Evaluation of S100B in the diagnosis of suspected intracranial hemorrhage after minor head injury in patients who are receiving platelet aggregation inhibitors and in patients 65 years of age and older.

OBJECT: Cranial CT (CCT) scans and hospital admission are increasingly performed to rule out intracranial hemorrhage in patients after minor head injury (MHI), particularly in older patients and in those receiving antiplatelet therapy. This leads to high radiation exposure and a growing financial burden. The aim of this study was to determine whether the astroglial-derived protein S100B that is released into blood can be used as a reliable negative predictive tool for intracranial bleeding in patients after MHI, when they are older than 65 years or being treated with antiplatelet drugs (low-dose aspirin, clopidogrel). METHODS: The authors conducted a prospective observational study in 2 trauma hospitals. A total of 782 patients with MHI (Glasgow Coma Scale Score 13-15) who were on medication with platelet aggregation inhibitors (PAIs) or were age 65 years and older, independent of antiplatelet therapy, were included. Clinical examination, bloodwork, observation, and CCT were performed in the traumatology emergency departments. When necessary, patients were admitted and observation took place on the ward; in these patients, CCT was performed during their hospital stay. Patients with severe trauma, focal neurological deficits, posttraumatic seizures, anticoagulant therapy, alcohol intoxication, coagulation disorder, blood sampling more than 3 hours after trauma, and unknown time of the trauma were excluded from the study. The median age of the patients was 83 years, and 69% were female. Sensitivity, specificity, and positive and negative predictive values of S100B with reference to CCT findings were calculated. The cutoff of S100B was set at 0.105 µg/L. RESULTS: Of the 782 patients, 50 (6.4%) had intracranial bleeding. One patient with positive results on CCT scan showed an S100B level below 0.105 µg/L. Of all patients, 33.1% were below the cutoff. S100B showed a sensitivity of 98.0% (CI 89.5%-99.7%), a negative predictive value of 99.6% (CI 97.9%-99.9%), a specificity of 35.3% (CI 31.9%- 38.8%), and a positive predictive value of 9.4% (CI 7.2%-12.2%). CONCLUSIONS: Levels of S100B below 0.105 µg/L can accurately predict normal CCT findings after MHI in older patients and in those treated with PAIs. Combining conventional decision criteria with measurement of S100B can reduce the CCT scan and hospital admission rates by approximately 30%.

Stress ulcer prophylaxis, thromboprophylaxis and coagulation management in patients with hip fractures.

Hip fracture in older patients is a major health concern. 20-25 % of hip fracture patients will die in the first year after the trauma (Lane, Clin Orthop Relat Res 471(8):2711, 2013). Postoperative venous thrombosis and gastrointestinal stress-ulcer bleeding are frequent complications with a high case-fatality rate particularly in older patients. Thromboprophylaxis and stress ulcer prophylaxis are important and well established measures to decrease postoperative complications and the mortality rate in this high-risk population.The working group on orthogeriatrics of the Austrian Society on Geriatrics and Gerontology (ÖGGG) is composed of geriatricians who work as trauma surgeons, internists, anaestesists and nurses. A thorough literature search was done, using the terms "orthogeriatrics" and "hip fracture" in combination with "stress ulcer", "gastrointestinal bleeding" and "thrombosis", "thromboprophylaxis". The data was collected, discussed and evaluated in several adjustment meetings of the group and summarized in this article.

Platelet aggregation inhibitors, platelet function testing, and blood loss in hip fracture surgery.

BACKGROUND: The purpose of our prospective study was to analyze how many patients with hip fractures are on treatment with platelet aggregation inhibitors (aspirin and clopidogrel), how many of these patients have impaired platelet function as measured by the PFA-100, and whether there is an association between perioperative blood loss and either intake of platelet inhibitors or platelet function. METHODS: Four hundred sixty-two patients with hip fractures were investigated. Surgery (most commonly dynamic screw fixation and hemiarthroplasty) was performed on day 1.3 (in patients on clopidogrel on day 3). Platelet function analysis was performed with the PFA-100, using the collagen and epinephrine closure time. Transfusion requirement and drain blood loss were measured. RESULTS: Ninety-eight patients (21%) were on treatment with aspirin, of those, 64 patients (65%) had impaired platelet function. Twenty-two patients (5%) were on clopidogrel, of those, 15 patients (68%) had impaired platelet function. Of the patients without platelet aggregation inhibitors, 29% had impaired platelet function. Mortality, major bleeding, red blood cell requirement, and drainage blood loss did not correlate with platelet aggregation inhibitor intake or platelet function. CONCLUSIONS: It is not possible to predict the platelet function by asking patients about intake of aspirin or clopidogrel. Perioperative blood loss did not correlate with either history of platelet aggregation inhibitor intake or platelet function as determined by PFA-100. Therefore, the measurement of platelet function is of little clinical relevance in patients with hip fractures. In patients treated with aspirin, surgery should not be delayed, and patients on clopidogrel can be operated on 3 days after stopping the drug without increased bleeding risk.