Split and whole liver transplantation outcomes: a comparative cohort study.

A specific split liver transplantation (SLT) program has been pursued in the North Italian Transplant program (NITp) since November 1997. After 5 yr, 1,449 liver transplants were performed in 7 transplant centers, using 1,304 cadaveric donors. Whole liver transplantation (WLT) and SLT were performed in 1,126 and 323 cases, respectively. SLTs were performed in situ as 147 left lateral segments (LLS), 154 right trisegment liver (RTL) grafts, and 22 modified split livers (MSL), used for couples of adult recipients. After a median posttransplant follow-up of 22 months, SLTs achieved a 3-yr patient and graft survival not significantly different from the entire series of transplants (79.4 and 72.2% vs. 80.6 and 74.9%, respectively). Recipients receiving a WLT or a LLS showed significantly better outcomes than patients receiving RTL and MSL (P < 0.03 for patients and P < 0.04 for graft survival). At the multivariate analysis, donor age of >60 yr, RTL transplant, <50 annual transplants volume, urgent transplantation (United Network for Organ Sharing (UNOS) status I and IIA), ischemia time of >7 hours, and retransplantation were factors independently related to graft failure and to significantly worst patient survival. Right grafts procured from RTL and either split procured as MSL had a similar outcome of marginal whole livers. In conclusion, in 5 yr, the increased number of pediatric transplants due to split liver donation reduced to 3% the in-list children mortality, and a decrease in the adult patient dropout rate from 27.2 to 16.2% was observed. Such results justify a more widespread adoption of SLT protocols, organizational difficulties not being a limit for the application of such technique.     

Osteoporosis intervention in ambulatory patients with previous hip fracture: a multicentric, nationwide Italian survey

Our study investigated the patterns of treatment and adherence to prescribed therapies in 2,191 ambulatory patients with previous hip osteoporotic fractures at 207 participating orthopedic centers throughout Italy. All patients who came to the attention of the involved orthopedic surgeons were administered a questionnaire investigating: age, sex, height, weight, date of admission and length of stay in the hospital, other previous clinical fractures, bone density or biochemical testing concerning mineral metabolism, treatment with bone-active drugs in the six months before the fracture, treatment after discharge from the hospital, continuous use of prescribed drugs, pain at the site of hip surgery, and comorbidity. A multivariate logistic regression model was applied, considering a subset of the variables in the questionnaire, in order to determine the factors that significantly influenced discontinuation of treatment after hip fracture. Among the patients, 88.1% were female and 86.2% of the subjects were older than 65. The mean length of hospital stay for hip fracture was 19.0±25.3 days. At the time of interview, the mean time elapsed since hospitalization was 542.9±1,197.3 days. A previous clinical fracture was referred by 20.2% of patients. Before hip fracture occurrence, 52.8% of patients had never received any kind of treatment, and this figure reached 80% if we also included those who had taken only calcium and/or vitamin D. Corresponding proportions after fracture were 22% and 31.3%, respectively. Finally, 52% of patients had stopped treatment given for osteoporosis after a mean period of 1.4 years. According to the results of the logistic regression, increasing age, pain [odds ratio (OR): 1.36; 95% confidence interval (CI): 1.21–1.65] and no use of diagnostic tests (OR: 2.46; CI: 1.79–3.37) showed a positive effect on the probability of quitting the medication. On the other hand, being female reduces by half (OR: 0.49; CI: 0.37–0.45) the probability of quitting medication. Our data showed a low rate of primary prevention, a still insufficient post-fracture therapy, along with a high rate of early discontinuation of osteoporosis medication in patients with previous hip fracture.     

Subacute posttraumatic ascending myelopathy (SPAM): A potential complication of subarachnoid shunt for syringomyelia?

Context: Treatment of primary spinal syringomyelia is still controversial. Among others, shunting syrinx fluid to the subarachnoid, peritoneal or pleural space has been utilized with varying success. Shunt obstruction, migration, and infection represent the most common complications of these procedures.

Findings: The authors present the case of an 81-year-old woman who developed an unusual neurological deterioration resembling a subacute posttraumatic ascending myelopathy (SPAM) after the insertion of a syringosubarachnoid shunt for the treatment of slow-growing D10 syringomyelia.

Conclusion/Clinical Relevance: To date, no cases of SPAM secondary to the insertion of a syringosubarachnoid shunt for the treatment of syringomyelia have been reported. The potential pathogenesis related to this phenomenon is discussed.     

Assunzione di glucosio in vitro da parte di frammenti di arterie umane e bovine in diverse condizioni

Riassunto E' stata studiata l'assunzione di glucosioin vitro da parte di frammenti d'arteria provenienti da animali o da uomo, affetto e non affetto, da diabete mellito. Le arterie provenienti da uomo non diabetico assumono in genere meno glucosio rispetto alla arteria proveniente da bovini. Tali differenze si riducono se le arterie umane vengono private dell'avventizia. Le arterie umane non diabetiche assumono più glucosio nei confronti delle arterie provenienti da soggetti affetti da diabete mellito. Mentre l'incubazione con plasma umano normale aumenta nettamente l'assunzione di glucosio in tutte le arterie di uomo diabetico e non, essa non determina significativi miglioramenti della'assunzione di glucosio da parte dei frammenti di arterie bovine. L'aggiunta di insulina cristallizzata di bue al liquido di incubazione delle arterie umane non induce significativi incrementi dell'assunzione di glucosio se non a concentrazioni di 2 mU/ml nell'incubazione di arterie umane private dell'avventizia.

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Summary The AA. have studied thein vitro glucose uptake by fragments derived from animals and from humans, both diabetic and non-diabetic. The arteries derived from non-diabetic humans generally assume less glucose than those derived from oxen. Such differences decrease if the human arteries are deprived of theadventitia. The human non-diabetic arteries assume more glucose than those derived from subjects suffering from diabetes mellitus. While incubation with normal human plasma clearly increases the glucose uptake in all the arteries of man, both diabetic and not, it does not cause significant improvements in the glucose uptake by the fragments of bovine arteries. The addition of crystallized ox insulin to the incubation liquid of the human arteries does not cause significant improvements in the glucose uptake except at 2 mU/ml, when human arteries deprived of theadventitia are used.

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Zusammenfassung Es wurde die Aufnahme von Glukosein vitro durch Arterien-Fragmente von Tieren oder Menschen mit oder ohne Diabetes mellitus untersucht. Die Arterien von nicht diabetischen Menschen nehmen im allgemeinen weniger Glukose auf, als die Arterien von Rindern. Diese Unterschiede werden geringer, wenn man den Humanarterien dieadventitia entzieht. Die Arterien von nicht diabetischen Menschen nehmen mehr Glukose auf, als die Arterien von Menschen mit Diabetes mellitus. Während die Inkubation mit normalem Humanplasma die Glukoseaufnahme in allen Arterien von Menschen mit oder ohne Diabetes klar steigert, bewirkt sie keine signifikante Verbesserung der Glukose-Aufnahme durch Arterien-Fragmente von Rindern. Der Zusatz von kristallisiertem Rinderinsulin zur Inkubations-Flüssigkeit der Human-Arterien induziert keine signifikanten Zunahmen der Glukoseaufnahme, es sei denn mit einer Konzentration von 2 mE/ml bei der Inkubation von Humanarterien ohneadventitia.

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Resumen Se estudió la captación de glucosain vitro de parte de fragmentos de arteria procedentes de animales o de hombres afectos y no de diabetes mellitus. En general, las arterias del hombre no diabético captan menos glucosa que las de los bovinos. Estas diferencias se reducen si se privan a las arterias humanas de la adventicia. Las arterias humanas no diabéticas captan más glucosa que las arterias de sujetos afectos de diabetes mellitus. Mientras la incubación con plasma humano normal aumenta netamente la captación de glucosa en todas las arterias del hombre diabético y no, la misma no determina mejorías significativas de la captación de glucosa de parte de los fragmentos de arterias bovinas. La adición de insulina cristalizada de buey al líquido de incubación de las arterias humanas no produce aumentos significativos en la captación de glucosa sino a concentraciones de 2 mU/ml en la incubación de arterias humanas sin adventicia.

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Resume Les AA. ont étudié l'assimilation de glucosein vitro par des fragments d'artère provenantes de animaux ou de sujets atteints ou non de diabète sucré. Les artères des sujets non diabétiques assument en général moins glucose que les artères d'origine bovine. Cettes différences sont réduites si les artères humaines sont privées de l'adventice. Les artères humaines non diabétiques assument plus glucose que les artères provenantes de sujets atteints de diabète sucré. Tandis que l'incubation avec du sérum humain normal augmente nettement l'assimilation du glucose dans toutes les artères du sujet diabétique et non diabétique, elle ne porte pas des améliorations significatives dans l'assimilation du glucose par les fragments des artères bovines. L'addition d'insuline cristallisée du boeuf au liquide d'incubation des artères humaines ne porte pas des augmentations significatives de l'assimilation du glucose, si non avec des concentrations de 2 mU/ml dans l'incubation des artères humaines privées de l'adventice.

     

Impaired saccadic eye movement in diabetic patients: the relationship with visual pathways function

The aim of this study was to evaluate whether a correlation existed between saccadic eye movements and visual pathways function in diabetic patients. Saccadic or fast Eye Movement System (EMS) and Visual Evoked Potentials (VEPs) were assessed in 20 insulin-dependent diabetic mellitus (IDDM) patients without long-term complications and in stable metabolic control and in 21 age-matched control subjects. In IDDM patients we observed significantly (p<0.01) longer EMS latency, while EMS velocity and accuracy were similar to those of controls; VEPs showed a significant delay in N75, P100, N145 latencies and significant reduction of N75-P100 and P100-N145 amplitudes. In IDDM patients no relationships between EMS and VEP parameters were found. In conclusion, EMS latency delay suggests an impairment of the saccadic eye movement system, while impaired VEPs may be ascribed to a dysfunction of the visual pathways. The lack of correlation between VEPs impairment and EMS latency delay suggests that in our IDDM patients the delay of saccadic latency cannot be exclusively related to a visual pathways dysfuction and could be ascribed to a diffuse neuronal involvement. This revised version was published online in July 2006 with corrections to the Cover Date.     

In vivo characterization of the inflammatory infiltrate and apoptotic status in imiquimod-treated basal cell carcinoma

Background Imiquimod use in the treatment of basal cell carcinoma (BCC) has proven to be successful in a large percentage of cases, inducing tumor regression; however, the exact cellular mechanism has not been fully clarified. Aim To measure the morphological changes in the tumor microenvironment and the markers of apoptosis in skin biopsies from patients with BCC before and after imiquimod treatment. Methods In this open label study, skin biopsies obtained from 11 patients with BCC were evaluated before and after imiquimod treatment for: (i) morphological changes in the tumor microenvironment, with specific emphasis on the immunophenotype of inflammatory cells around the tumor; and (ii) markers of apoptosis, including expression of death receptors. Results Imiquimod treatment induced a significant increase in the mononuclear inflammatory response. In the majority of cases, the cellular infiltrate was predominantly composed of CD3⁺/CD4⁺ T cells, suggesting that the effector response is mediated by CD3⁺/CD4⁺ lymphocytes, with a minor cytotoxic and natural killer (NK) component. An increase in the cytotoxic CD3⁺/CD8⁺ T‐cell population was also observed. Imiquimod treatment was associated with a marked increased in CD20⁺ B cells, and a less pronounced enhancement in cells of monocyte–macrophage origin (CD68⁺) surrounding, or within, the tumor. This finding indicates either that macrophages play a minor role in the imiquimod‐induced response, or the recruitment of these cells is related to time and dose. Imiquimod treatment decreased CD1A⁺ Langerhans cells in the epidermis and increased the number of CD1A⁺ dendritic cells within the tumor aggregates. Imiquimod reduced Bcl‐2 expression, but no difference was found in Bax, Fas/FasL, and p53 expression in BCC cells. Conclusions Our results support the hypothesis that imiquimod activity in the treatment of BCC is partly a result of a pro‐inflammatory action mediated by CD3⁺/CD4⁺ lymphoid cells and of a pro‐apoptotic activity associated with decreased Bcl‐2 expression.     

Assessment of advanced age candidates for liver transplantation warrants more caution

For patients with fulminant liver failure and end-stage liver disease, liver transplantation remains the only effective treatment. Over the years, as a result of the ageing population, the average age of liver transplant donors and recipients has increased and currently about one quarter of patients receiving transplantation in the United States are above the age of 65. Recently, a study reported that patients aged 65 years or older had lower one-year survival compared to a younger cohort. Herein, we express our opinion about this interesting publication.     

Omentopexy with Glubran®2 for reducing complications after laparoscopic sleeve gastrectomy: results of a randomized controlled study

Background

Gastric fistulas, bleeding, and strictures are commonly reported after laparoscopic sleeve gastrectomy (LSG), that increase morbidity and hospital stay and may put the patient’s life at risk. We report our prospective evaluation of application of synthetic sealant, a modified cyanoacrylate (Glubran®2), on suture rime, associated with omentopexy, to identify results on LSG-related complications.

Methods

Patients were enrolled for LSG by two Bariatric Centers, with high-level activity volume. Intraoperative recorded parameters were: operative time, estimated intraoperative bleeding, conversion rate. We prospectively evaluated the presence of early complications after LSG during the follow up period. Overall complications were analyzed. Perioperative data and weight loss were also evaluated. A control group was identified for the study.

Results

Group A (treated with omentopexy with Glubran®2) included 96 cases. Control group included 90 consecutive patients. There were no differences among group in terms of age, sex and Body Mass Index (BMI). No patient was lost to follow-up for both groups. Overall complication rate was significantly reduced in Group A. Mean operative time and estimated bleeding did not differ from control group. We observed three postoperative leaks in Group B, while no case in Group A (not statistical significancy). We did not observe any mortality, neither reoperation. Weight loss of the cohort was similar among groups. In our series, no leaks occurred applying omentopexy with Glubran®2.

Conclusion

Our experience of omentopexy with a modified cyanoacrylate sealant may lead to a standardized and reproducible approach that can be safeguard for long LSG-suture rime.

Trial registration

Retrospective registration on clinicaltrials.gov PRS, with TRN NCT03833232 (14/02/2019).

     

Relationship between plasma insulin and left ventricular mass in normotensive participants of the Gubbio Study

BACKGROUND: There is substantial but not conclusive evidence that insulin resistance is related to left ventricular mass (LVM) in hypertensive individuals. To what extent this association is mediated by the relationship between plasma insulin and body size and build is still debated, and is poorly explored in nonhypertensive people. OBJECTIVE: To explore the relationship between insulin or insulin resistance and LVM in a population-based sample of nonhypertensive participants of the Gubbio Study. METHOD: Echocardiographic LVM was determined in 91 nondiabetic, nonhypertensive individuals aged 45-54 years, participating in a population-based screening. LVM normalized for height2.7 was used in the analyses; LV hypertrophy was defined as a value of > or = 50 g/m2.7 in men or > or = 47 g/m2.7 in women. Fasting plasma insulin and glucose were measured and the Homeostasis Model Assessment (HOMA) index was used as a measure of insulin resistance. RESULTS: LVM was positively and significantly correlated with body mass index (BMI) (P < 0.01), waist circumference (P < 0.01) and HOMA index (P < 0.05), whereas correlations with plasma glucose and triglycerides did not reach statistical significance (P = 0.07 for both); all correlations were offset after adjusting for BMI. Fasting plasma insulin and HOMA index were not significantly different in subjects with or without LV hypertrophy (70.8 +/- 27.8 vs. 77.7 +/- 29.6 pmol/l and 2.2 +/- 1.0 vs. 2.6 +/- 1.4, respectively). Bivariate analysis performed stratifying participants above or below the 75th percentile of the sex-specific distribution for BMI (29.1 and 29.4 kg/m2 for males and females, respectively) and plasma insulin (84 pmol/l for either gender), did not result in appreciable differences in LVM due to insulin levels. Similar results were obtained replacing the HOMA index for insulin in the analysis. CONCLUSION: In nonhypertensive individuals left ventricular mass is not associated with plasma insulin independently of body mass index.