T raumaTic subdural hematomas (SDHs) are a common pathological entity in neurosurgical practice. Between 12% and 29% of patients admitted with a severe traumatic brain injury (TBI) have an acute SDH. When combining all patients with TBI, 11% present with an SDH. 10 Acute traumatic SDH has been traditionally considered a lesion that should be treated surgically, although some might be approached conservatively. In a study by Wong, 17 a midline shift greater than 5 mm in patients with a Glasgow Coma Scale (GCS) score below 15 was associated with deterioration and the need for surgical evacuation. In another study, 11 it was the initial thickness of the SDH that was predictive of the need for surgery, with all SDHs greater than 10 mm in thickness requiring surgical evacuation. Based on these findings, Servadei et al.12 attempted to establish a treatment protocol for comatose patients with SDH. They selected 15 comatose patients with abbreviatioNs AUC = area under the curve; BCR = bicaudate ratio; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; ISS = Injury Severity Score; ROC = receiver operating characteristic; SDH = subdural hematoma; SFR = sylvian fissure ratio; TBI = traumatic brain injury. obJect The Brain Trauma Foundation has published guidelines on the surgical management of traumatic subdural hematoma (SDH). However, no data exist on the proportion of patients with SDH that can be selected for conservative management and what is the outcome of these patients. The goals of this study were as follows: 1) to establish what proportion of patients are initially treated conservatively; 2) to determine what proportion of patients will deteriorate and require surgical evacuation; and 3) to identify risk factors associated with deterioration and delayed surgery. methods All cases of acute traumatic SDH (869 when inclusion criteria were met) presenting over a 4-year period were reviewed. For all conservatively treated SDH, the proportion of delayed surgical intervention and the Glasgow Outcome Scale score were taken as outcome measures. Multiple factors were compared between patients who required delayed surgery and patients without surgery. results Of the 869 patients with acute traumatic SDH, 646 (74.3%) were initially treated conservatively. A good outcome was achieved in 76.7% of the patients. Only 6.5% eventually required delayed surgery, and the median delay for surgery was 9.5 days. Factors associated with deterioration were as follows: 1) thicker SDH (p < 0.001); 2) greater midline shift (p < 0.001); 3) location at the convexity (p = 0.001); 4) alcohol abuse (p = 0.0260); and 5) history of falls (p = 0.018). There was no significant difference in regard to age, sex, Glasgow Coma Scale score, Injury Severity Score, abnormal coagulation, use of blood thinners, and presence of cerebral atrophy or white matter disease. coNclusioNs The majority of patients with SDH are treated conservatively. Of those, only 6.5% later required surgery, for raised intracranial pressure or SDH pr...
Hereditary breast cancers, mainly due to BRCA1 and BRCA2 mutations, account for only 5-10% of this disease. The threshold for genetic testing is a 10% likelihood of detecting a mutation, as determined by validated models such as BOADICEA and Manchester Scoring System. A 90-95% reduction in breast cancer risk can been achieved with bilateral prophylactic mastectomy in unaffected BRCA mutation carriers. In patients with BRCAassociated breast cancer, there is a 40% risk of contralateral breast cancer and hence prophylactic contralateral mastectomy is recommended, which can be performed simultaneiously with surgery for unilateral breast cancer. Other options for risk management include surveillance by mammogram and breast magnetic resonance imaging, and chemoprevention with hormonal agents. With the advent of next generation sequencing and development of multigene panel testing, the cost and time taken for genetic testing has reduced, making it possible for treatment focused genetic testing. There are also drugs such as the PARP inhibitors that specifically target the BRCA mutation. Risk-management multidisciplinary clinics are designed to quantify risk, and offer advice on preventative strategies. However such services are only possible in high-income settings. In low resource settings, the prohibitive cost of testing as well as the lack of genetic counsellors are major barriers to setting up a breast cancer genetics service. Family history is often not welldocumented because of the stigma associated with cancer. Breast cancer genetics services remain an unmet need in low and middle-income countries
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