Lateral Chest X-ray Films Research Articles

How to avoid pectus bar displacement in the MIRPE or MOVARPE technique: results of 12 years' experience: reply.

Bar displacement remains the most common complication of the minimally invasive repair of pectus excavatum (MIRPE). To date, no studies show results from 12 years' experience using a bar fixation technique with only absorbable sutures. Our aim is to show how to stabilize the bar using a modified approach for bar fixation. A retrospective review of 68 patients, who underwent MIRPE or the minor open videoendoscopic assisted repair of pectus excavatum, was performed. To stabilize the pectus bar, both wings of the pectus bar were tied to the ribs in 52 patients with circumcostal absorbable sutures using a Deschamps needle under endoscopic survey and in 16 patients with lateral stabilizers. The stability of pectus bar after the operation was assessed by lateral chest X-ray films and classified as being perfect, incomplete, or poor. No complications were observed in the perioperative period with the circumcostal suture technique. Lateral chest X-rays showed an excellent position of the pectus bar in 50 patients, incomplete position in 1, and poor position in another patient. Our technique seems to be effective in preventing bar displacement following pectus excavatum repair. It does not add any significant cost or time to the operation, and it is fairly simple to perform.

Phrenic Nerve Conduction Abnormalities Correlate with Diaphragmatic Descent in Chronic Obstructive Pulmonary Disease

Diaphragmatic weakness in chronic obstructive pulmonary disease (COPD) is ascribed to hyperinflation-induced diaphragm shortening as well as impairment in cellular and subcellular structures. Although phrenic neuropathy is known to cause diaphragmatic weakness, phrenic neuropathy is rarely considered in COPD. This work aimed at assessing phrenic nerve conduction in COPD and its relation to radiographic hyperinflation and pulmonary function. Patients and methods: Forty COPD patients were evaluated. Radiographic parameters of lung hyperinflation were measured on postero-anterior and lateral chest x-ray films. Flow volume loop parameters were obtained from all patients. Motor conduction study of the phrenic nerves was performed and potentials were recorded over the xiphoid process and the ipsilateral 7th intercostal space. Twenty-seven healthy subjects were enrolled as controls. Results: Parameters of phrenic nerve conduction differed significantly in patients compared to controls. Phrenic nerve abnormalities were detected in 17 patients (42.5%). Electrophysiological measures correlated with diaphragmatic angle of depression on lateral view films and with lung height on postero-anterior films. They did not correlate with the flow volume loop data or disease severity score. Conclusion: Phrenic nerve conduction abnormality is an appreciated finding in COPD. Nerve stretching associated with diaphragmatic descent can be a suggested mechanism for nerve lesion. The presence of phrenic neuropathy may be an additional contributing factor to diaphragmatic dysfunction in COPD patients.

How to Avoid Pectus Bar Dislocation in the MIRPE or MOVARPE Technique

Bar displacement remains the most common complication of the minimally invasive repair of pectus excavatum (MIRPE). To date, no studies show results from 12 years' experience using a bar fixation technique with only absorbable sutures. Our aim is to show how to stabilize the bar using a modified approach for bar fixation. A retrospective review of 68 patients, who underwent MIRPE or the minor open videoendoscopic assisted repair of pectus excavatum, was performed. To stabilize the pectus bar, both wings of the pectus bar were tied to the ribs in 52 patients with circumcostal absorbable sutures using a Deschamps needle under endoscopic survey and in 16 patients with lateral stabilizers. The stability of pectus bar after the operation was assessed by lateral chest X-ray films and classified as being perfect, incomplete, or poor. No complications were observed in the perioperative period with the circumcostal suture technique. Lateral chest X-rays showed an excellent position of the pectus bar in 50 patients, incomplete position in 1, and poor position in another patient. Our technique seems to be effective in preventing bar displacement following pectus excavatum repair. It does not add any significant cost or time to the operation, and it is fairly simple to perform.

The effect of tumor location and respiratory function on tumor movement estimated by real-time tracking radiotherapy (RTRT) system

The effects of tumor location and pulmonary function on the motion of fiducial markers near lung tumors were evaluated to deduce simple guidelines for determining the internal margin in radiotherapy without fiducial markers. Pooled data collected by a real-time tumor-tracking radiotherapy system on 42 markers in 39 patients were analyzed. The pulmonary functions of all patients were assessed before radiotherapy. Using chest X-ray film, the position of the marker was expressed relative to the geometry of the unilateral lung. Posterior location meant the area of the posterior half of the lung in a lateral chest X-ray film, and caudal location meant the caudal half of the chest X-ray film; these categories were determined by measuring the distance between the marker and anatomic landmarks, including the apex, costophrenic angle, midline of spinal canal, lateral, anterior, and posterior boundary of the lung. Before the radiotherapy, 18 patients had obstructive respiratory dysfunction (ratio of forced expiratory volume in 1 s to forced vital capacity [FEV1.0/FVC] <70), 5 patients had constrictive dysfunction (percent vital capacity [%VC] <80), and 3 had mixed dysfunction. Means of FEV1.0/FVC and %VC were 97.0% and 66.5%, respectively. Median tumor movements in the x (left-right), y (anteroposterior), and z (craniocaudal) directions were 1.1 mm, 2.3 mm, and 5.4 mm, respectively. There was no significant correlation between respiratory function and magnitude of marker movement in any direction. Median marker movement in the z direction was 2.6 mm for the cranial location and 11.8 mm for the caudal location, respectively (p < 0.001). Median movement in the z direction was 11.8 mm for posterior location and 3.4 mm for anterior location, respectively (p < 0.01). Simple measurement of the relative location on plain chest X-ray film was related, but respiratory function test was not related, to the craniocaudal amplitude of the motion of the fiducial marker near lung tumors.

Experience in 100 cases with the Nuss procedure using a technique for stabilization of the pectus bar.

The Nuss procedure is a new, minimally invasive technique for the repair of pectus excavatum. We describe our experience with this operation, in a relatively large series in a single institution, and introduce our technical modification for stabilizing the pectus bar. In 107 patients (75 male and 32 female) with pectus excavatum who underwent the Nuss procedure, age at operation ranged from 3 to 23 years old (mean: 7.5+/-4.1) and Haller's CT index ranged from 33 to 2.6 (mean: 6.1+/-3.5). To stabilize the pectus bars, we tied the rib and both edges of the bars with surgical steel wire, 0.8 mm in diameter, using a Duchenne needle to guide the wire behind the rib. Average operating time with this technique (n=100) was 48+/-20 min. The stability of pectus bars after the operation was assessed by lateral chest X-ray films. The position of the center of the pectus bars, facing the sternum at right angles, was classified as excellent. A minimal bar displacement of less than 45 degrees was classified as incomplete. The position of the bars that had rotated 90 degrees was classified as poor. The post-operative course was uneventful in all cases except for three patients who showed wound infection, hemothorax or pneumothorax, independently. Two patients required wire removal due to skin irritation as a late complication. Five patients underwent re-operations due to bar displacement. Among them, only two cases were included in the group of wire fixation. Only five teen-aged patients required a lateral stabilizing bar. Lateral chest X-ray films of 100 patients showed that the position of the pectus bar was excellent in 86 cases, incomplete in 12 cases and poor in two cases. In 70 patients aged less than 10 years, the position in 91% was excellent and in 9% was incomplete. In 30 patients aged 10 years and older, 14 required two pectus bars and the results were excellent in all cases. The other 16 patients with a single bar showed excellent results in eight (50%) cases, incomplete in six (37.5%) and poor in two (12.5%). The wire-fixation technique was safe, effective and time efficient to perform in young cases. Teen-aged patients, however, were at high risk of bar displacement. Therefore, the use of two bars and lateral stabilizing bars are recommended for these high-risk patients.

A bedside index assessing the reliability of pulmonary artery occlusion pressure measurements during mechanical ventilation with positive end-expiratory pressure

Pulmonary artery occlusion pressure (Ppao) represents the pressure in a pulmonary vein (Ppv) and reflects left atrial pressure (P la) provided alveolar pressure (Palv) does not exceed the pressure existing at the venous end of the collapsible alveolar vessels. Three major factors may influence the relationships between Palv and Ppv: mechanical ventilation with positive end-expiratory pressure (PEEP), vertical location of the pulmonary artery catheter (PAC) tip relative to the left atrium, and volemia. In an experimental and clinical study, we assessed a simple means to ensure meaningful measurements of Ppao during mechanical ventilation with PEEP, based on the following reasoning: if Ppao reflects Palv and not Ppv, it will increase during positive pressure inspiration by an amount (ΔPpao) similar to Palv; thus, ΔPpao will widely exceed the increase in pulmonary arterial pressure (ΔPpa), which approximates the increase in pleural pressure. Conversely, when Ppao actually reflects Ppv, ΔPpao will be close to ΔPpa. A preliminary experimental study in an animal with a left atrial catheter and PAC in place showed that Ppao widely exceeded P la when ΔPpao/ΔPpa widely exceeded 1 during mechanical ventilation with PEEP. After fluid infusion, P la and Ppao were almost identical and ΔPpao/ΔPpa was now close to 1. In 12 patients ventilated for adult respiratory distress syndrome and with a left ventricular catheter and PAC in place, we verified at four levels of PEEP (0, 10, 15, and 20 cm H 2O) that a Ppao close to left ventricular end-diastolic pressure was always associated with a ΔPpao/ΔPpa ratio close to 1 (38 measurements). In 34 additional patients ventilated for noncardiogenic pulmonary edema, we also tested the ΔPpao/ΔPpa ratio during the same incremental PEEP protocol and found that ΔPpao/ΔPpa was close to 1 at each level of PEEP in 30 of the patients (108 measurements). In five measurements in four hypovolemic patients, ΔPpao/ΔPpa widely exceeded 1; only one of these four patients was found to have a PAC tip located above the left atrium level on a lateral chest x-ray film. We conclude that the bedside determination of the ΔPpao/ΔPpa ratio should identify the cases in which Ppao measurements are not valid more reliably than lateral chest x-ray film, thus avoiding misleading interpretations of Ppao during PEEP ventilation.

An accurate means of detecting and characterizing abnormal patterns of ventricular activation by phase image analysis

The ability of scintigraphic phase image analysis to characterize patterns of abnormal ventricular activation was investigated. The pattern of phase distribution and sequential phase changes over both right and left ventricular regions of interest were evaluated in 16 patients with normal electrical activation and wall motion and compared with those in 8 patients with an artificial pacemaker and 4 patients with sinus rhythm with the Wolff-Parkinson-White syndrome and delta waves. Normally, the site of earliest phase angle was seen at the base of the interventricular septum, with sequential change affecting the body of the septum and the cardiac apex and then spreading laterally to involve the body of both ventricles. The site of earliest phase angle was located at the apex of the right ventricle in seven patients with a right ventricular endocardial pacemaker and on the lateral left ventricular wall in one patient with a left ventricular epicardial pacemaker. In each case the site corresponded exactly to the position of the pacing electrode as seen on posteroanterior and left lateral chest X-ray films, and sequential phase changes spread from the initial focus to affect both ventricles. In each of the patients with the Wolff-Parkinson-White syndrome, the site of earliest ventricular phase angle was located, and it corresponded exactly to the site of the bypass tract as determined by endocardial mapping. In this way, four bypass pathways, two posterior left paraseptal, one left lateral and one right lateral, were correctly localized scintigraphically. On the basis of the sequence of mechanical contraction, phase image analysis provides an accurate noninvasive method of detecting abnormal foci of ventricular activation.

Value of computerised tomography in children with non-specific mental subnormally.

Seventy-six children had computerized tomography scans as part of an investigation of mental subnormality; most of them are severely retarded and all those over age 5 years attend special schools. Seventy-two per cent of the children had normal scans. Twenty per cent showed cerebral atrophy and in only 8% was there a specific abnormality (agenesis of corpus callosum, arachnoid cyst, communicating hydrocephalus). None of these findings had any positive prognostic implication. Sedation or general anaesthesia was required for all except one child. Injection pethidine compound was used for children under age 5 years or less than 30 kg in weight, and trimeprazine orally was used for older children. The radiation exposure was high--5.6 rad per scan, which is 100 times greater than that from a posteroanterior and lateral chest x-ray film. For these reasons computerised tomography scans cannot be recommended as a routine part of the investigation of children with non-specific mental subnormality.

Mediastinal Mass in a Patient With Liver Disease

History A 20-year-old woman was examined for a mediastinal mass detected on chest roentgenograms. Biopsy diagnosis of chronic active hepatitis had been made at age 12 years, three years after an episode of acute infectious hepatitis. Three episodes of significant hemorrhage from esophageal varices were documented. Bleeding hemorrhoids, peptic ulcer disease, and easy bruising were also reported. She had been receiving immune suppression therapy with prednisone and azathioprine (Imuran) for two years. On admission, splenomegaly and thrombocytopenia were noted. Erect posteroanterior (PA) and lateral chest x-ray films (Fig 1) and a contrast-enhanced computed tomographic scan of the lower thorax (Fig 2) were obtained. Diagnosis Esophageal varices and venous collateral secondary to portal hypertension. Lateral and PA chest x-ray films showed a retrocardiac mediastinal mass (Fig 1). The azygous vein appeared normal on erect films but was enlarged on supine tomography. On lateral tomograms, the superior margin of the mass corresponded

Mediastinal mass in a patient with liver disease

<h3>History</h3> A 20-year-old woman was examined for a mediastinal mass detected on chest roentgenograms. Biopsy diagnosis of chronic active hepatitis had been made at age 12 years, three years after an episode of acute infectious hepatitis. Three episodes of significant hemorrhage from esophageal varices were documented. Bleeding hemorrhoids, peptic ulcer disease, and easy bruising were also reported. She had been receiving immune suppression therapy with prednisone and azathioprine (Imuran) for two years. On admission, splenomegaly and thrombocytopenia were noted. Erect posteroanterior (PA) and lateral chest x-ray films (Fig 1) and a contrast-enhanced computed tomographic scan of the lower thorax (Fig 2) were obtained. <h3>Diagnosis</h3> Esophageal varices and venous collateral secondary to portal hypertension. Lateral and PA chest x-ray films showed a retrocardiac mediastinal mass (Fig 1). The azygous vein appeared normal on erect films but was enlarged on supine tomography. On lateral tomograms, the superior margin of the mass corresponded

Aneurysms of the Ascending Aorta or Transverse Arch Presenting to the Left of the Spine

Aneurysms of the ascending aorta usually present to the right of the spine. Four patients with aneurysms of the ascending aorta or transverse arch presented to the left of the spine on the posteroanterior chest roentgenogram. On the lateral chest x-ray film, these were associated with the ascending aorta, and the apparent discrepancy led to diagnostic difficulty. All cases were proven by aortography and/or surgery.

The Radiologic Significance of the Left Pulmonary Ligament: Experience with 26 Patients

Pathologic processes confined to or by the left pulmonary ligament present a confusing radiographic appearance. Such processes may simulate pleural scarring, parenchymal scarring, or even left lower lobe collapse. Radiologic awareness of this structure is limited because in the normal state, it is not visualized on either posteroanterior or lateral chest x-ray films. The absence of secondary signs of left lower lobe collapse, together with a process which may extend above the level of the left hilum, is valuable in confirming that such a triangular density seen behind the left cardiac border is disease in or confined by the pulmonary ligament, rather than left lower lobe collapse.

Atypical Radiographic Findings in Neonates with Absent Pulmonary Valve and Tetralogy of Fallot

At birth, three infants had typical to-and-fro murmurs and laboratory features suggesting tetralogy of Fallot with absent pulmonary valve. Initial posteroanterior chest x-ray films were atypical for the condition because of the apparent absence of dilation of the proximal pulmonary arterial tree. Lateral chest x-ray films invariably demonstrated a large hilar mass. Radiographic findings on the posteroanterior chest x-ray film considered pathognomonic for the complex lesion may not evolve until later during the first year of life.

Radiographic appearance of the thorax in systolic click-late systolic murmur syndrome

The posteroanterior and lateral chest X-ray films of 64 consecutive patients with an isolated systolic click (55 patients) or a systolic click with a late systolic murmur (9 patients) showed a striking frequency of thoracic skeletal abnormalities. There were 50 female and 14 male subjects. The average age of the female subjects was 36.7 years (range 13 to 67), that of the male subjects 39.7 years (range 17 to 56). Seventy-two percent of the female and 78 percent of the male subjects had an anteroposterior/transverse thoracic ratio less than the mean ratio in a normal population. Bony abnormalities such as pectus excavatum, straight thoracic spine and scoliosis occurred alone or in combination in 31 of the 50 female patients (62 percent) and in 8 of the 14 male patients (57 percent). Overall, 39 of the 64 patients (61 percent) had at least one of the skeletal abnormalities. Scoliosis occurred in 25 subjects (39 percent) and was mild in 19. A “straight back” was found in 15 (23 percent) and pectus excavatum in 7 patients (11 percent). The explanation for these findings is not apparent. Thoracic cage abnormalities should be included as one of the nonauscultatory features of the systolic click-late systolic murmur syndrome.

Unusual QRS Wave Forms Associated with Permanent Pacemakers

Electrocardiograms from 86 patients with permanent pacemakers were reviewed to assess the frequency of unusual QRS configurations associated with properly placed pacemaker catheters. All nine patients with epicardial pacemaker wires had the expected QRS configuration, suggesting that the contralateral ventricle was depolarized last. Electrocardiograms from 71 of 77 patients with transvenous pacemakers showed the expected left bundle branch block type configuration. Six patients had unexpected QRS morphology, manifested either as typical right-bundle branch block morphology or as a prominent R wave or RsR’ pattern in lead V 1 . Clinical evaluation including lateral chest x-ray film findings revealed no evidence of catheter malposition in these six patients, and two with appropriate catheter position confirmed by direct visualization. These results suggest that unusual QRS configurations as described are not uncommonly associated with permanent transvenous pacemakers, and need not always imply inappropriate catheter position. Possible mechanisms of the unusual QRS configurations are discussed.

Mediastinal Tumors—Problems in Diagnosis and Treatment

The cases of 64 patients with a mediastinal tumor have been reviewed. A systemic routine for evaluation of these lesions has evolved, based on their characteristic configuration as well as their predilections for certain sites in the mediastinum. The posteroanterior and lateral megavolt chest x-ray film will allow localization of the lesion in one of the three mediastinal compartments and an impression as to the pathologic process involved. Fifty-five per cent of the lesions were found in the anterior mediastinum, and were further evaluated by laminagraphy. Thirty-one per cent were in the middle mediastinum, where bronchoscopy, nodal biopsy, and skin tests were of value. Fourteen per cent were found in the posterior mediastinum, where laminagraphy and selective angiography were most helpful. Sixty-three per cent of the patients came to operation, while in the remainder a tissue diagnosis was obtained by other means. Fifty per cent of all lesions were malignant. Several case histories are presented to illustrate both interesting and difficult diagnostic problems.

Mediastinal Histoplasmosis: Report of Three Cases with Dysphagia as the Presenting Complaint

Three cases are reported of dysphagia due to histoplasmosis. The dysphagia was caused by pressure on the esophagus from enlarged mediastinal lymph nodes, which are found in active histoplasmosis. Two of these cases are believed to be the first reported causing dysphagia that were diagnosed clinically and recovered without treatment, and these are belived to be the third, fourth, and fifth reported cases of dysphagia due to proved active histoplasmosis. It is hoped that this report will stimulate awareness of histoplasmosis as a possible cause of dysphagia. In endemic areas, lateral chest x-ray films, esophagograms, and serologic study for histoplasmosis are suggested as part of the evaluation of dysphagia.