[Algorithm for securing an unexpected difficult airway : User analysis on a simulator]. / Algorithmus zur Sicherung des unerwartet schwierigen Atemwegs : Eine Anwenderanalyse am Simulator.

BACKGROUND: Critical incidents in difficult airway management are still a main contributory factor for perioperative morbidity and mortality. Many national associations have developed algorithms for management of these time critical events. For implementation of these algorithms the provision of technical requirements and procedure-related training are essential. Severe airway incidents are rare events and clinical experience of the individual operators is limited; therefore, simulation is an adequate instrument for training and evaluating difficult airway algorithms. OBJECTIVE: The aim of this observational study was to evaluate the application of the institutional difficult airway algorithm among anesthetists. MATERIAL AND METHODS: After ethics committee approval, anesthetists were observed while treating a "cannot intubate" (CI) and a "cannot intubate, cannot ventilate" (CICV) situation in the institutional simulation center. As leader of a supportive team the participants had to deal with an unexpected difficult airway after induction of anesthesia in a patient simulator. The following data were recorded: sequence of the applied airway instruments, time to ventilation after establishing a secured airway using any instrument in the CI situation and time to ventilation via cricothyrotomy in the CICV situation. Conformity to the algorithm was defined by the sequence of the applied instruments. Analysis comprised conformity to the algorithm, non-parametric tests for time to ventilation and differences between junior and senior anesthetists. RESULTS: Out of 50 participants 45 were analyzed in the CI situation. In this situation 93% of the participants acted in conformity with the algorithm. In 62% the airway was secured by flexible intubation endoscopy, in 38% with another device. Data from 46 participants were analyzed in the CICV situation. In this situation 91% acted in conformity with the algorithm. The last device used prior to the decision for cricothyrotomy was flexible intubation endoscopy in 39%, a laryngeal mask in 22% and other instruments in 39%. Of the 50 participants 38 had already been institutionally trained in difficult airway management during the previous 2 years. For cricothyrotomy the participants needed a median time of 63 s and there was no difference between junior and senior anesthetists (p = 0.46). The cricothyrotomy was performed faster using a surgical approach than a transtracheal puncture approach using a Melker emergency cricothyrotomy set (52 s vs. 73 s, p = 0.014). CONCLUSION: The conformity to the algorithm of over 90% indicates a good training level of the participants concerning the difficult airway algorithm. In the observed sample flexible intubation endoscopy tended to be of high significance even in the unanticipated difficult airway. Cricothyrotomy was performed faster surgically than by the use of the transtracheal puncture approach, while no differences between junior and senior anesthetists were observed. For the successful management of an unexpected difficult airway, specific training of these special and rare events is crucial. A standardized provision of special airway instruments stored in a special trolley and frequent application of this trolley in the clinical routine is recommended.

[Is the Bishop-Koop anastomosis in treatment of neonatal ileus still current?]. / Ist die Bishop-Koop'sche Anastomose bei der Behandlung des Neugeborenenileus noch zeitgemäss?

Fourty-three cases of ileus in newborns are presented. Twenty-seven newborns received a Bishop-Koop anastomosis. In 19 cases, the Bishop-Koop anastomosis was performed primarily and in 8 cases as a second intervention. We consider the Bishop-Koop anastomosis to be a safer procedure than primary end-to-end or end-to-side anastomosis. Only one anastomotic leak occurred in our patients. We prefer the Bishop-Koop anastomosis not only in cases of meconium ileus, but also in other types of intestinal atresia and stenosis, especially for the management of greatly different intestinal diameters. In our experience, this method is also suitable for re-anastomosing a double-barrel anastomosis. The Bishop-Koop procedure minimizes the risks of primary anastomosis without enterostoma, and later extraperitoneal closure of the stoma is easy and safe.

Ultrasonographic late results after surgically treated cryptorchidism.

BACKGROUND: Because uncorrected cryptorchidism is accompanied by the high risk of later disturbed testicular function and cancer, early surgery in the second year of life is recommended. OBJECTIVE: To evaluate testicular morphology, the sonomorphologic testicular long-term outcome and additional complications, as well as possible differences depending on varying ages at surgery. MATERIALS AND METHODS: Seventy-five previously maldescended testes in 68 boys were studied with US, 2-11 years after intrascrotal orchidopexy. Nineteen had been operated on in the first or second year of life, while the other 49 boys underwent surgery at a later age (up to 7 years). Each examination utilised conventional B-mode and colour Doppler (7-MHz linear ART probe, Acuson XP 128) to examine the scrotal and inguinal regions on both sides; testicular volume and perfusion were assessed. Ultrasound changes in testicular volume, architecture and Doppler flow rates were regarded as the most valid indirect indices of testicular damage. Histopathological correlation was not obtained, for ethical reasons, in any of the probands. RESULTS: Thirty-five of the surgically fixed testes were normal with regard to position, volume, structure and perfusion. The other 40 (53%) showed abnormalities of one or more of these parameters without any correlation with the patient's age at surgery or the time interval between surgery and US. Additional relevant findings, which were also found on the non-operated side, were: microlithiasis (n = 6), inguinally retained testis (n = 6), hydrocoele (n = 5), hydatid (n = 5) and varicocoele (n = 1). CONCLUSIONS: Ultrasound, including colour Doppler, enables an exact morphological analysis of the late results after surgically corrected cryptorchidism. The spectrum of findings does not show any correlation with the time of surgery. Thus, the value of even early surgery has to be questioned. Pre-existent primary damage (dysplasia) seems more important for long-term outcome of the testis. Additionally, US was of high value in demonstrating additional unexpected anomalies, the majority of which needed sonographic follow-up or even surgery.

Client advocacy in the home.

As the health care system in American continues to change at a rapid rate, more nursing care services are provided in the home. With these changes, various components of clinical nursing practice change and take on added dimensions in response to the change of venue. Client advocacy is one of those components. When health care moves into the home, limited resources and stretched client care services may divert the focus of care from client welfare to concerns about resource allocation. Financial considerations may rise above client needs by limiting the availability of services and materials. Under these circumstances, nurses must strive to maintain client welfare as the central focus of care. This column addresses the issue of client advocacy in home care and outlines specific actions that constitute client advocacy in home care settings.

Effects of hydrogen/deuterium exchange on photosynthetic water cleavage in PS II core complexes from spinach.

H/D isotope exchange effects on P680+. reduction by Yz and electron abstraction from the water oxidizing complex (WOC) in redox state S3 by YZOX were analyzed in PS II core complexes from spinach by measurements of laser flash induced absorption changes at 820 nm and 355 nm. The results obtained reveal: (1) the rate of Yz oxidation by P680+. is almost independent of the substitution of exchangeable protons by deuterons; and (2) the reaction between YZOX and the WOC in S3 exhibits a kinetic H/D isotope exchange effect of similar magnitude as that recently observed in PS II membrane fragments [Renger, G., Bittner, T. and Messinger, J. (1994) Biochem. Soc. Trans. 22, 318-322]. Based on these results it is inferred that photosynthetic dioxygen formation comprises the cleavage of at least one hydrogen bond.

Out on a limb: a qualitative study of patient advocacy in institutional nursing.

This study explored the nature of patient advocacy among 40 institutionally employed registered nurses, nurse managers, clinical nurse specialists and nursing administrators. Participants were asked to define patient advocacy, to discuss their experiences with advocacy in institutions and their perceptions of risk associated with advocacy in institutional settings, and to identify one concept central to patient advocacy. The results delineated conceptual definitions of advocacy and numerous factors that influence nurses' decisions about acting as patient advocates in institutions. Additionally, they showed striking similarities between conceptual terms used to define advocacy and terms used to define caring.

Patients' rights and ethical dilemmas in home care: incorporation of psychological concepts.

As home care acuity increases, so will the ethical challenges faced by home care providers. This article discusses how one healthcare provider faced these challenges, as she worked with a patient enduring rheumatoid arthritis. A commentary on the ethical issues, by a nurse ethicist, follows the case study.

Biosynthesis and excretion of gangliosides by the isolated perfused rat liver.

De novo synthesis and excretion into perfusate and bile fluid of hepatic gangliosides were studied in isolated perfused rat livers. Addition of N-acetyl-[6-3H(n)]D-mannosamine to the perfusate resulted in radioactive synthesis of at least eight gangliosides labeled in their sialic acid residues. About 10% of total de novo synthesized gangliosides were excreted into the perfusate, less than 1% into the bile fluid. Labeled gangliosides were tentatively identified by cochromatography with known standards. All of them are known to occur in rat liver and sera. The results indicate that most, if not all, normal serum gangliosides are synthesized in the liver; excretion with bile fluid is negligible. They explain previous observations, and indicate clinical implications, which are discussed.

Oxidation and reduction of 4-hydroxyalkenals catalyzed by isozymes of human alcohol dehydrogenase.

4-Hydroxyalkenals, natural cytotoxic products of lipid peroxidation, are substrates for human alcohol dehydrogenases (ADH). Class I and II ADHs reduce aliphatic 4-hydroxyalkenals with chain lengths of from 5 to 15 carbons at pH 7 with kcat and Km values comparable to simple aliphatic aldehydes of the same chain length. Class II is particularly effective in the reduction with kcat values as high as 3300 min-1 for 4-hydroxyundecenal. Class III ADH is essentially inactive toward all of these substrates. The class I and II isozymes also catalyze the oxidation of the 4-hydroxy group at pH 10. However, during the reaction, an NAD(+)-dependent irreversible partial inactivation of the alpha beta 1 isozyme is observed which is attributed, with the aid of computer graphics modeling, to selective modification of the alpha subunit. Both ethanol and 1,10-phenanthroline, known to compete with conventional substrates, instantaneously, reversibly, and competitively inhibit 4-hydroxyalkenal reduction and oxidation, indicating that 4-hydroxyalkenals bind at the same site as do conventional substates. The fact that the class II enzyme pi pi-ADH so far is found only in the liver and that the 4-hydroxyalkenals are the best substrates known for this isozyme suggest that it may play a significant role in cellular defenses in the conversion of the cytotoxic aldehydes to the less reactive alcohols.

Electron paramagnetic resonance study of the active site of copper-substituted human glyoxalase I.

Zn2+ in native glyoxalase I from human erythrocytes can be replaced by Cu2+, giving an inactive enzyme. Cu2+ was demonstrated to compete with the activating metals Zn2+ and Mn2+, indicating a common binding site on the enzyme for these metal ions. The electron paramagnetic resonance (EPR) spectra of 63Cu(II) glyoxalase I at 77 K and of its complexes with glutathione and some glutathione derivatives are characteristic of Cu2+ in an elongated octahedral coordination (g parallel = 2.34, g perpendicular = 2.09, and A parallel = 14.2 mT). The low-field bands of the free enzyme are asymmetric and become symmetrical upon addition of glutathione or S-(p-bromobenzyl)glutathione but not S-(D-lactoyl)glutathione. The results indicate the existence of two conformations of Cu(II) glyoxalase I, in agreement with the effects caused by these compounds on the protein fluorescence. The copper hyperfine line at low field in the EPR spectrum of the S-(p-bromobenzyl)glutathione complex of 63Cu(II) glyoxalase I shows a triplet structure, indicative of coupling to one nitrogen ligand in the equatorial plane. Similar results were obtained with the glutathione complex. By addition of the spectrum of the S-(p-bromobenzyl)glutathione complex and a spectrum corresponding to two nitrogen ligands with two different coupling constants, a good fit was obtained for the low-field region of the asymmetric spectrum of free 63Cu(II) glyoxalase I. The first two spectra are assumed to correspond to two separate conformational states of the enzyme. The results demonstrate that at least one nitrogen ligand is involved in the binding of Cu2+.(ABSTRACT TRUNCATED AT 250 WORDS)

Metal dissociation constants for glyoxalase I reconstituted with Zn2+, Co2+, Mn2+, and Mg2+.

Metal dissociation constants for glyoxalase I from human erythrocytes were determined by use of nitrilotriacetic acid as a metal buffer. The constants for Zn2+, Co2+, Mn2+, and Mg2+ were (2.7 +/- 0.3) X 10(-11) M, (3.0 +/- 0.8) X 10(-10) M, (4.9 +/- 0.5) X 10(-9) M, and (1.0 +/- 0.2) X 10(-6) M, respectively, demonstrating that the natural cofactor, Zn2+, has the highest affinity for the apoprotein. The results are consistent with the proposal of nitrogen and oxygen atoms as ligands to the metal in the active site of glyoxalase I. In the application of the metal buffer technique, it was found that both 1:1 and 1:2 complexes of the metal ions and nitrilotriacetic acid have to be considered.

NMR and computer modeling studies of the conformations of glutathione derivatives at the active site of glyoxalase I.

The conformations of four derivatives of glutathione bound at the active site of the metalloenzyme glyoxalase I have been determined by NMR measurements and by computer model building using a distance geometry approach. Paramagnetic effects of Mn2+-glyoxalase I on the longitudinal relaxation rates of the carbon-bound protons of the substrate analog S-(acetonyl)-glutathione at three frequencies, the hydrophobic competitive inhibitor S-(propyl)glutathione at four frequencies, and the charged competitive inhibitor S-(carboxymethyl)glutathione at a single frequency were used to calculate Mn2+ to proton distances in each complex. These and previously determined distances from Mn2+ to the protons and 13C-enriched carbon atoms of the product S-(D-lactoyl)glutathione were used in a distance geometry program to compute the conformations of each enzyme-bound derivative which best fit the measured distances and other known constraints such as bond lengths, van der Waals radii, planar and trans-peptide bonds, and thioester linkages. The distance geometry program also provided a measure of the uniqueness of the conformations consistent with the experimental data. Extended Y-shaped conformations were detected for each of the bound glutathione derivatives, similar to the x-ray structure and the theoretically calculated conformation of glutathione itself, suggesting this to be a low energy form. Acceptable conformations of each enzyme-bound derivative fell into two classes with the metal either above or below the mean plane through the glutathione compound. The conformational uncertainty within each class was relatively small, ranging from deviations of 0.9-1.9 A in the average positions of each of the atoms. A small but significant difference in the conformation of the substrate analog as compared to the product was detected in the position of the reaction center carbon directly bonded to the glutathione sulfur atom. Unlike the second-sphere metal complexes formed by the bound substrate analog, the product, or the hydrophobic competitive inhibitor, the charged competitive inhibitor S-(carboxymethyl)glutathione binds farther from the metal, in the third coordination sphere.

X-ray absorption studies of the Zn2+ site of glyoxalase I.

X-ray edge and extended absorption fine structure spectra of Zn2+ at the active site of glyoxalase I have been measured. The edge spectrum reveals a simple set of transitions consistent with a 7-coordinate or distorted octahedral Zn2+ model complex. Analysis of the fine structure rules out sulfur ligands to Zn2+ and yields a best fit complex with Zn2+-N (or Zn2+-O) distances of 2.04 and 2.10 A, which are too great for tetrahedral Zn2+ coordination but are appropriate for an octahedral or more highly coordinated complex. Peaks of electron density in the Fourier-transformed region of the higher order shells at distances of 3-4 A from the Zn2+-imidazole model similar to those found with known Zn2+-imidazole model complexes, including carbonic anhydrase [Yachandra, V., Powers, L., & Spiro, T.G. (1983) J. Am. Chem. Soc. 105, 6596-6604], indicating at least two imidazole ligands to Zn2+ on glyoxalase I. Binding of the heavy atom substrate analogue S-(p-bromobenzyl)glutathione did not significantly alter the number of atoms directly bonded to Zn2+ or their distances. No evidence for coordination of the cysteine sulfur of glutathione by the Zn2+ was obtained, and no heavy atom signal from bromine was detected, indicating this atom to be greater than or equal to 4 A from the Zn2+. However, conformational changes of the imidazole ligands of Zn2+ upon binding of the substrate analogue were suggested by changes in the relative intensity of the doublet peaks at 3-4 A from the Zn2+ and assignable to imidazole.(ABSTRACT TRUNCATED AT 250 WORDS)

Reversal of the reaction catalyzed by glyoxalase I. Calculation of the equilibrium constant for the enzymatic reaction.

Glyoxalase I catalyzes the formation of S-D-lactoyl-glutathione via the hemimercaptal adduct of methylglyoxal and glutathione. This enzymatic reaction, which has been considered virtually irreversible, was found to be reversible under such conditions that glutathione liberated from the thiolester was trapped. The reverse reaction could be monitored spectrophotometrically by use of 5,5'-dithiobis-(2-nitrobenzoate). In addition to 5,5'-dithiobis-(2-nitrobenzoate), 2,2'-dithiobispyridine and cystamine were used to promote the reverse reaction. S-D-Lactoylglutathione did not hydrolyze in the presence of glyoxalase I under the conditions investigated, as shown by its stability in the absence of thioltrapping agents. Proof of the reversal of the reaction was obtained by demonstrating the formation of stoichiometric amounts of methylglyoxal and glutathione from S-D-lactoylglutathione. Catalysis of the reverse reaction was dependent upon the presence of a bivalent metal ion in the active site of the enzyme. Apoenzyme, obtained by removal of the essential Zn2+ from the active site, did not catalyze the reverse reaction, but catalytic activity was restored by addition of Zn2+, Mg2+, Mn2+, or Co2+. The reverse reaction was also catalyzed by glyoxalase I from yeast. Linear competitive inhibition (Ki = 0.64 mM) was obtained with 5,5'-dithiobis-(2-nitrobenzoate), which necessitated correction of the apparent kinetic parameters of the reverse reaction. The corrected values for the reverse reaction catalyzed by glyoxalase I from human erythrocytes with S-D-lactoylglutathione as substrate were kcat = 3.6 s-1 and Km = 1.9 mM. Combination of these values with the corresponding parameters for the forward reaction allowed calculation, through the Haldane relation, of the equilibrium constant, Keq = 1.1 X 10(4), for the isomerization between the hemimercaptal of methylglyoxal and glutathione and S-D-lactoylglutathione. The strong reversible competitive inhibitor of the forward reaction, S-p-bromobenzylglutathione, also inhibited the reverse reaction competitively (Ki = 0.38 microM).

13C NMR studies of the product complex of glyoxalase I.

The paramagnetic effects of Mn2+ . glyoxalase I on the 13C relaxation rates of the reaction product, S-(D-lactoyl)glutathione, separately enriched in the lactoyl carbonyl (C-1) and hydroxymethylene (C-2) carbons, have been measured at 62.8 MHz. The 1/fT1p values of C-1 (1100 +/- 120 s-1) and C-2 (712 +/- 290 s-1) and the previously determined tau c (0.74 ns) yield Mn2+ to carbon distances of 5.7 +/- 0.3 and 6.1 +/- 0.5 A, respectively. These distances, together with previously determined Mn2+-proton distances (Sellin, S., Rosevear, P.R., Mannervik, B., and Mildvan, A.S. (1982) J. Biol. Chem. 257, 10023-10029) constrain the thioester carbonyl group of the product to point toward the metal, with the oxygen positioned to accept a hydrogen bond from a water ligand, in a kinetically competent, second sphere complex. Model-building studies indicate that any averaging of multiple second sphere complexes would require as a major contributor at least one conformation with the lactoyl carbonyl oxygen within hydrogen-bonding distance of an intervening water ligand. Such a structure would facilitate polarization of the carbonyl group in the reverse glyoxalase reaction.

Octahedral metal coordination in the active site of glyoxalase I as evidenced by the properties of Co(II)-glyoxalase I.

Co(II)-glyoxalase I has been prepared by reactivation of apoenzyme from human erythrocytes with Co2+. The visible absorption spectrum showed maxima at 493 and 515 nm and shoulders at 465 and 615 nm. The absorption coefficients at 493 and 515 nm were 35 and 33 M-1 cm-1/cobalt ion, respectively; i.e. 70 and 66 M-1 cm-1 for the dimeric metalloprotein. The product of the enzymatic reaction, S-D-lactoylglutathione, although binding to Co(II)-glyoxalase I, had no demonstrable effect on the visible absorption spectrum, indicating binding outside the first coordination sphere of the metal. The EPR spectrum at 3.9 K was characterized by g1 approximately 6.6, g2 approximately 3.0, and g3 approximately 2.5, and eight hyperfine lines with A1 = 0.025 cm-1. Binding of the strong competitive inhibitor S-p-bromobenzylglutathione to Co(II)-glyoxalase I gave three g values: 6.3, 3.4, and 2.5, indicating a conformational change affecting the environment of the metal ion. Both optical and EPR spectra strongly suggest a high spin Co2+ with octahedral coordination in the active site of the enzyme. The similarities in kinetic properties between native Zn(II)-glyoxalase I and enzyme substituted with Mg2+, Mn2+, or Co2+ is consistent with the view that these enzyme forms have the same metal coordination in the protein.

Fluorescence and nuclear relaxation enhancement studies of the binding of glutathione derivatives to manganese-reconstituted glyoxalase I from human erythrocytes. A model for the catalytic mechanism of the enzyme involving a hydrated metal ion.

The apoenzyme of glyoxalase I (EC 4.4.1.5) from human erythrocytes was prepared by removal of Zn2+ with ethylenediaminetetraacetic acid (EDTA). Methanol was used as a stabilizing agent. Extended dialysis was required to remove EDTA from the resulting solution of apoenzyme. Reconstitution with Mn2+ was followed by measuring enzyme activity, electron paramagnetic resonance of free Mn2+ ions, and nuclear magnetic resonance of water protons. The holoenzyme contained two Mn2+ per protein dimer and had approximately 50% of the catalytic activity of the native enzyme. The binding of the cosubstrate glutathione (gamma-L-glutamyl-L-cysteinylglycine), the product S-D-lactoyl-glutathione, and the competitive inhibitor S-(p-bromo-benzyl)glutathione was monitored by the quenching of the intrinsic tryptophan fluorescence and by the proton relaxation enhancement of water bound to Mn2+ in the active site of the enzyme. The dissociation constants were 1.1 mM, 0.42 mM, and 0.54 microM for glutathione, S-D-lactoylglutathione, and S-(p-bromobenzyl)glutathione, respectively. The temperature and frequency dependences of the longitudinal and transverse paramagnetic relaxation rates, 1/T1p and 1/T2p, were studied for water. The results were analyzed in terms of correlation and exchange times. In addition proton and deuteron relaxation rates were measured in parallel at two different magnetic fields. Good agreement between the two approaches of analysis was noticed. The data show that two water molecules are bound in the first coordination sphere of Mn2+ in the active site of glyoxalase I. When S-(p-bromobenzyl)glutathione or S-D-lactoylglutathione is bound to the enzyme, only one exchangeable water molecule could be detected, indicating occlusion of the second water molecule. An enediol mechanism involving the metal-bound water is proposed for the catalysis effected by glyoxalase I.