Search

PURPOSE: To identify factors associated with the development of clinically significant venous thrombosis in cancer patients with long-term indwelling subclavian Groshong catheters (GC). Also, to assess both the subsequent performance of affected catheters and the effect of heparin and warfarin therapy on subsequent catheter function and longevity. METHODS: Longitudinal study of the outcome of clinical practice. Subset analysis of those catheters developing catheter-related venous thrombosis (CRVT). RESULTS: Thirty-seven cases of CRVT were identified in a population of 255 consecutive patients in whom a GC was inserted. Seventy percent of the thrombi occurred after an episode of previous catheter dysfunction; only 30% of the thrombi occurred de novo. An unexpectedly high risk of thrombosis was associated with insertion into the left-subclavian circulation (25 of 35 versus 135 of 220, p: 0.02) or with an antecedent episode of aspiration difficulty ('ball-valve el-feet' [BVE]) (20 of 35 versus 60 of 220, p (0.01). No correlation was identified between thrombosis and tumor type, tumor histology, or preexisthag medical disorders. Once identified, 79% of the involved patients received anticoagulant therapy with sequential heparin and warfarin. Overall longevity of the catheters preserved by anticoagulation (mean dwell: 202 days) far exceeded catheter longevity among the population of catheters that never developed thrombosis (mean dwell: 142 days). The mean catheter longevity after thrombesis (169 days) also exceeded the mean dwell time of all other catheters that were complication-free. CONCLUSIONS: CRVT is more likely in patients in whom the catheter is inserted in the left-subclavian circulation or who have experienced a previous episode of aspiration difficulty with the catheter (BVE). Catheter preservation with sequential heparin and warfarin therapy precludes the need for catheter removal and extends dramatically the useful life of the catheter.

Immune thrombocytopenic purpura (ITP) may develop during pregnancy or affect later pregnancies. When this occurs, the obstetrician usually seeks the internist for help. The mother and fetus are at serious risk from thrombocytopenia and the measures that can control it. Case reports published since 1950 examine the pathogenesis of ITP and its special problems during pregnancy. Recommendations for management derive from these problems.(JAMA 1980;244:2756-2758)

MEMBERS of surgical teams work for long hours in the operating rooms, dressed in cap, gown, and mask. All too naturally, they prefer an ambient temperature lower than elsewhere in the hospital. Hence, the thermostat is so set in most operating rooms.Cryoglobulinemia is a disorder in which circulating abnormal globulins precipitate in cold.1,2 The thermal amplitude of cryoglobulins is often low, and symptoms usually occur only at very low temperatures; in some cases, however, the thermal amplitude may be high, covering part of the normal ambient temperature.We describe a patient with cryoglobulinemia of high thermal amplitude. During a surgical procedure in a cool operating room, the cryoglobulins precipitated in the renal vascular system, causing acute renal failure.Report of a CaseA 60-year-old woman had pain and swelling of the ankles intermittently for six months. The swelling was associated with fever (to 39.5 °C), erythema, and petechiae

TO THE EDITOR. —I authored a feature that was published in the Archives (139:688-689, 1979). This feature has been widely circulated and seems to have been misinterpreted by many. I would like to reemphasize the following points and clarify my position: (1) Acetaminophen is an effective analgesic and antipyretic that is safe when used appropriately. (2) When misused as in suicide attempts, suicidal gestures, or when excessive amounts are prescribed, it may cause fatal hepatic necrosis and death.1 (3) Acetaminophen is readily available, being found in over 250 products. Because of this, it is mathematically possible to take an overdose while following package directions and simultaneously taking several medicines containing acetaminophen. While cumulative overdose2 and toxic reactions with prolonged administration3 have been reported, no deaths caused by ingestion of multiple medications taken as directed have been reported. (4) A safe, effective treatment for acetaminophen overdose, acetylcysteine, is

THE ASSOCIATION of pure red cell aplasia (PRCA) with thymoma1 is well known. The disease also may be associated with a variety of other conditions, including paraproteinemia.1-4 However, its association with lymphomas occurs infrequently. We have found only one report of PRCA in the course of histiocytic lymphoma.5The rarity of this association is intriguing because autoimmunity is now believed to play a part in the pathogenesis of PRCA, and the incidence of autoimmune phenomena in the course of lymphoproliferative disorders has been documented.6We describe a case of PRCA that occurred a few months after the diagnosis of poorly differentiated lymphocytic lymphoma.Report of a CaseA 27-year-old previously healthy woman complained of chest pain and progressive dyspnea. One month before admission she noted bilateral axillary lymphadenopathy, fever, and weight loss. Examination showed splenomegaly, ascites, and right pleural effusion confirmed by roentgenogram. Thoracentesis yielded 950

The capacity of the physician to do harm has long been recognized. Primum non nocere, first do not harm, is the advice that medical students receive at the beginning of their clinical responsibilities. Many of us are sometimes guilty of injuring patients—actively, by prescribing drugs we know little or nothing about; or passively, by not protesting to appropriate agencies when a drug that is widely available to the public is recognized as potentially lethal.Acetaminophen is such a drug. It is an effective analgesic and antipyretic. Acetaminophen is increasingly being used because of an impression that it is less harmful than aspirin. In 1973, a list of acetaminophen-containing products numbered around 250. Many other products containing acetaminophen have been introduced since then. While some of them are controlled by prescription, many are available for the asking. Many of these products might be used simultaneously for relief of various symptoms. For