The frequency and presentation of upper thoracic spinous process deviations, their relationship to articular morphology, and the potential influence on static palpation techniques.

BACKGROUND: Static palpation of vertebral spinous process deviations from the midline are often utilized by manual therapists as a means to determine area for treatment of manipulable lesions. Previous research has discussed the diagnostic validity of this technique, but no correlation to vertebral morphology has been presented. AIM: To evaluate the frequency and presentation of vertebral spinous process deviations and their relationship with articular morphology, and the impact this may have in terms of static palpation techniques in the upper thoracic spine. SETTING: This study was conducted on human T1-T6 vertebrae. METHOD: A skeletal sample consisting of 58 humans T1-T6 vertebrae were photographed and linear and angular measurements taken utilizing ImageJ software and non-metric visual observations. RESULTS: Spinous process deviations in the entire sample group (n = 348) were found to occur in a frequency ranging from 19% (n = 11) at T1 to 41.4% (n = 24) at T3. However, when evaluated in terms of frequency within an individual's T1-T6, 83.3% (n = 25) of males and 67.86% (n = 19) of females demonstrated this feature, with an overall incidence of 77.59% (n = 45). Age of individuals did not show an increase in frequency, and no clear pattern could be identified regarding metric measurements and its presence. CONCLUSION: Spinous process deviations in the upper thoracic spine are most probably the result of random normal variations between individuals and are more frequent in males. Static palpation without pain criteria is not a reliable diagnostic technique to determine areas needing manual treatment, as these may be considered normal osseous anatomical variations.

Effects of diaphragmatic and iliopsoas myofascial release in patients with chronic low back pain: A randomized controlled study.

BACKGROUND: Myofascial release (MFR) technique is frequently used in musculoskeletal problems. There are many studies of the MFR technique on the diaphragm or iliopsoas muscle. However, no studies in the literature performed both diaphragmatic and iliopsoas MFR techniques in patients with chronic low back pain. OBJECTIVE: To investigate the effects of diaphragmatic and iliopsoas MFR techniques on pain, lumbar spine range of motion (ROM), chest wall mobility, and flexibility in patients with chronic low back pain. DESIGN: Randomized controlled clinical study. PARTICIPANTS: Forty-two participants with chronic low back pain, aged between 20 and 50 years. INTERVENTION: The sample was randomly allocated into one of two groups; the myofascial group (n = 21) and control group (n = 21) received the MFR technique or the placebo MFR technique as a complementary therapy to traditional physiotherapy treatment. OUTCOME MEASURES: Primary outcomes were pain, chest wall mobility, lumbar spine range of motion (ROM), and flexibility. Secondary outcomes were depression, kinesiophobia, and functional disability. RESULTS: The MFR techniques significantly reduced the pain, with a between-group difference of -2.05 (95% CI, -2.93 to -1.15) for rest, -2.62 (95% CI, -3.34 to -1.89) for trunk flexion, and -2.00 (95% CI, -2.84 to -1.16) for trunk extension in favor of the EG. MFR techniques significantly increased the lumbar spine ROM after interventions, with a between-group difference of 16.67° (95% CI, 8.87 to 24.47) for flexion, 7.63° (95% CI, 5.44 to 9.80) for extension and, 9.53° (95% CI, 6.57 to 12.48) for right lateral flexion. There was also a significant difference between the groups in flexibility in favor of the MG of 1.95 cm (95% CI, 1.41 to 2.49) for MST, -13.52 cm (95% CI, -20.18 to -6.86) for trunk flexion and, -4.37 cm (-6.50 to -2.28) for right lateral flexion The MFR techniques also significantly increased the chest wall mobility after interventions, with a between-group difference of 2.52 cm (95% CI, 1.82 to 3.23) for the xiphoid region and 3.48 cm (95% CI, 2.60 to 4.36) for the subcostal region. CONCLUSION: Diaphragmatic and iliopsoas MFR techniques may be effective in pain, lumbar spine ROM, flexibility, and chest wall mobility in patients with chronic low back pain. CLINICAL TRIALS IDENTIFIER: NCT04415021.

Intraoperative local instillation anesthesia using injection technique from J-VACTM drain for postoperative pain relief in male-type chest wall contouring surgery.

For postoperative acute pain during mastectomy, a few studies have reported the usefulness of an intraoperative local anesthesia instillation technique in which analgesics are injected through a drain placed under the skin, intraoperatively. This study presented a novel administration method, and the efficacy of local instillation anesthesia in male-type chest wall contouring surgery was assessed. Fifty-four patients underwent chest wall contouring surgery under general anesthesia. The 27 patients in each of the study and control groups, with our instillation technique and without the technique were compared, in terms of the maximum numerical rating scale (NRS) score within 24 h after surgery, the postoperative analgesic use frequency, and dosage until 6 d. The analgesic used was a mixture of 5 ml 1% lidocaine hydrochloride, epinephrine (0.05 mg), 10 ml 0.75% bupivacaine, and 10 ml saline. Thereon, 25 ml analgesia was administered from the left and right drain (15-Fr J-VACTM) and infiltrated for 15 min. Both NRS scores of postanesthesia care unit (PACU) discharge and the maximum NRS score within 24 h after PACU discharge were significantly lower in the study group than in the control group (p < 0.001, p = 0.048). The frequency of analgesics administered within 24 h after surgery was significantly lower in the study group than in the control group (p = 0.025). Our anesthesia instillation method for chest wall contouring surgery was effective in relieving acute pain occurring within 24 h after surgery and can be a useful analgesic administration method.

Short Stay Management of Locally Advanced Breast Cancer Using Immediate Local Thoracoabdominal Advancement Flap and Enhanced Recovery After Surgery Protocol.

BACKGROUND: Patients with locally advanced invasive breast cancer (LABC) are often considered inoperable, because of the anticipated chest wall defect and need for complex reconstruction. We present a series of patients who underwent mastectomy with extensive skin resection and immediate chest wall reconstruction using a local thoracoabdominal advancement flap (TAAF). All patients were managed after surgery with an ERAS (Enhanced Recovery After Surgery) protocol, to decrease length of stay in hospital. We also present 1 patient who subsequently had satisfactory bilateral delayed breast reconstruction with pedicled latissimus dorsi myocutaneous flaps with prepectoral silicone implants. METHODS: This is a single-surgeon, single-institution retrospective chart review of patients with LABC who underwent mastectomy with skin resection and local TAAF from May 2017 to October 2019, with minimum 3-month follow-up. RESULTS: Thirteen patients met inclusion criteria. Twelve of 13 patients presented with stage III or IV invasive breast cancer, with skin involvement. The mean chest wall defect measured 248.7 cm2 (140-336 cm2; SD, 63.2 cm2), and all were successfully reconstructed with immediate local TAAF. There were no intraoperative complications, but 1 patient developed a postop hematoma. The mean hospital stay was 1.3 nights, with 9 patients (69.2%) staying less than 23 hours and 4 patients (30.8%) staying 2 nights. Nine patients (69.2%) underwent adjuvant therapy, beginning on average 32 days (13-55 days; SD, 13.1 days) after surgery. The mean follow-up time was 13.8 months (4.5-31.6 months; SD, 9.2 months). One patient underwent successful delayed bilateral breast reconstruction with pedicled latissimus dorsi myocutaneous flaps and silicone implant placement. CONCLUSIONS: Our study demonstrates that reconstruction with local TAAF is an outpatient procedure that reliably provides durable, immediate chest wall coverage, after mastectomy in patients with LABC. This technique has a short operative time, low blood loss, and low complication rate, allowing timely adjuvant therapy. Using an ERAS postop protocol we were able to reduce mean hospital stay to 1.3 days. Compared with other described techniques of reconstruction, the additional scars and donor site morbidity are minimal, allowing for delayed breast reconstruction. We also present survival outcomes data on these surgically managed patients.

Yoga in Burn: Role of pranayama breathing exercise on pulmonary function, respiratory muscle activity and exercise tolerance in full-thickness circumferential burns of the chest.

BACKGROUND: Circumferential burn of chest (CBC) is a significant type of burn and considers as a major cause of restrictive lung disease (RLD). Patient who has CBC with RLD leads to respiratory symptoms such as breathing difficulty, airway obstruction, reduced exercise capacity and altered pulmonary functions. However, studies examining the role of pranayama breathing exercise on pulmonary function, respiratory muscle activity and exercise tolerance in full thickness circumferential burn of chest are lacking. OBJECTIVE: To find the short term effects of pranayama breathing exercise on pulmonary function, respiratory muscle activity and exercise tolerance in full thickness circumferential burns of chest. METHODS: Through simple random sampling method thirty subjects (N = 30) with RLD following CBC were allocated to pranayama breathing exercise group (PBE-G; n = 15) and conventional breathing exercise group (CBE-G; n = 15). They received pranayama breathing exercise and conventional breathing exercise for 4 weeks respectively. All the subjects received chest mobility exercise as common treatment. Primary (Numeric Pain Rating Scale - NPRS, forced expiratory volume (FEV1), forced vital capacity (FVC) and maximum voluntary ventilation (MVV) and secondary (Electromyogram of sternocleidomastoid, scalene, external intercostal and diaphragm muscle, 6 min walk test & Global Rating of Change - GRC) outcome measures were measured at baseline, after four weeks and after three months follow up. RESULTS: Baseline demographic and clinical variables show homogenous distribution between the groups (p > 0.05). Four weeks following different breathing exercises, PBE-G group shows more significant changes in pain intensity, pulmonary function, respiratory muscle activity, exercise tolerance and global rating of change than CBE-G group (p ≤ 0.05) at four weeks and three months follow up. CONCLUSION: Both groups showed improvement over time. However, differences between the groups were noticed small. Still physiotherapy management, which included pranayama breathing exercises with chest mobilization program, had an effective strategy in the treatment of restrictive lung disease following circumferential burn of chest.

Chest Wall Mobility: Identification of Underlying Predictors.

OBJECTIVE: The purpose of this study was to identify factors contributing to normal mobility or hypermobility of the chest wall. METHODS: Seventy-eight young adults were divided into 2 groups: patients with normal mobility (group 1, n = 40) and hypermobility of the chest wall (group 2, n = 38). The mean mobility of the chest wall in groups 1 and 2 was 9.9 and 6.1 cm, respectively. The mean age of groups 1 and 2 was 22.2 and 21.5 years, respectively. The Brief Symptom Inventory, State-Trait Anxiety Inventory, Beck Depression Inventory, and the Perceived Stress Scale were used to evaluate the psychometric properties. Quality of life was assessed using 12-Item Short Form Health Survey. Smoking status was determined via self-report of current smoking status. Chest wall mobility was measured using thoracic and axillary cirtometry. Pulmonary functions were evaluated using a Spirobank II device. Subsequently, forced vital capacity (FVC), forced expiratory volume in 1 second, peak expiratory flow, and forced expiratory flow 25% to 75% were verified. Carefusion Micro RPM and the 6-minute walk test were used to evaluate maximal respiratory pressures and functional capacity, respectively. RESULTS: With backward linear regression models, FVC and obsessive-compulsive traits were significant predictors of chest wall mobility (R²â€¯= 0.27; P < .001 and P = .01, respectively). In logistic regression models, FVC, maximum inspiratory pressure, and obsessive-compulsive traits were significant predictors of normal mobility/hypermobility of the chest wall (R²â€¯= 0.42; P < .001, P = .01, and P = .03, respectively). CONCLUSION: Forced vital capacity, maximum inspiratory pressure, and obsessive-compulsive traits are significant predictors of chest wall mobility and normal mobility or hypermobility of the chest wall.

A Comprehensive Review of the Diagnosis, Treatment, and Management of Postmastectomy Pain Syndrome.

PURPOSE OF REVIEW: Postmastectomy pain syndrome (PMPS) remains poorly defined, although it is applied to chronic neuropathic pain following surgical procedures of the breast, including mastectomy and lumpectomy in breast-conserving surgery. It is characterized by persistent pain affecting the anterior thorax, axilla, and/or medial upper arm following mastectomy or lumpectomy. Though the onset of pain is most likely to occur after surgery, there may also be a new onset of symptoms following adjuvant therapy, including chemotherapy or radiation therapy. RECENT FINDINGS: The underlying pathophysiology is likely multifactorial, although exact mechanisms have yet to be elucidated. In this regard, neuralgia of the intercostobrachial nerve is currently implicated as the most common cause of PMPS. Numerous pharmacological options are available in the treatment of PMPS, including gabapentinoids, tricyclic antidepressants, selective serotonin reuptake inhibitors, NMDA receptor antagonists, and nefopam (a non-opioid, non-steroidal benzoxazocine analgesic). Minimally invasive interventional treatment including injection therapy, regional anesthesia, botulinum toxin, and neuromodulation has been demonstrated to have some beneficial effect. A comprehensive update highlighting current perspectives on the treatment of postmastectomy pain syndrome is presented with emphasis on treatments currently available and newer therapeutics currently being evaluated to alleviate this complex and multifactorial condition.

The practicality of a two-incision surgical approach for hypoglossal nerve stimulator implantation.

INTRODUCTION: Determine the feasibility of a two-incision surgical approach to hypoglossal nerve stimulator implantation based on anatomic considerations. METHODS: Upper airway stimulation (UAS) using the Inspire system uses three implanted devices-the implantable pulse generator (IPG), stimulation lead and sensing chest wall lead. The traditional surgical approach requires three skin incisions located on the submandibular neck, anterosuperior chest wall and inferolateral chest wall. Our surgical team sought to determine the anatomic considerations of combining the two chest wall incisions into one. In order to minimize morbidity and reduce operative time, the chest wall sensing lead was placed posterolateral to the IPG site via the same incision. RESULTS: Using an adult cadaver for anatomical analysis, access to the third and fourth intercostal spaces was made more difficult by the pectoralis major humeral head and upper arm. The intercostal space was narrower, the musculature along the anterior axillary line and anterior chest wall was devoid of the innermost intercostal muscle group found more laterally. Furthermore, there were much thinner external and internal intercostal muscle components as they transitioned to a membranous layer anteriorly in comparison to the inferolateral chest wall. CONCLUSION: Lack of the innermost intercostal muscle and thinning of the external and internal intercostal muscles lateral to the IPG site leaves little barrier between the thoracic musculature and parietal pleural increasing the risk of complications such as pleurisy and pneumothorax. Given the anatomical findings, a two-incision surgical approach for UAS therapy is at higher risk for complications.

Effects of deep thermotherapy on chest wall mobility of healthy elderly women.

Chest wall mobility decreases with age in community-dwelling women aged 65 years or older. Thermotherapy is used to improve soft-tissue extensibility. However, its effects on chest wall mobility are unclear. This study aimed to examine the effect of thermotherapy on chest wall mobility in healthy elderly women. Twenty-eight elderly women participated in this study. Chest wall mobility at three levels (axillary, xiphoid, and tenth rib), respiratory function (forced vital capacity and forced expiratory volume), and tissue temperature (skin temperature (ST)) and deep temperature (DT) with 10 mm and 20 mm depth from the skin (10 mm DT and 20 mm DT)) were measured before and after 15 minutes of thermotherapy. The subjects randomly received one of the three interventions (capacitive and resistive electric transfer (CRet), hot pack (HP), and sham CRet (sham)). Chest wall mobility at all levels significantly increased after CRet intervention. Hot pack significantly increased tenth rib excursion; it also significantly increased ST, 10 mm DT, and 20 mm DT, whereas CRet significantly increased 10 mm DT and 20 mm DT. There were significant differences between CRet, HP, and sham in ST, 10 mm DT, and 20 mm DT. Furthermore, 20 mm DT had increased more in CRet than in HP. CRet improved chest wall mobility at all levels and HP improved at the tenth rib level. This implies that CRet can be one of the approaches to improve chest wall mobility.

Regional Anesthesia in Cardiac Surgery: An Overview of Fascial Plane Chest Wall Blocks.

Optimal analgesia is an integral part of enhanced recovery after surgery (ERAS) programs designed to improve patients' perioperative experience and outcomes. Regional anesthetic techniques in a form of various fascial plane chest wall blocks are an important adjunct to the optimal postoperative analgesia in cardiac surgery. The most common application of fascial plane chest wall blocks has been for minimally invasive cardiac surgical procedures. An abundance of case reports has been described in the anesthesia literature and reports appear promising, yet higher-level safety and efficacy evidence is lacking. Those providing anesthesia for minimally invasive cardiac procedures should become familiar with fascial plane anatomy and block techniques to be able to provide enhanced postsurgical analgesia and facilitate faster functional recovery and earlier discharge. The purpose of this review is to provide an overview of contemporary fascial plane chest wall blocks used for analgesia in cardiothoracic surgery. Specifically, we focus on relevant anatomic considerations and technical descriptions including pectoralis I and II, serratus anterior, pectointercostal fascial, transverse thoracic muscle, and erector spine plane blocks. In addition, we provide a summary of reported local anesthetic doses used for these blocks and a current state of the literature investigating their efficacy, duration, and comparisons with standard practices. Finally, we hope to stimulate further research with a focus on delineating mechanisms of action of novel emerging blocks, appropriate dosing regimens, and subsequent analysis of their effect on patient outcomes.

Postoperative respiratory muscle training in addition to chest physiotherapy after pulmonary resection: A randomized controlled study.

Purpose: The effects of preoperative respiratory muscle training (RMT) on postoperative complications in patients with pulmonary resection have recently attracted the attention of researchers. More studies are obviously needed to clarify the effects of RMT after pulmonary resection. The aim of this study was to evaluate the effectiveness of intense RMT in addition to chest physiotherapy after pulmonary resection in terms of respiratory muscle strength, exercise capacity, and length of hospital stay rather than postoperative complications. Methods: Forty subjects undergoing pulmonary resection were included in the study. Subjects were divided into two groups using a simple randomization method. The subjects in the study group (SG; n = 20) received RMT in addition to regular chest physiotherapy in the postoperative period. The subjects in the control group (CG; n = 20) received only regular chest physiotherapy. Respiratory muscle strength (maximal inspiratory and expiratory pressure [PImax and PEmax]) was measured pre-postoperatively and before discharge, and exercise capacity, which was measured by the 6-min walk test (6MWT), was assessed preoperatively and before discharge. The length of hospital stay was also recorded. Results: There were no differences between groups in terms of demographic and surgical characteristics. The nonsignificant change of PImax from the preoperative to the discharge value was 65.1 ± 15.5 to 68.2 ± 19.2 cmH2O in SG and 59.2 ± 13.7 to 44.3 ± 14.8 cmH2O in CG (p > 0.05, p > 0.05, respectively). The change of PEmax from the preoperative to the discharge value was 80.4 ± 24.9 to 81.5 ± 24.9 cmH2O in SG (nonsignificant) and 85.4 ± 38.2 to 61.3 ± 25.4 cmH2O in CG (p > 0.05, p = 0.002, respectively). There was a significant difference between SG and CG in terms of RMT effect (PImax: 11.05 [21.84; 0.25] cmH2O p = 0.045; PEmax: 25.23 [42.83; 7.62] cmH2O p = 0.006). A significant difference was found in the 6MWT when the mean differences were compared between the groups (85.72 [166.15; 5.28] m p = 0.037). The length of hospital stay was significantly shorter in the SG (number of days for SG 9.1 ± 3 and for CG 12.9 ± 4.2 [p = 0.002]). Conclusion: The addition of RMT to chest physiotherapy after pulmonary resection can have positive effects on respiratory muscle strength, exercise capacity, and length of hospital stay.

Visualization of angiogenesis and vasculogenesis in a late tissue radiation injury of the chest wall treated with adjuvant hyperbaric oxygen therapy using fluorescence angiography.

Adjuvant radiation therapy for breast cancer treatment often involves high doses of radiation, making patients more susceptible to late radiation tissue injury (LRTI), severe complications of which involve necrosis and ulceration. Treatment of such wounds is challenging. One modality that can be utilized is hyperbaric oxygen (HBO2) therapy. However, an optimal dose and the objective evidence of its benefit in use as an adjunctive treatment modality is limited. Presented here is a case of a non-surgical candidate in which serial indocyanine green fluorescence angiography (ICGFA) was utilized to determine if it could detect changes in tissue perfusion over the course of treatment. Serial ICGFA allowed for visualization of the current phase of wound healing, angiogenesis and vasculogenesis. Future large studies should be employed to better determine the utility of serial ICGFA to improve HBO2 utilization in patients who are undergoing HBO2 as part of their course of treatment for LRTI.

Versatilidad del colgajo dorsal en cirugía de reconstrucción de sarcoma de pared torácica. Reporte de caso / Versatility of the dorsal flap in reconstruction surgery of toracica wall sarcoma. Case report

Entre los tumores malignos de la pared torácica, los sarcomas representan menos del 1% de los casos. A pesar de ser infrecuentes, es importante resaltar el manejo multidisciplinario de estos tipos de tumores ya que se caracterizan por ser de gran tamaño y afectar una amplia superficie torácica y por consiguiente de los tejidos blandos anexos a los mismos. De ahí la real importancia de la participación de cirujanos plásticos, torácicos y oncólogos en el tratamiento de estos tumores. La confección del colgajo dorsal en cirugías de sarcomas de la pared torácica ha permitido completar el tratamiento resectivo de dichos tumores. Presentamos el caso de un paciente varón de 64 años, con un sarcoma de la parrilla costal, quien fue sometido a resección amplia de la lesión que comprometia a la 7ma, 8va y 9na costillas, reconstrucción inmediata con próstesis de titanio y malla de polipropileno y cobertura del defecto con confección de colgajo del dorsal ancho. A 5 meses de seguimiento, sin evidencia de actividad de la enfermedad

Among malignant tumors of the chest wall, sarcomas account for less than 1% of cases. Despite being infrequent, it is important to highlight the multidisciplinary management of these types of tumors since they are characterized by being large and affecting a wide chest area and therefore the soft tissues attached to them. Hence the real importance of the participation of pásticos, thoracic and oncologos surgeons in the treatment of these tumors.The confection of the dorsal flap in surgeries of sarcomas of the thoracic wall has allowed to complete the treatment of these tumors. We present the case of a 64-year-old male patient with a sarcoma of the rib cage, who underwent extensive resection of the lesion involving the 7th, 8th and 9th ribs, immediate reconstruction with titanium prosthesis and mesh. polypropylene and coverage of the defect with flap made of the latissimus dorsi. At 5 months of follow-up, without evidence of disease activity.

Effects of Diaphragmatic Breathing With and Without Pursed-Lips Breathing in Subjects With COPD.

BACKGROUND: Breathing exercises, such as diaphragmatic breathing and pursed-lips breathing, play a role in some individuals with COPD and might be considered for those patients who are unable to exercise. However, in the literature are reports of some adverse effects of diaphragmatic breathing in patients with COPD. Thus, the purpose of this study was to assess the effects of diaphragmatic breathing and diaphragmatic breathing combined with pursed-lips on chest wall kinematics, breathlessness, and chest wall asynchrony in subjects with COPD, and also to assess whether the combination of both exercises reduces the adverse effects of diaphragmatic breathing while maintaining its benefits. METHODS: Seventeen subjects with COPD, mean ± SD, 65 ± 7 y of age, with a history of smoking and clinical stability without hospitalization or symptoms of exacerbation in the past 4 wk, were evaluated. On day 1, participants' characteristics were collected, and they learned diaphragmatic breathing and its combination with pursed-lips breathing. On day 2, the participants were evaluated by optoelectronic plethysmography with the participants in the seated position while performing breathing exercises. RESULTS: Diaphragmatic breathing and diaphragmatic breathing plus pursed-lips breathing promoted a significant increase in chest wall tidal volume and its compartments as well as a reduction in breathing frequency compared with quiet breathing. No significant changes were observed in dyspnea or end-expiratory volume of the chest wall. A significant increase in asynchrony (inspiratory-expiratory phase ratio) was observed during diaphragmatic breathing and diaphragmatic breathing plus pursed-lips breathing compared with quiet breathing, with no differences observed between the exercises. CONCLUSIONS: Despite the increase in asynchrony, both breathing exercises were able to improve chest wall volumes without affecting dyspnea. The combination of exercises maintained the benefits but did not reduce the adverse effects of diaphragmatic breathing.

Immediate effects of diaphragmatic myofascial release on the physical and functional outcomes in sedentary women: A randomized placebo-controlled trial.

BACKGROUND: Although diaphragmatic myofascial release techniques are widely used in clinical practice, few studies have evaluated the simultaneous acute effects of these techniques on the respiratory and musculoskeletal systems. OBJECTIVE: To evaluate the immediate effects of diaphragmatic myofascial release in sedentary women on the posterior chain muscle flexibility; lumbar spine range of motion; respiratory muscle strength; and chest wall mobility. DESIGN: A randomized placebo-controlled trial with concealed allocation, intention-to-treat analysis, and blinding of assessors and participants. PARTICIPANTS: Seventy-five sedentary women aged between 18 and 35 years. INTERVENTION: The sample was randomly allocated into one of two groups; the experimental group received two diaphragmatic myofascial release techniques in a single session, and the control group received two placebo techniques following the same regimen. OUTCOMES MEASURES: The primary outcome was chest wall mobility, which was analyzed using cirtometry. The secondary outcomes were flexibility, lumbar spine range of motion, and respiratory muscle strength. Outcomes were measured before and immediately after treatment. RESULTS: The manual diaphragm release techniques significantly improved chest wall mobility immediately after intervention, with a between-group difference of 0.61 cm (95% CI, 0.12-1.1) for the axillary region, 0.49 cm (95% CI, 0.03-0.94) for the xiphoid region, and 1.44 (95% CI, 0.88-2.00) for the basal region. The techniques also significantly improved the posterior chain muscle flexibility, with a between-group difference of 5.80 cm (95% CI, 1.69-9.90). All movements except flexion of the lumbar spine significantly increased. The effects on respiratory muscle strength were non-significant. CONCLUSION: The diaphragmatic myofascial release techniques improve chest wall mobility, posterior chain muscle flexibility, and some movements of the lumbar spine in sedentary women. These techniques could be considered in the management of people with reduced chest wall and lumbar mobility. TRIAL REGISTRATION: NCT03065283.

Transthoracic Arteriovenous Graft Repair With the Pectoralis (PECS) II Nerve Block for Primary Intraoperative Anesthesia and Postoperative Analgesia: A Case Report.

The PECS II nerve block is a relatively new regional anesthetic technique that targets the medial and lateral pectoral nerves, as well as the lateral cutaneous branches of the intercostal nerves. It has been described for surgical cases involving the breast, as an adjunct or alternative to neuraxial or paravertebral techniques. This case report describes the first successful use of the PECS II nerve block placed using ultrasound guidance as the primary anesthetic and postoperative analgesic in a non-breast-related chest wall surgery.

[Application of Intrabronchial Valves in High Risk Patients with Bronchopleural Fistula: an Alternative Therapeutic Option]. / Applikation intrabronchialer Ventile zur Behandlung der persistierenden bronchopleuralen Fistel nach komplikativem Pleuraempyem mit Lungendestruktion.

OBJECTIVES: Persistent air leak or bronchopleural fistula (BPF) is a challenging and frequently observed problem after pulmonary resection and may lead to prolonged chest tube therapy. One efficient nonsurgical approach to manage such a fistula is the application of intrabronchial valves. This may support earlier chest tube removal and hospital discharge. METHODS: Between 04/2015 and 03/2017, n = 8 patients (n = 4 female) with severe pleural empyema and necrotising lung tissue defects developed prolonged air leak and persistent BPF after surgery. Radiological and bronchoscopical investigations revealed the presence of a BPF. For closure, intrabronchial valves were endoscopically inserted into the affected bronchi. In patients with repeat development of empyema, a chest wall window was required (n = 6 patients). RESULTS: The mean age was 61 years (45 - 85 years). After repeated surgical debridement, the space was sterile and the chest wall window was closed. After valve placement, air leaks were no longer detectable. In all patients, the procedures were well tolerated without any negative events. After successful valve placement, chest tubes could be removed in all n = 8 patients within 7 days (3 - 15 days) and patients were discharged thereafter. CONCLUSIONS: Placement of intrabronchial valves presents an alternative option to conventional surgical and non-surgical methods for the treatment of postoperative persistent air leak or BPF. Particularly in high risk patients, this procedure is safe and effective.

Evaluation and selection of anatomic sites for magnetic resonance imaging-guided mild hyperthermia therapy: a healthy volunteer study.

PURPOSE: Since mild hyperthermia therapy (MHT) requires maintaining the temperature within a narrow window (e.g. 40-43 °C) for an extended duration (up to 1 h), accurate and precise temperature measurements are essential for ensuring safe and effective treatment. This study evaluated the precision and accuracy of MR thermometry in healthy volunteers at different anatomical sites for long scan times. METHODS: A proton resonance frequency shift method was used for MR thermometry. Eight volunteers were subjected to a 5-min scanning protocol, targeting chest wall, bladder wall, and leg muscles. Six volunteers were subjected to a 30-min scanning protocol and three volunteers were subjected to a 60-min scanning protocol, both targeting the leg muscles. The precision and accuracy of the MR thermometry were quantified. Both the mean precision and accuracy <1 °C were used as criteria for acceptable thermometry. RESULTS: Drift-corrected MR thermometry measurements based on 5-min scans of the chest wall, bladder wall, and leg muscles had accuracies of 1.41 ± 0.65, 1.86 ± 1.20, and 0.34 ± 0.44 °C, and precisions of 2.30 ± 1.21, 1.64 ± 0.56, and 0.48 ± 0.05 °C, respectively. Measurements based on 30-min scans of the leg muscles had accuracy and precision of 0.56 ± 0.05 °C and 0.42 ± 0.50 °C, respectively, while the 60-min scans had accuracy and precision of 0.49 ± 0.03 °C and 0.56 ± 0.05 °C, respectively. CONCLUSIONS: Respiration, cardiac, and digestive-related motion pose challenges to MR thermometry of the chest wall and bladder wall. The leg muscles had satisfactory temperature accuracy and precision per the chosen criteria. These results indicate that extremity locations may be preferable targets for MR-guided MHT using the existing MR thermometry technique.

Synchronous colorectal cancer and multiple myeloma with chest wall involvement: Is this a coincidence?

Multiple primary malignant neoplasms (MPMNs) are rare malignant neoplasms that simultaneously or successively occur in the same patient as 2 or more primary malignancies. Currently, an increasing number of cases are being reported. In general, MPMNs more commonly occur as 2 solid tumors or 2 hematological malignancies. Cases of MPMN that involve a solid tumor and a hematological malignancy are rare. Here, we report a case of synchronous colorectal cancer (CRC) and multiple myeloma (MM) with chest wall involvement. After reviewing the literature, we believe that there may be a distinct syndrome involving CRC and MM. The patient in our case study suffered refractory anemia following surgery and 2 cycles of chemotherapy. Initially, the anemia was considered to be a common manifestation of CRC in this patient. Interestingly, although he received a blood transfusion, his hemoglobin levels remained low. He later developed hematuria, proteinuria, multiple osteoporosis in the costal bones, and thrombocytopenia. These new symptoms drew our attention, and we considered a diagnosis of synchronous primary CRC and MM, with the anemia as a symptom of MM. Based on the results of a bone marrow aspirate, MM was confirmed. Therefore, when CRC is associated with refractory anemia, we should not only assume that anemia is a classical symptom of CRC, a result of chronic blood loss, nutritional deficiencies, or myelosuppression due to chemotherapy, but we should also consider that it may reflect the possibility of a coexisting hematologic malignancy. As the treatment of these 2 malignancies is different, early diagnosis and treatment based on definitive diagnosis as early as possible will be beneficial to overall prognosis.

Adjuvant Chemotherapy Does Not Improve Survival for Lung Cancer With Chest Wall Invasion.

BACKGROUND: The National Comprehensive Cancer Network recommends adjuvant chemotherapy (AC) for patients with completely resected (R0) pT3N0M0 non-small cell lung cancer (NSCLC) with chest wall invasion. There is minimal evidence to support this recommendation. We aimed to determine whether there is a survival benefit with AC and if so whether it depends on tumor size. METHODS: Patients who had undergone R0 resection for pT3N0M0 NSCLC with chest wall invasion were identified in the National Cancer Data Base from 2008 to 2012. Multivariable Cox proportional hazards modeling was used to determine independent predictors of overall mortality. RESULTS: Of 247 patients, 92 (37.3%) received AC. The median tumor size without AC was 42 mm (interquartile range [IQR], 30 to 60 mm) and with AC was 56 mm (IQR, 40 to 70 mm; p = 0.003). Median follow-up was 21.7 months (IQR, 10.6 to 29.1 months). There was no difference in AC based on tumor grade, but the 3-year overall survival for those with well-differentiated or moderately differentiated tumors was 68% versus 55% in those with poorly differentiated or undifferentiated tumors. Three-year overall survival for the entire cohort was 59%. There was no difference in overall survival between those who received AC and those who did not. The only significant predictor of mortality in both univariable and multivariable analyses was poorly or undifferentiated tumor grade. CONCLUSIONS: For patients with pT3N0M0 NSCLC with chest wall invasion there is no survival benefit with AC, regardless of tumor size or grade, after R0 resection. Poorly differentiated or undifferentiated tumor grade is an independent predictor of mortality.