Traumatic diaphragmatic injury: a review of CT signs and the difference between blunt and penetrating injury

PURPOSE

We aimed to present the frequency of computed tomography (CT) signs of diaphragmatic rupture and the differences between blunt and penetrating trauma.

MATERIALS AND METHODS

The CT scans of 23 patients with surgically proven diaphragmatic tears (both blunt and penetrating) were retrospectively reviewed for previously described CT signs of diaphragmatic injuries. The overall frequency of CT signs was reported; frequency of signs in right- and left-sided injuries and blunt and penetrating trauma were separately tabulated and statistically compared.

RESULTS

The discontinuous diaphragm sign was the most common sign, observed in 95.7% of patients, followed by diaphragmatic thickening (69.6%). While the dependent viscera sign and collar sign were exclusively observed in blunt-trauma patients, organ herniation (P = 0.05) and dangling diaphragm (P = 0.0086) signs were observed significantly more often in blunt trauma than in penetrating trauma. Contiguous injury on either side of the diaphragm was observed more often in penetrating trauma (83.3%) than in blunt trauma (17.7%).

CONCLUSION

Knowledge of the mechanism of injury and familiarity with all CT signs of diaphragmatic injury are necessary to avoid a missed diagnosis because there is variability in the overall occurrence of these signs, with significant differences between blunt and penetrating trauma.Traumatic diaphragmatic injury has been found in 3%–8% of patients undergoing surgical exploration after blunt trauma and in 10% of patients with penetrating trauma (1, 2). The rate of initially missed diagnoses on computed tomography (CT) ranges from 12% to 63%. A missed diagnosis can later present as intrathoracic visceral herniation and strangulation with a mortality rate of 30%–60% (2, 3). In this era of increasing nonoperative management for most cases of blunt abdominal trauma, it becomes essential to diagnose diaphragmatic rupture on imaging to ensure early and timely operative repair of the rupture. The reasons for missed early diagnoses include potentially distracting and more severe thoracic and abdominal visceral injuries and lack of familiarity with all the imaging appearances and signs of diaphragmatic rupture (2, 4).Various imaging modalities including chest radiographs, ultrasonography, CT, and magnetic resonance imaging have been used in the diagnosis of diaphragmatic rupture (1). Currently, multidetector CT (MDCT) is the modality of choice for the detection of diaphragmatic injury. MDCT has increased the accuracy of diagnosis of diaphragmatic rupture. MDCT has inherent technical advantages, such as rapid, volumetric data acquisition for the chest and abdomen within a single breath hold, minimization of motion artifacts, thin-section reconstruction and sagittal and coronal reformat-reducing partial-volume effects that assist in diagnosing subtle defects (1). MDCT also aids in detecting the associated chest, abdomen, ribs, and bony injuries in these polytrauma patients. Various studies have revealed CT to have a variable sensitivity and specificity of 61%–87% and 72%–100%, respectively, for the diagnosis of diaphragmatic rupture (1, 5–7). Killeen et al. (6) demonstrated that the sensitivity for detecting left-sided ruptures (78%) is higher than for right-sided ruptures (50%). This finding has been attributed to the better soft tissue-fat contrast on the left side and the difficulty in diagnosing subtle liver herniation on the right side.Various signs of diaphragmatic rupture have been described on CT. These signs have been divided into direct and indirect signs and signs of uncertain/controversial origin, according to Desir and Ghaye (8), and have been tabulated in 2, 3).

Table 1.

CT signs of diaphragmatic injury^a

Neuroprotective Effect of Curcuminoids Against Inflammation-Mediated Dopaminergic Neurodegeneration in the MPTP Model of Parkinson’s Disease

The present study investigated the neuroprotective effect of curcuminoids, the active polyphenols of Curcuma longa (L.) rhizomes against inflammation-mediated dopaminergic neurodegeneration in the 1-methyl-4-phenyl-1,2,3,6- tetrahydropyridine (MPTP) model of Parkinson's disease (PD). Male C57BL/6 mice were pre-treated with curcuminoids (150?mg/kg/day) for 1?week, followed by four intra-peritoneal (i.p.) injections of MPTP (20?mg/kg) at 2?h intervals with further administration of curcuminoids or deprenyl (3?mg/kg/day) for 2?weeks. Our results show that oral administration of curcuminoids significantly prevented MPTP-mediated depletion of dopamine and tyrosine hydroxylase (TH) immunoreactivity. In-addition, pre-treatment with curcuminoids reversed glial fibrillary acidic protein (GFAP) and inducible nitric oxide synthase (iNOS) protein expression, as well as, reduced pro-inflammatory cytokine and total nitrite generation in the striatum of MPTP-intoxicated mice. Significant improvement in motor performance and gross behavioural activity, as determined by rota-rod and open field tests were also observed. Taken together, our findings suggest that curcuminoids exert a neuroprotective effect against MPTP-induced dopaminergic neurodegeneration through its anti-inflammatory action and thus holds immense potential as a therapeutic candidate for the prevention and management of PD.     

Percutaneous lead and system extraction in patients with cardiac resynchronization therapy (CRT) devices and coronary sinus leads

Background: Cardiac resynchronization therapy (CRT) device and coronary sinus (CS) lead extraction is required due to the occurrence of system infection, malfunction, or upgrade. Published series of CS lead extraction are limited by small sample sizes. We present a 10‐year experience of CRT device and CS lead extraction. Methods: All lead extractions between 2000 and 2010 were entered into a computer database. From these, a cohort of 71 cases involving a CRT device or CS lead was analyzed for procedural method, success, and complications. Results: Sixty coronary sinus leads were extracted in 71 cases (median age 71 years; 90% male) by manual traction/locking stylets (n = 54) or using a laser sheath (n = 6). Procedural success was achieved in 98% of CS leads. A total of 143 non‐CS leads were extracted, with laser required in 46% of cases. The mean duration of lead implantation was 35.8 months (range 1–116 months) and 2.86 ± 1.07 leads were extracted per case. CRT extraction case load increased significantly over time. Minor complications occurred in four (5.6%) cases and major complications in one (1.4%) case. There were no intraprocedural deaths, but two deaths occurred within 30 days of extraction. Conclusions: Our 10‐year experience confirms that percutaneous removal of CS leads can be achieved with high procedural success. Our recorded complication rates are no higher than those of non‐CS lead extraction series, and should be taken in the context of the frail nature of CRT patients. Ongoing audit of procedure success and complications will be required to further guide best practice in CS lead extraction. (PACE 2011; 34:1209–1216)     

A Cephalometric Study to Determine the Plane of Occlusion in Completely Edentulous Patients: Part I

To determine the relationship between the plane of occlusion and the Camper's line (ala-tragus line). Lateral cephalograms of 105 dentulous subjects were obtained after outlining the tragus and the base of the ala of the nose with radiopaque markers. Tracings of the cephalograms were done and the relationship between the plane of occlusion and the Camper's line (ala-tragus line) was noted. The most common tragal reference as a posterior landmark for determination of plane of occlusion was found to be below inferior (in 30.48% of subjects), and inferior (in 24.76% of subjects). The least common tragal reference was found to be above superior (in 3.82% of subjects) followed by superior of tragus and the point between superior and middle of the tragus (in 6.66% of subjects). The tragal reference in this study population was more towards the inferior of the tragus, with most of the times being below the inferior border. Therefore, the orientation of the plane of occlusion using the superior of tragus as a posterior landmark (according to the widely accepted definition of Camper's line) may be considered to be questionable. Further, the use of the tragus as a posterior landmark for the orientation of the plane of occlusion may be questioned on the basis of the findings of this study.     

Synthesis and preliminary bioevaluation of 99mTc(CO)3-17α-triazolylandrost-4-ene-3-one derivative prepared via click chemistry route

Azolyl steroids are known to manifest antiprostate cancer and antiandrogenic activities. These azolyl steroids have been shown to express affinity toward androgen receptors (ARs) overexpressed on LNCaP (human prostate adenocarcinoma) cell line. Hence, suitably derivatized azolyl steroids can be envisaged as potential vectors for targeting overexpression of ARs in prostate cancer. In the present study, testosterone has been derivatized to 17α-azidoandrost-4-ene-3-one using microwave-mediated azidation of the mesylate. Subsequently, a facile one-pot Cu(I)-catalyzed Click reaction was carried out to synthesize (99m)Tc(CO)(3)-labeled 17α-triazolylandrost-4-ene-3-one, which was characterized by HPLC. The chemical characterization of (99m)Tc(CO)(3)-17α-triazolylandrost-4-ene-3-one was carried out by preparing its corresponding rhenium complex using [NEt(4)](2)[Re(CO)(3)Br(3)] precursor. The radiolabeled complex could be prepared in >95% radiochemical yield as determined by HPLC. In vitro studies of (99m)Tc(CO)(3)-17α-triazolylandrost-4-ene-3-one complex in LNCaP cell lines overexpressing ARs showed binding of 4.95%±1.2%, with inhibition of 8%±0.9%. In vivo biodistribution studies in male Wistar rats have shown uptake in the prostate to the extent of 0.48%±0.19% injected dose/g at 1?hpi and retention therein till 3?hpi. The present study demonstrates a novel and facile one-pot reaction for preparation of (99m)Tc-labeled 17α-triazolylandrost-4-ene-3-one complex using Click chemistry. The corresponding Re-analog has been prepared for purpose of comparative characterization with the (99m)Tc-labeled complex. The radiosynthetic strategy described in this article can be further extended toward preparation of radiolabeled complexes of other triazolyl steroidal derivatives.