The prevalence of clinically relevant delayed intracranial hemorrhage in head trauma patients treated with oral anticoagulants is very low: a retrospective cohort register study.

BACKGROUND: Current guidelines from Scandinavian Neuro Committee mandate a 24-hour observation for head trauma patients on anticoagulants, even with normal initial head CT scans, as a means not to miss delayed intracranial hemorrhages. This study aimed to assess the prevalence, and time to diagnosis, of clinically relevant delayed intracranial hemorrhage in head trauma patients treated with oral anticoagulants. METHOD: Utilizing comprehensive two-year data from Region Skåne's emergency departments, which serve a population of 1.3 million inhabitants, this study focused on adult head trauma patients prescribed oral anticoagulants. We identified those with intracranial hemorrhage within 30 days, defining delayed intracranial hemorrhage as a bleeding not apparent on their initial CT head scan. These cases were further defined as clinically relevant if associated with mortality, any intensive care unit admission, or neurosurgery. RESULTS: Out of the included 2,362 head injury cases (median age 84, 56% on a direct acting oral anticoagulant), five developed delayed intracranial hemorrhages. None of these five cases underwent neurosurgery nor were admitted to an intensive care unit. Only two cases (0.08%, 95% confidence interval [0.01-0.3%]) were classified as clinically relevant, involving subdural hematomas in patients aged 82 and 87 years, who both subsequently died. The diagnosis of these delayed intracranial hemorrhages was made at 4 and 7 days following initial presentation to the emergency department. CONCLUSION: In patients with head trauma, on oral anticoagulation, the incidence of clinically relevant delayed intracranial hemorrhage was found to be less than one in a thousand, with detection occurring four days or later after initial presentation. This challenges the effectiveness of the 24-hour observation period recommended by the Scandinavian Neurotrauma Committee guidelines, suggesting a need to reassess these guidelines to optimise care and resource allocation. TRIAL REGISTRATION: This is a retrospective cohort study, does not include any intervention, and has therefore not been registered.

Higher risk of traumatic intracranial hemorrhage with antiplatelet therapy compared to oral anticoagulation-a single-center experience.

PURPOSE: Traumatic brain injury is the main reason for the emergency department visit of up to 3% of the patients and a major worldwide cause for morbidity and mortality. Current emergency management guidelines recommend close attention to patients taking oral anticoagulation but not patients on antiplatelet therapy. Recent studies have begun to challenge this. The aim of this study was to determine the impact of antiplatelet therapy and oral anticoagulation on traumatic intracranial hemorrhage. METHODS: Medical records of adult patients triaged with "head injury" as the main reason for emergency care were retrospectively reviewed from January 1, 2017, to December 31, 2017, and January 1, 2020, to December 31, 2021. Patients ≥ 18 years with head trauma were included. Odds ratio was calculated, and multiple logistic regression was performed. RESULTS: A total of 4850 patients with a median age of 70 years were included. Traumatic intracranial hemorrhage was found in 6.2% of the patients. The risk ratio for traumatic intracranial hemorrhage in patients on antiplatelet therapy was 2.25 (p < 0.001, 95% confidence interval 1.73-2.94) and 1.38 (p = 0.002, 95% confidence interval 1.05-1.84) in patients on oral anticoagulation compared to patients without mediations that affect coagulation. In binary multiple regression, antiplatelet therapy was associated with intracranial hemorrhage, but oral anticoagulation was not. CONCLUSION: This study shows that antiplatelet therapy is associated with a higher risk of traumatic intracranial hemorrhage compared to oral anticoagulation. Antiplatelet therapy should be given equal or greater consideration in the guidelines compared to anticoagulation therapy. Further studies on antiplatelet subtypes within the context of head trauma are recommended to improve the guidelines' diagnostic accuracy.

Short- and long-term outcome after colon cancer resections performed by male and female surgeons: A single-center retrospective cohort study.

BACKGROUND AND OBJECTIVE: To assess the effect of surgeon sex on short- and long-term outcomes after colon cancer resections. METHODS: Clinical data of patients who underwent colon cancer resections between 2010 and 2020 at Helsingborg Hospital, Sweden, were retrospectively obtained from medical records. The sex of the surgeon of each procedure was recorded. Morbidity, mortality, and long-term survival were compared in patients operated by male and female surgeons. RESULTS: Colon cancer resections were performed by 23 male and 9 female surgeons in 1113 patients (79% elective, 21% emergent). After elective surgery, there was no difference in postoperative complications, 30-day mortality, or long-term survival between patients operated by male and female surgeons. Following emergent resections, the complication rate was significantly lower in patients operated by female surgeons (41.3% vs 58.1%, p = 0.019). Similarly, the rates of R1-resections (0% vs 5.2%, p = 0.039), reoperations (3.8% vs 14.2%, p = 0.014), and intensive care unit (ICU) care (6.3% vs 17.4%, p = 0.018) were significantly lower for patients operated by female surgeons, but there was no difference in 30-day mortality (6.3% vs 5.2%, p = 0.767). Cox regression analysis showed that long-term and cancer-free survival in patients emergently operated by male surgeons was significantly shorter than that of patients operated by female surgeons (hazard ratio = 1.9 (95% confidence interval (CI) = 1.3-2.8), p = 0.001 and hazard ratio = 1.7 (95% CI = 1.1-2.7), p = 0.016). CONCLUSIONS: The short- and long-term outcome after elective colon cancer resections were similar in patients operated by male and female surgeons. The outcome following emergent resections performed by female surgeons compared favorably with that of male surgeons, with fewer complications and reoperations and better long-term survival.

Delayed intracranial hemorrhage after head trauma seems rare and rarely needs intervention-even in antiplatelet or anticoagulation therapy.

BACKGROUND: Traumatic brain injury causes morbidity, mortality, and at least 2,500,000 yearly emergency department visits in the USA. Computerized tomography of the head is the gold standard to detect traumatic intracranial hemorrhage. Some are not diagnosed at the first scan, and they are denoted "delayed intracranial hemorrhages. " To detect these delayed hemorrhages, current guidelines for head trauma recommend observation and/or rescanning for patients on anticoagulation therapy but not for patients on antiplatelet therapy. The aim of this study was to investigate the prevalence and need for interventions of delayed intracranial hemorrhage after head trauma. METHODS: The study was a retrospective review of medical records of adult patients with isolated head trauma presenting at Helsingborg General Hospital between January 1, 2020, and December 31, 2020. Univariate statistical analyses were performed. RESULTS: In total, 1627 patients were included and four (0.25%, 95% confidence interval 0.06-0.60%) patients had delayed intracranial hemorrhage. One of these patients was diagnosed within 24 h and three within 2-30 days. The patient was diagnosed within 24 h, and one of the patients diagnosed within 2-30 days was on antiplatelet therapy. None of these four patients was prescribed anticoagulation therapy, and no intensive care, no neurosurgical operations, or deaths were recorded. CONCLUSION: Traumatic delayed intracranial hemorrhage is rare and consequences mild and antiplatelet and anticoagulation therapy might confer similar risk. Because serious complications appear rare, observing, and/or rescanning all patients with either of these medications can be debated. Risk stratification of these patients might have the potential to identify the patients at risk while safely reducing observation times and rescanning.

Effects of surgical specialization and surgeon resection volume on postoperative complications and mortality rate after emergent colon cancer resection.

BACKGROUND: The aim of this study was to evaluate the effect of surgical specialization and surgeon resection volume on short-term outcome after emergent colon cancer resections. METHODS: A retrospective analysis of all patients who underwent resections for colon cancer between 2011 and 2020 at Helsingborg Hospital, Sweden was performed. The senior surgeon participating in each procedure was classified as a colorectal surgeon or a non-colorectal surgeon. Non-colorectal surgeons were further divided into acute care surgeons or surgeons with other specialties. Surgeons were also divided into three groups based on median yearly resection volumes. Postoperative complications and 30- or 90-day mortality rate after emergent colon cancer resections were compared in patients operated on by surgeons with different specializations and yearly resection volumes. RESULTS: Of 1121 patients resected for colon cancer, 235 (21.0 per cent) had emergent procedures. The complication rate of emergent resections was similar in patients operated on by colorectal surgeons and non-colorectal surgeons (54.1 versus 51.1 per cent respectively), and the subgroup of acute care surgeons (45.8 per cent), whereas resections performed by general surgeons were significantly associated with more frequent complications (odds ratio (OR) 2.5 (95 per cent c.i. 1.1 to 6.1)). The complication rate was numerically highest in patients operated on by surgeons with the highest resection volumes, which differed significantly from that of surgeons with intermediate resection volumes (OR 4.2 (95 per cent c.i. 1.1 to 16.0)). There was no difference in the mortality rate of patients operated on by surgeons with different specializations or yearly resection volumes. CONCLUSION: This study documented similar morbidity and mortality rates after emergent colon resection performed by colorectal and acute care surgeons, but patients operated on by general surgeons had more frequent complications.

Cervical myoma causing colonic obstruction in the first trimester of pregnancy - a case report.

A 39-year-old nulliparous woman with a previously known cervical myoma was admitted to the obstetrics department during the first trimester with complaints of severe abdominal pain, lack of bowel movements and the suspicion of a clinical bowel obstruction. Because no literature on this exact condition could be found, clinical decisions were based on reports and practice in similar situations. Ultrasound revealed the progression of a cervical myoma (previously 9 cm across), now 12 × 12 × 11 cm in size and a distended large bowel. Sigmoidoscopy excluded intraluminal obstruction. The patient was treated with oral laxatives and enema without success and her condition deteriorated. The myomatous cervix was examined vaginally (bimanual manoeuvre) with the patient under anaesthesia; however, attempts to dislodge the obstruction proved unsuccessful. After surgical consultation the patient was planned for an emergency laparoscopic sigmoidostomy. The post-operative course was uneventful and the patient discharged. She delivered a healthy child with caesarean section in gestation week 36. Bowel continuity was later laparoscopically restored in conjunction with a hysterectomy. This case illustrates the importance of active multidisciplinary management in a case of severe colonic obstruction caused by pregnancy-related obstruction in the small pelvis. In this case, colonic perforation and abortion of the fetus were both avoided.

Diagnostic performance of biomarker S100B and guideline adherence in routine care of mild head trauma.

BACKGROUND: The Scandinavian Neurotrauma Committee (SNC) has recommended the use of serum S100B as a biomarker for mild low-risk Traumatic brain injuries (TBI). This study aimed to assess the adherence to the SNC guidelines in clinical practice and the diagnostic performance of S100B in patients with TBI. The aims of this study were to examine adherence to the SNC guideline and the diagnostic accuracy of serum protein S100B. METHODS: Data of consecutive patients of 18 years and above who presented to the emergency department (ED) at Helsingborg Hospital with isolated head injuries, were retrieved from hospital records. Patients with multitrauma, follow-up visits, and visits managed by a nurse without physician involvement were excluded. RESULTS: A total of 1671 patients were included of which 93 (5.6%) had intracranial hemorrhage. CT scans were performed in 62% of patients. S100B was measured in 26% of patients and 30% of all measurements targeted the low-risk mild head injuries indicated by the guideline. S100B's recommended cut-off value (≥ 0.10 µg/L) had a 100% sensitivity, 47% specificity, 10.1% positive predictive value, and 100% negative predictive value-if applied to the target SNC category (SNC 4). If applied to all patients tested, the sensitivity was 93% for traumatic intracranial hemorrhage (TICH). Current ED practices were adherent to the SNC guideline in 55% of patients. Non-adherent practices occurred in 64% of patients with low-risk mild head injuries (SNC4) including overtesting or undertesting of S100B and CT scans. CONCLUSION: Adherence to guidelines was low and associated with a higher admission rate than non-adherence practice but no significant increase in missed TICH or death associated with non-adherence to guideline was found. In routine care, we found that the sensitivity and NPV of serum protein S100B was excellent and safely ruled out TICH when measured in the patient category recommended by the guideline. However, measuring serum protein S100B in patients not recommended by the guideline rendered unacceptably low sensitivity with possible missed TICHs as a consequence. To further delineate the magnitude and impact of non-adherence, more studies are needed.

The epidemiology of and management of pediatric patients with head trauma: a hospital-based study from Southern Sweden.

BACKGROUND: Traumatic brain injury (TBI) is a common cause of morbidity and mortality in children worldwide. In Scandinavia, the epidemiology of pediatric head trauma is poorly documented. This study aimed to investigate and compare the epidemiology and management of pediatric patients with isolated head trauma (IHT) and head trauma in connection with multitrauma (MHT). METHODS: We conducted a retrospective review of medical records of patients < 18 years of age who attended any of the five emergency departments (ED) in Scania County in Sweden in 2016 due to head trauma. Clinical data of patients with IHT were analyzed and compared with those of patients with MHT. RESULTS: We identified 5046 pediatric patients with head trauma, 4874 with IHT and 186 with MHT, yielding an incidence of ED visits due to head trauma of 1815/100,000 children/year. There was male predominance, and the median age was four years. Falls were the dominating trauma mechanism in IHT patients, while motor vehicle accidents dominated in MHT patients. The frequencies of CT head-scans, ward admissions and intracranial injuries (ICI) were 5.4%, 11.1% and 0.7%, respectively. Four patients (0.08%) required neurosurgical intervention. The relative risks for CT-scans and admissions to a hospital ward and ICI were 10, 4.5 and 19 times higher for MHT compared with IHT patients. CONCLUSION: Head trauma is a common cause of ED visits in our study. Head-CTs and ICIs were less frequent than in previous studies. MHT patients had higher rates of CT-scans, admissions, and ICIs than IHT patients, suggesting that they are separate entities that should ideally be managed using different guidelines to optimize the use of CT-scans of the head.

Antiplatelet therapy contributes to a higher risk of traumatic intracranial hemorrhage compared to anticoagulation therapy in ground-level falls: a single-center retrospective study.

BACKGROUND: Traumatic brain injury (TBI) is a common injury and constitutes up to 3% of emergency department (ED) visits. Current studies show that TBI is most commonly inflicted in older patients after ground-level falls. These patients often take medications affecting coagulation such as anticoagulants or antiplatelet drugs. Guidelines for ED TBI-management assume that anticoagulation therapy (ACT) confers a higher risk of traumatic intracranial hemorrhage (TICH) than antiplatelet therapy (APT). However, recent studies have challenged this. This study aimed to evaluate if oral anticoagulation and platelet inhibitors affected rate of TICH in head-trauma patients with ground-level falls. METHODS: This was a retrospective review of medical records during January 1, 2017 to December 31, 2017 and January 1 2020 to December 31, 2020 of all patients seeking ED care because of head-trauma. Patients ≥ 18 years with ground-level falls were included. RESULTS: The study included 1938 head-trauma patients with ground-level falls. Median age of patients with TICH was 81 years. The RR for TICH in APT-patients compared to patients without medication affecting coagulation was 1.72 (p = 0.01) (95% Confidence Interval (CI) 1.13-2.60) and 1.08 (p = 0.73), (95% CI 0.70-1.67) in ACT-patients. APT was independently associated with TICH in regression analysis (OR 1.59 (95% CI 1.02-2.49), p = 0.041). CONCLUSION: This study adds to the growing evidence that APT-patients with ground-level falls might have as high or higher risk of TICH than ACT-patients. This is not addressed in the current guidelines which may need to be updated. We therefore recommend broad prospective studies.

Ways to improve guideline adherence in the emergency department: an interview study on the management of traumatic brain injuries.

PURPOSE: The aim was to explore factors affecting guideline adherence among doctors in the emergency department and to explore the general perception about local guidelines for traumatic brain injuries. METHODS: Thirty semi-structured interviews were conducted with doctors with experience working in the emergency department regarding different aspects of guideline use, with emphasis on the management of traumatic brain injuries. Twenty-eight interviews were included for analysis. The interviews were recorded, transcribed, and analysed iteratively. Emergent codes were identified and organised into themes and subthemes. RESULTS: Eight themes were identified. Barriers were centred on low availability of local guidelines and guideline document design. Facilitating factors included a concise document, appropriate visual aids, high accessibility, and encouragement by management and senior peers. The local guidelines on traumatic brain injuries were regarded as distinct, but it was occasionally difficult to determine when they were applicable. Mandatory admission of patients on anticoagulants was sometimes perceived as excessive. Biomarker S100b was believed to sometimes lead to delayed care. CONCLUSION: The participants believed that guideline adherence would increase by facilitating guideline availability, by providing concise, easy-to-understand, and well-illustrated guidelines available in printed form, as well as establishing a culture that promotes guideline use. The local guidelines for traumatic brain injuries were appreciated, but could be improved.

Role of the triad of procalcitonin, C-reactive protein, and white blood cell count in the prediction of anastomotic leak following colorectal resections.

PURPOSE: The enhanced recovery after surgery (ERAS) program expedites patient recovery after major surgery. This study aimed to investigate the role of the triad of procalcitonin (PCT), C-reactive protein (CRP), and white blood cells (WBC) trajectories as a predictive biomarker for the anastomotic leak (AL) after colorectal surgery. METHOD: Patients who had colorectal anastomosis were prospectively included. Postoperative clinical and laboratory parameters and outcomes were collected and analyzed. The 5-day trajectories of PCT, CRP, and WBC were evaluated. Based on the trajectory of the three biomarkers, we compared patients with and without AL as detected during the first 30 days after surgery using the area under receiver operator characteristic curves (AUC) for logistic estimation. RESULTS: This study included 205 patients, of whom 56% were men and 43.9% were women with a mean age of 56.4 ± 13.1 years. Twenty-two patients (10.7%) had AL; 77.3% underwent surgery, and 22.7% were treated with drainage and antibiotics. Procalcitonin was the best predictor for AL compared to CRP and WBC at three days postoperatively (AUC: 0.84, 0.76, 0.66, respectively). On day 5, a cutoff value of 4.93 ng/mL for PCT had the highest sensitivity, specificity, and negative predictive value. The predictive power of PCT was substantially improved when combined with either CRP or WBC, or both (AUC: 0.92, 0.92, 0.93, respectively). CONCLUSION: The 5-day trajectories of combined CRP, PCT, and WBC had a better predictive power for AL than the isolated daily measurements. Combining the three parameters may be a reliable predictor of early patient discharge, which would be highly beneficial to ERAS programs.

Microwave scan and brain biomarkers to rule out intracranial hemorrhage: study protocol of a planned prospective study (MBI01).

PURPOSE: The aim of this planned study is to evaluate the ability of a cranial microwave scanner in conjunction with nine brain biomarkers (Aß40, Aß42, GFAP, H-FABP, S100B, NF-L, NSE, UCH-L1 and IL-10) to detect and rule out traumatic intracranial hemorrhage in an emergency department setting. Traumatic brain injury is a world-wide topic of interest for researchers and clinicians. It affects 2% of the population per annum and presents challenges for physicians as patients' initial signs and symptoms do not always correlate with the extent of brain injury. The gold standard for diagnosis of intracranial hemorrhage is head computerized tomography (CT) with the drawbacks of high cost and radiation exposure. A fast, secure way of diagnosing without these drawbacks has potential to make care more effective and reduce cost. METHODS: Study will be prospective and enroll adult, consenting patients with head trauma who seek emergency department care. Only patients where the treating physician prescribes a head-CT will be included. The microwave scan and blood sampling will be performed in close temporal proximity to the CT scan. Results will be analyzed with sensitivity, specificity and receiver operator characteristics analysis to provide the best combination of a number of biomarkers and the microwave scan. CONCLUSION: This study will explore the diagnostic accuracy of a head microwave scanner in combination with biomarkers in ruling out intracranial hemorrhage in traumatic brain injury patients presenting to the emergency department. Potentially, this combined diagnostic approach could achieve both high sensitivity and high specificity, thereby reducing the need of CT-head scans when managing these patients. CLINICALTRIALS: gov identifier: NCT04666766. Registered December 11, 2020.

Comparison of the predictive value of two international guidelines for safe discharge of patients with mild traumatic brain injuries and associated intracranial pathology.

PURPOSE: To determine and compare the sensitivity, specificity, and proportion of patients eligible for discharge by the Brain Injury Guidelines and the Mild TBI Risk Score in patients with mild traumatic brain injury and concomitant intracranial injury. METHODS: Retrospective review of the medical records of adult patients with traumatic intracranial injuries and an initial Glasgow Coma Scale score of 14-15, who sought care at Helsingborg Hospital between 2014/01/01 and 2019/12/31. Both guidelines were theoretically applied. The sensitivity, specificity, and percentage of the cohort that theoretically could have been discharged by either guideline were calculated. The outcome was defined as death, in-hospital intervention, admission to the intensive care unit, requiring emergency intubation due to intracranial injury, decreased consciousness, or seizure within 30 days of presentation. RESULTS: Of the 538 patients included, 8 (1.5%) and 10 (1.9%) were eligible for discharge according to the Brain Injury Guidelines and the Mild TBI Risk Score, respectively. Both guidelines had a sensitivity of 100%. The Brain Injury Guidelines had a specificity of 2.3% and the Mild TBI Risk Score had a specificity of 2.9%. CONCLUSION: There was no difference between the two guidelines in sensitivity, specificity, or proportion of the cohort eligible for discharge. Specificity and proportion of cohort eligible for discharge were lower than each guideline's original study. At present, neither guideline can be recommended for implementation in the current or similar settings.

Late Campylobacter jejuni mastitis after augmentation mammoplasty.

Breast implant-associated infections (BIAI) occur in approximately 2% of patients after augmentation mammoplasty. In some cases, BIAI can be treated conservatively, whereas others need implant removal. Knowledge of uncommon potential pathogens in BIAI is important to ensure optimal treatment of BIAI. In the present case report, we describe a case of bilateral late Campylobacter jejuni mastitis in a 34-year-old woman without previous symptoms of gastroenteritis. While Staphylococci are common causative pathogens in BIAI, there are numerous potential pathogens. This case highlights the importance of careful consideration of antibiotic treatment and switch to broad-spectrum antibiotic regimen in BIAI not responding to initial treatment.

Features of urine S100B and its ability to rule out intracranial hemorrhage in patients with head trauma: a prospective trial.

PURPOSE: Traumatic brain injury causes morbidity and mortality worldwide. S100B is the most documented emergency brain biomarker and its urine-assay might be advantageous because of easier sampling. The primary aim was to evaluate urine S100B's ability to rule out intracranial hemorrhage. Secondary aims included S100B temporal pattern for 48 h post-trauma and chemical properties of urine that affect urine S100B. METHODS: Patients with head trauma were sampled for serum and urine S100B. Patients who were admitted for intracranial hemorrhage were sampled for 48 h to assess S100B-level, renal function, urine-pH, etc. RESULTS: The negative predictive value of serum S100B was 97.0% [95% confidence interval (CI) 89.5-99.2%] and that of urine S100B was 89.1% (95% CI 85.5-91.9%). The specificity of serum S100B was 34.4% (95% CI 27.7-41.6%) and that of urine was 67.1% (95% CI 59.4-74.1%). Urine-pH correlated strongly with urine S100B during the first 6-h post-trauma. Trend-analysis of receiver operator characteristics of S100B in serum, urine the arithmetic difference between serum and urine S100B showed the largest area under the curve for arithmetic difference, which had a negative predictive value of 93.1% (95% CI 89.1-95.8%) and a specificity of 71.8% (95% CI 64.4-78.4%). CONCLUSION: This study cannot support ruling out intracranial hemorrhage with urine S100B. Urine-pH might affect urine S100B and merits further studies. Serum and urine S100B have poor concordance and interchangeability. The arithmetic difference had a slightly better area under the curve and can be worth exploring in certain subgroups.

A proposed amendment to the current guidelines for mild traumatic brain injury: reducing computerized tomographies while maintaining safety.

PURPOSE: Head trauma is a common complaint in emergency departments. Identifying patients with serious injuries can be difficult and generates many computerized tomographies. Reducing the number of computerized tomographies decreases both cost and radiation exposure. The aim of this study was to evaluate whether the current Scandinavian Neurotrauma Committee guidelines could be revised in such a way that would enable hospitals to perform fewer computerized tomographies while maintaining the ability to identify all patients requiring neurological intervention. METHODS: A retrospective study of the medical records of adult patients suffering a traumatic brain injury was performed. A total of 1671 patients over a period of 365 days were included, and 25 parameters were extracted. Multitrauma patients managed with ATLS™ were excluded. The Scandinavian Neurotrauma Committee guidelines were amended with the previously derived "low-risk proposal" and applied retrospectively to the cohort. RESULTS: Incidence of intracranial hemorrhage was 5.6% (93/1671). Application of the current Scandinavian Neurotrauma Committee guidelines would have resulted in 860 computerized tomographies and would have missed 11 intracranial hemorrhages. The proposed amendment with the low-risk proposal would have resulted in 748 CT scans and would have missed 19 intracranial hemorrhages (a relative reduction of 13%). None of the missed intracranial hemorrhages required neurological intervention. CONCLUSION: For patients with mild and moderate traumatic brain injuries, application of the Scandinavian Neurotrauma Committee guidelines amended with the low-risk proposal may result in a significant reduction of computerized tomographies without missing any patients in need of neurological intervention.

Application of NICE or SNC guidelines may reduce the need for computerized tomographies in patients with mild traumatic brain injury: a retrospective chart review and theoretical application of five guidelines.

BACKGROUND: Traumatic brain injuries continue to be a significant cause of mortality and morbidity worldwide. Most traumatic brain injuries are classified as mild, with a low but not negligible risk of intracranial hemorrhage. To help physicians decide which patients might benefit from a computerized tomography (CT) of the head to rule out intracranial hemorrhage, several clinical decision rules have been developed and proven effective in reducing the amount of negative CTs, but they have not been compared against one another in the same cohort as to which one demonstrates the best performance. METHODS: This study involved a retrospective review of the medical records of patients seeking care between January 1 and December 31, 2017 at Helsingborg Hospital, Sweden after head trauma. The Canadian CT Head Rule (CCHR), the New Orleans Criteria (NOC), the National Emergency X-Radiography Utilization Study II (NEXUS II), the National Institute of Health and Care Excellence (NICE) guideline and the Scandinavian Neurotrauma Committee (SNC) guideline were analyzed. A theoretical model for each guideline was constructed and applied to the cohort to yield a theoretical CT-rate for each guideline. Performance parameters were calculated and compared. RESULTS: One thousand three hundred fifty-three patients were included; 825 (61%) CTs were performed, and 70 (5.2%) cases of intracranial hemorrhage were found. The CCHR and the NOC were applicable to a minority of the patients, while the NEXUS II, the NICE, and the SNC guidelines were applicable to the entire cohort. A theoretical application of the NICE and the SNC guidelines would have reduced the number of CT scans by 17 and 9% (P = < 0.0001), respectively, without missing patients with intracranial hemorrhages requiring neurosurgical intervention. CONCLUSION: A broad application of either NICE or the SNC guidelines could potentially reduce the number of CT scans in patients suffering from mTBI in a Scandinavian setting, while the other guidelines seemed to increase the CT frequency. The sensitivity for intracranial hemorrhage was lower than in previous studies for all guidelines, but no fatality or need for neurosurgical intervention was missed by any guideline when they were applicable.

Prospective comparison of capillary and venous brain biomarker S100B: capillary samples have large inter-sample variation and poor correlation with venous samples.

BACKGROUND: Guidelines for the emergency management of mild traumatic brain injury have been used for over a decade and are considered safe. However, they recommend computerized tomography for at least half of these patients. The Scandinavian Neurotrauma Committee guideline uses serum S100B protein level to rule out intracranial hemorrhage. Analysis of capillary serum S100B protein level has not yet been employed for this purpose. The primary aim of this study was to investigate the correlation and agreement of capillary and venous serum S100B protein level over a spectrum of concentrations typical for mild traumatic brain injury. METHODS: Eighteen patients with traumatic intracranial hemorrhage and 39 volunteers without trauma to the head within the past 7 days were recruited. Blood was sampled from patients with intracranial hemorrhage daily up to four consecutive days and healthy volunteers were sampled once during the study. One venous and two capillary samples were drawn at each sampling event. Samples were analyzed using the Cobas e411 S100 electrochemiluminescence assay. RESULTS: Median serum S100B protein level of capillary sampling 1 was 0.12 (IQR 0.075-0.21) µg/l and median serum S100B protein level of capillary sampling 2 was 0.13 (IQR 0.08-0.22) µg/l. Median serum S100B protein level of all venous samples was 0.05 (IQR 0.03-0.07) µg/l. Correlation plots of capillary and venous samples showed poor correlation and Bland-Altman plots showed a large dispersion of samples and wide limits of agreement. CONCLUSION: The results of this study indicate that correlation and agreement between capillary and venous samples are low, and because of this, we cannot recommend studies on capillary serum S100B protein level to rule out intracranial hemorrhage in mild traumatic brain injury. Given the limitations of the current sampling and analysis methods of capillary protein S100B protein level, we conclude that evaluating its predictive ability to rule out intracranial hemorrhage should be withheld until more reliable methods can be incorporated into the study design.

Management of mild traumatic brain injury-trauma energy level and medical history as possible predictors for intracranial hemorrhage.

PURPOSE: Head trauma is common in the emergency department. Identifying the few patients with serious injuries is time consuming and leads to many computerized tomographies (CTs). Reducing the number of CTs would reduce cost and radiation. The aim of this study was to evaluate the characteristics of adults with head trauma over a 1-year period to identify clinical features predicting intracranial hemorrhage. METHODS: Medical record data have been collected retrospectively in adult patients with traumatic brain injury. A total of 1638 patients over a period of 384 days were reviewed, and 33 parameters were extracted. Patients with high-energy multitrauma managed with ATLS™ were excluded. The analysis was done with emphasis on patient history, clinical findings, and epidemiological traits. Logistic regression and descriptive statistics were applied. RESULTS: Median age was 58 years (18-101, IQR 35-77). High age, minor head injury, new neurological deficits, and low trauma energy level correlated with intracranial hemorrhage. Patients younger than 59 years, without anticoagulation or antiplatelet therapy who suffered low-energy trauma, had no intracranial hemorrhages. The hemorrhage frequency in the entire cohort was 4.3% (70/1638). In subgroup taking anticoagulants, the frequency of intracranial hemorrhage was 8.6% (10/116), and in the platelet-inhibitor subgroup, it was 11.8% (20/169). CONCLUSION: This study demonstrates that patients younger than 59 years with low-energy head trauma, who were not on anticoagulants or platelet inhibitors could possibly be discharged based on patient history. Maybe, there is no need for as extensive medical examination as currently recommended. These findings merit further studies.