Wylan Peterson

Is Chest X-Ray an Adequate Screening Tool for the Diagnosis of Blunt Thoracic Aortic Injury?

BACKGROUND Blunt thoracic aortic injuries (BTAI) have a high mortality rate. For survivors, chest X-ray (CXR) findings are used to determine the need for further diagnostic testing with chest computerized tomography with angiography (CTA) or conventional angiography. We set to determine the adequacy of utilizing CXR alone as a screening tool for BTAI. METHODS All patients diagnosed with BTAI at a level I trauma-center during a 7-year-period were identified. CXRs of these patients and those of a control group of blunt trauma patients with an injury severity score >15 were reviewed by four trauma surgeons blinded to the diagnosis. Based on each CXR viewed, the surgeons decided if they would have proceeded to chest CTA, angiography, or required no further studies to rule out BTAI. RESULTS In the 7-year-period, 83 patients had BTAI. CXRs were available in 45 patients. The four surgeons viewed 96 CXRs including those of 51 controls. Based on the CXR appearance in patients with BTAI, the surgeons chose to proceed to chest CTA in 38 patients (84.4%), conventional aortography in two patients (4.4%), and no further testing in five patients (11.2%). A widened mediastinum (75%) and loss of the aorto-pulmonary window (40%) were the most frequent CXR abnormalities. Patients with BTAI were more likely to have an abnormal CXR-40 of 45 (88.8%) patients when compared with the controls-25 of 51 (49%)patients-p < 0.001. CONCLUSIONS Although CXR is a sensitive screening modality, it failed to identify the possibility of BTAI in 11% of patients. The liberal use of chest CTA after high speed motor vehicle crashes is recommended to minimize the incidence of missed BTAI.

Gammopathy-associated Acrosclerosis as a Cause of Flexion Contractures in an Older Adult Patient: A Case Report and Literature Review

BACKGROUND This article describes an 87-year-old woman with progressive debilitating flexion contractures involving both hands. In addition, a similar scariform process in this patient extended to involve the upper and lower extremities. The patient had an established history of an IgG monoclonal gammopathy of undetermined significance (MGUS). Her contraction deformities were treated surgically. This is the first known reported case of gammopathy-associated acrosclerosis eventuating in bilateral hand contractures. IgG lambda paraprotein may evoke fibrocyte hypercellularity and sclerosis. Recent studies have used chemotherapy and peripheral stem cell transplantation in the treatment of severe sclerosing reactions associated with MGUS. This more recent approach reflects the inherent basis of the fibrosis, at least in scleromyxedema, and is one that is reflective of a clonal B-cell lymphoproliferative disorder.