Outcome Prediction in Moderate and Severe Traumatic Brain Injury: A Focus on Computed Tomography Variables

Background

With this study we aimed to design validated outcome prediction models in moderate and severe traumatic brain injury (TBI) using demographic, clinical, and radiological parameters.

Methods

Seven hundred consecutive moderate or severe TBI patients were included in this observational prospective cohort study. After inclusion, clinical data were collected, initial head computed tomography (CT) scans were rated, and at 6 months outcome was determined using the extended Glasgow Outcome Scale. Multivariate binary logistic regression analysis was applied to evaluate the association between potential predictors and three different outcome endpoints. The prognostic models that resulted were externally validated in a national Dutch TBI cohort.

Results

In line with previous literature we identified age, pupil responses, Glasgow Coma Scale score and the occurrence of a hypotensive episode post-injury as predictors. Furthermore, several CT characteristics were associated with outcome; the aspect of the ambient cisterns being the most powerful. After external validation using Receiver Operating Characteristic (ROC) analysis our prediction models demonstrated adequate discriminative values, quantified by the area under the ROC curve, of 0.86 for death versus survival and 0.83 for unfavorable versus favorable outcome. Discriminative power was less for unfavorable outcome in survivors: 0.69.

Conclusions

Outcome prediction in moderate and severe TBI might be improved using the models that were designed in this study. However, conventional demographic, clinical and CT variables proved insufficient to predict disability in surviving patients. The information that can be derived from our prediction rules is important for the selection and stratification of patients recruited into clinical TBI trials.     

Intra-arterial thrombolysis in the carotid territory

Background: In patients who sustain abdominal trauma the liver is the most frequently injured organ. Although treatment for haemodynamically unstable patients remains urgent surgery, there has been a shift of management in haemodynamacally stable patients towards non-operative management. We performed an outcome assessment of traumatic hepatic injury.

Methods: A retrospective study was performed to assess incidence, mechanisms, management and outcome of traumatic liver injury in the region of ’s-Hertogenbosch, the Netherlands, in the period 1999–2007.

Results: A total of 47 patients were identified. Thirty-six patients had blunt hepatic trauma, eleven sustained penetrating hepatic injury. In 67% (n = 24) of the blunt hepatic trauma patients the initial intention was to treat non-operatively. Yet, two patients underwent explorative laparotomy after one and two days. In the penetrating liver trauma patients, 91% (n = 10) underwent urgent surgery. In total, 31 of 47 patients were treated conservatively.

Conclusion: Blunt hepatic trauma is the most common cause of hepatic trauma. Most patients sustaining hepatic trauma can be managed conservatively at a dedicated ICU and/or surgical trauma ward.     

Radiographic examination of apical extrusion of root canal irrigants during cavitation induced by Er,Cr:YSGG laser irradiation: an in vivo study

Objectives

The purpose of the present study was to test the hypothesis that apical extrusion of the irrigant occurs during laser-driven irrigation in vivo.

Materials and methods

Three hundred human root canals, in 181 patients, were divided into two groups: the no lesion group (n?=?140) and the lesion group (n?=?160). All the root canals were enlarged using a crown down technique up to size 30–80 K-files, depending on the original condition of the root canal. For the final irrigation, the teeth were irrigated with a mixture of radiopaque contrast medium and NaOCl in solution. The solution was activated for 60 s in teeth with one canal or two canals and for 120 s in teeth with three or four canals.

Results

Radiopaque contrast medium was absent from the periapical tissues of all samples.

Conclusions

No contrast medium was observed radiographically in the periapical tissues. The hypothesis that apical extrusion of root canal irrigants occur during laser cavitation was rejected

Clinical relevance

It appears that the power of the laser used at 1 W for 1–2 min can drive the irrigation solution to the tip of the canal without harming the apical tissues.     

Lack of long‐term clinical benefit of thrombus aspiration during primary percutaneous coronary intervention with paclitaxel‐eluting stents or bare‐metal stents: Post‐hoc analysis of the PASSION‐trial

Background : Although current clinical guidelines recommend the use of thrombus aspiration (TA) during primary percutaneous coronary intervention (PPCI), previous studies evaluating TA demonstrated contradictory results. The aim of this study was to evaluate long‐term clinical outcome after TA in adjunct to PPCI for acute ST‐segment myocardial infarction (STEMI), as compared with conventional treatment, with the use of paclitaxel‐eluting stents or bare‐metal stents. Methods : We analyzed data of the PASSION trial, in which 619 patients with STEMI were randomly assigned to a paclitaxel‐eluting stent or a bare‐metal stent. TA was performed in 311 patients (50.2%). Clinical endpoints at 2 years were compared between patients who received TA during PPCI with patients who underwent conventional PPCI. The primary outcome of interest was a composite of cardiac death, recurrent myocardial infarction (MI), or target‐lesion revascularization (TLR). A propensity score model was made to account for baseline differences that could have affected the probability of performing TA. Results : Complete follow‐up was available for 598 patients (96.6%). The cumulative incidence of the combined outcome measure of cardiac death, recurrent MI, or TLR was 40 (13.0%) in the TA group and 41 (13.5%) in the conventional PPCI group (HR 0.96; 95% CI 0.62–1.47; P = 0.84). Also after adjusting for propensity score, no significant difference in event rate was observed between both treatment groups. Conclusions : In this post‐hoc analysis of the PASSION trial, TA in adjunct to PPCI did not affect rates of major adverse cardiac events at 2 years follow‐up, as compared with conventional PPCI. © 2011 Wiley Periodicals, Inc.