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Fitzpatrick G, Huang Y, Qiu F, Habgood MD, Medcalf RL, Ho H, Dziegielewska KM, Saunders NR. Entry of cannabidiol into the fetal, postnatal and adult rat brain. Cell Tissue Res 2024; 396:177-195. [PMID: 38366086 DOI: 10.1007/s00441-024-03867-w] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/22/2024] [Indexed: 02/18/2024]
Abstract
Cannabidiol is a major component of cannabis but without known psychoactive properties. A wide range of properties have been attributed to it, such as anti-inflammatory, analgesic, anti-cancer, anti-seizure and anxiolytic. However, being a fairly new compound in its purified form, little is known about cannabidiol brain entry, especially during development. Sprague Dawley rats at four developmental ages: embryonic day E19, postnatal day P4 and P12 and non-pregnant adult females were administered intraperitoneal cannabidiol at 10 mg/kg with [3H] labelled cannabidiol. To investigate the extent of placental transfer, the drug was injected intravenously into E19 pregnant dams. Levels of [3H]-cannabidiol in blood plasma, cerebrospinal fluid and brain were estimated by liquid scintillation counting. Plasma protein binding of cannabidiol was identified by polyacrylamide gel electrophoresis and its bound and unbound fractions measured by ultrafiltration. Using available RNA-sequencing datasets of E19 rat brain, choroid plexus and placenta, as well as P5 and adult brain and choroid plexus, expression of 13 main cannabidiol receptors was analysed. Results showed that cannabidiol rapidly entered both the developing and adult brains. Entry into CSF was more limited. Its transfer across the placenta was substantially restricted as only about 50% of maternal blood plasma cannabidiol concentration was detected in fetal plasma. Albumin was the main, but not exclusive, cannabidiol binding protein at all ages. Several transcripts for cannabidiol receptors were expressed in age- and tissue-specific manner indicating that cannabidiol may have different functional effects in the fetal compared to adult brain.
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Affiliation(s)
- Georgia Fitzpatrick
- Department of Neuroscience, Monash University, Melbourne, VIC, 3004, Australia
| | - Yifan Huang
- Department of Neuroscience, Monash University, Melbourne, VIC, 3004, Australia
| | - Fiona Qiu
- Department of Neuroscience, Monash University, Melbourne, VIC, 3004, Australia
| | - Mark D Habgood
- Department of Neuroscience, Monash University, Melbourne, VIC, 3004, Australia
| | - Robert L Medcalf
- Department of Neuroscience, Monash University, Melbourne, VIC, 3004, Australia
| | - Heidi Ho
- Department of Neuroscience, Monash University, Melbourne, VIC, 3004, Australia
| | | | - Norman R Saunders
- Department of Neuroscience, Monash University, Melbourne, VIC, 3004, Australia.
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Barrett CD, Neal MD, Schoenecker JG, Medcalf RL, Myles PS. Tranexamic acid in trauma: After 3 hours from injury, when is it safe and effective to use again? Transfusion 2024. [PMID: 38461482 DOI: 10.1111/trf.17779] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/22/2024] [Accepted: 02/26/2024] [Indexed: 03/12/2024]
Abstract
Tranexamic acid (TXA) has proven mortality benefit if used early after traumatic injury, likely related to a combination of bleeding reduction and other non-bleeding effects. If TXA is given more than 3 h after traumatic injury, there is a significant and paradoxical increased risk of death due to bleeding. TXA has level 1 evidence for use as a bleeding reduction agent in isolated orthopedic operations, but in polytrauma patients undergoing orthopedic operations, it is not clear if and when TXA is safe or effective once outside the 3-h window of proven trauma efficacy.
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Affiliation(s)
- Christopher D Barrett
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jonathan G Schoenecker
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
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3
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McQuilten ZK, Wood EM, Medcalf RL. When to use tranexamic acid for the treatment of major bleeding? J Thromb Haemost 2024; 22:581-593. [PMID: 37827378 DOI: 10.1016/j.jtha.2023.10.001] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 08/15/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023]
Abstract
Tranexamic acid (TXA) is an antifibrinolytic agent originally developed for the management of bleeding in the setting of postpartum hemorrhage (PPH). Over the last 15 years, there has been accumulating evidence on the use of TXA for the treatment of active bleeding in a variety of clinical contexts. Clinical trials have shown that the efficacy and safety of TXA for the treatment of bleeding differ according to the clinical context in which it is being administered, timing of administration, and dose. Early administration is important for efficacy, particularly in trauma and PPH. Further studies are needed to understand the mechanisms by which TXA provides benefit, optimal modes of administration and dosing, and its effect in some clinical settings, such as spontaneous intracerebral hemorrhage. There is no evidence that TXA increases the risk of thrombotic events in patients with major bleeding overall. However, there is evidence of increased risk of venous thrombosis in patients with gastrointestinal bleeding. There is also evidence of increased risk of seizures with the use of higher doses. This review summarizes the current evidence for the use of TXA for patients with active bleeding and highlights the importance of generating evidence of efficacy and safety of hemostatic interventions specific to the bleeding contexts-as findings from 1 clinical setting may not be generalizable to other contexts-and that of individual patient assessment for bleeding, thrombotic, and other risks, as well as important logistical and other practical considerations, to optimize care and outcomes in these settings.
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Affiliation(s)
- Zoe K McQuilten
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Haematology, Monash Health, Melbourne, Victoria, Australia.
| | - Erica M Wood
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Haematology, Monash Health, Melbourne, Victoria, Australia
| | - Robert L Medcalf
- Central Clinical School, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
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Keragala CB, McFadyen JD, Ho H, McCutcheon FM, Liu Z, Stevens H, Monagle P, Chunilal S, Medcalf RL, Tran H. Plasma from patients with vaccine-induced immune thrombotic thrombocytopenia displays increased fibrinolytic potential and enhances tissue-type plasminogen activator but not urokinase-mediated plasminogen activation. J Thromb Haemost 2024; 22:785-793. [PMID: 37944898 DOI: 10.1016/j.jtha.2023.10.027] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/24/2023] [Accepted: 10/28/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare complication of adenovirus vector-based COVID-19 vaccines. VITT is associated with markedly raised levels of D-dimer; yet, how VITT modulates the fibrinolytic system is unknown. OBJECTIVES We aimed to compare changes in fibrinolytic activity in plasma from patients with VITT, patients diagnosed with venous thromboembolism (VTE) after vaccination but without VITT (VTE-no VITT), and healthy vaccinated controls. METHODS Plasma levels of plasmin-antiplasmin (PAP) complexes, plasminogen, and alpha-2-antiplasmin (α2AP) from 10 patients with VITT, 10 patients with VTE-no VITT, and 14 healthy vaccinated controls were evaluated by enzyme-linked immunosorbent assay and/or Western blotting. Fibrinolytic capacity was evaluated by quantitating PAP levels at baseline and after ex vivo plasma stimulation with 50-nM tissue-type plasminogen activator (tPA) or urokinase for 5 minutes. RESULTS Baseline PAP complex levels in control and VTE-no VITT individuals were similar but were ∼7-fold higher in plasma from patients with VITT (P < .0001). VITT samples also revealed consumption of α2AP and fibrinogenolysis consistent with a hyperfibrinolytic state. Of interest, VITT plasma produced significantly higher PAP levels after ex vivo treatment with tPA, but not urokinase, compared to the other groups, indicative of increased fibrinolytic potential. This was not due to D-dimer as addition of D-dimer to VTE-no VITT plasma failed to potentiate tPA-induced PAP levels. CONCLUSION A marked hyperfibrinolytic state occurs in patients with VITT, evidenced by marked elevations in PAP, α2AP consumption, and fibrinogenolysis. An unidentified plasma cofactor that selectively potentiates tPA-mediated plasminogen activation also appears to exist in the plasma of patients with VITT.
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Affiliation(s)
- Charithani B Keragala
- Australian Centre for Blood Diseases, the Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Hematology, Monash Health, Clayton, Victoria, Australia; School of Clinical Sciences, Monash Health, Monash University, Clayton, Victoria, Australia
| | - James D McFadyen
- Australian Centre for Blood Diseases, the Central Clinical School, Monash University, Melbourne, Victoria, Australia; Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Department of Hematology, Alfred Hospital, Melbourne, Victoria, Australia; Baker Department of Cardiometabolic Health, the University of Melbourne, Parkville, Victoria, Australia
| | - Heidi Ho
- Australian Centre for Blood Diseases, the Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Fiona M McCutcheon
- Australian Centre for Blood Diseases, the Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Zikou Liu
- Australian Centre for Blood Diseases, the Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Hannah Stevens
- Australian Centre for Blood Diseases, the Central Clinical School, Monash University, Melbourne, Victoria, Australia; Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Department of Hematology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Paul Monagle
- Department of Pediatrics, University of Melbourne, Melbourne, Victoria, Australia; Hematology Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Clinical Hematology, Royal Children's Hospital, Parkville, Victoria, Australia; Kids Cancer Centre, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Sanjeev Chunilal
- Department of Hematology, Monash Health, Clayton, Victoria, Australia; School of Clinical Sciences, Monash Health, Monash University, Clayton, Victoria, Australia
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, the Central Clinical School, Monash University, Melbourne, Victoria, Australia.
| | - Huyen Tran
- Australian Centre for Blood Diseases, the Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Hematology, Alfred Hospital, Melbourne, Victoria, Australia.
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Trinh N, Bhuskute KR, Varghese NR, Buchanan JA, Xu Y, McCutcheon FM, Medcalf RL, Jolliffe KA, Sunde M, New EJ, Kaur A. A Coumarin-Based Array for the Discrimination of Amyloids. ACS Sens 2024; 9:615-621. [PMID: 38315454 DOI: 10.1021/acssensors.3c01334] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Self-assembly of misfolded proteins can lead to the formation of amyloids, which are implicated in the onset of many pathologies including Alzheimer's disease and Parkinson's disease. The facile detection and discrimination of different amyloids are crucial for early diagnosis of amyloid-related pathologies. Here, we report the development of a fluorescent coumarin-based two-sensor array that is able to correctly discriminate between four different amyloids implicated in amyloid-related pathologies with 100% classification. The array was also applied to mouse models of Alzheimer's disease and was able to discriminate between samples from mice corresponding to early (6 months) and advanced (12 months) stages of Alzheimer's disease. Finally, the flexibility of the array was assessed by expanding the analytes to include functional amyloids. The same two-sensor array was able to correctly discriminate between eight different disease-associated and functional amyloids with 100% classification.
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Affiliation(s)
- Natalie Trinh
- School of Chemistry, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Kaustubh R Bhuskute
- Medicinal Chemistry, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Melbourne, Victoria 3052, Australia
- Australian Research Council Centre of Excellence for Innovations in Peptide and Protein Science, Monash University, Melbourne, Victoria 3052, Australia
| | - Nikhil R Varghese
- School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Jessica A Buchanan
- School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Yijia Xu
- Medicinal Chemistry, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Melbourne, Victoria 3052, Australia
| | - Fiona M McCutcheon
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria 3004, Australia
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria 3004, Australia
| | - Katrina A Jolliffe
- School of Chemistry, The University of Sydney, Sydney, New South Wales 2006, Australia
- Sydney Nano, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Margaret Sunde
- School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales 2006, Australia
- Sydney Nano, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Elizabeth J New
- School of Chemistry, The University of Sydney, Sydney, New South Wales 2006, Australia
- Australian Research Council Centre of Excellence for Innovations in Peptide and Protein Science, The University of Sydney, Sydney, New South Wales 2006, Australia
- Sydney Nano, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Amandeep Kaur
- Medicinal Chemistry, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Melbourne, Victoria 3052, Australia
- Australian Research Council Centre of Excellence for Innovations in Peptide and Protein Science, Monash University, Melbourne, Victoria 3052, Australia
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Mutch NJ, Medcalf RL. The fibrinolysis renaissance. J Thromb Haemost 2023; 21:3304-3316. [PMID: 38000850 DOI: 10.1016/j.jtha.2023.09.012] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 11/26/2023]
Abstract
Fibrinolysis is the system primarily responsible for removal of fibrin deposits and blood clots in the vasculature. The terminal enzyme in the pathway, plasmin, is formed from its circulating precursor, plasminogen. Fibrin is by far the most legendary substrate, but plasmin is notoriously prolific and is known to cleave many other proteins and participate in the activation of other proteolytic systems. Fibrinolysis is often overshadowed by the coagulation system and viewed as a simplistic poorer relation. However, the primordial plasminogen activators evolved alongside the complement system, approximately 70 million years before coagulation saw the light of day. It is highly likely that the plasminogen activation system evolved with its roots in primordial immunity. Almost all immune cells harbor at least one of a dozen plasminogen receptors that allow plasmin formation on the cell surface that in turn modulates immune cell behavior. Similarly, numerous pathogens express their own plasminogen activators or contain surface proteins that provide binding sites for host plasminogen. The fibrinolytic system has been harnessed for clinical medicine for many decades with the development of thrombolytic drugs and antifibrinolytic agents. Our refined understanding and appreciation of the fibrinolytic system and its alliance with infection and immunity and beyond are paving the way for new developments and interest in novel therapeutics and applications. One must ponder as to whether the nomenclature of the system hampered our understanding, by focusing on fibrin, rather than the complex myriad of interactions and substrates of the plasminogen activation system.
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Affiliation(s)
- Nicola J Mutch
- Aberdeen Cardiovascular & Diabetes Centre, Institute of Medical Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, UK.
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Kolev K, Medcalf RL. Editorial: Thrombosis meets inflammation. Front Immunol 2023; 14:1303385. [PMID: 37920472 PMCID: PMC10619713 DOI: 10.3389/fimmu.2023.1303385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 10/05/2023] [Indexed: 11/04/2023] Open
Affiliation(s)
- Krasimir Kolev
- Department of Biochemistry, Semmelweis University, Budapest, Hungary
| | - Robert L. Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
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Lam T, Medcalf RL, Cloud GC, Myles PS, Keragala CB. Tranexamic acid for haemostasis and beyond: does dose matter? Thromb J 2023; 21:94. [PMID: 37700271 PMCID: PMC10496216 DOI: 10.1186/s12959-023-00540-0] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/04/2023] [Indexed: 09/14/2023] Open
Abstract
Tranexamic acid (TXA) is a widely used antifibrinolytic agent that has been used since the 1960's to reduce blood loss in various conditions. TXA is a lysine analogue that competes for the lysine binding sites in plasminogen and tissue-type plasminogen activator impairing its interaction with the exposed lysine residues on the fibrin surface. The presence of TXA therefore, impairs the plasminogen and tPA engagement and subsequent plasmin generation on the fibrin surface, protecting fibrin clot from proteolytic degradation. However, critical lysine binding sites for plasmin(ogen) also exist on other proteins and on various cell-surface receptors allowing plasmin to exert potent effects on other targets that are unrelated to classical fibrinolysis, notably in relation to immunity and inflammation. Indeed, TXA was reported to significantly reduce post-surgical infection rates in patients after cardiac surgery unrelated to its haemostatic effects. This has provided an impetus to consider TXA in other indications beyond inhibition of fibrinolysis. While there is extensive literature on the optimal dosage of TXA to reduce bleeding rates and transfusion needs, it remains to be determined if these dosages also apply to blocking the non-canonical effects of plasmin.
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Affiliation(s)
- Tammy Lam
- Australian Centre for Blood Diseases, Monash AMREP Building, Monash University, Level 1 Walkway, Via The Alfred Centre, 99 Commercial Rd, Melbourne, 3004, Australia
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash AMREP Building, Monash University, Level 1 Walkway, Via The Alfred Centre, 99 Commercial Rd, Melbourne, 3004, Australia
| | - Geoffrey C Cloud
- Department of Clinical Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne VIC, Australia
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne VIC, Australia
| | - Charithani B Keragala
- Australian Centre for Blood Diseases, Monash AMREP Building, Monash University, Level 1 Walkway, Via The Alfred Centre, 99 Commercial Rd, Melbourne, 3004, Australia.
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Liu Z, McCutcheon FM, Ho H, Chia J, Xiao Y, Tippett I, Keragala CB, Cloud GC, Medcalf RL. Tranexamic acid in a mouse model of cerebral amyloid angiopathy: setting the stage for a novel stroke treatment approach. Res Pract Thromb Haemost 2023; 7:102166. [PMID: 37694270 PMCID: PMC10483050 DOI: 10.1016/j.rpth.2023.102166] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/22/2023] [Accepted: 07/04/2023] [Indexed: 09/12/2023] Open
Abstract
Background Symptomatic intracerebral hemorrhage (sICH) commonly occurs in patients with cerebral amyloid angiopathy (CAA). Amyloid also initiates plasminogen activation and might promote sICH. Objectives As amyloid-driven plasmin formation can be blocked by tranexamic acid (TXA), we aimed to evaluate the biodistribution and long-term consequences of TXA on brain amyloid-beta (Aβ) levels, inflammation, and neurologic function in APP/PS1 mice. Methods APP/PS1 mice overexpressing the mutant human amyloid precursor protein and wild-type littermates were randomized to TXA (20 mg/mL) or placebo in the drinking water for 6 months. TXA in plasma and various organs was determined by liquid chromatography-mass spectrometry. Plasmin activity assays were performed to evaluate changes in fibrinolytic activity. Neurologic function was evaluated by Y-maze and parallel rod floor testing. Proximity ligation-based immunoassays were used to quantitate changes of 92 biomarkers of inflammation. Brain Aβ levels were assessed by immunohistochemistry. Results Long-term oral TXA administration inhibited fibrinolysis. TXA accumulated in the kidney (19.4 ± 11.2 μg/g) with 2- to 5-fold lower levels seen in the lung, spleen, and liver. TXA levels were lowest in the brain (0.28 ± 0.01 μg/g). Over 6 months, TXA had no discernible effect on motor coordination, novelty preference, or brain Aβ levels. TXA reduced plasma levels of epithelial cell adhesion molecule and increased CCL20. Conclusion Long-term TXA treatment does not alter brain Aβ levels or impact neurologic behavior in mice predisposed to amyloid deposition and had minor effects on the levels of inflammatory mediators. This finding supports the safety of TXA and lays the foundation for TXA as a novel treatment to reduce sICH in patients with CAA.
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Affiliation(s)
- Zikou Liu
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Fiona M. McCutcheon
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Heidi Ho
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Joanne Chia
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Yunxin Xiao
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Isabel Tippett
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | | | - Geoffrey C. Cloud
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Robert L. Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
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Gruen RL, Mitra B, Bernard SA, McArthur CJ, Burns B, Gantner DC, Maegele M, Cameron PA, Dicker B, Forbes AB, Hurford S, Martin CA, Mazur SM, Medcalf RL, Murray LJ, Myles PS, Ng SJ, Pitt V, Rashford S, Reade MC, Swain AH, Trapani T, Young PJ. Prehospital Tranexamic Acid for Severe Trauma. N Engl J Med 2023; 389:127-136. [PMID: 37314244 DOI: 10.1056/nejmoa2215457] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [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: 06/15/2023]
Abstract
BACKGROUND Whether prehospital administration of tranexamic acid increases the likelihood of survival with a favorable functional outcome among patients with major trauma and suspected trauma-induced coagulopathy who are being treated in advanced trauma systems is uncertain. METHODS We randomly assigned adults with major trauma who were at risk for trauma-induced coagulopathy to receive tranexamic acid (administered intravenously as a bolus dose of 1 g before hospital admission, followed by a 1-g infusion over a period of 8 hours after arrival at the hospital) or matched placebo. The primary outcome was survival with a favorable functional outcome at 6 months after injury, as assessed with the use of the Glasgow Outcome Scale-Extended (GOS-E). Levels on the GOS-E range from 1 (death) to 8 ("upper good recovery" [no injury-related problems]). We defined survival with a favorable functional outcome as a GOS-E level of 5 ("lower moderate disability") or higher. Secondary outcomes included death from any cause within 28 days and within 6 months after injury. RESULTS A total of 1310 patients were recruited by 15 emergency medical services in Australia, New Zealand, and Germany. Of these patients, 661 were assigned to receive tranexamic acid, and 646 were assigned to receive placebo; the trial-group assignment was unknown for 3 patients. Survival with a favorable functional outcome at 6 months occurred in 307 of 572 patients (53.7%) in the tranexamic acid group and in 299 of 559 (53.5%) in the placebo group (risk ratio, 1.00; 95% confidence interval [CI], 0.90 to 1.12; P = 0.95). At 28 days after injury, 113 of 653 patients (17.3%) in the tranexamic acid group and 139 of 637 (21.8%) in the placebo group had died (risk ratio, 0.79; 95% CI, 0.63 to 0.99). By 6 months, 123 of 648 patients (19.0%) in the tranexamic acid group and 144 of 629 (22.9%) in the placebo group had died (risk ratio, 0.83; 95% CI, 0.67 to 1.03). The number of serious adverse events, including vascular occlusive events, did not differ meaningfully between the groups. CONCLUSIONS Among adults with major trauma and suspected trauma-induced coagulopathy who were being treated in advanced trauma systems, prehospital administration of tranexamic acid followed by an infusion over 8 hours did not result in a greater number of patients surviving with a favorable functional outcome at 6 months than placebo. (Funded by the Australian National Health and Medical Research Council and others; PATCH-Trauma ClinicalTrials.gov number, NCT02187120.).
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Affiliation(s)
- Russell L Gruen
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Biswadev Mitra
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Stephen A Bernard
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Colin J McArthur
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Brian Burns
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Dashiell C Gantner
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Marc Maegele
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Peter A Cameron
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Bridget Dicker
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Andrew B Forbes
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Sally Hurford
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Catherine A Martin
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Stefan M Mazur
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Robert L Medcalf
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Lynnette J Murray
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Paul S Myles
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Sze J Ng
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Veronica Pitt
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Stephen Rashford
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Michael C Reade
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Andrew H Swain
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Tony Trapani
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
| | - Paul J Young
- From the College of Health and Medicine, Australian National University (R.L.G.), Canberra Health Services (R.L.G.), and Joint Health Command, Australian Defence Force (M.C.R.), Canberra, ACT, the Emergency and Trauma Centre (B.M., P.A.C.) and the Departments of Anaesthesiology and Perioperative Medicine (P.S.M.) and Intensive Care (S.A.B., D.C.G.), Alfred Hospital, the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (D.C.G., L.J.M., S.J.N., T.T., P.J.Y.), the School of Public Health and Preventive Medicine (B.M., S.A.B., C.J.M., P.A.C., A.B.F., C.A.M., V.P.), the Australian Centre for Blood Diseases (R.L.M.), and the Central Clinical School (P.S.M.), Monash University, Ambulance Victoria (S.A.B.), and the Department of Critical Care, University of Melbourne (P.J.Y.), Melbourne, Aeromedical Operations, NSW Ambulance, Trauma Service, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Sydney (B.B.), MedSTAR Emergency Medical Retrieval Services, South Australian Ambulance Service (S.M.M.), and the Emergency Department, Royal Adelaide Hospital (S.M.M.), Adelaide, SA, and Queensland Ambulance Service (S.R.) and the Faculty of Medicine, University of Queensland (M.C.R.), Brisbane - all in Australia; Te Toka Tumai Auckland City Hospital (C.J.M.), Hato Hone St. John, Mt. Wellington (B.D.), and the Department of Paramedicine, Faculty of Health and Environmental Sciences, Auckland University of Technology (B.D., A.H.S.), Auckland, and Medical Research Institute of New Zealand (C.J.M., S.H., P.J.Y.), Wellington Free Ambulance (A.H.S.), and the Intensive Care Unit, Wellington Hospital (P.J.Y.), Wellington - all in New Zealand; Cologne-Merheim Medical Center, Department of Traumatology, Orthopedic Surgery, and Sports Medicine, and the Institute for Research in Operative Medicine, Witten-Herdecke University - both in Cologne, Germany (M.M.)
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Ameen SS, Griem-Krey N, Dufour A, Hossain MI, Hoque A, Sturgeon S, Nandurkar H, Draxler DF, Medcalf RL, Kamaruddin MA, Lucet IS, Leeming MG, Liu D, Dhillon A, Lim JP, Basheer F, Zhu HJ, Bokhari L, Roulston CL, Paradkar PN, Kleifeld O, Clarkson AN, Wellendorph P, Ciccotosto GD, Williamson NA, Ang CS, Cheng HC. N-Terminomic Changes in Neurons During Excitotoxicity Reveal Proteolytic Events Associated With Synaptic Dysfunctions and Potential Targets for Neuroprotection. Mol Cell Proteomics 2023; 22:100543. [PMID: 37030595 PMCID: PMC10199228 DOI: 10.1016/j.mcpro.2023.100543] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 02/23/2023] [Accepted: 04/04/2023] [Indexed: 04/10/2023] Open
Abstract
Excitotoxicity, a neuronal death process in neurological disorders such as stroke, is initiated by the overstimulation of ionotropic glutamate receptors. Although dysregulation of proteolytic signaling networks is critical for excitotoxicity, the identity of affected proteins and mechanisms by which they induce neuronal cell death remain unclear. To address this, we used quantitative N-terminomics to identify proteins modified by proteolysis in neurons undergoing excitotoxic cell death. We found that most proteolytically processed proteins in excitotoxic neurons are likely substrates of calpains, including key synaptic regulatory proteins such as CRMP2, doublecortin-like kinase I, Src tyrosine kinase and calmodulin-dependent protein kinase IIβ (CaMKIIβ). Critically, calpain-catalyzed proteolytic processing of these proteins generates stable truncated fragments with altered activities that potentially contribute to neuronal death by perturbing synaptic organization and function. Blocking calpain-mediated proteolysis of one of these proteins, Src, protected against neuronal loss in a rat model of neurotoxicity. Extrapolation of our N-terminomic results led to the discovery that CaMKIIα, an isoform of CaMKIIβ, undergoes differential processing in mouse brains under physiological conditions and during ischemic stroke. In summary, by identifying the neuronal proteins undergoing proteolysis during excitotoxicity, our findings offer new insights into excitotoxic neuronal death mechanisms and reveal potential neuroprotective targets for neurological disorders.
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Affiliation(s)
- S Sadia Ameen
- Department of Biochemistry and Pharmacology, University of Melbourne, Parkville, Victoria, Australia; Bio21 Molecular Science and Biotechnology Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Nane Griem-Krey
- Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Antoine Dufour
- Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
| | - M Iqbal Hossain
- Department of Biochemistry and Pharmacology, University of Melbourne, Parkville, Victoria, Australia; Bio21 Molecular Science and Biotechnology Institute, University of Melbourne, Parkville, Victoria, Australia; Department of Pharmacology and Toxicology, University of Alabama, Birmingham, Alabama, USA
| | - Ashfaqul Hoque
- St Vincent's Institute of Medical Research, Fitzroy, Victoria, Australia
| | - Sharelle Sturgeon
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Harshal Nandurkar
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Dominik F Draxler
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Mohd Aizuddin Kamaruddin
- Department of Biochemistry and Pharmacology, University of Melbourne, Parkville, Victoria, Australia; Bio21 Molecular Science and Biotechnology Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Isabelle S Lucet
- Chemical Biology Division, The Walter and Eliza Hall Institute for Medical Research, Parkville, Victoria, Australia; Department of Medical Biology, University of Melbourne, Parkville, Victoria, Australia
| | - Michael G Leeming
- Bio21 Molecular Science and Biotechnology Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Dazhi Liu
- Department of Neurology, School of Medicine, University of California, Davis, California, USA
| | - Amardeep Dhillon
- Faculty of Health, Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Waurn Ponds, Victoria, Australia
| | - Jet Phey Lim
- Faculty of Health, Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Waurn Ponds, Victoria, Australia
| | - Faiza Basheer
- Faculty of Health, Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Waurn Ponds, Victoria, Australia
| | - Hong-Jian Zhu
- Department of Surgery (Royal Melbourne Hospital), University of Melbourne, Parkville, Victoria, Australia
| | - Laita Bokhari
- Department of Biochemistry and Pharmacology, University of Melbourne, Parkville, Victoria, Australia; Bio21 Molecular Science and Biotechnology Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Carli L Roulston
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Prasad N Paradkar
- CSIRO Health & Biosecurity, Australian Centre for Disease Preparedness, East Geelong, Victoria, Australia
| | - Oded Kleifeld
- Faculty of Biology, Technion-Israel Institute of Technology, Technion City, Haifa, Israel
| | - Andrew N Clarkson
- Department of Anatomy, Brain Health Research Centre and Brain Research New Zealand, University of Otago, Dunedin, New Zealand
| | - Petrine Wellendorph
- Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Giuseppe D Ciccotosto
- Department of Biochemistry and Pharmacology, University of Melbourne, Parkville, Victoria, Australia; Bio21 Molecular Science and Biotechnology Institute, University of Melbourne, Parkville, Victoria, Australia.
| | - Nicholas A Williamson
- Bio21 Molecular Science and Biotechnology Institute, University of Melbourne, Parkville, Victoria, Australia.
| | - Ching-Seng Ang
- Bio21 Molecular Science and Biotechnology Institute, University of Melbourne, Parkville, Victoria, Australia.
| | - Heung-Chin Cheng
- Department of Biochemistry and Pharmacology, University of Melbourne, Parkville, Victoria, Australia; Bio21 Molecular Science and Biotechnology Institute, University of Melbourne, Parkville, Victoria, Australia.
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Smart C, Mitchell A, McCutcheon F, Medcalf RL, Thiele A. Tissue-type plasminogen activator induces conditioned receptive field plasticity in the mouse auditory cortex. iScience 2023; 26:105947. [PMID: 36711245 PMCID: PMC9874071 DOI: 10.1016/j.isci.2023.105947] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 12/13/2022] [Accepted: 01/05/2023] [Indexed: 01/09/2023] Open
Abstract
Tissue-type plasminogen activator (tPA) is a serine protease that is expressed in various compartments in the brain. It is involved in neuronal plasticity, learning and memory, and addiction. We evaluated whether tPA, exogenously applied, could influence neuroplasticity within the mouse auditory cortex. We used a frequency-pairing paradigm to determine whether neuronal best frequencies shift following the pairing protocol. tPA administration significantly affected the best frequency after pairing, whereby this depended on the pairing frequency relative to the best frequency. When the pairing frequency was above the best frequency, tPA caused a best frequency shift away from the conditioned frequency. tPA significantly widened auditory tuning curves. Our data indicate that regional changes in proteolytic activity within the auditory cortex modulate the fine-tuning of auditory neurons, supporting the function of tPA as a modulator of neuronal plasticity.
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Affiliation(s)
- Caitlin Smart
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, VIC 3004, Australia
| | - Anna Mitchell
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, VIC 3004, Australia
| | - Fiona McCutcheon
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, VIC 3004, Australia
| | - Robert L. Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, VIC 3004, Australia
| | - Alexander Thiele
- Biosciences Institute, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
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13
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Coupland LA, Rabbolini DJ, Schoenecker JG, Crispin PJ, Miller JJ, Ghent T, Medcalf RL, Aneman AE. Point-of-care diagnosis and monitoring of fibrinolysis resistance in the critically ill: results from a feasibility study. Crit Care 2023; 27:55. [PMID: 36765421 PMCID: PMC9912243 DOI: 10.1186/s13054-023-04329-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/22/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Fibrinolysisis is essential for vascular blood flow maintenance and is triggered by endothelial and platelet release of tissue plasminogen activator (t-PA). In certain critical conditions, e.g. sepsis, acute respiratory failure (ARF) and trauma, the fibrinolytic response is reduced and may lead to widespread thrombosis and multi-organ failure. The mechanisms underpinning fibrinolysis resistance include reduced t-PA expression and/or release, reduced t-PA and/or plasmin effect due to elevated inhibitor levels, increased consumption and/or clearance. This study in critically ill patients with fibrinolysis resistance aimed to evaluate the ability of t-PA and plasminogen supplementation to restore fibrinolysis with assessment using point-of-care ClotPro viscoelastic testing (VET). METHODS In prospective, observational studies, whole-blood ClotPro VET evaluation was carried out in 105 critically ill patients. In 32 of 58 patients identified as fibrinolysis-resistant (clot lysis time > 300 s on the TPA-test: tissue factor activated coagulation with t-PA accelerated fibrinolysis), consecutive experimental whole-blood VET was carried out with repeat TPA-tests spiked with additional t-PA and/or plasminogen and the effect on lysis time determined. In an interventional study in a patient with ARF and fibrinolysis resistance, the impact of a 24 h intravenous low-dose alteplase infusion on coagulation and fibrinolysis was prospectively monitored using standard ClotPro VET. RESULTS Distinct response groups emerged in the ex vivo experimental VET, with increased fibrinolysis observed following supplementation with (i) t-PA only or (ii) plasminogen and t-PA. A baseline TPA-test lysis time of > 1000 s was associated with the latter group. In the interventional study, a gradual reduction (25%) in serial TPA-test lysis times was observed during the 24 h low-dose alteplase infusion. CONCLUSIONS ClotPro viscoelastic testing, the associated TPA-test and the novel experimental assays may be utilised to (i) investigate the potential mechanisms of fibrinolysis resistance, (ii) guide corrective treatment and (iii) monitor in real-time the treatment effect. Such a precision medicine and personalised treatment approach to the management of fibrinolysis resistance has the potential to increase treatment benefit, while minimising adverse events in critically ill patients. TRIAL REGISTRATION VETtiPAT-ARF, a clinical trial evaluating ClotPro-guided t-PA (alteplase) administration in fibrinolysis-resistant patients with ARF, is ongoing (ClinicalTrials.gov NCT05540834 ; retrospectively registered September 15th 2022).
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Affiliation(s)
- Lucy A. Coupland
- grid.415994.40000 0004 0527 9653Intensive Care Unit, Liverpool Hospital, Liverpool, Australia ,grid.429098.eIngham Institute for Applied Medical Research, 1 Campbell St, Liverpool, NSW 2170 Australia
| | - David J. Rabbolini
- grid.1013.30000 0004 1936 834XKolling Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, Sydney, Australia ,grid.410556.30000 0001 0440 1440Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jonathan G. Schoenecker
- grid.412807.80000 0004 1936 9916Department of Orthopaedics and Pharmacology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Philip J. Crispin
- grid.413314.00000 0000 9984 5644Haematology Department, The Canberra Hospital, Canberra, Australia ,grid.1001.00000 0001 2180 7477The Australian National University Medical School, Canberra, Australia
| | - Jennene J. Miller
- grid.415994.40000 0004 0527 9653Intensive Care Unit, Liverpool Hospital, Liverpool, Australia
| | - Tony Ghent
- grid.413154.60000 0004 0625 9072Intensive Care Unit, Gold Coast University Hospital, South Port, Australia
| | - Robert L. Medcalf
- grid.1002.30000 0004 1936 7857Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Anders E. Aneman
- grid.415994.40000 0004 0527 9653Intensive Care Unit, Liverpool Hospital, Liverpool, Australia ,grid.429098.eIngham Institute for Applied Medical Research, 1 Campbell St, Liverpool, NSW 2170 Australia
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14
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McQuilten ZK, Venkatesh B, Jha V, Roberts J, Morpeth SC, Totterdell JA, McPhee GM, Abraham J, Bam N, Bandara M, Bangi AK, Barina LA, Basnet BK, Bhally H, Bhusal KR, Bogati U, Bowen AC, Burke AJ, Christopher DJ, Chunilal SD, Cochrane B, Curnow JL, Das SK, Dhungana A, Di Tanna GL, Dotel R, DSouza H, Dummer J, Dutta S, Foo H, Gilbey TL, Giles ML, Goli K, Gordon A, Gyanwali P, Haksar D, Hudson BJ, Jani MK, Jevaji PR, Jhawar S, Jindal A, John MJ, John M, John FB, John O, Jones M, Joshi RD, Kamath P, Kang G, Karki AR, Karmalkar AM, Kaur B, Koganti KC, Koshy JM, Krishnamurthy MS, Lau JS, Lewin SR, Lim LL, Marschner IC, Marsh JA, Maze MJ, McGree JM, McMahon JH, Medcalf RL, Merriman EG, Misal AP, Mora JM, Mudaliar VK, Nguyen V, O'Sullivan MV, Pant S, Pant P, Paterson DL, Price DJ, Rees MA, Robinson JO, Rogers BA, Samuel S, Sasadeusz J, Sharma D, Sharma PK, Shrestha R, Shrestha SK, Shrestha P, Shukla U, Shum O, Sommerville C, Spelman T, Sullivan RP, Thatavarthi U, Tran HA, Trask N, Whitehead CL, Mahar RK, Hammond NE, McFadyen JD, Snelling TL, Davis JS, Denholm JT, Tong SYC. Anticoagulation Strategies in Non-Critically Ill Patients with Covid-19. NEJM Evid 2023; 2:EVIDoa2200293. [PMID: 38320033 DOI: 10.1056/evidoa2200293] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Anticoagulation in Non-Critically Ill Covid-19 PatientsMcQuilten et al. conducted a randomized clinical trial comparing low-dose, intermediate-dose, low-dose plus aspirin, and therapeutic-dose anticoagulation in patients with Covid-19 of diverse ethnicities in high-, low-, and middle-income countries.
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Affiliation(s)
- Zoe K McQuilten
- Monash University, Melbourne, Australia
- Monash Health, Melbourne, Australia
| | - Balasubramanian Venkatesh
- University of Queensland, Brisbane, Australia
- The George Institute for Global Health, Sydney, Australia
- The George Institute for Global Health, Delhi, Delhi, India
- The Wesley Hospital, Brisbane, Queensland, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Vivekanand Jha
- The George Institute for Global Health, Delhi, Delhi, India
- Imperial College, London, England, United Kingdom
| | - Jason Roberts
- University of Queensland, Brisbane, Australia
- Metro North Health, Brisbane, Queensland, Australia
| | | | - James A Totterdell
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Grace M McPhee
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - John Abraham
- Christian Medical College, Ludhiana, Punjab, India
| | - Niraj Bam
- Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Bagmati, Nepal
| | - Methma Bandara
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Ashpak K Bangi
- Jivanrekha Multispeciality Hospital, Pune, Maharashtra, India
| | - Lauren A Barina
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Bhupendra K Basnet
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Bagmati, Nepal
| | - Hasan Bhally
- North Shore Hospital, Auckland, North Island, New Zealand
| | - Khema R Bhusal
- Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Bagmati, Nepal
| | - Umesh Bogati
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Bagmati, Nepal
| | - Asha C Bowen
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Perth Children's Hospital, Perth, Western Australia, Australia
| | - Andrew J Burke
- University of Queensland, Brisbane, Australia
- The Prince Charles Hospital, Brisbane, Queensland, Australia
| | | | - Sanjeev D Chunilal
- Monash University, Melbourne, Australia
- Monash Medical Centre, Melbourne, Victoria, Australia
| | - Belinda Cochrane
- Campbelltown Hospital, Campbelltown, New South Wales, Australia
- Western Sydney University, Sydney, New South Wales, Australia
| | - Jennifer L Curnow
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
| | - Santa Kumar Das
- Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Bagmati, Nepal
| | - Ashesh Dhungana
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Bagmati, Nepal
| | | | | | - Hyjel DSouza
- The George Institute for Global Health, Delhi, Delhi, India
| | - Jack Dummer
- University of Otago, Dunedin, Otago, New Zealand
- Dunedin Hospital, Dunedin, Otago, New Zealand
| | - Sourabh Dutta
- Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Hong Foo
- NSW Health Pathology, Sydney, New South Wales, Australia
| | - Timothy L Gilbey
- Wagga Wagga Base Hospital, Wagga Wagga, New South Wales, Australia
| | - Michelle L Giles
- Monash University, Melbourne, Australia
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Kasiram Goli
- Aditya Multi-speciality Hospital, Guntur, Andhra Pradesh, India
| | - Adrienne Gordon
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Newborn Care, Melbourne, Victoria, Australia
| | - Pradip Gyanwali
- Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Bagmati, Nepal
- Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Bagmati, Nepal
| | | | | | | | | | | | - Aikaj Jindal
- Satguru Partap Singh Hospitals, Ludhiana, Punjab, India
| | | | - Mary John
- Christian Medical College, Ludhiana, Punjab, India
| | | | - Oommen John
- The George Institute for Global Health, Delhi, Delhi, India
- Manipal Academy of Higher Education, Udupi, Karnataka, India
| | - Mark Jones
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Rajesh D Joshi
- The George Institute for Global Health, Delhi, Delhi, India
| | | | | | - Achyut R Karki
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Bagmati, Nepal
| | | | - Baldeep Kaur
- The George Institute for Global Health, Sydney, Australia
| | | | - Jency M Koshy
- Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | | | - Jillian S Lau
- Eastern Health, Melbourne, Victoria, Australia
- The Alfred Hospital, Melbourne, Victoria, Australia
| | - Sharon R Lewin
- Monash Health, Melbourne, Australia
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | | | - Ian C Marschner
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Julie A Marsh
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | | | - James M McGree
- Queensland University of Technology, Brisbane, Queensland, Australia
| | | | | | | | | | - Jocelyn M Mora
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | | | - Vi Nguyen
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Matthew V O'Sullivan
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
- NSW Health Pathology, Sydney, New South Wales, Australia
| | - Suman Pant
- Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Bagmati, Nepal
| | - Pankaj Pant
- Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Bagmati, Nepal
| | - David L Paterson
- National Institute of Singapore, Singapore, Singapore, Singapore
| | - David J Price
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Melbourne School of Population & Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Megan A Rees
- Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - James O Robinson
- College of Science, Health, Engineering and Education, Discipline of Health, Murdoch University, Perth, Western Australia, Australia
- PathWest Laboratory Medicine, Perth, Western Australia, Australia
| | - Benjamin A Rogers
- Monash University, Melbourne, Australia
- Monash Health, Melbourne, Australia
| | | | - Joe Sasadeusz
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Deepak Sharma
- Maharaja Agrasen Superspeciality Hospital, Delhi, Delhi, India
| | | | - Roshan Shrestha
- Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Bagmati, Nepal
| | - Sailesh K Shrestha
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Bagmati, Nepal
| | - Prajowl Shrestha
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Bagmati, Nepal
| | - Urvi Shukla
- Symbiosis University Hospital & Research Centre, Pune, Maharashtra, India
| | - Omar Shum
- The Wollongong Hospital, Wollongong, New South Wales, Australia
- University of Wollongong, Wollongong, New South Wales, Australia
| | - Christine Sommerville
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Tim Spelman
- Karolinska Institute, Solna, Stockholm, Sweden
- Burnet Institute, Melbourne, Victoria, Australia
| | - Richard P Sullivan
- St. George Hospital, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | | | - Huyen A Tran
- Monash University, Melbourne, Australia
- The Alfred Hospital, Melbourne, Victoria, Australia
| | - Nanette Trask
- Chartered Accountants Australia and New Zealand, Perth, Western Australia, Australia
| | - Clare L Whitehead
- The Royal Women's Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Robert K Mahar
- Melbourne School of Population & Global Health, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Perth, Western Australia, Australia
| | - Naomi E Hammond
- The George Institute for Global Health, Sydney, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - James D McFadyen
- The Alfred Hospital, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Thomas L Snelling
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Joshua S Davis
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- University of Newcastle, Newcastle, New South Wales, Australia
| | - Justin T Denholm
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Steven Y C Tong
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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15
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Palazzolo JS, Medcalf RL, Hagemeyer CE, Niego B. A novel ex vivo approach for measuring plasminogen activation upon established plasma clots. Res Pract Thromb Haemost 2022; 6:S2475-0379(22)00162-5. [PMID: 35873220 PMCID: PMC9301473 DOI: 10.1002/rth2.12771] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/31/2022] [Accepted: 06/14/2022] [Indexed: 11/07/2022] Open
Abstract
Background The fibrinolytic system plays a critical role in maintaining hemostasis. Central to fibrinolysis is the degradation of fibrin by plasmin, produced in the circulation following the activation of plasminogen by plasminogen activators (PAs). Accurately measuring the plasminogen activation rate is vital for the understanding of fibrinolytic processes, particularly in the context of thrombolysis. Yet, due to the insoluble nature of fibrin, in vitro and ex vivo investigations of PA-mediated plasminogen activation have proven challenging. As researchers frequently adopt soluble fibrinogen fragments and/or alter the experimental system beyond what is physiologically relevant, they limit the validation and interpretation of their findings. Here, we present a novel, high-throughput assay for measuring plasminogen activation rates on natural, plasma-derived fibrin that optimally simulates in vivo conditions. Method Human plasma was used as the source of plasmin(ogen) and fibrin(ogen). "Halo-shaped" plasma clots were produced in a 96-well plate using a thrombin-containing clotting mixture, ensuring that an optically compatible and plasma-free center is maintained in each well. Subsequent additions of a plasmin chromogenic substrate and different PAs were followed by absorbance measurements over time to extract the corresponding enzyme kinetics information. Results and Discussion Validation experiments demonstrated the capability of our approach to accurately model fibrin-dependent and -independent plasminogen activation as well as sensitively detect variations in plasminogen and fibrinogen plasma levels. Conclusion This assay allows a straightforward, yet powerful, measurement of plasminogen activation rates on established plasma clots, with the capability of properly assessing fibrin- and non-fibrin-dependent plasminogen activation by various therapeutic PAs.
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Affiliation(s)
- Jason S. Palazzolo
- NanoBiotechnology Laboratory, Australian Centre for Blood Diseases, Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
| | - Robert L. Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood DiseasesMonash UniversityMelbourneVictoriaAustralia
| | - Christoph E. Hagemeyer
- NanoBiotechnology Laboratory, Australian Centre for Blood Diseases, Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
| | - Be'eri Niego
- NanoBiotechnology Laboratory, Australian Centre for Blood Diseases, Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
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16
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Draxler DF, Hanafi G, Zahra S, McCutcheon F, Ho H, Keragala CB, Liu Z, Daly D, Painter T, Wallace S, Plebanski M, Myles PS, Medcalf RL. Tranexamic acid alters the immunophenotype of phagocytes after lower limb surgery. Thromb J 2022; 20:17. [PMID: 35410340 PMCID: PMC8996554 DOI: 10.1186/s12959-022-00373-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/04/2022] [Indexed: 11/23/2022] Open
Abstract
Background Tranexamic acid (TXA) is an antifibrinolytic agent frequently used in elective surgery to reduce blood loss. We recently found it also acts as a potent immune-modulator in patients undergoing cardiac surgery. Methods Patients undergoing lower limb surgery were enrolled into the “Tranexamic Acid in Lower Limb Arthroplasty” (TALLAS) pilot study. The cellular immune response was characterised longitudinally pre- and post-operatively using full blood examination (FBE) and comprehensive immune cell phenotyping by flowcytometry. Red blood cells and platelets were determined in the FBE and levels of T cell cytokines and the plasmin-antiplasmin complex determined using ELISA. Results TXA administration increased the proportion of circulating CD141+ conventional dendritic cells (cDC) on post-operative day (POD) 3. It also reduced the expression of CD83 and TNFR2 on classical monocytes and levels of circulating IL-10 at the end of surgery (EOS) time point, whilst increasing the expression of CCR4 on natural killer (NK) cells at EOS, and reducing TNFR2 on POD-3 on NK cells. Red blood cells and platelets were decreased to a lower extent at POD-1 in the TXA group, representing reduced blood loss. Conclusion In this investigation we have extended our examination on the immunomodulatory effects of TXA in surgery by also characterising the end of surgery time point and including B cells and neutrophils in our immune analysis, elucidating new immunophenotypic changes in phagocytes as well as NK cells. This study enhances our understanding of TXA-mediated effects on the haemostatic and immune response in surgery, validating changes in important functional immune cell subsets in orthopaedic patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00373-3.
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17
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Sandler N, Ho H, Draxler DF, Bain CR, Smith JA, Hauser CJ, Gruen RL, Myles PS, Medcalf RL. Characterisation of Plasma Mitochondrial DNA, MMP-9 and Neutrophil Elastase in Patients Undergoing Coronary Artery Bypass Grafting: Effects of Tranexamic Acid and Postoperative Pneumonia. Heart Lung Circ 2021; 31:439-446. [PMID: 34627673 DOI: 10.1016/j.hlc.2021.08.008] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/03/2021] [Accepted: 08/04/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Postoperative pneumonia is a major cause of morbidity and mortality following cardiac surgery. The inflammatory response to cardiac surgery has been widely studied, but specific mechanisms for postoperative pneumonia have not been determined. Tranexamic acid is renowned for its effect on bleeding but can also modulate inflammatory processes. Cardiac surgery is known to release mitochondrial DAMPs (mtDAMPs) and is linked to postoperative inflammation and atrial fibrillation. We speculated that mtDAMPs might be related to postoperative pneumonia and that this might be modulated by tranexamic acid. METHODS Forty-one (41) patients from the Aspirin and Tranexamic Acid for Coronary Artery Surgery (ATACAS) trial were studied. Levels of mitochondrial DNA, matrix metallopeptidase 9 (MMP-9) and neutrophil elastase (NE) were determined in plasma preoperatively, at 24 and 72 hours post-surgery and correlated with clinical outcome. RESULTS mtDNA was significantly elevated postoperatively in the placebo and tranexamic acid (TXA) groups. Neutrophil elastase increased immediately postoperatively and at 24 hours. MMP-9 was elevated in the placebo group early postoperatively and in the TXA group at the immediate postoperative time point and after 24 hours. Six (6) of the 41 (14.6%) patients subsequently developed pneumonia. mtDNA levels were significantly increased at the early postoperative period and the 24-hour time point in patients with pneumonia. CONCLUSIONS Cardiac surgery releases mtDNA, increases MMP-9 and NE and this was not influenced by TXA. Inflammation postoperatively might be linked to pneumonia since mtDNA was further elevated in these patients. Due to the low number of individuals developing pneumonia, further studies are warranted to clearly identify whether TXA impacts on the inflammatory response in postoperative pneumonia.
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Affiliation(s)
- Nicola Sandler
- Australian Centre for Blood Disease, Central Clinical School, Monash University, Melbourne, Vic, Australia.
| | - Heidi Ho
- Australian Centre for Blood Disease, Central Clinical School, Monash University, Melbourne, Vic, Australia
| | - Dominik F Draxler
- Australian Centre for Blood Disease, Central Clinical School, Monash University, Melbourne, Vic, Australia
| | - Christopher R Bain
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Vic, Australia
| | - Julian A Smith
- Department of Surgery, (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Vic, Australia
| | - Carl J Hauser
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Russell L Gruen
- College of Health and Medicine, The Australian National University Canberra, ACT, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Vic, Australia
| | - Robert L Medcalf
- Australian Centre for Blood Disease, Central Clinical School, Monash University, Melbourne, Vic, Australia.
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Mutimer CA, Keragala CB, Markus HS, Werring DJ, Cloud GC, Medcalf RL. Cerebral Amyloid Angiopathy and the Fibrinolytic System: Is Plasmin a Therapeutic Target? Stroke 2021; 52:2707-2714. [PMID: 34126761 DOI: 10.1161/strokeaha.120.033107] [Citation(s) in RCA: 4] [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] [Indexed: 11/16/2022]
Abstract
Cerebral amyloid angiopathy is a devastating cause of intracerebral hemorrhage for which there is no specific secondary stroke prevention treatment. Here we review the current literature regarding cerebral amyloid angiopathy pathophysiology and treatment, as well as what is known of the fibrinolytic pathway and its interaction with amyloid. We postulate that tranexamic acid is a potential secondary stroke prevention treatment agent in sporadic cerebral amyloid angiopathy, although further research is required.
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Affiliation(s)
- Chloe A Mutimer
- Department of Neurology, Alfred Hospital, Melbourne, Australia (C.A.M., G.C.C.)
| | - Charithani B Keragala
- Australian Centre for Blood Diseases (C.B.K., R.L.M.), Monash University, Melbourne, Australia
| | - Hugh S Markus
- Stroke Research Group, Department of Clinical Neuroscience, University of Cambridge, United Kingdom (H.S.M.)
| | - David J Werring
- Stroke Research Centre, Queen Square Institute of Neurology, London, United Kingdom (D.J.W.)
| | - Geoffrey C Cloud
- Department of Neurology, Alfred Hospital, Melbourne, Australia (C.A.M., G.C.C.).,Department of Clinical Neuroscience, Central Clinical School (G.C.C.), Monash University, Melbourne, Australia
| | - Robert L Medcalf
- Australian Centre for Blood Diseases (C.B.K., R.L.M.), Monash University, Melbourne, Australia
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Abstract
SSI are a universal economic burden and increase individual patient morbidity and mortality. While antibiotic prophylaxis is the primary preventative intervention, these agents are not themselves benign and may be less effective in the context of emerging antibiotic resistant organisms. Exploration of novel therapies as an adjunct to antimicrobials is warranted. Plasmin and the plasminogen activating system has a complex role in immune function. The immunothrombotic role of plasmin is densely interwoven with the coagulation system and has a multitude of effects on the immune system constituents, which may not always be beneficial. Tranexamic acid is an antifibrinolytic agent which inhibits the conversion of plasminogen to plasmin. Clinical trials have demonstrated a reduction in surgical site infection in TXA exposed patients, however the mechanism and magnitude of this benefit is incompletely understood. This effect may be through the reduction of local wound haematoma, decreased allogenic blood transfusion or a direct immunomodulatory effect. Large scale randomised clinical trial are currently being undertaken to better explain this association. Importantly, TXA is a safe and widely available pharmacological agent which may have a role in the reduction of SSI.
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Affiliation(s)
- Stuart Hastings
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, VIC 3004, Australia;
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Paul S. Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, VIC 3004, Australia;
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Robert L. Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC 3004, Australia;
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20
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Draxler DF, Medcalf RL. Fibrinolysis and tranexamic acid: mechanistic principles. ANZ J Surg 2021; 90:410-411. [PMID: 32339417 DOI: 10.1111/ans.15541] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/03/2019] [Accepted: 10/04/2019] [Indexed: 01/11/2023]
Affiliation(s)
- Dominik F Draxler
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
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21
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Affiliation(s)
- Krasimir Kolev
- Department of Medical Biochemistry, Semmelweis University, Budapest, Hungary
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
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Abstract
The fibrinolytic system provides an essential means to remove fibrin deposits and blood clots. The actual protease responsible for this is plasmin, formed from its precursor, plasminogen. Fibrin is heralded as it most renowned substrate but for many years plasmin has been known to cleave many other substrates, and to also activate other proteolytic systems. Recent clinical studies have shown that the promotion of plasmin can lead to an immunosuppressed phenotype, in part via its ability to modulate cytokine expression. Almost all immune cells harbor at least one of a dozen plasminogen receptors that allows plasmin formation on the cell surface that in turn modulates immune cell behavior. Similarly, a multitude of pathogens can also express their own plasminogen activators, or contain surface proteins that provide binding sites host plasminogen. Plasmin formed under these circumstances also empowers these pathogens to modulate host immune defense mechanisms. Phylogenetic studies have revealed that the plasminogen activating system predates the appearance of fibrin, indicating that plasmin did not evolve as a fibrinolytic protease but perhaps has its roots as an immune modifying protease. While its fibrin removing capacity became apparent in lower vertebrates these primitive under-appreciated immune modifying functions still remain and are now becoming more recognised.
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Affiliation(s)
- Robert L. Medcalf
- Molecular Neurotrauma and Haemostasis Laboratory, Australian Centre for Blood Diseases, Central Clinical School Melbourne, Monash University, Melbourne, VIC 3004, Australia;
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23
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Keragala CB, Woodruff TM, Liu Z, Niego B, Ho H, McQuilten Z, Medcalf RL. Tissue-Type Plasminogen Activator and Tenecteplase-Mediated Increase in Blood Brain Barrier Permeability Involves Cell Intrinsic Complement. Front Neurol 2020; 11:577272. [PMID: 33363504 PMCID: PMC7753024 DOI: 10.3389/fneur.2020.577272] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 11/09/2020] [Indexed: 11/26/2022] Open
Abstract
Background: Tissue-type plasminogen activator (t-PA) has been the mainstay of therapeutic thrombolysis for patients with acute ischaemic stroke (AIS). However, t-PA can cause devastating intracerebral hemorrhage. t-PA can also influence the CNS in part by modulation of BBB permeability. Complement activation also occurs after AIS and has also been reported to increase BBB permeability. The complement components, C3 and C5, can also be activated by t-PA via plasmin formation and cell intrinsic complement may be involved in this process. Tenecteplase (TNK-tPA) is a t-PA variant with a longer plasma half-life, yet the ability of TNK-tPA to modulate the BBB and complement is less clear. Aim: To evaluate the effect of C5 and C5a-receptor 1 (C5aR1) inhibitors on t-PA- and TNK-tPA-mediated opening of the BBB. Methods: We used an in vitro model of the BBB where human brain endothelial cells and human astrocytes were co-cultured on the opposite sides of a porous membrane assembled in transwell inserts. The luminal (endothelial) compartment was stimulated with t-PA or TNK-tPA together with plasminogen, in the presence of PMX205 (a non-competitive C5aR1 antagonist), Avacopan (a competitive C5aR1 antagonist) or Eculizumab (a humanized monoclonal inhibitor of human C5). BBB permeability was assessed 5 and 24 h later. Immunofluorescence was also used to detect changes in C5 and C5aR1 expression in endothelial cells and astrocytes. Results: PMX205, but not Avacopan or Eculizumab, blocked t-PA-mediated increase in BBB permeability at both the 5 and 24 h time points. PMX205 also blocked TNK-tPA-mediated increase in BBB permeability. Immunofluorescence analysis revealed intracellular staining of C5 in both cell types. C5aR1 expression was also detected on the cell surfaces and also located intracellularly in both cell types. Conclusion: t-PA and TNK-tPA-mediated increase in BBB permeability involves C5aR1 receptor activation from cell-derived C5a. Selective inhibitors of C5aR1 may have therapeutic potential in AIS.
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Affiliation(s)
- Charithani B Keragala
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Trent M Woodruff
- School of Biomedical Sciences, University of Queensland, Brisbane, QLD, Australia
| | - Zikou Liu
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Be'eri Niego
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Heidi Ho
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Zoe McQuilten
- Transfusion Research Unit, Department of Epidemiology and Preventative Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Robert L Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
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24
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Lillicrap T, Keragala CB, Draxler DF, Chan J, Ho H, Harman S, Niego B, Holliday E, Levi CR, Garcia-Esperon C, Spratt N, Gyawali P, Bivard A, Parsons MW, Montaner J, Bustamante A, Cadenas IF, Cloud G, Maguire JM, Lincz L, Kleinig T, Attia J, Koblar S, Hamilton-Bruce MA, Choi P, Worrall BB, Medcalf RL. Plasmin Generation Potential and Recanalization in Acute Ischaemic Stroke; an Observational Cohort Study of Stroke Biobank Samples. Front Neurol 2020; 11:589628. [PMID: 33224099 PMCID: PMC7669985 DOI: 10.3389/fneur.2020.589628] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 09/25/2020] [Indexed: 11/21/2022] Open
Abstract
Rationale: More than half of patients who receive thrombolysis for acute ischaemic stroke fail to recanalize. Elucidating biological factors which predict recanalization could identify therapeutic targets for increasing thrombolysis success. Hypothesis: We hypothesize that individual patient plasmin potential, as measured by in vitro response to recombinant tissue-type plasminogen activator (rt-PA), is a biomarker of rt-PA response, and that patients with greater plasmin response are more likely to recanalize early. Methods: This study will use historical samples from the Barcelona Stroke Thrombolysis Biobank, comprised of 350 pre-thrombolysis plasma samples from ischaemic stroke patients who received serial transcranial-Doppler (TCD) measurements before and after thrombolysis. The plasmin potential of each patient will be measured using the level of plasmin-antiplasmin complex (PAP) generated after in-vitro addition of rt-PA. Levels of antiplasmin, plasminogen, t-PA activity, and PAI-1 activity will also be determined. Association between plasmin potential variables and time to recanalization [assessed on serial TCD using the thrombolysis in brain ischemia (TIBI) score] will be assessed using Cox proportional hazards models, adjusted for potential confounders. Outcomes: The primary outcome will be time to recanalization detected by TCD (defined as TIBI ≥4). Secondary outcomes will be recanalization within 6-h and recanalization and/or haemorrhagic transformation at 24-h. This analysis will utilize an expanded cohort including ~120 patients from the Targeting Optimal Thrombolysis Outcomes (TOTO) study. Discussion: If association between proteolytic response to rt-PA and recanalization is confirmed, future clinical treatment may customize thrombolytic therapy to maximize outcomes and minimize adverse effects for individual patients.
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Affiliation(s)
- Thomas Lillicrap
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia.,Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | | | - Dominik F Draxler
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia.,Department of Cardiology, University Hospital of Bern, Bern, Switzerland.,Bern Centre for Precision Medicine, Bern, Switzerland
| | - Jilly Chan
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Heidi Ho
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Stevi Harman
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Be'eri Niego
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Elizabeth Holliday
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia.,Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Christopher R Levi
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia.,Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Sydney Partnership for Health, Education, Research and Enterprise, Sydney, NSW, Australia
| | - Carlos Garcia-Esperon
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia.,Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Neil Spratt
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia.,Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Prajwal Gyawali
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia.,Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Andrew Bivard
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia.,Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Neurology Department, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Mark W Parsons
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain.,Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío, Consejo Superior de Investigaciones Científicas (Spanish National Research Agency), University of Seville, Seville, Spain.,Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Alejandro Bustamante
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Israel Fernandez Cadenas
- Stroke Pharmacogenomics and Genetics Lab, Sant Pau Hospital Institute of Research, Barcelona, Spain
| | - Geoffrey Cloud
- Department of Neurology, The Alfred Hospital, Melbourne, VIC, Australia.,Department of Clinical Neuroscience, School of Nursing and Midwifery, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Jane M Maguire
- Department of Haematology, University of Technology Sydney, Sydney, NSW, Australia
| | - Lisa Lincz
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia.,Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Haematology Department, Calvary Mater Newcastle, Waratah, NSW, Australia
| | - Timothy Kleinig
- Neurology Department, Royal Adelaide Hospital, Adelaide, SA, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - John Attia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia.,Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Simon Koblar
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia.,Neurology, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Monica Anne Hamilton-Bruce
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia.,Neurology, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Philip Choi
- Department of Neurosciences, Eastern Health, Melbourne, VIC, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Bradford B Worrall
- Department of Neurology, University of Virginia, Charlottesville, VA, United States.,Department of Public Health Sciences, University of Virginia, Charlottesville, VA, United States
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
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25
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Daglas M, Galle A, Draxler DF, Ho H, Liu Z, Sashindranath M, Medcalf RL. Sex-dependent effects of tranexamic acid on blood-brain barrier permeability and the immune response following traumatic brain injury in mice. J Thromb Haemost 2020; 18:2658-2671. [PMID: 32668057 DOI: 10.1111/jth.15015] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 12/28/2019] [Revised: 07/08/2020] [Accepted: 07/10/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) is an anti-fibrinolytic agent used to reduce bleeding in various conditions including traumatic brain injury (TBI). As the fibrinolytic system also influences the central nervous system and the immune response, TXA may also modulate these parameters following TBI. OBJECTIVES To determine the effect of TXA on blood-brain barrier (BBB) integrity and changes in immune and motor function in male and female mice subjected to TBI. METHODS Wild-type and plasminogen deficient (plg-/-) mice were subjected to TBI then administered either TXA/vehicle. The degree of BBB breakdown, intracerebral hemorrhage (ICH), motor dysfunction, and changes in inflammatory subsets in blood and brain were determined. RESULTS AND CONCLUSIONS Tranexamic acid significantly reduced BBB breakdown, and increased blood neutrophils in male mice 3 hours post-TBI. In contrast, TXA treatment of female mice increased BBB permeability and ICH but had no effect on blood neutrophils at the same time-point. TXA improved motor function in male mice but still increased BBB breakdown in female mice 24 hours post-TBI. Brain urokinase-type plasminogen activator (u-PA) antigen and activity levels were significantly higher in injured females compared to males. Because TXA can promote a pro-fibrinolytic effect via u-PA, these sex differences may be related to brain u-PA levels. TXA also increased monocyte subsets and dendritic cells in the injured brain of wild-type male mice 1 week post-TBI. Plg-/- mice of both sexes had reduced BBB damage and were protected from TBI irrespective of treatment indicating that TXA modulation of the BBB is plasmin-dependent. In conclusion, TXA is protective post-TBI but only in male mice.
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Affiliation(s)
- Maria Daglas
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Adam Galle
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Dominik F Draxler
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Heidi Ho
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Zikou Liu
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Maithili Sashindranath
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Robert L Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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26
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Awad MM, Hutton ML, Quek AJ, Klare WP, Mileto SJ, Mackin K, Ly D, Oorschot V, Bosnjak M, Jenkin G, Conroy PJ, West N, Fulcher A, Costin A, Day CJ, Jennings MP, Medcalf RL, Sanderson-Smith M, Cordwell SJ, Law RHP, Whisstock JC, Lyras D. Human Plasminogen Exacerbates Clostridioides difficile Enteric Disease and Alters the Spore Surface. Gastroenterology 2020; 159:1431-1443.e6. [PMID: 32574621 DOI: 10.1053/j.gastro.2020.06.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 06/10/2020] [Accepted: 06/13/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS The protease plasmin is an important wound healing factor, but it is not clear how it affects gastrointestinal infection-mediated damage, such as that resulting from Clostridioides difficile. We investigated the role of plasmin in C difficile-associated disease. This bacterium produces a spore form that is required for infection, so we also investigated the effects of plasmin on spores. METHODS C57BL/6J mice expressing the precursor to plasmin, the zymogen human plasminogen (hPLG), or infused with hPLG were infected with C difficile, and disease progression was monitored. Gut tissues were collected, and cytokine production and tissue damage were analyzed by using proteomic and cytokine arrays. Antibodies that inhibit either hPLG activation or plasmin activity were developed and structurally characterized, and their effects were tested in mice. Spores were isolated from infected patients or mice and visualized using super-resolution microscopy; the functional consequences of hPLG binding to spores were determined. RESULTS hPLG localized to the toxin-damaged gut, resulting in immune dysregulation with an increased abundance of cytokines (such as interleukin [IL] 1A, IL1B, IL3, IL10, IL12B, MCP1, MP1A, MP1B, GCSF, GMCSF, KC, TIMP-1), tissue degradation, and reduced survival. Administration of antibodies that inhibit plasminogen activation reduced disease severity in mice. C difficile spores bound specifically to hPLG and active plasmin degraded their surface, facilitating rapid germination. CONCLUSIONS We found that hPLG is recruited to the damaged gut, exacerbating C difficile disease in mice. hPLG binds to C difficile spores, and, upon activation to plasmin, remodels the spore surface, facilitating rapid spore germination. Inhibitors of plasminogen activation might be developed for treatment of C difficile or other infection-mediated gastrointestinal diseases.
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Affiliation(s)
- Milena M Awad
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Australia
| | - Melanie L Hutton
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Australia
| | - Adam J Quek
- Australian Research Council Centre of Excellence in Advanced Molecular Imaging and Biomedicine Discovery Institute, Department of Biochemistry, Monash University, Clayton, Australia
| | - William P Klare
- School of Life and Environmental Sciences and Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Steven J Mileto
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Australia
| | - Kate Mackin
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Australia
| | - Diane Ly
- Illawarra health and Medical Research Institute, Wollongong, Australia; School of Chemistry and Molecular Bioscience and Molecular Horizons, University of Wollongong, Wollongong, Australia
| | - Viola Oorschot
- Australian Research Council Centre of Excellence in Advanced Molecular Imaging and Biomedicine Discovery Institute, Department of Biochemistry, Monash University, Clayton, Australia; Monash Micro Imaging, Monash University, Clayton, Australia
| | - Marijana Bosnjak
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Australia
| | - Grant Jenkin
- Monash Infectious Diseases, Monash Health, Clayton, Australia
| | - Paul J Conroy
- Australian Research Council Centre of Excellence in Advanced Molecular Imaging and Biomedicine Discovery Institute, Department of Biochemistry, Monash University, Clayton, Australia
| | - Nick West
- School of Chemistry and Molecular Biosciences and Australian Infectious Diseases Research Centre, University of Queensland, St. Lucia, Australia
| | - Alex Fulcher
- Monash Micro Imaging, Monash University, Clayton, Australia
| | - Adam Costin
- Australian Research Council Centre of Excellence in Advanced Molecular Imaging and Biomedicine Discovery Institute, Department of Biochemistry, Monash University, Clayton, Australia
| | | | | | - Robert L Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Clayton, Australia
| | - Martina Sanderson-Smith
- Illawarra health and Medical Research Institute, Wollongong, Australia; School of Chemistry and Molecular Bioscience and Molecular Horizons, University of Wollongong, Wollongong, Australia
| | - Stuart J Cordwell
- School of Life and Environmental Sciences and Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Ruby H P Law
- Australian Research Council Centre of Excellence in Advanced Molecular Imaging and Biomedicine Discovery Institute, Department of Biochemistry, Monash University, Clayton, Australia
| | - James C Whisstock
- Australian Research Council Centre of Excellence in Advanced Molecular Imaging and Biomedicine Discovery Institute, Department of Biochemistry, Monash University, Clayton, Australia; European Molecular Biology Laboratory Australia, Monash University, Clayton, Australia; South East University-Monash Joint Institute, Institute of Life Sciences, Southeast University, Nanjing, China
| | - Dena Lyras
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Australia.
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27
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Draxler DF, Bain CR, Taylor R, Wallace S, Gouldthorpe O, Corcoran TB, Myles PS, Bozaoglu K, Medcalf RL. Data on the modulatory effects of a single bolus dexamethasone on the surface marker expression of various leucocyte subsets. Data Brief 2020; 32:106117. [PMID: 32904373 PMCID: PMC7452708 DOI: 10.1016/j.dib.2020.106117] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/26/2020] [Accepted: 07/28/2020] [Indexed: 01/29/2023] Open
Abstract
Dexamethasone is frequently administered to surgical patients for anti-emetic prophylaxis. We have examined the immunomodulatory effects of a single bolus of dexamethasone on circulating peripheral blood mononuclear cells (PBMCs) in the same 10 healthy male volunteers, previously used in our investigation on early in vivo effects of a single anti-emetic dose of dexamethasone on innate immune cell gene expression and activation [1]. Blood samples were drawn at baseline, 2 h, 4 h and 24 h. Immune cell phenotypes were examined with flow cytometry. In this data article the expression strength of markers involved in immune activation and immunosuppression as well as maturation, migration, cell death and responsiveness to signalling on monocyte and cDC subsets, as well as NK cells, CD4+ and CD8+ T cells and regulatory T cells (Treg) are presented. These data improve our understanding of the immunomodulatory effects of the glucocorticoid dexamethasone in-vivo, which may be important for the optimisation of treatment regimens as well as the evaluation of new indications for glucocorticoid treatment.
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Affiliation(s)
- D F Draxler
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia.,Department of Cardiology, University hospital of Bern, Bern, Switzerland.,Bern Center for Precision Medicine, Bern, Switzerland
| | - C R Bain
- Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - R Taylor
- Genomics and Systems Biology Laboratory, Baker IDI Heart and Diabetes Institute Victoria, Melbourne, VIC, Australia
| | - S Wallace
- Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - O Gouldthorpe
- Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - T B Corcoran
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, University of Western Australia, Perth, WA, Australia and Monash University, Melbourne, VIC, Australia
| | - P S Myles
- Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - K Bozaoglu
- Bruce Lefroy Centre for Genetic Health Research, Murdoch Children's Research Institute and Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - R L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
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28
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Affiliation(s)
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Vic., Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Vic., Australia
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, Vic., Australia
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Abstract
The COVID-19 pandemic has provided many challenges in the field of thrombosis and hemostasis. Among these is a novel form of coagulopathy that includes exceptionally high levels of D-dimer. D-dimer is a marker of poor prognosis, but does this also imply a causal relationship? These spectacularly raised D-dimer levels may actually signify the failing attempt of the fibrinolytic system to remove fibrin and necrotic tissue from the lung parenchyma, being consumed or overwhelmed in the process. Indeed, recent studies suggest that increasing fibrinolytic activity might offer hope for patients with critical disease and severe respiratory failure. However, the fibrinolytic system can also be harnessed by coronavirus to promote infectivity and where antifibrinolytic measures would also seem appropriate. Hence, there is a clinical paradox where plasmin formation can be either deleterious or beneficial in COVID-19, but not at the same time. Hence, it all comes down to timing.
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Affiliation(s)
- Robert L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Charithani B Keragala
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
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30
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Affiliation(s)
- Hunter B Moore
- Department of Surgery, University of Colorado School of Medicine, Denver, Colorado
| | - Mark Walsh
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana.,Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Hau C Kwaan
- Division of Hematology and Oncology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Robert L Medcalf
- Molecular Neurotrauma and Haemostasis Laboratory, Australian Centre for Blood Diseases, Monash University, Victoria, Australia
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31
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Moore HB, Gando S, Iba T, Kim PY, Yeh CH, Brohi K, Hunt BJ, Levy JH, Draxler DF, Stanworth S, Görlinger K, Neal MD, Schreiber MA, Barrett CD, Medcalf RL, Moore EE, Mutch NJ, Thachil J, Urano T, Thomas S, Scărlătescu E, Walsh M. Defining trauma-induced coagulopathy with respect to future implications for patient management: Communication from the SSC of the ISTH. J Thromb Haemost 2020; 18:740-747. [PMID: 32112533 DOI: 10.1111/jth.14690] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/12/2019] [Accepted: 11/25/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Hunter B Moore
- Department of Surgery, University of Colorado, Denver, CO, USA
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Paul Y Kim
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Calvin H Yeh
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON,, Canada
| | - Karim Brohi
- Queen Mary University of London, London, UK
- Centre for Trauma Sciences, London, UK
| | | | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Dominik F Draxler
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria,, Australia
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre,, University of Oxford,, Oxford,, UK
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, Essen, Germany
- TEM Innovations GmbH, Munich, Germany
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Martin A Schreiber
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Christopher D Barrett
- Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Massachusetts Institute of Technology, Cambridge, MA, USA
- Division of Acute Care Surgery and Critical Care, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria,, Australia
| | - Ernest E Moore
- Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Nicola J Mutch
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Tetsumei Urano
- Department of Medical Physiology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Scott Thomas
- Beacon Medical Group Trauma and Surgical Research Services, South Bend, IN, USA
| | - Ecaterina Scărlătescu
- Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Mark Walsh
- Beacon Medical Group Trauma and Surgical Research Services, South Bend, IN, USA
- Departments of Emergency and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, USA
- Indiana University School of Medicine, South Bend Campus, South Bend, IN, USA
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Abstract
AbstractIt has long been known that the fibrinolytic system becomes activated following trauma. At first glance, this is not at all surprising and would appear to be in response to coagulation and the apparent need to remove blood clots and restore blood flow. However, in a bleeding patient, the opposite is what is actually needed. Therefore, one may ask why the fibrinolytic system gets activated in the first place or is there another purpose? Or is it that the waxing and waning of hemostasis in such severely injured patients creates a “moving target” such that the fibrinolytic system itself is constantly responding to changing circumstances? Depending on the injury modalities and the time point post injury, the fibrinolytic system could be either turned on or off. Various theories now abound that offer new insights into the turmoil and paradoxes associated with the fibrinolytic system in this unique setting and the use of antifibrinolytic agents. While this presents one conundrum, there is also another dimension to add to this discussion that has nothing to do with hemostasis per se but rather with the modulation of other critical processes that are also essential for optimal recovery following severe injury. Indeed, overwhelming data are now supporting an important role of the fibrinolytic system in the removal of necrotic tissue (mortolysis) and as a modulator of the innate immune response. Therefore, what is really going on when the fibrinolytic system decides to go into overdrive and generate plasmin, albeit even briefly after a traumatic event? Moreover, what other consequence may occur when antifibrinolytic agents are administered? This review will address this developing story and will outline a hypothesis that places the fibrinolytic system as a gateway to a myriad of processes that are not only linked to fibrin removal but are also broader players in the modulation of innate immunity.
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Affiliation(s)
- Robert L. Medcalf
- Molecular Neurotrauma and Haemostasis Laboratory, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Victoria, Australia
| | - Charithani B. Keragala
- Molecular Neurotrauma and Haemostasis Laboratory, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Victoria, Australia
| | - Dominik F. Draxler
- Molecular Neurotrauma and Haemostasis Laboratory, Australian Centre for Blood Diseases, Central Clinical School, Monash University, Victoria, Australia
- Department of Cardiology, University Hospital of Bern, Bern, Switzerland
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Draxler DF, Daglas M, Fernando A, Hanafi G, McCutcheon F, Ho H, Galle A, Gregory J, Larsson P, Keragala C, Wright DK, Tavancheh E, Au AE, Niego B, Wilson K, Plebanski M, Sashindranath M, Medcalf RL. Tranexamic acid modulates the cellular immune profile after traumatic brain injury in mice without hyperfibrinolysis. J Thromb Haemost 2019; 17:2174-2187. [PMID: 31393041 DOI: 10.1111/jth.14603] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 03/03/2019] [Accepted: 07/30/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is known to promote immunosuppression, making patients more susceptible to infection, yet potentially exerting protective effects by inhibiting central nervous system (CNS) reactivity. Plasmin, the effector protease of the fibrinolytic system, is now recognized for its involvement in modulating immune function. OBJECTIVE To evaluate the effects of plasmin and tranexamic acid (TXA) on the immune response in wild-type and plasminogen-deficient (plg-/- ) mice subjected to TBI. METHODS Leukocyte subsets in lymph nodes and the brain in mice post TBI were evaluated by flow cytometry and in blood with a hemocytometer. Immune responsiveness to CNS antigens was determined by Enzyme-linked Immunosorbent Spot (ELISpot) assay. Fibrinolysis was determined by thromboelastography and measuring D-dimer and plasmin-antiplasmin complex levels. RESULTS Plg-/- mice, but not plg+/+ mice displayed increases in both the number and activation of various antigen-presenting cells and T cells in the cLN 1 week post TBI. Wild-type mice treated with TXA also displayed increased cellularity of the cLN 1 week post TBI together with increases in innate and adaptive immune cells. These changes occurred despite the absence of systemic hyperfibrinolysis or coagulopathy in this model of TBI. Importantly, neither plg deficiency nor TXA treatment enhanced the autoreactivity within the CNS. CONCLUSION In the absence of systemic hyperfibrinolysis, plasmin deficiency or blockade with TXA increases migration and proliferation of conventional dendritic cells (cDCs) and various antigen-presenting cells and T cells in the draining cervical lymph node (cLN) post TBI. Tranexamic acid might also be clinically beneficial in modulating the inflammatory and immune response after TBI, but without promoting CNS autoreactivity.
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Affiliation(s)
- Dominik F Draxler
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Maria Daglas
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Anushka Fernando
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Gryselda Hanafi
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Fiona McCutcheon
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Heidi Ho
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Adam Galle
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Julia Gregory
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Pia Larsson
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Charithani Keragala
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - David K Wright
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
- The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Elnaz Tavancheh
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Amanda E Au
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Be'eri Niego
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Kirsty Wilson
- Department of Immunology and Pathology, Monash University, Melbourne, Victoria, Australia
| | - Magdalena Plebanski
- Department of Immunology and Pathology, Monash University, Melbourne, Victoria, Australia
- School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia
| | - Maithili Sashindranath
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Robert L Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
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Moore HB, Moore EE, Neal MD, Sheppard FR, Kornblith LZ, Draxler DF, Walsh M, Medcalf RL, Cohen MJ, Cotton BA, Thomas SG, Leeper CM, Gaines BA, Sauaia A. Fibrinolysis Shutdown in Trauma: Historical Review and Clinical Implications. Anesth Analg 2019; 129:762-773. [PMID: 31425218 PMCID: PMC7340109 DOI: 10.1213/ane.0000000000004234] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [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: 02/07/2023]
Abstract
Despite over a half-century of recognizing fibrinolytic abnormalities after trauma, we remain in our infancy in understanding the underlying mechanisms causing these changes, resulting in ineffective treatment strategies. With the increased utilization of viscoelastic hemostatic assays (VHAs) to measure fibrinolysis in trauma, more questions than answers are emerging. Although it seems certain that low fibrinolytic activity measured by VHA is common after injury and associated with increased mortality, we now recognize subphenotypes within this population and that specific cohorts arise depending on the specific time from injury when samples are collected. Future studies should focus on these subtleties and distinctions, as hypofibrinolysis, acute shutdown, and persistent shutdown appear to represent distinct, unique clinical phenotypes, with different pathophysiology, and warranting different treatment strategies.
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Affiliation(s)
- Hunter B. Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Ernest E. Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Matthew D. Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Lucy Z. Kornblith
- Department of Surgery, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Dominik F. Draxler
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Mark Walsh
- Department of Surgery, Memorial Hospital Trauma Center, Springfield, Illinois
- Department of Emergency Medicine, Memorial Hospital Trauma Center, Springfield, Illinois
| | - Robert L. Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Mitch J. Cohen
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Bryan A. Cotton
- Department of Surgery, Center for Translational Injury Research, The McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Scott G. Thomas
- Department of Surgery, Memorial Hospital Trauma Center, Springfield, Illinois
- Department of Emergency Medicine, Memorial Hospital Trauma Center, Springfield, Illinois
| | - Christine M. Leeper
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Barbara A. Gaines
- Department of Surgery, Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Angela Sauaia
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- Division of Health Systems, Management, and Policy, University of Colorado School of Public Health, Aurora, Colorado
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Draxler DF, Awad MM, Hanafi G, Daglas M, Ho H, Keragala C, Galle A, Roquilly A, Lyras D, Sashindranath M, Medcalf RL. Tranexamic Acid Influences the Immune Response, but not Bacterial Clearance in a Model of Post-Traumatic Brain Injury Pneumonia. J Neurotrauma 2019; 36:3297-3308. [PMID: 31140372 DOI: 10.1089/neu.2018.6030] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The antifibrinolytic agent, tranexamic acid (TXA), an inhibitor of plasmin formation, currently is evaluated to reduce bleeding in various conditions, including traumatic brain injury (TBI). Because plasmin is implicated in inflammation and immunity, we investigated the effects of plasmin inhibition on the immune response after TBI in the presence or absence of induced pneumonia. Wild-type mice treated with vehicle or TXA or mice deficient in plasminogen (plg-/-) underwent TBI using the controlled cortical impact model. Mice were then subjected to Staphylococcus aureus induced pneumonia and the degree of immune competence determined. Significant baseline changes in the innate immune cell profile were seen in plg-/- mice with increases in spleen weight and white blood cell counts, and elevation in plasma interleukin-6 levels. The plg-/- mice subjected to TBI displayed no additional changes in these parameters at the 72 h or one week time point post-TBI. The plg-/- mice subjected to TBI did not exhibit any further increase in susceptibility to endogenous infection. Pneumonia was induced by intratracheal instillation of S. aureus. The TBI did not worsen pneumonia symptoms or delay recovery in plg-/- mice. Similarly, in wild type mice, treatment with TXA did not impact on the ability of mice to counteract pneumonia after TBI. Administration of TXA after TBI and subsequent pneumonia, however, altered the number and surface marker expression of several myeloid and lymphoid cell populations, consistent with enhanced immune activation at the 72 h time point. This investigation confirms the immune-modulatory properties of TXA, thereby highlighting its effects unrelated to inhibition of fibrinolysis.
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Affiliation(s)
- Dominik F Draxler
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Milena M Awad
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia
| | - Gryselda Hanafi
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Maria Daglas
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Heidi Ho
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Charithani Keragala
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Adam Galle
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Antoine Roquilly
- Anaesthesia Intensive Care Unit, Centre Hospitalier Universitaire, Nantes, France
| | - Dena Lyras
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia
| | - Maithili Sashindranath
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Robert L Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
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Draxler DF, Lee F, Ho H, Keragala CB, Medcalf RL, Niego B. t-PA Suppresses the Immune Response and Aggravates Neurological Deficit in a Murine Model of Ischemic Stroke. Front Immunol 2019; 10:591. [PMID: 30972077 PMCID: PMC6445967 DOI: 10.3389/fimmu.2019.00591] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 10/12/2018] [Accepted: 03/05/2019] [Indexed: 01/08/2023] Open
Abstract
Introduction: Acute ischemic stroke (AIS) is a potent trigger of immunosuppression, resulting in increased infection risk. While thrombolytic therapy with tissue-type plasminogen activator (t-PA) is still the only pharmacological treatment for AIS, plasmin, the effector protease, has been reported to suppress dendritic cells (DCs), known for their potent antigen-presenting capacity. Accordingly, in the major group of thrombolyzed AIS patients who fail to reanalyze (>60%), t-PA might trigger unintended and potentially harmful immunosuppressive consequences instead of beneficial reperfusion. To test this hypothesis, we performed an exploratory study to investigate the immunomodulatory properties of t-PA treatment in a mouse model of ischemic stroke. Methods: C57Bl/6J wild-type mice and plasminogen-deficient (plg−/−) mice were subjected to middle cerebral artery occlusion (MCAo) for 60 min followed by mouse t-PA treatment (0.9 mg/kg) at reperfusion. Behavioral testing was performed 23 h after occlusion, pursued by determination of blood counts and plasma cytokines at 24 h. Spleens and cervical lymph nodes (cLN) were also harvested and characterized by flow cytometry. Results: MCAo resulted in profound attenuation of immune activation, as anticipated. t-PA treatment not only worsened neurological deficit, but further reduced lymphocyte and monocyte counts in blood, enhanced plasma levels of both IL-10 and TNFα and decreased various conventional DC subsets in the spleen and cLN, consistent with enhanced immunosuppression and systemic inflammation after stroke. Many of these effects were abolished in plg−/− mice, suggesting plasmin as a key mediator of t-PA-induced immunosuppression. Conclusion: t-PA, via plasmin generation, may weaken the immune response post-stroke, potentially enhancing infection risk and impairing neurological recovery. Due to the large number of comparisons performed in this study, additional pre-clinical work is required to confirm these significant possibilities. Future studies will also need to ascertain the functional implications of t-PA-mediated immunosuppression for thrombolyzed AIS patients, particularly for those with failed recanalization.
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Affiliation(s)
- Dominik F Draxler
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Felix Lee
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Heidi Ho
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Charithani B Keragala
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Robert L Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Be'eri Niego
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
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Medcalf RL, Hagemeyer CE, Alt K. Magnetic fibrinolysis: putting the therapeutic wheels in a corkscrew motion. J Thromb Haemost 2018; 16:615-617. [PMID: 29634087 DOI: 10.1111/jth.13969] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Indexed: 11/28/2022]
Affiliation(s)
- R L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - C E Hagemeyer
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - K Alt
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
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38
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Keragala CB, Draxler DF, McQuilten ZK, Medcalf RL. Haemostasis and innate immunity - a complementary relationship: A review of the intricate relationship between coagulation and complement pathways. Br J Haematol 2017; 180:782-798. [PMID: 29265338 DOI: 10.1111/bjh.15062] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Coagulation and innate immunity are linked evolutionary processes that orchestrate the host defence against invading pathogens and injury. The complement system is integral to innate immunity and shares numerous interactions with components of the haemostatic pathway, helping to maintain physiological equilibrium. The term 'immunothrombosis' was introduced in 2013 to embrace this process, and has become an area of much recent interest. What is less apparent in the literature however is an appreciation of the clinical manifestations of the coagulation-complement interaction and the consequences of dysregulation of either system, as seen in many inflammatory and thrombotic disease states, such as sepsis, trauma, atherosclerosis, antiphospholipid syndrome (APS), paroxysmal nocturnal haemoglobinuria (PNH) and some thrombotic microangiopathies to name a few. The growing appreciation of this immunothrombotic phenomenon will foster the drive for novel therapies in these disease states, including anticoagulants as immunomodulators and targeted molecular therapies.
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Affiliation(s)
- Charithani B Keragala
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Vic., Australia
| | - Dominik F Draxler
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Vic., Australia
| | - Zoe K McQuilten
- Transfusion Research Unit and Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Vic., Australia
| | - Robert L Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Vic., Australia
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Niego B, Broughton BRS, Ho H, Sobey CG, Medcalf RL. LDL receptor blockade reduces mortality in a mouse model of ischaemic stroke without improving tissue-type plasminogen activator-induced brain haemorrhage: towards pre-clinical simulation of symptomatic ICH. Fluids Barriers CNS 2017; 14:33. [PMID: 29157263 PMCID: PMC5696777 DOI: 10.1186/s12987-017-0081-2] [Citation(s) in RCA: 7] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 10/31/2017] [Indexed: 12/24/2022] Open
Abstract
Background Symptomatic intracerebral haemorrhage (sICH) following tissue-type plasminogen activator (rt-PA) administration is the most feared and lethal complication of thrombolytic therapy for ischaemic stroke, creating a significant obstacle for a broader uptake of this beneficial treatment. rt-PA also undermines cerebral vasculature stability in a multimodal process which involves engagement with LDL receptor-related protein 1 (LRP-1), potentially underlying the development of sICH. Aims and methods We aimed to simulate rt-PA-induced haemorrhagic transformation (HT) in a mouse model of stroke and to assess if it drives symptomatic neurological deterioration and whether it is attenuated by LDL receptor blockade. rt-PA (10 mg/kg) or its vehicle, with or without the LDL receptor antagonist, receptor-associated protein (RAP; 2 mg/kg), were intravenously injected at reperfusion after 0.5 or 4 h of middle cerebral artery occlusion (MCAo). Albumin and haemoglobin content were measured in the perfused mouse brains 24 h post MCAo as indications of blood–brain barrier (BBB) compromise and HT, respectively. Results rt-PA did not elevate brain albumin and haemoglobin levels in sham mice or in mice subjected to 0.5 h MCAo. In contrast, administration of rt-PA after prolonged MCAo (4 h) caused a marked increase in HT (but similar changes in brain albumin) compared to vehicle, mimicking the clinical shift from a safe to detrimental intervention. Interestingly, this HT did not correlate with functional deficit severity at 24 h, suggesting that it does not play a symptomatic role in our mouse stroke model. Co-administration of RAP with or without rt-PA reduced mortality and neurological scores but did not effectively decrease brain albumin and haemoglobin levels. Conclusion Despite the proven causative relationship between severe HT and neurological deterioration in human stroke, rt-PA-triggered HT in mouse MCAo does not contribute to neurological deficit or simulate sICH. Model limitations, such as the long duration of occlusion required, the type of HT achieved and the timing of deficit assessment may account for this mismatch. Our results further suggest that blockade of LDL receptors improves stroke outcome irrespective of rt-PA, blood–brain barrier breakdown and HT.
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Affiliation(s)
- Be'eri Niego
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Level 4 Burnet Building, 89 Commercial Road, Melbourne, 3004, VIC, Australia.
| | - Brad R S Broughton
- Cardiovascular & Pulmonary Pharmacology Group, Biomedicine Discovery Institute, Department of Pharmacology, Monash University, Clayton, VIC, Australia
| | - Heidi Ho
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Level 4 Burnet Building, 89 Commercial Road, Melbourne, 3004, VIC, Australia
| | - Christopher G Sobey
- Vascular Biology and Immunopharmacology Group, Department of Physiology, Anatomy & Microbiology, School of Life Sciences, La Trobe University, Bundoora, VIC, Australia
| | - Robert L Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Level 4 Burnet Building, 89 Commercial Road, Melbourne, 3004, VIC, Australia
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Samson AL, Ho B, Au AE, Schoenwaelder SM, Smyth MJ, Bottomley SP, Kleifeld O, Medcalf RL. Physicochemical properties that control protein aggregation also determine whether a protein is retained or released from necrotic cells. Open Biol 2017; 6:rsob.160098. [PMID: 27810968 PMCID: PMC5133435 DOI: 10.1098/rsob.160098] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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: 04/11/2016] [Accepted: 10/05/2016] [Indexed: 12/11/2022] Open
Abstract
Amyloidogenic protein aggregation impairs cell function and is a hallmark of many chronic degenerative disorders. Protein aggregation is also a major event during acute injury; however, unlike amyloidogenesis, the process of injury-induced protein aggregation remains largely undefined. To provide this insight, we profiled the insoluble proteome of several cell types after acute injury. These experiments show that the disulfide-driven process of nucleocytoplasmic coagulation (NCC) is the main form of injury-induced protein aggregation. NCC is mechanistically distinct from amyloidogenesis, but still broadly impairs cell function by promoting the aggregation of hundreds of abundant and essential intracellular proteins. A small proportion of the intracellular proteome resists NCC and is instead released from necrotic cells. Notably, the physicochemical properties of NCC-resistant proteins are contrary to those of NCC-sensitive proteins. These observations challenge the dogma that liberation of constituents during necrosis is anarchic. Rather, inherent physicochemical features including cysteine content, hydrophobicity and intrinsic disorder determine whether a protein is released from necrotic cells. Furthermore, as half of the identified NCC-resistant proteins are known autoantigens, we propose that physicochemical properties that control NCC also affect immune tolerance and other host responses important for the restoration of homeostasis after necrotic injury.
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Affiliation(s)
- Andre L Samson
- Australian Centre for Blood Diseases, Alfred Medical Research and Education Precinct (AMREP), Monash University, Melbourne, Victoria 3004, Australia .,Department of Biochemistry and Molecular Biology, Monash University, Clayton, Victoria 3800, Australia.,Heart Research Institute, and Charles Perkins Centre, University of Sydney, Camperdown, New South Wales 2006, Australia
| | - Bosco Ho
- Department of Biochemistry and Molecular Biology, Monash University, Clayton, Victoria 3800, Australia
| | - Amanda E Au
- Australian Centre for Blood Diseases, Alfred Medical Research and Education Precinct (AMREP), Monash University, Melbourne, Victoria 3004, Australia
| | - Simone M Schoenwaelder
- Australian Centre for Blood Diseases, Alfred Medical Research and Education Precinct (AMREP), Monash University, Melbourne, Victoria 3004, Australia.,Heart Research Institute, and Charles Perkins Centre, University of Sydney, Camperdown, New South Wales 2006, Australia
| | - Mark J Smyth
- Immunology in Cancer and Infection Laboratory, QIMR Berghofer Medical Research Institute, Herston, Queensland 4006, Australia.,School of Medicine, University of Queensland, Herston, Queensland 4006, Australia
| | - Stephen P Bottomley
- Department of Biochemistry and Molecular Biology, Monash University, Clayton, Victoria 3800, Australia
| | - Oded Kleifeld
- Department of Biochemistry and Molecular Biology, Monash University, Clayton, Victoria 3800, Australia.,Faculty of Biology, Technion-Israel Institute of Technology, Haifa 3200003, Israel
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Alfred Medical Research and Education Precinct (AMREP), Monash University, Melbourne, Victoria 3004, Australia
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Abstract
We all know about classical fibrinolysis, how plasminogen activation by either tissue-type plasminogen activator (t-PA) or urokinase-type plasminogen activator (u-PA) promotes fibrin breakdown, and how this process was harnessed for the therapeutic removal of blood clots. While this is still perfectly true and still applicable to thromboembolic conditions today, another dimension to this system came to light over two decades ago that implicated the plasminogen activating system in a context far removed from the dissolution of blood clots. This unsuspected area related to brain biology where t-PA was linked to a plethora of activities in the CNS, some of which do not necessarily require plasmin generation. Indeed, t-PA either directly or via plasmin, has been shown to not only have key roles in modulating astrocytes, neurons, microglia, and pericytes, but also to have profound effects in a number of CNS conditions, including ischaemic stroke, severe traumatic brain injury and also in neurodegenerative disorders. While compelling insights have been obtained from various animal models, the clinical relevance of aberrant expression of these components in the CNS, although strongly implied, are only just emerging. This review will cover these areas and will also discuss how the use of thrombolytic agents and anti-fibrinolytic drugs may potentially have impacts outside of their clinical intention, particularly in the CNS.
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Affiliation(s)
- R L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Vic, Australia
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Niego B, Lee N, Larsson P, De Silva TM, Au AEL, McCutcheon F, Medcalf RL. Selective inhibition of brain endothelial Rho-kinase-2 provides optimal protection of an in vitro blood-brain barrier from tissue-type plasminogen activator and plasmin. PLoS One 2017; 12:e0177332. [PMID: 28510599 PMCID: PMC5433693 DOI: 10.1371/journal.pone.0177332] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [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: 01/11/2017] [Accepted: 04/26/2017] [Indexed: 12/13/2022] Open
Abstract
Rho-kinase (ROCK) inhibition, broadly utilised in cardiovascular disease, may protect the blood-brain barrier (BBB) during thrombolysis from rt-PA-induced damage. While the use of nonselective ROCK inhibitors like fasudil together with rt-PA may be hindered by possible hypotensive side-effects and inadequate capacity to block detrimental rt-PA activity in brain endothelial cells (BECs), selective ROCK-2 inhibition may overcome these limitations. Here, we examined ROCK-2 expression in major brain cells and compared the ability of fasudil and KD025, a selective ROCK-2 inhibitor, to attenuate rt-PA-induced BBB impairment in an in vitro human model. ROCK-2 was highly expressed relative to ROCK-1 in all human and mouse brain cell types and particularly enriched in rodent brain endothelial cells and astrocytes compared to neurons. KD025 was more potent than fasudil in attenuation of rt-PA- and plasminogen-induced BBB permeation under normoxia, but especially under stroke-like conditions. Importantly, only KD025, but not fasudil, was able to block rt-PA-dependent permeability increases, morphology changes and tight junction degradation in isolated BECs. Selective ROCK-2 inhibition further diminished rt-PA-triggered myosin phosphorylation, shape alterations and matrix metalloprotease activation in astrocytes. These findings highlight ROCK-2 as the key isoform driving BBB impairment and brain endothelial damage by rt-PA and the potential of KD025 to optimally protect the BBB during thrombolysis.
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Affiliation(s)
- Be’eri Niego
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
- * E-mail:
| | - Natasha Lee
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Pia Larsson
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - T. Michael De Silva
- Department of Physiology, Anatomy and Microbiology, School of Life Sciences, La Trobe University, Melbourne, Victoria, Australia
| | - Amanda E-Ling Au
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Fiona McCutcheon
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Robert L. Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
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Draxler DF, Madondo MT, Hanafi G, Plebanski M, Medcalf RL. A flowcytometric analysis to efficiently quantify multiple innate immune cells and T Cell subsets in human blood. Cytometry A 2017; 91:336-350. [PMID: 28264143 DOI: 10.1002/cyto.a.23080] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 07/13/2016] [Revised: 12/20/2016] [Accepted: 02/16/2017] [Indexed: 01/28/2023]
Abstract
The balance of inflammation and immunosuppression driven by changed ratios in diverse myeloid and T cell subsets, as well as their state of activation and ability to migrate to lymphoid compartments or inflammatory sites, has emerged as a highly active area of study across clinical trials of vaccines and therapies against cancer, trauma, as well as autoimmune and infectious diseases. There is a need for effective protocols which maximally use the possibilities offered by modern flow cytometers to characterize such immune cell changes in peripheral blood using small volumes of human blood. Additionally, longitudinal clinical studies often use cryopreserved samples, which can impact flow cytometric results. To efficiently gauge both the innate and the adaptive immune response, two novel 15-color antibody panels to identify key myeloid and T cell subsets and their functional potential were established. This approach was used to compare cellular immune profiles in fresh whole blood and in matched cryopreserved peripheral blood mononuclear cells (PBMCs). Cocktail I was designed to identify and characterize myeloid cell populations including dendritic cells (DCs), monocytic monocyte-derived suppressor cells (MO-MDSC), and monocytes, determining further core aspects of their state of maturity, T cell stimulatory (or inhibitory) potential, and migration capability. Cocktail II was used for phenotyping diverse T cells subsets, and their key migration and functional regulatory capabilities. The two 15-color antibody panels for the evaluation of both immune-stimulating and immunosuppressive processes presented herein allowed for efficient evaluation of the balance of immune activation versus immunosuppression across key blood cells, with good resolution for all 15 markers stained for in each panel. Gating strategies for the myeloid and T cells are presented to further support specific subset identification. This protocol was shown to be reproducible across donors and useful to study both RBC-lysed whole blood and cryopreserved PBMCs. © 2017 International Society for Advancement of Cytometry.
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Affiliation(s)
- D F Draxler
- Molecular Neurotrauma and Haemostasis, Australian Center for Blood Diseases, Central Clinical School, Monash University, Clayton, Australia
| | - M T Madondo
- Vaccine and Infectious Diseases Laboratory, Department of Immunology and Pathology, Monash University, Clayton, Australia
| | - G Hanafi
- Molecular Neurotrauma and Haemostasis, Australian Center for Blood Diseases, Central Clinical School, Monash University, Clayton, Australia
| | - M Plebanski
- Vaccine and Infectious Diseases Laboratory, Department of Immunology and Pathology, Monash University, Clayton, Australia
| | - R L Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Center for Blood Diseases, Central Clinical School, Monash University, Clayton, Australia
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Affiliation(s)
- Hau Kwaan
- Division of Hematology/Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert L Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Clayton, Australia
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Fredriksson L, Lawrence DA, Medcalf RL. tPA Modulation of the Blood-Brain Barrier: A Unifying Explanation for the Pleiotropic Effects of tPA in the CNS. Semin Thromb Hemost 2017; 43:154-168. [PMID: 27677179 PMCID: PMC5848490 DOI: 10.1055/s-0036-1586229] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [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] [Indexed: 01/22/2023]
Abstract
The plasminogen activation (PA) system is best known for its role in fibrinolysis. However, it has also been shown to regulate many nonfibrinolytic functions in the central nervous system (CNS). In particular, tissue-type plasminogen activator (tPA) is reported to have pleiotropic activities in the CNS, regulating events such as neuronal plasticity, excitotoxicity, and cerebrovascular barrier integrity, whereas urokinase-type plasminogen activator is mainly associated with tissue remodeling and cell migration. It has been suggested that the role tPA plays in controlling barrier integrity may provide a unifying mechanism for the reported diverse, and often opposing, functions ascribed to tPA in the CNS. Here we will review the possibility that the pleiotropic effects reported for tPA in physiologic and pathologic processes in the CNS may be a consequence of its role in the neurovascular unit in regulation of cerebrovascular responses and subsequently parenchymal homeostasis. We propose that this might offer an explanation for the ongoing debate regarding the neurotoxic versus neuroprotective roles of tPA.
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Affiliation(s)
- Linda Fredriksson
- Department of Medical Biochemistry & Biophysics, Division of Vascular Biology, Karolinska Institutet, Stockholm, Sweden
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Daniel A. Lawrence
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI USA
| | - Robert L. Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
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46
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Dworkin S, Auden A, Partridge DD, Daglas M, Medcalf RL, Mantamadiotis T, Georgy SR, Darido C, Jane SM, Ting SB. Grainyhead-like 3 (Grhl3) deficiency in brain leads to altered locomotor activity and decreased anxiety-like behaviors in aged mice. Dev Neurobiol 2017; 77:775-788. [PMID: 27907249 DOI: 10.1002/dneu.22469] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 06/01/2016] [Revised: 10/17/2016] [Accepted: 11/15/2016] [Indexed: 01/24/2023]
Abstract
The highly conserved Grainyhead-like (Grhl) family of transcription factors, comprising three members in vertebrates (Grhl1-3), play critical regulatory roles during embryonic development, cellular proliferation, and apoptosis. Although loss of Grhl function leads to multiple neural abnormalities in numerous animal models, a comprehensive analysis of Grhl expression and function in the mammalian brain has not been reported. Here they show that only Grhl3 expression is detectable in the embryonic mouse brain; particularly within the habenula, an organ known to modulate repressive behaviors. Using both Grhl3-knockout mice (Grhl3-/- ), and brain-specific conditional deletion of Grhl3 in adult mice (Nestin-Cre/Grhl3flox/flox ), they performed histological expression analyses and behavioral tests to assess long-term effects of Grhl3 loss on motor co-ordination, spatial memory, anxiety, and stress. They found that complete deletion of Grhl3 did not lead to noticeable structural or cell-intrinsic defects in the embryonic brain; however, aged Grhl3 conditional knockout (cKO) mice showed enlarged lateral ventricles and displayed marked changes in motor function and behaviors suggestive of decreased fear and anxiety. They conclude that loss of Grhl3 in the brain leads to significant alterations in locomotor activity and decreased self-inhibition, and as such, these mice may serve as a novel model of human conditions of impulsive behavior or hyperactivity. © 2017 Wiley Periodicals, Inc. Develop Neurobiol 77: 775-788, 2017.
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Affiliation(s)
- Sebastian Dworkin
- Department of Medicine, Monash University Central Clinical School, Prahran, Victoria, 3181, Australia
| | - Alana Auden
- Department of Medicine, Monash University Central Clinical School, Prahran, Victoria, 3181, Australia
| | - Darren D Partridge
- Department of Medicine, Monash University Central Clinical School, Prahran, Victoria, 3181, Australia
| | - Maria Daglas
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University Central Clinical School, Prahran, Victoria, 3181, Australia
| | - Robert L Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University Central Clinical School, Prahran, Victoria, 3181, Australia
| | - Theo Mantamadiotis
- Department of Pathology, University of Melbourne, Parkville, Victoria, 3050, Australia
| | - Smitha R Georgy
- Department of Medicine, Monash University Central Clinical School, Prahran, Victoria, 3181, Australia
| | - Charbel Darido
- Peter MacCallum Cancer Centre, The Victorian Comprehensive Cancer Centre, Parkville, Victoria, 3050, Australia
| | - Stephen M Jane
- Department of Medicine, Monash University Central Clinical School, Prahran, Victoria, 3181, Australia.,Department of Hematology, Alfred Hospital, Prahran, Victoria, 3181, Australia
| | - Stephen B Ting
- Department of Medicine, Monash University Central Clinical School, Prahran, Victoria, 3181, Australia.,Department of Hematology, Alfred Hospital, Prahran, Victoria, 3181, Australia
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Larsson P, Alwis I, Niego B, Sashindranath M, Fogelstrand P, Wu MCL, Glise L, Magnusson M, Daglas M, Bergh N, Jackson SP, Medcalf RL, Jern S. Valproic acid selectively increases vascular endothelial tissue-type plasminogen activator production and reduces thrombus formation in the mouse. J Thromb Haemost 2016; 14:2496-2508. [PMID: 27706906 DOI: 10.1111/jth.13527] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [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: 08/27/2015] [Accepted: 08/25/2016] [Indexed: 01/04/2023]
Abstract
Essentials Stimulating endogenous fibrinolysis could be a novel antithrombotic strategy. The effect of valproic acid on endothelial tissue plasminogen activator in mice was investigated. Valproic acid increased tissue plasminogen activator expression in vascular endothelium. Valproic acid reduced fibrin deposition and thrombus formation after vascular injury. SUMMARY Background The endogenous fibrinolytic system has rarely been considered as a target to prevent thrombotic disease. Tissue-type plasminogen activator (t-PA) production is potently increased by histone deacetylase (HDAC) inhibitors in endothelial cells in vitro, but whether this translates into increased vascular t-PA production and an enhanced fibrinolytic capacity in vivo is unknown. Objectives To determine whether the HDAC inhibitor valproic acid (VPA) stimulates production of t-PA in the vasculature of mice, and whether VPA pretreatment affects fibrin deposition and clot formation after mechanical vessel injury. Methods Mice were injected with VPA twice daily for up to 5 days. t-PA mRNA, and antigen expression in the mouse aorta and the circulating levels of t-PA were determined. Fibrin and thrombus dynamics after mechanical vessel injury were monitored with intravital confocal microscopy. Potential effects of VPA on platelets and coagulation were investigated. Results and Conclusions We found that VPA treatment increased vascular t-PA production in vivo and, importantly, that VPA administration was associated with reduced fibrin accumulation and smaller thrombi in response to vascular injury, but still was not associated with an increased risk of bleeding. Furthermore, we observed that higher concentrations of VPA were required to stimulate t-PA production in the brain than in the vasculature. Thus, this study shows that VPA can be dosed to selectively manipulate the fibrinolytic system in the vascular compartment and reduce thrombus formation in vivo.
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Affiliation(s)
- P Larsson
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - I Alwis
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
- Heart Research Institute, Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - B Niego
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
- Molecular Neurotrauma and Haemostasis, Central Clinical School, Monash University, Melbourne, Australia
| | - M Sashindranath
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
- Molecular Neurotrauma and Haemostasis, Central Clinical School, Monash University, Melbourne, Australia
| | - P Fogelstrand
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M C L Wu
- Heart Research Institute, Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - L Glise
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Magnusson
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Daglas
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
- Molecular Neurotrauma and Haemostasis, Central Clinical School, Monash University, Melbourne, Australia
| | - N Bergh
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - S P Jackson
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
- Heart Research Institute, Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - R L Medcalf
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
- Molecular Neurotrauma and Haemostasis, Central Clinical School, Monash University, Melbourne, Australia
| | - S Jern
- Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Medcalf RL, Lawrence DA. Editorial: The Role of the Plasminogen Activating System in Neurobiology. Front Cell Neurosci 2016; 10:222. [PMID: 27757075 PMCID: PMC5048060 DOI: 10.3389/fncel.2016.00222] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 09/09/2016] [Indexed: 11/13/2022] Open
Affiliation(s)
- Robert L Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University Melbourne, VIC, Australia
| | - Daniel A Lawrence
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School Ann Arbor, MI, USA
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Medcalf RL. Plasminogen and stroke: more is better. J Thromb Haemost 2016; 14:1819-21. [PMID: 27362966 DOI: 10.1111/jth.13399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 06/15/2016] [Indexed: 11/30/2022]
Affiliation(s)
- R L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia.
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Szabo R, Samson AL, Lawrence DA, Medcalf RL, Bugge TH. Passenger mutations and aberrant gene expression in congenic tissue plasminogen activator-deficient mouse strains. J Thromb Haemost 2016; 14:1618-28. [PMID: 27079292 PMCID: PMC5322813 DOI: 10.1111/jth.13338] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [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: 02/22/2016] [Accepted: 04/05/2015] [Indexed: 12/16/2022]
Abstract
UNLABELLED Essentials C57BL/6J-tissue plasminogen activator (tPA)-deficient mice are widely used to study tPA function. Congenic C57BL/6J-tPA-deficient mice harbor large 129-derived chromosomal segments. The 129-derived chromosomal segments contain gene mutations that may confound data interpretation. Passenger mutation-free isogenic tPA-deficient mice were generated for study of tPA function. SUMMARY Background The ability to generate defined null mutations in mice revolutionized the analysis of gene function in mammals. However, gene-deficient mice generated by using 129-derived embryonic stem cells may carry large segments of 129 DNA, even when extensively backcrossed to reference strains, such as C57BL/6J, and this may confound interpretation of experiments performed in these mice. Tissue plasminogen activator (tPA), encoded by the PLAT gene, is a fibrinolytic serine protease that is widely expressed in the brain. A number of neurological abnormalities have been reported in tPA-deficient mice. Objectives To study genetic contamination of tPA-deficient mice. Materials and methods Whole genome expression array analysis, RNAseq expression profiling, low- and high-density single nucleotide polymorphism (SNP) analysis, bioinformatics and genome editing were used to analyze gene expression in tPA-deficient mouse brains. Results and conclusions Genes differentially expressed in the brain of Plat(-/-) mice from two independent colonies highly backcrossed onto the C57BL/6J strain clustered near Plat on chromosome 8. SNP analysis attributed this anomaly to about 20 Mbp of DNA flanking Plat being of 129 origin in both strains. Bioinformatic analysis of these 129-derived chromosomal segments identified a significant number of mutations in genes co-segregating with the targeted Plat allele, including several potential null mutations. Using zinc finger nuclease technology, we generated novel 'passenger mutation'-free isogenic C57BL/6J-Plat(-/-) and FVB/NJ-Plat(-/-) mouse strains by introducing an 11 bp deletion into the exon encoding the signal peptide. These novel mouse strains will be a useful community resource for further exploration of tPA function in physiological and pathological processes.
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Affiliation(s)
- R Szabo
- Proteases and Tissue Remodeling Section, Oral and Pharyngeal Cancer Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - A L Samson
- Australian Centre for Blood Diseases, Monash University, Alfred Medical Research and Education Precinct, Melbourne, Victoria, Australia
| | - D A Lawrence
- Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - R L Medcalf
- Australian Centre for Blood Diseases, Monash University, Alfred Medical Research and Education Precinct, Melbourne, Victoria, Australia
| | - T H Bugge
- Proteases and Tissue Remodeling Section, Oral and Pharyngeal Cancer Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
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