Assessing neuromuscular block at the larynx: the effect of change in resting cuff pressure and a comparison with video imaging in anesthetized humans

Neuromuscular block (NMB) at the larynx has been assessed by measuring the cuff pressure (CP) in an endotracheal tube (ETT) placed between the vocal cords. In this study, we evaluated the decrease in resting cuff pressure (RCP) after the administration of rocuronium and the effect of this decrease on the assessment of NMB, and we compared CP measurement with an alternative technique, video imaging (VI). In 20 patients, NMB was determined at the hand by mechanomyography and at the larynx initially by CP and subsequently by VI, recording images using a fiberoptic bronchoscope via a laryngeal mask. Train-of-four stimuli were applied at both sites. After baseline measurements, the ETT was replaced, and rocuronium was infused to achieve a steady-state 50% (n = 10) or 75% (n = 10) block at the hand. CP measurements were recorded before and after restoration of RCP to prerocuronium pressure, followed by further VI measurements. The mean RCP decreased from 21 +/- 4 to 12 +/- 5 mm Hg after rocuronium. At 50% block at the hand, the CP estimate of block at the larynx with reduced RCP was 62% +/- 18%, and that after restoring RCP was 29% +/- 13%; VI estimated 27% +/- 14% block. At 75% block at the hand, CP and VI estimated 52% +/- 11% and 46% +/- 9% block, respectively (RCP maintained). We conclude that RCP decreases after the administration of rocuronium, that restoring RCP significantly alters CP estimates of NMB, and that VI is in agreement with CP measurement if RCP is maintained at prerelaxant values. Implications: In this study, we show that a muscle relaxant-induced decrease in resting tension at the larynx may confound the assessment of neuromuscular block by cuff pressure measurement. The preliminary data suggest that video imaging may provide a suitable alternative to cuff pressure measurement to assess neuromuscular block at the larynx.     

An adaptive step-down procedure for fault variable identification

In a process with a large number of process variables (high-dimensional process), identifying which variables cause an out-of-control signal is a challenging issue for quality engineers. In this paper, we propose an adaptive step-down procedure using conditional T² statistic for fault variable identification. While existing procedures focus on selecting variables that have strong evidence of a change, the proposed step-down procedure selects a variable having the weakest evidence of a change at each step based on the variables that are selected in previous steps. The information of selected unchanged variables is effectively utilised in obtaining a powerful conditional T² test statistic for identifying the changed elements of the mean vector. The proposed procedure is designed to utilise the correlation information between fault and non-fault variables for the efficient fault variables identification. Further, the simulation results show that the proposed procedure has the better diagnostic performance compared with existing methods in terms of fault variable identification and computational complexity, especially when the number of the variables is high and the number of fault variables is small.     

Identification of 130 kDa cell surface LDL-binding protein from smooth muscle cells as a partially processed T-cadherin precursor

Atypical cell surface lipoprotein-binding proteins of 105 kDa and 130 kDa are present in membranes of vascular smooth muscle cells. We recently identified the 105 kDa protein from human aortic media as T-cadherin, an unusual glycosylphosphatidylinositol (GPI)-anchored member of the cadherin family of cell adhesion proteins. The goal of the present study was to determine the identity of 130 kDa lipoprotein-binding protein of smooth muscle cells. We applied different approaches that included protein sequencing of purified protein from human aortic media, the use of human T-cadherin peptide-specific antisera, and enzymatic treatment of cultured cells with trypsin and GPI-specific phospholipase C. Our results indicate that the 130 kDa protein is a partially processed form of T-cadherin which is attached to the membrane surface of smooth muscle cells via a GPI anchor and contains uncleaved N-terminal propeptide sequence. Our data disclose that, in contrast to classical cadherins, T-cadherin is expressed on the cell surface in both its precursor (130 kDa) and mature (105 kDa) forms.     

Management of chylothorax

BACKGROUND: Chylothorax is a rare primary or secondary condition the optimum management of which remains uncertain. METHODS: Twenty cases of chylothorax, including ten of primary chylothorax and ten secondary to either malignancy, subclavian vein thrombosis or lymphangioma treated between 1956 and 1986 have been reviewed. RESULTS: Open pleurectomy was the most successful treatment in preventing reaccumulation of the effusion. Three patients had thoracic duct-azygous vein anastomoses, but all anastomoses were probably occluded within a year of surgery. Three patients have been lost to follow-up and five died within 2 years of their treatment, but 12 patients were alive and free from an effusion 3-22 years after treatment. CONCLUSION: Patients with chylothorax should undergo lymphangiography to identify the cause and site of the lymphatic abnormality. Conservative treatment is successful in some patients but should be abandoned if the fluid loss exceeds 1.5 l/day for more than 5-7 days in an adult or more than 100 ml/day in a child. Parietal pleurectomy is the most successful treatment when no distinct chylous leak can be identified. Less commonly, an isolated chylous leak either in the chest or in the abdomen may be identified and this should be treated by direct ligation.     

Rat insulinoma-derived pancreatic beta-cells express a functional leptin receptor that mediates a proliferative response

In addition to its interaction at hypothalamic sites to affect feeding and energy expenditure, leptin has been shown to exhibit a proliferative response in erythropoietic cells. The functional leptin receptor is also present in pancreatic islets and we now demonstrate that a commonly used clonal insulin secreting beta-cell line, RINm5F, expresses high levels of the Ob-Rb mRNA. Leptin causes an increase in tyrosine phosphorylation of a number of intracellular proteins and a dose related (10 nM-200 nM) increase in expression of the immediate-early gene, c-fos. This precedes a leptin induced proliferative response in serum-deprived RINm5F cells, which suggests that leptin might be involved in the complex regulation of proliferation of the pancreatic beta-cell.     

Vaccination and the population structure of antigenically diverse pathogens that exchange genetic material

Populations of antigenically diverse pathogens undergoing genetic exchange may be categorized into strains on the basis of a set of principal protective antigens. The extent to which polyvalent vaccines based on these protective antigens can alter the population structure of the pathogen is determined by the degree of cross-protection between strains. In the case where there is no cross-protection, vaccinating against a particular strain will have no effect on the others. As cross-protection increases, the strains containing the antigenic variants included in the vaccine will be diminished in prevalence, and those that do not will increase in prevalence. The rise in prevalence of the latter will become more and more exaggerated as cross-protection increases. However, beyond a critical level of cross-protection, in the absence of vaccination, the steady state of the system is asymmetric in that a certain subset of strains (with non-overlapping repertoires of antigenic variants) will dominate over the others in terms of prevalence. Under these circumstances, a vaccine consisting of the most immunogenic combinations of antigenic variants can cause a dramatic increase in frequency of a subset of rare strains.