Natural history and clinical characteristics of inhibitors in previously treated haemophilia A patients: a case series.

BACKGROUND: Development of inhibitors is the most serious complication in haemophilia A treatment. The assessment of risk for inhibitor formation in new or modified factor concentrates is traditionally performed in previously treated patients (PTPs). However, evidence on risk factors for and natural history of inhibitors has been generated mostly in previously untreated patients (PUPs). The purpose of this study was to examine cases of de novo inhibitors in PTPs reported in the scientific literature and to the EUropean HAemophilia Safety Surveillance (EUHASS) programme, and explore determinants and course of inhibitor development. METHODS: We used a case series study design and developed a case report form to collect patient level data; including detection, inhibitor course, treatment, factor VIII products used and events that may trigger inhibitor development (surgery, vaccination, immune disorders, malignancy, product switch). RESULTS: We identified 19 publications that reported 38 inhibitor cases and 45 cases from 31 EUHASS centres. Individual patient data were collected for 55/83 (66%) inhibitor cases out of 12 330 patients. The median (range) peak inhibitor titre was 4.4 (0.5-135.0), the proportion of transient inhibitors was 33% and only two cases of 12 undergoing immune tolerance induction failed this treatment. In the two months before inhibitor development, surgery was reported in nine (22%) cases, and high intensity treatment periods reported in seven (17%) cases. CONCLUSIONS: By studying the largest cohort of inhibitor development in PTPs assembled to date, we showed that inhibitor development in PTPs, is on average, a milder event than in PUPs.

Potential biomarkers of haemophilic arthropathy: correlations with compatible additive magnetic resonance imaging scores.

INTRODUCTION: Although biomarkers are useful diagnostic tools to assess joint damage in osteoarthritis and rheumatoid arthritis, few data exist for biomarkers of haemophilic arthropathy. AIM: To evaluate the association between biomarkers and compatible additive magnetic resonance imaging (MRI) scores in patients with severe haemophilia A. METHODS: Patients aged 12-35 years with no history of factor VIII (FVIII) inhibitors were enrolled in a controlled, cross-sectional, multinational investigation. Patients received primary or secondary prophylaxis or on-demand treatment with FVIII and underwent MRI on four joints (two ankles, two knees). Soluble biomarkers of cartilage and bone degradation, inflammation, and angiogenesis were assessed (serum levels of C-terminal telopeptides of type I collagen [CTX-I], cartilage oligomeric matrix protein [COMP], chondroitin-sulphate aggrecan turnover 846 epitope [CS846], tissue inhibitor of metalloproteinase 1 [TIMP-1]; plasma levels of vascular endothelial growth factor [VEGF], matrix metalloproteinases 3 and 9 [MMP3, MMP9]). Relationships between biomarkers and MRI scores were evaluated using Spearman rank correlation. RESULTS: Biomarkers were assessed in 117 of 118 per-protocol patients. Mean and median CTX-I, COMP, TIMP-1, MMP3, MMP9, and VEGF values were within normal ranges (reference range not available for CS846 in healthy volunteers). No correlations between biomarkers and MRI scores were found, with the exception of CS846, which showed significant correlation in a subgroup of 22 on-demand patients (r = 0.436; P = 0.04). CONCLUSIONS: Compatible additive MRI scores showed no clear correlations with any of the potential biomarkers for haemophilic arthropathy in the overall population. CS846 levels were significantly correlated with MRI scores in patients treated on demand.

Efficacy and safety during formulation switch of a pasteurized VWF/FVIII concentrate: results from an Italian prospective observational study in patients with von Willebrand disease.

Von Willebrand disease (VWD) is an inherited bleeding disorder caused by the quantitative or qualitative deficiency of von Willebrand factor (VWF). Replacement therapy with plasma-derived VWF/factor VIII (FVIII) concentrates is required in patients unresponsive to desmopressin. To assess the efficacy, safety and ease of use of a new, volume-reduced (VR) formulation of VWF/FVIII concentrate Haemate(®) P in patients requiring treatment for bleeding or prophylaxis for recurrent bleeding or for invasive procedures. Pharmacoeconomic variables were also recorded. Data were analysed using descriptive statistics. This was a multicentre, prospective, observational study. Consecutively enrolled patients received Haemate(®) P VR according to their needs, and were followed for 24 months. Of the 121 patients enrolled, 25.6% had type 3 VWD and more than 40% had severe disease. All patients were followed for 2 years, for a total of 521 visits. On-demand treatment was given to 61.9% of patients, secondary long-term prophylaxis to 25.6% and prophylaxis for surgery, dental or invasive procedures to 45.5%. The response to treatment was rated as good to excellent in >93-99% of interventions. The new formulation was well tolerated by all patients with no report of drug-related adverse events. The switch to volume-reduced Haemate(®) P was easy to perform and infusion duration was decreased twofold compared with the previous formulation. Volume-reduced Haemate(®) P was at least as effective and well-tolerated as the previous formulation.

Central nervous system bleeding in patients with rare bleeding disorders.

Central nervous system (CNS) bleeding is one of the most severe and debilitating manifestations occurring in patients with rare bleeding disorders (RBDs). The aim of this study was to retrospectively collect data on patients affected with RBDs who had CNS bleeding, to establish incidence of recurrence, death rate, neurological sequences, most frequent location, type of bleeding and efficacy of treatments. Results pertained to 36 CNS bleeding episodes in 24 patients with severe deficiency except one with moderate factor VII (FVII) deficiency. Six patients (25%) experienced a recurrence and two had more than one recurrence. Seven patients (29%) had an early onset of CNS bleeding before the first 2 years of life, others (71%) later in life. In 76% of cases, CNS bleeding was spontaneous. CNS bleeding was intracerebral in 19 cases (53%), extracerebral in 10 (28%) and both intracerebral and extracerebral in two cases (6%). Neurosurgery was performed in 11 cases, in association with replacement therapy in seven cases. Seizures were noted in four patients. Residual psychomotor abnormalities were seen in two patients. No death was recorded. To prevent recurrence, 17/24 patients (71%) were put on secondary prophylaxis. In conclusion, recurrence of CNS bleeding was confirmed to be relatively frequent in patients with severe FV, FX, FVII and FXIII deficiencies. Most patients were managed with replacement therapy alone, surgery being reserved for those with worsening neurological conditions. Our results indicate that some RBDs require early prophylactic treatment to prevent CNS bleeding. Optimal dosage and frequency of treatment need further evaluation.

Axillary dissection in breast cancer patients with metastatic sentinel node: to do or not to do? Suggestions from our series.

Several studies have put to question and evaluated the indication and prognosis of sentinel lymph node biopsy (SNLB) as sole treatment in human breast cancer. We reviewed 1588 patients who underwent axillary surgery. In 239 patients, axillary lymph node dissection (ALND) was performed following positive fine needle aspiration cytology (FNAC), and, in 299 cases, ALND was executed after positive SNLB. The most dramatic result from our data is that patients with either micrometastasis of the sentinel lymph node (SLN) or only metastatic SLN have, respectively, an 84.5% and a 75.0% chance of having no other nodal involvement. We believe a more refined patient selection is neccessary when considering ALND. Where the primary tumor is larger than 5 cm, where radio or adjuvant therapies are not indicated, in cases of FNAC+ nodes, and in cases presenting more than one metastatic sentinel node, we prefer to carry out ALND. Having thus said, however, our data suggests that it is wise not to perform ALND in almost all cases presenting positive SLNs.

Efficacy and safety of highly purified, doubly virus-inactivated VWF/FVIII concentrates in inherited von Willebrand's disease: results of an Italian cohort study on 120 patients characterized by bleeding severity score.

The efficacy of highly purified VWF/FVIII concentrates with standardized ristocetin cofactor content (VWF:RCo) has been already proven in patients with von Willebrand's disease (VWD). Aim of this retrospective study is to confirm efficacy and safety of two highly purified, doubly virus-inactivated VWF/FVIII concentrates in a large cohort of patients with VWD who were characterized at enrolment by bleeding severity score. Study drugs Alphanate or Fanhdi were given to 120 cases (51 males, 69 females, median age 50 years, range 6-83 years). Patients had VWD3 (10), VWD2A (19), VWD2B (25), VWD2M (10) and DDAVP-unresponsive VWD1 (56) and a median bleeding severity score of 8 (range 0-27). A total of 114 bleeding episodes in 55 cases and 131 surgical procedures in 85 cases could be analysed. Excellent-good clinical responses were seen in 97% of bleeding episodes and in 99% of surgical procedures. To prevent recurrent gastrointestinal (GI) bleeding, cerebral (CNS) haemorrhage, haemarthroses, urogenital or multisite bleeding in more severe patients, secondary prophylaxis was also carried out in 15 cases with VWD3 (3), VWD2A (3), VWD2B (2), VWD1 (7). A median dose of 42 IU VWF:RCo kg(-1) given every other day or twice a week over a median period of 334 days (range 24-799) prevented bleeding completely in 13 cases and reduced its incidence in the remaining two. These results confirm the efficacy and safety of the study concentrates, not only in the management of bleeding and surgery but also in secondary prophylaxis of severe VWD.

MAGIC-5: an Italian mammographic database of digitised images for research.

The implementation of a database of digitised mammograms is discussed. The digitised images were collected beginning in 1999 by a community of physicists in collaboration with radiologists in several Italian hospitals as a first step in developing and implementing a computer-aided detection (CAD) system. All 3,369 mammograms were collected from 967 patients and classified according to lesion type and morphology, breast tissue and pathology type. A dedicated graphical user interface was developed to visualise and process mammograms to support the medical diagnosis directly on a high-resolution screen. The database has been the starting point for developing other medical imaging applications, such as a breast CAD, currently being upgraded and optimised for use in a distributed environment with grid services, in the framework of the Instituto Nazionale di Fisicia Nucleare (INFN)-funded Medical Applications on a Grid Infrastructure Connection (MAGIC)-5 project.

Information to cancer patients: a questionnaire survey in three different geographical areas in Italy.

GOALS OF WORK: The way to inform cancer patients varies widely among different countries. In most Mediterranean countries, the traditional approach has been of partial disclosure of the truth. The intent of our work was to find if the attitude in Italy has changed in recent years and if differences still exist among different geographical regions in our country. Both patients' and physicians' attitudes vary in Italy depending on geographical area. In the South, the focus is on traditional values and full involvement of patients' family, with limited communication to (and limited autonomy of) the patient. Such attitude is less pronounced in Central Italy, whereas the North is more oriented to open communication and full decisional autonomy of the patient. MATERIALS AND METHODS: Approximately 600 consecutive patients in three different centres in Northern, Central and Southern Italy (respectively, Udine, Ancona and Catanzaro) were asked to answer a 26-item questionnaire on communication aspects to investigate the quality of the information given and potential differences between geographical areas. RESULTS: Questionnaires were completed by 587 patients (median age 60 years, 57% women), mainly with gastrointestinal (32%) or breast cancer (30%). About 370 patients (63%) had active disease at time of interview. A high proportion of patients were correctly informed on diagnosis (86%) and therapy (84%). On the contrary, patients fully aware of their prognosis were only about 43%. Nevertheless, most patients (60%) stated they were completely satisfied with the information received. There were differences between geographical areas on various information aspects, with patients from Southern Italy being, in general, less informed. CONCLUSIONS: In Italy, the cultural attitude towards communication in oncology is changing on both the physician and the patient side. There are still significant geographical differences, but there is a general trend suggesting improved awareness about diagnosis and treatment, with the notable exception of prognosis.

A completely automated CAD system for mass detection in a large mammographic database.

Mass localization plays a crucial role in computer-aided detection (CAD) systems for the classification of suspicious regions in mammograms. In this article we present a completely automated classification system for the detection of masses in digitized mammographic images. The tool system we discuss consists in three processing levels: (a) Image segmentation for the localization of regions of interest (ROIs). This step relies on an iterative dynamical threshold algorithm able to select iso-intensity closed contours around gray level maxima of the mammogram. (b) ROI characterization by means of textural features computed from the gray tone spatial dependence matrix (GTSDM), containing second-order spatial statistics information on the pixel gray level intensity. As the images under study were recorded in different centers and with different machine settings, eight GTSDM features were selected so as to be invariant under monotonic transformation. In this way, the images do not need to be normalized, as the adopted features depend on the texture only, rather than on the gray tone levels, too. (c) ROI classification by means of a neural network, with supervision provided by the radiologist's diagnosis. The CAD system was evaluated on a large database of 3369 mammographic images [2307 negative, 1062 pathological (or positive), containing at least one confirmed mass, as diagnosed by an expert radiologist]. To assess the performance of the system, receiver operating characteristic (ROC) and free-response ROC analysis were employed. The area under the ROC curve was found to be Az = 0.783 +/- 0.008 for the ROI-based classification. When evaluating the accuracy of the CAD against the radiologist-drawn boundaries, 4.23 false positives per image are found at 80% of mass sensitivity.

GPCALMA: a Grid-based tool for mammographic screening.

OBJECTIVES: The next generation of high energy physics (HEP) experiments requires a GRID approach to a distributed computing system: the key concept is the Virtual ORGANISATION (VO), a group of distributed users with a common goal and the will to share their resources. METHODS: A similar approach, applied to a group of hospitals that joined the GPCALMA project (Grid Platform for Computer Assisted Library for MAmmography), will allow common screening programs for early diagnosis of breast and, in the future, lung cancer. The application code makes use of neural networks for the image analysis and is useful in improving the radiologists' diagnostic performance. GRID services allow remote image analysis and interactive online diagnosis, with a potential for a relevant reduction of the delays presently associated with screening programs. RESULTS AND CONCLUSIONS: A prototype of the system, based on AliEn GRID Services [1], is already available, with a central server running common services [2] and several clients connecting to it. Mammograms can be acquired in any location; the related information required to select and access them at any time is stored in a common service called Data Catalogue, which can be queried by any client. Thanks to the PROOF facility [3], the result of a query can be used as input for analysis algorithms, which are executed on the nodes where the input images are stored,. The selected approach avoids data transfers for all the images with a negative diagnosis and allows an almost real time diagnosis for the set of images with high cancer probability.

Ultrasonographically-guided fine-needle aspiration of axillary lymph nodes: role in breast cancer management.

The knowledge of the status of axillary lymph nodes (LN) of patients with breast cancer is a fundamental prerequisite in the therapeutic decision. In the present work, we evaluated the impact of fine-needle aspiration cytology (FNAC) of ultrasonographically (US) selected axillary LN in the diagnosis of LN metastases and subsequently in the treatment of patients with breast cancer. Axillary US was performed in 298 patients with diagnosed breast cancer (267 invasive carcinomas and 31 ductal carcinoma in situ DCIS), and in 95 patients it was followed by FNAC of US suspicious LN. Smears were examined by routine cytological staining. Cases of uncertain diagnosis were stained in immunocytochemistry (ICC) with a combination of anticytokeratin and anti-HMFG2 antibodies. Eighty-five FNAC were informative (49 LN were positive for metastases, 36 were negative). In 49 of 267 patients with invasive breast carcinoma (18%), a preoperative diagnosis of metastatic LN in the axilla could be confirmed. These patients could proceed directly to axillary dissection. In addition, US-guided FNAC presurgically scored 49 out of 88 (55%) metastatic LN. Of all others, with nonsuspicious LN on US (203 cases including 31 DCIS), in which no FNAC examination was performed, 28 invasive carcinomas (16%) turned out to be LN positive on histological examination. Based on these data, US examination should be performed in all patients with breast cancer adding ICC-supported FNAC only on US-suspect LN. This presurgical protocol is reliable for screening patients with LN metastases that should proceed directly to axillary dissection or adjuvant chemotherapy, thus avoiding sentinel lymph node biopsy.

Early transfusion of factor VIII/von Willebrand factor concentrates seems to be effective in the treatment of gastrointestinal bleeding in patients with von Willebrand type III disease.

The association between gastrointestinal angiodysplasia and von Willebrand disease was reported 30 years ago. The clinical course of patients with von Willebrand disease and angiodysplasia is characterized by numerous admissions to hospital for gastrointestinal bleeding necessitating transfusion with packed red cells, factor VIII and plasma. The management of these patients is problematic. Numerous treatments for the gastrointestinal bleeding have been proposed: surgery, electrocoagulation, laser photocoagulation, sclerotherapy, arteriography with embolization, immunoglobulins, oestrogens, and octreotide, but no treatment modality has been successful in all cases. We report a 66-year-old-female with small bowel angiodysplasia and von Willebrand type III disease in whom prompt administration of factor VIII/vWF concentrates was effective. Education of patients to recognize minimal gastrointestinal bleeding manifestations, periodical clinical visits and early infusion of factor VIII/vWF seems to be fundamental for the success of this therapy. A longer follow-up and the study of other patients are needed to confirm our observation.

Prevention of venous thromboembolism in high-risk surgical and medical patients.

Although pharmacologic prophylaxis against venous thromboembolism has become the standard of care following total hip and knee replacement, prophylaxis among patients undergoing surgery for hip fracture and other lower extremity trauma remains underutilized. Available experience consistently supports the view that low-molecular-weight heparins are more effective than unfractionated heparin for prevention of proximal deep vein thrombosis (DVT) with no additional hemorrhagic risk and more effective than oral anticoagulants for prevention of in-hospital (mostly distal) venous thrombosis at the price of a higher surgical site bleeding and wound hematoma. The choice between low-molecular-weight heparin and warfarin should be tailored to the individual patients based on the clinical assessment of postoperative thrombosis and bleeding risk as well as the prophylaxis-specific cost and convenience. Whether thromboprophylaxis should be continued for a few additional weeks after hospital discharge is controversial. The overall incidence of postoperative DVT in patients with cancer is about twice as high as that of patients free of malignancy. Accordingly, they require prophylactic measures comparable with those usually recommended for major orthopedic surgery. In this setting, dermatan sulfate shows promise. In contrast to surgical patients, prevention of venous thromboembolism is less well studied in hospitalized medical patients. In a recent controlled randomized trial, enoxaparin in high prophylactic doses was an effective and safe measure of thromboprophylaxis in ordinary bedridden patients.

[Evaluation of the body posture of nursing personnel when moving patients in bed]. / Avaliação da postura corporal dos trabalhadores de enfermagem na movimentação de pacientes acamados.

The patients' movement in bed, is a procedure that demand great physical effort and use of good corporal mechanics for the nursing personnel, relative of preventing them back pain problems. Recognizing the importance of the movement and positioning, to promote safety and comfort to the patient, and before the professionals' complaints, described in the literature, this work has for objectives: to identify and analyzer the postures assumed by the nursing workers and identify the means and difficulties found during the execution of the referred activity. Through the technique of direct observation they were filmed, through videotapes, thirty procedures of patient's movement in the bed executed by nursing workers of an orthopedic clinic of an university hospital. The results evidence that the thirty procedures were executed along 197.41 minutes and that the corporal postures more frequently assumed they were, in respect to back, arms and legs, back inclined/arms with elbow down of row of seats/legs extension (53.76%). In agreement with the beginnings of the corporal mechanics and of the ergonomics, such postures are considered painful to the man, due to the muscle-skeletal aggressions and to the physical overload that they cart. The workers aimed the aspects little space (58.82%), physical load (52.94%) and absence of the personal (47.06%), as the main difficulties found in the execution of patient's movement in the bed, corroborating with the discoveries of the literature, characterizing that activity as painful. They pointed: the adequate technique (36.29%), used of sheet (35.29%) and space adequate (23.52%), as aspects that would facilitate the execution of the procedure.

Venous thromboses of upper limbs are more frequently associated with occult cancer as compared with those of lower limbs.

Three hundred and forty-three consecutive patients with deep vein thrombosis (DVT) were investigated for the possible presence of occult or undiagnosed cancer, of whom 305 patients had DVT of the lower limbs whereas 38 had DVT of the upper limbs. Cancer was diagnosed during a 12-month follow-up in nine patients with DVT of the upper limbs (23.7%) and in 34 patients with DVT of the lower limbs (11.1%). The difference was statistically significant. Furthermore, it was shown that the majority of cancers (seven of nine) in the case of DVT of the upper limbs were discovered during the first week of hospital admission. In contrast, in the case of DVT of lower limbs, only eight of 34 cancers were discovered during the initial investigation. Lung cancer and lymphomas represented the majority of cancers associated with upper limb venous thrombosis (seven of nine). In the case of DVT of the lower limbs, cancers were heterogeneous; however, 12 of 34 were cancers of the colon or prostate.

[Percutaneous transcatheter therapy of visceral pseudoaneurysms]. / Terapia percutanea transcatetere degli pseudoaneurismi viscerali.

BACKGROUND: The purpose of this work is to show the effectiveness of percutaneous embolization therapy in the treatment of visceral arterial pseudoaneurysms and to propose the method as a valid alternative to surgery. METHODS: Twenty-eight patients with visceral artery pseudoaneurysms were treated: 10 of them were hepatic; 9 renal; 7 duodenal-pancreatic; 1 splenic and 1 of the celiac trunk. Materials employed were: Gianturco metallic coils, Spongostan and Poli-Vinyl-Alcohol. RESULTS: Immediate success was obtained in all cases; recurrences occurred in 5 patients (18%) and they have all been successfully retreated with percutaneous method; complications occurred in 3 patients (10%) and they were all directly related to the pre-existing pathology and not to the percutaneous treatment. CONCLUSIONS: To obtain the best results from embolization, it is necessary to respect some conditions regarding the correct choice of embolic materials, the superselective catheterization of the injured artery and the low injection pressure of the contrast medium in order to avoid rupturing the thin pseudoaneurysmatic wall. The advantages of the percutaneous treatment are: less trauma, local anesthesia, reduction of the time between diagnosis and therapy, reduction of hospitalization stay and limitation of parenchymal destruction, Complications are relatively not frequent and in no cases the percutaneous therapy compromised the surgical intervention when it became necessary.

[The percutaneous placement of intra-arterial catheters with "reservoirs" for subcutaneous infusion. The technic and preliminary results]. / Posizionamento percutaneo di cateteri intraarteriosi con "reservoir" per infusione sottocutanea. Tecnica e risultati preliminari.

INTRODUCTION: We report our personal technique and the preliminary results of percutaneous implantation of intraarterial catheters connected to a subcutaneous infusion reservoir (Port-a-cath) for the regional chemotherapy of hepatic and extrahepatic tumors. January, 1996, to February, 1997 fifty patients underwent the procedure: 44 had liver cancers (42 had metastases and 2 hepatocellular carcinomas), 4 pelvic tumors (2 bladder carcinomas, one uterine cancer and one vaginal cancer), one had inoperable pancreatic tumor and one breast cancer. MATERIALS AND METHODS: The access was the left axillary artery in 45 cases, the femoral artery in 4 and both the femoral and the axillary artery in one case. The infusion catheter was placed in the hepatic artery in 44 cases, in the splenic artery in one case of pancreatic cancer, in the hypogastric artery in 4 cases and in the internal mammary artery in one case. When the catheter was positioned in the hepatic artery, embolization of the gastroduodenal or accessory hepatic arteries was performed using metallic coils; when the catheter was positioned in the hypogastric artery, the contralateral hypogastric artery and the ipsilateral gluteal branches were embolized. The catheter was then tunnelled and connected to a subcutaneous reservoir, sutured to the pectoral fascia or to the inguinal ligament. After the injection of heparinated solution, infusion chemotherapy was started the day after the procedure. RESULTS: We obtained immediate technical success in all cases. Four major complications occurred: a pseudoaneurysm of the left axillary artery (percutaneously treated by placement of a covered stent), 2 thromboses of the hepatic artery and one case of gastritis. Among minor complications, the catheter was displaced in 9 cases and 7 catheters were percutaneously replaced. Side-effects, not related to the procedure, were pain, nausea, vomiting and mucositis. During the follow-up, 7 patients died (6 for tumor progression); median catheter patency was 5.14 months. Though the aim of this work is to present the technical aspects of the procedure, we report the preliminary clinical data: radiological examinations showed partial tumor regression in 15 of 33 patients with 3-month follow-up; no change was shown in 2 patients and disease progression was found in 4; the response could not be assessed in the other cases. CONCLUSIONS: In conclusion, the percutaneous placement of intraarterial catheters for continuous regional chemotherapy is a feasible, safe and tolerable procedure and can represent an alternative to the surgical implantation of catheters in the hepatic artery for the treatment of liver metastases from colorectal cancer. The technique opens new therapeutic possibilities for the local treatment of extrahepatic tumors (such as gynecologic, vesical, pancreatic and breast cancers), even though its clinical efficacy must be assessed in selected trials.

Transaxillary access to perform hepatic artery infusion (HAI) for secondary or primitive hepatic tumors.

There is a renewed interest in locoregional chemotherapy for hepatic tumors; trials in progress are experimenting with new therapeutic protocols with an approach combining different systems of infusion (HAI and systematic) or with the use of HAI as adjuvant or neoadjuvant of the surgical treatment or cryosurgical treatment of the hepatic metastases from colo-rectal cancer. However, HAI is practicable principally with the implantation of a catheter in the hepatic artery (port of Infusaid) by laparotomic access. This intervention limits wide-scale use of the infusion method, traditionally less toxic and more efficient in terms of results than systemic treatment. Limited experience of percutaneous access for HAI required more catheterisation with repeated puncturing of the artery and later necessity of surgery in cases of HAI with continuous spraying. Motivated by the first experience of certain authors from Chiba University, we have devised a system of catheterisation of the hepatic artery with transcutaneous access, with subcutaneous port that allows the use of HAI without recourse to the usual intervention. Access is made through the left axillary artery; the positioning of the catheter is in the hepatic artery with possible embolization of the collateral or abnormal hepatic artery that could hamper complete diffusion of the drug to the liver, or increase to toxicity of the method. The implantation is done in day-surgery. In the cases performed up to now there have been no complications regarding the method and the catheters function all perfectly thanks to the collaboration of ematologists to avoid possible thrombosis of the catheters.

[Percutaneous gastrostomy. Personal experience in 137 cases]. / La gastrostomia percutanea. Esperienza personale in 137 casi.

Percutaneous gastrostomy is reported to be an effective alternative to total parenteral feeding or long-term nasogastric tube in the treatment of mechanical or functional dysphagia. The authors report their personal experience with 137 percutaneous gastrostomies performed on 98 men and 39 women from January 1986 through December 1993. All the maneuvers were performed under fluoroscopic guidance in the patients with head or neck cancer, neoplastic, vascular or post-traumatic neuropathy and upper GI tract cancer. To avoid left hepatic lobe trauma, percutaneous gastrostomy needs to be performed under US guidance. A 7F nasogastric tube is used to fill the stomach with air. After distending the gastric cavity, with the Seldinger technique under local anesthesia, fascial dilators of progressively increasing caliber are introduced into the gastric cavity and the final 12F gastrostomy catheter is positioned under fluoroscopic guidance. No major complications, such as hemorrhage or peritonitis, occurred. In one case, during the maneuver, the patient complained of severe epigastric pain which regressed with no further problems two hours later. In three cases the gastrostomy catheter fell out of place and was replaced by running the fistolous tract with a venous cannula and then a guidewire for gastrostomy repositioning. With this type of treatment, the patient can be given enteral feeding the following day. The maneuver requires approximately 10 minutes to perform and is well tolerated by the patient as it requires no general anesthesia. Percutaneous gastrostomy is more cost-effective than surgery or endoscopy and hospitalization is shorter. The only contraindications to this maneuver are hepatomegaly (because of the risk of liver trauma during percutaneous maneuvers), ascites (because of the risk of infection) and finally the complications resulting from gastric resection.