Search

The management of complex anal fistulas remains a challenge, mainly due to the considerable risk of incontinence. We compared LIFT and VAAFT in the treatment of complex anal fistulas in terms of healing time, recurrence, continence, morbidity, and postoperative pain, focusing also on patients with local abscess at the time of surgery. We include all patients with high trans-sphincteric anal fistula even with abscess at the time of surgery. Anorectal manometry, endoanal ultrasound, Cleveland Clinic fecal incontinence score, VAS score, and number of previous fistula treatment were recorded. The clinical examination defined healing, insufficiency or recurrence of the fistula. Fifty-four consecutive patients are undergoing surgery: 26 patients underwent LIFT and 28 underwent VAAFT. During the 18 months of follow-up there were no differences in terms of AM, CCFIS and VAS scores. Days of healing, failure, and recurrence rate were comparable in both groups. The subgroup of patients with local abscess undergoing LIFT showed worse results in terms of failure and recurrence rate (p

Aim A new artificial anal sphincter placed into the intersphincteric space, SphinKeeper™, has recently been proposed to improve outcomes in the treatment of faecal incontinence (FI). We report our preliminary results with short‐term follow‐up, comparing preoperative and postoperative data after implant of SphinKeeper™ in patients suffering from FI. Methods All patients older than 18 years were included with FI of at least 6 months, incontinence episodes occurring more than once a week and resistance to other conservative treatments. Anorectal manometry, endoanal ultrasound, Cleveland Clinic FI Score, FI Quality of Life score and total number of episodes of FI per week were recorded preoperatively and at the end of the 6‐month follow‐up period. Results Thirteen consecutive patients were treated with SphinKeeper™. No intra‐operative nor postoperative complications were reported. Two cases of prosthesis extrusion occurred, and in one case an anterior dislocation was detected. Maximum resting pressure, total number of episodes of FI per week and Cleveland Clinic FI Score were improved after 6 months (P

An amendment to this paper has been published and can be accessed via the original article.

Background Surgical aortic valve replacement has been the treatment of choice for patients with aortic valve disease before the arrival of transcatheter aortic valve replacement (TAVI), although limited by degeneration of the bioprosthesis. “Redo” intervention itself is burdened by high risk of complications and valve-in-valve (ViV) TAVI could be a valid strategy of redo for patients with comorbidities. The aim of this meta-analysis is to give an overview of the state of the art of ViV TAVI in high-risk patients, analyzing efficacy, safety, intra-hospital outcomes and 1-year outcomes and assess predictors of survival at short and mid-term follow up. Methods Two independent reviewers screened all studies investigating patients undergoing ViV TAVI. PubMed database was searched for reports published in English according to the following highly sensitive strategy: (Transcatheter[All Fields] AND “aortic”[All Fields]) AND valve-in-valve[All Fields] AND “implantation”[All Fields] NOT (review[pt] OR editorial[pt] OR letter[pt])AND “humans”[MeSH Terms]). Mortality at 30 days and at 1 year were the primary end point, while procedural and short-term outcomes and echocardiographic parameters at hospital discharge were the secondary end points. Results Of 286 studies identified, 26 articles were included, with a total of 1448 patients. Median age was 78.8 years, 57.7% of the patients were male. Median STS-predicted risk of mortality was 9.4% while median Logistic EuroSCORE was 31.3%. Median age of bioprosthesis was 10 years with 84.6% of stented valves. Stenosis (45%), followed by regurgitation (31%) and mixed defects (21%) were the causes of prosthesis failure. Diameter of the degenerated valve was ≤21 mm in 25.4%, 22–25 mm in 55% and >25mm in 11.7% of the patients. Transfemoral approach was preferred (76%), with a prevalence of balloon expandable valve (73.3%). Mean post procedural gradient was 16.7±0.8 mmHg. Mean follow up was 376 days. Overall and cardiovascular mortality at 30 days was 6.5% and 5.5% respectively, while at 1 year it was 14.5% and 8.9% respectively. Regarding short-term outcomes, overall bleeding (10.4%), pacemaker implantation (9.4%) and vascular complications (8.3%) were the most common peri-procedural complications, while stroke (2.3%), myocardial infarction (2.7%) and coronary obstruction (2.8%) were less frequent. At meta-regression analysis study year (p Conclusions Percutaneous valve-in-valve aortic valve implantation offers a valid strategy to treat high risk patients with a degenerative bioprosthesis. Short and mid-term outcomes are substantially superimposable to those of TAVI, except for coronary obstruction which appears more frequent. Future studies are needed to find predictors of long- term survival and outcomes in lower risk patients. Outcome of VIV TAVI Funding Acknowledgement Type of funding source: None

Background In the era of TAVI, also very high surgical risk patients can be treated and the importance of the Heart Team is to address the patient to the right therapy. In some cases due to comorbidities, lack of symptoms and patients' decision not always a final decision is achieved after the first clinical evaluation and the final strategy could be deferred for months. Purpose The study aims to analyze outcomes in patients with severe aortic stenosis differently treated according to the various approaches proposed by the Heart Team. Methods All the patients with a diagnosis of severe aortic stenosis considered at high and very high surgical risk were enrolled. Three international cardiology departments participated in this multicentre study. All the patients were divided into four groups according to the Heart Team decision of approach. Patients with indication to medical therapy only (DTO Drug therapy only), Patients first deferred from heart team decision, personal reasons or lack of symptoms and then addressed to medical therapy (D-DTO Deferred-Drug therapy only), Patients deferred and then addressed to TAVI within 3 months (D-TP Deferred TAVI Procedure), Patients with direct indication to TAVI (ITP Immediate TAVI procedure). Primary endpoint were overall survive at follow up comparing the differences between the four groups and the impact of the deferred strategy. Results 795 patients were enrolled (80 DTO, 451 ITP, 264 initially deferred and then 155 D-DTO and 109 D-TP). Median follow-up was 465 days. Overall survive of the four groups at 1 year was 74% DTO, 73% D-DTO, 77% D-TP and 78% ITP, at 2 years 62% DTO, 38% D-DTO, 62% D-TP and 68% ITP, at 3 years 39% DTO, 11% D-DTO, 25% D-TP and 56% ITP (p≤0,001 at log rank test). At the multivariate analysis, compared to the referral group DTO, D-DTO was associated with higher mortality (HR=1,90; IC [95%]: 1,05–3,58; p=0,03 at 2 years; HR 1,66; IC [95%]: 1,01–2,76; p Conclusions The Heart team decision on the approach of treatment strongly influence the survive of the patient. Compared to direct medical therapy, there is a higher risk of mortality for patients initially deferred and then treated with medical therapy and there is no survival benefit for patients initially deferred and then treated with TAVI. The choice of deferring the treatment of patients with severe aortic stenosis clearly decrease long term survive at follow up regardless the strategy of the approach.

Highlights • Fungal endocarditis/aortitis. • The first case of polyethylene-terephthalate (PETE) graft aortitis caused by A. niger. • Transoesophageal echocardiography (TEE)., Fungal endocarditis/aortitis is an uncommon yet emerging entity accounting for 2% to 4% of all cases of infective endocarditis and continues to be associated with a poor prognosis. We present the first case of polyethylene-terephthalate (PETE) graft aortitis caused by A. niger, a rare fungal agent. Early diagnosis with frequent transoesophageal echocardiography (TEE) and a prompt surgical intervention coupled with optimal antifungal therapy are still the only option to reduce the exceedingly high mortality and morbidity.

The injection of bulking agents into the anal canal has been reported to help patients with fecal incontinence. Although it has been advocated as a safe and effective option, substantial data concerning long-term efficacy are still lacking, and the resorption process of the implants has not yet been carefully studied. The aim of our study was to investigate the long-term outcomes of bulking agents for the treatment of fecal incontinence and the behavior of implanted materials in the anorectum.At a median follow-up of 7 years, 19 patients with idiopathic fecal incontinence who had received bulking agent implants were evaluated. Clinical, manometric and ultrasound assessments were carried out.The clinical improvements that were achieved in the short term were not maintained over time. For each patient, the number of implants that could no longer be identified on ultrasound was significantly correlated with poorer clinical long-term outcomes. On average, only 14% of the originally injected volume was still detectable.In the long term, perianally injected bulking agents seem to lose effectiveness. The ultrasound assessment suggests that the process of resorption is almost complete, and the implants are no longer effective in treating incontinence.

Coronary artery disease (CAD) negatively affects prognosis in patients undergoing surgical aortic valve replacement, being currently evaluated in the most common used risk score. Our meta-analysis aims to clarify the prognostic role of CAD on mid-term survival in patients undergoing TAVI.Studies reporting multivariate predictors of adverse outcomes in patients undergoing TAVI were systematically searched for and pooled, when appropriate, using a random-effect method. 960 citations were first screened and finally 7 studies (2472 patients) were included. Diagnosis of CAD was reported in 52%(42-65) of patients and 1169 Edwards SAPIEN and 1303 CoreValve prostheses were implanted. After a median follow up of 452 days (357-585) 24% of patients (19-33) died, and 23 (14-32) for cardiovascular death. At pooled analysis of multivariate approach, diagnosis of coronary artery disease did not increase risk of death (OR 1.0, 95% CI, confidence interval, 0.67-1.50 I(2) 0%).CAD does not affect mid-term TAVI outcome: this finding should be weighted to accurately evaluate risk and strategies for patients with severe aortic stenosis.

Purpose To prospectively assess the technical feasibility and reproducibility of quantitative foot perfusion multidetector-row computed tomography (MDCT) in patients with peripheral occlusive artery disease (PAOD) and to evaluate perfusion parameters changes after endovascular treatment. Materials and methods Institutional review board approval and informed patient consent were obtained. 10 patients older than 65 years (mean 74.1 years, range 66–95 years) with PAOD and who were referred to our department for single-limb endovascular treatment were enrolled prospectively. All patients underwent foot CT perfusion examinations before and within 72 h after endovascular treatment. A 64-row CT lightspeed VCT scanner (GE Medical Systems) was used with acquisition of eight contiguous 5-mm reconstructed sections (60-s acquisition time; 40 mL Iomeprol 400 mgI/mL, @4 mL/s). Data were analyzed by two blinded readers using commercially available software to calculate perfusion parameters. Inter-observer and intra-observer agreement of perfusion CT analysis was assessed using Bland–Altman analyses and intra-class correlation coefficient (ICC). Changes in perfusion parameters after endovascular treatment were assessed using Wilcoxon's test. Results Good inter-observer and intra-observer agreement was obtained in all patients. Good agreement was obtained for perfusion parameters for the untreated foot and in repeated studies. By comparing perfusion parameters in the treated foot, a significantly shorter mean transit time (MTT) was obtained. Conclusions Foot CT perfusion is a feasible and reproducible technique. A significant decrease of MTT between pre- and post-revascularization suggests improved flow in the below-the-knee arteries.

Aim Rectourethral fistula (RUF) is a rare complication of radical prostatectomy. We report a trans-perineal approach using a fibrin sealant haemostatic patch. Method Five consecutive patients who developed RUF following radical prostatectomy had a direct transperineal repair with a haemostatic patch (TachoSil®) and were assessed at a median follow up of 35.5 (21-45) months. Results There were no early postoperative complications. The average length of hospital stay was 5 (4-7) days. One patient developed recurrence four weeks after removal of the urethral catheter. Following healing in four patients the stoma was reversed at a median interval of three months, and 9.5 (7-10) months following the prostatic surgery. In the four patients with successful closure there was no case of recurrence or anorectal or urinary dysfunction at a median follow-up of 35.5 (21-45) months,. Conclusion Direct transperineal repair of rectourethral fistula reinforced with a fibrin haemostatic patch of TachoSil® is safe and effective. This article is protected by copyright. All rights reserved.

Aim The authors present their experience of colonoscopic perforation and its management, with an analysis of factors affecting outcome. Method During the last 10 years, 22 cases of colonoscopic perforation (CP) were identified in two different institutions. Multiple logistic regression analysis was used to identify significant predictors of morbidity and mortality. Results Morbidity and mortality rates were 31% and 13.6%, respectively. Prompt diagnosis was the most powerful predictor of outcome of CP. Multiple logistic regression analysis showed that morbidity and mortality were significantly related to a delay in diagnosis of more than 24 h (P = 0.03 and P = 0.04). Conclusion The results emphasize the importance of prompt assessment of a patient who develops symptoms after colonoscopy.

OBJETIVO: A proposta do estudo foi investigar se indices de fadiga, obtidos a partir de eletromiografia de superficie, calculados no dominio do tempo e da frequencia, sao capazes de diagnosticar a dor objetivamente, discriminando entre sujeitos com e sem dor no trapezio superior e nos musculos lombares. METODOS: Quarenta e sete individuos foram submetidos a um teste de fadiga muscular por 35s a 80% da contracao voluntaria maxima (CVM), enquanto EMG e forca muscular foram registradas. O valor RMS e a mediana da frequencia (MF) foram calculados em janelas consecutivas de 1s. Analise de regressao linear foi utilizada para obter os coeficientes de inclinacao e seus respectivos valores de intersecao no eixo y, os quais foram considerados indices de fadiga muscular localizada. RESULTADOS: Os coeficientes de inclinacao analisados no dominio da frequencia apresentaram comportamento similar, sendo negativos para ambos os musculos, enquanto que, no dominio tempo, o trapezio superior apresentou coeficientes positivos, e musculos lombares, coeficientes negativos (p

Problem In consideration of the effect of adenosine deaminase (ADA) and ACP1 (a low-molecular-weight protein tyrosine phosphatase) on T-cell receptor activity, we have analysed the joint distribution of these polymorphisms in a sample of women with primary repeated spontaneous abortion (RSA) to search for possible interactive effects on susceptibility to RSA. Method of study ACP1 and ADA phenotypes were determined in 170 women with primary RSA in 79 healthy consecutive puerperae and in 160 female newborns from the Caucasian population of Rome and in 357 healthy consecutive puerperae from the Caucasian population of Penne. Chi-square test of independence and three way contingency table analysis by a log-linear model were performed. Results Women with low-ADA activity and high-ACP1 activity show the lowest susceptibility to RSA. Women with high-ADA activity and low-ACP1 activity, on the contrary, show the highest susceptibility to RSA and also the highest incidence of auto antibodies and of A blood group incompatibility. Conclusion The data are in agreement with those expected on the basis of the effects of ACP1 and ADA genetic variability on T-cell receptor activity and suggest a cooperative effect of the two polymorphic systems in the susceptibility/resistance to repeated spontaneous abortion.

Loss of skeletal muscle is a typical and early finding in critically ill patients, mostly related to forced immobility, systemic inflammatory response, and protein depletion; it is clinically associated with a functional impairment that may cause difficult weaning from mechanical ventilation, increased length of ICU and hospital stay and long term functional disability.

Background Pilonidal disease (PD) is a common inflammatory disease of the gluteal fold, resulting in recurrent acute/chronic infection at the level of the natal cleft. In this study, endoscopic pilonidal sinus treatment (EPSiT), a new endoscopic minimally invasive procedure, was evaluated for its effectiveness in treating PD. Methods Two hundred and fifty prospective patients with chronic PD were enrolled in a prospective multicentre study conducted at a secondary and tertiary colorectal surgery centre. The primary end-point of this study was wound healing, and the short-/long-term outcomes such as healing time, morbidity rate and recurrence rate were analysed. The secondary end-point of this study was quality of life (QoL). Results The complete wound healing rate was 94.8%, and the mean complete wound healing time was 26.7 ± 10.4 days. The incomplete healing rate (5.2%) was significantly related to the number of external openings (P = 0.01). There was no difference in the failure rate when EPSiT was performed as the first-line treatment for PD or when it was used after unsuccessful procedures (P = n.s.). Recurrence occurred in 12 cases (5%). The QoL significantly increased from preoperative levels 15 days after the EPSiT procedure (45.3 vs 7.9; P

Aim: 5-FU based chemotherapy is the most common regimen used for patients affected by gastric cancer both in metastatic and in adjuvant setting.Identification of predictive markers of both response and toxicity to chemotherapy is a promising approach for drug selection. The present study analyzes the predictive role of 5-FU degradation rate (5-FU-DR) and genetic polymorphisms (MTHFR, TSER, DPYD) on predicting toxicity to chemotherapy and survival Methods: 94 patients affected by gastric cancer were enrolled. Genetic polymorphisms of MTHFR, TSER and DPYD and the 5-FU-DR were analyzed. 5-FU degradation rate was determined by measuring the decrease of a fixed amount of 5-FU (10 [mu]g/mL) added to a solution of PBMC, after 2 hours incubation, expressed as nanogram per milliliter of 5-FU degraded per minute x 106 cells.Gene polymorphisms ofMTHFR, DPYD and TSER were analysed by pyrosequensing of genomic DNA extracted from peripheral blood samples. Genetic markers and the 5-FU-DR were correlated with clinical response, survival and toxicity to treatment. Results: We enrolled 94 patients with gastric adenocarcinoma. All of them received 5FU-based chemotherapy : 39 patients in metastatic setting (28 males and 11 females) and 55 in adjuvant setting (36 males and 19 females). Among the 55 patients in adjuvant setting, 44 of them developed grade 1 and 2 toxicities, while 11 patients developed grade 3 or 4 toxicities. Among the 39 patients treated for metastatic disease, 29 patients reported grade 1 or 2 toxicities while 10 reported toxicities of grade 3 and 4. We didn't found any association between polymorphisms, 5FU-DR and toxicities. We demonstrated a statistically significant association between the polymorphism of DPYD and 5FUDR (p = 0.01). In terms of survival, patients poor metabolizer with a 5-FU-DR Conclusions: 5-FU-DR and genetic polymorphisms of MTHFR and DPYD seem to be significantly involved in survival of patients undergone 5-FU based CHT for gastric cancer both in metastatic and adjuvant setting. Although, the small sample size of patients enrolled in the study, our results suggest that identification of predictive markers of toxicities and survival could help in providing a tailored treatment in patients affected by gastric cancer. Disclosure: All authors have declared no conflicts of interest.

In the last few years we have been working on feasibility studies of future instruments in the gamma-ray range, from several keV up to a few MeV. The innovative concept of focusing gamma-ray telescopes in this energy range, should allow reaching unprecedented sensitivities and angular resolution, thanks to the decoupling of collecting area and detector volume. High sensitivities are essential to perform detailed studies of cosmic explosions and cosmic accelerators, e.g., Supernovae, Classical Novae, Supernova Remnants (SNRs), Gamma-Ray Bursts (GRBs), Pulsars, Active Galactic Nuclei (AGN). In order to achieve the needed performance, a gamma-ray imaging detector with mm spatial resolution and large enough efficiency is required. In order to fulfill the combined requirement of high detection efficiency with good spatial and energy resolution, an initial prototype of a gamma-ray imaging detector based on CdTe pixel detectors is being developed. It consists of a stack of several layers of CdTe detectors with increasing thickness, in order to enhance the gamma-ray absorption in the Compton regime. A CdTe module detector lies in a 11 x 11 pixel detector with a pixel pitch of 1mm attached to the readout chip. Each pixel is bump bonded to a fan-out board made of alumina (Al 2 O 3 ) substrate and routed to the corresponding input channel of the readout ASIC to measure pixel position and pulse height for each incident gamma-ray photon. We will report the main features of the gamma-ray imaging detector performance such as the energy resolution for a set of radiation sources at different operating temperatures.

Background Triple therapy is the gold standard after heart transplantation while few reports have described experiences with cyclosporine monotherapy (CM). We have analyzed our experience with CM in long-term heart transplant recipients, surviving >5 years. Methods Of the 219 patients transplanted between January 1990 and December 1998, 143 survived >5 years (mean age, 49.6 ± 10.4). There were 124 (86.7%) male subjects. Matching patients respect to follow-up length, we obtained 2 groups: group A of 41 patients on double therapy (DT; cyclosporine plus Azathioprine) and group B of 41 patients on CM. Results After a mean follow-up of 119.8 ± 32.2 months, we did not observe a significant difference in terms of survival and major events: heart failure, malignancy, dialysis, infections, and CAV. Conclusion We strongly support the use of triple therapy in cardiac transplant recipients because of its known safety and efficacy. However, our experience with CM suggests the utility of this approach.

Objective Sacral nerve stimulation (SNS) is a recent treatment option in the management of severe faecal incontinence (FI) that offers promising results. The aim of this study was to compare SNS to artificial bowel sphincter (ABS) implanted patients to assess the rationale of this approach in achieving satisfying functional results and improved quality of life (QoL). Method Among 27 patients tested (December 2001 and April 2004), 15 patients were successfully managed with SNS. They were compared to 15 matched patients implanted with ABS in a previous period (control group). Assessment of continence level (Cleveland Clinic score), constipation score (Knowles, Eccersley, Scott Score) and QoL (Short-Form 36) were prospectively collected. Results Both groups were comparable for clinical parameters (age, gender, anal testing and aetiology of incontinence) and anal physiology. The mean postoperative continence score was significantly higher in the SNS group [9.4 (±3.3) vs 5.7 (±3.9), P

OBJETIVO: O objetivo desse estudo foi verificar o potencial da eletromiografia (EMG) de superfície para a avaliação da eficiência neuromuscular e da fadiga muscular localizada dos extensores lombares em indivíduos com escoliose. MÉTODOS: Participaram deste estudo 20 indivíduos divididos igualmente em dois grupos, (1) Grupo com Escoliose e (2) Grupo Controle, que foram submetidos a um teste de indução dos músculos extensores lombares a fadiga, o qual constituiu da realização de uma contração voluntária máxima isométrica (CVM), e realização de um teste com esforço a 80% da CVM. Foram coletados simultaneamente sinais de força e eletromiográficos (sinal EMG). O sinal EMG foi processado no domínio da freqüência, utilizando-se a transformada rápida de Fourier (FFT), por meio da mediana da freqüência (MF), e no domínio do tempo, pelo cálculo do valor root mean square (RMS). Os dados foram submetidos a uma análise de variância one-way para verificar as diferenças entre os dois grupos. Para verificar a simetria entre os lados direito e esquerdo, foi realizado o teste t pareado. O nível de significância adotado foi 0,05. RESULTADOS: os resultados demonstraram que indivíduos com escoliose apresentaram: (1) simetria de ativação neuromuscular entre os lados; (2) menor eficiência neuromuscular; (3) maior capacidade de resistir a fadiga; e (4) valores de força 42,6% menores que os indivíduos do GC. CONCLUSÕES: Os resultados sugerem que a EMG de superfície corresponde a um efetivo instrumento de avaliação funcional da escoliose, embora o protocolo estabelecido tenha limitado a participação dos indivíduos com escoliose, do ponto de vista da eficiência neuromuscular.

Purpose One of the main limitations of artero-venous ECMO (AV-ECMO) support is the inappropriate unloading of the left ventricle (LV). The increased risk of pulmonary edema and impairs LV function reduces the possibility of recovery or the feasibility of a permanent LVAD implantation or heart transplantation. The solution proposed is the surgical implantation of a transapical LV vent (TLVV) through a minimally invasive approach. TLVV reduces significantly the pulmonary edema and it gives the chance to convert AV- ECMO circuit to a short-term LVAD as a bridge to solution. Methods and Materials From January 2010 to June 2012, 16 patients supported by pheripheral AV ECMO for cardiogenic shock underwent TLVV implantation. Cannulation was done through a mini-torachotomy with the seldinger technique using an arterial high-flow cannula. TLVV was connected to the venous inflow line of the AV ECMO. The switch from AV ECMO to short term LVAD has been done in two stages: the weaning from the right circulatory support (intermediate stage: A-A ECMO) and the subsequent weaning from the oxygenator. Results In-hospital mortality was 47,5 %. In 12 patients (75,0%) pulmonary function significantly improved. AV ECMO circuit was simplified to a short term LVAD in 10 patients. Ten pts were bridged to a definitive treatment: heart transplantation in 3 patients, permanent LVAD implantation in 2 patients and bridge to recovery in 5 patients. In hospital survival in patients arrived to these solutions was 8/10 (80,0%). Conclusions TLVV improved pulmonary function and it gave the possibility to switch from the A-V ECMO to a short-term LVAD. After clinical stabilization of patients it was possible to access to a definitive treatment. We think that in the setting of an AV ECMO, TLVV implantation is useful in order to identify the best candidate for permanent LVAD, heart transplantation or recovery reducing significantly the risk of unsuccess.

We have studied cytosolic low molecular weight phosphotyrosine phosphatase (cLMWPTP or ACP1) in 364 healthy puerperae from the population of Penne, in 155 diabetic puerperae from the population of Rome and in 349 consecutive normal newborn infants from the population of Rome. The data from these independent samples point to a protective role of maternal ACP1 genotypes with medium-high activity against intrauterine growth retardation caused by smoking.

Introduction: One of the main limitations of Veno-Arterial ECMO (VA-ECMO) support is the inappropriate unloading of the Left Ventricule (LV). The increased risk of pulmonary edema and impairs LV function reduces the possibility of a recovery or the feasibility of other definitive treatments such as permanent LVAD implantation or emergency heart transplantation. The solution proposed by our center is the surgical implantation of a transapical LV vent (TLVV) through a minimal invasive approach. TLVV reduces significantly the pulmonary edema and it gave the chance to convert VA- ECMO circuit to a short-term LVAD as a bridge to solution. Methods: From January 2010 to June 2012, 16 consecutive pediatric and adult patients supported by pheripheral AV ECMO for acute profound cardiogenic shock underwent TLVV implantation. Cannulation was done in the ICU through a mini-torachotomy with the seldinger technique using an arterial high-flow multiperforated cannula. TLVV was subsequently connected to the venous inflow line of the AV ECMO. The switch from AV ECMO to short term LVAD has been done in two stages: the weaning from the right circulatory support (intermediate stage: A-A ECMO) and the subsequent weaning from the oxygenator. Results: In-hospital mortality was%. In 12 patients (75,0%) pulmonary function significantly improved after implanting TLVV and the VA ECMO circuit was simplified to a short term LVAD through an intermediate stage of A-A ECMO in order to evaluate the right ventricular and the pulmonary function in two different times. Ten pts were successfully bridged to a definitive treatment: heart transplantation in 3 patients, permanent LVAD implantation in 2 patients and bridge to recovery in 5 patients. In hospital survival in patients arrived to these solutions was 8/10 (80,0%). Conclusions: In our series the double drenaige both of the right and the left side of the heart improved pulmonary function and it gave the possibility to switch from the VA ECMO to a short-term LVAD in the majority of cases. After clinical stabilization of patients it was possible to access to a definitive treatment. We think that in the setting of an VA ECMO, TLVV implantation is useful in order to identify the best candidate for permanent LVAD, heart transplantation or recovery reducing significantly the risk of unsuccess.

Annual budgets for hospital library services in Spain are beginning to show a series of restrictions which present a threat to the relative well-being over the last few years of library services and collections, which have not in any case reached minimum internationally accepted standards. It must be borne in mind that as regards structure and planning. Spanish hospital libraries present a lack of organization which, as mentioned, fails to reach minimum standards. Nevertheless, these libraries provide a professionally interested and concerned human network, involved in a series of activities aimed at providing the use with a fast, efficient, and relevant service at reasonable cost. Those of us involved are concerned about the future of our library services and aim to demonstrate the importance of these services within the global context of hospital and, in particular, in the day-to-day work of the physician.

NEW THERAPEUTIC PERSPECTIVES FORMANAGEMENT OF ADVANCED HEPATOCELLULAR CARCINOMAWITH HEPATIC ARTERIOVENOUS FISTULA: BALLOON-OCCLUDED PERCUTANEOUS RADIO-FREQUENCY THERMAL ABLATION (RFA) PLUS TRANSCATHETER ARTERIAL CHEMOEMBOLIZATION (TACE) V. Cesario ∗ ,1, R. Iezzi 2, M.C. Campanale1 , E. Rinninella1 , F.R. Ponziani1, T.A. Di Rienzo1, F. Barbaro1 , B.E. Annicchiarico1 , M. Siciliano1 , M. Pompili 1, G.L. Rapaccini 1 , A. Grieco1, L. Miele1 , A. Milani 1 , L. Riccardi 1 , M.A. Zocco1, M. Santoro2, M. La Torre2, A.M. De Gaetano2 , G.B. Gasbarrini 3 , L. Bonomo2, A. Gasbarrini 1 1Medicina Interna, Ucsc, Policlinico Gemelli, Roma, Italy; 2Radiologia, Ucsc, Policlinico Gemelli, Roma, Italy; 3Fondazione Ricerca In Medicina, Bologna, Italy

The authors describe a rare case of Rieger's syndrome which, in addition to the classically associated dental malformations, also presents a Williams syndrome with bilateral megaloureter.