Neuroprotective effects of amantadine for experimental acute carbon monoxide poisoning

OBJECTIVE

Amantadine is known to have a neuroprotective effect in many neurological diseases. This study aims at investigating the neuroprotective effect of amantadine in rats exposed to carbon monoxide (CO) poisoning.

MATERIALS AND METHODS

Rats were maintained under standard experimental laboratory conditions and randomized into 4 different groups of 7 each namely control, amantadine only, CO exposure, and amantadine + CO exposure. For immunohistochemical analysis, tissues taken from the prefrontal and hippocampal regions were taken into formalin and kept for at least one day. Afterward, the tissue was followed and blocked for paraffin blocking. N-Methyl D-Aspartate (NMDA) levels in homogenates were studied by the Enzyme-Linked Immunosorbent Assay (ELISA) method. Superoxide dismutase (SOD) and catalase (CAT) activities in the supernatants were studied with commercial kits. Nitric oxide (NO) and Asymmetric Dimethyl Arginine (ADMA) levels were studied by the ELISA method. Enzyme activity values were calculated by dividing the protein values in the supernatants and normalizing them.

RESULTS

CAT, SOD, NMDA, ADMA, and NO levels were statistically significantly different between the groups (p < 0.05). According to post-hoc pairwise comparison test results, the values of the control and amantadine groups for CAT, SOD, NMDA, ADMA, and NO parameters were significantly higher than that of CO group. Similarly, values in the control and amantadine groups were considerably higher than values for the amantadine + CO group. NMDA values were significantly lower in group amantadine + CO than in CO group (p: 0.049).

CONCLUSIONS

Apoptosis and endothelial damage after CO poisoning is a complex process, and amantadine administration has a limited contribution in preventing this process.

Mitochondrial toxins potentiate hydroxyl radical production in rat striatum during carbon monoxide poisoning

Hydroxyl radical (•OH) production in the rat striatum during carbon monoxide (CO) poisoning, which inhibits complex IV, was enhanced synergistically by malonate, a mitochondrial complex II inhibitor, but not N-methyl-4-phenylpyridinium or NaCN, complex I and IV inhibitors, respectively. No such enhancement appeared in the case of NaCN combined with malonate. Intrastriatal dopamine, which is involved in •OH production by malonate, did not synergistically enhance CO-induced •OH production. Diphenyleneiodonium, a nonselective NADPH oxidase inhibitor, partly suppressed the potentiation of CO-induced •OH production by malonate. Impairment of mitochondrial functions might potentiate oxidative stress and intensify CO toxicity in the brain.

Microglia and Macrophages in the Pathological Central and Peripheral Nervous Systems

Microglia, the immunocompetent cells in the central nervous system (CNS), have long been studied as pathologically deteriorating players in various CNS diseases. However, microglia exert ameliorating neuroprotective effects, which prompted us to reconsider their roles in CNS and peripheral nervous system (PNS) pathophysiology. Moreover, recent findings showed that microglia play critical roles even in the healthy CNS. The microglial functions that normally contribute to the maintenance of homeostasis in the CNS are modified by other cells, such as astrocytes and infiltrated myeloid cells; thus, the microglial actions on neurons are extremely complex. For a deeper understanding of the pathophysiology of various diseases, including those of the PNS, it is important to understand microglial functioning. In this review, we discuss both the favorable and unfavorable roles of microglia in neuronal survival in various CNS and PNS disorders. We also discuss the roles of blood-borne macrophages in the pathogenesis of CNS and PNS injuries because they cooperatively modify the pathological processes of resident microglia. Finally, metabolic changes in glycolysis and oxidative phosphorylation, with special reference to the pro-/anti-inflammatory activation of microglia, are intensively addressed, because they are profoundly correlated with the generation of reactive oxygen species and changes in pro-/anti-inflammatory phenotypes.

Carbon monoxide increases utero-placental angiogenesis without impacting pregnancy specific adaptations in mice

BACKGROUND

Cigarette smokers have a reduced risk of developing preeclampsia, possibly attributed to an increase in carbon monoxide (CO) levels. Carbon monoxide is a gasotransmitter that has been implicated in maintaining vascular tone, increasing angiogenesis, and reducing inflammation and apoptosis at physiological concentrations. Moderately increasing CO concentrations may have therapeutic potential to prevent or treat preeclampsia; however, the effects of CO on pregnancy are under studied. Our objective was to investigate the effect of CO on major angiogenic and inflammatory markers in pregnancy, and to evaluate the effect of CO on indicators of placental health.

FINDINGS

Pregnant CD-1 mice were constantly exposed to either ambient air or 250 ppm CO from conception until gestation day (GD)10.5 or GD16.5. Using a qRT-PCR array, we identified that CO increased expression of major angiogenic genes at the implantation site on GD10.5, but not GD16.5. Pro-inflammatory cytokines in the plasma and tissue lysates from implantation sites in treated mice were not significantly different compared to controls. Additionally, CO did not alter the implantation site phenotype, in terms of proliferative capacity, invasiveness of trophoblasts, or abundance of uterine natural killer cells.

CONCLUSIONS

This study suggests that CO exposure is pro-angiogenic at the maternal-fetal interface, and is not associated with demonstrable concerns during murine pregnancy. Future studies are required to validate safety and efficacy of CO as a potential therapeutic for vascular insufficiency diseases such as preeclampsia and intrauterine growth restriction.

A neuroglobin-based high-affinity ligand trap reverses carbon monoxide-induced mitochondrial poisoning

Carbon monoxide (CO) remains the most common cause of human poisoning. The consequences of CO poisoning include cardiac dysfunction, brain injury, and death. CO causes toxicity by binding to hemoglobin and by inhibiting mitochondrial cytochrome c oxidase (CcO), thereby decreasing oxygen delivery and inhibiting oxidative phosphorylation. We have recently developed a CO antidote based on human neuroglobin (Ngb-H64Q-CCC). This molecule enhances clearance of CO from red blood cells in vitro and in vivo Herein, we tested whether Ngb-H64Q-CCC can also scavenge CO from CcO and attenuate CO-induced inhibition of mitochondrial respiration. Heart tissue from mice exposed to 3% CO exhibited a 42 ± 19% reduction in tissue respiration rate and a 33 ± 38% reduction in CcO activity compared with unexposed mice. Intravenous infusion of Ngb-H64Q-CCC restored respiration rates to that of control mice correlating with higher electron transport chain CcO activity in Ngb-H64Q-CCC-treated compared with PBS-treated, CO-poisoned mice. Further, using a Clark-type oxygen electrode, we measured isolated rat liver mitochondrial respiration in the presence and absence of saturating solutions of CO (160 μm) and nitric oxide (100 μm). Both CO and NO inhibited respiration, and treatment with Ngb-H64Q-CCC (100 and 50 μm, respectively) significantly reversed this inhibition. These results suggest that Ngb-H64Q-CCC mitigates CO toxicity by scavenging CO from carboxyhemoglobin, improving systemic oxygen delivery and reversing the inhibitory effects of CO on mitochondria. We conclude that Ngb-H64Q-CCC or other CO scavengers demonstrate potential as antidotes that reverse the clinical and molecular effects of CO poisoning.

Effects of hyperbaric oxygen on NLRP3 inflammasome activation in the brain after carbon monoxide poisoning

Neuroinflammation plays an important role in brain damage after acute carbon monoxide poisoning (ACOP). The nucleotide-binding domain, leucine-rich-containing family, pyrin domain-containing (NLRP) 3 inflammasome triggers the activation of inflammatory caspases and maturation of interleukin (IL)-1β and -18, and has been linked to various human autoinflammatory and autoimmune diseases. In this study we investigated the effects of hyperbaric oxygen (HBO2) on NLRP3 inflammasome activation after ACOP. Mice were randomly divided into four groups: sham group (exposure to normobaric air - i.e., 21% O2 at 1 atmosphere absolute); HBO2-only group; CO + normobaric air group; and CO + HBO2 group. Cognitive function was evaluated with the Morris water maze; myelin injury was assessed by FluoroMyelin GreenTM fluorescent myelin staining and myelin basic protein (MBP) immunostaining; and mRNA and protein levels of NLRP3 inflammasome complex proteins were measured by quantitative real-time PCR and Western blot, respectively. Additionally, serum and brain levels of IL-1ββ and -18 and nicotinamide adenine dinucleotide phosphate (NADPH) oxidase were determined by enzyme-linked immunosorbent assay. It was found that HBO2 improved learning and memory, and alleviated myelin injury in mice subjected to acute CO exposure. Furthermore, HBO2 decreased NLRP3, absent in melanoma 2 (AIM2), caspase-1, and apoptosis-associated speck-like protein containing a C-terminal caspase recruitment domain mRNA and protein levels, and reduced brain and serum concentrations of IL-1β and -18 and NADPH oxidase. These results indicate that HBO2 suppresses the inflammatory response after ACOP by blocking NLRP3 inflammasome activation, thereby alleviating cognitive deficits.

The neuroprotective effect of hyperoxygenate hydrogen-rich saline on CO-induced brain injury in rats

This study was designed to investigate the neuroprotective effect of hyperoxygenate hydrogen-rich saline (HOHS) against brain injury induced by carbon monoxide (CO) poisoning in rats. A rat model of CO poisoning was established by administering CO via intraperitoneal injection to male Sprague-Dawley rats. Forty-eight adult male rats were randomly divided into the following groups: normal control group (NG), CO poisoning group (CO), HOS treatment group (hyperoxygenated solution, HOS) and HOHS treatment group (HOHS). After CO poisoning, the carboxyhemoglobin (COHb) contents in the blood of rats in all the CO poisoning groups were increased significantly. However, HOS and HOHS significantly decreased COHb contents, furthermore, the HOHS group had lower COHb contents than the HOS group. Arterial oxygen partial pressure (PaO₂) and arterial oxygen saturation (SaO₂) results showed that HOS and HOHS could improve the oxygenation of the rats with CO poisoning. Compared with the CO group, the HOS group and the HOHS group had persistently neuroprotective effect on CO-induced brain injury, as assessed by modified neurological severity score (mNSS), furthermore, the HOHS group had better neurological functional recovery than the HOS group. The neuronal apoptosis induced by CO was also evaluated. Except the NG group, all the CO-poisoning groups had varying degrees of neuronal apoptosis. There was lesser degree of neuronal apoptosis in both the HOS group and the HOHS group than that in the CO group. Moreover, the HOHS group had more minor degree of neuronal apoptosis than the HOS group. Compared with the CO group, the free radicals production in the HOS group and the HOHS group were significantly inhibited. In addition, there were significantly difference in the free radicals production between the HOS group and the HOHS group. We could conclude that HOHS exerted a stronger neuroprotective effect against CO-induced brain injury than HOS, and the neuroprotective mechanism of HOHS may be related with inhibition of both neuronal apoptosis and free radicals.

iTRAQ-based differential proteomic analysis of the brains in a rat model of delayedcarbon monoxide encephalopathy

Delayed encephalopathy after acute carbon monoxide poisoning (DEACMP) is a difficult-to-manage neurological complication that can severely affect the life quality of patients. Although the central nervous system (CNS) injuries have been reported, the underlying molecular mechanisms are still unclear. Therefore, we established a rat model of DEACMP, applying isobaric tags for a relative and absolute quantification (iTRAQ)-based proteomics approach to identify differentially expressed proteins in cerebral tissue. A total of 170 proteins in the CO exposure groups were identified as differentially changed. Bioinformatics analysis suggested that these proteins are mainly involved in the biological processes, such as energy metabolism and many neurodegenerative diseases. Three proteins, Glial fibrillary acidic protein (GFAP), mitochondrial malate dehydrogenase (MDHM), and isocitrate dehydrogenase [NAD] subunit alpha (IDH3A), were identified as playing important roles in CNS injuries in DEACMP, and were successfully confirmed by immunohistochemistry analysis. Our study not only offers us new insights into the pathophysiological mechanisms of CNS injuries in DEACMP, but also may provide clinicians with important references in early prevention and treatment.

Effects of hyperbaric oxygen on hippocampal neuronal apoptosis in rats with acute carbon monoxide poisoning

INTRODUCTION

Acute carbon monoxide (CO) poisoning causes serious health problems such as neuropsychological sequelae. This study aimed to investigate neuronal apoptosis and the effects of hyperbaric oxygen (HBO₂) on different regions of the rat hippocampus after CO poisoning.

METHODS

90 mature male Sprague Dawley rats were randomly divided into three groups: the normal control group (NC group), the acute carbon monoxide-poisoned group (CO group) and the hyperbaric oxygen treatment group (HBO₂ group). CO exposure included 0, 1, 3, 7, 14 and 21 treatment days, one exposure on the first day, and sacrifice on each of the following days. HBO₂ exposure included treatment for 0, 1, 3, 7, 14 and 21 days, daily treatment after CO exposure, and sacrifice after the last HBO₂ treatment on each of those days. Hematoxylin-eosin staining, immunohistochemical staining, immunofluorescence staining, and western blot analysis were performed to detect apoptosis in brain tissue samples.

RESULTS

MMP-9 and caspase-3 were prominently increased by CO exposure and inhibited by HBO₂ in the CA3 region in the hippocampus at one, three and seven days (immunohistochemical staining [IHC]: P ⟨ 0.05). Neu N and the ratio of Bcl-2/ BAX were prominently decreased by CO exposure and rescued by HBO₂ in the CA3 region after seven days of treatment (IHC: P ⟨ 0.05).

CONCLUSION

These findings indicated that neuronal apoptosis in the rat hippocampus could be induced by acute CO exposure, especially in the CA3 region. HBO₂ could effectively inhibit neuronal apoptosis, especially in the CA3 region after seven days of treatment. The application of HBO₂ to inhibit MMP-9 and apoptosis may contribute to brain recovery after acute CO poisoning.

Carboxyhemoglobin half-life during hyperbaric oxygen in a patient with lung dysfunction: a case report

INTRODUCTION

The carboxyhemoglobin half-life (COHb t1/2) during hyperbaric oxygen (HBO₂) is often quoted as 23 minutes, derived from the average of two adult male volunteers breathing HBO₂ at 3 atmospheres absolute (ATA). However, the mean COHb t1/2 of 12 male volunteer smokers was 26.3 minutes at 1.58 ATA and in 12 non-intubated carbon monoxide (CO) poisoned patients treated at 3 ATA, was 43 minutes.

CASE REPORT

An 81-year old male, poisoned by an improperly ventilated natural gas heater, was intubated for coma, then treated with HBO₂. His PaO₂/FiO₂ = 283 from aspiration. His initial COHb was 34.4%, and 18 minutes before HBO₂, 5.9%. After a compression interval of 17 minutes, the COHb measured after 22 minutes at 3 ATA was 3.3%.

RESULTS

By exponential decay, his COHb t1/2 before HBO₂ was 95 minutes. We estimate the range for COHb t1/2 during compression as 62-81 minutes and for the 3-ATA interval, 58 to 49 minutes, respectively. The mid-point estimate of COHb t1/2 at 3 ATA was 53 minutes.

CONCLUSIONS

The COHb t1/2 we calculated is greater than previously reported, but longer in our patient possibly because of concomitant respiratory failure, lung dysfunction, and mechanical ventilation. The often-cited COHb t1/2 of 23 minutes, likely underestimates the actual COHb t1/2 in CO-poisoned patients, especially those with cardiopulmonary dysfunction.

A cost effective parameter for predicting the troponin elevation in patients with carbon monoxide poisoning: red cell distribution width

OBJECTIVE

Carbon monoxide (CO) poisoning is very common worldwide. Despite the fact that CO is known to have cardiotoxic effects, as it has non-specific symptoms; cardiotoxicity could easily be overlooked, especially when troponin is not measured. The present study aimed to evaluate the association between troponin I levels and red cell distribution width (RDW) levels, which can be measured rapidly, easily, and affordably in the Emergency Room (ER).

PATIENTS AND METHODS

This single-center observational study included a total of 504 consecutive patients, who presented to the ER due to CO poisoning between January 2011 and June 2015. The diagnosis of CO poisoning was made according to the medical history and carboxyhemoglobin (COHb) level of >5%. Elevated troponin test levels, which measure >0.04 ng/ml for our laboratory, were accepted as positive.

RESULTS

Patients (mean age 37±14) were classified into two groups: those who had positive troponin levels (38%) and those that did not. Patients with positive troponin, who were older, had longer CO exposure time and higher creatinine, COHb and RDW levels at the index admission following CO poisoning than patients with negative troponin. In a multivariate logistic regression model with forward stepwise method, age, COHb level, CO exposure time, and RDW (HR=1.681, 95% CI: 1.472-1.934, p<0.001) remained associated with an increased risk of troponin positivity following adjustment for the variables that were statistically significant in the univariate analysis and correlated with RDW.

CONCLUSIONS

In patients presenting to the ER with CO poisoning, RDW can be helpful for the risk stratification of troponin positivity.

Edaravone attenuates brain damage in rats after acute CO poisoning through inhibiting apoptosis and oxidative stress

Acute carbon monoxide (CO) poisoning is the most common cause of death from poisoning all over the world and may result in neuropathologic and neurophysiologic changes. Acute brain damage and delayed encephalopathy are the most serious complication, yet their pathogenesis is poorly understood. The present study aimed to evaluate the neuroprotective effects of Edaravone against apoptosis and oxidative stress after acute CO poisoning. The rat model of CO poisoning was established in a hyperbaric oxygen chamber by exposed to CO. Ultrastructure changes were observed by transmission electron microscopy (TEM). TUNEL stain was used to assess apoptosis. Immunohistochemistry and immunofluorescence double stain were used to evaluate the expression levels of heme oxygenase-1 (HO-1) and nuclear factor erythroid 2-related factor 2 (Nrf-2) protein and their relationship. By dynamically monitored the carboxyhemoglobin (HbCO) level in blood, we successfully established rat model of severe CO poisoning. Ultrastructure changes, including chromatin condensation, cytoplasm dissolution, vacuoles formation, nucleus membrane and cell organelles decomposition, could be observed after CO poisoning. Edaravone could improve the ultrastructure damage. CO poisoning could induce apoptosis. Apoptotic cells were widely distributed in cortex, striatum and hippocampus. Edaravone treatment attenuated neuronal apoptosis as compared with the poisoning group (P < 0.01). Basal expressions of HO-1 and Nrf-2 proteins were found in normal brain tissue. CO poisoning could activate HO-1/Nrf-2 pathway, start oxidative stress response. After the administration of Edaravone, the expression of HO-1 and Nrf-2 significantly increased (P < 0.01). These findings suggest that Edaravone may inhibit apoptosis, activate the Keapl-Nrf/ARE pathway, and thus improve the ultrastructure damage and neurophysiologic changes following acute CO poisoning.

Early Biomarkers in 1H Nuclear Magnetic Resonance Spectroscopy of Striatal Pathological Mechanisms after Acute Carbon Monoxide Poisoning in Rats

OBJECTIVE

In vivo Proton Magnetic Resonance Spectroscopy (1H-MRS) can be used to evaluate the levels of specific neurochemical biomarkers of pathological mechanisms in the brain.

METHODS

We conducted T2-Weighted Magnetic Resonance Imaging (MRI) and 1H-MRS with a 3.0-Tesla animal MRI system to investigate the early microstructural and metabolic profiles in vivo in the striatum of rats following carbon monoxide (CO) poisoning.

RESULTS

Compared to baseline, we found significant cortical surface deformation, cerebral edema changes, which were indicated by the unclear gray/white matter border, and lateral ventricular volume changes in the brain. A significant reduction in the metabolite to total creatine (Cr) ratios of N-acetylaspartate (NAA) was observed as early as 1 h after the last CO administration, while the lactate (Lac) levels increased marginally. Both the Lac/Cr and NAA/Cr ratios leveled off at 6 h and showed no subsequent significant changes. In addition, compared to the control, the choline (Cho)/Cr ratio was slightly reduced in the early stages and significantly increased after 6 h. In addition, a pathological examination revealed mild cerebral edema on cessation of the insult and more severe cerebral injury after additional CO poisoning.

CONCLUSION

The present study demonstrated that 1H-MRS of the brain identified early metabolic changes after CO poisoning. Notably, the relationship between the increased Cho/Cr ratio in the striatum and delayed neuropsychologic sequelae requires further research.

Effects of N-butylphthalide on the activation of Keap1/Nrf-2 signal pathway in rats after carbon monoxide poisoning

Carbon monoxide (CO) is the leading cause of death by poisoning all over the world and may result in neuropathologic changes and cognitive and neurologic sequelae, yet little is known regarding its outcomes. The present study aimed to evaluate the neuroprotective effects of N-butylphthalide (NBP) against brain damage after acute CO poisoning. The animal model of CO poisoning was established by exposed to 1000 ppm CO in air for 40 min and then to 3000 ppm for another 20 min. RT-PCR was used to assess the expressions of apoptosis-associated genes Bcl-2 mRNA and Bax mRNA. Mitochondrial membrane potential (MMP) was detected by fluorescent probe JC-1. Immunohistochemistry stain and Western blot assay were used to evaluate the expression levels of Kelch-like ECH-associated protein 1 (Keapl), nuclear factor erythroid 2-related factor 2 (Nrf-2) and

NAD(P)H

quinone oxidoreductase 1(NQO-1). CO poisoning could increase the levels of Bcl-2 mRNA and Bax mRNA expressions, and obviously decrease the MMP of cells. NBP treatment could maintain the high MMP, significantly up-regulate Bcl-2 mRNA and down-regulate Bax mRNA expression, and the ratio of Bcl-2 mRNA/Bax mRNA expressions was higher than that in the CO poisoning group (P<0.05). CO poisoning could start oxidative stress response. The expressions of Keap1, Nrf-2 and NQO-1 proteins significantly increased at 1, 3 and 7 day after NBP administration as compared with the CO poisoning group (P<0.01). These findings suggest that N-butylphthalide may protect mitochondrial function, balance the expressions of anti-apoptosis genes and pro-apoptosis genes, be in part associated with activation of Keap1-Nrf-2/antioxidant response element (ARE) signaling pathway, and play a neuroprotective role in brain damage after acute CO poisoning.

Effects of N-Butylphthalide on the expressions of Nogo/NgR in rat brain tissue after carbon monoxide poisoning

Carbon monoxide (CO) intoxication is one of the most common types of poisoning worldwide, and may result in neuropathologic sequelae, yet its pathogenesis is not clear and there is no optimal management strategy for patients with CO poisoning. In this study, the rat model of CO poisoning was established in a hyperbaric chamber by CO exposure. Rats were administered orally N-Butylphthalide (NBP) at a dose of 1 ml/100g. Neuronal apoptosis was assessed by TUNEL stain and flow cytometry. The expressions of neurite outgrowth inhibitor (Nogo), myelin-associated glycoprotein (MAG) and Nogo receptor-1 (NgR1) were observed in rat brain tissue by immunohistochemistry and double immunofluorescence staining. As we expected, CO poisoning could start the mechanism of apoptosis. The number of apoptotic cells and the early neuronal apoptosis percentage (EAR) were significantly increased at 1 day, 3 day after CO exposure. NBP treatment obviously reduce neuronal apoptosis and the EAR (P<0.05). CO poisoning could induce Nogo, MAG and NgR1 expressions. The increased Nogo, MAG and NgR1 proteins were still observed at 4 week after CO poisoning. NBP could significantly reduce the levels of Nogo and NgR1 proteins. Then we suspected that the expressions of Nogo, MAG and NGR1 proteins might be associated with brain injury and demyelination induced by CO poisoning. NBP might inhibit neuronal apoptosis and the EAR, down-regulate the expressions of Nogo and NgR1 proteins (but not MAG), and play a neuro-protective role in brain damage after acute CO poisoning.

Longitudinal changes in the dopamine transporter and cognition in suicide attempters with charcoal burning

Suicide with charcoal burning, which results in carbon monoxide (CO) poisoning, is common in Asia. This study was designed to elucidate associations between changes in the dopamine transporter (DAT) and cognitive function in patients following CO poisoning during a follow-up period of 6 months. Participants comprised 31 healthy controls (HCs) and 21 CO poisoning patients. Each subject underwent single photon emission computed tomography with [(99m)Tc] TRODAT-1 to measure DAT availability and completed a cognitive battery assessing attention, memory, and executive function. For CO poisoning patients, a second DAT measurement and repeated cognitive evaluations were performed 6 months later. At baseline, DAT availability over bilateral striatum in CO poisoning subjects was significantly lower than in HCs. After 6 months, there was no significant change of DAT availability in CO poisoning patients. CO poisoning patients also had worse cognitive performance in all domains compared with HCs at baseline. After 6 months, most cognitive functions were significantly improved, except for the Wisconsin Card Sorting Test (WCST), a measure of executive function. Interestingly, changes in the WCST were significantly correlated with changes in DAT availability during the 6-month follow-up period. The persistence of reduced DAT availability and its association with impaired performance on the WCST indicate a crucial role of DAT in the recovery of executive function following CO poisoning.

The effect of fatal carbon monoxide poisoning on the equilibria between cell membranes and the electrolyte solution

The effect of fatal carbon monoxide poisoning on equilibria between cell membranes and surrounding ions was described using a theoretical four-equilibria model. The model was developed to obtain parameters characterizing the interactions between solution ions and erythrocyte or thrombocyte membrane surface. The parameters are the total surface concentrations of both acidic and basic groups C A, C B and their association constants with solution ions K AH, K BOH. These parameters were used to calculate the theoretical values of surface charge density. The model was validated by comparison of these values to experimental data, which were determined from the electrophoretic mobility measurements of the blood cells. The experimental and theoretical surface charge density values agree at pH 2-8, and at higher pH, the deviation was observed.

The role of reactive oxygen species and oxidative stress in carbon monoxide toxicity: an in-depth analysis

The underlying mechanism of the central nervous system (CNS) injury after acute carbon monoxide (CO) poisoning is interlaced with multiple factors including apoptosis, abnormal inflammatory responses, hypoxia, and ischemia/reperfusion-like problems. One of the current hypotheses with regard to the molecular mechanism of CO poisoning is the oxidative injury induced by reactive oxygen species, free radicals, and neuronal nitric oxide. Up to now, the relevant mechanism of this injury remains poorly understood. The weakening of antioxidant systems and the increase of lipid peroxidation in the CNS have been implicated, however. Accordingly, in this review, we will highlight the relationship between oxidative stress and CO poisoning from the perspective of forensic toxicology and molecular toxicology.

[Otoneurologic and cardiovascular abnormalities associated to carbon monoxide poisoning in occupational exposed workers]

BACKGROUND

Even though Federal Labor Law includes carbon monoxide poisoning in the list of occupational diseases, the registration of this intoxication rarely occurs in a work environment. The objective was to determine the association of this poisoning with cardiovascular and otoneurologic disorders, in order to establish adequately this diagnosis as a work-related illness.

METHODS

Cross-sectional survey performed in a group of broiler production workers, compared with a control group (n = 54). The sample consisted of people aged between 18 and 74 years, males and females, smokers and non-smokers. We excluded those participants with clinical history of cardiac attack. We determined carboxyhemoglobin (COHb) rates in exhaled air, and performed an audiometric test, and a 12-lead electrocardiogram.

RESULTS

We studied 54 workers (57 % males and 43 % females). We obtained a statistically significant difference (p < 0.05) to develop hearing loss between the two groups, an odds ratio > 1 also in regards to hearing loss, and cardiovascular manifestations (anterior fascicle hemiblock).

CONCLUSIONS

Otoneurologic and cardiovascular abnormalities in occupationally exposed workers to carbon monoxide are not casual, and suggest a cause-effect relationship.

Therapeutic effect of magnesium sulphate on carbon monoxide toxicity-mediated brain lipid peroxidation

BACKGROUND

Carbon monoxide (CO) toxicity primarily results from cellular hypoxia caused by impedance of oxygen delivery. Studies show that CO may cause brain lipid peroxidation and leukocyte-mediated inflammatory changes in the brain.

AIM

The aim of this study was to investigate whether magnesium sulphate could prevent or diminish brain lipid peroxidation caused by carbon monoxide toxicity in rats.

MATERIALS AND METHODS

Fourty rats were divided into five groups of 8 rats each. Group l was not received any agent during the experiment. Group 2 was inhaled CO gas followed by intraperitoneally normal saline 30 minutes (min) later. Group 3 was inhaled CO gas followed by 100 mg/kg magnesium sulphate intraperitoneally 30 min later. Group 2 and Group 3 rats was undergone laparotomy and craniotomy while still under anesthesia at 6 hour, and tissue sample was obtained from the cerebrum. Group 4 was inhaled CO gas followed by intraperitoneally normal saline 30 min later. Group 5 was inhaled CO gas followed by 100 mg/kg magnesium sulphate intraperitoneally 30 min later. Group 4 and Group 5 rats was undergone laparotomy and craniotomy while still under anesthesia at 24 hour, and tissue sample was obtained from the cerebrum.

RESULTS

Nitric oxide levels were no significantly different between all groups. Malonyldialdehyde levels increased in intoxication group (group 2) and decreased in treatment group (group 3). Activities of superoxide dismutase decreased in intoxication group (group 2) and increased in treatment group (group 3). Activities of catalase increased in intoxication group (group 2) and decreased in treatment group (group 3). Activities of glutathione peroxidase (GSH-Px) decreased in intoxication group (group 4) and increased in treatment group (group 5).

CONCLUSIONS

CO poisoning caused significant damage, detected within the first 6 hours. Due to antioxidant enzymes, especially GSH-Px activity reaching the top level within 24th hours, significant oxidative damage was not observed. The protective effect against oxidative damage of magnesium sulfate has been identified within the first 6 hours.

Dual contradictory roles of cAMP signaling pathways in hydroxyl radical production in the rat striatum

Studies have suggested that cAMP signaling pathways may be associated with the production of reactive oxygen species. In this study, we examined how modifications in cAMP signaling affected the production of hydroxyl radicals in rat striatum using microdialysis to measure extracellular 2,3-dihydroxybenzoic acid (2,3-DHBA), which is a hydroxyl radical adduct of salicylate. Up to 50 nmol of the cell-permeative cAMP mimetic 8-bromo-cAMP (8-Br-cAMP) increased 2,3-DHBA in a dose-dependent manner (there was no additional increase in 2,3-DHBA at 100 nmol). Another cAMP mimetic, dibutyryl cAMP (db-cAMP), caused a nonsignificant increase in 2,3-DHBA at 50 nmol and a significant decrease at 100 nmol. Up to 20 nmol of forskolin, which is a direct activator of adenylyl cyclase, increased 2,3-DHBA, similar to the effect of 8-Br-cAMP; however, forskolin resulted in a much greater increase in 2,3-DHBA. A potent inhibitor of protein kinase A (PKA), H89 (500 μM), potentiated the 8-Br-cAMP- and forskolin-induced increases in 2,3-DHBA and antagonized the inhibitory effect of 100 nmol of db-cAMP. Interestingly, the administration of 100 nmol of 8-bromo-cGMP alone or in combination with H89 had no significant effect on 2,3-DHBA levels. Doses of 100 nmol of a preferential PKA activator (6-phenyl-cAMP) or a preferential PKA inhibitor (8-bromoadenosine-3',5'-cyclic monophosphorothionate, Rp-isomer; Rp-8-Br-cAMPS), which also inhibits the cAMP-mediated activation of Epac (the exchange protein directly activated by cAMP), suppressed or enhanced, respectively, the formation of 2,3-DHBA. Up to 100 nmol of 8-(4-chlorophenylthio)-2'-O-methyladenosine-cAMP, which is a selective activator of Epac, dose-dependently stimulated the formation of 2,3-DHBA. These findings suggest that cAMP signaling plays contradictory roles (stimulation and inhibition) in the production of hydroxyl radicals in rat striatum by differential actions of Epac and PKA. These roles might contribute to the production of hydroxyl radicals concomitant with cAMP in carbon monoxide poisoning, because the formation of 2,3-DHBA was potentiated by the PKA inhibitor H89 and suppressed by Rp-8-Br-cAMPS, which inhibits PKA and Epac.

Effects of immune reaction in rats after acute carbon monoxide poisoning

This study is designed to observe the immune reaction in rats after acute carbon monoxide (CO) poisoning. We observed brain injury, cognitive impairment, a variety of microglias and expression of immune factors, including major histocompatibility complex II (MHCII), CD4, vascular cell adhesion molecule-1 (VCAM-1) and interferon-gamma (IFN-gamma) in the brain tissues of CO-poisoned rats. Then relationships between cognitive impairment and immune factors were explored. We found that there were extensive neuronal degeneration and necrosis in the brains of CO-poisoned rats, and the escape latency of the CO Group in a Morris water maze became significantly longer than that of the Control Group (11.63 +/- 3.54s vs. 7.06 +/- 3.13s, p < 0.05) after six days of CO poisoning. Microglias, as immune effector cells, underwent activation and proliferation which reached 35.0 +/- 5.7 cells per five high-power fields (HPF) in the seventh day after CO poisoning, but 20.3 +/- 2.9 cells/5HPF in the Control Group (p < 0.05). Expression levels of immune factors increased in the brains of CO-poisoned rats. VCAM-1-positive cells peaked in quantity the first day, IFN-gamma-positive cells and MHCII-positive cells the third day and CD4-positive cells the seventh day. The results indicate that immune reaction plays an important role on CO-mediated neuropathology.

Mitochondrial injury in human acute carbon monoxide poisoning: the effect of oxygen treatment

The best oxygen therapy for acute carbon monoxide poisoning (ACOP) remains unestablished. Reported mitochondrial complex IV (mtCIV) inhibition, together with carboxyhaemoglobin (COHb)-induced hypoxia, may influence acute clinical symptoms and outcome. To "mitochondrially" evaluate treatment efficacy, we correlated intoxication severity and symptoms with mitochondrial function (mtCIV activity) and oxidative stress (lipid peroxidation) in 60 poisoned patients and determined ACOP recovery depending on either normobaric or hyperbaric oxygen therapy along a 3-month follow-up. In the present article we positively evaluate mtCIV as a good marker of ACOP recovery, treatment effectiveness, and late neurological syndrome development, which advocates for hyperbaric oxygen therapy as the treatment of choice. However, we discourage its usefulness as a severity marker because of its excessive sensitivity. We additionally evaluate oxidative stress role and prognostic factors for neurological sequelae development.

The effect of antioxidants (N-acetylcysteine and melatonin) on hypoxia due to carbonmonoxide poisoning

We aimed to determine the effect NAC (N-acetylcysteine) and melatonin on the histopathological and biochemical paramethers in the rats poisoned with CO (Carbon monoxide) experimentally. Winster albino female rats were placed in a plexiglass chamber and they were poisoned with CO. After the poisoning, rats were randomly divided into 3 groups. The group given only normal saline, was used as a control group (n = 9). The second group was given 30 mg/kg intraperitonally NAC (n = 10). And the third group was treated with 10 mg/kg of melatonin intramuscularly (n = 9). It is determined that some biochemical values affected by NAC but not by melatonin. CK, ALT, Lactate, MDA levels were significantly higher in NAC group than control and Melatonin group (p < 0.01 for all comparisons). Thiol level was lower in NAC group than control group and Melatonin group (p < 0.01 and p < 0.001, respectively). There were no statistical significant differences between the melatonin and control group. There were statistically significant difference between control, NAC and Melatonin groups according to brain and lung tissue damage. It is shown that both NAC and Melatonin are reducing the brain and lung tissue damage of CO poisoning but due to biochemical results worsened by NAC, Melatonin may recommend for CO poisoning (Tab. 3, Ref. 21).

[Forensic medical toxicometry of acute carbon monoxide poisoning during alcoholic intoxication]

Data on general toxicity of carbon monoxide (CO) are presented with reference to the gender, age, and the degree of alcoholic intoxication of the affected subjects. Threshold values of carboxyhemoglobinemia for clinical and morphological manifestations of alcoholic intoxication were determined. Expert evaluation of CO toxicokinetics in subjects with alcoholic intoxication revealed informative clinical and morphological signs of carbon monoxide poisoning, the basic parameters of carboxyhemoglobin kinetics, and the sequence of CO-induced clinical and morphological changes during alcoholic intoxication. The data obtained permit to exactly determine the specific cause of death from poisoning with carbon monoxide and ethanol.

Carbon monoxide is a poison... to microbes! CO as a bactericidal molecule

Inflammation and immunity result in a wide range of disease processes, including chronic obstructive pulmonary disease, ischemia-reperfusion injury, atherosclerosis, vascular thrombosis and sepsis. Heme oxygenase-1 (HO-1) is a key enzyme that is indispensable for the temporal and spatial regulation of host response and, together with its essential metabolite carbon monoxide (CO), is crucial for maintaining homeostasis, inhibition of inflammation and the preservation of function and life. The biology of HO-1 is being discussed in this review series by Soares and colleagues and thus will not be reviewed here. Rather we will complement the HO-1 overview with a comprehensive discussion of CO as perhaps the one product of HO-1 that has been most studied. Of the numerous physiologic effects observed with CO, in the past five years it has become apparent that CO has been ascribed an additional novel role as a 'bactericidal agent'. Its role in the maintenance of homeostasis remains intact; however, the designation necessitates the paradoxical induction of the inflammatory response and binding to hemoproteins in order to restore homeostasis and sustain life. In this article, we review and discuss reports that have propelled and challenged the paradoxical use of CO, once viewed as a toxic molecule, now as a host defense molecule agent against microbes.

Cerebral blood flow and metabolism

To date, regional measurements of cerebral blood flow in humans have not been especially helpful in predicting the outcome of acute brain injury. The recent appearance within the medical environment of biologically significant pharmaceuticals labelled with the positron-emitting isotopes 15O, 13N and 11C has made possible the quantitative regional measurement of cerebral metabolism in humans. This advance, coupled with the development of radically new detection systems, will allow the safe measurement of truly regional blood flow and metabolism in humans in the near future. Such information is basic to an understanding of the pathophysiology of acute injury to the brain and the rational prediction of outcome in the individual case.

Role of nitric oxide system in hydroxyl radical generation in rat striatum due to carbon monoxide poisoning, as determined by microdialysis

We explored the possible role of the nitric oxide (NO) system in hydroxyl radical (*OH) generation induced by carbon monoxide (CO) poisoning in rat striatum by means of microdialysis with the use of NO synthase (NOS) inhibitors, N(G)-nitro-L-arginine methyl ester (L-NAME) and N(G)-monomethyl-L-arginine (L-NMMA), as well as L-arginine (L-Arg; the NOS substrate) and D-arginine (D-Arg). The CO-induced *OH generation was suppressed by both L-Arg and D-Arg. It was also suppressed by L-NAME, which inhibits generation of reactive oxygen species (ROS) via neuronal NOS (nNOS) and inducible NOS, but not via endothelial NOS. In contrast, L-NMMA, which inhibits only ROS generation via inducible NOS, potentiated the *OH generation. L-Arg completely reversed the L-NAME effect and partly reversed the L-NMMA effect. D-Arg reversed the L-NAME effect more potently than did L-Arg, resulting in much more *OH generation than was observed with CO alone, and also potentiated the L-NMMA effect. On the other hand, W-7, an antagonist of calmodulin, which is critical for nNOS activity, had no effect on the CO-induced *OH generation. These findings suggest that complex mechanisms operate in *OH generation in rat striatum upon CO poisoning and that the NO system might not be included among those mechanisms.

Postmortem cardiac troponin I and creatine kinase MB levels in the blood and pericardial fluid as markers of myocardial damage in medicolegal autopsy

The present study investigated cardiac troponin I (cTnI) and creatine kinase MB (CK-MB) in the blood and pericardial fluid from medicolegal autopsy cases (n=234, within 48h postmortem) with regard to the cause of death. The cTnI and CK-MB levels in cardiac, peripheral blood and pericardial fluid generally showed a mild and gradual postmortem time-dependent elevation (r=0.231-0.449, P<0.05-0.001). However, postmortem elevation of cTnI was larger for specific causes of death including acute myocardial infarction (AMI), cerebrovascular diseases (CVD), hyperthermia, fatal methamphetamine (MA) abuse and carbon monoxide (CO) intoxication and insignificant for recurrent myocardial infarction (RMI), chronic congestive heart diseases (CHD) and drowning, while that of CK-MB was greater for CO intoxication and insignificant for drowning. Cardiac blood and pericardial cTnI levels were relatively high for AMI, RMI, hyperthermia, MA abuse and CO intoxication, and was low for drowning. Elevated CK-MB level was observed for cardiac blood in asphyxiation and MA abuse cases and for peripheral blood in hyperthermia and MA abuse cases. When the cTnI/CK-MB ratio was estimated, it was independent of postmortem time, and the ratios for cardiac blood and pericardial fluid were significantly higher in cases of AMI, RMI, hyperthermia and CO intoxication but lower in cases of drowning. Elevations of cTnI levels in cardiac blood and pericardial fluid were related to the morphological severity of myocardial damage. These findings suggest that elevated cTnI and CK-MB levels in blood and pericardial fluid are related to ischemic, hypoxic and/or cytotoxic myocardial damage, which are characteristic of the cause of death, although the levels increase after death depending on myocardial damage at the time of death.

Postmortem cardiac troponin T levels in the blood and pericardial fluid. Part 1. Analysis with special regard to traumatic causes of death

In forensic pathology, previous studies have suggested the possible application of cardiac troponins in the diagnosis of myocardial infarction. However, there appears to be insufficient practical data on other causes of death. The present study was a comprehensive analysis of the cardiac, peripheral blood and pericardial levels of cardiac troponin T (cTnT) in serial medicolegal autopsy cases (n = 405) with a survival time <24 h and within 48 h postmortem to assess the validity of investigating myocardial damage with special regard to traumatic causes of death. These included blunt and sharp instrument injury (n = 122 and 21, respectively), asphyxiation (n = 35), drowning (n = 27), fire fatalities (n = 94), hyperthermia (n = 13), hypothermia (n = 6), fatal methamphetamine (MA) abuse (n = 12) and carbon monoxide (CO) poisoning (n = 5) in comparison with myocardial infarction (MI, n = 57) and cerebrovascular diseases (n = 13). Cases within 12h postmortem usually showed lower cardiac and pericardial cTnT levels than did those of longer postmortem time of 12-48 h. In the early postmortem period of <12 h, significantly elevated serum cTnT levels were observed for hyperthermia. Thereafter, fatal MA abuse, CO poisoning and MI cases also showed higher levels. However, cTnT remained at lower levels for hypothermia and drowning. The elevation of cTnT was associated with the pathology of advanced myocardial damage involving swelling and liquefactive necrosis. The above-mentioned differences were the smallest for peripheral blood. These findings suggest that elevations in postmortem serum and pericardial cTnT levels depend on the severity of myocardial damage at the time of death and are related to the pathological findings, although postmortem interference should be taken into consideration.

Analysis of factors that influence rates of carbon monoxide uptake, distribution, and washout from blood and extravascular tissues using a multicompartment model

To better understand factors that influence carbon monoxide (CO) washout rates, we utilized a multicompartment mathematical model to predict rates of CO uptake, distribution in vascular and extravascular (muscle vs. other soft tissue) compartments, and washout over a range of exposure and washout conditions with varied subject-specific parameters. We fitted this model to experimental data from 15 human subjects, for whom subject-specific parameters were known, multiple washout carboxyhemoglobin (COHb) levels were available, and CO exposure conditions were identical, to investigate the contributions of exposure conditions and individual variability to CO washout from blood. We found that CO washout from venous blood was biphasic and that postexposure times at which COHb samples were obtained significantly influenced the calculated CO half times (P < 0.0001). The first, more rapid, phase of CO washout from the blood reflected the loss of CO to the expired air and to a slow uptake by the muscle compartment, whereas the second, slower washout phase was attributable to CO flow from the muscle compartment back to the blood and removal from blood via the expired air. When the model was used to predict the effects of varying exposure conditions for these subjects, the CO exposure duration, concentration, peak COHb levels, and subject-specific parameters each influenced washout half times. Blood volume divided by ventilation correlated better with half-time predictions than did cardiac output, muscle mass, or ventilation, but it explained only approximately 50% of half-time variability. Thus exposure conditions, COHb sampling times, and individual parameters should be considered when estimating CO washout rates for poisoning victims.

Apparent Suicidal Carbon Monoxide Poisonings with Concomitant Prescription Drug Overdoses

We report four separate suicides by apparent motor vehicle-related carbon monoxide (CO) poisoning in which complete toxicological analysis showed the absence of, or lower than expected, percent carboxyhemoglobin saturation and high concentrations of concomitant prescription drugs. These cases, within a population of 71 apparent CO suicides from the Wayne County Medical Examiner's Office over 1998-2004, represent cases where additional factors are in play. Multiple modalities (CO poisoning and drug overdose) and/or undetectable carbon dioxide poisoning from the vehicle exhaust of cars manufactured after laws regulating vehicle emissions were enacted are examples of additional factors that require consideration in these selected cases. All four cases demonstrated some degree of decomposition, so the possible loss of CO could not be ruled out. The need for full toxicological analysis in apparent suicidal CO poisoning is emphasized.

[Carbon monoxide--a toxic gas and ...a signal molecule with therapeutic potential]

The toxic gas, carbon monoxide (CO), is produced endogenously during the catabolism of heme, resulting in the co-production of biliverdin, and iron (Fe2+) in equimolar amounts. This process is catalysed by heme oxygenase (HO). HO exists in three different isoforms. Inducible HO-1 may be induced by a wide variety of stimuli. HO-2 and HO-3 are constitutively expressed. The toxic effects of CO are well known. At low concentrations, CO appears to be cytoprotective. CO shares some chemical and biological properties with nitric oxide (NO), which together with some experimental findings has led to the suggestion that CO also possesses physiological functions; a role as signalling molecule has been proposed. Subsequently, it has been demonstrated that CO is a mediator in the autonomic nervous system and also in the immune system. NO and CO production appears to be reciprocally modulated by the respective synthesizing enzyme, which indicates a complicated interrelationship between the two mediators.

Limiting iron availability confers neuroprotection from chronic mild carbon monoxide exposure in the developing auditory system of the rat

Iron deficiency and chronic mild carbon monoxide (CO) exposure are nutritional and environmental problems that can be experienced simultaneously. We examined the effects of chronic mild CO exposure and iron availability on auditory development in the rat. We propose that chronic mild CO exposure creates an oxidative stress condition that impairs the spiral ganglion neurons. The CO-exposed rat pups had decreased neurofilament proteins and increased copper, zinc-superoxide dismutase (SOD1) in the spiral ganglion neurons. We conclude that the increased amount of SOD1 causes an increase in hydrogen peroxide production that allows the Fenton reaction to occur. This reaction uses both iron and hydrogen peroxide to generate hydroxyl radicals and leads to the development of oxidative stress that impairs neuronal integrity. However, rat pups with decreased iron and CO exposure (ARIDCO) exhibited in their cochlea an up-regulation of transferrin, whereas their expression of neurofilament proteins and SOD1 were similar to control. Consequently, reduced iron availability and the normal expression of SOD1 do not promote oxidative stress in the cochlea. By using basal c-Fos expression as a marker for cellular activation we found a significant reduction in c-Fos expression in the central nucleus of the inferior colliculus in iron-adequate rat pups exposed to CO. By contrast, rather than being reduced, c-Fos expression in the ARIDCO group is the same as for controls. We conclude that the cochlea of rat pups with normal iron availability is selectively affected by mild CO exposure, causing a chronic oxidative stress, whereas limiting iron availability ameliorates the effect caused by mild CO exposure by averting conditions that facilitate oxidative stress.

[Five fatalities due to inhalation of "asphyxiant gases": pathophysiological analysis in autopsy cases]

Five autopsy cases were examined to investigate fatal factors involved in inhalation of "asphyxiant gases": carbon monoxide (CO, n=3), fluorocarbons (n=1) and butane (n=1). In all cases, there was severe pulmonary edema and congestion in all viscera, suggesting advanced circulatory failure. The airway was filled with bloody froth in cases of fluorocarbons and butane inhalation. In CO intoxication, a marked increase in serum cardiac troponins suggested severe myocardial damage. There were also biochemical findings of respiratory distress (an evident increase in intra-alveolar pulmonary surfactant protein A), alveolar injury (an increase in serum surfactant protein A and D), rhabdomyolysis (myoglobinuria) and prolonged hypoxia (myogenic hyperuricemia) in cases of inhaling incomplete combustion gases. In a case of fluorocarbons gas inhalation, biochemical findings suggested respiratory distress, myocardial ischemia (an increase in serum CK-MB) and advanced hypoxia. Similar findings were observed in a case of butane inhalation, although cardiac troponin levels were low in the peripheral blood. These observations suggested that myocardial damage was prominent in CO intoxication, accompanied by respiratory distress in cases of inhaling incomplete combustion gases, whereas respiratory distress and hypoxia were major findings in cases of fluorocarbons and butane gas inhalation.

Carbon Monoxide Research Group, LDS Hospital, Utah in reply to Scheinkestel et al. and Emerson: The role of hyperbaric oxygen in carbon monoxide poisoning

This comprehensive response was invited by the Editor of Emergency Medicine Australasia to allow our Group from Salt Lake City, Utah to review the two articles 'Where to now with carbon monoxide poisoning?' by Scheinkestel et al. and the accompanying

COMMENTARY

'The dilemma of managing carbon monoxide poisoning' by Emerson published in the April issue of Emergency Medicine Australasia.

[Ex vivo analysis of mitochondrial function in patients attended in an emergency department due to carbon monoxide poisoning]

BACKGROUND AND OBJECTIVE

Many experimental studies in animals have demonstrated that carbon monoxide (CO) has the ability to bind to complex IV of the mitochondrial respiratory chain (MRC) inhibiting its function. It is unknown, however, if this situation is also present in patients who are admitted to an emergency department because of acute CO poisoning. The objective of this study was to evaluate from different points of view whether or not mitochondrial function is abnormal in patients admitted because of an acute CO poisoning.

PATIENTS AND METHOD

Ten patients with an acute CO poisoning admitted in an emergency department were included in the study. Initial carboxyhemoglobin was 20.4 (6)%. Seven of these patients received hyperbaric-oxygen therapy. In all the patients, lymphocytes from 20 mL of blood were obtained at admission (t0), and at days 3-5 (t1), and 10-14 (t2). Mitochondrial content was estimated through citrate synthase activity (nmol/min/mg protein). Enzymatic activity of complexes III and IV (both containing cytochromes) as well as oxidative activities were measured. Lipid peroxidation was ascertained by means of cis-parinaric acid fluorescence. All the values were given as absolute values, and were corrected according to the mitochondrial content (relative values). The results were compared with the control values obtained from 130 historical normal individuals.

RESULTS

During acute poisoning (t0), there were no changes in mitochondrial content. On the other hand, there was a significant inhibition of the enzymatic activity of complexes III and IV, and a decrease in all oxidative activities, considering both absolute and relative values. Although all the activities showed a trend to recuperation with time (t1 y t2), statistical significance was only observed for complex IV and for the oxydative activity stimulated with glutamate.

CONCLUSIONS

In the present study we confirm that an inhibition of the MRC can be demonstrated ex vivo in patients attended in an emergency department due to acute CO poisoning. The inhibition is still present 14 days after the acute event. This mitochondrial dysfunction may play a pathogenic role in the persisting or delayed sings and symptoms that these patients occasionally refer.

Characterization of hydroxyl radical generation in the striatum of free-moving rats due to carbon monoxide poisoning, as determined by in vivo microdialysis

Carbon monoxide (CO) poisoning caused by CO exposure at 3000 ppm for 40 min resulted in stimulation of hydroxyl radical (*OH) generation (estimated by measuring 2,3-dihydroxybenzoic acid (2,3-DHBA) production from salicylic acid) in the striatum of free-moving rats, as determined by means of brain microdialysis. Pretreatment with a voltage-dependent Na+ channel blocker, tetrodotoxin (TTX), lowered the basal level of 2,3-DHBA and strongly suppressed the increase in 2,3-DHBA induced by CO poisoning. CO poisoning significantly, though only slightly, increased extracellular glutamate in the striatum, and glutamate (Glu) receptor antagonists, such as MK-801 (dizocilpine) and NBQX, failed to suppress the CO-induced increase in 2,3-DHBA. These findings suggest that CO poisoning may induce Na+ influx via the voltage-dependent Na+ channels, resulting in stimulation of *OH generation in rat striatum. This effect may be independent of Glu receptor activation by increased extracellular Glu.

Carbon monoxide poisoning while using a small cooking stove in a tent

Carbon monoxide (CO) is formed wherever incomplete combustion of carbonaceous products occurs.(1) CO is the leading cause of poisoning in the United States, and common sources of CO poisoning include housefires, automobile exhaust, water heaters, kerosene space heaters, and furnaces.(2) Stoves used for cooking and heating during outdoor activities also produce significant amounts of CO. Mountain climbers have been reported to succumb to fumes generated by small cook stoves.(3) The aim of this study was to investigate if burning a cooking stove inside a tent is a potential health hazard. Seven healthy male volunteers used a cooking stove inside a small tent for 120 minutes. CO levels in the ambient tent air were measured in addition to hearth rate (HR) and pulse oximetry (SpO2). Venous blood samples were obtained every 15 minutes for measurement of carboxyhemoglobin (COHb). After 2 hours, all the subjects had significant CO levels in their blood (mean COHb = 21.5%). Mean SpO2, also fell from 98% to 95.3% (P <.05), whereas mean HR increased from 63 to 90 beats/min (P <.05). Kerosene camping stoves do produce CO when burned in a small tent. The concentration is high enough to cause significant COHb levels in venous blood after 120 minutes' stay in the tent.

Carbon monoxide poisoning: two cases of assessment by magnetization transfer ratios and 1H-MRS for brain damage

We describe two patients with carbon monoxide (CO) poisoning. One developed diseased hypoxic encephalopathy, and the other recovered completely. In the patient with progressive hypoxic encephalopathy, the magnetization transfer ratios (MTRs) had already decreased during the lucid period, while the patient with complete recovery showed no reduction of MTRs during this period. 1H-MRS in the two patients revealed no definite abnormality during this lucid period. The MTR maps suggested that irreversible change had already occurred during the lucid period, and 1H-MRS was useful to determine the duration of treatment. The combination of MTRs and 1H-MRS may help to manage patients with CO poisoning.

Neuronal nitric oxide synthase and N-methyl-D-aspartate neurons in experimental carbon monoxide poisoning

We measured changes in nitric oxide (NO) concentration in the cerebral cortex during experimental carbon monoxide (CO) poisoning and assessed the role for N-methyl-d-aspartate receptors (NMDARs), a glutamate receptor subtype, with progression of CO-mediated oxidative stress. Using microelectrodes, NO concentration was found to nearly double to 280 nM due to CO exposure, and elevations in cerebral blood flow, monitored as laser Doppler flow (LDF), were found to loosely correlate with NO concentration. Neuronal nitric oxide synthase (nNOS) activity was the cause of the NO elevation based on the effects of specific NOS inhibitors and observations in nNOS knockout mice. Activation of nNOS was inhibited by the NMDARs inhibitor, MK 801, and by the calcium channel blocker, nimodipine, thus demonstrating a link to excitatory amino acids. Cortical cyclic GMP concentration was increased due to CO poisoning and shown to be related to NO, versus CO, mediated guanylate cyclase activation. Elevations of NO were inhibited when rats were infused with superoxide dismutase and in rats depleted of platelets or neutrophils. When injected with MK 801 or 7-nitroindazole, a selective nNOS inhibitor, rats did not exhibit CO-mediated nitrotyrosine formation, myeloperoxidase (MPO) elevation (indicative of neutrophil sequestration), or impaired learning. Similarly, whereas CO-poisoned wild-type mice exhibited elevations in nitrotyrosine and myeloperoxidase, these changes did not occur in nNOS knockout mice. We conclude that CO exposure initiates perivascular processes including oxidative stress that triggers activation of NMDA neuronal nNOS, and these events are necessary for the progression of CO-mediated neuropathology.

[Post mortem diffusion of carbon monoxide to muscles and blood--preliminary examinations]

The purpose of the study was to determine whether the postmortem diffusion of carbon monoxide (CO) significantly affected the results of carboxyhemoglobin (COHb) and carboxymyoglobin (COMb) determinations. The musculocutaneous and muscular specimens collected from adult cadavers were used. The specimens were treated with CO for 24 h at room temperature. COHb and COMb were determined using gas chromatography. It was demonstrated that the skin substantially limited the diffusion of CO which slightly penetrated only the superficial layers of the muscle and did not change the blood level of COHb in the 4.5-cm layer of the muscle located underneath. The CO diffusion through the superficially charred and thermally coagulated muscle did not differ from that observed in the intact integuments. On the other hand, the membrane of the skin completely deprived of the adipose layer was not the barrier to moderate diffusion into the blood layer situated below. Thus, in charred corpses the results pf COHb and COMb determinations in the material collected under the layer of charred and coagulated tissues enable us to determine whether the victim was alive at the moment of the outbreak.

Clinical status of carbon-monoxide-poisoned patients and the results of rest 99mTc-MIBI and 99mTc-Amiscan heart scintigraphy performed in the acute phase of intoxication and stress-rest 99mTc-MIBI scintigraphy six month later

The double tracer (99mTc-MIBI and 99mTc-Amiscan) scintigraphy is an useful technique to imagine cardiac injury due to CO intoxication. Accumulation (retention) of 99mTc-MIBI is dependent on blood flow and cellular and mitochondrial electrical potential of myocytes. The lower tracer accumulation is seen not only in necrotic heart tissue regions, but also in ischemic area of worse metabolic rate and perfusion. 99mTc-Amiscan contrary to 99mTc-MIBI, is accumulated only in regions of early necrosis so it can be can distinguished from transitory ischemia. Mechanisms of cardiac injury due to CO toxicity is different than due to coronary occlusion and the process of the heart damage is usually much longer. Results of control stress-rest 99mTcMIBI scintigraphy, performed after 6 months from CO exposure in relation to the clinical state on admission and results of 99mTc-MIBI and 99mTc-Amiscans scans obtained in acute phase of poisoning are presented in the study. Initial 99mTc-MIBI SPET examination had confirmed transitory myocardial ischemia of different degree in all the examined patients. The mutual dependence between degree of scintigraphic changes and blood lactate level and CK activity was found. 99mTc-Amiscan scintigraphy demonstrated areas of necrosis in myocardium of some patients; they had statistically higher COHb and blood lactate concentration compared to the rest. A control stress-rest 99mTc-MIBI SPET performed 6 months after CO intoxication, confirmed a late consequences of metabolic abnormalities and a necessity of cardiovascular system follow-up controlling.

Hypothermia attenuates delayed cortical cell death and ROS generation following CO inhalation

Carbon monoxide (CO) is the most popular cause of poisoning. The bilateral basal ganglia lesion characterizes the delayed neuronal cell death (DCD). We demonstrated there were both apoptosis and necrosis in the cortex, basal ganglia and hippocampus in a case of human CO accident. To elucidate the mechanism of DCD after CO inhalation, histological studies on the rat brain were conducted. Rats were ventilated with nitrous oxide (sham group), 10% O(2) (hypoxia group) or 1005 ppm CO (CO group) for 90 min, while the pericranial temperature was controlled at either 32, 37, or 39 degrees C during CO inhalation. After reoxygenation for 30 min, the rats were allowed to recover for 48 h. The ratio of eosinophilic and HNE-positive neurons in the cortex were higher in the CO group than in the hypoxia group at 37 degrees C, while the PaO(2) was much lower in the hypoxia than in the CO group. The damage was alleviated in the hypothermia (32 degrees C) as compared with normothermia, while the hyperthermia (39 degrees C) did not significantly increased it. CO inhalation injures neuron by reactive oxygen species (ROS), independent of hypoxia, as can be concluded from the histological comparison of DCD with HNE immunoreactivity.

Characterization of suppression of nitric oxide production by carbon monoxide poisoning in the striatum of free-moving rats, as determined by in vivo brain microdialysis

We examined the effect of carbon monoxide (CO) poisoning on the nitric oxide (NO) system in the striatum of free-moving rats by means of in vivo brain microdialysis. The extracellular levels of the oxidative NO products, nitrite (NO(2)(-)) and nitrate (NO(3)(-)), decreased during exposure to CO at 3000 ppm for 40 min, a condition which causes CO poisoning. The extracellular levels of citrulline (Cit; a by-product of NO production) and arginine (Arg; an NO precursor) also decreased during CO exposure. Following reoxygenation by withdrawal of CO, the NO(2)(-) and NO(3)(-) levels gradually recovered to the control values, though Arg and Cit remained at lower levels, except for a rapid, but transient, recovery shortly before and after reoxygenation, respectively. Simultaneous application of exogenous L-Arg (50 and 100 mM) with CO exposure attenuated the decreases in NO(2)(-) and NO(3)(-) during the CO exposure and accelerated their recovery following reoxygenation. However, D-Arg (100 mM) had no effect on the decrease in NO(2)(-) and NO(3)(-), except for slight and transient attenuation shortly after reoxygenation. Exogenous L-Cit (10 and 100 mM) failed to attenuate the CO-induced decrease in NO(2)(-) and NO(3)(-) levels. The decrease in the NO(2)(-) and NO(3)(-) levels during 8% O(2) exposure for 40 min, which was comparable with that in response to 3000 ppm CO, was resistant to exogenous 100 mM L-Arg, but the recovery of the NO(2)(-) and NO(3)(-) levels following reoxygenation was strongly accelerated. These findings suggest that CO poisoning suppresses NO production in rat striatum in vivo though a mechanism which may not be common with that in hypoxic hypoxia.