Posttraumatic hypothermia is neuroprotective in a model of traumatic brain injury complicated by a secondary hypoxic insult

OBJECTIVE

Human traumatic brain injury frequently results in secondary complications, including hypoxia. In previous studies, we have reported that posttraumatic hypothermia is neuroprotective and that secondary hypoxia exacerbates histopathologic outcome after fluid-percussion brain injury. The purpose of this study was to assess the therapeutic effects of mild (33 degrees C) hypothermia after fluid-percussion injury combined with secondary hypoxia. In addition, the importance of the rewarming period on histopathologic outcome was investigated.

DESIGN

Prospective experimental study in rats.

SETTING

Experimental laboratory in a university teaching hospital.

INTERVENTION

Intubated, anesthetized rats underwent normothermic parasagittal fluid-percussion brain injury (1.8-2.1 atmospheres) followed by either 30 mins of normoxia (n = 6) or hypoxic (n = 6) gas levels and by 4 hrs of normothermia (37 degrees C). In hypothermic rats, brain temperature was reduced immediately after the 30-min hypoxic insult and maintained for 4 hrs. After hypothermia, brain temperature was either rapidly (n = 6) or slowly (n = 5) increased to normothermic levels. Rats were killed 3 days after traumatic brain injury, and contusion volumes were quantitatively assessed.

MEASUREMENTS AND MAIN RESULTS

As previously shown, posttraumatic hypoxia significantly increased contusion volume compared with traumatic brain injury-normoxic animals (p <.02). Importantly, although posttraumatic hypothermia followed by rapid rewarming (15 mins) failed to decrease contusion volume, those animals undergoing a slow rewarming period (120 mins) demonstrated significantly (p <.03) reduced contusion volumes, compared with hypoxic normothermic rats.

CONCLUSIONS

These data emphasize the beneficial effects of posttraumatic hypothermia in a traumatic brain injury model complicated by secondary hypoxia and stress the importance of the rewarming period in this therapeutic intervention.

Results of surgery and radio-hyperthermo-chemotherapy for patients with soft-tissue sarcoma

BACKGROUND

Between 1990 and 1999, we performed radio-hyperthermo-chemotherapy (RHC) in 44 patients with high-grade soft-tissue sarcomas of the limbs.

METHODS

Radiotherapy involved the delivery of radiation at a dose of 2 Gy once daily on 16 days, to give a total dose of 32 Gy. Hyperthermia was conducted once a week, with a total of five sessions. Chemotherapy was performed by implanting a reservoir and administering cisplatin (3 mg/kg) three times, and pinorubin (an adriamycin derivative; 1 mg/kg) twice by intra-arterial infusion, at weekly intervals. These drugs were administered alternately during hyperthermia sessions.

RESULTS

Tumor shrinkage was observed in 98% (43/44) of the patients. Of the 36 patients with M0 tumors, 30 were disease-free at final follow-up, 2 had no evidence of disease, 1 was alive with disease, and 3 had died of the disease. Amputation was required only in the first patient, and the affected limb was preserved in the other 43 patients. The surgical margin was wide in 9 patients and marginal in 29 patients, and intralesional excision was performed in 5 patients. There was recurrence in only 1 of the 44 patients.

CONCLUSION

RHC is currently the most potent and relatively safe treatment method for high-grade soft-tissue sarcomas that is available clinically.

Optically active antifungal azoles. XII. Synthesis and antifungal activity of the water-soluble prodrugs of 1-[(1R,2R)-2-(2,4-difluorophenyl)-2-hydroxy-1-methyl-3-(1H-1,2,4-triazol-1-yl)propyl]-3-[4-(1H-1-tetrazolyl)phenyl]-2-imidazolidinone

1-[(1R,2R)-2-(2,4-Difluorophenyl)-2-hydroxy-1-methyl-3-(1H-1,2,4-triazol-1-yl)propyl]-3-[4-(1H-1-tetrazolyl)phenyl]-2-imidazolidinone (1: TAK-456) was selected as a candidate for clinical trials, but since its water-solubility was insufficient for an injectable formulation, the quaternary triazolium salts 2 were designed as water-soluble prodrugs. Among the prodrugs prepared, 4-acetoxymethyl-1-[(2R,3R)-2-(2,4-difluorophenyl)-2-hydroxy-3-[2-oxo-3-[4-(1H-1-terazolyl)phenyl]-1-imidazolidinyl]butyl]-1H-1,2,4-triazolium chloride (2a: TAK-457) was selected as an injectable candidate for clinical trials based on the results of evaluations on solubility, stability, hemolytic effect and in vivo antifungal activities.

A new treatment of aneurysmal bone cyst by endoscopic curettage without bone grafting

Curettage and bone grafting are the accepted methods of treatment of aneurysmal bone cysts. Unfortunately, recurrence is common. We treated 4 patients with atypical aneurysmal bone cysts that lacked aneurysmal dilatation by endoscopic curettage without bone grafting. New bone formation and remodeling were observed in all patients. In the patients in whom the follow-up was longer than 30 months, there was no evidence of recurrence. Endoscopic curettage without bone grafting is a simple and effective treatment for aneurysmal bone cysts.

Optically active antifungal azoles. XIII. Synthesis of stereoisomers and metabolites of 1-[(1R,2R)-2-(2,4-difluorophenyl)-2-hydroxy-1-methyl-3-(1H-1,2,4-triazol-1-yl)propyl]-3-[4-(1H-1-tetrazolyl)phenyl]-2-imidazolidinone (TAK-456)

1-[(1R,2R)-2-(2,4-Difluorophenyl)-2-hydroxy-1-methyl-3-(1H-1,2,4-triazol-1-yl)propyl]-3-[4-(1H-1-tetrazolyl)phenyl]-2-imidazolidinone [(1R,2R)-1: TAK-456] is a new antifungal agent selected as a candidate for clinical trials. The three stereoisomers [(1S,2R)-, (1S,2S)- and (1R,2S)-1] of this compound were prepared as authentic samples to determine the enantiomeric and diastereomeric purity of TAK-456 as well as to compare their in vitro antifungal activity. Pharmacokinetic studies of TAK-456 using rats identified the existence of metabolites in the liver homogenate. The structures of the major metabolites were assigned as 4-hydroxy-2-imidazolidinone (3) and/or 5-hydroxy-2-imidazolidinone (4), based on HPLC and LC/MS/MS analyses. These hydroxylated compounds, 3 and 4, were prepared by reduction of the corresponding imidazolidinediones, 11 and 12, and confirmed to be identical to the metabolites by HPLC. In vitro antifungal activities of the three stereoisomers and the synthesized metabolites were considerably weaker than TAK-456.

The tomato mosaic tobamovirus movement protein interacts with a putative transcriptional coactivator KELP

Viral movement through plasmodesmata in host plants likely depends on the interaction between virus-encoded movement protein (MP) and host proteins. In order to search for MP-interacting protein (MIP), we carried out far-western screening of a Brassica campestris cDNA library using a recombinant MP of tomato mosaic tobamovirus (ToMV) as a probe. One of the positive clones, designated MIP102, was found to be a putative orthologue for a transcriptional coactivator KELP of Arabidopsis thaliana. In vitro analysis with recombinant proteins revealed that ToMV MP could bind to KELP proteins that are derived from different plant species. At least 31 amino acids from the carboxyl-terminus of ToMV MP were dispensable for the interaction with KELP. Other MPs, derived from crucifer tobamovirus CTMV-W and cucumber mosaic cucumovirus, also exhibited comparable binding abilities. This suggests that these MPs could commonly interact with KELP, possibly to modulate the host gene expression.

Real time monitoring of glutamate following fluid percussion brain injury with hypoxia in the rat

In this study, extracellular glutamate (Glu) was monitored in real time using a biosensor following traumatic brain injury (TBI) either with or without inducing hypoxia in the rat Fluid-percussion model. We also measured the cortical contusion volume at 3 days after the insult. The animals were divided into 3 groups. Group 1 was subjected to TBI only, Group 2 to TBI followed by 20 min of moderate hypoxia (FiO2: 10%) and Group 3 to 20 min of moderate hypoxia without TBI. The surge increase in the extracellular Glu concentration occurred immediately after TBI in Groups 1 and 2. Group 2 showed a prolonged efflux of Glu during hypoxia. Group 3 Glu showed low continuous steady levels. The contusion volume in Group 2 was significantly larger than in Group 1. To test the possible involvement of apoptosis in Groups 1 and 2, rats were sacrificed at 1, 6, 24 and 72 h after TBI. Immunohistochemical studies showed an increased number of both CPP32 positive cells at 24 h and TUNEL cells at 72 h in Group 2. These results suggest that TBI with moderate hypoxia induced a prolonged efflux of Glu that resulted more cortical damage due to necrosis and apoptosis.

The synergistic effect of high K+ and hypoxia on extracellular concentrations of neuroactive amino acid in hippocampus

In the present study, we examined extracellular concentrations of glutamate (Glu) in hypoxia using ringer solution with a high potassium (K+) level using microdialysis. Based on our findings, we hypothesized that the concentration of extracellular K+ caused a greater efflux of Glu. We used male SD rats and separated them into 3 groups based on the K+ concentration of Ringer solution (RS), consisting of normal (4 mM), 40 mM and 150 mM groups. We stereotactically inserted the microdialysis probe into the hippocampus, and perfused the RS for 60 min before imposing hypoxia. Subsequently, while perfusing RS, hypoxia (7% O2 + 93% N2 gas) was induced in all 3 groups for 20 min. In the normal and 40 mM of K+ concentration groups, the Glu level did not increase, but in the 150 mM of K+ concentration group, the Glu level increased while being perfused with RS and a larger increase in Glu was observed after inducing hypoxia. This result suggests that the extracellular concentration of K+ plays a role in the mechanism of increased neuronal vulnerability caused by hypoxia after TBI.

[Prognostic factors of renal pelvic and ureteral cancer: a multivariate analysis]

We clinicopathologically reviewed 54 cases (40 males and 14 females) of renal pelvic and ureteral cancer examined between 1983 and 1998, in order to determine the impact of prognostic factors. Follow-up ranged from 2 to 173 months (mean, 45.6 months). The age of the patients ranged from 39 to 88 years (mean, 68.9 years). The 1, 3 and 5-year cause-specific survival rates (Kaplan-Meier's method) for all of the patients were 74.6%, 58.4% and 54.5%, respectively. According to univariate analysis, a high grade and high stage of tumor, the presence of lymphatic invasion and positive regional lymph nodes indicated a significantly poor prognosis. On the other hand, multivariate analysis using Cox proportional hazards regression revealed the presence of lymphatic invasion as the most significant predictor of survival. Therefore, patients with lymphatic invasion have a poor prognosis, and the development of effective adjuvant therapy is needed to improve the outcome in these patients.

Delayed hemorrhagic hypotension exacerbates the hemodynamic and histopathologic consequences of traumatic brain injury in rats

Alterations in cerebral autoregulation and cerebrovascular reactivity after traumatic brain injury (TBI) may increase the susceptibility of the brain to secondary insults, including arterial hypotension. The purpose of this study was to evaluate the consequences of mild hemorrhagic hypotension on hemodynamic and histopathologic outcome after TBI. Intubated, anesthetized male rats were subjected to moderate (1.94 to 2.18 atm) parasagittal fluid-percussion (FP) brain injury. After TBI, animals were exposed to either normotension (group 1: TBI alone, n = 6) or hypotension (group 2: TBI + hypotension, n = 6). Moderate hypotension (60 mm Hg/30 min) was induced 5 minutes after TBI or sham procedures by hemorrhage. Sham-operated controls (group 3, n = 7) underwent an induced hypotensive period, whereas normotensive controls (group 4, n = 4) did not. For measuring regional cerebral blood flow (rCBF), radiolabeled microspheres were injected before, 20 minutes after, and 60 minutes after TBI (n = 23). For quantitative histopathologic evaluation, separate groups of animals were perfusion-fixed 3 days after TBI (n = 22). At 20 minutes after TBI, rCBF was bilaterally reduced by 57% +/- 6% and 48% +/- 11% in cortical and subcortical brain regions, respectively, under normotensive conditions. Compared with normotensive TBI rats, hemodynamic depression was significantly greater with induced hypotension in the histopathologically vulnerable (P1) posterior parietal cortex (P < 0.01). Secondary hypotension also increased contusion area at specific bregma levels compared with normotensive TBI rats (P < 0.05), as well as overall contusion volume (0.96 +/- 0.46 mm(3) vs. 2.02 +/- 0.51 mm(3), mean +/- SD, P < 0.05). These findings demonstrate that mild hemorrhagic hypotension after FP injury worsens local histopathologic outcome, possibly through vascular mechanisms.

Two-staged operation for thoracolumbar osteomyelitis following methicillin-resistant staphylococcus aureus infection of a craniectomy wound--case report

A previously healthy 53-year-old woman developed pyogenic vertebral osteomyelitis (PVO) manifesting as progressive lumbago following wound infection of a decompressive craniectomy performed for brain contusion caused by a traffic accident. Magnetic resonance imaging disclosed vertebral osteomyelitis at T-12 and L-1 with paravertebral abscess. Anterior debridement and fusion using autografts were performed at the first operation. Methicillin-resistant Staphylococcus aureus (MRSA) was cultured from the abscess specimen. Antibiotic therapy resolved the infection. Pedicle screw fixation was performed at the second operation. The patient became free from back pain and no recurrence of infection was seen. The diagnosis of PVO is frequently observed or delayed because of the nonspecific symptomatic presentation in the early stage. Coexistent infection or trauma makes early diagnosis more difficult. Indications and timing of instrumentation for the spinal column infected with MRSA is difficult. Two-staged operation with anterior debridement and posterior instrumentation after eradication of the infection is a safe and effective procedure for MRSA vertebral osteomyelitis.

Coronary artery bypass in dialysis patients

This study evaluated the operative outcome of dialysis patients undergoing coronary artery bypass (CAB). In the past 6 years, 38 dialysis patients with a mean age of 57.5 years underwent CAB. Thirty-one operations were elective, and 7 were nonelective operations. Thirty-two operations were performed under cardiac arrest, 3 operations were performed under fibrillatory arrest, and 3 operations were performed without cardiopulmonary bypass. The average number of bypass grafts was 2.8. In all patients, the internal thoracic artery was used. Hospital mortality was 5.3%. Actuarial survival rates at 1, 3, and 5 years including all causes of death were 88%, 80%, and 72%, respectively. With improvements in perioperative management, coronary artery bypass can be performed with acceptable mortality and morbidity in dialysis patients. Complete revascularization without cardiopulmonary bypass is the ideal method and will increase in usage. However, the conventional CAB also provides acceptable results.

The molecular characterization and in situ expression pattern of pea SCARECROW gene

Certain mutants of shoot gravitropism were reported to be ascribed to the SCR and SHR loci in Arabidopsis thaliana. The SCR gene was known to regulate the development of endodermis cells that are responsible for sensing gravity in a shoot. With the aim of elucidating the molecular mechanism for gravitropic responses in pea seedlings, we have isolated a putative pea SCR ortholog from a shoot cDNA library. Analyses of the cDNA clones revealed the structure of a full-length ORF coding for 819 amino acid residues. A remarkable feature of pea SCR protein was the presence of asparagine stretches at the N-terminal transcriptional activation domain, which was distinct from the occurrence of glutamine or alanine stretches in the Arabidopsis or maize SCR. A Northern blot analysis revealed a single 3.2-kb pea SCR transcript in addition to a closely related 2.5-kb transcript. Our in situ hybridization data indicated that pea SCR mRNA accumulated in the shoot apical meristem, leaf primordia and a root single cell layer corresponding to the endodermis. The expression patterns were similar to those reported for A. thaliana and Zea mays, suggesting that SCR may be functionally conserved among plants and involved in the differentiation of the endodermis.

[Usefulness of OPCAB from the viewpoint of fluctuations in the level of blood natriuretic peptides]

Fluctuations in the level of blood natriuretic peptides (ANP and BNP) were compared between 41 patients who underwent conventional coronary artery bypass (CCAB) and 19 patients who underwent off-pump coronary artery bypass (OPCAB). A blood sample was collected before surgery, and 6, 12 and 24 hours; 2, 3, 5 and 7 days; and 1 month after the end of extracorporeal circulation. There were no significant differences in left ventricular ejection fraction (LVEF) before and after surgery in either group or between the two groups. On average, 3.3 +/- 1.0 bypass grafts were used for the CCAB group, and 2.2 +/- 0.8 grafts for the OPCAB group. Furthermore, the maximum postoperative creatine phosphokinase-MB (CK-MB) level for the CCAB group was 49.1 +/- 17.5 IU/l, whereas that for the OPCAB group was significantly lower at 23.2 +/- 24.8 IU/l. The preoperative level of blood ANP for the CCAB group was 24.6 +/- 19.9 pg/ml while that for the OPCAB group was 39.3 +/- 29.5 pg/ml, but there was no significant difference between the two groups. In both groups, the level of blood ANP reached a peak three days after the end of extracorporeal circulation and then decreased after that point. Although the level of blood ANP for the OPCAB group decreased to 51.4 +/- 26.4 pg/ml one month after the end of extracorporeal circulation, that for the CCAB group one month after the end of extracorporeal circulation remained significantly high at 61.3 +/- 30.6 pg/ml, when compared to that before surgery. Furthermore, the preoperative level of blood BNP for the CCAB group was 40.0 +/- 35.2 pg/ml and that for the OPCAB group was 75.5 +/- 59.7 pg/ml, but there was no significant difference between the two groups. Then, in both groups, the level of blood BNP reached a peak 2-5 days after the end of extracorporeal circulation and then decreased after that. Whereas the level of blood BNP for the OPCAB group decreased to 96.4 +/- 56.0 pg/ml one month after the end of extracorporeal circulation, that for the CCAB group one month after the end of extracorporeal circulation remained significantly high at 160.3 +/- 106.2 pg/ml when compared to that before surgery. The levels of ANP and BNP increased postoperatively for both OPCAB and CCAB groups since the following events caused a great degree of stress on the heart: general anesthesia, cardiac herniation, stabilizer compression, regional blood flow blockage and reperfusion injury. Although the level of natriuretic peptides for the CCAB group remained high one month after the end of surgical stress, that for the OPCAB group returned to near the preoperative level one month later, thus supporting the notion that OPCAB is less invasive.

Optically active antifungal azoles. XI. An alternative synthetic route for 1

New routes for the synthesis of the optically active antifungal triazoles 1-[(1R,2R)-2-(2,4-difluorophenyl)-2-hydroxy-1-methyl-3-(1H-1,2,4-triazol-1-yl)propyl]-3-[4-(1H-1-tetrazolyl)phenyl]-2-imidazolidinone (1b) and the 3-14-(1H-1,2,3-triazol-1-yl)phenyl]-2-imidazolidinone analog (1a) that possess an imidazolidine nucleus were established. The key synthetic intermediates, (2R,3R)-3-(2,2-diethoxvethyl)amino-2-(2,4-difluorophenyl)-1-(1H1,2,4-triazol-1-yl)-2-butanol (8) and (2R,3R)-2-(2,4-difiuorophenyl)-3-(2-h ydroxyethyl)amino-1-(1H-1,2,4-triazol-1-yl)-2-butanol (14), were prepared by the ring-opening reaction of the oxirane (2) with the corresponding 2-substituted ethylamines. The acetal (8) was converted to the imidazolidinones (1a, b) by condensation with the carbamates (10a, b) followed by treatment with hydrochloric acid and subsequent catalytic hydrogenation. The candidate selected for the clinical trials, 1b (TAK-456), was alternatively prepared from the hydroxyethylamino intermediate (14) via two reaction steps: condensation with the carbamate (10b) to the urea (15) and subsequent cyclization to the imidazolidinones. This newly developed synthetic route could be applied to a large scale preparation of 1b.

Optically active antifungal azoles. X. Synthesis and antifungal activity of N

New optically active antifungal azoles, N-14-(azolyl)phenyl]- and N-14-(azolylmethyl)phenyl]-N'-[(IR,2R)-2(2,4-difluorophenyl)-2-hydroxy-1-methyl-3-(IH-1,2,4-triazol-1-yl)propyllazolones (1, 2, 3), were prepared in a stereocontrolled manner. Compounds 1-3 showed strong antifungal activity against Candida albicans in vitro. Among them, the imidazolidinones 3 showed a broad antifungal spectrum in vitro as well as potent in vivo activity against candidiasis and aspergillosis in mice. The imidazolidinones (3i, j, k) having 1H-1,2,3-triazol-1-yl, 2H-2-tetrazolyl and IH-1-tetrazolyl moieties were found to exert strong protective effect against aspergillosis.