Association of neutrophil to lymphocyte ratio with bone mineral density in post-menopausal women: a systematic review and meta-analysis

BACKGROUND

We conducted a systematic review and meta-analysis to compare the neutrophil lymphocyte ratio (NLR) levels between women with post-menopausal osteopenia or osteoporosis to those with normal bone mineral density (BMD).

METHODS

We used Web of Science, PubMed, and Scopus to conduct a systematic search for relevant publications published before June 19, 2022, only in English language. We reported standardized mean difference (SMD) with a 95% confidence interval (CI). Because a significant level of heterogeneity was found, we used the random-effects model to calculate pooled effects. We used the Newcastle-Ottawa scale for quality assessment.

RESULTS

Overall, eight articles were included in the analysis. Post-menopausal women with osteoporosis had elevated levels of NLR compared to those without osteoporosis (SMD = 1.03, 95% CI = 0.18 to 1.88, p = 0.017, I2 = 98%). In addition, there was no difference between post-menopausal women with osteopenia and those without osteopenia in neutrophil lymphocyte ratio (NLR) levels (SMD = 0.58, 95% CI=-0.08 to 1.25, p = 0.085, I2 = 96.8%). However, there was no difference between post-menopausal women with osteoporosis and those with osteopenia in NLR levels (SMD = 0.75, 95% CI=-0.01 to 1.51, p = 0.05, I2 = 97.5%, random-effect model).

CONCLUSION

The results of this study point to NLR as a potential biomarker that may be easily introduced into clinical settings to help predict and prevent post-menopausal osteoporosis.

Cephalic Arch Stenosis: Location of Stenosis in Indian Hemodialysis Patients

The cephalic vein is formed over the "anatomical snuff box" and joins the axillary vein just below the clavicular level. The definition of cephalic arch is varied. In the radiology literature, it is defined as the central perpendicular portion of the cephalic vein as it traverses the deltopectoral groove and joins the axillary vein. The possible etiologies of cephalic arch stenosis are numerous. This study aimed to identify patients with cephalic arch stenosis and to discern the domain site of stenosis. This is a retrospective case series of patients who had an arteriovenous fistula with dysfunction of access and ipsilateral upper-limb edema. The clinical features of the access dysfunction were strong pulse due to increased pressure, weak thrill due to poor proximal flow, high static pressure, or decreased dialysis efficiency. All these 25 patients underwent computed tomography (CT) angiogram. The CT angiographic findings revealed cephalic arch stenosis and stenosis in 13 patients (52%). domain IV was slightly more affected than other domains of cephalic arch.

Hemiarthroplasty proximal femoral endoprostheses following tumour reconstruction: is acetabular replacement necessary?

AIMS

Dislocation rates are reportedly lower in patients requiring proximal femoral hemiarthroplasty than for patients undergoing hip arthroplasty for neoplasia. Without acetabular replacement, pain due to acetabular wear necessitating revision surgery has been described. We aimed to determine whether wear of the native acetabulum following hemiarthroplasty necessitates revision surgery with secondary replacement of the acetabulum after proximal femoral replacement (PFR) for tumour reconstruction.

PATIENTS AND METHODS

We reviewed 100 consecutive PFRs performed between January 2003 and January 2013 without acetabular resurfacing. The procedure was undertaken in 74 patients with metastases, for a primary bone tumour in 20 and for myeloma in six. There were 48 male and 52 female patients, with a mean age of 61.4 years (19 to 85) and median follow-up of two years (interquartile range (IQR) 0.5 to 3.7 years). In total, 52 patients presented with a pathological fracture and six presented with failed fixation of a previously instrumented pathological fracture.

RESULTS

All patients underwent reconstruction with either a unipolar (n = 64) or bipolar (n = 36) articulation. There were no dislocations and no acetabular resurfacings. Articular wear was graded using the criteria of Baker et al from 0 to 3, where by 0 is normal; grade 1 represents a narrowing of articular cartilage and no bone erosion; grade 2 represents acetabular bone erosion and early migration; and grade 3 represents protrusio acetabuli. Of the 49 patients with radiological follow-up greater than one year, six demonstrated grade 1 acetabular wear and two demonstrated grade 2 acetabular wear. The remainder demonstrated no radiographic evidence of wear. Median medial migration was 0.3 mm (IQR -0.2 to 0.7) and superior migration was 0.3 mm (IQR -0.2 to 0.6). No relationship between unipolar versus bipolar articulations and wear was evident.

CONCLUSION

Hemiarthroplasty PFRs for tumour reconstruction eliminate joint instability and, in the short to medium term, do not lead to native acetabular wear necessitating later acetabular resurfacing. Cite this article: Bone Joint J 2018;100B:101-8.

Mitochondrial Neurogastrointestinal Encephalomyopathy: A Nonrenal Indication for Peritoneal Dialysis

Mitochondrial neurogastrointestinal encephalomyopathy is a rare autosomal recessive disorder characterized by severe muscle wasting, gastrointestinal dysmotility, leukoencephalopathy, peripheral neuropathy, and ophthalmoplegia. The pathogenesis involves the accumulation of very high concentrations of nucleosides dThd and dUrd along with depletion of nucleotide dCTP. One of the treatment measures is the removal of nucleosides dThd and dUrd by hemodialysis and peritoneal dialysis. Only a few patient reports of dialysis as a measure to remove nucleosides had been reported.

Association of Amelogenesis Imperfecta and Bartter's Syndrome

Bartter's syndrome is an autosomal recessive renal tubular disorder characterized by hypokalemia, hypochloremia, metabolic alkalosis, and hyperreninemia with normal blood pressure. Bartter's syndrome is associated with hypercalciuria and nephrocalcinosis. Amelogenesis imperfecta (AI) is a group of hereditary disorders that affect dental enamel. AI could be part of several syndromes. The enamel renal syndrome is the association of AI and nephrocalcinosis. We report two patients of AI with Bartter's syndrome.

Employment Status of Patients Receiving Maintenance Dialysis - Peritoneal and Hemodialysis: A Cross-sectional Study

The long-term dialysis therapy for end-stage renal disease takes a heavy toll of quality of life of the patient. Several factors such as fatigue and decreased physical capability, impaired social and mental functioning, contribute to this forlorn state. To meld maintenance dialysis treatment with a regular employment can be a serious test. A cross-sectional study of employment of patients on hemodialysis and peritoneal dialysis in a state government tertiary institute in South India was performed between June 2015 and December 2015. Patients who completed 3 months of regular dialysis were only included in the study. The number of patients on hemodialysis was 157 and on peritoneal dialysis was 69. The employment status before the initiation of dialysis was 60% (93 out of 155) and 63.7% (44 out of 69) in hemodialysis and peritoneal dialysis, respectively. After initiation, the loss of employment was observed in 44% (41 out of 93) in hemodialysis and 51.2% (26 out of 44) in peritoneal dialysis (P = 0.2604). Even though there was fall of absolute number of job holders in both the blue and white collar jobs, the proportion of jobholders in the white collar job holders improved. On univariate analysis, the factors which influenced the loss of employment were males, age between 50 and 60 years, number of comorbidities >2, illiteracy and blue collar versus white collar job before the initiation of dialysis. The majority of patients had the scores above 80 on Karnofsky performance scale and the majority belonged upper and middle classes than lower classes on modified Kuppuswamy's socioeconomic status scale; however, the loss of employment was also disproportionately high. There appeared a substantial difference in the attitude of the patients toward the employment. There was no difference between hemodialysis and peritoneal dialysis in the loss of employment of our patients.

Biomarker response to contrast administration in diabetic and nondiabetic patients following coronary angiography

Neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C represent early renal injury markers for contrast-induced nephropathy (CIN). Baseline parameters such as type and quantity of contrast, patient preparation, renal function status, and diabetes mellitus (DM) are known to affect the response of the kidney to contrast-induced injury. This study was taken up to know the biomarker response to contrast administration in 58 diabetic and 59 nondiabetic male patients with same baseline parameters and baseline serum creatinine <1.2 mg/dl undergoing coronary angiography and their role in predicting the development of CIN. Serum creatinine, serum cystatin C, and urinary-NGAL (u-NGAL) were analyzed at baseline (0 h), 4 h, and 24 h after the administration of contrast medium. CIN was defined as a 25% increase in serum creatinine concentration from the baseline value or an absolute increase of at least 0.5 mg/dl within 48 h after the administration of contrast media. Serum creatinine rose 24 h after contrast administration in the diabetic group compared to 48 h in the nondiabetic group. Serum cystatin C levels rose 24 h after contrast administration in both the groups. The earliest marker to rise in both the groups was u-NGAL at 4 h. Diabetic patients had significantly higher u-NGAL (P = 0.005), and serum creatinine levels (P = 0.008) 4 h, and 24 h after contrast administration, respectively. Serum creatinine and u-NGAL/creatinine at 4 h were found to be the best predictors of CIN in the DM and non-DM patients, respectively. Biomarker response to contrast administration is different in diabetic and nondiabetic patients following contrast administration. Diabetic patients exhibit early and greater degree of renal impairment compared to the nondiabetic patients irrespective of the outcome. We propose the use of serum creatinine in patients with DM and u-NGAL/creatinine in non-DM patients to identify CIN as early as 4 h after contrast administration.

Gloriosa superba ingestion: Hair loss and acute renal failure

Gloriosa superba is a plant that grows wild in several parts of South India. Tubers of this plant contain several alkaloids. Acute intoxication following the ingestion of G. superba results in gastrointestinal and haematological abnormalities, hepatic and renal insufficiency, cardiotoxicity and hair loss. We present a case with typical features of G superba toxicity.

Cutaneous fungal infection in a renal transplantation patient due to a rare fungus belonging to order Pleosporales

Fungal infections are being increasingly reported from immuno-compromised as well as immuno-competent patients. Transplant patients are on long term immunosuppressive therapy which makes them highly vulnerable to opportunistic fungal infections .These infections can be cutaneous or systemic. Several fungi have been reported to be the culprits such as Candida spp., Aspergillus spp., C. neoformans, P. carinii, and zygomycetes group of fungi. Cutaneous infections are most commonly caused by Pityriasis (tinea) versicolor, dermatophytes, and candida sp but these days the demtiaceous fungi are becoming more frequently reported .Here we report a case of post renal transplant cutaneous infection caused by dematiaceous fungus belonging to the order Pleosporales.

Atenolol and amlodipine combination overdose managed with continuous venovenous hemodiafiltration: A case report

We present a patient of who ingested large dose of of atenolol and amlodipine and was treated successfully with continuous venovenous hemodiafiltration. Early recognition of indications for renal support and early initiation of the same is the key to successful management.

Larsen Syndrome: A Case Report

Larsen syndrome was first described in 1950 by Larsen, Schottstaedt and Bost. This rare inherited disorder is characterized by congenital dislocation of multiple joints along with other anomalies of heart, face, hands and bones. Awareness of this condition and assosciated complications helps in better follow up and management of these patients. Key words: Genu recurvatum; Short stature; Hypodontia; Bifid uvula; Submucosal cleft palate; Cardiac anomaly DOI: http://dx.doi.org/10.3126/jnps.v32i1.5349   J. Nepal Paediatr. Soc. Vol.32(1) 2012 85-87

Review of testing and use of adjuvant trastuzumab across a cancer network--are we treating the right patients?

This review of practice assessed all early breast cancer patients diagnosed over 12 months to determine the frequency of human epidermal growth factor receptor 2 (HER2) positivity and trastuzumab use. The frequency of HER2 positivity in routine practice (185/1319; 14%) was less than expected. A significant proportion of patients (56/185; 30%) did not receive trastuzumab, largely due to concerns about chemotherapy tolerability.

Effects of a novel anti-exospore monoclonal antibody on microsporidialNosema bombycisgermination and reproductionin vitro

A monoclonal antibody (mAb) 3C2, against an exospore protein of the microsporidiumNosema bombycis(N. bombycis) was prepared, and its effects on microsporidial germination and reproductionin vitrowere studied. MAb 3C2 was effective in inhibiting the germination and subsequent infection ofBombyx moricells compared to the control mAb. The antigen was isolated by 2-dimensional gel electrophoresis. Immunoblotting revealed it to be an 84 kDa protein corresponding to pI (7·2) on the 2-D gel. The present results suggest that the antibodies can be used for diagnostic purposes and for developing new therapeutic strategies in controlling microsporidian diseases.

Comparing wound complication rates following closure of hip wounds with metallic skin staples or subcuticular vicryl suture: a prospective randomised trial

PURPOSE

To compare 2 methods of wound closure-metallic staples or 3-0 undyed vicryl-according to postoperative wound complication rates.

METHODS

Patients who underwent surgery for proximal femoral fractures were randomised to have wound closure with metallic staples or with subcuticular vicryl suture. Wounds were regularly examined postoperatively and only those with positive wound swabs were regarded as wound infections.

RESULTS

Five infections and one superficial wound dehiscence occurred in the patients who had wound closure with metallic staples. The complication rate was significantly higher for this group compared with the group who had wound closure with subcuticular vicryl suture (p<0.025).

CONCLUSION

Superficial wound complication rates are higher for wounds closed with metallic staples compared to wounds closed with subcuticular vicryl.

Tennis elbow--outcome following the Garden procedure: a retrospective study

PURPOSE

From 1993 to 1999, 17 patients (18 elbows) underwent the Garden procedure for clinically diagnosed tennis elbow. Non-operative treatment was ineffective for these patients.

METHODS

The study group consisted of 10 men and 7 women, with a mean age of 49.6 years. Follow-up duration ranged from 18 months to 6 years, with a mean of 37 months. Patients' pain, activity level, and hand grip strength were evaluated postoperatively.

RESULTS

14 (77.8%) elbows had an excellent or good result, 2 elbows had a fair result, and another 2 elbows had a poor result and required revision surgery. Most patients had immediate relief of elbow pain, returned to work early, and did not notice any weakness of hand grip strength or radial wrist extension. There were no significant complications.

CONCLUSION

The Garden procedure produced good results for tennis elbow with minimal morbidity in an unselected group of patients. This retrospective study supports the view that the underlying lesion in tennis elbow is in the origin of extensor carpi radialis brevis.

Catatonic syndrome as a complication of enteric Fever

A person with enteric fever who developed neuropsychiatric complication of catatonia after the fever subsided is presented. The catatonic symptoms were not associated with any depressive or psychotic symptoms. The relevant literature is discussed.

Aerobic organocatalytic photoinitiated arene oxidations: application to electron transfer initiated cyclization reactions

[reaction: see text] Electron transfer initiated oxidative cyclization reactions can be effected by catalytic amounts of N-methylquinolinium hexafluorophosphate through photoirradiation in the presence of dioxygen. Solid sodium thiosulfate serves as an effective reducing agent to remove the reactive oxygen species formed from catalyst regeneration and radical coupling reactions with O(2), allowing these cyclizations to proceed efficiently on preparatively useful scales.

Inclusion adducts of 4,4-bis(4'-biphenylyl)cyclohexa-2,5-dienone: a clay mimic organic host

In the lamellar architecture of the title crystal structure mediated by C-H...O hydrogen bonds, 1,2-dimethoxyethane and n-hexane are included in the hydrophobic galleries; isostructurality of these clathrates is a unique case of guest mimicry.

Successful thrombolysis of prosthetic mitral valve thrombosis in early pregnancy

Prosthetic valve thrombosis occurring during pregnancy is a life-threatening complication. Surgical treatment requires clot removal or valve replacement under cardiopulmonary bypass, and carries a high mortality. We report successful thrombolytic therapy with streptokinase for prosthetic valve thrombosis in a pregnant, 28-year-old woman. The patient, who had undergone mitral valve replacement (St. Jude Medical prosthesis) two years previously for restenosis after closed mitral valvotomy, was successfully thrombolyzed during the first trimester (6-8 weeks) for prosthetic valve thrombosis, and without any complication. The patient delivered a normal healthy child at nine months' gestation. Although thrombolysis in pregnancy has been reported previously, this is the first case in which it was performed during the first trimester for prosthetic valve thrombosis.

Synthesis of novel cage oxaheterocycles

m-CPBA-promoted Baeyer-Villiger oxidation of pentacyclo[6.3.0.0(2,6).0(3,10).0(5,9)]undecan-4-one (1) afforded the corresponding lactone 2 in 93% yield. Lithium aluminum hydride promoted reduction of lactones 2, 6, and 9, performed in the presence of BF(3).OEt(2) reagent, afforded the corresponding cage ethers, i.e., 4, 7, and 10, respectively. Two methods that can be used to replace a cage C=O group by ether oxygen without concomitant rearrangement are delineated. A key step in the first of these methods employs m-CPBA promoted "double Criegee rearrangement", which was used to convert pentacyclo[6.3.0.0(2,6).0(3,10).0(5,9)]undecan-4-one diethyl acetal (11) into 7,9-dioxapentacyclo-[8.3.0.0(2,6).0(3,12).0(5,11)]tridecan-8-one (12). Subsequently, 12 was converted into 4-oxapentacyclo[6.3.0.0(2,6).0(3,10).0(5,9)]undecane (14) via a two-step reduction-dehydration reaction sequence. The second method utilized PhI(OAc)(2)-I(2) reagent to convert cage lactols 15 and 17 into the corresponding cage ethers, i.e., 14 and 2-oxaadamantane (18), respectively.

RH-5992--an ecdysone agonist on model system of the silkworm Bombyx mori

RH-5992 is a novel synthetic non-steroidal ecdysteroid agonist with a high selectivity towards Lepidopteran species. The effect of ecdysone agonist RH-5992 on larval period, larval weight, silk gland weight and haemolymph protein profile were examined in the model organism, the larvae of silkworm, Bombyx mori. The LD50 values were found to be 16.21 and 12.01 micrograms/larva for 72 and 96 hr respectively. In the present study, three sublethal concentrations of 1/5th, 1/10th and 1/20th of LD50 at 72 hr were selected and applied on the mid-dorsal line of the silkworm B. mori. The maximum mortality of 35% was observed in the group which received the highest (3.2 micrograms/larva) concentration of RH-5992. The mortality rate was found to be dose dependent as well as time dependent. Interesting results were observed in haemolymph profile of the RH-5992 treated larvae as staining intensity of 30 kDa protein decreased significantly whereas the effect was not marked on other major proteins like storage proteins and vitellogenin polypeptides. From the results, it is confirmed that RH-5992 causes changes in larval characters and protein profile of silkworm B. mori. It is proposed that RH-5992 may cause negative effect specifically on reproductive characters like development of ovary and egg production due to decrease in 30 kDa protein.

Involvement of cajal-retzius neurons in spontaneous correlated activity of embryonic and postnatal layer 1 from wild-type and reeler mice

Cajal-Retzius (CR) cells are a transient population of neurons in developing cortical layer 1 that secrete reelin, a protein necessary for cortical lamination. Combining calcium imaging of cortical hemispheres and cross-correlation analysis, we previously found spontaneous correlated activity among non-CR neurons in postnatal rat layer 1. This correlated activity was blocked by GABAergic and glutamatergic antagonists, and we postulated that it was controlled by CR cells. We now investigate the correlated activity of embryonic and postnatal layer 1 in wild-type and reeler mice, mutant in the production of reelin. We find that mouse layer 1 also sustains patterned spontaneous activity and that CR cells participate in correlated networks. These networks are present in embryonic marginal zone and are blocked by GABAergic and glutamatergic antagonists. Surprisingly, network activity in reeler mice displays similar characteristics and pharmacological profile as in wild-type mice, although small differences are detected. Our results demonstrate that the embryonic marginal zone has correlated spontaneous activity that could serve as the scaffold for the development of intracortical connections. Our data also suggest that reelin does not have a major impact in the development of specific synaptic circuits in layer 1.

Left ventricular mass index in patients of end stage renal disease (non-diabetic) on regular haemodialysis

Echocardiography in patients of end stage renal failure (non diabetic) on regular haemodialysis revealed increase in left ventricular mass index in comparison to healthy controls. Anaemia, chronic uraemic state and hypertension were the probable contributory factors.

Dog zona pellucida glycoprotein-3 (ZP3): expression in Escherichia coli and immunological characterization

An internal fragment (978 bp) corresponding to the dog zona pellucida glycoprotein-3 (DZP3), excluding the N-terminal signal sequence and the C-terminal transmembrane-like domain, was amplified by polymerase chain reaction from a full-length cDNA clone. The amplified SacI and PstI restricted fragment was cloned in-frame downstream of the T5 promoter under lac operator control for expression in the pQE-30 vector. Recombinant DZP3 (rec-DZP3) was expressed as a polyhistidine fusion protein in Escherichia coli. Optimum expression of rec-DZP3 was observed at 1.0 mM isopropyl-beta-D-thiogalactopyronoside. Immunoblots with a murine monoclonal antibody, MA-451 (raised against porcine ZP3beta-a homologue of DZP3 and cross-reactive with dog zona pellucida), revealed a major band of 42 kDa. Localization studies revealed that the recombinant protein was present only in an insoluble intracellular fraction. Further optimization studies revealed that the level of expression of rec-DZP3 was significantly higher in Luria broth medium containing glycerol rather than glucose and maximum expression was observed when cultures were induced during the mid-log phase of growth. Batch fermentation with glycerol as the carbon source yielded 30 mg/L of rec-DZP3 compared to 4 mg/L from a shake flask culture. Immunization of two male rabbits with Ni-NTA-purified rec-DZP3 and two female dogs with the rec-DZP3 conjugated to diphtheria toxoid generated high antibody titers against rec-DZP3 as determined by enzyme-linked immunosorbent assay. Rabbit immune serum reacted with porcine ZP3beta but failed to react with porcine ZP3alpha in a Western blot. Moreover, antisera when tested by indirect immunofluorescence on dog ovarian sections showed positive fluorescence with zona pellucida. The availability of rec-DZP3 will help in evaluating its efficacy for fertility regulation in stray dogs.

Networks of coactive neurons in developing layer 1

Spontaneous neuronal activity plays an important role in the development of cortical circuitry, yet its spatio-temporal dynamics are poorly understood. Cajal-Retzius (CR) neurons in developing layer 1 are necessary for correct cortical lamination and are strategically located to coordinate early circuit activity. To characterize the spontaneous activity of CR and other layer 1 neurons during cortical development, we imaged calcium transients in populations of layer 1 neurons in hemispheres and slices from postnatal rat somato-sensory neocortex. The spontaneous activity in layer 1 had complex spatio-temporal patterns. Groups of non-CR cells showed synchronous activations and formed networks of correlated neurons superimposed in the same territory. Correlated activity among non-CR cells was mediated by a depolarizing effect of GABA and was modulated by glutamate, probably released by CR cells. Our findings demonstrate that developing layer 1 can sustain complex patterns of correlated activity and reveal a circuit mechanism that can mediate this patterned activity.

Hepatic cysts in adult polycystic kidney disease

Of ninety two adult polycystic kidney patients 18.5% had liver cysts. Mostly they were multiple. Liver cysts were more common in men.

Treatment of intracranial hypertension. Analysis of 105 consecutive, continuous recordings of intracranial pressure

One hundred and five consecutive recordings of intracranial pressure (ICP) in 95 patients over a three-year period, using a Scott cannula inserted through a burr hole or a twist drill hole into the anterior horn of the lateral ventricle, represent the patient material for this report. The clinical diagnoses were head injury 32, intracranial tumour 31, aneurysm and arteriovenous malformation 18, brain swelling secondary to systemic disease 8, and brain swelling of unknown etiology 6. ICP exceeded 20 mm/Hg in 86 of the recordings (maximum 110 mm/Hg). Hypertonic mannitol was administered 73 times in 48 patients. ICP was reduced 10% or more (mean 52%) in all but three administrations. The effect of hyperventilation was tested in 50 trials in 34 patients. ICP was reduced 10% or more (mean 47%) in 34 trials. The mean time to maximum reduction of ICP was eight minutes, and ICP returned to control almost immediately after cessation of hyperventilation. Hypothermia was studied in 40 trials in 40 patients. ICP was reduced 10% or more (mean 51%) in half the patients. The infection rate was 6.3% in this four-hospital setting, but four of the six infections were in one hospital. If this hospital is excluded, the infection rate is 3.1%.

Embryonal rhabdomyosarcoma (sarcoma botryoides) of the common bile duct: a case report

A case of sarcoma botryoides of the common bile duct is described. A review of the literature reveals 24 reported cases of this entity. The clinical features of the disease and the poor prognosis associated with it are illustrated by a detailed presentation of the case. Although rare, this condition must be included in the differential diagnosis of jaundice in infancy or early childhood. Pathologic findings of diagnostic value are re-emphasized.

Analysis of the response to therapeutic measures to reduce intracranial pressure in head injured patients

Five methods of therapy for increased ICP were used in the treatment of 32 head-injured patients. The effects of steroids could not be evaluated. Withdrawal of CSF was always effective because intracranial volume was reduced and pressure must follow, but because of brain swelling and collapse of the ventricular system in this group of patients, it was not an effective permanent form of therapy. Hypertonic Mannitol reduced ICP in nearly every case irrespective of the degree of brain damage or the height of ICP. Hyperventilation was least effective in the most severely ill patients, presumably due to the non-responsiveness of the cerebral vessels to changes in PaCO2. The poorest response of ICP seemed to be with hypothermia.