Early Pharmacologic Therapy in Patients With Blunt Cerebrovascular Injury and TBI: Is it Safe and Effective? An EAST Multicenter Study.

BACKGROUND: Blunt cerebrovascular injury (BCVI) with concurrent traumatic brain injury (TBI) presents increased risk of both ischemic stroke and bleeding. This study investigated the safety and survival benefit of BCVI treatment (antithrombotic and/or anticoagulant therapy) in this population. We hypothesized that treatment would be associated with fewer and later strokes in patients with BCVI and TBI without increasing bleeding complications. METHODS: Patients with head AIS >0 were selected from a database of BCVI patients previously obtained for an observational trial. A Kaplan-Meier analysis compared stroke survival in patients who received BCVI treatment to those who did not. Logistic regression was used to evaluate for confounding variables. RESULTS: Of 488 patients, 347 (71.1%) received BCVI treatment and 141 (28.9%) did not. BCVI treatment was given at a median of 31 h post-admission. BCVI treatment was associated with lower stroke rate (4.9% vs 24.1%, P < .001 and longer stroke-free survival (P < .001), but also less severe systemic injury. Logistic regression identified motor GCS and BCVI treatment as the only predictors of stroke. No patients experienced worsening TBI because of treatment. DISCUSSION: Patients with BCVI and TBI who did not receive BCVI treatment had an increased rate of stroke early in their hospital stay, though this effect may be confounded by worse motor deficits and systemic injuries. BCVI treatment within 2-3 days of admission may be safe for patients with mean head AIS of 2.6. Future prospective trials are needed to confirm these findings and determine optimal timing of BCVI treatment in TBI patients with BCVI.

Neutrophils preferentially phagocytose elongated particles-An opportunity for selective targeting in acute inflammatory diseases.

Polymeric particles have recently been used to modulate the behavior of immune cells in the treatment of various inflammatory conditions. However, there is little understanding of how physical particle parameters affect their specific interaction with different leukocyte subtypes. While particle shape is known to be a crucial factor in their phagocytosis by macrophages, where elongated particles are reported to experience reduced uptake, it remains unclear how shape influences phagocytosis by circulating phagocytes, including neutrophils that are the most abundant leukocyte in human blood. In this study, we investigated the phagocytosis of rod-shaped polymeric particles by human neutrophils relative to other leukocytes. In contrast to macrophages and other mononuclear phagocytes, neutrophils were found to exhibit increased internalization of rods in ex vivo and in vivo experimentation. This result suggests that alteration of particle shape can be used to selectively target neutrophils in inflammatory pathologies where these cells play a substantial role.

Consensus statement of the consortium for LESS cholecystectomy.

Many surgeons attempting Laparo-Endoscopic Single Site (LESS) cholecystectomy have found the operation difficult, which is inconsistent with our experience. This article is an attempt to promote a standardized approach that we feel surgeons with laparoscopic skills can perform safely and efficiently. This is a four-trocar approach consistent with the four incisions utilized in conventional laparoscopic cholecystectomy. After administration of general anesthesia, marcaine is injected at the umbilicus and a 12-mm vertical incision is made through the already existing anatomical scar of the umbilicus. A single four-trocar port is inserted. A 5-mm deflectable-tip laparoscope is placed through the trocar at the 8 o'clock position, a bariatric length rigid grasper is inserted through the trocar at the 4 o'clock position (to grasp the fundus), and a rigid bent grasper is placed through the 10-mm port (to grasp the infundibulum). This arrangement of the instruments promotes minimal internal and external instrument clashing with simultaneous optimization of the operative view. This orientation allows retraction of the gallbladder in a cephalad and lateral direction, development of a window between the gallbladder and the liver which promotes the "critical view" of the cystic duct and artery, and provides triangulation with excellent visualization of the operative field. The operation is concluded with diaphragmatic irrigation of marcaine solution to minimize postoperative pain. Standardization of LESS cholecystectomy will speed adoption, reduce intraoperative complications, and improve the efficiency and safety of the approach.

Spontaneous action representation in smokers when watching movie characters smoke.

Do smokers simulate smoking when they see someone else smoke? For regular smokers, smoking is such a highly practiced motor skill that it often occurs automatically, without conscious awareness. Research on the brain basis of action observation has delineated a frontoparietal network that is commonly recruited when people observe, plan, or imitate actions. Here, we investigated whether this action observation network would be preferentially recruited in smokers when viewing complex smoking cues, such as those occurring in motion pictures. Seventeen right-handed smokers and 17 nonsmokers watched a popular movie while undergoing functional magnetic resonance imaging. Using a natural stimulus, such as a movie, allowed us to keep both smoking and nonsmoking participants naive to the goals of the experiment. Brain activity evoked by movie scenes of smoking was contrasted with nonsmoking control scenes that were matched for frequency and duration. Compared with nonsmokers, smokers showed greater activity in left anterior intraparietal sulcus and inferior frontal gyrus, regions involved in the simulation of contralateral hand-based gestures, when viewing smoking versus control scenes. These results demonstrate that smokers spontaneously represent the action of smoking when viewing others smoke, the consequence of which may make it more difficult to abstain from smoking.

Five-year outcome of lung cancer detection in patients with and without airflow obstruction in a primary care outpatient practice.

INTRODUCTION: We have previously published the outcome of a community-based lung cancer screening program. We now report on the 5-year follow-up of this study and include both patients with and without airflow obstruction. MATERIALS AND METHODS: One thousand two hundred fifty-six patients completed questionnaires in the office of their primary care physicians, and 430 of this group were assessed to be at high risk for lung cancer. These patients then underwent spirometry, and 88 of 126 patients with airflow obstruction consented to lung cancer screening test. TESTING METHODS: Complete screening testing included spirometry, two-view chest radiograph, chest CT scan, and sputum cytology examinations. RESULTS: Eight lung cancers were found in the high-risk group with airflow obstruction. No more cancers were found in the tested group in the 5 years since the earlier report. Ten cancers were found in the 304 patients with normal airflow, not previously reported. In all, 18 lung cancers were found in 430 patients deemed at risk by a simple one-page questionnaire (4.2%). CONCLUSIONS: A questionnaire, self-administered in a primary care office setting, helps identify patients at high risk of lung cancer. If upcoming results of randomized controlled trials show a benefit of lung screening, this tool could be of help to select patients for screening.

Transcriptomic and metabolic responses of Staphylococcus aureus exposed to supra-physiological temperatures.

BACKGROUND: Previous evaluation by different molecular and physiological assays of Staphylococcus aureus (S. aureus) responses to heat shock exposure yielded a still fragmentary view of the mechanisms determining bacterial survival or death at supra-physiological temperatures. This study analyzed diverse facets of S. aureus heat-shock adjustment by recording global transcriptomic and metabolic responses of bacterial cultures shifted for 10 min from 37 degrees C to a sub-lethal (43 degrees C) or eventually lethal (48 degrees C) temperature. A relevant metabolic model of the combined action of specific stress response mechanisms with more general, energy-regulating metabolic pathways in heat-shocked S. aureus is presented. RESULTS: While S. aureus cultures shifted to 43 degrees C or left at 37 degrees C showed marginal differences in growth and survival rates, bacterial cultures exposed to 48 degrees C showed a rapid growth arrest followed by a subsequent decline in viable counts. The most substantial heat shock-induced changes at both 43 degrees C and 48 degrees C occurred in transcript levels of HrcA- and CtsR-regulated genes, encoding classical chaperones DnaK and GroESL, and some Hsp100/Clp ATPases components, respectively. Other metabolic pathways up-regulated by S. aureus exposure at 48 degrees C included genes encoding several enzymes coping with oxidative stress, and DNA damage, or/and impaired osmotic balance. Some major components of the pentose phosphate cycle and gluconeogenesis were also up-regulated, which reflected depletion of free glucose by bacterial cultures grown in Mueller-Hinton broth prior to heat shock. In contrast, most purine- and pyrimidine-synthesis pathway components and amino acyl-tRNA synthetases were down-regulated at 48 degrees C, as well as arginine deiminase and major fermentative pathway components, such as alcohol, lactate and formate dehydrogenases. Despite the heat-induced, increased requirements for ATP-dependent macromolecular repair mechanisms combined with declining energy sources, intracellular ATP levels remained remarkably constant during heat shock. CONCLUSION: The sequential loss of replication and viability at 48 degrees C cannot be explained by significant reductions in intracellular ATP levels, but may reflect ATP rerouting for macromolecular repair mechanisms and cell survival. Our metabolic model also suggests that heat-stressed S. aureus should down-regulate the production of potential, DNA-damaging reactive oxygen species that might result from electron transport-generated ATP, involving excessive levels of free heavy metals, in particular iron.

A global view of Staphylococcus aureus whole genome expression upon internalization in human epithelial cells.

BACKGROUND: Staphylococcus aureus, a leading cause of chronic or acute infections, is traditionally considered an extracellular pathogen despite repeated reports of S. aureus internalization by a variety of non-myeloid cells in vitro. This property potentially contributes to bacterial persistence, protection from antibiotics and evasion of immune defenses. Mechanisms contributing to internalization have been partly elucidated, but bacterial processes triggered intracellularly are largely unknown. RESULTS: We have developed an in vitro model using human lung epithelial cells that shows intracellular bacterial persistence for up to 2 weeks. Using an original approach we successfully collected and amplified low amounts of bacterial RNA recovered from infected eukaryotic cells. Transcriptomic analysis using an oligoarray covering the whole S. aureus genome was performed at two post-internalization times and compared to gene expression of non-internalized bacteria. No signs of cellular death were observed after prolonged internalization of Staphylococcus aureus 6850 in epithelial cells. Following internalization, extensive alterations of bacterial gene expression were observed. Whereas major metabolic pathways including cell division, nutrient transport and regulatory processes were drastically down-regulated, numerous genes involved in iron scavenging and virulence were up-regulated. This initial adaptation was followed by a transcriptional increase in several metabolic functions. However, expression of several toxin genes known to affect host cell integrity appeared strictly limited. CONCLUSION: These molecular insights correlated with phenotypic observations and demonstrated that S. aureus modulates gene expression at early times post infection to promote survival. Staphylococcus aureus appears adapted to intracellular survival in non-phagocytic cells.

Molecular epidemiology of vesicular stomatitis New Jersey virus from the 2004-2005 US outbreak indicates a common origin with Mexican strains.

Vesicular stomatitis (VS) outbreaks of unknown origin occur at 8-10-year intervals in the south-western USA with the most recent outbreak beginning in 2004. A previous study has suggested that strains causing US outbreaks are closely related to strains causing outbreaks in Mexico [Rodriguez (2002) Virus Res 85, 211-219]. This study determined the phylogenetic relationships among 116 vesicular stomatitis New Jersey virus (VSNJV) strains obtained from the 2004 outbreak and from endemic areas in Mexico. All 69 US viruses showed little sequence divergence (

The role of the DIF motif of the DnaJ (Hsp40) co-chaperone in the regulation of the DnaK (Hsp70) chaperone cycle.

To perform effectively as a molecular chaperone, DnaK (Hsp70) necessitates the assistance of its DnaJ (Hsp40) co-chaperone partner, which efficiently stimulates its intrinsically weak ATPase activity and facilitates its interaction with polypeptide substrates. In this study, we address the function of the conserved glycine- and phenylalanine-rich (G/F-rich) region of the Escherichia coli DnaJ in the DnaK chaperone cycle. We show that the G/F-rich region is critical for DnaJ co-chaperone functions in vivo and that despite a significant degree of sequence conservation among the G/F-rich regions of Hsp40 homologs from bacteria, yeast, or humans, functional complementation in the context of the E. coli DnaJ is limited. Furthermore, we found that the deletion of the whole G/F-rich region is mirrored by mutations in the conserved Asp-Ile/Val-Phe (DIF) motif contained in this region. Further genetic and biochemical analyses revealed that this amino acid triplet plays a critical role in regulation of the DnaK chaperone cycle, possibly by modulating a crucial step subsequent to DnaK-mediated ATP hydrolysis.

Lung cancer detection in patients with airflow obstruction identified in a primary care outpatient practice.

INTRODUCTION: This prospective study describes a community-based lung cancer identification project focusing on high-risk patients who receive general care in a primary care outpatient practice. Within 1 calendar year, a simple questionnaire was completed in 1,296 patients > 50 years old to identify 430 patients at high risk of lung cancer (smoking, family history of aerodigestive tract cancer, or occupational exposures). Spirometric abnormalities were found in 126 of these patients. METHODS: Chest posteroanterior radiographs, thoracic CT scans, and sputum cytology were offered to subjects with airflow obstruction (n = 126). Eighty-eight patients underwent all tests. Thirty-eight patients refused or could not consent in a timely fashion. RESULTS: Six cancers were found in the screened group, and all were treated. Two more cancers were found in the nonscreened patients with airflow obstruction. Both were treated by surgical resection or radiation therapy. Costs per cancer found were $11,925 per patient. CONCLUSIONS: Case finding in high-risk patients in a primary care population can be accomplished at a relatively low cost.

Lipopolysaccharide-binding protein modulates acetaminophen-induced liver injury in mice.

Acetaminophen toxicity is the most common cause of acute liver failure in the United States and Europe. Although much is known about the metabolism of acetaminophen, many questions remain regarding the pathogenesis of liver injury. In this study, we examined the role of lipopolysaccharide-binding protein (LBP), a protein important in mediating cellular response to lipopolysaccharides, by using LBP wild-type and knockout (KO) mice. We found that LBP KO mice were protected from acetaminophen-induced hepatotoxicity. At 350 mg/kg of acetaminophen, LBP KO mice had significantly less liver injury and necrosis than wild-type mice. Repletion studies in LBP KO mice using an LBP-adenoviral construct resulted in significantly more hepatic injury and necrosis after acetaminophen exposure compared with mice receiving the control adenoviral construct. In conclusion, LBP KO mice are protected from toxicity with a decrease in hepatic necrosis following acetaminophen challenge. This suggests a novel role for LBP in modulating acetaminophen-induced liver injury. Supplementary material for this article can be found on the HEPATOLOGY website (http://interscience.wiley.com/jpages/O270-9139/suppmat/index.html).

Simian virus 40 T antigens and J domains: analysis of Hsp40 cochaperone functions in Escherichia coli.

The N-terminal exon of DNA tumor virus T antigens represents a J domain that can direct interaction with the host-encoded Hsp70 chaperones. We have taken advantage of rapid Hsp40 cochaperone assays with Escherichia coli to assess simian virus 40 (SV40)-encoded J-domain loss of function. We found a strong correlation between loss of cochaperone function in E. coli and defective SV40 growth, suggesting that the major role of the J domain in DNA tumor viruses is to provide cochaperone function. We also report the expression of native SV40 virus T antigens in E. coli. Our results show that small t antigen, but not large T antigen (LT) or LT truncation TN125 or TN136, can functionally replace under limited growth conditions DnaJ (Hsp40) function in vivo. In addition, purified small t antigen can efficiently stimulate E. coli DnaK's (Hsp70) ATPase in vitro, thus behaving like a bona fide cochaperone. Furthermore, small t amino acids 83 to 174, which are adjacent to the viral J domain, can replace the E. coli DnaJ J-domain glycine-phenylalanine-rich domain, immediately adjacent to the J-domain sequences, even in the absence of significant amino acid similarity to their DnaJ counterpart. Taken together, our studies demonstrate that functionally related Hsp40 proteins from mammalian viral systems can be rapidly studied in bacteria and exploited to probe the universally conserved Hsp70 chaperone machine mechanism.

Granting clinical privileges for telerobotic surgery.

Surgeons can now perform operations on their patients while sitting at a remote site. During telerobotic operations, the surgeon sits at a computer console. The computer translates the motions of the surgeon's hands into motions of the robotic instruments. Introduction of telerobotics into clinical practice raises issues comparable to those generated by the rapid introduction of laparoscopic cholecystectomy in the late 1980s. As a result, we have instituted processes in our hospitals for the granting of clinical privileges for telerobotic surgery. These processes are derived from the guidelines of the Society of American Gastrointestinal Endoscopic Surgeons for granting clinical privileges for laparoscopic general surgery. Our hospitals require the following: (1) board certification or board eligibility for the appropriate surgical board; (2) clinical privileges for the open and laparoscopic operations that will be performed telerobotically; (3) satisfactory completion of the Food and Drug Administration-mandated training course in the safe use of the robotic surgical system; (4) performance of telerobotic operations in animate models; (5) observation of clinical cases of telerobotic surgery by an expert surgeon; (6) acting as bedside assistant surgeon in telerobotic operations or supervision by a preceptor during the surgeon's initial operations; (7) observation by a proctor of the surgeon's initial clinical telerobotic operations; and (8) ongoing monitoring of surgical outcomes of telerobotic operations. This process has facilitated the safe and orderly introduction of telerobotics operations into clinical practice in our hospitals.