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Cancer Imaging : the Official... Jan 2022To demonstrate and analyze the relatively common imaging findings in this rare primary pleural angiosarcoma (PPA).
BACKGROUND
To demonstrate and analyze the relatively common imaging findings in this rare primary pleural angiosarcoma (PPA).
CASE PRESENTATION
Three cases of PPA, proven by video-assisted thoracic surgery biopsies are retrospectively reviewed. Patients were all male. Age ranges from 65 to 75 years old age (mean; 69). Major chief complaints were dyspnea and chest pain. One has a history of colon cancer, the other has a tuberculosis history and the other has no known history. Multidetector chest CT and PET CT were all done. Immunohistochemical studies were performed including CD31, CD34, or factor VIII-related antigen, vimentin, and cytokeratin. We also review the literatures on recently published PPA. All masses were from 1 to 10 cm. All three patients had multiple pleural based masses, which were ovoid in shape with relatively sharp margin in unilateral hemithorax. Multiple small circumscribed pleural masses are limited in the pleural space in two patients, whereas two, huge lobulated masses about up to 10 cm were present with pleural and extrapleural involvement in one patient. In two patients with pleural mass only, multiple pleural masses were only seen in parietal pleura in one patient and were in both visceral and parietal pleura in one patient. Pleural effusion were found in one side in one patient and in both sides in one patient. One angiosarcoma was arised from chronic tuberculotic pleurisy sequelae. All pleural masses are heterogenous with irregular internal low densities in all patients. Hematogenous metastases were found in liver, vertebra, rib in one patient, and were in lungs with mediastinal lymph node metastases in the other patient. Three patients survived for longer than 3months after diagnosis, but continued to deteriorate rapidly. Two patients underwent chemotherapy after surgical excision, and the other one with multiple metastases treated chemotherapy after CT-guided biopsy, but eventually all died. As a result of comparative analysis of a total of 13 patients' images including 10 cases previously published, there was pleural effusion in all except 2 cases.
CONCLUSIONS
PPA were all necrotic without any vascularized enhancing nature, and manifested as unilateral circumscribed or localized pleural-based masses.
Topics: Aged; Hemangiosarcoma; Humans; Male; Pleura; Pleural Effusion; Retrospective Studies; Tomography, X-Ray Computed
PubMed: 35022068
DOI: 10.1186/s40644-021-00435-1 -
Annals of the Royal College of Surgeons... Apr 2022Multiple traumatic rib fractures are associated with significant morbidity and mortality. The last decade has seen a significant increase in rates of surgical fixation... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Multiple traumatic rib fractures are associated with significant morbidity and mortality. The last decade has seen a significant increase in rates of surgical fixation for both flail and non-flail rib fractures; the evidence for this has come from largely retrospective studies. The aim of this meta-analysis was to compare the efficacy of this approach with that of non-operative management.
METHODS
A systematic search of the literature was performed to identify randomised controlled trials (RCTs) comparing surgical stabilisation to non-operative management. Both flail and non-flail injuries were included.
RESULTS
Five RCTs reported the results of 286 patients. Only one study assessed non-flail fractures. The studies were heterogenic in nature and of mixed quality. Surgical stabilisation was associated with a reduction in pneumonia (RR 0.46, 95% confidence intervals (CI) 0.29 to 0.73, I=42%, =0.001). The duration of mechanical ventilation (mean difference (MD) -6.3, 95% CI -12.16 to -0.43, I=95%, =0.05) and critical care length of stay was also shorter after surgery (mean difference -6.46 days, 95% CI 9.73 to -3.19, <0.001); however, the overall length of stay in hospital was not (MD -7.18, 95% CI -15.63 to -1.28, I=94%, =0.1). No study demonstrated a significant reduction in mortality (RR 0.54, 95% CI 0.18 to 1.8, I=0%, =0.28).
CONCLUSIONS
Surgical stabilisation of rib fractures is associated with some improved clinical outcomes. Further large RCTs are still needed to confirm if there is also a survival benefit.
Topics: Flail Chest; Humans; Length of Stay; Randomized Controlled Trials as Topic; Respiration, Artificial; Rib Fractures; Wounds, Nonpenetrating
PubMed: 34928718
DOI: 10.1308/rcsann.2021.0148 -
Resuscitation Dec 2021Summarise the evidence regarding the safety of mechanical and manual chest compressions for cardiac arrest patients. (Meta-Analysis)
Meta-Analysis Review
AIM
Summarise the evidence regarding the safety of mechanical and manual chest compressions for cardiac arrest patients.
METHODS
Two investigators separately screened the articles of EMBASE, PubMed, and Cochrane Central databases. Cohort studies and randomized clinical trials (RCTs) that evaluated the safety of mechanical (LUCAS or AutoPulse) and manual chest compressions in cardiac arrest patients were included. A meta-analysis was performed using a random effects model to calculate the pooled odds ratios (ORs) and their 95% confidence intervals (CIs). The primary outcome was the rate of overall compression-induced injuries. The secondary outcomes included the incidence of life-threatening injuries, skeletal fractures, visceral injuries, and other soft tissue injuries.
RESULTS
The meta-analysis included 11 trials involving 2,818 patients. A significantly higher rate of overall compression-induced injuries was found for mechanical compressions than manual compressions (OR, 1.29; 95% CI, 1.19-1.41), while there was no significant difference between the two groups in respect of the rate of life-threatening injuries. Furthermore, both modalities shared similar incidences of sternal fractures, vertebral fractures, lung, spleen, and kidney injuries. However, compared to mechanical compressions, manual compressions were shown to present a reduced risk of posterior rib fractures, and heart and liver lesions.
CONCLUSIONS
The findings suggested that manual compressions could decrease the risk of compression-induced injuries compared to mechanical compressions in cardiac arrest patients. Interestingly, mechanical compressions have not increased the risk of life-threatening injuries, whereas additional high-quality RCTs are needed to further verify the safety of mechanical chest devices.
TRIAL REGISTRY
INPLASY; Registration number: INPLASY2020110111; URL: https://inplasy.com/.
Topics: Cardiopulmonary Resuscitation; Heart Arrest; Heart Massage; Humans; Out-of-Hospital Cardiac Arrest; Pressure; Randomized Controlled Trials as Topic; Thoracic Injuries; Thorax
PubMed: 34699924
DOI: 10.1016/j.resuscitation.2021.10.028 -
The European Respiratory Journal Apr 2022Our purpose was to summarise the prognostic associations between various clinical risk factors and development of acute respiratory distress syndrome (ARDS) following... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Our purpose was to summarise the prognostic associations between various clinical risk factors and development of acute respiratory distress syndrome (ARDS) following traumatic injury.
METHODS
We conducted this review in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and CHARMS (Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies) guidelines. We searched six databases from inception through December 2020. We included English language studies describing the clinical risk factors associated with development of post-traumatic ARDS, as defined by either the American-European Consensus Conference or Berlin definition. We pooled adjusted odds ratios for prognostic factors using the random effects method. We assessed risk of bias using the QUIPS (Quality in Prognosis Studies) tool and certainty of findings using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology.
RESULTS
We included 39 studies involving 5 350 927 patients. We identified the amount of crystalloid resuscitation as a potentially modifiable prognostic factor associated with development of post-traumatic ARDS (adjusted OR 1.19, 95% CI 1.15-1.24 for each additional litre of crystalloid administered within the first 6 h after injury; high certainty). Non-modifiable prognostic factors with a moderate or high certainty of association with post-traumatic ARDS included increasing age, non-Hispanic White race, blunt mechanism of injury, presence of head injury, pulmonary contusion or rib fracture and increasing chest injury severity.
CONCLUSIONS
We identified one important modifiable factor, the amount of crystalloid resuscitation within the first 24 h of injury, and several non-modifiable factors associated with development of post-traumatic ARDS. This information should support the judicious use of crystalloid resuscitation in trauma patients and may inform development of risk stratification tools.
Topics: Crystalloid Solutions; Humans; Odds Ratio; Prognosis; Respiratory Distress Syndrome; Risk Factors
PubMed: 34625477
DOI: 10.1183/13993003.00857-2021 -
World Journal of Emergency Medicine 2021Suspension trauma syndrome is a life-threatening event that occurs when a person is "trapped" in a prolonged passive suspension. It is most commonly seen in people who... (Review)
Review
BACKGROUND
Suspension trauma syndrome is a life-threatening event that occurs when a person is "trapped" in a prolonged passive suspension. It is most commonly seen in people who engage in occupational or sport activities that require harness suspension. The aim of this study is to identify the predisposing factors, pathophysiology, and management of suspension trauma.
METHODS
A review and analysis of the literature published in English and Spanish from 1972 to 2020 on suspension trauma were performed. Search sources were PubMed, Medline, Cochrane Library, MeSH, UpToDate, and Google Scholar. Articles referring to suspension trauma associated with other injury mechanisms (traumatic impact injuries, drowning, asphyxiation, or bleeding), case reports, and pediatric population were excluded.
RESULTS
Forty-one articles were identified. Of these, 29 articles related to mechanism, pathophysiology, and management of individuals who suffered prolonged suspension trauma without associated traumatic injuries were included in the study. We encountered several controversies describing the putative pathophysiology, ranging from blood sequestration in the lower extremities versus accumulation of metabolic waste and hyperkalemia to dorsal hook-type harness as a trigger cause of positional asphyxia; to vascular compression of femoral vessels exerted by the harness causing decreased venous return. Pstients suspended in a full-body harness with dorsal hook showed more hemodynamic alterations in response to the compressive effect on the rib cage, causing a reduction in perfusion by presenting a decrease in pulse pressure. Management strategies varied across studies.
CONCLUSIONS
Progress has been made in individualizing the population at risk and in the management of suspension trauma. We recommend the formation of consensus definitions, larger cohort or registry studies to be conducted, and experimental animal models to better understand the mechanisms in order to develop management and life support guidelines from a trauma and emergency medicine perspective.
PubMed: 34512820
DOI: 10.5847/wjem.j.1920-8642.2021.04.001 -
Cureus Jul 2021Hereditary multiple exostoses (HME) are an autosomal dominant skeletal disorder characterized by the development of multiple benign osteochondromas (exostoses) that... (Review)
Review
Hereditary multiple exostoses (HME) are an autosomal dominant skeletal disorder characterized by the development of multiple benign osteochondromas (exostoses) that frequently involve long bones of the body. Less commonly, the ribs are a site of involvement, and long-term friction between an exostosis and pleura can produce a hemothorax or pneumothorax. The purpose of this study is to provide a comprehensive review of existing literature on pneumothorax or hemothorax secondary to costal exostosis in HME patients. We reviewed the databases of PubMed and Embase and included data as current as of February 15, 2021. All case reports included cases of hemothorax or pneumothorax in patients with a known personal or family history of HME. After evaluation for inclusion based on eligibility criteria, 18 cases were included. The average age at presentation was 11.7 years (range: 3-32), and most patients were male (83%). Hemothoraces occurred in 15 cases, while pneumothoraces occurred in three cases. All cases were evaluated using chest X-ray and CT scan, and the majority of the cases were treated with surgical resection of the exostosis, either with video-assisted thoracoscopic surgery (VATS; 61%) or thoracotomy (22%). Outcomes were successful with no cases of recurrence after surgical intervention. Although rare, costal exostosis should be considered as a differential in patients presenting with pneumothorax or hemothorax and past medical history or physical exam findings suggestive of HME. Immediate evaluation and surgical intervention to resect costal exostosis are essential to reduce the risk of recurrent life-threatening injury.
PubMed: 34395113
DOI: 10.7759/cureus.16326 -
Trauma Surgery & Acute Care Open 2021There is a critical need for non-narcotic analgesic adjuncts in the treatment of thoracic pain. We evaluated the efficacy of intercostal cryoneurolysis as an analgesic...
BACKGROUND
There is a critical need for non-narcotic analgesic adjuncts in the treatment of thoracic pain. We evaluated the efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain, specifically addressing the applicability of intercostal cryoneurolysis for pain control after chest wall trauma.
METHODS
A systematic review was performed through searches of PubMed, EMBASE, and the Cochrane Library. We included studies involving patients of all ages that evaluated the efficacy of intercostal cryoneurolysis as a pain adjunct for chest wall pathology. Quantitative and qualitative synthesis was performed.
RESULTS
Twenty-three studies including 570 patients undergoing cryoneurolysis met eligibility criteria for quantitative analysis. Five subgroups of patients treated with intercostal cryoneurolysis were identified: pectus excavatum (nine studies); thoracotomy (eight studies); post-thoracotomy pain syndrome (three studies); malignant chest wall pain (two studies); and traumatic rib fractures (one study). There is overall low-quality evidence supporting intercostal cryoneurolysis as an analgesic adjunct for chest wall pain. A majority of studies demonstrated decreased inpatient narcotic use with intercostal cryoneurolysis compared with conventional pain modalities. Intercostal cryoneurolysis may also lead to decreased hospital length of stay. The procedure did not definitively increase operative time, and risk of complications was low.
CONCLUSIONS
Given the favorable risk-to-benefit profile, both percutaneous and thoracoscopic intercostal cryoneurolysis may serve as a worthwhile analgesic adjunct in trauma patients with rib fractures who have failed conventional medical management. However, further prospective studies are needed to improve quality of evidence.
LEVEL OF EVIDENCE
Level IV systematic reviews and meta-analyses.
PubMed: 34079913
DOI: 10.1136/tsaco-2021-000690 -
European Journal of Trauma and... Oct 2022The aim of this systematic review was to provide an overview of the incidence of combined clavicle and rib fractures and the association between these two injuries. (Review)
Review
PURPOSE
The aim of this systematic review was to provide an overview of the incidence of combined clavicle and rib fractures and the association between these two injuries.
METHODS
A systematic literature search was performed in the MEDLINE, EMBASE, and CENTRAL databases on the 14 of August 2020. Outcome measures were incidence, hospital length of stay (HLOS), intensive care unit admission and length of stay (ILOS), duration of mechanical ventilation (DMV), mortality, chest tube duration, Constant-Murley score, union and complications.
RESULTS
Seven studies with a total of 71,572 patients were included, comprising five studies on epidemiology and two studies on treatment. Among blunt chest trauma patients, 18.6% had concomitant clavicle and rib fractures. The incidence of rib fractures in polytrauma patients with clavicle fractures was 56-60.6% versus 29% in patients without clavicle fractures. Vice versa, 14-18.8% of patients with multiple rib fractures had concomitant clavicle fractures compared to 7.1% in patients without multiple rib fractures. One study reported no complications after fixation of both injuries. Another study on treatment, reported shorter ILOS and less complications among operatively versus conservatively treated patients (5.4 ± 1.5 versus 21 ± 13.6 days).
CONCLUSION
Clavicle fractures and rib fractures are closely related in polytrauma patients and almost a fifth of all blunt chest trauma patients sustain both injuries. Definitive conclusions could not be drawn on treatment of the combined injury. Future research should further investigate indications and benefits of operative treatment of this injury.
Topics: Clavicle; Humans; Length of Stay; Multiple Trauma; Retrospective Studies; Rib Fractures; Thoracic Injuries; Wounds, Nonpenetrating
PubMed: 34075434
DOI: 10.1007/s00068-021-01701-4 -
European Radiology Sep 2021To assess the diagnostic performance of chest CT in the detection of rib fractures in children investigated for suspected physical abuse (SPA). (Meta-Analysis)
Meta-Analysis
The diagnostic performance of chest computed tomography in the detection of rib fractures in children investigated for suspected physical abuse: a systematic review and meta-analysis.
OBJECTIVES
To assess the diagnostic performance of chest CT in the detection of rib fractures in children investigated for suspected physical abuse (SPA).
METHODS
Medline, Web of Science and Cochrane databases were searched from January 1980 to April 2020. The QUADAS-2 tool was used to assess the quality of the eligible English-only studies following which a formal narrative synthesis was constructed. Studies reporting true-positive, false-positive, true-negative, and false-negative results were included in the meta-analysis. Overall sensitivity and specificity of chest CT for rib fracture detection were calculated, irrespective of fracture location, and were pooled using a univariate random-effects meta-analysis. The diagnostic accuracy of specific locations along the rib arc (anterior, lateral or posterior) was assessed separately.
RESULTS
Of 242 identified studies, 4 met the inclusion criteria. Of these, 2 were included in the meta-analysis. Chest CT identified 142 rib fractures compared to 79 detected by initial skeletal survey chest radiographs in live children with SPA. Post-mortem CT (PMCT) has low sensitivity (34%) but high specificity (99%) in the detection of rib fractures when compared to the autopsy reference standard. PMCT has low sensitivity (45%, 21% and 42%) but high specificity (99%, 97% and 99%) at anterior, lateral and posterior rib locations, respectively.
CONCLUSIONS
Chest CT detects more rib fractures than initial skeletal survey chest radiographs in live children with SPA. PMCT has low sensitivity but high specificity for detecting rib fractures in children investigated for SPA.
KEY POINTS
• PMCT has low sensitivity (34%) but high specificity (99%) in the detection of rib fractures; extrapolation to CT in live children is difficult. • No studies have compared chest CT with the current accepted practice of initial and follow-up skeletal survey chest radiographs in the detection of rib fractures in live children investigated for SPA.
Topics: Autopsy; Child; Humans; Physical Abuse; Rib Fractures; Sensitivity and Specificity; Tomography, X-Ray Computed
PubMed: 33725188
DOI: 10.1007/s00330-021-07775-3 -
European Journal of Trauma and... Apr 2022The objective of this systematic review is to compare the safety and efficacy of surgical fixation of rib fractures against non-surgical interventions for the treatment... (Meta-Analysis)
Meta-Analysis
PURPOSE
The objective of this systematic review is to compare the safety and efficacy of surgical fixation of rib fractures against non-surgical interventions for the treatment of flail chest in the adult population.
METHODS
A search was performed on the 22nd of July 2020 to identify articles comparing surgical fixation versus clinical management for flail chest in adults, with a description of the outcome parameters (resource utility, mortality, adverse effects of the intervention and adverse progression in pulmonary status). Relevant randomised controlled trials were selected, their risk of bias assessed, and the data then extracted and analysed.
RESULTS
157 patients were included from four studies in the analyses, with 79 and 78 patients in the surgical and non-surgical groups, respectively. The pooled effects of all outcomes tended towards favouring surgical intervention. Surgical intervention was associated with lower rates of pneumonia (I = 46%, Tau = 0.16, p = 0.16), significantly lower rates of tracheostomy (I = 76%, Tau = 0.67, p = 0.02), and a significantly lower duration of mechanical ventilation (I = 88%, Tau = 33.7, p < 0.01) in comparison to the non-surgical management methods.
CONCLUSION
Our results suggest that surgical intervention reduces the need for tracheostomy, reduces the time spent in the intensive care unit following a traumatic flail chest injury and could reduce the risk of acquiring pneumonia after such an event. There is a need for further well-designed studies with sufficient sample sizes to confirm the results of this study and also detect other possible effects of surgical intervention in the treatment of traumatic flail chest in adults.
Topics: Adult; Flail Chest; Fracture Fixation, Internal; Humans; Length of Stay; Pneumonia; Respiration, Artificial; Rib Fractures
PubMed: 33547910
DOI: 10.1007/s00068-021-01606-2