Multiple unilateral fibroadenomas.

Fibroadenomas account for the majority of breast biopsies performed today. The natural history of fibroadenomas varies. They are usually found as a solitary, 1-2 cm lesion that is described as being firm, rubbery, nontender, well-circumscribed, and found in women less than 30 years of age. We present an uncommon case of an adolescent female who had a cluster of fibroadenomas in one of her breasts, her treatment, and a review of the literature.

Anhydrous ammonia burns case report and review of the literature.

Chemical burns are associated with significant morbidity, especially anhydrous ammonia burns. Anhydrous ammonia is a colorless, pungent gas that is stored and transported under pressure in liquid form. A 28 year-old patient suffered 45% total body surface area of second and third degree burns as well as inhalational injury from an anhydrous ammonia explosion. Along with fluid resuscitation, the patient's body was scrubbed every 6 h with sterile water for the first 48 h to decrease the skin pH from 10 to 6-8. He subsequently underwent a total of seven wound debridements; initially with allograft and then autograft. On post burn day 45, he was discharged. The injuries associated with anhydrous ammonia burns are specific to the effects of ammonium hydroxide. Severity of symptoms and tissue damage produced is directly related to the concentration of hydroxyl ions. Liquefactive necrosis results in superficial to full-thickness tissue loss. The affinity of anhydrous ammonia and its byproducts for mucous membranes can result in hemoptysis, pharyngitis, pulmonary edema, and bronchiectasis. Ocular sequelae include iritis, glaucoma, cataracts, and retinal atrophy. The desirability of treating anhydrous ammonia burns immediately cannot be overemphasized. Clothing must be removed quickly, and irrigation with water initiated at the scene and continued for the first 24 h. Resuscitative measures should be started as well as early debridement of nonviable skin. Patients with significant facial or pharyngeal burns should be intubated, and the eyes irrigated until a conjunctivae sac pH below 8.5 is achieved. Although health care professionals need to be prepared to treat chemical burns, educating the public, especially those workers in the agricultural and industrial setting, should be the first line of prevention.

Vietnamese "coining": a burn case report and literature review.

"Coining," "coin rubbing," or çao gio, is an ancient Vietnamese folk remedy that is practiced by many Vietnamese-Americans to treat minor ailments. There are few reported cases of serious complications of çao gio; most of the complications have been minor burns. We present a case report of a 45-year-old woman who sustained 22% partial-thickness and full-thickness burns after she caught on fire during a coining treatment. She underwent fluid resuscitation, wound care management, and, eventually, burn debridement and autografting. She was discharged 10 days after the operation, with excellent take of all of her grafts. However, a contracture of her right axilla did develop and will require surgical release. This case represents a serious injury that can result from traditional cultural forms of medicine.

Are chest X-rays mandatory following central venous recatheterization over a wire?

Exchange of a central venous catheter (CVC) over a guidewire is a frequent clinical procedure, especially in surgical intensive care units. At most hospitals, a chest X-ray (CXR) is obtained routinely after recatheterization to confirm accurate catheter placement and to rule out complications such as pneumothorax. We hypothesized that the incidence of complications after central venous recatheterization over a guidewire is too low to justify automatic performance and the associated expense of a routine postprocedure CXR. Initially we undertook a retrospective study of a total of 295 patients with a Swan-Ganz catheter (SGC), of which 92 SGCs were exchanged over a guidewire for a CVC between July 1, 1994, and June 30, 1996, at a university-affiliated community hospital. Age, gender, duration of SGC placement, type of central catheter used for exchange with the SGC, and CXRs and their reports were noted. From July 1, 1996, to October 1, 1997, the study has been continued prospectively. Thus far, in this ongoing investigation, we have identified 505 patients (201 prospective) who had a SGC placed, 210 (116 prospective) of whom had their SGC removed electively, leaving the SGC introducer in place for advancement of a guidewire, and subsequent replacement by a CVC. Of all the patients with a SGC, 40 per cent had the SGC replaced with a CVC over a guidewire, and follow-up CXRs and their reports confirmed that all exchanged triple lumen catheter tips were appropriately positioned in the superior vena cava with zero complications. With the advent of managed care, a savings of $115/CXR (one view X-ray and reading cost at our hospital) would be gained without the added risk of radiation exposure to the patient if a CXR were not mandatory after an uncomplicated guidewire replacement of a central line. It appears from these data that a CXR is not justified as a routine study after replacement of all CVCs over a wire from the standpoints of both patient risk and expense. Conscientious physical examination together with good clinical acumen and judgement in evaluating patients after replacement of a CVC over a guidewire are likely to obviate the currently mandated postprocedure CXR, reserving its use for selected patients.

Routine chest radiographs following central venous recatheterization over a wire are not justified.

BACKGROUND: Subclavian vein central venous catheterization and the subsequent exchange of subclavian catheters over a guidewire are frequently performed procedures. We hypothesized that the policy of obtaining a routine postprocedure chest radiograph to confirm appropriate catheter placement and to rule out complications after exchanging central venous catheters over a wire was no longer justifiable. METHODS: A retrospective study of 295 patients with Swan-Ganz catheters (SGC) was performed between July 1, 1994 and June 30, 1996. One hundred fourteen of these SGCs were exchanged over a guidewire for a central venous catheter (CVC). Postexchange chest radiograph and associated radiologist's report, as well as age, gender, and duration of catheter placement were all recorded. Since July 1996, this study has been extended prospectively. RESULTS: Of the 380 documented over-a-wire exchanges, none has resulted in a complication, including catheter malposition. CONCLUSION: We conclude from these data that a routine chest radiograph following the replacement of a CVC over a guidewire is not necessary when good clinical judgment and discrimination are used in a monitored setting.