Comparing two techniques of performing an epidural catheter-assisted epidural blood patch using a 20 ml syringe versus a 5 ml syringe and its effect on clotting time, the strength of clot retraction and haemolysis - A prospective in vitro study (EC-EBP study).

Background and Aims: Epidural blood patch (EBP) is performed by injecting autologous blood into the epidural space using a Tuohy needle. Certain clinical scenarios mandate an epidural catheter (EC)-assisted EBP. Collecting blood in a 20-ml versus 5-ml syringe appears to influence the quality of the clot. This in vitro study compared the techniques of performing the EC-assisted EBP using 20-ml versus 5-ml syringe on clotting time (CT), clot retraction (CR) and haemolysis. Methods: This in vitro study was performed in a haematology laboratory. Five consented adult healthy male volunteers donated blood. In the 5-ml syringe technique, blood was injected through an EC, and as it flowed out of the tip, it was collected at the beginning and the end of 1 min. With the 20-ml technique, blood was collected at the beginning and end of the first, second and third minute. The samples were tested for CT, CR and haemolysis by measuring the plasma-free haemoglobin (PFHb). Results: Five injections were made using a 5-ml syringe, and another five with a 20-ml syringe. Injection time was shorter in the 5-ml technique (80.80 ± 5.89 vs. 272 ± 28.4 s, P < 0.0001). With the 20-ml technique, CT progressively increased (>15 min), whereas, with the 5-ml syringe, the CT was normal. Both techniques caused mild, insignificant haemolysis (PFHb >0.005 g/dl), without affecting the quality of CR. Conclusion: EC-assisted EBP using a 5-ml syringe technique shortens the injection time and deposits fresh blood quickly without affecting CT and CR.

Cleistanthin A causes peripheral vasoconstriction and myocardial depression in isolated tissue preparations.

BACKGROUND: Cleistanthus collinus is a poisonous shrub commonly used for deliberate self-harm in rural south India. Boiled decoction or a paste made from its leaves is used for suicide. Cleistanthoside A and Cleistanthin A are the major toxins identified from this plant. In this study, we disclose the mechanism of Cleistanthin A toxicity and concentrations of the two toxins in different extracts of Cleistanthus collinus. METHODS: The effect of Cleistanthin A was studied on isolated goat leg arteries using two different preparations namely transverse cylinder and longitudinal strip. The influence of Cleistanthin A on peripheral vascular resistance and myocardial contractility was evaluated by rat hind limb and isolated rat heart experiments, respectively. For the quantification of toxins, five different extracts of C. collinus leaves were prepared. The extracts were subjected to analytical HPLC to quantify Cleistanthoside A and Cleistanthin A. RESULTS AND CONCLUSION: Cleistanthin A increased vascular tension in transverse cylinder preparation and increased peak, trough and mean aortic pressures in the rat hind limb preparations. In isolated rat heart experiments, there was an increase in diastolic and mean ventricular pressure with a significant decrease in ventricular pulse pressure. These observations suggest that the hypotension in C. collinus poisoning patients may be due to cardiotoxicity and not due to vasodilation as is currently believed. Quantification of different extracts showed that boiled extracts had higher quantities of Cleistanthoside A whereas crushed leaf extracts yielded significantly higher amounts of Cleistanthin A.

Intra-arterial blood pressure measurement: sources of error and solutions.

Intra-arterial blood pressure measurement is the cornerstone of hemodynamic monitoring in intensive care units (ICU). Accuracy of the measurement is dependent on the dynamic response of the measuring system, defined by its natural frequency (fnatural) and damping coefficient (Zdamping). Gardner's plot (1981) has long been the only way to determine the accuracy of the pressure measurement. Specific objectives: (i) estimation of the amplitude of error in pressure measurement through simulations based on real-world data, (ii) a novel method to correct the error. Simulated blood pressure waveforms of various heart rates were passed through simulated measurement systems with varying fnatural and Zdamping. The numerical errors in systolic and diastolic pressures and mean error in the measured pressure were used to generate heat maps for the various recording conditions, in the same plot as that by Gardner (1981). fnatural and Zdamping from 121 patient recordings are plotted on these heat maps to demonstrate the fraction of unacceptable recordings. Performance of a tunable filter to correct the error is demonstrated. In many clinical settings, the measurement of intra-arterial pressure is prone to significant error. The proposed tunable filter is shown to improve the accuracy of intra-arterial pressure recording.

Electrical modelling of tissue experiments confirms precise locations of resistance and compliance in systemic arterial tree-they are mutually exclusive.

This study presents electrical modelling of the arterial system to understand the effect of adrenaline on the aortae and small arteries in terms of their resistance and compliance. There is no categorical documentation in the current literature on the precise locations of arterial resistance (R) and compliance (C) in vasculature. Knowledge of their exact locations in the arterial tree enables re-assessment of the differential action of vasoactive drugs on resistance versus compliance vessels once we resolve beat-to-beat changes in R and C in response to these drugs. Isolated goat aortae and small arteries were perfused with a pulsatile pump and lumen pressures were recorded before and after addition of adrenaline. Equivalent electrical models were simulated, and biological data was compared against the electrical equivalents to derive interpretations. In the aortae, systolic pressure increased, diastolic pressure decreased, pulse pressure increased (P = .018); but the mean pressure remained the same (P = .357). Whereas in small artery, vasoconstriction caused an increase in systolic, diastolic, and mean pressures (P = .028). Simulations allow us to infer that vasoconstriction in the aorta leads to a reduction in compliance, but an increase in resistance if any, is not sufficient to alter the mean aortic pressure. Whereas vasoconstriction in small arteries increases resistance, but a decrease in compliance, if any, does not affect any of the pressure parameters measured. The presented study is first of its kind to give experimental evidence that large arteries and aorta are the only compliance vessels and small arteries are the only resistance vessels.

Elusive Toxin in Cleistanthus collinus Causing Vasoconstriction and Myocardial Depression: Detailed NMR Analyses and Biological Studies of Cleistanthoside A.

Cleistanthus collinus leaf extracts are consumed for suicidal purposes in southern India. The boiled decoction is known to be more toxic than the fresh leaf juice. Although several compounds have been isolated and their toxicity tested, controversy remains as to which compounds are responsible for the high level of toxicity of C. collinus. We report herein that cleistanthoside A is the major toxin in the boiled aqueous extract of fresh leaves and causes death in rats in small doses. The toxicity of the boiled extract prepared in the manner described can be attributed entirely to cleistanthoside A. Cleistanthin A could also be isolated from the boiled extract, albeit in trace amounts. As hypotension not responding to vasoconstrictors is the cause of death in patients who have consumed the boiled extract, effects of cleistanthoside A on the determinants of blood pressure, namely, force of cardiac contraction and vascular resistance, were tested in isolated organ experiments. Cleistanthoside A has a direct vasoconstrictor effect; however, it inhibits ventricular contractility. Therefore, the notion that the shock in C. collinus poisoning is of vascular origin must be considered carefully, and the possibility of cardiogenic shock must be studied. We present the crystal structure of cleistanthin A and show the potency of fast NMR methods (NOAH4-BSCN-NUS) in the full spectral assignment of cleistanthoside A as a real-world sample of a natural product. We also compare the results of the NOAH4-BSCN-NUS NMR experiments with conventional NMR methods.

Correction: Phenylephrine induces relaxation of longitudinal strips from small arteries of goat legs.

[This corrects the article DOI: 10.1371/journal.pone.0227316.].

Phenylephrine induces relaxation of longitudinal strips from small arteries of goat legs.

Alpha adrenergic stimulation is known to produce vasoconstriction. We have earlier shown that, in spiral strips of small arteries Phenylephrine (PE) caused vasorelaxation under high nitric oxide (NO) environment. However, on further experimentation it was realized that the PE-induced vasorelaxant response occurred only with longitudinal strips of small arteries even under normal NO environment while circular strips showed contraction with PE even under high NO environment. Such PE-induced vasorelaxation of longitudinal strips was blocked by Phentolamine, an alpha-adrenergic receptor blocker. On delineation of specific receptor subtype, PE-induced relaxation was found to be mediated through alpha 1D receptor. However, this phenomenon is specific to small artery, as longitudinal smooth muscle of aorta showed only contractile response to adrenergic stimulation. There is no prior report of longitudinal smooth muscle in small artery up to our knowledge. The results of this study and histological examination of vessel sections suggest the presence of longitudinal smooth muscle in small artery and their relaxant response to alpha adrenergic stimulation is a novel phenomenon.

Cleistanthus collinus poisoning affects mitochondrial respiration and induces oxidative stress in the rat kidney.

Cleistanthus collinus is a poisonous shrub used for deliberate self-harm in rural areas of South India and intake of boiled decoction of leaves is a common method of self-harm. Distal renal tubular acidosis (dRTA) is an important clinical symptom observed in C. collinus poisoning, and renal V-ATPases may be potential targets of damage. However, a lack of understanding of molecular mediators involved hampers medical management, which is mainly supportive. We hypothesized that C. collinus poisoning induces renal oxidative stress; probably by inducing mitochondrial uncoupling, which compromises V-ATPase activity to ultimately produce dRTA. This was tested by exposing renal BBMV, kidney cells in culture, and Wistar rats to C. collinus poisoning. Exposure to C. collinus aqueous extract resulted in significant elevations in the lipid peroxidation marker, conjugated dienes, in cell culture and in vivo. A significant decrease in mitochondrial respiratory control ratio was observed in kidneys from C. collinus-treated animals suggesting that mitochondrial oxidative phosphorylation is uncoupled. This was accompanied by significant increase in ADP levels and a decrease in proton pump activity. Thus, these results demonstrate that C. collinus poisoning induces oxidative stress which influences proton pump activity, probably due to feedback inhibition by elevated ADP levels because of mitochondrial dysfunction in the rat kidney.

Phenylephrine Decreases Vascular Tension in Goat Arteries in Specific Circumstances.

Phenylephrine (PE) causes vasoconstriction through alpha adrenergic receptors. PE-induced vasodilatation has also been reported earlier in pre-constricted vessels. Here we demonstrate in spiral strips of goat arteries that addition of PE can decrease tone even from base-line levels (i.e. not pre-constricted) and show that this process requires nitric oxide (NO) and alpha adrenergic stimulation, but is cGMP-independent. Under control conditions, PE caused vasoconstriction, but under conditions where NO levels are higher, as with L-Arginine or sodium nitroprusside, PE decreased vessel tension. L-Arginine/PE combination was not able to decrease tension when alpha adrenoceptors were blocked with Phentolamine or endothelial nitric oxide synthase (eNOS) was blocked with Nω-Nitro-L-arginine (L-NNA). Propranolol, a beta blocker, was unable to prevent the reduction in tension by the L-Arginine/PE combination. Adrenaline and noradrenaline (and not isoproterenol) also reduced vessel tension in the presence of L-Arginine. Even when NO levels were not enhanced, relieving NO from having to stimulate the enzyme soluble guanylyl cyclase (sGC) (either by using sGC blockers, namely ODQ or methylene blue, or by enhancing cGMP levels (with sildenafil) which by negative feedback probably inhibits sGC) led to PE-induced reduction of vascular tension. PMA-phorbol myristate acetate-an agonist which stimulates Protein Kinase C was able to prevent the ability of PE to reduce vascular tension in a high NO environment. Our conclusion is that PE reduces vascular tension through alpha adrenoceptors if there is excess NO availability to activate a putative pathway. Though the reduction of vessel tone by PE is dependent on NO, it is independent of cGMP. Prior treatment with PMA or PE itself can prevent further PE-induced reduction of tension in a high NO environment. The results here suggest, counter-intuitively, that alpha blockers may be of help in the treatment of septic shock where nitric oxide levels are high.

Mechanisms of toxicity of Cleistanthus collinus: vacuolar ATPases are a putative target.

Ingestion of Cleistanthus collinus, a shrub native to South India, either intentionally or accidentally, is a common cause of death in the area. Consumption of a boiled decoction of leaves is highly toxic, but medical management of patients is mainly supportive because the molecular mechanisms of toxin action are unknown. Distal renal tubular acidosis is one of the symptoms of poisoning in patients and adenosine triphosphate (ATP) requiring proton pumps is important for acid secretion in the kidney. Hence, we hypothesized that these may be putative targets for C. collinus action and we tested this by exposing rat renal brush border membrane (BBM) as well as cultured kidney cells to a boiled decoction of C. collinus. Exposure to the C. collinus decoction resulted in significant inhibition of vacuolar type H(+)-ATPase (V-ATPase) activity in renal BBM as well as blocking of the proton pump in renal BBM vesicles. C. collinus decoction was also found to inhibit acidification of intracellular organelles in cells in culture, similar to the effect seen with either bafilomycin or concanamycin - specific inhibitors of the V-ATPase. This was accompanied by a decrease in V-ATPase activity, but an increase in protein levels. These results demonstrate that the V-ATPase in renal cells is a putative target for the toxins in C. collinus and the inhibition of this important proton pump probably plays a role in the development of distal renal tubular acidosis and subsequent renal failure seen in poisoned patients.

Cleistanthus collinus induces type I distal renal tubular acidosis and type II respiratory failure in rats.

BACKGROUND AND PURPOSE: A water decoction of the poisonous shrub Cleistanthus collinus is used for suicidal purposes. The mortality rate is 28%. The clinical profile includes distal renal tubular acidosis (DRTA) and respiratory failure. The mechanism of toxicity is unclear. OBJECTIVES: To demonstrate features of C. collinus toxicity in a rat model and to identify its mechanism(s) of action. MATERIALS AND METHODS: Rats were anesthetized and the carotid artery was cannulated. Electrocardiogram and respiratory movements were recorded. Either aqueous extract of C. collinus or control solution was administered intraperitoneally. Serial measurements of blood gases, electrolytes and urinary pH were made. Isolated brush border and basolateral membranes from rat kidney were incubated with C. collinus extract and reduction in ATPase activity was assessed. Venous blood samples from human volunteers and rats were incubated with an acetone extract of C. collinus and plasma potassium was estimated as an assay for sodium-potassium pump activity. RESULTS: The mortality was 100% in tests and 17% in controls. Terminal event in test animals was respiratory arrest. Controls had metabolic acidosis, respiratory compensation acidic urine and hyperkalemia. Test animals showed respiratory acidosis, alkaline urine and low blood potassium as compared to controls. C. collinus extract inhibited ATPase activity in rat kidney. Plasma K(+) did not increase in human blood incubated with C. collinus extract. CONCLUSIONS AND IMPLICATIONS: Active principles of C. collinus inhibit proton pumps in the renal brush border, resulting in type I DRTA in rats. There is no inhibition of sodium-potassium pump activity. Test animals develop respiratory acidosis, and the immediate cause of death is respiratory arrest.

Analysis of depolarization-induced outward currents in goat chondrocytes using the patch clamp technique.

This study analyzes outward currents in freshly isolated goat chondrocytes patched in the whole cell mode. Capacitance tracings were recorded from the cells by the time domain method. The average capacitance was 6.33 pF +/- 2.15pF (Mean +/- SD, n = 60). The range was 2.7 pF to 11.2 pF. A family of outward currents was seen when the cell was depolarized from -70 mV to +70 mV in 10 mV increments. The current density at +60 mV varied from 125 pA/pF to 2410 pA/pF. The currents were inhibited by 10 mM tetraethylammonium chloride (TEA) and the current-voltage profile suggests that these are voltage gated K+ channels. The currents were also recordable in a chloride-free external solution, thereby proving that these currents are not chloride currents. There was no evidence of voltage-gated sodium channels in these cells.

Actions of antidiuretic hormone analogues on intact and nystatin-permeabilized frog skins.

The roles of two antidiuretic hormone analogues, namely arginine vasotocin (AVT) and lysine vasopressin (LVP), in solute transport across the ventral abdominal skin of frogs (Rana hexadactyla) were studied using voltage-clamp methods on intact and nystatin-permeabilized preparations. Arginine vasotocin (40 nm), the amphibian analogue of antidiuretic hormone, did not have any effect on the skin of Rana hexadactyla. However, LVP, the porcine antidiuretic hormone, increased the transepithelial potential difference (TEPD) and short-circuit current (SCC) significantly, without affecting the slope conductance. Lysine vasopressin had no action subsequent to addition of amiloride (100 microm) on the apical side or ouabain (10 microm) on the basolateral side. Lysine vasopressin increased slope conductance in the nystatin-permeablized skin while decreasing TEPD. Such a change was not seen in chloride-free solutions. To elucidate the mechanism of action of LVP on intact skin, experiments were done with forskolin and a V(2) receptor blocker. The effects of forskolin (10 microm) were different from those of LVP in that forskolin significantly increased SCC and conductance of the intact skin, while decreasing TEPD. The forskolin-induced increase in conductance was not abolished by amiloride. Use of the V(2) receptor blocker inhibited the effects of LVP. We conclude that AVT does not have an action on the skin of Rana hexadactyla. Lysine vasopressin enhances transepithelial sodium transport by increasing sodium-potassium pump activity, while not affecting the epithelial sodium channel conductance. Lysine vasopressin also enhances an inward-directed conductance on the basolateral membrane, probably a chloride conductance. The action of LVP on the intact frog skin is through the V(2) receptors; however, downstream signalling does not seem to be mediated by cAMP. Analysis of the electrophysiological model of frog skin with LVP allows us additionally to conclude that modulation of channel activity and not carrier-mediated transport affects slope conductance.

An in vitro study on human ureteric smooth muscle with the alpha1-adrenoceptor subtype blocker, tamsulosin.

OBJECTIVE: To study the effects of tamsulosin on ureteric contractions and its effects on the basal tone of human ureteric specimens, as clinical trials with tamsulosin have shown promising results in the spontaneous expulsion of lower ureteric calculus, but the mechanism of action of tamsulosin in the expulsion of ureteric calculus has not been elucidated in in-vitro studies on human ureters. MATERIALS AND METHODS: Human mid-ureteric specimens were obtained from live kidney donors. The specimen was transported in Krebs' solution and the isometric contraction of human ureteric smooth muscle was recorded in the presence of tamsulosin. Ureteric rings from 19 kidney donors were studied. RESULTS: At 100 microm tamsulosin the frequency of ureteric contraction was blocked completely, or the contraction frequency was reduced in 89% of specimens. There was no change in the frequency or in the amplitude of contraction in the remaining specimens. The basal tone of the ureter was reduced in 16% of the specimens. CONCLUSION: Our results suggest that peristaltic activity in human ureteric smooth muscle is inhibited by tamsulosin. The effect of tamsulosin on basal tone is marginal.

Calcium-transporters in myocardial cells.

This is a concise review of important calcium-transporters on the sarcolemma and organellar membranes of myocardial cells, and their functional roles in cell physiology. It briefly addresses L and T type calcium channels, store-operated calcium channel (SOC), sodium-calcium exchanger (NCX), and the plasma membrane calcium ATPase (PMCA) on the sarcolemma, ryanodine receptor (RyR), IP3 receptor (IP3R) and the sarcoplasmic reticulum (SR) calcium ATPase (SAERCA) on the SR membrane and their contributions to contraction and rhythm-generation. Several agonists and blockers for every transporter that are commonly used in research, and those with therapeutic applications have also been discussed.

Differential effects of organic calcium-channel blockers on diastolic SR calcium-handling in the frog heart.

1. Gradual loss of sarcoplasmic reticular (SR) calcium during a rest-period is responsible for the rest-induced decay (RID) of force in mammalian myocardium. Effect of verapamil and diltiazem on a similar RID in the frog myocardium suggests a new mechanism of action of these drugs. 2. Strips of frog-ventricle were paced at 0.2 Hz and the rhythm was interrupted by varying rest-periods ranging from 10 to 180 s. In control conditions, the amplitude of the post-rest beat was significantly lower than that of the pre-rest beat for rest-periods more than 40 s (RID). 3. Verapamil and diltiazem (which are organic calcium-channel blockers (OCCB)) changed the pattern of RID in the control solution to a 'rest-induced potentiation' (RIP) in the same preparation while another OCCB nifedipine and the inorganic calcium-channel blocker cadmium did not alter the post-rest phenomenon. 4. We propose that verapamil and diltiazem produce an RIP due to either blockade of SR calcium-leak during rest or enhancement of SR calcium-uptake during rest.