Multicenter Study of Perioperative Hepatic Angioembolization as an Adjunct for Management of Major Operative Hepatic Trauma

BACKGROUND

The management of major liver trauma continues to evolve in trauma centers across the US with increasing use of minimally invasive techniques. Data on the outcomes of these procedures remain minimal. The objective of this study was to evaluate patient complications after perioperative hepatic angioembolization as an adjunct to management of major operative liver trauma.

STUDY DESIGN

A retrospective multi-institutional study was performed at 13 level 1 and level 2 trauma centers from 2012 to 2021. Adult patients with major liver trauma (grade 3 and higher) requiring operative management were enrolled. Patients were divided into 2 groups: angioembolization (AE) and no angioembolization (NO AE). Univariate and multivariate analyses were performed.

RESULTS

A total of 442 patients were included with AE performed in 20.4% (n = 90 of 442) of patients. The AE group was associated with higher rates of biloma formation (p = 0.0007), intra-abdominal abscess (p = 0.04), pneumonia (p = 0.006), deep vein thrombosis (p = 0.0004), acute renal failure (p = 0.004), and acute respiratory distress syndrome (p = 0.0003), and it had longer ICU and hospital length of stay (p < 0.0001). On multivariate analysis, the AE had a significantly higher amount intra-abdominal abscess formation (odds ratio 1.9, 95% CI 1.01 to 3.6, p = 0.05).

CONCLUSIONS

This is one of the first multicenter studies comparing AE in specifically operative high-grade liver injuries and found that patients with liver injury that undergo AE in addition to surgery have higher rates of both intra- and extra-abdominal complications. This provides important information that can guide clinical management.

Angiotensin II: A Review of Current Literature

Up to one-third of all patients admitted to intensive care units carry a diagnosis of shock. The use of angiotensin II is becoming widespread in all forms of shock, including cardiogenic, after the U.S. Food and Drug Administration's (FDA's) initial approval for vasoplegic shock in 2017. Here, the authors review the literature on angiotensin II's mechanism of action, benefits, and future therapeutic opportunities.

When Is It Safe to Start Pharmacologic Venous Thromboembolism Prophylaxis After Pelvic Fractures? A Prospective Study From a Level I Trauma Center

BACKGROUND

The ideal time for pharmacologic venous thromboembolism (VTE) prophylaxis initiation after pelvic fracture is controversial. This prospective study evaluated the safety and efficacy of early VTE prophylaxis after blunt pelvic trauma.

METHODS

Patients presenting to our American College of Surgeons-verified level I trauma center (between December 1, 2016 and November 30, 2017) with blunt pelvic fracture were prospectively screened. Exclusion criteria were emergency department death, immediate operative intervention, transfers, home anticoagulation, pregnancy, and patients receiving no pharmacologic VTE prophylaxis during hospitalization. Patients were dichotomized into study groups based on VTE prophylaxis initiation time ≤48 h (early prophylaxis [EP]) versus >48 h (late prophylaxis [LP]) after emergency department arrival. Demographics, injury data, clinical data, VTE prophylaxis agent and initiation time, and outcomes were compared.

RESULTS

After exclusions, 146 patients were identified: 74 (51%) patients in EP group and 72 (49%) patients in LP group. Pelvic fracture severity was comparable between groups (Abbreviated Injury Scale extremity score 2 [2-3] versus 2 [2-3]; P = 0.610). On univariate analysis, deep vein thrombosis rates were higher after LP (n = 5, 7% versus 0, 0%; P = 0.027). Pulmonary embolism rates were similar (n = 2, 3% versus n = 3, 4%; P = 1.000). No patient required delayed intervention for bleeding, and postprophylaxis blood transfusion was comparable between groups (P > 0.05). On multivariate analysis, timing of pharmacologic VTE prophylaxis initiation was not associated with VTE development (odds ratio, 0.647; P = 0.999). Pelvic angioembolization was independently associated with VTE (odds ratio, 1.296; P = 0.044).

CONCLUSIONS

Early initiation of pharmacologic VTE prophylaxis after blunt pelvic fracture is safe. Although EP initiation did not reduce the rate of VTE, these data identify angioembolization as an independent risk factor for VTE. Patients with blunt pelvic fracture who undergo angioembolization may therefore represent a high-risk population who may especially benefit from EP.

Effect of Interhospital ICU Relocation on Patient Physiology and Clinical Outcomes

Relocation of large numbers of critically ill patients between hospitals is sometimes necessary and the risks associated with relocation may be high. In the setting of adherence to an interhospital intensive care unit (ICU) relocation protocol, we aimed to determine whether the interhospital relocation of all ICU patients in a single day is associated with changes in vital signs, device removal, and worse clinical outcomes. We conducted a prospective, observational, cohort study of all critically ill adults admitted to a tertiary medical center's ICUs on the day of a planned hospital relocation and exposed to interhospital ICU relocation compared with unexposed critically ill adults. Changes in vital signs were evaluated by the before-and-after interhospital relocation measurement of vital signs, and clinical outcomes were collected for all patients. A total of 699 patients were admitted to the ICU during the observation period, 24 of whom were exposed to interhospital ICU relocation on a single day. The median interhospital transport duration was 28 minutes (interquartile range: 24-35) and 29% of patients were receiving invasive mechanical ventilation. Patients exposed to interhospital ICU relocation had no significant change in any vital sign measurement and no devices were unintentionally removed. Inhospital mortality was similar (8.3%) to patients not exposed to interhospital ICU relocation (9.2%, P > .99). In the setting of adherence to an ICU relocation protocol, the interhospital ICU relocation of all critically ill adults during a single day is not associated with changes in vital signs, device removal, or worse clinical outcomes.

Reproductive Life Plan Counseling and Effective Contraceptive Use among Urban Women Utilizing Title X Services

BACKGROUND

Although the Centers for Disease Control and Prevention and the U.S. Office of Population Affairs recommend inclusion of reproductive life plan counseling (RLPC) in all well-woman health care visits, no studies have examined the effect of RLPC sessions on the decision to use effective contraception at publicly funded family planning sites. RLPC could be a particularly impactful intervention for disadvantaged social groups who are less likely to use the most effective contraceptive methods.

METHODS

Using data from 771 nonpregnant, non-pregnancy-seeking women receiving gynecological services in the Cincinnati-Hamilton County Reproductive Health and Wellness Program, multinomial logistic regression models compared users of nonmedical/no method with users of 1) the pill, patch, or ring, 2) depot medroxyprogesterone acetate, and 3) long-acting reversible contraception (LARC). The effect of RLPC on the use of each form of contraception, and whether it mediated the effect of race/ethnicity and education on contraceptive use, was examined while controlling for age, insurance status, and birth history. The interaction between RLPC and race/ethnicity and the interaction between RLPC and educational attainment was also assessed.

FINDINGS

RLPC was not associated with contraceptive use. The data suggested that RLPC may increase LARC use over nonmedical/no method use. RLPC did not mediate or moderate the effect of race/ethnicity or educational attainment on contraceptive use in any comparison.

CONCLUSIONS

In this system of publicly funded family planning clinics, RLPC seems not to encourage effective method use, providing no support for the efficacy of the RLPC intervention. The results suggest that this intervention requires further development and evaluation.

Single-chain recombinant HLA-DQ2.5/peptide molecules block α2-gliadin-specific pathogenic CD4+ T-cell proliferation and attenuate production of inflammatory cytokines: a potential therapy for celiac disease

Celiac disease (CD) is a disorder of the small intestine caused by intolerance to wheat gluten and related proteins in barley and rye. CD4(+) T cells have a central role in CD, recognizing and binding complexes of HLA-DQ2.5 bearing gluten peptides that have survived digestion and that are deamidated by tissue transglutaminase (TG2), propagating a cascade of inflammatory processes that damage and eventually destroy the villous tissue structures of the small intestine. In this study, we present data showing that recombinant DQ2.5-derived molecules bearing covalently tethered α2-gliadin-61-71 peptide have a remarkable ability to block antigen-specific T-cell proliferation and inhibited proinflammatory cytokine secretion in human DQ2.5-restricted α2-gliadin-specific T-cell clones obtained from patients with CD. The results from our in vitro studies suggest that HLA-DQ2.5-derived molecules could significantly inhibit and perhaps reverse the intestinal pathology caused by T-cell-mediated inflammation and the associated production of proinflammatory cytokines.

Racial differences in HIV/AIDS discussion strategies and sexual risk behaviors among drug-abusing female criminal offenders

African-American female inmates are disproportionately affected by the human immunodeficiency virus (HIV), with heterosexual contact as the primary mode of transmission. This could be the result of racial differences in the strategies used by women to persuade a potential sexual partner to discuss HIV/AIDS and engage in condom use. Data were collected from 336 female inmates as part of the Reducing Risky Relationships for HIV (RRR-HIV) protocol within the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) cooperative agreement. Bivariate analyses indicated that African-American drug-using women were more likely than Whites to use the rational, withdrawal, and persistence approaches to discuss HIV/AIDS with a sexual partner. Negative binomial regression models were used to identify which interpersonal discussion strategies were significant correlates of the number of the times White and African-American participants had unprotected vaginal sex in the 30 days before incarceration. Results from the multivariate model indicate that White women who are more likely to use the rational discussion strategy were 15% less likely to engage in unprotected vaginal sex; however, these findings were not replicated in the African-American sample. Findings add to the literature on racial differences in HIV/AIDS discussion strategies and sexual risk behaviors among drug-abusing female criminal offenders.

Evidence that the proposed novel human "neurokinin-4" receptor is pharmacologically similar to the human neurokinin-3 receptor but is not of human origin

There have been proposals that the tachykinin receptor classification should be extended to include a novel receptor, the "neurokinin-4" receptor (NK-4R), which has a close homology with the human NK-3 receptor (hNK-3R). We compared the pharmacological and molecular biological characteristics of the hNK-3R and NK-4R. Binding experiments, with (125)I-[MePhe(7)]-NKB binding to HEK 293 cell membranes transiently expressing the hNK-3R (HEK 293-hNK-3R) or NK-4R (HEK 293-NK-4R), and functional studies (Ca(2+) mobilization in the same cells) revealed a similar profile of sensitivity to tachykinin agonists and antagonists for both receptors; i.e., in binding studies with the hNK-3R, MePhe(7)-NKB > NKB > senktide >> NKA = Substance P; with the NK-4R, MePhe(7)-NKB > NKB = senktide >> Substance P = NKA; and with antagonists, SB 223412 = SR 142801 > SB 222200 >> SR 48968 >> CP 99994 for both hNK-3R and NK-4R. Thus, the pharmacology of the two receptors was nearly identical. However, attempts to isolate or identify the NK-4R gene by using various molecular biological techniques were unsuccessful. Procedures, including nested polymerase chain reaction studies, that used products with restriction endonuclease sites specific for either hNK-3R or NK-4R, failed to demonstrate the presence of NK-4R in genomic DNA from human, monkey, mouse, rat, hamster, or guinea pig, and in cDNA libraries from human lung, brain, or heart, whereas the hNK-3R was detectable in the latter libraries. In view of the failure to demonstrate the presence of the putative NK-4R it is thought to be premature to extend the current tachykinin receptor classification.

Neuromedin U is a potent agonist at the orphan G protein-coupled receptor FM3

Neuromedins are a family of peptides best known for their contractile activity on smooth muscle preparations. The biological mechanism of action of neuromedin U remains unknown, despite the fact that the peptide was first isolated in 1985. Here we show that neuromedin U potently activates the orphan G protein-coupled receptor FM3, with subnanomolar potency, when FM3 is transiently expressed in human HEK-293 cells. Neuromedins B, C, K, and N are all inactive at this receptor. Quantitative reverse transcriptase-polymerase chain reaction analysis of neuromedin U expression in a range of human tissues showed that the peptide is highly expressed in the intestine, pituitary, and bone marrow, with lower levels of expression seen in stomach, adipose tissue, lymphocytes, spleen, and the cortex. Similar analysis of FM3 expression showed that the receptor is widely expressed in human tissue with highest levels seen in adipose tissue, intestine, spleen, and lymphocytes, suggesting that neuromedin U may have a wide range of presently undetermined physiological effects. The discovery that neuromedin U is an endogenous agonist for FM3 will significantly aid the study of the full physiological role of this peptide.

Identification and cloning of a human urea transporter HUT11, which is downregulated during adipogenesis of explant cultures of human bone

Bipotential cells in human trabecular bone explant cultures that express osteoblast characteristics are able to undergo adipogenesis in the presence of 3-isobutyl-1-methylxanthine plus dexamethasone (Nuttall et al. [1998] J Bone Miner Res 13:371-382). The initial studies of these bipotential cells in explant cultures have been extended to examine differential gene expression during osteoblast/adipocyte transdifferentiation. Using differential display, we have identified a gene expressed in trabecular bone explant cultures that is downregulated as these cells differentiate from an osteoblast to an adipocyte phenotype. Homology searching identified this gene as the human urea transporter HUT11. The expression and downregulation of HUT11 have been observed in multiple patient bone explant cultures. The size of the bone explant-derived HUT11 mRNA is approximately 4.4 kb, which is identical to the largest splice variant reported. In this article, we report the cloning and sequencing of this gene from primary human osteoblasts. In addition, we report tissue distribution for the bone explant-derived form of HUT11 mRNA and show a reciprocal relationship between the expression of HUT11 and the nuclear hormone receptor peroxisome proliferator-activated receptor gamma 2, which is a marker of adipocyte differentiation. Because the control of osteoblast/adipocyte transdifferentiation is unknown, selective downregulation of HUT11 during adipogenesis suggests that HUT11 expression may be a marker of the switch from an osteoblast to an adipocyte phenotype. Understanding the role of HUT11 in osteoblasts may provide insights into the mechanism controlling osteoblast and adipocyte differentiation.

Identification of novel inducible genes in airway epithelium

DNA differential display analysis (DD-PCR) was utilized to identify genes that are expressed in airway epithelium and are relevant to airway inflammation; cytokine-mediated induction of gene expression and inhibition of that induction by glucocorticoids were the criteria for selection. The IB3-1 cell line was cultured in the presence of tumor necrosis factor-alpha (TNF-alpha), dexamethasone, or dimethyl sulfoxide (DMSO) as a control, and analyzed via DD-PCR and Northern blot analyses. With this approach, two TNF-alpha-inducible and dexamethasone (DEX)-sensitive expressed sequence tags (EST8 and EST19) were identified. In IB3-1 cells, TNF-alpha increased messenger RNA (mRNA) expression of EST8 (34%, P < or = 0.005) and EST19 (41%, P < or = 0.01), whereas dexamethasone reduced this expression to resting levels. This pattern of mRNA expression was also observed in normal human bronchial epithelial cells (EST8: 21%, P < or = 0.009; EST19: 11%, P < or = 0.02) and in the basophil leukemia cell line KU812 (EST8: 34%, P < or = 0.01). Through basic local alignment search tool (BLAST) analysis, it was determined that these ESTs exhibited significant homology with the monomeric G protein rhoC (EST8: 100% homology, P = 1.6 x 10(-100)) and the UFO tyrosine kinase receptor (EST19: 86% homology, 5.3 x 10(-28).

Genetic analysis of suppressors of the veA1 mutation in Aspergillus nidulans

Light-dependent conidiation in the filamentous ascomycete, Aspergillus nidulans, is contingent on the allelic state of the velvet (veA) gene. Light dependence is abolished by a mutation in this gene (veA1), which allows conidiation to occur in the absence of light. We have isolated and characterized six extragenic suppressors of veA1 that restore the light-dependent conidiation phenotype. Alleles of four genes, defined by complementation tests, were subjected to extensive genetic and phenotypic analysis. The results of light-dark shifting experiments and the phenotypes of double mutant combinations are consistent with the possibility that the expression of the light-dependent phenotype is regulated by specific interactions of the suppressor gene products with the velvet gene product and with each other.

Light is required for conidiation in Aspergillus nidulans

Light is necessary for asexual sporulation in Aspergillus nidulans but will elicit conidiation only if irradiation occurs during a critical period of development. We show that conidiation is induced by red light and suppressed by an immediate shift to far red light. Conidiation-specific gene functions switch from light-independent to light-dependent activities coincident with the expression of brlA, a regulator of conidiophore development. We also show that light dependence is abolished by a mutation in the velvet gene, which allows conidiation to occur in the absence of light. We propose that the initiation of late gene expression is regulated by velvet and controlled by a red light photoreceptor, whose properties are reminiscent of phytochrome-mediated responses observed in higher plants.

Double-barreled K+-selective microelectrodes based on dibenzo-18-crown-6

Liquid ion-exchanger microelectrodes based on Corning code 477317 K+ exchanger are known to be much more sensitive to quaternary ammonium ions than to K+. In the presence of such cations, the capability of measuring K+ activities with Corning microelectrodes may be seriously impaired. We have developed a neutral carrier K+-selective microelectrode based on the crown ether dibenzo-18-crown-6. The crown ether cocktail contained (wt/wt) 2.3% dibenzo-18-crown-6, 0.8% Na-tetraphenylborate, 30.1% 2-nitrophenylocylether, and 66.8% O-nitrotoluene. Double-barreled crown ether and Corning microelectrodes were calibrated in KCl solutions with or without choline, acetylcholine, tetramethylammonium, imidazole, Na+, tris(hydroxymethyl)aminomethane (Tris), and N-methyl-D-glucamine. Both kinds of microelectrodes showed similar K+ over Na+, Tris, and N-methyl-D-glucamine selectivities. However, crown ether microelectrodes had immensely greater selectivities of K+ over quaternary ammonium ions and imidazole than Corning microelectrodes. Selectivity factors, defined as log K(ij)K, of crown ether microelectrodes with respect to K+ for tetramethylammonium, choline, acetylcholine, and imidazole were -1.92 +/- 0.13, -2.97 +/- 0.03, -1.75 +/- 0.15, and -1.30 +/- 0.20, respectively. Intracellular K+ activities measured in the same Necturus gallbladders with both kinds of microelectrodes did not differ significantly.