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PubMed2000

A surgical case of solitary plasmacytoma of rib origin with biclonal gammopathy.

Localized solitary plasmacytoma of the bone (SPB) is a rare disease and is characterized by only one or two isolated bone lesions with no evidence of disease dissemination. A previously healthy 44-year-old male was admitted for evaluation of an abnormal radiographic shadow in the left middle lung field with symptoms of left back pain. Radiological evaluation revealed a peripheral opacity in the left chest wall, which was highly suspected to be a chest wall tumor. CT-guided transcutaneous needle biopsy of the tumor was performed and the specimens showed a monomorphous population of mature plasma cells. The bone marrow biopsy findings revealed no evidence of myeloma and bone scanning revealed only abnormal accumulation in the left seventh rib. He had mild M-proteins in a urine sample and Bence-Jones protein was detected. Immunoelectrophoresis revealed mild biclonal gammopathy of Bence-Jones protein of both the kappa and lambda light-chain types. Under a diagnosis of solitary bone plasmacytoma, preoperative radiation therapy with doses of 40 Gy for the tumor was performed. He underwent complete en bloc resection of the chest wall, including one-third of the left sixth and seventh ribs, the intercostal muscle and the parietal pleura. The protein abnormalities in the urine sample disappeared following surgical resection. Adjuvant chemotherapy using melphalan and prednisolone was performed. He is doing well without evidence of tumor recurrence 2 years following his initial diagnosis.

Adult↗
PubMed2000

Hemangioma of the rib: a case report.

A case of hemangioma of the left seventh rib is presented. In January 1999, a 59-year-old woman presented with an enlarged costal mass which had been followed up for 4 years. Preoperative examination suggested chondrosarcoma because of tumor growth beyond the disrupted bony cortex. She underwent resection of the left seventh rib along with the sixth and seventh intercostal muscles and reconstruction of the chest wall defect. The pathological diagnosis of the lesion was hemangioma. She was discharged after an uneventful postoperative course. There has been no evidence of recurrence after a 14-month follow-up. Tumor growth beyond the disrupted bony cortex was a characteristic feature by both imagery and pathological examination in this case. This case represents a difficulty of a preoperative definite diagnosis of the chest wall tumors by imagery alone.

Bone Neoplasms↗
PubMed2000

Lung cancer implantation in the chest wall following percutaneous fine needle aspiration biopsy.

We describe a 70-year-old man with lung cancer implantation in the chest wall following percutaneous fine needle aspiration biopsy. He underwent lobectomy after percutaneous transthoracic fine needle aspiration biopsy using a 19-gauge needle. Twenty-six months after the biopsy, he noticed a hard subcutaneous tumor at the biopsy site in the chest wall. Ribs and intercostal muscles were resected. The primary lung tumor and the chest wall tumor were histologically identical, but were not contiguous to each other. We concluded that the subcutaneous tumor was due to needle biopsy implantation. This complication is extremely rare, but open biopsy should always be considered as a possible alternative. During the procedure, care must be taken with the least chance of implantation and patients should be observed carefully after needle biopsy.

Adenocarcinoma↗
PubMed1993

Recreational abdominal suspension: a fatal practice. A case report.

A 12-year-old girl fatally suspended herself accidentally from a tree branch with a circumferential webbing tape tied round the midtrunk area. This occurred as part of a recreational practice whereby the body, tied in this fashion, could be made to swing in a pendulumlike horizontal plane. She was found dead in this position, hanging transversely one foot above the ground. A complete autopsy showed a tram-line circumferential parchmented bruise of the midtrunk area and bruising of the intercostal muscles and diaphragm with occasional petechiae. The mechanism through which death resulted in this case is believed to have involved a progressive tightening and compression of the primary respiratory muscles, resulting in eventual failure of the respiratory effort.

Asphyxia↗
PubMed2001

Internal current mark in a case of suicide by electrocution.

Fatalities caused by electrocution often lack specific morphologic evidence. Investigation of the death scene along with technical inspection of the electrical apparatus may help in clarifying the cause and manner of death. Cutaneous current marks may be the only sign of low voltage associated fatalities. The authors report a case of an electrician who committed suicide by electrocution using a time switch after oral ingestion of diazepam. Electrodes (coins) were fixed with adhesive tape at the height of the heart to the front and back of the left side of the chest. Autopsy revealed a blackish linear mark on the pleura parietalis of the inner side of the thoracic cavity, connecting the cutaneous current marks. Current-related and heat-related changes, such as hypercontraction bands of the intercostal muscles and coagulative changes of the perineurium of peripheral nerves, were found at histologic examination. Taking into consideration that the body had been under the influence of low-voltage current for 7 days, the morphologic alteration on the pleura parietalis was in accordance with an internal current mark, indicating the main route of current flow through the body. To the authors' knowledge, such a current-related phenomenon has not been reported to occur on an inner body surface before.

Adult↗
PubMed1985

Halothane anesthesia reduces pulmonary function in the newborn lamb.

To study the effects of anesthesia on respiratory function of the neonate, the authors investigated the effect of breathing 100% oxygen and of breathing oxygen plus 0.75 MAC halothane on functional residual capacity, lung and airway resistance, expired minute volume, work of breathing, lung compliance, and blood gases and pH in nine 5-8-day-old, 4.6-7.7-kg lambs. Breathing 100% oxygen increased PaO2 but had no effect on PaCO2, minute ventilation, or lung mechanics. Three-fourths MAC halothane depressed minute ventilation 34% +/- 13% (P less than 0.05) and increased PaCO2 50% +/- 5% (P less than 0.05). Lung and airway resistance increased 59% +/- 26% (P less than 0.05); work of breathing decreased (P less than 0.05); and lung compliance was unchanged. Functional residual capacity was reduced 32% +/- 6% (P less than 0.05), which may be due to loss of diaphragm and intercostal muscle function and to an inability to take deep breaths. The authors conclude that 0.75 MAC halothane significantly impairs the pulmonary function of lambs who breathe spontaneously. Similar changes in human infants could account for the hypoxemia and hypercarbia that often are seen during anesthesia.

Airway Resistance↗
PubMed1986

Ventilatory pattern and chest wall mechanics during ketamine anesthesia in humans.

The effects of anesthetic doses of ketamine (iv bolus of 3 mg X kg-1 followed by a continuous infusion of 20 micrograms X kg-1 X min-1) on functional residual capacity (FRC) measured by the helium dilution method and on the breathing pattern recorded by a noninvasive method (NIM) based on chest wall circumference changes were studied in 14 ASA P.S. I patients. Ketamine anesthesia was associated with: 1) the maintenance of FRC, minute ventilation, and tidal volume; 2) an increase in rib cage contribution to tidal breathing; and 3) an alteration of volume-motion relationships of the chest wall compartments. It is concluded that: 1) in contrast to volatile anesthetic agents, ketamine anesthesia has a sparing effect on intercostal muscle activity, which may explain the maintenance of FRC; and 2) changes in chest wall geometry and compliance induced by anesthetic agents must be taken into account for NIM to be valid.

Adult↗
PubMed1993

Thoracic epidural anesthesia increases diaphragmatic shortening after thoracotomy in the awake lamb.

BACKGROUND: Prolonged inhibition of diaphragmatic function occurs after thoracic and upper abdominal surgery. It was hypothesized that thoracic epidural anesthesia on the day after a thoracotomy could block inhibitory neural pathways and increase the shortening of costal and crural diaphragmatic segments. METHODS: Pairs of sonomicrometer crystals were implanted into the costal and crural regions of the diaphragm through a right lateral thoracotomy in 14 30-kg, 4-5-month-old lambs. One day after surgery, a thoracic epidural catheter was placed at the T8-T9 level. Regional diaphragmatic shortening normalized to end-expiratory length (%LFRC), was measured by sonomicrometry in these awake lambs. Changes in gastric (delta Pgas), esophageal (delta Pes), and transdiaphragmatic (delta Pdi) pressures were measured with transnasal balloon catheters. End-tidal carbon dioxide (FETCO2), costal and crural electromyogram (Edi), and tidal volume (VT) were measured. Inductance plethysmography was used in four lambs to assess relative contributions of the rib cage and abdomen to VT. Control values were obtained during quiet breathing and while rebreathing at up to 10% FETCO2. To block thoracic dermatomes, 1% or 2% lidocaine was injected through the epidural catheter. Measurements were repeated after each lidocaine injection. RESULTS: There was no change of resting length with 1% lidocaine; costal resting length increased by 22% with 2% lidocaine. After 2% lidocaine, costal %LFRC increased from control both during quiet breathing (8.7 +/- 0.7 to 18.1 +/- 1, mean +/- SEM%) and at FETCO2 10% (22.1 +/- 2 to 33.7 +/- 3%). VT during quiet breathing was unchanged after 1% lidocaine but increased from 235 +/- 16 to 283 +/- 28 ml after 2% lidocaine. At 10% FETCO2, delta Pdi was unchanged after 1% lidocaine and decreased from 36.5 +/- 4.3 to 26.3 +/- 4.9 cmH2O after 2% lidocaine. Regional delta Edi was unchanged with both 1% and 2% lidocaine at rest and during carbon dioxide rebreathing. Plethysmography in three lambs showed a reduction in rib cage contribution to tidal volume with 2% lidocaine during quiet breathing. CONCLUSIONS: Improved postoperative tidal volume and diaphragmatic shortening after thoracic epidural blockade may be due to changes of chest wall conformation and resting length and a shift of the workload of breathing from the rib cage to the diaphragm caused by intercostal muscle paralysis.

Anesthesia, Epidural↗
PubMed1996

Divergence of intracranial and central venous pressures in lightly anesthetized, tracheally intubated dogs that move in response to a noxious stimulus.

BACKGROUND: Intracranial pressure (ICP) may increase in tracheally intubated subjects during periods of movement (e.g, "bucking" and coughing). Recent research has suggested that factors other than passive congestion of the cerebral vessels, resulting from increases in central venous pressure, may contribute to the ICP response. The current study evaluated this issue in a canine model of intracranial hypertension and additionally evaluated the relationship between ICP and static increases in superior vena caval pressure. METHODS: Six dogs were lightly anesthetized with 0.65% end-expired halothane in oxygen and nitrogen, and ventilation was mechanically controlled. Intracranial pressure was increased to a stable baseline of 15-20 mmHg using a subarachnoid infusion of warm 0.9% saline solution. The following variables were quantified before, and for 6 min after, initiating a 1-min noxious stimulus to the trachea and skin: ICP, central venous pressure, electromyograms (masseter, deltoid, and intercostal muscles), intrathoracic pressure, and cerebral perfusion pressure (defined as mean arterial pressure -- ICP). Later, the protocol was repeated in the presence of neuromuscular block with pancuronium. Finally, in the same dogs, occlusion of the superior vena cava at its junction with the right atrium was used to increase superior vena caval pressure in 5-mmHg increments, from 5 to 30 mmHG, so that the resulting increases in ICP could be quantified. RESULTS: In unparalyzed dogs whose heads were maintained at the level of the right atrium, there was a 22-mmHg increase in ICP at 1 min after initiating the noxious stimulus (P<0.05). The ICP increase was related to electromyogram activation and a 6-mmHg increase in central venous pressure; however, it was not associated with significant increases in intrathoracic pressure or cerebral perfusion pressure. Treatment with pancuronium abolished the electromyographic, ICP, and central venous pressure responses to noxious stimulus. When superior vena caval pressure was statically manipulated, the resulting ICP increase was only one half the magnitude of the superior vena caval pressure increase. After elevating the head 14 cm, the ratio of ICP to superior vena pressure increases was reduced to one third. CONCLUSIONS: If these results apply to humans, it was concluded that increases in ICP that accompany movement in tracheally intubated patients may arise from two complementary factors: (1) cerebrovascular dilation that correlates with electromyographic activity and is mediated by ascending neural pathways that transmit proprioreceptive information, and (2) passive venous congestion that results from any increase in central venous pressure. The influence of the latter factor can be reduced by elevating the head. (Key words: Blood pressure, venous pressure; mean arterial pressure. Muscle: afferent activity; electromyograms, skeletal. Neuromuscular relaxants: pancuronium.)

Anesthesia↗
PubMed1994

Respiratory rhythm generation in chick hindbrain: effects of MK-801 and vagotomy.

Hindbrain mechanisms generating the respiratory rhythm in chicks were analysed. In vivo, ventilation and intercostal muscle activity were recorded in chicks (1 and 2.5 weeks-old), vagotomized and treated with the NMDA receptor blocker MK-801 (dizocilpine). In vitro, synaptic transmission from vagal to second-order sensory neurones was studied in the nucleus of the solitary tract, using whole-cell recordings in slices. Vagal afferents were found to act through GABAergic synapses and control two hindbrain systems: a dizocilpine-sensitive control system and a rhythm generator. Although this organization is the same as in mammals, after vagotomy entirely different respiratory patterns emerge: (i) expiratory-inspiratory efforts triggered by the rhythm generator and (ii) periods of apnoea produced by the dizocilpine-sensitive system.

Animals↗
PubMed2003

Pharmacokinetics of doxorubicin and cisplatin used in intraoperative hyperthermic intrathoracic chemotherapy after cytoreductive surgery for malignant pleural mesothelioma and pleural thymoma.

Cytoreductive surgery combined with intraoperative hyperthermic intrathoracic chemotherapy (HITHOC) is studied in a phase I study in the treatment of malignant pleural mesothelioma and pleural thymoma. We studied the pharmacokinetics of doxorubicin and cisplatin used during the HITHOC procedure. Furthermore, the penetration characteristics of doxorubicin were examined. Between 1998 and 2001, 24 perfusions were performed with a solution containing doxorubicin and cisplatin for 90 min at 40-41 degrees C. The dose was first based on square meters body surface, whereas in later studies a fixed concentration of the perfusion fluid was used. Samples of blood and perfusion fluid were collected for doxorubicin and cisplatin measurements. The penetration characteristics of doxorubicin in tissue were determined by fluorescence microscopy. The mean AUC(perfusate):AUC(plasma) ratios for doxorubicin and cisplatin (ultrafiltration for plasma) were 99 and 59, respectively. During perfusion the concentration in the perfusate declined essentially according to first-order elimination kinetics for both doxorubicin and cisplatin with half-lives of 74 and 138 min, respectively. At the end of the perfusion, about 35 and 52% of the dose of doxorubicin and cisplatin, respectively, was recovered in the perfusion fluid. One patient developed a nephrotoxicity grade II. No leukopenia or hair loss was seen. Doxorubicin penetrated into the intercostal muscle specimen, albeit that there was considerable variation in distribution throughout the specimen. We conclude that HITHOC with doxorubicin and cisplatin is relatively a safe procedure with the advantage of high intrathoracic cytostatic drug concentrations, while having limited systemic side effects.

Adult↗
PubMedDate not supplied

Kinematic analysis of patients with spinal muscular atrophy during spontaneous breathing and mechanical ventilation.

Patients with infantile spinal muscular atrophy develop pectus excavatum along with a severe restrictive syndrome as a result of failure to expand the upper chest wall and lungs because of intercostal muscle weakness. By using an automatic motion analyzer to provide three-dimensional computer analyses of images sampled at 25 Hz, 9 spinal muscular atrophy Type II patients and 13 controls underwent kinematic analysis of thoracoabdominal movements partitioned into the upper thorax, lower thorax, and abdominal volume compartments. The analyses were performed during spontaneous breathing for the controls and during spontaneous breathing and while using mechanically assisted ventilation for the patients. Vital capacity, maximum inspiratory pressures, and nocturnal oxyhemoglobin saturation and transcutaneous carbon dioxide tensions were also measured for the patients. The kinematic data demonstrated a paradoxical ventilatory pattern for the spontaneously breathing SMA patients with the following inspiratory volume changes: upper thorax, -6.4+/-9.6%; lower thorax, 7.3+/-15.8%; abdominal, 99.1+/-21.3%. During mechanical ventilation, the compartmental volume changes were as follows: upper thorax, 13.5+/-6%; lower thorax, 13.7+/-7.9%; abdominal, 72.7+/-9.3%. This kinematic pattern is comparable with that seen in spontaneously breathing normal subjects. We conclude that mechanical ventilation can normalize kinematic volume changes during alveolar ventilation and that this might help deter loss of thoracic compliance caused by the chronic hypoventilation of the upper thoracic compartments. Kinematic analysis may be helpful for choosing the ventilation parameters to optimize therapeutic benefits.

Biomechanical Phenomena↗
PubMed1977

Rupture of the thoracic esophagus from blunt trauma.

A young man with severe multiple injuries following a motorcycle accident was admitted with head and mandible fractures, coma, fracture dislocation at C5-C6 resulting in total leg paralysis, partial paralysis of the right arm and intercostal muscles, and closed chest injury with possible pulmonary contusion. On the fourth day he developed fulminating mediastinitis and massive empyema, and was found to have a ruptured esophagus. Recovery became possible with surgical drainage of the pleural cavity and mediastinum, proximal and distal decompression of the esophagus, antimicrobial therapy, irrigation of the pleural cavity, complete intravenous hyperalimentation, and infusions of salt-poor albumin. The patient was discharged after 95 days, and 7 months after injury is neurologically intact except for a partial right wrist drop. This rare esophageal rupture should be suspected in any chest injury patients, especially those characterized by extreme cyanosis, dyspnea, shock, and prostration incompatible with thoracic cage injury.

Accidents, Traffic↗
PubMed1991

Ventilatory effects of medical antishock trousers in healthy volunteers.

The ventilatory effects of medical antishock trousers (MAST) were investigated using 10 healthy volunteers. Use of the MAST (60-80 mm Hg) decreased forced expiratory volume (-8% +/- 4%, p less than 0.01), vital capacity (-8% +/- 5%, p less than 0.01), and functional residual capacity (-12% +/- 6%, p less than 0.01) and induced a significant decrease in tidal volume (-30% +/- 17%, p less than 0.05), but minute ventilation was unmodified because of a concomitant increase in respiratory rate (+17% +/- 8%, p less than 0.001). The MAST modified the breathing pattern: the abdominal contribution to ventilation was markedly decreased (-57% +/- 22%, p less than 0.001), suggesting a decrease in the diaphragmatic contribution to ventilation. The MAST increased both the end-expiratory (+131% +/- 115%, p less than 0.01) and inspiratory variation (delta Pgas: +42% +/- 40%, p less than 0.05) of gastric pressure, whereas the end-expiratory and inspiratory variation of esophageal pressure remained unchanged. Because of a higher delta Pgas, the dynamic compliance of the abdominal compartment markedly fell (-77% +/- 10%, p less than 0.001). Transdiaphragmatic pressure (Pdi: +28% +/- 30%, p less than 0.05) significantly increased and the pressure-time index of the diaphragm significantly increased (+32% +/- 32%, p less than 0.05) after inflation of the MAST, suggesting an increase in the diaphragmatic cost of breathing. Inspiratory activity of the parasternal intercostal muscles significantly increased after the MAST was inflated. Computerized tomography showed that the MAST induced a cephalad shift of the diaphragm, which reduced pulmonary height.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2002

Imaging findings of an intercostal hemangioma.

SUMMARY: The authors present the imaging findings in a 44-year-old woman with a rare intercostal hemangioma that originated from the connective tissue between the intercostal muscle and parietal pleura and protruded into the thoracic cavity. The contrast-enhanced computed tomography (CT) showed a markedly enhancing mass, whereas dynamic magnetic resonance (MR) images showed heterogeneous and strong enhancement with incomplete early eccentric enhancement peripherally followed by complete filling-in on delayed scans. The imaging features of CT and MR imaging of a hemangioma may be useful for proper preoperative diagnosis.

Adult↗
PubMed1978

The great potential of the intercostal flap for torso reconstruction.

The intercostal flap has many uses for torso reconstruction, whether employed as an island flap or a free flap. With modifications, it can be used as a sensory skin flap, or as a compound osteocutaneous flap to restore stability in a chest wall construction, or as a skin flap with a permanent blood supply to provide stable cover after excision of radiation ulcers.

Adult↗
PubMed2001

The use of evoked EMG in detecting misplaced thoracolumbar pedicle screws.

STUDY DESIGN: Experimental study performed using an animal model. OBJECTIVES: To determine if EMG responses generated by the electrical stimulation of thoracolumbar pedicle screws could be used to predict the screw position. SUMMARY OF BACKGROUND DATA: Evoked EMG has been used successfully to predict pedicle screw position in the lumbar spine. No data have been published on its effectiveness in the thoracic spine. METHODS: A total of 91 screws were inserted into the pedicles from T8 to L2 in six sheep. Monitoring electrodes were placed into transversus abdominus at three levels, the lower two intercostal spaces, and into psoas. A constant voltage stimulus was applied to a probe inserted into each pedicle, and then to each pedicle screw after it had replaced the probe. The threshold voltage required to evoke EMG activity in the relevant myotome was noted. After monitoring the position of each screw was determined by gross dissection. RESULTS: EMG responses in abdominal and intercostal muscles were successfully evoked by thoracic pedicle screw stimulation. Of the 91 screws, 50 were within the pedicle and required an average voltage of 15.12 V to stimulate an EMG response, compared with the 41 misplaced screws that had an average voltage of 7.63 V (P < 0.0001). Using a threshold of 10 V the technique has a sensitivity of 94% and a specificity of 90%. CONCLUSION: Electrical stimulation of pedicle screws and EMG recording in abdominal and leg muscles in sheep provide a reliable indication of pedicle screw position. This technique can be directly applied to human thoracolumbar surgery, but differences in pedicle size would mean that new threshold voltage criteria would need to be established.

Animals↗
PubMed2005

Modeling the effect of non-penetrating ballistic impact as a means of detecting behind armor blunt trauma.

BACKGROUND: According to the National Institute of Justice (NIJ) Standard 0101.04, the maximum deformation a soft armor vest can undergo without penetration is 44 mm. However, this does not take into account the effect of the pressure wave or energy transferred to the organs within the torso due to behind armor blunt trauma (BABT). Therefore, a study was undertaken to develop a finite element model (FEM) to study these effects. METHODS: A finite element model (FEM) of the human thorax; complete with musculoskeletal structure and internal organs (heart, liver, lungs and stomach), intercostal muscle and skin, has been developed in LS-DYNA. A Kevlar vest was modeled on the chest to simulate non-penetrating ballistic impact. RESULTS: Using a projectile modeled with a size and mass equivalent to a 9 mm (124 grain) bullet at 360 and 425 m/s, four impacts were simulated against NIJ Level II and Level IIIa Kevlar vests at the midsternum and right thorax. At the same velocity, the pressures decreased by a factor of 3 and the energy absorbed by the organs decreased by a factor of 6 for the NIJ Level II and Level IIIa vests, respectively. As the projectile velocity increased, the peak pressures increased by a factor of 3 while the energy absorbed by the organs increased by a factor of 4. CONCLUSIONS: The resulting pressure profiles and kinetic energy exhibited by the respective organs indicate this model may be useful in identifying mechanisms of injury as well as organs at an elevated injury risk as a result of BABT.

Biophysical Phenomena↗