Estimated health impacts from maritime transport in the Mediterranean region and benefits from the use of cleaner fuels.

Ship traffic emissions degrade air quality in coastal areas and contribute to climate impacts globally. The estimated health burden of exposure to shipping emissions in coastal areas may inform policy makers as they seek to reduce exposure and associated potential health impacts. This work estimates the PM2.5-attributable impacts in the form of premature mortality and cardiovascular and respiratory hospital admissions, from long-term exposure to shipping emissions. Health impact assessment (HIA) was performed in 8 Mediterranean coastal cities, using a baseline conditions from the literature and a policy case accounting for the MARPOL Annex VI rules requiring cleaner fuels in 2020. Input data were (a) shipping contributions to ambient PM2.5 concentrations based on receptor modelling studies found in the literature, (b) population and health incidence data from national statistical registries, and (c) geographically-relevant concentration-response functions from the literature. Long-term exposure to ship-sourced PM2.5 accounted for 430 (95% CI: 220-650) premature deaths per year, in the 8 cities, distributed between groups of cities: Barcelona and Athens, with >100 premature deaths/year, and Nicosia, Brindisi, Genoa, Venice, Msida and Melilla, with tens of premature deaths/year. The more stringent standards in 2020 would reduce the number of PM2.5-attributable premature deaths by 15% on average. HIA provided a comparative assessment of the health burden of shipping emissions across Mediterranean coastal cities, which may provide decision support for urban planning with a special focus on harbour areas, and in view of the reduction in sulphur content of marine fuels due to MARPOL Annex VI in 2020.

A novel approach to evaluate the lung cancer risk of airborne particles emitted in a city.

Air quality still represents a main threat to human health in cities. Even in developed countries, decades of air pollution control not yet allowed to reduce pollutant concentrations in urban areas adequately. Indeed, high airborne particle concentrations are measured in several European cities; this is a main issue since particles represent a carrier for carcinogenic compounds. Numerous researches measuring the exposure to the different aerosol metrics in urban areas were recently performed, nonetheless, few data on the lung cancer risk in such environments are available. In the present paper a novel approach to evaluate the lung cancer risk related to the airborne particles emitted by the different sources located in a city is proposed and applied to a pilot case-study (i.e. an Italian city). In particular, an existing lung cancer risk model was modified and applied to assess the particle-related lung cancer "emitted" by the different sources of the city using pollutant emission factors provided by accredited emission inventory databases. Therefore, the average toxicity of the particles emitted by the city (i.e. lung cancer slope factor) and the lung cancer risk globally emitted by the city, expressed as new cases of lung cancer, were evaluated. The proposed emission inventory also allowed to identify and localize the main contributors to the overall risk emitted in a city. As an example, for the city under investigation, the research revealed that the main contributor, amongst the sources considered, is the vehicular traffic which is characterized by a lower mass fraction of carcinogenic compounds but a much higher sub-micron particle emission with respect to the other sources.

Characterization of airborne particles emitted by an electrically heated tobacco smoking system.

Smoking activities were recognized as a main risk factor for population. Indeed, mainstream smoke aerosol is directly inhaled by smokers then delivering harmful compounds in the deepest regions of the lung. In order to reduce the potential risk of smoking, different nicotine delivery products have been recently developed. The latest device released is an electrically heated tobacco system (iQOS®, Philip Morris) which is able to warm the tobacco with no combustion. In the present paper a dimensional and volatility characterization of iQOS-generated particles was performed through particle number concentration and distribution measurements in the mainstream aerosol. The experimental analysis was carried out through a condensation particle counter, a fast mobility particle sizer and a thermo-dilution sampling system allowing aerosol samplings at different temperatures. Estimates of the particle surface area dose received by smokers were also carried out on the basis of measured data and typical smoking patterns. The particle number concentrations in the mainstream aerosols resulted lower than 1 × 108 part. cm-3 with particle number distribution modes of about 100 nm. Nonetheless, the volatility analysis showed the high amount of volatile fraction of iQOS-generated particles, indeed, samplings performed at 300 °C confirmed a significant particle shrinking phenomena (modes of about 20 nm). Anyway, the particle number concentration does not statistically decrease at higher sampling temperatures, then showing that a non-volatile fraction is always presents in the emitted particles. The dose received by smokers in terms of non-volatile amount of particle surface area was equal to 1-2 mm2 per puff, i.e. up to 4-fold larger than that received by electronic cigarette vapers.

Lung cancer risk assessment due to traffic-generated particles exposure in urban street canyons: A numerical modelling approach.

Combustion-generated nanoparticles are responsible for negative health effects due to their ability to penetrate in the lungs, carrying toxic compounds with them. In urban areas, the coexistence of nanoparticle sources and particular street-building configurations can lead to very high particle exposure levels. In the present paper, an innovative approach for the evaluation of lung cancer incidence in street canyon due to exposure to traffic-generated particles was proposed. To this end, the literature-available values of particulate matter, PAHs and heavy metals emitted from different kind of vehicles were used to calculate the Excess Lifetime Cancer Risk (ELCR) at the tailpipe. The estimated ELCR was then used as input data in a numerical CFD (Computational Fluid Dynamics) model that solves the mass, momentum, turbulence and species transport equations, in order to evaluate the cancer risk in every point of interest inside the street canyon. Thus, the influence of wind speed and street canyon geometry (H/W, height of building, H and width of the street, W) on the ELCR at street level was evaluated by means of a CFD simulation. It was found that the ELCR calculated on the leeward and windward sides of the street canyon at a breathable height of 1.5 m, for people exposed 15 min per day for 20 years, is equal to 1.5 × 10-5 and 4.8 × 10-6, respectively, for wind speed of 1 m/s and H/W equal to 1. The ELCR at street level results higher on the leeward side for aspect ratios equal to 1 and 3, while for aspect ratio equal to 2 it is higher on the windward side. In addition, the simulations showed that with the increasing of wind speed the ELCR becomes lower everywhere in the street canyon, due to the increased in dispersion.

Variability of airborne particle metrics in an urban area.

In the present study a mobile monitoring approach (i.e. bike with onboard instruments) was proposed and applied to investigate the spatial variability of all the key airborne particle metrics in an Italian urban area from a statistical point of view. Particle number, alveolar-deposited surface area, and PM10 concentrations were measured through hand-held monitors and compared to simultaneous background concentrations by means of non-parametric tests and further post-hoc tests (Kruskal-Wallis test). Streets characterized by exposure levels statistically higher than the background levels for all the particle metrics were identified for different seasons in a pilot urban area (Cassino, Italy). A higher number of hot spots was detected for metrics affected by ultrafine particles (i.e. number and alveolar-deposited surface area concentrations) with respect to PM10. The effect of metrological requirements of the instrumentation on the proposed method was also discussed.

A new proposal of surgical suture in case of spontaneous renal allograft rupture.

INTRODUCTION: Spontaneous kidney allograft rupture (KAR) is a rare but potentially life-threatening complication after kidney transplantation. It is associated with a high risk of graft loss and patient death. We report a new technique of surgical repair in case of KAR. CASE REPORT: A 53-year-old man transplanted due to diabetic nephropathy-related end-stage renal disease experienced a spontaneous KAR 10 days after KT. Immediate laparotomy revealed the presence of a 4-cm linear kidney fracture. Dexon 2-0 wires were used for the suture, stopping each wire with Hem-o-Loks on a cylinder of oxidized cellulose gauze, with the intent of avoiding the risk of tissue fracture caused by the suture itself. Bleeding was thus controlled. The patient experienced an uneventful course and was discharged on postoperative day 26. CONCLUSIONS: According to the recent literature, graft nephrectomy for KAR is no longer considered the standard surgical treatment. A new approach to rupture repair has been proposed, providing good rates of graft and patient survival.

Management of kidney transplantation in a factor VII-deficient patient: case report.

Transplantation in patients with congenital bleeding disorders is a challenge requiring an integrated approach of various specialists. Renal transplantation, the most frequent type of solid organ transplantation, is rarely performed in individuals with congenital hemorrhagic disorders. We performed a renal transplantation in a 53-year-old man with end-stage renal disease and congenital coagulation factor VII deficiency, a rare bleeding disorder with a peculiar clinical picture requiring replacement therapy in surgical interventions. Perioperative bleeding was successfully prevented by administration of recombinant activated factor VII. Treatment schedule, administration rate, and long-term follow-up are reported in detail. Our report confirmed the feasibility and safety of recombinant activated factor VII in major surgical procedures like solid organ transplantations. Success requires evaluation of doses and therapeutic schedules as well as a multidisciplinary approach.

A rare case of herpes simplex type 1 bronchopneumonia associated with cardiomegaly in renal transplantation.

INTRODUCTION: We report a rare case of herpes simplex virus (HSV) type 1B in patient with kidney transplant as a possible cause of patient death. CASE REPORT: A 32-year-old renal transplanted Caucasian man was referred for asthenia, fever, anemia, chest pain, cough, dyspnea, myalgias, peripheral edema, acute renal failure, diffuse cutaneus and mucous vesicles, and acute weight gain. The home therapy consisted of tacrolimus, sodic mycophenolate, and steroids. Laboratory data, bronchoscopy, and bronchial mucosal biopsy revealed HSV1B. We administered antiviral and antibiotic agents and reduced tacrolimus with clinical resolution. But after 10 days from discharge, the patient was admitted for acute cardiomegaly. So using ex adiuvantibus criteria we administered antiviral therapy with complete clinical improvement. CONCLUSION: According to the literature, posttransplant HSV1B infection is a rare but severe complication of kidney transplantation associated with poor graft survival and a high mortality. Only an early, accurate diagnosis with efficient treatment permitted resolution of the problem. Our report stresses the difficulty of HSV2B clinical diagnosis and treatment.

Kidney transplantation from older donors.

BACKGROUND: The use of kidneys from older donors has become generally accepted and increasingly common, despite the knowledge that donor age is a well-known risk factor for graft failure. AIM: To review our experience with the utilization of kidneys from donors older than 60 years. PATIENTS AND METHODS: Among two hundred eight patients, 32 (group A) received an organ obtained from a donor older than 60 years. The organs were age-matched with a maximum gap of 20 years between donors and recipients. Organs from older donors were assigned to recipients presenting a body mass index lower than that of the donor. The primary end point was patient and graft survival. Secondary endpoints were incidences of delayed graft function and of acute rejection episodes as well as renal function at 3 months and yearly. RESULTS: The two groups were comparable in terms of demographic features, indications for transplantation, comorbidities, as well as cold and warm ischemia times. The Mean lengths of follow up were 31.4 ± 20.3 months and 30.3 ± 20.1 months, respectively. Graft and patient survivals were comparable. Mean creatinine values at the study intervals were significantly lower among group B who received grafts from younger donors. The incidence of delayed graft function and acute rejection episodes were similar: 15.6% (5/32) versus 20.5% (36/176; P=0.35) and 15.6% (5/32) and 12.1% (21/167; P=0.136) in groups A and B, respectively. CONCLUSIONS: Donor age older than 60 years showed a negative impact on kidney function. Though, given the escalating disparity between organ supply and demand, this precious source of organs cannot be neglected. We need better ways to use the available organs.

Superior vena cava syndrome due to thrombotic occlusion in a thrombophilic renal transplant recipient: a case report.

The case of a superior vena cava syndrome due to a central venous catheter thrombosis occurring in a second renal transplant patient is described. Imaging revealed thrombosis of the right internal jugular vein with extension along the confluence of the brachiocephalic veins and partial obstruction of the superior vena cava. Anticoagulant therapy with subcutaneous low-molecular-weight heparin was followed by warfarin administration. Despite adequate treatment, the symptomatology worsened because of thrombus organization. A workup revealed a complex prothrombotic underlying condition. Cardiothoracic surgeons were consulted, and an operative reconstruction of the superior vena cava using spiral vein bypass grafting was performed. In this report we describe the clinical presentation, diagnosis, and treatment of this case, with an emphasis on the role of thrombophilia.

A rare case of colic thrombotic microangiopathy in renal transplantation.

INTRODUCTION: We report a case of thrombotic microangiopathy (TM) in patient with UC and kidney transplantation. CASE REPORT: A 59-year-old Caucasian may with a renal transplant, with atrial fibrillation and ulcerative colitis (UC), was referred for asthenia, fever (38 degrees C), anemia, colicky pain, and bloody diarrhea. The maintenance therapy consisted of CSA, sodium mycophenolate, steroids, ticlopidine, and mesalazine. Laboratory data, colonscopy, and colic mucosal biopsy revealed de novo colic TM. We administered antibiotics and antishock therapy, reducing CSA, withdrawing ticlopedine and maintaining mesalazine with the resolution of the problem. CONCLUSION: Posttransplantation TM is an uncommon but severe complication of kidney transplantation associated with reduced graft survival and a high risk for death. Only an early, accurate diagnosis with optimal treatment permits resolution of the problem.

Clinical operational tolerance after solid organ transplantation.

Clinical operational tolerance (COT) is a clinical condition obtainable with difficulty after solid organ transplantation (SOT). It is characterized by perfectly normal graft function in the total absence of maintenance immunosuppression. Major benefits deriving from the onset of COT are the reduction of risk for immunosuppression-related side effects and the improved quality of life. Currently, COT can be safely achieved in stable liver transplant recipients; it remains a challenge after renal transplantation. Only 1 case of COT has been reported after lung transplantation; no cases have been described after other types of SOT. Overall, mechanisms of COT are unclear and strategies to induce COT cannot be applied on a regular base to a large cohort of SOT recipients. Due to the failure of molecularly based tolerogenic protocols, great hope relies in the adoption of cell-based strategies.

Scrotal herniation of the ureter: a rare late complication after renal transplantation.

Although late ureteral obstruction represents the most frequent urologic complication after renal transplantation, its etiology remains poorly understood. Benign prostatic hyperplasia (BPH) is the most common cause of urinary tract obstruction in the adult male population, but information regarding BPH epidemiology and its impact on clinical outcomes are lacking. We herein have described a case of ureteral herniation into the scrotum, secondary to concomitant upper and lower urinary tract obstruction: namely, BPH and ureterovesical junction stenosis causing massive urine retention and acute renal failure. The simultaneous presence of the 2 lesions rendered the diagnosis difficult. In addition, urine outflow responsible for bladder outlet obstruction resumed after transurethral resection of the prostate (TURP). The hydroureteronephrosis, which persisted after the TURP resolved only after positioning a double J stent, but renal function did not normalize. Attention must be paid to BPH in the differential diagnosis of urinary tract obstruction. Stenosis of the ureterovesical junction may occur very late after transplantation.

Serious renal hemorrhage in Masson tumor.

Intravascular papillary endothelial hyperplasia (IPEH; Masson tumor) is a vascular lesion of blood vessels, first described in 1923 by Masson, who termed it "hemangioendotheliome vegetant Intravasculaire." This lesion consists of an exuberant, usually intravascular, proliferation of normal endothelial cells and is considered to be a reactive vascular proliferation after traumatic vascular stasis. The disease frequently occurs in skin and subcutaneous tissue; occurrence in solid organs is rare. We report a rare case IPEH that recurred as a possible consequence of an acute hypertensive arterial crisis in a patient with chronic kidney failure after kidney transplantectomy. Thirty days after transplantectomy, a 49-year-old white man receiving hemodialysis had pain in the left abdominal flank and acute anemia with serious hypovolemia after a hypertensive arterial crisis. An emergency non-contrast enhanced abdominal computed tomographic scan showed a massive retroperitoneal hemorrhage. A left nephrectomy was performed for evidence of a native kidney breach with toilette of the abdominal cavity. Histologic analysis revealed that the renal lesion had several important distinguishing characteristics that confirmed the diagnosis of IPEH. This lesion is considered to be an usual form of thrombus organization that is marked by excessive papillary endothelial proliferation. In rare cases, it is present in a solid organ of the abdominal cavity especially the kidney. Intravascular papillary endothelial hyperplasia is a benign lesion but can be dangerous. Clinical, radiologic, and histologic diagnosis of IPEH is difficult.

Clinical operational tolerance after kidney transplantation: a short literature review.

The clinical era of solid organ transplantation started with a renal transplantation (RT) performed between identical twins in Boston in 1954. The patient did not receive any immunosuppression, thus representing the very first case of operational tolerance (Tol). However, more than half a century later, we must admit the inadequacy of our knowledge regarding such a fundamental aspect of transplant immunology, as demonstrated by the fact that Tol has never been achieved in an intention-to-treat protocol. Herein we aim to shortly review the worldwide experience on clinical operational Tol after RT. Thus far, reports on successful cases of Tol after RT have been anecdotal: the largest series included no more than 10 individuals. We will understand that Tol can develop even in the presence of either HLA mismatches or blood group incompatibility at baseline, in the presence of anti-HLA antibodies during follow-up, as well as in patients having experienced acute rejection. Despite the lack of robust evidence, the fact that Tol is often accidentally discovered by transplant physicians during follow-up in noncompliant patients justifies the hypothesis that the real number of Tol cases might be much higher than currently reported.

Incidence of urinary tract infections caused by germs resistant to antibiotics commonly used after renal transplantation.

BACKGROUND: The inadequate utilization of antibiotics is responsible for the development of urinary tract infections (UTI) after renal transplantation (RT), through the induction of resistance to the antibiotics themselves. The purpose of this study was to evaluate the incidence of resistance to cefotaxime (CEF) and trimethoprim/sulfamethoxazole (TMP-SMX), routinely used for surgical perioperative prophylaxis and prevention of Pneumocystis carinii, respectively. MATERIALS AND METHODS: We enrolled all adult patients having received an RT from 2001 to 2006 and having a minimum follow-up of 6 months. Urine cultures (UC) were routinely performed at every outpatient clinic control and whenever required by the onset of significant clinical signs/symptoms. UTI was diagnosed by the presence of a positive UC. The endpoint of the study was the emergence of bacterial strains resistant to either CEF or TMP/SMX. RESULTS: We recorded 169 UTI in 76 patients (38 men/38 women, 33%) over a mean follow-up of 779.9+/-523.3 days. Thirty-nine patients (51%) developed more than 1 UTI episode. When gram-negative bacteria were considered, 102/144 (70.8%) tests showed resistance to TMP/SMX, while data were available in about only 7 gram-positive infections (5/7, 71%). CEF was tested less frequently with 21/43 (49%) germs resistant to this molecule. CONCLUSIONS: The onset of bacterial resistance to either TMP/SMX or CEF is frequent after RT. A wiser stricter utilization of antibiotics is mandatory. Standard antibiotic protocols should be revised.

De novo autoimmune hepatitis following liver transplantation: a case report.

De novo autoimmune hepatitis (AIH), a rare disorder first described in 1998, appears in patients with liver transplants due to autoimmune and nonautoimmune etiologies. De novo AIH occurs in 2.5% to 3.4% of allografts; children seem to have a predilection for this syndrome. We have present herein a case of a liver allograft recipient who developed chronic hepatitis associated with autoimmune features outlining the clinical course, liver histology, and response to treatment.

Risk factors that can influence kidney transplant outcome.

The survival and function of a kidney transplant are influenced by numerous immunological and nonimmunological factors. The aim of this study was to evaluate the role of a number of cadaveric donor parameters on transplanted kidney function, and in particular on the occurrence of delayed graft function (DGF) since DGF is one of the most important factors in long-term organ survival. This study looked at 143 patients who underwent kidney transplant of whom 32 displayed DGF. The creatinine levels in organ recipients, which were evaluated during a follow-up that ranged between 6 months and 4 years, were significantly higher among recipients who developed DGF after transplant (1.8 +/- 0.7 vs 1.4 +/- 0.4; P = .02). The following donor parameters were taken into consideration: history of diabetes and hypertension; creatinine levels; inotropie therapy; problems relating to hemodynamics (hypotension and/or cardiac arrest); and cold ischemia time. We observed that a donor history of hypertension (46.8% DGF vs 23.27% no DGF; P = .01) and high levels of donor creatinine prior to organ removal (1.9 +/- 1.2 mg/dL DGF vs 1.2 +/- 0.9 mg/dL no DGF; P = .007) were significant risk factors for DGF among kidney recipients. No significant differences were found for others factors between recipients with versus without DGF.

Urologic complications in kidney transplantation.

Urologic complications in kidney transplantation have an incidence ranging from 3% to 20%, representing an important cause of organ loss. From January 2001 to September 2004, 123 renal transplantations were performed using an immunosuppressive protocol including basiliximab, mycophenolate mofetil, calcineurin inhibitors, and steroids. The surgical technique was vascular anastomoses to external iliac vessels, and ureteral anastomosis according to Lich Gregoire technique using a JJ ureteral stent. We report 5 renal complications (4.2%) and 4 extrarenal complications (3.5%), the majority of which required corrective surgery. The surgical strategy uses the clinical condition of the donor and the recipient; the anatomic anomalies of the graft, and a reduced cold ischemia time. Moreover, a reduction in acute rejection episodes and immediate renal function has been fundamental to reduce urologic complications. In fact, the main cause of urologic complications is ureteral ischemia, linked both to backtable surgery and to rejection episodes. Another important factor in the reduction of early urologic complications has been the routine use of a JJ stent, which allowed us a conservative approach in this setting.

Malignancies after kidney transplantation.

The most effective treatment of end-stage renal disease is renal transplantation; its superiority to prolong the longevity of patients is well established. Patient and graft survivals have improved with more potent immunosuppression but this advance has been associated with an increased incidence of cancer. The aim of this study was to assess the prevalence of cancer among 265 kidney transplant recipients engrafted between 1968 and October 2004. The overall prevalence of de novo malignancies was 3%. The mean age at diagnosis was 53.3 years (range, 28-63 years) and the duration of the transplant was 11.6 years (range, 0.3-33 years). One patient among 127 (0.8%) who had a history of less than 3 years under immunosuppression, developed a posttransplantation lymphoproliferative disorder (PTLD). Among the 138 patients who had more than 3 years immunosuppression, 7 (5%) developed neoplasms of vulva, colon, native kidneys, prostatic gland, and ovary. One patient was affected by de novo carcinoma in the transplanted kidney. Compared with other published studies, our early cancer prevalence is low, possibly due to a careful history before grafting, good HLA matching, and abstinence from anti-T-cell therapy for treatment of acute rejection episodes. The low level of immunosuppression may account for the low prevalence of neoplasia. The risk of developing a malignancy increases with long-term immunosuppression, comparable with most reports.