Radiological features of pulmonary fat embolism in trauma patients: a case series.

PURPOSE: Fat embolism syndrome (FES) is a rare complication in trauma patients (usually with long bone fractures) in which migrating medullary fat precipitates multiorgan dysfunction, classically presenting with dyspnoea, petechiae and neurocognitive dysfunction. Although this triad of symptoms is rare, it nonetheless aids diagnosis of pulmonary fat embolism (PuFE). Typical imaging features of PuFE are not established, although increasing use of CT pulmonary angiography (CTPA) in this cohort may provide important diagnostic information. We therefore conducted a case series of FES patients with CTPA imaging at a Level 1 Trauma Centre in Melbourne, Australia. METHODS: Medical records and various radiological investigations including CTPA of consecutive patients diagnosed clinically with FES between 2006 and 2018, including demographics, injury and their progress during their admission, were reviewed. RESULTS: Fifteen FES patients with retrievable CTPAs were included (mean age 31.2 years, range 17-69; 12 males [80%]). 93.3% had long bone fractures. CTPA was performed 2.00 ± 1.41 days post-admission. Review of these images showed pulmonary opacity in 14 (93.3%; ground-glass opacities in 9 [64.3%], alveolar opacities in 6 [42.9%]), interlobular septal thickening in 10 (66.7%), and pleural effusions in 7 (46.7%). Filling defects were identified in three (20%) CTPAs, with density measuring - 20HU to + 63HU. Ten patients (66.7%) had neuroimaging performed, with two patients demonstrating imaging findings consistent with cerebral fat emboli. CONCLUSION: CTPA features of PuFE are variable, with ground-glass parenchymal changes and septal thickening most commonly seen. Filling defects were uncommon.

Effect of Early Sustained Prophylactic Hypothermia on Neurologic Outcomes Among Patients With Severe Traumatic Brain Injury: The POLAR Randomized Clinical Trial.

Importance: After severe traumatic brain injury, induction of prophylactic hypothermia has been suggested to be neuroprotective and improve long-term neurologic outcomes. Objective: To determine the effectiveness of early prophylactic hypothermia compared with normothermic management of patients after severe traumatic brain injury. Design, Setting, and Participants: The Prophylactic Hypothermia Trial to Lessen Traumatic Brain Injury-Randomized Clinical Trial (POLAR-RCT) was a multicenter randomized trial in 6 countries that recruited 511 patients both out-of-hospital and in emergency departments after severe traumatic brain injury. The first patient was enrolled on December 5, 2010, and the last on November 10, 2017. The final date of follow-up was May 15, 2018. Interventions: There were 266 patients randomized to the prophylactic hypothermia group and 245 to normothermic management. Prophylactic hypothermia targeted the early induction of hypothermia (33°C-35°C) for at least 72 hours and up to 7 days if intracranial pressures were elevated, followed by gradual rewarming. Normothermia targeted 37°C, using surface-cooling wraps when required. Temperature was managed in both groups for 7 days. All other care was at the discretion of the treating physician. Main Outcomes and Measures: The primary outcome was favorable neurologic outcomes or independent living (Glasgow Outcome Scale-Extended score, 5-8 [scale range, 1-8]) obtained by blinded assessors 6 months after injury. Results: Among 511 patients who were randomized, 500 provided ongoing consent (mean age, 34.5 years [SD, 13.4]; 402 men [80.2%]) and 466 completed the primary outcome evaluation. Hypothermia was initiated rapidly after injury (median, 1.8 hours [IQR, 1.0-2.7 hours]) and rewarming occurred slowly (median, 22.5 hours [IQR, 16-27 hours]). Favorable outcomes (Glasgow Outcome Scale-Extended score, 5-8) at 6 months occurred in 117 patients (48.8%) in the hypothermia group and 111 (49.1%) in the normothermia group (risk difference, 0.4% [95% CI, -9.4% to 8.7%]; relative risk with hypothermia, 0.99 [95% CI, 0.82-1.19]; P = .94). In the hypothermia and normothermia groups, the rates of pneumonia were 55.0% vs 51.3%, respectively, and rates of increased intracranial bleeding were 18.1% vs 15.4%, respectively. Conclusions and Relevance: Among patients with severe traumatic brain injury, early prophylactic hypothermia compared with normothermia did not improve neurologic outcomes at 6 months. These findings do not support the use of early prophylactic hypothermia for patients with severe traumatic brain injury. Trial Registration: clinicaltrials.gov Identifier: NCT00987688; Anzctr.org.au Identifier: ACTRN12609000764235.

Emergency department interpretation of CT of the brain: a systematic review.

BACKGROUND AND OBJECTIVES: CT of the brain (CTB) is one of the most common radiological investigations performed in the emergency department (ED). Emergency clinicians rely upon this imaging modality to aid diagnosis and guide management. However, their capacity to accurately interpret CTB is unclear. This systematic review aims to determine this capacity and identify the potential need for interventions directed towards improving the ability of emergency clinicians in this important area. METHODS: A systematic review of the literature was conducted without date restrictions. We searched MEDLINE, EMBASE and Cochrane databases and studies reporting the primary outcome of concordance of CTB interpretation between a non-radiologist and a radiology specialist were identified. Studies were assessed for heterogeneity and a subgroup analysis of pooled data based on medical specialty was carried out to specifically identify the concordance of ED clinicians. The quality of evidence was assessed using the GRADE criteria. RESULTS: There were 21 studies included in this review. Among the included studies, 12 reported on the concordance of emergency clinicians, 5 reported on radiology trainees and 4 on surgeons. Clinical and statistical heterogeneity between studies was high (I2=97.8%, p<0.01). The concordance in the emergency subgroup was the lowest among all subgroups with a range of 0.63-0.95 and a clinically significant error rate ranging from 0.02 to 0.24. CONCLUSIONS: Heterogeneity and the presence of bias limit our confidence in these findings. However, the variance in the interpretation of CTB between emergency clinicians and radiologists suggests that interventions towards improving accuracy may be useful.

Erythropoietin in traumatic brain injury (EPO-TBI): a double-blind randomised controlled trial.

BACKGROUND: Erythropoietin might have neurocytoprotective effects. In this trial, we studied its effect on neurological recovery, mortality, and venous thrombotic events in patients with traumatic brain injury. METHODS: Erythropoietin in Traumatic Brain Injury (EPO-TBI) was a double-blind, placebo-controlled trial undertaken in 29 centres (all university-affiliated teaching hospitals) in seven countries (Australia, New Zealand, France, Germany, Finland, Ireland, and Saudi Arabia). Within 24 h of brain injury, 606 patients were randomly assigned by a concealed web-based computer-generated randomisation schedule to erythropoietin (40,000 units subcutaneously) or placebo (0·9% sodium chloride subcutaneously) once per week for a maximum of three doses. Randomisation was stratified by severity of traumatic brain injury (moderate vs severe) and participating site. With the exception of designated site pharmacists, the site dosing nurses at all sites, and the pharmacists at the central pharmacy in France, all study personnel, patients, and patients' relatives were masked to treatment assignment. The primary outcome, assessed at 6 months by modified intention-to-treat analysis, was improvement in the patients' neurological status, summarised as a reduction in the proportion of patients with an Extended Glasgow Outcome Scale (GOS-E) of 1-4 (death, vegetative state, and severe disability). Two equally spaced preplanned interim analyses were done (after 202 and 404 participants were enrolled). This study is registered with ClinicalTrials.gov, number NCT00987454. FINDINGS: Between May 3, 2010, and Nov 1, 2014, 606 patients were enrolled and randomly assigned to erythropoietin (n=308) or placebo (n=298). Ten of these patients (six in the erythropoietin group and four in the placebo group) were lost to follow up at 6 months; therefore, data for the primary outcome analysis was available for 596 patients (302 in the erythropoietin group and 294 in the placebo group). Compared with placebo, erythropoietin did not reduce the proportion of patients with a GOS-E level of 1-4 (134 [44%] of 302 patients in the erythropoietin group vs 132 [45%] of 294 in the placebo group; relative risk [RR] 0·99 [95% CI 0·83-1·18], p=0·90). In terms of safety, erythropoietin did not significantly affect 6-month mortality versus placebo (32 [11%] of 305 patients had died at 6 months in the erythropoietin group vs 46 [16%] of 297 [16%] in the placebo group; RR 0·68 [95% CI 0·44-1·03], p=0·07) or increase the occurrence of deep venous thrombosis of the lower limbs (48 [16%] of 305 vs 54 [18%] of 298; RR 0·87 [95% CI 0·61-1·24], p=0·44). INTERPRETATION: Following moderate or severe traumatic brain injury, erythropoietin did not reduce the number of patients with severe neurological dysfunction (GOS-E level 1-4) or increase the incidence of deep venous thrombosis of the lower limbs. The effect of erythropoietin on mortality remains uncertain. FUNDING: The National Health and Medical Research Council and the Transport Accident Commission.

"After-hours" staffing of trauma centres and outcomes among patients presenting with acute traumatic coagulopathy.

OBJECTIVE: To examine the effect of the "after-hours" (18:00-07:00) model of trauma care on a high-risk subgroup - patients presenting with acute traumatic coagulopathy (ATC). DESIGN, PARTICIPANTS AND SETTING: Retrospective analysis of data from the Alfred Trauma Registry for patients with ATC presenting between 1 January 2006 and 31 December 2011. MAIN OUTCOME MEASURE: Mortality at hospital discharge, adjusted for potential confounders, describing the association between after-hours presentation and mortality. RESULTS: There were 398 patients with ATC identified during the study period, of whom 197 (49.5%) presented after hours. Mortality among patients presenting after hours was 43.1%, significantly higher than among those presenting in hours (33.1%; P = 0.04). Following adjustment for possible confounding variables of age, presenting Glasgow Coma Scale score, urgent surgery or angiography and initial base deficit, after-hours presentation was significantly associated with higher mortality at hospital discharge (adjusted odds ratio, 1.77; 95% CI, 1.10-2.87). CONCLUSION: The after-hours model of care was associated with worse outcomes among some of the most critically ill trauma patients. Standardising patient reception at major trauma centres to ensure a consistent level of care across all hours of the day may improve outcomes among patients who have had a severe injury.

Acute colonic pseudo-obstruction in polytrauma patients.

BACKGROUND: Acute colonic pseudo-obstruction (ACPO) is characterized by severe colonic distension without mechanical obstruction. It has an uncertain pathogenesis and poses diagnostic challenges. This study aims to explore risk factors and clinical outcomes of ACPO in polytrauma patients, and contributing information to the limited literature on this condition. METHODS: This retrospective study, conducted at a Level 1 Trauma Centre, analysed data from trauma patients with ACPO admitted between July 2009 and June 2018. A control cohort of major trauma patients was utilized. Data review encompassed patient demographics, abdominal imaging, injury characteristics, analgesic usage, interventions, complications, and mortality. Statistical analyses, including logistic regression and correlation coefficients, were employed to identify risk factors. RESULTS: There were 57 cases of ACPO, with an incidence of 1.7 / 1000 patients, rising to 4.86 in major trauma. Predominantly affecting those over 50 years of age (75%) and males (75%), with motor vehicle accidents (50.8%) and falls from height (36.8%) being the commonest mechanisms. Noteworthy associated injuries included retroperitoneal bleeds (RPB) (37%), spinal fractures (37%), and pelvic fractures (37%). Analysis revealed significant associations between ACPO and Shock Index >0.9, Injury Severity Score > 18, opioid use, RPB, and pelvic fractures. A caecal diameter of ≥12 cm had a significant association with caecal ischemia or perforation. CONCLUSION: This study underscores the significance of ACPO in polytrauma patients, demonstrating associations with risk factors and clinical outcomes. Clinicians should maintain a high index of suspicion, particularly in older patients with RPB, pelvic fractures, and opioid use. Early supportive therapy, vigilant monitoring, and timely interventions are crucial for a favourable outcome. Further research and prospective trials are warranted to validate these findings and enhance understanding of ACPO in trauma patients. LEVEL OF EVIDENCE: Prognostic and Epidemiological, Level IV.

Can initial clinical assessment exclude thoracolumbar vertebral injury?

INTRODUCTION: The aim of this study was to test the hypothesis that all blunt trauma patients, presenting with a Glasgow coma scale (GCS) score of 15, without intoxication or neurological deficit, and no pain or tenderness on log-roll can have any thoracolumbar fracture excluded without imaging. MATERIALS AND METHODS: All patients diagnosed with a thoracolumbar fracture presenting to the emergency department of a major trauma centre and having an initial GCS score of 15 were included in the study. Variables collected included type of fracture, mechanism of injury, the presence of pain or tenderness on log-roll, ethanol levels and prehospital opioid analgesia. RESULTS: There were 536 patients with thoracolumbar fractures, of which 508 (94.8%) patients had either pain, tenderness or had received prehospital opioid analgesia. A small subgroup of 28 (5.2%) patients who received no prehospital opioid analgesia, did not complain of pain and had no tenderness to the thoracolumbar spine elicited on log-roll. This subgroup was significantly older (p=0.033) and a high proportion of patients (64.3%) had a concurrent fracture of the cervical spine. Within this subgroup, a clinically significant unstable thoracic fracture was present in three patients, with all three patients exhibiting symptoms and signs of neurological injury or having a concurrent cervical vertebral fracture. CONCLUSIONS: In this population of blunt trauma patients with a GCS score of 15, not under the influence of alcohol or prehospital morphine administration, the absence of pain or tenderness on log-roll can exclude a clinically significant lumbar vertebral fracture, but does not exclude a thoracic fracture.

Assessing the necessity of intravenous contrast for computed tomography in the acute undifferentiated abdomen.

INTRODUCTION: Undifferentiated abdominal pain in the emergency setting is frequently investigated with an intravenous contrast enhanced CT as a first line diagnostic test. However, global contrast shortages restricted the use of contrast for a period in 2022, altering standard practice with many scans performed without intravenous contrast. Whilst IV contrast can be useful to assist with interpretation, its necessity in the setting of acute undifferentiated abdominal pain is not well described, and its use comes with its own risks. This study aimed to assess the shortcomings of omitting IV contrast in an emergency setting, by comparing the rate of CT scans with "indeterminate" findings with and without the use of IV contrast. METHODS: Data from presentations to a single centre emergency department for undifferentiated abdominal pain prior to and during contrast shortages in June 2022 were retrospectively compared. The primary outcome was the rate of diagnostic uncertainty, where the presence or absence of intra-abdominal pathology could not be ascertained. RESULTS: 12/85 (14.1%) of the unenhanced abdominal CT scans provided an uncertain result, compared with 14/101 (13.9%) of control cases performed with intravenous contrast (P = 0.96). There were also similar rates of positive and negative findings between the groups. CONCLUSION: Omitting intravenous contrast for abdominal CT in the setting of undifferentiated abdominal pain demonstrated no significant difference in the rate of diagnostic uncertainty. There are significant potential patient, fiscal and societal benefits as well as potential improvements to emergency department efficiency with the reduction of unnecessary intravenous contrast administration.

Interpretation of computed tomography of the cervical spine by non-radiologists: a systematic review and meta-analysis.

BACKGROUND: After trauma, clearance of the cervical spine refers to the exclusion of underlying serious injuries. Accurate assessment of computed tomography (CT) is commonly required prior to clearance of the cervical spine. Delays to clearance can lead to prolonged immobilization with associated patient discomfort and adverse effects. This systematic review aimed to determine performance of non-radiologists to evaluate cervical spine CT. METHODS: MEDLINE, EMBASE, Cochrane library with sources of grey literature and reference lists of selected articles were appraised from inception to April 2021. We included manuscripts that reported discordance in CT cervical spine interpretation between non-radiologists and radiologists. The Newcastle-Ottawa scale (NOS) was used to assess quality of included studies and statistical heterogeneity was assessed using the I2 statistic. RESULTS: There were 43 studies identified for eligibility and 4 manuscripts included in the final analysis. There were two studies that reported on the performance of radiology residents, one study on the performance of surgical residents and one on emergency physicians. The pooled discordance was 0.25 (95%CI 0.21-0.28) but was lower for radiology residents (range 0.007-0.05). There was significant statistical heterogeneity (I2  = 99.6%, P < 0.001) among studies. CONCLUSION: There is a paucity of evidence documenting the ability of non-radiologists in accurately interpreting CT of the cervical spine. A number of discordant findings suggest that studies with larger sample sizes are indicated to accurately ascertain the ability of non-radiologists in this area.

The use of whole-body trauma CT should be based on mechanism of injury: A risk analysis of 3920 patients at a tertiary trauma centre.

BACKGROUND: Mechanism of injury (MOI) plays a significant role in a decision to perform whole-body computed tomography (CT) imaging for trauma patients. Various mechanisms have unique patterns of injury and therefore form an important variable in decision making. METHODS: Retrospective cohort study including all patients >18 years old who received a whole-body CT scan between 1 January 2019 and 19 February 2020. The outcomes were divided into CT 'positive' if any internal injuries were detected and CT 'negative' if no internal injuries were detected. The MOI, vital sign parameters, and other relevant clinical examination findings at presentation were recorded. RESULTS: 3920 patients met the inclusion criteria, of which 1591 (40.6%) had a positive CT. The most common MOI was fall from standing height (FFSH), accounting for 23.0%, followed by motor vehicle accident (MVA), accounting for 22.4%. Covariates significantly associated with a positive CT included age, MVA >60 km/h, motor bike, bicycle, or pedestrian accident >30 km/h, prolonged extrication >30 min, fall from height above standing, penetrating chest or abdominal injury, as well as hypotension, neurological deficit, or hypoxia on arrival. FFSH was shown to reduce the risk of a positive CT overall, however, sub-analysis of FFSH in patients >65 years showed a significant association with a positive CT (OR 2.34, p < 0.001) compared to <65 years. CONCLUSIONS: Pre-arrival information including MOI and vital signs have significant impact on identifying subsequent injuries with CT imaging. In high energy trauma, we should consider the need for whole-body CT based on MOI alone regardless of the clinical examination findings. However, for low-energy trauma, including FFSH, in the absence of clinical examination findings which support an internal injury, a screening whole-body CT is unlikely to yield a positive result, particularly in the age group <65yo.

Mid-Arm Point in PAEDiatrics (MAPPAED): An effective procedural aid for safe pleural decompression in trauma.

OBJECTIVE: Life-threatening thoracic trauma requires emergency pleural decompression and thoracostomy and chest drain insertion are core trauma procedures. Reliably determining a safe site for pleural decompression in children can be challenging. We assessed whether the Mid-Arm Point (MAP) technique, a procedural aid proposed for use with injured adults, would also identify a safe site for pleural decompression in children. METHODS: Children (0-18 years) attending four EDs were prospectively recruited. The MAP technique was performed, and chest wall skin marked bilaterally at the level of the MAP; no pleural decompression was performed. Radio-opaque markers were placed over the MAP-determined skin marks and corresponding intercostal space (ICS) reported using chest X-ray. RESULTS: A total of 392 children participated, and 712 markers sited using the MAP technique were analysed. Eighty-three percentage of markers were sited within the 'safe zone' for pleural decompression (4th to 6th ICSs). When sited outside the 'safe zone', MAP-determined markers were typically too caudal. However, if the site for pleural decompression was transposed one ICS cranially in children ≥4 years, the MAP technique performance improved significantly with 91% within the 'safe zone'. CONCLUSIONS: The MAP technique reliably determines a safe site for pleural decompression in children, albeit with an age-based adjustment, the Mid-Arm Point in PAEDiatrics (MAPPAED) rule: 'in children aged ≥4 years, use the MAP and go up one ICS to hit the safe zone. In children <4 years, use the MAP.' When together with this rule, the MAP technique will identify a site within the 'safe zone' in 9 out of 10 children.

Cervical spine magnetic resonance imaging in alert, neurologically intact trauma patients with persistent midline tenderness and negative computed tomography results.

STUDY OBJECTIVE: We aim to determine the prevalence and factors associated with cervical discoligamentous injuries detected on magnetic resonance imaging (MRI) in acute, alert, neurologically intact trauma patients with computed tomography (CT) imaging negative for acute injury and persistent midline cervical spine tenderness. We present the cross-sectional analysis of baseline information collected as a component of a prospective observational study. METHODS: Alert, neurologically intact trauma patients presenting to a Level I trauma center with CT negative for acute injury, who underwent MRI for investigation of persistent midline cervical tenderness, were prospectively recruited. Deidentified images were assessed, and injuries were identified and graded. Outcome measures included the presence and extent of MRI-detected injury of the cervical ligaments, intervertebral discs, spinal cord and associated soft tissues. RESULTS: There were 178 patients recruited during a 2-year period to January 2009. Of these, 78 patients (44%) had acute cervical injury detected on MRI. There were 48 single-column injuries, 15 two-column injuries, and 5 three-column injuries. Of the remaining 10 patients, 6 had isolated posterior muscle edema, 2 had alar ligamentous edema, 1 had epidural hematoma, and 1 had atlanto-occipital edema. The injuries to 38 patients (21%) were managed clinically; 33 patients were treated in cervical collars for 2 to 12 weeks, and 5 patients (2.8%) underwent operative management, 1 of whom had delayed instability. Ordinal logistic regression revealed that factors associated with a higher number of spinal columns injured included advanced CT-detected cervical spondylosis (odds ratio [OR] 11.6; 95% confidence interval [CI] 3.9 to 34.3), minor isolated thoracolumbar fractures (OR 5.4; 95% CI 1.5 to 19.7), and multidirectional cervical spine forces (OR 2.5; 95% CI 1.2 to 5.2). CONCLUSION: In patients with cervical midline tenderness and negative acute CT findings, we found that a subset of patients had MRI-detected cervical discoligamentous injuries and that advanced cervical spine degeneration evident on CT, minor thoracolumbar fracture, and multidirectional cervical spine forces were associated with increased injury extent. However, a larger study is required to validate which variables may reliably predict clinically important injury in such patients, thereby indicating the need for further radiographic assessment.

A positive response to a recruitment maneuver with PEEP titration in patients with ARDS, regardless of transient oxygen desaturation during the maneuver.

UNLABELLED: Recruitment maneuvers (RMs) can expand collapsed alveoli in ventilated patients. The optimal method for delivering RMs is unknown. PURPOSE: To evaluate the safety and the respiratory and hemodynamic effects of a staircase recruitment maneuver (SRM) with decremental positive end expiratory pressure (PEEP) titration and the consequences of desaturation during the SRM in patients with early acute lung injury (ALI). METHODS: In total, 20 consecutive patients with early ALI were enrolled and received an SRM. Patients were given 15 ± 3 cm H(2)O pressure-controlled ventilation. Positive end expiratory pressure was increased from baseline (range 10-18) to 20, 30, and 40 cm H(2)O every 2 minutes to achieve maximum alveolar pressure of 55 ± 3 cm H(2)O, then decreased at 3-minute intervals to 25, 22.5, 20, 17.5, and 15 cm H(2)O until a decrease of 1% to 2% oxygen saturation from maximum was detected. Positive end expiratory pressure was left at the level where the fall in oxygen saturation occurred. Standard respiratory and circulatory variables, arterial and central venous gases were measured before, during, and after the SRM. RESULTS: There were significant improvements in shunt fraction (36.3% ± 10% to 26.4% ± 14%, P < .001), oxygen saturation (93.4% ± 2% to 96.8% ± 3%, P = .007), partial pressure of oxygen, arterial (PaO(2))/fraction of inspired oxygen ([FIO(2)]; 150 ± 42 to 227 ± 100, P = .004), lung compliance (33.9 ± 9.1 to 40.1 ± 11.4 mL/cm H(2)O, P < .01), and chest x-ray (CXR) after the SRM. Briefly, 80% of the patients responded and the response was maintained at 1 hour. In total, 8 patients desaturated 6.1% ± 2.8% in SaO(2) during the SRM but 5 of those improved SaO(2) relative to baseline by the end of the SRM. CONCLUSIONS: In all, 80% of the patients with early ALI responded to the SRM with decremental PEEP titration. Desaturation during the SRM did not indicate a failed response 1 hour later.

Impact of COVID vaccination rollout on the use of computed tomography venography for the assessment of cerebral venous sinus thrombosis.

INTRODUCTION: Cerebral venous sinus thrombosis (CVST) is rare; however, it has been observed in patients with vaccine-induced immune thrombotic thrombocytopaenia syndrome (VITT) following the use of adenovirus vector vaccines against COVID-19. Adverse vaccine effects have been heavily addressed in mainstream media, likely contributing to vaccination anxiety. This study aimed to assess how the vaccine rollout and media coverage has influenced the use of computed tomography venography (CTV) in an acute care setting of a tertiary hospital. METHOD: Single-centre retrospective cohort study from 30 March 2021 to 13 June 2021. Direct comparison to same calendar dates in the preceding 3 years. RESULTS: In 2021, 57 patients received CTV with headache being the reason in 48 (84%) and 40 (70%) had received ChAdOx1 nCov-19 (AstraZeneca COVID-19 vaccination). Only 20 of these patients received CTV after platelets and D-Dimer had returned, and only three patients met existing guidelines for imaging. Zero cases were positive. The number of CTV studies was 5.2 times than in 2020 and 2.7 times the mean number for the 3 preceding years. CONCLUSION: The use of CTV in patients with headache has markedly increased at our centre since negatively biased vaccination influence of mainstream media. Headache is a common vaccine-related side effect and VITT is exceptionably rare. With the rates of vaccination increasing in the community, these results highlight the importance of strict adherence to established evidence-based guidelines. Otherwise, critical care capacity, and in particular imaging resources already under pressure will be strained further.

Risk stratification of emergency department patients with acute pulmonary thromboembolism: Is chest pain a reason to investigate?

BACKGROUND: This study aimed to risk-stratify chest pain as a presenting symptom in patients with a diagnosis of pulmonary thromboembolism (PE) to assess for any association. In addition, this study aimed to assess traditionally acknowledged PE risk factors in an Australian population. METHODS: This was a retrospective single-centre cohort study assessing patients who presented to our emergency department during the period of 1 January 2019 to 1 January 2020. 730 consecutive patients who went on to computed tomography pulmonary angiography (CTPA) examination after presentation were included. RESULTS: The rate of CTPA being positive in this study was 11.6% (85/730). Chest pain was associated with a non-significant reduction in the odds of PE (OR 0.774, P = 0.327). Univariate analysis showed significantly increased odds of a diagnosis of PE with presentation for leg pain/swelling (OR 6.670, P < 0.001). Multivariate analysis showed increasing age (OR 1.018, 95% CI 1.002-1.034, P = 0.024), clinical signs of a DVT (OR 3.194, 95% CI 1.803-5.657, P < 0.001) and positive D-dimer (OR 1.762, 95% CI 1.011-3.071, P = 0.046) were associated with increased odds of PE. CONCLUSION: In this study, Emergency Department presentation with chest pain, whilst the most common reason to perform a CTPA, resulted in reduced odds with regard to the diagnosis of pulmonary thromboembolism. The use of CTPA in this setting may be rationalised according to other factors such as localised leg pain as a symptom, signs of DVT, increasing age or positive D-dimer.

The status of radiation protection in medicine in the Asia-Pacific region.

More than half of the world's population live in Asia-Pacific. This region is culturally diverse, with significant disparities in terms of socio-economic status, provision of health care and access to advanced technology. The medical use of ionising radiation is increasing worldwide and similarly within the Asia-Pacific region. In this paper, we highlight the current status in usage of ionising radiation in medicine in the region, and review the legal framework, implementation and activities in radiation protection. Asia-Pacific countries are active in strengthening radiation protection by promoting education and training. Various projects and activities initiated by international organisations such as the IAEA, WHO and ICRP have provided stimulation in the region, but more work is needed to continue to improve protection practices.

Predicting fracture outcomes from clinical registry data using artificial intelligence supplemented models for evidence-informed treatment (PRAISE) study protocol.

BACKGROUND: Distal radius (wrist) fractures are the second most common fracture admitted to hospital. The anatomical pattern of these types of injuries is diverse, with variation in clinical management, guidelines for management remain inconclusive, and the uptake of findings from clinical trials into routine practice limited. Robust predictive modelling, which considers both the characteristics of the fracture and patient, provides the best opportunity to reduce variation in care and improve patient outcomes. This type of data is housed in unstructured data sources with no particular format or schema. The "Predicting fracture outcomes from clinical Registry data using Artificial Intelligence (AI) Supplemented models for Evidence-informed treatment (PRAISE)" study aims to use AI methods on unstructured data to describe the fracture characteristics and test if using this information improves identification of key fracture characteristics and prediction of patient-reported outcome measures and clinical outcomes following wrist fractures compared to prediction models based on standard registry data. METHODS AND DESIGN: Adult (16+ years) patients presenting to the emergency department, treated in a short stay unit, or admitted to hospital for >24h for management of a wrist fracture in four Victorian hospitals will be included in this study. The study will use routine registry data from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), and electronic medical record (EMR) information (e.g. X-rays, surgical reports, radiology reports, images). A multimodal deep learning fracture reasoning system (DLFRS) will be developed that reasons on EMR information. Machine learning prediction models will test the performance with/without output from the DLFRS. DISCUSSION: The PRAISE study will establish the use of AI techniques to provide enhanced information about fracture characteristics in people with wrist fractures. Prediction models using AI derived characteristics are expected to provide better prediction of clinical and patient-reported outcomes following distal radius fracture.

Technique, radiation safety and image quality for chest X-ray imaging through glass and in mobile settings during the COVID-19 pandemic.

The COVID-19 pandemic in 2020 has led to preparations within our hospital for an expected surge of patients. This included developing a technique to perform mobile chest X-ray imaging through glass, allowing the X-ray unit to remain outside of the patient's room, effectively reducing the cleaning time associated with disinfecting equipment. The technique also reduced the infection risk of radiographers. We assessed the attenuation of different types of glass in the hospital and the technique parameters required to account for the glass filtration and additional source to image distance (SID). Radiation measurements were undertaken in a simulated set-up to determine the appropriate position for staff inside and outside the room to ensure occupational doses were kept as low as reasonably achievable. Image quality was scored and technical parameter information collated. The alternative to imaging through glass is the standard portable chest X-ray within the room. The radiation safety requirements for this standard technique were also assessed. Image quality was found to be acceptable or borderline in 90% of the images taken through glass and the average patient dose was 0.02 millisieverts (mSv) per image. The majority (67%) of images were acquired at 110 kV, with an average 5.5 mAs and with SID ranging from 180 to 300 cm. With staff positioned at greater than 1 m from the patient and at more than 1 m laterally from the tube head outside the room to minimise scatter exposure, air kerma values did not exceed 0.5 microgray (µGy) per image. This method has been implemented successfully.

Management of Australian Patients with Severe Traumatic Brain Injury: Are Potentially Harmful Treatments Still Used?

Clinical trials have shown that intravenous albumin and decompressive craniectomy to treat early refractory intracranial hypertension can cause harm in patients with severe traumatic brain injury (TBI). The extent to which these treatments remain in use is unknown. We conducted a multi-center retrospective cohort study of adult patients with severe TBI admitted to five neurotrauma centers across Australia between April 2013 and March 2015. Patients were identified from local trauma and intensive care unit (ICU) registries and followed until hospital discharge. Main outcome measures were the administration of intravenous albumin, and decompressive craniectomy for intracranial hypertension. Analyses were predominantly descriptive. There were 303 patients with severe TBI, of whom a minority received albumin (6.9%) or underwent early decompressive craniectomy for treatment of refractory intracranial hypertension complicating diffuse TBI (2.3%). The median (intequartile range [IQR]) age was 35 (24, 58), and most injuries were caused by road traffic accidents (57.4%) or falls (25.1%). Overall, 34.3% of patients died while in the hospital and the remainder were discharged to rehabilitation (44.6%), other health care facilities (4.6%), or home (16.5%). There were no patient characteristics significantly associated with use of albumin or craniectomy. Intravenous albumin and craniectomy for treatment of intracranial hypertension were used infrequently in Australian neurotrauma centers, indicating alignment between best available evidence and practice.