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Concept: Thorax


OBJECTIVE: Anterior chest thrusts (with the subject sitting or standing and thrusts applied to the lower sternum) are recommended by the Australian Resuscitation Council as part of the sequence for clearing upper airway obstruction by a foreign body. Lateral chest thrusts (with the victim lying on their side) are no longer recommended due to a lack of evidence. We compared anterior, lateral chest and abdominal thrusts in the generation of airway pressures using a suitable animal model. METHODS: This was a repeated-measures, cross-over, clinical trial of eight anaesthetised, intubated, adult pigs. For each animal, ten trials of each technique were undertaken with the upper airway obstructed. A chest/abdominal pressure transducer, a pneumotachograph and an intra-oesophageal balloon catheter recorded chest/abdominal thrust, expiratory air flows, airway and intrapleural pressures, respectively. RESULTS: The mean (SD) thrust pressures generated for the anterior, lateral and abdominal techniques were 120.9 (11.0), 135.2 (20.0), and 142.4 (27.3) cmH(2)O, respectively (p<0.0001). The mean (SD) peak expiratory airway pressures were 6.5 (3.0), 18.0 (5.5) and 13.8 (6.7) cmH(2)O, respectively (p<0.0001). The mean (SD) peak expiratory intrapleural pressures were 5.4 (2.7), 13.5 (6.2) and 10.3 (8.5) cmH(2)O, respectively (p<0.0001). At autopsy, no rib, intra-abdominal or intra-thoracic injury was observed. CONCLUSION: Lateral chest and abdominal thrust techniques generated significantly greater airway and pleural pressures than the anterior thrust technique. We recommend further research to provide additional evidence that may inform management guidelines for clearing foreign body upper airway obstruction.

Concepts: Sternum, Pressure, Thorax, Obstructive lung disease, Pleural cavity, Victim, Thrust, Pressure sensor


BACKGROUND: Situs inversus totalis represents an unusual anomaly characterized by a mirror-image transposition of the abdominal and thoracic viscera. It often occurs concomitantly with other disorders that make difficult diagnosis and management of abdominal pathology. The relationship between situs inversus totalis and cancer remains unclear. CASE PRESENTATION: We describe a 33-year old Guinean man with situs inversus totalis who presented with obstructive jaundice. Imaging and endoscopic modalities demonstrated a mass of distal common bile duct which biopsy identified an adenocarcinoma. The patient was successfully treated by cephalic pancreaticoduodenectomy followed by adjuvant chemoradiation and he is doing well without recurrence 8 months after surgery. CONCLUSION: The occurrence of bile duct adenocarcinoma in patient with situs inversus totalis accounts as a rare coincidence. In this setting, when the tumor is resectable, surgical management should be considered without contraindication and must be preceded by a careful preoperative staging.

Concepts: Cancer, Digestive system, Liver, Hepatology, Abdomen, Thorax, Situs inversus, Gallstone


This study aimed to establish the incidence, number and location of CPR-related skeletal chest injuries (SCI) and to investigate the influence of age, gender, changes in resuscitation guidelines and technique of resuscitation.

Concepts: Bone, Sternum, Cardiopulmonary resuscitation, Wavelength, Thorax, Human rib cage


We herein report a case of primary marginal zone lymphoma (MZL) of the posterior mediastinum in an 84-year-old woman. Computed tomography of the chest showed a posterior mediastinal mass in the right thoracic paravertebral region with right pleural effusion. Pathological findings of a surgical biopsy from the posterior mediastinum, along with immunohistochemical and flow cytometric results, indicated MZL. The patient was treated with chemotherapy and radiation therapy for the mediastinal lesion and achieved complete remission. A relapse occurred 3 months after the initial treatment regimen. However, a second relapse has not occurred more than 2 years after second-line chemotherapy. This is the first case of MZL originating in the posterior mediastinum.

Concepts: Cancer, Heart, Chemotherapy, Thorax, Mediastinal tumor, Mediastinum, Thoracic cavity, Posterior mediastinum


Cardiac disease after mediastinal radiotherapy for thoracic malignancy (chest radiotherapy [XRT]) often manifests as progressive aortic stenosis. In patients with XRT-induced severe aortic stenosis undergoing surgical aortic valve replacement (SAVR), we sought to: (1) study long-term survival and compare these patients with a matched cohort undergoing SAVR during the same time frame; and (2) identify potential predictors of long-term mortality.

Concepts: Heart, Thorax, Aortic valve stenosis


The Heimlich manoeuvre is a well-known intervention for the management of choking due to foreign body airway occlusion, but the evidence base for guidance on this topic is limited and guidelines differ. We measured pressures during abdominal thrusts in healthy volunteers. The angle at which thrusts were performed (upthrust vs circumferential) did not affect intrathoracic pressure. Self-administered abdominal thrusts produced similar pressures to those performed by another person. Chair thrusts, where the subject pushed their upper abdomen against a chair back, produced higher pressures than other manoeuvres. Both approaches should be included in basic life support teaching.

Concepts: Person, Subject, Abdomen, Thorax, First aid, Rocket, Human abdomen, Henry Heimlich


Exercise-related transient abdominal pain (ETAP), commonly referred to as ‘stitch’, is an ailment well known in many sporting activities. It is especially prevalent in activities that involve repetitive torso movement with the torso in an extended position, such as running and horse riding. Approximately 70 % of runners report experiencing the pain in the past year and in a single running event approximately one in five participants can be expected to suffer the condition. ETAP is a localized pain that is most common in the lateral aspects of the mid abdomen along the costal border, although it may occur in any region of the abdomen. It may also be related to shoulder tip pain, which is the referred site from tissue innervated by the phrenic nerve. ETAP tends to be sharp or stabbing when severe, and cramping, aching, or pulling when less intense. The condition is exacerbated by the postprandial state, with hypertonic beverages being particularly provocative. ETAP is most common in the young but is unrelated to sex or body type. Well trained athletes are not immune from the condition, although they may experience it less frequently. Several theories have been presented to explain the mechanism responsible for the pain, including ischemia of the diaphragm; stress on the supportive visceral ligaments that attach the abdominal organs to the diaphragm; gastrointestinal ischemia or distension; cramping of the abdominal musculature; ischemic pain resulting from compression of the celiac artery by the median arcuate ligament; aggravation of the spinal nerves; and irritation of the parietal peritoneum. Of these theories, irritation of the parietal peritoneum best explains the features of ETAP; however, further investigations are required. Strategies for managing the pain are largely anecdotal, especially given that its etiology remains to be fully elucidated. Commonly purported prevention strategies include avoiding large volumes of food and beverages for at least 2 hours prior to exercise, especially hypertonic compounds; improving posture, especially in the thoracic region; and supporting the abdominal organs by improving core strength or wearing a supportive broad belt. Techniques for gaining relief from the pain during an episode are equivocal. This article presents a contemporary understanding of ETAP, which historically has received little research attention but over the past 15 years has been more carefully studied.

Concepts: Muscle, Liver, Abdominal pain, Stomach, Abdomen, Nerve, Thorax, Human abdomen


The turtle shell is a complex structure that currently serves a largely protective function in this iconically slow-moving group [1]. Developmental [2, 3] and fossil [4-7] data indicate that one of the first steps toward the shelled body plan was broadening of the ribs (approximately 50 my before the completed shell [5]). Broadened ribs alone provide little protection [8] and confer significant locomotory [9, 10] and respiratory [9, 11] costs. They increase thoracic rigidity [8], which decreases speed of locomotion due to shortened stride length [10], and they inhibit effective costal ventilation [9, 11]. New fossil material of the oldest hypothesized stem turtle, Eunotosaurus africanus [12] (260 mya) [13, 14] from the Karoo Basin of South Africa, indicates the initiation of rib broadening was an adaptive response to fossoriality. Similar to extant fossorial taxa [8], the broad ribs of Eunotosaurus provide an intrinsically stable base on which to operate a powerful forelimb digging mechanism. Numerous fossorial correlates [15-17] are expressed throughout Eunotosaurus' skeleton. Most of these features are widely distributed along the turtle stem and into the crown clade, indicating the common ancestor of Eunotosaurus and modern turtles possessed a body plan significantly influenced by digging. The adaptations related to fossoriality likely facilitated movement of stem turtles into aquatic environments early in the groups' evolutionary history, and this ecology may have played an important role in stem turtles surviving the Permian/Triassic extinction event.

Concepts: Evolution, Turtle, Reptile, Thorax, Rib, Human rib cage, Anapsid, Carapace


The genesis of cardiogenic oscillations, i.e. the small waves in airway pressure (COS(paw)) and flow (COS(flow)) signals recorded at the airway opening is under debate. We hypothesized that these waves are originated from cyclic changes in pulmonary artery (PA) pressure and flow but not from the physical transmission of heartbeats onto the lungs. The aim of this study was to test this hypothesis. In 10 anesthetized pigs, COS were evaluated during expiratory breath-holds at baseline with intact chest and during open chest conditions at: (1) close contact between heart and lungs; (2) no heart-lungs contact by lifting the heart apex outside the thoracic cavity; (3) PA clamping at the main trunk during 10 s; and (4) during manual massage after cardiac arrest maintaining the heart apex outside the thorax, with and without PA clamping. Baseline COS(paw) and COS(flow) amplitude were 0.70 ± 0.08 cmH(2)O and 0.51 ± 0.06 L/min, respectively. Both COS amplitude decreased during open chest conditions in step 1 and 2 (p < 0.05). However, COS(paw) and COS(flow) amplitude did not depend on whether the heart was in contact or isolated from the surrounding lung parenchyma. COS(paw) and COS(flow) disappeared when pulmonary blood flow was stopped after clamping PA in all animals. Manual heart massages reproduced COS but they disappeared when PA was clamped during this maneuver. The transmission of PA pulsatilty across the lungs generates COS(paw) and COS(flow) measured at the airway opening. This information has potential applications for respiratory monitoring.

Concepts: Blood, Lung, Heart, Chest, Vein, Pulmonary artery, Thorax, Thoracic cavity


STUDY DESIGN.: Prospective case series study. OBJECTIVE.: To study the effect of percutaneous thoracoplasty-only procedure on curve pattern in mature adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA.: The rib hump prominence on the convex side is the major cosmetic concern among patients with AIS. Thoracoplasty combined with spinal fusion is a commonly used procedure in scoliosis. However, there are no studies regarding the effect of isolated thoracoplasty procedure on curve pattern in skeletally matured patients with AIS. METHODS.: The study involved 7 skeletally matured female patients with AIS. The convex rib hump deformity was measured preoperatively using hump height and hump angle. We performed thoracoplasty without spinal fusion in patients with the Cobb angle less than 40° but with prominent hump deformity. Thoracoplasty was performed percutaneously using 1 or 2 transverse incisions along the rib hump, and apex portions of the deformed ribs were resected. The Cobb angle was measured before surgery, immediately after surgery, and at final follow-up visit. In all cases, clinical satisfaction was assessed using the Scoliosis Research Society Instrument (SRS-22 questionnaires) and trunk appearance perception scale before surgery and at final follow-up visit. RESULTS.: The mean patient age was 20.24 years and an average of 4 ribs were resected. The mean preoperative hump height and hump angle of 38.14 mm and 14.14° improved to 11.70 mm and 11.42° respectively, after surgery (P = 0.018 and 0.042). Preoperative and the final follow-up mean Cobb angles were 35.43° and 45.00°, respectively (P = 0.028). On average, the mean thoracic curve progressed by 9.57°. Preoperative Scoliosis Research Society Instrument SRS-22 questionnaires and trunk appearance perception scale scores of 4.09 and 2.57 respectively improved to and 4.26 and 3.66 after surgery (P = 0.126 and 0.014). CONCLUSION.: Percutaneous thoracoplasty-only procedure gives significant rib humps correction and satisfactory clinical outcome. However, progression of the curve was observed after surgery. This suggests that the convex ribs function as a buttress for curve progression.

Concepts: Vertebral column, Scoliosis, Arithmetic mean, Paul Randall Harrington, Scoliosis Research Society, Thorax, Spinal fusion, Case series