Comparison between azacitidine and decitabine as front-line therapy in elderly acute myeloid leukemia patients not eligible for intensive chemotherapy.

We compared the efficacy of azacitidine (AZA) and decitabine (DEC) in elderly patients with untreated AML, diagnosed according to WHO criteria. In the two groups, we evaluated complete remission (CR), overall survival (OS) and disease free survival (DFS). The AZA and DEC groups included 139 and 186 patients, respectively. To minimize the effects of treatment selection bias, adjustments were made using the propensity-score matching method, which yielded 136 patient pairs. In the AZA and DEC cohort, median age was 75 years in both, (IQR, 71-78 and 71-77), median WBCc at treatment onset 2.5 × 109/L (IQR, 1.6-5.8) and 2.9 × 109/L (IQR, 1.5-8.1), median bone marrow (BM) blast count 30% (IQR, 24-41%) and 49% (IQR, 30-67%), 59 (43%) and 63 (46%) patients had a secondary AML, respectively. Karyotype was evaluable in 115 and 120 patients: 80 (59%) and 87 (64%) had intermediate-risk, 35 (26%) and 33 (24%) an adverse risk karyotype, respectively. Median number of cycles delivered was 6 (IQR, 3.0-11.0) and 4 (IQR, 2.0-9.0), CR rate was 24% vs 29%, median OS and 2-year OS rates 11.3 (95% CI 9.5-13.8) vs 12.0 (95% CI 7.1-16.5) months and 20% vs 24%, respectively. No differences in CR and OS were found within the following subgroup: intermediate- and adverse-risk cytogenetic, frequency of WBCc at treatment ≥ 5 × 10^9 L and < 5 × 10^9/L, de novo and secondary AML, BM blast count < and ≥ 30%. Median DFS for AZA and DEC treated patients was 9.2 vs 12 months, respectively. Our analysis indicates similar outcomes with AZA compared to DEC.

[Three tasks for the exploration of verbal fluency: evidence of test-retest reliability in Argentine adults]. / Tres tareas para la exploración de la fluidez verbal: evidencias de su fiabilidad test-retest en adultos argentinos.

INTRODUCTION: The phonological and semantic verbal fluency tasks are frequently used in neuropsychological assessment due to their easy application and good sensitivity to dementia. In Argentina, the psychometric evidence for these tasks is limited, with a special lack of knowledge of the temporal stability of its measurements. The psychometric production is even lower for the action fluency variant (emission of verbs in the infinitive in one minute). In effect, this research analyzes the test-retest reliability of three verbal fluency tasks in Argentine adults. SUBJECTS AND METHODS: The sample was made up of 85 Argentine (average age, 63.7 years), 75,3% women and with a medium-high educational level. A prospective longitudinal design was carried out, administering phonological, semantic and action fluency tasks at two different times with an interval of up to four months. The intraclass correlation coefficient (ICC), a statistical method suggested for test-retest reliability studies, was analyzed. For the interpretation of the ICC, the Fleiss criteria were adopted. RESULTS: The phonological and semantic fluency tasks showed good reliability, with ICCs of 0.77 and 0.79. The fluidity of action variant yielded ICC of 0.90, indicating excellent reliability. CONCLUSIONS: All fluency tasks have appropriate temporal stability, and their use is recommended when prospective neuropsychological research is planned (with language evaluation at different times) or as a method of monitoring the evolution of aphasic patients undergoing neurorehabilitation. Based on its excellent reliability, it is recommended to use the action variant more frequently.

TITLE: Tres tareas para la exploración de la fluidez verbal: evidencias de su fiabilidad test-retest en adultos argentinos.Introducción. Las tareas de fluidez fonológica y semántica son de uso frecuente en la evaluación neuropsicológica por su fácil aplicación y buena sensibilidad al deterioro cognitivo. En Argentina es limitado el cuerpo de evidencia psicométrica para dichas tareas, con especial desconocimiento de la estabilidad temporal de sus medidas. La producción psicométrica es aún menor para la variante fluidez de acción (emisión de verbos en infinitivo en un minuto). En efecto, este estudio analiza la fiabilidad test-retest de tres tareas de fluidez en adultos argentinos. Sujetos y métodos. La muestra se compuso de 85 argentinos (medida de edad, 63,7) de población general no clínica, un 75,3% mujeres, de nivel de instrucción medio-alto. Se efectuó un diseño longitudinal-prospectivo administrando tareas de fluidez fonológica, semántica y de acción en dos momentos distintos con un intervalo hasta de cuatro meses. Se analizó el coeficiente de correlación intraclase (CCI), método estadístico sugerido para estudios de fiabilidad test-retest. Para interpretar el CCI se adoptaron los criterios de Fleiss. Resultados. Las tareas de fluidez fonológica y semántica demostraron buena fiabilidad, con un CCI de 0,77 y 0,79. La fluidez de acción obtuvo excelente fiabilidad, con un CCI de 0,9. Conclusión. Las tareas de fluidez relevadas poseen apropiada estabilidad temporal, por lo que se sugiere su uso en investigaciones neuropsicológicas prospectivas (cuando se evalúe el lenguaje en distintos momentos) o cuando se requiera un seguimiento de la evolución de pacientes afásicos en neurorrehabilitación. Basándose en su excelente fiabilidad, se recomienda utilizar con más frecuencia la variante de acción.

The Efficacy and Safety of Lenalidomide plus Rituximab in an Orbital Relapse of Diffuse Large B-Cell Lymphoma.

A 74-year-old male with diffuse large B-cell lymphoma, with an Ann Arbor stage IV-A, was submitted to immune-chemotherapy in 2014, with complete remission of the disease. Two years later, he presented with a left eye swelling leading to exophthalmos and blurred vision. A core biopsy was performed and revealed a local relapse of the disease. He was considered unfit for intensive salvage chemotherapy and was treated with a combination of rituximab and lenalidomide. After six courses of rituximab plus lenalidomide, the patient showed complete remission and was submitted to maintenance therapy with lenalidomide. After 24 months since the start of lenalidomide monotherapy, we did not observe any progression. In this experience, rituximab plus lenalidomide, without radiotherapy, was a safe and effective therapeutic combination in an elderly patient with a localized relapse of DLBCL who was unfit to receive more aggressive therapies.

Early diagnosis of anastomotic leakage after colorectal surgery by the Dutch leakage score, serum procalcitonin and serum C-reactive protein: study protocol of a prospective multicentre observational study by the Italian ColoRectal Anastomotic Leakage (iC.

BACKGROUND: Anastomotic leakage (AL) is a dreaded major complication after colorectal surgery. There is no uniform definition of anastomotic dehiscence and leak. Over the years many risk factors have been identified (distance of anastomosis from anal verge, gender, BMI, ASA score) but none of these allows an early diagnosis of AL. The DUtch LeaKage (DULK) score, C reactive protein (CRP) and procalcitonin (PCT) have been identified as early predictors for anastomotic leakage starting from postoperative day (POD) 2-3. The study was designed to prospectively evaluate AL rates after colorectal resections, in order to give a definite answer to the need for clear risk factors, and testing the diagnostic yeld of DULK score and of laboratory markers. Methods and analysis. A prospective enrollment for all patients undergoing elective colorectal surgery with anastomosis carried out from September 2017 to September 2018 in 19 Italian surgical centers. OUTCOME MEASURES: preoperative risk factors of anastomotic leakage; operative parameters; leukocyte count, serum CRP, serum PCT and DULK score assessment on POD 2 and 3. Primary endpoint is AL; secondary endpoints are minor and major complications according to Clavien-Dindo classification; morbidity and mortality rates; readmission and reoperation rates, length of postoperative hospital stay (Retrospectively registered at ClinicalTrials.gov Identifier: NCT03560180, on June 18, 2018). Ethics. The ethics committee of the "Comitato Etico Regionale delle Marche - C.E.R.M." reviewed and approved this study protocol on September 7, 2017 (protocol no. 2017-0244-AS). All the participating centers submitted the protocol and obtained authorization from the local Institutional Review Board.

Sports Eligibility After Risk Assessment and Treatment in Children with Asymptomatic Ventricular Pre-excitation.

BACKGROUND AND OBJECTIVE: Many studies concern the management of young patients with symptomatic Wolff-Parkinson-White (WPW) syndrome, but little information exists on the significance and prognosis of ventricular pre-excitation (VPE) in asymptomatic children. The aim of the study was to evaluate the risk of sudden death in young athletes with asymptomatic VPE by transesophageal electrophysiological study (TEEPS) and their sports eligibility after the risk assessment and/or ablative treatment. METHODS: Ninety-one asymptomatic children and adolescents underwent TEEPS both at rest and during adrenergic stress (exercise testing or isoproterenol infusion). After electrophysiological testing, patients were assessed in the 36 months of follow-up. RESULTS: Thirty-three patients (36.3 %) had a benign form of VPE and were allowed to participate in competitions. Ten patients (11 %) were at borderline risk; thus, sport eligibility was evaluated individually. Forty-eight patients (52.7 %) showed inducible sustained atrioventricular reentrant tachycardia and/or atrial fibrillation (AF), 11 of whom (12.1 % of total population) had a potential risk of sudden cardiac death due to AF inducibility during physical stress. Forty-five young athletes underwent transcatheter ablation (TCA). TCA was interrupted in 12 patients (26.7 %) because of the high procedural risk linked to septal accessory pathway (AP) location. There were no TCA-related complications, and all patients remained asymptomatic during follow-up. CONCLUSION: Most of the young athletes with asymptomatic VPE may be allowed to participate in competitive sports after an adequate risk assessment and/or ablative treatment. However, in our opinion, special care should be taken to avoid procedural complications, which are unacceptable in asymptomatic patients.

Ability of hydroxypropyl chitosan nail lacquer to protect against dermatophyte nail infection.

The development of a topical agent that would strengthen the nail, improve the natural barrier, and provide better drug penetration to the nail bed is needed. In this study, we examined the effects of a hydroxypropyl chitosan (HPCH)-based nail solution using a bovine hoof model. Following application of the nail solution, changes in the hardness of the hoof samples were measured using the Vickers method. Tensile and flexural strengths were tested by stretching or punching the samples, respectively. The ultrastructure was examined using scanning electron microscopy (SEM), and samples stained with periodic acid-Schiff (PAS) stain were used to determine the fungal penetration depth. The comparators included 40% urea and 70% isopropyl alcohol solutions. The HPCH nail solution increased hoof sample hardness in comparison to the untreated control sample (mean, 22.3 versus 19.4 Vickers pyramid number [HV]). Similarly, the HPCH solution increased the tensile strength (mean, 33.07 versus 28.42 MPa) and flexural strength (mean, 183.79 versus 181.20 MPa) compared to the untreated control. In contrast, the comparators had adverse effects on hardness and strength. SEM showed that the HPCH solution reduced the area of sample crumbling following abrasion compared to the untreated control (7,418 versus 17,843 pixels), and the PAS-stained images showed that the HPCH solution reduced penetration of the dermatophyte hyphae (e.g., penetration by Trichophyton mentagrophytes was <25 µm at day 9 versus 275 µm in the untreated control). Unlike chemicals normally used in cosmetic treatments, repeated application of the HPCH nail solution may help prevent the establishment of new or recurring fungal nail infection.

Does the nasogastric tube has a role in elective colo-rectal surgery?

INTRODUCTION: Routine use of nasogastric tubes (NGT) after abdominal operations is intended to hasten the return of bowel function, diminish the risk of anastomotic leakage and prevent pulmonary complications. The aim of our study was to prospectively assess the tolerability and the safety of the non use of NGT after elective colorectal open operations. PATIENTS AND METHODS: Between March 2009 and December 2010, 110 consecutive patients underwent colo-rectal elective open surgery for neoplasm without nasogastric decompression. We analyzed the incidence of nausea and vomiting, the pulmonary complications, the return of bowel function the deep wound breakdown (fascial dehiscence) and the anastomotic leakage. RESULTS: Only 15 patients (13,6%) reported nausea without vomiting immediately after surgery and 9 cases of vomiting were observed (8%), requiring the insertion of the NGT (nasogastric tube) in 5 (4,5%). A total of 105 patients (96,3%) were NGT free. No deep wound dehiscence was observed and only one real pneumonia occurred. Anastomotic dehiscence occurred in 4 patients (3,6%) and a second surgical procedure was needed in three cases. The return of bowel function, except in the last four patients, occurred in 3,8 days average (range 2-7 days). CONCLUSION: We confirm the uselessness of the NGT in the framework of fast track program adopted in elective open colo-rectal surgery.

Use of NaCl saline hydration and N-Acetyl Cysteine to prevent contrast induced nephropathy in different populations of patients at high and low risk undergoing coronary artery angiography.

AIM: Contrast-induced nephropathy (CIN) is most commonly defined as acute renal failure occurring within 48-72 h of exposure to intravascular radiographic contrast medium that is not attributable to other causes. In international literature a 25% increase in serum creatinine levels or an increase in absolute values of 0.5 mg/dL from baseline has been suggested to define CIN. The reported incidence of CIN varies widely, ranging from 2% to 50%. This variability results from differences in the presence or absence of risk factors. With a retrospective analysis authors evaluated the use of NaCl saline hydration and N-acetyl cysteine (NAC) to prevent CIN in different populations of patients at high and low risk undergoing coronary artery angiography. METHODS: From January 2007 to December 2008, 597 patients underwent coronary artery angiography with a low osmolarity contrast agent. Nephrotoxic drugs such as diuretics, metformin, ACE-I and ARBs were stopped at least 24 h before the procedure. The population was divided into two groups: group A (high risk 342 patients, 57.2%) identified for the presence of at least one risk factor such as diabetes, age >65 years, baseline creatinine >1.4 mg/dL and group B (low risk 255 patients, 42.8%) for the absence of any of the risk mentioned above. Only group A was treated with a saline hydration (1 mL/kg/h) plus NAC 600 mg 12 h before and 12 h after the procedure. RESULTS: The overall incidence of CIN was 6.7% (40 patients). In particular, the incidence of CIN was 4.4% (15 patients) in the group A and 9.8% (25 patients) in the group B respectively (P=0.017). Interestingly, the Contrast Index (volume administrated/theoretical maximum volume) was significantly lower in group B (P<0.005). In the multivariate analysis, including risk factors such as age, diabetes, hypertension, hypercholesterol-mia, current smoke, baseline creatinine level, Contrast Index and hydration, the last variable was the only one inversely correlated independently with the incidence of CIN (P=0.001). CONCLUSIONS: The hydration with saline and NAC is an effective and low-cost tool in preventing CIN in patients undergoing coronary artery angiography and, according to the current guidelines, should be used in all high-risk patients. Present results show that even in patients at low risk for CIN, hydration could be useful: in fact, despite the Contrast Index was significantly lower in this population, the incidence of CIN was greater, thus suggesting a potential role for hydration also in the low-risk population.

[Radio-guided parathyroidectomy]. / La paratiroidectomia radioguidata.

The Authors, after a careful review of literature about the instrumental diagnostic techniques (with particular attention to the nuclear-medical ones) and the surgical therapy of parathyroid diseases, report their experience on the use of the radio-guided mininvasive surgery with MIBI and gamma-probe for intraoperative localization of pathological glands. Once exposed their experience, the Authors conclude asserting that this technique is fast, slightly invasive and expensive, and certainly useful for the detection of pathological or ectopic glands. It can be widely employed because, in comparison to its numerous advantages, such as the reduction of the operating time and of the hospital-stay, the greater radicality and the possibility to use mininvasive techniques, it does not present significant technical limitations and/or radio-protectionistic problems.

Novel insights into the role of cardiotrophin-1 in cardiovascular diseases.

Cardiotrophin-1 (CT-1), a member of interleukin (IL)-6 family, was originally isolated for its ability to induce a hypertrophic response in neonatal cardiac myocytes. This cytokine mediates a pleiotropic set of growth and differentiation activities through a unique receptor system, consisting of IL-6 receptor (IL-6R) and a common signal transducer, the glycoprotein 130 (gp130). Both in humans and in mice, CT-1 mRNA has been detected in several tissues, such as liver tissue, adipose tissue, and tissues in the respiratory and nervous systems; in each of these tissues it performs different functions. Predominant actions of CT-1 are on the heart, where it is synthesized and where it provides first myocardial protection by promoting cell survival and proliferation, it carries on its haemodynamic effects and endocrine properties, and finally, it predisposes the heart to pathological conditions. The aim of this review is to describe the pathophysiological mechanisms through which CT-1 carries out its activities, especially on the heart, and its potential contribution as a disease marker in clinical cardiology. Recent studies have confirmed its active role in promoting structural changes typical of most common cardiovascular disease, such as hypertension, valve diseases, congestive heart failure, and coronary artery disease. In fact, CT-1 induces myocyte hypertrophy and collagen synthesis, thereby participating in the progression of ventricular remodelling, which results in cardiac muscle failure at the latest stage. CT-1 plasma levels are elevated in patients with hypertension and coronary artery diseases, and they are also correlated with the severity of valve diseases and heart failure. Therefore, CT-1 may represent a diagnostic, staging, and prognostic biomarker of cardiovascular diseases.

[The role of natriuretic peptides in heart failure]. / Ruolo dei peptidi natriuretici nello scompenso cardiaco.

Over the last decades, there has been a significant increase in incidence and prevalence of heart failure, a major cause of cardiac morbidity and mortality. Measurements of neurohormones, in particular B-type natriuretic peptide (BNP), can significantly improve diagnostic accuracy, and also correlate with long-term morbidity and mortality in patients with chronic heart failure presenting to the emergency department. BNP is secreted by cardiac ventricles mainly in response to wall stress and neurohormonal factors like the sympathetic nervous system, endothelins, and the rennin-angiotensin-aldosterone system. BNP increases myocardial relaxation and oppose the vasoconstrictive, sodium retaining, and natriuretic effects caused by vasoconstrictive factors. BNP is the first biomarker to prove its clinical value for the diagnosis of left ventricular systolic and diastolic dysfunction but also for the right ventricular dysfunction, guiding prognosis and therapy management. Emerging clinical data will help further refine biomarker-guided therapeutic and monitoring strategies involving BNP.

[Experience of a peripheral center in the surgical treatment of hepatic metastasis from colorectal cancer]. / Esperienza di un centro periferico nel trattamento chirurgico delle metastasi epatiche da cancro colorettale.

Surgical resection is still the first therapeutic option in patients with resectable colorectal cancer metastatic to the liver. Application of radiofrequency energy has been used in patients who did not meet the criteria for resectability and yet were candidates for a liver-directed procedure based upon the presence of liver-only disease. Hepatic resection has evolved in the last two or three decades from a procedure with associated mortality rate of up to 20% in the early 80s to usually less than 5% in patients undergoing liver resection thereafter. This improvement in morbidity and mortality is multifactorial; despite the increased safety of liver operations, hepatic resection still remains a complex surgical procedure with serious potential morbidity. The experience with liver resections and/or radiofrequency ablations, for colorectal cancer metastatic to the liver, performed at a medium-volume center (15 cases in 4 years) is presented. Some features of the metastatic disease, including the number, size and location of metastases are identified. The perioperative mortality is 0, morbidity for non surgical complications is 40%. In this series the reported overall 1-yr survival is 80%, 2-yr is 67%. This paper reviews the experienced factors that have defined the morbidity and mortality associated with liver surgery.

Albumin excretion in diabetic patients in the setting of acute myocardial infarction: association with 3-year mortality.

AIMS/HYPOTHESIS: Diabetes mellitus is associated with increased mortality in subjects with acute myocardial infarction (AMI). We aimed to estimate the risk of mortality in AMI patients with and without diabetes using the urinary albumin : creatinine ratio (ACR). METHODS: This is a prospective study of 121 consecutive, non-selected diabetic AMI patients, 121 age- and sex-matched non-diabetic AMI patients and 61 diabetic non-AMI outpatients as control subjects. All data were obtained during the first 7 days of hospitalisation and each AMI patient was followed for a period of exactly 3 years. Baseline ACR RIA measurements were made on the 1st, 3rd and 7th days of admission. RESULTS: Adjusted ACR values were significantly higher in the diabetic AMI patients than in the diabetic control outpatients ( p<0.0001), and a significant difference was observed between the weekly ACR slopes for these two groups ( p<0.0001). Microalbuminuria was more prevalent in the diabetic AMI patients than in the non-diabetic AMI patients on the 1st day (62% vs 46%, p=0.01) and 3rd day (41% vs 29%, p=0.04). Among the AMI patients with normoalbuminuria (ACR <30 microg/mg), the mortality rate was 11.6% for the patients without diabetes and 33.8% for those with diabetes ( p=0.001). The mortality rate was much higher among the AMI patients with microalbuminuria (ACR >/=30 microg/mg) and similar for the diabetic (68.0%) and non-diabetic patients (74.3%). In a multivariable Cox model, ACR ( p<0.0001) and diabetes status ( p=0.01) were associated with adverse outcome even when several other clinical variables were included in the model. Furthermore, a negative interaction was found between diabetes and ACR ( p=0.01). CONCLUSIONS/INTERPRETATION: Microalbuminuria frequently occurs in diabetic and non-diabetic AMI patients during the first 3 days of admission to hospital and can be used to identify subjects at high risk of mortality.

Arthrogenic muscle response to a simulated ankle joint effusion.

BACKGROUND: Arthrogenic muscle inhibition (AMI) is a continuing reflex reaction of the musculature surrounding a joint after distension or damage to the structures of that joint. This phenomenon has been well documented after knee joint injury and has been generalised to occur at other joints of the human body, yet minimal research has been conducted in this regard. The response of the muscles crossing the ankle/foot complex after ankle injury and effusion is not well understood. AMI may occur after an ankle sprain contributing to residual dysfunction. OBJECTIVE: To determine if AMI is present in the soleus, peroneus longus, and tibialis anterior musculature after a simulated ankle joint effusion. METHODS: Eight neurologically sound volunteers (mean (SD) age 23 (4) years, height 171 (6) cm, mass 73 (10) kg) participated. Maximum H-reflex and maximum M-wave measurements were collected using surface electromyography after delivery of a percutaneous stimulus to the sciatic nerve before its bifurcation into the common peroneal and posterior tibial nerves. RESULTS: The H-reflex and M-wave measurements in all muscles increased (p< or =0.05) after the simulated ankle joint effusion. CONCLUSIONS: Simulated ankle joint effusion results in facilitation of the soleus, peroneus longus, and tibialis anterior motoneurone pools. This may occur to stabilise the foot/ankle complex in order to maintain posture and/or locomotion.

Adrenocortical tumor in a boy: final height is not impaired despite a severe advancement of bone age.

The long-term sequelae on the growth pattern in successfully resected virilizing adrenal tumors (ACT) have not been clearly defined. We report on 10 years follow-up of a boy with virilizing ACT until the attainment of final height. This is the first clinical description in a boy with a marked advancement of bone age, indicating that despite advanced physical and skeletal maturity the prognosis on growth is good, provided that regression of virilization is obtained.

Severe clinical onset of diabetes and increased prevalence of other autoimmune diseases in children with coeliac disease diagnosed before diabetes mellitus.

AIMS/HYPOTHESIS: To analyse whether the time of diagnosis of coeliac disease with respect to the clinical onset of diabetes could differentiate subgroups of varying severity in patients with both diseases. METHODS: We investigated 383 patients with Type I (insulin-dependent) diabetes mellitus for coeliac disease. Sex distribution, age at diagnosis of diabetes, prevalence of ketoacidosis at the onset of diabetes and prevalence of other autoimmune diseases were compared in patients. We divided these patients according to whether coeliac disease was diagnosed before (Group A, n=8) or after (Group B, n=24) diabetes onset and whether they had presented clinical symptoms of coeliac disease. Group C (n=351) included diabetic patients without coeliac disease. RESULTS: Out of 383 Type I diabetic patients we found 32 coeliac subjects (8.3%). There was a higher number of girls (p=0.003), but similar age and prevalence of ketoacidosis compared with Group C; 18.7% had a third autoimmune disorder. The higher number of girls was confirmed in Groups A and B in comparison to Group C (p=0.013), while higher prevalence of both ketoacidosis (p=0.009) and other autoimmune diseases (p=0.001) was found only in Group A. Compared with symptomatic patients, asymptomatic subjects in Group B had a lower number of girls, older age at diabetes onset, lower prevalence of ketoacidosis and no other associated autoimmune disease. CONCLUSIONS/INTERPRETATION: A wide clinical spectrum characterises the association of coeliac disease and diabetes mellitus, with a severe clinical presentation (higher prevalence of ketoacidosis at the onset and occurrence of other autoimmune diseases) when coeliac disease is diagnosed before diabetes. Distinct phenotypes might imply the contribution of a peculiar genetic background.

[Use of totally implantable venous system in cancer patients. Surgical technique and initial clinical experience]. / L'utilizzo dei sistemi venosi totalmente impiantabili nel paziente neoplastico. Note di tecnica e nostra iniziale esperienza.

The experience with a totally implanted venous system (TIVS) in 27 cancer patients (15 males and 12 women) is reviewed, stressing simplicity of the cut down technique, which was successfully performed in 92.7% of patients. The common: est complications are described; port infection (7.4%), subclavian vein thrombosis (3.7%), and cutaneous necrosis (3.7%) at the port level. It is concluded that TIVS is a useful device for prolonged drugs administration and the cut down technique is indicated especially in the outpatients setting.

Clinical features associated with pre-hospital time delay in acute myocardial infarction.

BACKGROUND: The pre-hospital time delay in acute myocardial infarction (AMI) is still a challenging problem since for many patients there are long intervals between the onset of symptoms and the initiation of therapy. The aim of this study was to verify which, among several clinical variables, are associated with a prolonged pre-hospital time delay. METHODS: Five hundred and twenty-six unselected patients with AMI and consecutively admitted to three coronary care units were enrolled. The pre-hospital time delay was defined as the time interval from the onset of symptoms to admission to the coronary care unit. Clinical variables included: age, gender, body mass index, level of education, alcohol consumption, smoking habits, regular physical activity, history of hypertension, diabetes mellitus, history of coronary artery disease (documented history of angina and/or previous myocardial infarction), chronic atrial fibrillation, Q-wave AMI and off hours onset of symptoms. After univariate analysis, multivariable regression analysis was used. RESULTS: The mean age of the patients was 66.6 +/- 12.1 years and 28.7% were female. The median pre-hospital time interval was 200 min (95% confidence interval 60-1140). For 342 patients the pre-hospital time interval was < or = 6 hours and for 184 patients it was > 6 hours. Those variables which, at univariate analysis, were found to significantly influence the pre-hospital delay were analyzed using a multivariable regression model where the dependent variable was the pre-hospital time interval. Chronic atrial fibrillation (p = 0.010), a history of coronary artery disease (p = 0.017), diabetes (p = 0.016) and age > or = 70 years (p = 0.009) were found to be independently associated with a prolonged prehospital time interval. Similar results were obtained when considering only Q-wave AMI. As expected, the thrombolytic therapy rate was much lower in patients with a longer pre-hospital time delay. CONCLUSIONS: The present study shows that, in case of AMI, the time interval between the onset of symptoms and a patient's arrival to hospital is still far from being optimal. This is especially true for older patients with diabetes, a history of coronary artery disease or chronic atrial fibrillation. Cardiologists should be aware of this problem and should implement adequate educational strategies addressed to those patients at highest risk.