Hepatic radiation injury in distal esophageal carcinoma: a case report.

The liver is an organ at particular risk for toxicity after radiotherapy for distal esophageal cancer. We report the case of a 58-year-old man with distal esophageal carcinoma, who underwent follow-up FDG-PET/CT 6 weeks after completion of preoperative neoadjuvant chemoradiotherapy. The left hepatic lobe and caudate showed new, round areas of hypoenhancement on CECT and increased FDG-uptake, which resembled metastases. However an, as yet unreported, linear configuration of FDG uptake was noted and found to correlate with the anterior posterior-posterior anterior opposing field radiotherapy portal.

Reactive keratoma of the central corneal epithelium.

PURPOSE: The authors present a unique corneal tumor. METHODS: A 75-year-old gardener presented with a 1-year history of a slowly growing central corneal lesion with progressive visual loss. We performed an ophthalmic examination, slit lamp photography, high-frequency ultrasonography, and culture with sensitivity (followed by therapeutic scrape biopsy). RESULTS: Clinical examination revealed a gray-white central corneal tumor without extension to the limbus. No significant tumor neovascularization or intraocular inflammation was noted. High frequency ultrasound revealed no penetration of the corneal stroma. The tumor was removed with a platinum spatula. Histopathology revealed simple hyperkeratosis characterized by stratified hyperkeratotic corneal epithelium with metaplastic granular layer characteristic of epidermis. Few and focal clusters of passenger bacteria were found (as seen in cutaneous leukoplakia). Cultures revealed a few Gram-positive cocci and no fungus. A human papilloma virus wide-screen spectrum assay (in situ hybridization) was negative. CONCLUSIONS: The authors present a benign keratoma of the central corneal epithelium. High frequency ultrasound and scrape biopsy histopathologic techniques were used to diagnose and treat this keratoleukoma caused by a reactive keratoma as well as improve his vision.

Retrobulbar hemorrhage nine days after cosmetic blepharoplasty resulting in permanent visual loss.

A healthy 45-year-old man had a retrobulbar hemorrhage 9 days after cosmetic upper eyelid blepharoplasty that resulted in permanent visual loss. After performing a left lateral canthotomy and cantholysis, intraocular pressure returned to normal and vision improved from no light perception to 20/40; however, the patient did have permanent visual field loss. To our knowledge, this is the longest period of time after blepharoplasty that a retrobulbar hemorrhage occurred. Ophthalmologists should have a heightened level of suspicion 1 to 2 weeks after surgery.

Azygos tip placement for hemodialysis catheters in patients with superior vena cava occlusion.

Chronic central venous access is necessary for numerous life-saving therapies. Repeated access is complicated by thrombosis and occlusion of the major veins, such as the superior vena cava (SVC), which then require novel vascular approaches if therapy is to be continued. We present two cases of catheterization of the azygos system in the presence of an SVC obstruction. We conclude that the azygos vein may be used for long-term vascular access when other conduits are unavailable and that imaging studies such as magnetic resonance venography, contrast-enhanced computed tomography or conventional venography can be employed prior to the procedure to aid with planning and prevent unforeseen complications.

Efficacy of superactivated charcoal administered late (3 hours) after acetaminophen overdose.

The purpose of this study was to investigate the effect of superactivated charcoal (SAC) given late after a drug overdose. Acetaminophen was chosen as our overdose drug because it has relatively few side effects, serum levels are easily attainable and measurable, and it is generally a common drug overdose. Forty-six healthy adult volunteers participated in this randomized, controlled study. Acetaminophen was administered the morning after an overnight fast. Thirteen participants received 2000 mg acetaminophen and the remaining 33 received 3000 mg. After 3 hours, half of the participants (22 of 46) received 75 g of SAC (Requa, Greenwich, CT) orally as a slurry in 8 oz of apple juice. Serum acetaminophen levels were measured at 4 and 7 hours after the initial acetaminophen administration. There were significantly lower uncorrected and corrected acetaminophen levels in the SAC group compared with the control group at both 4 and 7 hours after ingesting acetaminophen. This randomized human experimental design trial demonstrates some detoxification benefit in administering superactivated charcoal 3 hours after an overdose.

Acetaminophen levels 4 and 7 hours after 2000 and 3000 mg single doses in healthy adults.

PURPOSE: Therapeutic acetaminophen levels are not achieved at currently recommended doses. The purpose of this study is to determine acetaminophen levels in healthy adults after taking a single dose well in excess of the recommended dose. METHODS: 24 healthy adults received single 2 or 3 gram acetaminophen doses. Serum acetaminophen levels were drawn at 4 and 7 hours after the dose. RESULTS: The 2 gram doses (6 subjects) ranged from 23 to 40 mg/kg of body weight. The 3 gram single doses (18 subjects) ranged from 38 to 69 mg/kg of body weight. Mean 4-hour acetaminophen levels for 2 and 3 gram doses were 8.8 (SD 3.6, range 3-13) and 21.8 (SD 6.5, range 6-32) mcg/ml, respectively. Mean 7-hour acetaminophen levels for 2 and 3 gram doses were 1.5 (SD 1.4, range 0-3) and 7.7 (SD 4.6, range 0-17) mcg/ml, respectively. CONCLUSIONS: Dosing by weight (i.e., mg/kg) appears to provide a more predictable dose-response relationship. Optimal adult dosing appears to be somewhere in the 20 to 30 mg/kg range based on the premise that the 4 hour level is a trough level that should be in the low therapeutic range.

Adverse effects of superactivated charcoal administered to healthy volunteers.

OBJECTIVES: Activated charcoal is frequently administered to drug overdose patients, who may experience nausea and vomiting secondary to the drug overdose. Drinking a charcoal slurry orally may be difficult for them necessitating a gastric tube. The purpose of this study is to report the frequency of adverse effects from oral superactivated charcoal (SAC) given to healthy volunteers. METHODS: Healthy adult study subject volunteers were given a single 2000 mg (first 13 subjects) or 3000 mg (remaining 35 subjects) dose of acetaminophen. Subjects were randomized to receive no charcoal (ctrl) or 75 grams of SAC administered orally in a slurry 3 hours following the acetaminophen dose. The adverse effects of both groups were recorded and compared. RESULTS: There were 48 study subject runs. The mean age was 27.4 years (SD6.5). SAC was administered to 24 subjects. Adverse effect rates were as follows (*one-tail p < 0.05): black stool* (SAC 22/ 24, ctrl 0), constipation or abdominal fullness* (SAC 12/24, ctrl 0), nausea* (SAC 5/24, ctrl 0), vomiting (SAC 2/24, ctrl 0), diarrhea (SAC 2/24, ctrl 0), anal irritation (SAC 2/24, ctrl 0), drowsiness/fatigue (SAC 2/24, ctrl 3/24), dizziness/lightheadedness (SAC 0, ctrl 1/24), headache (SAC 4/24, ctrl 0). 7 of 24 SAC subjects and 20 of 24 ctrl subjects experienced no adverse effects at all* (other than black stools for the SAC subjects). Acetaminophen may have been blunted some adverse effects. Two SAC subjects could not finish the charcoal. For the 22 subjects who finished the charcoal, SAC consumption took a mean of 10.9 minutes (SD 11.8, range 1 to 50 minutes). Thirteen subjects finished it in 7 minutes or less. Six subjects took 19 minutes or longer to finish it. The 12 heavier subjects (> 71kg) completed SAC consumption significantly faster than the 12 lighter subjects (18.7 vs 7.8 minutes, p = 0.04, single sided). This comparison included the two subjects (both lighter) who did not finish SAC consumption, so this difference was no longer significant when these two subjects were removed. CONCLUSIONS: Superactivated charcoal consumption is associated with significant adverse effects in some healthy volunteers, which may impede a drug overdose patient's ability to willingly drink charcoal slurry in a reasonable period of time.