A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension

OBJECT

The object of our study was to determine, in children with traumatic brain injury and sustained intracranial hypertension, whether very early decompressive craniectomy improves control of intracranial hypertension and longterm function and quality of life.

METHODS

All children were managed from admission onward according to a standardized protocol for head injury management. Children with raised intracranial pressure (ICP) were randomized to standardized management alone or standardized management plus cerebral decompression. A decompressive bitemporal craniectomy was performed at a median of 19.2 h (range 7.3-29.3 h) from the time of injury. ICP was recorded hourly via an intraventricular catheter. Compared with the ICP before randomization, the mean ICP was 3.69 mmHg lower in the 48 h after randomization in the control group, and 8.98 mmHg lower in the 48 hours after craniectomy in the decompression group (P=0.057). Outcome was assessed 6 months after injury using a modification of the Glasgow Outcome Score (GOS) and the Health State Utility Index (Mark 1). Two (14%) of the 14 children in the control group were normal or had a mild disability after 6 months, compared with 7 (54%) of the 13 children in the decompression group. Our conclusion was that when children with traumatic brain injury and sustained intracranial hypertension are treated with a combination of very early decompressive craniectomy and conventional medical management, it is more likely that ICP will be reduced, fewer episodes of intracranial hypertension will occur, and functional outcome and quality of life may be better than in children treated with medical management alone (P=0.046; owing to multiple significance testing P <0.0221 is required for statistical significance). This pilot study suggests that very early decompressive craniectomy may be indicated in the treatment of traumatic brain injury.

Subunit structure, cell surface orientation, and partial amino-acid sequences of murine histocompatibility antigens

Detergent and papain solubilized murine histocompatibility (H-2) antigens have been compared by gel exclusion chromatography, ultracentrifugation, sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and amino-acid sequence analysis. From these data, we propose a molecular model for the H-2 antigens that includes the size and arrangement of the subunits on the cell surface and in solution, and we provide evidence for the orientation of these molecules on the cell surface. Detergent solubilized H-2 antigens (molecular weight 116,000) consist of two disulfide-linked heavy chains (46,000 daltons) and two monocovalently associated light chains (12,000 daltons). Alkylation with iodoacetamide prior to extraction prevented the formation of a disulfide linkage between the two heavy chains. A water-soluble 51,000-dalton molecule (Fs) consisting of a 39,000-dalton fragment (FH) of the heavy chain and one intact light chain was obtained by papain digestion of cells or detergent extracts. Therefore, the disulfide linkage between the heavy chains is located in the remaining membrane-associated portion (Fm). Amino-acid sequence analysis of the FH fragment of H-2Kb by radiochemical techniques showed that it is identical to the detergent solubilized H-2Kb heavy chain in eight positions for the three amino acids tested. These data indicate that the fragment FH derives from the amino-terminus of the heavy chain and suggest that it projects outward from the cell surface, while the carboxyl-terminal region is associated with the plasma membrane. The described amino-terminal sequence data have been found constant in H-2Kb, H-2Kd, H-2Kk, H-2Db, and H-2Dd gene products. These data support the hypothesis that the K and D products of the major histocompatibility antigen complex have evolved by gene duplication.

Pink-beam serial crystallography

Serial X-ray crystallography allows macromolecular structure determination at both X-ray free electron lasers (XFELs) and, more recently, synchrotron sources. The time resolution for serial synchrotron crystallography experiments has been limited to millisecond timescales with monochromatic beams. The polychromatic, "pink", beam provides a more than two orders of magnitude increased photon flux and hence allows accessing much shorter timescales in diffraction experiments at synchrotron sources. Here we report the structure determination of two different protein samples by merging pink-beam diffraction patterns from many crystals, each collected with a single 100 ps X-ray pulse exposure per crystal using a setup optimized for very low scattering background. In contrast to experiments with monochromatic radiation, data from only 50 crystals were required to obtain complete datasets. The high quality of the diffraction data highlights the potential of this method for studying irreversible reactions at sub-microsecond timescales using high-brightness X-ray facilities.

Anthraquinones in Rheum palmatum and Rumex dentatus (Polygonaceae), and phorbol esters in Jatropha curcas (Euphorbiaceae) with molluscicidal activity against the schistosome vector snails Oncomelania, Biomphalaria and Bulinus

Hot water extracts of Rheum plamatum and Rheum dentatus (from China) showed molluscicidal activity against the snails Oncomelania hupensis, Biomphalaria glabrata and Bulinus globosus, which are vectors of Schistosoma japonicum, S. mansoni and S. haematobium, respectively. Activity was correlated with antraquinones which were identified by HPLC: rhein and chrysophanol-anthron were most active (> 50% dead snails after 2 days in a 0.03% solution). Molluscicidal activity was intermediate with Rheum-emodin and physcion and was not detectable with cinnamic acid or Aloe-emodin. The snail O. hupensis tended to be more sensitive for several compounds than B. glabrata. Extracts of Jatropha curcas seeds (from Mali) showed molluscicidal activity against both B. glabrata and O. hupensis, the latter being the more sensitive snail. The activity was associated with phorbol esters extracted from Jatropha oil. Of the pure phorbol esters tested, 4 beta-phorbol-13-decanoate killed both snail species at a concentration of 0.001% (10 p.p.m). As Jatropha is locally grown in Mali for other purposes, it might potentially be exploited for schistosomiasis control.

High statistics measurement of the positron fraction in primary cosmic rays of 0.5-500 GeV with the alpha magnetic spectrometer on the international space station

A precision measurement by AMS of the positron fraction in primary cosmic rays in the energy range from 0.5 to 500 GeV based on 10.9 million positron and electron events is presented. This measurement extends the energy range of our previous observation and increases its precision. The new results show, for the first time, that above ∼200  GeV the positron fraction no longer exhibits an increase with energy.

Simian virus 40 T-antigen-related cell surface antigen: serological demonstration on simian virus 40-transformed monolayer cells in situ

Simian virus 40 (SV40)-transformed monolayer cells were analyzed in situ by indirect immunofluorescence microscopy for the postulated cell surface location of SV40 T-antigen-related molecules. With antisera prepared against purified, sodium dodecyl sulfate-denatured SV40 T-antigen, positive surface staining was obtained when the cells had been treated with formaldehyde before immunofluorescence analysis. In contrast, living SV40-transformed cells analyzed in monolayer were surface fluorescence negative. The fixation procedure developed in this study combined with a double staining immunofluorescence technique allowed the simultaneous analysis of the same cells for the expression of both SV40 T-antigen-related surface antigen and nuclear T-antigen. The localization of SV40 T-antigen-related surface antigen on the outer surface of the plasma membrane of formaldehyde-fixed SV40-transformed cells was demonstrated directly by the protein A-mediated binding of Staphylococcus aureus bacteria on formaldehyde-fixed SV40-transformed cells precoated with antiserum against sodium dodecyl sulfate-denatured T-antigen. Both cell surface staining and S. aureus binding were found to be highly specific for SV40 T-antigen-related binding sites. These results indicate that T-antigen-related molecules in a cryptic form are located on the surface of SV40-transformed monolayer cells and can be detected in situ after modification of the cell surface architecture.

pH gradient across the lysosomal membrane generated by selective cation permeability and Donnan equilibrium

The pH within isolated Triton WR 1339-filled rat liver lysosomes was determined by measuring the distribution of [14C]methylamine between the intra- and extralysosomal space. The intralysosomal pH was found to be approximately one pH unit lower than that of the surrounding medium. Increasing the extralysosomal cation concentration lowered the pH gradient by a cation exchange indicating the presence of a Donnan equilibrium. The lysosomal membrane was found to be significantly more permeable to protons than to other cations. The relative mobility of cations through the lysosomal membrane is H+ greater than Cs+ greater than Rb+ greater than K greater than Na+ greater than Li+ greater than Mg2+, Ca2+. The presented data suggest that the acidity within isolated Triton WR 1339-filled lysosomes is maintained by: (1) a Donnan equilibrium resulting from the intralysosomal accumulation of nondiffusible anions and (2) a selective permeability of the lysosomal membrane to cations.

Synthesis and neuroleptic activity of a series of 1-[1-(benzo-1,4-dioxan-2-ylmethyl)-4-piperidinyl]benzim idazolone derivatives

A series of 1-[1-(benzo-1,4-dioxan-2-ylmethyl)-4-piperidinyl]benzimid azolones with various substituents in both aromatic rings have been synthesized and tested for neuroleptic activity (antiapomorphine effects and [3H]spiroperidol binding) as well as extrapyramidal effects (cataleptogenic effect). A strong dependence of activity on the 5-substituent in the benzimidazolone moiety could be demonstrated. Some compounds show a large split between the desired antiapomorphine and the undesired extrapyramidal effect. From these, 1-[1-(benzo-1,4-dioxan-2-ylmethyl)-4-piperidinyl]-5-chlor obenzimidazol-2-one hydrochloride (HR 723), 12, has been selected for further preclinical and toxicological profiling.

Cubic aluminum silicides RE8Ru12Al49Si9(Al(x)Si12-x) (RE = Pr, Sm) from liquid aluminum. Empty (Si,Al)12 cuboctahedral clusters and assignment of the Al/Si distribution with neutron diffraction

Two new quaternary aluminum silicides, RE8Ru12Al49Si9(Al(x)Si12-x) (x approximately 4; RE = Pr, Sm), have been synthesized from Sm (or Sm2O3), Pr, Ru, and Si in molten aluminum between 800 and 1000 degrees C in sealed fused silica tubes. Both compounds form black shiny crystals that are stable in air and NaOH. The Nd analog is also stable. The compounds crystallize in a new structural type. The structure, determined by single-crystal X-ray diffraction, is cubic, space group Pm3m with Z = 1, and has lattice parameters of a = 11.510(1) A for Sm8Ru12Al49Si9(Al(x)Si12-x) and a = 11.553(2) A for Pr8Ru12Al49Si9(Al(x)Si12-x) (x approximately 4). The structure consists of octahedral units of AlSi6, at the cell center, Si2Ru4Al8 clusters, at each face center, SiAl8 cubes, at the middle of the cell edges, and unique (Al,Si)12 cuboctohedral clusters, at the cell corners. These different structural units are connected to each other either by shared atoms, Al-Al bonds, or Al-Ru bonds. The rare earth metal atoms fill the space between various structural units. The Al/Si distribution was verified by single-crystal neutron diffraction studies conducted on Pr8Ru12Al49Si9(Al(x)Si12-x). Sm8Ru12Al49Si9(Al(x)Si12-x) and Pr8Ru12Al49Si9(Al(x)Si12-x) show ferromagnetic ordering at Tc approximately 10 and approximately 20 K, respectively. A charge of 3+ can be assigned to the rare earth atoms while the Ru atoms are diamagnetic.

Imaging nonequilibrium atomic vibrations with x-ray diffuse scattering

We use picosecond x-ray diffuse scattering to image the nonequilibrium vibrations in the lattice following ultrafast laser excitation. We present images of nonequilibrium phonons in InP and InSb throughout the Brillouin zone which remain out of equilibrium up to nanoseconds. The results are analyzed using a Born model that helps identify the phonon branches contributing to the observed features in the time-resolved diffuse scattering. In InP this analysis shows a delayed increase in the transverse-acoustic (TA) phonon population along high-symmetry directions accompanied by a decrease in the longitudinal-acoustic phonons. In InSb the increase in TA phonon population is less directional.

Neutron and X-ray structural studies of short hydrogen bonds in photoactive yellow protein (PYP)

Photoactive yellow protein (PYP) from Halorhodospira halophila is a soluble 14 kDa blue-light photoreceptor. It absorbs light via its para-coumaric acid chromophore (pCA), which is covalently attached to Cys69 and is believed to be involved in the negative phototactic response of the organism to blue light. The complete structure (including H atoms) of PYP has been determined in D(2)O-soaked crystals through the application of joint X-ray (1.1 A) and neutron (2.5 A) structure refinement in combination with cross-validated maximum-likelihood simulated annealing. The resulting XN structure reveals that the phenolate O atom of pCA accepts deuterons from Glu46 O(epsilon2) and Tyr42 O(eta) in two unusually short hydrogen bonds. This arrangement is stabilized by the donation of a deuteron from Thr50 O(gamma1) to Tyr42 O(eta). However, the deuteron position between pCA and Tyr42 is only partially occupied. Thus, this atom may also interact with Thr50, possibly being disordered or fluctuating between the two bonds.

Effects of nitric oxide synthase inhibition combined with nitric oxide inhalation in a porcine model of endotoxin shock

1. The present investigation compares the effects of intravenous infusion of the NO synthase inhibitor NG-monomethyl-L-arginine (L-NMMA) with that of an inhalation with NO gas in a porcine model of endotoxin (lipopolysaccharide, LPS) shock. In addition, the effects of the combination of these two treatments were also investigated. 2. Male pigs were anaesthetized and instrumented for the measurement of haemodynamic parameters. Blood samples were withdrawn at different time intervals for determination of blood gases, pH, and plasma levels of nitrite/nitrate and tumour necrosis factor. 3. Endotoxin infusion (15 micrograms kg-1 h-1 for 3 h) caused a progressive fall in mean arterial blood pressure (MABP) and cardiac output (CO) and a biphasic increase in mean pulmonary arterial pressure (MPAP) and pulmonary vascular resistance (PVR). A continuous infusion of L-NMMA (0.1 mg kg-1 min-1) significantly attenuated the fall in MABP, but did not affect MPAP, CO and PVR. NO-inhalation (50 p.p.m.) did not affect MABP, but significantly blunted the biphasic increase in MPAP and PVR and significantly delayed the fall in CO. The combination of L-NMMA infusion (0.1 mg kg-1 min-1) with NO-inhalation (50 p.p.m.) completely prevented the fall in MABP, significantly improved CO, and attenuated the biphasic increase in MPAP and PVR. 4. Endotoxin also caused a decline in PaO2 and a rise of PaCO2. Infusion of L-NMMA neither affected the fall in PaO2 nor the increase in PaCO2. In contrast, inhalation with NO gas alone as well as the combined administration of L-NMMA infusion and NO-inhalation completely prevented the fall in Pao2 and significantly protected against the increase in Paco2.5. Infusion of endotoxin for 180 min resulted in a mortality of 58%, which was not affected by L-NMMA (63%). In contrast, treatment of LPS-animals with either NO-inhalation alone or NO inhalation plus L-NMMA completely prevented mortality.6. This investigation demonstrates that treatment with NO-inhalation, in order to prevent the dramatic increase in MPAP, PVR and the alterations in peripheral blood gases combined with systemic L-NMMAto improve systemic MABP and thus organ perfusion, may be a new therapeutic regimen in the treatment of septic shock.

Measurement of functional residual capacity in rabbits and children using an ultrasonic flow meter

A sulfur hexafluoride (SF(6)) washin/washout technique was developed using an ultrasonic flowmeter to measure functional residual capacity (FRC) during mechanical ventilation. The ultrasonic flowmeter measures simultaneously flow and molar mass of the mainstream gas. Ventilation distribution was studied using moment ratios analysis (alveolar-based mean dilution number). Accuracy and precision of the measurement technique were tested in a mechanical lung model, and the method's sensitivity to changes of FRC was assessed in seven ventilated rabbits and six children. In the mechanical lung model with a volume range from 10 to 60 mL, the mean error of FRC measurement was 0.096 +/- 0.9 mL (range, 0-2 mL). In seven rabbits (mean body weight, 3.6 kg), measurements of FRC and alveolar-based mean dilution number were made at positive end-expiratory pressures (PEEP) of 0, 3, and 6 cm H(2)O. The mean coefficient of variation of 66 FRC-measurements was 5.5% (range, 0-15.3%). As the applied PEEP increased, mean FRC per kilogram body weight increased from 13.3 +/- 3.4 mL/kg (PEEP of 0 cm H(2)O) to 16.7 +/- 3.6 mL/kg (PEEP of 3 cm H(2)O) and to 20.8 +/- 4.3 mL/kg (PEEP of 6 cm H(2)O). Alveolar-based mean dilution number decreased accordingly from 1.94 +/- 0.42 (PEEP = 0; mean +/- SD), to 1.91 +/- 0.45 (PEEP = 3) and to 1.59 +/- 0.35 (PEEP = 6). In the six children, as applied PEEP increased, mean FRC per kilogram increased from 21.1 +/- 4.51 mL/kg (PEEP = 0), to 22.4 +/- 1.8 mL/kg (PEEP = 5) and 27.2 +/- 3.4 mL/kg (PEEP = 10). FRC measurement using the ultrasonic flowmeter is accurate and simple to use in ventilated and spontaneously breathing children.

Self-assembly of simian virus 40 large T antigen oligomers by divalent cations

In simian virus 40-transformed cells, simian virus 40 large T antigen can be detected in different forms separable by sucrose density gradient centrifugation. In our experiments, light forms sedimented around 5 to 7S, oligomers such as tetramers were detected around 16S, and higher aggregates sedimented in a broad distribution reaching above 23S. The oligomers sedimenting at and above 16S could be disassembled into the slowly sedimenting 5 to 7S forms by chelating agents [EDTA or ethylene bis(oxonitrilo)tetraacetate]. After the addition of divalent cations (CaCl2 or MgCl2) in excess of chelating agents, oligomeric forms reassembled and appeared in a sedimentation pattern resembling that observed before treatment with chelating agents. Time course studies permitted the identification of the 5 to 7S forms as precursors upon pulse-labeling (15 min); the 16S and higher oligomers were identified as the successors after a 14-h chase. Treatment of extracts of pulse-chase-labeled cells with chelating agents again disassembled the oligomers, whereas pulse-labeled precursors did not change their 5 to 7S sedimentation pattern. Adding an excess of divalent cations reassembled the pulse-chase-labeled T antigen to oligomers but did not influence the sedimentation behavior of pulse-labeled 5 to 7S precursors. It is therefore reasonable to assume that a posttranslational modulation induces divalent cation binding, leading finally to the oligomerization of T antigen. Thus, some of the multifunctional activities of T antigen can be dictated by divalent cation binding properties.