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.

Direct comparisons of peripheral T-cell lymphoma with diffuse B-cell lymphoma of comparable histological grades--should peripheral T-cell lymphoma be considered separately?

Peripheral T-cell lymphoma (PTCL) forms a morphologically heterogeneous group of non-Hodgkin's lymphomas (NHL) with distinct immunophenotypes of mature T cells. Progress has been slow in defining specific clinicopathological entities to this particular group of NHL. In order to elucidate the specific characteristics of PTCL, a direct comparison of PTCL with a group of diffuse B-cell lymphomas (DBCL) was performed. Between June 1983 and December 1987, we studied 114 adults with NHL, using a battery of immunophenotyping markers. Adult T-cell leukemia/lymphoma, lymphoblastic lymphoma, mycosis fungoides/Sézary syndrome, follicular lymphoma, well-differentiated lymphocytic lymphoma, and true histiocytic lymphoma were excluded from this study since these are distinct clinicopathologic entities with well-recognized immunophenotypes. Of the remaining 75 patients, 70 who had adequate clinical information were analyzed, and of these, 34 were PTCL and 36 were DBCL. Classified according to the National Cancer Institute (NCI) Working Formulation (WF), 68% of PTCL and 31% of DBCL were high-grade lymphomas. Clinical and laboratory features were similar, except PTCL had a characteristic skin involvement and tended to present in more advanced stages with more constitutional symptoms. Induction chemotherapy was homogeneous in both groups, and complete remission rates were 62% for PTCL and 67% for DBCL. Patients with DBCL had a better overall survival than patients with PTCL, but the survival benefit disappeared after patients were stratified according to intermediate- or high-grade lymphoma. A subgroup of PTCL patients who had received less intensive induction chemotherapy was found to have a very unfavorable outcome. We conclude that (1) PTCL follows the general grading concept proposed in WF classification; (2) within a given intermediate or high grade, PTCL and DBCL respond comparably to treatment; (3) the intensity of induction chemotherapy has a crucial impact on the outcome of PTCL patients; and (4) with a few exceptions, the clinical and laboratory features of PTCL and DBCL are comparable.

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.

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.

Video-assisted thoracic surgery. The Chang Gung experience.

Thoracoscopy has assumed a major role in the management of a variety of surgical diseases of the chest. This technique, which was primarily devised for diagnostic purposes, has subsequently come to be used for therapeutic applications in most centers today. In this report we review 300 cases of therapeutic thoracic procedures in which a video-assisted technique was used. We describe mainly our own experience and the basic approach strategies we found helpful in the video-assisted procedures. No complications or deaths were attributable to these procedures. Our conclusions were as follows: (1) Video-assisted thoracic surgery can be as effective therapeutically as many formal thoracotomy. (2) Excellent exposure can be obtained by the use of double-lumen endotracheal tubes. (3) Video-assisted thoracic surgery is an excellent alternative treatment for pneumothorax, blebs, and bullous disease. (4) Video-assisted thoracic surgery allows safe, complete, visually guided wedge resection of lung lesions, lobectomy, pericardiectomy, removal of mediastinal tumor, esophagectomy, and reconstruction of the thoracic esophagus. (5) Video-assisted thoracic surgery also allows management of a broad scope of other general thoracic diseases such as empyema, pleural effusion, and chest trauma (hemothorax), as well as cancer staging. (6) Video-assisted thoracic surgery will not compromise the primary diagnostic and therapeutic goals set forth for the patient. (7) Because conventional instruments and extended manipulation incisions can be used, video-assisted thoracic surgery offers the promise of expediency, safety, minimal discomfort, less postoperative pain, quick functional recuperation, excellent cosmetic healing, shortened stays in the hospital, and therefore savings in cost. Accordingly, we are now using video-assisted thoracic surgery to treat the majority of patients with surgical diseases of the chest.

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.

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.

Severe isolated acute hepatic graft-versus-host disease with vanishing bile duct syndrome.

A 28-year-old man with chronic myelogenous leukaemia in blastic transformation underwent allogeneic bone marrow transplantation from his HLA-identical brother. Severe, progressive cholestatic jaundice developed from day 25 and did not respond to repeated therapy with high-dose methylprednisolone. In addition to marked cholestasis, both liver biopsy (day 69) and autopsy (day 134) findings revealed total disappearance of interlobular bile ducts in all of the portal areas, although extrahepatic manifestations of GVHD were minimal. Isolated acute vanishing bile duct syndrome can occur as the most severe form of acute hepatic GVHD.

Epidemiologic studies of eosinophilic meningitis in southern Taiwan.

A study of the epidemiologic characteristics of 125 cases of eosinophilic meningitis or meningoencephalitis, probably caused by Angiostrongylus cantonensis, which occurred in southern Taiwan in 1968 and 1969 revealed a close association of the disease with the rainy season. In contrast to findings in other geographic areas, most such cases in this study occurred among children. A higher attack rate was observed among aborigines than among descendants of mainland Chinese. Most patients had eaten the giant African snail, Achatina fulica, prior to their illness and this mollusc was commonly found infected with third-stage larvae of A. cantonensis. However, in almost all instances the snail was eaten after it had been thoroughly cooked and examination of cooked snail meat revealed only dead larvae. It is suspected that patients became infected by inadvertently ingesting A. cantonensis larvae liberated when the snails were prepared for consumption.

Thoracoscopic management of effusive pericardial disease: indications and technique.

Video-assisted thoracoscopic technique was evaluated in 28 patients who underwent operation for massive pericardial effusion. Excellent results were obtained using this newly developed approach for inspection of all pericardial surfaces as well as pleural and pulmonary disorders. No perioperative or postoperative complications ensued. Videothoracoscopy revealed positive lung malignancies in 11 patients, and these would not have been promptly diagnosed without thoracoscopy. Thoracoscopy also confirmed metastatic deposits on the pleura and diaphragm in 4 other patients. The visible nodules were proved to be metastatic adenocarcinoma. In 13 patients, thoracoscopy did not reveal malignancy, although 2 of these patients had a clinically suspected malignant lung tumor. Other indications for thoracoscopic drainage included 2 patients with impending pericardial tamponade after heart procedures and 6 patients with recurrent/loculated pericardial effusion. All of the patients showed promising and favorable postoperative courses after thoracoscopy. From our experience, video-assisted thoracoscopy was a safe and effective procedure, especially for those patients with combined pericardial effusion and abnormal pulmonary or pleural pathology in whom subxiphoid pericardial window was not clearly diagnostic at the time of operation. It was effective also in the situation with recurrent or loculated pericardial effusion which allowed localization and drainage of it. We believe that the use of videothoracoscopy to visualize the whole pericardial and pleural cavity will continue to be of great benefit to patients with combined pericardial and pleural/lung diseases.

Clinicopathological spectrum of Epstein-Barr virus-associated T cell malignancies.

It has been recently demonstrated that the Epstein-Barr virus (EBV) can infect human thymocytes and may be involved in the T cell neoplasms, in addition to African Burkitt's lymphoma, nasopharyngeal carcinoma and Hodgkin's disease. Four distinct clinicopathologic categories of EBV-associated T cell malignancies have been recognized. The angiocentric T cell lymphoma or lymphomatoid granulomatosis involving the nose (or midline lethal granuloma) and skin is frequently EBV-associated. The other 3 groups include angioimmunoblastic lymphadenopathy-like lymphoma, node-based T immunoblastic lymphoma which may contain Reed-Sternberg-like giant cells (Hodgkin's-like lymphoma), and T cell lymphoma resembling malignant histiocytosis. Both the CD4 and CD8 T cell subsets, and a hitherto undefined T lineage lacking CD4/CD8 expression have been involved. The common clinical features are prolonged fever, skin lesions, lymphadenopathy, hepatosplenomegaly, and pancytopenia. Serologic assays suggest that a chronic active EBV infection may exist in most of these patients. The EBV genomes appear to proliferate in clonal and episomal form in the neoplastic cells which show expression of latent membrane proteins. Although an indolent local phase may exist, the clinical course is aggressive for most patients with frequent development of drug resistance to conventional chemotherapy. EBV-associated T cell lymphoma constitutes a separate entity of virus-associated human diseases and opens a potential field to investigate the pathogenesis of EBV-associated human malignancies.

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.

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.

Malignant transformation of condyloma acuminatum: report of a case.

Condyloma acuminatum is a benign warty lesion, whose malignant change is rarely seen. A 69-year-old woman with a large vulvar condyloma acuminatum, which she had had for about 14 years, underwent a vulvectomy, and a malignant component to the lesion was found unexpectedly. The continuity from a benign to a malignant lesion was evident in the histopathologic examination. Infection with human papillomavirus type 6 was documented by DNA hybridization. The use of a one-step reverse dot blot hybridization with nonisotope DNA probe in this case was convenient and is recommended.

Albright's syndrome with acromegaly and Hashimoto's thyroiditis: report of a case.

The case of a 35-year-old woman with Albright's syndrome, acromegaly and Hashimoto's thyroiditis is presented. She had noted deformity of the left mandible and chest from childhood. She developed persistent galactorrhea and amenorrhea after the delivery of her second child. X ray of the skull, and a head CT, revealed a pituitary tumor and fibrous dysplasia of the left mandible, sphenoid, zygomatic bone and pteryoid plate. Serum GH and PRL levels were markedly elevated. She received recontouring surgery of the left mandible, and a pathological examination confirmed the diagnosis of fibrous dysplasia. Chest X ray also showed fibrous dysplastic change of the left 4th, 5th, 6th and 7th ribs and left clavicle. Because of poor response to bromocriptine, she received a craniotomy to remove the pituitary macroadenoma. Pathological examination of the tumor revealed an acidophilic tumor. Postoperative radiotherapy was given for residual active tumor. She developed adrenal crisis two months after radiotherapy when she discontinued replacement therapy. The diagnosis of Hashimoto's thyroiditis was arrived at by palpation of the goiter, elevated thyroid antibodies, ultrasound pictures of the thyroid, fine needle aspiration cytology and hypothyroidism. To our knowledge, this is the first report of Albright's syndrome with Hashimoto's thyroiditis. The hypothesis of autoimmune disease is proposed to explain the hypofunction of the endocrine glands associated with Albright's syndrome.

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.

Primary myelofibrosis in children: report of 4 cases.

From 1982 to 1985, four cases of primary myelofibrosis were diagnosed in our department. Three were boys and one was a girl. Their ages ranged from 7 months to 15 years. The diagnosis was made based on anemia, leukoerythroblastic change and presence of giant platelets in the peripheral blood, and a bone marrow biopsy showing myelofibrosis. Most of them had anemia, fever, and hepatosplenomegaly on admission. The anemia was severe and refractory to repeated transfusions and steroid therapy in 3 out of the 4 cases. Splenectomy was performed in 1 case, but without satisfactory results. The clinical course and blood pictures in one case resembled leukemia of megakaryocyte lineage (M7), but results of marker studies of the blast cells ruled out the possibility of M7. Three of them underwent leukemic transformation within 2 years and died soon after. The other one died of sepsis 2 weeks after diagnosis. Myelofibrosis in childhood occurs rarely, however, when it does, it always runs a rapid and fatal course.

Somatostatin-containing carcinoid tumor of the duodenum in neurofibromatosis: report of a case.

We report a case of von-Recklinghausen's disease presenting with obstructive jaundice and found to have a somatostatin-containing carcinoid tumor in the papilla of Vater and a small neurofibroma in the duodenum. A 42-year-old woman with von-Recklinghausen's disease presented with intermittent jaundice, pruritus, and mild steatorrhea of a two-year duration. Abdominal ultrasonography and computed tomography showed dilated intrahepatic ducts, common bile duct and pancreatic ducts. Duodenoscopy showed a tumor at the papilla of Vater, but a preoperative biopsy failed to provide a definite diagnosis. Laparotomy revealed a yellowish tumor at the papilla of Vater and another nodule on the mesenteric side of the second section of the duodenum. Microscopically, the tumor at the papilla of Vater was found to be a somatostatin-containing carcinoid tumor. The small nodule on the mesenteric side was a neurofibroma. The jaundice, pruritus and steatorrhea disappeared after surgery.

Correlation between sonography and pathology in thyroid diseases.

Ultrasonography was performed on the thyroid glands of 47 patients with various thyroid diseases, in a fresh state, immediately following operation. The thyroid glands were then sectioned along the plane of the most significant sonographic changes. The pathologic changes of the sectioned plane were observed and compared with the sonographic changes. In nodular goiter, the sonographic changes were usually heterogeneous. The margin was either well-defined or ill-defined, and cystic changes might play a minor or major part in the thyroid nodules. In follicular adenoma, the changes were isoechoic in adenoma with embryonal type follicles and hyperechoic in adenoma with colloid type follicles. In adenoma of the oxyphilic cells, the echogenicity was somewhat greater in the hemorrhagic part compared to the area with oncocytic change only. In papillary carcinoma, the lesions usually manifested as well-limited, heterogeneous, hypoechoic nodules. Cystic degenerations were frequently noted. There were discrete particles corresponding to microcalcification in 4 out of 6 cases. In follicular carcinoma, the sonographic changes also showed well-limited nodules. However, the echogenicity was not decreased as much as in papillary carcinoma, and it could be either homogeneous and isoechoic, or hypoechoic. Relatively large particles with an acoustic sign, which corresponded to calcification, were noted in 2 out of 4 cases. In medullary carcinoma, the lesion was well-limited and hypoechoic. The particles present in sonography corresponded to calcification in the amyloid. In Graves' disease, the main sonographic change was a diffusely homogeneous, isoechoic or hypoechoic lesion. Cystic change was rarely present. Dispersed particles were rarely present and corresponded to fibrosis in the thyroid tissue.(ABSTRACT TRUNCATED AT 250 WORDS)