Development and validation of a comprehensive model to predict complications after hepatectomy.

OBJECTIVE: Despite advances in perioperative care, hepatectomy remains associated with morbidity rates of up to 40%. Currently, available nomograms for predicting severe post-hepatectomy complications do not include early postoperative data. This retrospective observational study aimed to determine whether the parameters routinely measured in patients admitted to the Intensive Care Unit (ICU) after hepatectomy could represent risk factors for severe morbidity and to propose a nomogram scoring system to predict severe postoperative complications. PATIENTS AND METHODS: 411 adult patients who underwent elective hepatectomy at a high-volume tertiary care center for hepatic surgery from December 2016 to June 2022 were enrolled. The primary outcome was the assessment of predictors of 30-day severe postoperative complications following hepatectomy, defined as Clavien-Dindo grade 3a or higher. As a secondary outcome, we aimed to develop an easy-to-use scoring system to estimate the risk of severe postoperative complications. RESULTS: Severe complications occurred in 78 patients (19%). The final model included body mass index, preoperative bilirubin level, and ICU data (i.e., pH, lactate clearance, arterial lactate concentration 12 hours after ICU admission, need for packed red blood cell transfusions, and length of stay). Notably, the latter three variables were proven to be independent predictors of the outcomes. The model showed an overall good fit (C-index=0.754, corrected Dxy=0.692). A calibration plot using bootstrap internal validity resampling confirmed the stability of the model (mean absolute error=0.017, root mean square error of approximation=0.00051). CONCLUSIONS: We developed an accurate and practical scoring system based on preoperative and early postoperative data to predict poor outcomes after hepatectomy. Further external validation on larger series could lead to the integration of such a tool in the routine clinical practice to support patients' management and early warning during ICU stay. Graphical Abstract: https://www.europeanreview.org/wp/wp-content/uploads/Graphical-Abstract-NEW-2.pdf.

High intraoperative blood product requirements in liver transplantation: risk factors and impact on the outcome.

OBJECTIVE: Liver transplantation (LT) is associated with a significant bleeding and the high transfusion requirements (HTR) negatively affect the outcome of LT patients. Our primary aim was to identify potential predictors of intraoperative transfusion requirements. Secondarily, we investigated, the effect of transfusion requirements on different clinical outcomes, including short-term morbidity and mortality. PATIENTS AND METHODS: Data collected in 219 adult LT from a deceased donor, grouped according to HTR (defined as the need of 5 or more red blood cell units), were compared. RESULTS: We found that previous portal vein thromboses (p=0.0156), hemoglobin (Hb) (p<0.0001), International Normalized Ratio (INR) (p=0.0010) at transplant and veno-venous by-pass (p=0.0048) independently predicted HTR. HTR was always associated with poorer outcomes, including higher simplified acute physiology II score at Intensive Care Unit admission (p=0.0005), higher rates of pulmonary infections (p=0.0015) and early rejection (p=0.0176), longer requirement of mechanical ventilation, (p<0.0001), more frequent need for hemodialysis after transplantation (p=0.0036), overall survival (p=0.0010) and rate of day-90 survival (p=0.0016). CONCLUSIONS: This study identified specific risk factors for HTR and confirmed the negative impact exerted by HTR on clinical outcomes, including recipient survival. Prospective investigations are worth to assess whether correcting pre-transplant Hb and INR levels may effectively reduce blood product need and improve prognosis.

Effects of remifentanil on human C20 microglial pro-inflammatory activation.

OBJECTIVE: Remifentanil (RF) is a potent short-acting µ-opioid receptor agonist. Although preferred for its unique pharmacokinetics, the clinical use may be limited by hyperalgesia. Preclinical studies have shown a potential role of microglia on the development of hyperalgesia, with limited and conflicting evidence on RF. Considering the role of microglia in the initiation and maintenance of brain inflammation and their different responses among species, we aimed at characterizing RF effects on human adult microglia in vitro. MATERIALS AND METHODS: RF was tested at clinically relevant concentrations on the human microglial C20 cell line. Expression and release of interleukin-6 (IL-6) and brain derived neurotrophic factor (BDNF) were assessed under basal and inflammatory conditions. RESULTS: The expression and secretion of IL-6 significantly increased in C20 cells in response to pro-inflammatory cytokines. RF did not modify this response neither under basal nor under inflammatory conditions. No toxicity due to RF was detected. The drug displayed a modest stimulatory effect on the production of BDNF. CONCLUSIONS: Although RF does not exert direct pro-inflammatory actions on human adult microglia, its effects on BDNF, a crucial mediator of pain transmission, suggest a possible role on neuroinflammation and pain perception.

Predictive power of modified frailty index score for pulmonary complications after major abdominal surgery in the elderly: a single centre prospective cohort study.

OBJECTIVE: The primary aim of this prospective cohort study was to evaluate the usefulness of the modified Frailty Index (mFI) score to predict postoperative pulmonary complications (PPCs) in elderly patients undergoing major open abdominal surgery. The secondary purpose was to compare the prediction power of mFI, Ariscat (Assess Respiratory Risk in Surgical Patients in Catalonia), and American Society physical status classification (ASA) scores. PATIENTS AND METHODS: After local Ethical Committee approval, 105 patients aged ≥65 years undergoing open major abdominal surgery were enrolled. Clinical data were compared between patients with or without PPCs (including respiratory failure, aspiration pneumonia, pulmonary infection, pleural effusion, pneumothorax, atelectasis, bronchospasm or un-planned re-intubation). t-test or χ2-test were performed for univariate analyses. Logistic regression analysis was used to identify independent predictors of PPCs. Non parametric ROC (Receiver Operating Characteristic) was used for cut-off calculation. AUCs (areas under ROC curve) of preoperative scores were compared using χ2-test. RESULTS: PPCs prevalence (11.3%) was associated with increased mFI, ASA, and Ariscat scores, greater age, hemoglobin levels <10 g/dl, peripheral oxygen saturation <95% (p=0.0001) and longer surgery duration. Logistic regression showed that mFI (p=0.0001) and Ariscat (p=0.04) were independent predictors of PPCs. The predictive power of mFI (AUC=0.90) was similar to that of Ariscat (AUC=0.81) (χ2=2.53; p=0.11) but greater than that of ASA (AUC=0.69) (χ2=9.85; p=0.002). An mFI≥0.18 was predictive of PPCs (sensitivity=90.91%; specificity=79.07%). An Ariscat score of 27 was the cut-off identified as determining factor for PPCs occurrence (sensitivity=90.91%; specificity=51.16%). CONCLUSIONS: Elderly patients with an mFI ≥0.18 and/or an Ariscat score ≥27 were at higher risk of PPCs after open major abdominal surgery. More attention should be paid to these patients by implementing both strict monitoring and strategies for PPCs prevention in the perioperative period.

Hyperthermic intrathoracic chemotherapy combined to iterative cytoreductive surgery to treat a pleural carcinosis from psudomixoma peritonei. A case report.

Pseudomyxoma peritonei (PMP) is an uncommon disease with locally-invasive attitude. Intrathoracic spread is rarely reported and its management extremely challenging. A 51-year-old Caucasian female presented with left pleural carcinosis 9-months after two sequential abdominal surgical procedures combined with HIPEC for low-grade PMP. Cytoreductive surgery (pleurectomy/decortication) was followed by 60-minutes hyperthermic intrathoracic chemotherapy mitomycin-C (215 mg/m2) infusing at same temperature (42°C) and intrapleural pression (2-4 mmH2O). No intra-operative complication occurred, the post-op stay was uneventful and no sign of recurrence was observed 9-months after surgery. Cytoreductive thoracic surgery and hyperthermic chemotherapy (HITHOC) could be a feasible therapeutic option in very selected cases.

Psychological, emotional and social impairments are associated with adherence and healthcare spending in type 2 diabetic patients: an observational study.

OBJECTIVE: The aim of the present study was to assess the association among anxiety, depression, stress, social support and emotional abilities with adherence and healthcare spending in type 2 diabetic patients. PATIENTS AND METHODS: Sixty-four patients were enrolled and completed: Interpersonal Processes of Care (IPC), 20-item Toronto Alexithymia Scale (TAS-20), Rapid Stress Assessment Scale (RSAS), Morisky Medication Adherence Scale (MMAS-4), International Physical Activity Questionnaire (IPAQ)-Short Form and a socio-anamnestic questionnaire regarding also the healthcare spending. RESULTS: Mathematical linear regressions models were performed showing the predictive effects of: anxiety and social support scores (RSAS) on adherence levels (respectively p =. 019; p =. 016); adherence levels on anxiolytic use (p =.04); aggressiveness scores (RSAS) on the number of general check-ups (p =.031); TAS-20 and physician-patient communication (IPC) on the number of hospitalization days (respectively p=.001; p=.008); physician patient decision making (IPC) scores on physical activity (IPAQ) levels (p=.025); physical activity (IPAQ) on the number of medical examinations (p=.039). CONCLUSIONS: An association among psychosocial impairment, adherence and healthcare spending was found. Future studies should investigate the effect of a brief psychological intervention in increasing adherence levels and reducing the healthcare spending in this clinical population.

Socio-emotional ability, temperament and coping strategies associated with different use of Internet in Internet addiction.

OBJECTIVE: The aim of the present study was to compare socio-emotional patterns, temperamental traits, and coping strategies, between a group of Internet addiction (IA) patients and a control group. PATIENTS AND METHODS: Twenty-five IA patients and twenty-six healthy matched subjects were tested on IA, temperament, coping strategies, alexithymia and attachment dimensions. Participants reported their prevalent Internet use (online pornography, social networks, online games). RESULTS: The IA patients using Internet for gaming online showed a greater attitude to novelty seeking and a lower tendency to use socio-emotional support and self-distraction compared to patients using Internet for social networking. Moreover, they showed a lower level of acceptance than patients using Internet for pornography. In the control group, the participants using Internet for online gaming showed higher levels of IA, emotional impairments and social alienation compared to social-networks and pornography users. CONCLUSIONS: Findings showed a higher psychological impairment in gaming online users compared to social networking and online pornography users.

Role of surgical setting and patients-related factors in predicting the occurrence of postoperative pulmonary complications after abdominal surgery.

OBJECTIVE: The aim of this retrospective study was to evaluate the role of surgical setting (urgent vs. elective) and approach (open vs. laparoscopic) in affecting postoperative pulmonary complications (PPCs) prevalence in patients undergoing abdominal surgery. PATIENTS AND METHODS: After local Ethical Committee approval, 409 patients who had undergone abdominal surgery between January and December 2014 were included in the final analysis. PPCs were defined as the development of one of the following new findings: respiratory failure, pulmonary infection, aspiration pneumonia, pleural effusion, pneumothorax, atelectasis on chest X-ray, bronchospasm or un-planned urgent re-intubation. RESULTS: PPCs prevalence was greater in urgent (33%) vs. elective setting (7%) (χ2 with Yates correction: 44; p=0.0001) and in open (6%) vs. laparoscopic approach (1.9%) (χ2 with Yates correction: 12; p=0.0006). PPCs occurrence was positively correlated with in-hospital mortality (Biserial Correlation r=0.37; p=0.0001). Logistic regression showed that urgent setting (p=0.000), Ariscat (Assess Respiratory Risk in Surgical Patients in Catalonia) score (p=0.004), and age (p=0.01) were predictors of PPCs. A cut-off of 23 for Ariscat score was also identified as determining factor for PPCs occurrence with 94% sensitivity and 29% specificity. CONCLUSIONS: Patients undergoing abdominal surgery in an urgent setting were exposed to a higher risk of PPCs compared to patients scheduled for elective procedures. Ariscat score fitted with PPCs prevalence and older patients were exposed to a higher risk of PPCs. Prospective studies are needed to confirm these results.

Psychological impairments burden and spirituality in caregivers of terminally ill cancer patients.

The role of spirituality on the psychological health was mostly investigated through studies conducted in terminally ill patients. However, there are not studies investigating the role of religious and spiritual beliefs on psychological state and on burden dimensions in caregivers. The purpose of this study was to investigate the association between spirituality, burden, and psychological state in caregivers of terminally ill cancer patients. Two hundred caregivers of terminally ill patients with cancer were interviewed using Prolonged Grief Disorder 12 (PG-12), Hamilton Anxiety Rating Scale (HAM-A), Hamilton Depression Scale (HAM-D), Caregiver Burden Inventory (CBI) and System of Belief Inventory (SBI-15R). The caregiver burden was positively correlated with anxiety, depression and PG-12 scores. The intrinsic spirituality was a significant predictor of the time-dependence burden (positively associated); and of the emotional burden (negatively associated). In caregivers of terminally ill cancer patients, higher levels of intrinsic spirituality predicted a higher amount of time devote to caregiving, and also protected against the emotional distress linked to providing assistance.

Relationship between blood remifentanil concentration and stress hormone levels during pneumoperitoneum in patients undergoing laparoscopic cholecystectomy.

OBJECTIVE: The effect of remifentanil on stress response to surgery is unclear. However, there are not clinical studies investigating the relationship between blood remifentanil concentrations and stress hormones. Therefore, the aim of the present study was to assess the association between blood remifentanil concentrations measured after pneumoperitoneum and cortisol (CORT) or prolactin (PRL) ratio (intraoperative/preoperative value), in patients undergoing laparoscopic cholecystectomy. PATIENTS AND METHODS: Patients did not receive any pre-anesthetic medication. Anesthesia induction was standardized. Anesthesia maintenance was performed with inhaled sevoflurane at age-adjusted 1.0 minimum alveolar concentration and intravenous remifentanil at infusion rate ranging from 0.1 to 0.4 mcg/kg/min. Blood samples were withdrawn before anesthesia induction and 5 min after achieving a pneumoperitoneum pressure of 12 mmHg. Correlation analyses were performed to evaluate the relationship between measured blood remifentanil concentrations, CORT or PRL ratio (intraoperative/preoperative value) and remifentanil dose delivered by the pump. RESULTS: A significant inverse correlation was found between CORT ratio and measured blood remifentanil concentration (p=0.03) or planned remifentanil dose (p=0.04). No correlations were found between blood remifentanil concentration and PRL ratio (p=0.83). CONCLUSIONS: Our data suggest that the CORT response to surgical stress is more efficiently counteracted by increased blood remifentanil concentration.

Anaesthesiological strategies to improve outcome in liver transplantation recipients.

Graft and patients survival are the main goal of anesthesiological management in patients undergoing liver transplantation (LT). Even if anesthesiological practice sustained major developments over time, some evidence-based intraoperative strategies have not yet been widely applied. The aim of this review was to summarize intraoperative anesthesiological strategies which could have the potential to improve LT graft and/or recipient survival. Monitoring must be as accurate as possible in order to manage intraoperative hemodynamic changes. The pulmonary artery catheter still represents the more reliable method to monitor cardiac output by using the intermittent bolus thermodilution technique. Minimally invasive hemodynamic monitoring devices may be considered only in stable cirrhotic patients. Goal-directed fluid-therapy has not yet defined for LT, but it could have a role in optimizing the long-term sequelae associated with volume depletion or overload. The use of vasopressor may affect LT recipient's outcome, by preventing prolonged hypotension, decreasing blood products transfusion and counteracting hepato-renal syndrome. The use of viscoelastic point of care is also warranted in order to reduce blood products requirements. Decreasing mechanical ventilation time, when it is feasible, may considerably improve survival. Finally, monitoring the depth of anesthesia when integrated into an early extubation protocol might have a positive effect on graft function.

Externally Oriented Thinking Predicts Phosphorus Levels in Dialyzed Patients.

BACKGROUND: The aim of the present study was to investigate the association between alexithymia scores and biological markers of adherence in dialyzed patients. The hypothesis was that higher scores of alexithymia would be associated with lower adherence to treatment. METHODS: Fifty-four adult dialyzed patients were enrolled during a follow-up visit. Participants were asked to complete a self-report questionnaire, namely, the Toronto Alexithymia Scale (TAS-20). Moreover, biological markers levels of adherence to treatment (phosphorus, creatinine, and serum uric acid) were measured. RESULTS: A positive correlation was found between phosphorous levels and TAS-F2 (r = 0.28; P = .04) and TAS-F3 (r = -0.31; P = .02). Stepwise regression with TAS-F2 and TAS-F3 as predictors of adherence to treatment showed a significant model, adjusted R(2) = 0.08, F(1,52) = 5.4; P < .02, where only TAS-F3 was able to predict phosphorous levels (P = .02). CONCLUSIONS: Findings showed that external oriented thinking was able to predict a biological marker of adherence to treatment in dialyzed patients.

Minimum alveolar concentration threshold of sevoflurane for postoperative dream recall.

BACKGROUND: Many factors affect postoperative dream recall, including patient characteristics, type of anesthesia, timing of postoperative interview and stress hormone secretion. Aims of the study were to determine whether Bispectral Index (BIS)-guided anesthesia might decrease sevoflurane minimum alveolar concentration (MAC) when compared with hemodynamically-guided anesthesia, and to search for a MAC threshold useful for preventing arousal, dream recall and implicit memory. METHODS: One hundred thirty patients undergoing elective thyroidectomy were enrolled. Anesthesia was induced with propofol 2 mg kg(-1), fentanyl 3 mcg kg(-1) and cis-atracurium 0.15 mg kg(-1). For anesthesia maintenance, patients were randomly assigned to one of two groups: a BIS-guided group in which sevoflurane MAC was adjusted on the basis of BIS values, and a hemodynamic parameters (HP)-guided group in which MAC was adjusted based on HP. An auditory recording was presented to patients during anesthesia maintenance. Dream recall and explicit/implicit memory were investigated upon awakening and approximately after 24 h. RESULTS: Mean sevoflurane MAC during auditory presentation was similar in the two groups (0.85 ± 0.16 and 0.87 ± 0.17 [P = 0.53] in BIS-guided and HP-guided groups, respectively). Frequency of dream recall was similar in the two groups: 27% (N. = 17) in BIS-guided group, 18% (N. = 12) in HP-guided group, P = 0.37. In both groups, dream recall was less probable in patients anesthetized with MAC values ≥ 0.9 (area under ROC curve = 0.83, sensitivity = 90%, and specificity = 49%). CONCLUSION: BIS-guided anesthesia was not able to generate different MAC values compared to HP-guided anesthesia. Independent of the guide used for anesthesia, a sevoflurane MAC over 0.9 was required to prevent postoperative dream recall.

Behavioural, psychological, and temperamental predictors of risk suicide trend after brief psychodynamic psychotherapy.

BACKGROUND: Evidence has shown that psychotherapy is effective for depression, whereas the outcome for suicide risk is unclear. AIM: It was to investigate whether possible pre-treatment predictors of suicide risk (SR) decrease after a brief psychodynamic psychotherapy treatment and at follow-up. PATIENTS AND METHODS: Forty-one patients were assessed at: baseline (T0) for clinical history, clinical family history, physical diseases, type of suffered abuse; after the treatment (T1); and, at six-month follow-up (T2) for mood ratings, temperamental features, and SR levels. RESULTS: The levels of depression and cyclothymia decreased at T1 and T2 compared to T0; however, the distribution of the patients with high SR level was similar between T0 and T1, and at T2 it increased. T1-T0 SR (Δ1SR) was correlated with suicidality in the last month and with depression levels at T0; T2-T0 SR (Δ2SR) was correlated with many historical, clinical, and temperamental variables; T2-T1 SR (Δ3SR) was correlated with the presence of previous psychotherapy, abuse, and anxiety. Linear regression models revealed that Δ1SR was predicted by the suicidality in the last month; Δ2SR was not significantly predicted by any variable; and, Δ3SR was predicted by anxiety. CONCLUSIONS: The treatment was able to decrease the depression but not the SR. Findings confirm the difficulty of affecting SR and the importance of carefully considering the anxiety and the previous experiences of abuse in order to manage the interruption of the psychotherapy.

Uricemia and homocysteinemia: nontraditional risk factors in the early stages of chronic kidney disease--preliminary data.

BACKGROUND: Patients with chronic kidney disease (CKD) show a risk of cardiovascular death, which is 10-100 times higher than that in the general population. This increase is not completely explained by the traditional cardiovascular risk factors. Hyperuricemia and hyperhomocysteinemia are highly prevalent in CKD. Patients suffering from these complications present accelerated atherosclerosis, determined mainly from the endothelial dysfunction that carries out a central role in the pathogenesis of cardiovascular diseases. AIM: The hypothesis was that brachial artery flow mediated dilation (FMD) and carotid intima-media thickness (cIMT) evaluation can be considered as early and systemic markers of atherosclerosis and that nontraditional risk factors, such as hyperhomocysteinemia and hyperuricemia, are associated with early endothelial dysfunction and vascular damage in patients suffering from first- and second-stage CKD. PATIENTS AND METHODS: The study comprised 50 patients, 10 for each CKD stage, and 15 age- and sex-matched healthy controls. We compared the traditional and nontraditional factors for cardiovascular diseases with alterations of vascular reactivity, such as cIMT, and brachial artery FMD, in patients affected by CKD with those in the control group. RESULTS: In our study, hyperuricemia was significantly and independently associated with brachial artery FMD reduction (p = 0.007), while hyperhomocysteinemia was significantly and independently associated with carotid intima-media thickening (p = 0.021) in patients at Stage I and II KDOQI (Kidney Disease Outcomes Quality Initiative). CONCLUSIONS: In our study, we found a progressive increase in the inflammatory indices and endothelial dysfunction at the early stages of CKD. Hyperuricemia and hyperhomocysteinemia were associated with IMT and FMD at Stage I-III KDOQI, and can be used as markers of subclinical atherosclerosis, especially in nephropathic patients with high cardiovascular risk.

Stress-related biomarkers of dream recall and implicit memory under anaesthesia.

The aim of this study was to investigate whether auditory presentation of a story during general anaesthesia might influence stress hormone changes and thus affecting dream recall and/or implicit memory. One hundred and ten patients were randomly assigned either to hear a recording of a story through headphones or to have routine care with no auditory recording while undergoing laparoscopic cholecystectomy. Anaesthesia was standardised. Blood samples for cortisol and prolactin assays were collected 20 min before anaesthesia and 5 min after pneumoperitoneum. Dream recall and explicit/implicit memory were investigated upon awakening from anaesthesia and approximately 24 h after the end of the operation. Auditory presentation was associated with lower intra-operative serum prolactin concentration compared with control (p = 0.0006). Twenty-seven patients with recall of dreaming showed higher intra-operative prolactin (p = 0.004) and lower cortisol (p = 0.03) concentrations compared with those without dream recall. The knowledge of this interaction might be useful in the quest to ensure postoperative amnesia.

Update on post-traumatic stress syndrome after anesthesia.

BACKGROUND: Between 0.5% and 2% of surgical patients undergoing general anesthesia may experience awareness with explicit recall. These patients are at a risk for developing anxiety symptoms which may be transient or can lead to post-traumatic stress disorder (PTSD). AIM: The aim of this review was to assess the prevalence of PTSD after intraoperative awareness episodes and analyze patients' complaints, type and timing of assessment used. METHODS: PubMed, MEDLINE and The Cochrane Library were searched up until October 2012. Prospective and retrospective studies on human adult subjects describing prevalence of PTSD and/or psychological sequalae after awareness episodes were included. RESULTS: Seven studies were identified. Prevalence of PTSD ranged from 0 to 71%. Acute emotions such as fear, panic, inability to communicate and feeling of helplessness were the only patients' complaints that were significantly correlated to psychological sequelae including PTDS. There were cases that reported psychological symptoms after 2-6 hours from awakening (%) or 30 days after (%). Previous studies used psychological scales lacking of dissociation assessment. CONCLUSIONS: Whenever an awareness episode is suspected, a psychological assessment with at least three interviews at 2-6 h, 2-36 h and 30 days must be performed in order to collect symptoms associated with both early and delayed retrieval of traumatic event. As a dissociative state could hide the expression of reactive symptoms after intraoperative awareness, future studies should be focused on detecting dissociative symptoms in order to carry out a prompt and appropriate treatment aimed at avoiding long-term psychological disability.

Low values of left ventricular ejection time in the post-anhepatic phase may be associated with occurrence of primary graft dysfunction after orthotopic liver transplantation: results of a single-centre case-control study.

BACKGROUND: Previous investigations on risk factors for orthotopic liver transplantation (OLT) surgery have not analyzed hemodynamic aberrations in great detail. Moreover, the usefulness of esophageal Doppler monitoring has not been extensively studied in this clinical setting. The aim of this study was to evaluate if the occurrence of primary graft dysfunction (PGD) may be anticipated by hemodynamic indexes measured by esophageal Doppler (ED) monitoring system as well as by pulmonary artery catheter (PAC) in patients undergoing OLT. MATERIALS AND METHODS: 38 OLT recipients were studied. Patients with acute liver failure or having non treated esophageal varices and those transplanted with marginal donors were excluded from the study. The haemodynamic data - measured by ED monitoring system (HemosonicTM 100, Arrow, OK, USA) and PAC - collected at the following 3 time points were considered for statistical analysis: 30 minutes after the induction of anesthesia but before skin incision, T0; 20 minutes after liver dissection, T1; at the beginning of biliary reconstruction, T2. On the basis of early outcome (72 hours after OLT), patients were distinguished into two groups: those with PGD (grade III-IV of Toronto classification) and those without PGD (grade I-II). RESULTS: LVETc (left ventricular ejection time) values, registered at the beginning of biliary reconstruction (T2), were lower in patients with PGD compared to those without PGD (p < 0.000), while there were no differences in hemodynamic parameters derived from PAC between the two groups. CONCLUSIONS: Since LVETc is related to preload, the results of this study would suggest that normovolemia could be the end point of a fluid replacement strategy in OLT setting.

Psychological risk factors for graft rejection among liver transplant recipients.

The purpose of this prospective study was to find psychological risk factors predicting acute, chronic, and psychological rejection in patients undergoing liver transplantation using Cognitive Behavioural Assessment (CBA-2.0). The primary scale included an assessment of fears, personality, obsessive-compulsive symptoms, state and trait anxiety, psychological reactions, and depression. We prospectively recruited 44 patients undergoing orthotopic liver transplantation (OLT). Exclusion criteria were: education level below secondary school, unstable clinical situation in an out-patient setting, fulminant hepatitis, psychotic disorders, neurocognitive deficits, dementia, serious mental retardation, current alcohol or drug abuse, recent ideation of or attempted suicide, and non-adherence to therapy. CBA-2.0 primary scale series of questionnaires were handed out to patients immediately after the medical examination, which had been performed to ascertain eligibility for OLT. Rejection (acute and/or chronic) was diagnosed according to clinical and histopathological criteria. Psychological rejection was diagnosed when patients declared, after transplantation, a refusal of the new organ which caused psychiatric symptoms requiring medical treatment and/or psychotherapy. Analysis of variance and logistic regression of psychological variables was performed to detect possible risk factors for each type of rejection. A greater fear of repulsive animals was able a predictor for an acute rejection episode (odds ratio=1.1; P<.05). No other psychological pretransplant predictor was noted for chronic or psychological rejection. In patients undergoing OLT, preoperative emotions of fear could predict an acute graft rejection episode. These findings imply that pre-OLT screening should include psychological factors in addition to traditional medical criteria with intervention in selected cases.

Preoperative psychological factors predicting graft rejection in patients undergoing kidney transplant: a pilot study.

BACKGROUND: The aim of this study was to investigate whether pretransplant psychological variables included in the CBA 2.0 Primary Scale-fear, personality, obsessive-compulsive symptoms, state and trait anxiety, psychological reactions, and depression-could predict graft rejection among patients undergoing kidney transplantation. METHODS: After ethical committee approval we enrolled 33 consecutive adult patients undergoing kidney transplantation. The inclusion criteria were a stable clinical situation in an out-of-hospital setting; Italian language literacy; a minimum of secondary school-level education, and written informed consent. We excluded patients with a psychotic disturbance, neurocognitive deficit, dementia, serious mental delay (IQ <50), current alcohol or drug abuse, recent ideation or attempted suicide or nonadherence to the therapeutic protocol. Acute and/or chronic graft rejection was diagnosed according to clinical and histopathologic criteria. CBA-2,0 "Primary Scale" series of questionnaires were handed out to patients at the time of the examinations to discrem eligibility for transplantation. Analyses of variance were performed to compare psychological scores among patients with versus without graft rejection. Logistic regression analyses of psychological variables were performed to detect possible predictors for graft rejection. The results of the analysis showed that higher psychoticism scores were able to predict graft rejection (P<.05). RESULTS: The findings of this study suggest that it is mandatory to preoperatively plan an holistic treatment including psychological intervention mainly focused on psychoticism.