Biomedical subjects
Publications and source records attributed to F Bozzetti.
The pathogenesis of sepsis of central venous catheters has been studied. Catheter exchange is a useful and effective technique for the treatment of sepsis.
There are two main routes for a central venous catheter to become infected and to produce septicemia: exogenous contamination from the skin or the hub, or from a contaminated infusate and endogenous seeding of the tip during bacterial and fungal episodes. Depending upon the patient population and medical and nursing care, one or the other mechanism may be involved. It is quite difficult to identify the route of infection in a single instance unless patients are enrolled in an ad hoc study protocol that guarantees the maximum safety in preparation of the solutions, administering them and managing the catheter. In critically ill patients, when the clinical picture is masked and confusing and the diagnosis is extremely difficult, a positive peripheral blood culture, a positive swab on the skin entry of the catheter or occasionally a quantitative culture of microorganisms from central blood that is higher than from peripheral blood dictates the removal or exchange of the catheter. Central venous catheter sepsis is usually resolved with catheter removal; however, in critical patients who still need the catheter in place, the risk of a new percutaneous catheter after removal of a suspected infected catheter must be weighted against the chance of resolving the sepsis by a simple exchange over a guidewire and long term irrigation of the new catheter with antibiotics.
Early surgical complications following colostomy closure in 65 cancer patients operated on at the Istituto Nazionale Tumori of Milan were evaluated retrospectively. The overall complication rate was 24.6 per cent, including infections (13.8 per cent), fistulas (6.1 per cent), wound dehiscence (3.0 per cent), and distal stenosis (1.5 per cent). Type and rate of complications were analyzed to find a correlation with type, site, and location of colostomy, technique of closure, presence or absence of drains, or time interval between construction and closure of colostomy. No statistically significant association between the aforementioned factors and occurrence and rate of complications was found. The authors think, therefore, that surgical attention, including meticulous manipulation of the stoma, avoidance of contamination of the wound, tension of sutures, dead spaces, and collection of blood in the wound, and use of antibiotics and antiseptics are the most important principles to minimize postoperative complications.
A new approach for preventing and treating sepsis due to central venous catheter (CVC) has been devised at the Istituto Nazionale Tumori of Milan. A prospective protocol has been developed that includes the weekly exchange of the CVC via a guidewire as well as its exchange when a CVC-related sepsis is suspected. Growth of microorganisms on the tip of the CVC is defined as contamination if peripheral blood culture is negative and as sepsis if it is positive for the same microorganism. Colonization simply means growth of microorganism independently of the results of peripheral blood culture. Two hundred seven CVCs (64 polyvinyl chloride and 143 rubber silicone) were evaluated in 62 patients, for a total of 170 exchanges. The incidence of colonization and sepsis was 33.8% and 4.8%, respectively, a rate which is not significantly different from the values found in 81 historical controls (30.8% and 11.1%). However, it is noteworthy that the sepsis rate was reduced strongly during the first month of observation (0% vs. 11.9%; p = 0.01), whereas in the second month, it was similar in both groups (15% vs. 7.1%). Moreover, it should be noted that three-fourths of the colonized CVCs became negative after the first exchange, and virtually all were negative at the fourth exchange. All of the episodes of sepsis resolved spontaneously with the CVC exchange. The study, therefore, concludes that this procedure: 1) is without risk for CVC cross contamination, 2) is effective in the treatment of contaminated CVCs and of septic patients without any interruption of total parenteral nutrition, and 3) can reduce the incidence of CVC sepsis during the first month of total parenteral nutrition. One must be cautious about the possible onset of pulmonary embolism in patients with subclavian venous thrombosis, since a transient pulmonary embolism occurred in one of the patients. With the use of silastic CVCs, which are less thrombogenic than polyvinyl ones, the rate of pulmonary embolism due to blind exchange (without previous venography) is estimated to be 0.1% to 0.2%.
The lack of a worldwide-accepted classification of liver metastases makes it difficult to compare data on natural history and results from different treatments. The increasing interest in aggressive multimodal therapies for hepatic metastases prompted us to review the chief prognostic factors and the main published classifications in order to propose a new clinical classification, whose principal application concerns metastases from colorectal adenocarcinomas. Following the general rules of the TNM classification, liver metastases are classified by expressing with letters and numbers the parameters selected for their prognostic importance, clinical applicability and objectivity. H (hepatic) is the letter that indicates the liver is the site of metastasis. Synchronous metastases are indicated by H, metachronous by rH (r = recurrent). The extent of liver involvement is defined: H1, liver involvement less than 25%; H2, from 25 to 50%; H3, more than 50%. Site of metastases is defined by s (single), m (multiple to one surgical lobe), b (to both lobes), i (infiltration of important structures). The alteration of liver functions is indicated by F. The presence of cirrhosis is noted by C.
The clinical records of 61 patients who underwent extended surgery, including resection of parietes or other viscera, from 1965 to 1977 for cancer of the rectum and sigmoid were reviewed. Abdominoperineal resection was performed in 41 patients, anterior resection in 18 and Hartmann's resection in 2. The postoperative mortality rate was 8.2 per cent, the non-lethal morbidity rate 30.3 per cent, but 4 patients presented multiple complications. The 5-year survival rate was evaluated separately for patients with and without microscopic evidence of neoplastic involvement of the simultaneously excised structures; in the first group it was 32 per cent, in the second 75 per cent. Local or distant recurrence occurred in 66 per cent of patients with microscopic infiltration and in 24 per cent of patients without microscopic infiltration. These results compare favourably with those reported after ordinary resections of Dukes' C cancers of the rectum and sigmoid, and seem to justify the use of extended surgery when cancer of the rectum and sigmoid has invaded contiguous structures.
This study analyzed the nutritional status of cancer patients in relation to type and site of origin of the tumor, stage of disease, and previous chemical or radiation therapy. The analysis was performed on 321 patients (280 with cancer and 41 controls). The nutritional parameters included per cent of weight loss, anthropometric indices (arm circumference, triceps skinfold, arm muscle circumference), creatinine-height index, serum protein, albumin, total iron binding capacity and cholinesterase, C3 and C4 components of complement, total peripheral lymphocytes, and skin tests. The statistical comparison between patients with different tumors and controls, between patients with different stages of the same tumor, and between patients treated with or without previous chemical or radiation therapy led to the following conclusions: 1) malnutrition is mainly related to the type and site of origin of the tumor and, in the early stages of disease, is more pronounced in patients with cancer of the esophagus and stomach; 2) except in patients with breast and cervix cancer, malnutrition gets more severe as the disease becomes advanced; 3) chemical or radiation therapy has a variable impact on the nutritional status, but in selected patients it causes a drop in body weight, arm circumference, arm muscle circumference, and peripheral lymphocytes; 4) body weight, cutaneous delayed hypersensitivity and serum albumin are the most commonly altered parameters.
This study determines the infiltration rate of proximal and distal margins of resection in patients operated on for gastric cancer at the Istituto Nazionale Tumori of Milan. Two hundred and eighty-five proximal margins and 286 distal margins were reviewed, and the incidence of infiltration was related to the length of grossly tumor-free edge, the location, site, size and gross appearance of the tumor, degree of invasion of the gastric wall, histologic type, and status of perigastric lymph nodes. Infiltration occurred in 7.3% of oral margins of transection and in 2.6% of aboral margins. Except for the degree of invasion of the gastric wall, no correlation was found among the infiltration rate and the above parameters. In fact, the incidence of infiltration of the proximal edge was significantly higher (6.4+ vs. 0.8%, p less than 0.01) when the tumor penetrated the serosa or spread beyond it than when the lesion was confined to the mucosa, submucosa, or muscular layer. With reference to the length of margin of resection, it is noteworthy that no involvement was found when cranial distance between the lesion and line of transection was equal to or greater than 6 cm. Proximal or distal infiltration for a distance greater than 3 cm did not occur in patients with lesions confined to the mucosa, submucosa, and muscularis. This data should provide the surgeon with a rational basis for assessing the extent of resection when performing gastrectomy for cancer.
The purposes of this study were to analyze the causes and routes of infection of indwelling central venous catheters and to improve the diagnosis of catheter sepsis before the removal of the cannula. One hundred forty catheter tips were prospectively studies; also, cultures of 52 proximal segments of catheters, 44 swabs of the subcutaneous segment, 195 skin entry sites, 181 infusional fluids, 208 blood samples, and 106 infected distant sites were examined. The catheter sepsis rate was 7.6%, but this sepsis was primary in only 3.4%, because in 4.2% prior isolation of organisms from the wound, urine, throat, or sputum was possible, indicating that the catheter was not primarily responsible for the infection. Primary infection always disappears with removal of the cannula (with or without antibiotics), whereas the course of the secondary infection is related to the gravity of the infected foci and the involved microorganisms. Contamination of the infusional fluid, the skin entry site, and some distant foci carry a real risk of seeding the catheter (from 5.8% to 19.5%). The cultures of the skin entry sites, infusional fluids, distant foci, and the subcutaneous segment of the catheter did not prove useful in predicting the infection. Only the blood cultures were a reliable diagnostic tool: a positive blood culture meant colonization of the catheter tip in 44% of cases and sepsis in 36%. Although the potential colonization varied greatly for different microorganisms, the growth of microorganisms in the blood was a strong indication for removing the cannula.
One hundred and fourteen cases of inflammatory breast cancer were reviewed. Actuarial survival curves, independent of the stage and type of treatment, showed a median survival of less than 15 months. As regards the three different subgroups of 80, 14, and 20 women, N0-1-2M0, N3M1 respectively, the acutuarial survival curves showed figures of median survival that decreased from 14 to 4 months, according to the extent of the disease. Survival rates for the subgroups of patients treated by radical mastectomy, radical mastectomy followed by radiotherapy, and radiotherapy alone were not significantly different. Neither the more sophisticated therapeutic approaches intended to modify the hormonal medium of the patients, nor the combined chemotherapy plus radiotherapy, proved to be successful. Inflmmatory breast cancer should be considered a systemic disease; consequently, in spite of discouraging results, only a systemic therapeutic approach, consisting of aggressive combination chemotherapy and perhaps immunostimulation, seems worthwhile.
Of 77 patients treated by sphincter-saving procedures (anterior or pull-through resection) for cancer of the rectum, 17 (22%) developed a local recurrence; 10 of them were submitted to abdominoperineal resection. The "rescue" operation was technically difficult, and major problems, including large blood loss and ureteral complications, were often encountered. At operation the recurrent malignancy was more extended than preoperative diagnosis suggested, and reoperation was not macroscopically radical in one case. All patients but one died for the disease after a mean period of 19.8 months. Causes of local failure are analyzed to interpret the rational of surgical approach related to the poor results observed; intensive follow-up programs are also discussed. It is concluded that surgical treatment of local recurrence after sphincter-saving procedures must be reserved only to selected patients, with limited malignancy, and adjuvant radiochemotherapy should also be employed.
The effect of intravenous hyperalimentation on the nutritional status of 84 cancer patients treated at the Istituto Nazionale Tumori, Milan, has been evaluated. The body weight increased in 78% of patients, mid upper arm circumferance in 93%, triceps skinfold in 73%, mid upper arm-muscle circumference in 73%, creatinine/height index in 30%, serum albumin in 32%, transferrin in 35%, total peripheral lymphocytes in 38%. Lymphocyte blastogenesis increased in 74% of the patients examined and skin tests were converted from negative to positive in about 20% of patients. In addition 8 our of 18 patients responsive to IVH benefited from chemotherapy and/or radiotherapy indicating that the nutritional repletion of the host did not significantly affect the growth of the tumor. These findings support the opinion that neoplastic cachexia may depend partially on malnutrition and can be often reversed by IVH. Moreover, IVH might have an adjunctive role as potentiator of chemotherapy which however must be confirmed by clinical trials.
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The resting metabolic expenditure of 65 patients with advanced cancer was measured by indirect calorimetry. Resting metabolic expenditure was found to be abnormally high in about 60 per cent of the patients, and there was a strong correlation between resting metabolic expenditure and weight loss and between resting metabolic expenditure and variation in serum transferrin. No relation was observed between resting metabolic expenditure and serum albumin or between resting metabolic expenditure and creatinine-height index. We suggest that these high values of resting metabolic rate, despite the weight loss and starvation, could play a role in the genesis of malnutrition in patients with cancer. The importance of these findings for an adequate planning of nutritional rehabilitation of patients with cancer is emphasized.
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The weight change of 16 adult patients with cancer receiving total parenteral nutrition for an average period of 12 days was evaluated. The nitrogen to calorie ratio of the hyperalimentation fluid ranged from 1:144 to 1:235. The amount of nonprotein calories delivered was expressed as a multiple of the resting metabolic expenditure, and patients were divided according to the following different rates of calories delivered/resting metabolic expenditure into three groups: group 1, 1.11 to 1.48, mean 1.33; group 2, 1.55 to 1.76, mean 1.67, and group 3, 1.78 to 2.10, mean 1.87. The weight change in group 2 patients, +0.32 kilograms per day, was statistically different from that of group 1 patients, p less than 0.01, but not from that of group 3 patients. We conclude that the optimal hyperalimentation infusion rate to achieve weight gain in patients with cancer includes 50 nonprotein calories per kilogram per day as well as 1.5 grams of amino acids per kilogram per day with a nitrogen to calorie ratio of 1:208.