Assessment of risk factors for post-rewarming "rebound hyperthermia" in cardiac arrest patients undergoing therapeutic hypothermia.

INTRODUCTION: The outcomes associated with therapeutic hypothermia (TH) after cardiac arrest, while overwhelmingly positive, may be associated with adverse events. The incidence of post-rewarming rebound hyperthermia (RH) has been relatively unstudied and may worsen survival and neurologic outcome. The purpose of this study was to determine the incidence and risk factors associated with RH as well as its relationship to mortality, neurologic morbidity, and hospital length of stay (LOS). METHODS: A retrospective, observational study was performed of adult patients who underwent therapeutic hypothermia after an out-of-hospital cardiac arrest. Data describing 17 potential risk factors for RH were collected. The primary outcome was the incidence of RH while the secondary outcomes were mortality, discharge neurologic status, and LOS. RESULTS: 141 patients were included. All 17 risk factors for RH were analyzed and no potential risk factors were found to be significant at a univariate level. 40.4% of patients without RH experienced any cause of death during the initial hospitalization compared to 64.3% patients who experienced RH (OR: 2.66; 95% CI: 1.26-5.61; p=0.011). The presence of RH is not associated with an increase in LOS (10.67 days vs. 9.45 days; absolute risk increase=-1.21 days, 95% CI: -1.84 to 4.27; p=0.434). RH is associated with increased neurologic morbidity (p=0.011). CONCLUSIONS: While no potential risk factors for RH were identified, RH is a marker for increased mortality and worsened neurologic morbidity in cardiac arrest patients who have underwent TH.

Thrombospondin binding to specific sequences within the A alpha- and B beta-chains of fibrinogen.

Thrombospondin is a multifunctional adhesive glycoprotein which binds to the surface of resting and activated platelets. Thrombospondin also binds to a variety of proteins, including fibrinogen. The interactions between platelet-bound thrombospondin and fibrinogen are thought to facilitate irreversible platelet aggregation. Both the A alpha- and B beta-chains of fibrinogen specifically bind to thrombospondin. Cyanogen bromide cleavage products of the fibrinogen A alpha- and B beta-chains, and synthetic peptides corresponding to specific regions of these cleavage products were utilized to identify the regions of the fibrinogen A alpha- and B beta-chains which bind to thrombospondin. Cyanogen bromide fragments of the A alpha- and B beta-fibrinogen chains, resolved by gel filtration and reversed-phase chromatography, were examined for thrombospondin binding activity. Thrombospondin specifically bound to the A alpha-chain fragment encompassing residues 92-147 and the B beta-chain fragment encompassing residues 243-305. Analyses of the binding characteristics of two series of overlapping synthetic peptides revealed that peptides corresponding to residues 113-126 of the A alpha-chain and residues 243-252 of the B beta-chain retained thrombospondin binding activity. Separate bovine serum albumin conjugates of the active A alpha-chain and B beta-chain peptides inhibited platelet aggregation. These studies reveal that fibrinogen possesses at least two unique sequences which are recognized by thrombospondin and that such interaction may affect platelet aggregation.

Thrombospondin interaction with plasminogen. Evidence for binding to a specific region of the kringle structure of plasminogen.

Platelet thrombospondin interacts with plasminogen in a specific and saturable manner. Thrombospondin was found to specifically bind to plasminogen and the nonenzyme chain of plasmin. Preincubation of 125I-labeled thrombospondin with 30 mmol/L lysine was without effect in the binding of thrombospondin to immobilized plasminogen; preincubation of 125I-labeled plasminogen with 30 mmol/L lysine, on the other hand, significantly reduced the binding of plasminogen to immobilized thrombospondin, suggesting that the interaction of thrombospondin with plasminogen is not the direct result of the lysine binding sites of plasminogen. Arginine and benzamidine, ligands known to specifically bind to the kringle 5 domain of plasminogen, blocked the binding of thrombospondin to plasminogen. Limited elastase proteolysis of plasminogen and plasmin resulted in the generation of two distinct thrombospondin binding domains, one of which was retained on lysine-agarose. The isolation and amino-terminal analysis of these domains following elastase proteolysis of plasminogen identified them, respectively, as a domain containing kringle structures 4 and 5 and plasmin and the other domain consisting of kringle 5-plasmin. A 16-residue synthetic peptide, which represents the amino acids linking kringle 4 to kringle 5 (residues 435-450 of native plasminogen), was without effect in either binding to thrombospondin or blocking the binding of thrombospondin to plasminogen. Plasminogen, therefore, possesses a single thrombospondin interactive site that is independent of, but influenced by, the lysine binding site containing kringle structures and most likely is located within the kringle 5 domain.

Thrombospondin interaction with fibrinogen. Evidence for binding to the A alpha- and B beta-chains of fibrinogen.

Platelet thrombospondin interacts with fibrinogen in a specific and saturable manner. Thrombospondin was found to specifically bind to the A alpha- and B beta-chains of fibrinogen; binding was independent of divalent ions. Binding could be blocked either by preincubation of thrombospondin with 9.4 microM fibrinogen or by preincubation of fibrinogen with 1.1 nM thrombospondin. Thrombospondin bound only to the beta-chain component of the D and DD plasmin fragment of fibrinogen. Thrombospondin interaction with fibrinogen was not blocked by preincubation with synthetic peptides which have previously been identified as either the fibrinogen receptor (alpha 572-575, the synthetic tetrapeptide arginyl-glycyl-aspartyl-serine) or cell attachment (gamma 400-411) domains. Fibrinogen, therefore, possesses at least two unique and distinct sites, within the A alpha- and B beta-chains, for its interaction with thrombospondin.