Inhaled beta-agonists for asthma in mechanically ventilated patients

BACKGROUND

A small number of patients with acute severe asthma require intubation and positive pressure ventilation. The beneficial effects of inhaled bronchodilators on acute asthma in spontaneously breathing subjects are well established, but there remain important questions regarding inhaled beta2-agonists, for patients who are intubated and receiving ventilation.

OBJECTIVES

To determine the effects of inhaled beta-agonists on asthmatic patients who require intubation and mechanical ventilation.

SEARCH STRATEGY

Randomised controlled trials were sought from the Cochrane Airways Group Asthma Register. Primary authors and content experts were contacted to identify eligible studies and bibliographies from known reviews and texts were searched.

SELECTION CRITERIA

Randomised, controlled clinical trials involving adult patients with acute asthma, who were intubated and supported with positive pressure ventilation. Studies were to be included if patients were treated with beta2-adrenergic agonist agents and there was a comparator group treated with either placebo, no medication, or 'standard' treatment.

DATA COLLECTION AND ANALYSIS

Two reviewers independently examined all identified articles. The full text of any potentially relevant article was reviewed independently by two reviewers.

MAIN RESULTS

The search yielded 152 abstracts. Of these, four articles were identified as potential trials. None of the four trials met the inclusion criteria for the review.

REVIEWER'S CONCLUSIONS

There are no data from randomised controlled trials to provide evidence for or against current practices regarding the use of inhaled beta2-agonists in asthmatic subjects who are intubated and ventilated.

Racemic ketamine decreases muscle sympathetic activity but maintains the neural response to hypotensive challenges in humans

BACKGROUND

Cardiovascular stimulation and increased catecholamine plasma concentrations during ketamine anesthesia have been attributed to increased central sympathetic activity as well as catecholamine reuptake inhibition in various experimental models. However, direct recordings of efferent sympathetic nerve activity have not been performed in humans. The authors tested the hypothesis that racemic ketamine increases efferent muscle sympathetic activity (MSA) and maintains the muscle sympathetic response to hypotensive challenges.

METHODS

Muscle sympathetic activity was recorded by microneurography in the peroneal nerve of six healthy subjects before and during anesthesia with racemic ketamine (2 mg/kg intravenously plus 30 microg x kg(-1) x min(-1)). Catecholamine plasma concentrations, heart rate, and blood pressure were also determined. Muscle sympathetic neural responses to a hypotensive challenge were assessed by injection of sodium nitroprusside (2-10 microg/kg) before and during ketamine anesthesia. In the final step, increased arterial pressure observed during ketamine anesthesia was adjusted to preanesthetic baseline by sodium nitroprusside infusion (1-6 microg x kg(-1) x min(-1)).

RESULTS

Ketamine significantly decreased MSA burst frequency (mean +/- SD, 18 +/- 9 bursts/min to 9 +/- 8 bursts/min) and burst incidence (26 +/- 11 bursts/100 heart beats to 9 +/- 6 bursts/100 heart beats). However, when increased mean arterial pressure (85 +/- 8 mmHg to 121 +/- 20 mmHg) was normalized to the awake baseline by sodium nitroprusside, MSA recovered (25 +/- 18 bursts/min; 23 +/- 14 bursts/100 heart beats). During ketamine anesthesia, both epinephrine (15 +/- 10 pg/ml to 256 +/- 193 pg/ml) and norepinephrine (250 +/- 105 pg/ml to 570 +/- 270 pg/ml) plasma concentrations significantly increased, as did heart rate (67 +/- 13 beats/min to 113 +/- 15 beats/min). Hypotensive challenges similarly increased MSA both in the awake state and during ketamine anesthesia.

CONCLUSIONS

During increased arterial blood pressure associated with ketamine, sympathetic discharge to muscle blood vessels decreases at the same time that plasma concentrations of norepinephrine increase. When this increase in arterial blood pressure is reversed, MSA during ketamine is not changed from preketamine baseline recordings. Finally, hypotensive challenges still evoke an unchanged sympathetic reflex response. Thus, our results do not support the assumption that ketamine anesthesia increases sympathetic nerve activity in a generalized fashion.

[Mechanisms of tachyphylaxis in regional anesthesia of long duration]

Tachyphylaxis to local anesthetics is defined as a decrease in duration, segmental spread or intensity of a regional block despite repeated constant dosages. However, there is disagreement about the incidence of tachyphylaxis. In contrast to tachyphylaxis, pseudotachyphylaxis denotes time dependent variations in pain or circadian changes in the duration of local anesthetic action. Tachyphylaxis appears neither to be linked to structural or pharmacological properties of the local anesthetics nor to the technique or mode of their administration. The mechanisms underlying tachyphylaxis are open to debate and include changes in pharmacokinetics or pharmacodynamics. Considering pharmacokinetics, local edema, an increased epidural protein concentration, changes in local anesthetic distribution in the epidural space or a decrease of perineural pH could result in decreased diffusion of the local anesthetics from the epidural space to their binding sites at the sodium channel. Increased clearance of local anesthetics from the epidural space may be caused both by increased epidural blood flow or increased local metabolism. Considering pharmacodynamics, antagonistic effects of nucleotides or increased sodium concentration, increased afferent input from nociceptors or receptor down regulation of the sodium channels have been implicated. However, none of these theoretical considerations is supported strongly enough by data to explain tachyphylaxis. A new possibility to maintain for a longer time neural blockade is the design of new ultralong-acting local anesthetics. Liposomal formulations of local anesthetics also appear suitable to provide longer lasting regional anesthesia. The recent observation that NMDA-antagonists as well as NO-synthase-inhibitors prevent the development of tachyphylaxis suggests involvement of the nitric oxide pathway in the development of tachyphylaxis. Accordingly, NMDA-antagonists or NO-synthase-inhibitors may prevent tachyphylaxis.

Identification of imprinted loci by methylation-sensitive representational difference analysis: application to mouse distal chromosome 2

Imprinted genes are distinguished by different patterns of methylation on their parental alleles, a property by which imprinted loci could be identified systematically. Here, representational difference analysis (RDA) is used to clone HpaII fragments with methylation differences on the maternal and paternal copies of distal chromosome (Chr) 2 in the mouse. Uniparental inheritance for this region causes imprinting phenotypes whose molecular basis is only partially understood. RDA led to the recovery of multiple differentially methylated HpaII fragments at two major sites of imprinted methylation: paternal-specific methylation at the Nesp locus and maternal-specific methylation at the Gnasxl locus. Nesp and Gnasxl represent oppositely imprinted promoters of the Gnas gene, which encodes the G-protein subunit, Gsalpha. The organization of the Nesp-Gnasxl-Gnas region was determined: Nesp and Gnasxl were found to be 15 kb apart, and Gnasxl was found to be 30 kb upstream of Gnas. Sites of imprinted methylation were also detected at the loci for neuronatin on Chr 2 and for M-cadherin on Chr 8. RDA was highly effective at identifying imprinted methylation, and its potential applications to imprinting studies are discussed.

Assessment of ambulance response performance using a geographic information system

The accessibility, distribution and utilisation of emergency medical services are important components of health care delivery. The impact of these services on well-being is heightened by the fact that ambulance resources must respond in a reliable and timely manner to emergency calls from demand areas. However, many factors, such as the unavailability of an ambulance at a center closest to a call, can adversely influence response time. This paper discusses the design and implementation of a framework developed in a Geographic Information System for assessing ambulance response performance. A case study of ambulance response in three communities in Southern Ontario, Canada is presented that allows easy and rapid identification of anomalous calls that may adversely affect overall operating performance evaluation. Extensions of the framework into a fully fledged service deployment and planning decision support system are discussed.

A randomized, prospective study to evaluate the efficacy and acceptance of three bowel preparations for colonoscopy in children

OBJECTIVE

We performed a prospective, randomized, single-blind study in children undergoing colonoscopy to evaluate the acceptance and efficacy of three different bowel preparations.

METHODS

Seventy patients (ages 3-20 yr, 38 males) were randomly assigned to one of the three study preparations: Magnesium citrate with X-prep and clear liquid diet for 2 days (group A); Dulcolax for 2 days and Fleet enema without dietary restriction (group B); and Golytely 20 ml/kg (up to 1 L) per hour for 4 h with clear liquid diet for 1 day (group C). Endoscopists blinded to bowel preparation graded the adequacy of colon cleansing. The preparations were rated by patients for tolerance, willingness to retake them, adverse effects, and compliance.

RESULTS

Data analysis using Fisher exact test and trend test showed that colon cleansing in groups A and C was superior to that in group B (p < 0.0001) and better in group C than A (p < 0.075). Overall tolerance and compliance were significantly better for groups A and B than group C (p < 0.003), but not different between A and B. More of group B patients were willing to retake the preparation than in group C (p < 0.002) and group A (p < 0.05), but this was not different between groups A and C. Adverse effects were reported more frequently by patients in group C than in groups A and B (p < 0.01).

CONCLUSIONS

Although the least well tolerated, Golytely provided the best cleansing. Dulcolax without dietary restriction provided unsatisfactory colon cleansing. Magnesium citrate with X-prep was acceptable and provided good cleansing.

Combining nursing roles in dermatology

There is an increasing demand for dermatology expertise among patients and community nurses. Combining the role of dermatology nurse practitioner with that of community dermatology liaison nurse allowed dermatology expertise to be provided in both hospital and the community. The aim was to reduce waiting times, provide a nursing alternative to dermatologists and open access for community nurses to specialist expertise.

The solution structure of VAT-N reveals a 'missing link' in the evolution of complex enzymes from a simple betaalphabetabeta element

BACKGROUND

The VAT protein of the archaebacterium Thermoplasma acidophilum, like all other members of the Cdc48/p97 family of AAA ATPases, has two ATPase domains and a 185-residue amino-terminal substrate-recognition domain, VAT-N. VAT shows activity in protein folding and unfolding and thus shares the common function of these ATPases in disassembly and/or degradation of protein complexes.

RESULTS

Using nuclear magnetic resonance (NMR) spectroscopy, we found that VAT-N is composed of two equally sized subdomains. The amino-terminal subdomain VAT-Nn (comprising residues Met1-Thr92) forms a double-psi beta-barrel whose pseudo-twofold symmetry is mirrored by an internal sequence repeat of 42 residues. The carboxy-terminal subdomain VAT-Nc (comprising residues Glu93-Gly185) forms a novel six-stranded beta-clam fold. Together, VAT-Nn and VAT-Nc form a kidney-shaped structure, in close agreement with results from electron microscopy. Sequence and structure analyses showed that VAT-Nn is related to numerous proteins including prokaryotic transcription factors, metabolic enzymes, the protease cofactors UFD1 and PrlF, and aspartic proteinases. These proteins map out an evolutionary path from simple homodimeric transcription factors containing a single copy of the VAT-Nn repeat to complex enzymes containing four copies.

CONCLUSIONS

Our results suggest that VAT-N is a precursor of the aspartic proteinases that has acquired peptide-binding activity while remaining proteolytically incompetent. We propose that the binding site of the protein is similar to that of aspartic proteinases, in that it lies between the psi-loops of the amino-terminal beta-barrel and that it coincides with a crescent-shaped band of positive charge extending across the upper face of the molecule.

Effect of spirometer temperature on FEV1 in a longitudinal epidemiological study

OBJECTIVES

To assess the magnitude of error in pulmonary function measurements introduced by variation in spirometer temperature under field conditions. In a large scale epidemiological study of school children, the influence was investigated of spirometer temperature on forced expiratory volume in 1 second (FEV1) measured with dry rolling seal volumetric spirometers and conventional body temperature, pressure, and saturation (BTPS) corrections.

METHODS

Linear regression analyses were performed on data from 995 test-retest pairs on 851 different children, with 1-110 days between test and retest, and spirometer temperature differences between -13 degrees C and +9 degrees C.

RESULTS

After adjusting for effects of growth (test-retest intervals) and circadian variation (changes in times of testing), differences in standard BTPS corrected FEV1 showed significant (p < 0.05) dependence on differences in spirometer temperature between tests (-0.24%/degree C).

CONCLUSIONS

When spirometer temperatures vary widely, standard BTPS correction does not fully adjust for gas contraction. To improve accuracy of volume measurements in epidemiological studies, additional correction for variation in spirometer temperature should be considered.

Effects of ambient air pollution and environmental tobacco smoke on respiratory health of non-smoking women in Hong Kong

BACKGROUND

Two-thirds of complaints received by the Hong Kong Environmental Protection Department in 1988 were related to poor air quality. In July 1990 legislation was implemented to reduce fuel sulphur levels. The intervention led to a reduction in respiratory symptoms and bronchial hyperresponsiveness of primary school children. The objectives of this study were to investigate the differences in respiratory health between non-smoking women living in the more polluted district (Kwai Tsing) and those living in the less polluted district (Southern); to assess the impact of the government air quality intervention; and to study the effect of environmental tobacco smoke on respiratory health in non-smoking women in both districts.

METHOD

A total of 3405 non-smoking women, aged 36.5 years (standard deviation = 3.0), from two districts with good and poor air quality respectively before the intervention were followed yearly from 1989 to 1991. Binary latent variable modelling was used to summarize the six respiratory symptoms and to estimate the effects of risk factors.

RESULTS

In 1989, living in the polluted district was associated with poor respiratory health (odds ratio [OR] = 1.55, 95% confidence interval [CI]: 1.11-2.17, P < 0.01). After the intervention, in the polluted district only, sulphur dioxide levels fell by up to 80% and sulphate concentrations in respirable particulates by 38%. Between 1989 and 1990-1991, there was no significantly greater decline (P > 0.241) in the more polluted compared with the less polluted district for poor respiratory health. In 1989, the effects on poor respiratory health for exposure to two or more categories of smokers relative to none in the home (OR = 1.80, 95% CI: 1.15-2.83, P < 0.01) were higher but not significantly than those for living in polluted relative to less polluted district (95% CI of the two effects overlapping each other).

CONCLUSIONS

Environmental tobacco smoke (ETS) and outdoor air pollution had independent adverse effects on respiratory health of non-smoking women and improvement in air quality had produced some but non-significant benefits.

The kinesin light chain gene: its mapping and exclusion in mouse and human forms of inherited motor neuron degeneration

The underlying genetic cause is known for only 10-20% of familial motor neuron disease (MND). Thus the genes involved in the aetiology of 80-90% of familial MND remain to be determined, and animal models are powerful tools for undertaking this task. We have mapped a heritable form of motor neuron degeneration in the mouse to a region that has homology to human chromosome 14q32.1-qter. This region contains the kinesin light chain gene (KLC1), which is a candidate for involvement in motor neuron degeneration because of its function in the motor-protein kinesin, and its neuronal expression. To investigate the role of KLC1 in a mouse motor neuron degeneration mutant that we are studying, we have identified mouse Klc1 gene sequences and mapped them with respect to our mutant locus. We have also investigated KLC1 in human patients with familial MND. Based on recombination and the absence of mutations in the coding region of KLC1, this gene can be excluded as a candidate gene in our mouse mutation and, where we have investigated, it is normal in human familial MND.

Glial cell swelling--effect of hypothermia

The effect of mild to moderate hypothermia (32/27 degrees C) was analyzed on the cell volume of C6 glioma cells and primary cultured astrocytes at normal pH, during lactacidosis (pH6.2) and during exposure to glutamate or arachidonic acid in vitro. The cells were suspended in an incubation chamber under continuous control of pH, pO2 and temperature. Cell swelling was quantified by an advanced Coulter-system. Following a control period at 37 degrees C, the ambient temperature was decreased to 27 and 32 degrees C for 30 min. Hypothermia alone led to an immediate and significant cell volume increase of 107.3 +/- 0.4% (mean +/- SEM) of control after 30 min at 32 degrees C. Yet, hypothermia (27 degrees C) afforded partial protection against the acidosis-induced cell swelling at pH 6.2, attaining 120.4 +/- 0.9% in the normothermic control group after 60 min, while only 111.3 +/- 0.9% at 27 degrees C. Hypothermia, however, was not associated with a reduction of the glutamate- or arachidonic acid-induced cell swelling. The results demonstrate that mild hypothermia per se induces glial cell swelling, but simultaneously inhibits cell swelling from acidosis, while not from glutamate- or arachidonic acid.

T lymphocytes and altered keratinocytes express interferon-gamma and interleukin 6 in lichen planus

Lichen planus is assumed to represent a delayed hypersensitivity reaction, in the course of which cytokines control the proliferation and differentiation of cytotoxic T lymphocytes which attack the epidermis and cause apoptosis of undifferentiated keratinocytes. Since interferon-gamma and interleukin 6 are known to be markedly generated in lichen planus, we investigated the cellular localization of these cytokines in affected skin/oral mucosa biopsy specimens using in situ hybridization for interferon-gamma and in situ reverse transcription-polymerase chain reaction for interleukin 6 mRNA. In the upper subepithelial connective tissue interferon-gamma mRNA was noted within proliferating CD3+ T lymphocytes. In this tissue compartment interleukin 6 mRNA was detected in infiltrating CD4+ and CD8+ T lymphocytes. In the epithelium, expression of interferon-gamma mRNA and interleukin 6 mRNA was observed in the basal and suprabasal keratinocytes of altered skin/oral mucosa. In contrast, normal skin did not reveal any interferon-gamma or interleukin 6 expression, although a few CD4+ and CD8+ T lymphocytes were noted in the dermis as well as the epidermis. These findings indicate that in lichen planus the proinflammatory cytokines interferon-gamma and interleukin 6 are produced not only by activated T lymphocytes but also by altered keratinocytes, and suggest that stimulated keratinocytes may amplify the course of lichen planus.

Effect of lactacidosis on cell volume and intracellular pH of astrocytes

Acute traumatic or ischemic cerebral lesions are associated with tissue acidosis leading to cytotoxic brain edema, predominantly affecting astrocytes. Glial swelling from acidosis is believed to be the attempt of cells to maintain a physiological intracellular pH (pHi). However, this concept, potentially important for the development of new treatment strategies for cytotoxic brain edema, has not been validated experimentally. In the present study, cell volume and pHi of astrocytes were measured simultaneously in vitro. Exposure of suspended astrocytes to levels of acidosis found in vivo during ischemia and trauma (pH 6.8-6.2) led to a maximal increase in cell volume of 121.2% after 60 min (n = 5, p < 0.05) and to immediate intracellular acidification close to extracellular levels (pH 6.2, n = 5, p < 0.05). Inhibition of membrane transporters responsible for pHi regulation (0.1 mM amiloride for the Na+/H+ antiporter or 1 mM SITS for HCO3- -dependent transporters) inhibited cell swelling from acidosis but did not affect the profound intracellular acidification. In addition, acidosis-induced cell swelling and intracellular acidification were partly prevented by the addition of ZnCl2 (0.1 mM), an inhibitor of selective proton channels not yet described in astrocytes (n = 5, p < 0.05). In conclusion, these data demonstrate that glial swelling from acidosis is not a cellular response to defend the normal pHi, as had been thought. If these results obtained in vitro are transferable to in vivo conditions, the development of blood-brain barrier-permeable agents for the inhibition of acidosis-induced cytotoxic edema might be therapeutically useful, since they do not enhance intracellular acidosis and thus cell damage.

The Janus face of the archaeal Cdc48/p97 homologue VAT: protein folding versus unfolding

Members of the AAA family of ATPases have been implicated in chaperone-like activities. We used the archaeal Cdc48/p97 homologue VAT as a model system to investigate the effect of an AAA protein on the folding and unfolding of two well-studied, heterologous substrates, cyclophilin and penicillinase. We found that, depending on the Mg2+ concentration, VAT assumes two states with maximum rates of ATP hydrolysis that differ by an order of magnitude. In the low-activity state, VAT accelerated the refolding of penicillinase, whereas in the high-activity state, it accelerated its unfolding. Both reactions were ATP-dependent. In its interaction with cyclophilin, VAT was ATP-independent and only promoted refolding. The N-terminal domain of VAT, which lacks ATPase activity, also accelerated the refolding of cyclophilin but showed no effect on penicillinase. VAT appears to be structurally equivalent over its entire length to Sec18/NSF, suggesting that these results apply more broadly to group II AAA proteins.

Novel molecular architecture of the multimeric archaeal PEP-synthase homologue (MAPS) from Staphylothermus marinus

The phosphoenolpyruvate (PEP)-synthases belong to the family of structurally and functionally related PEP-utilizing enzymes. The only archaeal member of this family characterized thus far is the Multimeric Archaeal PEP-Synthase homologue from Staphylothermus marinus (MAPS). This protein complex differs from the bacterial and eukaryotic representatives characterized to date in its homomultimeric, as opposed to dimeric or tetrameric, structure. We have probed the molecular architecture of MAPS using limited proteolytic digestion in conjunction with electron microscopic, biochemical, and biophysical techniques. The 2.2 MDa particle was found to be organized in a concentric fashion. The 93.7 kDa monomers possess a pronounced tripartite domain structure and are arranged such that the N-terminal domains form an outer shell, the intermediate domains form an inner shell, and the C-terminal domains form a core structure responsible for the assembly into a multimeric complex. The core domain was shown to be capable of assembling into the native multimer by recombinant expression in Escherichia coli. Deletion mutants as well as a synthetic peptide were investigated for their state of oligomerization using native polyacrylamide gel electrophoresis, molecular sieve chromatography, analytical ultracentrifugation, circular dichroism (CD) spectroscopy, and chemical cross-linking. Our data confirmed the existence of a short C-terminal, alpha-helical oligomerization motif that had been suggested by multiple sequence alignments and secondary structure predictions. We propose that this motif bundles the monomers into six groups of four. An additional formation of 12 dimers between globular domains from different bundles leads to the multimeric assembly. According to our model, each of the six bundles of globular domains is positioned at the corners of an imaginary octahedron, and the helical C-terminal segments are oriented towards the centre of the particle. The edges of the octahedron represent the dimeric contacts. Phylogenetic analysis suggests that the ancient predecessor of this family of enzymes contained the C-terminal oligomerization motif as a feature that was preserved in some hyperthermophiles.

The gene mutated in bare patches and striated mice encodes a novel 3beta-hydroxysteroid dehydrogenase

X-linked dominant disorders that are exclusively lethal prenatally in hemizygous males have been described in human and mouse. None of the genes responsible has been isolated in either species. The bare patches (Bpa) and striated (Str) mouse mutations were originally identified in female offspring of X-irradiated males. Subsequently, additional independent alleles were described. We have previously mapped these X-linked dominant, male-lethal mutations to an overlapping region of 600 kb that is homologous to human Xq28 (ref. 4) and identified several candidate genes in this interval. Here we report mutations in one of these genes, Nsdhl, encoding an NAD(P)H steroid dehydrogenase-like protein, in two independent Bpa and three independent Str alleles. Quantitative analysis of sterols from tissues of affected Bpa mice support a role for Nsdhl in cholesterol biosynthesis. Our results demonstrate that Bpa and Str are allelic mutations and identify the first mammalian locus associated with an X-linked dominant, male-lethal phenotype. They also expand the spectrum of phenotypes associated with abnormalities of cholesterol metabolism.

Resistance of enterococci to heat and chemical agents

Within the framework of the standardisation efforts on disinfectant testing on the European level the test germ Enterococcus hirae ATCC 10541 has been included for some time in the test requirements whereas the test strain Enterococcus faecium, which has frequently been used up to now, has been largely ignored. We compared the thermal and the chemical resistance of both test germ species. In the quantitative suspension test with active ingredients from the group of aldehydes, phenols, quaternaries and oxidizing agents with the exception of peracetic acid, no significant differences were determined between the two strains. In the case of the studies on thermal resistance at 65 degrees C and 68 degrees C, Enterococcus faecium ATCC 6057, by contrast, proved to be far more resistant than Enterococcus hirae ATCC 10541. According to these results, priority should be given to Enterococcus faecium over Enterococcus hirae as the test germ for chemical and also chemothermal disinfection.

A theoretical basis for investigating ambient air pollution and children's respiratory health

Acute respiratory health effects in children from exposure at current ambient levels of ozone are well documented; however, evidence for acute effects from other criteria pollutants such as nitrogen dioxide and respirable particles is inconsistent. Whether chronic effects result from long-term exposure to any of these pollutants during childhood is an important unresolved question. Establishing whether acute or chronic effects result from childhood exposure and identifying sensitive subgroups may require integration of biologic mechanisms of lung defenses, injury, and response into the study design and statistical models used in analyses. This review explores the theoretical basis for explaining such adverse effects in light of our contemporary understanding of mechanisms of lung injury and response at the cellular and molecular levels. The rapidly evolving understanding of the effects of air pollution on cellular and molecular levels presents an opportunity to develop and refine innovative biologically based hypotheses about the effects of childhood exposure. We hypothesize that children with low fruit and vegetable intake, low antioxidant levels, high polyunsaturated fat intake, or who have inherited certain alleles for genes involved in lung defenses and immune response regulation may be at increased risk for adverse effects. Because responses to air pollutants of interest are complex and involve a number of pathophysiologic processes, the magnitude of main effects of dietary factors, genes, and gene-environment interactions may be modest for individuals; however, each may make an important contribution to the population burden of preventable respiratory diseases.

Structure of VAT, a CDC48/p97 ATPase homologue from the archaeon Thermoplasma acidophilum as studied by electron tomography

Valosine-containing protein-like ATPase from Thermoplasma acidophilum is a member of the superfamily of ATPases associated with a diversity of cellular activities and is closely related to CDC48 from yeast and p97 from higher eukaryotes and more distantly to N-ethylmaleimide-sensitive fusion protein. We have used electron tomography to obtain low-resolution (2-2.5 nm) three-dimensional maps of both the whole 500 kDa complex and the N-terminally truncated valosine-containing protein-like ATPase from T. acidophilum complex lacking the putative substrate binding domain.

Botulism with respiratory insufficiency requiring extra corporeal carbon dioxide removal

Despite a low incidence of botulism in the industrialized world some cases occasionally occur in Germany after eating contaminated food. Because botulism is rarely seen, most physicians are unfamiliar with its early recognition and treatment. However, immediate intensive care treatment is important. We report the case of a previously healthy 54-year-old female who developed signs of botulism after eating vacuum packed smoked fish and developed severe respiratory insufficiency with difficult carbon dioxide elimination in the days following.