Update on abusive head trauma. Abuse-related head injuries and ESPED data

Abusive head trauma (AHT) is a clearly defined and established medical diagnosis, the basic concept of which has remained unchanged for a considerable length of time. In the last decade new and more precise data have evolved based on systematic reviews and meta-analyses concerning the validity of symptoms and the correct foundation of the diagnosis. The diagnosis of AHT requires a high level of attention and knowledge, integration of the patient history, symptoms and findings, targeted clinical, radiological and ophthalmological examinations, the exclusion of relevant differential diagnoses and a structured multidisciplinary child protection team approach. The results of the German study on the incidence and characteristics of AHT, which was coordinated by the Sampling Unit for Rare Pediatric Diseases in Germany (ESPED) showed comparable data concerning international epidemiology and characteristics of AHT. Controversies concerning acceptance of the validity of the diagnosis have come up mainly in court proceedings and in public media rather than in the medical and scientific debate; however, these debates must be known to the clinician who may have to serve as an expert at court. Different approaches and initiatives for prevention of AHT have increasingly been developed, so far without clear evidence for efficacy

Vorapaxar in the secondary prevention of atherothrombotic events

Item does not contain fulltextBACKGROUND: Thrombin potently activates platelets through the protease-activated receptor PAR-1. Vorapaxar is a novel antiplatelet agent that selectively inhibits the cellular actions of thrombin through antagonism of PAR-1. METHODS: We randomly assigned 26,449 patients who had a history of myocardial infarction, ischemic stroke, or peripheral arterial disease to receive vorapaxar (2.5 mg daily) or matching placebo and followed them for a median of 30 months. The primary efficacy end point was the composite of death from cardiovascular causes, myocardial infarction, or stroke. After 2 years, the data and safety monitoring board recommended discontinuation of the study treatment in patients with a history of stroke owing to the risk of intracranial hemorrhage. RESULTS: At 3 years, the primary end point had occurred in 1028 patients (9.3%) in the vorapaxar group and in 1176 patients (10.5%) in the placebo group (hazard ratio for the vorapaxar group, 0.87; 95% confidence interval [CI], 0.80 to 0.94; P<0.001). Cardiovascular death, myocardial infarction, stroke, or recurrent ischemia leading to revascularization occurred in 1259 patients (11.2%) in the vorapaxar group and 1417 patients (12.4%) in the placebo group (hazard ratio, 0.88; 95% CI, 0.82 to 0.95; P=0.001). Moderate or severe bleeding occurred in 4.2% of patients who received vorapaxar and 2.5% of those who received placebo (hazard ratio, 1.66; 95% CI, 1.43 to 1.93; P<0.001). There was an increase in the rate of intracranial hemorrhage in the vorapaxar group (1.0%, vs. 0.5% in the placebo group; P<0.001). CONCLUSIONS: Inhibition of PAR-1 with vorapaxar reduced the risk of cardiovascular death or ischemic events in patients with stable atherosclerosis who were receiving standard therapy. However, it increased the risk of moderate or severe bleeding, including intracranial hemorrhage. (Funded by Merck; TRA 2P-TIMI 50 ClinicalTrials.gov number, NCT00526474.)