Modifications of plasma enzyme activities after severe head injury; evaluation of prognosis using multivariate methods

The aim of this study was to analyse the plasma variations of four enzymatic activities (lactate dehydrogenase, aldolase, creatine kinase, aspartate aminotransferase) in 134 patients suffering from severe head injury. Enzymatic activities were assayed daily for 3 days after the trauma. Means of the four enzymatic activities were significantly different according to their evolution (death or survival), except for creatine kinase, 48 h after the trauma. Multivariate analysis indicated that lactate dehydrogenase and aldolase levels were useful in order to discriminate between potential survivors and non-survivors. The value of multivariate analysis in head traumatology is discussed.     

Prognostic value of combined data on enzymes and inflammation markers in plasma in cases of severe head injury

We measured certain enzyme activities (aldolase, aspartate aminotransferase, creatine kinase, and lactate dehydrogenase) and inflammation markers (alpha 1-antitrypsin, C-reactive protein, fibrinogen, and leukocytes) each day for four days in plasma of patients with severe head injury. The univariate prognostic efficiency of each biochemical parameter was assessed 24, 48, 72, and 96 h after trauma. By stepwise multivariate analysis applied every day, we found that (a) four variables, two enzymes (lactate dehydrogenase and aspartate aminotransferase) and two inflammation markers (C-reactive protein and leukocytes), sufficed to reliably predict the patient's outcome and (b) data recorded at 72 h best discriminated between survivors and nonsurvivors. A risk index based on the four selected variables and validated on a large control sample allowed the correct allocation of, respectively, 90% of survivors and 88% of nonsurvivors at 72 h. We discuss why results obtained at 72 h are more predictive than those obtained at any other of the times considered.     

Monitoring the autonomic nervous activity as the objective evaluation of music therapy for severely and multiply disabled children

Severely and multiply disabled children (SMDC) are frequently affected in more than one area of development, resulting in multiple disabilities. The aim of the study was to evaluate the efficacy of music therapy in SMDC using monitoring changes in the autonomic nervous system, by the frequency domain analysis of heart rate variability. We studied six patients with SMDC (3 patients with cerebral palsy, 1 patient with posttraumatic syndrome after head injury, 1 patient with herpes encephalitis sequelae, and 1 patient with Lennox-Gastaut syndrome characterized by frequent seizures, developmental delay and psychological and behavioral problems), aged 18-26 (mean 22.5 ± 3.5). By frequency domain method using electrocardiography, we measured the high frequency (HF; with a frequency ranging from 0.15 to 0.4 Hz), which represents parasympathetic activity, the low frequency/high frequency ratio, which represents sympathetic activity between the sympathetic and parasympathetic activities, and heart rate. A music therapist performed therapy to all patients through the piano playing for 50 min. We monitored each study participant for 150 min before therapy, 50 min during therapy, and 10 min after therapy. Interestingly, four of 6 patients showed significantly lower HF components during music therapy than before therapy, suggesting that these four patients might react to music therapy through the suppression of parasympathetic nervous activities. Thus, music therapy can suppress parasympathetic nervous activities in some patients with SMDC. The monitoring changes in the autonomic nervous activities could be a powerful tool for the objective evaluation of music therapy in patients with SMDC.     

Enzyme activities and properties of lysosomes and brush borders in jejunal biopsies from control subjects and patients with coeliac disease.

1. Reduced activities of four enzymes from brush borders were found in intestianl biopsies from patients with untreated coeliac disease. The activities returned towards control values after treatment by gluten withdrawal. Parallel changes were noted for the cytosol enzyme lactate dehydrogenase. 2. Measurement of brush-border integrity by differential centrifugation of biopsy extracts indicated increased fragility of the brush borders in biopsies from untreated patients. Normal values were obtained for biopsies from treated patients. 3. Increased activites of six acid hydrolases (lysosomal enzymes) were found in biopsies from untreated coeliac patients. Normal values were obtained for biopsies from treated patients. 4. Assement of lysosomal integrity by assay of latent N-acetyl-beta-glucosaminidase and of sedimentable activity of four acid hydrolases demonstrated increased lysosomal fragility in untreated coeliac mucosa. These lysosomal changes return to within the normal range after treatment by gluten withdrawal. 5. The lysosomal changes are consistent with their having a pathogenic role in the enterocyte damage of coeliac disease. Possible mechanisms for the lysosomal changes are discussed.     

益生菌对重型颅脑伤大鼠肠道菌群、消化酶及肠动力的影响

目的 探讨益生菌对重型颅脑伤大鼠肠道菌群、肠消化酶及小肠推进率的影响.方法 建立重型颅脑损伤大鼠模型.将SD大鼠随机分为A肠内营养组(三九全营素)、B益生菌组(三九全营素+益生菌)、C假手术组(正常饮食),于创伤后第3、7、14天留取肠黏膜、粪便标本,检测肠道消化酶、肠道菌群及小肠推进率的变化.结果 A组、B组同C组相比,乳杆菌、双歧杆菌的含量在创伤后2周内明显降低,而大肠杆菌数量则显著增加.A组同B组相比,双歧杆菌的数量在创伤后各时相点偏低,而大肠杆菌的水平则较高.A、B组的乳杆菌含量在创伤后7 d已无差异.2组致伤大鼠小肠二糖酶、Na+-K+-ATP酶的水平在创伤后2周内与假手术组相比显著降低,虽然B组的消化酶含量在各时相点均高于A组,但2组间无差异.同C组相比,A、B组的小肠推进率在颅脑损伤后2周内明显降低,但2组之间无差异.结论 益生菌可以改善重型颅脑伤后肠道的菌群紊乱,调节肠消化酶的活性,从而减轻小肠的吸收障碍.     

Discrimination between pain-induced head movement disturbances after whiplash injuries and their simulation

Neck pain after whiplash injury of the cervical spine often induces typical changes in head motion patterns (amplitude, velocity). These changes of kinematics may help to recognize malingerers. We investigated the hypothesis that malingerers are not able to reproduce their simulated head movement disturbances three times. The kinematics of head movements of 23 patients with neck pain after whiplash injury and of 22 healthy subjects trying to act as malingerers were compared. The healthy subjects were informed about the symptomatology of whiplash injury and were asked to simulate painful head movements. Two different kinds of head movements were registered and analyzed by Cervicomotography: (1) the slow free axial head rotation (yaw) and (2) the axial head rotation (yaw) tracking a moving visual target. Each experimental condition was presented three times, expecting the malingerers not to be able to produce as well as to reproduce the same head movement disturbances again and again. In patients, as a consequence of their distinct pain patterns, we expected less variance between the test repetitions. The statistical analysis showed significant differences of the calculated kinematic parameters between both groups and the inability of healthy subjects to simulate and to reproduce convincingly distinct pain patterns.     

急性脑外伤后血清甲状腺激素催乳素皮质醇和C肽的动态观察及其临床意义

为进一步了解脑外伤后体内甲状腺激素、催乳素、皮质醇和Ｃ肽的变化及其临床意义，对５５例急性脑外伤患者血清甲状腺激素、催乳素、皮质醇和Ｃ肽进行了动态观察，并对反映伤情的格拉斯哥昏迷计分（ＧＣＳ）和反映预后的格拉斯哥预后计分（ＧＯＳ）分别进行了多元逐步回归分析。结果：①脑外伤组血清３，５，３′三碘甲状腺原氨酸（Ｔ３）、甲状腺素（Ｔ４）、３，３′，５′Ｌ三碘甲状腺原氨酸（ｒＴ３）较对照组有明显改变，在动态观察中催乳素（ＰＲＬ）、皮质醇（ＣＯＬ）未见有显著改变。②不同伤情的各种激素改变不同，ｒＴ３和Ｃ肽水平与损伤程度呈正相关。③采用多因素分析方法对伤情的估计和对预后的预测进行了初步探讨，并建立了有统计学意义的回归方程。本研究表明，急性脑外伤后血清甲状腺激素和Ｃ肽水平的变化与伤情有密切关系，回归方程的建立，对急性脑外伤患者的抢救治疗及其预后判断有一定的临床指导意义     

Lysosomal enzyme pattern in lung lymph and blood during E. coli sepsis in sheep

Systemic release of lysosomal enzymes and local release in the pulmonary microcirculation from sequestrated and activated leucocytes could be an important factor in the development of the lung microvascular injury seen after septicaemia. The maximal activities of 11 lysosomal acid hydrolases (acid phosphatase, alpha- and beta-glucosidase, alpha- and beta-galactosidase, alpha-mannosidase, beta-acetylglucosaminidase, beta-glucuronidase, arylamidase and cathepsins B and C) were measured in serum and lung lymph from seven sheep before and after infusion of live E. coli bacteria. In the early phase of septicaemia (the first hour) the activities of eight enzymes were increased in serum and/or lung lymph (1.1 to 2X pre-infusion values). In the late phase, 3-4 h after sepsis, there were significantly elevated serum activities of beta-glucosidase (5.4X), alpha- and beta-galactosidases (2.7X, 1.5X), beta-acetylglucosaminidase (2.0X) arylamidase (1.2X) and cathespin B (1.7X). In lymph acid phosphatase (1.7X), alpha- and beta-glucosidases (1.6X, 6.4X), alpha- and beta-galactosidases (2.1X, 1.7X). Beta-acetylglucosaminidase (2.6X), and beta-glucuronidase (4.0X pre-infusion) were elevated. The findings of a heterogenicity of changes in serum and lymph activities, as well as the large molecular sizes of some of the enzymes with changed activities indicated to us that permeability changes were not major causes of increased lymph enzyme activities. The results could indicate a local release of enzymes either from sequestrated leucocytes or lung tissue due to local reactions in the lung or lung microvessels. The heterogenous changes in activities for the various lysosomal enzymes as found in the present study indicated that measurement of only one enzyme could be misleading.(ABSTRACT TRUNCATED AT 250 WORDS)     

Short-term sequelae of minor head injury (6 years experience of minor head injury clinic)

Purpose : It is known that post-concussive symptoms may persist after mild head injury. However, the majority of those patients are denied follow-up or support. A minor head injury clinic was thus established in North Staffordshire Hospital in 1993 to address these problems. Methods : Patients 16 - 65 years old attending hospital with minor head injury were invited to attend the clinic two weeks after presentation. A specialized brain injury nurse and/or assistant clinical psychologist assessed them. Patients with persistent symptoms were invited to a second assessment four weeks later. Results : One thousand two hundred and fifty-five patients were invited for first assessment, the most common cause of head injury was assault (454) followed by road traffic accident (334). Six hundred and sixteen patients did not attend the first assessment; most of non-attendees were those who had been assaulted (281). Six hundred and thirty-nine patients attended, (472) were male, their mean age was 33. Forty-three per cent of them had history of recent alcohol intake. One third had had a previous head injury. Although 391 attendees were in regular employment, 219 patients were unable to return to work 2 weeks after discharge (56% ), and 49 people were still off sick 6 weeks after the injury. The most common complaints at both assessments were fatigue, headache, dizziness, irritability, sleep disturbances, poor concentration and poor memory in that order. Conclusion : This study shows a significant number of patients with minor head injury still complaining of post concussive symptoms, which may contribute to a delay in return to work. The high incidence of non-attendance among the assaulted victims may indicate that this group needs to be more effectively targeted. Further study to look at the longer-term consequences of minor head injury is required in view of these findings.     

Glasgow Outcome Scale and Disability Rating Scale: comparative usefulness in following recovery in traumatic head injury

Clinical experience and analysis of use of the Disability Rating Scale (DRS) and the Glasgow Outcome Scale (GOS) are reported in 70 patients up to two years after head injury. Statistical analysis shows significant change demonstrated by the DRS across the intervals from two to four, two to six, and six to 12 months after injury. The DRS more sensitively reflects improvement during inhospital rehabilitation than the GOS, 71% to 33%, respectively. Significant improvement is shown up to one year after injury. Trend data on seven patients for whom two-year data were available showed continued improvement, although the data were not statistically significant. The DRS has shown itself to be a sensitive, functional, reliable, and quantitative means of monitoring patients with traumatic head injury during the course of their recovery.     

A contribution to the pathophysiology of post-traumatic brain oedema (author's transl)]

The aim of this paper is to contrast new results obtained on the activities of lysosomal proteases in the brain of traumatized animals with the previously held opinions concerning the development of post-traumatic brain oedema. Two hours after a standardized head injury in the cat, acid and neutral proteases were determined in the brain homogenate. Total as well as free activity, especially of the neutral proteases, were markedly increased after head injury, a circumstance indicating the important role of lysosomes in the development of post-traumatic brain oedema. It is postulated that not hypoxia alone, but primary or secondary disturbance of lysosomal function is the predominant factor in the development of brain oedema. Release of enzymes -- especially proteases -- causes irreversibility of initial vascular oedema by autolysis of cellular structures.     

急性颅脑损伤后的纤溶变化及其临床意义

目的探讨急性颅脑损伤后的纤溶变化及其临床意义。方法动态观察 75例急性颅脑损伤患者血浆中的纤溶酶、纤溶酶原激活剂抑制和D 二聚体 ,结合临床进行不同的分组比较分析。结果伤后 2 4小时内 3项纤溶指标的检测结果与对照组、伤后 7天、14天比较均有非常显著的差异 ;按伤情轻重、预后以及有无迟发颅内出血进行分组比较 ,差异均具有统计学意义 ;D 二聚体的异常率最高。结论急性颅脑损伤的早期可出现明显的纤溶异常 ,它对判断脑实质损伤程度及迟发颅内出血的发生具有参考价值 ,当D 二聚体血浆水平≥ 8mg/L时 ,可作为预后险恶的指标     

Short-term sequelae of minor head injury (6 years experience of minor head injury clinic)

Purpose : It is known that post-concussive symptoms may persist after mild head injury. However, the majority of those patients are denied follow-up or support. A minor head injury clinic was thus established in North Staffordshire Hospital in 1993 to address these problems.

Methods : Patients 16 - 65 years old attending hospital with minor head injury were invited to attend the clinic two weeks after presentation. A specialized brain injury nurse and/or assistant clinical psychologist assessed them. Patients with persistent symptoms were invited to a second assessment four weeks later.

Results : One thousand two hundred and fifty-five patients were invited for first assessment, the most common cause of head injury was assault (454) followed by road traffic accident (334). Six hundred and sixteen patients did not attend the first assessment; most of non-attendees were those who had been assaulted (281). Six hundred and thirty-nine patients attended, (472) were male, their mean age was 33. Forty-three per cent of them had history of recent alcohol intake. One third had had a previous head injury. Although 391 attendees were in regular employment, 219 patients were unable to return to work 2 weeks after discharge (56% ), and 49 people were still off sick 6 weeks after the injury. The most common complaints at both assessments were fatigue, headache, dizziness, irritability, sleep disturbances, poor concentration and poor memory in that order.

Conclusion : This study shows a significant number of patients with minor head injury still complaining of post concussive symptoms, which may contribute to a delay in return to work. The high incidence of non-attendance among the assaulted victims may indicate that this group needs to be more effectively targeted. Further study to look at the longer-term consequences of minor head injury is required in view of these findings.     

The use of rapid sequence intubation by ambulance paramedics for patients with severe head injury

Objective: To determine the effects of rapid sequence intubation in patients with severe head injury performed by paramedics on a helicopter emergency medical service. Methods: The patient care records for patients with severe head injury who underwent rapid sequence intubation between November 1999 and February 2002 (inclusive) were examined. Data were extracted on the demographics of the patients, as well as the physiological changes before and after rapid sequence intubation. Results: There were 122 patients with severe head injury evaluated at the scene during the study period. Rapid sequence intubation was attempted in 110 patients and was successful in 107 (97%). Intubation was associated with improvements in systolic blood pressure, oxygen saturation and end‐tidal carbon dioxide levels, compared with baseline levels. Conclusion: Rapid sequence intubation in patients with severe head injury may be safely undertaken by helicopter‐based ambulance paramedics and is associated with improvements in oxygenation, ventilation and blood pressure. Further studies of this skill undertaken by road‐based paramedics are warranted.     

急性上呼吸道感染儿童心肌酶测定及临床意义

目的 :探讨急性上呼吸道感染 (AURI)患儿心肌酶活性的变化及其临床意义。方法 :以 38例健康儿童作对照 ,对 5 8例AURI患儿行心肌酶及心电图检查 ,结果异常者加用抗氧化剂治疗后复查。结果 :观察组患儿心肌酶活性及心电图异常率均明显高于对照组 (P <0 .0 1) ,结果异常者经相应治疗后复查均恢复正常。结论 :部分AURI患儿存在程度不同的心肌损害。心肌酶可作为AURI儿童合并心肌损伤的诊断依据和观察病情及判断预后的有效指标。     

Head injuries: a study evaluating the impact of the NICE head injury guidelines

Background: The NICE head injury guidelines recommend a different approach in the management of head injury patients. It suggests that CT head scan should replace skull x ray (SXR) and observation/admission as the first investigation. We wished to determine the impact of NICE on SXR, CT scan, and admission on all patients with head injury presenting to the ED setting and estimate the cost effectiveness of these guidelines, which has not been quantified to date. Design: Study of head injury patients presenting to two EDs before and after implementation of NICE guidelines Methods: The rate of SXR, CT scan, and admission were determined six months before and one month after NICE implementation in both centres. The before study also looked at predicted rates had NICE been applied. This enabled predicted and actual cost effectiveness to be determined. Result: 1130 patients with head injury were studied in four 1 month periods (two in each centre). At the teaching hospital, the CT head scan rate more than doubled (3% to 7%), the SXR declined (37% to 4%), while the admission rate more than halved (9% to 4%). This represented a saving of £3381 per 100 head injury patients: greater than predicted with no adverse events. At the District General Hospital, the CT head scan rate more than quadrupled (1.4% to 9%), the SXR dropped (19 to 0.57%), while the admission rate declined (7% to 5%). This represented a saving of £290 per 100 head injury patients: less than predicted. Conclusion: The implementation of the NICE guidelines led to a two to fivefold increase in the CT head scan rate depending on the cases and baseline departmental practice. However, the reduction in SXR and admission appears to more than offset these costs without compromising patient outcomes.     

Changes in the activities of oxidoreductases, content of malondialdehyde and medium weight molecules in the blood of patients with craniocerebral injuries of different severity

Biochemical changes are determined by the severity of craniocerebral injury. Twenty-four hours after the injury the activity of succinate dehydrogenase in lymphocytes increases significantly in patients with brain concussion and contusion of medium severity. Glutamate dehydrogenase activity increases in patients with repeated brain concussion. The content of malonic dialdehyde is increased in patients with repeated brain concussion and decreased in severe brain contusion. The level of medium-weight molecules is increased in all patients with craniocerebral injuries. The activities of these enzymes are virtually unchanged in the patients with lethal outcomes.     

手足口病患儿心肌酶测定及临床意义

目的：探讨手足口病（HFMD）患儿心肌酶活性的变化及其临床意义。方法：以40例健康儿童作对照，对62例HFMD患儿行心肌酶及心电图检查。结果异常者加用抗氧化剂治疗后复查。结果：观察组患儿心肌酶活性及心电图异常率均明显高于对照组（P〈0．01），结果异常者经相应治疗后复查绝大部分患儿恢复正常。结论：部分HFMD患儿存在程度不同的心肌损害，心肌酶可作为HFMD患儿合并心肌损伤的诊断依据和观察病情及判断预后的有效指标。     

Utilizing clinical factors to reduce head CT scan ordering for minor head trauma patients

Our study objective was to determine whether simple clinical criteria can be used to safely reduce the number of patients who require cranial computed tomography (CT) scan after sustaining minor head trauma. Awake patients (Glascow Coma Scale = 15) who presented to the emergency department with acute head injury associated with a loss of consciousness were evaluated for clinical predictors of head injury prior to CT scan. The studied risk factors included severe headache, nausea, vomiting, and depressed skull fracture on physical examination. Patients with no risk factors present were compared with patients with one or more risk factors with respect to abnormal CT rate and rate of operative intervention for head injury. Of the 2143 patients entered into the study, 1302 (61%) had no risk factor for head injury, whereas 841 (39%) had one or more risk factors present. A total of 138 (6.4%) of those studied had an abnormal CT scan. This number included 3.7% of those patients with no risk factors vs. 11% in patients with one or more risk factors. The CT scan abnormalities in the no-risk-factor group were not clinically significant. All 5 patients who required operative intervention had at least one of the risk factors present. The use of four simple clinical criteria in minor head trauma patients would allow a 61% reduction in the number of head CT scans performed and still identify all patients who require neurosurgical intervention and the majority of patients with an abnormal CT scan. This method could lead to a large savings in patient charges nationwide. Further studies may be helpful in confirming these findings.     

An unusual presentation of a minor head injury sustained during a game of rugby

In the UK, about 2% of the population attend the accident and emergency (A&E) department every year after a head injury. A majority of the patients have minor head injury and are discharged. Studies reveal that patients who reattend the A&E after a minor head injury represent a high-risk group. Concussion injuries are common and not all require treatment at the time of presentation. However, some may worsen after initial presentation and develop signs of serious head injury. A case of minor head injury as a result of head butt during a game of rugby, not associated with alteration in conscious state or focal neurological signs, and subsequent development of frontal lobe abscess a month later is reported. It is important that patients fit to be discharged at the time of consultation are discharged in the care of a responsible adult with clear head injury instruction sheets and are advised to return should their symptoms change. A high index of suspicion should be maintained and an early imaging technique, such as CT scan should be considered in patients reattending the A&E with persistent symptoms even after minor head injury.