A United States marine presenting with hemoptysis after push-ups.

We present an unusual case of right lower lobe intralobar pulmonary sequestration in a previously healthy and physical active 27-year-old U.S. Marine, who presented with new onset hemoptysis after doing push-ups. Diagnosis was obtained by chest X-ray and contrast computed tomography scan. Preoperatively the patient underwent fluoroscopy-guided embolization of the aberrant systemic artery supplying the sequestration. The segmental resection of the sequestration was then successfully performed through a muscle-sparing thoracotomy.

Cryptogenic emboli in patients with patent foramen ovale or atrial septal defect associated with the use of nonsteroidal anti-inflammatory drugs.

BACKGROUND: Nonaspirin, nonsteroidal anti-inflammatory drugs (NANSAIDs) have been associated with arterial thromboembolic events in the general population. Our objective was to determine the prevalence of NANSAID use in patients diagnosed with cryptogenic emboli or paradoxical embolic events from a patent foramen ovale (PFO) or atrial septal defect (ASD) compared with a control population with an incidental PFO/ASD and no history of embolic events. METHODS: We performed a retrospective case-control study of 90 age-matched patients to assess the association of NANSAIDs with cryptogenic arterial embolic events in patients with and without a history of PFO/ASD. Odds ratios (ORs) were obtained by chi2 analysis. Multivariate analysis was conducted with a logistical regression method. RESULTS: Patients with cryptogenic embolic events had a high prevalence of prescription NANSAID use regardless of the presence of a PFO/ASD and were far more likely to have a history of NANSAID use than those with an incidentally discovered PFO/ASD and no history of arterial emboli (OR 4.30, 95% confidence interval 1.14-13.07, p = 0.01). CONCLUSIONS: Many patients previously diagnosed with paradoxical emboli may be experiencing the prothrombotic effects of NANSAIDs rather than a paradoxical mechanism for their arterial embolic event.

Intraoperative solumedrol helps prevent postpneumonectomy pulmonary edema.

BACKGROUND: Postpneumonectomy pulmonary edema and pneumonia are life threatening and seemingly unavoidable complications after pneumonectomy. We theorized that an intraoperative dose of intravenous steroids (as a prophylactic measure to reduce pulmonary injury to the remaining lung) just before pulmonary artery ligation might decrease this problem. METHODS: Seventy-two patients (52 men) who had pneumonectomy during two time periods were studied prospectively. Thirty-five patients received 250 mg of methylprednisolone sodium succinate (Solumedrol; Upjohn, Kalamazoo, MI) just before pulmonary artery ligation (S group) and 37 did not (non-S group). Groups were matched for known or suspected preoperative, intraoperative, and postoperative risk factors for postpneumonectomy pulmonary edema. RESULTS: The incidence of postpneumonectomy pulmonary edema or adult respiratory distress syndrome was less in the S group (0 of 35, 0% versus 5 of 37, 13.5%, p = 0.049), the overall major complication rate was less in the S group (7 of 35, 20% versus 16 of 37, 43%, p = 0.04), and the length of hospital stay was shorter in the S group (6.1 days versus 11.9 days, p = 0.02). In addition, there were no bronchopleural fistulas in the S group compared with two (both right-sided) in the non-S group. CONCLUSIONS: The intraoperative intravenous administration of 250 mg of methylprednisolone sodium succinate just before pulmonary artery ligation during pneumonectomy may reduce the incidence of postpneumonectomy pulmonary edema and adult respiratory distress syndrome as well as decrease other major complications and shorten the hospital stay. It does not seem to increase the incidence of bronchopleural fistula. Further randomized trials are needed.

Percutaneous endoscopic gastrostomy: the preferred method of elective feeding tube placement in trauma patients.

PURPOSE: The purpose of this study was to determine whether gastric feeding tubes placed by the percutaneous endoscopic route resulted in fewer and less severe complications than open surgical gastrostomy (SG). METHODS: Charts for all trauma patients admitted 1/94 to 12/98, which had an electively placed feeding tube, were individually reviewed. All tube-related complications were recorded. Of 8119 patients screened, 158 (1.9%) met inclusion criteria. Percutaneous endoscopic gastrostomies (PEGs) were placed in 95 (60.1%) and surgical gastrostomies in 63 (39.9%). Most patients (79.1%) had AIS 3 or greater head or spinal cord injury as the primary diagnosis leading to tube placement. RESULTS: Overall, SG patients were 5.4 times more likely than PEG patients to have a complication from their gastrostomy tube (95% CI, 2.1-13.8). They were 2.6 times more likely to have a major complication (internal leakage, dehiscence, peritonitis, and fistula), and 5.5 times more likely to have a minor complication (unplanned removal, dislodgment, external leak, skin infection, and nonfunction). The groups did not differ on ISS, ICU LOS, total LOS, or mortality (p > 0.05). Overall, a total of 39 individual complications related to tube placement were noted in 26 separate patients (PEG, 7; SG, 19). All four of the major complications requiring operative intervention were in the SG group. There were 31 minor complications, 8 in the PEG group and 27 in the SG group. Mean total charges for placement were also significantly lower in the PEG group than the SG group ($1271 vs. $2761, p < 0.001) CONCLUSION: Gastrostomy tubes placed via the percutaneous endoscopic route had a significantly lower complication rate than surgically placed tubes. In addition, the charges incurred for their placement were also significantly less. Based on the findings of this study, PEG should be considered as the method of choice for gastric feeding tube placement for trauma patients who do not have specific contraindications to the procedure.