Blunt carotid artery injury: the futility of aggressive screening and diagnosis

BACKGROUND: Blunt carotid artery injury (BCI) remains a rare but potentially lethal condition. Recent studies recommend that aggressive screening based on broad criteria (hyperextension-hyperflexion mechanism of injury, basilar skull fracture, cervical spine injury, midface fracture, mandibular fracture, diffuse axonal brain injury, and neck seat-belt sign) increases the rate of diagnosis of BCI by 9-fold. If this recommendation becomes a standard of care, it will require a major consumption of resources and may give rise to liability claims. The benefits of aggressive screening are unclear because the natural history of asymptomatic BCI is unknown and the existing treatments are controversial. HYPOTHESIS: The lack of an aggressive angiographic screening protocol does not result in delayed BCI diagnosis or BCI-related neurologic deficits. METHODS: A 10-year medical record review of patients with BCI was undertaken in 2 level I academic trauma centers. In both centers, urgent screening for BCI was performed in patients with focal neurologic signs or neurologic symptoms unexplainable by results of computed tomography of the brain as well as in selected patients undergoing angiography for another reason. RESULTS: Of 35 212 blunt trauma admissions, 17 patients (0.05%) were diagnosed as having BCI. Six showed no evidence of BCI-related neurologic symptoms during hospitalization or prior to death as a result of associated injuries. Eleven sustained a BCI-related stroke, 9 of whom had it within 2 hours of injury. The remaining 2 had a delayed diagnosis (9 and 12 hours after injury) and received only anticoagulation because the lesions were surgically inaccessible. Just 1 of these 2 patients met the criteria for BCI screening and could have been offered earlier treatment, of uncertain benefit, if we had adopted an aggressive screening policy. CONCLUSIONS: Of the few patients with BCI, most remain asymptomatic or develop neurologic deficits shortly after injury. Although a widely applied, resource-consuming screening program may increase the rate of early diagnosis of BCI, an improvement in outcome is uncertain. A cost-effectiveness analysis should be done before trauma surgeons accept an aggressive screening protocol as the standard of care.     

Comparison of image quality between conventional and low-dose nonenhanced head CT

BACKGROUND AND PURPOSE: Increasing use of CT for evaluating neurologic disease may expose patients to considerable levels of ionizing radiation. We compared the image quality of low-mAs head CT scans with that of conventional nonenhanced scans. METHODS: Conventional head CT scans were obtained in 20 patients (all >65 years with history of non-CNS malignancy) by using a multidetector technique: 170 mA and 1-second scanning time (ie, 170 mAs), 140 kVp, table speed of 7.5 mm per rotation, pitch of 0.75, section thickness of 5 mm, and field of view of 25 mm. A limited volume helical data acquisition covering four 5-mm-thick images was obtained by using 90 mAs but otherwise the same parameters. Three neuroradiologists visually rated the resulting images for quality in a blinded comparison. Representative 1- to 4-mm(2) regions of interest were chosen in gray matter and white matter locations. Conspicuity and the contrast-to-noise ratio were analyzed. Statistical comparisons were done by using the Student t test. RESULTS: Mean gray matter conspicuity was not significantly different between the 170- and 90-mAs groups (0.39 +/- 0.19 vs 0.41 +/- 0.03, P =.32). Mean gray matter contrast-to-noise ratio was approximately 22% higher with 170 mAs than with 90 mAs (1.77 +/- 0.52 vs 1.39 +/- 0.38, P =.005). All 90-mAs images were rated as having slightly greater image noise than the 170-mAs scans but with sufficient perceived resolution. CONCLUSION: Although 90-mAs head CT images were moderately noisier than 170-mAs images, they were rated as having acceptable diagnostic quality.     

Health care cost of analgesic use in hypertensive patients

BACKGROUND: Hypertension is one of the most frequently diagnosed chronic medical conditions in the United States and imposes a substantial financial and social burden on Americans. OBJECTIVE: The aim of this study was to compare the cost of health care resources for hypertensive patients taking analgesics stratified by having controlled versus uncontrolled hypertension. METHODS: This was a retrospective, database analysis of data for managed-care patients in Maryland and Washington, DC, recorded from February 1, 1999, to July 31, 2001. Hypertensive patients who were taking analgesics were stratified by their hypertension control status using a claims-based algorithm. Annualized costs and differences in annualized costs calculated for the periods before and after the initiation of analgesics were compared by patient hypertension control status. RESULTS: Of the 9805 patients in the study (mean [SD] age, 49.8 [12.04] years), 2523 (25.73%) were categorized as having uncontrolled hypertension. The mean total annualized costs differed significantly between the controlled and uncontrolled hypertension groups by 2568 dollars (P < 0.001). The annualized costs for emergency-department visits and hospitalizations for uncontrolled hypertensive patients exceeded those for controlled hypertensive patients by 9.3% and 28.0%, respectively. The differences between the postindex- and preindex-period costs for health care resources were 1972 dollars with controlled hypertension and 2961 dollars with uncontrolled hypertension (P < 0.001). The results of linear regression, after adjustments were made for preindex costs and other covariates, indicated that patients with uncontrolled hypertension had significantly increased billed annualized costs (P < 0.001). CONCLUSIONS: These data suggest that the costs of health care resources were significantly higher for analgesic users with uncontrolled hypertension than for analgesic users with controlled hypertension. A considerable proportion of the cost differential was directly attributable to hypertension-related treatment care.     

Was it necessary to add Bitrex (denatonium benzoate) to automotive products?

Oregon was the first state to mandate the addition of a bitter aversive agent to consumer automotive products containing > or = 10% ethylene glycol (EG) or > or = 4% methanol (MeOH). The 1995 Toxic Household Products statute required the addition of denatonium benzoate at a concentration of 30-50 ppm with the intent to reduce the frequency of serious pediatric exposures to these products. Retrospective review included Oregon Poison Center (OPC) records of all reported pediatric (< 6 y) exposures to automotive antifreeze (EG) and windshield washer fluid (MeOH) from 1987 through 2003, OPC charts of children treated with ethanol, fomepizole, or hemodialysis for EG or MeOH poisoning from 1987 through 2002, and coroner reports of poisoning deaths for 1994-1997 to identify EG or MeOH deaths not reported to the OPC. OPC recorded 332 EG and 117 MeOH exposures among preschool children from 1987-2003 with no change in annual frequency after 1995. No child died or suffered "major" effects before or after 1995. Ten children received ethanol infusions until laboratory results were available; 9 had no detectable concentration of the suspected agent, and 1 had a sub-toxic concentration. Two children received fomepizole but had no detectable EG. No child underwent hemodialysis. Coroner reports detected no missed pediatric deaths from toxic alcohols in 1994-1997. The mandatory addition of denatonium benzoate was unnecessary as unintentional ethylene glycol or methanol exposures in pre-school age children did not cause measurable toxicity.     

Sexual experience alters D1 receptor-mediated cyclic AMP production in the nucleus accumbens of female Syrian hamsters

Drugs of abuse produce long-term changes in dopamine neurotransmission and receptor-effected intracellular signaling. Similar changes in neuronal activity are mediated by motivated behaviors. To explore cellular mechanisms underlying these neuroadaptations following sexual experience, cyclic AMP accumulation following stimulation of D1 dopamine receptors, G-proteins, and adenylate cyclase was compared in the nucleus accumbens and caudate nucleus of sexually naive and experienced female hamsters following sexual behavior. Direct stimulation of adenylate cyclase with forskolin or indirectly by activation of G-proteins with Gpp(NH)p produced dose-dependent increases in the formation of cyclic AMP in the nucleus accumbens and caudate nucleus, with no effects of sexual experience on these measures. Specific D1 receptor stimulation increased Gpp(NH)p-induced adenylate cyclase activity in the nucleus accumbens and caudate nucleus of all animals. Interestingly, this stimulation was further enhanced only in membranes from the nucleus accumbens, but not from the caudate nucleus, of sexually experienced hamsters compared to the response of naive females. These results demonstrate that sexual behavior experience can sensitize mesolimbic dopamine pathways and that this sensitization occurs through an increase in D1 receptor-mediated signaling.     

The impact of motivational interviewing on substance abuse treatment retention: a randomized control trial of women involved with child welfare

Previous studies have supported the efficacy of Motivational Interviewing (MI) in increasing treatment engagement and retention among people with substance abuse disorders. However, few studies have assessed the impact of MI with coerced populations, particularly women referred to drug abuse treatment by child welfare due to prenatal drug use. Seventy-one such women who used drugs during pregnancy were randomly assigned to either receive three MI sessions or to watch two educational videos and participate in a home visit. Treatment retention group attendance and random urine analysis results were evaluated in these women during the first 8 weeks of treatment. No differences were found between the two conditions on these variables. Possible reasons for these negative findings are discussed, as are ideas for future research with coerced populations.     

Encouraging the consumption of fruit and vegetables by older Australians: an experiential study

OBJECTIVE: To explore perceptions of dietary recommendations for fruit and vegetables, and barriers and opportunities for increasing consumption. DESIGN: Qualitative study with an experiential component. SETTING: Older adults' households. PARTICIPANTS: Six focus groups with 38 Australian adults aged 50 to 64 years who reported low vegetable consumption. INTERVENTION: Week 1: focus group including demonstration of recommended fruit and vegetable servings; week 2: delivery of a week's supply of fruit and vegetables and recipes; week 3: follow-up focus group. VARIABLES MEASURED: Perceptions of a healthful diet, fruit and vegetable recommendations, barriers to consumption, and reactions to the food delivery and recipes. ANALYSIS: Qualitative, thematic analysis. RESULTS: Participants were unfamiliar with serving recommendations. Barriers to consumption were as follows: perceptions that vegetables are eaten only with evening meals, preference for eating meat, believing that recommended quantities were too big, and a lack of preparation time. The delivery had a positive impact on some (especially low fruit consumers), for whom the availability of appealing fruit served as a prompt for consumption. CONCLUSIONS AND IMPLICATIONS: Possible strategies for enabling consumers to achieve adequate fruit and vegetable consumption are education about the recommended number and size of servings and distribution of fruit and vegetables relative to meat and carbohydrates, encouragement to spread fruit and vegetable consumption over the day, and promoting the appealing sensory attributes of fruit and vegetables.