Use of magnesium in traumatic brain injury

Magnesium and Cognitive Health in Adults: A Systematic Review and Meta-Analysis

Magnesium (Mg) plays a key role in neurological functioning and manifestations. However, the evidence from randomized controlled trials (RCTs) and cohorts on Mg and cognitive health among adults has not been systematically reviewed. We aimed to examine the associations of various Mg forms (supplements, dietary intake, and biomarkers) with cognitive outcomes by summarizing evidence from RCTs and cohorts. PubMed, Embase, PsycINFO, and the Cochrane Central Register of Controlled Trials were searched for relevant peer-reviewed articles published up to May 3, 2024. Three random-effects models were performed, when appropriate, to evaluate the relationship between Mg and cognitive outcomes: 1) linear meta-regression, 2) non-linear (quadratic) meta-regression, and 3) meta-analysis using Mg variables categorized based on pre-existing recommendations. Three RCTs and 12 cohort studies were included in this systematic review. Evidence from the limited numbers of RCTs was insufficient to draw conclusions on the effects of Mg supplements. Cohort studies showed inconsistent dose-response relationships between dietary Mg and cognitive disorders, with high heterogeneity across populations. However, consistent U-shape associations of serum Mg with all-cause dementia and cognitive impairment were found in cohorts, suggesting an optimal serum Mg concentration around 0.85 mmol/L. This non-linear association was detected in meta-regression (Pquadratic = 0.003) and in meta-analysis based on the reference interval of serum Mg (0.75-0.95 mmol/L) [<0.75 compared with 0.85 mmol/L: pooled hazard ratio (HR) = 1.43; 95% confidence interval (CI) = 1.05, 1.93; >0.95 compared with 0.85 mmol/L: pooled HR = 1.30; 95% CI = 1.03, 1.64]. More evidence from RCTs and cohorts is warranted. Future cohort studies should evaluate various Mg biomarkers and collect repeated measurements of Mg intake over time, considering different sources (diet or supplements) and factors affecting absorption (e.g., calcium-to-Mg intake ratio). This systematic review was pre-registered in PROSPERO (CRD42023423663).

Assessment of transcranial Doppler indices after MgSO4 administration in severe preeclamptic women with neurologic symptoms

PURPOSE

To investigate the effect of intravenous MgSO4 on maternal cerebral hemodynamics as well as the association between altered Doppler indices of the ophthalmic arteries and ocular lesions in patients with preeclampsia.

METHODS

After each of the 15 included patients was diagnosed with preeclampsia, MgSO4 was infused followed by transcranial Doppler tests of the indices of the ophthalmic, anterior, middle, posterior cerebral, vertebral, and basilar arteries, followed by a second MgSO4 infusion. The peak, mean, diastolic velocity, and pulsatile and resistance indices of each artery were automatically measured during testing. Based on the emergent data, the cerebral perfusion pressure, resistance-area product, and cerebral flow index were calculated.

RESULTS

The cerebral perfusion pressure of the posterior cerebral arteries significantly decreased following the infusion of MgSO4 (p < 0.05). Before the infusion of MgSO4, cerebral perfusion pressure and cerebral flow index of the ophthalmic arteries were significantly increased (p < 0.05) in the preeclamptic pregnant patients with ocular lesions compared those without ocular lesions. After the infusion of MgSO4, the cerebral perfusion pressure and cerebral flow index of both ophthalmic arteries were slightly decreased, but the difference was not significant.

CONCLUSIONS

Altered Doppler indices following the infusion of MgSO4 suggest significant changes in the hemodynamics of the posterior cerebral and ophthalmic arteries that are particularly related to the neurological signs and symptoms of women with preeclampsia. These findings may improve the understanding of the mechanism of the cerebral complications of preeclampsia. Advancing comprehension of these underlying mechanisms is postulated to play a pivotal role in the mitigation of hypertensive encephalopathy associated with preeclampsia.

Identification of the modulatory Ca2+-binding sites of acid-sensing ion channel 1a

Acid-sensing ion channels (ASICs) are neuronal Na+-permeable ion channels activated by extracellular acidification. ASICs are involved in learning, fear sensing, pain sensation and neurodegeneration. Increasing the extracellular Ca2+ concentration decreases the H+ sensitivity of ASIC1a, suggesting a competition for binding sites between H+ and Ca2+ ions. Here, we predicted candidate residues for Ca2+ binding on ASIC1a, based on available structural information and our molecular dynamics simulations. With functional measurements, we identified several residues in cavities previously associated with pH-dependent gating, whose mutation reduced the modulation by extracellular Ca2+ of the ASIC1a pH dependence of activation and desensitization. This occurred likely owing to a disruption of Ca2+ binding. Our results link one of the two predicted Ca2+-binding sites in each ASIC1a acidic pocket to the modulation of channel activation. Mg2+ regulates ASICs in a similar way as does Ca2+. We show that Mg2+ shares some of the binding sites with Ca2+. Finally, we provide evidence that some of the ASIC1a Ca2+-binding sites are functionally conserved in the splice variant ASIC1b. Our identification of divalent cation-binding sites in ASIC1a shows how Ca2+ affects ASIC1a gating, elucidating a regulatory mechanism present in many ion channels.

A Review of Electrolyte, Mineral, and Vitamin Changes After Traumatic Brain Injury

INTRODUCTION

Despite the prevalence of traumatic brain injury (TBI) in both civilian and military populations, the management guidelines developed by the Joint Trauma System involve minimal recommendations for electrolyte physiology optimization during the acute phase of TBI recovery. This narrative review aims to assess the current state of the science for electrolyte and mineral derangements found after TBI.

MATERIALS AND METHODS

We used Google Scholar and PubMed to identify literature on electrolyte derangements caused by TBI and supplements that may mitigate secondary injuries after TBI between 1991 and 2022.

RESULTS

We screened 94 sources, of which 26 met all inclusion criteria. Most were retrospective studies (n = 9), followed by clinical trials (n = 7), observational studies (n = 7), and case reports (n = 2). Of those, 29% covered the use of some type of supplement to support recovery after TBI, 28% covered electrolyte or mineral derangements after TBI, 16% covered the mechanisms of secondary injury after TBI and how they are related to mineral and electrolyte derangements, 14% covered current management of TBI, and 13% covered the potential toxic effects of the supplements during TBI recovery.

CONCLUSIONS

Knowledge of mechanisms and subsequent derangements of electrolyte, mineral, and vitamin physiology after TBI remains incomplete. Sodium and potassium tended to be the most well-studied derangements after TBI. Overall, data involving human subjects were limited and mostly involved observational studies. The data on vitamin and mineral effects were limited, and targeted research is needed before further recommendations can be made. Data on electrolyte derangements were stronger, but interventional studies are needed to assess causation.

Electrolyte Imbalance and Neurologic Injury

Neurologic injury continues to be a debilitating worldwide disease with high morbidity and mortality. The systemic sequelae of a neural insult often lead to prolonged hospital stays and challenging nutritional demands that contribute to poorer prognoses. Clinical management of a given condition should prioritize preserving the homeostatic parameters disrupted by inflammatory response cascades following the primary insult. This focused review examines the reciprocal relationship between electrolyte disturbance and neurologic injury. A prolonged electrolyte imbalance can significantly impact morbidity and mortality in neurologic injuries. A detailed overview of the major electrolytes and their physiologic, iatrogenic, and therapeutic implications are included. The pathophysiology of how dysnatremias, dyskalemias, dyscalcemias, and dysmagnesemias occur and the symptoms they can induce are described. The manifestations in relation to traumatic brain injury, status epilepticus, and acute ischemic stroke are addressed. Each type of injury and the strength of its association with a disruption in either sodium, potassium, calcium, or magnesium is examined. The value of supplementation and replacement is highlighted with an emphasis on the importance of early recognition in this patient population. This review also looks at the current challenges associated with correcting imbalances in the setting of different injuries, including the relevant indications and precautions for some of the available therapeutic interventions. Based on the findings of this review, there may be a need for more distinct clinical guidelines on managing different electrolyte imbalances depending on the specified neurologic injury. Additional research and statistical data on individual associations between insult and imbalance are needed to support this potential future call for context-based protocols.

Role of Magnesium in the Intensive Care Unit and Immunomodulation: A Literature Review

Both the role and the importance of magnesium in clinical practice have grown considerably in recent years. Emerging evidence suggests an association between loss of magnesium homeostasis and increased mortality in the critical care setting. The underlying mechanism is still unclear, but an increasing number of in vivo and in vitro studies on magnesium's immunomodulating capabilities may shed some light on the matter. This review aims to discuss the evidence behind magnesium homeostasis in critically ill patients, and its link with intensive care unit mortality via a likely magnesium-induced dysregulation of the immune response. The underlying pathogenetic mechanisms, and their implications for clinical outcomes, are discussed. The available evidence strongly supports the crucial role of magnesium in immune system regulation and inflammatory response. The loss of magnesium homeostasis has been associated with an elevated risk of bacterial infections, exacerbated sepsis progression, and detrimental effects on the cardiac, respiratory, neurological, and renal systems, ultimately leading to increased mortality. However, magnesium supplementation has been shown to be beneficial in these conditions, highlighting the importance of maintaining adequate magnesium levels in the intensive care setting.

Initial Serum Levels of Magnesium and Calcium as Predictors of Mortality in Traumatic Brain Injury Patients: A Retrospective Study

Background: We sought to evaluate the predictor role of the initial serum level of calcium and magnesium in hospitalized traumatic brain injury (TBI) patients. Materials and methods: A retrospective analysis of all TBI patients admitted to the Hamad Trauma Center (HTC), between June 2016 and May 2021 was conducted. Initial serum electrolyte levels of TBI patients were obtained. A comparative analysis of clinical variables between patients with abnormal and normal serum electrolyte level was performed. Logistic regression analysis with the variables that showed a significant difference (p < 0.05) in the bivariate analysis was performed to calculate the odds ratios (OR) for mortality. Results: There was a total of 922 patients with clinical records of serum electrolyte levels at admission. Of these, 757 (82.1%) had hypocalcemia, 158 (17.1%) had normal calcium level, and 7 (0.8%) had hypercalcemia. On the other hand, 616 (66.8%) patients had normal magnesium level, 285 (30.9%) had hypomagnesemia, and 12 (1.3%) had hypermagnesemia. The mortality rate in hypocalcemia group was 24% while in patients with normal calcium level it was 12%, p = 0.001. Proportionate mortality rates in hypomagnesemia and normal magnesium groups were 15% and 23% (p = 0.006), respectively. On the other hand, 7 out of 12 (58%) hypermagnesemia patients died during the index hospitalization. The regression model including GCS, ISS, PT, aPTT, INR, Hemoglobin, Bicarbonate, Lactate, Sodium, Potassium, Calcium, Magnesium, and Phosphate showed that hypocalcemia was not a significant predictor [OR 0.59 (CI 95%: 0.20–1.35)] of mortality after TBI. However, hypermagnesemia was a significant predictor [OR 16 (CI 95%: 2.1–111)] in addition to the GCS, ISS, aPTT, Bicarbonate, and Lactate values on admission. Conclusion: Although hypocalcemia and hypomagnesemia are common in hospitalized TBI patients, hypocalcemia was not a significant predictor of mortality, while hypermagnesemia was an independent predictor. Further studies with larger sample size and with prospective design are required to support these findings and their importance.

Formulation and evaluation of magnesium sulphate nanoparticles for improved CNS penetrability

Magnesium (Mg²⁺) is the fourth most abundant cation in the human body and is involved in maintaining varieties of cellular and neurological functions. Magnesium deficiency has been associated with numerous diseases, particularly neurological disorders, and its supplementation has proven beneficial. However, magnesium therapy in neurological diseases is limited because of the inability of magnesium to cross the blood-brain barrier (BBB). The present study focuses on developing magnesium sulphate nanoparticles (MGSN) to improve blood-brain barrier permeability. MGSN was prepared by precipitation technique with probe sonication. The developed formulation was characterized by DLS, EDAX, FT-IR and quantitative and qualitative estimation of magnesium. According to the DLS report, the average size of the prepared MGSN is found to be 247 nm. The haemocompatibility assay studies revealed that the prepared MGSN are biocompatible at different concentrations. The in vitro BBB permeability assay conducted by Parallel Artificial Membrane Permeability Assay (PAMPA) using rat brain tissue revealed that the prepared MGSN exhibited enhanced BBB permeability as compared to the marketed i.v. MgSO₄ injection. The reversal effect of MGSN to digoxin-induced Na⁺/K⁺ ATPase enzyme inhibition using brain microslices confirmed that MGSN could attenuate the altered levels of Na⁺ and K⁺ and is useful in treating neurological diseases with altered expression of Na⁺/K⁺ ATPase activity.

Effects of Altering Magnesium Metal Surfaces on Degradation In Vitro and In Vivo during Peripheral Nerve Regeneration

In vivo use of biodegradable magnesium (Mg) metal can be plagued by too rapid a degradation rate that removes metal support before physiological function is repaired. To advance the use of Mg biomedical implants, the degradation rate may need to be adjusted. We previously demonstrated that pure Mg filaments used in a nerve repair scaffold were compatible with regenerating peripheral nerve tissues, reduced inflammation, and improved axonal numbers across a short-but not long-gap in sciatic nerves in rats. To determine if the repair of longer gaps would be improved by a slower Mg degradation rate, we tested, in vitro and in vivo, the effects of Mg filament polishing followed by anodization using plasma electrolytic oxidation (PEO) with non-toxic electrolytes. Polishing removed oxidation products from the surface of as-received (unpolished) filaments, exposed more Mg on the surface, produced a smoother surface, slowed in vitro Mg degradation over four weeks after immersion in a physiological solution, and improved attachment of cultured epithelial cells. In vivo, treated Mg filaments were used to repair longer (15 mm) injury gaps in adult rat sciatic nerves after placement inside hollow poly (caprolactone) nerve conduits. The addition of single Mg or control titanium filaments was compared to empty conduits (negative control) and isografts (nerves from donor rats, positive control). After six weeks in vivo, live animal imaging with micro computed tomography (micro-CT) showed that Mg metal degradation rates were slowed by polishing vs. as-received Mg, but not by anodization, which introduced greater variability. After 14 weeks in vivo, functional return was seen only with isograft controls. However, within Mg filament groups, the amount of axonal growth across the injury site was improved with slower Mg degradation rates. Thus, anodization slowed degradation in vitro but not in vivo, and degradation rates do affect nerve regeneration.

A Mini Review on the Various Facets Effecting Brain Delivery of Magnesium and Its Role in Neurological Disorders

Magnesium is an essential cation present in the body that participates in the regulation of various vital body functions. Maintaining normal level of magnesium is essential for proper brain functions by regulating the activities of numerous neurotransmitters and their receptors. Various studies have been reported that magnesium level is found to be declined in both neurological and psychiatric diseases. Declined magnesium level in the brain initiates various cumbersome effects like excitotoxicity, altered blood-brain permeability, oxidative stress, and inflammation, which may further worsen the disease condition. Shreds of evidence from the experimental and clinical studies proved that exogenous administration of magnesium is useful for correcting disease-induced alterations in the brain. But one of the major limiting factors in the use of magnesium for treatment purposes is its poor blood-brain barrier permeability. Various approaches like the administration of its organic salts as pidolate and threonate forms, and the combination with polyethylene glycol or mannitol have been tried to improve its permeability to make magnesium as a suitable drug for different neurological disorders. These results have shown their experimental efficacy in diseased animal models, but studies regarding the safety and efficacy in human subjects are currently underway. We present a comprehensive review on the role of magnesium in the maintenance of normal functioning of the brain and various approaches for improving its BBB permeability.

Neuro-Inflammation Modulation and Post-Traumatic Brain Injury Lesions: From Bench to Bed-Side

Head trauma is the most common cause of disability in young adults. Known as a silent epidemic, it can cause a mosaic of symptoms, whether neurological (sensory-motor deficits), psychiatric (depressive and anxiety symptoms), or somatic (vertigo, tinnitus, phosphenes). Furthermore, cranial trauma (CT) in children presents several particularities in terms of epidemiology, mechanism, and physiopathology-notably linked to the attack of an immature organ. As in adults, head trauma in children can have lifelong repercussions and can cause social and family isolation, difficulties at school, and, later, socio-professional adversity. Improving management of the pre-hospital and rehabilitation course of these patients reduces secondary morbidity and mortality, but often not without long-term disability. One hypothesized contributor to this process is chronic neuroinflammation, which could accompany primary lesions and facilitate their development into tertiary lesions. Neuroinflammation is a complex process involving different actors such as glial cells (astrocytes, microglia, oligodendrocytes), the permeability of the blood-brain barrier, excitotoxicity, production of oxygen derivatives, cytokine release, tissue damage, and neuronal death. Several studies have investigated the effect of various treatments on the neuroinflammatory response in traumatic brain injury in vitro and in animal and human models. The aim of this review is to examine the various anti-inflammatory therapies that have been implemented.

The Brain–Gut Axis in Traumatic Brain Injury: Implications for Nutrition Support

Purpose of Review

Early enteral nutrition improves outcomes following traumatic brain injury (TBI). This can prove difficult due to TBI-induced feeding intolerance secondary to disruption of the brain-gut axis, a network composed of central nervous system (CNS) input, autonomic signaling, and immunologic regulation that controls gut and CNS homeostasis. Here, we discuss the pathophysiology of brain–gut axis dysregulation and outline nutrition strategies in patients with TBI.

Recent Findings

Feeding intolerance following TBI is multifactorial; complex signaling between the CNS, sympathetic nervous system, parasympathetic nervous system, and enteric nervous system that controls gut homeostasis is disrupted within hours post-injury. This has profound effects on the immune system and gut microbiome, further complicating post-TBI recovery. Despite this disruption, calorie and protein requirements increase considerably following TBI, and early nutritional supplementation improves survival following TBI. Enteral nutrition has proven more efficacious than parenteral nutrition in TBI patients and should be initiated within 48 hours following admission. Immune-fortified nutrition reduces CNS and gut inflammation and may improve outcomes in TBI patients.

Summary

Although autonomic dysregulation of the brain–gut axis results in feeding intolerance following TBI, early enteral nutrition is of paramount importance. Enteral nutrition reduces post-TBI inflammation and enhances immunologic and gut function. When feasible, enteral nutrition should be initiated within 48 hours following injury.

Alterations of Serum Magnesium Concentration in Animal Models of Seizures and Epilepsy—The Effects of Treatment with a GPR39 Agonist and Knockout of the Gpr39 Gene

Several ligands have been proposed for the GPR39 receptor, including the element zinc. The relationship between GPR39 and magnesium homeostasis has not yet been examined, nor has such a relationship in the context of seizures/epilepsy. We used samples from mice that were treated with an agonist of the GPR39 receptor (TC-G 1008) and underwent acute seizures (maximal electroshock (MES)- or 6-hertz-induced seizures) or a chronic, pentylenetetrazole (PTZ)-induced kindling model of epilepsy. MES seizures and PTZ kindling, unlike 6 Hz seizures, increased serum magnesium concentration. In turn, Gpr39-KO mice that underwent PTZ kindling displayed decreased concentrations of this element in serum, compared to WT mice subjected to this procedure. However, the levels of expression of TRPM7 and SlC41A1 proteins—which are responsible for magnesium transport into and out of cells, respectively—did not differ in the hippocampus between Gpr39-KO and WT mice. Furthermore, laser ablation inductively coupled plasma mass spectrometry applied to hippocampal slices did not reveal differences in magnesium levels between the groups. These data show the relationship between magnesium homeostasis and certain types of acute or chronic seizures (MES seizures or PTZ kindling, respectively), but do not explicitly support the role of GPR39 in mediating magnesium balance in the hippocampus in the latter model. However, decreased expression of TRPM7 and increased expression of SLC41A1—which were observed in the hippocampi of Gpr39-KO mice treated with TC-G 1008, in comparison to WT mice that received the same treatment—implicitly support the link between GPR39 and hippocampal magnesium homeostasis.

Magnesium Sulfate and Cerebral Oxygen Saturation in Mild Traumatic Brain Injury: A Randomized, Double-Blind, Controlled Trial

Perioperative cerebral hypoperfusion/ischemia is considered to play a pivotal role in the development of secondary traumatic brain injury (TBI). This prospective randomized, double-blind, controlled study investigated whether magnesium sulfate (MgSO4) infusion was associated with neuroprotection in maintaining regional cerebral oxygen saturation (rSO2) values in patients with mild TBI undergoing general anesthesia. Immediately after intubation, we randomly assigned patients with TBI to receive either intravenous MgSO4 (30 mg/kg for 10 min, followed by a continuous infusion of 15 mg/kg/h) or a placebo (saline) during surgery. We also implemented an intervention protocol for a sudden desaturation exceeding 20% of the initial baseline rSO2. The intraoperative rSO2 values were similar with respect to the median (left. 67% vs. 66%, respectively; p = 0.654), lowest, and highest rSO2 in both groups. The incidence (left 31.2% vs. 24.3%; p = 0.521) and duration (left 2.6% vs. 3.5%; p = 0.638) of cerebral desaturations (the relative decline in rSO2 < 80% of the baseline value) were also similar for both groups. Although the patients suffered serious traumatic injuries, all critical desaturation events were restored (100%) following stringent adherence to the intervention protocol. Intraoperative remifentanil consumption, postoperative pain intensity, and fentanyl consumption at 6 h were lower in the MgSO4 group (p = 0.024, 0.017, and 0.041, respectively) compared to the control group, whereas the satisfaction score was higher in the MgSO4 group (p = 0.007). The rSO2 did not respond to intraoperative MgSO4 in mild TBI. Nevertheless, MgSO4 helped the postoperative pain intensity, reduce the amount of intraoperative and postoperative analgesics administered, and heighten the satisfaction score.

Aquaporin 4 in Traumatic Brain Injury: From Molecular Pathways to Therapeutic Target

Traumatic brain injury (TBI) is known as an acute degenerative pathology of the central nervous system, and has been shown to increase brain aquaporin 4 (AQP4) expression. Various molecular mechanisms affect AQP4 expression, including neuronal high mobility group box 1, forkhead box O3a, vascular endothelial growth factor, hypoxia-inducible factor-1 α (HIF-1 α) sirtuin 2, NF-κB, Malat1, nerve growth factor and Angiotensin II receptor type 1. In addition, inhibition of AQP4 with FK-506, MK-801 (indirectly by targeting N-methyl-D-aspartate receptor), inactivation of adenosine A2A receptor, levetiracetam, adjudin, progesterone, estrogen, V1aR inhibitor, hypertonic saline, erythropoietin, poloxamer 188, brilliant blue G, HIF-1alpha inhibitor, normobaric oxygen therapy, astaxanthin, epigallocatechin-3-gallate, sesamin, thaliporphine, magnesium, prebiotic fiber, resveratrol and omega-3, as well as AQP4 gene silencing lead to reduced edema upon TBI. This review summarizes current knowledge and evidence on the relationship between AQP4 and TBI, and the potential mechanisms involved.

Hormesis and neural stem cells

This paper provides a detailed identification and assessment of hormetic dose responses in neural stem cells (NSCs) as identified in a number of animal models and human tissues, with particular emphasis on cell proliferation and differentiation. Hormetic dose responses were commonly observed following administration of a number of agents, including dietary supplements [e.g., berberine, curcumin, (-)-epigallocatechin-3-gallate (EGCG), Ginkgo Biloba, resveratrol], pharmaceuticals (e.g., lithium, lovastatin, melatonin), endogenous ligands [e.g., hydrogen sulfide (H₂S), magnesium, progesterone, taurine], environmental contaminants (e.g., arsenic, rotenone) and physical agents [e.g., hypoxia, ionizing radiation, electromagnetic radiation (EMF)]. These data indicate that numerous agents can induce hormetic dose responses to upregulate key functions of such as cell proliferation and differentiation in NSCs, and enhance resilience to inflammatory stresses. The paper assesses both putative mechanisms of hormetic responses in NSCs, and the potential therapeutic implications and application(s) of hormetic frameworks in clinical approaches to neurological injury and disease.

Broad spectrum micronutrient formulas for the treatment of symptoms of depression, stress, and/or anxiety: a systematic review

Introduction: Vitamin and mineral nutritional supplements are becoming increasingly popular as alternative treatments for anxiety and depression, as issues such as side effects from medication, failure to respond to psychotherapy and workforce limitations pose barriers for successful treatment.Areas covered: This review covered double-blind, randomized controlled trials (DBRCTs) testing formulas including at least four vitamins and/or minerals used for the treatment of symptoms of anxiety, stress, or depression in adults not currently taking medication for psychiatric difficulties.Expert opinion: The majority of the 23 trials reviewed were conducted on people without psychological difficulties, limiting the generalizability of the results in people with diagnosed mood and anxiety difficulties. Sixteen studies demonstrated positive effects for symptoms of anxiety, depression, or stress. Micronutrient supplementation in healthy nonclinical adults has limited benefits for mood and anxiety symptoms, although may convey some subtle general improvements. The evidence for adults with physical or mental ill health is more positive although limited by small samples and variability in nutrients studied. Broad-spectrum nutrient products may be more effective than a selected few. While an effect of micronutrients cannot be dismissed, the variability of the studies makes it extremely challenging to identify specific treatment benefits.

A randomized cohort study of the efficacy of PO magnesium in the treatment of acute concussions in adolescents

INTRODUCTION/STUDY OBJECTIVE

Concussions are becoming a growing concern in society today with one out of every five adolescents being affected. This accounts for 1.6 to 3.8 million emergency department visits annually. The current standard of care involves an initial period of mental rest with symptomatic care and symptom-based return to daily activities/sports. High dose IV magnesium has been proven to be neuroprotective in severe TBI. We hypothesized that oral magnesium replacement following a concussion will decrease the overall symptomatic period allowing a quicker return to functional baseline.

METHODS

We used a randomized cohort study involving patients aged 12-18 who presented within 48 h after a concussion. Our study design had a treatment arm including acetaminophen, ondansetron, and magnesium PO and a placebo arm of acetaminophen and ondansetron. We then utilized the Post- Concussion Severity Score (PCSS) to evaluate the extent of the patient's symptoms. This score was collected immediately prior to obtaining medications, 1 h, 48 h, and 120 h after starting the study. The study relied on outpatient follow up through phone conversations, and a Sports Medicine clinic locally.

RESULTS

Our data shows that there was a statistically significant decrease in the PCSS at 48 h (p = 0.016) in the magnesium group relative to the placebo treatment arm. This study does imply that magnesium supplementation has potential benefit in treatment of concussions acutely.

CONCLUSION

Oral magnesium replacement decreases symptoms acutely following a concussion and should be provided with symptomatic management following a concussion in the emergency setting.

A Case-Control Study of Essential and Toxic Trace Elements and Minerals in Hair of 0-4-Year-Old Children with Cerebral Palsy

The objective of the present study was to assess hair essential and toxic trace elements and minerals in children with cerebral palsy in relation to age of the examinees. A total of 70 children with cerebral palsy and 70 healthy controls aged 0-4 years old were enrolled in the present study. The examined children were also divided into two age groups of those younger and older than 2 years old. Hair trace element content was assessed using ICP-MS at NexION 300D (PerkinElmer, USA). The obtained data demonstrate that hair boron was more than 2-fold lower in CP children as compared with the control group. At the same time, hair Na, Se, and V levels were 21%, 12%, and 20% lower when compared with healthy controls, respectively. It is also notable that a 9% and 28% decrease in hair Fe and Li levels respectively were nearly significant. The observed alterations were more profound in a younger group of patients. No significant group difference in hair toxic metal and metalloid levels was observed between the general cohorts of children with and without CP. In regression models, only hair Al and Ca contents were significantly associated with the presence of cerebral palsy, whereas hair Mg, Na, Ni, and Se levels were characterized as significant negative predictors. The observed alteration in trace element metabolism may also provide an additional link between cerebral palsy, psychomotor delay, and certain diseases, including diabetes, epilepsy, and osteoporosis. However, further studies using other substrates (blood, urine) or biomarkers are required.

Treatment Of Magnesium-L-Threonate Elevates The Magnesium Level In The Cerebrospinal Fluid And Attenuates Motor Deficits And Dopamine Neuron Loss In A Mouse Model Of Parkinson's disease

PURPOSE

Epidemiology research has demonstrated that magnesium (Mg) deficiency is associated with a high incidence of Parkinson's disease (PD). It is known that the systemic administration of MgSO4 is not able to elevate the Mg concentration in cerebrospinal fluid (CSF). This study aims to verify the protective effect of magnesium-L-threonate (MgT) in 1-methyl-4-phenyl-1, 2, 3, 6-tetrahydropyridine (MPTP) mouse model.

METHODS

C57BL/6J mice were orally administered MgT or MgSO4 for 4 weeks, and received MPTP in the third week. After analysis of open-field and rotarod tests on the last day, tyrosine hydroxylase (TH) immunopositive cells and protein levels were quantified in the substantia nigra pars compacta (SNpc) and striatum. The expression of inducible nitric oxide synthase (iNOS) level was evaluated. Mg concentration in serum and CSF was measured after oral administration of MgSO4 or MgT in normal mice. Mg concentration in the CSF was increased in the mice treated with MgT but not MgSO4.

RESULTS

The total distance and mean speed in open-field tests, and the time spent on rotarod in the MgT group were increased, compared with MPTP group. The MgT treatment but not MgSO4 dose-dependently attenuated the loss of TH-positive neurons, and the reduction of the TH expression in the SNpc. The MgT treatment also inhibited the expression of iNOS as measured by immunohistochemistry and Western blots. Double-immunofluorescence staining of TH and iNOS showed iNOS-positive cells were collocalized for TH-positive cells.

CONCLUSION

The treatment with MgT is associated with an increase of Mg in the CSF. MgT, rather than MgSO4, can significantly attenuate MPTP-induced motor deficits and dopamine (DA) neuron loss.

The Role of Magnesium in the Secondary Phase After Traumatic Spinal Cord Injury. A Prospective Clinical Observer Study

In the secondary injury phase after traumatic spinal cord injury (TSCI), oxidative stress and neuroinflammatory responses at the site of injury constitute crucial factors controlling damage extent and may serve as potential therapeutic targets. We determined Magnesium (Mg) serum concentration dynamics in context with the potential of neurological remission in patients with TSCI as Mg is suspected to limit the production of reactive oxygen species and reduce lipid peroxidation. A total of 29 patients with acute TSCI were enrolled, and blood samples were drawn over 3 months at 11 time-points and Mg quantification was performed. Patients were divided into those with (G1, n = 18) or without neurological remission (G0, n = 11). Results show a slight drop in Mg level during the first 4 h after injury, then remained almost unchanged in G1, but increased continuously during the first 7 days after injury in G0. At day 7 Mg concentrations in G1 and G0 were significantly different (p = 0.039, G0 > G1). Significant differences were detected between patients in G1 that presented an AIS (ASIA Impairment Scale) conversion of 1 level versus those with more than 1 level (p = 0.014, G1 AIS imp. = +1 > G1 AI imp. > +1). Low and decreasing levels of Mg within the first 7 days are indicative of a high probability of neurological remission, whereas increasing levels are associated with poor neurological outcome.

Efficacy of Simultaneous Administration of Nimodipine, Progesterone, and Magnesium Sulfate in Patients with Severe Traumatic Brain Injury: A Randomized Controlled Trial

OBJECTIVE

To investigate the safety and efficacy of simultaneous administration of nimodipine, progesterone, magnesium sulfate in patients suffering from severe traumatic brain injury (TBI).

METHODS

Overall, 90 patients with blunt head trauma who were admitted to the Besat hospital, Hamadan University of Medical Sciences, Iran through the Emergency Department in 2017 to 2018 were randomly assigned to the study or control groups each containing 45 patients. In the study group, intravenous nimodipine 60 mg every 12 hours for 5 days, intramuscular progesterone 1 mg/kg daily for 5 days, and magnesium sulfate 5 grams stat followed by 2.5 grams every 4 hours for 21 days were administered. Daily GCS and jugular venous oxygen saturation (SjvO2) of the patients were measured on admission day (day 0) through hospitalization day 4 at the intensive care unit. Then, all patients were visited at three months after discharge.

RESULTS

The mean age of the patients was 31.4 ± 12.8 years including 59 (65.6%) men with no significant difference between the groups. The baseline GCS and SjvO2 of the patients were comparable in both groups, however, GCS of the patients in the study group were significantly higher in the next 4 hospitalization days compared to the controls. Whereas, the SjvO2 of the patients were not significantly different between the groups during these days. Three-month mortality rate of the patients in the study group was significantly lower than the three-month mortality rate of the patients in the control groups (22.2% vs. 42.2%, p=0.042).

CONCLUSION

Administration of combined protocol of magnesium sulfide, progesterone and nimodipine may be safe and effective in patients suffering from severe TBI.

CLINICAL TRIAL REGISTRY

IRCT201210229534N2.

A systematic review of the role of vitamin D and calcium in premenstrual syndrome

Premenstrual syndrome (PMS) is a common disorder that affects millions of women of reproductive age worldwide. In recent years, there has been a focus on finding accessible, acceptable, and cost-effective therapeutic approaches with minimal side effects to treat the symptoms of PMS. This systematic review aimed to investigate the role of calcium and vitamin D in Premenstrual syndrome. The PubMed, EMBASE, Web of Science, Scopus, Science Direct, and Google Scholar databases were systematically searched for relevant articles from clinical trial, case-control, and cross-sectional studies. The Strengthening the Reporting of Observational Studies in Epidemiology checklist was used to assess the quality of the selected papers. A total of 28 eligible high-quality papers were reviewed. Low serum levels of calcium and vitamin D during the luteal phase of the menstrual cycle were found to cause or exacerbate the symptoms of PMS. Therefore, the administration of calcium and vitamin D supplements or the use of a diet rich in these two substances can restore serum levels and eliminate or reduce the symptoms of PMS. Calcium and vitamin D supplementation are recommended as an inexpensive, low-risk, acceptable, and accessible approach to eliminate or reduce the symptoms of PMS.

Chemogenomics Systems Pharmacology Mapping of Potential Drug Targets for Treatment of Traumatic Brain Injury

Traumatic brain injury (TBI) is associated with high mortality and morbidity. Though the death rate of initial trauma has dramatically decreased, no drug has been developed to effectively limit the progression of the secondary injury caused by TBI. TBI appears to be a predisposing risk factor for Alzheimer's disease (AD), whereas the molecular mechanisms remain unknown. In this study, we have conducted a research investigation of computational chemogenomics systems pharmacology (CSP) to identify potential drug targets for TBI treatment. TBI-induced transcriptional profiles were compared with those induced by genetic or chemical perturbations, including drugs in clinical trials for TBI treatment. The protein-protein interaction network of these predicted targets were then generated for further analyses. Some protein targets when perturbed, exhibit inverse transcriptional profiles in comparison with the profiles induced by TBI, and they were recognized as potential therapeutic targets for TBI. Drugs acting on these targets are predicted to have the potential for TBI treatment if they can reverse the TBI-induced transcriptional profiles that lead to secondary injury. In particular, our results indicated that TRPV4, NEUROD1, and HPRT1 were among the top therapeutic target candidates for TBI, which are congruent with literature reports. Our analyses also suggested the strong associations between TBI and AD, as perturbations on AD-related genes, such as APOE, APP, PSEN1, and MAPT, can induce similar gene expression patterns as those of TBI. To the best of our knowledge, this is the first CSP-based gene expression profile analyses for predicting TBI-related drug targets, and the findings could be used to guide the design of new drugs targeting the secondary injury caused by TBI.

Effect of Mannitol Infusion on Optic Nerve Injury After Acute Traumatic Subarachnoid Hemorrhage and Brain Injury

The primary aim of this paper is to investigate the neuroprotective and antiinflammatory effects of mannitol on optic nerve injury after acute traumatic subarachnoid hemorrhage and brain injury in rat models. Traumatic brain injury (TBI) and traumatic subarachnoid hemorrhage (tSAH) were produced by a custom-made weight-drop impact acceleration device. Thirty male Wistar rats were divided into 3 groups. Group I (n = 10) was the sham group, group II (n = 10) received TBI, and group III (n = 10) received TBI + mannitol (1 mg/kg intravenously). Optic nerve tissue glutathione peroxidase (GPx) and interleukin 1 beta (IL-1β) levels were measured 4 hours after the trauma. The authors used Kruskal-Wallis variance analysis and Mann-Whitney U tests for statistical analysis. Optic nerve tissue GPx levels were significantly higher in group III than in groups I and II (P < 0.05). Optic nerve tissue IL-1β levels were significantly lower in group III than in group II (P < 0.05) and higher than in group I (P < 0.05).Mannitol increased the antioxidant GPx levels and decreased the IL-1β levels, which can protect the optic nerve from secondary injury after severe acute trauma. Mannitol plays an important role in the treatment of acute severe indirect optic nerve injury after TBI and tSAH.

Magnesium administration after experimental traumatic brain injury improves decision-making skills

After sustaining a traumatic brain injury (TBI), a person's ability to make daily decisions can be affected. Simple tasks such as, deciding what to wear are no longer effortless choices, but are instead difficult decisions. This study explored the use of a discrimination task with a magnesium treatment in order to examine how decision-making skills are affected after TBI and if the treatment helped to attenuate cognitive and motor impairments. Thirty-one male rats were separated into MAG/TBI, VEH/TBI, or VEH/Sham groups. Pre-TBI, rats were trained to dig in the sand for a reinforcer. After establishment of consistent digging behavior rats received a bilateral frontal cortex injury. Rats received either an i.p. injection of 2 mmol/kg magnesium chloride or control at 4, 24, 72 h post-surgery. Dig task testing began 7 days post-injury, lasting for 4 weeks. The discriminations included two scent pairings; basil (baited) versus coffee then the reversal and then cocoa (baited) versus cumin then the reversal. The results indicated that the magnesium treatment was successful at attenuating cognitive and motor deficits after TBI. The results also indicated that the dig task is a sufficient operant conditioning task in the assessment of frontal functioning after TBI.

Supplements, nutrition, and alternative therapies for the treatment of traumatic brain injury

Studies using traditional treatment strategies for mild traumatic brain injury (TBI) have produced limited clinical success. Interest in treatment for mild TBI is at an all time high due to its association with the development of chronic traumatic encephalopathy and other neurodegenerative diseases, yet therapeutic options remain limited. Traditional pharmaceutical interventions have failed to transition to the clinic for the treatment of mild TBI. As such, many pre-clinical studies are now implementing non-pharmaceutical therapies for TBI. These studies have demonstrated promise, particularly those that modulate secondary injury cascades activated after injury. Because no TBI therapy has been discovered for mild injury, researchers now look to pharmaceutical supplementation in an attempt to foster success in human clinical trials. Non-traditional therapies, such as acupuncture and even music therapy are being considered to combat the neuropsychiatric symptoms of TBI. In this review, we highlight alternative approaches that have been studied in clinical and pre-clinical studies of TBI, and other related forms of neural injury. The purpose of this review is to stimulate further investigation into novel and innovative approaches that can be used to treat the mechanisms and symptoms of mild TBI.

Short and long gap peripheral nerve repair with magnesium metal filaments

A current clinical challenge is to replace autografts for repair of injury gaps in peripheral nerves, which can occur due to trauma or surgical interruption. Biodegradable metallic magnesium filaments, placed inside hollow nerve conduits, could support nerve repair by providing contact guidance support for axonal regeneration. This was tested by repairing sciatic nerves of adult rats with single magnesium filaments placed inside poly(caprolactone) nerve conduits. Controls were empty conduits, conduits containing titanium filaments and/or isografts from donor rats. With a nerve gap of 6 mm and 6 weeks post-repair, magnesium filaments had partially resorbed. Regenerating cells had attached to the filaments and axons were observed in distal stumps in all animals. Axon parameters were improved with magnesium compared to conduits alone or conduits with single titanium filaments. With a longer gap of 15 mm and 16 weeks post-repair, functional parameters were improved with isografts, but not with magnesium filaments or empty conduits. Magnesium filaments were completely resorbed and no evidence of scarring was seen. While axon outgrowth was not improved with the longer gap, histological measures of the tissues were improved with magnesium compared to empty conduits. Therefore, the use of magnesium filaments is promising because they are biocompatible and improve aspects of nerve regeneration. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 105A: 3148-3158, 2017.

Endocannabinoids: A Promising Impact for Traumatic Brain Injury

The endogenous cannabinoid (endocannabinoid) system regulates a diverse array of physiological processes and unsurprisingly possesses considerable potential targets for the potential treatment of numerous disease states, including two receptors (i.e., CB1 and CB2 receptors) and enzymes regulating their endogenous ligands N-arachidonoylethanolamine (anandamide) and 2-arachidonyl glycerol (2-AG). Increases in brain levels of endocannabinoids to pathogenic events suggest this system plays a role in compensatory repair mechanisms. Traumatic brain injury (TBI) pathology remains mostly refractory to currently available drugs, perhaps due to its heterogeneous nature in etiology, clinical presentation, and severity. Here, we review pre-clinical studies assessing the therapeutic potential of cannabinoids and manipulations of the endocannabinoid system to ameliorate TBI pathology. Specifically, manipulations of endocannabinoid degradative enzymes (e.g., fatty acid amide hydrolase, monoacylglycerol lipase, and α/β-hydrolase domain-6), CB1 and CB2 receptors, and their endogenous ligands have shown promise in modulating cellular and molecular hallmarks of TBI pathology such as; cell death, excitotoxicity, neuroinflammation, cerebrovascular breakdown, and cell structure and remodeling. TBI-induced behavioral deficits, such as learning and memory, neurological motor impairments, post-traumatic convulsions or seizures, and anxiety also respond to manipulations of the endocannabinoid system. As such, the endocannabinoid system possesses potential drugable receptor and enzyme targets for the treatment of diverse TBI pathology. Yet, full characterization of TBI-induced changes in endocannabinoid ligands, enzymes, and receptor populations will be important to understand that role this system plays in TBI pathology. Promising classes of compounds, such as the plant-derived phytocannabinoids, synthetic cannabinoids, and endocannabinoids, as well as their non-cannabinoid receptor targets, such as TRPV1 receptors, represent important areas of basic research and potential therapeutic interest to treat TBI.

A fully integrated new paradigm for lithium's mode of action - lithium utilizes latent cellular fail-safe mechanisms

It is proposed that lithium's therapeutic effects occur indirectly by augmenting a cascade of protective "fail-safe" pathways pre-configured to activate in response to a dangerous low cell [Mg⁺⁺] situation, eg, posttraumatic brain injury, alongside relative cell adenosine triphosphate depletion. Lithium activates cell protection, as it neatly mimics a lowered intracellular [Mg⁺⁺] level.

Comparison of different osmotic therapies in a mouse model of traumatic brain injury

BACKGROUND

Inflammation in the affected region, increased intracranial pressure, consequent oedema and congestion contribute to the negative outcome of traumatic brain injury. Osmotic therapies are recommended for improvement in cognitive and motor functions. Aim of the present study was to evaluate the effect of osmotic therapies in a mice model of traumatic brain injury.

METHODS

Experimental closed head injury was performed in adult Swiss albino mice by the weight-drop method. Different group of animals were treated with normal saline (G1), mannitol (G2), mannitol+glycerin (G3) and Neurotol (G4). Neurological Severity Score (NSS) was recorded at different time-points upto a period of six days. Effect of treatments on cerebral oedema, learning and memory function, motor function and co-ordination were evaluated by gravimetry, Morris water maze and beam walk test respectively. Histopathology was performed to evaluate the treatment effects on microscopic complications arising from primary closed head injury (CHI).

RESULTS

All the treatments showed a marked improvement in the evaluated parameters as compared with the vehicle control group. It was evident that G3 and G4 had a distinct advantage over mannitol therapy. Based on the NSS score, Neurotol proved to be comparatively safe and more efficacious than either mannitol or a combination of mannitol+glycerol. The effect of Neurotol could have been enhanced by the presence of VRP011 (a Mg⁺² salt).

CONCLUSIONS

Neurotol is safe and exhibits better efficacy as compared with other treatments for the management of traumatic brain injury.

Combined Magnesium/Polyethylene Glycol Facilitates the Neuroprotective Effects of Magnesium in Traumatic Brain Injury at a Reduced Magnesium Dose

AIMS

While a number of studies have shown that free magnesium (Mg) decline is a feature of traumatic brain injury (TBI), poor central penetration of Mg has potentially limited clinical translation. This study examines whether polyethylene glycol (PEG) facilitates central penetration of Mg after TBI, increasing neuroprotection while simultaneously reducing the dose requirements for Mg.

METHODS

Rats were exposed to diffuse TBI and administered intravenous MgCl2 either alone (254 μmol/kg or 25.4 μmol/kg) or in combination with PEG (1 g/kg PEG) at 30-min postinjury. Vehicle-treated (saline or PEG) and sham animals served as controls. All animals were subsequently assessed for blood-brain barrier permeability and edema at 5 h, and functional outcome for 1 week postinjury.

RESULTS

Optimal dose (254 μmol/kg) MgCl2 or Mg PEG significantly improved all outcome parameters compared to vehicle or PEG controls. Intravenous administration of 10% MgCl2 alone (25.4 μmol/kg) had no beneficial effect on any of the outcome parameters, whereas 10% Mg in PEG had the same beneficial effects as optimal dose Mg administration.

CONCLUSION

Polyethylene glycol facilitates central penetration of Mg following TBI, reducing the concentration of Mg required to confer neuroprotection while simultaneously reducing the risks associated with high peripheral Mg concentration.

Vitamins and nutrients as primary treatments in experimental brain injury: Clinical implications for nutraceutical therapies

With the numerous failures of pharmaceuticals to treat traumatic brain injury in humans, more researchers have become interested in combination therapies. This is largely due to the multimodal nature of damage from injury, which causes excitotoxicity, oxidative stress, edema, neuroinflammation and cell death. Polydrug treatments have the potential to target multiple aspects of the secondary injury cascade, while many previous therapies focused on one particular aspect. Of specific note are vitamins, minerals and nutrients that can be utilized to supplement other therapies. Many of these have low toxicity, are already FDA approved and have minimal interactions with other drugs, making them attractive targets for therapeutics. Over the past 20 years, interest in supplementation and supraphysiologic dosing of nutrients for brain injury has increased and indeed many vitamins and nutrients now have a considerable body of the literature backing their use. Here, we review several of the prominent therapies in the category of nutraceutical treatment for brain injury in experimental models, including vitamins (B2, B3, B6, B9, C, D, E), herbs and traditional medicines (ginseng, Gingko biloba), flavonoids, and other nutrients (magnesium, zinc, carnitine, omega-3 fatty acids). While there is still much work to be done, several of these have strong potential for clinical therapies, particularly with regard to polydrug regimens. This article is part of a Special Issue entitled SI:Brain injury and recovery.

Neurochemical cascade of concussion

PRIMARY OBJECTIVE

The aim of this literature review was to systematically describe the sequential metabolic changes that occur following concussive injury, as well as identify and characterize the major concepts associated with the neurochemical cascade.

RESEARCH DESIGN

Narrative literature review.

CONCLUSIONS

Concussive injury initiates a complex cascade of pathophysiological changes that include hyper-acute ionic flux, indiscriminant excitatory neurotransmitter release, acute hyperglycolysis and sub-acute metabolic depression. Additionally, these metabolic changes can subsequently lead to impaired neurotransmission, alternate fuel usage and modifications in synaptic plasticity and protein expression. The combination of these metabolic alterations has been proposed to cause the transient and prolonged neurological deficits that typically characterize concussion. Consequently, understanding the implications of the neurochemical cascade may lead to treatment and return-to-play guidelines that can minimize the chronic effects of concussive injury.

Magnesium as an Effective Adjunct Therapy for Drug Resistant Seizures

Objective:

To explore the use of magnesium (Mg), an endogenous ion and enzymatic co-factor used in a variety of medical applications, for the treatment of epileptic seizures resistant to traditional medical therapy.

Background:

For almost a century, Mg has been used as prophylaxis and treatment of seizures associated with eclampsia. Mg is a CNS depressant, with numerous functions intracellularly and extracellularly. However, because of the availability of well studied anticonvulsant drugs, Mg has not been tested widely in the treatment of epileptic seizures.

Methods:

A retrospective chart review of 22 cases of drug resistant epilepsy, where a trial of empiric oral Mg supplementation (mainly in the form of Mg-oxide) was conducted.

Results:

Oral Mg supplementation was associated with a significant decrease in the number of seizure days per month, from 15.3 ± 13.2 (mean ± SD) to 10.2 ± 12.6 at first follow up (3-6 months, p=0.021), and to 7.8 ± 10.0 seizure days/month at second follow up (6-12 months, p=0.004). Thirty-six percent had a response rate of 75% or greater at second follow-up. Two patients reported seizure freedom. Most patients were well maintained on MgO 420mg twice a day, or in 2 cases, Mg Lactate, without significant adverse effects, the most frequent being diarrhea (4/22).

Discussion:

These results suggest that oral Mg supplementation may prove to be a worthwhile adjunctive medication in treating drug intractable epilepsy.

Conclusions:

A prospective, double-blinded, placebo controlled study is warranted to evaluate the potential of Mg for the treatment of drug-resistant seizures.

Magnesium physiology and clinical therapy in veterinary critical care

OBJECTIVE

To review magnesium physiology including absorption, excretion, and function within the body, causes of magnesium abnormalities, and the current applications of magnesium monitoring and therapy in people and animals.

ETIOLOGY

Magnesium plays a pivotal role in energy production and specific functions in every cell in the body. Disorders of magnesium can be correlated with severity of disease, length of hospital stay, and recovery of the septic patient. Hypermagnesemia is seen infrequently in people and animals with significant consequences reported. Hypomagnesemia is more common in critically ill people and animals, and can be associated with platelet, immune system, neurological, and cardiovascular dysfunction as well as alterations in insulin responsiveness and electrolyte imbalance.

DIAGNOSIS

Measurement of serum ionized magnesium in critically or chronically ill veterinary patients is practical and provides information necessary for stabilization and treatment. Tissue magnesium concentrations may be assessed using nuclear magnetic resonance spectroscopy as well as through the application of fluorescent dye techniques.

THERAPY

Magnesium infusions may play a therapeutic role in reperfusion injury, myocardial ischemia, cerebral infarcts, systemic inflammatory response syndromes, tetanus, digitalis toxicity, bronchospasms, hypercoagulable states, and as an adjunct to specific anesthetic or analgesic protocols. Further veterinary studies are needed to establish the frequency and importance of magnesium disorders in animals and the potential benefit of magnesium infusions as a therapeutic adjunct to specific diseases.

PROGNOSIS

The prognosis for most patients with magnesium disorders is variable and largely dependent on the underlying cause of the disorder.

Hypocalcaemia as a prognostic factor of early mortality in moderate and severe traumatic brain injury

OBJECTIVES

Our main objective was to evaluate whether serum hypocalcaemia on the third day [defined as < 2.1 mmol/l (8.5 mg/dl)] is a prognostic factor for early mortality after moderate and severe traumatic brain injury (TBI).

METHODS

We developed an ambispective comparative case control study. We evaluated clinical profiles from included patients from January 2005 to July 2009 and we prospectively recruited additional patients from August 2009 to July 2011. Patients were between 1 and 89 years old and had a Glasgow Coma Scale of 3-12 points following TBI.

RESULTS

We calculated an Odds Ratio of 5.2 (Confidence Intervals 95%: 4.48 to 6.032) for hypocalcaemia on day three, which was associated with death. Retrospectively (January 2005 to July 2009) we compiled data from 81 patients. Prospectively (August 2009 to July 2011) we recruited 41 patients. The adjusted variables in the logistic regression final model were: serum calcium on day three (Odds Ratio 3.5, Confidence Intervals 95%: 1·12 to 13·61, P < 0·028) and anisocoria (Odds Ratio 8·24, Confidence Intervals 95%: 1·3 to 67·35, P < 0·019) obtaining an adjusted R2 of 0·22 (P < 0·005).

DISCUSSION

The serum levels of calcium on day three could be useful for the prediction of mortality in patients with moderate and severe TBI.

Predicting and preventing postconcussive problems in paediatrics (5P) study: protocol for a prospective multicentre clinical prediction rule derivation study in children with concussion

INTRODUCTION

Persistent postconcussive symptoms (PCSs) is the persistence of somatic, cognitive, physical, psychological and/or behavioural changes lasting more than 1 month following concussion. Persistent concussion impacts the quality of life through impaired cognition, memory and attention affecting school performance, mood and social engagement. No large epidemiological studies have determined the true prevalence of persistent concussion symptoms. Validated, easy-to-use prognosticators do not exist for clinicians to identify children at highest risk. The goal of Predicting and Preventing Postconcussive Problems in Pediatrics study is to derive a clinical prediction rule for the development of persistent postconcussion symptoms in children and adolescents presenting to emergency department following acute head injury.

METHODS AND ANALYSIS

This study is a prospective, multicentre cohort study across nine academic Canadian paediatric emergency departments. We will recruit the largest prospective epidemiological cohort of children with concussion. Eligible children will be followed using Post-Concussion Symptom Inventory, a validated tool in children as young as 5 years. Patients will follow-up at 1, 2, 4, 8 and 12 weeks postinjury. The main outcome will be the presence/absence of PCSs defined as three or more persistent concussion symptoms 1 month following the injury. 1792 patients provide adequate power to derive a clinical decision rule using multivariate analyses to find predictor variables sensitive for detecting cases of persistent postconcussion symptoms.

ETHICS AND DISSEMINATION

Results of this large prospective study will enable clinicians to identify children at highest risk, optimise treatment and provide families with realistic and appropriate anticipatory guidance. Ethics has been obtained through the Children's Hospital of Eastern Ontario Research Ethics Board. Results will be disseminated at international conferences and in four manuscripts to peer-reviewed journals.

TRIAL REGISTRATION

This study is registered at Clinicaltrials.gov through the US National Institute of Health/National Library of Medicine (NCT01873287; http://clinicaltrials.gov/ct2/show/NCT01873287).

Reactive oxygen species-activated nanoprodrug of Ibuprofen for targeting traumatic brain injury in mice

Traumatic brain injury (TBI) is an enormous public health problem, with 1.7 million new cases of TBI recorded annually by the Centers for Disease Control. However, TBI has proven to be an extremely challenging condition to treat. Here, we apply a nanoprodrug strategy in a mouse model of TBI. The novel nanoprodrug contains a derivative of the nonsteroidal anti-inflammatory drug (NSAID) ibuprofen in an emulsion with the antioxidant α-tocopherol. The ibuprofen derivative, Ibu2TEG, contains a tetra ethylene glycol (TEG) spacer consisting of biodegradable ester bonds. The biodegradable ester bonds ensure that the prodrug molecules break down hydrolytically or enzymatically. The drug is labeled with the fluorescent reporter Cy5.5 using nonbiodegradable bonds to 1-octadecanethiol, allowing us to reliably track its accumulation in the brain after TBI. We delivered a moderate injury using a highly reproducible mouse model of closed-skull controlled cortical impact to the parietal region of the cortex, followed by an injection of the nanoprodrug at a dose of 0.2 mg per mouse. The blood brain barrier is known to exhibit increased permeability at the site of injury. We tested for accumulation of the fluorescent drug particles at the site of injury using confocal and bioluminescence imaging of whole brains and brain slices 36 hours after administration. We demonstrated that the drug does accumulate preferentially in the region of injured tissue, likely due to an enhanced permeability and retention (EPR) phenomenon. The use of a nanoprodrug approach to deliver therapeutics in TBI represents a promising potential therapeutic modality.

Baseline serum magnesium concentrations and neurodevelopmental outcomes of extremely low birth weight premature infants

AIM

To test the hypothesis that, in ELBW infants who did not receive antenatal MgSO4, lower baseline serum Mg is associated with poorer neurodevelopmental outcomes (NDO).

STUDY DESIGN

The study was conducted in two phases: phase 1-- retrospective, and phase 2--prospective.

SUBJECTS

Extremely low birth weight infants.

OUTCOME MEASURES

Mortality and adverse NDO were assessed in relation to initial serum Mg measured in the first 12 hours of age.

RESULTS

We studied 156 ELBW infants. In phase 1 (n=102): initial serum Mg (median [IQ range]) was greater in the infants who died compared to those who survived (1.7 [1.5-2.2] mg/dL vs. 1.6 [1.4-1.7] mg/dL, p=0.034). In phase 2 (n=54): initial serum Mg was greater in infants who died or had adverse NDO at 9 months when compared to those who survived with better NDO (1.7 [1.55-2.1] mg/dL vs. 1.5 [1.4-1.68] mg/dL, p=0.008). Using receiver operating characteristic (ROC) curve, increased Mg concentration in the first 12 hours>1.6 mg/dL was associated with unfavorable outcomes with sensitivity of 73%, specificity of 67%, and odds ratio of 5.5 (CI=1.2-24.8, p=0.037).

CONCLUSIONS

In a cohort of preterm infants without antenatal exposure to MgSO4, initial serum Mg concentrations associated positively with poor outcomes. Further studies are needed in ELBW infants with poor NDO to determine whether they have a dysfunctional transport system that prevents Mg from entering into cells, or they have an active process that excretes Mg extracellularly.

[Nutritional therapy in traumatic brain injury : Update 2012]

Severe traumatic brain injury ranks among the most common causes of death in young adults in western countries. Severe traumatic brain injury is typically followed by a pronounced pathophysiological cascade that accounts for many deaths. The aim of intensive care medicine after traumatic brain injury is to minimize and to control the consequences of this potentially fatal cascade. The avoidance of hypoxemia, arterial hypotension, intracranial hypertension, hyperthermia, hyperglycemia, hypoglycemia and thromboembolic complications is essential in preventing this cascade. The effect of nutrition has been rather underestimated as a means of improving the outcome after traumatic brain injury. Nutrition should be started within the first 24 h after trauma. Enteral, wherever applicable, should be the route of administration of nutrition. Enteral administration of the whole calculated calorie requirement on day 1 after trauma, if possible, lowers the infection and overall complication rates. The present review gives an update of a practical approach to nutrition in traumatic brain injury.

Postconcussion syndrome: a review of pathophysiology and potential nonpharmacological approaches to treatment

The incidence of all-cause concussions in the United States is estimated to range from 1.6 to 3.8 million annually, with the reported number of sport- or recreation-related concussions increasing dramatically, especially in youth sports.(1,2) Additionally, the use of roadside bombs in Iraq and Afghanistan has propelled the incidence of concussion and other traumatic brain injuries to the highest levels ever encountered by the US military. As a result, there has also been a marked increase in postconcussion syndrome (PCS) and the associated cognitive, emotional, and memory disabilities associated with the condition. Unfortunately, however, there have been no significant advancements in the understanding or treatment of PCS for decades. The current management of PCS mainly consists of rest, reduction of sensory inputs, and treating symptoms as needed. Recently, researchers investigating the underlying mechanisms of PCS have proposed that activation of the immune inflammatory response may be an underlying pathophysiology that occurs in those who experience prolonged symptoms after a concussion. This article reviews the literature and summarizes the immune inflammatory response known as immunoexcitotoxicity. This article also discusses the use of nonpharmacological agents for the management of PCS that directly address this underlying mechanism.