Urinary Biomarkers of Brain Diseases

Biomarkers are the measurable changes associated with a physiological or pathophysiological process. Unlike blood, urine is not subject to homeostatic mechanisms. Therefore, greater fluctuations could occur in urine than in blood, better reflecting the changes in human body. The roadmap of urine biomarker era was proposed. Although urine analysis has been attempted for clinical diagnosis, and urine has been monitored during the progression of many diseases, particularly urinary system diseases, whether urine can reflect brain disease status remains uncertain. As some biomarkers of brain diseases can be detected in the body fluids such as cerebrospinal fluid and blood, there is a possibility that urine also contain biomarkers of brain diseases. This review summarizes the clues of brain diseases reflected in the urine proteome and metabolome.

[THE SEARCH AFTER PROGNOSTIC TESTS OF DEVELOPMENT OF UROLITHIASIS OF PATIENTS WITH VERTEBRO-CEREBROSPINAL TRAUMA]

The article presents analysis of alterations of biochemical indicators in blood serum and day urine of 22 patients in acute and early periods after vertebro-cerebrospinal trauma. Out of total number of patients in 10 (main group) in post-traumatic period urolithiasis developed In 12 patients no signs of urolithiasis were detected These examinedpatients were included into comparative group. The reference group was composed with 20 healthy individuals. The concentration of urea, creatinine, uric acid, calcium and inorganic phosphate in blood serum and day urine were detected In patients of main group statistically significant increasing of levels of urea and creatinine was detected in blood serum relative to patients of comparative group. In examined patients of main group clearance of urea was reliably lower than both values of comparative group (up to 2.55 times; p < 0.05) and indicators of reference group (up to 3.75 times; p < 0.05). In patients of this group, clearance of uric acid also had reliable differences from indicators both in comparative group and reference group. Therefore, in patients in acute and early periods of vertebro- cerebrospinal trauma expressed disorders of biochemical indicators of blood serum and urine that can be referred to predictors of risk of development of urolithiasis in the following. The most informative tests were increasing of concentration of urea in blood serum more than 5.30 mmol/l (ratio of likelihood ofpositive test--4.26) and decreasing of clearance of uric acid and urea.

Effect of marijuana use on outcomes in traumatic brain injury

Traumatic brain injury (TBI) is associated with significant morbidity and mortality. Several studies have demonstrated neuroprotective effects of cannabinoids. The objective of this study was to establish a relationship between the presence of a positive toxicology screen for tetrahydrocannabinol (THC) and mortality after TBI. A 3-year retrospective review of registry data at a Level I center of patients sustaining TBI having a toxicology screen was performed. Pediatric patients (younger than 15 years) and patients with a suspected nonsurvivable injury were excluded. The THC(+) group was compared with the THC(-) group with respect to injury mechanism, severity, disposition, and mortality. Logistic regression was used to determine independent associations with mortality. There were 446 cases meeting all inclusion criteria. The incidence of a positive THC screen was 18.4 per cent (82). Overall mortality was 9.9 per cent (44); however, mortality in the THC(+) group (2.4% [two]) was significantly decreased compared with the THC(-) group (11.5% [42]; P = 0.012). After adjusting for differences between the study cohorts on logistic regression, a THC(+) screen was independently associated with survival after TBI (odds ratio, 0.224; 95% confidence interval, 0.051 to 0.991; P = 0.049). A positive THC screen is associated with decreased mortality in adult patients sustaining TBI.

Indicators of lean body mass catabolism: emphasis on the creatinine excretion rate

BACKGROUND

The major stress response to critical illness leads to a catabolic state and loss of lean body mass.

AIMS

To test whether an increased rate of creatinine excretion might provide unique and timely information to monitor cell catabolism; to relate this information to balances of cell constituents (nitrogen, potassium, phosphate and magnesium); to evaluate the effectiveness of nutritional therapy to reverse this catabolic process.

DESIGN

Prospective observational study.

METHODS

Children with severe traumatic brain injury admitted to the paediatric critical care units of The Hospital for Sick Children, Toronto, Canada and Hospital das Clínicas, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Brazil were studied. Complete 24 h urine collections were obtained for measurement of creatinine excretion rate and daily balances of nitrogen, potassium, phosphate and magnesium.

RESULTS

Seventeen patients were studied for 3-10 days. On Day 1, all had negative balances for protein and phosphate. Balances for these intracellular constituents became positive when protein intake was >/=1 g/kg/day and energy intake was >/=50% of estimated energy expenditure (P < 0.0001). Creatinine excretion rate was positively correlated with the urea appearance rate (r = 0.60; P < 0.0001), and negatively with protein balance (r = -0.45; P < 0.0001). Sepsis developed in four patients; before its clinical detection, there were negative balances for all intracellular markers and an abrupt rise in the excretion of creatinine.

CONCLUSION

Negative balances of intracellular components and an increase in rate of creatinine excretion heralded the onset of catabolism.

Urinary S100B concentrations are increased after brain injury in children: A preliminary study

OBJECTIVE

S100B is a renally excreted protein concentrated in glial cells of the nervous system. Increases in serum S100B concentrations reflect brain injury. However, increases in serum are rapid and transient and therefore may be of limited use in certain patients. Urinary S100B concentrations may be able to provide information about brain injury in this subgroup of patients.

DESIGN

Prospective, descriptive study.

SETTING

Level I trauma center.

PATIENTS

Fifteen children with acute traumatic or hypoxemic brain injury (subjects) and 14 healthy controls.

INTERVENTIONS

Urine and serum samples were collected from subjects and controls. Serial samples were collected in brain injury subjects up to every 12 hrs for 3 days. S100B concentrations were measured by enzyme-linked immunosorbent assay (Nanogen, San Diego CA). Outcome was assessed by Glasgow Outcome Scale score.

MEASUREMENTS AND MAIN RESULTS

Urinary S100B concentrations were detectable in 80% of subjects with increased serum S100B concentrations and 0% of controls. Peak urinary S100B concentrations occurred significantly later than peak serum S100B concentrations: 55.3 (29.8) (mean [sd]) vs. 14.6 (11.8) hrs after injury (p = .002). All subjects with an undetectable urinary S100B had a good outcome vs. only 20% of subjects with a detectable urinary S100B. Subjects with increased serum S100B were more likely to have a poor outcome than those with normal S100B (p = .01).

CONCLUSIONS

Increases in urinary S100B are found in the majority of children with acute brain injury and an increased serum S100B. Urinary S100B concentrations peak later than serum concentrations, suggesting that measurement of urinary S100B may be helpful in subjects in whom early serum S100B is unavailable. Urinary and/or serum S100B concentrations may be useful to assist in the prediction of outcome after pediatric brain injury.

Basal ganglia lesions in a patient with 3-hydroxyisobutyric aciduria

3-hydroxyisobutyric aciduria (3HiB-uria) is a very rare organic aciduria that involves valine metabolism. We report the case of a 7-year-old boy with 3HiB-uria who has suffered more than 20 ketoacidotic episodes since the age of 15 months. In the most recent ketoacidotic episode, which was particularly severe, he developed mild dystonia and choreoathetosis. Magnetic resonance imaging (MRI) revealed bilateral swelling and signal abnormalities of the putamina and heads of the caudate nuclei. The abnormal movements showed a gradual improvement over several months, in correlation with neuroradiological findings. 3HiB-uria should be recognized as one of the group of branched chain organic acidemias that can produce lesions in the basal ganglia.

Significant elevation of urinary trypsin inhibitor in patients with brain contusion - a preliminary report

Urinary trypsin inhibitor (UTI) is a protease inhibitor, which is produced in the liver. The correlation between UTI level and head injury has not been evaluated. This study was designed to investigate UTI levels in patients with severe head injury. We measured UTI in the urine of patients with brain contusion. UTI was significantly higher in those patients compared to the control group. The results suggest that UTI may be useful for assessing the severity of head injury and also as a treatment marker in patients with brain contusion.

Serum and urine nitrate and nitrite are not reliable indicators of intrathecal nitric oxide production in acute brain injury

This study examined the correlation between nitric oxide (NO) metabolites in the three major body fluid compartments and assessed performance of newly described vanadium-based assay for simultaneous detection of nitrite and nitrate (NO(x)) in human samples. Vanadium reduces nitrate to nitrite, which can be measured after a colorimetric reaction with Griess reagents. Cisternal cerebro spinal fluid (CSF), serum and urine samples from 10 patients with acute brain injury (ABI) were compared to control subjects. Significantly higher CSF NO(x) levels were found in brain injury patients compared to control patients (19.7+/-13.7 vs. 6.5+/-2.3 microM; p=0.01), which persisted for 10-day period of observation. The serum and urine levels of NO(x) on admission were not statistically different (42.8+/-28.2 microM; 584.1+/-337.8 micromol/g Cr, respectively) from controls (36.8+/-14.8 microM; 819.7+/-356.0 micromol/g Cr), but tended to decrease during the disease course reaching the lowest level on day 6 (serum: 19.3+/-8.4 microM, urine: 300.4+/-111.9 micromol/g Cr). CSF levels of NO(x) correlated moderately with those in serum (p=0.001, R=0.5). Serum NO(x) concentrations correlated weakly with urine levels (p=0.04, R=0.3). There was no significant correlation between CSF NO(x) and urine NO(x) levels. In conclusion, patients suffering brain injury had increased NO(x) concentrations in CSF, which remained independent from other body fluid compartments. Serum and urinary NO(x) levels cannot be used as a reliable index to assess intrathecal NO production.

Amnesia, neuroendocrine levels and PTSD in motor vehicle accident victims

PRIMARY OBJECTIVE

To examine the initial neuroendocrine responses and subsequent PTSD symptomatology among amnesic and non-amnesic victims of motor vehicle accidents. It was hypothesized that amnesic patients would be less likely to meet PTSD criteria at 1 month follow-up and would display lower catechalomine levels and higher basal cortisol than non-amnesics.

METHODS AND PROCEDURE

Fifteen-hour urinary hormone samples were collected from 70 MVA victims upon hospital admission. Participants were assessed for PTSD symptomatology 1 month later.

MAIN OUTCOMES AND RESULTS

Amnesic patients displayed lower NE/cortisol ratios than non-amnesics, were less likely than non-amnesics to develop PTSD, and displayed fewer PTSD symptoms than non-amnesics.

CONCLUSIONS

Amnesics may physiologically experience a motor vehicle accident differently from non-amnesics and have lower subsequent PTSD incidence. These results provide partial support for the hypothesis that amnesia for a traumatic event can serve as a buffering function in the development of subsequent PTSD among MVA victims.

A method to estimate urinary electrolyte excretion in patients at risk for developing cerebral salt wasting

OBJECT

Two major criteria are necessary to diagnose cerebral salt wasting (CSW): a cerebral lesion and a large urinary excretion of Na+ and Cl- at a time when the extracellular fluid (ECF) volume is contracted. Nevertheless, it is difficult for the physician to confirm from bedside observation that a patient has a contracted ECF volume. Hyponatremia, although frequently present, should not be a criterion for a diagnosis of salt wasting. A contracted ECF volume is unlikely if there are positive balances of Na+ and Cl-. The goal of this study was to assess the accuracy of calculating balances for Na+ plus K+ and of Cl- over 1 to 10 days in an intensive care unit (ICU) setting.

METHODS

A prospective comparison of measured and estimated quantities of Na+ plus K+ and of Cl- excreted over 1 to 10 days in 10 children and 12 adults who had recently received a traumatic brain injury or undergone recent neurosurgery. Plasma concentrations of electrolytes were recorded at the beginning and end of the study period. The total volumes infused and excreted and the concentrations of Na+, K+, and Cl- in the infusate were obtained from each patient's ICU chart. The electrolytes in the patients' urine were measured and calculated. Correlations between measured and calculated values for excretions of Cl- and of Na+ plus K+ were excellent.

CONCLUSIONS

Mass balances for Na+ plus K+ and for Cl- can be accurately estimated. These data provide information to support or refute a clinical diagnosis of CSW. The danger of relying on balances for these electrolytes measured within a single day to diagnose CSW is illustrated.

Assessment of neuroendocrine dysfunction following traumatic brain injury

Posttraumatic neuroendocrine pathology may be a clinically significant complication following traumatic brain injury (TBI). Metabolic abnormalities are described after TBI in two cases. A 21 year old male injured in a motor vehicle accident admitted in a minimally responsive condition presented with fluctuating high sodium levels, undetectable serum testosterone, and depressed cortisol and thyroid function. Imaging revealed near complete avulsion of the pituitary stalk leading to panhypopituitarism. A 38 year old male admitted for occipital skull fractures and brain contusions presented with hyponatremia and low serum testosterone. Both patients required hormonal replacement and correction of electrolyte abnormalities. A screening protocol adapted for selected patients at risk for endocrine problems is described. While neuroendocrine screening is not advocated in all TBI patients, physicians should be aware of the importance of neuroendocrine dysfunction following TBI.

Increases in metabolism of valproate and excretion of 6beta-hydroxycortisol in patients with traumatic brain injury

AIMS

The objectives of this study were to determine the effect of brain trauma on the multiple pathways of metabolism of valproate and to evaluate the use of the urinary 6beta-hydroxycortisol to cortisol ratio in predicting changes in hepatic metabolism induced by brain injury.

METHODS

Fourteen patients with severe head injuries received a 15 mg kg(-1) loading dose and a maintenance dose of valproate to maintain therapeutic plasma concentrations. A minimum of one steady state trough blood sample and one dosage interval urine were collected during days 3-6 and during days 7-14 post-injury. Total and unbound valproate plasma concentrations were determined by gas chromatography-flame ionization detection (GC-FID) with and without ultrafiltration. Urinary valproate metabolites were measured by gas chromatography/mass spectrometry (GC-MS) (n = 10). Urinary 6beta-hydroxycortisol and cortisol concentrations were determined by high performance liquid chromatography (h.p.l.c.) (n = 14). Total intrinsic clearance (CL[int]) for valproate and individual formation clearances (CL[f]) to its major metabolites were calculated. Data obtained during baseline (days 3-6) were averaged for each patient and were compared with averaged data obtained from days 7 to 14 using a paired t-test.

RESULTS

Statistically significant increases in the CL(int), CL(f) of VPA glucuronide, 2-ene-VPA, and 4-OH-VPA pathways and the 6beta-hydroxycortisol to cortisol ratio were found. The percent change in the 6beta-hydroxycortisol to cortisol ratio correlated significantly with the changes in the CL(int) of valproate.

CONCLUSIONS

Brain trauma results in induction of multiple pathways of valproate metabolism and increases in the 6beta-hydroxycortisol to cortisol ratio, suggesting a non-specific enzyme induction in response to head injury.

Drugs and brain death

IN THE EARLY HOURS of the morning, a fit young man leaves a party, where drugs are reported to have been consumed, to walk home. A short time later he is found unconscious by the roadside, with severe head injuries. En route to hospital by ambulance, he suffers a cardiac arrest and is successfully resuscitated. On arrival at the Emergency Department he has obvious head injuries and is deeply unconscious, but shows spontaneous ventilatory movements. Available history is that he is a 20-year-old student with well-controlled epilepsy for which he takes phenytoin. It is not known how he sustained his injuries. Pupils are equal, small and react sluggishly to light. There is generalised flaccidity and an extensor-plantar response to painful stimuli. Skull x-rays show no fractures and computed tomography shows early cerebral oedema and scattered cerebral contusions with evidence of subarachnoid haemorrhage. He is transferred to the intensive care unit and measures to inhibit cerebral oedema, including mannitol, are commenced. An N-methyl-D-aspartate (NMDA) inhibitor is administered for neuroprotection and ventilatory support is commenced. Over the next 24 hours haemodynamic support is needed with fluid loading and vasopressors. A urine drug screen by Toxilab (Toxilab Incorporated, Irvine, Calif.) shortly after arrival shows the presence of phenytoin and morphine. The report states that the presence of benzodiazepines is suspected. Plasma phenytoin concentration at the time of arrival was 78 mumol/L (optimal range, 40-80 mumol/L). Forty hours after admission his condition has deteriorated. His pupils are at midposition, no longer reactive to light and his lower limbs exhibit only spinal reflexes. His relatives begin to prepare themselves for the fact he may not survive and raise the issue that he would have been keen to donate organs under such circumstances. What is the opinion regarding withdrawal of life support at this time?

Elevation of tumor necrosis factor in head injury

Tumor necrosis factor (TNF) is a cytokine which mediates protein wasting in pathological states by promoting the catabolism of visceral tissues and skeletal muscle. The role that TNF plays in nitrogen wasting following head injury was studied by measuring TNF in the serum of 21 patients with severe head injury. Parallel measurements of TNF and urinary nitrogen excretion were performed on days 1, 3, and 5 after head injury. TNF values after head injury ranged from 65 pg/ml to 7500 pg/ml, with a mean of 1147 pg/ml, compared to control values of serum TNF of less than 38 pg/ml. The mean daily urinary nitrogen loss was 13 g/day with a range of 2.8 to 27.6 g/day, and the mean nitrogen balance was -5.8 g with a range of +4.6 to -19.1 g. While both serum TNF levels and nitrogen loss were increased after head injury, the elevation of TNF did not correlate strongly with nitrogen wasting.

The acute-phase response of the brain-injured patient

The acute response to injury and infection is manifested by increased synthesis of acute-phase proteins by the liver, an increased white blood cell count, fever, a negative nitrogen balance, and altered serum mineral levels (zinc, iron, and copper). This response is thought to be partially mediated by cytokines such as interleukin-1, but has not been well studied in head-injured patients. In this study, 25 patients were studied for evidence of the acute-phase response extending from hospital admission up to 21 days postinjury. The patients were divided into two groups to determine if severity of injury influenced the response. Group 1 consisted of nine patients with admission peak 24-hour Glasgow Coma Scale (GCS) scores of 4 or less; Group 2 consisted of 16 patients with admission peak 24-hour GCS scores of 8 or greater. All patients demonstrated some evidence of the acute-phase response. Serum alpha-1 acid glycoprotein, ceruloplasmin, and C-reactive protein levels were elevated on admission and throughout the study. Serum albumin and zinc levels were depressed on admission; zinc levels gradually normalized by Day 21 in both groups, but hypoalbuminemia was observed throughout the study period. Serum copper levels were normal on admission but increased to above normal in both groups by Day 11 postinjury. Urinary urea nitrogen excretion was elevated in both groups and peaked on Day 7 for Group 1 and Day 11 for Group 2 patients. The patients with admission GCS scores equal to or less than 4 had overall higher temperatures than were seen in those with GCS scores greater than or equal to 8 (p = 0.009). All patients but one had an elevated white blood cell count on admission. It is concluded that brain-injured patients with admission GCS scores of 3 to 4 and 8 to 14 demonstrate an acute-phase response which lasts for at least 3 weeks postinjury. It is speculated that this response is at least partially mediated by increased intraventricular interleukin-1 activity.

Dexamethasone therapy and cortisol excretion in severe pediatric head injury

Glucocorticoids are used in an attempt to reduce brain edema secondary to head injury. Nevertheless, their usefulness remains uncertain and contradictory. In a randomized study of 24 children with severe head injury, urinary free cortisol was measured by radioimmunoassay. Twelve patients (group 1) received dexamethasone and 12 (group 2) did not. All patients were treated with a standardized regimen. In group 1 there was complete suppression of endogenous cortisol production. In group 2 free cortisol was up to 20-fold higher than under basal conditions and reached maximum values on days 1-3. Since the excretion of cortisol in urine reflects the production rate closely and is not influenced by liver function and barbiturates, the results in group 2 show that the endogenous production of steroids is an adequate reaction to severe head injury. Exogenous glucocorticoids are thus unlikely to have any more beneficial effects than endogenous cortisol.

Serum and urine zinc response in head-injured patients

A prospective longitudinal evaluation of serum zinc concentrations was performed in 26 head-trauma patients, and 24-hour urine zinc excretion was determined in 15 of these subjects. Patients had markedly depressed admission serum zinc concentrations (mean +/- standard error of the mean: 40.2 +/- 3.2 micrograms/dl; normal values: 70 to 120 micrograms/dl), which gradually increased during the 16-day study period. All subjects demonstrated increased urinary zinc losses throughout the study period. Urinary zinc excretion was greater in patients with more severe head injuries. Indeed, patients with more severe head trauma had mean peak urinary zinc losses of greater than 7000 micrograms/day (normal less than 500 (micrograms/day). The implications of this altered zinc metabolism for protein metabolism, wound healing, and immune function, and the specific role of zinc in brain function and recovery from injury are discussed.

Modified injury severity scale and concurrent steroid therapy: independent correlates of negative nitrogen balance in pediatric trauma

Twelve well-nourished children with multiple trauma were separately grouped by the presence or absence of a head injury and associated steroid treatment. They were studied to determine the impact of the severity of overall injury (measured by MISS), neurologic injury (measured by GCS), and steroid administration on total urinary nitrogen excretion. All six children with significant head injury received steroids. Nitrogen loss was higher in more severely injured patients. Severity of overall injury was similar in the steroid and nonsteroid treated groups. The nitrogen loss in head-injured patients treated with steroids was significantly greater (P less than 0.001) than in the nonsteroid-treated patients.

Steroid administration and nitrogen excretion in the head-injured patient

The effect of steroid administration on metabolic rate and nitrogen excretion was examined in 20 head-injured patients alternately assigned to receive either methylprednisolone for 14 days or no steroid treatment. Although metabolic rate, caloric intake, and nitrogen intake were not different between the two groups, the patients who received steroids had a 30% higher excretion of nitrogen during the first 6 days after injury than did the patients not receiving steroids. All patients had an increase in nitrogen excretion through the 2nd week, peaking on Day 11. By Day 21 after injury, the patients had an average cumulative nitrogen loss of 162 gm and had lost an average of 5 kg body weight regardless of whether they had received steroids. Serum albumin levels decreased in the steroid-treated patients but returned to nearly normal by Day 21 in the untreated group. Immunosuppression, evidenced by a lower initial total lymphocyte count and a higher incidence of infections, was present in the steroid group; hyperglycemia requiring insulin treatment was more common in those patients.

Determination of 3 methyl-L-histidine in human urine by ion exchange high performance liquid chromatography. Applications to patients in post-operative surgical care

A new chromatographic procedure is proposed for measuring 3 methyl-L-histidine (3 MH) in human urine. The sample was purified on a cation-exchange resin (AGR 50W-X4) and analysed by ion exchange high performance liquid chromatography on a PARTISIL 10 SCX Whatman column in UV light at 210 nm within 16 min. This procedure gave similar outputs of 3 MH to those described in human normal urine (mean +/- SEM = 213 +/- 15 mumol X 24 h-1, n = 19). It was used to measure the urinary outputs of 3 MH of five patients admitted to an intensive surgical care unit, for 48, 28, 25, 15 and 10 days, respectively. The urinary outputs of 3 MH were normal or lower than normal. The 10(3) urinary 3 MH/creatinine molar ratios were also calculated; this new 3 MH analysis could help the reanimator to prescribe an adequate nutritional assessment.

[CSF enzyme activities in patients with head injury--especially on GOT, GPT, LDH, and CPK (AUTHOR'S TRANSL)]

In our studies on patients with head injury, it was noted that there are some correlations between their clinical courses and the urinary excretion of creatine (cr), creatinine (Crn), 17-ketosteroid and 17-hydroxycorticosteroid. We observed the high urinary excretion of Cr in patients with severe head injury while almost negative in a mild case. We reported those facts in 1974. Also noted in patients with head injury is the relationship between the enzyme-activities (GOT, GPT, LDH and CPK) in the cerebrospinal fluid and their clinical courses. In this paper, we reported 34 cases of head injured patients (simple type: 2, concussion: 9, contusion: 8, acute intracranial hematoma: 7 and chronic intra-cranial hematoma: 8). The control values of CSF enzyme-activities were determined in these 14 cases (simple head injury, whip-lash injury and osteoma of the skull) as GOT less that 15, GPT less than 7, LDH less than 12 and CPK less than 8 units. In the moderate cases, a slight increase in activities of 4 enzymes in CSF were observed, while in severe or comatose cases, the enzyme-activities (especially LDH and CPK) were greater than in the controls. In the dead cases these values were five times as high as the normal case. In the patients recovering from a serious stage, these activities decreased to normal. High CSF enzyme-levels tend to indicate a poor prognosis and low levels a favorable progrosis. In the patients with a significant elevation of CSF enzymes, a high urinary excretion of Cr [normal range: 0-150 (ca. 50)mg/day] was often observed. There was no apparent correlation between the enzyme level in CSF and that in serum and the increase or decrease of these 4 enzymes are not always proprotionate with each other. As reported by Green (1958) and Lending (1961), cerebral cell necrosis and increased permeability of BLB, BBB or cerebral cell membrane can be related to the increase of enzymeactivities. With these observations, it can be considered that severe head injury gives influence on metabolic function in the hypothalamus and may cause in the levels of CSF enzymes and/or the urinary excretions of Cr, Crn and corticosteroids. And the examinations of enzyme activities in the patients with head injury may become a useful aid to make an outlook of their clinical coure and prognosis.

[Cranio-cerebral trauma and circadian rhythms of activity of several functions of the hypothalamo-hypophyseo-adrenal system in patients of different age groups]

The circadian rhythms of the androgenic and glucocorticoid activity of the adrenal cortex were examined in 7 patients with concussions of the brain, and in 22 -- with contusions. The excretion of 17-ketosteroids and of total 17-oxycorticosteroids was determined dynamically in separate 6-hour portions of the urine. In cases of brain concussions, both in the initial period of the trauma, and 10--12 days therafter, only a tendency towards increased excretion of corticosteroids during the night and decreased excretion in the morning hours was observed. In brain contusions the rhythm of andorgenic activity was altered. The most significant alterations caused by a severe trauma were observed in the rhythm of the glucocorticoid function of the adrenal cortex: its reduction in the morning hours, and increase during the night. Some 10--12 days after the brain contusions the rhythm of the hormonal activity remained altered, especially in young and middle-aged patients. These peculiarities of the rhythms should be taken into account when prescribing replacement corticosteroid therapy.

Lactosuria - a new metabolic feature of severe cerebrocranial trauma

Under controlled dietary conditions the urinary excretion of lactose was studied in 15 healthy persons, 15 patients with cerebrocranial trauma and 15 patients with extracranial trauma. Urinary lactose levels were found to be markedly increased in patients with head injury and ranged from 10.3 to 147.7 mg/24 h with a mean 63.4 mg/24 h in contrast to patients with other injuries (3.1 to 17.0 mg/24 h, mean 9.4 mg/24 h; P less than 0.001), and healthy individuals (3.3 to 17.93 mg/24 h, mean 7.6 mg/24h; P less than 0.001). In the head injury group the lowest values were found in drowsy or disoriented patients with cerebral concussion and the highest in comatose subjects. The level of lactosuria decreases after approximately 12 to 16 days to normal levels even when the patient remains unconscious. An earlier return to normal excretion parallels or preceeds the reappearance of consciousness. Unlike alimentary lactosuria, caused by ingestion of milk or other dairy products in large quantities, the elevated lactose levels in head injury patients were not usually accompanied by a comparable rise in galactose excretion, mean 11.45 mg/24 h versus 9.17 mg/24 h in controls; P less than 0.2. The mechanism of enhanced lactose excretion in severe cerebrocranial trauma remains unknown. It is suggested that it may be associated with either an increased catabolism of brain gangliosides or a stimulated lactose synthesis in peripheral tissues probably due to the participation of the lactogenic hormone prolactin.