Hodgkin's lymphoma of the thyroid: a clinicopathologic study of five cases and review of the literature.

Hodgkin's lymphoma rarely involves the thyroid gland. We report the clinical and pathologic features of five cases of Hodgkin's lymphoma that presented as thyroid lesions. All five patients were females, aged 29-59 years. Three patients had a history of chronic thyroiditis and hypothyroidism and two were euthyroid. One patient had a remote history of Hodgkin's lymphoma. Imaging studies showed a 'cold' nodule (three cases) or a diffusely enlarged thyroid gland, resembling goiter or fibrosclerosing thyroiditis (two cases). Thyroid fine-needle aspiration was performed before thyroidectomy in all cases; three of these cases contained some atypical cells, raising the possibility of Hodgkin's lymphoma. Histologically, all cases were classical Hodgkin's lymphoma, nodular sclerosis subtype. The four patients with primary thyroid lymphoma had Stage IIE disease. All patients were treated with surgical excision and chemotherapy, with or without radiation therapy, and were alive after 2 months to 7 years of follow-up. A review of the English literature between 1962 and 2005 revealed 16 cases of thyroid Hodgkin's lymphoma, with a female preponderance and generally favorable outcome similar to the cases in our series. Hodgkin's lymphoma of the thyroid is rare and can mimic a primary thyroid epithelial tumor or thyroiditis clinically. Histologic diagnosis may be difficult due to marked fibrosis. Hodgkin's lymphoma should be considered in the differential diagnosis of thyroid neoplasms.     

Percutaneous absorption of 2,6-di-tert-butyl-4-nitrophenol (DBNP) in isolated perfused porcine skin.

DBNP (2,6-di-tert-butyl-4-nitrophenol) has been reported as a potential contaminant in submarines. This yellow substance forms when lubrication oil mist containing the antioxidant additive 2,6-di-tert-butylphenol passes through an electrostatic precipitator and is nitrated. Percutaneous absorption of 14C-DBNP was assessed in the isolated perfused porcine skin flap (IPPSF). Four treatments were studied (n=4 flaps/treatment): 40.0 microgram/cm(2) in 100% ethanol; 40.0 microgram/cm(2) in 85% ethanol/15% H(2)O; 4.0 microgram/cm(2) in 100% ethanol; and 4.0 microgram/cm(2) in 85% ethanol/15% water. DBNP absorption was minimal across all treatment groups, with the highest absorption detected being only 1.08% applied dose in an aqueous ethanol group. The highest mass of 14C-DBNP absorbed was only 0.5 microgram. The majority of the applied dose remained on the surface of the skin. This suggests that there is minimal dermal exposure of DBNP when exposed topically to skin.     

Revisiting the biofragmentable anastomotic ring: Is it safe in colonic surgery?

INTRODUCTION: The use of the biofragmentable anastomotic ring (BAR) has been reported in the literature with good results. Our purpose in this review was to document the clinical outcomes after gastrointestinal anastomoses performed with use of the BAR. METHODS: Data were gathered systematically through chart review with the help of data collection forms from 159 patients who underwent 173 intestinal anastomoses performed with use of the BAR between 1992 and 1999. Of the 165 patients who had anastomoses (6 had 2 anastomoses constructed on separate occasions and were considered separately), 23 (13.9%) had surgery with anastomosis under emergency conditions, and 44 (26.7%) were steroid-dependent patients. The indications for surgery were malignant disease in 63 (38.2%) patients, inflammatory bowel disease in 54 (32.7%) patients, diverticular disease in 13 (7.9%) patients and other conditions in 35 (21.2%) patients. RESULTS: A clinical anastomotic leak developed in the first 2 weeks after surgery in 7 (4.2%) patients, 6 of whom required reoperation. All recovered well, withno deaths related to use of the BAR. Early small-bowel obstruction developed in 13 patients (7.9%), none of whom required reoperation. The average postoperative length of hospital stay was 9.0 days, the average time to pass the first flatus was 3.2 days, and the average time to begin oral fluid intake was 3.3 days. The rate of leakage at the anastomosis in our series was comparable to that found in randomized trials with the BAR (2.0%-4.4%) and as reported with hand-sewn and stapled anastomoses (1.9%-8.2%). CONCLUSIONS: Our data indicate that use of the BAR is safe and effective in both elective and emergent surgery. The rate of leakage is comparable to that reported in the literature when a BAR is used.     

Thoracoscopic Assisted Pneumonectomy

A lung carcinoma with tumor involving more than one lobe or in close proximity to the mainstem bronchus often requires pneumonectomy for surgical cure. Inflammation, bulky tumors, and dense adhesions limit the operative field of vision and may result in the abandonment of procedures with potential for complete extirpation. This case illustrates the utility of thoracoscopy in visualization of the hilum and other neurovascular structures in a patient with a proximal tumor and dense intrathoracic adhesions. Successful resection was made possible by use of combined open and thoracoscopic modalities.     

Patients' recollections of therapeutic paralysis in the intensive care unit.

BACKGROUND: Neuromuscular blocking agents used for therapeutic purposes, such as facilitating mechanical ventilation and relieving life-threatening agitation, paralyze patients but leave them fully conscious. Aggressive sedation or analgesia is necessary to reduce awareness, relieve fear, produce comfort, decrease anxiety, induce unconsciousness, and minimize possible complications such as posttraumatic stress syndrome. Little information is available on the extent to which patients experience awareness during therapeutic paralysis. OBJECTIVES: To determine and describe the remembered experiences of critical care patients who were given neuromuscular blocking agents and sedatives and/or analgesics to facilitate mechanical ventilation, improve hemodynamic stability, and improve oxygenation. METHODS: A phenomenological approach with in-depth interviews with 11 patients was used. Data were analyzed by using the constant comparative approach. RESULTS: A total of 4 themes and 3 subthemes were identified. The first theme was back and forth between reality and the unreal, between life and death; the subtheme was having weird dreams. The second theme was loss of control; the 2 subthemes were (1) fighting or being tied down and (2) being scared. The third theme was almost dying, and the fourth theme was feeling cared for. CONCLUSIONS: Patients can remember having both negative and positive experiences during neuromuscular blockade. Steps to improve the experiences of patients receiving neuromuscular blockers include improving assessment parameters, developing and using sedation/analgesia guidelines, and investing in quality improvement programs to provide assessment of awareness during therapeutic paralysis and follow-up and referral as necessary. Ways to decrease the use of neuromuscular blockers would also be useful.