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PubMed1998

Sternal defects associated with congenital pericardial and cardiac defects.

We describe three cases of sternal defects of varying severity associated with other congenital anomalies. In the most severe case, both anterior and posterior defects were seen, with near-absence of the sternum and pericardium continuous with a large omphalocele. This resulted in external location of organs usually confined within the thoracic and abdominal cavities. A ventricular septal defect was present, and the arterial duct was absent. The course of the ascending aorta was anomalous. The baby had anencephaly and rachischisis. In the intermediate case, a proximal sternal cleft was associated with shortening of the sternum, and absence of the manubrium. Anterior pericardial and diaphragmatic defects were seen, while a scalp defect and an encephalocele were present on the posterior aspect of the head. This baby had tricuspid atresia. The remaining case had only an anterior defect with a shortened sternum. A supra-umbilical omphalocele contained a left ventricular diverticulum without interposing pericardium or diaphragm. Ventricular and atrial septal defects were present. The first two cases can be considered as representing failure of development of both an anterior and a posterior midline field. The third case, much milder than the other two, represents failure of development of an anterior field.

Abnormalities, Multiple↗
PubMed1999

A 5-year experience with surgical repair of atrial septal defect employing limited exposure.

BACKGROUND: There has been a trend in recent years towards less invasive therapy for many congenital cardiac malformations. For the past 5 years, we have employed a technique of limited surgical exposure when repairing atrial defects within the oval fossa. METHODS: Over the 5-year period from July 1992 to August 1997, 115 consecutive patients underwent surgical repair of an isolated atrial septal defect in the region of the oval fossa by a single surgeon. The patients had a limited midline skin incision starting at the line of the nipples and extending inferiorly across 2 to 3 intercostal spaces. A partial sternotomy was performed, sparing the manubrium. Standard instruments and cannulation techniques were used for cardiopulmonary bypass and fibrillatory arrest. RESULTS: There were no deaths and no major complications. The median time to extubation after leaving the operating room was 3 hours (30 minutes to 8 days). Mediastinal drains were removed the morning after surgery. The median stay in the intensive care unit was 7 hours (3 hours to 10 days), and patients were discharged from the hospital a median of 4 days postoperatively (2 to 23 days). CONCLUSIONS: This approach using limited exposure can be applied safely without any new instruments and without peripheral incisions or sites of vascular access, while providing a comfortable exposure for the surgeon and achieving a cosmetically superior result for the patient.

Adolescent↗
PubMed2003

Steinernema weiseri n. sp. (Rhabditida, Steinernematidae), a new entomopathogenic nematode from Europe.

Steinernema weiseri n. sp. is described from a roadside with apple trees near Ceské Budejovice, Czech Republic. The species is also widely distributed in Germany and Slovakia, from where it had previously been reported as Steinernema spec. F. The British Steinernema sp. D1 is considered conspecific with S. weiseri n. sp. Males of the new species are mainly characterised by light brown, slightly curved spicules with a long manubrium and the presence of a short tail mucron in the second generation. Third-stage infective juveniles are characterised by a 'medium size' body and tail length, short hyaline tail portion (mostly around 1/3 of tail length), the excretory pore situated in the mid-pharynx region, lip region slightly offset, angular and flattened, and the lateral field having nine equally developed lines separated by eight distinct ridges. S. weiseri n. sp. is most similar to S. feltiae, with which it did not hybridise. RFLP analysis of the ITS region of the rDNA repeat shows S. weiseri n. sp. to be distinct from 50 other Steinernema species and isolates. The new species was found in a wide range of habitats and is readily maintained on Galleria mellonella larvae.

Animals↗
PubMed2001

Management of a floating sternum after repair of pectus excavatum.

PURPOSE: The aim of this study was to examine the authors' experience with patients who have floating sternum after correction of pectus excavatum via the classical Ravitch procedure. A floating sternum is defined as a sternum in which the only attachment to the chest wall is its superior (cranial) border, and in which the body is secured only by the manubrium and whatever lateral and inferior fibrous bands are present. Typically, a floating sternum is caused by either extensive resection of the costal cartilages and perichondrium during correction of pectus excavatum or failure of proper regrowth of these cartilages. METHODS: The authors retrospectively assessed the charts of all patients diagnosed with a floating sternum noting age at original correction of pectus excavatum, time from original correction of pectus excavatum to diagnosis of floating sternum, age at correction of floating sternum, complaints before stabilization of the sternum, methods of repair, and postoperative complications. RESULTS: Between July 1993 and June 1999, floating sternum was diagnosed in 7 patients. The mean age of patients who underwent operative correction of a floating sternum was 28.9 years (range, 16 to 42 years). The mean time interval between original correction of pectus excavatum, or "redo," and diagnosis of a floating sternum was 9.9 years (range, 2 to 20 years). Complaints before correction of the floating sternum included sternal pain and instability, exercise intolerance, and difficulty breathing. Operative repair consisted of mobilizing the lateral and inferior edges of the sternum, detaching the fibrous perichondrium, performing anterior sternal osteotomies, and finally supporting the sternum with substernal Adkins struts. All 7 patients had successful stabilization of the sternum. Two of 7 patients underwent 2 procedures to successfully stabilize the sternum. One patient has Adkins struts still in place because of hematopoetic malignancy. Six of 7 patients are now without symptoms. CONCLUSIONS: A floating sternum is a morbid phenomenon that may manifest many years after the original procedure. It can cause significant sternal pain, chest wall instability, and respiratory dysfunction, which are the hallmark indications for correction. Repair of a floating sternum can be accomplished successfully.

Adolescent↗
PubMed2001

Optimal electrocardiographic leads for detecting acute myocardial ischemia.

This study identifies the most sensitive electrocardiographic leads for monitoring ST-segment changes caused by acute coronary ischemia. The data set consisted of 120-lead electrocardiograms (ECGs) digitally recorded during balloon-inflation angioplasty in 3 groups of patients with single-vessel disease (left anterior descending [LAD], 32; right coronary artery [RCA], 36; left circumflex [LCx], 23). The ST deviation was measured in all recorded leads during baseline and ischemic states, and its difference between these 2 states (DeltaST) was calculated at 352 sites and plotted as DeltaST maps. The patients in each group were divided, by means of DeltaST criteria, into subgroups of "responders" and "nonresponders." Mean DeltaSTs for each group/subgroup were calculated and standardized by the corresponding standard deviation (SD); these values were plotted as mean DeltaST and t maps. Sites where extrema of DeltaST occurred most frequently were sought in bootstrap trials, performed in each group/subgroup. The results suggest that the optimal sites for the ischemia-sensitive leads are: V(3) (+) and just below V(8) (-) for LAD-related ischemia; the left iliac crest (+) and above V(3) at the third intercostal space (-) for RCA-related ischemia; and just below V(8) (+) and above V(2) at the third intercostal space (-) for LCx-related ischemia. Three "optimal" bipolar leads using these sites registered, in the responders from the LAD, RCA, and LCx groups, mean DeltaST (+/-SD) of 232 +/- 59, 245 +/- 96 and 158 +/- 91 microV, respectively; the corresponding t values were 15.14, 9.90, and 6.75. In the 12-lead ECG, only lead V(3) approached optimal DeltaST and t values for the LAD responders (187 +/- 61 microV; t = 11.75) and lead III for the RCA responders (191 +/- 76 microV; t = 9.73), but even these values were significantly suboptimal (P = 0.0011 and P = 0.0120, respectively). We found that the "optimal" bipolar leads can be derived, to an excellent approximation, from the 12 standard leads or from 3 EASI leads (with 3 electrodes at Frank's transverse level and 1 on the manubrium), by using precalculated regression coefficients. By means of bootstrap trials, we estimated the mean sensitivity (SE) and the mean positive predictive value (PPV) with which 3 "optimal" vessel-specific leads could identify ischemia related to the LAD, RCA, and LCx arteries, in the test set, as (SE/PPV) 94.7/92.8%, 78.7/80.9%, and 81.5/80.9%. A similar diagnostic performance can be achieved by vessel-specific leads derived from the 12-lead ECG (93.0/93.4%, 76.6/82.0%, and 82.7/77.1%) and, interestingly, from the EASI lead system (97.8/88.4%, 78.0/80.2%, and 76.8/83.2%). Thus, although the "optimal" bipolar leads for detecting ischemia related to each of the 3 coronary arteries were found to require sampling outside the 12-lead ECG, these leads can be derived from the full set of 12 standard leads or--for clinical monitoring applications--from the EASI lead system by using fewer electrodes at convenient locations.

Acute Disease↗
PubMed2002

Improved EASI coefficients: their derivation, values, and performance.

The EASI lead system, which is based on the dipole hypothesis of vectorcardiography, offers the possibility of deriving the standard 12-lead electrocardiogram (ECG) and other desired leads from ECGs recorded at only 4 sites; it uses the Frank E, A, and I electrode locations, a fourth electrode location (S) at the manubrium, and a reference electrode. Accordingly, the electrodes of this system can be applied rapidly on easy-to-locate, stable anatomical sites that leave the precordium free for other diagnostic procedures. In early EASI implementations, the derived leads differed from actual leads by more than some clinicians found acceptable. As these differences were thought to be caused by the fact that the coefficients that were used had been derived from a limited data set, we have calculated a new set of EASI coefficients for the standard 12 leads, and several other leads, by using a data set of 983 adult subjects with 120-lead ECGs and well-documented diagnoses. This database is a concatenation of 2 previously described ones: one consisting of 892 persons (normal subjects, postmyocardial-infarction patients with and without arrhythmias, and patients with ventricular arrhythmias but no history of myocardial infarction) and the other consisting of 91 patients with single-vessel coronary artery disease who underwent coronary balloon-inflation angioplasty. In addition to the coefficients for the standard 12 leads (derived for standard limb leads as well as for Mason-Likar leads), we derived coefficients for six additional unipolar leads (posterior V(7)-V(9), and right-sided V(3)R-V(5)R), the Frank orthogonal leads, and three bipolar, vessel-specific leads that have been previously shown to exhibit optimal sensitivity for acute myocardial ischemia. We also derived coefficients for the modified electrode locations of the EASI system that must be used with patients who have undergone a midline sternotomy. Optimal coefficients for lead transformations were determined by maximizing the ensemble average (over the entire data set) of the correlation between the derived and the true lead for the chosen interval of the averaged complex. For derived standard limb leads, the amplitude was adjusted to give the best root-mean-square fit over the entire PQRST interval, whereas for derived Mason-Likar leads it was adjusted to give the best ST-segment fit. The entire set of coefficients and their corresponding goodness-of-fit measures are presented.

Adult↗
PubMed2002

[Diagnosis and therapy of stapes fractures and luxations].

BACKGROUND: Injuries of the ossicular chain have various etiologies. Skull traumas from blows to the temporal, parietal or occipital region with or without fracture of the temporal bone are the main causes of the ossicular injury; other modes of injury are rare. It depends on the type of trauma which kind of injury occurs. Mainly subluxations, luxations and fractures are to be observed. The incus is the ossicle which is the most often injured. Mostly, only one ossicle is injured, rarely two or all of them. PATIENTS: From January 1997 to June 1999 we operated 19 patients with traumatic lesions of the membrane and the middle ear. In 4 cases the reason for the operation was an injury of the stapes. We observed 2 cases with broken stapes crura, 1 case with an impression of the stapes into the vestibulum with perilymphatic fistula and 1 case with subluxation of the stapes in the direction of the promontorium. By presenting 4 cases we want to point out the diagnostic possibilities and the operative management of such rare injuries. In all cases we applied the transmeatal approach for the operation of the middle ear. In 2 cases it was possible to place the stapes back in their anatomic position in order to re-establish the ossicular chain. In the other 2 cases we had to use middle ear prostheses which were interpositioned between the manubrium of the malleus and the footplate of the stapes. RESULTS: In all cases the immediate post-operative hearing results and the long-term hearing results after 10 to 28 months were satisfying. We did not notice any post-operative complications, especially no vestibular symptoms. One patient's tinnitus was the same as before the operation. CONCLUSIONS: The diagnosis of a stapes injury is despite the use of sophisticated technology, especially the CT-scan of the temporal bone, often very difficult. A sensitive anamnesis seems to be very important. It depends on the kind of injury which operative technique is to be applied in order to re-establish the ossicular chain. In our opinion, it is useful to take - if it is possible - the autolog stapes for the surgical re-establishment of transmission.

Adult↗
PubMed2001

Biomechanics of the movable pretarsal adhesive organ in ants and bees.

Hymenoptera attach to smooth surfaces with a flexible pad, the arolium, between the claws. Here we investigate its movement in Asian weaver ants (Oecophylla smaragdina) and honeybees (Apis mellifera). When ants run upside down on a smooth surface, the arolium is unfolded and folded back with each step. Its extension is strictly coupled with the retraction of the claws. Experimental pull on the claw-flexor tendon revealed that the claw-flexor muscle not only retracts the claws, but also moves the arolium. The elicited arolium movement comprises (i) about a 90 degrees rotation (extension) mediated by the interaction of the two rigid pretarsal sclerites arcus and manubrium and (ii) a lateral expansion and increase in volume. In severed legs of O. smaragdina ants, an increase in hemolymph pressure of 15 kPa was sufficient to inflate the arolium to its full size. Apart from being actively extended, an arolium in contact also can unfold passively when the leg is subject to a pull toward the body. We propose a combined mechanical-hydraulic model for arolium movement: (i) the arolium is engaged by the action of the unguitractor, which mechanically extends the arolium; (ii) compression of the arolium gland reservoir pumps liquid into the arolium; (iii) arolia partly in contact with the surface are unfolded passively when the legs are pulled toward the body; and (iv) the arolium deflates and moves back to its default position by elastic recoil of the cuticle.

Animals↗
PubMed1996

Computerized ECG recording in horses during a standardized exercise test.

In the horse, it is important to make a reliable ECG recording during exercise as cardiac arrhythmia is one of the possible causes of poor performance. The purpose of the present study was to obtain a satisfactory, standardized method for ECG recording by computer during a standardized treadmill exercise test and to evaluate the procedure both in healthy and in diseased horses. Ten experienced healthy research horses were used to develop and adapt the original method (for humans) of computerized ECG recording with the Cardio Perfect software program and to obtain reference values for heart rate and blood variables. Further, three diseased horses (patients) were examined to evaluate whether the test procedures were also usable for horses without extensive experience in treadmill and other experimental procedures. During a standardized exercise test on a treadmill at walk (1.7 m/s), trot (4.0 m/s), and canter (7.0 m/s at 0% and 4% treadmill inclination), the ECG was recorded using two bipolar leads (from xiphoid to manubrium respectively to the left withers) and one unipolar lead (on the left ventral thorax). The quality of the exercise ECGs was satisfactory. The heart rate was detectable and arrhythmias were identifiable. Most research horses did not show arrhythmias during exercise, except a single atrial premature complex (APC). The reference values for the mean heart rate for the different stages of the exercise test differed from 84 + or - 7 to 176 + or - 21 beats per minute (bpm). The exercise test provoked in healthy horses a plasma lactate concentration around the anaerobic threshold. Most patients were also able to finish the test. In conclusion, the developed method to obtain an exercise ECG during a standardized exercise test proved to be reliable and applicable both in research horses and in patients, thus extending the possibilities to diagnose arrhythmias.

Animals↗
PubMed1981

Formation and maturation of the human sternum. I. Fetal period.

In continuing attempts to develop reliable morphologic, x-ray, and gross criteria for age estimation utilizing the sternum and costal cartilages, it became necessary to study the fetal development of the sternum. While there is a wide variability in the number and configuration of the ossification centers of the developing sternum, several basic developmental patterns emerge. These are illustrated and compared with Ashley's classic work. In general, ossification begins in the manubrium and progresses to the mesosternal (body) segments, developing from rostral to caudal. The more or less final sternal pattern is not found until a number of years after birth. The wide variation in fetal sternal development would seem to preclude its use for satisfactory gestational age estimation; it is clearly less valuable than other morphologic criteria already available. However, an understanding of fetal development does greatly assist in understanding the pre- and postpubertal sternal patterns.

Female↗
PubMed1988

Development and morphology of the sternal foramen.

Bony defects (foramina) in the sternum were found in 6.7% of a large contemporary autopsy population. Usually solitary and located in the body of the sternum, these defects rarely occur multiply and in the manubrium. They have been found in children as young as 8 years as well as in persons of advanced age. Multiple mesosternal foramina and a manubrial foramen are described here for the first time. Sternal foramina form along lines of fusion of multiple centers of ossification and are the result of incomplete fusion. They have been misinterpreted as acquired lesions, usually gunshot wounds.

Autopsy↗
PubMed1989

Scintigraphic and CT findings of Tietze's syndrome: report of a case and review of the literature.

A case of Tietze's syndrome is reported. A 43-year-old woman, who had experienced right anterior chest pain and tender swelling of the right first costosternal junction for seven months, showed increased accumulation of the right first, the right fourth, and the left first costochondral junction on bone imaging. Ga-67 imaging showed increased accumulation at the right first costosternal junction. CT showed sclerosis of the sternal manubrium, partial calcification of costal cartilage, and soft tissue swelling. Biopsy of the right first costal cartilage showed chronic inflammation with fibrosis and ossification. Increased uptake of bone gallium imaging is consistent with Tietze's syndrome.

Adult↗
PubMedDate not supplied

Chondrosarcoma of the sternum: CT features.

Eleven sternal chondrosarcomas were reviewed with radiologic emphasis on the CT findings. Typical clinical presentation was a large painless anterior chest wall mass in an elderly individual. In six cases the chest radiograph strongly suggested an underlying cartilaginous neoplasm owing to the appearance of typical mineralized cartilage matrix, i.e., a pattern of stippled, flocculent, or curvilinear ("rings and arcs") calcifications. Calcifications were detected on CT in all 11 patients. Excepting the three smallest lesions, averaging 4 cm in diameter, on CT the tumors exhibited a scalloped or lobulated contour, also typical for cartilaginous neoplasms. Six tumors were centered in the sternal body, four in the xyphoid process, and one in the manubrium. In addition, CT was especially important in localizing the lesion when the tumor was either small in size or centered in the xyphoid process (where all four chondrosarcomas grew in an inferior direction). Because of its ability to detect subtle matrix mineralization and delineate the extent and probable origin of the tumor, CT strongly favored the preoperative diagnosis of sternal chondrosarcoma and was also helpful in surgical management.

Adult↗
PubMed1991

External fixation of the sternum for thoracic trauma.

A flail chest with a manubriosternal separation in a man with multiple injuries was treated with an external fixator applied to the sternum and the manubrium. Pain and ventilatory function were improved, permitting immediate postoperative extubation and prompt patient mobilization. The external fixator was removed after fracture union at 2 months. One year after injury, the patient's pulmonary function was normal. External fixation is an alternative to other methods of sternal fracture stabilization.

Abdominal Injuries↗
PubMed1989

Sternal fractures associated with spinal injury.

Twenty-eight cases of sternal fractures and/or dislocations were reviewed for the presence of associated spinal injury. Patient records and radiographs were studied. Sixteen cases had inadequate radiographs to rule out spine fracture. Three cases had known direct injuries to the sternum. Of the remaining nine patients, eight had spine fractures. All of the spine fractures were consistent with a flexion injury mechanism. Three patients had spine fractures at the thoracic level and four at the lumbar level. One patient had lower cervical and thoracic injuries. In the patients with spine injury, the proximal manubrial fragment tended to displace posteriorly. Similarly, the manubrium would move posteriorly in manubriosternal dislocations. A case of spontaneous sternal fracture in a patient with osteoporosis and multiple thoracic compression fractures is described. One patient had open reduction of the manubriosternal joint. Three patients who were admitted for their sternal injuries had spine fractures which were not recognized during the hospitalization. There were no cases of mediastinal injury in the patients with combined sternal and spinal injuries. Flexion injury to the spine may cause buckling of the sternum. However, indirect sternal injury continues to be overlooked. Careful evaluation for spine injuries should be done on all patients with sternal fractures and vice versa.

Adult↗
PubMed1996

Closed blunt chest trauma causing mediastinal abscess.

Posttraumatic bacterial mediastinal abscess resulting from closed blunt trauma without penetrating injury or tracheal or esophageal rupture is, to our knowledge, previously unreported. We report a case of a patient injured in a motor vehicle collision that resulted in closed blunt chest trauma and mediastinal abscess 14 days after injury. Initial chest roentgenogram revealed a widened mediastinum. Computed tomographic scan of the chest revealed comminuted fractures of the upper sternum, manubrium, and the 3rd and 4th left anteriolateral ribs and a retrosternal hematoma. Transesophageal echocardiography was negative. The patient was dismissed 2 days after injury and returned to the hospital 14 days after injury with a fluctuant, pulsatile, upper midline chest wall and anteriolateral chest wall staphylococcal abscesses. The abscesses were drained and the sternomanubrial wound debrided in stages. The mediastinal defect was reconstructed with a pectoralis major muscle flap. This most likely represents bacterial seeding of the mediastinal hematoma from a distant source.

Abscess↗
PubMed2001

Evaluation of eardrum laser doppler interferometry as a diagnostic tool.

OBJECTIVES: Laser Doppler interferometry (LDI) of the eardrum allows noncontact optical analysis of its vibrations in response to sound. Although LDI has been widely used in research, it has not yet been introduced into clinical practice as an adjunctive test for otological workup. The aim of this study was to evaluate LDI as a diagnostic tool in the clinical sphere. STUDY DESIGN: Prospective. METHODS: A measurement system was developed based on a commercially available scanning He-Ne laser Doppler interferometer. The study included 129 eardrums of 79 subjects that were divided into 3 groups: 1) normal subjects and 2) patients with sensorineural and 3) conductive hearing loss (HL). All the patients suffering from conductive HL underwent ossiculoplasty, which allowed confirmation of the final diagnosis, and patients were assigned accordingly to the subgroups malleus fixation, incus luxation, and stapes fixation. RESULTS: The modified LDI system allowed bilateral evaluation of a subject within 30 minutes. No significant difference between normal subjects and patients having sensorineural HL were found. However, it was possible to distinguish between normal subjects and patients with conductive HL. Furthermore, the system had the ability to differentiate between various middle ear diseases. These groups differed statistically significantly in terms of manubrium vibration amplitude and resonance frequency. In malleus fixation significant differences in tympanic membrane movement patterns were found. CONCLUSIONS: Our LDI is applicable in clinical otological practice and serves as a valuable addition to the routine audiological investigations for preoperative evaluation of the mobility and integrity of the ossicular chain.

Adult↗
PubMed1996

Median cleft of the lower lip and mandible: case reports, a new embryologic hypothesis, and subdivision.

Median clefts of the lower lip and mandible are rare. In the literature so far, about 62 cases have been described. In addition, three more patients are presented here. These cases show a broad variation in the severity of this deformity, ranging from a simple notch in the vermillion to a complete cleft of the lip involving the tongue, the chin, the mandible, the supporting structures of the median of the neck, and the manubrium sterni. Several hypotheses concerning the pathogenesis of median clefts of the lip and mandible have been proposed. Most authors consider it to be a failure of fusion of the first pair of branchial arches or failure of mesodermal penetration into the midline. From our embryologic point of view, however, instead of paired branchial arches, only one first branchial arch develops during the early embryonic period (< or = 17 mm crown-rump length). Within this first branchial arch, two mandibular processes grow out, separated by a groove in the median. These mandibular processes do not fuse but merge during the late embryonic period (> or = 17 mm to < or = 60 mm crown-rump length). In the same developmental period, there is formation of the lip and the alveolar process and the anlage and outgrowth of one membrane bone center in each mandibular process, resulting in the formation of the mandible with its symphysis. As a consequence of the preceding, we propose the following subdivision of the median clefts of the lip and/or mandible: Hypoplasia of the mandibular processes during the early embryonic period will lead to the severest cleft of the mandible extending into the neck. During the late embryonic period, the less severe median clefts will develop. Disturbances of the outgrowth of bone centers of the mandible, resulting in nonformation of its symphysis, cause clefting of the mandible with involvement of all related soft tissues. Defects in the merging process produce just a notch of the vermilion or a higher cleft of the lower lip with or without involvement of the alveolar process of the mandible. In conclusion, the variety of the clefts in the median of the lower lip and/or mandible as well as the low rate of incidence can be explained by the embryologic hypothesis proposed here.

Female↗