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Biomedical subjects

M J Shapiro

Publications and source records attributed to M J Shapiro.

At least 55 records · Page 3Linked to original sources

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↗

Contributions made by individual methylation sites of the Escherichia coli aspartate receptor to chemotactic behavior.

To determine the extent to which chemotactic behavior depends on methylation at multiple sites, chemotaxis assays were performed on bacteria that expressed mutant aspartate receptors in which methylation site residues were mutated from glutamate to aspartate. It was found that chemotaxis was impaired when methylation sites were mutated and that the effect on chemotaxis of mutating a rapidly methylated site was more severe than the effect of mutating a less-rapidly methylated site. Expression of mutant receptors in a wild-type strain interfered with chemotaxis to only a minor extent. In vivo methylation assays showed that the chemotactic defects of most mutants could be explained by the decreased rates at which methylation levels increased in response to aspartate.

Aspartic Acid↗

Interactions between the methylation sites of the Escherichia coli aspartate receptor mediated by the methyltransferase.

Mutations made at and near the methylation sites of the Escherichia coli aspartate receptor were found to affect the methylation rates of the remaining methylation sites. The results supported a model in which the methyltransferase enzyme contacts a residue seven amino acids to the C terminus of a site being methylated. The presence of a negatively charged residue at that position inhibits methylation, whereas a neutral residue has no effect. Methylation sites in the wild type receptor may also influence the methylation of other sites which are 7 residues away through a physical contact with the methyltransferase.

Amino Acid Sequence↗

Evaluation of the thoracic and lumbar spine after blunt trauma.

BACKGROUND: Routine performance of thoraco-lumbar (TL) spinal radiology in patients with blunt trauma is controversial. PATIENTS AND METHODS: To establish indications for radiologic screening of the TL spine, a retrospective review of 344 patients who had radiologic evaluation of the spine was performed. RESULTS: Forty-seven patients had abnormalities detected on radiologic evaluation. One hundred eighty-six patients had at least one clinical finding suggestive of injury. Thirty-two had abnormal radiographs. Thirteen of these abnormalities represented old or minor fractures and were not treated. Nineteen patients had injuries requiring treatment. Two patients were treated with activity restriction, 12 with a back brace, 4 with operative fixation, and 1 patient died prior to operation. Of the 129 patients who were awake, alert, and without clinical evidence of injury, 10 had abnormal radiologic studies. Three patients had old fractures, 4 had transverse process fractures, and 3 had spondylolisthesis. None of these patients required treatment. Twenty-nine patients had equivocal clinical examinations primarily due to altered levels of consciousness. Five patients had abnormal radiologic studies, 3 of whom required treatment. Three factors associated with the occurrence of TL spine injury were identified: an Injury Severity Score > or = 15, a positive clinical examination, and a fall of > or = 10 feet. CONCLUSIONS: These data suggest that patients who are awake, alert, and with no clinical evidence of injury do not require radiologic study of the TL spine. Patients with equivocal or positive clinical findings or with altered levels of consciousness should have complete TL spine evaluation.

Adult↗

MEGX (monoethylglycinexylidide): a novel in vivo test to measure early hepatic dysfunction after hypovolemic shock.

A quantitative liver test based on the formation of the lidocaine metabolite monoethylglycinexylidide (MEGX), was used to evaluate the effect of hemorrhagic shock at 40 mmHg for 90 min on Sprague-Dawley rats. After 2 h of stabilization, lidocaine was injected (2 mg/kg). A second group received volume resuscitation with Ringer's lactate over 1 h (15 mL/kg) after shock, and after 1 h of stabilization lidocaine was administered. These groups were compared to control animals. Blood samples were drawn at 0 time (baseline), prior to lidocaine injection, and at 10, 15, 30, and 60 min after lidocaine injection. MEGX values in shocked animals were significantly lower than in the control group; in animals receiving volume resuscitation, levels were higher than the shocked animals without resuscitation, but did not reach control levels. Thus, shock produced a significant depression of hepatocyte function, which was partially reversed by Ringer's lactate resuscitation. The MEGX test appears to be a suitable tool for clinical evaluation and therapeutic intervention after shock.

Animals↗

Trauma management in the 21st century.

Predicting the future can be interesting but difficult, particularly because of the exciting developments in the science of injury, inflammation, sepsis, and shock. Considering what has happened between 1895-1995, it is difficult to contemplate what will happen in the next 100 years. Will change accelerate in the 21st century? So far, our scientific knowledge and capability have exceeded the ability to care for injured and operated patients. Much of the future will depend upon society's ability to control violence and prevent injury. Most of the factors resulting in death after injury are beyond the control of those caring for patients or those studying patient problems. Thus the major risk factors for death after trauma are injury severity, the age of the patient, the problems of shock, and end-stage organ injury. If we are to decrease mortality from injury, we must work to prevent injury and decrease the severity of injury while improving our capabilities to care for the injured. New rapid diagnostic procedures, immediate therapy at the scene of the injury, portable or flying resuscitative and therapeutic units, and better understanding of the need for the inflammatory response in contrast to the disaster produced by an overwhelming inflammatory response will help. The major hazard for predicting the future in the management of injured patients could be predicting that something cannot be done. We recognize now that almost anything can be done if we learn enough and understand the problems sufficiently well. The Shock Society is dedicated to that purpose.

Forecasting↗

Cholangiocarcinoma: clinical significance of tumor location along the extrahepatic bile duct.

PURPOSE: To define the criteria for resection and/or radiation therapy (RT) of extrahepatic bile duct cancer. MATERIALS AND METHODS: Of 81 patients with extrahepatic bile duct cancer treated from 1983 to 1992, those with proximal duct lesions (n = 56) underwent RT and/or resection or palliative care, and those with distal lesions (n = 25) underwent resection with or without RT. Follow-up was available 3-114 months (median, 28 months). RESULTS: Patients with distal bile duct cancer lived longer than patients with proximal bile duct cancer (survival with Kaplan-Meier analysis, 53% vs 13% at 5 years, respectively, P < .01). Median survival in patients with proximal cancer after RT was more than double that without RT (17 months vs 6 months, respectively, regardless of stage [P = .01]); survival was not significantly different after resection. In patients with distal cancer, RT after resection made no significant difference in median survival (68 months). CONCLUSION: Patients with proximal cancer should undergo primary RT, and expectations should be limited. Patients with distal cancer should undergo resection, and RT may not be needed.

Aged↗

Management of malignant biliary obstruction: nonoperative and palliative techniques.

Biliary tract drainage, with or without placement of an endoprosthesis, is used as a palliative therapy for malignant biliary obstruction. The first truly internal endoprostheses represented a distinct improvement over internal-external catheters but still remained patent for only 4 to 6 months. Metallic stents have a long-term patency of 6 to 8 months. At present, it appears that patients with unresectable pancreatic cancer should be palliated with endoscopically placed plastic or metal stents, whereas those with malignant obstructions higher in the biliary tree are probably better managed with transhepatically placed stents. The combination of brachytherapy plus external-beam radiation followed by implantation of a Gianturco metal stent may be a viable approach to treating obstructions in patients with cholangiocarcinoma. For those with other noncholangiocarcinomas, particularly when life expectancy exceeds anticipated stent patency duration, the Wallstent may be the device of choice.

Biliary Tract Neoplasms↗

Microcephaly, lymphedema, and chorioretinal dysplasia: report of two additional cases.

In recent years, several patients with microcephaly, lymphedema and chorioretinal dysplasia have been described. We have studied two additional patients with similar findings. The question of whether microcephaly with lymphedema and microcephaly with chorioretinal dysplasia and lymphedema are distinct entities remains unanswered. Identification of other patients in the future may provide additional information.

Abnormalities, Multiple↗

Recombinant human interleukin 1 receptor antagonist in the treatment of patients with sepsis syndrome. Results from a randomized, double-blind, placebo-controlled trial. Phase III rhIL-1ra Sepsis Syndrome Study Group.

OBJECTIVE: To further define the safety and efficacy of recombinant human interleukin 1 receptor antagonist (rhIL-1ra) in the treatment of sepsis syndrome. STUDY DESIGN: Randomized, double-blind, placebo-controlled, multicenter, multinational clinical trial. POPULATION: A total of 893 patients with sepsis syndrome received an intravenous loading dose of rhIL-1ra, 100 mg, or placebo followed by a continuous 72-hour intravenous infusion of rhIL-1ra (1.0 or 2.0 mg/kg per hour) or placebo. OUTCOME MEASURE: Twenty-eight-day all-cause mortality. RESULTS: There was not a significant increase in survival time for rhIL-1ra treatment compared with placebo among all patients who received the study medication (n = 893; generalized Wilcoxon statistic, P = .22) or among patients with shock at study entry (n = 713; generalized Wilcoxon statistic, P = .23), the two primary efficacy analyses specified a priori for this trial. Results from secondary analyses suggest an increase in survival time with rhIL-1ra treatment among patients with dysfunction of one or more organs (n = 563; linear dose-response, P = .009). Retrospective analysis demonstrated an increase in survival time with rhIL-1ra treatment among patients with a predicted risk of mortality of 24% or greater (n = 580; linear dose-response, P = .005) as well as among patients with both dysfunction of one or more organs and a predicted risk of mortality of 24% or greater (n = 411; linear dose-response, P = .002). CONCLUSIONS: There was not a statistically significant increase in survival time for rhIL-1ra treatment compared with placebo among all patients who received the study medication or among patients with shock at study entry. Secondary and retrospective analyses of efficacy suggest that treatment with rhIL-1ra results in a dose-related increase in survival time among patients with sepsis who have organ dysfunction and/or a predicted risk of mortality of 24% or greater.

Adult↗

Mutagenic studies of the interaction between the aspartate receptor and methyltransferase from Escherichia coli.

The 4 glutamate residues that are the sites of methylation in the aspartate receptor, which mediates bacterial chemotaxis, were systematically mutated to aspartate residues. None of the aspartate residues were methylated. In each case, the presence of the aspartate mutations altered the methylation rates at glutamate residues on the same receptor. Methylation was nearly eliminated at residues two turns of alpha helix, in the N-terminal direction, from a site of mutation, whereas less severe changes occurred at other positions. The methyltransferase apparently must contact a glutamate or glutamine residue two turns of helix in the C-terminal direction from the site of modification in order to methylate that position at a maximal rate. Mutations from glutamate to aspartate at any of the four sites also appear to alter the methylation rate at the other sites through a change in the structure of the receptor. The aspartate mutations did not substantially alter the affinity of the methyltransferase for the receptor.

Amino Acid Sequence↗