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Biomedical subjects

M J Shapiro

Publications and source records attributed to M J Shapiro.

At least 19 recordsLinked to original sources

Protease-activated receptors 1 and 4 mediate activation of human platelets by thrombin.

Because of the role of thrombin and platelets in myocardial infarction and other pathological processes, identifying and blocking the receptors by which thrombin activates platelets has been an important goal. Three protease-activated receptors (PARs) for thrombin -- PAR1, PAR3, and PAR4 -- are now known. PAR1 functions in human platelets, and the recent observation that a PAR4-activating peptide activates human platelets suggests that PAR4 also acts in these cells. Whether PAR1 and PAR4 account for activation of human platelets by thrombin, or whether PAR3 or still other receptors contribute, is unknown. We have examined the roles of PAR1, PAR3, and PAR4 in platelets. PAR1 and PAR4 mRNA and protein were detected in human platelets. Activation of either receptor was sufficient to trigger platelet secretion and aggregation. Inhibition of PAR1 alone by antagonist, blocking antibody, or desensitization blocked platelet activation by 1 nM thrombin but only modestly attenuated platelet activation by 30 nM thrombin. Inhibition of PAR4 alone using a blocking antibody had little effect at either thrombin concentration. Strikingly, simultaneous inhibition of both PAR1 and PAR4 virtually ablated platelet secretion and aggregation, even at 30 nM thrombin. These observations suggest that PAR1 and PAR4 account for most, if not all, thrombin signaling in platelets and that antagonists that block these receptors might be useful antithrombotic agents.

Adenosine Triphosphate

Separate signals for agonist-independent and agonist-triggered trafficking of protease-activated receptor 1.

Protease-activated receptor 1 (PAR1), a G protein-coupled, protease-activated receptor for the serine protease thrombin, is activated when thrombin cleaves its amino-terminal exodomain. This irreversible mechanism of activation may have necessitated an unusual pattern of receptor trafficking. Unactivated PAR1 cycles tonically between the cell surface and an intracellular pool, providing an intracellular store of uncleaved receptors and allowing repopulation of the surface with uncleaved receptors after thrombin exposure without new receptor synthesis. Activated PAR1 internalizes rapidly and is degraded in lysosomes. We report characterization of a PAR1 mutant that trafficked like the wild-type receptor when activated but did not internalize and recycle in the absence of agonist. This complements a previous study in which a mutant with normal tonic internalization but defective agonist-triggered internalization was described. These observations suggest that the trafficking behaviors of unactivated and activated PAR1 are specified by distinct signals within the receptor and imply that PAR1 internalization in the presence or absence of agonist may be mediated by distinct molecular machinery. PAR1 mutants that did not internalize in the absence of agonist were also shown to localize exclusively to the cell surface and to be defective in their ability to repopulate the cell surface with uncleaved receptors after thrombin exposure. These observations suggest that tonic internalization is necessary for maintenance of the intracellular PAR1 pool.

Amino Acid Sequence

NMR methods in combinatorial chemistry.

The use of NMR spectroscopy in combinatorial chemistry has provided a versatile tool for monitoring combinatorial chemistry reactions and for assessing ligand-receptor interactions. The application of magic angle spinning NMR is widespread and has allowed structure determination to be performed on compounds attached to solid supports. A variety of two-dimensional NMR techniques have been applied to enhance the usability of the magic angle spinning NMR data. New developments for solution NMR analysis include high performance liquid chromatography, NMR, mass spectroscopy and flow NMR. NMR based methods currently being investigated may prove valuable as compound screening tools.

Chemistry, Organic

Effectiveness of helicopter versus ground ambulance services for interfacility transport.

BACKGROUND: Helicopters provide rapid interfacility transport, but the effect on patients is largely unknown. METHODS: Patients requested to be transported between facilities by helicopter were followed prospectively to determine survival, disability, health status, and health care utilization. A total of 1,234 patients were transported by the primary aeromedical company; 153 patients were transported by ground and 25 patients were transported by other aeromedical services because of weather or unavailability of aircraft. RESULTS: There were no differences at 30 days for survivors in disability, health status, or health care utilization. Nineteen percent of helicopter-transported patients died compared with 15% of those transported by ground (p=0.21). CONCLUSION: The patients transported by helicopter did not have improved outcomes compared with patients transported by ground. These data argue against a large advantage of helicopters for interfacility transport. A randomized trial is needed to address these issues conclusively.

Adult

Intraocular penetration of gentamicin after once-daily aminoglycoside dosing.

BACKGROUND: Intraocular concentrations-particularly intravitreal concentrations-after systemic administration of gentamicin are poor. Once-daily aminoglycoside dosing of intravenous gentamicin achieves peak serum levels up to five times higher than conventional dosing. Whether these increased serum levels of gentamicin improve the aqueous or vitreous concentrations in humans has not been determined. The authors sought to determine if the intraocular penetration of gentamicin would be improved using this method. METHODS: Patients undergoing vitrectomy procedures were administered intravenous gentamicin in a dose of 7 mg/kg approximately 1 hour before surgery. An adjustment in dosing was made for anyone more than 20% over his or her ideal body weight. Aqueous, vitreous, and serum samples were collected before any intraocular surgical manipulation. The samples were analyzed by fluorescence polarization immunoassay (TDx system). RESULTS: The average single gentamicin dose was 498 mg (range, 360-700 mg). The aqueous, vitreous, and serum levels averaged 1.14 microg/mL, 0.41 microg/mL, and 22.07 microg/mL, respectively. No correlation between serum level concentrations and time of administration was found for the aqueous and vitreous levels in this study. CONCLUSION: Although the average peak serum level of gentamicin was five times higher than previously reported, the vitreous levels averaged only 1.5 times higher. The blood-retinal barrier is difficult to penetrate even when higher serum levels are achieved. Due to its poor ocular penetration, gentamicin may not be among the best drugs for prophylaxis of penetrating eye injuries, surgical prophylaxis, or treatment of endophthalmitis.

Anti-Bacterial Agents

Effects of cytokine antagonists on the hepatic acute-phase response.

Endotoxin-induced hepatic acute-phase protein synthesis has been thought to be primarily regulated through cytokines such as interleukin-1 (IL-1) and interleukin-6 (IL-6). Previously, it was found that a 23-kDa murine acute-phase protein, the lipopolysaccharide (LPS)-induced protein (LIP), was synthesized following treatment of hepatocytes in vitro with LPS. Since this protein was also induced by IL-1 and IL-6, the present studies were undertaken to determine if the effect of endotoxin was mediated through these cytokines. Primary cultures of murine hepatocytes were treated with LPS, IL-1, IL-6, or an LPS-stimulated macrophage supernatant in the presence or absence of the IL-1 receptor antagonist (IL-1 RA) and/or an anti-IL-6 antibody. The cells were then radiolabeled with [35S]methionine. LIP was detected by electrophoresis and autoradiography of the secreted proteins. In vitro, IL-1 RA completely inhibited the stimulation of LIP synthesis elicited by IL-1 and the macrophage supernatant, but did not affect LPS-stimulated synthesis of this protein. The anti-IL-6 antibody inhibited IL-6-triggered synthesis of LIP, but had no effect on LPS-stimulated synthesis. Hepatocytes isolated from mice treated in vivo with both IL-1 RA and LPS synthesized LIP to the same degree as hepatocytes isolated from mice treated with LPS alone. LPS-stimulated synthesis of LIP in vitro does not require IL-1 or IL-6 as an obligatory intermediate. These results are consistent with the hypothesis that endotoxin can directly stimulate hepatocyte acute-phase protein synthesis in the absence of cytokines.

Acute-Phase Proteins

Do internists and emergency physicians agree on the appropriateness of emergency department visits?

The purpose of this study was to determine the levels of agreement between three methods of assessing appropriateness of emergency department (ED) visits. In particular, we tested the agreement between internists and emergency physicians reviewing the ED nurses' triage notes, containing information that might be available by telephone to an internist. For 892 adult patient ED visits reviewed, we found only moderate agreement (kappa = 0.47) between these groups. In cases of disagreement, emergency physicians were 10.3 times more likely than internists to classify those with minor discharge diagnoses as appropriate for ED care. As managed care grows, the determination of ED appropriateness may depend on open discussions between physician groups, as well as on access to timely care in office settings.

Adult

Delta-opiate DPDPE in magnetically oriented phospholipid micelles: binding and arrangement of aromatic pharmacophores.

D-Penicillamine(2,5)-enkephalin (DPDPE) is a potent opioid peptide that exhibits a high selectivity for the delta-opiate receptors. This zwitterionic peptide has been shown, by pulsed-field gradient 1H NMR diffusion studies, to have significant affinity for a zwitterionic phospholipid bilayer. The bilayer lipid is in the form of micelles composed of dihexanoylphosphatidylcholine (DHPC) and dimyristoylphosphatidylcholine (DMPC) mixtures, where the DMPC forms the bilayer structure. At high lipid concentration (25% w/w) these micelles orient in the magnetic field of an NMR spectrometer. The resulting 1H-13C dipolar couplings and chemical shift changes in the natural abundance 13C resonances for the Tyr and Phe aromatic rings were used to characterize the orientations in the bilayer micelles of these two key pharmacophores.

Biophysical Phenomena

Ofloxacin penetration into the eye after intravenous and topical administration.

PURPOSE: To determine the aqueous and vitreous fluid penetration of ofloxacin after a combined topical and single intravenous dose protocol before vitrectomy surgery. MATERIALS AND METHODS: Before undergoing vitrectomy surgery, patients were given two drops of ofloxacin 0.3% topically and a single intravenous dose of ofloxacin 400 mg. Aqueous (mean, 43 minutes) and vitreous (mean, 53 minutes) fluid samples were collected at the start of the surgical procedure. The samples were analyzed for ofloxacin penetration. RESULTS: The mean aqueous fluid concentration was 1.083 micrograms/mL +/- 0.406. The mean +/- SD vitreous fluid concentration in nondiabetic patients with intact vitreous was 0.352 microgram/mL +/- 0.301. Vitreous levels obtained more than 50 minutes after administration (0.414 microgram/mL +/- 0.336) were generally higher than those obtained after less than 50 minutes (P = 0.12). Eyes with prior vitrectomies achieved better ofloxacin penetration (0.984 microgram/mL +/- 0.680) than did nonvitrectomized eyes. CONCLUSION: Ofloxacin achieved measurable aqueous fluid penetration after topical and intravenous administration. Aqueous levels were above the minimum inhibitory concentration for most ocular pathogens. Vitreous levels were adequate in vitrectomized eyes to achieve inhibitory concentrations against many common ocular pathogens. Combined preoperative topical and a single dose of intravenous ofloxacin may provide inhibitory aqueous and vitreous antibiotic levels in vitrectomized eyes in cases where intravitreal antibiotics are not considered and oral administration is not practical.

Administration, Topical

Role of the thrombin receptor's cytoplasmic tail in intracellular trafficking. Distinct determinants for agonist-triggered versus tonic internalization and intracellular localization.

The G protein-coupled thrombin receptor is activated by an irreversible proteolytic mechanism and, perhaps as a result, exhibits an unusual trafficking pattern in the cell. Naive receptors tonically cycle between the cell surface and a protected intracellular pool, whereas receptors cleaved and activated at the cell surface internalize and move to lysosomes. Toward understanding how these trafficking events are regulated, we examined a series of receptor mutants. A receptor with alanine substitutions at all potential phosphorylation sites in the cytoplasmic tail failed to display agonist-triggered internalization but, like wild type receptor, displayed robust signaling, tonic cycling, and localization to both the cell surface and an intracellular pool. A truncation mutant that lacked most of the cytoplasmic tail also signaled robustly, lacked phosphorylation, and was defective in agonist-triggered internalization. However, in contrast to the specific phosphorylation site mutant, the truncation mutant did not display tonic cycling and localized exclusively to the cell surface. An analysis of a series of truncation mutants localized residues important for receptor trafficking to a 10-amino acid stretch in its cytoplasmic tail. These data suggest that phosphorylation may trigger internalization of activated thrombin receptors but that a second phosphorylation-independent signal mediates tonic internalization of naive receptors. They further suggest that maintenance of the intracellular pool of naive thrombin receptors requires tonic receptor internalization.

Animals

Percutaneous abscess drainage in gynecologic cancer patients.

Percutaneous abscess drainage (PAD) is regarded as an alternative treatment for the care of the gynecologic cancer patient with a pelvic infection. Four female patients with infected pelvic malignancies were evaluated and treated with PAD at Thomas Jefferson University Hospital over a 4-year period. Abscesses in three of the four patients were drained successfully and the catheters were ultimately removed. Successful drainage was defined as a good clinical response and avoidance of surgical debridement. For the patient with an infected pelvic malignancy, PAD offers an alternative to surgery without associated morbidity. Our experience indicates PAD is associated with expedient clinical recovery and preservation of quality of life for most patients.

Abscess

Management of selected rectal injuries by primary repair.

BACKGROUND: Diversion of the fecal stream with or without primary repair has been the mainstay of therapy for rectal injuries. Because primary repair has replaced colostomy as the treatment of choice for most colon injuries, we reviewed our experience with primary repair of rectal injuries in order to determine if primary repair without diversion is a feasible option in selected patients. MATERIALS AND METHODS: All traumatic rectal injuries over the past 48 months were reviewed for mechanism of injury, diagnosis, treatment, and outcome. RESULTS: Thirty consecutive patients with extraperitoneal rectal injuries were identified. Six of the 30 patients underwent primary repair without diversion. Five were repaired transanally, and 1 was repaired at celiotomy. There was no morbidity related to the rectal repair in patients who underwent primary repair without diversion, and there were no deaths. CONCLUSIONS: Based on a small number of patients, these data suggest that primary repair of rectal injuries in selected patients may be feasible. Further prospective investigation is needed to determine which patients may be successfully treated in this fashion.

Adolescent

The unreliability of CT scans and initial chest radiographs in evaluating blunt trauma induced diaphragmatic rupture.

OBJECTIVE: There is no gold standard for early and reliable diagnosis of traumatic diaphragmatic rupture (TDR). The purpose of this study is to correlate CT scans, chest radiographs, and intubation on the ability to diagnosis traumatic diaphragmatic rupture. MATERIALS AND METHODS: Twenty patients with blunt trauma induced diaphragmatic rupture were identified from a five year review of a Level 1 Trauma Registry. RESULTS: Ten of the 20 (50%) patients had TDR on initial chest X-ray, all on the left side. Twelve patients had both chest X-rays and a chest and abdominal CT scan; however, only five (42%) of the CT scans were diagnostic. Of the 12 patients initially intubated, TDR was diagnosed in only four (33%) patients on initial chest X-ray and in one (14%) of seven patients having chest and abdominal CT scans and being intubated. CONCLUSION: The early diagnosis of blunt traumatic diaphragmatic rupture, especially in intubated patients, continues to be a diagnostic dilemma. There is a significantly better possibility of identifying left over right-sided TDR (P < or = 0.05). Diagnosing TDR is also facilitated by extubation. If the suspicion exists, a post extubation chest radiograph should be performed to evaluate for TDR.

Adolescent

The use of oxygen consumption and delivery as endpoints for resuscitation in critically ill patients.

OBJECTIVE: Oxygen consumption (VO2I) and delivery (DO2I) indices have been stated to be superior to conventional parameters as endpoints for resuscitation. However, another interpretation of published data is that inability to increase VO2I/DO2I given adequate volume resuscitation reflects inadequate physiologic reserve and poor outcome. DESIGN: Fifty-eight critically ill patients were randomized to two groups. In group 1 (27 patients) attempts were made to maintain VO2I > or = 150 or DO2I > or = 600 mL/min/m2. If DO2I was > 600, no attempt was made to increase VO2I even if it was < 150. Group 2 (31 patients) was resuscitated based on conventional parameters. Volume resuscitation protocols and goals for pulmonary capillary wedge pressure were the same in both groups. VO2I/DO2I were recorded in group 2, but physicians were blinded to this data. Age, Injury Severity Score, and Acute Physiology and Chronic Health Evaluation (APACHE II) score were not different between groups. MAIN RESULTS: Three patients in group 1 and two patients in group 2 died of organ failure (OF). One additional patient in group 2 died of refractory shock within 24 hours. Two of the patients in group 1 who died failed to meet VO2I/DO2I goals within 24 hours despite maximal resuscitation. Mortality was not different between the groups even with exclusion of the group 1 patients who failed to meet VO2I/DO2I goals (p = 0.66). After exclusion of the patient in group 2 who died of refractory shock, OF occurred in 18 of 27 (67%) in group 1 and in 22 of 30 (73%) in group 2 (p = 0.58). Length of ventilator support, intensive care unit stay, and hospital stay were not different between groups. When all patients were assessed, no difference was found in the incidence of OF between patients who attained the VO2I goal and those who did not. OF occurred in 20 of 34 (59%) patients who maintained a mean DO2I > or = 600 during the first 24 hours of the study and in 21 of 24 (88%) of those who did not (p < 0.02). CONCLUSIONS: No difference was found in the incidence of OF or death in patients resuscitated based on oxygen transport parameters compared to conventional parameters. These data suggest that given adequate volume resuscitation, oxygen-based parameters are more useful as predictors of outcome than as endpoints for resuscitation.

APACHE

"Inappropriate" emergency department use: a comparison of three methodologies for identification.

OBJECTIVE: To determine the level of agreement between the rates of "inappropriate" ED visits assigned to a cohort of ambulatory patients based on three methods of defining ED use appropriateness. METHODS: Ambulatory adult patients seen at one urban, university-based teaching hospital ED between 8 AM and midnight during select days from April to June 1994 were assessed regarding the appropriateness of their ED visits. Patients triaged to acute resuscitation rooms in the ED were excluded. Eligible patients were asked to complete a 90-question survey including demographics and health service use (response rate 81%). The appropriateness of ED use was assessed for consenting respondents by 1) application of a list of 51 non-emergent complaints that have been used by managed care providers and previously published (TRIAGE), 2) use of ten explicit criteria (e.g., need for parenteral medication) from prior publications (EXPLICIT), and 3) the consensus of two emergency physicians (EPs) reviewing the records of ED patients (PHYS). All three methods were applied at the time of retrospective chart review. The agreement between methods was evaluated using kappa scores. RESULTS: Of the 892 eligible respondents, 64% were white, 54% were employed, 50% were female, and 29% were uninsured. Of the respondents, 26% had no regular source of ambulatory care and 25% considered the ED their regular source of care. The assigned rates of "inappropriate" visits using the three definitions were TRIAGE, 58%; PHYS, 47%; and EXPLICIT, 42%. Of those deemed "inappropriate" by the EXPLICIT criteria, 81% also were judged as "inappropriate" by the TRIAGE criteria, and 72%, by the PHYS criteria. Of those patients deemed "inappropriate" by the TRIAGE criteria, 59% also were judged as "inappropriate" by the EXPLICIT criteria, and 66%, by the PHYS criteria. Levels of agreement (kappas) were TRIAGE/EXPLICIT, 0.39; TRIAGE/PHYS, 0.42; and EXPLICIT/PHYS, 0.42. CONCLUSION: There is only moderate agreement between different methods of determining appropriateness of ED use. Until further refinement is made in triage assessment, managed care organizations and EPs should remain cautious when implementing a protocol that defines and restricts "inappropriate" ED visits.

Adult

Malignant biliary duct obstruction: long-term experience with Gianturco stents and combined-modality radiation therapy.

PURPOSE: To evaluate the effect of combined-modality therapy including intraluminal iridium-192 on stent patency and survival in patients with malignant biliary obstruction treated with Gianturco stents. MATERIALS AND METHODS: Twenty-two patients with unresectable biliary obstruction caused by cholangiocarcinoma (n = 11) or by secondary extrahepatic bile duct malignant tumors (n = 11) were treated with percutaneous biliary drainage followed by intraluminal Ir-192 wire placement (mean dose, 25 Gy) before insertion of Gianturco metal stents. Eleven patients also received external-beam radiation therapy, and 13 patients received chemotherapy. Patency was defined as absence of jaundice or cholangitis that necessitated hospitalization, or as seen on hepatobiliary scans. Survival was determined from the time of stent insertion after brachytherapy. RESULTS: Patients with cholangiocarcinoma had extended mean stent patency of 19.5 months (range, 2-46 months) and mean survival of 22.6 months (range, 2-72 months). Patients with secondary malignant tumors had a mean patency of 4.8 months (range, 1.5-8 months) and a mean survival of 5.3 months (range, 2-9 months). CONCLUSION: Radiation therapy including intraluminal Ir-192 appears to extend stent patency and survival in patients with inoperable cholangiocarcinoma treated with Gianturco metal stents compared with patients with other extrahepatic bile duct malignant diseases and patients treated without combined-modality therapy in other studies.

Aged

Calcium regulation and nonprotective properties of calcium in surgical ischemia.

Calcium is one of the most important electrolytes in the body. Calcium regulation involves the intricate interaction between intracellular and extracellular levels with the free form of calcium determining function. The parathyroid gland is the principal regulator of ionized calcium in the serum. The kidney and gastrointestinal tract calcium receptors respond to the incorporation of calcium into the cytosol for muscle contraction, cell-cell communication, coagulation, and hormonal and neurotransmitter release functions. The regulation of calcium and the role of calcium antagonists are discussed as they relate primarily to the gastrointestinal tract and liver functions. The use of calcium-channel blockers has augmented myocardial function and has met with some success in decreasing hemorrhagic mucosal ischemia after shock. However, clinical studies evaluating the role of these agents in ischemia have yet to be initiated.

Animals