Cellular interactions between axon terminals containing endogenous opioid peptides or corticotropin-releasing factor in the rat locus coeruleus and surrounding dorsal pontine tegmentum.

Recent evidence suggests that certain stressors release both endogenous opioids and corticotropin-releasing factor (CRF) to modulate activity of the locus coeruleus (LC)-norepinephrine (NE) system. In ultrastructural studies, axon terminals containing methionine(5)-enkephalin (ENK) or CRF have been shown to target LC dendrites. These findings suggested the hypothesis that both neuropeptides may coexist in common axon terminals that are positioned to have an impact on the LC. This possibility was examined by using immunofluorescence and immunoelectron microscopic analysis of the rat LC and neighboring dorsal pontine tegmentum. Ultrastructural analysis indicated that CRF- and ENK-containing axon terminals were abundant in similar portions of the neuropil and that approximately 16% of the axon terminals containing ENK were also immunoreactive for CRF. Dually labeled terminals were more frequently encountered in the "core" of the LC vs. its extranuclear dendritic zone, which included the medial parabrachial nucleus (mPB). Triple labeling for ENK, CRF, and tyrosine hydroxylase (TH) showed convergence of opioid and CRF axon terminals with noradrenergic dendrites as well as evidence for inputs to TH-labeled dendrites from dually labeled opioid/CRF axon terminals. One potential source of ENK and CRF in the dorsal pons is the central nucleus of the amygdala (CNA). To determine the relative contribution of ENK and CRF terminals from the CNA, the CNA was electrolytically lesioned. Light-level densitometry revealed robust decreases in CRF immunoreactivity in the LC and mPB on the side ipsilateral to the lesion but little or no change in ENK immunoreactivity, confirming previous studies of the mPB. Degenerating terminals from the CNA in lesioned rats were found to be in direct contact with TH-labeled dendrites. Together, these data indicate that ENK and CRF may be colocalized to a subset of individual axon terminals in the LC "core." The finding that the CNA provides, to dendrites in the area examined, a robust CRF innervation, but little or no opioid innervation, suggests that ENK and CRF axon terminals impacting LC neurons originate from distinct sources and that terminals that colocalize ENK and CRF are not from the CNA.

Opioid circuits originating from the nucleus paragigantocellularis and their potential role in opiate withdrawal.

Neurons in the rat nucleus paragigantocellularis (PGi), located in the ventrolateral medulla, send collateral projections to the locus coeruleus (LC) and to the nucleus of the solitary tract (NTS). The present study examined whether neurons in the PGi that project to both the LC and NTS contain leucine(5)-enkephalin (ENK), and also whether opioid-containing neurons in the PGi are activated following withdrawal from opiates. Retrograde transport of Fluoro-Gold (FG) from the LC and transport of a protein-gold tracer from the NTS was combined with detection of an antibody directed against ENK in the PGi. Using fluorescence and brightfield microscopy, it was established that more than half of the neurons containing both FG and the protein-gold tracer, also exhibited immunolabeling for ENK. The most frequent location of triply labeled neurons was the retrofacial portion of the PGi. In a separate series, rats were chronically implanted with morphine or placebo pellets and, on the fifth day, were subjected to an intraperitoneal injection of naltrexone. Two hours following initiation of withdrawal, rat brains were obtained and processed for detection of c-fos and in situ hybridization labeling of preproenkephalin (PPE) mRNA. Naltrexone injections into morphine-dependent rats caused a dramatic increase in c-fos as compared to control rats. Approximately 66% of the c-fos-labeled neurons exhibited labeling for PPE mRNA. These were also enriched in the retrofacial portion of the PGi. Taken together, the present data indicate that withdrawal from opiates engages opioid neurons in the PGi, some of which may coordinate activity of neurons in both the NTS and the LC.

Intermodal comparison of energy expenditure at exercise intensities corresponding to the perceptual preference range.

PURPOSE: This study compared the rate of energy expenditure among six popular exercise machines at intensities corresponding to ratings of perceived exertion (RPE) for fairly light (RPE-11), somewhat hard (RPE-13), and hard (RPE-15) in 9 healthy men and 10 healthy women. METHODS: A maximal exercise test on each exercise machine was used to anchor the Borg 15-point category scale. Subjects performed three submaximal exercise tests at selected RPEs on a treadmill, stair-stepper, cycle ergometer, rowing ergometer, cross-country ski simulator, and rider. The submaximal tests on each exercise device were performed in random order and were 6 min in duration with 15-min rest between trials. Oxygen uptake, heart rate, and blood lactate concentration were measured during the final 2 min of each exercise intensity. RESULTS: Energy expenditure at each RPE was highest on the treadmill and ski simulator in men, and on the treadmill, ski simulator, and rowing ergometer in women. Energy expenditure in men and women at all RPEs was lowest on the rider and cycle ergometer. Energy expenditure at a given RPE was greater in men than women on all exercise machines, but men and women used a similar percentage of their machine specific peak oxygen uptake at each RPE on all machines. Heart rate was generally similar among the machines and between both men and women at each RPE. CONCLUSIONS: Our results indicated that there are large differences in energy expenditure between exercise machines and between men and women at intensities perceived to be fairly light, somewhat hard, and hard. Consequently, subjects can expend more calories at the same RPE during treadmill and ski simulator exercise, for example, than during exercise with other devices. This may have important implications for the health benefits of different exercises and in promoting long term exercise adherence.

The lateral island trapezius myocutaneous flap for circumferential reconstruction of hypopharynx and cervical esophagus.

The lateral island trapezius was utilized for reconstruction of hypopharyngeal and cervical esophagus defects in high-risk patients, avoiding entry into the celomic cavities as an approach to decrease morbidity and mortality. Seven male patients were treated at the State University of New York between 1988 and 1991 and underwent reconstruction with the lateral island trapezius flap. There was no mortality, 2 patients developed pharyngocutaneous fistulas; 1 patient operated after radiation treatment failure remained with positive margins at resection but his fistula never healed, and another patient underwent a minor revision with successful closure of the fistula. All patients regained swallowing and none required dilatations. The preferred methods of reconstruction for the reasonable risk patient are gastric pull-up and free jejunal transfer; both of which require entry into cavities. The lateral island is a reliable alternate method of reconstruction for high-risk patients in whom intracavitary surgery may lead to unacceptably high morbidity and mortality. When the vascular anatomy is not favorable, rerouting of the vessels may be required utilizing microvascular reconstruction. The donor site defect is closed primarily or skin grafted, and subsequent functional limitations are minimal and well tolerated.

Effect of potassium phosphate supplementation on perceptual and physiological responses to maximal graded exercise.

This investigation evaluated the effect of oral potassium phosphate supplementation on ratings of perceived exertion (RPE) and physiological responses during maximal graded exercise tests (GXT). Eight highly trained endurance runners completed a GXT to anchor the Borg 15-point RPE scale and two double-blind counterbalanced GXTs. Subjects ingested either 4,000 mg x day(-1) of phosphate (PHOS) or a placebo (PLA) for 2 days. Two weeks separated GXTs. Phosphate levels obtained immediately prior to the GXTs were greater in PHOS than PLA. No differences between PHOS and PLA were noted for the submaximal and maximal physiological responses. RPE for the overall body were lower during PHOS than PLA at intensities corresponding to 70-80% of VO2max. This suggests that oral potassium phosphate supplementation mediates perceived exertion during moderately intense exercise.

Children's OMNI scale of perceived exertion: mixed gender and race validation.

PURPOSE: The newly developed Children's OMNI Scale of Perceived Exertion (category range: 0 to 10) was validated using separate cohorts of female and male, African American and white subjects. Each of the four cohorts contained 20 clinically normal, nonobese children, 8-12 yr of age. METHODS: A cross-sectional, perceptual estimation paradigm using a single multi-stage cycle ergometer test protocol was used. Oxygen uptake (VO2; mL x min(-1)), heart rate (HR; beats x min(-1)) and ratings of perceived exertion for the overall body (RPE-Overall), legs (RPE-Legs), and chest (RPE-Chest) were determined at the end of each continuously administered 3-min power output (PO) (i.e., 25, 50, 75, and 100 W) test stage. RESULTS: The range of responses over the four POs for all cohorts was VO2: 290.8 to 1204.0 mL x min(-1); HR: 89.2 to 164.4 beats x min(-1); and RPE-Overall, RPE-Legs, and RPE-Chest: 0.85 to 9.1. First-order correlation and linear regression analyses were performed for each cohort separately and the total sample using a repeated measures paradigm over the four POs. For all correlation/regression paradigms RPE-Overall, RPE-Legs, and RPE-Chest distributed as a positive linear function of both VO2 and HR; r = 0.85 to 0.94; P < 0.01. Differences between RPE-Overall, RPE-Legs, and RPE-Chest were examined with ANOVA for the repeated measures paradigm. RPE-Legs was higher (P < 0.01) than RPE-Chest and RPE-Overall at 25, 50, 75, and 100 W. RPE-Chest did not differ from RPE-Overall at 25 and 50 W but was lower (P < 0.01) than RPE-Overall at 75 and 100 W. CONCLUSION: The psycho-physiological responses provide validity evidence for use of the Children's OMNI Scale over a wide range of dynamic exercise intensities.

Evidence for coexistence of enkephalin and glutamate in axon terminals and cellular sites for functional interactions of their receptors in the rat locus coeruleus.

The authors previously showed that a subset of axon terminals in the locus coeruleus (LC) contains methionine5-enkephalin (ENK) and gamma-aminobutyric acid (GABA) immunoreactivities. However, numerous ENK-labeled terminals lacked GABA and exhibited synaptic specializations that were characteristic of excitatory-type transmitters. To determine whether ENK coexists with glutamate in the LC, preembedding immunoperoxidase detection of ENK or immunogold-silver was combined with postembedding identification of glutamate using a gold marker. Indeed, 28% of the ENK-labeled axon terminals examined (n = 250 axon terminals) also contained glutamate. To define further sites for functional interactions between opiate ligands and excitatory amino acid receptors, the ultrastructural localization of the mu-opioid receptor (MOR) was examined with respect to either the kainate receptor (KAR) or the R1 subunit of the N-methyl-D-aspartate (NR1)-type glutamate receptor in the LC. Gold-silver labeling for MOR and peroxidase labeling for either KAR or NR1 indicated that the MOR often was localized to the plasma membrane of dendrites that also exhibited immunolabeling for either glutamate receptor subtype. In contrast to the KAR, which was identified primarily in somata and dendrites, NR1 immunoreactivity also was found frequently in axon terminals as well as in glial processes. Glial processes containing NR1 occasionally exhibited immunolabeling for MOR and sometimes were directly apposed to MOR-containing dendrites in the LC. Furthermore, NR1-labeled receptors in axon terminals sometimes were presynaptic to MOR-labeled dendrites. The authors concluded that ENK and glutamate may be cotransmitters in LC afferents. Moreover, ligands at the KAR may modulate directly MOR-containing neurons in the LC, whereas actions at NR1 receptors may affect opioid-sensitive neurons through multiple cellular mechanisms, i.e., through presynaptic, postsynaptic, or glial actions.

Decreases in endogenous opioid peptides in the rat medullo-coerulear pathway after chronic morphine treatment.

Several biochemical changes have been described in noradrenergic neurons of the locus coeruleus (LC) after chronic morphine treatment. Changes in neurochemical expression in opioid afferent projections to the LC may be equally important in modulating noradrenergic neurons during chronic opiate exposure. To test the hypothesis that opioid peptides in LC afferents are altered after chronic opiate administration, we exposed adult male rats to either morphine or placebo pellets for 5 d. Tissue sections through the LC were processed for peroxidase or gold-silver labeling of methionine(5)-enkephalin (met-ENK) and analyzed using light or electron microscopy, respectively. Light level densitometry and ultrastructural analysis showed that there was a significant decrease in immunolabeling for ENK in LC-afferent terminals of morphine-treated rats. Western immunoblot analysis confirmed that protein levels for both leucine(5)- and methionine(5)-ENK were significantly decreased in tissue samples containing the LC after chronic morphine treatment. To test whether decreases in ENK protein expression were mirrored by decreases in gene expression, Northern blot analysis of preproenkephalin (PPE) mRNA was conducted in tissue samples obtained through the medulla, a brainstem area that contains the major opioid afferents to the LC. PPE mRNA was reduced in samples obtained from morphine-treated rats. Finally, in situ hybridization experiments confirmed significant decreases in PPE mRNA expression in the nucleus paragigantocellularis, a region known to provide a robust opioid input to the LC. These data suggest that there is a decrease in the synthesis of the opioid peptide mRNA and protein in the medullo-coerulear pathway after chronic exposure to morphine. Such alterations in opioid peptide levels during opiate dependence may contribute to the observed hyperactivity of LC neurons during opiate withdrawal.

A.E. Bennett Research Award. Anatomic basis for differential regulation of the rostrolateral peri-locus coeruleus region by limbic afferents.

BACKGROUND: Neurochemical and electrophysiological studies indicate that the locus coeruleus (LC)-norepinephrine system is activated by physiological and external stressors. This activation is mediated in part by corticotropin-releasing factor (CRF), the hypothalamic neurohormone that initiates the endocrine response to stress. We have previously shown that the central nucleus of the amygdala (CNA) provides CRF afferents to noradrenergic processes in the peri-LC area that may serve to integrate emotional and cognitive responses to stress. The bed nucleus of the stria terminalis (BNST) shares many anatomical and neurochemical characteristics with the CNA, including a high density of CRF-immunoreactive cells and fibers; however, recent studies have suggested that the CNA and the BNST may differentially regulate responses to conditioned and unconditioned fear, respectively, suggesting divergent neuroanatomical circuits underlying these processes. METHODS: In the present study, neuroanatomical substrates subserving regulation of the LC by the BNST were examined. Anterograde tract-tracing was combined with immunoelectron microscopy to test the hypotheses that BNST efferents target noradrenergic neurons of the LC and that these efferents exhibit immunolabeling for CRF. RESULTS: Ultrastructural analysis of sections that were dually labeled for the anterograde tracer biotinylated dextran amine (BDA) injected into the BNST and tyrosine hydroxylase (TH)-immunoreactivity demonstrated that BDA-labeled axon terminals formed synaptic specializations (primarily inhibitory) with TH-labeled dendrites and dendrites that lacked TH immunoreactivity. In contrast to CNA efferents that exhibited substantial immunolabeling for CRF, far fewer BDA-labeled terminals from the BNST in the rostrolateral peri-LC contained CRF. CONCLUSIONS: The present results indicate that the BNST may provide distinct neurochemical regulation of the peri-LC as compared to other limbic afferents such as the CNA. These data are interesting in light of behavioral studies showing that the CNA and BNST may be differentially involved in fear versus anxiety, respectively.

Pressure control inverse ratio ventilation in the treatment of adult respiratory distress syndrome in patients with blunt chest trauma.

The objective of this study was to evaluate the efficacy of pressure control inverse ratio ventilation (PCIRV) in improving oxygenation in trauma patients with adult respiratory distress syndrome (ARDS) and to assess the potential risks associated with this form of treatment. This was a cohort study assessing the trends in hemodynamic and ventilatory parameters after the initiation of PCIRV, conducted at a community Level I trauma center intensive care unit. The study comprised 15 trauma patients developing severe, progressive ARDS [two or more of the following criteria: positive end-expiratory pressure (PEEP) >10 cm H2O; arterial partial pressure of oxygen divided by fraction of inspired oxygen (PaO2:FiO2) ratio <150; and peak inspiratory pressure (PIP) >45 cm H2O]: ten due to blunt chest injuries, three due to sepsis, and two due to fat emboli syndrome. PCIRV was initiated. Main outcome measures were PIP, PEEP (total, auto), oxygen saturation, cardiac index, oxygen delivery, PaO2:FiO2 ratio, compliance, evidence of complications of PCIRV, and mortality. Within 24 hours of conversion to PCIRV, the patients stabilized and the mean PaO2:FiO2 ratio rose from 96.3+/-57.8 to 146.8+/-91.1 (P<0.05) and PIP fell from 47.9+/-13.8 to 38.8+/-8.4 cm H2O; auto-PEEP increased from 0.5+/-1.9 to 7.5+/-5.6 cm H2O (P<0.05); oxygen delivery index remained stable (563+/-152 to 497+/-175 mL/min/m2); three patients developed evidence of barotrauma, one patient developed critical illness polyneuropathy, and two patients died (13%). PCIRV is an effective salvage mode of ventilation in patients with severe ARDS, but it is not without complications. Auto-PEEP levels and cardiac index should be monitored to ensure tissue oxygen delivery is maintained.

The role of glutamine in skeletal muscle ischemia/reperfusion injury in the rat hind limb model.

OBJECTIVES: Ischemia/reperfusion injury is a commonly occurring event with severe pathologic consequences. Reperfusion initiates both the local and systematic damage in part through rapid oxygen generation. The glutathione system is a major mechanism of reducing this oxidative stress. If this system can be maintained or augmented during this stress then less damage may occur. Glutamine provides the source of glutamate to this system and has been shown to preserve total glutathione levels after injury/ischemia to both hepatic and gut models. To test this effect, we looked at glutamine and its role in ischemia/reperfusion injury in a rat hind limb model. METHODS: Fifty male HSD/Holtzman rats weighing 350-400 g were randomized to receive glutamine (3% sol) or normal saline via intraperitoneal injections. The groups were then subjected to 2 hours of ischemia to their hind limbs using the Tourni-Cot method. Animals were then randomized to reperfusion groups of 30 minutes, 2 hours, and 4 hours. Muscle tissue assays were performed for lipid peroxidation (LPO), total glutathione (GSH), and myeloperoxidase (MPO). Peripheral blood was analyzed for creatinephosphokinase levels (CPK). RESULTS: Animals that received glutamine showed a general trend of less lipid peroxidation products than the normal saline groups. In animals that received glutamine and underwent 2 hours of ischemia and reperfusion times of 0 minutes, 30 minutes, and 2 hours, there were significantly less percent changes in lipid peroxidation products from controls (4.6% vs 48.2%, P <0.05), (18.9% vs 123%, P <0.05), (12.6% vs 115%, P <0.05). A general trend upward was noted in CPK levels in both groups. In animals receiving 2 hours of ischemia and 30 minutes of reperfusion, there was a significantly greater level of creatinephosphokinase (CPK) calculated as percent change from control in the normal saline group as compared with the glutamine group (209.2% vs 92.7%). Myeloperoxidase assay of muscle tissue revealed a progressive increase as the reperfusion times grew. In animals receiving 2 hours of ischemia and 30 minutes of reperfusion, the normal saline group had a significantly larger percent increase from controls than the group that received glutamine (1126.4% vs 108%, P <0.05). Also, in those animals receiving 4 hours of reperfusion, the normal saline group had a significantly higher percent increase in MPO content than the glutamine group (6245% vs 108%, P <0.05). Total glutathione levels decreased rapidly as reperfusion occurred in both the normal saline and glutamine groups. No significant difference between the groups was noted. CONCLUSIONS: Total glutathione levels during reperfusion were not significantly different in the groups receiving glutamine versus normal saline. Glutamine may provide an initial protective effect on reperfusion injury after moderate reperfusion times in the hind limb model as defined by CPK and LPO levels. Glutamine may blunt neutrophil recruitment after longer reperfusion times (4 hours) in the ischemic hind limb. Total glutathione levels decreased significantly after moderate levels of ischemia (2 hours) and reperfusion (30 minutes, 2 hours).

Efferent projections of the nucleus of the solitary tract to peri-locus coeruleus dendrites in rat brain: evidence for a monosynaptic pathway.

Locus coeruleus (LC) neurons respond to autonomic influences, are activated by physiological stressors, and discharge in parallel with peripheral sympathetic nerves. The circuitry underlying modulation of LC activity by physiological manipulations (i.e., hemodynamic stress, hypovolumia) remains unclear. Specifically, monosynaptic projections from primary baroreceptor centers to the LC have been suggested by electrophysiological studies but have not been unequivocally established. Light microscopic anterograde tract-tracing studies have previously shown that neurons originating in the nucleus of the solitary tract (NTS) project to a region of the rostrodorsal pontine tegmentum, which contains noradrenergic dendrites of the LC; however, it is not known whether these NTS efferents specifically target LC dendrites. Therefore, we combined peroxidase labeling of biotinylated dextran amine (BDA) or Phaseolus vulgaris-leucoagglutinin (PHA-L) from the NTS with gold-silver labeling for tyrosine hydroxylase (TH) in the rostrolateral peri-LC region. Injections placed into neighboring nuclei (nucleus gracilis, hypoglossal nucleus) served as controls. Only injections centered in the NTS produced anterograde labeling in peri-LC regions containing TH processes. By electron microscopy, BDA- or PHA-L-labeled axon terminals originating from the NTS contained small, clear, and some large dense-core vesicles and formed heterogeneous synaptic contacts characteristic of both excitatory- and inhibitory-type transmitters. Approximately 19% of the BDA and PHA-L axon terminals examined originating from the commissural portion of the NTS formed synaptic specializations with dendrites exhibiting TH immunoreactivity in the peri-LC. These results demonstrate that neurons projecting from the cardiovascular-related portion of the NTS target noradrenergic dendrites, indicating that barosensitive NTS neurons may directly modulate the activity of LC neurons and may serve to integrate autonomic responses in brain by influencing the widespread noradrenergic projections of the LC. In addition, these findings demonstrate that extranuclear dendrites are an important termination site for afferents to the LC.

Traditional criteria for observation of splenic trauma should be challenged.

Age less than 55 years, normal Glasgow Coma Score (GCS), and absence of hypotension are traditional criteria for the selection of adult patients with blunt splenic trauma for observation. The objective of this study is to challenge these criteria. Two hundred twelve patients who presented with blunt splenic injury between 1992 and 1997 were identified from the Trauma Registry at our Level I trauma center. The patients were divided into three groups: 100 patients (47%) were observed, 108 (51%) underwent immediate splenorrhaphy or splenectomy, and 4 (2%) failed observation. The three groups were compared by participants' ages, GCSs, and histories of hypotension. No statistical differences were noted between the successfully observed patients and those requiring immediate surgery with respect to these criteria. Of the 4 patients who failed observation, all were younger than 55 years, all had a GCS >12, and all were normotensive. Our findings suggest that traditional criteria used to select patients for splenic trauma observation are not absolute indicators and should be liberalized: patients can be successfully observed despite having criteria that, in the past, would have led to immediate operative intervention.

A sandwich type acridinium-linked immunosorbent assay (ALISA) detects soluble ErbB1 (sErbB1) in normal human sera.

The epidermal growth factor receptor (ErbB1) is overexpressed in various human tumor-derived cell lines and neoplasms, where it is believed that receptor dysregulation plays a role in oncogenic transformation and tumor progression. In addition to the ErbB1 holoreceptor, numerous studies demonstrate that cells synthesize soluble or secreted forms of ErbB1, i.e., sErbB1. Overexpression of ErbB1 in a variety of tumors has led us to hypothesize that sErbB levels also may be altered during oncogenesis, tumor progression, and/or metastasis; and that these molecules may be useful tumor biomarkers. To address this hypothesis we have developed an acridinium-linked immunosorbent assay (ALISA) specific for the extracellular domain of ErbB1 that can be used to quantify the levels of sErbB1 molecules in body fluids and conditioned culture media. This assay can also detect full-length ErbB1 in cell and tissue extracts. Our ALISA is characterized by high sensitivity (intra-assay LLD < 1 fmol/ml), a broad linear range (approximately 1 to 4000 fmol/ml), and good reproducibility (CVs < 10%). Specificity experiments show that this ALISA detects p170 ErbB1 and soluble forms of ErbB1 that embody extracellular subdomains I through IV, but not forms of sErbB1 lacking subdomain IV. Our ALISA does not detect full-length ErbB2, ErbB3, or ErbB4; or p105 soluble ErbB2. We report that serum sErbB1 levels of healthy women (median = 3716 fmol/ml), ranging in age from 43 to 76 years, differ significantly from those of healthy men (median = 24,512 fmol/ml), ranging in age from 25 to 79 years. Additional analyses do not indicate that serum sErbB1 levels change with age in either healthy men or women. Immunoprecipitation experiments show that monoclonal antibodies specific for extracellular epitopes of ErbB1 completely neutralize the detection of sErbB1 in normal human sera by ALISA. Finally, we show by immunoprecipitation and Western immunoblot analyses with monoclonal antibodies specific for the extracellular domain of ErbB1 that normal human female and male sera contain a approximately 110-kDa protein. We conclude that our ALISA is measuring the relative levels of this p110 sErbB1 analog in normal human sera. Our ALISA, therefore, should be useful for measuring the levels of ErbB1 and sErbB1 molecules in tumor biopsy specimens and body fluids, respectively, and for determining whether sErbB1, like ErbB1, is a useful tumor biomarker.

Reduced use of resources by early tracheostomy in ventilator-dependent patients with blunt trauma.

BACKGROUND: Early tracheostomy has been advocated for ventilator-dependent patients with blunt trauma, but its advantages have not been examined critically. METHODS: We retrospectively reviewed our experience with all patients with blunt trauma undergoing tracheostomy during the 6-year period from 1990 to 1995. Patients undergoing tracheostomy within the first 6 days of hospitalization were designated as early recipients (ET) and those undergoing the procedure at 7 or more days were defined as late recipients (LT). RESULTS: The entire study group consisted of 157 patients. The ET group contained 62 patients and the LT group contained 95 patients. No statistical differences were noted between the 2 groups with respect to sex distribution, injury severity scores, probability of survival scores, or mortality rates. The mean stay in the intensive care unit for the ET group was 15 days compared with 29 days for the LT group (P < or = .001). The mean total hospital stay for the ET group was 33 days compared with 68 days for the LT group (P < or = .001). The mean estimated per-patient hospital charges for only room and ventilator care were $36,609 for the ET group compared with $73,714 for the LT group. CONCLUSIONS: ET in this patient group resulted in significantly lowered use of resources with no adverse effect on outcome.

Improved selection criteria for ordering stat venous ultrasounds from the emergency department.

BACKGROUND: The accuracy and convenience of venous ultrasound (VU) to exclude deep vein thrombosis (DVT) has led to indiscriminate use and low positive yield rates. METHODS: A total of 256 patients were referred from our emergency department (ED) for stat VU during a 2-year period (1995 to 1996). The VUs were interpreted as normal in 198 (77%). Positive findings were discovered in 58 (23%), with DVT accounting for 43 (17%). Retrospective multivariant analysis was used to identify predictive indicators. RESULTS: Unilateral leg swelling/edema identified 36 of 40 (90%) patients with DVT and 8 of 10 (80%) with other thrombotic disorders (saphenous and/or chronic venous thrombosis). A history of leg pain with prior DVT or recent trauma < or =3 days' duration increased DVT duration to 98% (39 of 40). Using these criteria, a 47% charge reduction would have been recognized. CONCLUSIONS: Improving ED screening criteria can safely increase yield rate and reduce charges with minimal loss of VU sensitivity.

A study of desmopressin and blood loss during spinal fusion for neuromuscular scoliosis: a randomized, controlled, double-blinded study.

BACKGROUND: Studies examining the use of desmopressin acetate (DDAVP) have shown variable results in DDAVP's efficacy for reducing blood loss. Studies of adults having cardiac surgery and of children having spinal fusion have suggested that patients with complicated medical histories and complex surgical procedures may benefit from use of DDAVP. Therefore, this study was designed to examine the homeostatic effects of DDAVP in children with severe cerebral palsy undergoing spinal fusion. METHODS: A randomized, double-blinded, and placebo-controlled trial of DDAVP was designed to enroll 40 patients. However, termination of the study was advised by the Institutional Review Board after 21 patients were enrolled. All patients had spastic quadriplegic-type cerebral palsy and were randomly assigned to one of two groups. The DDAVP group received 0.3 microg/kg DDAVP in 100 ml normal saline, and the placebo group received normal saline alone. All patients were anesthetized with nitrous oxide, oxygen, isoflurane, and fentanyl. Factor VIIIC and von Willebrand's factor (vWF) concentrations were measured in blood drawn before DDAVP infusion and 1 h after infusion. Blood pressure was maintained at a systolic pressure of less than 100 mmHg. Use of crystalloids, packed erythrocytes, platelets, and fresh frozen plasma were based on criteria established by protocol. Estimated blood loss was assessed by weighing sponges and measuring suctioned blood from canisters. RESULTS: Estimated blood loss (intraoperative and postoperative) and amount of packed erythrocytes transfused were similar for the DDAVP and placebo groups. Concentrations of both factor VIIIC and vWF were significantly greater after DDAVP infusion when compared with concentrations after placebo infusion. CONCLUSIONS: In the children who had complex spinal fusion, there was no difference in estimated blood loss between those who received DDAVP and those who received a placebo. Administration of DDAVP significantly increased factor VIIIC and vWF levels.

The 5' flanking regions of IRBP and arrestin have promoter activity in primary embryonic chicken retina cell cultures.

Primary cultures of embryonic chicken cells from various tissues were transiently transfected with plasmid vectors containing reporter genes linked to a 1.8 kb fragment of the mouse interphotoreceptor retinoid-binding protein (IRBP) 5' flanking region, a 1.5 kb fragment of the mouse arrestin 5' flanking region, or a 3.4 kb sequence of the bovine arrestin 5' flanking region. Promoter activity was evident in retina-derived cells, but not in fibroblasts or cells from whole brain. Transfection response also varied with transfection method, plasmid DNA concentration, post-transfection incubation time, and cell density. The data suggest that the primary embryonic chicken retinal cell culture system is a useful tool in studying photoreceptor-specific gene regulation.