Bullet and Shrapnel Embolism: When “Uncommon” Meets “Dangerous”

Bullet and shrapnel embolism (BSE) is well described in the literature. Despite that, its rare occurrence creates a diagnostic challenge for providers tending to penetrating trauma victims. As with other forms of embolic phenomena, cases of BSE require a blend of superb clinical expertise and experience, as well as a high diagnostic index of suspicion. Management is highly individualized and spans a broad spectrum of options from “watchful waiting” to open heart surgery. Due to the risk of retained projectile migration through tissues, including erosion into surrounding anatomic structures, non-operative approaches warrant long-term clinical surveillance. When promptly recognized and treated appropriately, patients with BSE can be expected to have excellent clinical outcomes

Foreign Intravascular Object Embolization and Migration: Bullets, Catheters, Wires, Stents, Filters, and More

Foreign intravascular object embolization (FIOE) is an important, yet underreported occurrence that has been described in a variety of settings, from penetrating trauma to intravascular procedures. In this chapter, the authors will review the most common types of FIOEs, including bullet or “projectile” embolism (BPE), followed by intravascular catheter or wire embolization (ICWE), and conclude with intravascular noncatheter object (e.g., coil, gelatin, stent, and venous filter) migration (INCOM). In addition to detailed topic-based summaries, tables highlighting selected references and case scenarios are also presented to provide the reader with a resource for future research in this clinical area

AVERT Shock Trial for Hemorrhagic Shock and the Use of mtDNA as a Biomarker During Trauma: an Interim Analysis

Trauma is the leading cause of death in people under the age of 40 years old, with hemorrhagic shock accounting for over 40% of deaths in the first 24 hours of admission. The current resuscitative strategy is based upon replenishing the intravascular volume with intravenous fluids and blood products. However, massive resuscitation is associated with serious complications such as acute respiratory distress syndrome, acute kidney injury, coagulopathy and infection. Indeed, the resuscitation with 6 or more units of blood product has been shown to be the greatest predictor of multi-organ failure. Large volume resuscitation also dilutes key hormones such as vasopressin which are needed to maintain vascular tone. Our previous research demonstrated that patients become deficient in vasopressin after transfusion with more than 5 units of blood product. We hypothesized that vasopressin use in patients presenting in hemorrhagic shock will result in a lower incidence of compli cations associated with over-resuscitation. We present an interim analysis of the data from our randomized, double blind, placebo-controlled study “Arginine Vasopressin for the Early Resuscitation of Traumatic (AVERT) Shock” which seeks to address the impact of early vasopressin supplementation during resuscitation. Free mitochondrial DNA (mtDNA) in plasma has also been suggested to play a role in the complications associated with trauma and therefore is being investigated as a potential biomarker for outcome. mtDNA has been shown in vitro to act as a danger-associated molecular pattern and trigger an inflammatory response. We developed refined methods for quantifying plasma mtDNA and present an analysis of its levels in trauma patients throughout their enrollment in the AVERT Shock Trial

A mitochondrial DNA variant of the COX-1 subunit of C. elegnas’ complex IV significantly alters mitochondrial energy metabolism of geographically divergent wild isolates.

Mitochondrial DNA (mtDNA) sequence variation is increasingly recognized to influence the penetrance of complex diseases and climatic adaptation in mammals, although little is known about its influence on invertebrate species’ adaptation to unique geographic niches. We investigated whether natural variation in mtDNA-encoded respiratory chain subunits alters the inherent mitochondrial energy capacity of wild C. elegans isolates to match local environmental energy demands. We found that relative to the classic N2 Bristol (England) wild-type strain, CB4856 wild isolates from a warmer and more equatorial native climate (Hawaii) had a unique A12S amino acid substitution in the N-terminal string of the COX-1 core catalytic subunit of complex IV. In silico modeling predicted that the A12S substitution increased MAPK-1 kinase binding affinity, which would increase COX-1 subunit phosphorylation in CB4856. Indeed, the CB4856 worms had significantly increased mitochondrial complex IV enzyme activity relative to N2 Bristol. While CB4856 had equivalent amounts of complex IV, mitochondria, and respiratory chain supercomplexes, its integrated mitochondrial respiratory capacity and membrane potential was significantly reduced when grown at 20°C. CB4856 also had significantly reduced lifespan and increased oxidative stress when grown at 20°C. Interestingly, the mitochondrial membrane potential of CB4856 was significantly increased relative to that of N2 Bristol when grown at its native temperature of 25°C degrees. To determine the effects of only the COX-1 sequence variant without possible contribution from the CB4856 nuclear genome background, we generated a transmitochondrial cybrid worm strain, chpIR(M,N2\u3eCB4856), containing the CB4856 mtDNA in the N2 Bristol wild-type nuclear background. This strain also had increased CIV activity, which supports that the A12S mtDNA variant is causative of the increased CIV activity of CB4856 relative to N2 Bristol. Differences in comparative functional analyses among the three strains further suggest their nuclear background also modulates mitochondrial function. The cybrid C. elegans strain also had reduced lifespan relative to CB4856, highlighting the importance of precise co-evolution of mitochondrial and nuclear genomes. Overall, these data show that C. elegans wild isolates of varying geographic origins may adapt to environmental challenges through mtDNA-encoded sequence alterations that modulate critical aspects of mitochondrial energy metabolism

A manual for the use of the General Court.

Contains rules of both branches of the General Court, the constitution of the commonwealth and that of the United States, lists of executive, legislative and judicial departments of the state, etc.Editors: W. Stowe, 1858, 1861; S.N. Gifford, 1861-86; W.S. Robinson, 1862-72; C.H. Taylor, 1873; G.A. Marden, 1874-82; E.A. McLaughlin, 1883-95; E.H. Clapp, 1887-88; G.T. Sleeper, 1896; H.D. Coolidge, 1889-19 ; J.W. Kimball, 1897-19.At head of title: The Commonwealth of Massachusetts.Contains rules of both branches of the General Court, the constitution of the commonwealth and that of the United States, lists of executive, legislative and judicial departments of the state, etc.Mode of access: Internet.Latest issue consulted: 2003/2004