[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.

[Steno-obstructions of haemodialytic FAV: new aspects of endovascular treatments]. / Trattamento endovascolare delle complicanze steno-ostruttive delle fistole artero-venose emodialitiche: nuovi aspetti di intervento con radiologia interventistica.

Angioplasty is the usual method for the treatment of stenosis of arteriovenous fistulas for hemodialysis, along with fibrinolysis and thrombus aspiration. We evaluated the efficacy and safety of interventional radiology procedures in the treatment of stenosis or occlusion of arteriovenous fistulas. One hundred thirteen patients suffering from malfunction of arteriovenous fistulas underwent interventional radiological procedures (140 treatments). In all patients color-Doppler was performed beforehand. Stenosis at the site of the fistula was found in all patients and was treated with percutaneous transluminal angioplasty (PTA); stenosis at the anastomosis site was found in 63 cases and was treated by angioplasty with a microcatheter. In 40 patients suffering from recent thrombotic occlusion, locoregional thrombolysis and PTA were necessary. Technical and clinical success was achieved in 107 patients (94.6%); in 1 of 6 unsuccessful treatments the procedure had to be interrupted due to the rupture of a vein. Follow-up exams demonstrated primary patency in 92.5%, 71.9% and 49.5% of patients at 6 months, 1 year and 2 years, respectively. In 19 patients (17.7%) hemodynamically significant restenosis was observed, which was treated with multiple PTAs (27 treatments, only 1 of which with a negative outcome), resulting in a 94.2% success rate; only 1 patient had to undergo a fourth PTA. The overall patency rate was 95%, 87.2%, 62.3% at 6 months, 1 year and 2 years, respectively. In our experience immediate success and excellent patency rates were observed, which persisted in the medium and long term. PTA, with thrombolysis and thromboaspiration, is the treatment of choice in cases of malfunctioning arteriovenous fistulas. PTA should always be attempted before making a new surgical access in order to preserve the vascular tree.

[Use of venae comitantes in the creation of arteriovenous fistulas: retrospective evaluation of our experience]. / L'utilizzo della vena comitans nel confezionamento delle fistole artero-venose: valutazione retrospettiva della nostra esperienza.

In order to estimate the outcome of arteriovenous fistula (AVF) for hemodialysis, we reviewed our experience in the construction of AVFs using the venae comitantes in patients without an adequate superficial venous vascular territory. The study included 34 patients affected by end-stage renal disease in whom an AVF was created using the deep venous system. In 26 of them we performed an anastomosis between the brachial artery and its vena comitans. Immediate success, defined by the presence of a thrill at the end of the anastomosis, was obtained in 84%, while primary failure of the AVF (immediate postoperative failure) occurred in 3 patients (12%). Early failure, defined as failure within 6 weeks of AVF placement, occurred in 4% of patients. Of the 22 patients with a functioning AVF, 8 (36%) subsequently requested a second operation to bring the fistula to the surface. Some of these involved the placement of synthetic grafts for better accessibility. The primary patency of the AVFs was equal to 64%, while the patency after a second intervention was 91%. Among the 26 AVFs created with venae comitantes, total patency at 50 weeks was 62%. Our experience with the placement of prosthetic grafts draining into the venae comitantes has not provided encouraging results. We believe that for adequate exploitation of venae comitantes it is important to use native veins that have to meet specific anatomical and functional requirements. The creation of an AVF with a native vein, taking advantage of the deep venous system, is feasible under the right circumstances.

[Central venous stenting in patients on hemodialysis: review of our case series and long-term follow-up]. / Stenting venoso centrale in pazienti emodializzati: revisione della nostra casistica e follow-up a distanza.

Aims of the study was validate the venous stenting technique as the treatment of choice in patients affected by stenosis or occlusion of the central venous area. To evaluate the long-term patency of placed stents in our series and to detect factors predisposing to restenosis. Twenty-three hemodialyzed patients were treated by PTA or placement of a metallic self-expandable stent in the central venous area because of occlusion or severe stenosis caused by repeated central venous access puncture for Port-A-Cath or pacemaker placement. All patients were examined every 3 months after treatment by clinical examination and color-Doppler ultrasound. Stents were placed with success in all cases but one, where it was impossible to get past the occlusion. Restenosis was observed in 12 cases at 4 to 12 months (average 8 months). Intrastent restenoses were treated with success by PTA alone and stent placement in 4 cases. A new restenosis was observed in 4 retreated patients in whom the stent was short or angled. In the other patients restenosis was attributable to disregard of anticoagulant therapy. In conclusions, the availability of new devices and dedicated stents is still necessary. There is a limited relationship between patency and wrong stent placement. Patients undergoing stenting should be controlled by clinical examination and color-Doppler ultrasound in hospitals where skilled interventional radiologists are available.

In vitro activation of mononuclear cells by two probiotics: Lactobacillus paracasei I 1688, Lactobacillus salivarius I 1794, and their mixture (PSMIX).

BACKGROUND: Most studies on probiotics have described their effects on the human immune system after ingestion of LAB, but little is known about their effect on in vitro stimulation of human immune cells. AIM OF THE STUDY: Evaluate the "in vitro" activity of Lactobacillus paracasei (I 1688), Lactobacillus salivarius (I 1794), and a commercial mix of the two (PSMIX, Proge Farm), on immune cells from healthy individuals. MATERIALS: Two probiotic strains, Lactobacillus salivarius (I 1794; Proge Farm, Italy) and Lactobacillus paracasei (I 1688; Proge Farm, Italy), which are contained in the functional food ENTEROBACILLI, were evaluated for their ability to stimulate peripheral blood mononuclear cells and modulate surface phenotype and cytokine production. RESULTS: All subjects responded to the bacteria, with different levels of response. The cell populations that showed a significant percent increase were CD4+/CD25+ cells (T-helper activated regulatory cells), CD8+/CD25+ (T-suppressor/cytotoxic activated cells), and CD16+/CD56+ (NK cells) (p<0.05). IL-12 and IFN-gamma in vitro production significantly increased with exposure to probiotics (p<0.05 for both). CONCLUSIONS: This study provides the first evidence that Lactobacillus paracasei and Lactobacillus salivarius are capable of inducing a specific immune response that may be useful in the clinical setting for improving innate and adaptive immune responses.

Isolated hydatid cyst of the diaphragm without liver or lung involvement: a case report.

The most common targets of the echinococcus are the liver and the lung, but several organs can be affected by this disease. The isolated diaphragmatic location of the cyst, not associated with liver or lung, is very rare. The aim of this work is to report a case of hydatid cyst located in the abdominal side of the diaphragm and to review the literature. The diagnosis was fortuitous and at CT scan the cyst was apparently located on segment VII of the liver. During surgery, after dissection of the adherences with the liver, the cyst remained attached to the diaphragm. Thirty months after the resection, the patient is free of symptoms without any recurrence.

[Use of the Floating Ball for hepatic resection in cirrhotic patients affected by hepatocellular carcinoma]. / Utilizzo del floating Ball nella chirurgia resettiva del carcinoma epatocellulare in pazienti cirrotici.

Done to the improvement of knowledges in hepatic surgery and postoperative care, hepatocellular carcinoma (HCC) have been treated more and more frequently by hepatic resection. Aim of this study is to report an initial series of patients affected by HCC treated by hepatic resection utilizing a new water-cooled, high-density, monopolar device, the Tissuelink Monopolar Floating Ball (Tissuelink Medical Inc., Dover, NH, U.S.A.), in order to avoid bleeding during hepatic surgery. Sex, age, kind of disease, viral and Child status, type of surgical procedure, in association to lenght of surgical procedure, blood loss, utilization of the vascular clamping of the liver, hospital stay, morbidity and mortality have been analized. Six liver resections have been performed utilizing this new device. No vascular clamping was established except one. No mortality was recorded. Morbidity was ascites in one case and pleural effusion in a second one. In conclusion the Floating Ball reduces the intraoperative bleeding during hepatic resection in patients with HCC.

Diagnosis of renovascular disease by extra- and intrarenal Doppler parameters.

It is still a matter of debate as to which parameters should be used for noninvasive diagnosis of renovascular disease by renal Doppler sonography (RDS). The accuracy of RDS in the detection of renal artery stenosis (RAS) was tested in 95 consecutive, moderate to severe hypertensive patients (I-II World Health Organization [WHO] stages). Reno-aortic ratio (RAR) for peak systolic velocity (PSV) was also calculated to assist in the diagnosis of significant (>50%) RAS. Paired receiver-operating characteristic (ROC) analysis was plotted for evaluating the relationship between sensitivity and specificity for each parameter. In a subset of 57 kidneys, the influence of blood pressure and age on intraparenchymal parameters was evaluated. Measurements of maximal peak systolic velocity (PSV) at the site of stenosis, RAR for PSV, and minimum acceleration index in the main renal artery showed high accuracy (areas under the ROC curve 0.97, 0.88, and 0.80, respectively). Among intraparenchymal parameters, early systolic acceleration showed the best area under the ROC curve (0.90), but provided a low positive predictive value (29%) and was significantly influenced by blood pressure (multiple r=0.56; p=0.001). Pulsatility and resistive indices were found to be less powerful as absolute values, and both significantly influenced by blood pressure and age (multiple r=0.60 and 0.50; p=0.001, p=0.02, respectively). However, interindividual variance of intrarenal indices should be minimized by calculation of side difference, although this procedure would become misleading or impossible in patients with bilateral RAS or a single kidney, respectively. These results support the use of extraparenchymal parameters for noninvasive detection of RAS, and emphasize that intrarenal parameters cannot be considered as absolute values.

Neonatal T4+ lymphocytes: analysis of the expression of 4B4 and 2H4 antigens.

Using monoclonal antibodies anti-2H4 and anti-4B4 we investigated by double immunofluorescence and immunorosette technique the presence of cells displaying the helper-inducer and the inducer of suppression phenotype among T4+ cord blood cells. The analysis of the estimated frequencies of subpopulations of T4+ cells shows that a high percentage of T4+ cord blood cells can coexpress both antigens in comparison to adult. Furthermore the percentage of T4+ cells with helper-inducer phenotype (2H4-4B4+) is significantly lower than that in the adult, while the percentage of T4+ cells with suppressor-inducer phenotype (2H4+4B4-) although higher, is not significantly different. These findings suggest that the relative immunoincompetence observed in the newborn may result from a variety of mechanisms including a low percentage of helper-inducer (4B4+2H4-) T4+ lymphocytes possibly also associated to an increased number of suppressor-inducer T4+ cells (2H4+4B4-).