A Clinical Review of Slipping Rib Syndrome.

ABSTRACT: Slipping rib syndrome is pain created at the lower, anterior border of the rib cage when performing upper-extremity activities, coughing, laughing, or leaning over. Defects in the costal cartilage of ribs 8 to 10 result in increased movement of the ribs, impinging soft tissue and intercostal nerves. Advancements have been made in the diagnosis of slipping rib syndrome by dynamic ultrasound. Ultrasound can identify abnormalities in the rib and cartilage anatomy, as well as soft tissue swelling. Although the mainstays of treatment continue to be reassurance, nonsteroidal anti-inflammatory drugs, physical therapy, intercostal nerve injections, osteopathic manipulative treatment, surgery for refractory pain, and botulinum toxin injections have been attempted, and there may be a role for prolotherapy in treatment. Surgical techniques are being examined secondary to recurrence of pain following resection. The hooking maneuver and surgery remain important for identification and treatment, respectively.

Informing Healthcare Decisions with Observational Research Assessing Causal Effect. An Official American Thoracic Society Research Statement.

Rationale: Decisions in medicine are made on the basis of knowledge and reasoning, often in shared conversations with patients and families in consideration of clinical practice guideline recommendations, individual preferences, and individual goals. Observational studies can provide valuable knowledge to inform guidelines, decisions, and policy.Objectives: The American Thoracic Society (ATS) created a multidisciplinary ad hoc committee to develop a research statement to clarify the role of observational studies-alongside randomized controlled trials (RCTs)-in informing clinical decisions in pulmonary, critical care, and sleep medicine.Methods: The committee examined the strengths of observational studies assessing causal effects, how they complement RCTs, factors that impact observational study quality, perceptions of observational research, and, finally, the practicalities of incorporating observational research into ATS clinical practice guidelines.Measurements and Main Results: There are strengths and weakness of observational studies as well as RCTs. Observational studies can provide evidence in representative and diverse patient populations. Quality observational studies should be sought in the development of ATS clinical practice guidelines, and medical decision-making in general, when 1) no RCTs are identified or RCTs are appraised as being of low- or very low-quality (replacement); 2) RCTs are of moderate quality because of indirectness, imprecision, or inconsistency, and observational studies mitigate the reason that RCT evidence was downgraded (complementary); or 3) RCTs do not provide evidence for outcomes that a guideline committee considers essential for decision-making (e.g., rare or long-term outcomes; "sequential").Conclusions: Observational studies should be considered in developing clinical practice guidelines and in making clinical decisions.

Clinical and molecular practice of European thoracic pathology laboratories during the COVID-19 pandemic. The past and the near future.

BACKGROUND: This study evaluated the consequences in Europe of the COVID-19 outbreak on pathology laboratories orientated toward the diagnosis of thoracic diseases. MATERIALS AND METHODS: A survey was sent to 71 pathology laboratories from 21 European countries. The questionnaire requested information concerning the organization of biosafety, the clinical and molecular pathology, the biobanking, the workload, the associated research into COVID-19, and the organization of education and training during the COVID-19 crisis, from 15 March to 31 May 2020, compared with the same period in 2019. RESULTS: Questionnaires were returned from 53/71 (75%) laboratories from 18 European countries. The biosafety procedures were heterogeneous. The workload in clinical and molecular pathology decreased dramatically by 31% (range, 3%-55%) and 26% (range, 7%-62%), respectively. According to the professional category, between 28% and 41% of the staff members were not present in the laboratories but did teleworking. A total of 70% of the laboratories developed virtual meetings for the training of residents and junior pathologists. During the period of study, none of the staff members with confirmed COVID-19 became infected as a result of handling samples. CONCLUSIONS: The COVID-19 pandemic has had a strong impact on most of the European pathology laboratories included in this study. Urgent implementation of several changes to the organization of most of these laboratories, notably to better harmonize biosafety procedures, was noted at the onset of the pandemic and maintained in the event of a new wave of infection occurring in Europe.

Refractory thoracic endometriosis.

Thoracic endometriosis syndrome (TES) is a rare entity caused by thoracic implantation of endometrial tissue, manifesting as catamenial pneumothorax, pleural effusion and haemoptysis in young female individuals. Its management and long-term prevention of recurrences, can be challenging. We present the case of a young woman who presented with recurrent pneumothorax, haemopneumothorax and pleural effusion. The diagnosis of TES was confirmed based on cytological findings of pleural fluid. She underwent treatment with mechanical pleurodesis twice but continued to have recurrences. Hormonal treatment failed to produce a satisfactory resolution. She underwent chemical pleurodesis, which successfully induced remission of her TES. A review of the literature suggests that chemical pleurodesis produces better results compared with mechanical pleurodesis and that hormonal treatment with gonadotropin-releasing hormone agonists is effective at preventing recurrences.

Artificial Intelligence Pertaining to Cardiothoracic Imaging and Patient Care: Beyond Image Interpretation.

Artificial intelligence (AI) is a broad field of computational science that includes many subsets. Today the most widely used subset in medical imaging is machine learning (ML). Many articles have focused on the use of ML for pattern recognition to detect and potentially diagnose various pathologies. However, AI algorithm development is now directed toward workflow management. AI can impact patient care at multiple stages of their imaging experience and assist in efficient and effective scheduling, imaging performance, worklist prioritization, image interpretation, and quality assurance. The purpose of this manuscript was to review the potential AI applications in radiology focusing on workflow management and discuss how ML will affect cardiothoracic imaging.

Thoracic Duct Embolization-Value Analysis Using a Time-Driven Activity-Based Costing Approach: A Single Institution Experience.

PURPOSE: To quantify cost drivers for thoracic duct embolization based on time-driven activity-based costing methods. MATERIALS AND METHODS: This was an Institutional Review Board-approved (HUM00141114) and Health Insurance Portability and Accountability Act-compliant study performed at a quaternary care institution over a 14-month period. After process maps for thoracic duct embolization were prepared, staff practical capacity rates and consumable equipment costs were analyzed via a time-driven activity-based costing methodology. Sensitivity analyses were performed to identify primary cost drivers. RESULTS: Mean procedure duration was 4.29 hours (range: 2.15-7.16 hours). Base case cost, per case, for thoracic duct embolization was $7466.67. Multivariate sensitivity analyses performed with all minimum and maximum values for cost input variables yielded a cost range of $1001.95 (minimum) to $89,503.50 (maximum). Using local salary information and negotiated prices for materials as cost parameters, the true cost per case of thoracic duct embolization at the study institution was $8038.94. Univariate analysis demonstrated that the primary driver of staffing costs was the length of time the attending anesthesiologist was present. The predominant modifiable cost drivers included cyanoacrylate glue volume used (minimum $4467; maximum $12,467), cost of glue utilized (minimum $5217; maximum $10,467), and cost of coils utilized (minimum $7377; maximum $10,917). Univariate analysis predicted that the use of Histoacryl glue in place of TRUFILL cyanoacrylate glue resulted in a cost savings of $2947.50 per case. CONCLUSIONS: The base cost per case for thoracic duct embolization was $7466.67. Costs, namely anesthesia staffing costs, cyanoacrylate glue, and coils were large, potentially modifiable drivers of overall cost for thoracic duct embolization.

Extrapelvic Endometriosis: A Systematic Review.

OBJECTIVE: To conduct a systematic review of the literature on patients with extrapelvic deep endometriosis. DATA SOURCES: A thorough search of the PubMed/Medline, Embase, and Cochrane databases was performed. METHODS OF STUDY SELECTION: Studies in the last 20 years that reported on primary extrapelvic endometriosis were included (PROSPERO registration number CRD42019125370). TABULATION, INTEGRATION, AND RESULTS: The initial search identified 5465 articles, and 179 articles, mostly case reports and series, were included. A total of 230 parietal (PE), 43 visceral (VE), 628 thoracic (TE), 6 central nerve system, 12 extrapelvic muscle or nerve, and 1 nasal endometriosis articles were identified. Abdominal endometriosis was divided into PE and VE. PE lesions involved primary lesions of the abdominal wall, groin, and perineum. When present, symptoms included a palpable mass (99%), cyclic pain (71%) and cyclic bleeding (48%). Preoperative clinical suspicion was low, the use of tissue diagnosis was indeterminate (25%), and a few (8%) malignancies were suspected. Surgical treatment for PE included wide local excision (97%), with 5% recurrence and no complications. Patients with VE involving abdominal organs - kidneys, liver, pancreas, and biliary tract - were treated surgically (86%) with both conservative (51%) and radical resection (49%), with 15% recurrence and 2 major complications reported. In patients with TE involving the diaphragm, pleura, and lung, isolated and concomitant lesions occurred and favored the right side (80%). Patients with TE presented with the triad of catamenial pain, pneumothorax, and hemoptysis. Thoracoscopy with resection followed by pleurodesis was the most common procedure performed, with 29% recurrence. Adjuvant medical therapy with gonadotropin-releasing hormone was administered in 15% of cases. Preoperative magnetic resonance imaging was performed in all cases of nonthoracic and nonabdominal endometriosis. Common symptoms were paresthesia and cyclic pain with radiation. Surgical resection was reported in 84%, with improvement of symptoms. CONCLUSION: Extrapelvic endometriosis, traditionally thought to be rare, has been reported in a considerable number of cases. Heightened awareness and clinical suspicion of the disease and a multidisciplinary approach are recommended to achieve a prompt diagnosis and optimize patient outcomes. Currently, there are no comparative studies to provide recommendations regarding optimal diagnostic methods, treatment options, and outcomes for endometriosis involving extrapelvic sites.

[Pyogenic granuloma with satellitosis]. / Satellitenrezidiv bei Granuloma pyogenicum.

A 16-year-old female developed a satellite-like recurrence of a pyogenic granuloma on her thorax 2 weeks after complete excision. Treatment with a pulsed dye laser led to a complete resolution. BRAF and RAS mutations detected in the pyogenic granuloma are considered major driver mutations. Whether these findings are also of importance for the etiopathogenesis of satellitosis is unknown. In our patient, no BRAF or NRAS mutation could be detected.

Absceso cervicotorácico secundario a punción con aguja fina guiada por ecografía endoscópica transesofágica / Cervicothoracic abscess secondary to transesophageal ultrasound-guided fine needle aspiration

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The interrater reliability of static palpation of the thoracic spine for eliciting tenderness and stiffness to test for a manipulable lesion.

Background: Despite widespread use by manual therapists, there is little evidence regarding the reliability of thoracic spine static palpation to test for a manipulable lesion using stiffness or tenderness as diagnostic markers. We aimed to determine the interrater agreement of thoracic spine static palpation for segmental tenderness and stiffness and determine the effect of standardised training for examiners. The secondary aim was to explore expert consensus on the level of segmental tenderness required to locate a "manipulable lesion". Methods: Two experienced chiropractors used static palpation of thoracic vertebrae on two occasions (pragmatic and standardised approaches). Participants rated tenderness on an 11-point numerical pain rating scale (NPRS) and raters judged segmental stiffness based on their experience and perception of normal mobility with the requested outcomes of hypomobile or normal mobility. We calculated interrater agreement using percent agreement, Cohen's Kappa coefficients ( κ ) and prevalence-adjusted bias-adjusted Kappa coefficients (PABAK). In a preliminary study, an expert panel of 10 chiropractors took part in a Delphi process to identify the level of meaningful segmental tenderness required to locate a "manipulable lesion". Results: Thirty-six participants (20 female) were enrolled for the reliability study on the 13th March 2017. Mean (SD) age was 22.4 (3.4) years with an equal distribution of asymptomatic (n = 17) and symptomatic (n = 17) participants. Overall, the interrater agreement for spinal segmental stiffness had Kappa values indicating less than chance agreement [ κ range - 0.11, 0.53]. When adjusted for prevalence and bias, the PABAK ranged from slight to substantial agreement [0.12-0.76] with moderate or substantial agreement demonstrated at the majority of spinal levels (T1, T2 and T6 to T12). Generally, there was fair to substantial agreement for segmental tenderness [Kappa range 0.22-0.77]. Training did not significantly improve interrater agreement for stiffness or tenderness. The Delphi process indicated that an NPRS score of 2 out of 10 identified a potential "manipulable lesion". Conclusion: Static palpation was overall moderately reliable for the identification of segmental thoracic spine stiffness and tenderness, with tenderness demonstrating a higher reliability. Also, an increased agreement was found within the mid-thoracic spine. A brief training intervention failed to improve reliability.

Accessory liver within the thoracic cavity.

Ectopic intrathoracic liver tissue is extremely rare. Studies are mainly limited to case reports. In the vast majority of reported cases, a diagnosis of intrathoracic liver tissue was made either after a thoracic surgery or during a postmortem examination. However, once included in differential diagnosis, surgical intervention or biopsy procedures may be avoided with optimal diagnostic approach. In the present study, we conducted a literature review and proposed a new classification method for accessory liver within the thoracic cavity. This approach may provide a better understanding of underlying pathophysiology and aid in determination of optimal diagnostic modality and clinical management of such cases. According to our literature review, type II ectopic liver is the most common subtype followed by types I and III. All types can be definitively diagnosed with imaging modalities. On the other hand, it is important to prevent patients, particularly children, from unnecessary radiation exposure during performance of sophisticated diagnostic imaging modalities. Ultrasound is a safe, low-cost and accessible imaging modality that has not been previously reported in diagnosis of this entity. With addition of Color Doppler Imaging, ultrasound may allow for diagnosis with high precision in types I and II, as demonstrated in the present study. Based on long-term follow-up of a case reported here, this study also illustrates the natural course of this entity via non-operative management. This approach may prevent an unnecessary surgical intervention.

Coil embolization for pulmonary artery injury caused by chest tube drainage.

Pulmonary artery injury caused by chest tube drainage is rare, but it requires prompt diagnosis to perform urgent surgical repair. We report that a 53-year-old man who suffered from pulmonary artery injury by chest tube drainage was successfully treated by coil embolization.

Extrapelvic Endometriosis.

Extrapelvic endometriosis is a rare and complex phenomenon. The pathologic mechanism of intrapelvic endometriosis is generally accepted as being largely due to retrograde menstruation through the fallopian tubes; however, the mechanism by which extrapelvic endometriosis forms has proven to be much more elusive. This article reviews the pathophysiology, clinical signs and symptoms, diagnostic techniques, and treatment recommendations for extrapelvic endometriosis of the umbilicus, abdominal wall, thorax, and vulva.

Nonoperative Management of a Large Extrapleural Hematoma after Blunt Chest Trauma.

BACKGROUND: An extrapleural hematoma (EH) is an uncommon and potentially life-threatening condition defined as the accumulation of blood in the extrapleural space between the parietal pleura and the endothoracic fascia. EH usually occurs after blunt thoracic trauma causing fractures of the sternum and ribs, which can tear the intercostal or internal mammary vessels. Typical radiological findings of EH are a biconvex opacity on the involved hemithorax and the so-called displaced "extrapleural fat sign." CASE REPORT: We present a case of a 36-year-old man with an isolated scapular fracture after a high-energy blunt chest trauma complicated with a large contralateral EH that was successfully managed nonoperatively with transcatheter arterial embolization (TAE) and image-guided drainage with a pig-tail catheter. To the best of our knowledge there is only one previous report describing a large EH after blunt thoracic trauma without rib fractures. Only two previous cases of large EHs have been treated initially with TAE, but both patients ultimately required open surgery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients with EH can present with respiratory distress and hypotension, so early identification is important to facilitate proper treatment. EH has characteristic radiological findings, and contrast-enhanced computed tomography is not only the best imaging tool for confirming an EH, but also the best technique for detecting the source of the bleeding and other serious thoracic complications that may not be evident on chest x-ray studies.