Catherine Tenn

Comparison of selected skin decontaminant products and regimens against VX in domestic swine

An anesthetized domestic swine model was used to compare the efficacy and cross-contamination potential of selected skin decontaminant products and regimens against the chemical warfare agent, VX. Animals topically exposed to 2×, 3× or 5× LD50 VX showed typical signs of organophosphate nerve agent poisoning, including miosis, salivation, mastication, dysrhythmias, and respiratory distress prior to death. Animals were exposed to 5× LD50 VX and then decontaminated 45 min later with the reactive skin decontamination lotion (RSDL®), Fuller’s earth (FE), 0.5% hypochlorite, or soapy water. Survival was 100% when the reactive skin decontamination lotion or FE was utilized, although 50% of Fuller’s earth-decontaminated animals exhibited serious signs of VX poisoning. Decontamination of VX-treated animals with 0.5% hypochlorite was less effective but also increased survival. Soapy water was ineffective in preventing lethality. Blood cholinesterase levels were not predictive of clinical outcome in decontaminated animals. The potential of “decontaminated” VX in open wounds to cause poisoning was assessed by vigorously mixing 5× LD50 VX with the test decontaminants for 5 min and then placing the mixture onto a full-thickness skin wound. Soapy water was ineffective in preventing lethality. Although treatment with dry Fuller’s earth prevented death and all signs of organophosphate poisoning, a significant proportion of treated animals decontaminated with Fuller’s earth in aqueous suspension exhibited serious signs of organophosphate poisoning, suggesting that live agent may be desorbed from Fuller’s earth when it is exposed to a liquid environment. Animals treated with reactive skin decontamination lotion or 0.5% hypochlorite-VX mixtures showed no signs of organophosphate poisoning during the 6- h test period.

A comparison of live tissue training and high-fidelity patient simulator: A pilot study in battlefield trauma training.

BACKGROUND Trauma procedural and management skills are often learned on live tissue. However, there is increasing pressure to use simulators because their fidelity improves and as ethical concerns increase. We randomized military medical technicians (medics) to training on either simulators or live tissue to learn combat casualty care skills to determine if the choice of modality was associated with differences in skill uptake. METHODS Twenty medics were randomized to trauma training using either simulators or live tissue. Medics were trained to perform five combat casualty care tasks (surgical airway, needle decompression, tourniquet application, wound packing, and intraosseous line insertion). We measured skill uptake using a structured assessment tool. The medics also completed exit questionnaires and interviews to determine which modality they preferred. RESULTS We found no difference between groups trained with live tissue versus simulators in how they completed each combat casualty care skill. However, we did find that the modality of assessment affected the assessment score. Finally, we found that medics preferred trauma training on live tissue because of the fidelity of tissue handling in live tissue models. However, they also felt that training on simulators also provided additional training value. CONCLUSION We found no difference in performance between medics trained on simulators versus live tissue models. Even so, medics preferred live tissue training over simulation. However, more studies are required, and future studies need to address the measurement bias of measuring outcomes in the same model on which the study participants are trained. LEVEL OF EVIDENCE Therapeutic/care management study, level II.

Role of the sodium hydrogen exchanger in maitotoxin-induced cell death in cultured rat cortical neurons

Maitotoxin (MTX) is one of the most potent toxins known to date. It causes massive calcium (Ca(2+)) influx and necrotic cell death in various tissues. However, the exact mechanism(s) underlying its cellular toxicity is not fully understood. In the present study, the role of the sodium hydrogen exchanger (NHE) in MTX-induced increases in intracellular Ca(2+) and subsequent cell death were investigated in cultured rat cortical neurons. Intracellular Ca(2+) concentrations ([Ca(2+)](i)) were measured fluorimetrically using FURA-2 as the fluorescence indicator. Cell death was measured with the alamarBlue cell viability assay and the vital dye ethidium bromide (EB) uptake assay. Results showed that MTX increased, in a concentration dependent manner, both [Ca(2+)](i) and cell death in cortical neurons. Decreasing the pH of the treatment medium from 7.5 to 6.0 diminished MTX-induced cell death. The protection offered by lowering extracellular pH was not due to MTX degradation, because it was still effective even if the cells were treated with MTX in normal pH and then switched to a lower pH. Pretreatment of cells with the specific NHE inhibitor, 5-(N-ethyl-N-isopropyl)-amiloride (EIPA), prevented MTX-induced increases in [Ca(2+)](i), as well as cell death in a concentration dependent manner. Furthermore, knockdown of NHE1 by SiRNA transfection suppressed MTX-induced cell death in human embryonic kidney (HEK) cells. Together, these results suggest that NHE1 plays a major role in MTX-induced neurotoxicity.

Immobilization of Russian VX skin depots by localized cooling: Implications for decontamination and medical countermeasures

The chemical weapon nerve agent known as Russian VX (VR) is a potent organophosphorus (OP) compound that is much less studied than its VX analogue with respect to toxicity, as well as to the effectiveness of several known countermeasures against it. An anaesthetized domestic swine model was utilized to assess several approaches in mitigating its toxicity, including the utility of cooling VR treated skin to increase the therapeutic window for treatment. The 6h LD₅₀ for VR topically applied on the ear was 100 μg/kg. Treatment of VR exposed animals (5 × LD₅₀) with pralidoxime (2PAM) very poorly regenerated inhibited blood cholinesterase activity, but was partially effective in preventing signs of OP poisoning and increasing survival. In contrast, treatment with the Hagedorn oxime HI-6 reactivated cholinesterase, eliminated all signs of poisoning and prevented death. Decontamination with the Reactive Skin Decontaminant Lotion (RSDL) 15 min after VR exposure was completely effective in preventing death. Cooling of the VR exposure sites for 2 or 6h prevented signs of OP poisoning and death during the cooling period. However, these animals died very quickly after the cessation of cooling, unless they were treated with oxime or decontaminated with RSDL. Blood analyses showed that cooling of agent exposure sites delayed the entry of VR into the bloodstream. Medical treatment with HI-6 and to a lesser extent 2PAM, or decontamination with RSDL are effective in protecting against the toxic effects of cutaneous exposure to VR. Immobilizing this agent (and related compounds) within the dermal reservoir by cooling the exposure sites, dramatically increases the therapeutic window in which these medical countermeasures are effective.

The therapeutic use of localized cooling in the treatment of VX poisoning

The organophosphate (OP) nerve agent VX is a weaponized chemical warfare agent that has also been used by terrorists against civilians. This contact poison produces characteristic signs of OP poisoning, including miosis, salivation, mastication, dysrhythmias and respiratory distress prior to death. Although successful treatment of OP poisoning can be obtained through decontamination and/or oxime reactivation of agent-inhibited cholinesterase, medical countermeasures that increase the therapeutic window for these measures would be of benefit. An anaesthetized swine model was utilized to examine the effects of lethal VX exposure to the skin, followed by cooling the exposure site prior to decontamination or treatment. The cooling was simply accomplished by using crushed ice in grip-seal plastic bags applied to the exposure sites. Cooling of skin exposed to lethal doses of VX significantly increased the window of opportunity for successful decontamination using the Reactive Skin Decontaminant Lotion(®) (RSDL(®)) or treatment with the oxime antidotes HI-6 and 2PAM. Analyses of blood VX levels showed that cooling acted to slow or prevent the entry of VX into the bloodstream from the skin. If the exposure site is known, the simple and non-invasive application of cooling provides a safe means with which to dramatically increase the therapeutic window in which decontamination and/or antidote treatment against VX are life-saving.

Non-cholinergic intervention of sarin nerve agent poisoning

The protective effects of selected anesthetic regimens on sarin (GB) were investigated in domestic swine. At 30% oxygen, the toxicity of this agent in isoflurane anesthetized animals (LD(50)=10.1μg/kg) was similar to literature sited values in awake swine (LD(50)=11.8μg/kg) and slightly higher than that of both ketamine (LD(50)=15.6μg/kg) and propofol (LD(50)=15.3μg/kg) anesthetized swine. Use of 100% oxygen in ketamine anesthetized animals resulted in three-fold protective effects compared to 30% oxygen. Use of 100% oxygen in both isoflurane and propofol anesthetized animals, compared to 30% resulted in profound protection against GB poisoning (>33×). There were no differences in the severity of the poisoning or recovery time in animals treated over dose ranges of 10-350μg/kg (isoflurane) or 15-500μg/kg GB (propofol). Survivors of high GB challenges that were revived from propofol anesthetic exhibited no signs of cognitive impairment seven days later. Protective treatments did not attenuate cholinesterase (ChE) inhibition; survivors of otherwise supralethal GB concentrations exhibited very low blood ChE activities. This work indicates that propofol has protective effects against GB, and that oxygen tension may have an important role in treating nerve agent casualties. More importantly, it demonstrates that non-cholinergic protective mechanisms exist that may be exploited in the future development of medical countermeasures against organophosphorous nerve agents.

VX-induced cell death involves activation of caspase-3 in cultured rat cortical neurons.

Exposure of cell cultures to organophosphorous compounds such as VX can result in cell death. However, it is not clear whether VX-induced cell death is necrotic or involves programmed cell death mechanisms. Activation of caspases, a family of cysteine proteases, is often involved in cell death, and in particular, caspase-3 activation appears to be a key event in programmed cell death processes including apoptosis. In this study, we investigated VX-induced neuronal cell death, as well as the underlying mechanism in terms of its effect on caspase-3 activity. Primary cortical neuronal cultures were prepared from gestational days 17 to 19 Sprague Dawley rat fetuses. At maturation, the cells were treated with varying concentrations of VX and cell death was evaluated by lactate dehydrogenase (LDH) release. VX induced an increase in LDH release in a concentration-dependent manner. Morphological VX-induced cell death was also characterized by using nuclear staining with propidium iodide and Hoechst 33342. VX induced a concentration- and time-dependent increase in caspase-3 activation. Caspase-3 activation was also confirmed by the proteolytic cleavage of poly(ADP-ribose)polymerase (PARP), an endogenous caspase-3 substrate. These data suggested that in rat cortical neurons, VX-induced cell death via a programmed cell death pathway that involves changes in caspase-3 protease.

Protective effects ofN-Methyl-D-Aspartate receptor antagonism on VX-induced neuronal cell death in cultured rat cortical neurons

Exposure of the central nervous system to organophosphorus (OP) nerve agents induces seizures and neuronal cell death. Here we report that the OP nerve agent, VX, induces apoptoticlike cell death in cultured rat cortical neurons. The VX effects on neurons were concentrationdependent, with an IC50 of approximately 30 μM. Blockade ofN-methyl-D-aspartate receptors (NMDAR) with 50 μM D-2-amino-5-phosphonovalerate (APV) diminished 30 μM VX-induced total cell death, as assessed byalamarBlueTM assay and Hoechst staining. In contrast, neither antagonists of α-amino-3-hydroxy-5-methylisoxazole-4-propionic acid receptors (AMPARs) nor metabotropic glutamate receptors (mGluRs) had any effect on VX-induced neurotoxicity. VX-induced neuronal cell death could not be solely attributed to acetylcholinesterase (AChE) inhibition, since neither the reversible pharmacological cholinesterase inhibitor, physostigmine, nor the muscarinic receptor antagonist, atropine, affected VX-induced cell death. Importantly, APV was found to be therapeutically effective against VX-induced cell death up to 2 h post VX exposure. These results suggest that NMDARs, but not AMPARs or mGluRs, play important roles in VX-induced cell death in cultured rat cortical neurons. Based on their therapeutic effects, NMDAR antagonists may be beneficial in the treatment of VX-induced neurotoxicities.

Cyclooxygenase-2 contributes to VX-induced cell death in cultured cortical neurons.

The link between cell death and increased cyclooxygenases-2 (COX-2) activity has not been clearly established. In this study, we examined whether COX-2 activation contributed to the mechanism of neurotoxicity produced by an organophosphorous nerve agent in cultured rat cortical neurons. Exposure of neuronal cells to the nerve agent, VX resulted in an increase in COX enzyme activity in the culture media. A concentration dependent increase in the activity levels of COX-2 enzyme was observed while there was little to no effect on COX-1. In addition, COX-2 mRNA and protein levels increased several hours post-VX exposure. Pre-treatment of the cortical cells with the COX-2 selective inhibitor, NS 398 resulted in a decrease in both the enzyme activity and prostaglandin (PGE(2) and PGF(2α)) release, as well as in a reduction in cell death. These findings indicate that the increase in COX-2 activity may contribute to the mechanism of VX-induced neurotoxicity in cultured rat cortical neuron.

Battlefield Trauma Training: A Pilot Study Comparing the Effects of Live Tissue vs. High-Fidelity Patient Simulator on Stress, Cognitive Function, and Performance

Within the Canadian Armed Forces (CAF), the Tactical Medicine (TACMED) course is used to train medical technicians (i.e., medics) in battlefield trauma care. Although training is administered using both simulators (SIM) and live tissue (LT), little is known about their relative effects on stress and cognitive function in this context. To address this shortcoming, we conducted a pilot study and collected self-report (State-Trait Anxiety Inventory [STAI]) and biological measures of stress (salivary cortisol and dehydroepiandrosterone [DHEA]), as well as working memory (WM) and short-term memory (STM) data from medics (N = 20) assigned randomly to training and skill assessment using either SIM or LT. Skill assessment resulted in the elevation of STAI scores and salivary cortisol and DHEA levels. WM and STM performance were better at the time of skill assessment, and WM performance exhibited a positive correlation with salivary cortisol level. Salivary cortisol and DHEA levels, STAI scores, and memory performance did not predict pass/fail rates on combat casualty care skills. Although the TACMED course was associated with elevated stress and improved memory performance, those effects were not affected by the training modality. We end by discussing lessons learned from our pilot study and highlight outstanding questions that remain to be addressed in future studies on this topic.