Vascular injuries of the upper thorax and the root of the neck.
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The morphologies of three common inhibitory motor neurones which innervate muscles of a hind leg and the homologous three neurones which innervate muscles in a middle leg are described in relation to known commissures, tracts, and areas of neuropile in their ganglia. The neurones were stained individually by the intracellular injection of cobalt, and the ultrastructure of common inhibitor 1 (CI1) in the metathoracic ganglion was revealed by the intracellular injection of horseradish peroxidase. Homologous inhibitory motor neurones in the meso- and metathoracic ganglia have similar shapes. CI1 has axons in nerves 3, 4, and 5, but common inhibitors 2 and 3 (CI2, CI3) have only a single axon in nerve 5. They nevertheless all share many features in common. All have large (60 70 micron diameter) cell bodies in the ventral cortex near the midline, well separated from those of the excitatory leg motor neurones. Their primary neurites run dorsally and laterally and send many fine branches into the dorsal and lateral neuropile, and some fine branches medially. None enter the ventral neuropile. CI1 and CI2 have a small branch that arises close to the cell body and arborises on either side of the midline. When examined with the electron microscope, CI1 was not found to make any output synapses, even though some of its fine branches are varicose and end in bulbous swellings. These were seen to be packed with mitochondria but not vesicles. Input synapses tend to be grouped together on the secondary neurites and, more especially, on the finer branches and their spines. The majority of processes presynaptic to CI1 contain round agranular vesicles.
Thoracic and retroperitoneal spindle-cell lesions represent a diagnostic challenge in the evaluation of fine-needle aspiration (FNA) specimens. The challenge is due to the morphologic similarities and wide variety of different entities with spindle-cell morphology in these two sites. The purpose of this study was to identify criteria helpful in the classification and differential diagnosis of spindle-cell lesions in these two locations. A set of cytologic features was analyzed in 57 thoracic or retroperitoneal spindle-cell lesions. Our results show that pleomorphism and abundant single cells were parameters associated with high-grade tumors in univariate and multivariate analysis, while coarse chromatin pattern was significant only in a univariate analysis. The combination of absence of pleomorphism, rare single cells, tight cluster arrangement, fine chromatin pattern, and absence of macronucleoli was seen only in benign cases. Assessment of background material was helpful in the differential diagnosis and classification. Necrosis was only found in high-grade cases.
Chest wall reconstructions can be complex and challenging procedures and may require a multidisciplinary approach. The most common indications for chest wall reconstruction are the repair of defects due to tumor ablation, infection, radiation necrosis, congenital deformities, and trauma. Flap reconstruction by plastic surgery is often required when skin is removed as part of the chest wall resection or when radiation therapy is given pre- or post-operatively. Tissue flaps may be needed to provide vascularized tissue over alloplastic materials used to stabilize the chest wall, to cover vital structures of the chest cavity, to fill dead space, and to improve cosmesis.
Pulmonary edema induced by injections of oleic acid was demonstrated using 111In-chloride lung/heart image in five anesthetized dogs. The anesthetized dogs were positioned under a gamma camera interfaced to a computer. After 111In-chloride IV injections, dynamic data were recorded at 1 frame/min before and after induced pulmonary edema. The computer generated the curve of the lung-to-heart activity ratio; the ratio rose from 0.5-0.6 at baseline to 0.85-1.5 at the end of the study in the dogs. At the end of each study, the removed lungs demonstrated edematous fluid, and a few red blood cells were seen in the alveoli. The results indicating pulmonary edema exhibited in the 111In-chloride lung-to-heart ratio obtained from a computerized gamma camera were compatible with the pathological result. Since 111In-chloride instantly binds to plasma transferrin, an excellent intravascular imaging agent, leakage of this tracer into alveoli indicates loss of membranous wall competence. Pulmonary edema, as in the adult respiratory distress syndrome, is sometimes difficult to diagnose; and this 111In-chloride lung-to-heart imaging technique may be potentially useful.
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Computed tomography has widened the diagnostic and indicatory potential in thoracic and cardiovascular surgery. The method allows discovery and localization of discrete pathological findings thus far evading routine diagnostics. Under certain conditions tissue may be characterized and a tumor staging performed. Computed tomography cannot replace preoperative angiography but is useful for noninvasive postoperative screening. The value of the procedure in diseases of the lung and pleura, the mediastinum, and the cardiovascular system is demonstrated.
The computed tomographic appearance of achalasia of the esophagus is described in three patients. The CT findings should enable one to suggest the diagnosis of achalasia even in those patients in whom this condition is not suspected. The final diagnosis can be confirmed by esophagography and manometric studies.
Patients who undergo thoracic surgical procedures often are at high risk. Several risk-scoring systems have been advocated; they are complex and unwieldy. Also, physicians-in-training need a teaching tool with a consistent format. A program for these needs has been written in the high-level language Modula-2 for the Macintosh Computer. The user enters height, weight and easily obtainable data. Normal values are accessed via a 'window' which is triggered by clicking the 'mouse'. When pulmonary data is entered, cardiovascular system questions are presented. The user is finally presented with entered data, calculated data and a risk estimate. Complications estimates are derived from a special LEARNER file. The program 'learns' from a constantly expanding database.
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After clinical investigation the most important diagnostic procedure is the simple chest X-ray in upright position. In case of hemothorax or pneumothorax the insertion of a large chest tube in the third of fourth intercostal space is necessary. Patients with traumatic flail chest and paradoxical respiration need first of all immediate intubation and artificial respiration, afterwards operative stabilization is beneficial in selected patients. In case of severe intrathoracic hemorrhage and in case of injuries of the lungs, heart and great vessels an active surgical approach is a life-saving treatment. Apart from patients with very bad general condition the usual diagnostic measures and an adequate conservative or surgical treatment can always be tolerated by the patient considering his life threatening condition.
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Extracorporeal membrane oxygenation (ECMO) has been performed on 45 neonates at the Children's Hospital of Michigan in a 39-month period. Ultrasound evaluation of these patients prior to and during ECMO therapy has demonstrated abnormalities in the central nervous system including intracranial hemorrhage (21), extra-axial fluid collections (5), and ventricular enlargement (2). Ultrasonic evaluation of the thoracic cavity in 12 infants revealed pleural fluid in 8. There were seven children with varying types of peritoneal fluid. Two children had visceral abnormalities - 1 with liver hemorrhage and 1 with hydronephrosis found prior to ECMO. Most of these findings could not have been diagnosed without ultrasound and may lead directly to alterations in clinical management. Ultrasound is an extension of physical examination which is important in hour-by-hour clinical care of patients on ECMO.
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In evaluating the image quality of the chest, four different analog and digital methods were compared. For peripheral lung field, the advanced multiple beam equalization radiography (AMBER) system was given the best score, followed in order by the storage-phosphor, conventional, and asymmetric film/screen systems. For the mediastinal field, the highest image quality was given to the AMBER system, followed by storage phosphor and asymmetric film/screen system. The best overall image quality, especially with regard to demonstration of pathologic alteration, was given to the AMBER system, followed by the storage-phosphor, conventional, and asymmetric film/screen radiography systems. In conclusion, AMBER demonstrated the highest image quality. The storage-phosphor system provided better results in the peripheral and mediastinal fields in comparison with conventional film/screen systems. Other digital systems including selenium chest radiography system and image intensifier digital radiography were also discussed.
The preclinical tension pneumothorax which even without technical support is easily recognizable, requires immediate decompression. However, there are a number of patients with thoracic injuries such as serial rib fractures or palpable skin emphysema which--in combination with a ventilator--may necessitate the insertion of a thoracic tube. In the preclinical setting this procedure usually only takes place in the ventilated patient. With patients who are respiratorily compensated and are breathing spontaneously, careful control and a conservative approach is advised even if pneumothorax is suspected.