[Project work: formation of health-care personnel for self-care of tunnelled central venous catheters in hemodialysis patients of the territory]. / Project work: formazione infermieristica per l'autocura educativa dei cateteri venosi tunnellizzati nei pazienti emodializzati del territorio.

BACKGROUND: Scientific data from current literature demonstrate an incidence of bacteraemia due to tunnelled central venous catheter (tCVC) use accounting for 1.6 / 1000 days per tCVC, with a range of 1.5 to 1.8. In Sicily no data on the incidence of tCVC- related bacteraemia are available. In our hospital, tCVC infection occurs 2.4 times in 1000 days during CVC use. A retrospective analysis carried out from 2006 to 2012 was performed on 650 patients with tunnelled catheters. Of the subjects who received tCVC in our hospital, 90% were destined to undergo haemodialysis in a private health care environment outside our hospital. MATERIALS AND METHODS: In order to improve the aforementioned infection outcome, we planned and implemented a specific work project. The work project (WP) was subdivided into two steps: 1) The first step was further subdivided into two sub-phases. The first was principally concerned with the implementation of educational courses, conducted directly on the ward and aimed at the implementation of meticulous nursing regimes for the care of tCVC by our health care nurse. The courses were entitled Management of Vascular Access: from doing - to teaching to do!. These educational courses were organized by the Nephrology Department, which takes care of the management and handling of the major complications of tCVCs for the maintenance of haemodialysis. After this first step, the nurses who had participated became the promoters of the second part of the course, which concerned the development of know-how within an outpatient clinic, which deals exclusively with the nursing management of tCVCs. 2) The title of the second phase was Therapeutic Education: self-Care and understanding and managing your venous access at home. The aim of this step was the integration of correct in-hospital care with that available in outsourced private institutions, via the involvement of the patient in the management of their own central venous access. During our training project, a more detailed analysis of the stakeholder as well as a swot analysis on the feasibility of the project were used to determine ad interim and final targets of the study. A summary of operative planning is included to explain in greater detail the study design, timing and costs of the various phases. Risk management and corrective measures adopted during the project are also mentioned and monitoring of the phases is described in relation to the fulfilling of intermediate goals. The prompt correction of mistakes allows for safer realisation of outcomes. CONCLUSION: From our experience with this work project, we can conclude that a more accurate management of tCVCs can significantly reduce the morbidity and mortality of patients. The project offers a positive cost-benefit balance through a decrease in costs of hospitalisation for tCVC-related infections and other life.threatening conditions related to the use of tCVCs an important goal for any spending review.

Treatment of anastomotic stenoses of peripheral bypass grafts with cutting balloon angioplasty.

PURPOSE: The aim of this study was to assess the efficacy of cutting-balloon angioplasty (CBA) in the treatment of anastomotic stenoses of peripheral arterial bypass grafts. MATERIALS AND METHODS: Seventeen patients (12 men and five women; age range 54-79 years, mean age 66.5) with stenosis or occlusion at the proximal or distal anastomoses of peripheral bypass grafts were treated with CBA. The diagnosis of stenosis was based on clinical and colour-Doppler ultrasound findings and confirmed by angiography with measurement of the intraluminal transstenotic pressure gradients. The diameter of the selected cutting balloon was 1-mm smaller than the vessel distal to the anastomosis and, in the event of suboptimal outcome, the procedure was completed with repeat dilatation with a larger standard balloon (+1 mm). RESULTS: Technical success was obtained in 100% of cases. In three patients, CBA was performed after locoregional thrombolysis. No patient required stent placement or emergency surgery due to the presence of residual stenosis, suboptimal outcome or dissection. No complication occurred either during or after the procedure. During a mean follow-up period of 10.4 months (range 5-21 months), two restenoses developed at 9 and 7 months, which were treated with the same technique; in one patient with recurrent bypass occlusion at 5 months, a new bypass was created surgically owing to contraindications for locoregional thrombolysis. Cumulative primary patency at 12 and 18 months was 82.35%, whereas the two cases of restenoses treated with repeat CBA underwent further follow-up at 10 and 7 months, respectively. CONCLUSIONS: Our data confirm the efficacy of CBA in the treatment of anastomotic stenoses of peripheral arterial bypass grafts.

Significance of microalbuminuria in atherosclerotic vascular disease.

Microalbuminuria is considered as a sign of high risk of renal disease in type 1 diabetes mellitus, and of cardiovascular disease in types 1 and 2 diabetes. In recent years numerous studies have suggested that microalbuminuria may be associated with atherosclerotic vascular disease, independently from diabetes mellitus. The presence of microalbuminuria was investigated in 30 patients suffering from atherosclerotic vascular disease: ischemic heart disease, cerebrovascular disease or arterial disease of the lower extremities. They were divided into two groups similar in age: 13 with type 2 diabetes mellitus, and 17 without diabetes. The aim of the research was to reveal eventually different prevalence of microalbuminuria in patients with vascular disease associated with diabetes or without diabetes. Microalbuminuria was present in 52.9% of the non diabetic patients and in 76.9% of the diabetics, but the difference did not reach statistical significance (in Mann-Whitney test p = 0.18; Chi-square test = 0.83; p = 0.3). No significant correlation was found between microalbuminuria and fibrinogen, total cholesterol, HDL-cholesterol and triglycerides. The hypertensive patients presented higher mean values of microalbuminuria than the normotensive ones (3.2 +/- 3.8 and 2.8 +/- 4.4 mg %, respectively), but the difference was again not significant (t = 0.25; p = 0.8). In the light of this research microalbuminuria seems to be a condition associated with atherosclerotic vascular disease, independently from the presence of diabetes mellitus and arterial hypertension.

[The prevalence of serum anti-hepatitis C virus antibodies in hemodialyzed patients]. / Prevalenza degli anticorpi sierici anti-virus dell'epatite C in pazienti emodializzati.

Hepatitis C virus (HCV) is responsible for a high percentage of cases of transfusional hepatitis and is often considered the etiological agent of numerous cases of non-A, non-B hepatitis in which parenteral transmission has not been documented. Patients undergoing hemodialysis are at risk for HCV infection. We used an immunoenzymatic method and confirmatory test (neutralization test) to determine serum anti-HCV antibody positivity in order to identify the factors associated with increased risk of HCV infection. We studied 63 hemodialyzed patients from eastern Sicily and compared the mean dialytic age and transfusion case history in positive and negative groups. 17.4 percent of the patients were anti-HCV positive. Mean dialytic age was significantly higher in the anti-HCV positive group. On the contrary no significant differences regarding transfusion case history or number of units of blood transfused were seen in the two groups. Our study confirms that hemodialyzed patients are at risk for HCV infection. This risk seems to increase with dialytic age. The lack of correlation between HCV and transfusion case history suggests that it may be a hospital-acquired infection.

[Evaluation of the risk of hepatitis delta virus (HDV) infection in a population of hemodialyzed patients: significance of the determination of anti-delta antibodies in the blood]. / Valutazione del rischio di infezione da virus dell'epatite delta (HDV) in una popolazione di emodializzati: significato della determinazione degli anticorpi sierici anti delta.

Hepatitis delta virus (HDV) is a defective virus which requires the helper function of hepatitis B virus (HBV) for replication. HDV infection occurs only during or after HDV infection. Viral infection spreads parenterally in both cases. However, it has been reported that the risk of HDV infection is limited to hemodialysed patients, unlike the risk of HBV infection. In order to verify these findings the Authors studied 108 patients undergoing periodical hemodialytic treatment in order to study the delta antibodies present in their blood. Sixty-one of these subjects had received previous blood transfusions, 15 were HBsAg positive and 7 positive for other serological markers of the hepatitis B virus. None of the subjects examined was positive for anti HDV. Our results agreed with the literature reporting an incidence of positive HDV serological markers limited to hemodialyzed patients. The Authors observed that the behaviour of the HDV serological markers can vary from patient to patient and that it is impossible to furnish diagnosis of HDV infection after HBV and HDV clearance. Since these factors can lead to underestimation of the real incidence of HDV infection in hemodialyzed patients, the Authors underline the need to perform long term epidemiological studies and to investigate all the HDV serological markers.