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Warner LL, Thalji L, Hunter Guevara LR, Warner MA, Kor DJ, Warner DO, Hanson AC, Nemergut ME. Transfusion targets and adverse events in pediatric perioperative acute Anemia. J Clin Anesth 2024; 94:111405. [PMID: 38309132 PMCID: PMC10939750 DOI: 10.1016/j.jclinane.2024.111405] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 01/12/2024] [Accepted: 01/29/2024] [Indexed: 02/05/2024]
Abstract
STUDY OBJECTIVE To evaluate the association between pretransfusion and posttransfusion hemoglobin concentrations and the outcomes of children undergoing noncardiac surgery. DESIGN Retrospective review of patient records. We focused on initial postoperative hemoglobin concentrations, which may provide a more useful representation of transfusion adequacy than pretransfusion hemoglobin triggers (the latter often cannot be obtained during acute surgical hemorrhage). SETTING Single-center, observational cohort study. PATIENTS We evaluated all pediatric patients undergoing noncardiac surgery who received intraoperative red blood cell transfusions from January 1, 2008, through December 31, 2018. INTERVENTIONS None. MEASUREMENTS Associations between pre- and posttransfusion hemoglobin concentrations (g/dL), hospital-free days, intensive care unit admission, postoperative mechanical ventilation, and infectious complications were evaluated with multivariable regression modeling. MAIN RESULTS In total, 113,713 unique noncardiac surgical procedures in pediatric patients were evaluated, and 741 procedures met inclusion criteria (median [range] age, 7 [1-14] years). Four hundred ninety-eight patients (68%) with a known preoperative hemoglobin level had anemia; of these, 14% had a preexisting diagnosis of anemia in their health record. Median (IQR) pretransfusion hemoglobin concentration was 8.1 (7.4-9.2) g/dL and median (IQR) initial postoperative hemoglobin concentration was 10.4 (9.3-11.6) g/dL. Each decrease of 1 g/dL in the initial postoperative hemoglobin concentration was associated with increased odds of transfusion within the first 24 postoperative hours (odds ratio [95% CI], 1.62 [1.37-1.93]; P < .001). No significant relationships were observed between postoperative hemoglobin concentrations and hospital-free days (P = .56), intensive care unit admission (P = .71), postoperative mechanical ventilation (P = .63), or infectious complications (P = .74). CONCLUSIONS In transfused patients, there was no association between postoperative hemoglobin values and clinical outcomes, except the need for subsequent transfusion. Most transfused patients presented to the operating room with anemia, which suggests a potential opportunity for perioperative optimization of health before surgery.
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Affiliation(s)
- Lindsay L Warner
- Department of Anesthesiology and Perioperative Medicine (Drs L. Warner, Thalji, Hunter Guevara, M. Warner, Kor, D. Warner, and Nemergut) and Division of Biomedical Statistics and Informatics (Mr Hanson), Mayo Clinic, Rochester, MN, United States of America.
| | - Leanne Thalji
- Department of Anesthesiology and Perioperative Medicine (Drs L. Warner, Thalji, Hunter Guevara, M. Warner, Kor, D. Warner, and Nemergut) and Division of Biomedical Statistics and Informatics (Mr Hanson), Mayo Clinic, Rochester, MN, United States of America
| | - Lindsay R Hunter Guevara
- Department of Anesthesiology and Perioperative Medicine (Drs L. Warner, Thalji, Hunter Guevara, M. Warner, Kor, D. Warner, and Nemergut) and Division of Biomedical Statistics and Informatics (Mr Hanson), Mayo Clinic, Rochester, MN, United States of America
| | - Matthew A Warner
- Department of Anesthesiology and Perioperative Medicine (Drs L. Warner, Thalji, Hunter Guevara, M. Warner, Kor, D. Warner, and Nemergut) and Division of Biomedical Statistics and Informatics (Mr Hanson), Mayo Clinic, Rochester, MN, United States of America
| | - Daryl J Kor
- Department of Anesthesiology and Perioperative Medicine (Drs L. Warner, Thalji, Hunter Guevara, M. Warner, Kor, D. Warner, and Nemergut) and Division of Biomedical Statistics and Informatics (Mr Hanson), Mayo Clinic, Rochester, MN, United States of America
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine (Drs L. Warner, Thalji, Hunter Guevara, M. Warner, Kor, D. Warner, and Nemergut) and Division of Biomedical Statistics and Informatics (Mr Hanson), Mayo Clinic, Rochester, MN, United States of America
| | - Andrew C Hanson
- Department of Anesthesiology and Perioperative Medicine (Drs L. Warner, Thalji, Hunter Guevara, M. Warner, Kor, D. Warner, and Nemergut) and Division of Biomedical Statistics and Informatics (Mr Hanson), Mayo Clinic, Rochester, MN, United States of America
| | - Michael E Nemergut
- Department of Anesthesiology and Perioperative Medicine (Drs L. Warner, Thalji, Hunter Guevara, M. Warner, Kor, D. Warner, and Nemergut) and Division of Biomedical Statistics and Informatics (Mr Hanson), Mayo Clinic, Rochester, MN, United States of America
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Raj S, Li S, Schears GJ, Nemergut ME, Gram K, Watson D, Overman DM. Survival-to-Hospital Discharge in Neonates With Congenital Heart Disease Supported With Prolonged Extracorporeal Membrane Oxygenation. Am J Cardiol 2023; 201:310-316. [PMID: 37399596 DOI: 10.1016/j.amjcard.2023.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/11/2023] [Indexed: 07/05/2023]
Abstract
Factors that determine early outcomes in neonates with congenital heart disease (CHD) supported with prolonged venoarterial extracorporeal membrane oxygenation (ECMO) are not known and contemporary multicenter data are limited. This Extracorporeal Life Support Organization registry-based retrospective cohort study included all neonates (age ≤28 days) with CHD supported with venoarterial ECMO >7 days at 111 centers in the United States from January 2011 to December 2020. The primary outcome was survival-to-hospital discharge, and the secondary outcome was ECMO survival (successful decannulation before hospital discharge or death). Of the 2,155 total ECMO runs, 948 neonates received prolonged ECMO (gestational age [mean ± SD] 37.9 ± 1.8 weeks; birth weight 3.1 ± 0.6 kg; ECMO duration 13.6 ± 11.2 days). The ECMO survival rate was 51.6% (489 of 948), and the survival-to-hospital discharge rate was 23.9% (226 of 948). Body weight at ECMO (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.44 to 0.78/kg), gestational age (OR 0.89, 95% CI 0.79 to 1.00 per week), risk-adjusted congenital heart surgery-1 score (OR 1.22, 95% CI 1.04 to 1.45), and pump flow at 24 hours (OR 1.11, 95% CI 1.04 to 1.18 per 10 ml/kg/min) were significantly associated with survival-to-hospital discharge. Pre-ECMO mechanical ventilation duration, time to extubation after ECMO decannulation, and length of stay were inversely associated with hospital survival. Patient-specific (higher body weight and gestational age) and CHD-related (lower risk-adjusted congenital heart surgery-1 score) attributes are associated with better outcomes in neonates who receive prolonged venoarterial ECMO. Further elucidation of the factors associated with reduced survival to discharge in ECMO survivors is needed.
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Affiliation(s)
- Shashi Raj
- Mayo Clinic Children's Minnesota Cardiovascular Collaborative, Mayo Clinic, Rochester, Minnesota; Divisions of Cardiovascular Critical Care, Children's Minnesota, Minneapolis, Minnesota; The Children's Heart Clinic, Minneapolis, Minnesota.
| | - Shengxu Li
- Children's Minnesota Research Institute, Minneapolis, Minnesota
| | - Gregory J Schears
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael E Nemergut
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kendra Gram
- Mayo Clinic Children's Minnesota Cardiovascular Collaborative, Mayo Clinic, Rochester, Minnesota; Divisions of Cardiovascular Critical Care, Children's Minnesota, Minneapolis, Minnesota; The Children's Heart Clinic, Minneapolis, Minnesota
| | - Dave Watson
- Children's Minnesota Research Institute, Minneapolis, Minnesota
| | - David M Overman
- Mayo Clinic Children's Minnesota Cardiovascular Collaborative, Mayo Clinic, Rochester, Minnesota; The Children's Heart Clinic, Minneapolis, Minnesota; Cardiovascular Surgery, Children's Minnesota, Minneapolis, Minnesota
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Ashikhmina Swan E, Brinkman NJ, Lahr BD, Nemergut ME, Dearani JA, Stephens EH. Activated Prothrombin Complex Concentrate in Pediatric Cardiac Patients, Our Early Experience. World J Pediatr Congenit Heart Surg 2023:21501351231174828. [PMID: 37272063 DOI: 10.1177/21501351231174828] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Pediatric cardiac surgery is associated with abnormal coagulation, bleeding, and nearly ubiquitous transfusions. With the popularization of patient blood management, attempts are being made to decrease liberal transfusions by administering prothrombin complex concentrates (PCCs). The safety and efficacy of PCCs in adult cardiac surgery has been studied extensively, but only few reports address this in children. We performed an observational study focused on transfusion requirements after off-label use of activated PCC Factor Eight Inhibitor Bypassing Activity (FEIBA) as an adjunct to post-cardiopulmonary bypass (CPB) hemostatic protocol. METHODS We reviewed the medical records of children ≤15 kg undergoing cardiac operations with CPB between May 2018 and March 2022. A propensity score (PS) analysis was performed to identify matched pairs of patients who did and did not receive FEIBA. RESULTS Out of 210 patients who met the inclusion criteria, 44 patients received FEIBA. Propensity score-based analysis identified 40 matched pairs of patients with similar baseline characteristics. There was no statistically significant difference in the primary outcome-the volume of transfusion after CPB, which included all allogeneic blood products and salvaged washed red cells administered after protamine. Specifically, FEIBA patients were transfused 28 (22-34) mL/kg and controls were transfused 22 (11-49) mL/kg, P = .989. Upon arrival to ICU, the FEIBA group averaged an 8% lower international normalized ratio, compared with the controls (P = .009) and a 1.08 g/dL higher hemoglobin (P = .050). Neither difference remained significant on POD 1. CONCLUSIONS In this exploratory study, we found no change in transfusion requirements after CPB despite FEIBA administration.
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Affiliation(s)
- Elena Ashikhmina Swan
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Brian D Lahr
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | | | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
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Wong AV, Balakrishnan K, Nemergut ME. Inability to Mask Ventilate During Myringotomy Tube Replacement: A Case Report. A A Pract 2020; 14:72-74. [PMID: 31850923 DOI: 10.1213/xaa.0000000000001151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We present the case of a 3-year-old female with multiple congenital anomalies, including postprandial otorrhea, who developed the inability to be mask ventilated secondary to a combination of velopharyngeal insufficiency and tympanic membrane perforation. When applied by mask, positive pressure ventilation was observed to preferentially escape the patient's left ear, resulting in significant air leak, insufficient tidal volumes, hypoventilation, and severe hypoxemia. The problem was remedied by the insertion of a finger into the patient's external auditory meatus, which controlled the air leak until the surgical team could provide definitive surgical correction of the velopharyngeal insufficiency and nasopharyngeal reflux.
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Affiliation(s)
- Ashley V Wong
- From the Department of Anesthesia and Perioperative Medicine
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5
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Padhya DR, Prutsky GJ, Nemergut ME, Schears GS, Flick RP, Farah W, Wang Z, Prokop LJ, Murad MH, Alsawas M. Routine laboratory measures of heparin anticoagulation for children on extracorporeal membrane oxygenation: Systematic review and meta-analysis. Thromb Res 2019; 179:132-139. [PMID: 31132667 DOI: 10.1016/j.thromres.2019.05.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 02/04/2019] [Revised: 05/03/2019] [Accepted: 05/06/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Specific protocols for anticoagulation for children on ECMO vary across institutions, with most using a continuous infusion of unfractionated heparin. The goal of this study is to aid clinician's decision on the best measure of heparin anticoagulation test; which would be the one that correlates well with heparin activity and helps in predicting hemorrhagic and thrombotic complications. DATA SOURCES A comprehensive search of MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Scopus was conducted from each database's inception to 07/13/2018. STUDY SELECTION Studies evaluating children (<18 years) treated with ECMO and evaluating ACT, aPTT, TEG and Anti-Xa in any language were included. DATA EXTRACTION Two reviewers selected and appraised studies independently, and abstracted data. RESULTS We included 19 studies (759 patients, mean age 19.8 months). Meta-analysis showed strong correlation between heparin dosing and anti-Xa. Additionally, there was not a strong correlation between laboratory tests and complications (hemorrhagic and thrombosis), or mortality. CONCLUSION Based on current evidence, Anti-Xa is the only laboratory test that shows strong correlation with heparin infusion dose and seems like the most suitable test for monitoring of anticoagulation with heparin in children on ECMO.
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Affiliation(s)
- D R Padhya
- Department of Pediatrics, Reading Hospital, Reading, PA, USA
| | - G J Prutsky
- Department of Pediatrics, Mayo Clinic Health System, Mankato, MN, USA; Unidad de Conocimiento y Evidencia (CONEVID), Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - M E Nemergut
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - G S Schears
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - R P Flick
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - W Farah
- Internal Medicine, St Joseph Mercy Hospital, Ann Arbor, MA, USA
| | - Z Wang
- Mayo Clinic, Evidence-based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - L J Prokop
- Mayo Clinic Libraries, Rochester, MN, USA
| | - M H Murad
- Mayo Clinic, Evidence-based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - M Alsawas
- Mayo Clinic, Evidence-based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
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Said SM, Qureshi MY, Taggart NW, Anderson HN, O'Leary PW, Cetta F, Alrahmani L, Cofer SA, Segura LG, Pike RB, Sharpe EE, Derleth DP, Nemergut ME, Van Dorn CS, Gleich SJ, Rose CH, Collura CA, Ruano R. Innovative 2-Step Management Strategy Utilizing EXIT Procedure for a Fetus With Hypoplastic Left Heart Syndrome and Intact Atrial Septum. Mayo Clin Proc 2019; 94:356-361. [PMID: 30711131 DOI: 10.1016/j.mayocp.2018.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 06/17/2018] [Accepted: 08/08/2018] [Indexed: 11/23/2022]
Abstract
Hypoplastic left heart syndrome (HLHS) with intact atrial septum (HLHS-IAS) carries a high risk of mortality and affects about 6% of all patients with HLHS. Fetal interventions, postnatal transcatheter interventions, and postnatal surgical resection have all been used, but the mortality risk continues to be high in this subgroup of patients. We describe a novel, sequential approach to manage HLHS-IAS and progressive fetal hydrops. A 28-year-old, gravida 4 para 2 mother was referred to Mayo Clinic for fetal HLHS. Fetal echocardiography at 28 weeks of gestation demonstrated HLHS-IAS with progressive fetal hydrops. The atrial septum was thick and muscular with no interatrial communication. Ultrasound-guided fetal atrial septostomy was performed with successful creation of a small atrial communication. However, fetal echocardiogram at 33 weeks of gestation showed recurrence of a pleural effusion and restriction of the atrial septum. We proceeded with an Ex uteroIntrapartum Treatment (EXIT) delivery and open atrial septectomy. This was performed successfully, and the infant was stabilized in the intensive care unit. The infant required venoarterial extracorporeal membrane oxygenator support on day of life 1. The patient later developed hemorrhagic complications, leading to his demise on day of life 9. This is the first reported case of an EXIT procedure and open atrial septectomy performed without cardiopulmonary bypass for an open-heart operation and provides a promising alternative strategy for the management of HLHS-IAS in select cases.
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Affiliation(s)
- Sameh M Said
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN
| | | | - Nathaniel W Taggart
- Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Heather N Anderson
- Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Patrick W O'Leary
- Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Frank Cetta
- Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Layan Alrahmani
- Division of Obstetrics and Maternal Fetal Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Shelagh A Cofer
- Division of Pediatric Otorhinolaryngology, Mayo Clinic College of Medicine, Rochester, MN
| | - Leal G Segura
- Division of Pediatric Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Roxann B Pike
- Division of Cardiovascular Anesthesia, Mayo Clinic College of Medicine, Rochester, MN
| | - Emily E Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Douglas P Derleth
- Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Michael E Nemergut
- Division of Pediatric Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Charlotte S Van Dorn
- Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Stephen J Gleich
- Division of Pediatric Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Carl H Rose
- Division of Obstetrics and Maternal Fetal Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | | | - Rodrigo Ruano
- Division of Obstetrics and Maternal Fetal Medicine, Mayo Clinic College of Medicine, Rochester, MN.
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Thalji L, Thum D, Weister TJ, Weber WV, Stubbs JR, Kor DJ, Nemergut ME. Incidence and Epidemiology of Perioperative Transfusion-Related Pulmonary Complications in Pediatric Noncardiac Surgical Patients. Anesth Analg 2018; 127:1180-1188. [DOI: 10.1213/ane.0000000000003574] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
Each year millions of young children undergo procedures requiring sedation or general anesthesia. An increasing proportion of the anesthetics used are provided to optimize diagnostic imaging studies such as magnetic resonance imaging. Concern regarding the neurotoxicity of sedatives and anesthetics has prompted the US Food and Drug Administration to change labeling of anesthetics and sedative agents warning against repeated or prolonged exposure in young children. This review aims to summarize the risk of anesthesia in children with an emphasis on anesthetic-related neurotoxicity, acknowledge the value of pediatric neuroimaging, and address this call for conversation.
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Affiliation(s)
- Kara A Bjur
- 1 Division of Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eric T Payne
- 2 Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Danqing Hu
- 4 Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Randall P Flick
- 3 Division of Pediatric Anesthesiology, Mayo Clinic, Rochester, MN, USA
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Gleich SJ, Tien M, Schroeder DR, Hanson AC, Flick R, Nemergut ME. Anesthetic Outcomes of Children With Arthrogryposis Syndromes. Anesth Analg 2017; 124:908-914. [DOI: 10.1213/ane.0000000000001822] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Affiliation(s)
- Stephen J Gleich
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA. .,Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Michael E Nemergut
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA.,Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
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11
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Kaur H, Naessens JM, Hanson AC, Fryer K, Nemergut ME, Tripathi S. PROPER: Development of an Early Pediatric Intensive Care Unit Readmission Risk Prediction Tool. J Intensive Care Med 2016; 33:29-36. [PMID: 27601481 DOI: 10.1177/0885066616665806] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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: 11/17/2022]
Abstract
OBJECTIVE No risk prediction model is currently available to measure patient's probability for readmission to the pediatric intensive care unit (PICU). This retrospective case-control study was designed to assess the applicability of an adult risk prediction score (Stability and Workload Index for Transfer [SWIFT]) and to create a pediatric version (PRediction Of PICU Early Readmissions [PROPER]). DESIGN Eighty-six unplanned early (<48 hours) PICU readmissions from January 07, 2007, to June 30, 2014, were compared with 170 random controls. Patient- and disease-specific data and PICU workload factors were compared across the 2 groups. Factors statistically significant on multivariate analysis were included in the creation of the risk prediction model. The SWIFT scores were calculated for cases and controls and compared for validation. RESULTS Readmitted patients were younger, weighed less, and were more likely to be admitted from the emergency department. There were no differences in gender, race, or admission Pediatric Index of Mortality scores. A higher proportion of patients in the readmission group had a Pediatric Cerebral Performance Category in the moderate to severe disability category. Cases and controls did not differ with respect to staff workload at discharge or discharge day of the week; there was a much higher proportion of patients on supplemental oxygen in the readmission group. Only 2 of 5 categories in the SWIFT model were significantly different, and although the median SWIFT score was significantly higher in the readmissions group, the model discriminated poorly between cases and controls (area under the curve: 0.613). A 7-category PROPER score was created based on a multiple logistic regression model. Sensitivity of this model (score ≥12) for the detection of readmission was 81% with a positive predictive value of 0.50. CONCLUSION We have created a preliminary model for predicting patients at risk of early readmissions to the PICU from the hospital floor. The SWIFT score is not applicable for predicting the risk for pediatric population.
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Affiliation(s)
- Harsheen Kaur
- 1 Department of Pediatric Critical Care, Mayo Clinic, Rochester, MN, USA
| | - James M Naessens
- 2 Department of Health Science Research, Mayo Clinic, Rochester, MN, USA
| | - Andrew C Hanson
- 2 Department of Health Science Research, Mayo Clinic, Rochester, MN, USA
| | - Karen Fryer
- 1 Department of Pediatric Critical Care, Mayo Clinic, Rochester, MN, USA
| | | | - Sandeep Tripathi
- 4 Pediatric Critical Care, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
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12
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Gleich SJ, Nemergut ME, Stans AA, Haile DT, Feigal SA, Heinrich AL, Bosley CL, Tripathi S. Improvement in Patient Transfer Process From the Operating Room to the PICU Using a Lean and Six Sigma-Based Quality Improvement Project. Hosp Pediatr 2016; 6:483-489. [PMID: 27471214 DOI: 10.1542/hpeds.2015-0232] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [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: 06/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Ineffective and inefficient patient transfer processes can increase the chance of medical errors. Improvements in such processes are high-priority local institutional and national patient safety goals. At our institution, nonintubated postoperative pediatric patients are first admitted to the postanesthesia care unit before transfer to the PICU. This quality improvement project was designed to improve the patient transfer process from the operating room (OR) to the PICU. METHODS After direct observation of the baseline process, we introduced a structured, direct OR-PICU transfer process for orthopedic spinal fusion patients. We performed value stream mapping of the process to determine error-prone and inefficient areas. We evaluated primary outcome measures of handoff error reduction and the overall efficiency of patient transfer process time. Staff satisfaction was evaluated as a counterbalance measure. RESULTS With the introduction of the new direct OR-PICU patient transfer process, the handoff communication error rate improved from 1.9 to 0.3 errors per patient handoff (P = .002). Inefficiency (patient wait time and non-value-creating activity) was reduced from 90 to 32 minutes. Handoff content was improved with fewer information omissions (P < .001). Staff satisfaction significantly improved among nearly all PICU providers. CONCLUSIONS By using quality improvement methodology to design and implement a new direct OR-PICU transfer process with a structured multidisciplinary verbal handoff, we achieved sustained improvements in patient safety and efficiency. Handoff communication was enhanced, with fewer errors and content omissions. The new process improved efficiency, with high staff satisfaction.
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Affiliation(s)
| | | | | | | | | | | | | | - Sandeep Tripathi
- Department of Clinical Pediatrics, University of Illinois College of Medicine, Peoria, Illinois
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Kaur H, Rohlik GM, Nemergut ME, Tripathi S. Comparison of staff and family perceptions of causes of noise pollution in the Pediatric Intensive Care Unit and suggested intervention strategies. Noise Health 2016; 18:78-84. [PMID: 26960784 PMCID: PMC4918686 DOI: 10.4103/1463-1741.178480] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Noise and excessive, unwanted sound in the Pediatric Intensive Care Unit (PICU) is common and has a major impact on patients' sleep and recovery. Previous research has focused mostly on absolute noise levels or included only staff as respondents to acknowledge the causes of noise and to plan for its reduction. Thus far, the suggested interventions have not ameliorated noise, and it continues to serve as a barrier to recovery. In addition to surveying PICU providers through internet-based software, patients' families were evaluated through in-person interviews utilizing a pretested instrument over 3 months. Families of patients admitted for more than 24 h were considered eligible for evaluation. Participants were asked to rank causes of noise from 1 to 8, with eight being highest, and identified potential interventions as effective or ineffective. In total, 50 families from 251 admissions and 65 staff completed the survey. Medical alarms were rated highest (mean ± standard deviation [SD], 4.9 ± 2.1 [2.8-7.0]), followed by noise from medical equipment (mean ± SD, 4.7 ± 2.1 [2.5-6.8]). This response was consistent among PICU providers and families. Suggested interventions to reduce noise included keeping a patient's room door closed, considered effective by 93% of respondents (98% of staff; 88% of families), and designated quiet times, considered effective by 82% (80% of staff; 84% of families). Keeping the patient's door closed was the most effective strategy among survey respondents. Most families and staff considered medical alarms an important contributor to noise level. Because decreasing the volume of alarms such that it cannot be heard is inappropriate, alternative strategies to alert staff of changes in vital signs should be explored.
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Affiliation(s)
- Harsheen Kaur
- Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
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14
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Räsänen J, Nemergut ME, Gavriely N. Effect of PEEP on breath sound power spectra in experimental lung injury. Intensive Care Med Exp 2015; 2:25. [PMID: 26266922 PMCID: PMC4512991 DOI: 10.1186/s40635-014-0025-y] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 09/09/2014] [Indexed: 11/10/2022] Open
Abstract
Background Acute lung injury (ALI) is known to be associated with the emergence of inspiratory crackles and enhanced transmission of artificial sounds from the airway opening to the chest wall. Recently, we described the effect of ALI on the basic flow-induced breath sounds, separated from the crackles. In this study, we investigated the effects of positive end-expiratory pressure (PEEP) on these noncrackling basic lung sounds augmented during ALI. Methods Lung sounds were recorded in six anesthetized, intubated, and mechanically ventilated pigs at three locations bilaterally on the chest wall. Recordings were obtained before and after induction of lung injury with oleic acid and during application of incremental positive end-expiratory pressure. Results Oleic acid injections caused severe pulmonary edema predominately in the dependent-lung regions. Inspiratory spectral power of breath sounds increased in all lung regions over a frequency band from 150 to 1,200 Hz, with further power augmentation in dependent-lung areas at higher frequencies. Incremental positive end-expiratory pressure reversed the spectral power augmentation seen with ALI, reducing it to pre-injury levels with PEEP of 10 and 15 cmH2O in all lung regions at all frequencies. The application of positive end-expiratory pressure to normal lungs attenuated spectral power slightly and only over a band from 150 to 1,200 Hz. Conclusions We confirm a gravity-related spectral amplitude increase of basic flow-induced breath sounds recorded over lung regions affected by permeability-type pulmonary edema and show that such changes are reversible by alveolar recruitment with PEEP. Electronic supplementary material The online version of this article (doi:10.1186/s40635-014-0025-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jukka Räsänen
- Department of Anesthesiology, H. Lee Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL, 33612-9416, USA,
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Kaushik R, Krisch IM, Schroeder DR, Flick R, Nemergut ME. Pediatric bicycle-related head injuries: a population-based study in a county without a helmet law. Inj Epidemiol 2015; 2:16. [PMID: 27747748 PMCID: PMC5005552 DOI: 10.1186/s40621-015-0048-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 06/08/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Head injuries are the leading cause of death among cyclists, 85 % of which can be prevented by wearing a bicycle helmet. This study aims to estimate the incidence of pediatric bicycle-related injuries in Olmsted County and assess differences in injuries between those wearing helmets vs. not. METHODS Olmsted County, Minnesota residents 5 to 18 years of age with a diagnostic code consistent with an injury associated with the use of a bicycle between January 1, 2002, and December 31, 2011, were identified. Incidence rates were calculated and standardized to the age and sex distribution of the 2000 US white population. Type of injuries, the percentage requiring head CT or X-ray, and hospitalization were compared using a chi-square test. Pediatric intensive care unit (PICU) admission, permanent neurologic injury, seizure, need for mechanical ventilation, and mortality were compared using Fisher's exact test. RESULTS A total of 1189 bicycle injuries were identified. The overall age-adjusted incidence rate of all injuries was 278 (95 % CI, 249 to 306) per 100,000 person-years for females and 589 (95 % CI, 549 to 629) for males. The corresponding rates for head injuries were 104 (95 % CI, 87 to 121) for females and 255 (95 % CI, 229 to 281) for males. Of patients with head injuries, 17.4 % were documented to have been wearing a helmet, 44.8 % were documented as not wearing a helmet, and 37.8 % had no helmet use documentation. Patients with a head injury who were documented as not wearing a helmet were significantly more likely to undergo imaging of the head (32.1 percent vs. 11.5 %; p < 0.001) and to experience a brain injury (28.1 vs. 13.8 %; p = 0.008). CONCLUSIONS Children and adolescents continue to ride bicycles without wearing helmets, resulting in severe head and facial injuries and mortality.
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Affiliation(s)
- Ruchi Kaushik
- Mayo Clinic Children's Center, 200 First Street SW, Mayo 16E, Rochester, MN, 55905, USA.
| | - Isabelle M Krisch
- Mayo Clinic Children's Center, 200 First Street SW, Mayo 16E, Rochester, MN, 55905, USA
| | - Darrell R Schroeder
- Mayo Clinic Children's Center, 200 First Street SW, Mayo 16E, Rochester, MN, 55905, USA
| | - Randall Flick
- Mayo Clinic Children's Center, 200 First Street SW, Mayo 16E, Rochester, MN, 55905, USA
| | - Michael E Nemergut
- Mayo Clinic Children's Center, 200 First Street SW, Mayo 16E, Rochester, MN, 55905, USA
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Gleich SJ, Nemergut ME, Stans AA, Haile DT, Feigal SA, Heinrich AL, Bosley CL, Ward JW, Tripathi S. Lean Six Sigma handoff process between operating room and pediatric ICU: improvement in patient safety, efficiency and effectiveness. Crit Care 2015. [PMCID: PMC4472799 DOI: 10.1186/cc14603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Kudchadkar SR, Nemergut ME. Propofol monotherapy for neonatal intubation provides high risk but few benefits. Acta Paediatr 2014; 103:e465. [PMID: 24990432 DOI: 10.1111/apa.12733] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Indexed: 11/28/2022]
Affiliation(s)
- Sapna R. Kudchadkar
- Department of Anesthesiology and Critical Care Medicine & Pediatrics; Division of Pediatric Anesthesiology and Critical Care Medicine; Charlotte R. Bloomberg Children's Center; Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Michael E. Nemergut
- Departments of Anesthesiology & Pediatrics; The Mayo Clinic; Rochester MN USA
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18
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Affiliation(s)
- Michael E Nemergut
- From the Departments of *Anesthesiology and †Pediatrics, Mayo College of Medicine, The Mayo Clinic, Rochester, Minnesota
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19
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Räsänen J, Nemergut ME, Gavriely N. Effect of positive end-expiratory pressure on acoustic wave propagation in experimental porcine lung injury. Clin Physiol Funct Imaging 2014; 35:134-41. [DOI: 10.1111/cpf.12138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 01/17/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Jukka Räsänen
- Department of Anesthesiology; H. Lee Moffitt Cancer Center; Tampa FL USA
| | - Michael E. Nemergut
- Departments of Anesthesiology and Pediatrics; Mayo Foundation for Education and Research; Rochester MN USA
| | - Noam Gavriely
- Technion - Israel Institute of Technology; Rappaport Faculty of Medicine; Haifa Israel
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20
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Abstract
Over the past decade, numerous preclinical and retrospective human studies have reported that the provision of anesthetic and sedative agents to infants and children may be associated with adverse neurodevelopmental outcomes. These data have gained widespread attention from professional and regulatory agencies, including the public at large. As such, pediatric anesthesiologists are being increasingly questioned by parents about the risks of anesthetic agents on their children's neurocognitive development. To impart a framework from which anesthesiologists may address the apprehensions of parents who actively bring up this issue, we review the data supporting anesthetic neurotoxicity and discuss its strengths and limitations. As many parents are not yet aware and do not actively raise these concerns, we also discuss whether such a conversation should be undertaken as a part of the consent process.
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Affiliation(s)
- Michael E Nemergut
- Departments of Anesthesiology and Pediatric and Adolescent Medicine, The Mayo Clinic, Rochester, MN, USA
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21
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Abstract
To evaluate the effect of acute lung injury on the frequency spectra of breath sounds, we made serial acoustic recordings from nondependent, midlung and dependent regions of both lungs in ten 35- to 45-kg anesthetized, intubated, and mechanically ventilated pigs during development of acute lung injury induced with intravenous oleic acid in prone or supine position. Oleic acid injections rapidly produced severe derangements in the gas exchange and mechanical properties of the lung, with an average increase in venous admixture from 16 ± 12 to 62 ± 16% (P < 0.01), and a reduction in dynamic respiratory system compliance from 25 ± 4 to 14 ± 4 ml/cmH2O (P < 0.01). A concomitant increase in sound power was seen in all lung regions (P < 0.05), predominantly in frequencies 150-800 Hz. The deterioration in gas exchange and lung mechanics correlated best with concurrent spectral changes in the nondependent lung regions. Acute lung injury increases the power of breath sounds likely secondary to redistribution of ventilation from collapsed to aerated parts of the lung and improved sound transmission in dependent, consolidated areas.
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Affiliation(s)
- Jukka Räsänen
- Department of Anesthesiology, H. Lee Moffitt Cancer Center, Tampa, Florida
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22
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Abstract
Patients with malignant hyperthermia experience an exaggerated metabolic response when exposed to volatile anesthetic gases and succinylcholine. The minimum concentration of anesthetic gas needed to trigger a malignant hyperthermia crisis in humans is unknown and may remain so because of the inherent risks associated with studying the complex nature of this rare and lethal genetic disorder. The Malignant Hyperthermia Association of the United States provides specific instructions on purging anesthesia machines of volatile agents to reduce the risk of exposure. However, these recommendations were developed from studies of older generation machines. Modern anesthesia workstations are more complex and contain more gas absorbing materials. A review of the literature found the current guidelines inadequate to prepare newer generation workstations, which require more time for purging anesthetic gases, autoclaving or replacement of parts, and modifications to the gas delivery system. Protocols must be developed to prepare newer generation anesthesia machines.
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Affiliation(s)
- Tae W. Kim
- Clinical Associate, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Michael E. Nemergut
- Pediatric Critical Care Fellow, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Abstract
Ran-binding protein 3 (RanBP3) is an approximately 55-kDa protein that functions as a cofactor for Crm1-mediated nuclear export. RanBP3 stimulates export by enhancing the affinity of Crm1 for Ran.GTP and cargo. However, important additional functions for this cofactor may exist. We now report that RanBP3 associates with the Ran-specific guanine nucleotide exchange factor, regulator of chromosome condensation 1 (RCC1). This interaction was stimulated by the addition of Ran; moreover, Ran.GDP, Ran.GTP, and Ran without nucleotide could all stimulate complex formation between RanBP3 and RCC1 even though binding of Ran.GDP to RanBP3 alone was undetectable. RanBP3 could also promote binding of Crm1 to RCC1 in the presence of Ran. Binding of RanBP3 to RCC1 increased the catalytic activity of RCC1 toward Ran, and importantly, the ability of RanBP3 to stimulate RCC1 was not affected by the presence of Crm1. These data indicate that RanBP3 acts as a scaffold protein to promote the efficient assembly of export complexes. By tethering Crm1 to catalytically enhanced RCC1, RanBP3 may lower the entropic barrier for the loading of Ran.GTP onto Crm1. We propose that this provides an additional mechanism by which RanBP3 facilitates export.
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Affiliation(s)
- Michael E Nemergut
- Department of Microbiology, The Center for Cell Signaling, The University of Virginia, Charlottesville, Virginia 22908, USA
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Gumienny TL, Brugnera E, Tosello-Trampont AC, Kinchen JM, Haney LB, Nishiwaki K, Walk SF, Nemergut ME, Macara IG, Francis R, Schedl T, Qin Y, Van Aelst L, Hengartner MO, Ravichandran KS. CED-12/ELMO, a novel member of the CrkII/Dock180/Rac pathway, is required for phagocytosis and cell migration. Cell 2001; 107:27-41. [PMID: 11595183 DOI: 10.1016/s0092-8674(01)00520-7] [Citation(s) in RCA: 445] [Impact Index Per Article: 19.3] [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: 01/26/2023]
Abstract
The C. elegans genes ced-2, ced-5, and ced-10, and their mammalian homologs crkII, dock180, and rac1, mediate cytoskeletal rearrangements during phagocytosis of apoptotic cells and cell motility. Here, we describe an additional member of this signaling pathway, ced-12, and its mammalian homologs, elmo1 and elmo2. In C. elegans, CED-12 is required for engulfment of dying cells and for cell migrations. In mammalian cells, ELMO1 functionally cooperates with CrkII and Dock180 to promote phagocytosis and cell shape changes. CED-12/ELMO-1 binds directly to CED-5/Dock180; this evolutionarily conserved complex stimulates a Rac-GEF, leading to Rac1 activation and cytoskeletal rearrangements. These studies identify CED-12/ELMO as an upstream regulator of Rac1 that affects engulfment and cell migration from C. elegans to mammals.
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Affiliation(s)
- T L Gumienny
- Cold Spring Harbor Laboratory, 1 Bungtown Road, Cold Spring Harbor, NY 11743, USA
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Abstract
The Ran guanosine triphosphatase (GTPase) controls nucleocytoplasmic transport, mitotic spindle formation, and nuclear envelope assembly. These functions rely on the association of the Ran-specific exchange factor, RCC1 (regulator of chromosome condensation 1), with chromatin. We find that RCC1 binds directly to mononucleosomes and to histones H2A and H2B. RCC1 utilizes these histones to bind Xenopus sperm chromatin, and the binding of RCC1 to nucleosomes or histones stimulates the catalytic activity of RCC1. We propose that the docking of RCC1 to H2A/H2B establishes the polarity of the Ran-GTP gradient that drives nuclear envelope assembly, nuclear transport, and other nuclear events.
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Affiliation(s)
- M E Nemergut
- Center for Cell Signaling, University of Virginia, Charlottesville, VA 22908, USA.
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Nemergut ME, Macara IG. Nuclear import of the ran exchange factor, RCC1, is mediated by at least two distinct mechanisms. J Cell Biol 2000; 149:835-50. [PMID: 10811825 PMCID: PMC2174574 DOI: 10.1083/jcb.149.4.835] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.4] [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: 02/02/2000] [Accepted: 04/13/2000] [Indexed: 01/19/2023] Open
Abstract
RCC1, the only known guanine-nucleotide exchange factor for the Ran GTPase, is an approximately 45-kD nuclear protein that can bind chromatin. An important question concerns how RCC1 traverses the nuclear envelope. We now show that nuclear RCC1 is not exported readily in interphase cells and that the import of RCC1 into the nucleoplasm is extremely rapid. Import can proceed by at least two distinct mechanisms. The first is a classic import pathway mediated by basic residues within the NH(2)-terminal domain (NTD) of RCC1. This pathway is dependent upon both a preexisting Ran gradient and energy, and preferentially uses the importin-alpha3 isoform of importin-alpha. The second pathway is not mediated by the NTD of RCC1. This novel pathway does not require importin-alpha or importin-beta or the addition of any other soluble factor in vitro; however, this pathway is saturable and sensitive only to a subset of inhibitors of classical import pathways. Furthermore, the nuclear import of RCC1 does not require a preexisting Ran gradient or energy. We speculate that this second import pathway evolved to ensure that RCC1 never accumulates in the cytoplasm.
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Affiliation(s)
- M E Nemergut
- Department of Microbiology, Markey Center for Cell Signaling, University of Virginia, Charlottesville, Virginia 22908, USA.
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