David Yates

Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial.

BACKGROUND Corticosteroids have been used to treat head injuries for more than 30 years. In 1997, findings of a systematic review suggested that these drugs reduce risk of death by 1-2%. The CRASH trial--a multicentre international collaboration--aimed to confirm or refute such an effect by recruiting 20000 patients. In May, 2004, the data monitoring committee disclosed the unmasked results to the steering committee, which stopped recruitment. METHODS 10008 adults with head injury and a Glasgow coma score (GCS) of 14 or less within 8 h of injury were randomly allocated 48 h infusion of corticosteroids (methylprednisolone) or placebo. Primary outcomes were death within 2 weeks of injury and death or disability at 6 months. Prespecified subgroup analyses were based on injury severity (GCS) at randomisation and on time from injury to randomisation. Analysis was by intention to treat. Effects on outcomes within 2 weeks of randomisation are presented in this report. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN74459797. FINDINGS Compared with placebo, the risk of death from all causes within 2 weeks was higher in the group allocated corticosteroids (1052 [21.1%] vs 893 [17.9%] deaths; relative risk 1.18 [95% CI 1.09-1.27]; p=0.0001). The relative increase in deaths due to corticosteroids did not differ by injury severity (p=0.22) or time since injury (p=0.05). INTERPRETATION Our results show there is no reduction in mortality with methylprednisolone in the 2 weeks after head injury. The cause of the rise in risk of death within 2 weeks is unclear.

Head injury outcome prediction in the emergency department: a role for protein S-100B?

Background: Biochemical markers released after head injury may reflect the degree of brain damage, which is related to subsequent disability. If the serum level of a marker were found to be related to outcome, then earlier identification and intervention would be possible. Objective: To investigate the potential of the serum marker S-100B protein to predict the outcome after head injury. Methods: Blood samples for S-100B concentrations were taken from 148 adults within six hours of a head injury (initial Glasgow coma score 4–15). Patients were recruited from the emergency departments of four hospitals in Greater Manchester, United Kingdom. Outcome was assessed in 119 patients (80%) at one month using the extended Glasgow outcome scale (GOSE). Results: A significant inverse correlation between serum S-100B level and GOSE was found (Spearman’s ρ = −0.349, p < 0.0001). A serum S-100B concentration of > 0.32 μg/l predicted severe disability (GOSE < 5) at one month with a sensitivity of 93% (95% confidence interval 68% to 100%), a specificity of 72% (54% to 79%), and a negative predictive value of 99% (93% to 100%). Conclusion: Serum S-100B concentration can be used in the emergency department to identify patients with head injury who are most likely to have a poor outcome at one month.

ABC of major trauma. Scoring systems for trauma.

Cost-benefit analysis of trauma care Input Anatomical injury Physiological derangement Treatment Variations in the system of care Variations in patient care Output Survival: alive or dead? Disability: temporary or permanent? Neurological? Musculoskeletal? Visceral? Previous articles in this series have emphasised the importance of an aggressive, integrated, interdisciplinary approach to trauma care by an experienced team that has immediate access to operating theatres and intensive care facilities. Many of the recommendations can be expected to incur appreciable additional costs. Will this money be well spent? Which changes are most effective in improving patient care and are there any which produce unexpected delays or complications? To answer these questions about a system which has to respond to patients with an almost infinite constellation of injuries is a major challenge in clinical measurement and audit. Clearly, statistical analysis must replace anecdote and dogma, but the complexity of the task should not be underestimated. The effects of injury may be defined in terms of input?an anatomical component and the physiological response?and output?mortality and morbidity. These must be coded numerically before we can comment with confidence on treatment. Elderly people and young children survive trauma less well than others, so age must be taken into account. The mechanism of injury is also important: the effect of a blunt impact from a fall or a car crash is quite different from that of a stab or gunshot wound. Most recent work has been concerned with the measurement of injury severity and its relation to mortality. The assessment of morbidity has been largely neglected, yet there are two seriously impaired survivors for every person who dies owing to trauma.

Reducing accident death rates in children and young adults: the contribution of hospital care

Abstract Objective: To assess the contribution of trauma care to the recent decline in accident death rates among children and young people. Design: Logistic regression modelling of temporal trends in the probability of death in patients admitted to hospital for the treatment of severe injury. Setting: Hospitals participating the United Kingdom major trauma outcome study. Subjects: 3230 patients with an injury severity score of 16 or more, who were admitted for more than three days, transferred or admitted to intensive care, or died from their injuries. Main outcome measures: Death or survival in hospital within three months of injury. Results: Over the seven year period 1989–95 there was a substantial decline in the probability of death among children and young adults admitted to hospital after severe injury. The overall estimate of the reduction in the odds of death was 16% per year (odds ratio for the yearly trend 0.84; 95% confidence interval 0.79 to 0.89). This decline did not differ significantly between age groups. (0–4 years 0.79; 5–14 years 0.87; 15–24 years 0.83). Conclusions: Reductions in hospital case fatality have made an important contribution to reaching the Health of the Nation targets. The contribution of hospital care in the reduction of accident mortality should be taken into account in decisions about the allocation of resources to preventive and curative services. Key messages Government publications emphasise the role of accident prevention in reaching the targets, but the hospital care of seriously injured children might also make an important contribution Analyses of data from the major trauma outcome study show that, after severity of injury is control- led for, there has been a substantial decline in hos- pital case fatality for severe injury Over the seven year period 1989–95 the odds of death after severe injury declined by 16% a year The contribution of hospital care to the reduction of child accident mortality should be taken into account in decisions about the allocation of resources to preventive and curative services

Abdominal injury due to child abuse

Diagnosis of abuse in children with internal abdominal injury is difficult because of limited published work. We aimed to ascertain the incidence of abdominal injury due to abuse in children age 0-14 years. 20 children (identified via the British Paediatric Surveillance Unit) had abdominal injuries due to abuse and 164 (identified via the Trauma Audit and Research Network) had injuries to the abdomen due to accident (112 by road-traffic accidents, 52 by falls). 16 abused children were younger than 5 years. Incidence of abdominal injury due to abuse was 2.33 cases per million children per year (95% CI 1.43-3.78) in children younger than 5 years. Six abused children died. 11 abused children had an injury to the gut (ten small bowel) compared with five (all age >5 years) who were injured by a fall (relative risk 5.72 [95% CI 2.27-14.4]; p=0.0002). We have shown that small-bowel injuries can arise accidentally as a result of falls and road-traffic accidents but they are significantly more common in abused children. Therefore, injuries to the small bowel in young children need special consideration, particularly if a minor fall is the explanation.

Hydroxyethylvaline adduct formation in haemoglobin as a biological monitor of cigarette smoke intake.

The ethylene oxide adduct formed on the N-terminal valine in haemoglobin was investigated as a biological monitor of tobacco smoke intake. The modified method developed for the determination of the hydroxyethylvaline adduct (HOEtVal) involved reaction of globin with pentafluorophenyl isothiocyanate, extraction of the HOEtVal thiohydantoin product, derivatization of this by trimethylsilylation and quantitation by capillary gas chromatography with selective ion monitoring mass spectrometry using a tetradeuterated internal standard. The method was applied to globin samples from 26 habitual cigarette smokers and 24 non-smokers. There was a significant correlation between cigarette smoke intake as measured by the average number of cigarettes smoked per day and HOEtVal levels (r=0.537, p<0.01). Background levels were found in non-smokers (mean 49.9 pmol/g Hb, range 22–106 pmol/g Hb). Smoking increased these levels by 71 pmol/g Hb/ 10 cigarettes per day.Cotinine levels in plasma of the smokers were determined by GC-NPD using 2-methyl-4-nitroaniline as internal standard. For non-smokers cotinine was determined by GC-MS selective ion monitoring using d3-methylcotinine as internal standard. There was no correlation between number of cigarettes smoked per day and cotinine levels (r=0.297, p>0.05) although cotinine was correlated with HOEtVal (r=0.43, p<0.01).The HOEtVal adduct levels thus appear to be a suitable biomonitor for exposure to hydroxyethylating agents in cigarette smoke, reflecting an integrated dose over the erythrocyte lifetime. This is in contrast to plasma cotinine determinations which reflect only the previous days exposure to nicotine in smoke.

Help Stop Teenage Pregnancy! Early-Age Neutering in Cats

Practical relevance Neutering kittens at an early age, typically between 6 and 14 weeks, has received increasing attention and gained prominence in recent years, particularly in the United States and in shelter medicine in the UK. However, in private practice it has yet to be generally endorsed. Global importance Among many of the animal welfare charities, early neutering is seen as a crucial step in conquering and controlling cat overpopulation. Clinical challenges Physiological differences between kittens and adult cats are very important to consider before undertaking elective early neutering. Increased sensitivity to drugs, prolongation of effects and a limited capacity for cardiovascular compensation are the principal anaesthetic concerns in kittens. Evidence base The optimal age for neutering, traditionally deemed to be between 5 and 8 months, is now questioned, as short- and longer-term studies demonstrate no significant behavioural and physical advantages conferred by traditional-age neutering. Furthermore, a number of safe anaesthetic and surgical protocols have been documented that produce lower morbidity and similar mortality rates in early-age neuters compared with traditional-age neuters.

Incidence of cryptorchidism in dogs and cats.

Over a period of 54 months, 3518 dogs and 3806 cats were castrated; 240 of the dogs and 50 of the cats were cryptorchid. Pedigree dogs, in particular the German shepherd dog, boxer and chihuahua were overrepresented. Among the dogs, right-sided inguinal cryptorchidism was the most common form, followed by right-sided abdominal cryptorchidism. The location of the affected testicle(s) was most variable in the boxer. Among the cats, left- or right-sided inguinal cryptorchidism were the most common forms of the condition.

Analgesia after feline ovariohysterectomy under midazolam-medetomidine-ketamine anaesthesia with buprenorphine or butorphanol, and carprofen or meloxicam: a prospective, randomised clinical trial

One hundred female cats undergoing routine ovariohysterectomy under midazolam-medetomidine-ketamine anaesthesia were included in a blinded, randomised, prospective clinical study to compare postoperative analgesia produced by four analgesic drug combinations given preoperatively (n = 25 per group). A secondary aim was to assess the effects in kittens and pregnant animals. Buprenorphine 180 µg/m2 or butorphanol 6 mg/m2 were given with either carprofen 4 mg/kg (groups BUPC and BUTC, respectively) or meloxicam 0.3 mg/kg (groups BUPM or BUTM, respectively). Medetomidine was not antagonised. A simple, descriptive scale (SDS; 0–4), a dynamic and interactive visual analogue scale (DIVAS; 0–100 mm) and mechanical nociceptive thresholds (MT; 2.5-mm diameter probe) were used to evaluate postoperative pain. All pain scores were low (DIVAS <10 mm, SDS <2 and MT >10 N) and there were no significant differences between the groups. It was concluded that all protocols provided adequate analgesia and when used with midazolam-medetomidine-ketamine are effective for routine feline ovariohysterectomy.

Triage: a literature review 1985–19930

Abstract Following an extensive literature review of Accident and Emergency (A & E) nursing from 1985–1993, the authors focused upon triage. A wide range of issues related to triage and its use in A & E departments are examined. An appendix is included to clarify major research finds in this area. Many of the claims made regarding triage require further investigation.