Rib and costal cartilage fractures are the most common injuries resulting from blunt thoracic loading scenarios, including motor vehicle collisions. The costal cartilage is a cylindrical hyaline cartilage composed of two layers: a core interstitial matrix enveloped by the perichondrium. The perichondrium itself has an inner chondrogenic layer and an outer fibrous layer. The objective of this study was to evaluate the tensile material properties of human costal cartilage perichondrium at two loading rates for a range of subject demographics. Fifty-six (n=56) samples containing the fibrous layer and chondrogenic layer (i.e., two-layered samples) were fabricated from thirty-three (n=33) donors aged from 11 to 69 years of age (19 M, 14 F). Thirteen (n=13) samples without the fibrous layer (i.e., one-layered samples) were fabricated from eight (n=8) donors aged from 11 to 54 years of age (5 M, 3 F). The perichondrium was isolated from the interstitial matrix for all samples and the fibrous layer was removed for one-layered samples to assess the effect of the absence of the fibrous layer. The tissue was then stamped into a dog bone-shaped coupon and sanded down to a uniform thickness of ~1.3 mm for two-layered samples and ~1 mm for one-layered samples. The gage length of the completed coupons was marked with a black ink dot pattern to facilitate strain calculations via video tracking. The coupons were loaded axially in tension to failure at either a slow (0.005 s⁻¹) or fast (0.5 s⁻¹) target loading rate using a material testing system. The elastic modulus, ultimate stress, ultimate strain, failure stress, failure strain, and strain energy density (SED) were then calculated for each test. Material property data were compared by sample type and loading rate. Since there was no significant influence of sex on any material properties, the data were grouped together for the analysis. Modulus, ultimate stress, failure stress, and SED were found to significantly decrease with donor age at both loading rates and ultimate and failure strain also significantly decreased with donor age at the 0.5 s⁻¹ target loading rate. Failure stress in the two-layered samples was found to be greater than that of the one-layered samples at both loading rates. One-layered samples had a greater failure strain than two-layered samples at both loading rates. Perichondrium data were compared to interstitial matrix data from a previous study to further investigate the role of cartilage layer on material properties. The modulus, ultimate stress, and failure stress of costal cartilage decreased moving radially inward (greatest in two-layered perichondrium samples, least in interstitial matrix samples). The opposite was true for ultimate and failure strain, with the greatest failure strain values occurring in the interstitial matrix and the least in the two-layered perichondrium samples. The sample size of one-layered samples was too small to draw any substantial conclusions regarding age trends. This was the first study to analyze the material property trends in costal cartilage perichondrium. The results of this study can be incorporated into virtual human body models to improve the accuracy of thoracic injury prediction in the context of motor vehicle safety. / Master of Science / Motor vehicle collisions are the second leading cause of death due to unintentional injury in the United States, with rib and costal cartilage fractures being the most commonly observed injuries. The cylindrical costal cartilage connects the front of the ribs to the sternum and is composed of two layers: a core interstitial matrix enveloped by the perichondrium. The perichondrium itself has an inner chondrogenic layer and an outer fibrous layer. Virtual human body models incorporate material property data to improve their ability to predict injury risk and are frequently used among vehicle manufacturers to evaluate safety during vehicle development. Currently, models have to make simplifications and assumptions regarding the perichondrium properties, since there are no material property studies on the isolated perichondrium to date. Therefore, the purpose of this study was to quantify the tensile material properties of human costal cartilage perichondrium at two loading rates for a range of subject demographics. Dog-bone shaped coupons with either both perichondrium layers (i.e., two-layered samples) or just the chondrogenic layer (i.e., one-layered samples) were loaded to failure under tension at either a slow (0.005 s⁻¹) or fast (0.5 s⁻¹) target loading rate using a material testing system. Data were obtained for fifty-six (n=56) two-layered samples from thirty-three (n=33) donors aged from 11 to 69 years old. Data were collected for thirteen (n=13) one-layered samples from eight (n=8) donors aged from 11 to 54 years old. The elastic modulus, ultimate stress, ultimate strain, failure stress, failure strain, and strain energy density (SED) were quantified for each test. Material properties of two-layered samples decreased with increasing donor age. No trends were found with regard to donor sex. Only ultimate and failure stress of two-layered samples were significantly affected by loading rate. Perichondrium material property data were compared to interstitial matrix data from a previous study to investigate the effect of cartilage layer on costal cartilage material properties. Elastic modulus, ultimate stress, and failure stress decreased when moving inward in cartilage layers, while ultimate and failure strain increased. Overall, this is the first study to evaluate the material properties of the perichondrium and the change in material properties with cartilage layer. These data can be used to improve the accuracy of human tolerance to thoracic injury in human body models.

The objective of this study was to evaluate the effects of sex, loading rate, and age on the tensile and compressive material properties of human rib cortical bone over a wide range of subject demographics. Tension coupons were tested from sixty-one (n = 61) subjects (M = 32, F = 29) ranging in age from 17 to 99 years of age (Avg. = 56.4 +/- 26.2 yrs.). Compression samples were tested from thirty (n = 30) subjects (M = 19, F = 11) ranging in age from 18 to 95 years of age (Avg. = 49.0 +/- 23.9 yrs.). For each subject, one coupon/sample was tested to failure on a material testing system at a targeted strain rate of 0.005 strain/s, while a second coupon/sample was tested at 0.5 strain/s. A load cell was used to measure axial load for both the tension coupons and compression samples. An extensometer was used to measure displacement within the gage length of the tension coupons and a deflectometer was used to measure displacement of the compression samples. Tension data were obtained from fifty-eight (n = 58) coupons at 0.005 strain/s and fifty-eight (n = 58) coupons at 0.5 strain/s, with fifty-five (n = 55) matched pairs. Compression data were obtained from thirty (n = 30) compression samples at 0.005 strain/s and thirty (n = 30) samples at 0.5 strain/s. The elastic modulus, yield stress, yield strain, ultimate stress, elastic strain energy density (SED), plastic SED, and total SED were then calculated for each tensile and compression test. In addition, failure stress and failure strain were calculated for each tension test. There were no significant differences in the tensile material properties between sexes and no significant interactions between age and sex for either method of loading. In regard to the differences in tensile material properties with respect to loading rate, yield stress, yield strain, failure stress, ultimate stress, elastic SED, plastic SED, and total SED were significantly lower at 0.005 strain/s compared to 0.5 strain/s. All material properties were significantly lower at 0.005 strain/s compared to 0.5 strain/s in compression. Spearman correlation analyses showed that all tensile material properties had significant negative correlations with age at 0.005 strain/s except modulus. At 0.5 strain/s, all tensile material properties except yield strain had significant negative correlations with age. No significant correlations were observed in material properties with respect to advanced age in compression at either loading rate. Although the results revealed that the tensile material properties of human rib cortical bone varied significantly with respect to chronological age, the R2 values only ranged from 0.15 - 0.62, indicating that there may be other underlying variables that better account for the variance within a given population. Overall, this is the first study to analyze the effects of sex, loading rate, and age on tensile material properties of human rib cortical bone using a reasonably large sample size and the first study to test the compressive material properties of human rib cortical bone. The results of this study provide data that allows FEMs to better assess thoracic injury risk for all vehicle occupants. Additionally, this study provides the necessary data to more accurately model and assess differences in the material response of the rib cage for nearly all vehicle occupants of driving age. / Master of Science / The thorax is one of the most frequently injured body regions in motor vehicle collisions (MVCs), and severe thoracic injuries have been shown to increase mortality risk. Finite element models (FEMs) of the human body are frequently used to evaluate thoracic injury risk. However, the accuracy of these models is dependent on the biomechanical data used to validate them. Although the material properties of bone have been shown to vary with respect to age and loading rate, previous studies that have evaluated the material properties of human rib cortical bone were limited to a small number of subjects, a narrow age range, one loading rate, and one loading mode (tension). Therefore, the purpose of this study was to evaluate the effects of sex, age, and loading rate on the tensile and compressive material properties of rib cortical bone over a wide range of subject demographics. Tension coupons were tested from sixty-one (n = 61) subjects (M = 32, F = 29) ranging in age from 17 to 99 years (Avg. = 56.4 ± 26.2 years). Compression samples were tested from thirty (n = 30) subjects (M = 19, F = 11) ranging in age from 18 to 95 years (Avg. = 49.0 ± 23.9 years). For each subject, one coupon/sample was tested to failure on a material testing system at a targeted strain rate of 0.005 strain/s, while the other coupon was tested at 0.5 strain/s. A load cell was used to measure axial load for both the tension coupons and compression samples. An extensometer was used to measure displacement within the gage length of the tension coupons and a deflectometer was used to measure displacement of the compression samples. There were no significant differences in material properties between sexes and no significant interactions between age and sex for either method of loading. In regard to the differences in tensile material properties with respect to loading rate, yield stress, yield strain, failure stress, ultimate stress, elastic SED, plastic SED, and total SED were significantly lower at 0.005 strain/s compared to 0.5 strain/s. All material properties were significantly lower at 0.005 strain/s compared to 0.5 strain/s in compression. In regard to the effect of age, all tensile material properties had significant negative correlations with age at except the modulus at 0.005 strain/s and yield strain at 0.5 strain/s. No significant correlations were observed in material properties with respect to advanced age in compression at either loading rate. Overall, this is the first study to provide the tension and compression data needed to more accurately model and assess differences in the material response of the rib cage for nearly all vehicle occupants of driving age.

The National Highway Traffic Safety Administration (NHTSA) reported that in 2008 there were a total of 37,261 automotive related fatalities, 26,689 of which were vehicle occupants. It has been reported that in automotive collisions chest injuries rank second only to head injuries in overall number of fatalities and serious injuries. In frontal collisions, chest injuries constitute 37.6% of all AIS 3+ injuries, 46.3% of all AIS 4+ injuries, and 43.3% of all AIS 5+ injuries. In side impact collisions, it has been reported that thoracic injuries are the most common type of serious injury (AIS≥3) to vehicle occupants in both near side and far side crashes which do not involve a rollover. In addition, rib fractures are the most frequent type of thoracic injury observed in both frontal and side impact automotive collisions. Anthropomorphic test devices (ATDs), i.e. crash test dummies, and finite element models (FEMs) have proved to be integral tools in the assessment and mitigation of thoracic injury risk. However, the validation of both of these tools is contingent on the availability of relevant biomechanical data. In order to develop and validate FEMs and ATDs with improved thoracic injury risk assessment capabilities, it is necessary to generate biomechanical data currently not presented in the literature. Therefore, the purpose of this dissertation is to present novel material, structural, and global thoracic skeletal response data as well as quantify thoracic injury timing in both frontal belt loading and side impact tests using cadaveric specimens. / Ph. D.

The purpose of this study was to develop material properties of human rib cortical bone using dynamic tension coupon testing. This study presents 117 human rib cortical bone coupon tests from six cadavers, three male and three female, ranging in age from 18 to 67 years old. The rib sections were taken from the anterior, lateral, and posterior regions on ribs 1 through 12 of each cadaver's rib cage. The cortical bone was isolated from each rib section with a low speed diamond saw, and milled into dog bone shaped tension coupons using a small computer numerical control machine. A high-rate servo-hydraulic Material Testing System equipped with a custom slack adaptor, to provide constant strain rates, was used to apply tension loads to failure at an average rate of 0.5 strains/sec. The elastic modulus, yield stress, yield strain, ultimate stress, ultimate strain, and strain energy density were determined from the resulting stress versus strain curves. The overall average of all cadaver data gives an elastic modulus of 13.9 GPa, a yield stress of 93.9 MPa, a yield strain of 0.883 %, an ultimate stress of 124.2 MPa, an ultimate strain of 2.7 %, and a strain energy density of 250.1 MPa-strain. For all cadavers, the plastic region of the stress versus strain curves was substantial and contributed approximately 60 strain % to the overall response and over 80 strain % in the tests with the 18 year old cadaver. The rib cortical bone becomes more brittle with increasing age, shown by an increase in the modulus (p < 0.01) and a decrease in peak strain (p < 0.01). In contrast to previous three-bending tests on whole rib and rib cortical bone coupons, there were no significant differences in material properties with respect to rib region or rib level. When these results are considered in conjunction with the previous three-point bending tests, there is regional variation in the structural response of the human rib cage, but this variation appears to be primarily a result of changes in the local geometry of each rib while the material properties remain nearly constant within an individual. / Master of Science

La respiration est un phénomène vital qui implique une synergie entre diverses structures anatomiques qui constituent le thorax. La physiologie articulaire reste un parent pauvre de la physiologie et la littérature concernant la quantification de la cinématique 3D des articulations du thorax durant le mouvement respiratoire est rare. Ce travail se concentre sur le développement et l'application d'une méthodologie permettant de répondre à cet objectif. La méthode développée combine le traitement de données tomodensitométriques réalisées à trois volumes pulmonaires différents et des techniques d'infographies. Les amplitudes (ROMs) et axes de mouvements (axe hélicoïdaux moyen, AHMs) ont été obtenus au niveau des articulations costo-vertébrales de 12 sujets asymptomatiques. En résumé, les amplitudes diminuent graduellement dans les étages inférieurs ; le volume pulmonaire et l'étage costal influencent significativement les amplitudes costales ; l'orientation des AHMs ne diffère pas entre les étages costaux. En complément, la méthode a été appliquée pour un échantillon de 10 patients atteints de mucoviscidose. La condition pathologique influençait significativement les amplitudes de mouvements mais pas l'orientation des AHMs. Enfin, le déplacement sternal, les variations de l'angle sternal et la cinématique des articulations sternocostales a été analysée. Les déplacements angulaires des côtes par rapport au sternum diminuaient dans les étages inférieurs comme au niveau des articulations costo-vertébrales. L'orientation des AHMs des articulations sternocostales ne différait pas entre les étages. Une corrélation linéaire a été mise en évidence entre les déplacements verticaux du sternum et les amplitudes de mouvement costales au niveau costo-vertébral et sternocostal. Ce travail contribue de façon substantielle à la modélisation 3D du thorax humain durant le mouvement respiratoire d'un point de vue qualitatif et quantitatif / Breathing is a vital phenomenon that implies synergy of various anatomical structures that constitute the thorax. Joint physiology remains a relatively poorly-known component of the overall thorax physiology. Quantitative literature related to in vivo thorax kinematics during breathing is scarce. The present work focuses specifically on developing and applying a methodology to reach this goal. The developed method combined processing of CT data obtained at different lung volumes and infographic techniques. Detailed ranges of motion (ROMs) and axes of movement (mean helical axes, MHAs) were obtained at costovertebral joints in 12 asymptomatic subjects; rib ROMs gradually decrease with increasing rib number; lung volume and rib level have a significant influence on rib ROM; MHAs did not differ between rib levels. In addition, the method was applied on a sample of 10 patients with cystic fibrosis. The pathological condition significantly influenced CVJ ROMs while the orientation of the MHAs did not differ. Finally, the sternal displacement, sternal angle variations and sternocostal joints (SCJ at rib1 to 7) kinematics during breathing motion were analyzed. Rib ranges of motion relative to sternum decreased with increasing rib number similarly to CVJ. Orientation of the MHAs did not differ between SCJ levels. A significant linear correlation was demonstrated between sternum vertical displacement and rib ranges of motion at both CVJ and SCJ. The present work substantially contributes to 3D modelling of human thorax in breathing at a joint level both qualitatively and quantitatively

Zielsetzung: In dieser Studie wurde an 15 gesunden Rindern die Methode der Thorakoskopie erprobt mit dem Ziel, eine Grundlage für den weiteren Einsatz dieses Verfahrens am bovinen Thorax zu schaffen. Im Mittelpunkt standen die Entwicklung einer geeigneten Untersuchungstechnik und die Beschreibung der endoskopisch dargestellten, im Pleuraspalt gelegenen Organe sowie möglicher pathologischer Befunde. Weiterhin galt es Komplikationen zu ermitteln und anhand der Erfahrungen aus diesem Versuch Indikationen für den Einsatz dieses minimal-invasiven Verfahrens beim Rind zu formulieren. Methodik: Alle Tiere wurden einer links- und rechtsseitigen Thorakoskopie jeweils mit und ohne intrapleurale Insufflation von Kohlenstoffdioxid über einen interkostalen Zugang unterzogen. Im Rahmen des Versuches fanden folglich vier Thorakoskopien je Rind und insgesamt 60 Thorakoskopien mit einer Wartezeit von 24 Stunden zwischen den einzelnen Untersuchungen statt. Die Untersuchungen erfolgten am im Zwangsstand fixierten, lokal anästhesierten Tier. Der endoskopische Zugang lag stets auf Höhe des Tuber coxae und variierte vom 8. bis zum 10. Interkostalraum. Nach interkostaler Schnittinzision wurde eine Zitzenkanüle bis in den Pleuraspalt vorgeschoben. Der spontane Einstrom von Raumluft in das Cavum pleurae führte zum Teilkollaps des ipsilateralen Lungenflügels. Die Kanüle wurde durch eine Trokar-Hülsen-Einheit ersetzt und die Hülse stellte nach Entfernung des Trokars den Zugang für die Optik. Je Hemithorax wurde die Untersuchungszeit auf 20 Minuten festgelegt. Sie begann im kranialen Pleuraspalt, wurde über (dorso)-kranial, (dorso)-medial, (dorso)-kaudal, ventrokaudal und ventral fortgeführt und endete mit ventrokranial ausgerichteter Optik. Ergebnisse: Die meisten im Cavum pleurae gelegenen Organe konnten ohne die Insufflation von CO2 ausreichend adspiziert werden. Während der links- und rechtsseitigen Thorakoskopien gelang die Adspektion großer Bereiche der Pleura costalis mit den Mm. intercostales interni sowie den Aa. et Vv. intercostales dorsales, Anteile der Lungenflügel und des Ligamentum pulmonale, der Aorta thoracica, des thorakalen Ösophagus, des M. longus colli, von Lymphknoten des Lc. thoracicum dorsale sowie der Lnn. mediastinales caudales, der Pars thoracica des Truncus sympathicus und des Truncus vagalis dorsalis des N. vagus. Des Weiteren konnten der M. psoas major, Anteile des Diaphragmas und der V. phrenica cranialis, der Hiatus aorticus, der Arcus lumbocostalis sowie unregelmäßig die A. et V. bronchoesophagea adspiziert werden. Die Untersuchung des rechten kranialen Pleuraspaltes war mit Einschränkungen behaftet und spiegelte sich in einer reduzierten Darstellung der sympathische Nervenfasern aus dem Ggl. cervicothoracicum, des Truncus costocervicalis dextra sowie der V. costocervicalis dextra wider. Linksseitig war die Betrachtung dieser Organe bzw. der korrespondierenden linksseitig angelegten Organe regelmäßig möglich. Weiterhin gelang während der linksseitigen Untersuchung die Adspektion des Ln. tracheobronchalis sinister, des Truncus brachiocephalicus sowie der V. azygos sinistra. Rechtsseitig konnte die V. azygos dextra stets adspiziert werden. Die Darstellung des Ductus thoracicus erfolgte nur bei einem der untersuchten Rinder infolge einer pathologischen Kompression. Während der Untersuchungen unter passivem Lungenkollaps war das Perikard nur bei einer rechtsseitigen Thorakoskopie zu sehen. Die Zweituntersuchungen des ipsilateralen Pleuraspaltes fanden während der Insufflation von CO2 bis zu einem Überdruck von 5 mm Hg statt. Dies sollte einen stärkeren Lungenkollaps bewirken und damit die Sicht auf intrapleural gelegene Organe verbessern. Während der Insufflation waren beidseits größere Anteile der Rippen und des Zwerchfells sowie das Perikard linksseitig bei drei Rindern und rechtsseitig bei einem Rind darstellbar. Postoperative Röntgenaufnahmen dienten dem Ausschluss des Vorhandenseins eines ipsi- oder kontralateralen Pneumothorax. Schlussfolgerung: Die Studie zeigt, dass Thorakoskopien an stehenden, gesunden Rindern sicher und komplikationsarm durchzuführen sind. Die beschriebene, minimal-invasive Technik stellt eine wertvolle, zusätzliche Methode zur tierschonenden Abklärung intrathorakaler Erkrankungen beim Rind dar. Der diagnostische, palliative oder therapeutische Nutzen muss in weiterführenden Untersuchungen ermittelt werden. / Objective: A study on 15 healthy cows was conducted to prove the thoracoscopic technique with the aim to establish a basis for further application of this procedure on cattle. Focus was on developing an adequate examination technique, displaying and describing of physical as well as pathological findings on intrathoracic organs examined endoscopically. Furthermore perioperative complications and indications of this minimally invasive method on cattle should be presented. Methods: The animals underwent a left and right side thoracoscopy under passive lung collapse and under insufflation of CO2. Therefore four thoracoscopies at each cow and a total of 60 thoracoscopies were performed with a waiting time of 24 hours between each examination. The cows were restrained in a stock and locally anesthetized. The endoscopic portal was lined up horizontally with the level of the ventral margin of the coxal tuber, at the point where the local anaesthetic had been injected and varied between the eighth and the tenth intercostal space. After a vertical stab incision through the skin and subcutaneous tissues a blunt stainless teat cannula was introduced into the pleural space. At this point air streamed spontaneously into the pleural space following by an ipsilateral lung collapse. The teat cannula was then removed and replaced by a sharp guarded trocar. After that the trocar was removed and the endoscope was passed through the remaining cannula. The time assessment for examination of each thorax was 20 minutes, started in the cranial pleural space, was continued in the (dorso)-cranial, (dorso)-medial, (dorso)-caudal, ventrocaudal und ventral direction and ended with ventrocranially aligned optic. Results: Most of the intrathoracic organs were seen without additional CO2 insufflation. During left and right side thoracoscopies large parts of the costal pleura, the internal intercostal muscles, the dorsal intercostal veins and arteries, parts of the lungs and the pulmonary ligament, the thoracic aorta, the thoracic part of the esophagus and the longus colli muscle, caudal mediastinal lymph nodes and lymph nodes associated with the dorsal thoracic lymph center, the thoracic part of the sympathic trunk and the dorsal vagus nerve were seen. Furthermore the psoas major muscle, parts of the diaphragm and the cranial phrenic vein, the aortic hiatus, the lumbocostal arch and intermittently the broncho-esophageal artery and vein could be identified. There were some constraints during right side thoracoscopy of the cranial pleural space which caused a limited view at the sympathic nerve fibres associated with the cervicothoracic ganglion, the right costocervical trunk and the right costocervical vein. At the left side these organs, the corresponding left side organs respectively, were constantly seen. Moreover during the exam at the left pleural space the left tracheobronchial lymph node, the brachiocephalic trunk and the left azygos could be well identified. During right side thoracoscopy the right azygos vein was always visible. In one case the presentation of the thoracic duct succeeded as a result of its pathological compression. During examination under passive lung collapse the pericard was visualized in one cow during right side thoracoscopy. The second thoracoscopies of the ipsilateral pleural space were conducted during insufflation of CO2 with a pressure of 5 mm Hg. A stronger lung collapse should result during insufflation with an enhanced view of the organs located intrapleurally. During insufflation at both sides larger parts of the ribs and diaphragm as well as the pericard on the left side at three cattle and on the right side at one cattle could be seen. Postoperative radiographies ensured the absence of an ipsi- or contralateral pneumothorax. Conclusion: This study shows that thoracoscopies on standing healthy cattle could be safely performed without major perioperative complications or side effects. The described minimally invasive procedure is a valuable, gentle and additional method to diagnose intrathoracic diseases in cattle. The use of thoracoscopy as diagnostic tool, for curative and palliative therapy should be identified in further studies.

Respiratory motion poses significant problems in the radiotherapy of tumors located at sites (lung, liver, pancreas, breast) that are affected by such motion. Effects of respiratory motion on the different stages of the radiotherapy process (imaging, treatment planning and treatment delivery), has formed the focus of significant research over the last decade. Results from such research have revealed that respiratory motion affects the instantaneous position of almost all structures in the thorax and abdomen to different degrees based on their corresponding anatomic location and muscular attachments. As an example, diaphragm motion was found to be of the order of 1.5 cm, predominantly in the superior-inferior (SI) direction during normal breathing. This indicates a similar magnitude of motion for tumors located in the lower lobes of the lung and in the abdomen.The conventional method of accounting for such motion is to add a margin (based on an estimate of the expected range of organ motion) around the clinical target volume (CTV) that is delineated from the image data. This margin also includes errors due beam-bony anatomy alignment during radiation delivery and errors in patient position between simulation and subsequent treatment delivery sessions. Such a margin estimate may or may not encompass the "current" extent of motion exhibited by the tumor, resulting in either a higher dose to the surrounding normal tissue or a potential cold spot in the tumor volume. Several clinical studies have reported the existence of a direct relationship between the reduction in mean dose to the lung and the incidence of radiation induced pneumonitis. Therefore, subjecting additional normal lung tissue to high dose radiation by adding large margins based on organ motion estimates may result in an increased risk of radiation induced lung injury.Monitoring and accounting for respiratory motion can however potentate a reduction in the amount of normal tissue that receives high dose radiation, thereby decreasing the probability of normal tissue complication and also increasing the possibility for dose escalation to the actual tumor volume. The management (monitoring and accounting) of respiratory motion during radiation oncology forms the primary theme of this dissertation.Specific aims of this thesis dissertation include (a) identifying the deleterious effects of respiratory motion on conventional radiation therapy techniques (b) examining the different solutions that have been proposed to counter the deleterious effects of respiratory motion during radiotherapy (c) summarizing the relevant work conducted at our institution as part of this thesis in addressing the issue of respiratory motion and (d) visualizing the future direction of research in the management of respiratory motion in radiation oncology.Among the various techniques available to manage respiratory motion in radiation oncology such as respiratory gated and breath hold based radiotherapy, our research initially focused on respiratory gated radiotherapy, employing a commercially available external marker based real time position monitoring system. Multiple session recordings of simultaneous diaphragm motion and external marker motion revealed a consistent linear relationship between the two signals indicating that the external marker motion (along the anterior-posterior (AP) direction) could be used as a "surrogate" for motion of internal anatomy (along the SI direction). The predictability of diaphragm motion based on such external marker motion both within and between treatment sessions was also determined to be of the order of 0.1 cm.Analysis of the parameters that affected the accuracy and efficacy of respiratory gated radiotherapy revealed a direct relationship between the amount of residual motion and the width of the "gate" window. It also followed therefore that a trade-off existed between the width of the "gate" and the accuracy of gated treatments and also the overall "Beam ON" time. Further, gating during exhale was found to be more reproducible than gating during inhale. Although, it was evident that a reduction in the width of the "gate" implied a reduction in the margins added around the clinical target volume (CTV), such a reduction was limited by setup error.A study of the potential gains that could be derived from respiratory gating (based on motion phantom experimental set up) indicated a potential CTV-PTV margin reduction of 0.2-1.1 cm while employing gating alone in combination with an electronic portal imaging device, thus decreasing the amount of healthy tissue receiving radiation. In addition, gating also improved the quality of images obtained during simulation by reducing the amount of motion artifacts that are typically seen during conventional spiral CT imaging.Imparting some form of training was hypothesized to better enable patients to breathe in a reproducible fashion, which was further thought to increase the accuracy and efficacy of gated radiotherapy, especially when the "gate" was set close to the inhale portion of the breathing cycle. An analysis of breathing patterns recorded from five patients over several sessions under conditions of normal quiet breathing, breathing with audio instructions and breathing with visual feedback indicated that training improved the reproducibility of amplitude or frequency of patient breathing cycles.An initial exploration into respiration synchronized radiotherapy was thought to facilitate realization of reduced margins without having to hold the radiation beam delivery during a breathing cycle (as is the case with gating). A feasibility study based on superimposition of respiratory motion of a tumor (simulated by a sinusoidal motion oscillator) onto the initial beam aperture as formed by the multileaf collimator (MLC) revealed that tumor dose measurements obtained with such a set up were equivalent to those delivered to a static tumor by a static beam.Finally, a feasibility study for a method to acquire respiration synchronized images of a motion phantom and a patient (in order to perform respiration synchronized treatment planning and delivery) yielded success in the form of a 4D CT data set with reduced motion artifacts.In summary, respiratory gated radiotherapy and respiration synchronized are both viable approaches to account for respiratory motion during radiotherapy. While respiratory gated radiotherapy has been successfully implemented in some centers, several technical advances are required to enable similar success in the implementation of respiration synchronized radiotherapy. However, the potential clinical gains that can be obtained from either of the above approaches and their relative contributions to margin reduction will determine their future applicability as routine treatment procedures.

Alan George Miller. / Thesis (Ph.D.)--Chinese University of Hong Kong, 1997. / Includes bibliographical references (p. 204-230). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Mode of access: World Wide Web.

O exame ultrassonográfico costumava ocupar um papel secundário na avaliação dos campos pulmonares, devido à barreira representada por este tecido aerado à propagação dos feixes ultrassônicos. No final da década de 90, sua aplicabilidade para avaliar o pulmão foi impulsionado devido ao reconhecimento de diferentes artefatos de reverberação gerados a partir de um pulmão normalmente aerado e quando este se apresenta com o interstício e/ou alvéolos infiltrados. Por ser um exame de baixo custo, livre de radiação ionizante, poder ser realizado em posição ortopneica e poder ser realizado à beira do leito, a avaliação ultrassonográfica do tórax ganhou notoriedade na área do intensivismo. Objetivou-se neste estudo avaliar a aplicabilidade e os aspectos do exame ultrassonográfico na avaliação de campos pulmonares de cães sadios e com edema pulmonar cardiogênico agudo. Foram avaliados 20 cães sadios e 10 cães com insuficiência valvar mitral em edema pulmonar agudo, de raças e idades variadas, machos e fêmeas. Todos os cães foram submetidos a exames físicos, radiográficos, ultrassonográficos e ecocardiográficos. Os animais doentes foram avaliados em três momentos: T0 (na admissão), T1 (4 horas após o início do tratamento) e T2 (24 horas depois). A ausculta, a avaliação radiográfica e o exame ultrassonográfico do tórax foram realizados de forma setorizada, com base no protocolo de avaliação ultrassonográfico dos campos pulmonares denominado de Veterinary Bedside Lung Ultrasound Exam (VetBLUE), entre o 2° e 3°, 4° e 5°, 6° e 7°, 8° e 9° espaços intercostais, nos hemitórax esquerdo e direito. Para cada região associou-se um escore de acordo com a alteração observada e um escore final para cada modalidade de avaliação. Nos cães do grupo controle foi fácil o reconhecimento do deslizamento pleural e do artefato de reverberação causado pela superfície pleura- pulmão (linhas A), exceto no 2º-3º espaço, onde houve maior dificuldade na observação dessas características. Sete cães do grupo controle (35%) apresentaram linhas B durante a avalição, porém geralmente o artefato foi observado em apenas um espaço intercostal e no máximo duas linhas por campo. Esse artefato foi mais observado no hemitórax direito e a região mais acometida foi o 8º e 9º espaço intercostal, porém sem diferença estatística significativa. No grupo com edema, na primeira avaliação do exame ultrassonográfico todos os pacientes apresentaram linhas B em grande quantidade. As avaliações aos exames físico, radiográfico e ultrassonográfico apresentaram um comportamento semelhante ao longo do tempo, demonstrando um escore menor naqueles animais responsivos ao tratamento. A concordância intraobservador para o exame ultrassonográfico foi elevada, o que demonstra uma boa repetibilidade do método. Por meio de uma avaliação segmentada de algumas janelas acústicas pode-se obter uma avaliação do tórax do paciente em um tempo curto, melhorando-se a tomada de decisões no atendimento emergencial. Contudo, esta técnica não exclui a avaliação por outras modalidades de imagem (exame radiográfico e tomografia computadorizada), e deve representar uma triagem para aqueles pacientes com síndromes respiratórias agudas. / Ultrasound examination has always played a secondary role in pulmonary assessment, as the gas content of the lungs does not favor the propagation of ultrasound beams. However, the recognition of different reverberating artifacts arising from the normal aerated lungs (A lines) or generated in the presence of interstitial and/or alveolar infiltrates (B lines), in the late 1990s, led to wider application of the technique. Ultrasonography is a low cost, ionizing radiation-free bedside imaging modality which can be performed in the orthopneic position with minimal patient restraint, and therefore has gained wide popularity in intensive care. The objective of this study was to evaluate the applicability and aspects of ultrasound examination in the evaluation of pulmonary fields of healthy dogs and dogs with acute cardiogenic pulmonary edema. Twenty healthy dogs and ten dogs with valvar disease presenting acute pulmonary edema were evaluated. All dogs were submitted to physical, radiographic, ultrasonographic and echocardiographic examinations. The animals with edema were evaluated at three times: T0 (admission), T1 (4 hours after initiation of the treatment) and T2 (24 hours later). Auscultation, radiographic and ultrasound examinations were performed using a regionally scan at the 2nd-3rd, 4-5th, 6-7th and 8-9th intercostal spaces, based on the VetBLUE (Veterinary Bedside Lung Ultrasound Exam) protocol in the right and left hemithoraces. For each region, a score was assigned according to the observed change and a final score for each evaluation modality was given summing the scores of all regions. Pleural sliding and A lines (hyperechoic, parallel equidistant lines arising from the visceral pleura-lung interface) could be easily seen at all intercostal spaces in all dogs in this sample, with more difficult visualization at the 2nd-3rdintercostal space. B lines were observed in seven out of 20 dogs (35%). However, this artifact was limited to one intercostal space and a maximum of two lines were detected per field. B line artifacts were more commonly seen in the right hemithorax and at the level of the 8-9th intercostal space (non-significant differences). In the group with pulmonary edema, in the first evaluation of the ultrasonographic examination all the patients presented B lines in great quantity. Physical, radiographic and ultrasonographic examinations showed a similar behavior over time, showing a lower score in those animals responsive to the treatment. The intraobserver agreement for the ultrasonographic examination was high, which demonstrates a good repeatability of the method. Using a segmented evaluation of some acoustic windows it is possible to obtain an evaluation of the patient\'s chest in a short time, improving the decision-making in the emergency service. However, ultrasonography does not eliminate the need for other imaging modalities such as radiography and computed tomography and should be seen as a screening tool for patients presenting with acute respiratory syndromes.

Rib fractures are present in 25 percent of all trauma-related deaths, making the mechanism and pattern of rib fractures an important area of trauma research (Lien et al. 2009). Rib fractures are important to consider when researching trauma because they can cause serious complications contributing to an individual's mortality. This retrospective research study focuses on rib fracture patterns in fatal motor vehicle accidents (MVAs). The sample consists of 105 MVA victims--68 males and 37 females. Data was collected at the Hillsborough County Medical Examiner's Office in Tampa, Florida. The study investigates motor-vehicle-related deaths from 2011 to 2013 to establish rib fracture patterns in association with several variables. Fractures of the manubrium and sternum are included in the analyses since the ribs articulate in several places with the manubrium and sternum and they are frequently injured in MVAs. First, this research study investigates the rib fracture patterns that exist in correlation to soft tissue organ injury. Injuries to the heart, lungs, liver, diaphragm, and spleen were analyzed based on their direct contact with the ribcage. The results show that several significant relationships exist, including that lung injury is about 12 times more likely to occur when a fracture is present in the left middle ribs and 4 times more likely to occur when there is a fracture on the manubrium. Heart injury is found to be 9 times more likely to occur when the sternum is fractured and the liver is found to be 4 times more likely when the right middle ribs are fractured and 0.3 times more likely when the right high ribs are fractured. Second, this study examines rib fracture patterns controlling for seatbelt use, airbag deployment, and cardiopulmonary resuscitation (CPR) administration. Each of these variables is tested to determine their influence in causing injury and the fracture patterns resulting from accidents. For drivers, specifically, it is also tested if fracture patterns can predict seatbelt use. The results show a significant relationship between fracture of the left low ribs and seatbelt use. In drivers, it is 5 times more likely that the individual was wearing a seatbelt if the left low ribs are fractured. Lastly, a significant relationship was found for fractures of the manubrium and CPR administration. Finally, this research study aims to predict the number of ribs fractured by an individuals' age. Progressive mineralization of the skeleton and other age-related changes increase the risk of fracture in elderly individuals. The results of this study indicate a significant, positive correlation between age and the total number of rib fractures sustained in MVAs, supporting the presumption that elderly are at a higher risk for rib fractures.