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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 -
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 -
Injury Aug 2020Blunt thoracic injury is present in around 15% of all major trauma presentations. To ensure a standardised approach to the management of physical injury, patient... (Review)
Review
How does the implementation of a patient pathway-based intervention in the acute care of blunt thoracic injury impact on patient outcomes? A systematic review of the literature.
BACKGROUND
Blunt thoracic injury is present in around 15% of all major trauma presentations. To ensure a standardised approach to the management of physical injury, patient pathway-based interventions have been established in many healthcare settings. It currently remains unclear how these complex interventions are implemented and evaluated in the literature. This systematic review aims to identify pathway effectiveness literature and implementation studies in relation to patient pathway-based interventions in blunt thoracic injury care.
METHODS
The databases Medline, Embase, Web of Science, CINAHL, WHO Clinical Trials Register and both the GreyLit & OpenGrey databases were searched without restrictions on date or study type. A search strategy was developed including keywords and MeSH terms relating to blunt thoracic injury, patient pathway-based interventions, evaluation and implementation. Due to heterogeneity of intervention pathways, meta-analysis was not possible; analysis was undertaken using an iterative narrative approach.
RESULTS
A total of 16 studies met the inclusion criteria and were included in analysis. Pathways were identified covering analgesic management, respiratory care, surgical decision making and reducing risk of complications. Studies evaluating pathways are generally limited by their observational and retrospective design, but results highlight the potential benefits of pathway driven care provision in blunt thoracic injury.
CONCLUSIONS
The results demonstrate the complexity of evaluating patient pathway-based interventions in blunt thoracic injury management. It is important that pathways undergo rigorous evaluation, refinement and validation to ensure quality and patient safety. Strong recommendations are precluded as the quality of the pathway evaluation studies are low.
Topics: Critical Care; Delivery of Health Care; Humans; Retrospective Studies; Thoracic Injuries; Wounds, Nonpenetrating
PubMed: 32576379
DOI: 10.1016/j.injury.2020.06.002 -
The Cochrane Database of Systematic... Jul 2019Vertebral fractures are associated with increased morbidity (e.g. pain, reduced quality of life) and mortality. Therapeutic exercise is a non-pharmacological...
BACKGROUND
Vertebral fractures are associated with increased morbidity (e.g. pain, reduced quality of life) and mortality. Therapeutic exercise is a non-pharmacological conservative treatment that is often recommended for patients with vertebral fractures to reduce pain and restore functional movement. This is an update of a Cochrane Review first published in 2013.
OBJECTIVES
To assess the effects (benefits and harms) of exercise intervention of four weeks or greater (alone or as part of a physical therapy intervention) versus non-exercise/non-active physical therapy intervention, no intervention or placebo among adults with a history of vertebral fractures on incident fragility fractures of the hip, vertebra or other sites. Our secondary objectives were to evaluate the effects of exercise on the following outcomes: falls, pain, physical performance, health-related quality of life (disease-specific and generic), and adverse events.
SEARCH METHODS
We searched the following databases until November 2017: the Cochrane Library (Issue 11 of 12), MEDLINE (from 2005), Embase (from 1988), CINAHL (Cumulative Index to Nursing and Allied Health Literature, from 1982), AMED (from 1985), and PEDro (Physiotherapy Evidence Database, from 1929). Ongoing/recently completed trials were identified by searching the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov. Conference proceedings were searched via ISI and SCOPUS, and targeted searches of proceedings of the American Congress of Rehabilitation Medicine and American Society for Bone and Mineral Research. Search terms or MeSH headings included terms such as vertebral fracture AND exercise OR physical therapy. For this update, the search results were limited from 2011 onward.
SELECTION CRITERIA
We included all randomized controlled trials and quasi-randomized trials comparing exercise or active physical therapy interventions with placebo/non-exercise/non-active physical therapy interventions or no intervention implemented in individuals with a history of vertebral fracture.
DATA COLLECTION AND ANALYSIS
Two review authors independently selected trials and extracted data using a pre-tested data extraction form. Disagreements were resolved by consensus, or third-party adjudication. We used Cochrane's tool for assessing risk of bias to evaluate each study. Studies were grouped according to duration of follow-up (i.e. a) 4-12 weeks; b) 16-24 weeks; c) 52 weeks); a study could be represented in more than one group depending on the number of follow-up assessments. For dichotomous data, we reported risk ratios (RR) and corresponding 95% confidence intervals (95% CI). For continuous data, we reported mean differences (MD) of the change from baseline and 95% CI. Data were pooled for Timed Up and Go test, self-reported physical function measured by the QUALEFFO-41 physical function subscale score (scale of zero to 100; lower scores indicate better self-reported physical function), and disease-specific quality of life measured by the QUALEFFO-41 total score (scale of zero to 100; lower scores indicate better quality of life) at 12 weeks using a fixed-effect model.
MAIN RESULTS
Nine trials (n = 749, 68 male participants; two new trials in this review update) were included. Substantial variability across the trials prevented any meaningful pooling of data for most outcomes. Risk of bias across all studies was variable; low risk across most domains in four studies, and unclear/high risk in most domains for five studies. Performance bias and blinding of subjective outcome assessment were almost all high risk of bias.One trial reported no between-group difference in favor of the effect of exercise on incident fragility fractures after 52 weeks (RR 0.54, 95% CI 0.17 to 1.71; very low-quality evidence with control: 184 per 1000 and exercise: 100 per 1000, 95% CI 31 to 315; absolute difference: 8%, 95% CI 2 to 30). One trial reported no between-group difference in favor of the effect of exercise on incident falls after 52 weeks (RR 1.06, 95% CI 0.53 to 2.10; very low-quality evidence with control: 262 per 1000 and exercise: 277 per 1000; 95% CI 139 to 550; absolute difference: 2%, 95% CI -12 to 29). These findings should be interpreted with caution because of the very serious risk of bias in these studies and the small sample sizes resulting in imprecise estimates.We are uncertain that exercise could improve pain, self-reported physical function, and disease-specific quality of life, because certain studies showed no evidence of clinically important differences for these outcomes. Pooled analyses revealed a small between-group difference in favor of exercise for Timed Up and Go (MD -1.13 seconds, 95% CI -1.85 to -0.42; studies = 2), which did not change following a sensitivity analysis (MD -1.09 seconds, 95% CI -1.78 to -0.40; studies = 3; moderate-quality evidence). Exercise improved QUALEFFO-41 physical function score (MD -2.84 points, 95% CI -5.57 to -0.11; studies = 2; very low-quality evidence) and QUALEFFO-41 total score (MD -3.24 points, 95% CI -6.05 to -0.43; studies = 2; very low-quality evidence), yet it is unlikely that we observed any clinically important differences. Three trials reported four adverse events related to the exercise intervention (costal cartilage fracture, rib fracture, knee pain, irritation to tape, very low-quality evidence).
AUTHORS' CONCLUSIONS
In conclusion, we do not have sufficient evidence to determine the effects of exercise on incident fractures, falls or adverse events. Our updated review found moderate-quality evidence that exercise probably improves physical performance, specifically Timed Up and Go test, in individuals with vertebral fracture (downgraded due to study limitations). However, a one-second improvement in Timed Up and Go is not a clinically important improvement. Although individual trials did report benefits for some pain and disease-specific quality of life outcomes, the findings do not represent clinically meaningful improvements and should be interpreted with caution given the very low-quality evidence due to inconsistent findings, study limitations and imprecise estimates. The small number of trials and variability across trials limited our ability to pool outcomes or make conclusions. Evidence regarding the effects of exercise after vertebral fracture in men is scarce. A high-quality randomized trial is needed to inform safety and effectiveness of exercise to lower incidence of fracture and falls and to improve patient-centered outcomes (pain, function) for individuals with vertebral fractures (minimal sample size required is approximately 2500 untreated participants or 4400 participants if taking anti-osteoporosis therapy).
Topics: Exercise; Exercise Therapy; Humans; Osteoporotic Fractures; Postural Balance; Quality of Life; Randomized Controlled Trials as Topic; Spinal Fractures; Time and Motion Studies
PubMed: 31273764
DOI: 10.1002/14651858.CD008618.pub3 -
Scandinavian Journal of Trauma,... Sep 2020Massive hemothorax secondary to thoracic spinal fractures is rare, and its clinical characteristics, treatment, and prognosis are unknown. We present two cases of...
BACKGROUND
Massive hemothorax secondary to thoracic spinal fractures is rare, and its clinical characteristics, treatment, and prognosis are unknown. We present two cases of thoracic spinal fracture-induced massive hemothorax and a systematic review of previously reported cases.
METHODS
This study included patients with traumatic hemothorax from thoracic spinal fractures at a Japanese tertiary care hospital. A systematic review of published cases was undertaken through searches in PubMed, EMBASE, and ICHUSHI from inception to October 13, 2019.
RESULTS
Case 1: An 81-year-old man developed hemodynamic instability from a right hemothorax with multiple rib fractures following a pedestrian-vehicle accident; > 1500 mL blood was evacuated through the intercostal drain. Thoracotomy showed hemorrhage from a T8-burst fracture, and gauze packing was used for hemostasis. Case 2: A 64-year-old man with right hemothorax and hypotension after a fall from height had hemorrhage from a T7-burst fracture, detected on thoracotomy, which was sealed with bone wax. Hypotension recurred during transfer; re-thoracotomy showed bleeding from a T7 fracture, which was packed with bone wax and gauze for hemostasis. The systematic review identified 10 similar cases and analyzed 12 cases, including the abovementioned cases. Inferior part of thoracic spines was prone to injury and induced right-sided hemothorax. Most patients developed hemodynamic instability, and some sustained intra-transfer hemorrhage; direct compression (gauze packing, bone wax, and hemostatic agents) was the commonest hemostatic procedure. The mortality rate was 33.3%.
CONCLUSIONS
Hemothorax due to thoracic spinal fracture can be fatal. Thoracotomy with direct compression is necessary in hemodynamically unstable patients.
Topics: Accidental Falls; Accidents, Traffic; Aged, 80 and over; Hemothorax; Humans; Male; Middle Aged; Radiography, Thoracic; Spinal Fractures; Thoracic Vertebrae; Thoracotomy; Tomography, X-Ray Computed
PubMed: 32917249
DOI: 10.1186/s13049-020-00783-0 -
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 -
Clinical Orthopaedics and Related... Jan 2019Multiple rib fractures are common in trauma patients, who are prone to trauma-associated complications. Surgical or nonsurgical interventions for the aforementioned... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Multiple rib fractures are common in trauma patients, who are prone to trauma-associated complications. Surgical or nonsurgical interventions for the aforementioned conditions remain controversial.
QUESTIONS/PURPOSES
The purpose of our study was to perform a meta-analysis to evaluate the clinical prognosis of surgical fixation of multiple rib fractures in terms of (1) hospital-related endpoints (including duration of mechanical ventilation, ICU length of stay [LOS] and hospital LOS), (2) complications, (3) pulmonary function, and (4) pain scores.
METHODS
We screened PubMed, Embase, and Cochrane databases for randomized and prospective studies published before January 2018. Individual effect sizes were standardized; the pooled effect size was calculated using a random-effects model. Primary outcomes were duration of mechanical ventilation, intensive care unit length of stay (ICU LOS), and hospital LOS. Moreover, complications, pulmonary function, and pain were assessed.
RESULTS
The surgical group had a reduced duration of mechanical ventilation (weighted mean difference [WMD], -4.95 days; 95% confidence interval [CI], -7.97 to -1.94; p = 0.001), ICU LOS (WMD, -4.81 days; 95% CI, -6.22 to -3.39; p < 0.001), and hospital LOS (WMD, -8.26 days; 95% CI, -11.73 to -4.79; p < 0.001) compared with the nonsurgical group. Complications likewise were less common in the surgical group, including pneumonia (odds ratio [OR], 0.41; 95% CI, 0.27-0.64; p < 0.001), mortality (OR, 0.24; 95% CI, 0.07-0.87; p = 0.030), chest wall deformity (OR, 0.02; 95% CI. 0.00-0.12; p < 0.001), dyspnea (OR, 0.23; 95% CI, 0.09-0.54; p < 0.001), chest wall tightness (OR, 0.11; 95% CI, 0.05-0.22; p < 0.001) and incidence of tracheostomy (OR, 0.34; 95% CI, 0.20-0.57; p < 0.001). There were no differences between the surgical and nonsurgical groups in terms of pulmonary function, such as forced vital capacity (WMD, 6.81%; 95% CI: -8.86 to 22.48; p = 0.390) and pain scores (WMD, -11.41; 95% CI: -42.09 to 19.26; p = 0.470).
CONCLUSIONS
This meta-analysis lends stronger support to surgical fixation, rather than conservative treatment, for multiple rib fractures. Nevertheless, additional trials should be conducted to investigate surgical indications, timing, and followup for quality of life.
LEVEL OF EVIDENCE
Level I, therapeutic study.
Topics: Critical Care; Fracture Fixation; Fracture Healing; Fractures, Multiple; Humans; Length of Stay; Postoperative Complications; Respiration, Artificial; Rib Fractures; Risk Assessment; Risk Factors; Treatment Outcome
PubMed: 30247228
DOI: 10.1097/CORR.0000000000000495