Evaluating the effects of hypoxic storage on platelet function and health using a novel storage system.

BACKGROUND: Thousands of units of whole blood (WB) and blood components are transfused daily to treat trauma patients. Improved methods for blood storage are critical to support trauma-related care. The Hemanext ONE® system offers a unique method for hypoxic storage of WB, with successfully demonstrated storage of clinically viable RBCs. This work evaluated the system for the storage of WB, focusing on platelet health and function. STUDY DESIGN AND METHODS: WB was collected from healthy donors and processed through the Hemanext ONE® system. Hemoglobin oxygen saturation (HbSO2) levels of WB were depleted to 10%, 20%, or 30% of total HbSO2 and then stored in PVC bags sealed in oxygen-impermeable bags (except for normoxic control) with samples collected on days 1, 7, and 14 post-processing. Flow cytometry assessed the activation and apoptosis of platelets. Clot dynamics were assessed based on aggregometry and thromboelastography assays, as well as thrombin generation using a calibrated-automated thrombogram method. RESULTS: Hypoxic storage conditions were maintained throughout the storage period. Hypoxia triggered increased lactate production, but pH changes were negligible compared to normoxic control. Storage at 10% HbSO2 had a significant impact on platelet function, resulting in increased activation and reduced clot formation and aggregation. These effects were less significant at 20% and 30% HbSO2. DISCUSSION: This study indicates that platelets are sensitive to hypoxic storage and suffer significant metabolic and functional deterioration when stored at or below 10% HbSO2.

Cold-stored platelets: A product with function optimized for hemorrhage control.

Early administration of blood products following severe trauma is pivotal for establishing hemostasis and achieving successful outcomes. Platelet transfusions, in particular, provide rapid control of hemostasis and help to restore platelet dysfunction induced by trauma. In the U.S. platelets used for therapeutic purposes are stored at room temperature with a limited shelf life of 5-7 days. Issues with room temperature storage of platelets, including an increased risk of bacterial growth and a decline in platelet hemostatic function, have led to a resurgence in interest in cold-stored platelets for therapeutic transfusion. This review presents the current state of cold-stored platelets and cold-stored whole blood as treatment for actively bleeding patients. Usage of cold stored platelets in alternative areas, such as in the field of regenerative medicine, is also discussed.

Impact of prescription drugs on second fragility fractures among US Medicare patients.

Drugs that increase the risk of fracture are commonly prescribed to survivors of a fragility fracture. This study shows that starting new high-risk medications after fracture increases the risk of a second, potentially preventable fracture. For most drug classes, however, it is safe to continue medications taken before the fracture. INTRODUCTION: Most patients who survive a fragility fracture are subsequently exposed to prescription drugs that have been linked to increased fracture risk. This study was designed to quantify the extent to which current prescribing practices result in potentially preventable second fractures. METHODS: We analyzed a cohort of 138,526 Medicare beneficiaries who returned to the community after a fragility fracture. Post-fracture drug use was defined using retail pharmacy fills. The risk of second fracture associated with individual drug classes was analyzed using Cox proportional hazard models. Data were further analyzed to determine whether there is a difference in risk between continuing previous therapy and initiating new therapy after fracture. RESULTS: Many drug classes previously identified as increasing fracture risk were not associated with increased fracture risk in this cohort. Discontinuing therapy at the time of fracture was only beneficial for patients taking selective serotonin reuptake inhibitors; however, initiating therapy in previous non-users increased second fracture risk for five classes of drugs (selective serotonin reuptake inhibitors, tricyclic antidepressants, antipsychotics, proton pump inhibitors, and non-benzodiazepine hypnotics). CONCLUSION: Discontinuing high-risk drugs after fracture was not generally protective against subsequent fractures. Preventing the addition of new medications may result in greater improvements in post-fracture care.

Second fractures among older adults in the year following hip, shoulder, or wrist fracture.

UNLABELLED: We report on second fracture occurrence in the year following a hip, shoulder or wrist fracture using insurance claims. Among 273,330 people, 4.3 % had a second fracture; risk did not differ by first fracture type. Estimated adjusted second fracture probabilities may facilitate population-based evaluation of secondary fracture prevention strategies. INTRODUCTION: The purpose of this study was estimate second fracture risk for the older US population in the year following a hip, shoulder, or wrist fracture. METHODS: Observational cohort study of Medicare fee-for-service beneficiaries with an index hip, shoulder, or wrist fragility fracture in 2009. Time-to-event analyses using Cox proportional hazards models to characterize the relationship between index fracture type (hip, shoulder, wrist) and patient factors (age, gender, and comorbidity) on second fracture risk in the year following the index fracture. RESULTS: Among 273,330 individuals with fracture, 11,885 (4.3 %) sustained a second hip, shoulder or wrist fracture within one year. Hip fracture was most common, regardless of the index fracture type. Comparing adjusted second fracture risks across index fracture types reveals that the magnitude of second fracture risk within each age-comorbidity group is similar regardless of the index fracture. Men and women face similar risks with frequently overlapping confidence intervals, except among women aged 85 years or older who are at greater risk. CONCLUSIONS: Regardless of index fracture type, second fractures are common in the year following hip, shoulder or wrist fracture. Secondary fracture prevention strategies that take a population perspective should be informed by these estimates which take competing mortality risks into account.

Impact of obesity on disability, function, and physical activity: data from the Osteoarthritis Initiative.

OBJECTIVES: Older adults with obesity are at risk for osteoarthritis (OA) and are predisposed to functional decline and disability. We examined the association between obesity and disability, physical activity, and quality of life at 6 years. METHOD: Using data from the longitudinal Osteoarthritis Initiative (OAI), we analysed older adults (age ≥ 60 years) with a body mass index (BMI) at baseline ≥ 18.5 kg/m(2) (n = 2378) using standard BMI categories. Outcomes were assessed at the 6-year follow-up and included: the Late-Life Function and Disability Index (LLDI), the 12-item Short Form Health Survey (SF-12), and the Physical Activity Scale for the Elderly (PASE). Linear regression predicted outcomes based on BMI category, adjusting for age, sex, race, education, smoking, cohort status, radiographic knee OA, co-morbidity scores, and baseline scores when available. RESULTS: Follow-up data were available for 1727 (71.9%) participants (mean age 67.9 ± 5.3 years; 61.6% female). At baseline, obese subjects compared to overweight and normal were on a greater number of medications (4.28 vs. 3.63 vs. 3.32), had lower gait speeds (1.22 vs. 1.32 vs. 1.36 m/s), higher Charlson scores (0.59 vs. 0.37 vs. 0.30), and higher Western Ontario and McMaster University OA Index (WOMAC) scores (right: 14.8 vs. 10.3 vs. 7.5; left: 14.4 vs. 9.9 vs. 7.5). SF-12 scores at 6 years were lower in obese patients than in overweight or normal [99.5 (95% CI 98.7-100.4) vs. 101.1 (95% CI 100.4-101.8) vs. 102.8 (95% CI 101.8-103.8)], as were PASE scores [115.1 (95% CI 110.3-119.8) vs. 126.2 (95% CI 122.2-130.2) vs. 131.4 (95% CI 125.8-137.0)]. The LLDI limitation component demonstrated differences in obese compared to overweight or normal [78.6 (95% CI 77.4-79.9) vs. 81.2 (95% CI 80.2-82.3) vs. 82.5 (95% CI 81.1-84.0)]. CONCLUSIONS: Obesity was associated with worse physical activity scores, lower quality of life, and higher risk of 6-year disability.

High fever following postpartum administration of sublingual misoprostol.

OBJECTIVE: To explore what triggers an elevated body temperature of > or =40.0 degrees C in some women given misoprostol, a prostaglandin E1 analogue, for postpartum haemorrhage (PPH). DESIGN: Post hoc analysis. SETTING: One tertiary-level hospital in Quito, Ecuador. POPULATION: A cohort of 58 women with a fever of above 40 degrees C following treatment with sublingual misoprostol (800 micrograms) for PPH. METHODS: Side effects were documented for 163 Ecuadorian women given sublingual misoprostol to treat their PPH. Women's body temperatures were measured, and if they had a fever of > or =40.0 degrees C, measurements were taken hourly until the fever subsided. Temperature trends were analysed, and the possible physiological mechanisms by which postpartum misoprostol produces a high fever were explored. MAIN OUTCOME MEASURES: The onset, duration, peak temperatures, and treatments administered for cases with a high fever. RESULTS: Fifty-eight of 163 women (35.6%) treated with misoprostol experienced a fever of > or =40.0 degrees C. High fevers followed a predictable pattern, often preceded by moderate/severe shivering within 20 minutes of treatment. Body temperatures peaked 1-2 hours post-treatment, and gradually declined over 3 hours. Fevers were transient and did not lead to any hospitalisation. Baseline characteristics were comparable among women who did and did not develop a high fever, except for known previous PPH and time to placental expulsion. CONCLUSIONS: An unexpectedly high rate of elevated body temperature of > or =40.0 degrees C was documented in Ecuador following sublingually administered misoprostol. It is unclear why temperatures > or =40.0 degrees C occurred with a greater frequency in Ecuador than in other study populations using similar treatment regimens for PPH. Pharmacogenetic studies may shed further light on variations in individuals' responses to misoprostol.

Characterization of adenosine-induced cytostasis in melanoma cells.

Relative to lymphoid cells and normal fibroblasts, mouse melanoma cells (B16) were moderately sensitive to adenosine, with 80% growth inhibition being observed at 50 micro M adenosine instead of at 5 micro M as was reported with lymphoid cells or 400 micro M as was reported for normal fibroblasts. These differences were not due to adenosine deaminase because lymphoid cells had two to four times more of this activity than did melanoma cells or normal fibroblasts. In melanoma cells, complete adenosine-induced growth inhibition was a gradual process which was observed only after one to two population doublings; after 4 days of treatment, complete recovery was gradual requiring 48 hr. N6,O2-Dibutyryladenosine-cyclic-3':5' phosphate and polyadenylic acid were ineffective as growth inhibitors, whereas guanosine exhibited potent growth-inhibiting properties. Homocysteine thiolactone enhanced the cytotoxicity of adenosine but not guanosine; adenosine relieved the cytotoxicity of guanosine. These observations indicated that the two purine nucleosides were exerting their growth-inhibiting effects by different mechanisms. Uridine did not relieve adenosine-induced cytostasis, but at 50 micro M adenosine enhanced the incorporation of [3H]uridine into RNA. This suggested that the uridine phosphate pools were depleted at low adenosine concentrations and that exogenous adenosine influences the availability of pyrimidines.

Chromatin-associated RNA: differential extraction and characterization.

Mammalian cells in different states of cytodifferentiation exhibited different RNA-synthesizing and processing patterns that could be used as markers for phenotypic variability. Inherent in these patterns was an RNA class which was differentially extracted from the cellular homogenate by elevating the temperature and pH of the buffer used in the phenol procedure. This class of RNA was initially designated fraction B (chromatin-associated RNA). In the characterization of fraction B, human myeloma cells labeled for 3 and 24 h were fractionated into subcytoplasmic and subnuclear components and the [3H]-RNA was differentially extracted. After 3 and 24 h labeling 84% and 73%, respectively, of the labeled RNA in the chromatin was extracted in fraction B. Only 10-20% of the polysomal RNA was extracted in fraction B with little enrichment in poly(A) RNA. These and other observations suggested that fraction B was a subpopulation of heterogeneous nuclear RNA which was tightly bound to the chromatin complex.

Monoclonal antibody specific for the T-tubule of skeletal muscle.

Monoclonal antibodies were raised against a triad-enriched (sarcoplasmic reticulum-T-tubule complex) microsomal membrane fraction of rabbit skeletal muscle. The avidin-biotin complex (ABC) immunoperoxidase staining method was used to screen hybrid colonies. Positive antibodies exhibited a granular doublet pattern at the A-I junction, consistent with the location of triads in rabbit muscle. One monoclonal antibody, M171, was further characterized by ultrastructural and immunoadsorption techniques. Postembedding electron immunocytochemistry was performed on tissue sections embedded in Lowicryl K4M. Goat anti-mouse immunoglobulin absorbed to 10 nm colloidal gold particles was used as an ultrastructural label. In these studies, M171 recognized an epitope at the triads and at periodic openings along the plasmalemma. Immunoadsorption on protein transfers of isolated sarcoplasmic reticulum, surface membrane (plasmalemma and T-tubule), and triad-enriched fractions showed that M171 reacts with a surface membrane component. Taken together, these studies suggest that M171 recognizes an epitope associated with the T-tubule at the triad and at the "mouth" of the T-system at the plasmalemma.

Prospective evaluation of clinical criteria to select older persons with acute medical illness for care in a hypothetical home hospital.

OBJECTIVE: To evaluate criteria to select older persons who need hospitalization for common acute medical illnesses for care in a hypothetical home hospital. DESIGN: Prospective record review. SETTING AND PARTICIPANTS: Patients aged 65 and older admitted to the general medical service of a community-based university hospital. MEASUREMENTS: We developed illness-specific selection criteria to identify older persons with certain acute medical conditions for treatment in a hypothetical home hospital. The selection criteria were reviewed prospectively against all community-dwelling older patients admitted to the general medical service of a community-based university hospital over a 2-month period. We determined eligibility for home hospital admission based on information available at the time of admission and then tracked the patient's hospital course. RESULTS: One hundred fifty-seven admissions of 143 patients were reviewed. The selection criteria identified 33% of patients admitted to the acute hospital with one of the three target diagnoses as eligible for a home hospital model of care had it been available. Eligible patients experienced shorter lengths of stay (3.7 vs 5.4 days, P = .012), fewer mean number of procedures performed (0.98 vs 1.70, P = .001), fewer mean number of complications (0.17 vs 0.56, P = .010), and fewer events that could be handled only in the acute hospital setting (P = .036). In addition, in logistic regression analysis, three criteria for home hospital ineligibility, pulmonary congestion associated with ischemic chest pain (odds ratio 6.85, 95% CI 2.64, 17.81), the presence of an acute coexisting illness requiring hospitalization independent of the target conditions (odds ratio 2.66, 95% CI 1.11, 6.41), and significant pulmonary congestion after initial treatment (odds ratio 14.4, 95% CI 1.77, 117.41) were significantly associated with items difficult to accomplish at home. CONCLUSIONS: Criteria can be delineated that identify older persons with acute medical illnesses who may be suitable for treatment in a home hospital.

Immunobiology of primary intracranial tumors. Part 7: Active immunization of patients with anaplastic human glioma cells: a pilot study.

Twenty patients with malignant gliomas were selected for active immunization within 4 weeks following surgery. Each patient had a Karnofsky Functional Rating equal to or greater than 70, a peripheral blood lymphocyte count equal to or greater than 1000 cells/cu mm, skin test responses to one or more of four recall antigens, peripheral blood T-cells equal to or greater than half that of control, and was not receiving steroid therapy at the time of entry into the study. Each patient received subcutaneous inoculations with one of two human glioma tissue culture cell lines (D-54MG or U-251MG) monthly, with 500 micrograms of bacillus Calmette-Guérin cell wall (BCG-CW) being included with the first inoculation. Each patient also received levamisole, 2.5 mg/kg 3 days per week every other week. Radiotherapy and chemotherapy with BCNU were begun after the first month of immunization. Follow-up evaluations included computerized tomography brain scans, neurological examinations, Karnofsky Functional Ratings, and studies of general immune competence. No evidence of allergic encephalomyelitis was noted clinically, nor was any gross or microscopic evidence of such pathology obtained upon autopsy of three of these patients. Serial studies of general immune competence showed no alterations from those previously described with non-immunized patients. Patients who were inoculated with the U-251MG cell line have had a longer survival time compared to those inoculated with the D-54MG cell line (p less than 0.0590) or compared to 58 historical cases of glioma patients treated with levamisole, radiation therapy, and chemotherapy alone (p less than 0.02).

Generation of murine monoclonal antihuman milk fat globule membrane antibodies using immunoprecipitation and BIAcore analyses.

A selection of monoclonal antibodies was developed against deoxycholine-solubilized human milk fat globule membranes (HMFG). The antibodies were selected for their ability to immunoprecipitate 125I-labeled HMFG and then further analyzed by surface plasmon resonance on the BIAcore for their reactivity with HMFG and with a fusion protein containing a 4-mer of the muc-1 tandem repeat. Both the HMFG and the fusion protein proved to be robust surfaces for the analysis of crude supernatants. The BIAcore evaluation was useful in identifying true positives. BIAcore analyses of purified antibody preparations were used to determine binding characteristics such as affinity and intensity. The latter proved useful in selecting a panel for evaluation by immunohistochemistry for breast tissue reactivity. Four of 6 antibodies appeared to react more intensely with tumor compared with normal breast tissues. One of those antibodies reacted with the fusion protein 4-mer of the muc-1 tandem repeat.

Development of class-switched, affinity-matured monoclonal antibodies following a 7-day immunization schedule.

Previously we reported making high-affinity monoclonal antibodies (MAbs) 13 days after the onset of Repetitive Immunizations Multiple Sites (RIMMS) strategy. The Ig subclass variety and affinity of these antibodies suggested that maturational processes had already begun within draining lymph nodes. We now demonstrate that this diversity can in fact be captured as early as Day 7. In the work reported here, somatic fusion of immune lymphocytes isolated from peripheral lymph nodes resulted in the isolation of affinity-matured MAbs reactive with cytosine deaminase. This model further demonstrates and substantiates at a cellular level the rapid development and maturation of T-cell-dependent B-cell responses occurring within draining lymph nodes following antigen challenge.

Combining medical information with a business data system.

The School of Primary Medical Care at the University of Alabama in Huntsville is presently developing and implementing a computerized clinical data system that incorporates data from the Family Practice Center and the community hospital. The system can be used for the problem-oriented medical record, business and billing, the teaching program, community medicine research, and the evaluation of medical students and family practice residents. This paper discusses plans for the total system and the present degree of implementation.