Assessment of brain response in operators subject to recoil force from firing long-range rifles

Mild traumatic brain injury (mTBI) may be caused by occupational hazards military personnel encounter, such as falls, shocks, exposure to blast overpressure events, and recoil from weapon firing. While it is important to protect against injurious head impacts, the repeated exposure of Canadian Armed Forces (CAF) service members to sub-concussive events during the course of their service may lead to a significant reduction in quality of life. Symptoms may include headaches, difficulty concentrating, and noise sensitivity, impacting how personnel complete their duties and causing chronic health issues. This study investigates how the exposure to the recoil force of long-range rifles results in head motion and brain deformation. Direct measurements of head kinematics of a controlled population of military personnel during firing events were obtained using instrumented mouthguards. The experimentally measured head kinematics were then used as inputs to a finite element (FE) head model to quantify the brain strains observed during each firing event. The efficacy of a concept recoil mitigation system (RMS), designed to mitigate loads applied to the operators was quantified, and the RMS resulted in lower loading to the operators. The outcomes of this study provide valuable insights into the magnitudes of head kinematics observed when firing long-range rifles, and a methodology to quantify effects, which in turn will help craft exposure guidelines, guide training to mitigate the risk of injury, and improve the quality of lives of current and future CAF service members and veterans.

Vasopressin in newborns with refractory acute pulmonary hypertension

BACKGROUND

Acute pulmonary hypertension (aPH) in newborns can be life threatening and challenging to manage. In newborns with refractory aPH, there is currently limited therapeutic agents.

METHODS

Retrospective single-center cohort study in newborns less than one month old who were treated with vasopressin for a minimum of one hour in the context of refractory aPH in the neonatal and pediatric intensive care units of a tertiary university center between 2016 and 2022. The objective was to evaluate the efficacy and safety of vasopressin in newborns as an adjuvant treatment for refractory aPH.

RESULTS

Twenty-five patients met inclusion criteria. In patients who received vasopressin, oxygenation index improved from 28.4 to 14.4 (p = 0.004) after twelve hours of continuous infusion. Oxygen requirements (FiO2) decreased from 0.91 to 0.50 (p = 0.004) and mean arterial pressure increased from 41 to 51 mmHg (p = 0.001). In our cohort, 68% of patients presented an episode of hyponatremia (serum sodium <130 mmol/L).

CONCLUSIONS

The use of vasopressin may be associated with improvement in oxygenation and hemodynamic status of neonatal patients with aPH refractory to initial therapy. Further prospective studies are needed to establish the safety profile of vasopressin in newborns, particularly in preterm infants.

IMPACT

Vasopressin may be an effective cardiotropic agent to improve oxygenation and hemodynamic status in newborns with acute pulmonary hypertension. Careful monitoring of serum sodium levels are warranted in newborns who are receiving vasopressin infusion. This provides additional evidence for the consideration of vasopressin in newborns with acute pulmonary hypertension refractory to inhaled nitric oxide.

A Preliminary Step Towards a Physical Surrogate of the Human Calvarium to Model Fracture

A surrogate model of the human calvarium can be used to assess skull-fracture-related head injuries without continuously requiring post-mortem human skulls. Skull simulants developed in the literature often require sophisticated manufacturing procedures and/or materials not always practical when factoring in time or expense considerations. This study's objective was to fabricate three exploratory surrogate models (1. pure epoxy prototype, 2. epoxy-chalk mix prototype, and 3. epoxy-chalk three-layered prototype) of the calvarium to mimic the calvarium's mechanical response at fracture using readily available and cost-effective materials, specifically epoxy and chalk. The surrogates and calvaria were subject to quasi-static and dynamic impact 4-point bending and their mechanical responses were compared statistically. Under quasi-static loading, all three surrogates showed a considerable number of differences in mechanical response variables to calvaria that was deemed significant (p < 0.05). Under dynamic impact loading, there was no sufficient evidence to reject that the average mechanical response variables were equal between the epoxy-chalk three-layered prototype and calvaria (p > 0.05). This included force and bending moment at fracture, tensile strain at fracture, tensile and compressive stress at fracture, tensile modulus, and tensile strain rate. Overall, our study illustrates two main remarks: (1) the three exploratory surrogate models are potential candidates for mimicking the mechanical response of the calvarium at fracture during impact loading and (2) employing epoxy and chalk, which are readily available and cost-effective has the potential to mimic the mechanical response of calvaria in impact loading.

Adaptation and Validation of the Standardized Swallowing Assessment Tool for Patients With Moderate-Severe Traumatic Brain Injury and Cervical Spinal Cord Injury

Oropharyngeal dysphagia is common in moderate-severe traumatic brain injury (TBI) and cervical spinal cord injury (SCI) patients and can have serious consequences. Delaying feeding in these patients can also be detrimental. Nonetheless, the psychometric properties of screening tools that can promptly identify dysphagia have never been tested in these neurotrauma populations. This study aimed to: (1) adapt, translate, and validate the content of the French-Canadian version of the the Standardized Swallowing Assessment (SSA) tool to meet the needs of moderate-severe TBI and cervical SCI patients, (2) examine its inter-rater reliability and criterion-concurrent validation, and (3) evaluate its clinical utility from the perspectives of critical care nurses. The SSA tool was adapted and translated using an integrated method for the cultural adaptation and translation of tools. Eleven experts participated in the adaptation of the SSA tool, which led to the clarification of one item, as well as a new step and instructions for the screening procedure. Content validation (i.e., item and scale relevance) was evaluated by multidisciplinary team members (n = 17). The mean content validity index (CVI) score was 0.97 for the entire scale, while the mean CVI scores for individual items ranged from 0.82 to 1.0. A total of 60 neurotrauma patients were enrolled for inter-rater reliability and criterion-concurrent validation. Interrater reliability was determined by comparing two scores: one score from nurses responsible for the care of enrolled patients and one score from the research nurse. The weighted kappa coefficients for inter-rater reliability were 0.86 for moderate-severe TBI patients (n = 30) and 0.73 for cervical SCI patients (n = 30). A speech language therapist (SLT) also assessed dysphagia and results were used as the standard clinical reference criterion to determine concurrent validity (sensibility and specificity) of the adapted SSA tool. The sensitivity and specificity were 92% and 50% for moderate-severe TBI, and 77% and 75% for cervical SCI, respectively. The positive predictive value (PPV) and the negative predictive value (NPV) were 65% and 87% in TBI patients, and 75% and 76% in SCI patients. Test accuracy was 71% and 77% for these same groups. The clinical utility of the tool was evaluated according to the following domains: appropriateness, accessibility of the required material, applicability, perceived effectiveness, and acceptability. Acceptability was the only domain with a level of agreement <80% (74%) among trauma critical care nurses (n = 49). Findings support the content validation and inter-rater reliability of the adapted French-Canadian version of the SSA tool in moderate-severe TBI and cervical SCI patients. Sensitivity was acceptable in both groups, but the specificity was lower, especially in moderate-severe TBI patients. Further validation of the adapted French-Canadian version of the SSA tool is needed in neurotrauma patients to confirm these results and to ensure safe dysphagia screening while avoiding oral feeding deferrals.

A technique for in situ intracranial strain measurement within a helmeted deformable headform

Despite the broad use of helmets, incidence of concussion remains high. Current methods for helmet evaluation focus on the measurement of head kinematics as the primary tool for quantifying risk of brain injury. Though the primary cause of mild Traumatic Brain Injury (mTBI) is thought to be intracranial strain, helmet testing methodologies are not able to directly resolve these parameters. Computational injury models and impact severity measures are currently used to approximate intracranial strains from head kinematics and predict injury outcomes. Advancing new methodologies that enable experimental intracranial strain measurements in a physical model would be useful in the evaluation of helmet performance. This study presents a proof-of-concept head surrogate and novel helmet evaluation platform that allows for the measurement of intracranial strain using high-speed X-ray digital image correlation (XDIC). In the present work, the head surrogate was subjected to a series of bare and helmeted impacts using a pneumatically-driven linear impactor. Impacts were captured at 5,000 fps using a high-speed X-ray cineradiography system, and strain fields were computed using digital image correlation. This test platform, once validated, will open the door to using brain tissue-level measurements to evaluate helmet performance, providing a tool that can be translated to represent mTBI injury mechanisms, benefiting the helmet design processes.

Educational needs and preferences of adult patients with acute or chronic pain: a mixed methods systematic review protocol

OBJECTIVES

This review will aim to synthesize the available quantitative and qualitative evidence on the educational needs and preferences of adult patients with acute or chronic pain.

INTRODUCTION

Acute and chronic pain are prevalent problems and are associated with significant individual and societal consequences. Education is a critical component of pain management. However, the impact of educational interventions on pain outcomes remains limited. The lack of patient input--what patients want to know and how they want to be informed--is one of the main issues underlying intervention design.

INCLUSION CRITERIA

We will include qualitative, quantitative, and mixed methods studies describing the educational needs and preferences of adult patients with acute or chronic pain.

METHODS

This review will follow the JBI guidelines for mixed methods systematic reviews. We will search MEDLINE (PubMed), Embase (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and ProQuest Dissertations and Theses. The search strategy will commence from the year 1990 onward and there will be no language restrictions. The retrieved titles, abstracts, and full-text reports will be screened by pairs of independent reviewers. These pairs of reviewers will also independently extract data using the JBI tools for mixed methods systematic reviews. Methodological quality will be assessed using the mixed methods appraisal tool. A convergent integrated approach to synthesis and integration of the quantitative and qualitative data will be used.

REVIEW REGISTRATION

PROSPERO CRD42022303834.

Evaluating the Intracranial Pressure Biofidelity and Response Repeatability of a Physical Head-Brain Model in Frontal Impacts

Headforms are widely used in head injury research and headgear assessment. Common headforms are limited to replicating global head kinematics, although intracranial responses are crucial to understanding brain injuries. This study aimed to evaluate the biofidelity of intracranial pressure (ICP) and the repeatability of head kinematics and ICP of an advanced headform subjected to frontal impacts. Pendulum impacts were performed on the headform using various impact velocities (1-5 m/s) and impactor surfaces (vinyl nitrile 600 foam, PCM746 urethane, and steel) to simulate a previous cadaveric experiment. Head linear accelerations and angular rates in three axes, cerebrospinal fluid ICP (CSFP), and intraparenchymal ICP (IPP) at the front, side, and back of the head were measured. The head kinematics, CSFP, and IPP demonstrated acceptable repeatability with coefficients of variation generally being less than 10%. The BIPED front CSFP peaks and back negative peaks were within the range of the scaled cadaver data (between the minimum and maximum values reported by Nahum et al.), while side CSFPs were 30.9-92.1% greater than the cadaver data. CORrelation and Analysis (CORA) ratings evaluating the closeness of two time histories demonstrated good biofidelity of the front CSFP (0.68-0.72), while the ratings for the side (0.44-0.70) and back CSFP (0.27-0.66) showed a large variation. The BIPED CSFP at each side was linearly related to head linear accelerations with coefficients of determination greater than 0.96. The slopes for the BIPED front and back CSFP-acceleration linear trendlines were not significantly different from cadaver data, whereas the slope for the side CSFP was significantly greater than cadaver data. This study informs future applications and improvements of a novel head surrogate.

The effect of morphometric and geometric indices of the human calvarium on mechanical response

BACKGROUND

When developing a surrogate model of the human skull, there is a multitude of morphometric and geometric properties to consider when constructing the model. To simplify this approach, it is important to identify only the properties that have a significant influence on the mechanical response of the skull. The objective of this study was to identify which morphometric and geometric properties of the calvarium were significant predictors of mechanical response.

METHODS

Calvarium specimens (N = 24) were micro-computed tomography scanned to determine morphometric and geometric properties. The specimens were assumed to be Euler-Bernoulli beams and were subject to 4-point quasi-static bending to determine mechanical response. Univariate linear regressions were performed whereby the morphometric and geometric properties were independent or predictor variables and the mechanical responses were dependent or outcome variables.

FINDINGS

Nine significant linear regression models were established (p < 0.05). In the diploë, trabecular bone pattern factor was a significant predictor of force and bending moment at fracture. The inner cortical table had more significant predictors (thickness, tissue mineral density, and porosity) of mechanical response compared to the outer cortical table and diploë.

INTERPRETATION

Morphometric and geometric properties had a key influence on the calvarium's biomechanics. Trabecular bone pattern factor and the morphometry and geometry of the cortical tables must be considered when evaluating the mechanical response of the calvarium. These properties can aid the design of surrogate models of the skull that seek to mimic its mechanical response for head impact simulation.

The Mechanical Characterization and Comparions of Male and Female Calvaria Under Four-Point Bending Impacts

The circumstances in which we mechanically test and critically assess human calvarium tissue would find relevance under conditions encompassing real-world head impacts. These conditions include, among other variables, impact velocities, and strain rates. Compared to quasi-static loading on calvaria, there is less reporting on the impact loading of the calvaria and consequently, there are relatively fewer mechanical properties on calvaria at relevant impact loading rates available in the literature. The purpose of this work was to report on the mechanical response of 23 human calvarium specimens subjected to dynamic four-point bending impacts. Impacts were performed using a custom-built four-point impact apparatus at impact velocities of 0.86-0.89 m/s resulting in surface strain rates of 2-3/s-representative of strain rates observed in vehicle collisions and blunt impacts. The study revealed comparable effective bending moduli (11-15 GPa) to the limited work reported on the impact mechanics of calvaria in the literature, however, fracture bending stress (10-47 MPa) was relatively less. As expected, surface strains at fracture (0.21-0.25%) were less compared to studies that performed quasi-static bending. Moreover, the study revealed no significant differences in mechanical response between male and female calvaria. The findings presented in this work are relevant to many areas including validating surrogate skull fracture models in silico or laboratory during impact and optimizing protective devices used by civilians to reduce the risk of a serious head injury.

Influence of surrogate scalp material and thickness on head impact responses: Toward a biofidelic head-brain physical model

Advanced physical head models capable of replicating both global kinematics and intracranial mechanics of the human head are required for head injury research and safety gear assessment. These head surrogates require a complex design to accommodate realistic anatomical details. The scalp is a crucial head component, but its influence on the biomechanical response of such head surrogates remains unclear. This study aimed to evaluate the influence of surrogate scalp material and thickness on head accelerations and intraparenchymal pressures using an advanced physical head-brain model. Scalp pads made from four materials (Vytaflex20, Vytaflex40, Vytaflex50, PMC746) and each material with four thicknesses (2, 4, 6, and 8 mm) were evaluated. The head model attached to the scalp pad was dropped onto a rigid plate from two heights (5 and 19.5 cm) and at three head locations (front, right side, and back). While the selected materials' modulus exhibited a relatively minor effect on head accelerations and coup pressures, the effect of scalp thickness was shown to be major. Moreover, by decreasing the thickness of the head's original scalp by 2 mm and changing the original scalp material from Vytaflex 20 to Vytaflex 40 or Vytaflex 50, the head acceleration biofidelity ratings could improve by 30% and approached the considered rating (0.7) of good biofidelity. This study provides a potential direction for improving the biofidelity of a novel head model that might be a useful tool in head injury research and safety gear tests. This study also has implications for selecting appropriate surrogate scalps in the future design of physical and numerical head models.

Strategies to improve the quality of nurse triage in emergency departments: A realist review protocol

AIM

The purpose of this realist review was to assess what works, for whom and in what context, regarding strategies that influence nurses' behaviour to improve triage quality in emergency departments (ED).

DESIGN

Realist review protocol.

METHODS

This protocol follows the PRISMA-P statement and will include any type of study on strategies to improve the triage process in the ED (using recognized and validated triage scales). The included studies were examined for scientific quality using the Mixed Methods Appraisal Tool. The framework for this realist review is based on the Behaviour Change Wheel (BCW) and the context-mechanism-outcome (CMO) models.

DISCUSSION

Nurses and ED decision makers will be informed on the evidence regarding strategies to improve the quality of triage and the factors required to maximize their effectiveness. Research gaps may also be identified to guide future research projects on the adoption of best practices in ED nursing triage.

Review of Mechanisms and Research Methods for Blunt Ballistic Head Injury

Head injuries account for 15% to 20% of all military injuries and pose a high risk of causing functional disability and fatality. Blunt ballistic impacts are one of the threats that can lead to severe head injuries. This review aims to examine the mechanisms and injury risk assessment associated with blunt ballistic head injury (BBHI). The review further discusses research methods and instrumentation used in BBHI studies, focusing on their limitations and challenges. Studies on the mechanisms of focal and diffuse brain injuries remain largely inconclusive and require further efforts. Some studies have attempted to associate BBHIs with head mechanics, but more research is required to establish correlations between head mechanics and injury severity. Limited access to experimental models and a lack of instrumentation capable of measuring the mechanics of brain tissue in-situ are potential reasons for the lack of understanding of injury mechanisms, injury correlations and injury tolerance levels specific to this loading regime. Targeted research for understanding and assessing head injuries in blunt ballistic impacts is a necessary step in improving our ability to design protection systems to mitigate these injuries.

Cortical and trabecular morphometric properties of the human calvarium

There is currently a gap in the literature that quantitatively describes the complex bone microarchitecture within the diploë (trabecular bone) and cortical layers of the human calvarium. The purpose of this study was to determine the morphometric properties of the diploë and cortical tables of the human calvarium in which key interacting factors of sex, location on the calvarium, and layers of the sandwich structure were considered. Micro-computed tomography (micro-CT) was utilized to capture images at 18 μm resolution of male (n = 26) and female (n = 24) embalmed calvarium specimens in the frontal and parietal regions (N = 50). All images were post-processed and analyzed using vendor bundled CT-Analyzer software to determine the morphometric properties of the diploë and cortical layers. A two-way mixed (repeated measures) analysis of variance (ANOVA) was used to determine diploë morphometric properties accounting for factors of sex and location. A three-way mixed ANOVA was performed to determine cortical morphometric properties accounting for factors of cortical layer (inner and outer table), sex, and location. The study revealed no two-way interaction effects between sex and location on the diploë morphometry except for fractal dimension. Trabecular thickness and separation in the diploë were significantly greater in the male specimens; however, females showed a greater number of trabeculae and fractal dimension on average. Parietal specimens revealed a greater porosity, trabecular separation, and deviation from an ideal plate structure, but a lesser number of trabeculae and connectivity compared to the frontal location. Additionally, the study observed a lower density and greater porosity in the inner cortical layer than the outer which may be due to clear distinctions between each layer's physiological environment. The study provides valuable insight into the quantitative morphometry of the calvarium in which finite element modelers of the skull can refer to when designing detailed heterogenous or subject-specific skull models to effectively predict injury. Furthermore, this study contributes towards the recent developments on physical surrogate models of the skull which require approximate measures of calvarium bone architecture in order to effectively fabricate a model and then accurately simulate a traumatic head impact event.

Evaluation of the Kinematic Biofidelity and Inter-Test Repeatability of Global Accelerations and Brain Parenchyma Pressure for a Head-Brain Physical Model

Head surrogates are widely used in biomechanical research and headgear assessment. They are designed to approximate the inertial and mechanical properties of the head and are instrumented to measure global head kinematics. Due to the recent interest in studying disruption to the brain, some head models include internal fluid layers and brain tissue, and instrumentation to measure head intracranial biomechanics. However, it is unknown whether such models exhibit realistic human responses. Therefore, this study aims to assess the biofidelity and repeatability of a head model, the Blast Injury Protection Evaluation Device (BIPED), that can measure both global head kinematics and intraparenchymal pressure (IPP) for application in blunt impact, a common loading scenario in civilian life. Drop tests were conducted with the BIPED and the widely used Hybrid III headform. BIPED measures were compared to the Hybrid III data and published cadaveric data, and the biofidelity level of the global linear acceleration was quantified using CORrelation and Analysis (CORA) ratings. The repeatability of the acceleration and IPP measurements in multiple impact scenarios was evaluated via the coefficient of variation (COV) of the magnitudes and pulse durations. BIPED acceleration peaks were generally not significantly different from cadaver and Hybrid III data. The CORA ratings for the BIPED and Hybrid III accelerations ranged from 0.50 to 0.61 and 0.51 to 0.77, respectively. The COVs of acceleration and IPP were generally below 10%. This study is an important step toward a biofidelic head surrogate measuring both global kinematics and IPP in blunt impact.

Quasistatic response of a shear-thickening foam: Microstructure evolution and infrared thermography

In this work, the authors study the thermo-mechanical response of a dilatant polymeric foam in quasistatic tension and compression, focusing on the links between microstructure, mechanical response, and associated temperature rises in these materials. The authors study these links for a commercially-available shear-thickening foam, named D3O LITE D. Samples were tested under quasi-static conditions for a strain rate of 0.1 s−1 in tension and compression. Micro X-ray computed tomography (XCT) was used to study the evolution of microstructure (pore size and wall thickness) as a function of strain and this was achieved by developing MATLAB-based programs to analyze these microstructural features. The foam specimens were loaded until failure which allowed for the investigation of the elastic, inelastic, and failure regimes. From the XCT images, pore stretching and cell wall tearing are observed in tension, and buckling and pore collapse are observed in compression. These mechanisms are studied in-situ using an infrared thermal camera which record temperature profiles, and temperature measurements are linked back to stress-strain, and temperature-strain responses. For this material, the tensile yield stress was 0.57 ± 0.10 MPa and the elastic modulus was 5.47 ± 0.10 MPa respectively, at a yield strain of 0.10 ± 0.04. At the time of failure, the average temperature of the specimen was found to increase by ∼3.00°C and a local temperature increase of ∼8.00°C was observed in the failure region. In compression, the elastic collapse stress and elastic modulus were found to be 0.130 ± 0.016 MPa and 2.5 ± 0.2 MPa, respectively. The temperature increase in compression at ∼0.83 strain was ∼0.65°C. These results represent some of the first mechanical properties on shear-thickening foams in the literature, and the discoveries on the linkages between the microstructure and the mechanical properties in this study are important for researchers in materials design and modelling.

Protective Headgear Attenuates Forces on the Inner Table and Pressure in the Brain Parenchyma During Blast and Impact: An Experimental Study Using a Simulant-Based Surrogate Model of the Human Head

Military personnel sustain head and brain injuries as a result of ballistic, blast, and blunt impact threats. Combat helmets are meant to protect the heads of these personnel during injury events. Studies show peak kinematics and kinetics are attenuated using protective headgear during impacts; however, there is limited experimental biomechanical literature that examines whether or not helmets mitigate peak mechanics delivered to the head and brain during blast. While the mechanical links between blast and brain injury are not universally agreed upon, one hypothesis is that blast energy can be transmitted through the head and into the brain. These transmissions can lead to rapid skull flexure and elevated pressures in the cranial vault, and, therefore, may be relevant in determining injury likelihood. Therefore, it could be argued that assessing a helmet for the ability to mitigate mechanics may be an appropriate paradigm for assessing the potential protective benefits of helmets against blast. In this work, we use a surrogate model of the head and brain to assess whether or not helmets and eye protection can alter mechanical measures during both head-level face-on blast and high forehead blunt impact events. Measurements near the forehead suggest head protection can attenuate brain parenchyma pressures by as much as 49% during blast and 52% during impact, and forces on the inner table of the skull by as much as 80% during blast and 84% during impact, relative to an unprotected head.

The impact of targeted therapy on healthcare resource use in patients with metastatic renal cell carcinoma: The University of Sherbrooke experience

INTRODUCTION

We assessed the impact of targeted therapies on healthcare resource use and compared treatment regimens used in patients diagnosed with metastatic renal cell carcinoma (mRCC).

METHODS

Clinicopathological and administrative data of patients with mRCC from our institution were retrospectively collected from January 2000 to August 2014. Patients were divided into two groups based on the use of targeted therapies. Healthcare resource use (HCRU) data included non-scheduled total number of hospitalizations, total days hospitalized, emergency department visits, and healthcare professional consultations. Each variable was presented with absolute and relative values (i.e., per month of survival). Statistics relied on the use of t-student and Chi-square tests.

RESULTS

Ninety-nine patients were included in the study; 60 were treated with targeted therapy. There were no statistically significant differences between the two groups for demographic features and clinicopathological stage. HCRU analysis revealed an absolute increase in the median number of healthcare consultants (6 vs. 4; p<0.01) and emergency department visits (1 vs. 0; p=0.02) for the targeted therapy group. However, analysis per month of survival showed the targeted therapy group had fewer consultants (0.33 vs. 0.40; p=0.04) and hospitalizations (0.09 vs. 0.13; p=0.03) than their counterpart. Population size, non-randomization, treatment selection bias, and heterogeneity were the main limitations of this study.

CONCLUSIONS

Monthly use of HCRU is lower in mRCC patients treated with targeted therapies. However, because of a greater overall survival, their absolute total HCRU will be higher than those not exposed to targeted agents.

Guidelines for conducting epidemiological studies of blast injury

Blast injuries are often caused by more than one mechanism, do not occur in isolation, and typically elicit a secondary multi-system response. Research efforts often do not separate blast injuries caused by blast waves from those caused by blunt force trauma and other mechanisms. 15 experts from nine different NATO nations developed in the HFM Research Task Group (RTG; HFM-234 (RTG)) 'Environmental Toxicology of Blast Exposures: Injury Metrics, Modelling, Methods and Standards' Guidelines for Conducting Epidemiological Studies of Blast Injury. This paper describes these guidelines, which are intended to provide blast injury researchers and clinicians with a basic set of recommendations for blast injury epidemiological study design and data collection that need to be considered and described when conducting prospective longitudinal studies of blast injury.

Guidelines for using animal models in blast injury research

Blast injury is a very complex phenomenon and frequently results in multiple injuries. One method to investigate the consequences of blast injuries is with the use of living systems (animal models). The use of animals allows the examination and evaluation of injury mechanisms in a more controlled manner, allowing variables such as primary or secondary blast injury for example, to be isolated and manipulated as required. To ensure a degree of standardisation across the blast research community a set of guidelines which helps researchers navigate challenges of modelling blast injuries in animals is required. This paper describes the guidelines for Using Animal Models in Blast Injury Research developed by the NATO Health Factors and Medicine (HFM) Research Task Group 234.

Metastatic renal cell carcinoma initially presenting with hematochezia and subsequently with vaginal bleeding: a case report

Background

We report an unusual case of a synchronous rectal and metachronous vaginal metastatic renal cell carcinoma.

Case presentation

A 78-year-old woman presented with hematochezia and a colonoscopy revealed a metastatic clear-cell renal cell carcinoma rectal polyp biopsy-proven. Abdominal computed tomography identified a 9.0-cm left renal mass with renal vein thrombosis, for which she underwent a laparoscopic radical nephrectomy. Histopathological examination confirmed a pT_3a clear-cell renal cell carcinoma. Seven months later, the patient presented with vaginal bleeding. Physical examination revealed a vaginal polypoid mass and biopsy confirmed a clear-cell renal cell carcinoma metastasis.

Conclusions

This case represents unusual manifestations of metastatic renal cell carcinoma and is a reminder of the wide spectrum of clinical course of this disease.

Transperitoneal laparoscopic nephrectomy: Assessing complication risk in cases of previous abdominal surgery

INTRODUCTION

We aimed to assess the effect of previous abdominal surgery on perioperative outcomes in patients undergoing transperitoneal laparoscopic partial (LPN) or radical (LRN) nephrectomy for renal masses.

METHODS

We retrospectively reviewed all cases of LPN and LRN for renal masses at our institution between 2008 and 2014. Patients were divided in two groups, those with and without prior abdominal surgery. Four perioperative outcomes were compared, namely, operative time (OT), estimated blood loss (EBL), length of stay (LOS), and 30-days complications rate. A subanalysis was performed to address the impact of previous open cholecystectomy on right LPN or LRN.

RESULTS

Of 293 patients identified, 146 (49.8%) had previous abdominal surgery. In univariate analysis, no differences in operative time (136 vs. 144 minutes; p=0.154), EBL (88 vs. 100 mL; p=0.211), or 30-day complication rate (24 vs. 14%; p=0.069) were recorded between the groups. Only LOS favoured patients without previous abdominal surgery (3 vs. 4 days; p=0.001). In multivariate analysis, prior abdominal surgery was not associated with an increased OT, EBL, LOS, or complication rate. The analysis of right nephrectomies showed increased OT (148 vs. 128 minutes; p=0.049) and complication rate (42 vs. 16%; p=0.004) for patients with past open cholecystectomy compared to those without. Multivariate analysis revealed that prior open cholecystectomy was associated with a longer LOS (OR_median=2.7 [1.2-8.0]) and an increased risk of complications (OR_median=4.5 [1.6-10.5]).

CONCLUSIONS

In this cohort, previous abdominal surgery was not associated with worse perioperative outcomes after transperitoneal LPN and LRN for renal masses. However, previous open cholecystectomy resulted in a higher risk of complication and a longer LOS in patients undergoing right laparoscopic nephrectomy.

Upconversion nanoparticle-decorated gold nanoshells for near-infrared induced heating and thermometry

The present work involves the design of a multifunctional system based on gold nanoshells (AuNSs) decorated with lanthanide-based upconversion nanoparticles (UCNPs) intended as an optical heater and temperature probe at the nanoscale.

Open cystolithotomy for very large calculi in a Studer ileal neobladder

Orthotopic ileal neobladder has been frequently performed as urinary diversion after cystectomy over the last decades. We report an unusual complication of very large calculi in a Studer ileal neobladder. Due to its size, open cystolithotomy was performed.

Perioperative outcomes for laparoscopic radical nephrectomies performed on ≥ 10 cm tumors

INTRODUCTION

The role of laparoscopic radical nephrectomy (LRN) in the management of very large renal masses has yet to be determined. Moreover, no studies have considered the total size of the specimen removed. We report our experience managing renal masses ≥ 10 cm with transperitoneal LRN.

MATERIALS AND METHODS

We retrospectively reviewed cases of LRN performed in the context of renal masses from 2006 to 2012 at our institution. LRNs were divided into two groups; tumors 10 cm or larger (n = 24) and tumors smaller than 10 cm (n = 124). Patient demographics, tumor characteristics, operative and perioperative outcomes were compared. Complication rate was assessed in relation to tumor and specimen size.

RESULTS

Mean pathologic tumor size was 11.8 cm (range 10.0 cm-17.0 cm) and 5.8 cm (range 2.1 cm-9.5 cm) for tumors ≥ 10 cm and < 10 cm, respectively. No difference was found in demographic characteristics, operative and perioperative outcomes (estimated blood loss, rate of conversion to open radical nephrectomy, length of postoperative stay and complication rate), between both groups, except higher surgical time in the ≥ 10 cm group (171 min versus 143 min, respectively, p = 0.005). There was no difference in tumor and total specimen size between patients with and without complications. Due to its retrospective nature, the major limitation of this study is missing data regarding specimen size.

CONCLUSION

LRN can be performed safely with acceptable operative and perioperative outcomes by experienced laparoscopists for very large renal masses (≥ 10 cm). Complication rates were unrelated to tumor and total specimen size.

Malignant peripheral nerve sheath tumour of the renal parenchyma presenting as a fast growing atypical renal cyst

Malignant peripheral nerve sheath tumours (MPNST) of the kidney are very rare, with only 3 cases reported in the English and French literature. However, we report the first case of fast growing atypical renal cyst where a magnetic resonance imaging was an interesting adjunct to the computed tomography scan in imaging this rare tumour.

Renal cell carcinoma associated with peritumoral sarcoid-like reaction without intratumoral granuloma

Non-necrotizing epithelioid granulomas have been described in association with many primary tumors. In such cases, they are designated as sarcoid-like reaction. Although it is more seen in carcinomas than in sarcomas, it is very rarely reported in renal carcinoma. Here, we describe a rare association of prominent peritumoral sarcoid-like reaction without intratumoral granulomas and conventional clear cell renal carcinoma in a 62-year-old-male, without clinical or laboratory finding of sarcoidosis. At 30 months follow-up, he had no recurrence. Virtual slides: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/4054525336657922.

Formation of a disordered solid via a shock-induced transition in a dense particle suspension

Shock wave propagation in multiphase media is typically dominated by the relative compressibility of the two components of the mixture. The difference in the compressibility of the components results in a shock-induced variation in the effective volume fraction of the suspension tending toward the random-close-packing limit for the system, and a disordered solid can take form within the suspension. The present study uses a Hugoniot-based model to demonstrate this variation in the volume fraction of the solid phase as well as a simple hard-sphere model to investigate the formation of disordered structures within uniaxially compressed model suspensions. Both models are discussed in terms of available experimental plate impact data in dense suspensions. Through coordination number statistics of the mesoscopic hard-sphere model, comparisons are made with the trends of the experimental pressure-volume fraction relationship to illustrate the role of these disordered structures in the bulk properties of the suspensions. A criterion for the dynamic stiffening of suspensions under high-rate dynamic loading is suggested as an analog to quasi-static jamming based on the results of the simulations.

Peroxynitrite mediates cytokine-induced IL-8 gene expression and production by human leukocytes

Recent studies indicate that nitric oxide (NO) or related compounds may regulate the production of interleukin (IL)-8, a potent proinflammatory chemokine. Here we report that peroxynitrite (ONOO(-)) formed by a reaction of NO with superoxide mediates IL-8 gene expression and IL-8 production in IL-1beta- and TNF-alpha-stimulated human leukocytes in whole blood. The NO synthase inhibitors aminoguanidine and N(G)-nitro-L-arginine methyl ester blocked nuclear accumulation of activator protein-1 (AP-1) and nuclear factor (NF)-kappaB in both polymorphonuclear (PMN) and mononuclear leukocytes and inhibited IL-8 mRNA expression and IL-8 release by approximately 90% in response to IL-1beta and TNF-alpha. Enhanced ONOO(-) formation was detected in granulocytes, monocytes, and lymphocytes after challenge with IL-1beta or TNF-alpha. The addition of ONOO(-) (0.2-80 microM) to whole blood increased nuclear accumulation of AP-1 and NF-kappaB in PMN and mononuclear leukocytes and augmented IL-8 mRNA expression and IL-8 production in a concentration-dependent fashion. Pyrrolidine dithiocarbamate, an inhibitor of NF-kappaB activation, attenuated approximately 70% of IL-8 release evoked by IL-1beta, TNF-alpha, or ONOO(-). These results indicate that ONOO(-) formation may underlie the action of cytokines towards IL-8 gene expression in human leukocytes.

Identification of three new DRB3* (DRB3*0106, DRB3*0107 and DRB3*02022) alleles

Three novel DRB3* alleles were identified using CANTYPE reverse hybridization assay. The initial unusual hybridization patterns of DRB3-specific polymerase chain reaction (PCR)-amplified DNA from each subject were confirmed by cloning and sequencing analysis. DRB3*0106 allele is identical to DRB3*0101 except for a single nucleotide substitution (CTG-->GTG) changing codon 38 from Leu to Val. This polymorphism is commonly found in DRB3*03 alleles. Compared with DRB3*0202, DRB3*02022 contains a single silent nucleotide substitution (AAT-->AAC, both encoding for Asn) at codon 77. This polymorphism is also present in DRB3*0204 allele. The new DRB3*0107 allele has a sequence unique to DRB3 alleles. From codon 5 to codon 36 the sequence is identical to that of DRB3*0101 allele. From codon 37 to codon 87 the sequence of DRB1*0107 allele is identical to that of DRB3*0202. This sequence would thus explain the CANTYPE(R) DRB3-specific unusual pattern of reactions. The new DRB3*0107 could have arisen from a gene conversion between DRB3*0101 and DRB3*0202 alleles, but the DRB3*0106 and the DRB3*02022 may have been generated by a point mutation event. The DRB3*0107 allele was identified in a Caucasoid individual. The ethnic origin of the subjects carrying the other two alleles are unknown. The three alleles presented here were only identified once, in a total population of 49,000.

The anti-inflammatory peptides, antiflammins, regulate the expression of adhesion molecules on human leukocytes and prevent neutrophil adhesion to endothelial cells

Antiflammin-1 and antiflammin-2 are nonapeptides corresponding to the region of highest similarity between glucocorticoid-inducible proteins lipocortin-1 and uteroglobin. We have studied whether antiflammins could affect expression of adhesion molecules on human leukocytes and coronary artery endothelial cells (HCAEC) and binding of neutrophils (PMNs) to HCAEC. Although neither antiflammin-1 nor antiflammin-2 affected expression of adhesion molecules on resting PMNs, monocytes, and lymphocytes in whole blood, they attenuated changes in L-selectin and CD11/CD18 expression evoked by platelet-activating factor or interleukin-8 with IC(50) values of 4-20 micromol/l. The maximum inhibition was similar to those seen with human recombinant lipocortin-1 (100 microgram/ml). Unlike dexamethasone (100 nmol/l), the antiflammins had little effect on LPS-stimulated expression of E-selectin and ICAM-1 on HCAEC. Consistently, culture of HCAEC with dexamethasone, but not with antiflammins, decreased PMN binding to endothelial cells. Preincubation of PMNs with antiflammins markedly decreased their adhesion to LPS-activated HCAEC. Inhibition of adhesion was additive with function blocking anti-E-selectin and anti-L-selectin antibodies, but was not additive with anti-CD18 antibody. These results show that antiflammins inhibit PMN adhesion to HCAEC by attenuating activation-induced up-regulation of CD11/CD18 expression on leukocytes, and suggest that antiflammins may represent a novel therapeutic approach in blocking leukocyte trafficking in host defense and inflammation.

A novel DRB3 allele (DRB3*0208), a new allelic variant of DRB1*1502 (DRB1*15023) and two new DQB1 (DQB1*03012 and DQB1*0614) alleles

Four novel HLA Class II alleles were identified using CANTYPE reverse hybridization assay. The initial unusual SSO hybridization patterns were confirmed by cloning and sequencing analysis. DRB3*0208 allele is identical to DRB3*0202 except for three nucleotide substitutions (GAT-->AGC) changing codon 57 from Asp to Ser. This polymorphism has so far been undetected in DRB3 alleles. DRB1*15023 differs from DRB1*15021 by a single silent nucleotide substitution (AAC-->AAT, both encoding for Asn) at codon 33. This polymorphism has not, until now, been identified in DRB alleles. Compared with DQB1*03011, the novel DQB1*03012 contains a single silent nucleotide substitution (GCA-->GCG, both encoding for Ala) at codon 38. Finally, DQB1*0614 allele is identical to DQB1*0603 except for a single nucleotide substitution (TAC-->TTC), changing codon 9 from Tyr to Phe. Polymorphisms observed here in the DQB1*03012 and DQB1*0614 alleles are present in several of the known DQB1 alleles. DRB3*0208, DQB1*03012 and DQB1*0614 may have arisen from gene conversion, but the DRB1*15023 most likely was generated by a point mutation event. DQB1*0614 was detected in three related subjects, while each of the other three new alleles has only been detected once.

Identification of novel DRB1*13 (DRB1*1333), DRB1*04 (DRB1*0426) and DRB5* (DRB5*0109) alleles

Three novel HLA class II alleles (DRB1*1333, DRB1*0426, DRB5*0109) are described here. The 3 novel alleles were initially detected as previously unidentified SSO hybridization patterns using the CANTYPE reverse hybridization assay. Sequences were determined by cloning/sequencing. DRB1*1333 is identical to DRB1*1303 except for a single nucleotide substitution (ACC-->AAC), changing codon 77 from Thr to Asn. This polymorphism is typical for DRB1*03 alleles. DRB1*0426 is identical to DRB1*0401 except for a single nucleotide substitution (GCC-->ACC) at codon 58, changing the encoded Ala to Thr. DRB5*0109 is identical to DRB5*0101, except for a single nucleotide substitution (GAC-->AAC), changing codon 70 from Asp to Asn. Both latter polymorphisms were so far undetected in DRB alleles. DRB1*1333 could have arisen from a gene conversion event, but DRB1*0426 and DRB5*0109 most likely were generated by point mutation events. For all 3 alleles, the sequence was confirmed by the original hybridization pattern (DRB1*1333) or by hybridization to a newly designed probe (DRB1*0426 and DRB5*0109). Ethnic backgrounds were Lebanese for DRB1*1333 and Caucasian for DRB1*0426 and DRB5*0109.

Identification of new DRB1*07 (DRB1*0703), DRB1*08 (DRB1*0817) and two DRB3* (DRB3*0302 and DRB3*01014) alleles

We report here the identification of four novel DRB alleles using a reverse hybridization (CANTYPE) assay. Molecular cloning and sequencing confirmed the initial unusual hybridization patterns. All four new alleles were detected during routine HLA typing for the Canadian Unrelated Bone Marrow Donor Registry. DRB1*0703 is identical to DRB1*0701 except for a single nucleotide substitution (AGA-->AGT), changing codon 29 from Arg to Ser, a so far undetected DRB polymorphism. DRB1*0817 differs from DRB1*0801 by a single nucleotide substitution (TAC-->TTC), changing codon 47 from Tyr to Phe. This polymorphism has not, until now, been identified in DRB1*08 alleles. Compared with DRB3*0301, DRB3*0302 contains a single nucleotide substitution (TAC-->CAC) at codon 30, changing the encoded Tyr to His. This polymorphism is typical for DRB3*02 alleles. DRB3*01014 is identical to DRB3*0101 except for a single silent nucleotide substitution (GGG-->GGA) at codon 84. This polymorphism has previously only been described for the DRB1*15012 allele. DRB1*0817, DRB3*0302 and DRB3*01014 may have arisen from gene conversion, but DRB1*0703 most likely was generated by a point mutation event. The DRB3*0302 allele was detected in two unrelated subjects, while the other three have each only been detected once.

Elimination of neuroblastoma and small-cell lung cancer cells with an anti-neural cell adhesion molecule immunotoxin

BACKGROUND

The development of immunotoxins has been hampered by difficulties, particularly in solid tumors, of finding appropriate target antigens and of linking sufficiently potent toxins.

PURPOSE

We evaluated the tissue specificity of an immunotoxin, N901-blocked ricin (N901-bR), and assessed its potential for eliminating neural cell adhesion molecule (NCAM)-positive tumor cells in conditions appropriate for in vitro purging, prior to autologous stem cell transplantation, and its potential for myelosuppression. N901-bR consists of a monoclonal antibody (MAb), N901, directed against CD56, an antigen of the family of NCAMs, covalently linked to blocked ricin as the cytotoxic effector moiety.

METHODS

The tissue specificity of the N901 MAb and the N901-bR immunotoxin was tested against a wide array of human tumor tissues and normal human tissues by immunohistochemical staining. The cytotoxic activity of N901-bR was tested against both small-cell lung cancer (SCLC) cells and neuroblastoma cells, either alone or among normal bone marrow mononuclear cells, and the efficacy of this treatment to specifically eliminate these cells was evaluated in a limiting dilution assay. In addition, normal bone marrow mononuclear cells were incubated with N901-bR, and the toxic effects of the immunotoxin on normal hematopoietic progenitors was evaluated.

RESULTS

N901 and N901-bR exhibited specificity for several neoplasms of neuroectodermal origin, including SCLC and neuroblastoma. Staining of normal tissues was essentially limited to various neuroendocrine cells, cardiac muscle cells, and cells in peripheral nerve tissue. We observed a time- and dose-dependent elimination of tumor cells in vitro, with three logs (i.e., > 99.9%) of malignant cells being killed following only 5 hours of exposure to 10 nM N901-bR. Unconjugated N901 MAb specifically blocked the elimination of NCAM-positive cells by N901-bR, whereas neither an isotype-matched control MAb nor galactose (the ligand of native ricin) had any effect on the activity of the immunotoxin, confirming the specificity of its cytotoxic activity. Importantly, N901-bR used under optimal conditions for in vitro tumor cell depletion was not toxic to hematopoietic precursors.

CONCLUSIONS

N901-bR has the properties required to target CD56, an antigen present not only on cells from a large number of cancers of neuroendocrine origin, but also on some important normal tissues. In addition, treatment with this immunotoxin results in the highly effective and specific elimination of neuroblastoma and SCLC cells and does not affect normal hematopoietic progenitors.

IMPLICATIONS

N901-bR may have clinical utility for purging of neuroblastoma cells and SCLC cells before autologous stem cell transplantation. Further toxicology studies are warranted to assess the potential of N901-bR for in vivo administration.

Distinctive profile of alveolar macrophage-derived cytokine release induced by fibrogenic and nonfibrogenic mineral dusts

Groups of 7 Wistar rats each received a single intratracheal instillation of either saline (control), UICC chrysotile B asbestos (5 mg), or very short 4T30 chrysotile asbestos fibers (5 mg). Five animals in each group were killed at 1, 3, and 6 wk posttreatment and analyzed by bronchoalveolar lavage (BAL) for BAL cell populations and cytokine production in conjunction with histopathological assessment of lung tissue. Chrysotile B and short 4T30 chrysotile fibers induced chronic inflammatory reactions characterized by alveolar macrophage (AM) accumulation that resulted, respectively, in lung fibrosis and resolving granuloma. Alveolar macrophages (AM) obtained from rats treated with UICC chrysotile B and short 4T30 chrysotile produced enhanced levels of interleukin-1 (IL-1) and interleukin-6 (IL-6), both spontaneously and in response to lipopolysaccharide (LPS). A different pattern of response was observed for tumor necrosis factor-alpha (TNF-alpha). Fibrogenic chrysotile B caused biphasic changes characterized by significant inhibition of LPS-induced TNF-alpha release by AM 1 and 3 wk after treatment, followed by stimulation of spontaneous and LPS-induced TNF-alpha at 6 wk. In contrast, no significant change in spontaneous and LPS-induced TNF-alpha release was seen with AM from animals with resolving granuloma (4T30 group). Thus, modulation of AM-derived TNF-alpha was correlated under these conditions with the fibrogenic potential of asbestos dusts. These data support a role for TNF-alpha in fibrosis and suggest that TNF-alpha may represent a useful marker of lung damage induced by fibrogenic dusts.

IFN-gamma up-regulates platelet-activating factor receptor gene expression in human monocytes

Human monocytes constitutively express the platelet-activating factor receptor (hPAF-R). In this report, we have investigated the modulation of hPAF-R by IFN-gamma. Treatment of monocytes with IFN-gamma caused a time- and concentration-dependent accumulation of hPAF-R mRNA. In contrast, IFN-alpha was inactive. The effect of IFN-gamma was rapid, evident by 1 h of stimulation and reaching a maximum after 2 h. The high level of hPAF-R mRNA was maintained for at least 24 h. Flow cytometry analysis revealed that monocytes treated with IFN-gamma had a two- to sixfold increase in PAF receptor expression at the cell surface, when compared with untreated cells. The increase in hPAF-R expression was associated with an augmented response of IFN-gamma-treated cells to PAF in terms of cytosolic calcium ([Ca2+]i) variations. The IFN-gamma-dependent accumulation of hPAF-R mRNA was not due to the stabilization of hPAF-R mRNA, as shown by unchanged hPAF-R mRNA t1/2. Pretreatment of monocytes with actinomycin D, however, completely abrogated the effect of IFN-gamma, suggesting a transcriptional regulation. Moreover, the up-regulation of hPAF-R mRNA by IFN-gamma was independent of de novo protein synthesis since cycloheximide, an inhibitor of protein synthesis, did not affect this up-regulation. These studies are the first report showing that IFN-gamma regulates hPAF-R gene expression in human monocytes, by a mechanism suggesting transcriptional regulation. This may represent a prototypic example of regulation by lymphocyte-derived cytokines of lipid mediator receptors in myeloid cells, thus adding a novel element in the interrelationship between immune and inflammatory responses.

IFN-gamma up-regulates platelet-activating factor receptor gene expression in human monocytes

Human monocytes constitutively express the platelet-activating factor receptor (hPAF-R). In this report, we have investigated the modulation of hPAF-R by IFN-gamma. Treatment of monocytes with IFN-gamma caused a time- and concentration-dependent accumulation of hPAF-R mRNA. In contrast, IFN-alpha was inactive. The effect of IFN-gamma was rapid, evident by 1 h of stimulation and reaching a maximum after 2 h. The high level of hPAF-R mRNA was maintained for at least 24 h. Flow cytometry analysis revealed that monocytes treated with IFN-gamma had a two- to sixfold increase in PAF receptor expression at the cell surface, when compared with untreated cells. The increase in hPAF-R expression was associated with an augmented response of IFN-gamma-treated cells to PAF in terms of cytosolic calcium ([Ca2+]i) variations. The IFN-gamma-dependent accumulation of hPAF-R mRNA was not due to the stabilization of hPAF-R mRNA, as shown by unchanged hPAF-R mRNA t1/2. Pretreatment of monocytes with actinomycin D, however, completely abrogated the effect of IFN-gamma, suggesting a transcriptional regulation. Moreover, the up-regulation of hPAF-R mRNA by IFN-gamma was independent of de novo protein synthesis since cycloheximide, an inhibitor of protein synthesis, did not affect this up-regulation. These studies are the first report showing that IFN-gamma regulates hPAF-R gene expression in human monocytes, by a mechanism suggesting transcriptional regulation. This may represent a prototypic example of regulation by lymphocyte-derived cytokines of lipid mediator receptors in myeloid cells, thus adding a novel element in the interrelationship between immune and inflammatory responses.

Bidirectional modulation of TNF-alpha production by alveolar macrophages in asbestos-induced pulmonary fibrosis

Bronchoalveolar lavage (BAL) cells were isolated from rats 1, 3, and 6 weeks after a single intratracheal instillation of saline, UICC chrysotile asbestos (5 mg), or silica (5 mg). In asbestos-exposed rats, the pulmonary response was characterized by a significant increase in the number of alveolar macrophages (AMs) and the appearance of fibrotic lesions within 1 week. By contrast, mixed macrophage and neutrophil accumulations were observed in the silica group without evidence of fibrosis. Tumor necrosis factor-alpha (TNF-alpha) production by lipopolysaccharide (LPS)-stimulated BAL cells from asbestos-treated rats was significantly lower than controls 1 and 3 weeks after exposure. However, by 6 weeks higher levels of TNF-alpha production were noticeable in this group. Decreases in LPS-induced TNF-alpha production were also observed with BAL cells from silica-treated animals at all time points studied. Lower levels of TNF-alpha were not related to decreased BAL cell viability or the presence of a significant proportion of neutrophils in the silica group. Furthermore, biphasic changes in TNF-alpha production seen in the asbestos group were correlated with concomitant decreases (3 weeks) and increases (6 weeks) in levels of TNF-alpha mRNA in AMs. These data indicate that lower levels of TNF-alpha resulted from inhibition at the gene expression level and provide evidence for bidirectional modulation of TNF-alpha production by AMs during inflammatory reactions.