Cerebral perfusion pressure and risk of brain hypoxia in severe head injury: a prospective observational study

INTRODUCTION Higher and lower cerebral perfusion pressure (CPP) thresholds have been proposed to improve brain tissue oxygen pressure (PtiO2) and outcome. We study the distribution of hypoxic PtiO2 samples at different CPP thresholds, using prospective multimodality monitoring in patients with severe traumatic brain injury. METHODS This is a prospective observational study of 22 severely head injured patients admitted to a neurosurgical critical care unit from whom multimodality data was collected during standard management directed at improving intracranial pressure, CPP and PtiO2. Local PtiO2 was continuously measured in uninjured areas and snapshot samples were collected hourly and analyzed in relation to simultaneous CPP. Other variables that influence tissue oxygen availability, mainly arterial oxygen saturation, end tidal carbon dioxide, body temperature and effective hemoglobin, were also monitored to keep them stable in order to avoid non-ischemic hypoxia. RESULTS Our main results indicate that half of PtiO2 samples were at risk of hypoxia (defined by a PtiO2 equal to or less than 15 mmHg) when CPP was below 60 mmHg, and that this percentage decreased to 25% and 10% when CPP was between 60 and 70 mmHg and above 70 mmHg, respectively (p < 0.01). CONCLUSION Our study indicates that the risk of brain tissue hypoxia in severely head injured patients could be really high when CPP is below the normally recommended threshold of 60 mmHg, is still elevated when CPP is slightly over it, but decreases at CPP values above it.

Enhanced production of indole-3-acetic acid by a genetically modified strain of Pseudomonas fluorescens CHA0 affects root growth of cucumber but does not improve protection of the plant against Pythium root rot

The biocontrol strain CHA0 of Pseudomonas fluorescens produces small amounts of indole-3-acetic acid via the tryptophan side chain oxidase and the tryptophan transaminase pathways. A recombinant plasmid (pME3468) expressing the tryptophan monooxygenase pathway was introduced into strain CHA0; this resulted in elevated synthesis of indole-3-acetic acid in vitro, especially after addition of -tryptophan. In natural soil, strain CHA0/pME3468 increased fresh root weight of cucumber by 17-36%, compared to the effect of strain CHA0; root colonization was about 106 cells per g of root. However, both strains gave similar protection of cucumber against Pythium ultimum. In autoclaved soil, at 6×107 cells per g of root, strain CHA0 stimulated growth of roots and shoots, whereas strain CHA0/pME3468 caused root stunting and strong reduction of plant weight. These results are in agreement with the known effects of exogenous indole-3-acetic acid on plant roots and suggest that in the system examined, indole-3-acetic acid does not contribute to the biocontrol properties of strain CHA0.

Synthesis and transport of creatine in the CNS: importance for cerebral functions.

J. Neurochem. (2010) 10.1111/j.1471-4159.2010.06935.x Abstract Apart of its well known function of 'energetic buffer' through the creatine/phosphocreatine/creatine kinase system allowing the regeneration of ATP, creatine has been recently suggested as a potential neuromodulator of even true neurotransmitter. Moreover, the recent discovery of primary creatine deficiency syndromes, due to deficiencies in l-arginine : glycine amidinotransferase or guanidinoacetate methyltransferase (the two enzymes allowing creatine synthesis) or in the creatine transporter, has shed new light on creatine synthesis, metabolism and transport, in particular in CNS which appears as the main tissue affected by these creatine deficiencies. Recent data suggest that creatine can cross blood-brain barrier but only with a poor efficiency, and that the brain must ensure parts of its needs in creatine by its own endogenous synthesis. Finally, the recent years have demonstrated the interest to use creatine as a neuroprotective agent in a growing number of neurodegenerative diseases, including Parkinson's and Huntington's diseases. This article aims at reviewing the latest data on creatine metabolism and transport in the brain, in relation to creatine deficiencies and to the potential use of creatine as neuroprotective molecule. Emphasis is also given to the importance of creatine for cerebral function.

Cerebral perfusion in sepsis.

This article is one of ten reviews selected from the Yearbook of Intensive Care and Emergency Medicine 2010 (Springer Verlag) and co-published as a series in Critical Care. Other articles in the series can be found online at http://ccforum.com/series/yearbook. Further information about the Yearbook of Intensive Care and Emergency Medicine is available from http://www.springer.com/series/2855.

Status of radiation protection at different hospitals in Nepal.

Nepal has a long history of medical radiology since1923 but unfortunately, we still do not have any Radiation Protection Infrastructure to control the use of ionizing radiations in the various fields. The objective of this study was an assessment of the radiation protection in medical uses of ionizing radiation. Twenty-eight hospitals with diagnostic radiology facility were chosen for this study according to patient loads, equipment and working staffs. Radiation surveys were also done at five different radiotherapy centers. Questionnaire for radiation workers were used; radiation dose levels were measured and an inventory of availability of radiation equipment made. A corollary objective of the study was to create awareness in among workers on possible radiation health hazard and risk. It was also deemed important to know the level of understanding of the radiation workers in order to initiate steps towards the establishment of Nepalese laws, regulation and code of radiological practice in this field. Altogether, 203 Radiation workers entertained the questionnaire, out of which 41 are from the Radiotherapy and 162 are from diagnostic radiology. The radiation workers who have participated in the questionnaire represent more than 50% of the radiation workers working in this field in Nepal. Almost all X-ray, CT and Mammogram installations were built according to protection criteria and hence found safe. Radiation dose level at the reference points for all the five Radiotherapy centers are within safe limit. Around 65% of the radiation workers have never been monitored for radiation. There is no quality control program in any of the surveyed hospitals except radiotherapy facilities.

Oral live attenuated human rotavirus vaccine (RotarixTM) offers sustained high protection against severe G9P[8] rotavirus gastroenteritis during the first two years of life in Brazilian children

In a large Phase III trial conducted in 10 Latin American countries, the safety and efficacy of the live attenuated monovalent rotavirus vaccine RIX4414 was evaluated in 15,183 healthy infants followed up during the first two years of life. Belém was the only site in Brazil included in this multicentre trial. The study in Belém included a subset of 653 infants who were followed up until 24 months of age for protection against severe rotavirus gastroenteritis. These subjects were randomly assigned in a 1:1 ratio to receive two doses of vaccine (n = 328) or two doses of placebo (n = 325) at approximately two and four months of age. Of the 653 enrolled infants, 23 dropped out during the study period. For the combined two-year period, the efficacy of RIX4414 was 72.3% [95% confidence interval (CI) 37.5-89.1%] against severe rotavirus-related gastroenteritis, reaching a protection rate of 81.8% (95% CI 36.4-96.6%) against circulating wild-type G9 rotavirus strains. It is concluded that two doses of RIX4414 are highly efficacious against severe rotavirus gastroenteritis in Belém during the first two years of life and provide high protection against the worldwide emergence and spread of G9P[8] strains.

Microdiàlisis cerebral aplicada a l'estudi del metabolisme energètic i a la resposta neuroinflamatòria dels pacients amb traumatisme cranioencefàlic

La tècnica de la microdiàlisis cerebral (MDC) és un instrument que proporciona informació rellevant en la monitorització del metabolisme cerebral en els pacients neurocrítics. El lactat i l’índex lactat-piruvat (ILP) són dos marcadors utilitzats per a la detecció de la hipòxia cerebral en pacients que han patit un traumatisme cranioencefàlic (TCE). Aquests dos marcadors poden estar anormalment elevats en circumstàncies que no cursen amb hipòxia tissular. Per una altra banda la recent aparició dels catèters de MDC amb porus de major mida denominats d’”alta resolució”, permet ampliar el rang de molècules que es poden detectar en el dialitzat. Objectius: 1) descriure les característiques del metabolisme energètic cerebral que s’observa en la fase aguda dels pacients que han patit un TCE en base als dos indicadors del metabolisme anaeròbic: lactat i ILP, i 2) determinar la recuperació relativa (RR) de les molècules implicades en la resposta neuroinflamatòria: de IL-1β, IL- 6, IL-8 i IL-10. Material i mètodes: Es van seleccionar 46 pacients d’una cohort de pacients amb TCE moderat o greu ingressats a la Unitat de Cures Intensives de l’Hospital Universitari de la Vall d’Hebron i monitoritzats amb MDC. Es van analitzar els nivells de lactat i ILP i es va correlacionar amb els nivells de PtiO2. Es van realitzar experiments in vitro per estudiar la recuperació de les membranes de 100 KDa per tal de poder interpretar posteriorment els nivells reals de les molècules estudiades en l’espai extracel•lular del teixit cerebral. Resultats: La concordança entre el lactat i l’índex LP per a determinar episodis de disfunció metabòlica va ser dèbil (índex de kappa = 0,36, IC 95%: 0,34-0,39). Més del 80% dels casos en què el lactat i l’índex LP es trobaven incrementats, els valors de la PtiO2 es van trobar dins els rangs de normalitat (PtiO2&15mmHg). La recuperació de les citoquines a través de la membrana de microdiàlisis va ser menor de l’esperat tenint en compte la mida dels porus de la membrana. Conclusions: el lactat i l’índex LP elevats va ser una troballa freqüent després d’un TCE i no es va relacionar, en la majoria de casos, amb episodis d’hipòxia tissular. Per un altra part la mida del porus de la membrana no és l’únic paràmetre indicador de la RR de macromolècules.

Bacterial-induced protection against allergic inflammation through a multicomponent immunoregulatory mechanism.

Background Airborne microbial products have been reported to promote immune responses that suppress asthma, yet how these beneficial effects take place remains controversial and poorly understood. Methods We exposed mice to the bacterium Escherichia coli and subsequently induced allergic airway inflammation through sensitization and intranasal challenge with ovalbumin. Results Pulmonary exposure to the bacterium Escherichia coli leads to a suppression of allergic airway inflammation. This immune modulation was neither mediated by the induction of a T helper 1 (Th1) response nor regulatory T cells; however, it was dependent on Toll-like receptor 4 (TLR4) but did not involve TLR desensitisation. Dendritic cell migration to the draining lymph nodes and activation of T cells was unaffected by prior exposure to E.coli, while dendritic cells in the lung displayed a less activated phenotype and had impaired antigen presentation capacity. Consequently, in situ Th2 cytokine production was abrogated. The suppression of airway hyper-responsiveness was mediated through the recruitment of gd T cells; however, the suppression of dendritic cells and T cells was mediated through a distinct mechanism that could not be overcome by the local administration of activated dendritic cells, or by the in vivo administration of tumour necrosis factor a. Conclusion Our data reveal a localized immunoregulatory pathway that acts to protect the airways from allergic inflammation.

Beclin 1-independent autophagy contributes to apoptosis in cortical neurons.

Neuronal autophagy is enhanced in many neurological conditions, such as cerebral ischemia and traumatic brain injury, but its role in associated neuronal death is controversial, especially under conditions of apoptosis. We therefore investigated the role of autophagy in the apoptosis of primary cortical neurons treated with the widely used and potent pro-apoptotic agent, staurosporine (STS). Even before apoptosis, STS enhanced autophagic flux, as shown by increases in autophagosomal (LC3-II level, LC3 punctate labeling) and lysosomal (cathepsin D, LAMP1, acid phosphatase, β-hexasominidase) markers. Inhibition of autophagy by 3-methyladenine, or by lentivirally-delivered shRNAs against Atg5 and Atg7, strongly reduced the STS-induced activation of caspase-3 and nuclear translocation of AIF, and gave partial protection against neuronal death. Pan-caspase inhibition with Q-VD-OPH likewise protected partially against neuronal death, but failed to affect autophagy. Combined inhibition of both autophagy and caspases gave strong synergistic neuroprotection. The autophagy contributing to apoptosis was Beclin 1-independent, as shown by the fact that Beclin 1 knockdown failed to reduce it but efficiently reduced rapamycin-induced autophagy. Moreover the Beclin 1 knockdown sensitized neurons to STS-induced apoptosis, indicating a cytoprotective role of Beclin 1 in cortical neurons. Caspase-3 activation and pyknosis induced by two other pro-apoptotic stimuli, MK801 and etoposide, were likewise found to be associated with Beclin 1-independent autophagy and reduced by the knockdown of Atg7 but not Beclin 1. In conclusion, Beclin 1-independent autophagy is an important contributor to both the caspase-dependent and -independent components of neuronal apoptosis and may be considered as an important therapeutic target in neural conditions involving apoptosis.

Lésions cérébrales du prématuré et techniques d'imagerie à visée pronostique du développement neurocognitif [Cerebral brain injury in preterm infants and the role of neuroimaging in predicting neurodevelopmental outcomes].

Due to advances in neonatal intensive care over the last decades, the pattern of brain injury seen in very preterm infants has evolved in more subtle lesions that are still essential to diagnose in regard to neurodevelopmental outcome. While cranial ultrasound is still used at the bedside, magnetic resonance imaging (MRI) is becoming increasingly used in this population for the assessment of brain maturation and white and grey matter lesions. Therefore, MRI provides a better prognostic value for the neurodevelopmental outcome of these preterms. Furthermore, the development of new MRI techniques, such as diffusion tensor imaging, resting state functional connectivity and magnetic resonance spectroscopy, may further increase the prognostic value, helping to counsel parents and allocate early intervention services.

Congenital ataxia and hemiplegic migraine with cerebral edema associated with a novel gain of function mutation in the calcium channel CACNA1A.

Mutations in the CACNA1A gene, encoding the α1 subunit of the voltage-gated calcium channel Ca(V)2.1 (P/Q-type), have been associated with three neurological phenotypes: familial and sporadic hemiplegic migraine type 1 (FHM1, SHM1), episodic ataxia type 2 (EA2), and spinocerebellar ataxia type 6 (SCA6). We report a child with congenital ataxia, abnormal eye movements and developmental delay who presented severe attacks of hemiplegic migraine triggered by minor head traumas and associated with hemispheric swelling and seizures. Progressive cerebellar atrophy was also observed. Remission of the attacks was obtained with acetazolamide. A de novo 3 bp deletion was found in heterozygosity causing loss of a phenylalanine residue at position 1502, in one of the critical transmembrane domains of the protein contributing to the inner part of the pore. We characterized the electrophysiology of this mutant in a Xenopus oocyte in vitro system and showed that it causes gain of function of the channel. The mutant Ca(V)2.1 activates at lower voltage threshold than the wild type. These findings provide further evidence of this molecular mechanism as causative of FHM1 and expand the phenotypic spectrum of CACNA1A mutations with a child exhibiting severe SHM1 and non-episodic ataxia of congenital onset.

Protection des travailleuses enceintes et des enfants à naître: ce que doit savoir le médecin

Quarante-cinq pour cent de la population active suisse est constituée de femmes. Parmi celles-ci beaucoup auront à concilier vie professionnelle et grossesse. La grossesse n'est certes pas une maladie mais elle engendre des changements dans l'organisme de la femme qui rendent certains travaux plus pénibles, voire dangereux pour leur santé et celle de l'enfant à naître. Employeurs et médecins se doivent donc d'assurer à la travailleuse enceinte une grossesse sans danger. Pour ce faire, il existe des directives légales relatives à la loi sur le travail et portant sur la protection de la femme enceinte qui doivent être connues et appliquées. L'article résume ainsi cette problématique et propose aux médecins des sources d'informations pratiques tout en leur faisant part de l'utilité de faire appel au médecin du travail. 45% of workers in Switzerland are women who will sooner or later have to accomodate work and pregnancy. Pregnancy is not a disease but some occupational activities become more difficult and may cause health problems for the pregnant woman or the child to be born. Employers and medical doctors have to assure to the working pregnant women a pregnancy without work risks. Consequently they have to know the legal recommandations for the pregnancy protection which are noticed in the Swiss law. This article summarizes this topic in giving to medical doctors the necessary informations and advices, and explains the role of the occupational physician