Derivation of the Falls Decision Rule to exclude intracranial bleeding without head CT in older adults who have fallen.

BACKGROUND: Ground-level falls are common among older adults and are the most frequent cause of traumatic intracranial bleeding. The aim of this study was to derive a clinical decision rule that safely excludes clinically important intracranial bleeding in older adults who present to the emergency department after a fall, without the need for a computed tomography (CT) scan of the head. METHODS: This prospective cohort study in 11 emergency departments in Canada and the United States enrolled patients aged 65 years or older who presented after falling from standing on level ground, off a chair or toilet seat, or out of bed. We collected data on 17 potential predictor variables. The primary outcome was the diagnosis of clinically important intracranial bleeding within 42 days of the index emergency department visit. An independent adjudication committee, blinded to baseline data, determined the primary outcome. We derived a clinical decision rule using logistic regression. RESULTS: The cohort included 4308 participants, with a median age of 83 years; 2770 (64%) were female, 1119 (26%) took anticoagulant medication and 1567 (36%) took antiplatelet medication. Of the participants, 139 (3.2%) received a diagnosis of clinically important intracranial bleeding. We developed a decision rule indicating that no head CT is required if there is no history of head injury on falling; no amnesia of the fall; no new abnormality on neurologic examination; and the Clinical Frailty Scale score is less than 5. Rule sensitivity was 98.6% (95% confidence interval [CI] 94.9%-99.6%), specificity was 20.3% (95% CI 19.1%-21.5%) and negative predictive value was 99.8% (95% CI 99.2%-99.9%). INTERPRETATION: We derived a Falls Decision Rule, which requires external validation, followed by clinical impact assessment. Trial registration: ClinicalTrials. gov, no. NCT03745755.

Post tuberculosis radiological sequelae in patients treated for pulmonary and pleural tuberculosis at a tertiary center in Pakistan.

Treating tuberculosis (TB) is not the end of the disease because of the wide spectrum of post TB sequelae associated with the disease. There is insufficient data on post TB radiological sequelae. The aim of this study is to evaluate the post TB radiological sequelae on chest x-rays in patients who had completed the treatment for pulmonary and pleural TB at a tertiary care hospital of a high TB burden country. This is a retrospective cross-sectional study conducted on patients treated for pulmonary and pleural TB. Adult patients (18 years or above) with a clinical or microbiological diagnosis of pulmonary or pleural TB were included. Patients were classified on the basis of site of TB into pulmonary and pleural TB. Post-treatment radiological sequelae on chest x-ray were evaluated and divided into three main types i.e. fibrosis, bronchiectasis and pleural thickening. During the study period a total of 321 patients were included with a mean age of 44(SD±19) years. Only 17.13% (n=55) patients had normal chest x-rays at the end of treatment and 82.87% (n=266) patients had post-TB radiological sequelae with fibrosis being the most common followed by pleural thickening. The post TB radiological sequelae were high in patients who had diabetes mellitus (78.94%), AFB smear-positive (90.19%), AFB culture-positive (89.84%), Xpert MTB/Rif positive (88.40%) and with drug-resistant TB (100%). As a clinician, one should be aware of all the post TB sequelae so that early diagnosis and management can be facilitated.

Emergency physician gender and head computed tomography orders for older adults who have fallen.

OBJECTIVE: Physicians vary in their computed tomography (CT) scan usage. It remains unclear how physician gender relates to clinical practice or patient outcomes. The aim of this study was to assess the association between physician gender and decision to order head CT scans for older emergency patients who had fallen. METHODS: This was a secondary analysis of a prospective observational cohort study conducted in 11 hospital emergency departments (EDs) in Canada and the United States. The primary study enrolled patients who were 65 years and older who presented to the ED after a fall. The analysis evaluated treating physician gender adjusted for multiple clinical variables. Primary analysis used a hierarchical logistic regression model to evaluate the association between treating physician gender and the patient receiving a head CT scan. Secondary analysis reported the adjusted odds ratio (OR) for diagnosing intracranial bleeding by physician gender. RESULTS: There were 3663 patients and 256 physicians included in the primary analysis. In the adjusted analysis, women physicians were no more likely to order a head CT than men (OR 1.26, 95% confidence interval 0.98-1.61). In the secondary analysis of 2294 patients who received a head CT, physician gender was not associated with finding a clinically important intracranial bleed. CONCLUSIONS: There was no significant association between physician gender and ordering head CT scans for older emergency patients who had fallen. For patients where CT scans were ordered, there was no significant relationship between physician gender and the diagnosis of clinically important intracranial bleeding.

Which adults aged 65 and older are at low-risk for cervical spine injuries after low-level falls?

OBJECTIVES: The population is aging and falls are a common reason for emergency department visits. Appropriate imaging in this population is important. The objectives of this study were to estimate the prevalence of cervical spine injury and identify factors associated with cervical spine injuries in adults ≥ 65 years after low-level falls. METHODS: This was a pre-specified sub-study of a prospective observational cohort study of intracranial bleeding in emergency patients ≥ 65 years presenting after low-level falls. The primary outcome was cervical spine injury. The risk factors of interest were Glasgow coma scale (GCS) < 15, head injury, neck pain, age, and frailty defined as Clinical Frailty Scale ≥ 5. Multivariable logistic regression was used to measure the strength of association between risk factors and cervical spine injury. A descriptive analysis of absence of significant risk factors was performed to determine patients who may not require imaging. RESULTS: There were 4308 adults ≥ 65 who sustained low-level falls with mean age of 82.0 (standard deviation ± 8.8) years and 1538 (35.7%) were male; 23 [0.5% (95% confidence interval (CI) 0.3-0.8%)] were diagnosed with cervical spine injuries. The adjusted odds ratios and 95% CIs were 1.3 (0.5-3.2) for GCS < 15, 5.3 (1.7-26.7) for head injury, 13.0 (5.7-31.2) for new neck pain, 1.4 (1.0-1.8) for 5-year increase in age, and 1.1 (0.4-2.9) for frailty. Head injury or neck pain identified all 23 cervical spine injuries. Management was a rigid collar in 19/23 (82.6%) patients and none had surgery. CONCLUSIONS: In emergency patients ≥ 65 years presenting after a low-level fall, head injury, neck pain, and older age were associated with the diagnosis of cervical spine injury. There were no cervical spine injuries in those without head injury or neck pain. Patients with no head injury or neck pain may not require cervical spine imaging.

RéSUMé: OBJECTIFS: La population vieillit et les chutes sont une raison courante pour les visites à l'urgence. Il est important d'avoir une imagerie appropriée dans cette population. Les objectifs de cette étude étaient d'estimer la prévalence des lésions de la colonne cervicale et d'identifier les facteurs associés aux lésions de la colonne cervicale chez les adultes de plus de 65 ans après des chutes de faible niveau. MéTHODES: Il s'agissait d'une sous-étude pré-spécifiée d'une étude prospective de cohorte observationnelle de saignements intracrâniens chez des patients d'urgence de plus de 65 ans se présentant après des chutes de faible niveau. Le résultat principal était une lésion de la colonne cervicale. Les facteurs de risque d'intérêt étaient l'échelle de coma de Glasgow (GCS)<15, les blessures à la tête, les douleurs au cou, l'âge et la fragilité définis comme l'échelle de fragilité clinique >5. La régression logistique multivariée a été utilisée pour mesurer la force de l'association entre les facteurs de risque et les lésions de la colonne cervicale. Une analyse descriptive de l'absence de facteurs de risque significatifs a été réalisée pour déterminer les patients qui ne nécessitent pas d'imagerie. RéSULTATS: Il y avait 4308 adultes de plus de 65 ans qui ont subi des chutes de faible intensité avec un âge moyen de 82.0 ans (écart-type 8.8) et 1538 ans (35.7 %) étaient des hommes; 23 (0.5 % (intervalle de confiance à 95 % 0.3­0.8 %) ont reçu un diagnostic de lésions du rachis cervical. Les rapports de cotes ajustés et les IC à 95 % étaient de 1.3 (0.5­3.2) pour les SCM<15, 5.3 (1.7­26.7) pour les blessures à la tête, 13.0 (5.7­31.2) pour les nouvelles douleurs au cou, 1.4 (1.0 ­ 1.8) pour l'augmentation de l'âge de cinq ans et 1.1 (0.4­2.9) pour la fragilité. Des blessures à la tête ou des douleurs au cou ont permis de déceler les 23 blessures à la colonne cervicale. La prise en charge était un collier rigide chez 19 patients sur 23 (82.6 %) et aucun n'a subi de chirurgie. CONCLUSIONS: Chez les patients d'urgence de plus de 65 ans se présentant après une chute de faible intensité, des blessures à la tête, des douleurs au cou et un âge plus avancé ont été associés au diagnostic de lésion de la colonne cervicale. Il n'y avait pas de blessures à la colonne cervicale chez les personnes sans blessure à la tête ou douleur au cou. Les patients sans blessure à la tête ou douleur au cou peuvent ne pas avoir besoin d'imagerie de la colonne cervicale.

Technical assessment of shear bond strength at ceramo-alloy interface after various surface treatment combinations and application of metal bonding agent.

BACKGROUND: Bonding between metal and ceramic is one of the most important aspects of a successful prosthesis. Various methods have been recommended for preparing the metal surface to enhance the bond between metal and ceramic including the use of a metal bonding agent. OBJECTIVE: This study aims to evaluate and compare the shear bond strength of the metal-ceramic (M-C) interface after combinations of various surface treatments including the application of a metal bonding agent. METHOD: 40 Ni-Cr alloy specimens were made and divided into 4 groups of 10 each based on the combination of surface treatments. Sandblasting, surface grinding, and Oxidation heat treatment (OHT) were performed on specimens from Group 1 (Control). In addition, Group 2 specimens received ultrasonic cleaning, Group 3 steam cleaning, and Group 4 metal bonding agent application. Following surface treatments on all specimens, porcelain build-up was performed, and shear bond strength was tested in a Digital Universal testing machine. The statistical tests used were independent t-test and ANOVA. RESULTS: Results revealed that Group 4 specimens had the highest mean value of shear bond strength of 39.087 MPa while Group 3 specimens showed the least mean shear bond strength of 18.154 MPa with highly statistically significant results (p< 0.001). CONCLUSION: The surface treatments and application of bonding agent to metal prior to porcelain application resulted in increased shear bond strength of the metal-ceramic interface.

Dimensional Stability of Light-Activated Urethane Dimethacrylate Denture Base Resins.

An accurate and dimensionally stable trial denture base is required for a successful denture. The aim of this in vitro study was to assess the dimensional stability of a light-activated urethane dimethacrylate (UDMA) visible light cure (VLC) denture base with three fabrication techniques and different curing cycles. Forty-five VLC denture base samples were divided evenly into three groups. Group A used a conventional fabrication technique with a curing cycle of 5 min. Group B used a modified fabrication technique with two 4-min curing cycles. Group C used a multi-step fabrication technique with three curing cycles (4 min, plus 4 min, plus 2 min). The samples were sectioned and observed under a stereomicroscope to measure the discrepancy between the sample and the master cast. The mean dimensional discrepancy (mm) at the molar region at mid-palate, after 24 h in Group A, B and C was 0.790 mm, 0.741 mm and 0.379 mm, respectively; at the right ridge crest, it was 0.567, 0.408 and 0.185, while at the left ridge crest it was 0.475, 0.331 and 0.125, respectively. Statistical analysis showed significantly different dimensional discrepancies among the groups at all three sites; right ridge crest (F = 93.54, p < 0.001), left ridge crest (F = 105.96, p < 0.001) and mid-palate (F = 125.53, p < 0.001). Within the limitations of this laboratory study, it can be concluded that the denture base using a multi-step fabrication technique with three curing cycles provides better adaptation than the conventional technique. The significance of the study is that clinicians should consider performing denture base fabrication using a multi-step technique to enhance adaptation and hence the stability of the dentures for patients.

The role of biomarkers in evaluating human health concerns from fungal contaminants in food.

Mycotoxins are toxic secondary metabolites that globally contaminate an estimated 25 % of cereal crops and thus exposure is frequent in many populations. Aflatoxins, fumonisins and deoxynivalenol are amongst those mycotoxins of particular concern from a human health perspective. A number of risks to health are suggested including cancer, growth faltering, immune suppression and neural tube defects; though only the demonstrated role for aflatoxin in the aetiology of liver cancer is widely recognised. The heterogeneous distribution of mycotoxins in food restricts the usefulness of food sampling and intake estimates; instead biomarkers provide better tools for informing epidemiological investigations. Validated exposure biomarkers for aflatoxin (urinary aflatoxin M(1), aflatoxin-N7-guaunine, serum aflatoxin-albumin) were established almost 20 years ago and were critical in confirming aflatoxins as potent liver carcinogens. Validation has included demonstration of assay robustness, intake v. biomarker level, and stability of stored samples. More recently, aflatoxin exposure biomarkers are revealing concerns of growth faltering and immune suppression; importantly, they are being used to assess the effectiveness of intervention strategies. For fumonisins and deoxynivalenol these steps of development and validation have significantly advanced in recent years. Such biomarkers should better inform epidemiological studies and thus improve our understanding of their potential risk to human health.

Large mediastinal mass in a 15-year-old boy.

Hyperimmunoglobulin E syndrome is a rare multisystem inherited disorder characterised by high serum IgE levels, skin disorder causing eczema, dermatitis, recurrent staphylococcal infections and pulmonary infections and various skeletal and connective tissue abnormalities. Common presentation is with recurrent skin and sinopulmonary infections. Several features unrelated to immune system such as characteristic facial features, hyperextensibility of joints, multiple bone fractures and craniosynostosis have been described in the literature. We describe a rare presentation of this disease with invasive aspergillosis presenting as mediastinal mass with extension to mediastinal structures and pulmonary vasculature.

Rehabilitation of Nose following Chemical Burn Using CAD/CAM Made Substructure for Implant Retained Nasal Prosthesis: A Clinical Report.

Insufficient knowledge of medical chemicals and their improper use have destructive effects. Accidental exposure to chemicals on facial tissue may result in large facial defect. For ages the tradition of piercing nose is common but improper use of unknown chemical for piercing has deleterious effect. Mostly rhinectomy defects are acquired caused by trauma or malignant diseases. Prosthetic rehabilitation is the preferred treatment of choice for any large rhinectomy defects as medical and surgical interventions are ineffective in developing esthetics. Main concern with the prosthesis for such defects is retention. This article describes rehabilitation of a patient with large size nasal defect created by chemical burn in childhood during piercing. Implant retained customized silicone nasal prosthesis was fabricated using simple O-ring attachments and innovative modified polyamide acrylic resin substructure acting as skeleton.

Two interesting cases of EEC syndrome.

AIM: To report two cases of EEC syndrome with oral involvement to highlight the fact that the dental surgeon may be among the first to recognise the condition. INTRODUCTION: The EEC syndrome, a rare congenital syndrome is characterised by ectodermal dysplasia, distal limb anomaly, cleft lip and palate and lachrymal duct anomalies although the term oligosymptomatic EEC syndrome has been suggested for cases in which ectrodactyly may be absent and that such cases should not be deprived of the EEC syndrome diagnosis. It is usually inherited as an autosomal dominant trait with variable expressivity and penetrance and all these features rarely coexist in a single individual. CONCLUSION: Both our cases had all three characteristic features of the EEC syndrome. Other syndromes with overlapping features such as the Rapp-Hodgkin syndrome and the AEC syndrome should be considered in the differential diagnosis of incomplete forms of EEC syndrome. CLINICAL SIGNIFICANCE: It is important to follow an interdisciplinary approach to attain the greatest degree of success possible in the treatment of such cases.

Shelf life determination of the brined golden mullet Liza aurata during vacuum refrigerated storage using some quality aspect.

BACKGROUND: Salted fi sh products are popular in many countries around the world. Salting is one of the oldest techniques for fi sh preservation, and is essentially intended to increase the shelf-life of the product depressing water activity by means of dehydration and salt uptake by the fi sh muscle. However, the current demand for salted fi sh is driven more by the flavour of the product than for preservation purposes. Vacuum-packaging represents a static form of hypobaric storage. It is widely used in the food industry because of its effectiveness in reducing oxidative reactions in the product at relatively low cost. Low temperature storage is one of the primary methods to maintain fi sh quality, based on the reduction in the rates of microbiological, chemical and biochemical changes. MATERIAL AND METHODS: Fresh Golden mullets were rapidly beheaded, scaled, gutted and immediately washed with tap water then, samples were taken to the laboratory in ice box for chemical and microbial analysis of fresh fish, other samples were put in the brine (6 liter water and 2160 g salt was used for brine solution). After 14 days of brining, fish were taken out of brine solution and drained, then they were Vacuum Packed and labelled (each pack contained two fish about 1500 g weight). All the packs were stored in a refrigerator 4°C. Some quality aspects including Total Volatile Nitrogen (TVN), Peroxide Value (PV), Thiobarbituric Acid (TBA), Total Viable Count (TVC), Halophilic Bacteria (HB) and presence of Clostridium Botulinum were determined in fresh mullets, fresh brined mullets after 14 days of brining, and in (Vacuum Packed) VP samples stored at 4°C at intervals of 30, 60 and 90 days. RESULTS: TVN increased from ten mg/100 g in fresh brined after 14 days to 30.80 mg/100 g in VP brined Golden mullet after 90 days of storage at 4°C, PV increased after brining from 1.50 meq/kg in fresh brined to 28.90 meq/kg in VP brined Golden mullet after 90 days of storage at 4°C, TBA increased from 0.07 mg MDA/kg in fresh brined to 0.10 after 60 days and then, decreased to 0.09 mg MDA/kg in VP brined Golden mullet after 90 days of storage and TVC decreased from 4.70 log CFU/gr in fresh brined to 4.40 log CFU/ gr after 30 days and then, increased to 5.70 log CFU/gr in VP brined Golden mullet after 90 days of storage at 4°C, HB increased from 4.55 log CFU/gr in fresh brined to 6.30 log CFU/gr after 90 days of storage period at 4°C and exceeded the permissible level. Clostridium botulinum toxin was not detected in any of the samples throughout the storage. CONCLUSIONS: The results from this study clearly suggested that a combination of brining, vacuum packaging and storage at refrigerated temperature prolongs the shelf-life of Golden mullet to a great extent. Our findings revealed that the longest shelf-life was for VP brined Golden mullet stored at 4°C is 30 days.

Association between Body Mass Index and Bone Mineral Density in Patients Referred for Dual-Energy X-Ray Absorptiometry Scan in Ajman, UAE.

Body Mass Index (BMI) is a good indicator for measurements of Bone Mineral Density (BMD) which measures the density of minerals present in the bones using a special scan. This study was conducted to assess the association between BMI and status of BMD among 101 individuals who underwent Dual-Energy X-ray Absorptiometry (DEXA) scan. 39 subjects had normal and 62 had low bone mineral density. BMD was low in 82.4% of people with normal BMI, 78.1% among overweight, and 44.2% among obese. There was a statistically significant association between these two variables (P < .001). Low BMD was recorded in 59.1% of females and 76.9% of males. Association between advancing age and lower BMI is an important risk factor in the occurrence of low BMD.