Should all anticoagulated patients with head injury receive a CT scan? Decision-analysis modelling of an observational cohort

Objectives: It is not currently clear whether all anticoagulated patients with a head injury should receive CT scanning or only those with evidence of traumatic brain injury (e.g. loss of consciousness or amnesia). We aimed to determine the cost-effectiveness of CT for all compared to selective CT use for anticoagulated patients with a head injury. Design: Decision-analysis modelling of data from a multi-centre observational study. Setting: 33 Emergency Departments in England and Scotland. Participants: 3566 adults (aged ≥16 years) who had suffered blunt head injury, were taking warfarin and underwent selective CT scanning. Main outcome measures: Estimated expected benefits in terms of quality-adjusted life years (QALYs) were the entire cohort to receive a CT scan; estimated increased costs of CT and also the potential cost implications associated with patient survival and improved health. These values were used to estimate the cost per QALY of implementing a strategy of CT for all patients compared to observed practice based on guidelines recommending selective CT use. Results: Of the 1420/3534 patients (40%) who did not receive a CT scan, 7 (0.5%) suffered a potentially avoidable head injury related adverse outcome. If CT scanning had been performed in all patients, appropriate treatment could have gained 3.41 additional quality-adjusted life years (QALYs) but would have incurred £193,149 additional treatment costs and £130,683 additional CT costs. The incremental cost-effectiveness ratio of £94,895/QALY gained for unselective compared to selective CT use is markedly above the threshold of £20-30,000/QALY used by the UK National Institute for Care Excellence to determine cost-effectiveness. Conclusions: CT scanning for all anticoagulated patients with head injury is not cost-effective compared with selective use of CT scanning based on guidelines recommending scanning only for those with evidence of traumatic brain injur

AHEAD Study: an observational study of the management of anticoagulated patients who suffer head injury

OBJECTIVES: Management of anticoagulated patients after head injury is unclear due to lack of robust evidence. This study aimed to determine the adverse outcome rate in these patients and identify risk factors associated with poor outcome. DESIGN: Multicentre, observational study using routine patient records. SETTING: 33 emergency departments in England and Scotland. PARTICIPANTS: 3566 adults (aged ≥16 years) who had suffered blunt head injury and were currently taking warfarin. MAIN OUTCOME MEASURES: Primary outcome measure was rate of adverse outcome defined as death or neurosurgery following initial injury, clinically significant CT scan finding or reattendance with related complication within 10 weeks of initial hospital attendance. Secondary objectives included identifying risk factors for adverse outcome using univariable and multivariable analyses. RESULTS: Clinical data available for 3534/3566 patients (99.1%), median age 79 years; mean initial international normalised ratio (INR) 2.67 (SD 1.34); 81.2% Glasgow Coma Scale (GCS) 15: 59.8% received a CT scan with significant head injury-related finding in 5.4% (n=208); 0.5% underwent neurosurgery; 1.2% patients suffered a head injury-related death. Overall adverse outcome rate was 5.9% (95% CI 5.2% to 6.7%). Patients with GCS=15 and no associated symptoms had lowest risk of adverse outcome (risk 2.7%; 95% CI 2.1 to 3.6). Patients with GCS=15 multivariable analysis (using imputation) found risk of adverse outcome to increase when reporting at least one associated symptom: vomiting (relative risk (RR) 1.8; 95% CI 1.0 to 3.4), amnesia (RR 3.5; 95% CI 2.1 to 5.7), headache (RR 1.3; 95% CI 0.8 to 2.2), loss of consciousness (RR 1.75; 95% CI 1.0 to 3.0). INR measurement did not predict adverse outcome in patients with GCS=15 (RR 1.1; 95% CI 1.0 to 1.2). CONCLUSIONS: In alert warfarinised patients following head injury, the presence of symptoms is associated with greater risk of adverse outcome. Those with GCS=15 and no symptoms are a substantial group and have a low risk of adverse outcome. TRIAL REGISTRATION NUMBER: NCT02461498

A case for improved assessment of gut permeability: a meta-analysis quantifying the lactulose:mannitol ratio in coeliac and Crohn’s disease

Background: A widely used method in assessing small bowel permeability is the lactulose:mannitol test, where the lactulose:mannitol ratio (LMR) is measured. However, there is discrepancy in how the test is conducted and in the values of LMR obtained across studies. This meta-analysis aims to determine LMR in healthy subjects, coeliac and Crohn’s disease. Methods: A literature search was performed using PRISMA guidance to identify studies assessing LMR in coeliac or Crohn’s disease. 19 studies included in the meta-analysis measured gut permeability in coeliac disease, 17 studies in Crohn’s disease. Outcomes of interest were LMR values and comparisons of standard mean difference (SMD) and weighted mean difference (WMD) in healthy controls, inactive Crohn’s, active Crohn’s, treated coeliac and untreated coeliac. Pooled estimates of differences in LMR were calculated using the random effects model. Results: Pooled LMR in healthy controls was 0.014 (95% CI: 0.006–0.022) while pooled LMRs in untreated and treated coeliac were 0.133 (95% CI: 0.089–0.178) and 0.037 (95% CI: 0.019–0.055). In active and inactive Crohn’s disease, pooled LMRs were 0.093 (95% CI: 0.031–0.156) and 0.028 (95% CI: 0.015–0.041). Significant differences were observed in LMR between: (1) healthy controls and treated coeliacs (SMD = 0.409 95% CI 0.034 to 0.783, p = 0.032), (2) healthy controls and untreated coeliacs (SMD = 1.362 95% CI: 0.740 to 1.984, p < 0.001), (3) treated coeliacs and untreated coeliacs (SMD = 0.722 95% CI: 0.286 to 1.157, p = 0.001), (4) healthy controls and inactive Crohn’s (SMD = 1.265 95% CI: 0.845 to 1.686, p < 0.001), (5) healthy controls and active Crohn’s (SMD = 2.868 95% CI: 2.112 to 3.623, p < 0.001), and (6) active Crohn’s and inactive Crohn’s (SMD = 1.429 (95% CI: 0.580 to 2.278, p = 0.001). High heterogeneity was observed, which was attributed to variability in protocols used across different studies. Conclusion: The use of gut permeability measurements in screening and monitoring of coeliac and Crohn’s disease is promising. LMR is useful in performing this function with significant limitations. More robust alternative tests with higher degrees of clinical evidence are needed if measurements of gut permeability are to find widespread clinical use

Cancer experience in the relatives of an unselected series of breast cancer patients.

First- and second-degree relatives of an unselected series of 402 breast cancer patients have been studied for their cancer experience. In the first-degree relatives an excess of all cancers is seen [overall relative risk (RR) = 1.28, P = 0.002; males RR = 1.26, P = 0.047; females RR = 1.30, P = 0.022). There is a marked excess of sarcoma (RR = 4.26, P = 0.0064); females are at high risk of breast cancer (RR = 2.68, P < 0.0001) and males have an excess of carcinoma of the lip, oral cavity and pharynx (RR = 4.22, P = 0.0032). Second-degree relatives have a non-significant excess of all cancers (RR = 1.14, P = 0.14); females have a borderline excess of breast cancer (RR = 1.53, P = 0.08) and an excess of carcinoma of the kidney (RR = 7.46, P = 0.0012) and males have an excess of carcinoma of the trachea and lung (RR = 1.50, P = 0.032). No excess of prostate or ovarian carcinoma was seen. Relatives are at slightly higher risk if the index patient is diagnosed between the ages of 40 and 49 (first-degree RR = 1.64, P = 0.007; second-degree RR = 1.43, P = 0.02). The excess of cancers, including breast cancers, is not limited to a few high-risk families, but appears to be spread across many. These observations may be accounted for by shared environmental factors within families or a common predisposing gene with low penetrance

The Princeton Variability Survey

The Princeton Variability Survey (PVS) is a robotic survey which makes use of readily available, ``off-the-shelf'' type hardware products, in conjunction with a powerful set of commercial software products, in order to monitor and discover variable objects in the night sky. The main goal of the PVS has been to devise an automated telescope and data reduction system, requiring only moderate technical and financial resources to assemble, which may be easily replicated by the dedicated amateur, a student group, or a professional and used to study and discover a variety of variable objects, such as stars. This paper describes the hardware and software components of the PVS device as well as observational results from the initial season of the PVS, including the discovery of a new bright variable star.Comment: 22 pages, 5 figures. Revised to fix typos and expand discussion. Accepted PAS

The Nature of SN 1961V

The nature of SN 1961V has been uncertain. Its peculiar optical light curve and slow expansion velocity are similar to those of super-outbursts of luminous blue variables (LBVs), but its nonthermal radio spectral index and declining radio luminosity are consistent with decades-old supernovae (SNe). We have obtained Hubble Space Telescope STIS images and spectra of the stars in the vicinity of SN 1961V, and find Object 7 identified by Filippenko et al. to be the closest to the optical and radio positions of SN 1961V. Object 7 is the only point source detected in our STIS spectra and only its H-alpha emission is detected; it cannot be the SN or its remnant because of the absence of forbidden lines. While the H-alpha line profile of Object 7 is remarkably similar to that of eta Car, the blue color (similar to an A2Ib supergiant) and lack of appreciable variability are unlike known post-outburst LBVs. We have also obtained Very Long Baseline Array (VLBA) observations of SN 1961V at 18 cm. The non-detection of SN 1961V places a lower limit on the size of the radio-emitting region, 7.6 mas or 0.34 pc, which implies an average expansion velocity in excess of 4,400 km/s, much higher than the optical expansion velocity measured in 1961. We conclude the following: (1) A SN occurred in the vicinity of SN 1961V a few decades ago. (2) If the SN 1961V light maximum originates from a giant eruption of a massive star, Object 7 is the most probable candidate for the survivor, but its blue color and lack of significant variability are different from a post-outburst eta Car. (3) The radio SN and Object 7 could be physically associated with each other through a binary system. (4) Object 7 needs to be monitored to determine its nature and relationship to SN 1961V.Comment: 16 pages, 3 figures, accepted by the Astronomical Journal for the 2004 May issu

A Process and Outcome Evaluation of a Shelter for Homeless Young Women

To evaluate the processes and outcomes of a short-term shelter, both quantitative and qualitative data were gathered via participant observation, focus group interviews with shelter staff and residents, and individual interviews with a sample of 40 young women who had been homeless prior to using the shelter. The process evaluation showed that the shelter staff strived to utilize an empowerment philosophy in their relationships with residents, but that there were many challenges to implementing this philosophy. The outcome evaluation showed that, at a 3-month follow-up, the participants reported significant improvements in housing, income, independence, and life satisfaction, but most continued to experience poverty and a number of other difficulties. The results were discussed in terms of the implications for future research and the value and limitations of shelters for dealing with homeless youth. The need for more sustained and comprehensive program interventions and supportive social policies was underscored