCLUSIONS: In the range of SaO2 tested, regardless of the sensor used, SpO2 overestimated SaO2. Large limits of agreement were found. Based on this result, the authors concluded that before defining a nurse-directed protocol of FIO2 titration with SpO2, the material used daily must be evaluated. A minimum threshold SpO2 value of 96% in both groups I and II is more reliable to ensure SaO2 > or = 90%.

Pseudo-native motifs in the noncovalent heme-apocytochrome c complex. Evidence from antibody binding studies by enzyme-linked immunosorbent assay and microcalorimetry.

When beef heart apocytochrome c is unfolded, it folds upon noncovalent heme binding (Dumont, M. E., Corin, A. F., and Campbell, G.A. (1994) Biochemistry, 33, 7368-7378). Here, the conformation of the heme-apocytochrome noncovalent complex is compared with that of holocytochrome c. A purification method was designed for obtaining in large amounts apocytochrome c that was shown by amino acid analysis and mass spectroscopy to be chemically intact. The apoprotein and its noncovalent complex were characterized by absorption, fluorescence, circular dichroism, and sedimentation velocity, confirming previous reports. Sedimentation-diffusion equilibrium showed that the apoprotein and its noncovalent complex with heme were monomeric. Surprisingly, whereas apocytochrome c was quite soluble, the noncovalent complex slowly formed heavy aggregates, thus precluding experiments at the concentrations needed for structural studies. Two monoclonal antibodies that bind strongly to distinct antigenic sites on native holocytochrome were used to probe the noncovalent complex conformation. For both antibodies, the affinity for the noncovalent complex was only about 5-10-fold smaller than that for native holocytochrome c, and about 50-100-fold larger than that for apocytochrome c. These results indicate that the noncovalent complex, although not entirely native, carries some pseudo-native structural motifs.

-Pancreatitis after blunt injuries to the abdomen-. / Pancréatite après traumatisme fermé de l'abdomen.

Three cases of pancreatitis occurring after a trauma to the pancrease are reported. They emphasize the difficulty of diagnosis at the initial phase of the condition. In all cases, computerized tomography (CT) scan was the main diagnostic method. Applying the same therapeutic strategy for pancreatitis as for other aetiologies facilitated a favourable outcome.

Evaluation of a new semi-continuous cardiac output system in the intensive care unit.

PURPOSE: A new semi-continuous thermodilution cardiac output (CCO) system has been developed recently (Opti-Q and Q-vue Abbott critical care system). The aim of this study was to compare the accuracy and reproducibility of this new device with conventional ice-bolus thermodilution cardiac output (BCO). METHODS: Fifteen critically ill patients who needed pulmonary artery catheterization were prospectively investigated. Eighty seven paired data using BCO and CCO methods were compared. Reproducibility was assessed from 90 BCO and 87 CCO determinations by calculation of the mean standard error (SEM) and according to Bland and Altman methodology. RESULTS: The BCO and CCO ranged from 2.46 to 11.20 L.min-1 and from 1.75 to 10.05 L.min-1 respectively. Bias (mean difference between BCO and CCO) was null (0.002 L.min-1, P = 0.98), precision (SD of the bias) was 0.74 L.min-1 and the limits of agreement (mean difference +/- 1.96 SD) ranged from -1.45 to 1.45 L.min-1. The threshold to consider two cardiac outputs as different (3 x SEM) was equivalent for BCO and CCO (0.54 and 0.465 L.min-1 respectively). According to the Bland and Altman method, reproducibility of CCO was greater than that of BCO; bias of repeated measurements of BCO and CCO were 0.15 L.min-1 (P < 0.05) and 0.047 L.min-1 (NS), respectively. CONCLUSION: Compared with BCO, this new device was accurate but cannot be considered as interchangeable regarding the limits of agreement. Reproducibility of CCO was superior to BCO.

Value of early blood Th-1 cytokine determination in predicting severity of acute pancreatitis.

BACKGROUND: Early evaluation of the severity of acute pancreatitis (AP) requires measurement of many variables within 48 h after admission. Septic complications (SC) are frequent, and preliminary studies have highlighted the value of prophylactic antibiotherapy; however, single and reliable predictive markers of sepsis are not yet available. The aim of this study was to assess the value of determining early blood Th-1 cytokines and their natural antagonists (interleukin-6 (IL-6), IL-1, IL-1ra, and the soluble form of tumor necrosis factor (sTNF) receptors RI and RII) to predict the severity and SC during AP. METHODS: Thirty-seven patients with AP were prospectively included; 25 of them had severe AP, including 8 with SC. Serum cytokines were measured 48 h and 72 h after the onset of AP with an enzyme-linked immunosorbent assay. The optimal severity or SC diagnostic thresholds was determined using receiver operative curves. RESULTS: Severe AP in accordance with the Atlanta criteria were better predicted by C-reactive protein and IL-6 serum determination, albeit these levels could not predict absolutely the death of two patients. In severe AP cases (n = 25) the IL-1 to IL-1-ra ratio was lower in cases further complicated by sepsis ((6+/-4) 10(-3) versus (34+/-13) 10(-3), P < 0.05); moreover, sTNF RI (2497+/-270 pg/ml versus 2133+/-611 pg/ml, P < 0.05) and RII (3751+/-400 pg/ml versus 3045+/-509 pg/ml, P < 0.05) were higher in AP characterized by further SC. The IL-1 to IL-1-ra ratio and IL-1 concentration were dramatically decreased within the first 48 h ((0.4+/-0.4) 10(-3) versus (30+/-11) 10(-3), P < 0.05, and 0.3+/-0.3 versus 15+/-3 ng/l, P < 0.05) in patients with further infection of the pancreatic necrosis (n = 3). The SC diagnosis was better anticipated by an IL-1 to IL-1-ra ratio lower than 5 x 10(-3) or by an sTNF RI higher than 1750 pg/ml and sTNF RII higher than 2750 pg/ml, and the infection of the pancreatic necrosis by an IL-1 concentration <2 ng/l or an IL-1 to IL-1-ra ratio <2 x 10(-3). CONCLUSION: Besides severity markers, IL-1, IL-1-ra, and sTNF RI and RII should be considered in base-line AP assays and, if confirmed by larger studies, could help to screen patients at risk for SC and candidates for prophylactic antibiotherapy with a good negative predictive value.

The "pre-molten globule," a new intermediate in protein folding.

In vitro folding studies of several proteins revealed the formation, within 2-4 msec, of transient intermediates with a large far-UV ellipticity but no amide proton protection. To solve the contradiction between the secondary structure contents estimated by these two methods, we characterized the isolated C-terminal fragment F2 of the tryptophan synthase beta 2 subunit. In beta 2, F2 forms its tertiary interactions with the F1 N-terminal region. Hence, in the absence of F1, isolated F2 should remain at an early folding stage with no long-range interactions. We shall show that isolated F2 folds into, and remains in, a "state" called the pre-molten globule, that indeed corresponds to a 2- to 4-msec intermediate. This condensed, but not compact, "state" corresponds to an array of conformations in rapid equilibrium comprising native as well as nonnative secondary structures. It fits the "new view" on the folding process.

Lack of coupling between secondary structure formation and collapse in a model polypeptide that mimics early folding intermediates, the F2 fragment of the Escherichia coli tryptophan-synthase beta chain.

The isolated, 101-residue long C-terminal (so called F2) fragment of the beta chain from Escherichia coli tryptophan synthase was shown previously to fold into an ensemble of conformations that are condensed, to contain large amounts of highly dynamic secondary structures, and to behave as a good model of structured intermediates that form at the very early stages of protein folding. Here, solvent perturbations were used to investigate the forces that are involved in stabilizing the secondary structure (monitored by far-UV CD) and the condensation of the polypeptide chain (monitored by dynamic light scattering) in isolated F2. It was observed that neither the ionic strength, nor the pH (between 7 and 10), nor salts of the Hofmeister series affected the global secondary structure contents of F2, whereas some of these salts affected the collapse slightly. Addition of trifluoroethanol resulted in a large increase in both the amount of secondary structure and the Stokes radius of F2. Conversely, F2 became more condensed upon raising the temperature from 4 to 60 degrees C, whereas in this temperature range, the secondary structure undergoes significant melting. These observations lead to the conclusion that, in isolated F2, there is no coupling between the hydrophobic collapse and the secondary structure. This finding will be discussed in terms of early events in protein folding.

[Mesenteric vein infarction associated with congenital antithrombin III (ATIII) deficiency]. / Infarctus veineux mésentérique associé à un déficit congénital en antithrombine III (ATIII).

A venous mesenteric infarction in a 27-year-old patient is reported. This patient presented a genetic quantitative AT-III deficiency without anticoagulation therapy. Ultrasonography revealed portal vein thrombosis and laparoscopy showed mesenteric vein infarction. Laparotomy was performed mmediately and revealed segmental infarction of 60 cm of the jejunum which was resected; the portal vein was considered to be partially occluded on palpation. No strangulation or mechanical factors were identified. Immediately postoperatively the patient received therapeutic doses of heparin with AT-III concentrates to increase AT-III levels; no recurrent thrombotic episode was observed. A systematic second-look operation 24 hours postoperatively showed good bowel viability. Five days later, long-term anticoagulation with acenocoumarol was decided. Twelve days later, ultrasonography showed complete portal revascularization which was confirmed by a third surgical operation on D60.

Importance of residues 2-9 in the immunoreactivity, subunit interactions, and activity of the beta 2 subunit of Escherichia coli tryptophan synthase.

The epitope recognized by a monoclonal antibody (mAb19) directed against the beta 2 subunit of Escherichia coli tryptophan synthase was found to be carried by residues 2-9 of the beta chain. The affinities of mAb19 for peptides of different lengths containing the 2-9 sequence were close to 0.6 x 10(9) M-1, the affinity of mAb19 for native beta 2. In view of these results, a model is proposed to account for the kinetics of appearance of the epitope during in vitro renaturation of beta 2 (Murry-Brelier, A., and Goldberg, M.E. (1988) Biochemistry 27, 7633-7640). A mutant producing beta chains lacking residues 1-9 (beta delta 1-9) was prepared. The beta delta 1-9 protein was able to fold into a heat stable homodimer resembling wild type beta 2. Isolated beta delta 1-9 had no detectable enzymatic activity. It could bind alpha chains extremely weakly and be slightly activated. In the presence of the 1-9 peptide, the beta delta 1-9 protein could bind alpha chains much more strongly and generate a 50% active enzyme. Thus, although having little role in the overall folding and stability of the protein, the 1-9 sequence of the beta chain appears strongly involved in the alpha-beta interactions and in the enzymatic activity.

[Massive entero-mesenteric infarction. A possible role of ostial stenosis of digestive arteries]. / Infarctus entéro-mésentérique massif. Rôle possible d'une sténose ostiale des artères digestives.

A case is reported of a 35-year-old woman who sustained a massive intestinal infarction requiring a total resection of small intestine and the colon, with a terminal duodenostomy. Preoperative arteriography and intraoperative findings at laparotomy showed a thrombosis of coeliac trunc, superior and inferior mesenteric arteries, originating possibly from a non atheromatous ostial stenosis of these vessels. The blood supply to stomach, duodenum, liver and spleen was maintained through collaterals from diaphragm. Postoperatively a dehiscence of duodenostomy suture occurred with a spontaneous favourable outcome. The closure of external duodenostomy orifice required an endoscopic aspirational gastrostomy. The patient was discharged with the perspective of intestinal transplantation, her nutrition being provided through an ambulatory parenteral nutritional support unit. A symptomatology of chronic mesenteric ischaemia should lead to an angiography of digestive arteries not only with a diagnostic but also a possible therapeutic goal using angioplasty techniques.

Native disulfide bonds greatly accelerate secondary structure formation in the folding of lysozyme.

To assess the respective roles of local and long-range interactions during protein folding, the influence of the native disulfide bonds on the early formation of secondary structure was investigated using continuous-flow circular dichroism. Within the first 4 ms of folding, lysozyme with intact disulfide bonds already had a far-UV CD spectrum reflecting large amounts of secondary structure. Conversely, reduced lysozyme remained essentially unfolded at this early folding time. Thus, native disulfide bonds not only stabilize the cfinal conformation of lysozyme but also provide, in early folding intermediates, the necessary stabilization that favors the formation of secondary structure.

[Bilateral phrenic nerve paralysis after heart surgery]. / Paralysie phrénique bilatérale après chirurgie cardiaque.

A bilateral phrenic nerve paralysis after open heart surgery with cold cardioplegia in a 78-year-old patient is reported. This injury is observed after aortic valve replacement without use of an ice slush around the pericardium and no surgical or other direct nerve trauma. The diagnosis of clinical and radiologic abnormalities suggestive of phrenic dysfunction is assisted by portable sonography and measurement of the diaphragmatic compound muscle action potential after cervical transcutaneous phrenic nerve stimulation. This bilateral phrenic nerve paralysis required prolonged mechanical ventilation for 68 days with incomplete regression of the neuropathy five months after surgery.

[Post-traumatic hemiplegia in a patient with fibromuscular dysplasia of the carotid artery]. / Hémiplégie posttraumatique sur dysplasie fibromusculaire carotidienne.

A 44-year-old patient, without remarkable medical history, was admitted with a head trauma with initial loss of consciousness and a thoracic trauma. The initial treatment included the insertion of a chest drain for evacuation of a pneumothorax and intrapleural analgesia with bupivacaine. The day after admission, the patient experienced a generalized epileptic crisis, without prodomes. Later, a left proportional hemiplegia with aphasia was recognized. The CT scan obtained immediately after the crisis, as well as the carotid Doppler ultrasonography and echocardiography were normal. The bilateral carotid angiography showed an image of fibromuscular dysplasia of the extracranial segment of the right internal carotid artery. The migration of a carotid thrombus initiated by the trauma was hypothetized. A treatment with a platelet aggregation inhibiting drug was started and associated 20 days later with low molecular weight heparin. The patient recovered a normal motility within 10 days; only the aphasia remained. Trauma of the carotid artery is not a frequent cause of cerebrovascular accident. The occurrence of the latter is favoured by a pre-existing lesion of this artery. This case demonstrates that in a trauma patient not all central nervous system manifestations are initiated by a head trauma.

Kinetic resolution of peptide bond and side chain far-UV circular dichroism during the folding of hen egg white lysozyme.

The kinetics of regain of the native ellipticity in the far- and near-UV spectra have been investigated during the refolding at pH 7.8 and 20 degrees C of guanidine-unfolded, nonreduced hen egg white lysozyme. Stopped-flow studies showed that the ellipticities at 260 and 289.5 nm exhibit biphasic kinetics with rate constants of about 50 s-1 and 2.5 s-1 for the rapid and slow phase, respectively. The ellipticity in the far-UV obeyed triphasic kinetics. In addition to a rapid and a slow phase with rate constants similar to those observed in the near-UV, a "burst" of ellipticity was shown to occur in the dead time of the experiments. The effects of low pH and of concentrations of guanidine ranging from 0.075 to 1.5 M on the rapid and slow rate constants were studied. Under all conditions investigated, the rate constants observed in the far- and near-UV for a given phase were the same, thus suggesting that the molecular events observed in the two regions of the UV spectrum are either identical or strongly coupled. Continuous-flow experiments at different wavelengths between 214 and 240 nm under conditions where the dead time for the observation was only 4 ms, followed by a detailed analysis of the kinetics of ellipticity change at each wavelength, provided the spectrum of the molecular species formed at the end of the burst phase. This spectrum was found to closely fit that predicted from the secondary structure of native lysozyme.(ABSTRACT TRUNCATED AT 250 WORDS)

A possible initial folding intermediate: the C-terminal proteolytic domain of tryptophan synthase beta chains folds in less than 4 milliseconds into a condensed state with non-native-like secondary structure.

The isolated F2-V8 peptide corresponding to the 101 C-terminal residues of Escherichia coli tryptophan synthase beta chains folds into a heat-stable, yet fluctuating, condensed state that contains a lot of secondary structure. However, this state has non-native-like secondary and supersecondary structures [Chaffotte, A., Guillou, Y., Delepierre, M., Hinz, H.-J., & Goldberg, M. E. (1991) Biochemistry 30, 8067-8074]. To characterize the rate of appearance of this state, stopped-flow studies on the far-ultraviolet circular dichroism (CD) and on the binding of 1-anilino-8-naphthalenesulfonate (ANS) have been conducted during the folding of guanidine-unfolded F2-V8. It was shown that both the CD signal at 222 nm and the ANS binding properties of folded isolated F2-V8 were regained, at 20 degrees C, within the dead time of the stopped-flow apparatus, which was 4 ms. At 12 degrees C, the binding of ANS was also completed within this dead time, but the ellipticity showed some minor later changes. After a rapid overshoot of the CD signal that occurred during the 4-ms dead time, a small readjustment of the ellipticity to the final value occurred more slowly and was completed after about 25 ms. Thus, even at 12 degrees C, the hydrophobic core and most of the secondary structure of folded F2-V8 were formed in less than 4 ms. These observations strongly suggest that the previously described condensed non-native-like state of F2-V8 results from a very rapid, nonspecific, hydrophobic collapse. It is proposed that such a state may be a general early intermediate in protein folding.

Inclusion bodies of the thermophilic endoglucanase D from Clostridium thermocellum are made of native enzyme that resists 8 M urea.

Endoglucanase D from Clostridium thermocellum was purified from inclusion bodies formed upon its overproduction in Escherichia coli, using 5 M urea as a solubilizing solution. We examined the effects of denaturing agents upon the stability of the pure soluble enzyme as a function of the temperature. At room temperature, guanidinium chloride induces an irreversible denaturation. By comparison, we observed no structural or functional effects at room temperature using high concentrations of urea as denaturing agent. The irreversible denaturation process observed with guanidinium chloride also occurs with urea but only at elevated temperature (greater than or equal to 60 degrees C); in 6 M urea, the activation energy of the denaturation reaction is decreased by a factor of only 1.8. We interpret the high resistance of this protein to urea as reflecting a reduced flexibility of its structure at normal temperatures which should be correlated to the thermophilic origin of this protein.

The isolated C-terminal (F2) fragment of the Escherichia coli tryptophan synthase beta 2-subunit folds into a stable, organized nonnative conformation.

Proteolysis of the beta 2-subunit of Escherichia coli tryptophan synthase by the endoproteinase Glu C from Staphylococcus aureus V8 yields a peptide, F2, corresponding to the C-terminal 101 residues of the beta-chain. The conformation and stability of isolated F2 in phosphate buffer at pH 7.8 (where native beta 2 is stable) have been investigated. Circular dichroism spectra in the far-UV showed the presence of large amounts of secondary structure (19% alpha-helices, 34% extended beta-structures). Circular dichroism spectra in the near-UV and sedimentation velocity studies indicated an open globular structure with the aromatic side chains in a symmetric (or disordered) environment. NMR spectra and rates of amide proton exchange showed that F2 fluctuates rapidly between several conformations. The thermal denaturation of F2 observed by the loss of far-UV circular dichroism with increasing temperature appeared noncooperative, and indicates a high thermal stability (Tm = 70 degrees C). Differential scanning microcalorimetry confirmed the absence of cooperativity and indicated a very low value for the calorimetric enthalpy of denaturation (delta H = 17 kJ/mol). All these properties were compatible with a molten globule. However, the low sedimentation coefficient of F2 suggested a very hydrated and/or expanded structure, and the secondary structure content of isolated F2 (see above) differed widely from that reported in the literature for F2 within the context of native beta 2 (49% alpha-helices and 13% extended beta-structures). Thus, neither the secondary nor the tertiary structure of isolated F2 resembled those of native F2. In this respect, isolated F2 is not a "molten globule".(ABSTRACT TRUNCATED AT 250 WORDS)

Pressure-induced changes in the secondary structure of the Escherichia coli methionine repressor protein.

The effect of hydrostatic pressure on the conformational properties of the E. coli methionine repressor protein in aqueous solution was investigated by infrared spectroscopy. Changes in hydrostatic pressure produce dramatic changes in the spectral region of the conformation-sensitive amide I band. As the pressure is raised up to 18 kbar, the protein undergoes a rearrangement of alpha-helical segments into beta-type structures; after the pressure is released the beta-strands reconvert into less ordered alpha-helical or random segments.