The utility of chest X-ray as a screening tool for blunt thoracic aortic injury.

BACKGROUND: The early and accurate identification of patients with blunt thoracic aortic injury (BTAI) remains a challenge. Traditionally, a portable AP chest X-ray (CXR) is utilized as the initial screening modality for BTAI, however, there is controversy surrounding its sensitivity. The purpose of this study was to assess the sensitivity of CXR as a screening modality for BTAI. METHODS: After IRB approval, all adult (≥18 yo) blunt trauma patients admitted to LAC+USC (01/2011-12/2013) who underwent CXR and chest CT were retrospectively reviewed. Final radiology attending CXR readings were reviewed for mediastinal abnormalities (widened mediastinum, mediastinal to chest width ratio greater than 0.25, irregular aortic arch, blurred aortic contour, opacification of the aortopulmonary window, and apical pleural haematoma) suggestive of aortic injury. Chest CT final attending radiologist readings were utilized as the gold standard for diagnosis of BTAI. The primary outcome analyzed was CXR sensitivity. RESULTS: A total of 3728 patients were included in the study. The majority of patients were male (72.6%); mean age was 43 (SD 20). Median ISS was 9 (IQR 4-17) and median GCS was 15 (IQR 14-15). The most common mechanism of injury was MVC (48.0%), followed by fall (20.6%), and AVP (16.9%). The total number of CXRs demonstrating a mediastinal abnormality was 200 (5.4%). Widened mediastinum was present on 191 (5.1%) of CXRs, blurred aortic contour on 10 (0.3%), and irregular aortic arch on 4 (0.1%). An acute aortic injury confirmed by chest CT was present in 17 (0.5%) patients. Only 7 of these with CT-confirmed BTAI had a mediastinal abnormality identified on CXR, for a sensitivity of 41% (95% CI: 19-67%). CONCLUSION: The results from this study suggest that CXR alone is not a reliable screening modality for BTAI. A combination of screening CXR and careful consideration of other factors, such as mechanism of injury, will be required to effectively discriminate between those who should and should not undergo chest CT.

Nonsuicidal self-injury-related foreign bodies in the emergency department.

Nonsuicidal self-injury is a common cause of foreign bodies encountered in emergency departments, resulting in significant morbidity, mortality, and economic costs. We review the role of imaging and frequent imaging findings in nonsuicidal self-injury, illustrated by case examples from a level 1 trauma center with dedicated jail and psychiatric wards in a major US metropolitan teaching hospital.

Vascular complications of penetrating brain injury: comparison of helical CT angiography and conventional angiography.

OBJECT: The authors conducted a study to compare the sensitivity and specificity of helical CT angiography (CTA) and digital subtraction angiography (DSA) in detecting intracranial arterial injuries after penetrating traumatic brain injury (PTBI). METHODS: In a retrospective evaluation of 48 sets of angiograms from 45 consecutive patients with PTBI, 3 readers unaware of the DSA findings reviewed the CTA images to determine the presence or absence of arterial injuries. A fourth reader reviewed all the disagreements and decided among the 3 interpretations. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CTA were calculated on a per-injury basis and in a subpopulation of patients with traumatic intracranial aneurysms (TICAs). RESULTS: Sensitivity of CTA for detecting arterial injuries was 72.7% (95% CI 49.8%-89.3%); specificity, 93.5% (95% CI 78.6%-99.2%); PPV, 88.9% (95% CI 65.3%-98.6%); and NPV, 82.9% (95% CI 66.4%-93.4%). All 7 TICAs were correctly identified by CTA. Sensitivity, specificity, PPV, and NPV of CTA in detecting TICAs were 100%. To compare agreement with DSA, the standard of reference, confidence scores categorized as low, intermediate, and high probability yielded an overall effectiveness of 77.8% (95% CI 71.8%-82.9%). CONCLUSIONS: Computed tomography angiography had limited overall sensitivity in detecting arterial injuries in patients with PTBI. However, it was accurate in identifying TICAs, a subgroup of injuries usually managed by either surgical or endovascular approaches, and non-TICA injuries involving the first-order branches of intracranial arteries.

Predicting arterial injuries after penetrating brain trauma based on scoring signs from emergency CT studies.

The objective of this study was to determine the accuracy of individual radiologists in detection of vascular injury in patients after penetrating brain injury (PBI) based on head CT findings at admission. We retrospectively evaluated 54 PBI patients who underwent admission head CT and digital subtraction angiography (DSA), used here as a reference standard. Two readers reviewed the CT images to determine the presence or absence of the 29 CT variables of injury profile and quantified selected variables. Four experienced trauma radiologists and one neuroradiologist assigned their own specific scores for each CT variable, a high score indicative of a high probability of artery injury. A sixth set consisted of the average score obtained from the five sets, generated by five experts. Receiver operating characteristic (ROC) curves were constructed for each set to assess the diagnostic performance of an individual radiologist in predicting an underlying vascular injury. The area under ROC curve (AUC) was higher for CT scores obtained from the sixth set (average of five sets of scores) of variable rank score 0.75 (95% CI 0.62-0.88) and for the rest of the data sets, the value ranged from 0.70 (95% CI 0.56-0.84) to 0.74 (95% CI 0.6-0.88). In conclusion, radiologists may be able to recommend DSA with a fair accuracy rate in selected patients, deemed 'high-risk' for developing intracranial vascular injuries after PBI based on admission CT studies. A better approach needs to be developed to reduce the false positive rate to avoid unnecessary emergency DSA.

A computational study of the electronic structure, bonding, and spectral properties of tripodal tetraamine Co(III) carbonate complexes.

Density functional calculations have been carried out on the experimentally characterized Co(III) [Co(N4)(O2CO)]+ carbonate complexes containing a tripodal tetraamine ligand (N4 = tpa, Metpa, Me2tpa, Me3tpa, pmea, pmap, tepa) and also the model [Co(NH3)4(O2CO)]+ system. Calculations on the model species, performed using both gas-phase and solvent-corrected procedures, have revealed that the inclusion of a condensed-phase environment is necessary to obtain generally satisfactory results for the structural and bonding properties in these systems. Using the solvent-corrected approach, the observed trends in structural parameters for the metal-ligand bonds, 59Co chemical shifts, and changes in visible absorption wavelengths have been satisfactorily reproduced for the [Co(N4)(O2CO)]+ complexes. A time-dependent density functional analysis of the electronic excitations indicates that the overall composition and character of the relevant (d-d) transitions remain similar throughout the series, indicating that the changes in the Co-N interactions, associated with the structural variations occurring as the N-donor ligand identity and size change, appear most likely responsible for the particular spectroscopic features displayed by these species. These observations are further supported by molecular orbital and energy decomposition analyses. The results from the present calculations confirm recent findings that the inclusion of a treatment for solvent effects plays a critical role in the computational modelling of coordination complexes involving mixed (anionic and neutral) ligands.

Cobalt(III) carbonate and bicarbonate chelate complexes of tripodal tetraamine ligands containing pyridyl donors: the steric basis for the stability of chelated bicarbonate complexes.

The synthesis and characterization (X-ray crystallography, UV/vis spectroscopy, electrochemistry, ESI-MS, and (1)H, (13)C, and (59)Co NMR) of the complexes [Co(L)(O(2)CO)]ClO(4)xH(2)O (L = tpa (tpa = tris(2-pyridylmethyl)amine) (x = 1), pmea (pmea = bis((2-pyridyl)methyl)-2-((2-pyridyl)ethyl)amine) (x = 0), pmap (pmap = bis(2-(2-pyridyl)ethyl)(2-pyridylmethyl)amine) (x = 0), tepa (tepa = tris(2-(2-pyridyl)ethyl)amine) (x = 0)) which contain tripodal tetradentate pyridyl ligands and chelated carbonate ligands are reported. The complexes display different colors in both the solid state and solution, which can be rationalized in terms of the different ligand fields exerted by the tripodal ligands. Electrochemical data show that [Co(tepa)(O(2)CO)](+) is the easiest of the four complexes to reduce, and the variation in E(red.) values across the series of complexes can also be explained in terms of the different ligand fields exerted by the tripodal ligands, as can the (59)Co NMR data which show a chemical shift range of over 2000 ppm for the four complexes. [Co(pmea)(O(2)CO)](+) is fluxional in aqueous solution, and VT NMR spectroscopy ((1)H and (13)C) in DMF-d(7) (DMF = dimethylformamide) over the temperature range -25.0 to 75.0 degrees C are consistent with inversion of the unique six-membered chelate ring. This process shows a substantial activation barrier (DeltaG(#) = 58 kJ mol(-1)). The crystal structures of [Co(tpa)(O(2)CO)]ClO(4)xH(2)O, [Co(pmea)(O(2)CO)]ClO(4).3H(2)O, [Co(pmap)(O(2)CO)]ClO(4), and [Co(tepa)(O(2)CO)]ClO(4) are reported, and the complexes containing the asymmetric tripodal ligands pmea and pmap both crystallize as the 6-isomer. The carbonate complexes all show remarkable stability in 6 M HCl solution, with [Co(pmap)(O(2)CO)](+) showing essentially no change in its UV/vis spectrum over 4 h in this medium. The chelated bicarbonate complexes [Co(pmea)(O(2)COH)]ZnCl(4), [Co(pmap)(O(2)COH)][Co(pmap)(O(2)CO)](ClO(4))(3), [Co(pmap)(O(2)COH)]ZnCl(4)xH(2)O, and [Co(pmap(O(2)COH)]ZnBr(4)x2H(2)O can be isolated from acidic aqueous solution, and the crystal structure of [Co(pmap)(O(2)COH)]ZnCl(4)x3H(2)O is reported. The stability of the carbonate complexes in acid is explained by analysis of the crystallographic data for these, and other slow to hydrolyze chelated carbonate complexes, which show that the endo (coordinated) oxygen atoms are significantly hindered by atoms on the ancillary ligands, in contrast to complexes such as [Co(L)(O(2)CO)](+) (L = (NH(3))(4), (en)(2), tren, and nta), which undergo rapid acid hydrolysis and which show no such steric hindrance.