Femoral neck width genetic risk score is a novel independent risk factor for hip fractures

Femoral neck width (FNW) derived from DXA scans may provide a useful adjunct to hip fracture prediction. Therefore, we investigated whether FNW is related to hip fracture risk independently of femoral neck bone mineral density (FN-BMD), using a genetic approach. FNW was derived from points automatically placed on the proximal femur using hip DXA scans from 38 150 individuals (mean age 63.8 yr, 48.0% males) in UK Biobank (UKB). Genome-wide association study (GWAS) identified 71 independent genome-wide significant FNW SNPs, comprising genes involved in cartilage differentiation, hedgehog, skeletal development, in contrast to SNPs identified by FN-BMD GWAS which primarily comprised runx1/Wnt signaling genes (MAGMA gene set analyses). FNW and FN-BMD SNPs were used to generate genetic instruments for multivariable Mendelian randomization. Greater genetically determined FNW increased risk of all hip fractures (odds ratio [OR] 1.53; 95% CI, 1.29-1.82 per SD increase) and femoral neck fractures (OR 1.58;1.30-1.92), but not trochanteric or forearm fractures. In contrast, greater genetically determined FN-BMD decreased fracture risk at all 4 sites. FNW and FN-BMD SNPs were also used to generate genetic risk scores (GRSs), which were examined in relation to incident hip fracture in UKB (excluding the FNW GWAS population; n = 338 742, 3222 cases) using a Cox proportional hazards model. FNW GRS was associated with increased risk of all incident hip fractures (HR 1.08;1.05-1.12) and femoral neck fractures (hazard ratio [HR] 1.10;1.06-1.15), but not trochanteric fractures, whereas FN-BMD GRS was associated with reduced risk of all hip fracture types. We conclude that the underlying biology regulating FNW and FN-BMD differs, and that DXA-derived FNW is causally related to hip fractures independently of FN-BMD, adding information beyond FN-BMD for hip fracture prediction. Hence, FNW derived from DXA analyses or a FNW GRS may contribute clinically useful information beyond FN-BMD for hip fracture prediction.

Association of Bone Shape and Alignment Analyzed Using Statistical Shape Modeling With Severity of First Metatarsophalangeal Joint Osteoarthritis

OBJECTIVE

We aimed to explore the relationship between bone shape and radiographic severity in individuals with first metatarsophalangeal joint osteoarthritis (first MTP joint OA).

METHODS

Weightbearing lateral and dorsoplantar radiographs were obtained for the symptomatic foot of 185 participants (105 females, aged 22 to 85 years) with clinically diagnosed first MTP joint OA. Participants were classified into none/mild, moderate, or severe categories using a standardized atlas. An 80-point model for lateral radiographs and 77-point model for dorsoplantar radiographs was used to define independent modes of variation using statistical shape modeling software. Odds ratios adjusted for confounders were calculated using ordinal regression to determine the association between radiographic severity and mode scores.

RESULTS

After assessment and grading of radiographs, 35 participants (18.9%) were included in the none/mild first MTP joint OA severity category, 69 (37.2%) in the moderate severity category, and 81 (43.7%) in the severe category. For lateral-view radiographs, 16 modes of variation were included, which collectively represented 83.2% of total shape variance. Of these, four modes were associated with radiographic severity. For dorsoplantar-view radiographs, 15 modes of variation were included, representing 82.6% of total shape variance. Of these, six modes were associated with radiographic severity.

CONCLUSIONS

Variations in the shape and alignment of the medial cuneiform, first metatarsal, and proximal and distal phalanx of the hallux are significantly associated with radiographic severity of first MTP joint OA. Prospective studies are required to determine whether bone shape characteristics are associated with the development and/or progression of this condition.

Hip geometric parameters are associated with radiographic and clinical hip osteoarthritis: Findings from a cross-sectional study in UK Biobank

OBJECTIVE

To examine the extent to which geometric parameters derived from dual-energy x-ray absorptiometry (DXA) scans in the UK Biobank study are related to hip osteoarthritis (HOA) independently of sex, age and body size.

DESIGN

Femoral neck width (FNW), diameter of the femoral head (DFH) and hip axis length (HAL) were derived automatically from left hip DXA scans in UK Biobank using outline points placed around the hip by a machine-learning program. Correlations were calculated between geometric parameters, age, height, and weight. Logistic regression was used to examine the relationship of geometric parameters with radiographic HOA, hospital diagnosed HOA (HESOA), and Cox proportional hazards model to evaluate the relationship with total hip replacement (THR). Analyses were adjusted for sex, age, height, weight, and geometric parameters.

RESULTS

The study consisted of 40,312 participants. In age and sex-adjusted analyses, FNW, HAL and DFH were related to increased risk of radiographic HOA. In a model adjusted for age, sex, height, weight and other geometric parameters, both FNW and HAL retained independent relationships with radiographic HOA [FNW: odds ratios 2.38 (2.18-2.59), HAL: 1.25 (1.15-1.36)], while DFH was now protective [0.55 (0.50-0.61)]. Only FNW was independently related to HESOA [2.20 (1.80-2.68)] and THR [hazard ratios 2.51 (1.89-3.32)].

CONCLUSION

Greater FNW and HAL were independently related to an increased risk of radiographic HOA, whereas greater DFH appeared to be protective. Greater FNW was independently associated with HESOA and THR. These results suggest that DXA-derived geometric parameters, particularly FNW, could help determine HOA and THR risk.

Cam morphology but neither acetabular dysplasia nor pincer morphology is associated with osteophytosis throughout the hip: findings from a cross-sectional study in UK Biobank

OBJECTIVES

To examine whether acetabular dysplasia (AD), cam and/or pincer morphology are associated with radiographic hip osteoarthritis (rHOA) and hip pain in UK Biobank (UKB) and, if so, what distribution of osteophytes is observed.

DESIGN

Participants from UKB with a left hip dual-energy X-ray absorptiometry (DXA) scan had alpha angle (AA), lateral centre-edge angle (LCEA) and joint space narrowing (JSN) derived automatically. Cam and pincer morphology, and AD were defined using AA and LCEA. Osteophytes were measured manually and rHOA grades were calculated from JSN and osteophyte measures. Logistic regression was used to examine the relationships between these hip morphologies and rHOA, osteophytes, JSN, and hip pain.

RESULTS

6,807 individuals were selected (mean age: 62.7; 3382/3425 males/females). Cam morphology was more prevalent in males than females (15.4% and 1.8% respectively). In males, cam morphology was associated with rHOA [OR 3.20 (95% CI 2.41-4.25)], JSN [1.53 (1.24-1.88)], and acetabular [1.87 (1.48-2.36)], superior [1.94 (1.45-2.57)] and inferior [4.75 (3.44-6.57)] femoral osteophytes, and hip pain [1.48 (1.05-2.09)]. Broadly similar associations were seen in females, but with weaker statistical evidence. Neither pincer morphology nor AD showed any associations with rHOA or hip pain.

CONCLUSIONS

Cam morphology was predominantly seen in males in whom it was associated with rHOA and hip pain. In males and females, cam morphology was associated with inferior femoral head osteophytes more strongly than those at the superior femoral head and acetabulum. Further studies are justified to characterise the biomechanical disturbances associated with cam morphology, underlying the observed osteophyte distribution.

The influence of adult hip shape genetic variants on adolescent hip shape: Findings from a population-based DXA study

OBJECTIVE

Hip shape is a well-recognized risk factor for hip osteoarthritis (OA) and hip fracture. We aimed to investigate whether the genetic variants known to be associated with adult hip shape were also associated with adolescent hip shape.

METHODS

Hip DXA scans, obtained in offspring from the Avon Longitudinal Study of Parents and Children (ALSPAC) at two time points (mean ages 13.8 and 17.8 years), were used to quantify hip morphology using a 53-point Statistical Shape Model (SSM). Principal component analysis was used to generate hip shape modes (HSMs). Genetic variants which had previously shown genome-wide significant association with specific HSMs in adults were tested for association with the same HSMs in adolescents (at each timepoint separately) using SNPTEST v2.

RESULTS

Complete genotypic and phenotypic data were available for 3550 and 3175 individuals at 14 and 18 years, respectively. The strongest evidence for association with adolescent hip shape was for a variant located near SOX9 (rs2158915) with consistent effects across both time points for HSM1 (age 14: beta -0.05, p = 9.9 × 10-8; age 18: -0.05, p = 3.3 × 10-6) and HSM5 (age 14: beta -0.07, p = 1.6 × 10-4; age 18: -0.1, p = 2.7 × 10-6). There was also strong evidence of association between rs10743612 (near PTHLH) and HSM1 (age 14: 0.05, p = 1.1 × 10-5; age 18: 0.04, p = 0.003) and between rs6537291 (near HHIP) and HSM2 (age 14: -0.06, p = 0.001; age 18: -0.07, p = 0.001) across both time points. The genes with the strongest associations with hip shape in adolescents, (SOX9, PTHLH and HHIP) are known to be involved in endochondral bone formation. HSM1 indicates narrower aspect ratio of the upper femur, whereas both HSM2 and HSM5 reflect variation in the femoral head size and femoral neck width, features previously found to be related to the risk of OA in later life. The SOX9 locus has previously been found to associate with increased risk of hip fracture.

CONCLUSION

In conclusion, variants implicated in endochondral bone formation appear to consistently influence hip shape between adolescence and adulthood, including those aspects related to risk of hip OA and/or fracture in later life.

Anticholinergic burden in middle-aged women and recurrent falls in later life: findings from the Aberdeen prospective osteoporosis screening study (APOSS)

Background:

Anticholinergic burden (ACB) is a recognised risk factor for falls in older people; however, whether ACB in middle age predicts falls in later life is unknown.

Methods:

We examined this association in the middle-aged women of the Aberdeen Prospective Osteoporosis Screening Study (APOSS). ACB was calculated at the second health visit (1997–1999, study baseline) using the Anticholinergic Cognitive Burden Scale. Outcomes were incidence of 1 fall and recurrent falls (⩾2 falls) during the 12 months prior to follow up 2007–2011. Multinomial logistic regression analyses adjusted for potential confounders including demographics, comorbidities and falls history.

Results:

A total of 2125 women {mean age (standard deviation [SD]): 54.7 (2.2) years at baseline and 66.0 (2.2) years at follow up} were included. Prevalence of baseline ACB score of 0, 1 and ⩾2 was 87.1%, 7.3% and 5.6%, respectively. Compared with no ACB, ACB ⩾2 was associated with recurrent falls in the previous 12 months [adjusted odds ratio (OR): 2.34, 95% confidence interval (CI): 1.31, 4.19] at an average of 11 years after initial exposure. No such association was found for an ACB score of 1.

Conclusions:

These findings highlight the potential negative effects of anticholinergic medications in middle age. While cautious use of anticholinergic medications is advisable, further longitudinal research should be conducted to confirm these findings before any specific clinical recommendations can be made.

Describing the application of statistical shape modelling to DXA images to quantify the shape of the proximal femur at ages 14 and 18 years in the Avon Longitudinal Study of Parents and Children

Bones are complex objects with considerable variation in the shape and structure often attributed to anatomical, environmental or genetic differences. In addition, bone shape has been of interest in relation to its associations with disease processes. Hip shape is an important determinant of hip osteoarthritis and osteoporotic hip fracture; however, its quantification is difficult. While previous studies largely focused on individual geometrical indices of hip geometry such as neck-shaft angle or femoral neck width, statistical shape modelling offers the means to quantify the entire contour of the proximal femur, including lesser trochanter and acetabular eyebrow. We describe the derivation of independent modes of variation (hip shape mode scores) to characterise variation in hip shape from dual-energy X-ray absorptiometry (DXA) images in the Avon Longitudinal Study of Parents and Children (ALSPAC) offspring, using statistical shape modelling. ALSPAC is a rich source of phenotypic and genotypic data which provides a unique opportunity to investigate the environmental and genetic influences on hip shape in adolescence, as well as comparison with adult hip shape.

Using statistical shape modelling of DXA images to quantify the shape of the proximal femur at ages 14 and 18 years in the Avon Longitudinal Study of Parents and Children

Hip shape is an important determinant of hip osteoarthritis and osteoporotic hip fracture; however, little is known about its development in childhood and adolescence. While previous studies largely focused on individual geometrical indices of hip geometry such as neck-shaft angle or femoral neck width, statistical shape modelling offers the means to quantify the entire contour of the proximal femur, including lesser trochanter and acetabular eyebrow. We describe the derivation of independent modes of variation (hip shape mode scores) to characterise variation in hip shape from dual-energy X-ray absorptiometry (DXA) images in the Avon Longitudinal Study of Parents and Children (ALSPAC) offspring, using statistical shape modelling. ALSPAC is a rich source of phenotypic and genotypic data which provides a unique opportunity to investigate the environmental and genetic influences on hip shape in adolescence, as well as comparison with adult hip shape.

Significant morphological change in osteoarthritic hips identified over 6-12 months using statistical shape modelling

OBJECTIVE

Predicting who will develop osteoarthritis, assessing how rapidly their disease will progress and monitoring early responses to treatment are key to the development of therapeutic agents able to treat this crippling disease and to their future clinical use. Statistical Shape Modelling (SSM) enables quantification of variations in multiple geometric measures describing the whole hip joint to be considered in concert. This prospective study evaluates the responsiveness of SSM to changes in hip-shape within 1 year.

METHODS

Sixty-two people, mean age 67.1 yrs, were recruited. Dual-energy X-ray Absorptiometry images were taken at three timepoints (baseline, 6 and 12 months). Based on Kellgren-Lawrence grading (KLG) of their baseline images, subjects were classified into control/doubtful OA: KLG < 1 in both hips; moderate OA: KLG = 2; and severe OA: KLG ≥ 3 in their most severe hip. Morphology was quantified using SSM and changes in shape were assessed using generalised estimating equations. Standardized response means (SRMs) were calculated for the first and second 6 month periods, then the full 12 months.

RESULTS

Disease severity ranged from KLG0-KLG4 in the 124 hips assessed at baseline. Three SSM modes (Modes 1, 3 and 4) were associated with OA severity. Across the whole cohort, SRM magnitudes ranged from 0.16 to 0.63. The greatest subgroup SRM (magnitude 0.91) was observed over 12 months in those subjects with moderate OA (KLG2).

CONCLUSIONS

We have demonstrated that SSM can capture changes in hip shape over 6 and 12 months across the entire hip joint providing a sensitive measure of hip OA progression.

Variations in Hip Shape Are Associated with Radiographic Knee Osteoarthritis: Cross-sectional and Longitudinal Analyses of the Johnston County Osteoarthritis Project

OBJECTIVE

Hip shape by statistical shape modeling (SSM) is associated with hip radiographic osteoarthritis (rOA). We examined associations between hip shape and knee rOA given the biomechanical interrelationships between these joints.

METHODS

Bilateral baseline hip shape assessments [for those with at least 1 hip with a Kellgren-Lawrence arthritis grading scale (KL) 0 or 1] from the Johnston County Osteoarthritis Project were available. Proximal femur shape was defined on baseline pelvis radiographs and evaluated by SSM, producing mean shape and continuous variables representing independent modes of variation (14 modes = 95% of shape variance). Outcomes included prevalent [baseline KL ≥ 2 or total knee replacement (TKR)], incident (baseline KL 0/1 with followup ≥ 2), and progressive knee rOA (KL increase of ≥ 1 or TKR). Limb-based logistic regression models for ipsilateral and contralateral comparisons were adjusted for age, sex, race, body mass index (BMI), and hip rOA, accounting for intraperson correlations.

RESULTS

We evaluated 681 hips and 682 knees from 342 individuals (61% women, 83% white, mean age 62 yrs, BMI 29 kg/m(2)). Ninety-nine knees (15%) had prevalent rOA (4 knees with TKR). Lower modes 2 and 3 scores were associated with ipsilateral prevalent knee rOA, and only lower mode 3 scores were associated with contralateral prevalent knee rOA. No statistically significant associations were seen for incident or progressive knee rOA.

CONCLUSION

Variations in hip shape were associated with prevalent, but not incident or progressive, knee rOA in this cohort, and may reflect biomechanical differences between limbs, genetic influences, or common factors related to both hip shape and knee rOA.

How many different types of femora are there in primary hip osteoarthritis? An active shape modeling study

We assessed the variation in proximal femoral canal shape and its association with geometric and demographic parameters in primary hip OA. In a retrospective cohort study, the joint geometry of the proximal femur was evaluated on radiographs and corresponding CT scans of 345 consecutive patients with end-stage hip OA. Active shape modeling (ASM) was performed to assess the variation in endosteal shape of the proximal femur. To identify natural groupings of patients, hierarchical cluster analysis of the shape modes was used. ASM identified 10 independent shape modes accounting for >96% of the variation in proximal femoral canal shape within the dataset. Cluster analysis revealed 10 specific shape clusters. Significant differences in geometric and demographic parameters between the clusters were observed. ASM and subsequent cluster analysis have the potential to identify specific morphological patterns of the proximal femur despite the variability in proximal femoral anatomy. The study identified patterns of proximal femoral canal shape in hip OA that allow a comprehensive classification of variation in shape and its association with joint geometry. Our data may improve future stem designs that will optimize stem fit and simultaneously allow individual restoration of hip biomechanics.

Can we improve the prediction of hip fracture by assessing bone structure using shape and appearance modelling?

PURPOSE

There is a continuing need to improve the prediction of hip fractures to identify those at highest risk, enabling cost-effective use of preventative therapies.

METHODS

The aim of this work was to validate an innovative imaging biomarker for hip fracture by modelling the shape and texture of the proximal femur assessed from dual energy X-ray absorptiometry (DXA) scans. Scans used were acquired at baseline from elderly patients participating in a prospective, placebo-controlled fracture prevention study of the bisphosphonate, clodronate. 182 subjects who subsequently suffered a hip fracture were age, weight and height matched with two controls who did not suffer a fracture during a median 4-year follow-up period. Logistic regression was used to test if variables were good predictors of fracture and adjust for bone mineral density (BMD).

RESULTS

Shape mode 2, reflecting variability in neck-shaft angle, neck width and the size of both trochanters (0.81 (OR), 0.68-0.97 (CI), 0.024 (P)), and appearance mode 6, recording grey-level contrast (1.33, 1.11-1.59, 0.002), were significant predictors of hip fracture and remained so after adjustment for BMD (shape mode 2 (0.77, 0.64-0.93, 0.006), appearance mode 6 (1.32, 1.10-1.59, 0.003)). Receiver Operating Curve analysis showed the combination of shape mode 2, appearance mode 6 and BMD was 3% better than any single predictor.

CONCLUSION

Variables derived from shape and appearance models gave a prediction of fracture comparable to BMD and in combination with BMD gave an improvement in the prediction of hip fracture that could predict an additional 2000 hip fracture cases per year in the UK, potentially saving more than £20 million per year and 10,000 cases in the US.

Spontaneous splenic artery hemorrhage with secondary antiphospholipid syndrome in lupus: a case report

Spontaneous hemorrhage is a rare complication of lupus. We describe a 36-year old female with lupus who suffered spontaneous, nontraumatic hemorrhage from branches of the splenic artery with massive blood loss while being treated for a lupus flare. We compare this to the two other reported cases of similar lupus-associated splenic artery hemorrhage documented in the literature, both of which had significant pre-existing hemorrhagic risk factors. Spontaneous, nontraumatic hemorrhage of the splenic artery in the absence of risk factors, and in a patient with secondary antiphospholipid syndrome, has been previously undescribed in lupus.

NMR detection and one-dimensional imaging using the inhomogeneous magnetic field of a portable single-sided magnet

A portable, nuclear magnetic resonance (NMR) probe is described which utilises the intrinsic inhomogeneity of the field produced by a single-sided magnet to provide spatial encoding of the NMR signal. The probe uses a longitudinally magnetized hollow cylinder, and a figure-8 radiofrequency (RF) surface coil. The system has been used to measure NMR relaxation times and one-dimensional NMR profiles of rubber phantoms.

Measurement of the solar gravitational deflection of radio waves using geodetic very-long-baseline interferometry data, 1979-1999

We used very-long-baseline interferometry (VLBI) to measure the deflection by the Sun of radio waves emanating from distant compact radio sources. This bending is characterized in the parametrized post-Newtonian formalism by gamma, which is unity in general relativity. Using a large geodetic VLBI data set, we obtained gamma=0.9998(3)+/-0.0004(5) (estimated standard error). We found no systematic biases from our analysis of subgroups of data.

A method for assessment of the shape of the proximal femur and its relationship to osteoporotic hip fracture

The shape of the proximal femur has been demonstrated to be important in the occurrence of fractures of the femoral neck. Unfortunately, multiple geometric measurements frequently used to describe this shape are highly correlated. A new method, active shape modeling (ASM) has been developed to quantify the morphology of the femur. This describes the shape in terms of orthogonal modes of variation that, consequently, are all independent. To test this method, digitized standard pelvic radiographs were obtained from 26 women who had suffered a hip fracture and compared with images from 24 age-matched controls with no fracture. All subjects also had their bone mineral density (BMD) measured at five sites using dual-energy X-ray absorptiometry. An ASM was developed and principal components analysis used to identify the modes which best described the shape. Discriminant analysis was used to determine which variable, or combination of variables, was best able to discriminate between the groups. ASM alone correctly identified 74% of the individuals and placed them in the appropriate group. Only one of the BMD values (Ward's triangle) achieved a higher value (82%). A combination of Ward's triangle BMD and ASM improved the accuracy to 90%. Geometric variables used in this study were weaker, correctly classifying less than 60% of the study group. Logistic regression showed that after adjustment for age, body mass index, and BMD, the ASM data was still independently associated with hip fracture (odds ratio (OR)=1.83, 95% confidence interval 1.08 to 3.11). The odds ratio was calculated relative to a 10% increase in the probability of belonging to the fracture group. Though these initial results were obtained from a limited data set, this study shows that ASM may be a powerful method to help identify individuals at risk of a hip fracture in the future.

Analysis of trabecular bone structure using Fourier transforms and neural networks

Hip fracture due to osteoporosis (OP) and hip osteoarthritis (OA) are both important causes of locomotor morbidity in the elderly population. In osteoporosis, bone mass gradually decreases until the skeleton is too fragile to support the body and a fracture occurs, typically in the femur, wrist, or spine. In osteoarthritis, there is a proliferation of bone, leading to a stiffening of the tissue. Current clinical methods for assessment of bone changes in these disorders largely depend on assessing bone mineral density. However, this does not provide any information about bone structure which is considered to be an equally important factor in assessing bone quality. This paper presents a novel approach for computer analysis of trabecular (or cancellous) bone structure. The technique uses a Fourier transform to generate a "spectral fingerprint" of an image. Principal components analysis is then applied to identify key features from the Fourier transform and this information passed to a neural network for classification. Testing this on a series of 100 histological sections of trabecular bone from patients with OP and OA and a normal group correctly classified over 90% of the OP group with an overall accuracy of 77%-84%. Such high success rates on a small group suggest that this may provide a simple, but powerful, method for identifying alterations in bone structure.

Extracorporeal venovenous recirculation for the treatment of hypothermia during elective aortic surgery: a phase I study

BACKGROUND

Hypothermia caused by massive transfusion or prolonged exposure during operation is difficult to reverse and is associated with adverse side effects. This prospective, randomized study evaluated a technique using extracorporeal venovenous recirculation (EVR) through a roller pump-driven device with a commercial countercurrent heat exchanger used for treatment of hypothermia (temperature < 35.5 degrees C) occurring during elective aortic operation.

METHODS

Patients undergoing aortic operation had routine prophylaxis against hypothermia including ventilator cascades, warming blankets, and low-velocity fluid warmers. When core temperature was less than 35.5 degrees C, patients were randomized to continue existing therapy (control, n = 7) or EVR (n = 8), performed through two large-bore venous lines.

RESULTS

There were no differences in age, sex, weight, body surface area, Acute Physiology and Chronic Health Evaluation II score, fluid replacement, length of operation, blood lost or given, induction temperature, red blood cell or platelet structure, hemolysis, length of intensive care unit or hospital stay, complications, or mortality rates. EVR was associated with increased final core temperature (35.5 degrees +/- 0.8 degrees [EVR] vs 33.8 degrees +/- 0.9 degrees [control]; p < 0.005) and body heat content (-13.9 +/- 62.3 kcal [EVR] vs -118.2 +/- 62.2 kcal [control]; p < 0.01), with heat gained being proportional to flow rate.

CONCLUSIONS

These data show that EVR provides a safe and effective method for the treatment of hypothermia.

Experience with phenylephrine as a component of the pharmacologic support of septic shock

OBJECTIVE

To evaluate the use of the selective alpha 1-adrenergic receptor agonist phenylephrine in the hemodynamic support of patients with septic shock.

DESIGN

Retrospective analysis of clinical use of phenylephrine.

SETTING

Surgical ICU in a university hospital.

PATIENTS

Thirteen patients with septic shock (diagnosed by defined criteria) requiring pharmacologic support for the treatment of hypotension.

INTERVENTIONS AND MAIN RESULTS

All patients underwent invasive hemodynamic monitoring followed by volume resuscitation and inotropic support to reverse flow-dependent oxygen consumption and lactic acidosis. Patients with persistent hypotension (mean arterial pressure [MAP] less than 65 mm Hg) and vasodilation (systemic vascular resistance index [SVRI] less than 1500 dyne.sec/cm5.m2 received phenylephrine at iv infusion rates of 0.5 to 9 micrograms/kg.min to maintain MAP greater than 70 mm Hg. MAP, SVRI, left ventricular stroke work index, and stroke volume index were significantly (p less than .05) increased after phenylephrine administration and at the time of highest oxygen consumption (VO2). Cardiac index was unchanged initially but increased at the time of highest VO2 (p less than .05). Pulmonary artery occlusion pressure and heart rate were unchanged. Average baseline VO2 increased from 145 to 200 mL/min.m2 and oxygen delivery (DO2) increased from 447 to 597 mL/min.m2 during phenylephrine treatment (p less than .05). Blood lactate concentrations decreased and urine output increased significantly (p less than .05), while serum creatinine concentrations remained unchanged during phenylephrine therapy.

CONCLUSIONS

Treatment with phenylephrine was associated with beneficial hemodynamic effects when used to maintain perfusion, while increasing DO2 and VO2 in patients with septic shock.

Comparison of three methods of rewarming from hypothermia: advantages of extracorporeal blood warming

We developed a new technique, extracorporeal venovenous rewarming (EVR), to rewarm hypothermic patients in the intensive care unit or operating room. We compared this method with the active external (standard) techniques of warming blankets; heated ventilator circuits, intravenous fluids, and gastric and peritoneal lavage; and cardiopulmonary bypass. The EVR technique warmed patients' blood or additional blood products and crystalloids to 40 degrees C at 150-400 mL/min and allowed survival from a core temperature of 31.1 degrees C after massive injury. The EVR technique rewarming patients more rapidly than standard techniques and may be most appropriate in patients with multisystem trauma when rapid correction of hypothermia-related hypovolemia, coagulopathy, and arrhythmia is necessary. Cardiopulmonary bypass is required in severely hypothermic patients with cardiac arrest. Standard techniques can be used when these immediately life-threatening conditions are not present.

Incidence and timing of hypothermia in trauma patients undergoing operations

Hypothermia is a major problem in patients who have sustained trauma. We reviewed the cases of 100 consecutive trauma patients transferred directly to the operating room (OR) from the Emergency Department (ED) in a Level I trauma center; 26 cases could not be evaluated. Forty-two patients (57%) became hypothermic at some time between injury and leaving the OR. Fifty-five patients (74%) had a temperature (T) recorded on arrival to the ED; but only 7 (12%) were hypothermic (34.7 degrees +/- 1.5 degrees C). In contrast, 34 patients (46%) arrived in the OR hypothermic (34.8 degrees +/- 0.9 degrees C) and 26 (76%) of these left the OR hypothermic (34.8 degrees +/- 0.9 degrees C). Eight additional patients (20%) arriving in the OR with a T greater than 35.9 degrees C left the OR hypothermic (35.1 degrees +/- 0.4 degrees C). The mean T loss in the ED was significantly greater than that lost in the OR (-0.8 degrees +/- 0.7 degrees C vs. 0.0 degrees +/- 0.6 degrees C; p less than 0.0001, ANOVA). Ninety-two percent of the patients lost temperature in the ED, while 43% of the patients gained temperature in the OR. Hypothermia was associated with lower Trauma Scores, and those patients who were severely hypothermic received more intravenous fluids. However, the impact of fluid infusion was not independent from Trauma Score and did not fully explain the magnitude of the heat loss. These data suggest that hypothermia in trauma patients has a multifactoral etiology related to the magnitude of injury and that the major T loss occurs in the ED rather than in the OR.(ABSTRACT TRUNCATED AT 250 WORDS)

Purification and properties of extracellular signal-regulated kinase 1, an insulin-stimulated microtubule-associated protein 2 kinase

In rat 1 fibroblasts, insulin has little or no stimulatory effect on the activities of either MAP2 protein kinase or ribosomal protein S6 kinase. In contrast, in rat 1 cells that overexpress the normal human insulin receptor (rat 1 HIRc B; McClain et al. (1987) J. Biol. Chem. 262, 14663-14671), insulin activates both MAP2 and S6 kinase activities close to 5-fold. A MAP2 kinase has been purified from insulin-treated rat 1 HIRc B cells over 6300-fold by chromatography on Q-Sepharose, phenyl-Sepharose, S-Sepharose, phosphocellulose, QAE-Sepharose, UltrogelAcA54, DEAE-cellulose, and a second Q-Sepharose. Its specific activity is approximately 0.8-1 mumol.min-1.mg-1 with MAP2 and 3 mumol.min-1.mg-1 with myelin basic protein. The enzyme preparation contains one major band of Mr = 43,000 upon SDS-polyacrylamide gel electrophoresis, which is immunoblotted by antibodies to phosphotyrosine. A sequence from the 43-kDa band led to the isolation of a cDNA encoding the enzyme, which we have named ERK1 for extracellular signal-regulated kinase (Boulton et al. (1990) Science 249, 64-67).

High-dose phenylephrine infusion in the hemodynamic support of septic shock

A 75-year-old man with hyperdynamic septic shock and vasodilation was successfully supported hemodynamically for 88.5 hours through the use of a continuous infusion of phenylephrine at dosages up to 360 micrograms/min. The only other vasoactive compound administered was dopamine at a dosage of 3.4 micrograms/kg/min. Hemodynamic evaluation indicated improvements in mean arterial pressure, cardiac output, and oxygen transport parameters during the period of hemodynamic support, which did not indicate a detrimental effect on perfusion of vital organs and tissues despite the use of this vasoconstrictor. Phenylephrine's pharmacologic properties may represent an advantage for its use as a vasoconstrictor over catecholamines such as norepinephrine and dopamine, particularly in patients who develop tachyarrhythmias with these agents. The pharmacology, dosage, and appropriate monitoring of therapy with phenylephrine in patients with septic shock are discussed.

An insulin-stimulated protein kinase similar to yeast kinases involved in cell cycle control

A protein kinase characterized by its ability to phosphorylate microtubule-associated protein-2 (MAP2), is thought to be an early intermediate in an insulin-stimulated phosphorylation cascade and in a variety of other mammalian cell responses to extracellular signals. A complementary DNA that encodes this protein serine-threonine kinase has been cloned, and the protein designated extracellular signal-regulated kinase 1 (ERK1). ERK1 has striking similarity to two protein kinases, KSS1 and FUS3, from yeast. The yeast kinases function in an antagonistic manner to regulate the cell cycle in response to mating factors. Thus, ERK1 and the two yeast kinases constitute a family of evolutionarily conserved enzymes involved in regulating the response of eukaryotic cells to extracellular signals.

Evidence for insulin-dependent activation of S6 and microtubule-associated protein-2 kinases via a human insulin receptor/v-ros hybrid

The abilities of a series of six mutants of the human insulin receptor, an insulin receptor/v-ros hybrid (IR-ros) and the P68gag-ros transforming protein to stimulate S6 protein kinase have been assessed. Insulin receptor mutants in which either 1 or 2 tyrosine residues have been replaced with phenylalanine (YF1, YF3) have lost some or all of the capacity to mediate the activation of S6 kinase in response to insulin. None of the four mutants that contain deletions (spBam, spBamYF3, iBgl, T-t) elicit an insulin-dependent stimulation of S6 kinase. A previous study of the IRros hybrid receptor demonstrated that it was unable to cause either insulin-stimulated thymidine incorporation or glucose uptake (Ellis, L., Morgan, D. O., Jong, S.-M., Wang, L.-H., Roth, R. A., and Rutter, W. J. (1987) Proc. Natl. Acad. Sci. U. S. A. 84, 5101-5105). In contrast, the IRros chimera appears to mediate the activation of S6 protein kinase by insulin. In further evaluating the biological activities of the IRros hybrid, we have examined its effects on a microtubule-associated protein-2 (MAP2) kinase that is thought to be an early target in the cascade of reactions leading to increased S6 phosphorylation (Sturgill, T. W., Ray, L. B., Erickson, E., and Maller, J. L. (1988) Nature 334, 715-718). We find that the IRros receptor stimulates the MAP2 protein kinase from 3- to 6-fold in insulin-treated cells, conferring more than a 30-fold increase in the insulin sensitivity of MAP2 kinase activation.

An insulin-stimulated ribosomal protein S6 kinase from rabbit liver

In this report we describe an activated form of S6 protein kinase in rabbits treated acutely with insulin. The major insulin-stimulated activity in rabbit liver is increased 2- to 5-fold compared to material from untreated animals based on DEAE-cellulose profiles. The activity observed in DEAE-cellulose fractions can be separated into a major and a minor peak, each having very similar chromatographic behavior. Chromatography on DEAE-cellulose, S-Sepharose, heptyl-Sepharose, heparin-agarose, and Mono Q results in greater than 20,000-fold purification of the insulin-stimulated enzyme with a 12% recovery. The stimulated activity has chromatographic properties similar to an S6 protein kinase studied previously in 3T3-L1 cells (Cobb, M. H. (1986) J. Biol. Chem. 261, 12994-12999) and other systems. The enzyme purified from insulin-treated animals contains a major band that migrates in sodium dodecyl sulfate-polyacrylamide gels with Mr congruent to 70,000; this band also appears in the control preparation. Treatment of the insulin-stimulated S6 kinase with the catalytic subunit of phosphatase 2a reduces its activity by 97%. The activity of the inactivated S6 kinase is stimulated nearly 5-fold by a 15-min preincubation with partially purified insulin-stimulated microtubule-associated protein-2 kinase.

A similar ribosomal protein S6 kinase activity is found in insulin-treated 3T3-L1 cells and chick embryo fibroblasts transformed by Rous sarcoma virus

Insulin and transformation by Rous sarcoma virus stimulate the phosphorylation of ribosomal protein S6. Soluble fractions containing activated S6 protein kinase from insulin-treated cells and from transformed chick embryo fibroblasts were compared. Based upon several characteristics notably elution from DEAE-cellulose and sedimentation in glycerol gradients, these two S6 protein kinase activities appear to be similar enzymes. Thus insulin and retroviral transformation may activate the same enzyme to regulate the phosphorylation state of S6.