Integrative profiling of gene expression and chromatin accessibility elucidates specific transcriptional networks in porcine neutrophils

Neutrophils are vital components of the immune system for limiting the invasion and proliferation of pathogens in the body. Surprisingly, the functional annotation of porcine neutrophils is still limited. The transcriptomic and epigenetic assessment of porcine neutrophils from healthy pigs was performed by bulk RNA sequencing and transposase accessible chromatin sequencing (ATAC-seq). First, we sequenced and compared the transcriptome of porcine neutrophils with eight other immune cell transcriptomes to identify a neutrophil-enriched gene list within a detected neutrophil co-expression module. Second, we used ATAC-seq analysis to report for the first time the genome-wide chromatin accessible regions of porcine neutrophils. A combined analysis using both transcriptomic and chromatin accessibility data further defined the neutrophil co-expression network controlled by transcription factors likely important for neutrophil lineage commitment and function. We identified chromatin accessible regions around promoters of neutrophil-specific genes that were predicted to be bound by neutrophil-specific transcription factors. Additionally, published DNA methylation data from porcine immune cells including neutrophils were used to link low DNA methylation patterns to accessible chromatin regions and genes with highly enriched expression in porcine neutrophils. In summary, our data provides the first integrative analysis of the accessible chromatin regions and transcriptional status of porcine neutrophils, contributing to the Functional Annotation of Animal Genomes (FAANG) project, and demonstrates the utility of chromatin accessible regions to identify and enrich our understanding of transcriptional networks in a cell type such as neutrophils.

Recommendations for the evaluation and management of the anticipated and non-anticipated difficult airway of the Societat Catalana d'Anestesiologia, Reanimació i Terapèutica del Dolor, based on the adaptation of clinical practice guidelines and expert consensus

The Airway Division of the Catalan Society of Anaesthesiology, Intensive Care and Pain Management (SCARTD) presents its latest guidelines for the evaluation and management of the difficult airway. This update includes the technical advances and changes observed in clinical practice since publication of the first edition of the guidelines in 2008. The recommendations were defined by a consensus of experts from the 19 participating hospitals, and were adapted from 5 recently published international guidelines following an in-depth analysis and systematic comparison of their recommendations. The final document was sent to the members of SCARTD for evaluation, and was reviewed by 11 independent experts. The recommendations, therefore, are supported by the latest scientific evidence and endorsed by professionals in the field. This edition develops the definition of the difficult airway, including all airway management techniques, and places emphasis on evaluating and classifying the airway into 3 categories according to the anticipated degree of difficulty and additional safety considerations in order to plan the management strategy. Pre-management planning, in terms of preparing patients and resources and optimising communication and interaction between all professionals involved, plays a pivotal role in all the scenarios addressed. The guidelines reflect the increased presence of video laryngoscopes and second-generation devices in our setting, and promotes their routine use in intubation and their prompt use in cases of unanticipated difficult airway. They also address the increased use of ultrasound imaging as an aid to evaluation and decision-making. New scenarios have also been included, such as the risk of bronchoaspiration and difficult extubation Finally, the document outlines the training and continuing professional development programmes required to guarantee effective and safe implementation of the guidelines.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Anaphylaxis in Adolescent/Adult Patients Treated in the Emergency Department: Differences Between Initial Impressions and the Definitive Diagnosis

OBJECTIVES

To contrast the initial suspected etiology of anaphylaxis with the postworkup diagnosis in patients attended at the emergency department (ED) of a tertiary-level hospital in Spain and to investigate the incidence, causes, and management of anaphylaxis.

METHODS

We performed an observational study of patients aged more than 15 years who came to the ED with anaphylaxis between 2009 and 2010. All clinical records from the ED were reviewed. We recorded data on clinical management, the etiology proposed by the attending emergency physician, and the cause reported by the patient. The findings were compared with the diagnosis reached after the allergy workup.

RESULTS

The incidence of anaphylaxis was 0.08%. The most common manifestation was skin-mucosal symptoms (98.3%). Anaphylaxis was diagnosed in the ED in only 44% of the cases, regardless of severity. Only 39.7% received epinephrine, which was administered more frequently when the ED physician diagnosed anaphylaxis, regardless of severity. A total of 60 patients were subsequently seen at the allergy department. The final etiology differed from the initial suspicion in the ED in 45% of cases. The frequency of anaphylaxis of uncertain origin decreased from 33.3% to 13.3%. After the allergy workup, drugs (41.7%) were considered the main cause of anaphylaxis, followed by food (25%).

CONCLUSIONS

The incidence of anaphylaxis (0.08%) was double that estimated in the ED. Anaphylaxis is underdiagnosed. A correct diagnosis conditions the administration of epinephrine, regardless of the severity of symptoms. The real etiology of anaphylaxis should only be proposed after an allergy workup, which is recommended in all cases, as the real cause can differ considerably from the initial impression in the ED.

[Efficacy of 0.1 mg of subarachnoid morphine combined with bupivacaine on postoperative analgesia in total hip arthroplasty]

OBJECTIVES

To analyze the analgesic efficacy, safety and side effects of subarachnoid morphine (0.1 mg) with bupivacaine in patients undergoing total hip arthroplasty.

PATIENTS AND METHODS

Thirty patients scheduled for total hip replacement under spinal anesthesia with bupivacaine were randomly assigned to two groups according to whether local anesthetic with 0.1 mg subarachnoid morphine was also provided or not (group M [n = 15] and group S ņ = 15[, respectively). Top-up analgesia with morphine was available through a patient-controlled device. Postoperative pain was assessed on a visual analogue scale (VAS) and consumption of intravenous morphine in the first 48 hours after surgery was recorded.

RESULTS

VAS scores (mean +/- SD) were significantly lower in the first six hours in group M, but no differences between the two groups were observed thereafter. Total consumption of morphine at 48 hours was much lower in group M (6.80 +/- 7.74 mg) than in group S (31.38 +/- 13.17 mg). The incidence of nausea was high in both groups (46%). Slight pruritus affected 26.6% of patients in group M. Urinary retention necessitating temporary placement of a catheter was observed only in group M, where the incidence was 35.7%. No cases of respiratory depression occurred. Drowsiness was observed in 26.6% of patients in group S in comparison with 6.6% in group M.

CONCLUSIONS

Combining 0.1 mg morphine and bupivacaine for total spinal anesthesia during hip arthroplasty significantly decreased the consumption of intravenous morphine during the first 48 hours after surgery. No respiratory depression occurred and the only side effects were urinary retention and mild pruritus and drowsiness.

Possible synergistic effect of metformin and enalapril on the development of hyperkaliemic lactic acidosis

A 71 year old hypertensive, non insulin-dependent diabetic patient with moderate renal insufficiency taking 500 mg/d of metformin and 5 mg/d of enalapril, developed metabolic acidosis characterized by fairly elevated anion gap, hyperchloremia, severe hyperkaliemia, normal plasma level of 3-hydroxybutyric acid, absence of ketonuria and high plasma level of lactic acid. This biochemical feature allowed us to ascribe the pathogenesis of metabolic acidosis, both to the increased plasma level of lactic acid and to the type IV renal tubular acidosis syndrome, the precipitating factor being an infection of urinary tract (as we assumed on the basis of the urine culture). The patient was dehydrated and lethargic; the ECG revealed the presence of nonparoxysmal junctional tachycardia. The clinical evolution was favorable under the treatment with an infusion of isotonic saline solutions, mild alkalinizing solutions, low-dose regular insulin and antibiotics. It is likely that metformin and enalapril, regularly taken by this nephropathic patient, could have played an iatrogenic role, even if the doses were low. This case highlights the importance of complying with the contraindications of these drugs, to avoid the rare but reported life-threatening complications of metformin administration.