Study objective: Although traditional teachings in regard to pneumothorax and hemothorax generally recommend chest tube placement and hospital admission, the increasing use of chest computed tomography (CT) in blunt trauma evaluation may detect more minor pneumothorax and hemothorax that might indicate a need to modify these traditional practices. We determine the incidence of pneumothorax and hemothorax observed on CT only and the incidence of isolated pneumothorax and hemothorax (pneumothorax and hemothorax occurring without other thoracic injuries), and describe the clinical implications of these injuries.Methods: This was a planned secondary analysis of 2 prospective, observational studies of adult patients with blunt trauma, NEXUS Chest , set in 10 Level I US trauma centers. Participants' inclusion criteria were older than 14 years, presentation to the emergency department (ED) within 6 hours of blunt trauma, and receipt of chest imaging (chest radiograph, chest CT, or both) during their ED evaluation. Exposure(s) (for observational studies) were that patients had trauma and chest imaging. Primary measures and outcomes included the incidence of pneumothorax and hemothorax observed on CT only versus on both chest radiograph and chest CT, the incidence of isolated pneumothorax and hemothorax (pneumothorax and hemothorax occurring without other thoracic injuries), and admission rates, hospital length of stay, mortality, and frequency of chest tube placement for these injuries.Results: Of 21,382 enrolled subjects, 1,064 (5%) had a pneumothorax and 384 (1.8%) had a hemothorax. Of the 8,661 patients who received both a chest radiograph and a chest CT, 910 (10.5%) had a pneumothorax, with 609 (67%) observed on CT only; 319 (3.7%) had a hemothorax, with 254 (80%) observed on CT only. Of 1,117 patients with pneumothorax, hemothorax, or both, 108 (10%) had isolated pneumothorax or hemothorax. Patients with pneumothorax observed on CT only had a lower chest tube placement rate (30% versus 65%; difference in proportions [D] -35%; 95% confidence interval [CI] -28% to 42%), admission rate (94% versus 99%; D 5%; 95% CI 3% to 8%), and median length of stay (5 versus 6 days; difference 1 day; 95% CI 0 to 2 days) but similar mortality compared with patients with pneumothorax observed on chest radiograph and CT. Patients with hemothorax observed on CT had only a lower chest tube placement rate (49% versus 68%; D -19%; 95% CI -31% to -5%) but similar admission rate, mortality, and median length of stay compared with patients with hemothorax observed on chest radiograph and CT. Compared with patients with other thoracic injury, those with isolated pneumothorax or hemothorax had a lower chest tube placement rate (20% versus 43%; D -22%; 95% CI -30% to -13%), median length of stay (4 versus 5 days; difference -1 day; 95% CI -3 to 1 days), and admission rate (44% versus 97%; D -53%; 95% CI -62% to -43%), with an admission rate comparable to that of patients without pneumothorax or hemothorax (49%).Conclusion: Under current imaging ...
ioral intervention to be useful for urinary symptoms in men. 3 The study objective was to determine whether combining behavioral and drug therapies improves outcomes compared with each therapy alone for overactive bladder in men and to compare 3 sequences for implementing combined therapy. Our study outcomes focused on the overactive bladder symptoms of urgency, frequency, nocturia, and urge urinary incontinence (UI).We did not target symptoms caused by benign prostatic hyperplasia (BPH) in this study, nor did we attempt to diagnose bladder outlet obstruction, because this requires use of urodynamics. Instead, we sought to minimize the potential role of bladder outlet obstruction in causing these symptoms by excluding men with a high postvoid residual (more than 150 mL) and low maximum noninvasive urinary flow rate (<8.0 mL/s on a void greater than 125 mL). Including an α-blocker in the drug treatment was consistent with our recognition that some participants still might have had undetected obstruction.Bahat et al rightly point out that α-blockers, when used for blood pressure control in older women, have been associated in an epidemiological study with 5-fold greater odds of reporting incident UI. 4 They further postulate that there could have been similar detrimental effects in the current study, such as new cases of UI, or that the use of α-blockers could have attenuated the effects of the drug therapy. While this is possible, we think it is unlikely, because men who reported UI at study entry showed a 52.9% reduction in UI episodes in the drug alone group, similar to that seen with behavioral treatment alone (52.7%). Given this improvement, we would not expect that new cases of UI would have occurred or had a significant effect. In addition, the effect of α-blockers is likely to be different in men compared with women due to anatomic differences. Finally, there is literature to support positive effects for the role of α-blockers for urinary symptoms in men. 5,6 We thank the authors for their inquiry.
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