Intra-Abdominal Cooling System Limits Ischemia-Reperfusion Injury During Robot-Assisted Renal Transplantation.

Robot-assisted kidney transplantation is feasible; however, concerns have been raised about possible increases in warm ischemia times. We describe a novel intra-abdominal cooling system to continuously cool the kidney during the procedure. Porcine kidneys were procured by standard open technique. Groups were as follows: Robotic renal transplantation with (n = 11) and without (n = 6) continuous intra-abdominal cooling and conventional open technique with intermittent 4°C saline cooling (n = 6). Renal cortex temperature, magnetic resonance imaging, and histology were analyzed. Robotic renal transplantation required a longer anastomosis time, either with or without the cooling system, compared to the open approach (70.4 ± 17.7 min and 74.0 ± 21.5 min vs. 48.7 ± 11.2 min, p-values < 0.05). The temperature was lower in the robotic group with cooling system compared to the open approach group (6.5 ± 3.1°C vs. 22.5 ± 6.5°C; p = 0.001) or compared to the robotic group without the cooling system (28.7 ± 3.3°C; p < 0.001). Magnetic resonance imaging parenchymal heterogeneities and histologic ischemia-reperfusion lesions were more severe in the robotic group without cooling than in the cooled (open and robotic) groups. Robot-assisted kidney transplantation prolongs the warm ischemia time of the donor kidney. We developed a novel intra-abdominal cooling system that suppresses the noncontrolled rewarming of donor kidneys during the transplant procedure and prevents ischemia-reperfusion injuries.

Pre-Kidney Transplant Lower Extremity Impairment and Post-Kidney Transplant Mortality.

Prediction models for post-kidney transplantation mortality have had limited success (C-statistics ≤0.70). Adding objective measures of potentially modifiable factors may improve prediction and, consequently, kidney transplant (KT) survival through intervention. The Short Physical Performance Battery (SPPB) is an easily administered objective test of lower extremity function consisting of three parts (balance, walking speed, chair stands), each with scores of 0-4, for a composite score of 0-12, with higher scores indicating better function. SPPB performance and frailty (Fried frailty phenotype) were assessed at admission for KT in a prospective cohort of 719 KT recipients at Johns Hopkins Hospital (8/2009 to 6/2016) and University of Michigan (2/2013 to 12/2016). The independent associations between SPPB impairment (SPPB composite score ≤10) and composite score with post-KT mortality were tested using adjusted competing risks models treating graft failure as a competing risk. The 5-year posttransplantation mortality for impaired recipients was 20.6% compared to 4.5% for unimpaired recipients (p < 0.001). Impaired recipients had a 2.30-fold (adjusted hazard ratio [aHR] 2.30, 95% confidence interval [CI] 1.12-4.74, p = 0.02) increased risk of postkidney transplantation mortality compared to unimpaired recipients. Each one-point decrease in SPPB score was independently associated with a 1.19-fold (95% CI 1.09-1.30, p < 0.001) higher risk of post-KT mortality. SPPB-derived lower extremity function is a potentially highly useful and modifiable objective measure for pre-KT risk prediction.

[Robotic-assisted organ transplantation]. / Transplantation d'organes avec assistance robotique.

Advanced surgical procedures have traditionally been a domain of open surgery. However, minimally invasive approaches are evolving with the development of robotic technology which appears capable to overcome technical limitations of conventional laparoscopy. While traditionally perceived as impossible indications for minimally invasive surgery, reports on robotic organ transplantations have surfaced with promising results.

A food borne outbreak of Salmonella enterica serotype Brandenburg as a hint to compare human, animal and food isolates identified in the years 2005-2009 in Italy.

INTRODUCTION: There are only a few reported cases of Salmonella enterica serotype Brandenburg foodborne outbreaks in the literature. In Italy Brandenburg is consistently present among the top ten serotypes from human source, but at low prevalences. MATERIALS AND METHODS: Fifty-five S. Brandenburg isolates from human, animal, environmental and food sources, including twelve isolates from a foodborne outbreak, were genotyped by Pulsed-Field Gel Electrophoresis (PFGE). RESULTS AND DISCUSSION: Eight pulsogroups and 19 pulsotypes were detected, with a unique pulsotype being attributed to the outbreak strains. Molecular subtyping can reliably complement the epidemiological investigations. Moreover, mapping molecular types of Salmonella isolates from human and non-human source may greatly contribute to risk assessment, by tracking possible animal sources, so improving cost-effectiveness of the prevention and control strategies.

Dietary phosphate restriction in dialysis patients: a new approach for the treatment of hyperphosphataemia.

BACKGROUND AND AIM: Elevated serum phosphate and calcium-phosphate levels play an important role in the pathogenesis of vascular calcifications in uraemic patients and appear to be associated with increased cardiovascular mortality. We aimed to evaluate the effects of a partial replacement of food protein with a low-phosphorus and low-potassium whey protein concentrate on phosphate levels of dialysis patients with hyperphosphataemia. METHODS AND RESULTS: Twenty-seven patients undergoing chronic haemodialysis were studied for a 3-month period. In the intervention group (n = 15), food protein were replaced by 30 or 40 g of low-phosphorus and low-potassium protein concentrate aimed at limiting the phosphate intake. In the control group (n = 12) no changes were made to their usual diet. Anthropometric measurements, biochemical markers and dietary interviews were registered at baseline and during the follow-up period. From baseline to the end of the study, in the intervention group, serum phosphate and circulating intact parathyroid hormone levels lessened significantly (8.3 ± 1.2 mg/dL vs 5.7 ± 1.4 mg/dL and 488 ± 205 pg/ml vs 177 ± 100 pg/ml respectively; p < 0.05) with decreasing of phosphate and potassium intake. No significant differences were found in the control group. No significant changes were observed in serum albumin, calcium, potassium, Kt/V, body weight and body composition in both the intervention and control groups. CONCLUSION: Dietary intake of phosphate mainly comes from protein sources, so dietary phosphorus restriction may lead to a protein/energy malnutrition in a dialysis patient. A phosphorus-controlled diet plan including a nutritional substitute resulted in serum phosphate and intact parathyroid hormone decrease without nutritional status modifications in dialysis patients.

Cluster of cases of Salmonella enterica serotype Rissen infection in a general hospital, Italy, 2007.

In 2007, three strains of Salmonella enterica serotype Rissen (S. Rissen) were isolated in the laboratory of diagnostic microbiology of the General Hospital of Prato, Tuscany, Italy, over a 1 month and half interval of time. The first isolate was recovered on January 26 from an outpatient with enteritis. Then, two strains were isolated on February 16 and March 11 respectively, from central venous catheters of patients who were being hospitalized in two departments of the Hospital. An epidemiologically linked cluster of cases of salmonellosis was suspected. The three strains were submitted to single enzyme-amplified fragment length polymorphism (SE-AFLP) and XbaI macrorestriction and pulsed-field gel electrophoresis (PFGE) that yielded undistinguishable profiles. Epidemiological investigations failed to identify a common source of infection within the Hospital. Moreover, the third patient had been exclusively total parenteral nutrition fed since his admission with a stomach cancer diagnosis. The first patient had a community-acquired infection, but the source of her illness was uncertain. Twenty-five further isolates identified in the years 2004-2007 in the same geographical area showed distinctly different PFGE and SE-AFLP patterns. The three patients seemed to represent a cluster of epidemiologically unrelated cases caused by a previously never recognized S. Rissen strain. Rapid subtyping of isolates is essential in the early investigation of potential outbreaks, but synthesis of conventional and molecular epidemiological investigation and availability of surveillance data is often critical to prevent the initiation of time-consuming, expensive and ineffective further investigations and control interventions.

[The viability of kidneys tested by gadolinium-perfusion MRI during ex vivo perfusion]. / La viabilité des reins marginaux testée par perfusion de gadolinium sous IRM pendant leur réanimation.

INTRODUCTION: Marginal kidneys must be reanimated before their transplantation. Reanimation is conducted with hypothermic pulsatile perfusion. The tests used generally to demonstrate the viability is the vascular resistance which is not convenient for everybody. We have developed a magnetic resonance compatible perfusional technology allowing us to test the organs during the perfusion by Gd-perfusion MRI. METHODS AND RESULTS: We have used pigs' kidneys with no warm ischemic time to establish the basis in a normal kidney. After an eight-hour hypothermic pulsatile perfusion, kidneys are submitted to a Gd perfusion. First, we measure the anatomy of the vessels, then the distribution of Gd in the kidney. We obtain simultaneously a dynamic study of the organs where T0 represents the Gd bolus arrival in the cortex and TP the maximum saturation time of Gd. CONCLUSION: We have observed that a normal T0 is inferior to 30s and TP is inferior to one minute. We have compared these values with ATP resynthesis in these organs and found that they correlate. We hope for the future through that predictive use of Gd-MRI to avoid the clinical use of "too" marginal kidneys or the discard of good kidneys but not corresponding with the vascular resistance theory.

Pheno-genotyping of Salmonella enterica serotype Enteritidis isolates identified in Sicily during a reemergence period.

After an upward trend paralleling that occurring in most European countries, including Italy, since October 2002 Salmonella enterica serotype Enteritidis (S. Enteritidis) has again gained the first position among outbreak and sporadic human isolates of Salmonella in Sicily. Because phage typing of S. Enteritidis has many technical and epidemiological limitations and molecular methods have proved to be poorly discriminative for this organism, multiple typing, using phage typing together with pulsed field gel electrophoresis (PFGE) and plasmid profiling on a sample of fifty human and poultry isolates identified during the period October 2002 to May 2003 in Sicily, was chosen as the most valuable strategy to explore key features of this new epidemic wave. Although the limited number of strains imposes a cautious interpretation of the results, an apparently increasing phage type heterogeneity has emerged with rise in PT6 as the more striking event. While PFGE has confirmed the findings by other authors about the close genetic homogeneity between PT4 and PT6, plasmid profiling has provided discriminative patterns for PT6 strains. Combined phenotypic and genotypic profiles are necessary for epidemiological studies and public health investigations on S. enteritidis.

Clonal circulation of Salmonella enterica serotype Heidelberg in Italy?

Phenotypic and genetic characteristics of 21 strains of Salmonella serotype Heidelberg isolated in the years 1999-2003 from different sources in Italy were studied. Susceptibility patterns, plasmid analysis, and PFGE were used as epidemiological markers. Although non-homogeneous drug resistance patterns and plasmid profiles had been detected, PFGE patterns suggest the hypothesis of a nationwide clonal spread of this serotype associated with poultry.

Impedance vector distribution by body mass index and conventional bioelectrical impedance analysis in obese women.

BACKGROUND AND AIM: To compare the body fluid status assessments provided by conventional bioelectrical impedance analysis (BIA) and vector BIA in moderate and severe obesity. METHODS AND RESULTS: We studied 516 normotensive Caucasian women (mean age: 48 +/- 9.2 years), who were age-matched and divided into four groups on the basis of their body mass index (BMI): 99 normal weight women with a BMI of 19-25 Kg/m2; 228 preobese overweight women with a BMI of 25-30 Kg/m2; 132 women with class I-II obesity (BMI: 30-35 Kg/m2), and 57 women with class III obesity (BMI: 40-64 Kg/m2). Single-frequency (50 kHz) tetrapolar (hand-foot) bioelectrical impedance measurements were made, and total body water (TBW) and extracellular water (ECW) were estimated using conventional BIA regression equations. The RXc graph method was used for vector BIA, with the set of 327 women with a BMI of 19-30 Kg/m2 being adopted as the reference population. Mean vector displacement followed a definite pattern, with progressive vector shortening as the BMI increased, and along a fixed phase angle. This pattern indicates more TBW due to a greater soft tissue mass with average normal hydration. Short and downsloping vectors indicating fluid overload were more frequent in the group with class III obesity than in the group with class I obesity (19 vs 5%). The absolute values of TBW and ECW were significantly higher in the obese and overweight subjects than in those with normal weight subjects. TBW as a percentage of body weight was significantly lower in the obese subjects. CONCLUSIONS: BMI influenced the impedance vector distribution pattern, which proved to be consistent up to a BMI of 64 Kg/m2. Obese women with an altered body composition can be identified and monitored using vector BIA.

Nutritional intervention in a hemodialysis pregnant woman: a case report.

Pregnancy in dialysis patients is a rare occurrence. When pregnancy does occur, the risk of spontaneous abortion, stillbirth and neonatal complications, such as prematurity and growth retardation, are fairly high. The authors describe their experience in the follow-up of a patient with chronic renal failure who became pregnant during regular dialysis treatment and followed nutritional care. The outcomes were successful and she gave birth to a healthy baby. It is emphasized that special dedication to the nutritional control enabled a good outcome of the pregnancy. The importance of the nutritionist intervention in the follow-up of dialysis patients with the integration of a multidisciplinary staff is stressed.

[Predictive and diagnostic factors of malnutrition in hemodialysis patients]. / Fattori predittivi e diagnostici della malnutrizione nel paziente in trattamento emodialitico.

The relationship between malnutrition and inflammation is by now well established. IL-6 and, probably, other proinflammatory cytokines (mainly IL-1 and TNF) may represent the link between these two entities since these interleukins may promote loss of appetite, muscle protein breakdown and reduced hepatic synthesis of "negative" acute phase proteins like albumin, prealbumin and transferrin. IL-6 also stimulates up to 1000 fold the hepatic synthesis of "positive" acute phase proteins, mainly C-reactive Protein (CRP) and Serum Amyloid A. The association between CRP and cardiovascular mortality in the general population, as well as in haemodialysed uraemic patients, is well established. These crucial interrelationships have modified the interpretation of serum albumin concentration in the diagnosis of malnutrition; a reduced serum albumin concentration, in fact, in the presence of high CRP values should point towards a diagnosis of inflammation, though the inflammation may often induce weight loss or a condition of malnutrition. After switching most patients to a more biocompatible dialysis membrane and improvement of the quality of the dialysis fluid (by adopting hydrophobic filters at the water entry of dialysis devices and bicarbonate powder cartridges) nephrologists have focused their attention on other sources of inflammation (e.g. artificial vascular protheses, presence of infected thrombi, Clamidiae, Helicobacter Pilori, dental granulomas etc.). Starting from these assumptions the diagnosis of malnutrition, once focused mainly on serum albumin reduction, must be based on other parameters (clinical history of body mass wasting, dietary and anthropometric assessment, subjective global assessment, bioimpedance analysis etc.). All these investigations, however, must be examined together to obtain suitable information on the risk of malnutrition in dialysis patients. A comprehensive approach to malnutrition-inflammation in dialysis patients is the object of the present nephrology conference.

Drug resistances in salmonella isolates from animal foods, italy 1998-2000.

We investigated the distribution of serotypes and patterns of drug resistance of 206 strains of salmonella isolated in southern Italy in the years 1998-2000 from raw food of animal origin, faeces of food animals and animal feed. To improve knowledge of mobile genetic elements carrying the resistance genes, some molecular features were also investigated within isolates resistant to three or more antibiotics. A high proportion of isolates, 52.2% and 37.7%, respectively, belonging to both Typhimurium and other serotypes of animal origin, proved to be multidrug resistant. The DT104 complex specific multidrug pattern of resistance was quite infrequent among isolates other than Typhimurium, but resistances to nalidixic acid and kanamycin were more frequent within these last ones (36.9% vs. 11.4% and 56.5% vs. 2.2%, respectively). Class I integrons were detected in isolates of Typhimurium and seven different serotypes. The relevance of food animal environment as a drug resistance reservoir and animal food as a potential resistance gene vehicle between the farm and human ecological niches is confirmed by our findings.

Clonal relations among Salmonella enteritidis phage type 3 outbreak isolates traced by DNA fingerprinting.

Isolates of Salmonella enteritidis PT3, a rare phage type, were recovered from patients and strains were isolated from an outbreak of gastroenteritis that occurred during the summer of 1997 in North-East Sardinia, Italy. To investigate possible clonal involvement in the outbreak and to evaluate the capacity to discriminate among S. enteritidis PT3 strains, a number of molecular typing methods including ribotyping with a mixture of PstI and SphI (PS-ribotyping), PFGE with endonuclease XbaI and RAPD typing with four arbitrary primers was used. The typical XbaI endonuclease generated PFGE pattern also explained the prevalence of highly clonal S. enteritidis PT3 strains in the outbreak and adjacent areas. RAPD fingerprinting with primers OPA 4, OPB 15, OPB17 and P1254 exhibited a single but unique RAPD profile among the outbreak strains from various sources that differed significantly from control strains. The results of this study showed that when an appropriately chosen set of primers is employed, RAPD fingerprinting can be used as an alternative, rapid, highly reproducible technique for tracing the clonal relations of S. enteritidis PT3, and can be more discriminatory than PFGE. Furthermore, this study revealed the possibility of PT3 causing outbreak.

Presence of class I integrons in multidrug-resistant, low-prevalence Salmonella serotypes, Italy.

In 1997 to 1999, we detected class I integrons in multidrug-resistant isolates of Salmonella enterica serovars Anatum, Blockley, Brandenburg, Bredeney, Derby, Heidelberg, Livingstone, Newport, Ohio, Panama, Paratyphi B, Saintpaul, Sandiego, and Stanley.

Genetic diversity of Mycobacterium tuberculosis in Sicily based on spoligotyping and variable number of tandem DNA repeats and comparison with a spoligotyping database for population-based analysis.

In a previous study, we proposed to associate spoligotyping and typing with the variable number of tandem DNA repeats (VNTR) as an alternative strategy to IS6110-restriction fragment length polymorphism (RFLP) for molecular epidemiological studies on tuberculosis. The aim of the present study was to further evaluate this PCR-based typing strategy and to describe the population structure of Mycobacterium tuberculosis in another insular setting, Sicily. A collection of 106 DNA samples from M. tuberculosis patient isolates was characterized by spoligotyping and VNTR typing. All isolates were independently genotyped by the standard IS6110-RFLP method, and clustering results between the three methods were compared. The totals for the clustered isolates were, respectively, 15, 60, and 82% by IS6110-RFLP, spoligotyping, and VNTR typing. The most frequent spoligotype included type 42 that missed spacers 21 to 24 and spacers 33 to 36 and derived types 33, 213, and 273 that, together represented as much as 26% of all isolates, whereas the Haarlem clade of strains (types 47 and 50, VNTR allele 32333) accounted for 9% of the total strains. The combination of spoligotyping and VNTR typing results reduced the number of clusters to 43% but remained superior to the level of IS6110-RFLP clustering (ca. 15%). All but one IS6110-defined cluster were identified by the combination of spoligotyping and VNTR clustering results, whereas 9 of 15 spoligotyping-defined clusters could be further subdivided by IS6110-RFLP. Reinterpretation of previous IS6110-RFLP results in the light of spoligotyping-VNTR typing results allowed us to detect an additional cluster that was previously missed. Although less discriminative than IS6110-RFLP, our results suggest that the use of the combination of spoligotyping and VNTR typing is a good screening strategy for detecting epidemiological links for the study of tuberculosis epidemiology at the molecular level.

Antimicrobial resistance in Salmonella enteritidis, southern Italy, 1990-1998.

During 1990 to 1998, we identified multidrug-resistant isolates of Salmonella Enteritidis in southern Italy. Plasmids containing class I integrons and codifying for synthesis of extended- spectrum beta-lactamases were detected. Active surveillance for resistance to antimicrobial agents is needed to guard against the possible spread of resistant clones.

Surveillance of multidrug-resistant strains of Salmonella enterica serotype Typhimurium in southern Italy in the years 1992-1997.

Spread of multidrug-resistant strains of Salmonella enterica serotype Typhimurium (S. typhimurium) is increasingly reported worldwide. The presence of a pattern of resistance to ampicillin, chloramphenicol, streptomycin, sulfonamides and tetracycline (ACSSuT), in some cases associated to trimethoprim and infrequently to quinolones, is of particular concern. This resistance pattern appears to be chromosomally encoded and, in most epidemiological studies, closely related to definitive type 104 (DT104). In southern Italy multidrug-resistant isolates of S. typhimurium had been identified since 1980, but only during 1992 S. typhimurium strains with chromosomally encoded drug resistance were first isolated from domestic animals. One hundred fifty-five isolates--52.5% of the multidrug-resistant strains identified in the years 1992-1997--were submitted to phage typing and plasmid profile analysis. Ribotyping was also performed in comparison with a random sample of 150 strains susceptible or resistant to three or less antibiotics identified in the same interval of time. Four ribotypes (RTs)--1, 5, 8, and 48--included approximately 90% of the multiresistant strains, RT8 accounting for 61.2%. Phage type (PT) 193 is the most prevalent phage type. Phage typing and ribotyping suggest that few bacterial clones are involved in spread of multidrug-resistant S. typhimurium strains in southern Italy.

Can dietary intake influence plasma levels of amino acids in liver cirrhosis?

BACKGROUND: Modifications in plasma amino acid patterns in cirrhotics are attributed to impaired liver function, being more evident in alcoholic than in viral cirrhosis. AIM: To evaluate whether diet influences plasma amino acid concentrations in different aetiological groups of cirrhotics. PATIENTS: Study population comprised 40 patients with cirrhosis (25 virus- and 15 alcohol-related], all Child A, and 30 healthy subjects (controls). METHOD: A food frequency and quality questionnaire was utilized to determine dietary history and alcohol intake. Nutritional status was evaluated by anthropometric method. Amino acids were determined, on venous blood samples, using a specific analyzer while cysteine was evaluated by fluorescent high power liquid chromatography RESULTS: The total daily intake of calories, proteins, lipids, and carbohydrates was similar in all individuals. Food quality distinguished the cirrhotics from the controls, but not the different aetiological groups of cirrhotics. Plasma cysteine levels were significantly lower, while aromatic amino acids and methionine were significantly higher, in all cirrhotics (p<0.001 and p<0.01, respectively, versus controls). The decrease in cysteine and the increase in other amino acids were more marked in alcoholics (p<0.01). CONCLUSIONS: Ethanol intake, but not diet, further enhances the changes in plasma aromatic amino acids, methionine and cysteine induced by impaired liver function in patients with cirrhosis, suggesting a direct interference of alcohol in their metabolism.