[Pelvic floor rehabilitation before prostatectomy: An update]. / Rééducation sphinctérienne et périnéale avant prostatectomie : Mise au point.

PURPOSE: Preoperative pelvic floor physiotherapy is commonly prescribed to limit postoperative stress urinary incontinence after radical prostatectomy. It can be done in different ways. The objective of this work is to achieve a description of the objectives and existing techniques. MATERIAL AND METHOD: A narrative review is carried out based on a non-systematic review of the literature and on the authors' experience. RESULTS AND CONCLUSION: Although discussed in the literature, preoperative pelvic floor therapy is essential for patient support and follow-up. It should not be limited to strengthening the pelvic floor. It includes a significant time of information, which should not be neglected and should be carried out in association with a holistic care to best prepare the patient before his intervention.

Metrical assessment of cutmarks on bone: is size important?

Extrapolating type of blade from a bone lesion has always been a challenge for forensic anthropologists: literature has mainly focused on the morphological characteristics of sharp force lesions, whereas scarce indications are available concerning the metrical assessment of cut marks and their correlation with the size of blade. The present study aims at verifying whether it is possible to reconstruct the metrical characteristics of the blade from the measurements taken from the lesion. Eleven blades with different thickness, height and shape were used for this study. A metallic structure was built, in order to simulate incised wounds and reiterate hits with the same energy. Perpendicular and angled tests were performed on fragments of pig femurs, in order to produce 110 lesions (10 for each blade). Depth, height and angle were measured and compared with metrical characteristics of each blade. Results showed a wide superimposition of metrical characteristics of width and angle of lesions regardless the type and the orientation of blade: for symmetric blades a high correlation index was observed between the depth of the lesion and the angle of the blade in perpendicular tests (0.89) and between the angle of lesion and the height of the blade in angled tests (-0.76); for asymmetric blades in both the tests a high correlation was observed between the angle of the blade and angle and width of the lesion (respectively 0.90 and 0.76 for perpendicular tests, and 0.80 and 0.90 for angled ones). This study provides interesting data concerning the interpretation of cutmarks on bone and suggests caution in assessing the size of weapons from the metrical measurements of lesions.

Does cone beam CT actually ameliorate stab wound analysis in bone?

This study aims at verifying the potential of a recent radiological technology, cone beam CT (CBCT), for the reproduction of digital 3D models which may allow the user to verify the inner morphology of sharp force wounds within the bone tissue. Several sharp force wounds were produced by both single and double cutting edge weapons on cancellous and cortical bone, and then acquired by cone beam CT scan. The lesions were analysed by different software (a DICOM file viewer and reverse engineering software). Results verified the limited performances of such technology for lesions made on cortical bone, whereas on cancellous bone reliable models were obtained, and the precise morphology within the bone tissues was visible. On the basis of such results, a method for differential diagnosis between cutmarks by sharp tools with a single and two cutting edges can be proposed. On the other hand, the metrical computerised analysis of lesions highlights a clear increase of error range for measurements under 3 mm. Metric data taken by different operators shows a strong dispersion (% relative standard deviation). This pilot study shows that the use of CBCT technology can improve the investigation of morphological stab wounds on cancellous bone. Conversely metric analysis of the lesions as well as morphological analysis of wound dimension under 3 mm do not seem to be reliable.

Extubation score in the operating room after liver transplantation.

BACKGROUND: Early extubation after liver transplantation (LT) is an increasingly applied safe practice. The aim of the present study was to provide a simple extubation rule for accelerated weaning in the operating room (OR). METHODS: Data of 597 patients transplanted at the LT center of Turin (Italy) were retrospectively analyzed. Fifty-two nonextubated patients (excluding those with a scheduled early reoperation) were compared with 545 successfully extubated patients (not in need of reintubation within the first 48 h). Significant variables at univariate analysis were entered into a logistic regression model and the regression coefficients of independent predictors were used to yield a prognostic score called the safe operating room extubation after liver transplantation (SORELT) score. RESULTS: Two major and three minor criteria were found. The major ones were blood transfusions (higher than/or equal to 7 U of packed red blood cells) and end of surgery lactate (higher than/or equal to 3.4 mmol/l). The minor ones were status before LT (home vs. hospitalized patient), duration of surgery (longer than/or equal to 5 h), vasoactive drugs at the end of surgery (dopamine higher than 5 microg/kg/min or norepinephrine higher than 0.05 microg/kg/min). Patients who fulfill the SORELT score-derived criteria (fewer than two major/one major plus two minor/three minor criteria) can be considered for OR extubation. CONCLUSION: Early extubation after LT requires a very careful assessment of the pre-operative, intraoperative, graft and post-operative care data available. The SORELT score helps as a simple and objective aid in considering such a decision.

Hyperpolarized agents for advanced MRI investigations.

The strong signal enhancement attainable by hyperpolarization methods has allowed the detection of heteronuclei in magnetic resonance imaging (MRI), allowing to obtain high quality images with very high signal to noise ratios in few seconds. The four methods to produce hyperpolarized molecules, i.e. the "brute force" approach, optical pumping of noble gases, parahydrogen induced polarization (PHIP) and dynamic nuclear polarization (DNP), are reported. The applications of hyperpolarized probes to MRI range from vascular imaging to interventional imaging and perfusion studies, up to the emerging and challenging field of molecular/metabolic imaging. In fact, the high signal intensities achievable by using hyperpolarized molecules make it possible to detect and image the metabolic products formed upon the administration of the hyperpolarized agent. The most striking examples are surveyed, including the use of hyperpolarized 13C-pyruvate in tumor diagnosis and stadiation, and in myocardium perfusion and activity studies, as well as the recently reported proposal of using 13C-bicarbonate as agent for pH-mapping in vivo.

Ischemic preconditioning (IP) of the liver as a safe and protective technique against ischemia/reperfusion injury (IRI).

The aim of the study was to evaluate safety and efficacy of IP in LT, particularly in marginal grafts. From 2007 to 2008, 75 LT donors were randomized to receive IP (IP+) or not (IP-). Considering the graft quality, we divided the main groups in two subgroups (marg+/marg-). IP was performed by 10-min inflow occlusion (Pringle maneuver utilizing a toruniquet). Donor variables considered were gender, age, AST/ALT, ischemia time and steatosis. Recipient variables were gender, age, indication to LT and MELD/CHILD/UNOS score. AST/ALT levels, INR, bilirubin, lactic acid, bile output on postoperative days 1, 3 and 7 were evaluated. Histological analysis was performed evaluating necrosis/steatosis, hepatocyte swelling, PMN infiltration and councilman bodies. Thirty patients received IP+ liver. No differences were seen between groups considering recipient and donor variables. Liver function and AST/ALT levels showed no significant differences between the main two groups. Marginal IP+ showed lower AST levels on day1 compared with untreated marginal livers (936.35 vs. 1268.23; p = 0.026). IP+ livers showed a significant reduction of moderate-severe hepatocyte swelling (33.3% vs. 65.9%; p = 0.043). IP+ patients had a significant reduction of positive early microbiological investigations (36.7% vs. 57.1%; p = 0.042). In our experience IP was safe also in marginal donors, showing a protective role against IRI.

Acute blood leukocyte reduction after liver reperfusion: a marker of ischemic injury.

INTRODUCTION: Reperfusion injury occurs after ischemic storage of the liver. The release of free radicals from endothelial cells leads to increased adherence of polymorphonuclear neutrophils to endothelium and further release of proteases and free radicals that alter the microcirculation and produce graft dysfunction. Acute blood leukocyte reduction after reperfusion may be an expression of this sequestration and activation of neutrophils within hepatic sinusoids. This study sought to evaluate whether reduction in white blood cells occurring immediately after reperfusion was a marker of poor graft preservation and postoperative dysfunction. METHODS: The leukocyte count was evaluated at the end of anhepatic phase and at 5 minutes after reperfusion among 65 patients undergoing liver transplantation. Group A included patients with a leukocyte reduction between the two phases greater than 50%; group B, patients with less than 50%. Hepatic enzymes, blood lactate (60 and 120 minutes after graft reperfusion) and factor V and VII and bilirubin levels (daily for 15 days after transplantation) were compared between groups to assess graft injury and postoperative dysfunction. RESULTS: Alanine aminotransferase levels were significantly higher among group A than group B at both 60 and 120 minutes after graft reperfusion. No differences were observed in lactate, and factor V and VII levels. Total bilirubin was significantly higher among group A than group B patients at 10 and 15 days postoperative. CONCLUSIONS: The acute blood leukocyte reduction after reperfusion, probably due to sequestration and activation into hepatic sinusoids, seemed to be an early intraoperative marker for poor graft preservation and function.

Neurological complications of liver cirrhosis and orthotopic liver transplant.

Neurological complications are common in cirrhotic patients with end-stage liver failure. They comprise a wide array of etiologies, which may originate before, during, or after liver transplantation. The objective of this study was to describe the nature of the main neurological complications in patients with end-stage liver failure. Several toxins including ammonia, manganese, benzodiazepine-like substances, gamma-aminobutyric acid-like substances, and impaired dopaminergic neurotransmission are at the top of the list of candidates for hepatic encephalopathy, subclinical encephalopathy, and extrapyramidal signs before liver transplantation. Central pontine myelinolysis, cerebrovascular autoregulation impairment, and paradoxical cerebral embolism are probably responsible for the neurological complications during liver transplantation. Neurological complications represented by alterations of mental status, seizures, and focal motor deficits have been described after liver transplantation. These complications have been attributed to several pathogenetic factors, such as a poorly functioning graft, an intracranial hemorrhage, a cerebral infarction, an infection, or the toxicity of immunosuppressants.

Sequential liver-kidney transplantation.

The indications for sequential liver and kidney transplantation have not been well defined. Two categories of patients may benefit from this procedure: patients with primary renal disease associated with hepatic disorders (glomerulonephritis, tubulointerstitial nephritis, metabolic diseases, and structural diseases) and patients who develop renal failure after liver transplantation. Chronic renal failure is a frequent long-term complication after liver transplantation. End-stage renal disease develops in 2% to 10% of cases by 10 years after transplantation. Kidney transplantation appears to be a better option than dialysis for the treatment of end-stage renal disease after liver transplantation. In contrast, survival rates, after kidney transplantation are significantly lower among liver transplant patients than primary-only kidney transplant recipients. Considering the donor shortage, kidney transplantation should be cautiously considered in liver transplantation patients. New immunosuppressive drugs and protocols are needed to reduce chronic renal failure after liver transplantation.

[Some remarks on the management of liver donor]. / Alcune considerazioni sulla gestione del donatore di fegato.

We evaluated 481 liver donors in order to assess the incidence of positive cultures on samples obtained before harvesting, at harvesting and on preservation fluid; to determine factors related to positive cultures in the donor; to analyse the bacterial and fungal transmission from donor to recipient; to verify the influence of donor culture positivity on graft and patient survival. Cultures were positive in 232 of 481 (48%) donors. Bacteremia was present in 101 of 481 (20%) donors. Intensive care length of stay was significantly longer in culture-positive donors. A Gram-negative bacteria transmission from the infected donor to the graft recipient was proven in 1 case. No differences in 1-year survival and retransplantation rates were found between patients receiving livers from culture-positive or negative donors. In conclusion, even if rare, donor to host infection transmission is proven. Extended criteria for organ procurement may explain the high number of culture-positive donors we report. Careful microbiological surveillance and treatment can reduce the clinical negative impact on recipient outcome.

Liver transplantation for erythropoietic protoporphyria: report of a case with medium-term follow-up.

A case of liver transplantation is described in a 35-year-old male with hepatic failure due to erythropoietic protoporphyria. Data regarding protoporphyrin levels in erythrocytes and faeces, before and after transplantation, seem to indicate that, in this case, protoporphyrin overproduction was, in part, due to liver synthesis. Four years after surgery, the patient is completely free of skin photosensitivity. Liver function tests are normal and there are no significant protoporphyrin deposits in the new liver. However, recurrence of the disease in the long-term cannot be excluded, since erythrocyte protoporphyrin levels have remained elevated after liver transplantation.

[Computerized tomography in the study of thoracic-pulmonary complications after liver transplantation]. / La Tomografia Computerizzata nello studio delle complicanze toraco-pulmonari dopo trapianto del fegato.

PURPOSE: To review the role of Computed Tomography (CT) in thoracic complications following orthotopic liver transplantation (OLT). MATERIAL AND METHODS: In a post-OLT population of 567 patients transplanted in our institution, 100 patients (17.6%) were examined with chest CT. We reviewed data relative to the total number of examinations, clinical and/or radiographic indications, the CT technique--i.e., conventional (with(out) intravenous, i.v., contrast material) or high-resolution (HRCT). We also reviewed the radiologic patterns and their correlation with the other clinical, bronchoscopic and/or laboratory results. RESULTS: Of 152 chest CT examinations, 45 (29.6%) were performed because of clinical indications, 31 (20.4%) because of a radiographic abnormality, 64 (42.1%) because of clinical and radiographic indications, while in 12 cases (7.9%) the reasons were unknown; 133/152 (87.5%) examinations had been performed with conventional CT scanning (100 with i.v. contrast agent and 33 without) and 19/152 (12.5%) with HRCT. Twenty of 152 (13.2%) examinations, in 16 patients, were normal; in the other 84 patients, 132/152 (86.8%) CT/HRCT studies showed 247 pathological findings (99 pleural effusions, 3 pericardial effusions, 62 cases of atelectasis, 1 pulmonary calcification, 70 suspected inflammatory parenchymal consolidations, 64 of them alveolar and 6 interstitial, 4 cases of interstitial edema and finally 8 neoplastic infiltrates). DISCUSSION: Correlated with clinical data, CT findings are very useful in detailing clinical-radiographic screening findings, despite the limitations in typifying pleural effusions, in differentiating atelectases from inflammatory parenchymal consolidations and in assessing pneumonia etiology. Also, despite its high sensitivity (94.1%) and specificity (92.8%), CT was not accurate enough in the differential diagnosis of pneumonia. History data were necessary to characterize the histology of neoplastic infiltrates. CONCLUSIONS: Chest CT has relatively uncommon, and sometimes only clinical, indications in post-OLT patients. The technique is chosen based on clinical-radiographic findings. CT proved useful in showing negative cases and in detailing clinical and radiographic findings but must be integrated with clinical findings to define inflammatory and neoplastic conditions.

Exhaled nitric oxide and impaired oxygenation in cirrhotic patients before and after liver transplantation.

BACKGROUND: Nitric oxide may be involved in the impaired oxygenation of cirrhotic patients, a condition that improves in most patients after liver transplantation. OBJECTIVE: To compare oxygenation and nitric oxide concentrations before and after liver transplantation. DESIGN: Before-and-after observational study. SETTING: Academic medical center. PATIENTS: 18 patients with cirrhosis and no obvious cardiopulmonary disease who underwent successful orthotopic liver transplantation. INTERVENTION: Orthotopic liver transplantation. MEASUREMENTS: Blood gas analysis, measurement of exhaled nitric oxide, contrast-enhanced echocardiography, and pulmonary function tests. RESULTS: Before transplantation, the mean (+/- SD) exhaled nitric oxide concentration was higher in patients than in normal controls (13 +/- 4.9 parts per billion [ppb] compared with 5.75 +/- 1.9 ppb; P < 0.001). After transplantation, the alveolar-arterial oxygen gradient significantly decreased (from 17.3 +/- 7.1 mm Hg to 9 +/- 5.2 mm Hg; P < 0.001), as did the exhaled nitric oxide concentration (from 13 +/- 4.9 ppb to 6.2 +/- 2.8 ppb; P < 0.001). The decrease in the exhaled nitric oxide concentration was significantly correlated with the decrease in the alveolar-arterial oxygen gradient (r = 0.56; P = 0.014). Five patients met the criteria for the diagnosis of the hepatopulmonary syndrome before transplantation; the syndrome was cured by transplantation. CONCLUSIONS: The correlation between the decrease in exhaled nitric oxide concentration after liver transplantation and the improvement in oxygenation reinforces the hypothesis that nitric oxide is an important mediator of impaired oxygenation in patients with cirrhosis.

Long-term follow-up of patients with chronic hepatitis C treated with different doses of interferon-alpha 2b.

Eighty patients with chronic hepatitis C who completed a previously reported randomized controlled trial on the efficacy of interferon-alpha 2b were followed up for at least 36 mo after therapy discontinuation. Seventeen patients (21.2%) maintained normal ALT values throughout the follow-up; 63 (78.8%) either did not normalize the levels of ALT or relapsed during the follow-up. A significantly greater proportion of patients treated with 3 million units of interferon three times a week subcutaneously for 48 wk were long-term responders compared with patients treated for 24 wk. Sex, age, hepatitis C virus antibody status, source of infection and pretreatment levels of ALT were not predictive of long-term response. Cirrhosis was found to be an unfavorable predictive factor. After 3 yr of follow-up, clearance of viremia was observed in 58.9% of the 17 long-term responders but in none of the non-responders (p = 0.002). E2-NS1 antibody tested negative in 88.2% of long-term responders and in 14.3% of nonresponders (p = 0.001). Fifty-nine percent of long-term responders tested negative for C100-NS4 antibody compared with 14.3% of nonresponders (p = 0.031). No significant change was observed in other antibodies. Four long-term responders underwent liver biopsy 2 yr after discontinuation of therapy. All four patients had normal liver histology compared with baseline assessment of chronic active hepatitis in three and chronic persistent hepatitis in the other. Three of the four were negative for serum hepatitis C virus RNA.

[A new ventilation method: the laryngeal mask]. / Un nuovo metodo di ventilazione: la maschera laringea.

A size 3 laryngeal mask was used in 20 patients who underwent elective general surgery. It consists of a silicon tube attached to mask which must be inserted into the hypopharynx and then inflated. No curarisation nor laryngoscopy is needed. Operations were performed in assisted or spontaneous ventilation, with good airway patency and absence of coughing, secretions and sore throat. In 2 cases introduction of the mask failed. Technique, advantages and problems related to its use are described.

Alpha-fetoprotein and tissue polypeptide antigen in non neoplastic hepatic disorders.

In order to evaluate the behaviour of alpha-fetoprotein (AFP) and Tissue Polypeptide Antigen (TPA) in non neoplastic chronic hepatic diseases 60 patients suffering from chronic hepatitis have been studied, 28 of them with different ethiology cirrhosis, 4 with primary biliary cirrhosis (CBP), 18 with chronic active hepatitis (ECA), 5 with chronic persistent hepatitis (ECP), 3 suffering from alcoholic and 2 drug-induced hepatitis. In each case the diagnosis was biopsy-proved. We have found that TPA clearly shows an increase in about 90% of cirrhosis and in about 50% of ECA. Moreover, the group with non-A, non-B (NANB) cirrhosis and chronic hepatitis has shown a statistically significant correlation between TPA and alanine aminotransferase (ALT). On the other hand, AFP hants' shown statistically significant variations. The reasons of the TPA increase must probably be looked for in the marked sensitivity of this protein to non neoplastic tissues in rapid regeneration, in addition to the sensitivity to neoplastic tissues. Further studies will be carried out to evaluate the usefulness of TPA to tracing possible cytolitic relapses or any resumption of activity in hepatic cirrhosis.