Elevated Hemidiaphragm Research Articles

A RARE CAUSE OF BRONCHOBILIARY FISTULA

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Bronchobiliary fistula (BBF) is a rare medical condition that presents a diagnostic dilemma. It may be congenital or acquired, with the former having a prevalence of less than 1 million. Once diagnosed its etiology is often evident, however with its incidence due to echinococcal origin being < 2 percent, patients often have multiple hospitalizations prior to diagnosis. We present a rare case of a BBF, treated successfully with a minimally invasive approach. CASE PRESENTATION: 74 year old Syrian female with prior of history of a liver cyst drained of 200 millimeters 3 years prior at another institution comes with right upper quadrant abdominal pain, nausea and vomiting. She has an abdominal magnetic resonance imaging, subsequent CT-guided fine-needle aspiration and is diagnosed with hydatid cyst, treated conservatively with albendazole. She is discharged and presents 3 days later, with productive cough of yellow/green mucus, malaise and fever. She is treated as a healthcare associated pneumonia. Sputum culture shows gram positive cocci and antibiotics are tailored from cefepime and vancomycin to cephalexin in view of MSSA. The patient improves clinically and is discharged on albendazole plus cephalexin and scheduled for elective hepatic cyst resection. She returns 8 days later for fever and productive cough. She is found to have persistent pneumonia with elevated right hemidiaphragm on chest x-ray, treated with piperacillin-tazobactam and vancomycin empirically along with albendazole for hydatid cyst. She has a laparoscopic echinococcal cyst resection with some hepatic resection to facilitate cyst removal. While on the medical floor, she develops bilioptysis and leukocytosis. A BBF is suspected and confirmed with DISIDA scan. An endoscopic retrograde cholangiopancreatography (ERCP) is done with sphincterotomy and stent placement. She continues to clinically improve and is subsequently discharged with no cough for outpatient follow-up. DISCUSSION: Acquired BBF is a rare complication of echinococcal origin. While bilioptysis is the hallmark sign of BBF it may not always be present. This poses a diagnostic dilemma for physicians and potential life threatening complications for patients. The diagnosis is made with a DISIDA. Historically treatment has been surgical, but conservative options such as embolization and stent placement have been proposed. In this case, an ERCP sphincterotomy and stent placement is successfully used. This intervention results in a decrease in the transpapillary pressure gradient, thereby facilitating biliary flow to the intestine and healing of the BBF. CONCLUSIONS: BBF of echinococcal origin has an incidence of < 2%. Bilioptysis, a clinical hallmark, maybe absent posing a clinical dilemma resulting in multiple hospitalizations. This case highlights a rare diagnosis of BBF secondary to hydatid cyst and a successful conservative option, to a once surgical problem. Reference #1: Mohammadreza Seyyedmajidi MD, Mojtaba Kiani MD, Hamid Javadi MD, Alireza Raeisi MD, Majid Assadi MD. Hepatobiliary scintigraphy with SPET in the diagnosis of bronchobiliary fistula due to a hydatid cyst. Hellenic Journal of Nuclear Medicine. 2015 May - August; 18(2):160-162. Reference #2: Guan-Qun Liao, Hao Wang, Guang-Yong Zhu, Kai-Bin Zhu, Fu-Xin Lv, Sheng Tai. Management of acquired bronchobiliary fistula: A systematic literature review of 68 cases published in 30 years. World Journal of Gastroenterology. 2011 September; 17(33): 3842-3849. Reference #3: Anton Crnjac, Vid Pivec, Arpad Ivanecz. Thoracobiliary fistulas: literature review and a case report of fistula closure with omentum majus. 2013 Radiol Oncol; 47(1): 77-85. DISCLOSURES: No relevant relationships by Sahai Donaldson, source=Web Response No relevant relationships by Killol Patel, source=Web Response No relevant relationships by Shanta Shrestha, source=Web Response

Early diaphragmatic plication after cardiac surgery: a case report in an obese patient

BackgroundDiaphragmatic plication to help ventilation weaning of an adult obese patient after cardiac surgery is very uncommon. Diaphragm paralysis is usually treated with conservative measures and ventilator support, after which surgical management is considered after months of medical monitoring.Case presentationWe report the case of a morbidly obese patient to whom ventilation weaning was unsuccessful following coronary artery bypass graft operation with mitral valve replacement. A de novo right hemidiaphragm elevation was seen on the chest X-ray. Diaphragmatic plication was performed promptly to treat severe respiratory insufficiency and generated favorable outcomes.ConclusionsEarly diaphragmatic plication could be considered in the postoperative period of cardiothoracic surgery to facilitate management and ventilation weaning in the context of de novo diaphragm paralysis.

Extrapulmonary sequestration with a left internal thoracic arterial feeding vessel in an infant treated with video-assisted thoracoscopic resection: a case report

BackgroundCongenital lung malformations exist along a spectrum of pathogenesis and disease severity. Extrapulmonary sequestration (EPS), in which nonfunctional lung tissue develops without connection to the tracheobronchial tree, is one rare manifestation of this disease. Atypical vascular anatomy with a systemic feeding vessel characterizes these lesions.Case presentationA 3 day old, 37 week gestation infant underwent chest X-ray for confirmation of umbilical catheter placement and was found to have an elevated left hemidiaphragm consistent with eventration versus congenital diaphragmatic hernia. He remained asymptomatic and was evaluated as an outpatient at the age of 9 months, where CT angiogram demonstrated extrapulmonary versus intrapulmonary sequestration with a systemic feeding vessel from the left internal mammary artery.ConclusionsIt is exceedingly rare for the feeding artery to arise from the internal mammary; two such cases have been reported to date, both in adult patients. Here we present a third case of EPS with arterial supply from the internal mammary successfully treated with video-assisted thoracoscopic resection in a 9 month old infant.

Computed Tomography Features associated With the Eighth Edition TNM Stage Classification for Thymic Epithelial Tumors.

The eighth edition of the TNM classification of malignant tumors for the first time includes an official staging system for thymic epithelial tumors (TETs) recognized by the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC). Staging is critical for the management of TETs, and determining stage accurately from imaging has the potential to improve clinical outcomes. We examine preoperative computed tomography (CT) characteristics of TETs associated with AJCC/UICC pathologic TNM stage. In this retrospective study, patients were included if they met all the following criteria: (1) diagnosis of TET, (2) had primary curative intent surgery performed at Stanford University, and (3) had available preoperative CT imaging for review. Tumor pathology was staged according to the eighth edition TNM classification. Fifteen CT scan features were examined from each patient case according to the International Thymic Malignancy Interest Group standard report terms in a blinded manner. A Lasso-regularized multivariate model was used to produce a weighted scoring system predictive of pathologic TNM stage. Examining the 54 patients included, the following CT characteristics were associated with higher pathologic TNM stage when using the following scoring system: elevated hemidiaphragm (score of 6), vascular endoluminal invasion (score of 6), pleural nodule (score of 2), lobulated contour (score of 2), and heterogeneous internal density (score of 1). Area under the receiver operating characteristic curve was 0.76. TETs with clearly invasive or metastatic features seen on CT are associated with having higher AJCC/UICC pathologic TNM stage, as expected. However, features of lobulated contour and heterogeneous internal density are also associated with higher stage disease. These findings need to be validated in an independent cohort.

New onset of phrenic nerve palsy after laser-assisted transvenous lead extraction: a single-centre experience.

Phrenic nerve palsy (PNP) after mechanical transvenous lead extraction (TLE) was recently described for the first time. We aimed to analyse our TLE database for the presence of PNP. All consecutive patients referred to our institution were included in this study. Every available post-procedural chest X-ray was compared to the routinely performed pre-procedural radiographs. A newly elevated hemidiaphragm ipsilateral to TLE was considered indicative of PNP. Altogether 255 TLE procedures with extraction of 364 leads were performed. Most common TLE indication was lead malfunction (63%). Complete radiographic success rate was 97.3% with an in-hospital procedure-related major complication rate of 2.4%, including one intra-procedural death (0.4%). We identified five cases with PNP (2%), all occurring after laser-assisted TLE. Clinical presentation varied from subtle and aspecific chest pain/discomfort to severe and acute dyspnoea, with time to diagnosis varying from immediate to several weeks after the procedure. In 80% of cases, the explanted lead was a defibrillator electrode and the median lead dwelling time was 70.2 months (29.3; 1084.9). In four cases, the extraction was performed using high-energy laser (pulse repetition rate 80 Hz). The present study reports the incidence of PNP after laser-assisted TLE. We postulate that the thermal energy generated by laser is not dissipated quickly enough in occluded or heavily calcified lesions, injuring the ipsilateral phrenic nerve. Our findings advise to carefully consider to increase pulse repetition rate at the subclavian level. Larger, possibly prospective studies are needed to evaluate the real incidence through systematic radiological assessment after TLE.

In-situ left-sided bilateral internal thoracic artery: elevated hemidiaphragm

Background Procurement of the internal thoracic artery risks ipsilateral phrenic nerve injury and elevated hemidiaphragm. Anatomical variations increase the risk on the right side. Patients receiving left-sided in-situ right internal thoracic artery configurations appear to be at greatest risk. Methods From 2014 to 2016, 432 patients undergoing left-sided in-situ bilateral internal thoracic artery grafting were grouped according to right internal thoracic artery configuration: retroaortic via transverse sinus (77%) or ante-aortic (23%); targets were the circumflex and left anterior descending artery territories, respectively. Elevated hemidiaphragm was assessed by serial chest radiographs and categorized by side, complete (≥2 intercostal spaces) versus partial, and permanent versus transient. Results Right elevated hemidiaphragm occurred in 4.2% of patients. The incidence of radiological complete right elevated hemidiaphragm was 2.8% (12/432); 8 cases were transient with recovery in 3.5 ± 0.3 weeks. Permanent right elevated hemidiaphragm occurred in 0.9% (retroaortic group only). Permanent left elevated hemidiaphragm occurred in 0.9% and was significantly higher in the ante-aortic group (3/99 vs. 1/333, p = 0.039). No bilateral hemidiaphragm elevation was documented. Partial right elevated hemidiaphragm occurred in 1.4% and was not associated with adverse early or late respiratory outcomes. Conclusions Despite susceptible right phrenic nerve-internal thoracic artery anatomy, the incidence of permanent right elevated hemidiaphragm is low and no higher than left-sided in prone bilateral internal thoracic artery subsets. This reflects skeletonized internal thoracic artery procurement. Although statistical significance was not achieved, a retroaortic right internal thoracic artery configuration may constitute a higher risk of right phrenic nerve injury.

Predictors of pneumonia on routine chest radiographs in patients with COPD: a post hoc analysis of two 1-year randomized controlled trials.

BackgroundPatients with COPD are at risk for life-threatening pneumonia. Although anatomical abnormalities in the thorax may predispose to pneumonia, those abnormalities identified on routine chest X-rays (CXRs) in patients with COPD have not been studied to better understand pneumonia risk.MethodsWe conducted a post hoc exploratory analysis of data from two replicate year-long clinical trials assessing the impact of fluticasone furoate–vilanterol versus vilanterol alone on COPD exacerbations (GSK studies: HZC102871/NCT01009463 and HZC102970/NCT01017952). Abnormalities on baseline CXRs from 179 patients who developed pneumonia and 50 randomly selected patients who did not were identified by blinded consensus readings conducted by two radiologists. Positive and negative likelihood ratios and diagnostic odds ratios (ORs) were calculated to evaluate the markers for subsequent pneumonia development during the 1-year study period.ResultsBaseline characteristics distinguishing the pneumonia and non-pneumonia groups included a lower body mass index (24.9 vs 27.5 kg/m2, P=0.008), more severe airflow obstruction (mean post-bronchodilator forced expiratory volume in 1 second [FEV1]/forced vital capacity ratio: 42.3% vs 47.6%, P=0.003), and prior pneumonia (36% vs 20%, P=0.030). Baseline CXR findings with the highest diagnostic ORs were: elevated hemi-diaphragm (OR: 6.87; 95% CI: 0.90, 52.26), thick tracheal-esophageal stripe (OR: 4.39 [0.25, 78.22]), narrow cardiac silhouette (OR: 2.91 [0.85, 9.99]), calcified pleural plaque/mid-chest pleural thickening (OR: 2.82 [0.15, 53.76]), and large/prominent pulmonary artery shadow (OR: 1.94 [0.95, 3.97]). The presence of a narrow cardiac silhouette at baseline was associated with a statistically significant lower mean pre-bronchodilator FEV1 (P=0.040). There was also a trend for a lower mean pre-bronchodilator FEV1 in patients with a large/prominent pulmonary artery shadow at baseline (P=0.095).ConclusionFindings on routine CXR that relate to pathophysiological mechanisms of pneumonia could help determine pneumonia risk in patients with COPD.

Long-term Outcomes of Carotid-Subclavian Bypass in the Setting of Thoracic Endovascular Aortic Repair

Subclavian artery revascularization is frequently performed in the setting of thoracic endovascular aortic repair (TEVAR) for a variety of indications ranging from prophylactic prevention of upper extremity and spinal cord ischemia to preservation of hemodialysis access or left internal mammary artery coronary artery bypass graft. Despite this, there is little information on the short- and long-term outcomes of patients undergoing carotid to subclavian artery bypass. We sought to define the outcomes associated with this procedure. Patients undergoing carotid-subclavian bypass in conjunction with TEVAR between June 2005 and September 2016 were retrospectively identified from a prospectively maintained, single-center aortic surgery database. Categorical and continuous variables were compared using χ2 and Wilcoxon rank sum tests, respectively. The 30-day outcomes specific to the carotid-subclavian bypass procedure were analyzed, including nerve injury, bleeding complications, and local vascular complications. All preoperative and postoperative chest radiographs were carefully analyzed to assess for hemidiaphragm elevation indicative of phrenic nerve palsy. Long-term outcomes included primary graft patency and anastomotic complications. Of 579 patients undergoing TEVAR during this time interval, 114 patients (20%) underwent concomitant carotid-subclavian bypass. The cohort was 39% female (n = 44), with a mean age of 65 ± 14 years. The majority of conduits were 8-mm polytetrafluoroethylene grafts (n = 107 [92.2%]), with a minority being reversed saphenous vein grafts (n = 4 [3.5%]). The bypass procedure was done concomitantly at the time of TEVAR in 90.4% (n = 103) of cases. The short-term complication rate attributed specifically to the carotid-subclavian bypass was 21% (n = 24). These complications included neck hematoma requiring re-exploration in 0.9% (n = 1), recurrent laryngeal nerve palsy in 5.3% (n = 6), axillary nerve palsy in 1.8% (n = 2), and phrenic nerve palsy in 13.2% (n = 15) of patients. The 30-day all-cause mortality rate was 5.3% (n = 6), and the rate of permanent paraparesis or paraplegia was 0.9% (n = 1). Of the operative survivors (n = 108), follow-up imaging of the bypass graft was available in 84% (n = 96) of patients. Actuarial primary graft patency was 97% at 10 years (Fig). There were three patients (2.5%) with bypass graft occlusions, two of which were clinically silent and detected in follow-up imaging. The third was detected because of the symptoms of subclavian steal and required repeated revascularization. Two patients (1.8%) developed a late anastomotic pseudoaneurysm requiring either endovascular (n = 1) or surgical (n = 1) intervention. Carotid-subclavian bypass for revascularization of the subclavian artery performed in the setting of TEVAR is durable, although the true complication rate is likely to be higher than generally reported in the literature because of a not insignificant rate of phrenic nerve palsy. These data should serve well as “gold standard” comparison data for emerging branch graft devices.

Respiratory Failure From Enlarging Diaphragmatic Hernia: A Rare Complication of Noninvasive Positive Pressure Ventilation

SESSION TITLE: Obstructive Lung Diseases SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Non-invasive positive pressure ventilation (NIPV) is useful for management of hypercapnic respiratory failure. Use of NIPV can have devastating complications.We report a rare case of diaphragmatic herniation that worsened due to gastric insufflation. CASE PRESENTATION: An 87-year-old man with history of COPD and left-sided diaphragmatic hernia presented with cough, worsening shortness of breath and wheezing. Vitals were significant for heart rate of 98 bpm, BP 140/90 mmHg, respiratory rate 28/min, and oxygen saturation 78% on room air. Physical examination demonstrated diffuse wheezing in the both lungs and tympanic percussion in the left hemi-thorax. The initial chest X-ray showed left hemi-diaphragm elevation (Figure 1). Patient was placed on bilevel NIPV (10/5 cm H2O and FIO2:60%) for hypercapnia due to COPD exacerbation. Patient’s respiratory distress worsened while on bilevel NIPV. Repeat CXR showed bowel loops compressing the whole left lung (Figure 2). NIPV was discontinued and patient was made NPO. CT thorax showed a large left diaphragmatic hernia containing most of the stomach, distal transverse colon, and proximal descending colon within the hernia. After discontinuing NIPV, patient’s respiratory status improved with O2 saturation of 95% on 2 L/min NC. Patient underwent surgical repair for bowel strangulation. Post-operative imaging confirmed re-expansion of the left lung with minimal basilar atelectasis and normal vasculature. Patient’s symptoms significantly improved after surgery. DISCUSSION: NIPV reduces the need for intubation, mortality, complications, and length of stay in COPD exacerbation. Some of the NIPV complications are mask intolerance, nasal bridge ulceration, inadequate gas exchange, sinus pain, aspiration and mucus plugging. Pneumothorax and pneumocephalus have been reported as the most serious complications of NIPV. Gastric insufflation is usually a minor adverse effect; however, our patient had significant worsening of diaphragmatic herniation and dyspnea due to to gastric insufflation with NIPV. CONCLUSIONS: There is no ideal target pressure when choosing NIPV settings. There should be a balance between inspiratory pressure supporting gas exchange and patient’s tolerance and comfort. When choosing NIPV physicians should watch for pre-existing diaphragmatic hernia and be aware that applying NIPV could potentially worsen herniation and gas exchange. Reference #1: Gay PC1.Complications of noninvasive ventilation in acute care.Respir Care. 2009 Feb;54(2):246-57. DISCLOSURE: The following authors have nothing to disclose: Mahsan Farokhi, Viren Kaul, Assad Oskuei, Michael Megally, Daniel Nicastri, Martin Warshawsky No Product/Research Disclosure Information

A Rare Case of Thoracoschisis.

A term male baby, after delivery, was found to have a 3-centimeter beefy-red mass protruding from the left chest wall, adjacent to the left nipple. Radiological imaging suggested it’s origin from the left lateral liver segment. A diagnostic laparoscopy confirmed the isolated connection to the liver, elevated left hemidiaphragm, and protrusion between the ribs. The mass was excised using electrocautery, and pathologic examination showed normal liver tissue.

Shrinking lung syndrome in systemic lupus erythematosus: a single-centre experience

Introduction Shrinking lung syndrome (SLS) is a rare manifestation of systemic lupus erythematosus (SLE), characterized by decreased lung volumes and extra-pulmonary restriction. The aim of this study was to describe the characteristics of SLS in our lupus cohort with emphasis on prevalence, presentation, treatment and outcomes. Patients and methods Patients attending the Toronto Lupus Clinic since 1980 ( n = 1439) and who had pulmonary function tests (PFTs) performed during follow-up were enrolled ( n = 278). PFT records were reviewed to characterize the pattern of pulmonary disease. SLS definition was based on a restrictive ventilatory defect with normal or slightly reduced corrected diffusing lung capacity for carbon monoxide (DLCO) in the presence of suggestive clinical (dyspnea, chest pain) and radiological (elevated diaphragm) manifestations. Data on clinical symptoms, functional abnormalities, imaging, treatment and outcomes were extracted in a dedicated data retrieval form. Results Twenty-two patients (20 females) were identified with SLS for a prevalence of 1.53%. Their mean age was 29.5 ± 13.3 years at SLE and 35.7 ± 14.6 years at SLS diagnosis. Main clinical manifestations included dyspnea (21/22, 95.5%) and pleuritic chest pain (20/22, 90.9%). PFTs were available in 20 patients; 16 (80%) had decreased maximal inspiratory (MIP) and/or expiratory pressure (MEP). Elevated hemidiaphragm was demonstrated in 12 patients (60%). Treatment with prednisone and/or immunosuppressives led to clinical improvement in 19/20 cases (95%), while spirometrical improvement was observed in 14/16 patients and was mostly partial. Conclusions SLS prevalence in SLE was 1.53%. Treatment with glucocorticosteroids and immunosuppressives was generally effective. However, a chronic restrictive ventilatory defect usually persisted.

Primary Hepatic Lymphoma in a 32-year-old Male

A 32-year-old male came with right upper abdominal pain with a mass increasing in size since the last 6 months, with no other typical symptoms. The physical findings revealed right upper abdominal mass, rubbery consistence, irregular surface, rounded edge, unclear border, immobile, without any tenderness. Other physical examination revealed normal findings, without any lymphadenopathy at another site. The laboratory findings revealed non-reactive hepatitis B and C markers, normal AFP, slightly increased LDH. Plain chest X-ray showed elevated right hemidiaphragm, and a large mass sized ± 14.18 x 8.56 x 12.56 cm compressing the liver. We’ve done biopsy with ultrasound guiding on the mass, and the histological examination revealed that it was lymphoma with negative CD20. The diagnosis was established as primary hepatic lymphoma and the patient was then given chemotherapy.

Platypnea-orthodeoxia syndrome in the right lateral decubitus position: a case report

BackgroundPlatypnea-orthodeoxia syndrome is a rare syndrome characterized by dyspnea and hypoxia when the patient is sitting or standing. Here we report a case of platypnea-orthodeoxia syndrome caused by a right hemidiaphragmatic elevation with giant liver cyst that triggered a right-to-left shunt through the patent foramen ovale. This case report is the first presentation of a case secondary to hemidiaphragmatic elevation with giant liver cyst. In addition to this, a malposition of the pacemaker lead could be associated with platypnea-orthodeoxia syndrome in this case.Case presentationA 91-year-old Japanese woman presented to our hospital with hypoxia of unknown origin. Severe hypoxia and cyanosis were observed only in the right lateral decubitus position. A chest X-ray and computed tomography scan revealed right hemidiaphragmatic elevation, which was probably compressing the right atrium. A transesophageal echocardiogram showed a compressed right atrium and shunt blood flow in both directions: from the left to the right atrium and vice versa. The shunt flow was exacerbated by postural changes from the left to the right lateral decubitus. A transesophageal echocardiogram also confirmed compression of the right atrium due to giant liver cyst and a malposition of the pacemaker lead abnormally placed in the left atrium through patent foramen ovale. We concluded that the cause of hypoxia was platypnea-orthodeoxia syndrome with right-to-left interatrial shunt through patent foramen ovale. Surgical closure of patent foramen ovale was not performed due to the age of our patient, surgical difficulties, and failure to obtain informed consent. For these reasons she was discharged after receiving medical advice about her posture.ConclusionsPlatypnea-orthodeoxia syndrome is rare and difficult to diagnose. The present case suggests that hypoxia due to postural changes should be considered a differential diagnosis of platypnea-orthodeoxia syndrome.

Elevated Hemi-diaphragms as a Cause of ST-segment Elevation: A case report and review of literature

While ST-segment elevation (STE) on ECG is widely recognized as representing myocardial infarction or injury such as coronary occlusion or pericarditis, STE may occasionally ensue from non-cardiac etiologies. Indeed, gastrointestinal disorders causing STE are not well documented in the literature. We present a case wherein extreme abdominal distension and hemi-diaphragm elevation resulted in extrinsic cardiac and epicardial coronary compression manifesting as STE. Subsequent relief of the abdominal distension resulted in resolution of STE representing a noncoronary cause of STE. A brief literature review, illustrating the importance of considering abdominal etiologies as a cause of STE is provided.

A study of the efficacy of stellate ganglion blocks in complex regional pain syndromes of the upper body.

Background and Aims:The effect of stellate ganglion blocks (SGBs) was examined in complex regional pain syndromes (CRPS) of the upper body.Material and Methods:A total of 287 SGB were given to patients with documented CRPS on medications. Spontaneous and provoked pain assessment was done with numeric pain rating scale (NPRS). The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and range of motion (ROM) was recorded before and after each blockade. Difference between a 15-point “global rating of change” scale determined the minimal clinically important difference of the DASH score.Results:The overall mean pain reduction was 73.2% (r = 0.83, P < 0.001) considering spontaneous and 55.8% (r = 0.77, P < 0.001) on provoked pain. Mean DASH score decreased from 53 (range 36–63; P = 0.14) to 10.4 (range 10–49.2; P = 0.005). The sensitivity to change was 6.9 for spontaneous and 4.9 for provoked pain. Increase in ipsilateral limb temperature has a good correlation with Horner's syndrome (HS) and sympathetic blockade. Minor, self-limiting complications, such as hoarseness, dysphagia, local hematoma, and ipsilateral brachial plexus block occurred in 11.5%. A rare complication of contralateral HS was documented. One patient developed a small pneumothorax, but it did not require intervention.Conclusions:SGB are relatively safe and effective management in patients with neuropathic conditions already on pharmacotherapy. Serial blocks attained an average reduction in pain by >3 NPRS points from the baseline for both spontaneous and provoked pain with a decrease in mean DASH score and improvement in ROM.

Mature Pericardial Teratoma in the Elderly

We report an unusual case of a very large Pericardial Teratoma in an adult 62 year old woman. Pericardial teratomas are common in the paediatric population, however, it is rare to find a large pericardial teratoma in the elderly. A routine x-ray Chest was performed, while being investigated for symptoms of renal calculi. The x-ray revealed a large left sided mass occupying almost the entire left hemi thorax with elevated left hemi diaphragm. She underwent resection of the mass, which was radiologically thought to be hydatid cyst in view of the enhancing rim of calcification with homogenous material within. A formal left posterolateral thoracotomy was performed and the mass was seen to be arising from the pericardium and inseparable from it. The mass was excised completely along with resection of a portion of the pericardium. The final histopathology was benign mature teratoma arising from the pericardium.

Chilaiditi’s Sign and Abdominal Pain: Chilaiditi’s Syndrome

Clinical Image: Chest X-ray obtained for an 83 year old female during chest pain evaluation demonstrated air beneath an elevated right hemidiaphragm with haustral markings (Figures 1 and 2). The patient did not have any abdominal pain at that time. This finding was seen on numerous prior studies. It represents interposition of the colon between the liver and right diaphragm, which is consistent with Chilaiditi’s sign. Chilaiditi’s sign was first described by a Greek radiologist, Demetrius Chilaiditi in 1910. This asymptomatic radiographic sign is used to describe the interposition of the colon between the liver and diaphragm. It occurs in about 0.025-0.28% of the general population. It tends to occur more frequently in adults and males. The etiology for Chilaiditi’s sign is unknown, however risk factors include increased space between the liver and diaphragm. 1 Treatment consists of conservative management with supportive care. When Chilaiditi’s sign is associated with abdominal pain, it is known as Chilaiditi’s Syndrome.

Unilateral Diaphragmatic Paralysis Resulting in Pulmonary Hypertension With Cor Pulmonale and Respiratory Failure

SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Vascular Disease I SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Diaphragmatic paralysis is a condition commonly associated with trauma, neurologic compromise, or systemic disease. Unilateral diaphragmatic paralysis (UDP) uncommonly results in respiratory symptoms and is typically found incidentally on imaging. We present an unusual case of UDP causing pulmonary hypertension with cor pulmonale and respiratory failure. CASE PRESENTATION: A 67 year-old male presented to an outside facility with shortness of breath; he was found to be hypoxic to 60% for which he was intubated and thereafter transferred to our facility. His chest xray on admission indicated an elevated left hemidiaphragm with atelectasis. His renal function precluded obtaining a contrast CT scan to exclude pulmonary embolism (PE), so a bedside echocardiogram demonstrated dilation and regional wall motion abnormalities of the right ventricle concerning for sub-massive pulmonary embolism (PE). Interventional Radiology (IR) was consulted for direct thrombolysis of suspected PE but IR pulmonary angiogram found no evidence of PE. A CT Chest without contrast confirmed elevation of left hemidiaphragm with associated atelectasis of left lower lobe and rightward shift of mediastinal structures. A bubble echocardiography demonstrated no right to left shunt. Pulmonary artery catheter measured mean PA pressure of 46 (78/30), cardiac output of 6 l/min and central venous pressure of 14 cm. With no other obvious etiology of sustained respiratory failure, thoracic surgery was consulted for consideration of diaphragmatic plication. The patient underwent diaphragmatic plication with expansion of left lung, following which he was successfully weaned from mechanical ventilation in a few days. At a one month follow up, a six minute walk distance was 384 meters with a nadir of 90%. Total lung capacity was 4.56 L (70%) and DLCO was 15.3 (57%). DISCUSSION: We propose that the patient’s hypoxemic respiratory failure was due to UDP with decreased lung expansion leading to alteration of gas exchange1,2. This resulted in chronic hypoxemia that led to development of pulmonary hypertension (group 3.3) and cor pulmonale. This can occasionally lead to a right to left shunt via a patent foramen ovale, which was ruled out in our patient. Once pulmonary mechanics were improved through diaphragmatic plication, he was liberated from mechanical ventilation. CONCLUSIONS: This case underlies the importance of recognizing UDP as a cause of pulmonary hypertension and cor pulmonale resulting in acute respiratory failure. Reference #1: Elshafie, G., Acosta, J., Aliverti, A., Bradley, A., Kumar, P., Rajesh, P., & Naidu, B. (2016). Chest wall mechanics before and after diaphragm plication. J Cardiothorac Surg Journal of Cardiothoracic Surgery, 11(1). Reference #2: Freeman, R. K., Wozniak, T. C., & Fitzgerald, E. B. (2006). Functional and Physiologic Results of Video-Assisted Thoracoscopic Diaphragm Plication in Adult Patients With Unilateral Diaphragm Paralysis. The Annals of Thoracic Surgery, 81(5), 1853-1857. DISCLOSURE: The following authors have nothing to disclose: Kirill Lipatov, Tasnim Lat, Thomas Delmas, Shekhar Ghamande No Product/Research Disclosure Information

Resolution of Dyspnea and Elevated Hemidiaphragm after Transcutaneous Electrical Stimulation and Manual Therapy in a Cervical Spinal Cord Injured Patient

Resolution of Dyspnea and Elevated Hemidiaphragm after Transcutaneous Electrical Stimulation and Manual Therapy in a Cervical Spinal Cord Injured Patient

Long-term Observation of Respiratory Function After Unilateral Phrenic Nerve and Multiple Intercostal Nerve Transfer for Avulsed Brachial Plexus Injury

Objective: Either phrenic nerve transfer (PNT) or multiple intercostal nerve transfer (MIT) alone was reported having no significant impact on pulmonary function in short or medium term. But it has rarely been reported whether the combination of PNT-MIT could influence respiratory function in the long term. In this study, pulmonary and diaphragmatic functions were compared between PNT and PNT-MIT after 7 to 19 years (mean 10 years) postoperatively. Methods: Twenty-three adult patients with brachial plexus avulsion injuries (BPAI) who underwent PNT-MIT were compared with 19 corresponding adult patients who underwent PNT only. Pulmonary function testing, phrenic nerve conduction study, and chest fluoroscopy were performed to assess ventilation, diaphragmatic response, and excursion. In the PNT-MIT group, further comparison was performed to investigate whether the number of transferred intercostal nerves and the timing of MIT would influence the results. Results: In PNT-MIT group, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and total lung capacity (TLC) were 73.69%, 72.04%, and 74.81%, respectively, of predicted values without significant differences from the PNT group. Diaphragmatic paralysis permanently existed with hemidiaphragm elevation of 1 to 1.5 intercostal spaces (ICSs) and near one ICS reduced excursion. No statistically significant difference was found between PNT and PNT-MIT groups. Furthermore, in the PNT-MIT group, the transfer of 3 and 4 intercostal nerves resulted in no further decrease in pulmonary function than that of 2 intercostal nerves. No significant difference was found when PNT-MIT was performed at the same stage or at an interval of 1 or 2 months. Conclusions: In the long-term observation, PNT-MIT did not result in additional impairment in respiratory function in adult patients compared with PNT alone. Transfer of 2 to 4 intercostal nerves at 1- to 2-month delay after PNT is a safe method for treating BPAI.