Identification of capillary blood pressure levels at which capillary collapse is likely in a tissue subjected to large compressive and shear deformations

Pressure ulcers (PU) are localised damage to skin and underlying tissues, caused by sustained tissue deformations and ischaemia. PU typically appear in insensitive or immobile patients, e.g. those with spinal cord injury (SCI) or geriatric patients. As these patients often experience fluctuations in blood pressure, and are also exposed to high-shear loads in their weight-bearing soft tissues during wheelchair sitting or bed rest, we used an inverse finite element method to determine the effects of capillary blood pressure (CBP) and shear deformations on occurrence of mechanical collapse in capillaries. We studied collapse in straight, U-shaped and bifurcated capillaries. All model configurations were consistent in demonstrating that the level of CBP has a considerable influence on the likelihood of capillary collapse in the physiological CBP range, particularly if shear is present. Our modelling therefore suggests that low CBP is a 'suspect' risk factor for PU in SCI and geriatric patients.     

REFRACTORY HYPOTENSION—Diagnosis and Management in Surgical Patients

Refractory hypotension is circulatory collapse of obscure cause which occurs in surgical patients who are thought to have a normal blood volume but in whom adequate circulation cannot be maintained. Such patients are usually treated empirically by the administration of intravenous vasopressor agents, and the mortality rate is relatively high.A specific diagnosis of the underlying cause for the refractory hypotension can be made by thorough clinical evaluation. Specific treatment aimed at correcting the underlying cause of the vascular collapse will lower the mortality rate in this serious type of circulatory failure.     

Cardiovascular collapse in laparoscopy

This report describes two cases of severe cardiovascular collapse occurring during laparoscopy using carbon dioxide insufflation under general anesthesia. Both patients made eventual complete recovery. The possible causes, gas embolism being the most likely, are discussed. A list of precautions for the safe conduct of laparoscopy is presented. Since these precautions have been followed there has been no recurrence of cardiovascular collapse in over 300 subsequent cases.     

Surgical treatment of pulmonary tuberculosis; a decade of change

To observe trends in the surgical therapy of pulmonary tuberculosis, the records of patients treated during the last ten years at the Tuberculosis Division of the San Diego County General Hospital (Vauclain Home) were reviewed. In this decade, a chemotherapeutic revolution permitted more patients to be treated with fewer beds, lower mortality and shorter hospitalization. Pneumoperitoneum has replaced other forms of temporary collapse. Pneumothorax, phrenic nerve interruption and pneumonolysis have been abandoned in favor of extraperiosteal plombage, particularly in older, poor risk patients. The use of permanent collapse measures as definitive treatment has decreased, thoracoplasty and extrapleural pneumothorax having been virtually abandoned. The use of resection in patients with permanent collapse failure, residual cavities, bronchostenosis and destroyed lobes or lungs has become common, and good results have been obtained.     

Postoperative Pulmonary Atelectasis and Collapse,and its Prophylaxis with Intravenous Bicarbonate

Of 181 patients undergoing major abdominal surgery 116 developed chest complications associated with a metabolic acidosis, low Pco2, depressed tidal volume, increased respiratory rate, but no increase in minute volume. In a matched group of 116 patients given intravenous bicarbonate postoperatively only 15 developed chest complications. This suggests that respiratory physiological dead space decreases in patients with pulmonary collapse and atelectasis following surgery. Acidotic respiration proved inefficient in the postoperative period, and intravenous bicarbonate had a very pronounced effect on the tidal and minute volumes of acidotic patients with pulmonary collapse and atelectasis.     

Growth cone collapse through coincident loss of actin bundles and leading edge actin without actin depolymerization

Repulsive guidance cues can either collapse the whole growth cone to arrest neurite outgrowth or cause asymmetric collapse leading to growth cone turning. How signals from repulsive cues are translated by growth cones into this morphological change through rearranging the cytoskeleton is unclear. We examined three factors that are able to induce the collapse of extending Helisoma growth cones in conditioned medium, including serotonin, myosin light chain kinase inhibitor, and phorbol ester. To study the cytoskeletal events contributing to collapse, we cultured Helisoma growth cones on polylysine in which lamellipodial collapse was prevented by substrate adhesion. We found that all three factors that induced collapse of extending growth cones also caused actin bundle loss in polylysine-attached growth cones without loss of actin meshwork. In addition, actin bundle loss correlated with specific filamentous actin redistribution away from the leading edge that is characteristic of repulsive factors. Finally, we provide direct evidence using time-lapse studies of extending growth cones that actin bundle loss paralleled collapse. Taken together, these results suggest that actin bundles could be a common cytoskeletal target of various collapsing factors, which may use different signaling pathways that converge to induce growth cone collapse.     

How, when and why proteins collapse: the relation to folding

Unfolded proteins under strongly denaturing conditions are highly expanded. However, when the conditions are more close to native, an unfolded protein may collapse to a compact globular structure distinct from the folded state. This transition is akin to the coil-globule transition of homopolymers. Single-molecule FRET experiments have been particularly conducive in revealing the collapsed state under conditions of coexistence with the folded state. The collapse can be even more readily observed in natively unfolded proteins. Time-resolved studies, using FRET and small-angle scattering, have shown that the collapse transition is a very fast event, probably occurring on the submicrosecond time scale. The forces driving collapse are likely to involve both hydrophobic and backbone interactions. The loss of configurational entropy during collapse makes the unfolded state less stable compared to the folded state, thus facilitating folding.     

Bites by puff-adder (Bitis arietans) in Nigeria,and value of antivenom.

Ten patients bitten by the puff-adder (Bitis arietans) were studied in the North of Nigeria. Six showed severe local signs, and four also had evidence of systemic envenoming, including spontaneous bleeding with thrombocytopenia, hypotension, and bradycardia. Two patients died after developing circulatory collapse and renal failure. Antivenom and intravenous fluid restored blood pressure in two hypotensive patients, and antivenom probably prevented the development of local necrosis in four others with massive local swelling. Victims of B arietans who have swelling of more than half the bitten limb or show signs of systemic envenoming should be given at least 80 ml of specific polyvalent antivenom and watched carefully for signs of circulatory collapse. Debridement of necrotic tissue may be necessary.     

Theoretical modeling of the interaction between alveoli during inflation and deflation in normal and diseased lungs

Alveolar recruitment is a central strategy in the ventilation of patients with acute lung injury and other lung diseases associated with alveolar collapse and atelectasis. However, biomechanical insights into the opening and collapse of individual alveoli are still limited. A better understanding of alveolar recruitment and the interaction between alveoli in intact and injured lungs is of crucial relevance for the evaluation of the potential efficacy of ventilation strategies. We simulated human alveolar biomechanics in normal and injured lungs. We used a basic simulation model for the biomechanical behavior of virtual single alveoli to compute parameterized pressure–volume curves. Based on these curves, we analyzed the interaction and stability in a system composed of two alveoli. We introduced different values for surface tension and tissue properties to simulate different forms of lung injury. The data obtained predict that alveoli with identical properties can coexist with both different volumes and with equal volumes depending on the pressure. Alveoli in injured lungs with increased surface tension will collapse at normal breathing pressures. However, recruitment maneuvers and positive endexpiratory pressure can stabilize those alveoli, but coexisting unaffected alveoli might be overdistended. In injured alveoli with reduced compliance collapse is less likely, alveoli are expected to remain open, but with a smaller volume. Expanding them to normal size would overdistend coexisting unaffected alveoli. The present simulation model yields novel insights into the interaction between alveoli and may thus increase our understanding of the prospects of recruitment maneuvers in different forms of lung injury.     

Convergent and divergent signaling mechanisms of growth cone collapse by ephrinA5 and slit2

EphrinA5 and slit2 are important repulsive guidance cues in the developing retinotectal system. Both ephrinA5 and slit2 cause growth cone collapse of embryonic chick retinal ganglion growth cones cultured on EHS laminin. However, the signaling mechanism that these guidance cues initiate to cause collapse remains unclear. Here we provide evidence that while both ephrinA5 and slit2 cause collapse in morphologically similar ways, the intracellular signaling leading to the collapse involves shared as well as divergent paths. Pharmacological inhibition of either phosphatidylinositol 3-kinase (PI3K) or src family kinases prevented both ephrinA5-mediated and slit2-mediated growth cone collapse. In contrast, the inhibition of nonclassical protein kinase C (PKC) isoforms blocked ephrinA5-mediated collapse, but did not interfere with slit2-mediated collapse. PI3K was copurified by affinity chromatography with either the ephrinA5 receptors (ephAs) or the slit2 receptor (roundabout). Colocalization studies have also shown that src family kinase members are recruited to the ephA and roundabout receptors upon activation. In contrast, PKC members are recruited to the ephA receptors, but not to the roundabout receptors, upon activation. This demonstrates distinct points of convergence and divergence between the two signaling molecules, ephrinA5 and slit2, and their repulsive guidance in the chick retinotectal system.     

Role of cdk5 and tau phosphorylation in heterotrimeric G protein-mediated retinal growth cone collapse.

During axonal growth, repulsive guidance cues cause growth cone collapse and retraction. In the chick embryo, membranes from the posterior part of the optic tectum containing ephrins are original collapsing factors for axons growing from the temporal retina. We investigated signal transduction pathways in retinal axons underlying this membrane-evoked collapse. Perturbation experiments using pertussis toxin (PTX) showed that membrane-induced collapse is mediated via G(o/i) proteins, as is the case for semaphorin/collapsin-1-induced collapse. Studies with Indo-1 revealed that growth cone collapse by direct activation of G(o/i) proteins with mastoparan did not cause elevation of the intracellular Ca(2+) level, and thus this signal transduction pathway is Ca(2+) independent. Application of the protein phosphatase inhibitor okadaic acid alone induced growth cone collapse in retinal culture, suggesting signals involving protein dephosphorylation. In addition, pretreatment of retinal axons with olomoucine, a specific inhibitor of cdk5 (tau kinase II), prevented mastoparan-evoked collapse. Olomoucine also blocks caudal tectal membrane-mediated collapse. These results suggest that rearrangement of the cytoskeleton is mediated by tau phosphorylation. Immunostaining visualized complementary distributions of tau phospho- and dephosphoisoforms within the growth cone, which also supports the involvement of tau. Taking these findings together, we conclude that cdk5 and tau phosphorylation probably lie downstream of growth cone collapse signaling mediated by PTX-sensitive G proteins.     

Steroid-Associated Hip Joint Collapse in Bipedal Emus

In this study we established a bipedal animal model of steroid-associated hip joint collapse in emus for testing potential treatment protocols to be developed for prevention of steroid-associated joint collapse in preclinical settings. Five adult male emus were treated with a steroid-associated osteonecrosis (SAON) induction protocol using combination of pulsed lipopolysaccharide (LPS) and methylprednisolone (MPS). Additional three emus were used as normal control. Post-induction, emu gait was observed, magnetic resonance imaging (MRI) was performed, and blood was collected for routine examination, including testing blood coagulation and lipid metabolism. Emus were sacrificed at week 24 post-induction, bilateral femora were collected for micro-computed tomography (micro-CT) and histological analysis. Asymmetric limping gait and abnormal MRI signals were found in steroid-treated emus. SAON was found in all emus with a joint collapse incidence of 70%. The percentage of neutrophils (Neut %) and parameters on lipid metabolism significantly increased after induction. Micro-CT revealed structure deterioration of subchondral trabecular bone. Histomorphometry showed larger fat cell fraction and size, thinning of subchondral plate and cartilage layer, smaller osteoblast perimeter percentage and less blood vessels distributed at collapsed region in SAON group as compared with the normal controls. Scanning electron microscope (SEM) showed poor mineral matrix and more osteo-lacunae outline in the collapsed region in SAON group. The combination of pulsed LPS and MPS developed in the current study was safe and effective to induce SAON and deterioration of subchondral bone in bipedal emus with subsequent femoral head collapse, a typical clinical feature observed in patients under pulsed steroid treatment. In conclusion, bipedal emus could be used as an effective preclinical experimental model to evaluate potential treatment protocols to be developed for prevention of ON-induced hip joint collapse in patients.     

The widespread collapse of an invasive species: Argentine ants (Linepithema humile) in New Zealand

Synergies between invasive species and climate change are widely considered to be a major biodiversity threat. However, invasive species are also hypothesized to be susceptible to population collapse, as we demonstrate for a globally important invasive species in New Zealand. We observed Argentine ant populations to have collapsed in 40 per cent of surveyed sites. Populations had a mean survival time of 14.1 years (95% CI = 12.9-15.3 years). Resident ant communities had recovered or partly recovered after their collapse. Our models suggest that climate change will delay colony collapse, as increasing temperature and decreasing rainfall significantly increased their longevity, but only by a few years. Economic and environmental costs of invasive species may be small if populations collapse on their own accord.     

The organization of F-actin and microtubules in growth cones exposed to a brain-derived collapsing factor

In previous work we characterized a brain derived collapsing factor that induces the collapse of dorsal root ganglion growth cones in culture (Raper and Kapfhammer, 1990). To determine how the growth cone cytoskeleton is rearranged during collapse, we have compared the distributions of F-actin and microtubules in normal and partially collapsed growth cones. The relative concentration of F-actin as compared to all proteins can be measured in growth cones by rationing the intensity of rhodamine-phalloidin staining of F-actin to the intensity of a general protein stain. The relative concentration of F- actin is decreased by about one half in growth cones exposed to collapsing factor for five minutes, a time at which they are just beginning to collapse. During this period the relative concentration of F-actin in the leading edges of growth cones decreases dramatically while the concentration of F-actin in the centers decreases little. These results suggest that collapse is associated with a net loss of F- actin at the leading edge. The distributions of microtubules in normal and collapsing factor treated growth cones were examined with antibodies to tyrosinated and detyrosinated isoforms of alpha-tubulin. The tyrosinated form is found in newly polymerized microtubules while the detyrosinated form is not. The relative proximal-distal distributions of these isoforms are not altered during collapse, suggesting that rates of microtubule polymerization and depolymerization are not greatly affected by the presence of collapsing factor. An analysis of the distributions of microtubules before and after collapse suggests that microtubules are rearranged, but their polymerization state is unaffected during collapse. These results are consistent with the hypothesis that the brain derived collapsing factor has little effect on microtubule polymerization or depolymerization. Instead it appears to induce a net loss of F-actin at the leading edge of the growth cone.     

Pathogenesis of obstructive sleep apnea.

The pathogenesis of obstructive sleep apnea (OSA) has been under investigation for over 25 years, during which a number of factors that contribute to upper airway (UA) collapse during sleep have been identified. Structural/anatomic factors that constrict space for the soft tissues surrounding the pharynx and its lumen are crucial to the development of OSA in many patients. Enlargement of soft tissues enveloping the pharynx, including hypertrophied tonsils, adenoids, and tongue, is also an important factor predisposing to UA collapse, inasmuch as this can impinge on the pharyngeal lumen and narrow it during sleep. Other factors, including impairment of UA mechanoreceptor sensitivity and reflexes that maintain pharyngeal patency and respiratory control system instability, have also been identified as possible mechanisms facilitating UA instability. This suggests that OSA may be a heterogeneous disorder, rather than a single disease entity. Therefore, the extent to which various pathogenic factors contribute to the phenomenon of repetitive collapse of the UA during sleep probably varies from patient to patient. Further elucidation of specific pathogenic mechanisms in individuals with OSA may facilitate the development of new therapies that can be tailored to individual patient needs according to the underlying mechanism(s) of their disease.     

Time-based partitioning model for predicting neurologically favorable outcome among adults with witnessed bystander out-of-hospital CPA

Background

Optimal acceptable time intervals from collapse to bystander cardiopulmonary resuscitation (CPR) for neurologically favorable outcome among adults with witnessed out-of-hospital cardiopulmonary arrest (CPA) have been unclear. Our aim was to assess the optimal acceptable thresholds of the time intervals of CPR for neurologically favorable outcome and survival using a recursive partitioning model.

Methods and Findings

From January 1, 2005 through December 31, 2009, we conducted a prospective population-based observational study across Japan involving consecutive out-of-hospital CPA patients (N = 69,648) who received a witnessed bystander CPR. Of 69,648 patients, 34,605 were assigned to the derivation data set and 35,043 to the validation data set. Time factors associated with better outcomes: the better outcomes were survival and neurologically favorable outcome at one month, defined as category one (good cerebral performance) or two (moderate cerebral disability) of the cerebral performance categories. Based on the recursive partitioning model from the derivation dataset (n = 34,605) to predict the neurologically favorable outcome at one month, 5 min threshold was the acceptable time interval from collapse to CPR initiation; 11 min from collapse to ambulance arrival; 18 min from collapse to return of spontaneous circulation (ROSC); and 19 min from collapse to hospital arrival. Among the validation dataset (n = 35,043), 209/2,292 (9.1%) in all patients with the acceptable time intervals and 1,388/2,706 (52.1%) in the subgroup with the acceptable time intervals and pre-hospital ROSC showed neurologically favorable outcome.

Conclusions

Initiation of CPR should be within 5 min for obtaining neurologically favorable outcome among adults with witnessed out-of-hospital CPA. Patients with the acceptable time intervals of bystander CPR and pre-hospital ROSC within 18 min could have 50% chance of neurologically favorable outcome.     

Catastrophic Collapse Can Occur without Early Warning: Examples of Silent Catastrophes in Structured Ecological Models

Catastrophic and sudden collapses of ecosystems are sometimes preceded by early warning signals that potentially could be used to predict and prevent a forthcoming catastrophe. Universality of these early warning signals has been proposed, but no formal proof has been provided. Here, we show that in relatively simple ecological models the most commonly used early warning signals for a catastrophic collapse can be silent. We underpin the mathematical reason for this phenomenon, which involves the direction of the eigenvectors of the system. Our results demonstrate that claims on the universality of early warning signals are not correct, and that catastrophic collapses can occur without prior warning. In order to correctly predict a collapse and determine whether early warning signals precede the collapse, detailed knowledge of the mathematical structure of the approaching bifurcation is necessary. Unfortunately, such knowledge is often only obtained after the collapse has already occurred.     

Sensitivity to Intravenous Anaesthetics: A Report of Three Cases

Three patients with sensitivity to an intravenous anaesthetic—thiopentone, propanidid, and Althesin (alphadolone and alphaxalone)—are described. In the cases of thiopentone and Althesin the reaction was characterized by cardiovascular collapse, while bronchospasm also occurred with thiopentone. The reaction to propanidid was a direct skin sensitivity. All patients had a personal or family history of asthma and all had been previously exposed to the offending drug. A leucocyte challenge test showed an allergic response to thiopentone and Althesin in two patients but gave a negative result in the patient with the skin reaction. Allergic reactions can occur to all types of intravenous anaesthetics in a few patients.