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BACKGROUND: The diagnosis of blunt abdominal trauma can be challenging and resource intensive. Observation with serial clinical assessments plays a major role in the evaluation of these patients, but the time required for intra-abdominal injury to become clinically apparent is unknown. The purpose of this study was to determine the amount of time required for an intra-abdominal injury to become clinically apparent after blunt abdominal trauma via physical examination or commonly followed clinical values. METHODS: A retrospective review of patients who sustained blunt trauma resulting in intra-abdominal injury between June 2010 and June 2012 at a Level 1 academic trauma center was performed. Patient demographics, injuries, and the amount of time from emergency department admission to sign or symptom development and subsequent diagnosis were recorded. All diagnoses were made by computed tomography or at the time of surgery. Patient transfers from other hospitals were excluded. RESULTS: Of 3,574 blunt trauma patients admitted to the hospital, 285 (8%) experienced intra-abdominal injuries. The mean (SD) age was 36 (17) years, the majority were male (194 patients, 68%) and the mean (SD) Injury Severity Score (ISS) was 21 (14). The mean (SD) time from admission to diagnosis via computed tomography or surgery was 74 (55) minutes. Eighty patients (28%) required either surgery (78 patients, 17%) or radiographic embolization (2 patients, 0.7%) for their injury. All patients who required intervention demonstrated a sign or symptom of their intra-abdominal injury within 60 minutes of arrival, although two patients were intervened upon in a delayed fashion. All patients with a blunt intra-abdominal injury manifested a clinical sign or symptom of their intra-abdominal injury, resulting in their diagnosis within 8 hours 25 minutes of arrival to the hospital. CONCLUSION: All diagnosed intra-abdominal injuries from blunt trauma manifested clinical signs or symptoms that could prompt imaging or intervention, leading to their diagnosis within 8 hours 25 minutes of arrival to the hospital. All patients who required an intervention for their injury manifested a sign or symptom of their injury within 60 minutes of arrival. (J Trauma Acute Care Surg. 2014;76:1020Y1023. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Therapeutic study, level IV. Epidemiologic study, level III.

BackgroundThe optimal time to initiate venous thromboembolism pharmacoprophylaxis after blunt abdominal solid organ injury is unknown.MethodsPostinjury coagulation status was characterized using thromboelastography (TEG) in trauma patients with blunt abdominal solid organ injuries; TEG was divided into 12-hour intervals up to 72 hours.ResultsForty-two of 304 patients (13.8%) identified underwent multiple postinjury thromboelastographic studies. Age (P = .45), gender (P = .45), and solid organ injury grade (P = .71) were similar between TEG and non-TEG patients. TEG patients had higher Injury Severity Scores compared with non-TEG patients (33.2 vs 18.3, respectively, P < .01). Among the TEG patients, the shear elastic modulus strength and maximum amplitude values began in the normal range within the first 12-hour interval after injury, increased linearly, and crossed into the hypercoagulable range at 48 hours (15.1 ± 1.9 Kd/cs and 57.6 ± 1.6 mm, respectively; P < .01, analysis of variance).ConclusionsPatients sustaining blunt abdominal solid organ injuries transition to a hypercoagulable state approximately 48 hours after injury. In the absence of contraindications, pharmacoprophylaxis should be considered before this time for effective venous thromboembolism prevention.

Author(s): Stonko, David P; Dennis, Bradley M; Callcut, Rachael A; Betzold, Richard D; Smith, Michael C; Medvecz, Andrew J; Guillamondegui, Oscar D | Abstract: BackgroundIncreased knowledge of the temporal patterns in the distribution of trauma admissions could be beneficial to staffing and resource allocation efforts. However, little work has been done to understand how this distribution varies based on patient acuity, trauma mechanism or need for intervention. We hypothesize that temporal patterns exist in the distribution of trauma admissions, and that deep patterns exist when traumas are analyzed by their type and severity.Study designWe conducted a cross-sectional observational study of adult patient flow at a level one trauma center over three years, 7/1/2013-6/30/2016. Primary thermal injuries were excluded. Frequency analysis was performed for patients grouped by ED disposition and mechanism against timing of admission; in subgroup analysis additional exclusion criteria were imposed.Results10,684 trauma contacts were analyzed. Trauma contacts were more frequent on Saturdays and Sundays than on weekdays (pl0.001). Peak arrival time was centered around evening shift change (6-7pm), but differed based on ED disposition: OR and ICU or Step-Down admissions (p = 0.0007), OR and floor admissions (pl0.0001), and ICU or Step-Down and floor admissions (pl0.0001). Step-Down and ICU arrival times (p = 0.42) were not different. Penetrating injuries peaked later than blunt (pl0.0001). Trauma varies throughout the year; we establish a high incidence trauma season (April to late October). Different mechanisms have varying dependence upon season; Motorcycle crashes (MCCs) have the greatest dependence.ConclusionWe identify new patterns in the temporal and seasonal variation of trauma and of specific mechanisms of injury, including the novel findings that 1) penetrating trauma tends to present at later times than blunt, and 2) critically ill patients requiring an OR tend to present later than those who are less acute and require an ICU or Step-Down unit. These patients present later than those who are admitted to the floor. Penetrating trauma patients arriving later than blunt may be the underlying reason why operative patients arrive later than other patients.

Objectives Recently a clinical decision rule (CDR) to identify children at very low risk for intraabdominal injury needing acute intervention (IAI) following blunt torso trauma was developed. Potential benefits of a CDR include more appropriate abdominal computed tomography (CT) use and decreased hospital costs. The objective of this study was to compare the cost-effectiveness of implementing the CDR compared to usual care for the evaluation of children with blunt torso trauma. The hypothesis was that compared to usual care, implementation of the CDR would result in lower CT use and hospital costs. Methods A cost-effectiveness decision analytic model was constructed comparing the costs and outcomes of implementation of the CDR to usual care in the evaluation of children with blunt torso trauma. Probabilities from a multicenter cohort study of children with blunt torso trauma were derived; estimated costs were based on those at the study coordinating site. Outcome measures included missed IAI, number of abdominal CT scans, total costs, and incremental cost-effectiveness ratios. Sensitivity analyses varying imputed probabilities, costs, and scenarios were conducted. Results Using a hypothetical cohort of 1,000 children with blunt torso trauma, the base case model projected that the implementation of the CDR would result in 0.50 additional missed IAIs, a total cost savings of $54,527, and 104 fewer abdominal CT scans compared to usual care. The usual care strategy would cost $108,110 to prevent missing one additional IAI. Findings were robust under multiple sensitivity analyses. Conclusions Compared to usual care, implementation of the CDR in the evaluation of children with blunt torso trauma would reduce hospital costs and abdominal CT imaging, with a slight increase in the risk of missed intraabdominal IAI.

Background: Traumatic pulmonary pseudocysts (TPPs) are rare sequelae of blunt chest trauma and may be incidentally visualized on initial, or subsequent, chest imaging. Case: We present the case of a 37-year-old male with no past medical history, who was recently hospitalized in the intensive care unit after a motor vehicle accident and referred to our institution for a traumatic cataract repair. His preoperative chest radiograph revealed multiple left-sided pulmonary nodules that were confirmed on thoracic computed tomography (CT) and noted to be cavitary. Comparison of the films to prior imaging, negative infectious workup, and absence of any symptoms led to the diagnosis of TPPs. Follow-up imaging showed complete resolution of the lesions. Conclusion: The TPPs may be discovered on imaging shortly after blunt chest trauma and, in asymptomatic individuals, can often be monitored with observation and serial imaging.

To evaluate the efficacy and safety of CO2 laser-assisted sclerectomy surgery (CLASS) in Chinese patients with advanced glaucoma. Patients with advanced glaucoma who were candidates for glaucoma filtration surgery were included. The intraocular pressure (IOP) and number of antiglaucoma medications were documented before surgery and at all postoperative clinic visits. All intra- and postoperative complications were documented. The primary outcome measures were the changes in IOP and medication use before and after the procedure as well as complications from the procedure. The secondary outcome measure included the CLASS success rate. Twenty patients (23 eyes) underwent CLASS between November 2014 and September 2015. Nineteen eyes had primary open-angle glaucoma, 2 eyes had primary angle-closure glaucoma, and 2 eyes had uveitic glaucoma. One patient was lost to follow-up. The mean age of subjects was 68.1 ± 11.9 years. IOP was significantly reduced at 1 day and 1 week after CLASS. At 6 months, the IOP and number of medications were significantly reduced by 19.0% and 38.2%, respectively (both P

Pediatric patients with suspected cervical spine injuries (CSI) often receive a computed tomography (CT) scan as an initial diagnostic imaging test. While sensitive, CT of the cervical spine carries significant radiation and risk of lethal malignant transformation later in life. Plain radiographs carry significantly less radiation and could serve as the preferred screening tool, provided they have a high functional sensitivity in detecting pediatric patients with CSI. We hypothesize that plain cervical spine radiographs can reliably detect pediatric patients with CSI and seek to quantify the functional sensitivity of plain radiography as compared to CT. We analyzed data from the NEXUS cervical spine study to assess the sensitivity of plain radiographs in the evaluation of CSI. We identified all pediatric patients who underwent plain radiographic imaging, and all pediatric patients found to have CSI. We then determined the sensitivity of plain radiographs in detecting pediatric patients with CSI. We identified 44 pediatric patients with CSI in the dataset with age ranging from 2 to 18years old. Thirty-two of the 44 pediatric patients received cervical spine plain films as a part of their workup. Plain films were able to identify all 32 pediatric patients with CSI to yield a sensitivity of 100% in detecting injury victims (95% confidence interval 89.1-100.0%). Plain radiography was highly sensitive for the identification of CSI in our cohort of pediatric patients and is useful as a screening tool in the evaluation of pediatric CSI.

© 2016 by the Society for Academic Emergency Medicine. Objectives The objective was to determine whether a child's race or ethnicity as determined by the treating physician is independently associated with receiving abdominal computed tomography (CT) after blunt torso trauma. Methods We performed a planned secondary analysis of a prospective observational cohort of children < 18 years old presenting within 24 hours of blunt torso trauma to 20 North American emergency departments (EDs) participating in a pediatric research network, 2007-2010. Treating physicians documented race/ethnicity as white non-Hispanic, black non-Hispanic, or Hispanic. Using a previously derived clinical prediction rule, we classified each child's risk for having an intra-abdominal injury undergoing acute intervention to define injury severity. We performed multivariable analyses using generalized estimating equations to control for confounding and for clustering of children within hospitals. Results Among 12,044 enrolled patients, treating physicians documented race/ethnicity as white non-Hispanic (n = 5,847, 54.0%), black non-Hispanic (n = 3,687, 34.1%), or Hispanic of any race (n = 1,291, 11.9%). Overall, 51.8% of white non-Hispanic, 32.7% of black non-Hispanic, and 44.2% of Hispanic children underwent abdominal CT imaging. After age, sex, abdominal ultrasound use, risk for intra-abdominal injury undergoing acute intervention, and hospital clustering were adjusted for, the likelihood of receiving an abdominal CT was lower (odds ratio [OR] = 0.8, 95% confidence interval [CI] = 0.7 to 0.9) for black non-Hispanic than for white non-Hispanic children. For Hispanic children, the likelihood of receiving an abdominal CT did not differ from that observed in white non-Hispanic children (OR = 0.9, 95% CI = 0.8 to 1.1). Conclusions After blunt torso trauma, pediatric patients identified by the treating physicians as black non-Hispanic were less likely to receive abdominal CT imaging than those identified as white non-Hispanic. This suggests that nonclinical factors influence clinician decision-making regarding use of abdominal CT in children. Further studies should focus on explaining how patient race can affect provider choices regarding ED radiographic imaging.

Acute vascular injuries are the second most common cause of fatalities in patients with multiple traumatic injuries; thus, prompt identification and management is essential for patient survival. Over the past few years, multidetector CT (MDCT) using dual-phase scanning protocol has become the imaging modality of choice in high-energy deceleration traumas. The objective of this article was to review the role of dual-phase MDCT in the identification and management of acute vascular injuries, particularly in the chest and abdomen following multiple traumatic injuries. In addition, this article will provide examples of MDCT features of acute vascular injuries with correlative surgical and interventional findings.

Wound healing is a physiological reparative response to injury and a well-orchestrated process that involves hemostasis, cellular migration, proliferation, angiogenesis, extracellular matrix deposition, and wound contraction and re-epithelialization. However, patients with type 2 diabetes mellitus (T2D) are frequently afflicted with impaired wound healing that progresses into chronic wounds or diabetic ulcers, and may lead to complications including limb amputation. Herein, we investigate the potential role of microRNA-26a (miR-26a) in a diabetic model of wound healing. Expression of miR-26a is rapidly induced in response to high glucose in endothelial cells (ECs). Punch skin biopsy wounding of db/db mice revealed increased expression of miR-26a (similar to 3.5-fold) four days post-wounding compared to that of WT mice. Local administration of a miR-26a inhibitor, LNA-anti-miR-26a, induced angiogenesis (up to similar to 80%), increased granulation tissue thickness (by 2.5-fold) and accelerated wound closure (53% after nine days) compared to scrambled anti-miR controls in db/db mice. These effects were independent of altered M1/M2 macrophage ratios. Mechanistically, inhibition of miR-26a increased its target gene SMAD1 in ECs nine days post-wounding of diabetic mice. In addition, high glucose reduced activity of the SMAD1-3'-UTR. Diabetic dermal wounds treated with LNA-anti-miR-26a had increased expression of ID1, a downstream modulator or SMAD1, and decreased expression of the cell cycle inhibitor p27. These findings establish miR-26a as an important regulator on the progression of skin wounds of diabetic mice by specifically regulating the angiogenic response after injury, and demonstrate that neutralization of miR-26a may serve as a novel approach for therapy. (C) 2016 Elsevier Ltd. All rights reserved.

The management of trauma patients has evolved in recent decades owing to increasing availability of advanced imaging modalities such as CT. Nowadays, CT has replaced the diagnostic function of angiography. The latter is considered when a therapeutic option is hypothesized. Arterial embolization is a life-saving procedure in abdominopelvic haemorrhagic patients, reducing relevant mortality rates and ensuring haemodynamic stabilization of the patient. Percutaneous transarterial embolization has been shown to be effective for controlling ongoing bleeding for patients with high-grade abdominopelvic injuries, thereby reducing the failure rate of non-operative management, preserving maximal organ function. Surgery is not always the optimal solution for stabilization of a patient with polytrauma. Mini-invasivity and repeatability may be considered as relevant advantages. We review technical considerations, efficacy and complication rates of hepatic, splenic, renal and pelvic embolization to extrapolate current evidence about transarterial embolization in traumatic patients.

Trauma is a leading cause of morbidity and mortality in childhood, and blunt trauma accounts for 80-90 % of abdominal injuries. The mechanism of trauma is quite similar to that of the adults, but there are important physiologic differences between children and adults in this field, such as the smaller blood vessels and the high vasoconstrictive response, leading to the spreading of a non-operative management. The early imaging of children undergoing a low-energy trauma can be performed by CEUS, a valuable diagnostic tool to demonstrate solid organ injuries with almost the same sensitivity of CT scans; nevertheless, as for as urinary tract injuries, MDCT remains still the technique of choice, because of its high sensitivity and accuracy, helping to discriminate between an intra-peritoneal form a retroperitoneal urinary leakage, requiring two different managements. The liver is the most common organ injured in blunt abdominal trauma followed by the spleen. Renal, pancreatic, and bowel injuries are quite rare. In this review we present various imaging findings of blunt abdominal trauma in children.

An interesting case of homicide involving the use of a heavy glass ashtray is described. The victim, a 81-years-old woman, has survived for few days and died in hospital. The external examination of the victim showed extensive blunt and sharp facial injuries and defense injuries on both the hands. The autopsy examination showed numerous tears on the face, as well as multiple fractures of the facial bones. Computer tomography scan, with 3D reconstruction, performed in hospital before death, was used to identify the weapon used for the crime. In recent years new diagnostics tools such as computer tomography has been widely used, especially in cases involving sharp and blunt forces. Computer tomography has proven to be very valuable in analyzing fractures of the cranial teca for forensic purpose, in particular antemortem computer tomography with 3D reconstruction is becoming an important tool in the process of weapon identification, thanks to the possibility to identify and make comparison between the shape of the object used to commit the crime, the injury and the objects found during the investigations. No previous reports on the use of this technique, for the weapon identification process, in cases of isolated facial fractures were described. We report a case in which, despite the correct use of this technique, it was not possible for the forensic pathologist to identify the weapon used to commit the crime. Authors wants to highlight the limits encountered in the use of computer tomography with 3D reconstruction as a tool for weapon identification when facial fractures occurred.

Summary Background Diaphragmatic injuries occur in 0.8–8% of patients with blunt trauma. The clinical diagnosis of diaphragmatic rupture is difficult and may be overshadowed by associated injuries. Diaphragmatic rupture does not resolve spontaneously and may cause life-threatening complications. The aim of this study was to present radiological findings in patients with diaphragmatic injury. Material/Methods The analysis of computed tomography examinations performed between 2007 and 2012 revealed 200 patients after blunt thoraco-abdominal trauma. Diaphragmatic rupture was diagnosed in 13 patients. Twelve of these patients had suffered traumatic injuries and underwent a surgical procedure that confirmed the rupture of the diaphragm. Most of diaphragmatic ruptures were left-sided (10) while only 2 of them were right-sided. In addition to those 12 patients there, another patient was admitted to the emergency department with left-sided abdominal and chest pain. That patient had undergone a blunt thoracoabdominal trauma 5 years earlier and complained of recurring pain. During surgery there was only partial relaxation of the diaphragm, without rupture. The most important signs of the diaphragmatic rupture in computed tomography include: segmental discontinuity of the diaphragm with herniation through the rupture, dependent viscera sign, collar sign and other signs (sinus cut-off sign, hump sign, band sign). Results In our study blunt diaphragmatic rupture occurred in 6% of cases as confirmed intraoperatively. In all patients, coronal and sagittal reformatted images showed herniation through the diaphragmatic rupture. In left-sided ruptures, herniation was accompanied by segmental discontinuity of the diaphragm and collar sign. In right-sided ruptures, predominance of hump sign and band sign was observed. Other signs were less common. Conclusions The knowledge of the CT findings suggesting diaphragmatic rupture improves the detection of injuries in thoraco-abdominal trauma patients.

The aim of this case report is to be aware of occult carotid lesions in thoracic- abdominal trauma because, carotid artery injury consequent to blunt trauma is rare, affecting less than 1% of patients as reported in literature. A 45-years-old female, involved in a traffic accident, arrived to Emergency Room hemodynamically stable, with a Glasgow Coma Scale of 15, complaining abdominal pain, without any neurological signs. She underwent Computed Tomography (CT) scan that showed a complete disruption of left abdominal wall muscles, associated with massive bowel loops herniation. No free air nor other visceral injuries were found. The radiological brain evaluation was negative for neurological injuries. Considering the nature of the trauma, an explorative laparotomy was performed. During the fifth postoperative day, the patient presented neurological side signs with right facial-brachial-crural hemiparesis and expressive aphasia. Head and neck CT scan revealed a lesion of the left common carotid artery with distal embolization of the internal carotid. A left-carotid-axis revascularization procedure and a surgical endarterectomy were immediately performed. Patient was discharged after 20 days without neurological consequences. Physicians should be aware of neck vascular injuries when evaluating patients with multiple trauma, even in neurological asymptomatic patients without seatbelt abrasions of the neck skin.Abdominal Hernia, Carotid artery, Seat belt, Surgery.

Background: The increased use of computed tomography (CT) results in higher occult hemothorax detection in blunt chest trauma. The indication for pleural decompression is not well defined. This research aims to study the overall factors determining pleural decompression. Methods: All blunt chest injury patients were retrospectively reviewed from the institutional trauma registry. Patients who underwent chest or whole-abdomen CT within 24 h were reviewed by a radiologist to identify initial occult hemothorax defined as a negative chest X-ray with the presence of hemothorax in the CT. The data included demographic data, mechanism of injury, complications, treatments, and characteristics of the hemothorax from the CT. Results: Six hundred and eighty-six blunt chest injury patients were reviewed over a period of 30 months. Eighty-one (24.9%) patients had occult hemothorax. The mean time from injury to CT was 5.7 h. Most patients (87.6%) were male. Most patients (70.2%) suffered from traffic collisions and 84.4% had rib fractures. Pleural decompression was performed in 25 patients who had significantly thicker hemothorax (1.1 cm vs. 0.8 cm,P < 0.01), higher rate of occult pneumothorax (88% vs. 53.8%,P < 0.01), and lung contusion (44% vs. 15%,P < 0.05) than those who did not undergo decompression. Multivariable logistic regression showed that a thickness of hemothorax >1.1 cm was associated with increased risk of pleural decompression (odds ratio [OR]: 5.51, 95% confidence interval [CI]: 1.42–21.42) and occult pneumothorax (OR: 6.93, 95% CI: 1.56–30.77). Conclusions: Drainage of occult hemothorax after blunt chest trauma was significantly associated with concomitant occult pneumothorax, lung contusion, and hemothorax thicker than 1.1 cm.

More than 90% of renal injuries in children result from blunt abdominal trauma. A 10-year-old female had a blunt abdominal trauma with macro-hematuria. The computed tomography scan revealed the presence of a horseshoe kidney and a 3rd grade renal lesion and contrast leakage from the right ureter. The ureteral rupture was confirmed by cystoscopy and ascendant pyelography and than a double J-stent was implanted. The stent was removed one month later. Non-surgical management has become the standard of care for both ureteral and renal lesions in children. Non-surgical treatment is a safe procedure for renal trauma with ureteral rupture in children.

Background Unnecessary diagnostic imaging leads to higher costs, longer emergency department stays, and increased patient exposure to ionizing radiation. We sought to prospectively derive and validate two decision instruments (DIs) for selective chest computed tomography (CT) in adult blunt trauma patients. Methods and Findings From September 2011 to May 2014, we prospectively enrolled blunt trauma patients over 14 y of age presenting to eight US, urban level 1 trauma centers in this observational study. During the derivation phase, physicians recorded the presence or absence of 14 clinical criteria before viewing chest imaging results. We determined injury outcomes by CT radiology readings and categorized injuries as major or minor according to an expert-panel-derived clinical classification scheme. We then employed recursive partitioning to derive two DIs: Chest CT-All maximized sensitivity for all injuries, and Chest CT-Major maximized sensitivity for only major thoracic injuries (while increasing specificity). In the validation phase, we employed similar methodology to prospectively test the performance of both DIs. We enrolled 11,477 patients—6,002 patients in the derivation phase and 5,475 patients in the validation phase. The derived Chest CT-All DI consisted of (1) abnormal chest X-ray, (2) rapid deceleration mechanism, (3) distracting injury, (4) chest wall tenderness, (5) sternal tenderness, (6) thoracic spine tenderness, and (7) scapular tenderness. The Chest CT-Major DI had the same criteria without rapid deceleration mechanism. In the validation phase, Chest CT-All had a sensitivity of 99.2% (95% CI 95.4%–100%), a specificity of 20.8% (95% CI 19.2%–22.4%), and a negative predictive value (NPV) of 99.8% (95% CI 98.9%–100%) for major injury, and a sensitivity of 95.4% (95% CI 93.6%–96.9%), a specificity of 25.5% (95% CI 23.5%–27.5%), and a NPV of 93.9% (95% CI 91.5%–95.8%) for either major or minor injury. Chest CT-Major had a sensitivity of 99.2% (95% CI 95.4%–100%), a specificity of 31.7% (95% CI 29.9%–33.5%), and a NPV of 99.9% (95% CI 99.3%–100%) for major injury and a sensitivity of 90.7% (95% CI 88.3%–92.8%), a specificity of 37.9% (95% CI 35.8%–40.1%), and a NPV of 91.8% (95% CI 89.7%–93.6%) for either major or minor injury. Regarding the limitations of our work, some clinicians may disagree with our injury classification and sensitivity thresholds for injury detection. Conclusions We prospectively derived and validated two DIs (Chest CT-All and Chest CT-Major) that identify blunt trauma patients with clinically significant thoracic injuries with high sensitivity, allowing for a safe reduction of approximately 25%–37% of unnecessary chest CTs. Trauma evaluation protocols that incorporate these DIs may decrease unnecessary costs and radiation exposure in the disproportionately young trauma population., In this multicenter prospective observational study, Robert Rodriguez and colleagues derive and validate two decision instruments for identifying which blunt trauma patients should receive chest CT and which can avoid unnecessary imaging., Editors' Summary Background Trauma—a serious injury to the body caused by violence or an accident—is a major global health problem. Every year, events that include traffic collisions, falls, and burns cause injuries that kill more than 5 million people (9% of annual global deaths). Road traffic accidents alone cause about 1.24 million deaths per year. In many countries, including the US, trauma is the number one killer of individuals aged 1–46 years. Chest injuries—damage to the chest wall such, as rib fractures, or damage to the lungs, heart, airways, or major blood vessels within the chest—are responsible for a quarter of trauma deaths. Chest injuries can be penetrating or blunt. Penetrating injuries (for example, stabbings) are generally easy to diagnose and usually require surgery. Blunt injuries, which are often the result of falls or road accidents, can often be managed with relatively simple interventions such as mechanical ventilation but can be hard to diagnose. Why Was This Study Done? Computed tomography (CT) is often used to evaluate patients with blunt trauma. This imaging procedure uses special X-ray equipment and computer programs to create two-dimensional and three-dimensional pictures of the organs, bones, and other tissues of the body. CT is good at providing information about internal injuries, and many trauma centers now routinely examine victims of major trauma using head-to-pelvis CT. However, chest CT exposes patients to radiation doses that may increase their risk of cancer. Moreover, chest CT is expensive and does not always provide much additional information if completed after a normal chest X-ray. To reduce the costs and radiation risks of unnecessary CT imaging after blunt trauma, in this prospective observational study, the researchers develop and validate two clinical decision instruments that identify patients with blunt chest injuries, thereby allowing clinicians to forego CT in patients who do not meet the decision instrument criteria for blunt injuries. What Did the Researchers Do and Find? The researchers had clinicians record the presence or absence of 14 candidate clinical criteria in 6,002 patients aged over 14 years attending eight US trauma centers with blunt trauma before viewing chest CT results and categorizing the injuries seen as major or minor using a preset classification scheme. They then derived two clinical decision instruments from these data using a statistical method called recursive partitioning. The Chest CT-All decision instrument, which maximized sensitivity (the ability to correctly identify people with a condition) for either major and minor chest injuries, consisted of seven clinical criteria including an abnormal x-ray, rapid deceleration mechanism (trauma caused by, for example, a road collision occurring at more than 40 mph), and bone tenderness (pain that occurs when an area is touched) in the chest. The Chest CT-Major instrument, which maximized sensitivity for only major chest injuries, consisted of the same criteria without rapid deceleration mechanism. Applied to 5,475 additional patients who presented with blunt trauma, the Chest CT-All instrument correctly identified 95.4% of patients with a major or minor blunt chest injury as having an injury (a sensitivity of 95.4%) and 25.5% of patients without a major or minor injury as not having an injury (a specificity of 25.5%); the instrument had a negative predictive value (NPV) of 93.9% (a patient judged injury-free using the instrument had a 93.9% probability of being injury-free). The Chest CT-Major instrument had a sensitivity of 99.2%, specificity of 31.7%, and NPV of 99.9% for major injuries. What Do These Findings Mean? These findings describe two decision instruments that detect clinically important blunt chest injuries with high sensitivity. Because the use of these instruments allows clinicians to identify virtually everyone who has this type of injury, clinicians can forego CT in patients who do not exhibit any of the decision instrument criteria for blunt chest injury. That is, clinicians can safely use physical examination and history findings, instead of imaging, to rule out blunt chest injury in many patients attending a trauma center. Limitations of this study include the criteria used to classify injuries as minor or major. Moreover, these decision instruments should be used to augment rather than replace clinical judgment and should not be used to evaluate patients younger than 15 years old. Importantly, however, use of these decision instruments could reduce the number of unnecessary chest CTs undertaken in trauma centers by up to a third, thus reducing costs and radiation exposure in people with trauma. Additional Information. This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001883. This study is further discussed in a PLOS Medicine Perspective by Emmanuel Lagarde The World Health Organization provides information in several languages about injuries around the world; its Guidelines for Essential Trauma Care seeks to set achievable standards for trauma treatment services that could realistically be made available to almost every injured person in the world The US National Institute of General Medical Sciences has a factsheet on trauma The National Trauma Institute, a not-for-profit organization that supports research on trauma, provides US trauma statistics, trauma survivor stories, and links to other organizations in the US that provide information on trauma Wikipedia has pages on major trauma, chest injury, and computed tomography (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages) MedlinePlus provides links to additional information about trauma and about chest injuries and disorders (in English and Spanish)

© 2015 Elsevier Ltd. All rights reserved. Study objective: Widespread chest CT use in trauma evaluation may increase the diagnosis of minor sternal fracture (SF), making former teaching about SF obsolete. We sought to determine: (1) the frequency with which SF patients are diagnosed by CXR versus chest CT under current imaging protocols, (2) the frequency of surgical procedures related to SF diagnosis, (3) SF patient mortality and hospital length of stay comparing patients with isolated sternal fracture (ISF) and sternal fracture with other thoracic injury (SFOTI), and (4) the frequency and yield of cardiac contusion (CC) workups in SF patients. Methods: We analyzed charts and data of all SF patients enrolled from January 2009 to May 2013 in the NEXUS Chest and NEXUS Chest CT studies, two multi-centre observational cohorts of blunt trauma patients who received chest imaging for trauma evaluation. Results: Of the 14,553 patients in the NEXUS Chest and Chest CT cohorts, 292 (2.0%) were diagnosed with SF, and 94% of SF were visible on chest CT only. Only one patient (0.4%) had a surgical procedure related to SF diagnosis. Cardiac contusion was diagnosed in 7 (2.4%) of SF patients. SF patient mortality was low (3.8%) and not significantly different than the mortality of patients without SF (3.1%) [mean difference 0.7%; 95% confidence interval (CI) -1.0 to 3.5%]. Only 2 SF patient deaths (0.7%) were attributed to a cardiac cause. SFOTI patients had longer hospital stays but similar mortality to patients with ISF (mean difference 0.8%; 95% CI -4.7% to 12.0). Conclusions: Most SF are seen on CT only and the vast majority are clinically insignificant with no change in treatment and low associated mortality. Workup for CC in SF patients is a low-yield practice. SF diagnostic and management guidelines should be updated to reflect modern CT-driven trauma evaluation protocols.

© 2015 Elsevier Ltd. All rights reserved. Introduction: Most high-grade renal injuries (American Association for Surgery of Trauma (AAST) grades III-V) result from motor vehicle collisions associated with numerous concomitant injuries. Sports-related blunt renal injury tends to have a different mechanism, a solitary blow to the flank. We hypothesized that high-grade renal injury is often isolated in sports-related renal trauma. Material and methods: We identified patients with AAST grades III-V blunt renal injuries from four level 1 trauma centres across the United States between 1/2005 and 1/2014. Patients were divided into "Sport" or "Non-sport" related groups. Outcomes included rates of hypotension (systolic blood pressure 110 bpm), concomitant abdominal injury, and procedural/surgical intervention between sports and non-sports related injury. Results: 320 patients met study criteria. 18% (59) were sports-related injuries with the most common mechanisms being skiing, snowboarding and contact sports (25%, 25%, and 24%, respectively). Median age was 24 years for sports and 30 years for non-sports related renal injuries (p = 0.049). Males were more commonly involved in sports related injuries (85% vs. 72%, p = 0.011). Median injury severity score was lower for sports related injuries (10 vs. 27, p < 0.001). There was no difference in renal abbreviated injury scale scores. Sports related trauma was more likely to be isolated without other significant injury (69% vs. 39% (p < 0.001)). Haemodynamic instability was present in 40% and 51% of sports and non-sports renal injuries (p = 0.30). Sports injuries had lower transfusion (7% vs. 47%, p < 0.001) and lower mortality rates (0% vs. 6%, p = 0.004). There was no difference in renal-specific procedural interventions between the two groups (17% sports vs. 18% non-sports, p = 0.95). Conclusions: High-grade sports-related blunt renal trauma is more likely to occur in isolation without other abdominal or thoracic injuries and clinicians must have a high suspicion of renal injury with significant blows to the flank during sports activities.

ObjectiveTo evaluate the association of pretrauma center (PTC) red blood cell (RBC) transfusion with outcomes in severely injured patients.BackgroundHemorrhage remains a major driver of mortality. Little evidence exists supporting PTC interventions to mitigate this.MethodsBlunt injured patients in shock arriving at a trauma center within 2 hours of injury were included from the Glue Grant database. Subjects were dichotomized by PTC RBC transfusion. Outcomes included 24-hour mortality, 30-day mortality, and trauma-induced coagulopathy [(TIC), admission international normalized ratio >1.5]. Cox regression and logistic regression determined the association of PTC RBC transfusion with outcomes. To address baseline differences, propensity score matching was used.ResultsOf 1415 subjects, 50 received PTC RBC transfusion. Demographics and injury severity score were similar. The PTC RBC group received 1.3 units of RBCs (median), and 52% were scene transports. PTC RBC transfusion was associated with a 95% reduction in odds of 24-hour mortality [odds ratio (OR) = 0.05; 95% confidence interval (CI), 0.01-0.48; P < 0.01], 64% reduction in the risk of 30-day mortality [hazard ratio = 0.36; 95% CI, 0.15-0.83; P = 0.02], and 88% reduction in odds of TIC (OR = 0.12; 95% CI, 0.02-0.79; P = 0.03). The matched cohort included 113 subjects (31% PTC RBC group). Baseline characteristics were similar. PTC RBC transfusion was associated with a 98% reduction in odds of 24-hour mortality (OR = 0.02; 95% CI, 0.01-0.69; P = 0.04), 88% reduction in the risk of 30-day mortality (hazard ratio = 0.12; 95% CI, 0.03-0.61; P = 0.01), and 99% reduction in odds of TIC (OR = 0.01; 95% CI, 0.01-0.95; P = 0.05).ConclusionsPTC RBC administration was associated with a lower risk of 24-hour mortality, 30-day mortality, and TIC in severely injured patients with blunt trauma, warranting further prospective study.

© 2015 Elsevier Inc. Background Orbital compartment syndrome is a sight-threatening emergency. Vision may be preserved when timely intervention is performed. Objective To present a case of orbital compartment syndrome caused by traumatic retrobulbar hemorrhage and the procedure of lateral canthotomy and cantholysis, reviewed with photographic illustration. Discussion Lateral canthotomy and cantholysis are readily performed at the bedside with simple instruments. The procedure may prevent irreversible blindness in cases of acute orbital compartment syndrome. Conclusions Emergency physicians should be familiar with lateral canthotomy and cantholysis in the management of orbital compartment syndrome to minimize the chance of irreversible visual loss.

Over the past 20 years the management of blunt liver trauma has evolved from a primary operative approach to a nonoperative one, for both low and high grade injuries, only on the basis of hemodynamic stability. However, in spite of a high success rate of non operative management, it is frequently observed, also in our country, an old fashioned way to approach these patients, based on habit more than observation and evidence based medicine.We present a case of successful nonoperative treatment of a grade IV blunt liver trauma (lacero-contusive injury of V, VI and VII segments) in a 34-year-old woman.Nowadays more than 85% of liver injuries are managed without operative intervention, irrespective of the injury grade. Success rate of the conservative approach ranges from 82% to 100% and almost all complications (14% in high grade injuries) can be managed with interventional radiology procedures, still avoiding major surgery.Today, in the absence of other abdominal injuries requiring surgical exploration, hemodynamic instability from ongoing hemorrhage after primary evaluation and resuscitative treatment, is the only indication to an operative management of traumatic liver injuries.Negli ultimi 20 anni il trattamento del trauma epatico chiuso si è modificato radicalmente passando da una gestione quasi costantemente chirurgica ad una non operativa in tutti i casi in cui non vi siano le condizioni di instabilità emodinamica o di variazione nella clinica del paziente traumatizzato. A tutt’oggi però non è raro osservare un approccio a tale condizione clinica seguendo criteri che la Medicina Basata sull’Evidenza dimostra essere superati. Presentiamo in questo lavoro il caso clinico di una donna di 34 anni che subiva un trauma diretto della regione postero-laterale dell’emitorace destro cadendo accidentalmente da una scala. Nonostante la gravità della lesione evidenziata dalla TC (IV grado secondo AAST Liver Injury Scale), si è optato per un trattamento non operativo data la condizione di stabilità emodinamica ottenuta con un primo bolo di cristalloidi. Una complicanza di tipo respiratorio ha complicato il quadro in terza giornata dal trauma richiedendo una toracentesi e dei cicli di ventilazione non invasiva. A 4 anni di distanza dal trauma la paziente sta bene e non lamenta disturbi. La letteratura mostra che il trattamento conservativo viene impiegato oggi in oltre l’85% dei traumi epatici, indipendentemente dall’entità della lesione. Il successo del trattamento conservativo varia nelle diverse casistiche dall’82% al 100% dei casi, e le sue complicanze, quando si verificano (14% dei traumi maggiori) possono spesso essere trattate con procedure di radiologia interventistica, evitando ancora l’intervento chirurgico. Oggi, in assenza di altre lesioni addominali che richiedano l’esplorazione chirurgica, l’indicazione al trattamento operativo è solo l’instabilità emodinamica del paziente che persiste o si ripresenta subito dopo un corretto trattamento rianimatorio iniziale.

Background Acute traumatic rupture of the descending thoracic aorta is usually considered a surgical emergency; a conventional surgical approach carries high morbidity and mortality rates in the perioperative period. Endovascular surgery has recently been considered as providing a new therapeutic strategy for these patients. The aim of our study was to evaluate the feasibility along with early and midterm results of this procedure in our experience. Methods Among 59 thoracic stent-graft procedures performed between May 2001 and May 2005 in our Department, 11 male patients (mean age 48 ± 7.3 years) underwent endovascular repair for acute traumatic rupture of the descending thoracic aorta caused by motor vehicle accidents. The feasibility of endovascular repair and the size of the endograft were assessed on the basis of urgent spiral computed axial tomography. In all cases, the lesion was limited to the isthmus. Follow-up was performed at discharge, at 3, 6, and 12 months, and yearly thereafter by clinical examination, chest x-ray, and computed axial tomography scan. Results Technical success was obtained in all patients, and no conversion to open repair was necessary. No intraoperative deaths or complications occurred, and no patient developed temporary or permanent neurologic deficits in the postoperative period. One patient died 22 days after the procedure from acute respiratory failure; cumulative 30-day mortality rate was 9.1%. The mean follow-up duration was 18.2 ± 4.5 months. No death, endoleak, or reintervention occurred during follow-up. Comments The treatment of acute traumatic rupture of the descending thoracic aorta with stent graft is a feasible and safe technique; it provides low morbidity and mortality rates in the early postoperative period, and midterm results are encouraging. However, long-term studies are worthwhile to evaluate the effectiveness and the durability of this procedure.

© 2015 American College of Emergency Physicians. Study objective: Chest computed tomography (CT) diagnoses more injuries than chest radiography, so-called occult injuries. Wide availability of chest CT has driven substantial increase in emergency department use, although the incidence and clinical significance of chest CT findings have not been fully described. We determine the frequency, severity, and clinical import of occult injury, as determined by changes in management. These data will better inform clinical decisions, need for chest CT, and odds of intervention. Methods: Our sample included prospective data (2009 to 2013) on 5,912 patients at 10 Level I trauma center EDs with both chest radiography and chest CT at physician discretion. These patients were 40.6% of 14,553 enrolled in the parent study who had either chest radiography or chest CT. Occult injuries were pneumothorax, hemothorax, sternal or greater than 2 rib fractures, pulmonary contusion, thoracic spine or scapula fracture, and diaphragm or great vessel injury found on chest CT but not on preceding chest radiography. A priori, we categorized thoracic injuries as major (having invasive procedures), minor (observation or inpatient pain control >24 hours), or of no clinical significance. Primary outcome was prevalence and proportion of occult injury with major interventions of chest tube, mechanical ventilation, or surgery. Secondary outcome was minor interventions of admission rate or observation hours because of occult injury. Results: Two thousand forty-eight patients (34.6%) had chest injury on chest radiography or chest CT, whereas 1,454 of these patients (71.0%, 24.6% of all patients) had occult injury. Of these, in 954 patients (46.6% of injured, 16.1% of total), chest CT found injuries not observed on immediately preceding chest radiography. In 500 more patients (24.4% of injured patients, 8.5% of all patients), chest radiography found some injury, but chest CT found occult injury. Chest radiography found all injuries in only 29.0% of injured patients. Two hundred and two patients with occult injury (of 1,454, 13.9%) had major interventions, 343 of 1,454 (23.6%) had minor interventions, and 909 (62.5%) had no intervention. Patients with occult injury included 514 with pulmonary contusions (of 682 total, 75.4% occult), 405 with pneumothorax (of 597 total, 67.8% occult), 184 with hemothorax (of 230 total, 80.0% occult), those with greater than 2 rib fractures (n=672/1,120, 60.0% occult) or sternal fracture (n=269/281, 95.7% occult), 12 with great vessel injury (of 18 total, 66.7% occult), 5 with diaphragm injury (of 6, 83.3% occult), and 537 with multiple occult injuries. Interventions for patients with occult injury included mechanical ventilation for 31 of 514 patients with pulmonary contusion (6.0%), chest tube for 118 of 405 patients with pneumothorax (29.1%), and 75 of 184 patients with hemothorax (40.8%). Inpatient pain control or observation greater than 24 hours was conducted for 183 of 672 patients with rib fractures (27.2%) and 79 of 269 with sternal fractures (29.4%). Three of 12 (25%) patients with occult great vessel injuries had surgery. Repeated imaging was conducted for 50.6% of patients with occult injury (88.1% chest radiography, 11.9% chest CT, 7.5% both). For patients with occult injury, 90.9% (1,321/1,454) were admitted, with 9.1% observed in the ED for median 6.9 hours. Forty-four percent of observed patients were then admitted (4.0% of patients with occult injury). Conclusion: In a more seriously injured subset of patients with blunt trauma who had both chest radiography and chest CT, occult injuries were found by chest CT in 71% of those with thoracic injuries and one fourth of all those with blunt chest trauma. More than one third of occult injury had intervention (37.5%). Chest tubes composed 76.2% of occult injury major interventions, with observation or inpatient pain control greater than 24 hours in 32.4% of occult fractures. Only 1 in 20 patients with occult injury was discharged home from the ED. For these patients with blunt trauma, chest CT is useful to identify otherwise occult injuries.

Letters The HVRN assembles home visiting stakeholders to set a na- tional research agenda, advance that agenda through innova- tion research methods, and translate research findings into policy and practice. 3 The HVRN identified the top 10 priorities for home visiting research with input from nearly 1800 individuals. 4 Now, the HVRN is building the Home Visiting Ap- plied Research Collaborative, a national practice-based re- search network of local home visiting programs to conduct field- initiated studies to address the research agenda’s priorities. We need to learn what works best for which families and under what circumstances and to translate this efficiently to policy and practice. The MIECHV Program’s state-level evalu- ative research, the Mother and Infant Home Visiting Program Evaluation, and the HVRN will substantially “clarify the evi- dence base” 1 related to home visiting investments to maxi- mize outcomes for children, families, and communities. Stake- holders are key participants in these efforts; they are eager to use results to ensure success in the adoption, adaptation, implementation, and sustainability of home visiting as part of the early childhood system of care and as part of efforts to pro- mote the foundations of health by enhancing the capacity of caregivers and communities. 5 Cynthia S. Minkovitz, MD, MPP Kay M. Gonsalves O’Neill, MSPH Anne K. Duggan, ScD Author Affiliations: Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland. Corresponding Author: Cynthia S. Minkovitz, MD, MPP, Departments of Population, Family and Reproductive Health, and Pediatrics, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, E4636, Baltimore, MD 21205 (cminkovi@jhsph.edu). Conflict of Interest Disclosures: None reported. Funding/Support: Each of the authors is funded in part through home visiting research supported by grants or subcontracts as part of the Patient Protection and Affordable Care Act. Role of the Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. 1. Shonkoff JP. Changing the narrative for early childhood investment. JAMA Pediatr. 2014;168(2):105-106. 2. Michalpoulos C, Duggan A, Knox V, et al. ACF-OPRE Reports 2011-16: Design Options for the Home Visiting Evaluation: Draft Final Report. Washington, DC: US Dept of Health & Human Services; 2011. 3. Duggan A, Minkovitz CS, Chaffin M, et al. Creating a national home visiting research network. Pediatrics. 2013;132(suppl 2):S82-S89. 4. Home Visiting Research Network. Home visiting research agenda. http://www.hvrn.org/research-agenda.html. Accessed December 30, 2013. 5. Mistry KB, Minkovitz CS, Riley AW, et al. A new framework for childhood health promotion: the role of policies and programs in building capacity and foundations of early childhood health. Am J Public Health. 2012;102(9):1688-1696. Incorrect Classification in Articles About Traumatic Brain Injuries in Children With Minor Blunt Head Trauma To the Editor We are writing to make readers aware of an ana- lytic error that affected the data reported in 2 of our articles. 1,2 During recent preparation of another manuscript based on the same data, we discovered an error in construction of the final jamapediatrics.com analytic database for the entire cohort (an erroneous SQL [Structured Query Language] join statement) that led to the incorrect classification of the mechanism of injury as moder- ate, rather than severe, for 394 children in our cohort of 42 412 patients. Most of the erroneous classifications were among chil- dren aged 2 years or older. The first article affected by this erroneous classification was titled “Prevalence of Clinically Important Traumatic Brain In- juries in Children With Minor Blunt Head Trauma and Isolated Severe Injury Mechanisms.” 1 We have carefully examined the effects of this error on the entire published analysis. As previ- ously noted, the number of children with severe injury mecha- nism increased by 394, and the number of children with iso- lated severe injury mechanism increased from 3302 to 3630 as a result. These increased numbers led to numerous modifica- tions to data points in the article. However, the most impor- tant data points in the report are only slightly affected. The over- all incidence of severe injury mechanism increases by only a single percentage point in this population (from 14% to 15%) and the rates of clinically important traumatic brain injuries asso- ciated with isolated severe injury mechanism remain low, de- creasing by one-tenth of 1% among older children (from 0.6% to 0.5% for isolated severe mechanism and no other Pediatric Emergency Care Applied Research Network predictors and from 0.3% to 0.2% for isolated severe mechanism and no other pre- dictors in the expanded definition), with no change among younger children from the published report. The second article affected by the erroneous classifica- tion was titled “Cranial Computed Tomography Use Among Children With Minor Blunt Head Trauma: Association With Race/Ethnicity.” 2 Again, an erroneous SQL join statement led to the incorrect classification of the mechanism of injury as moderate, rather than severe, for 394 children in our cohort of 42 412 patients. This led to minor effects on the reported tabular data (Tables 1, 2, and 3), as well as minor differences in reported odds ratios/confidence intervals for association of black non-Hispanic or Hispanic race/ethnicity with cranial com- puted tomography in the emergency department (these data are reported in the abstract and the Results section of the text). We regret these errors but also believe unequivocally that the key findings and conclusions of the published papers firmly stand. The articles have been corrected and correction no- tices published. Nathan Kuppermann, MD, MPH JoAnne E. Natale, MD, PhD Lise E. Nigrovic, MD, MPH Author Affiliations: Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento (Kuppermann); Department of Pediatrics, University of California, Davis School of Medicine, Sacramento (Kuppermann, Natale); Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts (Nigrovic). Corresponding Author: Nathan Kuppermann, MD, MPH, Departments of Emergency Medicine and Pediatrics, University of California, Davis Medical Center, 2315 Stockton Blvd, PSSB Bldg, Suite 2100, PSSB 2100, Sacramento, CA 95817 (nkuppermann@ucdavis.edu). Published Online: May 19, 2014. doi:10.1001/jamapediatrics.2014.651. Conflict of Interest Disclosures: None reported. JAMA Pediatrics June 2014 Volume 168, Number 6 Copyright 2014 American Medical Association. All rights reserved.

Background Chest radiography (CXR) is the most common imaging in adult blunt trauma patient evaluation. Knowledge of the yields, attendant costs, and radiation doses delivered may guide effective chest imaging utilization. Objectives The objectives were to determine the diagnostic yields of blunt trauma chest imaging (CXR and chest computed tomography [CT]), to estimate charges and radiation exposure per injury identified, and to delineate assessment points in blunt trauma evaluation at which decision instruments for selective chest imaging would have the greatest effect. Methods From December 2009 to January 2012, we enrolled patients older than 14 years who received CXR during blunt trauma evaluations at nine U.S. Level I trauma centers in this prospective, observational study. Thoracic injury seen on chest imaging and clinical significance of the injury were defined by a trauma expert panel. Yields of imaging were calculated, as well as mean charges and effective radiation dose (ERD) per injury. Results Of 9,905 enrolled patients, 55.4% had CXR alone, 42.0% had both CXR and CT, and 2.6% had CT alone. The yields for detecting thoracic injury were CXR 8.4% (95% confidence intervals [CIs]) = 7.8% to 8.9%), chest CT 28.8% (95% CI = 27.5% to 30.2%), and chest CT after normal CXR 15.0% (95% CI = 13.9% to 16.2%). The mean charges and ERD (millisievert [mSv]) per injury diagnosis of CXR, chest CT, and chest CT after normal CXR were $3,845 (0.24 mSv), $10,597 (30.9 mSv), and $20,347 (59.3 mSv), respectively. The mean charges and ERD per clinically major thoracic injury diagnosis on chest CT after normal CXR were $203,467 and 593 mSv. Conclusions Despite greater diagnostic yield, chest CT entails substantially higher charges and radiation dose per injury diagnosed, especially when performed after a normal CXR. Selective chest imaging decision instruments should identify patients who require no chest imaging and patients who may benefit from chest CT after a normal CXR. Resumen Introduccion La radiografia de torax (RXT) es la prueba de imagen mas frecuente en la evaluacion del paciente adulto con un traumatismo cerrado. El conocimiento del rendimiento, los costes relacionados y las dosis de radiacion recibidas pueden ayudar a la utilizacion efectiva de la imagen toracica. Objetivos Determinar los rendimientos diagnosticos de la imagen toracica (RXT y tomografia computarizada [TC] de torax) en el traumatismo cerrado, para estimar los costes y la exposicion a radiacion por lesion identificada, y para delinear los puntos de valoracion en la evaluacion del traumatismo cerrado en los que los instrumentos de decision por imagen toracica selectiva tendrian el mayor impacto. Metodologia Estudio observacional prospectivo que incluyo a pacientes mayores de 14 anos que recibieron radiologia durante las valoraciones de un traumatismo cerrado en nueve centros de traumatologia de nivel 1 en Estados Unidos, de diciembre de 2009 a enero de 2012. La lesion toracica vista en la imagen toracica y la importancia clinica de la lesion se definieron por un panel de expertos en traumatologia. Se calcularon los rendimientos de la imagen, asi como los costes medios y la dosis de radiacion efectiva por lesion. Resultados De los 9.905 pacientes incluidos, un 55,4% tenia una RXT, un 42,0% ambas, RXT y TC, y un 2,6% solo TC. Los rendimientos para detectar lesion toracica fueron: RXT 8,4% (intervalo de confianza [IC] 95% = 7,8% a 8,9%), TC de torax 28,8% (IC 95% = 27,5% a 30,2%) y TC de torax despues de RXT normal 15,0% (IC 95% = 13,9% a 16,2%). Los costes medios y la dosis de radiacion efectiva (milisievert [mSv] por diagnostico de lesion de la RXT, la TC de torax y la TC de torax tras RXT normal fueron de 3.845$ (0,24 mSv), 10.597$ (30,9 mSv), y 20.347$ (59,3 mSV), respectivamente. Los costes medios y la dosis de radiacion efectiva por diagnostico de lesion toracica clinicamente importante en la TC de torax despues de una RXT normal fueron de 203.467$ y 593mSv. Conclusiones A pesar de una mayor rentabilidad diagnostica, la TC de torax implica costes y dosis de radiacion por lesion diagnosticada sustancialmente mayores, especialmente cuando se realizan despues de una RXT normal. Las herramientas de decision de imagen toracica selectiva deberian identificar a los pacientes que no requieren ninguna imagen toracica y los pacientes que pueden beneficiarse de una TC de torax despues de una RXT normal.

A 65-year-old man presented with a nonspecific thymic neoplasm following blunt thoracic trauma. The lesion increased in size over 12 years, to reach 47 mm in diameter. After thymectomy, the lesion was described as an epidermoid lining cyst composed of thickened stratified squamous epithelium. We assume that this rare pathological condition was caused by skin tissue islands and fat migrating into the mediastinum.