Management of traumatic brain injury in the non-neurosurgical intensive care unit: a narrative review of current evidence

Each year, approximately 70 million people suffer traumatic brain injury, which has a significant physical, psychosocial and economic impact for patients and their families. It is recommended in the UK that all patients with traumatic brain injury and a Glasgow coma scale ≤ 8 should be transferred to a neurosurgical centre. However, many patients, especially those in whom neurosurgery is not required, are not treated in, nor transferred to, a neurosurgical centre. This review aims to provide clinicians who work in non-neurosurgical centres with a summary of contemporary studies relevant to the critical care management of patients with traumatic brain injury. A targeted literature review was undertaken that included guidelines, systematic reviews, meta-analyses, clinical trials and randomised controlled trials (published in English between 1 January 2017 and 1 July 2022). Studies involving key clinical management strategies published before this time, but which have not been updated or repeated, were also eligible for inclusion. Analysis of the topics identified during the review was then summarised. These included: fundamental critical care management approaches (including ventilation strategies, fluid management, seizure control and osmotherapy); use of processed electroencephalogram monitoring; non-invasive assessment of intracranial pressure; prognostication; and rehabilitation techniques. Through this process, we have formulated practical recommendations to guide clinical practice in non-specialist centres.

Dark Energy Survey Year 1 Results: Cosmological Constraints from Cluster Abundances, Weak Lensing, and Galaxy Correlations

We present the first joint analysis of cluster abundances and auto or cross-correlations of three cosmic tracer fields: galaxy density, weak gravitational lensing shear, and cluster density split by optical richness. From a joint analysis (4×2pt+N) of cluster abundances, three cluster cross-correlations, and the auto correlations of the galaxy density measured from the first year data of the Dark Energy Survey, we obtain Ω_{m}=0.305_{-0.038}^{+0.055} and σ_{8}=0.783_{-0.054}^{+0.064}. This result is consistent with constraints from the DES-Y1 galaxy clustering and weak lensing two-point correlation functions for the flat νΛCDM model. Consequently, we combine cluster abundances and all two-point correlations from across all three cosmic tracer fields (6×2pt+N) and find improved constraints on cosmological parameters as well as on the cluster observable-mass scaling relation. This analysis is an important advance in both optical cluster cosmology and multiprobe analyses of upcoming wide imaging surveys.

Constraints on Dark Matter Properties from Observations of Milky Way Satellite Galaxies

We perform a comprehensive study of Milky Way (MW) satellite galaxies to constrain the fundamental properties of dark matter (DM). This analysis fully incorporates inhomogeneities in the spatial distribution and detectability of MW satellites and marginalizes over uncertainties in the mapping between galaxies and DM halos, the properties of the MW system, and the disruption of subhalos by the MW disk. Our results are consistent with the cold, collisionless DM paradigm and yield the strongest cosmological constraints to date on particle models of warm, interacting, and fuzzy dark matter. At 95% confidence, we report limits on (i) the mass of thermal relic warm DM, m_{WDM}>6.5  keV (free-streaming length, λ_{fs}≲10h^{-1}  kpc), (ii) the velocity-independent DM-proton scattering cross section, σ_{0}<8.8×10^{-29}  cm^{2} for a 100 MeV DM particle mass [DM-proton coupling, c_{p}≲(0.3  GeV)^{-2}], and (iii) the mass of fuzzy DM, m_{ϕ}>2.9×10^{-21}  eV (de Broglie wavelength, λ_{dB}≲0.5  kpc). These constraints are complementary to other observational and laboratory constraints on DM properties.

The antioxidative enzyme SOD2 is important for physiological persistence of corpora lutea in lynxes

Corpora lutea (CL) are transient endocrine glands supporting pregnancy by progesterone production. They develop at the site of ovulation from the remaining follicle, are highly metabolically active and undergo distinct, transformative processes during their lifetime. In contrast to other species, CL of lynxes do not regress at the end of cycle, but remain functionally active (persist) for years. Reactive oxygen species (ROS) and anti-oxidative enzymes are described to be important for the functionality of CL. We examined ten anti-oxidative enzymes in fresh and persistent CL of lynxes as well as in domestic cat CL of different luteal stages. The gene expression profiles, especially those of SOD1 and SOD2, showed some remarkable differences between CL stages during non-pregnant and pregnant cycles of domestic cats and between fresh and persistent CL of lynxes. Lynx gene expression profiles of SODs were confirmed by western blot analysis, immunohistochemistry and activity assays. SOD2 was characterized by a conspicuous high expression and enzyme activity exclusively in persistent CL. We suggest that SOD2 is required to detoxify potential elevated superoxide anion levels by producing H₂O₂ in the physiologically persistent CL. This product might also act as a signaling molecule, securing the CL from apoptosis and insuring long-term luteal cell survival.

Cosmological Constraints from Multiple Probes in the Dark Energy Survey

The combination of multiple observational probes has long been advocated as a powerful technique to constrain cosmological parameters, in particular dark energy. The Dark Energy Survey has measured 207 spectroscopically confirmed type Ia supernova light curves, the baryon acoustic oscillation feature, weak gravitational lensing, and galaxy clustering. Here we present combined results from these probes, deriving constraints on the equation of state, w, of dark energy and its energy density in the Universe. Independently of other experiments, such as those that measure the cosmic microwave background, the probes from this single photometric survey rule out a Universe with no dark energy, finding w=-0.80_{-0.11}^{+0.09}. The geometry is shown to be consistent with a spatially flat Universe, and we obtain a constraint on the baryon density of Ω_{b}=0.069_{-0.012}^{+0.009} that is independent of early Universe measurements. These results demonstrate the potential power of large multiprobe photometric surveys and pave the way for order of magnitude advances in our constraints on properties of dark energy and cosmology over the next decade.

Clinical features of delayed endolymphatic hydrops and intralabyrinthine schwannoma : An imaging-confirmed comparative case series. English version

BACKGROUND

The aim of this study was to compare the clinical history and audiovestibular function test results of patients suffering from intralabyrinthine schwannoma or delayed endolymphatic hydrops (DEH).

PATIENTS AND METHODS

Five patients diagnosed with intralabyrinthine schwannoma by magnetic resonance imaging (MRI) and five patients diagnosed with DEH by locally enhanced inner ear MRI (LEIM) were retrospectively studied.

RESULTS

All patients with intralabyrinthine schwannoma or DEH initially presented with hearing loss. Vertigo occurred in two patients with intralabyrinthine schwannoma and in all patients with DEH. While audiometry achieved poorer results for patients with intralabyrinthine schwannomas, vestibular function tests revealed normal results in about half of the patients in both groups.

CONCLUSION

Patients with intralabyrinthine schwannomas may present with clinical symptoms similar to patients suffering from other inner ear disorders such as delayed endolymphatic hydrops and they may obtain similar findings in audiovestibular function tests. High-resolution magnetic resonance imaging with locally applied contrast agent may provide evidence of both underlying pathologies.

Recombinant expression of porcine spermadhesin AWN and its phospholipid interaction: Indication for a novel lipid binding property

AWN is a porcine (Sus scrofa domestica) seminal plasma protein and has been linked to a variety of processes related to fertilization. To acquire the protein in sufficient amount and purity for functional studies, we established its recombinant expression in E. coli and a three-step purification protocol based on different chromatographies. The test for AWN-phospholipid interaction revealed phosphatidic acid and cardiolipin as potential binding partners. As phosphatidic acid is surmised to play a role in cation-induced membrane destabilization and fusion events, we propose a membrane protective function of the presented binding affinity. Further studies with recombinant AWN will allow new insights into the mechanism of sperm-spermadhesin interaction and might provide new approaches for artificial reproduction techniques.

Ultrastructural calcium distribution and myocardial calcium content in human idiopathic dilated cardiomyopathy

Myocardial calcium overload in chronic heart failure is still a debatable issue. The aim of this study was to investigate the myocardial calcium content and intracellular calcium distribution in end-stage dilated cardiomyopathy. The explanted hearts of 13 patients (9 male, 4 female, mean age 49 ± 12 years) undergoing heart transplantation because of end-stage dilated cardiomyopathy were examined. Samples were obtained from the right and left ventricular free wall and from the septum. Calcium and magnesium content were measured by atomic absorption spectrophotometry. Ultrastructural calcium distribution was examined in dilated cardiomyopathy using the phosphate-pyroantimonate method. Ultrastructural calcium distribution was also examined in left ventricular biopsies obtained from 3 patients (male, mean age 47 ± 3.6 years) with nonfailing hearts. The number of mitochondrial calcium precipitates was estimated morphometrically by a point counting method. Myocardial calcium and magnesium content in dilated cardiomyopathy did not differ significantly among the right and left ventricles and septum ranging from 8.5 to 10.8 mmol/kg dry weight. The phosphate-pyroantimonate method visualized calcium precipitates being confined to the sarcolemma, T-tubules, intercalated disks, and mitochondria in both nonfailing myocardium and dilated cardiomyopathy. Because mitochondria may act as buffers of cytoplasmic calcium, mitochondrial calcium precipitates served as a criterion for a possible cellular calcium overload. No differences in the amount of mitochondrial calcium deposits were observed between dilated cardiomyopathy and nonfailing hearts. The data suggest that there is no global myocardial calcium overload in human eng-stage dilated cardiomyopathy.

Multiple indices of the 'bounce' phenomenon obtained from the same human ears

Loud low-frequency sounds can induce temporary oscillatory changes in cochlear sensitivity, which have been termed the 'bounce' phenomenon. The origin of these sensitivity changes has been attributed to slow fluctuations in cochlear homeostasis, causing changes in the operating points of the outer hair cell mechano-electrical and electro-mechanical transducers. Here, we acquired three objective and subjective measures resulting in a comprehensive dataset of the bounce phenomenon in each of 22 normal-hearing human subjects. We analysed the level and phase of cubic and quadratic distortion product otoacoustic emissions and the auditory thresholds before and after presentation of a low-frequency stimulus (30 Hz sine wave, 120 dB SPL, 90 s) as a function of time. In addition, the perceived loudness of temporary, tinnitus-like sensations occurring in all subjects after cessation of the low-frequency stimulus was tracked over time. The majority of the subjects (70 %) showed a significant, biphasic change of quadratic, but not cubic, distortion product otoacoustic emissions of about 3-4 dB. Eighty-six percent of the tested subjects showed significant alterations of hearing thresholds after low-frequency stimulation. Four different types of threshold changes were observed, namely monophasic desensitisations (the majority of cases), monophasic sensitisations, biphasic alterations with initial sensitisation and biphasic alterations with initial desensitisation. The similar duration of the three bounce phenomenon measures indicates a common origin. The current findings are consistent with the hypothesis that slow oscillations of homeostatic control mechanisms and associated operating point shifts within the cochlea are the source of the bounce phenomenon.

Effect of standard-dose Betahistine on endolymphatic hydrops: an MRI pilot study

This study aimed to assess whether standard-dose Betahistine (48 mg daily) exerts an effect upon the degree of endolymphatic hydrops in patients with Menière's disease using a retrospective case series in the setting of a tertiary neurotology referral centre. In six patients with definite unilateral Menière's disease, the degree of cochlear and vestibular endolymphatic hydrops was assessed before and after treatment with a standard dose of Betahistine (48 mg daily), using high-resolution 3 T MR imaging after intratympanic contrast medium application. The treatment duration was 3-7 months (mean 5 months), and the patients were followed-up for 6-29 months (mean 11 months). In the study cohort, the standard dose of Betahistine did not have an MR morphologically measurable beneficial effect on the degree of endolymphatic hydrops. The results indicated no effect of standard-dose Betahistine on endolymphatic hydrops found on high-resolution MR imaging. Possible explanations are: (1) insufficient dosage or duration of treatment with betahistine, (2) insufficient resolution of the MR imaging technique, and (3) insufficient length of follow-up. Further studies addressing these issues are warranted.

[Unilateral maxillary sinusitis: a cavernous haemangioma with bone destruction]

Haemangioma originating in the paranasal sinuses are a rare entity. In the case of unilateral sinusitis the differential diagnosis should include tumors. The following case of a 30-year-old female patient with a therapy-resistant sinusitis showed bone destruction and a maxillary shadow on computed tomography. The histological exam resulted in a cavernous haemangioma.

[Correlation of pure tone thresholds and hearing loss for numbers. Comparison of three calculation variations for plausibility checking in expertise]

BACKGROUND

The present study analyzes the best combination of frequencies for the calculation of mean hearing loss in pure tone threshold audiometry for correlation with hearing loss for numbers in speech audiometry, since the literature describes different calculation variations for plausibility checking in expertise. Three calculation variations, A (250, 500 and 1000 Hz), B (500 and 1000 Hz) and C (500, 1000 and 2000 Hz), were compared.

METHODS

Audiograms in 80 patients with normal hearing, 106 patients with hearing loss and 135 expertise patients were analyzed in a retrospective manner. Differences between mean pure tone audiometry thresholds and hearing loss for numbers were calculated and statistically compared separately for the right and the left ear in the three patient collectives.

RESULTS

We found the calculation variation A to be the best combination of frequencies, since it yielded the smallest standard deviations while being statistically different to calculation variations B and C. The 1- and 2.58-fold standard deviation (representing 68.3% and 99.0% of all values) was ±4.6 and ±11.8 dB for calculation variation A in patients with hearing loss, respectively.

CONCLUSIONS

For plausibility checking in expertise, the mean threshold from the frequencies 250, 500 and 1000 Hz should be compared to the hearing loss for numbers. The common recommendation reported by the literature to doubt plausibility when the difference of these values exceeds ±5 dB is too strict as shown by this study.

A Study on Oxidized Glassy Carbon sheets for Bipolar Supercapacitor Electrodes

Electrochemical Double Layer Capacitors (EDLC) for high energy and power density applications, based on glassy carbon (GO) electrodes, are being developed in our laboratory. In the context of this project, GC sheets were oxidized and investigated with Small Angle X-ray Scattering (SAXS), Electrochemical Impedance Spectroscopy (EIS) and Nitrogen Gas Adsorption (BET). During oxidation an active film with open pores is built on the surface of the GC. Upon oxidation, the internal volumetric surface area of the active film decreases, whereas the volumetric electrochemical double layer capacitance increases. We show that this effect is correlated with the opening, the growth and the coalescence of the pores.

Extracorporeal support: improves donor renal graft function after cardiac death

Donors after cardiac death (DCD) could increase the organ pool. Data supports good long-term renal graft survival. However, DCDs are <10% of deceased donors in the United States, due to delayed graft function, and primary nonfunction. These complications are minimized by extracorporeal support after cardiac death (ECS-DCD). This study assesses immediate and acute renal function from different donor types. DCDs kidneys were recovered by conventional rapid recovery or by ECS, and transplanted into nephrectomized healthy swine. Warm ischemia of 10 and 30 min were evaluated. Swine living donors were controls (LVD). ECS-DCDs were treated with 90 min of perfusion until organ recovery. After procurement, kidneys were cold storage 4-6 h. Renal vascular resistance (RVR), urine output (UO), urine protein concentration (UrPr) and creatinine clearance (CrCl), were collected during 4 h posttransplantation. All grafts functioned with adequate renal blood flow for 4 h. RVR at 4 h posttransplant returned to baseline only in the LVD group (0.36 mmHg/mL/min +/- 0.03). RVR was higher in all DCDs (0.66 mmHg/mL/min +/- 0.13), without differences between them. UO was >50 mL/h in all DCDs, except in DCD-30 (6.8 mL/h +/- 1.7). DCD-30 had lower CrCl (0.9 mL/min +/- 0.2) and higher UrPr >200 mg/dL, compared to other DCDs >10 mL/min and <160 mg/dL, respectively. Normothermic ECS can resuscitate kidneys to transplantable status after 30 min of cardiac arrest/WI.

Enhancement of saporin cytotoxicity by Gypsophila saponins--more than stimulation of endocytosis

Saporin is a type I ribosome-inactivating protein with N-glycosidase activity. It removes adenine residues from the 28S ribosomal RNA resulting in inhibition of protein synthesis. Recently we have shown that saporin exerts no cytotoxicity on seven human cell lines. However, the combination of saporin with a special mixture of Gypsophila saponins (Soapwort saponins) from Gypsophila paniculata L. (baby's breath) rendered saporin to a potent cytotoxin comparable to viscumin, a highly toxic type II ribosome-inactivating protein. In this study we investigated whether the enhancement of the saporin-cytotoxicity by Gypsophila saponins is mediated by a saponin-triggered modulation of endocytosis, exocytosis or impaired degradation processes of his-tagged saporin ((his)saporin) in ECV-304 cells. For this purpose (his)saporin was labelled with tritium and cytotoxicity of the toxin alone and in combination with Gypsophila saponins was scrutinized. The transport and degradation processes of (his)saporin were not different in Gypsophila saponin-treated and control cells. However, after ultracentrifugation of a post-nuclear supernatant the amount of cytosolic (his)saporin was significantly higher in saponin-treated cells than in cells, which were only incubated with (his)saporin. This indicates a saponin mediated endosomal escape of saporin.

Oxcarbazepin in der Epilepsietherapie

BACKGROUND

Oxcarbazepine (OXC; Timox) is a new antiepileptic drug (AED) chemically related to carbamazepine (CBZ), with comparable efficacy but superior safety according to controlled clinical trials. In a prospective, post-marketing surveillance (PMS) study the efficacy and tolerability of OXC were investigated under conditions of daily routine practice.

METHODS

The treatment of 1385 male and female epilepsy patients aged between 1 month and 94 years, who were newly stabilized on OXC or changed over from another AED, was documented in 362 centers over a period of 8 weeks. Efficacy and tolerability were assessed by documenting the frequency of seizures and adverse drug reactions (ADRs) and by global efficacy and tolerability ratings obtained from the patients and investigators.

RESULTS

Before the PMS study, 688/1335 patients (49.7 %) had received pre-treatment with CBZ, 342 (24.7 %) had received another AED and 335 (25.6 %) had had no AED pre-treatment (initial OXC monotherapy). In 161 patients pre-treated with CBZ (23,4 % of 688) an immediate (overnight) switch to OXC was performed while most others were switched during a titration phase. Of the patients with CBZ pre-treatment 21 % were switched to OXC at the recommended dose ratio of 1 : 1.4 - 1 : 1.6 (CBZ : OXC) while roughly 60 % were changed to OXC with a lower ratio. In the total sample the median OXC maintenance dose was 900 mg/day. During treatment with OXC the frequency of seizures per 4 weeks decreased by an average of 76 % in comparison to a retrospective pre-phase. 74 % of the patients showed an improved seizure situation, and 40.5 % became seizure-free under OXC (patients with initial monotherapy became seizure-free in 62 % of the cases). 71 % of the patients showed a reduction of their seizure frequency versus baseline by > or = 50 %. ADRs were reported in 10,8 % of the participants (incidence: 1 in 459 days of exposition to OXC; overnight switching from CBZ to OXC: 1 event in 1284 days). Only 2.5 % of the patients terminated OXC administration due to ADRs while 92 % continued treatment with OXC beyond the end of the study.

CONCLUSIONS

The results underline the high antiepileptic efficacy and good tolerability of OXC previously demonstrated in controlled clinical trials. When changing from CBZ to OXC, immediate (overnight) switching showed particularly favorable results.

Combined endovascular stent-graft repair and adjunctive visceral vessel reconstruction for complex thoracoabdominal aortic aneurysms

AIM

This study demonstrates the therapeutic value of the hybrid open and endovascular procedure in anatomically challenging thoracoabdominal aortic aneurysms (TAAAs) in high-risk patients.

METHODS

Between January 2000 and February 2006, 8 patients were treated with open visceral vessel revascularization and endovascular repair for TAAAs. Patient data were available from medical records. Pre- and postoperative physical examination, intra-arterial angiography, and spiral computed tomography scanning was performed in prearranged examinations.

RESULTS

A total of 28 visceral bypasses were performed in the 8 patients: 6 patients with complete visceral vessel revascularization and 2 with an aorto-mesenteric-celiac bypass. Aneurysm exclusion was achieved through the deployment of in total 23 stent-grafts. Seven out of the 8 procedures were conducted electively and one under urgent conditions. The mean follow-up period was 21 months. We recorded one procedure-related death due to postoperative hemorrhage resulting from diffuse retroperitoneal bleeding with consecutive multiorgan failure. Moreover, one patient developed acute renal insufficiency, but returned to normal values after temporary hemodialysis. Major adverse events included 2 cases of pneumonia and one myocardial infarction. Two reoperations were performed due to one mesenteric bypass occlusion and one groin hematoma. No neurological complications were observed.

CONCLUSION

The combined hybrid endovascular and open surgical approach in the treatment of complex TAAAs remains a feasible and effective operation technique. The less invasive character of the procedure and avoidance of aortic-cross clamping are clear advantages. Nevertheless, further study is mandatory to establish this alternative therapeutic option for complex TAAAs.

[The hard-of-hearing patient--what should the general practitioner do?]

When assessing hardness of hearing, the physician must in the first instance differentiate between an acute event--for example sudden loss of hearing--and chronic deafness. Otoscopy, tuning fork testing and measurement of hearing distance provide importance information for the differentiation of hardness of hearing. In the case of noise deafness, the general physician has a preventive task. With regard to the provision of a hearing aid he can play a supportive role as a mediator between the hearing aid wearer, the ENT specialist and the acoustician.

Proteomic analysis of Entamoeba histolytica

In this study, the proteome of axenically grown Entamoeba histolytica parasites was explored by two-dimensional gel electrophoresis (2-DE), employing a practical and effective procedure for the solubilization of E. histolytica proteins. Approximately 900 protein species in the pH range between 4 and 7 were detected by Coomassie Blue staining. Ninety-five spots were excised, trypsinated and subjected to mass spectrometry. The resultant data from peptide mass fingerprints were compared with those available in the E. histolytica genome and the (non-redundant) National Center for Biotechnology Information (NCBI) databases for the identification and categorization of proteins. Sixty-three of the proteins identified were predicted to relate to the cytoskeleton, surface, glycolysis, RNA/DNA metabolism, the ubiquitin-proteasome system, vesicular trafficking and signal transduction. The present study demonstrates, for the first time, that corresponding genes are indeed expressed in E. histolytica and provides a foundation for further proteomic studies of this parasite.

[Treatment of hearing impairment in children]

The prerequisite for normal speech development is the ability to hear normally. Our objective here is the detection of a hearing deficit with a relevant impact on the acquisition of speech before the child is three months old. Such a hearing impairment due to sensorineural deafness requires the provision of a hearing aid, which needs to be done before the child is six months old. If the provision of a hearing aid fails to provide the desired results, or if they may no longer be expected, a cochlear implant is indicated. In the event of tympanic effusion persistence, an adenotomy with paracentesis, and possibly the insertion of an ear tube, is indicated. This intervention can be done before the child is one year old. Permanent sound-conduction deafness may be due to auditory canal atresia or middle ear anomalies. In such cases, it is important to establish whether surgical reconstruction, for example of the sound conduction system, can restore good hearing over the long term. Prior to surgery at the age of about five, the child must be provided with a hearing aid.

On the self-association potential of transmembrane tight junction proteins

Tight junctions seal intercellular clefts via membrane-related strands, hence, maintaining important organ functions. We investigated the self-association of strand-forming transmembrane tight junction proteins. The regulatory tight junction protein occludin was differently tagged and cotransfected in eucaryotic cells. These occludins colocalized within the plasma membrane of the same cell, coprecipitated and exhibited fluorescence resonance energy transfer. Differently tagged strand-forming claudin-5 also colocalized in the plasma membrane of the same cell and showed fluorescence resonance energy transfer. This demonstrates self-association in intact cells both of occludin and claudin-5 in one plasma membrane. In search of dimerizing regions of occludin, dimerization of its cytosolic C-terminal coiledcoil domain was identified. In claudin-5, the second extracellular loop was detected as a dimer. Since the transmembrane junctional adhesion molecule also is known to dimerize, the assumption that homodimerization of transmembrane tight junction proteins may serve as a common structural feature in tight junction assembly is supported.