Simulated Crisis in Obstetric Anesthesia: Design and Evaluation of a Distance Education Presentation.

Patient simulators are useful tools for training residents and all levels of medical personnel. Simulator usefulness, in small group sessions, is limited by the costs of training large numbers of people. We present an interrupted methodology designed to involve a large group at a location remote from the simulator. The goal was to enable the remote participants to take part in decision making while under time pressure. Two volunteers were chosen as hands-on participants while eighteen remaining anesthesiology residents observed from a lecture room via a closed circuit audio/video feed. A series of five crises in obstetric anesthesia was presented. After each crisis the simulation was paused and the observers were given three minutes to formulate a differential diagnosis and plan to be carried out. At the end of the session facilitators led a debriefing session with all participants. Surveys completed after the simulation indicated that most residents felt personally involved in the simulation, despite being physically removed from it. Surveys also showed that residents believed they learned more from this format than they would have from a lecture. Residents recalled an average of 3.4 crises two days after the session. This paper presents a model for distance education using a simulator and shows that residents believed remote, interrupted, interactive simulator training is valuable. The interrupted nature and involvement of remotely located peers differentiate this methodology from a passive viewing of a remote session. Further study is warranted to quantify the effectiveness of group and/or distance training with a simulator.

Pathogenesis of HIV encephalitis.

A wide spectrum of infectious agents attack the central nervous system (CNS) of acquired immunodeficiency syndrome (AIDS) patients. Human immunodeficiency virus (HIV) itself, infects the CNS of a subgroup of these patients. The mechanism behind why HIV enters the CNS is unclear. We have observed an interesting association between HIV and opportunistic viral infections that may explain why HIV enters the brain. Infection of the CNS by opportunistic agents results in recruitment of latently HIV-infected monocytes. Upon differentiation into macrophages these cells produce abundant HIV. Latent HIV-infection of monocytes/macrophages provides a unique opportunity for cooperativity between opportunistic infections and HIV in mediating CNS damage.

T-cell-induced expression of human immunodeficiency virus in macrophages.

Macrophages are major reservoirs of human immunodeficiency virus (HIV) in the tissues of infected humans. As monocytes in the peripheral blood do not show high levels of infection, we have investigated the expression of HIV in T-cell-activated, differentiated macrophages. Peripheral blood mononuclear cells were isolated from HIV-seropositive individuals and stimulated with antigens or mitogens, and the nonadherent fraction was removed. Macrophages were cultured alone for 2 weeks, and HIV expression was assessed. Results from p24 antigen capture assays demonstrated that the presence of autologous T cells and concanavalin A or autologous T cells and allogeneic cells for the initial 24 h of culture induced HIV expression in 35 of 47 (74%) HIV-seropositive patients tested. The macrophage monolayers could be immunostained with anti-HIV antibodies to reveal discrete infectious centers, indicating that complete virus replication was occurring in the macrophages and that infection of adjacent cells was mediated by cell-cell contact. Time course studies of the interval of coculture of the adherent and nonadherent cells indicated that 24 h (but not 2 h) was sufficient for induction of HIV in the macrophages. Direct contact between the adherent cells and activated T cells was required as well. Since the presence of autologous T cells also appeared to be necessary, induction of HIV expression in macrophages may be genetically restricted. HIV-seronegative nonadherent cells were able to induce HIV expression in macrophages from HIV-seropositive donors, demonstrating that the virus originated in the monocytes and was reactivated in the context of a classic T-cell-mediated immune reaction. The high percentage of monocytes from HIV-seropositive donors which can be induced to replicate HIV by activated T cells suggests that infection of monocytes may be critical to the pathogenesis of this lentivirus infection.

Enkephalin convertase in the heart: similar disposition to atrial natriuretic factor.

Enkephalin convertase (EC; carboxypeptidase-E or -H) is a carboxypeptidase-B-like enzyme proposed to be involved in the synthesis of enkephalins and other neuropeptides. In this study we have characterized and localized EC in the rat heart and examined its correspondence with atrial natriuretic factor. Heart homogenates bind [3H]guanidinoethylmercaptosuccinic acid ([ 3H]GEMSA), a selective ligand for enkephalin convertase, with specificity and high affinity (Kd = 5-10 nM). The pharmacology of these sites matches that of convertase catalytic activity and of [3H]GEMSA binding in other tissues. The binding sites in the heart can be purified 4000-fold using p-aminobenzoylarginine affinity chromatography, and the purified sites have Co2+ stimulated carboxypeptidase activity identical to EC. By subcellular fractionation studies [3H]GEMSA-binding sites are localized to the granule fraction with ANF immunoreactivity. [3H]GEMSA autoradiography localizes EC in the heart to the left and right atria, with very low levels in mature and ventricles. The distribution, biochemical properties, and developmental course of EC suggest that it may be involved in the synthesis of atrial natriuretic factor.

Odorant-binding protein and its mRNA are localized to lateral nasal gland implying a carrier function.

Odorant-binding protein selectively binds various odorants and is discretely concentrated in nasal mucosa and secretions. We have localized rat odorant-binding protein mRNA to the lateral nasal gland by in situ hybridization histochemistry and have also localized the protein to this gland by immunohistochemistry and by tritiated-odorant autoradiography. The lateral nasal gland extends a long duct toward the external nares. Odorant-binding protein, released from this duct, may transport odorants to olfactory receptor neurons.

Enkephalin convertase: characterization and localization using [3H]guanidinoethylmercaptosuccinic acid.

Enkephalin convertase (carboxypeptidase E,H; EC 3.4.17.10) is a carboxypeptidase B-like enzyme which appears to be physiologically associated with the biosynthesis of the enkephalins and certain other peptides. We have localized enkephalin convertase in the brain and other tissues autoradiographically by labeling studies with [3H]guanidinoethylmercaptosuccinic acid ([3H]GEMSA). In the brain, [3H]GEMSA localizations parallel enkephalin distribution but with certain exceptions, suggesting a role in relation to other peptides. In the pancreas, [3H]GEMSA binding sites are localized to the islets suggesting an involvement in insulin, glucagon, or somatostatin formation. The selective concentration of [3H]GEMSA grains in cardiac atria suggests a link to atrial natriuretic factor.

Enkephalin convertase in the gastrointestinal tract an associated organs characterized and localized with [3H]guanidinoethylmercaptosuccinic acid.

Enkephalin convertase (carboxypeptidase EH; EC 3.4.17.10), a carboxypeptidase B-like enzyme which processes hormone and neuropeptide precursors, has been characterized in the gastrointestinal tract, submandibular gland, and pancreas using a binding assay with [3H]guanidinoethylmercaptosuccinic acid. Binding to homogenates of the membrane and soluble fractions of stomach, small intestine, colon, and submandibular gland is saturable, with Kd values of about 2 nM. Partial purification of the membrane fractions reveals a Co+2-stimulated carboxypeptidase B activity which is not detectable in crude homogenates. In vitro autoradiography with [3H]guanidinoethylmercaptosuccinic acid localizes enkephalin convertase to the epithelial cells of the stomach, colon, and intestine, the islet cells of the pancreas, and the acinar cells of the submandibular gland. This localization contrasts to the distribution of enkephalins and other neuropeptides in the gastrointestinal tract and associated organs, suggesting that enkephalin convertase may serve functions other than neuropeptide and prohormone processing.

Enkephalin convertase: localization to specific neuronal pathways.

3H-Guanidinoethylmercaptosuccinic acid (GEMSA) selectively labels the carboxypeptidase B-like enzyme enkephalin convertase (EC) in rat brain tissue sections. We have used autoradiography with 3H-GEMSA to map membrane-bound EC in the rat forebrain and, in conjunction with lesioning techniques, to localize EC to specific neuronal pathways. The highest levels of EC are in the median eminence. High levels of EC also occur in the hypothalamic magnocellular nuclei, in several nuclei of the amygdala, the lateral septum, and the bed nuclei of the stria terminalis. Knife-cut lesions of the stria terminalis increase EC posterior to the lesion in the stria and deplete EC from the stria adjacent to the bed nucleus, suggesting that EC, like enkephalins, is axonally transported within the stria terminalis. Ibotenic acid lesions of the caudate nucleus destroy binding in the substantia nigra pars reticulata ipsilateral to the lesion, suggesting that nigral EC is associated with axons originating in the caudate nucleus. We have also mapped EC in detail in the hippocampus. EC levels are highest near pyramidal cells of CA 3-4 and the dentate gyrus granule cells. Quinolinic acid lesions destroy both the granule and pyramidal cells and destroy all of the 3H-GEMSA labeling except for a small amount in the molecular layer of the dentate gyrus. Selective destruction of CA 3-4 pyramidal cells with kainic acid eliminates EC in the pyramidal cell region. Destruction of granule cells of the dentate gyrus with colchicine depletes binding in the dentate gyrus without any change in the area surrounding field CA 3-4. High levels of 3H-GEMSA binding are present in the hippocampus at least 3 d before birth. These observations suggest that in the hippocampus the majority of EC is associated with pyramidal cells, which have not been shown to contain enkephalins. 3H-GEMSA autoradiography of the trigeminal ganglion localizes EC to the sensory neurons and not to white matter tracts there. These studies demonstrate that while EC is contained in enkephalinergic pathways, it is also present in some neurons that do not contain enkephalins.