The recipient with portal thrombosis and/or previous surgery.

INTRODUCTION: Portal vein thrombosis (PVT) has been considered to be an absolute contraindication to liver transplantation (OLT) and previous upper abdominal surgery was considered to render it a high-risk procedure. Currently, these are only conditions considered risk factors increasing recipient morbidity and mortality. The objective of this study was to compare OLT perioperative morbidity, mortality, blood product consumption, and length of hospital stay among patients with or without PVT or with or without previous surgery. MATERIALS AND METHODS: Among 366 OLTs performed between July 1999 and November 2007, 33 liver transplant recipients displayed previous PVT while 34 had undergone previous surgery. The two groups of marginal recipients were compared with a cohort of 33 patients without PVT or previous surgery. RESULTS: The groups were homogeneous in terms of epidemiological variables, surgical techniques, and donor-related variables. In the PVT group, all analyzed parameters were the same as the control group; surgical time, anhepatic phase duration, early surgical complication, intensive care unit and hospital length of stay, and overall mortality. The only significant difference was the incidence of portal rethrombosis (P < .035). Among the previous surgery group, we did not observe significant differences. CONCLUSIONS: PVT and previous surgery should no longer be considered contraindications for OLT.

Amiodarone or lidocaine for cardiac arrest: A systematic review and meta-analysis.

BACKGROUND: Guidelines for treatment of out-of-hospital cardiac arrest (OOH-CA) with shockable rhythm recommend amiodarone, while lidocaine may be used if amiodarone is not available. Recent underpowered evidence suggests that amiodarone, lidocaine or placebo are equivalent with respect to survival at hospital discharge, but amiodarone and lidocaine showed higher hospital admission rates. We undertook a systematic review and meta-analysis to assess efficacy of amiodarone vs lidocaine vs placebo. METHODS: We included studies published in PubMed and EMBASE databases from inception until May 15th, 2016. The primary outcomes were survival at hospital admission and discharge in OOH-CA patients enrolled in randomized clinical trials (RCT) according to resuscitation with amiodarone vs lidocaine vs placebo. If feasible, secondary analysis was performed including in the analysis also patients with in-hospital CA and data from non-RCT. RESULTS: A total of seven findings were included in the metanalysis (three RCTs, 4 non-RCTs). Amiodarone was as beneficial as lidocaine for survival at hospital admission (primary analysis odds ratio-OR 0.86-1.23, p=0.40) and discharge (primary analysis OR 0.87-1.30, p=0.56; secondary analysis OR 0.86-1.27, p=0.67). As compared with placebo, survival at hospital admission was higher both for amiodarone (primary analysis OR 1.12-1.54, p<0.0001; secondary analysis OR 1.07-1.45, p<0.005) and lidocaine (secondary analysis only OR 1.14-1.58, p=0.0005). With regards to hospital discharge there were no differences between placebo and amiodarone (primary outcome OR 0.98-1.44, p=0.08; secondary outcome OR 0.92-1.33, p=0.28) or lidocaine (secondary outcome only OR 0.97-1.45, p=0.10). CONCLUSIONS: Amiodarone and lidocaine equally improve survival at hospital admission as compared with placebo. However, neither amiodarone nor lidocaine improve long-term outcome.

Pediatric liver transplantation: preliminary results at Istituto Mediterraneo Trapianti e Terapie ad Alta Specializzazione.

Between July 2003 and November 2004 14 pediatric liver transplantations (LTx) have been performed in 12 children using cadaveric donors. The primary diseases were as follows biliary atresia in 9 cases, whereas the other 3 children were affected by cystic fibrosis, Langherans cells histiocytosis, and hepatoblastoma, respectively. Median patient waiting time was 103 days (range, 2-158); no patient died while on the waiting list. Patients who underwent transplantation included 7 boys and 5 girls, ranging in age from 6 months to 14 years (median age, 5 years). Recipient median weight was 16 kg (range, 6-38). Donor median age was 19 years (range, 3-47), whereas donor median weight was 74 kg (range, 15-90). All children who underwent primary LTx were United Network for Organ Sharing (UNOS) status 2B. Of the 12 transplanted patients, 9 received a left lateral segment (LLS) from an in situ split liver, whereas 3 received a whole graft. Two children developed an episode of acute cellular rejection on the seventh postoperative day, which was treated successfully with a course of intravenous steroids for 3 days. After a median follow-up of 245 days, 10 children are alive but 2 children died due to primary nonfunction (PNF) on the second postoperative day and septic shock on the fifth postoperative day after retransplantation for acute hepatic artery thrombosis, respectively. One child who underwent retransplantation for hepatic artery thrombosis on the 31st postoperative day after primary LTx is currently alive. Evaluation of our initial data suggests that the split liver technique has the potential to meet the needs of pediatric LTx allowing grafting early in the course of the original disease and reducing waiting time.

Reproducibility of an Italian food frequency questionnaire for cancer studies: results for specific food items.

To evaluate the reproducibility of a quantitative food frequency questionnaire (FFQ) used in a case-control study on cancer of the breast, ovary and digestive tract, we compared the result of a 98-item questionnaire administered twice at an interval of 3-10 months (median = 5.4 months) to 452 volunteers (144 males and 308 females, median age = 50 years) from three Italian provinces (Pordenone, Genoa and Forlí). Spearman correlation coefficients (r) for intake frequency of 87 dietary items ranged from 0.35 ("chicken or turkey, boiled") to 0.84 ("wine"). Most coefficients were between 0.60 and 0.80, only two being below 0.40 and five equal or above 0.80 (mean r = 0.59). The concordance of the two measurements tended to be somewhat better for alcoholic and non-alcoholic beverages, bread, cereals and first courses, fruits and summary questions at the end of each section of the questionnaire than for side dishes, sweets and desserts. Also, the reproducibility of 11 subjective questions, such as those concerning the amount of fat in seasoning and the intake of garlic or salt, seemed to be high. Age, sex, educational level of the volunteers and interval between the two FFQ did not have a large or systematic impact on the concordance of the two measurements. In conclusion, the present study has shown a good level of reproducibility of our questionnaire and has provided a few important hints on ways of improving the description of various food items.

Central venous thrombosis: an early and frequent complication in cancer patients bearing long-term silastic catheter. A prospective study.

Studies on catheter-related central venous thrombosis (CRCVT) have been focused mainly on clinically evident CRCVT due to occlusive thrombi, underestimating therefore the actual thrombosis prevalence. This prospective study was aimed at evaluating prevalence, timing and evolution of thrombosis, and identifying involved veins and risk factors in cancer patients (pts) undergoing percutaneous subclavian central venous catheterization (CVC) for chemotherapy, parenteral nutrition or both. We enrolled 127 consecutive pts requiring partially or totally implanted central venous silastic catheters. The study protocol included peripheral phlebography (P) at day 8, 30 and every two months following CVC and/or when clinically indicated, along with peripheral and pullout P on catheter withdrawal. A quantitative scale was developed to evaluate thrombus grading in subclavian, innominate and cava veins. Age, sex, coagulation profile tumor histotype, metastases, therapy, catheter type, and catheter insertion side were also investigated. Only pts who underwent at least two P were evaluated, and chi 2 test was adopted for statistical analysis. Altogether, 95 pts were evaluable. CRCVT was observed in 63/95 (66%) pts. At day 8, 30 and 105 (representing the median days in which first, second and last P were performed) CRCVT was evidenced in 64%, 65% and 66% of the pts, respectively. Thrombus grading did not differ among first, second and last P. CRCVT was symptomatic in 4/63 (6%) pts. Thrombosis prevalence was higher in subclavian (97%) with respect to innominate (60%) or cava (13%) veins (p < 0.001). Thrombosis was higher in left subclavian catheters (14/16; 87.5%) than in right ones (49/79; 62%), p < 0.01. No associations were established between CRCVT and other investigated parameters. Our data show a very high actual frequency of CRCVT in cancer pts, and emphasize that first days following CVC are at the highest risk for CRCVT development. Based on our results, a study on short-term antithrombotic prophylaxis in cancer pts requiring CVC is warranted. Finally, our data indicate that left subclavian vein catheterization represents a risk factor for CRCVT.

Interferon versus steroids in patients with hepatitis C virus-associated cryoglobulinaemic glomerulonephritis.

BACKGROUND/AIMS: The association between mixed cryoglobulinaemia, cryoglobulinaemic glomerulonephritis, and chronic hepatitis C virus infection has recently been described. The renal disease had usually been treated with immunosuppressive therapy, but, given the presence of viral infection, this therapy is no longer recommended. In this study, we compare steroid vs interferon therapy in a group of patients affected by hepatitis C virus-positive cryoglobulinaemic glomerulonephritis in the stationary phase. PATIENTS/METHODS: The diagnosis of cryoglobulinaemic glomerulonephritis was made bearing in mind standard criteria. Patients were randomly assigned to 2 groups receiving oral prednisone 0.2 mg/kg/die for 6 months (6 patients, group A) or lymphoblastoid interferon 3 MU, three times a week for 6 months [7 patients, group B). Hepatitis C virus-RNA was determined by reverse transcription-polymerase chain reaction and hepatitis C virus genotype according to Okamoto. Hepatitis C virus-RNA quantitation was performed by competitive polymerase chain reaction. RESULTS; The 2 groups were comparable in terms of age and severity of kidney failure. All genotypes of hepatitis C virus were found with a prevalence of Type 1b. In group A, 4 patients showed a partial response; in group B, 1 patient achieved complete remission, 4 a partial response, 2 patients in both groups showed no response. At the end of the treatment, all patients in both groups relapsed. Only 1 patient in group B became hepatitis C virus-RNA negative, and recovered from cryoglobulinaemic glomerulonephritis. CONCLUSIONS: Interferon seems to be an effective drug in the treatment of cryoglobulinaemic glomerulonephritis, but dosage and length of treatment still need to be addressed by large multicentre studies.

Parenteral nutrition in cancer patients receiving chemotherapy: effects on toxicity and nutritional status.

The role of total parenteral nutrition (TPN) in reducing toxicity related to cancer chemotherapy (CT) is presently a controversial issue. To evaluate the effectiveness of TPN in reducing CT-associated toxicity and correcting and preventing CT-related impairments of nutritional status, a prospective crossover controlled study was performed in 43 cancer patients (19 normally nourished and 24 malnourished) randomly divided into two groups (A and B). Group A patients received TPN concomitantly with the first course of chemotherapy, and the second course was administered 21 to 28 days later without TPN support; group B patients were treated in the opposite sequence. The rates of myelotoxicities and gastrointestinal toxicities after CT courses with or without TPN were essentially similar in normally nourished and malnourished patients. No changes in nutritional indexes were detected in normally nourished subjects after each course. Conversely, in undernourished subjects, prealbumin, retinol-binding protein, and nitrogen balance increased in CT+TPN courses (p < .02). In CT-only courses, undernourished subjects showed a decrease in prealbumin and nitrogen balance. Significant changes of nitrogen balance in CT vs CT+TPN courses were detected in malnourished subjects. TPN appears to be unable to reduce CT-associated toxicity. CT administration does not result in any impairment of the nutritional status in normally nourished cancer patients. From our study, it appears that TPN should be limited to severely malnourished neoplastic patients undergoing CT, because of its ability to prevent further impairment of nutritional status and to improve the nitrogen balance and the levels of fast-turnover visceral proteins.

Malignant fibrous histiocytoma of the gallbladder: case report and review of the literature.

Malignant fibrous histiocytoma is a soft tissue sarcoma of mesenchymal origin. It can rarely present as a primary gallbladder tumor with only five cases having been reported to date in the English literature. Here we report the sixth documented case of malignant fibrous histiocytoma of the gallbladder, and we review all other cases reported. The outcome of the visceral sarcomas is poor when compared with tumors arising from the soft tissues. The treatment of primary malignant fibrous histiocytomas of the gallbladder is surgery. However, tumor recurrence is the norm even if wide clean margins are obtained. In contrast to tumors arising from the extremities the role of adjuvant radiotherapy and chemotherapy is less clear in the case of retroperitoneal and visceral sarcomas. Our patient is still alive and free of disease 46 weeks after surgery. The fact that this is the longest survival reported to date underscores the dismal prognosis of this disease.

Does continuous ambulatory peritoneal dialysis induce hypercholesterolemia?

Hypercholesterolemia has been recognized as a significant risk factor for atherosclerosis and coronary artery disease. The aim of this study was to evaluate the prevalence of hypercholesterolemia and the role, if any, of type of dialysis. In 19 hemodialysis (HD) and 20 continuous ambulatory peritoneal dialysis (CAPD) subjects, body weight, body mass index (BMI), arm muscle area (AMA), total cholesterol (C), HDL and LDL fractions, triglycerides, C/HDL ratio, glycosylated hemoglobin, and apolipoproteins AI, AII, B, CII, CIII, and E were evaluated. Hypercholesterolemia was defined as cholesterol greater than 220 mg/dL and LDL greater than 150 mg/dL. Body weight, body mass index, and arm muscle area were higher (p < 0.05) in CAPD as compared with HD; so were total cholesterol, LDL, C/HDL ratio, and glycosylated hemoglobin (Hbalc). Hypercholesterolemia prevalence was 3/19 in HD and 11/20 in CAPD (p < 0.05). A relationship between Hbalc and C/HDL ratio was found in the CAPD group (r = 0.48; p < 0.05). We are greatly concerned about these metabolic effects of CAPD; therefore, we should carefully select patients to be treated by CAPD. Aggressive nutritional and pharmacological treatment for glucose intolerance and hypercholesterolemia in CAPD patients must be performed in order to reduce the incidence of coronary artery disease (CAD).

Dialysis for the elderly: survival and risk factors.

We evaluated survival and risk factors in 86 elderly patients (pts) who underwent dialysis at one center throughout the last 10 years. Thirty-five pts received hemodialysis (HD), 32 intermittent peritoneal dialysis (IPD), and 19 continuous peritoneal dialysis (CAPD). Risk factors included: treatment, age, sex, underlying disease, heart failure (HF), peripheral vascular disease (PVD), diabetes mellitus (DM) and malignancy. Median age was 65 years for both HD and CAPD, and 69 for IPD (p less than 0.05). Survival evaluation demonstrated a longer life span for HD vs. IPD (p = 0.02) for CAPD vs. IPD (p = 0.03) and no difference between HD and CAPD pts. Cox analysis showed higher death odds ratio (OR = 2.4) for IPD vs. HD and lower ratio for CAPD vs. IPD (OR = 0.3). Other OR positive risk factors were: HF, PVD, DM and malignancy. The median value of risk factors for each group was higher for both IPD and CAPD vs. HD. Both life span and death OR for CAPD were equal to HD in spite of higher risk factors in CAPD group. The lower survival of the IPD group may be due to its older age. CAPD should represent the elective treatment for elderly uremics while HD or IPD should be reserved for selected patients.

[Central vascular access: rational and results]. / I cateteri venosi centrali modello Tesio: razionale e risultati.

Central venous catheterization for hemodialysis using double cannula has become the preferred central vascular form in acute cases. Moreover, in chronic cases, this form of vascular access has replaced the internal arterio-venous fistula whenever the latter is difficult to realize, or when patient's cardio-circulatory condition would discourage its creation. The central vascular access presents frequent complications, compromising their efficiency and duration. Tesio's central venous catheters were thoroughly studied and manufactured to overcome these complications, allowing a long life span of the vascular access. In this study 108 patients with Tesio's internal jugular central venous catheters were followed-up in the period 1990 to 1994. All patients underwent hemodialysis in Pordenone Center. Central venous access survival fluctuated between 93% and 82% in the first year and the fifth year respectively. However, access survival dropped to 32% after seven years. The accurate choice of the catheters' manufacturing material as well as the correct technical positioning has determined a significant increase in the vascular access survival, thanks to the important decrease in prevalence and seriousness of complications. We believe that the decreased accuracy in catheter management over time is the major cause of delayed loss of the central vascular access.

Cesarean section during ECMO support.

This article presents the case of a pregnant woman affected by A/H1N1 flu progressed to ARDS requiring rescue therapy by VV ECMO. Due to the early gestational age, the patient was placed on ECMO before delivery. Four weeks after VV-ECMO placement, a Cesarean section was successfully performed while on ECMO support. One week after delivery, the patient was weaned from ECMO and at 8 weeks from admission she was discharged home without O2 support. The newborn is alive and was discharged at 40 days of age on neurological follow-up.

[Leptospirosis: epidemiology, diagnosis and clinical aspects] / Leptospirosi: aspetti epidemiologici, diagnostici e clinici.

Leptospires, world-wide distributed spirochetes, affect a great variety of mammalian hosts; several serovars belonging to the L. interrogans s.l. species can cause clinical manifestations in humans, becoming infected through the contact of skin cuts and mucous membranes with water and soil polluted by infected animals' urine; rodents serve as the main reservoirs but the epidemiological importance of pets and cattle, as leptospire shedder is increasing. While the infection remains endemic in tropical regions, there is a new epidemiological trend in developed countries where, with the typical seasonal pattern, sporadic cases and/or outbreaks occur related more to recreational activities and poor sanitation than to occupational activities. The sudden onset presents a "flu-like" syndrome; the course is usually characterised by two clearly defined stages. All of the variable clinical manifestations, often independent of the responsible serovar, arise from the effects of a general vasculitis. The prognostic factors associated with severe forms (renal failure, jaundice, haemorrhagies) are not defined. Within the first days of illness, the leptospires can be isolated from blood and cerebrospinal fluid; serological diagnosis relies on microagglutination, IFA and ELISA; PCR early in the course, before the appearance of specific antibodies, allows etiological diagnosis. Prompt treatment has an enormous impact on outcome.

Clinical survey of Leishmania/HIV co-infection in Catania, Italy: the impact of highly active antiretroviral therapy (HAART).

The clinical and parasitological features of visceral leishmaniasis (VL) were investigated, retrospectively, in 27 HIV-infected patients who attended the out-patient clinic of Catania University's Department of Infectious Diseases between 1990 and 1998. The aim was to evaluate the epidemiological, clinical, therapeutic and prognostic characteristics of the co-infection, to determine if there were any interactions between the two infections, and to see if the use of highly active antiretroviral therapy (HAART) had any impact on the leishmaniasis. The most dramatic observation was a marked, HAART-attributable reduction in the annual incidence of VL relapses among the patients.

Rheological abnormalities of erythrocyte deformability and increased glycosylation of hemoglobin in the nephrotic syndrome.

This report is an attempt to gain more complete knowledge of the causes of the tendency to thrombosis in the nephrotic syndrome. Our purpose was to detect some rheological abnormalities in a group of nephrotic patients having normal renal function. Plasma and blood viscosity, erythrocyte filtration flow (EFF) and some indices of the carbohydrate metabolic state (glycosylated hemoglobin A1c; HbA1c, fasting glycemia and oral glucose tolerance test) were investigated in 10 patients with newly diagnosed primary nephrotic syndrome and 10 healthy subjects. EFF was determined in order to avoid variables depending upon plasma, white cells and hematocrit. The mean level of HbA1c was higher in the nephrotic group, in which we found 4 patients with impaired glucose tolerance according to the criteria of the National Diabetes Data Group. EFF was lower in nephrotic patients than in controls and correlated inversely with HbA1c. These findings indicate that nephrotic patients have a reduced red cell deformability which seems to be related to the abnormal carbohydrate metabolism commonly observed in this syndrome.

Torulopsis glabrata peritonitis complicating continuous ambulatory peritoneal dialysis: successful management with oral 5-fluorocytosine.

We report two cases of fungal peritonitis caused by Torulopsis glabrata, an uncommon opportunistic pathogen, in patients with end-stage renal disease receiving continuous ambulatory peritoneal dialysis (CAPD). The general clinical characteristic of T glabrata peritonitis was comparable to previously reported cases of Candida peritonitis. Although appropriate therapy of fungal peritonitis in patients undergoing CAPD still remains controversial, both for the drug of choice and for the dosage to be used, our study indicates that a 5-week course of oral 5-fluorocytosine (5-FC) may obviate the need to remove the peritoneal catheter during the management of peritonitis caused by susceptible strains of T glabrata.

Source and route of microbial colonisation of parenteral nutrition catheters.

To assess the effectiveness of tunnelling the polyurethane venous catheter for parenteral nutrition in reducing the frequency of catheter microbial colonisation, and to investigate the routes taken by microorganisms colonising the central venous catheter, 109 patients were randomised to traditional subclavian catheterisation (58, group A) or to subcutaneous catheter tunnelling (51, group B). Samples were taken from patients and their nurse attendants to identify their indigenous flora. Cultures were also done of swabs from the catheter insertion site, blood, nutrient solution, segment of the catheter, and washings of the catheter hub. Intravascular segment colonisation was commoner in group A (18/58) than in group B patients (4/51), and bacterial migration from insertion site to intravascular segment was also commoner among group A (9/58) than among group B patients (1/51). Catheter hub contamination was responsible in 10 out of 22 cases of microbial colonisation; in 6 of these 10 the bacterium isolated was present on the skin of nurses who changed the bag. Contamination of the insertion site skin and of the CVC hub were equally responsible for the microbial colonisation of the intravenous segment of the catheter.