Evaluation of an uncalibrated arterial pulse contour cardiac output monitoring system in cirrhotic patients undergoing liver surgery.

BACKGROUND: The pulmonary artery catheter is invasive and may cause serious complications. A safe method of cardiac output (CO) measurement is needed. We have assessed the accuracy and reliability of a recently marketed self-calibrating arterial pulse contour CO monitoring system (FloTrac/Vigileo) in end-stage liver failure patients undergoing liver transplant. The pattern of alterations known as cirrhotic cardiomyopathy, and the transplant procedure itself, provided an evaluation under varying clinical conditions. METHODS: The cardiac index was measured simultaneously by thermodilution (CI(TD): mean of four readings) using a pulmonary artery catheter and pulse contour analysis (CI(V): mean value computed by the FloTrac/Vigileo over the same time period). Readings were made at 10 time-points during liver transplant surgery (T1-T5) and on the intensive care unit (T6-T10). CI(V) was computed using the latest Vigileo software version 01.10. RESULTS: A total of 290 paired readings from 29 patients were collected. Mean (SD) CI(TD) was 5.2 (1.3) and CI(V) was 3.9 (0.9) litre min(-1) m(-2), with a corrected for repeated measures bias between readings of 1.3 (0.2) litre min(-1) m(-2) and 95% limits of agreement of -1.5 (0.2) to 4.1 (0.3) litre min(-1) m(-2). The percentage error (2SD(Bias)/meanCI(TD)) was 54%, which exceeded a 30% limit of acceptance. Low peripheral resistance and increasing bias were related (r=0.69; P<0.001). The Vigileo system failed to reliably trend CI data, with a concordance compared with thermodilution below an acceptable level (at best 68% of sequential readings). CONCLUSIONS: In cirrhotic patients with hyperdynamic circulation, the Vigileo system showed a degree of error and unreliability higher than that considered acceptable for clinical purposes.

False positive tardus-parvus waveforms after liver transplantation: a case of wide discrepancy between donor and recipient hepatic arteries mimicking anastomotic stenosis.

BACKGROUND: Parvus-tardus waveforms of the hepatic artery after liver transplantation usually indicate an arterial complication and severe impairment of hepatic arterial perfusion with a sensitivity of 91% and a specificity of 99.1%. Thus, it has been emphasized that detection of such waveforms should prompt emergency angiography. MATERIALS AND METHODS: Arterial reconstruction during a liver transplantation was successfully accomplished by an end-to-end anastomosis, performing a "flute-spout" widening of the anastomosis with a 7/0 prolene running suture between a small recipient proper hepatic artery and the donor common hepatic artery. RESULTS: On day 7 posttransplantation color Doppler ultrasonography revealed a parvus-tardus waveform pattern in the hepatic arterial flow. Computed tomographic (CT) angiography showed only a caliber discrepancy between the donor and recipient stumps, excluding an arterial stenosis or thrombosis. Since normal liver function persisted, the patient underwent routine follow-up. After 15 months the patient was alive and well; hepatic artery spectral waveforms were unchanged and liver functions were consistent with a mild hepatitis C virus (HCV) recurrence. CONCLUSIONS: This is a report of false positive tardus-parvus waveforms, due to a discrepancy between the donor and recipient arteries despite a wide anastomosis. Knowledge of technical reconstruction details may be helpful for correct interpretation of color Doppler findings. CT angiography should be considered before more invasive examinations.

Potential applications of extracorporeal photopheresis in liver transplantation.

Extracorporeal photopheresis (ECP) is an immunomodulatory therapy performed through a temporary peripheral venous access with documented efficacy in heart and renal transplantation. We originally reported that ECP represented a valuable alternative to treat graft rejection in selected liver transplant (OLT) recipients. We have investigated potential applications of ECP for prophylaxis of allograft rejection. The first field explored was the use of ECP for delayed introduction of calcineurin inhibitors (CNI) among high-risk OLT recipients seeking to avoid CNI toxicity. In 42 consecutive patients that we assigned to prophylaxis with ECP, we were able to delay CNI introduction after postoperative day 8 in one-third of them. The second field was the use of ECP for prophylaxis of acute cellular rejection among ABO-incompatible OLT recipients. In our experience, none of 11 patients treated with ECP developed a cell-mediated rejection. The third field was ECP application in hepatitis C virus-positive patients seeking to reduce the immunosuppressive burden and improve sustainability and efficacy of preemptive antiviral treatment with interferon and ribavirin. Among 78 consecutive patients, we were able to start preemptive antiviral treatment in 69.2% of them at a median time from OLT of 14 days (range = 7 to 130 days). Thirty-six (66.7%) patients completed the treatment course with an end of treatment virological response of 50.0% and a sustained virological response of 38.9%. These preliminary results await validation in larger prospective studies with longer follow-up periods.

The "You Are Not Alone" care program for liver transplantation.

Current clinical practice is based on the principles of efficacy, appropriateness, efficiency, quality, and safety. Compliance with these tenets requires experienced medical and nursing staff, and active participation of patients and their families in the planned therapeutic program. To match patients' expectations on quality and safety of care and spur active participation in the transplant care process, we set up an integrated, multiphase, multidisciplinary care program devoted to liver transplantation (LT) candidates, engrafted patients, and their families: the "Non Sei Solo" care program (You Are Not Alone). The basic principle of the care program was that, to provide efficient and effective education to their patients, health care professionals need to learn how to teach and what to teach, acquire successful communication skills, and monitor the process of education. The methodology encompassed 5 distinct phases: phase 1, exploration of patients' needs, by means of a questionnaire devoted to waitlisted and engrafted patients and their care givers; and phase 2, creation of 16 patient-oriented educational brochures directed to patients and their families. Once created, the educational brochures were presented, discussed, and amended during a consensus meeting involving all transplantation nurses and physicians (phase 3). To acquire the necessary skills and ease communication with patients, the transplantation nurses, physicians, surgeons, and anesthesiologists attended a 6-month counseling course under the tutorial of an expert counselor (phase 4). Finally, in June 2007 the program started officially with monthly meetings with patients and their families, guided hospital tours on patient request, and activation of a toll-free phone number to provide support to patients and answer their questions.

[Good practices and techniques for prevention of accidents at work and occupational diseases. New database of Inail]. / La ricerca di buone pratiche e di buone tecniche aziendali utili alla prevenzione degli infortuni e delle malattie professionali la nuova banca dati dell'Inail.

The project "The publication of good practices and good techniques for prevention" is one the priorities of nail. This computerized system for the collection of good practices and standards of Good Technology is aimed to health and safety of workers. The basic objective of the database is to provide a valuable tool, usable, dynamic and implemented, in order to facilitate and direct the access to BP and BT it by people responsible for SSL. At the same time constitutes a tool strategically important for enterprises (especially SMEs) in terms of technological innovation and competitiveness, related to the prevention, safety and health of workers. The realization of this project has involved many of the professionals (chemists, engineers, doctors, biologists, geologists, etc.), and everyone gives his intake of qualified professional competence.

[Occupational diseases in agricultural workers 2002-2006]. / Malattie professionali in agricoltura 2002-2006.

The authors have examined the data of the occupational diseases in agriculture in the period 2002-2006; such data evidence as in these years there has been an increase of the number of the denunciations of occupational diseases. The increase is referred to new emergent diseases" as occupational the syndrome of the carpal tunnel and the tendinitises. The acknowledgment of new occupational diseases must be accompanied also by an effective promotion of the security of workers.

[Accidents at work in agriculture workers in the period 2002-2006]. / Infortuni in agricoltura nel quinquennio 2002-2006.

The authors consider the accidents happened in agricultural environment in the period from 2002 to 2006. The data of the Inail evidence a decrease of the denounced events, but with a reduction of the occupied workers. Such data make demonstrate that not it there has not been an improvement. For this reason it's necessary put in action informative and formative campaigns about the culture of the prevention of agricultural accidents.

[Accidents at work in handicraft workers in the period 2002-2006]. / Infortuni in artigianato nel quinquennio 2002-2006.

The authors consider the phenomenon of the accidents at work in the handicraft workers in the last period; the data examined demonstrate that in this work environment there has not been an evident decrement of the cases in comparison to the past. It's however always necessary to promote and improve the preventional measures in these particular job places.

Low-temperature behaviour of K2Sc[Si2O6]F: determination of the lock-in phase and its relationships with fresnoite- and melilite-type compounds.

K2Sc[Si2O6]F exhibits, at room temperature, a (3 + 2)-dimensional incommensurately modulated structure [a = 8.9878 (1), c = 8.2694 (2) Å, V = 668.01 (2) Å3; superspace group P42/mnm(α,α,0)000s(-α,α,0)0000] with modulation wavevectors q1 = 0.2982 (4)(a* + b*) and q2 = 0.2982 (4)(-a* + b*). Its low-temperature behaviour has been studied by single-crystal X-ray diffraction. Down to 45 K, the irrational component α of the modulation wavevectors is quite constant varying from 0.2982 (4) (RT), through 0.2955 (8) (120 K), 0.297 (1) (90 K), 0.298 (1) (75 K), to 0.299 (1) (45 K). At 25 K it approaches the commensurate value of one-third [i.e. 0.332 (3)]: thus indicating that the incommensurate-commensurate phase transition takes place between 45 K and 25 K. The commensurate lock-in phase of K2Sc[Si2O6]F has been solved and refined with a 3 × 3 × 1 supercell compared with the tetragonal incommensurately modulated structure stable at room temperature. This corresponds to a 3 × 1 × 3 supercell in the pseudo-orthorhombic monoclinic setting of the low-temperature structure, space group P2/m, with lattice parameters a = 26.786 (3), b = 8.245 (2) c = 26.824 (3) Å, ß = 90.00 (1)°. The structure is a mixed tetrahedral-octahedral framework composed of chains of [ScO4F2] octahedra that are interconnected by [Si4O12] rings with K atoms in fourfold to ninefold coordination. Distorted [ScO4F2] octahedra are connected to distorted Si tetrahedra to form octagonal arrangements closely resembling those observed in the incommensurate structure of fresnoite- and melilite-type compounds.

Shock Synthesis of Decagonal Quasicrystals.

The Khatyrka meteorite contains both icosahedral and decagonal quasicrystals. In our previous studies, icosahedral quasicrystals have been synthesized and recovered from shock experiments at the interface between CuAl5 and stainless steel 304 alloys. In this study, we report a new shock recovery experiment aimed at synthesizing decagonal quasicrystals similar to decagonite, natural Al71Ni24Fe5. Aluminum 2024 and permalloy 80 alloys were stacked together and shocked in a stainless steel 304 recovery chamber. Abundant decagonal quasicrystals of average composition Al73Ni19Fe4Cu2Mg0.6Mo0.4Mn0.3 with traces of Si and Cr were found along the recovered interface between the Al and permalloy. The experiment also synthesized AlNiFe alloy with the B2 (CsCl-type) structure and the metastable Al9Ni2 phase. We present chemical (scanning electron microscopy and electron microprobe) and structural (electron backscatter diffraction and transmission electron microscopy) characterization of the recovered phases and discuss the implications of this shock synthesis for the stability of quasicrystals during high-pressure shocks and for the interpretation of the phase assemblage found in Khatyrka.

Vacancy pairing and superstructure in the high-pressure silicate K1.5Mg2Si2O7H0.5: a new potential host for potassium in the deep Earth.

The high-pressure silicate K1.5Mg2Si2O7H0.5, synthesized and characterized by Welch et al. [(2012), Am. Mineral. 97, 1849-1857], has been re-examined with the aim of determining the nature of the superstructure noted in their study. The composition corresponds to a 1:1 combination of KMg2Si2O7H and K2Mg2Si2O7 end-members, but it is not a solid solution. Single-crystal X-ray diffraction data for one of the original K1.5Mg2Si2O7H0.5 crystals synthesized at 16 GPa/1573 K, has been collected using a much longer exposure time in order to improve the intensity statistics of weak superlattice reflections identified by Welch et al. (2012). The superstructure has been determined using a superspace approach as having the superspace group Cmcm(0,ß,0)00s and t0 = 1/16 with refined parameters a = 8.7623 (10), b = 5.0703 (7), c = 13.2505 (11) Å, V = 588.69 (12) Å3. This structure corresponds to one with the conventional space group Pbnm and unit-cell parameters a = 8.7623 (10), b = 20.281 (3), c = 13.2505 (11) Å, V = 2354.7 (5) Å3 and is based upon a super-sheet motif in which ordering involves rows of pairs of vacant interlayer K sites. This is the third topologically distinct structure type for the KMg2Si2O7H-K2Mg2Si2O7 join and suggests that there is very limited solid solution, and so it can be expected that each of the three structures (P63cm, P\bar 3 1m and Pbnm) has its own stability field, rather than being part of a continuous compositional series based upon a single structure type. As such, K1.5Mg2Si2O7H0.5 should be considered as a potentially significant host of K in the Earth's mantle.

Combined twice-daily plasma exchange and continuous veno-venous hemodiafiltration for bridging severe acute liver failure.

Aiming to remove the toxins produced during the course of severe hepatic failure, we combined hemodiafiltration and plasma exchange (patient plasma replaced by fresh frozen plasma in a twice-daily regimen) for treatment of five patients: two affected by primary nonfunction of a liver graft and three by fulminant hepatic failure. The simultaneous use of the two extracorporeal techniques allowed a rapid reduction in the administration of vasoactive drugs and a rapid, significant decrease in the indices of liver necrosis. Native liver functional recovery occurred in one case, and the wait for a second graft was made possible in the other four. Although it has been reported that the detoxifying efficacy of plasma exchange is optimal when the replaced volume of plasma is high, such a technique requires both long treatment times and high blood flows in the extracorporeal circuit, making it often hemodynamically intolerable. Our approach leads to replacement of smaller volumes, allowing lower blood flows that are better tolerated despite the often unstable hemodynamics of these patients. Liver transplantation and retransplantation remains the definite therapy for severe liver failure or primary nonfunction. However, the organ waiting time is unpredictable and often does not coincide with the patients' clinical needs. Thus alternative strategies must be developed until a suitable donor is found or there is spontaneous recovery. From this point of view, in our albeit limited experience, twice-daily plasma exchange combined with hemodiafiltration has proved to be an effective therapeutic approach.

Selection and preparation of candidates for combined liver-kidney transplantation: experience at a single center-two case reports.

BACKGROUND: The published experiences of combined liver-kidney transplantation (LKT) are favorable, but there is still no uniformity concerning the impact on hepatorenal syndrome, or in cases of symptomatic hepatorenal polycystic disease. Herein we describe our experience with two LKTs, with particular reference to the selection and preparation of the candidates, and the surgical approach. METHODS: Between 1996 and June 2003, we performed 430 liver transplants in 398 recipients, including two LKTs: one in a patient with hepatorenal polycystic disease (case 1) and the other in a patient with HBV(+) cirrhosis undergoing dialysis after a previous isolated kidney transplant (case 2). RESULTS: In case 1, LKT and right nephrectomy were performed 2 months after a left lumbar nephrectomy. In case 2, LKT was performed 10 months after an isolated kidney transplant, without removing the first graft, which recovered function after 3 months. Both patients are now in good health with functioning grafts. CONCLUSIONS: LKT requires careful selection and preparation of candidates to optimize the probability of success. In well-compensated dialyzed patients with cirrhosis due to viral hepatitis, we believe that a combined approach is indicated after antiviral therapy. In cases of hepatorenal cystic disease, a two-stage surgical approach makes it possible to eliminate the risk of infection and intracyst hemorrhage in nonfunctioning polycystic kidneys.

Management of massive and persistent ascites and/or hydrothorax after liver transplantation.

PURPOSE: To describe the results of the treatment of eight liver transplantation (LT) patients subsequently developing large volumes of long-lasting ascites. PATIENTS AND METHODS: Between August 1996 and February 2003, 405 LTs were performed in 375 patients, eight (1.97%) of whom (six men and two women of mean age of 55.4 +/- 5.2 years) subsequently developed massive (> 500 mL/d) and persistent ascites and/or hydrothorax. All patients were HCV positive. The mean age of the liver donors was 66.8 +/- 21.9 years. All LTs were performed by replacement of the recipient retrohepatic vena cava. RESULTS: The eight patients displayed sinusoidal portal hypertension related to biopsy-proven recurrence of HCV infection. Mean wedged hepatic venous pressure was 14.9 +/- 5.1 mm Hg and mean portal vein/right atrial pressure gradient (PAPG) was 17.3 +/- 4.8 mm Hg. In two patients, the ascites appeared the day after LT; in the remaining six, ascites and/or hydrothorax appeared after 342.3 +/- 167.7 days. Seven patients with a mean PAPG of 18.4 +/- 3.9 mm Hg and a mean plasma/ascites albumin concentration gradient of 2.8 +/- 0.3 g/L were treated by means of a trans-jugular intrahepatic portosystemic shunt TIPS, and one (with a PAPG of 9 mm Hg and a plasma/ascites albumin concentration gradient of 1.38 g/L) by means of spleen arterial embolisation. After a mean follow-up of 558 +/- 147.2 days, the ascites and/or hydrothorax have resolved in five patients (62.5%), one (12.5%) has stable ascites not requiring paracentesis, and two (25%) have died of multiorgan failure. CONCLUSIONS: These data suggest the efficacy of the aggressive treatment of massive and persistent ascites and/or hydrothorax.

Perioperative anesthetic management for laparoscopic kidney donation.

OBJECTIVES: To report a single-center experience about the perioperative and anesthetic management of laparoscopic living kidney donation. PATIENTS AND INTERVENTIONS: Subjects undergoing laparoscopic (n = 39) (performed between April 2000 and August 2002) and traditional "open" kidney donation (n = 27) received a standard balanced anesthetic technique. However to counterbalance the reported abdominal insufflation-related kidney dysfunction, laparoscopic donors were administered an extra intravascular volume loading with colloid and crystalloid starting on the night before surgery. RESULTS: Laparoscopic donors underwent longer procedures with lower estimated blood losses (P =.0001), were intraoperatively administered higher amounts of intravenous fluids (P <.01), showed less postoperative analgesic requirement (P <.0001), shorter intensive care unit and overall hospitalization (P <.001), quicker resumption of solid oral intake (P <.01), and full return to work (P <.001) with no difference in the postoperative complication rate. Diuresis resumed intraoperatively in all recipients and early graft function did not differ between the two groups, although the serum creatinine declined earlier, but not significantly, in those receiving kidneys procured by the traditional method. No difference was seen in graft rejection rates. DISCUSSION AND CONCLUSIONS: Laparoscopic kidney donation does not require a particularly complex or expensive anesthetic management or approach; as it has been suggested that intra-abdominal hypertension coming from CO(2) insufflation inside the donor's peritoneal cavity may threaten graft function, during laparoscopic kidney donation it is advisable to adopt a strategy for "renal protection." Thus, when a laparoscopic kidney donation is performed at our center, a multidisciplinary approach is commonly adopted based on three key points: perioperative positive volemic balance in donors; intraoperative urinary output of at least 100 mL/h; inflation with an abdominal pressure not exceeding 12 mm Hg.

Hepatic resection after liver transplantation as a graft-saving procedure: indication criteria, timing and outcome.

BACKGROUND: Hepatic resection is uncommon after liver transplantation (LT), but can be a graft-saving procedure in selected cases. Herein we describe the criteria, outcome, and timing of this procedure in our series. METHODS: Between January 1996 and December 2002, 397 LTs were performed in 367 recipients, of whom 12 patients (3.2%) subsequently underwent liver graft resections because of ischemic-type biliary lesions (ITBLs) (n = 5, 41.6%), segmental hepatic artery thrombosis (S-HAT)(n = 3, 25%), recurrent hepatocellular carcinoma (HCC) (n = 2, 16.6%), liver abscess (n = 1, 8.3%), or liver trauma (n = 1, 8.3%). The patients were divided into group 1 (n = 3 all with S-HAT) who underwent early resections (within 3 months of LT), and group 2 (n = 9) who underwent late resections (after 3 months). The outcomes and postoperative mortality ratio (within 30 days) were compared. RESULTS: The resections consisted of four left lobectomies, three right hepatectomies, two extended right hepatectomies, one segmentectomy, one anterior trisegmentectomy, and one right lateral sectoriectomy. The perioperative mortality rate was 66.6% in group 1 (one case of myocardial infarction and one of sepsis), and 22% in group 2 (one case of sepsis and one of hepatic failure). CONCLUSIONS: Late resections in stable patients with damage confined to the graft yield good prognosis. Even major resections are feasible graft-saving procedures. In contrast, early hepatic resections in S-HAT are associated with a worse outcome. Retransplantation should be considered the first-choice option. Sepsis significantly affects the postsurgical course.

Surgical complications after liver transplantation.

AIM: The number of liver transplantations in Italy has steadily increased over the last 10 years as a result of the use of donors aged more than 60 years. The use of organs with a reduced functional reserve has been compensated for by improvements in immunosuppressive therapy, surgical techniques and the management of postoperative complications. This article describes the incidence and treatment of the main surgical complications after liver transplantation. METHODS: Between January 1996 and June 2003, 398 patients received 430 transplants at our Centre. Thirty-seven early relaparotomies were performed (8.6%), including 12 retransplantation (2.8%). The 1-, 3- and 5-year actuarial survival of the patients was 79.8%, 72.2% and 67.5%, and that of the grafts was 75.9%, 68% and 63.4%. Perioperative mortality was 10.5% (with no intraoperative deaths). RESULTS: The overall incidence of biliary complications was 31.6%, 9.1% of which were due to the removal of the Kehr tube. There were 42 (9.8%) anastomotic stenoses, 5 (1.2%) extra-anastomotic stenoses, 1 (0.2%) anastomotic leak, 5 (1.2%) extra-anastomotic leaks, and 19 (4.4%) ischemic-type biliary lesions. The overall incidence of vascular complications was 6.9%: 7 (1.6%) cases of hepatic artery thrombosis, 17 (4.0%) arterial stenoses, 1 (0.2%) arterial pseudoaneurysm, 4 (0.9%) cases of portal thromboses and 1 (0.2%) case of caval laminar thrombosis. Eight patients (1.9%) developed massive and persistent post-transplant ascites and/or hydrothorax. CONCLUSION: The use of donors aged more than 60 years makes it possible to maintain high standards of patient and graft survival that is not only due to the optimisation of immunosuppressive protocols, but also to improvements in surgical techniques, intensive care and the management of surgical complications.

[Biological risk for INAIL's clinical nurses]. / Il rischio biologico per gli infermieri dell'ambulatorio INAIL.

The authors analyse the biological risk inherent in nursing activity in INAIL's clinics. They highlight how this activity, though different from that in a hospital out-patient's department, involves risks inevitably connected to the contact with the insured person, injured in an accident or suffering from an occupational disease, especially in INAIL's surgical and orthopaedic "Prime cure" clinics. Then the authors mention concisely but exhaustively the prevention rules and broad criteria for general and specific prevention.

[Fundamental role of the workers' representative in preventive safety activity]. / Il ruolo fondamentale dei rappresentanti dei lavoratori nel programmare le attività di sicurezza.

With the arrival of Legislative Decree 626/94 which brought into Italian law the EU directives on workers' health and safety at the workplace, our country has also introduced rules that make a break with the past in this area, with the creation of new professional roles. The workers' safety representative takes on a fundamentally important role in the management of prevention, safety and health for workers in their place of employment in accordance with article 19. In fact, before the introduction of this Legislative Decree, the "protection" of workers' health was essentially based on rules and regulations the application of which was left to the exclusive and direct responsibility of the relationship between the employer and doctor, leaving out any participation by the worker. Whereas in the past workers could only be considered the final receivers of instructions about the security measures to apply, with Law 626 the workers themselves became active participants in the assessment of risks at work and consequently in the implementing of all the safety and hygiene measures contributing to the reduction of risk levels. The new regulations now in force assign important tasks to the workers' safety representative; all tasks and responsibilities associated with that role are examined and discussed, especially those relating to rights to information and training, consultation and participation in the process of designing and promoting safety measures. The job of workers' representative today takes on a fundamentally important meaning and role in a self-regulating system of work safety, where he or she has a proper area responsibility, so becoming a reference point for the workers generally.