Tracing the footprints of SARS-CoV-2 in oceanic waters

The detection of SARS-CoV-2 in water environments has predominantly focused on wastewater, neglecting its presence in oceanic waters. This study aimed to fill this knowledge gap by investigating the occurrence of SARS-CoV-2 in remote sea and oceanic waters, at large distances from the coastline. Forty-three 500-liter samples were collected between May 2022 and January 2023 from the Atlantic Ocean, the Mediterranean Sea, the Arctic region, the Persian Gulf and the Red Sea. Using molecular detection methods including real-time RT-qPCR and nested PCR followed by sequencing, we successfully detected SARS-CoV-2 RNA in 7 of the 43 marine water samples (16.3 %), and specifically in samples taken from the Atlantic Ocean and the Mediterranean Sea. The estimated concentrations of SARS-CoV-2 genome copies in the positive samples ranged from 6 to 470 per 100 l. The presence of mutations characteristic of the Omicron variant was identified in these samples by amplicon sequencing. These findings provide evidence of the unforeseen presence of SARS-CoV-2 in marine waters even at distances of miles from the coastline and in open ocean waters. It is important to consider that these findings only display the occurrence of SARS-CoV-2 RNA, and further investigations are required to assess if infectious virus can be present in the marine environment.

Clinical and radiographic outcomes in patients operated for complex open tibial pilon fractures

AIM

To report clinical and radiographic results of treatment of patients with complex open tibial pilon fractures.

METHODS

A retrospective analysis in 14 patients with complex open pilon fractures treated between 2010 and 2015 was conducted. The injuries were graded according to AO Classification and the Gustillo-Anderson system. Routine follow-up was performed at 1, 3, 6, 12 month with an annual evaluation thereafter. All patients were included for the assessment of the rate of infection, wound and fracture-healing. Functional outcome assessment was performed in all patients according to the American Orthopedic Foot and Ankle Score (AOFAS) at 12 months after the injury. The radiological outcome was evaluated through standard XR using the criteria proposed by Burwell and Charnley.

RESULTS

Analysis were conducted in 12 men and 2 women, with a mean age of 50.4 years (20-77) who were followed up for an average 34 months (range: 9-60 months). All patients had a AO type 43C fracture. There were three Gustilo Type IIIA injuries, seven Type III B and four Type III C. The mean time to fracture healing was 6.3 months. 4 patients underwent definitive treatment with external fixation at the time of the initial irrigation and debridement. 10 patients underwent delayed definitive surgery: in 10 patients ORIF was used. Soft-tissue coverage by vascularized muscle flap was necessary in 4 patients (28%) and was typically performed on the day of definitive fixation. One patient required iliac crest bone-grafting. 4 patients (28%) had a deep infection.6 patients (43%) had a superficial pin infection or cellulitis. 6 patients (43%) presented delayed union. The average AOFAS score was 71.5 (40-95). According to the Burwell-Charnley score, the anatomical reduction of the fracture was obtained in 50% of patients and a good reduction in 86% of cases. 5 patients (35.7%) had loss of joint congruity and evidence of osteoarthritis on radiographs at final follow-up. No patient needed arthrodesis or amputation.

CONCLUSION

The results of our study suggest that open tibial pilon fractures can be safely managed with low rate of complications using intensive debridement, antibiotics, adequate devices and patient-tailored timing of definitive surgical treatment.

Surgical treatment of acetabular metastasis

Breast cancer is the most common malignancy in women. Bone represents the first site of metastasis in more than 50% of patients who relapse systematically. The pelvis in the most common localization after spine in bone metastasis due to breast cancer. The peri-acetabular localization is a greater concern rather than another part of the pelvis. Bone destruction in this anatomical localization lead to pain and mechanical instability, resulting in a great reduction of autonomy and deterioration of patient's quality of life. In the current report, the Authors review the literature about the surgical treatment, the indications and complications of each surgical technique underling the importance of tailoring each surgical procedure on life span and quality of life in order to minimize peri-operative complications and maximize functional results for the patients.

PATHOLOGIC AND IMPENDING FRACTURES: BIOLOGICAL AND CLINICAL ASPECTS

Bone metastases from carcinomas are epidemiologically rising because of the increased survival rate of oncologic patients, related to several factors such as improvement of primary and secondary screening, advancement of medical research and technology and the better understanding of mechanisms underlying bone metastases origination from primary tumor. Skeletal Related Events (SREs) can seriously affect quality of life in patients with metastatic disease. These events include the necessity of radiotherapy or bone surgery, malignant hypercalcemia, pathologic fractures and spinal cord compression. Among the SREs, pathologic fractures are the most disabling events and represent an emergency in these delicate patients. A pathologic fracture is defined as a fracture that occurs at the level of a pre-existing bone lesion (that is often a tumor), spontaneously or as the result of low-energy trauma (1). The pre-existence of the metastatic lesion in the bone, its evaluation and the assessment of progression can make these complications predictable and preventable. Pathologic fractures imply several severe consequences, including patient immobilization (in the case of fractures involving the lower limbs), loss of autonomy, anaemia, need of blood transfusion, discontinuation of medical therapies or radiotherapy and protracted hospitalization. Secondary effects of prolonged immobilization and loss of autonomy further lengthen this list of complications in patients who are already significantly limited in their activities. In the present paper, the authors present a review on the main aspects involved in bone metastastic disease: biology, quality of life, economic impact and survival.

QUALITY OF LIFE FOLLOWING SURGICAL TREATMENT OF LOWER LIMB METASTASES IN LONG BONE

Pathological fractures have a high incidence in musculo-skeletal oncology, and localization in long bone causes severe pain, disability and poor quality of life. The aim of this retrospective case series is to evaluate the clinical results, in particular regarding the quality of life, in patients affected by lower long bone pathological fractures surgically treated. We analyzed 93 patients with pathological fractures of tibia and femur surgically treated in our Orthopaedic Department and followed up for at least 3 years or until their death. Intramedullary nailing or endoprosthetic reconstruction for pathologic fractures located in the metadiaphyseal and diaphyseal or proximal regions in advanced-stage cancer patients are suitable methods for a stable fixation or reconstruction. These approaches guarantee a good mechanical stability, a faster mobilization, a better control of pain with an overall improvement in quality of life in all patients, confirmed also by the trend of the ECOG performance status and QOL-ACD.

Local adjuvants in surgical management of bone metastases

Curettage is one of the most common method for surgical treatment of bone metastasis. Local adjuvant improve most commonly used for improving the effect of curettage in local cancer surgery may exerted their effects either chemically either physically; in Orthopedic Oncology the most common are phenol, liquid nitrogen, laser, and cement. This article reviewed the main characteristics of the most common chemical and physical agents used in bone oncology, emphasizing the toxic effects of some of them, especially phenol and liquid nitrogen.

The long-term risk of cancer in patients with a first episode of venous thromboembolism

BACKGROUND

In patients with venous thromboembolism (VTE), 15-20% will have prevalent cancer when VTE is diagnosed but little is known about such patients' long-term risk, time course and predictors of new cancer.

PATIENTS AND METHODS

We studied an inception cohort of patients with a first VTE who were not diagnosed with cancer within 3 months after VTE and who had follow-up for up to 120 months. We determined the annual risk for a new cancer [number of events and 95% confidence interval (CI)] per 100 person-years in all patients and in those with unprovoked VTE and identified predictors for new cancer.

RESULTS

We studied 1852 patients with VTE who received anticoagulant therapy for 12 months (mean) and were followed for 4.2 years (mean). During follow-up, there were 105 (5.7%) patients diagnosed with new cancer during the period after the initial 3 months from diagnosis, for an annual risk of 1.32 (CI, 1.09-1.60) per 100 person-years. The risk for new cancer appeared uniform over time. The annual risk for new cancer was more than 2-fold higher in patients presenting with unprovoked compared with those with provoked VTE [1.76 (CI, 1.39-2.20) vs. 0.83 (CI, 0.58-1.16) per 100 person-years; P<0.001]. Clinical predictors for new cancer were increasing age [hazard ratio (HR), 1.23; CI, 1.05-1.44] and unprovoked VTE (HR, 1.86; CI, 1.21-2.87).

CONCLUSION

In patients with a first VTE and without prevalent cancer, the risk for new cancer is about 1-2% per year, appears to be uniform over time, and is higher in patients with unprovoked VTE and those with advanced age.

[Accidents in health care workers: the experience from the Careggi Teaching Hospital]

In the last eleven years in the Careggi Hospital 4941 occupational accident has been registered, and 2951 workers were involved (28.9% of the total of the workers present in the period). The highest frequency of accident has been registered within the cooking staff, about one half of whom had an accident, and 7.2% more than 0.6 accident for person-year; the more serious consequences were registered for traffic accident, more than half happened coming to the workplace before the beginning of the work. Only 154 workers registered more than 0.6 accidents for person-year.

Venous thromboembolism and cancer: guidelines of the Italian Association of Medical Oncology (AIOM)

Thromboembolic complications represent one of the most important cause of morbidity and mortality in cancer patients. Although several data have been published demonstrating the strong association between cancer and venous thromboembolism (VTE), there is poor perception, among oncologists, of the level of risk of thrombosis and of relevance of managing VTE in these patients. The Associazione Italiana di Oncologia Medica (AIOM) has provided some recommendations to direct clinical practice according to evidence-based data concerning cancer and VTE. In fact, we conducted an extensive literature review (1996-2005) to produce evidence-based recommendations to improve perceptions of the magnitude of this risk among Italian medical and surgical oncologists and alert on the new approaches to prophylaxis and treatment of VTE in cancer patients. Levels of evidence are given according to a five-point rating system, and similarly for each key recommendation a five-point rating system suggests if the evidence is strong and indicate that the benefits do, or do not, outweigh risks and burden.

Variable Very-High-Energy Gamma-Ray Emission from the Microquasar LS I +61 303

Microquasars are binary star systems with relativistic radio-emitting jets. They are potential sources of cosmic rays and can be used to elucidate the physics of relativistic jets. We report the detection of variable gamma-ray emission above 100 gigaelectron volts from the microquasar LS I 61 + 303. Six orbital cycles were recorded. Several detections occur at a similar orbital phase, which suggests that the emission is periodic. The strongest gamma-ray emission is not observed when the two stars are closest to one another, implying a strong orbital modulation of the emission or absorption processes.

Decision analysis for cancer screening in idiopathic venous thromboembolism

BACKGROUND

The SOMIT trial randomized patients with idiopathic venous thromboembolism (IVTE) and without signs of cancer at routine medical examination, to extensive screening for cancer plus 2 years of follow-up or to just 2-year follow-up.

METHODS

The data of the SOMIT-trial were used to perform a decision analysis. The screening tests were divided in several possible strategies. The number of detected cancer patients and the number of patients investigated further for an eventually benign condition were calculated for each strategy. The total costs for the screening strategy and for each detected cancer patient were determined. Based on the tumor type, stage, age and gender of the individual cancer patient, the difference in live years gained (LYG) was calculated between the two study groups.

RESULTS

Computed tomography (CT) of the abdomen combined with sputum cytology and mammography detected 12 of the 14 patients with cancer and had one false-positive result. In general, screening strategies including abdominal/pelvic ultrasonography (US) or tumor markers yielded a higher number of patients needed to screen in comparison with those using abdominal/pelvic CT. Furthermore, the strategies which included colonoscopy, tumor markers, and abdominal/pelvic US were significantly more costly, had inferior LYG and higher costs per LYG, when compared with strategies using abdominal/pelvic CT.

CONCLUSIONS

Despite the limitations of this analysis, the screening for cancer with a strategy including abdominal/pelvic CT with or without mammography and/or sputum cytology appears potentially useful for cancer screening in patients with IVTE. The cost-effectiveness analysis of this strategy needs confirmation in a large trial.

Upper extremity deep vein thrombosis: risk factors, diagnosis, and management

Upper extremity deep vein thrombosis (UEDVT) should no longer be regarded as an uncommon and benign disease, as previously reported. It is usually associated with risk factors, as central venous lines, malignancy, and coagulation defects; however, up to 20% of UEDVTs are apparently spontaneous. The clinical picture is characterized by swelling, pain, and functional impairment, albeit UEDVT may be completely asymptomatic. Objective testing is mandatory prior to instituting anticoagulation because the prevalence of UEDVT is less than 50% in symptomatic subjects, and compression ultrasound or color Doppler represents the preferred diagnostic methods. Up to 36% of the patients develop pulmonary embolism, which may be fatal; postthrombotic sequelae and recurrent thromboembolism are also frequent complications. Unfractionated or low-molecular-weight heparin followed by oral anticoagulation should be regarded as the treatment of choice; thrombolysis and surgery may be indicated in selected cases. Prophylaxis with low-dose heparin or low-dose warfarin is necessary whenever central venous catheters are positioned.

Extensive screening for occult malignant disease in idiopathic venous thromboembolism: a prospective randomized clinical trial

Patients with symptomatic idiopathic venous thromboembolism and apparently cancer-free have an approximate 10% incidence of subsequent cancer. Apparently cancer-free patients with acute idiopathic venous thromboembolism were randomized to either the strategy of extensive screening for occult cancer or to no further testing. Patients had a 2-year follow-up period. Of the 201 patients, 99 were allocated to the extensive screening group and 102 to the control group. In 13 (13.1%) patients, the extensive screening identified occult cancer. In the extensive screening group, a single (1.0%) malignancy became apparent during follow-up, whereas in the control group a total of 10 (9.8%) malignancies became symptomatic [relative risk, 9.7 (95% CI, 1.3-36.8; P < 0.01]. Overall, malignancies identified in the extensive screening group were at an earlier stage and the mean delay to diagnosis was reduced from 11.6 to 1.0 months (P < 0.001). Cancer-related mortality during the 2 years follow-up period occurred in two (2.0%) of the 99 patients of the extensive screening group vs. four (3.9%) of the 102 control patients [absolute difference, 1.9% (95% CI, -5.5-10.9)]. Although early detection of occult cancers may be associated with improved treatment possibilities, it is uncertain whether this improves the prognosis.

Idiopathic venous thromboembolism as a first manifestation of cancer

Since Trousseau's time it has been documented the strong two-way relationship between cancer and venous thromboembolism (VTE). Moreover it has been clearly demonstrated that patients with a first episode of idiopathic VTE exhibit a higher risk of newly discovered cancer during follow-up when compared to those suffering from secondary VTE. The performance of a selected diagnostic work-up for cancer detection at the time of referral for index VTE in these patients appears to be capable to identify most of these malignancies and the earlier detection is likely to be associated with improved treatment possibilities and thus prognosis.

Venous thromboembolism as first manifestation of cancer

Since Trousseau's time numerous studies have addressed the relationship between cancer and venous thromboembolism (VTE) providing firm evidence of the increased risk of subsequent clinically overt malignancy during the follow-up of patients with idiopathic VTE. These malignancies are not limited to certain subtypes, but involve virtually all body systems. This knowledge has led to a long-standing debate on the need to screen for occult malignancies patients with idiopathic VTE with no clinical evidence of cancer at the time of the index thrombotic event. In fact the high incidence of newly discovered cancers does not automatically imply that screening is indicated in these patients since it is unknown whether a substantial proportion of cancers can be diagnosed, whether the diagnosed cancers are treatable and what the impact on cancer-related mortality is. Proper clinical trials are being conducted to find an answer to these questions.

The optimal treatment of venous thrombosis: current status and future perspectives

Acute deep venous thrombosis (DVT) of the lower extremities is a serious and potentially fatal disorder, which often complicates the course of hospitalized patients but may also affect ambulatory and otherwise healthy people. Venous thrombosis is uncommon in young individuals and becomes more frequent with advancing age. The clinically important problems associated with venous thrombosis are death from pulmonary embolism, morbidity resulting from the acute event, recurrent venous thromboembolic events, the post-thrombotic syndrome, and the inconvenience and side-effects of investigations and treatment. The main objectives of treatment of DVT are prevention of (both fatal and nonfatal) pulmonary embolism and thrombus extension in the acute phase of the disease, prevention of recurrences of venous thromboembolism in the months following the acute episode, and prevention of late sequelae (post-thrombotic syndrome). These objectives are satisfactorily achieved with anticoagulant drugs (heparin and vitamin K antagonists), which therefore are the mainstays of DVT treatment. Other therapeutic options have a more limited application.

Time course of recovery and complications of HELLP syndrome with two different treatments: heparin or dexamethasone

HELLP syndrome is a severe complication of pregnancy characterized by microangiopathic hemolytic anemia, hepatic dysfunction and thrombocytopenia. Though delivery is the ultimate therapeutic option, medical treatments, including the use of heparin or corticosteroids, have been employed in the attempt to improve maternal prognosis. The aim of this retrospective study was to compare the time course of recovery and the incidence of complications in women with HELLP syndrome receiving either heparin or dexamethasone. Between January 1990 and December 1998, 32 patients with HELLP syndrome were cared for at the Institute of Obstetrics and Gynecology of the University of Florence: 20 patients were treated with heparin, administered subcutaneously at a dose of 5000 IU every 12 h, whereas 12 women received dexamethasone, administered intravenously at a dose of 10 mg every 12 h. Categorical data were evaluated with chi-square and Fisher's exact test; continuous data were analyzed with Mann-Whitney U test; P < .05 was considered significant. In the subgroup treated with heparin the incidence of disseminated intravascular coagulation (DIC) (P < .02), the number of patients requiring blood transfusion (P < .05) and the length of stay at the Intensive Care Unit (ICU) (P < .04) were significantly increased as compared with the subgroup receiving dexamethasone; in this latter subgroup, significantly higher platelet count and hematocrit values, and significantly lower levels of lactate dehydrogenase (LDH) could be documented starting from day 2 after delivery. The results of our investigation suggest that the use of dexamethasone in patients with HELLP syndrome is associated with faster regression and lower incidence of complications in comparison to heparin.

Nomograms for the administration of unfractionated heparin in the initial treatment of acute thromboembolism--an overview

Despite the availability of low-molecular-weight heparins, unfractionated heparin (UFH) still remains the drug of choice for the initial treatment of acute venous thromboembolism in many countries. When appropriately employed, UFH treatment results in a degree of efficacy and safety that is fully comparable with that obtained with the use of heparin derivatives. The use of nomograms for the intravenous or subcutaneous administration of UFH assures that virtually all patients will promptly achieve adequate levels of anticoagulation, thus decreasing the likelihood of recurrent venous thromboembolism without extra bleeding-risk. In this article we reviewed clinical studies on the implementation and validation of UFH dosing nomograms, and attempted a quantitative analysis of their performance. According to the results of our analysis, a statistically significantly higher proportion of patients treated on the basis of a nomogram reached a therapeutic anticoagulant level within 24 h of treatment, as compared to patients treated following the standard practice (odds ratio, 3.6; 95% CI, 2.6 to 4.9). The rate of recurrent thromboembolic events was significantly lower for patients treated according to a nomogram (odds ratio, 0.3; 95% CI, 0.1 to 0.8), while no significant differences in terms of either major or minor bleedings were detected between nomogram patients and controls.

Cancer and venous thromboembolism: an overview

BACKGROUND AND OBJECTIVE

Although the relationship between malignant diseases and venous thromboembolism has been convincingly demonstrated, the clinical implications of this association still have to be thoroughly elucidated. The aim of this study was to review briefly the mechanisms by which cancer may induce the development of thrombosis and to analyze critically the most recent clinical advances in this field.

EVIDENCE AND INFORMATION SOURCES

The material examined in the present review includes articles published in journals covered by the Science Citation Index and Medline .

STATE OF THE ART

Neoplastic cells can activate the clotting system directly, thereby generating thrombin, or indirectly, by stimulating mononuclear cells to synthesize and express various procoagulants. Cancer cells and chemotherapeutic agents can injure endothelial cells, thereby intensifying hypercoagulability. Currently, primary prevention of venous thrombosis should be considered for cancer patients during and immediately after chemotherapy, when long-term indwelling central venous catheters are placed, during prolonged immobilization from any cause, and following surgical interventions. Secondary prevention of recurrent venous thromboses usually necessitates long-term anticoagulation. In some patients with cancer the condition is resistant to warfarin, and long-term adjusted high-dose heparin is required. The diagnosis of venous thromboembolism may help to uncover previously occult carcinoma by prompting a complete physical examination and a few routine tests.

PERSPECTIVES

Further investigations are required to evaluate the cost-benefit ratio of extensive diagnostic screening for occult malignancy in all patients presenting with idiopathic venous thromboembolism, and to explore the potential of low molecular weight heparins for improving survival in patients with cancer.

Use of an algorithm for administering subcutaneous heparin in the treatment of deep venous thrombosis

BACKGROUND

Despite the widespread use of subcutaneous heparin in the initial treatment of deep venous thrombosis, there are no guidelines for achieving adequate anticoagulation with this drug.

OBJECTIVE

To implement a weight-based algorithm for the administration of subcutaneous unfractionated heparin after an intravenous loading dose.

DESIGN

Prospective cohort study.

SETTING

University hospital.

PARTICIPANTS

70 outpatients with proximal venous thrombosis.

INTERVENTION

An intravenous bolus of heparin followed by a subcutaneous injection of heparin in doses adjusted for body weight. Subsequent adjustments of the subcutaneous heparin dose were scheduled twice daily according to the algorithm; the activated partial thromboplastin time (aPTT) was measured in the mid-interval (target range, 50 to 90 seconds).

RESULTS

The therapeutic threshold aPTT (> or = 50 seconds) was achieved in 61 patients (87%) within 24 hours and in 69 patients (99%) within 48 hours. In 7 patients (10%), a supratherapeutic aPTT lasted more than 12 hours. No major bleeding episodes or cases of heparin-induced thrombocytopenia were seen. Three patients (4.3% [95% CI, 0.9% to 12.0%]) had recurrent thromboembolism during 3 months of follow-up.

CONCLUSION

The administration of subcutaneous heparin according to a weight-based algorithm allows the rapid achievement of effective and safe anticoagulation in patients with deep venous thrombosis.

The clinical course of deep-vein thrombosis. Prospective long-term follow-up of 528 symptomatic patients

BACKGROUND AND OBJECTIVE

In contrast to the extensive documentation on the short-term outcome of patients with acute deep vein thrombosis (DVT) of the lower extremities, little is known about the long-term clinical course of this disease. To determine the clinical course of patients with a first episode of symptomatic DVTn over an 8-year follow-up period. The primary aims were to assess the long-term incidence of recurrent venous thromboembolism and that of the post-thrombotic syndrome. In addition, we determined mortality and evaluated potential risk factors for all these outcomes.

METHODS

This was designed as a prospective cohort follow-up study. Consecutive symptomatic outpatients with a first episode of venography proven DVT were treated with an initial course of full-dose (low molecular weight) heparin, followed by at least three months of oral anticoagulants. After discharge, they were instructed to wear compression elastic stockings for at least two years. Follow-up assessments were scheduled at three and six months, and then every six months up to eight years. Diagnosis of recurrent venous thromboembolism was made according to standard criteria. The presence of post-thrombotic syndrome was evaluated using a standardized scale.

RESULTS

A total of 528 consecutive patients with a first episode of venography confirmed DVT were included in the study. The cumulative incidence of recurrent venous thromboembolism after two, five and eight years was 17.2, 24.3 and 29.7%, respectively. Malignancy and impaired coagulation inhibition increased the risk of recurrent venous thromboembolism (RR = 1.48 and 2.0, respectively). In contrast, surgery and recent trauma or fracture were associated with a diminished risk of recurrent venous thromboembolism (RR = 0.65 and 0.39, respectively). The cumulative incidence of post-thrombotic syndrome after two, five and eight years was 24.5, 29.6 and 29.8%, respectively. The development of ipsilateral recurrent DVT was strongly associated with the risk for post-thrombotic syndrome (risk ratio, 2.4). Survival after eight years was 69%. The presence of malignancy increased the risk of death remarkably (risk ratio, 7.1).

INTERPRETATION AND CONCLUSIONS

Symptomatic DVT carries a high risk for recurrent venous thromboembolism that persists for many years, especially in patients without transient risk factors for DVT. The post-thrombotic syndrome occurs in almost one-third of patients and is strongly related to recurrent ipsilateral DVT. Our findings challenge the widely adopted short course of anticoagulation in patients with symptomatic DVT.

Venous thromboembolism and cancer: a two-way clinical association

In recent years, a growing body of evidence has provided the convincing demonstration of a strong association between cancer and venous thromboembolism. This relationship is further supported by the risk of developing overt malignancy in patients with idiopathic venous thromboembolism. However, the cost-to-benefit ratio of an extensive diagnostic work-up aimed at identifying an occult cancer in patients with spontaneous thromboembolism still has to be demonstrated. During prolonged immobilization from any cause, and following surgical interventions, patients with cancer are at a remarkably higher risk of venous thromboembolism than patients free from malignant disorders. Standard heparin in adjusted doses or a low-molecular-weight heparin in doses commonly recommended for high risk surgical patients represent the prophylactic treatment of choice for cancer patients undergoing an extensive abdominal or pelvic intervention. Furthermore, the risk of thrombotic episodes is increased in cancer patients by chemotherapy and by the use of indwelling central venous catheters. Recent data suggest a positive benefit-to-risk ratio with the systematical use of fixed mini-dose of warfarin in both conditions. After experiencing an episode of thrombosis, cancer patients remain at risk of recurrence for as long as the cancer is active. Therefore, they should be protected by a long-term course of oral anticoagulation. The risk of recurrent thrombotic events despite adequate anticoagulation is higher in patients with cancer than in those without cancer. The routine use of long-term subcutaneous heparin therapy rather than oral anticoagulants should be reserved for patients in whom warfarin has been ineffective. Can antithrombotic drugs improve survival in cancer patients? In cancer patients affected by deep-vein thrombosis, the treatment with low-molecular-weight heparins has been reported to lower mortality at a higher extent than the standard heparin therapy. Such an observation suggests that these agents might develop an antineoplastic activity.

Epidemiologic characteristics, management, and outcome of deep venous thrombosis in a tertiary-care hospital: the Brigham and Women's Hospital DVT registry

Entry into clinical trials of treatment for deep venous thrombosis (DVT) involves a screening process that excludes many patients with this condition. Therefore, to obtain a profile of patients with DVT that reflects actual day-to-day clinical practice, we initiated a prospective registry of 150 consecutive patients with DVT at Brigham and Women's Hospital, Boston. We reviewed the medical records of all patients who received a diagnosis of DVT from November 1, 1994 through March 31, 1995 and did not exclude any patients. Of the 150 patients, 120 (80%) were symptomatic and 30 (20%) were asymptomatic. Frequent baseline characteristics included surgery within the preceding 6 months (47%), cancer (26%), and previous venous thromboembolism (23%). DVT was diagnosed by ultrasonography(n = 145), contrast venography (n = 3), or clinical evaluation (in 2 patients who had technically unsatisfactory ultrasound results). Overall, 133 (89%) patients received anticoagulation; 5 (3%) received thrombolysis; and 27 (18%) underwent placement of an inferior vena caval filter. In 3 patients major hemorrhage developed from anticoagulation or thrombolysis. The 3-month mortality rate was 19%, including 10 patients who died during the index hospitalization. In no case was pulmonary embolism thought to be the cause of death. Ten patients had recurrent venous thrombosis during the initial 3 months after diagnosis. The most surprising findings in the DVT registry were the high rates of cancer and surgery, the high rate of filter placement, and the high mortality rate. These registry results differ substantially from findings in randomized controlled trials of DVT treatment.

Cancer and venous thromboembolism

Neoplastic cells can activate the clotting system directly, thereby generating thrombin, or indirectly, by stimulating mononuclear cells to synthesize and express various procoagulants. Clinical manifestations of increased thrombin generation may be accentuated by down-regulation of endothelial cell counterregulatory mechanisms, such as decreased hepatic synthesis of antithrombin III and protein C. Cancer cells and chemotherapeutic agents can injure endothelial cells, thereby intensifying hypercoagulability. In addition, normal endothelial cell function. may be disrupted by various defects in platelet function. Currently, primary prevention of venous thrombosis should be considered for cancer patients (1) during and immediately after chemotherapy, (2) when long-term indwelling central venous catheters are placed; or (3) when hospitalization for cancer is characterized by prolonged immobilization, trauma, or surgery. Secondary prevention of recurrent venous thrombosis usually necessitates anticoagulation. In some patients with cancer, the condition is resistant to warfarin, and long-term adjusted high-dose heparin is required. For patients unable to tolerate heparin or warfarin because of major bleeding problems, placement of an inferior vena caval filter should be considered. The diagnosis of venous thrombosis may help to uncover previously occult carcinoma by prompting a complete physical examination, chest roentgenography, and mammography. However, extensive cancer screening with total-body computed tomography or magnetic resonance imaging has not been shown to be cost effective for patients with venous thrombosis.

[Total enteral nutrition versus mixed enteral and parenteral nutrition in patients at an intensive care unit]

OBJECTIVE

To compare metabolic, nutritional and epidemiological data in two groups of patients, one receiving total enteral nutrition, via nasoenteric tube, and one receiving both enteral and parenteral nutrition.

DESIGN

A prospective, randomized study.

SETTING

A general ICU, with both medical and surgical patients, in a big regional University and National Health Service hospital.

PATIENTS

24 patients requiring Intensive Care after major surgery or because suffering from severe head injury or major neurological impairment.

INTERVENTIONS

All patients initially received total parenteral nutrition: after 4 days 12 patients were "weaned" to total enteral nutrition and 12 stayed on mixed parenteral and enteral nutrition. LABORATORY INVESTIGATIONS AND OBSERVATIONAL DATA: Blood levels of albumin, prealbumin, transferrin, ALT, AST, bilirubin, blood urea, blood glucose, total linfocite count, and nutritional and epidemiological data such as nitrogen balance, calorie intake, diarrhea incidence, blood and sputum cultures and radiologic evidence of pneumonia are analysed.

RESULTS

At T1, NET patients were able to reduce their nitrogen losses (0.27.1 g/kg +/-0.12 vs 0.35 +/- 0.13 at TO; p < 0.05) and improve nitrogen balance (-9 +/- 7 vs -2 +/- 6 at T0; p < 0.05); they also had a better total linfocite count (2034 +/- 304 vs. 1413 +/- 360 of the MISTA group; p < 0.05), and a lower incidence of pneumonia as documented by sputum cultures and radiograms.

CONCLUSIONS

Patients fed with both parenteral and enteral nutrition did no better than those on total enteral nutrition as far as nutritional and metabolic indices were concerned; they also seemed more prone to infections than those on total enteral nutrition, indicating that mixed nutrition may result in more stable feeding, but this does not seem to have any beneficial nutritional, immunological and metabolic effect.

The utility of non-invasive tests for detection of previous proximal-vein thrombosis

BACKGROUND

Despite the availability of several diagnostic methods for the detection of deep-vein thrombosis (DVT), the identification of previous episodes of DVT remains a diagnostic challenge.

STUDY OBJECTIVE

To assess the reliability of a combination of a standardized clinical score with three non-invasive tests: compression ultrasonography (CUS), Doppler ultrasound (DUS), and photoplethysmography (PPG), in determining the presence or the absence of previous proximal DVT.

METHODS

One hundred consecutive unselected outpatients were identified, who had undergone contrast venography six to nine years previously because of the clinical suspicion of DVT (confirmed in 43). They were blindly reinvestigated by a panel of trained operators unaware of venography results. They underwent a clinical evaluation of the lower limb, by applying a standardized score to five symptoms and six signs (grading each item from 0 to 3); a PPG test to determine the venous refilling time; a DUS test to determine the venous reflux separately in the common femoral and the popliteal vein; and a CUS test to determine vein compressibility in the same regions.

RESULTS

An abnormal CUS test and/or the demonstration of venous reflux in the popliteal region and/or a high clinical score (> or = 8) identified twenty-four of the 43 (56%) DVT + patients with a specificity of 89%. The combination of normal CUS with the absence of venous reflux in both the common femoral and popliteal vein and a low clinical score excluded previous thrombosis in 45 (79%) of the 57 DVT-patients (negative predictive value, 78%). Abnormal venous reflux in the isolated common femoral vein did not reliably predict the presence or absence of previous DVT. However, this occurred in only 13 (13%) patients. The PPG determination of venous refilling time did not improve the results obtained with the other tests.

CONCLUSIONS

The combination of a standardized clinical evaluation with the results of CUS and DUS can reliably diagnose or exclude previous proximal-vein thrombosis in almost 90% of patients with previous episodes of suspected DVT.

Bilateral massive adrenal hemorrhage due to sepsis: report of two cases

Two cases (a 57-year-old man and an 18-year-old girl) of bilateral massive adrenal hemorrhage (BMAH) due to sepsis (Streptococcus pneumoniae and Neisseira meningitidis, respectively) are reported. At admission, the man presented with fever, severe hypotension, hyperazotemia, acidosis, normonatremia and hypocoagulability, while the girl with severe hypotension, fever, hyponatremia, and hypocoagulability. A diagnostic protocol based on a very quick method for cortisol measurement is proposed, in an attempt to reach an earlier diagnosis of BMAH during sepsis.

[Hemodynamic stability in thoracic-abdominal trauma with multiple intrahepatic abscesses. A clinical case]

A case of multiple injury is reported in a young 35-year-old man affecting three different areas of the body which showed a septic-type development. Complete recovery was largely determined by the accuracy of the preoperative diagnosis and the correct maintenance of hemodynamic parameters.