PD-L1 expression and its significance in advanced NSCLC: real-world experience from a tertiary care center

BACKGROUND

Targeted therapies against programmed death ligand-1 (PD-L1) in non-small cell lung cancer (NSCLC) have revolutionized the management in recent years. There is paucity of data on the significance of PD-L1 expression in NSCLC from India. We aimed to study the prevalence of PD-L1 expression and its relation with different clinico-pathological parameters in advanced NSCLC from a tertiary care center in Eastern India.

METHODS

All consecutive patients with advanced NSCLC diagnosed from January 2020 to December 2021 were prospectively evaluated for PD-L1 expression in formalin fixed-paraffin embedded tumor tissue specimens using immunohistochemistry analysis. A PD-L1 expression of < 1%, 1-49%, and ≥ 50% were considered negative, low, and high expression positive respectively, and association with various parameters was performed.

RESULTS

Out of the 94 patients (mean age 59.6 ± 14 years and 63.8% males), PD-L1 positivity was seen in 42 (44.7%) patients, with low positivity (1-49%) in 29 patients and high positivity (≥ 50%) in 13 patients. Epidermal Growth Factor Receptor (EGFR) mutations were seen in 28 patients (29.8%). There were no significant differences in PD-L1 positivity with respect to gender, age, and molecular mutation status. PD-L1 positivity was significantly associated with tobacco use (p = 0.04), advanced tumor stage (p < 0.001), and higher nodal stage (p < 0.001). Median overall survival in the cohort was 17 months and it was not significantly different between the PD-L1 positive and negative groups.

CONCLUSIONS

Forty-five percent of advanced NSCLC patients in our cohort showed positive PD-L1 expression and it is associated with tobacco use and aggressive tumor characteristics.

PD-L1 expression in head and neck squamous cell carcinoma and its clinical significance: A prospective observational study from a tertiary care centre

BACKGROUND

Programmed Death Ligand 1 (PD-L1) expression in tumor cells contribute to tumor immunity and therapies directed against it, have shown encouraging results in recent years. As there is limited data on the significance of PD-L1 expression in Head and Neck Squamous Cell Carcinoma (HNSCC) from India, we aimed to study the PD-L1 expression and its relation with different clinic-pathological parameters in patients of HNSCC from a tertiary care center in Eastern India.

METHODS

A prospective evaluation of HNSCC patients diagnosed and managed at our center over a period of two and half years, was performed. PD-L1 expression in formalin fixed-paraffin embedded tumor tissue specimens was measured using SP-263 (Ventana) and 22C3 (Dako). A PD-L1 expression of <1%, 1-19%, ≥20% were considered negative, low, and high expression, respectively, and was correlated with various parameters.

RESULTS

A total of 71 patients (mean age 50.8 ± 13.3 years, 86% males) were diagnosed with HNSCC (buccal mucosa-28, tongue-22, rest of oral cavity-8, larynx-7, nasopharynx-6). The tumor was poorly differentiated in 12 (17%). PD-L1 positivity was seen in a total of 51 (71.8%) patients (1-19%:18, ≥20%:33). Thirty (85.7%) patients among those aged <50 years and 58.3% of those aged ≥50 years showed PD-L1 positivity which was significant (P = 0.01). There were no statistically significant differences in PD-L1 positivity with respect to gender, tobacco use, tumor grade as well as tumor and nodal stage. Median follow up duration was 18 months (range 3-31 months) and there was significant difference in overall survival among PD-L1 positive and negative groups (31 vs 24 months; log rank P = 0.03).

CONCLUSIONS

72% of HNSCC patients in our cohort showed PD-L1 positivity and it was not associated with any patient demographic characteristics or aggressive pathological features. Positive PD-L1 expression may have a beneficial effect on overall survival in HNSCC.

Gestational Choriocarcinoma Manifesting as Spontaneous Hemothorax in Third Trimester of Pregnancy: A Case Report

Gestational trophoblastic neoplasia (GTN) is an aggressive malignancy arising from the trophoblastic tissue. It is rarely seen in association with advanced intrauterine pregnancy. Most common manifestations are due to bleeding caused by the rich vascularity of trophoblastic tissue. We describe here a case of a 28-year-old female patient who presented to us at 32 weeks of pregnancy with sudden onset dyspnea and hemodynamic instability. On evaluation, imaging techniques revealed a gross left hemothorax requiring intercostal tube insertion for stabilization. Emergency thoracotomy and hemothorax drainage were performed wherein a tumor mass in the lower lobe of left lung was identified and resected. Histopathological examination confirmed the diagnosis of choriocarcinoma. Beta HCG levels were found to be elevated. Final diagnosis of a FIGO stage IV high-risk gestational choriocarcinoma was made. Following this, six cycles of multi-agent EMA-CO chemotherapy was administered to the patient. Patient had an excellent response to treatment with documented serial fall in β HCG levels and she continues to be in remission after 6 months of follow-up. In conclusion, in the circumstance of any pregnant women presenting with abnormal bleeding symptoms such as hemothorax, choriocarcinoma as a cause should be considered for early diagnosis and effective management.

Cutaneous involvement in diffuse large B cell lymphoma at presentation: report of two rare cases and literature review

BACKGROUND

Diffuse large B cell lymphoma (DLBCL) can occur at nodal and/or extra-nodal sites. After the gastrointestinal tract, cutaneous involvement predominates in extra-nodal DLBCL. Skin involvement at presentation can be in the form of plaques, papules, nodules or ulcers. Differentiating primary cutaneous DLBCL from systemic DLBCL with cutaneous involvement is important for appropriate patient management.

CASE PRESENTATION

We describe here, two interesting cases of skin involvement in DLBCL- one primary cutaneous DLBCL and the other, cutaneous involvement in systemic DLBCL with different clinico-pathological profiles. Though both cases had almost similar morphology of the skin lesions (ulcero-proliferative) at presentation, the disease was confined to the skin in the former, while the latter had involvement of lymph nodes and bone marrow.

CONCLUSIONS

Meticulous clinical evaluation, appropriate histopathological and immunohistochemical workup helped in their diagnosis and correct classification of the disease status, guiding the further treatment decisions.

Primary gastric Hodgkin's lymphoma: A rare coincidence

Mostly primary gastric lymphomas are of the non-Hodgkin variety. Primary Hodgkin lymphoma (HL) of the stomach is an unusual entity that may be a big challenge in diagnosis. We reporter are case presenting as gastric outlet obstruction, which was later diagnosed as primary Hodgkin's Lymphoma of the stomach. Its rare coincidence makes it worth to be reported to sensitize clinicians as well as pathologists for the uncommon extra nodal site of Hodgkin's Lymphoma.

Fluorescent markers of various organelles in the wheat pathogen Zymoseptoria tritici

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17 vectors are described that allow labelling of 7 subcellular structures.

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The fluorescent markers target the plasma membrane, endoplasmic reticulum, nucleus.

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Markers also target the actin cytoskeleton, peroxisomes and autophagosomes.

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These markers complete are toolkit of fluorescent reporters.

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Reporters allow cell biological studies in the Septoria tritici blotch fungus.

Development of novel strategies to control fungal plant pathogens requires understanding of their cellular organisation and biology. Live cell imaging of fluorescent organelle markers has provided valuable insight into various aspects of their cell biology, including invasion strategies in plant pathogenic fungi. Here, we introduce a set of 17 vectors that encode fluorescent markers to visualize the plasma membrane, endoplasmic reticulum (ER), chromosomes, the actin cytoskeleton, peroxisomes and autophagosomes in the wheat pathogen Zymoseptoria tritici. We fused either enhanced green-fluorescent protein (eGFP) or a codon-optimised version of GFP (ZtGFP) to homologues of a plasma membrane-located Sso1-like syntaxin, an ER signalling and retention peptide, a histone H1 homologue, the LifeAct actin-binding peptide, a mitochondrial acetyl-CoA dehydrogenase, a peroxisomal import signal and a homologue of the ubiquitin-like autophagosomal protein Atg8. We expressed these markers in wildtype strain IPO323 and confirmed the specificity of these markers by counterstaining or physiological experiments. This new set of molecular tools will help understanding the cell biology of the wheat pathogen Z. tritici.

Fluorescent markers for the Spitzenkörper and exocytosis in Zymoseptoria tritici

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We establish Z. tritici polarity markers ZtSec4, ZtMlc1, ZtRab11, ZtExo70 and ZtSpa2.

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All markers localize correctly, labeling the Spitzenkörper and sites of polar exocytosis.

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We provide 5 carboxin-resistance conveying vectors for integration of all markers into the sdi1 locus.

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We provide 5 hygromycin B-resistance conveying vectors for random integration of all markers.

Fungal hyphae are highly polarized cells that invade their substrate by tip growth. In plant pathogenic fungi, hyphal growth is essential for host invasion. This makes polarity factors and secretion regulators potential new targets for novel fungicides. Polarization requires delivery of secretory vesicles to the apical Spitzenkörper, followed by polarized exocytosis at the expanding cell tip. Here, we introduce fluorescent markers to visualize the apical Spitzenkörper and the apical site of exocytosis in hyphae of the wheat pathogen Zymoseptoria tritici. We fused green fluorescent protein to the small GTPase ZtSec4, the myosin light chain ZtMlc1 and the small GTPase ZtRab11 and co-localize the fusion proteins with the dye FM4-64 in the hyphal apex, suggesting that the markers label the hyphal Spitzenkörper in Z. tritici. In addition, we localize GFP-fusions to the exocyst protein ZtExo70, the polarisome protein ZtSpa2. Consistent with results in the ascomycete Neurospora crassa, these markers did localize near the plasma membrane at the hyphal tip and only partially co-localize with FM4-64. Thus, these fluorescent markers are useful molecular tools that allow phenotypic analysis of mutants in Z. tritici. These tools will help develop new avenues of research in our quest to control STB infection in wheat.

A codon-optimized green fluorescent protein for live cell imaging in Zymoseptoria tritici

Fluorescent proteins (FPs) are powerful tools to investigate intracellular dynamics and protein localization. Cytoplasmic expression of FPs in fungal pathogens allows greater insight into invasion strategies and the host-pathogen interaction. Detection of their fluorescent signal depends on the right combination of microscopic setup and signal brightness. Slow rates of photo-bleaching are pivotal for in vivo observation of FPs over longer periods of time. Here, we test green-fluorescent proteins, including Aequorea coerulescens GFP (AcGFP), enhanced GFP (eGFP) from Aequorea victoria and a novel Zymoseptoria tritici codon-optimized eGFP (ZtGFP), for their usage in conventional and laser-enhanced epi-fluorescence, and confocal laser-scanning microscopy. We show that eGFP, expressed cytoplasmically in Z. tritici, is significantly brighter and more photo-stable than AcGFP. The codon-optimized ZtGFP performed even better than eGFP, showing significantly slower bleaching and a 20-30% further increase in signal intensity. Heterologous expression of all GFP variants did not affect pathogenicity of Z. tritici. Our data establish ZtGFP as the GFP of choice to investigate intracellular protein dynamics in Z. tritici, but also infection stages of this wheat pathogen inside host tissue.

Yeast recombination-based cloning as an efficient way of constructing vectors for Zymoseptoria tritici

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Yeast recombination-based cloning (YRBC) is a reliable and inexpensive way of generating plasmids.

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We provide 4 vectors for YRBC that a cover different resistance genes.

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Using this technique promises rapid generation of molecular tools to study Z. tritici.

Many pathogenic fungi are genetically tractable. Analysis of their cellular organization and invasion mechanisms underpinning virulence determinants profits from exploiting such molecular tools as fluorescent fusion proteins or conditional mutant protein alleles. Generation of these tools requires efficient cloning methods, as vector construction is often a rate-limiting step. Here, we introduce an efficient yeast recombination-based cloning (YRBC) method to construct vectors for the fungus Zymoseptoria tritici. This method is of low cost and avoids dependency on the availability of restriction enzyme sites in the DNA sequence, as needed in more conventional restriction/ligation-based cloning procedures. Furthermore, YRBC avoids modification of the DNA of interest, indeed this potential risk limits the use of site-specific recombination systems, such as Gateway cloning. Instead, in YRBC, multiple DNA fragments, with 30 bp overlap sequences, are transformed into Saccharomyces cerevisiae, whereupon homologous recombination generates the vector in a single step. Here, we provide a detailed experimental protocol and four vectors, each encoding a different dominant selectable marker cassette, that enable YRBC of constructs to be used in the wheat pathogen Z. tritici.

Conditional promoters for analysis of essential genes in Zymoseptoria tritici

Development of new fungicides, needed for sustainable control of fungal plant pathogens, requires identification of novel anti-fungal targets. Essential fungal-specific proteins are good candidates, but due to their importance, gene deletion mutants are not viable. Consequently, their cellular role often remains elusive. This hindrance can be overcome by the use of conditional mutants, where expression is controlled by an inducible/repressible promoter. Here, we introduce 5 inducible/repressible promoter systems to study essential genes in the wheat pathogen Zymoseptoria tritici. We fused the gene for enhanced green-fluorescent protein (egfp) to the promoter region of Z. tritici nitrate reductase (Pnar1; induced by nitrogen and repressed by ammonium), 1,4-β-endoxylanase A (Pex1A; induced by xylose and repressed by maltodextrin), l-arabinofuranosidase B (PlaraB; induced by arabinose and repressed by glucose), galactose-1-phosphate uridylyltransferase 7 (Pgal7; induced by galactose and repressed by glucose) and isocitrate lyase (Picl1; induced by sodium acetate and repressed by glucose). This was followed by quantitative analysis of cytoplasmic reporter fluorescence under induced and repressed conditions. We show that Pnar1, PlaraB and Pex1A drive very little or no egfp expression when repressed, but induce moderate protein production when induced. In contrast, Pgal7 and Picl1 show considerable egfp expression when repressed, and were strongly induced in the presence of their inducers. Normalising the expression levels of all promoters to that of the α-tubulin promoter Ptub2 revealed that PlaraB was the weakest promoter (∼20% of Ptub2), whereas Picl1 strongly expressed the reporter (∼250% of Ptub2). The use of these tools promises a better understanding of essential genes, which will help developing novel control strategies that protect wheat from Z. tritici.

Libraries for two-hybrid screening of yeast and hyphal growth forms in Zymoseptoria tritici

Pathogenic fungi are constantly emerging resistance to anti-fungal treatments. Therefore, identification of new fungicide targets is important. Good candidates are essential fungal proteins and their regulators. An efficient way to reveal the molecular environment of an essential protein is the search for interacting factors. Here, we establish three yeast two-hybrid libraries, covering yeast and hyphal stages of the wheat pathogen Zymoseptoria tritici. No detectable genomic DNA was present in any of the 3 libraries. Random amplification revealed that the libraries include cDNA fragments of up to 2000bp, suggesting that small-to-medium sized proteins are represented therein. Indeed, full-length cDNAs of five proteins were found in all libraries. The full-length cDNA of large chitin synthase gene mcs1 (5742bp with introns; 5568bp without introns) could not be amplified, but its 5' and 3' regions were represented, suggesting that even larger genes are covered in all libraries. Finally, we tested for the expected interaction of the autophagy proteins ZtAtg4 and ZtAtg8 in Z. tritici, and then used ZtAtg4 to screen one of the two-hybrid libraries. Indeed, we found ZtAtg8 as a positive interaction partner, confirming that interacting proteins can be identified. Thus, these molecular tools promise to be useful in identifying novel fungicide target proteins.

A gene locus for targeted ectopic gene integration in Zymoseptoria tritici

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We establish the sdi1 of Z. tritici locus for targeted integration of constructs as single copies.

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Integration of constructs conveys carboxin resistance.

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We provide a vector for integration of eGFP-expressing construct into the sdi1 locus.

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Integration into sdi1 locus is not affecting virulence of Z. tritici.

Understanding the cellular organization and biology of fungal pathogens requires accurate methods for genomic integration of mutant alleles or fluorescent fusion-protein constructs. In Zymoseptoria tritici, this can be achieved by integrating of plasmid DNA randomly into the genome of this wheat pathogen. However, untargeted ectopic integration carries the risk of unwanted side effects, such as altered gene expression, due to targeting regulatory elements, or gene disruption following integration into protein-coding regions of the genome. Here, we establish the succinate dehydrogenase (sdi1) locus as a single “soft-landing” site for targeted ectopic integration of genetic constructs by using a carboxin-resistant sdi1^R allele, carrying the point-mutation H267L. We use various green and red fluorescent fusion constructs and show that 97% of all transformants integrate correctly into the sdi1 locus as single copies. We also demonstrate that such integration does not affect the pathogenicity of Z. tritici, and thus the sdi1 locus is a useful tool for virulence analysis in genetically modified Z. tritici strains. Furthermore, we have developed a vector which facilitates yeast recombination cloning and thus allows assembly of multiple overlapping DNA fragments in a single cloning step for high throughput vector and strain generation.

Fluorescent markers of the endocytic pathway in Zymoseptoria tritici

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We establish Z. tritici fimbrin (ZtFim1) and small GTPases (ZtRab5, ZtRab7) as endocytic markers.

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All markers localize correctly, proven by live cell imaging and co-staining and pharmaceutical studies.

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We provide 3 carboxin-resistance conveying vectors for integration of all markers into the sdi1 locus.

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We provide 3 hygromycin B-resistance conveying vectors for random integration of all markers.

Hyphal growth in filamentous fungi is supported by the uptake (endocytosis) and recycling of membranes and associated proteins at the growing tip. An increasing body of published evidence in various fungi demonstrates that this process is of essential importance for fungal growth and pathogenicity. Here, we introduce fluorescent markers to visualize the endocytic pathway in the wheat pathogen Zymoseptoria tritici. We fused enhanced green-fluorescent protein (eGFP) to the actin-binding protein fimbrin (ZtFim1), which is located in actin patches that are formed at the plasma membrane and are participating in endocytic uptake at the cell surface. In addition, we tagged early endosomes by eGFP-labelling a Rab5-homologue (ZtRab5) and late endosomes and vacuoles by expressing eGFP-Rab7 homologue (ZtRab7). Using fluorescent dyes and live cell imaging we confirmed the dynamic behavior and localization of these markers. This set of molecular tools enables an in-depth phenotypic analysis of Z. tritici mutant strains thereby supporting new strategies towards the goal of controlling wheat against Z. tritici.

Red fluorescent proteins for imaging Zymoseptoria tritici during invasion of wheat

The use of fluorescent proteins (FPs) in plant pathogenic fungi provides valuable insight into their intracellular dynamics, cell organization and invasion mechanisms. Compared with green-fluorescent proteins, their red-fluorescent "cousins" show generally lower fluorescent signal intensity and increased photo-bleaching. However, the combined usage of red and green fluorescent proteins allows powerful insight in co-localization studies. Efficient signal detection requires a bright red-fluorescent protein (RFP), combined with a suitable corresponding filter set. We provide a set of four vectors, suitable for yeast recombination-based cloning that carries mRFP, TagRFP, mCherry and tdTomato. These vectors confer carboxin resistance after targeted single-copy integration into the sdi1 locus of Zymoseptoria tritici. Expression of the RFPs does not affect virulence of this wheat pathogen. We tested all four RFPs in combination with four epi-fluorescence filter sets and in confocal laser scanning microscopy, both in and ex planta. Our data reveal that mCherry is the RFP of choice for investigation in Z. tritici, showing highest signal intensity in epi-fluorescence, when used with a Cy3 filter set, and laser scanning confocal microscopy. However, mCherry bleached significantly faster than mRFP, which favors this red tag in long-term observation experiments. Finally, we used dual-color imaging of eGFP and mCherry expressing wild-type strains in planta and show that pycnidia are formed by single strains. This demonstrates the strength of this method in tracking the course of Z. tritici infection in wheat.

Fluorescent markers of the microtubule cytoskeleton in Zymoseptoria tritici

The microtubule cytoskeleton supports vital processes in fungal cells, including hyphal growth and mitosis. Consequently, it is a target for fungicides, such as benomyl. The use of fluorescent fusion proteins to illuminate microtubules and microtubule-associated proteins has led to a break-through in our understanding of their dynamics and function in fungal cells. Here, we introduce fluorescent markers to visualize microtubules and accessory proteins in the wheat pathogen Zymoseptoria tritici. We fused enhanced green-fluorescent protein to α-tubulin (ZtTub2), to ZtPeb1, a homologue of the mammalian plus-end binding protein EB1, and to ZtGrc1, a component of the minus-end located γ-tubulin ring complex, involved in the nucleation of microtubules. In vivo observation confirms the localization and dynamic behaviour of all three markers. These marker proteins are useful tools for understanding the organization and importance of the microtubule cytoskeleton in Z. tritici.

Phylogenetic analysis, genomic organization, and expression analysis of multi-copper oxidases in the ectomycorrhizal basidiomycete Laccaria bicolor

In forest soils, ectomycorrhizal and saprotrophic Agaricales differ in their strategies for carbon acquisition, but share common gene families encoding multi-copper oxidases (MCOs). These enzymes are involved in the oxidation of a variety of soil organic compounds. The MCO gene family of the ectomycorrhizal fungus Laccaria bicolor is composed of 11 genes divided into two distinct subfamilies corresponding to laccases (lcc) sensu stricto (lcc1 to lcc9), sharing a high sequence homology with the coprophilic Coprinopsis cinerea laccase genes, and to ferroxidases (lcc10 and lcc11) that are not present in C. cinerea. The fet3-like ferroxidase genes lcc10 and lcc11 in L. bicolor are each arranged in a mirrored tandem orientation with an ftr gene coding for an iron permease. Unlike C. cinerea, L. bicolor has no sid1/sidA gene for siderophore biosynthesis. Transcript profiling using whole-genome expression arrays and quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) revealed that some transcripts were very abundant in ectomycorrhizas (lcc3 and lcc8), in fruiting bodies (lcc7) or in the free-living mycelium grown on agar medium (lcc9 and lcc10), suggesting a specific function of these MCOs. The amino acid composition of the MCO substrate binding sites suggests that L. bicolor MCOs interact with substrates different from those of saprotrophic fungi.

Selecting stent grafts for the endovascular treatment of abdominal aortic aneurysms

Minimally invasive endovascular techniques for the treatment of abdominal aortic aneurysms (AAA) have significantly reduced the morbidity of these procedures as compared with standard surgical repair. In addition, patients with extensive comorbid medical illnesses in whom standard operative repair is contra-indicated, may be successfully treated using endovascular means. A variety of endovascular stent grafts are currently being used clinically for endovascular AAA repair. The characteristics of these stent grafts vary significantly. In selecting the specific stent graft to be used for endovascular AAA repair, these specific characteristics must be considered particularly with regard to the individual patient's anatomic and physiologic characteristics. In addition, the indications for use of endovascular grafts as compared to standard open surgery have not yet been fully defined. Endovascular stent grafts in current use have limitations and their use must be tempered accordingly, until their long-term effectiveness is more completely evaluated. This article describes the general principles of use for endovascular devices for the repair of AAA. It details the features and results for the devices in current use and highlights the factors that influence the selection of specific stent graft types.

Cyclic strain activates the pro-survival Akt protein kinase in bovine aortic smooth muscle cells

BACKGROUND

Pulsatile pressure induced by the beating heart causes cyclic strain on arterial endothelial cells and smooth muscle cells (SMCs). This study examined whether Akt, a serine/threonine protein kinase known to promote cell survival by inhibiting apoptosis, is activated by cyclic strain in bovine aortic SMCs.

METHODS

Bovine aortic SMCs were cultured on flexible-bottomed membranes and then serum-starved for 24 to 36 hours. The cells were then exposed to 150-mm Hg repetitive deformations, which created an average of 10% strain on the monolayer SMCs at a frequency of 60 cycles/minute for 0 (negative control) and 30 minutes. Platelet-derived growth factor (PDGF)--stimulated SMCs were used as positive controls. Phosphorylation of Akt was determined by means of Western blot analysis. An apoptosis assay (TUNEL) was also performed on SMCs exposed to cyclic strain.

RESULTS

Akt phosphorylation was significantly increased over that of the negative control after 30 minutes of cyclic strain and in the PDGF group. Cyclic strain did not increase the prevalence of apoptosis in SMCs over the control.

CONCLUSIONS

Cyclic strain activated the pro-survival Akt kinase. The pro-survival function was supported by the fact that cyclic strain did not increase apoptosis in bovine aortic SMCs. This experiment suggests that cyclic strain may induce arterial wall thickening by tipping the balance toward arterial SMC proliferation through the inhibition of apoptosis.

Intermittent Pneumatic Compression Devices – Physiological Mechanisms of Action

There are many reports of how IPC is used effectively in the clinical setting; including the prevention of deep venous thrombosis, improvement of circulation in patients with lower extremity arterial diseases, reduction of lymphoedema, and the healing of venous ulcers. However, despite the widely accepted use of IPC, it is still unclear how IPC actually exerts its beneficial effects. The exact physiological mechanisms of action are unknown. The clinical utility of IPC and the putative mechanisms by which IPC could exert its therapeutic effect will be reviewed. The paper will examine the mechanical effects of IPC exerted on the lower extremity, and the subsequent biochemical changes in the circulation. In vitro studies of the effects of mechanical stress such as compressive strain and shear on cultured endothelial cells, and their clinical relevance to IPC will also be reviewed.

Long-term functional status and mortality of elderly patients with severe closed head injuries

OBJECTIVE

To evaluate long-term clinical outcome of elderly patients with severe closed head injuries.

DESIGN

Retrospective study.

PATIENTS AND METHODS

All patients older than 65 years of age admitted to a regional trauma center with a diagnosis of closed head injury and an admission Glasgow Coma Scale (GCS) score of 8 or less. Using chi 2 analysis, Student's t test, and multiple logistic regression, we correlated age, sex, mechanism of injury, pupillary reactivity, alcohol and drug use, admission GCS score, Injury Severity Score, Revised Trauma Score, heart rate, and blood pressure to the main outcome measures, i.e. long-term functional outcome and mortality.

RESULTS

Among 40 elderly patients who met the criteria, 27% were still alive at the end of 38 +/- 3 month follow-up. Eighty-five percent of patients who were discharged from the hospital were still alive long-term, but did not show significant neurologic improvement. In a univariate analysis, GCS and pupillary reactivity were predictive for long-term functional outcome and mortality. In a multivariate analysis, GCS and heart rate were predictive. All patients with an admission GCS score of 3 died in-hospital. All patients with an admission GCS score of 3 to 7 were either deceased or lived in persistent vegetative or dependent functional states.

CONCLUSIONS

Elderly patients with severe closed head injuries have high in-hospital mortality. Those who survived the hospital stay had high long-term survival, but did not show significant functional improvement. Prediction of long-term functional status is vital to the trauma care of elderly patients with severe closed head injuries.