Systematic review with meta-analysis: de novo non-alcoholic fatty liver disease in liver-transplanted patients.

BACKGROUND: De novo non-alcoholic fatty liver disease (NAFLD) in liver-transplanted patients for cirrhosis not due to non-alcoholic steatohepatitis (NASH) is becoming a growing phenomenon. AIMS: We performed a systematic review and evaluated the prevalence of this event and possible associated factors. METHODS: A literature search in medical databases (PubMed, MEDLINE/OVIDSP, Science Direct and EMBASE) was performed in March 2017. Relevant publications were identified in most important databases. We estimated the pooled prevalence of NAFLD and NASH in patients with liver transplant. The data have been expressed as proportions/percentages, and 95% confidence intervals (CI) were calculated, using the inverse variance method. Odd ratios (OR) and 95% confidence intervals (95% CI) were estimated. RESULTS: Twelve studies were selected, enrolling 2166 subjects overall undergoing post-liver transplant biopsy. The pooled weighted prevalence of de novo NAFLD was 26% (95% CI 20%-31%). The pooled weighted prevalence of NASH was 2% (95% CI 0%-3%). The highest prevalences of de novo NAFLD were found for patients transplanted for alcoholic cirrhosis (37%) and cryptogenic cirrhosis (35%) and for patients taking tacrolimus (26%). Tacrolimus showed a risk of NAFLD similar to ciclosporin (OR = 1.02, 95% CI 0.3-3.51). CONCLUSIONS: Patients undergoing liver transplant are more prone to experience diabetes, hypertension or dyslipidaemia, and NAFLD may be an important element in this context. In this study, we show how the prevalence of NASH tends to remain significant and similar to the general population. Moreover, this study suggests a possible association with specific transplant indications. Further studies are required to confirm these findings.

Systematic review with meta-analysis: post-operative complications and mortality risk in liver transplant candidates with obesity.

BACKGROUND: International guidelines rate class III (morbid) obesity (body mass index [BMI]≥40 kg/m2 ) as a relative contraindication for liver transplantation (LT) requiring further research. Moreover, data on the mortality risk in candidates with a BMI: 30-34.9 and 35-39.9 kg/m2 (class I and class II obesity, respectively) are weak. AIM: To compare post-operative complications and mortality risks in all obese candidates vs candidates with a BMI: 18.5-29.9 (normal/overweight) assumed as controls. METHODS: We searched the Cochrane library, PubMed, Scopus, Web-of-Science and article reference lists, restricted to the English language, and selected cohort studies analysing the following outcomes: all-causes mortality (at 30 days, 1-2-3-5 years), post-operative and cardiopulmonary complications, hospital and intensive care unit (ICU) length of stay. Two reviewers independently extracted the studies data and a third one resolved discrepancies. RESULTS: Twenty-four studies comprising 132 162 patients met the inclusion criteria. As compared to controls, mortality risk was increased at all time-periods (except at 3 years) for a BMI≥40, at 30 days for a BMI: 30-34.9 and in none of the considered time-periods for a BMI: 35-39.9. Post-operative complications were significantly higher for a BMI>30 and 30-34.9. Due to the shortage/absence of data, we evaluated cardiopulmonary complications, hospital and ICU length of stay only in the BMI≥30 category. In these patients, only cardiopulmonary complications were increased as compared to controls. CONCLUSIONS: Morbid obesity has an impact on patients' survival after LT. However, since even a BMI>30 increases post-transplant complications, new strategies should be included in the LT programme to favour weight loss in all obese candidates.

Small intestinal bacterial overgrowth and celiac disease: A systematic review with pooled-data analysis.

BACKGROUND: A link between small intestinal bacterial overgrowth (SIBO) and celiac disease (CD) has been hypothesized. METHODS: Literature search was performed in main medical databases. Methods of analysis/inclusion criteria were based on Preferred Reporting Items for Systematic reviews and Meta-Analyses recommendations. The end-point was to estimate, by a pooled-data analysis, SIBO prevalence in CD. Proportions/percentages and their 95% confidence intervals (CI) were calculated by inverse variance method, whereas odd ratios (OR) and their 95% CI were estimated, where available, based on the Mantel-Haenszel method. Data were entered into the RevMan 5.3 software. KEY RESULTS: Eleven articles fulfilled considered criteria. The pooled mean prevalence of SIBO in CD was 20% (95% CI of 10%-30%). In comparison to asymptomatic controls, CD was associated to higher risk of SIBO, with an OR of 10.52 (95% CI 2.69-41.21, P=.0007). Jejunal aspirate culture assessed SIBO prevalence of 11% (95% CI 3%-19%) in CD, whereas breath tests detected a higher value (23%, 95% CI 10%-37%). The pooled prevalence of SIBO in CD patients who were symptomatic despite a GFD was 28% (95% CI 10%-47%), higher than in asymptomatic celiac patients (pooled prevalence of 10%, with a 95% CI of 3%-16%), despite not statistically significant (P=.06). When GFD-unresponsive CD was defined only by clinical persistence of symptoms, the prevalence of SIBO was higher than in the case of villous atrophy association (31% vs 16% P=.33). CONCLUSIONS: The heterogeneity of available studies may not support a relationship SIBO-CD. Nevertheless, SIBO could be more common in CD when symptoms do not improve after GFD.

Recommendations for the diagnosis of pediatric tuberculosis.

Tuberculosis (TB) is still the world's second most frequent cause of death due to infectious diseases after HIV infection, and this has aroused greater interest in identifying and managing exposed subjects, whether they are simply infected or have developed one of the clinical variants of the disease. Unfortunately, not even the latest laboratory techniques are always successful in identifying affected children because they are more likely to have negative cultures and tuberculin skin test results, equivocal chest X-ray findings, and atypical clinical manifestations than adults. Furthermore, they are at greater risk of progressing from infection to active disease, particularly if they are very young. Consequently, pediatricians have to use different diagnostic strategies that specifically address the needs of children. This document describes the recommendations of a group of scientific societies concerning the signs and symptoms suggesting pediatric TB, and the diagnostic approach towards children with suspected disease.

Sequential vs. prolonged 14-day triple therapy for Helicobacter pylori eradication: the meta-analysis may be influenced by 'geographical weighting'.

BACKGROUND: Sequential therapy is a first-line regimen obtaining satisfactory Helicobacter pylori eradication. Triple therapy prolongation improves the success rate even if a recent meta-analysis showed satisfying results only for the 14-day regimen. Studies from Africa and North America were unavailable in previous meta-analyses. AIM: To perform a meta-analysis comparing sequential vs. prolonged 14-day triple therapy with regard to 'geographic weighting' by considering subgroups analysis according to metronidazole/clarithromycin low and high resistance areas. METHODS: Based on PRISMA recommendations, we considered all first-line clinical studies from 2003 to November 2014. Randomised clinical trials (RCTs) were included by a search on PubMed, MEDLINE, Science Direct, EMBASE. Data on eradication rates were expressed as ITT. Risk ratio (RR), pooled RR and 95% confidence intervals were calculated by the Mantel-Haenszel method. Data were entered into RevMan 5.2 software (Nordic Cochrane Centre) using a random-effects model. RESULTS: Databases identified 194 studies; seven met the inclusion criteria. Overall results showed a similar effectiveness of the two regimens considered (RR = 0.99; 95% CI = 0.94-1.05; p = 0.75). In areas with high resistance to clarithromycin, sequential was superior to 14-day triple therapy (RR = 0.95; 95% CI = 0.90-1.00; p = 0.03). In areas with high metronidazole resistance, sequential and 14-day triple therapy were equivalent (RR = 0.99; 95% CI = 0.91-1.08; p = 0.82). CONCLUSIONS: 'Geographic weighting' could be the main factor affecting the lack of differences between sequential and 14-day triple therapy outcomes.

A tool for measuring the bending length in thin wires.

Great effort is currently being put into the development and construction of the second generation, advanced gravitational wave detectors, Advanced Virgo and Advanced LIGO. The development of new low thermal noise suspensions of mirrors, based on the experience gained in the previous experiments, is part of this task. Quasi-monolithic suspensions with fused silica wires avoid the problem of rubbing friction introduced by steel cradle arrangements by directly welding the wires to silica blocks bonded to the mirror. Moreover, the mechanical loss level introduced by silica (φfs ∼ 10(-7) in thin fused silica wires) is by far less than the one associated with steel. The low frequency dynamical behaviour of the suspension can be computed and optimized, provided that the wire bending shape under pendulum motion is known. Due to the production process, fused silica wires are thicker near the two ends (necks), so that analytical bending computations are very complicated. We developed a tool to directly measure the low frequency bending parameters of fused silica wires, and we tested it on the wires produced for the Virgo+ monolithic suspensions. The working principle and a set of test measurements are presented and explained.

A "gentle" nodal suspension for measurements of the acoustic attenuation in materials.

Loss angle measurements in ultralow mechanical loss materials is normally affected by a large systematic error due to the excess losses introduced by the suspension system used to hold the samples. Crystals such as sapphire and silicon or amorphous materials such as fused silica can have loss angles in the range of 10(-10)-10(-7); such materials are of extreme interest in the detection of small displacements as it is required in quantum measurements, frequency stabilization, Micro Electro-Mechanical Systems (MEMS), and gravitational wave research. In the system proposed here the sample is suspended in equilibrium on top of a sphere, touching on one of the nodal points of vibration. The advantage of this system, as compared to others used so far, is twofold: (i) one surface only of the sample is touched and the contact surface is minimized because of the absence of applied forces; (ii) some relevant parameters of the suspension can be measured and eventually varied, giving the experimentalist the possibility to identify whether the measured loss is limited by the suspension system in use or it is an intrinsic property of the sample under investigation. The measurements of a 75 mm diameter and 3 mm thickness disk of Suprasil 311 gave a loss angle phi of 5x10(-8).

[Difficulty in diagnosing pediatric tuberculosis]. / Tubercolosi pediatrica una diagnosi difficile.

Tuberculosis (TB) in children is an important warning sign in a community, as it could signal recent infection of a cavitary form in an adult. Thus, while early diagnosis is crucial for effective treatment in children, it is also imperative for the control of tuberculosis at the public health level since it allows rapid identification of contagious adult cases. Here we report four cases of difficult and delayed diagnosis of TB in children. From this experience we highlight the need for an extensive medical history of the patient during diagnostic work-up. This includes: the positive history for contact with infected adults, especially for immigrant children; exclusion of TB diagnosis for persistent respiratory symptoms (2-3 weeks) after antibiotic therapy; and the need for high-definition CT scan when the radiological picture is not specific, especially for children under 5 years of age.

Varicella and its complications as cause of hospitalization.

Varicella is an acute contagious disease that most commonly occurs in childhood. Although normally benign, varicella can occasionally develop into a more serious illness. Moreover, the infection can lead to serious complications, such as Staphylococcus aureus infections, otitis media, endocarditis, pneumonia, and rare central nervous system (CNS) events like cerebellar ataxia and encephalitis. This study was conducted to analyze the hospitalization rate due to varicella or its complications in a tertiary care hospital in Italy, where varicella vaccination has not yet been implemented. The review was carried out on cases of children with varicella identified by ICD9 and ICD9-CM diagnostic codes and admitted to the Giannina Gaslini Children's Research Hospital of Genoa, Italy, from January 1st, 1995 to December 31st, 2004. For each case reporting complications, the clinical report form was extracted and the events recorded. Varicella was recorded in 346 (0,16%) out of 212,647 total hospital discharges. Chickenpox with detailed complications and cerebrovascular diseases accounted for 56 discharges (12.14%), for a total of 728 days. Fifteen patients needed more than one hospitalization because of severe sequelae as result of CNS involvement. We reported three particular cases of invasive infections and four children affected with cerebrovascular diseases following varicella. Our retrospective data regarding a single tertiary care pediatric hospital shows that hospitalization due to varicella or its sequelae may present an important medical and indirect economic problem.

Hepatitis B virus infection in native versus immigrant or adopted children in Italy following the compulsory vaccination.

BACKGROUND: Compulsory vaccination of children against hepatitis B virus (HBV) infection was introduced in Italy in 1991. PATIENTS AND METHODS: To evaluate the current importance of pediatric HBV infection, we studied 359 HBsAg-positive children admitted to 16 centers in Italy from 1991 to 1998. 185 patients were natives of Italy and 174 (39 immigrants and 135 adopted) came from highly endemic countries (eastern Europe: 60.9%, Asia: 16.7%, Africa: 14.9% and Central and South America: 5.7%). RESULTS: Transaminase Levels were moderately altered in both Italian (mean 134 UI/L) and foreign children (mean 168 UI/L). In total, 77% of ItaLian children and 88% of foreign children tested HBeAg positive. High transaminase levels and HBeAg positivity were more frequent in adopted children. Follow-up of 317 patients showed that the incidence of HBeAg/anti-HBe serum conversion was similar in all cohorts, but in adopted children it occurred at an earlier age and was associated with HBsAg clearance in 5%. CONCLUSION: HBV is not frequent in Italian children today, but it is common among children coming from highly endemic areas. The vaccination of nonimmune native populations must be strongly recommended.

Acyclovir plus CMV immunoglobulin prophylaxis and early therapy with ganciclovir are effective and safe in CMV high-risk renal transplant pediatric recipients.

Cytomegalovirus (CMV) infection is still a major cause of morbidity in high-risk renal transplant recipients. In the present report, we have reviewed our records of renal transplant pediatric recipients (RTPR; mean age 14.1 +/- 4.9 years) since 1991, when we started a policy of CMV prophylaxis constituting high-dose oral acyclovir plus CMV hyperimmune immunoglobulins (HIg) followed by early i.v. ganciclovir therapy in high-risk patients (i.e., CMV donor+/recipient-). Four patients received a kidney from a living relative (LR), 2 patients had one previous transplant, and 1 had a combined liver-kidney transplant. Thirty-three patients who were negative for CMV antibodies (ab) before transplantation received a kidney from CMV ab positive donors. The immunosuppressive regimen included cyclosporine A and steroids, with the addition of azathioprine in the 4 patients who received an LR kidney. Serial assessments for CMV antigenemia (pp 65) were routinely performed for 6 months after transplantation to define CMV infection. Among the 33 CMV seronegative recipients (R-) who received the graft from a CMV seropositive donor (D+), 18 (54.5%) experienced CMV infection, whereas among the 28 CMV R+, who received a graft from a CMV D+, 11 (39.3%) experienced CMV infection. With regard to CMV- related symptoms, only 2 patients suffered from a CMV syndrome (fever and leukopenia in 1 patient, fever and arthralgia in the other). In no case did the spectrum of CMV disease occur; only minor symptoms were present in 7 of the remaining CMV-infected patients (fever in 6 and leukopenia in 1). Rejection episodes and renal function did not differ between CMV-infected and non-CMV-infected patients. Our experiences support the use of prophylactic acyclovir plus CMV HIg followed by early therapy with i.v. ganciclovir to combat the risk of increased morbidity in high risk RTPR.