Detection of occult pneumothoraces in the significantly injured adult with blunt trauma.

BACKGROUND: Identification of pneumothoraces is essential during the initial assessment of major injury. Prompt intervention is crucial for effective resuscitation and for subsequent safe management. Historically, emergency departments have relied on chest X-ray for detection of pneumothoraces. More recently, the increasing availability of computed tomography (CT) has provided a more sensitive means of detection. Occult pneumothoraces are those that are missed on clinical examination and chest X-ray, but are detected on subsequent CT. OBJECTIVE: To determine the incidence of occult pneumothoraces and their impact on subsequent management. PATIENTS: All blunt trauma patients with CT scans from a single, large, adult emergency department in 1 year. METHODS: Patient records were analysed to determine the proportion of pneumothoraces detected on CT that had not been previously detected on chest X-ray. Records were further examined to determine how many occult pneumothoraces required additional management after detection. RESULTS: In all, 134 blunt trauma patients required a CT scan. Thirty-five pneumothoraces were detected in 27 patients; 15 were occult. Six of these 15 were managed with intercostal drain insertion, all proceeding to mechanical ventilation. Of the eight patients (one bilateral) managed observantly, all had uncomplicated recoveries. CT was significantly more sensitive in the detection of pneumothoraces (P=0.03). Retrospective review by a radiology specialist identified three chest X-rays that had findings (deep sulcus sign and prominent cardiac outline) that were suggestive of pneumothorax. CONCLUSIONS: A sufficiently high proportion of pneumothoraces is missed on chest X-ray to advocate a low threshold for use of CT in the early assessment of blunt trauma patients, especially if mechanical ventilation is required for ongoing management.

Pattern of recurrence changes in noninvasive bladder tumors observed during 2 decades.

PURPOSE: Previously published data on the 25-year outcome of G1Ta and G2Ta bladder tumors demonstrated that both tumors have a similarly low risk of recurrence in cases in which no tumor was detected in the first 5 years after presentation. A further 4 prospectively maintained cohorts were available for comparison between institutions or across time periods. MATERIALS AND METHODS: Review of a prospectively kept, computerized record of patients with bladder cancer allowed analysis of the long-term outcome of 4 further cohorts of bladder cancer presenting in 1978 to 1986 or 1991 to 1996. RESULTS: A total of 325 patients with G1Ta and 190 with G2Ta bladder tumors had up to 25 years of followup. The risk of recurrence in the first 5 years was identical in all cohorts from the 1980s. However, in those patients without recurrence in the initial 5 years, the subsequent risk of recurrence (in G1 and G2Ta tumors) was 3.2% in the earlier cohorts but increased 3-fold to 10.8% in the cohorts from the early 1990s (RR 3.3, 95% CI 1.2-9.5, p=0.016). CONCLUSIONS: A difference was observed in the pattern of late biopsy proven recurrence in the more contemporary cases. Increased use of prophylactic intravesical chemotherapy does not seem to be a strong factor. Changes in the ability to detect lesions and the readiness to biopsy suspicious lesions may be responsible for this difference.