Canadian CT head rule study for patients with minor head injury: methodology for phase II (validation and economic analysis)

Sports Related Concussion

Sports-related concussions (SRC) have been a topic of interest for decades and are a prevalent risk of sports participation. The definition of SRC continues to evolve but includes a plausible mechanism and associated symptoms of injury. Rates of concussion vary among sports, and many sports have adopted rule changes to limit this risk for its athletes. There has been a considerable effort to prevent the occurrence of SRC, as well as a focus on safe return to learn and sport alike. There is growing concern about the ramifications of concussions, which will continue to warrant further investigation.

Consideration of Brain CT Imaging Standard for Mild Head Injuries

It has been reported that various clinical criteria indicate computed tomography (CT) examination for mild head injury (MHI). However, the decision to perform CT for MHI largely depends on the physician. Data on severe head injuries is available in sources such as the Japan Neurotrauma Data Bank, but only a few data has been collected on MHI. A total of 1688 patients with MHI (Glasgow Coma Scale 14 and 15) treated at our hospital from June 2017 to May 2019 were reviewed. CT was performed in 1237 patients (73.28%), and intracranial hemorrhage was detected in 50 patients. Three patients deteriorated, and all were surgically treated. Statistical analysis of the presence or absence of acute intracranial hemorrhage and "risk factors for complications of intracranial lesions in MHI" showed significant differences in unclear or ambiguous accident history (p = 0.022), continued post-traumatic amnesia (p < 0.01), trauma above the clavicles including clinical signs of skull fracture (skull base or depressed skull fracture) (p = 0.012), age <60 years (p < 0.01), coagulation disorders (p < 0.01), and alcohol or drug intoxication (p < 0.01). The 453 patients who did not satisfy these risk factors included only one patient with intracranial hemorrhage, so the negative predictive value was 99.78%. This study shows that the "risk factors for complications of intracranial lesions in MHI" are effective criteria for excluding acute intracranial hemorrhage and CT should be actively considered for patients with the above factors that showed significant differences.

Head Injury Evaluation and Ambulance Diagnosis (HOME) Study protocol: a feasibility study assessing the implementation of the Canadian CT Head Rule in the prehospital setting

INTRODUCTION

Traumatic brain injury (TBI) is a common presentation in the prehospital environment. At present, paramedics do not routinely use tools to identify low-risk patients who could be left at scene or taken to a local hospital rather than a major trauma centre. The Canadian CT Head Rule (CCHR) was developed to guide the use of CT imaging in hospital. It has not been evaluated in the prehospital setting. We aim to address this gap by evaluating the feasibility and acceptability of implementing the CCHR to patients and paramedics, and the feasibility of conducting a full-scale clinical trial of its use.

METHODS AND ANALYSIS

We will recruit adult patients who are being transported to an emergency department (ED) by ambulance after suffering a mild TBI. Paramedics will prospectively collect data for the CCHR. All patients will be transported to the ED, where deferred consent will be taken and the treating clinician will reassess the CCHR, blinded to paramedic interpretation. The primary clinical outcome will be neurosurgically significant TBI. Feasibility outcomes include recruitment and attrition rates. We will assess acceptability of the CCHR to paramedics using the Ottawa Acceptability of Decision Rules Instrument. Interobserver reliability of the CCHR will be assessed between paramedics and the treating clinician in the ED. Participating paramedics and patients will be invited to participate in semistructured interviews to explore the acceptability of trial processes and facilitators and barriers to the use of the CCHR in practice. Data will be analysed thematically. We anticipate recruiting approximately 100 patients over 6 months.

ETHICS AND DISSEMINATION

This study was approved by the Health Research Authority and the Research Ethics Committee (REC reference: 22/NW/0358). The results will be published in a peer-reviewed journal, presented at conferences and will be incorporated into a doctoral thesis.

TRIAL REGISTRATION NUMBER

ISRCTN92566288.

Risk adapted diagnostics and hospitalization following mild traumatic brain injury

INTRODUCTION

Traumatic brain injury (TBI) remains a leading cause of hospital admission and mortality, intracranial hemorrhage (ICH) presents a severe complication. Low complication tolerance in developed countries and risk uncertainty, often cause excessive observation, diagnostics and hospitalization, considered unnecessary and expensive. Risk factors predicting ICH, progression and death in patients hospitalized with mild TBI have not been identified yet.

METHODS

Mild TBI cases indicated for cranial computer tomography (CT) and hospitalization, according to international guidelines, at our Level I Trauma Center between 2008 and 2018 were retrospectively included. Multivariate logistic regression was performed for ICH, progression and mortality predictors.

RESULTS

1788 mild TBI adults (female: 44.3%; age at trauma: 58.0 ± 22.7), were included. Skull fracture was diagnosed in 13.8%, ICH in 46.9%, ICH progression in 10.6%. In patients < 35 years with mild TBI, chronic alcohol consumption (p = 0.004) and skull fracture (p < 0.001) were significant ICH risk factors, whilst in patients between 35 and 65 years, chronic alcohol consumption (p < 0.001) and skull fracture (p < 0.001) revealed as significant ICH predictors. In patients with mild TBI > 65 years, age (p = 0.009), anticoagulation (p = 0.007) and neurocranial fracture (p < 0.001) were significant, independent risk factors for ICH, whilst increased age (p = 0.01) was a risk factor for mortality following ICH in mild TBI. Late-onset ICH only occurred in mild TBI cases with at least two of these risk factors: age > 65, anticoagulation, neurocranial fracture. Overall hospitalization could have been reduced by 15.8% via newly identified low-risk cases.

CONCLUSIONS

Age, skull fracture and chronic alcohol abuse require vigilant observation. Repeated CT in initially ICH negative cases should only be considered in newly identified high-risk patients. Non-ICH cases aged < 65 years do not gain safety from observation or hospitalization. Recommendations from our data might, without impact on patient safety, reduce costs by unnecessary hospitalization and diagnostics.

Advanced neuroimaging in traumatic brain injury: an overview

Traumatic brain injury (TBI) is a common condition with many potential acute and chronic neurological consequences. Standard initial radiographic evaluation includes noncontrast head CT scanning to rapidly evaluate for pathology that might require intervention. The availability of fast, relatively inexpensive CT imaging has fundamentally changed the clinician's ability to noninvasively visualize neuroanatomy. However, in the context of TBI, limitations of head CT without contrast include poor prognostic ability, inability to analyze cerebral perfusion status, and poor visualization of underlying posttraumatic changes to brain parenchyma. Here, the authors review emerging advanced imaging for evaluation of both acute and chronic TBI and include QuickBrain MRI as an initial imaging modality. Dynamic susceptibility-weighted contrast-enhanced perfusion MRI, MR arterial spin labeling, and perfusion CT are reviewed as methods for examining cerebral blood flow following TBI. The authors evaluate MR-based diffusion tensor imaging and functional MRI for prognostication of recovery post-TBI. Finally, MR elastography, MR spectroscopy, and convolutional neural networks are examined as future tools in TBI management. Many imaging technologies are being developed and studied in TBI, and some of these may hold promise in improving the understanding and management of TBI. ABBREVIATIONS ASL = arterial spin labeling; CNN = convolutional neural network; CTP = perfusion CT; DAI = diffuse axonal injury; DMN = default mode network; DOC = disorders of consciousness; DTI = diffusion tensor imaging; FA = fractional anisotropy; fMRI = functional MRI; GCS = Glasgow Coma Scale; MD = mean diffusivity; MRE = MR elastography; MRS = MR spectroscopy; mTBI = mild TBI; NAA = N-acetylaspartate; SWI = susceptibility-weighted imaging; TBI = traumatic brain injury; UHF = ultra-high field.

Cost-Effectiveness of Biomarker Screening for Traumatic Brain Injury

Intracranial hemorrhage after traumatic brain injury (TBI) can be life threatening and requires prompt diagnosis. Computed tomography (CT) scans are a rapid and accurate way to evaluate for hemorrhage. In patients with mild and moderate TBI, however, in whom the incidence of intracranial pathology is low, scanning every patient with CT can be costly. The Food and Drug Administration recently approved a novel biomarker screen, the Banyan Trauma Indicator (BTI), to help streamline the decision for CT scanning in mild to moderate TBI. The BTI screen diagnoses intracranial lesions with a sensitivity and specificity of 97.5% and 99.6%, respectively. We performed cost analyses of the BTI screen to determine the threshold of cost-effectiveness, compared with application of clinical decision rules or routine CT scans, for cases of mild or moderate TBI. With a 0.104 probability of an intracranial lesion in mild TBI, the biomarker screen is cost-effective if the cost is $308.96 or below per test. In moderate TBI, because of the greater prevalence of intracranial lesions at 0.663, there is a lower need for screening, and BTI becomes cost-effective up to $73.41 per test.

Evaluation of the Roche® Elecsys and the Diasorin® Liaison S100 kits in the management of mild head injury in the emergency room

INTRODUCTION

The aim of this single-center prospective study is to compare two commercially available S100ß kits (the Roche® Elecsys and the Diasorin® Liaison S100 kits) in terms of analytical and clinical performances in a population admitted in the emergency room for mild traumatic brain injury (mTBI).

MATERIAL AND METHOD

110 patients were enrolled from September 2014 to May 2015. Blood sample draws were performed within 3h after head trauma and the study population was split into pediatric and adult subpopulations (>18years of age).

RESULTS

Although both kits correlated well, we observed a significant difference in terms of S100ß levels (P value<0.05) in both subpopulations. In the pediatric subpopulation, both kits showed elevated S100ß levels for the only patient (3.5%) who displayed abnormal findings on a CT-scan. However, we observed a poor agreement between both kits (Cohen's kappa=0.345, P value=0.077). In the adult subpopulation, a total of 10 patients (12.2%) had abnormal head computed tomography scans. Using the Roche® (cut off=0.1μg/L) and the Diasorin® (cut off=0.15μg/L) S100ß kits, brain injuries were detected with a sensitivity of 100% (95% CI: 65-100%) and 100% (95% CI: 63-100%) and a specificity of 15.28% (95% CI: 7.9-25.7%) and 24.64% (95% CI: 15-36.5) respectively. Finally, a moderate agreement was concluded between both kits (Cohen's kappa=0.569, P value=0.001).

CONCLUSION

Although a good correlation could be found between both kits, emergency physicians should be aware of discrepancies observed between both methods, making those immunoassays not interchangeable. Furthermore, more studies are still needed to validate cut off used according to technique and to age, especially in the population below the age of 2years.

Imaging in paediatric spinal injury

Background

Paediatric spinal injury is rare and exhibits many unique features. Attending clinicians and radiologists often lack knowledge, expertise and experience in dealing with a potential injury to the paediatric spine. Within the paediatric age range itself there are different age-dependent mechanisms that can injure the paediatric spine. Moreover, the anatomical features and degree of osseous maturity of the developing paediatric spine determine the biomechanical characteristics which promote unique patterns of spinal injury in each paediatric age group.

Methods

An expert illustrated narrative review of the literature.

Results

Multiple factors make the imaging interpretation of the injured paediatric spine challenging. Each imaging modality has strengths and weaknesses in depicting spinal anatomy which vary with the type of spinal injury and age of the paediatric patient.

Conclusions

Attending doctors need to be familiar with the imaging appearances of the normal paediatric spine, its normal variants as well as the imaging features characteristics of paediatric spinal injury seen on radiographs, computed tomography and magnetic resonance imaging.

Using Machine Learning and Natural Language Processing Algorithms to Automate the Evaluation of Clinical Decision Support in Electronic Medical Record Systems

INTRODUCTION

As the number of clinical decision support systems (CDSSs) incorporated into electronic medical records (EMRs) increases, so does the need to evaluate their effectiveness. The use of medical record review and similar manual methods for evaluating decision rules is laborious and inefficient. The authors use machine learning and Natural Language Processing (NLP) algorithms to accurately evaluate a clinical decision support rule through an EMR system, and they compare it against manual evaluation.

METHODS

Modeled after the EMR system EPIC at Maine Medical Center, we developed a dummy data set containing physician notes in free text for 3,621 artificial patients records undergoing a head computed tomography (CT) scan for mild traumatic brain injury after the incorporation of an electronic best practice approach. We validated the accuracy of the Best Practice Advisories (BPA) using three machine learning algorithms-C-Support Vector Classification (SVC), Decision Tree Classifier (DecisionTreeClassifier), k-nearest neighbors classifier (KNeighborsClassifier)-by comparing their accuracy for adjudicating the occurrence of a mild traumatic brain injury against manual review. We then used the best of the three algorithms to evaluate the effectiveness of the BPA, and we compared the algorithm's evaluation of the BPA to that of manual review.

RESULTS

The electronic best practice approach was found to have a sensitivity of 98.8 percent (96.83-100.0), specificity of 10.3 percent, PPV = 7.3 percent, and NPV = 99.2 percent when reviewed manually by abstractors. Though all the machine learning algorithms were observed to have a high level of prediction, the SVC displayed the highest with a sensitivity 93.33 percent (92.49-98.84), specificity of 97.62 percent (96.53-98.38), PPV = 50.00, NPV = 99.83. The SVC algorithm was observed to have a sensitivity of 97.9 percent (94.7-99.86), specificity 10.30 percent, PPV 7.25 percent, and NPV 99.2 percent for evaluating the best practice approach, after accounting for 17 cases (0.66 percent) where the patient records had to be reviewed manually due to the NPL systems inability to capture the proper diagnosis.

DISCUSSION

CDSSs incorporated into EMRs can be evaluated in an automatic fashion by using NLP and machine learning techniques.

Results of delayed follow-up imaging in traumatic brain injury

OBJECT

There is a paucity of scientific evidence available about the benefits of outpatient follow-up imaging for traumatic brain injury patients. In this study, 1 year of consecutive patients at a Level 1 trauma center were analyzed to determine if there is any benefit to routinely obtaining CT of the head at the outpatient follow-up visit.

METHODS

This single-institution retrospective review was performed on all patients with a traumatic brain injury seen at a Level 1 trauma center in 2013. Demographic data, types of injuries, surgical interventions, radiographic imaging in inpatient and outpatient settings, and outcomes were assessed through a review of the institution’s trauma registry, patient charts, and imaging.

RESULTS

Five hundred twenty-five patients were seen for traumatic brain injury in 2013 at Regional One Health in Memphis, Tennessee. One hundred eighty-five patients (35%) presented for outpatient follow-up, all with CT scans of the head. Seven of these patients (4%) showed worsening of their intracranial injuries on outpatient imaging studies; however, surgical intervention was recommended for only 3 of these patients (2%). All patients requiring an intervention had neurological deterioration prior to their follow-up appointment.

CONCLUSIONS

These experiences suggest that outpatient follow-up imaging for traumatic brain injury should be done selectively, as it was not helpful for patients who did not exhibit worsening of neurological signs or symptoms. Furthermore, routine outpatient imaging results in unnecessary resource utilization and radiation exposure.

Eye tracking detects disconjugate eye movements associated with structural traumatic brain injury and concussion

Disconjugate eye movements have been associated with traumatic brain injury since ancient times. Ocular motility dysfunction may be present in up to 90% of patients with concussion or blast injury. We developed an algorithm for eye tracking in which the Cartesian coordinates of the right and left pupils are tracked over 200 sec and compared to each other as a subject watches a short film clip moving inside an aperture on a computer screen. We prospectively eye tracked 64 normal healthy noninjured control subjects and compared findings to 75 trauma subjects with either a positive head computed tomography (CT) scan (n=13), negative head CT (n=39), or nonhead injury (n=23) to determine whether eye tracking would reveal the disconjugate gaze associated with both structural brain injury and concussion. Tracking metrics were then correlated to the clinical concussion measure Sport Concussion Assessment Tool 3 (SCAT3) in trauma patients. Five out of five measures of horizontal disconjugacy were increased in positive and negative head CT patients relative to noninjured control subjects. Only one of five vertical disconjugacy measures was significantly increased in brain-injured patients relative to controls. Linear regression analysis of all 75 trauma patients demonstrated that three metrics for horizontal disconjugacy negatively correlated with SCAT3 symptom severity score and positively correlated with total Standardized Assessment of Concussion score. Abnormal eye-tracking metrics improved over time toward baseline in brain-injured subjects observed in follow-up. Eye tracking may help quantify the severity of ocular motility disruption associated with concussion and structural brain injury.

Pediatric critical care

Care of the ill and injured child requires knowledge of unique pediatric anatomic and physiologic differences. Subtleties in presentation and pathophysiologic differences impact management. This article discusses pediatric resuscitation, the presentation and management of common childhood illness, pediatric trauma, and common procedures required in the critically ill child.

Surgical perspectives in craniofacial trauma

Knowledge of relevant anatomy and underlying mechanisms of traumatic injury is essential for understanding the radiologic findings in craniofacial trauma and their clinical importance. Craniofacial anatomy is diverse, and as a result of this anatomic diversity, physicians from numerous different specialties scrutinize similar imaging sets, looking for different pathologic abnormalities within the same anatomic regions. Radiologists familiar with the chief concerns of this anatomically diverse region can help expedite the decision-making process by keeping those concerns in mind when they report their findings. This review provides an overview of situations wherein surgical management may be indicated.

Early CT findings to predict early death in patients with traumatic brain injury: Marshall and Rotterdam CT scoring systems compared in the major academic tertiary care hospital in northeastern Japan

RATIONALE AND OBJECTIVES

Computed tomography (CT) plays a crucial role in early assessment of patients with traumatic brain injury (TBI). Marshall and Rotterdam are the mostly used scoring systems, in which CT findings are grouped differently. We sought to determine the scoring system and initial CT findings predicting the death at hospital discharge (early death) in patients with TBI.

MATERIALS AND METHODS

We included 245 consecutive adult patients with mild-to-severe TBI. Their initial CT and status at hospital discharge (dead or alive) were reviewed, and both CT scores were calculated. We examined whether each score was related to early death; compared the two scoring systems' performance in predicting early death, and identified the CT findings that are independent predictors of early death.

RESULTS

More deaths occurred among patients with higher Marshall and Rotterdam scores (both P < .05, Mann-Whitney U test). The areas under the receiver operating characteristic curve (AUCs) indicated that both scoring systems had similarly good discriminative power in predicting early death (Marshall, AUC = 0. 85 vs. Rotterdam, AUC = 0.85). Basal cistern absence (odds ratio [OR] = 771.5, P < .0001), positive midline shift (OR = 56.2, P = .0011), hemorrhagic mass volume ≥25 mL (OR = 12.9, P = .0065), and intraventricular or subarachnoid hemorrhage (OR = 3.8, P = .0395) were independent predictors of early death.

CONCLUSIONS

Both Marshall and Rotterdam scoring systems can be used to predict early death in patients with TBI. The performance of the Marshall score is at least equal to that of the Rotterdam score. Thus, although older, the Marshall score remains useful in predicting patients' prognosis.

Understanding the Canadian adult CT head rule trial: use of the theoretical domains framework for process evaluation

BACKGROUND

The Canadian CT Head Rule was prospectively derived and validated to assist clinicians with diagnostic decision-making regarding the use of computed tomography (CT) in adult patients with minor head injury. A recent intervention trial failed to demonstrate a decrease in the rate of head CTs following implementation of the rule in Canadian emergency departments. Yet, the same intervention, which included a one-hour educational session and reminders at the point of requisition, was successful in reducing cervical spine imaging rates in the same emergency departments. The reason for the varied effect of the intervention across these two behaviours is unclear. There is an increasing appreciation for the use of theory to conduct process evaluations to better understand how strategies are linked with outcomes in implementation trials. The Theoretical Domains Framework (TDF) has been used to explore health professional behaviour and to design behaviour change interventions but, to date, has not been used to guide a theory-based process evaluation. In this proof of concept study, we explored whether the TDF could be used to guide a retrospective process evaluation to better understand emergency physicians' responses to the interventions employed in the Canadian CT Head Rule trial.

METHODS

A semi-structured interview guide, based on the 12 domains from the TDF, was used to conduct telephone interviews with project leads and physician participants from the intervention sites in the Canadian CT Head Rule trial. Two reviewers independently coded the anonymised interview transcripts using the TDF as a coding framework. Relevant domains were identified by: the presence of conflicting beliefs within a domain; the frequency of beliefs; and the likely strength of the impact of a belief on the behaviour.

RESULTS

Eight physicians from four of the intervention sites in the Canadian CT Head Rule trial participated in the interviews. Barriers likely to assist with understanding physicians' responses to the intervention in the trial were identified in six of the theoretical domains: beliefs about consequences; beliefs about capabilities; behavioural regulation; memory, attention and decision processes; environmental context and resources; and social influences. Despite knowledge that the Canadian CT Head Rule was highly sensitive and reliable for identifying clinically important brain injuries and strong beliefs about the benefits for using the rule, a number of barriers were identified that may have prevented physicians from consistently applying the rule.

CONCLUSION

This proof of concept study demonstrates the use of the TDF as a guiding framework to design a retrospective theory-based process evaluation. There is a need for further development and testing of methods for using the TDF to guide theory-based process evaluations running alongside behaviour change intervention trials.

Acute evaluation of pediatric patients with minor traumatic brain injury

PURPOSE OF REVIEW

This review focuses on minor traumatic brain injury (TBI), evaluates the most recent literature regarding clinical prediction rules for the use of cranial computed tomography (CT) in children presenting with minor TBI, reviews the evidence on the need for hospitalization in children with minor TBI, and evaluates the role of S100B testing.

RECENT FINDINGS

The majority of children presenting to an emergency department (ED) after TBI have a Glasgow Coma Scale (GCS) of 14-15, and the rate of clinically significant intracranial injury is exceedingly rare. Nevertheless, the number of cranial CTs performed in the US has increased dramatically over the past two decades. Several clinical prediction rules have been developed to aid the clinician in identifying children with low-risk TBI, but only the Pediatric Emergency Care Applied Research Network (PECARN) rules have been sufficiently validated to warrant clinical application. Two recent studies provide evidence that children with low-risk TBI can be safely discharged from the ED and do not require prolonged hospitalization for neurologic observation. Lastly, studies evaluating the diagnostic utility of S100B in patients with TBI have shown that it may be a useful adjunct to the clinical evaluation and aid in minimizing neuroimaging.

SUMMARY

Clinical prediction rules, most notably the PECARN rules, can be applied to determine children with low-risk TBI and help decrease unnecessary CT use and hospitalizations. S100B testing requires further investigation, but may serve as an adjunct in determining children with low-risk TBI.

Long-term outcome in patients with mild traumatic brain injury: a prospective observational study

BACKGROUND

Mild traumatic brain injury (MTBI) is common; up to 37% of adult men have a history of MTBI. Complaints after MTBI are persistent headaches, memory impairment, depressive mood disorders, and disability. The reported short- and long-term outcomes of patients with MTBI have been inconsistent. We have now investigated long-term clinical and neurocognitive outcomes in patients with MTBI (at admission, and after 1 and 10 years).

METHODS

Patients of a previous study investigating MTBI short-term outcome were prospectively reassessed after ±10 year using the same standardized data entry form and validated questionnaire (Beltztest with Beltz Score [BeSc]) for evaluation of Quality of life (QoL) and neurocognitive outcome (higher scores indicate lower QoL).

RESULTS

Eighty-six of 176 patients (49%) could be reassessed (n = 75 lost to follow-up; n = 8 second brain trauma; n = 7 death), 10.4 ± 2 years after initial evaluation. Over time, overall BeSc was significantly increased (5.92 ± 10.3 [admission] vs. 10.7 ± 12.8 [1 year] vs. 20.86 ± 17.1 [10 year]; p < 0.0001); only 54 of 86 patients (62.8%) presented with a normal BeSc. Long-term complaints were fatigue, insomnia, and exhaustion. Ten of eighty-six patients (11.6%) had intracranial injury (ICI) and initial BeSc was almost twofold higher in patients with ICI than in patients without ICI (10.0 ± 8.4 vs. 5.3 ± 9.6; p = 0.007). This difference was not seen after 1 year or after 10 years (10.3 ± 11.6 vs. 10.3 ± 10.1 and 21.4 ± 17.3 vs. 16.1 ± 16.4, respectively). Eight of eighty-six patients (9.3%) lost their jobs because of persistent complaints after MTBI.

CONCLUSION

BeSc deteriorates over time; our data suggest a decline in general health and QoL in a substantial proportion of patients (37.2%) 10 years after MTBI. Patients without ICI appear to have a better long-term outcome with regard to subjective complaints and QoL.

Clinical prediction rules for children: a systematic review

CONTEXT

The degree to which clinical prediction rules (CPRs) for children meet published standards is unclear.

OBJECTIVE

To systematically review the quality, performance, and validation of published CPRs for children, compare them with adult CPRs, and suggest pediatric-specific changes to CPR methodology.

METHODS

Medline was searched from 1950 to 2011. Studies were selected if they included the development of a CPR involving children younger than 18 years. Two investigators assessed study quality, rule performance, and rule validation as methodologic standards.

RESULTS

Of 7298 titles and abstracts assessed, 137 eligible studies were identified. They describe the development of 101 CPRs addressing 36 pediatric conditions. Quality standards met in fewer than half of the studies were blind assessment of predictors (47%), reproducibility of predictors (18%), blind assessment of outcomes (42%), adequate follow-up of outcomes (36%), adequate power (43%), adequate reporting of results (49%), and 95% confidence intervals reported (36%). For rule performance, 48% had a sensitivity greater than 0.95, and 43% had a negative likelihood ratio less than 0.1. For rule validation, 76% had no validation, 17% had narrow validation, 8% had broad validation, and none had impact analysis performed. Compared with CPRs for adult health conditions, quality and rule validation seem to be lower.

CONCLUSIONS

Many CPRs have been derived for children, but few have been validated. Relative to adult CPRs, several quality indicators demonstrated weaknesses. Existing performance standards may prove elusive for CPRs that involve children. CPRs for children that are more assistive and less directive and include patients' values and preferences in decision-making may be helpful.

American Academy of Pediatrics. Clinical report--sport-related concussion in children and adolescents

Sport-related concussion is a "hot topic" in the media and in medicine. It is a common injury that is likely underreported by pediatric and adolescent athletes. Football has the highest incidence of concussion, but girls have higher concussion rates than boys do in similar sports. A clear understanding of the definition, signs, and symptoms of concussion is necessary to recognize it and rule out more severe intracranial injury. Concussion can cause symptoms that interfere with school, social and family relationships, and participation in sports. Recognition and education are paramount, because although proper equipment, sport technique, and adherence to rules of the sport may decrease the incidence or severity of concussions, nothing has been shown to prevent them. Appropriate management is essential for reducing the risk of long-term symptoms and complications. Cognitive and physical rest is the mainstay of management after diagnosis, and neuropsychological testing is a helpful tool in the management of concussion. Return to sport should be accomplished by using a progressive exercise program while evaluating for any return of signs or symptoms. This report serves as a basis for understanding the diagnosis and management of concussion in children and adolescent athletes.

Role of Neuroprotein S-100B in the Diagnostic of Pediatric Mild Brain Injury

Traumatic brain injury is one of the leading causes of death and disability in children and adolescents. Patients with moderate or severe lesions can be readily recognized clinically, require immediate radiologic diagnostics by computed tomography (CT) or magnetic resonance imaging (MRI), admission to intensive care units, and, in some cases, will go on to require neurosurgical intervention. Patients with mild traumatic brain injuries (MTBIs) are diagnostically challenging. Often, the event is unobserved and head injury can only be suspected. Clinical symptoms are unreliable and clinical findings from neurological examination have to be interpreted with care. As a small percentage of MTBI patients progress to have a life-threatening intracranial hemorrhage, the recognition of this group of patients and their judicious and timely management is, therefore, an important goal. Subjecting every MTBI patient to a cranial CT scanning results in high costs and unnecessary exposure to ionizing radiation. Admitting all MTBI patients for observation and performing CTs only in case of clinical deterioration is costly and a substantial drain on resources, not to mention the radiation exposure and a source of stress for the majority of patients. Current European guidelines for diagnostics and therapy in MTBI patients are only partially applicable to the pediatric population. This article reviews the clinical problem, treatment options and guidelines, as well as diagnostic tools, with special focus on neuroprotein S-100B in pediatric and adolescent patients with MTBIs.

Measuring Acceptability of Clinical Decision Rules: Validation of the Ottawa Acceptability of Decision Rules Instrument (OADRI) in Four Countries

Background. Clinical decision rules can benefit clinicians, patients, and health systems, but they involve considerable up-front development costs and must be acceptable to the target audience. No existing instrument measures the acceptability of a rule. The current study validated such an instrument. Methods. The authors administered the Ottawa Acceptability of Decision Rules Instrument (OADRI) via postal survey to emergency physicians from 4 regions (Australasia, Canada, United Kingdom, and United States), in the context of 2 recently developed rules, the Canadian C-Spine Rule (C-Spine) and the Canadian CT Head Rule (CT-Head). Construct validity of the 12-item instrument was evaluated by hypothesis testing. Results. As predicted by a priori hypotheses, OADRI scores were 1) higher among rule users than nonusers, 2) higher among those using the rule ‘‘all of the time’’ v. ‘‘most of the time’’ v. ‘‘some of the time,’’ and 3) higher among rule nonusers who would consider using a rule v. those who would not. We also examined explicit reasons given by respondents who said they would not use these rules. Items in the OADRI accounted for 85.5% (C- Spine) and 90.2% (CT-Head) of the reasons given for not considering a rule acceptable. Conclusions. The OADRI is a simple, 12-item instrument that evaluates rule acceptability among clinicians. Potential uses include comparing multiple ‘‘protorules’’ during development, examining acceptability of a rule to a new audience prior to implementation, indicating barriers to rule use addressable by knowledge translation interventions, and potentially serving as a proxy measure for future rule use.

Prediction of intracranial computed tomography findings in patients with minor head injury by using logistic regression

Object

The aim of this study was to develop a decision rule for physicians in developing countries to identify patients with minor head injury who will benefit from emergency brain CT scanning.

Methods

Three hundred eighteen patients with a history of blunt head trauma and a Glasgow Coma Scale (GCS) score ≥ 13 who had presented within 12 hours of trauma underwent nonenhanced brain CT and were included in this prospective study. Computed tomography findings that necessitated neurosurgical care (either observation or intervention) were considered as positive findings. Logistic regression was used to develop the decision rule.

Results

Computed tomography scans were always normal in patients < 65 years old who did not have an obvious head wound, a raccoon sign, vomiting, memory deficit, or a decrease in their GCS score. Patients with 1 major criterion (GCS score < 14, raccoon sign, failure to remember the impact, age > 65 years, or vomiting) or 2 minor criteria (wound at the scalp or GCS score < 15) had an abnormal CT scan in 13% of the cases.

Conclusions

The decision rule developed by the authors appears to be 100% sensitive and 46% specific for positive findings on brain CT and will, in developing countries, help clarify the decision to obtain scans.

Neuroprotein s-100B -- a useful parameter in paediatric patients with mild traumatic brain injury?

AIMS

To examine the correlation of S-100B to cranial computerized tomography (CCT) scan results in children after mild traumatic brain injury (MTBI).

METHODS

One hundred and nine paediatric patients (0-18 years) with MTBI were included in this prospective single-centre study. Serum was collected within 6 h of trauma for determination of serum S-100B. The upper reference of S-100B was set to 0.16 mug/L. A CCT scan was performed in all patients and the results were correlated to the S-100B values.

RESULTS

Computerized tomography was abnormal in 36 patients showing intracerebral haemorrhages and/or skull fractures. Serum S-100B level was significantly higher in patients with a pathological condition as shown in CT scan results (p = 0.003). There were no false negative, but 42 false positive test results for S-100B. This resulted in a sensitivity of 1.00, specificity of 0.42, positive predictive value of 0.46 and negative predictive value of 1.00. An area under the receiver operating curve of 0.68 was calculated.

CONCLUSION

S-100B is a valuable tool to rule out patients with pathological CCT findings in a collective of paediatric patients with MTBI. Elevations of S-100B do not necessarily lead to a pathological finding in the CT scan, but values below the cut-off safely rule out the evidence of intracranial lesions.

Patients with mild traumatic brain injury: Immediate and long-term outcome compared to intra-cranial injuries on CT scan

BACKGROUND

Mild traumatic brain injury (MTBI) defined as Glasgow Coma Scale (GCS) 14 or 15 has shown contradictory short- and long-term outcomes. The objective of this study was to correlate intra-cranial injuries (ICI) on CT scan to neurocognitive tests at admission and to complaints after 1 year.

METHODS

Two hundred and five patients with MTBI underwent a CT scan and were examined with neurocognitive tests. After 1 year complaints were assessed by phone interviews.

RESULTS

The neurocognitive tests in 51% of the patients showed significant deficits; there was no difference for patients with GCS 14-15, nor was there a difference between patients with ICI to patients without. After 1 year patients with ICI had significantly more complaints than patients without ICI, the most frequent complaint was headache and memory deficits.

CONCLUSIONS

No correlation was found between GCS or ICI and the neurocognitive tests upon admission. After 1 year, patients with ICI have significantly more complaints than patients without ICI. No cost savings resulted by doing immediate CT scan on all.

Should a head-injured child receive a head CT scan? A systematic review of clinical prediction rules

CONTEXT

Given radiation- and sedation-associated risks, there is uncertainty about which children with head trauma should receive cranial computed tomography (CT) scanning. A high-quality and high-performing clinical prediction rule may reduce this uncertainty.

OBJECTIVE

To systematically review the quality and performance of published clinical prediction rules for intracranial injury in children with head injury.

METHODS

Medline and Embase were searched in December 2008. Studies were selected if they included clinical prediction rules involving children aged 0 to 18 years with a history of head injury. Prediction-rule quality was assessed by using 14 previously published items. Prediction-rule performance was evaluated by rule sensitivity and the predicted frequency of CT scanning if the rule was used.

RESULTS

A total of 3357 titles and abstracts were assessed, and 8 clinical prediction rules were identified. For all studies, the rule derivations were reported; no study validated a rule in a separate population or assessed its impact in actual practice. The rules differed considerably in population, predictors, outcomes, methodologic quality, and performance. Five of the rules were applicable to children of all ages and severities of trauma. Two of these were high quality (>or=11 of 14 quality items) and had high performance (lower confidence limits for sensitivity >0.95 and required <or=56% to undergo CT). Four of the 8 rules were applicable to children with minor head injury (Glasgow coma score >or=13). One of these had high quality (11 of 14 quality items) and high performance (lower confidence limit for sensitivity = 0.94 and required 13% to undergo CT). Four of the 8 rules were applicable to young children, but none exhibited adequate quality or performance.

CONCLUSIONS

Eight clinical prediction-rule derivation studies were identified. They varied considerably in population, methodologic quality, and performance. Future efforts should be directed toward validating rules with high quality and performance in other populations and deriving a high-quality, high-performance rule for young children.

Neuroimaging of traumatic brain injury

In this article, the neuroradiological evaluation of traumatic brain injury is reviewed. Different imaging strategies in the assessment of traumatic brain injury are initially discussed, and this is followed by a review of the imaging characteristics of both primary and secondary brain injuries. Computed tomography remains the modality of choice for the initial assessment of acute head injury because it is fast, widely available, and highly accurate in the detection of skull fractures and acute intracranial hemorrhage. Magnetic resonance imaging is recommended for patients with acute traumatic brain injury when the neurological findings are unexplained by computed tomography. Magnetic resonance imaging is also the modality of choice for the evaluation of subacute or chronic traumatic brain injury. Mild traumatic brain injury continues to be difficult to diagnose with current imaging technology. Advanced magnetic resonance techniques, such as diffusion-weighted imaging, magnetic resonance spectroscopy, and magnetization transfer imaging, can improve the identification of traumatic brain injury, especially in the case of mild traumatic brain injury. Further research is needed for other advanced imaging methods such as magnetic source imaging, single photon emission tomography, and positron emission tomography.

Concussive symptoms in emergency department patients diagnosed with minor head injury

BACKGROUND

Evidence-based protocols exist for Emergency Department (ED) patients diagnosed with minor head injury. These protocols focus on the need for acute intervention or in-hospital management. The frequency and nature of concussive symptoms experienced by patients discharged from the ED are not well understood.

OBJECTIVES

To examine the prevalence and nature of concussive symptoms, up to 1 month post-presentation, among ED patients diagnosed with minor head injury.

METHODS

Eligible and consenting patients presenting to Kingston EDs with minor head injury (n = 94) were recruited for study. The Rivermead Post-Concussion Symptoms Questionnaire was administered at baseline and at 1 month post-injury to assess concussive symptoms. This analysis focused upon acute and ongoing symptoms.

RESULTS

Proportions of patients reporting concussive symptoms were 68/94 (72%) at baseline and 59/94 (63%) at follow-up. Seventeen percent of patients (18/102) were investigated with computed tomography scanning during their ED encounter. The prevalence of somatic symptoms declined between baseline and follow-up, whereas some cognitive and emotional symptoms persisted.

CONCLUSION

The majority of patients who present to the ED with minor head injuries suffer from concussive symptoms that do not resolve quickly. This information should be incorporated into discharge planning for these patients.

Advanced trauma life support, 8th edition, the evidence for change

The American College of Surgeons Committee on Trauma's Advanced Trauma Life Support Course is currently taught in 50 countries. The 8th edition has been revised following broad input by the International ATLS subcommittee. Graded levels of evidence were used to evaluate and approve changes to the course content. New materials related to principles of disaster management have been added. ATLS is a common language teaching one safe way of initial trauma assessment and management.

Traumatic intracranial haemorrhage in conscious patients with facial fractures--a review of 1959 cases

OBJECTIVE

Facial fracture patients who are conscious with a Glasgow Coma Scale (GCS) score of 15 in the absence of clinical neurological abnormalities are commonly not expected to have suffered severe intracranial pathology. However, high velocity impact may result in intracranial haemorrhage in different compartments.

METHODS

Over a 7-year period, 1959 facial fracture patients with GCS scores of 15 and the absence of neurological abnormalities were analysed. In 54 patients (2.8%) computed tomography scans revealed the presence of accompanying intracranial haemorrhage (study group). These patients were compared with the 1905 patients without intracranial haemorrhage (control group).

RESULTS

Univariate analysis identified accompanying vomiting/nausea and seizures, cervical spine injuries, cranial vault and basal skull fractures to be significantly associated with intracranial bleeding. In multivariate analysis the risk was increased nearly 25-fold if an episode of vomiting/nausea had occurred. Seizures increased the risk of bleeding more than 15-fold. The mean functional outcome of the study group according to the Glasgow Outcome Scale was 4.7+/-0.7.

CONCLUSION

Intracranial haemorrhage cannot be excluded in patients with facial fractures despite a GCS score of 15 and normal findings following neurological examination. Predictors, such as vomiting/nausea or seizures, skull fractures and closed head injuries, enhance the likelihood of an intracranial haemorrhage and have to be considered.

A critical comparison of clinical decision instruments for computed tomographic scanning in mild closed traumatic brain injury in adolescents and adults

STUDY OBJECTIVE

A number of clinical decision aids have been introduced to limit unnecessary computed tomographic scans in patients with mild traumatic brain injury. These aids differ in the risk factors they use to recommend a scan. We compare the instruments according to their sensitivity and specificity and recommend ones based on incremental benefit of correctly classifying patients as having surgical, nonsurgical, or no intracranial lesions.

METHODS

We performed a secondary analysis of prospectively collected database from 7,955 patients aged 10 years or older with mild traumatic brain injury to compare sensitivity and specificity of 6 common clinical decision strategies: the Canadian CT Head Rule, the Neurotraumatology Committee of the World Federation of Neurosurgical Societies, the New Orleans, the National Emergency X-Radiography Utilization Study II (NEXUS-II), the National Institute of Clinical Excellence guideline, and the Scandinavian Neurotrauma Committee guideline. Excluded from the database were patients for whom the history of trauma was unclear, the initial Glasgow Coma Scale score was less than 14, the injury was penetrating, vital signs were unstable, or who refused diagnostic tests. Patients revisiting the emergency department within 7 days were counted only once.

RESULTS

The percentage of scans that would have been required by applying each of the 6 aids were Canadian CT head rule (high risk only) 53%, Canadian (medium & high risk) 56%, the Neurotraumatology Committee of the World Federation of Neurosurgical Societies 56%, New Orleans 69%, NEXUS-II 56%, National Institute of Clinical Excellence 71%, and the Scandinavian 50%. The 6 decision aids' sensitivities for surgical hematomas could not be distinguished statistically (P>.05). Sensitivity was 100% (95% confidence interval [CI] 96% to 100%) for NEXUS-II, 98.1% (95% CI 93% to 100%) for National Institute of Clinical Excellence, and 99.1% (95% CI 94% to 100%) for the other 4 clinical decision instruments. Sensitivity for any intracranial lesion ranged from 95.7% (95% CI 93% to 97%) (Scandinavian) to 100% (95% CI 98% to 100%) (National Institute of Clinical Excellence). In contrast, specificities varied between 30.9% (95% CI 30% to 32%) (National Institute of Clinical Excellence) and 52.9% (95% CI 52% to 54) (Scandinavian).

CONCLUSION

NEXUS-II and the Scandinavian clinical decision aids displayed the best combination of sensitivity and specificity in this patient population. However, we cannot demonstrate that the higher sensitivity of NEXUS-II for surgical hematomas is statistically significant. Therefore, choosing which of the 2 clinical decision instruments to use must be based on decisionmakers' attitudes toward risk.

A history of loss of consciousness or post-traumatic amnesia in minor head injury: "conditio sine qua non" or one of the risk factors?

OBJECTIVE

A history of loss of consciousness (LOC) or post-traumatic amnesia (PTA) is commonly considered a prerequisite for minor head injury (MHI), although neurocranial complications also occur when LOC/PTA are absent, particularly in the presence of other risk factors. The purpose of this study was to evaluate whether known risk factors for complications after MHI in the absence of LOC/PTA have the same predictive value as when LOC/PTA are present.

METHODS

A prospective multicentre study was performed in four university hospitals between February 2002 and August 2004 of consecutive blunt head injury patients (> or = 16 years) presenting with a normal level of consciousness and a risk factor. Outcome measures were any neurocranial traumatic CT finding and neurosurgical intervention. Common odds ratios (OR) were estimated for each of the risk factors and tested for homogeneity.

RESULTS

2462 patients were included: 1708 with and 754 without LOC/PTA. Neurocranial traumatic findings on CT were present in 7.5% and were more common when LOC/PTA was present (8.7%). Neurosurgical intervention was required in 0.4%, irrespective of the presence of LOC/PTA. ORs were comparable across the two subgroups (p>0.05), except for clinical evidence of a skull fracture, with high ORs both when LOC/PTA was present (OR = 37, 95% CI 17 to 80) or absent (OR = 6.9, 95% CI 1.8 to 27). LOC and PTA had significant ORs of 1.9 (95% CI 1.0 to 2.7) and 1.7 (95% CI 1.3 to 2.3), respectively.

CONCLUSION

Known risk factors have comparable ORs in MHI patients with or without LOC or PTA. MHI patients without LOC or PTA need to be explicitly considered in clinical guidelines.

The Galasko report implemented: the role of emergency medicine in the management of head injuries

INTRODUCTION

The objectives were to demonstrate the extra workload for emergency medicine of inpatient management of mild/moderate head injuries and to determine the effectiveness of current computed tomography guidelines.

METHOD

A retrospective study of head injuries presenting to St James's Hospital Dublin, where the Galasko report has been implemented since 2001. We studied injuries presented from January 2001 to January 2002. Length of stay, mechanism of injury, follow-up, indication for admission and computed tomography scan were identified.

RESULTS

A total of 2281 patients presented with head injury as their first or second triage complaint. One hundred and twenty-three patients were admitted to the emergency ward, of which 34 had computed tomography investigation. Ten computed tomography scans demonstrated intracranial injury. Intracranial injury was associated with vomiting, Glasgow coma score 14 (confusion), deterioration of Glasgow coma score, clinical basilar skull fracture and alcohol-related falls. The average length of stay for patients admitted to observation ward was 2.3 days and 5 days for those who had a brain injury on computed tomography scan.

CONCLUSIONS

Implementation of the Galasko report has resource, manpower and training implications for emergency medicine. The current computed tomography guidelines should be modified to include Glasgow coma score<15 and neurological symptoms for example, vomiting and alcohol-related falls.

Head injury outcome prediction: a role for protein S-100B?

INTRODUCTION

Prediction of the likely outcome of head injury from the outset would allow early rehabilitation to be targeted at those with most to gain. Clinical evaluation of a head injured patient may be confounded by intoxicants such as alcohol. Imaging modalities are insensitive (CT) or impractical (MR) for screening populations of such patients. A peripheral marker that reflected the extent of brain injury might offer an objective indication of likely adverse sequelae. This review evaluates the evidence for Protein S-100B as such a marker.

METHODS

A search of published literature revealed 18 studies designed to evaluate the relation between serum S-100B and measures of outcome after head injury.

RESULTS

A cut-off point of 2.5microg/L is related to dependent disability in those presenting with low conscious level, and may be a specific test for this. There appears to be a relation between initial serum S-100B concentration and measures of disability as well as post-concussion symptoms for those with seemingly mild injuries. There does not appear to be a relation between S-100B and measures of neuropsychological performance.

CONCLUSION

Patients with high levels of S-100B at initial assessment (>2.5microg/L) may represent a high risk group for disability after head trauma.

Computer-Assisted Categorizing of Head Computed Tomography Reports for Clinical Decision Rule Research

STUDY OBJECTIVE

To develop software that categorizes electronic head computed tomography (CT) reports into groups useful for clinical decision rule research.

METHODS

Data were obtained from the Second National Emergency X-Radiography Utilization Study, a cohort of head injury patients having received head CT. CT reports were reviewed manually for presence or absence of clinically important subdural or epidural hematoma, defined as greater than 1.0 cm in width or causing mass effect. Manual categorization was done by 2 independent researchers blinded to each other's results. A third researcher adjudicated discrepancies. A random sample of 300 reports with radiologic abnormalities was selected for software development. After excluding reports categorized manually or by software as indeterminate (neither positive nor negative), we calculated sensitivity and specificity by using manual categorization as the standard. System efficiency was defined as the percentage of reports categorized as positive or negative, regardless of accuracy. Software was refined until analysis of the training data yielded sensitivity and specificity approximating 95% and efficiency exceeding 75%. To test the system, we calculated sensitivity, specificity, and efficiency, using the remaining 1,911 reports.

RESULTS

Of the 1,911 reports, 160 had clinically important subdural or epidural hematoma. The software exhibited good agreement with manual categorization of all reports, including indeterminate ones (weighted kappa 0.62; 95% confidence interval [CI] 0.58 to 0.65). Sensitivity, specificity, and efficiency of the computerized system for identifying manual positives and negatives were 96% (95% CI 91% to 98%), 98% (95% CI 98% to 99%), and 79% (95% CI 77% to 80%), respectively.

CONCLUSION

Categorizing head CT reports by computer for clinical decision rule research is feasible.

Indications for CT Scanning in Mild Traumatic Brain Injury: A Cost-Effectiveness Study

BACKGROUND

There is considerable uncertainty about the indications for cranial computed tomography (CT) scanning in patient with minor traumatic brain injury (TBI). This analysis involves an evidence-based comparison of several strategies for selecting patients for CT with regard to effectiveness and cost.

METHODS

We performed a structured literature review of mild traumatic brain injury and constructed a cost-effectiveness model. The model estimated the impact of missed intracranial lesions on longevity, quality of life and costs. Using a 20-year-old patient for primary analysis, we compared the following strategies to screen for the need to perform a CT scan: observation in the emergency department or hospital floor, skull radiography, Selective CT based on the presence of additional risk factors and scanning all.

RESULTS

Outcome measures for each strategy included average years of life, quality of life and costs. Selective CT and the CT All policy performed significantly better than the alternatives with respect to outcome. They were also less expensive in terms of total direct health care costs, although the differences did not reach statistical significance. The model yielded similar, but smaller, differences between the selective imaging and other strategies when run for older patients.

CONCLUSIONS

Although the incidence of intracranial lesions, especially those that require surgery, is low in mild TBI, the consequences of delayed diagnosis are forbidding. Adverse outcome of an intracranial hematoma is so costly that it more than balances the expense of CT scans. In our cost-effectiveness model, the liberal use of CT scanning in mild TBI appears justified.

Clinical Features of Head Injury Patients Presenting With a Glasgow Coma Scale Score of 15 and Who Require Neurosurgical Intervention

STUDY OBJECTIVE

Emergency physicians are concerned about minor head injury patients who present with a Glasgow Coma Scale (GCS) score of 15 yet require neurosurgical intervention. Our objectives are to determine the accuracy of the Canadian CT Head Rule (CCHR) in this important subset, the prevalence of patients requiring urgent intervention, and their clinical course and possible warning signs.

METHODS

We conducted a secondary data analysis of the CCHR study cohorts from 10 hospital emergency departments (EDs). We included head trauma patients with witnessed loss of consciousness, disorientation, or definite amnesia and who presented with an initial GCS score of 15. Records were reviewed and specific variables added to the database. The primary outcome was need for urgent neurosurgical intervention.

RESULTS

Among the 4,551 study patients, only 26 (0.6%; 95% confidence interval [CI] 0 to 1.0%) required neurosurgical intervention, and the CCHR identified all 26 cases with 100% sensitivity. Eleven patients required "urgent" craniotomy within 7 days, and of those, 2 patients deteriorated precipitously. These 11 (0.2%; 95% CI 0.1% to 0.3%) cases had additional signs: GCS score decrease within 6 hours (82%), GCS score decrease within 3 hours (73%), confusion (64%), any vomiting (36%), focal temporal blow (36%), restlessness (36%), and severe headache (45%).

CONCLUSION

For patients with minor head injury and GCS score of 15, urgent neurosurgical intervention and precipitous deterioration are rare. The CCHR accurately identified all patients requiring neurosurgical intervention. Warning signs that may portend need for urgent intervention include any vomiting, restlessness, any GCS score decrease, severe headache, confusion, and focal temporal blow.

Musculoskeletal imaging in physical therapist practice

This article presents an overview of current concepts of evidence-based diagnosis using a variety of imaging modalities for a broad spectrum of musculoskeletal conditions and syndromes. There is limited but increasing evidence that physical therapists appropriately use diagnostic studies in clinical practice. Pathology revealed by diagnostic studies must be viewed in the context of the complete examination, as pathology is common in the asymptomatic population. Special diagnostic challenges are presented by patients with areas of referred pain, multiple injuries or multiple areas of pathology, neoplasms, and infections. Plain film radiographs have been overused in the clinical management of many conditions, including low back pain. Clinical decision rules provide simple evidence-based guidelines for the appropriate use of imaging studies.

Neuroimaging in traumatic brain imaging

Traumatic brain injury (TBI) is a common and potentially devastating clinical problem. Because prompt proper management of TBI sequelae can significantly alter the clinical course especially within 48 h of the injury, neuroimaging techniques have become an important part of the diagnostic work up of such patients. In the acute setting, these imaging studies can determine the presence and extent of injury and guide surgical planning and minimally invasive interventions. Neuroimaging also can be important in the chronic therapy of TBI, identifying chronic sequelae, determining prognosis, and guiding rehabilitation.

Imaging of maxillofacial trauma: Evolutions and emerging revolutions

The aim of diagnostic imaging for maxillofacial trauma is to provide additional information that can positively influence medical or surgical patient management. Current advances in diagnostic imaging have come from the confluence of 3 driving forces: (1) the demand from clinicians to enhance and expand their diagnostic abilities; (2) the development of new theoretical concepts by basic scientists; and (3) the application of concepts by engineers and manufacturers to provide increasingly sophisticated imaging capabilities. The role of imaging within the health care environment is, however, also buffeted by the complex, sometimes competing, interactions of external social, political, economic, and technological pressures at the national, regional, and local levels. The purposes of this review are to provide a perspective on current imaging modalities used for maxillofacial trauma and to provide an insight into the influences, both technologic and external, on future developments and applications.