Risk factors and possible mechanisms of intravenous port catheter migration.

OBJECTIVE: To identify the risk factors for catheter migration and demonstrate possible mechanisms of this migration. DESIGN: Retrospective study. SETTING: Chang Gung Memorial Hospital, a tertiary medical centre in Taiwan. PATIENTS: Patients who underwent implantation of intravenous ports via the superior vena cava (SVC). INTERVENTIONS: Procedures involving catheter placement and re-intervention for catheter migration. MAIN OUTCOME MEASURES: The anatomic location of the catheter tip was confirmed by plain chest X-rays (postero-anterior view). From these plain radiographs, the distance (in cm) between the carina and catheter tip and the angle (in degrees) between the locking nut and catheter were measured. METHODS: A total of 1542 procedures related to intravenous port implantation were retrospectively reviewed but only procedures involving implantation via the SVC were included in the analysis. The study group was composed of 31 interventions because of catheter migration, while the control group consisted of 1475 implantation and re-intervention procedures except those involving catheter migrations. RESULTS: Shallow catheter-tip location (p < 0.0001) and the presence of lung cancer (p = 0.006) were risk factors for catheter migration. CONCLUSIONS: Shallow catheter-tip location and the presence of lung cancer are risk factors for catheter migration. Strategies that ensure low catheter-tip location and avoid increased thoracic pressure may be useful preventive measures.

Visceral artery aneurysm: risk factor analysis and therapeutic opinion.

OBJECTIVES: To identify independent risk factors for visceral artery aneurysms. METHODS: Retrospective medical record review over 10 years. RESULTS: There were 26 men and 15 women, median age of 54 (range 22 to 85), and median follow-up was 20.6 months (range 0 to 94 months). There were 11 splenic, 17 hepatic, 8 gastroduodenal, 6 pancreatoduodenal, 5 superior mesenteric, and two inferior mesenteric artery aneurysms. Thirteen patients (13/41, 31.7%) were treated surgically without adjuvant endovascular intervention. Nineteen patients (19/41, 46.3%) were treated exclusively using endovascular procedures. Five patients (5/41, 12.2%) received second endovascular or surgical treatment as salvage procedure after the first procedure failed. Concomitant malignancy was positive predictors for in-hospital death. Renal failure, chronic lung disease, liver cirrhosis, previous abdominal surgery and concomitant malignancy were positive predictors of 2-year mortality. With the intention to treat in the whole cohort, less than 10% (2/21) of the endovascular treatments failed, compared to 18.5% (3/16) in the surgical group. Patients treated by surgery without aid of endovascular intervention, have lower 2-year mortality. In hospital-death rate was 9.8%, while overall mortality rate was 21.9%. CONCLUSIONS: The endovascular intervention provides compatible, even better early postoperative outcomes for visceral artery aneurysms to surgery. Concomitant malignancy was the major determinant of visceral artery aneurysms, both in-hospital death and survival.

Aortic valve endocarditis presents as pseudoaneurysm of the superior mesenteric artery.

Mycotic aneurysms are an important cause of morbidity and mortality in endocarditis despite advanced antibiotic therapy. Visceral artery aneurysms are uncommon and usually remain clinically silent until rupture. We now report a case of successful surgical treatment of a superior mesenteric mycotic aneurysm of the superior mesenteric artery, followed by a review of pertinent clinical information.

Limb preservation by Gore-Tex vascular graft for groin recurrence after postoperative adjuvant radiation in vulvar cancer.

BACKGROUND: Recurrent vulvar cancer involving the femoral artery after groin radiation is usually considered inoperable. A patient with such recurrent vulvar cancer successfully treated by femoral vascular graft and rectus abdominis myocutaneous flap reconstruction with limb salvage is described. CASE: A 51-year-old woman had recurrent vulvar cancer involving the right femoral vessels 6 months after a radical vulvectomy plus inguinal lymphadenectomy and postoperative pelvic and groin radiation. Radical en bloc excision of tumor along with the involved femoral artery and vein followed by Gore-Tex vascular graft and rectus abdominis myocutaneous flap reconstruction led to a complete remission. However, occlusion of the grafted vessels occurred 21 months following bypass surgery. Since the compensatory collaterals were established, debridement and removal of the occluded graft were carried out. The patient has been clinically free of disease for more than 48 months since graft reconstruction surgery. CONCLUSION: It is highlighted that aggressive tumor resection with limb salvage is feasible even for patients with vulvar cancer of the groin recurrence involving the femoral artery after primary surgery and groin radiation.

Thoracic outlet syndrome caused by first rib hemangioma.

We report a case of first rib hemangioma that caused thoracic outlet syndrome. A 50-year-ole woman who was admitted to our hospital with a clinical diagnosis of thoracic outlet syndrome presented with fullness and easy fatigue of her right arm. Her right arm discomfort was associated with intermittent engorgement of superficial veins over the shoulder girdle. A chest radiograph revealed an enlargement of the anterior aspect of the first rib with fine bony trabeculations. Computed tomography scan showed contrast enhancement over the enlarged rib. Our tentative preoperative diagnosis was a benign first rib hypertrophic change, such as an old fracture with exuberant callus formation. A right-arm venogram revealed a patent subclavian vein with an extrinsic compression, which occluded on arm abduction. The findings of neural conduction studies of both upper extremities were symmetric and normal. The patient agreed to surgery because of the occlusive condition of the subclavian vein on arm abduction and progressive arm weakness in recent months. Segmental transection of the offending portion of the enlarged first rib was complicated by difficulty in isolating the whole length of the compressed but normal-appearing subclavian vein by our initial transaxillary and infraclavicular approaches because the medial aspect of the subclavian vein was obstructed by the enlarged first rib, which extended medially to the junction of the right jugular and subclavian veins. Successful segmental transection of the enlarged first rib was finally accomplished by combined transaxillary, infraclavicular, and supraclavicular approaches. A moderate amount of rib bleeding from resection ends was noted during segmental resection of the enlarged first rib, resulting in local hematoma formation. A 470-mL bloody discharge was collected from the vacuum ball inserted via the transaxillary route during her 12-day hospitalization. Pathologic examination revealed an intraosseous hemangioma. The patient had a prolonged course to partial recovery of her arm numbness, but signs of venous compression were much improved at 6 months' follow-up. Although hemangioma is benign, its hypervascular nature may cause catastrophic intraoperative bleeding.

Toward an understanding of mothering: the care giving process of mothers with autistic children.

The purpose of this study was to explore the care-giving experience of mothers with autistic children. In this qualitative study, a focus group and in-depth interviews were conducted with mothers with an autistic child to uncover the nature of their mothering experience. Data were analyzed for themes with the constant comparison approach of grounded theory. Three themes emerged: (a) the perception about their disabled child; (b) their special concerns for caring for this child and (c) reclaiming and discovering self through understanding the meaning of mothering. The results can help health workers to gain a deeper understanding of the care-giving process for mothers with an autistic child and facilitate mothers to find the meaning of care and their well-being.

Extrasplenic pseudoaneurysm. The role of color flow Doppler ultrasound in diagnosis.

Pseudoaneurysm of the splenic artery has been rarely reported and the Doppler echocardiographic finding seldom described. Herein we report a rare case of huge extrasplenic pseudoaneurysm, which was detected by color flow Doppler ultrasonography and successfully treated by ligation of the splenic artery and resection of the pseudoaneurysm.

The possible role of magnesium in protection of premature infants from neurological syndromes and visual impairments and a review of survival of magnesium-exposed premature infants.

The survival rate of very preterm, low birth weight infants (weighing less than 1500 g) is 85 per cent in the USA and is ever increasing, while 42 to 75 per cent of extremely premature infants (weighing 751-1000 g) survive. Of great concern is the lack of consistent decrease in neurological syndromes and associated visual impairments. Because of short gestations, these infants have not had time to accrue up to 80 per cent of magnesium normally present at term. These very preterm infants are at highest risk for cerebral hypoxia/ischemia (H/I), intracranial hemorrhage (ICH), periventricular leukomalacia (PVL) or cystic PVL (CPVL), and possible sequelae, cerebral palsy (CP) and mental retardation (MR). These syndromes are associated with damage to optic structures and the visual pathways which traverse the brain. Visual defects are common in surviving preterm infants. Increased levels of harmful neurochemical mediators that have been reported in these conditions include oxygen free radicals, excitatory amino acids, tumor necrosis factor-alpha (TNF-a), and thromboxane A2 (TXA2) which are aggravated in magnesium deficiency and may be ameliorated by magnesium. We review the published data concerning the effects of prenatal magnesium supplementation on ICH, CPVL, CP and MR and available reports concerning survival. Further considerations on the safety and efficacy of magnesium sulphate administration given prenatally to the preterm neonate await the outcome of three trials that are continuing for more than a year on three continents.

Adrenal cancer with hypertension but low plasma renin and aldosterone.

Patients with malignant lesions of the adrenal gland may present with a syndrome of excess mineralocorticoids. Both primary hyperaldosteronism and excess mineralocorticoids other than aldosterone resulting from adrenal carcinoma have rarely been reported. In most patients with adrenal tumors secreting mineralocorticoids other than aldosterone, distant metastasis had already occurred at the time of diagnosis and the prognosis was poor. We present a rare case of adrenal cancer with hypertension in a patient with low plasma renin activity and a low plasma aldosterone concentration. The patient's blood pressure returned to normal after removal of the tumor. The patient is still alive and without recurrence 6 years after surgery. This case illustrates the value of thorough evaluation of hypertension and prompt surgical treatment for patients with adrenal cancer.

Minimally invasive cardiac surgery for intracardiac congenital lesions.

OBJECTIVE: Minimally invasive cardiac surgery has recently been applied to the correction of intracardiac lesions. This report reviews our experience of minimally invasive cardiac surgery in 119 patients with intracardiac congenital lesions. METHODS: From October 1995 to April 1997, 119 patients (48 male and 71 female, aged 0.9-65 years old, 18.5+/-17.8) received elective minimally invasive cardiac surgery at Chang Gung Memorial Hospital, Taipei, Taiwan for repair of atrial septal defect (96 patients) or ventricular septal defect (23 patients). The operations were performed through right submammary incision (ASD) or left parasternal minithoracotomy (VSD), under femoro-femoral or femoro-atrial cardiopulmonary bypass with fibrillatory arrest. RESULTS: All of the defects were repaired successfully. The bypass time was 25-125 min (46+/-18). The operation time was 1.5-5.2 h (2.8+/-0.8). The postoperative course was uneventful in all patients. Follow-up (1.0-18.2 months, mean 7.3) was complete, with no late deaths or residual shunt. All patients were found to be in NYHA functional class I or II. CONCLUSION: Our experience demonstrate that minimally invasive cardiac surgery is a technically feasible, safe, and effective procedure in surgical correction of selective simple intracardiac congenital lesions, yielding good short-term results.

Video-assisted cardiac surgery for intracardiac tumors.

OBJECTIVE: To present our experience in surgical excision of intracardiac tumors in three patients using video-assisted cardiac surgical techniques. METHODS: Three patients received emergency video-assisted cardiac surgery for excision of right atrial or left atrial tumors. These surgeries were performed through right anterior submammary minithoracotomies and guided by video-assisted endoscopic techniques by projected images on a video monitor while under femoro-femoral cardiopulmonary bypass. The myocardium was protected by continuous coronary perfusion with fibrillatory arrest. Conventional instruments were used. RESULTS: All but one of the tumors were excised completely. The bypass time was 88-148 min. The operation time was 3.5-4.4 h. There were no operative deaths. Pathological examination of the tumors showed left atrial myxoma, metastatic left atrial choriocarcinoma, and right atrial lymphoma. One patient died from non-cardiac origin 5 weeks after discharge. Follow-up was completed with the two survivors. Transthoracic echocardiographic examination showed good ventricular function without any residual tumors. They were both in New York Heart Association functional class I or II. They were satisfied with the cosmetic healing of their incisions. CONCLUSION: Video-assisted cardiac surgery is technically feasible and can be performed in surgical excision of intracardiac tumors.

Internal iliac artery aneurysmo-rectal fistula associated with multiple aortoiliac aneurysms.

Fistular communication between an internal iliac artery aneurysm and rectum presenting as massive lower gastrointestinal tract bleeding is a rare entity in clinical practice. Prompt diagnosis and experienced therapeutic application determine the outcome. Herein we report the successful management of such a complication. A 68-year-old male had multiple aneurysms over the abdominal aorta and bilateral iliac arteries. It was the largest aneurysm arising from the right internal iliac artery which ruptured into the rectum and resulted in massive hematochezia. After extraanatomical bypass with right axillo-femoral and femoro-femoral crossover grafts to restore the circulation to the bilateral lower limbs, the infrarenal abdominal aorta just immediately above the proximal aneurysm was transected and closed as a blind stump. All the aneurysms were included in this resection and as much of the infected aneurysm tissue was debrided as possible. The rectum was exteriorized using Hartmann's procedure. The patient survived the operation and was discharged in good condition.

Continuous antegrade warm blood cardioplegia attenuates augmented coronary endothelium-dependent contraction after cardiac global ischemia and reperfusion.

BACKGROUND: Experiments were designed to evaluate the effect of warm blood cardioplegia on endothelium-dependent contraction of the coronary endothelium after cardiac global ischemia and reperfusion. METHOD: Dogs (n = 12 in each group) were exposed to extracorporeal circulation with the body temperature at 37 degrees C (group 1) or 28 degrees C (groups 2 and 3). The ascending aorta was crossclamped for 120 minutes while continuous infusion of warm blood cardioplegec solution (group 1) or intermittent infusion of cold (4 degrees C) crystalloid cardioplegic solution (group 2) was performed via the coronary arteries through the aortic root. Cardioplegic solution was not used in group 3 animals. The heart was then allowed to function for 60 minutes of reperfusion. Reperfused (groups 1, 2, and 3) and control (group 4) coronary arteries were then harvested for study. RESULTS: Perfusate hypoxia caused endothelium-dependent contraction in the arteries of all four groups that could be attenuated by NG-monomethyl-L-arginine (L-NMMA) or L-NMMA plus D-arginine, but not by L-NMMA plus L-arginine or endothelin receptor A and B antagonist PD 145065. The endothelium-dependent contraction results in groups 2 and 3 (75% +/- 4% and 80% +/- 5%, respectively) were significantly greater than those in groups 1 and 4 (15% +/- 3% and 18% +/- 5%, respectively). Scanning electron microscope studies showed that platelet adhesion and aggregation, areas of microthrombi, disruption of endothelial cells, and separation of the intercellular junction could be found in coronary segments from groups 2 and 3, but not in vessels from groups 1 and 4. CONCLUSION: These experiments suggest that global ischemia and reperfusion enhances hypoxia-mediated endothelium-dependent contraction of the coronary endothelium and damages the ultrastructure. These kinds of changes can be prevented by continuous antegrade infusion of warm blood cardioplegic solution during global ischemia.

Isolated common iliac artery occlusion secondary to atherosclerotic plaque rupture from blunt abdominal trauma: case report and review of the literature.

Traumatic isolated common iliac artery occlusion is unusual. Only rare cases of common iliac arterial injuries resulting from blunt abdominal trauma have been reported, and most of them were attributed to the seat-belt syndrome and associated with visceral organ perforation or pelvic fracture. We reported an unusual isolated common iliac artery occlusion secondary to atherosclerotic plaque rupture from blunt abdominal compressive trauma without other visceral injury. This case presented with acute limb ischemia and paralysis that was successfully treated by thromboendarterectomy. The symptoms and signs, surgical modalities, and associated injuries were reported and the literature was also reviewed.

[Investigation on the parasites of alien laborers in Kaohsiung].

In the past year, stool specimens of 1,732 alien laborers were examined for intestinal parasites. There was no significant difference in the positive rate between males and females. All alien laborers were examined in 3 hospitals and the positive rates were 24.8% (191/769), 13.6% (109/804) and 12.6% (20/159). Broken down by nationality, the positive rates in laborers from Thailand, Indonesia, the Philippines and Malaysia were 23.9% (192/803), 20.3% (62/305), 12.1% (60/498) and 4.8% (6/126) respectively. Of all alien laborers, 17.2% (297/1,732) had single infections of parasites and 1.3% (23/1,732) had multiple infections. Opisthorchis viverrinii was the most prevalent parasite found in infected alien laborers. 91.5% of alien laborers were aged from 21 to 40-years-old and had positive rates of parasites reaching 91.0%. The time of arrival in Taiwan had an effect in all alien laborers examined for parasites. The positive rate in laborers arriving during April to June was 22.7% which was significantly higher than the 16.3% for laborers arriving in other months.

Value of immunoperoxidase staining of thyroglobulin in fine needle aspiration cytology of thyroid diseases.

To elucidate the value of thyroglobulin staining by the immunoperoxidase method in fine needle aspiration cytology of thyroid diseases, it was performed on fine needle aspiration smears of 57 cases of various thyroid diseases. Thirteen of 22 cases (59%) with benign nodular goiter were positive. Eight of 14 cases (57%) with papillary thyroid carcinoma were positive. Among these eight cases with positive staining, seven were at clinical stage II or less. Among the other six cases with negative staining, five cases were in clinical stage III or more. There was a significant relationship between clinical stage and thyroglobulin staining (P < .05). One of 10 cases with thyroid cysts was positive. One of four cases with anaplastic carcinoma was positive. One of two cases with follicular thyroid carcinoma was positive. Two cases of subacute thyroiditis were positive. One case of Hashimoto's thyroiditis was positive. Two cases of metastatic thyroid cancer from the ovary were negative. These results reveal that positive thyroglobulin staining was helpful in defining the source of tissue from the thyroid. However, negative staining could not definitively exclude a thyroid origin. Positive thyroglobulin staining in papillary thyroid carcinoma correlated with less advanced clinical stages.

A novel antibiofilm technology for contact lens solutions.

PURPOSE: Nonsteroidal anti-inflammatory drugs, including sodium salicylate, inhibit extracellular bacterial biofilm production. The authors studied the effect of the addition of sodium salicylate on bacterial adherence and biofilm formation on contact lenses and cases and commonly used medical polymers. METHODS: The study was done in vitro with bacterial adherence and biofilm measured on lenses and cases that were exposed to saline contaminated with Staphylococcus epidermidis and Pseudomonas aeruginosa with and without 1 and 3 mm sodium salicylate. Bacterial adherence to contact lenses was quantitated by a vortex assay and by scanning electron microscopy. Biofilm formation on contact lens cases and other polymers was measured by an optical density assay and a radiolabeling assay. RESULTS: Inhibition of biofilm formation was demonstrated on plastic contact lens cases in a dose-related manner with 1 and 3 mm sodium salicylate. A dose-related decrease in bacterial adherence also was noted. Assays with contact lenses also demonstrated less adherence in the presence of sodium salicylate. Electron micrographs of the contact lens showed less biofilm, most noticeable with 3 mm salicylate. Other studies demonstrated decreased adherence of S. epidermidis to polyethylene and polystyrene. Sodium salicylate also decreased biofilm on plastic tissue culture wells, but sorbic acid paradoxically increased deposition. CONCLUSION: The authors found that the addition of low-dose sodium salicylate to saline decreased the adherence of S. epidermidis and P. aeruginosa to contact lenses and lens cases. Biofilm production also was decreased on the lens cases and on medical polymers used to make plastic cases. These studies suggest that sodium salicylate deserves additional study to determine its use in contact lens solutions.

Endothelium-dependent contraction of canine coronary artery is enhanced by crystalloid cardioplegic solution.

Experiments were designed to determine whether hyperkalemic crystalloid cardioplegic solution enhances endothelium-dependent contraction of coronary arteries. Segments of canine coronary arteries (n = 8 in each group) were preserved in cold (4 degrees C) crystalloid cardioplegic solution (group 1) and physiologic solution (group 2) for 60 minutes. Segments of preserved and control (group 3) coronary arteries with or without endothelium were suspended in organ chambers to measure isometric force. Perfusate hypoxia (oxygen tension 35 +/- 5 mm Hg) caused endothelium-dependent contraction in the arteries of all three groups. However, vascular segments with endothelium of group 1 exhibited hypoxic contraction (68.5% +/- 15.3% of the initial tension contracted by prostaglandin F2 alpha 2 x 10(-6) mol/L, p < 0.05) that was significantly greater than contraction of the group 2 and group 3 segments with endothelium (26.6% +/- 5.6% and 20.6 +/- 4.4%). The hypoxic contraction in arteries of group 1 could be attenuated by NG-monomethyl-L-arginine, the blocker of endothelial cell synthesis of the nitric oxide from L-arginine. The action of NG-monomethyl-L-arginine could be reversed by L-arginine but not D-arginine. Thus after preservation with cardioplegic solution, augmented endothelium-dependent contraction, occurs by L-arginine-dependent pathway, would favor coronary vasospasm after cardiac operation.

Enhancement of endothelium-dependent contraction of the canine coronary artery by UW solution.

University of Wisconsin (UW) solution has been used almost routinely in the preservation of the hepatic, pancreatic, renal, and cardiac allografts. However, its effect on vascular endothelium is unknown. Experiments were designed to evaluate its effect on canine coronary endothelium. Canine coronary arteries (n = 8 in each group) were preserved in cold (4 degrees C) UW solution (group 1) and physiological solution (group 2) for 6 hr immediately after harvesting. Segments of preserved and control (group 3) coronary arteries with or without endothelium were then suspended in organ chambers to measure isometric force. Perfusate hypoxia (pO2 30 +/- 5 mmHg) caused endothelium-dependent contraction in the arteries of all 3 groups. However, vascular segments with endothelium of group 1 exhibited hypoxic contractions (107 +/- 26% of the initial tension contracted by prostaglandin F2 alpha 2 x 10(-6) mol/L, P < 0.05) that were significantly greater than those of the group 2 and group 3 segments with endothelium (25 +/- 5% and 20 +/- 4%). The hypoxic contraction in arteries of group 1 could be attenuated by NG-monomethyl-L-arginine (L-NMMA), the blocker of endothelial cell synthesis of the nitric oxide from L-arginine. The action of L-NMMA could be reversed by L-arginine but not D-arginine. Endothelium-dependent relaxation of coronary endothelium to acetylcholine and adenosine diphosphate and endothelium-independent relaxation and contraction of coronary smooth muscle were not altered by the UW solution. After preservation with the UW solution, endothelium-dependent contraction of the canine coronary arteries, occurs by L-arginine-dependent pathway, is enhanced. This augmentation by the UW solution would favor vasospasm after transplantation.

Imaged thoracic resection of a huge mediastinal tumor--role of extended incision and the use of conventional instruments.

Intrathoracic lesions are usually removed through conventional thoracotomy. The long incision and the spreading of the rib usually results in much pain and interference of chest wall mechanics. Today, with the development of imaged thoracic surgery (combination of thoracoscope and video optics), major procedures can be performed through small incisions. However, indications are greatly limited due to lack of suitable instrumentation and restricted space of the trocar channel especially when a huge intrathoracic tumor is encountered. In this selected report, we demonstrate a successful procedure using extended incision and conventional instruments in imaged resection of a huge cystic intrathoracic tumor. The procedure offers the benefit of safe, easy and fast manipulation. The patient had an uneventful postoperative course and was discharged on the fourth postoperative day.