Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Association between fecal methanogen species with methane production and grazed forage intake of beef heifers classified for residual feed intake under drylot conditions

Reduction in greenhouse gas emission from beef production is essential to the survival of the beef industry from environmental and social-economic perspectives. There are different systems available to measure methane from animals, but they are expensive, not easily accessible, and not suitable for large-scale methane measurements on the farm. Therefore exploring indicator traits, which are easy to measure, cost-effective, and suitable for large-scale measurement, are recommended. The objectives of this study were to examine the diversity of fecal methanogen profile among efficient and inefficient beef heifers on pasture and investigate methanogen profile as a possible proxy to predict methane emission in beef cattle consuming a forage diet. Forty pregnant (1st trimester) heifers previously classified for postweaning residual feed intake adjusted for off-test back fat (RFI_fat; 20 high and 20 low) were included in this study. To determine individual pasture grazing intake, heifers were dosed with 1 kg of C₃₂ labeled pellets once per day from Day 0 to Day 12, and fecal samples were collected twice daily from Day 8 to Day 15. Fecal samples from Days 8, 10, and 12 were analyzed for their methanogen profile. Animals were monitored individually for methane and carbon dioxide production using a GreenFeed Emissions Monitoring system. Total methanogen population and methanogenic community diversity of fecal samples were not different (P > 0.1) between low and high RFI_fat groups, as measured by quantitative PCR and α- and β-diversity indices. However, both groups had a different methanogen profile; the relative abundance of Methanobrevibacter wolinii and relatives were higher (P < 0.002), while that of Methanosphaera species ISO3-F5 was lower (P < 0.01) in low RFI_fat cattle compared to the high RFI_fat group. We also demonstrated that fecal methanogen profiles may be a useful proxy in predicting daily methane and carbon dioxide emissions with an adjusted R² of 0.53 and 0.33, respectively, for low RFI_fat heifers and 0.46 and 0.57, respectively, for the high RFI_fat group.

Methane and carbon dioxide emissions and grazed forage intake from pregnant beef heifers previously classified for residual feed intake under drylot conditions

The objectives of this study were to quantify the effect of post-weaning residual feed intake (RFI) on subsequent grazed forage intake, methane (CH4), and carbon dioxide (CO2) emissions. Beef heifers classified for RFI adjusted for off-test backfat (RFIfat; 55 high and 56 low) at 9 mo of age were monitored 7 mo later for CH4 and CO2 emissions using the GreenFeed Emissions Monitoring system. About 56 of these heifers were also monitored as high and low RFIfat groups using open-path Fourier-transform infrared spectroscopy (OP-FTIR). Heifers were dosed with 1 kg of C32-labelled pellets once daily for 15 d, with twice daily fecal sampling the last 8 d to determine individual grazed forage intake using the n-alkane method. Low RFIfat pregnant heifers consumed less forage (10.25 vs. 10.81 kg dry matter d−1; P < 0.001), and emitted less daily CH4 (238.7 vs. 250.7 g d−1; P = 0.009) and CO2 (7578 vs. 8041 g d−1; P < 0.001) compared with high RFIfat animals. Results from the OP-FTIR further confirmed that low RFIfat heifers emitted 6.3% less (g d−1; P = 0.006) CH4 compared with their high RFIfat cohorts. Thus, selection for low RFIfat will decrease daily CH4 and CO2 emissions from beef cattle.

Phenotypic and genetic correlations between feeding behaviours and feed efficiency in crossbred beef replacement females

The objectives of this study were to identify the phenotypic and genetic relationships and heritability (h2) of feeding behaviours (FB) in replacement beef females. Between 2005 and 2017, heifers (N = 1394) were tested for feed intake using an electronic feed bunk system. The various FB were feeding duration (DUR; min d−1), head down time (HD; min d−1), feeding frequency (FREQ; events d−1), time-to-bunk (TTB; min). Dry matter intake (DMI; kg d−1), and residual feed intake adjusted for off-test ultrasound back fat thickness (RFIFAT) were also reported. The h2 estimates for DUR, HD, FREQ, TTB, DMI, and RFIFAT were 0.25 ± 0.05, 0.26 ± 0.06, 0.27 ± 0.05, 0.29 ± 0.06, 0.26 ± 0.05, and 0.40 ± 0.07, respectively. These are the first h2 to be presented for these FB among developing replacement heifers on a high-forage diet.

Weight loss, insulin resistance, and study design confound results in a meta-analysis of animal models of fatty liver

The classical drug development pipeline necessitates studies using animal models of human disease to gauge future efficacy in humans, however there is a low conversion rate from success in animals to humans. Non-alcoholic fatty liver disease (NAFLD) is a complex chronic disease without any established therapies and a major field of animal research. We performed a meta-analysis with meta-regression of 603 interventional rodent studies (10,364 animals) in NAFLD to assess which variables influenced treatment response. Weight loss and alleviation of insulin resistance were consistently associated with improvement in NAFLD. Multiple drug classes that do not affect weight in humans caused weight loss in animals. Other study design variables, such as age of animals and dietary composition, influenced the magnitude of treatment effect. Publication bias may have increased effect estimates by 37-79%. These findings help to explain the challenge of reproducibility and translation within the field of metabolism.

Methane and carbon dioxide emissions from yearling beef heifers and mature cows classified for residual feed intake under drylot conditions

This study quantified methane (CH4) and carbon dioxide (CO2) production from beef heifers and cows classified for residual feed intake adjusted for off-test backfat thickness (RFIfat) and reared in drylot during cold winter temperatures. Individual performance, daily feed intake, and RFIfat were obtained for 1068 crossbred and purebred yearling heifers (eight trials) as well as 176 crossbred mature cows (six trials) during the winters of 2015–2017 at two locations. A portion of these heifers (147 high RFIfat; 167 low RFIfat) and cows (69 high RFIfat; 70 low RFIfat) was monitored for enteric CH4 and CO2 emissions using the GreenFeed Emissions Monitoring (GEM) system (C-Lock Inc., Rapid City, SD, USA). Low RFIfat cattle consumed less feed [heifers, 7.80 vs. 8.48 kg dry matter (DM) d−1; cows, 11.64 vs. 13.16 kg DM d−1] and emitted less daily CH4 (2.5% for heifers; 3.7% for cows) and CO2 (1.4% for heifers; 3.4% for cows) compared with high RFIfat cattle. However, low RFIfat heifers and cows had higher CH4 (6.2% for heifers; 9.9% for cows) and CO2 yield (7.3% for heifers; 9.8% for cows) per kilogram DM intake compared with their high RFIfat pen mates. The GEM system performed at air temperatures between +20 and −30 °C. Feed intake of heifers and mature cows was differently affected by ambient temperature reduction between +20 and −15 °C and similarly increased their feed intake at temperatures below −15 °C. In conclusion, low RFIfat animals emit less daily enteric CH4 and CO2, due mainly to lower feed consumption at equal body weight, gain, and fatness.

Effect of post-weaning residual feed intake classification on grazed grass intake and performance in pregnant beef heifers

Manafiazar, G., Basarab, J. A., Baron, V. S., McKeown, L., Doce, R. R., Swift, M., Undi, M., Wittenberg, K. and Ominski, K. 2015. Effect of post-weaning residual feed intake classification on grazed grass intake and performance in pregnant beef heifers. Can. J. Anim. Sci. 95: 369–381. There is limited knowledge of how cattle tested for feed efficiency under drylot conditions perform when they graze on summer pasture. Residual feed intake adjusted for end of test backfat thickness (RFIfat) was determined on 171 beef crossbred heifers under drylot conditions over 2 yr using an automated system. Upon completion of the test, the 10 lowest and 10 highest RFIfat (–0.54±0.17 vs. 0.58±0.15 kg DM d−1) heifers in 2012, and the 14 lowest and 14 highest RFIfat (−0.47±0.16 vs. 0.53±0.19 kg DM d−1) heifers in 2013 were selected and placed on meadow bromegrass pasture to investigate the effect of RFIfat ranking on their grass intake and performance on the pasture. The pasture adaptation period (8 d in 2012 and 19 d in 2013) was followed by a pasture feed intake experiment during which heifers were dosed twice daily (0815 and 1415) with 500 g of C32-labeled feed pellet for 13 d (day 0 to 12) and fecal sampled twice daily (0815 and 1415) from day 8 to 12. Forage DM intake on pasture for each heifer was determined using the double alkane (C31/C32) methodology. High and low RFIfat heifers were similar in body weight (BW), backfat and rump fat thickness, and average daily gain (ADG) during the grazing trial period, except backfat thickness at the end of test period. However, low RFIfat heifers consumed 5.3% less forage when expressed as kg DM d−1 (8.20±0.08 vs. 8.66±0.09, P<0.001) and 5.1% less when expressed as a percentage of body weight (1.86±0.02 vs. 1.96±0.02% of BW, P<0.001) compared with high RFIfat heifers. RFIfat measured under drylot conditions in growing heifers was positively correlated to grazed RFIfat determined in pregnant heifers (rp=0.30, P=0.04). These results suggest that beef heifers classified as low RFIfat during the post-weaning drylot period had lower dry matter intake as heifers in their first pregnancy grazing tame pasture, with no negative impact on their body weight, back-fat thickness, and ADG compared with their high RFIfat herdmates.

Stereo-selective inhibition of transient receptor potential TRPC5 cation channels by neuroactive steroids

BACKGROUND AND PURPOSE

Transient receptor potential canonical 5 (TRPC5) channels are widely expressed, including in the CNS, where they potentiate fear responses. They also contribute to other non-selective cation channels that are stimulated by G-protein-coupled receptor agonists and lipid and redox factors. Steroids are known to modulate fear and anxiety states, and we therefore investigated whether TRPC5 exhibited sensitivity to steroids.

EXPERIMENTAL APPROACH

Human TRPC5 channels were conditionally expressed in HEK293 cells and studied using intracellular Ca²⁺ measurement, whole-cell voltage-clamp and excised patch techniques. For comparison, control experiments were performed with cells lacking TRPC5 channels or expressing another TRP channel, TRPM2. Native TRPC channel activity was recorded from vascular smooth muscle cells.

KEY RESULTS

Extracellular application of pregnenolone sulphate, pregnanolone sulphate, pregnanolone, progesterone or dihydrotestosterone inhibited TRPC5 activity within 1–2 min. Dehydroepiandrosterone sulphate or 17β-oestradiol had weak inhibitory effects. Pregnenolone, and allopregnanolone, a progesterone metabolite and stereo-isomer of pregnanolone, all had no effects. Progesterone was the most potent of the steroids, especially against TRPC5 channel activity evoked by sphingosine-1-phosphate. In outside-out patch recordings, bath-applied progesterone and dihydrotestosterone had strong and reversible effects, suggesting relatively direct mechanisms of action. Progesterone inhibited native TRPC5-containing channel activity, evoked by oxidized phospholipid.

CONCLUSIONS AND IMPLICATIONS

Our data suggest that TRPC5 channels are susceptible to relatively direct and rapid stereo-selective steroid modulation, leading to channel inhibition. The study adds to growing appreciation of TRP channels as non-genomic steroid sensors.

Completeness and accuracy of International Classification of Disease (ICD) external cause of injury codes in emergency department electronic data

The accuracy of external cause of injury codes (E codes) for work-related and non-work-related injuries in Massachusetts emergency department data were evaluated. Medical records were reviewed and coded by a nosologist with expertise in E coding for a stratified random sample of 1000 probable work-related (PWR) and 250 probable non-work-related (PNWR) cases. Cause of injury E codes were present for 98% of reviewed cases and accurate for 65% of PWR cases and 57% of PNWR cases. Place of occurrence E codes were present in less than 30% of cases. Broad cause of injury categories were accurate for about 85% of cases. Non-specific categories (not elsewhere classified, not specified) accounted for 34% of broad category misclassifications. Among specified causes, machinery injuries were misclassified most often (39/60, 65%), predominantly as cut/pierce or struck by/against. E codes reliably identify the broad mechanism of injury, but inaccuracies and incompleteness suggest areas for training of hospital admissions staff, providers, and coders.

The discourse of dental hygiene practice in Canada

Recently the discourse in Canada relating to dental hygiene practice has changed. While dentistry still exercises controlling power over the public's oral cavity, dental hygienists have made inroads through legislative changes. A description of Canadian dental hygiene practice is provided to set the stage for a discussion about current discourse in the dental hygiene profession. Although power is often perceived as a shifting changing set of relations, these can be frozen in abstraction. It is rather like taking a photo of a single moment or event in an ongoing activity. This moment provides a starting point, an event that can be analysed. Four such events are evident in Canadian dental hygiene practice; they include, education, recognition of dental hygienists as primary care providers, the culture of dental hygiene and self-regulation. While all the events are important, self-regulation is critical to the viability and development of the profession. It is the central event that provides the backdrop for effecting change. With self-regulation comes responsibility and accountability for professional actions. It also provides possibilities for changing the discourse in oral care. As oral health care discourse is transformed through legislation and public awareness, the public will, hopefully, be able to directly access dental hygiene services, and dental hygienists themselves might increasingly recognise their importance as contributors in the health care system.

Social relations and breath odour

In this retrospective qualitative study, the researcher reviewed 55 client records of The Breath Odour Clinic. The purpose was to determine if individuals attended a clinic specialised in treating oral malodour for medical or social reasons. The study focused on the psychosocial and breath odour history. Clients had agreed to the use of information for research purposes. Society uses odour as a means to define and interact with the world. The olfactory, smelling experience is intimate, emotionally charged and connects us with the world. It follows that the smell from mouth breath odour can connect or disconnect a person from their social environment and intimate relationships. How one experiences one's own body is very personal and private but also very public. Breath odour is public as it occurs within a social and cultural context and personal as it affects one's body image and self-confidence. Body image, self-image and social relations mesh, interact and impact upon each other. Breath odour is a dynamic and interactive aspect of the self-image. In addition, breath odour may be value-coded as 'bad'. In 75% of the cases reviewed, decreased self-confidence and insecurity in social and intimate relations led clients to seek treatment at the specialised breath odour clinic. Their doctor, dental hygienist or dentist had treated medical and oral conditions but not resolved their breath odour problem. When a person perceives a constant bad breath problem, she/he uses defence techniques, and may avoid social situations and social relations. This affects a person's well-being.

Basal joint arthritis: trapeziectomy with ligament reconstruction and tendon interposition arthroplasty

This article provides a qualitative and quantitative outcomes assessment of a consecutive series of 27 patients (30 thumbs) with basal joint arthritis of the thumb undergoing ligament reconstruction and tendon interposition arthroplasty. Outcome analysis revealed that 24 (89%) patients were satisfied with the relief of pain provided by the arthroplasty and 23 (87%) would undergo surgery again. Eighteen (67%) thumbs were noted to have improvement in the ability to perform activities of daily living. Significant improvements were noted in web space measurements and in grip and pinch strength determination. X-ray film assessment using the trapezial space ratio averaged 0.33 +/- 0.08 in preoperative x-ray films of thumbs with stage III and IV degenerative arthritis and 0.23 +/- 0.07 in thumbs following basal joint arthroplasty. This represents a total decrease of 51% in the trapezial space ratio following arthroplasty compared to the normal values obtained in previous studies and 33% compared to the preoperative values obtained in this study. Outcomes assessment at a mean of 42 months after surgery showed that there was no significant correlation between maintenance of trapezial height and both objective and subjective clinical outcomes. Although ligament reconstruction consistently failed to restore trapezial height, primary and secondary clinical outcomes following basal joint arthritis were almost uniformly satisfactory.

Platelet adhesion to collagen in individuals lacking glycoprotein IV

The Naka isoantigen is expressed on glycoprotein (GP) IV (CD36), a platelet membrane GP that has been identified as having a role in platelet interactions with collagen and thrombospondin and in binding Plasmodium falciparum-infected erythrocytes to endothelial cells and melanoma cells. We have studied normal platelets and Naka- platelets from two Japanese donors that have 1% of GPIV by concentration-dependent antibody binding and flow cytometry. We studied the adherence of normal and Naka- platelets to types I, III, and IV collagen in static and to type I collagen in flowing systems at high shear force. We have also studied aggregation of normal and Naka- platelets to type I collagen. Naka- platelets showed normal or increased aggregation to type I collagen and normal adhesion to types I, III, and IV collagen in the presence of Mg++ or EDTA. Platelet aggregation and adhesion were inhibited by the anti-alpha 2 beta 1 antibody 176D7 to the same extent in Naka- as in normal platelets. We also studied endogenous thrombospondin surface expression and found that thrombin-stimulated Naka- platelets expressed the same amount of thrombospondin as did normal platelets. From our studies with Naka- platelets, we cannot identify a definitive role for GPIV in platelet aggregation, in adhesion to types I, III, and IV collagen, or in endogenous thrombospondin binding to platelets.

Platelet adhesion to collagen types I through VIII under conditions of stasis and flow is mediated by GPIa/IIa (alpha 2 beta 1-integrin)

Platelet adhesion to fibrillar collagens (types I, II, III, and V) and nonfibrillar collagens (types IV, VI, VII, and VIII) was investigated in the presence of physiologic concentrations of divalent cations under conditions of stasis and flow. Under static conditions, platelet adhesion was observed to collagen types I through VII but not to type VIII. Under flow conditions, platelet adhesion to collagen types I, II, III, and IV was almost independent of shear rates above 300/s. Collagen type V was nonadhesive. Platelet adhesion to collagen type VI was shear rate-dependent and optimal at a rate of 300/s. Collagen types VII and VIII showed minor reactivity and supported platelet adhesion only between shear rates 100 to 1,000/s. Monoclonal antibody (MoAb) 176D7, directed against platelet membrane glycoprotein Ia (GPIa; very late antigen [VLA]-alpha 2 subunit), completely inhibited platelet adhesion to all collagens tested, under conditions of both stasis and flow. Platelet adhesion to collagen type III at shear rate 1,600/s was only inhibited for 85%. The concentration of antibody required for complete inhibition of platelet adhesion was dependent on the shear rate and the reactivity of the collagen. An MoAb directed against GPIIa (VLA-beta subunit) partially inhibited platelet adhesion to collagen. These results show that GPIa-IIa is a major and universal platelet receptor for eight unique types of collagen.

A monomeric von Willebrand factor fragment, Leu-504--Lys-728, inhibits von Willebrand factor interaction with glycoprotein Ib-IX [corrected]

von Willebrand factor interaction with glycoprotein Ib alpha (GPIb alpha) plays a critical role in the initial phase of platelet adhesion at high shear rates, and it may also play a role in platelet thrombus formation in partially occluded arteries. Previous studies have indicated that two peptides, Cys-474--Pro-488 (peptide 153) and Ser-692--Pro-708 (peptide 154), inhibit von Willebrand factor--GPIb alpha interaction. We have expressed a recombinant fragment of von Willebrand factor, Leu-504--Lys-728 [corrected], with a single intrachain disulfide bond linking residues Cys-509--Cys-695 and examined its ability to inhibit von Willebrand factor--GPIb alpha interactions and platelet adhesion at high shear forces. This recombinant fragment, named VCL, inhibits ristocetin-induced, botrocetin-induced, and asialo-von Willebrand factor-induced platelet aggregation and binding to platelets at an IC50 = 0.011-0.260 microM, significantly lower than the IC50 of peptide 153 or 154, IC50 = 86-700 microM. Peptides 153 and 154 did not result in any inhibition of platelet adhesion (IC50 greater than 500 microM). In contrast, VCL inhibited 50% of platelet adhesion at 0.94 microM and at 7.6 microM inhibited greater than 80% of platelet adhesion to human umbilical artery subendothelium at high shear forces. VCL inhibited the contact and spreading of platelets and also caused a marked decrease in thrombus formation. These studies indicate that VCL may be an effective antithrombotic agent in preventing arterial thrombus formation in areas of high shear force.

Endogenous platelet fibrinogen: its modulation after surface expression is related to size-selective access to and conformational changes in the bound fibrinogen

Platelet stimulation results in the release of endogenous platelet fibrinogen which binds to the platelet surface. Previous studies have demonstrated that plasma fibrinogen bound to activated platelets becomes inaccessible to a variety of probes. We have studied endogenous platelet fibrinogen binding to activated platelets by employing an immunopurified polyclonal anti-fibrinogen antibody and F26, a monoclonal anti-fibrinogen antibody, which recognizes fibrinogen only when it is bound to a surface. Employing the Ig or F(ab')2 of the poly- or monoclonal antibody we found a marked decrease of fibrinogen accessibility 30-60 min after platelet activation. In contrast, platelet-bound fibrinogen remains accessible to the Fab fragment of F26 at a constant level for 30 min and increases at 60 min. The reduction of the polyclonal Fab fragment binding at 30 and 60 min is similar to the F26 Ig. These results indicate that the decreased accessibility of bound fibrinogen is related to two mechanisms; (1) that the access route to fibrinogen in size selective for the antibody probes and only small antibody probes, e.g. Fab fragments, can gain access to fibrinogen and (2) fibrinogen undergoes a conformational change(s) after binding which exposes at least one neo-epitope in the D domain of fibrinogen and which may decrease or mask the reactivity of other fibrinogen domains. Only the F26 Fab probe has full access to and identifies fibrinogen present on the platelet surface 60 min after stimulation.

Endogenous platelet fibrinogen surface expression on activated platelets

Intracellular platelet fibrinogen surface expression was studied in arabinogalactan-purified, resting, and thrombin-stimulated platelets. Platelet fibrinogen is derived from endocytosis of plasma fibrinogen by megakaryocytes. Like a variety of other adhesive proteins, it is stored in the platelet alpha-granule. Platelet fibrinogen surface expression was studied by using the antigen-binding fragments of a murine monoclonal antibody to platelet fibrinogen, F26, and an immunopurified polyclonal antifibrinogen antibody. Studies correlating platelet fibrinogen surface expression with the presence of the glycoprotein IIb-IIIa (GPIIb-IIIa) complex showed that in the presence of ethylene glycol tetraacetic acid (EGTA) at 37 degrees C, neither the GPIIb-IIIa complex nor platelet fibrinogen was expressed on the surface of thrombin-activated platelets. Similar experiments performed in the presence of EGTA and calcium showed proportional expression of the GPIIb-IIIa complex and platelet fibrinogen. The addition of Arg-Gly-Asp-Ser-containing peptides, the pentadecapeptide of the fibrinogen gamma-chain carboxy terminus, or the monoclonal antibody 10E5, when directed against the GPIIb-IIIa complex before thrombin activation, inhibited 65% to 94% of the platelet fibrinogen expression, as determined with the polyclonal and monoclonal antigen-binding fragments. When these same inhibitory agents were added immediately after or 5 minutes after thrombin, the amount of inhibition decreased significantly. Similar studies with a washed platelet system revealed that when the inhibitors of platelet fibrinogen expression were added before thrombin stimulation, the degree of inhibition observed was only 24% to 38%. This suggests that the major portion of platelet fibrinogen expression involves the release of platelet fibrinogen and its subsequent binding to GPIIb-IIIa. This binding may occur within the open canalicular system or on the platelet surface; in either case, wherever the site of released platelet fibrinogen binding occurs, it can be markedly inhibited by the RGD-containing peptides and the gamma-chain fibrinogen peptides. Approximately 10% to 30% of platelet fibrinogen may be expressed prebound to a platelet receptor, or else it is released and binds to a platelet receptor other than the GPIIb-IIIa complex.