A randomised controlled trial comparing fibreoptic-guided tracheal intubation through two supraglottic devices: Ambu® AuraGain™ laryngeal mask and LMA® Fastrach™.

The Ambu®AuraGain™ laryngeal mask (LM) (Ambu A/S, Ballerup, Denmark) is one of the few readily available second-generation supraglottic airway devices (SADs) that offer a conduit for fibreoptic-guided endotracheal intubation. We aimed to compare fibreoptic intubation through this device with the LMA® (laryngeal mask airway) Fastrach™ (Teleflex Medical, Co. Westmeath, Ireland), which has been a recommended dedicated rescue device for the management of the unanticipated difficult airway. This randomised controlled trial compared a previously described fibreoptic score in 116 patients with no known airway pathology, who had asleep fibreoptic endotracheal intubation via either the AuraGain LM or the LMA Fastrach. Time, ease and success rate of SAD and endotracheal tube (ETT) insertion and complications were recorded. The AuraGain LM demonstrated better laryngeal alignment with 29 out of 59 patients in the AuraGain LM (AG) group having a Grade 4 view (only vocal cords visible), compared to 20 out of 54 patients in the LMA Fastrach (FT) group (P=0.003). It allowed significantly quicker and easier ETT intubation when used as a conduit. The AuraGain LM was also quicker to insert compared to the Fastrach LMA. Similar rates of minor complications, such as sore throat and dysphonia occurred in both groups. Our study indicates that when used in patients with complete muscle relaxation and no known airway pathology, the AuraGain LM achieves better laryngeal alignment and quicker, easier and more successful fibreoptic-guided ETT intubation than the Fastrach LMA.

The use of Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) for pre-oxygenation in neurosurgical patients: a randomised controlled trial.

This study explored the use of high-flow nasal oxygen (HFNO) in both pre-oxygenation and apnoeic oxygenation in adults who were intubated following a non-rapid sequence induction. Fifty patients were randomised to receive pre-oxygenation via a standard facemask or the Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) device. After five minutes of pre-oxygenation, induction and muscle relaxant agents were given. While waiting for complete paralysis, patients in the standard facemask group received bag-mask ventilation (BMV), whereas patients in the HFNO group received apnoeic oxygenation via the THRIVE device. Serial blood samples for arterial blood gas analysis were taken. Baseline patient and airway characteristics were similar. The median PaO2 after pre-oxygenation was 357 (interquartile range [IQR] 324-450 [range 183-550]) mmHg in the facemask group, compared to 471 (IQR 429-516 [range 185-550]) mmHg in the HFNO group (P=0.01). The median arterial partial pressure of oxygen (PaO2) in the HFNO group decreased after a period of apnoeic oxygenation, and was significantly lower when compared to patients who received BMV in facemask group. The arterial carbon dioxide partial pressure (PaCO2) level after complete paralysis was significantly higher in the HFNO group when compared to the facemask group (median 52 [IQR 48-55 {range 40-65}] versus median 43 [IQR 40-48 {range 35-63}] mmHg, P=0.0005 and P=0.004 respectively). There were no differences in the time to muscle paralysis and time to intubation. Seven patients required use of airway adjuncts during BMV in the facemask group, compared to none in the HFNO group (P=0.004). No complications were observed in either group. HFNO produces a higher PaO2 after pre-oxygenation and safe PaO2 during intubation. However, the subsequent fall in PaO2 and rise in PaCO2 indicates that it is not as effective as BMV in maintaining oxygenation and ventilation following neuromuscular blockade.

A randomised controlled trial comparing high-flow nasal oxygen with standard management for conscious sedation during bronchoscopy.

Traditional conscious sedation for endobronchial ultrasound procedures places patients at risk of desaturation, and high-flow nasal oxygen may reduce the risk. We designed a parallel-group randomised controlled trial of high-flow nasal oxygen at a flow rate of 30-70 l.min-1 via nasal cannulae, compared with standard oxygen therapy at 10 l.min-1 via a bite block in adults planned for conscious sedation for endobronchial ultrasound. The primary outcome was the proportion of patients experiencing desaturation (defined as SpO2 < 90%). Secondary outcomes included oxygen saturation after pre-oxygenation, lowest oxygen saturation during procedure, number of hypoxic episodes, duration of hypoxia, end-procedure end-tidal CO2 , satisfaction scores and complications. Thirty participants were allocated to each group. Baseline patient characteristics, procedure time and anaesthetic agents used were similar between the groups. Desaturation occurred in 4 out of 30 patients allocated to the high-flow nasal oxygen group, compared with 10 out of 30 allocated to the standard oxygenation group, a non-significant difference (p = 0.07) with intention to treat analysis. The difference was significant (p = 0.047) when using a per-protocol analysis. Oxygen saturation after pre-oxygenation and the lowest oxygen saturation during procedure were significantly higher in the high-flow nasal oxygen group compared with the standard oxygenation group; median (IQR [range] 100 (99-100 [93-100]) vs. 98 (97-99 [94-100]), p = 0.0001 and 97.5 (94-99 [77-100]) vs. 92 (88-95 [79-98]), p < 0.001, respectively. There were no differences in other secondary outcomes. Although high-flow nasal oxygen may prevent desaturation due to some causes, it does not protect against hypoxaemia in all circumstances.

Mitochondrial fusion is regulated by Reaper to modulate Drosophila programmed cell death.

In most multicellular organisms, the decision to undergo programmed cell death in response to cellular damage or developmental cues is typically transmitted through mitochondria. It has been suggested that an exception is the apoptotic pathway of Drosophila melanogaster, in which the role of mitochondria remains unclear. Although IAP antagonists in Drosophila such as Reaper, Hid and Grim may induce cell death without mitochondrial membrane permeabilization, it is surprising that all three localize to mitochondria. Moreover, induction of Reaper and Hid appears to result in mitochondrial fragmentation during Drosophila cell death. Most importantly, disruption of mitochondrial fission can inhibit Reaper and Hid-induced cell death, suggesting that alterations in mitochondrial dynamics can modulate cell death in fly cells. We report here that Drosophila Reaper can induce mitochondrial fragmentation by binding to and inhibiting the pro-fusion protein MFN2 and its Drosophila counterpart dMFN/Marf. Our in vitro and in vivo analyses reveal that dMFN overexpression can inhibit cell death induced by Reaper or γ-irradiation. In addition, knockdown of dMFN causes a striking loss of adult wing tissue and significant apoptosis in the developing wing discs. Our findings are consistent with a growing body of work describing a role for mitochondrial fission and fusion machinery in the decision of cells to die.

Deoxyribonuclease IIalpha is required during the phagocytic phase of apoptosis and its loss causes perinatal lethality.

Deoxyribonuclease IIalpha (DNase IIalpha) is one of many endonucleases implicated in DNA digestion during apoptosis. We produced mice with targeted disruption of DNase IIalpha and defined its role in apoptosis. Mice deleted for DNase IIalpha die at birth with many tissues exhibiting large DNA-containing bodies that result from engulfed but undigested cell corpses. These DNA-containing bodies are pronounced in the liver where fetal definitive erythropoiesis occurs and extruded nuclei are degraded. They are found between the digits, where apoptosis occurs, and in many other regions of the embryo. Defects in the diaphragm appear to cause death of the mice due to asphyxiation. The DNA in these bodies contains 3'-hydroxyl ends and therefore stain positive in the TUNEL assay. In addition, numerous unengulfed TUNEL-positive cells are observed throughout the embryo. Apoptotic cells are normally cleared rapidly from a tissue; hence the persistence of the DNA-containing bodies and TUNEL-positive cells identifies sites where apoptosis occurs during development. These results demonstrate that DNase IIalpha is not required for the generation of the characteristic DNA fragmentation that occurs during apoptosis but is required for degrading DNA of dying cells and this function is necessary for proper fetal development.

The cloning, genomic structure, localization, and expression of human deoxyribonuclease IIbeta.

Acidic endonuclease activity is present in all cells in the body and much of this can be attributed to the previously cloned and ubiquitously expressed deoxyribonuclease II (DNase II). Database analysis revealed the existence of expressed sequence tags and genomic segments coding for a protein with considerable homology to DNase II. This report describes the cloning of this cDNA, which we term deoxyribonuclease IIbeta (DNase IIbeta) and comparison of its expression to that of the originally cloned DNase II (now termed DNase IIalpha). The cDNA encodes a 357 amino acid protein. This protein exhibits extensive homology to DNase IIalpha including an amino-terminal signal peptide and a conserved active site, and has many of the regions of identity that are conserved in homologs in other mammals as well as C. elegans and Drosophila. The gene encoding DNase IIbeta has identical splice sites to DNase IIalpha. Human DNase IIbeta is highly expressed in the salivary gland, and at low levels in trachea, lung, prostate, lymph node, and testis, whereas DNase IIalpha is ubiquitously expressed in all tissues. The expression pattern of human DNase IIbeta suggests that it may function primarily as a secreted enzyme. Human saliva was found to contain DNase IIalpha, but after immunodepletion, considerable acid-active endonuclease remained which we presume is DNase IIbeta. We have localized the gene for human DNase IIbeta to chromosome 1p22.3 adjacent (and in opposing orientation) to the human uricase pseudogene. Interestingly, murine DNase IIbeta is highly expressed in the liver. Uricase is also highly expressed in mouse but not human liver and this may explain the difference in expression patterns between human and mouse DNase IIbeta.

Deoxyribonuclease II: structure and chromosomal localization of the murine gene, and comparison with the genomic structure of the human and three C. elegans homologs.

Deoxyribonuclease II (DNase II) has been implicated in diverse functions including degradation of foreign DNA, genomic instability, and in mediating the DNA digestion associated with apoptosis. The production of a mouse deleted for DNase II would clearly help to discriminate these functions. We have cloned and sequenced the mouse gene encoding DNase II. It was found to have a similar intron/exon structure to the human gene, although introns 3 and 5 are considerably shorter. The gene is located on mouse chromosome 8. The order of genes at this locus is mGCDH, mEKLF, mDNase II, mSAST, which is the same order that these genes are found on human chromosome 19. The GenBank database contains incorrect expressed sequence tags (ESTs) for the 3' end of the mouse mRNA. Furthermore, the gene structure of two of the three homologs in C. elegans is also incorrectly predicted in the database. We have established the correct intron/exon structure for these genes and show the conserved sequence and structure of the C. elegans, murine and human genes.

Cleavage and nuclear translocation of the caspase 3 substrate Rho GDP-dissociation inhibitor, D4-GDI, during apoptosis.

While investigating endonucleases potentially involved in apoptosis, an antisera was raised to bovine deoxyribonuclease II, but it recognized a smaller protein of 26 kDa protein in a variety of cell lines. The 26 kDa protein underwent proteolytic cleavage to 22 kDa concomitantly with DNA digestion in cells induced to undergo apoptosis. Sequencing of the 26 kDa protein identified it as the Rho GDP-dissociation inhibitor D4-GDI. Zinc, okadaic acid, calyculin A, cantharidin, and the caspase inhibitor z-VAD-fmk, all prevented the cleavage of D4-GDI, DNA digestion, and apoptosis. The 26 kDa protein resided in the cytoplasm of undamaged cells, whereas following cleavage, the 22 kDa form translocated to the nucleus. Human D4-GDI, and D4-GDI mutated at the caspase 1 or caspase 3 sites, were expressed in Chinese hamster ovary cells which show no detectable endogenous D4-GDI. Mutation at the caspase 3 site prevented D4-GDI cleavage but did not inhibit apoptosis induced by staurosporine. The cleavage of D4-GDI could lead to activation of Jun N-terminal kinase which has been implicated as an upstream regulator of apoptosis in some systems. However, the results show that the cleavage of D4-GDI and translocation to the nucleus do not impact on the demise of the cell.

Expression and activity of urokinase and its receptor in endothelial and pulmonary epithelial cells exposed to asbestos.

An elongated endothelial cell phenotype, which demonstrated increased ICAM-1-dependent neutrophil adherence, was induced when these cells were exposed to noncytotoxic concentrations of asbestos (Treadwell et al., Toxicol. Appl. Pharmacol. 139, 62-70, 1996). The present study examined mechanisms underlying this phenotypic change by investigating the effects of asbestos on transcription factor activation and expression of urokinase-type plasminogen activator (uPA) and its receptor uPAR. In situ zymography was used to compare the effects of these fibers on the activity of uPA. Cultures incubated with chrysotile or crocidolite asbestos, but not refractory ceramic fiber 1 (RCF-1), demonstrate localized cleavage of plasminogen, which was inhibited by amiloride. Immunocytochemistry showed that chrysotile-stimulated uPA activity was associated with a time-dependent augmentation of uPAR protein levels. RT-PCR analysis was used to investigate molecular mechanisms for these increases. Chrysotile asbestos, but not RCF-1, increased endothelial cell uPA message, relative to changes in beta-actin mRNA. This response to asbestos was not limited to endothelial cells, since both uPA and uPAR mRNA levels increase in human bronchial epithelial BEAS-2B cells exposed to chrysotile fibers. Finally, both types of asbestos, but not RCF-1, increased nuclear levels of nuclear factor-kappaB (NF-kappa B), a transcription factor common to increased expression of ICAM-1 and uPA. These data demonstrate that asbestos caused fiber-specific activation of endothelial and pulmonary epithelial cells, resulting in phenotypes capable of facilitating tissue remodeling.

The cloning and expression of human deoxyribonuclease II. A possible role in apoptosis.

We have previously implicated deoxyribonuclease II (DNase II) as an endonuclease responsible for DNA digestion during apoptosis. The full-length human cDNA has now been cloned. The cDNA contains an open reading frame of 1078 bases coding for a 40-kDa protein. This protein is 10 kDa larger than commercially supplied enzyme, which has been proteolytically cleaved at an internal aspartate residue. The gene is located at chromosome 19p13.2, and has no significant homology to other human proteins, but has >30% identity to three predicted genes in Caenorhabditis elegans. To determine whether overexpression of DNase II induces apoptosis in Chinese hamster ovary cells, the cDNA was cotransfected with a plasmid encoding green fluorescent protein. Within 24 h, a significant proportion of green fluorescent protein-positive cells contained condensed chromatin, whereas vector-only controls remained viable. Considering that DNase II is normally active only at low pH, it was surprising that transfection induced chromatin condensation. To confirm that transfection was not activating another endonuclease, cells were incubated with the caspase inhibitor benzyloxycarbonyl-Val-Ala-Asp-(O-methyl)-fluoromethylketone; this failed to inhibit chromatin condensation induced by DNase II. These results demonstrate that DNase II acts downstream of caspase activation and that it may be activated by an as yet unknown mechanism to induce DNA digestion during apoptosis.

Transcutaneous electrical nerve stimulation (TENS) as a pain-relief device in obstetrics and gynecology.

Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological and non-invasive pain-relief method that has been proven effective for a variety of conditions. Electrical therapy has been recognized for a long time but its practical clinical application in the form of TENS has been evaluated only during the last 30 years as a result of several theories on pain. The most known of these with regard to TENS development is the "gate theory", although several others have also played a role. In obstetrics and gynecology, TENS has been found to be effective in alleviating labor pain and in the treatment of primary dysmenorrhea. It has also been used successfully following obstetric and gynecologic surgery. In order to be effective in clinical use for obstetric and gynecologic indications, a TENS device must have certain properties, which are detailed in this review. Although new TENS devices that meet all the necessary requirements have been developed and tested, their use is still far from widespread. Patients and medical staff should be encouraged to try the TENS device for obstetric and gynecologic indications, since it is non-invasive, efficient, and easy to use.