Adapting the Canadian CT head rule age criteria for mild traumatic brain injury

OBJECTIVE

With the ageing population, the prevalence of mild traumatic brain injury (mTBI) among older patients is increasing, and the age criteria of the Canadian CT head rule (CCHR) is challenged by many emergency physicians. We modified the age criteria of the CCHR to evaluate its predictive capacity.

METHODS

We conducted a retrospective cohort study at a level 1 trauma centre ED of all mTBI patients 65 years old and over with an mTBI between 2010 and 2014. Main outcome was a clinically important brain injury (CIBI) reported on CT. The clinical and radiological data collection was standardised. Univariate analyses were performed to measure the predictive capacities of different age cut-offs at 70, 75 and 80 years old.

RESULTS

104 confirmed mTBI were included; CT scan identified 32 (30.8%) CIBI. Sensitivity and specificity (95% CI) of the CCHR were 100% (89.1 to 100) and 4.2% (0.9 to 11.7) for a modified criteria of 70 years old; 100% (89.1 to 100) and 13.9% (6.9 to 24.1) for 75 years old; and 90.6% (75.0 to 98.0) and 23.6% (14.4 to 35.1) for 80 years old. Furthermore, modifying the age criteria to 75 years old showed a reduction of CT up to 25% (n=10/41) among the individuals aged 65-74 without missing CIBI.

CONCLUSION

Adjusting the age criteria of the Canadian CT head rule to 75 years old could be safe while reducing radiation and ED resources. A future prospective study is suggested to confirm the proposed modification.

Safety and efficacy of venoplasty in MS: A randomized, double-blind, sham-controlled phase II trial

Objective

To determine the safety and efficacy of balloon vs sham venoplasty of narrowing of the extracranial jugular and azygos veins in multiple sclerosis (MS).

Methods

Patients with relapsing or progressive MS were screened using clinical and ultrasound criteria. After confirmation of >50% narrowing by venography, participants were randomized 1:1 to receive balloon or sham venoplasty of all stenoses and were followed for 48 weeks. Participants and research staff were blinded to intervention allocation. The primary safety outcome was the number of adverse events (AEs) during 48 weeks. The primary efficacy outcome was the change from baseline to week 48 in the patient-reported outcome MS Quality of Life–54 (MSQOL-54) questionnaire. Standardized clinical and MRI outcomes were also evaluated.

Results

One hundred four participants were randomized (55 sham; 49 venoplasty) and 103 completed 48 weeks of follow-up. Twenty-three sham and 21 venoplasty participants reported at least 1 AE; one sham (2%) and 5 (10%) venoplasty participants had a serious AE. The mean improvement in MSQOL-54 physical score was +1.3 (sham) and +1.4 (venoplasty) (p = 0.95); MSQOL-54 mental score was +1.2 (sham) and −0.8 (venoplasty) (p = 0.55).

Conclusions

Our data do not support the continued use of venoplasty of extracranial jugular and/or azygous venous narrowing to improve patient-reported outcomes, chronic MS symptoms, or the disease course of MS.

ClinicalTrials.gov identifier

NCT01864941.

Classification of evidence

This study provides Class I evidence that for patients with MS, balloon venoplasty of extracranial jugular and azygous veins is not beneficial in improving patient-reported, standardized clinical, or MRI outcomes.

Severe cerebellar hemorrhage following transverse sinus stenting for idiopathic intracranial hypertension

We report a severe adverse event occurring in the course of a cohort study (ISRCTN13784335) aimed at measuring the efficacy and safety of venous stenting in the treatment of patients with medically refractory idiopathic intracranial hypertension (IIH). The patient was a 41-year-old woman who was not overweight, who presented with severe headache, grade 1 bilateral papilledema and transient tinnitus, refractory to medical treatment. Right transverse sinus stenting was successfully performed. Following surgery, the patient's state of consciousness decreased acutely with rapid and progressive loss of brainstem reflex. CT scan revealed acute cerebellar and intraventricular hemorrhage with obstructive hydrocephalus. Angioscan revealed normal venous sinus patency and cerebral MRI showed acute mesencephalic ischemia. Mechanical impairment of cerebellar venous drainage by the stent or venous perforation with the large guidewire used in this technique are two logical ways to explain the cerebellar hemorrhage seen in our patient. The risk of such a complication could probably be reduced using alternative tools and technique. However, given the low level of evidence around the safety of transverse sinus stenting in IIH, its formal assessment in clinical trials is required.

Maternal prenatal, postpartum, and concurrent stressors and temperament in 3-year-olds: a person and variable analysis

The study was based on the assumption that stressors in the lives of pregnant and parenting women are processes that affect prenatal, postpartum, and concurrent maternal hormones and emotions and that these processes affect child temperament. The hypotheses were tested in a group of 67 young mothers and their 3-year-old children. Mothers were clustered into groups based on longitudinal patterns of hormones and emotions at prenatal, postpartum. and 3-year follow-up assessments. The analyses focused on relating maternal patterns of hormones and emotions to the child's temperament at age 3 years. Temperament was assessed by questionnaire and observation of behavior during a challenging situation. Illustrative findings included the following. Verbal aggression and nonverbal aggression were significantly higher in children of mothers in the low prenatal hormone cluster than children of mothers in the high prenatal hormone cluster. Children of mothers in the postpartum low testosterone (T), estradiol (E2), and androstenedione (delta4-A) and medium cortisol (Cort) cluster (mainly low hormone cluster) exhibited significantly more physical aggression than children of mothers in the medium T and A4-A, high E2 and low Cort cluster. Maternal patterns of hormones, emotions, and parenting attitudes and practices were related to multiple aspects of temperament when the children were age 3 years. The findings support the important role of maternal biological and psychological processes in the development of child temperament.

Arteriovenous malformation of the mandible: embolization and direct injection therapy

Arteriovenous malformation (AVM) of the mandible is a rare entity but one that can be potentially fatal as a result of massive hemorrhage. Traditional treatment involved extensive surgical resection of the mandible. With the advent of improved endovascular techniques, interventional radiology is now the best method to control active hemorrhage and ultimately cure these lesions. The authors describe three cases of successfully treated mandibular AVM by percutaneous and/or endovascular techniques.

Differences in NK cell function in mice bred for high and low aggression: genetic linkage between complex behavioral and immunological traits?

In previous studies, we found differences in cellular immune responsiveness in Institute for Cancer Research (ICR) mice selectively bred for high and low levels of aggression. Compared to the high aggressive line, the low aggressive line had low levels of natural killer (NK) and T cell activity and increased susceptibility to tumor development. To dissect further this novel association, experiments were designed to test two competing hypotheses. The first hypothesis was that the phenotypic expression of the line differences in NK cell activity are dependent on and regulated by the expression of high and low levels aggressive behavior in the lines. The alternative hypothesis was that the differences in immune status are independent of the expression of aggression by the lines, suggesting linkage between a subset of genes involved in determining these complex behavioral and immunological traits or pleiotropic gene effects on both traits. In Experiment 1, three conditions of postweaning social experience (mice singly housed, group housed within line, or group housed between lines) were tested in males to determine whether experiential conditions which modify the expression of aggression would in turn modify the line differences in NK cell activity. This experiment revealed that the difference in NK cell activity between high aggressive and low aggressive male mice was attributable to line only. The different postweaning social conditions examined had no effect on modifying the differences in NK activity, and social dominance hierarchy did not correlate with levels of NK cell activity. Whereas males of the high and low lines exhibit differences in aggressive behaviors across most contexts, females do not exhibit such differences except in response to an intruder during the postpartum period. Therefore, in Experiment 2 we compared the NK cell activity of nulliparous females of the high and low aggressive lines. Under these conditions, females of the low aggressive line had low levels of NK activity compared to high aggressive females (differences comparable to those seen between males of the high and low lines). Taken together, these experiments lend support to the hypothesis that this association may be due to a genetic linkage between subsets of genes involved in determining these complex behavioral and immunological traits, or may possibly represent a fortuitous association which occurred during the selective breeding.

Association of genetic differences in social behavior and cellular immune responsiveness: effects of social experience

We have recently demonstrated that selective breeding of ICR mice for differences in social behavior (i.e., high versus low levels of social isolation-induced aggression) are related to increased susceptibility to tumor development and reduced levels of natural killer (NK) cell activity. In the present investigation, we sought to extend examination of the line differences in immune status to T and B cell responsiveness. In addition, we also sought to determine if social experience contributes to line differences in immune responsiveness. A cosibial design was used to examine whether single vs group housing modified the magnitude of line differences in immune status. Compared to aggressive (NC900) mice, nonaggressive (NC100) mice had significantly lower T cell proliferative responses to concanavalin A, lower IL-2 and gamma-interferon production, as well as significantly lower NK activity. Of the various measures of cellular immune responsiveness, housing condition was found to have a significant effect only on NK activity. No significant line by housing interactions were found for any of the immune measures tested. The present data demonstrate that the genetic selection for differences in social behavior is associated with line differences in several parameters of cellular immune responsiveness. These mouse lines provide a valuable research model to examine the association between selection for genetic differences in social behavior and differences in immune responsiveness.

Genetic differences in social behavior: relation to natural killer cell function and susceptibility to tumor development

The hypothesis that certain heritable personality traits would correlate with increased vulnerability to tumor development and reduced natural killer (NK) cell function was tested in mice selectively bred for high and low levels of aggression. This selection program produces a line of mice that fail to exhibit species typical, isolation-induced aggression, but appear socially inhibited in response to a novel partner mouse. All socially inhibited mice developed 3-methylcholanthrene-induced tumors compared with only 44% of the aggressive mice. Basal NK activity was also significantly lower among socially inhibited mice. Conversely, there were no line differences in NK activity between the aggressive line and nonselected, socially isolated mice, consistent with other unidirectional outcomes of this selective breeding program. No significant line differences were present for nonsocial measures of emotional reactivity (e.g., fearfulness) or serum corticosterone levels. These findings support the hypothesis that social "traits" may be related to immune function and tumor susceptibility.