Midclavicular Line Research Articles

A reappraisal of pediatric thoracic surface anatomy.

Accurate knowledge of surface anatomy is essential for physical examination, invasive procedures, and anatomy education. Individual factors such as age make surface landmarks variable so accurate descriptions are needed. The aim of this study is to describe age-related surface landmarks for intrathoracic structures in children. A total of 156 thoracic computed tomography scans of children aged 0-18 years were categorized into six groups, and the associations between major intrathoracic structures and surface landmarks were analyzed. Sternal angle is an accurate surface landmark for the azygos vein-superior vena cava junction in all age groups. However, the aortic arch (except in the 0-1year group), the bifurcation of the pulmonary trunk and the tracheal bifurcation in those aged 15-18 years were not within this plane. The left brachiocephalic vein was located behind the ipsilateral sternoclavicular joint except in the 1-3 years group, and the right was behind it in children older than 6 years. The apex of heart was at the 5th intercostal space level in the 0-1 and 12-18 years groups; however, it was higher in the other groups. The lower borders of the lungs were at the sixth costal cartilage level in the midclavicular line, eighth intercostal space level in the midaxillary line, and T12 adjacent to the vertebral column in the 15-18 years group; the lower borders were at higher levels in younger children. Defining the variations in surface anatomy by in vivo studies will increase its clinical and pedagogical value.

Anatomical Variation in Diaphragm Thickness Assessed with Ultrasound in Healthy Volunteers.

Ultrasonography of the diaphragm in the zone of apposition has become increasingly popular to evaluate muscle thickness and thickening fraction. However, measurements in this anatomical location are frequently hindered by factors that constrain physical accessibility or that alter diaphragm position. Therefore, other anatomical positions at the chest wall for transducer placement are used, but the variability in diaphragm thickness across the dome has not been systematically studied. The aim of this study was to evaluate anatomical variation of diaphragm thickness in 46 healthy volunteers on three ventrodorsal lines and two craniocaudal positions on these three lines. The intraclass correlation coefficient (ICC) for diaphragm thickness in the craniocaudal direction on the mid-axillary line was significantly higher than those on the posterior axillary and midclavicular lines, suggesting it had the lowest variability (ICCmidaxillary=.89, 95% confidence interval [CI]: 0.83-0.93, ICCposterior axillary=0.74, 95% CI: 0.62-0.85, ICCmidclavicular=0.62, 95% CI: 0.43-0.47, p < 0.05). Average diaphragm thickness was comparable on the posterior axillary and midaxillary lines and substantially larger on the midclavicular line (1.24 mm [1.06-1.47], 1.27 mm [1.10-1.42] and 2.32 [1.97-2.70], p < 0.01). We conclude that the normal diaphragm has a large variability in thickness, especially in the ventrodorsal direction. Variability in craniocaudal position is the lowest at the midaxillary line, which therefore appears to be the preferred site for diaphragm thickness measurement.

A RARE CASE OF DORV IN ADULTHOOD

Background: Double outlet right ventricle (DORV) is a rare cardiac malformation in children and even more rare when it comes to adulthood. Clinical Presentation: We report a boy with DORV with Mitral atresia and hypoplastic Left Ventricle who presented to us with breathlessness on climbing 2 flight of stairs at the age of 22 years.He was not seriously limited when he came to our hospital with complaint of breathlessness on exertion. The mother first noticed him getting breathless on climbing 2 flight of stairs at 5 years of age.The patient had history of recurrent infections in the past with failure to gain weight since childhood.On Examination the Pulse was 90 beats per minute,Spo2 was 85% on Room Air in all four limbs, BP was 90/60 mmhg, no tachypnea.There was Grade 2 clubbing present with cyanosis on the nails of all four limbs. Patient had cleft lip and cleft palate with pes cavus in left foot. On inspection, precordial bulge seen on left side with bony cage deformity and apex impulse in left 5th intercostal space lateral to midclavicular line and visible pulsations in 3rd intercostal space. On palpation, Diastolic thrill present in 2nd left intercostal space with grade 3 parasternal heave. On Auscultation, Grade 3/6 loud harsh diastolic murmur heard over the left precordium and interscapular and infrascapular area with diaphragm of stethoscope in supine position.Soft high pitched early diastolic murmur heard best at left upper sternal border and increased during inspiration. 2D echo suggestive of Double outlet Right ventricle with mitral atresia with hypoplastic left ventricle with pulmonary arterial hypertension and severe pulmonary regurgitation. Discussion: To our knowledge very few cases of DORV survives upto this age without any serious limitation that have been reported.DORV if diagnosed early and operated between the age of 1 year to 3 years have satisfactory results. Some cases that remain asymptomatic or are diagnosed late leads to development of pulmonary hypertension which makes them poor candidates of surgery.It was surprising as this patient have survived till now without any serious limitation or symptoms.

Paramedic Understanding of Tension Pneumothorax and Needle Thoracostomy (NT) Site Selection.

IntroductionTension pneumothorax is an immediate threat to life. Treatment in the prehospital setting is usually achieved by needle thoracostomy (NT). Prehospital personnel are taught to perform NT, frequently in the second intercostal space (ICS) at the mid-clavicular line (MCL). Previous literature has suggested that emergency physicians have difficulty identifying this anatomic location correctly. We hypothesized that paramedics would also have difficulty accurately identifying the proper location for NT.MethodsA prospective, observational study was performed to assess paramedic ability to identify the location for treatment with NT. Participants were recruited during a statewide Emergency Medical Services (EMS) conference. Subjects were asked the anatomic site for NT and asked to mark the site on a shirtless male volunteer. The site was copied onto a transparent sheet lined up against predetermined points on the volunteer’s chest. It was then compared against the correct location that had been identified using palpation, measuring tape, and ultrasound.Results29 paramedics participated, with 24 (83%) in practice for more than five years and 23 (79%) doing mostly or all 9-1-1 response. All subjects (100%) reported training in NT, although six (21%) had never performed a NT in the field. Nine paramedics (31%) recognized the second ICS at the MCL as the desired site for NT, with 12 (41%) specifying only the second ICS, 11 (38%) specifying second or third ICS, and six (21%) naming a different location (third, fourth, or fifth ICS). None (0%) of the 29 paramedics identified the exact second ICS MCL on the volunteer. Mean distance from the second ICS MCL was 1.37 cm (interquartile range (IQR): 0.7-1.90) in the medial-lateral direction and 2.43 cm in the superior-inferior direction (IQR: 1.10-3.70). Overall mean distance was 3.12 cm from the correct location (IQR: 1.90-4.50). Most commonly, the identified location was too inferior (93%). Allowing for a 2 cm radius from the correct position, eight (28%) approximated the correct placement. 25 (86%) were within a 5 cm radius.ConclusionIn this study, paramedics had difficulty identifying the correct anatomic site for NT. EMS medical directors may need to rethink training or consider alternative techniques.

Safety and efficacy of vacuum bottle plus catheter for drainage of iatrogenic pneumothorax

BackgroundIatrogenic pneumothorax is common after thoracic procedures. For patients with pneumothorax larger than 15%, simple aspiration is suggested. Although vacuum bottle plus non-tunneled catheter drainage has been performed in many institutions, its safety and efficacy remain to be assessed.MethodsThrough this prospective cohort study (NCT03724721), we evaluated the safety and efficacy of vacuum bottle plus non-tunneled catheter drainage. Patients older than 20 years old who developed post-procedural pneumothorax were enrolled. A non-tunneled catheter was placed at the intersection of the midclavicular line and the second intercostal space. A 3-way stopcock, a drainage set, and a digital pressure gauge were connected. The stopcock was manipulated to connect the pleural space to the pressure gauge for measurement of end-expiration intrapleural pressure or to the vacuum bottle for air drainage. The rate of successful drainage, the end-expiration intrapleural pressure before, during, and after the procedure and the duration of hospitalization were recorded.ResultsFrom August 2018 to February 2020, 21 patients underwent vacuum bottle plus catheter drainage (intervention group) and 31 patients received conservative treatment (control group). The end-expiration intrapleural pressure of all patients remained less than − 20 cmH2O during drainage. No procedure related complication was observed. Large pneumothorax (≥ 15%) was associated with higher risk of persistent air leak (Odds ratio 12, 95% CI 1.2–569.7). Vacuum bottle assisted air drainage yielded shorter event-free duration than that of conservative treatment (2 days vs 5 days [interquartile range 1–4 days vs 3–7 days], p < .05). Vacuum bottle assisted air drainage also help identifying patients with persistent pneumothorax and necessitate the subsequent management. The event-free duration of persistent air leak in the intervention group was also comparable with that of conservative treatment (5 days vs 5 days [interquartile range 5–8 days vs 3–7 days], p = .45).ConclusionsVacuum bottle plus catheter drainage of iatrogenic pneumothorax is a safe and efficient procedure. It may be considered as an alternative management of stable post-procedural pneumothorax with size larger than 15%.Trial registration The study protocol was approved by the Research Ethics Committee of National Taiwan University Hospital (No. 201805105DINA) on 6th August, 2018. The first participant was enrolled on 23rd August, 2018 after Research Ethics Committee approval. This clinical trial complete registration at U.S. National Library of Medicine clinicaltrials.gov with identifier NCT03724721 and URL: https://clinicaltrials.gov/ct2/show/NCT03724721 on 30th October, 2018.

Value of assessing liver enlargement as a group a parameter in chronic lymphocytic leukemia (CLL) clinical trials: Retrospective review of data from multiple trials for incidence of liver enlargement and impact on response assessment.

e19517 Background: iwCLL 2018 criteria defines liver enlargement as one of the important group A parameters for staging and overall response assessment (ORA). However, the authors acknowledge that given the impact of numerous medical conditions, liver size by physical examination or CT scan is not a reliable measure of hepatic involvement by CLL and should only be considered if hepatomegaly is clearly attributable to lymphoid involvement. The criteria even define partial response and progression categories as 50% decrease or increase, respectively, but no specific size or other criteria for assessing lymphoid involvement are proposed. Focal lesions in liver may be a sign of involvement by CLL but are assessed separately, as extranodal disease. Hepatomegaly may be non-specific with possible causes including metabolic, infectious, neoplastic, toxic, hereditary, vascular, and miscellaneous other causes. 20-30% of a general population may have non-alcoholic fatty liver enlargement. In the literature hepatomegaly by palpation has been defined as a portion of the liver below the costal margin and the cut-off for normal liver on imaging is considered &lt; 16 cm in mid-clavicular line. However, there are various anatomic variations with no consensus on the size criteria for liver enlargement. Methods: Independent review data from seven phase II/III CLL trials for frontline therapies as well as in relapsed/refractory setting, were retrospectively analyzed. Data included the independent review assessment results of a total of 22224 timepoints (TPs) of 2223 subjects (2223 baseline (BL) and 20001 post-BL TPs). The data were analyzed for the incidence of subjects with liver enlargement at baseline, post-BL assessment of liver and its impact on ORA. Liver assessment in all trials was qualitative, and the criteria for enlargement was based on the reviewer’s judgement; no size limit was defined. Results: Only 7 out of 2223 subjects (0.3%) had liver enlargement at baseline. Liver assessment of these subjects at post-BL did not cause an upgrade or downgrade of the ORA. None of the 2223 subjects had liver progression at post-BL TPs. Conclusions: Based on the data analysis of a large sample size, it is evident that assessment of liver enlargement as a group A parameter in CLL clinical trials, does not impact the ORA. Liver is rarely even assessed as enlarged by independent reviewers, since hepatomegaly may be caused by various other medical conditions besides CLL. No size or other criteria help distinguish between liver enlargement from CLL versus other causes. We recommend removing liver enlargement as a group A parameter for response assessment as it complicates the assessment paradigm without adding any value to it. Liver involvement should only be assessed for focal lesions, as extranodal disease.

An Accessory Muscle of the Pectoral Region

Among the variations of pectoral muscles, this case is unique in the literature. An accessory pectoral muscle located deep to the left pectoralis minor, and attached to ribs 4‐6 near the midclavicular line, was discovered during a routine anatomy dissection. The muscle fibers do not fuse with fibers from other muscles, yet they run parallel to pectoralis minor. The accessory muscle can be distinguished from pectoralis minor because it has its own investing fascia and because subcutaneous fascia lies posterolaterally to the accessory muscle. These features place it in a distinct plane with unique innervation. This muscle holds clinical importance in that it may be a consideration for surgeons performing procedures including pectoral flap surgeries. Further, breast imaging may be complicated by such unexpected variations in the muscle tissue.

C-Section in Uncorrected Ventricular Septal Defect and Pulmonary Hypertension Management in Anesthesia Perspective

Background: Pregnancy with cardiac defects and pulmonary hypertension happen 0.2% to 3% and is correlated with valuable hemodynamic burden due to cardiocirculatory changes which becomes a remarkable indirect cause of maternal mortality and poor fetal outcome. Ventricular septal defect (VSD) is one of the most common forms of heart disease among pregnant women, meanwhile the VSD-specific pregnancy data are insufficient. This case report addresses the anesthetics management for patient with uncorrected ventricular septal defect and pulmonary hypertension. Case: A 30-year-old multigravida with 37 weeks of gestation weighing 52 kg referred elective cesarean section and tubal ligation. She was compos mentis with arterial oxygen saturation was 87-88% room air. A grade IV/VI systolic murmur was heard at the second intercostal space of the left midclavicular line and the punctum maximum at the fourth intercostal spaces of the left sternal border. She had cyanotic in all of her extremities and clubbing fingers. Other examination is within normal limit. Titrated epidural was given at L1-2 level with parenteral levobupivacaine and fentanyl used as an adjuvant. The patient was stable during the surgery. Both maternal and fetal had a good outcome. The patient was discharged at the 7th day after surgery. Conclusion: To achieve a good outcome from management of the high-risk obstetric patients requires multidisciplinary approach involving anesthetist, obstetrician, and cardiologist in planning and managing the case.

The Modified Sternoplasty: A Novel Surgical Technique for Treating Mediastinitis

Summary:Deep sternal wound infection (DSWI) is one of the most complex and devastating complications post cardiac surgery. We present here the modified sternoplasty, a novel surgical technique for treating DSWI post cardiac surgery. The modified sternoplasty includes debridement and sternal refixation via bilateral longitudinal stainless-steel wires that are placed parasternally along the ribs at the midclavicular or anterior axillary line, followed by six to eight horizontal stainless-steel wires that are anchored laterally and directly into the ribs. On top of that solid structure, wound reconstruction is performed by the use of bilateral pectoralis muscle flaps followed by subcutaneous tissue and skin closure. We reported mortality rates and length of hospitalization of patients who underwent the modified sternoplasty. In total, 68 patients underwent the modified sternoplasty. Two of these critically ill patients died (2.9%). The average length of hospitalization from the diagnosis of DSWI was 24.63 ± 22.09 days. The modified sternoplasty for treating DSWI is a more complex surgery compared with other conventional sternoplasty techniques. However, this technique was demonstrated to be more effective, having a lower rate of mortality, and having a length of hospitalization lower than or comparable to other techniques previously reported in the literature.

Assessment of Abdominal Constrictor's Forces for Informing Computational Models of Orthostatic Hypotension.

Orthostatic hypotension is defined as a sudden drop in blood pressure upon standing from a sitting or supine position. The prevalence of this condition increases exponentially with age. Nonpharmacological treatments are always the first step in the management of this condition, such as the use of an abdominal constriction belt to optimize the blood volume in the abdomen. A multitude of clinical trials have shown the efficacy of elastic abdominal compression as well as compression using an inflatable bladder; however, there are currently few accessible consumer products that can provide abdominal compression by using an inflatable bladder that ensures the correct amount of pressure is being exerted on the subject. This study serves to quantitatively analyze forces exerted in inflatable abdominal binders, a novel treatment that fits the criterion for a first-line intervention for orthostatic hypotension. Quantitative values aim to indicate both the anatomic regions of the body subjected to the highest pressure by abdominal binding. Quantitative values will also create a model that can correlate the amount of compression on the subject with varying levels of pressure in the inflatable bladder. Inflatable binders of varying levels of inflation are used and localized pressure values are recorded at 5 different vertical points along the abdomen in the midsternal line and midclavicular line, at the locations of the splanchnic veins. These findings indicate both the differences in the compressive force applied through elastic and inflatable binding, as well the regions on the abdomen subject to the highest force load during compression by an abdominal binder. A medical manikin called the iStan Manikin was used to collect data. The pressure values on a manikin were sensed by the JUZO pressure monitor, a special device created for the purpose of measuring the force under compressive garments. The pressure inside the inflatable bladder was extrapolated from a pressure gauge and the pressure was recorded at different degrees of inflation of the belt (mmHG) along two different areas of the abdomen, the midsternal line and the midclavicular line, to discern differences in force exerted on the patient (mmHG). Computational studies on the data from the JUZO pressure monitor as well as the data from the pressure gauge on the inflatable bladder allow us to create a model that can correlate the amount of pressure in the inflatable bladder to the amount of pressure exerted on the belt, thus making sure that the patient is not being harmed by the compressive force. The results of our study indicate that there is no significant difference between the pressures exerted on the midsternal and midclavicular lines of the body by the abdominal binder and that no significant difference exists between the external pressure measured by the inflatable belt and the pressure sensed on the human body by the JUZO sensor; however, we were able to extrapolate an equation that can tell the user the amount of pressure that is actually being exerted on them based on the pressure in the inflatable bladder as recorded by the gauge.

“The Plane of Y0”: Evaluating Reliability of a Novel Method of Measuring the Liver With Sonography Using Internal References

Objective: The present methods for the linear measurement of the liver with sonography are based on external reference lines. In addition, these measurements are subject to interrater variability due to relative mobility of liver and abdominal wall during breathing, change in position, and so on. A novel method using a plane with two internal references (plane of Y0) was developed as an alternative. The purpose of this study was to estimate the reliability of the novel method and compare with other commonly used methods. Materials and Methods: A prospective, analytical, cross-sectional study was completed in a radiology department, including individuals referred for sonography and a contrast-enhanced computed tomography (CT) of abdomen. Three radiologists sonographically measured the craniocaudal dimension of liver in the “plane of Y0,” midclavicular, and anterior axillary lines for each participant. In 60 participants, the craniocaudal measurements obtained in the “plane of Y0,” in both contrast-enhanced CT and sonography, were compared for validity. Interrater correlation coefficients were calculated for each method. Results: Three hundred thirty-four participants underwent sonography of the liver. Sixty of them also underwent a contrast-enhanced CT. The craniocaudal measurements within the “plane of Y0” showed excellent reliability in comparison with other methods. It was found to be valid when compared with measurements completed on the CT image. Conclusion: Measuring the liver in the “plane of Y0,” with two identifiable internal references, is reliable, valid, and recommended for possible use in daily clinical practice. Key Takeaways Using internal reference points for measurements of internal organs, with sonography, will reduce interoperator variability. The “plane of Y0” passing through two internal reference points within the liver, the branching of right portal vein (Y shaped) and gallbladder (0 shaped lumen), can be easily acquired with sonography. Measurement in the craniocaudal dimension of liver, in the “plane of Y0,” showed validity and high interrater reliability (0.91). The normal range of measurements in adults was found to be 10.5 to 15.1 cm.

Robotic-assisted minimally invasive thymectomy for myasthenia gravis with thymoma.

Robotic-assisted minimally invasive thymectomy for myasthenia gravis with thymoma.

A Comparison of Central Venous Access to the Internal Jugular Vein and Two Standard Approaches to the Subclavian Vein: A Study of Cross-Sectional Areas Using Computed Tomography Scans.

IntroductionThe supraclavicular approach to the subclavian vein has been cited as having many advantages to the infraclavicular approach, including a larger short-axis cross-sectional area, a greater margin of safety, and fewer complications.MethodsTo examine whether a larger short-axis cross-sectional area of the subclavian vein at the supraclavicular fossa is a potential explanation for the reduction in attempts with the supraclavicular approach seen in a previous study, we examined computed tomography scans from 50 patients (24 M, 26 F). The short-axis cross-sectional areas of the subclavian vein at the mid-clavicular line, the subclavian vein in the supraclavicular fossa, and the internal jugular vein at the level of the thyroid cartilage were calculated.ResultsThe internal jugular vein short-axis cross-sectional area was significantly larger than the subclavian vein short-axis cross-sections measured at each location. We found no difference between the short-axis cross-sectional areas of the subclavian vein or when comparing measurements as a factor of gender, age, or race. Weight had a significant relationship to the short-axis cross-sectional area of the internal jugular vein and subclavian vein at the mid-clavicular vein.ConclusionsOn supine computed tomographic imaging, the subclavian vein short-axis cross-section was not larger in the supraclavicular fossa than the mid-clavicular line. The short-axis cross-sectional area of the subclavian vein at the supraclavicular fossa does not appear to contribute to the decrease in attempts to access it. Weight, but not necessarily height, appears to be correlated with central vein size.

The Amplitude of Diaphragm Compound Muscle Action Potential Correlates With Diaphragmatic Excursion on Ultrasound and Pulmonary Function After Supraclavicular Brachial Plexus Block.

ObjectiveThis prospective, double-blind, randomized study assessed (1) the associations between diaphragm compound muscle action potential (CMAP), hemidiaphragmatic excursion, and pulmonary function after supraclavicular brachial plexus block (SCBPB) and (2) diagnostic efficacy of pulmonary function for hemidiaphragmatic paralysis evidenced by diaphragm CMAP as an assessment of diaphragm strength was evaluated.MethodsEighty-six patients were scheduled for the removal of hardware after healing of a right upper limb fracture distal to the shoulder who were randomly assigned in a 1:1 ratio to two groups: Group A (diaphragmatic excursion), or Group B (pulmonary function). Phrenic nerve conduction studies (PNCSs), M-mode ultrasonography of the diaphragm, and pulmonary function tests (PFTs) were performed before and 30 min after SCBPB. PNCSs were used to determine the latency and amplitude of diaphragm CMAP. Ultrasonography of the diaphragm was performed with patients in a supine position using a low-frequency probe over the subcostal space at the midclavicular line. The diaphragmatic excursion was measured during quiet breathing and deep breathing. Pulmonary function, i.e., forced vital capacity (FVC), predicted value of FVC, and forced expiratory flow in the first second (FEV1), was measured with spirometry. Receiver Operating Characteristic (ROC) curve analysis was used to assess the diagnostic efficacy of pulmonary function for hemidiaphragmatic paralysis evidenced by diaphragm CMAP as an assessment of diaphragm strength.ResultsThere were significant associations between the reduction in amplitude of diaphragm CMAP and reductions in diaphragmatic excursion during quiet breathing (r = 0.70, p < 0.01) and deep breathing (r = 0.63, p < 0.01) when expressed as a percentage of baseline values. There were significant associations between the reduction in amplitude of diaphragm CMAP and reductions in FVC (r = 0.67, p < 0.01), FVC% (r = 0.67, p < 0.01), and FEV1 (r = 0.62, p < 0.01), when expressed as percentage of baseline values. The area under the ROC curve for FVC was 0.86. A decrease of >8.4% in FVC compared to pre-block predicted hemidiaphragmatic paralysis (determined by diaphragm CMAP) with sensitivity and specificity of 79.2 and 100%, respectively.ConclusionsThe relative reduction in diaphragm CMAP amplitude after SCBPB was correlated with relative reductions in diaphragmatic excursion and pulmonary function. FVC has potential as a useful diagnostic indicator of hemidiaphragmatic paralysis, evidenced by diaphragm CMAP, after SCBPB. These data establish diaphragm CMAP as a direct and objective index of diaphragmatic paralysis after SCBPB.

Failure of First Attempt Needle Decompression in Tension Pneumothorax: Case Report

Tension pneumothorax can occur as a potentially life threatening complication of chest trauma. Tension pneumothorax is commonly treated with needle decompression, both the 2nd intercostal space in the midclavicular line and the 4th/5th intercostal space in the anterior axillary. A 45 years old man came to our emergency department after blunt injury of the chest presenting tension pneumothorax with unstable hemodynamic treated with needle decompression using 14 gauge (4.5 cm) cannula at 2nd intercostal space mid clavicular line, patient successfully recover and became hemodynamic stable, after 30 minutes of successful needle decompression patient experienced with recurrent tension pneumothorax. Several studies show the failure of needle decompression it may due to several factor such as chest wall thickness, cannula length, and location of the needle decompression. In this case the cannula may has insufficient length (4.5 cm) to pass through the full thickness of the patient’s chest wall at 2nd intercostal space mid clavicular line (ICS 2) and makes air leaks from the lung faster than it can escape through the cannula.

Effectiveness and Safety of Prolonged Needle Decompression Procedures in Tension Pneumothorax Patients with COVID-19

Introduction: Coronavirus disease-19 (COVID-19) has become a pandemic that is still ongoing today. This is a new challenge for health workers in handling emergency cases. Several COVID-19 patients arrived at the hospital with severe respiratory problems. Meanwhile, other pathological conditions causing respiratory failure must also be considered, such as pneumothorax. Objective: This study aimed to examine the effective emergency procedures to treat COVID-19 cases with tension pneumothorax. Case report: A 45-year-old male patient arrived with a referral letter from a pulmonologist with a diagnosis of simple pneumothorax and pneumonia. The patient also presented a positive SARS COV-2 PCR test result. The patient complained about a worsening of shortness of breath. A symptom of dry cough for 14 days was also reported. Chest radiograph examination subsequently indicated right tension pneumothorax. In the emergency ward, needle decompression procedure connected to the vial containing sterile intravenous fluids was performed. Re-examination of the chest x-ray demonstrated right pulmonary re-expansion. The patient was monitored and after four days, needle decompression was removed and no chest tube was inserted because complete resolution of the lungs had occurred. Discussion: This case illustrates that tension pneumothorax causes worsening of the patient's condition with COVID-19 diagnosis. In another case of tension pneumothorax in a COVID-19 patient, needle decompression of the 2nd intercostal space and the mid-clavicular line was performed as initial treatment followed by chest tube insertion as definitive treatment. However, in this case, chest tube approach was not carried out because the patient had demonstrated clinical and radiological improvement and a worsening condition had not occurred. Conclusion: Prolonged needle decompression connected to a vial containing sterile intravenous fluids as deep as 2 cm from the water surface is an effective procedure in the management of tension pneumothorax even without the installation of a chest tube.

The importance of ultrasound in the diagnosis of pleura complications of acute destructive pneumonia in children

Background. The problem of timely diagnosis of complications of acute destructive pneumonia accompanied by pyofibrothorax remains relevant. The study was aimed to investigate the features of ultrasound diagnosis (ultrasound) of the condition of the visceral and parietal pleural lamina in acute destructive pneumonia in children at different stages of the disease. Materials and methods. In the departments of purulent surgery and pulmonology of the Regional Children’s Hospital of Dnipro for the period of 5 years, there were observed about 475 children aged from 1 to 17 years with pneumonia, purulent-destructive changes in the lungs and pleura. For analysis and further study, we choose a group of 50 patients of different age groups, who underwent ultrasound in real time without prior preparation of patients. The condition of the parietal and visceral pleural lamina at the different stages of diagnosis and treatment was studied. Results. A group of patients aged from 4 to 10 years was performed an ultrasound of the pleural cavities in real time without prior preparation on the paraspinal, scapular, axillary, midclavicular, and thoracic lines when admitted to the hospital and on the first day of treatment. Ultrasound was used to determine the structure and volume of free fluid as well as the condition of the parietal and visceral pleural lamina, their thickness, and other features. The use of ultrasound allowed diagnosing the early manifestations of pyofibrothorax and determining the condition of the parietal and visceral pleural lamina in the children with destructive pneumonia. Conclusion. Further improvement of the algorithm of ultrasound diagnosis of acute destructive pneumonia in children with pyofibrothorax will reduce radiation exposure to a child’s body, increase the efficiency of the development and improvement of treatment methods at the stages of pyofibrotorax, reduce the duration of inpatient treatment.

Sonographic Correlation of Liver Dimensions with Anthropometric Variables in Apparently Healthy Pediatrics in Kano Metropolis, Nigeria

Accurate measurement of liver size allows for the diagnosis of various liver pathologies. Establishing normal liver size and how it is influenced by anthropometric variables is critical in diagnosis and determining the treatment method for the underlying liver pathology. This study was aimed at establishing the relationship between liver dimensions and anthropometric variables. The study was a cross-sectional study conducted in some selected hospitals in Kano Metropolis, Nigeria. Four hundred and twenty-six apparently normal pediatric subjects were studied within the age range of 0 – &lt;18years. The liver was examined with the patient in supine position, both the cranio-caudal and antero-posterior liver dimension were obtained through the mid clavicular line in longitudinal and transvers planes respectively. Both descriptive inferential statistics were employed for the data analysis. Statistical Package for Social Sciences (SPSS) was used and p&gt;0.05 was set as significance level. There was a statistical significant strong positive correlation between cranio-caudal dimension and age, height, weight, BMI and BSA in &lt;1 month &gt;12month age group (r=0.74, p=0.000; r=0.86, p=0.000; r=0.64, p=0.000; r=0.74, 0.p=000 and r=0.53, p=0.000 respectively for males and r=0.60, p=0.000; r=0.61, p=0.000; r=0.59; p=0.000; r=0.81, p=0.000 and r=0.66, p=0.001 respectively for females). Also, in the same age group both male and female subjects show significant strong positive correlation between anterior-posterior dimension and BMI &amp; BSA: (r=0.67, p=0.000, r=0.67, p=0.000 respectively for males and r=0.69, p=0.000, r=0.77, p=0.000 respectively for females). This study reported that anthropometric variable such as age, height, BMI and BSA is positively correlated with both cranio-caudal and antero-posterior liver dimension.&#x0D; Keywords: Ultrasound, Liver, Cranio-Caudal, Antero-Posterior, Dimension

Chest wall muscle mass depletion is related to certain pulmonary functions and diseases in patients with bronchiectasis.

Background and objectiveMany bronchiectasis patients suffer dyspnea, decreased exercise tolerance, and low body mass index. Chest wall muscles play a special role in respiratory movement and make up parts of skeletal muscles. This study aimed to examine the chest wall muscle thickness and their relationship with disease severity in bronchiectasis.MethodsWe retrospectively included 166 patients with bronchiectasis and 62 patients with pneumonia as comparators. The thickness of chest wall muscle as determined in chest CT, pulmonary function, and Bronchiectasis Severity Index (BSI) score were recorded. We compared the thickness of the chest wall muscle in two groups and assessed the relationships among chest wall muscle thickness, pulmonary function, and BSI score.ResultsChest wall muscle thickness of the anterior midclavicular line and posterior exterior scapula were thinner in bronchiectasis patients than comparators both above the aortic arch level and at the aortic arch window level. Muscle thickness of the posterior interior scapula above the aortic arch level was significantly thinner in bronchiectasis patients. Chest wall muscle thickness at the anterior midclavicular line both the above aortic arch level and at the level of the aortic arch window were related to diffuse capacity in bronchiectasis patients. Anterior chest wall muscle thickness above the aortic arch was found to be a risk factor of disease severity.ConclusionAnterior chest wall muscles in the upper and middle chest were thinner in bronchiectasis patients than in comparators, and had relationship with spirometry and diffuse compacity factors. We provide another method to conveniently assess bronchiectasis severity.

PRINCIPLES OF DIAGNOSIS AND TREATMENT OF ASKIN’S TUMOR IN CHILDREN: CASE REPORT

The aim of the study was to show principles of diagnosis and treatment of Askin’s tumor in children. Diagnostic procedures include physical examination, chest X-ray, CT scan and PET CT, morphological, histological and immunohistochemical examinations, cytogenetic study. Primitive neuroectodermal tumors belong to the group of low differentiated, overly aggressive neoplasms, originating from cells of the parasympathetic autonomic nervous system. Patient F., 9 years old, first consulted by pediatric oncologist in 2014 with complaints of volume formation in the chest on the right side which progressively increases. Diagnosis: PNEP (primitive neuroectodermal tumor) of the soft tissues of the chest on the right side in the 4th intercostal space along the midclavicular line T2aN0M0, stage 2a, standard risk group. We’ve shown results of diagnostical process, treatment and it’s result in our patient. Patients who have received combination therapy, including chemotherapy, surgical removal of the tumor and radiation therapy, have better prognostic results. However, relapses often occur that require more aggressive treatment with high-dose chemotherapy, monoclonal antibodies, and bone marrow transplantation.