First Rib Research Articles

The effect of low-intensity pulsed ultrasound on rib fracture: An experimental study.

In this study, we aimed to investigate the effects of lowintensity pulsed ultrasound on rib fracture healing in a rat model. A total of 72 male Wistar-Albino rats were randomly divided into three equal groups. To induce a rib fracture, right thoracotomy was performed under general anesthesia and a 0.5-cm segment was removed from the fourth and fifth ribs. After 24 h of surgery, low-intensity pulsed ultrasound was implemented according to the groups. Group 1 served as the control group for the observation of normal bone healing. Low-intensity pulsed ultrasound was applied at a dose of 20% (2 msn pulse-8 msn pause) 100 mW/cm2 and 50% (5 msn pulse-5 msn pause) 200 mW/cm2 for six min, respectively in Group 2 and Group 3. All subjects were followed for six weeks. Eight animals from each group were sacrificed at two, four, and six weeks for further assessment. Histological alterations in the bone were examined. Although there was no statistically significant difference in osteoblasts, osteoclasts, new bone formation, and lymphocyte count among the groups, histological consolidation was significantly increased by low-intensity pulsed ultrasound. While low-intensity pulsed ultrasound induced osteoblastic, osteoclastic, and new bone formation, it inhibited lymphocyte infiltration. Low-intensity pulsed ultrasound, either at low or high doses, induced the histological consolidation of rib fractures and inhibited lymphocyte infiltration. This effect was more prominent in the long-term and at higher dose with increased daily and total administration time. We, therefore, believe that accelerating the natural healing process in patients with rib fractures would enable to treat more effectively in short-term.

Thoracic surgery by minimally invasion robot-assisted in children: “experience and current status”

Aim: We report our experience in minimally invasive thoracic robot-assisted surgery in children, and a current analysis is carried out on this topic. Methods: Observational, prospective, and longitudinal studies were performed for children with thoracic pathology treated with robotic surgery, from March 2015 to April 2019. We used the “da Vinci surgical system” (Intuitive Surgical, Inc., Sunnyvale, CA. USA). Registered variables included demographic data, diagnosis, surgery, total time, time of console surgery, bleeding, hemotransfusions, conversions, complications, postoperative (PO) stay, and follow-up. Measures of central tendency were used. Research Ethics Committee of Hospital approved the study. We conducted a detailed non-systematic review of previous publications of children undergoing thoracic robotic surgery. Results: We treated 11 children, with average age of 5.7 years and weight of 21.3 kg. Diagnosis were: congenital cystic adenomatoid malformation, intralobar sequestration, diaphragmatic paralysis, diaphragmatic eventration, mediastinal teratoma, Ewing’s tumor of the fourth left rib, and pulmonary tuberculosis. Surgeries performed were: four lobectomies, four diaphragmatic plications, two tumor resections, and a case of pleural and lung biopsies. The average of console surgery time was 166.45 min, PO stay was 3.6 days, and follow-up was 24.7 months. Conversions and PO complications were 9.1%, and there were no intraoperative complications and mortality. Currently, the number of children treated with thoracic robot-assisted surgery has barely reached 100 cases. Conclusion: Our results are encouraging, although our experience is limited to a few cases. Robotic surgery for the treatment of thoracic pathology is feasible and safe, and has advantages. To date, very few patients have been treated, and few pediatric surgeons worldwide have applied thoracic robotic surgery in children.

Justifi cation of the use of osteopathic correction in the complex rehabilitation of patients with consolidated fractures of the large tubercle of the humerus

Introduction.Fractures of the proximal humerus occur in 4–5 % of all fractures and 50–80 % of all fractures of the humerus. The treatment of this type of fracture is a relevant issue. This is due, on the one hand, to a rather high frequency of occurrence of such fractures, and, on the other hand, to a signifi cant probability of the development of persistent functional disorders. The use of osteopathic techniques is possible both in acute (without alteration of the integrity of bone structures) and in chronic injuries of the musculoskeletal system. Their use during the rehabilitation process is especially valuable. Currently, there are few works in the scientifi c literature exploring the effectiveness of osteopathic treatment as part of the comprehensive rehabilitation of this group of patients. The foregoing has predetermined the purpose of this work. The goal of research — to substantiate the possibility of using osteopathic correction in the comprehensive rehabilitation of patients with consolidated fractures of the large tubercle of the humerus after conservative treatment.Materials and methods.From January 2016 to December 2018, in the Arbatsky consultative diagnostic centre at the Pirogov National Medical and Surgical Center a prospective, controlled randomized trial was conducted. The study included 30 patients with consolidated fractures of the large tubercle of the humerus. Patient selection and sampling was carried out by the continuous method. Patients were divided into two groups of 15 people by the method of simple randomization with the use of a random number generator. In the main group, therapy consisted of rehabilitation treatment (physiotherapy, exercise therapy) and osteopathic correction, including 3 sessions with an interval of 1 week. Patients in the control group received only rehabilitation treatment. Before and after treatment, all patients underwent an assessment of the severity of pain in accordance with the visual analogue scale, measurement of the volume of active movements in the shoulder joint with the use of a goniometer, assessement of the timing of recovery of shoulder function using the OSS questionnaire, as well as osteopathic examination according to the approved protocol.Results.Most often, patients with a fracture of the large tubercle of the humerus presented somatic dysfunctions of the thoracic region (both structural and visceral components), as well as chronic local dysfunctions of the sternoclavicular joint, the fi rst rib, individual vertebral motor segments. In patients of both groups receiving both isolated traditional rehabilitation treatment and traditional rehabilitation treatment in combination with osteopathic correction, there was a decrease in the severity of pain and an increase in the volume of active movements in the shoulder joint. Moreover, in the group that additionally received osteopathic correction, lower pain indicators and higher range of motion were noted compared with the control group. Also, the functions of the shoulder joint in patients of the main group were restored faster.Conclusion.The obtained results confi rm the advisability of including osteopathic correction in the program of comprehensive rehabilitation of patients with fractures of the large tubercle of the humerus.

Recurrence of Paget-Schroetter Syndrome: A Rare Case Report and Review of Literature

Paget-Schroetter syndrome (PSS) is a primary upper extremity deep vein thrombosis (DVT) that occurs with no significant risk factors, mostly in a young and healthy patient. Treatment of this disease is discussed heavily in the literature and the optimal treatment method is still being debated. Here, we present a patient with PSS treated with balloon angioplasty, thrombolysis and treatment with an oral thrombin inhibitor (apixaban) who developed recurrence of PSS. A 38-year-old white male with no past medical history, presented to an urgent care center with sudden onset axillary pain and an axillary lump that was treated with outpatient antibiotics. Extensive deep venous thrombosis was diagnosed with computed tomography (CT) and ultrasound. He underwent percutaneous pharmacomechanical thrombectomy. Postprocedural angiogram showed significant improvement in the caliber of the axillary and subclavian veins where they crossed the first rib. He was discharged on apixaban and underwent removal of his first rib 1 month later. He returned 3 weeks later with recurrence of right arm pain and swelling. Repeat ultrasound showed thrombus in the right arm and venogram confirmed 80% stenosis at the subclavian vein as it enters the innominate vein. He was again treated with placement of a thrombolytic catheter and overnight thrombolysis of the central venous circulation on the right-side upper extremity balloon angioplasty of the subclavian vein, axillary vein, and basilic vein. He is disease-free for 6 months. Recurrence of PSS after surgical removal of rib, thrombectomy, thrombolysis while using apixaban is very rare. This is the first case to our knowledge presented with recurrent PSS treated with apixaban, early rib resection, balloon angioplasty and thrombectomy. J Med Cases. 2020;11(1):22-25 doi: https://doi.org/10.14740/jmc3416

Estimating Age of Mature Adults from Degeneration of the Medial End of the Clavicle in an African American Sample

Accurate age estimation is fundamental to identifying individuals in forensic anthropology and interpreting demographic patterns in bioarchaeology. Producing age estimates within useful ranges is particularly difficult when assessing older individuals (40+ years). Falys and Prangle (2015) developed a method (referred to henceforth as the FP method) for narrowing age-range estimates for older adults by scoring surface topography, porosity, and osteophytes of the medial end of the clavicle and applying regressions to create age-estimation ranges. That study included individuals of European decent aged 40+ years from four documented skeletal collections. New methods require testing for reproducibility as well as for the appropriateness and utility for subsamples from which the methods were not derived. Here we applied the FP method to a nineteenth-and twentieth-century African American age-and sex-documented skeletal sample (N = 229) from the Hamann-Todd Collection at the Cleveland Museum of Natural History. The method was reliable, and a statistically significant relationship was found between increased scores of degenerative features and older age. Accuracy in predicting age from the composite scores and regressions was 38.43–78.60% (compared to 96.4% from the original study). It failed to narrow age ranges beyond those available from other common aging methods (e.g., pubic symphysis, auricular surface of the ilium, sternal end of the fourth rib). Results suggest that differences in degeneration of articular surfaces are not negligible. This method should not be used universally across samples as a means of increasing accuracy of forensic identification. Sample-specific testing, in tandem with an exploration of variables that drive and/or affect age-related degeneration, should be pursued.

Tracheal Adenocarcinoma in a Cat

Background: Primary tracheal adenocarcinoma is a rare neoplasm in cats. The clinical signs often are indicative of upper airway obstruction accompanied with dyspnea, stridor, wheezing, exercise intolerance, and cough. The severity of the clinical signs is related to the size of the mass and consequently, the proportion of the tracheal lumen that is obstructed. The diagnosis is made using thoracic radiography and tracheobronchoscopy by collecting fragments for histopathological analysis and removing the mass. The present study aimed to report the case of a cat with tracheal adenocarcinoma.Case: A 17-year-old Persian female cat presented with clinical signs of dyspnea and progressive weight loss. Emergency therapy was started with bronchodilators, antibiotics, and corticosteroids, but there was no response to treatment. Complementary blood and imaging tests were performed. Thoracic radiography revealed soft tissue opacity overlying the dorsal trachea from the third to the fourth rib, bronchial pattern, and pulmonary hyperinflation. Tracheoscopy showed an irregular intraluminal thoracic trachea mass, occluded by approximately 95% of the airway lumen. The mass was biopsied multiple times with endoscopic cup biopsy forceps, followed by removal of approximately 50% of the mass lesion with an endoscopic wire snare. The patient was in intensive care, and since her clinical condition worsened 48 h after the endoscopic procedure, euthanasia was performed. Necropsy revealed a remanescent mass located in the trachea lumen 8 x 3 mm and a nodule in the right caudal pulmonary lobe with 8 mm of diameter . Histological examination showed epitelian cuboidal neoplastic cells with acinar patterns. Only a few mitosis and moderate anysocitosis were observed. The final diagnosis was primary tracheal adenocarcinoma with pulmonary metastasis.Discussion: The initial oxygen therapy associated with bronchodilators and antibiotics can be explained by the history of asthma. Tracheal tumors in cats are considered to be rare, which makes the diagnosis challenging. The suspicion of tracheal neoplasia was only raised after radiographic examination, but it was not possible to state whether it was intra- or extratracheal. The bronchial pattern reported herein can be observed both in inflammatory diseases such as asthma and bronchitis as well as aging-related diseases in animals. Pulmonary hyperinflation, with a caudal displacement of the diaphragm, is seen in bronchial diseases and in cases of tracheal neoplasms, with the latter justified by the retention of air in the pulmonary lobes. Dehydration and weight loss in the animal are justified by severe dyspnea, which makes it difficult to consume food and water. The tracheoscopy procedure was essential to confirm intraluminal tracheal neoplasia with almost complete lumen obstruction. An attempt was made to remove the neoplasms with polypectomy endoscopic forceps. However, because 95% of the trachea was obstructed, the manipulation led to local edema and bleeding, which promoted complete obstruction of the air passage to the lungs. The obstruction impaired the patient's oxygenation, justifying procedure suspension. The instability and worsening of the clinical picture persisted in the subsequent days, which prevented further intervention, culminating in the animal's euthanasia. Adenocarcinoma, in the present case, was in the advanced stage, evidenced by the presence of pulmonary metastasis. Dyspnea severity was related to neoplasm size, proportion of tracheal lumen obstruction, and presence of pulmonary metastasis. The tumor size associated with the presence of metastasis was a determining factor for the classification of neoplasia in the advanced stage, making more invasive interventions impossible and worsening the patient prognosis.

フレイルチェストに対する外科的肋骨固定が入院期間の短縮に有用であった1例(A case in which a presumed diagnosis of flail chest and the performance of rib fixation facilitated the shortening hospital stay)

要旨フレイルチェストの治療は，長期の陽圧換気による治療が標準的であるが，長期の陽圧換気は合併症として人工呼吸器関連肺炎，ICU滞在期間の延長などが考えられる。今回我々は，肋骨固定術が入院期間の短縮に有用であった可能性がある1例を経験したので報告する。60歳代の男性。プレス機で体幹部を挟まれ受傷，当院に搬送となった。右第1–12肋骨骨折に伴うフレイルチェスト，右外傷性血気胸の診断で入院となった。入院後は疼痛コントロールと持続的胸腔ドレナージを行っていたが，胸郭の動揺が持続しており，血腫と無気肺の増大を来していたため，第5病日に肋骨固定術を施行した。術後は早期に離床し，大きな合併症なく退院し，その後社会復帰した。本症例では無気肺の増大を契機に手術を行ったが，手術により早期離床が可能となり，長期臥床や人工呼吸器管理，さらに付随する合併症を回避することができた。フレイルチェストに対する早期の肋骨固定術により，入院期間を短縮できた可能性がある1例を経験した。

Comparison of 14 body size variables on adult skeletal age methods: how body mass, BMI, fat and muscle influence age estimations

Background: Skeletal age estimations consistently under-age individuals with low body mass and over-age individuals with high body mass.Aim: To assess the directional biases of body size variables, including fat and muscle tissue, on skeletal age estimates.Subjects and methods: CT scans of 420 age- and size-selected cadavers were assessed using the fourth rib and pubic symphysis age estimation methods. MANCOVA was used to test the effects of stature, body mass, circumference, and fat and muscle tissue area on age estimation biases.Results: For both methods, there were biases based on body mass, BMI, circumference and fat tissue area. Individuals with the lowest measurements for these variables were under-aged while individuals with the highest measurements were over-aged. Age estimation biases were not affected by stature, muscle area, or skeletal measurements of bi-iliac breadth, femoral head diameter, or femoral length.Conclusion: Increased body mass, and specifically fat tissue, accelerates skeletal ageing. Increased muscle area generally did not show a protective effect on skeletal ageing. The accuracy of age estimations would be improved by factoring in body mass. However, femoral head diameter and bi-iliac breadth are not good proxies for body mass. Osteological markers of obesity offer a promising new approach.

A Case of Generalized Crystal Storage Histiocytosis Presenting as Soft Tissue Sarcoma: Diagnostic Dilemma

Crystal storage histiocytosis (CSH) is a rare clinical entity. It comprises of benign histiocytes showing accumulation of refractile generally immunoglobulin crystals in the cytoplasm. Accumulation of non-immunoglobulin substances is also described, common being clofazimine, charcot-leyden, and cystine. Here, we present a case of generalized CSH presenting as a chest wall mass in a 62-year-old gentleman. X-ray showed a chest wall mass with destruction of the right sixth rib. Histopathological examination revealed plasmacytoma with the presence of histiocytes showing abundant pink cytoplasm. Bone marrow examination revealed the presence of plasma cells with dense azurophilic granules. The patient was started on chemotherapy for multiple myeloma. It is clinically important to identify these cases as part of published literature since it annotates poor prognosis to the generalised form of CSH compared to localized one. The unusual location, presence of morphologically distinct plasma cells in marrow, made the diagnosis challenging. The case also highlights the role played by immunohistochemistry to arrive at the right diagnosis.

Meat Goat Performance, Carcass Traits, and Meat Characteristics of Kid Meat Goats Supplemented with Sunn Hemp or Concentrates on Pasture

ObjectivesFeed is a large input cost to a goat operation (Gillespiex et al., 2013) so the optimal time to supplement pasture grazing impacts the economic return on the feed investment. The objective of this study was to compare growth, carcass traits, and goat meat properties of weaned kid goats on pasture with access to sunn hemp followed by concentrate feed 50 d prior to slaughter or supplementation with concentrates and switching to sunn hemp 50 d prior to slaughter.Materials and MethodsSavanna (n = 23) and Savanna-Kiko (n = 14) kid meat goats from the Louisiana State University meat goat herd were ranked by weight within each breed into groups of the four heaviest goats, next four heaviest goats and continuing until all goats were assigned into four groups. The two treatments were sunn hemp and native pasture or native pasture supplemented with 16% crude protein feed daily at 3% of the average group body weight with two replications of each treatment. After 50 d, the animals were switched to the opposite treatment. Goats were weighed weekly and linear dimensions were measured prior to overnight fasting and humane slaughter at Day 100 at an average live weight of 27.2 kg. Temperature and pH of the M. Semimembranosus were measured after hide removal and 1 h, 3 h and 24 h after stunning. Carcasses were chilled overnight at 2°C before determination of carcass characteristics, the M. Longissimus dorsi area and body wall thickness at the 13th thoracic vertebrae, and L*, a*, and b* color of the M. Rectus abdominis flank muscle and M. Longissimus dorsi. Right sides were fabricated into USDA IMPS food service style cuts with an additional transverse cut between the fourth and fifth ribs. Consistent with previous experiments, M. Semimembranosus muscles were vacuum packaged and held at 4°C for 7 d before grilling on a conveyor oven to an internal temperature of 75°C. Cook yield was determined as cooked weight divided by raw weight. Three 1.27-cm cores were removed parallel to the muscle grain for Warner-Bratzler shear force. Data were analyzed with effects of treatment, breed, replication, and interactions by R-studio aov function with separation of least squares means and significance set at P < 0.05.ResultsSavannah goats were heavier than Savannah-Kiko goats through the 100-d trial and finished on concentrate compared with those finished on sunn hemp, but average daily gain was not different (P > 0.05) with feed or breed. The only difference among the carcass traits were dressing percentages of 50.81% with the concentrate and 48.13% with sunn hemp (P < 0.05). Boneless lean yield and shear force were not different (P > 0.05) with treatment or breed.ConclusionThe minor differences in results did not clearly distinguish between the supplementation methods to improve growth, carcass traits, or meat characteristics of the two types of kid meat goats.

Tenderness and Juiciness of Beef Steaks from Varying Hot Carcass Weights

ObjectivesOur objectives were to determine how hot carcass weights affected temperature decline and pH decline of carcasses, and subsequently shear force, juiciness and color of steaks.Materials and MethodsCarcasses (n = 59) were selected at a commercial abattoir over five collection days at approximately 45 min after exsanguination and sorted by hot carcass weight. Carcasses were separated into light (< 363 kg), medium (363 to 408 kg), or heavy (> 408 kg) weight groups. Temperature decline was monitored with a data logger for 24 h with one probe inserted into the longissimus muscle at approximately the sixth rib and one probe inserted directly into the center of the semimembranosus muscle. Muscle pH was measured in the longissimus and semimembranosus muscle at 0, 4, and 24 h after carcasses were moved into chill coolers. After approximately 24 h of chilling, ribeye area, 12th rib fat, KPH, and USDA Quality and Yield Grades were collected. Ribeye rolls (IMPS 112A) and inside rounds (IMPS 160A) were transported to the North Dakota State University Meat Laboratory and aged in vacuum packaging for 14 d. Ribeye and rounds steaks were fabricated for Warner-Bratzler shear force and color analysis. Color analysis was determined on each steak using a Minolta colorimeter after a 30-min bloom time. A 50-g sample was collected for drip loss analysis. Data were analyzed using the mixed procedure of SAS.ResultsLongissimus muscle temperature at 4 h was less (P = 0.02) in light carcasses compared with heavy weight carcasses and semimembranosus muscle temperature was less (P < 0.0001) in light and medium weight carcasses compared with heavy weight carcasses. There were no differences in pH decline (P ≥ 0.16) among hot carcass weight groups. There were no differences in fat thickness, KPH or marbling score (P ≥ 0.12) among hot carcass weight groups. Longissimus area (P = 0.0002) was larger and USDA final yield grade was greater (P = 0.04) among hot carcass weight groups. There were no differences in drip loss, cook loss or WBSF in either longissimus or semimembranosus muscles (P ≥ 0.10) among carcass groups. Color data indicated that ribeye and round steaks from heavy weight carcasses were redder than steaks from light weight carcasses (P ≤ 0.02).ConclusionHot carcass weight did not have an influence on objective measures of meat palatability traits; however, carcass weight did have an effect on color.

A patient with a localized malignant pleural mesothelioma and 15-year disease-free survival

Localized malignant pleural mesothelioma (LMPM) is rare and its natural history is not well known. There is not enough evidence to allow the physician to follow a clear therapeutic plan in everyday clinical practice. This case report is about a 40-year-old female who was being studied because of right scapular pain, neck swelling and shortness of breath that led to identify a mass in the right upper lobe. Because of the rapid growth of the mass, the patient presented acute severe respiratory insufficiency and hypoxaemia resulting in haemodynamic instability that required intubation, mechanical ventilation and vasoactive drug support. With no definitive histo-pathological diagnosis, the patient underwent emergency thoracotomy for en bloc resection of the right upper lobe, the second to fourth ribs and pericostal tissue extending to the paravertebral muscle. The patient had a favourable postoperative course. Routine pathological study of the resected specimen revealed a highly undifferentiated tumour with no further characterization. Electron microscopy revealed a malignant pleural mesothelioma (MPM). In view of the diagnosis, the patient received adjuvant chemo-radiotherapy. The patient remains disease-free 15 years after the operation. The LMPM needs to be differentiated from the diffuse form of MPM. While the latter can rarely be cured, the former can be eradicated with tumour resection en bloc with the involved structures and adjuvant therapy. The purpose of this case report is to draw attention to this localized form of MPM and to the fact that an emergency operation was required with no certain preoperative diagnosis because of the rapid growth of the tumour.

Supero-Septum Pedicle Mammaplasty: A New Modification for Reduction Mammaplasty

Many techniques have been introduced for reduction mammaplasty and are utilized in diverse frequencies by different surgeons according to patient needs. Each technique is evaluated based on the aesthetic result, longevity, complication rate, and preservation of the nipple-areola complex (NAC) sensation. The authors sought to introduce the new modified technique of supero-septum pedicle mammaplasty (SSPM) that utilizes both the septum and superior pedicle and is suitable for macromastia and gigantomastia cases. Between 2015 and 2018, 60 women who underwent SSPM were evaluated in a prospective study after undergoing superior pedicle deepithelialization and resection of the inferior, lateral, and medial segments. In the lateral pillar, a tongue of tissue was preserved for fixation to the medial pectoral fascia through a window created in the superior pedicle at the third intercostal space. Finally, septum pedicle was sutured to the fascia and muscle at the upper border of the sixth rib somewhat medially. Patients were followed up for a minimum of 13 months. The mean nipple-to-sternal notch (N-SN) distance was 33.05 cm, and the mean NAC elevation was 10.92 cm. Breast reductions varied from 270 to 2800 g per breast. Complications included wound dehiscence (5%), wound infection (2.5%), and partial NAC necrosis (2.5%). At 6 months postoperation, the NAC sensation was significantly better compared with preoperative values (P < 0.005). SSPM is a relatively safe method of reduction mammaplasty, even for very large breasts, that leads to good aesthetic form along with preserving circulation and sensation of the NAC.

Compression-based injury variables from chestbands in far-side impact THOR sled tests

Objective: This study seeks to determine compression (Cmax) and compression-related injury variables (velocity and viscous injury criterion: Vmax and VCmax) from chestband data in pure lateral and oblique far-side impact sled tests.Methods: The 3-point belt–restrained mid-sized male Test Device for Human Occupant Restraint (THOR) dummy was placed on a buck and subjected to side impacts with and without center-mounted airbags. The change in velocity was 8.3 m/s for all conditions. Two chestbands were routed around the outer circumference of the THOR at the levels of the third and sixth ribs. Maximum chest deflections were computed using strain gauge signals from the chestbands and their temporal contours. Three methods were used to determine deflection metrics. The first method paralleled methods used in previously published human cadaver studies; the second method used the actual anchor point location and actual alignment of the dummy’s internal sensors; and the third method used the anchor location of the internal sensor but determined the sensor’s locations on the contour confining to the aspect of the sensor. These 3 approaches are abbreviated as the SD, ID, and TD variables. The injury variables Cmax, Vmax, and VCmax were determined according to accepted procedures. Their peak magnitudes were extracted and an evaluation of their accuracy was made based on the SD method.Results: The average SD-based Cmax magnitudes for the upper and lower chest levels were 0.12 and 0.17 m/s, the Vmax magnitudes were 5.3 and 1.8 m/s, and the VCmax magnitudes were 0.24 and 0.15 m/s, respectively. Other data are given for all variables at the 2 levels of the thorax in the body of this paper. The ID-based peak variables were the lowest, and this observation was true regardless of the aspect, right or left side. In contrast, the SD method produced the greatest magnitudes of the variables. The VCmax variable had the greatest normalized difference among all 3 injury variables.Conclusions: Though the present study is limited in scope, the predetermined placement of the internal sensors in the THOR dummy underpredicted chest deflection-related injury variables, and the viscous criterion was the least reliable variable in these lateral and oblique far-side impact sled tests.

Subxiphoid uniportal video‐assisted thoracoscopic surgery: A cosmetically superior approach to submammary rib tumor resection

This report describes a cosmetically superior approach to submammary rib tumor resection. Surgical resection is the most effective method for the treatment of rib tumors. Common surgical methods include thoracotomy and thoracoscopic surgery. Subxiphoid uniportal video‐assisted thoracoscopic surgery (VATS) has recently been described and is being increasingly used in a variety of thoracic procedures, including thymectomy, lobectomy, and resection of giant pleural fibroids. However, there has been no report in the literature which has described the use of uniportal subxiphoid VATS for rib tumor resection. We herein report the successful removal of fibrous dysplasia of the anterolateral segment of the sixth rib by subxiphoid uniportal VATS.

Detailed subject-specific FE rib modeling for fracture prediction

Objective: The current state of the art human body models (HBMs) underpredict the number of fractured ribs. Also, it has not been shown that the models can predict the fracture locations. Efforts have been made to create subject specific rib models for fracture prediction, with mixed results. The aim of this study is to evaluate if subject-specific finite element (FE) rib models, based on state-of-the-art clinical CT data combined with subject-specific material data, can predict rib stiffness and fracture location in anterior-posterior rib bending.Method: High resolution clinical CT data was used to generate detailed subject-specific geometry for twelve FE models of the sixth rib. The cortical bone periosteal and endosteal surfaces were estimated based on a previously calibrated cortical bone mapping algorithm. The cortical and the trabecular bone were modeled using a hexa-block algorithm. The isotropic material model for the cortical bone in each rib model was assigned subject-specific material data based on tension coupon tests. Two different modeling strategies were used for the trabecular bone.The capability of the FE model to predict fracture location was carried out by modeling physical dynamic anterior-posterior rib bending tests. The rib model predictions were directly compared to the results from the tests. The predicted force-displacement time history, strain measurements at four locations, and rotation of the rib ends were compared to the results from the physical tests by means of CORA analysis. Rib fracture location in the FE model was estimated as the position for the element with the highest first principle strain at the time corresponding to rib fracture in the physical test.Results: Seven out of the twelve rib models predicted the fracture locations (at least for one of the trabecular modeling strategies) and had a force-displacement CORA score above 0.65. The other five rib models, had either a poor force-displacement CORA response or a poor fracture location prediction. It was observed that the stress-strain response for the coupon test for these five ribs showed significantly lower Young’s modulus, yield stress, and elongation at fracture compared to the other seven ribs.Conclusion: This study indicates that rib fracture location can be predicted for subject specific rib models based on high resolution CT, when loaded in anterior-posterior bending, as long as the rib’s cortical cortex is of sufficient thickness and has limited porosity. This study provides guidelines for further enhancements of rib modeling for fracture location prediction with HBMs.

2323 Bone Metastasis as Index Presentation of Hepatocellular Carcinoma

INTRODUCTION: Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver, and the fifth most common cancer worldwide Extrahepatic mestastasis rarely occurs in patients with early course HCC. Bone metastasis as the initial presentation of HCC is even more rare. Here we present an unusual case of Bone metastasis to the ninth rib as the index presentation of HCC. CASE DESCRIPTION/METHODS: The patient is a 60 year old male with a medical history of hypertension, hepatitis C virus, hyperlipidemia, rheumatoid arthritis and chronic obstructive pulmonary disease who presented to the emergency department complaining of right upper quadrant pain for one week. Physical exam was notable for tenderness over the patients right ninth rib. The rest of the physical exam was unremarkable. Notable laboratory workup included a complete blood count and comprehensive metabolic panel within normal limits. Notable imaging included a computed tomography of the abdomen showing a mass over the ninth rib with multiple foci in liver. The next day an alpha fetoprotein (AFP) level was ordered and returned elevated at 1139.0 ng/ml. Other tumor markers including carcinoembryonic antigen (CEA), carbohydrate antigen 19 9 (CA 19 9) and prostate specific antigen (PSA) were within normal limits. Interventional radiology was then consulted and performed a biopsy of the ninth rib mass which showed metastatic carcinoma with a primary of hepatocellular malignancy. This diagnosis was supported by positive staining with Hep-Par 1. Following this diagnosis the oncology service was consulted and recommended palliative radiotherapy to the ninth rib and starting treatment with Sorafenib. The patient was then discharged with pain medications and follow up appointments. DISCUSSION: Common risk factors for the development of HCC include Hepatitis B, Hepatitis C, Aflatoxin exposure, and cirrhosis of any cause (including alcohol). The most common sites of extra-hepatic metastasis of HCC are lung, lymph node, musculoskeletal, and adrenal gland. Isolated bone metastasis of HCC is rare occurring in only 9.5% of patients. Symptoms associated with HCC include right upper quadrant pain, jaundice and ascites in more advanced cases. Treatment of metastatic HCC to bone includes chemotherapy and targeted radiotherapy. More recently Bisphosphonates have also been shown to have success.

AN UNUSUAL COMPLICATION OF PULMONARY BIOPSY: ATRAUMATIC LUNG HERNIATION

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Lung herniation, in which lung tissue protrudes through its bounding structures, is a rare condition which may occur as a result of trauma, thoracic operations, increased thoracic pressure, or congenital abnormalities(1). CASE PRESENTATION: A 57-year-old African American man presented to the emergency department after one day of right-sided chest pain accompanied by worsening dyspnea after a coughing episode. He described a painful pressure-like sensation adjacent to the sternum that worsened with deep inspiration and was not relieved with positioning. The patient had a history of a sarcoidosis, daily marijuana use, and a prior thoracoscopic right anterior lung wedge resection for a pulmonary biopsy 2 years prior. On physical exam the patient had a heart rate of 108 beats per minute, blood pressure of 137/98 mmHg, respiratory rate of 18, and oxygen saturation of 95% on room air. He had tenderness to palpation of the right upper quadrant of his abdomen with no palpable mass in the chest or abdomen. There was no tenderness to anterior rib palpation. Chest x-ray was unremarkable except for post-surgical changes of the right hemithorax. A chest computed tomography scan revealed a partial herniation of the right middle lobe of the lung between the right fourth and fifth ribs anteriorly. After initial assessment by thoracic surgery, the patient elected for conservative management and was discharged from the hospital. Due to increasing chest pain, he underwent successful surgical repair of the hernia six months later with subsequent resolution of his chest pain. DISCUSSION: Postoperative intercostal hernias are more common after minimally-invasive surgeries, such as video-assisted thoracoscopy (VATS), compared to major thoracic interventions(2). This increased risk has been attributed to the limited access to tissue in minimally-invasive procedures and resultant inadequate closure of the chest wall. Challenges with wound closure leading to lung hernia have been reported in the literature related to VATS with an anterior approach(3). Our case presents a patient with lung herniation likely secondary to inadequate closure of his prior mediastinoscopy incision. Additionally, his underlying sarcoidosis may have predisposed him to inadequate wound healing, and his chronic coughing from marijuana use may have incited the herniation through increased intrathoracic pressure. CONCLUSIONS: In a patient with a history of minimally invasive thoracic surgery who is complaining of parasternal pleuritic chest pain, lung herniation must be on the differential diagnosis. Increasing size, worsening pain, or incarceration of the hernia are indications for urgent surgical intervention that physicians must keep in mind when treating patients with this rare cause of chest pain. Reference #1: Weissberg D. Lung hernia - a review. Adv Clin Exp Med. 2013. Reference #2: Temes RT, Talbot WA, Green DP, Wernly JA: Herniation of the lung after video-assisted thoracic surgery. Ann Thorac Surg. 2001. Reference #3: Vasileios K. Kouritas, Robert S. George, Alessandro Brunelli, Emmanouel Kefaloyannis; Lung herniation after uniportal video-assisted thoracic surgery lobectomy presenting with subcutaneous surgical emphysema, European Journal of Cardio-Thoracic Surgery. 2016. DISCLOSURES: No relevant relationships by Dave Gupta, source=Web Response No relevant relationships by Erica Sheline, source=Web Response No relevant relationships by Manasi Tannu, source=Web Response

MEDICAL MANAGEMENT OF BILATERAL FLAIL CHEST CAUSED BY PROLONGED CPR

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Flail chest is a life-threatening condition caused by blunt trauma to the chest resulting in fractures of three or more consecutive ribs in two or more places with paradoxical motion. We present a rare case of bilateral flail chest secondary to trauma from manual CPR that recovered without surgical intervention. CASE PRESENTATION: A 65-year-old man presented to our hospital with MI, complicated by VF and cardiac arrest. He was emergently intubated and after 42 minutes of manual CPR he had ROSC. Several attempts at weaning the AC/PC were unsuccessful due to agitation, desaturation, tachypnea. CT chest showed acute fractures of lateral right fourth, anterior right fifth, anterior right sixth, lateral left fourth, anterior left fifth, and anterior left sixth ribs in addition to inward movement of the chest. There was a conservative strategy due to the high risk of bleeding on Ticagrelor and persistent fever (pan-sensitive MSSA on respiratory culture). Pain was managed with Precedex, Hydromorphone, and Midazolam drips then transitioned to Propofol and Gabapentin. He was then started on Oxycodone and Seroquel. On hospital day 25 the patient was weaned off Propofol, was A&O, and transitioned to tracheostomy collar/Fentanyl Patch. DISCUSSION: It is believed that the mortality from flail chest is secondary to complications rather than the flail chest itself, although visceral chest wall injuries such as pulmonary contusions and hemothorax are common. Nevertheless, without proper sedation/pain management (successive use of analgesics/sedatives with different pharmacological properties), and cautious attention to possible complications (VAP, mucous plugging, pulmonary contusions), this patient may have suffered from increased M&M.Pain control was difficult in an awake state; hence he was placed on Propofol for almost the entirety of his stay. At one point he was receiving high dose Hydromorphone, Oxycodone, Precedex, and Propofol. While there may be significant morbidity and additive effect of multiple opioids/sedatives, it was only with meticulous and slow discontinuation of these sedatives that the patient was able to successfully wake up with good pain control and relatively minimal delirium. While epidural/paravertebral blocks were considered, the patient’s DAPT precluded the their use. Secondly, because of the patient’s unusual distribution of fracture, regional anesthesia, would have also been difficult and short-lived. Early tracheostomy was warranted in this situation for comfort, pulmonary toilet, reduction of dead space, and sedative needs. CONCLUSIONS: Rib fractures and flail chest can produce significant morbidity for the elderly. Pain control, pulmonary toilet, and volume expansion measures are critical to reducing complications and further M&M. While surgical fixation continues to be controversial, medical management of even the most severe cases of flail chest can be successful. Reference #1: Phillips B, Murray E, Holzmer S . Bilateral Flail Chest: A review. Journal of Trauma and Orthopaedic Surgery.April - June 2017;12(2):2-7. Reference #2: Dehghan N, de Mestral C, McKee MD, et al. Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg 2014; 76:462. Reference #3: R.S. Hoke, D. Chamberlain. Skeletal chest injuries secondary to cardiopulmonary resuscitation. Resuscitation, 63 (2004), pp. 327-338. DISCLOSURES: No relevant relationships by Hany Abdallah, source=Web Response no disclosure on file for Leila Hosseinian

A RARE MALIGNANCY

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Ewing's sarcoma is a malignant neoplasm which arises from the skeletal bones. It most commonly affects children and young adults with a female preponderance. Ewing’s sarcoma of the rib is a rare enity as long bones are usually affected . CASE PRESENTATION: A 24 year-old male presented with complaints of shortness of breath , cough and left chest pain for 1 month. He also had episodes of seizures since last 3 years. He had multiple soft cutaneous nodules and macular patches over chest , back and upper limbs. There was bulging of left anterior chest wall with shifting of trachea as well as apex beat to right. There was increased vocal fremitus as well dull percussion note on left. There were reduced breath sounds with increased vocal resonance on left. Routine blood investigations were within normal limits. Chest X -ray revealed a homogeneously white left hemithorax with shifting of mediastinum to the right. Pleural fluid cytology had features suggestive of small round cell tumor. CECT thorax revealed a large heterogeneous mass in the left hemithorax with shifting of mediastinum to right and lytic destruction of left 6 th rib. There was minimal left pleural effusion with nodular pleural deposits. USG guided trucut biopsy from the left lung mass revealed small cell neuroendocrine carcinoma. The tumour was CD 99, Synaptophysin, CD 56 , FLI-1 - positive and negative for CK, CK7, TTF-1 and chromogranin. Dermatology opinion favoured the skin nodules to be neurofibromatosis. So a final diagnosis of Ewing’s sarcoma left sixth rib with Neurofibromatosis and seizure disorder was made. The patient received Vincristine , Adriamycine and Cyclophosphamide (VAC),alternating with Ifosfamide and Etoposide as well as was planned for radiotherapy DISCUSSION: Ewing sarcoma is an uncommon disease, which usually arises from the skeletal bones. It constitutes approximately 10 % of all primary malignant bone tumours. Only 40 % of such cases are seen in flat bones like innominate, ribs, scapula and sterum #1.A characteristic chromosomal translocation, (11; 22) (q24; q12) can be detected in 90% of cases .Patients with Ewing's Sarcoma of the ribs present with breathlessness, weight loss and painful chest wall mass. #2 pleural effusion as in our case, is an unusual finding #3 . The tumour has propensity to spread inwards towards the thoracic cavity and thus,may manifest as an extra pleural mass.our case unique in a wayas it had several other associated finding like neurofibromatosis,seizure disorder as well as skin lesion although such association are not commonly reported CONCLUSIONS: This case showcases the significance of IHC an important tool in diagnosis of lung malignancies and lays stress on excluding extrathoracic involvement in all such cases. Reference #1: MirraJM. Bone tumors: clinical, radiologic, and pathologic correlations. Philadelphia: Lea&Febiger, 1989; 1087-1117. Reference #2: Gladish GW, Sabloff BM, Munden RF, Truong MT, Erasmus JJ, Chasen MH. Primary thoracic sarcomas. Radiographics 2002 May-Jun;22(3):621-637 Reference #3: Wolf G, Aigner RM, Schwarz T. Massive pleural effusion with dyspnea in a 17-year-old boy as the first sign of ewing sarcoma. J Pediatr Hematol Oncol 2002 Jun-Jul;24(5):420 DISCLOSURES: No relevant relationships by UMER AHMED SYED, source=Web Response