Catheter induced superior vena cava syndrome aggravated by shunt placement.

A case is presented of a dialysis catheter induced SVC syndrome aggravated by a recently surgically created AV fistula. Conventional angiography as well as computed tomography showed a catheter induced stenosis in the SVC. Removal of the catheter and treatment with anticoagulants resulted in resolution of the syndrome without the need for invasive endovascular intervention.

Anticoagulation with dalteparin and nadroparin in nocturnal haemodialysis.

BACKGROUND: Low-molecular-weight heparins (LMWHs) are increasingly used as anticoagulant during haemodialysis. The aim of this study is to establish the efficiency and duration of anticoagulation with dalteparin and nadroparin administration in patients treated with nocturnal haemodialysis. METHODS: All patients were treated with nocturnal in-centre haemodialysis, 3-4 times a week. Anticoagulation was obtained with dalteparin (n = 15) or nadroparin (n = 10). Anti-factor- Xa activity was measured during a midweek dialysis session at t = 0, 4 and 8 hours. RESULTS: The LMWH dose necessary to prevent extracorporeal circuit clotting was higher for dalteparin than for nadroparin. In the dalteparin group, anti-Xa activity was almost negligible at the start of dialysis whereas most patients on nadroparin still had anti-Xa activity at the start of dialysis (0.08 (IQR 0.05-0.11) IU÷ml), reflecting the effect of previous LMWH administration. After eight hours of dialysis, median anti-factor-Xa activity was 0.49 (IQR 0.22-0.57) after dalteparin and 0.69 (IQR 0.55- .83) after nadroparin (p = 0.01). When a target range of 0.2-0.6 IU÷ml was applied, the present dosing method led to over-anticoagulation in more than half of the patients. CONCLUSION: Administration of two doses of LMWH is an effective method of anticoagulation in nocturnal, eight-hour haemodialysis. With two doses of dalteparin, a larger proportion of patients reached but did not exceed target levels of anticoagulation, compared with two doses of nadroparin. Nadroparin caused prolonged anti-Xa activity with measurable anticoagulation up to the next dialysis session. The measurement of anti-Xa activity is advocated for dose assessment of LMWH, when LMWH is used as anticoagulant during nocturnal haemodialysis.

A scanning electron microscopy analysis of a spontaneous hemodialysis catheter fracture.

Central venous catheters have become increasingly important in hemodialysis treatment. With their increased use, catheter-related problems will be seen more frequently, and more rare complications may be observed. We describe the first case of asymptomatic spontaneous breakdown of a tunneled cuffed silicone catheter used for long-term hemodialysis treatment. This was discovered on removal of the catheter, leaving behind a catheter fragment in the left lower pulmonary lobe. An extensive scanning electron microscopy study showed accumulation of lumps of nonsilicone material at the place of the fracture, leading to severe disruption of the original cross-linked elastomer structure. Using energy-dispersive X-ray spectral analysis, which shows all elements with an atomic number of 11 or greater in a material, we found the lumps were aggregates of barium sulfate particles used to visualize the catheter on fluoroscopy. We suggest that the use of too small or too many barium sulfate particles led to high viscosity of the raw silicone before polymerization, causing improper mixing of barium sulfate particles in the silicone matrix. This resulted in insufficient removal of admixed air bubbles and unequal dispersion of barium sulfate, with the potential for weak spots after extrusion of the silicone into its definitive shape. With the increasing use of hemodialysis catheters for prolonged periods, catheter-related complications related to materials or manufacturing errors can be expected to occur more often.

A bone biopsy is mandatory in the optimal management of bone lesions in patients with a long-term history of malignancy of the breast.

Bone lesions, present in two women with primary breast cancer treated more than 5 years ago, were investigated thoroughly by biochemical markers and imaging techniques. The definite diagnosis was established by bone biopsy, which revealed two totally unrelated disorders that altered the management and prognosis for these two patients. One patient had Paget's disease, and the other had metastatic hepatocellular carcinoma.

Case report of a patient with an intimal sarcoma of the pulmonary trunk presenting as a pulmonary embolism.

A fatal case of an 89-year-old woman with an intimal sarcoma obstructing the pulmonary trunk and an open foramen ovale is presented. Clinical symptoms, physical examination and further evaluation originally raised suspicion of a pulmonary embolism. Recent classification systems, specific radiological and pathological characteristics of sarcomas of the pulmonary trunk are discussed.

[A wandering spleen]. / Een wandelende milt.

A mobile asymptomatic abdominal mass was accidentally found in a 81-year-old man. Further studies revealed a wandering spleen. Wandering spleen is rare, the diagnosis can easily be made with ultrasonography. The patient presented was asymptomatic, but severe complications may occur. Congenital anomalies of ligaments, splenomegaly and pregnancy may be of aetiological importance. In young patients and in case of complaints splenopexia is the treatment of choice; the patient presented was treated conservatively.

Preliminary report: furunculosis and hypoferraemia.

16 patients with recurrent staphylococcal furunculosis but without anaemia had significantly lower serum iron concentrations than normal laboratory reference values, 8 controls with single furuncles, or 10 controls with acne conglobata. There were no significant differences in serum glucose or iron binding capacity between the groups studied. Furunculosis resolved after 3-4 weeks' treatment with iron supplements in all but 1 patient. The relation between iron and susceptibility to infection is unclear, but merits further investigation.