Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society

BACKGROUND

Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia.

METHODS

Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used.

RESULTS

Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality.

CONCLUSION

We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia.

LEVEL OF EVIDENCE

Systematic Review/Meta-analysis; Level IV.

A comparison among different techniques for human ERG signals processing and classification

Feature detection in biomedical signals is crucial for deepening our knowledge about the involved physiological processes. To achieve this aim, many analytic approaches can be applied but only few are able to deal with signals whose time dependent features provide useful clinical information. Among the biomedical signals, the electroretinogram (ERG), that records the retinal response to a light flash, can improve our comprehension of the complex photoreceptoral activities. The present study is focused on the analysis of the early response of the photoreceptoral human system, known as a-wave ERG-component. This wave reflects the functional integrity of the photoreceptors, rods and cones, whose activation dynamics are not yet completely understood. Moreover, since in incipient photoreceptoral pathologies eventual anomalies in a-wave are not always detectable with a "naked eye" analysis of the traces, the possibility to discriminate pathologic from healthy traces, by means of appropriate analytical techniques, could help in clinical diagnosis. In the present paper, we discuss and compare the efficiency of various techniques of signal processing, such as Fourier analysis (FA), Principal Component Analysis (PCA), Wavelet Analysis (WA) in recognising pathological traces from the healthy ones. The investigated retinal pathologies are Achromatopsia, a cone disease and Congenital Stationary Night Blindness, affecting the photoreceptoral signal transmission. Our findings prove that both PCA and FA of conventional ERGs, don't add clinical information useful for the diagnosis of ocular pathologies, whereas the use of a more sophisticated analysis, based on the wavelet transform, provides a powerful tool for routine clinical examinations of patients.

An approach based on wavelet analysis for feature extraction in the a-wave of the electroretinogram

Most biomedical signals are non-stationary. The knowledge of their frequency content and temporal distribution is then useful in a clinical context. The wavelet analysis is appropriate to achieve this task. The present paper uses this method to reveal hidden characteristics and anomalies of the human a-wave, an important component of the electroretinogram since it is a measure of the functional integrity of the photoreceptors. We here analyse the time-frequency features of the a-wave both in normal subjects and in patients affected by Achromatopsia, a pathology disturbing the functionality of the cones. The results indicate the presence of two or three stable frequencies that, in the pathological case, shift toward lower values and change their times of occurrence. The present findings are a first step toward a deeper understanding of the features of the a-wave and possible applications to diagnostic procedures in order to recognise incipient photoreceptoral pathologies.

ERG signal analysis using wavelet transform

The wavelet analysis is a powerful tool for analyzing and detecting features of signals characterized by time-dependent statistical properties, as biomedical signals. The identification and the analysis of the components of these signals in the time-frequency domain, give meaningful information about the physiological mechanisms that govern them. This article presents the results of the wavelet analysis applied to the a-wave component of the human electroretinogram. In order to deepen and improve our knowledge about the behavior of the early photoreceptoral response, including the possible activation of interactions and correlations among the photoreceptors, we have detected and identified the stable time-frequency components of the a-wave, using six representative values of luminance. The results indicate the occurrence of three frequencies lying in the range 20-200 Hz. The lowest one is attributed to the summed activities of the photoreceptors. The others are weaker and at low luminance one of them does not occur. We relate them to the response of the rods and the cones whose aggregate activities are non-linear and typically exhibit self-organization under selective stimuli. The identification of the stable frequency components and of their times of occurrence helps us to shine light about the complex mechanisms governing the a-wave. The present results are promising toward the assessment of more refined model concerning the photoreceptoral activities.

Analysis of the human a-wave ERG component

The a-wave is one of the main issues of research in the field of ocular electrophysiology, since it is strictly connected with early photoreceptoral activities. The present study proposes mathematical methods that analyse this component in human subjects, and supports experimental evidence relating to possible correlations among the responses of photoreceptoral units under a light stimulus. The investigation is organized in two parts: the first part concerns the onset and the initial slope, up to the first minimum (about 10-15 ms), the second part deals with the main portion of the wave, up to about 30 ms. In both cases, the a-waves, recorded at various levels of luminance, have been fitted with a set of appropriate functions representing possible models of physiological behaviour which would take place in the early stages of phototransduction. The statistical nature of the underlying processes is also discussed. The results indicate that correlations occur in the early stages, whereas random processes are set up later.

An atlas of the rat subpostremal nucleus tractus solitarius

The nucleus tractus solitarius (NTS) in the dorsal medulla is the principal visceral sensory relay nucleus in the brain. In the rat, numerous lines of evidence indicate that the caudal NTS at the level of the area postrema serves as a major integrating site for coordinating cardiorespiratory reflexes and viscerobehavioral responses. This region of the caudal NTS not only exhibits high densities of binding sites for an impressive array of transmitters and modulators but microinjections of many of these same neuroactive substances into the rat subpostremal NTS elicit pronounced cardiorespiratory and visceral response patterns. This report provides an abbreviated atlas of the rat subpostremal NTS consisting of a series of transverse, sagittal, and horizontal plates. Photomicrographs, together with their corresponding schematic drawings, are provided for the serial sections generated from each reference plane.

Organic calcium channel blockers enhance [3H]purine release from rat brain cortical synaptosomes

The release of [3H]purines was investigated in a crude mitochondrial fraction (P2 fraction) from rat brain cortex pre-loaded with [3H]adenosine for 30 sec at 37 degrees C in vitro. Potassium, veratridine and glutamate were used as depolarizing agents to evoke the release of [3H]purines. Ca2+ removal, the addition of EGTA, and treatment with organic or inorganic Ca2+ antagonists did not inhibit [3H]purine release in this preparation. On the other hand, Ca2+ removal and the addition of EGTA greatly enhanced 3H-purine release induced by glutamate. D-600 and diltiazem enhanced K+-evoked [3H]purine release, and nifedipine increased veratridine evoked [3H]purine release indicating that either these Ca2+ antagonists have different sites of action, or that K+ and veratridine may release [3H]purine from different metabolic pools. Organic Ca2+ antagonists failed to enhance the [3H]purine release evoked by glutamate, further supporting the notion that various depolarizing agents may release [3H]purines from different cellular compartments.

Effect of antibiotics on retention of visual discrimination training and on protein synthesis in the pigeon

Forty-three pigeons were trained for one day on a visual discrimination (horizontal vs. vertical stripes) and then immediately injected with either puromycin (PM), cycloheximide (CXM), control saline, or combined PM and CXM solution. PM produced a marked amnesic effect, CXM a weaker effect. PM injected animals (but not CXM's) also took significantly more than 1 day longer than controls to reach criterion levels, indicating an effect on continued acquisition of the discrimination beyond the amnesia for Day 1. Combination with CXM did not attenuate the PM effects. Protein inhibition profiles showed maximum PM activity of 90% inhibition, whereas CXM's maximum was 98% and was distributed more widely throughout different brain regions. In a second experiment, PM (N = 8), CXM (N = 8) or saline (N = 8) were again injected immediately after training, but the S+ was reversed on all postinjection training trials. In this case, PM animals were superior in percentage of S+ pecks on Day 2 to controls and CXM's. Further, the continued acquisition deficit was absent in the PM group, indicating that this effect is highly specific to those behavioral circuits active at the time of injection.