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Simple Summary A chest CT via central vein enhancement not only eliminates peripheral vein regurgitation but also provides better image quality that facilitates precise clinical staging. A chest CT via central vein enhancement may be considered after tissue proof in order to better discriminate disease severity. Abstract The differences in chest computed tomography (CT) image quality may affect the tumor stage. The aim of this study was to compare the image quality and accuracy of chest CT via central vein and peripheral vein enhancement. Fifty consecutive patients were enrolled from a tertiary medical center in Taiwan from May 2016 to March 2019. All the patients received a chest CT via central vein enhancement prior to neoadjuvant concurrent chemoradiation in order to compare the chest CT that was obtained via the peripheral vein. In addition, blind independent central reviews of chest CT via central vein and peripheral vein enhancement were conducted. For T and N stage, chest CT via central vein enhancement had a greater consistency with endoscopic ultrasonography and positron-emission tomography-computed tomography findings (kappa coefficients 0.4471 and 0.5564, respectively). In addition, chest CT via central vein enhancement also showed excellent agreement in the blind independent central review (kappa coefficient 0.9157). The changes in the T and N stage resulted in stage migration in 16 patients. Chest CT via central vein enhancement eliminated peripheral vein regurgitation and also provided more precise clinical staging. This study is registered under the registered NCT number 02887261.

Intravenous ports serve as vascular access and are indispensable in cancer treatment. Most studies are not based on a systematic and standardized approach. Hence, the aim of this study was to demonstrate long-term results of port implantation following a standard algorithm. A total of 2950 patients who underwent intravenous port implantation between March 2012 and December 2018 were included. Data of patients managed following a standard algorithm were analyzed for safety and long-term outcomes. The cephalic vein was the predominant choice of entry vessel. In female patients, wire assistance without use of puncture sheath was less likely and echo-guided puncture via internal jugular vein (IJV) with use of puncture sheath was more likely to be performed, compared to male patients (p &lt, 0.0001). The procedure-related complication rate was 0.07%, and no pneumothorax, hematoma, catheter kinking, catheter fracture, or pocket erosion was reported. Catheter implantations by echo-guided puncture via IJV notably declined from 4.67% to 0.99% (p = 0.027). Mean operative time gradually declined from 37.88 min in 2012 to 23.20 min in 2018. The proposed standard algorithm for port implantation reduced the need for IJV echo-guided approach and eliminated procedure-related catastrophic complications. In addition, it shortened operative time and demonstrated good functional results.

Introduction The catheter is the only intravascular portion of an implanted port and plays a crucial role in catheter related complications. Both polyurethane and silicone are biocompatible materials which are utilized for catheter manufacturing, but their correlation to complications remains controversial. The aim of this study was to try to analyze the relationship between catheter materials and complications. Materials and methods A total of 3144 patients who underwent intravenous port implantation between March 2012 and December 2018 at Chang Gung Memorial Hospital, Linkou, Taiwan were recruited. Of these, 1226 patients received silicone catheter port implantation and 1679 received polyurethane catheter ports. Case matching was done prior to analysis and catheter related complications and cumulative complication incidence for each group were compared. Results Intergroup differences were identified in entry vessel (p = 0.0441), operation year (p < 0.0001), operation method (p = 0.0095), functional period (p < 0.0001), patient follow up status (p < 0.0001), operating time for vessel cutdown (p < 0.0001) and wire assisted approach (p = 0.0008). Stratified by specific entry vessel, no statistical difference was found in complication rate or incidence between the silicone and polyurethane groups. We further compared the cumulative complication incidence of the silicone and polyurethane groups, and also found no statistical difference (p = 0.4451). Conclusion As long as external stress forces generated by surrounding structures and focused on potential weak points are avoided, both silicone and polyurethane materials provide sufficient structural stability to serve as reliable vascular access for patients.

Background: The role of circulating tumor cells (CTCs) for predicting the recurrence of cancer in lung cancer patients after surgery remains unclear. Methods: A negatively selected protocol of CTC identification was applied. For all the enrolled patients, CTC testing was performed before and after surgery on the operation day (day 0), postoperative day 1, and day 3. The daily decline and trend of CTCs were analyzed to correlate with cancer relapse. The mixed model repeated measures (MMRM) adjusted by cancer characteristics was applied for statistical significance. Results: Fifty patients with lung mass undergoing surgery were enrolled. Among 41 primary lung cancers, 26 (63.4%) were pathological stage Tis and I. A total of 200 CTC tests were performed. MMRM analysis indicated that surgery could contribute to a CTC decline after surgery in all patients with statistical significance (p = 0.0005). The daily decrease of CTCs was statistically different between patients with and without recurrence (p = 0.0068). An early rebound of CTC counts on postoperative days 1 and 3 was associated with recurrence months later. Conclusion: CTC testing can potentially serve as a tool for minimal residual disease detection in early-staged lung cancer after curative surgery.

All available conventional ports share a common design, including catheter, locking nut, and port body, and all share two sites of structural weakness. One site is the junction between the locking nut and the proximal end of the catheter. The other site is the catheter fixation site between the locking nut and the protruding stud of the connecting tube. To overcome these shortcomings, we designed a new type of intravenous port which combines the connecting tube into one piece. The aims of this study were to test the mechanical characteristics of the new design and assess its safety in animal study. The prototype of the preattached port was manufactured from biocompatible materials, including PEEK, silicone and polyurethane. All components were assembled with biocompatible glue and mechanical and safety tests were performed to determine the mechanical strength, and tissue reaction of surrounding soft tissue and entry vessels. The mechanical tests showed the new design would not lead to catheter fracture in the oscillation test. The traction test showed significant peak load (18.75 ± 3.29 vs. 26.61 ± 1.75 N; p = 0.036) because of the difference in catheter extension capacity (26.57 ± 4.28 vs. 47.93 ± 2.45 mm; p = 0.012). Significantly smaller endurable injection pressure was identified in the prototype. (90 ± 20 vs. 177.5± 9.48 psi; p = 0.01) The safety test showed good tolerance in beagle dogs and led to no intravascular thrombus and minimal reaction in surrounding tissues. The new prototype preattached port showed good mechanical strength and overcame two potential structural weakness points. The integrated fixation design not only reduced the dimensions of the port device but also provided a greater injection area compared to current designs. It did not cause intravascular thrombosis and produced minimal tissue reaction in surrounding soft tissue, as identified by autopsy. The new design of the fixation device could serve as the basis for the next generation of intravenous ports. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1017-1027, 2018.

Background: Lung cancer is the leading cause of cancer deaths in the world, and more and more treatment modalities have been introduced in order to improve patients’ survival. For patients with advanced non-small cell lung cancer (NSCLC), survival prognosis is poor and multimodality neoadjuvant therapies are given to improve patients’ survival. However, the possibility of occult metastases may lead to discrepancy between clinical and pathologic staging and underestimation of the disease severity. This discrepancy could be the reason for poor survival prediction reported by previous studies which conducted their analysis from the point of view of clinical stage. The aim of this study was to analyze the relationship between clinico-pathologic factors and survival from the pathologic point of view and to try to identify survival prognostic factors. Methods: From January 2005 to June 2011, 88 patients received neoadjuvant therapy because of initial locally advanced disease, followed by anatomic resection and mediastinal lymph node (LN) dissection. All their clinico-pathologic data were collected from a retrospective review of the medical records and subjected to further analysis. Results: We found that total metastatic LN ratio (P=0.01) and tumor size (P=0.02) were predictive factors for disease free survival (DFS). We used these two prognostic factors to stratify all patients into four groups. Group 4 (tumor size ≤5, total metastatic LN ratio ≤0.065) had the best DFS curve, while the DFS curve progressively deteriorated across group 3 (tumor size ≤5, total metastatic LN ratio >0.065), group 2 (tumor size >5, total metastatic LN ratio ≤0.065) and group 1 (tumor size >5, total metastatic LN ratio >0.065). However, no definitive prognostic factor could be identified in this study. Conclusions: In conclusion, tumor size greater than 5 cm and total metastatic LN ratio greater than 0.065 could predict the DFS of patients with advanced NSCLC after multimodality therapies followed by surgical resection. Tumor size plays a more important role than total metastatic LN ratio in DFS. Moreover, patients identified with these factors need active post-operation surveillance and additional aggressive adjuvant therapies.

Background Image characteristics of tumor, including tumor size and component are crucial for patients’ survival. Patients who presented with ground glass opacity (GGO) was found have less risk of intrapulmonary lymph node metastasis and good survival. However, it is difficult to get tissue prove for small GGO lesion preoperatively because of its tiny size and the accuracy of intraoperation frozen section. Some patients received another operation for anatomic resection after malignancy has been confirmed and others refused reoperation and only received wedge resection. The aim of this study was tried to compare the treatment result between anatomic and wedge resection for non small cell lung cancer patients who present as small ground glass opacity (GGO) predominant lesion in pre-operation CT. Materials and methods From January 2010 to May 2014, 500 non small cell lung cancer patients who underwent tumor resection were included. Patients who presented with small GGO predominant lesion in pre-operation CT were included and medical records were reviewed retrospectively. The survival status between anatomic and wedge resection was analyzed. Result 37 patients received anatomic resection (Group A) and 9 patients received wedge resection (Group B). Group B showed less staple usage (p = 0.01) and blood loss (p = 0.02). From view of pathology result, only less intrapulmonary lymph nodes was dissected was identified in group B. From view of survival, similar disease free and overall survival without statistical differences in both groups. Conclusion Wedge resection may provide equivalent treatment result for patients who presented as peripheral GGO or GGO predominant lesions that less than 2 cm in size.

The optimal tip position for an intravenous port and the angle between the locking nut and the catheter are still debatable. This study evaluates the use of chest X-ray plain films for screening patients with potential intravenous port complications. We reviewed, retrospectively, 1505 patients who had an intravenous port implanted between January 1 and December 31, 2006 at Chang Gung Memorial Hospital, and were followed up until June 30, 2010. Of the 1119 patients with an intravenous port implanted via the superior vena cava (SVC), 279 underwent re-interventions for complications. There were four different types of single lumen port, and entry vessels on the right side were utilized as the predominant entry sites through the vessel cut-down method for catheter cannulation. The anatomic catheter tip was confirmed on the postero-anterior view of plain chest X-ray films. We used the Picture Arching and Communicating System (PACS) (GE, Fairfield, CT, USA) to record the angle and distance in degrees and centimeters, respectively. The tracheal carina was seen easily on the chest X-ray plain film and the location of the catheter tip and the angle between the locking nut and the catheter were identified. The location of the catheter tip was significantly related to migration (p

Supplemental Digital Content is available in the text, Nursing staff play a crucial role in maintaining a functional port. Nursing guidelines recommend standard maintenance with 10 ml irrigation without consideration for variations among patients and individual nursing staff. The aim of this study is to identify the efficacy of the current maintenance strategy and analyze the correlation between complications and actual port presentations, based on disassembled intravenous ports after removal from patients. We attempt to organize the information and propose a definite maintenance strategy. After treatment completion, or due to complications, 434 implanted intravenous ports were removed from patients. All ports were deconstructed to observe their actual presentations and were then analyzed in conjunction with medical records. The correlation between complications and actual presentations was analyzed. From March 2012 to December 2017, 434 implanted intravenous ports were removed from oncology patients after completion of treatment or catheter related complications. From the view of maintenance related presentations, injection chamber blood clot was highly correlated with chemotherapy completion (P

Background: Metachronous malignancy is also found in the lung cancer population and may be identified before or after diagnosis of lung cancer. No prior studies have documented lung cancer patients with metachronous malignancy and its survival impact in this population. The aim of this study was to try to clarify the survival impact of locoregional metachronous malignancy in the lung cancer population with resectable disease from a pathology point of view. Methods: From January 2005 to December 2009, 199 lung cancer patients received curative treatment in Chang Gung Memorial Hospital, of which 34 were identified as having lung cancer and metachronous malignancy and 165 patients as having lung cancer only. Clinico-pathologic factors were collected from the medical records. Differences in clinical presentations between the two groups and survival impact were further analyzed. Results: Of these patients, 165 patients (82.9%) had lung cancer only (lung cancer group), and the remaining 34 patients (17.1%) had lung cancer and metachronous malignancy (metachronous malignancy group). There were no significant differences in clinical characteristics between the two groups. The disease free survival (P=0.3199) and overall survival (P=0.71) between these two groups showed no statistically significant difference. Metachronous malignancy only showed survival impact in lung cancer patients with pathologic stage IIIA (P=0.0389). Conclusions: Metachronous malignancy is also seen in the lung cancer population and may be identified before or after diagnosis of lung cancer. Locoregional metachronous malignancy has no survival impact on lung cancer patients who receive curative treatment. Anatomic resection with regional lymph node (LN) dissection is recommended if different tumor cell type and resectable disease are confirmed.

ObjectiveTo identify the risk factors for catheter migration and demonstrate possible mechanisms of this migration.DesignRetrospective study.SettingChang Gung Memorial Hospital, a tertiary medical centre in Taiwan.PatientsPatients who underwent implantation of intravenous ports via the superior vena cava (SVC).InterventionsProcedures involving catheter placement and re-intervention for catheter migration.Main outcome measuresThe 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.MethodsA 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.ResultsShallow catheter-tip location (p

Adequate catheter tip location is crucial for functional intravenous port and central venous catheter. Numerous complications were reported because of catheter migration that caused by inadequate tip location. Different guidelines recommend different ideal locations without consensus. Another debate is actual movement of intravascular portion of implanted catheter. From literature review, the catheter migrated peripherally an average of 20 mm on the erect chest radiographs. In this study, we want to verify the actual presentation of catheter movement within a vessel and try to find a quantitative catheter length model to recommend. From March 2012 to March 2013, 346 patients were included into this prospective cohort study. We collect clinical data from medical record and utilized picture archiving and communication system to measure all image parameters. Statistical analysis was utilized to identify the risk factors for catheter migration. The nonmigration group had 221 patients (63.9%); 67 (19.4%) patients were classified into the peripheral migration group; and 58 (16.8%) patients were classified into the central migration group. Patients with short height (P = 0.03), larger superior vena cava (SVC) diameters at the brachiocephalic vein confluence site (P = 0.02), and longer implanted catheter length (P = 0.0004) had greater risks for central migration. We utilized regression curve for further analysis and height (centimeters)/10 had moderate correlation distances from the entry vessel to the carina. Although intravascular movement of catheter was exist in implanted catheter, the intraoperative fluoroscopy could provide accurate catheter tip location in 63.9% patients. Additional length of catheter implantation seems unnecessary in 80.6% patients. Patients with short height, larger SVC diameters at the brachiocephalic vein confluence site had greater risk for catheter central movement. Height/10 may be consider as reference length of implantation for inexperience surgeon and precise implantation length could be adjust under guidance of fluoroscopy.

Dynamic preload indicators with pulse pressure variation and stroke volume variation are superior to static indicators for predicting fluid responsiveness in mechanically ventilated patients. However, they are influenced by tidal volume and the level of positive end-expiratory pressure. The present study was designed to evaluate the clinical applicability of pulse pressure variation and stroke volume variation in predicting fluid responsiveness on acute respiratory distress syndrome patients ventilated with protective strategy (low tidal volume and high positive end-expiratory pressure).Prospective, observational study.A 20-bed medical intensive care unit of a tertiary medical center.Twenty-two sedated and paralyzed early acute respiratory distress syndrome patients.After being enrolled, central venous pressure, pulmonary capillary wedge pressure, and cardiac output index were obtained from a pulmonary artery catheter (OptiQ SvO2/CCO catheter), and intrathoracic blood volume, global end-diastolic volume, stroke volume variation, and pulse pressure variation were recorded from a PiCCOplus monitor. The whole set of hemodynamic measurements was performed before and after volume expansion with 500 mL hydroxyethyl starch (10% pentastarch 200/0.5).Cardiac output index, central venous pressure, pulmonary capillary wedge pressure, global end-diastolic volume, and intrathoracic blood volume significantly increased, and pulse pressure variation and stroke volume variation significantly decreased after volume expansion. Baseline pulse pressure variation significantly correlated with volume expansion-induced absolute changes (r = .62), or percent changes in cardiac output index (r = .75) after volume expansion. The area under the receiver operating characteristic curve was the highest for pulse pressure variation (area under the receiver operating characteristic curve = 0.768) than other indicators. The threshold value for baseline pulse pressure variation greater than 11.8% predicted a significant positive response to volume expansion with a sensitivity of 68% and a specificity of 100%.Baseline pulse pressure variation accurately predicted the fluid responsiveness in early acute respiratory distress syndrome patients. Roughly, a baseline pulse pressure variation greater than the threshold value of 12% is associated with a significant increase in cardiac output index after the end of volume expansion.

The current TNM staging system did not provide disease relapse information. The aim of study was try to establish a predictive survival model for disease and overall survival in nonsmall cell lung cancer patients who presented as resectable disease and to develop a reference for follow-up imaging tool selection. From January 2005 to December 2011, 442 patients who initially presented as resectable disease (stages I–IIIa) and received anatomic resection and mediastinal lymph node dissection were included in the study. Medical charts were thoroughly reviewed and clinico-pathologic factors were collected and analyzed. Visceral pleural invasion, tumor size >5 cm, and postoperative adjuvant therapy were identified as risk factors for poorer disease-free survival. The 5-year disease-free survival from score 0 to 3 was 68.7%, 46.6%, 31.9%, and 26.1%, respectively. The disease relapse percentage for scores 0 to 3 were 26.49%, 50.61%, 65.05%, and 73.81%, respectively. For analysis of overall survival, age >60 years, tumor size >3 cm, and total metastatic lymph node ratio >0.05 were correlated to worse overall survival. Because greater age may be correlated with poor general condition, we re-scored risk factors that correlated to disease severity that ranging from 0 to 2. The 5-year overall survival range from score 0 to 2 was 56.3%, 43.1%, and 13.1%, respectively. Poor prognostic factors correlated to disease-free survival were tumor size >5 cm, visceral pleural invasion, and patients needing to receive postoperative adjuvant therapy. Disease-free survival of resectable nonsmall cell lung cancer patients and disease relapse can be stratified by these 3 factors. Chest tomography may be recommended for patients with 1 or more poor disease-free survival risk factors.

According to the National Comprehensive Cancer Network (NCCN) guidelines, treatment plans for nonsmall cell lung cancer are to be based on cancer stage. Cancer staging for patients with resectable disease has been based on pathologic stage instead of preoperative clinical stage. However, the possibility of occult mediastinal lymph node metastases could lead to discrepancy between clinical and pathologic stage. While multi-modality treatments may be beneficial for patients with locally advanced disease, most studies have been based on clinical stage. The aim of this study was to identify the beneficial impact of neoadjuvant therapy and the prognostic value of final pathologic stage in these patients. This study enrolled 530 lung cancer patients who received anatomic resection and mediastinal lymph node dissection at Chang Gung Memorial Hospital from January 2005 through June 2011. All resected specimens were examined by pathologists. Postoperative adjuvant therapies were given according to NCCN guideline recommendations. The clinico-pathologic factors of these patients were collected and analyzed. Patients not receiving neoadjuvant therapy had a better probability of disease-free survival (P

Background: Pathologic N2 non-small-cell lung cancer (NSCLC) was demonstrated with poor survival among literature. In this study, we retrospectively reviewed patients with pathologic N2 NSCLC and received anatomic resection (i.e. lobectomy) for further relapse risk factor analysis. The aim of this study is to identify the clinicopathologic factors related to relapse among resectable N2 NSCLC patients and to help clinicians in developing individualized follow up program and treatment plan. Method: From January 2005 to July 2012, 90 diagnosed pathologic N2 NSCLC patients were enrolled into this study. We retrospectively reviewed medical records, image studies, and pathology reports to collect the patient clinico-pathologic factors. Result: We identified that patients with visceral pleural invasion (p = 0.001) and skip metastases along mediastinal lymph node (p = 0.01) had a significant relationship to distant and disseminated metastases. Patients who had 2 or more risk factors for relapse demonstrated poor disease free survival than those who had less than 2 risk factors (p = 0.02). The number of involved metastatic area were significantly influential to the period of time-to-progression. The duration of time-to-progression was correlated with square of number of involved metastatic areas. (Pearson correlation coefficient = −0.29; p = 0.036). Conclusion: Relapse risk factors of resectable pathologic N2 NSCLC patient after anatomic resection were visceral pleural invasion, skip mediastinal lymph node involvement, and the receipt of neoadjuvant therapy. The duration of time-to-progression was correlated with square of number of involved metastatic areas.

Background: N2-positive non-small cell lung cancer (NSCLC) exhibits extremely low survival rates. The role of surgery in operable locally advanced N2 NSCLC remains controversial. In this study, we tried to analyze the role of surgery in resectable N2 NSCLC and the relationship between survival and clinico-pathologic factors from a pathologic point of view. Methods: 108 resectable pathologic N2-positive NSCLC patients, diagnosed from January 2005 to July 2012, were enrolled in this study. We retrospectively reviewed the medical records, image studies, and pathology reports to collect the clinico-pathologic factors in these patients. Results: Those who received lobectomy ( p = 0.002) and had a metastatic lymph node ratio less than 0.4 ( p = 0.01) had a better overall survival rate. In addition, our study also showed that perineural invasion may play a significant role in disease-free survival ( p = 0.01) Conclusions: Metastatic lymph node ratio greater than 0.4 and non-anatomic resection were poor prognostic factors for disease-free survival. Anatomic resection for selected N2 patients may play a crucial role in the overall survival rate. Perineural invasion showed an adverse impact on disease-free survival, but further investigation is warranted.

With regard to pathologic stage IIA (pIIA) non-small cell lung cancer (NSCLC), there is a paucity of literature evaluating the risk factors for disease-free survival (DFS) and overall survival (OS). The aim of this study was to identify the prognostic factors of DFS and OS in patients with NSCLC pIIA. We performed a retrospective review of 98 stage II patients (7th edition of the American Joint Committee on Cancer) who underwent lung resection from January 2005 to February 2011. Of these, 23 patients were excluded for this study because of loss of follow-up or different substage, and 75 patients with pIIA were included for further univariate and multivariate analysis. Risk factors for DFS and OS were analyzed, including age, gender, smoking history, operation method, histology, differential grade, visceral pleural invasion, angiolymphatic invasion, and metastatic N1 lymph node ratio (LNR). Of the 75 patients with pIIA NSCLC who were examined, 29 were female and 46 were male, with a mean age of 61.8 years (range: 34–83 years). The average tumor size was 3.188 cm (range: 1.10–6.0 cm). Under univariate analysis, angiolymphatic invasion and metastatic N1 LNR were risk factors for DFS (P = 0.011, P = 0.007). Under multivariate analysis, angiolymphatic invasion and metastatic N1 LNR were all independent risk factors for DFS, while adjuvant chemotherapy and higher metastatic N1 LNR were independent prognostic factors for OS. For patients with pIIA, higher metastatic N1 LNR and angiolymphatic invasion were related to poor DFS. In addition to DFS, higher metastatic N1 LNR was also a poor prognostic factor for OS rates and adjuvant therapy effectiveness. Clinical physicians should devise different postsurgical follow-up programs depending on these factors, especially for patients with high risk.

To identify the risk factors leading to catheter malfunction.Reliable venous access is crucial for cancer patients. Malfunction of intravenous ports may lead to discontinuation of treatment and repeated interventions. We retrospectively reviewed the independent risk factors for catheter malfunction among patients receiving intravenous port implantations.A total of 1508 procedures were included from the calendar year 2006, and clinical data and chest plain films were analyzed. The patients were followed-up until June 30, 2010. For patients still alive, the last outpatient follow-up date was considered as the end point. For the remaining patients, the date of death or discharge against advice was considered as the end points. The risk factors for catheter malfunction were then evaluated.The intervention-free periods of the malfunction group and nonmalfunction group were 317 and 413 days, respectively. Statistical analyses showed that the Nut-Catheter Angle was the only risk factor for catheter malfunction (P = 0.001). A logistic model also confirmed that the Nut-Catheter Angle was the only risk factor for catheter malfunction (P0.001). Valve tip catheters were not advantageous with regard to catheter malfunction prevention as compared to open tip catheters.A smaller Nut-Catheter Angle had a greater risk for catheter malfunction. Catheter impingement caused by inadequate pocket creation and port implantation lead to compromised catheter lumen and difficulty flushing. The possibility of retained blood and medications increased thin thrombotic biofilm formation and medication precipitation. Catheter malfunctions can be avoided by using proper surgical techniques and adequate maintenance.

Intravenous ports are widely used for oncology patients. However, catheter fractures may lead to the need for re-intervention. We aimed to identify the risk factors associated with catheter fractures. Between January 1 and December 31, 2006, we retrospectively reviewed the clinical data and plain chest films of 1,505 patients implanted with an intravenous port at Chang Gung Memorial Hospital. Different vascular sites were compared using the chi-square or Fisher’s exact test for categorical variables, and the t test was used for continuous variables with normal distribution; P

Renal failure requiring renal replacement therapy (RRT) is associated with a high mortality rate in intensive care unit (ICU) patients. Little information is available on the outcomes of patients having prolonged mechanical ventilation (PMV) in addition to RRT. The purpose of this study was to investigate the impact of RRT in PMV patients.This was an observational, retrospective study in the 24-bed respiratory care center (RCC) of Chang Gung Memorial Hospital, Taiwan, between May 2001 and April 2007. The end points were weaning rate and survival rate at the RCC.Of the 1301 RCC patients, 157 patients (13.7%) underwent RRT. The RRT patients had lower successful weaning rate (39.5% vs 58.4%, P.001) and RCC survival rate (45.9% vs 71.9%, P.001) compared with without-RRT patients. The successful weaning rates of end-stage renal disease (ESRD) patients, patients with RRT initiated at the ICU and continued at RCC, and patients whose RRT was initiated at the RCC were 49.2%, 39.1%, and 22.2%, respectively. The RCC survival rates were 50.8%, 47.8%, and 29.6%, respectively. The odds ratios of successful weaning rate and survival rate were 0.295 (95% confidence interval, 0.105-0.833; P = .021) and 0.407 (95% confidence interval, 0.155-1.021; P = .069) for patients whose RRT was initiated at the RCC vs ESRD patients.The present study demonstrates that the need for RRT had a negative impact on weaning and mortality in PMV patients compared with patients without RRT. Patients who had RRT initiated at the RCC had a significantly lower weaning rate compared with ESRD patients.

Objective Transpulmonary thermodilution cardiac output is used in calculating aortic impedance for calibrating the pulse-contour analysis and is applied to calculate extravascular lung water (EVLW). Whether pulmonary edema affects the accuracy of transpulmonary thermodilution is controversial. This study aimed to investigate the effects of extravascular lung water index (EVLWI) on the transpulmonary thermodilution measurement in acute respiratory distress syndrome (ARDS). Design A prospective study. Setting The medical intensive care unit of one medical center. Participants Twenty-four ARDS patients. Interventions The continuous pulmonary artery thermodilution cardiac index (CCIpa) and the bolus transpulmonary thermodilution cardiac index (BCItp) data were recorded at baseline and repeated immediately and at 2, 4, and 6 hours after volume expansion with a 500-mL infusion of 10% pentastarch (hydroxyethyl starch 200/0.5) at a rate of 10 mL/kg/h. Measurements and Main Results A total of 120 paired CI measurements were analyzed. Linear regression analysis showed a close correlation between BCItp and CCIpa (R = 0.87). The mean BCItp was higher than CCIpa, and the Bland-Altman analysis revealed a bias of 0.51 ± 0.78 L/min/m2. The limits of agreement (2 standard deviations) was 1.66 L/min/m2 (+2.07 and −1.05 L/min/m2), and the percentage error was 31.5%. Levels of EVLWI negatively correlated with the difference between BCItp and CCIpa (R = −0.19). Conclusion In ARDS patients, the agreement between transpulmonary thermodilution and pulmonary artery thermodilution for cardiac output measurement is marginally acceptable. The severity of pulmonary edema expressed as EVLWI weakly and negatively correlates with the difference between BCItp and CCIpa derived from the two techniques.

several studies have shown a close relationship between obstructive sleep apnoea (OSA) and dyslipidaemia. This study was designed to clarify the relationship of metabolic dysfunctions in sleep related-breathing disorders (SRBD), including OSA and simple snoring. The end point was to determine the prevalence of hyperlipidaemia and hyperuricaemia in SRBD. Factors contributing to hyperlipidaemia and hyperuricaemia in SRBD were also evaluated.Outpatients20 yr old with complaint of habitual snoring were prospectively enrolled. All patients underwent an overnight polysomnography (PSG) in a sleep laboratory and blood assay after overnight fasting. The factors of gender, age, body mass index (BMI), apnoea-hypopnoea index (AHI), and desaturation index (DI) were recorded in the PsG report. A logistic regression analysis was conducted to investigate the relationship between metabolic dysfunctions and these factors.Of the 275 patients (88.4% male), 236 (85.8%) were diagnosed with OSA (AHI5/h). The mean (+/- SD) of age, BMI, AHI, and DI were 44.2 +/- 11.4 yr, 27.4 +/- 4.0 kg/m(2), 37.9 +/- 30.6/h, and 21.2 +/- 23.2/h, respectively. The overall prevalence of hypercholesterolaemia, hypertriglyceridaemia, and hyperuricaemia in this study was 61.1, 55.3, and 25.8 per cent, respectively. Logistic regression analysis revealed that DI was a significant independent factors contributing to hypercholesterolaemia [odds ratio (OR)=1.016, P=0.010, 95% confidence interval (CI)=1.004-1.028] and hypertriglyceridaemia (OR=1.021, P=0.002, 95% CI=1.008-1.034).The data of the present study support a high prevalence of hyperlipidaemia in SRBD. DI may be a determining factor contributing to hyperlipidaemia in SRDB. Underdiagnosis of hyperlipidaemia in SRBD is a critical problem.

Vascular cutdown and echo guide puncture methods have its own limitations under certain conditions. There was no available algorithm for choosing entry vessel. A standard algorithm was introduced to help choose the entry vessel location according to our clinical experience and review of the literature. The goal of this study is to analyze the treatment results of the standard algorithm used to choose the entry vessel for intravenous port implantation.During the period between March 2012 and March 2013, 507 patients who received intravenous port implantation due to advanced chemotherapy were included into this study. Choice of entry vessel was according to standard algorithm. All clinical characteristic factors were collected and complication rate and incidence were further analyzed.Compared with our clinical experience in 2006, procedure-related complication rate declined from 1.09% to 0.4%, whereas the late complication rate decreased from 19.97% to 3.55%. No more pneumothorax, hematoma, catheter kinking, fractures, and pocket erosion were identified after using the standard algorithm. In alive oncology patients, 98% implanted port could serve a functional vascular access to fit therapeutic needs.This standard algorithm for choosing the best entry vessel is a simple guideline that is easy to follow. The algorithm has excellent efficiency and can minimize complication rates and incidence.

An entry vessel is crucial for intravenous port implantation. A safe alternative entry vessel that can be easily explored is crucial for patients without feasible cephalic vein or for those who need port reimplantation because of disease relapse. In this study, we tried to analyze the safety and feasibility of catheter implantation via the deltoid branch of the thoracoacromial vein. From March 2012 to November 2013, 802 consecutive oncology patients who had received intravenous port implantation via the superior vena cava were enrolled in this study. The functional results and complications of different entry vessels were compared. The majority of patients (93.6%) could be identified as thoracoacromial vessel. The deltoid branch of the thoracoacromial vein is located on the medial aspect of the deltopectoral groove beneath the pectoralis major muscle (85.8%) and in the deep part of the deltopectoral groove (14.2%). Due to the various calibers employed and tortuous routes followed, we utilized 3 different methods for catheter implantation, including vessel cutdown (47.4%), wire assisted (17.9%), and modified puncture method (34.6%). The functional results and complication rate were similar to other entry vessels. The deltoid branch of the thoracoacromial vein is located in the neighborhood of the cephalic vein. The functional results of intravenous port implantation via the deltoid branch of the thoracoacromial vein are similar to other entry vessels. It is a safe alternative entry vessel for intravenous port implantation.

Background This retrospective study evaluated the utility and safety of surgical lung biopsy (SLB) in cancer patients with acute respiratory distress syndrome (ARDS). Methods All cases of critically ill patients with cancer and diagnosed with ARDS who underwent SLB in a tertiary care hospital from January 2002 to July 2009 were reviewed. Clinical data including patient baseline characteristics, surgical complications, pathological findings, treatment alterations, and survival outcomes were retrospectively collected and analyzed. Results A total of 16 critically ill patients with cancer diagnosed with ARDS who underwent SLB were enrolled. The meantime from ARDS onset to SLB was 3.0 ± 1.5 days. All SLB specimens offered a pathological diagnosis, and specific diagnoses were made in 9 of 16 patients. Biopsy findings resulted in a change in therapy in 11 of 16 patients. Overall, the SLB surgical complication rate was 19% (3/16). SLB did not directly cause the observed operative mortality. The ICU mortality rate was 38% (6/16). Patients who switched therapies after SLB had a trend toward decreased mortality than patients without a change in therapy (27% versus 60%; P = 0.299). Conclusions In selected critically ill cancer patients with ARDS, SLB had a high diagnostic yield rate and an acceptable surgical complication rate.

Background Invasive fungal infection (IFI) is associated with high morbidity and high mortality in hematopoietic stem cell transplantation (HSCT) patientsThe purpose of this study was to assess the characteristics and outcomes of HSCT patients with IFIs who are undergoing MV at a single institution in Taiwan. Methods We performed an observational retrospective analysis of IFIs in HSCT patients undergoing mechanical ventilation (MV) in an intensive care unit (ICU) from the year 2000 to 2009. The characteristics of these HSCT patients and risk factors related to IFIs were evaluated. The status of discharge, length of ICU stay, date of death and cause of death were also recorded. Results There were 326 HSCT patients at the Linkou Chang-Gung Memorial Hospital (Taipei, Taiwan) during the study period. Sixty of these patients (18%) were transferred to the ICU and placed on mechanical ventilators. A total of 20 of these 60 patients (33%) had IFIs. Multivariate analysis indicated that independent risk factors for IFI were admission to an ICU more than 40 days after HSCT, graft versus host disease (GVHD), and high dose corticosteroid (p < 0.01 for all). The overall ICU mortality rate was 88% (53 of 60 patients), and was not significantly different for patients with IFIs (85%) and those without IFIs (90%, p = 0.676). Conclusion There was a high incidence of IFIs in HSCT patients requiring MV in the ICU in our study cohort. The independent risk factors for IFI are ICU admission more than 40 days after HSCT, GVHD, and use of high-dose corticosteroid.

Introduction Mechanical ventilation of patients may be accomplished by either translaryngeal intubation or tracheostomy. Although numerous intensive care unit (ICU) studies have compared various outcomes between the two techniques, no definitive consensus indicates that tracheostomy is superior. Comparable studies have not been performed in a respiratory care center (RCC) setting. Methods This was a retrospective observational study of 985 tracheostomy and 227 translaryngeal intubated patients who received treatment in a 24-bed RCC between November 1999 and December 2005. Treatment and mortality outcomes were compared between tracheostomized and translaryngeal intubated patients, and the factors associated with positive outcomes in all patients were determined. Results Duration of RCC (22 vs. 14 days) and total hospital stay (82 vs. 64 days) and total mechanical ventilation days (53 vs. 41 days) were significantly longer in tracheostomized patients (all P < 0.05). The rate of in-hospital mortality was significantly higher in the translaryngeal group (45% vs. 31%;P < 0.05). No significant differences were found in weaning success between the groups (both were >55%) or in RCC mortality. Because of significant baseline between-group heterogeneity, case-match analysis was performed. This analysis confirmed the whole cohort findings, except for the fact that a trend for in-hospital mortality was noted to be higher in the translaryngeal group (P = 0.08). Stepwise logistic regression revealed that patients with a lower median severity of disease (APACHE II score 2.5 g/dl) or had normal metabolism (BUN