Head injury among older adults and their clinical management: one year of emergency department attendances at a UK trauma center.

OBJECTIVES: Primary: describe characteristics of adults aged ≥65 attending the Emergency Department (ED) at one major trauma center. Secondary: examine co-morbidities and complications; identify use of anticoagulant/antiplatelet medication among older adults presenting with Head Injury (HI); assess clinical management against UK guidelines. METHODS: All ED admissions were screened prospectively to identify HI using case notes, hospital records and Trauma Audit Research Network data. Data were collected on demographics, cause and severity of injury, co-morbidities, anticoagulation/antiplatelet use, diagnostic imaging and discharge outcomes. RESULTS: Over 12 months, 697 patients aged ≥65 years attended the ED for HI, representing over a quarter of adult ED attendances for HI. Mean age was 78.5 years (range 65-106), 395 (56.7%) were female. Most HIs were mild (93.5%) and 86% caused by falls. Three-quarters were discharged without hospital admission. Most had a preexisting medical condition andtaking medications prior to HI. Of these 116 were taking anticoagulants/antiplatelets but only 37 (31.9%) received a head CT scan. Half the patients were given a written HI information sheet at ED discharge. CONCLUSIONS: Care of HI in older adults is challenging due to comorbidities. Practising evidence-based clinical management and following guidelines is important, but strict adherence is not common practice.

Anti-N-methyl-D-aspartate receptor encephalitis presenting as atypical psychosis in multiple sclerosis: a case report.

BACKGROUND: Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is an autoimmune disorder which often presents with neuropsychiatric symptoms. A large proportion of cases are associated with an identifiable tumor, most commonly ovarian teratoma. However, recent literature has also described an overlap of anti-NMDAR encephalitis and demyelinating syndromes. Cases have been reported of anti-NMDAR encephalitis in patients with ADEM, optic neuritis, myelitis and multiple sclerosis. This link is considered rare, however has important clinical implications as treatments and prognosis may differ. CASE PRESENTATION: A 33-year-old female with a history of multiple sclerosis presented with new-onset neuropsychiatric symptoms. After substance-induced psychosis was ruled out, she was admitted to the medical ward for work up of psychosis secondary to multiple sclerosis. However, the consultation-liaison psychiatry service noted atypical symptoms which were concerning for autoimmune encephalitis. Admission to a psychiatric inpatient ward was deferred. Anti-NMDAR encephalitis was diagnosed with CSF analysis demonstrating lymphocytic pleocytosis and anti-NMDAR antibodies. In addition to first-line treatment of encephalitis with steroids, second-line immunotherapies were also implemented given the patient's underlining demyelinating syndrome. The patient's neurologic and psychiatric symptoms began to improve. CONCLUSIONS: There is literature to demonstrate a possible connection between anti-NMDAR encephalitis and demyelinating syndromes. As such, autoimmune encephalitis should be considered in patients with multiple sclerosis presenting with atypical symptoms. Determining the correct diagnosis is crucial to inform the appropriate treatment protocol, and to improve prognosis.

Traumatic brain injuries in older adults-6 years of data for one UK trauma centre: retrospective analysis of prospectively collected data.

OBJECTIVES: Our aim was to determine the incidence of traumatic brain injury (TBI) in older adults and investigate the relationship between injury characteristics and outcomes. METHODS: Retrospective analysis of prospectively collected data submitted to Trauma Audit and Research Network (TARN) database for a major trauma centre in the West Midlands, UK, from 2008 to 2014. The Mayo Scale was used to categorise TBI. All patients were aged ≥65 years and were admitted with head or brain injuries meeting TARN inclusion criteria: injury resulting in immediate admission to hospital for 3 days, admitted to a high dependency area or death following trauma. We determined age, gender, mechanism of injury, Injury Severity Score, presenting Glasgow Coma Scale (GCS) and Mayo Score, and the association of outcome (Glasgow Outcome Scale (GOS)) with age and clinical presentation. RESULTS: 4413 patients were admitted with trauma meeting TARN criteria: 1389 were ≥65 years and 45% (624) had TBI. For patients ≥65 years with TBI, mean age was 79 (range 65-99); 56% were men. Falls accounted for 85% of all TBIs. Most TBIs were moderate/severe (80%) by the Mayo criteria. Of the 279 patients with subdural haematoma, 28% had neurosurgery. Most patients survived TBI (78%); 57% had a good outcome on GOS at discharge (not requiring care package). Mortality was associated with increased age (17% in ages 65-74 years, 19% in 75-84 years, 30% in ≥85 years, p=0.03). Outcome was significantly associated with injury severity (p=0.0001). CONCLUSIONS: Patients with TBI represented 45% of all trauma cases meeting TARN inclusion criteria. Falls at home accounted for most TBIs. Most had moderate/severe TBI, yet over half made a good recovery on GOS. Our data indicate that injury prevention initiatives should focus on home safety. Further research is needed to examine rehabilitation and follow-up after hospital discharge.

Bactericidal activity of porcine neutrophil secretions.

Antimicrobial proteins in neutrophil granules exert their bactericidal activity both within the neutrophil phagolysosome and as components of neutrophil extracellular traps. This study evaluated the bactericidal activity of porcine neutrophil secretions against four bacterial pathogens of swine. Porcine neutrophils were treated with or without phorbol myristate acetate (PMA), then the resulting supernatants were incubated with Escherichia coli K-12, Streptococcus suis, Actinobacillus suis, or Pasteurella multocida, and the surviving colony forming units were enumerated. Supernatants of PMA-activated neutrophils killed an average of 95% of E. coli K-12 cells, relative to supernatants from untreated neutrophils. Inhibition of elastase activity using chloromethylketone (CMK) prior to PMA stimulation significantly reduced the bactericidal activity of the neutrophil supernatants; 57% of the PMA-induced bactericidal activity against E. coli K-12 was estimated to be elastase-dependent. The same neutrophil supernatants had lower bactericidal activity against S. suis, A. suis, and P. multocida, with 30%, 36% and 13% reduction in bacterial numbers, respectively. The cathelicidin porcine myeloid antimicrobial peptide (PMAP)-36 and lactotransferrin were among the proteins identified in the supernatants of PMA-stimulated neutrophils by mass spectrometry. These findings imply that elastase-activated proteins, such as cathelicidins, are partially responsible for the bactericidal effect of porcine neutrophil secretions, but non-elastase-dependent proteins such as lactoferrin may also contribute. Further, the secretions of activated neutrophils were effective in killing the avirulent E. coli K-12 but were less effective against the other bacteria tested, suggesting that these pathogens may have evolved mechanisms to resist neutrophil-mediated killing.