The association between allogeneic perioperative blood transfusion on tumour recurrence and survival in patients with advanced ovarian cancer.

OBJECTIVE: To evaluate the association between perioperative blood transfusion on the recurrence and survival of patient with advanced ovarian cancer. BACKGROUND: Cytoreductive surgery for ovarian cancer can be an extensive procedure often requiring allogeneic blood transfusions. Blood transfusions can have detrimental effects on immune function which can lead to a decrease in the organism ability to detect and destroy metastasis. METHODS: The study was a retrospective cohort investigation. Patients with advanced ovarian cancer (stage III) undergoing cytoreductive surgery were stratified by the need for perioperative blood transfusion. Allogeneic transfusions were non-leucodepleted. Primary outcome included time to recurrence and survival. Data were extracted from the gynaecology oncology database at Northwestern University. Times to event outcomes were evaluated by constructing Kaplan-Meyer curves and Cox regression. RESULTS: The charts of 136 subjects were evaluated. Seventy-six received blood transfusion. Median [95% confidence interval (CI)] time to recurrence for the non-transfusion group was longer, i.e. 17 (6-27) months, compared to 11 (8-14) months for the transfused group (P = 0.03). Median (95% CI) survival following surgery was longer in the non-transfused group, i.e. 58 (43-73) months, compared to 36 (28-44) months for the transfused group (P = 0.04). Cox regression showed that transfused subjects had shorter median times to recurrence and mortality after adjusting for age and tumour grade. CONCLUSIONS: There is an association between ovarian cancer recurrence and allogeneic perioperative blood transfusion in patients with advanced ovarian cancer undergoing cytoreductive surgery. These findings may have important implications in the perioperative management of those patients.

Dose ranging study on the effect of preoperative dexamethasone on postoperative quality of recovery and opioid consumption after ambulatory gynaecological surgery.

BACKGROUND: Glucocorticoids are commonly administered before ambulatory surgery, although their effects on quality of recovery are not well characterized. The purpose of this study was to evaluate the dose-dependent effects of dexamethasone on patient recovery using the Quality of Recovery 40 questionnaire (QoR-40) after ambulatory surgery. METHODS: This prospective, double-blind trial studied 106 female subjects undergoing outpatient gynaecological laparoscopy. Subjects were randomized to receive saline, dexamethasone 0.05 mg kg(-1) or dexamethasone 0.1 mg kg(-1) before induction. The primary outcome was global QoR-40 at 24 h. Postoperative pain, analgesic consumption, side-effects, and discharge time were also evaluated. RESULTS: Global median (IQR) QoR-40 after dexamethasone 0.1 mg kg(-1) 193 (192-195) was greater than dexamethasone 0.05 mg kg(-1) 179 (175-185) (P=0.004) or saline, 171 (160-182) (P<0.005). Median (IQR) morphine equivalents administered before discharge were 2.7 (0-6.3) mg after dexamethasone 0.1 mg kg(-1) compared with 5.3 (2.4-8.8) mg and 5.3 (2.7-7.8) mg after dexamethasone 0.05 mg kg(-1) and saline (P=0.02). Time to meet discharge criteria was 30 min shorter after dexamethasone 0.1 mg kg(-1) compared with saline (P=0.005). At 24 h, subjects receiving dexamethasone 0.1 mg kg(-1) had consumed less opioid analgesics, reported less sore throat, muscle pain, confusion, difficulty in falling asleep, and nausea compared with dexamethasone 0.05 mg kg(-1) and saline. CONCLUSIONS: Dexamethasone demonstrated dose-dependent effects on quality of recovery. Dexamethasone 0.1 mg kg(-1) reduced opioid consumption compared with dexamethasone 0.05 mg kg(-1), which may be beneficial for improving recovery after ambulatory gynaecological surgery.

Detection of hypoventilation during deep sedation in patients undergoing ambulatory gynaecological hysteroscopy: a comparison between transcutaneous and nasal end-tidal carbon dioxide measurements.

BACKGROUND: Transcutaneous measurement of carbon dioxide (Tc(co(2))) provides a non-invasive estimation of arterial carbon dioxide (Pa(co(2))). Nasal capnography (Pe'(co(2))) is used to assess ventilation during monitored anaesthesia care (MAC) with sedation since it can readily detect apnoea. We compared the agreement between Tc(co(2)) and Pe'(co(2)) with Pa(co(2)) and the ability to detect hypercarbia in patients under deep sedation. METHODS: Forty healthy female subjects receiving deep sedation for hysteroscopy were studied. A Tc(co(2)) (TOSCA 500, Radiometer, Inc., Westlake, OH, USA) electrode was applied to the earlobe and Pe'(co(2)) capnography was monitored using nasal side-stream sampling. All subjects received oxygen (3 litre min(-1)). Subjects were evaluated at intervals using a modified Ramsay sedation score until they reached a score >or=5. Arterial blood gas values were compared with Tc(co(2)) and Pe'(co(2)) values. Bland-Altman, linear regression, and receiver operator characteristics analysis were performed. RESULTS: The mean (sd) absolute difference between the Tc(co(2)), Pe'(co(2)), and the Pa(co(2)) were 0.43 (0.35) and 1.06 (0.8) kPa, respectively (P=0.002). Tc(co(2)) demonstrated a mean bias (2 sd) of 0.23 (0.07-0.4) kPa with Pa(co(2)) compared with -0.93 (-1.24 to -0.63) kPa for Pe'(co(2)). One minute before blood sampling, the sensitivity of the Tc(co(2)) monitor for detecting Pa(co(2)) >6.65 kPa was greater than for Pe'(co(2)) (66.7% vs 33.3%, P<0.01). CONCLUSIONS: Tc(co(2)) demonstrated better agreement with Pa(co(2)) than Pe'(co(2)) for patients under MAC with deep sedation. Tc(co(2)) monitoring was more sensitive for detection of Pa(co(2)) >6.65 kPa than Pe'(co(2)).

Small RNA regulators and the bacterial response to stress.

Recent studies have uncovered dozens of regulatory small RNAs in bacteria. A large number of these small RNAs act by pairing to their target mRNAs. The outcome of pairing can be either stimulation or inhibition of translation. Pairing in vivo frequently depends on the RNA-binding protein Hfq. Synthesis of these small RNAs is tightly regulated at the level of transcription; many of the well-studied stress response regulons have now been found to include a regulatory RNA. Expression of the small RNA can help the cell cope with environmental stress by redirecting cellular metabolism, exemplified by RyhB, a small RNA expressed upon iron starvation. Although small RNAs found in Escherichia coli can usually be identified by sequence comparison to closely related enterobacteria, other approaches are necessary to find the equivalent RNAs in other bacterial species. Nonetheless, it is becoming increasingly clear that many if not all bacteria encode significant numbers of these important regulators. Tracing their evolution through bacterial genomes remains a challenge.

The pharmacokinetics of dexmedetomidine in volunteers with severe renal impairment.

UNLABELLED: Dexmedetomidine, an alpha2-adrenergic agonist with sedative and analgesic properties, is mainly cleared by hepatic metabolism. Because the pharmacokinetics of dexmedetomidine have not been determined in humans with impaired renal function, we studied them in volunteers with severe renal disease and in control volunteers. Six volunteers with severe renal disease and six matched volunteers with normal renal function received dexmedetomidine, 0.6 microg/kg, over 10 min. Venous blood samples for the measurement of plasma dexmedetomidine concentrations were drawn before, during, and up to 12 h after the infusion. Two-compartmental pharmacokinetic models were fit to the drug concentration versus time data. We also determined its hemodynamic, respiratory, and sedative effects. There was no difference between Renal Disease and Control groups in either volume of distribution at steady state (1.81 +/- 0.55 and 1.54 +/- 0.08 L/kg, respectively; mean +/- SD) or elimination clearance (12.5 +/- 4.6 and 8.9 +/- 0.7 mL x min(-1) x kg(-1), respectively). However, elimination half-life was shortened in the Renal Disease group (113.4 +/- 11.3 vs 136.5 +/- 13.0 min; P < 0.05). A mild reduction in blood pressure occurred in most volunteers. Although most volunteers were sedated by dexmedetomidine, renal disease volunteers were sedated for a longer period of time. IMPLICATIONS: The pharmacokinetics of dexmedetomidine in volunteers with severe renal impairment differed little from those in volunteers with normal renal function. In addition, there were no clinically significant differences in the hemodynamic responses to dexmedetomidine. However, dexmedetomidine resulted in more prolonged sedation in subjects with renal disease.

Differential gene expression in haemocytes of the snail Biomphalaria glabrata: effects of Schistosoma mansoni infection.

Parasite encapsulation and destruction in Biomphalaria glabrata has been shown to involve the cellular component of the snail's internal defence system, the haemocytes. To identify genes involved in the immunobiology of these cells, we used the method of differential display reverse transcriptase polymerase chain reaction (DDRT-PCR) to investigate differential gene regulation in haemocytes isolated from Schistosoma mansoni exposed and unexposed snails. RNA isolated from circulating haemocytes from resistant snails (BS-90 stock), previously exposed to S. mansoni, was analysed using 12 different arbitrary primers in conjunction with an anchored Oligo d(T(11)CG) primer. Transcription profiles between haemocytes of parasite exposed and unexposed snails were compared and a total of 87 differentially regulated bands were identified and isolated. Of these, 65 bands were cloned and used as probes in Southern blots to show the presence of corresponding sequences in the snail genome. RT-PCR was performed to verify the regulation of these transcripts. DNA sequence analysis showed that the majority of the cloned sequences were novel, although a few showed a high degree of sequence similarity to other sequences in the DNA and protein databases. One of these included a differentially expressed transcript that showed a significant degree of sequence identity to E. coli transposase Tn5, an enzyme whose activity is normally associated with generating mobility and instability in the genome.

Impact of the initial doses of rocuronium and pancuronium on subsequent maintenance for neuromuscular block.

PURPOSE: To determine the impact of the neuromuscular blocking agent given for intubation on the duration of effect of multiple maintenance doses of pancuronium and rocuronium. METHODS: Seventy-eight subjects were randomly assigned to receive one of four dosing combinations for intubation and neuromuscular maintenance: rocuronium for intubation and maintenance, rocuronium for intubation and pancuronium for maintenance, pancuronium for intubation and rocuronium for maintenance, or pancuronium for both. Each time that the first twitch response returned to 25% of the baseline value, the duration of the dose was determined and another maintenance dose was administered. The duration of action of the maintenance doses was compared between the groups. RESULTS: Twitch suppression from the first maintenance dose was shorter for subjects who received rocuronium for both doses (Group RR) compared with that for subjects that received pancuronium (Groups PR & PP) as their intubation dose (17.6 vs 34 & 59.8 min, respectively, P < 0.05). Subjects who received rocuronium followed by pancuronium (Group RP) showed a shorter duration of twitch suppression after the first maintenance dose than the group that received pancuronium for both doses (Group PP) (21.3 vs 59.8 min, P < 0.05). By the third maintenance dose, the influence of the intubating dose on the maintenance dose duration had essentially diminished. CONCLUSIONS: For combinations of rocuronium and pancuronium, the duration of twitch suppression after a maintenance dose is only dependent on the first agent given for the first two maintenance doses administered.

Is an infusion pump necessary to safely administer remifentanil?

UNLABELLED: We sought to determine if remifentanil could be administered as safely and effectively from an IV drip as from a calculator pump, because not all anesthesiologists have access to a calculator pump. Forty healthy adults undergoing outpatient knee arthroscopy were premedicated with midazolam, 2 mg. Total IV anesthesia was induced with propofol by bolus (2 mg/kg) and maintained by a continuous infusion of propofol and remifentanil. On a randomized, double-blinded basis, they received, IV, either remifentanil (50 microg/mL) by syringe from an infusion pump or from a bag of saline containing remifentanil 20 microg/mL through a minidrip set. The remifentanil infusion syringe pump rate was 0.4 microg. kg(-1). min(-1) until skin incision and then 0.2 microg. kg(-1). min(-1), whereas that from the bag/minidrip set was set to approximate the delivery rate from the pump. Both a syringe pump and bag/minidrip set infusion were administered to each patient but only one contained remifentanil, that one being determined in a randomized, double-blinded manner. There were no differences in demographic data, time to recovery of open eyes, response to command, ability to speak (approximately 7 min), total dose and time of administration of propofol and remifentanil, the incidence of intraoperative hypotension and bradycardia, and postoperative shivering. We demonstrated that remifentanil can be administered as safely and effectively from a bag with a minidrip set as from a syringe in a calculator infusion pump, provided the anesthesiologist is paying attention to the drip rate from the bag. IMPLICATIONS: Because remifentanil is rapidly degraded in the body, it can be safely and effectively administered from a bag through a minidrip set. We showed that there was no difference with this less expensive method of administration than from the more precise method of a calculator infusion pump.

Effect of dexmedetomidine on the minimum alveolar concentration (MAC) of sevoflurane in adults age 55 to 70 years.

STUDY OBJECTIVE: To determine the effect of two target dexmedetomidine infusions (0.3 ng/ml and 0.6 ng/ml) on the minimal alveolar concentration (MAC) of sevoflurane in adults age 55 to 70 years. DESIGN: Prospective, randomized, placebo-controlled study. SETTING: University-affiliated hospital. PATIENTS: 45 ASA physical status I and II adults, age 55 to 70 years, undergoing elective surgery with at least a 3 inch skin incision. INTERVENTIONS: Patients were given a dexmedetomidine or placebo infusion for at least 15 minutes before anesthetic induction with sevoflurane in oxygen by face mask. After tracheal intubation, a target sevoflurane concentration was maintained for 15 minutes while the dexmedetomidine or placebo infusion continued to run. MEASUREMENTS AND MAIN RESULTS: At the time of skin incision, two observers independently determined movement or nonmovement to the incision. Blood samples for dexmedetomidine were taken before the infusion and at the time of skin incision. The dexmedetomidine plasma concentrations were 0 before infusion with all treatment groups. At the time of incision, they were 0 in the placebo group, 0.39 +/- 0.13 ng/ml in the 0.3 ng/ml target group, and 0.7 +/- 0.13 ng/ml in the 0.6 ng/ml target group. The MAC of sevoflurane was 1.83% in the placebo group, 1.78% in the 0.3 ng/ml target dexmedetomidine group, and 1.51% in the 0.6 ng/ml target dexmedetomidine group. CONCLUSIONS: Dexmedetomidine 0.7 ng/ml decreased the MAC of sevoflurane by 17%, whereas there was no difference between the placebo and the dexmedetomidine 0.39 ng/ml group.

Nucleoside diphosphate kinase from the parasitic nematode Brugia malayi.

Using a reverse transcription-polymerase chain reaction (RT-PCR) procedure that exploited the presence of a conserved 22-nucleotide spliced leader (SL) sequence that is trans-spliced to the 5' end of nematode transcripts, a novel Brugia malayi (Bm) infective-stage SL cDNA expression library was constructed and characterized. The library was immunoscreened with rabbit anti-infective-stage antibodies (Ab) and an immunodominant clone, BmG4-7, was identified and characterized. BmG4-7 contained a full-length cDNA that had significant sequence similarity to nucleoside diphosphate kinase (NDK)-encoding sequences reported from a number of species, including Drosophila melanogaster and humans. BmNDK was found to be constitutively transcribed during all stages of parasite development. An anti-BmNDK Ab was used to immunostain a Western blot of extracts from adult and larval parasites. The Ab specifically recognized a 17.5-kDa molecule in all of the parasite extracts. Molecular modeling of the BmNDK showed several regions surrounding the conserved catalytic site that may be important in the design of drugs specific for the disruption of NTP synthesis in filarial parasites.

Cloning and characterization of a potentially protective chitinase-like recombinant antigen from Wuchereria bancrofti.

While there is no direct evidence demonstrating the existence of protective immunity to Wuchereria bancrofti infection in humans, the presence of individuals, in populations in areas where infection is endemic, with no clinical evidence of past or current infection despite appreciable exposure to the infective larvae, suggests that protective immunity to filarial parasites may occur naturally. Earlier work indicated that such putatively immune individuals generated antibodies to a 43-kDa antigen from larval extracts of the related filarial parasite Brugia malayi that was recognized by only 8% of the infected population. With rabbit antiserum raised against this 43-kDa antigen, this current study identified a recombinant clone, WbN43, with an insert size of 2.3 kb, from a W. bancrofti genomic expression library. The recombinant fusion protein was differentially recognized by the putatively immune individuals but not by the infected patients. The coding sequence (684 bp) from the 5' end had significant sequence similarity to chitinases from Serratia marcescens, Bacillus circulans, Streptomyces plicatus, and B. malayi. Peptide sequencing of the expressed product also defined a chitinase-like sequence. Molecular characterization indicated WbN43 to be a low-copy-number gene, with expression predominantly in infective larvae and microfilariae but not in adult parasites.

Polyethenoadenosine phosphate as a fluorogenic substrate for barnase.

Polyethenoadenosine phosphate is rapidly hydrolyzed by barnase with an accompanying large increase in fluorescence. At pH 8, 0.2 M ammonium acetate, the initial rate of fluorescence increase is proportional to barnase concentration and thus provides an excellent quantitative assay for its activity. The preparation and use of this substrate in the barnase assay is presented in detail.

Characterization of a muscle-associated antigen from Wuchereria bancrofti.

A recombinant clone, WbN1, isolated from a genomic expression library of Wuchereria bancrofti and showing restricted specificity at the DNA level (Southern and PCR analyses) for Wuchereria bancrofti and Brugia malayi has been previously described. Sequence analysis of WbN1 indicated that it had notable similarity to myosin. Further characterization using in situ hybridization has localized the mRNA in the muscle of the adult parasite and in the microfilariae. Rabbit polyclonal antiserum, raised against the recombinant WbN1 fused to the maltose-binding protein, recognized a 200-kDa polypeptide in immunoblots containing B. malayi antigen extracts. The same antibody also recognized myosin extracted from Brugia pahangi, Onchocerca volvulus, and Caenorhabditis elegans. Localization using the rabbit antiserum revealed the presence of the antigen in the adult muscle tissue and in the microfilariae; the same antibody inhibited the binding of a monoclonal antibody 28.2 (directed toward MHC B of C. elegans myosin) to the recombinant WbN1 antigen and also to purified C. elegans myosin. Based on homology data, structural location, competitive ELISA, and immunoblot we conclude that WbN1 is related to myosin or a similar myofibrillar protein.

Effects of sequence alterations in a DNA segment containing the 5 S RNA gene from Lytechinus variegatus on positioning of a nucleosome core particle in vitro.

Reassociation of a 260-base pair cloned fragment of Lytechinus variegatus DNA with core histones has been shown to give rise to a uniquely positioned nucleosome (Simpson, R. T., and Stafford, D. W. (1983) Proc. Natl. Acad. Sci. U. S. A. 80, 51-55). In an attempt to define the features that dictate the unique positioning of the nucleosome, we have constructed a number of mutants of this DNA sequence. The ability of these mutants to form positioned nucleosomes was analyzed by DNase I digestion of the DNA after reassociation with chicken erythrocyte core histones. While all the mutants were efficiently incorporated into core particles, not all of these modified sequences were capable of forming a positioned nucleosome. Of the 13 mutants examined, 7 fell into a class that gave rise to nucleosomes in which no unique positioning could be demonstrated. While no specific feature of the DNA sequences has been identified as the critical factor in allowing, or dictating, the formation of positioned nucleosomes, our results do indicate that the region 20-30 bases either side of the center of the core particle appears to contain the major elements necessary for positioning. Additionally, these studies clearly show that differences in the digestion of naked and core particle DNA are related to specific interactions of the DNA and histones rather than to an altered specificity of the enzyme induced by the presence of the proteins.

Sequence-specific interaction of histones with the simian virus 40 enhancer region in vitro.

DNA fragments containing either one or both of the 72-base pair (bp) elements which constitute the SV40 enhancer and the three adjacent 21-bp repeats were associated with histone octomers from chicken erythrocytes in vitro. Both fragments formed complexes with electrophoretic mobilities of nucleosomes containing the appropriate length of DNA. Analysis of DNase I cutting of uniquely end-labeled complexes suggests that the fragment containing a single 72-bp element forms a positioned core particle. Control experiments show that positioning is not due to the 21-bp repeats or to end effects. The fragment with a tandem repeat of the 72-bp element also does not associate randomly with histones. The data are consistent with formation of a core particle on one or the other of the repeated enhancer sequences. We discuss possible functional consequences of such nucleosome positioning.

Kinetic studies of the demetallization and inactivation of concanavalin A.

The demetallization of various metallo derivatives of Concanavalin A (i.e., MnMnPL, CoMnPL, CaCaPL, CoCaPL and MnCaPL, where PL represents protein in a locked conformation) has been examined by three separate procedures. These include the treatment of the protein with the metal ion chelators, EDTA and terpyridine, and subjecting the protein to low pH (i.e., pH 1.2). In all three procedure and for all five species examined, the immediate product of protein demetallization was the PL conformation previously described by Brown, R.D., III, Brewer, C.F. and Koenig, S.H. (Biochemistry (1977) 16, 3883-3896). The rates of dissociation of the metals from the different protein species, as measured spectrophotometrically using terpyridine, were found to be identical to the rates (k1) of loss of protein sugar binding affinity in the presence of EDTA as measured by assays with the fluorescent sugar, 4-methylumbelliferyl alpha-D-mannoside. The kinetic and thermodynamic data associated with the inactivation of the protein species have allowed the different metallo derivatives to be classed into two general categories. Class I forms include MnMnPL, CoMnPL and CaCaPL and possess an average k1 (25 degrees C) value of 3.88 X 10(-2) s-1 and an average Ea of 14.2 kcal X mol-1. Class II forms CoCaPL and MnCaPL have average values for k1 (25 degrees C) and Ea of 3.67 X 10(-5) s-1 and 21.6 kcal X mol-1, respectively.