Massive lower gastro-intestinal bleeding. A review.
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Biomedical subjects
Publications and source records attributed to J F Barrett.
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The action of purified N-acetylmuramoylhydrolase (muramidase, EC 3.2.1.17) of Streptococcus faecium ATCC 9790 on linear, uncross-linked, soluble, peptidoglycan chains produced by the same organism in the presence of benzylpenicillin was characterized as a processive exodisaccharidase. Specific labels, one [( 14C]Gal) added to the nonreducing ends of chains, and the other (3H from [3H]NaBH4) incorporated into the reducing ends of the chains, were used to establish that an enzyme molecule binds at the nonreducing terminus and sequentially hydrolyzes the glycosidic bonds, releasing disaccharide-peptide units. An enzyme molecule remains bond to a chain, and is not released at a detectable rate, until hydrolysis of that chain is complete. Reaction rates increased with the length of the polymer chain to give a maximum of 91 bonds cleaved/min/enzyme molecule for hydrolysis of a continuous polymeric substrate. The relationship between hydrolytic rate and glycan chain length is consistent with hydrolysis of bonds within the chain followed by slow release of enzyme from the distal, reducing terminus. This mechanism was experimentally confirmed by analysis of product formation during hydrolysis with stoichiometric mixtures of enzyme and soluble peptidoglycan chains. Kinetic analyses showed an apparent Km of 0.17 microM for the enzyme, independent of substrate polymer length. The dissociation constant for the initial enzyme-substrate complex was calculated to be 1.5 nM. Kinetic analyses are consistent with one catalytic site per enzyme molecule. The Kcat/Km value of 9 X 10(6) M-1 S-1 is near the limit imposed by diffusion for the initial hydrolytic events when long chains are hydrolyzed. The kinetic and physical properties of this muramidase are highly consistent with its location outside of the cellular permeability barrier and its ability to remain with and hydrolyze appropriate bonds in the cell wall in such an environment.
Two phenotypically autolysis-deficient strains of Streptococcus faecium ATCC 9790 were shown to produce high-molecular-weight, soluble, linear, uncross-linked peptidoglycan when incubated with benzylpenicillin in a wall medium which permits cell wall synthesis (wall thickening) but not balanced growth. This high-molecular-weight s-peptidoglycan was shown to have a molecular weight of 46,000 to 54,000, lack peptide cross-links, and be virtually devoid of accessory wall polymers. It was hydrolyzed by hen egg white lysozyme and the endogenous, autolytic N-acetylmuramidase of S. faecium, but was not attacked by proteinases. Chemical analyses of the polymer are consistent with the following structure, where n is the number of repeating disaccharide units: (formula; see text).
Soluble, linear, uncross-linked peptidoglycans, prepared from two autolysis-defective mutants of Streptococcus faecium ATCC 9790 and from Micrococcus leuteus, were used as substrates for studies of hydrolysis by an N-acetylmuramoylhydrolase (muramidase). The kinetics of hydrolysis of these substrates and the ability of the muramidases isolated from S. faecium ATCC 9790 and from two autolysis-defective mutants, Lyt-14 and Aut-3, to carry out transglycosylation reactions were compared with the action of hen egg white lysozyme (EC 3.2.1.17). Hydrolysis of these substrates by the endogenous streptococcal muramidases resulted in the production of disaccharide-peptide monomers with the structure (formula; see text) as nearly the sole product. As estimated from increases in reducing groups, hydrolysis proceeded at a linear rate for extended intervals, with consumption of up to 75% of the substrate, even at substrate concentrations well below the Km value. Apparent Km and relative Vmax values for the three streptococcal enzymes were indistinguishable from each other or from those for hen egg white lysozyme. These results indicate that the autolysis-defective phenotype of these mutants cannot be attributed to differences in their muramidases. In contrast to the action of hen egg white lysozyme, the streptococcal muramidase failed to catalyze transglycosylations. The extended periods of hydrolysis at constant rates are consistent with the occurrence of multiple catalytic events after the formation of the enzyme-substrate complex.
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CONTEXT: Epidural labor analgesia, if selected by the patient, is associated with high cesarean delivery rates. Results of randomized trials comparing rates of cesarean delivery using epidural anesthesia vs parenteral opioids are inconsistent. OBJECTIVE: To review the effects of epidural vs parenteral opioid analgesia on cesarean delivery rates. DATA SOURCES: Studies were identified by searching MEDLINE from January 1966 through January 1998, the Cochrane Database of Perinatal Trials, and relevant nonindexed journals and abstracts. STUDY SELECTION: We included all studies that randomized patients to epidural vs parenteral opioid labor analgesia. DATA EXTRACTION: Two authors independently extracted data from 10 trials enrolling 2369 patients. Odds ratios (ORs) for categorical data, weighted mean differences (WMDs) for continuous data, and 95% confidence intervals (CIs) were calculated using a random-effects model. DATA SYNTHESIS: The risk of cesarean delivery did not differ between patients receiving epidural (8.2%) vs parenteral opioid (5.6%) analgesia (OR, 1.5; 95% CI, 0.81-2.76). Epidural patients had longer first (WMD, 42 minutes; 95% CI, 17-68 minutes) and second (WMD, 14 minutes; 95% CI, 5-23 minutes) labor stages. While epidural patients were more likely to have instrumented delivery (OR, 2.19; 95% CI, 1.32-7.78), they were no more likely to have instrumented delivery for dystocia (OR, 0.68; 95% CI, 0.31-1.49). After epidural analgesia, neonates were less likely to have low 5-minute Apgar scores (OR, 0.38; 95% CI, 0.18-0.81) or to need naloxone (OR, 0.24; 95% CI, 0.07-0.77). Women receiving epidural analgesia had lower pain scores during the first (WMD, -40 mm on a 100-mm scale; 95% CI, -42 to -38 mm) and second (WMD, -29 mm; 95% CI, -38 to -21 mm) stages of labor. The odds of dissatisfaction were lower with epidural analgesia (OR, 0.25; 95% CI, 0.20-0.32). CONCLUSIONS: Epidural labor analgesia is not associated with increased rates of instrumented vaginal delivery for dystocia or cesarean delivery. Patients receiving epidural analgesia have longer labors. Patient satisfaction and neonatal outcome are better after epidural than parenteral opioid analgesia.