Left Fourth Rib Research Articles

Age estimation from the sternal end of left fourth rib in the Nepalese population

BackgroundForensic anthropological examinations help in identification of unidentified human remains. This study aims to establish population-specific standards for age estimation from the sternal ends of left fourth ribs in the Nepalese population. A quantitative, observational study was conducted on 387 Nepalese deceased (106 females, 281 males) between November 2021 and March 2023. Left fourth ribs were collected, macerated and examined for the study. The variables examined included pit depth, pit shape, rim and wall configurations and rib phase.ResultsPit depth significantly predicted age, β = 0.642, t(385) = 16.42, p < 0.001. Pit depth also explained a significant proportion of variance in age, R2 = 0.41, F(1, 385) = 269.54, p < 0.001. The age estimates from pit depth stage were 7–36 (stage 0), 7–49 (stage 1), 16–51 (stage 2), 10–58 (stage 3), 22–70 (stage 4) and 32–81 (stage 5). Age estimates for pit shape were 17–20 (stage 0), 13–48 (stage 2), 15–55 (stage 3), 24–68 (stage 4) and 39–82 (stage 5). Age estimates for rim and wall configurations were 17–20 (stage 0), 13–47 (stage 2), 17–53 (stage 3), 24–68 (stage 4) and 40–82 (stage 5). Similarly, age estimates for rib phase were 17–20 (phase 0), 18–20 (phase 1), 13–46 (phase 2), 18–50 (phase 3), 23–60 (phase 4), 32–71 (phase 5), 50–76 (phase 6), 44–81 (phase 7) and 62–85 (phase 8). The study also examined the use of transitional analysis to develop posterior probability distributions for estimation of age using rib phases.ConclusionThis study found significant differences in the age estimates from previous studies and shows the importance of developing population-specific models for use in forensic anthropology.

A RARE CASE OF DELAYED HEMOPTYSIS 20 YEARS AFTER A BLUNT CHEST TRAUMA

Blunt chest injury is a common presentation to the emergency department, it may result in a variety of delayed sequelae. However, a delayed hemoptysis after blunt trauma is rare. We report a case of a 36-year-old woman presenting with hemoptysis 20 years after an accidental fall from the first floor. Imaging revealed an intra-parenchymal migration of a fragment from the left fourth rib. The diagnosis was confirmed by video-assisted thoracoscopic surgery (VATS) with mini-thoracotomy, which enabled the extraction of the bone fragment.

Infective Costochondritis after Augmentation Mammoplasty: A Rare Case Report and Review of the Literature.

Silicone breast implant insertion is a commonly performed surgical procedure for breast augmentation or reconstruction. Among various postoperative complications, infection is one of the main causes of patient readmission and may ultimately require explantation. We report a case of infective costochondritis after augmentation mammoplasty, which has rarely been reported and is therefore difficult to diagnose. A 36-year-old female visited the clinic for persistent redness, pain, and purulent discharge around the left anteromedial chest, even after breast implant explantation. Magnetic resonance imaging showed abscess formation encircling the left fourth rib and intracartilaginous and bone marrow signal alteration at the left body of the sternum and left fourth rib. En bloc resection of partial rib and adjacent sternum were done and biopsy results confirmed infective costochondritis. Ten months postoperatively, the patient underwent chest wall reconstruction with an artificial bone graft and acellular dermal matrix. As shown in this case, early and aggressive surgical debridement of the infected costal cartilage and sternum should be performed for infective costochondritis. Furthermore, delayed chest wall reconstruction could significantly contribute to the quality of life.

Use of accelerometers for automatic regional chest movement recognition during tidal breathing in healthy subjects

Recognition of breathing patterns helps clinicians to understand acute and chronic adaptations during exercise and pathological conditions. Wearable technologies combined with a proper data analysis provide a low cost option to monitor chest and abdominal wall movements. Here we set out to determine the feasibility of using accelerometry and machine learning to detect chest-abdominal wall movement patterns during tidal breathing. Furthermore, we determined the accelerometer positions included in the clusters, considering principal component domains. Eleven healthy participants (age: 21 ± 0.2 y, BMI: 23.4 ± 0.7 kg/m2, FEV1: 4.1 ± 0.3 L, VO2: 4.6 ± 0.2 mL/min kg) were included in this cross-sectional study. Spirometry and ergospirometry assessments were performed with participants seated with 13 accelerometers placed over the thorax. Data collection lasted 10 min. Following signal pre-processing, principal components and clustering analyses were performed. The Euclidean distances in respect to centroids were compared between the clusters (p < 0.05), identifying two clusters (p < 0.001). The first cluster included sensors located at the right and left second rib midline, body of sternum, left fourth rib midline, right and left second thoracic vertebra midline, and fifth thoracic vertebra. The second cluster included sensors at the fourth right rib midline, right and left seventh ribs, abdomen at linea alba, and right and left tenth thoracic vertebra midline. Costal-superior and costal-abdominal patterns were also recognized. We conclude that accelerometers placed on the chest and abdominal wall permit the identification of two clusters of movements regarding respiration biomechanics.

Sex determination from chest measurements in a sample of Egyptian adults using Multislice Computed Tomography

BackgroundIn forensic sciences to determine one's sex is quite important during the identity defining stage. The reliability of sex determination depends on the completeness of the remains and the degree of sexual dimorphism inherent in the population. Computed Tomography is the imaging modality of choice for two- and three-dimensional documentation and analysis of many autopsy findings. ObjectiveThe aim of the present work was to assess the reliability of Three-dimensional Multislice Computed Tomography (3D MSCT) to determine sexual dimorphism from certain chest measurements; sternum and fourth rib using the 3D MSCT and to develop equations for sex determination from these bones among adult Egyptians sample. Subjects and methodsThe present study was performed on 60 adult Egyptians. Their age ranged from 21 up to 74 years and they were equally divided between both sexes. Sixty virtual chests (reconstructed Multislice Computed Tomography 3D images) were examined for detection of Sternal measurements; Manubrium length (ML), Sternal body length (BL), Manubrium width (MW), Sternal body widths(BWa&BWb), Sternal area (SA) [(ML + BL) × (MW + BWa + BWb)/3]and Fourth rib width (FRW). ResultsAll the studied measurements were significantly higher in males than in females. Multiple regression analysis was used to and three significant regression equations were developed for predicting sex using the different studied chest measurements; the sternal measurements, the sternal area and the widths of the right and left fourth ribs with their accuracies 96.67%.95.0%.72.68% respectively. ConclusionSterunm and fourth rib width revealed significant metric sex differences with the use of Multislice Computed Tomography 3D images thus provide a great advantage in the analysis of skeletal remains and badly decomposed bodies.

Successful Percutaneous Thrombectomy of Aortic Tumor Emboli Extending into the Origin of the Superior Mesenteric Artery with Half-Deployment of a Nitinol Stent

A 73-year-old woman with leiomyosarcoma presented with a 3-day history of abdominal pain. An abdominal computed tomography (CT) scan revealed a 1.5-cm abdominal aortic mass extending into the origin of the superior mesenteric artery (SMA) (arrow in Fig 1). Chest CT scan showed tumor thrombi in the left superior pulmonary vein and left atrium (straight and right-angle arrows in Fig 2) and multiple metastatic lesions in both lungs (arrowheads in Fig 2) and the left fourth rib (curved arrow in Fig 2). Together, these findings indicated that a pulmonary metastatic lesion had invaded the pulmonary vein and caused systemic tumor embolization. Aortography performed through a transfemoral 45-cm 8-F sheath (Super Arrow-Flex sheath; Arrow International, Inc, Reading, Pennsylvania) showed a filling defect at the SMA origin (arrow in Fig 3). A 16-F sheath (St. Jude Medical, Minnetonka, Minnesota) was inserted through the contralateral femoral artery using a “preclosure” technique. A 16-mm diameter self-expanding closed cell nitinol stent (Niti-S; Taewoong Medical Co, Ltd, Gimpo, Korea) was advanced through the sheath and halfdeployed, caudally, to capture emboli. A 6-F 20-mm thrombectomy-type

Giant Costal Osteochondroma in a Man With Multiple Exostoses

We report the case of a 42-year-old man who presented with kyphosis resulting from a giant symptomatic costal osteochondroma around the left fourth rib. The osteochondroma on the left side of the back was 56 cm × 47 cm × 33 cm and was painful. The size and growth of the tumor suggested a malignant transformation of a large costal osteochondroma. Multiple osteochondromas were also found on the legs. The patient's family history revealed hereditary characteristics. This patient was clinically diagnosed as a case of multiple familial osteochondromatosis. Complete removal of the tumor relieved the symptoms, and histopathologic examination confirmed malignant transformation of chondrosarcoma. There was no recurrence after 16 months of follow-up.

Thoracoscopic findings of an asymptomatic solitary costal exostosis: is surgical intervention required?

We report a case of a 21-year old male with an asymptomatic solitary costal exostosis incidentally detected on a chest X-ray. The exostosis originated from the costochondral junction of the left fourth rib and protruded into the thoracic cavity. Exploratory thoracoscopy showed that the exostosis had scratched the adjacent pericardium and visceral pleura. A 5.5-cm long rib segment including the exostosis was excised. This report describes that the thoracoscopic findings of an asymptomatic costal exostosis originate from the costochondral junction, demonstrating that this condition may cause more extensive thoracic organ injury than expected.

Long-term palliation of tetralogy of Fallot in dogs by use of a modified Blalock-Taussig shunt

To describe a modified Blalock-Taussig shunt (mBT) procedure and assess its use in dogs with clinical signs associated with tetralogy of Fallot (TOF). Descriptive report. 6 dogs with severe TOF-associated clinical signs. Each dog had TOF (confirmed echocardiographically or angiographically) and underwent an mBT shunt procedure for surgical palliation of signs. The surgery was performed through a left fourth rib resection or a left fifth intercostal thoracotomy. The left subclavian artery was dissected free from surrounding mediastinal tissue. The main pulmonary artery trunk was exposed through an incision in the overlying pericardium. A shunt comprised of a 6-mm-diameter tube of expanded polytetrafluoroethylene (5 dogs) or a segment of carotid artery (1 dog) was sutured end to side between the left subclavian artery and pulmonary artery trunk. 5 of the 6 dogs survived the immediate postoperative period. The dog that died shortly after surgery was the smallest of the dogs (weight, 2.9 kg [6.38 lb]) and had received the carotid artery autograft. Three dogs survived long term and 2 dogs died of unknown causes 6 years after undergoing the mBT shunt procedure. In all dogs that survived the mBT procedure, shunt patency was confirmed and quality of life appeared improved. These findings have suggested that the mBT shunt procedure safely provides long-term palliation of TOF-associated clinical signs in dogs. In addition, it may offer an effective low-risk and lower-cost alternative to open heart repair of TOF.

Multicentric epithelioid angiosarcoma of the spine: a case report of a rare bone tumor

Background context Epithelioid angiosarcoma (EA) is a high-grade sarcoma of vascular origin. EA is a rare variant of angiosarcoma. It is characterized by large cells with an epethelioid morphology. EA has been reported in sites like skin thyroid, adrenal gland, soft tissue, and rarely in bone. Purpose The current article describes a case of multicentric EA of the spine that presented simultaneously at T4 spine and the posterior one third of the left fourth rib. Study design/settings This study included a patient with a rare spinal tumor, which presented insidiously. Radiologically, the lesions were osteolytic with erosion of cortices. The tumor was composed of nests and cords of malignant cells with epithelioid morphology with areas of vascular differentiation, necrosis, and hemorrhage. Anastomosing vascular spaces lined by epithelioid endothelial cells suggested focal endotheliod differentiation. Methods Histopathological evaluation of the tumor obtained from en bloc resection of the fourth rib and specimen from decompression of the fourth thoracic vertebra was done. Immunohistochemistry showed positivity for endothelioid cell markers like CD31 and factor VIII related antigen. The authors point out the need for immunohistochemical evaluation after careful histological analysis for vascular differentiation for an accurate diagnosis of vascular bone tumors with epithelioid features so that an erroneous diagnosis of metastatic carcinoma can be avoided. EA occurs rarely in bone. EA is marked by the presence of large polygonal epithelioid malignant cells with marked cellular atypia and pleomorphism. The arrangement of the cells may mimic epithelial neoplasm. These types of lesions are a definite diagnostic challenge in bone biopsy. The tumor was treated with en bloc resection of the rib and decompression of the body of T4 spine, followed by megavoltage radiotherapy. Follow-up X-rays showed regression of the tumor at 2 years. CD31 is the most sensitive marker for EA. Even in the absence of obvious vascular differentiation, abundant intratumoral hemorrhage and intratumoral neutrophils are definite morphologic changes that should suggest a vascular origin. Results The patient was followed up for 2 years. A conservative surgical approach with a radical course of megavoltage radiotherapy could yield a good result in EA of bone. At the time of writing this report, there is no evidence of tumor recurrence. Conclusion It is important to differentiate EA from other tumors because the clinical course and treatment are specific for these conditions. Careful histologic and immunohistochemical analysis will clinch the diagnosis. Even though rare, we stress the importance to be aware of the existence of this tumor, which is essential for correct diagnosis.

Control of the pulmonary arterial resistance by the use of the oscillated assist flow.

In the clinical application of supporting circulation, the treatment of a patient with pulmonary hypertension is very important. We developed the electromagnetically driven vibrating flow pump (VFP) as a totally implantable type ventricular assist system. The artificial heart driven by electromagnetic forces creates high speed oscillation flow around 10-50 Hz. Assistance by high-speed oscillation flow has an interesting influence on the cardiovascular system. In this study, we carried out research on the influence such oscillation flow had on the pulmonary arterial vessels, and the supporting flow wave-form that controlled pulmonary vascular resistance was considered. Six healthy adult goats of both sexes were used in the experiments. We carried out inhalation anesthesia and performed intubation. The thorax was opened through left fourth rib resection. Right heart bypass was performed from the right atrium to the pulmonary artery. The flow of right heart assistance was maintained within 20-25% of total flow. Our purpose was to add flow of a specific high frequency to the right heart circulation. The hemodynamic parameters were recorded on a magnetic tape data recorder and input into a computer through an A-D converter. A result identified was that the pulmonary vascular resistance changed according to the alteration of the driving frequency of the VFP even during the same flow assistance. The resistance of the pulmonary arterial vessels became smaller when the driving of the VFP of 30 Hz was added to the right heart circulation. This was significant even when compared with continuous flow right heart assist. The characteristics of impedance appeared to have interesting alterations as well. Control of pulmonary vascular resistance by right heart assistance becomes possible if these results are applied. Accordingly, it may become one of the choices for treatment of a patient with pulmonary hypertension.

Rib Fracture Healing in Experimental Flail Chest

Sixteen dogs were placed under general anesthesia and flail segments of the left chest were created by transecting ribs 7,8,9, and 10 anteriorly and posteriorly. Fractures were 10 cm apart so that a 10-cm flail segment encompassing four ribs was created. In Group I, the control (N = 5), the chest wall muscles were closed without any stabilization of the fractures. Group II (N = 5) had stabilization of both anterior and posterior fracture sites by polypropylene sutures. Group III (N = 6) had stabilization of the fractures in ribs 7 and 8 with 2.5-cm bone grafts taken from the left fourth rib. Ribs 9 and 10 were stabilized by polypropylene sutures. The study established a canine model for flail chest. It also showed that strut stabilization of rib fractures with bone grafts promotes better healing than suture stabilization. It suggests that using bone grafts taken from another rib to stabilize flail segments may be unsatisfactory since the rib used as a donor showed no signs of regeneration at 30 days.