Electrically assisted pedal cycles: is new legislation required to mitigate increased head injury risk?

OBJECTIVES: Electrically Assisted Pedal Cycles (EAPCs) are pedal bikes that are fitted with a motor that travel at higher speeds than conventional bicycles. Recent international data shows that there is an association with increased severity of injury, particularly in paediatric populations. Currently, EAPCs are subject to the same legislation regarding helmet use as pedal bikes in the UK and EU which does not mandate the use of a helmet. Here we examine safety concerns surrounding EAPCs in the context of existing EU and UK legislation to assess whether changes to these should be made by public health bodies to mitigate the increased risk of injury. METHODS: A retrospective international literature review looking at electric bicycle-related trauma and legislation was conducted using a systematic search of internet databases. Peer-reviewed articles and online resources were reviewed based on relevance to the above objective. RESULTS: EAPCS can travel at up to 17.5 mph, resulting in higher speeds of travel and collision. The use of EAPCs has been associated with increased severity of head injuries. Bicycle helmets have been shown to reduce the severity of head injury in accidents involving both EAPCs and pedal cycles. Healthcare providers should pay extra attention to the possibility of severe injuries when a patient had a bicycle accident with an EAPC, especially in paediatric populations. CONCLUSIONS: Given that EAPCS have been associated internationally with increased severity of head injuries we propose that existing EU and UK legislation may not be fit for purpose with respects to increased EAPC usage and criteria for impact protection of existing helmets. Further research and audit with more accurate recording of data associated with EAPCs use and associated injuries would inform enhanced regulation regarding EAPC usage in the future.

Intratumoral and Peritumoral Brain Abscess Concomitant with Glioblastoma: Report of Two Cases with Review of Literature.

Intracranial abscess coexistent with a high grade glioma, without prior surgical intervention, is an unusual occurrence. This paper presents two such cases with Nocardia farcinica abscess surrounding the glioblastoma in an immunocompromised individual and Enterococcus faecium abscess within the glioblastoma in an immunocompetent patient. Adjuvant therapy was tapered as per each patient's clinical response. Till date, only eight cases of coexistent high-grade glioma and brain abscess have been reported in literature. This report stands distinct in highlighting the need to radiologically evaluate each foci of a multicentric cranial lesion on its own merit.

Rodent under the hat.

This report describes a case of neglected scalp basal cell carcinoma (BCC) resulting in total destruction of soft tissue and underlying cranium, with remarkably preserved dura and no parenchymal involvement. A 57-year-old woman presented with a 2-week history of lethargy. On removal of her hat, a large round ulcer was revealed. It transpired that the patient noticed a pruritic scalp lesion 9 months ago. As the lesion and wound enlarged, she was too embarrassed to inform her family and hid it under a hat at all time. She never experienced meningitic symptoms. Biopsy confirmed BCC. Subsequently, she underwent two free latissimus dorsi flap reconstructions to cover the wound and palliative radiotherapy. She responded well to treatment. This case provides a rare opportunity to observe the natural history of scalp BCC. The reasons for the rarity of this mode of presentation and the low incidence of intracranial infection are discussed.

Spontaneously disappearing lumbar disc protrusion.

Spontaneous disappearance of a herniated lumbar disc is known to occur. This case study describes a 45-year-old patient whose symptoms of lumbar radiculopathy resolved and follow-up imaging showed complete disappearance of the disc prolapse. This phenomenon strengthens the role of conservative treatment in the management of lumbar disc protrusions.

Factors affecting the survival following surgical treatment of chronic subdural haematoma: Single institutional experience.

BACKGROUND: Chronic subdural haematoma (CSDH) is one of the most commonly treated condition in neurosurgery. It affects elderly populations who often have significant medical co-morbidities resulting in poor prognosis. The study aimed at identifying clinical factors influencing the survival following surgical management of CSDH. METHODS: Retrospective study included 267 cases that underwent surgery for CSDH and followed over 5-year period (2010-2015); data retrieved with reference to operation details, radiology reports and discharge. Using logistic and Cox regression analysis, the patient survival data was analysed with respect to patient demographics, type of surgery, co-morbidities, anticoagulation treatment, and discharge destination. RESULTS: The overall survival in the cohort was 37.0months (IQR: 20.0-60.0). The median age of the patients was 76years (IQR: 66-82) and the median length of hospital stay was 10days (range 1-126days; IQR: 6-17days). The recurrence rate was 6.37% (n=17). Fifty-three (19.85%) patients recorded deceased on the IPM database as of October 2016 and of those 11 died in hospital. Univariate Cox-regression analysis revealed increased age (HR: 1.80; 95%CI: 1.04-3.11), length of hospital stay (HR: 2.50; 95%CI: 1.41-4.41) and number of co-morbidities (HR: 2.19; 95%CI: 1.26-3.79) were associated with poor prognosis. Glasgow coma scale (GCS) at discharge was found to be significantly associated with survival whilst anticoagulation treatment did not. Multivariate analysis confirmed similar findings significant statistically. CONCLUSION: Age at admission, median length of hospital stay, number of co-morbidities, GCS at discharge and discharge destination have been found to influence survival significant statistically.

Double trouble: a tale of two radio-treatments.

In recent years, an increasing number of patients are treated with radiation. In the early era of radiotherapy, which began soon after X-rays were discovered by Roentgen in 1895, tumours were irradiated with high doses of X-rays in a single fraction. The major initial setback was the damage caused to normal tissues; however, in recent times the use of stereotactic radiosurgery, which delivers high doses of radiation precisely to abnormal tissue targets while sparing the surrounding normal brain tissue, and particularly for surgically inaccessible tumours, has taken centre stage. Prophylactic whole brain radiation (in conjunction with aggressive chemotherapy) for childhood acute lymphoblastic leukaemia has been shown to improve patient survival, however, this is associated with complications in survivors. We report an interesting case of one of the longest survivors who has had double complications from radiotherapy-based interventions.

Posterior reversible encephalopathy syndrome mimicking a cerebral tumour.

Posterior reversible encephalopathy syndrome (PRES) is a syndrome characterised clinically by headache, confusion, seizures, vomiting and visual disturbances with radiographic vasogenic oedema. CT imaging is typically normal, non-specific or suggestive of PRES or stroke. MRI usually shows symmetrical parietal and occipital lobe vasogenic oedema. The authors discuss a 58-year-old man presenting with right homonymous haemianopia, hypertension and ataxia. CT imaging suggested a left occipital lobe space occupying lesion (SOL). Surprisingly, subsequent contrast enhanced MRI showed characteristic bilateral vasogenic oedema in occipital and temporal lobes indicative of PRES. Hypertension, an associated predisposing factor, was present in this case and symptoms improved with antihypertensive therapy. This case highlights PRES may present with asymmetrical CT imaging findings mimicking a SOL. PRES is a potentially reversible condition with prompt treatment. MRI is essential in diagnosing both PRES and the cause of acute visual loss.