Indication for resuscitative thoracotomy in thoracic injuries-Adherence to the ATLS guidelines. A forensic autopsy based evaluation.

BACKGROUND: The appropriate indications for Resuscitative Thoracotomy (RT) are still debated in the literature and various guidelines have been proposed. This study aimed to evaluate whether Advanced Trauma Life Support (ATLS) guidelines for RT were applied correctly and to evaluate the proportion of deceased patients with potentially reversible thoracic lesions (PRTL). METHODS: The database at the Department of Forensic Medicine at Copenhagen University was queried for autopsy cases with thoracic lesions indicated by the SNOMED autopsy coding system. Patients were included if thoracic lesions were caused by a traumatic event with trauma team activation. Patient cases were blinded for any surgical intervention and evaluated independently by two reviewers for indications or contraindications for RT as determined by the ATLS guidelines. Second, autopsy reports were evaluated for the presence of PRTL. RESULTS: Sixty-seven patients met the inclusion criteria. Two were excluded due to insufficient data. The overall agreement with guidelines was 86% and 77% for blunt and penetrating trauma, respectively. For patients submitted to RT the overall agreement with guidelines was 63% being 45% and 74% for blunt and penetrating trauma, respectively. For patients who did not undergo RT the agreement with guidelines was 100%. In all cases where RT was performed in agreement between guidelines and the clinical decision the autopsy reports showed PRTL in 16 (84%) patients. In cases of non-agreement PRTL were found in 9 (82%) patients. CONCLUSIONS: Agreement with ATLS guidelines for RT was 63% for intervention and 100% for non-intervention in deceased patients with thoracic trauma. Agreement was higher for penetrating trauma than for blunt trauma. The adherence to guidelines did not improve the ability to predict autopsy findings of PRTL. Although the study has methodical limitations it represents a novel approach to the evaluation of the clinical use of RT guidelines.

Particle size distribution of workplace aerosols in manganese alloy smelters applying a personal sampling strategy.

Air samples were collected by personal sampling with five stage Sioutas cascade impactors and respirable cyclones in parallel among tappers and crane operators in two manganese (Mn) alloy smelters in Norway to investigate PM fractions. The mass concentrations of PM collected by using the impactors and the respirable cyclones were critically evaluated by comparing the results of the parallel measurements. The geometric mean (GM) mass concentrations of the respirable fraction and the <10 µm PM fraction were 0.18 and 0.39 mg m(-3), respectively. Particle size distributions were determined using the impactor data in the range from 0 to 10 µm and by stationary measurements by using a scanning mobility particle sizer in the range from 10 to 487 nm. On average 50% of the particulate mass in the Mn alloy smelters was in the range from 2.5 to 10 µm, while the rest was distributed between the lower stages of the impactors. On average 15% of the particulate mass was found in the <0.25 µm PM fraction. The comparisons of the different PM fraction mass concentrations related to different work tasks or different workplaces, showed in many cases statistically significant differences, however, the particle size distribution of PM in the fraction <10 µm d(ae) was independent of the plant, furnace or work task.

Arterial pressure during cardiopulmonary bypass is not associated with acute kidney injury.

BACKGROUND: Acute kidney injury (AKI) after cardiac surgery is common and is associated with increased mortality. We wanted to investigate if the arterial pressure or the use of norepinephrine during cardiopulmonary bypass were associated with AKI. METHODS: A retrospective analysis of patients who underwent coronary artery bypass grafting with or without concomitant procedures was conducted. AKI was defined using the RIFLE criteria. Data on arterial pressure and use of norepinephrine during cardiopulmonary bypass were entered in a binary logistic regression model to control for possible perioperative confounders. RESULTS: A total of 623 patients were included. Mean age was 68.3 ± 9.7 years and 81% were males. AKI was observed in 198 patients (32%). Mean arterial pressure was 47 ± 6 mmHg and 45 ± 6 mmHg (P = 0.008) in the AKI and no-AKI group, respectively. Norepinephrine was used more frequently and in higher amounts, during cardiopulmonary bypass, in patients who developed AKI. These differences in arterial pressures and use of norepinephrine between the groups were not found to be significant when entered in the binary logistic regression model. CONCLUSION: No independent relationship between arterial pressure or use of norepinephrine and AKI was found.

SNARE-dependent upregulation of potassium chloride co-transporter 2 activity after metabotropic zinc receptor activation in rat cortical neurons in vitro.

The major outward chloride transporter in neurons is the potassium chloride co-transporter 2 (KCC2), critical for maintaining an inhibitory reversal potential for GABA(A) receptor channels. In a recent study, we showed that Zn(2+) regulates GABA(A) reversal potentials in the hippocampus by enhancing the activity of KCC2 through an increase in its surface expression. Zn(2+) initiates this process by activating the Gq-coupled metabotropic Zn(2+) receptor/G protein-linked receptor 39 (mZnR/GPR39). Here, we first demonstrated that mZnR/GPR39 is functional in cortical neurons in culture, and then tested the hypothesis that the increase in KCC2 activity is mediated through a soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE)-dependent process. We established the presence of functional mZnR in rat cultured cortical neurons by loading cells with a Ca(2+) indicator and exposing cells to Zn(2+), which triggered consistent Ca(2+) responses that were blocked by the Gq antagonist YM-254890, but not by the metabotropic glutamate receptor antagonist (RS)-α-methyl-4-carboxyphenylglycine (MCPG). Importantly, Zn(2+) treatment under these conditions did not increase the intracellular concentrations of Zn(2+) itself. We then measured KCC2 activity by monitoring both the rate and relative amount of furosemide-sensitive NH(4)(+) influx through the co-transporter using an intracellular pH-sensitive fluorescent indicator. We observed that Zn(2+) pretreatment induced a Ca(2+)-dependent increase in KCC2 activity. The effects of Zn(2+) on KCC2 activity were also observed in wild-type mouse cortical neurons in culture, but not in neurons obtained from mZnR/GPR39(-/-) mice, suggesting that Zn(2+) acts through mZnR/GPR39 activation to upregulate KCC2 activity. We next transfected rat cortical neurons with a plasmid encoding botulinum toxin C1 (Botox C1), which cleaves the SNARE proteins syntaxin 1 and synaptosomal-associated protein 25 (SNAP-25). Basal KCC2 activity was similar in both transfected and non-transfected neurons. Non-transfected cells, or cells transfected with marker vector alone, showed a Zn(2+)-dependent increase in KCC2 activity. In contrast, KCC2 activity in neurons expressing Botox C1 was unchanged by Zn(2+). These results suggest that SNARE proteins are necessary for the increased activity of KCC2 after Zn(2+) stimulation of mZnR/GPR39.

Emergency thoracotomies in the largest trauma center in Denmark: 10 years' experience.

AIM: The aim of our study was to investigate the outcome in terms of 30-day survival and to determine whether preoperative factors could predict the outcome. METHODS: All patients who underwent an emergency thoracotomy (ET) during the period 2000 to 2009 were included. The patients were divided into two groups: emergency department thoracotomy and operating room thoracotomy. Data on demographics, mechanism of injury, intraoperative data, Injury Severity Scores (ISS), probability of survival, signs of life, transportation time, indications, and outcome were collected. RESULTS: Forty-four ETs were performed. The mechanisms of injury were penetrating in 28 (64%) and blunt in 16 (36%) cases. In the emergency department thoracotomy group, the survival was 45 versus 20% for penetrating and blunt trauma, respectively. The total survival was 33%. In the operating room thoracotomy group, the survival was 83%. The survivors had a significantly lower ISS and a higher calculated probability of survival. The calculated mean probability of survival was 44 and 84% in the emergency department thoracotomy and operating room thoracotomy groups, respectively. The actual survival was similar, with 33% in the emergency department thoracotomy group and 83% in the operating room thoracotomy group. CONCLUSIONS: The probability of survival and ISS are good predictors of survival in these patients and should be included in the future in order to make upcoming studies easier to compare. Patients with very high ISS or low probability of survival survived, justifying the procedure in our center.

Synaptic changes underlying the strengthening of GABA/glycinergic connections in the developing lateral superior olive.

Before hearing onset, the topographic organization of the auditory GABA/glycinergic pathway from the medial nucleus of the trapezoid body (MNTB) to the lateral superior olive (LSO) is refined by synaptic silencing and strengthening. The synaptic mechanisms underlying the developmental strengthening of maintained MNTB-LSO connections are unknown. Here we address this question using whole-cell recordings from LSO neurons in slices prepared from prehearing mice. Minimal and maximal stimulation techniques demonstrated that during the first two postnatal weeks, individual LSO neurons lose about 55% of their initial presynaptic MNTB partners while maintained single-fiber connections become about 14-fold stronger. Analysis of MNTB-evoked miniature events indicates that this strengthening is accompanied by a 2-fold increase in quantal amplitude. Strengthening is not caused by an increase in the probability of release because paired pulse ratios (PPRs) increased from 0.7 in newborn animals to 0.9 around hearing onset, indicating a developmental decrease rather than increase in release probability. In addition, a possible soma-dendritic relocation of MNTB input seems unlikely to underlie their strengthening as indicated by analysis of the rise times of synaptic currents. Taken together, we conclude that the developmental strengthening of MNTB-LSO connections is achieved by a 2-fold increase in quantal size and an 8-fold increase in quantal content.

Suppression of pulmonary innate host defence in smokers.

BACKGROUND: Smoking increases the susceptibility to pulmonary infection and is a risk factor for the development of chronic obstructive pulmonary disease (COPD). It is postulated that cigarette smoke suppresses the activation of the innate immune system in response to bacterial infection. METHODS: Using sensitive ex vivo analysis, the level of the endogenous antibiotic peptide human beta-defensin-2 (hBD-2) was measured in pharyngeal washing fluid and sputum from patients with community acquired pneumonia. The regulation of antibacterial host defence molecules was studied in vitro. The effect of cigarette smoke on the antibacterial activity of differentiated airway epithelium and the expression of host defence molecules was studied in an in vitro infection model. RESULTS: Current or former smoking was associated with significantly reduced hBD-2 levels in pharyngeal washing fluid and sputum from patients with acute pneumonia. Exposure of airway epithelium to smoke in vitro inhibited the induction of hBD-2 by bacteria. This correlated with decreased antimicrobial activity. This effect was mimicked by hydrogen peroxide, and catalase blunted the smoke-induced inhibition of epithelial host defence. CONCLUSIONS: Smoke exposure suppresses the induction of epithelial antibacterial host defences. These findings link smoking with increased susceptibility to infection. This mechanism may be important in the pathogenesis of pneumonia and COPD.

Dendritic Ca2+ responses in neonatal lateral superior olive neurons elicited by glycinergic/GABAergic synapses and action potentials.

During development, GABA/glycinergic connections from the medial nucleus of the trapezoid body (MNTB) to the lateral superior olive (LSO) gradually change from being depolarizing to being hyperpolarizing. Previous studies have shown that depolarizing MNTB-LSO synapses can trigger action potentials and increase the concentration of intracellular calcium. In the present study we used confocal calcium imaging combined with whole-cell patch clamp recordings to investigate how depolarizing MNTB inputs in neonatal rats and mice increase the calcium concentration in the dendrites of LSO neurons. Our results show that subthreshold synaptic responses can elicit local dendritic calcium responses while suprathreshold responses reliably generate global calcium responses that are observed in all dendritic processes. The amplitude of global dendritic calcium responses increased with distance from the soma. Global calcium responses were blocked by tetrodotoxin and could not be recovered by somatic injection of action potential waveforms indicating that global calcium responses are generated by back-propagating sodium action potentials.

Glycinergic/GABAergic synapses in the lateral superior olive are excitatory in neonatal C57Bl/6J mice.

The lateral superior olive (LSO), a nucleus involved in sound localization, receives tonotopically organized, inhibitory input from the medial nucleus of the trapezoid body (MNTB). To better understand the development of this glycinergic/GABAergic pathway, we used Gramicidin-perforated patch clamp recordings to characterize MNTB-evoked postsynaptic potentials in LSO neurons of neonatal C57Bl/6J mice. We found that during the first postnatal week, MNTB-evoked responses change from being depolarizing to being hyperpolarizing. Most interestingly, depolarizing glycinergic/GABAergic synaptic potentials were able to trigger action potentials, demonstrating that the MNTB-LSO pathway can act as a true excitatory pathway. This transient excitatory action of immature MNTB-LSO synapses might play an important role in activity-dependent sharpening of the tonotopic organization of inhibitory connections in the LSO.

New phototriggers: extending the p-hydroxyphenacyl pi-pi absorption range.

[equation--see text] Introducing 3-methoxy or 3,5-dimethoxy substituents on the 4-hydroxyphenacyl (pHP) photoremovable protecting group has been explored with two excitatory gamma-amino acids, L-glutamic acid and gamma-amino butyric acid (GABA). These substituents significantly extend the absorption range of the pHP chromophore, e.g., the tail of absorption bands of 2a,b extend above 400 nm, well beyond the absorptions of aromatic amino acids and nucleotides. Irradiation releases the amino acids with rate constants of approximately 10(7) s(-)(1) and appearance efficiencies (Phi(app)) of 0.03-0.04. The photoproducts are formed through the pHP excited triplet and are primarily products of photoreduction and photohydrolysis. 1a,b also rearranged to the phenylacetic acid 3.

Enhancement of NMDA receptor-mediated currents by light in rat neurones in vitro.

1. N-Methyl-D-aspartate (NMDA) receptor function can be modified by the action of several endogenous and exogenous modulatory processes. In the present study, we report that brief pulses of light potentiate NMDA, but not non-NMDA glutamatergic receptor-mediated whole-cell and single channel currents in rat cortical neurones in vitro. In addition, light also potentiated NMDA receptor-mediated whole-cell responses in isolated rat retinal neurones. 2. Potentiation of NMDA whole-cell currents in cortical neurones was readily observed during and following a brief (< 2 s) exposure of neurones to wavelengths of less than 324 nm of relatively bright light (0.09 microW microm-2). In addition, prolonged exposures (> 30 s) to visible wavelengths (> 380 nm) or to attenuated light (1-3 % transmittance of non-attenuated light) were also sufficient to enhance NMDA receptor-mediated responses. 3. The light-induced potentiation of NMDA receptor-mediated currents persisted for several minutes, slowly reversing to control levels with a time constant of approximately 5 min. A subsequent exposure to light could potentiate NMDA receptor-mediated currents for a second time. 4. Light did not alter the apparent affinity of the NMDA receptor for the co-agonists NMDA and glycine. Additionally, potentiation of the NMDA-induced currents was not mediated by a change in the pH sensitivity of the receptor. In excised outside-out membrane patches, the effects of light on NMDA-activated unitary currents were manifested as a twofold increase in channel open frequency without alterations in single channel amplitude or open time. 5. Our results suggest the presence of a light-sensitive moiety within the NMDA receptor, or in a closely associated structure, which affects channel properties. This previously unrecognized form of NMDA receptor modulation may provide a tool for understanding the conformational changes associated with its gating. In addition, it is possible that light may affect NMDA receptor-mediated function or dysfunction in the retina.

Relationship between dye coupling and spontaneous activity in developing ferret visual cortex.

Neuronal coupling by gap junctions is common during early development of the brain. Coupling is thought to create functional cell assemblies which may be involved in the functional specification of brain areas and the formation of synaptic circuits. In the present study we used slices from the visual cortex of postnatal ferrets to investigate the temporal relationship of gap junction coupling and formation of functional synapses. Individual neurons were filled with the gap-junction-permeable dye biotin ethylenediamine while spontaneous synaptic currents were recorded using whole-cell patch clamp recording techniques. We found that dye coupling increased during the first 2 postnatal weeks resulting at a peak around P14, after which coupling steadily decreased until adult levels were reached in animals older than P30. Spontaneous synaptic activity increased 30-fold between birth and maturity (from 10.8 +/- 2.4 to 318 +/- 54 events/min). The sharpest rise in synaptic activity, an over 5-fold increase, occurred between P15 and P19, shortly after the invasion of thalamocortical fibers.

Coordination of neuronal activity in developing visual cortex by gap junction-mediated biochemical communication.

During brain development, endogenously generated coordinated neuronal activity regulates the precision of developing synaptic circuits (Shatz and Stryker, 1988; Weliky and Katz, 1997). In the neonatal neocortex, a form of endogenous coordinated activity is present as locally restricted intercellular calcium waves that are mediated by gap junctions (Yuste et al., 1992). As in other neuronal and non-neuronal systems, these coordinated calcium fluctuations may form the basis of functional cell assemblies (for review, seeWarner, 1992; Peinado et al., 1993b). In the present study, we investigated the cellular mechanisms that mediate the activation of neuronal domains and the propagation of intercellular calcium waves in slices from neonatal rat neocortex. The occurrence of neuronal domains did not depend on intercellular propagation of regenerative electrical signals because domains persisted after blockade of sodium and calcium-dependent action potentials. Neuronal domains were elicited by intracellular infusion of inositol trisphosphate (IP3) but not of calcium, indicating the involvement of IP3-related second-messenger systems. Pharmacological stimulation of metabotropic glutamate receptors, which are linked to the production of IP3, elicited similarly coordinated calcium increases, whereas pharmacological blockade of metabotropic glutamate receptors dramatically reduced the number of neuronal domains. Therefore, the propagating cellular signal that causes the occurrence of neuronal domains seems to be inositol trisphosphate but not calcium. Because coordination of neuronal calcium changes by gap junctions is independent of electrical signals, the function of gap junctions between neocortical neurons is probably to synchronize biochemical rather than electrical activity.

Focal photolysis of caged glutamate produces long-term depression of hippocampal glutamate receptors.

Separating contributions of pre- and postsynaptic factors to the maintenance of long-term potentiation (LTP) and long-term depression (LTD) has been confounded by their experimental interdependence. To isolate the postsynaptic contribution, glutamate-receptor-mediated currents were elicited by localized photolysis of caged glutamate in small spots along the dendrites of CA1 hippocampal pyramidal cells. With synaptic transmission blocked, pairing depolarization of pyramidal cells with repeated photolysis of caged glutamate at one site markedly and persistently depressed subsequent responses to glutamate; responses at a second, unpaired site were unchanged. Like synaptically induced LTD at the CA3-CA1 synapse, this depression was site specific, NMDA-receptor dependent and blocked by protein-phosphatase inhibitors. Thus, robust, persistent alterations of postsynaptic glutamate receptor efficacy can occur without presynaptic neurotransmitter release.

Coordination of neuronal activity by gap junctions in the developing neocortex.

During embryonic development, gap junctions link cells into functional communication compartments characterized by a common development fate. Increasing evidence for gap junctions between immature neurons suggest that similar mechanisms may also be at work in the developing vertebrate brain, where gap junction-coupled neuronal assemblies often precede synaptically-linked functional networks. Recent experiments in the developing mammalian neocortex demonstrated the presence of gap-junction mediated second messenger waves, similar to those in non-neuronal cells. The primary function of neuronal gap junctions, therefore, might be to coordinate biochemical activity, rather than to act as purely electrical synapses. Thus, gap junctions may serve to amplify neuronal activity produced by weak synaptic stimulation.

Development of glycinergic and glutamatergic synaptic transmission in the auditory brainstem of perinatal rats.

In contrast to our knowledge about the anatomical development of the mammalian central auditory system, the development of its physiological properties is still poorly understood. In order to better understand the physiological properties of the developing mammalian auditory brainstem, we made intracellular recordings in brainstem slices from perinatal rats to examine synaptic transmission in the superior olivary complex, the first binaural station in the ascending auditory pathway. We concentrated on neurons in the lateral superior olive (LSO), which in adults, are excited from the ipsilateral side and inhibited from the contralateral side. Already at embryonic day (E) 18, when axon collaterals begin to invade the LSO anlage, synaptic potentials could be evoked from ipsilateral, as well as from contralateral inputs. Ipsilaterally elicited PSPs were always depolarizing, regardless of age. They had a positive reversal potential and could be completely blocked by the non-NMDA glutamate receptor antagonist CNQX. In contrast, contralaterally elicited PSPs were depolarizing from E18-P4, yet they turned into "adult-like," hyperpolarizing PSPs after P8. Their reversal potential shifted dramatically from -21.6 +/- 17.7 mV (E18-P0) to -73.0 +/- 7.1 mV (P10). Regardless of their polarity, contralaterally elicited PSPs were reversibly blocked by the glycine receptor antagonist strychnine. Bath application of glycine and its agonist beta-alanine further confirmed the transitory depolarizing action of glycine in the auditory brainstem. Since the transient excitatory behavior of glycine occurs during a period during which glycinergic synaptic connections in the LSO are refined by activity-dependent mechanisms, glycinergic excitation might be a mechanism by which synaptic rearrangement in the contralateral inhibitory pathway is accomplished.

Patterns of excitation and inhibition evoked by horizontal connections in visual cortex share a common relationship to orientation columns.

Combined optical imaging and electrophysiological techniques were used to assess directly the functional nature of long-range excitatory and inhibitory synaptic interactions between orientation columns in area 17 of ferret visual cortex. A significant correlation was found between the layout of iso-orientation columns and the pattern of evoked synaptic inputs between cortical sites: the largest-amplitude inhibitory and excitatory synaptic responses were evoked in single neurons when stimulation and recording electrodes were located in orientation columns sharing the same angle preference. Both excitatory and inhibitory synaptic responses decreased in amplitude when stimulation and recording electrodes were located in orientation columns with orthogonal angle preferences. Changing the stimulus intensity altered the balance of evoked excitation and inhibition without changing the columnar specificity of inputs. These results directly demonstrate that horizontal connections modulate both excitatory and inhibitory synaptic interactions between iso-orientation columns.

Development of electrical membrane properties and discharge characteristics of superior olivary complex neurons in fetal and postnatal rats.

Although hearing onset occurs relatively late during ontogeny of rats [around postnatal day (P) 12], anatomical brainstem connections are formed much earlier and are present before birth, indicating that a substantial amount of maturation occurs without acoustic input. Electrical activity is thought to influence neuronal development, but the physiological properties of auditory brainstem neurons during perinatal maturation are barely known. The present study focuses on the development of electrophysiological membrane properties of neurons in the rat's superior olivary complex (SOC), the first binaural station in the mammalian auditory brainstem. In in vitro slice preparations, intracellular recordings were obtained from 115 SOC cells from embryonic day (E) 18 to P17, and cells were morphologically identified by intracellular injection of biocytin or neurobiotin. By E18, i.e. 4 days before birth, SOC neurons were capable of generating Na(+)-dependent action potentials. Several passive and active membrane properties, including the resting potential, spike threshold and spike amplitude, did not change with development. In contrast, input resistance, time constant and spike duration decreased significantly, and maximal spike frequency increased significantly during the age period sampled. Our results show that rat SOC neurons display mature as well as immature electrical membrane properties during the same developmental period when anatomical connections are refined and when the soma-dendritic morphology develops. We conclude, therefore, that their membrane properties represent adequate physiological adaptations to the immature auditory brainstem microcircuits and that they form a basis upon which the development of these microcircuits is shaped.

Neuronal coupling and uncoupling in the developing nervous system.

Sensitive new tracers and imaging techniques have revealed that gap junction coupling during brain development is much more pronounced than previously believed. Recent results demonstrate that cell coupling can produce functional neuron assemblies characterized by synchronized fluctuations in the cytosolic Ca2+ concentration. Coupling is especially pronounced before and during the period of synapse formation and initial establishment of neuronal circuits. Thus, communication via gap junctions may generate coordinated electrical or biochemical activity before the onset of synaptic transmission, and thereby provide the outlines of functional architecture in the developing brain.