Visual lung ultrasound protocol (VLUP) in acute respiratory failure: description and application in clinical cases.

Lung ultrasound (LUS) is widely used as a diagnostic and monitoring tool in critically ill patients. Lung ultrasound score (LUSS) based on the examination of twelve thoracic regions has been extensively validated for pulmonary assessment. However, it has revealed significant limitations: when applied to heterogeneous lung diseases with intermediate LUSS pattern (LUSS 1 and 2), for instance, intra-observer consistency is relatively low. In addition, LUSS is time-consuming and a more rapid overview of the extent of lung pathology and residual lung aeration is often required, especially in emergency setting. We propose a Visual Lung Ultrasound Protocol (VLUP) as a rapid monitoring tool for patients with acute respiratory failure. It consists of a probe sliding along the mid-clavicular, mid-axillary and scapular lines in transversal scan. VLUP allows a visualization of a large portion of the antero-lateral and/or posterior pleural surface. Serial assessments of two clinical cases are recorded and visually compared, enabling rapid understanding of lung damage and its evolution over time. VLUP allows a semi-quantitative and qualitative point-of-care assessment of lung injury. Through this standardized approach it is possible to accurately compare subsequent scans and to monitor the evolution of regional parenchymal damage. VLUP enables a quick estimation of the quantitative-LUSS (qLUSS) as the percentage of pleura occupied by artifacts, more suitable than LUSS in inhomogeneous diseases. VLUP is designed as a standardized, point-of-care lung aeration assessment and monitoring tool. The purpose of the paper is to illustrate this new technique and to describe its applications.

A geo-chemo-mechanical study of a highly polluted marine system (Taranto, Italy) for the enhancement of the conceptual site model.

The paper presents the results of the analysis of the geo-chemo-mechanical data gathered through an innovative multidisciplinary investigation campaign in the Mar Piccolo basin, a heavily polluted marine bay aside the town of Taranto (Southern Italy). The basin is part of an area declared at high environmental risk by the Italian government. The cutting-edge approach to the environmental characterization of the site was promoted by the Special Commissioner for urgent measures of reclamation, environmental improvements and redevelopment of Taranto and involved experts from several research fields, who cooperated to gather a new insight into the origin, distribution, mobility and fate of the contaminants within the basin. The investigation campaign was designed to implement advanced research methodologies and testing strategies. Differently from traditional investigation campaigns, aimed solely at the assessment of the contamination state within sediments lying in the top layers, the new campaign provided an interpretation of the geo-chemo-mechanical properties and state of the sediments forming the deposit at the seafloor. The integrated, multidisciplinary and holistic approach, that considered geotechnical engineering, electrical and electronical engineering, geological, sedimentological, mineralogical, hydraulic engineering, hydrological, chemical, geochemical, biological fields, supported a comprehensive understanding of the influence of the contamination on the hydro-mechanical properties of the sediments, which need to be accounted for in the selection and design of the risk mitigation measures. The findings of the research represent the input ingredients of the conceptual model of the site, premise to model the evolutionary contamination scenarios within the basin, of guidance for the environmental risk management. The study testifies the importance of the cooperative approach among researchers of different fields to fulfil the interpretation of complex polluted eco-systems.

Daratumumab in multiple myeloma: experience of the multiple myeloma GIMEMA Lazio group.

Daratumumab (DARA) is a human IgG-K monoclonal antibody (MoAb) targeting CD38 that is approved alone or in combination with bortezomib and dexamethasone or lenalidomide and dexamethasone for relapsed or refractory MM (RRMM) in patients previously exposed or double refractory to proteasome inhibitors (PI) and immunomodulatory drugs (IMiDs). However, there are limited data on its clinical activity and tolerability in real-world patients. Therefore, in the present study, we aim to determine the efficacy and toxicity profile of daratumumab in a real-life setting. In this study, we report the experience of the multiple myeloma GIMEMA Lazio Group in 62 relapsed/refractory MM patients treated with daratumumab as monotherapy who had previously received at least two treatment lines including a PI and an IMiDs or had been double refractory. Patients received DARA 16 mg/kg intravenously weekly for 8 weeks, every 2 weeks for 16 weeks, and every 4 weeks until disease progression or unacceptable toxicity. The overall response rate to daratumumab was 46%. Median progression-free survival (PFS) and overall survival reached 2.7 and 22.4 months, respectively. DARA was generally well tolerated; however, 2 patients interrupted their therapy due to adverse events. Present real-life experience confirms that DARA monotherapy is an effective strategy for heavily pre-treated and refractory patients with multiple myeloma, with a favorable safety profile.

Alkaline phosphatase (alp) levels in multiple myeloma and solid cancers with bone lesions: Is there any difference?

INTRODUCTION: Bone involvement in Multiple Myeloma results from increased osteoclast formation and activity that occurs in proximity to myeloma cells. The role of Alkaline Phosphatse (ALP) in this process and the diagnostic significance of plasma levels in patients with MM are unclear. AIM: To compare plasma ALP levels in patients with MM and solid cancers and metastatic lesions to the bone. RESULTS: In this observational retrospective study we enrolled 901 patients were enrolled: 440 patients (49%) with Multiple Myeloma, 461 (51%) with solid cancers. All 901 patients had bone lesions. Among patients with Multiple Myeloma, ALP values were mainly in the range of normality than those observed in patients with solid cancers and bone lesions. This difference is independent of stage, number and type of bone lesions. CONCLUSION: This study suggests that plasma ALP has a different clinical significance in MM than in other neoplasms and could be used as a discriminating marker in presence of bone lesions. In particular, lower or normal values, should suggest further investigations such as urinary and serum electrophoresis, associated with bone marrow aspirate in case of the presence of a monoclonal component, in order to confirm or exclude a MM diagnosis.

The impact of carbapenemase-producing Enterobacteriaceae colonization on infection risk after liver transplantation: a prospective observational cohort study.

OBJECTIVE: To investigate the impact of colonization with carbapenemase-producing Enterobacteriaceae (CPE) on the CPE infection risk after liver transplantation (LT). METHODS: Prospective cohort study of all adult patients undergoing LT at our centre over an 8-year period (2010-2017). Individuals were screened for CPE colonization by rectal swabs at inclusion onto the waiting list, immediately before LT and weekly after LT until hospital discharge. Asymptomatic carriers did not receive decolonization, anti-CPE prophylaxis or pre-emptive antibiotic therapy. Participants were followed up for 1 year after LT. RESULTS: We analysed 553 individuals who underwent a first LT, 38 were colonized with CPE at LT and 104 acquired colonization after LT. CPE colonization rates at LT and acquired after LT increased significantly over the study period: incidence rate ratios (IRR) 1.21 (95% CI 1.05-1.39) and 1.17 (95% CI 1.07-1.27), respectively. Overall, 57 patients developed CPE infection within a median of 31 (interquartile range 11-115) days after LT, with an incidence of 3.05 cases per 10 000 LT-recipient-days and a non-significant increase over the study period (IRR 1.11, 95% CI 0.98-1.26). In multivariable analysis, CPE colonization at LT (hazard ratio (HR) 18.50, 95% CI 6.76-50.54) and CPE colonization acquired after LT (HR 16.89, 95% CI 6.95-41.00) were the strongest risk factors for CPE infection, along with combined transplant (HR 2.60, 95% CI 1.20-5.59), higher Model for End-Stage Liver Disease at the time of LT (HR 1.03, 95% CI 1.00-1.07), prolonged mechanical ventilation (HR 2.63, 95% CI 1.48-4.67), re-intervention (HR 2.16, 95% CI 1.21-3.84) and rejection (HR 2.81, 95% CI 1.52-5.21). CONCLUSIONS: CPE colonization at LT or acquired after LT were the strongest predictors of CPE infection. Prevention strategies focused on LT candidates and recipients colonized with CPE should be investigated.

Previous infection and the risk of ischaemic stroke in Italy: the IN2 study.

BACKGROUND AND PURPOSE: There is an increasing interest in new risk factors for ischaemic stroke. Acute and chronic infections could contribute to different aetiological mechanisms of atherosclerosis that lead to cerebrovascular disease. The aim of this study was to investigate the hypothesis that previous infections and Chlamydia pneumoniae in particular increase the risk of ischaemic stroke in the population. METHODS: This was a prospective case-control study involving 11 Italian stroke units. Controls were age- and sex-matched with cases, represented by patients admitted to hospital for acute ischaemic stroke. For each participant classical vascular risk factors and previous inflammatory and infectious events up to 1 month before were registered. Blood samples were collected to analyse inflammatory markers and titres of antibodies against C. pneumoniae. RESULTS: A total of 1002 participants were included (mean age 69 years) with 749 ischaemic stroke patients. Infections occurred within 1 month previously in 12% of the entire sample with a higher prevalence in the case group (14.4% vs. 3.9%). At multivariate analysis of the seropositivity of IgA antibodies against C. pneumoniae increased the risk of stroke significantly (relative risk 2.121; 95% confidence interval 1.255-3.584) and an early previous infection (up to 7 days before the event) contributed to a rise in probability of acute cerebral ischaemia (relative risk 3.692; 95% confidence interval 1.134-6.875). CONCLUSIONS: Early previous infections and persistent chronic infection of C. pneumoniae could contribute to increase the risk of ischaemic stroke significantly, in the elderly especially.

Effect of age on native kidney function after adult intestinal transplants on long-term follow-up.

BACKGROUND: Kidney function usually deteriorates after intestinal transplant, with prevalence of renal failure almost 20% after 5 years. We report our results on adults from single institution over >10 years. METHODS: Forty-six patients were transplanted with 22 survivors; we divided them in 2 groups: Group 1, recipients with creatinine>1.2 mg/dL (normal, 0.50-1.2) and Group 2, normal creatinine. Group 1 included 12 patients (9 males) with a mean age of 42.8 years; all lived at home, with normal creatinine at transplant (apart from 1 patient with a creatinine of 1.6 mg/dL), and were mainly transplanted for short bowel syndrome. One underwent retransplantation. Immunosuppression was based on alemtuzumab (8 recipients) plus tacrolimus (FK). Group 2 included 10 patients (6 males) with a mean age of 34.7 years; all lived at home, had normal creatinine at transplantation, and were mainly transplanted for short bowel syndrome. Immunosuppression was mainly based on alemtuzumab (8 recipients) plus FK. RESULTS: There were no relevant differences between the 2 groups regarding number of recipients, sex, baseline creatinine at transplant, reason for transplantation, retransplantation, immunosuppression, antifungal or antiviral therapy, hospitalization, total parenteral nutrition (or fluids), or stoma. The only relevant difference was age (P=.04); patients with deteriorated kidney function or altered creatinine were found to be older.

Assessment of perioperative transfusion requirement for cirrhotic patients undergoing elective hepatectomy.

BACKGROUND: The possibility of outlining a risk profile for perioperative blood transfusion of cirrhotic patients submitted to hepatic resection can help to rationalize transfusion policy. METHODS: Data from 323 hepatic resections, performed in cirrhotic patients, were reviewed. Bootstrap and a leave-one-out logistic regressions were applied to test the accuracy of available risk scores for peri-operative transfusion identified from PubMed search of the last 20 years, to refine them, and to provide internal validation for present results. RESULTS: One-hundred-six patients (32.8%) required blood transfusions during either intra- and/or postoperative. The predictive accuracy of three identified risk scores was poor with the area under receiver operating characteristics (AUROC) curves <0.70 in all cases. Tumor diameter, hemoglobin and presence of coronary artery disease were confirmed, in the present cohort, as predictors of blood transfusion together with serum albumin and bilirubin. The leave-one-out logistic regression results in an AUROC of 0.80, and of 0.79 for internal validation, significantly higher than that of the three scores tested (P<0.001). A Maximal Surgical Blood Order Schedule stratification was proposed. CONCLUSION: The risk profile for transfusion of cirrhotic patients undergoing hepatectomy can be better assessed with a model that combines already known clinical factors and hepatic function indexes.

Induction therapy in adult intestinal transplantation: reduced incidence of rejection with "2-dose" alemtuzumab protocol.

The incidence of early rejection after intestinal transplantation correlates with heightened risk of graft loss and mortality. Many different induction or pre-conditioning protocols have been reported in the last 10 yr to improve outcomes; however, sepsis remains prevalent and diminishes long-term results. We recently began a "2-dose" alemtuzumab trial protocol - 15 mg at day 0 and 15 mg repeated on day 7 - with the hope of reducing our infection rate. We compared three different protocols used at our institution (daclizumab, conventional "4-dose" alemtuzumab, and "2-dose" alemtuzumab). There was a significantly lower rate of early rejection with the "2-dose" alemtuzumab protocol in our study group of mainly (88%) intestinal grafts without accompanying liver engraftment with its protective immunologic effect. Sepsis remained low. Longer follow-up will be required to evaluate the effects of this new protocol on longer-term outcomes.

Hyperdynamic circulation in cirrhosis: predictive factors and outcome following liver transplantation.

BACKGROUND: Liver cirrhosis is associated with a hyperdynamic circulation (HC). In this observational study, we aimed to investigate the predictive factors of HC, its impact on intraoperative hemodynamic and postoperative outcome, early ICU and in-hospital mortality, in cirrhotic patients undergoing orthotopic liver transplantation (OLT). METHODS: Two hundred and forty-two patients with cirrhosis undergoing cadaveric OLT were included. Before starting the transplant procedure and under general anesthesia, a pulmonary artery catheter was introduced to assess hemodynamic parameters. The baseline assessment was carried out approximately 30 minutes after the catheter placement and repeated during the anhepatic phase, 10 minutes after the reperfusion and at the end of surgery. The patients were divided into two groups: in group 1 the patients had SVR>900dynes s-1 m-2 cm-5, in group 2 SVR ≤900 dynes s-1 m-2 cm-5. RESULTS: Eighty-two patients (33%) presented severe HC. In multivariate analysis 2 factors were associated with the occurrence of HC: beta-blockers use (Exp [B]=4.42 (95% CI 1.18-17); P=0.001, [34% and 12% in groups 1 and 2, P<0.001, respectively]) and model for end-stage liver disease (MELD) score (Exp [B]=1.066; 95% CI=1.025-1.109; P=0.001). CONCLUSION: MELD score was an independent predictor of HC, and beta-blockers resulted associated with lower incidence of HC in cirrhotic patients undergoing cadaveric OLT. Intraoperative HC correlates with hemodynamic alterations, requiring more blood products and vasopressor use, this may increase the risk of renal failure, early ICU death and in-hospital mortality.

Multiple myeloma and paget disease with abnormal skull lesions and intracranial hypertension.

We report a 73 years old man with a diagnosis of Paget Disease (PD) and symptomatic Multiple Myeloma (MM). Coexistence of MM and PD has rarely been described. PD mimics many of the features of bone destructive process in MM, making differential diagnosis more complicated. In addition, the presence of serious muscolo-skeletal and metabolic complications in both diseases makes management of patients difficult, worsening the prognosis.The comparison of these two diseases has led to the characterization of a common molecular mechanism represented by the receptor activator of nuclear factor-kB ligand (RANKL)/Osteoprotegerin signaling pathway. The improved comprehension of these mechanisms led to the development of new pharmacologic agents (bisphosphonates, cytokines inhibitors) effective for the treatment of these bone diseases.

Postoperative troponin T elevation as a predictor of early acute kidney injury after orthotopic liver transplantation: a preliminary retrospective study.

BACKGROUND: Slight alterations in cardiac enzymes are frequently observed perioperatively among liver transplant patients. The significance of these changes in the absence of ongoing acute cardiac pathology is unknown. We sought to evaluate the link between early postoperative anomalies of serum cardiac troponin T (cTnT) in the absence of an evident cardiac cause and kidney injury during the first week of hospital stay. METHODS: We retrospectively enrolled 30 patients in the study, recording several perioperative variables, particularly cTnT on intensive care unit ICU arrival as well as 6 and 12 hours later. We grouped patients with cTnT levels >0.03 ng/mL as the high-TnT group; the others were control subjects. We recorded the highest serum creatinine, aspartate aminotransferase, alanine aminotransferase, and bilirubin levels during the first week of the hospital stay. Glomerular filtration rate (GFR) was calculated according to the Cockroft-Gault formula. RESULTS: Ten patients composed the high-TnT group. Their perioperative variables showed higher Model for End-Stage Liver Disease (MELD) scores and significantly greater incidences of acute kidney injury, failure, and dialysis need than control patients. GFR dropped from 118 to 66 mL/min among this group versus 112 to 105 mL/min in control subjects (P = .021). Binary logistic regression analysis revealed a higher association between the high-TnT group and acute kidney injury (P = .036) than with the MELD score (P = .719). CONCLUSIONS: Serum cTnT levels could be influenced by both preoperative and intraoperative conditions that predispose to kidney injury.

Evolution of bisphosphonate-related osteonecrosis of the jaw in patients with multiple myeloma and Waldenstrom's macroglobulinemia: a retrospective multicentric study.

Bisphosphonates (BPs) are used intravenously to treat cancer-related conditions for the prevention of pathological fractures. Osteonecrosis of the jaw (BRONJ) is a rare complication reported in 4-15% of patients. We studied, retrospectively, 55 patients with multiple myeloma or Waldenstrom's macroglobulinemia followed up from different haematological departments who developed BRONJ. All patients were treated with BPs for bone lesions and/or fractures. The most common trigger for BRONJ was dental alveolar surgery. After a median observation of 26 months, no death caused by BRONJ complication was reported. In all, 51 patients were treated with antibiotic therapy, and in 6 patients, this was performed in association with surgical debridement of necrotic bone, in 16 with hyperbaric O(2) therapy/ozonotherapy and curettage and in 12 with sequestrectomy and O(2)/hyperbaric therapy. Complete response was observed in 20 cases, partial response in 21, unchanged in 9 and worsening in 3. The association of surgical treatment with antibiotic therapy seems to be more effective in eradicating the necrotic bone than antibiotic treatment alone. O(2) hyperbaric/ozonotherapy is a very effective treatment. The cumulative dosage of BPs is important for the evolution of BRONJ. Because the most common trigger for BRONJ was dental extractions, all patients, before BP treatment, must achieve an optimal periodontal health.

Antiepileptic drugs for central post-stroke pain management.

Antiepileptic drugs (AEDs) are commonly prescribed for a wide range of disorders other than epilepsy, including both neurological and psychiatric disorders. AEDs play also a role in pharmacological management of neuropathic pain. Central post-stroke pain (CPSP) is a disabling morbidity occurring in 35% of patients with stroke. The pathophysiology of CPSP is not well known but central disinhibition with increased neuronal excitability has been suggested. AEDs include many different drugs acting on pain through several mechanisms, such as reduction of neuronal hyperexcitability. To our knowledge conclusive evidence has not been published yet. The aim of this review is to delineate efficacy and safety of AEDs in CPSP.

Anesthesia for liver transplantation: the experience of the University of Bologna in the MELD era.

AIM: The hepatic cirrhosis is associated with an important cardiovascular alterations. In this report, we review our transplant center experience with liver transplantation in the Model for End-Stage Liver Disease (MELD) era, in particular this study investigate the relationship between severity of liver disease assessed by MELD score and postoperative events. METHODS: Our retrospective review was performed on 242 cirrhotic patients underwent liver transplanation at the Department of Surgery and Transplantation of the University of Bologna. Biochemical and hemodynamic variables were evaluated by Swan-Ganz catherization. Dindo's classification of postoperative complications was used for the evaluation of postoperative course. RESULTS: Morbidity occurred in 158 patients (65.2%) and 13 patients died during the hospital stay. Considering the highest grade of complication occurred, non life-threatening complications occurred in the 47.9% of cases (116 patients) and life-threatening complications, excluding patient death, in 17.3% (42 patients). Patients with MELD >30 showed a longer ICU stay, tracheal intubation and in-hospital stay. CONCLUSION: In conclusion MELD score is tightly related to postoperative complications.

Hyperdynamic circulation in acute liver failure: reperfusion syndrome and outcome following liver transplantation.

BACKGROUND/AIMS: Liver transplantation (OLT) is a valid therapeutic option for patients with fulminant hepatic failure (FHF). The most critical phase during OLT is considered to be graft reperfusion, where in large changes in patient homeostasis occur. The aims of the present study were to evaluate the hemodynamic and cardiac changes among a large series of patients with FHF, to determine independent clinical predictors of the occurrence of postreperfusion syndrome (PSR) and its relationship to clinical and hemodynamic parameters and transplant outcomes. METHODS: Systemic hemodynamic and cardiac functions were evaluated by Swan-Ganz catheterization in 58 patients before OLT. The patients were divided into two subgroups on the basis of PSR, which was defined as a mean arterial blood pressure 30% lower than the immediate previous value lasting for at least 1 minute within 5 minutes after unclamping. RESULTS: PSR occurred in 24 patients (41%). Significant differences upon bivariate analysis was observed for the Model for End-stage Liver Disease score, which was significantly higher among patients with PSR, namely 32 (range = 18-43) versus 23 (range = 12-32) (P = .001). Higher serum creatinine values were significantly different among patients with PSR: 1.4 (range = 1.2-2.2) versus 2.1 (range = 2.5-3.2) mg/dL (P < .01). CONCLUSION: Systemic hemodynamic alterations of FHF progressively worsen with increasing severity of liver disease. PSR developed in approximately 40% of patients; its prevalence was significantly related to the severity of the disease. Finally, patients with renal failure showed greater risk to develop an PSR during OLT.

Daclizumab and alemtuzumab as induction agents in adult intestinal and multivisceral transplantation: rejection and infection rates in 40 recipients during the early postoperative period.

BACKGROUND: Allograft rejection in intestinal transplantation occurs frequently, and bacterial, fungal, and viral infections related to strong immunosuppression regimens remain an important complication posttransplantation. Induction therapy has enabled improvement in graft and patient survival rates. OBJECTIVES: In analyze the effects of daclizumab and alemtuzumab as induction therapies on inflections complications and incidence of acute cellular rejection (ACR) during the early posttransplantation period. PATIENTS AND METHODS: Between December 2000 and August 2009, we performed 43 intestinal transplantation procedures in 42 adult recipients (median [SD] age, 34.8 [9.5] years; male-female ratio, 22:20; isolated or multivisceral graft, 32/11), and compared findings during the first 30 days posttransplantation in 40 recipients. Patients were divided into 2 groups: 12 treated with daclizumab (Zenapax; Hoffman-La Roche Ltd, Basel, Switzerland): 8 isolated intestinal grafts and 4 multivisceral grafts) and 28 treated with alemtuzumab (Campath-1H: 22 isolated intestinal grafts and 6 multivisceral grafts). Maintenance immunosuppression was based on tacrolimus and steroids in the first group and low-dose tacrolimus in the second group. RESULTS: During the first month posttransplantation, 8 daclizumab recipients (66.6%) experienced 9 episodes of mild ACR, which were successfully treated with steroid therapy, and 8 patients (66.6%) developed a bacterial infection requiring treatment. Fourteen episodes of ACR occurred in 12 alemtuzumab recipients (42.8%): 11 mild, 1 mild to moderate, and 2 moderate; 16 patients (57.1%) required treatment for infections. Five-year patient cumulative survival was 66% in daclizumab recipients and 43% in alemtuzumab recipients. Five-year graft survivals was 66% in daclizumab recipients and 41% in alemtuzumab recipients. In both groups, P was not statistically significative. CONCLUSIONS: The infection rate is considerably high with both protocols. Alemtuzumab seems to offer better immunosuppression against ACRs during the first month posttransplantation.

Comprehensive surgical intestinal rescue and transplantation program in adult patients: Bologna experience.

INTRODUCTION: Surgical approaches to complicated benign intestinal failure are accepted worldwide, especially in the pediatric population. Intestinal transplant surgery is thought to rescue patients in whom complications of total parenteral nutrition (TPN) develop. OBJECTIVE: To report our experience with surgical intestinal rescue in an adult population with intestinal failure. PATIENTS AND METHODS: An intestinal rehabilitation program initiated at our institution included comprehensive medical rehabilitation, surgical bowel rescue, and transplantation. From 2000 to 2009, of 81 adult patients referred by our gastroenterologists for bowel rehabilitation, 42 (51,8%) underwent 43 transplantations (32 isolated intestinal grafts and 11 multivisceral grafts). Underlying diseases were primarily short-bowel syndrome, Gardner syndrome, and intestinal pseudo-obstruction. Thirty-nine patients (48,2%) underwent surgical rescue (40 cases) consisting of bowel resection, adhesiolysis, stricturoplasty, liver transplantation with portocaval hemitransposition (6 cases in 5 patients). Underlying diseases were primarily intestinal fistulas, stenosis, or perforations, short-bowel syndrome, cocoon syndrome, and complete portal thrombosis. RESULTS: After a mean (SD) follow-up of 1043 (1016) days, in the transplantation population, 21 patients (50%) are alive, with a 1-, 3-, 5-year patient survival of 76%, 59%, and 52%, respectively, and graft survival of 66%, 54%, and 48%, respectively. After 901 (404) days in the rescue population, 32 patients (82%) are alive (2 died, and 5 were lost to follow-up); in 75%, TPN 25% was discontinued, and are receiving oral feeding with TPN support. The 1- and 3-year survival rate was 100% and 83%, respectively. CONCLUSIONS: Deaths occurred primarily in the transplantation population. Intestinal surgical rescue, when possible, is optimal.