Biomedical subjects
Publications and source records attributed to B Young.
Adequate nutrition is vital to peak athletic performance. Insufficient energy and fluids can hinder ability to compete. Physicians and dietitians must emphasize nutrition's importance to athletes. Sports nutrition follows the same principles as good nutrition.
Patients with severe head injury have a disruption in metabolic homeostasis that includes increased energy expenditure and increased protein catabolism. These changes have been suggested to occur secondary to steroid administration, immobility, and other factors. A review of investigations indicates that the head injury itself causes these metabolic changes, although steroid administration can further alter plasma amino acid changes. Altered plasma amino acid profiles after head injury may have an effect on substrate availability to the brain, bacterial translocation, and overall nitrogen balance. Patients with severe head injury have increased skeletal muscle efflux of amino acids. Lack of nutrient supplementation in these patients is associated with increased morbidity and mortality. Enteral nutrition is the preferred mode of feeding but often is not tolerated in the patient with head injury. Parenteral nutritional support can be given to these patients without worsening cerebral edema.
The cytokine interleukin-6 (IL-6) plays a major role in initiating the acute phase response, especially in the production of acute phase reactants such as C-reactive protein. The objectives of this study were to determine whether plasma or ventricular fluid IL-6 levels were elevated at time of admission after head injury and whether plasma IL-6 levels related temporally to clinical improvement of levels of acute phase reactants. Thirty patients with Glasgow Coma Scale (GCS) scores of 3 through 10 were observed for 15 days after head injury. Peak elevation of plasma IL-6 occurred on admission (85 +/- 12 U/ml; normal level is less than 2 U/ml) and then decreased during the hospital course to a level of 29 +/- 4 U/ml on day 15. Plasma IL-6 levels decreased significantly faster in patients with admission peak 24-hour GCS scores of 8 through 10 compared with patients with GCS score less than 8 (p less than 0.01). Patients had markedly elevated and variable ventricular fluid IL-6 levels on admission (mean 3880 +/- 2022 U/ml; normal, less than 2 U/ml). A temporal relationship was found between plasma IL-6 levels and multiple acute phase reactants thought to be mediated by IL-6. We conclude that plasma and ventricular fluid levels of IL-6 are elevated after head injury and that plasma IL-6 level is temporally related to acute phase reactants and clinical improvement. We suggest that IL-6 may play an etiologic role in many of the metabolic or nutritional sequelae of head injury.
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To assess the efficacy of surgical resection of brain metastases from extracranial primary cancer, we randomly assigned patients with a single brain metastasis to either surgical removal of the brain tumor followed by radiotherapy (surgical group) or needle biopsy and radiotherapy (radiation group). Forty-eight patients (25 in the surgical group and 23 in the radiation group) formed the study group; 6 other patients (11 percent) were excluded from the study because on biopsy their lesions proved to be either second primary tumors or inflammatory or infectious processes. Recurrence at the site of the original metastasis was less frequent in the surgical group than in the radiation group (5 of 25 [20 percent] vs. 12 of 23 [52 percent]; P less than 0.02). The overall length of survival was significantly longer in the surgical group (median, 40 weeks vs. 15 weeks in the radiation group; P less than 0.01), and the patients treated with surgery remained functionally independent longer (median, 38 weeks vs. 8 weeks in the radiation group; P less than 0.005). We conclude that patients with cancer and a single metastasis to the brain who receive treatment with surgical resection plus radiotherapy live longer, have fewer recurrences of cancer in the brain, and have a better quality of life than similar patients treated with radiotherapy alone.
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Three assays have been compared for their ability to detect genetic damage caused by antineoplastic drugs in cancer patients and possible damage in the nurses who administered these drugs. The assays were sister chromatid exchanges (SCE) and chromosomal aberrations in peripheral blood lymphocytes, and the Salmonella/mammalian microsome assay on urine. Three comparisons were made: 1) patients before versus after treatment; 2) the administering nurses immediately after their work period versus after a few days off that followed (work and off-work); 3) the exposed nurses versus other nurses who did not administer antineoplastic drugs (controls). The SCE assay detected the treatments in all eight patients from whom complete data were obtained, and was positive in two nurses with a long history of smoking. The Salmonella/mammalian microsome assay detected eight of ten treatments in patients but failed to detect smokers. Four of nine patients receiving treatment were detected by the analysis of chromosomal aberrations. The SCE assay did not distinguish between the work and off-work samples in either the exposed or control nurses. The exposed nurses, as a group, had slightly fewer SCEs than the controls due to the two smokers detected in the latter group. Chromosomal aberration was the only assay which showed significant difference between the two samples of the exposed nurses and, consequently, between the exposed and control nurses. These differences, however, arose primarily from a higher frequency of aberrations found among the exposed nurses in samples taken after a few days away from work, rather than at the end of their work period. There is no evidence that the increase was connected to occupational exposure.
Cerebral pan-angiography was repeated in 24 patients with spontaneous subarachnoid hemorrhage confirmed by spinal fluid or computed tomography evidence after the initial pan-angiography was negative. Recent, long-term follow-up was also conducted. The pan-angiography was technically adequate and did not show vasospasm, both being causes of aneurysmal nonvisualization. No etiology was demonstrated on repeat study in all 24 patients. An additional three patients had only one study, but autopsy later confirmed lack of etiology for subarachnoid hemorrhage despite gross and microscopic serial sections. The mean duration of follow-up was 18.1 years and outcome was favorable. Our results suggest that repeat cerebral pan-angiography may not be indicated in the patient who has no further bleeding episodes and in whom the initial study was normal, technically adequate, and complete without evidence of vasospasm. Nonvisualization of a cerebral aneurysm is commonly proposed as the most likely cause of subarachnoid hemorrhage when angiography is normal following nontraumatic subarachnoid hemorrhage. Our results suggest this conclusion is no longer accurate if the angiogram is technically adequate with the absence of vasospasm.
Questionnaires were distributed to 346 fourth-year students in nine medical schools. The students were asked to state their selected specialty and to rank the importance that each of 25 influences, listed as questionnaire items, had had in making their choice of specialty. Factor analysis showed that particular items were significantly associated with particular factors. The first factor emphasized perceived lifestyle (items in this category gave importance to remuneration, personal time, and prestige); the second factor emphasized cerebral activities and a practice orientation; and the third factor stressed altruistic values and attitudes. The authors classified the selected specialties into three groups: those characterized as having a non-controllable lifestyle (NCL), those with a controllable lifestyle (CL), and surgery. (CL specialties were defined as those that allow the physician to control the number of hours devoted to practicing the specialty.) Data were analyzed using factor analysis, and analysis of variance, and the Scheffé method. Analysis indicated that the perceived lifestyle factor was most closely associated with the responses of those students choosing CL specialties. Furthermore, this factor received the highest total loading of the three factors from all the students, thus indicating the level of interest in lifestyle factors. Responses to items that defined the cerebral and practice factor were highest from the group of students choosing CL specialties and lowest from the group choosing NCL specialties. The NCL students scored highest in the altruism factor and the CL students scored the lowest. The surgery and NCL groups were similar in attitude patterns, and both were substantially different in attitude patterns from those of the CL groups.(ABSTRACT TRUNCATED AT 250 WORDS)
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This review has discussed the current status of metabolic alterations and demands, nutrient administration, and nutritional assessment of the head-injured patient. More work is necessary in all areas to further describe and ascertain the nutritional requirements of these patients. Future research in this area should involve specific nutrient requirement, modification of the acute-phase response, and possibly administration of growth factors.
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The finding that ribozymes can catalyze RNA chain elongation has led to the proposal that an early self-replicating system could have consisted of RNA alone. In such a chain elongation reaction, the Tetrahymena ribozyme was found to select 3',5'-linked substrates from a pool that contained a large molar excess of 2',5'-linked dinucleotides. The enzyme neither reacted with nor was inhibited by 2',5' phosphodiester linkages. The ability to exclude incorrectly linked substrates would have conferred an important selective advantage to a primordial RNA molecule with RNA replicase activity.
Brain death and the persistent vegetative state (PVS) share the following features: 1.) There is death of neurons in the brain; 2.) Both require an etiology which is capable of causing neuronal death. 3.) The potential for cognition is totally and permanently lost; 4.) Intensive medical support is usually withdrawn. In contrast, the diagnosis of brain death depends on death of the brainstem, while PVS implies permanent and total loss of forebrain function. While brainstem death can be diagnosed clinically, accurate prognosis in PVS requires additional investigation. Thus far, the EEG is the most specific test of neuronal function in the cerebral cortex. Brain death is equivalent to death, while PVS is not; management of the latter is more complex because of medical, social, ethical and legal factors.
Severe head injury is associated with a stress response that includes hyperglycemia, which has been shown to worsen outcome before or during cerebral ischemia. To better define the relationship between human head injury and hyperglycemia, glucose levels were followed in 59 consecutive brain-injured patients from hospital admission up to 18 days after injury. The patients who had the highest peak admission 24-hour serum glucose levels had the worse 18-day neurologic outcome (p = 0.01). Patients with peak 24-hour admission glucose levels greater than 200 mg/dL had a two-unit increase in Glasgow Coma Scale score while patients with admission peak 24-hour serum glucose levels less than or equal to 200 mg/dL had a four-unit increase in Glasgow Coma Scale score during the 18-day study period (p = 0.04). There was a significant relationship between 3-month and 1-year outcome and peak admission 24-hour serum glucose level (p = 0.02 and p = 0.02, respectively). Those patients with admission peak 24-hour serum glucose levels less than or equal to 200 mg/dL had a greater percentage of favorable outcome at 18 days, 3 months, and 1 year than those with admission peak 24-hour glucose levels greater than 200 mg/dL (p = 0.0007, p = 0.03, and p = 0.005, respectively). A significant relationship between admission peak 24-hour Glasgow Coma Scale score and 18-day, 3-month, and 1-year outcomes was found (p = 0.0001, p = 0.0002, and p = 0.0002, respectively). Patients with mean admission peak 24-hour Glasgow Coma Scale scores of 3.5, 6, and 10 had mean admission 24-hour peak serum glucose levels of 252 +/- 23.5, 219.1 +/- 19, and 185.8 +/- 21, respectively (p = 0.05). These relationships were not significantly altered when confounding variables such as the amount of glucose given over the initial 24-hour postinjury period, the presence of diabetes or multiple injuries, and whether patients were given steroids, dilantin, or insulin were statistically incorporated. These data suggest that admission hyperglycemia is a frequent component of the stress response to head injury, a significant indicator of severity of injury, and a significant predictor of outcome from head injury.
Visceral protein levels are used as indicators of prognosis, severity of injury, and nutritional status in hospitalized patients. Clinicians often use visceral protein levels to assess efficacy of nutritional support. The purpose of this study was to test the validity of such practices. Visceral protein levels were determined in patients in a medical ICU, head injury unit, and burn unit. The serum albumin and thyroxine-binding prealbumin (TBPA) levels correlated significantly with mortality in the medical ICU patients. Burn patients had depressed albumin and TBPA concentrations over the duration of hospitalization that related to the severity of thermal injury but not to adequacy of nutritional support. Head-injured patients had depressed admission albumin and TBPA levels, with neither protein level adequately related to caloric or protein supplementation. We conclude that visceral proteins may reflect severity of injury and prognosis in critically ill hospitalized patients, but they often do not accurately reflect nutritional status or adequacy of nutritional support.
Total parenteral nutrition (TPN) has been shown to decrease mortality and to increase the rate of recovery in head-injured patients. However, a recent short-term animal experiment has raised concern over the potential enhancement of vasogenic edema by TPN. The experiment described here was undertaken to examine longer-term effects of TPN infusion on vasogenic edema development. Twenty-four rats received an infusion of a TPN solution (35% glucose) or 0.9% saline at 4 ml/kg/hr for 4 or 26 hours following cold injury. In the 4-hour experiment, TPN increased the serum glucose level to 772 +/- 57 mg/dl compared to 160 +/- 14 mg/dl in the saline-treated animals (p = 0.0001) and increased serum osmolality to 312 +/- 3 mOsm/kg compared to 291 +/- 3 mOsm/kg in the saline-treated group (p = 0.0006). In the 26-hour experiment, TPN-infused rats were also hyperglycemic and hyperosmotic by 4 hours postinjury and remained hyperglycemic at 26 hours postinjury (serum glucose level 374 +/- 97 mg/dl compared to 141 +/- 3 mg/dl in saline-treated animals; p = 0.0371). Although by 26 hours the TPN-infused rats appeared hyperosmotic compared to the saline-treated rats, high variability in the TPN group prevented statistical confirmation of this observation (serum osmolality 337 +/- 35 mOsm/kg in the TPN group compared to 287 +/- 6 mOsm/kg in the saline group). A three-way analysis of variance with repeated measures was used to analyze the effect of infusion (saline vs. TPN), time (4 vs. 26 hours), and cold injury on the specific gravity of the five brain regions studied. Cold injury significantly increased edema development in the injured versus uninjured hemisphere for every region studied (p less than or equal to 0.0034, all five regions), and edema development increased significantly between 4 and 26 hours in three of the five regions (p less than or equal to 0.0207, all three regions). The infusion fluid was not a significant factor in any of the analyses. In conclusion, TPN infusion produced hyperglycemia and hyperosmolality in cold-injured rats but did not enhance vasogenic edema development in any brain region studied.