Treatment of Catheter-related Bacteremia with an Antibiotic Lock Protocol in Hemodilaysis Patients / 대한신장학회잡지

BACKGROUND: Catheter-related bacteremia is a frequent complication among hemodialysis patients using a tunneled cuffed catheter. The standard therapy of catheter-related bacteremia involves both systemic antibiotics and catheter replacement. This study was performed to evaluate the effect of antibiotic lock therapy in conjugation with systemic antibiotics without catheter removal on catheter-related bacteremia. METHODS: Thirty six chronic hemodialysis patients with tunneled cuffed catheter were monitored for infection between July 2001 and July 2005. We analyzed the efficacy of antibiotic lock protocol compared with systemic antibiotics alone. RESULTS: Twenty-nine episodes of catheter-related bacteremia occurred in 27 patients during the study periods. The incidence of catheter-related bacteremia was 1.5 episodes/1000 catheter-days. A single gram-positive coccus grew in the 16 cases (55.2 %), and gram-negative organisms grew in the 69 cases (31.0%). Sixteen of 18 patients (88.9%) treated with antibiotic lock protocol had successful catheter salvage versus only 6 of the 11 patients (54.5%) treated with systemic antibiotics alone (p=0.05). Three patients with Burkholderia pickettii and a patient with Acinetobactor calcoaceticus-baumannii complex were treated with antibiotic lock protocol with systemic ciprofloxacin and imipenem, respectively. CONCLUSION: This study suggests that antibiotic lock protocol in eradicating catheter-related bacteremia is effective treatment without requiring catheter replacement.

A Case of Tunneled Cuffed Catheter Dysfunction Treated with Fibrin Sheath Stripping / 대한신장학회잡지

With the increasing proportion of elderly and diabetic dialysis patients, permanent dual lumen catheters are becoming popular. One of the most frequent causes for the failure of hemodialysis in CRF patients with the tunneled cuffed catheter is the catheter dysfunction. It is thought to be due to encasement of the catheter by fibrin sleeve or fibrin sheath, kinking or malposition of the catheter. Catheter dysfunction due to fibrin sheath formation could sometimes be managed by reversal of arterial and venous lines, urokinase lock or infusion, and catheter exchange. Recently percutaneous fibrin sheath stripping (PFSS) became another modality of salvaging failing tunneled cuffed catheter before attempting catheter exchange. There was no report of applying PFSS to salvage the permanent dual lumen catheter in Korea. Authors recently experienced a case of successful application of PFSS to extend the life of catheter in a CRF patients as a last resort after failure of repeated urokinase trials. It is thought that PFSS is a simple and effective procedure which extends the longevity of permanent dual lumen catheter.

A Case of Gastric Mucinous Adenocarcinoma Presenting as a Characteristic Mucin Pool / 대한소화기내시경학회지

Mucinous adenocarcinoma is a rare histologic type of gastric carcinoma. Most mucinous gastric carcinoma is diagnosed by histology after surgical resection. However, in this report, we preoperatively predicted the type of a tumor (mucinous type) from its characteristic endoscopic finding. An endoscopic examination showed a cauliflower-like mass on the upper body of the posterior wall. At first we could not find the mass because it was covered with a thick mucin-like substance. After gastric lavage and mucin aspiration we found a tumor mass which was surrounded with a characteristic mucin pool. Abdominal CT showed a 6 cm sized-mass connected with the gastric fundus. Total gastrectomy with esophagojejunostomy was performed. The pathology of the tumor proved to be a mucinous adenocarcinoma.

Radiologic Findings of Direct Splenic Invasion by Malignant Tumors of Adjacent Organs

PURPOSE: To evaluate the radiologic findings of direct invasion of the spleen by malignant tumors of adjacent organs. MATERIALS AND METHODS: We retrospectively reviewed the CT(n=6) and MR(n=3) images of six patients with direct invasion of the spleen by malignant tumor of left lower lung, stomach, colon, pancreas, left kidney, and left adrenal gland. We evaluated the tumor margin, attenuation or intensity, perisplenic fat infiltration, regional lymphnode enlargement, and invaded site of the spleen. RESULTS: Ill-defined masses were found in the spleen with central necrosis and infiltration into perisplenic fatty tissue in all six patients; left adrenal mass was present also in three patients. Regional lymphnode enlargement was found in four patients. The masses showed heterogenous low attenuation on CT. The invaded site was variable and corresponding to their anatomical connections to the spleen. CONCLUSION: Direct invasion of the spleen by malignant tumors of adjacent organs showed ill-defined masses with central necrosis and were commonly associated with infiltration to perisplenic fatty tissue and adrenal invasion. The pattern and invaded site can be helpful to assess the primary cancer.

Value of Real-time Compound US in Diagnosis of Malignant Tumor in Breast Comparing with Conventional US, and Pulse Inversion Harmonic Images

PURPOSE: To compare the usefulness of real-time compound US (RCUS) with that of conventional US (CUS) and pulse inversion harmonic (PIH) imaging in the diagnosis of malignant breast tumors. MATERIALS AND METHODS: In 22 female patients whose mean age was 49 years, we evaluated the RCUS findings of pathologically proven [core biopsy (n=9), mammotome tissue bigpsy (n=10), excisional bispsy (n=3)] malignant breast tumors, comparing them with the findings of CUS and PIH imaging. Evaluation of these masses was in terms of their marginal distinction, internal echogenicity, boundary and posterior echo pattern, relationship with the adjacent lactiferous ductal system, and the presence of necrosis (12/22) and calcification (6/22). RESULTS: In terms of marginal distinction, internal echogenicity, boundary echo patterns, and the relationship with adjacent ductal system, RCUS was superior to both conventional US and PIH Imaging (p<0.05). CONCLUSION: For the diagnosis of malignant breast tumors RCUS was more useful than CUS or PIH imaging.

Celiac Axis Stenosis: Incidence and Etiologies in Asymptomatic Individuals

OBJECTIVE: To determine the incidence and etiologies of celiac axis stenosis in asymptomatic individuals. MATERIALS AND METHODS: This prospective study involved 400 consecutive patients (male: 319, female: 81) referred to us for celiac arteriography between April and July 1999. When celiac axis branches were opacified by collateral circu-lation during superior mesenteric arteriography, the presence of celiac axis stenosis was suspected; lateral projection celiac rteriography was performed and the pressure gradient was measured. The indicators used to determine whether or not celiac axis stenosis was significant were luminal narrowing of more than 50% and a resultant pressure gradient of at least 10 mmHg. Its etiology was deter-mined on the basis of angiographic appearances and CT findings. RESULTS: Twenty-nine patients (7.3%) had celiac axis stenosis. The etiology of the condition was extrinsic compression due to the median arcuate ligament in 16 patients (55%) and atherosclerosis in three (10%), while in ten (35%) it was not determined. The incidence of celiac axis stenosis did not vary significantly according to sex, age and the presence of calcified aortic plaque representing atherosclerosis. CONCLUSION: The incidence of hemodynamically significant celiac axis stenosis in this asymptomatic Korean population was 7.3% and the most important etiology was extrinsic compression by the median arcuate ligament of the diaphragm. Atherosclerosis was only a minor cause of the condition.

Gadolinium-Enhanced MR Angiogra p hy of Arterial Occlusive in Lower Extremity: Comparison with Conventional Digital Substraction Angiography

PURPOSE: To compare the diagnostic value of gadolinium-enhanced MR angiography with that of conventional digital substraction angiography for the evaluation of lower extremity arterial occlusive diseases. MATERIALS AND METHODS: In 26 patients with symptomatic lower extremity arterial occlusive disease, both conventional digital substraction angiography(DSA) and gadolinium-enhanced MR angiography (CE-MRA) were performed during the same week. MR angiography was performed using three-dimensional gradient-echo ac-quisition before, and two sequential acquisitions after, the administration of gadolinium(0.2 mmol/kg). In 23 patients, two separate, contiguous areas were scanned using additional doses. In three patients, only one field with a suspicious lesion was scanned. Three radiologists independantly analysed the CE-MRA and DSA find-ings of each vascular segment(20 segments per arterial tree) for the presence of obstructive lesions; the grade assigned was either mild or none (>50 %), stenotic(50 %-99 %),or occlusion(100 %). RESULTS: From among a total of 462 segments, DSA detected 99 which were significantly narrowed (stenosis, 33; occlusion, 66). Using MR angiography, 102 segments(stenosis 39; occlusion, 63)were identified, and 94 lesions (stenosis, 32; occlusion 62) were graded correctly. Seven lesions were overestimated and four were un-derestimated. For the detection of hemodynamically significant stenosis or occlusions using MR angiography, sensitivity, specificity, and diagnostic accuracy were 95%, 98%, and 98% (G=0.995, P<0.001), respectively. To prove the absence of lesions, we repeated DSA in two patients with arterial spasm due to puncture. Three occluded segments seen on DSA, which revealed intact segments on MR angiography, suggested slow distal flow after reconstitution. CONCLUSION: For the evaluation of lower extremity arterial occlusive disease, the diagnostic value of gadolini-um-enhanced MR angiography is comparable with that of digital substraction angiography. The advantages of the former are the absence of puncture-related spasm and visualization of slow distal flow.

Retroperitoneal Fibrosis: Spectrum of Imaging Findings

Retroperitoneal fibrosis is a fibroproliferative process involving the retroperitoneum. It may be idiopathic or can be caused by methysergide ingestion, perianeurysmal inflammation, a leaking aneurysm, urinoma or irradiation. The symptoms and signs of retroperitoneal fibrosis are variable, and for diagnosis, imaging is therefore essential. The typical imaging finding is a fibrotic lesion in front of the lower vertebrae with ureteral obstruction. Atypical lesions, however, may occur in other parts of the retroperitoneum. The aim of this report is to describe the clinical features and various imaging findings of etroperitoneal fibrosis.