Rib Cage Research Articles

A Cadaveric Study on Morphometric Features of Spleen and Splenomegaly with Accessory Spleen in Hilum

Background: Anatomical knowledge regarding the external morphology of the spleen is essential for surgical intervention and radiological diagnosis. Splenomegaly is defined as pathologic enlargement of the spleen measured by size or weight. A normal spleen has a craniocaudal length of no more than 12 cm and weighs less than 200 g. It is surrounded by a thin capsule. The spleen is usually not palpable unless it is enlarged; therefore, a palpable spleen is almost always abnormal. At times the spleen may be difficult to palpate, but dullness to percussion during inspiration in the area of the lower left intercostal space in the left anterior axillary line suggests splenic enlargement. Massive splenomegaly, weight >1000 g usually occurs in lymphoma, myeloproliferative disorders, visceral leishmaniasis, and malaria. Materials and Methods: This study was conducted in different medical institutions, to find morphometric features, spenomegaly in cadaver during routine anatomy dissection as part of curriculum, 100 cadavers were observed to find out splenomegaly. Results: Out of 100 spleens studied, 81 cases wedge shaped spleen was the most common, followed by 12 tetrahedral shaped spleens and 7 oval shaped spleens. Average weight of the spleen was 175g. Average length of the spleen was 11.64cm, Average breadth of the spleen was 7.3cm and average thickness of spleen was 3.6cm. Out of 100 cadavers observed only one cadaver observed with massive splenomegaly with one accessory spleen in hilum. The spleen weight was 875gm, length was 18.15 cm, width was 8.65cm, thickness was 5.75cm and extended upto 7 rib and it is easily palpable below the rib cage from lumbar aspect. The cadaver was male and age around 55 years. Conclusion: The morphometric knowledge of spleen will helpful for surgeons and for understanding deceases related spleen. The knowledge of splenomegaly is important in finding splenic disorders and accessory spleen information helpful in understanding embryonic development of spleen. KEY WORDS: Splenomegaly, Spleen, Hilum of Spleen, Accessory spleen.

3D Digital Imagery a Solution for the Teaching of Osteology: Example of the Thoracic cage

Osteology is a fundamental discipline, its classical teaching becomes difficult because of plethora of students and shortage of bony parts. It’s in this context that we have made, from 3D volume imaging, a modeling of the rib cage as a test using a software for post-treatment of CT images in order to propose a pedagogical tool for studying thorax’s skeletal and adding descriptions with the help of classical works. This was a prospective study involving 27 patients aged between 35 and 45 years. The scanners used were HITACHI ECLOS 16 cuts. Once the CT scan was selected, the DICOM data was transmitted to the post-processing console. The images were processed on the console "Aquarius Intuition Edition Version 4. 4. 7. 855113", for one patient we used Veiwer Osirix 10.6.8 Mac. All bones have been dynamically described thanks to the volume rendering. We thus obtained volumetric reconstructions of three-dimensional CT images of the different bone structures superimposed on those taught in classical anatomy practical work. We obtained a scenario of practical work in the form of a slide show that the teacher can use for works with or without model and even remotely. The virtual reality obtained with the 3D reconstructions of CT scans of the rib cage is a tool for self-learning of osteology for students but also a way for teachers to do practical work without having to use models, and even at a distance. KEY WORDS: 3D imaging, Teaching, Tomodensitometry, Osteology.

Review on the Performance Evaluation of Thermal Exchangers using Different Baffle Designs

The thermal performance of a heat exchanger depends upon various parameters like inlet temperature of hot fluid, type of hot fluid, type of cold fluid, the shape of baffles, the material of baffles, baffles angle, and property of ribs. Basically fluid flow and heat transfer characteristics largely depend upon the Reynolds number (Re). Reynolds number is basically the ratio of inertia force to viscous force. Re is only the factor by which we can decide whether the fluid is laminar or turbulent in shell and tube type of heat exchanger. The heat exchanger is an adiabatic device in which heat is transferred from one fluid to another fluid across a plate surface. In this paper, we have introduced some special types of triangular baffles with rectangular channels. The purpose of this apparatus is to enhance the performance of the heat exchanger. Heat exchangers, nowadays, are one of the most important heat & mass transfer apparatuses in industries like oil refining; heat treatment plants, electric power generation, etc. are long service life.

Detection of acute rib fractures on CT images with convolutional neural networks: effect of location and type of fracture and reader’s experience

The evaluation of all ribs on thin-slice CT images is time consuming and it can be difficult to accurately assess the location and type of rib fracture in an emergency. The aim of our study was to develop and validate a convolutional neural network (CNN) algorithm for the detection of acute rib fractures on thoracic CT images and to investigate the effect of the CNN algorithm on radiologists' performance. The dataset for development of a CNN consisted of 539 thoracic CT scans with 4906 acute rib fractures. A three-dimensional faster region-based CNN was trained and evaluated by using tenfold cross-validation. For an observer performance study to investigate the effect of CNN outputs on radiologists' performance, 30 thoracic CT scans (28 scans with 90 acute rib fractures and 2 without rib fractures) which were not included in the development dataset were used. Observer performance study involved eight radiologists who evaluated CT images first without and second with CNN outputs. The diagnostic performance was assessed by using figure of merit (FOM) values obtained from the jackknife free-response receiver operating characteristic (JAFROC) analysis. When radiologists used the CNN output for detection of rib fractures, the mean FOM value significantly increased for all readers (0.759 to 0.819, P = 0.0004) and for displaced (0.925 to 0.995, P = 0.0028) and non-displaced fractures (0.678 to 0.732, P = 0.0116). At all rib levels except for the 1st and 12th ribs, the radiologists' true-positive fraction of the detection became significantly increased by using the CNN outputs. The CNN specialized for the detection of acute rib fractures on CT images can improve the radiologists' diagnostic performance regardless of the type of fractures and reader's experience. Further studies are needed to clarify the usefulness of the CNN for the detection of acute rib fractures on CT images in actual clinical practice.

Association of thoracic cage fractures and pericardial effusion in blunt trauma.

Several case reports suggest that penetrating thoracic cage fractures are an important cause for hemopericardium and cardiac tamponade following blunt trauma. However, the prevalence of this mechanism of injury is not fully known, and considering this association may provide a better understanding of the utility of cardiac component of the FAST (Focused Assessment with Sonography for Trauma). To determine the association of thoracic cage fractures and pericardial effusion in patients with blunt trauma. We performed a retrospective, multicenter cohort study using the Trauma Quality Improvement Program (TQIP) database (2015-2017) of adults ≥18years of age whose mechanism of injury was either a fall or motor vehicle accident. Thoracic cage fractures were defined as any rib or sternum fracture. The primary outcome was the presence of pericardial effusion. Confounding variables were accounted for using multivariable logistic regression. We included 1,673,704 patients in the study; 226,896 (14%) patients had at least one thoracic cage fracture. A pericardial effusion was present in 4923 (0.3%) patients. When a thoracic cage fracture was present, the odds of having a pericardial effusion was significantly higher (adjusted Odds Ratio [aOR] 6.5 [95% CI: 6.1-7.0]). Patients with left and right-sided rib fractures had similar odds of a pericardial effusion (aOR 1.2 [95% CI 1.04-1.4]). Sternal fractures carried the highest odds of having a pericardial effusion (aOR 11.1 [9.9-12.3]). Thoracic cage fractures secondary to blunt trauma represent a significant independent risk factor for the development of a pericardial effusion. Our findings lend support for the mechanism of bony injuries causing penetrating cardiac trauma. Given these findings, and the fact that many thoracic cage fractures are detected after the initial evaluation, we support maintaining the cardiac view in the FAST examination for all blunt trauma patients.

Mesenchymal Hamartoma: A Review of Literature

Mesenchymal Hamartoma is a rare, benign osseous tumor that typically involves the rib cage and presents during the first year of life. There is a case of this tumor originating in the cervical spine, described in literature. I document a brief literature review. In this review, there are not figures and outcomes.

Clinical Features, Management, and Outcomes of Chest Trauma at a Tertiary-Care Centre in India: A Retrospective Observational Study.

Introduction Chest is one of the main sites of injuries in trauma being a part of the torso. Many important organs lie in rib cage. However, data on chest injuries are scarce. Methods A retrospective study was carried out for chest trauma patients including polytrauma (n = 184) from hospital records for five years (2016–2020). Various parameters including demographic profile, mode of injury, management, and outcomes were studied. Results Mean age of patients was 37 ± 16 years with a male to female ratio of 2.4 : 1. Road traffic injuries remained the most common cause of trauma followed by assaults. Most of the patients were managed conservatively (55.43%). Mortality was seen in only 1.63% patients. Conclusion Young male patients are usually affected by trauma. Road traffic injuries are the commonest cause. However, most patients can be managed by conservative treatment and mortality is seen only in polytrauma patients in the present study.

Experience in neuromuscular diseases in children and adolescents and their comorbidities in a tertiary hospital

IntroductionNeuromuscular diseases include a large group of heterogeneous and rare pathologies that affect different components of the motor unit. It is essential to optimize resources to know the prevalence of comorbidities in the most frequent groups to establish an early multidisciplinary approach in a specialized setting.Patients and methodsRetrospective descriptive study of pediatric and adolescent patients with neuromuscular diseases (NMDs). The Inclusion criteria were NMDs patients with motor neuron involvement divided into three groups, depending on the affected component of the motor unit. Group I: involvement of the motor neuron; Group II: peripheral neuropathies; Group III: myopathies. Demographic variables, association with comorbidities, need for respiratory support, and rehabilitative treatment were collected in each group.ResultsNinety-six patients who met the inclusion criteria were studied. In group I, when compared to the other two groups, a higher incidence of scoliosis (68.3%, p = 0.011), deformity of the rib cage (31.3%, p = 0.0001), chronic respiratory insufficiency (62.5%, p = 0.001) and bronchial aspiration (12.5%, p = 0.03) was detected. In this group, 50%of the patients required non-invasive mechanical ventilation (p = 0.0001). The in-hospital requirement for respiratory physiotherapy was higher in group I (75%, p = 0.001). We observed a higher incidence of scoliosis in Group III compared to Group II.ConclusionsNeuromuscular diseases with motor neuron involvement present more comorbidities and require an early approach after diagnosis to improve prognosis.

Effectiveness of Respiratory Proprioceptive Neuromuscular Facilitation Techniques on Pulmonary Functions in Patients with Spinal Cord Injury - A Pilot Study

Background: Spinal cord injury (SCI) is the injury of the spinal cord from the foramen magnum to the cauda equina which occurs as a result of compulsion, incision or contusion which is a life threatening condition that carries a high risk of morbidity and mortality. The Incidence of SCI varies from 9.2 to 56.1 per million. In the Indian setup, Approx. 20,000 new cases of SCI are added every year. Spinal cord injury (SCI) patients are at increased risk of chronic respiratory symptoms as Respiratory muscle paralysis both restricts maximum inflation of the lungs and impair the ability to cough. Patients with tetraplegia have decreased chest wall and lung compliance, rib cage stiffness with paradoxical chest wall movements. Material and method: A Pilot study was carried out on 04 Traumatic Spinal cord injury patients. The purpose of the study was To find out effectiveness of respiratory PNF on pulmonary functions (FVC & FEV1) & Chest Expansion in patients with spinal cord injury. The pulmonary Functions (FVC & FEV1) and chest expansion was measured by using Spirometer (PFT machine) and inch tape. The data was analyzed using standard statistical software. Result: In this study After 4 weeks of Intervention there was Significant Improvement in Pulmonary Functions ( Pre Mean of FEV1 & FVC 0.99 L & 1.03L and Post Mean of FEV1 & FVC was 1.25 L & 1.35L respectively) and Chest Expansion (Pre Mean was 1.15 cm and Post Mean was 1.62 cm at Xiphoid Process Level). Conclusion: This Study concluded that Respiratory PNF increases Pulmonary Functions and chest expansion in Patients with Spinal Cord Injury after 4 weeks of Intervention. Keywords: Spinal Cord Injury, Forced Expiratory Volume (FEV1), Forced vital Capacity, Peak expiratory flow rate, Respiratory Proprioceptive Neuromuscular Facilitation Technique.

Developments of Adapted Clothing for Physically Disabled People with Scoliosis Using 3D Geometrical Model

Scoliosis is a deformity of the spine that causes disorders of the rib cage. This makes it difficult to design clothes for affected people without following the shape of the rib cage. This paper presents a new 3D clothing design method based on virtual reality for women with physical disabilities such as scoliosis. The current design method is a variation of the draping techniques commonly used by fashion designers to design clothes on a mannequin or human body. However, the current design process highly considers the skeleton and body scan of the person. The skeleton is used to detect the anthropometric points of the patient, while the body scan allows us to detect the morphological contours at the onset of scoliosis. Thus, both allow us to accurately track the patient’s morphology and atypical shape. The position of the morphological contours is indicated by reference marks that are closely associated with the skeleton. This helps to automatically adapt the garment to the evolution of the patient’s pathology over time. The process of creating the 3D garment was processed based on the 3D model of the thorax, which helps to easily determine the anthropometric points and the morphological curves. Using this data, the geometrical model of the garment could be created with 3D ease allowances. The 2D block pattern was then obtained by flattening the 3D patterns using flattening methods. Finally, various tests were performed considering the evolution of pathology to predict the future garment. These tests validate our geometrical model of the garment with 3D ease allowances by comparing the results with previous work.

Evaluation of Clinical Performance of TiNi-Based Implants Used in Chest Wall Repair after Resection for Malignant Tumors.

In this study, we assessed the outcomes after surgical treatment of thoracic post-excision defects in 15 patients, using TiNi knitted surgical meshes and customized artificial TiNi-based ribs. Methods: Eight patients were diagnosed with advanced non-small cell lung cancer (NSCLC) invading the chest wall, of which five patients were T3N0M0, two were T3N1M0, and one was T3N2M0. Squamous cell carcinoma was identified in three of these patients and adenocarcinoma in five. In two cases, chest wall resection and repair were performed for metastases of kidney cancer after radical nephrectomy. Three-dimensional CT reconstruction and X-ray scans were used to plan the surgery and customize the reinforcing TiNi-based implants. All patients received TiNi-based devices and were prospectively followed for a few years. Results: So far, there have been no lethal outcomes, and all implanted devices were consistent in follow-up examinations. Immediate complications were noted in three cases (ejection of air through the pleural drains, paroxysm of atrial fibrillation, and pleuritis), which were conservatively managed. In the long term, no complications, aftereffects, or instability of the thoracic cage were observed. Conclusion: TiNi-based devices used for extensive thoracic lesion repair in this context are promising and reliable biomaterials that demonstrate good functional, clinical, and cosmetic outcomes.

Motorcyclist injuries: Analysis of German in-depth crash data to identify priorities for injury assessment and prevention

Globally there are more than 350,000 PTW fatalities each year. Safety concepts to protect Powered Two-Wheeler (PTW) riders exist and are being developed further, but they need appropriate procedures and test tools (Anthropometric Test Devices (ATDs) for physical testing and Human Body Models (HBMs) for virtual testing) to direct and promote those developments. To aid further development of the tools, we aim to rank the frequency of specific injuries arising from the prevalent impact types, discuss how current ATDs and HBMs are equipped to assess these injuries, and suggest what further development should be prioritized.We analyzed a sample of injured riders from the German In-depth Accident Study (GIDAS) according to the Abbreviated Injury Scale (AIS) 2015 classification, using severity thresholds of at-least-moderate (AIS2+) and at-least-serious (AIS3+). PTW rider injuries were ranked by frequency for all crashes and also for sub-samples of specific impact types (impact with passenger cars, ground, and roadside furniture).The most frequent AIS3+ injuries were: femur fracture (17%), rib cage fracture (13%), lung injury (9%), tibia fracture (7%), and cerebrum injury (7%). In all impacts together and as for impacts with the road surface, injuries to the thorax were most frequent. In impacts with cars and road furniture, thorax injuries were also frequent, but outranked by lower extremity injuries. Considering both AIS2+ and AIS3+ injuries, the priorities for PTW rider safety interventions are: fracture of the rib cage, femur fracture, tibia fracture, radius fracture, cerebrum injury, and cerebral concussion.The ATD currently used most frequently, the Hybrid III, is unlikely to provide adequate rib fracture injury assessments, but HBMs are promising in this area. Rib injury assessment may also reasonably predict other injuries that were correlated or in proximity to rib fractures: clavicle, lung, and upper abdomen organ injury. Lower extremity, upper extremity, and head injuries are likely addressable to some extent with current ATDs while HBMs hold the promise of more detailed and mechanism-specific injury assessments. Both ATDs and HBMs need more validation for use in the PTW environment.

Because a Small Kindness Can Carry Us Through.

Because a Small Kindness Can Carry Us Through.

Effects of manual hyperinflation with rib cage compression and endotracheal suctioning on arterial blood gas parameters in mechanically ventilated patients at a university hospital, Egypt

BackgroundManual hyperinflation and expiratory rib cage compression are methods of chest physiotherapy. They are commonly applied but their value and their early utilization managing mechanically ventilated remain questionable. The purpose of the study was to investigate the effects of manual hyperinflation with rib cage compression and endotracheal suctioning on arterial blood gas parameters in mechanically ventilated patients.ResultsSeventy mechanically ventilated patients at a teaching hospital in Egypt were assigned to the clinical trial study. The age of more than half of the studied samples ranged between 60 and 69 years with a mean age of 53.64 ± 16.44 years. Initially, the ABG parameters were assessed. Then, the patients were exposed to manual hyperinflation for 5 min and 20 min external expiratory chest compression followed by endotracheal suctioning. Later, ABG parameters were assessed again and compared to the initial one. The findings revealed significant differences in ABG parameters before and after completion of MHI and ERCC and ETT suctioning in relation to PaO2 (t = 3.892) and SaO2 (t= 5.904). Also, it showed significant improvement in PaO2 and SaO2 after the completion of interventions, while no significant differences were found in other ABG parameters. This study was registered retrospectively with an ISRCTN number 39983 on 5/6/2021.ConclusionApplying manual hyperinflation with rib cage compression and endotracheal suctioning improved mainly the arterial oxygenation parameters in mechanically ventilated patients despite no significant changes observed in other ABG parameters.

Measurement of chest wall motion using a motion capture system with the one-pitch phase analysis method

Spirometry is a standard method for assessing lung function. However, its use is challenging in some patients, and it has limitations such as risk of infection and inability to assess regional chest wall motion. A three-dimensional motion capture system using the one-pitch phase analysis (MCO) method can facilitate high precision measurement of moving objects in real-time in a non-contacting manner. In this study, the MCO method was applied to examine thoraco-abdominal (TA) wall motion for assessing pulmonary function. We recruited 48 male participants, and all underwent spirometry and chest wall motion measurement with the MCO method. A significant positive correlation was observed between the vital capacity (Spearman’s ρ = 0.68, p < 0.0001), forced vital capacity (Spearman’s ρ = 0.62, p < 0.0001), and tidal volume (Spearman’s ρ = 0.61, p < 0.0001) of spirometry and the counterpart parameters of MCO method. Moreover, the MCO method could detect regional rib cage and abdomen compartment contributions and could assess TA asynchrony, indicating almost complete synchronous movement (phase angle for each compartment: − 5.05° to 3.86°). These findings suggest that this technique could examine chest wall motion, and may be effective in analyzing chest wall volume changes and pulmonary function.

Aerothermal performance of a rotating two-pass furrowed channel roughened by angled ribs

• A compound-HTE method with angled ribs and furrowed passages was devised for cooling of gas turbine blades. • Without rotation, Nu 0 were raised to 4.9–4.77 times D-B levels with f 0 between 33.15 and 35.92 times Blasius equation values. • With rotation, overall Nu ( f ) on leading and trailing walls were 1.03–2.0 (1.10–1.66) and 1.02–1.91 (1.12–1.74) times Nu 0 ( f 0 ). • Thermal-performance indexes of static (rotating) channels were 1.53–1.45 (2.39–1.48). The aerothermal performance of a novel compound heat transfer enhancement method is assessed by measuring the full-field endwall Nusselt number map and Fanning friction factors of a rotating two-pass furrowed channel roughened by angled ribs. The tested Reynolds numbers, rotation numbers, and buoyancy numbers lie in the respective ranges of 5000–15,000, 0–0.4, and 0–0.183. Under the combined effects of the ribs and furrowed passages, the endwall-average Nusselt numbers of the static channel are upraised to 4.9–4.77 times the Dittus–Boelter levels. With rotation, the worst cooling condition develops at a rotation number of 0.05 with the spotted heat-transfer impediments to 0.77 and 0.82 times the static channel references on the leading and trailing endwalls, respectively. By raising the rotation number from 0 to 0.4, the Nusselt numbers on the stable endwalls are initially reduced from the static-channel levels and then converted to increase with the rotation number; however, the friction factors increase continuously. Over the rotating unstable endwalls, both the Nusselt numbers and the friction factors increase along with rotation number. When the buoyancy number is increased, the local Nusselt numbers on the leading and trailing endwalls increase with a negligible impact on their distribution patterns. The thermal-performance indexes of the rotating channel are reduced by increasing Reynolds number. To aid the relevant applications, two sets of experimental correlations are devised to determine the regional average Nusselt number and Fanning friction factor of the rotating two-pass furrowed channel fitted with angled ribs.

Estimating rotation angle from asymmetric projection of chest.

Manual or machine-based analysis of chest radiographs needs the images acquired with technical adequacy. Currently, the equidistance between the medial end of clavicles and the center of spinous processes serves as the only criterion to assess whether a frontal PA chest radiograph is taken with any rotation. However, this measurement is normally difficult to implement because there exists overlapping of anatomies within the region. Moreover, there is no way available to predict exact rotating angles even the distances were correctly measured from PA chest radiographs. To quantitatively assess positioning adequacy of PA chest examination, this study proposes and investigates a new method to estimate rotation angles from asymmetric projection of thoracic cage on radiographs. By looking into the process of radiographic projection, generalized expressions have been established to correlate rotating angles of thorax with projection difference of left and right sides of thoracic cage. A trunk phantom with different positioning angles is employed to acquire radiographs as standard reference to verify the theoretical expressions. The angles estimated from asymmetric projections of thoracic cage yield good agreement with those actual rotated angles, and an approximate linear relationship exists between rotation angle and asymmetric projection of thoracic cage. Under the experimental projection settings, every degree of rotation corresponds to the width difference of two sides of thoracic cage around 13-14 pixels. The proposed new method may be used to quantify rotating angles of chest and assess image quality for thoracic radiographic examination.

RiFNet: Automated rib fracture detection in postmortem computed tomography

Imaging techniques are widely used for medical diagnostics. In some cases, a lack of medical practitioners who can manually analyze the images can lead to a bottleneck. Consequently, we developed a custom-made convolutional neural network (RiFNet = Rib Fracture Network) that can detect rib fractures in postmortem computed tomography. In a retrospective cohort study, we retrieved PMCT data from 195 postmortem cases with rib fractures from July 2017 to April 2018 from our database. The computed tomography data were prepared using a plugin in the commercial imaging software Syngo.via whereby the rib cage was unfolded on a single-in-plane image reformation. Out of the 195 cases, a total of 585 images were extracted and divided into two groups labeled “with” and “without” fractures. These two groups were subsequently divided into training, validation, and test datasets to assess the performance of RiFNet. In addition, we explored the possibility of applying transfer learning techniques on our dataset by choosing two independent noncommercial off-the-shelf convolutional neural network architectures (ResNet50 V2 and Inception V3) and compared the performances of those two with RiFNet. When using pre-trained convolutional neural networks, we achieved an F1 score of 0.64 with Inception V3 and an F1 score of 0.61 with ResNet50 V2. We obtained an average F1 score of 0.91 ± 0.04 with RiFNet. RiFNet is efficient in detecting rib fractures on postmortem computed tomography. Transfer learning techniques are not necessarily well adapted to make classifications in postmortem computed tomography.

Ultrasound Assessment of Diaphragm Thickness and Thickening: Reference Values and Limits of Normality When in a Seated Position.

Background: Diagnosing diaphragm dysfunction in the absence of complete paralysis remains difficult. The aim of the present study was to assess the normal values of the thickness and the inspiratory thickening of both hemidiaphragms as measured by ultrasonography in healthy volunteers while in a seated position.Methods: Healthy volunteers with a normal pulmonary function test were recruited. The diaphragmatic thickness was measured on both sides at the zone of apposition of the diaphragm to the rib cage during quiet breathing at end-expiration, end-inspiration, and after maximal inspiration. The thickening ratio, the thickening fraction, and the thickness at end-inspiration divided by the thickness at deep breathing were determined. The mean values and the lower and upper limits of normal were determined for men and women.Results: 200 healthy volunteers (100 men and 100 women) were included in the study. The statistical analysis revealed that women had a thinner hemidiaphragm than men on both sides and at the various breathing times studied. The lower limit of normality of the diaphragm thickness measured at end-expiration was estimated to be 1.3 mm in men and 1.1 mm in women, on both sides. The thickening fraction did not differ significantly between men and women. In men, it ranged from 60 to 260% on the left side and from 57 to 200% on the right side. In women, it ranged from 58 to 264% on the left side and from 60 to 229% on the right side. The lower limits of normality of the thickening fraction were determined to be 40 and 39% in men and 39 and 48% in women for the right and left hemidiaphragms, respectively. The upper limit for normal of the mean of both sides of the ratio thickness at end-inspiration divided by the thickness at deep breathing was determined to be 0.78 in women and 0.79 in men.Conclusion: The normal values of thickness and the indexes of diaphragmatic function should help clinicians with detecting diaphragm atrophy and dysfunction.

Grading of "Back Rolls": Guide to Treatment Options.

“Back Rolls,” as the term indicates, are basically fat deposits on the back in the form of rolls. This is a common deformity in women, and concerns were encountered by cosmetic surgeons the world over, especially in patients with massive weight loss due to diet or bariatric surgery and who would like to wear a form hugging costume. The skin–fat envelope of the back normally adheres tightly to the underlying musculoskeletal anatomy of the rib cage. This envelope is held in place by facial attachments that are akin to the “zones of adherence” described by Rohrich et al.1 The extent of fat deposits and number of back rolls, as well as skin laxicity, varies from person to person and also from one side to the other. The rolls surely have a zone of adherence inferiorly over which the tissue fold hangs and medially in the midline. Treatment modalities for back rolls depend on the above-mentioned variables and involve three general approaches: Injection lipolysis in association with weight loss2; Ultrasound-assisted lipectomy with or without skin tightening3; Direct surgical excision of the skin fold4 as an upper back lift. The choice of treatment depends on the specific characteristic of the back roll; hence, a classification to grade the extent of back roll would help in guiding the surgeon to choose the best possible option. Fat deposits in the saddle bag area, abdomen, chest, and submental area have been classified clinically to guide the treatment modality, but unfortunately, we have not come across any published classification system (whether anatomical or clinical) to categorize back rolls. After retrospectively going through the photographs and surgical details of more than 1800 Indian women who have undergone back contouring in the last 17 years, we propose the following classification for categorizing back rolls (Fig. 1):Fig. 1.: Grading of back rolls as seen clinically. A, Left side shows Grade II back roll with a single incomplete indentation, whereas the right side (Grade III) shows two indentations: the lower is complete, whereas the upper is incomplete. Please note that the maximum protrusion of skin fold (yellow arrow) is higher than the inferior indentation (black arrow). B, Grade IV back roll. The maximum protrusion of skin fold (yellow arrow) is lower than the inferior indentation (black arrow). Grade I: Back rolls that appear when the arms are kept by the side and disappear when the arms are raised. Grade II: Back rolls having a single indentation (partial or complete) that reduces when the arm is raised. Grade III: Back rolls with two or more skin indentations with skin pinch of more than 2 cm. The skin fold should not be lower than the inferior tethering point. Grade IV: Back rolls secondary to massive weight loss that have multiple folds with skin pinch less than 2 cm and skin fold lower than the tethering point, or in patients who have undergone prior surgical treatment. A lack of a comprehensive and clinically appropriate classification system prevents an accurate diagnosis, limits the use of treatment algorithm, and makes it difficult to compare treatment outcomes. We believe that this categorization can be used to guide the most appropriate treatment modality for a specific type of back roll that would be ideal. Additional studies are required to validate this classification system in other parts of the world. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No funding has been received for this study.