Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury

Context  Current use of cranial computed tomography (CT) for minor head injury is increasing rapidly, highly variable, and inefficient. The Canadian CT Head Rule (CCHR) and New Orleans Criteria (NOC) are previously developed clinical decision rules to guide CT use for patients with minor head injury and with Glasgow Coma Scale (GCS) scores of 13 to 15 for the CCHR and a score of 15 for the NOC. However, uncertainty about the clinical performance of these rules exists. Objective  To compare the clinical performance of these 2 decision rules for detecting the need for neurosurgical intervention and clinically important brain injury. Design, Setting, and Patients  In a prospective cohort study (June 2000-December 2002) that included 9 emergency departments in large Canadian community and university hospitals, the CCHR was evaluated in a convenience sample of 2707 adults who presented to the emergency department with blunt head trauma resulting in witnessed loss of consciousness, disorientation, or definite amnesia and a GCS score of 13 to 15. The CCHR and NOC were compared in a subgroup of 1822 adults with minor head injury and GCS score of 15. Main Outcome Measures  Neurosurgical intervention and clinically important brain injury evaluated by CT and a structured follow-up telephone interview. Results  Among 1822 patients with GCS score of 15, 8 (0.4%) required neurosurgical intervention and 97 (5.3%) had clinically important brain injury. The NOC and the CCHR both had 100% sensitivity but the CCHR was more specific (76.3% vs 12.1%, P<.001) for predicting need for neurosurgical intervention. For clinically important brain injury, the CCHR and the NOC had similar sensitivity (100% vs 100%; 95% confidence interval [CI], 96%-100%) but the CCHR was more specific (50.6% vs 12.7%, P<.001), and would result in lower CT rates (52.1% vs 88.0%, P<.001). The values for physician interpretation of the rules, CCHR vs NOC, were 0.85 vs 0.47. Physicians misinterpreted the rules as not requiring imaging for 4.0% of patients according to CCHR and 5.5% according to NOC (P = .04). Among all 2707 patients with a GCS score of 13 to 15, the CCHR had sensitivities of 100% (95% CI, 91%-100%) for 41 patients requiring neurosurgical intervention and 100% (95% CI, 98%-100%) for 231 patients with clinically important brain injury. Conclusion  For patients with minor head injury and GCS score of 15, the CCHR and the NOC have equivalent high sensitivities for need for neurosurgical intervention and clinically important brain injury, but the CCHR has higher specificity for important clinical outcomes than does the NOC, and its use may result in reduced imaging rates.      

Diphenylhydantoinate-induced hyperplasia of the masticatory mucosa in an edentulous epileptic patient.

Gingival hyperplasia caused by phenytoin sodium is rarely encountered in edentulous persons. A case of generalized palatal hyperplasia is reported in which retained roots and teeth were suspected of having perpetuated a preextraction lesion, whereas a subsequently placed complete denture initiated a midpalatal hyperplasia. The lesion remained in spite of nonuse of the denture for several years.     

Lung retrieval from non-heart-beating donors: first experience with an innovative preservation strategy in a pig lung transplantation model

OBJECTIVE: Lung transplantation is limited by the scarcity of donor organs. Lung retrieval from non-heart-beating donors (NHBD) might extend the donor pool and has been reported recently. However, no studies in NHBD exist using the novel approach of retrograde preservation with Perfadex solution. METHODS: Heparinized asystolic pigs (n = 5, 30-35 kg) were ventilated for 90 min. The lungs were retrogradely preserved with Perfadex solution and stored inflated at 4 degrees C for 3 h. Left lung transplantation in the recipient was followed by exclusion of the right lung. Results were compared to sham-operated animals. Oxygenation, hemodynamics and dynamic compliance were monitored for 4 h. Infiltration of polymorphonuclear cells (PMNs) and stereological quantification of alveolar edema was performed. Statistical analysis comprised Kruskal-Wallis and Mann-Whitney tests and ANOVA analysis with repeated measures. RESULTS: No mortality was observed. During preservation, continuous elimination of blood clots via the pulmonary artery venting site was observed. Oxygenation and compliance were similar between groups, but sham controls showed significantly lower pulmonary vascular resistance. Stereological quantification revealed higher volume fractions of intra-alveolar edema in NHBD grafts, while PMN infiltration was comparable to sham controls. CONCLUSIONS: Use of NHBD lungs results in excellent outcome after 90 min of warm ischemia followed by retrograde preservation with Perfadex solution. This novel approach can optimize lung preservation by eliminating clots from the pulmonary circulation and might clinically be considered in brain-dead organ donors who become hemodynamically unstable prior to organ harvest. Further trials with longer warm and cold ischemic periods are necessary to further elucidate this promising approach to donor pool expansion.     

Direct and indirect autofluorescence laryngoscopy in the diagnosis of laryngeal cancer and its precursor lesions

Autofluorescence endoscopy has proven to facilitate the detection and delineation of precancerous lesions, carcinoma in situ and microinvasive cancer during bronchoscopy. The aim of the present study is to evaluate the diagnostic potential and limitations of this imaging technique applied during direct and indirect laryngoscopy. In a prospective study, 109 patients with suspected precancerous or cancerous lesions were investigated preoperatively by indirect autofluorescence laryngoscopy as well as during microlaryngoscopy. Autofluorescence was induced by filtered blue light (375-440 nm) of a xenon short arc lamp and processed by a CCD camera system (D-light-AF System, Storz, Tuttlingen, Germany). Autofluorescence images were immediately assessed for diagnosis, compared to the direct autofluorescence picture obtained during microlaryngoscopy and compared with pathohistological findings. Comparable to direct autofluorescence images, normal laryngeal mucosa showed a typical green fluorescence signal. Moderate and high epithelial dysplasia, carcinoma in situ, and microinvasive cancer displayed a diminished green fluorescence. False negative results were related to extreme hyperkeratosis. False positive cases showed mild dysplasia with inflammatory reactions or scarring. In 98 cases (90%) we found concordant results. According to our results, the presented technique seems to be a promising diagnostic tool for the early detection of laryngeal cancer and its precursor lesions during direct and indirect laryngoscopy. Scarring, marked hyperkeratosis, and inflammation can limit the predictive value of the method.