Glasgow Coma Scale and Outcomes after Structural Traumatic Head Injury in Early Childhood

Objective

To assess the association of the Glasgow Coma Scale (GCS) with radiological evidence of head injury (the Abbreviated Injury Scale for the head region, AIS-HR) in young children hospitalized with traumatic head injury (THI), and the predictive value of GCS and AIS-HR scores for long-term impairment.

Methods

Our study involved a 10-year retrospective review of a database encompassing all patients admitted to Starship Children’s Hospital (Auckland, New Zealand, 2000–2010) with THI.

Results

We studied 619 children aged <5 years at the time of THI, with long-term outcome data available for 161 subjects. Both GCS and AIS-HR scores were predictive of length of intensive care unit and hospital stay (all p<0.001). GCS was correlated with AIS-HR (ρ=-0.46; p<0.001), although mild GCS scores (13–15) commonly under-estimated the severity of radiological injury: 42% of children with mild GCS scores had serious–critical THI (AIS-HR 3–5). Increasingly severe GCS or AIS-HR scores were both associated with a greater likelihood of long-term impairment (neurological disability, residual problems, and educational support). However, long-term impairment was also relatively common in children with mild GCS scores paired with structural THI more severe than a simple linear skull fracture.

Conclusion

Severe GCS scores will identify most cases of severe radiological injury in early childhood, and are good predictors of poor long-term outcome. However, young children admitted to hospital with structural THI and mild GCS scores have an appreciable risk of long-term disability, and also warrant long-term follow-up.     

Hypolipoproteinemia and hyperinflammatory cytokines in serum of severe and moderate traumatic brain injury (TBI) patients

Traumatic brain injury (TBI) acts as an inducer of the inflammatory reaction expressed by the release of pro-inflammatory cytokines (interleukin-1beta [IL-1beta], interleukin-6 [IL-6] and interleukin-8 [IL-8]), and causes metabolic alterations in the early, post-traumatic state, either in the brain or/and the systemic circulation. The metabolic changes involve carbohydrates, proteins and lipids. We focused on the serum lipid profile, the impact of trauma on lipoproteins, and their subsequent effects, on inflammation. We investigated the role of cytokines and serum lipids, in patient outcome, reviewing 30-day mortality and the Glasgow Coma Scale (GCS). A total of 75 patients with severe or moderate TBI (GCS 相似文献   

Prognostic value of frontal and parietal somatosensory evoked potentials in severe head injury: a long-term follow-up study

We have shown that the combined analysis of the frontal and parietal somatosensory evoked response (SEP) improves the global short-term outcome prediction in severe head injury (SHI) after 3–6 months. In the present study the same pateints were reexamined 18 months after trauma and the prognostic value of the combined SEP parameters reassessed, in particular their value of predicting the exact Glasgow Outcome Scale (GOS) class reached (as opposed to a crude good or bad distinction). Frontal (P20/22, N30) and parietal (N20) SEP components were studied in 50 patients within 72 h after the injury and were related to the GOS after 3–6 months and again after 18 months. When both frontal and parietal components were used as predictors, discriminant analysis correctly classified 76% of the patients after 3–6 months and 82% after 18 months. Considering parietal SEP alone, classification was less accurate (74% after 3–6 months, and 68% after 18 months) and misclassifications were more severe. Our results show that (i) a combined analysis of frontal and parietal components of the SEP improves and refines the outcome prediction in SHI, (ii) the predictive power of the combined approach increases with time after trauma, while that of the parietal response alone decreases.     

猫听觉脑干诱发电反应中P_(2a)和P_(2b)波的起源

在33例猫将普鲁卡因或海人酸微量注入耳蜗核(CN)和上橄榄复合体(SOC)内,观察ABR的相应改变,以分析P_(2a)和P_(2b)波的来源。猫P_(2a)波的出现率与电极导联有关,颅顶-颈后为90％,颅顶-乳突仅为18％。普普卡因注入CN后,同侧耳短声诱发的ABR仅保留P_1波,对侧耳的则无改变。海人酸注入CN后,P_1和P_(2a)存留,P_(2a)不减小反而增大。普鲁卡因注入双侧SOC,可使P_3、P_4和P_5消失。这些结果提示,P_(2a)波主要起源于CN区域内的第一级听觉传入神经元轴突并受第二级神经元负电位的影响,P_(2b)波主要起源于SOC以下的第二级听觉传入神经元,猫的P_(2a)和P_(2a)波与对侧脑干结构无关。     

Brain-stem,middle latency and late cortical evoked potentials in children with speech and language disorders

The topography of the brain-stem (ABR), middle latency (MLR) and cortical (ACR) evoked responses was investigated in chilfren with nornal speech and language development and those with either a language or motor speech disorder. The aim was to determine whether it is possible to discriminate between the groups of children in terms of the evoked potential characteristics.There were significant inter-group differences, particularly relating to the amplitude of the different responses. The ABR in both the language and motor speech groups exhibited smaller amplitudes for waves I, III and V than the control group, with no change in latency. Two explanations were suggested; firstly abnormal functioning of the peripheral hearing mechanism even though the hearing thresholds were normal which could be a secondary effect due to deprivation normal speech recording effects due to differences in the electrical conductivity of tissue and the distance separating the generator site and recording electrodes. The MLR in the motor speech group was significantly larger at the mastoid and temporal electrode sites than either the control or language groups. This was considered to be an enhanced myogenic response like the other exaggerated brain-stem reflexes seen in congenital suprabulbar paresis. Significantly larger amplitudes of the ACR were also recorded from the motor speech group at the Cz electrode site. This was thought to be due to underactivity of some normal cortical inhibitory system and not a direct result of increased MLR amplitude.The ACR in the language disordered children exhibited an abnormal left temporal hemispheric dominance and a more inverted or ‘dissimilar’ wave from at the T3 electrode site on the correlation analysis. These findings suggest impaired functioning of the left temporal cortex in our children who have failed to develop language normally. We feel that this has more significance for the language abnormality than the low amplitude ABRs which were observed in both the language and motor speech disordered children.     

Immunosuppression following excision of burn eschar and syngeneic grafting in major thermal trauma.

Recent reports have suggested that very early excision (less than 24 hours post-burn) and primary closure of burn wounds might circumvent the immunosuppression which follows severe thermal trauma. The total body surface are (TBSA) involved in burn injuries of human subjects at risk for significant post-burn immunosuppression is large enough to require grafting. In the present study cell-mediated immunity was measured via one-way allogeneic mixed lymphocyte reactions (MLR) in mice subjected to full-thickness scald wounds over 25-30 percent TBSA followed by escharectomy and syngeneic full-thickness skin grafting. A significant decrease in the proliferative capability of T-cells could be demonstrated on days five and seven post-treatment in unburned grafted animals (day five, 30.7 percent; day seven, 24.8 percent) over untreated normals. T-cells from animals burned but not excised also showed significant hyporesponsiveness (day five, 33.2 percent; day seven, 26.1 percent normal MLR). Animals undergoing both burning and excision showed even more profound immunosuppression (day five, 18.3 percent to 23.7 percent; day seven, 7.4 percent to 11.6 percent normal MLR). Surgical incision without excising the skin did not suppress cell-mediated immunity (day five, 90.8 percent; day seven, 90.4 percent normal MLR). When T-cells from treated animals of each group (with the exception of the incision control group) were added to normal MLR cultures, significant (greater than 50 percent) cell-mediated suppression by suppressor T-cells could be demonstrated. This study showed that the trauma of excision and grafting alone results in depression of cell-mediated immunity. These data call into question the ability of very early excision and grafting to alter the immunosuppression which follows severe thermal trauma.     

Pulmonary embolization of fat and bone marrow in cynomolgus Macaques (Macaca fascicularis)

Fat embolization (FE), the introduction of bone marrow elements into circulation, is a known complication of bone fractures. Although FE has been described in other animal models, this study represents the first reported cases of FE and bone marrow embolism in nonhuman primates. Histopathologic findings from cynomolgus macaques (Macaca fascicularis) indicated that in all 5 cases, fat and bone marrow embolization occurred subsequent to multiple bone marrow biopsies. In the most severe case, extensive embolization was associated pulmonary damage consistent with acute respiratory distress syndrome. Fat embolism syndrome (FES) is an infrequent clinical outcome of FE and is triggered by systemic biochemical and mechanical responses to fat in circulation. Although clinical criteria diagnostic of FES were not investigated at the time of death, this severe case may represent the fulminant form of FES, which occurs within 12 h after trauma. Bone marrow biopsy as an etiology of FES has been reported only once in humans. In addition, the association of embolization with bone marrow biopsies suggests that nonhuman primates may be a useful animal model of FE. FE and FES represent important research confounders and FES should be considered as a differential diagnosis for clinical complications subsequent to skeletal trauma.     

淋巴结转移率对胃癌预后价值的评价

目的:评价淋巴结转移率(MLR)对胃癌术后患者预后的预测价值。方法:回顾性分析2004年至2006年间在我院就诊,临床资料完整的363例胃癌术后患者。按照第七版UICC/TNM(pN分期)及淋巴结转移率两种方法对淋巴结进行分期,比较两种方法评价胃癌预后的准确性及适用性,确定MLR分期方法的特点及优势。结果:363例胃癌术后患者按单变量生存分析方法将淋巴结转移率(MLR)分为四期:MLR0(0.0%)、MLR1(0-30%)、MLR2(30-70%)、MLR3(≥70%),其5年生存率分别为84.9%、58.3%、28.7%、12.9%,有显著性统计学差异(P<0.001)。pN分期分为pN0、pN1、pN2、pN3a、pN3b,其5年生存率分别为84.9%、60.8%、32.0%、21.9%、6.8%,有显著性统计学差异(P<0.001)。单因素COX生存分析后显示,MLR分期越高,预后越差(HR:MLR1,MLR2,MLR3/MLR0=1.589,4.455,9.900,P<0.001)。按清除淋巴结个数将所有病例分成两组:group1(≤15个)、group2(>15个),在该两组中比较pN及MLR分期的预后,结果显示pN3a在group1组中的5年生存率明显低于group2组(6.2%vs.38.4%,P<0.001),而MLR分期与清除淋巴结个数无统计学生存相关差异(P>0.05)。COX比例风险模型多因素分析表明,pN分期、MLR分期、肿瘤浸润深度、肿瘤分化程度均为影响预后的独立因素,以pN及MLR分期风险比最高。结论:MLR分期是评价胃癌术后患者预后的独立因素,该方法不受淋巴结清扫个数的影响,与pN分期方法相比,实用、准确、简单,可以降低pN分期因淋巴结清扫不足造成的期别转移现象。     

Treatment of low strength complex wastewater using an anaerobic baffled reactor (ABR)

Treatment of a low strength complex wastewater of chemical oxygen demand (COD) around 500mg/L was studied in a 10L capacity laboratory scale anaerobic baffled reactor (ABR). It was operated at hydraulic retention times (HRTs) of 20, 15, 10, 8 and 6h. Corresponding organic loading rates (OLRs) were 0.6, 0.8, 1.2, 1.5 and 2kg COD/m(3)d. At every HRT (or OLR), pseudo steady state (PSS) was achieved. Even at maximum OLR of 2kg COD/m(3)d, COD and biochemical oxygen demand (BOD) removals exceeded 88%. Removal of particulate fraction of organics was found to be greater than soluble fraction. Compartment-wise studies of various parameters revealed that if the OLR was larger, the number of initial compartments played significant role in the removal of organics. The values of volatile fatty acids (VFA) demonstrated that hydrolysis and acidogenesis were the main biochemical activities in the initial few compartments. Based on the tracer studies, dead space in the ABR was found to range from 23% to 34%. The flow pattern in the ABR was classified as intermediate between plug flow and perfectly mixed flows. Observations from scanning electron micrographs (SEM) also suggested that distinct phase separation takes place in an ABR. Study of organic and hydraulic shock loads revealed that ABR was capable of sustaining the type of shock loads generally experienced at a sewage treatment plant (STP).     

Effect of Sahaja Yoga Meditation on Auditory Evoked Potentials (AEP) and Visual Contrast Sensitivity (VCS) in Epileptics

The effect of Sahaja yoga meditation on 32 patients with primary idiopathic epilepsy on regular and maintained antiepileptic medication was studied. The patients were randomly divided into 3 groups: group I practiced Sahaja Yoga meditation twice daily for 6 months under proper guidance; group II practiced postural exercises mimicking the meditation for the same duration; and group III was the control group. Visual Contrast Sensitivity (VCS), Auditory Evoked Potentials (AEP), Brainstem Auditory Evoked Potentials (BAEP), and Mid Latency Responses (MLR) were recorded initially (0 month) and at 3 and 6 months for each group. There was a significant improvement in VCS following meditation practice in group I participants. Na, the first prominent negative peak of MLR and Pa, the positive peak following Na did not register changes in latency. The Na-Pa amplitude of MLR also showed a significant increase. There were no significant changes in the absolute and interpeak latencies of BAEP. The reduced level of stress following meditation practice may make patients more responsive to specific stimuli. Sahaja Yoga meditation appears to bring about changes in some of the electrophysiological responses studied in epileptic patients.     

Infection status of the sea eel (Astroconger myriaster) purchased from the Noryangjin fish market with anisakid larvae]

Although the sea eel (Astroconger myriaster) is suspected as one of the most important fish host for human anisakiasis in Korea, no report has been made on the infection status of the sea eel with anisakid larvae. In the present study, 26 sea eels (Astroconger myriaster) were purchased from the Noryangjin fish market in Seoul, and anisakid larvae were collected from their viscera, muscle, head and skin. The collected larvae were classified by their morphological types. A total of 1,351 anisakid larvae were collected from 15 of 26 fish examined. Among them, 1,269 were recovered from the viscera, 66 from the muscle, and 16 from the head and skin. Morphologically, most of the anisakids were classified into 6 known larval types, Anisakis type I (564 larvae) of Berland (1961), Contracaecum type A (409) and type D (5) of Koyama et al. (1969), Contracaecum type C' (83) and type D' (117) of Chai et al. (1986), and Contracaecum type V (1) of Yamaguti (1935). Remaining 172 specimens were new in the available literature, hence, designated as Contracaecum type A' (new type). The present results revealed that the sea eels caught in the Korean waters are heavily infected with anisakid larvae, not only in their viscera but also in the muscle, and Anisakis type I was the most common among the 7 larval types.     

The early (18-hr) human mixed lymphocyte reaction: identification and isolation of activated T-cell clones

This study provides direct evidence that de novo expression of the activation antigens B1 49.9 (49.9) (interleukin-2 receptor) and 4F2 enables identification of alloactivated cells within 18 hr of initiation of human mixed lymphocyte reactions (MLR). Using a dual-parameter flow cytometer (simultaneous assessment of immunofluorescence and DNA content on the same cell), it was demonstrated that these activation antigens emerge before activated cells enter into S/G2/M phase of the cell cycle. Family studies illustrate that early activation antigen appearance occurs in response to a mismatch at chromosome 6, and invariably heralds the proliferative outcome at 6 days of MLR. In order to directly study the small alloactivated T-cell population, 49.9-positive cells were isolated using a cell sorter after 18 hr of MLR and cloned by limiting dilution using purified recombinant interleukin-2 (rIL-2). Antigen-specific T4-positive T-cell clones were isolated. Analysis of these clones demonstrates that antigen-specific reactivity is acquired within 18 hr in the MLR. These methods should permit a dissection of the early events of alloactivation.     

神经节苷脂联合高压氧对重度脑外伤急性期患者凝血功能的影响及促醒作用

目的:分析神经节苷脂联合高压氧对重度脑外伤急性期患者凝血功能的影响及促醒作用。方法:收集我院2014年2月至2015年2月收治的重度脑外伤急性期患者120例,对照组60例行常规治疗,研究组60例在常规治疗基础上联合神经节苷脂及高压氧治疗,比较两组治疗后内皮功能、凝血功能、Barthel指数及格拉斯哥加昏迷量表(GCS)评分变化,清醒时间、并发症及预后情况。结果:治疗后,研究组内皮功能明显优于对照组,D-二聚体(D-D)、凝血酶原时间(PT)、活化部分凝血酶原时间(APTT)低于对照组,Barthel生活指数及GCS评分高于对照组,清醒时间短于对照组,并发症率低于对照组,预后良好率高于对照组,差异均具有统计学意义(P0.05)。结论:神经节苷脂联合高压氧可有效改善重度脑外伤急性期患者的凝血功能,促进患者苏醒,改善患者的预后。     

The assessment of severe head injury by short-latency somatosensory and brain-stem auditory evoked potentials

The relative prognostic value of short-latency somatosensory evoked potentials (SEPs) and brain-stem auditory evoked potentials (BAEPs) was assessed in 35 patients with post-traumatic coma. Analysis of the evoked potentials was restricted to those recorded within the first 4 days following head injury. Abnormal SEPs were defined as an increase in central somatosensory conduction time or an absence of the initial cortical potential following stimulation of either median nerve. Abnormal BAEPs were classified as an increase in the wave I–V interval or the loss of any or all of its 3 most stable components (waves I, III and V) following stimulation of either ear. SEPs reliably both good and bad outcomes. All 17 patients in whom SEPs were graded as normal had a favourable outcome and 15 of 18 patients in whom SEPs were abnormal had an unfavourable outcome. Although abnormal BAEPs were associated with an unfavourable outcome in almost all patients (6 of 7), only 19 of 28 patients with normal BAEPs had a favourable outcome. The finding of normal BAEPs was therefore of little prognostic significance. These results confirm the superiority and greater sensitivity of the SEP in detecting abnormalities of brain function shortly after severe head trauma.     

Metabolomic approaches reveal that phosphatidic and phosphatidyl glycerol phospholipids are major discriminatory non-polar metabolites in responses by Brachypodium distachyon to challenge by Magnaporthe grisea

Metabolomic approaches were used to elucidate some key metabolite changes occurring during interactions of Magnaporthe grisea--the cause of rice blast disease--with an alternate host, Brachypodium distachyon. Fourier-transform infrared (FT-IR) spectroscopy provided a high-throughput metabolic fingerprint of M. grisea interacting with the B. distachyon accessions ABR1 (susceptible) and ABR5 (resistant). Principal component-discriminant function analysis (PC-DFA) allowed the differentiation between developing disease symptoms and host resistance. Alignment of projected 'test-set' on to 'training-set' data indicated that our experimental approach produced highly reproducible data. Examination of PC-DFA loading plots indicated that fatty acids were one chemical group that discriminated between responses by ABR1 and ABR5 to M. grisea. To identify these, non-polar extracts of M. grisea-challenged B. distachyon were directly infused into an electrospray ionization mass spectrometer (ESI-MS). PC-DFA indicated that M. grisea-challenged ABR1 and ABR5 were differentially clustered away from healthy material. Subtraction spectra and PC-DFA loadings plots revealed discriminatory analytes (m/z) between each interaction and seven metabolites were subsequently identified as phospholipids (PLs) by ESI-MS-MS. Phosphatidyl glycerol (PG) PLs were suppressed during both resistant and susceptible responses. By contrast, different phosphatidic acid PLs either increased or were reduced during resistance or during disease development. This suggests considerable and differential PL processing of membrane lipids during each interaction which may be associated with the elaboration/suppression of defence mechanisms or developing disease symptoms.     

Inconsistency of auditory middle latency and steady-state responses in infants

Auditory middle latency and steady-state responses (MLR/SSRs) were recorded in normal infants (aged 3 weeks to 28 months) and adults. SSR amplitudes were maximum using stimulus presentation rates near 40 Hz in adults. By contrast, the infant data showed no consistent amplitude maximum across the rates tested (9–59 Hz). With the exception of the brain-stem response wave V to MLR Na deflection, MLR components in infant's responses to 10.85 Hz clicks did not show any consistent pattern. To investigate the hypothesis that the 40 Hz SSR is derived from overlapping of the 10 Hz MLR components, 43.4 Hz SSRs were synthesized from the responses recorded at 10.85 Hz and compared with those recorded at 43.4 Hz. The predictive accuracy of the synthesized 43.4 Hz SSRs was significantly better in adults than in infants. The results of these studies indicate the presence of large age-related differences in the auditory MLR and SSR, and in the relationship between the two responses.     

Methods for determining auditory evoked brain-stem response thresholds in human newborns

Previous investigators have reported that newborn auditory evoked brain-stem responses (ABRs) are 20–30 dB higher than adult psychophysical thresholds to the same stimuli. These investigators reduced the intensity of the stimulus until they no longer reported an ABR to the stimulus. We adapted 2 widely used psychophysical methods, the up-down-transformed response (UDTR) method and the method of constant stimuli, for ABR threshold determination of human newborns. Response judgments were made blindly. ABR thresholds of healthy normal newborns by both procedures were no more than 10–15 dB higher than adult psychophysical thresholds. The differences between the newborn ABR thresholds we reported and those in the literature were probably explained by different procedures including the method used to estimate adult psychophysical thresholds. The correlations between ABR thresholds and suprathreshold ABR latencies and amplitudes and latency and amplitude/intensity functions were modest at best. In normal newborns suprathreshold ABR measurements are of little value in predicting ABR thresholds.     

Quantitative imaging of immunocytochemical (PAP) estrogen receptor staining patterns in breast cancer sections

"Receptogram Analysis" has been developed as a pattern-oriented approach for predicting endocrine response in breast cancer based upon quantification of the estrogen receptor immunocytochemical assay (ERICA), using a Quantimet Imaging System. Response prediction was evaluated in 58 stage III and IV patients receiving endocrine therapy (primarily Tamoxifen). The Receptogram is a composite of the univariate distributions of nuclear receptor content, IOD(S), and concentration (MOD), and their bivariate contour plot; where (S) is the calculated nuclear radius in section. MOD distributions were classified into four types based upon peak modality and kurtosis (I-IV), and contour plots were classified into four subtypes (A-D) based upon contour slope. Patients failing therapy were ERICA--or their receptogram revealed co-existent ER+ and ER- tumor cells (type II), highly skewed MOD distributions lacking defined peaks (type IV), or contours with nearly horizontal slope (type C). Response was realized in 9/16 type I patients, with a single positive MOD peak, and in 9/15 type III patients, with discrete, multimodal MOD peaks. In contrast, 0/8 type II, 0/12 type IV, and 0/10 type C patients were responders. Receptogram analysis was superior to cytosol assay (DCC) as a response discriminant: positive predictive value, 53% vs. 33%; negative predictive value, 100% vs. 75%; sensitivity, 100% vs. 83%; specificity, 68% vs. 23%; and accuracy, 78% vs. 41%, respectively. Alternately, patients were assigned to potentially responsive or non-responsive groups based upon thresholded mean receptor parameters: field MOD, mean nuclear MOD (NMOD), and mean NMOD(PF) where PF is the ER+ nuclear fraction. While these parameters correlated with DCC (r = .72, 0.69, and 0.69), they were only marginally better in predictive value.     

Prediction of lower limb motor outcomes based on transcranial magnetic stimulation findings in patients with an infarct of the anterior cerebral artery

Abstract

The aim was to investigate the relationship between transcranial magnetic stimulation (TMS) at the early stage of stroke and 6-month motor outcome for patients with anterior cerebral artery territory infarct. Patients were classified into TMS(+) and TMS(?) groups. At the 6-month evaluation, lower limb motor function for the TMS(+) group was significantly better than those for the TMS(?) group. Thus, early TMS evaluation is useful for predicting recovery of lower limb motor function in patients experiencing this type of stroke.