Catheter-associated bloodstream infection in patients with cancer: comparison of left- and right-sided insertions.

BACKGROUND: There is limited research on the relationship between side of insertion of central venous catheter (CVAD) and bloodstream infection risk in patients with cancer. AIM: To conduct an exploratory analysis of data from a randomized control trial (RCT) and data from a prospective cohort study to compare infection rates for right- and left-sided insertions. METHODS: The study populations were patients aged >14 years with cancer from two tertiary hospitals in Brisbane, Australia. The primary endpoint was catheter-associated bloodstream infection (CABSI) adjudicated by blinded assessors. For the RCT, randomized intention-to-treat comparisons were conducted between left- and right-side allocated insertion for early (≤14 days) and late (>14 days) infection using Cox proportional hazards regression. The RCT data were also combined with cohort study data collected from one of the hospitals prior to the RCT and non-randomized comparisons conducted between left- and right-sided insertions. FINDINGS: In 634 randomly allocated CVADs there were 141 CABSIs. Analysis showed strong evidence of right-side allocated insertions having an increased risk of early infection by 2.5 times (95% confidence interval (CI): 1.3-4.7); however, there was no evidence of increased risk for late infection (hazard ratio: 1.06; 95% CI: 0.71-1.59). Results from analysis of the RCT and cohort study data combined (2786 CVADs and 385 CABSIs) were similar. CONCLUSION: There appears to be an increased risk of CABSI in patients with cancer for CVAD inserted into the right-side for around two weeks after line insertion. The mechanism underpinning the increased risk is unknown.

Catheter-associated bloodstream infections in adults with cancer: a prospective randomized controlled trial.

BACKGROUND: A common complication of central venous access devices (CVADs) is catheter-associated bloodstream infection (CABSI). We previously demonstrated that insertion of CVADs on the right side was associated with increased risk of CABSI, and hypothesized that this related to the predominance of right-handedness in the patient population, resulting in greater movement and bacterial contamination. AIM: To perform a prospective randomized, controlled, non-blinded study to determine whether the side of CVAD insertion influenced the incidence of CABSI. METHODS: Adult cancer patients were randomly allocated to either dominant or non-dominant side CVAD insertion. The primary endpoint of the study was the number of line-days until CABSI, determined in a blinded fashion by two assessors. FINDINGS: In all, 640 CVADs were randomized to dominant (N = 322) or non-dominant (N = 318) side of insertion, 60% had haematological malignancies, and 40% solid tumours. CVADs were a peripherally inserted central catheter line (67%), tunnelled CVAD (23%), and non-tunnelled CVAD (10%). Twenty-two percent of CVADs were complicated by CABSI. The rate of CABSI per 1000 line-days was 3.49 vs 3.66 in the non-dominant vs dominant group (hazard ratio (HR): 0.91; 95% confidence interval (CI): 0.65-1.28). By multivariable analysis, the rate of CABSI was increased by: use of tunnelled CVADs compared to peripherally inserted central venous catheter lines (HR: 2.05; 95% CI: 1.45-2.91); having a haematological malignancy compared to non-gastrointestinal solid tumours (5.55; 2.47-12.5); but not dominant compared to non-dominant side of CVAD (0.97; 0.69-1.36). CONCLUSION: CABSI in adult patients with cancer was not impacted by whether CVAD insertion was on the dominant or non-dominant side.

Clinical care and technical recommendations for 90yttrium microsphere treatment of liver cancer.

Selective internal radiation therapy (SIRT) with (90)yttrium microspheres is a relatively new clinical modality for treating non-resectable malignant liver tumours. This interventional radiology technique employs percutaneous microcatheterisation of the hepatic arterial vasculature to selectively deliver radioembolic microspheres into neoplastic tissue. SIRT results in measurable tumour responses or delayed disease progression in the majority of eligible patients with hepatocellular carcinoma or hepatic metastases arising from colorectal cancer. It has also been successfully used as palliative therapy for non-colorectal malignancies metastatic to the liver. Although most adverse events are mild and transient, SIRT also carries some risks for serious and--rarely--fatal outcomes. In particular, entry of microspheres into non-target vessels may result in radiation-induced tissue damage, such as severe gastric ulceration or radiation cholecystitis. Radiation-induced liver disease poses another significant risk. By careful case selection, considered dose calculation and meticulous angiographic technique, it is possible to minimise the incidence of such complications to less than 10% of all treatments. As the number of physicians employing SIRT expands, there is an increasing need to consolidate clinical experience and expertise to optimise patient outcomes. Authored by a panel of clinicians experienced in treating liver tumours via SIRT, this paper collates experience in vessel mapping, embolisation, dosimetry, microsphere delivery and minimisation of non-target delivery. In addition to these clinical recommendations, the authors propose institutional criteria for introducing SIRT at new centres and for incorporating the technique into multidisciplinary care plans for patients with hepatic neoplasms.

Repeat intra-arterial papaverine for recurrent cerebral vasospasm after subarachnoid haemorrhage.

We assessed the prevalence of recurrent vasospasm following failure of intra-arterial papaverine and the efficacy of repeat intra-arterial infusions of papaverine for control of recurrent vasospasm. Of 24 patients treated with intra-arterial papaverine for vasospasm following aneurysm surgery, 12 did not improve clinically after the initial treatment; 9 received second or third infusions on consecutive days; 6 received only a second infusion; and 3 received a third. Superselective infusion into the intracranial arteries was performed in all nine cases. Despite angiographic improvement after the initial or second infusions, all nine patients showed varying degrees of recurrent vasospasm at the time of the second or third treatment. Within 24 h of a second infusion, three of the six patients had significant clinical improvement, and one of these showed marked improvement soon after a third infusion. Our preliminary results suggest that repeat papaverine infusion may be a way of controlling recurrent or recalcitrant vasospasm.

Endovascular extraction of malpositioned fibered platinum microcoils from the aneurysm sac during endovascular therapy.

We describe two cases of coil malpositioning that occurred during endovascular occlusion of saccular basilar tip aneurysms with fibered platinum microcoils. The technique of endovascular coil extraction, accomplished successfully and without complication in both cases, is described and may be applicable to recently available controlled-detachment coil systems.

Bronchial artery aneurysms in association with Mycobacterium avium intracellulare complex.

An immunosuppressed patient with scleroderma presented with hemoptysis due to bronchial artery aneurysms associated with Mycobacterium avium-intracellulare complex (MAC).

Intraarterial papaverine infusion for cerebral vasospasm after subarachnoid hemorrhage.

PURPOSE: To evaluate the techniques and efficacy of intracranial intraarterial papaverine infusion for symptomatic vasospasm after subarachnoid hemorrhage caused by aneurysm rupture. METHODS: Papaverine was infused on 19 occasions in 14 patients, 6 hours to 2 days after spasm became apparent clinically. Sixty vascular territories were treated. Infusion was made into the supraclinoid internal carotid artery 20 times, cavernous internal carotid artery once, selective A1 anterior cerebral artery 8 times, M1 middle cerebral artery 7 times, and basilar artery 3 times. Papaverine doses ranged from 150 to 600 mg and exceeded 400 mg on 8 occasions. RESULTS: Angiographic improvement occurred in 18 (95%) of the 19 treatment sessions: results were excellent in 3 sessions, moderate in 8, and mild in 7. The best angiographic results often were obtained with superselective infusion, although angiographic results did not always correlate with clinical response. Seven (50%) of the 14 treated patients showed dramatic acute clinical improvement within 24 hours of papaverine therapy, and there was no clinical evidence of recurrent vasospasm in these patients. Recurrence of angiographic vasoconstriction was demonstrated in three patients; one showed marked clinical improvement after a second treatment. There were no episodes of systemic hypotension in any of the cases. Monocular blindness developed in one patient because of papaverine infusion near the ophthalmic artery. CONCLUSIONS: Papaverine was effective in dilating narrowed arteries in most patients with symptomatic vasospasm caused by subarachnoid hemorrhage. This series showed encouraging clinical results with no recurrence of neurologic deterioration in those patients who responded well to papaverine. Superselective infusion appears to be indicated in some cases for adequate papaverine delivery.

MR angiographic diagnosis of recanalization in a thrombosed pulmonary arteriovenous malformation.

Pulmonary arteriovenous malformation (PAVM) results from an anomalous communication between a pulmonary artery and vein and may lead to life-threatening hemoptysis. Pulmonary angiography is the standard diagnostic technique but may be falsely negative in the unusual instance of a thrombosed PAVM. We report a patient with a thrombosed PAVM in which the initial pulmonary angiogram incorrectly suggested pulmonary embolism. A subsequent magnetic resonance (MR) angiogram demonstrated recanalization of the PAVM, thus establishing the true nature of the lesion and leading to appropriate intervention.

Case report--CT findings in adenomyomatosis of the gallbladder.

A case report of the CT findings in adenomyomatosis of the gallbladder is presented. Significant CT findings of this entity are variation in wall density, marked differential enhancement of wall layers during dynamic liver scanning and detection of Rokitansky-Aschoff sinuses within the wall. CT apparently depicts both mucosal and muscularis thickening.

Kinetics of initiation of germination of Bacillus pumilus spores by hydrostatic pressure.

The kinetics of initiation of germination and inactivation by hydrostatic pressure of phosphate-buffered Bacillus pumilus spores is shown to be a consecutive first-order process at 25 C. The effect of increasing pressure at constant temperature was studied, and rate constants were derived by using the criteria of heat resistance, refractility, and stainability. The calculated volume change of activation (DeltaVdouble dagger) was -139 +/- 6 cm(3)/mole for loss of heat resistance, -158 +/- 8 cm(3)/mole for the loss of refractility, and -153 +/- 4 cm(3)/mole for the change in permeability to dilute stains for the pressure range 800 to 1,010 atm at 25 C. It is suggested that the spore exists as a Donnan phase and that pressure triggers germination by influencing the equilibrium.

Initiation of germination and inactivation of Bacillus pumilus spores by hydrostatic pressure.

The effect of hydrostatic pressures as high as 1,700 atm at 25 C on the heat and radiation resistance of Bacillus pumilus spores was studied. Phosphate-buffered spores were more sensitive to compression than spores suspended in distilled water. Measurements of the turbidity of suspensions, the viability, refractility, stainability, dry weight, and respiratory activity of spores, and calcium and dipicolinic acid release were made for different pressures and times. Initiation of germination occurred at pressures exceeding 500 atm and was the prerequisite for inactivation by compression. The rate of initiation increased with increasing pressure at constant temperature. This result is interpreted as a net decrease in the volume of the system during initiation as a result of increased solvation of the spore components.