Ljuba Stojiljkovic

Actin is part of pre-initiation complexes and is necessary for transcription by RNA polymerase II

Actin is abundant in the nucleus and has been implicated in transcription; however, the nature of this involvement has not been established. Here we demonstrate that β-actin is critically involved in transcription because antibodies directed against β-actin, but not muscle actin, inhibited transcription in vivo and in vitro. Chromatin immunoprecipitation assays demonstrated the recruitment of actin to the promoter region of the interferon-γ-inducible MHC2TA gene as well as the interferon-α-inducible G1P3 gene. Further investigation revealed that actin and RNA polymerase II co-localize in vivo and also co-purify. We employed an in vitro system with purified nuclear components to demonstrate that antibodies to β-actin block the initiation of transcription. This assay also demonstrates that β-actin stimulates transcription by RNA polymerase II. Finally, DNA-binding experiments established the presence of β-actin in pre-initiation complexes and also showed that the depletion of actin prevented the formation of pre-initiation complexes. Together, these data suggest a fundamental role for actin in the initiation of transcription by RNA polymerase II.

Supraclavicular Block in the Obese Population: An Analysis of 2020 Blocks

Regional anesthesia in the obese patient can be challenging and possibly carries a greater failure rate as compared with that in the non-obese patient. We retrospectively reviewed our prospectively gathered peripheral block data to determine the influence of body weight on success rate of the supraclavicular block. Obesity was defined as body mass index ≥30. The overall success rate was 97.3% in nonobese and 94.3% in obese patients (P < 0.01). Residents completed 80% of the blocks in nonobese patients and 73% in obese patients (P < 0.01). No difference in acute complications was observed. Obesity is associated with a slight decrease in success rate of supraclavicular block and an increase in its relative difficulty without apparent effect on acute complications.

Nuclear myosin I is necessary for the formation of the first phosphodiester bond during transcription initiation by RNA polymerase II

The nuclear isoform of myosin, Nuclear Myosin I (NMI) is involved in transcription by RNA polymerase I. Previous experiments showing that antibodies to NMI inhibit transcription by RNA polymerase II using HeLa cell nuclear extract (NE) suggested that NMI might be a general transcription factor for RNA polymerases. In this study we used a minimal in vitro transcription system to investigate the involvement of NMI in transcription by RNA polymerase II in detail. We demonstrate that NMI co‐purifies with RNA polymerase II and that NMI is necessary for basal transcription by RNA polymerase II because antibodies to NMI inhibit transcription while adding NMI stimulates transcription. Further investigation revealed that NMI is specifically involved in transcription initiation. Finally, by employing an abortive transcription initiation assay, we demonstrate that NMI is crucial for the formation of the first phosphodiester bond during transcription initiation. J. Cell. Biochem. 99: 1001–1009, 2006.

Primer of postoperative pruritus for anesthesiologists

Postoperative itching is an important problem in the postoperative care unit. Pruritus after surgery may be drug induced (including intrathecal opioids) or secondary to a preexisting systemic disease. Mechanisms of itching are complex and not completely understood. The purpose of this review is to highlight new discoveries in pathways and mechanisms of pruritus and to summarize up-to-date knowledge about treatment of itching after surgery. More basic and clinical studies are needed to address the effects of drugs on specific receptors and improve the treatment of postoperative pruritus.

Role of Renin Angiotensin System Inhibitors in Cardiovascular and Renal Protection: A Lesson from Clinical Trials

Beneficial effects of angiotensin converting enzyme inhibitors (ACEI) and angiotensin type 1 receptor (AT1) blockers in patients with cardiovascular and renal diseases have been clearly demonstrated in numerous large outcomes studies. In patients with heart failure (HF), ACEI have been shown to reduce overall mortality, mortality from cardiovascular causes, to increase life expectancy, as well as to preserve the renal function (CONSENSUS, SAVE, TRACE, AIRE, AIREX, CATS trials). In addition, in the PROGRESS study ACEI substantially decreased the risk of stroke and transient ischemic attacks in patients with cerebrovascular disorders. The HOPE and EUROPA studies confirmed that long term therapy with ACEI provides significant survival benefit in patients with broad range of atherosclerotic cardiovascular diseases. After these large and well designed clinical studies, ACEI have become standard therapy for routine secondary prevention in all patients with cardiovascular diseases, unless contraindicated. AT1 receptor blockers have been recently added to the cardiovascular therapeutic armamentarium. They are believed to provide additional protection by inhibition of locally synthesized angiotensin II on the level of AT1 receptor. The ELITE II, ValHeFT and CHARM studies have shown that AT1 receptor blockers are equally effective as ACEI in reduction of mortality and morbidity in patients with HF. Importantly, they may be used together with ACEI, or as alternative treatment in ACEI intolerant patients. Renal protection is another important effect of both ACEI and AT1 blockers that has been confirmed in several large clinical trials. The North American Microalbuminemia Study group and EUCLID group demonstrated significant reduction in progression of diabetic nephropathy in patients with insulin dependent diabetes mellitus (IDDM) treated with ACEI. AT1 receptor blockers are mainly studied in the non-insulin dependent diabetes mellitus (NIDDM) nephropathy. Four recent clinical trials (IRMA-2, DETAIL, RENAAL and IDNT) examined the effect of AT1 receptor blockers in patients with NIDDM nephropathy. These studies confirmed the beneficial effect of AT1 receptor blockers in patients with NIDDM nephropathy that was extended beyond the blood pressure reduction. Ongoing studies (ONTARGET, TRANSCEND and PROTECTION) should provide us with additional insights about cardiovascular, renal and other end-organ protective effects of these therapeutics.

Renin-angiotensin system inhibitors and angioedema: anesthetic implications.

PURPOSE OF REVIEW Angioedema is a serious complication of renin-angiotensin system inhibitor therapy. The incidence is 0.1-0.7%. It consists of nonpitting edema and involves the face and lips. In severe cases, it extends to pharyngeal and laryngeal structures. RECENT FINDINGS Decreased degradation of bradykinin and its metabolites is thought to be a culprit. When the angiotensin-converting enzyme is inhibited, bradykinin metabolism is dependent on degradation by neutral endopeptidase, dipeptidyl peptidase IV, and aminopeptidase P. When these enzymes are inhibited, as in treatment of diabetes or in transplant recipients, the incidence of angioedema increases significantly. African-Americans, people over 65, women, and those with a history of smoking are especially at risk. A fiberoptic laryngeal examination should be performed in all patients. Patients with rapid progression of symptoms are at risk for airway compromise. Supportive treatment with steroids and antihistamines is not very effective. Recently, icatibant, a bradykinin receptor antagonist, has been used to successfully shorten the resolution of edema. SUMMARY Trauma of the airway, especially during difficult intubation, may precipitate severe angioedema. In cases with laryngeal involvement, fiberoptic intubation may be necessary. After the episode of angioedema, lifetime discontinuation of all renin-angiotensin inhibitors may be warranted.

Enzymatic study of tonsil tissue alkaline and acid phosphatase in children with recurrent tonsillitis and tonsil hypertrophy

OBJECTIVE Indications for tonsillectomy in recurrent tonsillitis are defined according to the number of episodes of acute bacterial infections in a year. However, little is known about the tonsil immune competence status in patients presenting with recurrent tonsillitis with either hypertrophied or atrophied tonsils, or in patients presenting with obstructive sleep apnoea. In this study we examined the tonsil immune status in children with 3-5 acute recurrent infections a year and in children with obstructive sleep apnoea by comparing the activity of tonsil and adenoid tissue nonspecific alkaline and acid phosphatase. METHODS Specific activity of tonsil and adenoid tissue nonspecific alkaline and acid phosphatase was investigated in children who underwent tonsillectomy and adenoidectomy for recurrent infection (72 children) and for obstructive sleep apnoea (10 children). Tissue enzyme activities were measured using p-nitrophenylphosphate as a substrate. Tissue samples were examined by the haematoxylin-eosin histological technique. Statistical analyses were performed using SPSS v. 16 software. RESULTS The tissue nonspecific alkaline phosphatase activity was similar in hypertrophied tonsils in the recurrent infection group and in the obstructive sleep apnoea group (3.437+/-1.226 and 3.978+/-0.762 U/mg of protein, respectively). The enzyme activity in both hypertrophied tonsil groups was significantly higher as compared to atrophied tonsils in the recurrent tonsillitis group, p=0.021 and p=0.006, respectively. The enzyme activity was significantly higher in the adenoids compared to the tonsils from all three groups. Contrary to this, no significant differences were noticed for tonsil and adenoid acid phosphatase activities among the groups. CONCLUSION Similar acid phosphatase activity in all three groups implies that all three groups have preserved antigen presenting cell activity. In patients with hypertrophied tonsils similar tissue nonspecific alkaline phosphatase activity suggests preserved B cell tonsil immune activity, regardless of the pathology. Patients with atrophied tonsils had significantly lower alkaline phosphatase activity, indicating relative tonsil B cell immune deficiency. Thus, different immunological status in patients presenting with hypertrophied vs. atrophied tonsils could point to a different underlying pathophysiologic mechanism of the disease.

Training Induces Cognitive Bias: The Case of a Simulation-Based Emergency Airway Curriculum

Introduction Training-induced cognitive bias may affect performance. Using a simulation-based emergency airway curriculum, we tested the hypothesis that curriculum design would induce bias and affect decision making. Methods Twenty-three novice anesthesiology residents were randomized into 2 groups. The primary outcome measure was the initiation of supraglottic airway and cricothyroidotomy techniques in a simulated cannot-ventilate, cannot-intubate scenario during 3 evaluation sessions. Secondary outcomes were response times for device initiation. After a baseline evaluation and didactic lecture, residents received an initial practical training in either surgical cricothyroidotomy (CRIC group) or supraglottic airway (SGA group). After the midtest, the groups switched to receive the alternate training. Results From baseline to midtest, the SGA group increased initiation of supraglottic airway but not cricothyroidotomy. The CRIC group increased initiation of cricothyroidotomy but not supraglottic airway. After completion of training in both techniques, the SGA group increased initiation of both supraglottic airway and cricothyroidotomy. In contrast, the CRIC group increased initiation of cricothyroidotomy but failed to change practice in supraglottic airway. Final test response times showed that the CRIC group was slower to initiate supraglottic airway and faster to initiate cricothyroidotomy. Discussion Practical training in only 1 technique caused bias in both groups despite a preceding didactic lecture. The chief finding was an asymmetrical effect of training sequence even after training in both techniques. Initial training in cricothyroidotomy caused bias that did not correct despite subsequent supraglottic airway training. Educators must be alert to the risk of inducing cognitive bias when designing curricula.

Clamp-crushing vs. radiofrequency-assisted liver resection:changes in liver function tests.

BACKGROUND/AIMS Liver resection is the gold standard in managing patients with metastatic or primary liver cancer. The aim of our study was to compare the traditional clamp-crushing technique to the radiofrequency- assisted liver resection technique in terms of postoperative liver function. METHODOLOGY Liver function was evaluated preoperatively and on postoperative days 3 and 7. Liver synthetic function parameters (serum albumin level, prothrombin time and international normalized ratio), markers of hepatic injury and necrosis (serum alanine aminotransferase, aspartate aminotransferase and total bilirubin level) and microsomal activity (quantitative lidocaine test) were compared. RESULTS Forty three patients completed the study (14 had clamp-crushing and 29 had radiofrequency assisted liver resection). The groups did not differ in demographic characteristics, pre-operative liver function, operative time and perioperative transfusion rate. In postoperative period, there were similar changes in monitored parameters in both groups except albumin levels, that were higher in radiofrequency-assisted liver resection group (p=0.047). CONCLUSIONS Both, traditional clamp-crushing technique and radiofrequency assisted liver resection technique, result in similar postoperative changes of most monitored liver function parameters.

Anesthetic Management of Pheochromocytoma and Paraganglioma

Pheochromocytoma and paraganglioma are rare endocrine tumors that pose significant challenge to anesthesiologists. Increased sympathetic activation during induction of anesthesia, tracheal intubation, and surgical incision, and surges of catecholamine release during manipulation of the tumor can precipitate severe hemodynamic instability. Intraoperative complications include malignant hypertension, arrhythmia, myocardial infarction, acute cardiac decompensation, pulmonary edema, and stroke. Careful preoperative preparation with α- and β-blockers and oral intravascular fluid expansion have been shown to decrease the incidence and severity of perioperative hemodynamic instability. Preoperative tests should include 24-h urine catecholamine levels and cardiac evaluation with an electrocardiogram and an echocardiogram. In addition to standard intraoperative monitors, all patients should have an arterial line placed prior to induction of anesthesia. Most patients receive general anesthesia for these surgeries. During the induction of anesthesia, a deep plain of anesthesia and paralysis should be achieved prior to tracheal intubation, to avoid excessive sympathetic stimulation. Potent arterial and venous vasodilators should be readily available to treat hypertensive crises during anesthesia. Arrhythmias should be treated promptly with β-blockers and antiarrhythmic agents. Vasopressors are usually needed to treat hypotension after tumor resection. All vasodilators and vasopressors should be infused via central venous access. Maintenance of general anesthesia is achieved with a volatile anesthetic, with the careful titration of narcotics. The goal of fluid management is to achieve euvolemia. Fluid management should be guided by dynamic parameters of fluid responsiveness. All patients should be recovered in an intensive care unit. Elderly patients are at higher risk for postoperative complications and prolonged hypotension after tumor resection. Care of pheochromocytoma in pregnancy requires a multidisciplinary approach with an endocrinologist, obstetrician, surgeon, and anesthesiologist to best prepare for the timing of surgical resection.