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We report the in vitro longevity of a conventional soda lime carbon dioxide absorbent and an absorbent free from strong alkali (Amsorb). Although the times taken to breakthrough of carbon dioxide (> 0.5%) within an in vitro low flow breathing system were shorter with the alkali-free absorbent, we found that the size and shape of the absorbent container was the major factor in determining the efficiency of the carbon dioxide absorbents.

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OBJECTIVE: To establish current practice for the monitoring and management of acute intracranial hypertension in children in United Kingdom intensive care units (ICUs). DESIGN: Postal questionnaire, targetted by prior telephone survey, to all ICUs admitting five or more children per annum with acute neurological illness. RESULTS: Of the units contacted 70 % responded, approximately one-half of which reported the use of intracranial pressure (ICP) monitoring. Only data from these units are presented. Nearly all of these units consider monitoring following serious head injury, but its use in non-traumatic brain injury is less widespread. The decision to institute ICP monitoring is based mainly upon neuroimaging appearances and Glasgow Coma Scale score. ICP and cerebral perfusion pressure targets differ markedly between centres, with only 46 % and 65 % of units, respectively, setting age-dependent parameters. Mannitol and varying degrees of hyperventilation are employed by all units to lower ICP. The majority also use barbiturates, diuretics, and fluid restriction. Controlled hypothermia is used in 52 % of units. Paediatric units are more likely to employ age-dependent cerebral perfusion pressure targets. Specific therapies employed to lower ICP are similar to those used in adult centres. CONCLUSION: Faced with a lack of both evidence and consensus, the management of acute intracranial hypertension in childhood varies widely. National or international guidelines for the management of children with raised intracranial pressure are needed. These should incorporate the physiological differences between children of different ages.

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Two children are reported with hydrocephalus and aqueduct stenosis who presented with back and limb pains. Neither had the classic symptoms of headache and vomiting. The children had enlarged heads and later developed ataxic gait and papilloedema. The cause of the pains is uncertain but similar symptoms have been reported in subjects with benign intracranial hypertension and may relate to spinal nerve root pouch distension. Operative ventricular drainage resulted in rapid improvement of all symptoms in both children.

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IL-10, originally described as a cytokine synthesis inhibitory factor produced by T cells, has recently been found to suppress osteoblastic differentiation in mouse bone marrow cultures. Since osteoblastic cells exert a major influence on the production and regulation of osteoclasts, the cells that resorb bone, this suggests that the cytokine might play a role in the regulation of bone resorption. We, therefore, tested the actions of the cytokine on osteoclast formation and function. We found no effect of IL-10 on the resorptive function of mature osteoclasts, either when isolated or when incubated in the presence of osteoblastic cells. However, IL-10 suppressed bone resorption in bone marrow cultures and in cocultures of bone marrow stromal cell lines with hemopoietic spleen cells. In both systems, suppression of bone resorption was associated with a substantial reduction in the ratio of calcitonin receptor-positive cells to macrophages, suggesting that IL-10 exerts a reciprocal action on the differentiation of osteoclasts and macrophages from their shared precursor. This reciprocal action is very similar to that associated with the addition of macrophage CSF to hemopoietic cultures, and we found that IL-10 increased the expression of mRNA for macrophage CSF in bone marrow cultures. This potent inhibition of osteoclast formation by IL-10 suggests that IL-10 might play a role in the modulation of bone loss in inflammatory disorders.

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Although animal studies suggest that there may be major differences between the effects of bisphosphonates and ovarian hormones on skeletal metabolism, whether this also holds for their actions in patients is unknown. To address this question, we compared the effects of 12 weeks treatment with HRT on bone turnover markers in osteopenic postmenopausal women with those of an amino-bisphosphonate. Women within 15 yr of the menopause, with a lumbar and/or femoral neck bone mineral density 1 S.D. below the predicted value, received either oestradiol valerate 2 mg and dydrogesterone 5 mg (E/D; n = 16) or aminohexane bisphosphonate 400 mg (AHBP; n = 9). Urine and serum samples were collected on two separate occasions before starting treatment, and 1, 2, 4, 8 and 12 weeks afterwards. To assess bone resorption, we measured the urinary deoxypyridinoline/creatinine ratio (DPD/crea), while serum alkaline phosphatase (ALP), osteocalcin and C-terminal propeptide of type I collagen (CICP) were analysed to assess bone formation. Repeated measures analysis of variance revealed a highly significant decrease in DPD/crea over the treatment period. Furthermore, this pattern of response differed significantly between the two treatment groups, since DPD/crea was maximally suppressed within 2 weeks of starting AHBP, while E/D showed little decrease until 8 weeks. AHBP was also found to suppress ALP, osteocalcin and CICP more rapidly than E/D, the former reducing these markers by 8 weeks, while E/D caused little inhibition even by 12 weeks. We conclude that, in the doses used in this study, AHBP appears to suppress bone turnover significantly more rapidly than E/D, suggesting that clinically important differences may exist in the effects of bisphosphonates and ovarian hormones on bone metabolism.

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It is generally considered that osteoblastic cells are essential for osteoclast formation. We tested the ability of hemopoietic tissue to differentiate osteoclastic characteristics in the absence of osteoblastic cells. We found that large numbers of calcitonin-receptor positive (CTRP) cells can be induced by prostaglandin E2 and 1,25(OH)2 vitamin D3, in cultures of hemopoietic mouse spleen. Moreover, spleen stromal cells were equivalent to bone marrow stromal cells in CTRP-cell induction. The spleen CTRP cells did not resorb bone, but were rapidly induced to full resorptive activity upon osteoblast addition. Thus, bone cells may not be essential for osteoclast formation, but rather are required to activate and regulate the resorptive function of mature osteoclasts.

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We investigated whether androgens, for which the ovaries are the major source in female rats, contribute to the stimulation of cancellous bone formation by ovarian hormones in female rats. Ovariectomized animals were administered 5alpha-dihydrotestosterone (DHT; 10 and 100 microgram/kg) by daily subcutaneous injection for 13 days, after which histomorphometric analysis was performed at the proximal tibial metaphysis. To prevent ovariectomy from stimulating bone turnover, and hence complicating the interpretation of changes in bone formation, animals were also given the resorption inhibitor 3-amino-1-hydroxypropylidene-1-bisphosphonate. We found that ovariectomy markedly suppressed cancellous bone formation, which was partially prevented by DHT (100 microgram/kg). To further address whether androgens contribute to the stimulation of bone formation by ovarian hormones, we treated intact and ovariectomized female rats with the androgen antagonist flutamide (15 mg/kg/day) for 28 days. Whereas flutamide had no effect in ovariectomized rats, it significantly reduced cancellous bone formation in intact animals. We conclude that, in the female rat, androgens contribute under physiological conditions to the stimulation of cancellous bone formation by ovarian hormones.

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Although 17 beta-oestradiol (E2) is known to prevent bone loss, prolonged administration of E2 is unable to reverse this in female rats rendered osteopenic by ovariectomy. To determine whether this reflects a failure to replace other components of ovarian function involved in bone metabolism, we compared the effects of administering E2 to osteopenic ovariectomized (ovx) rats with those of ovarian transplantation. Ovariectomy was performed in female rats. After 13 weeks, by which time marked bone loss had occurred, one group of ovx animals received ovaries from donor rats, and, after a delay of 2 weeks to allow oestrus cycles to return, a further group received E2 5 micrograms.kg-1.day-1 for 9 weeks. The dose of E2 was chosen as that which in preliminary studies restored mean serum E2 levels to that of intact female rats. The study was terminated 24 weeks after ovariectomy. Both E2 and ovarian transplantation largely restored indices of oestrogenic exposure in ovx rats to those of sham-ovx animals. Animals receiving ovarian transplants also showed a small increase in serum progesterone and full restoration of serum testosterone. However, while ovarian transplantation also returned indices of cancellous bone metabolism to those of sham-ovx animals, there was little increase in bone volume. Interestingly, exogenous E2 caused a greater increase in cancellous bone volume than ovarian transplantation but also caused more marked suppression of bone formation, as assessed at the end of the study. In conclusion, exogenous E2 and ovarian transplantation exerted distinct effects on skeletal metabolism in osteopenic ovx rats, although the basis for this difference is currently unclear.

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Osteoblasts mediate much of the hormonal responsiveness of osteoclasts. We and others have found that one mechanism through which this regulation is effected is by release of osteoclast resorption-stimulating activity (ORSA) into culture supernatants. However, although hormonal responsiveness is regularly observed in co-cultures, ORSA is not always detectable in conditioned media. We show here that one explanation for this finding is that ORSA may be retained by heparin-like glycosaminoglycans (GAGs) of the cell surface or extracellular matrix of osteoblasts. We found that protease-sensitive ORSA could be extracted from monolayers of the osteoblastic cell line UMR 106 with 2M NaCl or collagenase. Production of this activity was increased in response to 1,25(OH)2D3. The presence of the GAG heparin was required to reveal ORSA. Immobilisation of ORSA by GAGs may assist osteoblastic cells in the regulation of the complex patterns of osteoclastic activity observed during skeletal morphogenesis and restructuring.

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Increased numbers of mast cells are commonly seen at sites of increased bone resorption and in osteoporosis. Long-term administration of heparin, a major component of mast cell granules, causes osteoporosis. We therefore tested the effect of heparin on bone resorption by osteoclasts disaggregated from neonatal rat long bones. We found that, in the absence of serum, heparin was without effect on osteoclast function. However, in the presence of newborn calf serum, rat serum, or bovine platelet-poor plasma-derived serum, heparin, in the range 25-100 micrograms/ml, induced an increase in osteoclastic bone resorption. Heparin appeared to act through binding and enhancement of an osteoclast resorption-stimulating activity (ORSA) present in serum. A number of known factors that show an affinity for heparin, including transforming growth factor-beta, platelet-derived growth factors, insulin-like growth factors I or II, acidic or basic fibroblast growth factors, fibronectin, or laminin, could not substitute for ORSA, suggesting that the activity may represent a novel heparin-binding factor. The ability of glycosaminoglycans (GAGs) and related molecules to enhance resorption was dependent on the degree of sulfation and on their size: The high molecular weight GAG heparan sulfate and polysaccharides fucoidan or dextran sulfate showed a similar effect, while low molecular weight heparin, chondroitin-2-sulfate, chondroitin-4-sulfate, and chondroitin-6-sulfate were without effect. We propose that mast cells or heparin therapy increases bone resorption through augmentation of the activity of a factor involved in the local and systemic regulation of osteoclastic bone resorption.

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