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1.
Sci Adv ; 8(38): eabq0273, 2022 09 23.
Article En | MEDLINE | ID: mdl-36149967

To develop vaccines for certain key global pathogens such as HIV, it is crucial to elicit both neutralizing and non-neutralizing Fc-mediated effector antibody functions. Clinical evidence indicates that non-neutralizing antibody functions including antibody-dependent cellular cytotoxicity (ADCC) and antibody-dependent cellular phagocytosis (ADCP) contribute to protection against several pathogens. In this study, we demonstrated that conjugation of HIV Envelope (Env) antigen gp120 to a self-assembling nanofiber material named Q11 induced antibodies with higher breadth and functionality when compared to soluble gp120. Immunization with Q11-conjugated gp120 vaccine (gp120-Q11) demonstrated higher tier 1 neutralization, ADCP, and ADCC as compared to soluble gp120. Moreover, Q11 conjugation altered the Fc N-glycosylation profile of antigen-specific antibodies, leading to a phenotype associated with increased ADCC in animals immunized with gp120-Q11. Thus, this nanomaterial vaccine strategy can enhance non-neutralizing antibody functions possibly through modulation of immunoglobulin G Fc N-glycosylation.


AIDS Vaccines , HIV Infections , HIV-1 , Nanofibers , Animals , Glycosylation , HIV Antibodies , HIV Infections/prevention & control , Immunoglobulin Fc Fragments/genetics , Immunoglobulin G , Vaccines, Subunit
2.
Cell Rep ; 39(13): 111021, 2022 06 28.
Article En | MEDLINE | ID: mdl-35767950

HIV-1 envelope (Env) proteins designed to induce neutralizing antibody responses allow study of the role of affinities (equilibrium dissociation constant [KD]) and kinetic rates (association/dissociation rates) on B cell antigen recognition. It is unclear whether affinity discrimination during B cell activation is based solely on Env protein binding KD and whether B cells discriminate among proteins of similar affinities that bind with different kinetic rates. Here, we use a panel of Env proteins and Ramos B cell lines expressing immunoglobulin M (IgM) B cell receptors (BCRs) with specificity for CD4-binding-site broadly neutralizing antibodies to study the role of antigen binding kinetic rates on both early (proximal/distal signaling) and late events (BCR/antigen internalization) in B cell activation. Our results support a kinetic model for B cell activation in which Env protein affinity discrimination is based not on overall KD but on sensing of association rate and a threshold antigen-BCR half-life.


HIV-1 , Antibodies, Neutralizing , Antigens, Viral , HIV Antibodies , Immunoglobulin M , Receptors, Antigen, B-Cell/metabolism , env Gene Products, Human Immunodeficiency Virus
3.
J Clin Transl Sci ; 5(1): e177, 2021.
Article En | MEDLINE | ID: mdl-34849253

Rapid whole genome sequencing (rapid WGS) is a powerful diagnostic tool that is becoming increasingly practical for widespread clinical use. However, protocols for its use are challenging to implement. A significant obstacle to clinical adoption is that laboratory certification requires an initial research development phase, which is constrained by regulations from returning results. Regulations preventing return of results have ethical implications in cases which might impact patient outcomes. Here, we describe our experience with the development of a rapid WGS research protocol, that balanced the requirements for laboratory-validated test development with the ethical needs of clinically relevant return of results.

4.
Sci Rep ; 11(1): 14494, 2021 07 14.
Article En | MEDLINE | ID: mdl-34262096

A major challenge in developing an effective vaccine against HIV-1 is the genetic diversity of its viral envelope. Because of the broad range of sequences exhibited by HIV-1 strains, protective antibodies must be able to bind and neutralize a widely mutated viral envelope protein. No vaccine has yet been designed which induces broadly neutralizing or protective immune responses against HIV in humans. Nanomaterial-based vaccines have shown the ability to generate antibody and cellular immune responses of increased breadth and neutralization potency. Thus, we have developed supramolecular nanofiber-based immunogens bearing the HIV gp120 envelope glycoprotein. These immunogens generated antibody responses that had increased magnitude and binding breadth compared to soluble gp120. By varying gp120 density on nanofibers, we determined that increased antigen valency was associated with increased antibody magnitude and germinal center responses. This study presents a proof-of-concept for a nanofiber vaccine platform generating broad, high binding antibody responses against the HIV-1 envelope glycoprotein.


HIV Antibodies/metabolism , HIV Antigens/immunology , HIV Envelope Protein gp120/chemistry , HIV Envelope Protein gp120/immunology , Nanofibers/chemistry , Animals , Female , Germinal Center/immunology , HIV Antibodies/immunology , HIV Envelope Protein gp120/metabolism , Herpes Simplex Virus Vaccines/immunology , Immunoglobulin G/blood , Mice, Inbred C57BL , T-Lymphocytes, Helper-Inducer/immunology
5.
Pharmaceuticals (Basel) ; 14(4)2021 Apr 13.
Article En | MEDLINE | ID: mdl-33924734

Murine double minute 2 (MDM2), a negative regulator of the p53 tumor suppressor protein, is overexpressed in several human cancers. Herein we investigate the feasibility of developing 18F-labeled compounds based on the small molecule inhibitor SP-141 for imaging tumor MDM2 expression levels with positron emission tomography (PET). Three nonradioactive fluorinated SP-141 analogues, 1-3, were synthesized, and their binding to the MDM2 protein was analyzed by surface plasmon resonance (SPR). One of these, a fluoroethoxy analogue, was labeled with fluorine-18 (18F) using 18F-fluorethyl bromide to provide [18F]1 and evaluated in vitro and in vivo. SPR analysis confirmed the binding of the fluorinated analogues to MDM2 at 1.25-20 µM concentrations. Cell uptake studies revealed high uptake (67.5-71.4%/mg protein) and specificity of [18F]1 in MCF7 and HepG2 cells. The uptake of [18F]1 in these cells could be modulated using 100 µM SP-141, potentially reflecting changes in MDM2 expression because of p53 activation by SP-141. [18F]1 exhibited stable uptake and retention in HepG2 tumor xenografts (~3 %ID/g) in vivo, but poor clearance from blood and other normal tissues, yielding low tumor-to-background ratios (<2) at 2 h post injection. Our results suggest that [18F]1 has suboptimal characteristics for in vivo evaluation as a PET tracer for MDM2, but warrant radiolabeling and assessment of the other fluorinated analogues synthesized in this work, 2 and 3, and potentially other molecular scaffolds for developing MDM2 targeted radiotracers.

6.
Nat Struct Mol Biol ; 28(2): 128-131, 2021 02.
Article En | MEDLINE | ID: mdl-33402708

The SARS-CoV-2 spike (S) protein, a primary target for COVID-19 vaccine development, presents its receptor binding domain in two conformations, the receptor-accessible 'up' or receptor-inaccessible 'down' states. Here we report that the commonly used stabilized S ectodomain construct '2P' is sensitive to cold temperatures, and this cold sensitivity is abrogated in a 'down' state-stabilized ectodomain. Our findings will impact structural, functional and vaccine studies that use the SARS-CoV-2 S ectodomain.


Spike Glycoprotein, Coronavirus/chemistry , Antibodies, Viral/chemistry , COVID-19 Vaccines/chemistry , Cold Temperature , Cryoelectron Microscopy , Enzyme-Linked Immunosorbent Assay , Humans , Protein Denaturation , Protein Domains , Protein Stability , Spike Glycoprotein, Coronavirus/ultrastructure , Surface Plasmon Resonance
7.
bioRxiv ; 2020 Oct 13.
Article En | MEDLINE | ID: mdl-32699852

The SARS-CoV-2 spike (S) protein, a primary target for COVID-19 vaccine development, presents its Receptor Binding Domain in two conformations: receptor-accessible "up" or receptor-inaccessible "down" conformations. Here, we report that the commonly used stabilized S ectodomain construct "2P" is sensitive to cold temperature, and that this cold sensitivity is resolved in a "down" state stabilized spike. Our results will impact structural, functional and vaccine studies that use the SARS-CoV-2 S ectodomain.

8.
PLoS Pathog ; 15(12): e1008165, 2019 12.
Article En | MEDLINE | ID: mdl-31841553

Viral glycoproteins are a primary target for host antibody responses. However, glycans on viral glycoproteins can hinder antibody recognition since they are self glycans derived from the host biosynthesis pathway. During natural HIV-1 infection, neutralizing antibodies are made against glycans on HIV-1 envelope glycoprotein (Env). However, such antibodies are rarely elicited with vaccination. Previously, the vaccine-induced, macaque antibody DH501 was isolated and shown to bind to high mannose glycans on HIV-1 Env. Understanding how DH501 underwent affinity maturation to recognize glycans could inform vaccine induction of HIV-1 glycan antibodies. Here, we show that DH501 Env glycan reactivity is mediated by both germline-encoded residues that contact glycans, and somatic mutations that increase antibody paratope flexibility. Only somatic mutations in the heavy chain were required for glycan reactivity. The paratope conformation was fragile as single mutations within the immunoglobulin fold or complementarity determining regions were sufficient for eliminating antibody function. Taken together, the initial germline VHDJH rearrangement generated contact residues capable of binding glycans, and somatic mutations were required to form a flexible paratope with a cavity conducive to HIV-1 envelope glycan binding. The requirement for the presence of most somatic mutations across the heavy chain variable region provides one explanation for the difficulty in inducing anti-Env glycan antibodies with HIV-1 Env vaccination.


AIDS Vaccines/immunology , HIV Antibodies/immunology , HIV-1/immunology , Polysaccharides/immunology , env Gene Products, Human Immunodeficiency Virus/immunology , AIDS Vaccines/genetics , Animals , Antibodies, Neutralizing/genetics , Antibodies, Neutralizing/immunology , Base Sequence , HIV Infections/immunology , Humans , Mutation
10.
Mucosal Immunol ; 12(4): 1004-1012, 2019 07.
Article En | MEDLINE | ID: mdl-30976088

Interactions between innate antiviral factors at mucosal surfaces and HIV-1 virions contribute to the natural inefficiency of HIV-1 transmission and are a platform to inform the development of vaccine and nonvaccine strategies to block mucosal HIV-1 transmission. Tenascin-C (TNC) is a large, hexameric extracellular matrix glycoprotein identified in breast milk and genital fluids that broadly neutralizes HIV-1 via interaction with the HIV-1 Envelope (Env) variable 3 (V3) loop. In this report, we characterize the specific determinants of the interaction between TNC and the HIV-1 Env. We observed that TNC binding and neutralization of HIV-1 is dependent on the TNC fibrinogen-like globe (fbg) and fibronectin-type III (fn) domains, oligomerization, and its newly-mapped glycan structure. Moreover, we observed that TNC-mediated neutralization is also dependent on Env V3 residues 321/322 and 326/327, which surround the IGDIR motif of the V3 loop, as well the N332 glycan, which is critical to the broadly neutralizing activity of glycan-dependent V3-specific antibodies such as PGT128. Our results demonstrate a striking parallel between innate and adaptive immune mechanisms of broad HIV neutralization and provide further insight into the host protein-virus interactions responsible for the natural inefficiency of mucosal HIV-1 transmission.


HIV-1/metabolism , Tenascin/chemistry , Tenascin/metabolism , env Gene Products, Human Immunodeficiency Virus/chemistry , env Gene Products, Human Immunodeficiency Virus/metabolism , Amino Acid Sequence , Amino Acids , Epitope Mapping , Epitopes/chemistry , Epitopes/immunology , Glycosylation , HIV Envelope Protein gp120/chemistry , HIV Envelope Protein gp120/immunology , HIV Envelope Protein gp120/metabolism , HIV-1/immunology , Humans , Models, Molecular , Neutralization Tests , Peptide Fragments/chemistry , Peptide Fragments/immunology , Peptide Fragments/metabolism , Protein Binding , Protein Conformation , Protein Interaction Domains and Motifs , Protein Multimerization , Recombinant Proteins , env Gene Products, Human Immunodeficiency Virus/immunology
11.
Nat Commun ; 10(1): 654, 2019 02 08.
Article En | MEDLINE | ID: mdl-30737386

Somatic mutations within antibody variable and framework regions (FWR) can alter thermostability and structural flexibility, but their impact on functional potency is unclear. Here we study thermostability and use molecular dynamics (MD) simulations to assess the role of FWR mutations during maturation of HIV-1 broadly neutralizing antibodies (bnAbs). The tested bnAbs show lower thermostability than their unmutated ancestor antibodies. FWR mutations in the Fab elbow region are frequently observed in HIV-1 bnAbs and MD simulations show that such FWR mutations alter interdomain flexibility in two HIV-1 bnAbs. In a CD4-binding site lineage, reversion mutations result in a loss of neutralization potency in an early intermediate and affinity-matured bnAb against autologous and heterologous Tier-2 viruses, respectively. Elbow region reversion mutations in a glycan-V3 bnAb modestly reduces potency against an autologous virus isolate. Thus, selection of mutations in the Fab elbow region impacts interdomain conformational flexibility and paratope plasticity during bnAb development.


Antibodies, Neutralizing/genetics , Antibodies, Neutralizing/immunology , HIV Antibodies/genetics , HIV Antibodies/immunology , Mutation/genetics , Calorimetry, Differential Scanning , Circular Dichroism , HIV-1/immunology , Humans , Molecular Dynamics Simulation , Neutralization Tests , Surface Plasmon Resonance
13.
Biochemistry ; 57(14): 2140-2149, 2018 04 10.
Article En | MEDLINE | ID: mdl-29558110

Multivalent binding is an efficient means to enhance the affinity and specificity of chemical probes targeting multidomain proteins in order to study their function and role in disease. While the theory of multivalent binding is straightforward, physical and structural characterization of bivalent binding encounters multiple technical difficulties. We present a case study where a combination of experimental techniques and computational simulations was used to comprehensively characterize the binding and structure-affinity relationships for a series of Bromosporine-based bivalent bromodomain ligands with a bivalent protein, Transcription Initiation Factor TFIID subunit 1 (TAF1). Experimental techniques-Isothermal Titration Calorimetry, X-ray Crystallography, Circular Dichroism, Size Exclusion Chromatography-Multi-Angle Light Scattering, and Surface Plasmon Resonance-were used to determine structures, binding affinities, and kinetics of monovalent ligands and bivalent ligands with varying linker lengths. The experimental data for monomeric ligands were fed into explicit computational simulations, in which both ligand and protein species were present in a broad range of concentrations, and in up to a 100 s time regime, to match experimental conditions. These simulations provided accurate estimates for apparent affinities (in good agreement with experimental data), individual dissociation microconstants and other microscopic details for each type of protein-ligand complex. We conclude that the expected efficiency of bivalent ligands in a cellular context is difficult to estimate by a single technique in vitro, due to higher order associations favored at the concentrations used, and other complicating processes. Rather, a combination of structural, biophysical, and computational approaches should be utilized to estimate and characterize multivalent interactions.


Histone Acetyltransferases/chemistry , TATA-Binding Protein Associated Factors/chemistry , Transcription Factor TFIID/chemistry , Calorimetry , Crystallography, X-Ray , Dynamic Light Scattering , Histone Acetyltransferases/metabolism , Humans , Molecular Probes/metabolism , TATA-Binding Protein Associated Factors/metabolism , Transcription Factor TFIID/metabolism
14.
Biomaterials ; 142: 52-61, 2017 Oct.
Article En | MEDLINE | ID: mdl-28727998

Early recruitment of non-classical monocytes and their macrophage derivatives is associated with augmented tissue repair and improved integration of biomaterial constructs. A promising therapeutic approach to recruit these subpopulations is by elevating local concentrations of chemoattractants such as fractalkine (FKN, CX3CL1). However, delivering recombinant or purified proteins is not ideal due to their short half-lives, suboptimal efficacy, immunogenic potential, batch variabilities, and cost. Here we report an approach to enrich endogenous FKN, obviating the need for delivery of exogenous proteins. In this study, modified FKN-binding-aptamers are integrated with poly(ethylene glycol) diacrylate to form aptamer-functionalized hydrogels ("aptagels") that localize, dramatically enrich and passively release FKN in vitro for at least one week. Implantation in a mouse model of excisional skin injury demonstrates that aptagels enrich endogenous FKN and stimulate significant local increases in Ly6CloCX3CR1hi non-classical monocytes and CD206+ M2-like macrophages. The results demonstrate that orchestrators of inflammation can be manipulated without delivery of foreign proteins or cells and FKN-aptamer functionalized biomaterials may be a promising approach to recruit anti-inflammatory subpopulations to sites of injury. Aptagels are readily synthesized, highly customizable and could combine different aptamers to treat complex diseases in which regulation or enrichment of multiple proteins may be therapeutic.


Aptamers, Peptide/pharmacology , Chemokine CX3CL1/pharmacology , Hydrogels/pharmacology , Inflammation/pathology , Animals , CX3C Chemokine Receptor 1/metabolism , Cell Movement/drug effects , Humans , Kinetics , Macrophages/drug effects , Macrophages/metabolism , Male , Mice , Mice, Inbred C57BL , Phenotype , Polyethylene Glycols/chemical synthesis , Polyethylene Glycols/chemistry , Surface Plasmon Resonance , Time-Lapse Imaging
15.
DNA Repair (Amst) ; 18: 63-7, 2014 Jun.
Article En | MEDLINE | ID: mdl-24674899

During replication in yeast, the three B family DNA replicases frequently incorporate ribonucleotides (rNMPs) into DNA, and their presence in the nuclear genome can affect genome stability. This prompted us to examine ribonucleotide incorporation by the fourth B family member, Pol ζ, the enzyme responsible for the majority of damage-induced mutagenesis in eukaryotes. We first show that Pol ζ inserts rNMPs into DNA and can extend primer termini containing 3'-ribonucleotides. We then measure rNMP incorporation by Pol ζ in the presence of its cofactors, RPA, RFC and PCNA and at normal cellular dNTP and rNTP concentrations that exist under unstressed conditions. Under these conditions, Pol ζ stably incorporates one rNMP for every 200-300 dNMPs incorporated, a frequency that is slightly higher than for the high fidelity replicative DNA polymerases. Under damage-induced conditions wherein cellular dNTP concentrations are elevated 5-fold, Pol ζ only incorporates one rNMP per 1300 dNMPs. Functional interaction of Pol ζ with the mutasome assembly factor Rev1 gives comparable rNMP incorporation frequencies. These results suggest that ribonucleotide incorporation into DNA during Pol ζ-mediated mutagenesis in vivo may be rare.


DNA, Fungal/metabolism , DNA-Directed DNA Polymerase/metabolism , Ribonucleotides/metabolism , Saccharomyces cerevisiae Proteins/metabolism , Saccharomyces cerevisiae/enzymology , DNA Damage , DNA Replication , Deoxyribonucleotides/metabolism , Mutation , Nucleotidyltransferases/genetics , Nucleotidyltransferases/metabolism , Replication Protein A/metabolism , Saccharomyces cerevisiae Proteins/genetics
16.
DNA Repair (Amst) ; 11(8): 649-56, 2012 Aug 01.
Article En | MEDLINE | ID: mdl-22682724

We have investigated the ability of the 3' exonuclease activity of Saccharomyces cerevisiae DNA polymerase ɛ (Pol ɛ) to proofread newly inserted ribonucleotides (rNMPs). During DNA synthesis in vitro, Pol ɛ proofreads ribonucleotides with apparent efficiencies that vary from none at some locations to more than 90% at others, with rA and rU being more efficiently proofread than rC and rG. Previous studies show that failure to repair ribonucleotides in the genome of rnh201Δ strains that lack RNase H2 activity elevates the rate of short deletions in tandem repeat sequences. Here we show that this rate is increased by 2-4-fold in pol2-4 rnh201Δ strains that are also defective in Pol ɛ proofreading. In comparison, defective proofreading in these same strains increases the rate of base substitutions by more than 100-fold. Collectively, the results indicate that although proofreading of an 'incorrect' sugar is less efficient than is proofreading of an incorrect base, Pol ɛ does proofread newly inserted rNMPs to enhance genome stability.


DNA Mismatch Repair , DNA Polymerase II/metabolism , Ribonucleotides/metabolism , Saccharomyces cerevisiae/enzymology , Base Pair Mismatch , Base Sequence , DNA Polymerase II/genetics , DNA Replication , Exonucleases/metabolism , Gene Deletion , Molecular Sequence Data , Ribonucleases/genetics , Ribonucleases/metabolism , Saccharomyces cerevisiae/genetics , Saccharomyces cerevisiae/metabolism , Saccharomyces cerevisiae Proteins/genetics , Saccharomyces cerevisiae Proteins/metabolism , Tandem Repeat Sequences
17.
Nat Chem Biol ; 6(10): 774-81, 2010 Oct.
Article En | MEDLINE | ID: mdl-20729855

Maintaining the chemical identity of DNA depends on ribonucleotide exclusion by DNA polymerases. However, ribonucleotide exclusion during DNA synthesis in vitro is imperfect. To determine whether ribonucleotides are incorporated during DNA replication in vivo, we substituted leucine or glycine for an active-site methionine in yeast DNA polymerase ϵ (Pol ϵ). Ribonucleotide incorporation in vitro was three-fold lower for M644L and 11-fold higher for M644G Pol ϵ compared to wild-type Pol ϵ. This hierarchy was recapitulated in vivo in yeast strains lacking RNase H2. Moreover, the pol2-M644G rnh201Δ strain progressed more slowly through S phase, had elevated dNTP pools and generated 2-5-base-pair deletions in repetitive sequences at a high rate and in a gene orientation-dependent manner. The data indicate that ribonucleotides are incorporated during replication in vivo, that they are removed by RNase H2-dependent repair and that defective repair results in replicative stress and genome instability via DNA strand misalignment.


DNA, Fungal/metabolism , Genomic Instability , Ribonucleotides/metabolism , Saccharomyces cerevisiae/genetics , Base Sequence , DNA Replication , DNA, Fungal/chemistry , DNA-Directed DNA Polymerase/chemistry , DNA-Directed DNA Polymerase/genetics , DNA-Directed DNA Polymerase/metabolism , Genome, Fungal , Molecular Sequence Data , Mutagenesis , Mutation , Phenotype , Ribonuclease H/deficiency , Ribonuclease H/genetics , Ribonuclease H/metabolism , Saccharomyces cerevisiae/enzymology , Templates, Genetic
18.
Proc Natl Acad Sci U S A ; 107(11): 4949-54, 2010 Mar 16.
Article En | MEDLINE | ID: mdl-20194773

Measurements of nucleoside triphosphate levels in Saccharomyces cerevisiae reveal that the four rNTPs are in 36- to 190-fold molar excess over their corresponding dNTPs. During DNA synthesis in vitro using the physiological nucleoside triphosphate concentrations, yeast DNA polymerase epsilon, which is implicated in leading strand replication, incorporates one rNMP for every 1,250 dNMPs. Pol delta and Pol alpha, which conduct lagging strand replication, incorporate one rNMP for every 5,000 or 625 dNMPs, respectively. Discrimination against rNMP incorporation varies widely, in some cases by more than 100-fold, depending on the identity of the base and the template sequence context in which it is located. Given estimates of the amount of replication catalyzed by Pols alpha, delta, and epsilon, the results are consistent with the possibility that more than 10,000 rNMPs may be incorporated into the nuclear genome during each round of replication in yeast. Thus, rNMPs may be the most common noncanonical nucleotides introduced into the eukaryotic genome. Potential beneficial and negative consequences of abundant ribonucleotide incorporation into DNA are discussed, including the possibility that unrepaired rNMPs in DNA could be problematic because yeast DNA polymerase epsilon has difficulty bypassing a single rNMP present within a DNA template.


DNA Replication , DNA, Fungal/metabolism , DNA-Directed DNA Polymerase/metabolism , Ribonucleotides/metabolism , Saccharomyces cerevisiae/enzymology , Base Sequence , Deoxyribonucleotides/metabolism , Kinetics , Substrate Specificity , Templates, Genetic
19.
Ann Emerg Med ; 43(1): 106-13, 2004 Jan.
Article En | MEDLINE | ID: mdl-14707949

STUDY OBJECTIVE: Out-of-hospital hypotension may signify need for intensive resuscitation and rapid diagnosis on emergency department (ED) arrival. We hypothesized that nontraumatic out-of-hospital hypotension confers risk of inhospital mortality. METHODS: This was a multicenter study of ambulance-transported, nontrauma, non-cardiopulmonary resuscitation patients conducted at 2 venues: (1) a cross-sectional risk assessment study of high-priority medical transports at a US metropolitan county; and (2) a Canadian prospective multicenter cohort study of patients with respiratory distress. Data at both venues were extracted from prospectively recorded, standardized run sheets by either a physician or a paramedic. Data extraction and analysis at each venue were conducted independently. Exposures to hypotension were defined as age older than 17 years old, systolic blood pressure less than 100 mm Hg during transport, and 1 or more of 10 predefined symptoms of circulatory insufficiency. Nonexposures to hypotension had the same definition as exposures, except the systolic blood pressure had to be more than 100 mm Hg during the entire out-of-hospital transport. The main outcome variable was inhospital mortality. RESULTS: At venue 1, of 3,128 transports, 395 (13%) exposures and 395 nonexposures were identified. Inhospital mortality of exposures was 26% versus 8% for nonexposures (adjusted odds ratio [OR] 4.6; 95% confidence interval [CI] 2.0 to 5.9). At venue 2, of 7,679 transports, 532 exposures (7%) and 7,147 nonexposures were identified. Out-of-hospital exposure to hypotension conferred a mortality rate of 32% versus 11% for nonexposures (OR 3.0; 95% CI 2.4 to 3.7), representing a sensitivity of 18% and a specificity of 95%. CONCLUSION: The inhospital mortality rate after out-of-hospital, nontraumatic hypotension is high and reproducible. Future research should focus on ED clinical protocols to ensure appropriate resuscitation and investigation of etiology of out-of-hospital hypotension.


Ambulances/statistics & numerical data , Emergency Medical Services/statistics & numerical data , Emergency Service, Hospital/organization & administration , Hospital Mortality , Hospitalization/statistics & numerical data , Hypotension/mortality , Aged , Cohort Studies , Cross-Sectional Studies , Early Diagnosis , Emergency Medical Services/organization & administration , Female , Humans , Hypotension/diagnosis , Hypotension/therapy , Intensive Care Units/organization & administration , Life Support Care/organization & administration , Life Support Care/statistics & numerical data , Male , Middle Aged , North Carolina , Ontario , Patient Transfer/organization & administration , Prospective Studies , Risk Assessment , Sensitivity and Specificity , Survival Rate , Transportation of Patients/organization & administration
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