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Objective: To identify the significance of spontaneous pneumomediastinum (SPM) and to optimize its management. Methods: A retrospective analysis was undertaken of all patients presenting with SPM over a 5-year period. Eighteen patients were identified, and information on their presentations, initial diagnoses, comorbidities, investigations, clinical courses, length of hospital stays, and outcomes were collated. Setting: The emergency department referrals of two major Melbourne teaching hospitals. Results: SPM is an uncommon condition presenting in approximately 1 in 30,000 emergency department referrals. The typical patient identified from this study is a young man who is likely to have a history of asthma, and who is also likely to smoke or to use illicit drugs. The most common presentation is nonspecific pleuritic chest pain with dyspnea. Complications are rare, and the clinical course benign, but the possibility of a ruptured viscus or an initial misdiagnosis often leads to a great number of investigations. A proposed algorithm of management is given. Other serious and potentially life-threatening conditions, such as Boerhaave syndrome need to be excluded.

A retrospective analysis was performed to determine whether coronal thoracic [ 18 F]fluoro-2-deoxy-glucose positron emission tomography (FDG-PET) scans, if viewed at the time of radiotherapy (RT) planning, would have influenced the anterior–posterior (AP) RT volumes that were administered to a group of unoperated lung cancer patients. Viewing of PET and diagnostic images enabled a qualitative assessment of whether abnormal thoracic PET activity was present in areas regarded as normal by diagnostic imaging; this would, therefore, have influenced the RT volume if done prospectively. Additionally a method of graphical co-registration was devised to quantitate the adequacy of coverage of each patient's abnormal PET activity by his/her actual RT field. Of 15 patients analyzed, 26.7% (four patients) would have had their RT volume influenced by PET findings, highlighting the potential value of PET in treatment planning.

BACKGROUND Lung cancer (LC) is the most common fatal malignancy, but there are no useful tumor markers for diagnosis or monitoring. Mucin 1 has an established role as a marker in other malignancies, but has undergone limited assessment in LC. METHODS Serum from 86 patients with LC and 24 with benign pulmonary disease (BPD), and bronchial lavage fluid from 55 LC patients and 21 BPD patients were tested using the Mucin 1 assays mammary serum antigen (MSA) and cancer-associated serum antigen (CASA). RESULTS For LC, serum CASA achieved sensitivity of 57%, specificity of 93% relative to normals, and 63% specificity relative to BPD. For MSA the same parameters were 19%, 95%, and 92%. Serum CASA levels were significantly higher in LC patients compared with BPD (P = 0.024) but there was no difference for MSA (P = 0.635). CASA showed excellent correlation with tumor stage and in patients with changing status of disease, while MSA did not. By contrast there was no difference in bronchial lavage fluid tumor marker levels from LC and BPD patients (CASA, P = 0.87; MSA, P = 0.89). CONCLUSIONS In a small series serum CASA appears to be a useful agent in detecting LC because it is elevated in all types and stages of LC, and its level correlates with stage and progress of disease. Some patients with BPD have elevated levels suggesting a greater value for monitoring rather than diagnosis. Both serum MSA testing and measurements of either marker in bronchial lavage fluid are of no value.

This competition weightlifter was referred to an endocrinologistafter a positive -human chorionic gonadotropin (HCG) result onroutine urine screening (B sample). He was asymptomatic anddenied illicit drug use. Blood tests confirmed an increase in -HCG levels, with decreased leutenizing hormone and follicle-stimulating hormone levels and also increased testosterone levels(Table 1). Examination, including testicular assessment with ul-trasonography, was unremarkable, and an extragonadal germ celltumor was suspected. Computed tomographic scanning of thechest, abdomen, and pelvis was performed and showed a 33-mmanterior mediastinal mass (Figure

To identify the significance of spontaneous pneumomediastinum (SPM) and to optimize its management.A retrospective analysis was undertaken of all patients presenting with SPM over a 5-year period. Eighteen patients were identified, and information on their presentations, initial diagnoses, comorbidities, investigations, clinical courses, length of hospital stays, and outcomes were collated.The emergency department referrals of two major Melbourne teaching hospitals.SPM is an uncommon condition presenting in approximately 1 in 30,000 emergency department referrals. The typical patient identified from this study is a young man who is likely to have a history of asthma, and who is also likely to smoke or to use illicit drugs. The most common presentation is nonspecific pleuritic chest pain with dyspnea. Complications are rare, and the clinical course benign, but the possibility of a ruptured viscus or an initial misdiagnosis often leads to a great number of investigations. A proposed algorithm of management is given. Other serious and potentially life-threatening conditions, such as Boerhaave syndrome need to be excluded.

Hand-assisted thoracoscopic surgery is a novel minimally invasive approach for performing techniques conventionally performed by posterolateral thoracotomy. Hand-assisted thoracoscopic surgery overcomes one of the major drawbacks of minimally invasive thoracic surgery in allowing full manual palpation of the lungs through a subcostal incision under video guidance, while avoiding a thoracotomy when the indication is pulmonary metastasectomy with curative intent or resection of undiagnosed lung nodules. The technique may result in improved quality of life outcomes compared with a thoracotomy.

We report a case of persistent twitching of the latissimus dorsi muscle following a posterolateral thoracotomy, which continued despite several attempts at control including denervation, and was ultimately cured by total resection of the muscle.

Clinical Summary We present the case of a 62-year-old woman from outback Victoria, Australia, who presented to her local doctor with left-sided chest wall pain. Her chest x-ray film demonstrated a large lesion in the left upper lobe. She had a history of migraines and mild osteoarthritis and had quit smoking 10 months earlier after a 15 pack per year habit. She was further investigated with a computed tomography (CT) scan, which demonstrated a large lesion in the left upper lobe adjacent to the pleura, and a PET scan (Figure 1). The PET scan confirmed high fluorine-18 deoxyglucose (FDG) uptake in the mass with equivocal uptake in the hilar nodal tissue. A tissue diagnosis was attempted by bronchoscopy and washings, and a CT-guided percutaneous needle biopsy. Both attempts failed to find any neoplastic tissue. The biopsy revealed no granulomata. Sputum revealed polymorphs and some nonspecific gram-positive cocci. She underwent an open thoracotomy and a left upper lobectomy. The mass was adherent to the chest wall, and the offending section of pleura was also stripped. Some soft enlarged hilar lymph nodes were identified and resected with the specimen. The pleura was examined as a frozen specimen, and no neoplastic cells were identified. The lung pathology demonstrated multifocal areas of suppuration and tissue necrosis containing granules of gram-positive cocci surrounded by a fringe of eosinophilic material (Splendore-Hoeppli phenomenon), and a diagnosis of primary pulmonary botryomycosis was made. An opinion was sought from our infectious disease unit, and the decision was not to treat with long-term antibiotics. The patient fully recovered. Discussion Primary pulmonary botryomycosis is a rare condition with only 16 cases described before 2005. Botryomycosis was first described by Bollinger in 1870 as a disease of horses. Fungi were thought to the causative factor; however, in 1919 Magrou successfully isolated Staphylococcus aureus from his horse specimen and reproduced the disease in guinea pigs. Since that time, other microbes such as Pseudomonas aeruginosa, Escherichia coli, alpha-hemolytic streptococcus, Actinobacillus lignieresii, Actinobacillus actinomycetemcomitans, and Serratia marcescens have also been described. Predisposing factors including cystic fibrosis and acquired immune deficiency syndrome have been implicated in many cases, with 11 of the 16 cases of primary pulmonary botryomycosis possibly related to impaired immune responses. Pathologically, botryomycosis is characterized by the presence of eosinophilic granules, with eosinophils surrounding central foci of necrosis, known as the Splendore-Hoeppli effect (Figure 2). The difference between botryomycosis and fungal infection (eg, with actinomyces) is the bacteria shown on Gram staining. The presentation of patients with pulmonary botryomycosis is varied with symptoms including chronic cough, hemoptysis, and chest wall pain described. Clinical examination is usually unremarkable, with the exception of decreased breath sounds over the consolidated lung. Most previously documented cases were investigated with fine-needle biopsy to obtain a tissue diagnosis before open biopsy. A minority of authors, such as Katapadi and colleagues, successfully diagnosed botryomycosis on fine-needle biopsy. The diagnosis was not clarified in all documented cases with CT scan, with reports that lesions were highly suspicious for malignancy. The majority of reported cases progressed to open biopsy, usually lobectomy, to exclude malignancy as the primary diagnosis. There are no other documented cases of PET scan reports in primary pulmonary botryomycosis. Our scans demonstrated marked uptake in the region of the lung mass, consistent with a diagnosis of malignancy or infection. Similarly, uptake in the hilar region is also consistent with hilar node involvement of malignancy or lymphadenitis. We submit the need for thorough preoperative workup for lung lesions suspected of being bronchogenic carcinomas. Unfortunately, even with the addition of PET scanning, the majority of patients with pulmonary botryomycosis, a rare chronic infection, will ultimately require open biopsy to exclude malignancy. From the Department of Surgery, Austin Health, Heidelberg, Victoria, Australia.

We report a case of persistent twitching of the latissimus dorsi muscle following a posterolateral thoracotomy, which continued despite several attempts at control including denervation, and was ultimately cured by total resection of the muscle.

nder normal conditions in vivo blood flows in a pulsatile manner. That this is not an essential feature of the circulation U is shown by the regular successful practice of extracorporeal circulation using roller pumps, which give an essentially nonpulsatile flow, and by the palliation of cyanotic disorders by means of superior vena cava-right pulmonary artery anastomosis (Glenn operation). Nevertheless, it has been recently reported that pulsatile perfusion is in fact preferable to nonpulsatile perfusion for the performance of extracorporeal bypass [3, 14, 151, especially during lengthy procedures and when low flow rates are used [15]. Furthermore, experimental work has demonstrated that pulsatile flow has an important role in the maintenance of normal vasomotor tone [5] and gives improved function of the isolated kidney [lo] and liver [19] when compared with nonpulsatile flow. Lee and DuBois [12] elegantly demonstrated that the pulmonary capillary bed has a pulsatile blood flow under normal conditions, but whether this is an essential or incidental feature is not clear. This study examines the changes in oxygen uptake, pulmonary vascular resistance, and microscopic appearance of canine lungs subjected to nonpulsatile perfusion in both acute and chronic preparations.

Animal experiments were performed to evaluate the use of a diaphragmatic flap, based on a major branch of the phrenic artery, for myocardial revascularization. Even without the stimulus of ischaemia, a significant cross-anastomosis of blood vessels between the myocardium and flap was demonstrated. There may be a useful place for such a flap for myocardial revascularization as an alternative or additional procedure to internal mammary artery implantation.

The integrity of the right pulmonary artery following a Waterston shunt procedure must be checked by catheterization and angiography prior to complete correction of tetralogy of Fallot. If the lumen of the right pulmonary artery is adequate, the shunt may be closed by direct suture. If there is relative kinking of the right pulmonary artery at the site of the anastomosis, the vessel should be inspected carefully at the time of shunt closure. The use of a small Dacron patch to close the shunt may avoid further kinking.