Circadian sleep-wake disorders and professional driving.

The changes in work organization have significantly modified our lifestyle and increased the number of workers with shift-work schedules, staggered hours and sleep debt. Professional drivers are particularly at risk of excessive sleepiness due to circadian factors (such as night driving), sleep deprivation (professional obligations) and sleep disorders (i.e. obstructive sleep apnea syndrome). About 5% of the population is supposed to suffer from Excessive Daytime Sleepiness (i.e. difficulty staying awake). Public health studies have shown that sleepiness at the wheel is responsible for 5% to 30% of road accidents, depending on the type of driver and/or road. Excessive sleepiness in professional drivers can thus depend on homeostatic process (for a sleep debt related to extended work time or to sleep disorders) and on circadian process (such as in shift-work syndrome or in delayed phase shifts). Strategies to reduce accidents related to sleepiness include: reliable diagnosis and treatment of sleep disorders, management of chronobiological conflicts, adequate recovery sleep and countermeasures against sleepiness at the wheel.

[Sleep disorders, risk of accidents and traffic accidents in a group of drivers of public transport]. / Disturbi del sonno, rischio infortunistico e incidenti stradali in un gruppo di autisti di mezzi pubblici.

In order to evaluate the prevalence of sleep disorders and visuomotor performance, a survey was conducted on 253 drivers of public transport company, aged between 25 and 64 years. Biometric data (BMI, neck circumference and waist, PA) were collected and three questionnaires were administered to investigate sleep disorders. Simple and multiple choice reaction times were administered using a computerized test battery. Records on road accidents in the period 2005-2011 and all accidents in the period 2002-2010 were analyzed. On the basis of clinical and anamnestic questionnaire, workers were divided into two groups: 194 drivers (group 1) without suspicion of sleep disorders and 59 drivers (group 2) with suspected sleep disorders, and 41 with suspected obstructive sleep apnea syndrome (OSAS). The drivers with suspicion of sleep disorders, in particular those with suspected diagnosis of OSAS, showed reaction times significantly prolonged as compared to the drivers of the group 1. In group 2, a higher incidence of (all) accidents was found, whereas the incidence of road accidents was significantly increased only in drivers with suspected OSAS. In addition to the sleep disorders, the use of drugs altering vigilance (antihistamines and benzodiazepines) were significant determinants. In-depth clinical examinations are in progress to confirm the suspected diagnosis of sleep disorders.

Combined liver-kidney transplantation in patients infected with human immunodeficiency virus.

Although human immunodeficiency virus (HIV) infection has been a major global health problem for almost 3 decades, with the introduction of highly active antiretroviral therapy in 1996 and effective prophylaxis and management of opportunistic infections, mortality from acquired immunodeficiency syndrome has decreased markedly. In developed countries, this condition is now being treated as a chronic condition. As a result, rates of morbidity and mortality from other medical conditions leading to end-stage liver, kidney, and heart disease are steadily increasing in individuals with HIV. Because the definitive treatment for end-stage organ failure is transplantation, the demand for it has increased among HIV-infected patients. For these reasons, many transplant centers have eliminated HIV infection as a contraindication to transplantation, as a result of better patient management and demand.

[Is there an age limit for radical surgery in case of tumors infiltrating the duodenum?]. / Per le neoplasie infiltranti il duodeno esiste un limite di età per una chirurgia radicale?

AIM: Radical resection is the only potential cure for pancreatic malignancies and a useful treatment for other benign diseases, such as pancreatitis. Over the last two decades, medical and surgical improvements have drastically changed the postoperative outcome of elderly patients undergoing pancreatic resection, and appropriate treatment for elderly potential candidates for pancreatic resection has become an important issue. METHODS: A hundred and five consecutive patients undergoing radical pancreatic resection between 2003 and 2007 at the Surgery Unit of the University of Modena, Italy, were considered and divided into two groups according to their age, i.e., over 75-year olds (group 1, 25 patients) and under 75-year-olds (group 2, 80 patients). The two groups were compared as regards to demographic features, American Society of Anesthesiologists scores, comorbidities, previous major surgery, surgical procedure, postoperative mortality, and morbidity. RESULTS: There were no significant differences between the two groups concerning postoperative mortality, and the duration of hospital stay and days in the postoperative Intensive Care Unit were also similar. Complications such as pancreatic fistulas, wound infections, and pneumonia were more frequent in the older group, but the differences were not statistically significant. CONCLUSION: In the light of these findings and as reported for other series, old age is probably not directly related with any increase in the rate of postoperative complications, but comorbidities (which are naturally related to the patients' previous life) may have a key role in the postoperative course.

Cholecystocolonic fistula: A rare case report of Mirizzi syndrome.

INTRODUCTION: Mirizzi syndrome is a rare complication of gallstone disease that more rarely is associated with the formation of cholecystoenteric fistula. PRESENTATION OF CASE: The patient presented with a five-day history of abdominal pain in the right upper quadrant (RUQ), nausea, and emesis. Further ultrasound (US) imaging demonstrated a large gallstone with associated thickened gallbladder with pericholecystic fluid. Computed tomography (CT) imaging, preoperative Hepatobiliary Scintigraphy and Endoscopic Retrograde Cholangiopancreatography (ERCP) displayed findings consistent with a Csendes type IV Mirizzi syndrome associated with cholecystocolonic fistula. Description of surgical approach, management and outcome is presented. DISCUSSION: Surgical management of Mirizzi syndrome varies by classification of its severity. Open operation is preferred in cases with severe inflammation and concern for malignancy. The patient underwent a cholecystocolonic fistula takedown. A cholecystectomy was attempted though aborted due to concerns of malignancy. Biopsies returned negative for malignancy and the patient demonstrated findings on ERCP consistent with Mirizzi syndrome. Stenting of the common bile duct (CBD) was performed with ERCP and later the patient underwent an open biliary exploration with subsequent choledochotomy, biliary stone removal, and primary closure with interrupted sutures using remnant gallbladder wall flaps. CONCLUSION: To our knowledge, Mirizzi syndrome with concurrent cholecystocolonic fistula is exceedingly rare with a paucity of reports within the literature. Our report discusses principles of management of Mirizzi syndrome as well as best practices of surgical management for Mirizzi syndrome with concurrent cholecystocolonic fistula.

Portojejunostomy in Split Liver Transplantation as a Rescue Technique for Challenging Biliary Reconstruction: A Case Report.

Cadaveric split liver transplantation (SLT) is a valid option to increase the pool of cadaveric organs, obtaining 2 functioning grafts from a single donor. Typically, SLT is performed for 1 adult and 1 pediatric recipient. However, on the heels of great results achieved in living donor liver transplantation, splitting cadaveric liver into full right graft and full left graft for 2 adults has become a feasible idea. The rate of biliary complications remains the "Achilles heel" in partial graft liver transplantation, either from cadaveric or living donors. In cases of biliary complications, interventional radiology and/or endoscopic procedures are the cornerstone of management. Surgical revision is left as the last option. When surgical revision fails, retransplantation becomes the only rescue option. Herein we describe the case of a cadaveric SLT, complicated by biliary leakage in the presence of multiple bile ducts. A duct-to-duct anastomosis was not feasible. Therefore, a hepaticojejunostomy was performed and resulted in a high-output biliary leak from different sources. Given the anatomy of the biliary tree, radiologic interventional measures were not feasible to address the leak. The idea of performing a portoenterostomy to restore bilioenteric continuity proved to be successful. Portoenterostomy should not be performed in lieu of other alternatives, but rather as the last option to avoid retransplantation in cases of complicated biliary reconstruction after partial graft liver transplant.

Italian Association of Sleep Medicine (AIMS) position statement and guideline on the treatment of menopausal sleep disorders.

Insomnia, vasomotor symptoms (VMS) and depression often co-occur after the menopause, with consequent health problems and reductions in quality of life. The aim of this position statement is to provide evidence-based advice on the management of postmenopausal sleep disorders derived from a systematic review of the literature. The latter yielded results on VMS, insomnia, circadian rhythm disorders, obstructive sleep apnea (OSA) and restless leg syndrome (RLS). Overall, the studies show that menopausal hormone therapy (MHT) improves VMS, insomnia, and mood. Several antidepressants can improve insomnia, either on their own or in association with MHT; these include selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and mirtazapine. Long-term benefits for postmenopausal insomnia may also be achieved with non-drug strategies such as cognitive behavioral therapy (CBT) and aerobic exercise. Continuous positive airway pressure (CPAP) and mandibular advancement devices (MADs) both reduce blood pressure and cortisol levels in postmenopausal women suffering from OSA. However, the data regarding MHT on postmenopausal restless legs syndrome are conflicting.

Effects of everolimus monotherapy on hematological parameters and iron homeostasis in de novo liver transplant recipients: preliminary results.

INTRODUCTION: Anemia after orthotopic liver transplantation (OLT) is a common complication due to several reasons. Immunosuppressive drugs play an important role in anemia occurring at 1 month or more after OLT. Several studies describe myelosuppression immunosuppressants such as the mammalian target of rapamycin inhibitors. METHODS: We performed a single-center, prospective trial consisting of a short 30-day course of cyclosporine (CsA) associated with everolimus (EVL) from postoperative day 10 (Group EVL) versus a CsA immunosuppressive regimen (Group CsA) in de novo OLT patients. We explored the influence of immunosuppressive drugs on hematological parameters comparing EVL versus CsA. RESULTS: Twenty-eight patients were enrolled in the EVL and 12 in the CsA Groups. After OLT, hemoglobin (Hb), hematocrit (Hct), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), white blood cell (WBC), platelets (PLT), transferrin saturation (TSAT), iron, ferritin, and transferrin did not differ significantly between the 2 groups at any time point. Among the patients who reached 6-months of follow-up, 5 (41.7%) EVL and 4 (80%) CsA subjects were anemic (P=not significant [NS]). Only anemia in patients enrolled in Group EVL showed a trend toward the features of microcytic, hypochromic anemia. DISCUSSION: Our results demonstrated that de novo anemia in OLT patients treated with EVL monotherapy showed the same incidence as in patients treated with CsA. Hb values remained similar during the entire follow-up. Moreover, overall myelosuppression in the EVL Group was not significantly different from patients in the CsA Group.

Human immunodeficiency virus and liver transplantation: our point of view.

INTRODUCTION: Highly active antiretroviral therapy (HAART) has been able to improve the immune system function and survival of HIV patients with a consequent increase in the number of HIV patients affected by end-stage liver disease (ESLD). Between June 2003 and October 2006, 10 HIV-positive patients underwent liver transplantations in our center. METHODS: All patients were treated with HAART before transplantation; treatment was interrupted on transplantation day and was restarted once the patients' conditions stabilized. Five patients were hepatitis C virus (HCV)-positive, 3 were hepatitis B virus (HBV)-positive, and 2 were HBV-HCV coinfected. HIV viral load before transplantation was <50 copies/mL in all cases. CD4+ cell count before transplantation ranged between 144 and 530 c/microL. Immunosuppression was based on Cyclosporine (CyA) and steroid weaning for 8 patients, and on Tacrolimus and steroid weaning for 2 patients. RESULTS: Five patients were cytomegalovirus (CMV)-positive pp65 antigenemia posttransplantation, and 1 patient was EBV-positive; 2 patients had a coinfection with HHV6. Four patients suffered from a cholestatic HCV recurrent hepatitis treated with antiviral therapy (peginterferon and Ribavirin). Three patients died after transplantation. DISCUSSION: The outcome of liver transplantation in HIV patients was influenced by infections (HCV, CMV, and EBV) and Kaposi's Sarcoma. HCV recurrence was more aggressive, showing a faster progression in this patient population. Drug interaction between HAART and immunosuppressants occurs; longer follow-up and better experience may improve the management of these drug interactions.

Model for End-Stage Liver Disease (MELD) system to allocate and to share livers: experience of two Italian centers.

BACKGROUND: The use of the Model for End-stage Liver Disease (MELD) score to prioritize patients on liver waiting lists and to share organs among centers was effective according to US data, but few reports are available in Europe. MATERIALS AND METHODS: We evaluated the outcome of 887 patients listed between April 2004 and July 2006 in a common list by two transplant centers (University of Bologna [BO] and University of Modena [MO] ordered according to the MELD system. Patients with hepatocellular carcinoma had a score calculated according to their real MELD, tumor stage, and waiting time. RESULTS: Five hundred eighty-six (67%) patients were listed from BO and 291 (33%) from MO. The clinical features of recipients (sex, age, blood group, and real MELD) were comparable between centers. The number of liver transplantations performed was 307, and 273 (89%) recipients had a calculated MELD >or=20. Liver transplantations were equally distributed according to the number of patients listed: 215 out of 586 (36.7%) for BO and 92 out of 291 (31.6%) for MO. The median real MELD of patients transplanted was 20, and 246 out of 307 (80.1%) grafts transplanted were functioning. The dropouts from the list were 124 (14%), and 87 (70%) of these patients had a calculated MELD >or=20. CONCLUSION: The MELD system was effective to share livers among the two Italian centers. According to this policy, livers were allocated to the recipients with the highest probability of dropout and who had a satisfactory survival after liver transplantation.

Temporary porto-caval shunt utility during orthotopic liver transplantation.

INTRODUCTION: In liver transplantation (OLT) a porto-caval shunt is a well-defined technique practiced by many surgeons in several centers. METHODS: We considered 186 cadaveric OLT patients who underwent a cavo-cavostomy-type reconstruction; they were divided into two groups: those in whom we performed a porto-caval shunt (group A) and those in whose we did not (group B). We evaluated several variables: warm and total ischemia time, intraoperative blood and fresh frozen plasma transfusions, crystalloid and colloid requirements, blood loss, operative duration, hemodynamic intraoperative changes and diuresis, length of hospital stay, and creatinine values at days 1 and 2, and at discharge day. RESULTS: Total and warm ischemic time differed significantly between the two groups. Infusion of blood, fresh frozen plasma, colloid, and crystalloid did not significantly differ. Blood loss was lower, and intraoperative diuresis was not significantly increased in group A subjects. Postoperative hospitalizations were 16.5 and 17.8 days and operative times, 504 and 611 minutes in the two groups. Both cardiac index and ejection fraction values during the anhepatic phase were significantly greater among group A than group B patients. PAD at the two phases was greater in group B. The PAS was significantly different only at reperfusion time. Creatinine values were significantly different at discharge. Better survival was shown for group A patients over group B subjects. CONCLUSION: The results presented herein confirmed that a porto-caval shunt during OLT was a safe, useful expedient contributing to an improved hemodynamic status and a better time distribution in the various phases of liver transplantation.

[Sleep medicine in occupational health]. / Aspetti della fisiopatologia del sonno di rilevanza occupazionale.

Particular time-scheduled works are nowadays increasing in frequency and diffusion, beside typical shift-work. As sleep researchers know in details, clinical consequences of such atypical time-schedules include: sleep loss, daytime vigilance impairment, decrease in neurocognitive performances, increased risk of accidents (in work environment or while driving) and biological effects, such as metabolic and endocrine impairment and immunity decline. Moreover, shift-work has been associated with breast cancer, due to a circadian disruption and to a nocturnal suppression in melatonin production. Despite overwhelming evidence, there is only a mild awareness of the risks and costs related to sleep loss and circadian disruption. In addition, a great amount of sleep disorders produce daytime sleepiness and workers often suffer from an impaired vigilance due to a misdiagnosis or a neglected sleep disorder. Occupational health physicians need to be educated about the importance of detecting impaired alertness in workers. A more correct organization of time-schedules is mandatory to obtain a reduction of occupational related health problems and to bear the modern "24-hours society".

[Sleep disorders questionnaire for medical surveillance of workers]. / Un questionario sui disturbi del sonno per la sorveglianza sanitaria dei lavoratori.

According to Italian law, occupational physicians should assess the fitness of employees for night work before their assignment, at regular intervals, and in cases of health issues related to night work. Moreover, sleep disorders among occupational drivers and shift workers need to be systematically investigated. Sleepiness at the wheel is now identified as one of the main reasons behind fatal crashes and highway accidents caused by occupational drivers. A significant percentage of workers suffer from sleep-disordered breathing, narcolepsy, sleep deprivation, poor sleep hygiene and circadian rhythm diseases. However, all these problems are underestimated. A questionnaire aimed at carefully assessing sleep disorders during medical surveillance of workers was carried out by the Italian Association of Sleep Medicine. It includes twenty-three questions and helps highlight any substantial sleep problem which could require further investigation by sleep medicine specialists.

Eculizumab for Prevention of Antibody-Mediated Rejection in Blood Group-Incompatible Renal Transplantation.

Antibody-mediated rejection (AMR) is one of the leading causes of allograft failure especially in patients undergoing ABO-incompatible (ABOi) renal transplantation. We hypothesized that complement inhibition with eculizumab, a C5 inhibitor, would protect against AMR and maintain graft function in ABOi renal transplant recipients. Four patients undergoing living donor kidney transplant from ABOi donors were treated with a 9-week eculizumab course without therapeutic plasma exchange, intravenous immunoglobulin, or splenectomy. All patients had successful transplants and have normal graft function at the time of last follow-up. There were no cases of AMR or acute cellular rejection. Of note, 2 patients were transplanted despite persistent ABO antibody titers of 1:32, conventionally considered a contraindication to proceed in standard protocols. Eculizumab is a promising option to prevent AMR with ABOi renal transplantation without the need for splenectomy, post-transplant therapeutic plasma exchange, and intravenous immunoglobulin. Future multicenter studies are needed to determine long-term efficacy and safety.

Emergency Kidney Transplantation in Recipients With Iliocaval Thrombosis Using Splenic Vessel Anastomosis After Splenectomy: A Case Series.

BACKGROUND: The external iliac vein is the standard site used for venous anastomosis in kidney transplantation. When a pre-transplantation diagnosis of iliocaval thrombosis is established, a different and suitable venous drainage for the renal outflow must be identified for successful transplant. METHODS: We report 4 cases of kidney transplantation, performed from 2004 to 2016, in recipients presenting with thrombosis of the inferior vena cava and iliac system needing, because of the lack of access for dialysis, urgent kidney transplantations. The splenic vessels were used in all cases for the graft's vascular anastomosis after splenectomy. RESULTS: Kidney transplantation after splenectomy, with anastomosis of the renal vessels to the splenic ones, was completed in all 4 patients. All of the cases were technically successful with good renal function on discharge. During the follow-up, no graft losses were registered as due to thrombotic event or inadequate renal venous outflow. A normal vascular inflow and outflow was confirmed by means of follow-up ultrasound. Two grafts were lost at 31 months and 91 months, both to noncompliance with immunosuppressive therapy. The other 2 are currently functioning well. Notably, the kidney's position in the left upper quadrant has not caused technical difficulties in urologic reconstruction. CONCLUSIONS: In our experience, kidney transplantation using splenic vessels for vascular anastomosis is technically feasible and very useful in the setting of complete iliocaval thrombosis.

Hepatic hilum management in 250 liver-multivisceral procurements.

An accurate in vivo preparation of the hepatic hilum is a fundamental prerequisite for a successful multiorgan transplantation. Our preferred technique in this surgical setting is in vivo procurement in the heart-beating donor. This technique allows an effective exposition of the hilum structures and recognition of anatomical vascular variants, particularly those of the hepatic artery. Also, the cold ischemia time is drastically reduced, and the back-table preparation is left to a minimum. In this article we show the results of a consecutive series of 250 procurements.

Sleep reactivity during acute nasal CPAP in obstructive sleep apnea syndrome.

OBJECTIVE: To measure the readjustments of sleep macro- and microstructure in patients with obstructive sleep apnea syndrome (OSAS) after acute nasal continuous positive airway pressure (NCPAP) treatment. BACKGROUND: The conventional polysomnographic analysis (macrostructure of sleep) does not necessarily provide the best measures of sleep disruption associated with OSAS. In contrast, microstructural methods of analyzing sleep (i.e., arousals and cyclic alternating pattern) may improve evaluation of patients with OSAS. METHOD: - Ten patients with OSAS were monitored polygraphically before and during the first night of NCPAP therapy. The results were compared with those of 10 age- and sex-matched controls without sleep-related breathing disorders. Each nocturnal recording was followed by daytime observation using the multiple sleep latency test and Visual Analogue Scale (VAS). RESULTS: The first night of ventilatory therapy was characterized by a remarkable expansion of stages 3 and 4 and of REM sleep. In addition, NCPAP suppressed the presence of cyclic alternating pattern (CAP) in REM sleep and induced an impressive rebound of arousals and of certain CAP variables-i.e., CAP rate, CAP time, number of CAP cycles-which dropped well below the physiologic values expressed by controls. A normal duration of phases A and B was re-established starting the first treatment night. When we matched sleep variables with the indices of daytime function, a significant correlation emerged only between the variations of CAP rate and VAS scores. In particular, improvement of daytime sleepiness was less evident when the ventilatory-induced drop of CAP rate was more pronounced. CONCLUSIONS: The application of CAP variables to the microstructural analysis of sleep may expand our knowledge regarding sleep and respiration.

Nocturnal eating syndrome in adults.

Ten adult subjects were referred to our sleep disorders center complaining of difficulty in maintaining sleep due to frequent and recurrent awakenings to eat or drink. All patients manifested more than one episode per night, characterized by compulsive food seeking and a return to sleep only after adequate food intake. Food-seeking drive was described as an urgent abnormal need to swallow food and was associated with an absence of real hunger. Six subjects showed an elective nighttime intake of carbohydrates, and in all cases only edible substances were injected. The patients were always fully awake during the episodes and could clearly recall them in the morning. Polysomnographic investigation showed low levels of sleep efficiency, a high number of awakenings and a strict relation between nocturnal eating episodes and nonrapid eye movement (NREM) sleep. The average length of each episode was 3.5 minutes. The "eating latency", that is the interval between awakening and chewing start, was shorter than 30 seconds in 50% of the episodes. No medical, hormonal or neurological disorders were found during clinical and laboratory investigations. Body mass index was abnormally high in six patients. Anorexia nervosa and bulimia were carefully excluded. Various psychiatric disturbances were found in nine subjects, who were nevertheless well-functioning adults. Concurrent dyssomniac disorders, such as narcolepsy or periodic leg movements occasionally associated with restless legs syndrome, were diagnosed in five patients.(ABSTRACT TRUNCATED AT 250 WORDS)