Does the use of locking plates or mesh and wires influence the risk of symptomatic non-union of the sternal osteotomy after modified Ravitch?

BACKGROUND: Patients with pectus excavatum which is unsuitable for minimally invasive repair are usually treated by modified Ravitch procedure. For fixation of the sternal osteotomy, mesh and wires are mostly used. To decrease non-union risk, we introduced a technique with double locking plate fixation of the osteotomy and compared this to fixation using mesh and wires. METHODS: Patients undergoing a modified Ravitch procedure for pectus excavatum between 2006 and 2016 were included. From 2006 to 2012, the sternum was fixated with mesh and wires. From 2012 to 2016, locking compression plates (LCP) were used. Baseline parameters, symptomatic non-union and total number of complications were retrospectively compared. Statistical analysis was performed using Mann-Whitney or Fisher's exact test. Data are presented as means +/- SD. RESULTS: Forty-four patients were included. In 18 patients, the sternum was fixed with mesh and wires, in 26 patients with LCP. Mean follow-up was 35 months in the mesh and 30 months in the LCP group, P=0.71. Haller index was similar in both groups (mesh 3.8±1.3 vs. LCP 3.9±1.1, P=0.81). Symptomatic non-union occurred in 17% (n=3) in the mesh group and did not occur after LCP, P=0.062. Total number of complications was 33% (n=6) in the mesh group and 15% (n=4) after LCP, P=0.27. CONCLUSIONS: After modified Ravitch procedure, union of the sternal osteotomy is challenging. In this retrospective cohort study, a lower incidence of symptomatic non-union was observed after fixation of the sternum with LCPs, with a trend towards statistical significance.

Pectus excavatum severity underestimated due to lack of objective measures in radiological reports.

During a routine physical examination, the degree of pectus excavatum (PE) is not always appreciated as the external appearance does not always reflect the severity of the deformity. In the patient in this case report, the severity had been underestimated for 33 years. The physicians, having requested standard two-view chest radiographs, had relied solely on the radiological reports, where the PE had been ambiguously described as 'moderate' or 'substantial'. In patients where PE has been observed, it is essential that an objective numeric measure of severity, using the Haller index, is included in radiological reports.

Cognitive Inflexibility in Gamblers is Primarily Present in Reward-Related Decision Making.

One hallmark of gambling disorder (GD) is the observation that gamblers have problems stopping their gambling behavior once it is initiated. On a neuropsychological level, it has been hypothesized that this is the result of a cognitive inflexibility. The present study investigated cognitive inflexibility in patients with GD using a task involving cognitive inflexibility with a reward element (i.e., reversal learning) and a task measuring general cognitive inflexibility without such a component (i.e., response perseveration). For this purpose, scores of a reward-based reversal learning task (probabilistic reversal learning task) and the Wisconsin card sorting task were compared between a group of treatment seeking patients with GD and a gender and age matched control group. The results show that pathological gamblers have impaired performance on the neurocognitive task measuring reward-based cognitive inflexibility. However, no difference between the groups is observed regarding non-reward-based cognitive inflexibility. This suggests that cognitive inflexibility in GD is the result of an aberrant reward-based learning, and not based on a more general problem with cognitive flexibility. The pattern of observed problems is suggestive of a dysfunction of the orbitofrontal cortex, the ventrolateral prefrontal cortex, and the ventral regions of the striatum in gamblers. Relevance for the neurocognition of problematic gambling is discussed.

Symptomatic pectus excavatum in seniors: an exploratory study on clinical presentation and incidence in daily practice.

Objectives. Doctors all over the world consider a pectus excavatum usually as an incidental finding. There is some evidence suggesting that a pectus excavatum may cause symptoms in the elderly. It is not known how often a pectus excavatum occurs and how strong the relation is with symptoms. Methods. In hospitals and general practice data, we searched for evidence of a connection between cardiac symptoms and the presence of a pectus excavatum in a retrospective survey among patients in whom a pectus excavatum was found in a chest X-ray. In radiology reports, we searched for "pectus excavat(∗) " in almost 160000 chest X-rays. The identified X-rays were reviewed by 2 radiologists. Reported symptoms were combined to a severity sum score and the relation with pectus excavatum was assessed through logistic regression. Results. Pectus excavatum was found in 1 to 2 per 1000 chest X-rays. In 32% of patients (N = 117), we found symptoms that might reflect the presence of symptomatic pectus excavatum. We found a significant relation between the SPES sum score and the radiological level of pectus excavatum. Conclusions. A pectus excavatum found when examining the patient should not be neglected and should be considered as a possible explanation for symptoms like dyspnoea, fatigue, or palpitations.

Medical photography: a reliable and objective method for documenting the results of reconstructive surgery of pectus excavatum.

Patients with a pectus excavatum frequently experience medical problems such as dyspnoea, fatigue and palpitations. After surgical intervention most patients are alleviated of their symptoms. Pectus excavatum can easily be diagnosed by a proper inspection of the chest. In the Atrium Medical Center photographic documentation of the deformation of the chest is part of the treatment protocol before and after surgical correction of a pectus excavatum. In addition to the normal photographic routine two special recording techniques are applied: measuring the depth of the excavation with a rule, and documenting the depth of the excavation in a 3-D grid-projection image. The applied 3-D technique (raster stereography) can also be an asset to other medical specialty areas in which changes in body shape and appearance play a major role.

Pectus excavatum, not always as harmless as it seems.

Pectus excavatum is usually considered meaningless and without clinical significance. The following case may put a different complexion on the matter. A healthy 59-year-old male patient complained of progressive heart palpitations, fatigue and postural dyspnoea; bending over caused a clear increase of dyspnoea. At repeated examinations no overt abnormality or explanation was found, except a supraventricular arrhythmia and a nodal tachycardia. In the years to follow the symptoms led to considerable physical impairments. Finally, the patient himself, after searching the web, came up with a possible cause: his pectus excavatum. A lateral chest x-ray with the patient bending over and a lateral computed tomography of the thorax revealed an impression of the heart by the sternum. Ten years after the patient's signs and symptoms first appeared, a modified Ravitch procedure was carried out, after which the physical condition of the patient improved rapidly.