Neutrophils have key roles in modulating the immune response. We present a robust methodology for rapidly isolating neutrophils directly from whole blood with 'on-chip' processing for mRNA and ...protein isolation for genomics and proteomics. We validate this device with an ex vivo stimulation experiment and by comparison with standard bulk isolation methodologies. Last, we implement this tool as part of a near-patient blood processing system within a multi-center clinical study of the immune response to severe trauma and burn injury. The preliminary results from a small cohort of subjects in our study and healthy controls show a unique time-dependent gene expression pattern clearly demonstrating the ability of this tool to discriminate temporal transcriptional events of neutrophils within a clinical setting.
Pelvic fractures may be associated with significant hemorrhage. Although this hemorrhage may emanate from the pelvic vasculature, it may also be secondary to abdominal visceral injury. The purpose of ...this study was to determine factors associated with pelvic and/or abdominal visceral bleeding in hypotensive patients with pelvic fractures to guide the appropriate therapeutic intervention sequence for these difficult-to-manage patients.
Medical records of all hypotensive (systolic blood pressure < or = 90 mm Hg) patients with pelvic fractures seen at a Level I trauma center from January 1995 to December 1999 were evaluated. Records were abstracted for age, base deficit, 24-hour blood requirement, hemoperitoneum (positive ultrasound, diagnostic peritoneal lavage, or computed tomographic scan), abdominal hemorrhage discovered at celiotomy, pelvic hemorrhage discovered at angiography, emergency department disposition, Injury Severity Score, and mortality. Pelvic fracture categories were derived by adapting the Young-Burgess pelvic fracture classification scheme. Lateral compression (LC) I and anteroposterior compression (APC) I fractures were characterized as stable fracture patterns (SFPs), and APC II, APC III, LC II, LC III, and vertical shear were characterized as unstable fracture patterns (UFPs).
Of 231 hypotensive patients, 38 patients died in the emergency department, leaving 193 surviving initial resuscitation. One hundred seven patients stabilized (group I) and were transferred to the intensive care unit. Eighty-six patients (group II) required ongoing resuscitation and underwent celiotomy and/or angiography in an attempt to manage their hemorrhage. Within group II, in the SFP population, abdominal hemorrhage was responsible for hypotension in 34 of 40 (85%), and 10 patients died (25%). In patients with UFP injury, hemorrhage was predominantly from a pelvic source, as shown by 27 positive angiograms in the 46 patients (59%). Twenty-four of 46 (52%) UFP patients died. In patients with a UFP, 14 had both angiography and celiotomy. Four patients underwent angiography before celiotomy and one of four (mortality, 25%) died. In contrast, 10 patients underwent celiotomy before angiography and 6 of 10 died (mortality, 60%).
Patients with signs of ongoing shock with SFP pelvic injury and hemoperitoneum require celiotomy as the initial intervention, as the hemorrhagic focus is predominantly intraperitoneal. In patients with UFP, even in the presence of hemoperitoneum, consideration should be given to angiography before celiotomy.
Sepsis and organ dysfunction are common and likely contribute to death after burn trauma. We sought to define relationships between sepsis, severe multiple organ dysfunction (MOD), and death after ...burn trauma.
Adults with > or = 20% total body surface area burns were prospectively enrolled. Information regarding infection, severity of sepsis, and organ failure was collected daily. Risk factors (e.g., age, burn size, shock) were analyzed for their association with severe MOD, complicated sepsis, and death. We characterized the temporal relationship between organ failure and sepsis.
Of 175 patients, 27% developed severe MOD, 17% developed complicated sepsis, and 22% died. Full-thickness burn size, age, and inhalation injury were associated with MOD, sepsis, and death. Infection preceded MOD in 83% of patients with both. A base deficit of > or = 6 mEq/L at 24 hours after injury was associated with death.
When it occurs, severe MOD is usually preceded by infection. In addition, an elevated base deficit at 24 hours and septic shock are the most important factors associated with and possibly contributing to death after burn trauma.
Elevated ribosome biogenesis in oncogene‐driven cancers is commonly targeted by DNA‐damaging cytotoxic drugs. Our previous first‐in‐human trial of CX‐5461, a novel, less genotoxic agent that ...specifically inhibits ribosome biogenesis via suppression of RNA polymerase I (Pol I) transcription, revealed single‐agent efficacy in refractory blood cancers. Despite this clinical response, patients were not cured. In parallel, we demonstrated a marked improvement in the in vivo efficacy of CX‐5461 in combination with PI3K/AKT/mTORC1 pathway inhibitors. Here, we reveal the molecular basis for this improved efficacy observed in vivo, which is associated with specific suppression of translation of mRNAs encoding regulators of cellular metabolism. Importantly, acquired resistance to this cotreatment is driven by translational rewiring that results in dysregulated cellular metabolism and induction of a cAMP‐dependent pathway critical for the survival of blood cancers including lymphoma and acute myeloid leukemia. Our studies thus identify key molecular mechanisms underpinning the response of blood cancers to selective inhibition of ribosome biogenesis and define metabolic vulnerabilities that will facilitate the rational design of more effective regimens for Pol I‐directed therapies.
Synopsis
Specific inhibition of rRNA synthesis has been reported as an effective new treatment for refractory blood cancer, but patients relapse. Here, the development of resistance is shown to depend on reprogrammed mRNA translation and subsequent upregulation of a metabolism‐dependent survival pathway.
The efficacy of acute, combinatorial ribosome‐targeting therapy in vivo is associated with downregulation of the cells’ translational activity and energy metabolism
Therapeutic resistance is mediated by translational alterations that promote elevated metabolic activity and activate a cAMP‐dependent pro‐survival mechanism
The induced pro‐survival mechanism acts via EPAC1/2 and is targetable by metformin in vitro and in vivo
The identified metabolic vulnerability of ribosome‐targeting therapy resistance can be exploited to improve treatment efficacy in hematological cancers including lymphoma and acute myeloid leukemia.
The elevated metabolic activity and activation of cAMP‐dependent pro‐survival mechanisms that lead to resistance of hematological cancers towards rRNA synthesis inhibition also poses a potentially targetable vulnerability.
Clinical factors do not adequately explain why some patients develop severe sepsis after trauma and why others do not. We sought to determine whether genetic factors contribute to this risk.
Patients ...admitted to a single Level I trauma center were enrolled and DNA was isolated from leukocytes. The risk for severe sepsis and for death associated with polymorphism in the tumor necrosis factor-alpha promoter was determined by multivariate analysis.
One hundred fifty-two patients had a 24% incidence of severe sepsis and a 13% case fatality rate. The A-allele was most common at the -308 position (n = 35). A-allele carriage at this location was associated with an adjusted odds ratio of 4.6 (95% confidence interval, 1.9-10.9) for severe sepsis and of 2.1 (95% confidence interval, 0.6-7.3) for death.
The A-allele at the -308 position in the tumor necrosis factor-alpha promoter increases the risk for severe sepsis and possibly for death after trauma.
Many individuals are now surviving their injuries to face the consequences of an activated immunoinflammatory system and the complications of supportive therapy. The pulmonary system bears the force ...of this insult. An understanding of the epidemiology of acute respiratory failure, as well as a greater knowledge of the cellular and subcellular mechanisms by which pulmonary dysfunction occurs, has led to novel approaches to the management of acute respiratory failure. It also appears that lung injury is caused, or at least exacerbated, by iatrogenic insults, such as positive-pressure ventilation. The purpose of this review is to discuss the etiology and pathophysiology of acute respiratory failure following severe injury and the novel therapeutic approaches. A combination of immunomodulating and mechanical ventilation strategies will likely provide the most successful approach to reducing the morbidity and mortality associated with acute respiratory failure following injury.
Organ dysfunction and sepsis are frequent after major burn trauma, represent quantifiable consequences of the systemic response to injury, and may be important end points by which to measure ...treatment effectiveness. However, standard and widely applied methods for their measurement have not been applied to burn trauma victims. Therefore, the purpose of this study was to quantify these complications after burn trauma.
Patients with > or = 20% total body surface area burns admitted to a single center were prospectively enrolled. Standard sepsis criteria and multiple organ dysfunction (MOD) scores for the pulmonary, renal, cardiovascular, hepatic, and hematologic systems were determined. The incidence and risk factors for severe MOD (cumulative MOD score > or = 6) and severe sepsis were determined. The relationships between these complications and mortality and resource utilization were examined by univariate and multivariate analyses.
A total of 85 patients were enrolled over 1 year. Severe MOD developed in 24 (28%) and severe sepsis or septic shock developed in 12 (14%). Both were associated with increasing age and burn size and were more likely to occur in men. Most patients who developed severe MOD or severe sepsis survived (71% and 67%, respectively), and both were associated with longer intensive care unit stays and duration of mechanical ventilation.
According to simple and objective scoring systems, severe MOD and severe sepsis/septic shock are both related to burn size, age, and male sex. Both are related to intensive care unit length of stay and duration of mechanical ventilation.
The use of an observation period to identify missed injuries in trauma patients has gained favor in recent years. This study was undertaken in a population of patients with minimal or no identified ...injuries to determine the following: whether a period of in-patient observation identifies missed injuries; demographic factors associated with missed injuries; and morbidity of missed injuries.
Over 4 years at a Level I trauma center, 4,738 patients were observed for 23 hours. Of these patients, 630 were converted to full admission and were reviewed. All medical records were reviewed for reason for observation, reason for conversion to full admission, and presence of missed injury.
In the 4,738 patients observed, 35 had a missed injury identified. No clinical factors studied were associated with identifying a missed injury. Of the 35 patients that had a missed injury, 21 did not have clinically relevant injuries, whereas the 14 remaining patients did. All of the 14 required prolonged hospital admissions and 9 underwent invasive procedures.
Of over 4,700 observed trauma patients, less than 0.5% remained hospitalized for significant missed injuries. No factors were identified that predicted missed injuries. Twenty-three-hour observation for the purpose of identifying missed injuries after thorough emergency department evaluation may not be justified.
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