Clinical Response and Remission in Patients With Severe Asthma Treated With Biologic Therapies

BACKGROUND

The development of novel targeted biologic therapies for severe asthma has provided an opportunity to consider remission as a new treatment goal.

RESEARCH QUESTION

How many patients with severe asthma treated with biologic therapy achieve clinical remission, and what predicts response to treatment?

STUDY DESIGN AND METHODS

The Danish Severe Asthma Register is a nationwide cohort including all adult patients receiving biologic therapy for severe asthma in Denmark. This observational cohort study defined "clinical response" to treatment following 12 months as a ≥ 50% reduction in exacerbations and/or a ≥ 50% reduction in maintenance oral corticosteroid dose, if required. "Clinical remission" was defined by cessation of exacerbations and maintenance oral corticosteroids, as well as a normalization of lung function (FEV1 > 80%) and a six-question Asthma Control Questionnaire score ≤ 1.5 following 12 months of treatment.

RESULTS

Following 12 months of treatment, 104 (21%) of 501 biologic-naive patients had no response to treatment, and 397 (79%) had a clinical response. Among the latter, 97 (24%) fulfilled the study criteria of clinical remission, corresponding to 19% of the entire population. Remission was predicted by shorter duration of disease and lower BMI in the entire population of patients treated with biologic therapy.

INTERPRETATION

Clinical response was achieved in most adult patients initiating biologic therapy, and clinical remission was observed in 19% of the patients following 12 months of treatment. Further studies are required to assess the long-term outcome of achieving clinical remission with biologic therapy.

[Patients with COPD have low adherence to inhaled medicine]

Medicine adherence in patients with obstructive pulmonary disease (COPD), has not been studied in Denmark. Studies from other countries, however, unequivocally report low prevalence of patients who follow their doctor's advice and have sufficient adherence to inhaled medicine. In this review we describe results of previous studies on prevalence of adherence to inhaled medicine in COPD, and define characteristics of the patients and treatment associated with degree of adherence. We conclude that health professionals should always consider non-adherence, strive to simplify regiments, and that there is an urgent need of studies aiming at improving adherence in patients with COPD.

Risk factors for aneurysmal subarachnoid hemorrhage - BMI and serum lipids: 11-year follow-up of the HUNT and the Tromsø Study in Norway

OBJECTIVES

Life-style factors have been associated with the risk for aneurysmal subarachnoid hemorrhage (aSAH), but it is not clear whether body mass index (BMI) and serum lipids are associated with risk. We prospectively assessed these associations in two large population studies.

METHODS

A total of 65,526 participants in the Nord-Trøndelag Health Study (1995-1997) and 26,882 participants in the Tromsø Study (1994-1995) were included. Studies included measurements of body weight and height, serum lipids, and self-administered questionnaires. Participants who experienced aSAH were identified, and hazard ratios (HRs) were estimated using Cox regression analysis.

RESULTS

During 11 years of follow-up, aSAH was diagnosed in 122 participants. Overweight (BMI 25-29.9) was negatively associated with the risk of aSAH (HR 0.7, 95% CI 0.4-1.0). There was no over all association of total serum cholesterol, HDL cholesterol, or triglycerides with the risk of aSAH, but in participants younger than 50 years, HDL cholesterol was inversely associated with the risk (HR per standard deviation increase 0.6, 95% CI 0.4-0.9).

CONCLUSIONS

Overweight may be associated with reduced risk of aSAH, but there was no over all association of total serum cholesterol, HDL cholesterol, or triglycerides with the risk of aSAH in this prospective study.

Incidence and mortality of aneurysmal subarachnoid hemorrhage in two Norwegian cohorts, 1984-2007

OBJECTIVE

The incidence of aneurysmal subarachnoid hemorrhage (aSAH) ranges from 4 to 10 per 100,000 person-years in most countries, and 30-day case fatality is high. The aim of this study was to estimate the incidence and case fatality of aSAH and to assess preictal predictors of survival in 2 large Norwegian population-based cohort studies.

METHODS

A total of 94,976 adults (≥20 years) in the Nord-Trøndelag Health Study and 31,753 participants (aged ≥20 years) in the Tromsø Study were included. During follow-up, aSAHs were identified, incidence rates were estimated, and predictors of survival were assessed using Cox and Poisson regression analysis.

RESULTS

A total of 214 patients with aSAH were identified during 2,077,927 person-years of follow-up from 1984 to 2007. The incidence rate was 10.3 per 100,000 person-years: 13.3 for women and 7.1 for men. The incidence increased by 2% (95% confidence interval [CI] 0-4) per 5-year time period. Case fatality at 3, 7, and 30 days was 20%, 24%, and 36%. Thirty-day case fatality remained stable during follow-up (odds ratio 1.01, 95% CI 0.97-1.06 per year). Never smokers had poorer survival after aSAH than current and former smokers combined (hazard ratio 1.6, 95% CI 0.9-2.9).

CONCLUSIONS

The slight increase in incidence of aSAH over time may be explained by differences in diagnostic procedures. Case fatality remained stable during 23 years of follow-up.

Incidence of aneurysmal subarachnoid hemorrhage in Norway, 1999-2007

OBJECTIVE

To investigate changes and regional variations in annual incidence rates of aneurysmal subarachnoid hemorrhage (SAH) in Norway between 1999 and 2007.

METHODS

The authors retrospectively reviewed data from the Norwegian Patient Register for the period 1999-2007.

RESULTS

Crude incidence of aneurysmal SAH was 10.0/100,000 person years [95% CI (confidence interval): 9.7-10.3] and was higher in women (12.0/100,000 person years; 95% CI: 11.5-12.5) than men (8.1/100,000 person years; 95% CI: 7.7-8.4). Decreasing annual incidence rates were observed from 11.1/100,000 person years (95% CI: 10.5-11.6) in the period 1999-2001 to 8.9/100,000 person years (95% CI: 8.4-9.4) in the period 2005-2007 (P for trend <0.001). Regional variations were observed, from 8.4/100,000 person years (95% CI: 7.7-9.00) in the southern region, 10.4/100,000 person years (95% CI: 9.5-11.2) in the central region and 11.9/100,000 person years (95% CI: 10.8-12.9) in the northern region.

CONCLUSIONS

Incidence of aneurysmal SAH in Norway decreased from 1999 to 2007, with significant regional variations indicating an increasing gradient from south to north.

Chronic mucus hypersecretion: prevalence and risk factors in younger individuals

SETTING

Chronic mucus hypersecretion (CMH) is a common condition in patients with chronic respiratory diseases. Little is known about the incidence, prevalence and determinants of CMH in younger individuals.

OBJECTIVE

To determine prevalence, incidence and risk factors for CMH in a young general population.

DESIGN

A cohort of Danish twins (aged 12-41 years) was prospectively examined using questionnaires in 1994 (n = 29 180) and in 2002 (n = 21 130). Prevalence and incidence of CMH were determined, and risk factors for the condition were assessed using logistic regression.

RESULTS

Lifetime prevalence of CMH was 8.6% in females and 6.9% in males in 1994, and the cumulative incidence among females and males was respectively 10.7% and 8.7% during the study period. Smoking and asthma were risk factors for CMH, with a dose-response effect of tobacco consumption, and smoking habits also predicting incidence of CMH.

CONCLUSION

Among the young, CMH is a condition related to asthma and smoking, with a dose-response relationship with tobacco consumption and a relation between smoking habits and incidence. Female susceptibility to development of CMH was observed, as well as signs of greater susceptibility related to young age.

Altered brain myelin sheath morphology after rewarming in situ

In this study cerebral ultrastructure was examined in an in vivo rat model, after rewarming from profound hypothermia (15-13 degrees C). Animals held at 37 degrees C served as controls. After rewarming, brains were examined by electron microscope. Micrographs were taken randomly, analyzed anonymously, and quantified by morphometry. Serum analysis of the stress marker S-100beta was carried out in identical groups. The most striking findings in rewarmed animals, when compared to controls, were alterations of myelin sheaths (p<.008) and elevated S-100beta (p<.0001). This indicates that cells in the central nervous system are susceptible to injury in an experimental model of accidental hypothermia and rewarming.

Organisation of traumatic head injury management in the Nordic countries

OBJECTIVE

The aim of this study is to map and evaluate the available resources and the premises of traumatic head injury management in the Nordic countries, before the implementation of a Nordic adaption of the Brain Trauma Foundation guidelines for prehospital management.

METHODS

The study is a synthesis of two cross-sectional surveys. Questionnaires were used to collect data on the annual number of acute head injury operations, the infrastructure, the level of education, the use of trauma protocols and the management of traumatic head injury at Nordic hospitals.

RESULTS

The proportion of acute head injury operations performed outside a neurosurgical department was 0% in Denmark, 16% in Finland, 19% in Norway and 33% in Sweden. Eighty-four per cent of Nordic hospitals had written protocols for the assessment and treatment of trauma patients and 78% had regular training in trauma management; 67% had specific protocols for the treatment of traumatic head injury. Computed tomography (CT) was available in 93% of the hospitals, and 59% of the hospitals could link CT scans to the regional neurosurgical department.

CONCLUSIONS

Most Nordic hospitals are well prepared to manage patients with acute traumatic head injury. A substantial proportion of the operations are performed at local and central hospitals without neurosurgical expertise, despite an efficient pre and interhospital transport system. The Nordic adaption of the Brain Trauma Foundation guidelines recommends that this practice is terminated.

Introduction of endovascular embolization for intracranial aneurysms in a low-volume institution

BACKGROUND

Studies indicate a relationship between hospital caseload and health outcomes after both surgical and endovascular repair of intracranial aneurysms.

PURPOSE

To evaluate outcomes after introduction of endovascular embolization for intracranial aneurysms in a low-volume regional university hospital.

MATERIAL AND METHODS

Retrospective study of 243 consecutive patients treated for 284 intracranial aneurysms with endovascular embolization or surgical clipping from 2000 to 2006 at the University Hospital of North Norway. Postoperative complications were registered. The Glasgow Outcome Scale (GOS) was used for assessment of outcome.

RESULTS

The mean annual number of procedures was 39 (microsurgery 23, embolization 16). Seventy-four percent of patients with ruptured aneurysms and all patients with unruptured aneurysms had a favorable outcome (GOS 4 or 5) at 1 year follow-up. Patients with subarachnoid hemorrhage were more likely to experience postoperative complications than patients treated for unruptured aneurysms (42% versus 8% of the patients, P<0.01). The immediate incomplete occlusion rate (Raymond II-III) in the initial embolization procedure was 29%. Ten endovascularly treated patients and one surgically treated patient required retreatments due to residual aneurysm or neck remnants.

CONCLUSION

The present study indicates that acceptable outcome from aneurysm treatment, both endovascular and microsurgical, is possible in a low-volume institution.

[Chronic obstructive pulmonary disease and genetics]

Chronic obstructive pulmonary disease (COPD) is characterised by airflow limitation and is associated with an inflammatory response of the lungs primarily caused by cigarette smoking. Cigarette smoking is by far the most important environmental risk factor for COPD, but less than half of all heavy smokers develop COPD. This indicates a genetic contribution to the individual disease susceptibility. Although many genes have been examined, the puzzle of COPD genetics seems still largely unsolved. It is therefore important to measure phenotypes and to perform genome-wide scans of COPD patients in order to unravel the contribution of the COPD susceptibility genes.

Five-year outcome after mild head injury: a prospective controlled study

OBJECTIVES

To study the prevalence of post-concussion symptoms (PCS) 5-7 years after mild head injury (MHI) and to investigate whether patients suffer from more symptoms than the normal population.

METHODS

We conducted a 5- to 7-year follow-up of patients (n = 89) with MHI. Post-concussion symptoms were quantified with the Rivermead Post Concussion Symptoms Questionnaire (RPQ) and health-related quality of life (HRQL) was measured with the EuroQol-5D (EQ-5D). We also quantified subjective general health state with the EuroQol Visual Analogue Scale (EQ-VAS). An age- and sex-matched, but otherwise randomly chosen control group of 89 persons was recruited from the National Population Registry for a cross-sectional comparison. Twenty-eight patients (30%) and 27 (30%) controls responded.

RESULTS

Patients reported significantly (P = 0.017) more PCS (median RPQ score 10, 95% CI 2-20) than controls (median 2, 95% CI 0-4). They also reported significantly (P = 0.008) lower HRQL (median EQ-5D score 0.866, 95% CI 0.796-1.000) than controls (1.000, 95% CI 1.000-1.000), but there was no difference between the groups in their subjective ratings of general health state.

CONCLUSIONS

Patients reported significantly more PCS and lower HRQL 5 to 7 years after MHI than age- and sex-matched controls from the normal population.

Outcome 1 year after aneurysmal subarachnoid hemorrhage: relation between cognitive performance and neuroimaging

OBJECTIVE

To assess the cognitive impairment and the association between neuropsychological measures and neuroimaging 1 year after aneurysmal subarachnoid hemorrhage (SAH).

METHOD

Forty-two patients were examined clinically according to Glasgow Outcome Scale (GOS). Computed tomography (CT), single photon emission computed tomography (SPECT) and neuropsychological examination were performed.

RESULTS

There were no association between GOS and cognitive impairment index based on the neuropsychological examination. CT showed no sign of cerebral ischemia in 17 (40%) and low attenuating areas indicating cerebral infarction(s) in 25 (60%) patients. A significant correlation (P = 0.01) was observed between the cognitive impairment index and the SPECT index (r = 0.6). SPECT measurement was the only independent predictor for cognitive impairment.

CONCLUSION

GOS is a crude outcome measure and patients classified with good recoveries may have significant cognitive deficits. Neuropsychological examination is the preferred method for outcome evaluation as this method specifically addresses the disabilities affecting patients' everyday life.

Surgery for unruptured intracranial aneurysms in a low-volume neurosurgical unit

OBJECTIVES

To evaluate outcomes after surgical treatment for unruptured intracranial aneurysms in a low-volume neurosurgical unit.

MATERIAL AND METHODS

Consecutive patients operated during the years 1988-98 at the Department of Neurosurgery, University Hospital of North Norway, were studied retrospectively. Procedure-related complications were registered. The modified Rankin Scale and the Glasgow Outcome Scale, Extended version (GOS-E), were used for assessment of outcome.

RESULTS

Thirty-six aneurysms were repaired in 32 patients during 34 surgical procedures. Surgery-related central nervous system complications occurred in eight (25%) patients. The complication rate was 35% for the first 17 procedures, and 12% for the last 17. The latter group of procedures were performed during a period of 3 years, whereas the former group was spread over a period of 8 years. A favourable outcome (GOS-E score 6-8) was reached in 27 (84%) patients.

CONCLUSION

Decision-making in patients with unruptured intracranial aneurysms must be based on knowledge about institution-specific complication rates, preferably followed on a prospective basis.

Dipeptidomimetic Ketomethylene Isosteres as Pro-moieties for Drug Transport via the Human Intestinal Di-/Tripeptide Transporter hPEPT1: Design, Synthesis, Stability, and Biological Investigations

Five dipeptidomimetic-based model prodrugs containing ketomethylene amide bond replacements were synthesized from readily available alpha,beta-unsaturated gamma-ketoesters. The model drug (BnOH) was attached to the C-terminus or to one of the side chain positions of the dipeptidomimetic. The stability, the affinity for the di-/tripeptide transporter hPEPT1, and the transepithelial transport properties of the model prodrugs were investigated. ValPsi[COCH(2)]Asp(OBn) was the compound with highest chemical stability in buffers at pH 6.0 and 7.4, with half-lives of 190 and 43 h, respectively. All five compounds showed high affinity for hPEPT1 (K(i) values < 1 mM), and PhePsi[COCH(2)]Asp(OBn) and ValPsi[COCH(2)]Asp(OBn) had the highest affinities with K(i) values of 68 and 19 microM, respectively. An hPEPT1-mediated transport component was demonstrated for the transepithelial transport of three compounds, a finding that was corroborated by hPEPT1-mediated intracellular uptake. The results indicate that the stabilized Phe-Asp and Val-Asp derivatives are promising pro-moieties in a prodrug approach targeting hPEPT1.

Results of surgery for aneurysmal subarachnoid haemorrhage in northern Norway: a retrospective study with special focus on timing of surgery in a rural area

OBJECTIVES

This study reports data on time consumption before aneurysm surgery and the results of treatment in northern Norway.

MATERIAL AND METHODS

A total of 279 cases were identified and included in our analysis of time span from bleeding to arrival at our department. Fifty-one patients were treated conservatively, either because of bad clinical condition or because angiography revealed no aneurysm. The remaining 228 patients were operated and included in our analysis of outcome after early aneurysm surgery.

RESULTS

Among all 279 patients with aneurysmal subarachnoid haemorrhage (SAH), median time from ictus to arrival at the university hospital was 1 (0-30) day. Forty-one per cent arrived at the day of bleeding and 86% within the first 3 days after bleeding. Among the 228 patients who underwent surgical aneurysm repair, median time from bleeding to operation was 2 (0-33) days. Early aneurysm surgery (< 72 h) was performed in 146 patients (64%). Fifty patients (22%) underwent intermediate surgery (days 4-10) and 32 patients (14%) were operated later (day 11 or later). A significant association was found between Hunt and Hess (HH) grade and Glasgow Outcome Scale (GOS) score (P < 0.001).

CONCLUSIONS

Most patients suffering aneurysmal SAH in northern Norway undergo early aneurysm surgery and the outcome is comparable with that obtained in other Scandinavian centres. Initial Hunt and Hess grade is a major determinant for outcome in aneurysmal subarachnoid haemorrhage.

Risk factors for aneurysmal subarachnoid haemorrhage: the Tromsø study

OBJECTIVES

To conduct a population based case-control study with premorbid registration of potential risk factors to address the difficulty in identifying risk factors for aneurysmal subarachnoid haemorrhage (SAH). SAH is rare in prospective studies, and retrospective studies may have a selection bias.

METHODS

The Tromsø health study is a population based survey of risk factors for cardiovascular disease in 27 161 subjects. 26 cases of aneurysmal SAH were identified in which risk factors were registered before the bleeding. Four age and sex matched controls were selected for each case. A backward logistic regression analysis was conducted and odds ratios (ORs) for significant risk factors were calculated. Systolic and diastolic blood pressure, cigarette smoking habits, serum concentrations of lipoproteins, body mass index, and coffee consumption were analysed.

RESULTS

The crude annual incidence rate of aneurysmal SAH was 8.84/100 000 population. The proportion of current smokers was significantly (p = 0.003) higher in patients with SAH (73.1%) than in controls (41.3%). Drinking more than five cups of coffee per day was more common among patients (85%) than controls (59%) (p = 0.004). Mean (SD) systolic blood pressure was higher (p = 0.017) in patients (154.0 (32.5)) than in controls (136.3 (23.3)). Regression analysis showed that cigarette smoking (p = 0.04), systolic blood pressure (p < 0.0001), and coffee consumption (p = 0.004) were independent risk factors for SAH. The OR of current smokers versus never smokers was 4.55 (95% confidence interval (CI) 1.08 to 19.30) and the OR of drinking more than five cups of coffee a day was 3.86 (95% CI 1.01 to 14.73). The OR of an increase in systolic blood pressure of 20 mm Hg was 2.46 (95% CI 1.52 to 3.97).

CONCLUSIONS

Cigarette smoking and hypertension are significant independent risk factors for aneurysmal SAH. A high coffee consumption may also predispose patients to aneurysmal SAH.

A four-year experience with a stereotactic computer in a small neurosurgical department

BACKGROUND

A stereotactic computer with a mechanical, proprioceptive arm was acquired in 1996. The aim of this report is to review the 4-year experience with frameless, computer-aided stereotaxy in a small neurosurgical department.

METHODS

From 1996 to 1999 the computer was used for 121 operations. The surgical files from these operations were either retrospectively or prospectively registered. Patient and computer data, type of surgery, complications and number of surgeons were noted. The versatility, benefits, and drawbacks of the stereotactic computer were evalued based on these findings.

RESULTS

Seven surgeons performed a total of 121 computer-assisted operations. The procedures consisted of 63 stereotactic tissue samplings, 44 craniotomies, 7 abscess punctures and 3 insertions of intracerebral devices (shunts and microelectrodes). Technical complications were seen in 6 cases (4.8%), but this did not affect the surgical outcome.

CONCLUSIONS

The stereotactic computer has enabled the department to broaden its spectrum of procedures. High precision surgery such as stereotactic biopsy has been possible without the use of a framebased system. The results indicate that even small neurosurgical units with a limited number of procedures can safely and successfully implement neuronavigation in daily routines.

Prophylactic hyperdynamic postoperative fluid therapy after aneurysmal subarachnoid hemorrhage: a clinical, prospective, randomized, controlled study

OBJECTIVE

To investigate the role of prophylactic hyperdynamic postoperative fluid therapy in preventing delayed ischemic neurological deficits attributable to cerebral vasospasm.

METHODS

We designed a prospected, randomized, controlled study and included 32 patients with subarachnoid hemorrhage. Sixteen patients received hypervolemic hypertensive hemodilution fluid therapy; the other 16 patients received normovolemic fluid therapy. All patients were monitored for at least 12 days, with clinical assessments, transcranial Doppler recordings, single-photon emission computed tomographic (SPECT) scanning, and routine computed tomographic scanning. For fluid balance monitoring, a number of blood samples were obtained on a daily basis and continuous central venous pressure and mean arterial blood pressure measurements were performed for both groups. All patients received intravenous nimodipine infusions between Day 1 and Day 12. End points of this study were clinical outcomes, clinically evident and transcranial Doppler sonography-evident vasospasm, SPECT findings, complications, and costs. Clinical examinations (using the Glasgow Outcome Scale) performed 1 year after discharge, together with neuropsychological assessments and SPECT scanning, were the basis for the evaluation of clinical outcomes.

RESULTS

No differences were observed between the two groups with respect to cerebral vasospasm (as observed clinically or on transcranial Doppler recordings). When regional cerebral blood flow was evaluated by means of SPECT analysis performed on Day 12 after subarachnoid hemorrhage, no differences were revealed. One-year clinical follow-up assessments (with the Glasgow Outcome Scale), including SPECT findings and neuropsychological function results, did not demonstrate any significant group differences. Costs were higher and complications were more frequent for the hyperdynamic therapy group.

CONCLUSION

Neither early nor late outcome measures revealed any significant differences between the two subarachnoid hemorrhage treatment models.

Renal elimination of protein S-100beta in pigs with acute encephalopathy

BACKGROUND

Protein S-100beta is an established biochemical marker for cerebral injury in serum. For the further interpretation and possible use of S-100beta serum measurements in acute hepatic encephalopathy, renal elimination of S-100beta was measured in pigs with elevated S-100beta levels due to hepatic encephalopathy.

METHODS

Eighteen female Norwegian Landrace pigs were randomly allocated to either hepatic devascularization (n=13) or sham operation (n=5). Repeated samples from the common carotid artery, right renal vein, and urine were simultaneously drawn for S-100beta analysis, using the Sangtec100 Liamat immunoassay.

RESULTS

In hepatic devascularized pigs, arterial serum levels of S-100beta increased from 0.96+/-0.04 microg/L (mean +/- SEM) at t = 0h to 1.74+/-0.11 microg/L (mean +/- SEM) at t = 5 h. Urinary excretion increased simultaneously from 8.48+/-3.66 ng/h (mean +/- SEM) to 20.4+/-9.54 ng/h (mean +/- SEM), while renal arterial-venous fluxes for both kidneys increased from 1022+/-404 ng/h (mean +/- SEM) to 2444+/-590 ng/h (mean +/- SEM).

CONCLUSIONS

Increased arterial S-100beta levels in pigs with acute hepatic encephalopathy are not a result of decreased renal elimination. The large difference between the renal arterial venous S-100beta concentrations and the urinary excretion of S-100beta indicate that renal metabolism is the major route of elimination.

Impact of occupational variables in carpal tunnel syndrome

OBJECTIVE

We studied the impact of work-related factors on the outcome in patients operated for carpal tunnel syndrome.

METHODS

The population consisted of 106 CTS patients who worked at the time of operation. We registered social and occupational data from the patients.

RESULTS

Median time of sick leave was 7 weeks for the total group. Sixty-four percent reported a relationship between their work and the disease. Eighty-nine percent of the operated patients returned to their previous work after operation.

CONCLUSIONS

A majority of the patients attributed the CTS-related symptoms to their occupation. Work-related factors may therefore be one possible explanation for the socioeconomical consequences of CTS. A permanent drop-out from work in more than 1 out of 10 patients after CTS treatment indicate that CTS form a substantial socioeconomical burden in the society.

The clinical value of serum S-100 protein measurements in minor head injury: a Scandinavian multicentre study

PURPOSE

This study of patients with minor head injury was designed to investigate the relation of S-100 protein measurements to computed tomograpy (CT) findings and patients outcomes. Increased serum levels of this protein were hypothetized to predict intracranial pathology and increased frequency of post-concussion symptoms.

METHODS

One hundred and eighty-two patients were studied with Glasgow Coma Scale scores of 13-15. The study recruited patients from three Scandinavian neurotrauma centres. Serum levels of S-100 protein were measured at admittance and CT scans of the brain were obtained within 24 hours postinjury in all patients. Outcome was evaluated with the Rivermead Postconcussion Symptoms Questionnaire (RPQ) 3 months after the injury.

RESULTS

Increased serum level of S-100 protein was detected in 69 (38%) patients, and CT scan demonstrated intracranial pathology in 10 (5%) (brain contusion in seven, epidural haematoma in two, traumatic subarachnoid haemorrhage in one). The proportion of patients with detectable serum level was significantly (p < 0.01) higher among those with intracranial pathology (90%) compared to those without (35%). The negative predictive value of an undetectable S-100 level was 0.99. Sixty-two per cent reported one or more post-concussion symptoms at follow-up. A trend was observed towards an increased frequency of post-concussion symptoms among patients with detectable serum levels.

CONCLUSIONS

Undetectable serum level of S-100 protein predicts normal intracranial findings on CT scan. Determination of S-100 protein in serum may be used to select patients for CT scanning. Increased S-100 serum levels may be more related to post-concussion symptoms caused by mild traumatic brain injury than to symptoms of psychological origin.

The epidemiology of hospital-referred head injury in northern Norway

This retrospective population-based survey describes the epidemiology of head injury in a defined population in Northern Norway. It includes all 247 patients with head injury referred to the University Hospital of Tromsø, Norway, during 1993. Head injury was defined as physical damage to the brain or skull caused by external force. The annual incidence rate of hospital-referred head injury was 229/100,000 population with a male preponderance of 1.7:1.0. The cause was a fall in 62%, road traffic accident in 21% and assault in 7% of the cases. The observed incidence rate is low despite the use of wide inclusion criteria, probably due to a decrease in road traffic accidents. A further decrease in the number of head injuries in our region may be achieved by preventing falls.

Traumatic brain damage: serum S-100 protein measurements related to neuroradiological findings

This study was designed to investigate the correlation between S-100 protein serum measurements and neuroradiological findings in patients with head injury. We studied 278 patients with minor, moderate, and severe head injuries and 110 controls with no history of neurological disease. The study recruited patients from three Scandinavian neurotrauma centers. Serum levels of S-100 protein were measured at admittance, and computed tomographic scans of the brain were obtained within 24 h postinjury in all patients. In a subgroup of 45 patients with minor head injuries, magnetic resonance imaging was also performed. Increased serum level of S-100 protein was detected in 108 (39%) patients, and CT scan demonstrated intracranial pathology in 25 (9%) (brain contusion n = 13, subdural hematoma n = 6, epidural hematoma n = 2, traumatic subarachnoid hemorrhage n = 2, and brain edema n = 2). The proportion of patients with detectable serum level was significantly (p < 0.01) higher among those with intracranial pathology (92%) compared to those without (34%). The negative predictive value of an undetectable S-100 serum level was 0.99. Undetectable serum level of S-100 protein predicts normal intracranial findings on CT scan. Determination of S-100 protein in serum may be used to select patients for CT scanning.

[Scandinavian guidelines for management of head injuries. Evidence-based management of minimal, mild and moderate head injuries]

The Scandinavian Neurotrauma Committee (SNC) was created by the Scandinavian Neurosurgical Society in order to develop evidence-based guidelines for improved care of neurotrauma patients. A MEDLINE search identified 475 papers dealing with the management of minimal, mild and moderate head injuries. Forty-two studies presenting Class II evidence on the initial management of such injuries were reviewed, and management guidelines were developed. Implementation of the Head Injury Severity Scale is advocated. Patients with Minimal injuries (no loss of consciousness [LOC], Glasgow Coma Scale [GCS] score 15) can be safely discharged. Routine early computerized tomography [CT] scan is recommended in cases with Mild injuries (history of LOC, GCS 14-15) and patients with normal scans may be discharged. CT scan and admission is mandatory in Moderate injuries (GCS 9-13). All patients with additional risk factors should be scanned and admitted. A flow-chart for clinical decision making and a Head Injury Instruction card is introduced. The SNC suggests guidelines that should be safe and cost-effective for the initial management of minimal, mild and moderate head injuries.

[Scandinavian guidelines for management of minimal, mild and moderate head injuries]

The Scandinavian Neurotrauma Committee (SNC) was initiated by the Scandinavian Neurosurgical Society to develop evidence-based guidelines for improved care of neurotrauma patients. A MEDLINE search identified 475 papers dealing with the management of minimal, mild and moderate head injuries. Fourty-two studies presenting Class II evidence on the initial management of such injuries were reviewed and management guidelines were developed. Implementation of the Head Injury Severity Scale is advocated. Patients with minimal injuries (no loss of consciousness (LOC), Glasgow Coma Scale (GCS) score 15) can be safely discharged. Routine early CT scan is recommended in cases with mild injuries (history of LOC, GCS 14-15) and patients with normal scans may be discharged. CT scan and admission is mandatory in moderate injuries (GCS < or = 13). All patients harbouring additional risk factors should be scanned and admitted. A flow chart for clinical decision making and a Head Injury Instruction card are introduced.

[Scandinavian guidelines for management of head injuries. Evidence-based management of minimal, mild and moderate head injuries]

The Scandinavian Neurotrauma Committee (SNC) was created by the Scandinavian Neurosurgical Society in order to develop evidence-based guidelines for improved care of neurotrauma patients. A MEDLINE search identified 475 papers dealing with the management of minimal, mild and moderate head injuries. Forty-two studies presenting Class II evidence on the initial management of such injuries were reviewed, and management guidelines were developed. Implementation of the Head Injury Severity Scale is advocated. Patients with Minimal injuries (no loss of consciousness (LOC), Glasgow Coma Scale (GCS) score 15) can be safely discharged. Routine early computerized tomography (CT) scan is recommended in cases with Mild injuries (history of LOC, GCS 14-15) and patients with normal scans may be discharged. CT scan and admission is mandatory in Moderate injuries (GCS 9-13). All patients with additional risk factors should be scanned and admitted. A flow-chart for clinical decision making and a Head Injury Instruction card is introduced. The SNC suggests guidelines that should be safe and cost-effective for the initial management of minimal, mild and moderate head injuries.

Protein S-100beta: a biochemical marker for increased intracranial pressure in pigs with acute hepatic failure

BACKGROUND

Acute hepatic failure (AHF) may cause encephalopathy. Intracranial pressure (ICP) is frequently monitored to guide therapy, but such monitoring may cause intracerebral haemorrhagic complications. We hypothesize that determination of serum levels of S-100beta, a protein synthesized in astroglial cells, will provide useful clinical information on the presence and extent of intracranial hypertension in AHF.

METHODS

Continuous intraparenchymatous ICP monitoring and serial S-100beta measurements in serum were performed in 11 Norwegian Landrace pigs with surgically induced AHF and in 4 sham-operated controls.

RESULTS

ICP increased hour by hour in the devascularized pigs in parallel with increased serum levels of protein S-100beta. In the sham-operated controls S-100beta was not detectable at any time point.

CONCLUSIONS

Serum levels of S-100beta are increased early in experimental AHF. Determination of protein S-100beta may provide useful information on the presence and extent of intracranial hypertension in AHF.

Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries. The Scandinavian Neurotrauma Committee

BACKGROUND

The Scandinavian Neurotrauma Committee was initiated by the Scandinavian Neurosurgical Society to develop evidence-based guidelines for improved care of neurotrauma patients.

METHODS

A MEDLINE search identified 475 papers dealing with the management of minimal, mild, and moderate head injuries. Forty-two studies presenting class II evidence on the initial management of such injuries were reviewed and management guidelines were developed.

RESULTS

Implementation of the Head Injury Severity Scale is advocated. Patients with minimal injuries (no loss of consciousness, Glasgow Coma Scale score of 15) can be safely discharged. Routine early computed tomographic scan is recommended in cases with mild injuries (history of loss of consciousness, Glasgow Coma Scale score = 14-15) and patients with normal scans may be discharged. Computed tomographic scan and admission is mandatory in moderate injuries (Glasgow Coma Scale score = 13). All patients harboring additional risk factors should be scanned and admitted. A flow-chart for clinical decision making and a Head Injury Instruction card is introduced.

CONCLUSIONS

The Scandinavian Neurotrauma Committee suggests guidelines that should be safe and cost-effective for the initial management of minimal, mild, and moderate head injuries.

Survey of the management of patients with minor head injuries in hospitals in Sweden

OBJECTIVES

Development of guidelines for quality assurance in head injury care has to be based on knowledge about how today's management is organized. To address the need for guidelines in minor head injury (MHI), the authors studied management practice in Sweden.

METHODS

We performed a cross-sectional mail survey including all 76 hospitals treating head-injured patients. The questionnaire outlined present management practice in MHI; including routines for clinical and radiological examinations, in-hospital observation, discharge criteria and follow-up.

RESULTS

The initial evaluation is frequently performed by inexperienced physicians. The level of consciousness is assessed according to the Swedish Reaction Level Scale or the Glasgow Coma Scale in 96% of the hospitals. Routine computerized tomography is used in 4%. Skull radiography is not routinely performed. Eighty percent of the hospitals discharge selected patients without in-hospital observation and most (93%) offer no routine follow-up.

CONCLUSIONS

This survey shows a variation in the management of MHI in hospitals in Sweden. Routines for assessment of consciousness level are satisfactory, but CT scan for detection of skull fracture and early diagnoses of intracranial complications is usually not performed. Guidelines should be based on present routines including decision rules for CT scan.

[Routines required for management of minor head injuries]

Developing guidelines for quality assurance in the management of head injury requires knowledge concerning present management practice. We studied management of minor head injury (MHI) using a cross-sectional mail survey of 76 Swedish hospitals. In 96% of the hospitals, initial patient evaluation, frequently performed by inexperienced physicians, entails neurological assessment according to the Swedish Reaction Level Scale or the Glasgow Coma Scale, while computerised tomography (CT) is used routinely in 4%. This survey indicates great variability in the management of MHI in hospitals in Sweden. Fifteen (21%) hospitals consistently hospitalize all MHI patients for overnight observation, while 56 (79%) have established criteria for early discharge of selected patients. Routines for neurological assessment are satisfactory, while CT scan for skull fracture and early diagnosis of intracranial complications is usually not performed.

[Decompression craniectomy--life-saving treatment in acute cerebral infarction]

Massive cerebral infarction is often accompanied by early death secondary to transtentorial herniation. Decompressive hemicraniectomy has been suggested as a lifesaving procedure. We report the case of a 61 year old man who had an acute infarction in the distribution area of the right middle cerebral artery. Initially, he was awake and suffered from total left-sided hemiparalysis. Over the next two days, his level of consciousness deteriorated to a Glasgow Coma Scale score of 5. Intracranial pressure (ICP) monitoring was then established. Three days later, the ICP increased from 20 to 40 mm Hg. We performed a right-sided decompressive hemicraniectomy, and the ICP was normalized immediately. Ten months after surgery the patient was at home and functioning with minimal assistance. He had moderate paresis of the left leg and was able to walk, but his left arm was paralytic. The presented case confirms that decompressive hemicraniectomy may prevent death and allow survival without severe disability in patients with massive cerebral infarction.

Traumatic brain damage in minor head injury: relation of serum S-100 protein measurements to magnetic resonance imaging and neurobehavioral outcome

OBJECTIVE

The present study was conducted to validate S-100 protein as a marker of brain damage after minor head injury.

METHODS

We studied 50 patients with minor head injuries and Glasgow Coma Scale scores of 13 to 15 in whom computed tomographic scans of the brain revealed no abnormalities. Serum levels of S-100 protein were measured at admittance and hourly thereafter until 12 hours after injury. Magnetic resonance imaging and baseline neuropsychological examinations were performed within 48 hours, and neuropsychological follow-up was conducted at 3 months postinjury.

RESULTS

Fourteen patients (28%) had detectable serum levels of S-100 protein (mean peak value, 0.4 microg/L [standard deviation, +/- 0.3]). The S-100 protein levels were highest immediately after the trauma, and they declined each hour thereafter. At 6 hours postinjury, the serum level was below the detection limit (0.2 microg/L) in five (36%) of the patients with initially detectable levels. Magnetic resonance imaging revealed brain contusions in five patients, four of whom demonstrated detectable levels of S-100 protein in serum. The proportion of patients with detectable serum levels was significantly higher when magnetic resonance imaging revealed a brain contusion. In patients with detectable serum levels, we observed a trend toward impaired neuropsychological functioning on measures of attention, memory, and information processing speed.

CONCLUSION

Determination of S-100 protein levels in serum provides a valid measure of the presence and severity of traumatic brain damage if performed within the first hours after minor head injury.

[Management of minor head injuries in Norwegian hospitals--can the quality be improved?]

Management protocols for minor head injury should include strategies for early detection of intracranial haematomas. This study focuses on the management of minor head injury in 63 Norwegian hospitals. We report considerable inter-hospital variation. In most (81%) hospitals, minor head injury patients were treated by general surgeons. Emergency room evaluation included routine radiological evaluation, usually skull radiography, in 18 (29%) hospitals, and assessment according to the Glasgow Coma Scale (GCS) in 27 (43%). GCS was used during in-hospital observation in 32 (51%) hospitals. 33 (52%) discharged selected minor head injury patients without in-hospital observation. We conclude that the quality of care for minor head injury patients in Norwegian hospitals can be improved through extended use of routine early CT and consistent evaluation according to GCS.

[Epidemiology of head injuries in Troms]

This retrospective population-based survey describes the epidemiology of head injury in a defined population in Troms. It includes all 247 patients with head injury referred to the University Hospital of Tromsø during 1993. Head injury was defined as physical damage to the brain or skull caused by external force. The annual incidence rate of hospital-referred head injury was 229/100,000 population with a male preponderance of 1.7:1.0. Causes were fall in 62%, traffic accident in 21%, and assault in 7% of the cases. The observed incidence rate is low despite the use of wide inclusion criteria, probably due to a decrease in road traffic accidents and fewer referrals. A further decrease in the number of head injuries in our region may be achieved by preventing falls.

Quantification of post-concussion symptoms 3 months after minor head injury in 100 consecutive patients

Post-concussion symptoms (PCS) (such as headaches, irritability, anxiety, dizziness, fatigue and impaired concentration) are frequently experienced by patients who have sustained a minor head injury (MHI). The post-concussion syndrome has been defined as a clinical state where 3 or more symptoms persist for more than 3 months. This report focuses on the quantification of PCS according to the Rivermead Postconcussion Symptoms Questionnaire (RPQ). We studied 100 consecutive patients with MHI and normal computed tomography of the brain. At 3 months after injury, 62% reported the presence of one or more symptoms, and 40% fulfilled the diagnostic criteria for post-concussion syndrome. Patients with post-concussion syndrome had significantly (P < 0.001) higher RPQ scores (mean 19.1, SD 11.9) than those without (mean 1.2, SD 1.8). Patients on sick leave owing to the injury reported significantly (P = 0.05) higher RPQ scores (mean 10.3, SD 13.2) than those not on sick leave (mean 5.5, SD 8.6). We observed no association between age, gender, cause of injury, severity of injury, duration of amnesia and RPQ score. RPQ score provides useful information about the severity of PCS regardless of whether the diagnostic criteria for the post-concussion syndrome are met or not.

[Ten years of neurosurgery at the University Hospital in Tromsø. Need for further development]

The Department of Neurosurgery at the University Hospital of Tromsø was established in January 1986 to provide neurosurgical treatment for the population of northern Norway. During the first ten years, 3,225 patients were operated on, including 1,157 craniotomies and 1,335 spinal procedures. The annual number of operations increased from 201 to 442, and the number of hospitalized patients from 265 to 908. The number of patients treated per employee increased by 250%, while the mean duration of hospital stay decreased by 43% to 4.5 days. The growth in activity is expected to continue. This is because of improved diagnostics of nervous system disease, a growing number of elderly patients and new treatment options. The falling number of spinal surgical procedures in local hospitals is also a contributing factor. Neurosurgery is highly cost-effective. It is impossible to make further cost savings without a decline in quality. The department must be expanded to cater for more operations by increasing both the number of beds and employees.

Neuropsychological function in patients with increased serum levels of protein S-100 after minor head injury

Protein S-100 is a calcium binding protein, synthetized in astroglial cells in all parts of the central nervous system (CNS). We have previously reported high serum levels of protein S-100 in patients after minor head injury (MHI). A battery of conventional and computerized neuropsychological measures was administered to two groups of MHI patients. Neuropsychological outcome at 12 months postinjury was examined in a group of 7 patients with increased serum levels of protein S-100 after MHI and 7 age- and sex-matched controls without detectable S-100 in serum after MHI. Our results demonstrate no overall cognitive dysfunction in either of the two groups. Our findings indicate specific dysfunction on measures of reaction time, attention and speed of information processing for the S-100 group. Posttraumatic depression does not explain the neuropsychological differences between the groups. These findings support that increased serum levels of protein S-100 may be of predictive and prognostic value for longlasting neurocognitive abnormalities after minor head injury. Presence of S-100 in serum may indicate the presence of diffuse brain damage. Our results suggest that information processing measures in computerized neuropsychological assessment are more sensitive for detecting small signs of neurocognitive abnormalities after MHI than conventional test batteries.

Management of minor head injuries in hospitals in Norway

Management protocols for minor head injury (MHI) should include strategies for early detection of intracranial hematomas and prevention of persistent sequelae. This study focuses on today's management of MHI in Norwegian hospitals. We report considerable inter-hospital variation in the management of MHI. In most hospitals (81%), MHI patients are treated by general surgeons. The management is focused on the risk of complications in the acute stage. Emergency room evaluation includes assessment according to the Glasgow Coma Scale in 27 (43%) hospitals and routine radiological examination in 18 (29%). Thirty-three (52%) hospitals discharge MHI patients without in-hospital observation. Most hospitals (83%) offer no follow-up. We conclude that the acute care as well as the follow-up of MHI patients can be improved in Norwegian hospitals. Neurosurgeons and neurologists should initiate this process.

[Minor head injuries in sport. Occurrence, management, sequelae and prevention]

Approximately 10% of all head injuries are caused during sport and about 10% of all sport-related injuries are head injuries. Most of these are minor head injuries. Many sports involve risk of repeated head injury. The classic punch-drunk syndrome in boxers reflects severe chronic traumatic encephalopathy. Recent research shows that repeated head injury can entail encephalopathy also in other types of athletes. They may experience symptoms such as headache, dizziness, irritability, memory deficit and concentration deficit. Neuropsychological testing reveals such cognitive deficits as impaired memory and attention, and reduced speed of information processing. Persistent sequelae can be prevented by correct management in the acute stage, appropriate follow-up, and prevention of repeated head injuries.

Methylprednisolone attenuates airway and vascular responses induced by reactive oxygen species in isolated, plasma-perfused rat lungs

The effects of methylprednisolone (MP) on the acute airway and pulmonary vascular responses induced by reactive oxygen species (ROS) were investigated in isolated, plasma-perfused rat lungs. ROS were generated by adding xanthine oxidase and hypoxanthine to the perfusate. MP was administered in 3 different ways: 1. Added to the perfusate (1 mg*ml-1) 5 min prior to xanthine oxidase and hypoxanthine, 2. Given as intraperitoneal injections (40 mg*kg-1) to lung donor rats 12 and 2 hours prior to the experiments, or 3. Combining 1 and 2. The lungs were perfused at constant volume inflow (15 ml*min-1). Pulmonary arterial pressure and transpulmonary pressure were followed for 30 min after addition of xanthine oxidase and hypoxanthine. ROS induced a powerful, acute broncho- and vasoconstriction, which was inhibited by addition of MP to the perfusate. Pretreatment with MP also inhibited the vascular and airway responses. Adding MP to the perfusate of pretreated lungs further reduced the ROS-induced smooth muscle constriction. In conclusion, MP inhibits vasoconstriction and bronchoconstriction induced by ROS in isolated rat lungs.