Increased relative risk of delayed hemorrhage in patients taking anticoagulant/antiplatelet medications with concurrent aspirin therapy: implications for clinical practice based on 3-year retrospective analysis in a large health system.

PURPOSE: The incidence of delayed posttraumatic intracranial hemorrhage (DH) in patients on anticoagulant (AC) and antiplatelet (AP) medications, especially with concurrent aspirin therapy, is not well established, with studies reporting disparate results with between 1-10% risk of DH and 0-3% mortality. The purpose of this 3-year retrospective study is to evaluate the true risk of DH in patients on AP/AC medications with or without concurrent aspirin therapy. METHODS: One thousand forty-six patients taking AP and AC medications presenting to network emergency departments with head trauma who had repeat CT to evaluate for DH were included in the study. Repeat examinations were typically performed within 24 h (average follow-up time was 21 h and 99% were within 3 days). Mean time to DH was 20 h. All positive studies were reviewed by two board-certified neuroradiologists. Patients were excluded from the study if hemorrhage was retrospectively identified on the initial examination. Cases were reclassified as negative if hemorrhage on the follow-up examination was thought to be not present or artifactual. Cases were considered positive if the initial examination was negative and the follow-up examination demonstrated new hemorrhage. RESULTS: Overall, there was 1.91% incidence (20 patients) of DH and 0.3% overall mortality (3 patients). The group of patients taking warfarin or AP agents demonstrated a significantly higher rate of DH (3.2% compared to 0.9%) and higher mortality (0.9% compared to 0.0%) compared to the DOAC group (p < 0.01). The risk of DH in patients taking AC or AP agents with aspirin (13/20 cases) was significantly higher (RR 3.8, p < 0.01) than that of patients taking AC or AP alone (7/20 cases). CONCLUSION: The risk of DH was significantly higher in patients taking aspirin in addition to AC/AP medications. Repeat imaging should be obtained for trauma patients taking AC/AP agents with concurrent aspirin. The rate of DH was also significantly higher in patients taking warfarin or AP agents when compared to patients taking DOACs. Repeat examination should be strongly considered on patients taking warfarin or AP agents without aspirin. Given the relatively low risk of DH in patients taking DOACs alone, repeat imaging could be reserved for patients with external signs of trauma or dangerous mechanism of injury.

Differentiation of Low- and High-Grade Pediatric Brain Tumors with High b-Value Diffusion-weighted MR Imaging and a Fractional Order Calculus Model.

PURPOSE: To demonstrate that a new set of parameters (D, ß, and µ) from a fractional order calculus (FROC) diffusion model can be used to improve the accuracy of MR imaging for differentiating among low- and high-grade pediatric brain tumors. MATERIALS AND METHODS: The institutional review board of the performing hospital approved this study, and written informed consent was obtained from the legal guardians of pediatric patients. Multi-b-value diffusion-weighted magnetic resonance (MR) imaging was performed in 67 pediatric patients with brain tumors. Diffusion coefficient D, fractional order parameter ß (which correlates with tissue heterogeneity), and a microstructural quantity µ were calculated by fitting the multi-b-value diffusion-weighted images to an FROC model. D, ß, and µ values were measured in solid tumor regions, as well as in normal-appearing gray matter as a control. These values were compared between the low- and high-grade tumor groups by using the Mann-Whitney U test. The performance of FROC parameters for differentiating among patient groups was evaluated with receiver operating characteristic (ROC) analysis. RESULTS: None of the FROC parameters exhibited significant differences in normal-appearing gray matter (P ≥ .24), but all showed a significant difference (P < .002) between low- (D, 1.53 µm(2)/msec ± 0.47; ß, 0.87 ± 0.06; µ, 8.67 µm ± 0.95) and high-grade (D, 0.86 µm(2)/msec ± 0.23; ß, 0.73 ± 0.06; µ, 7.8 µm ± 0.70) brain tumor groups. The combination of D and ß produced the largest area under the ROC curve (0.962) in the ROC analysis compared with individual parameters (ß, 0.943; D,0.910; and µ, 0.763), indicating an improved performance for tumor differentiation. CONCLUSION: The FROC parameters can be used to differentiate between low- and high-grade pediatric brain tumor groups. The combination of FROC parameters or individual parameters may serve as in vivo, noninvasive, and quantitative imaging markers for classifying pediatric brain tumors.

Regulation of nicotinic acetylcholine receptor assembly.

The four muscle-type nicotinic acetylcholine receptor (AChR) subunits, alpha, beta, gamma, and delta, assemble into functional alpha(2)betagammadelta pentamers in the endoplasmic reticulum (ER) through a series of interdependent folding and oligomerization events. The first stable assembly intermediate is a trimer composed of alpha, beta, and gamma subunits. The formation of alphabetagamma trimers initiates a series of subunit folding and processing events that allow addition of delta subunits to form alphabetagammadelta tetramers. Subunit folding and processing continue with formation of the ligand-binding sites on the alpha subunit of alphabetagammadelta tetramers and the second alpha subunit added to assemble alpha(2)betagammadelta pentamers. AChR assembly is inefficient. Only 20-30% of synthesized subunits assemble into mature receptors in the ER, while the remaining unassembled subunits are degraded. However, the efficiency of subunit assembly can be regulated under certain conditions leading to higher AChR expression. Increased intracellular cAMP levels cause a 2- to 3-fold increase in AChR assembly efficiency and a comparable increase in surface expression. Additionally, block of ubiquitin-proteasome degradation appears to enhance AChR assembly and expression. Thus, the regulation of AChR assembly through posttranslational mechanisms is a potential therapeutic target for increasing AChR expression in diseases in which expression is compromised.

Comparison of 2D and 3D views for evaluation of flat lesions in CT colonography.

RATIONALE AND OBJECTIVES: Flat lesions in the colon may result in false-negative computed tomography colonography interpretations. It is unknown whether flat lesions are better measured on two-dimensional (2D) or three-dimensional (3D) images and which settings are optimal for enhanced reproducibility and decreased variability. We evaluated these factors to determine whether 2D or 3D is best for flat lesion measurements. METHODS AND MATERIALS: Eighty-eight lesions in 66 patients from a previously published clinical trial were analyzed. Lesions were viewed with four methods including 2D at three window/level settings and 3D endoluminal view. Lesions in either supine or prone were counted as one dataset. Long axis and height were measured. Criteria of "height" (

Endoplasmic reticulum chaperones stabilize nicotinic receptor subunits and regulate receptor assembly.

We examined interactions between the endoplasmic reticulum (ER) chaperones calnexin (CN), ERp57, and immunological heavy chain-binding protein (BiP) and nicotinic acetylcholine receptor (nAChR) subunits. The three chaperones rapidly associate with newly synthesized nAChR subunits. Interactions between nAChR subunits and ERp57 occur via transient intermolecular disulfide bonds and do not require subunit N-linked glycosylation. The associations of ERp57 or CN with AChR subunits are long lived and prolong subunit lifetime approximately 10-fold. Coexpression of CN or ERp57 alone does not affect nAChR assembly or trafficking, but together they cause a significant decrease in nAChR expression and assembly. In contrast, associations with BiP are shorter lived and do not alter nAChR expression and assembly. However, a mutated BiP that slows its dissociation significantly increases its associations and decreases nAChR expression and assembly. Our results suggest that interactions with the chaperones regulate the levels of nAChRs assembled in the ER by stabilizing and sequestering subunits during assembly.

N-linked glycosylation is required for nicotinic receptor assembly but not for subunit associations with calnexin.

We investigated how asparagine (N)-linked glycosylation affects assembly of acetylcholine receptors (AChRs) in the endoplasmic reticulum (ER). Block of N-linked glycosylation inhibited AChR assembly whereas block of glucose trimming partially blocked assembly at the late stages. Removal of each of seven glycans had a distinct effect on AChR assembly, ranging from no effect to total loss of assembly. Because the chaperone calnexin (CN) associates with N-linked glycans, we examined CN interactions with AChR subunits. CN rapidly associates with 50% or more of newly synthesized AChR subunits, but not with subunits after maturation. Block of N-linked glycosylation or trimming did not alter CN-AChR subunit associations nor did subunit mutations prevent N-linked glycosylation. Additionally, CN associations with subunits lacking N-linked glycans occurred without subunit aggregation or misfolding. Our data indicate that CN associates with AChR subunits without N-linked glycan interactions. Furthermore, CN-subunit associations only occur early in AChR assembly and have no role in events later that require N-linked glycosylation.

A role for presenilin 1 in regulating the delivery of amyloid precursor protein to the cell surface.

Presenilin 1 (PS1) and presenilin 2 play a critical role in the gamma-secretase processing of amyloid precursor protein (APP) and Notch1. Here, we investigate maturation and intracellular trafficking of APP and other membrane proteins in cells expressing an experimental PS1 deletion mutant (deltaM1,2). Stable expression of deltaM1,2 impairs gamma-secretase processing of Notch1 and delays Abeta secretion. Kinetic studies show enhanced O-glycosylation and sialylation of holo-APP and marked accumulation of APP COOH-terminal fragments (CTFs). Surface biotinylation, live staining, and trafficking studies show increased surface accumulation of holo-APP and CTFs in deltaM1,2 cells resulting from enhanced surface delivery of newly synthesized APP. Expression of a loss-of-function PS1 mutant (D385A) or incubation of cells with gamma-secretase inhibitors also increases surface levels of holo-APP and CTFs. In contrast to APP, glycosylation and surface accumulation of another type I membrane protein, nicastrin, are markedly reduced in deltaM1,2 cells. Finally, expression of deltaM1,2 results in the increased assembly and surface expression of nicotinic acetylcholine receptors, illustrating that PS1's influence on protein trafficking extends beyond APP and other type I membrane protein substrates of gamma-secretase. Collectively, our findings provide evidence that PS1 regulates the glycosylation and intracellular trafficking of APP and select membrane proteins.