Mandatory admission after isolated mild closed head injury in children: is it necessary?

BACKGROUND/PURPOSE: Children with closed head injuries diagnosed as concussion alone or concussion with brief loss of consciousness are admitted routinely for observation despite a normal central nervous system finding, negative computed tomography (CT) scan, and a Glasgow Coma Score (GCS) of 15. Recent studies have questioned the necessity of such an admission. The purpose of this study was to review a large pediatric database and study the length of stay as well as any required procedures or complications in these children. The hypothesis was that routine admission is unnecessary in this population. METHODS: The National Pediatric Trauma Registry-Phase II was reviewed for the period from October 1988 to January 1996. Entry criteria included age less than 18 and an isolated closed head injury after blunt trauma with an admission GCS of 15. Variables studied included age, gender, mechanism of injury, length of stay, procedures, and outcome. RESULTS: A total of 1,033 children met criteria for this study. The average age was 8.3 years. Males predominated at 61.9%. Falls, sports, and motor vehicle crashes were the most common mechanisms of injury. The average length of stay was 1.19 days, and 60 children were not admitted. A total of 583 children had no procedures performed, whereas 386 received a CT scan, and 148 had x-rays. None required neurosurgical intervention, and all were discharged alive. CONCLUSION: These findings indicate that routine admission may not be necessary for children with isolated mild closed head injuries with a negative CT scan and a normal neurologic finding and allows for a prospective randomized trial to confirm this.     

Intrathoracic humeral head fracture-dislocation: is removal of the humeral head necessary?

Intrathoracic fracture dislocation of the humeral head due to a blunt trauma is very rare. It may be accompanied by local and systemic injuries associated with high-energy trauma. Because a limited number of cases were reported, appropriate treatment modality remains unclear. A case of intrathoracic humeral head fracture-dislocation caused by a high-speed motor vehicle accident is presented herewith, along with the treatment methods used within the scope of the current literature.     

Lower urinary tract injury: is urology consultation necessary?

International Urology and Nephrology - There is a paucity of data regarding urology involvement in the management of lower urinary tract injuries (LUTI). We seek to analyze the incidence and...     

Lung biopsy: is it necessary?

OBJECTIVE: Lung biopsy is associated with substantial mortality rates. We reviewed our experience with this operation, primarily in patients with immunocompetence, to determine whether the results justify the continued performance of this procedure. METHODS: We conducted a retrospective review of all diagnostic lung biopsies performed at 3 university-affiliated hospitals between July 1, 1992, and December 31, 1998. RESULTS: There were 75 patients: 25 patients were treated electively, 17 were treated on an urgent basis, 27 patients on an emergency basis, and the urgency was unclear in 6 patients. Significant beneficial therapeutic changes were made in 15 of 25 elective procedures (60%), in 16 of 17 urgent procedures (94%), and in 11 of 27 emergency procedures (41%; P =.001). Significant beneficial therapeutic changes consisted of immunosuppression in 13 of 15 (87%) patients treated on an elective basis, in 9 of 16 (56%) treated on an urgent basis, and in 9 of 11 (82%) treated on an emergency basis in whom therapy was altered (P =.14). Operative death was 0 of 25 for elective operations (0%), 3 of 17 for urgent operations (18%), and 14 of 26 for emergency operations (54%). Multivariable analysis of operative death showed urgency to be the only significant predictor of death (P =.002). CONCLUSIONS: In patients with immunocompetence, elective and urgent lung biopsies have acceptable operative mortality rates and frequently result in important beneficial therapeutic changes. Consequently biopsies are appropriate in these patients. Emergency biopsies are associated with high operative mortality rates and rarely result in a therapeutic change other than immunosuppression. These patients should not undergo lung biopsy if they are in stable condition and should be treated empirically with immunosuppression without operation if their condition is deteriorating.     

Comminuted fractures of the radial head and neck: is fixation to the shaft necessary?

Mason type III fractures of the radial head are treated by open reduction and internal fixation, resection or prosthetic joint replacement. When internal fixation is performed, fixation of the radial head to the shaft is difficult and implant-related complications are common. Furthermore, problems of devascularisation of the radial head can result from fixation of the plate to the radial neck. In a small retrospective study, the treatment of Mason type III fractures with fixation of the radial neck in 13 cases (group 2) was compared with 12 cases where no fixation was performed (group 1). The mean clinical and radiological follow-up was four years (1 to 9). The Broberg-Morrey index showed excellent results in both groups. Degenerative radiological changes were seen more frequently in group 2, and removal of the implant was necessary in seven of 13 cases. Post-operative evaluation of these two different techniques revealed similar ranges of movement and functional scores. We propose that anatomical reconstruction of the radial head without metalwork fixation to the neck is preferable, and the outcome is the same as that achieved with the conventional technique. In addition degenerative changes of the elbow joint may develop less frequently, and implant removal is not necessary.     

Informed consent: is it always necessary?

Informed consent plays a pivotal role in human clinical research. It serves as a marker for the subject's comprehension of all the pertinent elements of the study. It is also a pledge by the investigator that during the trial, the rights and safety of the subject will be protected. Informed consent attempts to ensure that ethical behaviour will be upheld throughout the study. However, obtaining informed consent from certain vulnerable populations is a challenge, and thus warrants improvement. While informed consent is mandated for almost all clinical trial involving human subjects, there are situations of emergency research and trials with minimal risk that call for a waiver of the consent.     

Annual mammography screening: is it necessary?

Recent recommendations from the U.S. Preventative Services Task Force suggest that screening mammography for women should be biennial starting at age 50 years and continue to age 74 years. With these recommendations in mind, we proposed a study to evaluate women at our institution in whom breast cancer is diagnosed within 1 year of a previously benign mammogram. A retrospective chart review was performed over a 4-year period. Only patients who had both diagnostic mammograms and previous mammograms performed at our institution and a pathologic diagnosis of breast cancer were included. Benign mammograms were defined as either Breast Imaging Reporting And Data System 1 or 2. Analysis of the time elapse between benign mammogram and subsequent mammogram indicative of the diagnosis of breast cancer was performed. A total of 205 patients were included. The average age was 64 years. From our results, 48 patients, 23 per cent of the total, had a documented benign mammogram at 12 months or less before a breast cancer diagnosis. One hundred forty-three (70%) patients had a benign mammogram at 18 months or less prior. This study raises concern that 2 years between screening mammograms may delay diagnosis and possible treatment options for many women.     

What works in severe head injury?

Traumatic brain injury has an important socioeconomic impact in industrialized countries. However, well-conducted clinical trials are rare. Case-control studies have shown that prevention works. Pathophysiological understanding is becoming more complete as data on chemokines, local brain tissue oxygen tension and hypothermia accumulate. Multimodality monitoring will certainly assume greater importance in the future. Research with targeted therapeutic strategies indicates that secondary ischaemic insults can be prevented. Specific subgroups of patients with traumatic brain injury who will benefit from the use of hypothermia and barbiturates have been identified. Enteral feeding is the preferred nutritional strategy, and the follow-up period should be extended beyond the traditional 1 year.     

Surgery for appendicitis: is it necessary?

ABSTRACT Background: Appendectomy for acute appendicitis is an effective, universally accepted procedure performed more than 300,000 times annually in the United States. It is generally believed that appendicitis progresses invariably from early inflammation to later gangrene and perforation, and that appendectomy is required for surgical source control. Although non-operative management with antibiotics of uncomplicated diverticulitis, salpingitis, and neonatal enterocolitis is now established, the non-operative management of appendicitis remains largely unexplored. Methods: Systematic review of published literature and derived expert opinion. Results: Clinical, epidemiologic, radiologic, and pathologic evidence is presented for spontaneous resolution of uncomplicated acute appendicitis. The pathogenesis of appendicitis is reviewed with specific consideration of the role of bacterial infection in the pathogenesis. Evidence is also provided documenting the clinical success of non-operative management. Conclusions: Appendectomy may not be necessary for the majority of patients with acute uncomplicated appendicitis, as many patients resolve spontaneously and others may be treatable with antibiotics alone. However, the supporting documentation is scant and of poor quality. A randomized, prospective trial of non-operative management versus early appendectomy of acute uncomplicated appendicitis corroborated by radiologic imaging is called for.     

Escalation therapy in severe traumatic brain injury: how long is intracranial pressure monitoring necessary?

Neurosurgical Review - Traumatic brain injury frequently causes an elevation of intracranial pressure (ICP) that could lead to reduction of cerebral perfusion pressure and cause brain ischemia....     

Morbidity of urodynamic testing in patients with spinal cord injury: is antibiotic prophylaxis necessary?

STUDY DESIGN: Prospective, non-randomized study. OBJECTIVES: To assess the incidence of urinary tract infection after urodynamics in patients with spinal cord injury. SETTING: Outpatient clinic of a university hospital in Germany. METHODS: Urinary tract infection and clinical symptoms in 109 consecutive outpatients with spinal cord injury following urodynamic evaluation were studied. RESULTS: Data from 72 patients were evaluable. Of these, seven patients (9.7%) developed a significant urinary tract infection. Five of these were symptomatic. Pre-existing asymptomatic bacteriuria was not associated with a higher risk for post-interventional infection. The technique of the bladder management did not correlate with urinary tract infection rates. CONCLUSION: In this study, symptomatic urinary tract infections after cystometry were not infrequent. Therefore, it seems that antibiotic prophylaxis cannot be omitted in patients with spinal cord injury undergoing urodynamic investigation.     

Ovarian torsion in children: is oophorectomy necessary?

Background

Most pediatric surgeons perform oophorectomy in girls presenting with ovarian torsion in which the ovary appears necrotic. However, the adult gynecology literature suggests that many ovaries can be treated by detorsion alone.

Methods

All children with ovarian torsion on the gynecology and general surgery services between 1988 and 2002 were reviewed.

Results

There were 36 torsions in 34 children. Seventeen underwent detorsion with or without ovarian cystectomy, and 19 had oophorectomy (mean age 10 years in both groups). Torsion was suspected preoperatively in 94% of the detorsion cases and in 47% of the oophorectomy patients. Median time from presentation to surgery was significantly lower in the detorsion than the oophorectomy group (median 14 v 27 hours; P = .04). Postoperative complications and length of stay were similar between the 2 groups. Despite the ovary being judged intraoperatively as moderately to severely ischemic in 53% of the detorsion cases, follow-up sonogram or ovarian biopsy available in 14 of the 17 cases showed normal ovary with follicular development in each case.

Conclusions

Simple detorsion was not accompanied by an increase in morbidity, and all patients studied had functioning ovarian tissue on follow-up despite the surgeon’s assessment of the degree of ovarian ischemia. Detorsion is the procedure of choice for most cases of ovarian torsion in children.