1
|
Simmons G, Sabo R, Aziz M, Martin E, Bernard RJ, Sriparna M, McIntire C, Krieger E, Brophy DF, Natarajan R, Fowler A, Roberts CH, Toor A. INTRAVENOUS VITAMIN C SUPPLEMENTATION IN ALLOGENEIC HEMATOPOIETIC CELL TRANSPLANT RECIPIENTS: SALUTARY IMPACT ON CLINICAL OUTCOMES. medRxiv 2023:2023.10.24.23297165. [PMID: 37961224 PMCID: PMC10635184 DOI: 10.1101/2023.10.24.23297165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Intravenous (IV) vitamin C improves organ function and reduces inflammation in sepsis, an inflammatory state like the post-hematopoietic stem cell transplant (SCT) milieu. The safety and efficacy of parenteral vitamin C after allogeneic hematopoietic stem cell transplant (HSCT) were evaluated in a phase I/II trial and clinical outcomes compared with a propensity score - matched historical control. Methods Patients with advanced hematologic malignancies were enrolled in a phase 2 clinical trial, receiving IV vitamin C, 50mg/kg/d, divided into 3 doses given on days 1-14 after HSCT, followed by 500 mg bid oral from day 15 until 6 months post-SCT. Results 55 patients received IV vitamin C: these include 10/10 HLA-MRD and MUD (n=48) and 9/10 HLA MUD recipients (n=7). All patients enrolled were deficient in vitamin C at day 0 and had restoration to normal levels for the remainder of the course. Vitamin C recipients had lower non-relapse mortality (11% vs. 25%, p-value = 0.07) and consequently, improved survival compared to historical controls (82% vs 62% p=0.06), with no attributable grade 3 and 4 toxicities to vitamin C. Patients with myeloid malignancies had improved survival (83% vs. 54%, p=0.02) and non-relapse mortality (NRM) (10% vs. 37%, p=0.009), as well as chronic GVHD, with similar relapse rates compared to controls. Conclusions In patients undergoing allogeneic HSCT the administration of IV vitamin C is safe and reduces non-relapse mortality improving overall survival. Randomized trials are needed to confirm the utility of this easily available and inexpensive therapy.
Collapse
Affiliation(s)
- Gary Simmons
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Roy Sabo
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - May Aziz
- School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Erika Martin
- School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Robyn J Bernard
- School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Manjari Sriparna
- School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Cody McIntire
- School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Elizabeth Krieger
- Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia
| | - Donald F Brophy
- School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Ramesh Natarajan
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Alpha Fowler
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | | | - Amir Toor
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
- Lehigh Valley Health Network, Allentown, Pennsylvania
| |
Collapse
|
2
|
Das K, Pendurthi UR, Manco-Johnson M, Martin EJ, Brophy DF, Rao LVM. Factor VIIa treatment increases circulating extracellular vesicles in hemophilia patients: Implications for the therapeutic hemostatic effect of FVIIa. J Thromb Haemost 2022; 20:1928-1933. [PMID: 35608928 PMCID: PMC9846311 DOI: 10.1111/jth.15768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 03/22/2022] [Indexed: 01/21/2023]
Affiliation(s)
- Kaushik Das
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, Texas, USA
| | - Usha R. Pendurthi
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, Texas, USA
| | | | - Erika J. Martin
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - Donald F. Brophy
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - L. Vijaya Mohan Rao
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, Texas, USA
| |
Collapse
|
3
|
Zhu J, Parsons JT, Yang Y, Martin E, Brophy DF, Spiess BD. Platelet and White Cell Reactivity to Top-Load Intravenous Perfluorocarbon Infusion in Healthy Sheep. J Surg Res 2021; 267:342-349. [PMID: 34192613 DOI: 10.1016/j.jss.2021.05.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 04/20/2021] [Accepted: 05/25/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Perfluorocarbon emulsions (PFCs) are intravenous artificial oxygen carriers with enhanced gas solubility. As lipid micelle nanoparticle emulsions, PFCs may have a class effect that causes degrees of thrombocytopenia. Understanding the extent of the platelet effects, including mechanism and potential inflammation after PFC infusion, is important for safe human trials. METHODS Normal sheep (Dorper) were infused with 5 mL/kg of Oxygent (w/v 60% PFC) or Perftoran (w/v 20% PFC). Controls received 6% Hetastarch or were naive. Blood samples were analyzed from baseline, time 0 (the end of infusion), 3 and 24 hours, and 4 and 7 days. Platelet count, plateletcrit, mean platelet volume, platelet distribution width, and CD-62p (a platelet activation-dependent membrane protein) were measured. Neutrophils, monocytes, and total white blood cell counts were analyzed. RESULTS In these inflammatory cell lines, there were no consistent changes or cellular activation after PFC infusion. A decrease (<10% from baseline and naive controls) in platelet count was seen on day 4 after Oxygent infusion (3 g/kg), which recovered by day 7. No platelet effect was seen in Perftoran (1 g/kg). Plateletcrit, mean platelet volume, and platelet distribution width did not change significantly at any time point among the groups. CD-62p, ADP, and collagen aggregometry showed no significant change in platelet function. CONCLUSION There was no evidence of overall reduction in platelet number, or any correlation with the change in platelet activation or inhibition. Therefore, the risk of increased thrombosis/bleeding after PFC intravenous infusion is low in this non-trauma sheep model.
Collapse
Affiliation(s)
- Jiepei Zhu
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida 32610.
| | - J Travis Parsons
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida 32610
| | - Yang Yang
- Department of Biostatistics, University of Florida College of Public Health & Health Professions and College of Medicine, Gainesville, Florida 32611
| | - Erika Martin
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia 23298
| | - Donald F Brophy
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia 23298
| | - Bruce D Spiess
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida 32610
| |
Collapse
|
4
|
Martin EJ, Nolte ME, Kuhn J, Schmidt N, Pfaff N, Brophy DF. An in vitro pharmacodynamic spiking study of befovacimab, a tissue factor pathway inhibitor monoclonal antibody, in blood samples from patients with severe FVIII deficiency. Haemophilia 2021; 27:690-698. [PMID: 33915599 DOI: 10.1111/hae.14314] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/17/2021] [Accepted: 03/31/2021] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Tissue factor pathway inhibitor (TFPI) is an endogenous protein that inhibits the extrinsic (tissue factor) pathway and negatively regulates thrombin production during coagulation. Inhibiting TFPI may become a useful target for haemophilia drug development to allow greater thrombin generation without use of the intrinsic (contact) pathway. AIMS The in vitro effects of befovacimab, a humanized TFPI neutralizing antibody, were studied in whole blood and plasma samples from patients with severe FVIII deficiency. METHODS Blood and plasma obtained from participants was supplemented in vitro with befovacimab (0.5, 1, 5, 10 and 100 nM) or recombinant factor VIII (rFVIII) 5-, 10- and 40% and analysed using rotational thromboelastometry (ROTEM), thrombin generation assay (TGA) and the dilute prothrombin time (dPT) assay. The in vitro coagulation effects of befovacimab were compared to samples supplemented with rFVIII. RESULTS Befovacimab induced consistent pro-coagulant responses in ROTEM parameters including reduction in clotting times and increases in α-angle; induced reductions in dPT clotting time; and improvements in TGA parameters (reduced lag time and increased thrombin generation parameters). There was a modest concentration-dependent response generally from 0.5- to 10 nM, after which, the pharmacodynamic effect plateaued through the 100 nM concentration. Befovacimab concentrations of 5 to 10 nM showed pro-coagulant activity comparable to blood samples supplemented with rFVIII 10-40%. CONCLUSIONS Befovacimab has modest dose-response effects from 0.5 to 10 nM with minimal improvement with higher concentrations. In vitro befovacimab blood concentrations of 5 to 10 nM had pro-coagulant effects similar to blood supplemented with rFVIII 10- to 40%.
Collapse
Affiliation(s)
- Erika J Martin
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Sciences, Virginia Commonwealth University (VCU) School of Pharmacy, Richmond, VA, USA
| | - Melinda E Nolte
- Department of Internal Medicine, Division of Hematology/Oncology, VCU School of Medicine, Richmond, VA, USA
| | - Janice Kuhn
- Department of Internal Medicine, Division of Hematology/Oncology, VCU School of Medicine, Richmond, VA, USA
| | - Nicole Schmidt
- Research & Development, Pharmaceuticals, Bayer AG, Berlin, Germany
| | - Nils Pfaff
- Research & Development, Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Donald F Brophy
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Sciences, Virginia Commonwealth University (VCU) School of Pharmacy, Richmond, VA, USA
| |
Collapse
|
5
|
Brophy DF, Sowinski KM, Kraus MA, Moe SM, Klaunig JE, Mueller BA. Small and Middle Molecular Weight Solute Clearance in Nocturnal Intermittent Peritoneal Dialysis. Perit Dial Int 2020. [DOI: 10.1177/089686089901900607] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives To determine the dialysate-to-plasma (D/P) concentration ratios and peritoneal dialytic clearance (ClD) of substances with a wide range of molecular weights in subjects receiving a simulated nocturnal intermittent peritoneal dialysis (NIPD) session. Design Open-label single-dose study. Subjects Six end-stage renal disease patients undergoing peritoneal dialysis (PD). Setting Clinical research center of a university-affiliated hospital. Interventions Subjects received intravenous gentamicin and vancomycin on the first day of the study. Subjects received no PD until their return on the following day, when subjects underwent a simulated NIPD session utilizing four 2- to 2.5-L peritoneal dialysate dwells of 2 hours. Blood and dialysate samples were collected immediately before the session and after each dialysate dwell for determination of urea, creatinine, gentamicin, vancomycin, and β2-microglobulin (β2M) concentrations. Each solute's D/P concentration ratio and peritoneal ClD were calculated. Measurements and Main Results The (mean ±SD) 2-hour D/P concentration ratios were 0.78 ± 0.05 (urea), 0.49 ± 0.11 (creatinine), 0.38 ± 0.08 (gentamicin), 0.11 ± 0.06 (vancomycin), and 0.07 ± 0.03 (β2M). Peritoneal ClD values (mL/min of dialysis) were 19.0 ± 2.8 (urea), 12.1 ± 3.5 (creatinine), 8.4 ± 2.8 (gentamicin), 2.7 ± 1.5 (vancomycin), and 1.7 ± 0.8 (β2M). The D/P concentration ratios and peritoneal ClD values for urea, creatinine, and gentamicin were significantly different from vancomycin and β2M (repeated measures ANOVA, p < 0.05). β2-Micro-globulin peritoneal ClD was strongly related to gentamicin peritoneal ClD ( r = 0.96, p < 0.05). Conclusion Small molecular weight solutes have significantly greater D/P and peritoneal ClD than middle molecular weight solutes in NIPD. In NIPD, daily peritoneal ClD of β2M is lower than that reported in continuous ambulatory PD. NIPD also results in lower drug ClD than that reported in continuous ambulatory PD studies.
Collapse
Affiliation(s)
- Donald F. Brophy
- Department of Pharmacy, School of Pharmacy, Virginia Commonwealth University/Medical College of Virginia Campus, Richmond, Virginia
| | - Kevin M. Sowinski
- Department of Pharmacy Practice, School of Pharmacy and Pharmacal Sciences, Purdue University, Indianapolis, Indiana
| | - Michael A. Kraus
- Department of Medicine and Pharmacology and Toxicology, Indianapolis, Indiana, U.S.A
| | - Sharon M. Moe
- Department of Medicine and Pharmacology and Toxicology, Indianapolis, Indiana, U.S.A
| | - James E. Klaunig
- School of Medicine, Indiana University, Indianapolis, Indiana, U.S.A
| | - Bruce A. Mueller
- Department of Pharmacy Practice, School of Pharmacy and Pharmacal Sciences, Purdue University, Indianapolis, Indiana
| |
Collapse
|
6
|
Enoksson M, Martin EJ, Holmberg H, Jensen MS, Kjelgaard-Hansen M, Egebjerg T, Buchardt J, Krogh TN, Demuth H, Sanfridson A, Hilden I, Kjalke M, Brophy DF. Enhanced potency of recombinant factor VIIa with increased affinity to activated platelets. J Thromb Haemost 2020; 18:104-113. [PMID: 31549480 DOI: 10.1111/jth.14644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 09/09/2019] [Accepted: 09/19/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa) enhances thrombin generation in a platelet-dependent manner; however, rFVIIa binds activated platelets with relatively low affinity. Triggering receptor expressed on myeloid cells (TREM)-like transcript (TLT)-1 is expressed exclusively on activated platelets. OBJECTIVE To enhance the potency of rFVIIa via binding TLT-1. METHODS Recombinant FVIIa was conjugated to a TLT-1 binding Fab. In vitro potency of this platelet-targeted rFVIIa (PT-rFVIIa) was evaluated using factor X activation assays and by measuring viscoelastic changes in whole blood. In vivo potency was evaluated using a tail vein transection model in F8-/- mice expressing human TLT-1. RESULTS PT-rFVIIa and rFVIIa had similar dissociation constant values for tissue factor binding and similar tissue factor-dependent factor X activation. However, PT-rFVIIa had increased catalytic efficiency on TLT-1-loaded vesicles and activated platelets. The in vitro potency in normal human blood with antibody-induced hemophilia A was dependent on assay conditions used; with maximally activated platelets, the half maximal effective concentration for clot time for PT-rFVIIa was 49-fold lower compared with rFVIIa. In the murine bleeding model, a 53-fold lower half maximal effective concentration was observed for blood loss for PT-rFVIIa, supporting the relevance of the assay conditions with maximally activated platelets. In vitro analysis of blood from subjects with hemophilia A confirmed the data obtained with normal blood. CONCLUSIONS Increasing the affinity of rFVIIa to activated platelets resulted in approximately 50-fold increased potency both in vitro and in the mouse model. The correlation of in vivo with in vitro data using maximally activated platelets supports that these assay conditions are relevant when evaluating platelet-targeted hemostatic concepts.
Collapse
Affiliation(s)
| | - Erika J Martin
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | | | | | | | | | | | | | | | | | | | | | - Donald F Brophy
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| |
Collapse
|
7
|
Trankle CR, Vo C, Martin E, Puckett L, Siddiqui MS, Brophy DF, Stravitz T, Guzman LA. Clopidogrel Responsiveness in Patients With Decompensated Cirrhosis of the Liver Undergoing Pre-Transplant PCI. JACC Cardiovasc Interv 2019; 13:661-663. [PMID: 31883726 DOI: 10.1016/j.jcin.2019.08.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/09/2019] [Accepted: 08/20/2019] [Indexed: 01/12/2023]
|
8
|
Al-Horani RA, Abdelfadiel EI, Afosah DK, Morla S, Sistla JC, Mohammed B, Martin EJ, Sakagami M, Brophy DF, Desai UR. A synthetic heparin mimetic that allosterically inhibits factor XIa and reduces thrombosis in vivo without enhanced risk of bleeding. J Thromb Haemost 2019; 17:2110-2122. [PMID: 31397071 PMCID: PMC6893084 DOI: 10.1111/jth.14606] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 07/15/2019] [Accepted: 08/07/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Human factor XIa (FXIa) is an actively pursued target for development of safer anticoagulants. Our long-standing hypothesis has been that allosterism originating from heparin-binding site(s) on coagulation enzymes is a promising approach to yield safer agents. OBJECTIVES To develop a synthetic heparin mimetic as an inhibitor of FXIa so as to reduce clot formation in vivo but not carry high bleeding risk. METHODS We employed a gamut of methods involving synthetic chemistry, biophysical biochemistry, enzyme assays, blood and plasma coagulation assays, and in vivo thrombosis models in this work. RESULTS Sulfated chiro-inositol (SCI), a non-saccharide mimetic of heparin, was synthesized in three steps in overall yields of >50%. SCI inhibited FXIa with potency of 280 nmol/L and preferentially engaged FXIa's heparin-binding site to conformationally alter its active site. SCI inhibition of FXIa could be rapidly reversed by common antidotes, such as protamine. SCI preferentially prolonged plasma clotting initiated with recalcification, rather than thromboplastin, alluding to its intrinsic pathway-based mechanism. Human blood thromboelastography indicated good ex vivo anticoagulation properties of SCI. Rat tail bleeding and maximum-dose-tolerated studies indicated that no major bleeding or toxicity concerns for SCI suggesting a potentially safer anticoagulation outcome. FeCl3 -induced arterial and thromboplastin-induced venous thrombosis model studies in the rat showed reduced thrombus formation by SCI at 250 μg/animal, which matched enoxaparin at 2500 μg/animal. CONCLUSIONS Overall, SCI is a highly promising, allosteric inhibitor of FXIa that induces potent anticoagulation in vivo. Further studies are necessary to assess SCI in animal models mimicking human clinical indications.
Collapse
Affiliation(s)
- Rami A. Al-Horani
- Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, VA 23298
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219
| | - Elsamani I. Abdelfadiel
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219
- Department of Biochemistry, Virginia Commonwealth University, Richmond, VA 23298
| | - Daniel K. Afosah
- Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, VA 23298
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219
| | - Shravan Morla
- Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, VA 23298
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219
| | - Jyothi C. Sistla
- Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, VA 23298
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219
| | - Bassem Mohammed
- Department of Pharmacotherapy and Outcomes Sciences, Virginia Commonwealth University, Richmond, VA 23298
| | - Erika J. Martin
- Department of Pharmacotherapy and Outcomes Sciences, Virginia Commonwealth University, Richmond, VA 23298
| | - Masahiro Sakagami
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, VA 23298
| | - Donald F. Brophy
- Department of Pharmacotherapy and Outcomes Sciences, Virginia Commonwealth University, Richmond, VA 23298
| | - Umesh R. Desai
- Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, VA 23298
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219
| |
Collapse
|
9
|
Cudjoe EK, Hassan ZH, Kang L, Reynolds PS, Fisher BJ, McCarter J, Sweeney C, Martin EJ, Middleton P, Ellenberg M, Fowler AA, Spiess BD, Brophy DF, Hawkridge AM, Natarajan R. Temporal map of the pig polytrauma plasma proteome with fluid resuscitation and intravenous vitamin C treatment. J Thromb Haemost 2019; 17:1827-1837. [PMID: 31322812 DOI: 10.1111/jth.14580] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 07/16/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Fluid resuscitation plays a prominent role in stabilizing trauma patients with hemorrhagic shock yet there remains uncertainty with regard to optimal administration time, volume, and fluid composition (e.g., whole blood, component, colloids) leading to complications such as trauma-induced coagulopathies (TIC), acidosis, and poor oxygen transport. Synthetic fluids in combination with antioxidants (e.g., vitamin C) may resolve some of these problems. OBJECTIVES We applied quantitative mass spectrometry-based proteomics [liquid chromatography-mass spectrometry (LC-MS/MS)] to map the effects of fluid resuscitation and intravenous vitamin C (VitC) in a pig model of polytrauma (hemorrhagic shock, tissue injury, liver reperfusion, hypothermia, and comminuted bone fracture). The goal was to determine the effects of VitC on plasma protein expression, with respect to changes associated with coagulation and trauma-induced coagulopathy (TIC). METHODS Longitudinal blood samples were drawn from nine male Sinclair pigs at baseline, 2 h post trauma, and 0.25, 2, and 4 h post fluid resuscitation with 500 mL hydroxyethyl starch. Pigs were treated intravenously (N = 3/treatment group) with saline, 50 mg VitC/kg (Lo-VitC), or 200 mg VitC/kg (Hi-VitC) during fluid resuscitation. RESULTS A total of 436 plasma proteins were quantified of which 136 changed following trauma and resuscitation; 34 were associated with coagulation, complement cascade, and glycolysis. Unexpectedly, Lo-VitC and Hi-VitC treatments stabilized ADAMTS13 levels by ~4-fold (P = .056) relative to saline and enhanced ADAMTS13/von Willebrand factor (VWF) cleavage efficiency based on LC-MS/MS evidence for the semitryptic VWF cleavage product (VWF1275-1286 ). CONCLUSIONS This study provides the first comprehensive map of trauma-induced changes to the plasma proteome, especially with respect to proteins driving the development of TIC.
Collapse
Affiliation(s)
- Emmanuel K Cudjoe
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Zaneera H Hassan
- Department of Pharmaceutics, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Penny S Reynolds
- Department of Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Bernard J Fisher
- Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Jacquelyn McCarter
- Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Christopher Sweeney
- Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Erika J Martin
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Paul Middleton
- Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Matthew Ellenberg
- Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Alpha A Fowler
- Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Bruce D Spiess
- Department of Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Donald F Brophy
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Adam M Hawkridge
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
- Department of Pharmaceutics, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
- Institute for Structural Biology, Drug Discovery, and Development, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Ramesh Natarajan
- Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia
| |
Collapse
|
10
|
Fowler AA, Truwit JD, Hite RD, Morris PE, DeWilde C, Priday A, Fisher B, Thacker LR, Natarajan R, Brophy DF, Sculthorpe R, Nanchal R, Syed A, Sturgill J, Martin GS, Sevransky J, Kashiouris M, Hamman S, Egan KF, Hastings A, Spencer W, Tench S, Mehkri O, Bindas J, Duggal A, Graf J, Zellner S, Yanny L, McPolin C, Hollrith T, Kramer D, Ojielo C, Damm T, Cassity E, Wieliczko A, Halquist M. Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients With Sepsis and Severe Acute Respiratory Failure: The CITRIS-ALI Randomized Clinical Trial. JAMA 2019; 322:1261-1270. [PMID: 31573637 PMCID: PMC6777268 DOI: 10.1001/jama.2019.11825] [Citation(s) in RCA: 526] [Impact Index Per Article: 105.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE Experimental data suggest that intravenous vitamin C may attenuate inflammation and vascular injury associated with sepsis and acute respiratory distress syndrome (ARDS). OBJECTIVE To determine the effect of intravenous vitamin C infusion on organ failure scores and biological markers of inflammation and vascular injury in patients with sepsis and ARDS. DESIGN, SETTING, AND PARTICIPANTS The CITRIS-ALI trial was a randomized, double-blind, placebo-controlled, multicenter trial conducted in 7 medical intensive care units in the United States, enrolling patients (N = 167) with sepsis and ARDS present for less than 24 hours. The study was conducted from September 2014 to November 2017, and final follow-up was January 2018. INTERVENTIONS Patients were randomly assigned to receive intravenous infusion of vitamin C (50 mg/kg in dextrose 5% in water, n = 84) or placebo (dextrose 5% in water only, n = 83) every 6 hours for 96 hours. MAIN OUTCOMES AND MEASURES The primary outcomes were change in organ failure as assessed by a modified Sequential Organ Failure Assessment score (range, 0-20, with higher scores indicating more dysfunction) from baseline to 96 hours, and plasma biomarkers of inflammation (C-reactive protein levels) and vascular injury (thrombomodulin levels) measured at 0, 48, 96, and 168 hours. RESULTS Among 167 randomized patients (mean [SD] age, 54.8 years [16.7]; 90 men [54%]), 103 (62%) completed the study to day 60. There were no significant differences between the vitamin C and placebo groups in the primary end points of change in mean modified Sequential Organ Failure Assessment score from baseline to 96 hours (from 9.8 to 6.8 in the vitamin C group [3 points] and from 10.3 to 6.8 in the placebo group [3.5 points]; difference, -0.10; 95% CI, -1.23 to 1.03; P = .86) or in C-reactive protein levels (54.1 vs 46.1 μg/mL; difference, 7.94 μg/mL; 95% CI, -8.2 to 24.11; P = .33) and thrombomodulin levels (14.5 vs 13.8 ng/mL; difference, 0.69 ng/mL; 95% CI, -2.8 to 4.2; P = .70) at 168 hours. CONCLUSIONS AND RELEVANCE In this preliminary study of patients with sepsis and ARDS, a 96-hour infusion of vitamin C compared with placebo did not significantly improve organ dysfunction scores or alter markers of inflammation and vascular injury. Further research is needed to evaluate the potential role of vitamin C for other outcomes in sepsis and ARDS. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02106975.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Rahul Nanchal
- Froedtert Hospital and the Medical College of Wisconsin, Milwaukee
| | - Aamer Syed
- Virginia Commonwealth University, Richmond
| | | | | | | | | | | | | | | | | | | | | | | | | | - Jeanette Graf
- Froedtert Hospital and the Medical College of Wisconsin, Milwaukee
| | | | - Lynda Yanny
- Froedtert Hospital and the Medical College of Wisconsin, Milwaukee
| | | | - Tonya Hollrith
- Froedtert Hospital and the Medical College of Wisconsin, Milwaukee
| | - David Kramer
- Froedtert Hospital and the Medical College of Wisconsin, Milwaukee
| | - Charles Ojielo
- Froedtert Hospital and the Medical College of Wisconsin, Milwaukee
| | - Tessa Damm
- Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | | | | | | |
Collapse
|
11
|
Patel‐Hett S, Martin EJ, Mohammed BM, Rakhe S, Sun P, Barrett JC, Nolte ME, Kuhn J, Pittman DD, Murphy JE, Brophy DF. Marstacimab, a tissue factor pathway inhibitor neutralizing antibody, improves coagulation parameters of ex vivo dosed haemophilic blood and plasmas. Haemophilia 2019; 25:797-806. [DOI: 10.1111/hae.13820] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/18/2019] [Accepted: 06/21/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Sunita Patel‐Hett
- Rare Disease Research Unit Early Clinical Development, Pfizer Inc Cambridge MA USA
| | - Erika J. Martin
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science Virginia Commonwealth University (VCU) Richmond VA USA
| | - Bassem M. Mohammed
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science Virginia Commonwealth University (VCU) Richmond VA USA
- Department of Clinical Pharmacy, Faculty of Pharmacy Cairo University Cairo Egypt
- Department of Pathology, Microbiology, and Immunology Vanderbilt University Medical Center Nashville TN USA
| | - Swapnil Rakhe
- Rare Disease Research Unit Early Clinical Development, Pfizer Inc Cambridge MA USA
| | - Pengling Sun
- Rare Disease Research Unit Early Clinical Development, Pfizer Inc Cambridge MA USA
| | - John C. Barrett
- Division of Hematology/Oncology, Department of Internal Medicine VCU Richmond VA USA
| | - Melinda E. Nolte
- Division of Hematology/Oncology, Department of Internal Medicine VCU Richmond VA USA
| | - Janice Kuhn
- Division of Hematology/Oncology, Department of Internal Medicine VCU Richmond VA USA
| | - Debra D. Pittman
- Rare Disease Research Unit Early Clinical Development, Pfizer Inc Cambridge MA USA
| | - John E. Murphy
- Rare Disease Research Unit Early Clinical Development, Pfizer Inc Cambridge MA USA
| | - Donald F. Brophy
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science Virginia Commonwealth University (VCU) Richmond VA USA
| |
Collapse
|
12
|
Liebrecht LK, Newton J, Martin EJ, Wickramaratne N, Jayaraman S, Han J, Aboutanos M, Brophy DF, Mangino MJ. Effects of a novel low volume resuscitation solutions on coagulation and platelet function. PLoS One 2019; 14:e0215386. [PMID: 31042735 PMCID: PMC6493729 DOI: 10.1371/journal.pone.0215386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/01/2019] [Indexed: 11/18/2022] Open
Abstract
Background Novel crystalloid solutions containing polyethylene glycol polymers (PEG-20k) produce dramatic resuscitation effects but dose-dependently produce a hypocoagulative state. The objective of this study was to examine possible mechanisms of this effect. Based on previous thromboelastography data, we hypothesize the effect is largely due to platelet interactions with the polymers. Methods Whole citrated blood from healthy volunteers was diluted ex-vivo 10% with crystalloids and tested for coagulation and platelet function. The specific tests included prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen and von Willebrand factor (vWf) activity, thrombin generation, thromboelastography with and without platelet mapping, platelet flow cytometry, and erythrocyte sedimentation rate. Findings Fibrinogen and vWF activities, PT, and aPTT were not affected by PEG-20k dilutions. Thrombin activity was mildly suppressed with PEG-20k (TTP- 20%). Platelet mapping demonstrated significantly greater % inhibition of both ADP and arachidonic acid-induced platelet aggregation with PEG-20k, but direct ADP-activated gpIIa/IIIb (PAC1) and P-selectin (CD62P) binding site expression was not altered. Mild dose-dependent suppression of TEG-MA was seen with PEG-20k using platelet poor plasma. Erythrocyte Sedimentation Rates (ESR) were dramatically accelerated after dilution with 10% PEG-20k, which was competitively blocked by smaller PEG polymers, suggesting nonspecific PEG-20k cell binding effects. Conclusions PEG-20k creates a mild hypocoagulative state in whole blood at concentrations ≥10%, which may be due to platelet-PEG interactions at the IIb/IIIa interface with lesser effects on fibrin polymerization. This interaction may cause a functional thrombasthenia induced by nonspecific platelet surface passivation by the PEG polymer.
Collapse
Affiliation(s)
- Loren K. Liebrecht
- Department of Surgery, Division of Acute Care Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Jason Newton
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Erika J. Martin
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA, United States of America
| | - Niluka Wickramaratne
- Department of Surgery, Division of Acute Care Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Sudha Jayaraman
- Department of Surgery, Division of Acute Care Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Jinfeng Han
- Department of Surgery, Division of Acute Care Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Michel Aboutanos
- Department of Surgery, Division of Acute Care Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Donald F. Brophy
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA, United States of America
| | - Martin J. Mangino
- Department of Surgery, Division of Acute Care Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
- Department of Physiology and Biophysics, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
- Department of Emergency Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
- * E-mail:
| |
Collapse
|
13
|
St John AE, Newton JC, Martin EJ, Mohammed BM, Contaifer D, Saunders JL, Brophy GM, Spiess BD, Ward KR, Brophy DF, López JA, White NJ. Platelets retain inducible alpha granule secretion by P-selectin expression but exhibit mechanical dysfunction during trauma-induced coagulopathy. J Thromb Haemost 2019; 17:771-781. [PMID: 30784176 PMCID: PMC6494686 DOI: 10.1111/jth.14414] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Indexed: 01/27/2023]
Abstract
Essentials Platelets in trauma-induced coagulopathy (TIC) are impaired, but the mechanism is not known. We performed comprehensive longitudinal platelet function testing in trauma patient samples. Platelets in TIC are widely impaired early after injury, but platelet activatability is intact. This suggests a mechanism of transient platelet cytoskeletal/integrin dysfunction during TIC. SUMMARY: Background Trauma-induced coagulopathy (TIC) is a common and deadly bleeding disorder. Platelet dysfunction is present during TIC, but its mechanisms remain unclear. Platelets are currently thought to become "exhausted," a state in which they have released their granule contents and can no longer aggregate or contract. Methods This prospective observational cohort study tested the hypothesis that platelet exhaustion is present during TIC and characterized the early time course of platelet dysfunction. Blood was collected from 95 adult trauma patients at a Level I trauma center at time of Emergency Department arrival and several time points over 72 h. Platelet activation state and function were characterized using CD62P (P-selectin) and PAC-1 surface membrane staining, platelet function analyzer (PFA-100), aggregometry, viscoelastic platelet mapping, and, to test for exhaustion, their ability to express CD62P after ex vivo adenosine diphosphate (ADP) agonism. Platelet function was compared between patients with and without TIC, defined by prothrombin time ≥18 s. Results Platelets in TIC showed no initial increase in their level of surface activation markers or impairment of their capacity to express CD62P in response to ADP stimulation. However, TIC platelets were impaired in nearly all functional assays, spanning adhesion, aggregation, and contraction. These effects largely remained after controlling for platelet count and fibrinogen concentration and resolved after 8 h. Conclusion The TIC platelets exhibit early impairment of adhesion, aggregation, and contraction with retained alpha granule secretion ability, suggesting a specific mechanism of cytoskeletal or integrin dysfunction that is not a result of more general platelet exhaustion.
Collapse
Affiliation(s)
- Alexander E St John
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
- Bloodworks Northwest Research Institute, Seattle, WA, USA
| | - Jason C Newton
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University, Richmond, VA, USA
| | - Erika J Martin
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - Bassem M Mohammed
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
- Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Daniel Contaifer
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - Jessica L Saunders
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - Gretchen M Brophy
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Bruce D Spiess
- Department of Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Kevin R Ward
- Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - Donald F Brophy
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - José A López
- Bloodworks Northwest Research Institute, Seattle, WA, USA
- Division of Hematology, University of Washington, Seattle, WA, USA
| | - Nathan J White
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
- Bloodworks Northwest Research Institute, Seattle, WA, USA
| |
Collapse
|
14
|
Brophy DF, Martin EJ, Kuhn J. Use of global assays to monitor emicizumab prophylactic therapy in patients with haemophilia A with inhibitors. Haemophilia 2019; 25:e121-e123. [DOI: 10.1111/hae.13689] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/18/2018] [Accepted: 01/13/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Donald F. Brophy
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science Virginia Commonwealth University (VCU) School of Pharmacy Richmond Virginia
| | - Erika J. Martin
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science Virginia Commonwealth University (VCU) School of Pharmacy Richmond Virginia
| | - Janice Kuhn
- Division of Hematology/Oncology VCU School of Medicine Richmond Virginia
| |
Collapse
|
15
|
Boothello RS, Patel NJ, Sharon C, Abdelfadiel EI, Morla S, Brophy DF, Lippman HR, Desai UR, Patel BB. A Unique Nonsaccharide Mimetic of Heparin Hexasaccharide Inhibits Colon Cancer Stem Cells via p38 MAP Kinase Activation. Mol Cancer Ther 2019; 18:51-61. [PMID: 30337351 PMCID: PMC6332501 DOI: 10.1158/1535-7163.mct-18-0104] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 07/23/2018] [Accepted: 10/12/2018] [Indexed: 12/13/2022]
Abstract
Targeting of cancer stem cells (CSC) is expected to be a paradigm-shifting approach for the treatment of cancers. Cell surface proteoglycans bearing sulfated glycosaminoglycan (GAG) chains are known to play a critical role in the regulation of stem cell fate. Here, we show for the first time that G2.2, a sulfated nonsaccharide GAG mimetic (NSGM) of heparin hexasaccharide, selectively inhibits colonic CSCs in vivo G2.2-reduced CSCs (CD133+/CXCR4+, Dual hi) induced HT-29 and HCT 116 colon xenografts' growth in a dose-dependent fashion. G2.2 also significantly delayed the growth of colon xenograft further enriched in CSCs following oxaliplatin and 5-fluorouracil treatment compared with vehicle-treated xenograft controls. In fact, G2.2 robustly inhibited CSCs' abundance (measured by levels of CSC markers, e.g., CD133, DCMLK1, LGR5, and LRIG1) and self-renewal (quaternary spheroids) in colon cancer xenografts. Intriguingly, G2.2 selectively induced apoptosis in the Dual hi CSCs in vivo eluding to its CSC targeting effects. More importantly, G2.2 displayed none to minimal toxicity as observed through morphologic and biochemical studies of vital organ functions, blood coagulation profile, and ex vivo analyses of normal intestinal (and bone marrow) progenitor cell growth. Through extensive in vitro, in vivo, and ex vivo mechanistic studies, we showed that G2.2's inhibition of CSC self-renewal was mediated through activation of p38α, uncovering important signaling that can be targeted to deplete CSCs selectively while minimizing host toxicity. Hence, G2.2 represents a first-in-class (NSGM) anticancer agent to reduce colorectal CSCs.
Collapse
Affiliation(s)
- Rio S Boothello
- Division of Hematology and Oncology, Department of Internal Medicine, Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
- McGuire VA Medical Center, Richmond, Virginia
| | - Nirmita J Patel
- McGuire VA Medical Center, Richmond, Virginia
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, Virginia
- Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, Virginia
| | | | - Elsamani I Abdelfadiel
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, Virginia
| | - Shravan Morla
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, Virginia
- Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, Virginia
| | - Donald F Brophy
- Department of Pharmacotherapy and Outcomes Sciences, Virginia Commonwealth University, Richmond, Virginia
| | | | - Umesh R Desai
- Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, Virginia.
- Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, Virginia
| | - Bhaumik B Patel
- Division of Hematology and Oncology, Department of Internal Medicine, Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia.
- McGuire VA Medical Center, Richmond, Virginia
| |
Collapse
|
16
|
Liebrecht LK, Newton J, Martin EJ, Wickramaratne N, Jayaraman S, Han J, Aboutanos M, Brophy DF, Mangino MJ. Thromboelastographic analysis of novel polyethylene glycol based low volume resuscitation solutions. PLoS One 2018; 13:e0207147. [PMID: 30439979 PMCID: PMC6237338 DOI: 10.1371/journal.pone.0207147] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/25/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Low volume resuscitation (LVR) in shock prevents deleterious effects of crystalloid loading in pre-hospital settings. Polyethylene glycol 20,000 (PEG-20k) based LVR solutions are 20-fold more effective at maintaining perfusion and survival in shock compared to conventional crystalloids. The aim of this study was to determine coagulation and platelet function of whole blood treated with 10% PEG-20k. METHODS Citrated blood from volunteers (n = 25) or early admission severely injured trauma patients (n = 9) were diluted 10% with various LVR solutions in a matched design with a paired volume control (saline), and studied using thromboelastography (TEG). FINDINGS In healthy volunteers and patients, 10% PEG-20k significantly increased clot amplification time (k), decreased propagation (angle), maximal clot size and strength (MA), and the overall coagulation index (CI), but not clot initiation (R) or fibrinolysis (Ly30), relative to paired saline dilutional controls. Clinically, K, angle, and MA were just outside of the normal limits in volunteers but not in patients. No statistical differences existed between PEG-20k and Hextend (HES) in either patient population. In a dose response series using volunteer blood, all effects of 10% PEG-20k on TEG were reversed and normalized by lower concentrations (7.5% and 5%). Furthermore, 7.5% PEG-20k produced similar resuscitation effects as 10% PEG in rodent hemorrhagic shock models (n = 5). CONCLUSIONS In conclusion, PEG-20k based LVR solutions produced a dose-dependent minor hypocoagulative state, possibly associated with changes in clot propagation and platelet function, which can be reversed by dose reduction in concentration while providing superior LVR, microvascular rescue, and lactate clearance compared to saline or starch.
Collapse
Affiliation(s)
- Loren K. Liebrecht
- Department of Surgery, Division of Acute Care Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, United States of America
| | - Jason Newton
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, United States of America
| | - Erika J. Martin
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, United States of America
| | - Nina Wickramaratne
- Department of Surgery, Division of Acute Care Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, United States of America
| | - Sudha Jayaraman
- Department of Surgery, Division of Acute Care Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, United States of America
| | - Jinfeng Han
- Department of Surgery, Division of Acute Care Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, United States of America
| | - Michel Aboutanos
- Department of Surgery, Division of Acute Care Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, United States of America
| | - Donald F. Brophy
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, United States of America
| | - Martin J. Mangino
- Department of Surgery, Division of Acute Care Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, United States of America
- Department of Physiology and Biophysics, Virginia Commonwealth University School of Medicine, Richmond, Virginia, United States of America
- Department of Emergency Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, United States of America
- * E-mail:
| |
Collapse
|
17
|
|
18
|
Reynolds PS, McCarter J, Sweeney C, Mohammed BM, Brophy DF, Fisher B, Martin EJ, Natarajan R. Informing efficient pilot development of animal trauma models through quality improvement strategies. Lab Anim 2018; 53:394-404. [PMID: 30296892 DOI: 10.1177/0023677218802999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Poor quality data in preclinical trials can result from inconsistent and unstandardized experimental processes. Unpredictable pre-intervention variability generates unreliable data, biases outcomes and results in needless waste of animals and resources. We applied Define-Measure-Analyse-Improve-Control (DMAIC) quality improvement processes to pilot development of a swine model of trauma, haemorrhagic shock and coagulopathy. The goal was to reduce variability through protocol standardization and error reduction. Six male Sinclair swine were sequentially anesthetized, intubated, mechanically ventilated and instrumented, then subjected to multiple-hit injury, followed by fluid resuscitation monitoring and coagulation testing. Experimental tasks were defined and mapped. Performance measures were task performance times, subject stabilization time and number of task execution errors. Process improvement was assessed by reduced times and errors, and subject stability at target physiological values. Previously-overlooked performance errors and deficiencies were identified. 'Mistake-proofing' actions included personnel retraining, revisions of standard operating procedures and use of checklists. The quality improvement pilot trial produced a stable model with reduced protocol deviations. Data quality can be improved and animal waste minimized, if experimental planning incorporates strategies to ensure protocol adherence and reduced operator performance variation and errors. Properly designed pilot trials can be essential components of refinement and reduction strategies in animal-based research.
Collapse
Affiliation(s)
- Penny S Reynolds
- 1 Department of Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, USA.,2 Department of Anesthesiology, University of Florida, Gainesville, USA
| | - Jacquelyn McCarter
- 3 Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, USA.,4 Department of Neuroscience, Virginia Commonwealth University Medical Center, Richmond, USA
| | - Christopher Sweeney
- 3 Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, USA.,4 Department of Neuroscience, Virginia Commonwealth University Medical Center, Richmond, USA
| | - Bassem M Mohammed
- 5 Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University Medical Center, Richmond, USA.,6 Department of Pathology, Vanderbilt University Medical Center, Nashville, USA.,7 Department of Clinical Pharmacy, Cairo University, Egypt
| | - Donald F Brophy
- 5 Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University Medical Center, Richmond, USA
| | - Bernard Fisher
- 3 Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, USA
| | - Erika J Martin
- 5 Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University Medical Center, Richmond, USA
| | - Ramesh Natarajan
- 3 Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, USA
| |
Collapse
|
19
|
Brophy DF, Martin EJ, Ninivaggi M, Mohammed BM, Barrett JC, Kuhn J, Nolte ME, Waters EK, Ezban M. Evaluating the thrombin generation profiles of four different rFVIII products in FVIII-deficient plasma using FIXa and FXIa activation. Haemophilia 2018; 24:815-822. [DOI: 10.1111/hae.13597] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/11/2018] [Accepted: 07/11/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Donald F. Brophy
- Coagulation Advancement Laboratory; Department of Pharmacotherapy & Outcomes Science; Virginia Commonwealth University (VCU); Richmond Virginia
| | - Erika J. Martin
- Coagulation Advancement Laboratory; Department of Pharmacotherapy & Outcomes Science; Virginia Commonwealth University (VCU); Richmond Virginia
| | | | - Bassem M. Mohammed
- Coagulation Advancement Laboratory; Department of Pharmacotherapy & Outcomes Science; Virginia Commonwealth University (VCU); Richmond Virginia
- Department of Clinical Pharmacy; Faculty of Pharmacy; Cairo University; Cairo Egypt
| | - John C. Barrett
- Internal Medicine/Division of Haematology/Oncology; VCU; Richmond Virginia
| | - Janice Kuhn
- Internal Medicine/Division of Haematology/Oncology; VCU; Richmond Virginia
| | - Melinda E. Nolte
- Internal Medicine/Division of Haematology/Oncology; VCU; Richmond Virginia
| | | | | |
Collapse
|
20
|
Reynolds PS, Fisher BJ, McCarter J, Sweeney C, Martin EJ, Middleton P, Ellenberg M, Fowler E, Brophy DF, Fowler AA, Spiess BD, Natarajan R. Interventional vitamin C: A strategy for attenuation of coagulopathy and inflammation in a swine multiple injuries model. J Trauma Acute Care Surg 2018; 85:S57-S67. [PMID: 29538225 DOI: 10.1097/ta.0000000000001844] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Coagulopathy and inflammation induced by hemorrhagic shock and traumatic injury are associated with increased mortality and morbidity. Vitamin C (VitC) is an antioxidant with potential protective effects on the proinflammatory and procoagulant pathways. We hypothesized that high-dose VitC administered as a supplement to fluid resuscitation would attenuate inflammation, coagulation dysfunction, and end-organ tissue damage in a swine model of multiple injuries and hemorrhage. METHODS Male Sinclair swine (n = 24; mean body weight, 27 kg) were anesthetized, intubated, mechanically ventilated, and instrumented for physiologic monitoring. Following stabilization, swine were subjected to shock/traumatic injury (hypothermia, liver ischemia and reperfusion, comminuted femur fracture, hemorrhagic hypotension), resuscitated with 500 mL of hydroxyethyl starch, and randomized to receive either intravenous normal saline (NS), low-dose VitC (50 mg/kg; LO), or high-dose VitC (200 mg/kg; HI). Hemodynamics, blood chemistry, hematology, and coagulation function (ROTEM) were monitored to 4 hours postresuscitation. Histological and molecular analyses were obtained for liver, kidney, and lung. RESULTS Compared with VitC animals, NS swine showed significant histological end-organ damage, elevated acute lung injury scores, and increased mRNA expression of tissue proinflammatory mediators (IL-1β, IL-8, TNFα), plasminogen activation inhibitor-1 and tissue factor. There were no statistically significant differences between treatment groups on mean arterial pressure or univariate measures of coagulation function; however, NS showed impaired multivariate clotting function at 4 hours. CONCLUSION Although correction of coagulation dysfunction was modest, intravenous high-dose VitC may mitigate the proinflammatory/procoagulant response that contributes to multiple organ failure following acute severe multiple injuries. LEVEL OF EVIDENCE Prospective randomized controlled blinded trial study, Preclinical (animal-based).
Collapse
Affiliation(s)
- Penny S Reynolds
- From the Department of Anesthesiology (P.S.R., B.D.S.), Department of Internal Medicine (B.J.F., J.M., C.S., P.M., M.E., E.F., A.A.F., R.N.), Department of Pharmacotherapy and Outcomes Science (E.J.M., D.F.B.), Virginia Commonwealth University, Richmond, Virginia; Department of Anesthesiology (P.S.R., B.D.S.), University of Florida, Gainesville, Florida; and Naval Medical Center Portsmouth (R.N.), Portsmouth, Virginia
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Shah KB, Gunda S, Emani S, Kanwar MK, Uriel N, Colombo PC, Uber PA, Sears ML, Chuang J, Farrar DJ, Brophy DF, Smallfield GB. Multicenter Evaluation of Octreotide as Secondary Prophylaxis in Patients With Left Ventricular Assist Devices and Gastrointestinal Bleeding. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.117.004500. [DOI: 10.1161/circheartfailure.117.004500] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 10/19/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Keyur B. Shah
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Sampath Gunda
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Sitaramesh Emani
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Manreet K. Kanwar
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Nir Uriel
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Paolo C. Colombo
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Patricia A. Uber
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Melissa L. Sears
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Joyce Chuang
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - David J. Farrar
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - Donald F. Brophy
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| | - George B. Smallfield
- From The Pauley Heart Center (K.B.S., S.G., P.A.U., M.L.S.), Department of Pharmacotherapy and Outcomes Research (D.F.B.), and Division of Gastroenterology (G.B.S.), Virginia Commonwealth University, Richmond; Division of Cardiovascular Medicine, The Ohio State University, Columbus (S.E.); McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA (M.K.K.); Division of Cardiology, University of Chicago, IL (N.U.); Division of Cardiology, Columbia University, New York, NY (P.C.C.)
| |
Collapse
|
22
|
Brophy DF, Martin EJ, Mohammed BM, Barrett JC, Kuhn JG, Nolte ME, Wiinberg B, Holmberg HL, Lund J, Salbo R, Waters EK. Modulation of the activated protein C pathway in severe haemophilia A patients: The effects of thrombomodulin and a factor V-stabilizing fab. Haemophilia 2017; 23:941-947. [PMID: 28750471 DOI: 10.1111/hae.13300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The thrombomodulin (TM)/activated protein C (APC) system is a key regulator of haemostasis, limiting amplification and propagation of the formed blood clot to the injury site. Dampening APC's inhibition of factor V (FV) and factor VIII (FVIII) may be a future strategy in developing next-generation therapeutic targets for haemophilia treatment. AIMS To determine ex vivo the respective concentration-dependent effects of TM and a FV-stabilizing Fab on the APC regulatory pathway in severe FVIII-deficient blood and plasma. METHODS Ten severe haemophilia A subjects and one healthy control were enrolled. Blood was spiked with TM (0, 1, 2.5, 5, 10, 20.0 nmol/L) and FV-stabilizing Fab (0, 3, 15, 65, 300 nmol/L). The respective effects were compared to FVIII concentrations of 3- and 10% using rotational thromboelastometry clotting time (CT) and thrombin generation analysis (TGA). RESULTS With 1 and 2.5 nmol/L TM, 5% FVIII resulted in CT similar to the absence of TM, suggesting it completely reversed the effect of APC. Increasing TM concentrations also reduced peak thrombin generation and ETP. The addition of 300 nmol/L FV-stabilizing Fab returned CT to nearly baseline, but for most subjects was less than the effects of 3- or 10% FVIII. The FV-stabilizing Fab produced similar or greater thrombin generation compared to samples with 3- or 10% FVIII. CONCLUSIONS The FV-stabilizing Fab resulted in enhanced CT and TGA parameters consistent with FVIII levels of 3- and 10%. Additional studies need to further characterize how modulating the APC pathway may prove beneficial in developing new haemophilia drug targets.
Collapse
Affiliation(s)
- D F Brophy
- Coagulation Advancement Laboratory, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University (VCU), Richmond, VA, USA
| | - E J Martin
- Coagulation Advancement Laboratory, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University (VCU), Richmond, VA, USA
| | - B M Mohammed
- Coagulation Advancement Laboratory, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University (VCU), Richmond, VA, USA.,Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - J C Barrett
- Internal Medicine/Division of Hematology/Oncology, VCU, Richmond, VA, USA
| | - J G Kuhn
- Internal Medicine/Division of Hematology/Oncology, VCU, Richmond, VA, USA
| | - M E Nolte
- Internal Medicine/Division of Hematology/Oncology, VCU, Richmond, VA, USA
| | | | | | - J Lund
- Novo Nordisk A/S, Bagsvaerd, Denmark
| | - R Salbo
- Novo Nordisk A/S, Bagsvaerd, Denmark
| | | |
Collapse
|
23
|
|
24
|
Mohammed BM, Sanford KW, Fisher BJ, Martin EJ, Contaifer Jr D, Warncke UO, Wijesinghe DS, Chalfant CE, Brophy DF, Fowler III AA, Natarajan R. Impact of high dose vitamin C on platelet function. World J Crit Care Med 2017; 6:37-47. [PMID: 28224106 PMCID: PMC5295168 DOI: 10.5492/wjccm.v6.i1.37] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 09/15/2016] [Accepted: 11/02/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To examine the effect of high doses of vitamin C (VitC) on ex vivo human platelets (PLTs).
METHODS Platelet concentrates collected for therapeutic or prophylactic transfusions were exposed to: (1) normal saline (control); (2) 0.3 mmol/L VitC (Lo VitC); or (3) 3 mmol/L VitC (Hi VitC, final concentrations) and stored appropriately. The VitC additive was preservative-free buffered ascorbic acid in water, pH 5.5 to 7.0, adjusted with sodium bicarbonate and sodium hydroxide. The doses of VitC used here correspond to plasma VitC levels reported in recently completed clinical trials. Prior to supplementation, a baseline sample was collected for analysis. PLTs were sampled again on days 2, 5 and 8 and assayed for changes in PLT function by: Thromboelastography (TEG), for changes in viscoelastic properties; aggregometry, for PLT aggregation and adenosine triphosphate (ATP) secretion in response to collagen or adenosine diphosphate (ADP); and flow cytometry, for changes in expression of CD-31, CD41a, CD62p and CD63. In addition, PLT intracellular VitC content was measured using a fluorimetric assay for ascorbic acid and PLT poor plasma was used for plasma coagulation tests [prothrombin time (PT), partial thrombplastin time (PTT), functional fibrinogen] and Lipidomics analysis (UPLC ESI-MS/MS).
RESULTS VitC supplementation significantly increased PLTs intracellular ascorbic acid levels from 1.2 mmol/L at baseline to 3.2 mmol/L (Lo VitC) and 15.7 mmol/L (Hi VitC, P < 0.05). VitC supplementation did not significantly change PT and PTT values, or functional fibrinogen levels over the 8 d exposure period (P > 0.05). PLT function assayed by TEG, aggregometry and flow cytometry was not significantly altered by Lo or Hi VitC for up to 5 d. However, PLTs exposed to 3 mmol/L VitC for 8 d demonstrated significantly increased R and K times by TEG and a decrease in the α-angle (P < 0.05). There was also a fall of 20 mm in maximum amplitude associated with the Hi VitC compared to both baseline and day 8 saline controls. Platelet aggregation studies, showed uniform declines in collagen and ADP-induced platelet aggregations over the 8-d study period in all three groups (P > 0.05). Collagen and ADP-induced ATP secretion was also not different between the three groups (P > 0.05). Finally, VitC at the higher dose (3 mmol/L) also induced the release of several eicosanoids including thromboxane B2 and prostaglandin E2, as well as products of arachidonic acid metabolism via the lipoxygenases pathway such as 11-/12-/15-hydroxyicosatetraenoic acid (P < 0.05).
CONCLUSION Alterations in PLT function by exposure to 3 mmol/L VitC for 8 d suggest that caution should be exerted with prolonged use of intravenous high dose VitC.
Collapse
|
25
|
Contaifer D, Carl DE, Warncke UO, Martin EJ, Mohammed BM, Van Tassell B, Brophy DF, Chalfant CE, Wijesinghe DS. Unsupervised analysis of combined lipid and coagulation data reveals coagulopathy subtypes among dialysis patients. J Lipid Res 2016; 58:586-599. [PMID: 27993949 DOI: 10.1194/jlr.p068833] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 12/01/2016] [Indexed: 01/22/2023] Open
Abstract
Hemodialysis (HD) and peritoneal dialysis (PD) are the primary means of managing end stage renal disease (ESRD). However, these treatment modalities are associated with the onset of coagulation abnormalities. Effective management of coagulation risk among these patients requires the identification of surrogate markers that provide an early indication of the coagulation abnormalities. The role of sphingolipids in the manifestation and prediction of coagulation abnormalities among dialysis patients have never been investigated. Herein, we report the first instance of an in depth investigation into the sphingolipid changes among ESRD patients undergoing HD and PD. The results reveal distinct differences in terms of perturbations to specific sphingolipid biosynthetic pathways that are highly dependent on the treatment modality. Our studies also demonstrated strong correlation between specific sphingolipids and coagulation parameters, such as HexCer(d18:1/26:0) and maximal amplitude (MA), SM(d18:1/24:1) and tissue factor pathway inhibitor, and sphingosine 1-phosphate d18:1 and FX (Spearman ρ of 0.93, 0.89, and -0.89, respectively). Furthermore, our study revealed the potential for using HexCer(d18:1/22:0), HexCer(d18:1/24:0), and HexCer(d18:1/26:0) (r2 = 0.71, 0.82, and 0.63, respectively) and coagulation parameter MA (r2 = 0.7) for successful diagnosis of differential coagulopathies among ESRD patients undergoing HD, providing an opportunity toward personalized disease management.
Collapse
Affiliation(s)
- Daniel Contaifer
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University (VCU), Richmond, VA
| | - Daniel E Carl
- Departments of Internal Medicine, Virginia Commonwealth University (VCU), Richmond, VA
| | - Urszula Osinska Warncke
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University (VCU), Richmond, VA
| | - Erika J Martin
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University (VCU), Richmond, VA
| | - Bassem M Mohammed
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University (VCU), Richmond, VA
| | - Benjamin Van Tassell
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University (VCU), Richmond, VA
| | - Donald F Brophy
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University (VCU), Richmond, VA
| | - Charles E Chalfant
- Biochemistry and Molecular Biology, Virginia Commonwealth University (VCU), Richmond, VA .,Hunter Holmes McGuire Veterans Administration Medical Center, VCU Johnson Center for Critical Care Research, VCU Massey Cancer Center, and VCU Institute of Molecular Medicine, Richmond, VA
| | - Dayanjan S Wijesinghe
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University (VCU), Richmond, VA .,Surgery, Virginia Commonwealth University (VCU), Richmond, VA
| |
Collapse
|
26
|
Abstract
Objective:To review the potential risks of administering intravenous iron to patients with infection.Data Sources:Literature was accessed through MEDLINE (1977–June 2007) and Google Scholar, using the terms intravenous iron, iron sucrose, ferric gluconate, iron dextran, and infection. In addition, reference citations from publications identified were reviewed.Study Selection and Data Extraction:All English-language articles identified from the data sources were evaluated. Studies that provided data relevant to the objective were used, including in vitro and animal studies.Data Synthesis:The role of iron in bacterial growth and the pathophysiology of cellular immunity create legitimate, yet theoretical, concerns that active infection may be exacerbated by the administration of intravenous iron. Human data relating to this issue are limited. A few small, human studies in a population with chronic kidney disease suggest a possible increased risk of developing an infection associated with intravenous iron; however, prospective human data directly linking intravenous iron to exacerbation of existing infection or infection-related mortality are lacking. In vitro data suggest that increased transferrin saturation related to iron administration may result in polymorphonuclear leukocyte dysfunction and decreased inhibition of bacterial growth. Sparse animal data have linked intravenous iron therapy with morbidity and mortality in sepsis models.Conclusions:Despite the limited human data, careful consideration of risk versus benefit should be used when administering intravenous iron to patients with ongoing infection. Additional clinical data are needed to determine whether intravenous iron administration worsens outcomes of patients with infection.
Collapse
Affiliation(s)
- Lena Maynor
- Department of Pharmacy Services, Virginia Commonwealth University Health System, Richmond, VA 23298, USA
| | | |
Collapse
|
27
|
White NJ, Wang Y, Fu X, Cardenas JC, Martin EJ, Brophy DF, Wade CE, Wang X, St John AE, Lim EB, Stern SA, Ward KR, López JA, Chung D. Post-translational oxidative modification of fibrinogen is associated with coagulopathy after traumatic injury. Free Radic Biol Med 2016; 96:181-9. [PMID: 27105953 PMCID: PMC4912420 DOI: 10.1016/j.freeradbiomed.2016.04.023] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 04/13/2016] [Accepted: 04/17/2016] [Indexed: 12/16/2022]
Abstract
Victims of trauma often develop impaired blood clot formation (coagulopathy) that contributes to bleeding and mortality. Fibrin polymerization is one critical component of clot formation that can be impacted by post-translational oxidative modifications of fibrinogen after exposure to oxidants. In vitro evidence suggests that Aα-C domain methionine sulfoxide formation, in particular, can induce conformational changes that prevent lateral aggregation of fibrin protofibrils during polymerization. We used mass spectrometry of plasma from trauma patients to find that fibrinogen Aα-C domain methionine sulfoxide content was selectively-increased in patients with coagulopathy vs. those without coagulopathy. This evidence supports a novel linkage between oxidative stress, coagulopathy, and bleeding after injury.
Collapse
Affiliation(s)
- Nathan J White
- University of Washington Division of Emergency Medicine, Harborview Medical Center, Box 359702, 325 9th Avenue, Seattle, WA 98104, USA; Bloodworks Northwest Research Institute, 1551 Eastlake Avenue E, Seattle, WA 98102, USA.
| | - Yi Wang
- Bloodworks Northwest Research Institute, 1551 Eastlake Avenue E, Seattle, WA 98102, USA
| | - Xiaoyun Fu
- Bloodworks Northwest Research Institute, 1551 Eastlake Avenue E, Seattle, WA 98102, USA
| | - Jessica C Cardenas
- Center for Translational Injury Research and Division of Acute Care Surgery, University of Texas Health Science Center at Houston, 6431 Fannin St. MSB 5.240, Houston, TX 77030, USA
| | - Erika J Martin
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, 410 N 12th Street, P.O. Box 980533, Richmond, VA 23298, USA
| | - Donald F Brophy
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, 410 N 12th Street, P.O. Box 980533, Richmond, VA 23298, USA
| | - Charles E Wade
- Center for Translational Injury Research and Division of Acute Care Surgery, University of Texas Health Science Center at Houston, 6431 Fannin St. MSB 5.240, Houston, TX 77030, USA
| | - Xu Wang
- University of Washington Division of Emergency Medicine, Harborview Medical Center, Box 359702, 325 9th Avenue, Seattle, WA 98104, USA
| | - Alexander E St John
- University of Washington Division of Emergency Medicine, Harborview Medical Center, Box 359702, 325 9th Avenue, Seattle, WA 98104, USA
| | - Esther B Lim
- University of Washington Division of Emergency Medicine, Harborview Medical Center, Box 359702, 325 9th Avenue, Seattle, WA 98104, USA
| | - Susan A Stern
- University of Washington Division of Emergency Medicine, Harborview Medical Center, Box 359702, 325 9th Avenue, Seattle, WA 98104, USA
| | - Kevin R Ward
- Michigan Center for Integrative Research in Critical Care, University of Michigan, Building 10-103A North Campus Research Complex 2800 Plymouth Road, Ann Arbor, MI 48109, USA
| | - José A López
- Bloodworks Northwest Research Institute, 1551 Eastlake Avenue E, Seattle, WA 98102, USA
| | - Dominic Chung
- Bloodworks Northwest Research Institute, 1551 Eastlake Avenue E, Seattle, WA 98102, USA
| |
Collapse
|
28
|
Mehta AY, Mohammed BM, Martin EJ, Brophy DF, Gailani D, Desai UR. Allosterism-based simultaneous, dual anticoagulant and antiplatelet action: allosteric inhibitor targeting the glycoprotein Ibα-binding and heparin-binding site of thrombin. J Thromb Haemost 2016; 14:828-38. [PMID: 26748875 PMCID: PMC4828251 DOI: 10.1111/jth.13254] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 12/24/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND Allosteric inhibition is a promising approach for developing a new group of anticoagulants with potentially reduced bleeding consequences. Recently, we designed sulfated β-O4 lignin (SbO4L) as an allosteric inhibitor that targets exosite 2 of thrombin to reduce fibrinogen cleavage through allostery and compete with glycoprotein Ibα to reduce platelet activation. OBJECTIVE To assess: (i) the antithrombotic potential of a novel approach of simultaneous exosite 2-dependent allosteric inhibition of thrombin and competitive inhibition of platelet activation; and (ii) the promise of SbO4L as the first-in-class antithrombotic agent. METHODS A combination of whole blood thromboelastography, hemostasis analysis, mouse arterial thrombosis models and mouse tail bleeding studies were used to assess antithrombotic potential. RESULTS AND CONCLUSIONS SbO4L extended the clot initiation time, and reduced maximal clot strength, platelet contractile force, and the clot elastic modulus, suggesting dual anticoagulant and antiplatelet effects. These effects were comparable to those observed with enoxaparin. A dose of 1 mg of SbO4L per mouse prevented occlusion in 100% of arteries, and lower doses resulted in a proportionally reduced response. Likewise, the time to occlusion increased by ~ 70% with a 0.5-mg dose in the mouse Rose Bengal thrombosis model. Finally, tail bleeding studies demonstrated that SbO4L does not increase bleeding propensity. In comparison, a 0.3-mg dose of enoxaparin increased the bleeding time and blood volume loss. Overall, this study highlights the promise of the allosteric inhibition approach, and presents SbO4L as a novel anticoagulant with potentially reduced bleeding side effects.
Collapse
Affiliation(s)
- Akul Y. Mehta
- Department of Medicinal Chemistry and Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219, USA
| | - Bassem M. Mohammed
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA 23298, USA
- Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, Cairo 11562, Egypt
| | - Erika J. Martin
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Donald F. Brophy
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - David Gailani
- Department of Pathology, Immunology and Microbiology, Vanderbilt University Medical Center, Nashville, TN 37203
| | - Umesh R. Desai
- Department of Medicinal Chemistry and Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219, USA
| |
Collapse
|
29
|
Mohammed BM, Contaifer D, Lastrapes KK, Martin EJ, Mazepa MA, Hoffman M, Monroe DM, Brophy DF. Coated platelet assay: a feasible approach to a complicated science. Haemophilia 2015; 22:e67-70. [PMID: 26612351 DOI: 10.1111/hae.12845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2015] [Indexed: 11/26/2022]
Affiliation(s)
- B M Mohammed
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA.,Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, Giza, Egypt
| | - D Contaifer
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - K K Lastrapes
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA.,Department of Pediatric Hematology/Oncology, Children's Hospital of Richmond and Virginia Commonwealth University Health System, Richmond, VA, USA
| | - E J Martin
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - M A Mazepa
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - M Hoffman
- Department of Pathology, Duke University and Durham Veterans Affairs Medical Centers, Durham, NC, USA.,Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - D M Monroe
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - D F Brophy
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| |
Collapse
|
30
|
Lastrapes KK, Mohammed BM, Mazepa MA, Martin EJ, Barrett JC, Massey GV, Kuhn JG, Nolte ME, Hoffman M, Monroe DM, Brophy DF. Coated platelets and severe haemophilia A bleeding phenotype: Is there a connection? Haemophilia 2015; 22:148-51. [PMID: 26561343 DOI: 10.1111/hae.12844] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 09/23/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Coated platelets are a subpopulation of platelets that possess highly prothrombotic properties. Previous observational data suggest that bleeding phenotype in severe haemophilia A is associated with coated platelet levels. Haemophilia A patients with higher coated platelet levels may have a mild bleeding phenotype; those with lower levels may have a more severe bleeding phenotype. AIM The aim of the study was to test the hypothesis that coated platelet levels are correlated with clinical bleeding phenotype. METHODS This cross-sectional, observational study enrolled 20 severe haemophilia A patients, including 15 with severe and five with a mild bleeding phenotype, and a control group of 12 healthy volunteers. The haemophilia bleeding phenotype was determined by the patient's medical history and haemophilia treatment centre records. Blood was obtained from each patient by venipuncture and platelets were analysed by flow cytometry. RESULTS Patients categorized as having a severe bleeding phenotype experienced a median eight bleeds per year compared to one bleed annually in the mild bleeding phenotype group. Both groups had similar total platelet counts and fibrinogen levels. There was no difference in coated platelet percentage between severe and mild bleeding phenotype (17 and 16% respectively), however, both groups had significantly lower % coated platelets compared to controls (44%, P < 0.0001). CONCLUSION Coated platelet levels were not associated with bleeding phenotype in this study; however, these data may suggest coated platelet levels are lower in haemophilia patients relative to healthy volunteers.
Collapse
Affiliation(s)
- K K Lastrapes
- Department of Pediatric Hematology/Oncology, Children's Hospital of Richmond and Virginia Commonwealth University Health System, Richmond, VA, USA.,Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - B M Mohammed
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA.,Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, Giza, Egypt
| | - M A Mazepa
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - E J Martin
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - J C Barrett
- Division of Hematology/Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | - G V Massey
- Department of Pediatric Hematology/Oncology, Children's Hospital of Richmond and Virginia Commonwealth University Health System, Richmond, VA, USA
| | - J G Kuhn
- Division of Hematology/Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | - M E Nolte
- Division of Hematology/Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | - M Hoffman
- Department of Pathology, Duke University and Durham Veterans Affairs Medical Centers, Durham, NC, USA.,Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - D M Monroe
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - D F Brophy
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| |
Collapse
|
31
|
Mohammed BM, Fisher BJ, Kraskauskas D, Ward S, Wayne JS, Brophy DF, Fowler AA, Yager DR, Natarajan R. Vitamin C promotes wound healing through novel pleiotropic mechanisms. Int Wound J 2015; 13:572-84. [PMID: 26290474 DOI: 10.1111/iwj.12484] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 05/27/2015] [Accepted: 07/14/2015] [Indexed: 01/11/2023] Open
Abstract
Vitamin C (VitC) or ascorbic acid (AscA), a cofactor for collagen synthesis and a primary antioxidant, is rapidly consumed post-wounding. Parenteral VitC administration suppresses pro-inflammatory responses while promoting anti-inflammatory and pro-resolution effects in human/murine sepsis. We hypothesised that VitC could promote wound healing by altering the inflammatory, proliferative and remodelling phases of wound healing. Mice unable to synthesise VitC (Gulo(-/-) ) were used in this study. VitC was provided in the water (sufficient), withheld from another group (deficient) and supplemented by daily intra-peritoneal infusion (200 mg/kg, deficient + AscA) in a third group. Full thickness excisional wounds (6 mm) were created and tissue collected on days 7 and 14 for histology, quantitative polymerase chain reaction (qPCR) and Western blotting. Human neonatal dermal fibroblasts (HnDFs) were used to assess effects of In conclusion, VitC favorably on proliferation. Histological analysis showed improved wound matrix deposition and organisation in sufficient and deficient +AscA mice. Wounds from VitC sufficient and deficient + AscA mice had reduced expression of pro-inflammatory mediators and higher expression of wound healing mediators. Supplementation of HnDF with AscA induced the expression of self-renewal genes and promoted fibroblast proliferation. VitC favourably impacts the spatiotemporal expression of transcripts associated with early resolution of inflammation and tissue remodelling.
Collapse
Affiliation(s)
- Bassem M Mohammed
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA.,Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Bernard J Fisher
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Donatas Kraskauskas
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Susan Ward
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Jennifer S Wayne
- Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, VA, USA
| | - Donald F Brophy
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - Alpha A Fowler
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Dorne R Yager
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Ramesh Natarajan
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| |
Collapse
|
32
|
White NJ, Contaifer D, Martin EJ, Newton JC, Mohammed BM, Bostic JL, Brophy GM, Spiess BD, Pusateri AE, Ward KR, Brophy DF. Early hemostatic responses to trauma identified with hierarchical clustering analysis. J Thromb Haemost 2015; 13:978-88. [PMID: 25816845 PMCID: PMC4452397 DOI: 10.1111/jth.12919] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND Trauma-induced coagulopathy is a complex multifactorial hemostatic response that is poorly understood. OBJECTIVES To identify distinct hemostatic responses to trauma and identify key components of the hemostatic system that vary between responses. PATIENTS/METHODS A cross-sectional observational study of adult trauma patients at an urban level I trauma center emergency department was performed. Hierarchical clustering analysis was used to identify distinct clusters of similar subjects according to vital signs, injury/shock severity, and comprehensive assessment of coagulation, clot formation, platelet function, and thrombin generation. RESULTS Among 84 total trauma patients included in the model, three distinct trauma clusters were identified. Cluster 1 (N = 57) showed platelet activation, preserved peak thrombin generation, plasma coagulation dysfunction, a moderately decreased fibrinogen concentration and normal clot formation relative to healthy controls. Cluster 2 (N = 18) showed platelet activation, preserved peak thrombin generation, and a preserved fibrinogen concentration with normal clot formation. Cluster 3 (N = 9) was the most severely injured and shocked, and showed a strong inflammatory and bleeding phenotype. Platelet dysfunction, thrombin inhibition, plasma coagulation dysfunction and a decreased fibrinogen concentration were present in this cluster. Fibrinolytic activation was present in all clusters, but was particularly increased in cluster 3. Trauma clusters were most noticeably different in their relative fibrinogen concentration, peak thrombin generation, and platelet-induced clot contraction. CONCLUSIONS Hierarchical clustering analysis identified three distinct hemostatic responses to trauma. Further insights into the underlying hemostatic mechanisms responsible for these responses are needed.
Collapse
Affiliation(s)
- N J White
- Department of Medicine/Division of Emergency Medicine, University of Washington, and Puget Sound Blood Center Research Institute, Seattle, WA, USA
| | - D Contaifer
- Coagulation Advancement Laboratory, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - E J Martin
- Coagulation Advancement Laboratory, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - J C Newton
- Coagulation Advancement Laboratory, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - B M Mohammed
- Coagulation Advancement Laboratory, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
- Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - J L Bostic
- Coagulation Advancement Laboratory, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - G M Brophy
- Pharmacotherapy and Outcomes Science and Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - B D Spiess
- Department of Anesthesiology, Virginia Commonwealth University, Richmond, VA, USA
| | - A E Pusateri
- United States Army Medical Research and Materiel Command, Fort Detrick, MD, USA
| | - K R Ward
- Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - D F Brophy
- Coagulation Advancement Laboratory, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| |
Collapse
|
33
|
Mangrum JB, Martin EJ, Brophy DF, Hawkridge AM. Intact stable isotope labeled plasma proteins from the SILAC-labeled HepG2 secretome. Proteomics 2015; 15:3104-15. [DOI: 10.1002/pmic.201400369] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 11/05/2014] [Accepted: 12/05/2014] [Indexed: 01/26/2023]
Affiliation(s)
- John B. Mangrum
- Department of Pharmaceutics; Virginia Commonwealth University; Richmond VA USA
| | - Erika J. Martin
- Department of Pharmacotherapy & Outcomes Science; Virginia Commonwealth University; Richmond VA USA
| | - Donald F. Brophy
- Department of Pharmacotherapy & Outcomes Science; Virginia Commonwealth University; Richmond VA USA
| | - Adam M. Hawkridge
- Department of Pharmaceutics; Virginia Commonwealth University; Richmond VA USA
- Department of Pharmacotherapy & Outcomes Science; Virginia Commonwealth University; Richmond VA USA
| |
Collapse
|
34
|
Mohammed BM, Martin EJ, Salinas V, Carmona R, Young G, Brophy DF. Failure of corn trypsin inhibitor to affect the thrombin generation assay in plasma from severe hemophiliacs. J Thromb Haemost 2014; 12:1558-61. [PMID: 25041427 DOI: 10.1111/jth.12659] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Indexed: 08/31/2023]
Abstract
BACKGROUND The thrombin generation assay (TGA) is an important global coagulation assay; however, it suffers from the lack of preanalytical standardization. The addition of corn trypsin inhibitor (CTI) to blood collection tubes before TGA has been previously advocated to block the contact activation pathway. Emerging data, however, suggest that CTI may only be necessary when minimal tissue factor (TF) concentrations < 1 pmol are used. OBJECTIVES To determine whether blood collection tubes containing CTI influenced TGA parameters. METHODS This cross-sectional, observational study performed the TGA using TF 1 pmol L(-1) in 15 healthy volunteers, 14 severely factor VIII (FVIII)-deficient patients, and 15 severely FVIII-deficient patients with documented FVIII inhibitors. TGA was conducted using blood tubes that contained CTI 33 μg mL(-1) and no CTI. RESULTS CTI markedly reduced peak thrombin (P = 0.002) and endogenous thrombin potential (P < 0.001) in the healthy volunteers but had no significant effect on TGA parameters in severely FVIII-deficient patients or those with inhibitors. CONCLUSIONS This lack of effect raises additional questions regarding the need for CTI as a preanalytical addition to blood collection tubes during TGA in severe hemophiliacs, particularly when activating samples with TF 1 pmol L(-1) .
Collapse
Affiliation(s)
- B M Mohammed
- Coagulation Advancement Laboratory, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA; Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | | | | | | | | | | |
Collapse
|
35
|
Mehta AY, Thakkar JN, Mohammed BM, Martin EJ, Brophy DF, Kishimoto T, Desai UR. Targeting the GPIbα binding site of thrombin to simultaneously induce dual anticoagulant and antiplatelet effects. J Med Chem 2014; 57:3030-9. [PMID: 24635452 PMCID: PMC4203406 DOI: 10.1021/jm4020026] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
![]()
Exosite 2 of human thrombin contributes
to two opposing pathways, the anticoagulant pathway and the platelet
aggregation pathway. We reasoned that an exosite 2 directed allosteric
thrombin inhibitor should simultaneously induce anticoagulant and
antiplatelet effects. To assess this, we synthesized SbO4L based on
the sulfated tyrosine-containing sequence of GPIbα. SbO4L was
synthesized in three simple steps in high yield and found to be a
highly selective, direct inhibitor of thrombin. Michelis–Menten
kinetic studies indicated a noncompetitive mechanism of inhibition.
Competitive inhibition studies suggested ideal competition with heparin
and glycoprotein Ibα, as predicted. Studies with site-directed
mutants of thrombin indicated that SbO4L binds to Arg233, Lys235,
and Lys236 of exosite 2. SbO4L prevented thrombin-mediated platelet
activation and aggregation as expected on the basis of competition
with GPIbα. SbO4L presents a novel paradigm of simultaneous
dual anticoagulant and antiplatelet effects achieved through the GPIbα
binding site of thrombin.
Collapse
Affiliation(s)
- Akul Y Mehta
- Department of Medicinal Chemistry and Institute for Structural Biology and Drug Discovery, Virginia Commonwealth University , Richmond, Virginia 23219, United States
| | | | | | | | | | | | | |
Collapse
|
36
|
Fowler AA, Syed AA, Knowlson S, Sculthorpe R, Farthing D, DeWilde C, Farthing CA, Larus TL, Martin E, Brophy DF, Gupta S, Fisher BJ, Natarajan R. Phase I safety trial of intravenous ascorbic acid in patients with severe sepsis. J Transl Med 2014; 12:32. [PMID: 24484547 PMCID: PMC3937164 DOI: 10.1186/1479-5876-12-32] [Citation(s) in RCA: 359] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 01/02/2014] [Indexed: 02/07/2023] Open
Abstract
Background Parenterally administered ascorbic acid modulates sepsis-induced inflammation and coagulation in experimental animal models. The objective of this randomized, double-blind, placebo-controlled, phase I trial was to determine the safety of intravenously infused ascorbic acid in patients with severe sepsis. Methods Twenty-four patients with severe sepsis in the medical intensive care unit were randomized 1:1:1 to receive intravenous infusions every six hours for four days of ascorbic acid: Lo-AscA (50 mg/kg/24 h, n = 8), or Hi-AscA (200 mg/kg/24 h, n = 8), or Placebo (5% dextrose/water, n = 8). The primary end points were ascorbic acid safety and tolerability, assessed as treatment-related adverse-event frequency and severity. Patients were monitored for worsened arterial hypotension, tachycardia, hypernatremia, and nausea or vomiting. In addition Sequential Organ Failure Assessment (SOFA) scores and plasma levels of ascorbic acid, C-reactive protein, procalcitonin, and thrombomodulin were monitored. Results Mean plasma ascorbic acid levels at entry for the entire cohort were 17.9 ± 2.4 μM (normal range 50-70 μM). Ascorbic acid infusion rapidly and significantly increased plasma ascorbic acid levels. No adverse safety events were observed in ascorbic acid-infused patients. Patients receiving ascorbic acid exhibited prompt reductions in SOFA scores while placebo patients exhibited no such reduction. Ascorbic acid significantly reduced the proinflammatory biomarkers C-reactive protein and procalcitonin. Unlike placebo patients, thrombomodulin in ascorbic acid infused patients exhibited no significant rise, suggesting attenuation of vascular endothelial injury. Conclusions Intravenous ascorbic acid infusion was safe and well tolerated in this study and may positively impact the extent of multiple organ failure and biomarkers of inflammation and endothelial injury. Trial registration ClinicalTrials.gov identifier NCT01434121.
Collapse
Affiliation(s)
- Alpha A Fowler
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, School of Medicine, Virginia Commonwealth University, PO Box 980050, Richmond, VA 23298-0050, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Brophy DF, Carl DE, Mohammed BM, Song J, Martin EJ, Bostic JL, Gehr TWB. Differences in coagulation between hemodialysis and peritoneal dialysis. Perit Dial Int 2013; 34:33-40. [PMID: 24293664 DOI: 10.3747/pdi.2013.00036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
UNLABELLED BACKGROUND End-stage renal disease patients have significant cardiovascular morbidity and mortality, but little is known about differences in coagulation profiles between patients on hemodialysis (HD) and on peritoneal dialysis (PD). Given their long-term exposure to glucose-based dialysate, patients on PD can experience metabolic derangements. Theoretically, that exposure should create a more prothrombotic environment than occurs in HD patients. The objective of the present study was to quantify potential differences in baseline coagulation between PD and HD patients. ♢ METHODS Our single-center cross-sectional study at a large academic health science center enrolled 50 age-, race-, and sex-matched subjects (10 control subjects, 20 HD patients, and 20 PD patients). Measurements included platelet function, platelet receptor distribution, and coagulation dynamics by thromboelastography and Hemodyne hemostasis assay (Hemodyne, Richmond, VA, USA). ♢ RESULTS Compared with healthy control subjects, patients on both forms of dialysis showed prothrombotic coagulation protein profiles. The tissue-factor pathway was markedly elevated in both groups, but PD was associated with significantly greater concentrations of tissue factor (p = 0.0056) and tissue-factor pathway inhibitor (p = 0.0138). Similarly, compared with patients receiving HD, patients on PD had greater concentrations of fibrinogen (p = 0.0325), which corresponded with platelet hyperfunction as measured by platelet contractile force and clot elastic modulus (p = 0.003 and 0.017 respectively, compared with values in HD patients). Platelet receptor distribution was similar between the groups. ♢ CONCLUSIONS Compared with patients on HD, patients on PD appear to have a more prothrombotic profile. The clinical relevance of these findings needs to be studied in a prospective manner.
Collapse
Affiliation(s)
- Donald F Brophy
- Division of Nephrology,1 Department of Internal Medicine, Virginia Commonwealth University (VCU) School of Medicine
| | | | | | | | | | | | | |
Collapse
|
38
|
Mohammed BM, Fisher BJ, Kraskauskas D, Farkas D, Brophy DF, Fowler AA, Natarajan R. Vitamin C: a novel regulator of neutrophil extracellular trap formation. Nutrients 2013; 5:3131-51. [PMID: 23939536 PMCID: PMC3775246 DOI: 10.3390/nu5083131] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 07/30/2013] [Accepted: 08/05/2013] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Neutrophil extracellular trap (NET) formation was recently identified as a novel mechanism to kill pathogens. However, excessive NET formation in sepsis can injure host tissues. We have recently shown that parenteral vitamin C (VitC) is protective in sepsis. Whether VitC alters NETosis is unknown. METHODS We used Gulo-/- mice as they lack the ability to synthesize VitC. Sepsis was induced by intraperitoneal infusion of a fecal stem solution (abdominal peritonitis, FIP). Some VitC deficient Gulo-/- mice received an infusion of ascorbic acid (AscA, 200 mg/kg) 30 min after induction of FIP. NETosis was assessed histologically and by quantification for circulating free DNA (cf-DNA) in serum. Autophagy, histone citrullination, endoplasmic reticulum (ER) stress, NFκB activation and apoptosis were investigated in peritoneal PMNs. RESULTS Sepsis produced significant NETs in the lungs of VitC deficient Gulo-/- mice and increased circulating cf-DNA. This was attenuated in the VitC sufficient Gulo-/- mice and in VitC deficient Gulo-/- mice infused with AscA. Polymorphonuclear neutrophils (PMNs) from VitC deficient Gulo-/- mice demonstrated increased activation of ER stress, autophagy, histone citrullination, and NFκB activation, while apoptosis was inhibited. VitC also significantly attenuated PMA induced NETosis in PMNs from healthy human volunteers. CONCLUSIONS Our in vitro and in vivo findings identify VitC as a novel regulator of NET formation in sepsis. This study complements the notion that VitC is protective in sepsis settings.
Collapse
Affiliation(s)
- Bassem M. Mohammed
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA 23298, USA; E-Mails: (B.M.M.); (D.F.B.)
- Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, Cairo 11562, Egypt
| | - Bernard J. Fisher
- Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA; E-Mails: (B.J.F.); (D.K.); (D.F.); (A.A.F.)
| | - Donatas Kraskauskas
- Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA; E-Mails: (B.J.F.); (D.K.); (D.F.); (A.A.F.)
| | - Daniela Farkas
- Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA; E-Mails: (B.J.F.); (D.K.); (D.F.); (A.A.F.)
| | - Donald F. Brophy
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA 23298, USA; E-Mails: (B.M.M.); (D.F.B.)
| | - Alpha A. Fowler
- Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA; E-Mails: (B.J.F.); (D.K.); (D.F.); (A.A.F.)
| | - Ramesh Natarajan
- Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA; E-Mails: (B.J.F.); (D.K.); (D.F.); (A.A.F.)
| |
Collapse
|
39
|
Fisher BJ, Kraskauskas D, Martin EJ, Farkas D, Puri P, Massey HD, Idowu MO, Brophy DF, Voelkel NF, Fowler AA, Natarajan R. Attenuation of sepsis-induced organ injury in mice by vitamin C. JPEN J Parenter Enteral Nutr 2013; 38:825-39. [PMID: 23917525 DOI: 10.1177/0148607113497760] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Multiple organ dysfunction syndrome (MODS) is the principal cause of death in patients with sepsis. Recent work supports the notion that parenteral vitamin C (VitC) is protective in sepsis through pleiotropic mechanisms. Whether suboptimal levels of circulating VitC increase susceptibility to sepsis-induced MODS is unknown. MATERIALS AND METHODS Unlike mice, humans lack the ability to synthesize VitC because of loss of L-gulono-γ-lactone oxidase (Gulo), the final enzyme in the biosynthesis of VitC. To examine whether physiological levels of VitC are required for defense against a catastrophic infection, we induced sepsis in VitC sufficient and VitC deficient Gulo(-/-) mice by intraperitoneal infusion of a fecal stem solution (FIP). Some VitC deficient Gulo(-/-) mice received a parenteral infusion of ascorbic acid (AscA, 200 mg/kg) 30 minutes after induction of FIP. We used molecular, histological, and biochemical analyses to assess for MODS as well as abnormalities in the coagulation system and circulating blood cells. RESULTS FIP produced injury to lungs, kidneys and liver (MODS) in VitC deficient Gulo(-/-) mice. MODS was not evident in FIP-exposed VitC sufficient Gulo(-/-) mice and attenuated in VitC deficient Gulo(-/-) mice infused with AscA. Septic VitC deficient Gulo(-/-) mice developed significant abnormalities in the coagulation system and circulating blood cells. These were attenuated by VitC sufficiency/infusion in septic Gulo(-/-) mice. CONCLUSIONS VitC deficient Gulo(-/-) mice were more susceptible to sepsis-induced MODS. VitC sufficiency or parenteral infusion of VitC, following induction of sepsis, normalized physiological functions that attenuated the development of MODS in sepsis.
Collapse
Affiliation(s)
- Bernard J Fisher
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Donatas Kraskauskas
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Erika J Martin
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Daniela Farkas
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Puneet Puri
- Division of Gastroenterology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - H Davis Massey
- Department of Pathology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Michael O Idowu
- Department of Pathology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Donald F Brophy
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Norbert F Voelkel
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Alpha A Fowler
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Ramesh Natarajan
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| |
Collapse
|
40
|
Brophy GM, Candeloro CL, Robles JR, Brophy DF. Recombinant activated factor VII use in critically ill patients: clinical outcomes and thromboembolic events. Ann Pharmacother 2013; 47:447-54. [PMID: 23535812 DOI: 10.1345/aph.1r729] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Hemorrhage and coagulopathy are associated with morbidity and mortality in critically ill patients. Recombinant activated factor VII (rFVIIa) is frequently used in these situations to control bleeding; however, few controlled clinical trials have demonstrated clinical benefit and prolonged survival. OBJECTIVE To compare clinical outcomes and thromboembolic events in intensive care unit (ICU) patients who received rFVIIa versus ICU patients who did not between 2000 and 2005. METHODS A total of 2918 nonhemophiliac adult ICU patients, which included 1459 who received at least 1 dose of rFVIIa and 1459 matched controls who did not, were included in a retrospective database study. Data were extracted from the Solucient ACTracker database, which included 550 hospitals across the US. Measures included patient demographics, rFVIIa prescribing, death, thromboembolic events, discharge disposition, length of stay, and transfusion data. RESULTS The most common primary diagnoses for patients receiving rFVIIa included traumatic brain injury, cirrhosis, and nontraumatic intracranial hemorrhage. Patients receiving rFVIIa were more likely to have comorbidities, including mechanical ventilation, acute kidney injury, sepsis, hemodialysis, and gastrointestinal bleeding (p < 0.0001). The average rFVIIa dose was 4.8 mg and 82% of patients received 1 dose. Compared to controls, patients receiving rFVIIa had greater odds of death (OR 2.1, 95% CI 1.8-2.6, p < 0.0001), transfusion (OR 2.1, 95% CI 1.8-2.5, p < 0.0001), and longer length of stay (p < 0.001). There was no significant difference in thromboembolic events between groups. CONCLUSIONS While we cannot show direct causality between rFVIIa and the poor clinical outcomes documented in ICU patients, they provide important insight for critical care clinicians.
Collapse
Affiliation(s)
- Gretchen M Brophy
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | | | | | | |
Collapse
|
41
|
Al Hawaj MA, Martin EJ, Venitz J, Barrett JC, Kuhn JG, Nolte ME, Brophy DF. Monitoring rFVIII prophylaxis dosing using global haemostasis assays. Haemophilia 2013; 19:409-14. [PMID: 23510278 DOI: 10.1111/hae.12110] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2013] [Indexed: 11/28/2022]
Abstract
Secondary factor VIII (FVIII) prophylaxis converts severe haemophiliacs (FVIII:C < 1 IU dL(-1)) to a moderate phenotype (FVIII:C ≥ 1 IU dL(-1)), however, plasma FVIII:C is a poor predictor of bleeding risk. This study used thromboelastography (TEG) and thrombin generation assay (TGA) to quantify coagulation across a 48 h rFVIII prophylaxis period. 10 severe haemophiliacs with varying clinical bleeding phenotypes received their standard rFVIII prophylaxis dose and blood samples were obtained over 48 h. Measured parameters included FVIII:C, TEG and TGA at each time point. FVIII:C pharmacokinetics (PK) and correlation between global assay parameters was performed. The FVIII:C PK parameters were consistent with previous literature. There was significant correlation between FVIII:C and TEG R-time and aPTT (both P < 0.001). Significant correlations existed between FVIII:C and TGA peak, ETP and velocity parameters (all P < 0.001). At 24 h the TEG parameters were sub-therapeutic despite median FVIII:C of 13.0 IU dL(-1). TGA was sensitive to FVIII:C below 1 IU dL(-1). Those with the severest bleeding phenotype had the lowest TGA parameters. There was significant correlation between FVIII:C and TEG and TGA. TEG lost sensitivity at 48 h, but not TGA. Prospective studies are needed to determine whether these data can be used to design individualized rFVIII prophylaxis regimens.
Collapse
Affiliation(s)
- M A Al Hawaj
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA 23298-0533, USA
| | | | | | | | | | | | | |
Collapse
|
42
|
Brophy DF, Carr ME, Martin EJ, Venitz J, Gehr TWB. The Pharmacokinetics of Enoxaparin Do Not Correlate With Its Pharmacodynamic Effect in Patients Receiving Dialysis Therapies. J Clin Pharmacol 2013; 46:887-94. [PMID: 16855073 DOI: 10.1177/0091270006289975] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The pharmacokinetics and pharmacodynamics of enoxaparin were studied in healthy volunteers and hemodialysis and peritoneal dialysis subjects. Antifactor Xa activity estimated the pharmacokinetics, whereas thrombin generation time (TGT) estimated the pharmacodynamics. Enoxaparin 1 mg/kg was given subcutaneously to all subjects. Antifactor Xa Amax and AUC(0-12) were similar between groups, but the TGTmax was significantly greater in the dialysis groups (P = .001). The thrombin generation time remained significantly more prolonged throughout the 12-hour study period, and there was a trend toward greater TGT AUEC(0-12) for both dialysis groups (P = .07). Patients receiving hemodialysis had greater sensitivity to enoxaparin compared to the other groups. These results suggest that in dialysis patients, there may be accumulation of active heparin metabolites that are undetected by the antifactor Xa assay. Therefore, these subjects exhibit greater thrombin generation time prolongation despite similar antifactor Xa exposure. Further large-scale studies are needed to corroborate the results of this exploratory pilot study.
Collapse
Affiliation(s)
- Donald F Brophy
- Department of Pharmacy, Coagulation Special Studies Laboratory, Virginia Commonwealth University/Medical College of Virginia (VCU/MCV), Richmond, Virginia, USA
| | | | | | | | | |
Collapse
|
43
|
White NJ, Leong BSH, Brueckner J, Martin EJ, Brophy DF, Peberdy MA, Ornato J, Ward KR. Coagulopathy during cardiac arrest and resuscitation in a swine model of electrically induced ventricular fibrillation. Resuscitation 2011; 82:925-31. [PMID: 21482008 PMCID: PMC3549665 DOI: 10.1016/j.resuscitation.2011.02.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 01/19/2011] [Accepted: 02/11/2011] [Indexed: 01/20/2023]
Abstract
AIMS Coagulopathy is often present after resuscitation from cardiac arrest but plays an undefined role in the post cardiac arrest syndrome. The aim of this study was to characterize coagulation changes during cardiac arrest and post-resuscitation care in order to direct further focused study. METHODS Ventricular fibrillation (VF) was induced electrically in immature male swine, followed by normothermic American Heart Association Advanced Cardiac Life Support and a uniform post-resuscitation goal-directed resuscitation protocol. PT, aPTT, fibrinogen, Thrombelastography (TEG), platelet contractile force (PCF), clot elastic modulus (CEM), and collagen-induced platelet aggregation were compared at baseline, at 8 min of VF, during the 3rd round of chest compressions (CPR), and at 15, 90, 180, and 360 min after return of circulation using repeated measures ANOVA. RESULTS 8/18 (44%) animals were resuscitated after 10.9 ± 0.9 min of VF and 7.6 ± 3.4 min of CPR. TEG revealed a significant impairment in clot strength (MA) and clot formation kinetics (K, alpha angle) arising during CPR, followed by a brief prolongation of clot onset times (R) after return of circulation. Both PCF and CEM fell significantly during CPR (PCF by 50%, CEM by 47% of baseline) and platelet aggregation was significantly decreased during CPR. Coagulation changes were partially recovered by 3h of post-resuscitation care. CONCLUSION Whole blood coagulation was rapidly impaired during CPR after electrically induced VF in this swine model by impaired platelet aggregation/contractile function and clotting kinetics. Further platelet-specific study is indicated.
Collapse
Affiliation(s)
- Nathan J White
- Department of Medicine, University of Washington, Seattle, WA, USA.
| | | | | | | | | | | | | | | |
Collapse
|
44
|
Brophy DF, Martin EJ, Christian Barrett J, Nolte ME, Kuhn JG, Gerk PM, Carr ME, Pelzer H, Agersø H, Ezban M, Hedner U. Monitoring rFVIIa 90 μg kg⁻¹ dosing in haemophiliacs: comparing laboratory response using various whole blood assays over 6 h. Haemophilia 2011; 17:e949-57. [PMID: 21362113 DOI: 10.1111/j.1365-2516.2011.02492.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Recombinant FVIIa is a haemostatic agent administered to patients with severe FVIII or FIX deficiency with inhibitors. Although rFVIIa is effective at stopping bleeding, a reliable assay to monitor its effect is lacking. To characterize the pharmacokinetics and global coagulation effects of rFVIIa for 6 h following a IV dose of 90 μg kg⁻¹. Ten non-bleeding subjects with severe FVIII or FIX deficiency were infused with a single-dose of rFVIIa 90 μg k⁻¹ body weight and blood was collected before and at 0.5, 1, 2, 4 and 6 h postdose. Global haemostasis was characterized throughout the study utilizing whole blood analyses (Hemodyne HAS, TEG, ROTEM). The clearance and half-life of factor FVII:C was estimated as 39.0 ± 8.8 mL h⁻¹ kg⁻¹ and 2.1 ± 0.2 h respectively. There was good inter-assay agreement with respect to clot initiation parameters (R, CT and FOT) and these parameters all fell to a mean of approximately 9 min following rFVIIa dosing. The platelet contractile force (PCF) and clot elastic modulus (CEM) were positively correlated to FVII:C (P < 0.0001), and these parameters were dynamic throughout the 6-h period. The MA and MCF did not correlate to FVII:C nor did they significantly change during the study. Prothrombin F1 + 2 significantly increased following rFVIIa dosing (P < 0.001), but remained steady throughout the study. There was no change in D-dimer concentrations over time. The FOT, R and CT characterized clot initiation following rFVIIa dosing. The PCF and CEM were correlated to FVII:C and characterized the dynamics of platelet function and clot strength over the rFVIIa dosing interval. The clinical significance of these findings needs additional study.
Collapse
Affiliation(s)
- D F Brophy
- Coagulation Advancement Laboratory, Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University (VCU), Richmond, VA, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Brophy GM, Brackbill ML, Bidwell KL, Brophy DF. Prospective, randomized comparison of lansoprazole suspension, and intermittent intravenous famotidine on gastric pH and acid production in critically ill neurosurgical patients. Neurocrit Care 2011; 13:176-81. [PMID: 20596795 DOI: 10.1007/s12028-010-9397-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND There is a paucity of studies comparing stress ulcer prophylaxis (SUP) agents in high-risk neurosurgical patients. METHODS In this prospective, randomized study, critically ill neurosurgical patients received lansoprazole 30 mg suspension via NG/NJ tube daily or famotidine 20 mg IV q12 h for SUP. Gastric pH and residual volumes were recorded for 3 days and adverse events for 7 days after admission. RESULTS There were 51 patients randomized to lansoprazole (n = 28) or famotidine (n = 23) who received SUP for ≥ 3 days. All patients had at least two risk factors for SRMD, and 75% had a baseline GCS < 9. On day 1 of therapy, more famotidine patients had a gastric pH ≥ 4 at least 80% of the time as compared to lansoprazole patients (74 vs. 36%, P = 0.01, respectively); however, there was no difference on days 2 and 3. Enteral feedings on day 1 predicted a pH ≥ 4 (P = 0.01). There were no significant differences in the percentages of time gastric residual volumes < 28 ml (P = NS). Heme-positive aspirates were present in 18-39% of patients (P = NS); one patient receiving famotidine met the criteria for overt bleeding. Thrombocytopenia occurred in 17% in the famotidine group and 4% in the lansoprazole group (P = NS). CONCLUSIONS Neurosurgery ICU patients receiving famotidine for SUP achieved a gastric pH ≥ 4 more often than lansoprazole-treated patients, but only on day 1 of the 3-day study period. Both agents were equally effective in reducing gastric acid production. There was no difference in the incidence of mucosal damage and thrombocytopenia.
Collapse
Affiliation(s)
- Gretchen M Brophy
- Departments of Pharmacotherapy & Outcomes Sciences and Neurosurgery, Virginia Commonwealth University School of Pharmacy, P.O Box 980533, 410 N. 12th Street, Richmond, VA 23298, USA.
| | | | | | | |
Collapse
|
46
|
Agersø H, Brophy DF, Pelzer H, Martin EJ, Carr M, Hedner U, Ezban M. Recombinant human factor VIIa (rFVIIa) cleared principally by antithrombin following intravenous administration in hemophilia patients. J Thromb Haemost 2011; 9:333-8. [PMID: 21114621 PMCID: PMC3030656 DOI: 10.1111/j.1538-7836.2010.04152.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of the present study was to evaluate the pharmacokinetics and the clearance pathways of rFVIIa after intravenous administration to hemophilia patients. METHODS Ten severe hemophilia patients were included in the study; all patients were intravenously administered a clinically relevant dose of 90 μg kg(-1) (1.8 nmol kg(-1)) rFVIIa. Blood samples were collected consecutively to describe the pharmacokinetics of rFVIIa. All samples were analyzed using three different assays: a clot assay to measure the activity (FVIIa:C), an enzyme immunoassay (EIA) to measure the antigen levels (FVII:Ag), and an EIA (FVIIa-AT) to measure the FVIIa antithrombin III (AT) complex. Pharmacokinetic parameters were evaluated both by use of standard non-compartmental methods and by use of mixed effects methods. A population pharmacokinetic model was used to simultaneously model all three datasets. The total body clearance of rFVIIa:C was estimated to be 38 mL h(-1) kg(-1). The rFVII-AT complex formation was responsible for 65% of the total rFVIIa:C clearance. The initial and the terminal half-life of rFVIIa:C was estimated to be 0.6 and 2.6 h, respectively. The formation of rFVII-AT complex was able to explain the difference observed between the rFVIIa:C and the rFVII:Ag concentration. The non-compartmental analysis resulted in almost identical parameters.
Collapse
Affiliation(s)
- Henrik Agersø
- Pharmacology, Biopharmaceuticals Research Unit, Novo Nordisk A/S
| | - Donald F. Brophy
- Coagulation Advancement Laboratory, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | - Hermann Pelzer
- Pharmacology, Biopharmaceuticals Research Unit, Novo Nordisk A/S
| | - Erika J. Martin
- Coagulation Advancement Laboratory, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | | | | | - Mirella Ezban
- Pharmacology, Biopharmaceuticals Research Unit, Novo Nordisk A/S
| |
Collapse
|
47
|
White NJ, Martin EJ, Shin Y, Brophy DF, Diegelmann RF, Ward KR. Systemic central venous oxygen saturation is associated with clot strength during traumatic hemorrhagic shock: A preclinical observational model. Scand J Trauma Resusc Emerg Med 2010; 18:64. [PMID: 21138566 PMCID: PMC3006355 DOI: 10.1186/1757-7241-18-64] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 12/07/2010] [Indexed: 02/01/2023] Open
Abstract
Background Clot strength by Thrombelastography (TEG) is associated with mortality during trauma and has been linked to severity of tissue hypoperfusion. However, the optimal method for monitoring this important relationship remains undefined. We hypothesize that oxygen transport measurements will be associated with clot strength during traumatic shock, and test this hypothesis using a swine model of controlled traumatic shock. Methods N = 33 swine were subjected to femur fracture and hemorrhagic shock by controlled arterial bleeding to a predetermined level of oxygen debt measured by continuous indirect calorimetry. Hemodynamics, oxygen consumption, systemic central venous oxygenation (ScvO2), base excess, lactate, and clot maximal amplitude by TEG (TEG-MA) as clot strength were measured at baseline and again when oxygen debt = 80 ml/kg during shock. Oxygen transport and metabolic markers of tissue perfusion were then evaluated for significant associations with TEG-MA. Forward stepwise selection was then used to create regression models identifying the strongest associations between oxygen transport and TEG-MA independent of other known determinants of clot strength. Results Multiple markers of tissue perfusion, oxygen transport, and TEG-MA were all significantly altered during shock compared to baseline measurements (p < 0.05). However, only ScvO2 demonstrated a strong bivariate association with TEG-MA measured during shock (R = 0.7, p < 0.001). ScvO2 measured during shock was also selected by forward stepwise selection as an important covariate in linear regression models of TEG-MA after adjusting for the covariates fibrinogen, pH, platelet count, and hematocrit (Whole model R2 = 0.99, p ≤ 0.032). Conclusions Among multiple measurements of oxygen transport, only ScvO2 was found to retain a significant association with TEG-MA during shock after adjusting for multiple covariates. ScvO2 should be further studied for its utility as a clinical marker of both tissue hypoxia and clot formation during traumatic shock.
Collapse
Affiliation(s)
- Nathan J White
- Reanimation Engineering Science Center, Virginia Commonwealth University, Richmond, 23298, USA.
| | | | | | | | | | | |
Collapse
|
48
|
Brophy DF, Daniel G, Gitlin M, Mayne TJ. Characterizing Hospitalizations of End-Stage Renal Disease Patients on Dialysis and Inpatient Utilization of Erythropoiesis-Stimulating Agent Therapy. Ann Pharmacother 2010; 44:43-9. [DOI: 10.1345/aph.1m429] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND In 2006, there were over 350,000 patients with end-stage renal disease (ESRD) receiving dialysis therapy. Studies have found that hemoglobin concentrations are often low among dialysis patients after hospital discharge, yet little is known about inpatient anemia treatment. OBJECTIVE To characterize hospitalizations among patients with ESRD on dialysis, specifically, inpatient utilization of erythropoiesis-stimulating agent (ESA) therapy. METHODS A cross-sectional, retrospective study of claims data from 5 commercial health plans for the years 2004–2006 was conducted. Inclusion criteria included 1 or more ESRD-specific International Classification of Diseases Ninth Edition (ICD-9) codes, 3 or more ESRD-specific Current Procedural Terminology/Healthcare Common Procedure Coding System (CPT/HCPCS) procedures on different days, or 3 or more dialysis ICD-9 codes or CPT/HCPCS dialysis procedures on separate days. ESRD patient and hospital characteristics were outlined. RESULTS ESRD patients were hospitalized an average of 1.8 times in both 2004–2005 and 2005–2006. The mean ± SD hospital length of stay (LOS) was 13.3 ± 20.5 and 12.8 ± 19.0 days for 2004–2005 and 2005–2006, respectively. For each year, LOS greater than 7 days occurred in 44% of hospitalizations. Many of these patients were admitted for kidney-related comorbidities and ultimately received procedures and services relevant to dialysis care. For each year, ESA utilization was 13% in year 1 and 11% in year 2 across any LOS. For ESRD patients with a 4- to 7-day LOS (the most common LOS), less than 20% received ESA treatment. ESA utilization increased correspondingly with longer hospital LOS (p < 0.001). CONCLUSIONS Although ESRD patients are commonly hospitalized and claims recognize that kidney-related conditions exist, the utilization of ESAs is low.
Collapse
Affiliation(s)
- Donald F Brophy
- Donald F Brophy PharmD MSc FCCP FASN BCPS, Professor of Pharmacy and Medicine; Chairman, Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA
| | - Gregory Daniel
- Gregory Daniel MS PhD MPH BS Pharm, Director, Government and Academic Research, HealthCore, Inc., Wilmington, DE
| | - Matthew Gitlin
- Matthew Gitlin PharmD, Senior Manager, Global Health Economics, Amgen Inc., Thousand Oaks, CA
| | - Tracy J Mayne
- Tracy J Mayne PhD, at time of writing, Director, Global Health Economics, Amgen Inc
| |
Collapse
|
49
|
White NJ, Martin EJ, Brophy DF, Ward KR. Coagulopathy and traumatic shock: characterizing hemostatic function during the critical period prior to fluid resuscitation. Resuscitation 2009; 81:111-6. [PMID: 19854556 DOI: 10.1016/j.resuscitation.2009.09.017] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Accepted: 09/19/2009] [Indexed: 11/26/2022]
Abstract
AIMS Identifying early changes in hemostatic clot function as a result of tissue injury and hypoperfusion may provide important information regarding the mechanisms of traumatic coagulopathy. A combat-relevant swine model was used to investigate the development of coagulopathy during trauma by monitoring hemostatic function during increasing severity of shock. METHODS Swine were injured (soft tissue+femur fracture) and hemorrhaged while continuously monitoring Oxygen Debt (OD) by indirect calorimetry at the airway. Hemostatic function was assessed by Thrombelastography (TEG), Prothrombin Time (PT), Partial Thromboplastin Time (PTT), and fibrinogen concentration and compared before hemorrhage (D0) and during shock when OD=40 and 80 ml/kg. An instrumented sham group was used for comparison. RESULTS N=23 swine (N=18 hemorrhage, N=5 sham) weighing 45+/-6 kg were studied after removing an average of 34+/-14% of blood volume during hemorrhage. Hgb, Hct, platelet counts, PT and PTT did not change with increasing OD (p<0.05). Fibrinogen was reduced significantly by OD=40 ml/kg (mean diff.=-59.9 mg/dl, 95% CI diff. [-95.1, -24.6]). TEG parameters representing clot initiation (R) and polymerization (K and Alpha Angle) did not change with increasing OD during shock (p>0.053). Clot strength (MA) was reduced in the hemorrhage group by OD=80 ml/kg (mean diff.=-4.1mm, 95% CI diff. [-7.4, -0.8]). CONCLUSION In this swine model of traumatic shock, fibrinogen was significantly reduced and an isolated reduction in clot strength (MA) was found with increasing OD. Fibrinogen consumption and altered platelet function may account for the earliest changes in hemostatic function during traumatic shock.
Collapse
Affiliation(s)
- Nathan J White
- Department of Emergency Medicine, Virginia Commonwealth University, AD Williams Clinic 2nd Floor, Room 242, 1201 East Marshall Street, Richmond, VA 23298, USA.
| | | | | | | |
Collapse
|
50
|
Siegel J, Jorgenson J, Johnson PE, Brophy DF, Comstock T, Feng A, Audhya P. Use and prescribing patterns for erythropoiesis-stimulating agents in inpatient and outpatient hospital settings. Am J Health Syst Pharm 2008; 65:1711-9. [DOI: 10.2146/ajhp070526] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
- Jerry Siegel
- The Ohio State University Medical Center, Columbus
| | - James Jorgenson
- University Health Care Pharmacy Services, University of Utah Hospitals and Clinics, Salt Lake City
| | | | - Donald F. Brophy
- Virginia Commonwealth University, Medical College of Virginia Campus, Richmond
| | | | | | | |
Collapse
|