Rib Cage Research Articles

Anatomical basis of retrograde thoracic veins flow and its implications in complex thoracic wall reconstructive surgery

PurposeInternal thoracic veins are increasingly used as recipient’s vessels in chest wall reconstructive surgery due to their predictable anatomy and to the possibility to make a double venous anastomosis, exploiting the retrograde flow within them. Over the years, retrograde flow had been explained by the absence of valves in internal thoracic veins, which have been found recently instead. Therefore, our aim is to analyze the retrograde flow and its relationship with valves in the internal thoracic veins.MethodsWe evaluated 32 internal thoracic veins of 16 fresh-frozen specimens with undamaged thoracic cages by dynamic analysis focused on retrograde flow assessment through a partial external circulation system obtained cannulating the subclavian veins. Gross anatomical and morphological evaluations about the presence of valves and their pattern were then made.ResultsEfficient, partial, and absent retrograde flow was, respectively, found in 17/30, 8/30 and ITVs and 5/30 internal thoracic veins. Following Arnez’s classification, 20/32 Type I and 12/32 Type II internal thoracic veins were identified. Valves were observed in 10/16 specimens (62.50%) corresponding to 36.67% of examined veins (11/30). Three valves were found between the 2nd intercostal space and 12 valves in the 3rd intercostal space. 13/15 valves were bicuspid, 2/15 tricuspid. A significant correlation (p < 0.001) between the retrograde flow and the presence of valves in internal thoracic veins was observed.ConclusionOur study suggests a possible influence of the presence and the number of valves in the efficient retrograde flow of the internal thoracic veins, suggesting that, especially for more complex cases, a preoperative or intraoperative evaluation of the chest wall drainage should be recommended.

Computational model for fetal skeletal defects potentially linked to disruption of retinoic acid signaling.

All-trans retinoic acid (ATRA) gradients determine skeletal patterning morphogenesis and can be disrupted by diverse genetic or environmental factors during pregnancy, leading to fetal skeleton defects. Adverse Outcome Pathway (AOP) frameworks for ATRA metabolism, signaling, and homeostasis allow for the development of new approach methods (NAMs) for predictive toxicology with less reliance on animal testing. Here, a data-driven model was constructed to identify chemicals associated with both ATRA pathway bioactivity and prenatal skeletal defects. The phenotype data was culled from ToxRefDB prenatal developmental toxicity studies and produced a list of 363 ToxRefDB chemicals with altered skeletal observations. Defects were classified regionally as cranial, post-cranial axial, appendicular, and other (unspecified) features based on ToxRefDB descriptors. To build a multivariate statistical model, high-throughput screening bioactivity data from >8,070 chemicals in ToxCast/Tox21 across 10 in vitro assays relevant to the retinoid signaling system were evaluated and compared to literature-based candidate reference chemicals in the dataset. There were 48 chemicals identified for effects on both in vivo skeletal defects and in vitro ATRA pathway targets for computational modeling. The list included 28 chemicals with prior evidence of skeletal defects linked to retinoid toxicity and 20 chemicals without prior evidence. The combination of thoracic cage defects and DR5 (direct repeats of 5 nucleotides for RAR/RXR transactivation) disruption was the most frequently occurring phenotypic and target disturbance, respectively. This data model provides valuable AOP elucidation and validates current mechanistic understanding. These findings also shed light on potential avenues for new mechanistic discoveries related to ATRA pathway disruption and associated skeletal dysmorphogenesis due to environmental exposures.

Design of a compliant mechanism for a sternum prosthesis using the pseudo-rigid-body model

When a sternum prosthesis is implemented, it must allow the movement of the rib cage. The sternum prosthesis designs that have been developed are completely rigid, this aspect can present discomfort when breathing, as well as fixation problems between the prosthesis and the bone tissue. The aim of this work is to develop a flexible device that allows the movement of the rib cage during breathing. Compliant mechanism design was developed by using the pseudo-rigid body model (PRBM) starting from a 4-bar rigid mechanism. The flexible model was obtained by developing the methodology of replacement from rigid to flexible body. The results show the obtained parameters of the compliant mechanism and the three-dimensional model for subsequent numerical and experimental analysis.

Research and Development of Deep Learning Algorithms for the Classification of Pneumonia Type and Detection of Ground-Glass Loci on Radiological Images

Pneumonia is a highly dangerous state that poses serious risks to the health of a patient. In contrast to common pneumonia, lung disease COVID-19 causes a large number of lethal outcomes. The pneumonia of a viral etiology caused by the RNA virus SARS-CoV-2 is visually hardly distinguishable from the bacterial pneumonia or inflammation caused by other viral infections. Now, COVID-19 can be diagnosed using PCR tests or X-rays of the thoracic cage. However, the results of a molecular study take a long time to prepare. In contrast, the radiological images of the thoracic cage can be obtained immediately after the radiological study. Although there exist guiding principles which help radiologists to differentiate COVID-19 from other types of infections, their assessments differ. In addition, doctors who are not radiologists can be assisted in better locating the disease, for instance, by a bounding box. Development of precise computer methods based on artificial intelligence can help medical workers in quickly determining the type of pneumonia and detecting the loci of inflammation. In this study a package of methods is developed to determine the type of pneumonia and detect the ground-glass loci using the appropriate architectures of neural networks, loss functions, augmentations at the training data generation stage, test time augmentation, and computer vision model ensembles. This task is successfully solved in the SIIM-FISABIO-RSNA COVID-19 Detection competition [17] and the proposed algorithm is in the top 10% of the best solutions.

Admission Triage With Pain, Inspiratory Effort, Cough Score can Predict Critical Care Utilization and Length of Stay in Isolated Chest Wall Injury

Damage to the thoracic cage is common in the injured patient, both when the injuries are confined to this single cavity and as part of the overall injury burden of a polytraumatized patient. In a subset of these patients, the severity of injury to the intrathoracic viscera is either underappreciated at admission or blossom over the following 48-72h. The ability to promptly identify these patients and abrogate complications therefore requires triage of such at-risk patients to close monitoring in a critical care environment. At our institution, this triage hinges on the Pain, Inspiratory effort, Cough (PIC) score, which generates a composite unitless score from a nomogram which aggregates several variables-patient-reported Pain visual analog scale, Incentive spirometry effort, and the perceived adequacy of Cough. We thus sought to audit PIC's discriminant power in predicting intensive care unit (ICU) need. This retrospective cohort study was performed at an urban, academic, level 1 trauma center. All isolated chest wall injuries (excluded any Abbreviated Injury Score >2 in head or abdomen) from January 2020 to June 2021 were identified in the local trauma registry. The electronic medical record was queried for standard demographics, admission PIC score, postadmission destination, ICU and hospital length of stay (LOS), and any unplanned admissions to the ICU. Chi-squared tests were used to determine differences between PIC score outcomes and the recursive partitioning method correlated admission PIC score to ICU LOS. Two hundred and thirty six isolated chest wall injury patients were identified, of whom 194 were included in the final analysis. The median age was 60 (interquartile range [IQR] 50-74) years, 63.1% were male, and the median (IQR) number of rib fractures was 3.0 (2.0-5.0). A cutoff PIC score of 7 or lower was associated with ICU admission (odds ratio [OR] 95% CI: 8.19 [3.39-22.55], P<0.001 with a PPV=41.4%, NPV=91%), and with ICU admission for greater than 48h [OR (95% CI): 26.86 (5.5-43.96), P<0.001, with a PPV=25.9%, NPV=98.7%] but not anatomic injury severity score, hospital LOS or ICU, or the requirement for mechanical ventilation. The association between PIC score 7 or below and the presence of bilateral fractures, flail chest, or sternal fracture did not meet statistical significance. The accurate cut point of the PIC score to predict ICU admission over 48h in our retrospective cohort was calculated as PIC≤7 for P=0.013 and PIC≤6 for P=0.001. Patients with isolated chest wall injuries require effective reproducible triage for ICU-level care. The PIC score appears to be a moderate discriminator of critical care need, per se, as judged by our recorded complication rate requiring critical care intervention. This vigilance may pay dividends in early detection and abrogation of respiratory failure emergencies. Furthermore, PIC score delineation for ICU need appears to be appropriate at 7 or less; this threshold can be used during admission triage to guide care.

Physiotherapy practice for hospitalized patients with COVID-19.

ABSTRACTObjective:To identify the indications for physiotherapy and to evaluate physiotherapy practices in patients with COVID-19 admitted to the ICU (on mechanical ventilation) or to the ward (spontaneously breathing). Methods:An online, 50-item survey was completed by physiotherapists who had been treating hospitalized patients with COVID-19 in Brazil. Results:Of the 644 physiotherapists who initiated the survey, 488 (76%) completed it. The main reasons for indications for physiotherapy in both settings reported as “very frequently” and “frequently” both in the ICU and the ward by most respondents were oxygenation improvement (> 95%) and prevention of general complications (> 83%). Physical deconditioning was considered an infrequent indication. When compared with mobilization strategies, the use of respiratory interventions showed great variability in both work settings, and techniques considered effective were underutilized. The most frequently used respiratory techniques in the ICU were positioning (86%), alveolar recruitment (73%), and hard/brief expiratory rib cage compression (46%), whereas those in the ward were active prone positioning (90%), breathing exercises (88%), and directed/assisted cough (75%). The mobilization interventions reported by more than 75% of the respondents were sitting on the edge of the bed, active and resistive range of motion exercises, standing, ambulation, and stepping in place. Conclusions:The least common reason for indications for physiotherapy was avoidance of deconditioning, whereas oxygenation improvement was the most frequent one. Great variability in respiratory interventions was observed when compared with mobilization therapies, and there is a clear need to standardize respiratory physiotherapy treatment for hospitalized patients with COVID-19.

Effect of internal effusion on aerothermal performance of a three-pass channel roughened by angled ribs and pin-fins with lateral flow exit

The effect of internal effusion on the aerothermal performance of a three-pass channel with smooth walls, the in-lined 45° ribs, and the attached-detached pin-fins along the first, second, and third passes, respectively, is experimentally studied by comparing the full-field endwall Nusselt numbers, friction factors, and aerothermal performance indexes between the test channels with and without effusion. The coolant stream that serpentines through the three-pass channel with the inlet Reynolds numbers between 10,000 and 30,000 is discharged from the sidewall of the third pin-fin pass. In the internal effusion channel, there are nine pairs of horizontal square slots adjacent to the two channel endwalls for bypassing the near-wall flows behind the angled ribs from the second pass into the third pin-fin pass. The weak heat convection underneath the sealed channel tip of the third pin-fin pass in the non-effusion channel is considerably enhanced by the near-wall flows through the effusion slots, leading to the modified Nusselt number map with regional heat transfer elevations. Along with the significant reduction of streamwise pressure gradients along the second and third passes, the aerothermal performance of the channel with the internal effusion is substantially improved from that without effusion. The endwall-average Nusselt numbers and friction factors of the pin-fin pass in the effusion channel are, respectively, upraised to 1.68–1.44 and reduced to 0.25–0.33 times the non-effusion channel levels. Under the combined heat-transfer and pressure-drop effects of the internal effusion for the pin-fin pass, the aerothermal performances indexes are substantially increased to 3.04–4.24 from the non-effusion channel in the range of 1.46–1.59. To aid the cooling applications to gas turbine static blades, the empirical correlations are developed to determine the regional average Nusselt number and Fanning friction factor of the three-pass channels with and without internal effusion.

Anatomofunctional comparison between the ribs of man and domestic animals

The objective was to compare the ribs in men, canines, horses and cattle, highlighting structural similarities in terms of functions, types, quantities and formats, using parts from the Human and Veterinary Anatomy Laboratory of the University of Franca, articles and books in this area of ​​expertise. Among the similar functions of the ribs, the support of the skeleton by participating in the formation of the rib cage, aid in respiratory movements and protection of organs stood out. As for the types, all species presented sternal ribs (articulating directly with the sternum) and sternal ribs (indirect contact with the sternum) in different amounts; on the other hand, only the canine and human, the floating ones (without connection with adjacent cartilage). The number of ribs corresponded to that of thoracic vertebrae, varying between species (13 pairs in the canine, 18 in the equine, 13 in the bovine and 12 in the human). Regarding the shape, there was variation according to each species, being longer, wider and flatter in cattle compared to horses; in canines more narrow and curved and in humans in semi-arches. It is possible to infer that, regardless of the species, the ribs perform the same functions, however, there are alternations in terms of types, quantities and formats, which may be involved with evolutionary and postural characteristics.

Revisiting the Balancing Act Model of Singing

Revisiting the Balancing Act Model of Singing Robert Edwin (bio) SINGING A CAPPELLA TO ZYDECO Ask any of your students to stand in the middle of your studio. Then ask them how they did that. More than likely, they'll tell you they looked at the walls on all sides to calculate the middle. Welcome to a revisit of The Balancing Act Model of singing. First introduced in "The Bach to Rock Connection" iteration of this column in January 1999, the Model is a useful way for singers to find balance in their voice and performance technique by exploring its extremes. The extremes are identified as hyper (too much), and hypo (too little), while balanced (just right) is defined by the vast middle ground between the two extremes. In the almost a quarter century since I presented The BAM, much has changed in voice pedagogy, especially in our community's embrace of genrespecific training. Happily, the old phrase, "If you learn to sing classically, you can sing anything," may be in its death throes, replaced by a fact-based mantra, "Exercise the whole body and voice and then target genre-specific singing techniques." More colloquially, as my colleague and friend Jeannette LoVetri puts it, "One size does not fit all." Therefore, the balanced (just right) aspect of the Model may lean toward hyper or hypo, depending upon the style of singing. The Model can be used systematically to encompass the entire process of singing, or randomly to demonstrate a particular pedagogic point. Throughout the process, both teacher and student must be aware that, although all aspects of singing can be isolated and addressed for instruction, they are interdependent activities during the act of singing. Each affects the other. Let's first isolate the element called posture or body alignment. Have students overelevate the sternum and rib cage, pull back the shoulders, tense the back, and pull in the chin. This "too much" (hyper) position resembles the "come to attention" posture of the military. "Too little" (hypo) body alignment, by contrast, requires students to collapse the sternum and rib cage, roll the shoulders forward, and lower the head. Finally, have them try to find a "just right" (balanced) posture, usually initiated by putting their arms fully over their heads. Repeat the hyper, hypo, and balanced exercise until students can competently demonstrate all three general positions. It's helpful if teachers model this as well as all of the other exercises so that students get a clear idea of what they're supposed to do. It also gives teachers "street cred" with students because they're practicing what they preach. Next, experiment with breathing. Hyper breathing can be modeled by raising the shoulders, drawing air in using the neck and upper chest, and tensing [End Page 69] the throat to create audible noise on inhalation. Hypo breathing, on the other hand, requires students to take a very shallow breath by barely drawing any air into the lungs. This underenergized breath cannot provide a sufficient quantity of air and breath pressure for most styles of speaking or singing, unless, of course, a character is required to do that in a play or music theater role. Balanced breathing is the breath management process (often called appoggio) that coordinates the activities of the inspiratory and expiratory muscles. We know that most students need to spend a considerable amount of time to achieve balanced breathing. The Balancing Act Model can identify the direction students need to go and not go. Breathing naturally leads to phonation. Hyper phonation is often pressed phonation, a "too much" closure of the vocal folds and depressed larynx demonstrated by the iron throated Jim Henson through his Kermit the Frog character. Also, both Bachers and rockers can be guilty of oversinging by asking their vocal folds to do "too much," exceeding their limitations. Hypo phonation, by contrast, is breathy phonation caused by an insufficient closure of the vocal folds. After their Jim Henson impersonation, have your students inhabit Marilyn Monroe as she sings, "Happy Birthday" to the president. If your students ask, "Who are Jim Henson and Marilyn Monroe?," send them to YouTube and tell them a very old singing...

Post-Extubation Laryngoespasm during Recovery from General Anesthesia in a Patient with Parkinson's disease

Introduction: Parkinson's disease is a common progressive neurovegetative disorder, associated with rigidity, bradykinesia, tremor and postural instability; the conditions are not only limited to the extremities but can extend to the striated muscles within the upper airways and rib cage [1]. Anesthetic management in these patients can be difficult during the preoperative, intraoperative, and postoperative period. Objective: present the clinical case of an 81-year-old man diagnosed with Cholelithiasis, who underwent laparoscopic cholecystectomy at the Hospital General Enrique Garcés, who manifested an adverse event after extubation in the recovery room. Conclusion: upper airways present modifications in Parkinson's patients, this can difficult their management. The prevention of complications during this process will be largely due to the adequate pharmacological treatment for Parkinson's disease or its prompt introduction, and knowledge of the pharmacological effects of the different agents used during the anesthetic period.

P50. T1 tilt and clavicle angle are the best predictors of postoperative shoulder and neck balance in AIS patients

<h3>BACKGROUND CONTEXT</h3> Shoulder imbalance after PSF is a major concern. Most studies have analyzed multiple radiographic parameters associated with postop uneven shoulders. However, there is paucity in the literature analyzing predictors for balanced shoulders. <h3>PURPOSE</h3> Shoulder imbalance after PSF is a major concern. Most studies have analyzed multiple radiographic parameters associated with postop uneven shoulders. However, there is paucity in the literature analyzing predictors for balanced shoulders. <h3>STUDY DESIGN/SETTING</h3> Retrospective review. <h3>PATIENT SAMPLE</h3> AIS patients who underwent PSF from 2012 to 2020 were included in this study. <h3>OUTCOME MEASURES</h3> Radiographic shoulder height, median shoulder height, T1 tilt, clavicle angle, first rib angle and cobb angle. <h3>METHODS</h3> Radiographic shoulder height (RSH) was used as our proxy for shoulder height. RSH. <h3>RESULTS</h3> Part I: 211 control patients were evaluated. 191 had normal RSH and 20 were abnormal. T1 tilt (2.0 vs 4.1) and CA (1.1 vs 4.95) were significantly different between the two groups (p < .05). Part II: In 186 patients, preoperative and postoperative CA correlated very strongly with RSH (r = 0.856/0.921). T1 tilt correlated moderately with RSH (r = 0.399), but was better when concordant (r = 0.51). RSH did not change significantly from immediate postop to final follow up (p=0.423). Restoring CA below 3 degrees yielded normal RSH postop (p < 0.0001). Restoring Concordant T1 tilt below 3 degrees yielded normal RSH in nearly all cases (p < 0.006). Part III: In 59 patients across 4 surgeons, restoring CA below 3 degrees yielded normal RSH at postop in all cases. Restoring concordant T1 tilt below 3 degrees yielded normal RSH at postop in nearly all cases. <h3>CONCLUSIONS</h3> Restoring shoulder balance in AIS patients is a challenging aspect of surgery. We found that restoring the CA < 3° yields normal RSH postoperatively. In addition, when T1 is concordant, restoring it to < 3 degrees can yield normal RSH. Proximal thoracic fusion did not correlate with post op RSH. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

296 Knowing When to Put the Knife Down - a Case Report on Osteoradionecrosis of the Chest Wall

Abstract Radiation therapy is a common treatment for carcinoma of the breast. It has shown to reduce the incidence of local reoccurrence and improve life expectancy, but it is not without complications. Osteoradionecrosis (ORN) of the chest wall is a recognised but rare complication, which can lead to full thickness necrosis, localised infection, and pathological rib fractures. This case report discusses a 78-year-old female with a history of adjuvant radiotherapy for a left breast malignancy, who developed three distinct wounds on her left anterior chest wall. Over five years, these wounds ulcerated and formed sinus tracks exposing the rib cage. The patient also developed various local infections requiring antibiotics. Management options were explored, ranging from conservative dressings, anti-inflammatories and steroids to medical options traditionally used to treat ORN of the mandible, such as the combination of Pentoxifylline and vitamin E, and Hyperbaric Oxygen Therapy (HBO2). However, the most beneficial definitive treatment proposed was surgical intervention using either a latissimus dorsi or an upper limb fillet flap. Despite this, the patient's social, cosmetic, and surgical concerns focussed the current management towards the conservative highlighting the importance of “putting down the knife” and the role of monitoring the disease with biannual clinic follow ups. While surgery is likely a necessity in the future, this case study highlights the importance of considering medical input and keeping the patient's interests at the forefront of surgical practice.

Energy-absorbing mechanism and crashworthiness performance of thin-walled tubes diagonally filled with rib-reinforced foam blocks under axial crushing

Thin-walled structures are widely used as crucial structural components for energy absorbing applications. To design lightweight thin-walled-involved composite structures with better mechanical performance remains an open issue. In this study, the X-shaped rib-reinforced foam-filled tubes were designed and tested under quasi-static axial compression. Two types of foams, i.e., the aluminum foam and the additively manufactured polylactide (PLA) foam were considered as lightweight fillers. The effects of foam block filling ratio (rib angle) and arrangement of different foam fillers on the axial crushing performance of the diagonally rib-reinforced foam block-filled tube were analyzed. Results indicated that tubes that were diagonally filled with PLA foam blocks possessed better energy absorption capacity, whereas the higher mean crushing strength was achieved by diagonally filling with two aluminum blocks. It also revealed that tubes filled with different foam blocks did not always show advantages over those filled with the same foams. Moreover, the diagonally aluminum foam blocks filled tubes with a large rib angle could induce the global buckling, whereas that with the rib angle of 120 degrees exhibited better mechanical properties in load consistency and specific energy absorption capacity. Numerical simulations were conducted to reveal the energy absorption enhancement mechanism of the tubes filled with varying combinations of the reinforced fillers. Results indicated that the interaction between the foam blocks and the reinforced rib contributed most to the increased energy absorption. Further, an analytical model for evaluating the crushing strength of the developed structure was proposed. The theoretical predictions are in good agreement with the experimental results. The idea of tailoring the fillers arrangement and assembling pattern would promote the development of optimal energy-absorbing thin-walled involved composite structures.

NPHP3 splice acceptor site variant is associated with infantile nephronophthisis and asphyxiating thoracic dystrophy; A rare combination

Nephronophthisis (NPHP) is a group of rare inherited ciliopathy disorders characterized by the multicystic dysplastic kidney, oligohydramnios, and tubulointerstitial nephritis that progresses to end-stage renal disease (ESRD). NPHP is a clinically and genetically heterogeneous disorder with extrarenal symptoms including skeletal deformities, nervous system anomalies, and ophthalmologic features. Three clinical subtypes, infantile, juvenile, and adolescent, have been recognized based on age of onset of ESRD. Infantile nephronophthisis with asphyxiating thoracic dystrophy is a very rare association. Here, we investigated a consanguineous family having two neonates with a clinical phenotype of lethal infantile NPHP associated with asphyxiating thoracic dystrophy. Whole exome sequence data analysis identified a splice acceptor site variant (Chr3-132408107-CCT-C; NM_153240.4: c.2694-2_2694-1del) in the NPHP3 gene. The segregation of a variant in the family was confirmed by Sanger sequencing. The lethal phenotype in our case might be due to respiratory insufficiency secondary to a severely restricted thoracic cage. Present work is an exclusive depiction of lethal infantile NPHP phenotype in association with asphyxiating thoracic dystrophy that has not been reported before in families segregating NPHP3 mutations. Moreover, this work expands the phenotypic spectrum of NPHP3 variants. Overall, our findings add to the increasing body of evidence that mutations in ciliary genes/proteins show pleiotropic effects with phenotypic overlap between related disorders and apparently unrelated clinical entities.

Early menopause and weight loss are significant factors associated with risk of future fracture in middle-aged women

BackgroundTo identify factors related to reproductive history and weight change associated with first incident fracture in middle-aged women.MethodsIn total, 18,326 women from the Malmö Diet and Cancer study were included in this prospective population-based cohort study. Participants were included 1991–1996 and followed to 2016. Using data from the National Patient Registry, linked with every participants’ unique personal identification number, any first fracture affecting spine, thoracic cage, upper and lower extremities was identified. The association of baseline factors with incident fracture risk was analyzed using Cox regression models.ResultsFor participating women, median age 56.0 years, the multivariable Cox regression analysis observed that early menopause (40–44 years) (hazard ratio (HR) 1.14, 95% confidence interval (CI) 1.03–1.27) but not premature menopause < 40 years (HR 1.06, 95% CI 0.91–1.24) was associated with future fracture risk. Self-reported weight loss since age 20 was also associated with future fracture risk (HR 1.39, 95% CI 1.17–1.65) whereas a daily alcohol consumption in the third quartile (5.36–11.42 g/day) compared to the lowest quartile (0–0.80 g/day) was associated with decreased future fracture risk (HR 0.88, 95% CI 0.81–0.96). The multivariable Cox regression analysis also observed that increasing age and weight at baseline, current smoking, a positive history of previous fracture and family history of fractures were associated with increased fracture risk whereas an increasing BMI was associated with a decreased fracture risk. No association to parity or period of lactation was observed nor ever-use of oral contraceptives and menopausal hormone therapy.ConclusionThis study shows that early menopause between 40 to 45 years and self-reported weight loss since age of 20 are relevant factors associated with increased fracture risk in middle-aged women. These factors were independent of traditional predictors of fracture risk among women and may be considered in preventive initiatives.Trial registrationClinicaltrials.gov with identifier: NCT04151732, since Nov 5th 2018.

Evidence-based region of interest (ROI) definition for surface-guided radiotherapy (SGRT) of abdominal cancers using deep-inspiration breath-hold (DIBH).

To define and evaluate the appropriate abdominal region of interest (ROI) as a surrogate of diaphragm positioning in deep-inspiration breath-hold (DIBH) for surface-guided radiotherapy (SGRT) of abdominal cancers using 3D optical surface imaging (OSI). Six potential abdominal ROIs were evaluated to calculate their correlations with the diaphragm position using 4DCT images of 20 abdominal patients. Twelve points of interest (POIs) were defined (six on the central soft tissue and six on the bilateral ribs) at three superior-inferior levels, and different sub-groups represented different ROIs. ROI-1 was the largest, containing all 12 POIs from the xiphoid to the umbilicus and between the lateral body midlines while ROI-2 had only eight inferior POIs, ROI-3 had six lateral POIs, and ROI-4 had four superior-lateral POIs over the ribs, ROI-5 contained six central and two most inferior-lateral POIs and ROI-6 contained six central and four inferior-lateral POIs. Internally, the right diaphragm dome was used to represent its positions in 4DCT (0% and 50% within the cycle). The Pearson correlation coefficients were calculated between the diaphragm dome and all 12 external POIs individually or grouped as six ROIs. The quality of the abdominal ROIs was evaluated as potential internal surrogates and, therefore, potential ROIs for SGRT DIBH setup. The four most inferior POIs show the highest mean correlation (r=0.75) with diaphragmatic motion, and the correlation decreases as POIs move superiorly. The mean correlations are the highest for ROIs with little or no rib support: r=0.67 for ROI-2, r=0.64 for ROI-5, and r=0.63 for ROI-6, while lower for ROIs with rib support: ROI-1 has r=0.60, ROI-3 has r=0.50, and ROI-4 has only r=0.28. This study demonstrates that the rectangular/triangular soft-tissue ROI (with little rib support) is an optimal surrogate for body positioning and diaphragmatic motion, even when treating tumors under the rib cage. This evidence-based ROI definition should be utilized when treating abdominal cancers with free-breathing (FB) and/or DIBH setup.

Rib abnormalities and their association with focal dark spots in Atlantic salmon fillets

Focal dark spots (DS) represent the most common quality problem in farmed Atlantic salmon (Salmo salar L.). DS are predominantly located in the cranio-ventral region of the fillet, that is characterized by the presence of ribs. The current study explores the possible association between abnormal rib morphology and DS types and the frequency of rib abnormalities in the rib cage by X-ray imaging. The fish used were salmon from a common smolt group that were sampled in freshwater (smolt farm) and subsequently two, five, eight and 14 months after sea transfer to small-scale land-based tanks or commercial sea-cages. Large size wild salmon were used as additive. Rib abnormalities were found in most fish, with a consistent number of four abnormalities per rib cage side of smolts, land-based and wild salmon. After transfer from freshwater to sea-cages, there was an abrupt increase from four to 10 abnormal ribs per rib cage side, mainly explained by low-density and shorter ribs. The number of abnormal ribs stabilized in further samplings at around eight abnormalities per rib cage side. In contrast to wild salmon, abnormalities in farmed salmon were symmetrically concentrated in the center of the rib cage in mid and distal parts of ribs, where also most DS were concentrated. No typical black DS were observed in smolts, salmon farmed in land-based tanks or wild salmon. Two months after transfer to sea-cages, 15% of the salmon had fillet-red DS, while fillet-black DS were observed five months after sea transfer (30%). The prevalence of fillet-red DS oscillated between 15 and 3% during the seawater phase, while fillet-black DS increased until the eighth month after seawater transfer, stabilizing in further samplings at 43–45%. The prevalence of rib abnormalities was 1.6 times higher in fillet-black DS than in control tissue, and 2 times higher for peritoneum DS, principally because of various forms of bent-, and broken ribs. There was an association between rib abnormalities and DS, although additional factors influenced the final DS phenotype. Preventing damaging incidents in the late smolt phase and sea-cage operations can likely reduce the prevalence of abnormal ribs and DS.

Measurement of global mechanical properties of human thorax: Costal cartilage

Surgical resection of chest wall tumours may lead to a loss of ribcage stability and requires reconstruction to allow for physical thorax functioning. When titanium implants are used especially for larger, lateral defects, they tend to break. Implant failures are mainly due to specific mechanical requirements for chest-wall reconstruction which must mimic the physiological properties and which are not yet met by available implants. In order to develop new implants, the mechanical characteristics of ribs, joints and cartilages are investigated.Rib loading is highly dependent on the global thorax kinematics, making implant development substantially challenging. Costal cartilage contributes vastly to the entire thorax load-deformation behaviour, and also to rib loading patterns. Computational models of the thoracic cage require mechanical properties on the global stiffness, to simulate rib kinematics and evaluate stresses in the ribs and costal cartilage.In this study the mechanical stiffness of human costal cartilage is assessed with bending, torsion and tensile tests. The elastic moduli for the bending in four major directions ranged from 2.2 to 60.8 MPa, shear moduli ranged from 5.7 to 24.7 MPa for torsion, and tensile elastic moduli ranging from 5.6 to 29.6 MPa.This article provides mechanical properties for costal cartilage. The results of these measurements are used for the development of a whole thorax finite element model to investigate ribcage biomechanics and subsequently to design improved rib implants.

Effects of Muscle Energy Technique and Joint Manipulation on Pulmonary Functions, Mobility, Disease Exacerbations, and Health-Related Quality of Life in Chronic Obstructive Pulmonary Disease Patients: A Quasiexperimental Study.

Chronic obstructive pulmonary disease (COPD) is primarily a disease of the lungs; however, extrapulmonary comorbidities like rib cage stiffness, decreased thoracic spine mobility, postural changes, and skeletal muscle dysfunctions also coexist. Muscle energy technique (MET) and joint manipulation (JM) may help alleviate these musculoskeletal problems. This study was aimed at evaluating the effectiveness of MET and JM on pulmonary functions, dyspnea, chest wall mobility, disease exacerbations, and health-related quality of life in COPD patients. A total of 16 patients (7 women and 9 men) suffering from COPD between the ages of 35 and 65 years participated in the study. Pretest-posttest quasiexperimental design was used. MET was applied to the sternocleidomastoid, anterior scalene, pectoralis major muscles, and at the C4-C6 level of the cervical spine. Maitland JM was performed in the thoracic region at the intervertebral, costovertebral, and costotransverse joints. The treatment intervention lasted for 3 weeks. FEV1/FVC, maximum inspiratory pressure (MIP), SpO2, modified Borg dyspnea scale (MBDS), COPD assessment test (CAT), mMRC dyspnea scale, BODE index, right and left hemidiaphragm excursion, and chest wall expansion at T4 and T10 levels were the outcome measures. Significant improvement (p < 0.05) was observed in FEV1/FVC, MIP, SpO2, MBDS, CAT, mMRC dyspnea scale, BODE index, and chest expansion at T4 and T10 levels. Only for the hemidiaphragm excursion, no significant (p > 0.05) improvement was observed. Combined application of MET to accessory respiratory muscles and cervical spine and JM to thoracic spine improved pulmonary functions, chest wall mobility, and health-related quality of life and reduced dyspnea and disease exacerbations in patients with mild to moderate COPD.

On the systematic position of the Early Cretaceous fern genus “Athyrium”

The oldest fossils assigned to Athyrium (mostly based on the sorus morphology) comprise fronds and spores from the Lower Cretaceous of Northeast Asia. However, most molecular dating suggests that extant Athyrium diverged from its sister genus during the Eocene or later, implying that the Cretaceous fossils probably belong to another polypodiaceous taxon. By examining the sorus morphology of extant genera related to the family Athyriaceae, we found that the primary diagnostic feature for assigning the Cretaceous fossils to Athyrium, i.e., the sorus shape, is common to the entire extant family, or plesiomorphic for the genus. As the fronds are more commonly preserved than the reproductive parts, we compared the fossil frond morphology with those of living taxa of the family that is divided into two types. The Cretaceous fossil we examined here bears the frond’s costal groove characters on adaxial side, which is more closely related to that of the Deparia-clade instead of the clade including Athyrium and other genera of the family. The observation is further confirmed by the cladistic analysis using morphological characters. The systematic position of the Early Cretaceous “Athyrium” was resolved as a stem member of the total Athyriaceae using a tip-dating approach with the Fossilized Birth-Death model in a Bayesian framework. Our study suggests that Early Cretaceous fossils previously assigned to Athyrium require taxonomic revision.