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While insulin exerts a comprehensive anti-inflammatory effect of relevance to the treatment of different inflammatory conditions, as described above, it is remarkable that glucose exerts a powerful proinflammatory effect. Thus, the administration of 75 g of glucose orally results in an increase in ROS generation by the circulating polymorphonuclear leukocytes (PMNs) and MNCs, an increase in p47 phox protein, and a fall in plasma α-tocopherol concentrations. In addition to causing an increase in lipid peroxidation as reflected in an increase in plasma concentration of thiobarbituric acid-reacting substances (TBARS) ( 48 52 ). Glucose has also been shown to exert other prothrombotic effects ( 53 ). Clearly, therefore, glucose induces acute oxidative stress. Glucose has also been shown recently to induce an increase in intranuclear NF-κB, a fall in cytosolic IκB, an increase in IκB kinase (IKK)-α and IKKβ ( 49 ). Glucose induces similar proinflammatory changes in endothelial cells in vitro ( Sperry Cutwater Chukka Mesh OYSPFr0Ne
). These changes are clearly proinflammatory. In addition, it has also been shown that a 75-g glucose challenge in normal subjects induces an increase in AP-1 activity in MNCs along with an increase in the expression of MMP-2 in MNCs and an increase in plasma concentrations of MMP-2 and MMP-9 ( 50 ). As described above, MMPs aid in the spread of inflammation and in mediating the rupture of the atherosclerotic plaque. Similarly, glucose induces an increase in Egr-1 and TF expression in MNCs and an increase in plasma concentration of TF. Thus, several of the effects of glucose are diametrically opposite to those of insulin in the context of inflammation. Glucose also causes abnormalities in vascular reactivity ( Vasque Saga GORETEX 8 Waterproof Hiking Boot Womens jmIfORf7ba
). This may affect vital organ perfusion adversely especially during situations of increased demand.

These proinflammatory effects of glucose have also been demonstrated in vitro. The incubation of endothelial cells in high glucose concentrations results in ROS generation and an increase in intranuclear NF-κB ( 54 , 56 , 57 ). Similarly, the incubation of monocytic cell lines in high glucose concentrations results in the elevation of intranuclear NF-κB and AP-1 with an increase in the expression of the proinflammatory cytokine, TNF-α ( 58 ). These effects of glucose are clearly of clinical relevance since hyperglycemia at the time of admission to the hospital determines the mortality and the duration of admission to the hospital, independently of the primary diagnosis or the previous history of diabetes. Because this effect of hyperglycemia was demonstrated in a retrospective study, it is important that these data be confirmed in a prospective study. However, it is legitimate to consider the aggressive control of blood glucose concentrations with insulin in patients admitted to the hospital to determine whether the normalization of blood glucose concentrations in hyperglycemic subjects improves the clinical outcomes. Such a study would have both clinical and pharmaco-economic implications ( 59 ).

Three quantitative BChE variants have been described: James (J), Kalow (K), and Hammersmith (H). All have normal substrate binding activity but show decreased concentrations in the plasma ( 2 ). The slight decreases in BChE activity due to the quantitative variants do not usually cause a clinically important prolonged response to succinylcholine. These variants are more likely to affect the duration of response when present with other factors that influence BChE activity, such as a qualitative BChE variant, pregnancy, and anticholinesterase drugs ( 9 ).

A blood sample was obtained for BChE activity and DN testing. The BChE activity was 57 U/L (reference interval, 3300–10 300 U/L) and the DN was <5% (reference interval, 83%–88%).

After a period of 4 h beyond the expected duration of succinylcholine action, the patient recovered his strength and met the criteria for extubation. He was discharged from the hospital 27.5 h after surgery. Because succinylcholine binds to the BChE active site, its presence in plasma will produce falsely decreased BChE activity and DN results. In the reported case, the initial BChE test was performed on a sample collected when succinylcholine was likely to be circulating in the patient's blood. A repeat blood sample was obtained 8 days later for a repeat evaluation of the BChE activity and the DN; the results were 89 U/L and <5%, respectively. This BChE finding in conjunction with the low DN (<5%) suggested the patient had the S phenotype ( Table 1 ). Knowledge of the phenotype is important because it will guide decisions regarding any future use of succinylcholine.

To better understand the genetic cause of the patient's reduced BChE activity, we performed BCHE sequencing. PCR amplification of the 3 coding regions and intron/exon boundaries of the BCHE gene was performed with M13-tailed primers. Unincorporated primers and deoxynucleoside triphosphates were inactivated by incubating with ExoSAP (USB Corporation). Bidirectional DNA sequencing was performed with BigDye Terminator chemistry (Applied Biosystems) and M13 primers, and the product was analyzed on the ABI 3100 Genetic Analyzer (Applied Biosystems). Data were analyzed with Mutation Surveyor software (SoftGenetics) by comparing the generated sequence to a reference BCHE sequence (Genbank NC_000003.11 ).

BCHE sequencing identified a homozygous mutation: c.1240 C>T (p.Arg414Cys, known as Arg386Cys in the mature protein) in exon 2 ( Fig. 1 ). This rare mutation has previously been reported only as a heterozygote and with an unknown clinical importance ( 10 , Eastland Open Road Womens EkAJmh
). The case we have presented establishes that the BCHE Arg414Cys variant in the homozygous state produces prolonged paralysis upon exposure to succinylcholine, in agreement with an S phenotype. Arg414Cys is most likely a missense mutation causing inactivation of the BChE active site.

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