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Introduction and aim. Computed tomography (CT) is the first imaging modality in the evaluation of children in case of patients with head injury in pediatric Emergency Departments (EDs). Radiological CT reports include not only lesions that are the main cause of the child's complaints but also incidental findings. The objective of this study is to assess incidental findings observed in children who were admitted to the ED and had the head CT performed. Material and methods. This retrospective, cross-sectional study enrolled 644 children under the age of 18, from 1st January 2021 to 31st June 2021. Each child could have had one or more incidental findings in CT Results. Among all CT studies, incidental findings were found in 279 out of 644 (43.32%) cases, of which 73 (11.34%) had both lesions detected incidentally and related to the trauma. Conclusion. Head CT is an incredibly useful tool in the assessment of some head emergencies. However, evaluation of the prevalence of incidental findings is difficult. Most of them require no specific further investigation. Pediatricians, who order CTs in children, must be prepared to interpret and communicate findings to families and introduce treatment in necessary situations. [ABSTRACT FROM AUTHOR]

Background: Child abuse represents an important issue in the medico-legal and social context. In the last few decades, various aspects and mechanisms have been identified in child abuse case studies; however, constant research is needed in the field. With this paper, the authors will present a case of a new entity of Abusive Head Trauma that has come to the attention of medico-legal experts. Discussion: The trauma analysis performed on the cranio-encephalic district of the baby revealed quite peculiar lesions that led the authors to exclude that the injuries had been solely caused by violent shaking of the baby's head, as suggested by Shaken Baby Syndrome. Instead, the authors hypothesised that another lesion mechanism had been added to this one, namely latero-lateral cranial compression. The comprehensive and exhaustive analysis of the case led the authors to present a new possible entity in child abuse trauma, namely 'Compressed Baby Head'. Conclusions: To the best of our knowledge, in the current literature, no similar clinical cases have ever been described. Thus, the case's uniqueness deserves to be brought to the attention of experts and the entire scientific community, as well as medical personnel, paediatricians, and reanimators. These professional figures are the first individuals who may encounter complex clinical cases such as the one presented in this paper; thus, they need to know how to properly manage the case and ensure protection for the abused infants and children. [ABSTRACT FROM AUTHOR]

In order to assess the value of magnetic resonance imaging (MRI) and diffusion tensor imaging (DTI) in microscopic brain scans. Diffusion tensor imaging (DTI) and magnetic resonance spectroscopy (MRI) changes over time in patients with traumatic brain injury (TBI) show a relationship between recovery from coma and overall Glasgow prognostic parameters. The value of DTI combined with MRI in evaluating TBI has been investigated. 10 patients with TBI received 10 evaluations of magnetic resonance imaging, DTI and MRI scans. Thalamic plate nucleus, reticular nucleus, and retinal developmental activity were measured in normal controls and TBI coma (2-3 weeks) and mild (>4 weeks) patients. Anisotropy, mean diffusion coefficient, axial diffusion coefficient, and radial diffusion coefficient were measured using MRI together with acetylaspartic acid, choline, creatinine, and lactic acid. Independent control t-tests were conducted between controls and TBI patients, and 1-test paired between moderate and severe injuries, and regression and correlation were evaluated. Evaluated for all measures and treatments. DTI and MRI scores in TBI patients differed from normal controls. DTI and MRI can predict the prognosis of TBI patients better. The limitations of the thalamus-retinal activation system are gradually restored. axial diffusion coefficient and radial diffusion coefficient can be used to evaluate the reliability of comatose patients with TBI. DTI and MRI scans of the patient's brain can predict recovery and guide treatment in TBI coma patients. [ABSTRACT FROM AUTHOR]

Self-efficacy (SE) can affect athletic training students' progression during their professional education and transition to autonomous clinical practice. It is unclear how course delivery may affect athletic training students' SE in various injury evaluation courses. Determine the relationship of course delivery modality and athletic training students' injury evaluation SE. Cross-sectional investigation. Web-based survey. Ninety-five noncertified National Athletic Trainers' Association student members (38/95 undergraduate athletic training students; 57/95 graduate athletic training students). A 2-part survey including participant characteristic questions and piloted adapted General Self Efficacy (GSE) scales were distributed using the National Athletic Trainers' Association's Research Survey Service. The adapted GSE scales asked participants to rate their agreeance from 1 (not at all true) to 4 (exactly true) for 10 statements focused on injury evaluations in 6 areas. Descriptive statistics were calculated, and nonparametric tests were used to determine the differences in GSE scores based on course delivery modality (online model, hybrid model, and traditional face-to-face model). Measures of central tendencies were also calculated. Only completed surveys (66.4%; 95/143) were included in the analysis (access rate = 14.3%). A significant difference existed between course delivery modality and upper extremity GSE scores (P =.001). No significant differences were found between GSE scores for courses with delivery modalities affected or not affected by the COVID-19 pandemic as well as between athletic training students who had or did not have previous online or hybrid course experiences. As health care education continues to shift toward technology-rich environments, educators can consider offering courses through various delivery modalities to promote didactic and clinical education. However, consideration of the content area and difficulty may be warranted while purposefully planning courses to best address learning objectives and students' SE. [ABSTRACT FROM AUTHOR]

The term "shaken baby syndrome" has been replaced by "abusive head trauma (AHT)" based on the mechanism of injury. The reported mortality rate of AHT ranges from 10% to 30%. Up to two-thirds of survivors suffer from serious long-term disabilities. Thus, an expeditious and accurate diagnosis is crucial to prevent further abuse that might result in death or serious disabilities. It remains a challenge for physicians to diagnose AHT when parents do not give a history of trauma in preverbal infants without any external signs. Here, we report a case of a 14-day-old boy who presented with a febrile convulsion without evident external injuries nor history of trauma according to his parents. He was diagnosed with AHT based on MRI findings of subacute subdural hemorrhage, multiple cortical hemorrhages, cerebral edema, and diffuse axonal injury. In conclusion, health care providers should keep in mind that the history of trauma provided by the parents or caregivers might not always be true and that reasonable suspicion of abuse is the most important in the diagnosis of AHT, although neuroimaging plays a pivotal role. Reasonable suspicion of AHT in combination with a thorough physical examination, neuroimaging, and skilled neuroradiologist can improve diagnosis and help victims in a timely manner. [ABSTRACT FROM AUTHOR]

Aims: The aim was to analyze the homicide pattern in South Kerala from autopsies conducted between 2002 and 2016. Objectives: Exploring the age and gender distribution of death due to homicide, the type and distribution of injuries according to the region of the body, and trends of homicide. We also tried to study the pattern of defense wounds in homicidal cases and characteristics in dyadic deaths (homicide-suicide). Materials and Methods: It was a retrospective descriptive study. The setting was the Department of Forensic Medicine, State Medico-Legal Institute, Government Medical College (GMC), Thiruvananthapuram. All cases of autopsies with an alleged history of homicide, between 2002 and 2016, done at Mortuary of GMC, Thiruvananthapuram, were included in the study. Records of all cases of an alleged history of homicide from January 1, 2002 to December 31, 2016 were perused. Results: 957 cases were analyzed. The annual incidence of homicide is declining after 2012. Young adult males (31-40 years) are the most common group involved (24.97%). Head injury was the most common cause of death (43.68%). The head was the most common area to be affected in fatal blunt force injuries (49%) while the chest was involved commonly in fatal sharp force injuries (36%). Females were more often the homicide victims in murder-suicides. Husband-wife and father-child combination was the most common pairs in dyadic deaths. Conclusion: The characteristics which were associated with the homicides were generally in agreement with the existing forensic literature. The findings encourage examining the motives of homicide and potential sociocultural factors affecting the victims and possibly the assailants. We also found that the murder-suicide cases differed from the homicides requiring a separate domain of understanding and subsequent investigations. [ABSTRACT FROM AUTHOR]

Background: This study aimed to examine the characteristics of older adults patients who suffered a head injury after a ground-level fall in comparison to non-head injury patients as well as the factors associated with severity in those with head injury only.Methods: Patients were classified into two groups, the head injury group and the non-head injury group. The characteristics were compared and factors associated with head injury were evaluated. Factors relating to severe injury in the head injury group were also investigated.Results: The head injury group comprised 42 % of a study subjects. Male sex; fall time of 18:00-23:59; fall location of medical facility, transportation area, and public or commercial facility; fall in an outdoor area; fall during daily activity; alcohol ingestion; fall from stairs; non-slippery floor conditions; concrete flooring; sloped flooring; and presence of obstacles on the floor were risk factors for head injury in the older adults after a ground-level fall. Male sex and age over 70 years; fall time of 00:00-05:59; fall in a residential facility; fall in an indoor area; fall during daily activity; fall from stairs; non-slippery floor conditions; and presence of obstacles on the floor were factors associated with severe injury in the head injury group.Conclusions: Male sex with advanced age, indoor fall, and the presence of obstacles on the floor were risk factors for severe injury in the head injury group in older adults individuals who suffered a ground-level fall. It is necessary to develop appropriate ground-level fall prevention programs by evaluating the individual and environmental characteristics of older adults patients. [ABSTRACT FROM AUTHOR]

To analyze the relationship between high mobility group protein B1 (HMGB1), transforming growth factor - β1 (TGF- β1) and CT image scores after craniocerebral injury. From February 2017 to December 2018, 93 patients with craniocerebral injury were randomly selected from our hospital. According to the different CT imagescores, the patients were divided into three groups: group 0-5 points (24 cases), group 6-10 points (47 cases), group 11¬15 points (22 cases). The serum levels of high mobility group protein B1 (HMGB1), transforming growth factor - β1 (TGF- β1), interleukin (IL-12), C-reactive protein (CRP), myelin basic protein (MBP), neuron-specific enolase (NSE) and protein S100B (S100B) were measured by ELISA. Glasgow score was used to evaluate the severity of craniocerebral injury. Pearson correlation test was used to analyze the relationship between HMGB1, TGF - β1, MMP-2, MMP-9, IL-12, CRP, Glasgow score, MBP, NSE, S100B and CT image scores. There was no statistical significance (P > 0.05) of the significant difference in the comparison of clinical basic data such as age, gender, body mass index, type of brain injury and the causes of brain injury between each group. With the increase of CT image scores, the levels of HMGB1, IL-12, CRP, MBP, NSE and S100B in serum of the patients increased significantly, the levels of TGF - β1 and Glasgow score in serum decreased significantly (P<0.05). The level of HMGB1, TGF - β1, IL-12, CRP, MBP, NSE, S100B was the lowest in group 0-5 points' serum, and Glasgow was the highest; the group 6-10 points take the second place; the level of HMGB1, TGF - β1, IL- 12, CRP, MBP, NSE, S100B was the highest in group 11-15 points' serum, and Glasgow was the lowest. According to Pearson correlation test analysis, the levels of HMGB1, IL-12, CRP, MBP, NSE and S100B in serum were positively correlated with CT image scores, while the levels of TGF - β1 and Glasgow score were negatively correlated with CT image scores (P < 0.05). The level of HMGB1, IL-12, CRP, MBP, NSE, S100B, TGF - β1 and Glasgow score in serum were significantly correlated with CT image scores. The level of HMGB1, IL-12, CRP, MBP, NSE and S100B in serum level were positively correlated with CT image scores, while serum TGF - β1 levels and Glasgow scores were negatively correlated with CT image scores. All of the above indexes can be used as important indexes for the diagnosis of craniocerebral injury. [ABSTRACT FROM AUTHOR]

Meningitis is a potentially life-threatening condition. The clinical manifestation can vary depending on the age of the child. This report presents the case of a 7-year-old male patient who was admitted to ED due to loss of consciousness after a head injury. Upon admission, the patient had seizures. Head CT scan did not show any signs of intracerebral bleeding or cerebral oedema. During hospitalization in the ICU, the patient began to be febrile and inflammatory markers started to rise. Treatment with antibiotics and antiviral agents was administered. Later, meningeal signs were observed. Additional imaging tests revealed ambiguous findings. The patient's symptoms resolved gradually, and he was discharged after 19 days of hospitalization. The final diagnosis was meningitis. This case highlights that the diagnosis of meningitis requires careful investigation and precise examination. This diagnosis should therefore be considered in all patients who present with symptoms concerning for meningitis. [ABSTRACT FROM AUTHOR]

Background: Off-field screening tools, such as the Sports Concussion Assessment Tool (SCAT), have been recommended to identify possible concussion following a head impact where the consequences are unclear. However, real-life performance, and diagnostic accuracy of constituent sub-tests, have not been well characterized. Methods: A retrospective cohort study was performed in elite Rugby Union competitions between September 2015 and June 2018. The study population comprised consecutive players identified with a head impact event undergoing off-field assessments with the World Rugby Head Injury Assessment (HIA01) screening tool, an abridged version of the SCAT3. Off-field screening performance was investigated by evaluating real-life removal-from-play outcomes and determining the theoretical diagnostic accuracy of the HIA01 tool, and individual sub-tests, if player-specific baseline or normative sub-test thresholds were strictly applied. The reference standard was clinically diagnosed concussion determined by serial medical assessments. Results: One thousand one hundred eighteen head impacts events requiring off-field assessments were identified, resulting in 448 concussions. Real-life removal-from-play decisions demonstrated a sensitivity of 76.8% (95% CI 72.6–80.6) and a specificity of 86.6% (95% CI 83.7–89.1) for concussion (AUROC 0.82, 95% CI 0.79–0.84). Theoretical HIA01 tool performance worsened if pre-season baseline values (sensitivity 89.6%, specificity 33.9%, AUROC 0.62, p < 0.01) or normative thresholds (sensitivity 80.4%, specificity 69.0%, AUROC 0.75, p < 0.01) were strictly applied. Symptoms and clinical signs were the HIA01 screening tool sub-tests most predictive for concussion; with immediate memory and tandem gait providing little additional diagnostic value. Conclusions: These findings support expert recommendations that clinical judgement should be used in the assessment of athletes following head impact events. Substitution of the tandem gait and 5-word immediate memory sub-tests with alternative modes could potentially improve screening tool performance. [ABSTRACT FROM AUTHOR]

Few medico-legal matters have generated as much controversy--both in the medical literature and in the courtroom--as Shaken Baby Syndrome (SBS), now known more broadly as Abusive Head Trauma (AHT). The controversies are of enormous significance in the law because child abuse pediatricians claim, on the basis of a few non-specific medical findings supported by a weak and methodologically flawed research base, to be able to "diagnose" child abuse, and thereby to provide all of the evidence necessary to satisfy all of the legal elements for criminal prosecution (or removal of children from their parents). It is a matter, therefore, in which medical opinion claims to fully occupy the legal field. As controversies flare up increasingly in the legal arena, child abuse pediatricians and prosecutors now respond by claiming both that there is actually no real controversy about SBS/AHT, and that it is a purely medical "diagnosis" and not a legal conclusion, so testimony in support of the SBS hypothesis should not be challenged in court. This article, coauthored by four law professors, two physicians, and a physicist, demonstrates that there is very much a live controversy about the SBS/AHT hypothesis and maintains that, under traditional principles of evidence law, physicians should not be permitted to "diagnose" abuse in court (as opposed to identifying specific symptoms or medical findings). [ABSTRACT FROM AUTHOR]

Background: Bicycle riding is a widely practiced mode of transportation, commuting, competition, fitness and recreation. We aimed to describe the incidence, risk factors and outcomes of Bicycle-Related Traumatic Injury (BRTI) in a Middle Eastern country. Methods: Data were extracted from a prospectively collected trauma registry over a period of six years (2010- 2015) from the national trauma center. Demographics and clinical characteristics of patients, and outcomes were analyzed. Results: There were 150 patients with a mean age of 27.2±16.6 years, 98% were males, 86.6% were hit by a car and 8.7% died. The average annual incidence of BRTIs was 1.3 per 100,000 populations. The mean Glasgow Coma Score (GCS) and injury severity score (ISS) were12.7±4.0 and 13.6±9.8; respectively. Almost one-third of cases had an ISS of 9-15. The most commonly injured region was the head (47%) followed by a lower extremity (30%), chest (25%), upper extremity (21.3%), spine (20.7%), abdomen (18.7%) and (7%) pelvis. Conclusions: BRTI is relatively uncommon in Qatar; however, it is characterized by a distinct epidemiology with a considerable mortality. Young male nationals, recreational cyclists and expatriate young commuter cyclists comprise the majority of victims and should be the focus of primary prevention efforts. Complementary prevention should aim at enforcing helmet laws to reduce fatal head injuries, and educating motorists of safer practices around cyclists. [ABSTRACT FROM AUTHOR]

Traumatic diastasis of cranial sutures is a type of bone fracture more common in children than in adults, but little attention has been paid to this skull damage. Differentiation between inflicted and accidental traumatic head injury is still a challenge in forensic pathology, particularly in pediatric population. In fact, diastasis of cranial sutures may occur with or without other skull fractures and may be the only evidence of an abusive head trauma (AHT). This is a case study dealing with undetected traumatic diastasis of cranial sutures in child abuse. The skeletonized juvenile remains were found inside a suitcase. A diastasis of the coronal and sagittal sutures was the only finding recorded at the autopsy with no other relevant bone defects. The diastasis was originally attributed by the medical examiner to a physiological unfused stage of the calvarial bones. Therefore, the cause of death was undetermined. Twelve years later an anthropological revision of the cold case showed that diastasis of the coronal and sagittal sutures was assessed as the evidence of an AHT. Analysis of skull fractures in child abuse can be challenging as normal skull suture variants mimicking intentional injury are reported. Diastasis of the cranial sutures can be also a post-mortem effect of burning or freezing. Therefore, a differential diagnosis between natural, accidental or inflicted skull defects is mandatory in death investigation. A multidisciplinary approach in such circumstances is strongly recommended in order to reduce the risk of misdiagnosis. [ABSTRACT FROM AUTHOR]

Self-report measures, particularly symptom inventories, are critical tools for identifying patients with persistent post-concussion symptoms and their follow-up. Unlike in military or sports-related assessment, in general civilian settings pre-injury levels of concussion-like symptoms are lacking. Normative data are available in adolescent and college populations, but no reference data exist to guide clinical adult explorations. The purpose of this study was to use the second edition of the Sport Concussion Assessment Tool (SCAT2) to profile a cohort of 60 healthy community volunteers who had not sustained a head injury. Participating volunteers underwent MRI scanning and were evaluated with the Hospital Anxiety and Depression Scale (HADS). Participants reported a median of 3 concussion-like symptoms and the 97.5 percentile score was found at 10.5 symptoms, out of a total of 22. The median severity score was 4.9 points, and 28.9 was the upper limit of the reference interval. Only 10 participants (16.7%) did not endorse any symptom. The most frequently endorsed symptom was feeling difficulty in concentrating, with 41.7% of the sample reporting it. Age, sex and general distress, anxiety and depressive symptoms were not associated with concussion-like symptoms. Our data yielded elevated cut-offs scores for both the number of symptoms and the symptom severity. In conclusion, postconcussive-like symptoms are frequent in the general non-concussed adult population and it should be taken into account in any future models developed for screening patients at risk of developing physical, cognitive, and psychological complaints following mild traumatic injury. [ABSTRACT FROM AUTHOR]

Background The hypothesis of this study is that the diagnosis of infant abuse is associated with criteria for shaken baby syndrome (SBS)/abusive head trauma (AHT), and that that changes in incidence of abuse diagnosis in infants may be due to increased awareness of SBS/AHT criteria. Methods This was a population-based register study. Setting: Register study using the Swedish Patient Register, Medical Birth Register, and Cause of Death Register. The diagnosis of infant abuse was based on the International Classification of Diseases, 9th and 10th revision. Participants: All children born in Sweden during 1987–2014 with a follow-up until 1 year of age (N = 2 868 933). SBS/AHT criteria: subdural haemorrhage, cerebral contusion, skull fracture, convulsions, retinal haemorrhage, fractures rib and long bones. Outcomes: Incidence, rate ratios, aetiologic fractions and Probit regression analysis. Results Diagnosis of infant abuse was strongly associated with SBS/AHT criteria, but not risk exposure as region, foreign-born mother, being born preterm, multiple birth and small for gestational age. The incidence of infant abuse has increased tenfold in Sweden since the 1990s and has doubled since 2008, from 12.0 per 100 000 infants during 1997–2007 to 26.5/100 000 during 2008–2014, with pronounced regional disparities. Conclusions Diagnosis of infant abuse is related to SBS/AHT criteria. The increase in incidence coincides with increased medical preparedness to make a diagnosis of SBS/AHT. Hidden statistics and a real increase in abuse are less plausible. Whether the increase is due to overdiagnosis cannot be answered with certainty, but the possibility raises ethical and medico-legal concerns. [ABSTRACT FROM AUTHOR]

Previous research has sought to quantify head impact exposure using wearable kinematic sensors. However, many sensors suffer from poor accuracy in estimating impact kinematics and count, motivating the need for additional independent impact exposure quantification for comparison. Here, we equipped seven collegiate American football players with instrumented mouthguards, and video recorded practices and games to compare video-based and sensor-based exposure rates and impact location distributions. Over 50 player-hours, we identified 271 helmet contact periods in video, while the instrumented mouthguard sensor recorded 2,032 discrete head impacts. Matching video and mouthguard real-time stamps yielded 193 video-identified helmet contact periods and 217 sensor-recorded impacts. To compare impact locations, we binned matched impacts into frontal, rear, side, oblique, and top locations based on video observations and sensor kinematics. While both video-based and sensor-based methods found similar location distributions, our best method utilizing integrated linear and angular position only correctly predicted 81 of 217 impacts. Finally, based on the activity timeline from video assessment, we also developed a new exposure metric unique to American football quantifying number of cross-verified sensor impacts per player-play. We found significantly higher exposure during games (0.35, 95% CI: 0.29–0.42) than practices (0.20, 95% CI: 0.17–0.23) (p<0.05). In the traditional impacts per player-hour metric, we observed higher exposure during practices (4.7) than games (3.7) due to increased player activity in practices. Thus, our exposure metric accounts for variability in on-field participation. While both video-based and sensor-based exposure datasets have limitations, they can complement one another to provide more confidence in exposure statistics. [ABSTRACT FROM AUTHOR]

Alcohol use and traumatic brain injury (TBI) are inextricably and bidirectionally linked. Alcohol intoxication is one of the strongest predictors of TBI, and a substantial proportion of TBIs occur in intoxicated individuals. An inverse relationship is also emerging, such that TBI can serve as a risk factor for, or modulate the course of, alcohol use disorder (AUD). Critically, alcohol use after TBI is a key predictor of rehabilitation outcomes, prognosis, and additional head injuries. This review provides a general overview of the bidirectional relationship between TBI and AUD and a discussion of potential neuropsychological and neurobiological mechanisms that might underlie the relationship. [ABSTRACT FROM AUTHOR]

Background. Head injury is one of the leading causes of morbidity and mortality throughout the world. Fall injury is the main cause of head trauma followed by road traffi c accidents (RTA) and physical assault. Every victim with altered level of consciousness must be evaluated for brain injury. Radiological evaluation has undergone dramatic changes with the advent of computed tomography (CT) as it can precisely defi ne the nature and location of the culprit lesion(s). Aim and projective. The aims of this study are to identify the major CT scan fi ndings in suspected cases of Head injury. Materials and methods. This is an exploratory study carried out in the specialized surgical hospital and neurosurgical hospital from October 2016 to July 2017 on patients attending to the emergency department with acute head trauma and examined by spiral computed tomography (CT). All patients undergo a full neurological examination. Result. The study was conducted on 160 patients, 106 males and 54 females, by males: females = 2: 1, aged 21-64 years, with an average age of 43 years. One hundred twenty patients (75%) had abnormal CT fi ndings, while 40 patients (25%) had normal CT. Patients with blunt (closed) head injury were 126 (78.75%), while 34 patients (21.25%) had penetrating (open) head injury. In this study, the number of patients was 160, 106 (66%) of males and 54 (34%) of females with male to female ratio 2/1. The most common age group was between 20-29 years as shown in (Table 1 and Fig. 1). The patient had severe (closed) head injuries (16%), while 34 patients (21.25%) had an open head injury. Data analysis was performed in this study as shown in Table 2 and Fig. 2 are frequency, consciousness level disorders were found in 62 patients (38.75%), followed by multiple injuries including chest and abdominal injuries in 34 patients (21.2), injury penetration Head in 31 patients (19.3%). After a head injury in 30 patients (18.7%), vomiting over one episode was seen in 17 patients (10.6%), and only 6 patients (3.7%) were provided with signs of fracture at the base of the skull including runny nose Warm CSF, vessels, skull double nerve, battle mark (Mastoid) and raccoon (black) eye. Twenty-one patients (75%) had abnormal CT scan results while 40 (25%) had regular CT as shown in (Table 3 and Fig. 3). CT abnormalities are shown in accordance with the mechanism of infection (Table 3 and Fig. 3), indicating that the swelling of the entire brain occurs mainly in adolescents and children, and the most age group between 20-29 years as shown in Table 1 and Fig. 1), The patient with severe injuries was 16% (10%), while 34 patients (21.25%) had an open head injury. CT resection of the mechanism is less in (Table 3 and Fig. 3), indicating that the brain swelling. There are Road traffi c accident (RTA) was the most common cause of acute head trauma seen in 63 patients (39.4%), followed by penetrating injury seen in 34 patient (21.2%), fall from height in 28 patients (17.5%) blunt injury of blast in 25 patient (15.7%) and assault seen in 10 patient (6.2%). Acute head trauma was divided into 3 types according to the Glasgow coma scale (GCS) score including: moderate head trauma (score 9-12) was the commonest type seen in 60 patients (37.5%), 48 (80%) of them had abnormal CT fi ndings, mild head trauma (score 13-15) seen in 53 patients (33.2%), 33 (62.2%) of them had abnormal CT, and severe head trauma (score <8) seen in 47 patients (29.3%), 39 (83%) of them had abnormal CT fi ndings. Skull fracture was the commonest abnormal CT fi nding, seen in 70 patients (43.7%),followed in order of frequency by: cerebral contusion in 47 patients (29.3%), subgalial hematoma in 34 patients (21.2%), intracranial air seen in 27 patients (16.8%), epidural hematoma in 15 patients (9.3%), subdural hematoma seen in 12 patients (7.5%) subarachnoid hemorrhage in 11 patients (6.8%), diffuse cerebral edema in 10 patients (6. 2%), and intraventricular hemorrhage seen in 8 patients (5%). Eighty-eight patients (55%) had skull x-ray, (62.5%) of them were normal, (21.5%) had linear skull fracture, (9.2%) had comminuted fracture and (6.8%) had depressed fracture. The main indication for CT scan was disturbance in the level of consciousness and was found in 62 patients (38.7%). Conclusion. We conclude that CT is now the fi rst imaging technique used after acute head trauma in those places. Where CT scans are available. CT is the preferred imaging technique for assessing head trauma. CT was found highly sensitive in demonstrating fractures and was considered the modality of choice when imaging suspected cases of head injury and in emergency patients due to its accuracy, reliability, safety and wide availability. CT scan is still the primary method for evaluating patients with acute head trauma, which is fast, easy and reliable, and is the best choice for cranial fractures and acute axial or acute intraocular bleeding. CT is the imaging method chosen in the evaluation of patients with acute injuries. CT is valuable in making fi lm diagnosis, as well as excluding alternative diagnosis, or crevice of other pathologies, even among uncooperative patients. Patient monitoring is safe and simple; CT is compatible with other patient install devices. The identity and localization of cranial fracture and bone/metal fragment are easily determined. Evaluation of acute bleeding and mass effects is optimal. [ABSTRACT FROM AUTHOR]

Objective: The objective of the study is to determine the validity of bispectral in diagnosis of mild and moderate head injury keeping GCS as a gold standard. Study Design: A cross sectional validation study. Place and Duration of Study: This Study was conducted in main Intensive Care Unit of the Combined Military Hospital Rawalpindi and was carried out over eight months from Dec 2009 to Aug 2010. Material and Methods: A minimum of 137 patients were included in study. At the time of admission, Glasgow coma score was calculated by 3 different anesthetists and mean was calculated. At the same time BIS reading was taken using Aspect BIS monitor. Results: Mean age of the patients was 29.5 ± 6.2. 108 (78.8%) patients were male while 29 (29.2%) patients were female. Mean glasgow coma score was 12.2 ± 0.9 and mean bispectral index score was 69.9 ± 8.4. A 2 x 2 table was made between GCS and BIS. Sensitivity was found to be 95.65%, specificity 98.53%, positive predictive value 98.50% and negative predictive value 95.7%. ROC curve was drawn and demonstrated area under curve value of 0.999. Conclusion: BIS monitor can prove to be a useful adjunct in the diagnosis and management of mild and moderate head injury patients in the intensive care units. [ABSTRACT FROM AUTHOR]

Background: Handball is a contact sport, and a head-injury is one of many possible injuries. The diagnosis concussion has been reported as one of the more complex sports injuries, both regarding the diagnostic procedure and the sports medical management and rehabilitation. Hereby a handball-related head-injury is expected to be challenging both for the players and for the medical-team and there is a need to explore how medical team professionals' reason regarding management and return to play. Objectives: The aim of the study was to explore how the medical team in Swedish elite handball, medical doctors and physiotherapists, reason regarding principals of managing a handball related head-injury and return to sport decisions. Methods: A Qualitative individual interview study with a semi-structured interview guide was performed. Data was analyzed with content analysis and an inductive approach. Study participants were eight medical doctors and twelve physiotherapist supporting Swedish elite handball team during the season of 2019/2020. Results: The participants descriptions and reasoning regarding management and return to play principals emerged into the following three main categories; "Organization and working routine"; "Experienced complicating factors and feeling insufficient and scarce"; "Management strategies". Together with nine subcategories the analysis exposed a variety of principals, challenges and expressed needs related to the process of medical decisions and management for handball players sustaining a head injury. Conclusion: The results reveal a need for clearer guidelines, enhanced collaboration, and improved management of head-injuries. There is also an expressed need for sharpened handball rules and regulations as well as a need of clarified health-care pathways for players with more complex post-concussion symptoms. The medical team members expressed an uncertainty regarding symptoms due to the concussion, so being acquainted with the player is hereby very important. [ABSTRACT FROM AUTHOR]

Athletes in contact sports sustain repetitive subconcussive head impacts in a brief window, yet neurophysiological sequelae from repetitive subconcussion remain unclear. This prospective longitudinal study examined a relationship between changes in plasma Tau protein levels and subconcussive impact kinematic data in 23 Division I collegiate football players during a series of pre-season practices. Plasma measures for Tau and S100β proteins, symptom scores, and near point of convergence were obtained at pre-season baseline and pre-/post-practices. During each practice, impact frequency and linear and rotational head accelerations were recorded via an accelerometer-embedded mouth guard. There were significant elevations in plasma Tau levels at all post-practice time-points, compared with those of pre-practice and baseline levels. However, the highest degree of elevation in plasma Tau was observed after the first practice, for which players sustained the lowest number of hits and magnitudes for these hits. Subconcussive impact exposure during practice (e.g., head impact frequency and magnitude) did not predict increased plasma Tau levels. Concussion history and years of football experience also were unrelated to changes in plasma Tau levels. Increases in plasma Tau levels were associated with increases in S100β levels only after the first practice. There were no significant associations between changes in Tau levels, symptom scores, or near point of convergence. These data suggest that the changes in levels of circulating Tau protein were independent of subconcussive head impact exposure, pointing to the possibility that other factors may have played roles in changes in plasma Tau levels. [ABSTRACT FROM AUTHOR]

Context: Based on Glasgow Coma Scale (GCS), head injury can be classified as minor (GCS 13-15), moderate (GCS 9-12), and severe (GCS 3-8). There is a lot of controversy in the use of computed tomography (CT) in head injury patients. Aims: This study was intended to estimate the rate of CT positivity in head injury patients and to define the criteria for doing CT in head injury patients. Settings and Design: This was a prospective observational study in the emergency department (ED) over a 12-month period. Subjects and Methods: Study involved all head injury patients attending ED. Risk factors studied were a loss of consciousness (LOC), vomiting, seizures, ear bleed, nosebleed, external injuries, and alcohol intoxication. Statistical Analysis Used: Comparison of CT positivity with the patient's demographics and clinical characteristics was carried out using Chi-square. Results: A total of 1782 patients were included in this study. Overall CT positivity was 50.9%. In minor head injury (MHI), CT positivity rate was 38%. The study showed significant association of CT positivity with five variables: LOC >5 min, vomiting, seizures, ear bleed, and nosebleed. Conclusions: From the study, we recommend following: CT is indicated in all patients with moderate and severe head injury (GCS =12). Low threshold for taking CT is advisable in elderly and alcohol-intoxicated patients. In MHI, CT is indicated if any one of the following risk factors are present: LOC >5 min, history of vomiting, history of seizures, history of ear bleed, and history of nosebleed. [ABSTRACT FROM AUTHOR]

The correct and complete diagnosis is essential for the adequate care and the favourable clinical evolution of the patients with head trauma. Purpose: To identify the error rate in the clinical diagnosis of head injuries as shown in comparison with the autopsy diagnosis and to identify the most common sources of error. Material and method: We performed a retrospective study based on data from the medical files and the autopsy reports of patients with head trauma who died in the hospital and underwent forensic autopsy. We collected: demographic data, clinical and laboratory data and autopsy findings. To quantify the concordance rate between the clinical diagnosis of death and the autopsy diagnosis we used a 4 classes classification, which ranged from 100% concordance (C1) to total discordance (C4) and two classes of partial discordance: C2 (partial discordance in favour of the clinical diagnosis-missing injuries in the autopsy reports) and C3 (partial discordance in favor of the necroptic diagnosis-missing injuries in the medical files). Data were analyzed with SPSS version 20.0. Results: We analyzed 194 cases of death due to head injuries. We found a total concordance between the clinical death diagnosis and autopsy diagnosis in 30.4% of cases and at least one discrepancy in 69.6% of cases. Increasing the duration of hospitalization directly correlates with the amount of the imaging investigations and these in turn correlates with an increased rate of diagnosis concordance. Among the patients with stage 3 coma who associated a spinal cord injury, we found a partial diagnosis discordance in 50% of cases and a total discordance in 50% of cases, possibly due to the need for conducting emergency imaging investigation and the need for surgical treatment. In cases with partial and total discordant diagnosis, at least one lesion was omitted in 45.1% of the cases. The most commonly omitted injuries in C2 cases were subdural hematoma, intracerebral hematoma and ventricular hemorrhage (21.6%). In C3 cases the most frequently omitted injuries were subarachnoidian hemorrhage and skull base fractures (17.9%). Conclusions: The clinical cause of death is not always concordant with the autopsy diagnosis. Autopsy may identify the inconsistencies in diagnosis, the injuries frequently skipped and the factors favoring the discordance rate between the clinical death diagnosis and the autopsy diagnosis, making it a valuable tool for improving the clinical care of the patients with head trauma. [ABSTRACT FROM AUTHOR]

Study Objectives. Differences between returning and non-returning minor head injury (MHI) emergency department (ED) patients, between the characteristics of the first visit and revisit, and between admitted and nonadmitted returning patients were investigated. Methods. This was a retrospective study. All discharged ED patients with ICD-9 codes 850.0 to 850.9, 920, and 959.01 in 2013 were enrolled. Patients’ demographic data, vital signs, Glasgow Coma Scale, ED diagnosis, length of stay, triage levels, ED examinations performed, and comorbidities were recorded for analysis. Results. A total of 2,815 patients were enrolled. Of 57 (2%) patients who revisited the ED, 47 (82%) were discharged from the ED and ten (18%) were admitted to the hospital. Patients who returned to the ED were older, and they exhibited more comorbidities. Those who presented with vomiting, triage level of 1 or 2, and GCS score of <15 and who received more blood tests during their first visit were more likely to be admitted when they returned to the ED. Conclusions. Discharging MHI patients who are older or exhibit comorbidities only when symptoms and concerns are relieved completely, providing clear discharge instructions, and arranging timely clinical follow-ups may help reduce such patients’ return rate. [ABSTRACT FROM AUTHOR]

Background: Traumatic brain fungus is manifestation of neglected head injury. Although rare it is not uncommon. The patients are usually intact with good Glasgow coma (GCS) score inspite of complex injuries and exposed brain parenchyma but morbidity and mortality is very high with time if no proper and timely management is offered. There is very less study on traumatic brain fungus with no defined management protocols. So an attempt was made to explain in details the surgical strategies and other management techniques in patients with traumatic brain fungus. Aims: To study and evaluate the pattern of causation, clinical presentations, modalities of management of traumatic brain fungus and outcome after treatment. Methods: All patients with fungus cerebri, admitted to our centre from January 2012 to December 2015 were studied prospectively. All the patients were examined clinically and triaged urgently for surgery. CT head was done in all patients to look for any brain parenchymal injury. All patients were managed surgically. Outcome was assessed as per the Glassgow Outcome Score. Results: Total 10 patients were included in the study. 8 were men and 2 women. The patients' ages ranged from 3-48 years (mean 31.6 years). The interval between initial injury and protrusion ranged from 3 days to 6 days (mean 4.1 days). Mean GCS at the time of presentation was 13.2.60% of the patients (n = 6) sustained moderate head injury. (GCS-9-13). Size of the fungus ranged from 5cm×3cm to 8cm×10cm. Conclusion: Early and proper local wound treatment prevents fungus formation. Pre-emptive antibiotics, AEDs and cerebral decongestants are recommended. Loose water-tight duroplasty prevents CSF leak. But mortality and morbidity can be reduced significantly if brain fungus is managed properly by applying basic surgical principles and antibiotic protocols combined with newer surgical modalities. [ABSTRACT FROM AUTHOR]

Background: Clinicians, afraid of missing intracranial injuries, liberally obtain computed tomographic (CT) head imaging in blunt trauma patients. Prior work suggests that clinical criteria (National Emergency X-Radiography Utilization Study [NEXUS] Head CT decision instrument [DI]) can reliably identify patients with important injuries, while excluding injury, and the need for imaging in many patients. Validating this DI requires confirmation of the hypothesis that the lower 95% confidence limit for its sensitivity in detecting serious injury exceeds 99.0%. A secondary goal of the study was to complete an independent validation and comparison of the Canadian and NEXUS Head CT rules among the subgroup of patients meeting the inclusion and exclusion criteria.Methods and Findings: We conducted a prospective observational study of the NEXUS Head CT DI in 4 hospital emergency departments between April 2006 and December 2015. Implementation of the rule requires that patients satisfy 8 criteria to achieve "low-risk" classification. Patients are excluded from "low-risk" classification and assigned "high-risk" status if they fail to meet 1 or more criteria. We examined the instrument's performance in assigning "high-risk" status to patients requiring neurosurgical intervention among a cohort of 11,770 blunt head injury patients. The NEXUS Head CT DI assigned high-risk status to 420 of 420 patients requiring neurosurgical intervention (sensitivity, 100.0% [95% confidence interval [CI]: 99.1%-100.0%]). The instrument assigned low-risk status to 2,823 of 11,350 patients who did not require neurosurgical intervention (specificity, 24.9% [95% CI: 24.1%-25.7%]). None of the 2,823 low-risk patients required neurosurgical intervention (negative predictive value [NPV], 100.0% [95% CI: 99.9%-100.0%]). The DI assigned high-risk status to 759 of 767 patients with significant intracranial injuries (sensitivity, 99.0% [95% CI: 98.0%-99.6%]). The instrument assigned low-risk status to 2,815 of 11,003 patients who did not have significant injuries (specificity, 25.6% [95% CI: 24.8%-26.4%]). Significant injuries were absent in 2,815 of the 2,823 patients assigned low-risk status (NPV, 99.7% [95% CI: 99.4%-99.9%]). Of our patients, 7,759 (65.9%) met the inclusion and exclusion criteria of the Canadian Head CT rule, including 111 patients (1.43%) who required neurosurgical intervention and 306 (3.94%) who had significant intracranial injuries. In our study, the Canadian criteria for neurosurgical intervention identified 108 of 111 patients requiring neurosurgical intervention to yield a sensitivity of 97.3% (95% CI: 92.3%-99.4%) and exhibited a specificity of 58.8% (95% CI: 57.7%-59.9%). The NEXUS rule, when applied to this same cohort, identified all 111 patients requiring neurosurgical intervention, yielding a sensitivity of 100% (95% CI: 96.7%-100.0%) with a specificity of 32.6% (95% CI: 31.5%-33.6%). Our study found that the Canadian medium-risk factors identified 301 of 306 patients with significant injuries (sensitivity = 98.4%; 95% CI: 96.2%-99.5%), while the NEXUS rule identified 299 of these patients (sensitivity = 97.7%; 95% CI: 95.3%-99.1%). In our study, the Canadian medium-risk rule exhibited a specificity of 12.3% (95% CI: 11.6%-13.1%), while the NEXUS rule exhibited a specificity of 33.3% (95% CI: 32.3%-34.4%). Limitations of the study may arise from application of the rule by different clinicians in different environments. Clinicians may vary in their interpretation and application of the instrument's criteria and risk assignment and may also vary in deciding which patients require intervention. The instrument's specificity is also subject to spectrum bias and may change with variations in the proportion of "low-risk" patients seen in other centers.Conclusions: The NEXUS Head CT DI reliably identifies blunt trauma patients who require head CT imaging and could significantly reduce the use of CT imaging. [ABSTRACT FROM AUTHOR]

Contrecoup injuries comprise a group of focal brain injuries that occur at areas distant from the point of impact. It has been hypothesized that patients with contrecoup injuries would have a worse outcome because of the diffuse nature of injury. At Nilratan Sircar Medical College, Kolkata, 74 patients presenting with contrecoup injuries over a period of 1 year were prospectively analyzed. Site of primary impact was determined by clinical and CT scan criteria. The age, modes of injury, Glasgow coma scale (GCS), site of injury, pattern of injury, and mortality were analyzed. Delayed presentation of contrecoup injury in patients who deteriorated over time was also noted in imaging. The presence of contrecoup injury implies that the traumatic forces have dissipated into the brain, and from the biomechanisms explained, the brain is likely to have suffered greater damage than the case in coup injury alone. The present study shows that the presence of contrecoup contusions is associated with a poor prognosis across all GCS and age categories. [ABSTRACT FROM AUTHOR]

Objectives: To assess the impact of positive postoperative CT head during the initial 72 hours on overall clinical course and outcome. Methodology: 157 patients of head trauma who underwent cranial surgery were prospectively included. All patients underwent a repeat head CT during the initial 72 hours or as was indicated by neurological status of the patient. Data was collected about patient demographics, initial CT diagnosis, repeat CT findings, re-operation if performed, GCS at discharge, mortality and outcome in terms of GOS. Data was analysed for impact of positive finding in postoperative CT head and its impact on clinical course and outcome. Results: The overall mean age was 34.25 ±11.59 years with a mean arrival GCS of 9.2 ±2.32. The mean time to first postoperative CT was 21.45 ±9.83 hours. The postoperative CT scan was positive in 29 (18.5%) patients in which 16 (10.2%) cases required re-intervention. Overall mortality was 19 (12.1%), of which 9 (44.1%) had a positive post-operative CT scan and 4 (21.1%) of them underwent a repeat intervention. 2.3% of patients with negative CT were re-operated while 44.8% were re-operated in the positive CT (p <0.0001). Similarly, mortality was 7.8% in the negative CT group while it was 31.0% in the positive CT group (p <0.0001). Conclusions: Positive follow-up CT scan during early post-operative period can affect significantly the clinical course and neurological outcome of patients. [ABSTRACT FROM AUTHOR]

Introduction and objectives: Evaluation of injuries in emergency departments is based on CT scans. The objective of this forensic study is to reveal certain types and location of skull fractures that can escape CT diagnosis. Methods: This study was conducted by retrospective analysis of 115 cases of hospitalized traumatic brain injury autopsied at INML “Mina Minovici” Bucharest during the year 2011. Results and discussions: In 35 cases were discovered that skull fractures have not been highlighted in CT examinations. Undiagnosed skull fractures were predominantly linear fractures. A linear fracture that comes in the plane of a CT slice may not be visualized if is not depressed or separated. Conclusion: Skull fractures were mostly undiagnosed in men, over the age of 50 with serious traumatic brain injury, with a survival period of less than 5 days and with a single CT examination. In 30.43% of studied cases were detected skull fractures that were not diagnosed on CT. The most common was involved the cranial vault from temporal-parietal areas, followed by frontal area, with irradiation in the anterior and medium fossa. A good accuracy of imaging diagnostic was in the occipital region, and in the posterior fossa of the skull base. [ABSTRACT FROM AUTHOR]

Despite being underreported, American football boasts the highest incidence of concussion among all team sports, likely due to exposure to head impacts that vary in number and magnitude over the season. This study compared a biological marker of head trauma in American football athletes with non-contact sport athletes and examined changes over the course of a season. Baseline serum neurofilament light polypeptide (NFL) was measured after 9 weeks of no contact and compared with a non-contact sport. Serum NFL was then measured over the course of the entire season at eight time-points coincident with expected changes in likelihood of increased head impacts. Data were compared between starters ( n = 11) and non-starters ( n = 9). Compared with non-starters (mean ± standard deviation) (7.30 ± 3.57 pg•mL−1) and controls (6.75 ± 1.68 pg•mL−1), serum NFL in starters (8.45 ± 5.90 pg•mL−1) was higher at baseline (mean difference; ±90% confidence interval) (1.69; ± 1.96 pg•mL−1 and 1.15; ± 1.4 pg•mL−1, respectively). Over the course of the season, an increase (effect size [ES] = 1.8; p < 0.001) was observed post-camp relative to baseline (1.52 ± 1.18 pg•mL−1), which remained elevated until conference play, when a second increase was observed (ES = 2.6; p = 0.008) over baseline (4.82 ± 2.64 pg•mL−1). A lack of change in non-starters resulted in substantial differences between starters and non-starters over the course of the season. These data suggest that a season of collegiate American football is associated with elevations in serum NFL, which is indicative of axonal injury, as a result of head impacts. [ABSTRACT FROM AUTHOR]

Despite an improved understanding of traumatic head and neck injury mechanisms, the impact tests required by major motorcycle helmet standards have remained unchanged for decades. Development of new test methods must reflect the specific impact loads causing injury in real crashes as well as test criteria appropriate for the observed injury profiles. This study analysed a collection of in-depth crash investigations of fatally injured helmeted riders in the Adelaide metropolitan region between 1983 and 1994 inclusive to review the head and neck injury patterns that resulted from specific types of impact. Inertial brain injury was sustained in 49% of examined cases, most often resulting from facial impacts but also in a large proportion of tangential, run over, and occipital impact cases. Focal brain and brainstem injury was also common (53%) and regularly associated with skull vault (11/12) and skull base fractures (22/31). Prevention of these fractures in impacts outside the area of required protection and in impacts with a straight edge would provide a significant increase in helmeted rider protection. Cervical spinal cord injury was sustained in facial, straight edge, and tangential impacts on the head. Motorcycle helmets are effective for preventing local skull fractures in impacts for which they are designed, whereas other serious injuries such as basilar skull fracture (BSF) and inertial brain injury persist despite helmet protection. Further impact test procedures should be developed for injurious impact types not currently assessed by major helmet standards, in particular facial impacts, and using test criteria based on commonly observed injuries. This study provides the necessary link, from impact load to injury, for guiding impact test development. [ABSTRACT FROM AUTHOR]

Background: The management of minor and moderate head trauma in children differs widely between countries. Presently, there are no existing guidelines for management of these children in Scandinavia. The purpose of this study was to produce new evidence-based guidelines for the initial management of head trauma in the paediatric population in Scandinavia. The primary aim was to detect all children in need of neurosurgical intervention. Detection of any traumatic intracranial injury on CT scan was an important secondary aim.Methods: General methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used. Systematic evidence-based review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and based upon relevant clinical questions with respect to patient-important outcomes. Quality ratings of the included studies were performed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 and Centre of Evidence Based Medicine (CEBM)-2 tools. Based upon the results, GRADE recommendations, a guideline, discharge instructions and in-hospital observation instructions were drafted. For elements with low evidence, a modified Delphi process was used for consensus, which included relevant clinical stakeholders.Results: The guidelines include criteria for selecting children for CT scans, in-hospital observation or early discharge, and suggestions for monitoring routines and discharge advice for children and guardians. The guidelines separate mild head trauma patients into high-, medium- and low-risk categories, favouring observation for mild, low-risk patients as an attempt to reduce CT scans in children.Conclusions: We present new evidence and consensus based Scandinavian Neurotrauma Committee guidelines for initial management of minor and moderate head trauma in children. These guidelines should be validated before extensive clinical use and updated within four years due to rapid development of new diagnostic tools within paediatric neurotrauma. [ABSTRACT FROM AUTHOR]

Background. Images of head CT for the supratentorial compartment are sometimes recommended to be reconstructed with a thickness of 8–10 mm to achieve lesion conspicuity. However, additional images of a thin slice may not be routinely provided for patients with trauma in the emergency room (ER). We investigated the diagnostic sensitivity of a head CT, where axial images were 10 mm thick slices, in cases of linear skull fractures. Methods. Two trauma surgeons retrospectively reviewed head CT with 10 mm slices and skull X-rays of patients admitted to the ER that were diagnosed with a linear skull fracture. All patients had undergone both head CT and skull X-rays (n=410). Result. The diagnostic sensitivity of head CT with a thickness of sequential 10 mm was 89% for all linear skull fractures but only 56% for horizontal fractures. This CT technique with 10 mm slices missed 6% of patients with linear skull fractures. False-negative diagnoses were significantly more frequent for older (≥55 years) than for young (<15 years) individuals (p=0.048). Conclusions. A routine head CT of the supratentorial region for patients in the ER with head injuries requires both thick-slice images to visualize cerebral hemispheres and thin-slice images to detect skull fractures of the cranial vault. [ABSTRACT FROM AUTHOR]

Computed tomography (CT) scanning is an essential diagnostic tool and has revolutionized care of patients in the acute care setting. However, there is widespread agreement that overutilization of CT, where benefits do not exceed possible costs or harms, is occurring. The goal was to seek consensus in identifying and prioritizing research questions and themes that involve the comparative effectiveness of "traditional" CT use versus alternative diagnostic strategies in the acute care setting. A modified Delphi technique was used that included input from emergency physicians, emergency radiologists, medical physicists, and an industry expert to achieve this. [ABSTRACT FROM AUTHOR]

Background: Overuse of computed tomography (CT) for minor head injury continues despite developed and rigorously validated clinical decision rules like the Canadian CT Head Rule (CCHR). Adherence to this sensitive and specific rule could decrease the number of CT scans performed in minor head injury by 35%. But in practice, the CCHR has failed to reduce testing, despite its accurate performance. Objectives: The objective was to identify nonclinical, human factors that promote or inhibit the appropriate use of CT in patients presenting to the emergency department (ED) with minor head injury. Methods: This was a qualitative study in three phases, each with interview guides developed by a multidisciplinary team. Subjects were recruited from patients treated and released with minor head injuries and providers in an urban academic ED and a satellite community ED. Focus groups of patients (four groups, 22 subjects total) and providers (three groups, 22 subjects total) were conducted until thematic saturation was reached. The findings from the focus groups were triangulated with a cognitive task analysis, including direct observation in the ED (>150 hours), and individual semistructured interviews using the critical decision method with four senior physician subject matter experts. These experts are recognized by their peers for their skill in safely minimizing testing while maintaining patient safety and engagement. Focus groups and interviews were audio recorded and notes were taken by two independent note takers. Notes were entered into ATLAS.ti and analyzed using the constant comparative method of grounded theory, an iterative coding process to determine themes. Data were double-coded and examined for discrepancies to establish consensus. Results: Five core domains emerged from the analysis: establishing trust, anxiety (patient and provider), constraints related to ED practice, the influence of others, and patient expectations. Key themes within these domains included patient engagement, provider confidence and experience, ability to identify and manage patient anxiety, time constraints, concussion knowledge gap, influence of health care providers, and patient expectations to get a CT. Conclusions: Despite high-quality evidence informing use of CT in minor head injury, multiple factors influence the decision to obtain CT in practice. Identifying and disseminating approaches and designing systems that help clinicians establish trust and manage uncertainty within the ED context could optimize CT use in minor head injury. [ABSTRACT FROM AUTHOR]

Background: There is no clear consensus regarding radiologic evaluation of head trauma in young children without traumatic brain injury. We conducted a study to develop and validate a clinical decision rule to identify skull fracture in young children with head trauma and no immediate need for head tomography.Methods: We performed a prospective cohort study in 3 tertiary care emergency departments in the province of Quebec. Participants were children less than 2 years old who had a head trauma and were not at high risk of clinically important traumatic brain injury (Glasgow Coma Scale score < 15, altered level of consciousness or palpable skull fracture). The primary outcome was skull fracture. For each participant, the treating physician completed a standardized report form after physical examination and before radiologic evaluation. The decision to order skull radiography was at the physician's discretion. The clinical decision rule was derived using recursive partitioning.Results: A total of 811 patients (49 with skull fracture) were recruited during the derivation phase. The 2 predictors identified through recursive partitioning were parietal or occipital swelling or hematoma and age less than 2 months. The rule had a sensitivity of 94% (95% confidence interval [CI] 83%-99%) and a specificity of 86% (95% CI 84%-89%) in the derivation phase. During the validation phase, 856 participants (44 with skull fracture) were recruited. The rule had a sensitivity of 89% and a specificity of 87% during this phase.Interpretation: The clinical decision rule developed in this study identified about 90% of skull fractures among young children with mild head trauma who had no immediate indication for head tomography. Use of the rule would have reduced the number of radiologic evaluations by about 60%. [ABSTRACT FROM AUTHOR]

Over the past 60 years, the diagnosis of abuse in children has been challenged within both the medical and the legal communities. Nowhere has this been more apparent than in the literature addressing abusive head trauma in infants and children. The diagnostic terminology used currently, while more encompassing than terminology used in the past, has contributed to confusion about the strength of scientific evidence for inflicted injuries. Fortunately, a variety of medical disciplines, including pediatrics, emergency medicine, radiology, ophthalmology, pathology, biomechanics, neurosurgery, and neurology, have contributed to an unprecedented growth in our understanding of inflicted head trauma in children. We can now confirm that abusive head trauma does occur, that it is the leading cause of traumatic death in children under 2 years of age, that it has a characteristic clinical presentation and injury pattern, and that it can involve a variety of different injury mechanisms. Awareness of these mechanisms and rigorous efforts to ensure comprehensive clinical assessments will best inform the diagnostic process. Being able to identify abusive head trauma and finding answers to the challenging questions that remain, including how to mitigate damage when a young patient presents with head trauma, will lead ultimately to improvements in both outcomes and prevention. [ABSTRACT FROM AUTHOR]

Abusive head trauma is a serious form of child abuse and mostly seen in infants below the age of two years as a result of a strong shaking by the caregiver who aims to stop the infant's crying. Characteristic symptoms include subdural hematomas, encephalopathy, retinal hemorrhages and fractures of the long bones. When physically examined, there are generally no externally visible signs. For this reason, it can be underdiagnosed, if it is not considered in the differential diagnosis. When the information provided from the parents is inconsistent and contradictory with the clinical picture of the patient, this form of abuse must be suspected and retinal hemorrhages should be searched. In this article, two patients who were admitted to our emergency department and diagnosed with physical child abuse are reported. One of these patients had a history of minor head trauma after falling down from the sofa and the other one had a history of breathlessness and loss of consciousness as a result of excessive crying. [ABSTRACT FROM AUTHOR]

Existing helmet sensor technologies are cost prohibitive or limited in capability to comprehensively assess sports-related head injury. Therefore, development of an accurate, fully compatible low-cost pressure-sensitive sensor is warranted. The aim was to develop a piezo-resistive sensor platform for direct measurement of HIC. Using a programmable microcontroller and 30x35 mm sensor, fifty drop tests with a 5 kg mass were conducted using a Kistler force plate with maximum vertical force of 5000 N. The Power function correlation between force-plate-derived peak force and sensor-derived peak resistance was high (r 2 = 0.974) and used to calculate sensor-derived force-time data. Analysis of force-time curves yielded comparable peak forces (R = 0.982) and time to peak forces (R = 0.938), yet sensor-derived impact durations were elevated (R = 0.498). High linear correlation was found between force-plate- and sensor-derived HIC (r 2 = 0.974). The force plate-derived HIC can be directly estimated with sufficient accuracy from sensor-derived force (r 2 = 0.980) and a residual standard deviation of 11% at HIC >100. Overall, results substantiated the piezo-resistive sensor platform for direct HIC measurement and development of a full-scale helmet system. [ABSTRACT FROM AUTHOR]

Objectives Concussion is the most common type of mild traumatic brain injury for which patients present to the emergency department ( ED). It is critical to understand the contemporary epidemiology of concussion and rates of head computed tomography ( CT) use in head-injured patients to inform education of evidence-based clinical practice guidelines to emergency medicine providers. Methods This was a cross-sectional analysis of the Nationwide Emergency Department Sample ( NEDS) for years 2006 to 2011, representing a stratified probability sample of all U.S. hospital-based EDs. Patients of all ages with concussion diagnoses were included, and those with intracranial hemorrhages or prolonged loss of consciousness were excluded. Descriptive and bivariate statistics were summarized for patient demographics, injury mechanism, Injury Severity Scores ( ISS), and concussion incidence rates, based on U.S. Census Bureau population estimates. Results There were 756,214,762 (weighted) ED visits in the NEDS between 2006 and 2011, of which 0.5% received diagnoses of concussion. The national incidence rate of concussion visits increased 22.6% from 195 visits per 100,000 person-years in 2006 to 239 visits per 100,000 person-years in 2011. The incidence of concussion visits increased by 28.1% from 2006 to 2011 overall (580,573 to 743,994) and within all age group categories. The rate of head CT use in patients diagnosed with concussion increased 35.7% (range = 34.5% to 46.8%) for the entire group from 2006 to 2011 (p < 0.0001). The injury severity of patients' injuries decreased over time (66.4% ISS < 5 in 2006 and 75% in 2011; p < 0.0001), while the proportion of discharged patients increased over time (78.1% in 2006 and 86.6% in 2011; p < 0.0001). Conclusions ED visits for concussions have increased over time, with a corresponding increase in head CT utilization despite a decrease in injury severity. Increased visits may be due to more concussion awareness and recognition of subtle injuries. Evidence-based clinical practice guidelines for neuroimaging in head-injured patients and management of concussion should be reinforced to emergency medicine providers. [ABSTRACT FROM AUTHOR]

Shared decision-making ( SDM), a collaborative process in which patients and providers make health care decisions together, taking into account the best scientific evidence available, as well as the patient's values and preferences, is being increasingly advocated as the optimal approach to decision-making for many health care decisions. The rapidly paced and often chaotic environment of the emergency department ( ED), however, is a unique clinical setting that offers many practical and contextual challenges. Despite these challenges, in a recent survey emergency physicians reported there to be more than one reasonable management option for over 50% of their patients and that they take an SDM approach in 58% of such patients. SDM has also been selected as the topic on which to develop a future research agenda at the 2016 Academic Emergency Medicine consensus conference, 'Shared Decision-making in the Emergency Department: Development of a Policy-relevant Patient-centered Research Agenda' (). In this paper the authors describe the conceptual model of SDM as originally conceived by Charles and Gafni and highlight aspects of the model relevant to the practice of emergency medicine. In addition, through the use of vignettes from the authors' clinical practices, the applicability of SDM to contemporary EM practice is illustrated and the ethical and pragmatic implications of taking an SDM approach are explored. It is hoped that this document will be read in advance of the 2016 Academic Emergency Medicine consensus conference, to facilitate group discussions at the conference. [ABSTRACT FROM AUTHOR]

Objective--To review results of MRI performed within 48 hours after head trauma in dogs and identify associations between MRI findings and outcome. Design--Retrospective case series. Animals--18 dogs that underwent MRI within 48 hours after known head trauma. Procedures--Medical records were reviewed for information on signalment, history, clinical findings, MRI findings, treatment, and outcome. Results--2 dogs were euthanized, 1 died, and 1 had major persistent deficits. The remaining 14 dogs had a good outcome, including 9 that recovered completely and 5 that had minor persistent deficits. The most common MRI abnormalities were intra-axial changes (n = 13) and extra-axial hemorrhage (13). Intra-axial changes were best seen on T2-weighted and fluid attenuation inversion recovery (FLAIR) images. A mass effect was detected in 9 dogs, 6 of which had a midline shift (mean, 2.18 mm). Three dogs had transtentorial herniation, and 2 had transcranial herniation. Extra-axial hemorrhage was best seen on FLAIR images. The most common location was subdural, with subdural extra-axial hemorrhage most often seen on the same side as the injury. Epidural hemorrhage was seen in 2 dogs. The affected area was larger in these dogs than in dogs with subdural hemorrhage. One dog required surgery and the other was euthanized. Conclusions and Clinical Relevance--Results suggested that in dogs with acute (< 48 hours' duration) head trauma,T2-weighted and FLAIR images provided the most diagnostic information. Dogs with injuries affecting the caudal fossa or affecting both the rostral and caudal fossae typically had poorer outcomes. [ABSTRACT FROM AUTHOR]

Background Computed tomography ( CT) utilization has increased rapidly over the past 15 years. CT is the most common source for radiation exposure. Objectives The objective was to measure the effective dose of radiation delivered during routine head and abdominal CT examinations at a children's hospital. Methods This was a retrospective study of emergency department ( ED) patients < 20 years of age who underwent head or abdominal CT scans in 2012 at a single children's hospital. The authors abstracted the dose-length product from the CT scanners and calculated the effective radiation dose delivered. Patient demographics were abstracted from the medical record. The relationship between effective dose and age, patient weight, and reason for examination were evaluated. Results A total of 478 subjects were included: 255 underwent head CT, and 223 underwent abdominal CT. The median age was 8.1 years (interquartile range = 2.71 to 14.40 years) and 56.9% were male. The median effective dose for head CT was 2.68 mSv (95% confidence interval [ CI] = 2.54 to 2.84 mSv) and decreased as age increased. For abdominal CT, the median effective dose was 5.06 mSv (95% CI = 4.58 to 6.03 mSv) and increased as age increased (3.67 to 11.12 mSv, p < 0.001). For abdominal CT, 8% of 5- to 10-year-olds, 28% of those 10 to 15 years, and 60% of patients over age 15 years received effective doses over 10 mSv. Conclusions The amount of radiation delivered to pediatric patients during routine CT examinations of the head and abdomen was low. Regardless, a large proportion of older patients were exposed to elevated effective doses of radiation during abdominal CT. [ABSTRACT FROM AUTHOR]

Objective: To analyze the correlation between early-term blood glucose level and prognosis in patients with isolated head trauma. Methods: This study included a total of 100 patients younger than 18 years of age who had isolated head trauma. The admission blood glucose levels of these patients were measured. Age at the time of the incident, sex, mode of occurrence of the trauma, computed tomography findings, and GCSs were recorded. Kruskall Wallis test was used compare of groups. A p value less than 0.05 was considered statistically significant. Results: The median age of the study population was 7 years and the median GCS was 11. There was a significant negative correlation between blood glucose level and GCS (p < 0.05). A significant correlation in the negative direction was observed between GCS and blood glucose level (r = −0.658, p < 0.05). Seventy-seven percent of the patients were admitted to hospital, while 6% died in ED. Conclusion: The results of the present study suggest that hyperglycemia at an early stage and a low GCS may be reliable predictors of the severity of head trauma and prognosis. A higher blood glucose level may be an ominous sign that predicts a poor prognosis and an increased risk of death. [ABSTRACT FROM AUTHOR]

It has been noted that benign paroxysmal positional vertigo (BPPV) may be associated with certain disorders and medical procedures. However, most studies to date were done in Europe, and epidemiological data on the United States (US) population are scarce. Gender-based information is even rarer. Furthermore, it is difficult to assess the relative prevalence of each type of association based solely on literature data, because different comorbidities were reported by various groups from different countries using different patient populations and possibly different inclusion/exclusion criteria. In this study, we surveyed and analyzed a large adult BPPV population (n = 1,360 surveyed, 227 completed, most of which were recurrent BPPV cases) from Omaha, NE, US, and its vicinity, all diagnosed at Boys Town National Research Hospital (BTNRH) over the past decade using established and consistent diagnostic criteria. In addition, we performed a retrospective analysis of patients’ diagnostic records (n = 1,377, with 1,360 adults and 17 children). The following comorbidities were found to be significantly more prevalent in the BPPV population when compared to the age- and gender-matched general population: ear/hearing problems, head injury, thyroid problems, allergies, high cholesterol, headaches, and numbness/paralysis. There were gender differences in the comorbidities. In addition, familial predisposition was fairly common among the participants. Thus, the data confirm some previously reported comorbidities, identify new ones (hearing loss, thyroid problems, high cholesterol, and numbness/paralysis), and suggest possible predisposing and triggering factors and events for BPPV. [ABSTRACT FROM AUTHOR]

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The article presents case study of a 21-year-old women soccer midfielder, from the National Collegiate Athletic Association Division III, who suffered a blow to her head from an opponent's shoulder while participating in an away match. She reported various symptoms including headache, fatigue and drowsiness, and was diagnosed with Concussion. She wore an accelerometer and her Movement and Activity in Physical Space (MAPS) scores were recorded using the Global Positioning system (GPS).