Stratification of THROMBOTIC RISK in patients that are undergoing to PICC implantation. The “CoRa-MaPiCC STUDY”

Background: The PICC is a central venous system inserted in the peripherally vein. The central peripheral catheter catheter system (PICC=peripherally inserted central catheters) is a widely used procedure in clinical practice by medical and nurse team. PICC has potential complications that are rare but not entirely irrelevant. It is used for continuous and discontinuous treatment and, after a correct insertion procedure, it can be used for a period of time between 1 week to 3 months. The last-generation dispositive has an high-biocompatibility due to the high quality of the materials (silicone or polyurethane), a total length of 40-60 cm and a diameter between 16 to 25 Gauge or 2 to 5 French. Aims: The aim of our study is to evaluate the trombotic risk related to the positioning of the device in relation to the individual risk factors. Therefore we have elaborated the CoRaMaPicc protocol that allows, based on the preliminary data evaluation, to reduce the trombotic risk in patients with high cardiovascular risk profile. Methods: The study has started in July 2016. We have enrolled 30 patients (18 males and 12 females with range age of 30-99 yrs and mean age of 82+13,5 yrs). Enrolled patients have Body mass Index or (BMI) with range from 16,3-26,5 Kg/mq and mean BMI value of 23,5+2,5 Kg/mq. Enrolled patients were subjected to laboratory assessment of cardiovascular risk factors like laboratory assessment of Methyl-Tetra-Hydro-Folate-Reductase or (MTHFR) and Homocysteine, Fibrinogen, D-Dimer, International Normalized Ratio (INR), Prothrombin Time (PT), activated Partial Thromboplastin Time (aPTT), Platelets (PLT), trombotic risk evaluation (CHA2DS2-VASc Score), and bledding risk evaluation (HAS-BLED Score). Before the insertion procedure of the PICC, single or duble lumen (Groshong or Power PICC type), the patient were subjected to a preliminary ultrasound and echo-doppler vein evaluation to underline the presence of atipical anatomical state of the patients veins. After the procedure the patients were subjected to second ultrasound and echo-doppler vein evaluation and then to a radiographic examination to verify the correct position of the PICC. All patients were enrolled for follow- Up to evaluate trombotic complications. Statistical analysis was performed using the Survival Analysis test to evaluate the patients during the follow-up period in relation to thrombotic events. The data obtained from our study have been described taking also into account the data present in the international literature. Setting: The study was performed using a specific setting in a room of the Internal Medicine Department of the Alfredo Fiorini Hospital (Terracina, Italy), guarantee an aseptic procedure , the right comfort for the patients and the appropriate privacy. Discussion: More data in the literature underline the presence of non-eliminable risk factors like anatomic state of the patients vein that can play a variable role of procedural risk factor and can predispose to procedural or post-procedural complication after the implantation procedure. In specific cases it is difficult to asses an echo-doppler examination of heart for meteorism or ascites and radiographic exams for the presence of pleural effusion. The CoRaMaPiCC protocol use different technique to explore the post-insertion period and the follow-up time at 12 week. In case of meteorism or ascites the ultrasound examination of the heart cameras was replaced by the radiographyc evaluation while in case of pleural effusion, the evaluation of the device position was deduced using the only ultrasound approach (when the vein system is explorable). Procedural algorithm utilized in our implant protocol allows to improve the diagnostic capabilities of the conditions that can predispose to thrombotic complications. During the study period (1 year), the PICCs were removed for death (7 patients; 4 patients for irreversible heart disease, 1 patient for cardiogenic shock 1 patient for septic shock and 1 patient for Creutzfeld-Jacob disease), for spontaneously remotion (1 patient for low compliance of the patient) and for end of therapy (22 patients). The presence of cardiovascular risk factors alone is not sufficient for determining statistically significant changes in the thrombotic risk. As reported historically by the description of the wirkow triad, the presence of three clinical signs, and in particular the presence of endothelial damage (functio lesa) is a sine qua non condition for the occurrence of thrombotic episodes. Conclusion: The CoRaMaPicc protocol allows, based on the evaluation of the data, to minimize endothelial damage and therefore to reduce the incidence of the wirchof's triade related with an high trombotic risk. The data were elaborated considering the different thrombotic risk linked to the presence of the homozygous MTHR mutation responsible for the increase of homocysteine values and therefore of the further thrombotic risk. Further studies are needed to expand the number of enrolled patients and increase the follow-up period. Our data give comfortable results but further evaluation are needed to have conclusive results

Locally advanced leiomyosarcoma of the spleen. A case report and review of the literature

<p>Abstract</p> <p>Background</p> <p>Leiomyosarcomas are rare tumours, predominantly localized in the stomach, small intestine and retroperitoneum. Only one case of primary leiomyosarcoma of the spleen is described in human beings in literature.</p> <p>Case presentation</p> <p>We report a case of locally advanced primary leiomyosarcoma of the spleen in a 54 year-old woman, diagnosed only after splenectomy, performed with the suspicion of splenic haematoma.</p> <p>Conclusion</p> <p>Due to the lack of cases, no specific chemotherapy regimen has been tested to provide a longer survival.</p

[The role of colonoscopy in early diagnosis of intraluminal recurrences in patients already treated for colorectal cancer].

It is a common opinion that the more often and the more rigorously the colon is examined, the more lesions will be discovered and diagnosed. However it has not been shown which methods of colonic examination and which regimen of surveillance should be used. Chart review was conducted on 481 patients who underwent curative resection for colorectal cancer between 1980 and 1990. Colonoscopy was performed preoperatively, after 12-15 months from surgical treatment, and then at an interval of 12-24 months, or when symptoms appeared. About ten percent of patients developed intraluminal recurrences, and more than 25% adenomatous polyps. More than one half of the metachronous lesions arise within the first 24 months. The median time to diagnosis was 25 months for intraluminal recurrences and 22 months for adenomatous polyps. Patients with left sited tumor at an advanced stage run a higher risk of developing recurrent intraluminal disease, and patients who presented associated polyps at the time of the operation for the index cancer have a higher risk of developing new polyps. About 50% of recurrences were detected when patients were asymptomatic. Colonoscopy must be performed within the first 12-15 months after operation, while an interval of 24 months between each examination seems sufficient to guarantee an early detection of metachronous lesion. Asymptomatic patients are more frequently reoperated for cure and thus have a better survival rate

[Carcinoma of the gastric stump. Our experience in 28 treated cases].

A chart review was conducted on 28 patients with gastric stump cancer who were radically treated at the First Department of Surgery of University "La Sapienza" of Rome between 1978 and 1990. The data obtained were compared with those of 401 patients radically treated, in the same period, for primary cancer of the proximal third of the stomach. There were no significant differences between the two groups in terms of stage and nodal involvement. Surgical treatment was total gastrectomy in 86% of cases, and an extended procedure in 57% of patients. The morbidity rate was similar to patients treated for primary gastric cancer, as well the 5-year survival, which depend on the stage of disease. We can conclude that gastric stump cancer must be treated surgically with radical intent as the prognosis is similar to that of primary gastric cancer