Subacute reaction to endoscopic mucosal resection mimicking perforation.

A 25-year-old woman underwent routine day-case endoscopic mucosal resection (EMR) of two ascending colonic polyps. Six hours later she re-presented with severe abdominal pain. On examination she was tachycardic with tenderness and peritonism in the right lower quadrant. Urgent abdominal computed tomography (CT) did not reveal any signs of free intra-abdominal gas or fluid but did detect transmural thickening and oedema in the ascending colon and caecum. As there was no radiological evidence of perforation, the patient was managed conservatively and made a full recovery. The exact aetiology of this patient's symptoms is not known. She may have developed post-polypectomy electrocoagulation (a transmural diathermy injury), localised ischaemia of the colonic wall (secondary to the adrenaline used during EMR) or an allergic reaction to the dye used during EMR. As EMR is an increasingly used treatment modality in the management of colonic polyps, clinicians should have an awareness of the complications of treatment. We would advocate a low threshold for prompt CT investigation in any patient presenting with abdominal pain after EMR to detect any evidence of free intraperitoneal air. Patients without signs of perforation may be managed conservatively, as in this case.

The effects of footshock and immobilization stress on tyrosine hydroxylase phosphorylation in the rat locus coeruleus and adrenal gland.

Tyrosine hydroxylase (TH), the rate-limiting enzyme in catecholamine biosynthesis, is regulated acutely by protein phosphorylation. No studies have systematically investigated the time course of TH phosphorylation in vivo in response to different stressors. We therefore determined the extent of TH phosphorylation at Ser19, Ser31, and Ser40 over a 40-min period in response to footshock or immobilization stress in the rat locus coeruleus and adrenal medulla. There were significant changes in TH phosphorylation in both tissues and the responses to the two stressors differed markedly. With each of the phosphorylation sites immobilization stress caused a much smaller, or less sustained, response than footshock stress. With immobilization stress there was a transient increase in Ser31 phosphorylation in the locus coeruleus and in the adrenal medulla, but there were no effects on Ser19 or Ser40 phosphorylation. With footshock stress there was a substantial decrease in Ser19 phosphorylation over time, a substantial increase in Ser31 phosphorylation over time, but there were no effects on Ser40 phosphorylation. Measuring TH phosphorylation at Ser19, Ser31, and Ser40 over time can therefore be used as a sensitive index to differentiate the effects of different stressors on catecholaminergic cells.

Attributes of trainers for postgraduate training in general surgery--a national consensus.

BACKGROUND: The aim of this study was to obtain consensus amongst consultant surgeons on the attributes of a good surgical trainer that can be used to inform continuing professional development programmes for trainers. METHODS: good trainer attributes were generated from an intensive qualitative study using a participative inquiry process with consultant general surgeons and specialist registrars in the Tayside region. These good trainer attributes were then used as the basis of a modified Delphi study; the early rounds of the Delphi simultaneously sought participants' views concerning stated attributes and sought to generate new attributes. A final Delphi questionnaire was sent to all 180 consultant general surgeons in Scotland to identify consensus. RESULTS: The first two rounds of the Delphi process produced 45 attributes covering seven themes: interest in training, trainer as a team member, communication, receptiveness to trainee needs, trainer as a role model, reflection on practice and clinical and operative competence. The final survey identified significant consensus among surgeons. Clinical and operative competence achieved the highest consensus with 89.2% of surgeons believing it to be an essential attribute. CONCLUSIONS: The results indicate that there is consensus on the seven themes identified as essential for a trainer in general surgery. The recognition of the importance by trainers of non-surgical trainer attributes in the changed training structure is encouraging. Surgeons' level of awareness of their roles as a trainer will help inform the level and direction of trainer training and support required as part of a flexible and continuing developmental process.

Angiotensin II promotes the phosphorylation of cyclic AMP-responsive element binding protein (CREB) at Ser133 through an ERK1/2-dependent mechanism.

In cells from the adrenal medulla, angiotensin II (AII) regulates both the activity and mRNA levels of catecholamine biosynthetic enzymes whose expression is thought to be under the control of cAMP-responsive element (CRE) binding protein (CREB). In this study, we evaluated the effect of AII stimulation on CREB phosphorylation at Ser133 (pCREB) in bovine adrenal chromaffin cells (BACC). We found that AII produces a rapid and AII type-1 receptor (AT1)-dependent increase in pCREB levels, which is blocked by the MEK1/2 inhibitor U0126 but not by H-89, SB203580 or KN-93, suggesting that it is mediated by the extracellular-regulated protein kinases 1 and 2 (ERK1/2) and not by cAMP-dependent protein kinase (PKA), p38 mitogen-activated protein kinase (p38MAPK) or Ca(2+)/calmodulin-dependent protein kinases (CaMKs) dependent pathways. Gel-shift experiments showed that the increase in pCREB levels is accompanied by an ERK1/2-dependent upregulation of CRE-binding activity. We also found that AII promotes a rapid and reversible increase in the activity of the non-receptor tyrosine kinase Src and that the inhibition of this enzyme completely blocks the AII-induced phosphorylation of ERK1/2, the CREB kinase (p90)RSK and CREB. Our data support the hypothesis that in BACC, AII upregulates CREB functionality through a mechanism that requires Src-mediated activation of ERK 1/2 and (p90)RSK.

Phosphorylation of Ser(19) alters the conformation of tyrosine hydroxylase to increase the rate of phosphorylation of Ser(40).

The effect of phosphorylation on the shape of tyrosine hydroxylase (TH) was studied directly using gel filtration and indirectly using electrospray ionization mass spectrometry. Phosphorylation of Ser(19) and Ser(40) produced a TH molecule with a more open conformation than the non-phosphorylated form. The conformational effect of Ser(19) phosphorylation is less pronounced than that of the Ser(40) phosphorylation. The effect of Ser(19) and Ser(40) phosphorylation appears to be additive. Binding of dopamine produced a more compact form when compared with the non-dopamine-bound TH. The interdependence of Ser(19) and Ser(40) phosphorylation was probed using electrospray ionization mass spectrometry. The rate constants for the phosphorylation of Ser(19) and Ser(40) were determined by electrospray ionization mass spectrometry using a consecutive reaction model. The rate constant for the phosphorylation of Ser(40) is approximately 2- to 3-fold higher if Ser(19) is already phosphorylated. These results suggest that phosphorylation of Ser(19) alters the conformation of tyrosine hydroxylase to allow increased accessibility of Ser(40) to kinases.

Tyrosine hydroxylase phosphorylation in bovine adrenal chromaffin cells: the role of MAPKs after angiotensin II stimulation.

Angiotensin II (AII, 100 nM) stimulation of bovine adrenal chromaffin cells (BACCs) produced angiotensin II receptor subtype 1 (AT1)-mediated increases in extracellular regulated protein kinase 1/2 (ERK1/2) and stress-activated p38MAPK (p38 kinase) phosphorylation over a period of 10 min. ERK1/2 and p38 kinase phosphorylation preceded Ser31 phosphorylation on tyrosine hydroxylase (TOH). The inhibitors of mitogen-activated protein kinase kinase 1/2 (MEK1/2) activation, PD98059 (0.1-50 microM) and UO126 (0.1-10 microM), dose-dependently inhibited both ERK2 and Ser31 phosphorylation on TOH in response to AII, suggesting MEK1/2 involvement. The p38 kinase inhibitor SB203580 (20 microM, 30 min) abolished Ser31 and Ser19 phosphorylation on TOH and partially inhibited ERK2 phosphorylation produced by AII. In contrast, 1 microM SB203580 did not affect AII-stimulated TOH phosphorylation, but fully inhibited heat shock protein 27 (HSP27) phosphorylation produced by AII. Also, 1 microM SB203580 fully inhibited Ser19 phosphorylation on TOH and HSP27 phosphorylation in response to anisomycin (30 min, 10 microg/mL). The results suggest that ERKs mediate Ser31 phosphorylation on TOH in response to AII, but p38 kinase is not involved. Previous studies suggesting a role for p38 kinase in the phosphorylation of Ser31 are explained by the non-specific effects of 20 microM SB203580 in BACCs. The p38 kinase pathway is able to phosphorylate Ser19 on TOH in response to anisomycin, but does not do so in response to AII.

The use of permeabilized cells to assay protein phosphorylation and catecholamine release.

A number of approaches can be used to determine the protein kinases and protein phosphatases acting on particular phosphoproteins in vivo. Cell permeabilization represents one such approach. In this overview we discuss the different permeabilization procedures used in bovine adrenal chromaffin cells and in particular the use of digitonin. The effect of various factors on the extent of digitonin-permeabilization, protein phosphorylation and catecholamine release are also discussed. The factors include the permeabilization medium, the ions such as calcium, and the second messengers, such as cAMP, IP3, cADPR and calmodulin. The effect of specific peptide inhibitors of protein kinases on tyrosine hydroxylase phosphorylation is illustrated. Advantages and disadvantages of cell permeabilization procedures are discussed throughout the text.

Modulation of the phosphorylation and activity of calcium/calmodulin-dependent protein kinase II by zinc.

Calcium/calmodulin-dependent protein kinase II (CaMPK-II) is a key regulatory enzyme in living cells. Modulation of its activity, therefore, could have a major impact on many cellular processes. We found that Zn(2+) has multiple functional effects on CaMPK-II. Zn(2+) generated a Ca(2+)/CaM-independent activity that correlated with the autophosphorylation of Thr(286), inhibited Ca(2+)/CaM binding that correlated with the autophosphorylation of Thr(306), and inhibited CaMPK-II activity at high concentrations that correlated with the autophosphorylation of Ser(279). The relative level of autophosphorylation of these three sites was dependent on the concentration of zinc used. The autophosphorylation of at least these three sites, together with Zn(2+) binding, generated an increased mobility form of CaMPK-II on sodium dodecyl sulfate gels. Overall, autophosphorylation induced by Zn(2+) converts CaMPK-II into a different form than the binding of Ca(2+)/CaM. In certain nerve terminals, where Zn(2+) has been shown to play a neuromodulatory role and is present in high concentrations, Zn(2+) may turn CaMPK-II into a form that would be unable to respond to calcium signals.

Determination of phosphorylation levels of tyrosine hydroxylase by electrospray mass spectrometry.

A novel approach has been developed to quantify the extent of phosphorylation of tyrosine hydroxylase (TH). The strategy consists of a chemical cleavage and characterization of the products using electrospray mass spectrometry (ESMS). The chemical cleavage involves selective hydrolysis of the aspartyl-peptide bond. Of the peptides formed, an 8-kDa NH2-terminus fragment is found to accurately duplicate the phosphorylation of TH using standard mixtures of TH-P/TH. The calibration yields a straight line with an R2 of 0.996, which is valid within the 10-90% range. The ESMS protocol has been used to determine the extent of phosphorylation of TH in the presence of CaM-PKII. The experimental conditions were designed to produce low levels of phosphorylation. Nevertheless, the ESMS analysis yielded single, double, and nonphosphorylation forms of TH. With respect to in vivo measurements, this ESMS protocol may be a generic procedure for determining the extent of phosphorylation of proteins.

Ca(2+) influx stimulated phospholipase C activity in bovine adrenal chromaffin cells: responses to K(+) depolarization and histamine.

The role of Ca(2+) influx in activating phospholipase C in bovine adrenal chromaffin cells has been investigated. Phospholipase C activity in response to K(+) depolarization (56 mM) was blocked by the L-type Ca(2+) channel antagonist nifedipine and partially inhibited by the omega-conotoxins GVIA and MVIIC. In contrast, phospholipase C activity in response to histamine receptor activation was unaffected by omega-conotoxin GVIA and partially inhibited by omega-conotoxin MVIIC or nifedipine. This response was however markedly inhibited by the non-selective Ca(2+) channel antagonists La(3+) or 1-[beta-[3-(4-Methoxyphenyl)propoxy]-4-methoyphenethyl]-H-imidazol e (SKF-96365). Despite this Ca(2+) dependence phospholipase C activity was not increased during periods of "capacitative" Ca(2+) inflow generated by histamine-, caffeine- or thapsigargin-mediated depletion of internal Ca(2+) stores. Thus, while Ca(2+) influx in response to K(+) depolarization or G-protein receptor activation can increase phospholipase C activity in these cells, in the latter case it appears to be ineffective unless there is concurrent agonist occupation of the receptor.

GFAP phosphorylation studied in digitonin-permeabilized astrocytes: standardization of conditions.

Cycles of assembly/disassembly of the intermediate filaments of astrocytes are modulated by the phosphorylation of glial fibrillary acidic protein (GFAP). The sites on GFAP are localized at the N-terminal where they are phosphorylated by cAMP-dependent and Ca(2+)-dependent protein kinases. Phosphorylation of GFAP has been investigated in brain slices, astrocyte cultures, cytoskeletal fractions and purified systems. Here we describe a different approach to study GFAP phosphorylation. We show that permeabilization of astrocytes in culture with digitonin allows direct access to the systems phosphorylating GFAP. Conditions for the permeabilization were established with an assay based on the exclusion of Trypan blue. Incubation of permeabilized cells with cAMP and Ca(2+) increased the phosphorylation state of GFAP. Immunocytochemistry with anti-GFAP showed that permeabilized astrocytes retained their typical flat, fibroblast morphology and exhibited well preserved glial filaments. On incubation with cAMP the filaments apparently condensed to form long processes. The results suggest the approach of studying structural changes in glial filaments in parallel to protein phosphorylation, in the presence of specific modulators of protein kinases and phosphatases has considerable potential.

Effect of intracorporeal-extracorporeal instrument length ratio on endoscopic task performance and surgeon movements.

HYPOTHESIS: Better endoscopic task performance and more ergonomic movements of a surgeon's dominant upper limb can be achieved within a certain range of intracorporeal-extracorporeal instrument length ratio. DESIGN: Investigating the effect of 3 intracorporeal-extracorporeal instrument length ratios (240:120 mm, level 1; 180:180 mm, level 2; and 120:240 mm, level 3) on efficiency and quality of a standardized endoscopic task (intracorporeal surgeon's knot). Ten surgeons tied 360 knots inside a trainer in a random sequence. Task efficiency was measured by the execution time, which was recorded for each knot. Task quality was measured by the knot quality score, derived from the force-extension curves obtained by distraction of each knot in a tensiometer. Motion analysis parameters were obtained at the elbow and shoulder joints using a 3-dimensional motion analysis system (Kinemetrix Model 5.0-3D/3MBM; Medical Research Ltd, Leeds, England). The Kruskal-Wallis and Mann-Whitney tests were used for analysis. RESULTS: The level 3 ratio had the lowest knot quality score (P = .07) and longest execution time (P<.05). The range of movement at the elbow was significantly greater with the level 3 ratio than with the level 1 ratio (P<.05). The level 3 ratio also resulted in the widest range of movement at the shoulder (P<.05 for level 2 vs 3; P = .06 for level 1 vs 3). The median angular velocity was 329.5 degrees/s, 360 degrees/s, and 530 degrees/s for levels 1, 2, and 3, respectively (P = .10). CONCLUSIONS: Intracorporeal-extracorporeal instrument length ratio below 1.0 degrades task performance and is associated with a wider range of movement at the elbow and shoulder and a higher angular velocity at the shoulder.

Surgical simulation: an animal tissue model for training in therapeutic and diagnostic bronchoscopy.

A series of surgical simulation exercises has been developed using an animal model to allow trainees to practise basic instrument handling and develop psychomotor skills in bronchoscopy, without risk to patients. A pig model was found to be most suitable. After suitable preparation the model can be used for diagnostic and therapeutic exercises in bronchoscopy, including lavage, biopsy and the removal of various foreign bodies. The model is a safe, inexpensive and convenient means of bronchoscopic training for otolaryngology trainees. For the trained specialist who has to remove bronchial foreign bodies infrequently, the model is a useful way of maintaining skills.

Simultaneous measurement of tyrosine hydroxylase activity and phosphorylation in bovine adrenal chromaffin cells.

A method for simultaneous measurement of tyrosine hydroxylase (TH) activation and phosphorylation in permeabilised and intact bovine adrenal chromaffin cells (BACCs) was established. Permeabilised cells were stimulated with cyclic AMP (1--10 microM) in the presence of [32P]ATP and L-[carboxyl-(14)C]tyrosine. Intact BACCs were preincubated with 32P(i) for 3 h and stimulated with forskolin (1--5 microM) in the presence of L-[carboxyl-(14)C]tyrosine. On stimulation each well was covered with a sealed 'chimney' fitted with a small plastic cup containing 300 microl of 1.0 M NaOH that trapped the 14CO(2) released. TH activity was determined by measuring 14C radioactivity. TH phosphorylation was measured in the same cells by separating the solubilized proteins on SDS PAGE followed by autoradiography and/or HPLC analysis. It was found that H89, a protein kinase A inhibitor, significantly blocked both TH phosphorylation and activation in response to cyclic AMP in permeabilised cells. However, in intact cells, H89 was effective only in respect to forskolin-stimulated TH activity and did not block the forskolin-stimulated TH phosphorylation of Ser-40. The reason(s) for this lack of correlation between TH activation and phosphorylation is presently not understood.

Technique training: endoscopic percutaneous tracheostomy.

Percutaneous tracheostomy is being used increasingly in the intensive care unit and endoscopic control of this procedure affords an improved level of safety. Training in such new minimal access techniques can be a significant risk factor in patient outcome. Surgical simulation provides training which minimizes this risk. We present a method of training in percutaneous endoscopic tracheostomy using a simulation model based on animal tissue. Our experience with this model is reported.

Tyrosine hydroxylase in bovine adrenal chromaffin cells: angiotensin II-stimulated activity and phosphorylation of Ser19, Ser31, and Ser40.

The aim of this study was to determine the effect of angiotensin II (AII) on tyrosine hydroxylase (TOH) activity and phosphorylation in bovine adrenal chromaffin cells (BACCs). We report here that stimulation of BACCs with AII (100 nM) produced a significant increase in both TOH activity and phosphorylation over a period of 10 min. The increase in TOH activity was receptor-mediated. Tryptic phosphopeptide analysis by HPLC revealed that AII stimulated an increase in phosphorylation of three sites on TOH, Ser19, Ser31, and Ser40, with the largest increase being observed for Ser31 phosphorylation. Pretreatment of the cells with the protein kinase C inhibitor Ro 31-8220 (10 microM, 15 min) did not affect TOH activity or phosphorylation produced by AII. The inhibitor also did not affect the TOH activity or Ser40 phosphorylation produced by forskolin (10 microM, 10 min). In contrast, Ro 31-8220 fully inhibited the TOH activation as well as Ser31 and Ser40 phosphorylation of TOH produced by phorbol 12,13-dibutyrate (500 nM, 10 min). Removal of extracellular Ca2+ from the incubation medium inhibited the AII-induced TOH activity by 50% and significantly blocked Ser19 and Ser31 phosphorylation but did not affect Ser40 phosphorylation in response to AII. These results indicate that AII activates a complex and perhaps novel signaling pathway leading to the phosphorylation and activation of TOH. The TOH activation by AII appears to be partially independent of Ser40 phosphorylation, suggesting a potentially important role for Ser31 phosphorylation.

Tyrosine hydroxylase phosphorylation in digitonin-permeabilized bovine adrenal chromaffin cells: the effect of protein kinase and phosphatase inhibitors on Ser19 and Ser40 phosphorylation.

The protein kinases and protein phosphatases that act on tyrosine hydroxylase in vivo have not been established. Bovine adrenal chromaffin cells were permeabilized with digitonin and incubated with [gamma-32P]ATP, in the presence or absence of 10 microM Ca2+, 1 microM cyclic AMP, 1 microM phorbol dibutyrate, or various kinase or phosphatase inhibitors. Ca2+ increased the phosphorylation of Ser19 and Ser40. Cyclic AMP, and phorbol dibutyrate in the presence of Ca2+, increased the phosphorylation of only Ser40. Ser31 and Ser8 were not phosphorylated. The Ca2+-stimulated phosphorylation of Ser19 was incompletely reduced by inhibitors of calcium/calmodulin-stimulated protein kinase II (46% with KN93 and 68% with CaM-PKII 273-302), suggesting that another protein kinase(s) was contributing to the phosphorylation of this site. The Ca2+-stimulated phosphorylation of Ser40 was reduced by specific inhibitors of protein kinase A (56% with H89 and 38% with PKAi 5-22 amide) and protein kinase C (70% with Ro 31-8220 and 54% with PKCi 19-31), suggesting that protein kinases A and C contributed to most of the phosphorylation of this site. Results with okadaic acid and microcystin suggested that Ser19 and Ser40 were dephosphorylated by PP2A.

Histamine-stimulated phospholipase C signalling in the adrenal chromaffin cell: effects on inositol phospholipid metabolism and tyrosine hydroxylase phosphorylation.

1. The present report gives a detailed account of histamine-stimulated phospholipase C (PLC) activity in bovine adrenal chromaffin cells. 2. Histamine activation of H1 receptors stimulates PLC with a biphasic sensitivity to extracellular Ca2+. The initial response (the first 15 s stimulation) was not reduced by the removal of extracellular Ca2+, whereas the maintenance of PLC activity beyond this time required Ca2+ influx. 3. Phospholipase C activity in response to a 10 min incubation with histamine was inhibited by La3+ (3 mmol/L) or SKF96365 (10 mumol/L). Nifedipine (10 mumol/L), but not omega-agatoxin IVA (100 nmol/L) or omega-conotoxin GVIA (300 nmol/L), produced a partial inhibition of PLC activity. The response was also partially inhibited by a reduction in the extracellular Cl- concentration (40 mmol/L) or by the inclusion of the Cl- channel blocker N-phenylanthranilic acid (300 mumol/L). 4. Kinetic analysis of the rate of turnover of the various inositol phosphate isomers in response to histamine suggested that the inositol monophosphates were being produced from a source in addition to inositol 1,4,5-trisphosphate (Ins(1,4,5)P3) metabolism. This conclusion was supported by the differential action of pertussis toxin and neomycin on Ins(1,4,5)P3 formation compared with inositol monophosphate formation. 5. We have attempted to identify a defined role for the intracellular Ca2+ mobilized in these cells in response to histamine. After short incubations (up to 3 min), histamine was able to regulate the site-specific phosphorylation of tyrosine hydroxylase, the rate-limiting enzyme in catecholamine synthesis. This observation has important implications for a possible role for the PLC signalling pathway in controlling the rate of catecholamine biosynthesis.