A prospective evaluation of hemodynamic management in acute spinal cord injury patients.

STUDY DESIGN: Prospective observational study of acute spinal cord-injured (SCI) patients. OBJECTIVES: To determine how effectively mean arterial blood pressure (MAP) and spinal cord perfusion pressure (SCPP) are maintained at target levels in acute SCI patients. SETTING: Single-institution study at a Canadian level-one trauma center. METHODS: Twenty-one individuals with cervical or thoracic SCI were enrolled within 48 h of injury. A lumbar intrathecal drain was inserted for monitoring intrathecal cerebrospinal fluid pressure (ITP). The MAP was monitored concurrently with ITP, and the SCPP was calculated. Data was recorded hourly from the time of first assessment until at least the end of the 5th day post injury. RESULTS: All subjects had at least one recorded episode with a MAP below 80 mm Hg, and 81% had at least one episode with a MAP below 70 mm Hg. On average, subjects with cervical injuries had 18.4% of their pressure recordings below 80 mm Hg. Subjects with thoracic cord injuries had on average 35.9% of their MAP recordings <80 mm Hg. CONCLUSION: It is common practice to establish MAP targets for optimizing cord perfusion in acute SCI. This study suggests that even in an acute SCI referral center, when prospectively scrutinized, the actual MAP may frequently fall below the intended targets. Such results raise awareness of the vigilance that must be kept in the hemodynamic management of these patients, and the potential discrepancy between routinely setting target MAP according to 'practice guidelines' and actually achieving them.

Immunogenicity and antigenicity of conserved peptides from the envelope of HIV-1 expressed at the surface of recombinant bacteria.

We expressed peptides from the HIV-1 envelope protein at the surface of Escherichia coli by genetic insertions into an exposed loop of the outer membrane protein LamB. Recombinant bacteria expressing eight peptides from gp110 (pep1-pep8), conserved between HIV-1 and HIV-2, were used as live immunogens in rabbits by the intravenous route. The eight constructions elicited anti-LamB antibodies, showing that the hybrid proteins were immunogenic. One of them, LamB-pep8, gave rise to antibodies able to react with gp160 and to neutralize HIV-1 in vitro. We also show that this type of recombinant E. coli can provide a convenient reagent to monitor and characterize specific antibodies. Recombinant clones were used to test sera of seropositive individuals, as well as to narrow down the monoclonal antibody 110-1 recognition site to a cluster of eight residues at the carboxy-terminal end of gp110.

Creation of targets for proteolytic cleavage in the LamB protein of E coli K12 by genetic insertion of foreign sequences: implications for topological studies.

LamB, an integral outer membrane protein of E coli K12, is highly resistant to protease digestion. We had previously genetically inserted a foreign sequence corresponding to an epitope from the poliovirus next to amino acids 146, 153, 189, and 374 of LamB. In 3 cases (sites 146, 153, 374), insertion of the foreign peptide did not extensively affect the functions of LamB (and therefore folding). In 2 cases (sites 146 and 374) the polio virus epitope was detectable on the bacterial surface with a specific monoclonal antibody. We show here that the 4 modified proteins are sensitive to trypsin, including on intact cells. The sizes of the major cleavage products is that expected for proteolysis at or near the sequences inserted. In 1 case (site 153), this was directly demonstrated by protein sequencing. The results confirm the cell surface exposure of the regions of residues 153 and 374 and provide information on the regions around residues 146 and 189. Perspectives and limitations of this approach for fine studies on the mode of insertion of membrane proteins are briefly discussed.

High-titer HIV-1 neutralizing antibody response of rhesus macaques to gp160 and env peptides.

Three groups of four rhesus macaques were immunized twice, one month apart with purified recombinant HIV-1LAI gp160 in the presence of either alum, incomplete Freund's adjuvant (IFA), or SAF-1. Two months later, the animals were injected twice again with a synthetic peptide with the sequence of the principal neutralization determinant (PND) of the HIV-1LAI isolate mixed with the same adjuvants. All animals received a booster injection of gp160 and PND peptide at 6 months. This regimen of immunization induced in the SAF-1 and IFA groups a high-titer neutralizing antibody response that declined progressively over the course of the following 6 months. In contrast, only a weak response was observed in the alum group. Neutralizing antibody titers varied as anti-PND titers, suggesting that they were principally targeted to the PND. A shortened immunization protocol comprising two injections of gp160 at 0 and 1 month followed by one injection of PND peptide at 3 months is suggested as optimal for the induction of high titers of HIV-1 neutralizing antibodies in primates.

Spontaneous pulmonary hemorrhage after thrombolytic therapy for acute myocardial infarction.

We report a case of 63-year-old man who developed massive pulmonary hemorrhage following intravenous streptokinase for acute myocardial infarction. Pulmonary hemorrhage was diagnosed by the triad of hemoptysis, a drop in hematocrit, and a new unilateral infiltrate on chest radiograph. This diagnosis was confirmed by autopsy findings. Pulmonary hemorrhage has rarely been reported following thrombolytic therapy. We believe that pulmonary hemorrhage is a rare but a potentially life-threatening complication of thrombolytic therapy and should be considered in the differential diagnosis of pulmonary infiltrates or falling hemoglobin after thrombolytic therapy for acute myocardial infarction with no obvious site of bleeding.

Physiologic effects and side effects of prostaglandin E1 in the adult respiratory distress syndrome.

Because PGE1 previously has been reported to increase survival of patients with ARDS, we evaluated physiologic effects and side effects of PGE1 in a prospective open-label study of patients with ARDS. Seventeen patients with ARDS who did not have significant renal or hepatic dysfunction received PGE1 by continuous central venous infusion (30 ng/kg/min). Seventeen control patients with ARDS without renal or hepatic dysfunction who had similar APACHE II and ARDS scores and causes of ARDS did not receive PGE1. Prostaglandin E1 significantly decreased the SVRI and oxygen extraction ratio. Concentrations of total and polymorphonuclear leukocytes, but not platelets, increased significantly during PGE1 infusion, but did not change in control patients. There was no change in the Do2I and Vo2I during the course of the PGE1 infusion. There were no differences in Do2I and Vo2I during PGE1 infusion between survivors and nonsurvivors. Prostaglandin E1 was infused for a mean of 5.9 +/- 1.8 days (+/- SD) and was discontinued on ten occasions in seven patients because of supraventricular dysrhythmias (n = 4), hypotension (n = 3), thrombocytopenia (n = 3), and cardiac arrest (n = 2). Nonsurvivors had PGE1 discontinued prematurely more frequently than survivors (56 percent [5/9] vs 25 percent [2/8], respectively). The prevalence of multiple-system organ failure and the in-hospital mortality of both PGE1-treated and control patients were not different. Although PGE1 causes significant systemic vasodilation and possibly decreased intrapulmonary polymorphonuclear leukocyte sequestration, PGE1 does not influence multiple-system organ failure or mortality of patients with ARDS without renal or hepatic dysfunction.

Pathologic dependence of oxygen consumption on oxygen delivery in acute respiratory failure secondary to AIDS-related Pneumocystis carinii pneumonia.

Oxygen consumption is pathologically dependent on oxygen delivery in ARDS and sepsis. We asked whether oxygen consumption is dependent on oxygen delivery in severe acute respiratory failure secondary to AIDS-related PCP. In five patients who had AIDS-related PCP, diffuse bilateral pulmonary infiltrates, no evidence of bacterial infection, and acute respiratory failure requiring mechanical ventilation with arterial oxygen tensions less than 75 mm Hg while breathing at least 50 percent oxygen, and PEEP greater than 10 cm H2O, we determined oxygen delivery and consumption by calculation from thermodilution cardiac output and arterial and mixed venous oxygen contents. Oxygen delivery was increased using transfusion of two units of packed red blood cells over one hour. Oxygen delivery increased 22 percent (638 +/- 204 to 778 +/- 201 ml/min.m2, p less than or equal to 0.006). Oxygen consumption increased 11 percent (134 +/- 34 to 149 +/- 29 ml/min.m2, p less than or equal to 0.02). The oxygen extraction ratio did not change. We conclude that similar to ARDS and sepsis, oxygen consumption may be pathologically dependent on oxygen delivery in patients who have severe acute respiratory failure secondary to AIDS-related PCP.

Multisystem organ failure predicts mortality of ICU patients with acute respiratory failure secondary to AIDS-related PCP.

OBJECTIVE: To evaluate the ability of a variety of scoring systems to predict mortality of patients admitted to an intensive care unit (ICU) with acute respiratory failure (ARF) secondary to AIDS-related Pneumocystis carinii pneumonia (PCP). METHODS: All patients with AIDS-related PCP admitted to ICU at St. Paul's Hospital between January 1, 1985 and April 1, 1991 were reviewed. For each case, the following scores were calculated from data obtained within 24 h of ICU admission: acute physiology and chronic health evaluation II (APACHE II); acute lung injury score; AIDS score as described by Justice and Feinstein; and modified multisystem organ failure (MSOF) score. The serum lactate dehydrogenase (LDH) level was also recorded when obtained within 24 h of ICU admission. RESULTS: A total of 52 ICU admissions in 51 patients were studied. Overall mortality was 65 percent. Mortality increased with increasing MSOF (p < 0.05) score and LDH (p < 0.05). Based on receiver operating characteristic (ROC) curves, the MSOF score and the LDH were found to be good predictors of mortality. Multivariate logistic regression showed that the MSOF score was the only independent predictor of mortality (p < 0.05). The AIDS score, APACHE II, and the acute lung injury score were not significantly associated with mortality. Addition of the serum LDH level improved the performance of both the MSOF and AIDS scores, though the AIDS score plus LDH performed no better than the LDH alone. Of all the scores tested, the MSOF plus LDH level was the best (p < 0.005) predictor of mortality. CONCLUSIONS: The modified MSOF score and the serum LDH level are the best predictors of mortality of patients admitted to ICU with ARF secondary to AIDS-related PCP. The performance of the MSOF score was enhanced when the LDH level was added. The AIDS score, APACHE II, and the acute lung injury score were not found to be useful in this group of critically ill patients.

Decreasing frequency but worsening mortality of acute respiratory failure secondary to AIDS-related Pneumocystis carinii pneumonia.

OBJECTIVE: To describe changes in incidence and outcome of acute respiratory failure (ARF) due to AIDS-related Pneumocystis carinii pneumonia (PCP) at a tertiary care center over the 4-year period starting April 1, 1987 with reference to previously reported data from the preceding 6 years. METHODS: All patients admitted to St. Paul's hospital with a diagnosis of AIDS-related PCP during the study period were reviewed with regard to diagnostic, clinical, therapeutic, and outcome variables. RESULTS: A total of 456 episodes of PCP were diagnosed during the study period. These were compared against 127 cases diagnosed between 1981 and 1987. The frequency of hospitalization for PCP decreased to 78% in 1987 to 1991 from 100% in 1981 to 1987 (p < or = 0.001). A similar decreasing trend was observed with regard to the incidence of PCP-related ARF that declined from 21% in 1981 to 1987 to 9% in 1987 to 1991 (p = 0.009). Despite this, overall PCP-related mortality remained stable at 12% in 1981 to 1987 and 9% in 1987 to 1991 (p = 0.26). The proportion of patients with PCP-related ARF who received mechanical ventilation decreased from 89% in 1981 to 1987 to 64% in 1987 to 1991 (p < 0.001). Despite this, the case fatality rate among mechanically ventilated patients increased from 50% in 1981 to 1987 to 89% in 1987 to 1991 (p = 0.003). These changes were associated with a significant change in the pattern of use of corticosteroids as adjunctive therapy for AIDS-related PCP. In 1985 to 1986, nearly 100% of patients admitted to the ICU received corticosteroids only after admission to the ICU, following the development of ARF. In contrast, in 1989 to 1990, 50% of patients were admitted to the ICU already receiving systemic corticosteroids. The rise in the proportion of patients receiving corticosteroids prior to ICU admission between these two intervals was statistically significant (p = 0.017). CONCLUSION: Our data show a decreasing frequency but a worsening mortality of ARF secondary to AIDS-related PCP. We conclude that ARF secondary to AIDS-related PCP developing despite maximal therapy, including adjunctive corticosteroids, carries a dismal prognosis.

Hydroxymalonate inhibits lactate uptake by the rabbit hindlimb.

Lactate uptake by skeletal muscle occurs under diverse conditions, including hypoxia and electrical stimulation. A possible metabolic fate of lactate in resting muscle is its conversion to pyruvate followed by carboxylation to malate in the cytosolic malic reaction. To test this hypothesis, we measured hindlimb lactate uptake in hypoxic mechanically ventilated rabbits. Rabbits were given intravenous infusions of hydroxymalonate, an inhibitor of the malic reaction (200 mM; n = 7), or normal saline (n = 7) at 1.1 ml/min. Hindlimb lactate uptake/release was calculated as femoral blood flow times the arteriovenous lactate difference. Saline or hydroxymalonate was infused continuously during sequential 30-min periods of normoxia (arterial PO2 approximately 150 Torr), hypoxemia (arterial PO2 approximately 30 Torr), and reoxygenation (arterial PO2 approximately 150 Torr). Hindlimb O2 transport decreased with hypoxemia, but O2 consumption remained unchanged in both groups. During hypoxemia there was net uptake of lactate by the hindlimb of the group given normal saline [4.5 +/- 0.9 (SE) mumol/min]. The hindlimb of the hydroxymalonate group continued to release lactate (-0.5 +/- 1.0 mumol/min). The inhibition of lactate uptake by hydroxymalonate supports the hypothesis that the malic reaction plays a major role in the metabolism of lactate by resting rabbit skeletal muscle.

Structural studies of sheep IgG1 precipitating and co-precipitating antibodies.

Descriptions have previously been given of the physiochemical and immunobiological behaviour of IgG co-precipitating antibodies, isolated from different animal species, compared with that of the precipitating ones belonging to the same immunoglobulin class. From those investigations it seems reasonable to assume that only one of the combining sites present in the two binding arms of the co-precipitating antibody molecule firmly binds the antigen. Consequently, the antibody does not form insoluble Ag-Ab complexes. The peptide maps, diagonal peptide maps and high voltage electrophoresis developed with peptides obtained after previous reduction and radioactive alkylation did not show differences between sheep IgG1 precipitating and co-precipitating antibodies. When diffused against rat anti-sheep IgG1 precipitating antibody serum, sheep IgG1 precipitating antibody gave a band of precipitation which was identical to the band given by sheep IgG1 co-precipitating antibody. Similar results were obtained when rat anti-sheep IgG1 co-precipitating antibody serum was used for precipitation. By immunodiffusion with cross absorbed sera no antigenic differences between the two antibodies could be demonstrated. The results obtained indicate that the different behaviour of precipitating and co-precipitating antibodies when interacting with antigen would probably not be a consequence of differences in the primary structures of their constant fragments. Both antibodies would belong to the same class, sub-class or type of immunoglobulin.

A validation and comparison study of two metabolic monitors.

Two portable metabolic cart systems of indirect calorimetry (Deltatrac Metabolic Monitor, 2900 MMC System) were validated. CO2 and N2 were delivered at precise rates into a constructed lung model to simulate CO2 production (VCO2) and O2 consumption (VO2). VCO2 (200-400 ml/min) and VO2 (250-750 ml/min) were measured at varying combinations of minute ventilation (VE) (6, 10, 20 liter/min) and FiO2 (0.21, 0.30, 0.60, 0.80). VCO2 was measured with overall errors of 1.5% and 2.4% for the Deltatrac and 2900 monitors, respectively. VO2 was measured with overall errors of 1.9% and 3.2% by the Deltatrac and 2900 monitors, respectively. Both monitors performed equally well for measurement of VO2 at FiO2 up to 0.6, but the Deltatrac had less error for measurements of VO2 at FiO2 of 0.8.

Does increasing oxygen delivery improve outcome in the critically ill? No.

The strategy of treating critically ill patients by increasing oxygen delivery and consumption to values previously observed among survivors of critical illness (supranormal values) is based on the belief that (1) tissue hypoxia may persist in critically ill patients despite aggressive early resuscitation to traditional endpoints of adequate tissue perfusion and (2) that increasing oxygen delivery can reverse tissue hypoxia. This article addresses the question of whether increasing oxygen delivery improves outcomes in critically ill patients by reviewing the relationship between whole-body oxygen delivery and consumption and by critically examining the randomized controlled trials that have increased oxygen delivery to supranormal values.

Cationic lipid DC-Chol induces an improved and balanced immunity able to overcome the unresponsiveness to the hepatitis B vaccine.

Th1 and Th2 immune responses against antigens can be modulated by the use of adjuvants. Since antibody isotypes (IgG1 and IgG2a) and cytokines induced may reflect the Th differentiation taking place during the immune response, the humoral and cellular immune responses induced in mice against hepatitis B virus surface antigen (HBsAg) were examined when the antigen was either adsorbed to aluminum hydroxyde or administered with a new adjuvant the cationic lipid 3beta-[N-(N',N'-dimethylaminoethane)carbamoyl]cholesterol (DC-Chol). The use of DC-Chol increased antibody responses in responding BALB/c mice, induced more consistent IgG1 and IgG2a antibody responses in OF1 mice and overcame the nonresponse to HBsAg in B10.M mice. Furthermore, DC-Chol was able to induce cellular immune responses to HBsAg. The DC-Chol induced a balanced Th1/Th2 response, which enabled mice to overcome the inherited unresponsiveness to HBsAg encountered with aluminum-adjuvanted vaccine. Thus, the DC-Chol provides a signal to switch on both Th1 and Th2 responses, which may have important implications for vaccination against hepatitis B virus, as well as for enhancing weak immunogenicity of other recombinant purified antigens in a nonresponder population.

Permissive sites and topology of an outer membrane protein with a reporter epitope.

We are developing a genetic approach to study with a single antibody the folding and topology of LamB, an integral outer membrane protein from Escherichia coli K-12. This approach consists of inserting the same reporter foreign antigenic determinant (the C3 epitope from poliovirus) at different sites of LamB so that the resulting hybrid proteins have essentially kept the in vivo biological properties of LamB and therefore its cellular location and structure; the corresponding sites are called permissive sites. A specific monoclonal antibody can then be used to examine the position of the reporter epitope with respect to the protein and the membrane. We present an improved and efficient procedure that led us to identify eight new permissive sites in LamB. These sites appear to be distributed on both sides of the membrane. At one of them (after residue 253), the C3 epitope was detected on intact bacteria, providing the first direct argument for exposure of the corresponding LamB region at the cell surface. At this site as well as at four others (after residues 183, 219, 236, and 352), the C3 epitope could be detected with the C3 monoclonal antibody at the surface of the extracted trimeric LamB-C3 hybrid proteins. We provide a number of convergent arguments showing that the hybrid proteins are not strongly distorted with respect to the wild-type protein so that the conclusions drawn are also valid for this protein. These conclusions are essentially in agreement with the proposed folding model for the LamB protein. They agree, in particular, with the idea that regions 183 and 352 are exposed to the periplasm. In addition, they suggest that region 236 is buried at the external face of the outer membrane and that region 219 is exposed to the periplasm. Including the 3 sites previously determined, 11 permissive sites are now available in LamB, including 3 at the cell surface and most probably at least 3 in the periplasm. We discuss the nature of such sites, the generalization of this approach to other proteins, and possible applications.

Interaction of purified precipitating and non-precipitating (coprecipitating) antibodies with hapten and with haptenated protein. Evidence of an asymmetric antibody molecule.

The interaction of monovalent hapten dinitrophenyl epsilon-amino caproic acid (DNP-EACA) with purified IgG1 sheep anti-DNP precipitating and non-precipitating antibodies, and their F(ab')2, F(ab') and Fab fragments, was studied by fluorescence quenching and by a radioimmunoassay. The Scatchard plots of whole non-precipitating antibody and its F(ab')2 fragment showed a bi-modal curve that could be interpreted as due to the existence of two populations of sites with very different affinity for the ligand, each population representing 50% of the total number of sites. The F(ab) fragments of the non-precipitating antibody could be fractionated by immunoadsorption into two populations of high and low affinity whose association constants differed by more than 2 logs. The study of the interaction of whole antibodies with DNP-bovine serum albumin (BSA) demonstrated that each molecule of precipitating antibody can combine with two molecules of antigen but non-precipitating antibody cannot combine with more than one molecule of antigen. It is concluded that the molecule of non-precipitating antibody is asymmetric and has a site of high affinity and another of low affinity. As a consequence of this structure the non-precipitating antibody behaves functionally as univalent and is unable to form precipitates with the multivalent antigen and to activate effector mechanisms.

Oxygen consumption is independent of increases in oxygen delivery by dobutamine in septic patients who have normal or increased plasma lactate.

We asked whether the relationship between oxygen delivery and oxygen consumption is different between patients who have sepsis and normal (n = 6) or increased (n = 8) concentrations of plasma lactate. We determined oxygen consumption using analysis of respiratory gases while increasing oxygen delivery using a dobutamine infusion. The relationship between oxygen delivery and consumption was y = 124 + 0.043 * x in the normal lactate group and y = 131 - 0.003 * x in the high lactate group (95% CI for differences in slopes, -0.003 to 0.096; p < or = 0.05 for slope, normal versus high lactate). In the normal lactate group, direct oxygen consumption increased by only 8 +/- 6 ml/min/m2 after dobutamine infusion (from 144 +/- 26 to 153 +/- 22 ml/min/m2, p < or = 0.02) despite an average increase of 220 +/- 80 ml/min/m2 in oxygen delivery (from 446 +/- 91 to 666 +/- 90 ml/min/m2, p < or = 0.01). The oxygen extraction ratio fell from 0.27 +/- 0.03 to 0.21 +/- 0.02 after dobutamine (p < or = 0.017). In the high lactate group, direct oxygen consumption decreased by 1 +/- 6 ml/min/m2 after dobutamine (from 131 +/- 33 to 130 +/- 35 ml/min/m2, p > 0.60) despite an average increase of 168 +/- 138 ml/min/m2 in oxygen delivery (from 467 +/- 194 to 635 +/- 300 ml/min/m2, p < or = 0.01). The oxygen extraction ratio fell from 0.30 +/- 0.14 to 0.26 +/- 0.12 after dobutamine (p < or = 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)