[APOΕ gene polymorphism and markers of brain damage in the outcomes of severe traumatic brain injury in children]. / Polimorfizm gena APOΕ i markery povrezhdeniya mozga v iskhodakh tyazheloi cherepno-mozgovoi travmy u detei.

OBJECTIVE: To compare apolipoprotein E (APOE) genotypes with outcomes and levels of neuromarkers in children with severe traumatic brain injury (TBI). MATERIAL AND METHODS: APOE polymorphisms were genotyped in 69 children with severe TBI. The following markers of brain damage were identified: neuron-specific enolase (NSE), glial protein S100b, content of autoantibodies (aAB) to glutamate receptors (to the NR2 subunit of NMDA receptors), aAB to S100b and brain-derived neurotrophic factor (BDNF). RESULTS AND CONCLUSION: There was no association between APOE 3/3, 3/4, 3/2 genotypes and outcomes assessed by the Glasgow Outcome Scale (GOS). The greatest number of favorable outcomes was noted in the group of APOE 3/3 genotype carriers (60%). The ratio of favorable outcomes to unfavorable outcomes was equal (50%:50%) in groups with APOE 3/4 and APOE 3/2 genotypes. An association between APOE polymorphism and BDNF was found: there were normal BDNF levels in the APOE 3/3 group and reduced levels in the APOE 3/2 group. The correlation between neuromarkers and GOS scores was shown for BDNF and aAB to S100b. In children with favorable TBI outcomes, normal BDNF levels and a lower level of aAB to S100b were observed. Regardless of APOE genotypes, almost all children with severe TBI (95%) showed a significant increase in aAB to glutamate receptors in the remote period and most children had an increase in aAB to S100b in the blood. This fact can be explained by the presence of cerebral hypoxia, activation of autoimmune processes and increased BBB permeability, which may be enhanced by increased NO content and intensification of oxidative processes in children with severe TBI.

[The regional epidemiological characteristics of craniocerebral injury in children in Russia in 2003-2014].

The craniocerebral injury is a global problem of health care and society. The fatal and incapacitating aftermaths developed because of this type of trauma result in significant social and economic losses. To develop effective measures of decreasing these losses epidemiological studies are needed to be implemented considering gender, age, regional and other characteristics. The purpose of study was to analyze regional and epidemiological characteristics of craniocerebral injury in children population of Russia. The study was based on data of state statistic reports in Russia and in its regions in 2003-2004. During analyzed period, dynamics of children morbidity of craniocerebral injury are characterized by its maximal level reached in 2010 (6.3 per 1,000 of children population) and by its decreasing to initial level (5.4% per 1,000 of children population) in 2014. The two-fold increase of percentage of children of the first year of life in mortality of craniocerebral injury was established against the background of stable decrease of craniocerebral injury mortality among children aged from 0 to 17 years. In 2014, every ninth child who died because of head trauma did not survived age of 1 year. In Russia, decreasing of level of hospitalization of children with craniocerebral injury was established. At that, indices of hospitalized morbidity of children of the first year of life increased up to 30%. The actual statistical reporting in Russian Federation provides no full measure evaluation of true levels of mortality, morbidity and hospitalized morbidity. this condition occurs due to limitations of including additional nosological forms in state statistic reporting and to specificity of main disease codification or leading causes of death. The study established significant regional specificity of craniocerebral injury in children that determines necessity of development effective measures considering established epidemiological characteristics.

Mean Square Deviation of ICP in Prognosis of Severe TBI Outcomes in Children.

OBJECTIVES: Prognostic value of intracranial pressure (ICP) is discussed in the recent literature. The aim of our study was to find the parameter that could be representative of ICP variations and might become a good predictor of severe traumatic brain injury (TBI) outcomes in children. MATERIALS AND METHODS: The study included 81 patients with severe TBI (2004-2014). INCLUSION CRITERIA: GCS ≤ 8, age > 3 years old, admission time to our clinic <24 h from the time of injury. Mean daily values of ICP were used as a predictor, Glasgow outcome scale value was used as a grouping variable. Outcomes were assessed 6 months after injury. RESULTS: Total mortality was 27%. We have entered the indicator "energy ICP" (E 2), which describes the dynamics of the process and energy. E 2 value in the group of survivors was <500 mmHg2; the probability of accurate forecasting was 91%. Sensitivity, 0.9; specificity; 0.94. CONCLUSIONS: The proposed method is accessible and easy to perform. This method has high specificity in the prediction of severe traumatic brain injury outcome and can be a reliable tool for ICP control.

[Changes in serum levels of the key factors of angiogenesis in different outcomes of combined injuries in children]. / Izmeneniia kontsentratsii v syvorotke krovi kliuchevykh faktorov angiogeneza pri razlichnykh iskhodakh sochetannoi travmy u detei.

AIM: To study the changes in the key angiogenic factors VEGF-A and angiogenin (ANG) in children with different outcomes of combined injuries. MATERIAL AND METHODS: Contents of VEGF-A and ANG in blood serum were determined by enzyme immunoassay. The study included 40 patients, 21 boys and 19 girls. Patients were divided into 4 groups according to the outcome of injury: 1 - the recovery or mild residual symptoms; 2 - disabled; 3 - vegetable state; 4 - death. Patients were examined at different times after injury: 1-6 days, 7-11 days, 12-19 and 20-33 days. RESULTS AND CONCLUSION: In the first days after injury, the content of VEGF-A in patients of 1-3 groups was at the level of the reference group, moreover, in patients of the 3rd group it was close to the top edge. In group 4, the content of VEGF-A was maximal in the first days after injury and then gradually decreased to the point of death. In groups 1 and 3, the level of VEGF-A increased significantly starting from the 2nd week while in group 2 this indicator was slightly increased approaching later (up to 33 days of observation) to the upper values in the reference group. In the 3rd group, the content of VEGF-A reached the plateau on the 19th day after injury and was higher than the reference data, but lower than in patients of the 1st group. No correlation between the changes in ANG content at different times after combined injuries and outcome was found. There was a trend towards decreased levels of ANG, especially after 3-4 weeks after injury. The data obtained are important for the control over processes of vascular and tissue reparation after injury and for searching for effective ways of treatment of altered angiogenesis in such patients.

[The experience with the early rehabilitation of the children presenting with the vertebral cerebrospinal injury]. / Opyt rannei reabilitatsii detei s pozvonochno-spinnomozgovoi travmoi.

This article was designed to report the experience with the provision of early rehabilitation care to the children suffering from a spinal-cord injury (SCI) that was gained at the Clinical and Research Institute of Urgent Pediatric Surgery and Traumatology. The authors have developed and describe the combined multidisciplinary approach making it possible to promote the recovery of the children presenting with SCI at the first stage of the rehabilitative treatment. They distinguish three basic periods in the early rehabilitation of the children with this condition, defined the main goals of rehabilitation and the role of each specialist in their achievement. The results of the work provided the basis for the development of a stepwise approach for the extension of the rehabilitation measures and the solution of the tasks facing rehabilitation of the patients with vertebral cerebrospinal injuries. The correction of nutritive losses was found to be a most important component of the early stage of the rehabilitation process preceding the full-scale rehabilitative treatment. The role of various technical devices designed for the patients' re-education in functional motor activities, development and acquisition of the sustained self-service skills, enhancement of the patient's mobility, and improvement of his/her quality of life is discussed. The importance of the early beginning of the rehabilitation measures for the children suffering from a vertebral cerebrospinal injury has been confirmed.

[Biomarkers in children with traumatic brain injury].

OBJECTIVE: to study the content of biomarkers of diagnostic and prognostic value in the assessment of traumatic brain injury (TBI) severity in children. MATERIAL AND METHODS: Authors determined the levels of glial protein S100B, neuronspecific enolase (NSE), autoantibodies (aAb) to glutamate receptors and natural autoantibodies (nAb) to S100B and brain-derived neurotrophic factor (BDNF) in serum/plasma of children with different outcomes of TBI. All parameters were analyzed in the 1-3rd, 7-8th, 14-15th and 20-23rd days after TBI, and, in some cases of severe brain injury and long stay patients in hospital, in 11-12 months after TBI. The severity and outcome of TBI were assessed according the Glasgow coma scale (GCS) and the Glasgow outcome scale (GOS), respectively. RESULTS AND CONCLUSION: The content of NSE and S100B increased immediately after TBI regardless of TBI severity, but in cases with favorable outcome it dropped to a normal level in the first 3 days. The maximum levels of S100B protein and NSE were observed in children with fatal TBI, and higher values were observed throughout the post-traumatic period. The low levels of aAb to NR2-subtype of glutamate receptors that were similar to controls and the high level of nAb to S100B in the first days after severe TBI indicate the failure of compensatory-adaptive immunological mechanisms and the high permeability of the brain-blood barrier, which were poor prognostic signs for children with severe TBI. Mild and severe TBI with full recovery were accompanied by higher values of ВDNF in the 1st day followed by a decline to the 3rd day. The level of BDNF in the 1st day of TBI was the lowest and subsequently continued to decline in patients with severe TBI with fatal outcome.

[Peripheral Blood Lymphocytes Mitochondrial Function in Children with Traumatic Brain Injury].

BACKGRAUND: It is known that mitochondria play an important role in the mechanisms of brain cells damage and death following traumatic brain injury (TBI). However, the relationship between the severity of brain damage following TBI and mitochondrial dysfunction are not well defined. AIM: to study activities of NADN- and succinate dehydrogenases, a key enzyme of mitochondrial oxidative phosphorylation in children with TBI of varying severity and different outcomes; to detect ATP content in lymphocytes; the level of NOx and 3-nitrotyrosine in serum and plasma. Methods: all parameters were determined in the dynamics of one month following TBI, and in some cases up to the death ofpatients. The severity of TBI was scored by Glasgow Coma Scale (GCS), the outcome of TBI-Glasgow Outcome Scale (GOS). Based on the clinical examination children with TBI were divided into 3 groups: (1) mild TBI; (2) severe TBI and (3) severe TBI with fatal outcome. RESULTS: we found that activity of dehydrogenases is significantly reduced only in patients with the poor neurologic outcome. The greatest decrease in these parameters was observed in patients with severe traumatic brain injury and fatal outcome. A direct correlation was found between the indices of dehydrogenases activity and A TP content in lymphocytes (r = 0.97, p = 0.005). The levels of NOx metabolites and 3-nitrotyrosine were significantly increased in children with severe TBI. CONCLUSION: obtained results suggest that mitochondrial dysfunction, impaired cerebral energy metabolism and oxidative stress contribute to cell death in the brain and thus represent therapeutic targets for the treatment of TBI.

[Specialized surgical care for children (victims of the earthquake) with open injuries].

The article presents the authors' experience of providing specialized surgical care for 197 children who had been affected by the earthquake in Pakistan (2005), Indonesia (2006 and 2009) and Haiti (2010). All victims had open injuries of soft tissues and bones. The article recites the strategy and principles of work organization of the mobile team of specialists from the Research Institute of Clinical and Research Institute of Urgent Pediatric Surgery and Traumatology in disaster areas. It includes the creation of a center for specialized surgical care for children, consultative work in all regional hospitals to where victims are initially evacuated, transportation and concentration of children with the most severe injuries in a specialized center. The basic principles of interaction with the central and local public health authorities and medical staff of hospitals were developed. The main characteristics of such injuries and their complications were defined as well. Mistakes made by the local and international surgical teams at the stages of primary and specialized surgical care were described. The effectiveness of the applied strategy of active surgical treatment of open injuries of soft tissue and bones complicated by surgical infection has been analyzed.

[Autoantibodies to α7-subunit of neuronal acetylcholine receptor in children with traumatic brain injury].

An objective of the study was to search for new biologically significant markers of brain damage. Levels of blood serum autoantibodies (aAB) to different fragments of α7-subunit of acetylcholine receptor (ACR) were studied in children with traumatic brain injury of different severity. The more severe was trauma, the higher was the level of aAB to fragments of α7-subunit of ACR in the first week after trauma. The data obtained suggest that α7-subunits of ACR and aAB to them are involved in the pathogenesis of traumatic brain lesions and, probably, play a significant role in the course of post traumatic period.

[S100B protein and autoantibodies to S100B protein in diagnostics of brain damage in craniocerebral trauma in children].

Levels of antibodies AB (AB) to S100B and S100B protein were studied in the blood serum of children with different severity and outcomes of traumatic brain injury (TBI) from the 1st to 15-75th days after TBI. Severity and outcomes were assessed using the Glasgow Coma Scale (GCS). Patients were stratified by outcomes into the following groups: complete recovery (group 1), moderate disability (group 2), high disability (group 3), vegetative state (group 4) and fatal outcome (group 5). In patients of groups 1-3, the changes of S100B in the blood serum didn't depend on the severity of brain's damage; the significant increase of S100B protein levels in the 1st day was accompanied by the decrease to the normal range in the following 2-3 days. On the contrary, the levels of nAB in these groups increased starting from 3-5 days corresponding to the severity of brain's damage. The development of vegetative state was accompanied by low S100B and high AB to S100B levels in the blood serum. The maximal level of S100B protein and increased levels of AB were observed in patients with fatal outcome. In most patients with combined TBI, the levels of both parameters were higher compared to those with separate TBI.

Effect of cell therapy on recovery of cognitive functions in rats during the delayed period after brain injury.

We studied the effect of systemic transplantation of human stem cells from various tissues on cognitive functions of the brain in rats during the delayed period after experimental brain injury. Stem cells were shown to increase the efficacy of medical treatment with metabolic and symptomatic drugs for recovery of cognitive functions. They accelerated the formation of the conditioned defense response. Fetal neural stem cells had a stronger effect on some parameters of cognitive function 2 months after brain injury. The efficacy of bone marrow mesenchymal stem cells from adult humans or fetuses was higher 3 months after brain injury.

Morphofunctional study of the therapeutic efficacy of human mesenchymal and neural stem cells in rats with diffuse brain injury.

We studied the effect of transplantation of human stem cells from various tissues on reparative processes in the brain of rats with closed craniocerebral injury. Combined treatment with standard drugs and systemic administration of xenogeneic stem cells had a neuroprotective effect. The morphology of neurons rapidly returned to normal after administration of fetal neural stem cells. Fetal mesenchymal stem cells produced a prolonged effect on proliferative activity of progenitor cells in the subventricular zone of neurogenesis. Adult mesenchymal stem cells had a strong effect on recovery of the vascular bed in ischemic regions.

Autoantibodies to glutamate receptors and products of nitric oxide metabolism in serum in children in the acute phase of craniocerebral trauma.

Levels of serum autoantibodies (aAb) to glutamate receptors and products of nitric oxide (NO) metabolism, i.e., nitrates and nitrites, were assayed in children with recent craniocerebral trauma (CCT) of different levels of severity. All the children showed increases in serum aAb to both AMPA and NMDA receptor subtypes from day 1 to day 10 after trauma. The highest levels of serum aAb were to the NMDA subtype of glutamate receptor, which was characteristic of children with mild CCT (MCCT), with Glasgow Coma Scale (GCS) scores of 14-15 points. Levels of aAb to NMDA (NR2A) receptors in children with severe CCT (SCCT, GCS < 9 points) were lower than in children with MCCT, the lowest levels being seen in the group of children with lethal CCT (SCCT-2). Serum concentrations of NO metabolites increased by large factors in the group of children with SCCT, indicating marked brain hypoxia.

[Autoantibodies to glutamate receptors and metabolic products of nitric oxide in blood serum of children in the acute period of brain trauma].

Autoantibodies (AB) to glutamate receptors of AMPA (Glur1) and NMDA (NR2A) types and nitric oxide metabolites, nitrates and nitrites (NOx), were studied in the blood serum of children with brain trauma of different severity. The level of both AB types increased from the 1st to the 10th day after trauma. The level of NMDA (NR2A) AB was higher comparing to AMPA (Glur1). Patients with mild brain trauma, scoring 14-15 on the Coma Glasgow Scale, had the highest AB concentration while patients with severe brain trauma (scores <9), had the lower level of NMDA (NR2A) AB. The lowest level of AB and the highest level of NOx in the blood serum were found in a group of children with the fatal outcome of severe brain trauma. The many-fold increase of NOx concentration in this group points to marked hypoxia after severe brain trauma.

Glutamate receptor autoantibody concentrations in children with chronic post-traumatic headache.

We report here studies on the levels of autoantibodies (aAb) to AMPA glutamate receptors (GluR1 subunit) and NMDA glutamate receptors (NR2A subunit) in serum from 60 children aged 7-16 years with chronic posttraumatic headache (CPTHA) following mild craniocerebral trauma (CCT). The first group consisted of 48 children who had sustained cerebral concussion (CC), of which 34 had single-episode CC (subgroup 1a) and 14 had repeated CC (subgroup 1). The second group included 12 children with mild cerebral contusions (MCC). Serum glutamate receptor aAb levels were measured six months and one year after trauma. Increased aAb levels were expressed as percentages and were regarded as significant when increases were to 120% of the level seen in healthy children of the same age. The highest levels of aAb to NMDA receptors were seen in children with MCC (165 +/- 34%) and single CC (145 +/- 12.6%). Children with repeated CC had NMDA receptor aAb at normal levels (108 +/- 12.4%). Increases in NMDA receptor aAb were seen during the first year after trauma. Increases in AMPA receptor aAb were seen in children with repeated CC and MCC (150 +/- 16.8% and 167 +/- 31.3%). EEG studies showed that 18% of these children had nonspecific paroxysmal changes and 6% showed epileptiform activity. These results provide evidence that children with post-traumatic headache demonstrated hyperstimulation of glutamate receptors and overdevelopment of the autoimmune process. Increases in serum levels of aAb to NMDA glutamate receptors reflected hypoxic-ischemic brain lesions in children with CPTHA and dictate the need for these children to receive metabolic therapy.

Evaluation of psychoemotional status of rats after brain injury and systemic transplantation of mesenchymal stem cells.

We studied the effects of systemic transplantation of mesenchymal stem cells obtained after culturing of autologous bone marrow on psychophysiological status of Wistar rats after diffuse brain trauma. Two months after systemic injection of mesenchymal stem cells we observed a decrease in manifestations of emotional behavioral reactions (anxiety and excitability) and shortening of the time of realization of drinking behavior in a T-maze. A significant positive effect of systemic transfusion of mesenchymal stem cells on avoidance conditioning in a shuttle box was observed 3 months after brain injury.

[Autoantibodies to glutamate receptors in children with chronic posttraumatic headache].

Autoantibodies (aAB) to AMPA (Glu R1 subunit) and NMDA (NR 2A subunit) glutamate receptors were studied in blood serum of 60 children, aged 7-16 years, with chronic posttraumatic headache after mild skull injury. All the children were divided into 2 groups: group 1 included 48 children with concussion of the brain, group 2--12 children with brain contusion. Group 1 was divided into 2 subgroups: subgroup 1a comprised 34 children with single concussion and subgroup 1b--14 children with repeated concussion. The aAB level was determined 6 months and 1 year after skull injury. The aAB concentration was expressed in percents to the control level being considered significant if the increase was higher than 120%. The increased NMDA aAB level was observed during the first year after skull injury. In the la subgroup, the NR2 aAB level in blood serum was 145 +/- 12,6%, in the 1b one--108 +/- 12,4%, in group 2--165 +/- 34%. The content of aAB to AMPA receptors was elevated only in children of lb subgroup and group 2 (150 +/- 16,8% and 167 +/- 31,3%, respectively). The EEG examination of this group revealed the nonspecific paroxysmal discharges in 18% of cases and epileptiform activity in 6% of children. The results obtained suggest that children with posttraumatic headache have elevated levels of aAB to glutamate receptors, hyperstimulation of which reflects hypoxic processes in the brain, and are in need of metabolic therapy.

Morphofunctional study of the therapeutic effect of autologous mesenchymal stem cells in experimental diffuse brain injury in rats.

Effects of systemic transplantation of mesenchymal stem cells obtained by culturing of autologous bone marrow on proliferative activity of cells and functional morphology of neurons after diffuse brain injury were studied in Wistar rats. Comparative analysis of the results indicated that systemic injection of mesenchymal stem cells in a syngeneic organism produced proliferotropic, angiogenic, and, presumably, neurotrophic effects. The therapeutic effect visually manifested on day 2 after intravenous injection of mesenchymal stem cells during the early period of reparative regeneration of ischemic cell and tissue structures of the brain. The neuroprotective effect of mesenchymal stem cells was more pronounced against the background of basic therapy.

[The enteral feeding during the treatment of appendicular peritonitis in children]. / Enteral'noe pitanie pri lechenii peritonita appendikuliarnogo proiskhozhdeniia u detei.

A total of 65 patients, aged 3 to 14, with different forms of appendicular peritonitis, in whom the intestinal insufficiency syndrome (IIS), stage 2, was diagnosed, were investigated. 35 patients were in the main group, and 30 patients were in the control group; the subjects of the latter group had a similar form of peritonitis, i.e. IIS, stage 2, it was confirmed clinically and by ultrasound examinations. The laparoscopic operations were carried out in all patients. The patients of both groups received postoperatively a similar therapy, i.e. the antibacterial, metabolic and infusive ones, as well as vitamins and parenteral feeding (daily caloric values--50-120 kcal/kg, protein--2-3 g/kg/day) according to a child's age and a clinical course of peritonitis. All children of the main group received postoperatively an early enteral therapy (EET), which involved 4 stages. Stage 1: introduction of the salt solution with added glutamine through the naso-gastric probe by increasing volumes and with respect to an individual tolerability of a patient; stage 2: introduction of semi-element mixtures; stage 3: introduction of 10% solutions of polymer balanced mixture; stage 4: introduction of 20% solutions of polymer mixtures. Ultrasound scanning and clinical methods were used to assess the efficiency of the recovery of intestinal peristalsis. The conducted investigations showed that the mean duration of the gastric-type EET amounted to 3-4 days, and the IIS was, on the average, arrested by days 6 or 7. The duration of infusive therapy and parenteral feeding went down, in the main group, by 2 days. A trend towards an increase of the erythrocyte level was noted in these patients. No differences were registered in the values of concentrations of total protein and albumin in the blood serum of patients in both groups from the 1st to 7th postoperative days, however, the infusions of plasma and albumin were made by 2 times more often in the main group as compared to the control one. The EET technique preserved the gastric mucous tunic intact, which cut the postoperative complications 2-fold, and consequently, it reduced the stay of patients in hospital on the average by 8 days. A conclusion was made, on the basis of the conducted study, that EET is a pathophysiologically substantiated treatment method for IIS, stage 2, in children with appendicular peritonitis; EET ensures a rapid recovery of gastric-tract functions, it reduces the frequency rate of postoperative complications and cuts the length of both the infusive therapy and of the patients' stay in hospital.