Early hemostatic responses to trauma identified with hierarchical clustering analysis

BACKGROUND

Trauma-induced coagulopathy is a complex multifactorial hemostatic response that is poorly understood.

OBJECTIVES

To identify distinct hemostatic responses to trauma and identify key components of the hemostatic system that vary between responses.

PATIENTS/METHODS

A cross-sectional observational study of adult trauma patients at an urban level I trauma center emergency department was performed. Hierarchical clustering analysis was used to identify distinct clusters of similar subjects according to vital signs, injury/shock severity, and comprehensive assessment of coagulation, clot formation, platelet function, and thrombin generation.

RESULTS

Among 84 total trauma patients included in the model, three distinct trauma clusters were identified. Cluster 1 (N = 57) showed platelet activation, preserved peak thrombin generation, plasma coagulation dysfunction, a moderately decreased fibrinogen concentration and normal clot formation relative to healthy controls. Cluster 2 (N = 18) showed platelet activation, preserved peak thrombin generation, and a preserved fibrinogen concentration with normal clot formation. Cluster 3 (N = 9) was the most severely injured and shocked, and showed a strong inflammatory and bleeding phenotype. Platelet dysfunction, thrombin inhibition, plasma coagulation dysfunction and a decreased fibrinogen concentration were present in this cluster. Fibrinolytic activation was present in all clusters, but was particularly increased in cluster 3. Trauma clusters were most noticeably different in their relative fibrinogen concentration, peak thrombin generation, and platelet-induced clot contraction.

CONCLUSIONS

Hierarchical clustering analysis identified three distinct hemostatic responses to trauma. Further insights into the underlying hemostatic mechanisms responsible for these responses are needed.

Helicobacter pylori arginase inhibits nitric oxide production by eukaryotic cells: a strategy for bacterial survival

The antimicrobial effect of nitric oxide (NO) is an essential part of innate immunity. The vigorous host response to the human gastric pathogen Helicobacter pylori fails to eradicate the organism, despite up-regulation of inducible NO synthase (iNOS) in the gastric mucosa. Here we report that wild-type strains of H. pylori inhibit NO production by activated macrophages at physiologic concentrations of l-arginine, the common substrate for iNOS and arginase. Inactivation of the gene rocF, encoding constitutively expressed arginase in H. pylori, restored high-output NO production by macrophages. By using HPLC analysis, we show that l-arginine is effectively consumed in the culture medium by wild-type but not arginase-deficient H. pylori. The substantially higher levels of NO generated by macrophages cocultured with rocF-deficient H. pylori resulted in efficient killing of the bacteria, whereas wild-type H. pylori exhibited no loss of survival under these conditions. Killing of the arginase-deficient H. pylori was NO-dependent, because peritoneal macrophages from iNOS(-/-) mice failed to affect the survival of the rocF mutant. Thus, bacterial arginase allows H. pylori to evade the immune response by down-regulating eukaryotic NO production.

Pacing during ventricular fibrillation: factors influencing the ability to capture

INTRODUCTION

Recent studies showed that pacing atrial and ventricular fibrillation (VF) is possible. The studies presented here determined which parameters influence the efficacy of a pacing train to capture fibrillating ventricular myocardium. Electrode type, current strength, order of pacing trains, polarity, and VF morphology preceding the pacing trains were investigated.

METHODS AND RESULTS

A 504-electrode recording plaque sutured to the right ventricle of pig hearts was used to record the activations of VF and those resulting from the pacing stimulation. Capture of VF by pacing was determined by observing an animated display of the first temporal derivative of the electrograms. A series of electrodes in a line captured the heart more frequently during VF than did a point electrode. Increasing the current strength to 10 x diastolic pacing threshold increased the incidence of capture, but increasing this strength further did not. The second or third train of 40 stimuli had greater capture rates than did the first train during the same VF episode. Anodal and cathodal unipolar, and bipolar stimulation were equally efficacious in capturing VF. VF activation during the 1-second interval preceding pacing was more organized for pacing trains that captured than those that did not. The highest incidence of capture, 46% to 61% of pacing trains, occurred with a line of electrodes at 10 x diastolic pacing threshold delivered by the second or third train.

CONCLUSION

The probability of a pacing train capturing fibrillating myocardium can be influenced by the pacing protocol parameters.

Computed tomographic characteristics of multilobular tumor of bone involving the cranium in 7 dogs and zygomatic arch in 2 dogs

Computed tomography (CT) images of nine dogs with a multilobular tumor of bone of the head were reviewed. The CT characteristics of the neoplasms involving the calvarium (n = 7) were rounded, well defined with a fine granular, nonhomogeneous bone opacity usually in the occipital region. Cranial vault invasion (5 of 7) was commonly found with a significant portion of the mass within the vault. The neoplasms involving the zygomatic arch (n = 2) were also generally rounded and well defined but with a more coarse granular appearance. The common CT findings were best seen when the images were viewed in a bone window.

Prevalence of antibodies to Neospora sp. in horses from Alabama and characterisation of an isolate recovered from a naturally infected horse [corrected]

An IFAT was used to determine the prevalence of Neospora-specific IgG antibodies in serum from Alabama horses. Serum samples (n = 536) were from asymptomatic horses routinely submitted for equine infectious anaemia virus infection testing. We also subjected a 13-year-old horse with CNS disease to necropsy examination for isolation and in vitro cultivation of protozoal organisms. In antemortem tests, this horse was positive for antibodies to Neospora sp. in the IFAT and western immunoblot. Results of the prevalence survey indicated that IgG antibodies to Neospora were present in 62 (11.5%) of the 536 serum samples. Endpoint titres for the positive samples were 1:50 (35/6.5%), 1:100 (19/3.5%), 1:200 (7/1.3%) and 1:1600 (1/0.2%). Tachyzoites were first seen in cultured bovine turbinate cells 32 days after inoculation with spinal cord homogenates from the horse with CNS disease. Tachyzoites reacted with known N. caninum-positive serum from horses, cows, dogs and mice, but did not react with murine anti-Toxoplasma gondii or equine anti-Sarcocystis neurona serum. Ultrastructural features of tachyzoites and results of comparison of tachyzoite immunodominant proteins revealed that they were identical to those of N. hughesi, a species described recently from a naturally infected horse. The isolate recovered from the naturally infected horse in the present study (designated NA1) is thought to be an isolate of N. hughesi, although confirmation of this awaits additional molecular characterisation. These results provide some additional evidence that N. hughesi is a valid species and that Neospora infections in horses may occur in widely separated geographic regions of the United States.

Review of mechanisms by which electrical stimulation alters the transmembrane potential

Electrical stimuli pace, cardiovert, or defibrillate the heart by changing transmembrane potential (deltaVm). Recent simulation studies provide insights into mechanisms by which stimuli establish deltaVm. This review attempts a nonmathematical description of these mechanisms. We start with the cable model in which the intracellular core conductor is bounded by a highly resistive and capacitive membrane that separates the intracellular and extracellular spaces. Intracellular and extracellular resistances are assumed to vary linearly with position. Although this model predicts anodal extracellular stimuli hyperpolarize adjacent tissue and cathodal extracellular stimuli depolarize that tissue, it fails to reproduce regions of opposite deltaVm distant from the electrodes. We then consider the sawtooth model in which microscopic discontinuities in intracellular resistance represent gap junctions. While model studies with such discontinuities demonstrate large deltaVm at cell ends, experimental validation of such deltaVm remains elusive. Extending the analysis to the two- and three-dimensional syncytium, we also consider the bidomain model in which intracellular, extracellular, and interstitial currents are explicitly characterized. Differences in resistance to these currents gives rise to virtual electrodes, which are experimentally observed regions of large deltaVm that arise distant from the stimulating electrode. Distant deltaVm regions are also evident when macroscopic discontinuities in intracellular resistance are introduced into the bidomain model. Such discontinuities are associated with clefts or scars that give rise to "secondary sources." Albeit the cable model offers remarkable insight the bidomain model and the concept of secondary sources provide a more complete understanding of membrane excitation, especially when combined into a unifying activating function.

In-vitro modelling of the bactericidal activity of teicoplanin versus flucloxacillin as used in surgical prophylaxis, against Staphylococcus aureus

The bactericidal activities of teicoplanin and flucloxacillin in a 50:50 mixture of human serum and Iso-sensitest broth were compared in an in-vitro pharmacokinetic model, at serum concentrations present during surgical prophylaxis. The bactericidal activity of teicoplanin with and without serum was also compared. Six strains of Staphylococcus aureus were tested. The bactericidal rate of teicoplanin in serum was significantly lower than the rate in broth alone. However, there was no significant difference in the bactericidal rates in serum of teicoplanin compared with flucloxacillin, an antibiotic which is commonly used as prophylaxis for certain surgical procedures.

On the mechanism of ventricular defibrillation

The mechanism of ventricular defibrillation can be considered at many different levels. The highest level is considered at strength of the shock given through the defibrillation electrodes. At the next level, the mechanism of defibrillation can be examined in terms of the electrical field that the shock produces throughout the ventricles. Other levels include the effects this electric field has on the activation sequences and on the cellular action potentials that either initiate or inhibit the early sites of activation following the shock. Yet another level considers the mechanism by which the shock field initiates new action potentials or prolongs the action potential by changing the transmembrane potential during the shock. Finally, the subcellular level is considered, which involves the response of the individual ion channels to the shock. This review gives a brief overview of some salient features of defibrillation at each of these mechanistic levels.

Metastasizing extra-adrenal paraganglioma with neurological signs in four dogs

Extra-adrenal paragangliomas associated with vertebral pain and clinical neurological abnormalities as a result of metastasis to the vertebral column were diagnosed in four dogs of different breeds by light microscopy. All were males (two intact and two neutered) aged 8 years. Metastatic neoplasms occurred as extradural masses with associated bone lysis at vertebrae C4 (2 cases), T12-L1 (1 case) and L4 (1 case). The neoplastic cells exhibited similar morphology with little variation between cases. All neoplasms showed cytoplasmic granules after staining with the Churukian-Schenk modification of the Pascual argyrophil stain for neurosecretory granules or for membrane bound electron-dense granules (dense-core granules). On immunohistochemical examination the neoplastic cells gave positive results for neuron-specific enolase and negative results for chromogranin and epithelial membrane antigen. Multiple organ metastasis and metastasis to bone have been reported previously, but these cases were unusual due to the involvement of the spine as an apparent predilection site for metastasis, and the sex (male) and age of the animals affected.

Isolation and partial characterization of glycolipid fractions from Mycobacterium avium serovar 2 (Mycobacterium paratuberculosis 18) that inhibit activated macrophages

Glycolipid fractions from Mycobacterium avium serovar 2 (Mycobacterium paratuberculosis 18) inhibited the killing of Candida albicans by activated bovine peripheral-blood-derived macrophages. Fractions were derived by using the matrix solid-phase dispersion technique, which is a new method of simultaneous lysis and partial fractionation of components of bacterial cells. Further purification of active fractions was performed by concanavalin A affinity chromatography, centrifugal filtration, and differing solvent solubility. Three different fractions were isolated and partially characterized. Two of these fractions have characteristics typical of glycolipids, and the third fraction has characteristics compatible with a peptidoglycolipid. This peptidoglycolipid fraction has been purified and named MIF-A3.

Outer membrane protein profiles of Edwardsiella ictaluri from fish

Outer membrane proteins (OMP) prepared with sodium N-lauroyl sarcocinate (SLS) from 33 Edwardsiella ictaluri isolates from fish were examined by electrophoresis. Twenty-eight isolates from channel catfish (Ictalurus punctatus) had similar OMP profiles. Ten bands (71 kilodaltons [kD] to 19.5 kD) were identified in all isolates from channel catfish. One major 35-kD protein comprised most of the protein content of the outer membrane of isolates from channel catfish. Differences existed among isolates in the amount of protein within minor OMP bands. Edwardsiella ictaluri ATCC 33202 contained larger quantities of the 38.5- and 37-kD proteins than did the other isolates. Outer membrane protein profiles of E ictaluri derived from Bengal danio (Danio devario) and walking catfish (Clarias batrachus) were identical to OMP profiles of isolates from channel catfish. In contrast, OMP profiles from single isolates from green knife fish (Eigemannia virescens) and white catfish (Ictalurus catus) were different. Variations in incubation time, SLS extraction time, SLS extraction number, and in vivo and in vitro passage had no effect on the OMP profile of E ictaluri ATCC 33202. An increase in duration of sample solubilization did affect the OMP profile of E ictaluri ATCC 33202 by decreasing the amount of protein in 52-, 46-, and 43.5-kD bands. Accompanying the decrease were increased staining intensity in the 31.5- and 28.5-kD bands and the appearance of 4 new bands (34, 33, 25.5, and 22.5 kD). Edwardsiella ictaluri, a gram-negative bacterium in the family Enterobacteriaceae, is the cause of enteric septicemia of catfish.(ABSTRACT TRUNCATED AT 250 WORDS)

Isolation, characterization, and molecular cloning of cryptic plasmids isolated from Edwardsiella ictaluri

Fifty-five isolates of Edwardsiella ictaluri were examined for the presence of plasmid DNA by a rapid alkaline extraction procedure. All 49 isolates from channel catfish and a single isolate from Bengal danio carried 2 plasmids with molecular masses of approximately 3.2 and 3.7 megadaltons (Mdal). Five E ictaluri isolates from other fish contained 1 to 3 plasmids, which had molecular masses ranging from 2.5 to 45 Mdal. The 2 plasmids (3.2 and 3.7 Mdal) from the type strain of E ictaluri (ATCC 33202) were ligated into pUC19 cloning vectors, and restriction endonuclease maps of each insert were prepared.

Penetration of imipenem into human aqueous and vitreous humor

Twenty-five patients about to undergo cataract surgery and ten patients about to undergo vitrectomy received a 1-g intravenous dose of imipenem before surgery. Specimens of aqueous or vitreous humor were then obtained and assayed for antibiotic content with a microbiologic disk agar technique. A mean peak aqueous humor level of 2.99 micrograms/ml was found at approximately two hours after administration, and a mean vitreous level of 2.53 micrograms/ml was found from two hours to three hours 15 minutes after administration. These concentrations were well above the minimum inhibitory concentration of imipenem for 90% (MIC90) of Staphylococcus epidermidis, S. aureus, and the Enterobacteriaceae commonly involved in bacterial endophthalmitis.

Ceftriaxone. A new cephalosporin with aqueous humor levels effective against enterobacteriaceae

One- or two-gram doses of ceftriaxone were administered intravenously to 30 patients before cataract extraction. With the 1-g dose, mean aqueous humor concentrations of 0.93 and 0.88 microgram/mL were found at approximately 2 and 12 hours after administration, respectively. With the 2-g dose, a mean level of 2.47 micrograms/mL was observed at two hours; levels of more than 2 micrograms/mL were found in two patients 13 hours after administration. Both the 1- and 2-g doses thus produce aqueous humor levels many times higher than the minimum inhibitory concentration of ceftriaxone for 90% of most Enterobacteriaceae, excluding Pseudomonas. Concentrations adequate for Staphylococcus aureus and Staphylococcus epidermidis were not, however, obtained.

Effects of X-radiation on the retina of the albino rabbit as viewed with the transmission electron microscope

The eyes of albino rabbits were exposed in vivo to 7,000 rad of X-radiation. The retinae were dissected and examined with a transmission electron microscope 24 and 72 h following irradiation. Damage after 24 h was minimal, but after 72 h it was very pronounced. In both cases the damage was restricted to the photoreceptors.

Disseminated intravascular coagulation in experimental intestinal strangulation obstruction in ponies

Total strangulation obstruction of the caudal part of the jejunum was induced in 3 groups (each of 3 ponies) for 2, 4, and 6 hours. Coagulation tests which included blood platelet counts, prothrombin time, activated partial thromboplastin time, activated coagulation time, plasma fibrinogen level, and fibrin/fibrinogen degradation products assay were performed at specified time intervals for 1 week or until death of the experimental ponies. Another 3 ponies (sham-operated) were similarly treated, except that intestinal strangulation obstruction (ISO) was not induced. Necropsy was done on ponies that were euthanatized 9 days after the sampling period and on 2 ponies that died. Six hours of ISO resulted in severe ischemic damage to the intestines, characterized by hemorrhagic infarction, with or without perforation, in ponies that died, and total loss of mucosa with moderate to severe fibrosis of the intestinal wall in the surviving pony of this group. This damage was associated with significant coagulopathies, notably prolonged prothrombin time and activated partial thromboplastin time, decreased blood platelets count, and the presence of high levels of fibrin/fibrinogen degradation products (40 micrograms/ml). These laboratory findings are indicative of disseminated intravascular coagulation. In contrast, the jejunal segments of the ponies subjected to 2 and 4 hours of ISO were viable as revealed by histopathologic examination. There were no significant changes found in their coagulation profiles.(ABSTRACT TRUNCATED AT 250 WORDS)

Petrologic History of Moon Suggested by Petrography, Mineralogy, and Crystallography

Opaque mineral compositions indicate that the fugacity of oxygen is approximately 10(-13) (earth basalts, 10(-10)). Experiments under reducing conditions suggest that the crystallization range is approximately 1140 degrees to 1070 degrees C. Iron-rich pyroxmangite, fayalite, and hedenbergite occur in microgabbro. Ferropseudobrookite rimmed by ilmenite containing rutile and Cr-spinel lamellae occurs in ferrobasalt. Plagioclase vitrophyres in breccia can explain highland Surveyor VII analysis. We suggest crystal-liquid differentiation of out-gassed convecting moon with growing Fe-rich core, olivine-pyroxene mantle, plagioclase-rich dynamic crust underlain by nonspherical, inversely stratified ferrobasalt. Impact-breaking or convection-thrusting of crust releases fraction rich in Fe and Ti. Scanning electron microscopy of glass balls reveals minute depressions consistent with micrometeorite impact.