Atrial thrombosis: a near fatal complication of a Portacath.

Portacaths (Bard Medical Division, Georgia, USA) are routinely used for central venous access in patients with poor peripheral veins who require regular long-term venous access. Complications associated with central venous access devices, including infection and thrombosis, are well described in the literature; however, to our knowledge there have been few case reports of right atrial thrombi and pulmonary emboli related to implanted ports. This paper discusses the case of a patient who developed an atrial thrombosis 4 months after port placement and subsequent pulmonary emboli.

Isolates of cytomegalovirus (CMV) from the black rat Rattus rattus form a distinct group of rat CMV.

Two different betaherpesviruses, the English and Maastricht species of rat cytomegalovirus (CMV), have previously been isolated from Rattus norvegicus. CMVs were isolated from both the brown rat, R. norvegicus, and the black rat, R. rattus, within Australia. The viruses isolated from R. norvegicus appeared to be genetically related to the English species of rat CMV by PCR, RFLP, and sequencing, but the viruses isolated from R. rattus were distinct from both prototype virus species, although more closely genetically related to the Maastricht virus. This is the first genetic characterization of cytomegaloviruses from R. rattus, and the first isolation of CMVs from Australian rats.

Transtemporal facial nerve schwannoma without facial nerve paralysis.

Facial schwannoma is a relatively rare but well documented lesion, presenting either as a mass or with facial nerve symptoms. In this report, an extensive facial schwannoma, extending from the brain stem to the periphery with minimal facial nerve symptoms and normal facial function is presented.

Interventional radiology placement of twin Tesio catheters for dialysis access: review of 75 patients.

PURPOSE: To evaluate the safety and efficacy of modern interventional radiology techniques and imaging guidance for placement of jugular vein twin Tesio hemodialysis catheters. MATERIALS AND METHODS: Eighty-two sets (75 patients) of twin Tesio catheters were percutaneously placed in the right (n = 70) and left (n = 12) internal jugular veins with use of ultrasound (US) and fluoroscopic guidance. Immediate procedural and late complications were recorded. The efficacy of the Tesio system was also evaluated. RESULTS: With US and fluoroscopic guidance, the technical success for access and catheter placement was 100%. Measured dialysis blood flow rate of greater than 375 mL/min was obtained in 95% of the patients and recirculation averaged 4.6% +/- 5%. An inadvertent common carotid artery puncture occurred in one (0.6%) patient and prolonged exit site bleeding occurred in another five patients (3%). Each of these was successfully controlled with compression. More chronically, catheter thrombosis and exit site infection occurred each at the rate of 0.16 episodes per 100 catheter days. All thrombosis and exit site infections responded to local thrombolysis and antibiotic therapy, respectively. Bacteremia occurred in 20 patients and required catheter removal in five patients. There was no clinical evidence of upper extremity or superior central vein thrombosis. CONCLUSION: Placement of internal jugular, twin Tesio catheters with use of imaging and interventional techniques provides a safe and efficacious means of either short or long-term hemodialysis.

Sonographic guidance when using the right internal jugular vein for central vein access.

OBJECTIVE: The intent of this study was to substantiate the advantages of the use of sonographic guidance for central venous access via the right internal jugular vein. SUBJECTS AND METHODS: Eighty sequential patients requiring central vein access were examined with a hand-held sonography transducer to determine the size, patency, and location of the right internal jugular vein before puncture. Access to the right internal jugular vein was subsequently performed, under sterile conditions, using sonographic guidance. Periprocedural complications were prospectively recorded. Subsequently, we compared our findings with published reports of complications when visible and palpable anatomic landmarks were used for guidance during cannulation of the internal jugular vein. RESULTS: Among these 80 patients, the anatomy of the right internal jugular vein was typical in only 57 (71%). In another 13 patients (16%), sonography showed a medial position of the right internal jugular vein, anterior to the common carotid artery. In three other patients (4%), the right internal jugular vein was positioned laterally by more than 1 cm. In the remaining seven patients (9%), the vein was thrombosed. Its diameter, measured without use of the Valsalva maneuver, also varied, measuring 0.5-2.0 cm. Cannulation was achieved in all 73 patients with a patent right internal jugular vein. One puncture was required in 68 patients (93%); two punctures in three other patients (4%); and three punctures in the remaining two patients (3%). In no case was the common carotid artery inadvertently punctured. Only one periprocedural complication occurred, and it was unrelated to the use of sonographic guidance. CONCLUSION: Sonographic guidance for central vein access via the right internal jugular vein is safer and more efficient than the traditional landmark approach.

Vestibular schwannoma in an only hearing ear.

A vestibular schwannoma in an only hearing ear is a difficult management problem. A case is presented of a patient who had a Nucleus-22 channel device implanted into a nonfunctioning ear and auditory rehabilitation prior to resection of a large vestibular schwannoma in the contralateral ear.

Klippel-Feil syndrome associated with malformed larynx. Case report.

We report a case of a 45-year-old man with Klippel-Feil syndrome with fusion of the C2-3 and C4-5 cervical vertebrae and severe voice impairment associated with malformation of the laryngeal cartilages. The condition was also complicated by bilateral inflexibility of the arms and legs and external malformation of the ears. This case broadens the spectrum of anomalies, of branchial arch derivation, now identified in association with Klippel-Feil syndrome. We discuss the possibility that perturbation of segmentation, distinct from somitogenesis, may be linked to Klippel-Feil syndrome-associated craniofacial abnormalities.

Surgical treatment of tumours of the skull base.

OBJECTIVE: To describe the special features of surgical removal of tumours of the skull base and to review a series of patients treated for skull base tumours. DESIGN: A retrospective review of patients followed up for between six months and six years. SETTING: A unit specialising in surgery of the skull base at a tertiary referral centre. PATIENTS: Sixty-six patients with skull base tumours were referred to the unit between February 1984 and December 1989. INTERVENTIONS: Fifty-six of the patients underwent complete or partial surgical removal of the tumour. Radiotherapy was used as primary treatment in 10 patients, for tumour recurrence in four patients and as adjuvant postoperative treatment in 10 patients. RESULTS: In the majority of patients the tumours were benign and have been controlled or are considered cured. Of the seven patients with malignant tumours five have died and two are long-term survivors (one has multiple metastases). Three patients with histologically "benign" tumours died of multiple metastases. There have been a total of 10 deaths in the series but only one occurred in the perioperative period. Cranial nerve palsy was the major postoperative complication. CONCLUSION: Modern microsurgical techniques and modern anaesthesia and intensive care skills lead to a cure in many patients with skull base tumours previously considered inoperable.

Registered nurse stress in intensive care units--an Australian perspective.

This paper describes a study of stressors and coping mechanisms in different grades of registered nurses in Intensive Care Units (ICUs). The research demonstrated that significant correlation existed between relating what and when to report clinical patient changes and relating theory to practice. Significant differences existed between groups with regard to the stress associated with caring for acutely ill patients, role conflict with medical staff and relationships with senior medical and nursing staff. The findings confirm that environmental stressors are the major stressors in ICU and demonstrate that sound knowledge and clinical assessment skills are important factors in reducing perceived stress, thus supporting the continued need for competency and skills focused post registration courses and in-service education.

Meningioma of the posterior skull base.

Combined intratemporal and cerebellopontine angle meningiomas are rejatively rare. There are unsolved problems with the stability of the skull and spine and the lower cranial nerves and there is a marked tendency for the tumor to involve the spinal cord. This article reports on five cases of combined intratemporal and cerebellopontine angle meningiomas.

Acute open-chest complete heart block by transeptal electrocoagulation.

A method of producing complete heart block (CHB) in open-chest dogs is described. Having found previous methods unreliable in our hands or excessively complex for the acute open-chest setting, we constructed an electrocautery pinch-clamp device that functions in both locating and destroying the area of the atrial septum that contains the atrioventricular node and His bundle. Fifteen male mongrel dogs were anesthetized with alpha-chloralose, intubated, and ventilated (Harvard 607). Through a left thoracotomy at the fifth intercostal space, the two arms of the clamp are introduced into the left and right atria, respectively, via the atrial appendages. The correct site for electrocautery is located by gently squeezing the atrial septum between the arms of the clamp. Systematic testing of the region of the septum that lies, roughly, between the coronary sinus ostium and the anterior portion of the septal leaflet of the tricuspid valve will result in a rhythm disturbance when the correct site is squeezed. Sustained pressure will yield overt dissociation of the atrial and ventricular contractions. The electrocautery current is then activated for 10-15 s. Lead II of the electrocardiogram is monitored, and if CHB is not sustained after 5 min, the procedure is repeated. Once CHB is established, the clamp is removed and the atrial defects are ligated. By application of this method with no prior use of the technique, 12 of 15 attempts produced stable CHB lasting at least 3-4 h. Examination of the hearts of eight of the animals revealed no septal defects or damage to the tricuspid valve. We conclude that this method offers significant advantages for the production of CHB in acute studies in the dog.

Magnetic resonance imaging evaluation of cerebellopontine angle tumours.

In the evaluation of tumours of the cerebellopontine angle MRI has a sensitivity and a specificity slightly greater than that of CT. At present it does not appear justified to displace CT as the standard means of investigation of a CPA tumour. The role of MRI is analagous to that of air-CT.