Healing News

An IAEA mission to get powerful radioactive sources out of Lebanon was completed 30 August 2009, after a plane carrying the high-activity cargo safely touched down in Russia, where the sources are now securely and safely stored.

They comprised 36 Cobalt-60 sources, with a combined activity of 3.500 curies. A single source is powerful enough to kill a person within minutes, if directly exposed.

Mr. Robin Heard, an IAEA radioactive source specialist, oversaw the mission.

“Given the political situation in the Middle East and particularly in Lebanon we saw this source as vulnerable to malicious acts. If it was stolen it could cause a lot of damage to people,” Mr. Heard said.

The Cobalt-60 sources were from an irradiator that was once used for an agricultural project. But that was 10 years ago. The project ceased, and the staff that had the knowledge to properly look after the irradiation had left the organization.

In support of the IAEA activities in nuclear security, in 2005, the Council of the European Union decided to provide funds of € 3.914 million to the IAEAВґs Nuclear Security Fund. This paves the way to securing high radioactive sources like those in Lebanon.

“The challenges to this project were all security related,” Mr. Heard said. “Just after we went on our first fact finding mission to Lebanon in 2006, the Israelis bombed the airport, so there was no way we could fly the sources out at that time. So there was a long delay while we waited for things to normalise in Lebanon,” he said.

But their perseverance paid off, working closely with the Lebanese Atomic Energy Commission. “Having some Cobalt-60 sources for the research irradiator in the agriculture centre not secure and not used, posed some threat, actually a lot of threat on the public, on Lebanon. So the IAEA experts, with the acceptance of the Lebanese authorities agreed that they be removed… It was a very good thing for Lebanon and for nuclear security in the world,” Ms. Muzna Assi, Section Head, Radioactive Waste Management and Safe Transport of Radioactive Sources at the Commission said.

The job involved extracting the sources from the irradiator and moving them to special transport containers. They were then flown to Russia on an aeroplane hired specifically for the job.

Source:
Press Office

International Atomic Energy Agency

Radiologist Laura W. Bancroft, M.D., from Florida Hospital in Orlando, will bring her medical expertise to Bolivia as part of the International Visiting Professor Program offered by the Radiological Society of North America (RSNA). The program fosters international relations among radiology societies to assist with medical education in developing and newly developed nations.

Dr. Bancroft, clinical professor at Florida State University School of Medicine and diagnostic radiologist at Florida Hospital in Orlando, will be joined by a fellow radiologist as she embarks September 18 on the 12-day trip. She will spend her visit giving presentations and teaching intensive seminars to members of Bolivian radiology societies and hospital radiology departments.

The program is mutually beneficial. The visiting team of radiologists informs local doctors and hospitals about the latest advances in diagnostic and therapeutic radiology. In turn, the visiting professors experience firsthand the obstacles faced by medical professionals in the host countries.

“I am thrilled to be part of the RSNA Visiting Professor program, and I am looking forward to sharing my interesting musculoskeletal imaging cases with radiologists in this region,” Dr. Bancroft said. “Furthermore, I am eager to learn about unique musculoskeletal diseases from the radiologists serving South America, and share them with my North American colleagues.”

Dr. Bancroft, who is also adjunct faculty at University of Central Florida School of Medicine and Mayo Clinic College of Medicine, is accompanied by William W. Mayo-Smith, M.D., from Rhode Island Hospital and Brown University in Providence. Locations of the presentations in Bolivia include Hospital Obrero, Hospital Materno Infantil and the annual meeting of the Bolivian Radiological Society in La Paz.

The International Visiting Professors Program was founded in 1986 and is administered by RSNA’s Committee on International Relations and Education (CIRE).

Source
RSNA

Agriculture Secretary Tom Vilsack issued the following statement regarding the House Committee on Education and Labor’s mark-up of H.R. 5504, “The Improving Nutrition for America’s Children Act:”

“I applaud the commitment of Chairman Miller, Ranking Member Kline, Congresswoman McCarthy and Congressman Platts to ensuring that our children have access to healthy, nutritious meals. Through the work of the Chairman and the membership of the House Committee on Education and Labor to reauthorize and reform the Child Nutrition Act, today’s bipartisan passage of the Improving Nutrition for America’s Children Act (H.R. 5504) demonstrates a commitment to reduce hunger, improve the health of our children and support their academic achievement. The House legislation complements the Senate’s Healthy, Hunger-Free Kids Act recently reported out of Committee. Both bills advance the Administration’s priorities to improve meal quality, strengthen nutrition standards for school meals, reduce barriers and increase access to healthy school meals, promote nutrition education, establish standards for competitive foods, and provide food to needy children during gap periods when the regular nutrition assistance programs are not in operation. Today’s action is a very positive step forward and I congratulate the House Committee on Education and Labor for its constructive, bipartisan work. I urge Congress to continue making enactment of Child Nutrition Reauthorization legislation a priority this year. This is a bill that will improve the health and nutrition of America’s children – a top concern of moms and dads throughout the country. I urge Congress to finish this process by the time kids head back to school this fall.”

Source:

USDA

An article published Online First and in a future edition of The Lancet reports that using validated prediction rules to identify children at very low risk of clinically-important traumatic brain injuries (ciTBIs) can reduce the need for CT scans. This can therefore diminish their resulting radiation exposure. The article is the work of Prof Nathan Kuppermann, Departments of Emergency Medicine and Pediatrics, University of California, Davis Medical Center, Sacramento, CA, USA and colleagues from the PECARN investigators network.

Worldwide, traumatic brain injury is the principal cause of death and disability in children. Every year in the USA, head trauma in individuals under 18 years of age results in about 7,400 deaths, over 60,000 hospital admissions, and over 600,000 emergency department visits. The CT scan is a vital diagnostic tool. However it elevates future risk of radiation-induced cancer. The authors determined how to identify children at very low risk of ciTBI for whom CT might be both pointless and undesirable.

A total of 42,000 children were included in this study. A quarter was less than 2 years of age. The rest were aged between 2 to 18 years. When investigators want to create a prediction rule, they should do so on a large group of patients to get as precise a rule as possible. This group of patients is called a “derivation group” on which the prediction rule is “derived”. However, any group of patients has certain characteristics and modes of behaviour. This may cause the prediction rule derived on that group to only be accurate when applied to that unique group. The investigators should therefore then test the prediction rule derived on the “derivation group” on a new group of patients, called the “validation group” to assess the validity of the rule.

The prediction rules were created using a ‘derivation’ population, and then applied to see if they worked on a ‘validation’ population. CT scans were obtained on 35 percent of the children, ciTBIs occurred in 376 (1 percent) and 60 (0.1 percent) underwent neurosurgery.

In the validation population, the clinical characteristics used to predict that children younger than 2 years did not have a ciTBI were:

• normal mental status
• no scalp haematoma (swelling) except frontal
• no loss of consciousness or loss of consciousness of less than five seconds

• non-severe injury mechanism
• no palpable skull fracture
• acting normally according to the parents

This predicted with 100 percent accuracy for 1,176 patients younger than 2 years who did not have a ciTBI in the validation population. 24 percent of the CT-imaged children younger than 2 years were in this low-risk group.

The prediction rule to identify children 2 years and older who did not have ciTBI included these characteristics:

• normal mental status
• no loss of consciousness
• no vomiting

• non-severe injury mechanism
• no signs of basilar skull fracture

• no severe headache

This correctly predicted all but 2 out of 3,800 patients (99.95 percent) who did not have a ciTBI in the validation population. 20 percent of the CT-scanned patients 2 years and older were in this low-risk group. Therefore, the results showed that, using these prediction rules for children presenting with head trauma, 1 in 4 children younger than 2 years and 1 in 5 older than 2 years who would likely have had CT scans without prediction rules could avoid these CT scans and their accompanying radiation exposure when the rules are applied.

The authors write in conclusion: “In this study of more than 42 000 children with minor blunt head trauma, we derived and validated highly accurate prediction rules for children at very low risk of ciTBIs for whom CT scans should be avoided. Application of these rules could limit CT use, protecting children from unnecessary radiation risks. Furthermore, these rules provide the necessary data to assist clinicians and families in CT decision making after head trauma.”

In an associated note, Dr Patricia C. Parkin, Hospital for Sick Children, University of Toronto Faculty of Medicine, Canada, and Dr Jonathon L. Maguire, Hospital for Sick Children, University of Toronto Faculty of Medicine, Canada, and Li Ka Shing, Knowledge Institute of St Michael’s Hospital, Toronto, Canada, remark: “Decision aids might provide structured presentations of options and outcomes, and many decisions, even in acute care settings, are sensitive to patients’ values and preferences…Perhaps as this field moves forward to assessment of the effect of the rules on physicians’ behaviour and clinical outcomes (impact analysis), clinicians and investigators might consider involving patients in the decision-making process. Then, when asking the question ‘should my head-injured child have a CT scan?, parents can weigh the probability of a clinically important traumatic brain injury with the probability of harm from ionising radiation from the CT scan.”

“Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study”

Nathan Kuppermann, James F Holmes, Peter S Dayan, John D Hoyle, Jr, Shireen M Atabaki, Richard Holubkov, Frances M Nadel, David Monroe, Rachel M Stanley, Dominic A Borgialli, Mohamed K Badawy, Jeff E Schunk, Kimberly S Quayle, Prashant Mahajan, Richard Lichenstein, Kathleen A Lillis, Michael G Tunik, Elizabeth S Jacobs, James M Callahan, Marc H Gorelick, Todd F Glass, Lois K Lee, Michael C Bachman, Arthur Cooper, Elizabeth C Powell, Michael J Gerardi, Kraig A Melville, J Paul Muizelaar, David H Wisner, Sally Jo Zuspan, J Michael Dean, Sandra L Wootton-Gorges, for the Pediatric Emergency Care Applied Research Network (PECARN)
DOI: 10.1016/S0140-6736(09)61558-0
The Lancet

Stephanie Brunner (B.A.)

Particle beam radiation therapy, a technology used to treat several types of cancer, is considered by some clinicians to be better than traditional radiation, but there is limited evidence about its safety compared with other types of radiation therapy, according to a new comparative effectiveness report funded by HHS’ Agency for Healthcare Research and Quality.

“As technologies develop and new clinical interventions arise, it is important to balance access to potentially beneficial new technologies with ongoing research and evaluation to determine whether the technologies deliver what they promise,” said AHRQ Director Carolyn M. Clancy, M.D. “Increased funding for comparative effectiveness research is an exciting opportunity to continue important research on medical therapies and interventions.”

Particle beam radiation therapy also known as charged particle radiation therapy or proton beam radiation therapy uses beams of protons or other charged particles for cancer radiation treatment. Particle beam radiation therapy is an alternative to other types of cancer radiation therapy such as external radiotherapy with ionizing photon (X- or gamma-ray) beams or brachytherapy with implanted radioactive sources.

All types of radiation therapy can harm both cancerous and healthy tissues, so clinicians strive to target the radiation to the cancer while avoiding adjacent healthy tissues. This is particularly important for tumors adjacent to critical body parts such as those in the eye, brain, head and neck. Particle beam radiation therapy can target the radiation with a high degree of precision, but its potential advantages over other radiotherapy alternatives have not been verified in long-term outcome studies, according to the new AHRQ technical brief.

Particle beam radiation therapy was introduced as an experimental treatment in the 1950s but was not cleared for widespread use by the U.S. Food and Drug Administration until 2001. The technology is very expensive an estimated $175 million for each device and is usually only available in large academic medical centers. Only seven centers in the United States currently provide the therapy, with an additional center currently under construction and expected to be operational by 2010. Although details have not been disclosed, several other hospitals are considering developing smaller treatment facilities based on upcoming technologies that have not yet been cleared by the Food and Drug Administration.

The technical brief did not indicate that particle beam radiation therapy is riskier than conventional radiation therapy. However, most studies about the therapy were conducted on small numbers of patients and did not compare the safety of particle beam radiation therapy against other therapies. For many cancers other than head and neck cancers, there are not enough comparative studies in the literature to base an evaluation of the clinical or cost effectiveness of particle beam radiation therapy compared with other treatments. AHRQ is currently reviewing scientific studies on radiation therapies for head and neck cancers that will evaluate the clinical effectiveness of particle beam radiation therapy for those cancers.

The report is the Agency’s first in a series of technical briefs rapid-turnaround reports that summarize key issues regarding emerging treatments. Technical briefs highlight where more research is needed and where research may be sufficient to warrant a full systematic review. Technical briefs are produced by AHRQ’s Effective Health Care program. Future technical briefs will describe the evidence on fetal surgery, stereotactic surgery for non-brain cancers and percutaneous heart valves.

AHRQ’s new report, Technical Brief: Particle Beam Radiation Therapies for Cancer, is the newest research review from the Agency’s Effective Health Care program. That program, authorized by the Medicare Prescription Drug, Improvement and Modernization Act, represents an important federal effort to compare alternative treatments for health conditions and make the findings public. The program is intended to help patients, doctors, nurses, pharmacists and others choose the most effective treatments.

Source: Agency for Healthcare Research and Quality

A team of researchers led by Massachusetts General Hospital (MGH) radiologists has developed a computed-tomography-based protocol that identifies both narrowing of coronary arteries and areas of myocardial ischemia – restricted blood flow to heart muscle tissue – giving a better indication of clinically significant coronary artery disease. Their report appears in the September 15 issue of the Journal of the American College of Cardiology.

“This is among the first demonstrations of the use of cardiac CT [computed tomography] to detect both coronary artery stenosis and resulting myocardial ischemia simultaneously in a single examination,” says Ricardo C. Cury, MD, a cardiac imaging specialist at the MGH Heart Center and the study’s principal investigator.

CT scanning uses conventional X-rays to produce cross-sectional images of anatomic structures and can detect plaques in coronary arteries. But the appearance of plaques on CT images may not indicate whether or not they actually compromise the heart muscle’s blood supply. More detailed angiographic images obtained via invasive cardiac catheterization give a better picture of how obstructive a plaque may be, and perfusion studies utilizing technologies such as MRI scans or the nuclear medicine technologies SPECT and PET reveal areas where limited blood flow has damaged the heart muscle, information that can determine whether a patient can be treated with drugs or requires surgical intervention.

Earlier studies showed that CT can identify areas of restricted coronary blood supply in resting individuals. The MGH-led study was designed to see whether a comprehensive cardiac CT examination could incorporate myocardial perfusion studies in both resting and stress situations along with the anatomic data provided by CT angiography. The study enrolled 34 cardiac patients who recently had SPECT stress tests and were likely to also require angiography via cardiac catheterization.

Participants first had a cardiac CT taken while receiving an infusion of adenosine, which produces physiologic stress symptoms such as elevated heart rate and blood pressure. When vital signs returned to normal several minutes after the adenosine infusion, a resting cardiac CT was taken. Both of those scans involved the use of contrast material, and to detect areas with little or no contrast agent – indicating restrictions to the myocardial vasculature – a third CT scan was taken 7 minutes later.

The accuracy of CT-based perfusion imaging in diagnosing coronary artery narrowing that significantly affected myocardial perfusion was virtually the same as SPECT stress imaging, and the results of coronary CT angiography also compared favorably to those of cardiac catheterization. Because the investigators used new radiation-dose-reduction techniques, the radiation dose of the three CT scans did not exceed the dosage involved in the SPECT stress perfusion study.

“While nuclear perfusion imaging provides information that can help guide patient treatment, it has limitations that can lead to either false negative or false positive findings,” Cury explains. “The ability to acquire anatomical visualization of coronary artery stenosis together with physiological assessment of myocardial perfusion in a single study could improve diagnostic accuracy while potentially reducing costs and radiation exposure. Since our study was relatively small, we need to test this approach in a larger multicenter trial and further investigate the additional value of CT perfusion studies over CT angiography.” A consulting radiologist at MGH, Cury recently joined the Baptist Cardiac and Vascular Institute in Miami.

Ron Blankstein, MD, of the MGH Cardiac MR/PET/CT Program and the Noninvasive Cardiovascular Imaging Program at Brigham and Women’s Hospital (BWH) is the lead author of the Journal of the American College of Cardiology paper. Co-authors of the JACC report are Leon Shturman, MD, Ian Rogers, MD, Jose Rocha-Filho, MD, David Okada, MD, Ammar Sarwar, MD, Anand Soni, MD, Brian Ghoshhajra, MD, Milena Petranovic, MD, Ricardo Loureiro, MD, Henry Gewirtz, MD, Udo Hoffmann, MD, MPH, and Thomas Brady, MD, MGH; Hiram Bezerra, MD, Case Wastern Reserve University; Gudrun Feuchtner, MD, Innsbruck Medical University, Austria; and Wilfred Mamuya, MD, PhD, BWH. The study was supported by grants from Astellas Pharma, Inc. and the National Institutes of Health.

Source:
Jennifer Gundersen

Massachusetts General Hospital

A research project looking for ways to reduce bone loss in astronauts may yield methods of improving the bone health of cancer patients undergoing radiation treatment.

It is well documented that living in the microgravity environment of space causes bone loss in astronauts, but until recently, little was known about the effects of space radiation on bones. Dr. Ted Bateman leads a project funded by the National Space Biomedical Research Institute (NSBRI) to understand radiation-induced bone loss and to determine which treatments can be used to reduce that loss and lower the risk of fractures.

“Our studies indicate significant bone loss at the radiation levels astronauts will experience during long missions to the moon or Mars,” said Bateman, a member of NSBRI’s Musculoskeletal Alterations Team.

Bateman, an associate professor of bioengineering at Clemson University, and colleagues at Clemson and Loma Linda University have discovered in experiments with mice that bone loss begins within days of radiation exposure through activation of bone-reducing cells called osteoclasts. Under normal conditions, these cells work with bone-building cells, called osteoblasts, to maintain bone health.

“Our research challenges some conventional thought by saying radiation turns on the bone-eating osteoclasts,” Bateman said. “If that is indeed the case, existing treatments, such as bisphosphonates, may be able to prevent this early loss of bone.”

Bisphosphonates are used to prevent loss of bone mass in patients who have osteoporosis or other bone disorders.

Even though the research is being performed to protect the health of NASA astronauts, cancer patients, especially those who receive radiation therapy in the pelvic region, could benefit from the research.

“We know that older women receiving radiotherapy to treat pelvic tumors are particularly vulnerable to fracture, with hip fracture rates increasing 65 percent to 200 percent in these cancer patients,” said Bateman. “Hip fractures are very serious; nearly one in four patients who fracture a hip will not survive a year. A large number of surviving patients will require long-term care. More than 80 percent of the patients will not be able to walk unaided or will not be back to pre-fracture activity levels after a year.”

Once a person loses bone, their long-term fracture risk depends on their ability to recover lost bone mass. For older cancer patients, early introduction of bisphosphonates and other forms of treatment could help greatly since the process of regaining bone mass can be more difficult due to lower activity levels.

Clemson’s Dr. Jeff Willey is a collaborator with Bateman and the lead investigator of an NSBRI-funded project looking at the cellular mechanisms involved in radiation-induced bone loss. He said the bone loss in the spaceflight-related experiments has occurred quickly and cell physiology has changed.

“If we expose mice to a relatively low dose of radiation, the cells that break down bone are turned on several days after exposure,” he said. “After radiation exposure, osteoclasts appear to have a different shape. They get flatter, and there are certainly more of them.”

The mice used in the research have received the amount of radiation exposure that is expected to occur during a lengthy mission to the moon or Mars. The amount is much less than what cancer patients receive during treatment. For example, patients receiving radiation treatment in the pelvic region can receive doses up to 80 gray over a six- to eight-week period, with the hip receiving up to 25 gray. Astronauts are likely to receive about 0.5 to 1 gray during a long-duration lunar or martian mission.

Astronauts are at risk of radiation exposure from two sources. The first is proton radiation from the sun. The second, and less understood type, is galactic cosmic radiation from sources outside the galaxy. Galactic cosmic rays and protons would be the source of radiation damage for astronauts during a mission to Mars.

Marcelo Vazquez, NSBRI’s senior scientist for space radiation research, said Bateman’s project and other NSBRI radiation projects will influence spacecraft design and mission planning. “The research will help to define the radiation risks for astronauts during long-term missions,” Vazquez said. “This will lead to strategies for shielding and medical countermeasures to protect against exposure.”

Bateman’s NSBRI work is leading to other studies. “We have been able to initiate a couple of clinical trials with cancer patients to determine if what we are seeing in mice corresponds with bone loss in humans. Preliminary results in these trials show rapid declines in bone mass and strength,” Bateman said.

Source:
Brad Thomas

National Space Biomedical Research Institute

For years scientists have struggled to find quick ways of assessing the extent of radiation damage, at a cellular level, in those involved in radiological and nuclear incidents. Because of this bottleneck choosing the right treatment for people caught up in such incidents, but who are not suffering visible medical effects, can be slow.

Now scientists from the Health Protection Agency, the University of Oxford and the Gray Cancer Institute are in the process of creating devices which would look for evidence of radiation damage, specifically breaks in DNA strands, in blood cells and deliver results fast.

Scientists behind the technology believe it could play a vital role in speeding up frontline treatment.

Details of the emerging technology were revealed during a lecture at the Health Protection Agency’s annual conference at the University of Warwick.

“If there was a major radiological or nuclear event the hospitals in this country could be overwhelmed,” said Dr Kai Rothkamm, head of Cytogenetics & Biomarkers at the HPA.

“This work is about enabling scientists to carry out accurate and rapid analysis of samples so that clinicians can then use the information in treatment – as well as reassuring those who are not affected.”

Current methods involve scientists taking blood samples, culturing white blood cells for two days, and analysing them to detect chromosomal abnormalities. But it is a slow and complex process. Existing UK lab facilities could handle about 100 samples in a week.

The new technology being worked on could test about 30 blood samples in an hour for exposure to critically high levels of radiation. If more time was available for analysis, it could also detect radiation down to the level of just a few millisieverts (mSv) although only if used within a few hours after the exposure. The average person in the UK is exposed to 2.2mSv of radiation from natural sources every year.

The estimate of the radiation dose received by the patient would then allow frontline medics to determine what kind of treatment would be best.

For now the research team behind the technology has prototype devices and is developing software for testing. But it’s hoped when complete the equipment could fit inside a suitcase.

Notes

- In March the Government’s Advisory Group on Ionising Radiation said more work needed to be done to develop triage facilities in the UK that could deliver fast radiation dose estimates in the aftermath of a major radiological, or nuclear, incident.

- Funding for the work has come through the Home Office and the EU.

- The Health Protection Agency has a duty to advise Government on radiation issues.

Source
Health Protection Agency

1. Three Medications Reduce the Risk for Invasive Breast Cancer but Carry Heavy Risks for Adverse Events

Breast cancer is the second most common cancer among women, causing 40,000 deaths a year. For women with a close family history of the disease, physicians may prescribe drugs to help reduce their risk of getting breast cancer. However, these medications carry their own potential health risks. Researchers reviewed seven placebo-controlled, randomized clinical trials and one head-to-head trial to assess the benefits and harms of three medications for preventing invasive breast cancer in women who had not previously had breast cancer. They found that the medications tamoxifen citrate, raloxifene, and tibolone reduced the risk of invasive breast cancer but increased the risk for thromboembolic events (tamoxifen and raloxifene), endometrial cancer (tamoxifen), or stroke (tibolone). The researchers suggest caution in prescribing these drugs to prevent breast cancer, as more research is needed to determine which patients would benefit the most, while suffering the least amount of harm.

2. Particle Beam Radiation Therapy Shows Promise for Treating Cancer, More Research Needed

Radiation therapy plays a pivotal role in cancer treatment. However, radiotherapy does not always eradicate tumors, as physicians aim to balance damage to the tumor with the undesired effect of causing radiation damage to surrounding healthy tissue. Radiotherapy with charged particles, or particle beam radiation, can potentially deliver maximum doses of radiation to the tumor while minimizing damage to other areas. For this reason, particle beam radiation may be more effective or less harmful than other forms of radiotherapy. Researchers reviewed available evidence about the benefits and harms of particle beam radiotherapy for cancer patients. They found that more evidence on the comparative effectiveness and safety of charged particle beam therapy in cancers is needed to assess the benefits, risks, and costs of treatment.

In this Issue:

3. The Benefits of Treating Type 2 Diabetes Outweigh the Health Care Costs

As the debate over health care reform continues, the nation has become more focused on the growing cost of health care. While health care spending has increased substantially, so have longevity and quality of life for patients. However, some question whether improved outcomes justify the high costs of care. Researchers conducted an economic analysis on 613 patients with type 2 diabetes being treated at the Mayo Clinic in Rochester continuously for eight years. The researchers found that the value of prevention of future mortality and morbidity for patients exceeded the increased cost of managing their illness. The researchers concluded that while the outcome is worth the extra cost, value for money spent can still be enhanced in diabetes management.

4. Case Management by Health Care Assistants May Improve Outcomes for Patients with Clinical Depression

Most patients with depression seek treatment in primary care. Typically, primary care physicians collaborate with mental health case workers to provide self-management and follow-up support to their patients. Researchers studied 74 small primary care practices in Germany over one year to determine whether case management provided by health care assistants would be more effective than usual care for patients with major depression. The researchers randomly assigned 626 adults with depression to either case management by a health care assistant (310) or usual care (316). Health care assistants contacted their patients via telephone twice a week in the first month and then once a month for the next 11 months to monitor depression symptoms and adherence to medication. They also encouraged patients to follow self-management activities. At one year, researchers found that patients assigned to receive case management by health assistants reported slightly greater improvements in depression symptoms, better adherence to antidepressant therapies, and more favorable assessments of the quality of their care than did the usual care patients. The health assistant approach to depression management could be an effective and cost-effective option for small primary care offices.

Source:
Angela Collom

American College of Physicians

Using validated prediction rules to identify children at very low risk of clinically-important traumatic brain injuries (ciTBIs) can reduce the need for CT scans and their resultant radiation exposure. This is the conclusion of an Article published Online First and in an upcoming edition of The Lancet, Prof Nathan Kuppermann, Departments of Emergency Medicine and Pediatrics, University of California, Davis Medical Center, Sacramento, CA, USA and colleagues from the PECARN investigators network.

Traumatic brain injury is a leading cause of death and disability in children worldwide. In the USA, head trauma in individuals aged 18 years and younger results in about 7400 deaths, over 60 000 hospital admissions, and over 600 000 emergency department visits every year. A CT scan, while a vital diagnostic tool, elevates future risk of radiation-induced cancer. The authors aimed to identify children at very low risk of ciTBI for whom CT might be both unnecessary and undesirable.

The study analysed more than 42,000 children, of whom a quarter were aged under 2 years, with the rest aged 2- 18 years. The prediction rules were created using a ‘derivation’* population, and then applied to see if they worked on a ‘validation’* population. CT scans were obtained on 35% of the children, ciTBIs occurred in 376 (1%) and 60 (0.1%) underwent neurosurgery. In the validation population, the clinical characteristics used to predict that children younger than 2 years did not have a ciTBI were: normal mental status, no scalp haematoma (swelling) except frontal, no loss of consciousness or loss of consciousness of less than five seconds, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents. This correctly predicted 100% of 1176 patients younger than 2 years who did not have a ciTBI in the validation population. 24% of the CT-imaged children younger than 2 years were in this low-risk group.

The prediction rule to identify children 2 years and older who did not have ciTBI included the characteristics: normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache. This correctly predicted all but 2 out of 3,800 patients (99.95%) who did not have a ciTBI in the validation population. 20% of the CT-scanned patients 2 years and older were in this low-risk group. Thus, the results showed that, using these prediction rules for children presenting with head trauma, 1 in 4 children younger than 2 years and 1 in 5 older than 2 years who would likely have had CT scans without prediction rules could avoid these CT scans and their accompanying radiation exposure when the rules are applied.

The authors conclude: “In this study of more than 42 000 children with minor blunt head trauma, we derived and validated highly accurate prediction rules for children at very low risk of ciTBIs for whom CT scans should be avoided. Application of these rules could limit CT use, protecting children from unnecessary radiation risks. Furthermore, these rules provide the necessary data to assist clinicians and families in CT decision making after head trauma.”

In an accompanying Comment, Dr Patricia C. Parkin, Hospital for Sick Children, University of Toronto Faculty of Medicine, Canada, and Dr Jonathon L. Maguire, Hospital for Sick Children, University of Toronto Faculty of Medicine, Canada, and Dr Li Ka Shing, Knowledge Institute of St Michael’s Hospital, Toronto, Canada, say: “Decision aids might provide structured presentations of options and outcomes, and many decisions, even in acute care settings, are sensitive to patients’ values and preferences…Perhaps as this field moves forward to assessment of the effect of the rules on physicians’ behaviour and clinical outcomes (impact analysis), clinicians and investigators might consider involving patients in the decision-making process. Then, when asking the question ‘should my head-injured child have a CT scan?’, parents can weigh the probability of a clinically important traumatic brain injury with the probability of harm from ionising radiation from the CT scan.”

Link to article

Source
The Lancet