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Becker N, Franz N, Eguchi A, Wagner A, Sturm R, Rinderknecht H, Kobayashi Y, Iwasa M, Weber B, Marzi I, Relja B. Elevated extracellular particle concentration in plasma predicts in-hospital mortality after severe trauma. Front Immunol 2024; 15:1390380. [PMID: 38933277 PMCID: PMC11199388 DOI: 10.3389/fimmu.2024.1390380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/27/2024] [Indexed: 06/28/2024] Open
Abstract
Background Extracellular particles (EPs), particularly extracellular vesicles, play a crucial role in regulating various pathological mechanisms, including immune dysregulations post-trauma. Their distinctive expression of cell-specific markers and regulatory cargo such as cytokines or micro-ribonucleic acid suggests their potential as early biomarkers for organ-specific damage and for identifying patients at risk for complications and mortality. Given the critical need for reliable and easily assessable makers to identify at-risk patients and guide therapeutic decisions, we evaluated the early diagnostic value of circulating EPs regarding outcomes in severely injured multiple-trauma patients. Methods Plasma samples were collected from 133 severely injured trauma patients (Injury Severity Score (ISS) ≥16) immediately upon arrival at the emergency department (ED). Patients were categorized into survivors and non-survivors. Injury characteristics and outcomes related to sepsis, pneumonia, or early (<1 day after admission) and late mortality were assessed. Circulating EPs, cytokine profiles, and blood counts of platelets and leukocytes were determined. Receiver operating characteristic analyses were conducted. Results Despite no significant differences in injury pattern or severity, non-survivors exhibited significantly elevated counts of circulating EPs compared to survivors. The optimal cut-off for EPs <200 nm indicating non-survivors was 17380/µl plasma, with a sensitivity of 77% and a specificity of 61% in predicting in-hospital mortality. Later non-survivors received significantly higher numbers of units of packed red blood cells [8.54 ± 5.45 vs. 1.29 ± 0.36 units], had higher serum lactate [38.00 ± 7.51 vs. 26.98 ± 1.58 mg/dL], significantly lower platelet counts [181.30 ± 18.06 vs. 213.60 ± 5.85 *10³/µL] and lower heart rates [74.50 ± 4.93 vs. 90.18 ± 2.06 beats/minute] upon arrival at the ED compared to survivors. Conclusion Our results demonstrate the high diagnostic potential of elevated concentrations of circulating EPs <200 nm for identifying patients at risk of mortality after severe trauma. This parameter shows comparable sensitivity to established clinical predictors. Early evaluation of EPs concentration could complement assessment markers in guiding early therapeutic decisions.
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Affiliation(s)
- Nils Becker
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, Translational and Experimental Trauma Research, Ulm University Medical Center, Ulm, Germany
| | - Niklas Franz
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, Frankfurt, Germany
| | - Akiko Eguchi
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Alessa Wagner
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, Translational and Experimental Trauma Research, Ulm University Medical Center, Ulm, Germany
| | - Ramona Sturm
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, Frankfurt, Germany
| | - Helen Rinderknecht
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, Translational and Experimental Trauma Research, Ulm University Medical Center, Ulm, Germany
| | - Yoshinao Kobayashi
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Motoh Iwasa
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Birte Weber
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, Frankfurt, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, Frankfurt, Germany
| | - Borna Relja
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, Translational and Experimental Trauma Research, Ulm University Medical Center, Ulm, Germany
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Dziedzic A, Michlewska S, Jóźwiak P, Dębski J, Karbownik MS, Łaczmański Ł, Kujawa D, Glińska S, Miller E, Niwald M, Kloc M, Balcerzak Ł, Saluk J. Quantitative and structural changes of blood platelet cytoskeleton proteins in multiple sclerosis (MS). J Autoimmun 2024; 145:103204. [PMID: 38520895 DOI: 10.1016/j.jaut.2024.103204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/22/2024] [Accepted: 03/11/2024] [Indexed: 03/25/2024]
Abstract
Epidemiological studies show that cardiovascular events related to platelet hyperactivity remain the leading causes of death among multiple sclerosis (MS) patients. Quantitative or structural changes of platelet cytoskeleton alter their morphology and function. Here, we demonstrated, for the first time, the structural changes in MS platelets that may be related to their hyperactivity. MS platelets were found to form large aggregates compared to control platelets. In contrast to the control, the images of overactivated, irregularly shaped MS platelets show changes in the cytoskeleton architecture, fragmented microtubule rings. Furthermore, MS platelets have long and numerous pseudopodia rich in actin filaments. We showed that MS platelets and megakaryocytes, overexpress β1-tubulin and β-actin mRNAs and proteins and have altered post-translational modification patterns. Moreover, we identified two previously undisclosed mutations in the gene encoding β1-tubulin in MS. We propose that the demonstrated structural changes of platelet cytoskeleton enhance their ability to adhere, aggregate, and degranulate fueling the risk of adverse cardiovascular events in MS.
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Affiliation(s)
- Angela Dziedzic
- University of Lodz, Faculty of Biology and Environmental Protection, Department of General Biochemistry, Pomorska 141/143, 90-236 Lodz, Poland.
| | - Sylwia Michlewska
- University of Lodz, Faculty of Biology and Environmental Protection, Laboratory of Microscopic Imaging and Specialized Biological Techniques, Banacha 12/16, 90-237, Lodz, Poland
| | - Piotr Jóźwiak
- University of Lodz, Faculty of Biology and Environmental Protection, Department of Invertebrate Zoology and Hydrobiology, Banacha 12/16, 90-236 Lodz, Poland
| | - Janusz Dębski
- Institute of Biochemistry and Biophysics, Polish Academy of Sciences, Pawinskiego 5a 02-106, Warsaw, Poland
| | | | - Łukasz Łaczmański
- Laboratory of Genomics & Bioinformatics, Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Weigla 12, 53-114 Wroclaw, Poland
| | - Dorota Kujawa
- Laboratory of Genomics & Bioinformatics, Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Weigla 12, 53-114 Wroclaw, Poland
| | - Sława Glińska
- University of Lodz, Faculty of Biology and Environmental Protection, Laboratory of Microscopic Imaging and Specialized Biological Techniques, Banacha 12/16, 90-237, Lodz, Poland
| | - Elżbieta Miller
- Department of Neurological Rehabilitation, Medical University of Lodz, Milionowa 14, 93-113 Lodz, Poland
| | - Marta Niwald
- Department of Neurological Rehabilitation, Medical University of Lodz, Milionowa 14, 93-113 Lodz, Poland
| | - Malgorzata Kloc
- The Houston Methodist Research Institute, Houston, TX 77030, USA; Department of Surgery, The Houston Methodist Hospital, Houston, TX 77030, USA; M.D. Anderson Cancer Center, Department of Genetics, The University of Texas, Houston, TX 77030, USA
| | - Łucja Balcerzak
- University of Lodz, Faculty of Biology and Environmental Protection, Laboratory of Microscopic Imaging and Specialized Biological Techniques, Banacha 12/16, 90-237, Lodz, Poland
| | - Joanna Saluk
- University of Lodz, Faculty of Biology and Environmental Protection, Department of General Biochemistry, Pomorska 141/143, 90-236 Lodz, Poland
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Gando S, Levi M, Toh CH. Trauma-induced innate immune activation and disseminated intravascular coagulation. J Thromb Haemost 2024; 22:337-351. [PMID: 37816463 DOI: 10.1016/j.jtha.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/12/2023]
Abstract
Dysregulated innate immunity participates in the pathomechanisms of disseminated intravascular coagulation (DIC) in trauma-induced coagulopathy. Accidental and regulated cell deaths and neutrophil extracellular traps release damage-associated molecular patterns (DAMPs), such as histones, nuclear and mitochondrial DNA, and high-mobility group box 1, into circulation immediately after trauma. DAMP-induced inflammation activation releases tissue factor-bearing procoagulant extracellular vesicles through gasdermin D-mediated pore formation and plasma membrane rupture by regulated cell death. DAMPs also evoke systemic inflammation, platelet, coagulation activation, and impaired fibrinolysis associated with endothelial injury, leading to the dysfunction of anticoagulation systems, which are the main pathophysiological mechanisms of DIC. All these processes induce systemic thrombin generation in vivo, not restricted to the injury sites immediately after trauma. Thrombin generation at the site of injury stops bleeding and maintains homeostasis. However, DIC associated with endothelial injury generates massive thrombin, enhancing protease-activated, receptor-mediated bidirectional interplays between inflammation and coagulation, aggravating the diverse actions of thrombin and disturbing homeostasis. Insufficiently regulated thrombin causes disseminated microvascular thrombosis, resulting in tissue hypoxia due to reduced oxygen delivery, and mitochondrial dysfunction due to DAMPs causes tissue dysoxia. In addition, DAMP-induced calcium influx and overload, as well as neutrophil activation, play a role in endothelial cell injury. Tissue hypoxia and cytotoxicity result in multiple organ dysfunction in DIC after trauma. Controls against dysregulated innate immunity evoking systemic inflammation, thrombin generation, and cytotoxicity are key issues in improving the prognosis of DIC in trauma-induced coagulopathy.
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Affiliation(s)
- Satoshi Gando
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan; Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan.
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands; Department of Medicine, University College London Hospitals NHS Foundation Trust, and Cardio-Metabolic Program - NIHR UCLH/UCL BRC London, London, United Kingdom
| | - Cheng-Hock Toh
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, United Kingdom; Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
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Haemostasis and Inflammatory Parameters as Potential Diagnostic Biomarkers for VTE in Trauma-Immobilized Patients. Diagnostics (Basel) 2023; 13:diagnostics13010150. [PMID: 36611442 PMCID: PMC9818770 DOI: 10.3390/diagnostics13010150] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/10/2022] [Accepted: 12/12/2022] [Indexed: 01/03/2023] Open
Abstract
Venous thromboembolism (VTE), which encompasses deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major public health concern due to its high incidences of morbidity and mortality. Patients who have experienced trauma with prolonged immobilization are at an increased risk of developing VTE. Plasma D-dimer levels have been known to be elevated in trauma patients, and they were closely correlated with the number of fractures. In other words, plasma D-dimer levels cannot be used as the only indicator of VTE in trauma cases. Given the limitations, further study is needed to explore other potential biomarkers for diagnosing VTE. To date, various established and novel VTE biomarkers have been studied in terms of their potential for predicting VTE, diagnostic performance, and improving clinical therapy for VTE. Therefore, this review aims to provide information regarding classic and essential haemostasis (including prothrombin time (PT), activated partial thromboplastin time (aPTT), D-dimer, fibrinogen, thrombin generation, protein C, protein S, antithrombin, tissue factor pathway inhibitor, and platelet count) and inflammatory biomarkers (C-reactive protein, erythrocyte sedimentation rate, and soluble P-selectin) as potential diagnostic biomarkers that can predict the risk of VTE development among trauma patients with prolonged immobilization. Thus, further advancement in risk stratification using these biomarkers would allow for a better diagnosis of patients with VTE, especially in areas with limited resources.
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DeBot M, Mitra S, Lutz P, Schaid TR, Stafford P, Hadley JB, Hom P, Sauaia A, Silliman CC, Moore EE, Cohen MJ. SHOCK INDUCES ENDOTHELIAL PERMEABILITY AFTER TRAUMA THROUGH INCREASED ACTIVATION OF RHOA GTPASE. Shock 2022; 58:542-548. [PMID: 36548645 PMCID: PMC9793983 DOI: 10.1097/shk.0000000000002008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
ABSTRACT Introduction: Severely injured patients develop a dysregulated inflammatory state characterized by vascular endothelial permeability, which contributes to multiple organ failure. To date, however, the mediators of and mechanisms for this permeability are not well established. Endothelial permeability in other inflammatory states such as sepsis is driven primarily by overactivation of the RhoA GTPase. We hypothesized that tissue injury and shock drive endothelial permeability after trauma by increased RhoA activation leading to break down of endothelial tight and adherens junctions. Methods: Human umbilical vein endothelial cells (HUVECs) were grown to confluence, whereas continuous resistance was measured using electrical cell-substrate impedance sensing (ECIS) Z-Theta technology, 10% ex vivo plasma from severely injured trauma patients was added, and resistance measurements continued for 2 hours. Areas under the curve (AUCs) were calculated from resistance curves. For GTPase activity analysis, HUVECs were grown to confluence and incubated with 10% trauma plasma for 5 minutes before harvesting of cell lysates. Rho and Rac activity were determined using a G-LISA assay. Significance was determined using Mann-Whitney tests or Kruskal-Wallis test, and Spearman ρ was calculated for correlations. Results: Plasma from severely injured patients induces endothelial permeability with plasma from patients with both severe injury and shock contributing most to this increased permeability. Surprisingly, Injury Severity Score (ISS) does not correlate with in vitro trauma-induced permeability (-0.05, P > 0.05), whereas base excess (BE) does correlate with permeability (-0.47, P = 0.0001). The combined impact of shock and injury resulted in a significantly smaller AUC in the injury + shock group (ISS > 15, BE < -9) compared with the injury only (ISS > 15, BE > -9; P = 0.04) or minimally injured (ISS < 15, BE > -9; P = 0.005) groups. In addition, incubation with injury + shock plasma resulted in higher RhoA activation ( P = 0.002) and a trend toward decreased Rac1 activation ( P = 0.07) compared with minimally injured control. Conclusions: Over the past decade, improved early survival in patients with severe trauma and hemorrhagic shock has led to a renewed focus on the endotheliopathy of trauma. This study presents the largest study to date measuring endothelial permeability in vitro using plasma collected from patients after traumatic injury. Here, we demonstrate that plasma from patients who develop shock after severe traumatic injury induces endothelial permeability and increased RhoA activation in vitro . Our ECIS model of trauma-induced permeability using ex vivo plasma has potential as a high throughput screening tool to phenotype endothelial dysfunction, study mediators of trauma-induced permeability, and screen potential interventions.
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Affiliation(s)
- Margot DeBot
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Sanchayita Mitra
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Patrick Lutz
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Terry R. Schaid
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Preston Stafford
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Jamie B. Hadley
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Patrick Hom
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Angela Sauaia
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
- University of Colorado Denver, School of Public Health, Management and Policy, Department of Health Systems, Aurora, CO
| | - Christopher C. Silliman
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
| | - Ernest E. Moore
- Denver Health Medical Center, Ernest E Moore Shock Trauma Center, Denver, CO
| | - Mitchell J. Cohen
- University of Colorado Denver, School of Medicine, Department of Surgery/Trauma Research Center, Aurora, CO
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Niemann M, Otto E, Eder C, Youssef Y, Kaufner L, Märdian S. Coagulopathy management of multiple injured patients - a comprehensive literature review of the European guideline 2019. EFORT Open Rev 2022; 7:710-726. [PMID: 36287131 PMCID: PMC9619392 DOI: 10.1530/eor-22-0054] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The European guideline on the management of trauma-induced major bleeding and coagulopathy summarises the most relevant recommendations for trauma coagulopathy management. The management of trauma-induced major bleeding should interdisciplinary follow algorithms which distinguish between life-threatening and non-life-threatening bleeding. Point-of-care viscoelastic methods (VEM) assist target-controlled haemostatic treatment. Neither conventional coagulation assays nor VEM should delay treatment in life-threatening trauma-induced bleeding. Adjustments may be rational due to local circumstances, including the availability of blood products, pharmaceuticals, and employees.
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Affiliation(s)
- Marcel Niemann
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany,Correspondence should be addressed to M Niemann;
| | - Ellen Otto
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Eder
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Yasmin Youssef
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Lutz Kaufner
- Charité – Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sven Märdian
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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7
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Plasma thrombin generation kinetics in trauma patients across the age spectrum. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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8
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Goswami J, MacArthur TA, Mahony C, Kizhakkedathu JN, Vappala S, Smith S, Morrissey JH, Spears GM, Bailey KR, Dong JF, Kozar RA, Hall N, Johnstone A, Park MS. DNASE-MEDIATED DISSOLUTION OF NEUTROPHIL EXTRACELLULAR TRAPS ACCELERATES IN VITRO THROMBIN GENERATION KINETICS IN TRAUMA PATIENTS. Shock 2022; 58:217-223. [PMID: 35959777 PMCID: PMC9810375 DOI: 10.1097/shk.0000000000001972] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
ABSTRACT Introduction: Neutrophil extracellular traps (NETs) trigger thrombin generation. We aimed to characterize the effects of deoxyribonuclease (DNAse) on NET components (cell-free DNA [cfDNA] and histones) and thrombin generation after trauma. Methods: Citrated plasma samples were collected from trauma patients and healthy volunteers. Thrombin generation (calibrated automated thrombogram) was measured as lag time (LT, in minutes), peak height (in nM), and time to peak thrombin generation (in minutes). Citrullinated histone 3 (CitH3) and 4 (CitH4) were measured by enzyme-linked immunosorbent assay; cfDNA by PicoGreen (all in nanograms per milliliter). Samples analyzed +/- DNAse (1,000 U/mL). Results expressed as median and quartiles [Q1, Q3], Wilcoxon testing, P < 0.05 significant. Results: We enrolled 46 patients (age, 48 [31, 67] years; 67% male) and 21 volunteers (age, 45 [28, 53] years; 43% male). Deoxyribonuclease treatment of trauma plasma led to shorter LT (3.11 [2.67, 3.52] min; 2.93 [2.67, 3.19] min), shorter time to peak thrombin generation (6.00 [5.30, 6.67] min; 5.48 [5.00, 6.00] min), greater peak height (273.7 [230.7, 300.5] nM; 288.7 [257.6, 319.2] nM), decreased cfDNA (576.9 [503.3, 803.1] ng/mL; 456.0 [393.5, 626.7] ng/mL), decreased CitH3 (4.54 [2.23, 10.01] ng/mL; 3.59 [1.93, 7.98] ng/mL), and increased H4 (1.30 [0.64, 6.36] ng/mL; 1.75 [0.83, 9.67] ng/mL), all P < 0.001. The effect of DNAse was greater on trauma patients as compared with volunteers for LT (ΔLT, -0.21 vs. -0.02 min, P = 0.007), cfDNA (ΔcfDNA -133.4 vs. -84.9 ng/mL, P < 0.001), and CitH3 (ΔCitH3, -0.65 vs. -0.11 ng/mL, P = 0.004). Conclusion: Deoxyribonuclease treatment accelerates thrombin generation kinetics in trauma patient samples as compared with healthy volunteers. These findings suggest that NETs may contribute to the hypercoagulable state observed in trauma patients.
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Affiliation(s)
- Julie Goswami
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN 55905
| | - Taleen A. MacArthur
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN 55905
| | - Cillian Mahony
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN 55905
| | - Jayachandran N. Kizhakkedathu
- Department of Pathology and Laboratory Medicine, Centre for Blood Research, University of British Columbia, Vancouver, BC, V6T 2B5
| | - Sreeparna Vappala
- Department of Pathology and Laboratory Medicine, Centre for Blood Research, University of British Columbia, Vancouver, BC, V6T 2B5
| | - Stephanie Smith
- Department of Biological Chemistry, University of Michigan Medical School, 1150 W. Medical Center Drive, Ann Arbor, MI 48109
| | - James H. Morrissey
- Department of Biological Chemistry, University of Michigan Medical School, 1150 W. Medical Center Drive, Ann Arbor, MI 48109
| | - Grant M. Spears
- Clinical Statistics and Biostatistics, Department of Health Sciences Research, Mayo Clinic, 200 1st St. SW, Rochester, MN 55905
| | - Kent R. Bailey
- Clinical Statistics and Biostatistics, Department of Health Sciences Research, Mayo Clinic, 200 1st St. SW, Rochester, MN 55905
| | - Jing-Fei Dong
- Division of Hematology, University of Washington School of Medicine, Bloodworks Research Institute, 1551 Eastlake Avenue E, Seattle, WA 98102
| | - Rosemary A. Kozar
- Shock Trauma Center, University of Maryland School of Medicine, 22 S Greene St., Baltimore, MD 21201
| | - Nathan Hall
- EpiCypher, Inc. 6 Davis Dr., Durham, NC 27709
| | | | - Myung S. Park
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN 55905
- Division of Hematology, Mayo Clinic, 200 1st St. SW, Rochester, MN 55905
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Zeineddin A, Wu F, Dong JF, Huang H, Zou L, Chao W, Dorman B, Kozar RA. TRAUMA-DERIVED EXTRACELLULAR VESICLES ARE SUFFICIENT TO INDUCE ENDOTHELIAL DYSFUNCTION AND COAGULOPATHY. Shock 2022; 58:38-44. [PMID: 35984759 PMCID: PMC9750939 DOI: 10.1097/shk.0000000000001950] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACTINTRODUCTION Although a number of studies have demonstrated increased release of extracellular vesicles (EVs) and changes in their origin differentials after trauma, the biologic significance of EVs is not well understood. We hypothesized that EVs released after trauma/hemorrhagic shock (HS) contribute to endotheliopathy and coagulopathy. To test this hypothesis, adoptive transfer experiments were performed to determine whether EVs derived from severely injured patients in shock were sufficient to induce endothelial dysfunction and coagulopathy. Methods: Total EVs were enriched from plasma of severely injured trauma/HS patients or minimally injured patients by ultracentrifugation and characterized for size and numbers. Under isoflurane anesthesia, noninjured naive C57BL/6J mice were administered EVs at varying concentrations and compared with mice receiving equal volume vehicle (phosphate-buffered saline (PBS)) or to mice receiving EVs from minimally injured patients. Thirty minutes after injection, mice were sacrificed, and blood was collected for thrombin generation (thrombin-antithrombin, thrombin-antithrombin complex [TAT] assay) and syndecan-1 by enzyme-linked immunoabsorbent assay (ELISA). Lungs were harvested for examination of histopathologic injury and costained with von Willebrand factor and fibrin to identify intravascular coagulation. Bronchial alveolar lavage fluid was aspirated from lungs for protein measurement as an indicator of the endothelial permeability. Data are presented as mean ± SD, P < 0.05 was considered significant, and t test was used. Results: An initial proof-of-concept experiment was performed in naive mice receiving EVs purified from severely injured trauma/HS patients (Injury Severity Score [ISS], 34 ± 7) at different concentrations (5 × 106 to 3.1 × 109/100 μL/mouse) and compared with PBS (control) mice. Neither TAT nor syndecan-1 levels were significantly different between groups at 30 minutes after EV infusion. However, lung vascular permeability and histopathologic injury were significantly higher in the EV group, and lung tissues demonstrated intravascular fibrin deposition. Based on these data, EVs from severely injured trauma/HS patients (ISS, 32 ± 6) or EVs from minimally injured patients (ISS, 8 ± 3) were administered to naive mice at higher concentrations (1 × 109 to 1 × 1010 EV/100 μL/mouse). Compared with mice receiving EVs from minimally injured patients, plasma TAT and syndecan-1 levels were significantly higher in the trauma/HS EV group. Similarly, bronchial alveolar lavage protein and lung histopathologic injury were higher in the trauma/HS EV group, and lung tissues demonstrated enhanced intravascular fibrin deposition. Conclusion: These data demonstrate that trauma/HS results in the systemic release of EVs, which are capable of inducing endotheliopathy as demonstrated by elevated syndecan-1 and increased permeability and coagulopathy as demonstrated by increased TAT and intravascular fibrin deposition. Targeting trauma-induced EVs may represent a novel therapeutic strategy.
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Affiliation(s)
- Ahmad Zeineddin
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD US
| | - Feng Wu
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD US
| | - Jing-Fei Dong
- Bloodworks Research Institute, Seattle, WA, US
- Hematology Division, Department of Medicine, University of Washington School of Medicine, Seattle, WA, US
| | - Huang Huang
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, US
| | - Lin Zou
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, US
| | - Wei Chao
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, US
| | - Brooke Dorman
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD US
| | - Rosemary A Kozar
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD US
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10
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Touw CE, Nemeth B, Lijfering WM, van Adrichem RA, Wilsgård L, Latysheva N, Ramberg C, Nelissen RGHH, Hansen J, Cannegieter SC. Effect of lower-leg trauma and knee arthroscopy on procoagulant phospholipid-dependent activity. Res Pract Thromb Haemost 2022; 6:e12729. [PMID: 35702586 PMCID: PMC9175257 DOI: 10.1002/rth2.12729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/25/2022] [Accepted: 04/10/2022] [Indexed: 11/10/2022] Open
Abstract
Background Lower-leg injury and knee arthroscopy are both associated with venous thromboembolism (VTE). The mechanism of VTE in both situations is unknown, including the role of procoagulant microparticles. This may provide useful information for individualizing thromboprophylactic treatment in both patient groups. Objective We aimed to study the effect of (1) lower-leg trauma and (2) knee arthroscopy on procoagulant phospholipid-dependent (PPL) activity plasma levels. Methods POT-(K)CAST trial participants who did not develop VTE were randomly selected for the current study. Plasma was collected shortly after lower-leg trauma or before and after knee arthroscopy. For aim 1, samples of 67 patients with lower-leg injury were compared with control samples (preoperative samples of 74 patients undergoing arthroscopy). Linear regression was used to obtain mean ratios (natural logarithm retransformed data), adjusted for age, sex, body mass index, infections, and comorbidities. For aim 2, pre- and postoperative samples of 49 patients undergoing arthroscopy were compared using paired t tests. PPL activity was measured using modified activated factor X-dependent PPL clotting assay. Results For aim 1, PPL activity levels were almost threefold higher in patients with lower-leg injury compared with controls, that is, mean ratio, 2.82 (95% confidence interval [CI], 1.98-4.03). For aim 2, postoperative PPL activity levels did not change significantly, that is, mean change, -0.72 mU/mL (95% CI, -2.03 to 0.59). Conclusion Lower-leg trauma was associated with increased plasma levels of PPL activity, in contrast to knee arthroscopy. Lower-leg trauma triggers the release of procoagulant microparticles.
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Affiliation(s)
- Carolina E. Touw
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of OrthopaedicsLeiden University Medical CenterLeidenThe Netherlands
| | - Banne Nemeth
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of OrthopaedicsLeiden University Medical CenterLeidenThe Netherlands
| | - Willem M. Lijfering
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Raymond A. van Adrichem
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of OrthopaedicsLeiden University Medical CenterLeidenThe Netherlands
| | - Line Wilsgård
- Thrombosis Research Center (TREC)The Arctic University of NorwayTromsoNorway
| | - Nadezhda Latysheva
- Thrombosis Research Center (TREC)The Arctic University of NorwayTromsoNorway
| | - Cathrine Ramberg
- Thrombosis Research Center (TREC)The Arctic University of NorwayTromsoNorway
| | | | - John‐Bjarne Hansen
- Thrombosis Research Center (TREC)The Arctic University of NorwayTromsoNorway
- Division of internal medicineUniversity Hospital of North NorwayTromsøNorway
| | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Internal MedicineSection of Thrombosis and HaemostasisLeiden University Medical CenterLeidenThe Netherlands
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11
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Alsaadi N, Srinivasan AJ, Seshadri A, Shiel M, Neal MD, Scott MJ. The emerging therapeutic potential of extracellular vesicles in trauma. J Leukoc Biol 2022; 111:93-111. [PMID: 34533241 PMCID: PMC9169334 DOI: 10.1002/jlb.3mir0621-298r] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Traumatic injury is a major cause of morbidity and mortality worldwide, despite significant advances in treatments. Most deaths occur either very early, through massive head trauma/CNS injury or exsanguination (despite advances in transfusion medicine), or later after injury often through multiple organ failure and secondary infection. Extracellular vesicles (EVs) are known to increase in the circulation after trauma and have been used to limited extent as diagnostic and prognostic markers. More intriguingly, EVs are now being investigated as both causes of pathologies post trauma, such as trauma-induced coagulopathy, and as potential treatments. In this review, we highlight what is currently known about the role and effects of EVs in various aspects of trauma, as well as exploring current literature from investigators who have begun to use EVs therapeutically to alter the physiology and pathology of traumatic insults. The potential effectiveness of using EVs therapeutically in trauma is supported by a large number of experimental studies, but there is still some way to go before we understand the complex effects of EVs in what is already a complex disease process.
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Affiliation(s)
- Nijmeh Alsaadi
- Division of General and Trauma Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amudan J Srinivasan
- Division of General and Trauma Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anupamaa Seshadri
- Division of General and Trauma Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Matthew Shiel
- Division of Hematology-Oncology, Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Matthew D Neal
- Division of General and Trauma Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Melanie J Scott
- Division of General and Trauma Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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12
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Cardenas JC. Thrombin Generation Following Severe Trauma: Mechanisms, Modulators, and Implications for Hemostasis and Thrombosis. Shock 2021; 56:682-690. [PMID: 33660669 DOI: 10.1097/shk.0000000000001773] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Thrombin is the central coagulation enzyme that catalyzes the conversion of fibrinogen to form insoluble fibrin blood clots. In vivo, thrombin production results from the concerted effort of plasma enzymatic reactions with essential contributions from circulating and vessel wall cells. The relative amount of thrombin produced directly dictates the structure and stability of fibrin clots; therefore, sufficient thrombin generation is essential for normal hemostasis to occur. Examination of thrombin generation phenotypes among severely injury trauma patients reveals important relationships between the potential for generating thrombin and risks of bleeding and thrombotic complications. Thus, understanding determinants of thrombin generation following traumatic injury is of high clinical importance. This review will focus on patterns and mechanisms of thrombin generation in severely injured patients, the role of fluid resuscitation in modulating thrombin generation and implications for outcomes.
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Affiliation(s)
- Jessica C Cardenas
- Division of Acute Care Surgery and Center for Translationssal Injury Research, Department of Surgery, McGovern School of Medicine, The University of Texas Health Science Center, Houston, Texas
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13
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Rognes IN, Hellum M, Ottestad W, Bache KG, Eken T, Henriksson CE. Extracellular vesicle-associated procoagulant activity is highest the first 3 hours after trauma and thereafter declines substantially: A prospective observational pilot study. J Trauma Acute Care Surg 2021; 91:681-691. [PMID: 34225342 PMCID: PMC8460081 DOI: 10.1097/ta.0000000000003333] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/07/2021] [Accepted: 06/24/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Trauma patients have high concentrations of circulating extracellular vesicles (EVs) following injury, but the functional role of EVs in this setting is only partly deciphered. We aimed to describe in detail EV-associated procoagulant activity in individual trauma patients during the first 12 hours after injury to explore their putative function and relate findings to relevant trauma characteristics and outcome. METHODS In a prospective observational study of 33 convenience recruited trauma patients, citrated plasma samples were obtained at trauma center admission and 2, 4, 6, and 8 hours thereafter. We measured thrombin generation from isolated EVs and the procoagulant activity of phosphatidylserine (PS)-exposing EVs. Correlation and multivariable linear regression analyses were used to explore associations between EV-associated procoagulant activity and trauma characteristics as well as outcome measures. RESULTS EV-associated procoagulant activity was highest in the first 3 hours after injury. EV-associated thrombin generation normalized within 7 to 12 hours of injury, whereas the procoagulant activity of PS-exposing EVs declined to a level right above that of healthy volunteers. Increased EV-associated procoagulant activity at admission was associated with higher New Injury Severity Score, lower admission base excess, higher admission international normalized ratio, prolonged admission activated partial thromboplastin time, higher Sequential Organ Failure Assessment score at day 0, and fewer ventilator-free days. CONCLUSION Our data suggest that EVs have a transient hypercoagulable function and may play a role in the early phase of hemostasis after injury. The role of EVs in trauma-induced coagulopathy and posttraumatic thrombosis should be studied bearing in mind this novel temporal pattern. LEVEL OF EVIDENCE Prognostic/epidemiologic, level V.
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14
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Goswami J, MacArthur T, Bailey K, Spears G, Kozar RA, Auton M, Dong JF, Key NS, Heller S, Loomis E, Hall NW, Johnstone AL, Park MS. Neutrophil Extracellular Trap Formation and Syndecan-1 Shedding Are Increased After Trauma. Shock 2021; 56:433-439. [PMID: 33534396 PMCID: PMC8316482 DOI: 10.1097/shk.0000000000001741] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Damage-associated molecular patterns (DAMPs) stimulate endothelial syndecan-1 shedding and neutrophil extracellular traps (NET) formation. The role of NETs in trauma and trauma-induced hypercoagulability is unknown. We hypothesized that trauma patients with accelerated thrombin generation would have increased NETosis and syndecan-1 levels. METHODS In this pilot study, we analyzed 50 citrated plasma samples from 30 trauma patients at 0 h (n = 22) and 6 h (n = 28) from time of injury (TOI) and 21 samples from healthy volunteers, for a total of 71 samples included in analysis. Thrombin generation was quantified using calibrated automated thrombogram (CAT) and reported as lag time (LT), peak height (PH), and time to peak (ttPeak). Nucleosome calibrated (H3NUC) and free histone standardized (H3Free) ELISAs were used to quantify NETs. Syndecan-1 levels were quantified by ELISA. Results are presented as median [interquartile range] and Spearman rank correlations. RESULTS Plasma levels of H3NUC were increased in trauma patients as compared with healthy volunteers both at 0 h (89.8 ng/mL [35.4, 180.3]; 18.1 ng/mL [7.8, 37.4], P = 0.002) and at 6 h (86.5 ng/mL [19.2, 612.6]; 18.1 ng/mL [7.8, 37.4], P = 0.003) from TOI. H3Free levels were increased in trauma patients at 0 h (5.74 ng/mL [3.19, 8.76]; 1.61 ng/mL [0.66, 3.50], P = 0.002) and 6 h (5.52 ng/mL [1.46, 11.37]; 1.61 ng/mL [0.66, 3.50], P = 0.006). Syndecan-1 levels were greater in trauma patients (4.53 ng/mL [3.28, 6.28]; 2.40 ng/mL [1.66, 3.20], P < 0.001) only at 6 h from TOI. H3Free and syndecan-1 levels positively correlated both at 0 h (0.376, P = 0.013) and 6 h (0.583, P < 0.001) from TOI. H3NUC levels and syndecan-1 levels were positively correlated at 6 h from TOI (0.293, P = 0.041). TtPeak correlated inversely to H3 NUC (-0.358, P = 0.012) and syndecan-1 levels (-0.298, P = 0.038) at 6 h from TOI. CONCLUSIONS Our pilot study demonstrates that trauma patients have increased NETosis, measured by H3NUC and H3Free levels, increased syndecan-1 shedding, and accelerated thrombin generation kinetics early after injury.
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Affiliation(s)
- Julie Goswami
- Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Taleen MacArthur
- Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Kent Bailey
- Clinical Statistics and Biostatistics, Department of Health Sciences Research, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Grant Spears
- Clinical Statistics and Biostatistics, Department of Health Sciences Research, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Rosemary A. Kozar
- Shock Trauma Center, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD, 21201
| | - Matthew Auton
- Biochemistry and Molecular Biology, Department of Hematology, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Jing-Fei Dong
- Division of Hematology, University of Washington School of Medicine, Bloodworks Research Institute, 1551 Eastlake Avenue E, Seattle, WA, 98102
| | - Nigel S. Key
- Division of Hematology and UNC Blood Research Center, Department of Medicine, University of North Carolina at Chapel Hill, NC, 27514
| | - Stephanie Heller
- Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | - Erica Loomis
- Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
| | | | | | - Myung S. Park
- Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN, 55905
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Hayakwa M, Ooyasu T, Sadamoto Y, Saito T, Yoshida T, Katabami K, Wada T, Maekawa K, Ieko M. Microparticles and Nucleosomes Are Released From Parenchymal Cells Destroyed After Injury in a Rat Model of Blunt Trauma. Clin Appl Thromb Hemost 2021; 26:1076029620950825. [PMID: 32833555 PMCID: PMC7448264 DOI: 10.1177/1076029620950825] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
We investigated the relationships between circulating procoagulants and trauma severity, including cellular destruction, and the effects of thrombin generation on procoagulants in a rat blunt trauma model. The rats were subjected to tumbling blunt trauma, where they were tumbled for 0, 250, 500, or 1000 revolutions. Creatine kinase, nucleosome, and microparticle plasma levels increased gradually with trauma severity. Strong interrelationships were observed among creatine kinase, nucleosome, and microparticle levels. Time to initiation of thrombin generation shortened with increasing trauma severity. In accordance with trauma severity, prothrombin activity decreased, but the thrombin generation ratio increased. Time to initiation of thrombin generation and the thrombin generation ratio correlated with creatine kinase levels. In an in vitro study, a homogenized muscle solution, which included massive nucleosomes and microparticles, showed accelerated thrombin generation of plasma from healthy subjects. Procoagulants, such as microparticles and nucleosomes, are released from destroyed parenchymal cells immediately after external traumatic force, activating the coagulation cascade. The procoagulants shorten the time to initiation of thrombin generation. Furthermore, although coagulation factors are consumed, the thrombin generation ratio increases.
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Affiliation(s)
- Mineji Hayakwa
- Department of Emergency Medicine, 163693Hokkaido University Hospital, Sapporo, Japan
| | - Takayoshi Ooyasu
- Department of Emergency Medicine, 163693Hokkaido University Hospital, Sapporo, Japan
| | - Yoshihiro Sadamoto
- Department of Emergency Medicine, 163693Hokkaido University Hospital, Sapporo, Japan
| | - Tomoyo Saito
- Department of Emergency Medicine, 163693Hokkaido University Hospital, Sapporo, Japan
| | - Tomonao Yoshida
- Department of Emergency Medicine, 163693Hokkaido University Hospital, Sapporo, Japan
| | - Kenichi Katabami
- Department of Emergency Medicine, 163693Hokkaido University Hospital, Sapporo, Japan
| | - Takeshi Wada
- Department of Emergency Medicine, 163693Hokkaido University Hospital, Sapporo, Japan
| | - Kunihiko Maekawa
- Department of Emergency Medicine, 163693Hokkaido University Hospital, Sapporo, Japan
| | - Masahiro Ieko
- Department of Internal Medicine, School of Dentistry, 12811Health Sciences University of Hokkaido, Ishikari-Tobetsu, Japan
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16
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MacArthur TA, Spears GM, Kozar RA, Dong JF, Auton M, Jenkins DH, Bailey KR, Ashrani AA, Ferrara MJ, Immermann JM, Halling TM, Park MS. Thrombin Generation Kinetics are Predictive of Rapid Transfusion in Trauma Patients Meeting Critical Administration Threshold. Shock 2021; 55:321-325. [PMID: 32826809 PMCID: PMC7970628 DOI: 10.1097/shk.0000000000001633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION We hypothesize that a patient (pt) with accelerated thrombin generation, time to peak height (ttPeak), will have a greater odds of meeting critical administration threshold (CAT) criteria (> 3 packed red blood cell [pRBC] transfusions [Tx] per 60 min interval), within the first 24 h after injury, independent of international normalized ratio (INR). METHODS In a prospective cohort study, trauma patients were enrolled over a 4.5-year period and serial blood samples collected at various time points. We retrospectively stratified pts into three categories: CAT+, CAT- but receiving some pRBC Tx, receiving no Tx within the first 24 h. Blood collected prior to Tx was analyzed for thrombin generation parameters and prothrombin time (PT)/INR. RESULTS A total of 484 trauma pts were analyzed: injury severity score = 13 [7,22], age = 48 [28, 64] years, and 73% male. Fifty pts met criteria for CAT+, 64 pts CAT-, and 370 received no Tx. Risk factors for meeting CAT+: decreased arrival systolic blood pressure (OR 2.82 [2.17, 3.67]), increased INR (OR 2.09, [1.66, 2.62]) and decreased time to peak OR 2.27 [1.74, 2.95]). These variables remained independently associated with increased risk of requiring Tx in a multivariable logistic model, after adjusting for sex and trauma type. CONCLUSIONS Pts in hemorrhagic shock, who meet CAT+ criteria, are characterized by accelerated thrombin generation. In our multivariable analysis, both ttPeak and PT/INR have a complementary role in predicting those injured patients who will require a high rate of Tx.
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Affiliation(s)
| | - Grant M. Spears
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Rosemary A. Kozar
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jing-fei Dong
- Division of Hematology, Department of Medicine, University of Washington, School of Medicine, Seattle, Washington
| | - Matthew Auton
- Division of Hematology, Department of Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | | | - Kent R. Bailey
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Aneel A. Ashrani
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Timothy M. Halling
- Division of Hematology, Department of Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Myung S. Park
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, Minnesota
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17
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Ferrara MJ, MacArthur TA, Butenas S, Mann KG, Immermann JM, Spears GM, Bailey KR, Kozar RA, Heller SF, Loomis EA, Stephens D, Park MS. Exploring the utility of a novel point-of-care whole blood thrombin generation assay following trauma: A pilot study. Res Pract Thromb Haemost 2021; 5:395-402. [PMID: 33870025 PMCID: PMC8035795 DOI: 10.1002/rth2.12483] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/17/2020] [Accepted: 12/28/2020] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Plasma thrombin generation kinetics as measured by the calibrated automated thrombogram (CAT) assay is a predictor of symptomatic venous thromboembolism after trauma. We hypothesized that data from a new prototype assay for measurement of thrombin generation kinetics in fresh whole blood (near patient testing of thrombin generation), will correlate with the standard CAT assay in the same patients, making it a potential tool in the future care of trauma patients. METHODS Patients were enrolled from June 2018 to February 2020. Within 12 hours of injury, blood samples were collected simultaneously for both assays. Variables compared and correlated between assays were lag time, peak height, time to peak, and endogenous thrombin potential. Data are presented as median with interquartile range (IQR). Spearman and Pearson correlations were estimated and tested between both assays; a P value of <0.05 was considered to be significant. RESULTS A total of 64 trauma patients had samples analyzed: injury severity score = 17 (IQR), 10-26], hospital length of stay = 7.5 (IQR), 2-18) days, age = 52 (IQR, 35-63) years, 71.9% male, and 42.2% of patients received a transfusion within 24 hours of injury. Thrombin generation parameters between plasma and whole blood were compared and found that all parameters of the two assays correlate in trauma patients. CONCLUSION In this pilot study, we have found that a novel point-of-care whole blood thrombin generation assay yields results with modest but statistically significant correlations to those of a standard plasma thrombin generation assay. This finding supports studying this device in a larger, adequately powered study.
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Affiliation(s)
| | | | | | | | | | | | | | - Rosemary A. Kozar
- Shock Trauma CenterUniversity of Maryland School of MedicineBaltimoreMDUSA
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Fields AT, Matthay ZA, Nunez-Garcia B, Matthay EC, Bainton RJ, Callcut RA, Kornblith LZ. Good Platelets Gone Bad: The Effects of Trauma Patient Plasma on Healthy Platelet Aggregation. Shock 2021; 55:189-197. [PMID: 32694397 PMCID: PMC8547718 DOI: 10.1097/shk.0000000000001622] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Altered postinjury platelet behavior is recognized in the pathophysiology of trauma-induced coagulopathy (TIC), but the mechanisms remain largely undefined. Studies suggest that soluble factors released by injury may inhibit signaling pathways and induce structural changes in circulating platelets. Given this, we sought to examine the impact of treating healthy platelets with plasma from injured patients. We hypothesized that healthy platelets treated ex-vivo with plasma from injured patients with shock would impair platelet aggregation, while treatment with plasma from injured patients with significant injury burden, but without shock, would enhance platelet aggregation. METHODS Plasma samples were isolated from injured patients (pretransfusion) and healthy donors at a Level I trauma center and stored at -80°C. Plasma samples from four separate patients in each of the following stratified clinical groups were used: mild injury/no shock (injury severity score [ISS] 2-15, base excess [BE]>-6), mild injury/with shock (ISS 2-15, BE≤-6), severe injury/no shock (ISS>25, BE>-6), severe injury/with shock (ISS>25, BE≤-6), minimal injury (ISS 0/1, BE>-6), and healthy. Platelets were isolated from three healthy adult males and were treated with plasma for 30 min. Aggregation was stimulated with a thrombin receptor agonist and measured via multiple-electrode platelet aggregometry. Data were normalized to HEPES Tyrode's (HT) buffer-only treated platelets. Associations of plasma treatment groups with platelet aggregation measures were tested with Mann-Whitney U tests. RESULTS Platelets treated with plasma from patients with shock (regardless of degree of injury) had significantly impaired thrombin-stimulated aggregation compared with platelets treated with plasma from patients without shock (P = 0.002). Conversely, platelets treated with plasma from patients with severe injury, but without shock, had amplified thrombin-stimulated aggregation (P = 0.030). CONCLUSION Shock-mediated soluble factors impair platelet aggregation, and tissue injury-mediated soluble factors amplify platelet aggregation. Future characterization of these soluble factors will support development of novel treatments of TIC.
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Affiliation(s)
| | | | | | - Ellicott C. Matthay
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Roland J. Bainton
- Department of Anesthesia and Perioperative Care, University of California, San Francisco
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19
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Alencar JBDE, Lira RCA, Cavalcante RDAS, Lopes MBG, Sousa CJDDE, Lima DADE. INCIDENCE OF DEEP VEIN THROMBOSIS IN FLOATING KNEE. ACTA ORTOPEDICA BRASILEIRA 2021; 29:17-20. [PMID: 33795963 PMCID: PMC7976868 DOI: 10.1590/1413-785220212901230444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 07/14/2020] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To report the incidence of deep vein thrombosis (DVT) in ipsilateral femur and tibial fractures (floating knee). METHODS This is a retrospective, analytical, observational study conducted with the medical records of thirty patients admitted to a trauma hospital between October 2016 and July 2017 with floating knee. RESULTS Patients aged between 21-30 years were the most affected by the condition (36%). Seventeen patients affected the dominant limb (57%); 19 (63%) patients were classified as Fraser type I, 18 (60%) had open (compound) fractures, 16 (53%) tibial fractures, and 8 (26%) femoral fractures. External fixation of the femur and tibia (25 patients = 83%) was the most common emergency treatment. In total, 17% of patients presented deep venous thrombosis (p = 0.409). CONCLUSION Despite antithrombotic prophylaxis, the incidence of DVT in the affected limb of patients with floating knee was high. We found patients with Fraser I fractures, male, and with fractures in the non-dominant limb to present a higher chance of developing DVT. Level of Evidence III, Comparative retrospective study .
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20
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Strandvik G, El-Menyar A, Asim M, Galwankar S, Al-Thani H. Clinical Characteristics, Management Practices, and In-hospital Outcomes among Trauma Patients with Venous Thromboembolism. J Emerg Trauma Shock 2020; 13:124-130. [PMID: 33013091 PMCID: PMC7472818 DOI: 10.4103/jets.jets_83_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 02/04/2020] [Accepted: 02/24/2020] [Indexed: 11/04/2022] Open
Abstract
Background We aimed to assess the clinical characteristics, management practices, and inhospital outcomes of venous thromboembolism (VTE) among trauma patients. Methods A retrospective analysis of all trauma patients with documented venous thromboembolic events in a level 1 trauma center was conducted. Patients were categorized into two groups based on the primary initial presentation postinjury (deep-vein thrombosis [DVT] or pulmonary embolism [PE]). Results Across the study period, a total of 662 patients were confirmed to have DVT and 258 patients were diagnosed with acute PE. Among them, 84 patients were identified to have trauma-associated VTE; 56 (8.5%) had DVT and 28 (10.9%) had PE. Two patients who initially presented with DVT developed PE on follow-up. There were 38 females and 46 males with a mean age of 46 ± 18 years. Abnormal coagulation profile was reported as 7 protein C deficiencies, 5 protein S deficiencies, 6 homocystinemia, 4 antithrombin III deficiency, 4 lupus anticoagulant, and 2 Factor V Leiden. Age, sex, obesity, D-dimer level, and treatment (except for heparin) were comparable between the two groups; whereas protein S deficiency, prior history of PE, bedridden status, congestive heart failure, and history of recent surgery, were more evident in the PE group. The incidence of postthrombotic syndrome was significantly higher in the DVT group. Overall mortality rate was 8.3% (DVT; 8.9% vs. PE; 7.1%, respectively = 0.78). Conclusion Coagulation profile plays an important role in posttraumatic thromboembolic disease. A thorough assessment for features of thromboembolic disorders is warranted in polytrauma patients to avoid missing this potentially life-threatening diagnosis. Larger studies are needed for better understanding and management of VTE in trauma.
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Affiliation(s)
- Gustav Strandvik
- Trauma Surgery Section, Department of Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Ayman El-Menyar
- Clinical Research, Trauma and Vascular Surgery Section, Department of Surgery, HGH, Doha, Qatar, Qatar.,Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Mohammad Asim
- Clinical Research, Trauma and Vascular Surgery Section, Department of Surgery, HGH, Doha, Qatar, Qatar
| | - Sagar Galwankar
- Department of Emergency Medicine, Sarasota Memorial Hospital and Florida State University, Sarasota, Florida, USA
| | - Hassan Al-Thani
- Trauma Surgery Section, Department of Surgery, Hamad General Hospital (HGH), Doha, Qatar
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Thrombin Provokes Degranulation of Platelet α-Granules Leading to the Release of Active Plasminogen Activator Inhibitor-1 (PAI-1). Shock 2019; 50:671-676. [PMID: 29280928 DOI: 10.1097/shk.0000000000001089] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The balance of fibrinolytic mediators is crucial to the survival of the critically ill patient, with tissue plasminogen activator (t-PA) and plasminogen activator inhibitor-1 (PAI-1) playing significant roles. While elevated levels of PAI-1 are associated with increased morbidity and mortality, the source of this PAI-1 remains elusive. Platelets contain 90% of circulating plasma PAI-1, however, their ability to release active PAI-1 is controversial. We hypothesize platelets contain active PAI-1 in α-granules capable of immediate degranulation when exposed to high concentrations of thrombin. METHODS In vitro apheresis platelets were stimulated with thrombin (1 IU/mL, 5 IU/mL) followed by the collection of supernatant (5-120 min). Supernatant and lysate PAI-1 was measured by ELISA. The experiment was repeated in the presence of t-PA followed by measurement of t-PA:PAI-1 complex measurement by ELISA. Finally, healthy whole blood underwent dilution with control and thrombin-treated platelet lysate followed by thrombelastography (TEG) in a t-PA-stimulated TEG. RESULTS Thrombin provoked immediate near-complete degranulation of PAI-1 from α-granules (median 5m 5 IU/mL thrombin 125.1 ng/mL, 1 IU/mL thrombin 114.9 ng/mL, control 9.9 ng/mL). The released PAI-1 rapidly complexed with t-PA, with a 4-fold increase in complex formation in the thrombin-treated supernatant. Conversely, PAI-1 in the control lysate demonstrated a 6-fold increase in complex formation compared with thrombin lysate. Last, control platelet lysate inhibited t-PA-induced fibrinolysis by TEG (median LY30 control 15m 7.9%), while thrombin-treated platelet lysates, after PAI-1 degranulation, were unable to affect the fibrinolysis profile (median LY30 5 IU/mL 28.5%, 1 IU/mL 12.4%). CONCLUSION Thrombin provokes rapid α-degranulation of active PAI-1, capable of complexing with t-PA and neutralizing t-PA-induced fibrinolysis by TEG.
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Dyer MR, Alexander W, Hassoune A, Chen Q, Alvikas J, Liu Y, Haldeman S, Plautz W, Loughran P, Li H, Boone B, Sadovsky Y, Sunnd P, Zuckerbraun BS, Neal MD. Platelet-derived extracellular vesicles released after trauma promote hemostasis and contribute to DVT in mice. J Thromb Haemost 2019; 17:1733-1745. [PMID: 31294514 PMCID: PMC6773503 DOI: 10.1111/jth.14563] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 06/24/2019] [Accepted: 06/27/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Traumatic injury can lead to dysregulation of the normal clotting system, resulting in hemorrhagic and thrombotic complications. Platelet activation is robust following traumatic injury and one process of platelet activation is to release of extracellular vesicles (PEV) that carry heterogenous cargo loads and surface ligands. OBJECTIVES We sought to investigate and characterize the release and function of PEVs generated following traumatic injury. METHODS PEV content and quantity in circulation following trauma in humans and mice was measured using flow cytometry, size exclusion chromatography, and nanoparticle tracking analysis. PEVs were isolated from circulation and the effects on thrombin generation, bleeding time, hemorrhage control, and thrombus formation were determined. Finally, the effect of hydroxychloroquine (HCQ) on PEV release and thrombosis were examined. RESULTS Human and murine trauma results in a significant release of PEVs into circulation compared with healthy controls. These PEVs result in abundant thrombin generation, increased platelet aggregation, decreased bleeding times, and decreased hemorrhage in uncontrolled bleeding. Conversely, PEVs contributed to enhanced venous thrombus formation and were recruited to the developing thrombus site. Interestingly, HCQ treatment resulted in decreased platelet aggregation, decreased PEV release, and reduced deep vein thrombosis burden in mice. CONCLUSIONS These data demonstrate that trauma results in significant release of PEVs which are both pro-hemostatic and pro-thrombotic. The effects of PEVs can be mitigated by treatment with HCQ, suggesting the potential use as a form of deep vein thrombosis prophylaxis.
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Affiliation(s)
- Mitchell R. Dyer
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Adnan Hassoune
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Qiwei Chen
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jurgis Alvikas
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Yingjie Liu
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Shannon Haldeman
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Will Plautz
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Patricia Loughran
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
- Center for Biological Imaging, University of Pittsburgh, Pittsburgh, PA
| | - Hui Li
- Magee-Women’s Research Institute, Department of Obstetrics, Gynecology, and Reproductive Science, Pittsburgh, PA
- Xiangya School of Medicine, Central South University, Changsha, Hunan, 410000, China
| | - Brian Boone
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Yoel Sadovsky
- Magee-Women’s Research Institute, Department of Obstetrics, Gynecology, and Reproductive Science, Pittsburgh, PA
| | - Prithu Sunnd
- Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Matthew D. Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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Coleman JR, Moore EE, Samuels JM, Ryon JJ, Nelson JT, Olson A, Caus S, Bartley MG, Vigneshwar NG, Cohen MJ, Banerjee A, Silliman CC, Butenas S. Whole blood thrombin generation is distinct from plasma thrombin generation in healthy volunteers and after severe injury. Surgery 2019; 166:1122-1127. [PMID: 31522748 DOI: 10.1016/j.surg.2019.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 05/16/2019] [Accepted: 07/03/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Plasma thrombin generation has been used to characterize trauma-induced coagulopathy, but description of whole blood thrombin generation is lacking. This study aimed to evaluate plasma and whole blood thrombin generation in healthy volunteers and trauma patients. We hypothesized that (1) plasma and whole blood thrombin generation are distinct, (2) whole blood thrombin generation is more pronounced in trauma patients than in healthy volunteers, and (3) thrombin generation correlates with clinical coagulation assays. METHODS Blood was collected from healthy volunteers and trauma patients at a single, level-1 trauma center. Whole blood thrombin generation was assessed with a prototype point-of-care whole blood thrombin generation device, and plasma thrombin generation was measured with a calibrated automated thrombogram analogue. Plasma and whole blood thrombin generation were compared and correlated with international normalized ratio and thrombelastography. RESULTS Overall, 10 healthy volunteers (average age 30, 50% men) were included and 58 trauma patients (average age 34, 76% men, 55% blunt mechanism, and with a median new injury severity score of 17) were included. Plasma and whole blood thrombin generation differed with more robust thrombin generation in plasma. Trauma patients had a significantly increased whole blood thrombin generation compared with healthy volunteers]. Plasma thrombin generation correlated with international normalized ratio, whereas whole blood thrombin generation did not correlate with thrombelastography. CONCLUSION Plasma and whole blood thrombin generation are distinct, highlighting the need to perform standardized assays to better understand their correlation and to assess how whole blood thrombin generation confers differential outcomes in trauma.
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Affiliation(s)
- Julia R Coleman
- Department of Surgery, University of Colorado-Denver, Aurora, CO.
| | - Ernest E Moore
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, CO
| | - Jason M Samuels
- Department of Surgery, University of Colorado-Denver, Aurora, CO
| | - Joshua J Ryon
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, CO
| | | | - Alexander Olson
- Department of Biochemistry, University of Vermont, Burlington, VT
| | - Sandi Caus
- Department of Biochemistry, University of Vermont, Burlington, VT
| | | | | | - Mitchell J Cohen
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, CO
| | - Anirban Banerjee
- Department of Surgery, University of Colorado-Denver, Aurora, CO
| | - Christopher C Silliman
- Department of Hematology, Children's Hospital of Colorado, Aurora, CO; Vitalant Research Institute, Denver, CO
| | - Saulius Butenas
- Department of Biochemistry, University of Vermont, Burlington, VT
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Kornblith LZ, Moore HB, Cohen MJ. Response to Letter to the Editor submitted by Dr. Wada and Dr. Yamakawa re: Trauma-induced coagulopathy: The past, present, and future. J Thromb Haemost 2019; 17:1574-1576. [PMID: 31479184 PMCID: PMC6727975 DOI: 10.1111/jth.14581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 07/17/2019] [Indexed: 11/29/2022]
Abstract
It is with equal appreciation and enthusiasm that we have the opportunity to participate in these valuable scientific discussions with our respected colleagues Dr. Wada and Dr. Yamakawa, as we did with Dr. Gando and Dr. Otomo on their analogous disseminated-intravascular coagulation (DIC)-centric views of trauma-induced coagulopathy (TIC). We welcome and appreciate Drs Wada and Yamakawa’s expounded descriptions on their areas of their expertise specific to the critical thrombin-specific biologies. We find their additions valuable to the overall framing of the state of the science and controversies that exists in TIC investigations. However, we continue to support that it would be erroneous to continue to force an inflexible view of the complex biology of TIC, thereby failing to acknowledge the various competing mechanisms and mediators described throughout the literature, including the sometimes contradictory biomarker phenotypes that are ‘impaired’ in TIC. In addition, much of our following response to Drs Wada and Yamakawa’s letter will involve referring back to what was already addressed within the manuscript that appears to have been overlooked. However, of absolute importance, we would like to stress that TIC remains open science should therefore be regarded with open minds and without siloed opinions.
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Affiliation(s)
- Lucy Z. Kornblith
- Department of Surgery, Zuckerberg San Francisco General Hospital and the University of California, San Francisco, San Francisco, California, 1001 Potrero Avenue, Building 1, Suite 210, San Francisco, CA 94110
| | - Hunter B. Moore
- Department of Surgery, Denver Health Medical Center and the University of Colorado, Denver, Colorado, 777 Bannock Street. Mail Code 0206, Denver, CO 80203
| | - Mitchell J. Cohen
- Department of Surgery, Denver Health Medical Center and the University of Colorado, Denver, Colorado, 777 Bannock Street. Mail Code 0206, Denver, CO 80203
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Mendoza CE, Brant EJ, McDermott ML, Froment A, Hu Y, Hogan SL, Jennette JC, Falk RJ, Nachman PH, Derebail VK, Bunch DO. Elevated Microparticle Tissue Factor Activity Differentiates Patients With Venous Thromboembolism in Anti-neutrophil Cytoplasmic Autoantibody Vasculitis. Kidney Int Rep 2019; 4:1617-1629. [PMID: 31891003 PMCID: PMC6933462 DOI: 10.1016/j.ekir.2019.07.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 06/18/2019] [Accepted: 07/08/2019] [Indexed: 01/12/2023] Open
Abstract
Introduction Venous thromboembolism (VTE) is a life-threatening complication of anti-neutrophil cytoplasmic autoantibody (ANCA) vasculitis whose mechanism remains incompletely elucidated. We tested the hypothesis that elevated microparticle tissue factor activity (MPTFa) or anti-plasminogen antibodies (anti-Plg) may identify patients at risk for VTE. Methods In this prospective study, patients were enrolled during active disease and followed longitudinally. Twelve patients who experienced a VTE (VTEpos) were compared with patients without VTE (VTEneg, n = 29) and healthy controls (HC, n = 70). MPTFa, anti-Plg, interleukin-6, high-sensitivity C-reactive protein (hs-CRP), D-dimer, serum creatinine, and serum albumin were assessed. Fisher’s exact tests and Wilcoxon tests compared categorical and continuous variables, respectively. Cox regression for time to VTE or last follow-up was performed. Results VTEpos patients had higher MPTFa (peak median = 14.0, interquartile range = 4.3–36.6) than HC (0, 0–3.5) and VTEneg patients (0, 0–1.4). In time-to-event analysis, MPTFa was associated with VTE when measured during both active disease (hazard ratio [HR]; 95% confidence interval [CI]: 1.04; 1.01–1.08) and remission (1.4; 1.11–1.77). Anti-Plg during remission was also associated with VTE (1.17; 1.03–1.33). Each g/dl decrease of serum albumin was associated with a 4-fold increase in VTE risk (4.4; 1.5–12.9). Adjusting for estimated glomerular filtration rate (eGFR), anti-Plg during remission remained significantly associated with VTE. Conclusion Elevated MPTFa and increased anti-Plg in remission are strong indicators of VTE independent of renal function. Association of anti-Plg during remission with VTE implies hypercoagulability even during disease quiescence. Hypoalbuminemia strongly portends VTE risk, which is a novel finding in ANCA vasculitis. A thrombotic signature would allow improved management of patients to minimize VTE risk and complications of anticoagulation.
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Affiliation(s)
- Carmen E Mendoza
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Elizabeth J Brant
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Matthew L McDermott
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Anne Froment
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Yichun Hu
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Susan L Hogan
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - J Charles Jennette
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ronald J Falk
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Patrick H Nachman
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Vimal K Derebail
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Donna O'Dell Bunch
- Department of Medicine, Division of Nephrology, UNC Kidney Center, University of North Carolina, Chapel Hill, North Carolina, USA
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 696] [Impact Index Per Article: 139.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
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Affiliation(s)
- Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic
- Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005 Hradec Kralove, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003 Hradec Kralove, Czech Republic
- Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS B3H 2Y9 Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J. Hunt
- King’s College and Departments of Haematology and Pathology, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000 Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924 Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
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Validation of a Gravitational Model to Study Local Endogenous Biomarkers in Chronic Venous Insufficiency. Eur J Vasc Endovasc Surg 2018; 56:865-873. [DOI: 10.1016/j.ejvs.2018.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 08/02/2018] [Indexed: 02/01/2023]
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Protease-activated receptor 2 induces migration and promotes Slug-mediated epithelial-mesenchymal transition in lung adenocarcinoma cells. BIOCHIMICA ET BIOPHYSICA ACTA-MOLECULAR CELL RESEARCH 2018; 1866:486-503. [PMID: 30321617 DOI: 10.1016/j.bbamcr.2018.10.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 08/31/2018] [Accepted: 10/11/2018] [Indexed: 01/20/2023]
Abstract
Protease-activated receptor 2 (PAR2), a G protein-coupled receptor for trypsin, contributes to growth, anti-apoptosis, and migration in lung cancer. Given that PAR2 activation in airway epithelial cells compromises the airway epithelium barrier by disruption of E-cadherin adhesion, PAR2 may be involved in epithelial-mesenchymal transition (EMT) in lung adenocarcinoma cells. Although PAR2 is known to promote the migration of lung cancer cells, the detailed mechanism of this event is still not clear. Here, we found that PAR2 is highly expressed in several lung adenocarcinoma cell lines. In two lung adenocarcinoma cell lines, CL1-5 and H1299 cells, activation of PAR2 induces migration and Slug-mediated EMT. The underlying mechanisms involved in PAR2-induced migration and EMT in CL1-5 cells were further investigated. We showed that PAR2-induced migration of CL1-5 cells is mediated by the Src/p38 mitogen-activated protein kinase (p38 MAPK) signaling pathway. β-arrestin 1, not G protein, is involved in this PAR2-mediated Src/p38 MAPK signaling pathway. PAR2-induced EMT in CL1-5 cells is dependent on the activation of extracellular-signal-regulated kinase 2 (ERK2). The activation of ERK2 further mediates Slug stabilization through suppressing the activity of glycogen synthase kinase 3β. In addition, a poor prognosis was observed in lung adenocarcinoma patients with a high expression of PAR2. Thus, PAR2 regulates migration through β-arrestin 1-dependent activation of p38 MAPK and EMT through ERK2-mediated stabilization of Slug in lung adenocarcinoma cells. Our finding also suggests that PAR2 might serve as a therapeutic target for metastatic lung adenocarcinoma and a potential biomarker for predicting the prognosis of lung adenocarcinoma.
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Pohlman TH, Fecher AM, Arreola-Garcia C. Optimizing transfusion strategies in damage control resuscitation: current insights. J Blood Med 2018; 9:117-133. [PMID: 30154676 PMCID: PMC6108342 DOI: 10.2147/jbm.s165394] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
From clinical and laboratory studies of specific coagulation defects induced by injury, damage control resuscitation (DCR) emerged as the most effective management strategy for hemorrhagic shock. DCR of the trauma patient who has sustained massive blood loss consists of 1) hemorrhage control; 2) permissive hypotension; and 3) the prevention and correction of trauma-induced coagulopathies, referred to collectively here as acute coagulopathy of trauma (ACOT). Trauma patients with ACOT have higher transfusion requirements, may eventually require massive transfusion, and are at higher risk of exsanguinating. Distinct impairments in the hemostatic system associated with trauma include acquired quantitative and qualitative platelet defects, hypocoagulable and hypercoagulable states, and dysregulation of the fibrinolytic system giving rise to hyperfibrinolysis or a phenomenon referred to as fibrinolytic shutdown. Furthermore, ACOT is a component of a systemic host defense dysregulation syndrome that bears several phenotypic features comparable with other acute systemic physiological insults such as sepsis, myocardial infarction, and postcardiac arrest syndrome. Progress in the science of resuscitation has been continuing at an accelerated rate, and clinicians who manage catastrophic blood loss may be incompletely informed of important advances that pertain to DCR. Therefore, we review recent findings that further characterize the pathophysiology of ACOT and describe the application of this new information to optimization of resuscitation strategies for the patient in hemorrhagic shock.
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Affiliation(s)
- Timothy H Pohlman
- Department of Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN, USA,
| | - Alison M Fecher
- Department of Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN, USA
| | - Cecivon Arreola-Garcia
- Department of Surgery, Section of Acute Care Surgery, Indiana University Health, Indianapolis, IN, USA
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Munrós J, Martínez-Zamora MA, Tàssies D, Reverter JC, Rius M, Gracia M, Ros C, Carmona F. Total Circulating Microparticle Levels After Laparoscopic Surgical Treatment for Endometrioma: A Pilot, Prospective, Randomized Study Comparing Stripping with CO 2 Laser Vaporization. J Minim Invasive Gynecol 2018; 26:450-455. [PMID: 29803597 DOI: 10.1016/j.jmig.2018.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 05/10/2018] [Accepted: 05/17/2018] [Indexed: 01/17/2023]
Abstract
STUDY OBJECTIVE To evaluate serial generation of microparticles (MPs) after laparoscopic stripping or CO2 laser vaporization in the surgical treatment of patients with ovarian endometrioma (OE). DESIGN A prospective, randomized, blinded, pilot study (Canadian Task Force classification I). SETTING Tertiary care university hospital from December 2014 to July 2016. PATIENTS Thirty women with unilateral OE undergoing laparoscopic surgery. INTERVENTION Patients were randomly selected to undergo either CO2 laser vaporization (L group) or laparoscopic stripping (S group) of OE. MEASUREMENTS AND MAIN RESULTS Blood samples were collected before surgery and at 2 hours, 24 hours, 1 month, and 3 months after surgery. An MP generation curve after OE surgery was created. MP generation was greater in the S group than in the L group at all time points evaluated. The MP generation curve showed a significantly higher area under the curve after excisional surgery (p <.05). CONCLUSION The higher MP levels in the S group suggest an increased inflammation and procoagulant response after this procedure.
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Affiliation(s)
- Jordina Munrós
- Department of Gynecology, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clinic of Barcelona, Faculty of Medicine, University of Barcelona, Institut d'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Maria-Angeles Martínez-Zamora
- Department of Gynecology, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clinic of Barcelona, Faculty of Medicine, University of Barcelona, Institut d'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Dolors Tàssies
- Department of Hemotherapy and Hemostasis, Hospital Clinic of Barcelona, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Juan Carlos Reverter
- Department of Hemotherapy and Hemostasis, Hospital Clinic of Barcelona, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Mariona Rius
- Department of Gynecology, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clinic of Barcelona, Faculty of Medicine, University of Barcelona, Institut d'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Meritxell Gracia
- Department of Gynecology, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clinic of Barcelona, Faculty of Medicine, University of Barcelona, Institut d'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Cristina Ros
- Department of Gynecology, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clinic of Barcelona, Faculty of Medicine, University of Barcelona, Institut d'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Francisco Carmona
- Department of Gynecology, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Hospital Clinic of Barcelona, Faculty of Medicine, University of Barcelona, Institut d'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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Fröhlich M, Schäfer N, Caspers M, Böhm JK, Stürmer EK, Bouillon B, Maegele M. Temporal phenotyping of circulating microparticles after trauma: a prospective cohort study. Scand J Trauma Resusc Emerg Med 2018; 26:33. [PMID: 29703240 PMCID: PMC5921785 DOI: 10.1186/s13049-018-0499-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 04/11/2018] [Indexed: 11/29/2022] Open
Abstract
Background After severe polytrauma the dynamic process of coagulation may deteriorate towards a trauma-induced coagulopathy (TIC) promoting a dramatic increase in morbidity and mortality. Recent evidence suggests that microparticles (MPs) play a pivotal role at the interface between cellular and plasmatic coagulation systems. However, the impact of MPs on functional coagulation has not been clarified yet in the setting of traumatic injuries. We assessed the temporal patterns of circulating MP concentrations including their cellular origin in the context of clinical presentation and global coagulation assays. Methods Blood samples from 22 consecutive polytrauma patients (ISS ≥16) from 2015 were collected at hospital admission, after 24 and 72 h and compared to those from healthy individuals and minor injured patients with isolated extremity fractures. Flow cytometry (BD Accuri C6; Heidelberg/Germany) was used to determine MP concentrations and cellular origin using cell-specific markers (platelet derived (PDMP): CD42b+, CD61+, CD62p+; endothelial cell derived (EDMP): CD144+, CD62e+, CD144+/62e+). Results were correlated with clinical data and results from viscoelastic testing (ROTEM). Results Twenty two polytrauma patients (17 males, agemedian 60 yrs) with a median ISS 26.5 (IQR 14.5) were assessed. PDMP and EDMP concentrations increased significantly in polytrauma patients as compared to healthy individuals and minor injured patients. MP concentrations correlated with injury severity (CD144+: ρsp = 0.79, p < 0.001; CD42b+: ρsp = 0.61, p < 0.001). EDMP displayed a negative correlation with aPTT (CD144/62e+, ρsp = − 0.55, p < 0.05), INR (CD144/62e+, ρsp = − 0.61, p < 0.05) and ROTEM-INTEM CT (CD144/62e+, ρsp = − 0.68, p < 0.05) reflecting increased dynamics of clot formation and an overall procoagulative effect. Additionally, EDMP showed a negative association with FIBTEM values (10 min amplitude, maximum clot firmness) indicating a fibrinolytic potential. Discussion In a small cohort, analysing most severly injured patients, the association of increased MP levels and altered coagulation parameters could be demonstrated. However, these findings are based on correlation analysis, which do not enable causel evidence. Therefore, further in-vitro studies are needed analysing the underlying pathomechanisms. Conclusion In conclusion, this study could demonstrate that PDMP and EDMP levels increase significantly following polytrauma correlating with injury severity. Although severe coagulopathy was not observed, EDMP levels were associated with improved coagulation parameters suggesting their essential role for regulating blood coagulation after trauma.
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Affiliation(s)
- Matthias Fröhlich
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany. .,Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, D-51109, Cologne, Germany.
| | - Nadine Schäfer
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany
| | - Michael Caspers
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.,Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, D-51109, Cologne, Germany
| | - Julia K Böhm
- The Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany
| | - Ewa K Stürmer
- Department of Translational Wound Research, Centre for Biomedical Education and Research (ZBAF), Witten/Herdecke University, Stockumer Street 10, D-58453, Witten, Germany
| | - Bertil Bouillon
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, D-51109, Cologne, Germany
| | - Marc Maegele
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, D-51109, Cologne, Germany
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Clinical Significance of Tissue Factor and CD13 Double-Positive Microparticles in Sirs Patients with Trauma and Severe Sepsis. Shock 2018; 47:409-415. [PMID: 27753793 DOI: 10.1097/shk.0000000000000768] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Activated immune cells such as monocytes are key factors in systemic inflammatory response syndrome (SIRS) following trauma and sepsis. Activated monocytes induce almost all tissue factor (TF) expression contributing to inflammation and coagulation. TF and CD13 double-positive microparticles (TF/CD13MPs) are predominantly released from these activated monocytes. This study aimed to evaluate TF/CD13MPs and assess their usefulness as a biomarker of pathogenesis in early SIRS following trauma and sepsis. This prospective study comprising 24 trauma patients, 25 severe sepsis patients, and 23 healthy controls was conducted from November 2012 to February 2015. Blood samples were collected from patients within 24 h after injury and diagnosis of severe sepsis and from healthy controls. Numbers of TF/CD13MPs were measured by flow cytometry immediately thereafter. Injury Severity Score (ISS) and Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores were calculated at patient enrollment. APACHE II and SOFA scores and International Society of Thrombosis and Haemostasis (ISTH) overt disseminated intravascular coagulation (DIC) diagnostic criteria algorithm were calculated at the time of enrollment of severe sepsis patients. Numbers of TF/CD13MPs were significantly increased in both trauma and severe sepsis patients versus controls and correlated significantly with ISS and APACHE II score in trauma patients and with APACHE II and ISTH DIC scores in severe sepsis patients. Increased numbers of TF/CD13MPs correlated significantly with severities in the acute phase in trauma and severe sepsis patients, suggesting that TF/CD13MPs are important in the pathogenesis of early SIRS following trauma and sepsis.
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Huebner BR, Moore EE, Moore HB, Gonzalez E, Kelher MR, Sauaia A, Banerjee A, Silliman CC. Thrombin stimulates increased plasminogen activator inhibitor-1 release from liver compared to lung endothelium. J Surg Res 2018; 225:1-5. [PMID: 29605018 DOI: 10.1016/j.jss.2017.12.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 11/05/2017] [Accepted: 12/13/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Plasminogen activator inhibitor-1 (PAI-1) is a major regulator of the fibrinolytic system, covalently binding to tissue plasminogen activator and blocking its activity. Fibrinolysis shutdown is evident in the majority of severely injured patients in the first 24 h and is thought to be due to PAI-1. The source of this PAI-1 is thought to be predominantly endothelial cells, but there are known organ-specific differences, with higher levels thought to be in the liver. Thrombin generation is also elevated in injured patients and is a potent stimulus for PAI-1 release in human umbilical endothelial cells. We hypothesize that thrombin induces liver endothelial cells to release increased amounts of PAI-1, versus pulmonary endothelium, consisting of both stored PAI-1 and a larger contribution from de novo PAI-1 synthesis. METHODS Human liver sinusoidal endothelial cells (LSECs) and human microvascular lung endothelial cells (HMVECs) were stimulated in vitro ± thrombin (1 and 5 IU/mL) for 15-240 min, the supernatants were collected, and PAI-1 was measured by enzyme-linked immunosorbent assays. To elucidate the PAI-1 contribution from storage versus de novo synthesis, cycloheximide (10 μg/mL) was added before thrombin in separate experiments. RESULTS While both LSECs and HMVECs rapidly stimulated PAI-1 release, LSECs released more PAI-1 than HMVECs in response to high-dose thrombin, whereas low-dose thrombin did not provoke immediate release. LSECs continued to release PAI-1 over the ensuing 240 min, whereas HMVECs did not. Cycloheximide did not inhibit early PAI-1 release from LSECs but did at the later time points (30-240 min). CONCLUSIONS Thrombin elicits increased amounts of PAI-1 release from liver endothelium compared with lung, with a small presynthesized stored contribution and a later, larger increase in PAI-1 release via de novo synthesis. This study suggests that the liver may be an important therapeutic target for inhibition of the hypercoagulable surgical patient and the associated complications that result.
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Affiliation(s)
| | - Ernest E Moore
- Department of Surgery, University of Colorado, Aurora, Colorado; Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Hunter B Moore
- Department of Surgery, University of Colorado, Aurora, Colorado
| | | | | | - Angela Sauaia
- Department of Surgery, University of Colorado, Aurora, Colorado; Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | | | - Christopher C Silliman
- Bonfils Blood Center, Denver, Colorado; Department of Pediatrics, University of Colorado, Aurora, Colorado
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Shantsila E, Montoro-García S, Gallego P, Lip GYH. Circulating microparticles: challenges and perspectives of flow cytometric assessment. Thromb Haemost 2017; 111:1009-14. [DOI: 10.1160/th13-11-0937] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 01/07/2014] [Indexed: 12/18/2022]
Abstract
SummaryCirculating blood microparticles are likely to play a significant role as messengers of biological information. Their accurate quantification and characterisation is challenging and needs to be carefully designed with preferable usage of fresh minimally-processed blood samples. Utilisation of flow cytometers specifically designed for analysis of small-size particles is likely to provide considerable methodological advantages and should be the preferable option. This viewpoint manuscript provides a critical summary of the key methodological aspects of microparticle analysis.Note: The review process for this viewpoint article was fully handled by Christian Weber, Editor in Chief.
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Engelmann C, Splith K, Krohn S, Herber A, Boehlig A, Boehm S, Pratschke J, Berg T, Schmelzle M. Absolute quantification of microparticles by flow cytometry in ascites of patients with decompensated cirrhosis: a cohort study. J Transl Med 2017; 15:188. [PMID: 28877719 PMCID: PMC5586054 DOI: 10.1186/s12967-017-1288-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 08/24/2017] [Indexed: 01/06/2023] Open
Abstract
Background Microparticles (MPs) are small (<1 μm) cell membrane-derived vesicles that are formed in response to cellular activation or early stages of apoptosis. Increased plasma MP levels have been associated with liver disease severity. Here we investigated the clinical impact of ascites MPs in patients with decompensated liver cirrhosis. Methods Ascites and blood samples of 163 patients with cirrhosis (ascites n = 163, blood n = 31) were collected between February 2011 and December 2012. MPs were obtained from ascites and from blood by two-step ultracentrifugation and quantified by flow cytometry. Quantitative absolute MP levels were correlated with clinical and laboratory baseline parameters as well as patient outcomes. Ascites microparticles were stained with antibodies against CD66b (neutrophils) and CD3 (lymphocytes) in a subgroup of 60 matched patients. Results MPs were detected in all ascites and blood samples. Absolute ascites MP levels correlated with blood levels (r = 0.444, p = 0.011). Low ascites MP levels (<488.4 MP/μL) were associated with a poor 30-day survival probability (<488.4 MP/μL 71.1% vs. >488.4 MP/μL 94.7%, log rank p = 0.001) and such patients had a higher relative amount of ascites microparticles derived from neutrophils and lymphocytes. Low levels of ascites MPs, high MELD score and antibiotic treatment were independent risk factors for death within 30 days. Conclusions Ascites MP levels predict short-term survival along with the liver function in patients with decompensated cirrhosis. Further studies which evaluate ascites MPs as disease specific biomarker with a validation cohort and which investigate its underlying mechanisms are needed. Neutrophils and lymphocytes contributed more frequently to the release of microparticles in patients with low ascites levels, possibly indicating an immune activation in this cohort. Electronic supplementary material The online version of this article (doi:10.1186/s12967-017-1288-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Cornelius Engelmann
- Section of Hepatology, Department of Internal Medicine, Neurology, Dermatology, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.
| | - Katrin Splith
- Department of Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Sandra Krohn
- Section of Hepatology, Department of Internal Medicine, Neurology, Dermatology, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Adam Herber
- Section of Hepatology, Department of Internal Medicine, Neurology, Dermatology, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Albrecht Boehlig
- Section of Hepatology, Department of Internal Medicine, Neurology, Dermatology, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Stephan Boehm
- Klinische Virologie, Max von Pettenkofer-Institut, Medizinische Fakultät, Ludwig-Maximilians-Universität München, Pettenkoferstrasse 9a, 80336, Munich, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Thomas Berg
- Section of Hepatology, Department of Internal Medicine, Neurology, Dermatology, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Moritz Schmelzle
- Department of Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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Kuravi SJ, Yates CM, Foster M, Harrison P, Hazeldine J, Hampson P, Watson C, Belli A, Midwinter M, Nash GB. Changes in the pattern of plasma extracellular vesicles after severe trauma. PLoS One 2017; 12:e0183640. [PMID: 28837705 PMCID: PMC5570308 DOI: 10.1371/journal.pone.0183640] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 08/08/2017] [Indexed: 11/30/2022] Open
Abstract
Background Extracellular vesicles (EV) released into the circulation after traumatic injury may influence complications. We thus evaluated the numbers of EV in plasma over 28 days after trauma and evaluated their pro-coagulant and inflammatory effects. Methods and findings 37 patients suffering trauma with an injury severity score >15 were studied along with 24 healthy controls. Plasma samples were isolated by double centrifugation (2000g 20min; 13000g 2min) from blood collected from within an hour up to 28 days after injury. Plasma EV were counted and sized using nanoparticle tracking analysis (NTA); counts and cellular origins were also determined by flow cytometry (FC) using cell-specific markers. Functional effects were tested in a procoagulant phospholipid assay and in flow-based, leukocyte adhesion assay after endothelial cells (EC) were treated with EV. We found that EV concentrations measured by NTA were significantly increased in trauma patients compared to healthy controls, and remained elevated over days. In addition, or FC showed that patients with trauma had higher numbers of EV derived from platelets (CD41+), leukocytes (CD45+) and endothelial EC (CD144+). The increases were evident throughout the 28-day follow-up. However, the FC count represented <1% of the count detected by NTA, and only 1–2% of EV identified using NTA had a diameter >400nm. The procoagulant phospholipid activity assay showed that patient plasma accelerated coagulation on day 1 and day 3 after trauma, with coagulation times correlated with EV counts. Furthermore, treatment of EC for 24 hours with plasma containing EV tended to increase the recruitment of peripheral flowing blood mononuclear cells. Conclusions EV counted by FC represent a small sub-population of the total load detected by NTA. Both methods however indicate a significant increase in plasma EV after severe traumatic injury that have pro-coagulant and pro-inflammatory effects that may influence outcomes.
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Affiliation(s)
- Sahithi J. Kuravi
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Clara M. Yates
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Mark Foster
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Paul Harrison
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Jon Hazeldine
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Peter Hampson
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Chris Watson
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Antonio Belli
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Mark Midwinter
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Gerard B. Nash
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- * E-mail:
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Herbert JP, Guillotte AR, Hammer RD, Litofsky NS. Coagulopathy in the Setting of Mild Traumatic Brain Injury: Truths and Consequences. Brain Sci 2017; 7:brainsci7070092. [PMID: 28737691 PMCID: PMC5532605 DOI: 10.3390/brainsci7070092] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 07/09/2017] [Accepted: 07/18/2017] [Indexed: 12/03/2022] Open
Abstract
Mild traumatic brain injury (mTBI) is a common, although poorly-defined clinical entity. Despite its initially mild presentation, patients with mTBI can rapidly deteriorate, often due to significant expansion of intracranial hemorrhage. TBI-associated coagulopathy is the topic of significant clinical and basic science research. Unlike trauma-induced coagulopathy (TIC), TBI-associated coagulopathy does not generally follow widespread injury or global hypoperfusion, suggesting a distinct pathogenesis. Although the fundamental mechanisms of TBI-associated coagulopathy are far from clearly elucidated, several candidate molecules (tissue plasminogen activator (tPA), urokinase plasminogen activator (uPA), tissue factor (TF), and brain-derived microparticles (BDMP)) have been proposed which might explain how even minor brain injury can induce local and systemic coagulopathy. Here, we review the incidence, proposed mechanisms, and common clinical tests relevant to mTBI-associated coagulopathy and briefly summarize our own institutional experience in addition to identifying areas for further research.
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Affiliation(s)
- Joseph P Herbert
- Division of Neurological Surgery, University of Missouri School of Medicine, Columbia, MO 65212, USA.
| | - Andrew R Guillotte
- Division of Neurological Surgery, University of Missouri School of Medicine, Columbia, MO 65212, USA.
| | - Richard D Hammer
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, Columbia, MO 65212, USA.
| | - N Scott Litofsky
- Division of Neurological Surgery, University of Missouri School of Medicine, Columbia, MO 65212, USA.
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Tissue injury suppresses fibrinolysis after hemorrhagic shock in nonhuman primates (rhesus macaque). J Trauma Acute Care Surg 2017; 82:750-757. [PMID: 28129263 DOI: 10.1097/ta.0000000000001379] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hypoperfusion is associated with hyperfibrinolysis and early death from exsanguination, whereas tissue trauma is associated with hypofibrinolysis and delayed death from organ failure. We sought to elucidate the effects of injury patterns on fibrinolysis phenotypes using a nonhuman primate (NHP) model. METHODS NHPs were randomized to three injury groups (n = 8/group): 60 minutes severe pressure-targeted controlled hemorrhagic shock (HS); HS + soft tissue injury (HS+); or HS + soft tissue injury + femur fracture (HS++). Animals were resuscitated and monitored for 360 minutes. Blood samples were collected at baseline, end-of-shock, end-of-resuscitation (EOR), and T = 360 minutes for assessments of: severity of shock (lactate) and coagulation via prothrombin time, partial thromboplastin time, D-dimer, fibrinogen, antithrombin-III, von Willebrand factor, and viscoelastic testing (ROTEM). Results are reported as mean ± SEM; statistics: two-way analysis of variance and t-tests (significance: p < 0.05). RESULTS Blood loss, prothrombin time, partial thromboplastin time, antithrombin-III, fibrinogen, and von Willebrand factor were equivalent among groups and viscoelastic testing revealed few differences throughout the study. D-dimer increased approximately threefold, at EOR in the HS group, and at T = 360 minutes in the HS+ and HS++ groups (p < 0.05). At EOR, in the HS group compared with the HS+ and HS++ groups; the D-dimer-lactate ratio was twofold greater (2.2 ± 0.3 vs. 1.1 ± 0.3 and 1.1 ± 0.2, respectively; p < 0.05) and tissue factor-activated fibrin clot 30-minute lysis index was lower (98 ± 1% vs. 100 ± 0% and 100 ± 0%, respectively; p < 0.05). CONCLUSION NHPs in HS exhibit acute suppression of fibrinolysis in the presence of tissue injury. Additional assessments to more comprehensively evaluate the mechanisms linking tissue injury with the observed fibrinolysis shutdown response are warranted.
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Preoperative Platelet Count Predicts Lower Extremity Free Flap Thrombosis: A Multi-Institutional Experience. Plast Reconstr Surg 2017; 139:220-230. [PMID: 27632402 DOI: 10.1097/prs.0000000000002893] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Thrombocytosis in patients undergoing lower extremity free tissue transfer may be associated with increased risk of microvascular complications. This study assessed whether preoperative platelet counts predict lower extremity free flap thrombosis. METHODS All patients undergoing lower extremity free tissue transfer at Duke University from 1997 to 2013 and at the University of Pennsylvania from 2002 to 2013 were retrospectively identified. Logistic regression was used to assess whether preoperative platelet counts independently predict flap thrombosis, controlling for baseline and operative factors. RESULTS A total of 565 patients underwent lower extremity free tissue transfer, with an overall flap thrombosis rate of 16 percent (n = 91). Elevated preoperative platelet counts were independently associated with both intraoperative thrombosis (500 ± 120 versus 316 ± 144 × 10/liter; p < 0.001) and postoperative thrombosis (410 ± 183 versus 320 ± 143 × 10/liter; p = 0.040) in 215 patients who sustained acute lower extremity trauma within 30 days before reconstruction. In acute trauma patients, preoperative platelet counts predicted a four-fold increased risk of intraoperative thrombosis (cutoff value, 403 × 10/liter; OR, 4.08; p < 0.001) and a two-fold increased risk of postoperative thrombosis (cutoff value, 361 × 10/liter; OR, 2.16; p = 0.005). In patients who did not sustain acute trauma, preoperative platelet counts predicted a four-fold increased risk of intraoperative thrombosis (cutoff value, 352 × 10/liter; OR, 3.82; p = 0.002). CONCLUSIONS Acute trauma patients with elevated preoperative platelet counts are at increased risk for lower extremity free flap complications. Prospective evaluation is warranted for guiding risk stratification and targeted treatment strategies. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Vozel D, Uršič B, Krek JL, Štukelj R, Kralj-Iglič V. Applicability of extracellular vesicles in clinical studies. Eur J Clin Invest 2017; 47:305-313. [PMID: 28156006 DOI: 10.1111/eci.12733] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 01/29/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Extracellular vesicles (EVs) are submicron cellular fragments that mediate intercellular communication. EVs have in the last decade attracted major interest as biomarkers or platforms for biomarkers of health and disease. To better understand the reasons why despite great expectations and considerable effort, EV-based methods have not yet been introduced into clinical practice, we present a systematic analysis of published results of clinical studies. MATERIALS AND METHODS Clinical studies on populations of body fluid samples, published from 2010 to including 2015, applying centrifugation of fluid human samples with centrifuge accelerations up to about 25 000 g and flow cytometry for detection of EVs were analysed with respect to statistical significance (p), statistical power (P), clinical significance (CS), defined as the difference between the means divided by the sum of standard deviations, and size of the populations (Nmin ), defined as the number of samples in the smaller group. RESULTS Final analysis included 65 publications with 716 comparisons reporting 308 (43%) statistically significant differences (P < 0·05), 242 (34%) had statistical power P > 0·8 and 88 (12%) had clinical importance CS > 1·96. None of comparison with CS > 1·96 included populations in which the smaller group consisted of 50 or more samples. CONCLUSIONS To fulfil claimed expectations for EV-based methods as promising diagnostic tools, more evidence on EV-based mechanisms of diseases should be gathered. Also, the methods of EV harvesting and assessment should be improved to yield better repeatability and thus allow clinical studies with larger number of samples.
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Affiliation(s)
- Domen Vozel
- Laboratory of Clinical Biophysics, Faculty of Health Sciences, University of Ljubljana, Ljubljana, Slovenia
| | - Bojana Uršič
- Laboratory of Clinical Biophysics, Faculty of Health Sciences, University of Ljubljana, Ljubljana, Slovenia
| | - Judita Lea Krek
- Laboratory of Clinical Biophysics, Faculty of Health Sciences, University of Ljubljana, Ljubljana, Slovenia
| | - Roman Štukelj
- Laboratory of Clinical Biophysics, Faculty of Health Sciences, University of Ljubljana, Ljubljana, Slovenia
| | - Veronika Kralj-Iglič
- Laboratory of Clinical Biophysics, Faculty of Health Sciences, University of Ljubljana, Ljubljana, Slovenia
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Hayakawa M. Pathophysiology of trauma-induced coagulopathy: disseminated intravascular coagulation with the fibrinolytic phenotype. J Intensive Care 2017; 5:14. [PMID: 28289544 PMCID: PMC5282695 DOI: 10.1186/s40560-016-0200-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 12/17/2016] [Indexed: 01/29/2023] Open
Abstract
In severe trauma patients, coagulopathy is frequently observed in the acute phase of trauma. Trauma-induced coagulopathy is coagulopathy caused by the trauma itself. The pathophysiology of trauma-induced coagulopathy consists of coagulation activation, hyperfibrino(geno)lysis, and consumption coagulopathy. These pathophysiological mechanisms are the characteristics to DIC with the fibrinolytic phenotype.
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Affiliation(s)
- Mineji Hayakawa
- Emergency and Critical Care Center, Hokkaido University Hospital, N14W5 Kita-ku, Sapporo, 060-8648 Japan
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Hayakawa M. Dynamics of fibrinogen in acute phases of trauma. J Intensive Care 2017; 5:3. [PMID: 34798699 PMCID: PMC8600928 DOI: 10.1186/s40560-016-0199-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 12/17/2016] [Indexed: 11/10/2022] Open
Abstract
Fibrinogen is a unique precursor of fibrin and cannot be compensated for by other coagulation factors. If plasma fibrinogen concentrations are insufficient, hemostatic clots cannot be formed with the appropriate firmness. In severe trauma patients, plasma fibrinogen concentrations decrease earlier and more frequently than other coagulation factors, predicting massive bleeding and death. We review the mechanisms of plasma fibrinogen concentration decrease, which include coagulation activation-induced consumption, hyper-fibrino(geno)lysis-induced degradation, and dilution by infusion/transfusion. Understanding the mechanisms of plasma fibrinogen concentration decrease in severe trauma patients is crucial.
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Lee J, Jackman JG, Kwun J, Manook M, Moreno A, Elster EA, Kirk AD, Leong KW, Sullenger BA. Nucleic acid scavenging microfiber mesh inhibits trauma-induced inflammation and thrombosis. Biomaterials 2016; 120:94-102. [PMID: 28049065 DOI: 10.1016/j.biomaterials.2016.12.024] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 11/21/2016] [Accepted: 12/21/2016] [Indexed: 12/11/2022]
Abstract
Trauma patients produce a host of danger signals and high levels of damage-associated molecular patterns (DAMPs) after cellular injury and tissue damage. These DAMPs are directly and indirectly involved in the pathogenesis of various inflammatory and thrombotic complications in patients with severe injuries. No effective therapeutic agents for the removal of DAMPs from blood or tissue fluid have been developed. Herein, we demonstrated that nucleic acid binding polymers, e.g., polyethylenimine (PEI) and polyamidoamine dendrimers, immobilized onto electrospun microfiber mesh can effectively capture various DAMPs, such as extracellular DNAs and high mobility group box 1 (HMGB1). Furthermore, treatment with PEI-immobilized microfiber mesh abrogated the ability of DAMPs, released from dead and dying cells in culture or found in patients following traumatic injury, to activate innate immune responses and coagulation in vitro and in vivo. Nucleic acid scavenging microfiber meshes represent an effective strategy to combat inflammation and thrombosis in trauma.
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Affiliation(s)
- Jaewoo Lee
- Department of Surgery, Duke University, Durham, NC, 27710, USA.
| | - Jennifer G Jackman
- Department of Biomedical Engineering, Duke University, Durham, NC, 27710, USA
| | - Jean Kwun
- Department of Surgery, Duke University, Durham, NC, 27710, USA; Duke Transplant Center, Department of Surgery, Duke University, Durham, NC, 27710, USA
| | - Miriam Manook
- Department of Surgery, Duke University, Durham, NC, 27710, USA; Duke Transplant Center, Department of Surgery, Duke University, Durham, NC, 27710, USA
| | - Angelo Moreno
- Department of Molecular Genetics and Microbiology, Duke University, Durham, NC, 27710, USA
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
| | - Allan D Kirk
- Department of Surgery, Duke University, Durham, NC, 27710, USA; Duke Transplant Center, Department of Surgery, Duke University, Durham, NC, 27710, USA
| | - Kam W Leong
- Department of Biomedical Engineering, Duke University, Durham, NC, 27710, USA; Department of Biomedical Engineering, Columbia University, New York, NY, 10027, USA
| | - Bruce A Sullenger
- Department of Surgery, Duke University, Durham, NC, 27710, USA; Department of Molecular Genetics and Microbiology, Duke University, Durham, NC, 27710, USA.
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O’Dea KP, Porter JR, Tirlapur N, Katbeh U, Singh S, Handy JM, Takata M. Circulating Microvesicles Are Elevated Acutely following Major Burns Injury and Associated with Clinical Severity. PLoS One 2016; 11:e0167801. [PMID: 27936199 PMCID: PMC5148002 DOI: 10.1371/journal.pone.0167801] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 11/21/2016] [Indexed: 01/26/2023] Open
Abstract
Microvesicles are cell-derived signaling particles emerging as important mediators and biomarkers of systemic inflammation, but their production in severe burn injury patients has not been described. In this pilot investigation, we measured circulating microvesicle levels following severe burns, with severe sepsis patients as a comparator group. We hypothesized that levels of circulating vascular cell-derived microvesicles are elevated acutely following burns injury, mirroring clinical severity due to the early onset and prevalence of systemic inflammatory response syndrome (SIRS) in these patients. Blood samples were obtained from patients with moderate to severe thermal injury burns, with severe sepsis, and from healthy volunteers. Circulating microvesicles derived from total leukocytes, granulocytes, monocytes, and endothelial cells were quantified in plasma by flow cytometry. All circulating microvesicle subpopulations were elevated in burns patients on day of admission (day 0) compared to healthy volunteers (leukocyte-microvesicles: 3.5-fold, p = 0.005; granulocyte-microvesicles: 12.8-fold, p<0.0001; monocyte-microvesicles: 20.4-fold, p<0.0001; endothelial- microvesicles: 9.6-fold, p = 0.01), but decreased significantly by day 2. Microvesicle levels were increased with severe sepsis, but less consistently between patients. Leukocyte- and granulocyte-derived microvesicles on day 0 correlated with clinical assessment scores and were higher in burns ICU non-survivors compared to survivors (leukocyte MVs 4.6 fold, p = 0.002; granulocyte MVs 4.8 fold, p = 0.003). Mortality prediction analysis of area under receiver operating characteristic curve was 0.92 (p = 0.01) for total leukocyte microvesicles and 0.85 (p = 0.04) for granulocyte microvesicles. These findings demonstrate, for the first time, acute increases in circulating microvesicles following burns injury in patients and point to their potential role in propagation of sterile SIRS-related pathophysiology.
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Affiliation(s)
- Kieran P. O’Dea
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
| | - John R. Porter
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
- Intensive Care Unit, Chelsea and Westminster Hospital, London, United Kingdom
| | - Nikhil Tirlapur
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
| | - Umar Katbeh
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
| | - Suveer Singh
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
- Intensive Care Unit, Chelsea and Westminster Hospital, London, United Kingdom
| | - Jonathan M. Handy
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
- Intensive Care Unit, Chelsea and Westminster Hospital, London, United Kingdom
| | - Masao Takata
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
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Impact of Platelets and Platelet-Derived Microparticles on Hypercoagulability Following Burn Injury. Shock 2016; 45:82-7. [PMID: 26529651 DOI: 10.1097/shk.0000000000000460] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
An acute burn induced coagulopathy develops after scald injury, which evolves into a subacute, hypercoagulable state. Microparticles, specifically platelet-derived MPs (PMPs), have been suggested as possible contributors. We first developed a model of burn-induced coagulopathy and then sought to investigate the role of platelets and PMPs in coagulation after burn. We hypothesized that changes in circulating platelet and PMP populations after injury would contribute to the post-burn, hypercoagulable state. A murine scald model with 28% TBSA full thickness burn injury was utilized and blood samples were collected at intervals after injury. Circulating MP populations, platelet counts, overall coagulation, and platelet function were determined. Burn injury led to hypercoagulability on post-burn day one (PBD1), which persisted 6 days after injury (PBD6). On PBD1, there was a significant decrease in platelet numbers and a decline in platelet contribution to clot formation with a concomitant increase in circulating procoagulant PMPs. On PBD6, there was a significant increase in platelet numbers and in platelet activation with no change in PMPs compared with sham. Further, on PBD1 decreased ADP-induced platelet activation was observed with a contrasting increase in ADP-induced platelet activation on PBD6. We therefore concluded that there was a temporal change in the mechanisms leading to a hypercoagulable state after scald injury, that PMPs are responsible for changes seen on PBD1, and finally that ADP-induced platelet activation was key to the augmented clotting mechanisms 6 days after burn.
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Advances in the understanding of trauma-induced coagulopathy. Blood 2016; 128:1043-9. [PMID: 27381903 DOI: 10.1182/blood-2016-01-636423] [Citation(s) in RCA: 183] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 06/27/2016] [Indexed: 01/10/2023] Open
Abstract
Ten percent of deaths worldwide are due to trauma, and it is the third most common cause of death in the United States. Despite a profound upregulation in procoagulant mechanisms, one-quarter of trauma patients present with laboratory-based evidence of trauma-induced coagulopathy (TIC), which is associated with poorer outcomes including increased mortality. The most common causes of death after trauma are hemorrhage and traumatic brain injury (TBI). The management of TIC has significant implications in both because many hemorrhagic deaths could be preventable, and TIC is associated with progression of intracranial injury after TBI. This review covers the most recent evidence and advances in our understanding of TIC, including the role of platelet dysfunction, endothelial activation, and fibrinolysis. Trauma induces a plethora of biochemical and physiologic changes, and despite numerous studies reporting differences in coagulation parameters between trauma patients and uninjured controls, it is unclear whether some of these differences may be "normal" after trauma. Comparisons between trauma patients with differing outcomes and use of animal studies have shed some light on this issue, but much of the data continue to be correlative with causative links lacking. In particular, there are little data linking the laboratory-based abnormalities with true clinically evident coagulopathic bleeding. For these reasons, TIC continues to be a significant diagnostic and therapeutic challenge.
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Noble-Collip Drum Trauma Induces Disseminated Intravascular Coagulation But Not Acute Coagulopathy of Trauma-Shock. Shock 2016; 43:261-7. [PMID: 25423126 DOI: 10.1097/shk.0000000000000281] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There are two opposing possibilities for the main pathogenesis of trauma-induced coagulopathy: an acute coagulopathy of trauma shock and disseminated intravascular coagulation with the fibrinolytic phenotype. OBJECTIVE The objective of this study was to clarify the main pathogenesis of trauma-induced coagulopathy using a rat model of Noble-Collip drum trauma. METHODS Eighteen rats were divided into the control, trauma 0, and trauma 30 groups. The trauma 0 and 30 groups were exposed to Noble-Collip drum trauma. Blood samples were drawn without, immediately after, and 30 min after Noble-Collip drum trauma in the control, trauma 0, and trauma 30 groups, respectively. Coagulation and fibrinolysis markers were measured. Thrombin generation was assessed according to a calibrated automated thrombogram. RESULTS Spontaneous thrombin bursts resulting from circulating procoagulants were observed in the nonstimulated thrombin generation assay immediately after trauma. Soluble fibrin levels (a marker of thrombin generation in the systemic circulation) were 50-fold greater in the trauma groups than in the control group. The resultant coagulation activation consumed platelets, coagulation factors, and antithrombin. Endogenous thrombin potential and factor II ratio were significantly negatively correlated with antithrombin levels, suggesting insufficient control of thrombin generation by antithrombin. High levels of active tissue-type plasminogen activator induced hyperfibrin(ogen)olysis. Soluble thrombomodulin increased significantly. However, activated protein C levels did not change. CONCLUSIONS The systemic thrombin generation accelerated by insufficient antithrombin control leads to the consumption of platelets and coagulation factors associated with hyperfibrin(ogen)olysis. These changes are collectively termed disseminated intravascular coagulation with the fibrinolytic phenotype.
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Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer EAM, Ozier Y, Riddez L, Schultz A, Vincent JL, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016; 20:100. [PMID: 27072503 PMCID: PMC4828865 DOI: 10.1186/s13054-016-1265-x] [Citation(s) in RCA: 597] [Impact Index Per Article: 74.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/11/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.
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Affiliation(s)
- Rolf Rossaint
- />Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Bertil Bouillon
- />Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne-Merheim Medical Centre, Ostmerheimer Strasse 200, 51109 Cologne, Germany
| | - Vladimir Cerny
- />Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, 40113 Usti nad Labem, Czech Republic
- />Department of Research and Development, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesiology and Intensive Care, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, QE II Health Sciences Centre, 10 West Victoria, 1276 South Park St., Halifax, NS B3H 2Y9 Canada
| | - Timothy J. Coats
- />Emergency Medicine Academic Group, University of Leicester, University Road, Leicester, LE1 7RH UK
| | - Jacques Duranteau
- />Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Cedex France
| | - Enrique Fernández-Mondéjar
- />Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Granada, ctra de Jaén s/n, 18013 Granada, Spain
| | - Daniela Filipescu
- />Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, 022328 Bucharest, Romania
| | - Beverley J. Hunt
- />King’s College, Departments of Haematology, Pathology and Lupus, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- />Department of Traumatology, General and Teaching Hospital Celje, Oblakova 5, 3000 Celje, Slovenia
| | - Giuseppe Nardi
- />Shock and Trauma Centre, S. Camillo Hospital, Viale Gianicolense 87, 00152 Rome, Italy
| | - Edmund A. M. Neugebauer
- />Faculty of Health - School of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
| | - Yves Ozier
- />Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent, 29200 Brest, France
| | - Louis Riddez
- />Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden
| | - Arthur Schultz
- />Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre, Donaueschingenstrasse 13, 1200 Vienna, Austria
| | - Jean-Louis Vincent
- />Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Donat R. Spahn
- />Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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Abstract
Orthopedic trauma results in systemic physiologic changes that predispose patients to venous thromboembolism (VTE). In the absence of prophylaxis, VTE incidence may be as high as 60%. Mechanical and pharmacologic thromboprophylaxis are effective in decreasing rates of VTE. Combined mechanical and pharmacologic thromboprophylaxis is more efficacious for decreasing VTE incidence than either regimen independently. If pharmacologic thromboprophylaxis is contraindicated, mechanical prophylaxis should be used. Patients with isolated lower extremity fractures who are ambulatory, or those with isolated upper extremity trauma, do not require pharmacologic prophylaxis in the absence of other VTE risk factors.
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Affiliation(s)
- Paul S Whiting
- Department of Orthopaedics and Rehabilitation, University of Wisconsin, 1685 Highland Avenue, Madison, WI 53705, USA
| | - A Alex Jahangir
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, 1215 21st Avenue South, MCE South Tower, Suite 4200, Nashville, TN 37232, USA.
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50
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Mihara K, Ramachandran R, Saifeddine M, Hansen KK, Renaux B, Polley D, Gibson S, Vanderboor C, Hollenberg MD. Thrombin-Mediated Direct Activation of Proteinase-Activated Receptor-2: Another Target for Thrombin Signaling. Mol Pharmacol 2016; 89:606-14. [PMID: 26957205 DOI: 10.1124/mol.115.102723] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 03/03/2016] [Indexed: 01/30/2023] Open
Abstract
Thrombin is known to signal to cells by cleaving/activating a G-protein-coupled family of proteinase-activated receptors (PARs). The signaling mechanism involves the proteolytic unmasking of an N-terminal receptor sequence that acts as a tethered receptor-activating ligand. To date, the recognized targets of thrombin cleavage and activation for signaling are PAR1 and PAR4, in which thrombin cleaves at a conserved target arginine to reveal a tethered ligand. PAR2, which like PAR1 is also cleaved at an N-terminal arginine to unmask its tethered ligand, is generally regarded as a target for trypsin but not for thrombin signaling. We now show that thrombin, at concentrations that can be achieved at sites of acute injury or in a tumor microenvironment, can directly activate PAR2 vasorelaxation and signaling, stimulating calcium and mitogen-activated protein kinase responses along with triggeringβ-arrestin recruitment. Thus, PAR2 can be added alongside PAR1 and PAR4 to the targets, whereby thrombin can affect tissue function.
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Affiliation(s)
- Koichiro Mihara
- Inflammation Research Network-Snyder Institute for Chronic Disease, Department of Physiology and Pharmacology (K.M., R.R., M.S., K.K.H., B.R., D.P., S.G., M.D.H.), and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada; and Department of Physiology and Pharmacology, Western University, London, Ontario, Canada (C.V., R.R.)
| | - Rithwik Ramachandran
- Inflammation Research Network-Snyder Institute for Chronic Disease, Department of Physiology and Pharmacology (K.M., R.R., M.S., K.K.H., B.R., D.P., S.G., M.D.H.), and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada; and Department of Physiology and Pharmacology, Western University, London, Ontario, Canada (C.V., R.R.)
| | - Mahmoud Saifeddine
- Inflammation Research Network-Snyder Institute for Chronic Disease, Department of Physiology and Pharmacology (K.M., R.R., M.S., K.K.H., B.R., D.P., S.G., M.D.H.), and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada; and Department of Physiology and Pharmacology, Western University, London, Ontario, Canada (C.V., R.R.)
| | - Kristina K Hansen
- Inflammation Research Network-Snyder Institute for Chronic Disease, Department of Physiology and Pharmacology (K.M., R.R., M.S., K.K.H., B.R., D.P., S.G., M.D.H.), and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada; and Department of Physiology and Pharmacology, Western University, London, Ontario, Canada (C.V., R.R.)
| | - Bernard Renaux
- Inflammation Research Network-Snyder Institute for Chronic Disease, Department of Physiology and Pharmacology (K.M., R.R., M.S., K.K.H., B.R., D.P., S.G., M.D.H.), and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada; and Department of Physiology and Pharmacology, Western University, London, Ontario, Canada (C.V., R.R.)
| | - Danny Polley
- Inflammation Research Network-Snyder Institute for Chronic Disease, Department of Physiology and Pharmacology (K.M., R.R., M.S., K.K.H., B.R., D.P., S.G., M.D.H.), and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada; and Department of Physiology and Pharmacology, Western University, London, Ontario, Canada (C.V., R.R.)
| | - Stacy Gibson
- Inflammation Research Network-Snyder Institute for Chronic Disease, Department of Physiology and Pharmacology (K.M., R.R., M.S., K.K.H., B.R., D.P., S.G., M.D.H.), and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada; and Department of Physiology and Pharmacology, Western University, London, Ontario, Canada (C.V., R.R.)
| | - Christina Vanderboor
- Inflammation Research Network-Snyder Institute for Chronic Disease, Department of Physiology and Pharmacology (K.M., R.R., M.S., K.K.H., B.R., D.P., S.G., M.D.H.), and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada; and Department of Physiology and Pharmacology, Western University, London, Ontario, Canada (C.V., R.R.)
| | - Morley D Hollenberg
- Inflammation Research Network-Snyder Institute for Chronic Disease, Department of Physiology and Pharmacology (K.M., R.R., M.S., K.K.H., B.R., D.P., S.G., M.D.H.), and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada; and Department of Physiology and Pharmacology, Western University, London, Ontario, Canada (C.V., R.R.)
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