A computer tablet software can quantify the deviation of scapula medial border from the thoracic wall during clinical assessment of scapula dyskinesis.

PURPOSE: Aim of this study is to establish an objective and easily applicable method that will allow clinicians to quantitatively assess scapular dyskinesis during clinical examination using a computer tablet software. Hypothesis is that dyskinetic scapulae present greater motion-deviation from the thoracic wall-compared to the non-dyskinetic ones and that the software will be able to record those differences. METHODS: Twenty-five patients and 19 healthy individuals were clinically evaluated for the presence of dyskinesis or not. According to the clinical diagnosis, the observations were divided into three groups; A. Dyskinetic scapulae with symptoms (n = 25), B. Contralateral non-dyskinetic scapulae without symptoms (n = 25), C. Healthy control scapulae (n = 38). Then, all individuals were tested using a tablet with the PIVOT™ image-based analysis software (PIVOT, Impellia, Pittsburgh, PA, USA). The motion produced by the scapula medial border and inferior angle deviation from the thoracic wall was recorded. RESULTS: The deviation of the medial border and inferior angle of the scapula from the thoracic wall was 24.6 ± 7.3 mm in Group A, 14.7 ± 4.9 mm in Group B, and 12.4 ± 5.2 mm in Group C. The motion recorded in the dyskinetic scapulae group was significantly greater than both the contralateral non-dyskinetic scapulae group (p < 0.01) and the healthy control scapulae group (p < 0.01). CONCLUSION: The PIVOT™ software was efficient to detect significant differences in the motion between dyskinetic and non-dyskinetic scapulae. This system can support the clinical diagnosis of dyskinesis with a numeric value, which not only contributes to scapula dyskinesis grading but also to the evaluation of the progress and efficacy of the applied treatment, thus providing a feedback to the clinician and the patient. LEVEL OF EVIDENCE: IV, laboratory study.

PHOTOGRAMMETRY: A PROPOSAL OF OBJECTIVE ASSESSMENT OF CHEST WALL IN ADOLESCENT IDIOPATHIC SCOLIOSIS.

OBJECTIVE: To evaluate the chest wall shape in patients with adolescent idiopathic scoliosis (AIS) in comparison to healthy subjects and the association between the chest wall shape with the spine deformity and lung function in patients with AIS. METHODS: This cross-sectional study enrolled 30 AIS patients and 20 healthy subjects aged 11-18 years old. The Cobb angle evaluation was performed in AIS patients. The chest wall shape was assessed by the photogrammetry method, using the Postural Assessment Software (PAS). We created thoracic markers shaped as angles (A) and distances (D), as follows: A2 (right acromion/xiphoid/left acromion), A4L (angle formed between the outer point of the smallest waist circumference and its upper and lower edges on the left side), A7 (angle formed by the intersection of the tangent segments of the upper and lower scapulae angles), D1R/D1L [distance between the xiphoid process and the last false rib on the right (R) and left (L) sides], and D3 (distance between xiphoid process and anterior superior iliac spine). RESULTS: The thoracic markers A2 and A7 were significantly higher, while the A4L and D1R/D1L were significantly reduced in the AIS group compared to the control. Moderate correlations were found between: A2 and the main and proximal thoracic Cobb angles (r=0.50, r=0.47, respectively); D1R/D1L and the main thoracic Cobb angle (r=- 0.40); and the forced expiratory volume in the first second (FEV1) and D3R (r=0.47). CONCLUSIONS: The photogrammetry method was able to detect chest wall changes in AIS patients, besides presenting correlation between Cobb angles and lung function.

Photogrammetry: a proposal of objective assessment of chest wall in adolescent idiopathic scoliosis / Fotogrametria: uma proposta de avaliação objetiva da caixa torácica na escoliose idiopática do adolescente

ABSTRACT Objective: To evaluate the chest wall shape in patients with adolescent idiopathic scoliosis (AIS) in comparison to healthy subjects and the association between the chest wall shape with the spine deformity and lung function in patients with AIS. Methods: This cross-sectional study enrolled 30 AIS patients and 20 healthy subjects aged 11-18 years old. The Cobb angle evaluation was performed in AIS patients. The chest wall shape was assessed by the photogrammetry method, using the Postural Assessment Software (PAS). We created thoracic markers shaped as angles (A) and distances (D), as follows: A2 (right acromion/xiphoid/left acromion), A4L (angle formed between the outer point of the smallest waist circumference and its upper and lower edges on the left side), A7 (angle formed by the intersection of the tangent segments of the upper and lower scapulae angles), D1R/D1L [distance between the xiphoid process and the last false rib on the right (R) and left (L) sides], and D3 (distance between xiphoid process and anterior superior iliac spine). Results: The thoracic markers A2 and A7 were significantly higher, while the A4L and D1R/D1L were significantly reduced in the AIS group compared to the control. Moderate correlations were found between: A2 and the main and proximal thoracic Cobb angles (r=0.50, r=0.47, respectively); D1R/D1L and the main thoracic Cobb angle (r=- 0.40); and the forced expiratory volume in the first second (FEV1) and D3R (r=0.47). Conclusions: The photogrammetry method was able to detect chest wall changes in AIS patients, besides presenting correlation between Cobb angles and lung function.

RESUMO Objetivo: Avaliar o formato da caixa torácica em pacientes com escoliose idiopática do adolescente (EIA), comparando-os com indivíduos saudáveis e analisar a associação do formato da caixa torácica com a deformidade da coluna vertebral e função pulmonar em pacientes com EIA. Métodos: Estudo transversal que avaliou 30 pacientes com EIA e 20 indivíduos saudáveis com idade entre 11 e 18 anos. O ângulo de Cobb foi avaliado em pacientes com EIA. O formato da caixa torácica foi analisado pelo método da fotogrametria, utilizando o Software para Avaliação Postural (SAPO). Foram criados marcadores torácicos descritos como ângulos (A)e distâncias (D): A2 (acrômio direito/processo xifoide/acrômio esquerdo), A4E (ângulo formado entre o ponto externo da menor circunferência da cintura e suas bordas superior e inferior do lado esquerdo), A7 (ângulo formado pela interseção das retas tangentes aos ângulos superior e inferior das escápulas), D1D/D1E [distância entre o processo xifoide e a última costela falsa nos lados direito (D) e esquerdo (E)] e D3 (distância entre o processo xifoide e a espinha ilíaca anterossuperior). Resultados: Os marcadores torácicos A2 e A7 foram significativamente maiores, enquanto o A4E e o D1D/D1E foram significativamente menores no grupo EIA em relação ao controle. Foram encontradas correlações moderadas entre: A2 e os ângulos de Cobb torácico principal e proximal (r=0,50 e r=0,47, respectivamente); D1D/D1E e o ângulo de Cobb torácico principal (r=-0,40); e o volume expiratório forçado no primeiro segundo (VEF1) e D3D (r=0,47). Conclusões: O método da fotogrametria detectou alterações na caixa torácica de pacientes com EIA, além de apresentar correlações significativas entre os ângulos de Cobb e a função pulmonar.

Quantitative assessment and risk factors for chest wall deformity resulting from tissue expansion for breast reconstruction.

BACKGROUND: Chest wall deformity after tissue expansion for breast reconstruction is less recognized than complications such as infection, hematoma, skin necrosis and capsular contracture. However, the condition should not be discounted because pain, rib fracture and dyspnea may occur in severe cases. The aim of this study is to evaluate the extent of chest wall deformity quantitatively using computed tomography (CT) and to identify risk factors for this condition after tissue expansion. METHODS: The subjects were 34 patients who underwent unilateral two-stage reconstruction and were examined by multidetector-row CT before expander surgery and during maximal tissue expansion. Chest wall deformity was assessed quantitatively using the Chest Wall Deformity Index (CWDI), which was measured before expander surgery (pre-CWDI) and during maximal tissue expansion (post-CWDI). Post minus pre (post-pre) CWDI was used as the index of chest wall deformity in the assessment of risk factors. RESULT: Post-CWDI was significantly higher than pre-CWDI (3.66 ± 3.23% vs. 0.03 ± 2.74%, P < 0.001 by paired t test), showing that chest wall deformity occurred after maximum expansion. In a multiple linear regression model, capsular contracture emerged as a significant predictor of increased post-pre CWDI (P = 0.003). BMI was a significant predictor of decreased post-pre CWDI (P = 0.003), but this result may have been due to the measurement method. CONCLUSIONS: Our findings suggest that chest wall deformity is common after maximum tissue expansion for breast reconstruction. Awareness of the possibility of chest wall deformity during tissue expansion is important, particularly in cases with capsular contracture.

Assessment of the acute effects of different PEP levels on respiratory pattern and operational volumes in patients with Parkinson's disease.

The aim of the study was to determine the acute effects of positive expiratory pressure (PEP) on breathing pattern, operational volumes and shortening velocity of respiratory muscles on patients with Parkinson's disease. It was evaluated 15 patients and healthy controls, by optoelectronic plethysmography, using PEP in three different levels (10, 15 and 20cmH2O). Breathing pattern changed in both groups. Parkinson group increased tidal volume in all PEP levels (p<0.001), but with lower values compared to control. End-inspiratory chest wall volume increased in the Parkinson group at all PEP levels (p<0.001), end-expiratory chest wall volume show a slightly increase when we compared QB to all PEP levels in Parkinson's. There was an intergroup difference in the index of shortening velocity of abdominal, diaphragm and inspiratory muscles of the rib cage at all PEP levels (p<0.01). We conclude that Parkinson's disease promotes important alterations in different breathing pattern components and PEP has significant effects on these alterations.

Simultaneous assessment of airway instability and respiratory dynamics with low-dose 4D-CT in chronic obstructive pulmonary disease: a technical note.

BACKGROUND: Advanced-stage chronic obstructive pulmonary disease (COPD) is associated with severely altered respiratory dynamics. Dynamic airway instability is usually diagnosed by invasive bronchoscopy. Cine-computed tomography (CT) may be used alternatively, but is limited to predefined anatomical positions. Also, a paradoxical diaphragmatic motion has been described in patients with emphysema. OBJECTIVES: As the airways and chest wall show inherently high contrast to airway lumen and lung tissue, low-dose CT acquisitions potentially suffice for depicting tracheobronchial and chest wall motion. Therefore, we propose low-dose dynamic respiratory-gated multidetector CT (4D-CT) of the whole chest as a new method to assess respiratory dynamics. METHODS: 4D-CT was performed in 3 patients (52, 62 and 76 years old) with suspected tracheal instability due to COPD or tracheal stenosis at minimal pitch (0.09) and radiation exposure (1.4-1.9 mSv) during regular tidal breathing registered by a belt system. Image reconstruction involved a raw data-based iterative algorithm (1.5-mm slice thickness, 1.0-mm z-axis increment, 5% respiratory increment), resulting in a stack of 6,700 images, which were evaluated with a 4D-viewing tool. RESULTS: An excessive dynamic collapse of the trachea in combination with tracheobronchomalacia (TBM) of the main-stem and segmental bronchi, and a paradoxical diaphragmatic motion were demonstrated in 1 case. Moreover, we detected a saber-sheath trachea and main-stem TBM in another case. The third case showed a fixed tracheal stenosis. CONCLUSIONS: 4D-CT provides unprecedented z-axis coverage and time-resolved volumetric datasets of the whole chest. Airway instability, stenosis and paradoxical diaphragmatic motion may be assessed simultaneously, preceding interventions such as airway stabilization or lung volume reduction.

Two-dimensional speckle tracking strain analysis for efficacy assessment of myocardial cell therapy.

The subtle effects of transplanted bone marrow cells (BMC) on regional myocardial behavior in patients with ischemic heart disease are difficult to assess. Novel echocardiographic techniques can quantify regional myocardial deformation (strain) and distinguish between passive and active wall motion. We hypothesized that this technique may help delineate cell therapy-induced changes in regional LV contractility that escape clinical routine studies. Twelve patients with coronary artery disease and impaired LV function (LVEF &<35%) underwent CABG surgery plus intramyocardial injection of autologous bone marrow mononuclear cells. Between two and five predefined segments of ischemic myocardium per patient received BMCs, and untreated ischemic segments served as internal controls. Segmental echocardiographic analysis of peak systolic strain by speckle tracking was performed before and 1 year after surgery and compared with standard wall motion analysis. Two patients died during the follow-up period. In the remaining 10 patients, mean LVEF increased from 24.5 +/- 10% to 32.1 +/- 11% (p = 0.02). A moderate improvement of systolic function was noted in ischemic control segments by both wall motion score (WMS) and 2D strain echocardiography (2DSE). In BMC-treated segments, WMS improved slightly, but the data failed to reach statistical significance. As assessed by 2DSE, however, systolic function of BMC-treated segments improved by nearly 100%. 2DSE proved to detect BMC-induced change with 30-fold higher sensitivity than WMS, and the Receiver Operating Characteristic curve (ROC) confirmed the diagnostic precision of 2DSE (area-under-the-ROC = 0.87). We conclude that echocardiographic speckle tracking two-dimensional strain analysis can detect cell therapy-induced changes in regional contractile function that may escape detection by standard wall motion assessment. Thus, 2DSE may be a useful tool for the further development of clinical cardiac cell therapy.

Incomplete chest wall decompression: a clinical evaluation of CPR performance by trained laypersons and an assessment of alternative manual chest compression-decompression techniques.

BACKGROUND: Complete chest wall recoil improves hemodynamics during CPR by generating relatively negative intrathoracic pressure, which draws venous blood back to the heart, providing cardiac preload prior to the next chest compression. OBJECTIVE: This study was designed to assess the quality of CPR delivered by trained laypersons and to determine if a change in CPR technique or hand position would improve complete chest wall recoil, while maintaining adequate duty cycle, compression depth, and proper hand position placement. Standard manual CPR and three alternative manual CPR approaches were assessed. METHODS: This randomized prospective trial was performed on an electronic test manikin. Thirty laypersons (mean age of 40.6 years (range 28-55)), who were trained in CPR within the last 24 months, signed an informed consent and participated in the trial. Subjects performed 3 min of CPR on a Laerdal Skill Reportertrade mark CPR manikin using the Standard Hand Position followed by 3 min of CPR (in random order) using three alternative CPR techniques: (1) Two-Finger Fulcrum Technique - lifting the heel of the hand slightly but completely off the chest during the decompression phase of CPR using the thumb and little finger as a fulcrum; (2) Five-Finger Fulcrum Technique - lifting the heel of the hand slightly but completely off the chest during the decompression phase of CPR using all five fingers as a fulcrum; (3) Hands-Off Technique - lifting the heel and all fingers of the hand slightly but completely off the chest during the decompression phase of CPR. The participants did not know the purpose of the study prior to, or during this investigation. RESULTS: Adequate compression depth was poor for all hand positions tested and ranged only from 18.6 to 35.7% of all compressions. When compared with the Standard Hand Position, the Hands-Off Technique decreased the mean compression duty cycle from 39.0 +/- 1.0 to 33.5 +/- 1.0%, (P < 0.0001) but achieved the highest rate of complete chest wall recoil (92.5% versus 24.1%, P < 0.0001) and was 46.3 times more likely to provide complete chest wall recoil (OR: 46.3; CI: 16.4-130.3). There were no significant differences in accuracy of hand placement, adequate depth of compression, or perceived discomfort with its use compared with the Standard Hand Position. CONCLUSIONS: The Hands-Off Technique decreased compression duty cycle but was 46.3 times more likely to provide complete chest wall recoil (OR: 46.3; CI: 16.4-130.3) compared to the Standard Hand Position without differences in accuracy of hand placement, adequate depth of compression, or perceived discomfort with its use. All forms of manual CPR tested (including the Standard Hand Position) in trained laypersons produced an inadequate depth of compression for two-thirds of the time. These data support development and testing of more effective layperson CPR training programmes and more effective means to deliver manual as well as mechanical CPR.