Images of the good doctor in Western medicine: The doctor-patient relationship

ObjectiveTo determine whether the management of head injuries differs between patients aged ⩾65 years and those <65.DesignProspective observational national study over four years.Setting25 Scottish hospitals that admit trauma patients.Participants527 trauma patients with extradural or acute subdural haematomas.ResultsPatients aged ⩾65 years had lower survival rates than patients <65 years. Rates were 15/18 (83%) v 165/167 (99%) for extradural haematoma (P=0.007) and 61/93 (66%) v 229/249 (92%) for acute subdural haematoma (P<0.001). Older patients were less likely to be transferred to specialist neurosurgical care (10 (56%) v 142 (85%) for extradural haematoma (P=0.005) and 56 (60%) v 192 (77%) for subdural haematoma (P=0.004)). There was no significant difference between age groups in the incidence of neurosurgical interventions in patients who were transferred. Logistic regression analysis showed that age had a significant independent effect on transfer and on survival. Older patients had higher rates of coexisting medical conditions than younger patients, but when severity of injury, initial physiological status at presentation, or previous health were controlled for in a log linear analysis, transfer rates were still lower in older patients than in younger patients (P<0.001).ConclusionsCompared with those aged under 65 years, people aged 65 and over have a worse prognosis after head injury complicated by intracranial haematoma. The decision to transfer such patients to neurosurgical care seems to be biased against older patients.

What is already known on this topic

Older patients with acute intracranial haematomas have significantly higher mortality and poorer functional outcome than younger patients with similar injuriesIntracranial haematomas are larger and more common in older patients with head injury than in younger patientsEarly diagnosis and surgical intervention for operable lesions is a crucial factor in determining patients'' outcomes

What this study adds

Older patients with acute intracranial haematomas were less likely to be transferred for specialist neurosurgical care than younger patients with similar severities of injuries, extracranial injuries, and physiological status at presentationSignificant differences in transfer rates related to age were still seen after pre-existing medical conditions were controlled for     

Risks of acute traumatic intracranial haematoma in children and adults: implications for managing head injuries.

OBJECTIVE--To determine the factors influencing the risk of an acute traumatic intracranial haematoma in children and adults with a recent head injury. DESIGN--Prospective study of incidence of risk factors in samples of patients attending accident and emergency departments and in all patients having an acute traumatic intracranial haematoma evacuated in one regional neurosurgical unit during 11 years. SETTING--Accident and emergency departments in Scotland or Teesside and regional neurosurgical centre in Glasgow. PATIENTS--8406 Adults and children (less than or equal to 14 years) who attended accident and emergency departments and 1007 consecutive patients who had an operation for an acute traumatic intracranial haematoma. Data were complete in 8366 and 960 patients respectively. RESULTS--Overall, children were less at risk than adults (one in 2100 v one in 348 respectively). In both age groups the presence of a skull fracture and changes in conscious level permitted identification of subgroups of patients with widely differing degrees of risk. In children the absolute risk ranged from one in almost 13,000 without a fracture or altered conscious level to one in 12 for a child in a coma and with a fracture; the pattern was similar in adults, the risks in corresponding groups ranging from one in almost 7900 to one in four. CONCLUSIONS--Although children attending hospital after a head injury have a lower overall risk of a traumatic haematoma, the main indicators of risk, a skull fracture and conscious level, are the same as in adults, and the pattern of their combined effect is similar. Guidelines for managing adults with recent head injury may therefore be applied safely to children; with the increasing provision of facilities for computed tomography they should be revised to ensure early scanning of more patients with head injury.     

Avoidable factors contributing to death after head injury.

We reviewed 116 patients, known to have talked before dying after head injury, to discover factors which had contributed to death but which might have been avoided. All the patients were admitted to a neurosurgical unit and had a neuropathological post-mortem examination. One or more avoidable factors were identified in 86 patients (74%); an avoidable factor was judged certainly to have contributed to death in 63 patients (54%). The most common avoidable factor was delay in the treatment of an intracranial haematoma; others included poorly controlled epilepsy, meningitis, hypoxia, and hypotension. Changes in the management of patients with head injuries which reduce the incidence of avoidable factors should decrease mortality from this condition.     

Risks of intracranial haematoma in head injured adults.

A study was conducted to estimate the risk that an adult (age 15 or over) will develop a surgically significant intracranial haematoma after a head injury. Two simple features were used that can be recognised by clinicians with minimal training: a skull fracture and the conscious level. The risks were calculated from samples of 545 patients with haematomas, 2773 head injured patients in accident and emergency departments, and 2783 head injured patients in primary surgical wards. With radiological evidence of skull fracture and any impairment of consciousness (including disorientation) one patient in four in an accident and emergency department or primary surgical ward will develop a haematoma. With no skull fracture and preserved orientation the risk to a patient in an accident and emergency department is one in 6000. The use of risk levels as a basis for decision making about head injured patients may result in fewer haematomas being detected too late and savings of resources by reducing the admission and investigation of low risk categories of patients.     

Effects of case management after severe head injury.

OBJECTIVES--To examine the effects of early case management for patients with severe head injury on outcome, family function, and provision of rehabilitation services. DESIGN--Prospective controlled unmatched non-randomised study for up to two years after injury. SETTING--Four district general hospitals and two university teaching hospitals, each with neurosurgical units, in east central, north, and north east London and its environs. SUBJECTS--126 patients aged 16-60 recruited acutely and sequentially after severe head injury. All received standard rehabilitation services in each of the six hospitals and districts: case management was also provided for the 56 patients admitted to three of the hospitals. MAIN OUTCOME MEASURES--Standard measures of patients'' physical and cognitive impairment; disability and handicap; and affective, behavioural, and social functioning and of relatives'' affective and social functioning. Relatives'' perception of burden; changes in patients'' and relatives'' housing, financial, vocational, recreational, and medical needs; and ongoing requirements for care and support; and the amount and type of paramedical input provided were assessed with structured questionnaires. RESULTS--For a given severity of injury, case management increased the chance and range of contact with inpatient and outpatient rehabilitation services. However, duration of contact was not increased by case management, and there was no demonstrable improvement in outcome in the case managed group. Any trends were in favour of the control group and could be accounted for by group differences in initial severity of injury. CONCLUSIONS--Widespread introduction of early case management of patients after severe head injury is not supported, and early case management is not a substitute for improvement in provision of skilled and specialist rehabilitation for patients.     

Avoidable factors contributing to death of children with head injury.

OBJECTIVE--To assess the incidence of potentially avoidable complications contributing to death of children with head injuries. DESIGN--Retrospective review of children who died with head injuries from 1979 to 1986 from data of the Office of Population Censuses and Surveys, Hospital Activity Analyses, case notes, coroners'' records, and necropsy reports. SETTING--District general hospitals and two regional neurosurgical centres in Northern region. RESULTS--255 Children died from head injury in the region, the mortality being 5.3 per 100,000 children per year. Head injury was the single most important cause of death in children aged greater than 1 year, accounting for 15% of deaths in children aged 1-15 years and a quarter for those aged 5-15 years. 121 Potentially avoidable factors possibly or probably contributing to death occurred in 81 children (32%). Half the children (125) died before admission, 27 of whom (22%) had potentially avoidable factors possibly or probably contributing to death, and 130 died after admission, 54 of whom (42%) had 93 such factors, which included failure of diagnosis or delayed recognition of intracranial haemorrhage or associated injury, inadequate management of the airways, and poor management of the transfer between hospitals. IMPLICATIONS--Regions should revise urgently their guidelines for optimal management and indications for neurosurgical referral to include children with severe head injuries and audit their systems of care for all patients with head injuries.     

Traumatic subdural haematoma with electrocardiographic abnormalities simulating myocardial infarction

A 58-year-old man with a history of alcohol abuse and smoking presented with a subdural haematoma due to head trauma after alcohol intoxication. He was disorientated; general and specific cardiological and neurological examinationswere unremarkable. Cardiac troponin T (0.053 μg/l), N-terminal pro-B type natriuretic peptide (768 pg/ml) and serum ethanol (3316 mg/l) were elevated.     

Availability of computed tomography for the management of head injuries in England and Wales.

Senior neuroradiologists or radiologists of 42 hospitals with computed tomography available for NHS patients in England and Wales were contacted by postal questionnaire about the use of this facility in the management of patients with acute head injuries. Replies were obtained from 39 hospitals. Requests for computed tomography from general surgeons or physicians and staff of accident and emergency departments received positive responses for scanning with only half to three-quarters the frequency of responses to requests from neurosurgeons. Continuous computed tomography facilities were available generally to neurosurgeons. The combined effect of partial responses to requests and the availability of the computed tomography service meant that only 44% of hospitals gave a continuous service for general surgeons or physicians. The percentage of hospitals giving a continuous service to accident and emergency departments was 54%. It appeared that computed tomography scanning was being used most often as a diagnostic/management instrument after clinical selection among patients with head injuries rather than as an instrument to be used in primary assessment.     

Effects of damping head movement and facial expression in dyadic conversation using real–time facial expression tracking and synthesized avatars

When people speak with one another, they tend to adapt their head movements and facial expressions in response to each others'' head movements and facial expressions. We present an experiment in which confederates'' head movements and facial expressions were motion tracked during videoconference conversations, an avatar face was reconstructed in real time, and naive participants spoke with the avatar face. No naive participant guessed that the computer generated face was not video. Confederates'' facial expressions, vocal inflections and head movements were attenuated at 1 min intervals in a fully crossed experimental design. Attenuated head movements led to increased head nods and lateral head turns, and attenuated facial expressions led to increased head nodding in both naive participants and confederates. Together, these results are consistent with a hypothesis that the dynamics of head movements in dyadicconversation include a shared equilibrium. Although both conversational partners were blind to the manipulation, when apparent head movement of one conversant was attenuated, both partners responded by increasing the velocity of their head movements.     

头颈部木村病的CT、MRI影像学表现

目的:探讨头颈部木村病的CT、MRI的影像学表现。方法:对6例经手术或活检病理证实的头颈部木村病的CT及MRI影像学表现进行回顾性分析。结果:本组6例以中青年男性患者多见,病灶位于耳周2例、颊面部1例、颌下区1例,腮腺区1例、头皮下1例,均表现为无痛性肿块。3例CT表现为单侧或双侧、单发或多发等或略高密度软组织肿块,密度均或不均,边缘清楚或局部欠清,伴邻近皮下组织受累;增强扫描病灶表现为不同程度强化。3例MRI表现为对比邻近肌肉信号,病灶在T1WI上为等、稍高信号,在T2WI上为高信号,大部分病灶中等至明显强化。本组6例病变均伴有周围多发淋巴结肿大及实验室检查外周血嗜酸性粒细胞增多,可伴病侧局部皮下脂肪层萎缩。结论:头颈部木村病的CT、MRI影像表现有一定特征性,结合临床病史及实验室检查,可提高木村病的诊断准确率。     

Maurice Ravel's illness: a tragedy of lost creativity

Maurice Ravel had been subject to psychiatric disorder for many years when signs of organic brain disease appeared at the age of 52. Aphasia, apraxia, agraphia, and alexia became established some five years later. Musical creativity was lost. Alajouanine diagnosed cerebral atrophy with bilateral ventricular enlargement. Though Ravel''s condition deteriorated progressively, generalised dementia was not apparent. He died in December 1937, after a craniotomy performed by Clovis Vincent, possibly from a subdural haematoma. Vincent''s operative findings are described here. The likely cause of Ravel''s illness was a restricted form of cerebral degeneration.     

Is Sonic Hedgehog Involved in Human Fracture Healing? - A Prospective Study on Local and Systemic Concentrations of SHH

Introduction

Sonic Hedgehog (SHH) is a new signalling pathway in bone repair. Evidence exist that SHH pathway plays a significant role in vasculogenesis and limb development during embryogenesis. Some in vitro and animal studies has already proven its potential for bone regeneration. However, no data on the role of SHH in the human fracture healing have been published so far.

Methods

Seventy-five patients with long bone fractures were included into the study and divided in 2 groups. First group contained 69 patients with normal fracture healing. Four patients with impaired fracture healing formed the second group. 34 volunteers donated blood samples as control. Serum samples were collected over a period of 1 year following a standardized time schedule. In addition, SHH levels were measured in fracture haematoma and serum of 16 patients with bone fractures.

Results

Fracture haematoma and patients serum both contained lower SHH concentrations compared to control serum. The comparison between the patients'' serum SHH level and the control serum revealed lower levels for the patients at all measurement time points. Significantly lower concentrations were observed at weeks 1 and 2 after fracture. SHH levels were slightly decreased in patients with impaired fracture healing without statistical significance.

Conclusion

This is the first study to report local and systemic concentration of SHH in human fracture healing and SHH serum levels in healthy adults. A significant reduction of the SHH levels during the inflammatory phase of fracture healing was found. SHH concentrations in fracture haematoma and serum were lower than the concentration in control serum for the rest of the healing period. Our findings indicate that there is no relevant involvement of SHH in human fracture healing. Fracture repair process seem to reduce the SHH level in human. Further studies are definitely needed to clarify the underlying mechanisms.     

Effectiveness of bicycle helmets in preventing head injury in children: case-control study.

OBJECTIVE--To examine the risk of injury to the head and the effect of wearing helmets in bicycle accidents among children. DESIGN--Case-control study by questionnaire completed by the children and their carers. SETTING--Two large children''s hospitals in Brisbane, Australia. SUBJECT--445 children presenting with bicycle related injuries during 15 April 1991 to 30 June 1992. The cases comprised 102 children who had sustained injury to the upper head including the skull, forehead and scalp or loss of consciousness. The controls were 278 cyclists presenting with injuries other than to the head or face. A further 65 children with injuries to the face were considered as an extra comparison group. MAIN OUTCOME MEASURES--Cause and type of injury, wearing of helmet. RESULTS--Most children (230) were injured after losing control and falling from their bicycle. Only 31 had contact with another moving vehicle. Children with head injury were significantly more likely to have made contact with a moving vehicle than control children (19 (19%) v 12 (4%), P < 0.001). Head injuries were more likely to occur on paved surfaces than on grass, gravel, or dirt. Wearing a helmet reduced the risk of head injury by 63% (95% confidence interval 34% to 80%) and of loss of consciousness by 86% (62% to 95%). CONCLUSIONS--The risk of head injury in bicycle accidents is reduced among children wearing a helmet. Current helmet design maximises protection in the type of accident most commonly occurring in this study. Legislation enforcing helmet use among children should be considered.     

北方草原牧户心理载畜率与草畜平衡生态管理途径

探讨牧户心理载畜率与草畜平衡生态管理的途径对于草原有效减畜、遏止草原退化、实现可持续发展具有重要意义。从生态学和社会科学相结合的角度,采用问卷调查、情景实验及综合分析等多种方法,探讨了北方草原牧户心理载畜率的存在、计算和影响因素,以及牧户生产决策行为特征和可能的生态管理途径。研究发现,在草甸草原、典型草原和荒漠草原,牧户行为属"有限理性",是有限理性的"生态经济人",风险规避是其基本特征,牧户生产决策表现出禀赋效应、损失厌恶、框架效应等;牧户草场所属草原类型和牲畜存栏数显著影响牧户对草场超载的认知和判断,在不同草原类型区,户主文化水平、性别、民族和是否嘎查干部等亦显著影响牧户对超载的认知和判断;需采取基于进化博弈的分步式、合作式及示范引导式的适应性减畜的生态管理途径,以实现牧户心理载畜率向生态优化载畜率的转移,实现优化牧户生产方式、减少牲畜数量、治理草原退化、北方牧区生态和牧民经济双赢的目标。     

Sign left by introduced and native predators feeding on Hutton's shearwaters Puffinus huttoni

Abstract

The identification of introduced and native predators is important for many conservation studies within New Zealand. Carcasses of Hutton's shearwaters were collected over three field seasons, and where predation was probable, the bodies were autopsied. Paired bites identified stoats as the principal predator of Hutton's shearwater, but also revealed that a feral cat was present within the colony. Stoats killed their prey with a bite to the back of the neck or head, and commenced feeding on the neck or head. Despite the limited number of cat‐killed birds, cats appeared to feed on Hutton's shearwaters differently from stoats, starting on the breast muscles. Harriers and kea left sign that allowed birds killed or scavenged by these native birds to be distinguished from those killed by stoats or cats.     

Infantile Subdural Haematoma and its Relationship to Whiplash Injuries

Subdural haematoma is one of the commonest features of the battered child syndrome, yet by no means all the patients so affected have external marks of injury on the head. This suggests that in some cases repeated acceleration/deceleration rather than direct violence is the cause of the haemorrhage, the infant having been shaken rather than struck by its parent. Such an hypothesis might also explain the remarkable frequency of the finding of subdural haemorrhage in battered children as compared with its incidence in head injuries of other origin, and the fact that it is so often bilateral.     

Mortality of lemmings, Lemmus lemmus, at peak density in a mountainous area of Norway

We estimated carcass density and determined cause of death in a peak-density lemming, Lemmus lemmus , population at Finse, Norway. Of 74 recovered carcasses, 80% had subcutaneous haematoma (blood underneath the skin) in the head region, though the skin on the skull most often appeared unharmed. Thirty percent were apparently killed by a mustelid predator, while 51% were probably killed by corvids. Carcass density was 26.6 and 9.4ha^-1 in good and poor lemming habitats, respectively.     

Management of traumatic intracranial haematoma.

Deciding which head-injured patients should be transferred to a neurosurgical unit can be difficult. Traditional criteria emphasise the development of deteriorating responsiveness but lead to delayed diagnosis and to avoidable mortality and morbidity. To discover if a more liberal admission policy improved results a study was conducted analysing data collected prospectively from 683 patients who had a traumatic intracranial haematoma evacuated in the Glasgow neurosurgical unit between 1974 and 1980. In the first four years, before the change in policy, mortality was 38% but decreased to 29% afterwards. This reflected a reduction in the proportion of patients who talked after injury but who deteriorated into coma before operation--that is, 31% before the change in policy, 16% afterwards. If the potential benefits of CT scanning in the management of head injuries are to be realised patients must be scanned sooner than in the past. This will usually mean that more patients should go to a neurosurgical unit and that simple criteria for transfer should be established.     

Automatic imitation in dogs

After preliminary training to open a sliding door using their head and their paw, dogs were given a discrimination task in which they were rewarded with food for opening the door using the same method (head or paw) as demonstrated by their owner (compatible group), or for opening the door using the alternative method (incompatible group). The incompatible group, which had to counterimitate to receive food reward, required more trials to reach a fixed criterion of discrimination performance (85% correct) than the compatible group. This suggests that, like humans, dogs are subject to ‘automatic imitation’; they cannot inhibit online the tendency to imitate head use and/or paw use. In a subsequent transfer test, where all dogs were required to imitate their owners'' head and paw use for food reward, the incompatible group made a greater proportion of incorrect, counterimitative responses than the compatible group. These results are consistent with the associative sequence learning model, which suggests that the development of imitation depends on sensorimotor experience and phylogenetically general mechanisms of associative learning. More specifically, they suggest that the imitative behaviour of dogs is shaped more by their developmental interactions with humans than by their evolutionary history of domestication.     

Odour,and the recognition of lambs by Merino ewes

Ewes that had been separated from their lambs for several hours were each presented with a choice between three anaesthetized lambs, one of which was the ewe's own. Each lamb was in a separate cage adjacent to a passage-way in which the ewe was free to move. The ability of the ewe to select her own lamb was equally good whether the head or the tail region of the lamb was placed against the corridor for examination at close-quarters, but when the lamb was 0.25 m from the corridor, very few ewes appeared able to find their own lambs. Although the ewes displayed less interest in the lamb's head than in the tail region, the head, as well as the tail, appears to provide the ewe with close-quarter clues, presumably olfactory, to the identity of the lamb.