Effects of using the simplified airway risk index vs usual airway assessment on unanticipated difficult tracheal intubation - a cluster randomized trial with 64,273 participants.

BACKGROUND: Unanticipated difficult intubation remains a challenge in anaesthesia. The Simplified Airway Risk Index (SARI) is a multivariable risk model consisting of seven independent risk factors for difficult intubation. Our aim was to compare preoperative airway assessment based on the SARI with usual airway assessment. METHODS: From 01.10.2012 to 31.12.2013, 28 departments were cluster-randomized to apply the SARI model or usual airway assessment. The SARI group implemented the SARI model. The Non-SARI group continued usual airway assessment, thus reflecting a group of anaesthetists' heterogeneous individual airway assessments. Preoperative prediction of difficult intubation and actual intubation difficulties were registered in the Danish Anaesthesia Database for both groups. Patients who were preoperatively scheduled for intubation by advanced techniques (e.g. video laryngoscopy; flexible optic scope) were excluded from the primary analysis. Primary outcomes were the proportions of unanticipated difficult and unanticipated easy intubation. RESULTS: A total of 26 departments (15 SARI and 11 Non-SARI) and 64 273 participants were included. In the primary analyses 29 209 SARI and 30 305 Non-SARI participants were included.In SARI departments 2.4% (696) of the participants had an unanticipated difficult intubation vs 2.4% (723) in Non-SARI departments. Odds ratio (OR) adjusted for design variables was 1.03 (95% CI: 0.77-1.38). The proportion of unanticipated easy intubation was 1.42% (415) in SARI departments vs 1.00% (302) in Non-SARI departments. Adjusted OR was 1.26 (0.68-2.34). CONCLUSIONS: Using the SARI compared with usual airway assessment we detected no statistical significant changes in unanticipated difficult- or easy intubations. CLINICAL TRIAL REGISTRATION: NCT01718561.

Tracheal intubation in patients with anticipated difficult airway using Boedeker intubation forceps and McGrath videolaryngoscope.

BACKGROUND: Videolaryngoscopes with sharp angulated blades improve the view of the vocal cords but this does not necessarily result in higher success rates of intubation The aim of this study was to evaluate the efficacy of using Boedeker intubation forceps in conjunction with McGrath Series 5 Videolaryngoscope (MVL) in patients with predictors for difficult intubation. METHODS: The study was conducted at the Department of Anaesthesia, Copenhagen University Hospital from September to December 2013. Patients with one or more predictors of difficult intubation scheduled for general anaesthesia were assessed for eligibility. Patients were intubated using Boedeker intubation forceps and MVL. The primary endpoint was time to intubation. The secondary endpoints were intubation success rate, number of intubation attempts, intubation conditions and post-operative hoarseness. RESULTS: Thirty-three patients were assessed for eligibility, and 25 patients were included in the study with a median SARI score of 3 (IQR 3-4). Twenty-two (88%, 95% confidence interval [74-100%]) of the patients were successfully intubated by the method with a median time to intubation of 115 s (IQR 78-247). Steering and advancement of the tube were reported as acceptable in 21 (84%) and 22 cases (88%), respectively, and excellent in 10 cases (45%) for both measures. Ten cases (40%) were intubated on the first attempt. There were three cases (12%) of failed intubation; in these cases, successful intubation was obtained by using a styletted tube. CONCLUSION(S): Most patients with anticipated difficult intubation can be successfully intubated with Boedeker intubation forceps and MVL. However, endotracheal tube placement failed in 3/25 patients despite a good laryngeal view.

Laryngeal morbidity after tracheal intubation: the Endoflex(®) tube compared to conventional endotracheal intubation with stylet.

BACKGROUND: Tracheal intubation may cause vocal fold damage. The trial was designed to assess laryngeal morbidity comparing the Endoflex(®) tube with a conventional endotracheal tube with stylet. We hypothesised that laryngeal morbidity within the first 24 h after extubation would be lower with the Endoflex tube than with the conventional endotracheal tube with stylet because of less rigidity. METHODS: This randomised trial included 130 elective surgical patients scheduled for general anaesthesia with endotracheal intubation. Pre- and post-operative assessment of hoarseness, vocal fold pathology, and voice analysis using the Multidimensional Voice Program was performed. Induction of anaesthesia was standardised. After complete neuromuscular paralysis, intubation was done with an Endoflex tube or a conventional endotracheal tube with stylet. RESULTS: Post-operative hoarseness was found in 45% with the Endoflex tube and 55% with the endotracheal tube with stylet at 24 h after extubation (P = 0.44). Post-operative vocal fold injury was present in 23% in the Endoflex tube group and in 36% in the endotracheal tube with stylet group (P = 0.13). The increase in shimmer, the voice analysis variable reflecting vocal fold oedema, was 0.5% in the Endoflex tube group and 2.5% in the endotracheal tube with stylet group (P = 0.02). CONCLUSION: No significant difference was found in the incidence of hoarseness or vocal fold injury using the Endoflex tube. However, the statistically significant lower increase in the shimmer values in that group implies that the Endoflex may be associated with less laryngeal morbidity.

Wound-induced apoplastic peroxidase activities: their roles in the production and detoxification of reactive oxygen species.

Production of reactive oxygen species (ROS) is a widely reported response of plants to wounding. However, the nature of enzymes responsible for ROS production and metabolism in the apoplast is still an open question. We identified and characterized the proteins responsible for the wound-induced production and detoxification of ROS in the apoplast of wheat roots (Triticum aestivum L.). Compared to intact roots, excised roots and leachates derived from them produced twice the amount of superoxide (O2(*-)). Wounding also induced extracellular peroxidase (ECPOX) activity mainly caused by the release of soluble peroxidases with molecular masses of 37, 40 and 136 kD. Peptide mass analysis by electrospray ionization-quadrupole time-of-flight-tandem mass spectrometry (ESI-QTOF-MS/MS) following lectin affinity chromatography of leachates showed the presence of peroxidases in unbound (37 kD) and bound (40 kD) fractions. High sensitivity of O2(*-)-producing activity to peroxidase inhibitors and production of O2(*-) by purified peroxidases in vitro provided evidence for the involvement of ECPOXs in O2(*-) production in the apoplast. Our results present new insights into the rapid response of roots to wounding. An important component of this response is mediated by peroxidases that are released from the cell surface into the apoplast where they can display both oxidative and peroxidative activities.

How does auxin enhance cell elongation? Roles of auxin-binding proteins and potassium channels in growth control.

Elongation growth and a several other phenomena in plant development are controlled by the plant hormone auxin. A number of recent discoveries shed light on one of the classical problems of plant physiology: the perception of the auxin signal. Two types of auxin receptors are currently known: the AFB/TIR family of F box proteins and ABP1. ABP1 appears to control membrane transport processes (H+ secretion, osmotic adjustment) while the TIR/AFBs have a role in auxin-induced gene expression. Models are proposed to explain how membrane transport (e.g., K+ and H+ fluxes) can act as a cross-linker for the control of more complex auxin responses such as the classical stimulation of cell elongation.

Inhibitors of the plasma membrane redox system of Zea mays L. roots. The vitamin K antagonists dicumarol and warfarin.

The action of the 4-hydroxycoumarins dicumarol and warfarin, antagonists of probable vitamin K type components of the plasma membrane electron-transport system, on plasma membrane redox activity of intact maize roots was compared. Both effectors inhibited electron transfer to extracellular hexacyanoferrate III. While the effect of the strongly lipophilic dicumarol on the electron-transport system was irreversible by rinsing, the inhibition caused by the hydrophilic warfarin could be reverted completely by exchange of the incubation medium. We take these results as possible evidence for the integration of dicumarol into the plasma membrane. The action of warfarin may be confined to enzymic sites freely accessible from the aqueous apoplasmic solution.

Condensation of vector DNA by the chromosomal protein HMG1 results in efficient transfection.

The aim of this study was the search for a method of vector packaging using natural chromatin constituents. The interaction of the chromosomal non-histone protein HMG1 with a vector plasmid (pLTEneo) was studied by sedimentation analysis and electron microscopy at physiological salt concentration. At high protein input the complexes exist in a condensed, monodisperse form sedimenting with 80 S irrespective of the supercoiled or relaxed conformation of DNA. Saturation binding is already observed at much lower input ratios. Dilution of 80 S complexes results in decondensation of the complexes. In the decondensed complex form, HMG1 binds in a bead-like manner to specific DNA regions. Condensation by HMG1 is sufficient to introduce the vector into mammalian cells without the need for unphysiological additives. The transfection rates were similar to or even higher than those obtained by the calcium phosphate coprecipitation technique.

Oxidoreductases in plant plasma membranes.

Electron transporting oxidoreductases at biological membranes mediate several physiological processes. While such activities are well known and widely accepted as physiologically significant for other biological membranes, oxidoreductase activities found at the plasma membrane of plants are still being neglected. The ubiquity of the oxidoreductases in the plasma membrane suggests that the activity observed is of major importance in fact up to now no plant without redox activity at the plasmalemma is known. Involvement in proton pumping, membrane energization, ion channel regulation, iron reduction, nutrient uptake, signal transduction, and growth regulation has been proposed. However, positive proof for one of the numerous theories about the physiological function of the system is still missing. Evidence for an involvement in signalling and regulation of growth and transport activities at the plasma membrane is strong, but the high activity of the system displayed in some experiments also suggests function in defense against pathogens.

Electron donation to the plasma membrane redox system of cultured carrot cells stimulates proton release.

Membrane-permeable electron donors, duroquinol, diphenylcarbazide, pyrocatechol and tert-octylcatechol, promoted both reduction of an impermeant electron acceptor and proton transport with cultured carrot cells. These cells were preloaded with electron donors for 15, 30, 45 and 60 min. Aliquots of cells were removed at various times, washed free of excess electron donors and assayed for their effect on transplasma membrane redox with impermeable hexacyanoferrate (HCF III) as the electron acceptor and for simultaneous H+ excretion in the presence of hexacyanoferrate. All four electron donors stimulated HCF III reduction and associated H+ excretion. Below a rate of hexacyanoferrate reduction of 6 mumol/g dry wt. per min, the ratios of H+/e- were between 0.3 and 1 with low concentrations (0.1 mM) of the added electron donors. When hexacyanoferrate reduction exceeded 6 mumol/g dry wt. per min, proton release began to cascade to give ratios of 1 to 3, suggesting activation of an H(+)-ATPase or a proton transporter. This behavior by cultured carrot cells indicates that a certain threshold of proton concentration in a limited membrane domain must be reached in order for the proton channel to be opened.

Acid nuclear extracts as mediators of gene transfer and expression.

In an attempt to demonstrate transfection-active DNA packaging proteins in the cell nucleus, we prepared acid nuclear extracts with perchloric acid and subsequent protein fractions by stepwise acetone precipitation. The original extract and these fractions containing different compositions of nuclear proteins were used as DNA packaging agents. After the formation of complexes between these protein fractions and reporter genes, the addition of these complexes to the cells resulted in high transfection rates. Gel electrophoresis shows that the most active fractions contain histone H1 and HMG17. HMG1 exhibits a smaller activity. This result was confirmed by positive transfection experiments with commercial histone H1. Our results show that the transfection activity of acid nuclear protein fractions and histone H1 is dependent on the presence of calcium.

Calcium ions as efficient cofactor of polycation-mediated gene transfer.

We investigated the effect of calcium on the transfection of non-viral DNA transfer systems. Cationic proteins such as the nuclear protein H1, the polycation polylysine and a number of commercial transfection agents exhibited high transfection rates in the presence of Ca2+. Without Ca2+ H1 and HMG1 were inactive in transfection of the human permanent endothelial cell line ECV 304 while cationic liposomes such as Lipofectin and Lipofectamine did not show any Ca2+ dependence. More detailed experiments showed that Ca2+ was replaceable by the lysosomotropic agent chloroquine. Furthermore, it was possible to separate the transfection-enhancing role of Ca2+ from the actual transfection process by adding Ca2+ to the cells after the transfection period and still to obtain a significant transgene expression. This makes it possible to distinguish between cellular uptake of H1 (or mediator)-DNA complexes and endocytotic release. We also replaced soluble Ca2+ by Ca-phosphate precipitates not containing DNA and obtained similar transfection results. This allowed us to suggest that the addition of free Ca2+ to the transfection medium resulted in nascent Ca-phosphate microprecipitates. The known fusogenic and membranolytic activity of such microprecipitates could facilitate the transport through and the release of the transfecting complexes from the endosomal/lysosomal compartment.

Influence of Temperature on Proton Secretion and Hexacyanoferrate (III) Reduction of Zea mays L. Roots.

Responses of potassium hexacyanoferrate (III) [HCF(III)] reduction and net proton secretion by Zea mays L. cv Goldprinz roots to changes in ambient temperature were investigated. Arrhenius plots of proton secretion and redox activity showed a constant slope between 5 and 20[deg]C, indicating that reaction kinetics do not change. Proton secretion without HCF(III) was strongly temperature dependent. This dependence was not altered when H+ efflux was stimulated by fusicoccin or by increased K+ concentration. The temperature coefficient for HCF(III) reduction was low, indicating that the velocity of this reaction was limited by apoplastic diffusion of the ferric complex. In the presence of HCF(III) but not hexacyanoferrate (II), temperature dependence of proton efflux markedly declined, indicating fundamental changes in the process(es) contributing to net proton secretion. It is concluded that HCF(III) establishes a proton extrusion path that is directly linked with the reduction reaction.

Are Redox Reactions Involved in Regulation of K+ Channels in the Plasma Membrane of Limnobium stoloniferum Root Hairs?

The effects of the impermeant electron acceptor hexacyanoferrate III (HCF III) and the potassium channel blocker tetraethylam-monium (TEA) on the current-voltage relationship and electrical potential across the plasma membrane of Limnobium stoloniferum root hairs was investigated using a modified sucrose gap technique. One millimolar HCF III immediately and reversibly depolarized the membrane by 27 mV, whereas the effect on the trans-membrane current was markedly delayed. After 6 min of treatment with this electron acceptor, outwardly rectifying current was inhibited by 50%, whereas the inwardly rectifying current was activated approximately 3-fold. Ten millimolar TEA blocked both outward (65%) and inward (52%) currents. Differential TEA-sensitive current was shown to be blocked (55%) by HCF III at -20 mV and was shown to be stimulated (230%) by this electron acceptor at -200 mV. The inward current at -200 mV was eliminated in the absence of K+ or after addition of 10 mM Cs+ and was not affected by addition of either 10mM Na+ or Li+, independent of the presence of HCF III. The addition of any alkali cation to the external medium decreased the outward current both in the presence and in the absence of HCF III. The membrane depolarization evoked by HCF III did not correlate with the corresponding modification of the inward current. HCF III is proposed to activate inwardly rectifying potassium channels and to inactivate outwardly rectifying potassium channels. It is concluded that the plasma membrane depolarization did not result from modulation of the potassium channels by HCF III and may originate from trans-plasma membrane electron transfer.

Penetration by Artificial Electron Acceptors of the Plasma Membrane-Bound Redox System into Intact Zea mays L. Roots Investigated by Proton-Induced X-Ray Emission.

Proton-induced x-ray emission was used to investigate the penetration of compounds of the membrane-impermeant electron acceptors hexabromoiridate IV, hexachloroiridate IV, and hexacyanoferrate III into corn (Zea mays L.) roots. Maps of the heavy element distribution in cross-sections of fixed, epoxy-embedded roots showed for hexabromoiridate IV small amounts of Br in samples treated for 24 h with concentrations normally used in physiological experiments (0.02 mM). After treatment with high concentrations (0.8 mM) of these complexes, Fe and Ir as well as Br were found in root cross-sections. In samples taken at a distance of 5 mm behind the root tip, we found an even distribution of Fe, Ir, and Br over the whole cross-section. In samples taken 15 mm behind the root tip, about 99% of both Br and Ir was confined to the rhizodermal cell layer. The distribution did not change with the complex used. These data are consistent with the view that apoplastic diffusion of the electron acceptors was blocked by the hypodermal Casparian band.

Excretion of 2-hydroxyestrone in urine throughout human pregnancies.

Urinary 2-hydroxyesterone was quantitatively determined in the course of several normal human pregnancies. The urine was subjected to hot acid hydrolysis and after chromatographic purification, 2-hydroxyesterone was converted into the corresponding phenazine derivative, which was submitted to a final column chromatogrphy and then quantitated by UV-spectrometry. For correction of procedural losses 2-hydroxyestrone-4-14C was used as internal standard. The urinary 2-hydroxyestrone of different subjects varied within a wide range especially at mid-pregnancy between 100 and 2500 mug/24 h. The day-to-day variation of the excretion of 2-hydroxyestrone was mostly less than 30% of the total value of that day, but sometimes could even reach 60%. The investigation of 2-hydroxyestrone and total estrogens at regular intervals throughout several pregnancies, showed that the excretion of 2-hydroxyesterone generally reached a maximum during the second trimester, while the excretion of the total estrogens steadily increased up to parturition. When analyzing the urines of different subjects during the last 4 months of pregnancy, no correlation appeared to exist for the excretions of the total estrogens and of 2-hydroxyestrone.

High-mobility-group proteins and cancer--an emerging link.

In the last few years, considerable interest has been generated in the role of high-mobility-group (HMG) proteins, and HMG box proteins generally, in cancer development and therapy. These proteins were discovered in the early 1970s (Goodwin et al. 1973) as a group of nonhistone proteins. Some members of the HMG protein family (i) constitute a class of important architectural proteins involved in transcriptional regulation of genes, (ii) are frequently expressed in transformed cells at levels that correlate with the degree of neoplastic cell transformation, (iii) participate in gene rearrangements, which are linked to the emergence of benign solid tumors, (iv) confer the ability to recognize DNA-cisplatin adducts selectively, and (v) provide a new delivery system for efficient gene transfer. It should be considered that some HMG proteins, acting as architectural proteins that bring many of the transcription factors into precise three-dimensional shapes, may have a similar critical role in neoplastic transformation to that of some transcription factors themselves.

Immunocytochemical visualization of transfected DNA in cultured cells.

Nonviral transfection is one of the modern methods for the incorporation of foreign genes into cells. This process involves uptake of foreign genetic material by the cell and further trafficking through the cytoplasm to the nucleus. Elucidation of cytoplasmic pathways of transfection complexes can be useful to improve already existing gene delivery systems or to establish new systems. To monitor transfection complexes in the cell during transfection, we elaborated a method for the visualization of transfection complexes by introducing digoxigenin-labelled nucleotides into foreign DNA followed by detection of digoxigenin label with the use of antibodies directed against digoxigenin. This procedure allowed the visualization of DNA in transfection complexes and to monitor these complexes in cells during transfection.

Phylloquinone, what can we learn from plants?

The plant plasma membrane contains redox proteins able to mediate a trans-membrane electron flow. This electron flow might be responsible for the generation of the active oxygen species observed as a reaction to pathogen attack or stress. Vitamin K1 could be identified as a possible lipid soluble electron carrier in plant plasma membrane preparations. Such a function would be analogous to coenzyme Q in animal plasma membranes. What we are going to outline in this contribution is a concept of how the electron transport system of the plant plasma membrane could interact with quinones, thus contributing to the metabolism of free radicals in plants.

In vitro transformation and mutation of Chinese hamster cells by different SV40 nucleoprotein complexes.

SV40 minichromosomes (MCH) either isolated from SV40 infected CV-I monkey cells (native MCH) or reconstituted in vitro from viral DNA and the H1 depleted calf thymus histone fraction could transform and mutate Chinese hamster (CH) cells in vitro. Whereas reconstituted MCH transformed and mutated CH cells with about the same efficiency as purified SV40 DNA, approximately 10-200-fold increase in the transforming activity had been demonstrated for native MCH. All transformed cell colonies and a major part of the isolated mutant cell clones recovered after inoculation of CH cells with SV40 MHC expressed the SV40 T antigen. Addition of H1 to both purified SV40 DNA and reconstituted MHC drastically diminished the transforming capacities of both agents. Possible reason(s) for the inhibition effect of H1 histone is discussed.