A simplified regimen of targeted antifungal prophylaxis in liver transplant recipients: A single-center experience.

BACKGROUND: Invasive fungal infection (IFI) is a severe complication of liver transplantation burdened by high mortality. Guidelines recommend targeted rather than universal antifungal prophylaxis based on tiers of risk. METHODS: We aimed to evaluate IFI incidence, risk factors, and outcome after implementation of a simplified two-tiered targeted prophylaxis regimen based on a single broad-spectrum antifungal drug (amphotericin B). Patients presenting 1 or more risk factors according to literature were administered prophylaxis. Prospectively collected data on all adult patients transplanted in Turin from January 2011 to December 2015 were reviewed. RESULTS: Patients re-transplanted before postoperative day 7 were considered once, yielding a study cohort of 581 cases. Prophylaxis was administered to 299 (51.4%) patients; adherence to protocol was 94.1%. Sixteen patients developed 18 IFIs for an overall rate of 2.8%. All IFI cases were in targeted prophylaxis group; none of the non-prophylaxis group developed IFI. Most cases (81.3%) presented within 30 days after transplantation during prophylaxis; predominant pathogens were molds (94.4%). Only 1 case of candidemia was observed. One-year mortality in IFI patients was 33.3% vs 6.4% in patients without IFI (P = .001); IFI attributable mortality was 6.3%. At multivariate analysis, significant risk factors for IFI were renal replacement therapy (OR = 8.1) and re-operation (OR = 5.2). CONCLUSIONS: The implementation of a simplified targeted prophylaxis regimen appeared to be safe and applicable and was associated with low IFI incidence and mortality. Association of IFI with re-operation and renal replacement therapy calls for further studies to identify optimal prophylaxis in this subset of patients.

Low-dose Spinal Block With Continuous Epidural Infusion for Renal Transplantation in a Patient With Alport Syndrome: A Case Report.

OBJECTIVE: We aim to describe management of a patient receiving renal transplantation for chronic renal failure due to Alport syndrome with low dose of intrathecal bupivacaine and continuous epidural infusion of local anesthetic. CASE REPORT: A 38-years-old man with chronic renal failure secondary to Alport syndrome underwent kidney transplantation. Because of a high risk of respiratory and cardiovascular complications related to the patient's baseline lung disease and abnormalities in heart conduction, we selected combined spinal-epidural anesthesia. The block was ultrasound-guided and performed at the T12-L1 interspace with 4.5 mg of 0.5% intrathecal hyperbaric bupivacaine followed by a continuous epidural infusion of 0.5% levobupivacaine mixed with 25 µg of Fentanyl at the initial rate of 8 mL/h. Sensory block to T5-T6 was obtained within 10 minutes. The patient then received mild sedation with Propofol and Remifentanil. Methylprednisolone and diuretics were administered before vascular unclamping according to our internal protocol. Surgery lasted 3 hours with no clinical or procedural complication. CONCLUSIONS: Although renal transplantation is usually performed under general anesthesia, in a particularly complex patient with chronic renal failure, chronic obstructive pulmonary disease and a worsened respiratory mechanics, we applied a combined approach with a low dose of intrathecal bupivacaine and continuous epidural infusion of local anesthetic. The technique did not affect hemodynamics while having a positive impact on recovery of function of the transplanted organ with rapid improvement of urine output, serum creatinine, and blood urea nitrogen levels.

Effectiveness of an Education Program on Donation and Transplant Aimed at Students of the Nursing Degree Course.

BACKGROUND: Health workers' awareness and knowledge of transplant medicine can improve people's sensitivity and reduce their degree of opposition to donations. The medical literature contains numerous examples of education programs aimed at university students. This work describes the experience of an education program for students of the second and third year of a nursing degree course. METHODS: From April to September 2013, an education program was set up for 80 university students. It was divided into 3 stages: group self-learning based on prearranged topics, sharing of the results, and participation in the final seminar. The effectiveness was assessed according to a pretest/posttest design. RESULTS: The first questionnaire contained 19 questions, and the second contained 27. The questions were subdivided into specific areas: subjective knowledge, objective knowledge, attitude, awareness, participation in the event, evaluation of the information material handed out, and appreciation of the tools used. There was a significant increase for items relating to knowledge, whereas awareness and attitude (already high at the start of the program) showed no changes. After the program, many students discussed the question of donation with their relatives and friends, and about 70% filled in a donor card. The students expressed a highly positive opinion of the initiative and the tools used. CONCLUSIONS: The initiative proved its validity, improving subjective and objective knowledge to a statistically significant extent and also increasing awareness and attitude. The students' evaluation was extremely positive.

Invasive Candida infections in low risk liver transplant patients given no antifungal prophylaxis in the post-operative period.

BACKGROUND: In recent years the incidence of invasive fungal infections (IFIs) in post liver transplant (LT) has reduced to about 5%, however the majority of IFIs develops early in the post-transplant course. Candida species are the most frequent causative pathogens followed by Aspergillus species. Mortality for invasive candidiasis is still 40-50%. For this reason universal prophylaxis is still considered useful and is adopted by different LT centers, although it is not justified by available data. The aim of study is to evaluate Candida infection incidence and mortality in low risk patients and therefore not subjected to antifungal prophylaxis in the immediate post-LT. METHODS: The patient is defined low risk if without any risk factor for IFIs as reported in literature and according to our center protocol described below. We analyzed retrospectively the records (with 90 days follow-up) of all adult patients underwent to LT at our center in 2011-2012. RESULTS: At our center between 2011 and 2012, 247 LT in 232 adult patients were performed: 137 patients (59%) received prophylaxis with Amphotericin B lipid complex or liposomal Amphotericin B, 95 patients (41%) didn't receive any prophylaxis. In these latter patients was observed only one case of Candida oesophagitis at the second month post-LT. The incidence of invasive candidiasis was 0%, and there wasn't mortality ascribed to Candida infection. CONCLUSIONS: It is possible to identify low risk patients for IFIs post-LT and the no prophylaxis policy in the early LT course appears safe and feasible.

Organ and tissue donation in migrants: advanced course for cross-cultural mediators.

Between 2004 and 2010 in Piedmont (Italy Northern Region) 1556 brain-death situations were reported, including 113 (7.3%) in migrants as potential organ and tissue donors. The health staff often has to face migrants, who show great cultural differences and language difficulties. The Molinette Hospital Customer Care Service, the Piedmont Regional Tissue and Organ Procurement Coordination Agency (RPC), and the Cross-Cultural Mediators Association (CMA) organized a special course for intercultural mediators, to decrease misunderstandings between the health staff and the migrants' families and to improve professional communication. In 2011, 28 cultural-linguistic mediators representing different groups of migrants in Piemonte took part in a specific course. Over a 5 month period they were informed about emotional and communicative aspects, proper to the moment of death, as well as organ donation as an intercultural field, the professional role of the mediator, the clinical and forensic aspects of brain death and donation, and the psychological aspects of organ donation. The course was organized by cultural-linguistic mediators of the CMA, the staff of the RPC and the teachers at Turin University. The list of the 21 mediators who passed the final exam was given to organ and tissue donation hospital co-ordinators in Piedmont, so that if necessary, they could obtain the cooperation of these qualified people.

Organ donation awareness project for Piedmont high school students.

FOREWORD: Law no. 91 of April 1, 1999 confirmed the principle of citizens' free choice and awareness with regards the donation of their own organs and tissue. Many studies have shown that information/communication programs aimed at secondary school students are able to significantly increase their propensity toward donation. Students who are made more aware of the topics of donation and transplantation are, in turn, a means of information for their families and acquaintances. METHODS: To be effective, communication must contain both cognitive and emotional elements. This is the principle underlying the development of an awareness-building project that involves the viewing of a play-"Two of Hearts"-telling the story of a transplant patient, followed by a brief scientific presentation aimed at clarifying the basic concepts of transplantation medicine, and then an open discussion between the students and experts. This initiative was promoted by the Piedmont Regional Tissue and Organ Procurement Coordination Agency, the Communication Office of the Piedmont Region, and the Regional Education Office for Piedmont. RESULTS: Seven meetings took place in the main town of each of the provinces that make up the Piedmont Region. These were attended by a total of 1373 students, who were each given an anonymous questionnaire. In all, 785 returned the questionnaire; of these, 95% affirmed that the contents of the meeting had been clearly presented, and 57% stated that they had spoken about it with their family and friends. The project proved be a good tool for communicating with young people and, via them, with their families; at least 2300 people were reached in this way.

[Complications of tracheostomy in critically ill patients: comparison of dilation and surgical techniques]. / Confronto sulle complicanze di varie tecniche tracheotomiche in area critica.

The tracheotomy, one of the oldest surgical procedures, has in recent years been the focus of particular attention given the undoubted, and not always justified, increase in indications, and by the introduction of dilatational tracheotomy techniques, particularly in critically patients. The present work compares the standard surgical tracheotomy with the more recent percutaneous techniques (Ciaglia dilatational tracheotomy and Fantoni translaryngeal tracheotomy). In particular, the relationship between the technique adopted, timing and complications were analyzed for 215 tracheotomies performed at different Intensive Care Units at our Hospital between 1993 and 1998 (106 performed using the standard surgical technique, 51 with the Ciaglia technique and 58 with the Fantoni technique). The pre-operative oro-tracheal intubation time ranged between 4-54 days (17 tracheotomies performed before oro-tracheal intubation). The results of this study showed that percutaneous techniques present fewer early post-operative complications (severe bleeding, erosive stomitis, dislocation of the cannula) and above all fewer sequelae in time (tracheal stenosis, tracheomalacia). The surgical procedures are shorter and nursing is limited to a few days which certainly results in a savings in health care resources. After decannulation, the esthetic result in patients that underwent the dilatational tracheotomy can be considered excellent. Among the disadvantages one must recall the possible dislocation of the cannula immediately after surgery: forced reinsertion of the cannula exposes the patient to the risk of creating a dangerous false route. The results obtained are statistically significant and in line with those found in the literature. The conclusion is drawn that, when performed by skilled surgeons and aided by endoscopy, the percutaneous tracheotomy techniques are the method of choice for patients in critical areas.

CVVH in postoperative care of liver transplantation.

OBJECTIVE: To evaluate CVVH (Continuous Veno-Venous Hemofiltration) as acute renal replacement treatment in postoperative care of liver transplantation. DESIGN: Retrospective study. SETTING: Intensive Care Unit, year 1995. PATIENTS: 86 OLT performed in 1995, 11 of them underwent acute renal replacement treatment. In the same period, in the ICU were admitted 237 patients, and 20 underwent acute renal replacement treatment (control group). Evaluation with SOFA (Sepsis-related Organ Failure Assessment) score. INTERVENTION: CVVH performed heparin free, pump system, polyamide or polysulphone 0.6 mq membrane hemofilter device, blood flow 150-200 ml/min, UF rate 1000-1200 ml/h, clearance 16-20 ml/min. MEASUREMENTS: Coagulation monitoring (PT as INR, PTT, fibrinogen, antithrombin III, d-dimer, platelet count) was performed 3 times a day or on variation of the clinical conditions. RESULTS: SOFA score did not differ between the two groups. Mortality was higher in the patients treated with CVVH. CVVH was performed from 16 to 18 hrs/day for 9.90 +/- 2.33 days. Three patients developed clinical bleeding before CVVH, 3 during CVVH but 1 of them underwent repeated surgical procedures. CONCLUSIONS: We cannot demonstrate that CVVH doesn't affect bleeding, but we can say that, for the complexity of the post OLT patients, CVVH can be the treatment of choice in case of renal replacement treatment.

Oxidative damage in human liver transplantation.

The aim of this study was to evaluate oxygen-dependent hepatic reperfusion injury in humans following orthotopic liver transplantation. To this end, a number of blood indices of impaired tissue redox balance were monitored in 19 adult patients for 3 weeks after liver transplantation. Both red cell malonaldehyde and plasma lipid peroxides increased significantly soon after organ reperfusion. This finding was consistently accompanied by decreased plasma vitamin E and red cell total glutathione. A peak of oxidative stress, as measured by the parameters monitored, was evident within 24 h after reperfusion, together with a maximum expression of cytolysis, as measured by plasma alanine aminotransferase. The occurrence of redox imbalance after hepatic reperfusion was shown to be linearly related to irreversible cell damage. As regards the low plasma levels of the two antioxidants after reperfusion, only that of vitamin E appeared statistically related to oxidative stress. With the background of an increasing body of proof, mainly from animal models, the involvement of toxic oxygen metabolites in hepatic cytolysis following orthotopic liver transplantation appears likely. The statistical correlation among the markers of redox imbalance monitored indicates their combined use in further investigation.

[Endocrine-metabolic response to 2 different techniques in surgery of the abdominal aorta]. / Risposta endocrino-metabolica a due diverse tecniche anestesiologiche nella chirurgia dell'aorta addominale.

Plasma cortisol and PRL were measured in two groups of patients undergoing reconstructive aortic surgery under either general anaesthesia and continuous epidural analgesia with supplemental general anaesthesia. The results confirmed that epidural analgesia with light general anaesthesia is much able than general anaesthesia to suppress the metabolic response associated with aortic surgery procedures.

[Aspects of general anesthesia in cerebral angiography]. / Aspetti dell'anestesia generale nelle angiografie cerebrali.

The need for continuous control of the parameters that may influence cerebral homeostasis has made it advisable to use general anaesthesia for cerebral angiography. A combination of propanidide and neuroleptanalgesia, with controlled ventilation, was employed in a group of 66 patients with various cerebral diseases. The stability of narcosis and the absence of significant changes in the cardiocirculatory and respiratory parameters prevented alterations in cerebral flow and intracranial pressure during the examination. Prompt reawakening enabled the patient's neurological state at the end of the examination to be immediately evaluated. In addition, the angiograms were of better quality.