[Show abstract][Hide abstract] ABSTRACT: A young adult male suffered a combat gunshot wound to his anterior trachea, which resulted in bullet migration, via aspiration, to the point of lodgment in the right upper lobe bronchus. He subsequently spontaneously expectorated the intact bullet, a first report of such events. A bronchoscopy was then performed confirming the site of entry, position of previous lodgment, and lack of further pathology. A brief discussion of expected findings, management, and complications are discussed.
[Show abstract][Hide abstract] ABSTRACT: Family physicians commonly care for older patients with disabilities. Many of these patients need help maintaining a therapeutic home environment to preserve their comfort and independence. Patients often have little time to decide how to address the limitations of newly-acquired disabilities. Physicians can provide patients with general recommendations in home modification after careful history and assessment. Universal design features, such as one-story living, no-step entries, and wide hallways and doors, are key adaptations for patients with physical disabilities. Home adaptations for patients with dementia include general safety measures such as grab bars and door alarms, and securing potentially hazardous items, such as cleaning supplies and medications. Improved lighting and color contrast, enlarged print materials, and vision aids can assist patients with limited vision. Patients with hearing impairments may benefit from interventions that provide supplemental visual and vibratory cues and alarms. Although funding sources are available, home modification is often a nonreimbursed expense. However, sufficient home modifications may allow the patient and caregivers to safely remain in the home without transitioning to a long-term care facility.
Full-text · Article · Nov 2009 · American family physician
[Show abstract][Hide abstract] ABSTRACT: Despite the large number of gunshot wounds treated in civilian and military practice, embolization of missiles to the pulmonary artery is relatively uncommon. In a review of 7,500 medical reports from casualties from the Vietnam Vascular Registry, only 22 patients with known vascular trauma had missile emboli (0.3%), and of those, only 4 (.0005%) were to the pulmonary artery. Causative agents of missile embolism are numerous and are often a considerable diagnostic and therapeutic challenge. We believe this is the first reported case clearly demonstrating venous fragment embolus to the pulmonary artery from the lower extremity, specifically the popliteal vein using x-rays pre- and post-migration. The fragment was created when a ground-fired rifle bullet shattered the inferior nose bubble of a military helicopter, and a mixture of material was subsequently introduced into the popliteal fossa of the navigator. We also offer a review of the literature and introduce an algorithm for the workup and management options of missile emboli.
[Show abstract][Hide abstract] ABSTRACT: Methadone is increasingly prescribed for chronic pain, yet the associated mortality appears to be rising disproportionately relative to other opioid analgesics. We review the available evidence on methadone-associated mortality, and explore potential pharmacokinetic and pharmacodynamic explanations for its greater apparent lethality. While methadone shares properties of central nervous system and respiratory depression with other opioids, methadone is unique as a potent blocker of the delayed rectifier potassium ion channel (IKr). This results in QT-prolongation and torsade de pointes (TdP) in susceptible individuals. In some individuals with low serum protein binding of methadone, the extent of blockade is roughly comparable to that of sotalol, a potent QT-prolonging drug. Predicting an individual's propensity for methadone-induced TdP is difficult at present given the inherent limitations of the QT interval as a risk-stratifier combined with the multifactorial nature of the arrhythmia. Consensus recommendations have recently been published to mitigate the risk of TdP until further studies better define the arrhythmia risk factors for methadone. Studies are needed to provide insights into the clinical covariates most likely to result in methadone-associated arrhythmia and to assess the feasibility of current risk mitigation strategies.
No preview · Article · Feb 2009 · Cardiology journal
[Show abstract][Hide abstract] ABSTRACT: PURPOSE/AIM
1. Present multiple documented cases of improvised explosive device (IED) fragment and bullet emboli. 2. Increase awareness of this rare but increasing occurrence. 3. Propose problems with imaging that may reduce detection such as obscuration of intravascular lesions with IV contrast and fragments misread as “radiographic artifact.”
- Present images of IED and bullet fragments within soft tissue and venous structures that demonstrate interval migration into vital structures such as the right heart ventricle, posterior cerebral artery, and pulmonary arteries. - Discuss optimal imaging techniques that referring providers and radiologists need to be aware of to increase detection. - Explain the “Even Number Guide” which recommends counting the entrance/exit wounds and fragements found on clinical exam and on images.
- Increase awareness and optimize imaging of this unusual but increasing phenomenon given the current wartime environment. - Perform comprehensive review of the literature. - Manage fragment embolus according to symptoms, its location in the vascular system, and risk versus benefit of extraction.