Intercostal Muscles Research Articles

Complete resection of a giant costal chondrosarcoma with reconstruction of the thoraco-abdominal wall: a case report

BackgroundChondrosarcoma primarily occurs in the pelvis and femur, with occasional cases in the ribs. Surgical resection remains the main treatment method for costal chondrosarcoma. However, complete resection often leads to a large range of chest wall defects and a challenging reconstruction.Case presentationA 49-year-old female patient presented with progressive swelling of the right chest and abdominal wall over 15 years. Chest CT revealed a 20.1 × 15.6 × 13.7 cm multilocular cystic-solid mass with internal calcification, encircling the 8th to 12th ribs and causing elevation of the right diaphragm. Compression of the liver resulting in a significant reduction in volume. Based on an ultrasound-guided biopsy, chondrosarcoma Grade I was diagnosed. After a multi-disciplinary discussion, we performed a complete resection of the tumor, including the 8th to 12th anterolateral ribs and part of the diaphragm. The diaphragm was then reconstructed by suturing it to the ribs and intercostal muscles at the resection margin. The thoraco-abdominal wall defects were reconstructed with a polypropylene mesh. Finally, we excised the excess skin and then closed the incision. Histopathologic diagnosis was chondrosarcoma Grade II. The postoperative course was uneventful. At the 3-month postoperative follow-up, no signs of recurrence were observed.ConclusionsWide en-bloc resection followed by reconstruction using polypropylene mesh is feasible and cost-effective for costal chondrosarcoma with limited invasion. This case illustrates the importance of meticulous preoperative planning and multi-disciplinary discussion.

Features of inspiratory muscles’ functional state in chronic heart failure with preserved ejection fraction

BACKGROUND: It is known that chronic heart failure contributes to the development of multiple organ pathology, including skeletal muscle pathology. AIM: To determine the strength and electrical activity of the inspiratory muscles in patients with chronic heart failure with preserved left ventricular ejection fraction. MATERIAL AND METHODS: The study involved 80 patients of both sexes aged 45 to 74 years, who were divided into three groups: the first group consisted of 24 patients with stage IIA chronic heart failure, the second group consisted of 20 patients with stage I chronic heart failure, and the third group (control group) consisted of 36 patients without chronic heart failure. All patients underwent serum N-terminal fragment of natriuretic brain propeptide determination, 6-minute walk test, measurement of inspiratory muscle strength, and surface electromyography of the inspiratory muscles using three exercise tests. The statistical significance of differences between the groups was assessed using the Mann–Whitney test and Pearson χ2. RESULTS: It was found that when dividing the groups by gender, the maximum inspiratory pressure in women of the first group was lower than in women of the control group by 31.5% (p=0.006). In patients of the first group, a smaller increase in the amplitude of the diaphragm electromyogram was recorded in the 1st test — with maintaining an inspiratory effort of 30% power for 15 s by 27.9% (p=0.010), 26.1% (p=0.025) and 40.7% (p=0.033) at the 5th, 10th and 15th seconds, respectively, in the 2nd test — with maintaining an inspiratory effort of 50% power for 5 s, by 32.6% (p=0.041) at the 5th second, in the 3rd test — with maintaining an inspiratory effort of 70% power for 5 s, by 42.8% (p=0.009) at the 5th second compared to the control group. At the same time, a more pronounced decrease in the electromyogram frequency was noted in the 1st sample — by 24.2% (p=0.048), 24.7% (p=0.030) compared to the control group, which serves as a sign of fatigue. On the accessory inspiratory muscles, the amplitude increase was higher in patients of the first group compared to the control group, which indicates activation of additional motor units: on the external intercostal muscles in the 1st sample — by 31.7% (p=0.032), 37.9% (p=0.044), in the 2nd sample — by 28.9% (p=0.048), 43.1% (p=0.036); on the sternocleidomastoid muscle in the 1st sample — by 66.1% (p=0.033), 49.4% (p=0.043), in the 2nd sample — by 128.6% (p=0.032). CONCLUSION: In patients with chronic heart failure stage IIA, surface electromyography using stress tests revealed diaphragm fatigue and increased activity of accessory inspiratory muscles.

Effect of Body Position on Electrical Activity of Respiratory Muscles During Mouth and Nasal Maximal Respiratory Pressure in Healthy Adults: A Pilot Study.

Background: This study aimed to analyze the impact of seated, 45° inclined, and supine positions on respiratory muscle strength (Maximal Inspiratory Pressure-MIP, Maximal Expiratory Pressure-MEP, Sniff Nasal Inspiratory Pressure-SNIP and Sniff Nasal Expiratory Pressure-SNEP) and the electrical activity of respiratory muscles in healthy adults. Ten healthy subjects were evaluated. Methods: Personal, anthropometric data (weight, height, BMI) and lung function (spirometry) were collected, followed by random assessments of inspiratory (MIP, SNIP) and expiratory (MEP, SNEP) muscle strength. Respiratory muscle strength maneuvers and surface electromyographic (sEMG) activity were assessed in sitting, 45° inclined, and supine positions. Results: present that MIP was statistically higher in the sitting position compared to the supine position (p < 0.05) and the 45° supine position (p < 0.05), with SNIP: p < 0.05 and SNEP: p < 0.05 as well. Intercostal muscle activity was higher during MIP, MEP, and SNEP maneuvers in the sitting position (p < 0.05). Additionally, rectus abdominis muscle activity was higher in this position during MIP and SNEP maneuvers. Conclusions: The results suggest there are significant differences in inspiratory pressures between positions, with the difference in activity muscle pattern. In conclusion, body position affected maximal respiratory pressures and influences EMG activation of specific respiratory muscles during MIP.

Effects of ultrasound-guided external oblique intercostal plane block on the postoperative analgesia after open liver surgery: study protocol for a randomised controlled trial

BackgroundOpen liver surgery remains a primary surgical approach for complex liver resections and liver transplantation. However, the postoperative pain management is still a major challenge. Ultrasound-guided external oblique intercostal (EOI) plane block is a novel approach of regional anaesthesia and has a great potential to relieve postoperative pain after upper abdominal surgeries. This study aims to investigate the efficacy and safety of ultrasound-guided EOI plane block in managing postoperative pain after open liver surgery.MethodsSeventy-four participants scheduled for open liver surgery will be randomly assigned to either the intervention group, receiving an ultrasound-guided EOI plane block with a single dose of 30 ml 0.375% ropivacaine, or the control group, which will not receive this block. All participants will be provided with opioid-based patient-controlled intravenous analgesia (PCIA) postoperatively. The primary outcome is resting pain score at 3 h postoperatively, assessed using numerical rating scale. Secondary outcomes include pain score at 6, 24, 48, and 72 h postoperatively, perioperative opioid consumption, remedial analgesics within 72 h postoperatively, PCIA usage within postoperative 72 h, postoperative recovery, length of hospital stay, postoperative side effects, block-related complications, and ropivacaine plasma concentration of participants receiving the block.DiscussionThis study is a randomised controlled trial to evaluate the efficacy and safety of ultrasound-guided EOI plane block for postoperative analgesia after open liver surgery. As regional anaesthesia plays an important role in the multimodal pain management, EOI plane block may prove to be an effective regional technique for enhancing postoperative pain relief and contributing to enhanced recovery after open liver surgery.Trial registrationChinese Clinical Trial Registry ChiCTR2200065745. Registered on November 14, 2022.

Successful use of ultrasound guided pecto-intercostal fascial plane block to provide intraoperative analgesia in four dogs undergoing median sternotomy.

To evaluate the impact of pecto-intercostal fascial plane block on providing intraoperative analgesia in dogs undergoing median sternotomy. 4 dogs. The dogs were presented with a history of inappetence, lethargy and respiratory distress. Thoracic radiographs, point of care ultrasound, thoracocentesis, bronchoscopy and computed tomography was performed to characterize the disease. 4 male castrated, 5.3 ± 3 years old dogs weighing 19.7 ± 13.5 kg and belonging to Dalmatian, Beagle, Siberian Husky and Rottweiler breeds were included. Three dogs were diagnosed with suppurative pleural effusions because of pulmonary abscesses and one dog with spontaneous pneumothorax due to the presence of pulmonary bullae. All dogs underwent median sternotomy under general anesthesia to explore the thorax. A pecto-intercostal fascial plane block was performed by injecting local anesthetic bupivacaine in the parasternal fascial plane between the deep pectoral and external intercostal muscles to provide antinociception by anesthetizing ventral cutaneous branches of intercostal nerves second through sixth. Analgesia from the block resulted in reduced requirement of inhalant anesthesia and minimal requirement for opioid to augment analgesia intraoperatively. Median sternotomy is required to perform thoracic surgery in dogs with various thoracic pathologies. Pecto-intercostal fascial plane block is a locoregional technique that can blunt nociception arising from the ventral thorax and can significantly improve perioperative patient care in dogs undergoing median sternotomy by providing effective intraoperative and potentially postoperative analgesia.

Chest Wall Hydatid Disease: Surgical management and risk Factors for Recurrence and Mortality

Background Hydatidosis of the thoracic wall differs from other hydatid localizations in its pathophysiology, diagnostic, and therapeutic management. It is a little-studied entity. The objectives of our work were to describe its surgical management and to analyze the factors that may influence recurrence and mortality. Methods A retrospective, descriptive, longitudinal, and multicenter study on four university hospital surgical centers of Tunis, from January 1995 to December 2022 including operated hydatid cysts of the thoracic wall. Overall survival (OS) and cumulative recurrence rates were calculated. Univariate and multivariable Cox regression analyses were performed to identify recurrence and mortality risk factors. Results Forty-nine patients were included. The mean age was 41 ± 17 years [8-76]. The main presenting sign was thoracic parietal swelling (n=22). Chest ultrasound and CT scan showed multivesicular formation in 17 and 33 cases, respectively. Muscle involvement was in the intercostal (n=4), paravertebral (n=13), and pectoralis major (n=3) muscles. Bone involvement was vertebral (n=11), costal (n=12), costo-vertebral (n=21) and sternal (n=2). A posterolateral thoracotomy was performed (n=20). Surgical excision at various levels of the chest wall with spinal stabilization (n=15) was performed. Sixty-three percent of the patients received antiparasitic medical treatment. Recurrence occurred in 37% of cases. Four patients died from hydatidosis-related complications. Factors could be independently associated with recurrence such as male gender, and vertebral involvement. The presence of a visceral hydatid cyst located at a distance from the parietal lesion at the time of diagnosis and the occurrence of postoperative infectious complications could increase mortality. Conclusions Chest wall hydatidosis represents a rare medical condition where surgery remains the preferred treatment modality. However, it carries a substantial burden of morbidity and mortality, influenced by various factors. Further large-scale studies are necessary to gain a deeper understanding of these factors and to optimize management strategies accordingly.

Effectiveness of Intercostal Stretch on Chest Expansion and Peak Expiratory Flow Rate

Introduction: The intercostal muscles play a role in moving the ribs upward and outward. This action leads to an increase in the antero-posterior diameter of the thoracic cavity. In respiratory physiotherapy, manual stretching techniques are widely used to improve lung function Objective: To determine the effect of Intercostal stretch on chest expansion and peak expiratory flow rate. Methods: A total of 100 subjects were recruited according to inclusion criteria i.e.age group 60-70 years, both genders and written informed consent was taken. Assessment and evaluation of participants was done. Chest expansion was measured and then after 2 minutes rest peak expiratory flow rate was taken using peak flow meter before the intervention. The stretch was applied in sync with the patient’s exhalation and held while they continued breathing normally. As the stretch was sustained, there was a gradual increase in inspiratory movements in the area being stretched. Each subject received intercostal stretching for 20 days, with 5 repetitions per session and a 20-second hold on both the right and left sides. After the 20-day period, chest expansion and peak expiratory flow measurements were recorded. Results: By applying Paired t-test for Pre-test and Post-test values of chest expansion and peal expiratory flow rate p-value obtained was &lt; 0.01, which was statistically significant. This suggests that Intercostal stretch is effective in improving chest expansion and peak expiratory flow rate. Conclusion: The study concludes that there was significant improvement in chest expansion and peak expiratory flow rate among the healthy older adults who underwent intercostal stretch.

Intravenous Bolus Injection of Fentanyl Triggers an Immediate Central and Upper Airway Obstructive Apnea via Activating Vagal Sensory Afferents.

Intravenous bolus (IVb) injection of fentanyl induces an immediate apnea, but the characteristics of the apnea and relevant mechanism remain unclear. Here, we tested whether IVb injection of fentanyl induced an immediate central and upper airway obstructive apnea associated with chest wall rigidity via activating vagal C-fibers (VCFs) and vagal afferent opioid receptors (ORs). Cardiorespiratory and electromyography of external and internal intercostal, thyroarytenoid and superior pharyngeal constrictor muscles (EMGEI, EMGII, EMGTA and EMGSPC) responses to IVb injection of fentanyl were recorded in anesthetized and spontaneously breathing rats with or without bilateral peri-vagal capsaicin treatment or intra-vagal microinjection of naloxone. Immunohistochemical approach was employed to define the presence of opioid mu-receptor (MOR) expression in vagal C-neurons and a patch clamp technique utilized to determine the evoked current responses of vagal C-neurons to fentanyl in vitro. Fentanyl induced an immediate apnea and subsequent respiratory depression. The apnea was characterized by cessation of EMGEI activity and augmentation of tonic discharges of EMGII, EMGTA, and EMGSPC, i.e., central expiratory apnea, laryngeal closure and pharyngeal constriction/collapse accompanied with chest wall rigidity. The apneic response was abolished by blockade of VCF signal conduction and largely attenuated by antagonism of vagal afferent ORs. The latter significantly alleviated the initial (within 5 min post injection), but not the later, respiratory depression. Vagal C-neurons expressed MORs and were activated by fentanyl. We conclude that IVb injection of fentanyl causes a VCF- and vagal afferent OR-mediated immediate central apnea, upper airway obstruction and chest wall rigidity.

Ultrasound-Guided Deep Serratus Plane Block in Cat Cadavers (Felis catus): A Description of Dye and Contrast Media Distribution.

The serratus plane block is an ultrasound-guided anaesthetic technique that aims to provide analgesia to the lateral thoracic wall cranial to the 8th rib. This block can be performed in a superficial (between the latissimus dorsi and the serratus ventralis thoracis (SVT) muscles) or deep plane (between the intercostales externi and the SVT muscles). This study aimed to assess the distribution and nerve staining of a mixture of 0.4 mL kg-1 of methylene blue and iopromide 50:50 performing a deep serratus plane (DSP) block at the level of the 5th rib. We hypothesise that this technique would be feasible and could stain the rami cutanei laterales (RCL) of the intercostales nerves cranial to the 8th rib in cat cadavers. This study was divided into two phases. Phase 1 consisted of an anatomical study of the thoracic wall (2 cadavers). Phase 2 consisted of the ultrasound-guided injection of the aforementioned mixture and the assessment of its distribution by computed tomography and anatomical dissection (12 cadavers). Contrast media spread a median of 5.5 (2.5-7.5) intercostal spaces. The dye stained a median of 3 (0-5) RCL, affecting RCL 2 (17.39%), RCL 3 (57.17%), RCL 4 (78.26%), RCL 5 (91.30%), RCL 6 (78.26%), and RCL 7 (8.70%) within the DSP. Occasionally, the rami dorsales laterales and the thoracicus longus nerve were stained. Based on these findings, the DSP block performed with a volume of 0.4 mL kg-1 of an anaesthetic could provide analgesia in the area innervated from T4 to T6.

Assessment of Respiratory Muscles, Lung Parenchyma, and Cardiac Function by Ultrasound for Predicting Weaning Failure in Critically Ill Adults: A Prospective Observational Study.

The parasternal intercostal muscle activity, a marker of accessory muscle usage, is found to correlate inversely with the pressure-generating capacity of the diaphragm and level of support of mechanical ventilation. The primary objective of our study was to determine whether the parasternal intercostal muscle thickening fraction (PMTF) measured by ultrasonography can predict weaning. We also evaluated whether addition of lung ultrasound score and echocardiographic assessment can add on to predicting weaning failure. This prospective observational study conducted in a mixed medical-surgical intensive care unit, included 60 adult patients who were eligible for a spontaneous breathing trial (SBT) after being invasively mechanically ventilated for more than 48 hours. Ultrasound of respiratory muscles, lung parenchyma, and echocardiographic assessment were performed before and after 120 minutes of SBT. Parasternal intercostal muscles were imaged with a high frequency linear probe on the right second intercostal space 5 cm lateral to the sternal margin. PMTF was calculated as (maximum-minimum thickness)/minimum thickness. Among 60 patients, SBT failure was seen in 11 patients and extubation failed in 8 patients. PMTF (%) was significantly higher in the weaning failure group (13.33 [8.33-19.05]) as compared to patients with successful weaning (6.67 [6.06-11.54]). Diaphragmatic thickening fraction (DTF) correlated inversely to PMTF in patients with weaning failure. A pre-SBT PMTF cut-off of ≥7.7% and post-SBT cut-off of ≥15.38% were good predictors of weaning failure and extubation failure, respectively. PMTF has good discriminatory power to predict weaning outcomes (area under the receiver operating characteristic curve: 0.74 [0.59-0.88]). Pre-SBT PMTF had similar power as DTF to predict weaning failure.

7999 Tumor Induced Osteomalacia Caused By Glomangiopericytoma

Abstract Disclosure: N. Kabir: None. E. Campbell: None. S. Singh: None. Introduction: Tumor induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused primarily by FGF-23 secreting tumors. Excessive production of FGF23 causes hypophosphatemia, decreased phosphate resorption in the gut, increased renal phosphate wasting, and decreased activation of Vitamin D. This leads to decreased bone density, bone pain, proximal muscle weakness, impaired gait, and recurrent fractures. Case Presentation: 44 year old male with a history of recurrent insufficiency fractures and weakness. At the time of evaluation, he reported fracture of tibial growth plate, sacral fracture, and metatarsal stress fracture. Other symptoms included bone pain, fatigue, muscle weakness, and intercostal muscle spasms with exertion. His pain was debilitating, requiring crutches to ambulate. Available labs at that time were significant for hypophosphatemia (1.3 mg/dL), elevated ALP (160 U/L), low 25OH-vitamin D (26 ng/mL), and normal calcium (8.7 mg/dL). Urine studies demonstrated phosphaturia (fractional excretion of phosphate, 62.4%). FGF23 level resulted at the upper limit of normal (210 RU/mL). Pending further evaluation, burosumab was started. Further work up included a 68Ga-PET-DOTATATE scan revealing a somatostatin receptor expressing soft tissue mass in the left sphenoid sinus and posterior left ethmoid sinus. The scan also demonstrated impending bilateral femur fractures, prior rib fractures, and sacral insufficiency fractures. Based on these findings, he was admitted to the hospital and underwent prophylactic, intramedullary nail fixation of his bilateral femur fractures. He underwent resection of skull base tumor with the final pathology revealing a sinonasal glomangiopericytoma. Immunohistochemical stain was positive for CD99 and cyclin D1, and focally positive for SMA, consistent with histopathologic diagnosis. Patient required prolonged inpatient rehabilitation to recover independent ambulation. Discussion: Sinonasal glomangiopericytoma (SNGP) is a mesenchymal tumor that accounts for &amp;lt;0.5% of all nasal and sinus tumors. TIO due to SNGP is extremely rare, with only a few cases reported since the 1990s. As seen with our patient, TIO from SNGP rarely presents with sinonasal symptoms, and can often be overlooked. Our patient hadb significant progression of disease and disability due to numerous delays in diagnosis and management. Definitive cure for TIO can be achieved with complete surgical resection of the tumor, but failure to diagnose in a timely manner can result in decline in quality of life. Our takeaway from this case is that providers should obtain FGF23 levels, especially in the setting of hypophosphatemia and phosphaturia, to complete the work up for osteomalacia. Presentation: 6/1/2024

Effect of Ultrasound-Guided External Oblique Intercostal Block on Postoperative Recovery After Subxiphoid Video-Assisted Thoracoscopic Thymectomy: A Randomized Controlled Trial.

Severe postoperative pain can occur after subxiphoid video-assisted thoracoscopic thymectomy (SVATT), affecting the quality of postoperative recovery. This study aimed to evaluate the effect of ultrasound-guided external oblique intercostal (EOI) block on recovery after SVATT. A total of 60 patients undergoing SVATT were randomly divided into the EOI group (group E, n = 30) and the control group (group C, n = 30). Group E underwent ultrasound-guided bilateral EOI block at the 6th rib level and was injected 20 mL of 0.375% ropivacaine on each side. Group C was injected with 20 mL of 0.9% saline at the same site. After the operation, both groups received a patient-controlled intravenous analgesic (PCIA) pump. The 15-item Quality of Recovery (QoR-15) scores were recorded at 24 hours before surgery (T0), 24 hours after surgery (T3), and 48 hours after surgery (T4). The sufentanil usage in the first 24 hours postoperatively, the remifentanil dosage during surgery, the time of first pressing PCIA, and the cases of rescue analgesia were recorded. The visual analog scale (VAS) scores of patients at 6 (T1), 12 (T2), 24 (T3), and 48 hours (T4) after an operation during rest and coughing were recorded. The dermatomes of the sensory plane, block complications in group E, and the incidence of other postoperative adverse reactions in both groups were also recorded. Compared with group C, the QoR-15 scores of patients were significantly higher at T3 and T4 in the group E. The VAS scores were significantly lower at T1, T2, and T3 during rest and coughing in the group E. The sufentanil usage in the first 24 hours postoperatively, the remifentanil dosage during surgery, and the cases of rescue analgesia were significantly lower in group E, and the time of first pressing PCIA was significantly increased in group E (all P < .05). Ultrasound-guided EOI block can be safely used in patients undergoing SVATT, which can improve the quality of postoperative recovery and reduce postoperative pain.

The Ultrasonographic Changes of Intercostal Muscles and Diaphragm in Mechanically Ventilated Preterm Neonates

Abstract Background Although mechanical ventilation is a lifesaving treatment, abundant evidence indicates that its prolonged use (one week or more) promotes respiratory muscle weakness due to both contractile dysfunction and atrophy. Along with the diaphragm, the intercostal muscles are one of the most important groups of respiratory muscles. In recent years, muscular ultrasound has become a useful bedside tool for the clinician to identify patients with respiratory muscle dysfunction related to critical illness and/or invasive mechanical ventilation. Objective To assess the impact of mechanical ventilation on diaphragm and intercostal muscles using ultrasonography in preterm neonates. Patients and Methods This observational prospective study was conducted at Neonatal Intensive Care Unit (NICU), Children's Hospital Ain Shams University over 6 months from October 2022 to April 2023, It included 60 preterm neonates, divided into two groups; 30 cases of respiratory distress syndrome (RDS) who were on mechanical ventilation for one week or less and 30 preterm infants of matched age and gender who didn’t require respiratory support. Results A total of 60 premature neonates participated in the study. Among them, 30 neonates required mechanical ventilation, whereas the other group consisted of 30 spontaneously breathing neonates of matched age and gender. The mean gestational age of both groups was 33 weeks, there was no statistical significant difference between our two groups as regards weight and gestational age. The relation between the right and left diaphragmatic thickness fraction (DTF) and parasternal intercostals muscle thickness fraction (TFiC) in the ventilated group in day 1 and day 3 was of non significance (p-value = 0.089 in left TFiC, p-value = 0.554 in right DTF), while the relation between them from day 1 to day 5 was significantly decreasing (p-value = 0.019 in left TFiC, p-value = 0.008 in left DTF), demonstrating the relation between the duration of ventilation and muscle function and that prolonged ventilation has a great impact on diaphragmatic effort and amplitude, on the other hand the control group measurements were significantly increasing at both right and left diaphragmatic and intercostals muscle fraction from day 1 to day 5 (p-value = 0.001 in left TFiC, p-value = 0.020 in left DTF). Conclusion Musculoskeletal ultrasound can detect early diaphragm and intercostals muscle atrophy that was observed in most of the patients treated by invasive mechanical ventilation.

Dehazing Ultrasound Using Diffusion Models.

Echocardiography has been a prominent tool for the diagnosis of cardiac disease. However, these diagnoses can be heavily impeded by poor image quality. Acoustic clutter emerges due to multipath reflections imposed by layers of skin, subcutaneous fat, and intercostal muscle between the transducer and heart. As a result, haze and other noise artifacts pose a real challenge to cardiac ultrasound imaging. In many cases, especially with difficult-to-image patients such as patients with obesity, a diagnosis from B-Mode ultrasound imaging is effectively rendered unusable, forcing sonographers to resort to contrast-enhanced ultrasound examinations or refer patients to other imaging modalities. Tissue harmonic imaging has been a popular approach to combat haze, but in severe cases is still heavily impacted by haze. Alternatively, denoising algorithms are typically unable to remove highly structured and correlated noise, such as haze. It remains a challenge to accurately describe the statistical properties of structured haze, and develop an inference method to subsequently remove it. Diffusion models have emerged as powerful generative models and have shown their effectiveness in a variety of inverse problems. In this work, we present a joint posterior sampling framework that combines two separate diffusion models to model the distribution of both clean ultrasound and haze in an unsupervised manner. Furthermore, we demonstrate techniques for effectively training diffusion models on radio-frequency ultrasound data and highlight the advantages over image data. Experiments on both in-vitro and in-vivo cardiac datasets show that the proposed dehazing method effectively removes haze while preserving signals from weakly reflected tissue.

A rare case of tetanus with early manifestation of apnea but without trismus

BackgroundTetanus is a life-threatening disease caused by tetanus neurotoxin (TeNT) produced by Clostridium tetani. Early symptoms of tetanus are trismus and muscle stiffness, both caused by spasticity. TeNT mainly exerts its effect by impairment of inhibitory neurons in the spine and brainstem, resulting in the hyperactivity of motor neurons, which causes spasticity and muscle spasms. Apnea is not a symptom that is predicted to occur in the early stages. Case ReportWe present a rare case of severe tetanus with an early manifestation of apnea but without trismus. We believe that apnea was caused by spasms of the intercostal muscles and its early manifestation was due to a high load of TeNT, considering that the speed of disease progression is related to disease severity. We hypothesize that the absence of trismus was also due to a high load of TeNT, exerting toxic effect at the neuromuscular junction and causing flaccid paralysis of the massetersWhy Should an Emergency Physician Be Aware of This?:Since there is no diagnostic laboratory test for tetanus, emergency physicians must be well aware of symptoms that may or may not appear in tetanus. Tetanus should be considered as a differential diagnosis for patients arriving at the emergency department with apnea as an early symptom. The absence of trismus should not rule out the possibility of tetanus.

Combined Korean Medicine Treatment of a Patient Diagnosed with Posterior Limb of Internal Capsule Infarction Presenting with Hiccups as the Chief Complaint - A Case Report

Objective: Hiccup is a sudden, involuntary contraction of the diaphragm and intercostal muscles, followed by laryngeal closure. Persistent hiccups can occur in the central nervous system following a cerebral infarction. While medications, for example chlorpromazine, are commonly used for treatment, they often fail to fully resolve the hiccups, showing little to no improvement in symptoms. The aim of this study was to present the treatment response of a patient diagnosed with posterior limb of internal capsule (PLIC) infarction, who was experiencing hiccups and was treated with combined Korean medicine after taking chlorpromazine.Case Presentation: A 71-year-old male diagnosed with left PLIC infarction was experiencing problems in daily life due to hiccups and dysarthria. During the 10-day hospitalization, he received treatment that included herbal medicine (modified Hyeolbuchugeo-tang, Xiěfǔzhúyūtāng), acupuncture (GV20, LI11, ST36, LI4, LR3, and submandibular area acupoint), moxibustion, cupping, and physical therapy. After 10 days of hospitalization, the patient’s hiccups disappeared, and he did not have to take any chlorpromazine. The score on the Numerical Rating Scale fell from 7-8 to 1-2. The 5-level EQ-5D version (EQ-5D-5L) fell from 11 to 7, and the EQ Visual Analogue Scale (EQ-VAS) rose from 20 to 80. The frequency (times per minute) of hiccups decreased and almost disappeared. During outpatient treatment, the patient stated that he did not experience hiccups for 7 months, and no significant side effects were observed.Conclusion: This study suggests that a patient with hiccups as a chief complaint can be effectively treated with combined Korean medicine. However, more studies with control groups are needed to confirm these findings.

Resected intramuscular hemangioma in the chest wall: a case report

BackgroundIntramuscular hemangioma is an uncommon benign tumor found mainly in the limbs of adolescents and young adults. The local recurrence rate is high, ranging from 30 to 50%, necessitating wide local excision of intercostal intramuscular hemangiomas. However, preoperative diagnosis of intramuscular hemangiomas is challenging. Herein, we report a rare case of an intramuscular hemangioma arising from the chest wall.Case presentationA healthy 29-year-old asymptomatic man was referred to our hospital after an abnormal shadow was observed on his chest radiography. Computed tomography and magnetic resonance imaging revealed a 30-mm-sized mass in the right second intercostal space. Neoplastic lesions, such as schwannomas or solitary fibrous tumors, were included in the preoperative differential diagnosis. Tumor resection was performed using video-assisted thoracoscopic surgery. The tumor, which had a smooth surface covered with parietal pleura, was dissected from the external intercostal muscle and costal bone. Postoperative histopathological examination revealed proliferation of spindle-shaped endothelial cells arranged in a capillary vascular structure accompanied by entrapped smooth muscle fibers, adipose tissue, and muscle vessels. The final diagnosis was an intramuscular hemangioma with negative surgical margins. There was no evidence of recurrence during the 1-year postoperative follow-up period.ConclusionIntramuscular hemangiomas should be considered in the differential diagnosis of chest wall tumors, particularly in young people, owing to their potential for recurrence. Moreover, postoperative follow-up may be necessary for resected intramuscular intercostal hemangiomas.

Benefits of chest wall mobilization on respiratory efficiency and functional exercise capacity in people with severe chronic obstructive pulmonary disease (COPD): A randomized controlled trial.

Coexistence of chest wall hypomobility and lung hyperinflation compromises respiratory muscle function and respiratory efficiency in people with severe chronic obstructive pulmonary disease (COPD). This study aimed to investigate the effect of chest wall mobilization on functional exercise capacity, respiratory muscle activity and respiratory muscle tissue oxygen saturation for people with severe COPD. Thirty male adults (age: 75 ± 6) diagnosed with severe COPD completed a 6-week programme (twice/week) according to intervention randomization (chest wall mobilization group, CWMG, n = 15; control group, CG, n = 15). Both groups received standardized education and walking exercise, while CWMG also received chest wall and thoracic spine mobilization. Electromyography of the essential and accessory respiratory muscles and tissue oxygen saturation of the intercostal muscle (StO2, measured by near-infrared spectroscopy) during incremental cycle exercise test were measured and compared between the two groups at pre-programme, post-programme and 3-month follow-up. Patients in CWMG demonstrated a significant increase in exercise tolerance from <3 METS to 4-6 METS (p = 0.000) after intervention. A significant decrease in activity of scalene, sternocleidomastoids and intercostal muscle during exercise test (p < 0.01) was found in CWMG, as compared to CG. A significant decrease in StO2 (p < 0.05) and greater decline in the slope of oxygenation dissociation (p = 0.000) were seen in CWMG during exercise test. These positive results were maintained at 3-month follow-up in CWMG. Improvements in exercise tolerance, respiratory muscle efficiency and oxygenation extraction ability in CWMG suggest a potential clinical benefit of integrating chest wall and thoracic spine mobilization for rehabilitation of people with severe COPD.

In vivo Imaging and Pharmacokinetics of Percutaneously Injected Ultrasound and X-ray Imageable Thermosensitive Hydrogel loaded with Doxorubicin versus Free Drug in Swine.

Intratumoral injections often lack visibility, leading to unpredictable outcomes such as incomplete tumor coverage, off-target drug delivery and systemic toxicities. This study investigated an ultrasound (US) and x-ray imageable thermosensitive hydrogel based on poloxamer 407 (POL) percutaneously delivered in a healthy swine model. The primary objective was to assess the 2D and 3D distribution of the hydrogel within tissue across three different needle devices and injection sites: liver, kidney, and intercostal muscle region. Secondly, pharmacokinetics of POL loaded with doxorubicin (POLDOX) were evaluated and compared to free doxorubicin injection (DOXSoln) with a Single End Hole Needle. Utilizing 2D and 3D morphometrics from US and x-ray imaging techniques such as Computed Tomography (CT) and Cone Beam CT (CBCT), we monitored the localization and leakage of POLDOX over time. Relative iodine concentrations measured with CBCT following incorporation of an iodinated contrast agent in POL indicated potential drug diffusion and advection transport. Furthermore, US imaging revealed temporal changes, suggesting variations in acoustic intensity, heterogeneity, and echotextures. Notably, 3D reconstruction of the distribution of POL and POLDOX from 2D ultrasound frames was achieved and morphometric data obtained. Pharmacokinetic analysis revealed lower systemic exposure of the drug in various organs with POLDOX formulation compared to DOXSoln formulation. This was demonstrated by a lower area under the curve (852.1 ± 409.1 ng/mL·h vs 2283.4 ± 377.2 ng/mL·h) in the plasma profile, suggesting a potential reduction in systemic toxicity. Overall, the use of POL formulation offers a promising strategy for precise and localized drug delivery, that may minimize adverse effects. Dual modality POL imaging enabled analysis of patterns of gel distribution and morphology, alongside of pharmacokinetics of local delivery. Incorporating hydrogels into drug delivery systems holds significant promise for improving the predictability of the delivered drug and enhancing spatial conformability. These advancements can potentially enhance the safety and precision of anticancer therapy.

409. TWO-STAGE OPERATIVE PROCEDURE FOR A BENIGN, COMPLICATED TRACHEOESOPHAGEAL FISTULA CAUSED BY FOREIGN BODY IMPACTION

Abstract Background Benign Tracheoesophageal fistula (TOF) caused by foreign body impaction is a rare condition requiring technical expertise. There are choices available based on the individual patient's situation, including endoscopic management, local resection and defect closure, and, in rare cases, esophagectomy. Methods A 58-year-old male had a history of artificial tooth dislodgement that got impacted in the esophagus, resulting in dysphagia. Endoscopy showed an impacted denture with an underlying transmural esophageal perforation, closed with clips and an endoloop. Two weeks later, partially covered SEMS was placed. Failure to retrieve the SEMS after repeated attempts due to tissue ingrowths, he was referred for management. CECT showed a stent in situ with a small air-filled cavity left lateral to the tracheal bifurcation. Bronchoscopy revealed the compression of the posterior tracheal wall and the presence of an endoclip in the posterior wall of the left main bronchus (LMB). Results The patient was planned for a two-stage operation. In the first stage, esophagus was mobilized along with the stent and the fistulous tract was excised. The esophagus was divided at both ends in the thorax. Up to this part, the procedure was done with single-port VATS without CO2 and in the left semi-prone position with a bronchial blocker in the right main bronchus. The fistula with the LMB was closed with an intercostal muscle flap and a bovine pericardial patch with transient apnoea. During this part, we extended the incision in the fourth space to raise the flap. Cervical esophagostomy was matured, and a feeding jejunostomy was created. The postoperative phase was uneventful, and he was discharged on the 5th postoperative day. After 4 weeks, we did the second phase of surgery, where we made a 4 cm retrosternal gastric conduit and performed the hand-sewn anastomosis with the cervical esophagus, which was taken down from the skin. The patient had an uneventful postoperative course and was allowed to be taken orally on day five and discharged subsequently two days later. Conclusions TOF demands a multidisciplinary treatment strategy. Successful outcomes are determined by patient triage, delineation of the location and size of the defect, mediastinal contamination, and the availability of expertise.