ABSTRACT
BACKGROUND: Thoracic aortic injury (TAI) is associated with high mortality. It is not practical to evaluate all patients with blunt chest trauma with dedicated aortic imaging. The purpose of this study was to define a group of patients with blunt chest trauma after motor vehicle collision (MVC) that do not require aortic imaging based on information available in the emergency department. METHODS: This was a secondary analysis of a prospectively-collected database. Consecutive patients with blunt chest trauma after MVC were included. Characteristics of mechanism, examination, and chest radiographic findings were collected for each patient. All patients underwent chest computed tomography (CT), aortography, or both for TAI evaluation. Binary recursive partitioning was used to derive and validate a clinical decision rule to predict exclusion of TAI. RESULTS: During the study period, 1,096 patients were included, and 22 (2.0%) were diagnosed with TAI. The decision rule for exclusion of TAI included findings from the chest radiograph, incorporating left paraspinous line displacement, obscured aortic knob, and mediastinal widening. The rule resulted in a sensitivity of 86% (95% confidence interval [CI]: 65% to 97%), a specificity of 77% (95% CI: 75% to 80%), a positive predictive value of 7% (95% CI: 4% to 11%), a negative predictive value (NPV) of 99.6% (95% CI: 99.0% to 99.9%), a positive likelihood ratio of 3.8 (95% CI: 1.1-12.9), and a negative likelihood ratio of 0.18 (95% CI: 0.05-0.61). This would potentially reduce aortic imaging by 76% (95% CI: 74% to 79%). CONCLUSION: We report a clinical decision rule with a high NPV for exclusion of TAI. This may standardize the approach to such patients and may reduce the need for CT.
Subject(s)
Aorta, Thoracic/injuries , Decision Support Techniques , Thoracic Injuries/diagnostic imaging , Wounds, Nonpenetrating/diagnostic imaging , Accidents, Traffic , Adult , Aorta, Thoracic/diagnostic imaging , Emergency Medical Services/methods , Humans , Injury Severity Score , Middle Aged , Multivariate Analysis , Practice Guidelines as Topic , Predictive Value of Tests , Radiography , Reproducibility of Results , Retrospective Studies , Thoracic Injuries/etiologyABSTRACT
Seasonal changes in the neuroendocrine actions of gonadal steroid hormones are triggered by fluctuations in daylength. The mechanisms responsible for photoperiodic influences upon the feedback and behavioral effects of testosterone in Siberian hamsters are poorly understood. We hypothesized that daylength regulates the expression of androgen receptor (AR) and/or steroid receptor coactivator-1 (SRC-1) in specific forebrain regions. Hamsters were castrated and implanted with either oil-filled capsules or low doses of testosterone; half of the animals remained in 16L/8D and the rest were kept in 10L/14D for the ensuing 70 days. The number of AR-immunoreactive (AR-ir) cells was regulated by testosterone in medial amygdala and caudal arcuate, and by photoperiod in the medial preoptic nucleus and the posterodorsal medial amygdala. A significant interaction between photoperiod and androgen treatment was found in medial preoptic nucleus and posterodorsal medial amygdala. The molecular weight and distribution of SRC-1 were similar to reports in other rodent species, and short days reduced the number of SRC-1-ir cells in posteromedial bed nucleus of the stria terminalis (BNST) and posterodorsal medial amygdala. A significant interaction between androgen treatment and daylength in regulation of SRC-1-ir was found in anterior medial amygdala. The present results indicate that daylength-induced fluctuations in SRC-1 and AR expression may contribute to seasonally changing effects of testosterone.
