Safety, complications and clinical outcome after ultrasound-guided paravertebral catheter insertion for rib fracture analgesia: a single-centre retrospective observational study.

Rib fractures are associated with significant morbidity and mortality. Ultrasound-guided thoracic paravertebral catheter insertion has been described for the management of pain secondary to rib fractures. We conducted a retrospective observational study of all patients with rib fractures who had a paravertebral catheter inserted for analgesia provision over a 4-year period. Data from the Trauma Audit and Research Network were used to compare patients with rib fractures who were managed with paravertebral catheters to those managed with systemic analgesia. A total of 314 consecutive paravertebral catheters were inserted in 290 patients. Five (1.9%) catheters were removed due to ineffective analgesia. Other minor complications occurred in three cases (0.96%). The proportion of rib fracture patients managed with paravertebral catheters increased from 31/200 (15.5%) in the first year of study to 81/168 (48.2%) in the fourth; over this time-period the observed:predicted mortality ratio fell from 1.04 to 0.66. Proportional hazard regression with and without propensity score matching demonstrated a reduction in mortality associated with paravertebral catheter use, but this became statistically non-significant when time-dependent analysis was used. Paravertebral catheters are a safe and effective technique for rib fracture analgesia; however, our data were insufficient to demonstrate any improvement in mortality.

IgG antiendothelial cell autoantibodies from scleroderma patients induce leukocyte adhesion to human vascular endothelial cells in vitro. Induction of adhesion molecule expression and involvement of endothelium-derived cytokines.

IgG autoantibodies that bind human endothelial cells (AECA) were detected by ELISA in 30 of 42 samples of sera from patients with scleroderma. Pretreatment of human umbilical vein endothelial cells with AECA-positive scleroderma sera, or IgG purified from these sera, led to a dose- and time-dependent increase in the ability of the cells to bind human U937 monocytic cells. Threshold-active IgG concentrations were 1-10 micrograms/ml; effects were significant after 3 h and maximal after 6-12 h. IgG from AECA-negative sera or normal sera were without effect. Increased adhesion of U937 cells was accompanied by increased expression of endothelial intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and E-selectin. Transfer of endothelial cell-conditioned media after pretreatment with AECA and immunodepletion of IgG demonstrated the presence of transferable activity that mimicked the effects of AECA. Treatment with neutralizing anticytokine antibodies indicated that IL-1, generated by the endothelial cells in response to AECA, was involved in the upregulation of adhesion molecules and U937 cell adhesion. We conclude that AECA can play a pathogenic role in scleroderma by activating endothelial cells, in part due to autocrine or paracrine actions of IL-1.

Neutrophils in development of multiple organ failure in sepsis.

Multiple organ failure is a major threat to the survival of patients with sepsis and systemic inflammation. In the UK and in the USA, mortality rates are currently comparable with and projected to exceed those from myocardial infarction. The immune system combats microbial infections but, in severe sepsis, its untoward activity seems to contribute to organ dysfunction. In this Review we propose that an inappropriate activation and positioning of neutrophils within the microvasculature contributes to the pathological manifestations of multiple organ failure. We further suggest that targeting neutrophils and their interactions with blood vessel walls could be a worthwhile therapeutic strategy for sepsis.

Prostate-specific antigen testing of older men.

BACKGROUND: Elevated serum prostate-specific antigen (PSA) levels are predictive of a future diagnosis of prostate cancer. To test the hypothesis that older men with low PSA levels may require less intensive PSA testing because of a reduced prostate cancer detection rate, we evaluated the association between age, baseline PSA level, and prostate cancer detection. METHODS: We conducted a prospective cohort study among participants in a study of aging who had serial PSA measurements taken from age 60 or 65 years until they either were diagnosed with prostate cancer (cancer case subjects) or reached the age of 75 years (subjects without prostate cancer). The time of cancer detection among cancer case subjects was defined as the measurement date on which a PSA level above 4.0 ng/mL was detected (i.e., PSA conversion). Cancer case subjects and subjects without prostate cancer were analyzed according to baseline PSA level and age. RESULTS: All cancer case subjects in the 60-year-old cohort had baseline PSA levels above 0.5 ng/mL, and 14 of 15 cancer cases that would have been detected by a PSA conversion among the 65-year-old cohort were associated with baseline PSA levels of 1.1 ng/mL or more. If PSA testing were discontinued in men aged 65 years with PSA levels of 0.5 ng/mL or less, 100% (95% confidence interval [CI] = 78%-100%) of the cancers would still be detected by age 75 years; if PSA testing were discontinued in men aged 65 years who had PSA levels of 1.0 ng/mL or less, 94% (95% CI = 70%-100%) of the cancers would still be detected by age 75 years. CONCLUSIONS: These data suggest that a decrease in the intensity of screening among older men with low PSA values may not lead to an increase in undetected prostate cancer.

Estimation of prostatic growth using serial prostate-specific antigen measurements in men with and without prostate disease.

Prostate growth curves were estimated from serial prostate-specific antigen (PSA) measurements on frozen sera in three groups of men: (a) 16 men with no prostatic disease by urological history and examination; (b) 20 men with a histological diagnosis of benign prostatic hyperplasia (BPH) who had undergone simple prostatectomy; and (c) 18 men with a histological diagnosis of prostate cancer. The median number of repeated PSA measurements over an 8- to 26-yr period prior to histological diagnosis or exclusion of prostate disease was eight and 11 for noncancer and cancer subjects, respectively. Predicted rates of change in PSA (PSA velocity) were linear and curvilinear for control and BPH subjects, respectively. Subjects with cancer demonstrated both a linear and an exponential phase of PSA velocity. Based on time to double PSA, we estimated the epithelial doubling time for men without prostate disease to range from 54 +/- 13 yr at age 40 to 84 +/- 13 yr at age 70. For men with BPH, doubling times ranged from 2 +/- 13 yr at age 40 to 17 +/- 5 yr at age 85. Subjects with local/regional and advanced/metastatic cancer had similar PSA doubling times of 2.4 +/- 0.6 yr and 1.8 +/- 0.2 yr, respectively. These data are consistent with what is known about prostatic growth with age in men without prostate disease and BPH, and the kinetics of prostate cancer growth. Estimates of prostatic growth rate from changes in PSA may be useful clinically in management of men with prostate disease.

Cloning and base sequence analysis of a cDNA encoding mouse lung thioether S-methyltransferase.

Thioether S-methyltransferase catalyzes transfer of the methyl group from S-adenosylmethionine to X in compounds of the structure R-X-R', where X may be sulfur, selenium, or tellurium, and R and R' may be various organic groups. To obtain a cDNA clone of thioether S-methyltransferase, a mouse lung cDNA library in lambda gt11 was screened with a 99 base-pair probe obtained by performing the polymerase chain reaction on oligo(dT) primed, reverse transcribed, mouse lung RNA using two degenerate primers designed from partial amino-acid sequences of the enzyme. The entire coding and 3'-untranslated regions were obtained and sequenced. The predicted protein contains 264 amino-acid residues and has a calculated M(r) of 29,460. The amino-acid sequence of thioether S-methyltransferase contains three motifs characteristic of many methyltransferases and has a high level of identity with the amino-acid sequences of nicotinamide N-methyltransferase and phenylethanolamine N-methyltransferase. However, in spite of the fact that they are both mammalian cytosolic sulfur methyltransferases, the sequences of thioether S-methyltransferase and thiopurine S-methyltransferase share little identity.

Lysosomal hydrolases of human vascular cells: response to agonists of endothelial function.

Endothelial injury has been proposed as a feature of a wide variety of vascular diseases, and release of endothelial lysosomal hydrolases could contribute to the pathological changes seen. We have determined the relative activities of 14 glycosidases, two esterases and four peptide hydrolases in human umbilical vein endothelial cells and investigated whether known agonists of endothelial function, or materials known to modulate hydrolase secretion in other phagocytic cells, influenced the activity or secretion of these enzymes by human umbilical vein endothelial cells. Hexosaminidase, beta-galactosidase, beta-glucuronidase and alpha-iduronidase accounted for most of the measured glycosidase activity. Acid phosphatase activity greatly exceeded arylsulphatase activity, and most of the measured peptidase activity was due to acid peptidases. Optimum pH and apparent Km values were determined for the most abundant hydrolases. Exposure of human umbilical vein endothelial cells to bradykinin, thrombin or interleukin-1 resulted in negligible release of either hexosaminidase or lactate dehydrogenase (LDH), in contrast to phorbol myristate acetate, which caused a parallel, dose-dependent release of both enzymes. Treatment of these cells with calcium ionophore A23187, trypsin or platelet-activating factor, caused less than 10% release of either hexosaminidase or LDH. Agents known to modulate lysosomal enzyme secretion by other phagocytic cells failed to induce selective secretion of lysosomal enzymes by human umbilical vein endothelial cells.

Insulin-like effects of histones H3 and H4 on isolated rat adipocytes.

Crude preparations of histones had insulin-like actions in isolated adipocytes. This activity was attributed to the arginine-rich histones, H3 and H4. The metabolic effects of purified H3 and H4 on isolated adipocytes were similar to those of insulin in a number of respects. Like insulin, H3 and H4 stimulated the incorporation of both glucose and pyruvate in isolated cells and stimulated intercellular oxidation of glucose; in contrast, the lipolytic agents ACTH and isoproterenol actually inhibited the incorporation of pyruvate into adipocytes. In contrast to the effects of the lipolytic hormones, the effects of H3 and H4, like insulin, were not blocked by the presence of adenosine deaminase in the medium. The same concentrations of phenylarsine oxide were required to inhibit the stimulation of glucose incorporation whether by insulin or by histones. Furthermore, the addition of H4 or insulin to isolated adipocytes resulted in the increased phosphorylation of 17 kDa phosphoproteins as detected by two-dimensional electrophoresis. The insulin-like effect of the active histones was specific to their structure. Lysine-rich histones (H1, H2A and H2B), various polycations, and proteolytic fragments of purified H3 or H4 were all inactive. It is unknown whether this phenomenon might imply a physiological function for such endogenous molecules; however, a comparison of the detailed effects of insulin and histones might be informative in terms of common intracellular transduction systems.

P2 purinoceptors on vascular endothelial cells: physiological significance and transduction mechanisms.

The characterization of P2 gamma purinoceptors on vascular endothelial cells has progressed rapidly since their existence was first demonstrated in 1983. They transduce the actions of extracellular ATP and ADP--endothelium-dependent relaxation, prostacyclin synthesis, endothelial cell mitogenesis--which play a vital role in the interaction between platelets (a rich source of extracellular adenine nucleotides) and the vessel wall. Release of prostacyclin limits the extent of intravascular platelet aggregation following vascular damage and platelet stimulation, while the mitogenic effect may accelerate the repair of a lesion. P2 gamma receptors on endothelial cells are coupled to a phospholipase C by a GTP-binding protein. Jean-Marie Boeynaems and Jeremy Pearson explain how the increases in cytoplasmic Ca2+ and diacylglycerol resulting from this initial event mediate several further effects. In particular, activation of a Ca2(+)-sensitive phospholipase A2 explains the increased synthesis of prostacyclin, while the phosphorylation of several proteins by calmodulin-dependent kinases modulates other endothelial cell functions.

Equilibrative nucleoside transporter 2 is expressed in human umbilical vein endothelium, but is not involved in the inhibition of adenosine transport induced by hyperglycaemia.

Human equilibrative, Na(+)-independent nucleoside transport is mediated by membrane proteins sensitive (system es, hENT1) or insensitive (system ei, hENT2) to nitrobenzylthioinosine (NBMPR). Gestational diabetes and elevated extracellular concentrations of D-glucose reduce adenosine transport in human umbilical vein endothelium (HUVEC). We studied hENT2 and hENT1 expression in HUVEC, and the effect of D-glucose on their activity and expression in HUVEC preincubated with 25 mM D-glucose (24 h). hENT2 and hENT1 mRNA were quantified by real-time reverse transcription polymerase chain reaction, and their proteins were detected by Western blotting. hENT2 and hENT1 proteins are co-expressed in HUVEC and are located at the plasma membrane, however, hENT2 was mainly cytoplasmatic and perinuclear in location. D-Glucose reduced hENT1 and hENT2 mRNA expression, but only hENT1 protein abundance at the plasma membrane. Adenosine transport was inhibited by D-glucose and NMBPR (1 microM) in intact cells and membrane vesicles. Hypoxanthine inhibited adenosine transport in the absence or in the presence of 1 microM NBMPR. D-Glucose reduced NBMPR maximal binding in intact cells, membrane vesicles, and plasma membrane fractions. In conclusion, the present study demonstrates that hENT2 and hENT1 are co-expressed in HUVEC, and even when adenosine transport is also mediated by hENT2, the hENT2-mediated transport activity is not involved in the d-glucose-induced down-regulation of total adenosine transport.

Cross-linking of brain endothelial intercellular adhesion molecule (ICAM)-1 induces association of ICAM-1 with detergent-insoluble cytoskeletal fraction.

Intercellular adhesion molecule (ICAM)-1 plays a vital role in the process of leukocyte transmigration through endothelial cell (EC) barriers and has been shown to mediate signal transduction events in ECs induced either by its cross-linking or by the binding of T lymphocytes. Immunoblotting of ICAM-1 of Triton X-100 detergent fractions demonstrated that the majority of ICAM-1 was contained within the detergent-soluble fraction (noncytoskeletal associated) under basal conditions. After cross-linking of endothelial ICAM-1 with monoclonal antibody or coculture with T lymphocytes, EC ICAM-1 was observed to partition with a Triton X-100-insoluble (cytoskeletal associated) fraction in a dose- and time-dependent manner. Redistribution of ICAM-1 was specific, inasmuch as no association with the Triton X-100-insoluble fraction was observed after cross-linking of vascular cell adhesion molecule-1, nor did cross-linking of ICAM-1 result in a redistribution of the platelet and EC adhesion molecule. ICAM-1 association with the endothelial cytoskeleton after cross-linking was unaffected after treatment of the cells with cytochalasin D, C3-transferase, removal of extracellular calcium ions, or chelation of intracellular calcium ions. These data show that ICAM-1 colocalizes with the endothelial cytoskeleton and associates with a detergent-insoluble fraction after cross-linking.

Scleroderma fibroblasts show increased responsiveness to endothelial cell-derived IL-1 and bFGF.

Fibroblasts cultured from lesional skin in scleroderma (systemic sclerosis) demonstrate an activated phenotype that may be important in pathogenesis. Endothelial cell-derived cytokines can modulate fibroblast properties, and endothelial cell changes occur early in scleroderma. Thus, endothelial cell and fibroblast dysfunction may be linked through the paracrine activity of soluble endothelial cell products. We have explored endothelial cell-fibroblast interactions in vitro by investigating the modulation of scleroderma and control fibroblast properties by endothelial cell-conditioned medium (EC-CM). EC-CM caused a concentration-dependent stimulation of fibroblast DNA and protein synthesis and upregulation of cell surface ICAM-1 expression. Scleroderma fibroblasts showed consistently greater responses than control cells. Medium conditioned by mechanically wounded endothelial cells had a greater effect than that from resting endothelial cells. Pre-incubation of EC-CM with anti-bFGF significantly reduced the promotion of fibroblast thymidine incorporation but did not affect endothelial cell-induced leucine incorporation. Conversely, anti-IL-1 antibodies abrogated EC-CM-induced leucine incorporation and ICAM-1 expression but did not diminish thymidine incorporation. Recombinant bFGF or IL-1 modulated fibroblast properties similarly. These data demonstrate that endothelial cell-derived IL-1 and bFGF modulate fibroblast properties independently and that lesional scleroderma strains are more responsive than control fibroblasts to endothelial cell-induced modulation, which supports the hypothesis that altered endothelial cell-fibroblast communication may be involved in the pathogenesis of scleroderma.

Fibroblast matrix gene expression and connective tissue remodeling: role of endothelin-1.

This study examines endothelin-induced modulation of extracellular matrix synthesis and remodeling by fibroblasts, and its potential role in the pathogenesis of systemic sclerosis (scleroderma). Endothelin-1 promoted fibroblast synthesis of collagen types I and III, but not fibronectin, by a mechanism dependent upon both ETA and ETB receptors. Conversely, endothelin-1 inhibited both protein expression of matrix metalloproteinase 1 and zymographic activity exclusively via ETA receptors. A dual regulatory role for endothelin-1 in transcriptional regulation was suggested by the ability of endothelin-1 to enhance steady-state levels of collagen mRNA and activate the proalpha2(I) collagen (Col1a2) promoter, but in contrast to reduce matrix metalloproteinase 1 transcript expression and suppress transcription of a human matrix metalloproteinase 1 promoter reporter construct in transient transfection assays. Although endothelin-1 significantly enhanced remodeling of three-dimensional collagen lattices populated by normal fibroblasts, this was not observed for lattices populated by systemic sclerosis fibroblasts. Promotion of matrix remodeling was dependent upon ETA receptor expression and was blocked by specific inhibitors of tyrosine kinases or protein kinase C. Reverse transcriptase polymerase chain reaction, S1 nuclease, and functional cell surface binding studies showed that normal and systemic sclerosis fibroblasts express both ETA and ETB receptors (predominantly ETA), but that ETA receptor mRNA levels and ETA binding sites on fibroblasts cultured from systemic sclerosis skin biopsies are reduced by almost 50%. Endothelin-1 is thus able to induce a fibrogenic phenotype in normal fibroblasts that is similar to that of lesional systemic sclerosis fibroblasts. Moreover, reduced responsiveness to exogenous endothelin-1 in systemic sclerosis suggests that downstream pathways may have already been activated in vivo. These data further implicate dysregulated endothelin-receptor pathways in fibroblasts in the pathogenesis of connective tissue fibrosis.

Vascular endothelium: a potential role in HIV infection and the pathogenesis of Kaposi's sarcoma: observations and speculations.

Kaposi's sarcoma (KS) has become a source of interest in recent years primarily for its strong association with the acquired immune deficiency syndrome (AIDS). Endothelial cells (EC) are central to inflammation and can regulate coagulation and leucocyte emigration and may be central to the development of the disease. As they are also capable of being infected by HIV in vivo, this infection may contribute to the immunosuppressive effects of HIV seen in AIDS. Recent work has shed new light on the mechanisms involved in EC proliferation. The aim of this article is to review such evidence implicating EC in the development of KS. Additionally, hypotheses will be put forward to explain the mechanism of the vascular proliferation in KS and the possible role of EC in HIV infection. There is therefore enormous potential for the therapeutic targeting of endothelium to control these diseases.

Exogenous ATP raises cytoplasmic free calcium in fura-2 loaded piglet aortic endothelial cells.

Cultured piglet endothelial cells were grown to confluence on glass coverslips and loaded with the fluorescent Ca2+ indicator, fura-2. Using a dual-wavelength excitation fluorescence spectrophotometer it was found that ATP caused a rapid transient elevation in [Ca2+]i in the presence of extracellular calcium which decreased to a maintained elevated level. With no extracellular calcium ATP evoked a similar transient increase which returned to the basal level. Addition of 50 mM K+ had no effect on [Ca2+]i or on the effect of ATP on [Ca2+]i in the presence of extracellular Ca2+. The data suggest that ATP causes both discharge of calcium from an intracellular pool and influx across the plasma membrane although this is unlikely to be via a voltage-operated channel. ATP stimulated simultaneously the production of PGI2 to a similar extent in the presence or absence of extracellular calcium. Elevated [Ca2+]i may be an important activation pathway in the endothelial cell.

Characterization of a novel zinc binding site of protein kinase C inhibitor-1.

The zinc-binding properties of an endogenous protein inhibitor of protein kinase C was studied. Equilibrium gel penetration revealed that 1 mol of this protein binds 0.97 mol of zinc with a dissociation constant of 4.3 microM. The site of zinc-binding, MVVNEGSDGGQSVYHVHLHVLGGR, was identified by a multi-step process consisting of tryptic digestion, fragment isolation, transfer to nitrocellulose, and hybridization with 65ZnCl2. Binding of 65ZnCl2 to selected synthetic fragments further localized the site of interaction to the sequence QSVYHVHLHVL. This region contains 3 closely positioned histidine residues and represents a novel zinc-binding site.

Inhibition of MAP kinase kinase (MEK) blocks endothelial PGI2 release but has no effect on von Willebrand factor secretion or E-selectin expression.

We have examined the potential role of MAP kinase in the regulation of endothelial cell PG12 synthesis, vWF secretion and E-selectin expression using the specific MEK inhibitor PD98059. PD98059 dose-dependently attenuated the tyrosine phosphorylation and activation of p42 mapk in response to thrombin or inflammatory cytokines. Inhibition of thrombin-induced p42 mapk activation was paralleled by an inhibitory effect of PD98059 on thrombin-driven PG12 generation but not on vWF secretion or IL-1 alpha/TNF alpha-induced E-selectin expression. These results provide evidence for a key role for p42 mapk in the acute regulation of PG12 synthesis in human endothelial cells and suggest that activation of the MAP kinase cascade is not obligatory for cytokine-stimulated E-selectin expression.

A sensitive fluorometric assay for measuring xanthine dehydrogenase and oxidase in tissues.

The conversion of xanthine dehydrogenase to a free radical producing oxidase is an important component of oxygen-mediated tissue injury. Current assays for these enzymes are of limited sensitivity, making it difficult to analyze activities in organ biopsies or cultured cells. The xanthine oxidase-catalyzed conversion of pterin (2-amino-4-hydroxypteridine) to isoxanthopterin provides the basis for a fluorometric assay which is 100-500 times more sensitive than the traditional spectrophotometric assay of urate formation from xanthine. Enzyme activity as low as 0.1 pmol min-1 ml-1 can be measured with the fluorometric pterin assay. Xanthine oxidase is assayed in the presence of pterin only, while combined xanthine dehydrogenase plus oxidase activity is determined with methylene blue which replaces NAD+ as an electron acceptor. The relative proportions and specific activities of xanthine oxidase and dehydrogenase determined by the fluorometric pterin assay are comparable with the spectrophotometric measurement of activities present in rat liver, intestine, kidney, and plasma. The assay has been successfully applied to brain, human kidney, and cultured mammalian cells, where xanthine dehydrogenase and oxidase activities are too low to detect spectrophotometrically.

Induction of the antioxidant stress proteins heme oxygenase-1 and MSP23 by stress agents and oxidised LDL in cultured vascular smooth muscle cells.

Enhanced expression of the antioxidant stress proteins heme oxygenase-1 (HO-1) and macrophage stress protein (MSP23) by oxidative stress agents and oxidatively modified low density lipoproteins (LDL) was investigated in cultured porcine aortic smooth muscle cells. Treatment of smooth muscle cells with glucose oxidase, CdCl2 or diethylmaleate resulted in a time-dependent (6-48 h) induction of HO-1 and MSP23 expression. Exposure of cells to 100 micrograms protein/ml highly oxidised LDL increased the expression of HO-1 and MSP23 within 24 h, and the induction was dependent on the degree of LDL oxidation. The induction of HO-1 and MSP23 may thus play an important cytoprotective role against oxidative stress in atherogenesis.

Functional relevance of antiemetic control. Experience using the FLIE questionnaire in a randomised study of the NK-1 antagonist aprepitant.

Little information exists on the functional impact of effective antiemetic protection. In the present study, the Functional Living Index-Emesis (FLIE), was used to assess patient-reported impact of chemotherapy-induced nausea and vomiting (CINV) after administration of a new NK-1 receptor antagonist (aprepitant). Cisplatin-treated patients in a double-blind randomised trial received either aprepitant+dexamethasone+ondansetron on day 1 and aprepitant+dexamethasone on days 2-5 or standard antiemetic therapy (dexamethasone and ondansetron on day 1 and dexamethasone on days 2-5). Emetic events, nausea ratings and rescue medications were recorded in a 5-day diary and the FLIE was completed on day 6. Compared with standard therapy, significantly more patients treated with the high dose aprepitant regimen achieved a Complete Response (71 vs 44%, P<0.001) and also reported no impact on daily life as indicated by the FLIE total score (84 vs 66%, P<0.01). Use of the FLIE demonstrated that improved control of emesis was highly effective in reducing the impact of CINV on patients' daily lives.