Prevalence of venous thromboembolism in patients undergoing diagnostic venous ultrasound during the first SARS-CoV-2 pandemic.

Background: Venous thromboembolism appears to be associated with severe COVID-19 infection than in those without it. However, this varies considerably depending on the cohort studied. The aims of this single-centre, multi-site retrospective cross-sectional study were to assess the number of all venous scans performed in the first month of pandemic in a large university teaching hospital, to evaluate the incidence of deep venous thrombosis (DVT), and assess the predictive ability of the clinical information available on the electronic patient record in planning work-up for DVT and prioritising ultrasound scans. Patients and methods: All consecutive patients undergoing venous ultrasound for suspected acute DVT between 1st of March and 30th of April 2020 were considered. Primary outcome was the proportion of scans positive for DVT; the secondary outcomes included association of a positive SARS-CoV-2 PCR test, demographic, clinical factors, and Wells scores. Results: 819 ultrasound scans were performed on 762 patients across the Trust in March and April 2020. This number was comparable to the corresponding pre-pandemic cohort from 2019. The overall prevalence of DVT in the studied cohort was 16.1% and was higher than before the pandemic (11.5%, p=.047). Clinical symptoms consistent with COVID-19, irrespective of the SARS-CoV-2 PCR test result (positive_COVID_PCR OR 4.97, 95%CI 2.31-10.62, p<.001; negative_COVID_PCR OR 1.97, 95%CI 1.12-3.39, p=.016), a history of AF (OR 0.20, 95%CI 0.03-0.73, p=.037), and personal history of venous thromboembolism (VTE) (OR 1.95, 95%CI 1.13-3.31, p=.014), were independently associated with the diagnosis of DVT on ultrasound scan. Wells score was not associated with the incidence of DVT. Conclusions: Amongst those referred for the DVT scan, SARS-CoV-2 PCR test was associated with an increased risk of VTE and should be taken into consideration when planning DVT work-up and prioritising diagnostic imaging. We postulate that the threshold for imaging should possibly be lower.

Quantification of Fluid Volume and Distribution in the Paediatric Colon via Magnetic Resonance Imaging.

Previous studies have used magnetic resonance imaging (MRI) to quantify the fluid in the stomach and small intestine of children, and the stomach, small intestine and colon of adults. This is the first study to quantify fluid volumes and distribution using MRI in the paediatric colon. MRI datasets from 28 fasted (aged 0-15 years) and 18 fluid-fed (aged 10-16 years) paediatric participants were acquired during routine clinical care. A series of 2D- and 3D-based software protocols were used to measure colonic fluid volume and localisation. The paediatric colon contained a mean volume of 22.5 mL ± 41.3 mL fluid, (range 0-167.5 mL, median volume 0.80 mL) in 15.5 ± 17.5 discreet fluid pockets (median 12). The proportion of the fluid pockets larger than 1 mL was 9.6%, which contributed to 94.5% of the total fluid volume observed. No correlation was detected between all-ages and colonic fluid volume, nor was a difference in colonic fluid volumes observed based on sex, fed state or age group based on ICH-classifications. This study quantified fluid volumes within the paediatric colon, and these data will aid and accelerate the development of biorelevant tools to progress paediatric drug development for colon-targeting formulations.

Paediatric developmental venous anomalies (DVAs): how often do they bleed and where?

INTRODUCTION: Developmental venous anomalies (DVAs) are anomalies of venous drainage and considered a low-flow malformation. Studies evaluating natural history and risk factors for intracranial haemorrhage in the paediatric population are rare. We evaluate clinical and radiological features, risk factors and outcomes of paediatric DVAs. METHODS: A retrospective study was conducted over a 10-year period between 2004 and 2014. Medical records, imaging and prospective databases were reviewed. Three-hundred-and-three radiological studies in total were evaluated. RESULTS: Fifty-two children (20 boys and 32 girls [median age: 6 years] were identified with DVAs. Their age distribution was as follows: 1.9% neonates (< 1 month), 11.5% infants (1 month to 1 year), 30.8% 1-5 years, 30.8% 5-12 years and 25% 12-16 years. The majority (92.3%) presented with asymptomatic DVAs identified incidentally. Overall, anatomical distribution revealed predilection for frontal region (42.3%) with other common sites being posterior fossa (17.3%) and basal ganglia (13.5%). Temporal (11.5%), parietal (9.6%) and occipital (5.8%) were the remainder. Associated cavernous malformations (CMs) were present in 3/52 (5.8%), and no DVAs were associated with aneurysms or arteriovenous malformations (AVMs). Three patients had more than one DVA. There were three deaths unrelated to DVAs over median follow-up of 3.8 years. Four patients (7.7%) suffered DVA-related intracranial haemorrhage presenting with neurological deficits. The ages of the children with DVA-related haemorrhages were 21 days, 2 years and 6 months, 7 years and 1 month and 11 years and 7 months. Left-sided DVA haemorrhages predominated (3/4, 75%). The relative risk of a cerebellar DVA haemorrhage compared to its supratentorial counterpart was 5.35 (OR 6.8, 95% CI 0.8-58). DISCUSSION: DVA-related haemorrhage is sevenfold greater in our paediatric cohort compared to adults and is significantly associated with cerebellar location and cavernous malformations. There were no haemorrhages over a median period of 3.8 years of prospective follow-up.

Spontaneous neonatal subdural haemorrhage: always non-accidental injury?

In any neonate or infant presenting with an acute onset of encephalopathy, and/or retinal haemorrhages with no history of major trauma and imaging showing subdural haemorrhage (SDH), the diagnostic priority is to exclude a non-accidental injury (NAI), given the association of these clinical features with the shaken baby syndrome. However, other causes of SDH may present in a similar manner in neonates and infants, in particular vascular lesions such as aneurysms. A four week old neonate presenting with seizures and retinal haemorrhages, was diagnosed with an acute subdural haemorrhage (ASDH) on imaging with significant midline shift needing surgical evacuation. As there was some blood extending into the left sylvian fissure, further imaging was considered before surgical intervention. This showed a distally located middle cerebral artery aneurysm, which was successfully treated and the neonate made a remarkable recovery. We present a case of a neonate presenting with spontaneous acute subdural haematoma in the absence of classical diffuse subarachnoid haemorrhage, intracerebral haemorrhage or intraventricular haemorrhage, secondary to a ruptured middle cerebral artery aneurysm. The distribution of aneurysms in the neonatal age group is different to adults, with middle cerebral artery aneurysms and more distally located peripheral aneurysms being more common. Vigilance should be borne to exclude the aforementioned as causes for this presentation especially prior to undertaking surgical intervention.

Consent in paediatric neurosurgery: adequacy of documentation and parental perspectives.

INTRODUCTION: Consenting paediatric patients for surgical procedures remains inherently unique in that it is underpinned by principles such as parental responsibility, assessment of the child's capacity to consent, and adherence to national/legal guidelines. Quality record keeping is an important objective evidence to demonstrate the highest standards of medical care provided to our patients. The consent form is a crucial medical record encapsulating the attainment of informed consent from a parent/guardian for performing a procedure on their child. We aimed to prospectively evaluate the consenting process in our department to assess adequacy of documentation and parental perspectives. METHODS: A prospective study using qualitative descriptive design was conducted with parents of 50 children requiring neurosurgical procedures over a 3-month period. RESULTS: All patients understood the primary diagnosis and type of surgery. Procedure-specific risks were understood by 98% and 84% could remember the mentioning of general risks of surgery. Only a minority of parents (24%) could recollect that alternative options of management including no treatment were discussed. In cases where relevant, laterality was only documented in 56% of consent forms. All patients felt that an informed decision regarding consent to surgery was made. However, 12% suggested areas where further improvement could be made in the timing of consent and the way information could be better provided. DISCUSSION: Consent is more than a signature on a form. It provides objective evidence of a shared decision-making process between the surgeon, patient, and their parent/guardian. Our initial study highlights multiple areas for improvement.

Males with prolactinoma are at increased risk of incident cardiovascular disease.

OBJECTIVE: To investigate whether the risk of incident cardiovascular disease (CVD) is increased in patients with prolactinoma. DESIGN: Population-based, retrospective, open-cohort study using The Health Improvement Network (THIN) database. PATIENTS: A total of 2233 patients with prolactinoma and 10 355 matched controls (1:5 ratio) from UK General Practices contributing to THIN were included. Sex, age, body mass index and smoking status were used as matching parameters. The primary outcome was any incident CVD, defined by Read codes suggesting myocardial infarction, angina pectoris, stroke, transient ischaemic attack or heart failure. Sex-specific-adjusted incidence rate ratios (aIRRs) were calculated with Poisson regression, using clinically relevant parameters as model covariates. Sensitivity analyses were performed to check whether a change in the initial assumptions could have an impact on the findings. RESULTS: During the 6-year observation period, the composite CVD outcome was recorded in 54 patients with prolactinoma and 180 "nonexposed" individuals. The incidence rate was 1.8 and 14.8 per 1000 person-years for the females and males with prolactinoma, respectively. The aIRRs for CVD were estimated at 0.99 [95% confidence interval (CI): 0.61-1.61, P = .968)] in female patients and 1.94 (95% CI: 1.29-2.91, P = .001) in male patients. These findings remained robust in sensitivity analyses restricting to patients with documented record of dopamine agonist treatment and those with newly diagnosed prolactinoma. CONCLUSIONS: In contrast to females, men with prolactinoma have increased risk for incident CVD; the aetiology of this gender-specific finding remains to be elucidated.

Surgery for Acute Subdural Hematoma: Replace or Remove the Bone Flap?

OBJECTIVE: In surgery for acute subdural hematoma (ASDH), the bone flap can be fixed onto the skull, left riding to provide partial skull decompression, or removed. This study assessed whether removing the bone flap improved outcome. METHODS: We conducted an observational study on consecutive patients who were operated for ASDH in our hospital from July 2011 to June 2014. We retrospectively collected data on demographics, injury severity, and predicted and observed outcomes at 6 months. The cohort was divided into 2 groups based on whether the bone flap was replaced (fixed and riding flap craniotomy) or removed (decompressive craniectomy). The differences in functional status, postoperative control of intracranial hypertension, and number of cranial reoperations were analyzed. A subgroup analysis compared decompressive craniectomy with riding flap craniotomy alone. RESULTS: Data were obtained for 99 patients; 69 had decompressive craniectomy, 17 had riding flap craniotomy, and 13 had fixed flap craniotomy. The decompressive craniectomy group had statistically worse injuries, more predicted poor outcomes (69% vs. 57%, P = 0.013), more observed poor outcomes (59% vs. 37%, P = 0.037), equivalent control of intracranial hypertension, and a similar number of reoperations compared with the craniotomy groups. Subgroup analysis between decompressive craniectomy and riding flap craniotomy showed no significant difference in baseline characteristics and outcomes. CONCLUSIONS: Our study concluded that removing the bone flap after ASDH evacuation was not associated with a better outcome. We recommend replacing the bone flap if brain conditions allow. Further research is required to evaluate the role of skull decompression in surgery for ASDH.