Characterisation of hemidiaphragm dysfunction using dynamic chest radiography: a pilot study

ObjectivesDynamic chest radiography (DCR) is a novel real-time digital fluoroscopic imaging system that produces clear, wide field-of-view diagnostic images of the thorax and diaphragm in motion, alongside novel metrics on moving structures within the thoracic cavity. We describe the use of DCR in the measurement of diaphragm motion in a pilot series of cases of suspected diaphragm dysfunction.MethodsWe studied 21 patients referred for assessment of diaphragm function due to suspicious clinical symptoms or imaging (breathlessness, orthopnoea, reduced exercise tolerance, and/or an elevated hemidiaphragm on plain chest radiograph). All underwent DCR with voluntary sniff manoeuvres.ResultsParadoxical motion on sniffing was observed in 14 patients, and confirmed in 6 who also underwent fluoroscopy or ultrasound. In 4 patients, DCR showed reduced hemidiaphragm excursion but no paradoxical motion; in 3, normal bilateral diaphragm motion was demonstrated. DCR was quick to perform, well-tolerated in all cases and with no adverse events reported. DCR was achieved in around five minutes per patient, with images available to view by the clinician immediately within the clinical setting.ConclusionDCR is a rapid, well-tolerated and straightforward X-ray technique that warrants further investigation in the assessment of diaphragm dysfunction.

Paradoxical spinopelvic motion: does global balance influence spinopelvic motion in total hip arthroplasty?

Background Recent research has proposed a classification of spinopelvic stiffness according to pelvic spatial orientation for risk stratification in patients who undergo total hip arthroplasty (THA). However, the influence of global alignment was not investigated, and this study evaluated the effect of global balance (sagittal vertical axis [SVA]) on spinopelvic motion. Methods We conducted a retrospective review of consecutive primary THA patients. We measured SVA, spinopelvic parameters (pelvic tilt [PT], pelvic incidence, and sacral slope), thoracic kyphosis (TK), lumbar lordosis (LL), proximal femur angle (PFA), and cup version using functional radiographs of patients in the standing and upright sitting positions. Linear regression was performed to identify parameters related to global trunk alignment change (∆SVA). Spinopelvic stiffness was defined as PT position change < 10°, and a subset of patients with PT change < 0° was categorized into a paradoxical spinopelvic motion group. Results One hundred twenty-four patients were analyzed (mean age: 65 years, 61% female). In univariate regression analysis, ∆TK, ∆LL, and ∆PFA were correlated to ∆SVA. In multivariate regression analysis, ΔLL (p < 0.001) and ΔPFA (p < 0.001) were found to be correlated to ΔSVA (ΔSVA = − 11.97 + 0.05ΔTK – 0.23ΔLL – 0.17ΔPFA; adjusted R2 = 0.558). Spinopelvic stiffness was observed in 40 patients (32%), including five (4%) with paradoxical motion (∆PT = − 3° ± 1°, p < 0.001) with characteristics of balanced standing global trunk alignment (standing SVA = − 1.0 ± 5.1 cm), similar stiffness of the lumbosacral spine (∆LL = − 7° ± 5°), higher hip motion (∆PFA = − 78° ± 6°, p = 0.017), and higher anterior trunk shift (∆SVA = 6.2 ± 2.0 cm, p = 0.003) from standing to sitting as compared to the stiffness group. Two of these five patients experienced dislocation events after THA. Conclusions The lumbosacral and hip motions were the major contributors to global alignment postural change. Paradoxical motion is a rare but dangerous clinical condition in THA that might be related to a disproportionally large trunk shift in the stiff lumbosacral spine causing excessive hip motion. In paradoxical motion, diminishing functional acetabular clearance during position change might pose the prosthesis at higher risk of impingement and instability than spinopelvic stiffness.

External flail chest stabilization; The simple, low-cost way

Flail chest is a life-threatening clinical entity which can be complicated by respiratory insufficiency. Paradoxical motion of a part of chest wall is the basic cause to put the blame on. Consequently, stabilization of the chest wall is occasionally of paramount importance to achieve early extubation in a patient with post-trauma respiratory insufficiency. Hereby, a simple, low cost, harmless and effective approach of external stabilization is presented.

The ‘Raging Motions’ of Eros on Shakespeare’s Stage

Chapter 2 studies Shakespeare’s metaphors of stillness and motion in Measure for Measure and Othello. While some of Shakespeare’s characters are immobilised by erotic desire, others experience desire as a stirring, physically moving, experience. For Angelo, Claudio, and Othello, it is both. In both Measure for Measure and Othello, Shakespeare’s metaphors trace the fine line that separates the extremity of erotic motion (chaos, convulsions, compulsivity) from the extremity of stasis (death, violent restraint). If over such extremes Shakespeare’s characters have little control, they nonetheless attempt to exert some degree of agency by reaching for certain knowledge, attempting to understand the aetiology and significance of their lustful impulses. Drawing on the work of Stanley Cavell, Emmanuel Levinas, and Jean-Luc Marion, this chapter considers the ontological and ethical consequences of metaphors of stillness and motion. The concluding pages explore a form of heightened erotic activity based on Aristotle’s writings on entelechy. For characters such as Desdemona, Juliet, and Cleopatra, ‘entelechial desire’ is conceptualised through metaphors of perpetual, if paradoxical, motion.