Green Line Hospital-Territory Study: A Single-Blind Randomized Clinical Trial for Evaluation of Technological Challenges of Continuous Wireless Monitoring in Internal Medicine, Preliminary Results.

BACKGROUND: Wireless vital parameter continuous monitoring (WVPCM) after discharge is compared to regular monitoring to provide data on the clinical-economic impact of complex patients (CPs) discharged from Internal Medicine Units of Ospedale dei Castelli, Lazio. PRIMARY OUTCOME: Major complications (MC) reduction. SECONDARY OUTCOMES: Patients who reached discharge criteria within the 7th day from admission; difference in MC incidence at the conclusion of the standard telemonitoring/clinical monitoring phase, 5 and 30 days after discharge; and conditions predisposing to MC occurrence. METHODS: Open label randomized controlled trial with wearable wireless system that creates alerts on portable devices. Continuous glycemic monitoring is performed for patients with diabetes mellitus. RESULTS: There were 110 patients enrolled (mean age: 76.2 years). Comorbidity: Cumulative Illness Rating Scale CIRS-CI (comorbidities index): 3.93, CIRS SI (severity index): 1.93. About 19% scored a BRASS (Blaylock Risk Assessment Screening Score) ≥20 indicating need for discharge planning requiring step-down care. Globally, 48% of patients in the control group had major complications (27 out of 56 patients), in contrast to 22% in the intervention group (12 out of 54 patients). CONCLUSIONS: Since WVPCM detects early complications during the post-discharge CPs monitoring, it increases safety and reduces inappropriate access to the Emergency Room, preventing avoidable re-hospitalizations.

Colorectal endoscopic submucosal dissection: predictors and neoplasm-related gradients of difficulty.

BACKGROUND AND STUDY AIM: The role of colorectal endoscopic submucosal dissection (ESD) is standardized in Japan and East Asia, but technical difficulties hinder its diffusion. The aim was to identify predictors of difficulty for each neoplasm type. METHODS: A competent operator performed all procedures. ESD difficulty was defined as: en bloc with a slow speed (< 0.07 cm 2 /min; 30 × 30 mm neoplasm in > 90 min), conversion to endoscopic mucosal resection, or resection abandonment. Pre- and intraoperative difficulty variables were defined according to standard criteria, and evaluated separately for the rectum and colon. Difficulty predictors and gradients were evaluated by the multivariate logistic regression model. RESULTS: A total of 140 ESDs were included: 110 in the colon and 30 in the rectum. Neoplasms were laterally spreading tumors - granular type (LST-G) in 85 cases (61 %); the median longer axis was 30 mm (range 15 - 180 mm); a scar was present in 15 cases (11 %). ESD en bloc resection and difficulty rates were 85 % (n = 94) and 35 % (n = 39) in the colon, and 73 % (n = 22) and 50 % (n = 15) in the rectum ( P  = 0.17 and 0.28, respectively). The scar was the only preoperative predictor of difficulty in the rectum (odds ratio [OR] 12.3, 95 % confidence interval [CI] 1.27 - 118.36), whereas predictors in the colon were: scar (OR 12.7, 95 %CI 1.15 - 139.24), LST - nongranular type (NG) (OR 10.5, 95 %CI 1.20 - 55.14), and sessile polyp morphology (OR 3.1, 95 %CI 1.18 - 10.39). Size > 7 - ≤ 12 cm 2 (OR 0.20, 95 %CI 0.06 - 0.74) and operator experience > 120 procedures (OR 0.19, 95 %CI 0.04 - 0.81) were predictors for a easy procedure. No intraoperative predictors of difficulty were identified in the rectum, whereas predictors in the colon were: severe submucosal fibrosis (OR 21.9, 95 %CI 2.11 - 225.64), ineffective submucosal exposure by gravity countertraction (OR 12.3, 95 %CI 2.43 - 62.08), and perpendicular submucosal dissection approach (OR 5.2, 95 %CI 1.07 - 25.03). When experience was /= 90, preoperative gradient of colonic ESD difficulty was the highest for LST-NGs (scar positive and negative up to 47 % and 20 %, respectively), intermediate for sessile polyps with scar (up to 23 %), and the lowest for LST-Gs (< 8 %). Different difficulty gradients between neoplasm types persisted with increasing experience: LST-NG rate up to 14 % after 120 procedures. CONCLUSIONS: Colonic and rectal ESD difficulty has qualitative differences. Preoperative predictors should be considered to identify the difficulty gradient of each neoplasm type and the appropriate setting for ESD.

Heterotopic gastric mucosa in the anus and rectum: first case report of endoscopic submucosal dissection and systematic review.

BACKGROUND: Heterotopic gastric mucosa (HGM) is the most reported epithelial heterotopia, but it is very rare in the rectum and anus. METHODS: The first case of an asymptomatic adult male with a large nonpolypoid HGM in the low rectum underwent complete resection by endoscopic submucosal dissection (ESD) is reported. The systematic review was based on a comprehensive search of MEDLINE, EMBASE and Google Scholar. Studies on humans were identified with the term 'heterotopic gastric mucosa in the rectum and /or anus.' RESULTS: The search identified 79 citations, and 72 cases were evaluated comprising the present report. Congenital malformations were observed in 17 (24%) patients; rectal duplication accounted for most of the cases. The HGM was located in the anus and perineal rectum in 25 cases (41%) and low, middle and proximal pelvic rectum in 20 (33%), five (8%) and 11 cases (18%), respectively. Morphology was nonpolypoid in 37 cases (51%), polypoid in 26 cases (36%) and ulcerated in nine cases (13%). Specific anorectal symptoms were reported by 50 (69%) patients of the whole study population, and by 33 (97%) of 34 patients ≤ 18 years. Complications were observed in 23 cases (32%). The HGM was excised in 50 cases (83%). Endoscopic resection was performed in 17 cases (34%); resection was piecemeal in five of 12 lesions ≥15 mm, required argon plasma coagulation in two cases and was associated with residual tissue in two (17%). Intestinal metaplasia and an adenoma with low-grade dysplasia were described in three adults (4%). DISCUSSION: This systematic review shows that the HGM in the rectum and anus may be associated with specific rectal symptoms and serious complications, mainly in the pediatric population, and a risk of malignancy in adults. Its complete excision should be recommended, and the ESD can overcome the technical limits of conventional endoscopic snare resection and avoid unnecessary surgery.

Detection methods and clinical significance of free peritoneal tumor cells found during colorectal cancer surgery.

Peritoneal washing is now part of the standard clinical practice in several abdominal and pelvic neoplasias. However, in colorectal cancer surgery, intra-peritoneal free cancer cells (IFCC) presence is not routinely investigated and their prognostic meaning is still unclear. When peritoneal washing results are positive for the presence of IFCC a worse outcome is usually expected in these colorectal cancer operated patients, but it what is not clear is whether it is associated with an increased risk of local recurrence. It is authors' belief that one of the main reasons why IFCC are not researched as integral part of the routine staging system for colon cancer is that there still isn't a diagnostic or detection method with enough sensibility and specificity. However, the potential clinical implications of a routine research for the presence IFCC in colon neoplasias are enormous: not only to obtain a more accurate clinical staging but also to offer different therapy protocols, based on the presence of IFCC. Based on this, adjuvant chemotherapy could be offered to those patients found to be positive for IFCC; also, protocols of proactive intraperitoneal chemotherapy could be applied. Although presence of IFCC appears to have a valid prognostic significance, further studies are needed to standardize detection and examination procedures, to determine if there are and which are the stages more likely to benefit from routine search for IFCC.

Hepatic venous pressure gradient determination in patients with hepatitis C virus-related and alcoholic cirrhosis.

OBJECTIVES: Few data exist regarding the degree of portal hypertension in hepatitis C virus (HCV)-related cirrhosis, as the majority of studies have included mainly patients with alcoholic cirrhosis. This study was aimed at comparing the severity of portal hypertension in patients with HCV-related or alcoholic cirrhosis. METHODS: In total, 59 cirrhotic patients with portal hypertension (HCV-related in 34 cases and alcoholic in 25) underwent main right hepatic vein catheterization, with determination of the wedged and free hepatic venous pressures, and of hepatic venous pressure gradient (HVPG). RESULTS: HVPG values did not differ between the two groups of patients (19.4 +/- 6.0 mmHg vs 18.5 +/- 3.5 mmHg; P = 0.51). The prevalence and degree of oesophageal and gastric varices and portal hypertensive gastropathy did not correlate with the aetiology. Patients with viral cirrhosis had a lower prevalence of previous bleeding than those with alcoholic cirrhosis, despite a similar proportion of large varices in the two groups and similar HVPG levels. In both groups of patients, HVPG did not differ between patients with previous bleeds and those without. CONCLUSIONS: The degree of portal hypertension in cirrhotic patients does not correlate with the cause of the disease. Thus, current statements on the management of portal hypertension, although based upon studies including mainly patients with alcoholic cirrhosis, can be applied also to patients with viral-related cirrhosis.

Treatment of peri-anal fistula in Crohn's disease.

Anal fistulas are a common manifestation of Crohn's disease (CD). The first manifestation of the disease is often in the peri-anal region, which can occur years before a diagnosis, particularly in CD affecting the colon and rectum. The treatment of peri-anal fistulas is difficult and always multidisciplinary. The European guidelines recommend combined surgical and medical treatment with biologic drugs to achieve best results. Several different surgical techniques are currently employed. However, at the moment, none of these techniques appear superior to the others in terms of healing rate. Surgery is always indicated to treat symptomatic, simple, low intersphincteric fistulas refractory to medical therapy and those causing disabling symptoms. Utmost attention should be paid to correcting the balance between eradication of the fistula and the preservation of fecal continence.

Histological and virological features and follow-up of hepatitis C virus carriers with normal aminotransferase levels: the Italian prospective study of the asymptomatic C carriers (ISACC).

BACKGROUND/AIMS: To evaluate demographic characteristics, liver histology and virological features of hepatitis C virus (HCV) carriers with normal alanine transaminase (ALT) levels. METHODS: A nationwide prospective study was started in 1997. Four Italian centres have participated in this study. RESULTS: Eight hundred and eighty subjects entered the study. One hundred and eighty-nine (21.5%) were excluded during the follow-up because of ALT increase. Among the 691 patients with persistent ALT normality, 72% were females. An overall prevalence of genotype 2 was found (52%). Normal liver was found in 17% of the patients; 34% had minimal chronic hepatitis, 44% mild hepatitis, 4% moderate to severe hepatitis, and 1% had cirrhosis. Clinical and virological features did not differ between subjects with ALT flares and those with persistently normal ALT. Baseline ALT levels have no effects on liver histology and clinical outcome. CONCLUSIONS: Many HCV carriers have significant chronic liver damage, although in the majority of them liver lesions are minimal or mild. Up to 60% of HCV carriers in Italy harbour non-1 HCV types. Current definition of HCV carriers with persistently normal ALT levels, based upon three normal ALT values over a 6-month period, is not adequate to discriminate between carriers with persistent ALT normality and those with transient biochemical remission. Longer follow-ups are needed.