A SOLUBLE ANTIGEN OF LYMPHOCYTIC CHORIOMENINGITIS : II. CHARACTERISTICS OF THE ANTIGEN AND ITS USE IN PRECIPITIN REACTIONS

The soluble antigen of lymphocytic choriomeningitis which is readily separable from the virus is a relatively stable substance and appears to be of a protein nature. A specific precipitin reaction can be demonstrated when immune serum is added to solutions of antigen which have been freed of certain serologically inactive substances. The complement-fixation and precipitation reactions which occur in the presence of immune serum and non-infectious extracts of splenic tissue obtained from guinea pigs moribund with lymphocytic choriomeningitis seem to be manifestations of union of the same soluble antigen and its antibody. On the other hand, the antisoluble substance antibodies and neutralizing substances appear to be different entities.

JNJ-28312141, a novel orally active colony-stimulating factor-1 receptor/FMS-related receptor tyrosine kinase-3 receptor tyrosine kinase inhibitor with potential utility in solid tumors, bone metastases, and acute myeloid leukemia

There is increasing evidence that tumor-associated macrophages promote the malignancy of some cancers. Colony-stimulating factor-1 (CSF-1) is expressed by many tumors and is a growth factor for macrophages and mediates osteoclast differentiation. Herein, we report the efficacy of a novel orally active CSF-1 receptor (CSF-1R) kinase inhibitor, JNJ-28312141, in proof of concept studies of solid tumor growth and tumor-induced bone erosion. H460 lung adenocarcinoma cells did not express CSF-1R and were not growth inhibited by JNJ-28312141 in vitro. Nevertheless, daily p.o. administration of JNJ-28312141 caused dose-dependent suppression of H460 tumor growth in nude mice that correlated with marked reductions in F4/80(+) tumor-associated macrophages and with increased plasma CSF-1, a possible biomarker of CSF-1R inhibition. Furthermore, the tumor microvasculature was reduced in JNJ-28312141-treated mice, consistent with a role for macrophages in tumor angiogenesis. In separate studies, JNJ-28312141 was compared with zoledronate in a model in which MRMT-1 mammary carcinoma cells inoculated into the tibias of rats led to severe cortical and trabecular bone lesions. Both agents reduced tumor growth and preserved bone. However, JNJ-28312141 reduced the number of tumor-associated osteoclasts superior to zoledronate. JNJ-28312141 exhibited additional activity against FMS-related receptor tyrosine kinase-3 (FLT3). To more fully define the therapeutic potential of this new agent, JNJ-28312141 was evaluated in a FLT3-dependent acute myeloid leukemia tumor xenograft model and caused tumor regression. In summary, this novel CSF-1R/FLT3 inhibitor represents a new agent with potential therapeutic activity in acute myeloid leukemia and in settings where CSF-1-dependent macrophages and osteoclasts contribute to tumor growth and skeletal events.

Adenosine signalling at immature parallel fibre-Purkinje cell synapses in rat cerebellum

The purine adenosine is an extracellular signalling molecule involved in a large number of physiological and pathological conditions throughout the mammalian brain. However little is known about how adenosine release and its subsequent clearance change during brain development. We have combined electrophysiology and microelectrode biosensor measurements to investigate the properties of adenosine signalling at early stages of cerebellar development, when parallel fibre-Purkinje cell synapses have recently been formed (postnatal days 9-12). At this stage of development, we could detect little or no inhibitory A(1) receptor tone in basal conditions and during trains of stimuli. Addition of pharmacological agents, to inhibit adenosine clearance, had only minor effects on synaptic transmission suggesting that under basal conditions, the concentration of adenosine moving in and out of the extracellular space is small. Active adenosine release was stimulated with hypoxia and trains of electrical stimuli. Although hypoxia released significant concentrations of adenosine, the release was delayed and slow. No adenosine release could be detected following electrical stimulation in the molecular layer. In conclusion, at this stage of development, although adenosine receptors and the mechanisms of adenosine clearance are present there is very little adenosine release.

The novel NTPDase inhibitor sodium polyoxotungstate (POM-1) inhibits ATP breakdown but also blocks central synaptic transmission, an action independent of NTPDase inhibition

Understanding the mechanisms and properties of purinergic signalling would be greatly assisted by the discovery of subtype selective and potent inhibitors of the NTPDase enzymes, which metabolise nucleotides such as ATP and ADP in the extracellular space. Currently ARL 67156 is the best available NTPDase inhibitor, but its relatively poor efficacy means that negative results are difficult to interpret. POM-1 (sodium polyoxotungstate) is a novel NTPDase inhibitor, which has shown promising results with the inhibition of recombinant NTPDases 1, 2 and 3. We have tested the effectiveness and physiological effects of POM-1 with cerebellar and hippocampal slices. Using the malachite green phosphate assay, HPLC and biosensor measurements we have found that POM-1 is more effective at blocking ATP breakdown in cerebellar slices than ARL 67156. The site of inhibition is at the first step of the breakdown cascade (conversion of ATP to ADP) and the effects of POM-1 appear readily reversible. However, POM-1 has multiple effects on synaptic transmission. At the cerebellar parallel fibre-Purkinje cell (PF) synapse POM-1 produced a long lasting inhibition of transmission, which was preceded in a minority of synapses by a transient increase in PF excitatory postsynaptic potential (EPSP) amplitude (approximately 20%). This increase in PF EPSP amplitude appears to result from a reduction in the tonic activation of presynaptic A1 receptors, consistent with POM-1 preventing the breakdown of ATP to adenosine. The reduction in PF EPSP amplitude does not however appear to result from NTPDase inhibition as it persists when both adenosine and ATP (P2Y and P2X) receptors are blocked. An increase in paired pulse ratio and a reduction in presynaptic volley amplitude suggest that there is a presynaptic component of POM-1 action which reduces glutamate release. POM-1 produced similar inhibition at climbing fibre synapses and at hippocampal CA1 pyramidal synapses. Thus although POM-1 is more effective than ARL 67156 at blocking ATP breakdown its usefulness is limited by off-target actions on synaptic transmission.

Manganese (Mn2+)-dependent storage stabilization of Rhodotorula glutinis phenylalanine ammonia-lyase activity

Phenylalanine ammonia-lyase (PAL; E C 4.3.1.5) reverse reaction has been exploited for the commercial production of optically pure l-phenylalanine from trans-cinnamic acid. Optimal conditions for the growth and PAL activity of Rhodotorula glutinis cells and an improved method for the synthesis of l-phenylalanine have been reported. A major problem encountered during these studies was rapid loss of PAL activity during storage of the yeast cells, which were therefore unsuitable for long-term and repeated use. Enhancement of enzyme stability in the presence of various additives including polyhydric compounds and metal ions is described. Whole cells retained nearly 85% of the original enzyme activity for at least 12 weeks when a low concentration of Mn2+ (0.01%) was included in the storage buffer medium (50 mM Tris-HCl, pH 8.8). In contrast, <3.0% activity was present in the control within 4 weeks. Mn2+-dependent stabilization of PAL was also observed with an isolated enzyme preparation (73% retention in activity for 12 weeks) obtained by ultrasonication of R. glutinis whole cells. The data suggest that Mn2+ ions may be responsible for the specific stabilization of a more active conformation of the enzyme. In addition, enzyme stability as a function of temperature was studied, and the optimal temperature for maximal activity retention was 0-2 degrees C. The effects of various additives on the induction of PAL have also been examined. These results could have direct implications in studies on activity, inhibition, and reaction mechanism of this biotechnologically important enzyme.

Expression of cocaine- and amphetamine-regulated transcript (CART) peptides at climbing fibre-Purkinje cell synapses in the rat vestibular cerebellum

Cocaine- and amphetamine-regulated transcript (CART) peptides have a wide CNS distribution and appear to play an important role in a number of physiological processes including reward and reinforcement, feeding, locomotion, stress responses and perception of pain. We have further investigated the expression of CART peptides in rat cerebellum, using multiple fluorescent antibodies. Dense fibre-like immunofluorescence was observed in the molecular layer of the vestibular cerebellum (paraflocculus and lobes IX and X of the vermis). There was little or no immunofluorescence in any other region of the cerebellum (vermis or hemispheres). The immunofluorescence in lobes IX and X of the vermis showed a parasagittal banding pattern, with one medial and two lateral bands. We have provided several lines of evidence that CART peptides are expressed by climbing fibres: (1) There is CART peptide immunofluorescence in the inferior olivary complex, the source of climbing fibres. (2) No cerebellar cell bodies were labelled by the CART peptide antibody. (3) The developmental profile of CART peptide expression was consistent with climbing fibre development and finally (4) triple antibody labelling revealed co-expression of CART peptides with VGluT2 (the glutamate transporter at climbing fibre synapses) at boutons innervating calbindin D-28K labelled proximal Purkinje cell dendrites. Analysis of VGluT2 and CART peptide labelling in more detail showed that not all climbing fibres in the vestibular cerebellum expressed CART peptides but those fibres which did express CART peptides were immunofluorescent at all Purkinje cell synapses.

Control of basal extracellular adenosine concentration in rat cerebellum

To re-examine how the basal extracellular concentration of adenosine is regulated in acutely isolated cerebellar slices we have combined electrophysiological and microelectrode biosensor measurements. In almost all cases, synaptic transmission was tonically inhibited by adenosine acting via A₁ receptors. By contrast, in most slices, the biosensors did not measure an adenosine tone but did record a spatially non-uniform extracellular tone of the downstream metabolites (inosine and hypoxanthine). Most of the extracellular hypoxanthine arose from the metabolism of inosine by ecto-purine nucleoside phosphorylase (PNP). Adenosine kinase was the major determinant of adenosine levels, as its inhibition increased both adenosine concentration and A₁ receptor-mediated synaptic inhibition. Breakdown of adenosine by adenosine deaminase was the major source of the inosine/hypoxanthine tone. However adenosine deaminase played a minor role in determining the level of adenosine at synapses, suggesting a distal location. Blockade of adenosine transport (by NBTI/dipyridamole) had inconsistent effects on basal levels of adenosine and synaptic transmission. Unexpectedly, application of NBTI/dipyridamole prevented the efflux of adenosine resulting from block of adenosine kinase at only a subset of synapses. We conclude that there is spatial variation in the functional expression of NBTI/dipyridamole-sensitive transporters. The increased spatial and temporal resolution of the purine biosensor measurements has revealed the complexity of the control of adenosine and purine tone in the cerebellum.

Auto-inhibition of rat parallel fibre-Purkinje cell synapses by activity-dependent adenosine release

Adenosine is an important signalling molecule involved in a large number of physiological functions. In the brain these processes are as diverse as sleep, memory, locomotion and neuroprotection during episodes of ischaemia and hypoxia. Although the actions of adenosine, through cell surface G-protein-coupled receptors, are well characterized, in many cases the sources of adenosine and mechanisms of release have not been defined. Here we demonstrate the activity-dependent release of adenosine in the cerebellum using a combination of electrophysiology and biosensors. Short trains of electrical stimuli delivered to the molecular layer in vitro, release adenosine via a process that is both TTX and Ca²⁺ sensitive. As ATP release cannot be detected, adenosine must either be released directly or rapidly produced by highly localized and efficient extracellular ATP breakdown. Since adenosine release can be modulated by receptors that act on parallel fibre–Purkinje cell synapses, we suggest that the parallel fibres release adenosine. This activity-dependent adenosine release exerts feedback inhibition of parallel fibre–Purkinje cell transmission. Spike-mediated adenosine release from parallel fibres will thus powerfully regulate cerebellar circuit output.

Alterations in GABAA receptor occupancy occur during the postnatal development of rat Purkinje cell but not granule cell synapses

The identification of synaptic GABA(A) receptors has proved difficult as neurones express multiple GABA(A) receptor subunits. For example, cerebellar granule cells express alpha1, alpha6, gamma2, delta and beta2/3 subunits and thus express many different GABA(A) receptor subtypes. Furthermore, the contribution of individual GABA(A) receptor subtypes is changed by developmental alterations in subunit expression. To further characterise the pharmacology of Golgi cell to granule cell synapses during development, the benzodiazepine-site ligand zolpidem was used. Zolpidem shows selectivity for alpha1betaxgamma2 receptors (x is any beta subunit) and slows the decay and enhances the amplitude of alpha1betaxgamma2 receptor-mediated synaptic currents, provided the receptors are not fully occupied. For comparison, zolpidem was applied to Purkinje cell synapses, since the synaptic receptors are of known composition (alpha1betaxgamma2). At immature and adult Golgi cell to granule cell synapses, the decay of spontaneous and miniature inhibitory postsynaptic currents (sIPSCs and mIPSCs) was slowed by zolpidem but their amplitude and frequency were unaffected. At Purkinje cell synapses, although zolpidem slowed the decay of IPSCs at both immature and adult synapses, zolpidem only enhanced the amplitude of IPSCs at adult synapses. Thus during development, the level of receptor occupation remains constant at Golgi cell to granule cell synapses but falls at Purkinje cell synapses.

Short-term synaptic plasticity during development of rat mossy fibre to granule cell synapses

Changes occur during the postnatal development of the rat glutamatergic mossy fibre to granule cell synapse: to the morphology of synapses, glutamate transporter expression, AMPA receptor expression and the kinetics of AMPA receptor-mediated synaptic transmission. For example, both the rise and decay times of AMPA receptor-mediated excitatory postsynaptic currents significantly shorten. To further define the development of mossy fibre to granule cell synaptic transmission, the properties and mechanisms of short-term plasticity have been described. The characterization of short-term plasticity will aid our understanding of the mechanisms that define the parameters of synaptic transmission during development and furthermore short-term plasticity may play an important role in determining information transfer between mossy fibres and granule cells. In response to pairs of stimuli (2-100-ms interval), depression (second excitatory postsynaptic current amplitude smaller than the first) was observed at both mature (older than 40 postnatal days) and immature (between 8 and 12 postnatal days) synapses. The degree of depression was similar at both stages of development, although recovery from depression was slower at mature synapses (tau 22 vs 12.5 ms). Several experimental approaches (coefficient of variation, low-affinity antagonists and cyclothiazide) suggest that depression at immature synapses results from multiple mechanisms. At mature synapses, postsynaptic receptor desensitization appears to be the major cause of depression.

A role for zinc in cerebellar synaptic transmission?

There is considerable evidence that the transition metal zinc plays an important role in mammalian neural development, physiology and pathology. The most compelling evidence for a synaptic role for zinc comes from hippocampal studies: zinc is concentrated in the synaptic vesicles of some glutamatergic neurons, zinc can be released during neural activity and zinc can modulate postsynaptic GABA and glutamate receptors. The possibility that zinc is involved in cerebellar synaptic transmission is supported by the expression of specific zinc transporters (ZnT, including the synaptic vesicle transporter ZnT-3) in the cerebellar cortex. Furthermore, some subtypes of neurotransmitter receptors, expressed by cerebellar neurones, are highly sensitive to low concentrations of exogenous zinc. However there appears to be little chelatable (synaptic) zinc in the cerebellum, deletion of the ZnT-3 gene has no effect on motor phenotype and there is currently no evidence that zinc is released from cerebellar neurones to have physiological actions. Thus it is possible that the different types of zinc transporter found in the cerebellum play a neuroprotective rather than a signalling role.

Actions of zinc at mature Golgi cell to granule cell synapses in cerebellum of rats and mice

A recent study has shown that cerebellar GABAergic interneuron (Golgi cell) terminals contain the zinc transporter znt3, raising the possibility that zinc is synaptically released to modulate GABAergic transmission. To test this possibility, the actions of exogenous zinc on Golgi cell to granule cell synaptic transmission were investigated and then the effects of removing endogenous zinc were examined. Application of zinc markedly reduced the tonic GABA(A)-receptor-mediated current in granule cells but produced a much smaller heterogeneous inhibitory effect on evoked phasic GABAergic currents. Neither the tonic current, single evoked synaptic currents nor trains of synaptic currents were modulated when endogenous zinc was chelated. Thus, there is no physiological evidence that zinc is released from Golgi cells to modulate GABAergic transmission.

Structure of avian AICAR transformylase with a multisubstrate adduct inhibitor beta-DADF identifies the folate binding site

The penultimate catalytic step of the purine de novo synthesis pathway is the conversion of aminoimidazole-4-carboxamide ribonucleotide (AICAR) to 5-formyl-AICAR that requires the cofactor N(10)-formyl-tetrahydrofolate as the formyl donor. This reaction is catalyzed by the AICAR transformylase domain of the bifunctional enzyme AICAR transformylase/inosine monophosphate cyclohydrolase (ATIC). Identification of the location of the AICAR transformylase active site was previously elucidated from the crystal structure of the avian ATIC with bound substrate AICAR; however, due to the absence of any bound folate, the folate binding region of the active site could not be identified. Here, we have determined the homodimeric crystal structure of avian ATIC in complex with the ATIC-specific multisubstrate adduct inhibitor beta-DADF to 2.5 A resolution. Beta-DADF encompasses both the AICAR and folate moieties into a single covalently linked entity, thereby allowing for the characterization of the folate binding pocket of the AICAR transformylase active site. Beta-DADF is intimately bound at the dimer interface of the transformylase domains with the majority of AICAR moiety interactions occurring within one subunit, whereas the primary interactions to the folate occur with the opposing subunit. The crystal structure suggests that a buried Lys(267) is transiently protonated during formyl transfer allowing for the stabilization of the oxyanion transition state and subsequent protonation of N10 on the tetrahydrofolate leaving group. Furthermore, the beta-DADF-bound structure provides a more optimal three-dimensional scaffold to improve the design of specific antineoplastic agents.

Endogenous nitric oxide modulates GABAergic transmission to granule cells in adult rat cerebellum

Nitric oxide (NO) is a gaseous neurotransmitter which plays an important role in neuronal signalling and plasticity throughout the brain. In the cerebellum, NO synthase (NOS) is expressed in parallel fibres and within the internal granule cell layer (IGL). During development there are changes in NOS concentration, distribution and activity within the IGL, suggesting NO may play a role in IGL function. Therefore, the actions of NO in the IGL were investigated. The similar actions of a range of NOS inhibitors and NO scavengers strongly suggested the presence of a tonic level of endogenous NO in the IGL. Both the neuronal and inducible forms of NOS appeared to be sources of this endogenous NO. The effects observed following a reduction in the concentration of endogenous NO were consistent with enhanced granule cell GABAA receptor activation. For example, a reduction in NO concentration led to an increase in the frequency of action potential-dependent phasic GABAergic inhibitory postsynaptic currents (IPSCs) and produced a TTX-insensitive GABAA receptor-mediated current. A direct action of NO on Golgi cell membrane potential and input resistance accounted for the increase in the frequency of phasic GABA release. The mechanism underlying the tonic GABA current is unclear but does not appear to be via the modulation of GABA uptake or the activation of nicotinic acetylcholine receptors. NO is a potentially novel mechanism for tuning GABAergic signalling to granule cells and therefore modulating the throughput of an important cerebellar circuit.

Competitive GABA(A) receptor antagonists increase the proportion of functional high-affinity alpha6 subunit-containing receptors in granule cells of adult rat cerebellum

To investigate the properties of alpha6 subunit-containing GABA(A) receptors, whole-cell patch-clamp recordings were made from granule cells in adult rat cerebellar slices. In control, only currents evoked by low concentrations of GABA were significantly reduced in amplitude by furosemide, the alpha6 subunit-containing receptor antagonist. However, in the presence of competitive GABA(A) receptor antagonists, the furosemide block of currents evoked by higher GABA concentrations was markedly increased. Zinc, which preferentially blocks alpha6 subunit-containing receptors, also produced an increased block in the presence of bicuculline. To investigate whether similar effects occurred at synaptic receptors, inhibitory postsynaptic currents (IPSCs) were recorded. In most cells, furosemide produced little or no reduction in evoked IPSC amplitude. However in the presence of SR95531, a competitive antagonist, furosemide markedly reduced IPSC amplitude. One hypothesis, which could account for these observations, is that competitive antagonists prevent the continual activation of alpha6beta2/3gamma2 receptors by endogenous GABA and thus prevent their desensitisation. This hypothesis appears feasible as prolonged applications of low concentrations of GABA to recombinant alpha6beta2gamma2s receptors resulted in their desensitisation.

Furosemide reveals heterogeneous GABA(A) receptor expression at adult rat Golgi cell to granule cell synapses

The contribution that alpha6 subunit-containing GABA(A) receptors make to inhibitory synaptic transmission to granule cells was investigated by making whole-cell patch clamp recordings from granule cells in adult rat cerebellar slices and applying furosemide, the specific alpha6 subunit-containing GABA(A) receptor antagonist. Endogenous, extracellular GABA continually activated GABA(A) receptors producing a tonic current. Since this current was markedly reduced by furosemide it was probably produced by alpha6 subunit-containing receptors. In contrast, furosemide had little effect on the amplitude or kinetics of fast spontaneous inhibitory postsynaptic currents (sIPSCs), although such sIPSCs were abolished by bicuculline and SR95331. However, the amplitude of evoked IPSCs with a very slow rise and decay were markedly reduced by furosemide. These IPSCs probably resulted from the spillover of GABA from neighbouring synapses activating high affinity alpha6 subunit-containing receptors. In the rest of the cells (40 out of 46), evoked IPSCs had rise and decay kinetics that lay in-between fast sIPSCs and slow 'spillover' IPSCs. Such IPSCs had variable kinetics and also exhibited considerable variation in the magnitude of furosemide block. Thus the GABA(A) receptors present at adult Golgi cell-granule cell synapses, at a developmental stage where receptor expression is complete, are highly heterogeneous.

The speeding of EPSC kinetics during maturation of a central synapse

Several factors contribute to the shape of excitatory postsynaptic currents (EPSCs) in CNS neurons, among them the kinetics of presynaptic release, transmitter clearance, and the properties and distribution of postsynaptic receptors. The decays of AMPA receptor-mediated EPSCs at rat cerebellar mossy fibre-granule cell (MF-gc) synapses follow a bi-exponential time-course. The fast component dominates the decay, accounting for 84-94% of the peak amplitude. Here we show that both components of decay, and also the risetimes, became faster during postnatal maturation. At adult, but not immature, synapses, the risetimes and decays of evoked multiquantal EPSCs were similar to those of monoquantal miniature (m)EPSCs. The faster risetimes at mature synapses reflected increased synchrony of multivesicular release, whereas the faster decays appeared to reflect changes in the properties of postsynaptic receptors. Inhibition of glutamate uptake was without effect on evoked EPSCs at both ages. Furthermore, after slowing receptor desensitization with cyclothiazide, the EPSCs at mature synapses decayed as slowly as EPSCs at immature synapses, suggesting that faster glutamate clearance does not account for the developmental speeding of EPSC decay. Our results support previous conclusions that glutamate clearance and receptor deactivation are important determinants of the fast decay component at immature synapses. Desensitization becomes increasingly important during development and plays a major role in shaping EPSC decay at mature synapses.

Cis-4-amino-crotonic acid activates alpha 6 subunit-containing GABA(A) but not GABA(C) receptors in granule cells of adult rat cerebellar slices

The expression of GABA(C) receptors in granule cells of adult rat cerebellar slices was investigated. The GABA(C) receptor agonist cis-4-amino-crotonic acid (CACA) evoked currents in granule cells. However, CACA-evoked currents were not blocked by the GABA(C) receptor antagonist (1,2,5,6-tetrahydropyridine-4-yl)methylphosphinic acid (TPMPA), but were blocked by the GABA(A) receptor antagonist bicuculline. CACA activated alpha6 subunit-containing GABA receptors as CACA-evoked currents were reduced by furosemide and CACA activated alpha6beta2gamma2s receptors expressed in HEK 293 cells. The channels opened by CACA had conductances which were larger than those described for GABA(C) receptors but were similar to those described for GABA(A) receptors. GABAergic synaptic currents were blocked by low concentrations of bicuculline, but not by TPMPA. Thus, cerebellar granule cells express functional GABA(A) but not GABA(C) receptors.

Thoracic aortic and thoracic vascular injuries

Patients with thoracic vascular injuries fall into two groups: those who are exsanguinating and require an empiric operation with a high mortality and those with contained injuries that permit preoperative evaluation. The unstable group requires judgment to determine the appropriate empiric position, exposure, and operation. Unlike abdominal trauma, which is addressed by way of a midline incision, there are multiple thoracic incisions that can be used to access thoracic vascular injuries. Thus, the stable group may benefit from preoperative imaging, which then can suggest a patient position, incision, and operative approach. Avoiding overaggressive resuscitation, obtaining appropriate imaging studies, choosing an operative strategy to achieve proximal and distal control, and using adjuncts based on the injury can make the care of these patients a rewarding but challenging activity.

Management of traumatic lung injury: a Western Trauma Association Multicenter review

BACKGROUND

Improved outcomes following lung injury have been reported using "lung sparing" techniques.

METHODS

A retrospective multicenter 4-year review of patients who underwent lung resection following injury was performed. Resections were categorized as "minor" (suture, wedge resection, tractotomy) or "major" (lobectomy or pneumonectomy). Injury severity, Abbreviated Injury Scale (AIS) score, and outcome were recorded.

RESULTS

One hundred forty-three patients (28 blunt, 115 penetrating) underwent lung resection after sustaining an injury. Minor resections were used in 75% of cases, in patients with less severe thoracic injury (chest AIS scores "minor" 3.8 +/- 0.9 vs. "major" 4.3 +/- 0.7, p = 0.02). Mortality increased with each step of increasing complexity of the surgical technique (RR, 1.8; CI, 1.4-2.2): suture alone, 9% mortality; tractotomy, 13%; wedge resection, 30%; lobectomy, 43%; and pneumonectomy, 50%. Regression analysis demonstrated that blunt mechanism, lower blood pressure at thoracotomy, and increasing amount of the lung resection were each independently associated with mortality.

CONCLUSION

Blunt traumatic lung injury has higher mortality primarily due to associated extrathoracic injuries. Major resections are required more commonly than previously reported. While "minor" resections, if feasible, are associated with improved outcome, trauma surgeons should be facile in a wide range of technical procedures for the management of lung injuries.

Feature mining and predictive model construction from severe trauma patient's data

In management of severe trauma patients, trauma surgeons need to decide which patients are eligible for damage control. Such decision may be supported by utilizing models that predict the patient's outcome. The study described in this paper investigates the possibility to construct patient outcome prediction models from retrospective patient's data at the end of initial damage control surgery by using feature mining and machine learning techniques. As the data used comprises rather excessive number of features, special attention was paid to the problem of selecting only the most relevant features. We show that a small subset of features may carry enough information to construct reasonably accurate prognostic models. Furthermore, the techniques used in our study identified two factors, namely the pH value when admitted to ICU and the worst partial active thromboplastin time, to be of highest importance for prediction. This finding is pathophysiologically reasonable and represents two of three major problems with severe trauma patients, metabolic acidosis, hypothermia, and coagulopathy.

Timing of urgent thoracotomy for hemorrhage after trauma: a multicenter study

HYPOTHESIS

It is possible to quantify an amount of thoracic hemorrhage, after blunt and penetrating injury, at which delay of thoracotomy is associated with increased mortality.

DESIGN

A retrospective case series.

SETTING

Five urban trauma centers.

STUDY SELECTION

Patients undergoing urgent thoracotomy (within 48 hours of injury) for hemorrhage (excluding emergency department thoracotomy).

DATA EXTRACTION

Respective registries identified patients who underwent urgent thoracotomy. Injury characteristics, initial and subsequent chest tube outputs, time before thoracotomy, and outcomes were evaluated.

MAIN OUTCOME MEASURE

Death.

RESULTS

One hundred fifty-seven patients (36 with blunt and 121 with penetrating injuries) underwent urgent thoracotomy for hemorrhage between January 1, 1995, and December 31, 1998. Mortality correlated with mean (+/- SD) Injury Severity Score (38 +/- 19 vs 22 +/- 12.6 for survivors; P<.01) and mechanism (24 [67%] for blunt vs 21 [17%] for penetrating injuries; P<.01). Mortality increased as total chest blood loss increased, with the risk for death at blood loss of 1500 mL being 3 times greater than at 500 mL. Blunt-injured patients waited a significantly longer time to thoracotomy than penetrating-injured patients (4.4 +/- 9.0 h vs 1.6 +/- 3.0 h; P =.02) and also had a greater total chest tube output before thoracotomy (2220 +/- 1235 mL vs 1438 +/- 747 mL; P =.001).

CONCLUSIONS

The risk for death increases linearly with total chest hemorrhage after thoracic injury. Thoracotomy is indicated when total chest tube output exceeds 1500 mL within 24 hours, regardless of injury mechanism.