A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / compression of the right atrium and ventricle yet their LV function is within normal range. In the setting of normal LV function, symptomatic PE could potentially be the result of right heart compression causing right heart strain. Emphasis should therefore be placed on analyzing the presence and degree of right heart strain in patients with symptomatic pectus excavatum. When assessing for a correlation between the HI, CI, DI, or CCI together and independently with cardiopulmonary impairment, no significant relationships were identified. While it would be highly advantageous for a PE severity index to correlate with objective physiologic impairment, our data suggest that the currently defined indices fail to do so. Data confirming such a correlation would provide a means to measure both the severity of deformity and changes in functional disability in patients with PE. We aim to analyze the correlation between the HI and three new indices with cardiopulmonary impairment using the cardiopulmonary exercise test (CPET). In this study we evaluated the correlation of the Haller, correction, depression, and cardiac compression indices with functional cardiopulmonary impairment using preoperative cardiopulmonary exercise test (CPET) data. We hypothesize that the correction and cardiac compression indices will be strongly correlated with physiologic impairment in patients with PE, thus providing a novel means to measure functional disability as a function of disease severity. Study Design This is a retrospective study of 71 children between the ages of birth and 18 years of age who underwent evaluation for corrective surgery for pectus excavatum between 2010 and 2016 at Phoenix Children’s Hospital. Our final sample underwent preoperative computed tomography (CT) or MRI scan results as well as cardiopulmonary exercise testing. For each patient, the HI, CI, DI, and CCI were independently assessed using the PACS System by a single rater. Preoperative functional capacity was determined by measurement of peak oxygen consumption (VO2max reported as percent predicted) and stroke volume (a surrogate for cardiac output) which was assessed via the O2 pulse (VO2max/heart rate) reported as percent predicted. The possible values range from zero to 100% of the predicted value. Assessments Halller Index Correction Index Depression Index Cardiac Compression Index Correction, Depression, Cardiac Compression and Haller Indices Fail to Correlate with Cardiopulmonary Impairment in Pectus Excavatum Abstract Results Background: Pectus excavatum (PE) affects 1 in every 300 to 1,000 live births with a male to female ratio of 5:1, making it the most common congenital chest wall deformity in children. The standard for determining disease severity has become the Haller Index, which has been shown to poorly correlate with physiologic impairment. Recently, more novel indices have been introduced in an effort to more effectively represent disease burden. We aim to analyze the correlation between these indices and cardiopulmonary impairment in patients with PE using chest CT/ MRI as well as preoperative cardiopulmonary exercise testing data. Conclusions: We found that when assessing for a correlation between the HI, CI, DI, or CCI together and independently with cardiopulmonary impairment, both the linear and multiple regression models failed to identify a statistically significant relationship. While it would be highly advantageous for a PE severity index to correlate with objective physiologic impairment, our data suggest that the currently defined indices fail to do so.

Background: Pectus excavatum is the most common deformation of the chest, affecting mainly boys. The etiology is unclear. Objective: The aim of this study is to characterize the patients with pectus excavatum and clarify changes of posture after surgical correction by Nuss. Method: 19 patients (17.3 ± 1.9 years) with pectus excavatum chest deformity were tested a day before and 6 months after surgical correction of the chest according to Nuss. Testing included: clinical examination of range of motion in the shoulder and hip joint, range of motion of the spine Thomayer test, Shober and Stibor distances, as well as paraclinic test mCTSIB on Balance Master ® System and the questionnaire method by means of Pectus Excavatum Evaluation Questionnaire. Statistical significance was determined at 0.05. Results and Discussion: The results show that the correction of the chest has a significant influence on the evaluation of and satisfaction with appearance, increases range of motion of shoulder joints and spine, and positively affects postural stability and balance. Conclusion: A simple and non-invasive tests have shown that the effect of correction of the chest is not just a cosmetic nature and can be an incentive to continue to study this issue.

The aim of this paper was, at first, to evaluate the effectiveness of education of child patients with inborn deformation of pectoral wall in the University Hospital Motol in the MIRPE (Minimally Invasive Pectus Excavatum) operation correcting the inborn deformation of pectoral wall by using of a metal bar and for its surgery extraction after three years. At second, to map the effectiveness of education of child patients done by the hospital personnel during their hospitalization in the University Hospital Motol. This paper also presents its own opinions of both groups of respondents on the current system of education done in the clinical practice. According to the available sources there was not in the Czech Republic any similar study about this problem realized up to now. There were 116 respondents involved in the research who went through the MIRPE surgery and the extraction of their bar in the University Hospital Motol. The data that were received by the method of own constructive form was further statistically processed. From the analysis of the results came up a need to improve the education in the pre-surgery time, and to better develop the system of education during the hospitalization of child patients. There was an interest confirmed from the researched respondents about printed...

Title: Comparison of Rehabilitation Procedures in the Operative and Conservative Approach to Manage Chest deformity in Children Aim: The aim of this thesis is to determine the efficacy of a conservative approach in the treatment of inverted chest and to compare the effect of therapy with the surgical approach. Methodology of thesis: At the beginning of this project, a total of 9 children and adolescents (n = 9) from 10 years to 21 years of age (mean 15 years), male and female (8: 1) participated. All participants were diagnosed with thoracic deformity of pectus excavatum, which was not indicated for surgery. At the beginning of the project, all probands passed an initial examination, which included an obtaining of anthropometric values using a pelvimeter and a tailor's meter, to assess the anthropometric index and chest circumferences during breathing. Subsequently, a rehabilitation instructions have been given to all participants and all participants have obtained a printed version of these exercises. Results: The results of this study show that in patients with pectus excavatum, the regular and long term exercises, can bring the expected positive results. Especially in subjective complaints, chest flexibility and postural improvement. The final effect of thoracic deformity changes after 3 months...

Įgimtos krūtinės sienos deformacijos, kurių korekcijai reikalingas chirurginis gydymas apima visa spektrą skeleto raumenų sistemos morfologinių sutrikimų. Didžiausią dalį šių deformacijų sudaro įdubusi krūtinė. Nors daugiau nei du dešimtmečius chirurginė korekcija atliekama taikant minimaliai invazinę metodiką, optimaliausias ankstyvojo pooperacinio skausmo malšinimo metodas yra aktyvių diskusijų objektas mokslinėje literatūroje. Disertacijos tikslas – ištirti regioninio skausmo malšinimo metodikos – tarpšonkaulinių nervų blokados (TNB) efektyvumą vaikams, kuriems atliekamos įdubusios krūtinės korekcijos operacijos minimaliai invaziniu metodu. Disertacinis darbas atliktas taikant dvigubai aklą, atsitiktinių imčių tyrimo metodiką. Toks tyrimas yra vienintelis TNB efektyvumo mokslinis tyrimas vaikams, kuriems atliekama minimaliai invazinė įdubusios krūtinės chirurginė korekcija. Tyrimo rezultatai parodė, kad TNB yra efektyvus multimodalinio skausmo malšinimo komponentas, nulėmęs kokybiškesnį skausmo malšinimą, mažesnį opioidų sunaudojimą, mažesnį opioidų šalutinio poveikio dažnį ir aukštesnį pasitenkinimą pooperaciniu laikotarpiu. / Pain management in pediatric patients undergoing the minimally invasive repair of pectus excavatum (MIRPE) continues to be a challenge and is currently debated in the literature. Pain management strategies have included systemic opioids via patient-controlled analgesia, non-steroidal anti-inflammatory drugs and regional analgesia. Although studies have demonstrated that modern pain management strategies are adequate, the optimal technique has yet to be clearly determined. The aim of this study was to investigate the efficacy of a single shot bilateral intercostal block (IB) for pain control in pediatric patients undergoing the MIRPE. The study was conducted in a double-blind, randomized manner. This study is the first and the only study describing efficacy of bilateral IB in pediatric patients undergoing MIPRE. Study showed that the IB with local anesthetic group demonstrated improved quality of pain relief, reduced intraoperative and postoperative opioid consumption, less side effects associated with opioid consumption in the early postoperative period and improved level of satisfaction with the effectiveness of pain management and overall postoperative period.

Submitted by Divisão de Documentação/BC Biblioteca Central (ddbc@ufam.edu.br) on 2018-08-22T13:34:04Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertação com ficha catalográfica após a contra capa embaixo.pdf: 3346672 bytes, checksum: d45f2694d12afdf51239618f7b16b889 (MD5) / Approved for entry into archive by Divisão de Documentação/BC Biblioteca Central (ddbc@ufam.edu.br) on 2018-08-22T13:34:17Z (GMT) No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertação com ficha catalográfica após a contra capa embaixo.pdf: 3346672 bytes, checksum: d45f2694d12afdf51239618f7b16b889 (MD5) / Made available in DSpace on 2018-08-22T13:34:17Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertação com ficha catalográfica após a contra capa embaixo.pdf: 3346672 bytes, checksum: d45f2694d12afdf51239618f7b16b889 (MD5) Previous issue date: 2018-03-15 / BACKGROUND: Pectus excavatum (PE) is a congenital deformity characterized by the depression of the anterior chest wall with deviation of the sternum, cartilages and ribs. Patients can show many different physical symptoms caused by the possible heart and chest compression, but the esthetic complaints seem to be the most frequent ones and may be associated with psychosocial changes and quality of life (QL) changes. Minimally invasive surgical correction (Nuss procedure) was introduced only 20 years ago and quickly gained popularity for the good esthetical results obtained by the technic. OBJECTIVES: To evaluate the level of satisfaction and QL of patients with PE during postoperative phase of Nuss procedure; determinate the level of satisfaction of patients and their parents after surgical correction. METHODS: This is a cross-sectional study. Patients subjected to surgical treatment of PE with the Nuss procedure in public and private hospitals of Manaus were selected and interviewed between December 2016 and July 2017. All patients answered, in a retrospective form, a specific questionnaire for evaluation of QL in patients with PE, the Pectus Excavatum Evaluation Questionnaire (PEEQ), at two moments: before and after the surgery. For patients under 18 years old, it was requested that both the patient and the parents answered the generic questionnaire CHQ, and those 18 years old and over answered the generic questionnaire of QL SF 36. The average and the standard deviation of the obtained answers were calculated and compared to the results from before and after the surgery through the Student’s t-test. RESULTS: 23 patients and 11 parents were interviewed. 82% of the patients were male and their interview happened after an average of three years after the surgery. From the patients’ perspective, there was improvement in all psychosocial aspects after the surgery. As to physical aspects, there was improvement in the occurrence of shortness of breath and fatigue after the surgery. From the parents perspective, the changes in psychosocial aspects were lower. Parents related worrying less about the effects of PE on their children’s life after the surgery. Considering physical aspects, parents reported partial improvement and did not observe improvement in the difficulty of exercising and in the frequency of chest pain after surgical correction. CONCLUSIONS: Surgical correction of PE through Nuss procedure provided significant improvement of patients’ QL, especially on psychosocial aspects either from the patient’s perspective as well as parents. / JUSTIFICATIVA: O pectus excavatum (PE) é uma deformidade congênita caracterizada pela depressão da parede torácica anterior, com desvio do esterno, das cartilagens e arcos costais. Os pacientes podem apresentar diversos sintomas físicos causados pela possível compressão cardíaca e pulmonar, mas as queixas estéticas parecem ser as mais prevalentes e podem estar associadas a alterações psicossociais e alterações na qualidade de vida (QV). A correção cirúrgica minimamente invasiva (cirurgia de Nuss) foi introduzida há cerca de 20 anos e rapidamente ganhou popularidade devido aos bons resultados estéticos obtidos pela técnica. OBJETIVOS: Avaliar a satisfação e a QV dos pacientes portadores de PE no pós-operatório da cirurgia de Nuss; determinar a satisfação do paciente e de seus pais após a correção cirúrgica. MÉTODOS: Trata-se de um estudo transversal. Foram selecionados pacientes submetidos ao tratamento cirúrgico do PE pela técnica de Nuss em hospitais da rede pública e privada de Manaus e as entrevistas ocorreram de dezembro de 2016 a julho de 2017. Todos os pacientes responderam ao questionário específico para avaliação da QV para pacientes com PE, o Pectus Excavatum Evaluation Questionnaire (PEEQ), de forma retrospectiva para dois momentos: antes e após a cirurgia. Para pacientes menores de 18 anos, foi solicitado que tanto o paciente quanto os pais respondessem ao questionário genérico CHQ. Pacientes maiores de 18 anos responderam ao questionário genérico de QV SF 36. Foram calculadas as médias e desvio-padrão das respostas obtidas e comparados os resultados obtidos antes e após a cirurgia pelo teste t de student. RESULTADOS: Foram entrevistados 23 pacientes e 11 pais. Dos pacientes, 82% eram do gênero masculino e a entrevista ocorreu em média três anos após a cirurgia. Na perspectiva dos pacientes, houve melhora em todos os aspectos psicossociais após a cirurgia. Em relação aos aspectos físicos, houve melhora quanto a ocorrência de respiração curta e cansaço após a cirurgia. Para os pais, as mudanças nos aspetos psicossociais foram menores. Os pais relataram se preocupar menos com os efeitos do PE sobre a vida dos seus filhos após a cirurgia. Quanto aos aspectos físicos, os pais relataram melhora parcial, pois não observaram melhora nas dificuldades de realizar exercícios físicos e na frequência da dor torácica após a correção cirúrgica. CONCLUSÕES: A correção cirúrgica do PE pela técnica de Nuss proporcionou melhora significativa na qualidade de vida dos pacientes, sobretudo nos aspectos psicossociais e sob o ponto de vista do próprio paciente e de seus pais.

<p>Cilj: Proveriti da li je moguće promeniti način CT verifikacije Hallerovog indeksa u okviru preoperativne pripreme pacijenata sa deformitetom grudnog ko&scaron;a po tipu pectus excavatum-a, uz utvrđivanje fiziolo&scaron;kog opsega vrednosti indeksa, njegove zavisnosti od uzrasta i pola, kao i respiratorne faze u kojoj se CT pregled izvodi. Utvrditi značaj vrednosti indeksa korekcije, indeksa asimetrije i indeksa torzije sternuma. Proveriti i mogućnost smanjivanja efektivne doze jonizujućeg zračenja kod primene CT tehnike jednog skena (single slice). Materijal i metod rada: Ispitivanje se sastojalo iz prospektivne studije koja je obuhvatila 30 pacijenata sa pektus ekskavatumom uz CT snimanje (single slice) u respiratornim fazama: ekspirijum i inspirijum. Na dobijenim snimcima su izračunati pored Halerovog indeksa i indeksi asimetrije, korekcije i sternalne torzije. Prema dobijenim rezultatima merenja i izračunavanja, dono&scaron;ena je odluka o načinu terapijskog tretmana. U retrospektivnoj studiji, urađena je analiza 100 CT pregleda grudnog ko&scaron;a kod dece gde nije verifikovan pectus excavatum, uz kalibriranje vrednosti indeksa u odnosu na uzrast i pol pacijenata. Retrospektivno istraživanje je obuhvatilo i analizu dodatnih 30 CT pregleda grudnog ko&scaron;a pacijenata sa deformitetom grudnog ko&scaron;a po tipu pectus excavatum-a, koji su dijagnostikovani i/ili operisani. Kod svih operisanih pacijenata je primenjenja Nusova operativna tehnika. U ovoj grupi pacijenata je izračunata srednja vrednost efektivne doze jonizujućeg zračenja, a dobijene vrednosti su potom komparirane sa efektivnim dozama koje su dobijene niskodoznim CT pregledima grudnog ko&scaron;a uz primenu novog protokola (&quot;single-slice&quot; tehnika u respiratornim fazama inspirijuma i ekspirijuma). Rezultati: Fiziolo&scaron;ki opseg vrednosti Haller-ovog indeksa u populaciji zdravih pacijenata se kretao od 1,47 do 3,17 i u proseku je iznosio 2,23&plusmn;0,32 (znatna pozitivna korelacija uzrasta i vrednosti HI). Na osnovu rezultata Man-Vitnijevog testa nije postojala polna razlika u posmatranoj grupi. Haller-ov indeks u grupi dijagnostikovane/operisane dece je u proseku iznosio 3,39 i kretao se u intervalu od 2,23 do 5,72 (korelacija između uzrasta ovih pacijenata i Haller-ovog indeksa je bila neznatna i negativna). Utvrđena je zavisnost veličine Haller-ovog indeksa od respiratorne faze u kojoj se CT pregled izvodi. Tako su prosečne vrednosti Haller-ovog indeksa u inspirijumu dece sa dijagnostikovanim deformitetom iznosile 2,69&plusmn;0,76. Kod dece ove grupe u ekspirijumu vrednosti Haller-ovog indeksa su iznosile 3,49&plusmn;1,19. U inspirijumu su samo 3/32 (9%) ispitanika imali vrednost HI preko 3,25 (granična vrednost za operativni tretman), dok ih je u ekspirijumu bilo znatno vi&scaron;e 13/32 (41%), &scaron;to je statistički značajna razlika (&chi;2=6,250; df =1; p=0,012). &quot;Single-slice&quot; tehnika CT pregleda u inspirijumu i ekspirijumu 20-25 puta smanjuje efektivnu dozu jonizujućeg zračenja. Zaključak: Vrednost Haller-ovog indeksa raste sa uzrastom deteta, dok nije utvrđena zavisnost Haller-ovog indeksa od pola. Moguće je promeniti načini CT verifikacije Haller-ovog indeksa u preoperativnoj pripremi za Nuss-ovu operaciju primenom &quot;single-slice&quot; tehnike u ekspiratornoj fazi. Osim Hallerovog indeksa, korisno je određivati i indeks korekcije, indeks asimetrije i indeks sternalne rotacije. Predlaže se protokol standardne preoperativne pripreme i lečenja pacijenata dečjeg uzrasta sa deformitetom grudnog ko&scaron;a po tipu pektus ekskavatuma, sa ciljem njegove primene u svakodnevnom radu u institucijama koje se bave ovim problemom, a u cilju pobolj&scaron;anja kvaliteta dijagnostikovanja i krajnjeg ishoda lečenja.</p> / <p>Aim: The aim of this study was to verify whether it is possible to change the way of CT verification of Haller index (HI), as part of preoperative preparation for patients with pectus excavatum, with the determination of the physiological range of the index value, its dependence on the age and sex, as well as the respiratory phase during which the scan is performed. Also, the aim was to determine the significance of correction, asymmetry and sternal torsion indices values. Evaluate the possibility of reduction the effective dose of ionizing radiation using a single slice CT scan technique. Materials and methods: The study consisted of prospective study that included evaluation of CT scans (single slice technique) of 30 patients with pectus excavatum in both respiratory phases: expirium and inspirium. Haller index and indices of asymmetry, correction and sternal torsion were measured. The decision for the treatment was made according to the results of measurements and calculations of these indices. In retrospective study, 100 CT scans of the chest in children without the deformity (pectus excavatum) were analyzed, and the index value was calibrated depending on the age and gender. The retrospective study also included the analysis of another 30 CT scans in patients who were operated or diagnosed with pectus excavatum. Nuss procedure was used in all operated patients. In this group of patients the median value of effective dose of ionizing radiation was calculated, and the values were compared with the effective dose obtained using low-dose CT examinations applied in the new protocol (single-slice technique in inspiratory and expiratory respiratory phases). Results: The physiological range of Haller index value in healthy patients was from 1.47 to 3.17 and average value was 2.23&plusmn;0.32 (significant positive correlation between age and the value of HI). Results of Mann- Whitney test did not demonstrate any difference between gender in the observed group. In the group of patients who were operated/diagnosed with pectus excavatum the average value of Haller index was 3.39 within the range of 2.23 to 5.72 (correlation between the age of these patients and Haller index was negative, but not significant). The dependence of the Haller index value and certain respiratory phase during which the CT scan was performed also was determined. Thus, the average value of Haller index in inspirium in children with diagnosed deformity was up to 2.69&plusmn;0.76. In the same group of patients the value of Haller index in expirium was up to 3.49&plusmn;1.19. Only 3/32 (9%) patients had HI value over 3.25 (a boundary value for surgical treatment) during inspirium, while 13/32 (41%) patients had it in expirium, this data showed statistically significant difference (&chi;2=6.250; df=1; p=0.012). Single-slice CT technique during the inspiratory and expiratory phase reduces 20-25 times the effective dose of ionizing radiation. Conclusion: The value of Haller index increases with the age, but its dependence on the gender was not determined. It is possible to change the way of CT verification of Haller index in preoperative preparation for the Nuss operation using the &quot;single-slice&quot; technique in exspiratory phase. In addition to Haller index it is useful to determine correction index, the index of asymmetry and the index of sternal rotation as well. This protocol is proposed for standard preoperative preparation and treatment of pediatric population with pectus excavatum with the aim of its application in daily work in institutions that deal with this problem, but also to improve the quality of diagnosis and treatment outcomes.</p>

Objective: The goal of the thesis "Monitoring of the Respiratory Functions in patients after the Rib Cage Surgery according to Nuss" was to confront the present knowledge about respiratory functions and the strength of respiratory muscles of patients with inherited pectoral deformity pectus excavatum, to compare it with my own measuring and to find out about their development after the surgical correction according to Nuss. Methodology: There were 15 patients being monitored (13 men and 3 women), who underwent spirometric and bodypletysmographic examination and the occlusal mouth pressures were determined before the surgery. The same pulmonary function tests were run in the course of 4 to 10 months (7.1 months on average) on all the patients, the control determination of mouth pressures is available for 13 of them. Results: In the entry tests, compared to adequate values the patients in this file had increased residual lung capacities (RV 142%, p=0.001; ITGV 116.2%, p=0.004; RV%TLC 133.8%, p=0.002; ITGV% 116.1%, p=0.001) at the expense of statistically lower vital lung capacity (VC 81.9%, p=0.0004) and inspiratory reserve capacity (IC 84.2%, p=0.0003), while the total lung capacity remained unaltered (TLC 99.7%, p=0.877). The obstructive parameters of these patients were significantly altered (FEV1 95.7%,...