51 CT Head and Cervical Spine Audit in Patients Over the Age of 65: A District General Hospital Perspective

Introduction

Cervical spine (c-spine) injury has a high morbidity and mortality in patients over the age of 65; more than 60% result from falls from standing height (Beedham et al., 2019).

The Canadian Cervical Spine Rule (Stiell et al., 2001) deems that there is a high risk of c-spine fracture if any of the following apply:

The c-spine cannot be cleared clinically if the patient fits any of the above criteria. Imaging should be considered. As a result of recent clinical experiences Trust Guidelines at Stoke Mandeville Hospital now reflect this evidence (Hadley et al., 2019).

Methods

Fifty patients over the age of 65 who had a computerised tomography (CT) head scan in the Emergency Department (ED) following a traumatic head injury were randomly selected over a 1 month period. Cases were checked for examination of c-spine and/or CT c-spine. Results of the first cycle of the audit were presented at an ED Education Meeting. Indications for CT c-spine were displayed in poster format around the ED. Following these interventions, a re-audit was carried out using the same methodology.

Results

In fifty patients aged over 65 attending ED during one month, 16% had a CT c-spine in addition to a CT head. There was documented c-spine examination of 16% of those without CT c-spine on admission. In the re-audit 38% of the fifty patients who had a CT head underwent CT c-spine. In the group that did not have imaging of the c-spine, the proportion with documented cervical spine examination on admission remained the same (16%).

Conclusion

There was a 137.5% increase in the number of patients aged over 65 who appropriately underwent a CT c-spine as per Trust and National guidelines. Simple interventions (staff education and posters within the ED) were sufficient to significantly alter practice. Current trauma triage is not optimal for older patients who are reviewed by more junior doctors, less likely to be transferred to Major Trauma Centres and more likely to die than younger patients with similar injuries (Major Trauma In Older People 2017 Report). An older person’s trauma team in ED with age-appropriate triage would lead to appropriate imaging in a timely fashion, potentially improving the morbidity and mortality of these vulnerable patients.

A potential pathway for managing diabetic patients with arterial emboli detected by retinal screening

OBJECTIVE

The aim was to review a pathway of care for diabetic patients found to have retinal artery emboli detected by retinal screening.

DESIGN

This was a retrospective review of a pathway agreed in 2001 by a multidisciplinary team.

MATERIALS AND METHODS

The prospectively collected Gloucestershire Diabetic Retinal Screening Programme database was reviewed; patients sent for carotid duplex imaging underwent review of their scan results and their casenotes.

RESULTS

The prevalence of retinal emboli was 214 out of 25,299 diabetic patients who had retinal screening (0.85%). Some 200 diabetic patients underwent carotid duplex imaging; 23 had ipsilateral and 2 had contralateral carotid stenosis > 70%. Of these, ten patients underwent carotid endarterectomy without any major morbidity.

CONCLUSIONS

[corrected] A pathway was established for the small number of patients with retinal emboli, and could be tested in other populations.

Deficiency of Atf3, an adaptive-response gene, protects islets and ameliorates inflammation in a syngeneic mouse transplantation model

AIMS/HYPOTHESIS

Islet transplantation is a potential therapeutic option for type 1 diabetes. However, the need for multiple donors per patient and heavy immunosuppression of the recipients limit its use. The goal of this study was to test whether the gene encoding activating transcription factor 3 (ATF3), a stress-inducible pro-apoptotic gene, plays a role in graft rejection in islet transplantation.

METHODS

We compared wild-type (WT) and Atf3 knockout (KO) islets in vitro using stress paradigms relevant to islet transplantation: isolation, inflammation and hypoxia. We also compared the WT and KO islets in vivo using a syngeneic mouse transplantation model.

RESULTS

ATF3 was induced in all three stress paradigms and played a deleterious role in islet survival, as evidenced by the lower viability of WT islets compared with KO islets. ATF3 upregulated various downstream target genes in a stress-dependent manner. These target genes can be classified into two functional groups: (1) apoptosis (Noxa [also known as Pmaip1] and Bnip3), and (2) immunomodulation (Tnfalpha [also known as Tnf], Il-1beta [also known as Il1b], Il-6 [also known as Il6] and Ccl2 [also known as Mcp-1]). In vivo, Atf3 KO islets performed better than WT islets after transplantation, as evidenced by better glucose homeostasis in the recipients and the reduction of the following variables in the KO grafts: caspase 3 activation, macrophage infiltration and expression of the above apoptotic and immunomodulatory genes.

CONCLUSIONS/INTERPRETATION

ATF3 plays a role in islet graft rejection by contributing to islet cell death and inflammatory responses at the graft sites. Silencing the ATF3 gene may provide therapeutic benefits in islet transplantation.

Acute humoral rejection of renal allografts in CCR5(-/-) recipients

Increasing detection of acute humoral rejection (AHR) of renal allografts has generated the need for appropriate animal models to investigate underlying mechanisms. Murine recipients lacking the chemokine receptor CCR5 reject cardiac allografts with marked C3d deposition in the parenchymal capillaries and high serum donor-reactive antibody titers, features consistent with AHR. The rejection of MHC-mismatched renal allografts from A/J (H-2(a)) donors by B6.CCR5(-/-) (H-2(b)) recipients was investigated. A/J renal allografts survived longer than 100 days in wild-type C57BL/6 recipients with normal blood creatinine levels (28 +/- 7 micromol/L). All CCR5(-/-) recipients rejected renal allografts within 21 days posttransplant (mean 13.3 +/- 4 days) with elevated creatinine (90 +/- 31 micromol/L). The rejected allografts had neutrophil and macrophage margination and diffuse C3d deposition in peritubular capillaries, interstitial hemorrhage and edema, and glomerular fibrin deposition. Circulating donor-reactive antibody titers were 40-fold higher in B6.CCR5(-/-) versus wild-type recipients. Depletion of recipient CD8 T cells did not circumvent rejection of the renal allografts by CCR5-deficient recipients. In contrast, microMT(-/-)/CCR5(-/-) recipients, incapable of producing antibody, did not reject most renal allografts. Collectively, these results indicate the rapid rejection of renal allografts in CCR5(-/-) recipients with many histopathologic features observed during AHR of human renal allografts.

The safety and efficacy of the StarClose® vascular closure system: The ultrasound substudy of the CLIP study

BACKGROUND

The StarClose Vascular Closure System (Abbott Vascular, Redwood City, CA) features a nitinol clip that is designed to achieve closure of the femoral arteriotomy access site. The CLIP Study was performed to assess the safety and efficacy of StarClose when compared with standard manual compression following 5-6 French diagnostic or interventional percutaneous procedures. A substudy of this trial was designed to assess the utility of duplex ultrasonography to assess patency of the femoral artery and to determine access site complications (pseudoaneurysm, arteriovenous fistula, hematoma, deep vein thrombosis) in a multicenter prospective trial. This is the report of the duplex ultrasound (DUS) substudy of the CLIP trial.

METHODS

A total of 17 U.S. sites enrolled 596 subjects with 483 subjects randomized at a 2:1 ratio to receive StarClose or manual compression of the arteriotomy after a percutaneous procedure. The study included roll-in (n = 113), diagnostic (n = 208), and interventional (n = 275) arms with a primary safety endpoint of major vascular complications through 30 days and a primary efficacy endpoint of postprocedure time to hemostasis. A substudy of the CLIP interventional arm evaluated DUS images of the closure site at five study sites, targeting 100 subjects at day 30 following hemostasis. The DUS protocol was devised and implemented by an independent vascular ultrasound core laboratory with extensive experience in vascular device trials. DUS inguinal region from 6 cm proximal to 6 cm distal to the arteriotomy puncture was performed. A qualitative examination was performed to determine the presence of iatrogenic vascular injuries: hematoma, pseudoaneurysm (PSA), arteriovenous fistula (AVF), and arterial/venous thrombosis or stenosis using 2-dimensional gray scale, color, and focused Doppler images.

RESULTS

DUS of 96 subjects randomized to StarClose (n = 71) and compression (n = 25) were performed and evaluated. There was no evidence of hematoma, PSA, or AVF observed in the StarClose group. No StarClose subjects in the substudy had a PSA or AVF. All patients in the substudy demonstrated patency of the access site artery and vein without thrombosis or stenosis. Finally, in the entire study cohort, no clinically-driven DUS studies demonstrated iatrogenic vascular injury or vessel thrombosis in the StarClose treated patients.

CONCLUSION

DUS, a safe and reliable method for determining the safety and efficacy of access site closure devices, is a reliable, safe, inexpensive and accurate method of assessing vascular access site complications in multicenter trials. In this substudy of the CLIP study, DUS found no statistical difference in access site complications between the StarClose and manual compression groups. Both groups maintained vessel patency without stenosis, thrombosis, hematoma, pseudoaneurysm, or AV fistula.

Comparison of two methods for use in adaptive automation

Two psychophysiological adaptive automation methods were compared to assess their relative influence on teaching performance of 16 adults.

Inclusion of peripancreatic lymph node cells prevents recurrent autoimmune destruction of islet transplants: evidence of donor chimerism

BACKGROUND

Recurrent autoimmune beta-cell destruction may contribute to the poor results of clinical islet transplantation. Pancreas transplants from diabetes-resistant BB rats (BB-DR) are uniformly successful in autoimmune diabetic BB rats (BB-Ac), but isolated islets are destroyed, despite immunosuppression. In this study we tested the hypothesis that whole pancreas transplants abrogate autoimmunity by passive transfer to the host of an autoregulatory T-cell subset.

METHODS

BB-Ac rats served as recipients of BB-DR or Wistar Furth (WF) pancreas or islet transplants. Two cohorts of islet transplants included 50 or 100 x 10(6) peripancreatic lymph node cells (LNCs). Recipients were monitored for recurrent diabetes and subjected to fluorescence-activated cell sorter analysis of peripheral blood lymphocytes after 200 days by using monoclonal antibodies to class I, CD4, CD8, RT6.2, and RT6.1.

RESULTS

BB-DR pancreas transplants replete the RT6.1+ T-cell subset in BB-Ac rats, whereas BB-DR islet transplants, which are susceptible to recurrent autoimmunity, do not. Addition of 100 x 10(6) LNC results in repletion of RT6.1 to the same degree as the whole pancreas and leads to complete protection of the islets. WF pancreas transplants result in the appearance of RT6.2+ T cells in BB-Ac recipients, an RT allele that BB rats lack.

CONCLUSIONS

BB-Ac rat recipients of whole pancreatic or islets plus LNCs transplants become chimeric for a donor T-cell population that prevents recurrent autoimmune diabetes. Deliberate inclusion of donor lymphoid cells with clinical islet transplants may be beneficial.

Antiidiotypic antibodies to HLA class I alloantibodies in normal individuals: a mechanism of tolerance to noninherited maternal HLA antigens

Recent reports indicate that 25%-50% of transplant patients exhibit B-cell nonresponsiveness to their noninherited maternal HLA antigens (NIMAs). To test the hypothesis that tolerance of NIMAs is mediated by antiidiotypic antibodies, sera from seven normal human subjects were tested for the capacity to inhibit the reactivity of HLA alloantisera directed to NIMAs. Five of seven sera inhibited (50%-100%) the cytotoxicity of monospecific alloantisera directed to their NIMAs. This inhibition was specific in that antisera directed to third-party HLA antigens were not inhibited. Cytotoxicity inhibition by normal sera was selective for antisera directed to HLA-B locus antigens. Absorption with an antibody specific for an HLA class I framework determinant eliminated the inhibitory activity of three of the five sera, suggesting that the inhibition was mediated by soluble HLA antigens in these cases. However, two of the sera retained inhibitory activity following soluble antigen depletion, suggesting that, in these cases, inhibition is mediated by antiidiotypic antibodies. This hypothesis was confirmed by purifying the immunoglobulin (Ig) fraction of one of these sera by anti-Ig affinity chromatography; the column eluate (Ig fraction) but not the effluent (Ig-depleted serum) was capable of inhibition. These data are consistent with the hypothesis that tolerance of NIMAs is mediated, at least in part, by antiidiotypic antibodies.

Mesenchymal hamartoma of the liver. A report of 5 cases

Mesenchymal hamartoma of the liver is a rare benign tumour of childhood, characterised by an admixture of ductal structures within a copious loose connective tissue stroma. Less consistent features include hepatocytes and haemopoietic elements. The stroma has a propensity to accumulate fluid and to create macroscopic cystic spaces. Five cases are reported.

Functional and biochemical parameters of peptide antigen presentation

To understand the mechanism by which peptide antigens are processed and presented to T cells, we examined the T-cell response to the 13-amino-acid peptide alpha-melanocyte-stimulating hormone (alpha-MSH). To determine the fine specificity of T-cell recognition, T cells specific for alpha-MSH, and genetically restricted by I-Ab/d, were challenged with different alpha-MSH analogs and homologs. It was found that intact alpha-MSH, including the blocked amino and carboxy termini of the native molecule, was required for T-cell responsiveness. Antigen-presenting cells (APC) could be briefly pulsed with alpha-MSH and then present the alpha-MSH antigenic determinant to T cells, indicating that the relevant antigen was retained by the APC. APC stimulatory capacity was dramatically reduced by aldehyde treatment of the APC, or by pulsing the APC with alpha-MSH at low temperature. Efficient alpha-MSH pulsing was also impaired by treatment of the APC with the carboxylic ionophore, monensin, but not by the lysosomotropic agents chloroquine and methylamine. In addition, isolated APC plasma membranes added to the T cells in the presence of soluble alpha-MSH were not stimulatory. However, plasma membranes isolated from APC that had been previously pulsed with alpha-MSH retained stimulatory activity for T-cell responses. The only detectable alpha-MSH contained in these pulsed APC membranes was in an acid-stable complex of higher molecular weight than native peptide. The amount of alpha-MSH detected in the cellular membrane fraction isolated by density gradient sedimentation was also reduced by treatments that reduced the APC stimulatory capacity, such as pulsing at low temperature or in the presence of monensin. Taken together, these results suggest that processing of alpha-MSH is unlike that heretofore described for other peptide antigens and seems to involve APC handling to form the stimulatory moiety presented on the APC surface.

Fine structure of the host-fungus interface in orchid mycorrhiza

Electron microscopy of protocorms of Dactylorhiza purpurella infected with a symbiotic Rhizoctonia sp. showed that the intracellular hyphae examined did not penetrate the plasmalemma of the host cell. Walls of hyphae within cells bore many hemispherical protuberances over which the host plasmalemma was closely pressed. we estimate that these protuberances would increase the area of contact between hyphae and host plasmalemma by about 15%. They were not found on hyphae growing on agar. Except for these protuberances, and some vesicles or tubules which invaginated the fungus plasmalemma, no other structures were seen which could be suggested to be adaptations to transport across the living fungus-host interface.