Development of a Randomized Trial Comparing ICP-Monitor-Based Management of Severe Pediatric Traumatic Brain Injury to Management Based on Imaging and Clinical Examination Without ICP Monitoring-Research Algorithms

BACKGROUND AND OBJECTIVES

The efficacy of our current approach to incorporating intracranial pressure (ICP) data into pediatric severe traumatic brain injury (sTBI) management is incompletely understood, lacking data from multicenter, prospective, randomized studies. The National Institutes of Health-supported Benchmark Evidence from Latin America-Treatment of Raised Intracranial Pressure-Pediatrics trial will compare outcomes from pediatric sTBI of a management protocol based on ICP monitoring vs 1 based on imaging and clinical examination without monitoring. Because no applicable comprehensive management algorithms for either cohort are available, it was necessary to develop them.

METHODS

A consensus conference involving the 21 intensivists and neurosurgeons from the 8 trial sites used Delphi-based methodology to formulate management algorithms for both study cohorts. We included recommendations from the latest Brain Trauma Foundation pediatric sTBI guidelines and the consensus-based adult algorithms (Seattle International Brain Injury Consensus Conference/Consensus Revised Imaging and Clinical Examination) wherever relevant. We used a consensus threshold of 80%.

RESULTS

We developed comprehensive management algorithms for monitored and nonmonitored cohort children with sTBI. We defined suspected intracranial hypertension for the nonmonitored group, set minimum number and timing of computed tomography scans, specified minimal age-adjusted mean arterial pressure and cerebral perfusion pressure targets, defined clinical neuroworsening, described minimal requisites for intensive care unit management, produced tiered management algorithms for both groups, and listed treatments not routinely used.

CONCLUSION

We will study these protocols in the Benchmark Evidence from Latin America-Treatment of Raised Intracranial Pressure-Pediatrics trial in low- and middle-income countries. Second, we present them here for consideration as prototype pediatric sTBI management algorithms in the absence of published alternatives, acknowledging their limited evidentiary status. Therefore, herein, we describe our study design only, not recommended treatment protocols.

Development of a Randomized Trial Comparing ICP-Monitor-Based Management of Severe Pediatric Traumatic Brain Injury to Management Based on Imaging and Clinical Examination Without ICP Monitoring-Study Protocol

BACKGROUND AND OBJECTIVES

Traumatic brain injury (TBI) is a major global public health problem. It is a leading cause of death and disability in children and adolescents worldwide. Although increased intracranial pressure (ICP) is common and associated with death and poor outcome after pediatric TBI, the efficacy of current ICP-based management remains controversial. We intend to provide Class I evidence testing the efficacy of a protocol based on current ICP monitor-based management vs care based on imaging and clinical examination without ICP monitoring in pediatric severe TBI.

METHODS

A phase III, multicenter, parallel-group, randomized superiority trial performed in intensive care units in Central and South America to determine the impact on 6-month outcome of children aged 1-12 years with severe TBI (age-appropriate Glasgow Coma Scale score ≤8) randomized to ICP-based or non-ICP-based management.

EXPECTED OUTCOMES

Primary outcome is 6-month Pediatric Quality of Life. Secondary outcomes are 3-month Pediatric Quality of Life, mortality, 3-month and 6-month Pediatric extended Glasgow Outcome Score, intensive care unit length of stay, and number of interventions focused on treating measured or suspected intracranial hypertension.

DISCUSSION

This is not a study of the value of knowing the ICP in sTBI. This research question is protocol-based. We are investigating the added value of protocolized ICP management to treatment based on imaging and clinical examination in the global population of severe pediatric TBI. Demonstrating efficacy should standardize ICP monitoring in severe pediatric TBI. Alternate results should prompt reassessment of how and in which patients ICP data should be applied in neurotrauma care.

Patterning small-molecule biocapture surfaces: microcontact insertion printing vs. photolithography

Chemical patterns prepared by self-assembly, combined with soft lithography or photolithography, are directly compared. Pattern fidelity can be controlled in both cases but patterning at the low densities necessary for small-molecule probe capture of large biomolecule targets is better accomplished using microcontact insertion printing (μCIP). Surfaces patterned by μCIP are used to capture biomolecule binding partners for the small molecules dopamine and biotin.

Running in the surf: hydrodynamics of the shore crab Grapsus tenuicrustatus

When locomoting in water, animals experience hydrodynamic forces due to ambient water motion and their own motion through the water. Because an aquatic pedestrian must maintain contact with the substratum to locomote, hydrodynamic forces which can dislodge an animal have the capacity to constrain the postures, gaits and speeds an animal can use. This study measured hydrodynamic forces on the amphibious shore crab Grapsus tenuicrustatus in aquatic and terrestrial postures. The crabs’ locomotory speeds and ambient water velocities in their habitat were considered in predicting the conditions under which a crab is likely to overturn or wash away. A non-moving crab can withstand 200% faster flow in the aquatic posture than in the terrestrial posture. A crab using the terrestrial posture while locomoting through still water experiences 132% greater drag and 17% greater acceleration reaction forces than it does in the aquatic posture. Due to the lower hydrodynamic forces in the aquatic posture, a crab could locomote up to 50% more quickly or through a faster water flow environment than it could in the terrestrial posture. In faster flow environments like wave-swept rocky shores, a crab in either posture would have to actively grasp the substratum to keep from being dislodged, preventing it from using a punting gait. In slower flow environments, animals can locomote faster and take advantage of different gaits that are not available to them in faster flow environments.

Underwater punting by an intertidal crab: a novel gait revealed by the kinematics of pedestrian locomotion in air versus water

As an animal moves from air to water, its effective weight is substantially reduced by buoyancy while the fluid-dynamic forces (e. g. lift and drag) are increased 800-fold. The changes in the magnitude of these forces are likely to have substantial consequences for locomotion as well as for resistance to being overturned. We began our investigation of aquatic pedestrian locomotion by quantifying the kinematics of crabs at slow speeds where buoyant forces are more important relative to fluid-dynamic forces. At these slow speeds, we used reduced-gravity models of terrestrial locomotion to predict trends in the kinematics of aquatic pedestrian locomotion. Using these models, we expected animals in water to use running gaits even at slow speeds. We hypothesized that aquatic pedestrians would (1) use lower duty factors and longer periods with no ground contact, (2) demonstrate more variable kinematics and (3) adopt wider stances for increased horizontal stability against fluid-dynamic forces than animals moving at the same speed on land. We tested these predictions by measuring the three-dimensional kinematics of intertidal rock crabs (Grapsus tenuicrustatus) locomoting through water and air at the same velocity (9 cm s-1) over a flat substratum. As predicted from reduced-gravity models of running, crabs moving under water showed decreased leg contact times and duty factors relative to locomotion on land. In water, the legs cycled intermittently, fewer legs were in contact with the substratum and leg kinematics were much more variable than on land. The width of the crab's stance was 19 % greater in water than in air, thereby increasing stability against overturning by hydrodynamic forces. Rather than an alternating tetrapod or metachronal wave gait, crabs in water used a novel gait we termed 'underwater punting', characterized by alternating phases of generating thrust against the substratum and gliding through the water.

Genetic mapping of adrenergic receptor genes in humans

We have genetically mapped the genes encoding four human adrenergic receptors (ARs) of subtypes alpha 1C, alpha 2A, alpha 2B, and beta 1, which are prototypic G protein coupled receptors that mediate the physiological effects of neurotransmitters, hormones, and drugs. We placed these genes onto the Cooperative Human Linkage Center (CHLC) and Genethon framework maps, within confidence intervals with greater than 1000:1 odds. With multipoint analysis the alpha 1C gene (locus ADRA1C) mapped to the interval between NEFL and D8S283; alpha 2-C4, the gene encoding the alpha 2C AR (locus ADRA2C), mapped to the interval between D4S126 and D4S62; and the alpha 2-C10 (alpha 2A AR)/beta 1 haplotype (loci ADRA2A/ADRB1) mapped to the interval between D10S259 and D10S187. A fifth AR gene, beta 2, yielded significant LOD scores with markers on the long arm of chromosome 5; however, this locus (ADRB2) could not be mapped to any specific interval with odds of greater than 1000:1. The two AR genes that are completely linked, alpha 2-C10 and beta 1, were oriented on their shared 225-kb genomic fragment relative to the direction of transcription, with beta 1 being 5' to alpha 2-C10. The positioning of these genes on high-density framework maps allows them to be tested as candidates in a spectrum of diseases that might involve AR dysfunction.

Genetic and physical mapping of the human cannabinoid receptor gene to chromosome 6q14-q15

A cDNA encoding a G protein-coupled receptor that appears to mediate the behavioral effects of cannabinoids, the psychoactive ingredients of marijuana, has recently been cloned from rat cerebral cortex and expressed. We have now determined the genomic location of the human cannabinoid receptor gene (CNR) by a combination of genetic linkage mapping and chromosomal in situ hybridization. The segregation pattern of a CNR DNA polymorphism was analyzed in 508 individuals from two or three generations of 40 families. Linkage of CNR to chromosome 6 centromeric loci and to DNA markers on the long and short arms was detected. CNR was tightly linked to D6S27, which is known to be located at 6q (log10 odds ratio [lod score, Zmax] of 10.54 at a recombination fraction [theta] of 0.02). Close linkage was suggested between CNR and CGA, the locus for the alpha subunit of human chorionic gonadotropin (Zmax = 2.71 at theta = 0). Moreover, CNR was linked to the two markers 308/BamHI (theta = 0.14) and 308/TaqI (theta = 0.20) defining locus D6Z1, an extended, highly repetitive, and highly conserved sequence localized exclusively to centromeres of all chromosomes and enriched on chromosome 6. In situ hybridization using a biotinylated cosmid probe localizes the gene to 6q14-q15, thereby confirming the linkage analysis and defining a precise alignment of the genetic and cytogenetic maps.

Sampling strategies for linkage studies

Broadly there are three alternative sampling strategies for linkage studies of complex disorders such as schizophrenia. These are to select either affected sib pairs (and their parents) or small-to-medium-size pedigrees, or large pedigrees. The advantages and disadvantages of each are discussed. Our studies show that, even in the presence of heterogeneity, linkage can be found in clinically realistic sample sizes of nuclear families or medium-sized pedigrees. However, relying on affected sib pair methods in less satisfactory.

Manic depressive illness not linked to factor IX region in an independent series of pedigrees

We studied seven informative kindreds segregating for manic depressive illness (MDI), consistent with X-chromosome transmission of the trait (families do not show affective disease in both a father and a son), using markers mapped to the region of Xq27-Xq28. The lod scores were consistently below -2 in the region extending from about 10 cM centromeric from the Factor IX locus (F9) to the colorblindness region. This study does not replicate previous reports of linkage of MDI to Factor IX (Xq27) and colorblindness region (Xq28) chromosomal markers in other kindreds.

N3-arylspiroimidazolidine-2,4-diones N3-arylspiroimidazolidine-2-thio-4-ones and 4-hydroxy derivatives. Synthesis and anthelmintic activity

The synthesis of new N3-arylciclohexanespiroimidazolidine-2,4-diones, N3-arylciclohexanespiroimidazolidine-2-tio-4-ones and the 4-hydroxy derivatives is described and their structures discussed on the basis of I.R. and 1H-N.R.M. data. The anthelmintic activity of these compounds was tested.

The detection of linkage and heterogeneity in nuclear families for complex disorders: one versus two marker loci

Using exact expected likelihoods, we have computed the average number of phase-unknown nuclear families needed to detect linkage and heterogeneity. We have examined the case of both dominant and recessive inheritance with reduced penetrance and phenocopies. Most of our calculations have been carried out under the assumption that 50% of families are linked to a marker locus. We have varied both the number of offspring per family and the sampling scheme. We have also investigated the increased power when the disease locus is midway between two marker loci 10 cM apart. For recessive inheritance, both linkage and heterogeneity can be detected in clinically feasible sample sizes. For dominant inheritance, linkage can be detected but heterogeneity cannot be detected unless larger sibships (four offspring) are sampled or two linked markers are available. As expected, if penetrance is reduced, sampling families with all sibs affected is most efficient. Our results provide a basis for estimating the amount of resources needed to find genes for complex disorders under conditions of heterogeneity.

Antinuclear factors and chronic articular inflammation

Antinuclear antibodies were looked for in the leucocytes from synovial effusions of subjects with inflammatory arthritis. Antinuclear antibodies were found concentrated in the lysates of synovial fluid leucocytes from five of seven effusions of adults with rheumatoid arthritis, and in low titres from a patient with Reiter's syndrome. In three subjects the antinuclear antibody was detected in cell lysates when it was not demonstrable in the corresponding synovial fluid. These findings are interpreted as evidence that antinuclear antibodies play a role in articular inflammation.