Patients with mild traumatic brain injury on CT scan are routinely admitted for inpatient observation. Only a small proportion of patients require clinical intervention. We recently developed a ...decision rule using traditional statistical techniques that found neurologically intact patients with isolated simple skull fractures or single bleeds <5 mm with no preinjury antiplatelet or anticoagulant use may be safely discharged from the emergency department. The decision rule achieved a sensitivity of 99.5% (95% CI 98.1% to 99.9%) and specificity of 7.4% (95% CI 6.0% to 9.1%) to clinical deterioration. We aimed to transparently report a machine learning approach to assess if predictive accuracy could be improved.
We used data from the same retrospective cohort of 1699 initial Glasgow Coma Scale (GCS) 13-15 patients with injuries identified by CT who presented to three English Major Trauma Centres between 2010 and 2017 as in our original study. We assessed the ability of machine learning to predict the same composite outcome measure of deterioration (indicating need for hospital admission). Predictive models were built using gradient boosted decision trees which consisted of an ensemble of decision trees to optimise model performance.
The final algorithm reported a mean positive predictive value of 29%, mean negative predictive value of 94%, mean area under the curve (C-statistic) of 0.75, mean sensitivity of 99% and mean specificity of 7%. As with logistic regression, GCS, severity and number of brain injuries were found to be important predictors of deterioration.
We found no clear advantages over the traditional prediction methods, although the models were, effectively, developed using a smaller data set, due to the need to divide it into training, calibration and validation sets. Future research should focus on developing models that provide clear advantages over existing classical techniques in predicting outcomes in this population.
There is international variation in hospital admission practices for patients with mild traumatic brain injury (TBI) and injuries on CT scan. Only a small proportion of patients require neurosurgical ...intervention, while many guidelines recommend routine admission of all patients. We aim to validate the Hull Salford Cambridge Decision Rule (HSC DR) and the Brain Injury Guidelines (BIG) criteria to select low-risk patients for discharge from the emergency department.
A cohort from 18 countries of Glasgow Coma Scale 13-15 patients with injuries on CT imaging was identified from the multicentre Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) Study (conducted from 2014 to 2017) for secondary analysis. A composite outcome measure encompassing need for ongoing hospital admission was used, including seizure activity, death, intubation, neurosurgical intervention and neurological deterioration. We assessed the performance of our previously derived prognostic model, the HSC DR and the BIG criteria at predicting deterioration in this validation cohort.
Among 1047 patients meeting the inclusion criteria, 267 (26%) deteriorated. Our prognostic model achieved a C-statistic of 0.81 (95% CI: 0.78 to 0.84). The HSC DR achieved a sensitivity of 100% (95% CI: 97% to 100%) and specificity of only 4.7% (95% CI: 3.3% to 6.5%) for deterioration. Using the BIG criteria for discharge from the ED achieved a higher specificity (13.3%, 95% CI: 10.9% to 16.1%) and lower sensitivity (94.6%, 95% CI: 90.5% to 97%), with 12/105 patients recommended for discharge subsequently deteriorating, compared with 0/34 with the HSC DR.
Our decision rule would have allowed 3.5% of patients to be discharged, none of whom would have deteriorated. Use of the BIG criteria may select patients for discharge who have too high a risk of subsequent deterioration to be used clinically. Further validation and implementation studies are required to support use in clinical practice.
The optimal management of mild traumatic brain injury (TBI) patients with injuries identified by computed tomography (CT) brain scan is unclear. Some guidelines recommend hospital admission for an ...observation period of at least 24 h. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED). The objective of our review and meta-analysis was to estimate the risk of death, neurosurgical intervention, and clinical deterioration in mild TBI patients with injuries identified by CT brain scan, and assess which patient factors affect the risk of these outcomes. A systematic review and meta-analysis adhering to PRISMA standards of protocol and reporting were conducted. Study selection was performed by two independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks for: clinical deterioration, neurosurgical intervention, and death. Meta-regression was used to explore between-study variation in outcome estimates using study population characteristics. Forty-nine primary studies and five reviews were identified that met the inclusion criteria. The estimated pooled risk for the outcomes of interest were: clinical deterioration 11.7% (95% confidence interval CI: 11.7%-15.8%), neurosurgical intervention 3.5% (95% CI: 2.2%-4.9%), and death 1.4% (95% CI: 0.8%-2.2%). Twenty-one studies presented within-study estimates of the effect of patient factors. Meta-regression of study characteristics and pooling of within-study estimates of risk factor effect found the following factors significantly affected the risk for adverse outcomes: age, initial Glasgow Coma Scale (GCS), type of injury, and anti-coagulation. The generalizability of many studies was limited due to population selection. Mild TBI patients with injuries identified by CT brain scan have a small but clinically important risk for serious adverse outcomes. This review has identified several prognostic factors; research is needed to derive and validate a usable clinical decision rule so that low-risk patients can be safely discharged from the ED.
Head injury is an extremely common clinical presentation to hospital emergency departments (EDs). Ninety-five percent of patients present with an initial Glasgow Coma Scale (GCS) score of 13-15, ...indicating a normal or near-normal conscious level. In this group, around 7% of patients have brain injuries identified by CT imaging but only 1% of patients have life-threatening brain injuries. It is unclear which brain injuries are clinically significant, so all patients with brain injuries identified by CT imaging are admitted for monitoring. If risk could be accurately determined in this group, admissions for low-risk patients could be avoided and resources could be focused on those with greater need.This study aims to (a) estimate the proportion of GCS13-15 patients with traumatic brain injury identified by CT imaging admitted to hospital who clinically deteriorate and (b) develop a prognostic model highly sensitive to clinical deterioration which could help inform discharge decision making in the ED.
A retrospective case note review of 2000 patients with an initial GCS13-15 and traumatic brain injury identified by CT imaging (2007-2017) will be completed in two English major trauma centres. The prevalence of clinically significant deterioration including death, neurosurgery, intubation, seizures or drop in GCS by more than 1 point will be estimated. Candidate prognostic factors have been identified in a previous systematic review. Multivariable logistic regression will be used to derive a prognostic model, and its sensitivity and specificity to the outcome of deterioration will be explored.
This study will potentially derive a statistical model that predicts clinically relevant deterioration and could be used to develop a clinical risk tool guiding the need for hospital admission in this group.
care home residents aged over 65 have disproportionate rates of emergency department (ED) attendance and hospitalisation. Around 40% attendances may be avoidable, and hospitalisation is associated ...with harms. We synthesised the evidence available in qualitative systematic reviews of different stakeholders' experiences of decisions to transfer residents to the ED.
six electronic databases, references and citations of included reviews and relevant policy documents were searched. Reviews of qualitative studies exploring factors that influenced care home staff, medical practitioners, residents' family or residents' experiences and factors influencing decisions to transfer residents to the ED were included. Thematic analysis was used to synthesise findings.
six previous reviews were included, which synthesised the findings of 34 primary studies encompassing 152 care home residents, 283 resident family members or carers and 447 care home staff. Of the primary studies, 19 were conducted in the North America, seven in Australia, five were conducted in Scandinavia, two in the United Kingdom and one in Holland. Three themes were identified: (i) power dynamics between residents, family members, care home staff and health care professionals (external to the care home) influence decisions; (ii) admission can be necessary; however, (iii) some decisions may be driven by factors other than clinical need.
transfer decisions are complex and are determined not just by changes in health status interventions aimed at reducing avoidable transfers need to address the key role family members have in transfer decisions, the medical legal fears of care home staff and barriers to accessing community services.
BackgroundTranexamic Acid (TXA) is an anti-fibrinolytic agent that promotes haemostasis and counteracts coagulopathy in trauma. A wealth of research supports TXA use in adults, yet no large trials ...have been performed in paediatric populations. The RCPCH in 2012 advocated TXA use in paediatric trauma, recommending future evaluation of outcomes utilising the Trauma Audit and Research Network (TARN).ObjectivesTo describe TXA use in paediatric trauma over time, exploring association with best practice statements and evidence from adult trials. Primary outcome was to determine change in prevalence of use over time. Secondary outcomes captured details or impact of change, including thrombotic events, blood product use, surgical intervention, and evaluation of injury patterns.MethodsRetrospective analysis of TARN data between 2008–2020 for patients under 16 years in England and Wales, with no clinical exclusions.A time series analysis was performed, with descriptive statistics given as mean (95% CI) or median (IQR)Results27,385 patients were included of which 18535 (67.7%) were male. 7804 (28.5%) were aged 12–15, 6966 (25.4%) aged 6–11, 6570 (24%) aged 2–5 and 6045 (22.1%) under 1. Overall mortality within 30 days was 799 (2.9%).TXA use increased year on year, from 25 (1.2%) in 2012 to 196 (10.1%) in 2020. Apart from an initial rapid rise in use in 2012–2013, no other annual progression showed a disproportionate increase. There was no change in 30-day mortality rate over time, ranging between 2.1% (in 2015) and 3.3% (in 2016). Change over time analysis showed no significant increase in thrombotic complications. In 2012 data revealed 4 (0.2%) thrombotic events compared to 2 (0.1%) in 2020, with a tenfold increase in TXA over same time period.In total, 1346 (4.9%) patients received TXA, of which 735 (54.6%) were aged 12–15. Road traffic collisions (64%) and penetrating injuries (12.7%) were the commonest mechanisms of injury in those receiving TXA. In relation to trauma severity, the median Injury Severity Score in those treated with TXA was 20 IQR 10–33, compared to 9 IQR 9–16 in untreated patients; 829 (61%) of those treated with TXA were admitted to ICU, compared to 4849 (18.6%) without. Blood products were transfused in 245 (18.2%) patients receiving TXA compared to 110 (0.4%).ConclusionsWe have demonstrated consistent increases in proportional use of TXA over time since the RCPCH statement in 2012, with no change in mortality. Despite significant increase in TXA use, the incidence of thrombotic events has remained stable. Within the constraints of the small rate of adverse events in this large cohort, there is no evidence to suggest harm following TXA treatment.TXA is more likely to be given in those aged 12–15 years. This may be explained by different trauma patterns, with road traffic accidents and penetrating injuries more common in older children. Administration of blood products and ICU admission were strongly associated with administration of TXA. Further analyses of change over time are ongoing for secondary outcome analyses
An Unusual cause of Endocarditis Watkins, Rhys; Marincowitz, Carl; Locke, Thomas ...
BMJ case reports,
12/2022, Letnik:
15, Številka:
12
Journal Article
Recenzirano
A man in his 20s attended the emergency department with three days of fever, headache, reduced appetite and a sore throat. COVID-19 point-of-care test was negative. Blood cultures grew a ...gram-negative coccobacillus,
Following an episode of confusion, MRI head revealed septic emboli. Prolapse of the mitral valve with regurgitation was noted on echocardiography. Infection was found to have originated from multiple dental caries and treatment required a combination of dental extraction, prolonged antibiotic therapy and surgery for mitral valve repair.
is part of the normal oropharyngeal flora but is also a rare cause of endocarditis. There are no established treatment guidelines for endocarditis of this aetiology.
endocarditis may present atypically, with a murmur only developing several days later. 'Classical' stigmata should not be relied on to make a diagnosis.
predominantly affects the left side of the heart and predisposes to embolic events.
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