Transanal repair of rectocele with high frequency radio scalpel.

AIM: This is a prospective randomized study to analyze results obtained in two groups of patients, affected by stage 2 rectocele and treated with rectum anterior wall repair and strength, performed with standard or modified Khubchandani technique, using High Frequency (HF) Radio Scalpel. MATERIALS AND METHODS: A cohort of 24 patients with stage 2 rectocele (Mellgren's classification) have been included. Twelve (group A) underwent surgery with standard technique and twelve (group B) underwent surgery using the HF Radio Scalpel, which cuts and coagulates tissues without damage thanks to its low working temperature (45-70°C). Each patient underwent proctolo-gical examination and anoscopy in 7th, 15th, 45th POD and after 6 and 12 months. RESULTS: During post-operative follow-up 5 patients from group A and 1 from group B didn't show up so that they drop out the study. As a result, group A is composed by 7 patients and group B by 11 patients. Mean operating time was significantly favourable in group B (51 vs 33 minutes, p< 0.01). The differences between other parameters weren't statistically significant, even if post-operative course was less difficult in HF Radio Scalpel group. CONCLUSIONS: The surgical technique to repair and reinforce anterior rectal wall is easier and faster if performed with HF Radio Scalpel respect to the standard procedure described by Khubchandani. Post-operative course was less painful and, even more importantly considering the patient age, surgical time was shorter. Therefore, the results obtained cast positive light on using this technique to treat uncomplicated grade 2 rectocele.

Ambulatory therapy with combined hemorrhoidal radiocoagulation.

BACKGROUND: This is a prospective randomized study to analyze results obtained in two groups of patients affected of grade II hemorrhoids and treated with Radiofrequency Coagulation (RFC) or Combined Hemorrhoidal Radiocoagulation (CHR). PATIENTS AND METHODS: The study comprehended 30 patients of which 27 had at least 6 months of follow-up. Two groups of patients were considered: group A, represented by 12 individuals treated with RFC, and group B, consisting of 15 patients treated with CHR. Our purpose was to determine: grade of pain felt immediately after procedure and at first evacuation (score from 1 to 10), bleeding, patient's satisfaction 15 days and 6 months after treatment (score from 1 to 10) and incidence of failures. RESULTS: Mean pain score reported immediately after procedure was 2.08 ± 0.9 for group A and 2.40 ± 1.5 for group B (p = NS). At first evacuation, mean pain score for group A and for group B was 2.16 ± 1.1 vs 2.33 ± 1.17, respectively (p = NS). Satisfaction score during first 15 days was 6.75 ± 2.76 for patients treated with RFC and 6.08 ± 2.20 for patients who received CHR (p = NS), while mean score of overall satisfaction after 6 months was 6.33 ± 1.96 (group A) vs 7.83 ± 2.05 (group B) (p < 0.05). At 6 months of follow-up, we observed 8 patients free from pain in group A (66.7%) and 13 patients in group B (86.7%). CONCLUSIONS: Results reported in both groups of patients confirm validity and efficacy of the two techniques used in this study, even if later in time CHR showed better results than RFC.        

Implementation of epidural analgesia for labor: is the standard of effective analgesia reachable in all women? An audit of two years.

BACKGROUND: Social and cultural factors combined with little information may prevent the diffusion of epidural analgesia for pain relief during childbirth. The present study was launched contemporarily to the implementation of analgesia for labor in our Department in order to perform a 2 years audit on its use. The goal is to evaluate the epidural acceptance and penetration into hospital practice by women and care givers and safety and efficacy during childbirth. PATIENTS AND METHODS: This audit cycle measured epidural analgesia performance against 4 standards: (1) Implementation of epidural analgesia for labor to all patients; (2) Acceptance and good satisfaction level reported by patients and caregivers. (3) Effectiveness of labor analgesia; (4) No maternal or fetal side effects. RESULTS: During the audit period epidural analgesia increased from 15.5% of all labors in the first trimester of the study to 51% in the last trimester (p < 0.005). Satisfaction levels reported by patients and care givers were good. A hierarchical clustering analysis identified two clusters based on VAS (Visual Analogue Scale) time course: in 226 patients (cluster 1) VAS decreased from 8.5±1.4 before to 4.1±1.3 after epidural analgesia; in 1002 patients (cluster 2) VAS decreased from 8.12±1.7 before (NS vs cluster 1), to 0.76±0.79 after (p < 0.001 vs before and vs cluster 2 after). No other differences between clusters were observed. CONCLUSIONS: Present audit shows that the process of implementation of labor analgesia was quick, successful and safe, notwithstanding the identification of one cluster of women with suboptimal response to epidural analgesia that need to be further studies, overall pregnant womens'adhesion to labor analgesia was satisfactory.

Prospective randomised comparison of rubber band ligation (RBL) and combined hemorrhoidal radiocoagulation (CHR).

BACKGROUND: In this prospective randomized study we compared two groups of patients with grade II hemorrhoids treated with standard Rubber Band Ligation (RBL) and Combined Hemorrhoidal Radiocoagulation (CHR), respectively. METHODS: Out of 90 patients initially randomized, a total of 75 patients regularly returned to visit controls at least for 6 months of follow-up. Consequently, two groups of patients were considered: Group A, represented by 36 individuals treated with RBL, and Group B, consisting of 39 patients treated with CHR. In this study primary endpoints were determined as evaluation of the grade of pain felt immediately after the procedure and at the first evacuation (score from 1 to 10), bleeding, patient's satisfaction after 15 days and after 6 months from the treatment (score from 1 to 10), appearance of failures. RESULTS: Comparing two techniques, the mean pain score reported immediately after the procedure was 2.08 +/- 1.1 for Group A and 2.13 +/- 1.26 or Group B. At the first evacuation, the mean pain score for Group A and for Group B was 2.69 +/- 1.12 vs. 2.38 +/- 1.18, respectively. The satisfaction score during the first 15 days from the procedure was 6.61 +/- 2.35 for patients treated with RBL and 6.72 +/- 2.28 for patients who received CHR, while the mean score on overall satisfaction after 6 months was 7.11 +/- 2.11 (Group A) vs. 7.31 +/- 2.04 (Group B). At 6 months of follow-up, we observed remission of symptoms in 25 patients in Group A (69.4%) and 31 patients in Group B (79.5%). CONCLUSIONS: Satisfactory results were reported in both groups of patients after different treatments, which confirm the validity and efficacy of the two techniques used in this study. At least all patients reported positive results in terms of immediate and long-term comfort after both procedures. CHR showed better results than standard RBL, but further studies are required to evaluate the validity of these methods.

Switch From Twice-daily Tacrolimus to Once-daily, Prolonged-release Tacrolimus in Kidney Transplantation: Long-term Outcome.

BACKGROUND: One daily dose of tacrolimus (QDT) improves adherence in kidney transplant (KT) recipients. A switch from twice-daily tacrolimus (BDT) to QDT showed similar efficacy and safety. METHODS: The aim of our study was to demonstrate the long-term efficacy and safety of switching from BDT to QDT in KT recipients. Preliminary results have already been published. Forty-one patients (34 men and 7 women), mean age at KT of 43.9 ± 12.7 years, underwent a 1:1 dose switch from BDT to QDT; the mean time from KT to switch was 36.6 ± 16.1 months. In our study population, 4 patients received a living donor KT and 2 received a second allograft. RESULTS: The mean follow-up was 86.8 ± 13 months from the switch and 126.2 ± 22.3 months from KT. Graft and patient survival rates were 90.2% and 95.1%, respectively. All patients maintained stable renal function during follow-up. During the first 3 months after the switch we observed a significant decrease in tacrolimus blood level (P = .0001). No significant differences were observed regarding tacrolimus dose before and after QDT introduction (P = not significant [NS]). Fourteen patients who stopped steroids under BDT treatment and 16 patients who stopped steroids after the switch are currently steroid-free. CONCLUSION: Our study showed safety and efficacy in switching from BDT to QDT. After early (<1 year) dose adjustment, tacrolimus blood levels remained stable throughout follow-up. Moreover, QDT represented a valid alternative for patients showing steroid side effects.

Ab initio Everolimus-based Versus Standard Calcineurin Inhibitor Immunosuppression Regimen in Liver Transplant Recipients.

AIM: We designed a retrospective case-control study to determine the efficacy and feasibility of everolimus (EVR) combined with low-dose tacrolimus (Tac) ab initio versus standard-dose Tac after liver transplantation (LT). METHODS: Seventy-one adult LT patients, receiving EVR and low-dose Tac without corticosteroids or induction therapy from postoperative day 1 (EVR group) were compared with a well-matched control group of 61 recipients treated with standard-dose Tac in association with antimetabolite. RESULTS: Baseline characteristics for the two groups were comparable. The overall patient and graft survival rates were similar (P = .908). Liver function was stable during the follow-up. In the EVR group, biopsy-proven acute rejection occurred in two cases (2.8%), whereas chronic rejection occurred in one (1.4%). The EVR group experienced a better renal function already after 2 weeks (estimated glomerular filtration rate: 89.85 [36.46 to 115.3] mL/min/1.73 m2 vs. 68.77 [16.11 to 115.42] mL/min/1.73 m2; P = .013), which was also observed after a median time of 27 months (range, 0 to 82 months) from LT (estimated glomerular filtration rate: 80 [45 to 118.3] mL/min/1.73 m2 vs. 70.9 [45 to 88.4] mL/min/1.73 m2; P = .04). After a median time of 27 months, the EVR group showed lower incidence of arterial hypertension and insulin-dependent diabetes mellitus. CONCLUSION: Ab initio EVR-based immunosuppression could be a valid option immediately after surgery in recipients at high-risk for post-LT renal impairment.

Conversion to rapamycin immunosuppression for malignancy after kidney transplantation: case reports.

INTRODUCTION: Malignancies are a well-known complication of immunosuppressive therapy among renal transplant recipients, representing an important cause of long-term morbidity and mortality. Rapamycin has been shown to limit the proliferation of a number of malignant cell lines in vivo and in vitro. METHODS: Eight patients developed the following malignancies after kidney transplantation (mean 102.6 months; range 12 to 252): metastatic gastric cancer (n = 1), metastatic colon cancer (n = 1), bilateral nephrourothelioma (n = 1), skin cancer (n = 1), Kaposi's sarcoma (n = 2), posttransplant lymphoproliferative disorder (PTLD) (n = 2). After the diagnosis of malignancy, the patients were switched from calcineurin inhibitor-based immunosuppression to rapamycin (monotherapy, n = 2), associated with steroids (n = 4) or mycophenolate mofetil (n = 2). RESULTS: Both patients with metastatic cancer underwent chemotherapy and then succummbed after 6 and 13 months. After a mean follow-up of 20.3 months (range 2 to 47), the remaining six patients are free from cancer disease. Renal graft function was unchanged from diagnosis throughout the follow-up. CONCLUSION: Our observations suggested that rapamycin-based immunosuppression offered the possibility of regression of nonmetastatic tumors. Nevertheless, it is difficult to assess whether tumor regression was attributed to Rapamycin treatment or to the reduced immunosuppression.

Everolimus and Advagraf Ab Initio in Combined Liver and Kidney Transplant With Donor-Specific Antibodies: A Case Report.

Although donor-specific antibodies are regarded as a contraindication for kidney transplantation, the data available for combined liver and kidney transplantation (cLKTx) are scarce, and there is no established therapeutic approach for this category of transplant recipients. De novo use of everolimus and a reduced dose of calcineurin inhibitor reportedly provides excellent kidney function compared with a standard regimen containing a calcineurin inhibitor. This strategy, however, has been applied in only some recipient categories. Here we report a case of A highly sensitized male patient who underwent a cLKTx and received everolimus with low-dose tacrolimus (once-daily prolonged-release formulation) as ab initio immunosuppressive treatment. The pretransplant panel-reactive antibody estimate was 97%, and multiple anti-HLA antibodies were detected at the time of transplantation. Thus far, patient and allograft survival have reached 2 years, with the recipient remaining on a regimen of immunosuppression with everolimus and low-dose tacrolimus, with no episodes of rejection.

A retrospective analysis of 1.011 percutaneous liver biopsies performed in patients with liver transplantation or liver disease: ultrasonography can reduce complications?

OBJECTIVE: In the last decades, liver biopsy was the reference procedure for the diagnosis and follow-up of liver disease. Aim of present retrospective analysis was to assess the prevalence of complications and risk factors after Percutaneous Liver Biopsy (PLB) performed for diagnosis and staging in patients with chronic liver disease and for monitoring the graft in liver transplanted patients PATIENTS AND METHODS: Data were collected from a total of 1.011 PLB performed with the Menghini technique between January 2004 and December 2014 at the Hepatology and Transplant Units of the University of Rome Tor Vergata. The indications for biopsy were: follow-up of liver transplantation, chronic Hepatitis B Virus (HBV) or Hepatitis C Virus (HCV), with or without Human Immunodeficiency Virus (HIV) and alcohol-related liver disease. Our patients were divided into two groups according to the biopsy indication: follow-up of liver transplantation (Group A) and chronic liver disease (Group B). All the procedures were performed in Day Hospital regimen. After the biopsy, patients remained in bed for about 4-6 hours. In the absence of complications, they were then discharged on the same day. RESULTS: The most frequent complication after biopsy was pain (Group A n. 57, 8.8%; Group B n. 105, 29.0%), hypotension as a result of a vasovagal reaction resolved spontaneously (Group A n. 7, 1.1%; Group B n. 6, 1.7%), and intrahepatic bleeding resolved with conservative therapy (Group A n. 1, 0.2%; Group B n. 6, 1.7%). Two cases of pneumothorax in the Group A (0.3%) were treated with a chest tube. Other complications did not have a significant impact. Also, we did not observe statistically significant differences in patients who underwent PLB without and with ultrasound guidance. CONCLUSIONS: Liver biopsy is not a replaceable tool in diagnosis and follow-up of several chronic liver diseases. The Menghini technique with the percutaneous trans costal approach, might be preferred because less traumatic and related with a low occurrence of minor and major complications. According to our case load and comparing our findings with the previous published data, we speculate that ultrasound guidance is not crucial in the prevention of major complications.

Beneficial effects of Flavonoids after ambulatory therapy with Combined Hemorrhoidal Radiocoagulation (CHR).

BACKGROUND: Phlebotropic activity, protective effect on the capillaries and anti-inflammatory properties of the Flavonoids have been reported in literature. Recently, we evaluated the effect of these drugs in controlling postoperative symptoms of proctologic surgery. In this randomized study we compared the results obtained in two groups of patients, with grade II haemorrhoids, submitted to radiofrequency coagulation of the hemorrhoidal nodule with radiofrequency scalpel (CHR), to verify the effects of Flavonoids to reduce further symptoms after treatment. PATIENTS AND METHODS: Out of 70 patients initially randomized, a total of 59 patients regularly returned to outpatient visit at least for 1 month of follow-up. Consequently, two groups of patients were considered: Group A, represented by 28 individuals treated with Flavonoids, and Group B, consisting of 31 patients as a control group. Our purpose was to determine: grade of pain after procedure and at first evacuation (score from 1 to 10), bleeding, incidence of failures and complications, patient's satisfaction after 30 days from the treatment (score from 1 to 10). RESULTS: We observed that the results obtained regarding the pain reported at the end of procedures (2.51 ± 1.4 for group A and 2.54 ± 1.15 for group B) and at the first evacuation (2.6 ±.1.52 for group A and 2.7 ± 1.18 for group B) are similar in both study groups. Instead, the mean score on overall satisfaction at 30 days from the treatment showed a statistical significance (8.32 ± 1.72 for group A and 6.64 ± 1.78 for group B; p < 0.05). There were no reported other important issues. CONCLUSIONS: Our results confirm the usefulness of Flavonoids to make more comfortable the post-treatment period.

Complications and risk factors of a large series of percutaneous liver biopsies in patients with liver transplantation or liver disease.

OBJECTIVE:   Liver biopsy is a very important investigation in Hepatology. The aim of this retrospective study was to assess the prevalence of complications after Percutaneous Liver Biopsy (PLB), performed in two groups of patients with liver transplantation or with liver disease. We compared our results with those most representative of the literature and discussed about indications, advantages and disadvantages in relation to the different modes for the execution of this procedure, with particular regard to the use of ultrasound guidance. PATIENTS AND METHODS: We analyzed the results of 847 PLB performed with the Menghini technique between January 2004 and December 2013 at the Transplant Unit of the University of Rome Tor Vergata. The indications for biopsy were: follow-up liver transplantation, HBV, HCV and HBV/HCV related liver disease, alcohol related liver disease and HIV coinfected with HBV or HCV. Our patients were classified into two groups according to specific indication: patients with liver transplantation (group A) and patients with liver disease (group B). The procedure was always performed in the Day Hospital regimen. After the biopsy, the patients remained in bed for about 4-6 hours. In absence of complications, they were then discharged in the same day. RESULTS: The most frequent complication was pain after biopsy (group A n. 45, 7.9%; group B n. 85, 30.9%), requiring analgesics administration, hypotension as a result of a vasovagal reaction resolved spontaneously (group A n. 6, 1.0%; group B n. 6, 2.2%), and bleeding (group A n. 1, 0.2%; group B n. 6, 2.2%), which, however, has never necessitated surgery, except in one case of hemothorax. Two cases of pneumothorax were resolved with chest tube. Other complications did not have a significant impact. CONCLUSIONS: Liver biopsy is not replaceable investigation to diagnose several liver diseases and their course and also to monitor the condition of the hepatic parenchyma after transplantation. Among the various methods we preferred the Menghini technique with percutaneous transcostal approach, because less traumatic. This procedure presents low occurrence of various problems. We reviewed the literature regarding the major complications related to the technique and the use of ultrasound guidance. Based on our case series and data reported by the main Authors, we believe that ultrasound guidance is not decisive in the prevention of major complications. It is useful if done in the days or weeks prior to biopsy only in order to know any anatomical abnormalities or rather diseases that may pose a specific indication for the procedure with ultrasound guidance.

Use of Flavonoids for the treatment of symptoms after hemorrhoidectomy with radiofrequency scalpel.

OBJECTIVES: Control of postoperative symptoms is of paramount importance in proctologic surgery. Phlebotropic activity, protective effect on the capillaries and anti-inflammatory properties of the flavonoids have been reported in several studies. They have been used to treat a variety of conditions including chronic venous insufficiency, lymphedema and hemorrhoids. Numerous trials, assessing the effect of phlebotonics in treating the symptoms and signs of haemorrhoidal disease, suggest that there is a potential benefit. Our trial was conducted to evaluate whether the flavonoids reduce postoperative bleeding, pain and other symptoms after hemorrhoidectomy. PATIENTS AND METHODS: We compared the results obtained in 24 patients undergoing open hemorrhoidectomy with radiofrequency scalpel. Our study cohort was randomized in two groups: the Group A received flavonoids in the postoperative period, the Group B has constituted the control group, without administration of study drug. Follow-up outpatient visits were performed on 7, 15 and 30 postoperative day (POD). During the visits the patients expressed trough a list of specific questions, based on a scoring system (1 to 10), their opi-nion about the extent of postoperative symptoms as pain, bleeding, tenesmus, pruritus and perianal weight. RESULTS: We observed that the results obtained after 7 days of surgery are similar in both study groups. Even after 15 and 30 days no significant changes were observed between the two groups about pain and bleeding. Instead, we observed significant differences regarding tenesmus (group A: 8.0±1.1 vs Group B: 5.4 ± 1.5 at 15 POD, p < 0.05; group A: 9.1±0.8 vs Group B: 5.7 ± 0.9 at 30 POD, p < 0.05), pruritus (group A: 7.1 ± 1.4 vs Group B: 4.8 ± 1 at 15 POD, p < 0.05; group A: 9.5 ± 0.5 vs Group B: 6.6 ± 0.8 at 30 POD, p < 0.05) and perianal weight (group A: 7.2 ± 0.9 vs Group B: 6.2 ± 0.8 at 15 POD, p < 0.05; group A: 9.75 ± 0.4 vs Group B: 7.3 ± 0.9 at 30 POD, p < 0.05). CONCLUSIONS: Our results confirm the usefulness of this drug to reduce the prevalence and the importance of post-hemorrhoidectomy symptoms and make more comfortable the postoperative period.

Deep vein thrombosis as debut of cytomegalovirus infection associated with type II cryoglobulinemia, with antierythrocyte specificity in a kidney transplant recipient: a case report.

Immunologic alterations, such as cryoglobulinemia, have been described in the acute phase of primary cytomegalovirus (CMV) infections in immunocompetent patients. There are few references about these influences of a primary CMV infection in an at-risk kidney transplant recipient (donor positive/recipient negative-D(+)/R(-)). Herein we have described the case of a 46-year-old man, who was naive for CMV and underwent renal transplantation from a CMV+ cadaveric donor, thereby at high risk for disease transmission. The immunosuppression consisted of basiliximab, tacrolimus, mycophenolate mofetil, and steroids. The recipient was not treated with CMV prophylaxis, but rather regularly screened for possible pre-emptive treatment. At 35 days after transplantation, he was admitted because of deep vein thrombosis (DVT) in the transplant ipsilateral lower limb accompanied by oliguria, fever, and epigastric pain accompanied by type II cryoglobulinemia and acute CMV infection. The direct antiglobulin test (DAT) for C3d was positive. The cryoglobulins displayed anti-red blood cell specificity, with maximum activity at 4°C. The DVT was successfully treated with locoregional thrombolysis in combination with anticoagulant therapy. The DAT improved with CMV treatment and increased steroid therapy. The urine output and renal function tests improved with resolution of the thrombosis, achieving complete recovery without sequelae. Our hypothesis was that CMV infection triggered cryoglobulinemia. The blood disorder caused hyperviscosity, inducing DVT. This case, of CMV infection showed associated cryoglobulinemia presenting with antierythrocyte specificity in a kidney transplant recipient.

De novo malignancies following liver transplantation: results from a multicentric study in central and southern Italy, 1990-2008.

OBJECTIVE: The objective of this study was to quantify incidence rates (IR) and risks of de novo tumors (except nonmelanoma skin cancers) in patients who underwent orthotopic liver transplantation (OLT) in central and southern Italy. METHODS: Data were collected on 1675 patients (75.5% males) who underwent OLT in six Italian transplantation centers in central and southern Italy (1990-2008). The time at risk of cancer (person years [PY]) was computed from OLT to the date of cancer diagnosis, death, or last follow-up, whichever occurred first. The number of observed cancer cases were compared with the expected one using data from population-based cancer registries. We computed gender- and age-standardized incidence ratios (SIRs) and 95% confidence intervals (CIs). RESULTS: During 10,104.3 PYs (median follow-up, 5.2 years), 98 patients (5.9% of the total) were diagnosed with a de novo malignancy (for a total of 100 diagnoses). Twenty-two of these cancers were post-transplantation lymphoproliferative disorders (PTLD; 18 non-Hodgkin lymphoma [NHL] and 2 Hodgkin's lymphoma [HL]), 6 were Kaposi's sarcoma (KS), and 72 were solid tumors (19 head and neck [H&N], 13 lung, 11 colon-rectum, 6 bladder, and 4 melanoma). The overall incidence was 9.9 cases/10(3) PYs, with a 1.4-fold significantly increased SIR (95% CI, l.2-1.7). Significantly increased SIRs were observed for KS (37.3), PTLD (3.9), larynx (5.7), melanoma (3.1), tongue (7.1), and H&N (4.5) cancers. CONCLUSIONS: These results confirmed that OLT patients are at greater risk for cancer, mainly malignancies either virus-associated or related to pre-existent factors (eg, alcohols). These observations point to the need to improve cancer surveillance after OLT. The on-going enrollment of patients in the present cohort study will help to elucidate the burden of cancer after OLT and better identify risk factors associated with its development.

Effects of perianeurysmal environment during the growth of cerebral aneurysms: a case study.

BACKGROUND AND PURPOSE: The natural history of cerebral aneurysms is thought to be governed by multifactorial processes involving hemodynamics, biomechanics, mechanobiology, and perianeurysmal environment. The purpose of this study was to highlight the importance of considering the influence of contacts with perianeurysmal environment structures on the hemodynamics and geometric evolution of intracranial aneurysms. MATERIALS AND METHODS: A large aneurysm of the basilar artery in contact with bone and observed to grow during a 4-year follow-up period was selected for study. Anatomic models were constructed from longitudinal CTA images acquired at 1-year intervals during the observation period. Computational fluid dynamics simulations were carried out under pulsatile flow conditions to analyze the blood flow pattern and WSS distribution in the aneurysm during its evolution. RESULTS: The aneurysm was observed to grow against the bone, resulting in a geometric change of the proximal parent artery, which, in turn, induced substantial changes in the aneurysm hemodynamics. In particular, a region of elevated WSS created by the inflow streams was observed to shift locations around the place where the aneurysm enlarged in contact with the bone as the aneurysm progressed. In addition, a "notch" near the distal end of the aneurysm, away from the bone and subject to relatively high WSS, was observed to grow and, later, completely disappear. CONCLUSIONS: Contacts with perianeurysmal structures need to be considered and analyzed to assess whether they could exert a significant influence on the geometric evolution of each individual intracranial aneurysm and its hemodynamics.

Everolimus and enteric-coated mycophenolate sodium ab initio after liver transplantation: midterm results.

BACKGROUND AND AIM: Everolimus (EVR) use in liver transplantation (OLT) has been prescribed with calcineurin inhibitors (CNIs), steroids, and monoclonal antibodies. The aim of our study was to evaluate the safety, feasibility, and impact on renal function of EVR ab initio, in combination with enteric-coated mycophenolate sodium (EC-MPS) without the use of induction treatment, steroids, or CNIs. PATIENTS AND METHODS: We retrospective analyzed nine consecutive patients who underwent OLT at our institution. The initial dose of EVR (1.5 mg/d) was adjusted to achieve trough levels of 8 to 12 ng/mL. EC-MPS introduced at 1080 mg/d was maintained at the same dose over time. RESULTS: At a mean follow-up of 21.48 (standard deviation [SD] 1.4) months from OLT, 7/9 recipients were alive with stable graft function. The 2-year patient and graft survivals were 77%. One recipient died due to cerebral hemorrhage and one, lung failure. No clinical evidence of an acute rejection episode was observed. Mean estimated glomerular filtration rate value, according to the Modification of Diet in Renal Disease formula increased from 59.5 (SD 9.89) mL/min/1.73 m(2) at OLT to 100.2 (SD 47.5) mL/min/1.73 m(2) (P = .03) after 12 months and 98.71 (SD 33.74) mL/min/1.73 m(2) (P = .03) after 24 months' follow-up. CONCLUSION: A double immunosuppression therapy with EVR and EC-MPS ab initio seemed to be efficacions and safe, representing a valid alternative to CNIs to prevent renal failure after OLT.

Clinical Application of Image-Based CFD for Cerebral Aneurysms.

During the last decade, the convergence of medical imaging and computational modeling technologies has enabled tremendous progress in the development and application of image-based computational fluid dynamics modeling of patient-specific blood flows. These techniques have been used for studying the basic mechanisms involved in the initiation and progression of vascular diseases, for studying possible ways to improve the diagnosis and evaluation of patients by incorporating hemodynamics information to the anatomical data typically available, and for the development of computational tools that can be used to improve surgical and endovascular treatment planning. However, before these technologies can have a significant impact on the routine clinical practice, it is still necessary to demonstrate the connection between the extra information provided by the models and the natural progression of vascular diseases and the outcome of interventions. This paper summarizes some of our contributions in this direction, focusing in particular on cerebral aneurysms.

Switch from twice-daily tacrolimus (Prograf) to once-daily prolonged-release tacrolimus (Advagraf) in kidney transplantation.

Advagraf is a new modified-release once-daily formulation of tacrolimus. The aim of this study was to define the efficacy and safety of switching from Prograf to Advagraf immunosuppression in kidney transplant recipients. The switched dose ratio of Prograf to Advagraf was 1:1. Forty-one patients (34 men and 7 women) were switched at 36.6 ± 16.1 months after kidney transplantation. All patients maintained stable renal function and the conversion. In 16 subjects it was possible to withdraw steroid administration after obtaining adequate Advagraf blood levels, among whom 14 remained steroid free. Adverse events, including dizziness and tinnitus, were reported in 1 patient, who was reverted to Prograf. One patient who was receiving triple therapy with low tacrolimus blood levels experienced are acute rejection episode. The switch to Advagraf was safe and efficacious in kidney transplant recipients with or without steroid administration. Moreover, interruption of steroid was possible and well tolerated after achieving adequate stable blood levels with Advagraf.

Prospective study of switch from cyclosporine to tacrolimus for fibroadenomas of the breast in kidney transplantation.

INTRODUCTION: Breast fibroadenomas may result from exposure to cyclosporine (CsA). The aim of this prospective study was to assess the reversibility of breast fibroadenomas following conversion from CsA to tacrolimus among a small cohort of female renal transplant recipients. METHODS: Following renal transplantation, fibroadenomas either developed or progressed in eight Caucasian female patients with CsA-based immunosuppression. These patients were enrolled in a pilot study assessing whether conversion from a CsA-based to a tacrolimus-based regimen prevented progression of breast disease or reversed existing lumps. Patients underwent a baseline visit in which we assessed the clinical history, number and dimension of fibroadenomas, graft function and hormonal profile (FSH prolactin, estradiol and progesterone). Twenty-one lumps were described in six patients; in addition, two patients had "grapes of fibroadenomas," of nondefinable numbers. RESULTS: Patients underwent conversion to tacrolimus after a mean of 63.8 +/- 37.4 months after renal transplantation. Of the 21 clearly described lumps complete reversibility was observed for eight fibroadenomas. Other fibroadenomas either decreased in size or remained stable without further progression. These changes were reported within 1 year following conversion to tacrolimus. CONCLUSION: A switch from CsA to tacrolimus was effective to prevent the progression of fibroadenomas. In female renal transplant recipients with CsA-based immunosuppression suffering from breast fibroadenomas, early CsA withdrawal may avoid the need for breast surgery.

Liver transplantation for hepatitis B and C virus-related cirrhosis: mid-term results.

Hepatitis C virus (HCV) recurrence after orthotopic liver transplantation (OLT) is almost universal; cirrhosis develops in up to 30% of cases. Currently there is interest in the midterm outcomes of HCV patients with concomitant hepatitis B virus (HBV) infection among OLT recipients. We therefore retrospectively analyzed our database of patients who underwent OLT for HCV-HBV-related cirrhosis. Between April 1992 and December 2008, 350 patients underwent OLT, including 20 (5.7%) transplanted for HBV-HCV cirrhosis. We assessed patient and graft survivals at 1 and 5 years, as well as the progression of fibrosis. Protocol liver biopsies were available yearly after OLT. The survival curves were analyzed by the Kaplan-Meier approach and chronic hepatitis evaluated according to the Ishak scoring system. At a median follow-up of 68.4 +/- 53 months, the 1- and 5-year patient and graft survival rates were 80% and 70%, respectively. The 5-year fibrosis progression rate was 0.17 +/- 0.08 units of fibrosis. The only patient who developed histologic cirrhosis within 10 years of follow-up showed a lamivudine-resistant HBV recurrence. Patients transplanted for HBV-HCV coinfection showed a lower fibrosis progression rate compared with HCV monoinfected subjects.