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Intraocular invasion by neoplastic plasma cells is a rare ophthalmic manifestation of plasma cell dyscrasias. A 67-year-old man who had documented multiple myeloma presented with an infiltration of the iris that simulated a nongranulomatous uveitis. Cytologic examination of the aspirate obtained by anterior chamber paracentesis demonstrated that the infiltrate was composed of neoplastic plasma cells.
We adapted a 27-gauge, 0.75-in needle for the placement of iris fixation sutures. The needle requires neither the formation of a paracentesis nor a sclerotomy site. Additionally, the self-sealing nature of the needle tract eliminates the need for closure of the entry site. We have found this instrument to be helpful in the rapid, atraumatic placement of iris fixation sutures.
Fifty-eight eyes of 31 anesthetized rabbits received one drop of proparacaine hydrochloride, 0.05%, and two drops of tissue plasminogen activator (tPA) separated by 5 minutes. Four eyes of two additional rabbits had epithelial defects created before drug delivery. Tissue plasminogen activator in multiple doses was given to eight eyes of four other rabbits. We used this dosing regimen to investigate the effect of topical tPA on anterior chamber fibrin clots in three rabbits. A two-site enzyme-linked immunosorbent assay test was used to measure tPA levels in the aqueous samples, obtained by paracentesis in each eye. Of 53 eyes treated with the original dosing regimen, 21 (40%) had detectable tPA aqueous levels. Blood and aqueous from eyes of untreated control rabbits, contralateral control eyes of treated rabbits, and eyes with epithelial defects had nondetectable tPA. Multiple tPA drop dosing resulted in 75% of aqueous samples with detectable tPA and a higher average tPA concentration than the original dosing regimen. Eyes treated with tPA showed a significantly faster resolution of anterior chamber fibrin clots than did control eyes.
Hydroxyethylmethacrylate is a biomaterial still under clinical trial for use in foldable intraocular lenses. We observed a patient in whom a geographic opacification developed within an implanted hydroxyethylmethacrylate lens, together with granular deposits on the posterior lens capsule and in the scar of a paracentesis. The intraocular lens and posterior lens capsule were removed because of impaired visual acuity. Light and scanning electron microscopy disclosed nodular calcifications within the intraocular lens and granular, partially crystalline, calcifications on the posterior lens capsule. Energy-dispersive x-ray analysis and x-ray diffraction showed the deposits in the intraocular lens to consist of calcium hydroxyapatite. We presume this mineralization to be dystrophic, with calcium derived from lens remnants and phosphorus possibly derived from a thymoxamine solution used briefly during the cataract operation. Our observation suggests caution in the use of phosphated solutions together with hydroxyethylmethacrylate intraocular lenses and may warrant reconsideration of the suitability of hydroxyethylmethacrylate intraocular lenses, should additional similar cases be reported.
The findings on paracentesis and aspiration of the middle ear were compared with preoperative tympanometry. From the results obtained, it was found that if tympanometry alone is used to determine the presence or absence of fluid the best discriminant is a compliance of 0.21 or a gradient of 0.04 equivalent volume units. The average failure rate with either or these criteria is 20%. A numerical estimate of the validity of tympanometry may be made for individual cases.
HYPOTHESIS: Early risk factors for hepatic-related morbidity in patients undergoing initial nonoperative management of complex blunt hepatic injuries can be accurately identified. DESIGN: Multicenter historical cohort. SETTING: Seven urban level I trauma centers. PATIENTS: Patients from January 2000 through May 2003 with complex (grades 3-5) blunt hepatic injuries not requiring laparotomy in the first 24 hours. INTERVENTION: Nonoperative treatment of complex blunt hepatic injuries. MAIN OUTCOME MEASURES: Complications and treatment strategies. RESULTS: Of 699 patients with complex blunt hepatic injuries, 453 (65%) were treated nonoperatively. Overall, 61 patients (13%) developed 87 hepatic complications including bleeding (38), biliary (bile peritonitis, 7; bile leak, 9; biloma, 11; biliary-venous fistula, 1; and bile duct injury, 1), abdominal compartment syndrome (5), and infections (abscess, 7; necrosis, 2; and suspected abdominal sepsis, 6), which required 86 multimodality treatments (angioembolization, 32; endoscopic retrograde cholangiopancreatography and stenting, 9; interventional radiology drainage, 16; paracentesis, 1; laparotomy, 24; and laparoscopy, 4). Hepatic complications developed in 5% (13 of 264) of patients with grade 3 injuries, 22% (36 of 166) of patients with grade 4 injuries, and 52% (12 of 23) of patients with grade 5 injuries. Univariate analysis revealed 24-hour crystalloid, total and first 24-hour packed red blood cells, fresh frozen plasma, platelet, and cryoprecipitate requirements and liver injury grade to be significant but only liver injury grade (grade 4 odds ratio, 4.439; grade 5 odds ratio, 12.001) and 24-hour transfusion requirement (odds ratio, 6.446) predicted complications by multivariable analysis. CONCLUSIONS: Nonoperative management of high-grade liver injuries is associated with significant morbidity and correlates with grade of liver injury. Screening patients with transfusion requirements and high-grade injuries may result in earlier diagnosis and treatment of hepatic-related complications.
The records of 56 consecutively treated patients with hepatic trauma were reviewed for clinical features, treatment, and results. Nonpenetrating trauma was the cause of 60% of the injuries, 40% of which were considered major. Peritoneal irritability, hypotension, and a positive abdominal paracentesis were common findings leading to abdominal exploration. Prompt fluid resuscitation followed by operation was successful in most patients. Various suture techniques were effectively used to control hemorrhage, and extensive debridement short of lobectomy was used if possible. Drainage was effective in reducing postoperative complications. Death was associated with extensive injuries that required right hepatic lobectomy in two patients, and in three patients deaths were unrelated to the hepatic injury. Complications were predominantly pulmonary problems, sepsis, and hemorrhage. These results support the prompt operative management of hepatic injuries with accepted procedures of debridement, precise vascular and biliary control, and drainage, conserving hepatic tissues.
We studied 32 consecutive cases of small-bowel perforations treated in a single surgical unit during the last three years. Clinical features are typical and diagnosis is not difficult. Suprapubic peritoneal paracentesis in head-high position is the most accurate diagnostic investigation. Ultimate results are not related to cause, but are directly proportional to the degree of contamination of the peritoneal cavity, delay in manifestation, antibiotic resistance of the contaminating organism, and the method of treatment of the perforation. There were two deaths in the 16 patients who had exteriorization of the suture line (12.5%), compared with seven deaths in the group of 16 patients who did not have exteriorization (43.75%). Exteriorization of the suture line (16 cases) is a superior method of treatment and significantly lowers the mortality.
Massive accumulation of intraperitoneal air may result in an entity known as tension pneumoperitoneum. The patient usually complains only of abdominal fullness, and the abdomen becomes ballooned, barrel-shaped, and tympanic in all quadrants. Upward displacement of the diaphragm may cause respiratory embarrassment. There may also be diminished venous return due to compression of the inferior vena cava. Abdominal paracentesis may be necessary to improve respiratory exchange before laparotomy. In one patient with a perforated peptic ulcer and tension pneumoperitoneum, an enormous increase in intra-abdominal pressure apparently led to acute aortic occlusion. This particular complication of tension pneumoperitoneum has not previously been reported, to our knowledge. The clinical findings of aortic occlusion were reproduced in a canine model by insufflation of air into the abdomen. An intra-abdominal pressure of 100 mm Hg resulted in loss of the femoral pulse wave measured by an indwelling arterial catheter.
The development of chylous ascites after an abdominal surgical procedure is potentially grave. It frequently leads to malnutrition and significant mortality. Chylous ascites developed after emergency repair of a ruptured abdominal aneurysm. In spite of treatments with low-fat diet (medium-chain triglycerides), hyperalimentation, and abdominal paracentesis, hypoproteinemia and peripheral edema developed and symptomatic ascites continued. Though some success has been reported following ligation of leaking lymphatics, we avoided laparotomy because the patient was recovering from formidable complications. A peritoneovenous shunt was placed. No complications occurred and permanent recovery promptly resulted. We believe this is a reasonable alternative to laparotomy.
CONTEXT: Invasive procedures are often performed emergently in the intensive care unit (ICU), and patients or their proxies may not be available to provide informed consent. Little is known about the effectiveness of intensivists in obtaining informed consent. OBJECTIVES: To describe the nature of informed consent in the ICU and to determine if simple interventions could enhance the process. DESIGN, SETTING, AND PATIENTS: Prospective study of 2 cohorts of consecutively admitted patients (N = 270) in a 16-bed ICU at a university hospital. All patients admitted to the ICU during the baseline period from November 1, 2001, to December 31, 2001, and during the intervention period from March 1, 2002, to April 30, 2002, were included. INTERVENTION: A hospital-approved universal consent form for 8 commonly performed procedures (arterial catheter, central venous catheter, pulmonary artery catheter, or peripherally inserted central catheter placement; lumbar puncture; thoracentesis; paracentesis; and intubation/mechanical ventilation) was administered to patients or proxies. Handouts describing each procedure were available in the ICU waiting area. Physicians and nurses were introduced to the universal consent form during orientation to the ICU. MAIN OUTCOME MEASURES: Incidence of informed consent for invasive procedures at baseline and after intervention; whether the patient or proxy provided informed consent; and understanding by the consenter of the procedure as determined by the responses on a questionnaire. RESULTS: Fifty-three percent of procedures (155/292) were performed after consent had been obtained during the baseline period compared with 90% (308/340) during the intervention period (absolute difference, 37.4%; P<.001). During baseline, the majority (71.6%; 111/155) of consents were provided by proxies. This was also the case during the intervention period in which 65.6% (202/308) of consents were provided by proxies (absolute difference, 6.0%; P =.23). Comprehension by consenters of indications for and risks of the procedures was high and not different between the 2 periods (P =.75). CONCLUSIONS: Invasive procedures are frequent in the ICU and consent for them is often obtained by proxy. Providing a universal consent form to patients, proxies, and health care clinicians significantly increased the frequency with which consent was obtained without compromising comprehension of the process by the consenter.
Toxoplasmosis, caused by the intracellular protozoan Toxoplasma gondii, has as its major routes of acquisition either ingestion (of the cyst or oocyte) or transplacental infection (by trophozoites). Transplacental transmission occurs to the fetus in utero or to the newborn at vaginal delivery. Maternally acquired infections can infect the embryo as early as the 7th week of gestation. It has been estimated that 15-17% of maternal infections acquired between the 7th and 14th weeks of gestation are transmitted to the embryo (Lynfield R, Eaton RB., Teratology 1995;52:176-180.). We present a 7-wk-old white male, delivered at 38 wk of gestation, who shortly after birth was found to have hepatosplenomegaly and anemia; he developed liver failure and ascites with persistent anemia during the first week of life. After an extensive, but nondiagnostic, work-up, a paracentesis was performed which led to a diagnosis of congenital toxoplasmosis. This case demonstrates the utility of exfoliative cytology in determining the cause of neonatal ascites, especially of an infectious etiology. To our knowledge, this represents the first reported case of Toxoplasma gondii diagnosed by exfoliative cytology in a pediatric patient.
Pseudo-Gaucher cells have been observed in the bone marrow of patients suffering from a variety of hematologic disorders, including chronic myeloid leukemia, multiple myeloma, and immune thrombocytopenic purpura, as well as other conditions, such as rheumatoid arthritis. While the presence and potential clinical significance of pseudo-Gaucher cells have been documented in the hematology literature, references in standard cytology texts and journals are lacking. We report a case of ascites developing in the context of myelofibrosis, in which abdominal paracentesis yielded numerous pseudo-Gaucher cells as part of a mixed cellular population containing immature hematopoietic elements, consistent with extramedullary hematopoiesis.
Pseudomyxoma peritonei is a rare condition in which the abdominal cavity fills with thick mucoid material as a result of either a benign or malignant disease. We report the findings with gray-scale sonography and laparoscopy in a 74-year-old man with pseudomyxoma peritonei. After paracentesis and drainage of the ascites, sonography visualized hypoechoic nodules in the peritoneum at the surface of the liver and between bowel loops. Laparoscopy revealed mucoid material diffusely throughout the abdominal cavity. The diagnosis of pseudomyxoma peritonei was confirmed by cytologic examination of peritoneal fluid and histologic examination of laparoscopically obtained specimens.
The treatment of choice for pseudomyxoma peritoneai is surgical resection and removal of free mucus. Massive intra-abdominal reaccumulation of viscous mucus has usually been managed by repeat celiotomies. We characterized the mucus of one patient and showed large amounts of immunoglobulins and carcinoembryonic antigens. Intraperitoneal instillation of 5% dextrose and water made the mucus less viscous and easy to remove by paracentesis. The need for repeat celiotomies was obviated.
Two cases of chylous ascites following retroperitoneal lymphadenectomy are presented. The first case, a 3-year-old girl, undersent a right radical nephrectomy and retroperitoneal lymph node dissection for Wilms' tumor. Chylous ascites developed postoperatively and resolved after 3 months of supportive therapy. The second case, a 45-year-old woman, underwent a right radical nephrectomy and retroperitoneal lymph node dissection for renal carcinoma. Chylous ascites occurred postoperatively and resolved after a single paracentesis. Diagnosis, evaluation, and therapeutic modalities are outlined and the literature is reviewed.
Five cases of pathologic rupture of the spleen in patients with hematologic malignancy are presented along with a review of the 48 cases previously described in the English literature. Pathologic splenic rupture occurred most commonly in patients with acute leukemia but has been well documented in chronic leukemias and in lymphoma as well. Nearly all patients experience abdominal pain at the time of rupture; however, this pain was frequently confused clinically with that of biliary tract obstruction, aortic aneurysm, perforated viscus, pancreatitis, and angina pectoris. Pain referred to the left shoulder (Kehr's sign) was present in only 17% of patients. Hypotension was documented in 66%, fever in 74%, and tachycardia in 75%. The most effective diagnostic procedure was paracentesis, which confirmed intraabdominal hemorrhage in each of the nine cases in which the procedure was used. A correct preoperative diagnosis of splenic rupture was reported in only 10 of the 53 cases reviewed. Fifty-two percent of the patients underwent laparotomy; 48% died without operation. Of those that underwent surgery, 78% survived the procedure and the immediate postoperative period. The survival rate of all patients was 38%. There was no correlation of the type of hematologic malignancy, occurrence or type of treatment, peripheral blood counts, or spleen size to survival. The most important factor in predicting survival was appropriate surgery.
Twenty peritoneovenous shunts were inserted in 17 patients with intractable malignant ascites. The ascites was controlled without the need for further paracentesis abdominis in 13 patients. Four shunts blocked and three patients had second shunts inserted, but other complications were minor. Patients who benefited from the procedure included those with macroscopically light blood staining of the ascites and those with malignant cells in the ascitic fluid. Unless the ascites is heavily blood-stained or the patient's anticipated survival is less than 1 month, peritoneovenous shunting is indicated for the treatment of uncontrollable malignant ascites.