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Background The effect of pre-injury antiplatelet treatment in the risk of intracranial lesions in subjects after mild head injury (Glasgow Coma Scale (GCS) 14–15) is uncertain. Methods The potential risk was determined, considering its increasing use in guidelines on cardiovascular disease prevention, and ageing of the trauma population in Europe. Patients The interaction of antiplatelet therapy with the prediction variables of main decision aids was analysed in 14 288 consecutive adolescent and adult subjects with mild head injury. Measurements Any intracranial lesion at CT scan was selected as an outcome measure in a multivariable logistic regression analysis. Results Intracranial lesions were demonstrated in 880 cases (6.2%), with an unfavourable outcome at 6 months in 86 (0.6%). Antiplatelet drugs were recorded in 10% of the entire cohort (24.7% in the group over 65 years). They increased the risk of intracranial lesions in the univariate analysis (OR 2.6; 95% CI 2.2 to 3.1), interacting with age in the multivariate analysis (antiplatelet OR 2.7 (1.9 to 3.7); age ≥75 years 1.4 (1.0 to 1.9)). The inclusion of these two variables with those included in previous decision aids for CT scanning (GCS, neurodeficit, post-traumatic seizures, suspected skull fracture, vomiting, loss of consciousness, coagulopathy) predicted intracranial lesions with a sensitivity of 99.7% (95% CI 98.9 to 99.8) and a specificity of 54.0% (95% CI 53.1 to 54.8), with a CT ordering rate of 49.3% (undetermined events 0.2:1000). Interpretation Antiplatelet drugs need to be considered in future prediction models on mild head injury, considering their increasing use and progressive ageing of the trauma population.

The model of care for patients with mild-to-moderate head injury and CT-detected lesions that do not require an immediate intervention is a matter of debate. This study compared the effects on outcome of a model based either on observation in a neurosurgical unit (NSU) or in a peripheral hospital (PH), making use of neurosurgical expertise via a teleradiology system.The investigation reviewed the data that was prospectively collected in 865 cases with mild-to-moderate head injury and positive CT scan, not needing immediate neurosurgical evacuation. Outcome was determined at 6 months. The predictive value of location of observation on outcome was evaluated by logistic regression, after adjustment for the propensity score to the type of observation (calculated on main entry variables).700 subjects had a mild head injury, 105 had a moderate injury with GCS 13-11 and 60 with Glasgow Coma Scale (GCS) 10-9. Only 152/865 subjects (17.6%) were admitted to a NSU. During observation, neurosurgery was necessary in 117 cases (13.5%), 74/152 (48.7%) NSU-observed patients and 43/713 (6.0%; p0.001) PH-observed cases. The outcome was unfavourable in 18% of the NSU cases versus 10% of the PH cases (p = 0.143). After correction for propensity, no significant differences were found between models of observation (NSU vs. PH; odds ratio, 0.92; 95% confidence interval, 0.49 to 1.75).A model of care based on observation in PH with neurosurgical consult by teleradiology system, repeat CT scanning and transfer time 30-60 min to a NSU is not detrimental for subjects with initial non-neurosurgical lesions after mild-to-moderate head injury.

Background: Subjects with moderate head injury are a particular challenge for the emergency physician. They represent a heterogeneous population of subjects with large variability in injury severity, clinical course and outcome. We aimed to determine the early predictors of outcome of subjects with moderate head injury admitted to an Emergency Department (ED) of a general hospital linked via telemedicine to the Regional Neurosurgical Centre. Patients and methods: We reviewed, prospectively, 12 675 subjects attending the ED of a General Hospital between 1999 and 2005 for head injury. A total of 309 cases (2.4%) with an admission Glasgow Coma Scale (GCS) 9–13 were identified as having moderate head injury. The main outcome measure was an unfavourable outcome at 6 months after injury. The predictive value of a model based on main entry variables was evaluated by logistic regression analysis. Findings: 64.7% of subjects had a computed tomographic scan that was positive for intracranial injury, 16.5% needed a neurosurgical intervention, 14.6% had an unfavourable outcome at 6 months (death, permanent vegetative state, permanent severe disability). Six variables (basal skull fracture, subarachnoid haemorrhage, coagulopathy, subdural haematoma, modified Marshall category and GCS) predicted an unfavourable outcome at 6 months. This combination of variables predicts the 6-month outcome with high sensitivity (95.6%) and specificity (86.0%). Interpretation: A group of selected variables proves highly accurate in the prediction of unfavourable outcome at 6 months, when applied to subjects admitted to an ED of a General Hospital with moderate head injury.

A male patient with portal hypertension, portal vein thrombosis, spontaneous splenorenal shunt formation, and encephalopathy, thought to have post-hepatitis B cirrhosis, is described. His condition deteriorated and necessitated liver transplantation. In the explant liver, nodular regenerative hyperplasia with pronounced vascular lesions both in portal venules and in arterioles was found instead of classical cirrhosis. Two years post-transplant he developed bilateral ischaemic femur head necrosis. The three disorders (portal vein thrombosis, nodular regenerative hyperplasia, and ischaemic hip necrosis) seemed to be due to a common vasculopathy induced by hyperhomocyteinaemia. Genetic studies showed that he carried a mutation in the gene encoding for formation of methylenetetrahydrofolate reductase. Treatment with folic acid combined with pyridoxine (vitamin B6) and cyanocobalamin (vitamin B12) normalised his serum homocysteine levels.