Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Plasminogen Activators t-PA, u-PA and Its Inhibitor (PAI) in Normal Males and Females

We determined the plasma levels of tissue plasminogen activator (t-PA), plasminogen activator inhibitor (PAI) activity and their antigen levels including urokinase plasminogen activator (u-PA) in 33 male and 27 female normal subjects. Males had mean t-PA activity of 0.50 iu/ml which was significantly lower (p <0.01) than the females 0.64 iu/ml. Males had higher (p <0.001) mean PAI activity (15.5 AU/ml) as compared to females 10.3 AU/ml. The respective mean levels of t-PA and PAI antigen were significantly higher (p <0.01) in males (8.1 ng/ml and 17.6 ng/ml) than in females (6.2 ng/ml and 12.1 ng/ml). The mean u-PA level in males was 1.54 ng/ml which was significantly higher (p <0.01) than in females with 1.02 ng/ml. In post-venous occlusion studies, females had a greater mean response of 8.6 fold in t-PA activity as compared to males with a mean of 4.5 fold increase. The mean t-PA antigen response in males was 2.0 fold increase as compared to 2.6 fold increase in the females. No significant responses were seen in both sexes in either PAI activity or antigen levels when compared with the resting state. In zymography studies, free t-PA, its inhibitor complexes and u-PA were demonstrated in the euglobulin fractions of stored plasma. This study demonstrates that significant differences in t-PA, u-PA and PAI exist between male and female subjects which should be taken into account when determining their levels in clinical conditions.

IFPA Meeting 2010 Workshop Report I: Immunology; ion transport; epigenetics; vascular reactivity; epitheliochorial placentation; proteomics

Workshops are an important part of the IFPA annual meeting. At IFPA Meeting 2010 there were twelve themed workshops, six of which are summarized in this report. 1. The immunology workshop focused on normal and pathological functions of the maternal immune system in pregnancy. 2. The transport workshop dealt with regulation of ion and water transport across the syncytiotrophoblast of human placenta. 3. The epigenetics workshop covered DNA methylation and its potential role in regulating gene expression in placental development and disease. 4. The vascular reactivity workshop concentrated on methodological approaches used to study placental vascular function. 5. The workshop on epitheliochorial placentation covered current advances from in vivo and in vitro studies of different domestic species. 6. The proteomics workshop focused on a variety of techniques and procedures necessary for proteomic analysis and how they may be implemented for placental research.

Plasminogen activators and inhibitors in normal late pregnancy, postpartum and in the postnatal period

Tissue plasminogen activator (t-PA), urokinase plasminogen activator (u-PA) and plasminogen activator inhibitors (PAI) are elevated in late pregnancy with t-PA and u-PA remaining so at 6 weeks postnatal. PAI-2 remains at postpartum but was absent by 6 weeks postnatal unlike PAI activity which was absent at postpartum and returned to nonpregnant level at postnatal. The potential fibrinolytic response to stress is much reduced in pregnancy thus increasing the risk of thromboembolism.

Role of free thiol groups in the biological activities of stonustoxin, a lethal factor from stonefish (Synanceja horrida) venom

Stonustoxin (SNTX) is a two-subunit protein purified from the venom of a stonefish, Synanceia horrida. It has potent lethal activity and is also a membrane pore-forming cytolysin. The role of thiol groups in the biological activities of SNTX was investigated. Both the hemolytic and lethal activities of SNTX were potentiated by the reducing agent, dithiothreitol (DTT). The hemolytic activity of SNTX was sensitive to the modification of thiol groups by 5,5'-dithiobis(2-nitrobenzoic acid) (DTNB). The loss of haemolytic activity correlated with the number of thiol groups that were titrated with DTNB. Thiol modification of SNTX with DTNB also inhibited its lethality. These inhibitory effects of thiol modification could be reversed by reduction with DTT. It was also found that the haemolytic activity of SNTX could not be inhibited by cholesterol. These observations indicate that free thiol groups play an important role in the haemolytic activity and lethality of SNTX but unlike other thiol-activated cytolysins, SNTX was not inhibited by cholesterol. Thus, SNTX may represent a new class of cytolytic toxin.

The role of cationic amino acid residues in the lethal activity of stonustoxin from stonefish (Synanceja horrida) venom

Stonustoxin (SNTX) is a two subunit pore-forming cytolytic protein purified from the venom of the stonefish (Synanceja horrida). SNTX also possesses lethal activity. Since cationic residues contribute significantly to the cytolytic activity of several pore-forming toxins, we examined the role of lysine and arginine residues in the lethal activity of SNTX. SNTX lost its lethal activity when the positively-charged side chains of lysine residues were converted to negatively-charged side chains upon succinylation. When the arginine residues were modified using 2,3-butanedione, SNTX also lost its lethal activity. However, the domains for cytolytic and lethal activity may not necessarily be the same.

Haemolytic activity of stonustoxin from stonefish (Synanceja horrida) venom: pore formation and the role of cationic amino acid residues

Stonustoxin (SNTX) is a two-subunit protein toxin purified from the venom of the stonefish (Synanceja horrida), which induces potent haemolytic activity. We examined the pore-forming property of this non-enzymic protein by an osmotic protection assay. SNTX-induced haemolysis was completely prevented by osmotic protectants of adequate size [poly(ethylene) glycol 3000; molecular diameter approx. 3.2 nm]. Uncharged molecules of smaller size, such as raffinose and poly(ethylene) glycol 1000-2000, failed to protect against cell lysis. These findings indicate that SNTX induces the formation of hydrophilic pores in the cell membrane, which results in the lysis of erythrocytes. Since cationic residues contribute significantly to the cytolytic activity of several other pore-forming toxins, we examined the role of positively charged lysine and arginine residues in the haemolytic activity of SNTX. SNTX lost its haemolytic activity when the positively charged side chains of lysine residues were neutralized or converted into negatively charged side chains upon carbamylation or succinylation respectively. The haemolytic activity of SNTX was also inhibited by the modification of positively charged arginine residues using 2,3-butanedione. The loss of haemolysis showed strong correlation with the number of Lys or Arg residues modified. CD analyses, however, showed that the conformation of SNTX was not significantly affected by these chemical modifications. Further, the haemolytic activity of SNTX was competitively inhibited by various negatively charged lipids, such as phosphatidylserine, cardiolipin and monosialogangliosides. These results indicate that SNTX induces potent haemolytic activity through the formation of pores in the cell membrane, and that cationic residues play a crucial role in its cytolytic mechanism.

Effects of thymosin alpha1 on the development of amoeboid microglial cells in the corpus callosum of neonatal BALB/c and athymic mice

The present study investigated the effects of intraperitoneal injections of thymosin alpha1 on the supraventricular amoeboid microglial cells (SAMC) in the newborn athymic and normal BALB/c mice. The microglial cells labelled by the lectin GSA I-B4 and the antibody Mac-1 showed a 27% reduction in number in the athymic mice receiving thymosin alpha1 injections compared with those receiving vehicle injections, and a 37% reduction in BALB/c mice receiving thymosin alpha1 injections compared with those receiving vehicle injections. Some of the SAMC in both BALB/c and athymic mice receiving thymosin alpha1 injections became ramified, while the remainder still exhibited their normal amoeboid appearance with few filopodial processes. Ultrastructurally, the lectin reaction product was confined to the plasma membrane and some cytoplasmic vacuoles of labelled SAMC. In both BALB/c and athymic mice, some labelled microglial cells became slender or elongated after thymosin alpha1 injections. Also their cytoplasm was reduced and contained fewer organelles. Radioimmunoassay of the plasma of thymosin alpha1 and vehicle-injected mice showed that there was a significant increase in the cortisol level in BALB/c (P < 0.01) and athymic (P < 0.001) mice 5 days after thymosin alpha1 injections, compared with that of the control mice. The results point to a strong correlation between the reduction of SAMC and the increased level of plasma cortisol. Supporting this is the fact that cortisol is known to suppress the production of monocytes considered to be the precursors of amoeboid microglia.

Stimulation of haemolytic activity of sea anemone cytolysins by 8-anilino-1-naphthalenesulphonate

This study reports for the first time stimulation of protein activity by the hydrophobic probe, 8-anilino-1-naphthalenesulphonate (ANS). Magnificalysin (HMg) I and II and equinatoxin (EqTx) II and III are cytolysins isolated from the sea anemone Heteractis magnifica and Actinia equina, respectively. The haemolytic activity of these cytolysins could be stimulated by treatment with ANS. Their activation involved conformational changes following ANS treatment as shown by fluorescence spectra. ANS-induced conformational changes were reversible upon removal of ANS. ANS-stimulated activity of HMg I was inhibited by sphingomyelin and antiserum but not affected by bromosuccinimide (NBS) which oxidises tryptophan residues. However, toxin pre-treated with NBS could no longer be stimulated by addition of ANS. Energy transfer from tryptophan to ANS was observed by a fluorescence scan. Hence the tryptophan residues appear to be involved, at least partially, in ANS-binding. ANS-induced conformational change may be responsible for the activation of the cytolytic activity of these cytolysins.

Stonustoxin is a novel lethal factor from stonefish (Synanceja horrida) venom. cDNA cloning and characterization

Stonustoxin (SNTX) is a multifunctional lethal protein isolated from venom elaborated by the stonefish, Synanceja horrida. It comprises two subunits, termed alpha and beta, which have respective molecular masses of 71 and 79 kDa. SNTX elicits an array of biological responses both in vitro and in vivo, particularly a potent hypotension that appears to be mediated by the nitric oxide pathway. As a prelude to structure-function studies, we have isolated and sequenced cDNA clones encoding the alpha- and beta-subunits of SNTX from a venom gland cDNA library. The deduced amino acid sequence of neither subunit shows significant homology with any known protein. Protein sequence alignment does, however, show the subunits to be 50% homologous to each other and implies that they may have arisen from a common ancestor. The subunits of this novel toxin lack typical N-terminal signal sequences commonly found in proteins that are secreted via the endoplasmic reticulum-Golgi apparatus pathway, indicating the possibility of its being secreted by a non-classical pathway, which is not clearly understood. The SNTX subunits have been expressed in Escherichia coli as cleavable fusion proteins that cross-react with antibodies raised against the native toxin. To the best of our knowledge, this is the first complete sequence of a fish-derived protein toxin to be reported.

Inhibition of sodium-dependent uptake processes in purified rat brain synaptosomes by Lophozozymus pictor toxin and palytoxin

To get an insight into the mechanism of neurotoxicity exhibited by Lophozozymus pictor toxin (LPTX) and the toxin isolated from P.caribaeorum (C-PTX) studies were carried out on the effect of these toxins on the uptake of selected substrates (neurotransmitters, amino acids and glucose) in isolated nerve endings. The toxins were found to inhibit the uptake of gamma-aminobutyric acid (GABA), noradrenaline, choline, L-leucine and 2-deoxy-D-glucose in rat brain synaptosomes. LPTX- or C-PTX-induced inhibition of synaptosomal uptake was reduced in the absence of Na+ in the assay medium. Synaptosomes exposed to LPTX and C-PTX release K+ in a dose-dependent manner. Ouabain, a selective inhibitor of the plasma membrane Na+, K(+)-ATPase could inhibit LPTX- and C-PTX-induced K+ efflux from synaptosomes and alleviate the toxin-induced inhibition of synaptosomal GABA uptake. It appears that the induction of ionic flux is the primary cause of toxicity by these toxins leading to the inhibition of Na(+)-dependent uptake processes in synaptosomes. The antagonistic action of ouabain suggests the involvement of the membrane sodium pump in the development of cytotoxicity.

The chemical composition of gallstones: its relevance to surgeons in Southeast Asia

This paper describes the methods in the study of the chemical composition of gallstones and the application of this knowledge to the practising surgeon in Southeast Asia. There are three types of stone in this part of the world. Inspecting with the naked eye, the surgeon is usually able to recognize accurately the stone type--cholesterol, black pigment and brown pigment. The stone type together with the clinicopathological and radiological findings enable the surgeon to make a confident diagnosis of either the Western-type (cholesterol and black pigment) or Asiatic-type (brown pigment) gallstone disease in each patient, and based on this, a rational approach in the management of the patient can be instituted. In a personal series of 484 cases, cholesterol stones formed 46% of the cases, black pigment stones 30.5% and brown stones 13%; and cholesterosis and acalculous cholecystitis constituted the remaining 10.5%. In rapidly developing Singapore, Western-type cholesterol stones now predominate while brown stones appear to be decreasing. In patients with small bile duct stones of any stone type, endoscopic extraction followed by laparoscopic cholecystectomy appears to be the procedure of choice. Large bile duct stones require open surgery. In patients with grossly dilated bile ducts containing brown stones, biliary enteric bypass is performed to reduce biliary stasis, cholangitis and recurrent stone formation.

Synaptosomal binding of 125I-labelled daboiatoxin, a new PLA2 neurotoxin from the venom of Daboia russelli siamensis

Daboiatoxin (DbTx), the PLA2 neurotoxin from Daboia russelli siamensis venom, was shown to bind specifically and saturably to rat cerebrocortical synaptosomes and synaptic membrane fragments. Two families of binding sites were detected by equilibrium binding analysis in the presence and absence of Ca2+. Scatchard analysis of biphasic plateaus revealed Kdl 5 nM and Bmax1, 6 pmoles/mg protein, and Kd2 80 nM and Bmax2 20 pmoles/mg protein, respectively, for the high- and low-affinity binding sites. The binding of 125I-DbTx to synaptosomes did not show marked dependence on Ca2+, Mg2+, Co2+ and Sr2+. Native DbTx was the only strong competitor to 125I-DbTx synaptosomal binding (IC50 12.5 nM, KI 5.5 nM). Two other crotalid PLA2 neurotoxins, crotoxin CB and mojave toxin basic subunit, and nontoxic C. Atrox PLA2 enzyme, were relatively weaker inhibitors, while two viperid PLA2 neurotoxins, ammodytoxin A and VRV PL V, were very weak inhibitors. Crotoxin CA was a poor inhibitor even at microM concentrations, whereas no inhibitory effect at all was observed with crotoxin CACB, ammodytoxin C, VRV PL VIIIa, taipoxin, beta-bungarotoxin, or with PLA2 enzymes from N. naja venom, E. schistosa venom, bee venom and porcine pancreas. All other pharmacologically active ligands examined (epinephrine, norepinephrine, histamine, choline, dopamine, serotonin, GABA, naloxone, WB-4101, atropine, hexamethonium and alpha-bun-garotoxin) also failed to interfere with 125I-DbTx binding. As those competitors that showed partial inhibition were effective only at microM concentration range compared to the Kd (5 nM) of 125I-DbTx synaptosomal binding, DbTx could well recognize a different neuronal binding site. Rabbit anti-DbTx polyclonal antisera completely blocked the specific binding. When a range of Ca2+ and K+ channels modulators were examined, Ca2+ channel blockers (omega-conotoxins GVIA and MVIIC, taicatoxin, calciseptine and nitrendiprene) did not affect the binding even at high concentrations, while charybdotoxin was the only K+ channel effector that could partially displace 125I-DbTx synaptosomal binding amongst the K+ channel blockers tested (apamin, dendrotoxin-I, iberiotoxin, MCD-peptide, 4-aminopyridine and tetraethylammonium), suggesting that neither K+ nor Ca2+ channels are associated with DbTx binding sites.

Production and characterization of monoclonal antibodies against stonustoxin from Synanceja horrida

Stonustoxin (SNTX), a lethal factor purified from the venom of stonefish Synanceja horrida, is a protein (148,000 mol. wt) existing as a dimer comprising two subunits (alpha and beta) of mol. wts 71,000 and 79,000, respectively. Its LD50 (i.v.) is 17 ng/g in mice and it causes haemolysis of rat and rabbit erythrocytes in vitro. Eight monoclonal antibodies (Mabs) against SNTX have been developed using the Balb/C mouse. These Mabs have been purified by Protein G affinity membrane disc chromatography. They were all classified as IgG1 with half of them having kappa and the rest lambda light chains. They had affinity constants ranging from 3.75 x 10(-9) to 9.74 x 10(-9) M. Six were able to protect mice from a challenge of a lethal dose of SNTX. However, not all protective Mabs were able to neutralize the haemolytic effect in vitro. Only four Mabs (31A, 32B, 38A and 46A) could inhibit rat and rabbit erythrocyte haemolysis, while one Mab (43D) offered partial inhibition and another Mab (8A) did not inhibit haemolysis at all. The non-protective Mabs (43B and 44G) were also incapable of neutralizing haemolysis. Five epitopes were recognized by the eight Mabs. Four Mabs (31A, 32B, 38A and 46A) were found to have similar epitope specificity while the rest were directed at different epitopes on the SNTX molecule. Thus these results suggest that the domain on the SNTX molecule responsible for lethality is probably distinct from the domain important for in vitro haemolytic activity.

Lophozozymus pictor toxin: a fluorescent structural isomer of palytoxin

Purified Lophozozymus pictor toxin (LPTX) shares many properties similar to palytoxin (PTX). LPTX and palytoxin isolated from Palythoa caribaeorum (C-PTX) have similar mol. wts of approx. 2680 on ionspray mass spectrometry (MS). In addition, antibodies against PTX could recognize and bind LPTX. Mixed mode high-performance liquid chromatography (HPLC) of LPTX, C-PTX and H-PTX (isolated from Palythoa tuberculosa) showed a major PTX component common to all three with the characteristic PTX-like UV spectrum at a retention time (Rt) of 17 min. However, LPTX exhibits fluorescence but PTX of equivalent toxicity does not. LPTX showed a unique peak at Rt of approx. 22 min on mixed mode HPLC. In addition, LPTX and C-PTX showed different ion fragmentation patterns on MS/MS. These results suggest that LPTX and the palytoxins are structural isomers, containing at least one difference which gives rise to fluorescence in LPTX.

Effects of stonustoxin (lethal factor from Synanceja horrida venom) on platelet aggregation

Stonustoxin (SNTX) is a 148,000 mol. wt lethal factor isolated from Synanceja horrida venom. It induces species-restricted red cell haemolysis which correlates with its effects on platelet aggregation in whole blood. SNTX induced a concentration-dependent and irreversible platelet aggregation in rabbit or rat but not in human or mouse whole blood. The degree of haemolysis and platelet aggregation induced by SNTX in rabbit or rat whole blood were concentration dependent. At concentrations of SNTX where only slight or no haemolysis was observed, no platelet aggregation occurred. Although SNTX itself could not induce platelet aggregation in rabbit or rat platelet-rich plasma (PRP), it had biphasic effects on collagen- or ADP-induced platelet aggregation in PRP. It inhibited collagen- or ADP-induced platelet aggregation at high concentrations (0.08-0.8 micrograms/ml) but the response was potentiated by lower stonustoxin concentrations (0.008-0.016 micrograms/ml). The inhibition of collagen- or ADP-induced platelet aggregation might be due to the lytic activity of SNTX on the platelets.

Bioactivity and mechanism of action of Lophozozymus pictor toxin

The bioactivity of Lophozozymus pictor toxin (LPTX) and the possible mechanism of action of the purified toxin are described. LPTX is found to possess palytoxin-like bioactivities. Besides exhibiting cytotoxic and haemolytic properties, LPTX causes the release of K+ from erythrocytes and inhibits 2-[14C]deoxy-D-glucose uptake into HeLa cells. Although LPTX acts on HeLa cell and erythrocyte membranes, it does not interact with mitochondrial or liposomal membranes containing different phospholipid compositions. Ouabain, but not sphingomyelin, is able to prevent the toxic effects of LPTX. This antagonistic effect of ouabain on LPTX suggests that the toxin might mediate its toxic effects via the membrane Na+/K(+)-ATPase but not through interaction with membrane lipids.

Ethanolic extraction, purification, and partial characterization of a fluorescent toxin from the coral reef crab, Lophozozymus pictor

A purification procedure for Lophozozymus pictor toxin (LPTX) following ethanolic extraction of whole crab homogenate is described. The ethanol-extracted toxin (LPTX-E) had higher yield and specific activity than the hot aqueous-extracted one (LPTX-H). It was found that LPTX-E was fluorescent and cochromatographed with LPTX-H on two-dimensional thin-layer chromatography. Although LPTX-E, LPTX-H, and palytoxin (P. caribaeorum, PTX) had similar migration and retention times when analysed on high performance capillary electrophoresis and gel permeation-high performance liquid chromatography respectively, LPTX-E and LPTX-H were both fluorescent in contrast to PTX. In addition, LPTX-E had a different retention time compared with PTX when chromatographed on reversed phase high performance liquid chromatography in the solvent system 80% acetonitrile and 0.02 M Tris-HCl, pH 7.2, at a 4:1 ratio, respectively, indicating some differences in their chemical structures.

A major lethal factor of the venom of Burmese Russell's viper (Daboia russelli siamensis): isolation, N-terminal sequencing and biological activities of daboiatoxin

A major lethal factor, daboiatoxin (DbTx), showing strong PLA2 activity (specific activity 91.7 nmoles/min/mg), was purified to homogeneity from the venom of Burmese Russell's viper (Daboia r. siamensis) by a combination of gel filtration on Sephadex G-75 and ion-exchange chromatography on CM-Sephadex C-25, followed by purification on high-performance gel filtration Shim-pack Diol-150 column. DbTx is a single-chain PLA2 toxin with approximate mol. wt 15,000 as determined by HPLC gel filtration and SDS-PAGE. It constitutes 12% of total venom protein and is the main lethal component of Burmese Russell's viper venom with an LD50 i.p. (0.05 mg/kg) 12-fold greater than that of the whole venom (LD50 i.p. 0.6 mg/kg). DbTx produces neurotoxic symptoms in mice and exhibits potent oedema-inducing activity (minimum oedema dose 0.05 microgram), indirect haemolytic activity and a strong myonecrotic activity, but no haemorrhagic activity. DbTx is cytotoxic to HeLa cells causing cytolysis of the cells 24 hr post-exposure to toxin (50 micrograms/ml). The first 20 N-terminal amino acid sequence (NFFQF AEMIV KMTGK EAVHS) shows a significant resemblance to those of the PLA2s from the venoms of Bulgarian viper (V. a. ammodytes) and Taiwan Russell's viper (V. r. formosensis).

A genomic region encoding stonefish (Synanceja horrida) stonustoxin beta-subunit contains an intron

The polymerase chain reaction (PCR) has been used to amplify a 1899 base pair fragment from stonefish genomic DNA. A comparison of the translated nucleotide sequence of this product with the separately determined N-terminal amino acid sequence of the beta-subunit reveals the presence of a 416 bp intron at Gly 18. The nucleotide sequence following this intron encodes 476 amino acids whose sequence showed no homology to other known toxins. This region, however, contained amino acid sequences identical to internal peptide sequences determined separately from the toxin's beta-subunit.

A study of occupational skin disease in the metal industry (1986-1990)

A retrospective study of the epidemiology of occupational skin disease among metal workers showed that irritant contact dermatitis (75%) prevailed over allergic contact dermatitis. Most workers belonged to the age group 20 to 29 years. There was a slight preponderance of Malays and Indians compared to the working population of Singapore. Most presented for treatment within 10 days of their dermatitis. Ninety-five percent presented with dermatitis on the hands and arms. There was no significant difference in the prevalence of atopy between workers with irritant and allergic contact dermatitis. In most cases of allergic contact dermatitis from cutting fluid, the causative allergen in the cutting fluid cannot be identified.

Stonustoxin: effects on neuromuscular function in vitro and in vivo

Stonustoxin (8-50 micrograms/ml) produced a rapid and concentration-dependent rise in tension (contracture) of the electrically stimulated mouse hemidiaphragm followed by a gradual waning of tension from the peak to the baseline; the nerve-evoked and the directly (muscle)-evoked twitches of the hemidiaphragm were also progressively and irreversibly blocked in a time- and concentration-dependent manner. Stonustoxin (22 and 44 micrograms/ml) produced a similar rapid rise in tension of the chick biventer cervicis muscle as well as irreversible and concentration-dependent blockade of nerve-evoked twitches and contractures produced by acetylcholine (200 microM), carbachol (8 microM) and KCl (40 mM). The muscle contracture produced by stonustoxin was blocked by dantrolene sodium (6 microM) but not by tubocurarine (15 microM). Moreover, stonustoxin (40 micrograms/ml) did not inhibit nerve conduction in the toad sciatic nerve and stonustoxin (60 micrograms/ml) did not exhibit any anticholinesterase activity. The inhibition of neuromuscular function by stonustoxin in the mouse hemidiaphragm and chick biventer cervicis muscle can therefore be attributed to some irreversible myotoxic action(s) of the toxin, whereas the stonustoxin-induced muscle contractures could have been mediated via depolarization of muscle fibres.

A review of stonefish venoms and toxins

Venoms from stonefish (genus Synanceja) have marked effects on the cardiovascular and neuromuscular systems and on vascular permeability; the venoms also exhibit haemolytic and hyaluronidase activity. Recently, a toxic protein, stonustoxin (SNTX), was purified from the venom of S. horrida: the primary lethal action of SNTX has been attributed to its potent endothelium-dependent vasorelaxant activity causing a rapid, marked and irreversible hypotension; the other actions of SNTX resemble those of the stonefish crude venoms.

Stonustoxin: a highly potent endothelium-dependent vasorelaxant in the rat

Stonefish venom has been documented to cause marked hypotension and respiratory difficulties in envenomed animals. Stonustoxin, a lethal protein recently isolated from the venom of the stonefish Synanceja horrida produced hypotension and, at concentrations above 20 micrograms/kg, death in anaesthetized rats, with no observable effects on nerve-evoked twitches of the tibialis and diaphragm muscles. Stonustoxin (20-160 ng/ml) induced endothelium-dependent relaxations of rat thoracic aortae precontracted with noradrenaline. Higher concentrations induced relaxations followed by contractions. Methylene blue, haemoglobin and the specific NO-synthase inhibitor L-NG-nitro arginine methyl ester inhibited stonustoxin-induced relaxations, while the cyclooxygenase inhibitor indomethacin was without effect. The results of the present study show that stonustoxin causes marked vasorelaxation of the rat isolated aorta, which appears to be due to the release of endothelium-derived relaxing factor (probably nitric oxide or nitric oxide-yielding substances) from the vascular endothelium, and this may be responsible for the in vivo hypotensive and lethal actions of stonustoxin and of stonefish venom.

Isolation of a novel fluorescent toxin from the coral reef crab, Lophozozymus pictor

A novel toxin has been isolated from an aqueous extract of the coral reef crab Lophozozymus pictor by a combination of ion exchange and two-dimensional thin layer chromatography. The isolated toxin exhibited bioactivities similar to palytoxin (toxicity response of mice, cytotoxicity towards HeLa cells and release of potassium ions from rat erythrocytes). Unlike palytoxin it gave an intense blue fluorescence under ultraviolet light. A fluorescence scan showed that the toxin had a maximum excitation wavelength at 285 nm and a maximum emission wavelength at 355 nm. The toxin was distinguishable from palytoxin when analysed by high performance capillary electrophoresis and reverse phase high performance liquid chromatography.

Concentration of plasminogen activators and inhibitor in the human endometrium at different phases of the menstrual cycle

The concentrations of tissue plasminogen activator (t-PA), urokinase plasminogen activator (u-PA) and plasminogen activator inhibitor (PAI-1) have been determined in endometrial curettings obtained from 46 subfertile women during proliferative, early or late secretory phases of the menstrual cycle. t-PA activity and antigen concentrations was significantly higher (P < 0.001) in late secretory endometrium than in proliferative or early secretory endometrium. Higher concentrations of PAI-1 antigen (P < 0.05) were also noted in late secretory phase than in proliferative and early secretory endometrium. However, u-PA concentration was not significantly different and no PAI activity could be demonstrated in the menstrual phases studied. Zymography studies confirmed the presence of both t-PA and u-PA in the endometrium. Ovarian hormonal patterns may therefore influence the activity of plasminogen activators especially of t-PA in the endometrium during various phases of the menstrual cycle.

Identification of the reaction products of the purified hyaluronidase from stonefish (Synanceja horrida) venom

Recently we purified to homogeneity hyaluronidase from stonefish (Synanceja horrida) venom, for the first time from a marine source [Poh, Yuen, Chung & Khoo (1992) Comp. Biochem. Physiol., in the press]. In the present study the reaction products of the hyaluronidase purified from stonefish venom were analysed. It produced tetra-, hexa-, octa- and deca-saccharides as major end products, but not disaccharides. The structure of the tetrasaccharide product was determined by enzymic analysis, in conjunction with h.p.l.c. and by 1H n.m.r., as GlcA beta 1-3GlcNAc beta 1-4GlcA beta 1-3GlcNAc. Chemical shifts of the structural-reporter-group protons of the constituent monosaccharides for the tetrasaccharide have been assigned. The enzyme did not act on chondroitin sulphate or dermatan sulphate. The results indicate that the stonefish hyaluronidase is an endo-beta-N-acetylglucosaminidase specific for hyaluronate.

Biological activities ofSynanceja horrida (stonefish) venom

Some biological and neurochemical properties of the venom of stonefish (Syanceja horrida) were investigated. The venom exhibited oedema-inducing, haemolytic, hyaluronidase, thrombin-like, alkaline phosphomonoesterase, 5' nucleotidase, acetylcholinesterase, phosphodiesterase, arginine esterase, and arginine amidase activities. Recalcification clotting time, prothrombin, and kaolin-cephalin clotting times were increased 1.7-2.3- and 2.4-fold respectively. The LD50 (i.v. mouse) was 300 micrograms/Kg. Its effects on uptake and stimulation of neurotransmitter synthesis and release were observed in rat brain synaptosomes. In the presence of 100 micrograms venom, uptake of [methyl-3H] choline in rat brain synaptosomes was inhibited 70%, while that of 4-amino-n-[U-14C] butyric acid was inhibited 20%. The toxin also stimulated the release of [3H]-acetylcholine from the synaptosomes.

Purification and partial characterization of hyaluronidase from stonefish (Synanceja horrida) venom

1. A marine hyaluronidase was purified 261-fold from the stonefish (Synanceja horrida) crude venom using Sephacryl S-200 HR and heparin affinity-gel chromatography. 2. Stonefish hyaluronidase has a pI of 9.2, a mol. wt of 62,000 and it was purified to a very high spec. act. of 1.6 x 10(6) NFU/mg protein. 3. It was heat sensitive and was inhibited by Cu2+, Hg2+ and heparin. 4. Stonefish hyaluronidase did not contain any haemorrhagic or lethal activity. 5. The N-terminal sequence of stonefish hyaluronidase has been determined to be A-P-S-X-D-E-G-N-K-K-A-D-N-L-L-V-K-K-I-N.

Plasminogen activators t-PA, u-PA and its inhibitor (PAI) in normal males and females

We determined the plasma levels of tissue plasminogen activator (t-PA), plasminogen activator inhibitor (PAI) activity and their antigen levels including urokinase plasminogen activator (u-PA) in 33 male and 27 female normal subjects. Males had mean t-PA activity of 0.50 iu/ml which was significantly lower (p less than 0.01) than the females 0.64 iu/ml. Males had higher (p less than 0.001) mean PAI activity (15.5 AU/ml) as compared to females 10.3 AU/ml. The respective mean levels of t-PA and PAI antigen were significantly higher (p less than 0.01) in males (8.1 ng/ml and 17.6 ng/ml) than in females (6.2 ng/ml and 12.1 ng/ml). The mean u-PA level in males was 1.54 ng/ml which was significantly higher (p less than 0.01) than in females with 1.02 ng/ml. In post-venous occlusion studies, females had a greater mean response of 8.6 fold in t-PA activity as compared to males with a mean of 4.5 fold increase. The mean t-PA antigen response in males was 2.0 fold increase as compared to 2.6 fold increase in the females. No significant responses were seen in both sexes in either PAI activity or antigen levels when compared with the resting state. In zymography studies, free t-PA, its inhibitor complexes and u-PA were demonstrated in the euglobulin fractions of stored plasma. This study demonstrates that significant differences in t-PA, u-PA and PAI exist between male and female subjects which should be taken into account when determining their levels in clinical conditions.

Plasma and lymphocyte cyclic nucleotide response to acute exercise in healthy adults

Plasma and lymphocytic cyclic nucleotide levels were assayed in 11 (5 male, 6 female) healthy normal adults before and after bicycle ergometry exercise. Lymphocytosis after exercise was observed. Plasma cAMP level was increased by almost 2 fold after exercise. However, plasma cGMP level was not affected. On the contrary, lymphocytic cAMP level was decreased by one third while cGMP level was halved. There were linear regression relationships between maximum heart rate and % difference in lymphocyte count and lymphocytic cyclic nucleotide levels pre- and post-exercise. Our findings demonstrate that higher cardiac output leads to increased lymphocytosis but decreased lymphocytic cyclic nucleotide levels.

Purification and partial characterization of stonustoxin (lethal factor) from Synanceja horrida venom

1. The lethal factor of the stonefish (Synanceja horrida) venom, designated as the stonustoxin, was purified to homogeneity by a two-step procedure on Sephacryl S-200 High Resolution (HR) gel permeation and DEAE Bio-Gel A anion exchange chromatography. 2. Stonustoxin has a native mol. wt of 148,000 and an isoelectric point of 6.9. 3. SDS-polyacrylamide gel electrophoresis revealed two subunits (designated alpha and beta) with mol. wts of 71,000 and 79,000, respectively. 4. The amino acid composition of both subunits and the N-terminal amino acid sequence of the beta subunit were also determined. 5. Purified stonustoxin had an LD50 of 0.017 microgram/g which is 22-fold more potent than that of the crude venom. 6. The toxin exhibited potent haemolytic activity in vitro and edema-inducing activity with a minimum edema dose (MED) of 0.15 micrograms in mouse paw. The edema effect was not antagonized by diphenhydramine.

A plasmin generation method for the determination of tissue plasminogen activator (t-PA) activity in blood

A plasmin generation method to determine tissue plasminogen activator (t-PA) activity in plasma is described. A protein solution of homogenized fibrin was used as a stimulator in the presence of plasminogen and the plasmin generated was measured by the release of para-Nitroanilide (p-NA) from the chromogenic substrate S-2251. Plasmin generation by 5 iu/mL t-PA in the presence of 1 CU/mL of plasminogen and 850 micrograms/mL of fibrin solution reaches a peak at about 5 h incubation whilst in plasma, plasmin generation peaks after about 16 h incubation. The highest t-PA activity in plasma was determined using an assay involving 18 h incubation. In the 21 subjects studied by this method the t-PA activity at rest ranged from 0.34 to 0.92 iu/mL with a mean of 0.57 +/- 0.15 iu/mL of plasma whilst in the post-occlusion state the activity ranged from 1.12 to 18.0 iu/mL, with a mean of 5.25 +/- 4.49 iu/mL of plasma. We also found that subjects who developed petechiae during occlusion had significantly higher t-PA activity both at pre- and post-occlusion when compared with those who did not develop petechiae. The t-PA activity of acid-treated plasma stored at -70 degrees C showed no significant changes in activity after 12 weeks of storage when compared with the t-PA activity of the same plasma tested prior to storage.

Effect of plant lectins on low density lipoprotein metabolism in adipocytes

The effect of plant lectins on low density lipoprotein metabolism was studied in isolated human adipocytes. Concanavalin A (0.1 mg X mL-1) resulted in 3-5 fold increase in [125I]-low density lipoprotein uptake in isolated human adipocytes but [125I]-low density lipoprotein degradation was not significantly affected. Adipocytes pre-incubated with alpha-methyl-D-mannopyranoside showed normal amount of [125I]-low density lipoprotein uptake. Wheat germ agglutinin and ricin both showed significant increase in [125]I-low density lipoprotein uptake in adipocytes. The effects of wheat germ agglutinin and ricin are likely mediated through their specific interactions with plasma membrane glycoprotein since the respective free saccharides can abolish the increased uptake. Lectin from Lotus tetragonolobus (10-30 micrograms . mL-1) resulted in reduction of [125I]-low density lipoprotein uptake but enhanced its uptake at 80 micrograms . mL-1. The effect of Lotus tetragonolobus lectin seems to be unrelated to interaction with L-fucosyl residue on the adipocyte membrane.

Chemical composition of biliary calculi in relation to the pattern of biliary disease in Singapore

The chemical composition of biliary calculi from 25 Singapore patients operated upon over a three month period was determined by a microanalytical technique and equilibrium swelling tests. Twelve patients had biliary calculi confined to the gallbladder and the main component of six calculi was cholesterol. In the other 6 patients, the dark brown to black pigment calculi contained bilirubin and calcium and a small quantity of cholesterol, but the chief component was an insoluble pigment with the swelling characteristics of a bilirubin polymer. These cholesterol and pigment calculi have similarities in composition to gallstones of Western patients. In 13 patients with cholangitis, the brown, soft pigment calculi found in the dilated bile ducts (and also concurrently in the gallbladder in 5 patients) had bilirubin as the main component. Fatty acid was frequently present. The insoluble pigment component was considerably less but the lower swelling ratio suggested more cross linkage compared with black gallbladder stones. Differences in chemical composition between pigment gallbladder and bile duct calculi support the concept that Western type cholelithiasis and Oriental cholangitis occur as separate disease entities in Singapore patients.

Radioimmunoassay of gastrin--our experience and a review of current status

The procedures of radioimmunoassays for gastrin are presented in this paper. Techniques are described and evaluated with special reference to preparation of radioiodinated gastrin, purification of monoiodinated gastrin, characterisation of the immunochemical properties of radiolabelled gastrin, raising and characterisation of specific antibodies, incubation conditions, separation of bound and free hormone and treatment of data. Factors contributing to discrepancies of radioimmunoassay results and problems encountered are discussed. Methods employed by the authors in gastrin radioimmunoassay are described. Commercially available gastrin kits are also compared.

Zollinger-Ellison syndrome--report of four cases and review of literature

Four patients with Zollinger-Ellison Syndrome (ZES) are presented to highlight the difficulties in the recognition, diagnosis and management of this rare disease. The presentation of ZES is usually indistinguishable from ordinary peptic ulcer disease and in those patients with symptoms not related to peptic ulcer, i.e., diarrhoea, as their main complaint, the diagnosis is often not even considered. A high index of suspicion is required, however, in patients with recurrent ulcers, multiple ulcers and in those with resistant or rapidly relapsing ulcers after conventional therapy. A presumptive diagnosis can be made by the demonstration of grossly elevated fasting serum gastrin levels combined with a secretin stimulation test in doubtful cases. The main problem is the location of the gastrin-secreting tumour which is usually pancreatic but often too small to be detected by currently available techniques. Histamine H2-receptor antagonists in high doses are effective in controlling the gastric acid hypersecretion which is chiefly responsible for the morbidity and mortality in ZES. They provide the treatment of choice in patients where the tumour cannot be located, though every attempt should be made to do this as surgery is the treatment of choice for this invariably malignant tumour. Total gastrectomy is now reserved for those patients in whom medical therapy has failed. The role of chemotherapy in metastatic disease has yet to be established.

The influence of setting and task partner on the performance of adults over age 65 on a communications task

The present study was an investigation of the influence of two methodological variables on the performance of adults sixty-four to seventy-nine years old. Participants gave directions on a map reading task to a peer (similar aged) partner and a non-peer (younger) partner. Testing was conducted in either the laboratory or the participants' homes. Contrary to expectations, communication performances with the non-peer required less time and fewer utterances, morphemes, repetitions and start overs than with the peer. The influence of setting was apparent only in the number of attention cues used, with the more distracting home setting requiring more attention cues to maintain partner attention.

Exchange of free cholesterol between low density lipoproteins and human adipocytes

Free cholesterol uptake from low density lipoproteins (LDL) by fat cells was investigated using exchange-labelled [1,2-3H]cholesterol-LDL and isolated human adipocytes, prepared by collagenase digestion of subcutaneous fat tissue biopsies. Radioactivity appeared in the cellular lipids within 2 min and accumulated at a slower rate approaching linearity for 3 h. At 5 and 120 min, 90% of the recovered cellular radioactivity was found in the bulk lipid fraction and the remainder was distributed among organelle fractions. Uptake of [3H]cholesterol was linearly related to substrate concentrations up to 5 micrograms unesterified cholesterol - LDL . mL-1. At higher concentrations up to 22 micrograms unesterified cholesterol - LDL . mL-1, [1,2-3H]cholesterol accumulated more gradually but did not reach a plateau. Metabolic inhibitors, sodium azide plus sodium fluoride, had no effect on radiocholesterol uptake. Native LDL and high density lipoprotein at equivalent unesterified cholesterol concentrations decreased [1,2-3H]cholesterol uptake, to a similar extent suggesting isotope dilution. The results demonstrate a rapid, receptor-independent uptake of cholesterol from LDL by adipocytes, consistent with an exchange mechanism. This process could explain the rapid labelling of adipose tissue cholesterol in vivo following intravenous administration of radiocholesterol and efflux of free cholesterol from adipose tissue during starvation.