Diagnosis and management of paediatric concussion

Heightened recognition of concussions and concerns about their sequelae in children has become an increasing community and public health concern. Biomarkers and clinical tests are being explored, but the diagnosis of concussion in the emergency department continues to be based on clinical signs and symptoms. While the majority of children go on to recover from post‐concussive symptoms within 2 weeks, it is unclear which patients with concussion will go on to develop short‐ or long‐term sequelae. A number of more or less evidence‐based guidelines have become available which seek to guide clinicians on how to manage children post‐concussion. In general, care after the emergency department is focused on reducing the risk of re‐injury and rest until cerebral recovery with a graduated return to school and then play.     

Influence of circadian rhythm on mortality after myocardial infarction: data from a prospective cohort of emergency calls

Myocardial infarction (MI) occurs more frequently in the morning as a result of the concomitant unfavorable timing of several physiological parameters and/or biochemical conditions. However, little is known about the possible influence of this circadian pattern on prognosis. To evaluate whether the time of symptom onset could potentially influence mortality from acute MI, this prospective study considered all consecutive MIs admitted to the ED of Ferrara, Italy, after a call to the Emergency Coordinating Unit from January 1, 1998, to December 31, 2001. The total sample consisted of 442 MIs (mean age, 68.7 years; males, 72%). Eighty patients (males, 82.5%) died in the ED; the remaining 362 were admitted to the hospital. Of these, 50 (males, 60%) died during their hospital stay. Based on the timing of their symptom onset, cases were categorized both into 24 1-hour intervals and four 6-hour intervals (midnight to 5:59 am, 6:00 am to 11:59 am, noon to 5:59 pm, and 6:00 pm to 11:59 pm), and the circadian distributions of fatal versus nonfatal MIs were compared. The circadian variation of MI peaked between 6:00 am and noon (P < .001), and in this period, there was a trend toward a higher frequency of fatal cases (41.5% vs. 35.2%; chi(2) = 1.911, P = .167). To verify whether this higher frequency of fatal events in the morning hours could be related to possible higher severity of cases observed in that hours, a further separate analysis considering age, infarct site, and peak levels of MB was made. Again, no significant temporal differences among the four 6-hour intervals were found between fatal and nonfatal Mis, although a trend toward older age was observed in morning MIs. Not only the frequency, but also the mortality, of acute MI could be increased in the morning hours. This could be of practical interest for emergency doctors and could have significant implications for acute treatment, because several studies have reported a lowered efficacy of thrombolytic drugs in the morning hours.     

Intra-articular Chlamydial Antigen and Inflammatory Arthritis

Joint material from 133 patients with well-characterized inflammatoryarthritis, including individuals likely to have suffered reactivearthiritis, was studied. The majority of patients were alsoexamined for the presence of genital tract infection with Chlamydiatrachomatis. Fluorescein-conjugated monoclonal antibodies demonstratedthe presence of C. trachomatis antigen in synovial fluid celldeposits or synovial sections from inflamed knee joints of sevenpatients with reactive arthritis. The significance of thesefindings is discussed, as is the low rate of detection of chlamydialantigen in either the genital tract or the joint from patientsin this study. We emphasize the need for further work aimedat identifying the relevant immunogenic chlamydial antigensresponsible for the initiation of reactive arthritis.