Transversus Thoracic Muscle Plane Block For Postoperative Pain in Pediatric Cardiac Surgery: A Systematic Review And Meta-Analysis of Randomized And Observational Studies

OBJECTIVES

Pediatric patients undergoing cardiac surgery usually experience significant surgical pain. Additionally, the effect of poor surgical analgesia creates a pain continuum that extends to the postoperative period. Transversus thoracic muscle plane block (TTMPB) is a novel plane block technique that can provide analgesia to the anterior chest wall. The analgesic role of TTMPB in pediatric cardiac surgery is still uncertain. A meta-analysis was conducted to determine the analgesic efficacy of this procedure.

DESIGN AND SETTING

Systematic review and meta-analysis. PubMed, Embase, Web of Science, CENTRAL, WanFang Data, and the China National Knowledge Infrastructure were searched to November 2023, and the Grading of Recommendations Assessment, Development, and Evaluation approach was followed to evaluate the certainty of evidence.

PARTICIPANTS

Eligible studies enrolled pediatric patients from 2 months to 12 years old scheduled to undergo cardiac surgery, and randomized them to receive a TTMPB or no block/sham block.

MEASUREMENTS AND MAIN RESULTS

Six studies that enrolled 601 pediatric patients were included. Low-certainty evidence from randomized trials showed that, compared with no block or sham block, TTMPB in pediatric patients undergoing cardiac surgery may reduce postoperative modified objective pain score at 12 hours (weighted mean difference [WMD] -2.20, 95% CI -2.73 to -1.68) and 24 hours (WMD -1.76, 95% CI -2.09 to -1.42), intraoperative opioid consumption (WMD -3.83, 95% CI -5.90 to -1.76 μg/kg), postoperative opioid consumption (WMD -2.51, 95% CI -2.84 to -2.18 μg/kg), length of intensive care unit (ICU) stay (WMD -5.56, 95% CI -8.30 to -2.83 hours), and extubation time (WMD -2.13, 95% CI -4.21 to -0.05 hours). Retrospective studies provided very low certainty that the results were consistent with the randomized trials.

CONCLUSION

Very low- to low-certainty evidence showed that TTMPB in pediatric patients undergoing cardiac surgery may reduce postoperative pain, opioid consumption, ICU length of stay, and extubation time.

Outcomes From a Nurse Practitioner Led Dynamic Compression System Bracing Program for Pectus Carinatum

BACKGROUND

Dynamic compression system (DCS) is often effective at treating pectus carinatum (PC). However, some patients will fail therapy. This study reports outcomes from a nurse-practitioner led bracing program, and evaluates what factors are predictive of successful therapy.

METHODS

We performed a retrospective cohort study involving all patients treated with DCS bracing at our institution between February 2018 and February 2022. Patients with at least three visits were included. The primary outcome was achieving neutral chest. Factors considered potentially predictive included patient age, sex, initial pressure of correction (PIC), and the change in pressure of correction between the first two visits (deltaPC1). A Cox proportional hazards model was used for analysis, and Kaplan-Meier analyses estimated the median time to correction.

RESULTS

283 patients were evaluated. The median age was 14 (IQR 12-15), the majority were male (90.1 %) and white (92.6 %). The median PIC and deltaPC1was 4.13 PSI (IQR 3.17-5.3), and 1.34 PSI (IQR 0.54-2.25), respectively. 117 patients achieved correction. The median estimated time to correction was 7.5 months (95 % CI 5.9-10.1). In the final Cox model, greater deltaPC1 was associated with increased risk of correction (HR: 2.46; 95 % CI 2.03-2.98), and increased PIC was associated with decreased risk of correction up to one year of therapy (0-3 months HR 0.62, 95 % CI 0.50-0.78; 3-12 months HR 0.62; 95 % CI 0.45-0.85).

CONCLUSIONS

DCS bracing administered by advanced care providers in collaboration with surgeons can effectively treat PC. The deltaPC1 and PIC are the factors most predictive of successful therapy.

LEVEL OF EVIDENCE

Level III.

A 25-Year-Old Man with a History of Substance Abuse Presenting with Pneumomediastinum Due to Methamphetamine Vapor Inhalation

BACKGROUND There has been an increase in the use of inhalation methods to abuse drugs, including freebasing crack cocaine (alkaloid) and inhaling methamphetamine vapor. This report is of a 25-year-old man with a history of substance abuse presenting with pneumomediastinum due to methamphetamine vapor inhalation. Acute pneumomediastinum is an extremely rare complication of methamphetamine use. CASE REPORT A 25-year-old man was treated for polysubstance abuse following 9 days of methamphetamine abuse. EKG did not show any ST &T change. D-dimer was normal, at 0.4 mg/L, so we did not do further work-up for pulmonary embolism. His chest pain worsened in the Emergency Department (ED), and a physical exam demonstrated crepitation of the posterior neck, trapezius, and right scapula. A portable chest X-ray revealed subcutaneous air over the right scapular region, in addition to pneumomediastinum. The urine drug screen test was positive for methamphetamine. A chest CT was ordered, which showed a moderate-volume pneumomediastinum with soft-tissue air tracking into the lower neck and along the right chest wall. The patient underwent an esophagogram, which showed no air leak, and Boerhaave's syndrome was ruled out. His symptoms improved and he did not require any surgical intervention. CONCLUSIONS Considering the higher rates of illicit substance use, especially methamphetamine, it is important to pay attention to the associated pathologies and to keep spontaneous pneumomediastinum on the list of differentials for patients using methamphetamine, particularly those who inhale it, which can cause pneumomediastinum, even without Boerhaave's syndrome.

Growth of the brachial nerve plexus with reference to topographical relation of the medianus nerve ansa with the thoracic wall and shoulder: a histologic study using human embryos and fetuses

BACKGROUND

There is currently no information on positional changes in the brachial nerve plexus during prenatal growth. The subclavian-axillary artery passing through the medianus nerve ansa is considered a good landmark for evaluating the height of the plexus.

MATERIALS AND METHODS

We used histologic sections from 9 embryos and 17 fetuses (approximately 6-15 weeks of gestational age) to identify the height of the ansa by referring to the level of the rib and the glenohumeral joint.

RESULTS

The nerve ansa was usually (23 plexuses) observed at the level of the first and/or second ribs. However, it was sometimes observed above the first rib, at a distance equal to or more than an intercostal width (7 plexuses). In the latter group, the ansa was usually located below the glenohumeral joint. Thus, the joint was located higher than the first rib, although the upper extremities were in the anatomic position for all specimens. The left-right difference in the height of the plexus corresponded to or was less than the width of the first intercostal space. Despite the synchronized growth between the thorax and shoulder girdle, the brachial plexus showed a considerable variation in comparative height; the range corresponded to twice of an intercostal width. Whether the nerve plexus is located high or low is determined at an early developmental stage and is maintained during the later growth stages.

CONCLUSION

The high-positioned plexus might cause nerve injury at delivery, followed by a glenohumeral joint deformity because of the fragility without fixation in the thorax.

Inter-institutional variability of knowledge-based plan prediction of left whole breast irradiation

PURPOSE

Within a multi-institutional project, we aimed to assess the transferability of knowledge-based (KB) plan prediction models in the case of whole breast irradiation (WBI) for left-side breast irradiation with tangential fields (TF).

METHODS

Eight institutions set KB models, following previously shared common criteria. Plan prediction performance was tested on 16 new patients (2 pts per centre) extracting dose-volume-histogram (DVH) prediction bands of heart, ipsilateral lung, contralateral lung and breast. The inter-institutional variability was quantified by the standard deviations (SDint) of predicted DVHs and mean-dose (Dmean). The transferability of models, for the heart and the ipsilateral lung, was evaluated by the range of geometric Principal Component (PC1) applicability of a model to test patients of the other 7 institutions.

RESULTS

SDint of the DVH was 1.8 % and 1.6 % for the ipsilateral lung and the heart, respectively (20 %-80 % dose range); concerning Dmean, SDint was 0.9 Gy and 0.6 Gy for the ipsilateral lung and the heart, respectively (<0.2 Gy for contralateral organs). Mean predicted doses ranged between 4.3 and 5.9 Gy for the ipsilateral lung and 1.1-2.3 Gy for the heart. PC1 analysis suggested no relevant differences among models, except for one centre showing a systematic larger sparing of the heart, concomitant to a worse PTV coverage, due to high priority in sparing the left anterior descending coronary artery.

CONCLUSIONS

Results showed high transferability among models and low inter-institutional variability of 2% for plan prediction. These findings encourage the building of benchmark models in the case of TF-WBI.

The depth of neuromuscular blockade is not related to chest wall elastance and respiratory mechanics in moderate to severe acute respiratory distress syndrome patients. A prospective cohort study

BACKGROUND

Data concerning the depth of neuromuscular blockade (NMB) required for effective relaxation of the respiratory muscles in ARDS are scarce. We hypothesised that complete versus partial NMB can modify respiratory mechanics.

METHOD

Prospective study to compare the respiratory mechanics of ARDS patients according to the NMB depth. Each patient was analysed at two times: deep NMB (facial train of four count (TOFC) = 0) and intermediate NMB (TOFC >0). The primary endpoint was the comparison of chest wall elastance (ELCW) according to the NMB level.

RESULTS

33 ARDS patients were analysed. There was no statistical difference between the ELCW at TOFC = 0 compared to TOFC >0: 7 cmH2O/l [5.7-9.5] versus 7 cmH2O/l [5.3-10.8] (p = 0.36). The depth of NMB did not modify the expiratory nor inspiratory oesophageal pressure (Pesexp = 8 cmH2O [5-9.5] at TOFC = 0 versus 7 cmH2O [5-10] at TOFC >0; (p = 0.16) and Pesinsp = 10 cmH2O [8.2-13] at TOFC = 0 versus 10 cmH2O [8-13] at TOFC >0; (p = 0.12)).

CONCLUSION

In ARDS, the relaxation of the respiratory muscles seems to be independent of the NMB level.

Line-based iterative geometric calibration method for a tomosynthesis system

BACKGROUND

A next generation tomosynthesis (NGT) system, capable of two-dimensional source motion, detector motion in the perpendicular direction, and magnification tomosynthesis, was constructed to investigate different acquisition geometries. Existing position-based geometric calibration methods proved ineffective when applied to the NGT geometries.

PURPOSE

A line-based iterative calibration method is developed to perform accurate geometric calibration for the NGT system.

METHODS

The proposed method calculates the system geometry through virtual line segments created by pairs of fiducials within a calibration phantom, by minimizing the error between the line equations computed from the true and estimated fiducial projection pairs. It further attempts to correct the 3D fiducial locations based on the initial geometric calibration. The method's performance was assessed via simulation and experimental setups with four distinct NGT geometries: X, T, XZ, and TZ. The X geometry resembles a conventional DBT acquisition along the chest wall. The T geometry forms a "T"-shaped source path in mediolateral (ML) and posteroanterior (PA) directions. A descending detector motion is added to both X and T geometries to form the XZ and TZ geometries, respectively. Simulation studies were conducted to assess the robustness of the method to geometric perturbations and inaccuracies in fiducial locations. Experimental studies were performed to assess the impact of phantom magnification and the performance of the proposed method for various geometries, compared to the traditional position-based method. Star patterns were evaluated for both qualitative and quantitative analyses; the Fourier spectral distortions (FSDs) graphs and the contrast transfer function (CTF) were extracted. The limit of spatial resolution (LSR) was measured at 5% modulation of the CTF.

RESULTS

The proposed method presented is highly robust to geometric perturbation and fiducial inaccuracies. After the line-based iterative method, the mean distance between the true and estimated fiducial projections was [X, T, XZ, TZ]: [0.01, 0.01, 0.02, 0.01] mm. The impact of phantom magnification was observed; a contact-mode acquisition of a calibration phantom successfully provided an accurate geometry for 1.85× magnification images of a star pattern, with the X geometry. The FSD graphs for the contact-mode T geometry acquisition presented evidence of super-resolution, with the LSR of [0°-quadrant: 8.57, 90°-quadrant: 8.47] lp/mm. Finally, a contact-mode XZ geometry acquisition and a 1.50× magnification TZ geometry acquisition were reconstructed with three calibration methods-position-based, line-based, and iterative line-based. As more advanced methods are applied, the CTF becomes more isotropic, the FSD graphs demonstrate less spectral leakage as super-resolution is achieved, and the degree of blurring artifacts reduces significantly.

CONCLUSIONS

This study introduces a robust calibration method tailored to the unique requirements of advanced tomosynthesis systems. By employing virtual line segments and iterative techniques, we ensure accurate geometric calibration while mitigating the limitations posed by the complex acquisition geometries of the NGT system. Our method's ability to handle various NGT configurations and its tolerance to fiducial misalignment make it a superior choice compared to traditional calibration techniques.

Delayed development of a huge chest wall hematoma post pacemaker implantation: A case report

An 83-year-old Chinese man presented with a huge left chest wall hematoma and hemorrhagic shock 4 months after permanent pacemaker implantation. Computed Tomography of Angiogram of the left subclavian artery revealed a pseudoaneurysm. He underwent radiologically guided stenting followed by hematoma clearance. It is rare to have delayed formation of pseudoaneurysm at 4 months post pacemaker implantation. Radiologically guided stenting is the preferred treatment, followed by hematoma clearance. It is strongly advised against blind surgery for wound debridement or bleeding detection. Familiarizing with axillary vein anatomy, improving axillary vein cannulation skills, and detecting early complications of artery injury are key strategies in preventing pseudoaneurysm formation post pacemaker implantation.

The addition of a leaded arm sleeve to leaded aprons further decreases operator upper outer quadrant chest wall radiation dose during fluoroscopically guided interventions

OBJECTIVE

Breast cancer most commonly occurs in the upper outer quadrant (UOQ) chest wall (CW). The effectiveness of routine leaded aprons to protect this region of the body in interventionalists during fluoroscopically guided interventions (FGIs) is unknown. Given the high lifetime attributable risks of prolonged occupational exposure to ionizing radiation and the increasing number of practicing female vascular surgeons and interventionalists, we sought to determine if the use of a leaded arm shield would offer additional protection to the lateral CW and axilla in operators compared with routine leaded aprons.

METHODS

Effectiveness of leaded sleeves in attenuating radiation dose to the axilla and UOQ was evaluated in clinical practice and simulated scenarios. In the clinical setting, optically stimulated luminescence nanoDot detectors were placed at the UOQ lateral CW position, both over and under a standard leaded apron vest with and without the addition of an antimony/bismuth Enviro-Lite sleeve on two vascular surgeons performing FGIs. In the simulation, nanoDots were similarly placed on an anthropomorphic phantom positioned to represent a primary operator performing right femoral access. Fluorography was performed on 12-inch-thick acrylic scatter phantom at 80 kVp for an exposure of 3 Gy reference air kerma. Experiments were done with and without the sleeve. Paired Wilcoxon and χ2 tests were performed to identify the statistical significance of radiation attenuation.

RESULTS

Operator UOQ CW dose was measured during 61 FGIs: 33 cases (54%) with and 28 cases (46%) without the sleeve. Median procedure reference air kerma and fluoroscopy time was 180 mGy (interquartile range [IQR], 85-447 mGy) and 21 minutes (IQR, 11-39 minutes) when the sleeve was worn vs 100 mGy (IQR, 67-270 mGy) and 11 minutes (IQR, 6.3-25 minutes) without the sleeve. Radiation dose to the operator's UOQ was reduced by 96% (IQR, 85%-96%) when the sleeve was present and by 62% (IQR, 44%-82%; P < .001) without the sleeve. In the simulated setting, the sleeve reduced the radiation dose to the UOQ compared with the apron alone (96% vs 67%; P < .001).

CONCLUSIONS

Routine leaded aprons do attenuate the majority of UOQ chest wall radiation dose; however, the addition of a lead-equivalent sleeve further significantly reduces this dose. Because this area of the body has a high incidence of cancer formation, additional protection, especially to female interventionalists, seems prudent. Vascular surgeons should consider using a protective sleeve with their personal protective equipment when performing complex fluoroscopically guided procedures.

Is Traumatic Anterior Stove-In Chest Truly so Rare? A Single Institution Experience

INTRODUCTION

The anterior stove-in chest (ASIC) is a rare form of flail chest involving bilateral rib or sternal fractures resulting in an unstable chest wall that caves into the thoracic cavity. Given ASIC has only been described in a handful of case reports, this study sought to review our institution's experience in the surgical management of ASIC injuries.

METHODS

A retrospective review of patients with ASIC was conducted at our level I trauma center from 1//2021 to 3//2023. Information pertaining to patient demographics, fracture pattern, operative management, and outcomes was obtained and compared across patients in the case series.

RESULTS

6 patients met inclusion criteria, all males aged 37-78 years. 5 suffered motor vehicle collisions, and 1 was a pedestrian struck by an automobile. The median injury severity score was 28. All received ORIF within 5 days of admission, most commonly for ongoing respiratory distress. Patients 2 and 4 underwent bilateral ORIF of the ribs and sternum while patients 1, 5, and 6 underwent left-sided repair. Patient 3 required ORIF of left ribs and the sternum to stabilize their injuries. 5 of 6 patients were liberated from the ventilator and survived to discharge.

CONCLUSIONS

This study demonstrates successful operative management of 6 patients with ASIC and suggests that early operative intervention with ORIF for affected segments may improve respiratory mechanics, ability to wean from the ventilator, and overall survival. Further research is needed to generate standardized guidelines for the management of this uncommon and complex thoracic injury.

Recent Advancements in Pectus Surgery: Crane Lifting, Multiple-Bar Approach, Bridge Stabilization, and Sandwich Technique

PURPOSE

The most recent procedure for pectus excavatum repair involves crane-powered entire chest wall remodeling, which employs crane lifting, multiple-bar approach, bridge stabilization, and sandwich techniques. This resulted in a paradigm shift in pectus deformity repair from merely lifting the sunken bone to remodeling the chest wall into normal anatomy.

METHODS

We analyzed 649 patients who underwent surgery for pectus excavatum or complex combined deformities between March 2018 and January 2022. A crane with sternal wiring or screwing was used to lift the chest wall without using the pectus bar turning power. Multiple bars with bridge connections were placed to eliminate bar displacement. Modified sandwich techniques were applied to relieve the lower coastal flare (flare-buster) and focal protuberance (magic string).

RESULTS

The mean age of the patients included in the study was 12.2 years (range: 3-45 years). A single bar was used for 202 patients until 2021. For the multiple-bar technique, parallel bars (n = 142), crossbars (n = 166), and crossbars plus upper horizontal bars (XI pattern; n = 139) were used. The overall complication rate was 6.2 %. There was no cases of bar displacement were observed, but other minor complications such as pneumothorax (n = 20, 3.1 %), pleural effusion (n = 7, 1.1 %), and wound infection (n = 5, 0.8 %) were detected. Three patients required reoperation (infection, two: hemorrhage, one).

CONCLUSIONS

The crane-powered entire chest wall remodeling technique improved the safety and comprehensiveness of the repair procedure. By incorporating bridge stabilization and the use of multiple bars, we effectively resolved the issues related to bar displacement and incomplete repair.

TYPE OF STUDY

Retrospective Cohort Study.

LEVEL OF EVIDENCE: 3

Biomechanical Effectivity Evaluation of Single- and Double-Metal-Bar Methods with Rotation and Equilibrium Displacements in Nuss Procedure Simulations

Surgical treatment of the pectus excavatum has led to the introduction of the Nuss procedure, a minimally invasive surgical procedure that involves inserting a metal bar under the sternum through a small lateral thoracic incision. An additional metal bar was inserted in patients with pectus excavatum to improve the retention of the restored chest wall after the Nuss procedure. However, a need still exists to analyze the mechanistic advantages and disadvantages of the double-bar method owing to the increased surgical time and proficiency. The purpose of this study is to compare and evaluate the efficiency of single- and double-bar methods using rotational and equilibrium displacement simulations of the Nuss procedure. A finite-element model was constructed for two types of metal bars inserted into the chest wall. Boundary conditions for the rotation and equilibrium displacements were set for the metal bar. The anterior sternal translation, Haller index and maximum equivalent stress and strain owing to the behavior of the metal bar were estimated and compared with the single-bar method and postoperatively acquired patient data. The simulation results showed that the influences of the intercostal muscle and equilibrium after rotation displacement were significant. The stresses and strains were distributed across the two metal bars, and the upper-metal bar was heavily loaded. The double-bar method was advantageous regarding the load distribution effects of the two metal bars on the chest wall. However, mechanical assessments are also important because an excessive load is typically applied to the upper-metal bar.

Is pregnancy safe with an implanted pectus bar? An uneventful pregnancy with implanted pectus bar following correction of pectus excavatum

Limited data are available on the implications on pregnancy following pectus bar implantation for correction of pectus excavatum (Nuss procedure), while the pectus bars are in place. Limited data is also available on long-term reproductive implications following pectus bar removal.Providers at times need to consider the necessity to counsel a woman desiring pectus excavatum correction and pregnancy whether to postpone one of the two in favour of the other.We present the case of a woman of reproductive age with an uneventful pregnancy and delivery while carrying an implanted pectus bar and subsequent uneventful pregnancy and delivery after bar removal.

Chest Wall Motion Model of Cardiac Activity for Radar-Based Vital-Sign-Detection System

An increasing number of studies on non-contact vital sign detection using radar are now beginning to turn to data-driven neural network approaches rather than traditional signal-processing methods. However, there are few radar datasets available for deep learning due to the difficulty of acquiring and labeling the data, which require specialized equipment and physician collaboration. This paper presents a new model of heartbeat-induced chest wall motion (CWM) with the goal of generating a large amount of simulation data to support deep learning methods. An in-depth analysis of published CWM data collected by the VICON Infrared (IR) motion capture system and continuous wave (CW) radar system during respiratory hold was used to summarize the motion characteristics of each stage within a cardiac cycle. In combination with the physiological properties of the heartbeat, appropriate mathematical functions were selected to describe these movement properties. The model produced simulation data that closely matched the measured data as evaluated by dynamic time warping (DTW) and the root-mean-squared error (RMSE). By adjusting the model parameters, the heartbeat signals of different individuals were simulated. This will accelerate the application of data-driven deep learning methods in radar-based non-contact vital sign detection research and further advance the field.

[Analysis of Influencing Factors of Complications for CT-guided Percutaneous Lung Biopsy]

BACKGROUND

Computed tomography guided percutaneous lung biopsy (CT-PLB) is a widely used method for the diagnosis of lung lesions. However, it is invasive, and the most common complications are pneumothorax and pulmonary hemorrhage, which can be life-threatening in severe cases. Therefore, the aim of this study is to analyze the independent risk factors affecting the occurrence of different complications of CT-PLB, so as to reduce the incidence of complications.

METHODS

The 605 patients with complete clinical data who underwent CT-PLB in our hospital from May 2018 to December 2019 were retrospectively analyzed. According to the location of the lesions, they were divided into subpleural group and non-subpleural group. The patients were divided into pneumothorax group, pulmonary hemorrhage group, pneumothorax with pulmonary hemorrhage group and non-pneumothorax/pulmonary hemorrhage group according to the complications. The risk factors affecting the incidence of different complications and the independent risk factors of each complication were analyzed.

RESULTS

The incidence of pneumothorax was 34.1%, the incidence of pulmonary hemorrhage was 28.1%, and the incidence of pneumothorax complicated with pulmonary hemorrhage was 10.8% (63 cases). The independent risk factor affecting the incidence of subpleural pneumothorax was lesion size (P=0.002). The independent risk factors affecting the occurrence of pneumothorax in the non-subpleural group were plain scan CT value (P=0.035), length of needle through lung tissue (P=0.003), and thickness of needle through chest wall (P=0.020). Independent risk factors affecting the occurrence of pulmonary hemorrhage in the non-subpleural group were length of needle through lung tissue (P<0.001), △CT value of needle travel area (P=0.001), lesion size (P=0.034) and body position (P=0.014). The independent risk factors affecting the co-occurrence of pneumothorax and pulmonary hemorrhage were the length of needle through lung tissue (P<0.001) and the △CT value of needle travel area (P<0.001).

CONCLUSIONS

CT-PLB is a safe and effective diagnostic method, which of high diagnostic value for lung lesions. Selecting the appropriate puncture program can reduce complications such as pneumothorax and pulmonary hemorrhage, and improve diagnosis and treatment efficiency.

Vacuum bell therapy for pectus excavatum: a retrospective study

BACKGROUND

Pectus excavatum, the most common chest wall deformity, is frequently treated with Nuss procedure. Here we will describe non-invasive procedure and analyze the variables associated vacuum bell therapy for patients with pectus excavatum.

METHODS

Retrospective case-control study in a single center between July 2018 and February 2022, including patients with pectus excavatum treated with vacuum bell. Follow-up was continued to September 2022. The Haller index and Correction index was calculated before and after treatment to analysis the effectiveness of vacuum bell therapy.

RESULTS

There were 98 patients enrolled in the treatment group, with 72 available for analysis, and the follow-up period ranged from 1.1 to 4.4 years (mean 3.3 years). When analyzing with the Haller Index, 18 patients (25.0%) showed excellent correction, 13 patients (18.1%) achieved good correction, and 4 patients (5.6%) had fair correction. The remaining patients had a poor outcome. Characteristics predicting a non-poor prognosis included initial age ≤ 11 years (OR = 3.94, p = 0.013) and patients with use over 24 consecutive months (OR = 3.95, p = 0.013). A total of 9 patients (12.5%) achieved a CI reduction below 10. Patients who started vacuum bell therapy at age > 11 had significantly less change compared to those who started at age ≤ 11 (P < 0.05). Complications included chest pain (5.6%), swollen skin (6.9%), chest tightness (1.4%) and erythema (15.3%).

CONCLUSIONS

A certain percentage of patients with pectus excavatum can achieve excellent correction when treated with pectus excavatum therapy. Variables predicting better outcome including initial age ≤ 11 years both in HI and CI and vacuum bell use over 24 consecutive months in HI. In summary, pectus excavatum is an emerging non-invasive therapy for pectus excavatum and will be widely performed in a certain group of patients.

Changes in Respiratory Mechanics With Trunk Inclination Differs Between Patients With ARDS With and Without Obesity

BACKGROUND

Studies investigating the effect of trunk inclination on respiratory mechanics in mechanically ventilated patients with ARDS have reported postural differences in partition respiratory mechanics. Compared with more upright positions, the supine-flat position provided lower lung and chest wall elastance, allowing reduced driving pressures and end-inspiratory transpulmonary pressure. However, the effect of trunk inclination on respiratory mechanics in patients with obesity and ARDS is uncertain.

RESEARCH QUESTION

Does the effect of change in posture on partition respiratory mechanics differ between patients with ARDS with and without obesity?

STUDY DESIGN AND METHODS

In this single-center study, patients with ARDS with and without obesity were randomized into two 15-minute steps in which trunk inclination was changed from semi-recumbent (40° head up) to supine-flat (0°), or vice versa. At the end of each step partition respiratory mechanics, airway opening pressure and arterial blood gases were measured. Paired t test was used to examine respiratory mechanics and blood gas variables in each group.

RESULTS

Forty consecutive patients were enrolled. Twenty were obese (BMI, 38.4 [34.5-42.3]), and 20 were non-obese (BMI, 26.6 [25.2-28.5]). In the patients with obesity, lung and chest wall elastance, driving pressure, inspiratory transpulmonary pressure, Paco2, and ventilatory ratio were lower supine than semi-recumbent (P < .001). Airways resistance was greater supine (P = .006). In the patients without obesity, only chest wall elastance was lower in supine vs semi-recumbent (P < .001).

INTERPRETATION

In mechanically ventilated patients with ARDS and obesity, supine posture provided lower lung and chest wall elastance, and better CO2 clearance, than the semi-recumbent posture.

CLINICAL TRIAL REGISTRATION

This study was registered with Australian New Zealand Clinical Trials Registry (ACTRN12623000794606).

Acupuncture-Induced Hemothorax with Hypovolemic Shock: A Case Report

This report describes a very rare but life-threatening complication that occurred in a 43-year-old woman after an acupuncture (AC) for lumbago. The patient presented to the emergency department displaying symptoms indicative of shock. Physical examination revealed the absence of breath sounds on the right thoracic side, further investigations indicated the presence of a hemothorax. Emergency surgery was performed to evacuate the hemothorax and control bleeding from two intercostal veins. Although AC is often considered a gentle form of medicine, it is important to recognize that it can occasionally result in severe complications, especially when acupoints are used on the thorax.

Fractures and other chest wall abnormalities after thoracotomy for esophageal cancer: A retrospective cohort study

BACKGROUND

Chest pain following a thoracotomy for esophageal cancer is frequently reported but poorly understood. This study aimed to (1) determine the prevalence of thoracotomy-related thoracic fractures on postoperative imaging and (2) compare complications, long-term pain, and quality of life in patients with versus without these fractures.

METHODS

This retrospective cohort study enrolled patients with esophageal cancer who underwent a thoracotomy between 2010 and 2020 with pre- and postoperative CTs (<1 and/or >6 months). Disease-free patients were invited for questionnaires on pain and quality of life.

RESULTS

Of a total of 366 patients, thoracotomy-related rib fractures were seen in 144 (39%) and thoracic transverse process fractures in 4 (2%) patients. Patients with thoracic fractures more often developed complications (89% vs. 74%, p = 0.002), especially pneumonia (51% vs. 39%, p = 0.032). Questionnaires were completed by 77 after a median of 41 (P25 -P75 28-91) months. Long-term pain was frequently (63%) reported but was not associated with thoracic fractures (p = 0.637), and neither were quality of life scores.

CONCLUSIONS

Thoracic fractures are prevalent in patients following a thoracotomy for esophageal cancer. These thoracic fractures were associated with an increased risk of postoperative complications, especially pneumonia, but an association with long-term pain or reduced quality of life was not confirmed.

Long-Term Sensory Function 3 years after Minimally Invasive Repair of Pectus Excavatum with Cryoablation

INTRODUCTION

Minimally invasive repair of pectus excavatum (MIRPE) with intercostal nerve cryoablation (Cryo) decreases length of hospitalization and opioid use, but long-term recovery of sensation has been poorly described. The purpose of this study was to quantify long-term hypoesthesia and neuropathic pain after MIRPE with Cryo.

METHODS

A prospective cohort study was conducted single-institution of patients ≤21 years who presented for bar removal. Consented patients underwent chest wall sensory testing and completed neuropathic pain screening. Chest wall hypoesthesia to cold, soft touch, and pinprick were measured as the percent of the treated anterior chest wall surface area (TACWSA); neuropathic pain was evaluated by questionnaire.

RESULTS

The study enrolled 47 patients; 87% male; median age 18.4 years. The median bar dwell time was 2.9 years. A median of 2 bars were placed; 80.9% were secured with pericostal sutures. At enrollment, 46.8% of patients had identifiable chest wall hypoesthesia. The mean percentage of TACWSA with hypoesthesia was 4.7 ± 9.3% (cold), 3.9 ± 7.7% (soft touch), and 5.9 ± 11.8% (pinprick). Hypoesthesia to cold was found in 0 dermatomes in 62%, 1 dermatome in 11%, 2 dermatomes in 17% and ≥3 dermatomes in 11%. T5 was the most common dermatome with hypoesthesia. Neuropathic symptoms were identified by 13% of patients; none required treatment.

CONCLUSION

In long-term follow up after MIRPE with Cryo, 46.8% of patients experienced some chest wall hypoesthesia; the average TACWSA with hypoesthesia was 4-6%. Hypoesthesia was mostly limited to 1-2 dermatomes, most commonly T5. Chronic symptomatic neuropathic pain was rare.

LEVEL OF EVIDENCE

Level IV.

MRI in suspected chest wall fractures: diagnostic value in work-related chest blunt trauma

OBJECTIVE

To describe and analyze MRI findings in suspected early fractures of the chest (ribs and sternum) and assess if this technique can add value in occupational medicine.

MATERIALS AND METHODS

In this retrospective study, we reviewed 112 consecutive patients with work-related mild closed chest trauma who underwent early thoracic MRI, when there was not a clear fracture on radiograph or when the symptoms were intense and not explained by radiographic findings. MRI was evaluated by two experienced radiologists independently. The number and location of fractures and extraosseous findings were recorded. A multivariate analysis was performed to correlate the fracture characteristics and time to RTW (return-to-work). Interobserver agreement and image quality were assessed.

RESULTS

100 patients (82 men, mean age 46 years, range 22-64 years) were included. MRI revealed thoracic wall injuries in 88%: rib and/or sternal fractures in 86% and muscle contusion in the remaining patients. Most patients had multiple ribs fractured, mostly at the chondrocostal junction (n=38). The interobserver agreement was excellent, with minor discrepancies in the total number of ribs fractured. The mean time to return-to-work was 41 days, with statistically significant correlation with the number of fractures. Time to return-to-work increased in displaced fractures, sternal fractures, extraosseous complications, and with age.

CONCLUSION

Early MRI after work-related chest trauma identifies the source of pain in most patients, mainly radiographically occult rib fractures. In some cases, MRI may also provide prognostic information about return-to-work.

Verification of surface-guided radiation therapy (SGRT) alignment for proton breast and chest wall patients by comparison to CT-on-rails and kV-2D alignment

BACKGROUND

Surface-guided radiation therapy (SGRT) systems have been widely installed and utilized on linear accelerators. However, the use of SGRT with proton therapy is still a newly developing field, and published reports are currently very limited.

PURPOSE

To assess the clinical application and alignment agreement of SGRT with CT-on-rails (CTOR) and kV-2D image-guided radiation therapy (IGRT) for breast treatment using proton therapy.

METHODS

Four patients receiving breast or chest wall treatment with proton therapy were the subjects of this study. Patient #1's IGRT modalities were a combination of kV-2D and CTOR. CTOR was the only imaging modality for patients #2 and #3, and kV-2D was the only imaging modality for patient #4. The patients' respiratory motions were assessed using a 2-min surface position recorded by the SGRT system during treatment. SGRT offsets reported after IGRT shifts were recorded for each fraction of treatment. The agreement between SGRT and either kV-2D or CTOR was evaluated.

RESULTS

The respiratory motion amplitude was <4 mm in translation and <2.0° in rotation for all patients. The mean and maximum amplitude of SGRT offsets after application of IGRT shifts were ≤(2.6 mm, 1.6° ) and (6.8 mm, 4.5° ) relative to kV-2D-based IGRT; ≤(3.0 mm, 2.6° ) and (5.0 mm, 4.7° ) relative to CTOR-based IGRT without breast tissue inflammation. For patient #3, breast inflammation was observed for the last three fractions of treatment, and the maximum SGRT offsets post CTOR shifts were up to (14.0 mm, 5.2° ).

CONCLUSIONS

Due to the overall agreement between SGRT and IGRT within reasonable tolerance, SGRT has the potential to serve as a valuable auxiliary IGRT tool for proton breast treatment and may improve the efficiency of proton breast treatment.

Non-surgical approaches to the management of chest wall deformities

Chest wall deformities in children encompass a broad spectrum of disorders but pectus excavatum and carinatum are by far the most common. Treatment varies substantially by center, and depends on patient symptoms, severity of disease, and surgeon preference. Historically, surgical approaches were the mainstay of treatment for these disease processes but new advances in non-surgical approaches have demonstrated reasonable results in select patients. These non-surgical approaches include vacuum bell therapy, autologous fat grafting and hyaluronic acid injections for pectus excavatum, and orthotic brace therapy for pectus carinatum. There is debate with regards to optimal patient selection for these non-surgical approaches, as well as other barriers including reimbursement issues. This paper will review the current non-surgical approaches to chest wall deformities available, including optimal patient selection, treatment protocols, indications, contraindications, and outcomes.

Salvage treatment of acute respiratory failure after autogenous tissue flap transplantation for chronic empyema with chest wall sinus: a case report and literature review

BACKGROUND

Chronic empyema with chest wall sinus is a difficult and complex disease caused by multiple causative factors. It is difficult to control local infection due to its possible combination of bronchopleural fistula (BPF) and residual bone.The relevant literature emphasizes some risk factors for empyema progression after pneumonectomy, while the correlation between empyema and BPF after pneumonectomy increases mortality by infecting the remaining lungs. After pneumonectomy, the lung function of the contralateral side is particularly important.

CASE PRESENTATION

This paper reports a 62-year-old male patient who underwent right pneumonectomy for squamous cell carcinoma of the lung 12 years ago and began to develop empyema with anterior chest wall sinus 3 years ago. After admission, chest computed tomography (CT) showed right pleural effusion and formation of chest wall sinus. According to his clinical symptoms and imaging examination, he was diagnosed as chronic empyema with chest wall sinus.Due to the huge residual cavity of the patient,the clinical effect of using free vastus lateralis myocutaneous flap combined with pedicled pectoralis major muscle flap to fill the abscess cavity was satisfactory,but acute respiratory failure occurred due to left lung aspiration pneumonia after operation.

CONCLUSIONS

After a series of treatment measures such as tracheal cannula, tracheotomy, anti-infection, maintenance of circulatory stability, and rehabilitation training, the patient was ultimately rescued and cured. Postoperative follow-up showed that the muscle flaps survived and empyema was eliminated.

The boundary of posterior to level V region and the theoretical feasibility of irradiation dose reduction of level Va in nasopharyngeal carcinoma

The lymph node involvement in the posterior to level V (PLV) region is mainly observed in nasopharyngeal carcinoma (NPC). Recently, we have reported the distribution of metastatic lymph nodes in the PLV region and there are correlations between the neck node levels (NNL) of NPC, but what is the boundary of the PLV region and how to delineate it remains unclear, and we further to elaborate whether the bilateral level Va should be covered as intermediate-risk nodal regions (CTVn2, about 60 Gy equivalent) for all T and N categories based on these correlations. A total of 1021 consecutive NPC patients with N1-3 stage from January 2012 to December 2020 were reviewed. The lymph node metastasis level of each patient was evaluated according to the updated guidelines proposed in 2013. According to the distribution pattern of lymph node metastasis and the anatomical structure in the PLV region, the boundaries of PLV region was delineated, and whether it is appropriate to cover the bilateral level Va as CTVn2 for all the NPC patients was further discussed. The correlations of level Va with other NNL were studied using logistic regression model. The cranial boundary of PLV region is the caudal border of cricoid cartilage, the caudal boundary is the plane serratus anterior muscle begins to appear, the anterior boundary is the anterior border of trapezius, and the posterior boundary is the convergence of levator scapulae and trapezius. Laterally, the PLV region is limited by the medial edge of trapezius and medially by the lateral surface of levator scapulae. The nodal spread in level Va is based on the lymph node metastasis of level IIb in NPC. The PLV region is a missing NNL of head and neck tumors, especially in NPC. The proposed boundaries of the PLV region can provide a preliminary proposal for the further revision of NNL in head and neck tumors. It is theoretically feasible to reduce the prophylactic irradiation dose of the bilateral level Va in patients with N0 stage or with isolated metastases in level VIIa.

Scapular dislocation following radical surgical excision of lung sarcomatoid carcinoma: A rare case report

RATIONALE

Scapular prolapse is a rare complication of thoracotomy. Only a few cases of scapular prolapse after thoracotomy have been reported. Here, we report the case of a 52-year-old male patient who underwent standard posterior thoracotomy for lung sarcomatoid carcinoma invading the left upper chest wall.

PATIENT CONCERNS

The surgery was performed to remove some ribs and chest wall muscles; however, no reconstruction or repair of the chest wall defect was performed. The patient experienced a sharp pain and severe limitation of movement of the left shoulder within 1 month of receiving adjuvant therapy.

DIAGNOSES

The patient was diagnosed with left intrathoracic scapular prolapse after careful consideration of medical history, physical examination, and chest radiography.

INTERVENTIONS

We performed closed manual reduction because the patient refused to undergo surgery.

OUTCOMES

The patient's shoulder pain and movement limitation were significantly relieved, but the symptoms relapsed. After repeated closed manual reduction, the patient was instructed not to abduct the shoulder joint above 90°. The patient did not relapse during a 1-year observation period.

CONCLUSION

If scapular prolapse occurs, manual or surgical reduction can be selected based on the needs. If a patient refuses to undergo surgery, manual reduction can be an effective treatment method.

The frequency and presentation of upper thoracic spinous process deviations, their relationship to articular morphology, and the potential influence on static palpation techniques

BACKGROUND

Static palpation of vertebral spinous process deviations from the midline are often utilized by manual therapists as a means to determine area for treatment of manipulable lesions. Previous research has discussed the diagnostic validity of this technique, but no correlation to vertebral morphology has been presented.

AIM

To evaluate the frequency and presentation of vertebral spinous process deviations and their relationship with articular morphology, and the impact this may have in terms of static palpation techniques in the upper thoracic spine.

SETTING

This study was conducted on human T1-T6 vertebrae.

METHOD

A skeletal sample consisting of 58 humans T1-T6 vertebrae were photographed and linear and angular measurements taken utilizing ImageJ software and non-metric visual observations.

RESULTS

Spinous process deviations in the entire sample group (n = 348) were found to occur in a frequency ranging from 19% (n = 11) at T1 to 41.4% (n = 24) at T3. However, when evaluated in terms of frequency within an individual's T1-T6, 83.3% (n = 25) of males and 67.86% (n = 19) of females demonstrated this feature, with an overall incidence of 77.59% (n = 45). Age of individuals did not show an increase in frequency, and no clear pattern could be identified regarding metric measurements and its presence.

CONCLUSION

Spinous process deviations in the upper thoracic spine are most probably the result of random normal variations between individuals and are more frequent in males. Static palpation without pain criteria is not a reliable diagnostic technique to determine areas needing manual treatment, as these may be considered normal osseous anatomical variations.

The Frontal Phocomelia in a 3-Year-Old Girl

Background: Phocomelia is a congenital limb deformity in which the proximal part of the upper or lower limb does not develop. Occasionally the malformed limb may be located ectopically. Case report: We present a frontal phocomelia in a three-year-old girl with right-hand phocomelia and thoracoschisis. The patient's arm was connected directly from the front of the chest, with a rudimentary thumb and two fingers. The truncated arm was not functional. The acromioclavicular joint was abnormal and ectopic, the limb articulated with the medial side of sternum. The thoracoschisis manifested as eventration of the right liver lobe and right side of chest wall. Conclusion: Ectopic phocomelia can be associated with thoracoschisis, it can be nonfunctional, and can articulate with the sternum.

A robust treatment planning approach for chest motion in postmastectomy chest wall intensity modulated radiation therapy

PURPOSE

Chest wall postmastectomy radiation therapy (PMRT) should consider the effects of chest wall respiratory motion. The purpose of this study is to evaluate the effectiveness of robustness planning intensity modulated radiation therapy (IMRT) for respiratory movement, considering respiratory motion as a setup error.

MATERIAL AND METHODS

This study analyzed 20 patients who underwent PMRT (10 left and 10 right chest walls). The following three treatment plans were created for each case and compared. The treatment plans are a planning target volume (PTV) plan (PP) that covers the PTV within the body contour with the prescribed dose, a virtual bolus plan (VP) that sets a virtual bolus in contact with the body surface and prescribing the dose that includes the PTV outside the body contour, and a robust plan (RP) that considers respiratory movement as a setup uncertainty and performs robust optimization. The isocenter was shifted to reproduce the chest wall motion pattern and the doses were recalculated for comparison for each treatment plan.

RESULT

No significant difference was found between the PP and the RP in terms of the tumor dose in the treatment plan. In contrast, VP had 3.5% higher PTV Dmax and 5.5% lower PTV V95% than RP (p < 0.001). The RP demonstrated significantly higher lung V20Gy and Dmean by 1.4% and 0.4 Gy, respectively, than the PP. The RP showed smaller changes in dose distribution affected by chest wall motion and significantly higher tumor dose coverage than the PP and VP.

CONCLUSION

We revealed that the RP demonstrated comparable tumor doses to the PP in treatment planning and was robust for respiratory motion compared to both the PP and the VP. However, the organ at risk dose in the RP was slightly higher; therefore, its clinical use should be carefully considered.

A medication reconciliation failure: A case report and incident analysis

BACKGROUND

Medication reconciliation is advocated to ensure the continuity, safety, and effective use of medicines across transitions of care.

CASE REPORT

In this report, we describe the case of a 90-year-old female with previous diagnoses of atrial fibrillation and cutaneous metastatic breast cancer presenting with bilateral ulcerative lesions on the chest wall. The patient was diagnosed with Deep Vein Thrombosis at the Emergency Department and started on rivaroxaban, although the patient was already taking edoxaban. This therapeutic duplication was noticed only one week later, even though she was already experiencing significant bleeding managed through a prescribing cascade. Despite the technical error (action-based), it is possible to identify several weaknesses in the organisation's structure, which provided a trajectory of accident opportunity.

CONCLUSION

Anticoagulants are ranked first for the highest priority to receive a medication reconciliation. To achieve an optimal level of medication reconciliation, we ought to recognise and correct latent failures.

Breast Pain Differential: Mondor's Disease of the Breast

Breast pain is a common concern among women in primary care clinics. A rare cause of breast pain is Mondor's disease (MD), which can present as an acute, painful, erythematous, cord-like induration on the breast or anterior chest wall. The disorder is caused by sclerosing superficial thrombophlebitis of the anterolateral thoracoabdominal wall veins. There does not appear to be a racial or ethnic propensity for this condition; however, it is important to understand that it may be more difficult to see in darker skin types (Fitzpatrick skin types IV-VI) and requires close attention on physical exam. The cause of MD is poorly understood but may be related to direct trauma, strenuous exercise, or hormone changes. We review a case of a 54-year-old woman who presented with an anterior chest wall palpable cord, better visualized with adequate lighting and skin traction, ultimately diagnosed as MD based on clinical findings and imaging studies. Mondor's disease often resolves spontaneously with supportive care, as in this patient's case; however, clinicians should be aware of this rare cause of breast pain and its association with hypercoagulable state, vasculitis, and breast cancer.

Non-Invasive Assessment of Abdominal/Diaphragmatic and Thoracic/Intercostal Spontaneous Breathing Contributions

(1) Background: Technically, a simple, inexpensive, and non-invasive method of ascertaining volume changes in thoracic and abdominal cavities are required to expedite the development and validation of pulmonary mechanics models. Clinically, this measure enables the real-time monitoring of muscular recruitment patterns and breathing effort. Thus, it has the potential, for example, to help differentiate between respiratory disease and dysfunctional breathing, which otherwise can present with similar symptoms such as breath rate. Current automatic methods of measuring chest expansion are invasive, intrusive, and/or difficult to conduct in conjunction with pulmonary function testing (spontaneous breathing pressure and flow measurements). (2) Methods: A tape measure and rotary encoder band system developed by the authors was used to directly measure changes in thoracic and abdominal circumferences without the calibration required for analogous strain-gauge-based or image processing solutions. (3) Results: Using scaling factors from the literature allowed for the conversion of thoracic and abdominal motion to lung volume, combining motion measurements correlated to flow-based measured tidal volume (normalised by subject weight) with R2 = 0.79 in data from 29 healthy adult subjects during panting, normal, and deep breathing at 0 cmH2O (ZEEP), 4 cmH2O, and 8 cmH2O PEEP (positive end-expiratory pressure). However, the correlation for individual subjects is substantially higher, indicating size and other physiological differences should be accounted for in scaling. The pattern of abdominal and chest expansion was captured, allowing for the analysis of muscular recruitment patterns over different breathing modes and the differentiation of active and passive modes. (4) Conclusions: The method and measuring device(s) enable the validation of patient-specific lung mechanics models and accurately elucidate diaphragmatic-driven volume changes due to intercostal/chest-wall muscular recruitment and elastic recoil.

Better late than never-a single-center review of delayed rib fixation for symptomatic rib fractures and nonunions

BACKGROUND

Surgical stabilization of rib fractures (SSRFs) has become an emerging therapy for treatment of patients with rib fractures. More commonly, it is used in the acute setting; however, delayed SSRF can be utilized for symptomatic rib fracture nonunions. Here, we describe our institution's experience with delayed SSRF, hypothesizing it is safe and resolves patient symptoms.

METHODS

This is a retrospective review of patients presenting to our Level I trauma center to undergo delayed SSRF for symptomatic nonunions from January 2017 to September 2022. Delayed SSRF was defined as SSRF over 2 weeks in the outpatient setting. Basic demographics were obtained. Outcomes of interest included mean pain score (preoperatively and postoperatively), intensive care unit (ICU) and hospital length of stay (LOS), and resolution of preoperative symptoms, specifically chest wall instability, with return to activities of daily living (ADLs).

RESULTS

Forty-four patients met inclusion criteria with a total of 156 symptomatic nonunion rib fractures that received delayed SSRF. The average age was 59.2 ± 11.9 years and median number of days from injury to SSRF was 172.5 (interquartile range, 27.5-200). The average number rib fractures plated per patient 3.5 ± 1.8. Only three patients required ICU admission postoperatively for no longer than 2 days. Median hospital LOS was 2 days (interquartile range 1-3 days). Average preoperative and postoperative pain score was 6.8 ± 1.9 and 2.02 ± 1.5, respectively ( p < 0.001). Chest wall instability and preoperative symptoms resolved in 93.2% of patients postoperatively ( p < 0.001). Two patients (4.5%) had postoperative complications that resolved after additional surgical intervention. Rib fracture healing was demonstrated on radiographic imaging during postoperative follow-up.

CONCLUSION

Delayed SSRF is safe and demonstrates significant resolution of preoperative symptoms by decreasing pain, improving chest wall stability, and allowing patients to return to activities of daily living.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Injury pattern and clinical outcome in patients with and without chest wall injury after cardiopulmonary resuscitation

BACKGROUND

Cardiopulmonary resuscitation (CPR), although lifesaving may cause chest wall injury (CWI) because of the physical force exerted on the thorax. The impact of CWI on clinical outcome in this patient group is unclear. The primary aim of this study was to investigate the incidence of CPR-related CWI and the secondary aim to study injury pattern, length of stay (LOS), and mortality in patients with and without CWI.

METHODS

This is a retrospective study of adult patients who were admitted to our hospital due to cardiac arrest (CA) during 2012 to 2020. Patients were identified in the Swedish CPR Registry and those undergoing CT of the thorax within 2 weeks after CPR were included. Patients with traumatic CA, chest wall surgery prior or after CA were excluded. Demographic data, type and length of CPR, type of CWI, LOS on mechanical ventilator (MV), in intensive care unit (ICU) and in hospital (H), and mortality were studied.

RESULTS

Of 1,715 CA patients, 245 met the criteria for inclusion. The majority (79%) of the patients suffered from CWI. Chondral injuries and rib fractures were more common than sternum fractures (95% vs. 57%), and 14% had a radiological flail segment. Patients with CWI were older (66.5 ± 15.4 vs. 52.5 ± 15.2, p < 0.001). No difference was seen in MV-LOS (3 [0-43] vs. 3 [0-22]; p = 0.430), ICU-LOS (3 [0-48] vs. 3 [0-24]; p = 0.427), and H-LOS (5.5 [0-85] vs. 9.0 [1-53]; p = 0.306) in patients with or without CWI. Overall mortality within 30 days was higher with CWI (68% vs. 47%, p = 0.007).

CONCLUSION

Chest wall injuries are common after CPR and 14% of patients had a flail segment on CT. Elderly patients have an increased risk of CWI, and a higher overall mortality is seen in patients with CWI.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Surgical management of traumatic sternal body nonunions: Technical tricks and clinical experience

BACKGROUND

Rarely, traumatic sternum fractures may result in nonunion, which can have drastic, negative implications. Literature on traumatic sternal nonunion reconstruction outcomes is limited to case reports. We present the surgical principles and report clinical outcomes for seven patients following surgical reconstruction of a traumatic sternal body nonunion.

METHODS

Consecutive adult patients with a nonunion after a traumatic sternum fracture who underwent reconstruction using locking plate technology and iliac crest bone graft at a Level I trauma center from 2013 to 2021 were identified. Demographic, injury, and surgery data was collected, and postoperative patient-reported outcome (PRO) scores were obtained. Patient-reported outcome scores included the one-question single assessment numeric evaluation (SANE), and the combined 10-question global physical health and global mental health values. Injuries were classified and all fractures were mapped onto a sternum template. Postoperative radiographs were reviewed for union.

RESULTS

Of the study's seven patients, five were female, and the mean age was 58 years. Mechanism of injury included motor vehicle collision (5) and blunt object chest trauma (2). The mean time from initial fracture to nonunion fixation was 9 months. Four of the seven patients achieved in-clinic follow-up at ≥12 months (mean = 14.3 months), while the other three achieved ≥6 months of in-clinic follow-up. Six patients completed outcomes surveys ≥12 months after surgery (mean = 28.9 months). Mean PRO scores at final follow-up included: SANE of 75 (out of 100), and global physical health and global mental health of 44 and 47, respectively (US population mean = 50).Six of seven patients achieved known radiographic union.

CONCLUSION

We describe an effective and practical method of achieving stable fixation in traumatic sternal body nonunions as evidenced by the positive clinical outcomes of a seven-patient series. Despite the variation in presentation and fracture morphology of this rare injury, the surgical technique and principles outlined can serve as a useful tool for chest wall surgeons.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Health care utilization outcomes in patients with blunt chest wall trauma following discharge from the emergency department: A retrospective, observational data-linkage study

BACKGROUND

Although much is published reporting clinical outcomes in the patients with blunt chest wall trauma who are admitted to hospital from the ED, less is known about the patients' recovery when they are discharged directly without admission. The aim of this study was to investigate the health care utilization outcomes in adult patients with blunt chest wall trauma, discharged directly from ED in a trauma unit in the United Kingdom.

METHODS

This was a longitudinal, retrospective, single-center, observational study incorporating analysis of linked datasets, using the Secure Anonymised Information Linkage databank for admissions to a trauma unit in the Wales, between January 1, 2016, and December 31, 2020. All patients 16 years or older with a primary diagnosis of blunt chest wall trauma discharged directly home were included. Data were analyzed using a negative binomial regression model.

RESULTS

There were 3,205 presentations to the ED included. Mean age was 53 years, 57% were male, with the predominant injury mechanism being a low velocity fall (50%). 93% of the cohort sustained between 0 and 3 rib fractures. Four percent of the cohort were reported to have chronic obstructive pulmonary disease, and 4% using preinjury anticoagulants. On regression analysis, inpatient admissions, outpatient appointments and primary care contacts all significantly increased in the 12-week period postinjury, compared with the 12-week period preinjury (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.33-1.99; p < 0.001; OR, 1.28; 95% CI, 1.14-1.43; p < 0.001; OR, 1.02; 95% CI, 1.01-1.02; p < 0.001, respectively). Risk of health care resource utilization increased significantly with each additional year of age, chronic obstructive pulmonary disease and preinjury anticoagulant use (all p < 0.05). Social deprivation and number of rib fracture did not impact outcomes.

CONCLUSION

The results of this study demonstrate the need for appropriate signposting and follow-up for patients with blunt chest wall trauma presenting to the ED, not requiring admission to the hospital.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Effect of chest wall mobilization on respiratory muscle function in patients with severe chronic obstructive pulmonary disease (COPD): A randomized controlled trial

BACKGROUND

Clinical trials have demonstrated positive correlation between pulmonary function and chest wall expansion in COPD. Decrease in chest wall expansion in patients with COPD compromises rib cage mobility and functional length of respiratory muscles that ultimately jeopardize the efficacy and function of respiratory system.

METHOD

Thirty male adults (mean age: 74.97 ± 6.29) suffered with severe COPD were randomly allocated to either experimental group (chest wall mobilizations) or control group. Both groups received standardized education and walking exercise (twice/week) for 6 weeks. Patients in experimental group received additional chest wall mobilizations that include stretching and joints mobilization. Pulmonary function, respiratory muscle strength, thoracic excursion, cervical and thoracic range of movement were evaluated at baseline, post-program and at 3-month follow-up.

RESULTS

There were significantly greater improvements in respiratory muscle strength, thoracic excursion and thoracic range of movement (p < 0.01) except thoracic flexion. Lower thoracic excursion is strongly associated with increase in maximum inspiratory pressure (β = 13.64, p < 0.001) and maximum expiratory pressure (β = 16.23, p < 0.001). Thoracic range of movement especially extension (p < 0.001) and bilateral rotation (p < 0.01) exhibit a strong relationship with increase in lower thoracic excursion (adjusted R2 = 0.876) as shown in multiple regression analysis.

CONCLUSION

Additional chest wall mobilization in the rehabilitation of patients with COPD is likely to enhance thoracic extension and rotation which increase lower thoracic excursion. This significant improvement in chest expansion capacity allows respiratory muscles to work at an optimal functional length which result in greater respiratory muscle strength in patients with severe COPD.

Chest Wall Injury Society recommendation for surgical stabilization of nonunited rib fractures to decrease pain, reduce opiate use, and improve patient reported outcomes in patients with rib fracture nonunion after trauma

BACKGROUND

Rib fractures are common injuries which can be associated with acute pain and chronic disability. While most rib fractures ultimately go on to achieve bony union, a subset of patients may go on to develop non-union. Management of these nonunited rib fractures can be challenging and variability in management exists.

METHODS

The Chest Wall Injury Society's Publication Committee convened to develop recommendations for use of surgical stabilization of nonunited rib fractures (SSNURF) to treat traumatic rib fracture nonunions. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject the recommendation.

RESULTS

No identified studies compared SSNURF to alternative therapy and the overall quality of the body of evidence was rated as low. Risk of bias was identified in all studies. Despite these limitations, there is lower-quality evidence suggesting that SSNURF may be beneficial for decreasing pain, reducing opiate use, and improving patient reported outcomes among patients with symptomatic rib nonunion. However, these benefits should be balanced against risk of symptomatic hardware failure and infection.

CONCLUSION

This guideline document summarizes the current CWIS recommendations regarding use of SSNURF for management of rib nonunion.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Novel nomogram for predicting paradoxical chest wall movement in patients with flail segment of traumatic rib fracture: a retrospective cohort study

Flail chest is a severe injury to the chest wall and is related to adverse outcomes. A flail chest is classified as the physiologic, paradoxical motion of a chest wall or flail segment of rib fracture (RFX). We hypothesized that patients with paradoxical chest wall movement would present different clinical features from patients with a flail segment. This retrospective observational study included patients with blunt chest trauma who visited our level 1 trauma center between January 2019 and October 2022 and were diagnosed with one or more flail segments by computed tomography. The primary outcome of our study was a clinically diagnosed visible, paradoxical chest wall motion. We used the least absolute shrinkage and selection operator (LASSO) logistic regression model to minimize overfitting. After a feature selection using the LASSO regression model, we constructed a multivariable logistic regression (MLR) model and nomogram. A total of five risk factors were selected in the LASSO model and applied to the multivariable logistic regression model. Of these, four risk factors were statistically significant: the total number of RFX (adjusted OR [aOR], 1.28; 95% confidence interval [CI], 1.09-1.49; p = 0.002), number of segmental RFX including Grade III fractures (aOR, 1.78; 95% CI, 1.14-2.79; p = 0.012), laterally located primary fracture lines (aOR, 4.00; 95% CI, 1.69-9.43; p = 0.002), and anterior-lateral flail segments (aOR, 4.20; 95% CI, 1.60-10.99; p = 0.004). We constructed a nomogram to predict the personalized probability of the flail motion. A novel nomogram was developed in patients with flail segments of traumatic RFX to predict paradoxical chest wall motion. The number of RFX, Grade III segmental RFX, and the location of the RFX were significant risk factors.

Cigarette smoking and disproportionate changes of thoracic skeletal muscles in low-dose chest computed tomography

Association between smoking intensity and the quantity and quality of thoracic skeletal muscles (TSMs) remains unexplored. Skeletal muscle index (SMI; skeletal muscle area/height2) and percentage of normal attenuation muscle area (NAMA%) were measured to represent the quantity and quality of the skeletal muscles, respectively, and quantification was performed in pectoralis muscle at aortic arch (AA-PM), TSM at carina (C-TSM), erector spinae muscle at T12 (T12-ESM), and skeletal muscle at L1 (L1-SM). Among the 258 men (median age, 62 years [IQR: 58-69]), 183 were current smokers (median smoking intensity, 40 pack-years [IQR: 30-46]). SMI and NAMA% of AA-PM significantly decreased with pack-year (β =  - 0.028 and - 0.076; P < 0.001 and P = 0.021, respectively). Smoking intensity was inversely associated with NAMA% of C-TSM (β =  - 0.063; P = 0.001), whereas smoking intensity showed a borderline association with SMI of C-TSM (β =  - 0.023; P = 0.057). Smoking intensity was associated with the change in NAMA% of L1-SM (β =  - 0.040; P = 0.027), but was not associated with SMI of L1-SM (P > 0.05). Neither NAMA% nor SMI of T12-ESM was affected by smoking intensity (P > 0.05). In conclusion, smoking intensity was associated with the change of TSMs. Its association varied according to the location of TSMs, with the most associated parts being the upper (AA-PM) and middle TSMs (C-TSM).

Human Respiration Rate Measurement with High-Speed Digital Fringe Projection Technique

This paper proposes a non-contact continuous respiration monitoring method based on Fringe Projection Profilometry (FPP). This method aims to overcome the limitations of traditional intrusive techniques by providing continuous monitoring without interfering with normal breathing. The FPP sensor captures three-dimensional (3D) respiratory motion from the chest wall and abdomen, and the analysis algorithms extract respiratory parameters. The system achieved a high Signal-to-Noise Ratio (SNR) of 37 dB with an ideal sinusoidal respiration signal. Experimental results demonstrated that a mean correlation of 0.95 and a mean Root-Mean-Square Error (RMSE) of 0.11 breaths per minute (bpm) were achieved when comparing to a reference signal obtained from a spirometer.