Metabolically healthy polycystic ovary syndrome (MH-PCOS) and metabolically unhealthy polycystic ovary syndrome (MU-PCOS): a comparative analysis of four simple methods useful for metabolic assessment.

STUDY QUESTION: Is it possible to distinguish metabolically healthy polycystic ovary syndrome (MH-PCOS) from metabolically unhealthy PCOS (MU-PCOS) by simple diagnostic tools such as body mass index (BMI), waist/hip ratio (WHR), at-risk category suggested by Androgen Excess Society (AES) and visceral adiposity index (VAI)? SUMMARY ANSWER: VAI could be an easy and useful tool in clinical practice and in population studies for assessment of MU-PCOS. WHAT IS KNOWN ALREADY: VAI is a good indicator of insulin sensitivity and cardiometabolic risk in oligo-ovulatory women with PCOS. STUDY DESIGN, SIZE, DURATION: We conducted a cross-sectional study of 232 women with PCOS in a university hospital setting. PARTICIPANTS/MATERIALS, SETTING, METHODS: Anthropometric, hormonal and metabolic parameters were evaluated. An oral glucose tolerance test measured areas under the curve (AUC) for insulin (AUC 2h insulin) and for glucose (AUC 2h glucose). Homeostasis model assessment of insulin resistance (HOMA2-IR), the Matsuda index of insulin sensitivity (ISI), the oral dispositional index (DIo) and VAI were determined. MAIN RESULTS AND THE ROLE OF CHANCE: The prevalence of MU-PCOS according to the different criteria was: BMI, 56.0%; WHR, 18.1%; at-risk criteria of AES, 72.0% and VAI, 34.5%. The likelihood that a woman would exhibit MU-PCOS (except when diagnosed by the WHR criterion) showed a significant positive association with high HOMA2-IR [BMI criterion: (odds ratio (OR): 1.86; 95% confidence interval (CI): 1.43-2.41); risk criteria of AES (OR: 1.86; 95% CI: 1.36-2.56); VAI criterion (OR: 1.45; 95% CI: 1.17-1.80)] and a significant negative association with low ISI Matsuda [BMI criterion: (OR: 0.81; 95% CI: 0.72-0.91); risk criteria of AES (OR: 0.78; 95% CI: 0.69-0.89); VAI criterion (OR: 0.82; 95% CI: 0.71-0.94)]. Only MU-PCOS according to the VAI criterion showed a significant association with low DIo (OR: 0.85; 95% CI: 0.75-0.96); these women also showed a significant association with low luteal progesterone levels (OR: 0.97; 95% CI: 0.95-0.99). LIMITATIONS, REASONS FOR CAUTION: The analysis is limited by the lack of a gold standard definition of metabolic health that would have allowed the execution of a receiver operator characteristic analysis of the four proposed criteria. WIDER IMPLICATIONS OF THE FINDINGS: The results will facilitate the early recognition of cardiometabolic risk in women with PCOS before they develop overt metabolic syndrome.

Right hemiliver transplants from cadavers or living donors: a comparative analysis.

INTRODUCTION: The aim of this article was to compare the results of right hemiliver transplants from living versus cadaver donors in a single institution. METHODS: Between March 1999 and May 2003, we performed 10 right hemiliver transplants from living donors (LD) and 8 right hemiliver transplants from cadavers (CD). The procedure consisted of grafting liver segments 5, 6, 7, and 8. The procedure was performed with a fully perfused liver also in the CD group (in situ split). RESULTS: With follow-up between 7 days and 26 months in the LD group, 2 patients died with functioning grafts: 1 patient died because of massive pulmonary bleeding due to Rendu-Osler Syndrome; the other one died as a consequence of systemic aspergillosis. One patient underwent retransplantation due to arterial thrombosis. In the CD group with a follow-up between 31 days and 48 months, 3 patients died due to sepsis, including 2 who were status 2A. There were 4 early complications among the LD group and 5 in the CD group. The patient and graft survival rates were 80% and 70%, respectively, in the LD group; and both about 62% in the CD group. CONCLUSION: Right hemiliver grafts are at high risk due to technical and septic complications. A higher morbidity is observed in the CD group, where the vascular and biliary tree anatomy cannot be investigated with accuracy. We must avoid transplanting status 2A recipients with this kind of graft.

Right hemiliver transplants from living donors: report of 10 cases.

INTRODUCTION: A right lobe living related liver transplantation (LRLT) was performed for the first time in Italy on March 16, 2001 at our institution. METHODS: All donors underwent celiac and mesenteric axis angiography. Computed tomography scan to determinate the liver size and anatomical vascular variation, cholangio-magnetic resonance imaging, intraoperative cholangiography, and ultrasonography. All recipients were status 2B on the waiting list for cadaveric liver transplants. The surgical procedures were carried out by grafting segments 5, 6, 7, and 8 of the donor liver. RESULTS: Of the donors, all are alive; 4 had uneventful postoperative courses, 3 had moderate right pleural effusions; 3 had bilious drainage that resolved spontaneously: and 1 had a biliary leak and a pulmonary embolism. Of the recipients, 8 are alive with well-functioning grafts. One recipient has undergone retransplantation due to an arterial thrombosis and another recipient developed a stricture of the biliary anastomosis. Two recipients died: one because of pulmonary hemorrhage in Rendu-Osler syndrome, the other as a consequence of overwhelming systemic aspergillosis. CONCLUSIONS: Our experience suggests that few anatomical vascular and biliary variations are considered contraindications for right lobe LRLT. This challenging surgical procedure seems effective for well-selected recipients of United Network for Organ Sharing II B status. Appropriate recipient selection is crucial as we face a living donor.

[Pancreas transplantation. Experience in the first 50 patients at the Niguarda Hospital of Milan: clinical outcome and open questions]. / Il trapianto di pancreas. Esperienza dell'Ospedale Niguarda sui primi 50 pazienti: dubbi e certezze.

AIM: Personal experience in 50 patients who underwent combined pancreas-kidney transplantation (PKT), with particular reference to mortality and surgical complications is reported. METHODS: Between October 1993 and December 2001, 50 adult patients (36 males and 14 females), mean age 37 years (range 25-60), with chronic renal failure, and Insulin Dependent Diabetes Mellitus (IDDM), underwent 54 pancreas transplantation (4 patients retransplanted) and 52 kidney transplantation (2 patients retransplanted). Different surgical procedures have been employed during the period of 9 years. All patients underwent the same immunosuppressive regimen; the mean length of follow-up was 49 months. During the follow-up, 30 out of 43 patients who maintained a good graft function fulfilled a questionnaire about their quality of life following the criteria of the Medical Outcome Study (MOS). RESULTS: All patients became euglycemic immediately after the surgical procedure. One patient died post-operatively due to pulmorary thromboembolism after pancreas retransplantation for acute venous thrombosis; 1 other patient died 9 months after the procedure for acute myocardial infarction. Four patients developed acute venous thrombosis. All these patients underwent pancreas retransplantation, but 3 of these patients who survived the procedure lose the graft function for chronic rejection within 1 year. Fourteen patients showed acute rejection, 7 patients CMV infection. Three patients showed hyperchloremic acidosis, 12 patients bronchopulmonar infection and 7 patients urinary infection. Among surgical complications anastomotic fistula in 6 patients was also recorded. Five patients out of 50 lose the pancreatic graft function. After 1 from PKT, 83% of patients who fulfilled a questionnaire were strongly satisfied about their quality of life. No patients developed de novo tumors following chronic immunosuppression. The 5-year survival for patient, kidney and pancreas was 95.6%, 93.4% and 84.7% respectively. CONCLUSIONS: Our experience in 50 patients submitted to PKT shows no graft loss due to acute rejection. Surgical complications (acute venous thrombosis) and chronic rejection are the most important factors leading to graft loss. A graft in "head-up" position, a short portal vein of the graft, a "no-touch technique" during pancreas retrieval can be some of the most important factors which can reduce the rate of surgical complications. Combined kidney-pancreas transplantation showed in our experience a low mortality rate and a moderate incidence of morbidity and should be considered, at the moment, the treatment of choice for patients with renal failure and IDDM.

[Surgical treatment of hepatocellular carcinoma: resection or transplantation? Results of a multivariate analysis]. / Trattamento chirurgico del carcinoma epatocellulare: resezione o trapianto? Risultati di un'analisi multivariata.

This retrospectively study presents the results of a large series of transplanted or resected patients, with the aim of defining the characteristics of those patients who may benefit from resection or transplantation in an era in which these two surgical options can both be offered with low risks and extremely satisfactory results. Two hundred and seventy-five patients (154 resected and 121 transplanted) with hepatocellular carcinoma were submitted to surgical treatment in our department from December 1985 to December 1999. Age, sex, presence of cirrhosis, aetiology of liver disease, Child-Pugh classification, and alpha-fetoprotein levels were considered. Twenty-two of the 121 (18.1%) transplanted patients and 7 of the 154 (4.5%) resected patients died within 3 months of surgery. All curves show an evident trend towards increased mortality or recurrence rates in the resected group after prolonged follow-up. Liver transplantation appears to offer better survival and recurrence-free rates than liver resection in patients with hepatocellular carcinoma. Liver resection should be considered a good therapeutic alternative in patients who do not fulfill the transplant criteria.

Combined therapy with interferon and low-dose ribavirin in posttransplantation recurrent hepatitis C: a pragmatic study.

Recurrent hepatitis C is a common problem after liver transplantation that can progress to liver cirrhosis of the graft. Preliminary reports of combination treatment with interferon (IFN) and ribavirin have been promising, but long-term follow-up data are not yet available. We report our experience with 1 year of combination therapy with IFN (3 million units thrice weekly) and low-dose ribavirin (600 mg/d), followed by long-term ribavirin monotherapy in 18 patients with moderate to severe recurrent hepatitis C and a median follow-up of 32 months after the completion of combined therapy. All patients were followed up clinically and histologically at regular intervals. Overall, in an intention-to-treat analysis, 15 patients had normal alanine aminotransferase levels (biochemical end-treatment response [ETR], 83%), and 8 patients were also hepatitis C virus RNA negative in serum (virological ETR, 44%) at the end of combined treatment. At last follow-up after the completion of combined therapy (median, 32 months; range, 18 to 73 months), 13 patients were biochemical responders (biochemical long term-sustained response [LT-SR], 72%), and 5 patients also maintained viral clearance (virological LT-SR, 27%). Comparison of liver biopsy specimens before and after 12 months of combined therapy showed improvement in grading scores of at least two points in the majority of the patients (73%). Notably, a trend toward fibrotic progression was only noted in nonresponders. Regarding side effects, despite the low dose of ribavirn, almost half the patients developed hemolytic anemia requiring dose reductions. In addition, long-term ribavirin monotherapy was not associated with iron accumulation. We conclude that combined therapy with low-dose ribavirin followed by long-term ribavirin monotherapy can be recommended because it favorably modifies the natural history of recurrent hepatitis C in most patients and possibly halts histological disease progression without causing iron accumulation.

Kaposi's sarcoma in liver transplant recipients: morphological and clinical description.

The clinical course and outcome of 5 adult patients who underwent orthotopic liver transplantation (OLT) and developed Kaposi's sarcoma (KS) is reported. From October 1986 to July 2000, a total of 459 patients underwent 499 OLTs at our hospital. The immunosuppressive regimen consisted of cyclosporine, azathioprine, prednisone, and antithymocyte globulin. Tacrolimus was administered only in selected patients. Five patients developed KS, and the pathological diagnosis was established months 9 to 23 after OLT. Four of 5 patients died of KS, surviving 0 to 6 months after pathological diagnosis. The fifth patient, with KS confined to the skin, is disease free 6 months after diagnosis. All patients were treated with reduction of immunosuppressive therapy and/or chemotherapy. Retrospective molecular investigation by polymerase chain reaction for human herpesvirus type 8 DNA detected specific viral sequences in histological specimens of tissues involved by KS. In our experience with adult liver transplant recipients, we registered a slightly lower prevalence of KS compared with other reported data, but observed a high rate of graft involvement and mortality.

Rapid disappearance of hepatic adenoma after contraceptive withdrawal.

We present the case of a 25-year-old woman who developed a large central liver adenoma after 8 years of continuous oral contraceptive use. The first diagnosis was made by ultrasonography, after a rise in plasmatic gamma-glutamyl-transpeptidase and alkaline phosphatase levels was noted. Withdrawal of the oral contraceptive was followed by shrinkage of the adenoma, with complete disappearance 9 months after the diagnosis. Hepatic adenoma (HA) still presents problems in terms of differential diagnosis and clinical management. There are reports of complete or partial regression of an HA after discontinuation of oral contraceptives, but they are poorly documented. To our knowledge, a patient with such rapid disappearance of a large HA has never been reported.

Influence of immunogenetic background on the outcome of recurrent hepatitis C after liver transplantation.

In immunocompetent patients, specific human leukocyte antigen (HLA) class II alleles have been associated with the severity of hepatitis C virus (HCV)-related disease, in particular, HLA-DRB1*11 has been found to exert a protective effect. The authors have analyzed the role of HLA class I and II alleles in determining the frequency, timing, and progression of histologically proven recurrent hepatitis C in 89 patients who underwent a liver transplant for HCV-related cirrhosis. In addition, the influence of HLA mismatch between donor and recipient, HCV genotype, and use of steroid pulses was also evaluated. Median patient follow up was 35 months (range 4-119). HLA-DRB1 typing was performed by genomic analysis in all cases. Liver biopsies were obtained routinely and at least at yearly intervals. Histologically proven recurrent hepatitis was observed in 46 patients (52%), 10 patients progressing to stage 5-6 fibrosis in most cases within 2 years after transplant. By univariate analysis, 3 variables, HLA-B14, HLA-DRB1*04, and HLA-DRB1 donor/recipient mismatch, showed a significant effect on time to recurrent hepatitis C disease. These parameters were included in a multivariate regression model along with HCV genotype, treatment with steroid pulses and DRB1*11. HLA-B14, HLA-DRB1*04, and HLA-DRB1 donor/recipient mismatch were confirmed to provide a significant and independent contribution to the risk of hepatitic disease recurrence. As for the severity of the disease, none of the 10 patients with stage 5-6 hepatitis carried the HLA-DRB1*11 allele, in line with what was observed in nontransplant subjects. Our results suggest that in posttransplant recurrent hepatitis C, immunogenetic factors are relevant in determining HCV infection outcome.

Is lymphocele in renal transplantation an avoidable complication?

BACKGROUND: This study evaluated the impact of surgery in the incidence of lymphocele after kidney transplantation (KTx). METHODS: A prospective randomized study was conducted during a 6-year period on a group of patients undergoing KTx and operated on by the same surgeon (CVS). A total of 280 patients undergoing KTx were randomly allocated into two groups: (1) group C (control group) was 140 patients who were submitted to KTx with standard technique: implantation of the kidney in the controlateral iliac fossa with vascular anastomoses on the external iliac vessels; and (2) group M (modified technique group) was 140 patients who underwent a modified technique with a cephalad implantation of the graft in the ipsilateral iliac fossa and vascular anastomoses in the common iliac vessels. Both groups were comparable for age, cold ischemia time, incidence of rejection episodes, presence of adult polycystic kidney disease, and source of donor graft. RESULTS: Group M showed an incidence of lymphocele production (3 patients, 2.1%) significantly lower than group C (12 patients, 8.5%). Eight patients (1 in group M and 7 in group C) required surgical treatment by peritoneal fenestration. No allograft or recipient was lost as a result of fluid collection but the hospitalization was shorter in group M than in group C. CONCLUSIONS: A cephalad implantation of the renal graft in the ipsilateral iliac fossa has been associated with a lower incidence of lymphocele, probably because vascular anastomoses on the common iliac vessels cause less lymphatic derangement than those performed on the external iliac vessels.